ftMl 
 
 CIM. 
 
 COLLEGE OF 
 
 PHYSICIANS AND SURGEONS 
 
 LIBRARY 
 
 Gift of 
 
 Dr. A, E. S. Lambert 
 
Digitized by the. Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/antisepticsurgerOOchey 
 
ANTISEPTIC SUEGEEY 
 
ANTISEPTIC SURGERY 
 
 ITS PRINCIPLES, PRACTICE, HISTORY 
 AND RESULTS 
 
 W. WATSON CHEYNE, M.B., F.K.C.S. 
 
 ASSISTAXT-SURGEON TO KING'S COLLEGE HOSPITAL 
 DEMOXSTRATOU OF SURGICAL PATHOLOGY AT KING'S COLLEGE 
 
 Mit^ Illustrations 
 
 LONDON 
 iSMlTH, EI.DEK, & CO., 15 WATEKLOO PLACE 
 
 1882 
 
 [All riijhts reserveil ] 
 
 I 
 
PREFACE. 
 
 The interest which Antiseptic Snrgery has awakened' 
 throughout the profession has led to many j)ublic debates 
 and to the accumulation of a great mass of literature on 
 the subject. The time seems now to have come for a 
 detailed account and discussion of the whole matter, and 
 it is with the view of furnishing such an account that 
 the present volume has been published. The question 
 might have been dealt with in two ways ; either by the 
 discussion of the present standpoint of the principles and 
 practice of Antiseptic Surgery, with but little reference 
 to former literature ; or, as I have attempted to do, by 
 tracing in addition the development of its theory and 
 practice, and following out and criticising the various 
 steps by which the present state of knowledge on the 
 subject has been reached. The former mode might no 
 doubt have produced a shorter work, but it could not have 
 been made complete in the present transitory state of our 
 knowledge, and, taken alone, it would have necessarily 
 raised side issues confusing to readers unacquainted with 
 tlie earlier literature. I have therefore, in addition to 
 tlie discussion (jf the present state of knowledge on the 
 subject, tried to trace out its development, and 1 have 
 done this the more readily because it seems to me that 
 when an attempt is made, almost for the first time, to 
 
X riiEFACE. 
 
 discuss fully a new department of science, the work of 
 those who have chiefly helped by experiment or criticism 
 to build it up should be acknowledged and properly 
 estimated. Such a way of treating the subject will 
 perhaps also supply a want to those who have not the 
 time nor the opportunity of searching out the literature 
 for themselves. Among other facts which have been 
 brought forward here I may draw special attention to the 
 folio wino;, which I think have been now made certain: — 
 Fermentations in wounds occur as the result of the 
 entrance of particles — micro-organisms — from without ; 
 a variety of methods of treatment may be grouped under 
 the heading ' Antiseptic treatment ' ; lives are saved in 
 proportion to the asepticity of the wound, and, when 
 the wound is kept aseptic, infective diseases more 
 especially are avoided ; the aseptic or Listerian method 
 prevents the development of micro-organisins and the 
 occurrence of fermentation in wounds. 
 
 Portions of this work have been previously published. 
 Some investigations on micro-organisms in wounds and 
 on temperature after operations formed part of my essay 
 Avhich gained the Syme Surgical Fellowship of the 
 University of Edinburgh in 1877. I have since that 
 time repeated and extended these investigations. In 
 the essay to which was awarded the Boylston Medical 
 Prize and the Boylston Gold Medal ^ of the Harvard 
 
 ' By an order adopted in 1826 the Secretary of the Boylston Prize 
 Committee was directed to publish annually the following votes : — 
 
 1st. That the Board do not consider tliemselves as approving tlie 
 doctrines contained in any of the dissertations to which pi-eniiiinis may be 
 adj udgt'd. 
 
 2\\(\. That in case of publication of a successful dissertation, tlio autlior 
 be considered bound to print tlie above vote in connection therewilli. 
 
TREFA CE. xi 
 
 University, United States, in 1880, 1 discussed the various 
 methods of Antiseptic Surgery and the best modes of 
 apply mg them to practice. And, in 1881, the council 
 of the College of Surgeons of England awarded me the 
 Jacksonian prize for a discussion of the history, prin- 
 ciples, practice, and results of Antiseptic Surgery. This 
 work is the outcome and development of these essays. 
 
 The drawings in this book (both the woodcuts and 
 the plates) have been made by Mr. Edgar Thurston, 
 to whom I am much indebted for the great pains which 
 he has bestowed m their preparation. Mr. Groves also 
 kindly took some photographs, from which certain of 
 the woodcuts have been drawn. Dr. Heron has ren- 
 dered me great assistance in revising the proof-sheets 
 and in preparing the Index. 
 
 In dedicating this work to Mr. Lister I have 
 attempted to acknowledge my great indebtedness 
 to him. 
 
 W. WATSON CHEYNE. 
 Old Cavendish St., \V. 
 October 1881. 
 
CONTENTS. 
 
 CHAPTER I. 
 
 THE PARTICULATE THEORY OF FERMENTATION. 
 ON THE FERMENTATION OF BOILED SUBSTANCES. 
 
 TAGR 
 
 Definition of putrefaction and fermentation — Chemical fermentations — 
 Living ferments — Various views on fermentation — Lavoisier — Fa- 
 broni — Tlienard — \ppert — Gay-Lussac's experiments and conclusions 
 — Caignard-Latour — Schwann, heated air inert — Schulze — Ure and 
 Helmholtz, nascent oxj^gen inert — Liebig's views— Review of the 
 subject — Schroeder and Dusch, filtered air inert — Schroeder, ozone 
 inert — Schroeder's final views — Pasteur's researches — Lister — Roberts 
 — Tyndall^My own results, carbolised air inert — Conclusions as to 
 the cause of the fermentation of boiled substances .... 1 
 
 CHAPTER II. 
 
 THE PARTICULATE THEORY OF FERMENTATION {continued). 
 
 ON THE FERMENTATION OF UNBOILED SUBSTANCES. 
 
 {jVAiiti yncc—Gaif-Liiasa' — Van tier Brocck— Pasteur — Boberts; blood — 
 Van (Icr Broech — Pasteur — Bvrdoii- Sanderson — Lister — 3Iy own re- 
 sults; unboiled urine — Van der Broeelt — Pasteur — Lister — My own 
 results— Boberts — Cazeneure and Liron; milk — Hoppe-Seyler — Bo- 
 hrrts — LAster — My own, experiments ; egg albumen — Van der Liroerk 
 
 — Gayon — BobeHs — My own experiments; vegetable tissues — Boberts; 
 animal tissues — Billroth — 'Hegel — Burdon-Sanderson — My own ex- 
 periments — C'Mene and Ewart — Meissner — General review of the facts 
 
 — Behaviour of fluids and tissues in the living body— Principles of 
 aseptic surgery ;{() 
 
 CHAPTER in. 
 
 ASEPTU; SUR(;EKY — materials EMPLOYED, 
 
 Problems to be solved in order to kcoi) a wound aseptic : Carbolic acid - 
 Carbolic lotions - Pure earbolic aeid — Solution in methylated spirit — 
 rarbol/e oil - Carbo/ie aeid and ylyrerine : Spray fjroducers: Catgut 
 
CONTENTS. 
 
 — Carholisrd caffpit- Mr. Litsfcr'a earholtsi'd chromic catf/nt — Dr. J\fac- 
 Ewcn's chromic catf/iit — Caft/iit troiir/h a)id j/ochct caxc: Carbolised silk: 
 Protective: Carbolic gauze — Composition — Method of preparation — Yon 
 lirun\'< gauze : Macintosh : Sponges : Boracic acid — Boracic lotion — 
 Boradc lint — Boracic ointment : Salicylic acid —SalicijUc acid, cream. 
 ■ — Salici/Uc ointment : Chloride of zinc : Iodoform : Carbolised cotton 
 wool 52 
 
 CHAPTER IV. 
 
 ASEPTIC SURGERY [confinned). 
 
 Example of an aseptic operation : Purification of the skin — Fingers — 
 Instruments: Spray — Precautions— Probable errors, and mode of re- 
 medying them : Guard : Ligature of arteries : Drainage of wounds — 
 India-rubber tubes — Catgut drains —Horse hair — Decalcified bone tubes 
 (Neuber's and MacBwen's) : Sutures: Button stitches — Stitches of re- 
 laxation — Stitches of coaptation — Aseptic strapping — Protective : DeeiJ 
 dressing : Loose gauze : Gauze dressing : Elastic bandage. Changing 
 THE DRESSINGS — Time — Method. Treatment of ulcers : Purifica-* 
 tion of the sore : Boracic dressing : Boracic and salicylic ointment : 
 Boracic poultice 67 
 
 CHAPTER V. 
 
 ASEPTIC SURGERY (cOUtintieJ). 
 
 Special dressings : Head dressfiiigs : Neck dres.tings : Bread dresKinfiK — 
 Abscess of mamma — Excision of mamma alone — Excision, of mamma, 
 and axillary glands : Axillary dressings : Dressings on the limhs : 
 Dressings for psoas abscess : Lumbar abscess : Hip-joint abscess : 
 Dressings in cases of hernia a7id operations on the scrotum: Excisions 
 of joints. AsejDtic treatment of abscesses. Chief points to be con- 
 sidered in opening abscesses — Method of opening abscesses — Drainage 
 of absresscs— After-treatment of abscesses — Empyema — Perineal and 
 anal abscesses. Treatment of wounds produced accidentally : Problem 
 to be solved— Purification of wound — Further treatment of the n'ound. 
 Special wounds : Compound fractures : Wounds innolring tendons, 
 nerves, <^'c. : Wounds of joints : Compound fr act w'es of the skull: Pene- 
 trating wounds of the thorax: Wounds of the abdomen. Putrid sinuses 
 and wounds. Treatment cf burns. Treatment of gangrene. Treat- 
 ment of na;vi and varicose veins ........ 0(5 
 
 CHAPTER VL 
 
 ASEPTIC SURGERY — MODIFICATIONS. 
 
 Country practice : How to dispense with the spray during the operation — 
 and during the aft:;-: '^-eatment: How to render the ilreasings less fre- 
 
CONTEXTS. XV 
 
 PAOK 
 
 quent. Is the aseptic method applicable in war ? 3rr. Lister' s< 
 snggestians : Esmarch's X}liui : Jiei/Jier's method. Development of 
 Aseptic Surgery in Mr. Lister's hands : Compound fractures— Pvre 
 carbolic acid — Formation of crust — Carbolic putty — Lead 2)laster — 
 Imc plaster, syringing wounds with carbolic lotion, protect'n^e, catgut 
 ligatm-es, method in 1870 — Present method in the main introduced in 
 1871 — Further introduction of wet gauze, steam spray, elastic bandages: 
 abscesses — Method of opening them under carbolic oil : wounds . .120 
 
 CHAPTER Vll. 
 
 ASEPTIC SURGERY {concluded). 
 
 other methods of carrying out Aseptic Surgery. Substitutes for carbolic 
 acid: Salicylic acid : Thymol: Acetate of Alumina : Eucaltjptus oil. 
 Aseptic surgery by filtration of the air. Subcutaneous surgery . . i.SO 
 
 CHAPTER Vni. 
 
 THEORIES OF SPONTANEOUS GENERATION, HETEROGENESIS 
 AND ABIOGENESIS. 
 
 Principles on which other methods of Antiseptic Surgery act. Organisms 
 are always present in fermenting liquids : their significance. Theory 
 of the origin of organisms independently of a parent. Theories of 
 Needham and Buffon : Needham's proofs. Spallanzani"s experiments : 
 Needham's objections : Spallanzani's replies. Schulze's experiments. 
 Schwann — Schroeder and Duscli — Schroeder. Doctrine of Hetero- 
 genesis. Poiichet's work : his method of test ing the matter : proofs 
 that the source of the organisms in infusions is neither the air, water, 
 nor the putrescible substances : modes of repeating Schulze's and 
 Schwann's experiments : examination of dust. Criticism of his re- 
 sults. Pasteur's experiments : results with ordinary fluids : introduc- 
 tion of dust into sterilised fluids : results with milk and alkaline 
 fluids : the cause in the air which gives rise to the growth of organ- 
 isms is particulate : Pasteur's cultivating fluid : estimate of Pasteur's 
 work. Pouchet's reply : New experiments— Criticism of tliese . . 14") 
 
 CHAPTER IX. 
 
 SPONTANEOUS GENERATION {continued). 
 
 The experiments of Jeffries Wyman : explanation of the results : VVyman's 
 views on the subject. Dr. Uastian's views: Cases in which it is still 
 possible that abiogcnesis may occur : Growth in vacuo— Bastian's ex- 
 periments— my own results — Cohn's facts — Dj- Roberts's ohjection.s, 
 the walls of the ve.s.sels remain impure — Basfian's reply — Objections 
 to the latter — Graitlmiscn's experiments — Pau i.i-rt's results wiili 
 
CONTENTS. 
 
 compressed air — Pouchct looks on a vacuum as preventing spontaneous 
 generation — Paul Bert's results with rarefied air — Ur. Bastian does not 
 always get positive results : Experiments in airless and hermetically 
 sealed flasks raised to a high temperature — Objections— Prof. Huxley's 
 and Dr. Sanderson's statements — Ray Lankester's results — Hartley: 
 expei'imen-ts with alkaline fluids — Roberts's counter-experiment. Mr. 
 Lister's experiments. Experiments by Roberts and Tyndall . .172 
 
 CHAPTER X. 
 
 SPONTANEOUS GENERATION (conchtded). 
 
 Facts with regard to unboiled fluids and tissues : Mr. Lister's facts 
 with regard to milk : my own experiments with animal tissues. 
 Present state of the question — Dr. Bastian's latest standpoint : Lie- 
 big's doctrine. Can organic molecules derived otherwise than from 
 pre-existing bacteria give rise to bacteria ? Firstly, there is nothing 
 unreasonable in looking on these particles as bacteria or their germs: 
 seeds carried by air : excessive minuteness of the germs of bacteria : 
 Mr. Lister's experience with micrococci. Secondly, there is no direct 
 evidence that organic molecules not derived from bacteria can give 
 rise to bacteria : facts with regard to unboiled fluids and tissues — 
 conclusions from these facts : Paul Bert's experimenTs : Cazeneuve 
 and Livon: Pasteur: Dr. Bastian. Thirdly, there is no evidence 
 that active organic molecules (chemical ferments, &c.) can resist 
 heat more than living things can : effects of heaJt on ptyalin, pepsin, 
 •&c. : my own case of difficulty in sterilising mil'k : Wyman's fact as 
 to an alga living at 208 F I94 
 
 CHAPTER XT, 
 
 RELATION OF MICRO-ORGANISMS TO FERMENTATION. 
 
 ■Summary of what has preceded with reference to fermentation. Relation 
 between ' vital ' and ' chemical ' fermentations : theories of fermen- 
 tation. Liebig's views. Alcoholic fermentation : Paxte^ir'' » experiments 
 tnid eonchishms. Rfsnmc. Butyric fermentation. Formation of pig- 
 iiTicnt by bacteria. Schroeter : Cohn. Viscous fermentation. Lactic 
 fermentation : Panteur : Lister. Other fermentations, especiaJly tJbe 
 putrefactive: Levi aire ; Cazeneuve and Liron:: Paul Bert. C'onclu- 
 ■sions ............. 20;'i 
 
 (mAPTER Xn. 
 
 RELATION -OF MI€RO-ORGANISMS TO THE FLUIDS AND TISSUES 
 OF THE LIVING BODY. 
 
 Propo.sed mode of cnquir;- — Does the aseptic met liod prevent putref^ac- 
 tion? Does it exclude organisms from wound.s? Kanke's results: 
 
CONTENTS. 
 
 Klebs' objection: Ranke's reply: Demarquay : Fischer: Schiiller : 
 my own method — Results in aseptic wounds — Results in wounds 
 treated otherwise — Koch's method of staining pus — Results in cases 
 not treated aseptically — Examples of complete exclusion of organ- 
 isms in aseptic cases — Examples of the entrance of micrococci in 
 aseptic cases — Detiuition of micrococci — Distinctions between micro- 
 cocci and bacteria. Are organisms present in the healthy living 
 body ? — ' Bistournage.' Are organisms present in the body in states 
 of disease ?— Experiments with ammonia, phosphorus, &c. — The 
 healthy blood and tissues can destroy organisms — Relation of organ- 
 isms to abscesses. How do micrococci enter aseptic wounds 1 Car- 
 bolic lotion a salficient germicide ; Spray, its value — Stimson's 
 experiments ; Gauze dressing as a protection against entrance of 
 organisms ; Carbolic acid as a germicide in albuminous fluids ; Rela- 
 tions of micrococci aud bacteria to fluids containing carbolic acid. 
 Conclusions . . ......... 225 
 
 CHAPTER XIII. 
 
 ANTISEPTIC SURGERY. 
 
 Complete definition of antiseptic surgery. Varieties of antiseptic sur- 
 gery. Treatment by Antiseptics : Carbolic acid — objections to it : 
 Chloride of zinc : Boracic acid : Sulphurous acid : Chlorinated Soda : 
 Alcohol — Hutchinson's method : Terebene and Sanitas — Bilguer's 
 method — Neudorfer's salicylic powder. Free drainage as an an- 
 tiseptic 3IETHOD. Irrigation and immersion. Open method: 
 Modes in which it acts antiseptically : Bartscher and Vezin's method : 
 Burow's method: Rose's modification. Healing by scabbing: 
 Methods of forming a crust : Bouisson's ventilation method : other 
 modes. Cuerin's cotton-wool dressing. Modes in which 
 
 THE destructive ACTION OF THE TISSUES ON BACTERIA IS AS- 
 SISTED. Wliy does not fermentation always occur in the blood in 
 wounds in wliich organisms are present ? Best practical methods. 
 Conclusions 265 
 
 CHAPTER XIV. 
 
 HISTORY OF ANTISEPTIC SURGERY. 
 
 Practice of the ancient writers. Attempts of the ancients to secure im- 
 mediate union of wounds. Pare and Paracelsus : Delacroix : Arcjeus : 
 Progress of wound treatment in the sixtcentli century. Seventeenth 
 century: Magatus: Wiseman: Colbatch : Progress in the seventeenth 
 century. Eighteenth century and the early jiart of the nineteenth : 
 Boerhaave : Col dc Villars : Heister : Bilguer : Benjamin Bell : Abcr- 
 nethy : John Hunter's objections to the views of Bell and Abernethy : 
 John Bell : opinion and practice of other surgeons : Conclusions : Von 
 Kern . . 290 
 
CONTENTS. 
 CHAPTER XV. 
 
 HISTORY OF ANTISEPTC SURGERY (continued). 
 
 I'AOB 
 
 History of the various methods. Incubation : Gu3'^ot. Subcutaneous 
 surgery, preliminary attempts : Stroraeyer : DielTcnbach : Jules 
 Guerin : Langenbeck : Other authors. Occlusion : Jules Guerin : 
 Chassaignac — Eochard's remarks: Pansement ouate — Alphonse 
 Guerin, method and results — Oilier. Substitution of various gases 
 for air: Demarquay and Leconte. Open Method: I'Sartscher and 
 Vezin: Burow: Humphre}-. Healing by scabbing: John Hunter: 
 Xeudorfer : Bennion : Lister : Bouisson : Bonnet, kc. Irrigation 
 and the water-bath : early history : Josse : Berard : Mayor: Amussat : 
 Langenbeck: Valette 317 
 
 CHAPTER XVI. 
 
 HISTORY OF ANTISEPTIC SURGERY (conckuhd). 
 
 Use of antiseptics: Alcohol — older WTiters — Nelaton — Hutchinson: Glyce- 
 rine— Demarquay : Chlorine: Chloride of zinc: Iodine: Iodoform: 
 Chlorate of Potash : Perchloride of iron, &c. : Coal tar — Corne and De- 
 raeaux — Report of the commission : Coal tar saponine — Lemaire — his 
 views on putrefaction : Carbolic acid — Lemaire — Lemaire"s position 
 n regard to Aseptic Surgery — Lister : Further phases in the historjr of 
 this subject : Objections to Mr. Lister's claim as originator of the 
 Aseptic method — Simpson — Neudorfer. Modifications of the method. 
 Su.bstitutes for carbolic acid. Objections to the Aseptic method . . 347 
 
 CHAPTER XVII. 
 
 RESULTS OF ANTISEPTIC SURGERY. 
 
 Chief points for consideration. How far do the various methods prevent 
 fermentations in wounds ? How to ascertain the true value of any 
 individual method. The value of the various methods in guarding 
 against infective disease: meaning of the term 'infective disease' 
 Relations of Aseptic Surgery to infective disease. 3/r. Lufrr's remdtn 
 iv fllaariow. The recent Glasgow .tfatiaficK. Mr. Lixter's resvlts in 
 Edinlmrf/h ; re.snlts in sejftic and asej)tio ca^es — 3/r. Sjfcnce's jwactice 
 — Mr. Slime's results — Mr. Lister\'< results at Kinff's Cnlle/je Hospital : 
 — Volkmann — Nmshauni — Socin — Saxtorph — Esmareh. — lluetcr — 
 Czeriiy — Lucas- Cliamqnonnix-re — Gross — LHievant — Panas — Schede— 
 Reyher — Spencer Wells — Keitli^Thornton. TliicrscVs results with 
 salicylic acid. Thymol. The relations of other forms of Antiseptic 
 Surgery to these diseases — Treatment hy Antiseptics — Beyher — lAstcr 
 — Nvlaton — JTutchinson. Occlusion — Jules Gverin — Alphonse Guerin. 
 Treatment hy irrigation and mater hath — Langcnheck — Valette. Open 
 
CONT'ENTS. xix 
 
 PAGE 
 
 Method — Barischer and Vezin — Bvrmv — Kr'onlein. Results where no 
 antiseptic measures were adopted — Billroth — Malyaigne — Paul — 
 Holmes — Erich&en. Eesults of cleanliness — Mo Vail — Bardenheuer . 365 
 
 CHAPTER XVIII. 
 
 RESULTS OF ANTISEPTIC SURGERY {continued). 
 
 General considerations. Wounds of, and operations on, healthj* joints. 
 Method of treatment adopted in these cases. Definition of the term 
 'Aseptic course': Example. Wounds of healthy joints. Operations 
 on healthy joints. Objections to the value of these cases : reply. In- 
 cisions into joints affected with synovitis. Incisions into joints af- 
 fected with pulpy degeneration of the synovial membrane — a without 
 suppuration, b with suppuration. A''oliimann's results : Max Schede : 
 Paul Barth : Saxtorph : Piechaud : Nussbaum : Albert : Hueter : 
 Letievant : Kraske : Eeyher: Bergmann. Comparison of Pieyher's 
 results with those obtained during the Crimean war, and with Heint- 
 zel's. Treatment bj' irrigation. Necessity for observing the minutest 
 precautions as shown by Mr. Lister's case. Piesults of removing 
 foreign bodies from joints without aseptic precautions : Larrej^ : 
 Speuce : Paget 417 
 
 CHAPTER XIX. 
 
 RESULTS OF ANTISEPTIC SURGERY {continued). 
 
 Compound fractures. Differences between those produced accidentallj^ 
 and those caused by the surgeon : treatment and after-progress of each 
 class. Tables of accidental compound fractui-es treated by Mr. Lister: 
 thigh; leg; liutner us ; forearm ; skull; summary of results. Tables 
 of compound fractures produced intentionally bj' Mr. Lister ; femur ; 
 leg ; clavicle ; humerus ; forearm ; lower jaw. General summary of 
 Mr. Lister's results. Mr ^pence's results. Other operations on bones 
 by Mr. Lister. MacEwen's osteotomies : Volkmann : Max Schede : 
 Bardenheuer : MacCormac. Combined aseptic results: Results br- 
 other methods . Volkmann and Fraenckel : Holmes : St. Thomas's 
 IIosjDital. Rej'her's results in war. Open method: Kronlein. Septic 
 methods 461 
 
 CHAPTER XX. 
 
 RESULTS OF ANTISEPTIC SURGERY {continued). 
 
 Abscesses connected with di-sease of the vortebne. Best situation for 
 opening psoas abscesses : best time for opening them : after-treatment 
 and after- progress. Table of Mr. Lister'.s results : general summary 
 and remarks on these cases. Comparative statistics are wanting. Sir 
 James Paget 's views . . . 'Al 
 
XX CONTENTS. 
 
 CHAPTER XXI. 
 
 RESULTS OF ANTISEPTIC SURGERY (concluded). 
 
 PAGE 
 
 General consideration of the results. Results of the various methods in 
 saving life. Results in avoiding infective disease. Cleanliness : defi- 
 nition of the term : Mr. Savorj-'s definition and method : cleanliness 
 has not abolished infective disease even in healthy hospitals : cleanli- 
 ness is a complex method : infective disease may appear even in the 
 best hygienic conditions. The source of infective disease. Conclu- 
 sions as to the value of the various methods in preventing infective 
 disease. Deaths from prolonged suppuration after chronic abscesses, 
 compound fractures, &c. Operations on weak or diseased individuals 
 are rendered possible by the aseptic method. Operations otherwise 
 iinjustifiable,but nevertheless necessary for the recovery of the patient, 
 may be safely done by the aseptic method. The patient may be made 
 a more useful member of society: joint cases : tenotomy, &c. : com- 
 pound fracture : dangers of operations of convenience. Local results 
 of wounds treated aseptically : absence of pain, inflammation, &c. : 
 experiments of Yeo and Ferrier : organisation of blood-clot, catgut, 
 sloughs, &c. Histological details of the process : Tillmann's experi- 
 ments. Temperature in aseptic cases : contrast with septic cases. 
 Local and constitutional course of cases not treated aseptically. Objec- 
 tions to aseptic surgery: carbolic acid poisoning: the surgeon is said 
 to neglect the constitutional state of the patient: expense: trouble : 
 necessity for the spray. Conclusion : great principle of wound treat- 
 ment is Rest . 540 
 
 Index 603 
 
LIST OF ILLUSTRATIONS. 
 
 1. .Schwann's method of admitting heated air to putrescible fluids . . 7 
 
 2. Schroeder and Dusch's apparatus for supplying filtered air . .13 
 
 3. Pasteur's flask with the bent neck 16 
 
 4. Door of Mr. Lister's hot box 18 
 
 5. Mr. Lister's hot box 18 
 
 6. Mr. Lister's large double-necked flasks 19 
 
 7. Method of filling these flasks 20 
 
 8. Mr. Lister's arrangement to protect fluids in liqueur glasses from dust 21 
 
 9. Mode of filling Mr. Lister's liqueur glasses ...... 21 
 
 10. Dr. Roberts's bulbs (copied from Roberts) , 23 
 
 11. Prof. Tyndall's pure chamber (copied from Tyndall) . . . .24 
 
 12. Dr. Roberts's experiments with grape juice (from Roberts) . . 33 
 
 13. Pa.steur's method of obtaining fresh blood (from Pasteur) . . .34 
 
 14. Beaker containing unboiled meat and a putrescible fluid . . .46 
 
 15. Hand spray producer 54 
 
 16. The ordinary steam spray producer . 54 
 
 17. Steam spray producer, showing the lamp at present in i;se . . . 55 
 
 18. Large steam spray producer with double nozzle for ovariotomy, kc. . 56 
 
 19. Trough for catgut 59 
 
 20. Lister's pocket catgut holder 59 
 
 21. Machine used in the Glasgow Royal Infirmary for manufacturing 
 
 gauze 63 
 
 22. Porcelain trough containing instruments .soaking in carbolic lotion , 70 
 
 23. General arrangement of surgeon, assistants, towels, spray, &c., in an 
 
 operation performed with complete aseptic precautions . . .71 
 
 24. To .show the arrangement of towels, &c., in a large operation . . 72 
 2'>aMcth()(\ of tving vessels in dense tissues ...... 75 
 
xxii LIST OF ILLUSTRATIONS. 
 
 25/'.Anotlier method of tying vessels in dense tissues (from Esmarch) . 76 
 
 26. Ordinary oblique-ended drainage-tube ready for use . . . .77 
 
 27. Drainage-tube with masses of gauze in the loops of tliread . . 77 
 
 28. Incision for inguinal hernia, stitched, showing tlie position of the 
 
 drainage-tube at the outer angle of the wound . . . .78 
 
 20. Sinus forceps ^9 
 
 .30. Catgut drain ready for insertion 80 
 
 31. Operation for stretching the sciatic nerve 82 
 
 32. The same wound stitched 83 
 
 33. Method of preparing a horse-hair drain for re-introduction . . 84 
 3-1. Lead buttons for deep stitches 85 
 
 35. Wound after removal of mamma and axilliary glands, stitched . 86 
 
 36. Excision of the hip-joint 88 
 
 37. Dressing in a case of psoas abscess opened above Poupart's ligament 90 
 
 38. Method of changing a psoas abscess dressing 92 
 
 30. General arrangement of dressings on the neck . .... 97 
 
 40. To show the arrangement of the turns of bandage on the head, seen 
 
 from above 98 
 
 41 . Dres.sing applied in a case of abscess of tlie mamma (breast dressing 
 
 No. 1) 98 
 
 42. Breast dressing No. 2 98 
 
 43. Dressing after excision of the mamma 99 
 
 44. Dressings applied after excision of mamma and axillary glands, to 
 
 show the arrangement of the dressings and bandages . . . 100 
 
 45. Binder applied outside the dressing represented in tig. 44, so as to 
 
 keep the parts and dressing at rest ...... 101 
 
 46. Dressing in cases of operation on tlie axilla alone .... 102 
 
 47. Dressing in a case of psoas abscess opened above Poupart's ligament, 
 
 seen from the front 103 
 
 48. Psoas abscess dressing (fig. 47), seen from behind .... 104 
 
 49. Dressing in a case of lumbar abscess, seen from behind . . . 101 
 
 50. Dressing in a case of hip-joint abscess, with elastic api^lied . . 105 
 
 51. Deeper part of the hernia and scrotal dressings 106 
 
 52. Dressing in a case of operation for hernia, or on the scrotum on the 
 
 left side, showing the arrangement of the dressing and elastic 
 bandage 106 
 
 53. Dressing in hernia cases or in operations on the scrotum, showing 
 
 the arrangement of the bandages in the perineum. (Seen from 
 below) 107 
 
 54. Si^lint for excision of knee, read}' for application .... 108 
 
LIST OF ILLUSTRATIONS. xxiii 
 
 nr,. PAGE 
 
 5. Splint applied in a case of excision of the knee ..... 108 
 
 56. Two forms of sharp spoon.s, a large round one and a .small oval one . 117 
 
 57. Esmarch'.s first dressing for the wounded in battle (from MacCormac) 121: 
 
 58. Schulze's method of demonstrating that organisms are derived from 
 
 the air and do not originate spontaneou.sly in liquids . . . 150 
 
 59. Pouchet's mode of repeating Schulze's experiment (from Pouchet) . 156 
 
 60. Another mode adopted by Pouchet for testing Schulze's views (from 
 
 Pouchet) 156 
 
 61. A simple mode of repeating Schulze's experiments (from Pouchet) . 161 
 
 62. Pasteur's mode of introducing dust into flask containing calcined air 165 
 
 63. Another mode of repeating Schulze's experiment (from Pouchet) . 169 
 
 64. Bacillus subtilis ; without spores; with spores in the rods; free 
 
 spores; x 600 (after Cohn) ........ 180 
 
 65. Deposit in rennet, consisting of a mass of micrococci and spores of 
 
 bacilli, X 600 (after Cohn) 180 
 
 66. Dr. Roberts's experiment with alkaline fluids ..... 192 
 
 67. Torula cerevisiaj (after Pasteur) 210 
 
 68. Pasteur's experiment on unboiled grape juice ..... 210 
 
 69. Bacillus subtilis, x 650 (after Cohn) 212 
 
 70. Pigment producing organisms ........ 213 
 
 71. Bacterium lactis in pairs and chains . . . . . . .216 
 
 72. Flask containing cultivating fluid inoculated from a wound . . 231 
 
 73. Thiersch's ichampagne bottle irrigator . 273 
 
 7-1. Arrangement for irrigation in the upper limb (after Esmarch) . . 274 
 
 75. Arrangement for irrigation in the lower limb (after Esmarch) . . 275 
 
 76. Apparatus for continuous immersion (after Esmarch) . . . 275 
 
 77. Temperature chart from a case of operation for fracture of the 
 
 patella. (No. 21, p. 434) 421 
 
 Temperature charts of Mr. Lister's cases of wounds and operations 
 on joints (i.-xvii.) 438, 439 
 
 78. Temperature chart from a case of compound fracture in which the 
 
 attempt to eradicate the causes of fermentation was unsuccessful, 
 and which therefore became a septic case. (No. 26, p. 472) . . 463 
 
 79. Temperature chart from a case of compound fracture which followed 
 
 anasopticcour.se. (Case 23, p. 472) 4f,4 
 
 Temperature charts of Mr. Lister's cases of compound fracture 
 
 (xviil.-xxx.) 482, 483 
 
 Temperature charts of IMr. Lister's cases of compound fracture 
 
 (xxxi.-L.) 500, ,501 
 
 Temperature charts of cases of psoas and lumbar abscess (li.- 
 LXVli.) 534,535 
 
xxiv LIST OF ILLUSTRATIONS. 
 
 FIG. I'AGE 
 
 80. Temperature cliart. from a case of MacEvven's operation for double 
 
 genu vulgum ........... 576 
 
 81. Temperature chart from a case of compound fracture, in which there 
 
 was great difficulty in retaining the fragments in position. (Case 
 27, p. 472) 
 
 82. Temperature chart from a case where the ankle-joint was incised in a 
 
 hajmophilious patient, and where hfemorrhage recurred several 
 times. (Case 16, p. 430) 581 
 
 83. Temperature chart from the case of removal of loose cartilage from 
 
 the knee-joint, in which fermentation occurred. (Case 22, p. 434) 582 
 
 84. Temperature chart from a case of operation for recent fracture of the 
 
 patella. (Case 15, p. 430) 582 
 
 Temperature charts of septic cases 584 
 
 Temperature charts of aseptic cases 585 
 
ANTISEPTIC SUEGEEY. 
 
 CHAPTER I. 
 
 THE PARTICULATE THEORY OF FERMENTATION. 
 ON THE FERMENTATION OF BOILED SUBSTANCES. 
 
 Definition of putrefaction and fermentation — Chemical fermentations — Living 
 ferments — Various views on fermentation — Lavoisier — Fabroni — Thenard 
 — Appert — Gay-Lussac's experiments and conclusions — Caignard-Latour — 
 Schwann, heated air inert — Schulze — Ure and Helmholtz, nascent oxygen 
 inert — Liebig's views — Review of the subject — Schroeder and Dusch, 
 filtered air inert — Schroeder, ozone inert — Schroeder's final views — Pas- 
 teur's reseai'ches — Lister — Roberts — Tyndall — My own results, carbolised 
 air inert — Conclusions as to the cause of the fermentation of boiled sub- 
 stances. 
 
 The term ' septic ' so much used in surgery at the present day 
 is derived from the Greek word (X7]ittlkos, which means some- 
 thing that causes putrefaction, the verb (ji!]itw signifying to 
 cause to rot, to make putrid. An 'antiseptic' is therefore, 
 according to this derivation, something w^hich acts against the 
 causes of putrefaction, and ' Antiseptic Surgery ' is surgery 
 directed not against its effects but against its caitses. In deal- 
 ing, then, with the subject of antiseptic surgery, we must first 
 enquire what is putrefoction, and how is it brought about ? 
 
 Putrefaction is now held to be a form of fermentation ac- 
 companied by the development of offensive odours, and fermen- 
 tation may be defined as ' a new arrangement of the elements of 
 an organic compound (often with the assimilation of the ele- 
 ments of water), and the consequent formation of new products.' 
 (Fownes.) 
 
 Changes coming under the nbove definition of fermentation 
 
 B 
 
2 THE PARTICULATE THEORY OF FERMENTATION. 
 
 have been long known as the result of what is termed Catalysis. 
 Of this perhaps the best example is the change effected in 
 Amygdalin by the action on it of Emulsin. As a result of the 
 contact of these two bodies in presence of water, the amygdalin 
 is broken up into various products, of which the chief are 
 hydrocyanic acid and oil of bitter almonds. This decomposition 
 of amygdalin is, however, not effected by combination with 
 emulsin, for the latter remains unchanged, although its presence 
 is necessary for the chemical action. Similar fiicts are known 
 with regard to the Pepsin of the gastric juice, the Ptyalin of 
 saliva, the pancreatic ferment, &c. But although these ferments 
 undergo little or no change, yet nevertheless it has been clearly 
 proved that they have not the jwwer of self-multiplication. 
 Hence these ferments generally receive the name of ' chemical ' 
 ferments. 
 
 There is, however, another class of ferments which possess 
 this power of self-multiplication in a remarkable degree. An 
 instance of this may be given in the alcoholic fermentation. 
 Here a minute piece of yeast is introduced into grape juice, or 
 into a sugary solution, and as a result fermentation soon sets in, 
 and goes on slowly till the sugar is decomposed. If we compare 
 this process with the former we see two marked points of 
 difference ; in the first place, in the former the change is rapid 
 and more or less instantaneous; in the latter it progresses 
 slowly and steadily, and requires much more time for its com- 
 pletion. In the former there is no increase in quantity of the 
 ferment ; in the latter the increase is very marked, and when 
 the fermentation has gone on for some time the minutest 
 portion of the fermenting substance added to unfermented 
 material of like composition produces in it a similar series 
 of changes ; and this multiplication of the ferment goes on 
 continuously whenever it is brought in contact with fresh 
 material. As this power of multiplication is a property of living 
 things, the term ' vital ' is usually applied to this class of 
 ferments. 
 
 In one point the ' chemical ' ferment is allied to the ' vital ' 
 ferment. It is not a substance as yet formed by the "chemist. 
 It is the product of living cells ; and it is quite possible that 
 the yeast plant may act in the same way as the salivary or 
 
THE FERMENTATION OF BOILED SUBSTANCES. 3 
 
 peptic cells, viz. by excreting a ferment which produces the 
 change in the fermentescible substance, this ferment in neither 
 case possessing the power of self-multiplication. In the case of 
 the salivary ferment the cells which produce it are an integral 
 part of a complex organism, and cannot live apart from the body ; 
 hence the ptyalin, introduced into starch, does not increase in 
 amount. On the other hand, the yeast plant is an independent 
 cell, and grows free in the fermenting fluid, and it is to the 
 growth and multiplication of these living cells, and not to an 
 increase in quantity of the chemical ferment as such, that the 
 multiplication of the fermenting power is due. 
 
 In the putrefaction of discharges in wounds we have to deal 
 with a ferment belonging to the same class as the alcoholic fer- 
 ments — with a ferment capable of multiplication, which acts 
 slowly and steadily, not suddenly. We must therefore enquire 
 a little more fully into the nature of this class of ferments, into 
 theii- origin and history, in order to obtain some principles to 
 guide us in attempting to prevent their action. 
 
 In reviewing the history of this subject, the first research of 
 any consequence which it is necessary for us to consider is that 
 of Gay-Lussac* Previous to the publication of this paper at- 
 tempts had been made by Lavoisier, Fabroni, and Thenard 
 to give some explanation of the process of fermentation. 
 
 Lavoisier's work was in the main carried out with the view 
 of ascertaining the changes which a fermenting liquid under- 
 goes.^ He did not attempt to assign a definite cause for the 
 process. 
 
 Fabroni,^ writing on the subject of the alcoholic fermentation, 
 concluded that fermentation was a decomposition of one sub- 
 stance by another, 'just as a carbonate is decomposed by an 
 acid, or sugar by nitric acid. The substance which decomposes 
 sugar is a vegeto-animal substance. It is contained in certain 
 utricles in the grape. When the grape is crushed this material, 
 which is of the nature of gluten, mixes with the sugar in the 
 juice, and as soon as these two substances come into contact, 
 effervescence or fermentation commences just as occurs in every 
 
 • Annates de Cliinrie, Ixxvi. 1810. 
 ^ J'JUtiindit de CMmic, i. 2nd ed. 
 ^ Annalrs de Chimtr, xxxi. 1799. 
 
4 THE PARTICULATE THEORY OF FERMENTATION. 
 
 other chemical process, as, for instance, when an acid and a 
 carbonate are mixed in the same vessel.' 
 
 Some years later, but ignorant of Fabroni's views, 
 Thenard published a research on alcoholic fermentation,' in 
 which he showed that gluten had no power whatever of causing 
 the fermentation of sugar. He observed that during the pro- 
 cess of fermentation, a deposit occurred which had the power 
 of inducing a similar change in a fresh saccharine liquid. This 
 substance was apparently the same in a great variety of liquids 
 of different chemical composition, and it presented characters 
 similar to those of yeast. Thenard states that he was unable 
 to determine whether this substance was formed in the course 
 of the fermentation, or whether it was in solution at the com- 
 mencement and became deposited as a result of the changes 
 which occurred. He, however, inclines towards the latter 
 view. 
 
 Gay-Lussac was led to make his investigations by studying 
 the procedure of M. Appert for preserving vegetable and animal 
 substances.^ Appert's method consisted in placing the materials 
 to be preserved in bottles, very closely corked. These bottles 
 were exposed to the temperature of boiling water for a longer 
 or shorter period of time. They were then packed up and kept 
 for use. There can be no doubt as to the efficiency of this 
 method, for in Appert's work certificates are furnished by 
 several scientific commissions, containing such names as Gay- 
 Lussac, Bordel, &c. 
 
 Gay-Lussac noticed that, though the sul^stances so prepared 
 could be preserved unaltered for an indefinite period so long 
 as the vessels were kept thoroughly closed, yet, as soon as 
 the vessels were opened, and more especially if the substances 
 were decanted into other vessels, their contents underwent 
 fermentative changes. 
 
 To ascertain why this occurred, he took a flask of grape-juice 
 which had been preserved for a year unaltered, and which was ac- 
 cordingly quite limpid. Having opened the flask he poured its 
 contents into another vessel, which he closed very accurately 
 and kept at the temperature of 15° to 30° C. Eight days later 
 
 ' Atuudcs de ChhnU; xlvi. ISOiJ. 
 
 ^ The Art of Preserving Animal and Vegctuhlc Suhstanees. 
 
GAY-LVSSACS EXPERIMENTS. 5 
 
 the juice had lost its transparency, fermentation had become 
 established, and it soon became an alcoholic fluid. A second 
 vessel containing gi'ape-juice, prepared by Appert's method, 
 was kept at the same temperatm-e and in the same place, but 
 unopened. This remained pure. This latter flask, the neck of 
 which had been drawn out and sealed, was now taken, and 
 a deep notch having been made with a file, its neck was 
 plunged into mercury and then broken off. A portion of 
 the contents was then introduced into a bell-jar containing no 
 oxygen, and a second portion into one containing a small quan- 
 tity of that gas. The first remained without change for forty 
 days, while the second underwent fermentation very rapidly. 
 In the latter flask all the oxygen had disappeared, but much 
 more carbonic acid in proportion had been produced. Gay- 
 Lussac therefore concluded that, although oxygen is necessary 
 to initiate the fermentation, yet it is not essential for its con- 
 tinuance. The same results were obtained when currant-juice 
 or freshly prepared gi'ape-juice were used. Gay-Lussac further 
 found that, if this juice after being transferred from one vessel 
 to another were again heated after secure corking, it could 
 again be preserved for an indefinite time. He observed that 
 during the boiling the fluid lost its transparency and a deposit 
 took place. He came to similar conclusions as to the necessity 
 of oxygen for the initiation of fermentative processes, in the case 
 of the putrefaction of meats, &c., preserved according to Appert's 
 method, 
 
 Gay-Lussac concludes from his experiments that oxygen is 
 necessary for the commencement of the fermentation ; that 
 this oxygen combines with some substance in the fermentescible 
 fluid, thus producing the ferment, which can then act without 
 further oxygen ; that the effect of the heat in Appert's method 
 is to decompose any combination already formed, and to make 
 the oxygen which is present unite to form some substance which 
 is not a ferment ; that the product of this union with oxygen 
 is the deposit which is seen to occur on heating these fluids. 
 1 [e however recognises that fermentation is still a mysterious 
 process, since it occurs slowly and not immediately like other 
 chemical actions. 
 
 Passing now over a period of some years, we come to the 
 
G THE PARTICULATE THEORY OF FERMENTATION. 
 
 views of Caiguard-Latour, made known in papers presented to 
 the French Academy dming the years 1835-37.' On examin- 
 ing fermenting grape-juice, he found (as indeed had been im- 
 perfectly observed before by Leuwenhoeck and Desmazieres) 
 that it contained numerous globular bodies which he considered 
 to be of vegetable nature, and which he found to possess the 
 power of reproduction, partly by budding and partly, as he sup- 
 posed, by contracting and liberating numerous spores. From 
 several facts — amongst others, from finding that in juices not 
 undergoing alcoholic fermentation these bodies were absent, 
 while they were always present where that fermentation oc- 
 curred — he concluded that they were the cause of the fermenta- 
 tion. He fm-ther found that the de})Osit of which Thenard 
 spoke, and which he had stated to be the ferment, was composed 
 entirely of these bodies. 
 
 Similar views were announced almost simultaheously by 
 Schwann,'-* and to him rather than to Caignard-Latour must be 
 given the credit of having furnished the first real proof of the 
 view that these cells were the causes of the fermentation. 
 
 Schwann prepared infusions of meat, fruits, &c., somewhat 
 after Appert's method, but, instead of leaving the vessels com- 
 pletely sealed, he allowed air which had been previously heated 
 to come in contact with the fluids. The following is his de- 
 scription of the method which he ultimately adopted. 
 
 ' Into a three-ounce vessel a small piece of meat was introduced, 
 and then water was added so that the whole occupied about one- 
 fourth of the capacity of the vessel ; the bottle was then closely corked, 
 the cork being firmly fastened down by wire. This cork was traversed 
 by two small glass tubes, one of which was at once bent downwards 
 on its exit from the vessel, and its orifice dipped into a small beaker 
 containing mercury covei-ed by a layer of oil. The other tube ran at 
 first horizontally and then directly downwards for an inch and a half. 
 There it had two narrow spiral turnings, then it again ran upwards, 
 and finally horizontally, being di'awn out to a fine point at its termi- 
 nation. The cork was covered with several layers of a solution of 
 caoutchouc in linseed oil, rendered thinner by the addition of oil of 
 turpentine. The fluid in the flask was now boiled, and the steam was 
 made to issue from the two tubes till the mercury and oil became so 
 
 ■ See Annales de CMmie ct de Ph unique, t. Ixviii. 2" seric, 1838. 
 * Pofjgendorf's Annalen, xli. 1837. 
 
SCHWANN'S EXPERIMENTS. 
 
 hot that they no longer condensed the steam. (In order that no 
 organisms might develop in the water which remained between the 
 oil and the mercury, a layer of corrosive sublimate was placed between 
 them.) While the boiling was going on a spirit lamp was placed 
 under the spirals of the second tube, and the heat was continued until 
 the tube began to soften (see Fig. 1). Thedropaof water condensing 
 in the cooler parts of the tubes were dispelled by another lamp. After 
 boiling bad continued for a quarter of an hour it was stopped, and, 
 during the cooling of the flask, air passed through the second glass 
 tube into the vessel, being however j^reviously heated in the spiral 
 part of that tube. After complete cooling of the flask the orifice of 
 this tube was sealed and the portion of the tube between the spiral 
 and the end, containing unheated air, was heated. That being done 
 the spirit lamp was completely removed.' 
 
 Fig. 1. — Schwann's mkthod. 
 
 Prepared in this way, the flask contained only boiled meat 
 infusion and heated air. From time to time this air was 
 renewed in the following manner : the spiral part of the tube 
 having been heated almost to melting, the point was broken 
 and fresh air forced slowly in, the old air bubbling out through 
 the mercury. After a time the tube was again sealed with the 
 same precautions as before. 
 
 By operating thus Schwann succeeded in preserving meat 
 and other substances at a temperature of 63° to 77° F. without 
 any putrefaction, and without the appearance of organisms in 
 them ; while the same materials when exposed to ordinary air 
 underwent putrefactive changes in a few days. 
 
8 THE PARTICULATE THEORY OF FERMENTATION. 
 
 It was thus evident that there was a something present in 
 the air, other than the gases of the air which had the power of 
 bringing about fermentative changes in boiled liquids, and 
 that this something could be destroyed by heat. 
 
 Some -further experiments which Schwann performed with 
 reference to the alcoholic fermentation furnish additional 
 evidence against the view that the gases of the air are the causes 
 of putrefaction. 
 
 A solution of cane sugar having been mixed with yeast, four flasks 
 were quite filled with the mixture and then corked. These flasks 
 were placed in boihng water for an equal length of time (ten minutes 
 each). They were then inverted over heated mercury, and air was 
 introduced so as to displace one-third to one-fourth of the fluid. The 
 flasks were afterwards corked under mercury and kept at a tempera- 
 ture of 63° to 77° F. In two flasks the air thus introduced bad been 
 previously heated, in the other two it had not been so treated. In 
 four to six weeks the flasks which had received the unheated air 
 burst, their contents having undergone alcoholic fermentation. The 
 other two flasks remained unchanged for more than three months. 
 
 Schwann states that this latter experiment with heated air 
 is generally, but not always, successful, and he explains this by 
 the supposition that after the heating of the mercury, and in 
 the processes of uncorking and corking, organic matter, which 
 had not been previously heated, might very possibly mix with 
 the mercury and enter the flasks. (This view has since been 
 proved to be correct by Pasteur.) 
 
 It is but fair to refer here to the experiments on spontaneous 
 generation published in 1836 by Franz Schulze. These will 
 be described at a later period. They are, however, of interest 
 here, because Schulze anticipated Schwann in the principle of 
 admitting air previously acted on "in some way or other, in 
 his case chemically, to Appert's preserves. 
 
 Schwann's experiments were repeated and confirmed by Ure 
 in 1840 1 and by Helmholtz in 1843.^ The latter author, in 
 order to test the oxygen view still further, prepared an infusion 
 in the usual manner in a vessel into which platinum electrodes 
 were fixed. After the infusion had remained unaltered for some 
 
 ' Journal fiir pralttischc Chemic, xix. 
 ^ Mailer's Archir. 1843. 
 
LIEBICrS VIEWS. 9 
 
 time a current of electricity was sent through the liquid, 
 decomposing the water into hydrogen and oxygen. But even 
 this oxygen in its nascent, and therefore in its most active state, 
 was unable to produce any fermentation in the fluid. 
 
 In the meantime Liebig had stepped forward as the oppo- 
 nent of the views advanced by Caignard-Latour and by Schwann. 
 He proposed a theory of a totally different nature.^ After 
 pointing out that organic molecules have a tendency to alter 
 their constitution, to break up and rearrange themselves, 
 he approacVies the question of putrefaction and fermentation. 
 With regard to the cause of these changes he writes as follows : 
 ' Cette cause est la faculte que possede un corps en decomposi- 
 tion ou en combinaison, c'est-a-dire, en action chimique, d'eveiller 
 la meme action dans un autre corps qui se trouve en contact 
 avec lui, ou de le rendre apte a subir I'alteration qu'il eprouve 
 lui-meme.' He compares this sort of action to combustion, and 
 cites several well-known instances of this kind, such as the de- 
 composition of nitric acid by an alloy of platinum and silver, 
 a change which does not take place with the platinum alone ; 
 or the decomposition of peroxide of manganese by oxide of 
 silver, &e., in water containing oxygen. 
 
 He includes under the term ' eremacausis,' the alterations 
 which organic substances undergo at ordinary temperatures, 
 and as the result of the action of oxygen. When oxygen is 
 excluded, putrefaction occurs. Putrefaction is a combustion 
 of one or more of the elements of the organic substances at 
 the expense of their own oxygen. Where no foul smelling 
 products result, the process is termed fermentation. Putrefac- 
 tion occurs when the equilibrium of the attractions of a complex 
 organic molecule is upset, and it results in a rearrangement of 
 these elements. Non-nitrogenous organic substances do not 
 imdergo this putrefaction spontaneously when they are pure. 
 They must be brought in contact with some substance already 
 undergoing change. This latter substance is therefore termed 
 a ferment. This ferment is a nitrogenous substance under- 
 going putrefaction and eremacausis, it converts the oxygen of 
 the air into carbonic acid, &c. Its activity is destroyed by 
 desiccation, by heat, alcohol, &c. It is the soluble portion of 
 ' Annalex de Chimir ct de Physitpw, 2« serie, Ixxi. 1831). 
 
10 THE PARTICULATE THEORY OF FERMENTATION, 
 
 the ferment which is active, and this does not act by direct 
 contact, but in consequence of a decomposition which it itself 
 undergoes. The elements of the ferment take no part in the 
 formation of the products which sugar furnishes when fer- 
 mented, though at the same time the ferment is itself under- 
 going destruction. (This latter statement is based on an ob- 
 servation by Thenard, who found that 20 parts of fresh yeast, 
 added to 100 parts of sugar left, after fermentation was com- 
 plete, only '13*7 parts of an insoluble residue. This residue 
 placed in a new portion of sugar became reduced to 10 parts. 
 This last residue no longer exerted any action. Pasteur has 
 since completely disproved the accru-acy of Thenard's results. 
 On the contrary he iinds that yeast increases markedly 
 during fermentation, and in his latest work Liebig admits 
 this.) 
 
 The ferment is, therefore, according to Liebig, a body 
 undergoing decomposition. If the ferment is too small in 
 quantity for the sugar, when the decomposition of the former is 
 complete the latter ceases to ferment (this statement has since 
 been shown to be quite erroneous), and therefore a sufficient 
 quantity must be present in order that its decomposition may 
 not be completed till that of the sugar has ended. No special 
 substance is, according to this view, required in order to act as 
 a ferment, but merely one which shall be the constant exciter 
 of action in the fermentescible substance. (This statement is 
 also wrong, because putrefying fluids and tissues added to 
 sugary solutions do not convert the sugar into alcohol. This 
 was latterly admitted by Liebig, who was compelled to allow 
 the existence of some relation between the yeast plant and the 
 alcoholic fermentation, a connection which he, however, 
 attributed to the effect propagated from the dead and dying, 
 not from the living, cells.) 
 
 Liebig sums up as follows : — 
 
 Organic compounds present two opposite and definite 
 phenomena. 
 
 1. They give rise to bodies endowed with new properties, 
 the elements of several molecules of a more simple compound 
 uniting to form one molecule of a more com^ilex nature. 
 
 2. Some complex molecules of a high degree of complexity 
 
LIEBIG'S VIEWS. 11 
 
 break up into one or more less complex molecules of a lower 
 order, in consequence of the destruction of the equilibrium of 
 the attractions of their elements. This equilibrium may be 
 destroyed by heat, by contact with a body of different compo- 
 sition, or by the action of a body which is itself undergoing 
 change. 
 
 As an example of this Liebig takes the case of urine : ' In 
 fresh urine,' he says, ' if oxygen be entirely excluded there 
 occiu-s no alteration of the urea or of the hippuric acid con- 
 tained in it, but if exposed to the air another substance present 
 in the urine (probably the mucus) undergoes a change of form 
 and composition (eremacausis), which is transferred or com- 
 municated to the urea and the hippuric acid ; the urea is 
 resolved into carbonic acid and ammonia; the hippuric acid 
 disappears, and in its place is found benzoic acid,' 
 
 He continues : ' When we reflect that the power of exciting 
 putrefaction belongs to bodies of the most different composition, 
 that blood, flesh, cheese, saliva, infusion of malt, emulsion of 
 almonds, &c., acquire this property as soon as, by the chemical 
 action of oxygen, a disturbance in the equilibrium of the 
 attraction of their elements has taken place, all doubt as to 
 the true cause of these phenomena seems to disappear.' (We 
 shall see later that in this Liebig is wrong, that meat, cheese, 
 &c., cause putrefaction not from any inherent tendency to do 
 so or from any state of decay, but because they introduce the 
 necessary particles into the putrescible liquid.) 
 
 Liebig then goes on to say, with reference to the germ 
 theory of putrefaction, that after the death of fungi and in- 
 fusoria we observe the same putrefactive phenomena as after 
 the death of a larger animal. These organisms, according to 
 him, only appear at a late period of putrefaction, and therefore 
 are not the cause of it, though no doubt by their vital actions 
 they must hasten and modify the change. 
 
 And now let us pause in the history of this important sub- 
 ject, aud methodise somewhat the views expressed. These may 
 be divided into three sets. Firstly, we have that of Gay- 
 Lussac, who attributes putrefactive and fermentative changes 
 solely to the influence of oxygen in the flrst instance. 
 
12 THE PARTICULATE THEORY OF FERMENTATION. 
 
 Then come the views of Caignard-Latour and Schwann, 
 refeiTing these changes to the entrance into the fluids of solid 
 particles from without, which may be destroyed by heat. These 
 authors go further, and ascribe the whole fermentative process 
 to the growth of the organisms which are found in the ferment- 
 ing liquids. 
 
 And, lastly, we have the view of Liebig, who looks on oxy- 
 gen as in so far favouring fermentation that it causes erema- 
 causis, the molecules undergoing this change being now capable 
 of setting up putrefactive and other fermentative changes. 
 The latter changes are therefore due to the presence of some 
 substance itself undergoing change, and to this substance the 
 term ' ferment ' is applied. This ferment may be destroyed 
 by heat. 
 
 It will be more convenient if for the present we class these 
 views under two heads — the oxygen theory (Gay-Lussac's) on 
 the one hand, and the particulate theory (Schwann's) on the 
 other. At a later period we shall determine whether Liebig's 
 or Schwann's is the more tenable view. 
 
 I have already mentioned the researches of Schulze, Schwann, 
 Ure, and Helmholtz as tending more or less to upset the views 
 of Gay-Lussac. 
 
 The next research of importance on this subject is that by 
 Schroeder and Dusch.' Their aim was to see \N]\eihex jiltraiion 
 of the air would be sufficient to prevent the fermentation of 
 boiled fluids. Their apparatus was the following : — 
 
 A glass vessel containing the material to be tested (meat infvision, 
 &c.,) was closed by a close-fitting cork, which was dipped into hot wax 
 previous to its insertion. This cork had two holes in it wliich gave 
 exit to two tubes bent outside to a right angle, these tubes being also 
 firmly embedded in the cork ; one tube was for the purpose of con- 
 ducting air to the vessel, and the other to suck air out of it. 
 
 The conducting tube was connected by means of a short piece of 
 vulcanised caoutchouc with a glass tube ; the latter was again attached 
 to a wider tube (1 inch in diameter and 20 inches long) by means of 
 a similar cork to that in the bottle, and at the other end of this tube 
 was a cork with a bit of tubing in it, called the open tube. The wide 
 
 ' Annalen dcr Chcmic tind Pharmacic, 1854. 
 
SCHROEDER AND DUSCH. 
 
 13 
 
 tube was loosely filled with cotton wool which had been pi-eviously 
 heated for some time in a water bath. 
 
 The other tube — the suction tube — which in the interior of the 
 flask reached almost to the level of the fluid, was connected by means 
 of a vulcanised india-rubber tube with the upper tube of an ordinary 
 gasometer, this latter tube being provi<led with a stop-cock. The 
 gasometer was filled with water, and on opening the lower tube of 
 this vessel the water flowed out and thus the gasometer acted as an 
 aspirator. (See Fig. '1.) 
 
 Such was the apparatus employed. The fluid having been 
 introduced into the flask, and all the connections having been 
 
 Fig. 2.— Scheoedee akd Dusch's appaeatus foe supplying 
 filtered aie. 
 
 (Till; tulic to tlic left ought to rcacli almost to the level of the liquid.) 
 
 ascertained to be air-tight, the cock of the aspirator was shut 
 and the substance to be tested was boiled, till all the tubes as 
 far as the cotton wool had been thoroughly heated ; then, the 
 joinings having been again examined, the aspirator was so 
 arranged that water flowed out of it drop by dro}), and thus 
 sucked air slowly through the flask. 
 
 Meat, boiled in water and ke2)t in a flask of this kind with 
 constant change of air, was preserved for twenty-three days, and 
 wlicji tested at the end of that time was found to lie quite un- 
 altered, vvliile a similar infusion left exposed to ordinary air liad 
 to be removed fioni the laboratory during the second week on 
 
14 THE PARTICULATE THEORY OF FERMENTATION. 
 
 account of its intolerable stench. This experiment was repeated 
 several times with similar results. 
 
 Schroeder and Dusch experimented in a similar manner 
 with fresh sweet malt containing hops. After twenty-three days, 
 the fluid being still unaltered, the cotton wool was removed, but 
 the introduction of air — now unfiltered — was continued. The 
 fluid was muddy and covered with fimgi, and had undergone 
 fermentation in a week. 
 
 These observers were, however, unable to obtain like results 
 with milk, or with meat heated without the addition of water. 
 These substances invariably underwent putrefaction. 
 
 In a paper published five years later Schroeder returns to 
 this subject.' Having found that white of egg mixed with 
 water, if constantly shaken while boiling, could be preserved for 
 an indefinite time, he tried whether ozone had any power in 
 inducing fermentation. Dilute sulphuric acid was decomposed 
 by electricity, and the ozone thus generated was conducted into 
 a vessel containing pure white of egg. The latter was kept for 
 thirty-eight days, and was at the end of that time unaltered. 
 
 Schroeder was still unable to succeed with milk or yolk of 
 egg, although the latter, if previously heated in a closed vessel 
 in an oil bath to 160° C. (310° F.) generally remained un- 
 changed, and the milk sometimes also kept pm^e. 
 
 The special constituents of milk could be easily preserved. 
 He tested casein prepared by precipitation with acetic acid and 
 then washing with water. The whey also which remained after 
 this precipitation could be preserved with ease. When this 
 whey was boiled a deposit occurred, and this was readily kept 
 pure ; and the whey which still remained did not ferment 
 when preserved with the precautions mentioned. 
 
 Schroeder tried and succeeded with other materials, such as 
 blood, urine, starch, &c. 
 
 The only substances which failed were milk, yolk of egg, 
 meat heated without addition of water, and occasionally meat 
 infusion. 
 
 As the result of these contradictory experiments he came 
 to the conclusion that there were two ways in which fermenta- 
 tion might be caused ; firstly, by some solid particle which 
 ' Annalcii der Chcmic zoid PJiarviacie, cix. 1859. 
 
SCHROEDER'S VIEWS. 15 
 
 can be arrested by cotton wool, and, secondly, by oxygen gas 
 (in the case of milk, yolk of e^g., &c.). 
 
 Two years later there appeared another j)aper by Schroeder 
 referring to those substances which he had previously failed to 
 preserve, and in this research he has recoiu-se to the use of 
 higher temperatures than formerly-' 
 
 Yolk of egg, after being heated for half an hour in a closed 
 glass vessel, at a temperature of 130° C. (266° F.), was placed 
 in a flask the neck of which was stuffed when hot with cotton 
 wool, and was again boiled with a little water. This remained 
 for seventy days unchanged. 
 
 He succeeded in a similar manner with meat and milk, and 
 in the case of the latter he found that prolonged boiling at 
 100° C. was sufficient. 
 
 From these facts he gives up his formerly expressed view as 
 to the spontaneous fermentation of organic substances under 
 the influence of oxygen, and concludes that in these fluids 
 spores were present which could resist a boiling temperature, 
 the development of these spores being, according to him, the 
 cause of the fermentation. He further considers that these 
 spores were present originally in the milk, and were not intro- 
 duced from the air, because he finds that milk which has not 
 been Iwiled at all putrefies sooner than pure boiled milk 
 exposed to the air. 
 
 It may be interesting to mention here that similar difficul- 
 ties were experienced by Appert in his attempts to preserve 
 milk. He succeeded by the following method : ' Condense the 
 milk to two-thirds of its volume, strain it, then put it in the 
 bottle, seal and boil in a water bath for two hours.' In order 
 to prevent the cream from separating he found it well to add 
 yolk of Qgg. This did not increase the difficulty in preserving it. 
 
 Still fmlher evidence disproving the gaseous theory is fur- 
 nished by Pasteur.^ He repeated Schwann's exiDeriments and 
 was successful with most fluids, but for a time he failed in the 
 case of milk. He, however, succeeded when he boiled the milk 
 under pressure at 110° C. (2.30° F.) for one or two minutes, 
 heated air l)eing then allowed to come in contact with it ; and 
 
 ' Aimalcti dvr Chemie nnd I'karmacie, cxvii. 1801. 
 
 - Annalcs dcg Sciences NaUircllcs, scrie iv. t. xvi. 18G1 : Zaolofjic 
 
16 THE PARTICULATE THEORY OF FERMENTATION. 
 
 he also succeeded if he subjected the milk to prolonged boiling 
 at 100° C. Such milk remains unaltered for an indefinite 
 length of time, but it readily decomposes if unheated dust be 
 introduced into it in the manner to be afterwards described. 
 
 The most striking of Pasteur's experiments is that of the 
 flask with the bent neck. A flask containing, say, yeast water is 
 heated so as to render its contents pure. Its neck is drawn out 
 and bent, and then, after boiling, the lamp is simply with- 
 
 FiG. 3. — Pasteur's flask with the bent neck. 
 
 (From Pasteur.) 
 
 drawn, the neck being neither heated, sealed, nor plugged 
 (Fig. 3). Nevertheless the fluid does not undergo any change. 
 
 If, on the other hand, the neck of this flask be sealed 
 during ebullition, a more or less perfect vacuum is thus pro- 
 duced, and then, if the neck be broken after cooling, air rushes 
 violently into the flask, carrying with it its dust. The result 
 is that fermentative changes occur in the fluid. In the same 
 way, if one of the flasks with open necks, the contents of 
 which have remained for some time pure, has the neck broken 
 off short, the fluid in its interior rapidly undergoes fermenta- 
 tion ; or again, if the neck be not bent but be kept straight, so 
 as to allow dust to fall in, fermentation rapidly occurs. 
 
 The explanation of these results is that in the case of the 
 flask with the long neck the dust is caught in the curve, which 
 in the first inrush of air is filled with water, which filters the 
 air (Mr. Lister's view). Pasteur had supposed that part of 
 the air dust entered the vessel instantly, but that the fluid and 
 the walls of the flask were at that time so hot that any living 
 particles present were immediately destroyed. 
 
 As will be seen further on. Pastern- also found that it was 
 
TYNDALL. LISTER. 17 
 
 not necessary to filter the air of its dust, but that if the air were 
 merely left undisturbed for some time till the dust settled, it 
 might then be introduced into flasks without causing any 
 development. 
 
 These experiments have been repeated by various observers 
 with success, and Mr. Lister has at present in his possession a 
 flask of this kind containing urine which is now thirteen years 
 old, but which still remains unaltered and as limpid as on the 
 day it was prepared. 
 
 In a lecture on Haze and Dust,^ Professor Tyndall showed 
 that if no dust were present in a flask, a beam of condensed 
 light passed through the vessel in a dark room would only be 
 visible on each side of it, but would be invisible in its interior ; 
 in other words, we see light only because there are particles in 
 the air which render it visible. Were there no particles all 
 would be darkness. 
 
 Such being the case, Tyndall found that when the air 
 which was admitted to a flask had been previously heated, as 
 in Schwann's experiment, the beam of light was not visible in 
 the interior, showing that all or almost all the particles had 
 been destroyed by heat, or, in other words, were in the main of 
 an organic nature. By the same method Mr. Lister has found 
 that in Pasteur's flasks with the long open necks, no floating 
 dust is present after what was originally there has settled. 
 
 Another method of excluding dust was published in 1873 
 by Mr. Lister.^ It seemed probable that the occasional failures 
 which occurred in the attempts to preserve boiled fluids arose 
 from the fact that the steam did not destroy the septic energy of 
 the dust in the necks of the flasks which had not been previously 
 heated. Mr. Lister, therefore, in addition to the precautions as to 
 boiling under cotton-wool caps, &c., subjected his flasks to a high 
 temperature previous to the introduction of the fluid. This is 
 done by keeping them, after the cotton cap has been applied, 
 in an iron box, which is kept at a high temperature for two 
 hours. 
 
 This box is of a square form, with one of its sides movable so as 
 
 ' Nature, Jan. 27, 1870. 
 
 ' Microseojncal Journal iox October 1873; see also Tratix. of Path. Society 
 of London, vol. xxvii. 1878. 
 
 C 
 
18 THE PARTICULATE THEORY OF FERMEXTATIOK 
 
 to form a door. ' This door has its circumferential part in tbe form of 
 a groove capable of being packed with a considerable mass of cotton 
 wool (Fig. 4, f). This door can be secured by means of nuts against the 
 
 edge of the box ; and the cotton wool, 
 having the narrow rim of metal thus 
 firmly pressed against it, serves as an 
 effectual filter of the air that passes in 
 during cooling. But then it is essen- 
 tial that the heat be so equally distri- 
 buted as to avoid heating any portion 
 of the cotton to such a degree as to 
 destroy its physical properties. This 
 uniformity of heat is provided foi- by 
 having three shelves of sheet iron inter- 
 posed between the large Bunsen's burner and the bottom of the box, 
 no as to prevent the heat from acting directly upon it, while at the 
 
 Fig. 4. — Door of 
 Lister's box. 
 
 Mr. 
 
 Fig. 5.— Mr. Lister's hot box. 
 
 same time the box is covered over with a cover of sheet iron (Fig. 5, k), 
 which reaches nearly to the ground, and, while it checks radiation, 
 compels the heated air to ti-avel over the whole exterior of the box 
 
MR. LISTER'S EXPERIMENTS. 
 
 19 
 
 and escape by holes at the top of the cover, whence it is conducted 
 into a chimney by a tube (l). By these two means combined, the 
 shelves below and the cover round about, we get a uniform browning 
 of the cotton. Into such a box the requisite number of vessels are 
 introduced (Fig. 5). An aperture in the top of the box well packed 
 with cotton wool transmits a thermometer (m), to show us when the 
 temperature of 300° F. has been reached, and when this, or any other 
 higher degree short of 350"- F., 
 has been continued for two 
 hours, the gas is turned off 
 and cooling is allowed to take 
 place ; and when the apparatus 
 is quite cool, the covered glasses 
 may be removed with confi- 
 dence that they are perfectly 
 free from living organisms.' 
 
 In this manner Mr. Lister 
 purifies his flasks. The larger 
 flasks have two necks, a large 
 vertical one and a lateral one, 
 which is a bent spout, large at 
 its commencement and com- 
 paratively narrow at its shorter 
 terminal part beyond the bend 
 (Fig. 6, o). The large size of 
 the first part prevents it from acting as a siphon, and the result is 
 that when the liqrdd is poured from such a flask and the vessel is 
 afterwards restored to the erect position, the end of the nozzle remains 
 filled with a drop of the liquid, and this guards the orifice so that 
 regurgitation of air can never take place thiough the nozzle. This 
 drop of fluid being sucked away by means of a carbolised rag, a pure 
 cotton cap is tied over the orifice, and the flask is kept for future use. 
 This flask, purified by heat and with each orifice covered with 
 pure cotton caps, is used for the experiments (see Fig. 7). The fluid 
 to be tested is introduced into it by means of a siphon, consisting of 
 two glass tubes (s and T)connected by a tube of india-rubber (u), with 
 a stop-cock (v) in the course of the india-rubber tubing. The siphon 
 is first completely filled with water, the tenqjerature of which should 
 be higher than that of the air, so that there is no dissolved air given 
 off to form bubbles. Place one leg of the siphon in the vessel contain- 
 ing the fluid to be used (w), then turn the tap and permit a sufficient 
 amount of fluid to flow out to ensure that all the water has escaped 
 from the siphon ; then turn off the stop-cock, wash the outside of 
 
 c 2 
 
 Fig. 6.— Mr. Lister's large 
 double-necked flasks. 
 
20 THE PARTICULATE THEOBY OF FERMENTATION. 
 
 the tube (t) with carbolic lotion, wrap a mass of carbolised rag (y) 
 around its lower extremity, and apply this to the mouth of the flask 
 (x) as soon as the cottou cap is removed, push the tube steadily 
 down to the bottom of the flask through the carbolised rag, turn 
 the stop-cock, and let the required amount of fluid flow into the flask 
 (Fig. 7). When this has taken place the tap is again turned off", the 
 
 Fig. 7. — Method op filling the flasks. 
 
 siphon is withdrawn through the antiseptic rag, and a fresh cap of 
 carbolised cotton (the cotton is carbolised by being soaked in a solu- 
 tion of one part of crystallised cai-bolic acid in one hundred parts 
 of anhydrous ether and allowed to dry) is tied over the mouth of 
 the flask when the rag is withdrawn. The fluid is now heated for 
 the desired length of time, and then abandoned under the protection 
 of the caps. 
 
 In this way Mr. Lister has found that he can preserve 
 turnip infusion, hay infusion, urine, fresh milk, &c., for any 
 length of time without any alteration taking place. To pre- 
 serve milk, the flask containing it is immersed in boiling water 
 for half an hour or more. 
 
MR. LISTER'S EXPERIMENTS. 
 
 21 
 
 Fig. 8. 
 
 But this is not all, for these fluids can be transfen-ed to 
 smaller vessels without undergoing any fermentation after this 
 transfen-ence. This is done as follows : a liqueur glass (a) is 
 covered by a glass cap (b) (watch glass), and the whole by a 
 glass shade (c), the liqueur glass 
 and the shade standing on a glass 
 plate (see Fig. 8). This an-ange- 
 ment is introduced into the hot 
 box and thoroughly purified. 
 Thus we have a pm-e glass filled 
 with pure air, and the problem 
 is to transfer the fluid from the 
 flask to the glass without con- 
 tamination in the process. To 
 
 do this, the cotton cap is removed from the nozzle of the flask 
 (Fig. 7, z) and the end of this is instantly slipped into an 
 opening in the centre of half an india-rubber ball (Fig. 9, r) 
 previously steeped in a strong watery solution of carbolic acid. 
 The outer glass shade is then removed, and the watch glass 
 being lifted, the india-rubber cap is instantly applied in its 
 place (see Fig. 9). The required quantity of fluid is then poured 
 into the glass, and the cap and shade 
 immediately reapplied. A fresh cotton 
 cap is now tied over the nozzle of the 
 flask. In this manner any number of 
 glasses may be charged, and these are 
 found to remain as piue and unaltered 
 as the fluid in the original flask. 
 
 And now observe what such experi- 
 ments teach. In the first place, into 
 the original flask, when cooling, air 
 enters, but this air having passed 
 through a cotton-wool plug is incapable 
 of causing putrefaction. Then in the 
 
 decanting of this liquid from the flask, fresh air must enter 
 through the large mouth of the flask, but as this passes through 
 a filter of cotton wool it is in like manner incapable of causing 
 fermentation. Further the liqueur glasses are full of air, which 
 lias either been previously heated, or which has been filtered 
 
 Fig. 9. 
 
22 THE PARTICULATE THEORY OF FERMENTATION. 
 
 through tlie cotton wool around the door of the hot box. The 
 fluid when poured from the flask into the glass mixes freely 
 with this air, but no change is set up. And, lastly, the loosely- 
 fitting glass cap and shade allow a free interchange of air, but 
 are so placed as to make sure that the air dejDosits its dust 
 outside the glass, thus corresponding in action to Pasteur's flasks 
 with the bent necks. In spite of all these opportunities of 
 admixture with the gases of the air, all sorts of fluids remain 
 unaltered, while, on the other hand, the same liquids exposed 
 freely to unfiltered air rapidly undergo fermentative changes. 
 
 These experiments are of themselves an absolute proof that 
 the gases of the air alone are unable to cause fermentative 
 changes in organic substances. 
 
 In 1874 Dr. Eoberts ' demonstrated again that fresh milk 
 and other substances could be prevented from putrefying if 
 kept in a flask with a cotton-wool plug after having been pre- 
 viously boiled. 
 
 His method was as follows : An ordinary delivery pipette, having 
 on it an oblong bulb capable of containing 30-50 cc, was sealed at one 
 end, and the materials to be experimented on were then introduced 
 into the bulb until it was two-thirds full (Fig. 10, a). The inside 
 of the neck of the bulb was next wiped dry, and a plug of cotton 
 wool was inserted about its middle. Lastly, the neck was drawn 
 out above the plug and sealed in the flame (Fig. 10, b). 
 
 When the bulb Avas thus charged and sealed it was weighted with 
 a leaden collar, and submerged in tbe upright position (so as to pre- 
 vent the wetting of the cotton-wool plug) in a can full of water. 
 The can was placed over a soiirce of heat and boiled for the re- 
 quired time. The bulb was then withdrawn and, when quite cold, 
 its neck was filed off above the cotton-wool plug (Fig. 10, c). 
 Finally it was set aside in the upright position and maintained at a 
 suitable temperatvire. 
 
 By exposure to the heat of boiling water for from twenty to 
 forty minutes Koberts was able to preserve those substances 
 with which Schroeder and other observers had foiled, viz., milk, 
 pieces of meat, and egg albumin. 
 
 In 1876 experiments were published by Professor TyndalP 
 
 ' PMlosojjhieal Ti'ansactiom, 1 874. 
 " Philomphical Transactiotu, 187C. 
 
DR. ROBERTS' EXPERIMENTS. 
 
 23 
 
 which afford still fmlher evidence on this subject. I have al- 
 ready mentioned the method by which he demonstrated the 
 presence or absence of particles in suspension by passing a 
 powerful beam of light through the air to be examined. He 
 found that ' in order to render air optically pure it was only 
 necessary to leave it to itself for a sufBcient time in a closed 
 chamber or in a suitably-closed vessel. The floating matter 
 gradually attaches itself to the top and sides, or sinks to the 
 bottom, leaving behind it air possessing no scattering power. 
 Sent through such air the most concentrated beam fails to 
 render its track visible.' 
 
 Fig. 10.— Dn. Roberts' btilbs (copied from Egberts). 
 
 His method as described by himself is as follows : ' A chamber or 
 case was constructed with a glass front, its top, bottom, back and 
 sides being of wood. At the back is a little door which opens and 
 closes on hinges, while into the sides are in.serted two panes of glass 
 facing each other. The walls of this case are smeared with glycerine 
 in order to make the dust adhere. The top is perforated in the 
 middle by a hole 2 inches in diameter, closed air-tight by a sheet of 
 india-rubber. This sheet is pierced in the middle by a pin, and through 
 the pinhole is passed the shank of a long pipette ending above in a 
 small funnel. A circular tin collar 2 inches deep surrounds the 
 pipette, the space between both being packed with cotton wool mois- 
 
24 THE PARTICULATE THEORY OF FERMENTATION. 
 
 tenecl with glycerine. Thus the pipette, in moving up and down, is 
 not only firmly clasped by the india-rubbei', but it also passes through 
 a stuffing box of sticky cotton wool. The width of the aperture 
 closed by the india-rubber secures the free lateral play of the lower 
 end of the pipette. Into two other small apertures in the top of the 
 cupboard are inserted, air-tight, the open ends of two narrow tubes 
 intended to connect the interior space with the atmosphere. The 
 tubes are bent several times up and down so as to intercept and 
 
 retain the particles cari'ied by 
 such feeble currents as changes of 
 temperature might cause to set in 
 between the inner and the outer 
 air (see Fig. 11). 
 
 ' The bottom of the box is 
 pierced with holes, in which are 
 fixed, air-tight, twelve test tubes, 
 intended to contain the liquid to 
 be exposed to the action of the 
 motel ess air.' 
 
 The case so prepared is closed 
 and allowed to stand for three or 
 four days, till it is found by the 
 beam of light that all the dust has 
 settled. Then, the pipette being 
 dipped into the test tubes, the 
 fluid to be experimented on is 
 introduced into each in succession. 
 They are then boiled for five 
 minutes in a brine bath. During the cooling, plugs of cotton wool 
 are introduced into the small external convoluted tubes, but these 
 plugs are afterwards withdi'awn. The apparatus is then kept at a 
 suitable temperature and at perfect rest. At the same time a part of 
 the same infusion boiled for the same length of time is placed outside 
 the box in free contact with the air. 
 
 In this way Tyndall has been able to preserve for an inde- 
 finite time, boiled urine, mutton infusion, beef infusion, haddock 
 infusion, turnip infusion, hay infusion, infusion of sole, liver 
 infusion, infusion of hare, rabbit, pheasant, grouse, codfish, 
 turbot, herring, mullet, fowl and kidney; while flasks contain- 
 ing the same infusions, left exposed to the air after boiling for 
 the same length of time, invariably putrefied in a few days. 
 
 Fig. n.— Prof. Tyndall's pure 
 
 CHAMBER (COPIED FROM TyNDALL) 
 
TYNDALL. 25 
 
 This experiment, though resembling in many respects 
 Pasteur's experiment with the flasks with long bent necks, differs 
 from it materially. In Pasteur's ex]3eriment the whole of the 
 interior of the vessel is acted on by the heat, and thus when the 
 boiling is ended there is no part of the flask, except the neck, 
 which contains any particles capable of causing fermentation. 
 In this case, however, the steam from the tubes, passing into 
 a larger chamber, is not able to destroy the vitality of the dust 
 lining the walls of that chamber, and therefore the infusion is 
 here not only in contact with ordinary air which has not been 
 acted on by heat nor filtered of its dust, but the septic dust 
 itself is present in the same vessel though not in actual contact 
 with the fluids. Tyndall found that as soon as ordinary labora- 
 tory air, laden with dust, was admitted, putrefaction commenced. 
 
 Tyndall has further shown that the gases arising from 
 ymtrefying substances, however foul smelling, cannot produce 
 decomposition in other fermentescible liquids, although this 
 readily occurs when ordinary dust is admitted. 
 
 Thus, * on the 30th of November a quantity of animal refuse, 
 embracing beef, fish, rabbit, have, was placed in two large test tubes, 
 opening into a protecting chamber containing six tubes. On December 
 13th, when the refuse was in a state of noisome putrefaction, infusion 
 of whiting, turnip, beef, and mutton were placed in the other four 
 tubes ; they were then boiled and abandoned to the action of the foul 
 sewer gases emitted by their two putrid companions. On December 
 25th these tubes were still unchanged. On the same day the end of 
 the pipette was dipped into one of the putrid tubes and then inserted 
 into the turnip, aiid on the 27th a similar speck was transferred to 
 the whiting. These rapidly underwent decomposition, while the 
 remaining two tubes remained unaltered.' 
 
 By operating in the manner described by Mr. Lister I have 
 succeeded equally well in preserving fresh milk, meat, cucumber 
 or turnip infusion for any length of time. As I shall have to 
 refer at a later period to experiments in which extensive use is 
 made of the ease with which these fluids can be preserved 
 though retaining great readiness to undergo fermentation, I 
 need not say more at present. 
 
 Not only is air which has been filtered incapable of caus- 
 ing fermentation in a boiled liquid, but air which has been 
 
26 THE FAIiTICULATE THEORY OF FERMENTATION. 
 
 acted on by carbolic acid is also without effect. I may 
 mention a few facts made out by myself in support of this 
 statement. 
 
 In the small room in which most of my experiments were 
 done it was almost impossible for me to transfer fluids fi"om one 
 flask to another, by Mr. Lister's method, without contamination 
 and subsequent fermentation, but if I performed the same 
 manipulations in a spray of about 1 to 30 carbolic acid and water 
 I could transfer all sorts of fluids with ease from one flask to 
 another without any risk, even though done in the most leisurely 
 manner. In doing this I have used Mr. Lister's double-necked 
 flasks without the jirotection of the india-rubber cap. I have 
 also in a few instances simply poured the fluid from one single- 
 necked flask to another, and when this was done in a carbolic 
 acid spray without other precaution, the fluid remained pure. 
 
 That milk once rendered barren by boiling can be readily preserved 
 for any lengtli of time, thougli i-etaining its capability for undergoing 
 fermentation, is shown by the following experiment. 
 
 On January 30th milk was prepared by boiling for twenty minutes 
 in a flask purified by boiling distilled water in it under a cotton cap, 
 the flnsk being afterwards dried by heat. 
 
 On the same afternoon three purified tubes with glass caps and 
 shades (just like Mr. Lister's liqueur glasses) were half filled with this 
 milk under the spray. 
 
 February 6. — The caps were removed under the spray, and a 
 heated needle being introduced, jwrtions of the fluid were taken from 
 each tube for microscopical examination. All the milks were found 
 to present the normal appearance of fresh milk externally and micro- 
 scopically. 
 
 February 1 1 . — Examined as before. No change. 
 
 February 19. — No change. 
 
 March 3. — Still fluid and unchanged in appearance. Two of the 
 tubes were now tested by the addition of a drop of fluid from a tube 
 containing milk which had been left open, and which had putrefled. 
 In three days the milk in these two flasks had separated into two 
 layers, and had lost its normal characters. 
 
 April 11.- — The milk in the third test tube still remains un- 
 changed. 
 
 I might multiply instances to show that milk and other 
 fermentescible fluids can be kept in this way for months at a 
 
MY OWN EXPERIMENTS. 27 
 
 suitable temperature, without undergoing any change. This is 
 not due to any effect of the carbolic acid on the milk, because milk 
 so preserved rapidly undergoes fermentation when exposed to the 
 air. Indeed the minute quantity of the solution which comes in 
 contact with it can have no effect whatever, as is shown by the 
 following experiment performed in 1877. 
 
 February 1. — Five pure tes^t tubes were taken and into each was 
 introduced 100 minims of boiled milk, along with a certain number of 
 minims of watery solution of carbolic acid, 1-20. 
 
 To No. I. were added 2 mins., making a proportion of 1-1000. 
 „ II. „ 5 „ „ „ 1-400. 
 
 „ III. „ 10 „ „ „ 1-200. 
 
 „ IV. „ 20 „ „ „ 1-120. 
 
 „ V. „ .50 „ „ „ 1-60. 
 
 They were then shaken up and left exposed to the air for twenty- 
 four hours, and afterwards covered with very loosely- fitting caps, 
 which were removed at intervals during the following day. 
 
 February 6. — The milks wei'e beginning to alter in appearance 
 and to separate into layers. This was the case even in No. V. 
 April 19. — They were all much advanced in decomposition. 
 
 Thus we see that decanting can be safely done in a spray 
 of carbolic acid, the fluid still remaining as putrescible as ever ; 
 while, on the other hand, experience had taught me- that in the 
 particular room to which I have referred, it was very difficult 
 to decant successfully without the spray. 
 
 The following experiment which I performed some time 
 ago directly proves the efficacy of the spray : — 
 
 Two flasks containing pure milk were opened in my room, and 
 left open for ten minutes. In both bacteria developed. As soon as 
 these flasks were removed two other flasks similarly charged were put 
 in the same place in a fine cloud of carbolic spray. They were opened 
 and left open for ten minutes. Both of these remained pure, though 
 when inoculated at a later period organisms rapidly developed in them. 
 When they were removed the spray was stojiped, and two fresh flasks 
 were placed in the same position, opened and left open for ten minutes. 
 One of the latter lemained pure ; in the other organisms appeared. 
 (As will be later seen, the presence of organisms is synonymous with 
 the presence of fermentation, and their absence with the absence of 
 such changes.) 
 
28 THE PARTICULATE THEORY OF FERMENTATION. 
 
 Another experiment proves to demonstration the efficacy of 
 the spray in destroying the putrefactive agents in the air : — 
 
 Four flasks provided with cotton caps were puiified according to 
 Mr. Lister's method. Into two of these, pure encumber infusion was 
 introduced in the manner ah-eady described. These two flasks were 
 placed for four days in an incubator, kept at the temperature of 98° F. 
 At the end of this time the fluid was unchanged in both. About 
 half of the liquid in one of the flasks was then poured into one of the 
 empty previously purified flasks, in a cloud of carbolic spray, and the 
 caps reapplied. These were then placed in the incubator and they 
 remained permanently unchanged, and without the development of 
 organisms. The same process was gone through with the two flasks 
 without the use of a spi^ay. In both of these organisms developed 
 and putrefactive changes occurred. 
 
 In this experiment, when the fluid was poured from one 
 vessel to the other it passed through the air, and air also 
 entered into the first flask to take the place of the liquid. 
 When this air had not been acted on by carbolic acid, organisms 
 developed and fermentation took place, but where the air had 
 previously passed through the spray it failed to cause any 
 further change. (1 do not of course mean to imply that the 
 former will be a constant result, for in ordinary air there are but 
 few organisms present, and probably many flasks would escape. 
 This experiment refers to the air of the room in which it was 
 performed, that air being loaded with causes of fermentation.) 
 
 A very striking proof of the value of the carbolic acid 
 spray which occm'red to me lately may be mentioned. The 
 flasks which I at that time used were purified by heating them 
 to a temperature of about 600° V. in a box like that described 
 by Mr. Lister. The flasks were in the first instance heated 
 without any covering, the cotton caps were then applied under 
 the spray, and the flask with its cap reintroduced into the box, 
 where it was thoroughly dried in order to drive off any carbolic 
 acid which might be adhering to it. As the temperature to 
 which the apparatus was in the first instance raised chars cotton 
 wool, I used asbestos to filter the air as it passed into the 
 interior of the box during cooling. For a while this answered 
 quite well, but after a time portions of the asbestos became 
 detached, and holes were thus formed through Avhich air could 
 
(JONCL USIONS. 29 
 
 enter without being filtered, and as a result on several occasions 
 I found that all the flasks so prepared were impure. This 
 was obviated simply by directing the spray against the door of 
 the box as soon as the lamp which heats it was extinguished. 
 The box was thus surrounded by spray; the air passing into 
 it first passed through this spray, and, as a result, since I 
 did this, I never failed in any instance in obtaining pure flasks.^ 
 From these researches we learn that the gases of the air, 
 whether oxygen, nascent oxygen, ozone, nitrogen, carbonic acid, 
 emanations from fermenting substances, &c., are powerless to 
 cause fermentation in boiled fluids or tissues. Further, that 
 it is sufficient, in order to prevent this occurrence, that the air 
 be either previously heated, or filtered through cotton wool, or 
 acted on by chemical substances, such as sulphuric acid or 
 carbolic acid, or merely allowed to remain at rest so as to 
 permit the dust to settle outside the substance tested. It is 
 therefore evident that the causes of putrefaction in boiled 
 substances are solid particles present in the atmosphere and on 
 surrounding objects, which may be deprived of their fermentative 
 properties in various ways. When we come to consider the 
 further questions of spontaneous generation and the relation of 
 organisms to fermentative changes, we shall find much additional 
 evidence confirming this view. 
 
 ' The exact merits of the carbolic spray as a means of purifying the atmo- 
 sphere will be discussed later. What I wish to point out here is, that in 
 ordinary air, in circumstances where we know that particles capable of causing 
 fermentation are present, carbolic acid is able to render these particles inert. 
 
30 THE PARTICULATE THEORY OF FERMENTATION. 
 
 CHAPTER II. 
 
 THE PARTICULATE THEORY OF FERMENTATION (continvrd). — 
 ON THE FERMENTATION OF UNBOILED SUBSTANCES. 
 
 Grape juice — Gaji-Lnssac — Van der Broech — Pasteii/i' — liohcrts; blood — Van 
 der Brocch — Pasteur — Burdoii-Sanderson — Lister — 3Iy awn results ; un- 
 boiled ui-ine — Vaih der Broecli, — Pasteur — Lister — My own results — Roberts 
 — Cazeneure and Livon ; milk — Hojfpe-Seyler — RoleHs — Lister — My own 
 experiments; egg albumen — Van der Broecli — Gay on — Roierts — 3Ty own 
 exjJenments ; vegetable tissues — Roberts ; animal tissues — Billroth — Tiegel 
 — Bur don- Sanderson — My own experiments — Chiene and Ewart — Meissner — 
 General review of the facts — Behaviour of similar fluids and tissues in the 
 living body — Principles of aseptic surgery. 
 
 While it cannot be doubted that the causes of the fermenta- 
 tion of boiled fluids and tissues are particles which reach them 
 from the air and from surrounding objects, is this equally the 
 case with the unboiled ? Experiments with these substances 
 are apt to yield very contradictory results, for it is a matter of 
 extreme difficulty to prevent their contamination after their 
 removal from the living body. How this has been managed 
 and with what results we must now enquire. 
 
 I. — Orape Juice. 
 
 Gay-Lussac in the research mentioned before attempted to 
 ascertain whether unboiled grape juice remained unaltered when 
 oxygen gas was excluded. He took a bell jar and introduced into 
 it small grapes, still intact. The jar was now reversed over 
 mercury, and was filled five times with hydrogen gas in order 
 to wash out all the oxygen. The grapes were then crushed by 
 means of an instrument introduced through the mercury, and 
 the juice thus obtained was kept at a temperature of 15° to 20° 
 C. Fifteen days later, no fermentation having taken place, a 
 
THE FERMENTATION OF UNBOILED SUBSTANCES. 31 
 
 small quantity of oxygen was introduced, and immediately 
 fermentation commenced. 
 
 From these experiments he concludes that the oxygen 
 introduced caused the fermentation. But here there are two 
 main fallacies. In the first place, the skins of the grape were 
 left mixed with the grape juice, no sufficient means being 
 taken to destroy any solid particles adhering to them ; and then 
 also the oxygen introduced might have carried in the necessary 
 particles. There can indeed be no doubt, from Pasteur's sub- 
 sequent investigations, that the Torula cerevisise — the cause of 
 the alcoholic fermentation — was present on the skins of the 
 grapes ; and Pasteur has further shown that oxygen is absolutely 
 necessary for the development of the old cells of the Torula, 
 though the young cells may go on developing without the 
 presence of free oxygen. The explanation of Gay-Lussac's 
 experiment is, therefore, that the old Torula cells present could 
 not develop without oxygen, but that when a small quantity 
 of oxygen was introduced, they developed, and fermentation 
 occurred. 
 
 The next attempt to preserve grape juice of which I can 
 find any record was made by Van der Broeck, and narrated to 
 the ' Provincial Gresellschaft fiir Kunst und Wissenschaft,' 
 Utrecht, January 1858. His method was the following' : — 
 
 Small beakers were filled with mercury, and then heated in a sand 
 bath till the boiling point of the mercury was almost reached. Fi-om 
 time to time they were placed under the receiver of an air-pump, and 
 at the same time shaken in order to detach any bubbles of gas adher- 
 ing to the side of the flask. This process of heating and exhausting 
 was continued till all the air was removed from the bottom or sides 
 of the glass. These glasses were then inverted in a basin containing 
 previously heated mercury, and were firmly fixed in this position. 
 Ripe and uninjured gi'apes were now passed into the mercury and 
 brought under the orifice of the flask, a portion of the skin of the 
 gi-ape was clipped out by a heated knife, and by gentle pressure some 
 of the juice was made to ascend m the vessel, the rest of the gi-ape 
 being removed. When a sufiicient quantity of juice had been thus 
 introduced the vessels were placed in a room of which the tempei'a- 
 ture was 2.5° to 28° C, and giupe juice thus obtained could l)e kept for 
 months or years without undergoing any change. 
 
 ' See Annalcn der Chcinie unci Pharniacir, cxv. 18G0. 
 
32 THE PARTICULATE THEORY OF FERMENTATION. 
 
 In this experiment not only was all air excluded, but the 
 dust adhering to the walls of the vessel and in the mercury 
 was subjected to strong heat, and its fermentative power 
 destroyed. The juice of the grape, in ascending through 
 the mercury, did not come in contact with unheated dust, nor 
 did it touch the skin of the grape. 
 
 Into some of the flasks containing pure grape juice obtained 
 in this way, pure and fresh oxygen was introduced from a retort 
 containing chlorate of potash and oxide of copper. (The 
 nozzle of the flask was heated previously to its immersion in 
 the mercury, and the oxygen was allowed to stream out for a 
 time sufficient to wash out all the dust.) In none of these 
 flasks was there a trace of fermentation. Into others, atmo- 
 spheric air, passed through a mass of cotton wool, was intro- 
 duced in the same manner, but without producing any effect. 
 
 Into these vessels containing oxygen, yeast was introduced 
 in minute quantity, and fermentation at once commenced. 
 Into others containing only grape juice, young cells which had 
 never been exposed to free oxygen were introduced by a 
 method which is fully described in his research, and these also 
 caused fermentation ; thus proving that oxygen is not necessary 
 even for the commencement of the change, if only the yeast 
 cells be young (three or four days old). 
 
 By these experiments it was absolutely demonstrated — 1 
 That oxygen is not the cause of the fermentation of unboiled 
 gra})e juice ; and 2. That the juice itself contains no ferment. 
 
 That grape juice contains no ferment was further shown 
 by Pasteur,' who introduced unboiled juice into his flasks with 
 bent necks, containing pure boiled juice. No fermentation 
 occurred, though, as he says, if a single Torula cell had been 
 added, the whole mass would have fermented. 
 
 Dr. Roberts - likewise succeeded with grape juice. 
 
 Test tubes were drawn out at their lower ends to capillary 
 points and sealed in the flame; the upper ends were plugged with 
 cotton wool ; they were then passed and repassed through the flame of 
 a spirit lamp until they were quite hot, as shown by the commencing 
 charring of the cotton. (Fig. 12.) 
 
 ' Eleven sterilised tubes, six empty and Ave containing water, were 
 
 ' Etudes sur la BVcre. ^ PhM. Transactions, 1874:. 
 
PRESERVATION OF GRAPE JUICE AND BLOOI). 33 
 
 grape 
 urface 
 
 charged with grape juice in the following manner : — A fresh 
 
 was firmly seized with the fiiiger and thumb, and a spot on its s 
 
 was pi-essed for a few seconds against the flame 
 
 of a spirit lamp so as to destroy any adhering 
 
 germs. The point of the sterilised tube, also 
 
 heated in the flame and quickly snipped off" by an 
 
 assistant, was then thrust into the grape at the 
 
 heated spot. Compression was now made on the 
 
 gi-ape until a sufiicient quantity of the turbid 
 
 juice was forced into the tube. The tube was 
 
 then withdi-awn, and its point sealed in the 
 
 flame. The eleven tubes thus charged remained 
 
 permanently unchanged, and when examined, at 
 
 various periods from five to eight weeks, the taste 
 
 and reaction of their contents were undistin- 
 
 guishable from that of the fresh grape juice.' 
 
 II.— Blood. 
 
 Blood is one of the substances which eobeets). 
 
 have been frequently referred to as having 
 an inherent tendency to decompose, but several experiments 
 have now demonstrated that this is not the case. 
 
 The first observer who succeeded in preserving blood was 
 Van der Broeck. 
 
 Van der Broeck procteded as follows: — Having prepared his 
 beakers filled with mercury as formerly described, he introduced one 
 end of a previously heated copper tube into the carotid artery of a dog. 
 To the other end of this a caoutchouc tvibe was connected, while the 
 free end of the lattei- dipped into the mercury and the blood passed 
 along it into the purified beakers. (This caoutchouc tube had been 
 purified by the jjassage of steam through it for some time, and by 
 placing a plug of cotton wool in each end while it was cooling.) 
 The vessels were then kept at a temperature of 25° to 30'^ C. for 
 weeks without the contained blood undergoing any change. 
 
 Into some of these flasks oxygen or filtered air was intro- 
 duced, but still there was no putrefaction. The minutest por- 
 tion of putrescent or even non-put re scent but unheated substance 
 at once set up fermentation. 
 
 In 1863, Pasteur ' stated that he had obtained blood from 
 
 ' Comptcs llcnduv, Ivi. 738. 
 ]) 
 
34 THE PARTICULATE THEORY OF FERMENTATION. 
 
 healthy iinimals by means preventing contamination with un- 
 heated atmospheric dust, and that this blood had remained free 
 from change. In a later publication ^ he describes the method 
 pursued. 
 
 ' For this I made use of a flask connected by means of a 
 caoutchouc tube with a brass tube and stop-cock. The two parts 
 of the tube are about twelve centimetres in leugth ; that which is 
 free is filed down like the extremity of a cauula. In order to cleanse 
 this vessel from all living dust the free extremity of the brass tube 
 was connected 'with a platinum tube .strongly heated, a small 
 
 Fig. 13 (FROM Pasteur). 
 
 quantity of water having been previously introduced into the flask. 
 This water is then boiled, and the flask allowed to cool, the air which 
 enters during cooling being previously heated. It is well to boil the 
 water in the flask under pressure, to effect which the free extremity 
 of the platinum tube is connected with a glass tube bent at right 
 angles, which dips into a deep vessel filled with mercury. After 
 boiling for some time under pressure, this tube is detached, and boiling 
 is continued at the ordinary pi-essure ; then the flask is allowed to 
 cool and to become filled with heated air. When the flask is cold the 
 cock is shut and the platinum tube detached. Till it is required it is 
 well to hold the orifice of the brass tube down, in order to prevent 
 dust from falling into it. Before being used this portion is heated 
 carefully in the flame of a spiiit lamp. 
 
 ' A vein or artery of a dog is now opened, the end of the brass tube 
 introduced, and secured in the blood-vessel by a ligature ; the cock is 
 then turned on. Blood flows into the flask, and when enough has been 
 ol>tained the cock is shut and the flask placed in a suitaljle tempei'a-- 
 ture.' 
 
 As a result this blood does not putrefy, and its odour re- 
 mains quite fresh. There is not even an active absorption of 
 
 ' Etudes xvr la JJihr, 187G. 
 
BLOOD: BURDON-S ANDERSON, ROBERTS, LISTER. 36 
 
 oxygen, for after several weeks only 2 or 3 per cent, of that 
 gas was found to have disappeared in a vessel sealed imme- 
 diately after the blood had been introduced. 
 
 Dr. Burdon-Sanderson • also found that blood taken from 
 rabbits with suitable precautions, and put into purified flasks 
 covered with cotton wool, remained free from change. 
 
 Dr. Eoberts,^ having purified his tubes in the way described, 
 and having thoroughly cleansed his finger, punctured it, and 
 sucked up about two drops into each tube. Of ten tubes pre- 
 pared in this way, six remained unaltered. This experiment 
 is of little value, partly on account of the imperfect method of 
 experimentation, and partly on account of the small amount of 
 blood obtained. 
 
 Mr. Lister ^ took blood from the jugular vein of an ox in 
 the following manner : — 
 
 A large glass tube was fixed in the lai'ge oiifice of one of his 
 double-necked flasks, the interval between the flask and the tube 
 being filled with tightly-packed cottou wool. Over the outer end of 
 this glass tube a cotton cap was applied, and there was a cotton cap as 
 usual over the orifice of the spout. The fiask thus arranged was heated 
 in the hot box. The jugidar vein of an ox having been exposed 
 antiseptically, was divided, the cotton cap removed fi'om the end of the 
 tube, and the end of the vein slipped over the orifice of the tube. 
 Blood thus flowed through a pure tube into a pure flask. When 
 enough had been obtained the vein was removed and a pure cotton cap 
 immediately aj^plied in its stead. Before coagulation had occurred, 
 various liqueur glasses, arranged as formerly described, wei'e charged 
 from the large flask. 
 
 Blood so obtained remained unaltered in the liqueur glasses 
 and in the flask, though kejit for six weeks. 
 
 Mr. Lister also found that not only blood, but blood and 
 water — a much more putrescible mixture — remained unaltered. 
 (The water was introduced into a large pure flask, and boiled so 
 as to purify it. A portion of blood clot from one of the liqueur 
 glasses was then spooned into the flask, careful precautions 
 being taken against the entrance of living dust.) 
 
 In some experiments, performed in a manner to be shortly 
 
 ' Quarterly Journal of Micraisropiful Sriciicr, xi. J871. 
 
 - Loc. cit, '■' Mirriixropical Jour mil, 1878. 
 
 1) 2 
 
36 THE I'ARTICULATE THEORY OF FERMENTATION. 
 
 described, I have found that blood, removed from the healthy 
 living body and placed in calcined flasks or in flasks containing 
 infusion of cucumber, maybe preserved for an indefinite length 
 of time without alteration. 
 
 Hence blood has no inherent tendency to undergo fermen- 
 tative changes, nor can oxygen alone induce such alterations. 
 
 III. — Urine. 
 
 Healthy mine was first preserved without alteration by Van 
 der Broeck. The flasks in which it was received were prepared 
 in the manner before described. An animal (dog or sheep) 
 was killed, the abdomen was immediately cut open, and the 
 ureters and m-ethra having been rapidly tied, the bladder was 
 removed and immersed in the mercury. A heated needle was 
 then introduced, and the bladder was torn, the urine then 
 ascending into the glass. This urine remained pure even after 
 the addition of oxygen or filtered air. 
 
 In the same paper in which Pastern- mentions that he has 
 succeeded in preserving blood he states that he has also 
 obtained pure urine. The method is described in his ' Etudes 
 sui* la Biere.' The flask with its nozzle and stop-cock are 
 prepared as in the case of the blood ; then the free extremity of 
 the brass tube is introduced into the urethra. Urine being 
 passed, the stop-cock is turned, and the urine flows into the 
 flask. Urine thus obtained undergoes no fermentation. ' Elle 
 depose des cristaux en petite quantite, mais sans se troubler 
 ni se putrefier d'aucune facon.' 
 
 In 1871 Mr. Lister succeeded in obtaining and preserving 
 unboiled urine.' The method he employs is to wash the 
 meatus urinarius and the glans penis with 1-40 carbolic lotion. 
 A prepared flask is then taken, the cotton cap is removed, the 
 glans immediately applied over the orifice, and urine passed 
 into the flask. A fresh cotton cap is then applied. This 
 urine may, like other fluids, be decanted into liqueur glasses. 
 This experiment was apparently constantly successful, no alter- 
 ation occurring in the urine in the flasks or in the glasses. 
 
 ' Transactions nj the Itvijal Society of Edinhuryh, 1875. 
 
URINE: ROBERTS, CAZENEUVE AM> LI FOX. 37 
 
 I may here state that I have often repeated this experiment 
 with the view of obtaining pm-e nnboiled urine for other experi- 
 ments, and always with success. I have, however, used the spray, 
 and have thus avoided the necessity of applying the glans penis 
 to the orifice of the flask. The glans having been purified, 
 urine is simply passed in a spray of carbolic acid into a pure 
 flask. This urine passed through the air, but that air, having 
 been acted on by carbolic acid, was inert. 
 
 Dr. Roberts has also obtained similar results by passing urine 
 into a pure test-tube, and afterwards charging tubes of the 
 form previously described, by breaking oft the capillary end 
 below, and letting the urine flow up. Of eight tubes so 
 obtained, the urine remained unaltered in seven, while in one 
 it putrefied. 
 
 Cazeneuve and Livon ^ succeeded in preserving urine in the 
 urinary bladder without the occurrence of any alteration in it. 
 
 A ligature was placed around the prepuce of a dog for five 
 hours, in order to have a considerable amount of urine in the 
 bladder. An incision being made into the abdominal cavity at 
 the end of that time, the ureters and the urethra were ligatured, 
 and the bladder was cut out. The bladder was then suspended 
 in the air at a temperatm-e of about 25° C. The wall of the 
 bladder soon dries, and though liquid slowly transudes, that 
 liquid evaporates immediately, and thus the bladder wall cannot 
 putrefy. Urine may be kept thus for several days without 
 undergoing any change, although if the bladder be opened it 
 becomes ammoniacal in twenty-four hours. I shall return to 
 these experiments at a later period. 
 
 Thus healthy unboiled urine has no inherent tendency to 
 putrefy, but follows the same law in this respect as boiled 
 urine. 
 
 IV.— Milk. 
 
 In 1859 Hoppe-Seyler attempted to preserve milk pure in 
 the following manner: — ^ 
 
 A small funnel was carefully fastened over the teat of a goat. To 
 the lower end cf this was fastened a piece of caoutchouc tubing, the 
 
 ' Rcrue Menmclle, 1877, p. 733. 
 ^ Vircliow's Archiv. xvii. (1859). 
 
38 THE PARTICULATE THEORY OF FERMENTATION. 
 
 other end of which was attached to a glass tube below. This glass tube 
 passed down to the bottom of a glass test tube, the u])per vim of 
 which was provided with a piece of caoutchouc tubing open above. 
 None of the tubes were heated nor in any way purified. The milk 
 was now withdrawn in a continuous stream, so as to flow for a long 
 time over the edge of the caoutchouc tube till it was quite free from 
 bubbles of air. The test tiibe was then lowered, and then, while the 
 milk was still flowing, the caoutchouc tube was firmly tied around a 
 thick glass rod. 
 
 Milk obtained in this manner, and kept at the ordinary 
 temperature, coagvdated in three days. Hoppe-Seyler therefore 
 concluded that milk when shed contains a ferment. 
 
 This experiment proves that oxygen is not necessary for the 
 occurrence of fermentation in milk ; in other words, it is not the 
 cause of such changes, and therefore, as the tubes were not 
 purified, the cause must either be in the milk itself or be some- 
 thing adhering to the tubes. As I have just stated, Hoppe- 
 Seyler concluded that the cause was inherent in the milk. 
 
 Which of these is the true agent is decided by the following 
 experiments performed by Dr. Eoberts : — ^ 
 
 * A glass tube was drawn out at each end to a narrow orifice. The 
 lesser portion of this was tightly wrapped round with cotton wool and 
 inserted as a plug into a large test tube containing water to the depth 
 of one inch. A cap of cotton wool was also tied over the narrow 
 orifice. The water in the test tube was then briskly boiled, and the 
 boiling was continued almost to diyness. When the apparatus was 
 cold I took it into the cowhouse, and seizing a teat, I pulled ofi" 
 qvuckly the cotton- wool cap and pushed the narrow point into the 
 duct of the teat. Holding it firmly in this position I milked into the 
 test tube until sufiicient milk had been obtained. I then drew away 
 the test tube from the little tulie, pressing in the cotton wool around 
 it as I did so, until the latter was entirely withdrawn from the test 
 tube. 
 
 ' From the test tube I charged ten empty pure tubes ' (in the manner 
 descril)ed under urine), 'and resealed their capillary orifices : of these 
 ten tubes three remained unchanged, the milk remaining perfectly 
 normal as regards taste, reaction, kc. The other tubes curdled or 
 putrefied in ten days.' 
 
 ' Loc. cit. 
 
MILK: LISTER, MY OWN EXPERIMENTS. 39 
 
 The method described here is imperfect, but the fact that 
 three tubes remained unaltered absolutely demonstrates that 
 the cause of the fermentation is nothing inherent in the milk 
 itself, but something which it acquires after it leaves the body — 
 that something being particulate, not gaseous. 
 
 Mr. Lister ' describes several series of experiments performed 
 with the same aim. In one of these he succeeded in preserving 
 the milk unaltered. 
 
 A numbei' of little tubes were covered with glass caps and shades, 
 and purified in the usual manner. After a rainy day he washed the 
 udder of a cow and the hands of the milkman with water. A 
 wide glass tube connected with an elastic tube was then placed under 
 the nipple (the glass tube had been heated and the elastic tube 
 boiled). This -was filled with milk, and then each little tube in suc- 
 cession had a small quantity mtroduced by relaxing the elastic tube. 
 
 Of twenty-four tubes so prepared and charged two remained 
 permanently pure. The results in the other tubes equally demon- 
 strated that the cause of the fermentation of milk is not inherent 
 in the milk, for the milk in each underwent a different change. 
 These experiments will be more fully considered at a later 
 period. 
 
 While in the Shetland Islands in the summer of 1880 I 
 performed a series of experiments, which consisted in obtaining 
 the milk under the protection of a spray of carbolic acid. A 
 number of flasks with cotton caps and long necks were heated 
 before leaving London. The udder of the cow and the hands 
 of the milkmaid being washed with carbolic lotion (1-20), the 
 flasks were uncorked and filled with milk under the spray. 
 In doing so the mouth of the flask was held as close as possible 
 to the teat. The cow was restive and would not allow me to do 
 the milking, and therefore the experiment was performed by 
 the milkmaid. When the restiveness of the cow, the inex- 
 perience of the milkmaid at antiseptic work, and the dark and 
 draughty cowhouse are taken into account, it will not be sur- 
 l)rising that the milk in a considerable number of the flasks 
 f(;rmented; but nevertheless evidence was got, of tlio same 
 kind as that obtained by Dr. Roberts and Mr. Lister, sufficient 
 
 ' Micrusccjncal Jourmil, 1878. 
 
40 THE PARriCULATE THEORY OF FERMENTATION. 
 
 to disprove the existence of a ferment in the milk when with- 
 drawn from the body. 
 
 In order to transfer these flasks to London I had intended 
 to draw ont and seal their necks, but I found this impossible, 
 and therefore I soaked pieces of cork in carbolic lotion, inserted 
 them into the mouth of the flask, and covered them with tar 
 — a very inefficient method. During the voyage the milk was 
 much shaken, and some of the corks proved inefficient, as shown 
 by the leakage of the milk. 
 
 The following are the experiments, with their results : — 
 
 First Experiment. 
 
 August 5, 1880. — The udder and teats of the cow and the hands 
 of the milkmaid having been Avashed with 1-20 carbolic lotion, and a 
 small spray being directed as well as possible over the part, eight 
 purified long-necked flasks were filled with milk, the milk being 
 drawn directly into each flask, which were held as near the teats as 
 possible. Eash flask was re-covered with its cotton cap, and they 
 were then placed in the upright position in a warm room. 
 
 Augtist 8. — The milk in these flasks seems unaltered. There is a 
 little cream on the top in each. 
 
 August 10. — Ditto. 
 
 August 24. — Four of the flasks have undergone change, the change 
 varying in nature in each flask. The other four are perfectly fluid 
 and present the appearance of pure milk. 
 
 To-day the corks were inserted. 
 
 Se2:)temher 21 (twenty-three days after the transport to London). — 
 Only two flasks now remain pure, the other six having undergone 
 alterations of various kinds. 
 
 October 27. — Examined. The milk in two flasks is perfectly 
 normal. 
 
 The result of the first experiment was, that after nineteen 
 days four of the milks had undergone alterations of various kinds, 
 while four remained apparently pure. On October 27 — i.e. 
 after two months and twenty-two days — two milks were still 
 perfectly right, in spite of a sea voyage and great disturbance. 
 
MILK: MY OWN EXPERIMENTS. 41 
 
 Second Experiment. 
 
 («) August 10. — Two flask?^ were filled after washing the udder of 
 the cow and the milkmaid's hands with carbolic acid (1-20). No 
 spray used. 
 
 August 24. — The milk in one of these flasks has undergone altera- 
 tions \ the milk in the other Ls perfectly pure. 
 
 September 21. — Both milks have coagulated and are undergoing 
 changes. 
 
 (b) August 10. — After the spray employed in experiment (c) had 
 been stopped, two flasks were filled without it. 
 
 Augiist 24. — I am doubtful whether these are pure or not ; I think 
 they are not. 
 
 September 21. — Changes have occurred in both. 
 
 (c) August 10. — Seven flasks were filled under the spray as usual. 
 August 24. — Three of these milks have altered ; four are still 
 
 apparently pure. 
 
 September 21. — Three still remain apparently pure : four have 
 undergone change. 
 
 October 27. — Examined. Three still pure. 
 
 On December 24 I opened one of these flasks, and found a slightly 
 suety smell but a perfectly sweet taste, and the milk presented the 
 appearance of normal milk. I examined it microscopically — no 
 organisms. I have stained some specimens of this milk (Plate V. 
 Fig. 33), and it will be seen that no organisms whatever are present, 
 and this in unboiled milk kept for moi'e than five months. 
 
 The result here is that three out of seven of the flasks filled 
 under the sjjray have remained permanently pure, while all of 
 those filled without the spray have ultimately undergone 
 fermentative changes. 
 
 Third Experiment. 
 
 (a) August 1 6. — One flask filled without spray and without previous 
 application of carbolic acid to the hands or teats. 
 
 Aiigust 24. — This milk has coagulated. 
 
 {b) Aiigust 16. — One flask filled without the spraj' and without 
 washing the teats with carbolic acid. The hands of the milkmaid, 
 were, however, purified. 
 
 August 24. — This milk has undergone fermentation, having 
 separated into two layere — the upper clear, the lower thick but not 
 coagulated. 
 
42 THE PARTICULATE THEORY OF FERMENTATION. 
 
 (c) August 16. — Two flasks were filled without the spray, but after 
 washing both the teats and the hands with carbolic lotion. 
 
 AiKjust 24. — One of these is doubtful, the other apparently iin- 
 altered. 
 
 Septeiniber 21. — Fermentative changes are occurring in both. 
 
 {d) August 16. — Six flasks filled under the spray as usual. 
 
 Aug^ist 24. — All these are appai-ently unchanged. 
 
 September 21. — Four have undergone some fermentative changes. 
 One is doubtful. One is still pure. Thi-ee of the corks have not 
 fitted perfectly. 
 
 October 27. — Examined. One still pure. 
 
 The whole result is, that of twenty-one flasks filled under 
 the spray, six remained permanently unaltered, and that after 
 having been exposed in a manner which sufficiently explained 
 the occurrence of femientation in some of the others. 
 
 Up till August 24th no less than fourteen of these milks had 
 remained apparently unchanged, while similar specimens taken 
 without any precautions had undergone alteration, 
 
 I have still in my possession (June 1881) four of these 
 six flasks, and the milk in these still remains perfectly pure 
 and free from fermentative changes. 
 
 From all the facts narrated I think it is absolutely certain 
 that milk has no inherent tendency to undergo fermentation 
 of any kind, and that the cause of the fermentation is not 
 the gases of the air, but solid particles which the milk meets 
 with after it is drawn from the cow. 
 
 V. — Egg Albttmen. 
 
 The difficulty experienced by Schroeder in preserving boiled 
 white and yolk of eggs will be remembered. 
 
 Van der Broeck introduced an egg into the merciuy ar- 
 ranged as formerly described, broke the shell with a heated 
 iron rod, stirred up the contents with a similar rod, and then 
 allowed them to ascend into the glass. This egg albumen 
 remained pure, even after subsequent addition of oxygen or 
 of filtered air. 
 
 Gay on ' found that some eggs may be preserved unaltered, 
 while others undergo change. He supposes that in the latter 
 
 ' C'onijjtvg Itendiix, Ixxvi. Ixxvii. 
 
EGG ALBUMEN: ROBERTS. 43 
 
 case the causes of putrefaction entered as the egg passed through 
 the oviduct. Such an idea is, however, hardly tenable. 
 
 Eoberts has shown by experiments similar to those pre- 
 viously described that egg albumen has no inherent tendency 
 to undergo fermentation. 
 
 He proceeded in the following manner : — Eight sterilised tubes 
 were prepared containing pure water. ' A fresh egg was fixed in a 
 convenient support, and a small piece of the shell was chipped off, 
 care being taken to leave the subjacent membrane uninjured ; then a 
 sterilised bulb was taken, and the capillary portion immersed for a 
 few seconds in boiling water, in order to destroy any adherent septic 
 particles. The sealed end was then rapidly snipped off and the 
 capillaiy portion plunged into the interior of the egg. About 2 gm. of 
 the albumen were then sucked up by the mouth into the bulb. When 
 this was accomplished the bulb was quickly withdrawn and its capil- 
 lary end sealed in the flame.' 
 
 Six of these eight tubes remained unaltered for seven months. 
 
 Of a second series of seven tubes similarly charged and kept for 
 two months, five remained unaltered. That is, of fifteen tubes filled, 
 eleven remained pure. 
 
 I may refer to an experiment which I did for another 
 purpose, accepting as true the view that egg albumen had no 
 inherent tendency to undergo fermentation, aud which proves 
 the truth of that view. 
 
 On July 7th, 1880, 1 took four purified beakers and four fresh eggs. 
 These eggs were washed with carbolic lotion (1-20), and were then 
 Ijroken, one into each lieaker, under the spray. 
 
 One of these beakers was covered with its cotton cap, and placed in 
 an incubator kept at the temperature of 98° F. 
 
 On July 20th no change whatever had occurred. The other flasks 
 were used at once for various experiments. Into one a special form 
 of organism was introduced, and here only this one form of organism 
 developed, with the production only of a special kind of fermentation. 
 
 Hence egg albumen has no inherent tendency to undergo 
 fermentative changes. 
 
44 THE PAliriCULATE THEORY OF FERMENTATION. 
 
 VI. — Vegetable Tissues. 
 
 Dr. Eobei'ts' has also experimented on the solid tissues of 
 the turnip, potato, orange, and tomato, with similar success. 
 
 The following is his method for turnip : — 
 
 ' A stei-ilised tube containing- water was nickecl with a file near the 
 base of the capillary part, where the tube had a diameter of about two 
 millimetres, A fresh oblong turnip was then fractui-ed aci-oss, and 
 the tube, snipped off at the nicked jjoint, was quickly thrust into the 
 substance of the turnip. A naiTow cylind-er of turnip about an inch 
 long w'as thus foi-ced into the column of water in the tube. The tube 
 was then detached, and its end sealed with melted sealing-wax.' Of 
 
 14 tubes thus chai-ged with turnip 10 were successful; 
 
 7 „ „ potatoes 4 „ 
 
 8 „ „ orange 8 „ 
 3 ,, ,, tomato 3 ,, 
 
 Ferments which induce changes after death are therefore 
 not present in living vegetable tissues. 
 
 VII. — Animal Tissues. 
 
 Some years ago experiments were made by Billroth ' and 
 Tiegel^with the view of ascertaining whether the living tissues 
 did or did not contain the causes of putrefaction. Having 
 killed an animal, they opened its body rapidly, and removed with 
 heated implements various portions of tissue such as liver, 
 spleen, kidney, &c., and immediately dropped this into heated 
 paraffin. They supposed that by this means any dust which 
 fell on the tissue in its transit from the body to the flask would 
 be destroyed by the hot paraffin, while this heat would not 
 penetrate into and act on the interior of the tissue. At the 
 same time the organs would be protected from air or dust by the 
 paraffin. 
 
 They found that many portions of the body preserved in 
 this way, notably the liver and spleen, underwent putrefaction 
 rapidly, and they therefore concluded that the causes of this 
 putrefaction were present in the living blood and tissues. 
 
 ' CuceohacteHa sejHica. * Virchow's ArcJiir. Ix. 
 
ANIMAL TISSUES: MY OWN EXPERIMENTS, 45 
 
 These experiments were repeated by Dr. Burdon-Sauderson, 
 who obtained similar results and adopted the same views. 
 
 If, however, we look at the method, we shall find several 
 objections to it. Thus, heated paraffin must be looked on as 
 dry heat ; it does not moisten solid particles in contact with it. 
 Now it has been shown that dust, if kept dry, may be heated 
 even to 300° F. without losing its power of causing fermenta- 
 tion. Further, paraffin solidifies at about 136° F., or even 
 lower, and therefore paraffin, merely at its melting point, is not 
 likely to be hot enough to destroy all septic particles. Further, 
 during the cooling of the paraffin heavy particles of dust may 
 fall into it and sink on to the tissue. Then, also, on the sides 
 and bottom of the vessel is coarser dust, which likewise may not 
 be destroyed. 
 
 But, again, paraffin is very apt to crack, and after cooling 
 small cracks may occur which admit moistm-e and dust. To 
 obviate this risk the paraffin has been covered with oil ; but even 
 here the oil becomes laden with dust and passes down through 
 the cracks. 
 
 And, lastly, the knife, before dividing the tissue, compresses 
 the vessels and forces the blood out of them, and thus, when 
 these vessels are cut, air is sucked in, and this air carries its 
 dust with it quite out of reach of the heat of the paraffin. 
 
 In December 1877 I commenced a series of experiments on 
 this subject, and these have been continued at intervals since 
 that time. 
 
 The first experiment was an imitation of those of Billroth 
 and Tiegel (only it was performed antiseptically), and yielded 
 conflicting results. Thus the liver and kidney putrefied, while 
 the spleen, muscle, and mesentery remained unaltered. 
 
 This being the case, I determined to abandon this method 
 entirely, and to see if some definite conclusion might not be 
 arrived at in some other way. The following is a description of 
 the method I have employed : — 
 
 A number of beakers, each provided with a cotton cap, were puri- 
 fied by heat, somewhat after Mr. Lister's method, and into each vessel 
 about one-fourth of its volume of pure turnip iut'usioii was introduced 
 from one of the double-necked Masks (Fig 6, p. 1*J). This was done under 
 the spray, and the cotton caps were then reapplied. These beakeis 
 
40 THE rARTICULATE THEORY OF FERMENTATION. 
 
 were placed in an incubator, and kept at a temperature of 98° F. for 
 three or four days. At the end of that time the turnip infusion was 
 clear and unaltered, and the flasks were therefore considered ready for 
 use. 
 
 On January 6tli, 1878, four beakers having been thus jirepared, and 
 six beakers containing melted pai-affin being also at hand, a healthy 
 rabbit was iised for the following experiment. 
 
 The skin and hair of its abdomen having been thoroughly washed 
 with 1-20 carbolic lotion, the animal was killed by a blow on the back 
 of its neck, and the tibdominal cavity was rapidly opened, under a fine 
 spray of carbolic acid, with purified and heated instruments. Portions 
 
 of its organs and tissues were 
 rapidly cut out and intro- 
 duced into the beakers, 
 which were opened in the 
 spray. 
 
 Into the four vessels 
 containing the pure turnip 
 infusion portions of liver, 
 spleen, kidney, and muscle 
 respectively were intro- 
 duced, and the caps having 
 been reapplied while the 
 flasks were still in the spray, 
 they were then placed in an 
 incubator (see Fig. 14). 
 
 Into the six flasks con- 
 taining melted pai-affin por- 
 tions of liver, kidney, 
 spleen, muscle, mesentery, and vena cava, with its blood, were dropped 
 also undei- the spray. The parafl[in was left to solidify, and the 
 vessels were then placed in the incubator. 
 
 All those portions of organs introduced into the turnip infusion 
 remained ])ermanently puie and free from })utrefaction.' 
 
 Of the paraffin beakers, two (muscle and vena cava) remained 
 without change ; while the other four (liver, spleen, kidney, and 
 mesentery) putrefied. 
 
 In this experiment we have in the first case a series of 
 
 ' On December 24, 1880, I killed a rabbit and preserved its organs in the 
 way described here. Fig. :-54, Plate A^, is drawn from a specimen taken from 
 the beaker containing the spleen, and stained. It will be seen that no organ- 
 isms whatever arc present. 
 
ANIMAL TISSUES: MY OWN EXPERIMENTS. 47 
 
 beakers heated so as to destroy the activity of the dust adhering 
 to them, and that this was effectually done was proved by the 
 fact that the turnip infusion introduced into them underwent 
 no change, although, as has been amply shown in the fore- 
 going experiments, had ordinary unheated dust been jjresent, 
 this infusion would have undergone fermentation. 
 
 Further, the portions of the tissue are transferred from the 
 body to the beaker without the possibility of acquiring living 
 dust, for, as we have seen before, a spray of carbolic acid in an 
 ordinary atmosphere is able to destroy the fermenting power of 
 the dust. Such being the case, if the tissue, taken with all pre- 
 cautions undergo putrefaction, it is possible that the causes of this 
 fermentation were present in it while in the living body — the 
 degi'ee of probability depending of course in great measure on 
 the known skill of the experimenter. But if no change occm-s, 
 it is proof positive that there were no causes of change present 
 in the body. In other words, as these unboiled tissues remained 
 unaltered, it is quite certain that they have no inhei'ent tendency 
 to undergo fermentation even when freely exposed to air. 
 
 I used the turnip infusion partly because I wished to know 
 whether the beakers had been thoroughly purified, and partly 
 in order to keep the tissues moist, for I had found in a former 
 experiment that they dried too rapidly in the open-mouthed 
 vessel if no fluid were present. Since that time I have used 
 cucumber fluid, as being more putrescible. 
 
 Further, by the use of tliese infusions the conditions favoui- 
 ing fermentation are greater, for we have here a boiled highly 
 putrescible infusion of turnip, and an unboiled, if possible still 
 more putrescible, infusion of meat, as well as the meat itself. It 
 wei'e hardly possible to provide more favourable conditions for 
 fermentation. Nevertheless no change occurred. 
 
 I may here point out the light thrown by these experiments 
 on the cause of the want of success in the paraffln experiments. 
 In the first attempt which I made with tlie paraffln any of the 
 sup])osed causes of failure might have l)een in 0])erati()n, but in 
 the experiment just narrat(;d the entrance of aii- laden will) 
 septic dust into the blood-vessels is excluded because the opera- 
 tion was done in a spray of carbolic acid. Therefore the failure in 
 
48 THE rARTICULATE THEORY OF FERMENTATION. 
 
 the four vessels must have been due to dust in the paraffin, or 
 to cracking of this after solidification. 
 
 But, it may be said, the absence of putrefaction in the 
 beakers was due to the action of the carbolic acid on the 
 tissue. This, however, is not the case, for the following 
 reasons : — 
 
 In a preliminary experiment I touched the outside of the 
 flask (which was of course covered with impure dust) with one 
 of the portions of the tissue, and afterwards introduced this 
 piece into the flask, and in it putrefaction occurred rapidly. 
 Again, the fact that four paraffin flasks went wrong (the organs 
 being there also subjected to the action of the spray) shows 
 that this had no influence. Again, when the gall-bladder is 
 wounded fermentation often occurs. This latter fact is illus- 
 trated by the following experiment : — 
 
 A medium-sized rabbit was killed by a blow on the nape of the 
 neck. The abdomen bad been washed beforeliand with 1-20 carbolic 
 acid lotion, and was now rapidly opened under the spray. Into seven 
 beakers containing pure cucumber infusion, two pieces of liver, one 
 piece of kidney, one piece of spleen, one of muscle, and one of 
 mesentery were introduced. In cutting out the liver the gall-bladder 
 was injured. 
 
 Four weeks later, five beakers were unaltered, the two which had 
 fermented being those containing the pieces of liver, which indeed had 
 undergone fermentation within twenty-four hours. 
 
 I have since met with sevei-al similar instances. 
 
 Further, if putrid matter be injected into the jugular vein 
 of the animal a few minutes before death, all the tissues re- 
 moved and preserved in the manner described undergo putre- 
 faction. 
 
 I have repeated these experiments many times with like 
 results,' and I therefore conclude that the tissues of the healthy 
 
 ' On two occasions I have found that the apparently healthy living tissues, 
 preserved by the method before described, underwent fermentation and 
 organisms developed in them. In one case the kidney alone of all the organs 
 taken, and in another both kidney and liver, miderwent fermentation with 
 development of organisms, and as I was very careful in performing the expe- 
 riments, I do not think that this could have occurred from any error in experi- 
 mentation, and therefore I conclude that the causes of fermentation (micro- 
 organisms, as we shall afterwards see) were present in the healthy circulating 
 
GENERAL CONCLUSIONS. 49 
 
 living body, like the fluids, contain no ferment capable of causing 
 putrefaction after death, and remain pure in flasks so long as the 
 dust of the atmosphere is excluded. (In some instances the heart 
 with its contained blood was also removed, and remained, like 
 the other tissues, unaltered. Rabbits and cats were the animals 
 used for the experiments.) 
 
 Somewhat similar experiments Avere published in 1878 by 
 Chiene and Ewart, and they yielded similar results.' 
 
 Quite recently,^ Rosenbach mentioned experiments on this 
 subject performed by Meissner. Meissner was able to preserve 
 the internal organs of cats and rabbits in contact with boiled 
 water and pure air, for two to three years, without the occur- 
 rence of any putrefactive change. He was also successful in 
 preserving the blood of mammalia, human urine, and g'oat's 
 milk. The experiments were done with strict aseptic j^recau- 
 tions, and led him to conclusions similar to the above. 
 
 Such, then, are the chief facts at present known with regard 
 to boiled and unboiled fluids and tissues. We shall add much 
 to them, and to the support which they give to the views here 
 expressed, when we come to consider more minutely what is 
 the nature of the particles which cause putrefaction. 
 
 On reviewing the mass of evidence before us we have it dis- 
 tinctly shown that boiled fluids and tissues have no inherent 
 tendency to undergo fermentative changes ; that oxygen, whether 
 pure, nascent, or mixed with nitrogen in the proportions present 
 in air, cannot cause fermentation, if only the air be previously 
 passed through such a liquid as sulphuric acid, be heated 
 strongly, be Altered through cotton wool, be made to enter 
 very slowly into the flask containing the fluid or allowed to 
 deposit its dust by gravitation, or be previously acted on by 
 carbolic acid. 
 
 blfiod. That an orgniiif^jn may be present in an active state in tlic circulating 
 blood need not be a matter of surprise, and need not therefore lead us to the 
 conclusion that they are always or even generally there, especially as one 
 single organism would be sufficient to account for the result in each of these 
 instances. It is indeed surjirising that organisms which must now and then 
 enter the blood arc so rapidly and surely destroyed. 
 
 ' Journal of Aiuitonnj and I'Jn/Riolofjy. 
 
 ■ Uvidschc ZcitH'-hrift fiir C/nrurf/ie, xiii. .'544. 
 
 E 
 
50 THE PARTICULATE THEORY OF FERMENTATION. 
 
 Thus the material in the air which causes putrefaction is 
 not a gas, for that would be continuous, and would not be re- 
 movable by filtration or by rest ; but it is something discon- 
 tinuous, something heavier than air, something particulate. 
 These particles may be deprived of their power of causing 
 fermentation by the action of chemical substances, such as 
 sulphm'ic and carbolic acids, and also by being subjected to a 
 high temperatm'e. As they are completely destroyed by heat 
 (as shown by Tyndall), they are probably of an organic 
 nature. 
 
 And it is not that by boiling these fluids an inherent 
 tendency to ferment has been destroyed, for, as we have seen, 
 they possess no such inherent tendency. For not only do 
 unboiled fluids and tissues outside the body fail to putrefy 
 when protected carefully from dust — they also undergo no 
 change, as indeed necessarily follows from the foregoing, when 
 confined in natural or artificial cavities in the living body. 
 Who is not acquainted with the behaviour of blood when ex- 
 travasated into the tissues or cavities of the living body so long 
 as it is not exposed to the outer world ? We all know what 
 a large amount of effused blood may be present about the 
 ends of a fractured bone without decomposition occurring in it, 
 and the same is the case in the hemorrhages into joints in 
 hemophilia, hemorrhages within the skull, &c. And we also 
 know what frequently happens if we cut into any of these 
 extravasations and admit dust-laden air into them. The blood 
 which we found odourless, and it may be clotted, may become 
 in a few hours a foul- smelling liquid ; it has, in fact, putrefied, 
 just as it may do when kept in a flask without exclusion of dust. 
 And just as in the case of blood, so with other fluids. Hy- 
 drocele and serous effusions remain unaltered so long as they 
 are kept from the dust. Examine the pus from a chronic 
 abscess, and even though that abscess be connected with carious 
 bone, it will be found to be odourless and bland, and if carefully 
 received into pure flasks, will, just as in the case of blood, 
 remain odourless and apparently unchanged for an indefinite 
 length of time. (I shall give later on the explanation of the 
 cases where the pus of acute abscesses, when let out, is found to 
 have a foul smell, as is sometimes the case in acute necrosis.) 
 
CONCLUSIONS. 51 
 
 And not only is this the case with fluids, it is also the case 
 with tissues in the living body. In a fractm-e many portions 
 of the tissue are cut off from their vascular supply, or killed by 
 the violence causing the injury, and yet they do not decompose ; 
 they are not separated as sloughs — they disappear by absorption. 
 Yet if the same injury be not subcutaneous and the injured 
 parts be exposed to ordinary air, they putrefy, and come away in 
 a few days as sloughs. 
 
 So in infarcts in internal organs, the tissue in the region of 
 the infarct dies, but does not putrefy — does not slough ; while 
 when death of the integuments occurs, putrefaction and slough- 
 ing follow, for here the dead tissue is exposed to the dust of 
 the atmosphere. 
 
 Similarly, in the case of wounds, when a piece of skin is cut 
 away and an open sore is left, the blood and serum which col- 
 lect in that sore ferment, in all probability putrefy, because the 
 air admitted to them was not heated air, not filtered air, was 
 air which had not been acted on by suitable chemical sub- 
 stances. 
 
 The causes of fermentation are therefore solid particles, pro- 
 bably of an organic nature, which are present in varying quan- 
 tities in the surrounding air, and which are deposited as dust 
 on all surrounding objects. 
 
 It is thus evident that in order to prevent putrefaction it is 
 only necessary to prevent the access of these particles, or, if 
 this cannot be done, to destroy their fermenting power in some 
 way or other before they reach the wounds — as, for instance, by 
 the use of carbolic acid. 
 
 It is on this principle that Aseptic Su7'gery,^- as introduced 
 by Mr. Lister, is based. 
 
 ' The term ' aseptic ' is the best to indicate this form of antiseptic surgery, 
 because, as we siiall see, there are many different forms of treatment which 
 come under the term 'antiseptic,' while this is the only one which can truly 
 bear the name 'aseptic' In other words, there are many methods by which 
 the occurrence of putrefaction is more or less interfered with, but they all act 
 on a more or less imperfect principle, with the exception of that introduced 
 by Mr. Lister, which, founded on a true principle, attains the ideal of results 
 — viz. a complete absence of putrefaclion— an asepsis. His methcd, then, is 
 best designated by the term expressing its result — Aseptic. 
 
 E 2 
 
52 ASEPTIC SURGERY— MATERIALS EMPLOYED. 
 
 CHAPTER in. 
 
 ASEPTIC SURGERY MATERIALS EMrLOYED. 
 
 Problems to be solved in order to keep a wound aseptic : Carbolic acid — 
 CarhoUc lotions — Pure carholic acid — SoUttioitin metliylated sjnrit — carbolic 
 oil — Carbolic acid and glycerine: Sj^ray producers: Catgut — Carholiscd 
 catf/ut — Mr. Lister's carholiscd chromic catgut — Dr. MacEwen's chromic 
 catgut— Ca-tguttrough and pocltet caxe: Carbolised silk : Protective: Carbolic 
 gauze — Composition — 3Iethod of preparation — Von Bruns'' gauze: Mac- 
 intosh : Sponges : Boracic acid — Boracic lotion — Boracic lint — Boracic 
 ointm-ent: Salicylic a-cid— Salicylic acid cream — Salicylic ointment : Chlo- 
 ride of zinc : Iodoform : Carbolised cotton wool. 
 
 Aseptic surgery is based on the piinciple first enunciated by 
 Mr. Lister, and indicated in the preceding pages ; viz. the 
 exclusion of active ferments from the discharges of wounds. 
 
 Theoretically, this is the ideal form of antiseptic surgery, for 
 here, supposing that the attempt is successful, the causes of 
 putrefaction do not enter the wound in a state capable of pro- 
 ducing fermentation, and therefore decomposition of the dis- 
 charges, or of dead portions of tissue, &c., cannot 2:)0ssibly 
 occur. 
 
 The problem which Mr. Lister sought to solve may be 
 shortly stated as follows : — 
 
 On all objects in the external world septic dust is present — 
 on the skin of the patient, on the hands of the surgeon and 
 his assistants, on all instruments, in water, in the air, &c. ; 
 and when a wound is made any introduction of this dust 
 must be carefidly avoided. Then after the wound has been 
 made, care must be taken to prevent its entrance during the 
 after-treatment. Some sort of dressing must be provided 
 which shall prevent its passage in an active state, and at 
 each change of this dressing the problem is the same as at 
 the time of infliction of the wound. Such being the question 
 
CARBOLIC ACID. 63 
 
 at issue, I must now proceed to the modes in which it has been 
 answered. 
 
 I shall first enumerate the substances employed in aseptic 
 surgery. 
 
 Carbolic Acid is the antiseptic employed to destroy the 
 particles in the air and on surrounding objects which give rise 
 to putrefaction. It is obtained in the solid state and of ex- 
 treme purity from Bowdler and Bickerdike, Church, Lancashire, 
 who give it the name of Absolute Phenol. It is used in various 
 forms. 
 
 The Cai'bolic Lotions used are of two strengths — 1 in 20 
 and 1 in 40 ; one part of crystallised carbolic acid dissolved in 
 20 or 40 parts of water respectively. The solution is kept in 
 a stoppered bottle in order to avoid evaporation of the acid. It 
 ought to be quite clear ; when it is not so, and more especially 
 when globules of oily matter are present, it is impure, the 
 oily particles consisting of cresylic acid. It is a mistake to add 
 alcohol or glycerine to aid the solubility of the acid, because 
 these substances hold the acid more tenaciously than water, and 
 it is thus not so potent for producing an instantaneous effect. 
 
 Undiluted Liquid Carbolic Acid may in some cases be 
 required. This is obtained by liquefying the crystals by the 
 addition of a few drops of water. This is chiefly used for 
 injecting naevi, varicose veins, vtc. 
 
 A solution of carbolic acid in methylated spirit or in recti- 
 fied spii-it, in the proportion of 1-5, is used for the purpose of 
 purifying wounds inflicted some twenty-four or thirty-six hours 
 before coming under treatment. 
 
 Carbolic Oil is employed in various proportions, generally 
 1 in 5, 1 in 10, and 1 in 20, consisting of carbolic acid mixed 
 with olive oil in the foregoing proportions. 
 
 Carbolic oil 1-5 is but rarely used, tliough it is occasionally 
 applied as a dressing to foul wounds, for the purpose of purify- 
 ing them. It is chiefly known as the solution in which catgut 
 is permanently preserved. 
 
 Carbolic oil 1-10 is used as a dressing for wounds in the 
 neighbourhood of the anus, penis, &c. 
 
 Carbolic oil 1-20 is used for oiling catheters or other in- 
 
64 
 
 ASEPTIC SUROERY^MATERIALS EMPLOYED. 
 
 struments before introducing them into tlie bladder. Carbolic 
 acid of this strength does not seem to be too irritating for the 
 
 Fig. 15.— Hand spray producer. 
 
 mucous membrane of the urethra, while it apparently secures 
 against the introduction into the bladder of matters which are 
 capable of causing putrefaction. 
 
 There are various objections 
 to these oily dressings. The chief 
 are, that the carbolic acid is very 
 rapidly washed out by the dis- 
 charge, and that they are very 
 dirty, and soon spoil india-rubber 
 tissues. 
 
 The latter disadvantage is got 
 rid of by the use of carbolic acid 
 and glycerine in the proportions 
 of 1-5 and 1-10. This is now 
 employed as a dressing in the cir- 
 cumstances in which the oil has been generally used. 
 
 A sjjray of carbolic acid is generally employed in order to 
 purify the atmosphere. This is obtained by driving a rapid 
 
 Fig. 16.— The ordinary steam 
 spray producer. 
 
CARBOLIC ACID SPRAY. 
 
 55 
 
 current of air or steam through a horizontal tube so as to pass 
 over the orifice of a more or less vertical one. In this way a 
 vacuum is produced in the vertical tube, and the fluid at its 
 lower end rises, and is expelled from the orifice in the form of 
 spray. We have two forms of spray : one in which air is 
 
 
 Fig. 17, 
 
 Steam spray producer, showing the lamp at present 
 
 IN USE. 
 
 It consists of a small flamo, which plays on a plate of metal attached to a hollow central tiibe 
 containing a wick, and perforated by holes at the top. The heat is communicated to tlie wick 
 —the spirit volatilises, and Inirns as it escapes from the top of the tube. The hole in the plate 
 allows the flame of tlje snjall wick to pass up and li^■ht the spirit vapour, which jiasscs out through 
 the holes at the top of the central tube. The cap, which is jjlacfd over the lamp when not in use, 
 and the boiler and vessel for the carbolic acid, are indicated by dotted lines. 
 
 driven over the vertical tube — hand or foot sprays ; and the 
 other in which steam is employed — steam sprays. The hand 
 or foot sprays produce a somewhat coarse spray, and the force 
 required is such as soon to exhaust the individual employed. 
 They are therefore very uncertain implements, and have now 
 entirely given place to the steam spray.-;, where there is a steady 
 current as long as the water in the boiler lasts. When the 
 hand s])rays are emi)loypd 1-40 solution is placed in the bottle. 
 
50 
 
 ASEPTIC SURGERY— MATERIALS EMPLOYED. 
 
 In the steam spray the 1-20 solution is used because the steam, 
 mixing with the solution, reduces its strength to 1-30 or 1-35. 
 I need not describe here the steam spray apparatus, more 
 especially as it can be easily obtained, of Mr. Lister's pattern, 
 from David Marr, 27 Little Queen Street, Holborn. These 
 sprays consist of the following parts : — A boiler which contains 
 water, and which is heated by a spirit lamp placed beneath it. 
 The steam issues through a tube placed at an angle to another 
 more upright one, through which the carbolic acid lotion 1-20, 
 
 which is placed in the glass 
 retort, is sucked up. This 
 1-20 lotion, mixing with the 
 steam, makes a solution of 1-30 
 to 1-35. The carbolic acid 
 solution passes through a 
 sponge at the bottom of the 
 upright tube, which filters it, 
 and thus prevents the minute 
 orifice of the tube from be- 
 coming choked up by coarse 
 particles. These sprays are of 
 various sizes, and the largest 
 ones have two nozzles, which 
 may be vised singly, or to- 
 gether where the field of operation is large as in ovariotomy. 
 
 The catgut used for tying the vessels is prepared in the 
 following manner : — Ordinary catgut as obtained from the 
 shops, when introduced into blood-serum, soon swells up and 
 becomes weak. At the same time it is very slippery, and a 
 knot will not hold ; and when placed in the tissues it very 
 rapidly becomes absorbed. With the view of obviating these 
 defects it is prepared by placing it in a solution of carbolic acid 
 in oil (1-5) with a very small quantity of Avater (10 per cent.) 
 diffused through the oil. As the water ultimately falls to the 
 bottom, a few pebbles are placed on the bottom of the vessel, on 
 which the catgut rests. It does not then come in contact with 
 the water. As a result of keeping it in this solution, the 
 catgut first becomes supple and soft, but afterwards harder and 
 firmer, and is then al)le to resist the action of the fluids and 
 
 Fig. 18.— Large steam spray riio- 
 
 DUCER WITH DOUBLE NOZ/LE FOR 
 OVARIOTOMY, ETC, 
 
CATGUT. 67 
 
 tissues for a considerable time. It is kept in this fluid for six 
 or eight months, and is then transferred to the ordinary 1-5 
 oily solution. The longer it is kept in this solution the better 
 it becomes. The rationale of this method will be found in 
 ^Mr. Lister's paper in the ' Lancet ' of Feb. 5, 1881. 
 
 Quite recently ^ jNL-. Lister has published a new method of pre- 
 paring catgut, by means of which a stronger article is obtained, 
 and one not absorbed nearly so soon as the old kind. It also 
 possesses an advantage over the old kind, in that it disappears 
 by erosion of the surface, and does not become infiltrated with 
 cells, as is the case with the ordinary forms. It thus remains 
 as a firm constricting band, till it is completely replaced by new 
 tissue. I cannot do better than quote JVIr. Lister's description 
 of the method by which this gut is prepared : ' I dissolve one 
 part of chromic acid in 4,000 parts of distilled water, and add 
 to the solution 200 parts of pure carbolic acid, or absolute 
 phenol. In other words, I use a 1-20 watery solution of 
 carbolic acid — only that the carbolic acid is dissolved, not in 
 pure water, but in an exceedingly 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 power- 
 ful effect upon the gut. The first effect of the addition of 
 the carbolic acid to the chromic solution is to change its pale 
 yellow 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 considerable 
 amount of reddish grey j)recipitate 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 bright- 
 ness, and the only change observed is the gradual diminution of 
 the depth of the yellow colour; the precipitate, which I pre- 
 sume still occurs, taking place into the substance of the catgut. 
 As soon, therefore, as the preparing liquid has been made, cat- 
 gut equal in weight to the phenol is introduced into it. If 
 you have too large a ]»roportion of catgut, it will-not be suffi- 
 ciently ])repared; if you have too small a (juantity, it may run 
 the risk of being over-prepared. At the end of forty-eiglit 
 
 ' Lancet, Feb. 5, 1881. 
 
58 ASEPTIC SURGERY— MATERIALS EMPLOYED. 
 
 hours the chromic element of the liquid has nearly spent itself, 
 and precipitation is complete. The catgut is then taken out 
 of the solution and dried, and when dry placed in 1-5 carbolic 
 oil : it is then fit for use. . . . The preparing liquid causes 
 a certain amount of softening of the catgut, and if it is intro- 
 duced in loose hanks, this will tend to produce a little uncoil- 
 ing 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 degi'ees 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 manufacturer. I may only say this, that the surgeon 
 who wishes to prepare it himself 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, 
 and then bringing it up again, and fixing the other end 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, with a little 
 shot 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 
 completely 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 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.' Erosion of this catgut does not begin till about a 
 fortnight after its introduction into the tissues. 
 
 Dr. MacEwen has lately brought forward a somewhat 
 different method of preparing catgut.' ' These ligatures are 
 prepared by making, first, a watery solution of cliromic acid, one 
 
 ' Britisli Medical Journal, Jan. 2'.), 1881. 
 
CATGUT. 
 
 59 
 
 to five ; then one part of this solution is added to twenty of 
 glycerine. This forms a dark greenish compound, in which the 
 hanks of catgut are inserted and retained for seven or eight 
 months, the bottle containing them being occasionally shaken. 
 At the end of this time the catgut acquires a semi-translucency, 
 and has a dark colour like preserved ginger. It is then ready 
 
 Fig. 19. — Trough for catgut. 
 
 for use, and is stored in a solution of carbolic acid and glycerine 
 (one to ten).' Ligatures so prepared begin to soften on an 
 average about the fourteenth day, and are more or less com- 
 pletely absorbed the twentieth day. 
 
 A very convenient method of keeping catgut for use in 
 hospital is to wind it round reels, say three, each holding a 
 different thickness of gut, which are suspended in a vessel 
 
 X._^ 
 
 V ^ 
 
 ^ ^' 
 
 -^^^^ 
 
 Fig. 20. — Lister's pocket catgut holder. 
 
 A, HoMcr complete. B, The reel on which the catgiit is wound. 
 
 containing carbolic oil 1-5 (see Fig. 19). The lid of the box 
 is perforated with holes through which the ends of the catgut 
 pass. In this way the gut may be taken directly from the 
 oily solution without any trouble. 
 
 In order to have a supply of gut always at hand, jNIr. T.,ister 
 has devised the catgut holder shown in the accompanying figure 
 (P^'ig. 20). The gut is wound on a reel which is carried in a 
 German silver case. There is no necessity to fill tin's case with 
 
60 ASEPTIC SURGERY— MATERIALS EMPLOYED. 
 
 carbolic oil, as is done by some surgeons. Sometimes the case 
 is combined with a caustic holder at the other end. 
 
 Carbolised Silk is often used for sutures, and is prepared 
 as follows : — Nine parts of beeswax and one part of carbolic acid 
 are melted together. Silk thread of various sizes is steeped 
 for some minutes in this mixture, till it is thoroughly impreg- 
 nated with it. As the thread is taken out, it is drawn through 
 a cloth in order to remove the superfluous wax. The wax holds 
 the carbolic acid, makes the thread more useful, and fills up to 
 some extent its interstices, thus preventing it from becoming 
 soaked with fluids. The carbolised silk thus prepared is kept 
 permanently in stoppered bottles, or wrapped in carbolic gauze. 
 It must- not be steeped for any length of time in the lotion 
 before being used, because the threads become opened out. If 
 the thread be properly kept, the interior is aseptic or even anti- 
 septic, and passing the thread through the fingers moistened 
 with carbolic lotion, or a momentary immersion in 1-20 car- 
 bolic solution, is sufficient to destroy any septic dust adhering 
 to its exterior. 
 
 In order to protect healing wounds from the irritation of 
 carbolic acid a special material is employed termed the Protec- 
 tive. This consists of oiled silk coated with copal varnish. 
 When this is dry a mixture of one part of dextrine, two parts of 
 powdered starch, and sixteen parts of cold watery solution of 
 carbolic acid (1-20) is brushed over the surface. The rationale 
 of this method of preparation is the following : — Oiled silk alone 
 is better for the purpose of a protective than gutta-percha 
 tissue, because carbolic acid does not so readily pass through it. 
 It does, however, do so, and therefore copal varnish, which is 
 almost absolutely impermeable to carbolic acid, is added. As, 
 however, the fluid collects on this as on a duck's back, leaving 
 intervals between each drop on which dust may fall and escape 
 the action of the acid, the dextrine solution is added, and the 
 result is, that when moistened the whole surface of the protec- 
 tive remains imiformly wet. The use of the carbolic acid in 
 the dextrine solution is not to add any carbolic acid to the pro- 
 tective, but because it is better than water for enabling the 
 dextrine to adhere to the varnished oiled silk. For the same 
 reason the ])owdered starch is added. The original carbolic 
 
CARBOLIC GAUZE. 61 
 
 acid flies off very quickly from the protective, leaving a material 
 containing no antiseptic in its substance. 
 
 Garholic Gauze is the material generally employed as a 
 dressing to guard against the entrance of causes of fermentation 
 into a wound after an operation. The gauze used is ordinary 
 fine unbleached tarlatan washed and dried. There are various 
 methods of impregnating this gauze with carbolic acid. I will 
 give Mr. Lister's description of a simple method, w^hich can be 
 used in any hospital, and which was recently employed during the 
 Russo-Turkish war for making fresh gauze in camps. ^ The 
 mixture employed for charging the gauze was originally one part 
 of carbolic acid, five parts of resin, and seven parts of paraffin. 
 Lately the formula has been changed to one part of crystallised 
 carbolic acid, four parts of common resin, and four parts of 
 paraffin. These materials, mixed together, are added to an equal 
 weight of unprepared gauze. ' In order to charge the gauze, 
 the paraffin and resin are first melted together in a w^ater 
 bath, after which the acid is added, and blended by stirring. 
 The object now is to diffuse this melted mixture equally 
 through the cotton cloth, and for this purpose two things are 
 requisite, viz. that the cotton be at a higher tem})erature 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 l^een 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. There 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 fjurface. The weight is lieatcd along 
 with the cotton, and is puf, ^rst into the cl;:imber so as to leave 
 ' See Lancet, Marcli 13, 1875. 
 
(i2 ASEPTIC SURGERY— MATERIALS EMPLOYED. 
 
 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 equally 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 pro- 
 tect 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 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 com- 
 plete diffusion of the liquid, when the material is fit for use. 
 The apparatus above described can be made by a common tin- 
 man for about lOL' Fig. 21 shows the apparatus employed in 
 the Griasgow Infirmary. • 
 
 As the muslin is the dearest item in the gauze Mr. Lister 
 has suggested that the dressings should be washed and the 
 gauze recharged. The larger dressings are therefore kept and 
 sent back to the manufacturer, who washes and recharges them. 
 This recharged gauze can then be used as loose gauze in future 
 dressings. 
 
 In this gauze the carbolic acid is the only active agent ; the 
 resin is used to hold the acid — i.e. to prevent it from being 
 washed out too soon by the discharge — while the paraffin is 
 employed to lessen the adhesiveness of the resin. The gauze 
 
 ' See ' Practical Papers on the JIaterials of the Antiseptic Method of 
 Treatment.' I'y George lieatson. Glastjow Medical Journal, March 1880. 
 
CARBOLIC GAUZE. 
 
 63 
 
 ought to be kept in a tin box, closing tightly to prevent 
 evaporation of the carbolic acid. It is used either in the form 
 of loose gauze or folded dressings and bandages. 
 
 A great many different ways of preparing gauze have been 
 published, but none are so good as that just described. 
 
 Von Bruns has lately recommended a gauze containing 
 castor-oil instead of paraffin. 
 
 His formula is — 
 
 Carbolic, acid 
 Resin 
 Castoi--oil 
 Spirit 
 
 1 part 
 4 parts 
 8 „ 
 20 „ 
 
 Fig. 21. — Machine used in the Glasgow royal infikjiary for 
 manufacturing gauze. 
 
 A is tlie receptacle for the antiseptic mLxture of carbolic acid, resin, and paraffin ; E is the tin 
 case in whicli the muslin is heated, impregnated with the mixture, and submitted to pressure. 
 IJ is a pipe whicli conveys steam for heating the apparatus, and E E are stopcocks for turning 
 on or shutting off the steam in connection with either A or B. (From Dr. Beatson's ' Practical 
 Papers on Antiseptic Surgery.') 
 
 The resin is first dissolved in the spirit, then the carbolic 
 acid and castor-oil are added. The gauze is simply soaked in 
 this, and then hung up to allow the spirit to evaporate. The 
 objection to this gauze is that the castor-oil interferes with the 
 affinity of resin for carbolic acid, and thus the carbolic acid will 
 be sooner washed out, «ind the gauze thereby rendered less 
 trustworthy. 
 
 In order to prevent the discharge from soaking directly 
 through the dressing macintosh cloth is used. This is 
 cotton cloth with a thin layer of india-rubber spread on one 
 
64 ASEPTIC SURGERY—MATERIALS EMRLOYED. 
 
 side. It is placed outside the gauze dressing. As a rule one 
 layer of the gauze comes outside it, partly in order to keep it 
 in position, and partly also, in case any hole should exist in the 
 macintosh, to have a little antiseptic material outside. Care 
 is taken that the side on which the india-rubber is spread goes 
 next the wound, for if the other side be placed inwards it absorbs 
 discharge, and, not being itself antiseptic, it becomes in reality 
 a piece of impure cotton in the interior of the dressing, and 
 may thus communicate putrefaction inwards. The macin- 
 tosh itself also gets spoilt when so used. The dressing con- 
 sists of a piece of gauze of sufficient size folded in eight layers, 
 beneath the outer layer of which the mackintosh cloth is 
 placed. 
 
 Sponges are washed after an operation, and are then kept 
 soaking till required in a jar containing carbolic acid 1-20. 
 During an operation they are washed in 1-40 carbolic acid 
 lotion. 
 
 These sponges often become filled with fibrin, and thus 
 rendered more or less useless. It is very difficult to remove 
 this fibrin by washing. Mr. Lister, therefore, after an operation 
 places the sponges in a tank containing water. Putrefaction 
 of the fibrin occurs, and after some days the sponges can be 
 easily cleansed. They are then placed till required in the 
 1—20 carbolic solution. 
 
 When the wound becomes quite superficial, various prepar- 
 ations of BoKACic Acid may be employed with advantage. 
 
 Boracic lotion is a cold saturated solution of boracic acid 
 (BgOgSHgO) in water. This acid is soluble in 25 to 30 parts 
 of cold water, and in very much larger proportion when the 
 water is boiling. It is convenient to tinge this solution with 
 litmus in order to distinguish it from the carbolic lotions. 
 
 Boracic lint is ordinary surgical lint soaked in a hot saturated 
 solution of boracic acid and then hung up to dry. About half 
 its weight consists of crystals of the acid. This is also stained 
 with litmus. 
 
 Boracic ointment is employed in certain cases. Two 
 strengths are commonly used, called full strength and half 
 strength ; the former being applied to wounds where cavities 
 exist, the latter to superficial wounds which one wishes to heal 
 
SALICYLIC ACID. 65 
 
 rapidly. The following is the original formula for the full 
 strength ointment : — 
 
 Boracic acid crystals ..... 1 part 
 
 White wax ....... 1 „ 
 
 Paraffin ........ 2 parts 
 
 Almond-oil ....... 2- „ 
 
 First mix the wax and paraffin by heating them together, 
 then add the oil ; mix the crystals with this in a warm 
 mortar, and continue the process of mixing till the liquid 
 solidifies. Spread on thin cotton cloth. 
 
 The half strength contains half the quantity of boracic acid. 
 
 A much softer and more manageable boracic ointment is 
 now made with vaseline. The following is the best formula : — 
 
 Make a basis of 2 parts of paraffin to 1 part of vaseline. 
 Take of this o parts 
 
 „ boracic acid, 1 part. Mix. 
 
 Salicylic acid cr'eam is used for applying around a wound 
 when a dressing is to be left on for some days. It prevents 
 irritation by the discharge. It formerly consisted of salicylic 
 acid crystals mixed with 1-20 carboh'c acid lotion in sufficient 
 quantity to form a creamy fluid. This is apt to separate into 
 two layers, and therefore it is better to make a cream by mixing 
 salicylic acid with glycerine so as to form a paste. This latter 
 cream remains of uniform consistence, and is easily applied. For 
 this purpose Mr. Lister uses glycerine and carbolic acid 1-10. 
 
 The' formula for salicylic oinhnent is — 
 
 Of the same l^ase as is used for boracic acid . 29 parts 
 Salicylic acid ....... 1 part. 
 
 For the purpose of purifying sinuses, putrid ulcers, &c., a 
 solution of chloride of zinc is used of the strength of 40 grs. 
 to the oz. of water. This is either apjdied on lint to the whole 
 surface of a wound, or it is injected by means of a syringe and 
 catheter into all the deep parts of the wound, care being taken 
 to provide free exit for the fluid injected. If the exit of the 
 solution is obstructed, it may pass into the tissues and cause 
 gangrene. 
 
 lodofoivi is now applied to the surface of ulcers, and 
 
 F 
 
66 ASEPTIC SURGERY— MATERIALS EMPLOYED. 
 
 answers the same purpose as the chloride of zinc solution, while 
 it causes no pain. 
 
 Carholised cotton ivool is used in some cases of gangrene. 
 It is obtained by soaking pure cotton wool in a 1 per cent, 
 solution of carbolic acid in ether. The cotton is then dried and 
 used immediately. 
 
DESCRIPTION OF AN ASEPTIC OPERATION. 
 
 CHAPTER IV. 
 
 ASEPTIC SURGERY (continvcd). 
 
 Example of an aseptic operation : Purification of the skin — Fingers — Instru- 
 ments : Spray — Precautions — Probable errors, and mode of remedying 
 them : Guard : Ligature of arteries : Drainage of wounds — India-rubber 
 tubes — Catgut drains — Horse hair — Decalcified bone tubes (Neuber's and 
 MacEwen's) : Sutures ; Button stitches — Stitches of relaxation — Stitches 
 of coaptation — Aseptic strapping — Protective : Deep dressing : Loose 
 gauze : Gauze dressing : Elastic bandage. Changing the dressings — 
 Time— Method. Treatment op ulcers : Purification of the sore : Boracic 
 dressing : Boracic and salicylic ointment : Boracic poultice. 
 
 Having described the materials employed in aseptic sm-gery, 
 we must now consider how they may best be employed. Take 
 as an example of an operation the removal of a fatty tumonr. 
 
 The patient having been brought under the influence of 
 chloroform or other amesthetic, the skin over the tumour, and 
 for some distance in the vicinity, is thoroughly pmified from 
 any active dust by washing it well with a solution of carbolic 
 acid 1-20. The surgeon and his assistants also wash their 
 hands in 1-40 carbolic lotion, while the instruments are put to 
 soak in 1-20. A towel is arranged close to the tumour, gene- 
 rally on the part of the table between the operator and the 
 patient, which towel has been well soaked in 1-20 carbolic 
 lotion, and is meant as an antiseptic basis on which instruments 
 may be laid during the course of the operation without any 
 fear of their contamination. This towel is so arranged as to be 
 within the cloud of spray. A spray being now made to play 
 over the i)art from a convenient distance, the surgeon makes his 
 incisions, removes the tumour, ties the vessels with catgut, 
 introduces a suitable drain, stitches up the wound, and a])i)lies 
 a piece of protective but little larger than the wound — the pro- 
 tective being of course dipped in the 1-40 carbolic solution. 
 
 p2 
 
68 ASEFTIC SURGERY. 
 
 Outside this is applied a piece of wet gauze, consisting of 
 several layers of loose gauze which has been soaking for some 
 time in the 1-40 carbolic solution. This wet gauze and pro- 
 tective are called the deep dressing. The wet gauze must 
 overlap the protective in all directions. Then any remaining 
 hollow is filled up with loose gauze, and outside the whole a 
 gauze dressing is fixed. This dressing consists of a piece of 
 carbolic gauze of suitable size, folded in eight layers, and having 
 the macintosh placed beneath the outermost layer, with the 
 india-rubber side inwards. The dressing is fixed by means of a 
 bandage, and when this is accomplished the spray may be 
 stopped. Then around the edge of the dressing an elastic 
 bandage is applied so as to keep the edge constantly in contact 
 with the body, and to allow no interval to occur between the 
 dressing and the skin during the movements of the patient. 
 The elastic is carefully fixed to the edge of the dressing by 
 means of safety pins. 
 
 In the after progress of the case the dressing is changed 
 according to the amount of discharge, though in no instance 
 is it left longer than eight days. 
 
 Such is, very briefly, a sketch of the ordinary method of 
 performing operations aseptically. I shall now consider each 
 step in detail, and point out the most frequent sources of 
 failure in carrying out the method ; for it must always be 
 borne in mind that the whole operation, as far as regards the 
 avoidance of putrefaction, requires as much care as if it were an 
 experiment performed in a laboratory on putrescible fluid con- 
 tained in glass vessels. 
 
 The first thing, then, is to purify the skin in the neigh- 
 bourhood of the seat of operation. This is necessary, because 
 the skin is covered with dust. The natural grease of the skin is 
 not easily removed by simple washing, and it protects the septic 
 particles present beneath it and in the hair or sebaceous follicles. 
 This purification of the skin is carried out by washing it well 
 with 1-20 carbolic lotion, the antiseptic being allowed to act 
 for some little time. It is well, having first washed the neigh- 
 bourhood thoroughly, to apply over the seat of operation a 
 large rag or towel soaked in 1-20 solution, and to allow this to 
 remain on the part for some minutes. Where the epidermis 
 
PURIFICATION OF THE SKIN. 69 
 
 is thick, or where there is any putrid matter present, it is best 
 to apply this towel about half-au-hour before the operation. It 
 is not necessary to wash the skin with soap and water, or with 
 alcohol or ether, as is often done in Germany. The carbolic 
 acid has a wonderful power of penetrating grease or epidermis ; 
 and if time be given for it to act it is unnecessary to wash off 
 the grease beforehand. If the wound is to be in the neigh- 
 bourhood of hair, as in the axilla or near the pubis, the part 
 must be shaved, and then well soaked with the carbolic lotion. 
 
 The errors in the purification of the part may be that the 
 skin is not purified at all, or that it is washed with water ; or, 
 as I have seen, the operator simply allows a carbolic spray to 
 play over it for a minute or two, and is satisfied with this ; or 
 he merely rubs the siuface with his wet finger. This purifica- 
 tion must, however, be done thoroughly, for every hair follicle 
 and gland duct may contain causes of putrefaction. Carbolic 
 oil is used by some instead of the watery solution to purify the 
 skin. This is a great mistake, for oil has a much greater 
 affinity for carbolic acid than water has, and therefore the 
 carbolic acid in the oily solution does not act with the same 
 rapidity as the watery solution. Thus 1-20 or even 1-10 car- 
 bolic oil is not nearly so useful for producing an instantaneous 
 effect as 1-20 carbolic lotion. 
 
 At the same time the operator and his assistants purify their 
 hands. This must also be done thoroughly, and the folds of 
 skin about the nail more especially must be well cleansed with 
 the lotion. In an important operation, as in an o})eration on 
 a joint, it is well to use 1-20 carbolic lotion for this purpose, 
 so as to avoid any chance of a lurking particle ; but in ordinary 
 operations 1-40 is quite sufficient. This purification of the 
 hands is only too apt to be a sham, no care being taken about 
 the nails and folds of skin. The 1-20 is not used in all cases, 
 because 1-40 is really sufficient, and the stronger solution is 
 apt to benumb the hand. 
 
 The instruments are purified by immersion in 1-20 carbolic 
 lotion before theojjeration. A tin or jxHcelain trough filled with 
 the 1-20 solution is employed for tliis purpose, the instruments 
 being placed in it souk; time liefore an operation (l*'ig. 22). 
 The instruments are not merely dipped ; they must remain in 
 
70 
 
 ASEPTIC SURGERY. 
 
 the lotion for some time, because the carbolic acid requires a 
 little time to act on the grease or dirt on them. For the same 
 reason the teeth of toothed instruments ought to be cleaned 
 thoroughly, and forceps locking by catches ought to be widely 
 opened, so as to allow the solution to come in contact with all 
 parts. The whole instrument must be immersed, for if only the 
 point be purified it may happen that the impure handle is in- 
 advertently brought into contact with the wound during the 
 course of the operation. 
 
 The errors most likely to occur are either that during the 
 course of the operation an instrument not previously in the tray 
 is used without any attempt at purification, or that the instru- 
 ment is imperfectly purified or only part of it cleansed. I have 
 seen the danger of partial purification more than once exem- 
 
 FlG. 22. — I'DRCELAIN TROUGH CONTAINING INSTRUMENTS SOAKING IN 
 CARBOLIC LOTION. 
 
 plified. Thus I have seen the blade of a knife alone purified, 
 and the surgeon in the middle of the operation use the unclean 
 handle to separate the tissues. Other errors in the manipu- 
 lation of instruments will be referred to presently. 
 
 The spray is very important in many cases, for it provides 
 an atmosphere in which instruments, &c., may be kept without 
 danger of contamination. In order to have a wide and large 
 antiseptic area in which to work, the spray ought not to be too 
 near, about six or eight feet or more being a suitable distance 
 for a good spray. Care must be taken that the spray is not 
 blown off the part by draughts or by people moving about. The 
 spray is most necessary in opening abscesses or in stitching up 
 wounds, for, to take the latter case, as the wound is not syringed 
 
SPRAY 
 
 71 
 
 out after the stitches are inserted, septic air may be inclosed 
 in the cavity of the wound, and may give rise to putrefaction if 
 
 S ° a g 
 
 ""'■♦J ° 42 
 
 o o ag 
 
 If 
 
 - a. 
 
 « a) a a. 
 
 s 2 § a 
 S ^ S '^ 
 
 M ° 9 a 
 S 2 ii-^ 
 
 J3 f! .a 
 
 
 tlic 
 ions 
 e in 
 rah 
 are 
 
 11 
 
 c ;5 a -*f 
 
 
 
 
 
 
 " 
 
 >- r: -s ^ j3 
 
 ■'J 
 
 £;g-3|-s 
 
 
 
 -^ 
 
 
 
 ■- •^ 2 of ^ 
 
 
 
 OrC^ C 
 
 the spray has not been playing over the wound while the 
 stitches were being introduced. 
 
 During the course of an operation any instrument which has 
 been once purified, if kept in the spray, even though covered' 
 with blood, remains piu*e, and may be introduced into the 
 
ASEPTIC SURGERY. 
 
 wound without hesitation. The same is the case with the 
 hands of the operator or assistants ; and therefore the dresser, in 
 handing instruments to the surgeon, if)iust hand them into 
 the spray (Fig. 23). If in the course of the operation the 
 surgeon reaches his hand or an instrument out of the spray 
 for any reason whatever, it must be repurified before being 
 put into the wound. For this purpose there is generally a 
 
 
 Fig. 2i.— To show the arrangement of towels, etc., in a large 
 
 OPERATION. 
 
 a a a Are tliree towels which have been soaked in 1-20 rarholic lotion, so that inatruments, &c. 
 may be placed on them without fear of contamination. Tlm^ a small sponse will be seen on the 
 upper one. d is tlie dish containing 1-40 carbolic lotion wliioli alwavs stands before the oiicrator, 
 and in the line of tlie spray. In this he places the instruments which are not being used, and 
 in it lie rcpurifies his hands or instruments if they have been removed from tlie elonil of spray. 
 In tliis particular instance we have a lar^e wound to deal with— one so large that a single spray, 
 unless of large volume, may not cover it completely. Hence a piece of gnai-d soaked in carbolic 
 lotion Is thrown over the front of the wound while the surgeon is attending to the axillary part, 
 or rice versd. 
 
 basin of 1-40 carbolic lotion placed close to the operator in the 
 line of the spray, in which fingers, instruments, &c., may be 
 re-purified by momentary dipping. When instruments are laid 
 down out of the spray, or, in the spray, on a blanket, they 
 must be repurified before being used again. To provide a basis 
 on which instruments may be laid, the carbolised towel is 
 arranged before the operator as formerly described, and the 
 blankets in the neighbourhood are generally also covered up 
 
SPRAY, 73 
 
 with wet towels, so as to avoid the chance of the instruments 
 being laid on the blankets (see Fig. 24). Should the operator, 
 during the course of an operation, wipe his hands in a dry towel, 
 or touch any unpurified substance, he must remember to wash 
 his hands in 1-40 carbolic lotion before re-introducing them 
 into the wound. 
 
 These precautions seem on the one hand self-evident, while 
 on the other they seem so burdensome to remember that 
 they are often neglected by self-sufficient surgeons. And yet 
 it is by the neglect of these, rather than by error in any other 
 part of the Listerian method, that mistakes arise and failures 
 occur. Many people think that the spray is the essential part 
 of the treatment, and neglect the precautions as to constant 
 purification of instruments, &c., and when their cases go wrong 
 they say that the principle is incorrect. And yet one thoroughly 
 acquainted with the Listerian method will readily detect the 
 loopholes, and the general loophole is the omission of some of the 
 precautions with regard to purification of fingers, instruments, 
 &c. Thus I have seen a surgeon with considerable experience 
 in aseptic treatment, during the com-se of a difficult operation 
 wipe his hands with a dry towel and immediately introduce 
 them, covered with the dust from the towel, into the wound. 
 The patient died of septic poisoning. Now many surgeons 
 might have said, ' I used the spray ; 1 used all precautions ; 
 my instruments were soaking ; my hands were purified ; ' for- 
 getting this one little incident. When the point was men- 
 tioned, however, the mistake was at once seen. People are too 
 apt to trust to the spray as sufficient, and to speak of aseptic or 
 Jjisterian surgery as treatment by the spray. This is a great 
 and often fatal mistake. Of all the precautions required by 
 Mr. Lister, that of purifying the air by means of a carbolic acid 
 spray is the least necessary, for there are but few septic particles 
 present in the atmosphere, and even though some of them fall 
 on to a wound they may be rendered inert by washing the 
 wound with carbolic lotion. It must always be remembered 
 that Mr. Lister carried out aseptic treatment for years with 
 great success without any spray ; and if at the present time he 
 were compelled for any reason to give up some one precaution, he 
 would at once throw aside the spray, as that one which is least 
 
74 ASEPTIC SURGERY. 
 
 necessary, and which could be the most readily dispensed with. 
 At the same time, the spray is an immense convenience in many 
 cases, more especially in abscesses, empyemata, in stitching up 
 wounds, &c. ; and it saves the necessity of applying a great deal 
 of carbolic acid to wounds by irrigating them, with the con- 
 sequent irritation and risk of carbolic acid poisoning. 
 
 To return to the errors which may arise in this part of the 
 treatment. It may be that the spray is too near, and that thus 
 the cloud is so narrow that the surgeon is constantly getting 
 his hands or his instruments out of it, and forgetting to re- 
 purify them. There are other disadvantages when the spray is 
 too near. Thus it is very wetting, and the hands of the surgeon 
 and the wound are unnecessarily irritated by the carbolic 
 acid. If too near, the opaque spray also obscures the field of 
 vision. On the other hand, where the spray is visible, it may 
 be sufficiently trusted. Other sources of error are that instru- 
 ments may be used which have never been purified, which have 
 been only imperfectly purified, which have after their use lain 
 about outside the spray or on blankets, &c. ; or it may be that 
 the carbolic acid gets exhausted in the spray bottle, or that for 
 some other reason the spray does not act properly. 
 
 What is to be done should any of these accidents occur ? 
 Suppose that an impure instrument or finger be introduced into 
 the wound, that wound must be at once thoroughly washed 
 out with 1-40 carbolic lotion. This is a bad thing for the 
 wound, because it irritates it, and may prevent lijealing by first 
 intention ; or it may, by causing a much larger quantity of dis- 
 charge than usual, so saturate the gauze dressing as to render 
 it unable to prevent the spread of putrefaction inwards. There- 
 fore it is better to use the spray, and to take all the precautions 
 before mentioned. Should the spray stop, the wound must be 
 washed out just as in the former case, and then, till the spray 
 can be set agoing again, the wound is covered with a piece 
 of rag soaked in carbolic lotion. 
 
 This piece of rag, called the guard, ought to be always 
 present in the basin by the side of the surgeon, and when there 
 is any indication that the spray is failing, or should it be advis- 
 able to stop the spray for any reason, this is thrown over the 
 wound for the time being. Should any time elapse before the 
 
METHOD OF TYING VESSELS. 75 
 
 spray is again ready for use, this guard must be repeatedly 
 moistened with carbolic acid lotion 1-40. 
 
 Where the wound is very large it may be protected during 
 the operation either by having two sprays, or by covering up the 
 part of the wound which is not being operated upon by a guard 
 (see Fig. 24). 
 
 The arteries are ligatured with catgut. This catgut is 
 generally employed of three different sizes. The largest is 
 used only for large vessels or for stitches; the medium for 
 medium-sized vessels, or for vessels in inflamed or dense tissues 
 where considerable force is required to constrict the vessel, or 
 for stitches ; the small or fine catgut is that ordinarily employed 
 
 ^-^ 
 
 Fig. 25a. — Method op tying vessels in dense tissues. 
 
 (After MacCormac.) 
 
 for the smaller vessels. The vessel having been securely tied, 
 the catgut is cut short and gives no more trouble. It is well 
 to tie all the visible bleeding points, because a little oozing of 
 blood may give trouble afterwards from tension. If the vessel 
 be situated in dense tissue, so that a ligature cannot be applied 
 around it, a needle carrying a double catgut thread should be 
 passed througli the tissue and tied on each side of the vessel 
 (see Figs. 25a and 2oh). The catgut should be taken direct 
 from the trough containing carbolic oil, and should not be 
 wetted in the lotion. Where the bleeding is from a tear in 
 a large vein, and where it would be dangerous to ligature the 
 
76 
 
 ASEPTIC SURGERY 
 
 vessel, I have seen the following method adopted by Mr. 
 Lij^ter: — In removing some cancerous glands from the axilla, 
 a small vein was torn away from the axillary vein at their 
 junction, making practically a longitudinal rent in the axillary 
 vein. Taking a fine curved needle and the finest catgut, he 
 stitched up the rent by the glover's suture. The patient 
 recovered without the slightest bad symptom. There was no 
 pain in the wound, nor swelling of the arm, &c. In another 
 case, where the longitudinal sinus was injured in trephining 
 the skull, the w^ound was plugged with catgut, and the patient 
 recovered without any untoward symptom. 
 
 The drainage of an aseptic wound is the point next in im- 
 portance to keeping the wound aseptic. For if the blood and 
 
 serum which collect in the in- 
 terior of the wound within the 
 first twenty-four or forty- eight 
 hours do not get free exit, they 
 give rise to tension, and tension 
 gives rise to inflammation, and 
 the latter, if allowed to go on long 
 enough, to suppm'ation ; and 
 thus the rapid healing of the 
 TYING VESSELS IN DENSE TISSUES, wouud is prevented, though the 
 (From Esmarch.) paticut is uot as a rulc subjcctcd 
 
 to any danger to life. To avoid these consequences Mr. Lister 
 has paid very special attention to the drainage of wounds. 
 There are two main ways in which this may be done— drainage 
 through tubes, or drainage by capillarity. The former is the 
 most universally applicable and the most certainly successful. 
 
 Drainage by means of tubes is that first used by Mr. Lister, 
 and, as just stated, is the form of drainage which is most uni- 
 versally applicable. The tubes generally employed are the 
 india-rubber tubes introduced by Chassaignac, though of late 
 the kind of rubber has been altered, that now used being red 
 rubber, which contains no free sulphur. By the use of these 
 red rubber tubes disagreeable smells and blackening of the 
 X^rotective, which often occurred when the black tubes contain- 
 ing free sulphur were employed, are avoided. These tubes have 
 round holes cut in them at short intervals, the diameter of each 
 
 Fig. 25&. — Another method of 
 
DRAINAGE-TUBES. 
 
 77 
 
 hole being about one-third of the circumference of the tube. 
 At the outer end the tubes are cut flush with the surface of 
 the skin — straight across if the tube goes directly downwards, 
 or with varying degrees of obliquity according to the direction 
 
 Fig. 26. -Ordinary oblique-ended drainage-tube ready for use. 
 
 which the tube takes (Fig. 26). The tube must not project be- 
 yond the surface, for if it does, its orifice gets compressed by the 
 dressing, and the exit of fluid is prevented. To keep the drain- 
 age tube from slipping in, two threads of carbolised silk are 
 
 Fig. 27.— Duainage-tubk with masses of gauze in the loops of 
 
 thread. 
 
 fastened into it at its orifice, and tied in a knot. This knot, 
 held between the dressing and the skin, retnins the tube in 
 ])08ition. In souk; cases, however — as for cxiimple, in ompyeuia — 
 the tube niiglit sli]) in in s})ite of these thrends, and th(n-('f()re it 
 is well to fill u|» (he ]oo])S witli strips of gauze soaked in the 
 
78 
 
 ASEPTIC SURGERY. 
 
 carbolic lotion (Fig. 27). These absolutely prevent the tubes 
 from slipping in. These tubes are always kept in a large vessel 
 containing 1-20 carbolic acid solution, and are thus always ready 
 for use. When a tube is altogether removed from a wound it 
 is not thrown away, but is washed and put into the bottle 
 with the other tubes, and used for another case. These tubes 
 vary in size according to the size of the wound and the amount 
 of discharge expected, and are arranged so as to drain the 
 parts of the wound which form cavities or from which the 
 greatest amount of discharge will come It is not necessary that 
 their orifices be dependent, though it is of course better that 
 they should be so. It is not essential, however, because the 
 fluid, as it forms, wells out, and, not being putrid, that w^hich 
 lies at the bottom of the drainage-tube does not cause irritation. 
 In cases where the most dependent opening would be near 
 sources of putrefaction, it is well to have the drainage-tube in 
 another part of the wound, even though it be not so de- 
 pendent. Thus in inguinal 
 hernia the tube would no 
 doubt be in the most depen- 
 dent part if its orifice were 
 close to the pubis, but as that 
 would be much too near 
 sources of putrefaction, such 
 as the vagina and penis, the 
 orifice of the tube ought to be 
 at the outer angle of the 
 wound (see Fig. 28). In a 
 large wound it is well to have 
 more than one tube; and it is 
 better to have two smallish 
 tubes in any case, rather than 
 HERNIA, STITCHED, SHOWING THE OHC large ouB, bccausc ou the 
 POSITION OF THE DRAINAGE-TUBE day after the operation one of 
 
 OUTER ANGLE OF THE ^|^ggg ^^j^^g ^^^ ^^ rCmOVCd 
 
 altogether ; whereas if a large 
 one were pulled out in order to insert a smaller, there would 
 be the gi-eatest difficulty in introducing either. No tube which 
 one wishes to put back again should be removed till the third 
 
 Fig. 28.— Incision for inguinal 
 
 AT THE 
 WOUND. 
 
BRAIXAGE. 70 
 
 day, on account of the difficulty of returning it. By that time, 
 however, it Hes in a channel in the blood clot or Ijonph, and slips 
 back easily. Fig. 29 represents forceps introduced by Mr. Lister, 
 and called ' sinus forceps,' which are of the greatest service in 
 inserting drainage tubes. Generally on the third day half the 
 tube is cut off, and it is reduced in length at subsequent 
 dressings till it becomes no longer necessary. No exact rules 
 can be given for shortening or leaving out the tube. This must 
 simply be a matter of experience, guided by the amount of 
 discharge and the tendency to accumulation or otherwise. 
 Should tension occur, a larger and longer tube ought to be at 
 once introduced. 
 
 A point which has always seemed to me of great importance 
 in connection with the use of these tubes, and one which has 
 apparently been overlooked, is the following. A tube is taken 
 
 Fig. 29.— Sikus forceps. 
 
 out of carbolic lotion at some distance from the spray, is 
 earned through the air, and then directly introduced into the 
 wound. I can hardly believe that when a large tube is taken 
 out of the lotion there would be sufficient vapour of carbolic 
 aoid in it to destroy any septic dust which might get into its 
 interior, for a considerable mass of air must take the place of 
 the fluid, and this amount of hospital air may often, as I have 
 found by experiment, contain causes of putrefaction. Of course 
 when passing through the spray this air may be displaced or 
 purified, and also when introduced into the wound a consider- 
 able amount of it would be forced out ; while at the same time 
 there is a good deal of carbolic acid present, and purification in 
 one way or another would probably occur. And further the 
 purifying power of healthy living tissues, which will be after- 
 wards demonstrated, must be taken into account. But in 
 the case of a cavity, pm'ification in any of these ways may 
 
80 ASEPTIC SURGERY. 
 
 not happen, and putrefaction may result. In a ease of incision 
 into the knee-joint, which will be afterwards alluded to, in 
 which fermentation and inflammation occurred, this seemed 
 to me the most probable explanation. My suggestion there- 
 fore is always to take the tubes out of the lotion in the spray, 
 and then the air which enters them will be air previously acted 
 on by the spray. 
 
 Drainage by capillarity was introduced by Mr. John Chiene, 
 who was also the first to enunciate the principle of absorbable 
 drains. For this purpose he uses catgut, and generally the 
 
 Fig. 30.— Catgut drain ready foe insertion. 
 
 finest threads. A skein of catgut, containing say twenty threads, 
 is tied at its middle by a single thread of the same gut. One 
 end of this thread is passed through a needle (Fig. 30), and by 
 means of this the centre of the skein is stitched to the deepest 
 part of the wound (Fig. 31). The skein is now broken up into 
 bundles of five or six threads each. One bundle comes out 
 at each angle of the incision, and the other bundles at inter- 
 vals between the stitches (Fig. 32). More than one skein 
 may be required in a large wound. This catgut becomes 
 absorbed, and never requires to be removed. In five or six 
 days the ends which hang out' drop off, and little granulating 
 sores are formed which heal in a few days. In this method the 
 serum escapes by capillarity, and by distributing the threads 
 
DEAINAGE BY CAPILLARITY. 81 
 
 over various parts of the wound the true principle of drainage 
 is carried out ; for, as pointed out by Mr. Chiene, in draining 
 a field one does not have one large drain going from one end 
 of the field to another ; on the contrary, the field is traversed 
 by numerous small drains. And so in Chiene's method of 
 draining v^rounds we have a number of small drains traversing 
 the wound in several directions. In this method there is no 
 trouble about pulling out the drain, and no necessity for 
 changing the dressing simply to remove a tube ; the drain 
 disappears of itself. It is well to leave the ends of the catgut 
 outside the wound as long as possible, so as to get a siphon 
 action, and care must be taken not to break up the bunches 
 of catgut outside the wound, for the capillary action occurs 
 in the intervals between the threads when they are closely 
 ajjposed. 
 
 The objections urged against this method are, firstly, that 
 in lai'ge wounds it is not sufficient, and that the catgut becomes 
 a pulpy mass, and when in large quantity takes a long time to 
 organise. Not only may it be insufficient at first, but it may 
 become absorbed too soon — before, indeed, a drain of some 
 kind can be dispensed with. 
 
 Now these objections rest in great part on the fact that 
 the drain is often improperly employed. If, for instance, it be 
 not stitched to the deepest part of the wound, the catgut may 
 slip and the deeper parts may not be drained ; and again, if a 
 large bundle of it be used, coming out at one part of the wound 
 only, it does become a pulpy mass, and takes a long time to 
 organise. But this is not the method recommended by Mr. 
 Chiene, for he says that only five or six threads ought to be 
 brought out at each place. There is, however, no doubt that 
 in some cases it is absorbed too quickly, and this was the real 
 objection to the use of this method when we had only the 
 catgut prepared by the old method, though even with it, if the 
 gut was well prepared and old, the drainage was often very 
 satisfactory. This difficulty will probably be overcome by the 
 use of the chromic catgut recently introduced ; the only fear, 
 indeed, will now be that the drain may last too long. Mr. 
 Lister, however, thinks that if only the finest gut be used, 
 according to Mr. Chiene's directions, the probability is that it 
 
 G 
 
82 ASEPTIC SURGERY. 
 
 will be absorbed with sufficient rapidity. Of course, if neces- 
 sary, the ends of the drain can be cut off, when it has served 
 its purpose, below the level of the skin, and then, even though 
 the internal part be not all absorbed, the wound can heal 
 completely. 
 
 Catgut can only drain fluids such as blood or serum ; it 
 cannot drain pus. It is, however, unsuitable in cases of chronic 
 abscess, where we have only a serous discharge, because the 
 catgut is absorbed long before a drain can be dispensed with. 
 
 Fig. ni.— Operation for stretching the sciatic nerve. 
 
 Catfrut drain stitolicd to the deepest part of the wound, beneath the gluteus maximus, and 
 lirukon up into four separate bunclics. 
 
 If the wound is very large it is well to introduce tubes as 
 well as catgut drains at first. The tubes may be removed in 
 twenty-four hours. 
 
 Instead of catgut, horse-hair has been a good deal used. 
 This is simply laid into the wound in the situation where it 
 seems most required. It is diminished by degrees, threads 
 being taken out at various intervals of time. It has an advan- 
 tage over catgut in draining joints, for no part of the drain 
 
DRAINAGE BY CATGUT AND HORSEHAIR. 
 
 83 
 
 remains in the interior of the joint, while portions of catgut do. 
 Further, it is not absorbable. 
 
 But it has the same disadvantages as the drainage tubes, 
 and it is not readily retained in the deeper parts of the wound. 
 It is preferred by Mr. Lister to the catgut, but there can be no 
 doubt that the catgut, when used strictly according to Mr. 
 Chiene's directions, and of good quality, is a very efficient 
 method of drainas^e. 
 
 It is easy to re-introduce a horse-hair drain if necessary by 
 proceeding in the following manner : — A sufficient quantity 
 
 Fig. 32.— The same wound stitched. 
 
 The h'jnclips of rntpiit cnminp out at intprvals between t)ie stitclies. (Tlie woiintl lias teen 
 exapperated, and the thnails of ratjzut separated, in order to sliow the nietliod more clearly. 
 'I'lie thnads of catpiit onpht to lie in close apiiositioii, for it is tin: iiitervnls between the 
 threads which act as raiiillary drains'. 
 
 being taken, the bundle is bent at its middle over a probe, and 
 tied close to the probe by carbolised silk (Fig. 33). In this 
 w^ay, the ])robe being withdrawn, a blunt compact end is oblained, 
 which may be introduced into the wound with ease. 
 
 Of lute the princi])le of absorbable drains has been applied 
 by Dr. Neuber of Kiel ' in his absorl)al)le drainag(! tubes. 
 
 ' Ein AnihepHgchcr Daucm-rhand narh fir'dndlichrr Jilutstillnii;/. Von 
 LangenhccJt'x Archiv, Bd. xxiv. Heft. 2. 
 
 a 9. 
 
84 ASEPTIC SURGERY. 
 
 These are tubes drilled in long bones, and then decalcified and 
 carbolised. Holes are afterwards cut in the sides, and they are 
 used like ordinary india-rubber tubes. These tubes are said to 
 answer very well, though they are sometimes absorbed too soon, 
 and sometimes last too long. They sometimes get soft and 
 collapse about the third or fourth day, and thus, though not 
 absorbed, become useless as a drain. 
 
 Dr. INIacEwen ^ has lately somewhat modified Neuber's tubes. 
 He uses chicken-bones, which are already hollow, and decalcifies 
 them. ' The method of preparation is as folloAvs : — The tibia? 
 and femora are scraped and steeped in hydrochloric acid and 
 water (1 to 5) until they are soft. Their articular extremities 
 are then snipped off with a pair of scissors ; the cndosteum is 
 
 Fig. 33. — Method of preparing a horse-hair drain for 
 re-introduction. 
 
 raised at one end and pushed through to the other extremity, 
 along with its contents. They are then re-introduced into a 
 fresh solution of the same strength until they are rendered a 
 little more pliable and softer than Avhat is ultimately required 
 (as they afterwards harden a little by steeping in the carbolised 
 solution). When thus prepared they are placed in a solution of 
 carbolic acid in glycerine 1-10. They may be used at the end 
 of a fortnight from the time of introduction into the glycerine 
 solution. Holes may be drilled in them with a punch, or clipped 
 out with scissors.' These tubes are threaded with horse-hair 
 before being introduced into the tissues. This hair helps to 
 maintain the calibre of the tube during the first few days, and 
 also itself acts by capillarity. 
 
 ' British Medical Journal, Feb. 5, 1881. 
 
BUTTON STITCHES. 
 
 85 
 
 The average duration of j\IacE\ven's tubes in the tissues 
 was something over eight days. If, however, a tube is likely to 
 be required for a longer time, it can be obtained by steeping 
 the decalcified tubes in a chromicised instead of a carbolised 
 solution. These resist the action of the tissues for two or three 
 weeks. 
 
 The accurate stitching of the edges of the wound is another 
 feature in aseptic surgery. In operating aseptically the same 
 care need not be taken to remove as little skin as possible as 
 is necessary in wounds treated by other methods where swelling 
 and inflammation of the edges are expected. One may take 
 away a wide sweep of skin, such as would seem to render 
 hopeless any attempt to bring the edges of the wound into 
 apposition ; and yet if the edges can only be apposed, and if 
 
 A c 
 
 Fig. 34. — Lead buttons for deep stitches. 
 
 A, The present form, describerl in tlie text. B, Form of button deviscrl by Dr. Ogilvie Will (seen 
 in section). C, The old form, where the wire was fastened by passing it beneatli the button. 
 
 the wound remains aseptic, union by first intention may be 
 expected along the whole line. 
 
 Button stitches are employed to relax the edges of the 
 wound, and thus to leave the cutaneous margins free from the 
 irritation which must occur if they are tightly drawn together. 
 These consist of flat pieces of lead cut of an oval form and of 
 various sizes, perforated in the centre by a hole through which 
 silver wire is passed, and provided Avith two lateral wings round 
 which the wire is twisted (Fig. 34). (There are various forms 
 of button suture, but all act on the same principle.) These are 
 a[)})lied some distance on each side of the edge of the wound, 
 and connected by strong silver wire drawn tight enough to 
 permit the edges of the wound to come pretty easily together. 
 The number used varies according to the amount of tension. 
 
8(> 
 
 ASEPTIC SURGERY. 
 
 In order to bring the edges of the wound into actual contact, 
 two sets of stitches are employed : silver wire stitches, which 
 take a good hold of the tissues and are placed at regular inter- 
 vals, termed stitches of relaxation ; and in the intervals between 
 these, in order to have the cutaneous margins accurately applied 
 to each other, numerous stitches of coaptation, consisting of 
 carbolised silk, horse-hair, or catgut are inserted (Fig. 35). 
 The speedy healing which occurs when the edges of the wound 
 are accurately brought in contact, while they are at the same 
 time, by the button stitches and the stitches of relaxation, 
 
 Fig. 35. — Wound after removal oi'^ mamma and axillary glands, 
 
 STITCHED. 
 
 To show tlie tliree kinds of stitches. Tlip button .stitchrs will lie at onee recognised ; the tliick 
 stitches, of which three arc represented, are the stitches of relaxation ; and the remainder 
 are tlie stitches of coaptation. 
 
 freed from any tension, rewards the surgeon for the time 
 spent in inserting a large number of these stitches of coapta- 
 tion. 
 
 In taking out these stitches it is best to follow a reverse 
 order to that of insertion. The first to be removed are the 
 stitches of coaptation, while the stitches of relaxation are pro- 
 bably cut on the same day. Do not be in a hurry to remove 
 the stitches where there was much tension in bringing the 
 edges of the wound together. A week or ten days is time 
 enough. 
 
 Should the wound gape, strapping may be employed, even 
 under an antiseptic dressing. To render the stra])ping aseptic, 
 it is immersed in warm carbolic lotion (one part of 1-20 and an 
 equal part of boiling water) before being applied. This both 
 
BEESSINGS. 87 
 
 renders it aseptic and also takes the place of the hot- water can 
 for heating the strapping. 
 
 Having proceeded thus far in the aseptic operation — having 
 tied the vessels, aiTanged the drainage, and brought the edges 
 of the skin well together— we must now apply a dressing which 
 shall prevent the occurrence of putrefaction till the case is 
 again seen. 
 
 In applying a dressing we must in the first place be careful 
 to make it as little irritating as possible to the young epithelium 
 along the Hne of incision. The dressing employed is the car- 
 bolic gauze ; and, to prevent the irritation of the healing edge 
 of the wound by the carbolic acid, a piece of protective is inter- 
 posed between the gauze and the wound. This protective is 
 cut a little larger than the wound, and it is well to cover the 
 buttons with a little bit also, in order to prevent the threads 
 of the gauze from becoming entangled in them. This protective 
 need not extend over the orifice of the drainage tube, as its 
 essential object is to protect the healing part from the irritation 
 of the carbolic acid. The protective is also of use in preventing 
 the dressing from sticking to the Avound, and in preventing the 
 formation of scabs, and the consequent possible retention of 
 the discharge. 
 
 An eiTor which is frequently made is to put on too large a 
 piece of protective. There is nothing antiseptic in its substance, 
 and it protects the discharge beneath it from the action of the 
 carbolic acid. Therefore if at any part it projects beyond or comes 
 close to the edge of the dressing, it allows the causes of putre- 
 faction to spread inwards beneath it, and prevents the carbolic 
 acid from acting on this putrefying discharge. It is therefore 
 a very good rule, having covered the woimd with sufficient pro- 
 tective, to look on this protective as a wound, and to be as careful 
 in having the gauze dressing overlap it in all du-ections as if it 
 itself were the wounded surface. Where there is very little 
 space for overlapping, as in inguinal hernia, no protective ought 
 to be applied. It is better to have somewhat slower healing 
 than to have putrefaction spre-ad into the wound. As men- 
 tioned before, this protective is di))i)ed in carbolic lotion 1-40 
 befoi'e being applied. 
 
 Outside the protective a piece of gauze wet in the carbolic 
 
88 ASEPTIC SUliGEliT. 
 
 lotion 1—40 is applied so as to overlap the protective in all 
 directions. The reason for this is that dry gauze is apt to 
 receive dust on its surface before being used, while at the 
 ordinary temperature of the atmosphere but little carbolic acid 
 is given off from the gauze, certainly not enough to destroy 
 immediately the activity of the septic particles in the dust. 
 But if the piece of gauze applied next to the protective be 
 moistened in the 1— iO solution, this dust is at once deprived 
 of septic energy, and we apply over the wound a layer of pure 
 and powerfully antiseptic material. 
 
 Fig. 36.— Excision of the hip-joint. 
 
 Wound stitclied ; ])rotective anil deep di-essing applied. 
 
 The piece of wet gauze and the protective go by the name 
 of the deep dressing. This deep dressing may in some cases, 
 and more especially where catgut stitches and catgut drains are 
 used, be left for several days undisturbed. In this way the 
 wound is not irritated by the application of carbolic acid to it 
 every time the dressing is changed. If the deep dressing be 
 thus left on, it must be remembered that the deep piece of 
 gauze loses all its carbolic acid very soon, and that therefore 
 it must be treated as a wound — ^.e., in renewing the dressing 
 this deep part must be overlapped in all directions by a 
 piece of wet gauze, and that again by a dressing of suitable 
 size. 
 
DEEP DRESSING. ^9 
 
 In some cases it may be desirable to fix down the deep 
 dressing with a piece of gauze bandage. If it be intended to 
 leave on this deep dressing for some time it is well, before 
 applying it, to rub the neighbourhood of the wound with the 
 salicylic cream mentioned before. It sometimes happens that 
 when a dressing is left on for many days together, the discharge 
 becomes somewhat irritating, and the skin around the wound 
 becomes excoriated. This is generally entirely prevented by 
 the use of salicylic cream. 
 
 Having arranged the deep dressing in a suitable manner, 
 any hollows which exist in the neighbourhood of the wound 
 are filled up with carbolic gauze, and special masses of this 
 material are placed where the greatest amount of discharge is 
 expected. Outside this a large gauze dressing, made as before 
 described, is applied. The size of this dressing varies accord- 
 ing to the amount of discharge expected, but in all cases it must 
 extend well beyond the deep dressing in all directions. Some 
 special examples will be mentioned presently. 
 
 This dressing is fixed on with a suitable bandage. The gauze 
 bandage is preferable to an ordinary bandage under certain 
 circumstances. It is especially convenient in bandaging a 
 stump next the skin to prevent retraction of the flaps, and also 
 for fixing down the deep dressing. It also increases the amount 
 of antiseptic material outside the macintosh if there happens 
 to be a hole in it. But for ordinary use in fixing on dressings 
 very light and cheap bandages may be made from the ordinary 
 thin muslin which is used as a guard. They do not stick to 
 the skin as the gauze bandage is apt to do. 
 
 The dressing is pinned round its edge to the bandage. 
 Care must be taken not to put pins through the macintosh at 
 any part except at its edge. Pinholes through the centre of 
 the macintosh simply defeat its object by permitting the 
 discharge to come directly through the dressing. The object 
 of the macintosh is to make the discharge travel through a 
 large extent of the gauze, and thus the same result is obtained 
 as if a mass of gauze were applied over the wound, of the same 
 thickness as the distance from the centre of the macintosh to 
 its edge. If therefore there be a pinhole near the centre of 
 the macintosh, the object of the latter is seriously interfered 
 
90 
 
 ASEPTIC SURGERY 
 
 with. Accordingly, it is always the duty of the i)ersoii who 
 makes the dressings to examine the macintosh with the view 
 of detecting any holes in it. 
 
 If the dressing is to be used as soon as it is made up, it is 
 well to sponge the surface of the macintosh with 1-20 carbolic 
 lotion before inserting it. The same piece of macintosh may 
 be used for a whole case, or for more than one — so long, in fact, 
 as it does not become worn into holes. Two pieces of macin- 
 tosh are generally provided for each case, and a dressing is 
 always made immediately after the case has been dressed, and 
 is ready for application at any time. 
 
 Fio. 37.— Dressing in a case of psoas abscess opened above 
 Poupakt's ligament. 
 
 To show tlie an-angement of tlie elastic bandage along the margins of the dressing. 
 
 It might happen that, in the movements of the patient, the 
 edge of the dressing might become separated from the skin, 
 and air pass into the space thus formed. To prevent this, the 
 German surgeons as a rule pack in salicylic jute or wool be- 
 neath the edge of the dressing. This may serve the purpose, 
 but it is by no means safe. Mr. Lister some time ago intro- 
 duced the use of elastic webbing, which is of various breadths. 
 It is better not to be too broad. It is put moderately on the 
 stretch, and surrounds the edge of the dressing. Its general 
 arrangement varies of course with the situation. It is not much 
 used on the extremities, because the ann or leg is generally so 
 
CHANGING OF THE DRESSING. 91 
 
 fixed by means of splints that there is no chance of separa- 
 tion of the dressing. 
 
 The operation and first dressing ha\iug now been com- 
 pleted, the question arises when the dressing should be changed. 
 It is only extremely rarely that it is necessary to change it the 
 same evening. The only cases in which this is usually done 
 are large empyemata or very large abscesses, and cases of am- 
 putation at the hip-joint, where the discharge of bloodly serum 
 is profuse, and there is but little space for overlapping of the 
 dressing. 
 
 As a rule, the dressing ought to be changed entirely on the 
 following day, the deep part as well as the superficial. It is 
 well to change the deep dressing in order to see that none of 
 the stitches are too tight, and that the drains are acting pro- 
 perly. After the first day the deep dressing need not be 
 touched, unless the patient is complaining of uneasiness, or 
 unless the sm-geon wishes to see the wound for the purpose of 
 removing stitches or drain. If it is not necessary to disturb it, 
 it may, especially where there is an organising blood-clot, be 
 better not to do so, for that would only be to expose the wound 
 unnecessarily to the irritation of the carbolic acid. If the deep 
 dressing is not changed, great care must be taken to have an 
 efficient spray playing over the part. 
 
 In changing the dressing the spray is used, and also 1-40 
 carbolic lotion, in which a piece of loose gauze and protective 
 are put before the dressing is begun. The elastic bandage 
 is first removed, and then the patient or an assistant places 
 his hand over the centre of the dressing while the bandage 
 is being cut, so as to prevent the dressing being lifted up 
 and air pumj)ed in. Then the surgeon, having purified his 
 fingei's, and having turned on the spray, lifts the edge of the 
 dressing carefully, taking care that the spray passes into the 
 angle between the dressing and the skin (see Fig. 38). Having 
 removed the superficial dressing, he again dips his fingers, 
 and then removes the deeper parts and exposes the wound. 
 
 If nothing is wrong, he immediately applies fresh protective 
 and wet gauze, and then washes the parts round about, as far 
 as the discharge has extended, with 1-40 carbolic lotion. The 
 
92 
 
 ASEPTIC SURGERY 
 
 edge of the wound is not washed or exposed to the action of 
 the spray longer than is absolutely necessary. It is well to 
 apply the deep dressing at once, for in washing the surround- 
 ing parts, one is apt to give the wound a final touch with the 
 rag. Now this rag may contain some gross particles of putrid 
 material (such as a crust of discharge from the exterior of the 
 dressing, faeces, &c.), and thus putrefaction would be com- 
 municated to the wound. There is no necessity for cleansing 
 the edges of the wound. Dirt, so long as it is clean, i.e., so 
 long as it does not contain causes of putrefaction, does no 
 harm ; indeed, it rather aids the action of the protective ; while 
 
 Fig. 38.— Method of changing a psoas abscess dressing. 
 
 A Hand of patient holding down tlie dressing over the wound. BB, Hands of surgeon lifting 
 ' the lower^«l?e of th^ dressing (C). D, The spray machine so placed that the spray passes m 
 beneath the dressing as it is lifted. 
 
 to rub it away is to irritate and injure the healing edge— to 
 produce a state of unrest. A fresh dressing is applied as before 
 
 described. 
 
 Where there are two wounds in different situations, so 
 placed that the spray cannot command both, each must be 
 dressed separately, care being taken not to uncover the one 
 till the other is at any rate protected by a deep dressing. The 
 patient or assistant must keep his hand on the dressing over 
 the one wound, while the other wound is being attended to. 
 
 The next dressing takes place on the following day at visit, 
 
RULES FOR CHANGING THE DRESSINGS. 98 
 
 if there is any discharge at the edge of the dressing or if the 
 wound feels uneasy. If there is no discharge on the drawsheet 
 and if the wound is free from pain, the dressing is not changed ; 
 and even though discharge should appear a few hours later, 
 the dressing is not changed till next day at visit hour. The 
 rule for changing the dressings is therefore : Change if 
 discharge is through at the visit hour, or if there be any other 
 reason for it ; if not, leave the dressing till next day at visit, 
 and then follow the same rule. 
 
 Never leave a dressing unchanged longer than a week. By 
 that time most of the carbolic acid ha5 passed off by evapora- 
 tion ; and therefore, if the discharge once came to the edge, 
 putrefaction could spread inwards with great rapidity. And it 
 would not be necessary for the discharge to appear at the edge 
 in order to have putrefaction of the wound, for the sweat 
 collecting beneath the dressing permits the multiplication of 
 septic particles in it, and thus they may reach the wound. 
 Where a dressing is to be left on for a week, it is well to use 
 the salicylic cream in the way before described. 
 
 Such is the general method of using carbolic dressings ; 
 special modifications will be noticed presently. Let me pass 
 on in the meantime to the general points as to boracic 
 dressings. 
 
 Let us sup})Ose that a patient is admitted with a foul ulcer 
 of the leg : how is he to be treated ? If he were to be ti'eated 
 with carbolic dressings, the ulcer would very probably remain 
 foul, or even though it ultimately became free from odour, it 
 would heal excessively slowly. Hence, Mr. leister first piuifies 
 the sore, and then dresses it with boracic acid. 
 
 To purify the sore, chloride of zinc, 40 grs. to the ounce 
 of water, may be used. This is applied tlioroughly to the 
 whole surface of the sore, and at the same time the surrounding 
 skin is well purified by thoroughly washing it with 1-20 carbolic 
 lolion, whieli is em])loyed on account of its special power of 
 jx'uet rating the epidermis. When iliis lias been done, a. jiiece 
 of protective, dii)ped in boracic lotion and slightly larger than 
 the sore, is applied over it, and outside tliis is placed one or 
 two layers of moist or dry (it docs not much matter which) 
 
94 ASEPTIC SURGERY. 
 
 boracic lint, of sufficient size to cover the protective well in 
 all directions. There is the same objection here to allowing 
 the protective to project beyond the edge of the dressing 
 as in the case of the carbolic dressings. Lately, instead of 
 applying the chloride of zinc solution, which causes consider- 
 able uneasiness, iodoform has been yjowdered over th,e whole 
 surface of the ulcer, and it has been equally successful. The 
 chloride of zinc or the iodoform need only be applied once ; 
 but should putrefaction not be eradicated, the application is 
 repeated. 
 
 This dressing is changed next day, but aftei-wards, as a 
 rule, if only requires to be changed every two or three days, or 
 indeed at longer intervals, provided that there is not much 
 discharge. That is to say, as there is a very large store of the 
 antiseptic in the lint, and as it is but slightly soluble at the 
 temperature of the human body, the discharge may go through 
 the dressing many times without washing out all the antiseptic. 
 At the same time it is found as a general rule that the wound 
 heals most rapidly when the dressing is changed once in three 
 or four days. 
 
 At the changing of the dressing no spray is required. The 
 bandage (which may be a common cotton bandage, if preferred) 
 having been removed, the dressing is taken off' and the wound 
 well washed with boracic lotion. Any septic dust which falls 
 on the wound during its exposure is destroyed by giving the 
 wound a final wash with the lotion before applying a fresh piece 
 of protective and boracic lint. 
 
 This boracic dressing is not used for wounds which are not 
 quite superficial, because the acid is not volatile, and because 
 it is but a feeble antiseptic ; but when once a wound has be- 
 come quite superficial, it will heal more quickly if treated with 
 boracic dressing. 
 
 In some cases, more especially where the sore is septic, or 
 where the patient dresses it himself, boracic ointment is prefer- 
 . able to protective, and where the sore is healing, the half- 
 strength ointment is the best. Outside the ointment a piece 
 of boracic lint is applied as usual. Of late, salicylic ointment 
 has been used, and found to answer, as a rule, better than the 
 boracic. It is less irritating, and permits healing more readily. 
 
B-ORACIC DRESSINGS. 95 
 
 A eucalyptus ointment has been employed quite recently, and 
 has given excellent results. 
 
 VV^hen the effects of a poultice are wanted along with an 
 antiseptic effect, the boracic lint is applied like water dressing. 
 A suitable piece of the lint moistened in boracic lotion is ap- 
 plied, and outside this a larger piece of macintosh or gutta- 
 percha, overlapping the lint in all directions. 
 
96 ASEPTIC SURGERY. 
 
 CHAPTER V. 
 
 ASEPTIC SURGERY_(co«^f««frt?). 
 
 Special dressings : Head dressi/if/s : Ned; dressings : Breast dressiiiffs — Abscess 
 of vKimina — Excision of mamma alone — Excision of inamnia and axillary 
 qlands : Axillary dressings : Dressings on the limbs : Dressings for psoas 
 abscess : Lumbar abscess : Hijf-joint abscess : Dressings in cases of hernia 
 and operations on the scrotum: Excisions of joints. Aseptic treatment of 
 abscesses. Chief xjoints to be considered in opening abscesses — Mi-thod of 
 openi7ig abscesses — Drainage of abscesses — After-treatment of abscesses — 
 Empyema — Perinealand anal abscesses. Treatment of wounds produced acci- 
 dentally : Problem to be solved — Purification of wound — Further treatment 
 of the wound. Special wounds : Compound fractures : Wounds invoicing 
 tendons, nerves, ^'c. : Wounds of joints : Compound fractures of the skull : 
 Penetrating wounds of the thorax: Wounds of the abdomen. Putrid sinuses 
 ■ and wounds. Treatment of burns. Treatment of gangrene. Treatment 
 of na3vi and varicose veins. 
 
 I SHALL now describe the special methods of dressing and other 
 precautions required in different sitiuitions. 
 
 In operating on the scalp the hair must be shaved for some 
 distance around the wound, and the hair beyond ought to be 
 soaked with carbolic lotion 1-20. If the incision be in the 
 centre of the scalp, or, in other words, if there be a circle of 
 hair all round it, it is better not to use j^rotective at all. The 
 dressing in such a wound is fixed by the ordinary capelline 
 bandage. Where the wound is more or less to one side, the 
 dressing must extend downwards on the neck, and it is then 
 well to have a narrow elastic bandage along the edges, more 
 especially around the neck. In the neighbourhood of the ears, 
 the various cavities in the ear, and the space behind it, must 
 be filled up with gauze. 
 
 Nech dressings have nothing very unusual about them. The 
 dressing must be ftistened round the neck. It must be pre- 
 vented from slipping down by a turn passing above the ears 
 
BREAfiT DRESSISGS. 
 
 and around the forehead, and also by two vertical turns over 
 the head, one transverse and the other longitudinal, these 
 various tiurns being pinned together 
 where they cross. To prevent the dress- 
 ing from slipping up, turns are passed 
 under the axilla. A narrow elastic band- 
 age must be applied round the edge of 
 the dressing in this situation, for the 
 movements of the head are extremely a})t 
 to cause an interval between the skin 
 and the dressing (Figs. 39 and 40). 
 
 Breast dressings are very important ; 
 they are arranged in three different ways 
 according to the size and extent of the 
 wound. 
 
 No. 1. — Where an abscess of the 
 mamma is opened, or where some small 
 incision, not interfering with the form of 
 the organ, is made, the dressing consists 
 of an ordinary gauze dressing covering Fig. 3"j. 
 
 the whole mamma, some loose gauze This figme illustrates the genr. 
 
 being packed in in front and behind. '"' ^'''"■^'^■"^"^ °f '»■•«- 
 
 This is fixed by turns of bandage passing 
 
 round the body alternately above and 
 
 below the organ, with straps over the 
 
 shoulder. The arm is placed in a sling. 
 
 by elastic bandage (Fig. 41). 
 
 No. 2. — Where the mamma has been removed and the dis- 
 charge has become much diminished in amount, there mav 
 remain enough of room between the wound and the axilla for 
 overlapping of the dressing. In order to fix the dressing and 
 keep it well up in the armpit, it is split vertically at the 
 axilla, folded over, and pinned on the top of tlie shoulder. It 
 is then bandaged securely, and an elastic bandage a])i)lir(l 
 around the edges (Fig. 42). 
 
 No. 3. — Where the mamma and axillary glands have been 
 removed, or for the first few days after excision of the mamma 
 alone, this arrangement is not enough, for it does not leave 
 sufficient room for overlajipiiig. The arm must therefore be 
 
 nigs on the neck. The ar- 
 rangement shown liero 
 would do for any operation 
 about the region of the stcv- 
 nouia.stoid behind or below 
 the ear. 
 
 The edges are fixed 
 
98 
 
 ASEPTIC SURGERY. 
 
 included in the dressing. This is accomplished most con- 
 veniently in the following manner : — A large dressing is applied 
 
 FICt. 40. — To SHOW THE ARRANGEMENT OF THE TURNS OP BANDAGE ON 
 THE HEAD SEEN FROM ABOVE. 
 
 posteriorly, reaching behind as far back as the middle line, 
 and folding over the arm so as to touch the thorax in front, 
 
 Fig. 41.— Dressing applied in a 
 case of abscess of the mam- 
 MA (BREAST DRESSING NO. 1). 
 
 The position of tlip drainage tube is indicated 
 by dotted lines. 
 
 Fig. 42.— ]5reast dressing- 
 no. 2. 
 
 the arm being applied to the side. This dressing must be 
 broader than the length of the upper arm from the top of 
 
BREAST DRESSINGS. 
 
 99 
 
 the shoulder to the tip t)f the elbow, the overlapping parts 
 being caught by the turns of bandage passing over the 
 shoulder and round the body respectively. To prevent the 
 internal condyle from suffering from the pressure, a large 
 mass of gauze is applied behind the arm, extending downwards 
 almost to the condyloid region, but not reaching quite so far. 
 A mass of gauze is packed in between the arm and the side, 
 and in front filling up the angle between the arm and the 
 thorax (Fig. 43). A smaller anterior dressing is then applied, 
 narrower than the posterior, reaching as far forwards as the 
 middle line or beyond it, and outwards to the upper arm, the 
 edge of the anterior dressing passing beneath the edge of the 
 
 Fig. 43.— Case op excision of the mamma. 
 
 Back dressing lying ready for application ; sliowing also the deep di-cssiug and padding in 
 the axilla and beljind the arm. 
 
 ])Osterior. Thus the side of the patient is completely encased 
 in a gauze dressing. This is very easily bandaged on. One 
 turn of bandage passes round tlie body outside the arm (Fig. 
 44, 1); the second also passes round the body, but below the 
 elbow (2), thus catching the portion of the dressing overhang- 
 ing the elbow and also the lower edge of the front dressing ; 
 the next passes roimd the body and over the top of the 
 shoulder on the side operated on, thus catching tlie portion 
 of the dressing projecting above the shoulder (3) ; tlu; bandao-c 
 then passes down beliind but parallel to tlie arm, turns round 
 below the elbow, runs obliquely upwards in front to the top of 
 
100 
 
 ASEPTIC SUR(rERY. 
 
 the opposite shoulder (4), then obliquely back again behind the 
 body (thus fixing the upper angles of the dressing in front 
 and behind) to the middle of the arm, over which it passes 
 obliquely downwards (5), to go under the wrist and end at the 
 top of the shoulder (6) — in this way completing the fixing of 
 the dressing to the arm, and at the same time acting as a sling 
 for the hand. A bandage six yards long generally does this 
 exactly. 
 
 Pins are now inserted at all the necessary points, more es- 
 pecially where the bandage passes over the shoulder and under 
 the elbow. The arm and dressing are then fixed seciu'ely to 
 the side by a binder of calico, broader than the length of the 
 
 Ki«. 44— Dressings applfeu aftek excision ov mamma and axillary 
 
 GLANDS, TO SHOW THE ARRANGEMENT OF THE DRESSINGS AND BANDAGES. 
 
 The turns of bandage are numbered, and arrows are placed on them to show the direction iu 
 which they run. 
 
 upper arm, passing round the body, below the axilla of the 
 other side, and pursed up and pinned above the shoulder, and 
 below the elbow of the included arm. Thus perfect rest is 
 procured, and no elastic bandage is required. 
 
 When the axillary incision is soundly cicatrised, and the 
 discharge has become small in amount, the axillary dressing or 
 the breast dressing No. 2 may be applied, the arm being 
 simply supported in a sling. 
 
 An axillary dressing must be ap[)lied partly to the chest 
 and partly to the upper arm, and made to fold over the top of 
 the shoulder. It requires an elastic bandage (P'ig. 46). 
 
 Elastic bandage is not as a rule required for dressings on 
 
DRESSING Foil PSOAS ABSCESS. 
 
 101 
 
 the extremities, because the limb operated on is generally 
 placed on a splint for a few days, in order to procure absolute 
 rest till healing by first intention is complete. Thus the 
 movements which it is the function of the elastic band to 
 neutralise are avoided, and the constriction of the elastic is 
 also avoided. With regard to this constriction, however, the 
 elastic need never be applied so tight as to produce cedema ; 
 indeed, I have more than once seen oedema which was present 
 before an operation subside afterwards, even although an elastic 
 bandage was used. Where the patient is allowed to move the 
 extremity — as, for instance, when he is allowed to walk after a 
 small operation on the lower extremity — an elastic bandage is 
 
 Fir. 4.").— Bindee applied outside the dressing represented ix 
 FiG. 44, so AS TO keep the parts and dressing at rest. 
 
 absolutely necessary. In the case of the lower extremity, the 
 padding at the upper part of the splint should be covered with 
 macintosh, and the foot of the bed should be supported on 
 blocks. In this way all the discharge flows upwards, and as it 
 cannot soak into the padding of the splint, it is shed on the 
 draw-sheet soon after it has reached the edge of tlie dressing, 
 and thus one can ascertain accurately whetlier or not it is 
 necessary to change the dressings. 
 
 The dressing required for psoas abscess opened abo\e Pou- 
 part's ligament is one of the most important dressings, as well 
 as one of the simplest illustrations of the method of applying 
 the elastic bandage. I may say here with regard to this method 
 of opening psoas abscess :>bo\(' P()U))!irt's lignmcnt that there 
 
102 ASEPTIC SURGERY. 
 
 are two reasons for choosing, this situation. In the first place, 
 the old rule that these abscesses must not be opened early is 
 now done away with, and under truly aseptic treatment, as 
 soon as fluctuation is detected, an operation is performed of a 
 similar nature to that for tying the external iliac artery, and 
 the abscess is opened after a careful dissection. The sooner the 
 abscess is opened the better, for the abscess cavity is thus 
 smaller than if the surgeon waits till the pus has burrowed its 
 way into the thigh ; and, further, so long as the pus is there 
 it irritates by its tension, and thus keeps up the chronic in- 
 
 FiG. 46. — Dressing in cases ov operation on the axilla alone. 
 
 In t)iis case an abscess has boen opened and tlie position of tlie draina.s;e tube is Indicated by 
 dotted lines. TLe ed!,'e of the dressing lias also been dotted in. 
 
 flammation in the si)ine. This, then, is one reason why the 
 opening leading into these abscesses is generally above Pou- 
 part's ligament. Another is, that even supposing the abscess 
 to be pointing in the thigh, it ought to be opened as far as 
 possible from sources of putrefaction, and the most convenient 
 place in this resj)ect, as well as the best for the attachment of 
 a dressing, is the neighbourhood of the anterior superior spine. 
 I shall hereafter discuss the reasons why it is thought best by 
 some surgeons, more especially by Mr. Chiene, to try to get 
 
DRESSINGS FOll PSOAS AND LUMBAR ABSCESSES. 10.3 
 
 at these abscesses from behind either by perforating the ala of 
 the innominate bone or by getting at the pus above the crest 
 of the ilium. Such a method has advantages both by pro- 
 viding a dependent opening, and also by leaving a shorter 
 channel between the seat of the disease and the cutaneous 
 siu'face. 
 
 The dressing applied when the opening is in the neighbour- 
 hood of the anterior superior spine extends from the middle line 
 in front to the middle line behind. It reaches as high up as the 
 lower border of the ribs and as low as about three inches 
 below Pou})art's ligament. Special masses of gauze are placed 
 
 ^ 1 iliVildlH''/ 
 
 Fig. 47.~Dres3ing in a case of psoas abscess opened above 
 Poupart's ligament, seen from the front. 
 
 T]ie position of the drainage tube is indicated by dotted lines. 
 
 in the neighbourhood of the pubis, which is also shaved on 
 that side. The dressing is fastened on by a spica bandage with 
 circular turns around the thigh and abdomen. The elastic 
 bandage is applied accurately to the edge. It begins, say, 
 at the upper and anterior angle of the dressing, runs vertically 
 downwards along the anterior edge ; then, passing back round 
 the inner side of the thigh, it encircles the thigh, thus fixing 
 the lower border ; then it runs vertically upwards behind till it 
 reaches the upper posterior angle ; then, being held there, it is 
 carried round the abdomen. The two ends of the two vertical 
 pieces are fastened to the circular ])iece by pins, and pins are 
 also applied at all the angles and along the edge where neces- 
 
104 
 
 ASEPTIC SURGERY 
 
 sary. In some deformed persons shoulder straps are necessary 
 to prevent the dressing from slipping down (Figs. 47 and 48). 
 
 Fro. 48. — r^iOAS abscess dre^sixo (Fig. 47), seex from behind. 
 
 In Inmhar abscess straps must pass over the shoulders to 
 prevent the dressing from slipping down, and between the 
 thighs to prevent it from slipping up (Fig. 49). 
 
 Vui. 49.— Dressing ix a case of lumbar abscess, seen from behind. 
 
 Tlie position of tlip rlrainage tube is indicated by dotted lines : the vertical dotted lines at the 
 niiildle of the back indicate the edge of the dressing. 
 
 In abscess of the hip-joint the arrangement of the dressings 
 is much the same as in psoas abscesses, except that they pass 
 lower down and not quite so high up. As a long splint is 
 
I)Iii:SSINGS FOE HERNIA, ETC. 
 
 ]05 
 
 generally in use, an elastic bandage is unnecessary, unless in 
 children (Fig. 50). 
 
 Where abscesses are opened near the top of the thigh on 
 the inner side, and are thus pretty near sources of putrefaction, 
 large masses of gauze must be applied between the orifice and 
 the perineum, and an elastic bandage carefully fastened along 
 the upper edge. 
 
 In operations for hernia^ varicocele, and on the scrotum, 
 in the male, there is one form of dressing which is generally 
 applicable. In the first place, no protective is used, on account 
 of the immediate vicinity of sources of putrefaction, as has been 
 previously explained. The gauze applied to the wound, instead 
 
 Fir. 50.— Dressing in a cask op hip-joint abscess, with elastic 
 
 APPLIED. 
 
 The dotted part sliows tlie position of tlie wound. 
 
 of being merely wet with carbolic lotion, is steeped in 1-5 or 
 in 1-10 solution of carbolic acid in glycerine, and this is 
 wrapped around the penis and over the scrotum. This gauze 
 sticks to the skin and does not become detached with the 
 movements of the body, while it is more powerfully antiseptic 
 than the ordinary carbolic gauze. Then a mass of gauze is 
 rolled into a ball, and this is suspended in the centre of a long 
 strip of gauze. The ball is i)laced in the jjerineum behind 
 the scrotum, and the strip of gauze passes u}) in each groin. 
 This strip retains the pad in position (Fig. 51). The pad 
 serves the double purpose of supporting the scrotum and re- 
 ceiving the discharge, which passes chiefly downwards. The 
 
106 
 
 ASEPTIC SURGERY. 
 
 hollows having been filled np with loose gauze, the general 
 dressing is applied. A hole is cut in this dressing towards the 
 
 Fig. 51.— Deeper part of the hernia and scrotal dressings. 
 
 Left side of Bcrotum covered with gauze soaked in carbolised glycerine. Mass of gauze in the 
 perineum enclosed in a roll of gauze. 
 
 upper border, and the penis is passed through this hole, and 
 thus helps to keep the dressing in position. The dressing 
 
 „., 'l!£LlmMM/jJ,/Jj^/^/^^^jj^^^ 
 
 Fig. 52. — Dressing in a case op operation for hernia, or on the 
 
 scrotum on the LEb'T SIDE, SHOWING THE ARRANGEMENT OP THE 
 DRESSING AND ELASTIC BANDAGE. 
 
 passes over the scrotum and over the perineal pad, and is fixed 
 bv a double spica bandage (Fig. 52). The pad in the j)eri- 
 
EXCISIONS OF JOINTS. 
 
 107 
 
 neum is fixed there by a St. Andrew's cross. The elastic band- 
 age is applied in the form of a St. Andrew's cross in the peri- 
 neum, and of a double spica (Fig 53). The bandages, dress- 
 ing, and perineal pad are carefully pinned together in the 
 perineum. 
 
 The methods of managing excisions of joints^ operations for 
 ununited fractures, &c., in the lower extremities, are very im- 
 portant. Here jjerfect rest must be combined as far as possible 
 with the aseptic treatment. For two or three days after an 
 
 Fig. 53. — Dressing in hernia cases or in operations on the scrotum, 
 showing the arrangement op the bandages in the perineum. 
 
 (seen from BELOW). 
 
 operation it is better to change the dressing, which is the 
 ordinary gauze dressing applied round the limb, simply by lift- 
 ing the limb, because there is generally a large amount of 
 bloody and serous oozing at first. After a few days this 
 oozing has become much diminished in amount, and the 
 dressing is then accomplished in the following manner : — A 
 Gooch's splint is padded above and below the situation of the 
 wound, the part opposite the wound being left unpadded. The 
 whole splint and padding is covered with a piece of macintosh 
 cloth, and is firmly fixed to the posterior aspect of the limb 
 above and below the situation of tlie wound. Behind the 
 wound, at the part where tlif jjadding is deficient, masses 
 
10.H 
 
 ASEPTIC SlTIiGEliY 
 
 of gauze of sufficient thickness are arranged transversely and 
 superficial to the macintosh. These pieces are three or four 
 or more in number, and they act as padding for the splint, 
 and at the same time as an antiseptic dressing (Fig. 54). 
 When the dressing is changed, a piece of gauze is pinned to each 
 
 Fig. 5i.— Splint for excision of knee, ready for application. 
 
 The splint is padded at the upper and lower parts, and tlie splint and padding are covered with 
 a piece of macintosh cloth. The space opposite the knee is filled with masses of gauze 
 arranged transversely and superficial to the macintosh. 
 
 of the old pieces, and then the old piece being pulled out the 
 new is pulled in, and thus the limb is never left without 
 support (Fig. 55). Over the front of the limb an ordinary 
 gauze dressing of suitable size is applied. 
 
 Splint applied in a case op excision op the knee. 
 
 This shows the method of changing the dressing. In the first way described a mass of gauze 
 would be pinned on to the end of the old piece on the other side of the limb, so that as the 
 old piece is pulled out the new is pulled in, or it may be arranged in the second manner de- 
 sc^ribed, and shown in Fig. 54— viz., a piece only extends to the middle line behind, and as 
 soon as each is pulled out afresh piece is pushed in. 
 
 Another more convenient way in which this may be 
 managed with even less movement is to have each of the 
 masses of gauze mentioned in the former paragraph divided, in 
 the middle line, and thus the half of each mass is pulled out 
 at a time and a new piece substituted (Fig. 54). 
 
TREATMEXT OF ABSCESSES. lO'J 
 
 Another way is to apply a wire splint next the skin, fix it 
 there, and then apply the dressings outside. 
 
 When the discharge becomes still less the limb may be put 
 up in plaster of Paris, a window being left for dressing. 
 
 Excision of joints is now, however, rarely performed, for 
 with aseptic treatment an incision into a joint and the insertion 
 of a drainage tube is generally sufficient in cases where formerly 
 excision or even amputation would have been required. Several 
 advantages are thus gained, among the most prominent of these 
 being absence of shortening of the limb (and this is most im- 
 portant in children), and often a certain and even a considerable 
 amount of motion in the joint afterwards. 
 
 It may be mentioned here that Mr. Knowsley Thornton in 
 ovariotomy cases does not apply a bandage round the abdomen. 
 He fastens the dressing with adhesive plaster, and does not 
 change it for a week, by which time healing is generally 
 complete, except where the stitches are. 
 
 Such are the chief points as to the application of antiseptic 
 dressings in different situations. I must now say a few words 
 as to the aseptic treatment of abscesses. 
 
 I have already referred to the question of the necessity for 
 a dependent opening, and I pointed out that, as the discharge 
 from an abscess treated aseptically is not irritating, because not 
 putrid, it does little harm even though left to well out, instead 
 of being permitted to flow ou.t through a dependent opening. 
 In fact, aseptic surgery has altered the relative importance of 
 the questions to be considered in selecting a situation for open- 
 ing an abscess ; and now the chief point to be looked at is not 
 whether the orifice of the tube is in the most dependent position 
 possible, but whether it is at the point furthest removed from 
 sources of putrefaction — i.e.. whether there is the greatest pos- 
 sible space for the overlapping of the antiseptic dressings. 
 
 Indeed, in some abscesses pointing near such canals as the 
 pharynx, anus, &c., it is better to make an opening in healthy 
 structures at some distance from the abscess, and burrow a 
 channel into it, than to make an incision directly into the 
 abscess cavity. 
 
 I saw a striking example of tliis iu Kdiubui-gh se\cral vears 
 
110 ASEPTIC SURGERY. 
 
 ago. A boy was admitted into the infirmary with retropha- 
 ryngeal abscess connected with occipito-atloidean disease. The 
 abscess was on the point of bursting into the pharynx. Mr. 
 John Chiene, who had charge of the case, instead of opening 
 the abscess at the only place where it was pointing, viz., in the 
 pharynx, cut down behind the sterno-mastoid, and burrowed into 
 the abscess cavity from behind. The abscess followed a typical 
 aseptic course, and the patient recovered completely. Thus 
 then the great rule in selecting a situation for opening abscesses 
 is to make the incision as far as possible from sources of 
 putrefaction. 
 
 When opened, instead of dealing tenderly with the pyogenic 
 membrane as was formerly done under the impression that it 
 was a hurtful thing to injure it, we now empty the cavity 
 thoroughly, especially in the case of chronic abscesses, in order 
 to get out all curdy masses of pus, &c., which may have gravi- 
 tated to the bottom of the abscess. When this is done oppor- 
 tunity is given for, the rapid adhesion of the greater part of the 
 wall of the abscess cavity, and thus in a very short time there 
 is merely a sinus left leading down to the seat of disease. 
 
 There is no necessity for washing out the cavity of an 
 abscess, as is done in so many quarters. To do so is simply to 
 irritate the pyogenic membrane unnecessarily without securing 
 any corresponding benefit. Indeed, it might give rise to such 
 an amount of oozing from the wall of the abscess as would wash 
 out all the carbolic acid from the dressings in a very short 
 time, and thus lead to the putrefaction of the discharge. The 
 treatment by hyperdistension, while erroneous in theory, is 
 very dangerous in practice, as the fluid may be forced into the 
 cellular tissue, and lead to diffuse inflammation and even 
 gangrene, or to carbolic acid poisoning and death. 
 
 The greatest care must be taken in the drainage of abscesses. 
 In the case of a large psoas abscess the surgeon should intro- 
 duce the largest sized drainage tube in the first instance. This 
 tube may be changed for a smaller in a few days. It ought not 
 to be removed for the first time till at least three days have 
 elapsed since the abscess was opened, otherwise there may be 
 great difficulty in replacing it. It should not be shortened till 
 it is found to be absolutely impossible to get it in fully. When- 
 
TREATMEXT OF ABSCESSES. Ill 
 
 ever this is the ease a piece must be cut otif from the end. 
 (Here I speak of chronic abscesses, an acute abscess heals in a 
 week or ten days.) In some cases, where the same tube is 
 left in for a week (where the case is only dressed once a week), 
 some difficulty will be found in withdrawing it, owing to the 
 granulations having grown in at the holes and holding it in 
 position. In this instance the guide as to shortening is lost, 
 because the tube cannot be pushed out ; and therefore it will 
 be found best in old cases to use a tube having holes only 
 close to its inner end. This cannot be held, and is gradually 
 pushed out as the sinus heals from the bottom. If on removal 
 of a tube the discharge is found to increase in quantity, the 
 tube must be reintroduced. 
 
 As the incision into the abscess is merely large enough to 
 admit the tube, there would be no reason for using protective ; 
 and therefore the wet gauze is applied directly over the orifice 
 of the tube. A tube is the only form of drain suitable in 
 these cases. 
 
 The precautions required in order to ensure an aseptic result 
 are precisely the same as in the case of wounds. 
 
 In changing the dressings the same rules are followed as 
 were formerly described with regard to incised wounds. Chronic 
 abscesses, more PS]>ecially abscesses connected with diseased 
 bones, are extremely tedious ; but nevertheless, as a rule they 
 ultimately recover. The same care must, however, be taken 
 from first to last. It is never safe to change the carbolic 
 dressing for a boracic one, however superficial the wound ap- 
 pears to be. In the case of spinal abscesses absolute rest in 
 the recumbent posture must be maintained till healing is com- 
 plete ; and as the cases generally extend over many months it 
 is well to warn patient and friends before commencing to treat 
 the case. Whether the rule as to the maintenance of the 
 recumbent posture may not be modified by the use of Sayre's 
 jacket, or even without it, is now a question. Lately in two 
 cases which had been under treatment for a long time, and in 
 which all uneasiness in the spine had passed off, Mr. Lister 
 allowed the patients to get up before healing was complete, 
 and without any bad results. 
 
 Empyema does particularly \sv\] under this dressing. I 
 
112 ASEPTIC SUllGERY. 
 
 mention it, in order to state that a metallic drainage tube with 
 a shield like a tracheotomy tube, and with lateral holes, is the 
 best because the india-rubber tube may get compressed between 
 the ribs or be too abruptly bent where it passes into the interior 
 of the pleural cavity. 
 
 There are some cases in which neither the gauze dressing 
 nor the boracic can be employed, but which may nevertheless 
 be treated aseptically. I refer especially to abscess in the 
 perineum or by the side of the anus. 
 
 Abscess in the perineum may be treated aseptically with 
 very satisfactory results. The abscess is opened under the 
 spray, and a piece of lint dipped in 1-5 carbolic oil or 1-10 
 carbolic glycerine is introduced into the cavity to act as a drain. 
 Outside this two or three layers of lint soaked in 1-5 carbolic 
 oil or 1-10 carbolic glycerine are applied, and fixed with a T 
 bandage. Should this become displaced or wet with urine, e^c, 
 the patient pours a little carbolic oil or glycerine over the 
 wound and over the lint, and replaces the dressing. No spray 
 is required in changing the dressings. On the third day a 
 piece of lint dipped in carboHc oil is laid over the wound, and 
 a pair of oiled forceps is slipped under the lint to seize and with- 
 draw the plug ; or the plug may simply be pulled out under 
 the spray. Carbolic oil or glycerine 1-10 is then used for 
 dressino-, and when the wound has become superficial boracic or 
 salicylic ointment is employed. 
 
 The same method of dressing is employed in abscesses 
 beside the anus. In this case, when the patient defsecates, he 
 holds aside the dressing, defeecates past it, wipes the parts with 
 1-20 carbolic lotion and then with 1-10 carbolic oil. He then 
 soaks the dressing with the oil, or applies a new dressing. 
 (The glycerine and carbolic acid may also be used.) The result 
 of this method of treating these abscesses is often excellent, 
 fistula in ano being apparently often avoided when the abscess 
 is taken in time. 
 
 So much for wounds made by the surgeon and their treat- 
 ment. I now come to the consideration of tuounds 'produced 
 accidentally. Here the problem is different from and much 
 more difficult than the former. In the cases we have just 
 
WOUNDS PRODUCED ACCIDENTALLY. 113 
 
 been considering we had merely to keep out the septic particles ; 
 in the present instance these particles have already gained 
 admission, and therefore we have not only to prevent the 
 entrance of more but also to destroy those ah'eady present. 
 
 This is done by washing out the wound with 1-20 carbolic 
 lotion, provided it be recent, i.e., made within twenty-four 
 hours, and then treating it like a wound made by a siu-geon. 
 
 This washing out of the wound must be done very 
 thoroughly. It is best carried out by using a syringe with a 
 catheter attached to it. The point of the catheter is intro- 
 duced into all the recesses of the wound and the 1-20 lotion is 
 injected through it, and thus comes thoroughly in contact with 
 all parts. There must be no attempt to distend the cavity, as, 
 for instance, by shutting the orifice of the wound around the 
 syringe, for the fluid might be forced into the cellular tissue 
 and lead to inflammation or even sloughing. The opening 
 must be left perfectly free and enlarged if necessary. Should 
 there be any shreds of tissue, they had better be cut off, and if 
 there be much dirt ground into the tissue, it must be got rid 
 of by means of a nail brush. The injection and the subsequent 
 procedures are carried out under the spray. 
 
 If the wound was made twenty-four to forty-eight hours 
 before being seen, a stronger solution is employed, viz., the 1-5 
 spirituous solution. This is used in the same way as the 
 other. 
 
 Having thus got the wound pure the question of stitching 
 it up arises. The answer to this question varies according to 
 the parts injured. As a rule, in injury of the soft parts, a 
 drain is introduced, and the same accurate stitching employed 
 under the spray as was described on a former page. More 
 especially is this the rule in scalp wounds, where most brilliant 
 results maybe obtained by the use of catgut drains and accurate 
 stitching. The rest of the treatment is the same as in ojiera- 
 tion wounds. 
 
 Where the wound is much contused, the same rules apply 
 as to purification, but it must not be stitched up. After purifi- 
 cation a drainage tube is inserted if necessary, the wound is 
 lefto],)en, a piece of protective is placed over it, and the dressing 
 applied in the usual manner. 
 
 1 
 
114 ASEPTIC SURGERY. 
 
 I have mentioned the methods to be employed when the 
 womid is seen within the first forty-eight hours. It may be, 
 however, that it does not come under notice till putrefaction 
 already exists. In this case it may be purified by the intro- 
 duction of iodoform suspended in water by the aid of ;dcohol, 
 or if superficial, by stuffing it thoroughly with lint dipped in 
 1-5 carbolic oil. This dressing repeated for several days 
 generally converts it into an aseptic wound. In most cases it 
 is best to apply iodoform or the chloride of zinc solution. 
 
 Certain special wounds call for attention. 
 
 Compound fractures are the wounds in which this treat- 
 ment was first applied, and in which excellent results can be 
 obtained. There are a few special points to be noted. In 
 purifying the wounds great pains must be taken. Any dirt 
 • must be carefully scraped or scrubbed out. All blood clots 
 ought to be turned out as completely as possible. The ends of 
 the bones are cleaned, and if they cannot be returned or got to 
 fit, portions should be sawn off. The ends may be tied together 
 with silver wire. The parts ought to be well kneaded as the 
 carbolic lotion is injected through the catheter, in order to 
 diffuse the lotion as much as possible into all the recesses of 
 the wound. No stitches are inserted, but on the contrary, free 
 drainage by tubes is used. The same sort of dressings and 
 apparatus are employed as in excisions. 
 
 Wounds involving tendons, nerves, or muscles, are treated 
 in the same manner as others, and the ends of the divided 
 muscles, tendons, or nerves, ought to be stitched together 
 with catgut, and the position of the part so arranged as to 
 avoid dragging on these stitches. 
 
 Wounds of joints are very imj^ortant. When recent no 
 operation (excision or amputation) is required in the first 
 instance. As a rule the joint may be saved, and perfect move- 
 ment obtained by washing it out very thoroughly with carbolic 
 lotion 1-20. The wound in the joint is enlarged if necessary. 
 Where several hours have elapsed since the accident (more than 
 eight or ten hours), it is well to employ the sj)irituous solution. 
 A drainage tube is introduced into the joint, but no stitches 
 are used. After a few days, when the discharge has diminished, 
 
SPECIAL WOUNDS. 115 
 
 the drain is removed. In about three weeks, or earlier, passive 
 motion ought to be begun, otherwise the adhesions outside the 
 joint may become so strong as to require to be broken down 
 under chloroform. 
 
 Compound fractures of the skull are treated in the same 
 manner as compound fractures elsewhere, purification being 
 attempted with 1-20 carbolic lotion. The dm-a mater may 
 be freely dealt with without fear of inflammation, for the 
 irritation of carbolic acid is only very transient. Bleed- 
 ing vessels are secured by catgut. Should one of the great 
 sinuses be wounded, a graduated compress of catgut arrests the 
 haemorrhage satisfactorily. This I have known to act very well 
 in a case of woimd of the longitudinal sinus, occurring during 
 the operation of trephining over the seat of an old injury. 
 
 Wounds penetrating the thoracic cavity are much more 
 difficult to treat. Should the wound penetrate the lung, and 
 should the lung protrude, the exposed parts and those around 
 are purified with carbolic lotion 1-20. In deciding as to the 
 returning of the injured lung and the stitching up of the wound, 
 the surgeon must be guided by the circumstances of the par- 
 ticular injury. In some cases, if the wound in the lung were 
 superficial, the edges of the divided visceral pleura might be 
 stitched together with fine catgut, the lung returned, and the 
 external wound closed. Where a large bronchus is injured it 
 might be better practice to leave the limg in the wound, and 
 leave the wound open. 
 
 Where there is merely a wound of the parietal pleura, and 
 where the lung is not wounded, the external wound only is 
 purified and is closely stitched, in the hope that union by first 
 intention may occur, that the air may be absorbed, and that 
 any septic dust present in the pleural cavity may be unable to 
 cause mischief. 
 
 Wounds of the abdomen are variously treated, according as 
 there is or is not protrusion of the contents. Where there is 
 no protrusion, and where there is no reason to suspect injm-y of 
 the viscera, the external wound ought to be purified and 
 closely stitched, so as to get primary union throughout, no drain 
 being used. 
 
 Where the intestines protrude, they ought to be carefully 
 
116 ASErriC SURGERY. 
 
 bathed in warm carbolic lotion 1-30 or even 1-20, and if there 
 be no injury of them in any part they may be returned. If 
 they are cut, the gut may be stitched with catgut by the 
 glover's suture. 
 
 If the omentum protrudes, opinions vary as to the treat- 
 ment. When it can be returned do so after thorough purifica- 
 tion, and then stitch the abdominal walls, including the perito- 
 neum, close together. Where, from adhesion or other sufficient 
 cause, this cannot be done, or where the omentum is very 
 dirty, I should, from a research into the consequences of un- . 
 returned omentum by Dr. Kenneth McLeod, of Calcutta, con- 
 sider it the safest practice, especially in the case of a person 
 with strong muscular parietes, to stitch the deepest parts of 
 the omentum to the deep part of the wound, cut off the 
 remainder and close the skin over all. 
 
 If internal haemorrhage is going on, apparently from the 
 mesenteric vessels, the wound may be enlarged and the bleeding 
 point sought for. Simon advised that in bleeding from the 
 kidney, the injiu-ed organ should be excised ; this suggestion 
 was never put into practice, but nevertheless it is one well 
 worth bearing in mind. 
 
 Such are the chief points to be attended to in recent 
 wounds ; there remains for consideration the class of cases in 
 which putrefaction has been present for a long time. I refer 
 to cases of putrid sinuses, generally connected with diseased 
 bones or joints. An attempt may be made to purify these 
 during the course of an operation, and sometimes when the 
 sinuses are few and uncomplicated, and where all the dead bone 
 is removed, this attem})t may be successful. The sinus is 
 scraped out with one of Volkmann's sharp spoons (Fig. 56), and 
 all the granulation tissue, as far as possible, removed. The 
 raw surface of the sinus, &c., is then washed out with the 
 chloride of zinc solution, which is applied thoroughly to all 
 parts, and a gauze dressing is used, in the hope that putre- 
 faction has been thus eradicated. The spray should be employed 
 during the whole procedure. 
 
 If this is successful, well and good. If not, boracic oint- 
 ment (at first full strength, afterwards half) or salicylic oint- 
 
TREATMENT OF BURNS. 117 
 
 ment, covered with boracic lint, is the best dressing, indeed, it 
 is the best dressing in all cases where strict aseptic measures 
 are inapplicable. 
 
 The aseptic treatment of burns varies according to the 
 degree and extent of the injury. In any case, unless where 
 the burn is very extensive and where the parts are extremely 
 dirty (necessitating scrubbing of the surface and consequent 
 shock, and also risk of carbolic poisoning), an attempt should 
 be made to purify the surface with 1-20 carbolic lotion. This 
 having been done, if the surface is small, boracic ointment (full 
 strength) and boracic lint form a convenient dressing. When 
 the extent of the burn is greater, wet boracic dressing (wet 
 boracic lint used as water dressing — covered by gutta-percha 
 
 Fig. 56.— Two foejis op sharp spoons, a large round one akd a 
 small oval one. 
 
 tissue or macintosh) is the most suitable. The wet boracic 
 dressing is also applied in those cases where, on account of the 
 extent of the burnt surface and the amount cf dirt, purification 
 with carbolic acid is not advisable. Where the surface is 
 thoroughly charred and where the wound is not very extensive, 
 boracic ointment or carbolic oil 1-10 are the best dressings. 
 The objection to carbolic oil, which was formerly used in all cases, 
 is that, when the surface is large, there may be a fatal absorp- 
 tion of carbolic acid. 
 
 In the after-treatment the sores are dressed with boracic 
 dressings (protective and boracic lint, or better, in the first 
 instance, boracic ointment) just as in the case of ulcers. 
 
 The rules as to the treatment of gangrene are altered in 
 
118 ASEPTIC SURGERY. 
 
 aseptic surgery, and this is more especially the case with senile 
 gangrene. Should symptoms of senile gangrene set in, say in the 
 lower extremity, the skin of the foot, toes and leg, are 
 thoroughly cleansed with 1-20 carbolic lotion. This must be 
 done very efficiently. All the folds about the nails, &c., must 
 be carefully cleansed and washed. This having been done, the 
 whole limb and foot are enveloped in a large mass of carbolised 
 cotton wool (carbolised in a 1 per cent, ethereal solution of 
 carbolic acid). This being pure in its substance, and being 
 applied over a pure surface, completely shuts out causes of 
 putrefaction. The carbolic acid soon flies off, and then the 
 cotton wool acts simply as a filter, while it protects the part 
 from unequal pressure and retains the heat. This may be 
 kept on for any length of time, and so long as discharge does 
 not extend to the surface or the gangrene above the limits of 
 the dressing, the part remains sweet, and very often the gan- 
 grene, which in the first instance threatened to involve the 
 whole leg, becomes limited, and there may even be merely a 
 small cutaneous slough. In any case, as a rule, the gangrene 
 does not go on spreading as it does when treated in the usual 
 manner, and for this reason : — Suppose that the part is not 
 treated aseptically, the tissue at the edge of the dried gan- 
 grenous mass becomes putrid, the living tissue in the neigh- 
 bourhood is very weak, the putrid material acts on it like a 
 caustic, destroys its vitality or excites an inflammation which 
 kills it, and so the gangrene goes on spreading, till at length 
 parts are met with of sufficient vitality to resist this action of 
 the putrid materials. Then a line of demarcation is formed. 
 On the other hand, when the gangrenous parts are not putrid, 
 the weak parts in the vicinity, which would to a certainty 
 have died in the former case, retain their vitality and gain 
 strength. Thus also the rule of never amputating in senile 
 gangrene, except to trim a stump formed naturally, is done 
 away with, and it is generally better to amputate as soon as 
 it is clear to what extent the tissue is dead, rather than to 
 subject the })atient to the continual pain and irritation arising 
 from the presence of the dead piece. The same reasoning 
 a])plies to cases of traimaatic spreading gangrene. This is 
 only one instance of how completely many current ideas as 
 
TREATMENT OF N.EVI, ETC. 119 
 
 to surgical pathology and treatment are reversed, when means 
 are taken to render the dust of the atmosphere inert before it 
 reaches a wound. 
 
 In treating nasvi great benefit is obtained from the in- 
 jection of pure carbolic acid. The na3vus is first thoroughly- 
 cut off from the circulation by ligatures tightly applied around 
 its base, and then half minims of pure carbolic acid are in- 
 jected into various parts of the tumom-. Ten minutes or so 
 having been allowed to pass, in order to ensure com])lete and 
 firm coagulation, the ligatures are divided and removed, and the 
 punctures are touched with collodion. The surface being left 
 completely dry, any slough which forms becomes absorbed or 
 separates as a crust after some time, the part beneath being 
 found to be a scar. 
 
 The same method answers excellently in the treatment of 
 varicose veins. A tourniquet having been firmly applied around 
 the upper part of tlie limb in order to arrest the circulation, 
 the vein is punctured at various parts, and half minims of car- 
 bolic acid are introduced into it. The tourniquet is kept on 
 for ten minutes after the injection is completed. Coagulation 
 and a slight degree of inflammation are thus induced, but this, 
 so far as I have seen, never goes to any dangerous extent, and 
 is followed by at least temporary cure. I have not known 
 any case return with reformation of varicose veins. 
 
 A dissection or post-mortem wound does not give rise to 
 bad results if the wound be instantly purified with 1-20 car- 
 bolic lotion. 
 
120 ASEPTIC SURGERY— MODIFICATIONS. 
 
 CHAPTER VI. 
 
 ASEPTIC SURGERY — MODIFICATIONS. 
 
 Country practice : Hoiv to dispense, with the sjjray diinng the operation — and 
 during the after-treatment : How to render the dressings less frequent. Is 
 the aseiDtic method applicable in war? Mr. Lister's svggestions : 
 Esmarch''s2)lan : Reyher's method. Development of Aseptic S>Trgery in ]Mr. 
 Lister's hands : Conipoimd fractures — Pure carbolic acid — Formation of 
 crust — Carholic p%dty — Lead plaster — Lac plaster, syringing wounds with 
 carVolic lotion, protective, catgut ligat^ires, method in 1870 — Present method 
 in tlis main introduced in 1871 — Fwther introduction of wet gauze, steam 
 spray, elastic bandages : abscesses — Method of opening them under carbolic 
 oil : wounds. 
 
 Such are the methods usually employed in carrying out the 
 Listerian principle in hospital or in private practice. It is, 
 however, said to be difficult of application to country practice, 
 and we must therefore enquire in what way it can be made 
 easier. The difficulties urged are that the spray is too heavy 
 to carry : that it is not always easy to return a long distance to 
 see a patient on the day after the operation, and that the dress- 
 ings are too expensive for the lower classes. We must there- 
 fore, in some way or other, render the dressings very infrequent, 
 so as to avoid expense and unnecessary visits, and we must try 
 to dispense with the spray. 
 
 In the first instance in going to perform an operation or to 
 treat a wound, the surgeon takes instruments with him, and he 
 may, without any additional trouble, easily add a spray to the 
 contents of his bag, and this spray may be left at the patient's 
 house, and brought home again after the first dressing. But, 
 suppose the surgeon has not a spray at hand. What is to be 
 done ? Well, he must use all the other i)recautions before 
 described, and wash out the wound frequently with 1-40 
 carbolic acid lotion during the operation, and while the stitches 
 
MODIFICATIONS FOR COUNTRY PRACTICE. 121 
 
 are being inserted ; and then, before the piece of wet gauze is 
 applied, he may distend the wound with the same lotion, the 
 wet gauze being applied while this is still flowing out. At 
 the same time I caimot see that, in the great majority of cases, 
 it can be any great hardship to carry a spray to an operation. 
 
 During the after-treatment a spray is not necessary. The 
 spray may be rendered unnecessary diuring the after-treatment 
 in two ways. In the case where catgut stitches and catgut 
 drains are used a deep dressing may be applied at the time 
 of the operation, and may never require to be changed. 
 This deep dressing is fixed down in some way or other, and is 
 treated as a wound, the gauze being soaked with carbolic lotion 
 every time the superficial dressing is removed, and then a 
 piece of wet gauze larger than the deep dressing, and the 
 general dressing are applied. Should it be necessary to remove 
 the deep dressing, there is no necessity for the spray, if catgut 
 drains be used, because there is no cavity into which air may 
 pass. The deep dressing having been removed, carbolic lotion 
 is allowed to flow over the wound till a guard is applied. 
 Where a tube is used it is more difficult to do without the 
 spray, for in that case there is an open orifice into which dust 
 may fall, and be sucked into the interior of the wound, and 
 further, when the tube is removed, air must enter to take its 
 place. This may be avoided by the use of a syringe which 
 constantly keeps a stream of carbolic acid lotion passing over 
 the wound and over the drainage tube, till a fresh dressing 
 is applied. Should it be necessary to remove the tube it is 
 well, in addition to this constant flow of lotion, to cover the 
 orifice of the tube with a rag dij^ped in the antiseptic lotion. 
 The best way is to take a guard soaked in carbolic lotion and 
 folded in several layers, and place this over the orifice of the 
 drainage tube, extending on each side of it for a considerable 
 distance. The tube is now seized with a pair of forceps through 
 this rag, and as it is pulled out the rag is carefully tucked in 
 around it, so as to compel the air, as it passes in to take the 
 place of the drainage tube, to traverse the moist guard. This 
 seems to me better than the method of slipi)ing in forceps 
 under the guard and pulling out the tube, the guaid being well 
 pressed down on it. In taking out wire or silk stitches, the 
 
122 ASErilV SURGERY— MODIFICATIONS. 
 
 guard is pulled aside so as to expose the stitch, a little carbolic 
 lotion is then dropped over the suture, and as the latter is 
 withdrawn, a few drops of the lotion are applied to the orifice 
 of the puncture. 
 
 These methods — the use of catgut stitches and catgut 
 drain, and the employment of a permanent deep dressing, 
 together with the hints in cases where a drainage tube or non- 
 absorbable stitches are employed, suffice to render the operator 
 independent of a spray. 
 
 Can we now render the dressings less frequent ? This may 
 of course be done to a certain extent by applying a larger 
 amount of gauze, but the best way is to use sponges in the 
 interior of the dressing for the purpose of absorbing and retain- 
 ing the fluid. The deep dressing having been applied and 
 fixed, a large sponge or several small ones are placed outside it, 
 these sponges having just been wrung out of carbolic lotion ; 
 outside the sponges and extending well beyond them is a piece 
 of wet gauze, and then the masses of loose gauze and general 
 gauze dressing. In this way the discharge is retained in the 
 interior of the dressing, and of course so long as it is there, 
 and so long as the discharge has not reached the edge of the 
 dressing, it is as safe from putrefaction as if it were in a pure 
 flask. By the use of these sponges several days may be 
 allowed to elapse, in many cases, before the first dressing is 
 changed, though it is well in every case to change the first 
 dressing on the day after the operation. When the dressing 
 is changed these sponges are squeezed thoroughly, washed in 
 carbolic lotion 1-40, and reapplied. By the use of sponges two 
 or three dressings suffice for the treatment of most operation 
 wounds. 
 
 By the use of salicylic jute in large masses, the same avoid- 
 ance of frequent dressings may be obtained, but this material 
 is not very trustworthy as an antiseptic. 
 
 Thoroughly purified cotton wool, which may be obtained 
 cheaply by impregnating it with sulphurous acid fumes, ap- 
 plied in large mass may prevent the necessity of frequent 
 dressing. 
 
 By the means described, the difficulties in the way of the 
 adoption of this system in country practice may be overcome. 
 
APPLICATION IX JVAP. 123 
 
 and instead of causing additional expense to a poor patient, it 
 saves expense in many ways. The dressings required are so 
 few that the price of the materials employed is not greater 
 than that which would be necessary even if water dressing 
 were used ; and expense is saved in many other ways, as I shall 
 mention in the latter part of this work, notably in the rapid 
 healing, which is of course of the greatest consequence to the 
 bread winner. 
 
 Is the Aseptic method applicable in War"? 
 
 In the 'British Medical Journal ' for September 3, 1870, 
 Mr. Lister describes a method for the use of army surgeons. 
 He suggests that the wound should, as soon as possible after 
 the injury, be thoroughly washed out with 1-20 carbolic lotion, 
 the smTounding skin being at the same time purified. 
 Bleeding vessels are secured by catgut, by torsion, or by car- 
 bolised silk. While the wound is full of lotion, extract the 
 bullet, clothes, &c. Then cover the wound with two or three 
 layers of oiled silk, smeared on both sides with carbolic oil 1-5. 
 Over this apply layers of lint soaked in the 1-5 oil. overlapping 
 the oiled silk for about three inches in every direction, and 
 about a quarter of an inch in thickness. This is covered with 
 gutta-percha tissue, and the whole is fastened on with a bandage 
 soaked in carbolic oil. This is the permanent dressing. Out- 
 side this, another and larger dressing of oiled lint covered by 
 gutta-percha tissue is applied daily. During the first day apply 
 fresh oil to the outer cloth once in six or twelve hours. On 
 the following day the outer dressing is changed, carbolic 
 lotion being introduced under the edge, as it is lifted, by 
 means of a syringe ; or carbolic oil may be poured in. After 
 the first dressing use the 1-10 oily solution, and later the 
 1-20. On the second day oil is only applied once in twelve 
 hours, after that it is applied daily for five or six days, and then 
 once in two days. 
 
 Jn compound fractures use a wire splint next the deep 
 dressing, and apply the fresh superficial dressings outside the 
 wire. This s})lint need not be removed till union is complete, 
 the oil being merely poured between the meshes when the 
 dressing is changed. 
 
124 
 
 ASEPTIC SURGER Y—MODIFICA TIONS. 
 
APPLICATION IN WAR. 125 
 
 Esmarch, in Langenbeck's ' Archiv,' vol. xx. p. 171, proposes 
 another plan of treatment. 
 
 He points out that the new form of bullets passing quickly 
 through the clothes may not carry into the wound any causes 
 of putrefaction. Therefore, if the wound is not examined by 
 dirty fingers or instruments, and if it be seen at once, it may 
 in most cases be regarded as aseptic. Starting on this prin- 
 ciple, he suggests that each soldier should be provided with 
 tampons of salicylic cotton, wrapped in salicylic gauze. Fig. 
 •57 represents the contents of the packet of dressings which 
 Esmarch proposes to supply to each soldier. At the front, when 
 there seems any possibility of saving the limb, these tampons 
 are introduced into the openings, and bandaged on without 
 any preliminary probing or examination of the wound. Any 
 other necessary apparatus is applied, and the patient sent to 
 the rear. At the rear the skin around the orifice is purified 
 with some antiseptic lotion, and if there is any necessity to 
 explore the wound, as for removing bullets, splinters, &c., the 
 tampon is removed under the spray, the wound washed out, 
 and an antiseptic dressing applied. If there is no necessity 
 for exploring the wound, the skin is merely purified, and 
 then a mass of salicylic jute or other antiseptic material is 
 applied without disturbing the tampon. If putrefaction occurs 
 later the wound must be enlarged, and an attempt made to 
 purify it. 
 
 Conservative surgery being more a})plicable with the aseptic 
 method, the necessity for primary amputation at the front is less 
 frequent, and as a rule exists only in the case of sjnashes from 
 large balls. Esmarch considers that for such cases a sutficient 
 supply of antiseptic materials should be present in the am- 
 bulance. Referring to those cases not treated aseptically which 
 do well, and to the evils of investigating the wound at the first, 
 Esmarch says : ' So weit ich habe in Erfahrung bringen kon- 
 nen sind diejeningen Kalle, welche asei)tisch verliefen, auf 
 dem Schlachtfelde nicht mit dem Finger griindhch untersucht, 
 sondern gleieh verbunden worden, wahrend solche Falle bei 
 denen wiederholte Untersuchungen vorgenommen waren, mir 
 oft einen besonders schlimmen Verlauf zu iiehmen schienen.' 
 
 Esmarch's method has been put to the test by Dr. Reyher 
 
]2G SEPTIC SURGERY— MODIFICATIONS. 
 
 during the late Kusso-Turkish campaign. His results were 
 excellent, and will be referred to later on. He carried out the 
 aseptic method in two ways, according to the nature of the 
 injury and the treatment before the case came into the sur- 
 geon's hands. These are, either that the surgeon closes the 
 wound without further treatment, merely disinfecting the sur- 
 rounding parts, or else that he cleans out and purifies the track 
 of the bullet, and afterwards makes provision for free aseptic 
 drainage. In the first instance healing occurs under a crust ; 
 in the second, under a moist and antiseptic dressing. 
 
 The cases which are suitable for the first method of treat- 
 ment — treatment by a crust — are those in which the wound is 
 small, where no clothing has been carried in with the bullet, 
 where the edges of the wound fall together as where the 
 wound is more or less valvular, and where no examination of 
 the wound by finger, probe, &c., has been made. In such a 
 case the surrounding skin is carefully purified, and an attempt 
 is made to obtain a dry crust either by allowing the blood to 
 dry, or by aiding the drying by applying charpie, gauze, &c. ; 
 or the wound may be covered by a mass of salicylic wool or 
 carbolic gauze. Keyher lays particular stress on the avoidance 
 of probing or draining such wounds. On the contrary, any 
 communication with the outer world should be shut off as soon 
 as possible. 
 
 In many cases this ' occlusion ' of the wound cannot be 
 depended on, and the bullet track must be washed out, and 
 treated in the way described under compound fracture, free 
 drainage being carefully provided. This is chiefly the case 
 where the missile has been travelling slowly, and where, conse- 
 quently, the wound in the skin is not so small nor valvular, and 
 where there is more likelihood of articles of dress being carried 
 in with it ; where, also, as Eeyher puts it, the wound is open 
 and ' the air has not only entered but must enter again.' This 
 treatment is also necessary in cases where wounds have been 
 examined with unclean fingers or instruments before reaching 
 the ambulance. 
 
 It is thus evident that the spray is not required for the 
 majority of cases, and indeed by following the lines previously 
 indicated it may be entirely dispensed with. The gauze re- 
 
ATTLICATION IN WAR. 127 
 
 quired for the dressings can be made in the vicinity, and for 
 this purpose Eeyher carried with him the machine for making 
 gauze described in Chapter III., and had thus a constant supply 
 of the freshly-prepared material. There is not much difficulty, 
 therefore, with regard to the materials ; the real question is 
 how to have the cases treated aseptically from the very first. 
 Eeyher was able to overcome these difficulties by proceeding in 
 the following manner. In the first place, instructions were 
 given that wounds were never to be examined at the front, 
 either with fingers or instruments, nor was any attempt to be 
 made to extract a bullet. The only exceptions to these rules 
 were cases where blood-vessels were injured, though even in 
 these it was generally possible to apply an Esmarch's elastic 
 band to control the haemorrhage temporarily ; and cases where 
 the projectile had passed into the large cavities of the body, 
 and, without wounding the contents, had remained in the wall 
 of the cavity. In such a case the bullet ought to be extracted 
 at once, lest it should fall into the cavity during the transit of 
 the patient. ' For surgeons at the front there is only one line 
 of treatment — to occlude the wound provisionally — to lay the 
 wounded part in a suitable position on the litter, and to render 
 it provisionally immovable. As provisional dressing the sali- 
 cylic balls recommended by Esmarch are the best.' This 
 method is chiefly suitable for cases where the soft parts alone 
 are injured. ]Most of the serious cases can be attended to as 
 a rule at the foremost ambulance. 
 
 The more surgeons become imbued with the true principles 
 of aseptic surgery, and the more thoroughly they grasp anti- 
 septic surgery in all its developments, so much the greater is the 
 likelihood of obtaining aseptic results. Reyher's results show 
 strikingly what can be done with the methods at present at 
 our disposal. There can be no doubt that with improved 
 methods and increased knowledge and experience, aseptic 
 surgery will soon be universally carried out in war.' 
 
 It will be interesting now to trace the gradual development 
 
 ' For a resume of the opinions of army surgeons on the best methods of 
 carrying out aseptic surgery in war, see a little pamphlet by Surgeon- Major 
 H. Melladew, Xvtcson Antincptie Surgery in War. London : Ilanken ."v Co. 1881. 
 
128 ASEPTIC SURGERY. 
 
 of this system in Mr. Lister's hands. This will not only be 
 interesting but instructive, as showing how aseptic surgery 
 may be carried out in circumstances where spray, gauze, &c., 
 cannot be obtained. 
 
 • The first cases in which the treatment was tried were com- 
 pound fractures, and the first attempt recorded by Mr. Lister 
 was made in March 1865. This attempt was imsuccessful, as 
 Mr. Lister subsequently believed, from mismanagement.^ The 
 next case was a compound fracture of the tibia, caused by the 
 wheel of a waggon passing over the leg. The external wound 
 in this case was 1^ inch long, and | inch broad. A piece of 
 lint dipped in carbolic acid (which was at that time only got 
 as an impure liquid known as German creosote) was placed 
 upon the wound. Four days later this lint was removed, and 
 the wound dressed with lint soaked in water in which this im- 
 pure carbolic acid was diffused. Five days afterwards a solution 
 of one part of carbolic acid in from 10 to 20 parts of olive oil 
 was used for four days, and then ordinary water dressing was 
 resorted to. 
 
 The aim in this case was to form a crust consisting of lint, 
 carbolic acid, and blood, which would protect the deeper parts 
 from putrefaction. In this instance, however, the scab came 
 off on the fourth day, and in order to avoid this occurrence, 
 Mr. Lister, in his next cases, applied a piece of lint dipped in 
 pure carbolic acid as before, large enough to overlap the sound 
 skin for a quarter of an inch all round, and covered with oiled 
 paper, applying for the first four days outside this arrangement 
 a piece of lint soaked in pure carbolic acid. The crust was 
 left untouched till the eleventh day, and then water dressing 
 was used. 
 
 It now became evident that, owing to the volatility of the 
 carbolic acid, means were required to prevent its evaporation. 
 Accordingly, in the next cases a layer of sheet lead or of block 
 fin was applied outside and overlapping the crust. 
 
 Up to this time there was no attempt made to purify the 
 
 interior of the wound in the first instance. How was it, then, 
 
 that no putreftiction occurred ? Probably for the following 
 
 reasons. It may have been that no septic particles had got 
 
 ' See numbers of the Lancet for 1867. 
 
ITS DEVELOPMENT. 129 
 
 into the interior of the wound because the blood flowing con- 
 stantly out would prevent the entrance of solid particles, which 
 would thus only be present if dirt was introduced at the time 
 of the accident, or if much movement of the fragments oc- 
 curred afterwards, with consequent introduction of air. Further, 
 if any septic particles were present they may not have been 
 able to produce any effect in the presence of healthy living 
 blood clot. (This will be discussed hereafter.) Lastly, the 
 strong carbolic acid, though appKed only to the surface, rapidly 
 spreads into the interior even to a depth of one or two 
 inches. 
 
 The necessity for pmifying the deeper parts of the wound 
 soon became evident. A case was admitted in which, when the 
 tissues around the wound were pressed, bubbles of air escaped 
 along with the blood. Here Mr. Lister squeezed out as much 
 of the clotted blood and air as he could, and then applied a 
 piece of lint dipped in pure carbolic acid, slightly larger than 
 the wound, and over this the piece of block tin. The crust 
 was daily painted with carbolic acid, the tin cap being reap- 
 plied on each occasion. This treatment was continued for 
 three weeks. 
 
 This purification of the deeper parts was carried out more 
 thoroughly in the next case, in w^hich it was necessary to saw 
 off a portion of the ulna, and here the whole of the interior of 
 the wound was swabbed out with pm-e carbolic acid. In this 
 case Mr. Lister first became acquainted with ' antiseptic sup- 
 puration,' i.e. su})puration due to the irritation of the anti- 
 septic applied. (The evil effects of the piure caustic carbolic 
 acid in causing excoriation of the skin had been already 
 noticed.) 
 
 Finding that no harm resulted from the free application of 
 pure carbolic acid to the interior of the wound in the last case, 
 the next which came under notice was more thoroughly treated, 
 the contused parts being well manipulated and squeezed, so 
 as to induce the liquid carbolic acid, which was introduced, to 
 penetrate into all the interstices of the wound. At a later period, 
 in order to permit cicatrisation, the crust was chpped away 
 around the margin, and a solution of sulphite of potash (5 grains 
 to the ounce) applied. 
 
 K 
 
130 ASEPTIC SURGERY. 
 
 In future, the method of introducing strong carbolic acid 
 into wounds by means of a piece of lint soaked in the undi- 
 luted acid, held in dressing forceps, was adopted. The blood 
 clots were as far as possible removed. 
 
 In order to obtain a more substantial crust and one less 
 likely to be detached, in cases where there was too little blood, 
 a paste was made use of, composed of starch, moistened with 
 carbolic acid placed outside a piece of calico soaked in pure 
 acid, and applied next the wound. As a rule, however, there 
 is enough blood to form a substantial crust if several layers of 
 calico are used. 
 
 A great risk of putrefaction was all along experienced, 
 owing to the fact that the pure acid could not be made to 
 overlap the skin around the wound because of the excoriation 
 caused by it. This risk was especially great in the first 
 twenty-four hours, during which there was a profuse flow of 
 blood and serum. Hence attempts were made to obtain some 
 sort of dressing containing the acid in a more diluted form, 
 and the first-fruits of these attempts was the formation of 
 various pastes, of which the chief was long known as carbolic 
 putty. This consisted of a 1 in 5 solution of carbolic acid in 
 boiled linseed oil mixed with common whiting (CaC03), to 
 the consistence of a firm paste or putty. This was then spread 
 on a sheet of block tin, forming a layer of about a quarter of 
 an inch in thickness. A piece of lint dipped in 1-5 oily solu- 
 tion was retained permanently next the wound so as to prevent 
 its exposm-e during the changing of the dressings. The whole 
 dressing was firmly fixed down by means of a continuous series 
 of strips of plaster, which, however, were absent at the most 
 dependent part, so as to allow the escape of discharge, which 
 was received on a towel. After some time it was found better 
 to apply this putty between two layers of calico, and then the 
 block tin outside all. 
 
 The advantages of this dressing are : the tin applied out- 
 side prevents the escape of the carbolic acid, the acid in the 
 putty is just sufficiently diluted not to excoriate the skin, while 
 the paste serves as a reservoir for the acid during the interval 
 which elapses between the changing of the dressings, the dis- 
 charge, as it flows out beneath the putty, taking up only a 
 
ITS DEVELOPMENT. 131 
 
 certain amount of the acid in its course. If necessary the 
 strength of the acid in the putty may be reduced. 
 
 Its disadvantages are that it is clumsy and inconvenient 
 to manipulate, and that it is very apt, when subjected to move- 
 ment, to crumble away, and thus become an uncertain dress- 
 ing. Attempts were therefore made to improve it, and recourse 
 was had to various forms of plasters. The first of these was the 
 lead 'plaster,^ 
 
 The following is the mode in which this is prepared : — 
 
 Take of olive oil 12 parts by measure 
 „ ,, litharge (finely powdered) 12 parts by Aveight 
 „ „ beeswax 3 „ „ „ 
 
 ,, „ crystallised carbolic acid 2^ ,, ,, „ 
 
 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 the mass as before, till it becomes 
 thick. Then add the wax gradually till the liquid again thickens. 
 Remove from the fire and add the acid, stirring briskly till thoroughly 
 mixed. Cover up close and set aside, and let the litharge settle, then 
 pour ofi" the fluid and spread on calico. The large quantity of litharge 
 in this mixture was introduced for the purpose of preventing the 
 melting of the plaster at the temperature of the body. 
 
 The wound was dressed with layers of lint soaked in car- 
 bolic oil, and this dressing was covered in all directions with 
 the plaster. This plaster was renewed daily. 
 
 As with the putty, so here, the deep dressing was apt to be- 
 come displaced, and therefore Mr. Lister used lead plaster as 
 the outermost layer of the deep dressing, in the hope that it 
 would adhere to the skin and prevent lifting of the edges of 
 the dressing. In order to prevent the outer layer of the 
 plaster from sticking to this inner portion, a piece of calico 
 moistened in the watery solution was interposed. But though 
 the plaster does very well for the outside layer, it does not do 
 for the permanent dressing, for it allows the watery solution 
 from the calico to soak through to the wound beneath. At the 
 same time this deep layer, not having formed a crust, is apt to 
 shift its place, and to leave the wound more or less exposed. 
 
 ' Brit. .Vrd. JiniriKil. Octolicr ;>!, 1878. 
 K 2 
 
J32 ASEPTIC SURGERY. 
 
 Mr. Lister accordingly tried other sorts of plaster, and at 
 length in shell lac he seemed to have found all that he wanted. 
 This lac mixes in any proportion with carbolic acid, and is more 
 or less fluid or tenacious, according to the quantity of acid 
 present. The shell lac parts but slowly with its acid, and thus 
 forms a good dressing. It is, however, very apt to stick, and 
 in order to prevent this Mr. Lister interposed a layer of gutta- 
 percha between it and the skin. The carbolic acid passes 
 through the gutta-percha with extreme readiness, while the 
 latter prevents the lac from sticking to the deeper parts. 
 Gutta-percha tissue, however, proved apt to crack, and then 
 the discharge got between it and the lac plaster, and thus 
 the fluid beneath it received but little carbolic acid. Hence 
 the same result happens with this cracked gutta-percha as when 
 protective extends to the edge of the dressing — viz., a deep 
 layer of the fluid is more or less protected from the action of 
 the acid, and putrefaction can spread inwards. 
 
 After several experiments he ultimately employed a solution 
 of gutta-percha in bisulphide of carbon to brush over the 
 surface of the lac plaster. 
 
 The following is the method of preparing the plaster : — 
 * Take of shell lac ...... 3 parts 
 
 „ „ crystallised carbolic acid ... 1 part 
 
 ' Heat the lac with about one-third of the carbolic acid over a slow 
 fire til] the lac is completely melted, then remove from the fire and 
 add the remainder of the acid, and stir briskly till the ingredients ai-e 
 thoroughly mixed. Strain through muslin and pour into the 
 machine for spreading plaster, and when the liquid has thickened by 
 cooling to a degree sufficient, spread to the tliickness of one-fiftieth of 
 an inch. Afterwards brush the surface of the plaster with a solution 
 of gutta-percha in about 30 parts of bisulphide of carbon. When the 
 bisulphide 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.' 
 
 For the permanent dressing in compound fracture adhe- 
 siveness is wanted, and this is obtained by rubbing off the 
 gutta-percha and brushing liquid carbolic acid over the surface. 
 
 At this time (1868) the necessity for protecting the healing 
 l)arts from the direct action of the carbolic acid was beginning 
 
ITS DEVELOPMENT. 1^3 
 
 to be recognised, and Mr. Lister first speaks of the use of block 
 tin or sheet lead as a protective. 
 
 At the same time, having obtained a pmrer carbolic acid 
 soluble in water, he gives up the application of the pure acid 
 to the interior of the wound in compound fractures, and syringes 
 it out with a solution of 1-20 instead. 
 
 In the 'British Medical Journal' for March 19, 1870, a 
 description is given of the method then used. The wound was 
 in the first instance thoroughly syringed out with 1-20 carbolic 
 lotion. Then oil silk covered with a layer of dextrin was applied 
 iu one or two layers, and outside this the lac plaster. If much 
 discharge was expected lint or a towel was placed outside the lac 
 piaster in order to absorb the discharge. Where the dressing 
 was left undistui'bed for a week two layers of plaster were used. 
 Where a small piece of lac plaster was applied as a deep dressing, 
 and where consequently the gutta-percha was rubbed off to allow 
 the plaster to adhere to the skin, the gutta-percha was left at one 
 part so as to afford a channel for the escape of discharge. 
 
 In changing these dressings a solution of carbolic acid 1-20 
 was thrown over the wound by means of a syringe, as the dressing 
 was raised, and then a guard soaked in the lotion was applied. 
 
 In 1869 catgut ligatures were introduced. 
 
 The objections to the lac plaster are that the discharge 
 putrefies outside the plaster and irritates the skin, that the lac 
 keeps the surface beneath it moist with what is really a film of 
 watery solution of carbolic acid, and this again makes its way 
 under the protective and irritates the woimd. 
 
 Very shortly after the use of the aseptic method in the 
 treatment of compound fractures it was a})plied to abscesses. 
 
 The first publication on this subject appeared in the 
 'Lancet' for July 27, 1867. The method of opening the 
 abscess and of changing the dressings employed with the 
 means at that time at disposal are very important with 
 reference to the question of operating and dressing without a 
 s})iay. A piece of rag dipped in 1-5 carl)olic oil is laid on the 
 skin where the incision is to be made. The lower edge of this 
 rag being raised, a knife dipped in the oil is at once plunged 
 into the abscess, and the rag immediately dropped over the 
 orifice through which the pus is pressed out. A piece of lint 
 
134 ASEPTIC SURGERY. 
 
 soaked in the oily solution is then introduced into the opening 
 in order to stop bleeding and to prevent it from closing. This 
 is done by slipping the strip of lint under the antiseptic rag. 
 With regard to the dressing, the putty is here described and 
 used outside a deep dressing of carbolic oiled lint, a layer of 
 calico being interposed between the putty and the deep dressing 
 to prevent them from sticking together. The putty is changed 
 once in twenty-four hours, or oftener if necessary. In doing so 
 a rag dipped in the oily solution is placed over the wound or 
 the deep dressing the instant the old putty is removed. If a 
 plug of lint has been introduced in the first instance it is after 
 a time (two or three days) withdrawn by pushing oiled forceps 
 under the piece of oiled rag, seizing hold of the plug and 
 pulling it out, the oiled rag being pressed thoroughly around 
 the forceps. If a probe is introduced it must be oiled and then 
 slipped in between the folds of the oiled rag. As the various 
 means described under compound fracture were introduced they 
 were applied to abscesses on the principles already described. 
 
 The first example of efficient aseptic treatment in the case 
 of wounds published by Mr. Lister will be found in ' The British 
 Medical Journal ' for October .31, 1868,^ The case narrated is 
 one of operation for badly united Pott's fracture. 
 
 ' On the 11th 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, a solution of carbolic 
 acid in 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 gave 
 way, divided the callus, and at once covered the wound with the 
 antiseptic lint. . . . The wounds were then dressed with a 
 weak oily solution of carbolic acid, and covered with the anti- 
 septic (lead) plaster. Fresh plaster was applied daily.' 
 
 I need not repeat the various modifications in the treatment 
 
 ' Reports published during the same year by Drs. Heron and Malloch will 
 be found in the Glasgow Medical Jonrnal. 
 
ITS DEVELOPMENT. 135 
 
 of wounds, as they are similar to those just described under 
 compound fractures. 
 
 In the 'British Medical Journal' for January, 1871, JMr. 
 Lister first mentions the gauze dressings, and also refers to the 
 use of oakum. The spray is also tried. In August, 1871, 
 this method has been established, the present protective was com- 
 pleted, and macintosh was substituted for gutta-percha tissue 
 below the outer layer of the gauze. The drainage tube is first 
 mentioned in August, 1871, in the treatment of wounds, 
 though it had been used for a short time previously in the case 
 of abscesses. At that time the piece of gauze next the wound 
 was not wet. It was some two or three years later that the 
 necessity for wetting the deep layer was recognised, and since 
 that time the results have been much more constant. With 
 the introduction of the steam spray, of the elastic bandage, 
 of the improved gauze, &c., there has been a marked improve- 
 ment in results, and the avoidance of putrefaction, in cases 
 where the wound is made by the surgeon, is now reckoned on 
 as a matter of course. 
 
130 ASEPTIC SURGERY. 
 
 CHAPTER VI r. 
 
 ASEPTIC SURGERY — {concluded). 
 
 Other methods of carrying out AsejDtic Surgery. Substitutes for carbolic 
 acid: Salicylic acid: Thymol: Acetate of Alumina: Eucalyjrtiis oil. 
 Aseptic surgery by filtration of the air. Subcutaneous surgery. 
 
 Such are the essential details of aseptic surgery as introduced 
 and i^ractised by Mr. Lister. The disadvantages arising from 
 the irritating and poisonous qualities of carbolic acid have led 
 some to seek other antiseptics as substitutes for carbolic acid. 
 These attempts have not as yet, however, succeeded in producing 
 any substance possessing so many advantages as that acid. 
 The most successful substitute up till quite recently was 
 salicylic acid, which is used on exactly the same principles, 
 but not with the same constant aseptic results. 
 
 The use of salicylic acid was first advocated by Professor 
 Thiersch, of Leipzig, and the following is a short abstract of 
 his method of using it. 
 
 Salicylic acid is chemically nearly related to carbolic acid. 
 Its formula is C^HgOy, differing therefore from that of carbolic 
 acid in containing in addition the atoms of carbonic anhy- 
 dride. (The formula of carbolic acid is CgHgO.) Salicylic 
 acid is not poisonous, but it affects the hands in the same 
 way as carbolic acid. It is absorbed, and may be found in the 
 urine of patients whose wounds are dressed with it. 
 
 A lotion of salicylic acid is employed. This is a saturated 
 solution of the acid in water at the ordinary temperature, and 
 its strength is about 1 part of salicylic acid to 300 parts of 
 water. 
 
 Two materials are used as dressings — viz., salicylic wool and 
 saHcylic jute. 
 
TREATMENT BY SALICYLIC ACID. ]37 
 
 Salicylic wool is cotton wool impregnated with salicylic acid 
 in the proportions of 3 and 10 per cent, by weight. 
 
 The 3 per cent, wool is made by dissolving 750 grammes of 
 salicylic acid in 7,500 grammes of spirit (83 sp. gr.). This 
 solution is then diluted with 150 litres of water at the temper- 
 ature of 70°-80° C. 25 kilogrammes of pure cotton wool are 
 saturated with this mixture. 
 
 The 10 per cent, wool is obtained by dissolving one kilo- 
 gramme of salicylic acid in 10,000 grammes of spirit (83 sp. gr.), 
 the solution being then mixed with 60 litres of water. Ten 
 kilogrammes of pure cotton wool are soaked in this solution. 
 
 This soaking is best done in a large wooden vat, in which 
 the layers of cotton wool have plenty of room. It is best to 
 place only small quantities of wool (two to three kilogrammes) 
 in this vat at a time in order to get an equal distribution of 
 the acid. Thin layers of cotton wool are introduced into the 
 salicylic solution under light pressure, fresh layers being added 
 only when the former have been thoroughly soaked. When 
 the whole quantity has been introduced the mass is turned 
 over, so that the undermost layer becomes the uppermost, and 
 then it is left for about ten minutes, so as to have equable 
 distribution of the fluid. The wool is then taken from the vat 
 and spread out in layers. On cooling, the acid crystallises out, 
 and the layers are made up into small parcels, not exceeding 
 two to three kilogrammes each. After twelve hours this wool is 
 spread out to dry in a moderately warm place. It should not be 
 hung up, lest the acid should become unequally distributed. 
 
 The 10 per cent, wool is coloured with carmine for the sake 
 of distinction. 
 
 It is important to note that Thiersch, in speaking of 3 per 
 cent, and 10 per cent, wool, means wool soaked in the solutions 
 of the strength described. The wool does not contain that per 
 centage of salicylic acid. 
 
 This cotton wool does not absorb fluids readily, and therefore 
 Thiersch now uses jute. This is made from the bark of various 
 species of Corchorus grown in Bengal, and is cheaper than 
 cotton wool, and at the same time more absorlient. It is used of 
 two strengths — 3 and 10 per cent, prepared in the same way 
 as the salicylic wool. 
 
138 ASEPTIC SURGERY. 
 
 Grlycerine is added to the solution in order to prevent the 
 crystals of salicylic acid from falling out, because they are apt 
 to produce violent sneezing, coughing, &c. 
 
 In order to obtain the 3 per cent, jute 2,500gTammes of jute are put 
 into a sohition of 75 grammes of salicylic acid, in 500 grammes of 
 glycerine and 4,500 grammes of water at 70°-80° C. 
 
 In the glycerine jute the acid is more equally distributed 
 than in the cotton wool. In the case of the latter the cotton 
 is frequently so imperfectly charged that it is necessary to place 
 a layer of 10 per cent, cotton next the wound, and then outside 
 this the 3 per cent. wool. In the case of the glycerine jute a 
 4 per cent, material is sufficient for the whole dressing. 
 
 As to the spray Thiersch does not care whether it is 1-50 
 carbolic acid or 1-300 salicylic acid. Carbolic acid is to be 
 jjreferred, because it causes less coughing and sneezing, and it 
 does not adhere to the clothes. 
 
 Salicylic acid is best in some cases, as it irritates the wound 
 less than the carbolic. 
 
 For disinfecting the hands and skin, carbolic acid or salicylic 
 acid may be used, but for the instruments carbolic acid must 
 be employed, because the steel becomes oxidised in a solution 
 of salicylic acid. 
 
 The sponges are washed in carbolic acid. 
 
 No protective is required, because the salicylic acid is but 
 little irritating. 
 
 Macintosh is also unnecessary. 
 
 In order to enable the dressing to peel off and to let the 
 discharge get away more easily a layer of gutta-percha tissue 
 or of oiled silk riddled with holes and covered with a piece of 
 gauze is applied next the wound. 
 
 This treatment may be illustrated by a case of amputation. 
 
 The patient having been chloroformed and Esmarch's elastic 
 bandage applied, the part is shaved, washed with soap and 
 water, spirit and turpentine oil, and then with salicylic acid 
 lotion, or with the 1—20 carbolic acid solution. It is also 
 scrubbed with a nail-brush for a few minutes (quite unneces- 
 sary). The operation is carried out with the usual aseptic 
 precautions. After arresting the haemorrhage the wound is 
 
TREATMENT BY ^SALICYLIC ACID. 139 
 
 closed with deep and superficial stitches. A drainage tube is 
 then introduced into each angle, and the wound is washed 
 out with salicylic acid solution till the fluid which comes out 
 is clear (unnecessary). Three finger-breadths of perforated 
 gutta-percha and of carbolic gauze is then applied ; over this 
 one finger's thickness of the strong salicylic wool, and outside 
 this two fingers' thickness of the weak wool. The whole is 
 then fastened on with a bandage. 
 
 If the patient complains of pain the dressing is changed 
 and the wound examined. If not, it is left till the eighth or 
 tenth day, when it is changed, in order to remove the drain- 
 age tube. If any discharge comes through in the first instance 
 fresh wool is put outside the dressing. The second dressing 
 is left till healing is complete. 
 
 Large compound fractures are treated at first by irrigation 
 with salicylic acid. In order to protect the skin from maceration 
 by the fluid it is from time to time rubbed with palm oil. 
 After all risk of abscess formation has passed off and the wound 
 is granulating well, one may apply dry salicylic dressing as 
 before described. 
 
 Where there is a tendency to inflammation, more especially 
 where there is imperfect drainage with progressive abscess 
 formation, wet salicylic dressing should be applied. This is 
 ordinary salicylic dressing, which is from time to time soaked 
 with salicylic lotion. 
 
 Thymol as an antiseptic application to wounds was intro- 
 duced some years ago by Eanke of Halle, and was much lauded 
 on account of its non-poisonous and non-irritating qualities. 
 
 The thymol gauze was made on the same principles as the 
 carbolic gauze, spermaceti being, however, employed. A thymol 
 solution of the strength of 1-1000 is made by the addition of 
 alcohol and glycerine. 
 
 This antiseptic has not answered the expectations entertained 
 at first. It does not prevent putrefaction, and has been justly 
 abandoned in aseptic work. 
 
 Acetate of alumina has been lately used by Maas. He 
 applies lint dipped in the solution (2^ per cent.) to the wounds, 
 
140 ASEPTIC SURGERY. 
 
 and covers this with macintosh. The strength of the spray is 
 also 2^ per cent. 
 
 He says that this is a powerful antiseptic, and that with it 
 he gets typical aseptic results. The substance is unirritating, 
 and very few dressings are required. 
 
 Eucalyptus oil has recently been strongly advocated by Dr. 
 Schulz of Bonn.' Its antiseptic properties were shown by 
 Bucholtz in his paper on antiseptics. He found that it was 
 three times as strong as carbolic acid, for while carbolic acid 
 prevented putrefaction when present in the proportion of 1 in 
 200 parts, the eucalyi^tus oil only required to be present in 
 the proportion of 1 to 666*6 parts to produce the same effect. 
 
 Siegen also showed that eucalyptus oil prevents putrefaction 
 and alcoholic fermentation better than carbolic acid. He found 
 that blood to which ^ per cent, of eucalyptus oil had been 
 added was quite odourless ten days later. Eing states further 
 that it hinders the passage of white corpuscles out of the vessels, 
 and that therefore, on Cohnheim's theory, it is an agent capable 
 of arresting suppuration. 
 
 With regard to its usefulness, its smell is more pleasant 
 than that of carbolic acid. It dissolves readily in alcohol or 
 in oil, and mixes perfectly with pure paraffin. 
 
 Schulz also states from Siegen's experiments and from his 
 own that the eucalyptus oil is not poisonous. The tree from 
 which the oil is obtained grows in large numbers in Australia, 
 and the oil can be obtained in large quantities and very cheap. 
 
 Schulz recommends that for the spray the glass bottle 
 should be filled with the pure oil or with oil dissolved in alcohol. 
 The steam would then pick this up and make an emulsion. 
 
 As a lotion it might be used in the form of an emulsion. 
 Schulz proposes that the wounds should be dressed with 
 lint saturated with a 10 per cent, solution of eucalyptus or olive 
 oil. Outside this, or instead of it, may be used Lister's gauze 
 dressing containing eucalyptus oil instead of carbolic acid. 
 A gauze which contains even 50 per cent, of eucalyptus oil may 
 be made with paraffin. Dr. Schulz has not himself, however, 
 used this method. 
 
 ' Ciidnilhlultfiir Chvrimjit', Jannury 24, 1880. 
 
USE OF COTTON WOOL. 141 
 
 Quite recently .Mi-. Lister has been making an extensive 
 trial of eucalyptus oil in the treatment of wounds. A gauze 
 has been prepared similar to the ordinary gauze, but containing 
 eucalyptus oil instead of carbolic acid. Dammar has also been 
 substituted for the ordinary resin. So far this has proved very 
 satisfactory. It seems to be trustworthy as an antiseptic, and 
 can be used under circumstances where carbolic acid is apt 
 to cause irritation, as in dressings on the scrotum, or in patients 
 whose skins are liable to be irritated by carbolic acid. Being 
 non-poisonous, it may also be substituted for carbolic acid in 
 cases where constitutional effects are apt to follow the absorption 
 of the latter. 
 
 It has also been employed as an ointment in the proportion 
 of 1 part by measure of the oil to 4 parts by weight of the same 
 base as is used for the boracic and salicyHc ointments (p. Q5\ 
 This ointment is employed in the cases for which boracic and 
 salicylic ointments have up to the present been used, and it 
 possesses the advantage over the latter in that the oil not only 
 renders the discharge pure as it passes over it, but also on 
 account of its volatility bathes the parts in an antiseptic 
 vapour. Hence it will probably be especially useful in the 
 treatment of burns (see p. 116). Its non-poisonous qualities are 
 also a great point. As yet no experiments have been made with 
 the view of substituting it for carbolic acid in the lotions used 
 in the spray, in washing wounds, purifying instruments, &c., 
 and indeed the whole matter is only for the present under trial. 
 
 So far we have been considering modes of preventing 
 putrefaction in wounds based on the fact that the septic particles 
 in the air and on surrounding objects may be deprived of their 
 power of causing fermentation by contact with some suitable 
 chemical substance. But we also saw in the preliminary 
 considerations that it sufficed for the avoidance of fermentation 
 in flasks to keep the dust out mechanically, as, for instance 
 by means of cotton wool. This fact was made use of by Mr. 
 Lister some years ago in the following manner. I may quote 
 his remarks, which are given in a foot-note to his article on 
 Amputations in Holmes' ' Surgery,' vol. v. p. 619, published in 
 1871. 
 
142 ASEPTIC SURGERY. 
 
 ' Amonar recent contributions of foct to the elucidation of 
 this question (the germ theory) may be mentioned Professor 
 Tyndall's simple but beautiful proof of the existence of organic 
 particles of dust of excessive minuteness in the air by means 
 of a condensed beam of light, and the equally clear ocular 
 demonstration afforded by the same method, that even the 
 finest particles are capable of being removed from the air by 
 causes which Pasteur, in some of his experiments, inferred must 
 clear it of suspended organisms, such as the action of gravity 
 and filtration by cotton wool. The fact last named seemed to 
 promise valuable results in antiseptic surgery, and experiments 
 made with this view have afforded further evidence in favour 
 of the germ theory which it may be well to mention here. I 
 found that if cotton wool impregnated with either chlorine or 
 sulphurous acid gas or with the vapour of benzine or carbolic 
 acid, was placed upon a wound or granulating sore, after 
 washing the surface with a solution containing the same agent, 
 although the volatile antiseptic left the cotton in about a day, 
 the blood or pus still effused beneath the cotton remained free 
 from putrefaction for an indefinite time, provided that the 
 discharge was not sufficiently copious to soak through the 
 cotton and appear at the surface, in which case the meshes 
 between the fibres affording ample space for microscopic 
 organisms to develop in, putrefaction spread within a few 
 hours throughout the moistened part of the mass. This cir- 
 cumstance greatly interfered with the practical utility of the 
 dressing, and it has since been superseded by the antiseptic 
 gauze to be described in the text, but the facts seem to me 
 important with regard to the germ theory. The cotton wool, 
 though it loses all chemical antiseptic virtue in a day, yet will 
 keep out putrefaction for a month or more. It cannot possibly 
 keep out any atmospheric gas, which is necessarily diffused 
 freely between its fibres, and gets in for the same reason that 
 the volatile antiseptic gets out. That which it does exclude 
 can only be suspended particles of dust. It follows, therefore, 
 as a matter of certainty, that the cause of putrefaction through 
 atmospheric influence of blood or pus, oi-, in other words, such 
 materials as the surgeon has to deal with in treating wounds. 
 
USH OF COTTON WOOL. 143 
 
 are not the atmospheric gases, but dust, and the fact that this 
 dust is deprived of its putrefactive energy by agents which are 
 chemically so unlike as chlorine, sulphurous acid, benzine, and 
 carbolic acid, but which agree in having a common hostility to 
 animal or vegetable life (I used benzine because I knew that 
 the entomologist employs its vapour to kill insects), this fact 
 confirms the view that the putrefactive particles are really 
 organisms. I commend these simple experiments with cotton 
 wool to the candid judgment of the reader, because, whatever 
 may be thought of their bearing upon the allied subject of 
 spontaneous generation, they must be allowed to afford absolute 
 demonstration of the truth which is the foundation of the anti- 
 septic system, viz,, that the putrefaction of blood or pus under 
 atmospheric influences is caused not by the gases of the air, 
 but by suspended particles, which can be deprived entirely of 
 their septic energy by the vapour of an agent like carbolic acid.' 
 
 It will thus be seen, that what Mr. Lister used here was 
 not an antiseptic application but an aseptic one, and that the 
 only mode in which this dressing acted was by mechanically 
 preventing the particles from reaching the wound. For the 
 reasons quoted, this method has not been turned to practical 
 account, though, as we have seen, it is still used in cases of 
 gangi-ene in order to protect the weak ^Jarts from all sources of 
 irritation. 
 
 Mr. Barker, assistant surgeon to University College Hospital, 
 has tried a similar method in one or two cases. He piuified 
 cotton wool by heat, and applied between it and the woimd a 
 layer of lint dipped in carbolic oil. This method, however, 
 seems to be impracticable, for after the wool has been heated, 
 but before it is applied, dust would very probably gain access to 
 it unless very complicated precautions were taken. I believe 
 that if ])ure cotton wool is used Mr. Lister's method is the only 
 practicable one. 
 
 I have mentioned these experiments more as confirming 
 the flask experiments described before than for the purpose of 
 recommending the method for adoption. I believe that tho- 
 roughly satisfactory and indeed the best results maybe obtained 
 by the use of suitable chemical means. 
 
144 ASEPTIC SURGERY. 
 
 Subcutaneous surgery is another way in which the aseptic 
 principle may be carried out. Here the wound is made under 
 the skin and away from the air dust altogether. This method 
 will be better understood when we come to trace the history 
 of antiseptic surgery. 
 
PARTICLES WHICH CAUSE FERMENTATION. 145 
 
 CHAPTER VIII. 
 
 THEORIES OF SPONTANEOUS GENERATION, HETEROGENESIS 
 AND ABIOGENESIS. 
 
 Principles on wliich other methods of antiseptic surgery act. Organisms are 
 always present in fermenting liquids : their significance. Theory of the 
 origin of organisms independently of a parent. Theories of Needham and 
 Buffon : Needham's proofs. Spallaazani's experiments: Needham's objec- 
 tions : Spallanzani"s replies. Schulze's experiments. Schwann — Schroeder 
 and Dusch — Schroeder — Doctrine of Heterogenesis. Pouchet's work : his 
 method of testing the matter : proofs that the source of the organisms in 
 infusions is neither the air, water, nor the putrescible substances : modes 
 of repeating Schulze's and Schwann's experiments : examination of dust. 
 Criticism of his results. Pasteur's experiments : results with ordinary 
 fluids : introduction of dust into sterilised fluids : results with milk and 
 alkaline fluids : the cause in the air which gives rise to the growth of 
 organisms is particulate : Pasteur "s cultivating fluid : estimate of Pasteur's 
 work. Poachefs reply : New experiments — Criticism of these. 
 
 8uCH are the methods by which that form of antiseptic surgery 
 which aims at the total exclusion of septic ferments may be 
 best earned out. But ' Antiseptic Surgery ' in its broad sense 
 includes another class of methods of treatment acting on a 
 totally distinct principle, and interfering more or less perfectly 
 with the occurrence of fermentations. These all act on the 
 principle of rendering inert the causes of jjutrefaction after 
 their entrance into the luownd, of offering obstacles, more or less 
 co')nplete to the fermentation ivhich these pai^ticles would other- 
 luise occasion. In order to understand these methods, to see 
 on what ja-inciples they act, to decide which are the best, and 
 to carry them out with the greatest success, it is necessary to 
 take up our discussion of the causes of putrefaction at the point 
 wliich we have already reached, and to consider what is the 
 nature of the particles which we fotind to be ihe causes of 
 
 L 
 
146 SPONTANEOUS GENERATION. 
 
 fermentative changes, and how it is tlmt they bring about these 
 changes. 
 
 As is well known, micro-organisms of some form or other 
 (bacteria, toruUie, &c.)are always present in fermenting liquids, 
 and the view which is now almost universally held by scientific 
 men is that these bodies are the initiators of the chemical 
 change. 
 
 We have nlready seen that fermentation occurs only after 
 the access of particles from the outer world, and it is asserted 
 by the supporters of the germ theory of fermentative changes, 
 that these particles aire organisms or their spores, and that it is 
 by the growth of these organisms in the fermentescible material 
 that the latter undergoes alteration. 
 
 Soriie, however, assert that these organisms are only acci- 
 dental accompaniments of the process of fermentation ; in fact 
 a few still maintain that they arise in fermenting substances 
 from agglomeration of the molecules of that material, that in 
 feet they are generated anew and are not necessarily derived 
 from a parent. It is therefore necessary for us, before discuss- 
 ing the germ theory of fermentation, to consider what are the 
 real focts with regard to this matter of abiogenesis. 
 
 The first views of which we must take notice, as being the 
 first founded on experiment and observation apart from mere 
 philosophical speculation, are those of Needham and Buffon, 
 published in the middle of the eighteenth century.' Needham's 
 
 ' It may be of interest to quote Needham 's own words somewhat in detail. 
 Referring to Spallanzani's criticisms of his viOT:]<i{Xnurvlles liecherches sitr Ics 
 litres wicroscojnqiies, by Spallanzani, translated by M. I'Abbe Regley, 1769), 
 he savs (vol. i. p. 142) : ' II (Spallanzani) sait trrs-bien par toute la tenenr de 
 mes observations raicroscopiqnes que je ne donne aucune autre puissance h la 
 mati^re que celle qui produit la pure vitalite denuee de toule sensation, et qui 
 derive, comiue son existence primitive, de la seule Divinite ; que cette 
 vitalite est un compose materiel de la force resistante et de la force expansive, 
 dont les premiers principes ont ete donnes a la matiere par le Crc'ateur au 
 moment de la creation : que tout corps, ou partie organisee, est une proces- 
 sion ou prolongation d'un corps organise, soit vegetal ou animal, qui doit 
 nrcessairement preexister, et dont la soucheiDrimitive sort immediatement des 
 mains de Dieu ; que cette procession ou prolongation insensible, que doit 
 donner ce germe nouveau, dont la petitesse est indetinie, pour se conformer A, 
 toutes les circonstances possibles, se fait moyennant une espece de reduction 
 dirigee par les forces plastiques, et une concentration des parties specitiqucs, 
 (lui tendent, en les attenuant, vers nn point determine ou un certain foyer 
 commun, de mrine u ]ieu ]ir(\s que Tccil est au monde visible, un centre ou les 
 
NEEDHAM. 147 
 
 theory was, that there is in matter a force charged with the 
 formation and government of the organic world, which force he 
 
 rayons viennent s'arranger de toutes parts, sans confusion, dans le mcme ordre 
 qu'ils re9oivent de I'harmonie preetablie de I'univers ; que quant aux premiers 
 principes de cette vitalite purement materielle, il y a une mati^re indubitable- 
 meut demontree par des experiences constant es, trfe-attenuee, tr^s-exaltee , 
 etheree selon Newton, electrique selon les idees presentes, tres-elastique par sa 
 nature intime, toujours prete iidonner lebranle a la mati^re brute et rusistante, 
 et qui penetre substantiellement la masse enti^re ; que par consequent ces 
 deux especes de mati^re, melees dans toutes les proportions possibles, peuvent 
 fournir les temperaments necessaires pour tout degre de vitalite quelconque, et 
 pour tons les grands phenomenes on changements physiques de I'univers en 
 partant d'un seul principe ; que cette vitalite, n'etant autre chose qu'un esprit 
 tres-subtil et trfes-actif, agissant dans une matiere brute, tenace et ductile, 
 pour former, selon les forces specitiques de chaque corps vital, un nouveau 
 systeme organise, est tr^s-dilferente, selon mes idees, du principe seiisitif, qui 
 ne pent etre compose, et encore plus distinguee du principe intellectuel et 
 sptrituel, I'ame de rhomme.' 
 
 Further on (p. 150) he reiterates his view that these beings are distinct 
 from the higher classes of animals which possess sensation. ' En general, 
 toute substance quelconque, animale ou veg6tale, se decompose, selon moi, en 
 etres que j'appelle Hte?/.a; pour les distinguer des animaux parfaits a qui la 
 Divinite a ajoute par surcroit les puissances purement sensitives, ou sensi- 
 tives-intellectuelles.' 
 
 Again (p. 172), ' L'auteur (Spallanzani) croit que j'ai parle de la force 
 ordinaire vegetante des plantcs, par laquelle elles develop25ent en feuilles, en 
 branches et en racines. II n'est rien de tout cela. Quand il s'agit de la pro- 
 duction de ces corps organiques, je considere an contraire la plaute dans un 
 etat de corruption comma jilante : car c'est alors qu'elle perd absolument 
 sa forme primitive et, quapres avoir ete depouillee de ses sels, de ses huiles, 
 et des autres principes constitutifs, ce qui reste devient une matiere gela- 
 tineuse et loute tilamenteuse qui vegete par elle-meme en branches vitales et 
 se partage en corps ronds animes ou pousse au-dehors des globules mouvants.' 
 
 ' Voila en jjeu de mots le vrai tableau, voilii le raisonnement de M. de 
 BiifTon et le mien. II y a certainement un principe de vitalite materiel dis- 
 tingue du principe sensitif, seul constitutif de la stricte animalite, qui se dis- 
 pose organ iquement, et qui, subordonne aux lois generales etablies jDar la 
 Divinite, vegete dans les corps animaux qu'il forme conime dans les vegetaux, 
 en les animant ^ la fa(;on ordinaire ' (p. 166). 
 
 ' Ce principe de vitalite est le seul principe d^conomie et d'action dans lea 
 vegetaux, et dans une certaine classe de ces Ctrcs qui, paraissant scnsitifs sans 
 Fetrc, servent i\ lier ensemble le vegetal et I'animal sensitif ' (p. 166). 
 
 'Mais j'ai toujours reconnu comme necessaire pour completer le vrai 
 animal, qui doit etre sensitif, un principe de sensation, une time qui n'est pas 
 coniposee comme le systeme organique, et qui, quoique aneantie avec le corps 
 selon le bon plaisir de son cn'atcm-, est ni'anmoius superieure ^ la vitality, et 
 hors de toutes les puissances du la matiere la plus exaltee.' 
 
 Bullon {IlisUmr Xaturcllc, vol. ii. p. 420, 171'.)) says : ' Tous les aniruaux 
 
 L 2 
 
148 SPONTANEOUS GENERATION. 
 
 calls force vegetatrice. He imagines that this force, by setting 
 into motion all the particles of matter, excites in some of them 
 a sort of vitality distinct from sensation, and produced by the 
 union of two other forces, which he terms fo7xe resistance and 
 force expansive. 
 
 The proofs on which Needham bases his views as to the 
 spontaneous origin of these minute organisms are of three 
 distinct kinds. 
 
 The first discussing the different phenomena furnished by 
 different infusions, more especially the enormous variety of 
 forms arising in them ; and the second alluding to the behaviour 
 of infusions after being subjected to heat, dependent as these 
 arguments are on microscopical examination, need not be con- 
 sidered here, because the construction of the microscope was at 
 that time so imperfect as to make it of little or no use for such 
 observations. 
 
 The third, and indeed the only experiments which require 
 to be noticed, are those in which infusions, contained in vessels 
 hermetically sealed, are subjected to the action of heat for a 
 prolonged period. In infusions treated in this way by Need- 
 
 se nourrissent de vegetaux ou d'autres animaux, qui se nourrissent eux-memes 
 de vegetaux ; il y a done dans la nature une mati^re commune aux uns et aux 
 autres qui sert a la nutrition et au developpement de tout ce qui vit ou veg^te; 
 cette matiere ne peut operer la nutrition et le developpement qu'en s'assimi- 
 lant k chaque partie du corps de I'animal ou du vegetal, et en penetrant in- 
 timement la forme de ces parties, que j'ai appelee le moule interieur. Lorsque 
 cette matiere nutritive est plus abondantequ'il ne faut pour nourrir et develop- 
 per le corps animal ou vegetal, elle est renvoyee de toutes les parties du corps 
 dans un ou dans plusieurs reservoirs sous la forme d'une liqueur ; cette liqueur 
 contient toutes les molecules analogues au corps de I'animal, et par consequent 
 tout ce qui est necessaire a la reproduction d'un petit etre enti6rement sem- 
 blable au premier. Ordinairement cette matiere nutritive ne devient sura- 
 bondante, dans le plus grand nombre des especes d'animaux, que quand le 
 corps a pris la plus grande partie de son accroissement, et c'est par cette raison 
 que les animaux ne sont en etat d'engendrer que dans ce temps. 
 
 ' Lorsque cette matiere nutritive et productive, qui est universellement 
 repandue, a passe par le moule interieur de I'animal ou du vegetal, et qn'elle 
 trouve une matrice convenablc, elle produit un animal ou un vegetal de meme 
 espece ; mais lorsqu'elle ne se trouve pas dans une matrice convenable, elle 
 produit des etres organises difl'^rents des animaux et des vegetaux, comme les 
 corps mouvans et vegetants (jue Ton voit dans les liqueurs seminales des ani- 
 maux, dans les infusions des germes des plant es, kc' 
 
SPALLANZAIK. 149 
 
 ham and boiled for many minutes organisms developed very 
 readily. 
 
 Spallan5^ani ' repeated these experiments, and he found that 
 though some infusions could be sterilised after boiling for a 
 short time, yet it was necessary to keep others at the boiling 
 temperature for an hour or more before they would remain 
 permanently sterile. Spallanzani's method was to heat his 
 flasks, then to pom- in the liquid, hermetically seal the flask, 
 and place it in a water bath. The error in this method is 
 probably that the impure fluid when poured into the flask, 
 soiled the neck which he had previously purified by heat. 
 
 To these experiments Needham objected that Spallanzani 
 had much enfeebled or perhaps destroyed the force vegetatrice 
 of the infusions by keeping them exposed to the action of heat 
 for so long a period of time as an hour. 
 
 This objection was at once met by Spallanzani, who showed 
 that organisms rapidly developed in these same infusions, if 
 they were left exposed to the air after this prolonged boiling ; 
 and he truly says that, if the organisms only come from the 
 fluid, and if the power which this possesses of generating these 
 beings is destroyed by heat, they would remain absent whether 
 the flasks were open or shut. He even went further and heated 
 the vegetables very strongly before infusing them, but even 
 in this case organisms developed in the fluids so prepared. 
 
 Needham, however, said that the small quantity of air re- 
 maining in the flasks was completely altered by the exhalations 
 from the fluid and by the heat of the fire, and that thus the 
 force vegetatrice could not act. This objection cannot be 
 said to have been in any way met by Spallanzani. In some 
 cases, indeed, he succeeded in preventing the appearance of 
 organisms by boiling the fluid from a half to two minutes, but in 
 many cases minute organisms appeared. In order to prevent 
 their occurrence in all instances, it was necessary to prolong 
 the heat for at least three-quarters of an hour. 
 
 As an answer to Needham's last objection the experiments 
 of Schulze ^ form a most important step in advance. The 
 
 ' Opvsciiles de Physiqve animale et vegetale ; traduits par Jean Senebier, 
 Geneve, 1777. 
 
 * See translation in Microgcnpical Jmirnal, 1841. 
 
150 
 
 SPONTANEOUS GENERATION. 
 
 following was the problem which he proposed and the method 
 adopted to solve it. 
 
 Query : ' If the access of atmospheric air, light, and heat 
 to substances in flasks included of itself all the conditions for 
 the primary formation of animal or vegetable organisms ? The 
 difficulties to be overcome consist in the necessity of being 
 assured first, that at the beginning of the experiments there 
 was no animal germ capable of development present in the 
 infusion, and secondly, that the air admitted contained nothing 
 of the kind.' 
 
 His method of procedure is described by himself as follows : — 
 ' I filled a glass flask half full of distilled water, in which I mixed 
 vai'ious animal aud vegetable substances. I then closed it with a 
 
 Fif4. 58.— Schulze's method of demonstrating that organisms are 
 
 DERIVED FRO.Vr THE AIR AND DO NOT ORIGINATE SPONTANEOUSLY 
 IN LIQUIDS. 
 
 good cork, through which I passed two glass tubes, bent .it right 
 angles, the whole being air-tight. It was next placed in a sand-bath 
 and heated vintil the water boiled violently, and thus all parts had 
 reached the temperature of 212° F. 
 
 ' While the watery vapour was escaping by the glass tubes I 
 fastened at each end an apparatus which chemists employ for collect- 
 ing carbonic acid ; that to the left was filled with concentrated sul- 
 phuric acid, and the other with a solution of potash. By means of 
 the boiling heat everything living and all germs in the flask or in 
 the tubes Avere destroyed, and all access was cut off by the sulphuric 
 acid on the one side and by the potash on the othei-. I placed this 
 easily moved apparatus before my window, where it was exposed to 
 the action of light, and also, as I performed my experiments during 
 
SCHULZE. 151 
 
 the summer, to that of heat. At the same time I placed near it an 
 open vessel with the same substances that had been introduced into 
 the flask, and also after having subjected them to the boiling tempera- 
 ture. In order now to I'enew constantly the air within the flask, I 
 sucked with my mouth several times a day the open end of the 
 apparatus filled with solution of potash ; by which process the air 
 entered my mouth from the flask through the caustic liquid, and the 
 atmospheric air entered the flask from without through the sulphuric 
 acid (Fig. 58). The air was of course not at all altered in its com- 
 position by passing through the sulphuric acid in the flask, but if 
 sufficient time was allowed for the passage, all the portions of living 
 matter or of matter capable of becoming animated, were taken up by 
 the acid and destroyed. From May 28 till the beginning of August 
 I continued uninterruptedly the renewal of the air in the flask, 
 without being able, by the aid of the mici-oscope (magnifying glass ?), 
 to perceive any living animal or vegetable substance, although during 
 the whole of the time I made my observations almost daily on the 
 edge of the liquid ; and when at last I separated the dififerent parts 
 of the apparatus I could not find in the whole liquid the slightest 
 trace of infusoria, of confervse, or of mould. But all the three pre- 
 sented themselves in great abundance a few days after I had left the 
 flask standing open. The vessel which I placed near the apparatus 
 contained on the following day vibriones and monads, to which 
 were soon added larger Polygastric Infusoria, and afterwards Eotatoria.' 
 
 By these experiments the fears entertained by Needham as 
 to an alteration in the air contained in the flask being the cause 
 of the sterility of the infusion, were completely set at rest ; 
 for here air, which had not been subjected to heat, and which 
 was constantly changed, was present in the vessel in which no 
 development occurred, while the second open vessel showed that 
 the power of the liquid to nourish organisms had not been lost 
 by boiling. It was therefore clear that in this instance the 
 organisms which grew in the outer vessel came in some way 
 or other from ])articles in the atmos})here, which could be 
 destroyed by sulphuric acid. Whether or not both modes of 
 origin might not exist, and whether the bodies falling into 
 the fluid from the atmosphere were organisms or their spores, 
 or merely albuminous matters which gave rise to organisms, 
 was as yet in no way determined. 
 
 And the results of the experiments of Schwann, mentioned 
 
]52 SPONTANEOUS GENERATION. 
 
 before, leave us in the same position. In his case the heating 
 of the air was substituted for Schulze's method of passing it 
 through a chemical substance, but no further evidence was 
 obtained. Advance was no doubt made by his results in that 
 the objection which might have been urged by some against 
 Schulze's experiments, viz., that particles of the sulphuric acid 
 were carried over with the air, or that the air was in some way 
 or other altered, are entirely removed,' while at the same time 
 it was then known that heating air joroduced no alteration in 
 the gases of the air. Schwann himself explained his results 
 by supposing that the spores of infusoria and other smaller 
 organisms are present in air, and are destroyed by heat ; and he 
 held that putrefaction and other fermentative changes are 
 brought about by these organisms abstracting materials for 
 their nutrition from the fluids in which they grow, and leaving 
 the compounds thus broken up to form new combinations. 
 
 One most important fact he does mention, viz., that blood 
 can be received into and preserved in a flask with certain pre- 
 cautions, without the development in it of any form of life. 
 
 Further evidence with regard to boiled substances was 
 brought forward by Schroeder and Dusch, and later by Schroeder 
 alone. Their method of experimentation by filtration of the 
 air through cotton wool, and their results, have been already 
 referred to (p. 12, et seq.), and it will be sufficient to add here 
 that in those cases where putrefaction occurred, organisms were 
 present, while in the flasks, in which no change took place, 
 organisms were absent. By their method, meat, meat infusion, 
 and malt were preserved after boiling without any appearance 
 of organisms. 
 
 Difficulties were experienced with milk and yolk of egg, but 
 these were finally overcome either by heating them to the 
 temperature of 130° C, or by prolonged heat at 100° C. These 
 experiments are of the greatest importance, as with the method 
 
 ' This objection that the air is altered in passing through sulphuric acid is 
 not urged by Pouchet, who indeed states that no alteration occurs, and that 
 organisms can develop as readily when such air is admitted as in presence of 
 ordinary air. Schulze's experiment also proves that the barrenness of the 
 liquid was not due to the entrance of sulphuric acid into it, for the liquid 
 became full of life after having been exposed for a few days to ordinary air. 
 
POUCHET. 153 
 
 employed no objections can be raised as to any alteration in 
 composition of the air. 
 
 When, then, we look at Needham's two objections, which 
 have been urged against experiments with boiled fluids, and 
 when we compare with them the answers furnished by all 
 observers, but more especially by Spallanzani to the first, and the 
 progressively strong replies to the second by Schulze, Schwann, 
 and Schroeder and Dusch, we must, I think, come to the con- 
 clusion that they have been completely met. Hence in order 
 to retain the theory of spontaneous generation it became neces- 
 sary for the heterogenists to change their ground. They had 
 to admit that there were present in the air and on surrounding 
 objects particles (not necessarily bacteria or their germs, though 
 very probably so) which, falling on suitable soil, gave rise to the 
 development of bacteria ; but they still held that under certain 
 circumstances heterogenesis may also occur, though possibly 
 more rarely than propagation from a parent. 
 
 They attempted to support this view in two ways : firstly, 
 by denying the accuracy of the former experiments, by pointing 
 out that they do not always succeed, and that organisms develop 
 in some materials, even after prolonged exposure to a high tem- 
 perature ; and secondly, by reference to the results of attempts to 
 preserve unboiled fluids and tissues. 
 
 In 1859 there appeared the work of one of the most ardent 
 supporters of the theory of spontaneous generation — Pouchet — 
 and it is necessary for us to examine his views and facts some- 
 what in detail.' 
 
 Pouchet does not look on these organisms as originating 
 from dead matter through the action of some mysterious force, 
 as has been since advanced by some heterogenists. Their sources 
 are, according to him : ' Des particules organiques, debris des 
 anciennes generations d'animaux et de plantes, qui se trouvent 
 combinees aux parties constituantes des mineraux. Selon cette 
 doctrine ce ne sont done pas des molecules minerales qui s'orga- 
 nisent, mnis bien des particules organiques qui sont appelees 
 a nne nouvelle vie.' He further states that though he believes 
 that it is the contact of different bodies which gives rise to the 
 
 ' Heterogenie im Traitr de hi Gl-ncrotwn spontant'c hasr siir des nourcllcs 
 experiences. Pjiris, 1859. 
 
1.34 SPONTANEOUS GENERATION. 
 
 development of proto-organisms, yet he does not think that 
 their origin is due to affinity alone — vital force must also come 
 into play. This vital force owes its manifestation to certain 
 unknown concomitant circumstances ; thus fermentative or 
 catalytic phenomena precede all spontaneous generation. In 
 connection with these views he describes the development of 
 ova in what he terms the proligerous pellicle, or scum on the 
 surface of fermenting fluids. With regard to this he says : ' La 
 generation primaire ne produit jamais un animal de toutes 
 pieces, mais seulement elle engendre des ovules spontanes 
 dans le milieu proligere absolument sous I'empire des memes 
 forces qui fa^onnent des ovules dans le tissu de I'ovaire.' 
 
 The essentials for the production of new forms are, according 
 to him, a putrescible body, water, and air, while heat, light, and 
 electricity considerably favour the result. Having shown that 
 the first three are essential, though they need not necessarily 
 be present in large amount, he proceeds to state the problem 
 in a very fallacious manner : ' Si I'on admet,' says he, ' que dans 
 nos experiences la generation ne pent s'operer qu'a I'aide de 
 trois facteurs, et que c'est I'un d'eux seul qui recele les germes 
 des proto-organismes, il est evident que si Ton prend chacun 
 de ces trois corps en particulier, sans s'inquieter nuilement 
 alors des deux autres, et que Ton demontre successivement 
 que ce n'est aucun d'eux qui contient ces germes, il faudra bien, 
 en somme, reconnaitre quand le fait aura ete strictement etabli 
 pour chacun isolement, que ce n'est done aucun de ces trois 
 coi-ps qui pent servir d'asile aux oeufs ou aux seminales introu- 
 vables des etres divers qu'on voit s'engendrer sous les yeux.' 
 
 He tests the question in the following manner: 1. With 
 regard to the first point he says that it is evident that the 
 putrescible material does not contain the germs of the proto- 
 organisms since, even though it is charred previously to its 
 employment, the water in which it is placed becomes rapidly 
 filled with microzoaires and cryptogams. 
 
 Experiment. — 10 grammes of any of the following seeds, maize, 
 peas, beans or lentils, were placed in an iron spoon and completely 
 charred ; then the pi'oduct was placed in a glass vessel containing 500 
 grammes of distilled water and covered with a bell jar. In twenty 
 days the fluids were found to contain micro-organisms and cryptogams. 
 
POUCHET. 155 
 
 2. He next points out that it is not the water which con- 
 tains the germs because, if one places organic substances in an 
 artificial water, animalculge and cryptogams still develop. 
 
 To show this an artificial water was obtained in the following 
 manner : — ' Into a large flask with two orifices, water and fragments 
 of zinc are placed : one of the orifices transmits a tube terminating in 
 a funnel by means of which sulphuric acid may be introduced into 
 the flask ; the other orifice is attached to a large horizontal tube filled 
 Avith asbestos, which leads to a small tube drawn out at its extremity, 
 and terminating close to the outside of a metal vessel filled with cold 
 water. The sulphuric acid having been introduced, hydrogen gas is 
 disengaged, and is lit at its exit from the tube. The flame being close 
 to the metal vessel, moistens its walls with watery vapour, the result 
 of the combination of the oxygen of the air with the hydrogen from 
 the apparatus : and this vapour, being condensed, is caught in a 
 platinum vessel. The apparatus having been maintained in this 
 state for three days, 200 gi'ammes of water were obtained, and were 
 employed in the two following comparative experiments.' 
 
 Half of this water was boiled for a quarter of an hour, in order to 
 kill the germs which might have fallen into it, although he does not 
 consider that to be necessary. This water was then introduced into 
 a ves.sel with 5 gi^ammes of hay, which had been raised to a tempera- 
 ture of 200° C. The vessel was placed in a basin containing a little 
 water, and the whole was covered with a small shade. In four days 
 there was a granular pellicle and two species of Paramecia. 
 
 The other portion of distilled water was not boiled, and to it was 
 added hay which had not been heated; the result was absolutely 
 identical. 
 
 3. Lastly, Pouchet states that it is evidently not the atmo- 
 sphere which disseminates the germs, since he has seen organisms 
 appear in flasks containing only artificial air, or in flasks con- 
 taining air which had been heated or which had passed through 
 sulphuric acid. 
 
 He next takes up Schulze's experiment, and jiresents the 
 following as a counter experiment and as a complete disproof 
 of the former :^ 
 
 A vessel of the capacity of one litre was half filled with water, to 
 which 5 grammes of hay were added. The cork of the vessel was 
 traversed l)y two tubes each bent at right angles, five centimetres above 
 the place of exit ; one, the afii^rent, did not descend into the interior 
 
156 
 
 SrOXTANEO US GENERA TION. 
 
 of the vessel lower than its neck, the other, the efferent, reached to 
 within one centimetre of the liquid, in order the better to remove the 
 heavy stagnant gases. To each of the tubes was attached Liebig's 
 bulbs filled with sulphuric acid. To the efferent was further attached 
 
 Fig. 5f».— Pouchet's mode op kepeating Schulze"s experiment. 
 
 (FROM POUCHET). 
 
 a water aspirator, which was kept constantly acting (Fig. 59). The 
 cork, &c., were all luted with copal. The fluid was then boiled for 
 an hour. In twenty-six days spirilla, vibriones, and penicillium were 
 present in the fluid. 
 
 In order, as he supposes, to have more rigorous conditions 
 than those of Schulze, he introduces the following method of 
 procedure : 
 
 Fig. 60. — Another mode adopted by Pouchet for testing 
 Schulze's views (from Pouchet). 
 
 A flask is used having the capacity of one litre, and having three 
 necks. This is quite filled with concentrated sulphuric acid. The 
 first neck contains a bent tube, which by one extremity communicates 
 with an air pump, while the other extremity passes down to the 
 
rOUCHET. 157 
 
 bottom of the acid; through the middle neck passes a siphon, which 
 commences in the flask at the level of union of the uppei' and middle 
 thirds, while its other end passes into an empty vessel. The third 
 orifice contains a tube passing down to the bottom of a second vessel, 
 but only originating in the first vessel at the very top. This second 
 vessel, of the same capacity as the other, had been filled with boiling 
 water ; the first neck allowed the passage of the tube from the first 
 vessel ; through the central one passed a siphon similarly arranged 
 to that in the first vessel : while from the third opening a tube led 
 into a third vessel. This third vessel had the same capacity as the 
 others, but had only two openings, the fii'st receiving the tube from 
 the second flask, which, however, did not pass down to the bottom of 
 the third flask as in the other two cases ; and the second giving exit 
 to a siphon arranged as before (Fig. 60). 
 
 A strong decoction of boiling hay having been introduced into the 
 third vessel so as to fill it exactly, the whole apparatus was luted with 
 the greatest care, and thus the apparatus contained only this decoc- 
 tion, the sulphuric acid and the water which had been previously 
 boiled. Air was then forced slowly into the sulphuric acid, and 
 traversing the acid, it collected at the toj), forcing the sulphuric 
 acid through the siphon ; this air then passed on thiough the second 
 flask, passing through the water and forcing the water through the 
 siphon ; and from the second into the thiid vessel, forcing some of 
 the decoction through the siphon ; then the apparatus was abandone J 
 to itself, and a quantity of the same decoction was placed outside 
 for compai-ison. In twenty days the hay infusion, both in the appa- 
 ratus and in the vessel outside, contained * mucor ' and bacteiia. 
 
 A second experiment was done by introducing into the thiixl flask 
 5 grammes of hay, which had been exposed to the action of steam for 
 five minutes. The vessel was then filled with boiling water. A 
 similar lesult was obtained. 
 
 Again, he introduced into the third flask filtered water, and 10 
 grammes of hay exposed for thirty minutes to a temperature of 200° C. 
 Nevertheless, monads and vibriones weie found. 
 
 A similar experiment to Schwann's was also perfonned, the 
 air in the apparatus just described being passed over a heated 
 tube instead of through sulphuric acid. Nevertheless, organisms 
 (penicillium and vibriones) developed. Two flasks (instead of 
 three) were used, the first being filled with boiling water (this 
 flask having the three necks as usual, one receiving the heated 
 air, one for the siphon, and the third leading into the second 
 
158 sroyTAXJSOUS GENERATIOX. 
 
 flask), and the second containing boiled decoction of hay and 
 ha\dn2: two necks. He states that he succeeded more often in 
 obtaining organisms when filtered, unboiled water was sub- 
 stituted for the boiled water ; and, as he has already proved, as 
 he thinks, that water does not contain organisms, he considers it 
 a matter of indifference whether the water has been boiled 
 or not ! 
 
 Similar experiments with artificial air yielded the same 
 results. 
 
 A new objection is then brought forward, viz., that if the 
 atmosphere be the universal disseminator of germs, the greater 
 the mass of air in contact with a fluid, so much the greater 
 ought to be the number of organisms which grow in that fluid. 
 This he has not found to be the case, and he also points out 
 that in flasks containing the same fluid, placed close to each 
 other at the same time, different forms of organisms may de- 
 velop, a fact which he does not consider capable of ex- 
 planation on the theory of Panspermism. 
 
 Pouchet further examined air dust microscopically, and he 
 admits that he finds spores of fungi and other microscopic 
 organisms, but he does not think that they are ever present in 
 sufficient quantities to explain the numbers which are found 
 in an infusion, for he states that the bacteria themselves do not 
 increase in number by fission (or but very slowly), but that on 
 the contrary each is spontaneously generated. 
 
 To prove thut organis)iis do not in tlie main come from the air he 
 took five gi'ammes of dust from the I'oof of the Ruuen Cathedral, and 
 placed it in 100 gi'ammes of distilled water. Then in another similar 
 vessel he placed 100 grammes of distilled water, containing tive 
 grammes of the dry stalks of China aster, previously exposed for two 
 hours to a temperature of 200° C. These two vessels were placed 
 under the same glass shade. Eight days later the first contained 
 vibriones, monads in small numbers, and a few kolpodes. The second 
 was full of monads and kolpodes. 
 
 During a later research Pouchet examined the dust which 
 collected in the lungs and bones of birds, and he states that 
 there can always be found evidences of the locality in which 
 the birds lived. For instance, this dust in the case of forest 
 
CRITICISM OF rOUCIIET'S EXPERIMENTS. 159 
 
 birds contains fragments of wood, leaves, starch, &c. He says 
 that -he never found spores of plants nor ova of microscopic 
 animals nor encysted animalculge. That he should not have 
 found spores of fungi, which one would think are more nume- 
 rous in the forest air than starch granules, is inconceivable, 
 unless it is supposed that there is a special provision in the 
 animal economy which prevents their entrance into the lungs, 
 though permitting the admission of starch granules. The 
 probability is that he did not recognise them. 
 
 Not only does Pouchet sup})ort the doctrine of the spon- 
 taneous generation of bacteria and the lowest foi^ms of animal 
 or vegetable life, but he is also prepared to accept the spon- 
 taneous origin of fleas, acari, and cysticerci ! 
 
 If, now, we carefully examine these experiments, we shall 
 see that they are full of the grossest blunders. Take, for in- 
 stance, his experiments to show that organisms are not present 
 in putrescible substances, in water or in air. The first experi- 
 ment is simply absurd. Some seeds are charred and introduced 
 into a vessel containing distilled water, and covered with a bell 
 jar ; organisms develop. What does this prove ? Does it 
 prove that organisms were not present and may not constantly 
 be present in putrescible substances exposed to the air ? No. 
 It merely proves that this cannot be their only source ; for here 
 the water and the air were not heated or otherwise purified, and 
 therefore the organisms might be easily communicated through 
 them. 
 
 Again, to prove that water does not contain them, an artificial 
 water is prepared, boiled for a quarter of an hour, placed in an 
 unpurified vessel containing some hay, which had been pre- 
 viously heated and exposed to ordinary air. What does this 
 show ? Certainly not that ordinary water does not contain 
 organisms. Even admitting that this specimen of water did 
 not contain them, there was ample explanation of their 2:»resence 
 from the fact that the fluid was put into an impure vessel, 
 and that the air had access to it. 
 
 Nor is Pouchet more successful in liis attempt to show that 
 the air is not the vehicle. 
 
 In considering the question as to the presence of organisms 
 or their spores in the air Pouchet puts forward the idea that if 
 
160 SFONTANEOUS GENERATION. 
 
 organisms were present in the atmosphere in sufficient numbers 
 the atmosphere would be totally obscured. But it has been 
 asserted and shown by Pasteur and others (as we shall see later 
 on) that organisms are by no means so numerous in the atmo- 
 sphere as was formerly supposed, but that they are generally 
 derived from dust which has settled or from water. Further, 
 Tyndall has shown, by means of the beam of light, what 
 numbers of minute particles fill the air around us, and up to a 
 certain point, instead of obscuring it, really render the light 
 visible. 
 
 In his repetition of Schulze's experiment it must be admitted 
 that Pouchet has a stronger case, but even here the flask and 
 the tubes were not purified, the quantity of fluid as compared 
 with the size of the flask was very small, and there is always 
 the possibility of a flaw in the cork or in the joinings of the 
 various tubes. And further, this experiment loses its force 
 when Pouchet admits that he does not always get organisms, 
 and states, on the contrary, that, when a simple apparatus is 
 employed, a negative result is obtained. Thus to quote his 
 own words : ' Dans un appareil a simple rentree d'air ' (this 
 consists of a flask having only one tube passing through its cork, 
 to which tube Liebig's bulbs are attached, see Fig. 61 ), ' et dont 
 les boules de Liebig contenaient de I'eau, on remplit le tiers du 
 ballon de colle de farinelegere: que I'ony tient quinze minutes 
 en ebullition a I'aide d'une lampe. Celle-ci eteinte. Pair rentra 
 dans I'appareil en traversant I'eau peu-a-peu. L'appareil fut 
 abandonne deux mois a une temperature moyenne de 14 
 degi-es, et pas la moindre moisissure ne se declara a la surface 
 de la colle durant tout ce temps. 
 
 ' Au contraire un criterium, place a cote et en contact avec 
 I'atmosphere, avait au bout de cinq jours toute sa surface 
 envahie par des champignons. 
 
 ' Une experience enterprise le meme jour et dans les memes 
 conditions, mais dans laquelle Pair est introduit dans l'appareil 
 en traversant des boules de Liebig remplies d'acide sulfurique, 
 donna absolument les memes resultats.' 
 
 Thus Pouchet showed that not only was Schulze's experi- 
 ment successful, when performed with a simple apparatus, but 
 he fiu-ther demonstrated that it was not necessary that the air 
 
CRITICISM OF FOUCHET'S EXFERIMENTS. 
 
 161 
 
 should pass through sulphuric acid ; if it were merely tuashed 
 in water it was sufficient. 
 
 Again, ' Dans notre appareil a simple rentree d'air, et dont 
 les boules etaient remplies d'eau, on mit 175 grammes d'urine 
 humaine et on I'y tint en ebullition pendant un quart d'heure. 
 Ensuite Fair rentra en traversant I'eau et I'appareil fut 
 abandonne sous I'influence d'une temperature moyenne de 12 
 degres. Deux mois apres, I'urine etait encore parfaitement 
 limpide et pas la moindre moisissm-e ne s'etait declaree a sa 
 surface. Un criterium place a cote, au 
 bout de huit jours, etait envahi par 
 une abondante vegetation crypto- 
 gamique. 
 
 ' Une experience est faite le meme 
 jour et absolument dans les memes 
 circonstances, seulement Fair ne rentre 
 dans I'appareil qu'en traversant des 
 boules remplies d'acide sulfurique. Le 
 resultat est absolument le meme que 
 dans I'experience precedente : I'm-ine 
 est intacte.' 
 
 Such are exainples of Pouchet's 
 general results with this simple ap- 
 paratus, and, when he states that with 
 the more complicated arrangement, 
 even with much more prolonged boil- 
 ing, he generally obtains cryptogamic 
 vegetation, I do think that I am only 
 drawing a fair inference when I sup- 
 pose that there was something defective about his apj)aratus. 
 
 Nor is he more fortunate with Schwann's experiment. 
 Referring to Pasteur's results — that when he (Pasteur) per- 
 formed Schwann's experiment of having in contact with fer- 
 mentescible substances only previously' heated air, he obtained 
 neither fermentation, nor yeast, nor infusoria — he says : ' L'air 
 calcine a ici encore arrete la fermentation et les i)roduits 
 organiques qui en derivent ; cet air est done egalement 
 iiiipropre au developpement de phenomenes chimiques, comme 
 il Test a celui des phenomenes vitaux. L'experieuce de 
 
 M 
 
 M 
 
 l( Inaiiiiiiiiiiuiiiiiiniiil \\ 
 
 Fia. 61. — A PI3IPLE MODE 
 OF REPEATING SCHULZE'S 
 EXPERIMENTS (FROM POU- 
 CHET). 
 
1G2 SPONTANEOUS GENERATION. 
 
 Schwann, et celles qui ont ete calquees siir elle, sont done 
 absolument insignifiantes.' Truly a strange interpretation of 
 the facts, more especially as he had previously attempted to 
 demonstrate that calcined air and air which had previously 
 passed through sulphuric acid were equally incapable of pre- 
 venting the development of organisms, and as in the ' more 
 rigorous " conditions under which he performed the experiments 
 he found that organisms always developed ! 
 
 Looking more closely at these so-called ' more rigorous ' 
 conditions, we find that they contain a sufficient number of 
 loopholes to explain the result. 
 
 What are we to think of the third experiment to show that 
 the air is not the vehicle of these organisms ? An impure 
 vessel is taken, containing dust, and unboiled filtered water is 
 introduced into it along with some heated hay. Is it any matter 
 for surprise that organisms are found here, however pure the air ? 
 The dust in the vessel contained plenty of their spores, the 
 various tubes passing into it contained dust and impure air, 
 while the water itself was teeming with organisms or their 
 spores. And similar objections may be urged against, the first 
 and most rigorous experiment. Boiling hay infusion is intro- 
 duced into a vessel containing dust ; no attempt is made to 
 destroy the septic properties of this dust or to purify the air 
 and the dust in the tubes leading to and from it. Air is now 
 forced into the infusion, carrying along with it the organisms 
 which Pouchet ought to have known were theoretically present 
 in the air in the last connecting tube, as well as on the walls 
 of that tube. This is the ' rigorous ' experiment, which is 
 sufficient ' to overturn the experiments of Schwann and 
 Schulze.' It is needless to pursue the criticism of such methods. 
 
 The following experiment is stronger, and he considers it 
 sufficient to upset those of Schwann and Schulze. A flask was 
 introduced to the bottom of a vessel containing a decoction of 
 barley, which had been kept boiling for six hours. The flask 
 being completely filled with this fluid, was brought to the sur- 
 face and corked, and then the circumference of the cork was 
 surrounded by varnish. On the sixth day a deposit of yeast 
 was seen, and the flask burst on the seventh. 
 
 Here an impmre vessel, cork, &c., were used, and the heat 
 
rOUCHET. 1G3 
 
 was not applied to them for a sufficient length of time. Fur- 
 ther, the fluid cannot have been boiling when the vessel was 
 introduced and corked, otherwise, if he had done it efficiently, 
 the operator would have scalded his fingers. It is, moreover, 
 noteworthy that Pouchet only got organisms in one experiment 
 of this kind. 
 
 In his ' Micrographie Atmospherique,' Pouchet falls into 
 the great error of assuming that organisms do not subdivide 
 quickly enough to account for their rapid appearance in infu- 
 sions. Now it has since been made out by several observers 
 that organisms do divide with sufficient rapidity, and of this I 
 may mention two instances from Mr. Lister's work. In the 
 course of observations on a form of micrococcus, which he terms 
 ' Granuligera,' he found that in little more than an hour and a 
 half they had trebled their numbers, a fact which he made out 
 by observing the subdivision of a little group. And with re- 
 gard to the Bacteriuvi lactis, he found definitely by nume- 
 ration that it doubled by fission in an hour, so that given one 
 BacteriuTYi lactis there would be in twenty-four hours no less 
 than 8,388,608 bacteria ; and other forms of organisms deve- 
 lop even more quickly. 
 
 Then, again, Pouchet objects that with free access of air, a 
 greater variety of forma ought to be found, but it must be 
 remembered that what may novu-ish one form may not be good 
 for another, and that the products of the growth of the form 
 which in the first instance was most vigorous and most nume- 
 rous, may interfere seriously with the growth of other varieties ; 
 and in the experiment which he mentions it is quite evident 
 that in the vessel to which the dust was added there is little 
 or no nutriment compared with that contained in the stalks of 
 the China aster. And lastly, when he 2)laces similar infusions, 
 similarly treated, in flasks of the same size, under the same 
 glass shade, and in similar conditions, and finds that the organ- 
 isms which appear differ in form in the two flasks, he does not 
 obtain, as he supposes, a proof of spontaneous generation, but 
 the contrary. For on that theory the same infusion, in the 
 same conditions, ought to give rise to the same species of 
 organisms ; and the occurrence of different forms can only be 
 explained by su})posiiig that different spores gained access to 
 
 M 2 
 
164 SPONTANEOUS GENERATION. 
 
 the various infusions, a view quite in accordance with the theory 
 of Panspermism. 
 
 Appearing shortly after Pouchet's work, and leading to 
 diametrically opposite conclusions, were the researches of M. 
 Pasteur, which have by many been considered as administering 
 the death-blow to the theory of heterogeny. 
 
 Pasteur,^ in his account in the ' Annales des Sciences 
 naturelles,' begins by attempting to demonstrate the exist- 
 ence of spores in the atmosphere, a fact which Pouchet had 
 previously admitted. Such attempts are, however, very un- 
 satisfactory, partly from the difficulty of recognising what are 
 and what are not spores, and also from the fact that if spores 
 do exist they must be so excessively minute as to be in many 
 cases invisible under the microscope. Professor Tyndall has 
 shown, by means of the condensed beam of light, the existence 
 of innumerable solid particles in fluids, in which but few could 
 be detected by the microscope. Pasteur certainly demonstrated, 
 and this is generally admitted, that spores of fungi do occur in 
 the atmosphere. It is not necessary, however, to have this 
 demonstration of the existence of spores, for the matter can be 
 set at rest by experiment alone, and it is these experiments, 
 and not the demonstration of the existence of spores of fungi 
 in the atmosphere, which give the value to Pasteur's work. 
 
 Operating with an albuminous saccharine fluid, in the man- 
 ner described below, Pasteur always succeeded in preventing 
 the growth of organisms in that liquid, in presence of heated 
 air. ' J'ai certainement eu I'occasion de repeter plus de cinquante 
 fois I'experience, et, dans aucun cas, cette liqueur, si alterable, 
 n'a donne vestige de productions organisees en presence de I'air 
 calcine.' 
 
 Into a flask with a capacity of 250 to 300 com. were introduced 100 
 to 150 com. of the saccharine albuminous fluid. The neck of this 
 flask, which had been drawn out, was then connected with a platinum 
 tube in which the air could be raised to a very high temperature. 
 The fluid was boiled for two or three minutes, and then the calcined 
 air allowed to enter. 
 
 Although the experiment succeeded in the case of the 
 
 Annales des Sciences naturelles, surie 4, t. xvi. 1861. 
 
PASTEUR. 165 
 
 saccharine albuminous material, and some other fluids, it did 
 not succeed with milk. Leaving milk out of consideration for 
 a moment, it was shown that other fluids which, although pre- 
 viously boiled, when exposed to ordinary air, rapidly become 
 the seat of development of organisms, remain barren when 
 exposed to heated air. (It has been remarked by several 
 authors, especially by Pouchet, that Pasteur was unable to 
 succeed, in many cases, in repeating Schwann's experiment 
 with calcined air. This is true : but the experiment which 
 failed was the one where the flask is inverted over mercury, 
 and the calcined air then introduced, and Pasteur has pointed 
 out that it is from the mercury that the source of contamina- 
 tion is derived.) It remained to enquire further what happened 
 when dust which had not been heated was introduced into the 
 
 Fig. 62.— Pasteur's mode of introducing dust into flask con- 
 taining CALCINED AIR. 
 
 h, the fla.sk containing the infusion sealed after being filled witli heated air. a, piece of asbestos 
 containing dust. When the tube in which this rests lias been purified and filled with heated 
 air, tiie neck of the flask 6 is broken at c, and the dust slipped in. The neck of the flask is 
 again sealed. (From Pasteur.) 
 
 fluid in presence of heated air. This was done ; the air coming 
 in contact with the boiled fluid was, as in the former case, pre- 
 viously heated, and the fluid had remained barren for one or 
 two months; then precautions being taken that no unheated 
 air was introduced, unheated dust was put into the flask (Fig. 
 62), and, as a consequence of this, development of organisms 
 rapidly occurred, and these organisms were of the same kind 
 as those which appeared in fluids freely exposed to air. Thus 
 Pouchet's objection to Schwann's experiment (viz., that heated 
 air interfered with the growth of organisms) was completely 
 up.set. 
 
 Fresh urine behaves in exactly the same manner when 
 treated in the two ways described. 
 
 In the case of Tnilk Pasteur was, however, unsuccessful 
 when the boiling temperature was maintained for only two or 
 
16G SPONTANEOUS GENERATION. 
 
 three minutes (a length of time quite sufficient in the former 
 cases) ; and this want of success he believes to be due to the 
 fact that in this fluid organisms can resist the boiling tempera- 
 ture for a longer period than in other liquids. Two or three 
 minutes of a temperature of 110° C, or a prolonged tempera- 
 ture of 100° C, werej however, sufficient to sterilise milk. This 
 resisting power he considers to be due to the alkalinity of the 
 fluid, for he finds the same difficulty if he renders his sugared 
 yeast water alkaline by the addition of carbonate of lime. In 
 the case of milk and of the latter fluid, thus purified and pre- 
 served unchanged for some weeks, the addition of the atmo- 
 spheric dust, in the way described, produces the same results as 
 in the fluids previously referred to. 
 
 But it is not necessary to use calcined air, ordinary air will 
 be equally inert, if only it has had opportunity to deposit its 
 dust before being admitted into i\ie flask. This he showed to 
 be the case by his well-known experiments with flasks with bent 
 necks. Into a flask a suitable quantity of the fluid to be ex- 
 perimented on is introduced, the neck is then drawn out long 
 and bent in various directions (Pasteur only figures one long 
 curve) so as to present obstructions to the entrance of solid 
 particles along with the air (see Fig. 3, p. 16). The fluid is 
 then boiled for the requisite length of time, and, the lamp 
 being removed, ordinary air is allowed to enter. Fluids may be 
 prepared in this way, and preserved for any length of time de- 
 sired. On the other hand, if the neck be straight, so as to 
 allow the dust to fall readily into the flask, organisms appear, 
 however long the neck. In the same way, if the neck be 
 broken off short, so that there is no obstruction to the entrance 
 of dust, organisms rapidly develop. 
 
 In the case of milk the boiling point must be raised to 
 about 110'" by heating the fluid under pressure, or the milk 
 must be boiled for a long time. 
 
 That the cause of the growth of these organisms is not 
 continuous, as would be the case were it some known or un- 
 known force, but that it is the advent to the fluids of solid 
 particles floating in the atmosphere, is likewise demonstrated by 
 the following experiment. Flasks containing the saccharine 
 yeast solution were j)repared, and sealed during boiling. These 
 
PASTEUR. 1C7 
 
 jQasks being opened in different places, with certain precautions 
 against the admission of dust from its neck, &c., air rushed in, 
 carrying with it any suspended dust. The neck of the flask 
 was again sealed, so as to prevent any further entrance of dust. 
 It was thus found that the air in some places and under some 
 conditions contained none of the particles which give rise to 
 organisms, while, on the other hand, when they were present the 
 organisms might be of very various kinds. One of the situ- 
 ations in which such flasks could be opened without any de- 
 velopment of organisms, was in some cellars which had not 
 been entered for a long time, and in which the dust had there- 
 fore settled. Precautions were of course taken that the 
 operator neither introduced the particles himself nor stirred 
 up the dust of the cellar. 
 
 I may quote one experiment : I^e 14 aout 1860 j'ai ouvert et 
 renferme dans les caves de TObservatoire dix ballons contenaut de 
 I'eau de levure de biere, et onze autres ballons de la meme preparation 
 dans la cour de I'etablissement. ;\ 50 centimetres du sol, par un vent 
 leger. Tous ont ete rapportes le merae jour dans I'etuve de inon 
 laboratoii-e, dont la temperature est de 25 a 30 degres. J'ai conserve 
 jusqu'a ce jour tous ces ballons. Un seul de ceux ouverts dans les 
 caves renferme une production vegetale. Les onze ballons ouverts 
 dans la cour ont tous fourni des Infusoires ou des vegetaux du genre 
 de ceux que j'ai deja decrits.' 
 
 But the greatest blow was given to the views of the hetero- 
 genists when Pasteur demonstrated that albuminoid materials 
 are not necessary for the development of bacteria and fungi, 
 but that they can be replaced by crystalline salts, such as 
 phosphates and salts of ammonia. He prepared a fluid 
 of the following composition, in which these organisms readily 
 grew : — 
 
 Eau pure 100 grammes 
 
 Sucre canrli ........ 10 ,, 
 
 Tartrate d'ainmoniaque . . . . . 2i\5 „ 
 
 Cenrlrcs fondues de levure de bii'^re . . . 4 „ 
 
 ' Si Ton seme dans cette liqueur, en presence de I'air cal- 
 cine, les poussieres qui existent en suspension dans Fair, 
 
1G8 SPONTANEOUS GENERATION. 
 
 on y voit naitre les Bacteriums, les Vibrions, les Mucedinees 
 &c." 
 
 Here there is no question of albuminoid particles com- 
 bining to form an organism. If they develop here sponta- 
 neously they must be built up from mineral salts. 
 
 Such is Pasteur's first work — the work which is considered 
 by many to have struck the final blow at heterogenesis. Let 
 us see what it really does prove. 
 
 It shows that a certain number of boiled fluids prone to 
 the development of organisms can be preserved, without any 
 growth of organisms in them, in the presence of calcined air, 
 or of ordinary air, the dust of which has been allowed to settle ; 
 that the introduction of dust into these flasks is the only con- 
 dition requisite for the development of organisms ; that the 
 source of organisms is something discontinuous — particulate ; 
 that organisms are not necessarily the result of changes in 
 albuminoid materials, for they grow vigorously in an artificial 
 mineral fluid. Further, Pasteur has shown that among the 
 particles present in the dust of the atmosphere there are 
 spores of fungi and bodies which may be bacteria or their spores. 
 
 This is all that is proved by these experiments ; and how 
 does Pouchet answer them ? By asserting that these solid par- 
 ticles are not bacteria or their spores, but lifeless particles, 
 which under certain conditions become vivified, and appear as 
 various forms of organisms ? The only possible theory, one 
 would think ! No. Pouchet disputes the facts. He does not, 
 it is true, take the trouble to repeat Pasteur's striking experi- 
 ment of the flask with bent neck. He simply says : ' C'etait 
 une erreur.' Further, ' Nous avons refuse de repeter les ex- 
 periences de M. Pasteur parce que, logiquement, rationnelle- 
 ment, pour des physiologistes, du moment oii il est reconnu 
 
 ' It may be mentioned here that, since Pasteur published, other simihir 
 fluids in which organisms can grow have been cmploj'ed. Tlius Cohn uses 
 the following: — 
 
 Distilled water 
 Tartrate of ammonia 
 Pliosphate of potash 
 Crystallised sulphate of magnesia 
 Tribasic phosphate of lime 
 
 20 c.cm. 
 •2 grammes 
 •1 „ 
 •1 
 •01 
 
POUCHET'S REPLY. 
 
 ]69 
 
 que celles de Schwann * sont absolument erronees, et je pense 
 que pas un seul de ceux-ci ne voudrait aujoiurd'hui le contester, 
 les experiences du chimiste de Paris sont consequemment frap- 
 pees de la meme nullite.'^ 
 
 Pouchet again retiu'ns to the simple experiment in repeti- 
 tion of Schulze's, which we have previously quoted, but now 
 his statement is directly opposed to that formerly made. He 
 now says, ' En employant dans cet appareil ' (a simple rentree 
 d'air) ' de la colle de farine extremement legere, de I'albumine, de 
 I'urine, de la biere, du foin, ou de la noix de galle, constam- 
 TYient on voit apparaitre des microphytes ou des microzoaires 
 apres un temps fort court.' How is this contradiction to be 
 reconciled ? Is not the former experiment most likely to be 
 correct ? 
 
 Fig. 63. 
 
 -Another mode op repeating Schulze's experiment. 
 (FROM Pouchet.) 
 
 He then goes on to describe an experiment ' much more 
 ' rigorous ' than that of M. Schulze. 
 
 'Dans un ballon dont le col place horizontalement siipporte un 
 robinet, je mets une certaine quantite d'eau ordinaire. Un corps 
 fermentescible renferme dans un gvos tube de veri-e, et qui a ete prea- 
 
 ' I previously pointed out that Scliwann's experiment, whicii was occasion- 
 ally unsuccessful in Pasteur's hands, was not that to which M. Pouchet alludes, 
 but that performed over mercury ; and Pasteur has abundantly demonstrated 
 the fallacy here and liow it can be overcome. 
 
 ^ ijee Nouvelles Ej.-pcHenccs sur la (reiteration spontanee. 
 
170 SPONTANEOUS GENERATION 
 
 lablemeut cliauffe k 150° C. pendant cinq beures, est plac6 a I'interieur 
 du col de ce ballon : ce tube est ferme par un opercule rode a I'emeri 
 et scelle hermetiquementavec lui par line substance facilement soluble 
 dans I'eau. Le ballon communique avec irois tubes en U et des 
 boules de liiebig. L'un de ces tubes contient de la ponce sulfurique, 
 tin autre de la pota,sse causti(|ue, et le troisieme du coton carde. 
 
 ' Les boules de Liebig sont remplies d'acide sulfurique concentr6. 
 
 ' A I'aide d'une lampe on met I'eaiT du ballon en Ebullition pendant 
 dix minutes, et ce n'est qu'ensuite qu'on articule les tubes en U 
 a I'extremite du tube de Liebig. Enfin on eteint la lampe, et, tandis 
 que I'appareil se refroidit, I'air extei-ieur y rentre en traversant I'acide 
 sulfurique, le coton, la ponce sulfurique et la potasse. Quand 
 I'appareil est parvenu a la temperature ambiante, on fait tomber le 
 tube dans le liquide, et loi-sque celui-ci a dissous la substance soluble 
 qvii lute I'opercule, ce dernier s'ouvre et I'eau envabit I'interieur 
 de ce tube. 
 
 * Peu de temps apres, constamment on voit la liqueur du ballon se 
 peupler de v6getaux et d'animaux microscopiques, selon les substances 
 que Ton a confinees dans le tube. Jamais en suivant ce proced6 
 I'experience ne manque.' 
 
 Such is the experiment which is more rigorous, certainly 
 much more complicated than Schulze's. Nevertheless there 
 are numerous loopholes in it. 
 
 Thus this little tube containing the fermentescible material 
 is cold, and may be covered with dust when introduced into the 
 neck of the flask. It is certainly strange that, in order to be 
 certain that organisms should develop, it is necessary to heat 
 the great bulk of the water used, and the putrescible material 
 in a small quantity of water separately, and then to unite them 
 in the manner described. For Pouchet himself admits that he 
 does not always get organisms with Schwann's simpler method. 
 
 Then, again, it is no easy task to cork thoroughly a vessel 
 heated to the boiling point of water ; and the cork used was in 
 no way purified. It is true that steam passed over it for a short 
 time, but then steam is dry heat, and it is generally admitted 
 that dry heat at the temperature of boiling water is not sufficient 
 to destroy all organisms. This argument also applies to the dust 
 on the wall of the vessels. And then in tilting the vessel to 
 introduce the tube into the water, the joints, unless very 
 securely fixed, may oj^en, or living dust may be shaken into the 
 
POUCHETS REPLY. 171 
 
 fluid from the neck or cork, leaving out of consideration the 
 fact that it is in all probability carried in with the small tube. 
 
 Pouchet looks on this experiment as completely disproving 
 those of Schulze, Schroeder and Dusch, and Pasteur, and why ? 
 Because with this apparatushe constantly obtains organisms. How 
 then does he explain Pastem-'s results ? Pasteur boils his fluids 
 for two or three minutes, and finds that they remain barren. 
 This experiment can only be answered by Pouchet (so long as 
 he adheres to this line of argument) by supposing that Pasteur 
 is making a false statement, or that by boiling his fluid he has 
 destroyed its power of producing organisms spontaneously. As 
 regards the first, a committee composed of the first scientific 
 men in France confirm the truth of what Pasteur asserts ; while 
 the second can have no force when looked at in the light of 
 Pouchet's own experiments ; for we find that the latter obtains 
 organisms after keeping his fermentescible material at a tempe- 
 rature of 110° C. for several hours, and boiling the water for from 
 30 to 60 minutes. 
 
 Such a method of reasoning and of experimentation would 
 not have deserved so much notice were it not for the great in- 
 fluence which Pouchet's work has exercised and does still exer- 
 cise on those who have not read or studied it. And I have felt 
 it the more necessary to consider his work in detail as he is one 
 of the last observers who has maintained a more or less complete 
 heterogenesis, and also as I am not aware of any work in which 
 his experiments have been subjected to a searching criticism.' 
 
 ' Pouchet's experiments and conclusions were objected to by Mihie- 
 Edwards, Payen, Quatrefages, Claude Bernard and Dumas, who examined 
 them, and also those of Pasteur. 
 
172 SPONTANEOUS GENERATION. 
 
 CHAPTEE IX. 
 
 SPONTANEOUS GENERATION {continited). 
 
 The experiments of Jeffries Wyman : exi^lanation of the results : Wj'inan's 
 views on the subject. Dr. Bastian's views: Cases in which it is still pos- 
 sible that abiogenesis may occur : Growth in vacuo — Bastian's experiments 
 — my own results — Cohn's facts — Dr. Roberts's objections, the walls of the 
 vessels remain impure — Bastian's reply — Objections to the latter — Gruit- 
 huisen's experiments — Paul Bert's results with compressed air — Pouchet 
 looks on a vacuum as preventing spontaneous generation — Paul Bert'sresults 
 with rarefied air — Dr. Bastian does not always get positive results : Ex- 
 periments in airless and hermetically sealed flasks raised to a high tem- 
 perature — Objections — Prof. Huxley's and Dr. Sanderson's statements — Ray 
 Lankester's results — Hartley: experiments with alkaline fluids— Roberts's 
 counter-experiment. Mr. Lister's experiments. Experiments by Roberts 
 and Tjmdall. 
 
 Other writers, chiefly French and Italian, among whom may be 
 mentioned Joly, Musset, and Mantegazza, have sn])ported 
 Pouchet, but as their experiments furnish little or no additional 
 evidence nor new argument I think it unnecessary to discuss 
 them. Those of Joly and Musset will be found in the ' Comptes 
 Kendus de I'Academie des Sciences,' about the same period as 
 the papers of Pasteur and Pouchet. 
 
 I must, however, refer at length to the experiments of 
 Professor Jeffries Wyman, of Cambridge, U.S. These have been 
 largely quoted by the supporters of heterogenesis, as proving 
 their view, though it ought to be borne in mind that Wyman 
 himself expressed no such opinion. It must be confessed that 
 at first sight the experiments seem difficult of explanation on 
 the Panspermic theory, and it is the more necessary to scrutinise 
 them carefully, as he has evidently approached the subject with 
 a perfectly unbiassed mind, and has therefore simply recorded 
 his facts without attempting to force any definite conclusion on 
 this question from them. 
 
JEFFRIES WYMAN. 173 
 
 The following are the facts which have been adduced by 
 supporters of spontaneous generation as favouring their views. 
 Flasks were prepared in three ways : 
 
 1. 'The materials of the infusion were put into a flask' 
 (the general relation between the quantity of fluid and the 
 capacity of the flask was, that about 20 c.cm of fluid were 
 introduced into flasks of about 500 c.cm. of capacity) ' and 
 a cork through which passed a glass tube drawn out to a 
 neck was pushed deeply into the mouth of it. The space above 
 the cork was filled with an adhesive cement composed of resin, 
 wax, and varnish. The glass tube was bent at a right angle 
 and inserted into an iron tube and cemented there with plaster 
 of Paris. The iron tube was filled with wires, leaving only very 
 naiTow passage ways between them.' 
 
 Into these flasks such fluids as sugar, gelatine, and hay 
 infusion — cheese, sugar, and gelatine — flesh, sugar, and gelatine, 
 &c., were introduced, and boiled for periods varying from fifteen 
 minutes to two hours, while at the same time the ii'on tube, 
 filled with wires, was heated to redness. On withdrawing the 
 lamp from the flask, the air which entered passed over these 
 heated iron wires. When cold the flasks were sealed with the 
 blow-pipe. Fourteen vessels were prepared in this way. and in 
 ten of these, when opened after the lapse of various periods of 
 time, organisms were found, generally vibriones and bacteria. 
 The other four remained barren. 
 
 2. In a second set of experiments the cork in the neck of 
 the flask was avoided, the neck itself being drawn out and bent 
 at right angles, and into the orifice of this tube the iron tube 
 was cemented. The other conditions were the same as in No. 1. 
 
 Similar fluids were used here as in the former case, such as 
 gelatine and sugiir with a few drops of urine and milk, beef 
 infusion, &c. Thirteen flasks were treated in this way, and in 
 all organisms appeared. 
 
 3. In others the flask was sealed at the ordinary temperature 
 of the room, after the fluid to be tested had been introduced, 
 and then it was submerged for a variable period in boiling 
 water. This was a repetition of the experiments of Needham 
 and Spallanzani. In :ill llic flasks so treated organisms de- 
 velo])ed. 
 
174 SPONTANEOUS GENERATION. 
 
 Four experiments were made under pressure, and of these 
 two gave evidence of life (' monads and vibrios '), the other two 
 remaining barren. 
 
 Such facts coming from an accurate and totally imjirejudiced 
 observer cannot be dismissed lightly. It is quite evident, on 
 reading Wy man's paper, that the facts are accurately narrated, 
 and we must therefore see whether any flaw can be detected in 
 the method of experimentation, and we must attempt to find 
 some explanation of results so diametrically opposed to those 
 obtained by Pasteur which are, it must be remembered, equally 
 indisputable. 
 
 Now, if we compare this method with that adopted by 
 Pasteur, we shall see that with one exception the essential 
 details are the same. This exception is, however, an extremely 
 important one, and is probably the explanation of the diverse 
 results obtained by several honest workers, and even by the 
 same worker at different times. Pasteur takes a flask having a 
 capacity of 250 to 300 c.cm., and into this 100 to 150 c.cm. 
 of the liquid are introduced. Wyman uses flasks varying from 
 500 to 800 c.cm. in capacity, and into these he puts 12 to 40 
 c.cm. of the liquid. (In neither case was there any attempt 
 at preliminary purification of the walls of the flask or of the air 
 in the interior.) In Pasteur's experiments the fluid occupies 
 ^ or more of the capacity of the vessel ; in Wyman's only -J^ 
 to -3^ part. 
 
 Such is the only important difference between their methods ; 
 and this affords, I believe, sufiicitsnt explanation of the opposite 
 results. For in Pasteur's flask only a proportionally small 
 part of the wall of the flask has to be purified by the steam, 
 and the extent of this part is of course much diminished, by 
 the ebullition of the fluid during boiling. There is also in 
 Pasteur's flask only a very small quantity of air, Avith its dust, 
 to be acted on. It is thus not to be wondered at that a 
 barren result was obtained. But in Wyman's experiments 
 by far the greater part of the flask and of its contents is 
 impure, and can only be purified by the steam. Now steam, as 
 heat, must be looked on as dry heat, and it is stated by Wyman, 
 in a later publication,' that certain forms of organisms may 
 ' American Journal of Science, vol. xliv. 18C7. 
 
JEFFRIES WYMAN. 175 
 
 resist the prolonged application of even a higher dry tempera- 
 ture than 212° F. Wyman also points out that the tempera- 
 ture of the air even half an inch above the surface of boiling 
 water is many degrees below the boiling point. How much lower 
 then will this temperature be at the orifice of this large flask 
 during the greater part of the time in which the fluid is 
 boiled ? But even admitting that steam is moist heat (what I 
 am by no means disposed to allow) several remarkable instances 
 of vegetable growth at high temperatm'es are produced by 
 Wyman, in one case even at a temperature of 208° F. 
 
 Such is the explanation I would give of Wyman's results, 
 and that this is a true explanation will be very evident when I 
 come to the consideration of the method of experimentation 
 adopted by ]\Ir. Lister. This explanation accords in every way 
 with my own experience, in which I could point to several 
 similar instances. 
 
 As I ?iave said, Wyman is generally quoted in support of 
 the theory of spontaneous generation, and at one time I thought 
 that he had entertained that view, but the following facts 
 brought to my notice by his brother. Dr. JMorrill Wyman, show 
 that he never gave any expression of opinion on this point, and 
 that he appreciated the possibility of such an explanation of his 
 results as I have given. 
 
 His first article is entitled ' Experiments on the formation 
 of infusoria in boiled solutions of organic matter enclosed in 
 hermetically sealed vessels and supplied with pure air,' ' and his 
 second, ' Observations and experiments on living organisms in 
 heated water.' ^ With regard to the object of his research he 
 says, ' The observations and experiments contained in this com- 
 munication have not been brought together either for sustain- 
 ing or refuting the doctrine (spontaneous generation) just 
 referred to, but partly with the view of testing the accuracy of 
 the experiments formerly made, and chiefly for the puri)Ose of 
 determining how far the life of certain kinds of low organisms 
 is either sustained or destroyed in water which has been raised 
 to a high temperature, a result which must be readied before 
 spontaneous generation can be either asserted or denied.' 
 
 ' >Sillimft/i'.i Jiiin-nal, vol. xxxiv. 1SG2. 
 - Ihid, vol. xliv. 1S(;7. 
 
176 SPONTANEOUS GENERATION. 
 
 With regard to his experiments he says, ' In the first 
 experiments the red hot tube, beyond a question, destroys all 
 organisms contained in the air which enters the flask through 
 it, but is without effect on such as may be contained in the 
 solution, or adhere to the inner surface of the glass. These 
 come in contact only with boiling water or steam, and unless 
 destroyed by one or the other of these would be sufficient to 
 vitiate any experiment, however careful the adjustment and 
 heating of the tube may have been. We therefore believe that 
 the tube is an unnecessary and useless complication of the 
 apparatus.' 
 
 In another set of experiments it was shown ' That if the 
 boiling of the flasks was continued for four hours, the infusoria 
 may appear nevertheless — though in other cases it has happened 
 that life ceased to be manifested if it was continued only for 
 two hours.' ' In pushing the experiment still further, we have 
 not found that infusoria appeared in any instance if the boiling 
 was prolonged to five or six hours.' Several experiments, in 
 which many flasks were used, were tried, but ' the result was 
 uniformly the same. Thus a limit to the development of 
 infusoria in boiling water was reached.' Dr. Wyman tells me 
 that in the summer of 1880 he examined one of these flasks, 
 which is marked as having been prepared in June, 1867, and 
 which has remained unopened ever since. ' Judging by the 
 signs above given ' (absence of scum, of muddiness, or of fer- 
 mentation) 'there is no evidence of infusorial life.' 
 
 The last defence of heterogenesis which it is necessary to 
 consider is that by Dr. Bastian.' He gives up the theory of 
 organic molecules derived from previously living molecules, 
 and attempts to demonstrate that vital force and living matter 
 may arise de novo under the action of the ordinary physical 
 forces — heat, light, electricity, &c. This change of front on the 
 part of the heterogenists is clearly brought about by the over- 
 whelming evidence produced against Pouchet's views, and more 
 especially by Pasteur's success in cultivating organisms from 
 dust in fluids containing no organic matter. A further admis- 
 sion is made which somewhat simplifies the question, viz., that 
 organisms have the power of self-multiplication. 
 ' The BcfjinniiKjs of Life, 1872, &c. 
 
BASTIAN. 177 
 
 The limitation of cases of spontaneous generation, which 
 has been gradually taking place, is exceedingly instructive. 
 Beginning with the higher animals, it became gradually more 
 limited, frogs, flies, &c., being by degrees excluded, till now it 
 is only in the case of the lowest forms of life that the doctrine 
 is asserted, and even there only in certain instances. The cases 
 which are yet doubtful are given by Eastian in the work 
 quoted, and may be grouped into three divisions. 
 
 I. The first division relates to the development of organisms 
 in various fluids, more especially m vacuo — a condition which 
 Pouchet looked on as inimical to life ! 
 
 Into flasks portions of various infusions were introduced. The 
 latter were then boiled for from ten to twenty minutes, and hermeti- 
 cally sealed while still boiling. The fluids used were turnip and hay- 
 infusions, o.nd also solutions of certain salts, chiefly citrate of iron 
 and ammonia coutainiug portions of wood, cheese, &c. 
 
 The conditions of the first experiment mentioned are very 
 striking and unusual. 
 
 ' A closed flask containing a very strong infusion of hay 
 (boiled for five minutes), to ivhich had been added 7,\th part of 
 carbolic acid, was opened twelve days after it had been hermeti- 
 cally sealed.' Bastian states that this flask contained organisms 
 of a peculiar form. 
 
 Such a statement as this, that a saturated solution of carbolic 
 acid (for a watery fluid at the ordinary temperature containing 
 -Jjjth part of carbolic acid is saturated) can jjerinit the growth 
 of organisms, is absolutely opposed to all experience and ex- 
 periment. In experimenting with turnip infusion, cucumber 
 infusion, &c., I have never been able to grow any sort of organ- 
 ism in these fluids, when they contained a larger proportion of 
 carbolic acid than 7, y- th part, even though several drops of fluids 
 swarming with bactt'ria were introduced. Further, I liave lately 
 jicrformed the following experiment : — In January 1880 I intro- 
 duced carbolic acid into flasks containing strong unboiled hay 
 infusion so as to have a strength of the acid present, varying from 
 1 in 20 to 1 in 200 [)arts. Tlu'se flasks were then covered with 
 cotton-wool caps, and placed in an incubator. When examined 
 six weeks later, there had not yet appeared in any one of them 
 
 N 
 
178 SFONTANEOUS GENERAriON. 
 
 any sort of organism. And lastly, tliis statement, that organ- 
 isms can develop in acid fluids after boiling, is contrary to the 
 whole tenor of Dr. Bastian's later remarks, for his strong point 
 is the develo})ment of organisms in alkaline — not in acid — fluids 
 after })ro]onged boiling. 
 
 Bastian also employs turnip and hay infusions (without 
 carbolic acid) and solutions of such salts as citrate of iron and 
 annnonia, and he finds that a slight sediment occurs which 
 contains organisms. He generally has to introduce such 
 things as deal wood, cheese, &c., in order to get this result. 
 
 With regard to experiments on such fluids as hay infusion 
 and turnip infusion without cheese, I may state that I have 
 quite lately repeated them with exactly op})osite results. At 
 first I proceeded to repeat them, following closely Dr. Bastian's 
 directions, in the expectation of getting organisms, and looking 
 out for some explanation of their occurrence. The physical 
 forces, or whatever else it may be, were, however, not favourably 
 disposed for spontaneous generation at the time and place 
 where I performed those experiments, for to my surprise I 
 was unable to obtain any development of organisms. I tried 
 several modifications, in the hope of finding the cause of their 
 absence, but whichever of these vegetable fluids I used I was 
 able, with proper precautions, to preserve them with the 
 greatest ease. Some specimens were very difficult to filter, 
 and in some a slight muddiness occurred on boiling, and the 
 granular de])Osit might very readily be mistaken at first sight 
 for organisms, though some care and experience would easily 
 prevent such an error. But I have boiled the fluids for 
 a few minutes and then filtered them under pressure (I could 
 not in this way remove any of Dr. Bastian's supposed physical 
 forces) , and having thus obtained a perfectly clear liquid, 1 
 treated it like the others. There was now no deposit, and 
 nothing which could be mistaken for organisms. 
 
 No doubt other observers have produced evidence which 
 apparently at first sight supported Dr. Bastian's views. I 
 refer to the class of experiments in which prolonged boiling 
 was required for sterilisation, but many of these results depend, 
 I believe, on the same causes as Wyman's, viz., imperfect puri- 
 fication of the walls of the flasks and of the air in their interior, 
 
COHN'S REPLY TO BASTIAN. 179 
 
 while the fact, that in some instances such resistance was met 
 with, surely implies the presence of some form of encysted 
 organism or resisting spore, or of an organism placed under 
 conditions in which it is not perfectly heated, rather than 
 some rare form of organic molecule or physical force. 
 
 The former view — that there is present in the infusions 
 some form of resisting spore which can withstand the high 
 temperature — was shown by Cohn to be correct in the case of 
 the experiments where portions of cheese were introduced.^ 
 He repeated Bastian's cheese experiments with great care, and 
 found that after exposure to a temperature of 100° C. for ten 
 minutes, organisms still developed in the mixtm-e of cheese 
 and tm'nip. He, however, observed that these organisms were 
 always of one form {Bacillus subtilis), and that Bacterium tenno 
 and other forms were absent. On investigating this subject 
 further he found that these bacilli did not merely grow in the 
 form of long rods, but that they produced spores, and he had 
 previously ascertained ^ that the spores of these organisms were 
 possessed of peculiar resisting powers. Indeed, such was their 
 power of endurance under high temperatures, that if some 
 satisfactory explanation could be given why they should 
 always occur in these experiments, the whole mystery would 
 be solved, and the theory of spontaneous generation would no 
 longer be supported by these facts. 
 
 Cohn therefore turned his attention to the manufacture of 
 cheese. The Swiss cheese is made in the following manner : 
 milk is placed in large copper vats, and is coagulated by the 
 addition of rennet. This is allowed to stand for a quarter of 
 an hour, and then, after having been kept at a temperature of 
 from 55° to G0° C. for an hour, it is broken up into small 
 masses. These are now taken up in a cloth, placed in a 
 mould, and pressed for twenty-four hours. The cheese is then 
 taken out of the mould, transferred to a cellar, and kept at a 
 temperature of 10° to 12° C. for several months, salt being 
 daily rubbed over its surface. Lastly, it is stored till it 
 attains its full ripeness. 
 
 ' See UnterxuckuiKjcn iibcr Bactmcn, Cnhti'x Jieitriii/e zuv Biulwjic der 
 I'Jtanzcii, Erster Band, Urittes Heft, p. 188. 
 « Colin, ibid., lleft 2, p. 17G. 
 
 N 2 
 
180 
 
 SPOXTANEO US GENERATION. 
 
 The only stage in the process which it is necessary to con- 
 sider is the ripening of the cheese. Cohn points out that this 
 is a true fermentation clue to the growth of organisms ; this 
 
 YiG. 6-t. — Bacillus subtilis ; without spores ; with spores in the 
 
 RODS ; FREE SPOKES ; X GOO (AFTER COHN). 
 
 fermentation begins during the first twenty-four hours, while the 
 curd is still under the press, and is accompanied by the develop- 
 ment of large quantities of gas. The slower development of 
 this gas, which occm'S later, explains the 
 formation of cavities in the cheese. The 
 chemical change consists in the partial 
 transformation of the milk sugar into 
 butyric acid. The preliminary heating 
 to 55° or 60° C. kills all the organisms 
 except the bacilli which give rise to this 
 butyric fermentation. On examining 
 the rennet Cohn found that it was full of 
 bacilli, many of which contained spores, 
 and of free spores. By the addition of 
 the rennet to the milk enormous num- 
 bers of these spores are sown in it, and 
 the subsequent stirring mixes them 
 thoroughly with it. These spores escape death at the tem- 
 perature of 55° — 60° C, and develop in the cheese, thus 
 causing its ripening. They have been shown to resist high 
 
 Fig. 65. — Deposit in 
 rennet, consisting 
 of a mass of micro- 
 cocci and spores of 
 bacilli, x goo (af- 
 ter c'oiin). 
 
ROBERTS'S OBJECTIONS. 181 
 
 temperatures, and, when used in Bastian's infusions, they are 
 not destroyed, and thus we have a satisfactory explanation of 
 the frequent development of bacilli in these experiments.' 
 
 The other view — that the organisms were imperfectly 
 heated — was urged against Dr. Bastian's experiments by Dr. 
 Roberts as long ago as 1873. After pointing out that atmo- 
 spheric germs may get into the flasks at the time of sealing, he 
 goes on to a second source of error, which he considers much 
 more important. ' It is this : Dr. Bastian's process does not 
 insure that the entire contents of the flask are effectively 
 exposed to the boiling heat.' He refers to the difficulty in 
 boiling milk and other substances, owing to the spurting and 
 frothing of the fluid ; but he shows that if this is avoided by 
 simply immersing the flasks in boiling water, the difficulty in 
 rendering them ban-en is overcome. He says : ' The essential 
 conditions of the experiment are first the effective exposure of 
 the whole contents of the flask to a boiling heat ; secondly, 
 the absolute prevention of any fresh entrance of extraneous 
 solid or liquid particles ; and the conclusion I have come to is 
 that if these conditions are rigidly observed, the flasks remain 
 barren. If they do not remain barren it is simply because one 
 or other of these conditions has not been observed.' 
 
 In answer to this Dr. Bastian ^ replies : ' I feel quite sure 
 that in my experiments no portion of the inner surface of the 
 glass has escaped the scathing action of the boiling fluid. The 
 vessel has generally been more than three-fourths full before 
 the ])rocess of heating has been commenced, so that where 
 ebullition occurs the fluid has always swept over the previously 
 uncovered inner surface and, as Dr. Sanderson testifies, " dur- 
 ing th(! boiling some of the liquid was frequently ejected from 
 the almost cajjillary orifice of the retort." The inner surface of 
 the vessel was, in fact, always thoroughly and re[)eatedly 
 washed with the boiling fiuid, nearly half of which has been 
 spurted away in order that I might effect this object.' 
 
 Now it is just tlie spurting of the liquid which is so danger- 
 
 ' Tlie experiments of Huizinfja, on whicli P.astian lays ^eat stress, have 
 been refuted b}' Samuelson {P/fiitjcr's Arc/tir, viii. p. 277) and }>>■ Gscbeidlen 
 (Ifnd. ix. p. 163). 
 
 * Nature, Februarj- 27, 1873. 
 
182 SPOXTANJEOUS GENERATION. 
 
 ous, for, with the bubbles, solid particles are carried up and 
 deposited on the neck or sides of the flask, out of reach of the 
 boiling liquid, and they may not be acted on by the frothing 
 fluid. I also very much doubt if a bubble of steam sweeping 
 over the wall is to be regarded as a very efficient way of 
 applying moist heat ; certainly it is not so efficient as boiling 
 in a fluid. That greater success is obtained when this spurt- 
 ing and frothing do not take place has been stated by Dr. 
 Roberts, and this statement is quite confirmed by Mr. Lister's 
 experience with milk, where he uses the method of immersion 
 with perfect success, and for the same reasons. 
 
 But surely this view, that the walls of the vessels remain 
 impure, is the only way in which Bastian's facts can be recon- 
 ciled with Gruithuisen's experiments mentioned by Bastian 
 himself in a paper read before the Eoyal Society on March 
 20th, 1873. I will just quote Dr. Bastian's remarks and 
 experiments in connection with this paper. It is to be observed 
 that Bastian used this method for ascertaining the death-point 
 of bacteria, and the title of the paper in which these state- 
 ments occur is, ' On the temperature at which bacteria, 
 vibriones, and their supposed germs are killed when immersed 
 in fluids or exposed to heat in a moist state.' 
 
 He says : ' It was pointed out by Gruithuisen early in the 
 present century, that many infusions, otherwise very productive, 
 ceased to be so when they were poured into a glass vessel whilst 
 boiling, and when this was filled, so that the tightly fitting 
 stopper touched the fluid. Having myself proved the truth of 
 this assertion for hay infusion, it seemed likely that, by having 
 recourse to a method of this kind I should be able to lower 
 the virtues of boiled hay and turnip infusions to the level of 
 those possessed by the boiled saline solution with which I had 
 previously experimented, that is, to reduce them to a state in 
 which, whilst they appear quite unable of themselves to en- 
 gender bacteria or vibriones, they continue well capable of 
 favouring the rapid multiplication of such organisms. 
 
 ' This was found to be the case, and I have accordingly per- 
 formed upwards of 100 experiments with inoculated portions of 
 these two infusions raised to different temperatures. The mode 
 in which the exjieriments were conducted was as follows : 
 
GRUITHUISEN'S EXrERIMENTS. 183 
 
 ' Infusions of hay and turnip of slightly different strengths were 
 employed. These infusions having been first loosely strained through 
 muslin, were boiled for about ten or fifteen minutes, and then whilst 
 boiling strained through ordinaiy Swedish filtering paper into a glass 
 beaker, which had previously been well rinsed with boiling water, A 
 number of glass bottles or tubes were also prepared, which, together 
 with their stoppers or corks, had been boiled in ordinary tap water 
 for a few minutes. They were taken out full of the boiling fluid, and 
 the stoppers or corks being at once inserted, the vessels and their 
 contents were set aside to cool. When the filtei'ed infusion of hav or 
 turnip had been rapidly cooled down to about 110° F. (by letting the 
 Ijeaker containing it stand in a large basin of cold water), it was 
 inocxalated with some of a turbid infusion of hay swarming with 
 active bacteria and vibriones, in the pi'oportion of one drop of the 
 turbid fluid to each fluid ounce of the now clear filtered infusion. 
 The beaker was then placed upon a sand bath, and its contained fluid 
 (in which a thermometer was immersed) gradually raised to the 
 required temperature. The fluid was maintained at the same 
 temperature for five minutes by alternately raising the beaker from 
 and replacing it upon the sand bath. The bottles to be iised were 
 then one by one uncorked, emptied, and refilled to the brim with the 
 heated inoculated fluid. The corks or stoppers were at once very 
 tightly pressed down, so as to leave no air between them and the 
 sux-face of the fluids. The beaker was then replaced upon the sand 
 bath and the gas turned on more fully, in order that the experimental 
 fluid might be rapidly raised to a temperature 9° F. (5° C.) higher 
 than it had been before. After five minutes' exposure to this tempera- 
 ture, other bottles were filled in the same manner, and so on for the 
 various tem^ieratures, the influence of which it was desired to test.' 
 
 These bottles were kept at a temperature of from 0)5° to 75° 
 F. The results were as follows :— 
 
 'The experimental results here tabulated seem naturally 
 divisible into three groups. Thus, when heated only to 131° F. 
 all the infusions became turbid within two days, just as the 
 inoculated saline solutions had done. Heated to 158° F. all 
 the inoculated organic infusions remained clear, as had been 
 the case with the saline solutions in my previous experiments, 
 when heated to 140° F. There remains therefore an inter- 
 mediate heat zone (ranging from a little below 140° F. to a 
 little below 158° F.), after an exposure to which the inoculated 
 organic infusions are apt to become more slowly turbid, although 
 
184 SPONTANEOUS GENERATION. 
 
 inoculated saline solutions raised to the same temperature in- 
 variably remain unaltered. ... we may quite safely conclude 
 that bacteria, vibriones, and their supposed germs are either 
 actually killed or else completely deprived of their powers of 
 multiplication after a brief exposure to the temperatm^e of 158° 
 F. (70° C).' 
 
 With the conclusions drawn from these experiments as to 
 the death point of bacteria, I, for the most part, agree, but I 
 shall have to refer to them again presently. I have introduced 
 the facts here, because I believe that they add strong confirma- 
 tory evidence of one of the explanations of Bastian's results 
 which I have been trying to establish, viz., that in many cases 
 the organisms which appeared in his fluids after boiling did 
 not arise de novo, but were derived from particles on the walls 
 and in the air of the vessel, which had not been deprived of life. 
 For in Cxruithuisen's experiments and in Bastian's repetition 
 of them, there was no part of the wall of the vessel nor any air 
 in the interior left to be acted on by more or less dry heat. 
 The vessel was filled with fluid, and all the particles in it were 
 subjected to moist heat. And here the high temperatures 
 required in the other cases were not necessary. A temperature 
 of 158° F. continued for a very short time was sufficient to 
 render the liquid permanently barren.' 
 
 ' It is of great interest to mention here tlie difficulties experienced by Dr. 
 Paul Bert in attempting to preserve meat after subjecting it to high pressure 
 (' La pression barometrique,' p. 880). 
 
 ' Ainsi, dans mes premieres experiences, lorsque je voulais conserver une sub- 
 stance, apr^s I'avoir soumise A, la compression, je fermais d'un bon bouchon de 
 liege le flacon oi\ elle etait placee : ce bouchon etait perce d'un trou, et lorsque 
 j'avais retire le flacon de I'appareil, j'appliquais sur cet orifice fin une goutte 
 de cire fondue, avec laquelle, du reste, je cachetais tout le bouchon. 
 
 ' Je ne tardai pas tl apprcndre que cette precaution etait insufiisante. Les 
 bouchons, meme neufs, mcme laves, meme chauft'es rec^lent trop souvent des 
 germes encore en activite. J'cus alors recours aux matras, ballons, tubes, que 
 j'etirais 4 1a lanipe, apres y avoir introduit la substance en experience; le 
 trou presque capillaire de la partic etiree permetlait a I'equilibre de pression 
 de s'ctablir. 
 
 ' Je m'aper^us encore, a mes depcns, que les germes restes ill'etat sec sur les 
 parois du petit recipient suffisaient, surtout quand il s'agissait de la putrefac- 
 tion, mon laboratoire de dissection en etant bourre, pour t roubler les plienomi^nes. 
 Je ne pouvais me mettre sCirement a Tabri qu'en ajoutant un peu deau et en 
 renuiant avec soin le recipient, avant de la soumettrc a la compression, afin 
 de tuer en meme temps et les germes contenus dans la substance, et ceux des 
 parois qui se trouvaient mouilles.' 
 
PA UL BERT OX LIFE IX VACUO. 185 
 
 But was the fluid in these vessels in any special condition 
 which prevented the origin of organisms ? It is to be observed 
 that when the heat was not high enough to kill organisms, they 
 developed readily, there was then nothing in the conditions 
 which prevented the development of organisms. The only 
 difference in the two sets of experiments, and it seems to be 
 indicated by Bastian, appears to be that in Bastian's former ex- 
 periments the fluids were under diminished atmospheric pres- 
 sure, while here they were not. The conclusion then ajjparently 
 is that a vacuum is better suited for the spontaneous origin of 
 organisms than the normal pressure ; and that such is Bastian's 
 view is openly stated by him, and among facts in support of it 
 we find the admission that turnip infusion, urine, and some- 
 times hay infusion, may remain for an indefinite time in Pas- 
 teur's flasks with open bent necks without any development of 
 organisms in them, while in a vacuum organisms arise in 
 similar fluids, especially if a piece of cheese has been added to 
 them. 
 
 We must therefore see if any other facts favour this in vacuo 
 idea. As I have already stated, Pouchet, who is largely quoted 
 by Bastian, states distinctly that a vacuum is most unfavourable 
 for the occun-ence of spontaneous generation, and he employs a 
 vacuum for repeating some of Pasteur's experiments, in order to 
 showthatas soon as air is admitted, spontaneous generation occurs. 
 
 And in regarding a vacuum as inimical to life when com- 
 pared with the ordinary atmospheric pressure, Pouchet was 
 con-cct, as will be evident from the following quotations from 
 Paul Bert's recent remarkable work, entitled 'La Pression baro- 
 metrique.' 
 
 On submitting seeds to low pressures he found that germi- 
 nation was nmch delayed. 
 
 Tims in his 350th experiment ho sowed barley in eartli in tlu^ec 
 pots, and placed them : 
 
 A undei- a glass at the normal pressure. 
 B „ „ at .50<=' of pressure. 
 
 Five day.s later in A the slioots were numerous, very green and 
 very Gvvn, measuring about 10^- 
 
 B less numerous, less green, measuring about 8"^' 
 C still less, measure about G*^- 
 
186 SrONTANEOUS GENEliATION. 
 
 Next day these shoots were cut off at the level of the grain, dried 
 and weighed : 
 
 End shoots of A weighed S'^s-S. 
 
 !> )j ;; -" )> ' ■'• 
 
 A low pressure was also found tb be inimical to vegetation. 
 
 Thus to take his 359tli experiment : 
 
 A number of sensitive plants abovit lO'^" in height wei'e each 
 placed under a bell jar on August 1. 
 
 August 1. A at 60<=' of pressure. 
 B „ 50- „ 
 C „ 25- „ 
 
 August 3. Some leaves have fallen from C. 
 
 August 6. A leaflets sensitive and open. 
 
 B „ half open and little sensitive. 
 C „ completely closed. 
 
 August 7. All restored to normal pressure. 
 
 They are all sensitive, but C much less so than the others. C 
 does not close well this evening. 
 
 August 9. A is all right, very sensitive. 
 
 B. Little sensitive — sickly, yellowish. 
 
 C. Leaves falling off — dying. 
 
 A similar result, was obtained when putrescible substances 
 were submitted to varying degrees of low pressure. 
 
 Thus in experiment 38G the muscles of a dog were placed : 
 
 A at the normal pi'essure. 
 B at SS"^" of pressure. 
 
 Four days later A was horribly putrid. 
 B is a little less putrid. 
 
 Experiment 392. — On January 17, equal sized morsels of meat 
 were placed : 
 
 A in a pressure of half an atmosphere. 
 B at the ordinary pressure. 
 
 Other two, C and D containing increased amounts of oxygen. 
 January 25. The meat, which is the least altered in appearance, is 
 A. The pieces which are most altered are C and D. 
 
EXPERIMENTS WITH SUPERHEATED FLUXES. 187 
 
 Without multiplying the experiments, I may give his results. 
 To quote his own words : 
 
 ' Si nous envisageons d'ahord eelles de nos experiences qui 
 ont porte sur la diminution de pression, nous voyons d'une 
 maniere nette que dans I'air rarefie la putrefaction a ete nota- 
 blement ralentie et I'oxydation diminuee. 
 
 ' Mais ces resultats n'ont rien de bien extraordinaire ; Ton 
 savait depuis longtemps que la putrefaction na pas lieu dans 
 le vide, et il etait tout naturel de penser qu'elle serait d'autant 
 moins active que I'air serait plus rarefie.' 
 
 Dr. Bastian does not always obtain these results (growth of 
 organisms) with infusions containing cheese, &c.' If he uses the 
 rind of the turnip in preparing the turnijD infusion spontaneous 
 generation may not occur ! At least such is Dr. Bastian's ex- 
 planation of his failure to get organisms in one or two instances. 
 An exj^eriment is also nan-ated in Dr, Sanderson's letter in which 
 the walls of the flasks v/ere thoroughly purified by heat before 
 the introduction of the fluid, in order to see whether the organ- 
 isms were or were not attached to the walls of the vessels. But 
 this experiment is completely nullified by the mode in which 
 the flasks were afterwards filled, for Dr. Bastian charged them 
 by ' bi'eaking off their points ' (they had been sealed when hot) 
 ' under the surface of a neutral infusion of turnips and cheese, 
 freshly prepared for the puqiose without employing any of the 
 rind.' Here the previous purification of the walls of the vessels 
 was useless, for they were again soiled by the unpurified fluid 
 passing into the flask. 
 
 II. The second series of facts on which Dr. Bastian bases his 
 arguments . is, that certain solutions may be exposed in airless 
 and hermetically sealed flasks to a temperature of 270° to 275° F. 
 for 20 minutes, and yet that organisms may subsequently de- 
 velop in these flasks. Such fluids are chiefly strong infusions 
 of turnip rendered alkaline by liquor potassas. 
 
 Now I have already referred at length to the error that the 
 organisms may not be subjected to moist heat at all, and my 
 remarks apply here also. For 275° F. is not always sufiHcient 
 as dry heat. 
 
 But I would remark — and tliis may apply to some of the 
 ' Sec letter by Ur. Biirdon-Sandcrson in Xuiiirc of Januar}- f), 187?.. 
 
188 SPO^TANJEOirs GENERATION. 
 
 first series of experiments — that in only one or two cases were 
 numerous and distinct bacteria found; and I have ventured 
 to think that in some of the other cases the deposit which 
 occiuTed was simply due to imperfect filtration, and contained the 
 forms described, these forms not having developed since the 
 introduction of the fluid into the flask. For, I would ask, if 
 they had developed anew, why was the fluid not full of them ? 
 Why was there only a slight deposit ? When organisms are 
 really present in cultivating fluids (as in some of Bastian's 
 experiments) they fill the fluid and render it turbid, often 
 with a scum on the surflice. 
 
 In some flasks various forms of organisms were found, and 
 fungi were present in the deposit at the bottom, more especially 
 when tartrate of ammonia was used. In some cases Dr. 
 Bastian mixed deal wood with the fluid, and found bodies like 
 vegetable cells, which were undoubtedly portions of the wood. 
 With regard to the fungi, Dr. Bastian has himself pointed out 
 that crystals of tartrate of ammonia, when old, generally con- 
 tain fungi in their interior. 
 
 Professor Huxley, in ' Nature ' for October 13, 1871, stated 
 that he had seen Dr. Bastian's experiments and preparations, 
 and expressed his belief that the organisms which Dr. Bastian 
 got out of his tubes were exactly those which he put into them, 
 that in fact he had used impure materials, and that what he 
 imagined to be the gradual development of life and organisation 
 was the simple result of the settling of these solid impurities. 
 For instance, he relates how on one occasion Dr. Bastian showed 
 him a specimen of a fungus developed spontaneously, which 
 Professor Huxley recognised as a fragment of the leaf of a 
 Sphagnum, and that it was so he ultimately, after great diffi- 
 culty, convinced Dr. Bastian. 
 
 On the other hand, it is but fair to Dr. Bastian to admit 
 that these settled impurities were not the only things which he 
 got, and that in reality in some cases undoubted organisms 
 developed. Dr. Burdon-Sanderson, in the letter just quoted, 
 says : ' The accuracy of Dr. Bastian's statements of fact, with 
 reference to the particular experiments now under consideration, 
 has been publicly questioned. I myself doubted it, and ex- 
 pressed my doubts if not publicly, at least in conversation. I 
 
THEIR FALLACY. 189 
 
 am content to have established, at all events to my own satis- 
 faction, that by following Dr. Bastian's directions infusions can ' 
 be prepared which are not deprived, by an ebullition of from 
 five to ten minutes, of the faculty of undergoing those chemical 
 changes which are characterised by the presence of swarms of 
 bacteria, and that the development of these organisms can pro- 
 ceed with the greatest activity in hermetically sealed flasks, 
 from which almost the whole of the air has been expelled by 
 boiling.' Cheese was used in most of the experiments which 
 Dr. Sanderson witnessed. 
 
 Among others who have been unsuccessful in repeating Dr. 
 Bastian's experiments may be mentioned Dr. E. Ray Lankester. 
 In ' Nature ' for January 30, 1870, he says, ' In numerous ex- 
 periments with turnip solution made by Dr. Poole and myself 
 recently in the Laboratory of the Kegius Professor of Medicine 
 of this University, we found that under the conditions given in 
 Dr. Bastian's book, no life was developed, a result contrary to 
 that obtained by him in 999 cases out of 1000.' 
 
 The fallacy of Dr. Bastian's experiments with saline solu- 
 tions was well demonstrated as long ago as 1 872 by Mr. Hartley.^ 
 In no instance was he able to confirm Dr. Bastian's statements. 
 In his first experiment he made a fluid consisting of a 5 ^^er cent, 
 solution of tartrate of ammonia and phosphate of soda in distilled 
 water slightly acidified with tartaric acid. Several tubes were 
 filled with these solutions, and were heated for four hours to a 
 temperature of 1 50° C. They were afterwards kept at a tem- 
 perature of about 25° C. In none of them did any organisms 
 develop, but in some he found that a slight deposit occurred 
 which apparently was what Bastian had taken for a develop- 
 ment of organisms. On examination this deposit was found to 
 be inorganic, and to consist of silica alone. 'The disodic phos- 
 }»hate had attacked the glass, the silica dejjosited on standing, 
 and hence the jelly-like mass.' He adds further, in reference 
 to Dr. Bastian's use of magenta as a test for fungi, that mao-enta 
 also stains silica.^ Hartley does not consider these solutions 
 
 ' The italics arc my own. 
 
 ^ ProcrcdiiiiiH nf the lioijdl Socii'tji, vul. xx. 
 
 ■' Dr. Frankland (Natiirr, January 11), 1871), in whose laboratory Dr. I'asfian 
 had performed these experiments, was not satisfied with the results, and 
 repeated sonu; of the experiments, lusinjr a soluficni of carbonate of ainuuiuia 
 
190 SrONTAA\EOUS GENERATION. 
 
 capable of supporting life. In another set of experiments he 
 kept the tubes at a fluctuating temperature, which is another 
 of the conditions which Dr. Bastian considers favourable to 
 spontaneous generation ; but here also there was no develop- 
 ment. Similar experiments, which gave similar results, were 
 made with turnip infusions and with urine boiled and filtered 
 from mucus. After keeping such fluids in vacuo for a long 
 .time they were exposed to air, filtered through cotton wool, and 
 kept at fluctuating temperatures without any development ; but 
 when they were exposed to unfiltered air under the same 
 conditions, organisms rapidly developed. 
 
 Dr. Bastian ' says : ' The disruptive agency of heat is fairly 
 enough supposed by the evolutionists to destroy some of the 
 more mobile combinations in each solution — to break up more 
 or less completely, in fact, those very complex organic products 
 whose molecular instability is looked upon as one of the con- 
 ditions essential to the evolutional changes which are supposed 
 to take place.' With regard to this Hartley remarks, ' l^efore 
 granting such a supposition it would be necessary to know, first, 
 what are the " very complex organic products " of such peculiar 
 " molecular instability " existing in a solution of tartrate of 
 ammonia, sodic phosphate, acetate of ammonia, oxalate of am- 
 monia, in a solution of sugar and calcined yeast, in turnip 
 infusion, or any other putrescible liquid. My experiments show 
 that there is no such disruptive agency in a high temperature ; 
 that it does not influence the " more mobile combinations " 
 either in solutions of organic salts or vegetable infusions ; . . . 
 Dr. Bastian records the development of organisms in a liquid 
 heated as high as 153°C. ; yet the assumed "disruptive agency 
 of heat " is supposed to have influenced the results of Schwann 
 and Pasteur at a temperatm'e of 100° C. ! His experience is 
 contradictory to his own theory, and at the same time to the 
 experiments of others to which his theory raises objection.' 
 
 and pliospliateof soda, as had been done by Bastian in one of Ins experiments. 
 lie also states that the figure of eiglit particles and bodies which Dr. ]5astian had 
 mistaken for living organisms were merely 'particles of glass which had be- 
 come detached from the inner walls of the tube by the corrosive action of the 
 enclosed liquid at the high temperature to wJiich it had been exposed in the 
 ' digester.' 
 
 ' Nature, vol. i. p. 17G. 
 
EXPERIMENTS WITH ALKALINE FLUIDS. 101 
 
 III. The third, unci indeed the only series of experiments 
 which can still be held to be worthy of consideration, are those 
 with alkaline fluids which, as is well known, are more difficult 
 to sterilise than acid or neutral fluids. Dr. Bastian states that 
 even though superheated, organisms may develop in them. 
 
 This difficulty in purifying alkaline fluids was long ago re- 
 cognised by M. Pasteur, and was attributed by him to imperfect 
 wetting of the organisms. 
 
 However that be. Dr. Roberts • has conclusively proved that 
 this is not a case of spontaneous generation, for he has shown 
 that while on the one hand an alkaline fluid is very difficult to 
 sterilise, yet as the same fluid without the caustic potash is very 
 easily rendered barren, and as the caustic potash is pure, if each 
 be sterilised separately and then brought together, without any 
 fresh access of dust, the fluid still remains pure ; in other words, 
 the caustic potash does not determine spontaneous generation. 
 He shows, in fact, that the potash acts by increasing the re- 
 sisting power to heat of the particles, which are the forerunners 
 of organisms — not by increasing the abiogenic aptitude of the 
 infusion. 
 
 Ten flasks were charged with unneutralised hay infusion. Five 
 of these were simply plugged with cotton wool, and boiled over the 
 flame of a lamp for five minutes. The other five were also plugged 
 Avith cotcon wool, but through the centre of each plug there passed 
 an hermetically sealed glass tube bent obliquely, and containing the 
 quantity of liquor potassse requisite to neutralise the fluid in the 
 flask. These tubes had been previously he;ited (after being charged 
 with liquor potassse and sealed) in oil up to 121"^ C. in order to 
 destroy any organisms they might contain. The flasks thus prepared 
 were then boiled over the flame for five minutes. At the end of a 
 fortnight their contents were unchanged. The tube was now broken 
 and the liquor potassaj mixed with the fluid. Not one fl isk ger- 
 minated ; at the end of two months they were still barren. But 
 although these flasks had not acquired the power to germinate, they 
 had accjuired the propcrtij of I'uahling frcaldij introducad germs to 
 survivi a boiliiuj heat, for when the flasks were un])lugged and 
 infected with ortUnary air or water and then replugged and boiled 
 five minutes, their contents in every instance germinated in a few 
 days. 
 
 ' I'/nl. Tranx. 1874. 
 
192 
 
 SPONTANEOUS GENERATION. 
 
 m 
 
 I can quite confirm Dr. Roberts's statements, for 1 have 
 used his method of boiling these fluids separately as an easy 
 mode of obtaining any required degree of alkalinity, and I have 
 never got any results which in the least support the view that 
 the addition of liquor potassa3 to any sterilised infusion will 
 make organisms develop in that fluid. 
 
 I have already mentioned Mr. Lister's method of procedure 
 preserving fluids. I have mentioned how successful this 
 was, and how all the difficulties as to tall and 
 small flasks, &c., were overcome simply hy 
 purifying the lualls and the air in the 
 jiasks ; hy taking care, in the introduction 
 of the ir)ipit7'e fluids, to avoid contact luith 
 the neck and lualls of the flask so purified 
 (above the level of the liquid) ; and hy 
 avoiding spurting or frotJting during the 
 heating of the fluid. By Mr. Lister's method 
 all sorts of fluids may be preserved and 
 transferred from one vessel to another, with- 
 out the development of any organism, with 
 the same certainty as without the occurrence 
 of any fermentative change (see Chapter I.) 
 Mr. Lister's method has removed a great 
 source of error in all these experiments, and 
 I am confident that if his instructions be 
 strictly followed out, the instances of difficulty in purifying 
 fluids will become fewer and fewer. During four years more 
 or less constant work at such experiments, I have only once 
 met with an instance of difficulty in purifying fluids. This case 
 will be alluded to presently. 
 
 The experiments of Dr. Roberts and of Prof. Tyndall • as to 
 the absence of fermentative changes in preserved fluids show 
 also the absence of organisms under the circumstances re- 
 ferred to. For their experiments were made with a view to the 
 determination of the question of spontaneous generation. And 
 in my own experience, in order to test various materials, as 
 
 ' For later experiments than those (juoled at p. 24, rf wy., see Tyndall's 
 paper in the Philusoj)liical Transactions, vol. 1G7, 1S77, where some difficulties 
 which he experienced arc explained. 
 
 Fig. G6.— Dk. Ro- 
 bkrts's experi- 
 ment with al- 
 kaline eluids. 
 
rRESERVATION OF MILK. 193 
 
 to whether they contained organisms or not, I have prepared 
 many hundred flasks of cucumber and turnip infusion, and 
 also many of milk, meat, &c., without in any instance obtain- 
 ing the slightest evidence in favour of abiogenesis. (The case 
 in which I found difficulty in preserving milk has been 
 already mentioned, and will be alluded to presently.) The 
 rapid souring of milk during a thunderstorm is looked on as 
 a change due to electricity. Accompanying this rapid souring 
 there is a rapid increase of bacteria. I have kept flasks of pure 
 milk for a year, through several violent thunderstorm-s, without 
 any change taking place in it, and without the appearance of 
 any organisms ; and at the end of the year the milk was quite 
 fluid and of normal character, though in a few days after the 
 flasks were opened (they were covered with cotton wool caps) 
 it had coagulated, become putrid, and contained numerous 
 bacteria. 
 
194 SPONTANEOUS GENERATION. 
 
 CHAPTER X. 
 
 SPONTANEOUS GENERATION {concluded). 
 
 Facts with regard to unboiled flioids and tissues : Mr. Lister's facts with re- 
 gard to milk : my own experiments with animal tissues. Present state of 
 the question — Dr. Bastian's latest standpoint : Liebig's doctrine. Can or- 
 ganic molecules derived otherwise than from pre-existing bacteria give rise 
 to bacteria ? Firstly, there is nothing unreasonable in looking on these 
 particles as bacteria or their germs : seeds carried by air : excessive 
 minuteness of the germs of bacteria : Mr. Lister's experience with micrococci. 
 Secondly, there is no direct evidence that organic molecules not derived 
 from bacteria can give rise to bacteria: facts with regard to unboiled fluids 
 and tissues — conclusions from these facts : Paul Bert's experiments : 
 Cazeneuve and Livon : Pasteur : Dr. Bastian. Thirdlj', there is no evi- 
 dence that active organic molecules (chemical ferments, &c.) can resist 
 heat more than living things can : effects of heat on ptyalin, pepsin, 
 &c. : my own case of difficulty in sterilising milk : Wyman's fact as 
 to an alga living at 208° F. 
 
 With the great mass of evidence existing against the doctrine 
 of spontaneous generation, I should have no hesitation in casting 
 it aside. But much stronger evidence remains to be alluded to ; 
 viz., the behaviour of unboiled fluids and tissues when preserved 
 with certain precautions. 
 
 I have already referred to these experiments in a former 
 part of this work, and I may now state that where I have said 
 that fermentation was absent, I might equally well have said 
 that organisms were absent. I have mentioned that blood, 
 milk, and urine could be preserved, unboiled and unacted on 
 by chemical reagents, for an indefinite period, without under- 
 going fermentation, and, I may now add, without the develop- 
 ment of organisms. 
 
 Of these I may revert for one moment to Mr. Lister's 
 experiments with milk. Mr. Lister, in his attempts to obtain 
 pure unboiled milk, found that in none of his flasks did he 
 obtain lactic fermentation, but that in all but two (out of 
 
UNBOILED FLUIDS AND TISSUES. 105 
 
 some 50 or 60 flasks) organisms of some form or other occurred, 
 these organisms being in many flasks of totally distinct kinds. 
 Now these results prove a great deal against the view of spon- 
 taneous generation. Two flasks had no organisms at all, there- 
 fore milk does not spontaneously generate organisms, does 
 not naturally contain them, has no inherent tendency to 
 undergo fermentation. Then milk which has never been in 
 the dairy does not undergo lactic fermentation ; hence the cause 
 of this fermentation is something coming from the dairy, not 
 some form of organic molecule present in the milk. Then not 
 only the fact that in two flasks no organisms developed, but 
 also the great variety which appeared in the different flasks 
 prove that they could not have developed de novo. For if 
 we have twelve flasks under the same shade, each containing 
 the same specimen of milk taken at the same time, under the 
 same conditions, any change occurring in one, due to something 
 inherent in milk, or due to some physical force or combination 
 of physical forces acting on it, would have occm-red equally 
 in all. But when we see one specimen remaining without 
 organisms, another having a pigment micrococcus, another 
 having bacteria, another fvmgi, and so on, we must conclude 
 that the appearance of these forms cannot be due to anything 
 inherent in this milk, but that it is due to something which 
 has entered the milk from without. 
 
 My own experiments on milk, referred to before, bear out 
 Mr. Lister's statements in every particular, and bring additional 
 evidence, in that they show that a much larger proportion of 
 flasks may be preserved if attempts be made to render the 
 particles in the air, or at least on the udder of the cow and the 
 hands of the milkmaid, inert by the use of carbolic acid or 
 other antiseptic. 
 
 Cazeneuve and Livon's experiments on urine have been 
 already referred to, and will be further discussed under the 
 head of fermentation, when they will be found to furnish 
 much additional evidence against the view of spontaneous 
 generation. 
 
 After referring to blood, uiilk, and u)ine, I also mentioned 
 the experiments on gi-ape juice by Van der Broeck, Pasteur, &.c. 
 and on vegetable ti^sues by Roberts, and I then pasi-ed on to 
 
 (> 2 
 
lOG SPONTANEOUS GENERATION. 
 
 my own experiments on animal tissues. I described the 
 method I had employed, how the tissues were introduced into 
 and preserved in flasks containing cucumber fluid, and how 
 they remained unchanged, and, I miny now add, without any 
 development of organisms. That no organisms developed I 
 further ascertained by testing the beakers. By transferring, by 
 means of a pure syringe, a droj:) of their contents into a flask 
 containing pure cucumber or meat infusion, I found that no 
 organisms developed in the latter, proving that none were 
 present in the former. That organisms would have been 
 found by this method, if they had been present in the fluid, is 
 shown by the fact that, if bacteria were injected into the 
 animal immediately before death, they were found in the 
 beakers and in the flasks. I have also stained the granular 
 matter present in these beakers with methyl violet, according 
 to Koch's method, and have failed to find any organisms (see 
 Plate V. fig. M). 
 
 From all these facts it may therefore be regarded as certain 
 that organisms do not originate spontaneously, in the sense 
 formerly held, under any circumstances, but that they appear 
 in animal or vegetable fluids and tissues as the result of the 
 entrance of solid 'particles into these after their exit from the 
 living organism. That the question has narrowed itself to 
 this, that it is now no longer a question of spontaneous origin 
 of organisms in fluids which have been severely boiled, but that 
 it is a question as to whether some of the 'particles which get 
 into fluids and which resist heat may not be organic molecules 
 not necessarily derived from pre-existing bacteria, or whether 
 they are bacteria or their germs, is evident from what has gone 
 before, and at last Dr. Bastian has formulated similar views 
 in his paper in the 'Nineteenth Century 'for February 1878. 
 He says : — 
 
 ' The modern opponents and supporters of the doctrine of 
 spontaneous generation have always been principally concerned 
 with two sets of problems, (1) As to the nature of the material 
 in the air, the access of which is so apt to induce fermentation 
 in suitable fluids ; (2) As to whether some degree of heat 
 below 212° Y. can be proved to be always sufficient to destroy 
 
FINAL STANDrOlXT OF THE THEORY. 107 
 
 the life of different kinds of living matter in the moist state, 
 but especially that of bacteria and fungus germs. 
 
 ' In regard to the first set of problems it has been generally 
 agreed for some time that the air contains some germs of living 
 organisms, but that what proportion these bear to the much 
 more bulky, and probably more numerous, organic particles and 
 fragments resulting from the breaking up of previous living 
 matter of various kinds, is uncertain. It has also been gener- 
 ally admitted that any living organisms or germs which chanced 
 to fall from the air into suitable fluids would initiate fermenta- 
 tion or putrefaction therein. The question really requiring to 
 be solved has always been (though it has not been uniformly 
 recognised) whether mere organic debris from the air, either in 
 the form of particles or of larger fragments, could or could not 
 also bring about such changes in suitable fluids.' 
 
 This view corresponds very closely with the position which 
 Liebig was ultimately driven to take up on the subject of fer- 
 mentation, and Dr. Bastian says : ' It is Liebig's doctrine which 
 legitimately suggests the doubt above mentioned in regard to 
 the possible potencies of atmospheric particles other than actual 
 germs .... If it has been shown that the appearance and 
 increase of the lowest living particles are always a coiTelative of 
 these processes (fermentation and putrefaction), Liebig's view, 
 if it be true at all, must be true for the tuliole of the -processes ' 
 which are essentially included under the term fermentation.' 
 It will thus be seen* that Liebig's theory and Bastian's recent 
 views stand or fall together, and that the facts against one tell 
 equally against the other. Just now I shall only deal with 
 Bastian's views, but their intimate relation with Liebig"s theory 
 must be borne in mind, so that the full significance of the facts 
 opposing the latter may be recognised in their bearings also on 
 the former. 
 
 Dr. Bastian later on says : ' I go no further than to say that 
 in the present state of the evidence bearing upon the subject I 
 regard the hypothesis of spontaneous generation as the most 
 logical and consistent interpretation of the facts which are at 
 present known.' We must therefore consider what the evidence 
 on this subject is, and whether there are any grounds for accept- 
 
 ' Tlie italics are miue. 
 
108 SPONTANEOUS GENERATION. 
 
 ing the theory that the organic molecules which give rise to 
 bacteria originate from matter other than pre-existing bacteria, 
 rather than the view that they are directly derived from pre- 
 existing bacteria, in other words, that these particles are 
 nothing more or less than bacteria or their germs. . 
 
 I. Firstly, there is nothing unreasonable in looking on 
 these particles as bacteria or their spores ; indeed, Dr. Bastian 
 admits that some of them are derived from bacteria. But if 
 some, why not all ? Because some resist heat more than others ? 
 We shall return to this presently. 
 
 We know that the seeds of plants are often wafted by the 
 air, and this is more likely to be the case the lighter the seed, 
 and therefore it is generally admitted that the seeds of fungi, 
 large or small, are carried by the air. Indeed, both Pouchet 
 and Pasteur found and recognised the spores of fungi in air 
 dust.' 
 
 Further, bacteria propagate by fission in fluids, that is to 
 say, one bacterium develops from another. This process has 
 been often observed. Then, again, some forms of bacteria have 
 been found to produce spores, notably forms of bacilli. Thus 
 the spores of Bacillus anthracis have been fully described by 
 Koch, and still more recently the occurrence of small sporules 
 of excessive minuteness has been described by Ewart.^ Ewart 
 has also asserted that other forms of bacteria, especially of 
 Spirillum, produce spores in like manner. If then in fluids 
 bacteria always grow from bacteria, if some bacteria like fungi 
 produce spores, why refuse to believe that the particles in the air 
 which give rise to bacteria are these organisms themselves or 
 their spores, just as the particles which produce the larger fungi 
 have been shown to be their spores ? The excessive minute- 
 ness of the bacillus spores renders them difficult of discernment 
 in fluids under the microscope. When dried and shrunk we 
 
 ' In December 1880, having collected a quantity of laboratory dust by 
 aspiration of the air through gun cotton for several weeks, I dissolved the 
 gun cotton in ether and alcohol, and collected the dust on a glass slide : this 
 dust was stained with methyl violet according to Koch's method (see Chapter 
 XII.), and a drawing of it is given in Fig. 35, Plate V. It will be seen that 
 one or two bodies are present which are indistinguishable from bacteria and 
 micrococci, and these bodies have been stained by the methyl violet. 
 
 '^ Se3 Praccedings of the Royal Society, 1878. 
 
SPORES CARRIEU BY THE AIR. 1L»0 
 
 should expect them to be hardly visible ; and if the spores of 
 such large organisms as Bacillus anthracis are hardly visible, 
 how much less likely are we to find the spores of organisms which 
 themselves can be seen only with difficulty ? It seems to me 
 that it would be a very extraordinary thing if in the case of 
 these minute organisms alone, the particles which gave rise 
 to them were not derived from pre-existing forms. 
 
 But when we find that under certain circumstances the 
 same form of organism originates from these particles, as we 
 should expect were the latter spores, the case is made still 
 stronger. This latter fact will be more evident w^hen we come 
 to consider the relations of these bodies to fermentations, but 
 I shall here mention one experience related by Mr. Lister.' In 
 some experiments on the growth of a fungus in urine, a form of 
 micrococcus, which he terms Granuligera, constantly appeared in 
 the urine. He found that these were really organisms, from 
 an opportunity which he had of watching their growth. He 
 then says: — 'About this time, my study suffered from an epi- 
 demic of Granuligera. I could not now perform the same 
 experiments with the same success as in the first instance : any 
 that I tried was sure to be followed by the development of this 
 pervading organism. I eluded it, however, by continuing the 
 investigation in a room at the top of the house, which had been 
 for a considerable time unoccupied. Here the results of the 
 experiments corresponded with those originally obtained in the 
 study.' In this experiment there cannot be the slightest doabt 
 that the particles which gained access to the cultivating fluids 
 were these micrococci or their spores, if they have any. It could 
 hardly have been some form of organic molecule not derived from 
 these organisms which always gave rise to exactly the same forms. 
 
 Such are some of the facts which show that it is not un- 
 reasonable to look on these particles as bacteria or their germs ; 
 and Dr. Bastian, as I have already said, admits that some of the 
 particles are derived from pre-existing bacteria. 
 
 II. Secondly, not only is it not unreasonable to regard these 
 particles as bacteria or their germs, but there is no direct evi- 
 dence whatever that organic molecules not derived from bacteria 
 can give rise to bacteria. 
 
 ' See Transactions ofihc Royal Sonrty of Edinhuryh, 1875. 
 
'_>UU SPONTAXEOUS GENERATION. 
 
 Look at all the facts I have brought forward as to unboiled 
 fluids aud tissues. I have shown that the most diverse organic 
 fluids and tissues may be preserved for an indefinite period, 
 without the development of organisms so long as the particles in 
 the air and on surrounding objects are excluded. And yet 
 these substances are full of organic molecules derived from 
 previously living structures. 
 
 Cut a piece of liver, kidney, muscle, or other tissue from a 
 healthy animal not yet dead, and place it, with precautions to 
 exclude atmospheric dust, in a flask containing cucumber solu- 
 tion. Here you have at first in the fluid and in the tissue living 
 cells and living organic molecules — and we know, as in the case 
 of muscles, that life may be retained for some time — and yet no 
 organisms appear. These living organic molecules of all kinds do 
 not give rise to bacteria or any other form of life — they die. 
 
 Again, when the same specimen has stood for some time, 
 we have a highly putrescible and fermentescible material con- 
 taining dead organic molecules of all kinds ; and yet no life 
 appears, and such flasks may be kept for an indefinite time 
 without the development in them of life. 
 
 But again, these organic molecules are not only dead, but 
 decaying. They undergo slow oxidation — what Liebig has 
 termed eremacausis. And yet they do not develop into or 
 induce the appearance of living forms. 
 
 Organisms only develop in these fluids and tissues when 
 bacteria or their germs or when atmospheric dust is introduced. 
 Whence, then, are the hy|3othetical organic molecules derived ? 
 If they do not develop life in such fluids as cucumber or meat 
 infusion, or in meat itself, under the conditions described, how 
 is it that they come to do so after having floated through the air ? 
 Is it that they have acquu-ed new ijroperties in the air, or is it 
 that the organic molecules (not derived from pre-existing bac- 
 teria) which, falling from the air into the fluids or on the tissues, 
 give rise to living forms, are specially manufactured in the air ? 
 One or other of these conclusions must be accepted, and I say 
 they are both equally untenable. 
 
 And when I come to speak of the relations of organisms to 
 fermentations, more especially to fermentations occurring in 
 wounds, I shall bring forward evidence of a similar character. 
 
EVIDENCE FROM UNBOILED TISSUES. L^Ol 
 
 Thus I take flasks containing pure, highly putrescible fluids, 
 such as meat or cucumber infusion, or milk, and I introduce 
 into them pus, blood, or serum from wounds, and place them 
 under the most favourable circumstances for the development 
 of organisms, and yet no organisms develop. The same 
 reasoning applies here as in the case where larger living masses, 
 as liver, have been introduced into similar infusions. On the 
 other hand, if bacteria or micrococci are present in the dis- 
 charge (and I confirm this by microscopical observation), organ- 
 isms develop in these flasks, and organisms of precisely the 
 same morphological characters as were present in the original 
 discharge. 
 
 But let us glance for one moment at Paul Bert's work. 
 
 He subjects such substances as saliva, pepsine, myrosin, 
 emulsin, &c., to high pressures, say twenty atmospheres, and 
 he finds that when the normal pressure is restored, these 
 substances have not in anyway suffered, as regards their ferment- 
 ing power. 
 
 On the other hand, he places putrefying or fresh meat under a 
 similar pressure, and after restoring the normal pressure, he finds 
 that if he excludes fi'esh atmospheric particles, putrefaction is 
 in the first case arrested, and in the second, never takes place. 
 Organisms never again develop unless fresh dust is admitted. 
 
 From the first set of experiments we see that organic mole- 
 cules when they have any power of acting are not deprived of 
 it by high pressure, while from the second we learn that under 
 similar circumstances life is destroyed, and no new life appears. 
 And yet this cannot be because the power of generating organ- 
 isms, which organic molecules are supposed by Dr. Bastian to 
 possess, has been destroyed by the high pressure ; for, as we 
 see in the first experiment, dead organic molecules, as distin- 
 guished from living ones, retain their powers even under this 
 pressure. The organic molecules, then, which originated the 
 bacteria were living molecules, but tiot imerely any living 
 molecules, as is evident from the liver experiments, hut living 
 molecules derived from 'pre-existing bacteria. 
 
 Then, again, Cazeneuve and Livon's experiments, which will 
 })e detailed presently, prove exactly the same points. They 
 show that it is not organic nioloculos in urine or in the wall of 
 
'202 SPONTANEOUS GENERATION. 
 
 the urinary bladder which originate bacteria, but that it is 
 organic molecules derived from the dust of the air ; in other words, 
 derived from pre-existing bacteria.' 
 
 All the proof which Dr. Bastian attempts to adduce on this 
 point is to bring forward the opinions of several eminent meta- 
 physicians as to the first origin of life on this globe. But with all 
 respect for these great minds, I do not see one particle of proof, 
 but merely metaphysical speculation, in the extracts quoted. 
 Dr. Bastian removes the question to the first origin of life, and 
 at once throws aside the creation view as untenable. I do not 
 intend here to enter on this question, but I for one am not 
 prepared to go so far. 
 
 III. Thirdly and lastly, we have no evidence that active 
 organic molecules can resist heat more than living things can. 
 Let us take the so-called ' unformed ' ferments, which consist 
 of active organic molecules. The action of saliva on starch is 
 favoured by a temperature of from 35° to 40° C, but its amy- 
 lolytic activity is permanently destroyed by heat, even below 
 the boiling point, applied for a few minutes. 
 
 The same is true of gastric juice ; 'at temperatures much 
 above 40° or 50° C. the action of the juice is impaired. By 
 boiling for a few minutes the activity of the most powerful 
 juice is irrevocably destroyed.' (Foster.) And so with pan- 
 creatic juice, &c.^ 
 
 I have previously discussed at length the errors in experi- 
 ment and observation which have led to the belief that or- 
 ganisms can develop in materials subjected to a m.oist heat for 
 a sufficient length of time. And I have quoted Dr. Eoberts's 
 refutation of the experiments with alkaline fluids. 
 
 1 stated on page 193 that I had only met with one in- 
 stance, in an exceptionally long experience, of difficulty in 
 sterilising an organic fluid. This fluid was milk got from a 
 particular shop near the Strand. When I got fresh milk from 
 
 ' Again, Pasteur by his experiments of opening vessels in different situations 
 has distinctlj' shown that all particles of dust do not cause development of 
 organisms ; for undoubtedly organic debris did get into all his flasks, esijecially 
 those opened outside, and yet it was only when certain special particles 
 entered that organisms developed. 
 
 2 Compare also Bastiau's views on the Disrvpticc At/piici/ of Ilcaf, referred 
 to at page 190. 
 
RESISTANCE OF BACTERIA TO HEAT. 203 
 
 a dairy in Albany Street, I had no difficulty in rendering it 
 barren by immersion in boiling water for a few minutes. 
 But the milk from the shop near the Strand has been immersed 
 in boiling water even for three hours, and yet organisms deve- 
 loped in it. It is to be noted that in all cases the bacteria were 
 identical in form and in the effect which they produced on the 
 milk : they were a form of long bacillus. Now here we had 
 some particle which got into the milk and caused a special 
 change in it, and a constant development of a particular and 
 easily recognisable form of organism — an organism which, more- 
 over, has been found by other observers to resist heat, and 
 especially dry heat, in an extraordinary manner. Is it reason- 
 able to suppose that the particles which gave rise to these 
 organisms were organic molecules derived, goodness knows from 
 what, or specially manufactured in the air of this shop ? Or is 
 it not more reasonable to suppose that the air was infected 
 with some form of bacterium or its spores, just as in Mr. 
 Lister's case with Granuligera, and that this special form or 
 its spores possessed the same resisting powers which it has 
 been found to have in other parts of the world. For I may add 
 that the spores of bacilli are stated by all who have investigated 
 the subject to be possessed of extraordinary resisting power. 
 
 After all it is not a matter of great surprise that an 
 organism should resist a heat of 210° F. (that has been ascer- 
 tained by Mr. Lister to be the temperature of milk immersed 
 in this way), for Prof. Jeffries Wyman tells us of a form of alga 
 which lives normally in water the temperature of which is 
 208° F.' 
 
 With this great mass of evidence, and I could have multi- 
 plied it manifold, I do not see that there can be grounds for 
 
 ' Doy^res found tliat dried Tardigratlos were not destroyed till the tem- 
 perature reached 140'^. 
 
 Payen showed that thcspores of oidium aurantiacum did not lose tlieir ger- 
 minating power till the temperature readied 140° C. 
 
 Milne-Edwards has found tliat dried organisms could resist a \Qry high 
 temperature. 
 
 Instances of great resisting power of seeds to heat have been brought 
 forward by Tyndall and others. Mr. James Sanderson, of Galashiels, tells me 
 that in some specimens of wool obtained from South America, seeds of 
 medicago are present, which develop even after the wool containing them has 
 been dyed— ?.^. after the}' have been subjected to \ n, longed boiling and to the 
 action of various clicmical sulistanccs. 
 
204 SPONTANEOUS GENERATION. 
 
 any longer retaining the view of spontaneous generation. It 
 wonld just be as sensible to suppose that in the impregnation 
 of the ovum of higher animals it is not the spermatozoa, but 
 some organic molecule accidentally introduced at the . same 
 time which causes the development of the ovum, as to suppose 
 that it is not bacteria or their spores but some organic molecule 
 manufactm'ed in or specially altered by passing through the air 
 which produces bacteria in organic fluids and tissues. 
 
'VITAL' AND 'CHEMICAL' FERMENTATION. 205 
 
 CHAPTEE XL 
 
 RELATION OF MICRO-ORGANISMS TO FERMENTATION. 
 
 Summary of what has preceded with reference to fermentation. Relation be- 
 tween ' vital ' and • chemical ' fermentations : theories of fermentation. 
 Liebig's views. Alcoholic fermentation : PasteitrKt experiments and concln- 
 shns. Resume. Butyric fermentation. Formation of pigment by bacteria 
 Schroeter : Colin. Viscous fermentation. Lactic fermentation : Pasteur: 
 Lister. Other fermentations, especially the putrefactive : Lemaire ; Caze- 
 neuve and I.ieon : Paul Bert. Conclusions. 
 
 We must now pass on to the relation of these bodies to fermen- 
 tations, and I will here merely indicate the chief points without 
 entering into a discussion on the subject And first, I may .say 
 that it is now admitted by Dr. Bastian, s well as by other 
 observers, that organisms are present in all fermenting fluids. 
 This statement was formerly denied, on account of the imperfec- 
 tion of the methods of examination. 
 
 We have already seen in the iirst part of this work that the 
 cause of fermentation in organic substances was the entrance 
 into them of solid particles held in suspension in air. We have 
 also seen that the cause of the development of organisms in 
 fluids and tissues was the entrance into them of particles sus- 
 pended in the air. We also know that in all fermentations 
 organisms are present, and that in the absence of organi.sms no 
 fermentation occurs. What more likely, then, than that the 
 particles which cause fermentation, and the particles which 
 originate organisms, are one and the same ? that in fact the 
 fermentation of a fluid is the result of the growth of organisms 
 in it ? 
 
 The process in these ' vital' fermentntions may be brouo-lit 
 into the same category as that in fermentation by the 'un- 
 formed ' ferments, if we sn])])<)S(» that the immediate cause of 
 the chemical change in the fujiner instance is some chemical 
 
20G FERMENT A TION. 
 
 substance resembling ptyalin, pepsin, &e. No doubt there is 
 this difference between ordinary fermentations and those due 
 to a chemical substance, that in the former case the ferment 
 itself increases in quantity. This difference would, however, be 
 easily reconciled if we were to suppose that each organism was a 
 former of the ferment, even though to an extremely limited 
 degree. The process in these ' vital ' fermentations, of which we 
 may take the alcoholic as an example, would then be the same as 
 in the so-called chemical fermentations. Thus, to speak of the 
 case of the saliva, ptyalin is not a chemical compound formed 
 spontaneously, nor is it the result of any sort of double decom- 
 position ; it is a substance formed as the result of the vital 
 action of certain living cells. According to the view under 
 consideration, the alcoholic ferment would be likewise the pro- 
 duct of the vital action of certain cells, the yeast cells. The 
 ptyalin itself has not the power of self-multiplication, but the 
 cells which form it produce it continuously; the ferment of 
 alcohol would not have the power of self-multiplication, but the 
 cells which form it produce it continuously. This explanation 
 agrees completely with the contrast between the effects of 
 ptyalin on starch, and those of yeast on sugar. The ptyalin is 
 more or less immediate in its effect. It is a very active formed 
 ferment. The yeast acts slowly because the ferment is only 
 produced as the plant grows. Hence the explanation of the 
 rapid action of the one and of the progressive action of the other. 
 The apparent self-multiplication of the ferment in the alcoholic 
 case would be due to the fact that the producers of it are free — 
 float freely in the fluid - and hence ultimately no drop of it can 
 be taken which will contain sufficient ferment to act without 
 the ferment-producers being also present. In the case of the 
 saliva, the ferment-producer is fixed, and the ferment is obtained 
 alone and apart from its originator, hence it does not multiply. 
 The same causes which arrest the production of ptyalin arrest 
 also the alcoholic fermentation, for they destroy the living 
 cells which form the ferment. 
 
 The case of emulsin would be exactly the same as that of 
 yeast. The emulsin itself does not multiply, but the seed, the 
 producer of it, does. Sow a seed of the bitter almond, and there 
 sjjrings up a phnt bearing numerous seeds, numerous producers 
 
THEORIES OF FERMENTATION. 207 
 
 of emiilsin. Sow a yeast cell, and there follows the growth of 
 numerous yeast cells, each producing a quantity of the ferment. 
 
 Considerable support is given to this view by the experi- 
 ments of Musculus, on the mechanism of the ammoniacaL 
 fermentation of urine. This has been shown to be due to the 
 growth of an organism in the urine (Micrococcus urese, Cohn). 
 Musculus' demonstrated that, by adding absolute alcohol to am- 
 moniacal urine, a precipitate was obtained which could be filtered 
 and dried. This precipitate transformed urea into carbonate 
 of ammonia. Its power was destroyed by exposure to a tem- 
 perature of 80° C. This soluble ferment is a secretion of the 
 micrococcus urese. 
 
 According to another view it may be that the organisms, 
 while living in various substances, feed on them, and the pro- 
 ducts of the fermentation may be either the portion of the food 
 which has been rejected by them, or products formed in and 
 excreted by the organism. 
 
 Or it may be that, as Pasteur holds, the cause of the fer- 
 mentation is not the production of a ferment but the breaking 
 up of the chemical compounds by the growing plants in the 
 search for nutriment, more especially for oxygen. It is quite 
 clear that there must be such a breaking up. Or, again, it may 
 be that in this breaking up of the organic compounds some of 
 the molecules may rearrange themselves and form a ferment, 
 and the presence of a ferment of this kind I consider the best 
 explanation of some of the special fermentations, though I 
 incline to hold that the ferment is excreted by the cell itself. 
 
 It is, however, probable that in different fermentations the 
 process occurs in different ways. Thus in the pigment fermen- 
 tations, as will be seen, the second is probably the correct 
 explanation. The point of importance is that in any case 
 there is nothing unreasonable in associating these changes 
 with the growth of living cells ; in fact all analogy points to 
 such a relation. 
 
 The only other theory which is tenable in the presence of 
 the facts stated, would be that the ])articles which cause fermen- 
 tations are not the same as those which give rise to the growth 
 of organisms, but that they are bodies which have only the 
 
 • 3Iagni2i, Jiaetrria 
 
208 FERMENTATION. 
 
 power of causing fermentation, and are possibly either sub- 
 stances in a state of decomposition or special ferments. But 
 then it is inconceivable that fermentation and the development 
 of organisms should always be associated, or that organisms of 
 the same form, e.g. the yeast cell, should always be present 
 in the same fermentation. Supposing this view possible, we 
 must assume that there is a special organic molecule for each 
 fermentation, for otherwise we could not explain the occurrence 
 of lactic fermentation in one flask, putrid fermentation in 
 another, pigment fermentation in another, &c., all the flasks 
 containing the same specimen of milk having been filled at 
 the same time and kept under the same conditions. 
 
 Liebig originally propounded the view that fermentation 
 was a change in organic fluids and tissues, set in motion by the 
 access of oxygen or of bodies in a state of decomposition. He 
 at that time regarded organisms as quite accidental. He sup- 
 posed that when organic matter was exposed to the air, it 
 underwent a slow process of oxidation which he termed ereraa- 
 causis ; and that this change, communicating itself to other 
 molecules, caused them to break up or putrefy. In the presence 
 of the facts stated as to the relation of dust to the fermentation 
 of boiled and unboiled fluids, Liebig modified his views, and 
 in his last publication he admitted that the yeast plant was 
 in some way or other connected with the alcoholic fermentation, 
 but he thought that the relation between them most frequently 
 consisted in this : — that when the yeast cells died, they decom- 
 posed, and that the chemical change thus set agoing was propa- 
 gated to the sugar, and caused it to break up into alcohol and 
 carbonic acid. 
 
 That Liebig's theory of decaying inatter is incorrect Avill be 
 seen by a consideration of the facts mentioned on pages 200 and 
 210. Liebig was not latterly, however, absolutely opposed to the 
 acceptance of the doctrine that living organisms are initiators 
 of fermentative changes. On the contrary, to quote from Bastian, 
 ' he slightly widened his views after the coiTelation of organisms 
 with fermentations had become established, and endeavoured to 
 show that the admitted actions of living units in initiating fer- 
 mentations were but other exemplifications of his general 
 doctrine, that fermentations are induced by certain communi- 
 
ALCOHOLIC FEIiMENTATION. 209 
 
 cated molecular movements, sometimes emanating from organic 
 matter in a state of decay, and sometimes resulting from the 
 vital processes of living units.' 
 
 Had Liebig left out the part of the view which holds that 
 fermentations may be caused by movements, ' sometimes 
 emanating from organic matter in a state of decay,' there would 
 not have been much to find fault with. His theory would then 
 have been merely another way of viewing the mode of action of 
 these living bodies. 
 
 Certain definite facts are known which show that organisms 
 do take part in certain fermentations, while I have already 
 disproved Liebig's view that decaying matter has any power 
 of causing these changes. The facts to which I am about 
 to allude, when taken together with the constant presence of 
 organisms in other fermentations of the same class not yet in- 
 vestigated, render it, to my mind, certain that living organisms 
 are, probably in one or other of the ways indicated, the causes 
 of these chemical changes. 
 
 A Icoholic Fev)iieittatioit. 
 
 The first case of fermentation which was studied, and about 
 which most is known, is the alcoholic fermentation. The facts 
 and experiments on tliis subject are now so universally known 
 that it would be superfluous for me to do more than summarise 
 them here. 
 
 The yeast plant (Toriila cerevisice) is always present in a 
 state of vitality during the alcoholic fermentation of sugar. 
 
 If yeast be raised to the temperature of 60° C, at which 
 temperature the cells die, the fermentation of sugar no longer 
 occurs. Here the cells are dead, and if Liebig's view be 
 correct, that dead cells, not living ones, are the cause of the 
 fermentation, the process ought still to go on. 
 
 The juice of the grape has no spontaneous tendency to 
 imdergo fermentation, as shown by the exijeriments of Van der 
 Broeck, S:c., formerly mentioned, and by the following experi- 
 ment narrated by Pasteur. In a flask of the form shown in Fig. 
 68, A) the neck (a) of which w^as drawn out to a fine point, 
 Pasteur boiled water which had ])een used to wash the outside 
 
 p 
 
210 
 
 FERMENT A TIOX. 
 
 of a grape, and which therefore, according to other experiments, 
 contained abundant causes of the alcoholic fermentation. This 
 point (a), which had been sealed, was heated, and plunged 
 through the heated skin of a grape (Fig. 68, B). It was then 
 
 broken in the interior of the 
 grape, and, by causing a diminu- 
 tion of pressure inside of the 
 flask, a drop or two of the juice 
 was sucked into the boiled water. 
 (The diminution in pressure was 
 thus obtained. After heating the 
 walls of the flask with the hand or 
 a lamp, the orifice of the bent 
 neck (Fig. 68, A, 6) was sealed. 
 When the point of a was broken 
 off in the interior of the grape a 
 little juice passed into the flask.) 
 The orifice a was then sealed? 
 and the orifice h opened. Here, then, he had in the flask unboiled 
 grape juice, oxygen, water, dead organisms, and organic mole- 
 
 FlG. C7.— TOKULA CEREVISIiE. 
 
 (AFTER Pasteur.) 
 
 3 A 
 
 Fig. G8. — Pasteur's experiment on unuoiled grape juice. 
 
 A, tlic flask cmployorl. a. The neck v/hicli is represented in B a-s plunj^ed into the grape. 6, Tlic 
 orifiof of the lient neck at first scaled till the grape juice has been introduced and tlien ojjencd 
 and left open. (From Pasteur.) 
 
 cules, and yet no alcoholic fermentation occurred. This and 
 other experiments' led Pasteur to the following conclusions : — 
 
 ' Sue Etudes mr la Biire. 
 
ALCOHOLIC FERMENTATION. 211 
 
 'The boiled juice of the grape never ferments when kept in 
 contact with air which has been deprived of the germs suspended 
 in it. 
 
 ' Boiled grape juice ferments when a very small quantity of 
 water is introduced, in which the surface of the grapes and of 
 the branches of the vine have been washed. 
 
 ' Grape juice does not ferment after the introduction of this 
 water if the latter has been previously boiled and cooled. 
 
 ' Grape juice does not ferment when a small quantity of the 
 juice taken from the interior of a grape is introduced.' 
 
 Pasteur further shows that the apparently spontaneous com- 
 mencement of fermentation in these fluids is due to the 
 existence of spores of the torulse in the air, though they are 
 not, as a rule, present in great abundance. He also brings 
 forward experiments to show how other fungi, such as Myco- 
 derma aceti, can, when there is too little oxygen present, cause 
 the splitting up of sugar into alcohol. 
 
 .Seeing, then, that boiled and unboiled grape juice may be 
 preserved unaltered in presence of air which has been heated, 
 or in some way or other deprived of its dust, it is quite evident 
 that alcoholic fermentation is not a spontaneous decomposition 
 nor one which can be brought about by the action of the gases 
 of the air alone. Seeing, also, that the yeast plant is alwavs 
 ])resent when fermentation is going on, that anything which 
 destroys the vitality or interferes with the growth of that plant 
 arrests or interferes wuth the alcoholic fermentation, and that 
 the introduction of dust which does not contain the torula 
 cells is not rccompanied by the alcoholic fermentation but by 
 some other change, we must conclude that the particles which 
 fall into fluids and give rise to alcoholic fermentations are in- 
 timately associated with the particles which give rise to yeast 
 cells, and further that they are living particles subject to the 
 same laws as the yeast cell itself. And seeing, further, that other 
 ]>lants when living under certain conditions are also capable of 
 giving rise to the alcoholic fermentation, we must conclude that 
 this change is a process due to changes in living tissues, that, 
 in fact, the fermentation is the result of the life of these cells 
 and ])lants, and that, therefore, the i)articles which, falling into 
 iluids, give rise to tlic Toiiila cerevisia', and those which give 
 
 V 2 
 
212 
 
 FERMENT A Tl ON. 
 
 rise to alcoholic fermentations, are one and the same ; in fact thai 
 the growth of the yeast cell is in some way or other the cause 
 of the alcoholic fermentation. 
 
 Butyric Fermentation. 
 
 Pasteur has also brought forward evidence of a similar 
 nature as to the butyric fermentation. The organisms which 
 produce butyric fermentation are bacilli [Bacillus stibtilis, Colm), 
 
 which apparently live without 
 free oxygen, and indeed are 
 killed by it, and which when 
 cultivated in various fluids, 
 even in Pasteur's solution, 
 cause butyric fermentation in 
 all (see Fig. 69 and also Fig. 
 64). 
 
 Formation of Pigmeoit by 
 Bacteria. 
 
 Fig. 69. 
 
 -Bacillus subtilis, 
 (after Cohn.) 
 
 Striking facts as to the 
 *'°^' association of a definite chemi- 
 cal change with the presence 
 of organisms of a definite form were brought forward by Cohn 
 and Schroeter with regard to ' pigment bacteria.' ' 
 
 They showed that while many forms of organisms could 
 grow on such soil as boiled potatoes, yet a definite pigment 
 was produced only when one particular form was present. 
 These organisms gener.dly belonged to the group of ' micro- 
 cocci,' though sometimes pigmentation was caused by bacteria, 
 as in blue pus (see Fig. 70). 
 
 These pigments were sometimes scarlet, sometimes blue, 
 sometimes soluble, sometimes insoluble ; and when a variety 
 of soils were inoculated from an individual specimen, the same 
 colour, with the same chemical and other characteristics and 
 the same organism, always resulted. Not only might these 
 pigment bacteria grow on boiled potatoes, they could flourish 
 
 Beitragc zur Biologic dcr Fjlanzim. 
 
FORMATION OF PKrMENT BY BACTERIA. 
 
 218 
 
 Fig. 70.— Pigment producing 
 organisms. 
 
 A, Micrococcus prodigiosus. B, Micrococcus 
 fill vis. C, Bacillus ruber. 
 
 on cheese, meat, white of egg, bread, starch, &c., the same 
 2)igment being invariably produced. 
 
 The conditions under which this pigment appeared were 
 exactly those which were most favourable to the life of the 
 organisms, while those in 
 which it was absent were those 
 in which the organisms could 
 not develop. 
 
 Schroeter concludes from his 
 investigations that these ex- 
 amples show what a manifold 
 series of pigments may be 
 produced ' by bacteria and bac- 
 teridia.' He adds that the or- 
 ganisms which form them can 
 often be recognised as distinct 
 owing to the difference in the 
 pigment produced ; the organ- 
 isms which form the various 
 pigments being often also dis- 
 tinctly separable by different morphological characters, and 
 tlie different pigments behaving differently with reference to 
 chemical reagents. He considers that it is not unjustifiable to 
 hold that each separate pigment is formed by a distinct specific 
 organism. 
 
 Schroeter points out that the pigments are definite chemical 
 substances formed by the bacteria from organic, albuminous 
 materials, and tliat the process is therefore quite analogous to 
 the formation of alcohol by the yeast plant or of lactic acid liy 
 other bacteria. 
 
 Cohn farther found that these same organisms developed 
 readily and produced tlie same pigment in artificial cultivating 
 fluids contarninr/ ammonia, and a carhonate, hut no trace of 
 albumen. Once obtained in this fluid tliey could be propagated 
 indefinitely, the same pigment being constantly ])roduced. 
 Tn this instance we have an exam])l(' of a definite change 
 bi'ought about by the growth of a dfliiiitc form of organism. 
 No spontaneous change ever occurs in Colm's artifu-ial fluids 
 resulting in the formation of these pigments, and yet as soon 
 
214 FFAtMENTATIOX. 
 
 as these organisms, which are associated with definite pigments 
 when growing on albuminous soil, are introduced into these 
 mineral solutions, the same pigments appear. That in the latter 
 case the pigment is formed by the bacteria is evident, for it is a 
 complex organic substance, closely related to the aniline colours, 
 and yet in this instance it is derived from a few inorganic salts. 
 It is therefore a substance formed by the living plants, and, as 
 before remarked, there is nothing remarkable in this production 
 of pigment by living cells. It is only what is constantly occur- 
 ring in many animal and vegetable cells, and in the latter it is 
 formed from inorganic compounds. Indeed, it would be against 
 all chemical experience that by any purely chemical process a 
 complex organic compound would be so readily built up from a 
 few inorganic compounds of a very simple kind. 
 
 These facts absolutely prove that the pigment fermentation 
 was the result of the life of the organism, for the pigment 
 must have been built up by it and could not have originated 
 from chemical changes projoagated to the fluid. If then Dr. 
 Bastian is correct in his opinion that ' Liebig's view, if it be 
 true at all, must be true for the tvhole of the processes which 
 are essentially included under the term fermentation,' these 
 facts alone overturn Liebig's theories. 
 
 Viscous Fertnentation. 
 
 Similar facts are known with regard to the viscous fermen- 
 tation of sugar. This is a transformation of sugar into gum 
 mannite, and carbonic acid, and results in the formation of a 
 viscid, ropy fluid. Pasteur found that organisms of a special form 
 were present in such instances, and these organisms when sown 
 in Pasteur's solution always caused this viscous fermentation. 
 The kind of proof is exactly the same as in the other instances 
 of fermentation, and need not be repeated here. 
 
 Lactic Fermentation. 
 
 An instance in which the causal relation of organisms to a 
 fermentative process is absolutely demonstrated is the lactic 
 fermentation of milk. 
 
 This fermentation was investigated several years ago by 
 
LACTIC FERMENTATION. -215 
 
 Pasteur, ' who showed that it was exactly analogous to the alcoholic 
 fermentation, and that it was caused by a special organism. On 
 examining fluids which were undergoing lactic fermentation 
 he observed that minute round or oval cells were constantly 
 present. These organisms when transferred to fluids capable 
 of nourishing them always produced lactic acid. To prove 
 that these organisms were the cause of the fermentation he 
 made a decoction of yeast, to which he added sugar and chalk. 
 When they were sown in this fluid lactic fermentation oc- 
 curred, resulting in the formation of large quantities of calcium 
 lactate. 
 
 This fermentation has of late been more fully studied by 
 Mr. Lister, and as his experiments bear on the whole subject of 
 fermentation, I shall refer to them somewhat at length. 
 
 As I have previously mentioned, Mr. Lister ^ found that milk 
 had no inherent tendency to undergo the lactic fermentation ; in 
 fact, unless it was brought into a dairy or into contact with 
 dairy vessels or workers, all sorts of fermentations would occur 
 rather than the lactic. On examining milk undergoing lactic 
 fermentation he found that an organism of a definite and easily 
 recognisable form was constantly present, while in milk which 
 was not brought into the dairy, and which did not undergo 
 lactic fermentation, this form of organism was absent. 
 
 ' This organism is a motionless bacterium occm'ring most 
 commonly in pairs, but frequently in chains of 3, 4, or more indi- 
 viduals, each segment being of somewhat rounded form, more 
 or less oval, with the long diameter in the direction of the 
 length of the chain, and often showing, on careful focussing, a 
 line across their central part, indicating transverse segmenta- 
 tion. They vary in diameter. . . full-sized specimens measur- 
 ing about y7rt¥^^^^ inch.' 
 
 The question now arose, Was this organism, so constantly 
 present in milk which was undergoing the lactic fermentation, 
 the cause of that change or not? Was some other bacterium 
 the active agent, or was it some hypothetical organic molecule ? 
 
 Mr. Tiister solved these jjoints in the following beautiful 
 manner. He prepared a series of flasks containing milk which 
 
 ' A II lift lis tic Chilli rf lie P/ii/ti., vol. lii. ]). III". 
 
 - Triinaarliiinii iif ihr Pitniohuprtil Snrirfi/ of Linii/iin, 1878. 
 
1^10 
 
 FERMENT A TION. 
 
 had been boiled. These were kept for some time till it was 
 certain that the milk had been rendered sterile. Having cal- 
 culated how many of these oval organisms were present in a 
 given quantity of fermenting milk, he diluted this milk so as to 
 have only one bacterium in a definite quantity {e.g. yJ,oth of a 
 minim) of the fluid, su})posing that the bacteria were equally 
 diffused throuirhout it. 
 
 Fig. 71.— r.ACTEiuuM lacti-; 
 
 IN PAIKS AND CHAINS. 
 
 In one cliain the component cells arc 
 uncU-roroing division. (After Lister.) 
 
 This was rlone in the following manner :— ' By means of the syringe 
 already described ' (one graduated to the y-i-^th of a minim) 'one or 
 
 more hundredths of a minim could l>e 
 measiu'ed with precise accuracy; and I 
 found that J^th minim exactly occupied 
 a circular plate of thin covering glass, 
 half an inch in diameter, so that when 
 such a drop was placed on a glass slide, 
 and a cover glass of the size mentioned 
 and quite flat was put down upon it, all 
 air was expelled from under the latter, 
 nnd the rim of fluid that formed round 
 about its margin was so narrow as not 
 to measure a quarter of the diameter of 
 the field of the micro.scope even when 
 the highest magnifying power was used. 
 In other words, -^^M^ minim was disposed 
 in a thin uniform layer of the exact size of the cover glass. Hence 
 the number of bacteria under the glass slip — that is to say, in ^g'o^h 
 minim— was equal to the number of the bacteria in a field of the 
 miscroscope multiplied by the number of times the area of that field 
 went into the area of the covering glass. The micrometer gave the 
 diameter of the field in thousandths of an inch ; and the cover glass 
 measured 500 thousandths of an inch across ; and the areas of the 
 circles were of course proportioned to the squares of those diameters. 
 All that was needful, therefore, in order to enable me to calculate 
 the number of bacteria in -^(^th. minim, was to form a fair estimate of 
 the number of bacteria per field, and this was done by counting the 
 organisms in a cousidei-able number of fields, and taking the average. 
 
 ' As the result of the estimate which I made of the number of 
 bacteria present in every -^th minim, I found it necessary to dilute 
 the milk with no less than a million parts of boiled water, in order 
 that eveiy xocj^^i minim should cont:iin on the avei-age a single bac- 
 terium.' 
 
LACTIC FERMENTATION. 217 
 
 Having obtained the necessary dilution Mr. Lister pro- 
 ceeded as follows : — ' One-hundredth minim of the infected 
 water was added by means of the syringe to each of five glasses of 
 pure boiled milk. The result of this inoculation was that only 
 one of the five glasses was affected at all.' The others remained 
 unchanged, without fermentation, and without bacteric develop- 
 ment. The one which was affected underwent lactic fermen- 
 tation, and in it the bacterium lactis alone was found, no 
 other form of organism was present. This bacterium was inocu- 
 lated into urine and developed there. After four days milk was 
 inoculated from this urine. The milk underwent lactic fer- 
 mentation, and these bacteria were again found. Drops of urine, 
 diluted so as to contain three bacteria per drop, caused lactic 
 fermentation in all the vessels to which they were added. 
 
 The following experiments afford absolute proof that the 
 bacterium was the cause of the fermentation : — 
 
 ' On August 30 last (1877), having provided sixteen pure 
 glasses of boiled milk, and having estimated, in the manner 
 already described, the number of bacteria present in every -^^\\\ 
 minim of a glass of boiled milk, which had been inoculated the 
 day before by touching it with a heated needle dipped in milk 
 curdled under the influence of the pure ferment, I diluted a 
 drop of this milk with boiled water to the requisite degree, and 
 introduced into each of ten of the sixteen uncontaminatod 
 glasses a drop calculated to contain on the average a single 
 bacterium, while five of the rest received each a drop supposed 
 to contain two of the organisms, and the remaining glass was 
 inoculated with a quantity in which, according to the estimate, 
 there would be four bacteria. The result was that within 
 three and a half days the glass into which four bacteria were 
 supposed to have been introduced contained a curdled mass, 
 and tlie five which had received the drops arranged for two 
 bacteria each had all undergone a similar change. Of the ten 
 inoculated with drops averaging one bacterium each the 
 majority were at tliis period still fluid, but some assumed the 
 solid condition in the course of the next twenty-four hoTU's, 
 though at different times. P>ut of this series of ten, exactly 
 five, ns it so hapjwned. remained permanently fluid.' 
 
 Every glass in which curdling had occurred contained the 
 
•218 FERMENTATION. 
 
 bacterium lactis ; the five glasses in which the milk was 
 unaifected contained no organisms. 
 
 Hence it seems clear that when this organism is present in 
 milk lactic fermentation occurs. Where it is absent this 
 change does not take place, for, as jMr. Lister argues, we 
 could hardly suppose that an organic molecule or ferment 
 would occur exactly in the same cases as the organisms 
 appeared, unless there was some intimate relation between 
 them. If organic molecules, independently of the organisms, 
 were the cause of this fermentation, some flasks ought to 
 undergo lactic fermentation without the presence of any 
 organisms ; others ought to show development of these organ- 
 isms, but no lactic fermentation. 
 
 Other Feo'TJientations, especially the Putrefactive. 
 
 I may just refer more as a matter of historical interest than 
 of real use in this question to Lemaire's experiments with 
 carbolic acid and his opinions on fermentation.^ 
 
 Lemaire showed that the addition of carbolic acid to organic 
 fluids and tissues prevented putrefaction and other fennentations. 
 Carbolic acid, according to hira, did not interfere with the fermen- 
 tations caused by ' unformed ' ferments, such as synaptase, &c. 
 
 He then pointed out that the unformed ferments can act at 
 temperatures at which the other ferments are inert, as, for in- 
 stance, at zero and at 70° C. Trituration of yeast destroys its 
 fermenting power, w'hile trituration of emulsin does no harm. 
 In, fact anything that favours life favours alcoholic and 
 allied fermentations, while anything which is inimical to life is 
 also inimical to these fermentations, though many of these 
 things do not interfere with the action of ' unformed ' fer- 
 ments. 
 
 I have before referred to the experiments of Cazeneuve and 
 Livon on unboiled urine. 
 
 The method of obtaining the bladder with its contained 
 urine has been previously described ; and in the successful 
 experiments formerly mentioned on p. 37, no organisms were 
 
 ' L'ac'ulc plii'niqiic, 18(;5. 
 
CAZENEUVE AM) LI VOX. -JIU 
 
 found, while if the somewhat concentrated urine were removed 
 and diluted with ordinary water it became alkaline in twenty-four 
 hours, and filled with ' torulacee.' Results similar to those men- 
 tioned were obtained when the urine had been previously 
 rendered alkaline by the administration of soda or potash. 
 
 Puncture of the bladder was soon followed by alkalinity and 
 development of organisms in the urine : hence it is not the 
 absence of oxygen from the m-ine which is the cause of the 
 absence of change in it. The following experiment shows that 
 the merest trace of oxygen is all that is required, if indeed it 
 be at all necessary. 
 
 Prevent the evaporation through the walls of the bladder, 
 by immersing it, immediately on its removal from the body, in 
 melted paraffin at the temperature of 45° C. This temperature 
 is insufficient to destroy the germs which fell on the wall of the 
 bladder dming its transit from the abdomen to the paraffin.* 
 Thus a layer of paraffin covers the outside of the bladder, pre- 
 venting the rapid evaporation of the fluid which exudes while 
 living organisms are present on the wall of the bladder. In 
 twenty-fom' hours remove the paraffin case. It is then found 
 to contain an alkaline tmbid fluid full of organisms. These 
 organisms have not, however, had time in twenty-four hours to 
 penetrate into the interior of the bladder, and therefore the 
 urine inside is found to be still acid and devoid of life. The 
 same is the case with ttrine rendered alkaline — the fluid outside 
 contains organisms, that inside is free. 
 
 But let the bladder be first dipped in paraffin at 100° C, so 
 as to destroy any living organism in contact with the wall, and 
 then, after removing it from this paraffin at the end of a 
 minute, let it be plunged into paraffin at 45° C, so as to get a 
 thicker coat (this paraffin is previously heated to 110° C, and 
 during cooling is protected from the dust), it will be found that 
 even after three days the fluid outside the bladder — in the 
 paraffin cup — is still clear, acid, and devoid of organisms. Leave 
 this bladder now exposed to the air for say five hours, then 
 give it a new coating of paraffin at 45° C, and leave this on 
 
 ' 'I'lie reason why the organisms do not develop on tlie bladder Iiung up in 
 the air is tliat the fluid dries as soon as it exudes, and therefore tlie organisms 
 ha\e IKJ tluid in wliirh to develop. 
 
220 FERMENTATION. 
 
 for three days. The fluid outside the bladder will be found 
 in this case to be ammoniacal and to contain organisms. 
 Hence the walls of the bladder and the fluid in the interior 
 were not modified by the heated paraffin in the first part of the 
 experiment. 
 
 These experiments alone are sufficient to refute Liebig's view 
 of organic molecules and decaying matter ; for in the first part of 
 the experiment they were present in an unlimited amount, but 
 so long as organisms were excluded no fermentation occurred. 
 Their bearing also on the theory of spontaneous generation 
 will be at once evident, and has indeed been already alluded to. 
 I would only refer here to the experiments in which the urine 
 was made alkaline.^ and in which therefore we had a natural 
 alkaline urine full of organic molecules and in contact with the 
 tissues of the bladder, and yet no organisms appeared in it so 
 long as the dust of the air was excluded ; in other words, the 
 alkali had no influence in determining the re-arrangement of 
 the nur)ierous organic molecules ivhich were -present in the 
 wcdl of the bladder and in the fluid in its interior^ so as to 
 form new living beings. This is in exact correspondence with 
 Dr. Eoberts's results, and is a much more telling experiment. 
 
 Some very remarkable and convincing facts have been lately 
 obtained by Dr. Paul Bert.' 
 
 On subjecting the ' unformed ' ferments, such as ptyalin, 
 pepsin, inversive ferment, myrosin, find eraulsin to high degrees 
 of pressure, he found that the properties of these ferments were 
 not in any way impaired. 
 
 Thus to quote Experiment 467 : — 
 
 ' 21 Juillet 1 874. Saliva humaine etendue cl'eau et plac^e clans un 
 mairas etii^e a la lampe, et soumis k 15 atm. d'un air suroxygdne. 
 
 ' Le 30 Juillet je decompinme et soude I'extremit^ du tube effiI6. 
 
 ' 18 Janvier 187.^. Cette saliva qui ne. sent rien et parait bien 
 noi-male, neutre aux reactifs, transforme avec une grande 6iiergie 
 I'amidon cnit en glycose.' 
 
 It was proved by a former experiment (p. 201) that the amy- 
 lolytic property of ptyalin was not altered by diminution of 
 pressure, and the same is true when the pressure is increased: 
 
 ' La Pi-egsion haromvir'uiuc. 
 
PAUL BERTS EXPERIMENTS. 221 
 
 and, what is of great importance, other ferments of the same class, 
 which axe apt to lose their properties when kept, owing to the 
 occmrence of putrefaction, retain these after being subjected 
 to strong pressure if new causes of putrefaction are excluded. 
 The explanation of this fact is simply that the bacteria and 
 fungi are killed by the high pressure. 
 
 Bert also enquired whether these ferments could continue 
 to act, in this compressed air, and he found that though they 
 did continue to act the rapidity of their action was manifestly 
 diminished. Thus Exp. 470 : — 
 
 ' 20 Janvier. Salive, amidon cm et eau. Bien mele et place dans 
 plusieurs tubes. On s'assme que le melange ne contient pas de 
 glycose. 
 
 ' A — a la pression normale, bouche avec coiiiet de papier leu verse. 
 
 'B — a 21 atm. d'air suroxygene. 
 
 ' Tous les deux sont mis a I'etuve, 30 degi-es. 
 
 ' 25 Janvier. Essay e avec liqueur bleiie : — 
 
 ' A — 7ce en redui&ent 35 gouttes. 
 
 ' B — 7ce en reduisent 14 gouttes.' 
 
 This result was, however, not obtained unless the fluids were 
 examined within a few days. At a later period, especially if 
 diastase was employed, the contrary was found ; the fluid, 
 subjected to compression, containing more sugar than the other. 
 It was found that the explanation of this was that the diastase 
 which had remained exposed to the air had become altered, 
 owing to the growth of organisms in it, while organisms being 
 unable to develop in that subjected to high pressure, the 
 diastase had retained its properties and continued to act. 
 
 Paul Bert concludes : ' All the soluble false ferments with 
 which we have experimented, diastase, ptyalin, pepsin, inversive 
 ferment, myrosin, emulsin, have yielded the same result, and 
 liave retained their characteristic properties, after the prolonged 
 action of oxygen, at a high pressure. Indeed, as this compressed 
 oxygen destroys the germs of fungi, vibriones, &c., which 
 sooner or later destroy these ferments when exposed to ordinary 
 air, the latter remain unaltered for an apparently indefinite 
 period of time.' 
 
 If we now coni])iux' these f.icts with lliosc oblained by sub- 
 jecting the ' true ' ferments — those causing putrefaction, &c. — to 
 
2-2-2 FERMENTA TION. 
 
 high pressures, we shall find a remarkable contrast ; the latter 
 class of ferments behave under high pressures like living beings, 
 not like the unformed ferments just mentioned. 
 
 Bert says : ' The most striking face which has been made out 
 in these experiments is that, in air sufficiently compressed, 
 putrefaction does not occur, no disagreeable odour manifests 
 itself, and muscle, for instance, preserves its normal appearance 
 except in colour ; its microsco})ic structure is not markedly 
 altered.' 
 
 Thus Ex}). 404. ' 17 Mars. Viande en morceaux et eau ; dans 2 
 petits matias effilus a la laiiipe. A — a la pression noimale. 
 
 ' B, B' — a 16 atmospheres d'une compression faite avec de I'air 
 contenant 80 pour 100 d'oxygene. 
 
 ' 26 Mars. Decompiime. A, pouni, infect. B n'a pas d'odein- et est 
 neutre aux papiers reactifs,' 
 
 But this is not all ; for when one restores the pressure to 
 the normal, taking sufficient precautions to prevent the 
 entrance of new organisms from without, putrefaction no longer 
 occius, and unboiled meat may be preserved at the normal 
 pressure for an indefinite time after being subjected to high 
 atmospheric pressures. The precautions required to prevent 
 the entrance of organisms after the compression, and to ensure 
 the complete destruction of those present, are detailed on p. 184. 
 
 Exp. 407. ' 20 fevrier. On met dans 1.5 tubes 15 morceaux de 
 viande pesant chacun 1 gr. Ces tubes sent ensnite etires a la lamj)e et 
 soumis dans I'appareil en fer, a 15 atmospheres tr6s-siiroxygenes. 
 
 ' 3 Mars. On decomprime avec precaution et Ton ferme a la lampe 
 les 15 tubes. L'analyse de 3 d'entrc eux, faite aussitot, donne de 70 
 a 80 povir 100 d'oxygene. 
 
 ' 13 Mars. ' On brise nn des tubes sous le mcrcure : viande ambreo, 
 pas d'odeur, reaction acide. On trouve 6-2 pour 100 d'acide carbo- 
 nifpie et 77-8 d'oxygene.' 
 
 From a large number of experiments Bert finds that a pres- 
 sure of twenty-one atmospheres is sufficient to kill the organisms 
 which cause putrefaction. Similar facts were made out as 
 to fermentations in blood, eggs, urine, milk, alcoholic fermen- 
 tations, &c. A fact which he observed more especially in con- 
 nection with blood and milk, is worth mentioning. He found 
 that in the case of milk, as in the case of other substances. 
 
PAUL BERTS EXPERIMENTS. 223 
 
 putrefaction was arrested by compressed air. But if tubes 
 were used neither coagulation nor rapid acidification were 
 prevented. Was this because oxygen in tension was without 
 action on the bacterium lactis ? or was it that the coagulation 
 of milk was not the work of these microscopic organisms, but 
 rather of some agent which can resist oxygen, as we have seen 
 to be the case with the ' unformed ' ferments ? On further in- 
 vestigation, however, he found that the result depended on the 
 thickness of the layer of liquid. If it was thin the tendency 
 to coagulation was destroyed. 
 
 Exp. 431. ' 10 Aout. Lait bouilli ; mis £^n couche de 2 a 3 
 millimetres d'epaisseur dans deux cristallisoirs neufs et bien laves. 
 ' A — a Fair libre, sous un verre qui arrete les poussieres. 
 * B — a 25 atmospheres d'air suroxygene. 
 ' 14 Aoiit. Decomprime. 
 
 ' A est coagule depuis le 11 et sent tres-mauvais. 
 ' B est licjuide, ne sent aucune odeur et parait normal.' 
 
 Paul Bert sums up his results with milk as follows : ' These 
 experiments prove in a very conclusive manner that oxygen in 
 a state of high tension prevents the coagulation of milk, that is 
 to say, kills the vibrios which cause the lactic fermentation. 
 As the action of these organisms is very rapid, it is necessarv, 
 in order to arrest it, to employ oxygen at very high pressures 
 and to have the fluid in a thin layer, so that the oxygen can 
 saturate it quickly. In the case of putrefaction, which 
 occurs much more slowly, these excessive precautions are not 
 necessary ; milk differing from blood in not consuming the 
 oxygen as it penetrates the liquid, the gas has time to reach 
 the bottom of the tubes and to kill all the jjutrefactive agents 
 present. This fact explains how one can so easily, by means 
 of compressed air, prevent milk from putrefying, and yet have 
 so much difficulty in preventing its coagulation.' 
 
 It would be superfluous to pursue the })roof of this matter 
 further. The greater part of the preceding ])ortion of this 
 work has consisted of evidence which, taken together, can leave 
 no doubt on the mind that putrefaction, like other fermen- 
 tations, is caused by the growth of organisms in the putrefying 
 material Pasteur's researches have Itnl him further, and caused 
 
2-M FERMEXTATIOX. 
 
 liini to adopt a theory of fermentation which has certainly 
 many facts to support it, though I doubt if it can hold good in 
 many instances. He thinks that when a substance putrefies 
 two classes of microscopic organisms are at work, the first in 
 point of time being chiefly engaged in abstracting the free 
 oxygen from the material, and the second, which then appear, 
 being unable to live in free oxygen, but nevertheless requiring 
 oxvgen for their growth, and obtaining it from the chemical 
 combinations present. The result of this extraction of oxygen 
 is the breaking up of these compounds — their putrefaction — 
 and the rearrangement of their elements to form new com- 
 pounds, which constitute the products of putrefaction. Whe- 
 ther Pasteur's theory be true or not, all the experimental results 
 taken together, as well as the numerous facts known as to the 
 power of antiseptics in arresting this class of fermentations, 
 render it no longer doubtful that the particles which fall 
 into organic materials and cause fermentations there, are the 
 same as those which, falling on the same substances, give rise 
 to the lower forms of organisms ; in other words, are bacteria 
 or their spores. 
 
MICRO-ORGANISMS IN THE LIVING BODY. -255 
 
 CHAPTER XII. 
 
 RELATION OF MICRO-ORGANISMS TO THE FLUIDS AND TISSUES 
 OF THE LIVING BODY. 
 
 Proposed mode of enquir}^ — Does the aseptic method prevent putrefaction ? 
 Does it exclude organisms from wounds ? Ranke's results : Klebs' objec- 
 tion : Ranke's reply : Demarquay : Fischer : Schiiller : my own method — 
 Results in aseptic wounds — Results in wounds treated otherwise — Koch's 
 method of staining pus — Results in cases not treated aseptically — Exam^Dles 
 of complete exclusion of organisms in aseptic cases — Examples of the en- 
 trance of micrococci in aseptic cases — Definition of micrococci — Distinc- 
 tions between micrococci and bacteria. Are organisms present in the 
 healthy living body 1 — ' Bistournage.' Are organisms present in the body 
 in states of disease ? — Experiments with ammonia, phosphorus, &c. — The 
 healthy blood and tissues can destroy organisms — Relation of organisms to 
 abscesses. How do micrococci enter aseptic wounds ? Carbolic lotion a 
 sufficient germicide ; Spra}^, its value — Stimson's experiments ; Gauze dress- 
 ing as a protection against entrance of organisms ; Carbolic acid as a 
 germicide in albuminous fluids ; Relations of micrococci and bacteria to 
 fluids containing carbolic acid. Conclusions. 
 
 All the experiments which have been referred to as yet 
 relate to fluids and tissues removed from the body and pre- 
 served in flasks. It now remains, before quitting the subject, 
 to enquire if our conclusions hold good for fluids and tissues 
 retained in connection with the living body. An investigation 
 of this sort has been demanded by some writers, as, for instance, 
 by Mr. Holmes. At least that is what I take him to imply by 
 the following passage' (I can see no other meaning in it): 
 'When we are told that, in order to practise antiseptic surgery, 
 we must believe in the germ theory, then I cannot but say that 
 belief is not a voluntary act ; it must follow upon proof, and 
 no convincing proof of the germ theory as applied to living 
 tissues and living pheno7nena has, as far as I know, yet been 
 offered.' Granting that I inteqn-et Mr. Holmes' meaning 
 aright, I venture to differ from him as to the necessity for such 
 
 ' See MacC'ormac's Antisejjtic Surgery, p. 51. 
 Q 
 
226 FERMENTATION. 
 
 facts, but nevertheless I think it well to introduce here some 
 investigations which I have carried on with reference to this 
 question.' 
 
 The mode in which I propose to ascertain whether the 
 former conclusions apply to the living body or not is by the 
 examination, in various ways and under varying circumstances, 
 of fluids and tissues in the body. 
 
 We have before seen that the method which we have agreed 
 to term the aseptic method of treatment is nothing more or 
 less than a series of experiments on the germ theory of putre- 
 faction — experiments made with the object of rendering atmo- 
 spheric dust inert before it reaches the wounds. We shall 
 attain the object of the present enquiry by ascertaining how 
 far these experiments are successful. In discussing this ques- 
 tion the following points suggest themselves : — 
 
 Does the aseptic method of treatment prevent putrefactive 
 or other fermentations in the discharges or tissues of wounds ? 
 
 If putrefaction is prevented are organisms also excluded ? 
 
 If under any circumstances organisms do enter wounds so 
 treated, what are the peculiarities of these bodies ? 
 
 Are organisms present or do fermentations occur in fluids 
 or tissues in the living body, which have never been exposed 
 to the atmospheric dust ? 
 
 If organisms are present, how is their occurrence to be 
 explained ? 
 
 If organisms enter wounds treated aseptically how do they 
 get in ? 
 
 1. First, then, does this method prevent putrefaction ? Un- 
 doubtedly it does. Compare the course of an abscess, con- 
 nected with diseased bone, opened and kept open without 
 aseptic precautions, with that of one opened in accordance 
 with strict aseptic principles. In the former case the i)us 
 raj^idly undergoes fermentation, in all i)robability putrefaction ; 
 in the latter case the discharge does not undergo fermentation, 
 and remains sweet and pure till healing is complete, however 
 long that may be. I have at this present moment in my mind 
 such a case. A patient, a young woman, came under Mr. 
 
 ' For many details not luentioued here, see the Transactionis of the 
 Pathol nijica I Sorirty for 1879. 
 
MICRO-ORGANISM^'^ IN WOUNDS. 227 
 
 Lister's care in August 1876, with spinal disease and psoas 
 abscess. Subsequently a psoas abscess appeared on the other 
 side, and later a lumbar abscess also. I dressed the case almost 
 from the first myself, and though these dressings were changed 
 at first daily and then ultimately weekly for nearly four years 
 (for complete healing did not occur till June 1880, though 
 there had been, for a long time, only minute sinuses furnishing 
 almost no discharge), yet neither putrefaction nor any other 
 fermentation ever occurred in the discharge from these wounds. 
 Indeed, I may say, from long experience of Mr. Lister's practice 
 and from long use of his method myself, that one who has 
 had some experience in this method may now reckon with 
 certainty on avoiding putrefaction or other fermentative change 
 in discharges from any wound made in a situation where 
 aseptic dressings can be applied, provided always that the 
 treatment be strictly carried out by the method described at 
 length at the beginning of this work. 
 
 2. Such being the facts with regard to the absence of 
 putrefaction, is it equally the case that organisms are absent 
 from the wounds ? We saw a constant relation between the 
 bacterium lactis and the lactic fermentation : can similar facts 
 be found with regard to aseptic and septic wounds ? 
 
 The first communication on this subject was made by Dr. 
 Ranke,' of Halle, in 1874. He published a note of 300 exami- 
 nations of the discharge from fifteen wounds treated aseptically, 
 and following an aseptic course, in which he states that on only 
 one occasion did he fail to find organisms. His method was 
 v^imply to look at the discharge through a microscope, and it 
 was not a particularly high power which he employed. The 
 organisms which he says were present were for the most part mi- 
 crococci in pairs, also streptococci ; more rarely small or middle- 
 sized bacteria. He did not carry his investigations farther, but 
 on this evidence he rejects the germ theory as sufficiently 
 explaining the etiology of septic diseases. 
 
 While by some these observations have been regarded as 
 accurate and as confirming their previously formed views, by 
 many they have been looked on as erroneous, either from having 
 been made on cases in which the aseptic method had been 
 
 ' Chirurg. Centralhlatt, No. lii, 1874. 
 ti 1.' 
 
228 FERMENT A TIOX. 
 
 imperfectly carried out, or in themselves faulty. In answer to 
 objections of the former nature urged by Professor Klebs ' of 
 Prague, Dr. Eanke^ published another paper in July 1876, 
 quoting cases to show that the treatment had been in reality 
 properly carried out. He instances especially cases of hydro- 
 cele, treated by making a small incision into the sac with 
 aseptic precautions and stitching it to the skin, where cure 
 followed without any inflammation or constitutional disturbance, 
 but where, nevertheless, organisms were present in the dis- 
 charge. From those cases, as well as from the various pub- 
 lished reports of the results of Professor Volkmann's practice, 
 there seems no reason for doubting that the observations were 
 made on wounds treated with all due precautions, and following 
 an aseptic course similar to that which Mr. Lister himself 
 would expect. 
 
 About the same time Demarquay ^ published the results of 
 eight cases treated ' antiseptically,' in all of which organisms 
 were found. The general course of the wounds so treated, as 
 described by the author, and the fact that one of the eight 
 cases died of pyaemia, show that whether the cases were treated 
 antiseptically or no, they were not treated aseptically. 
 
 Two years later there appeared a paper by Dr. Fischer of Stras- 
 burg,'* giving the result of investigations carried on in Professor 
 Llicke's wards. He employed chemical tests, especially acetic 
 acid and glycerine, as recommended by Von Eecklinghausen, 
 and he found organisms in all the cases examined. He, how- 
 ever, states that bacteria were not imfrequently present, his 
 results differing in this respect from those of Dr. Eanke. Now, 
 it so happens, I spent the summer of 1876 in Strasbjirg, and 
 thus had frequent opportunities of seeing the ' aseptic practice ' 
 in that hospital, and 1 can only say that I was not sui-prised 
 when I heard that bacteria had been found in the wounds. 
 
 The last paper on this subject was published by Dr. 
 Schiiller^ in the spring of 1877. In his investigations at- 
 
 ' Archivfiir ExperimvtAclle Patholor/ie, Bd. iii. p. 315. 
 
 - Deutsche Zeitschrift fUr Ckirurgie, Bd. vii. p. 68. 
 
 3 Comjjics-Bendiis, 1874. 
 
 ' Deutsche Zeitschrift filr (,'hvnirfjic, Bd. vi. p. 320. 
 
 * Ihid. Bd. vii. 
 
EXAMINATION OF ASEPTIC WOUNDS. '2->U 
 
 tempts were made to cultivate organisms from wounds. He 
 found that in many eases organisms were absent both from the 
 discharge and the cultivating liquid, whilst in other cases they 
 were present. He does not specify what the nature of these 
 organisms was, and he is inclined to associate their presence in 
 wounds with the occiurence of tension, &c. There are various 
 objections to his results, but these I need not stay to discuss. 
 
 As long ago as 1876 I began a series of investigations on 
 this matter. My first observations were of the same nature as 
 those made by Dr. Fischer; that is to say, I not only examined 
 the discharges microscopically, but I also treated them with 
 acetic acid and glycerine. These substances are recommended 
 by Professor Recklinghausen for this purpose, the glycerine being 
 supposed to dissolve the fat granules and the acetic acid to 
 render the protoplasm invisible ; thus, only nuclei and micro- 
 organisms are left. On treating pus in this way I found that a 
 large quantity of granular matter remained, and, though I very 
 soon arrived at the conclusion that bacteria — i.e. rod-shaped 
 organisms — are not present in the discharge from cases treated 
 asejjtically, I could not say whether among the granular 
 matter seen there were or were not micrococci. This difficulty 
 is the greater as there is more granular matter in aseptic 
 wounds than in others. 
 
 I therefore soon commenced a series of cultivation experi- 
 ments. The following was the principle on which I acted. On 
 introducing a particular form of organism into a suitable pabu- 
 lum with precautions against the entrance of others, this form 
 of organism will grow there. This being the case, theoreti- 
 cally one would only require to inoculate some suitable pabulum 
 with various discharges — on the one hand to get a development 
 of organisms, on the other to find the fluid remain free from 
 organisms, and unchanged. Various preliminary experiments, 
 which I need not detail, established this. For the present 
 investigation some suitable pabulum must be taken, sterilised, 
 and inoculated under proper precautions with discharges from 
 wounds. If we have a really pure pabulum, and the inocula- 
 tion has been carried out in such a way as to prevent the en- 
 trance of any extraneous organisms, the inference, where 
 development occurs, would naturally be that organisms have 
 
280 FERMENT A TIOK 
 
 been present in the fluid from which the inoculation was made. 
 If, on the other hand, the same method has been employed, 
 and no organisms develop, the inference would be that no 
 ors^anisms existed in the fluid. 
 
 I first used milk, but for various reasons I gave it up, and 
 tried Pasteur's and Cohn's fluids, and, after reading Schiiller's 
 paper, Bergmann's ; but I found these artificial solutions too 
 insensitive to be of any value for my purpose. I then used 
 vegetable infusions, more especially turnip, and ultimately 
 infusion of cucumber, which last seems to be very sensitive. 
 I also employed in many cases an infusion f meat. 
 
 The infusion having been prepared, is filtered, introduced 
 by syphon into Mr. Lister's double-necked flasks, boiled for 
 twenty minutes, kept for some days (at least two) in an incu- 
 bator, and then decanted under a spray of carbolic acid into 
 smaller purified flasks, which are likewise placed in an incubator 
 for several days before being used. These flasks are covered 
 with cotton wool caps purified by heat or carbolic acid, or they 
 stand on a glass plate and are covered by a glass cap and a glass 
 shade, as described before in the case of Mr. Lister's liqueur 
 glasses. 
 
 For the purpose of inoculation, small capillary tubes, such 
 as those used for vaccination, were employed. These possess 
 the advantage over needles, in that, while they take up a larger 
 quantity of the discharge, they protect it from the carbolic acid 
 of the spray during the transit from the wound to the flask. 
 The tubes are dropped into the flask containing the cucumber, 
 and this is then placed in an incubator kept at the temperature 
 of the human body. (See Fig. 72.) 
 
 The procedure maybe shortly described as follows: — The 
 outer portion of the dressing having been removed under the 
 carbolic acid spray, a tube which has been previously purified 
 in carbolic lotion is heated in the flame of a spirit lamp in the 
 spray, so as to drive off all the carbolic lotion and to render it 
 dry. This tube is now rapidly introduced into the drainage 
 tube, and from thence immediately into the flask which is 
 opened in the spray close to the wound. The flask is then 
 placed in an incubator kept constantly at a temperature of 
 98° Fahr. In the case where flasks with cotton caps are used 
 
EXAMINATION OF WOUNDS. 
 
 231 
 
 it is well in performing an experiment to wet the margin of the 
 cap with carbolic lotion before lifting it, so as to prevent any 
 dust from falling from the cap into the fluid. This is a very 
 important precaution. 
 
 Having ascertained that the method proposed was perfectly 
 trustworthy, I proceeded to the investigation. 
 
 In performing the experiments I always inoculated two 
 flasks, and often another was taken and the whole process gone 
 through in the same place, with this difference, that the tube 
 in the latter case, when heated, was put directly into the flask 
 without touching the wound. These latter 
 flasks remained, without exception, clear. 
 
 When development occurs in the flasks 
 inoculated the fluid generally becomes 
 muddy in 30 to 50 hours, but where the 
 fluids remained clear I have kept them in 
 the incubator for weeks, and then tested 
 them by the addition of some substance 
 containing bacteria. 
 
 As a result, I find that in cases treated 
 aseptically, where of course there was an 
 unbroken skin to start with, one of two 
 things may happen — either the fluid re- 
 mains perfectly clear, without the develop- 
 ment of organisms, showing that none were 
 present in the wound ; or the fluid becomes turbid from the 
 presence in it of organisms of the form seen in Fig. 1, Plate I. 
 In both cases the wound may follow an aseptic course ; i.e. no 
 local or constitutional disturbance results from the operation, 
 and from the appearance of the wound one could not tell in 
 many cases whether these organisms were present or absent. 
 
 From Fig. 1 it will be seen that these organisms are minute 
 spherical bodies arranged in pairs ; in t riplets, in which case 
 they form a triangle (a very important point in distinguishing 
 them from other forms); in groups of four (positions which 
 bacteria never take up) ; also in short chains and groups of 
 larger or smaller size. In fact they belong to the group of the 
 Bchizomycetes termed micrococci. 
 
 I have said that in many cases one could not tell from the 
 
 Fig. 72. —Flask con- 
 taining CULTIVAT- 
 ING FLUID INOCU- 
 LATED FROM A 
 WOUND. 
 
202 FERMENT A TIOX. 
 
 course of the wound whether these organisms are present or 
 absent, but sometimes their presence can be suspected. Those 
 who have worked long at aseptic surgery will have met with 
 cases where when a dressing is left on for six or seven days, or 
 when adeep dressing is left for some weeks, the discharge acquires 
 a sour odour and the skin around the wound becomes somewhat 
 excoriated. As the wound in other respects follows an aseptic 
 course, Mr. Lister concluded that this was probably a chemical 
 change taking place between the discharge and the materials 
 in the gauze dressing. Knowing the peculiar property pos- 
 sessed by salicylic acid of preventing chemical fermentations, 
 Mr. Lister uses it in such cases with the effect of diminishing 
 or preventing this change. 
 
 In these cases I have always found micrococci. 
 If micrococci be grown in a small quantity (3 to 8 drachms) 
 of cucumber fluid, after three days they seem to die ; at any 
 rate, they will not grow in any liquid. But yet if the fluid be 
 kept for some weeks it will gradually become red, till it ulti- 
 mately is of a dark vermilion tint. Thus chemical changes 
 continue after the activity of the organism has ceased. May 
 not something of the same kind occur in these cases ? Chemical 
 changes are primarily set agoing by these organisms, but con- 
 tinue of themselves, and thus salicylic acid acts by preventing 
 these changes, as Mr. Lister supposed, though, according to 
 this view, the organisms are necessary for their commencement. 
 If now we contrast these results with those obtained in 
 wounds not treated strictly asej^tically we find this marked 
 difference, that in none of the latter were organisms absent^ 
 while in almost all bacteria as tvell as micrococci were present. 
 It is to be observed that in many of the cases antiseptics were 
 employed, both in the external dressings and injected into the 
 wound, but no precautions were taken either to penetrate to all 
 the recesses of the wound with the antiseptic so injected, or to 
 prevent the access of organisms during and after the dressings. 
 I may mention that in four cases which were originally 
 treated aseptically bacteria were found, but in all these their 
 presence was indicated by disagreeable smell or by symptoms 
 of local or constitutional disturbance. It is thus evident that 
 bacteria as well as micrococci can flourish under an antiseptic 
 
KOCH'S METHOD. 233 
 
 dressing. The explanation of their absence must therefore 
 be that the circumstances which permit of the entrance of 
 micrococci are not such as to allow the advent of bacteria. ■ 
 
 It was thus satisfactorily established that there was a very 
 marked difference between the discharges of aseptic wounds 
 and of those not treated aseptically. From the former, 
 organisms were generally absent till about the end of the case 
 when the dressings were left on for several days. In the 
 latter, organisms are ^present, even within the first twenty-four 
 hours. Again, in the former, when organisms did appear they 
 constantly belonged to the group of micrococci, in the latter 
 rod-shaped organisms were frequently present as well, and 
 generally in large quantities if there was any putridity in the 
 wound. 
 
 It was just possible that an objection could be brought 
 against these results to the effect that organisms might have 
 been present in the discharge of aseptic wounds, but that they 
 were unable to develop in the fluid used for cultivation. To 
 obviate this objection as far as possible I used a variety of 
 cultivating fluids and got the same results with all.- 
 
 During the spring and summer of 1880 I renewed the study 
 of this subject in a different manner. I adopted Koch's 
 method of staining bacteria ' and I employed it in all Mr. 
 Lister's cases from the beginning of March till the end of June 
 (four months), and my results confirm in every respect those 
 which I had got by the method of cultivation. 
 
 I find that, in the first few days after an aseptic operation no 
 organisms can be found in the discharge, and that, when they 
 ultimately do appear, they are micrococci, not bacteria. On the 
 other hand, after operations not performed aseptically organisms 
 are generally present from the first, and as a rule these consist of 
 bacteria as well as micrococci. 
 
 The principle of this method of staining is that various 
 aniline dyes, more especially metliyl violet, fuchsin and aniline 
 brown, stain chiefly the nuclei of cells and bacteria ; though these 
 are generally the only bodies stained, yet in some cases, especially 
 if the staining is excessive, other albuminous granular matter 
 may also become coloured. However, even where such is the case 
 
 ' See Cohn's Bcitr'dgc znr liiologif dcr PJianzcn. 
 
234- FERMENTATION. 
 
 the organisms can, as a rule, be easily recognised by their form 
 and arrangement. The pus or other fluid to be examined is 
 spread in a very thin layer on a cover glass or slide, and left to 
 itself to dry or dried over a spirit lamp. In the case of albu- 
 minous fluids it is well to do nothing more for at least twenty- 
 four hours. These cover glasses may be kept for months and 
 then used, for no organisms can grow on the dried materials. 
 
 In order to stain the specimens a few droj^s of a saturated 
 solution of methyl violet or of fuchsin in alcohol are added to 
 distilled water till a sufiicient depth of colour is obtained. This 
 can only be determined by experience, but it is well to stop be- 
 fore any precipitation can be detected. (Dr. Ogston recom- 
 mends a watery solution of methyl violet of the strength of 
 half a grain to the ounce.) A drop of this solution is allowed 
 to fl-ow over the cover glass, being retained in contact with the 
 material to be stained for about one minute. It is then washed 
 off with distilled water and the cover glass again dried as before. 
 When quite dry it is mounted in Canada balsam. 
 
 When aniline brown is used a concentrated solution in 
 glycerine i^ prepared. This is filtered, and one part of the 
 filtrate is added to an equal quantity of distilled water and an 
 equal quantity of pure glycerine. This mixture is now filtered and 
 is then ready for use. I find that this fluid, while it does excel- 
 lently for staining organisms in such fluids as cucumber, turnip 
 infusions, &c., does not stain them well in pus. I find it best 
 in the latter case to place a drop of the staining fluid on a slide, 
 then lay on the cover glass, the material to be stained being of 
 course lowermost. Leave this for twenty-four hours and then suck 
 out the staining fluid with filter paper, introducing in its stead 
 pure glj'cerine. This is a difficult process, and the specimens are 
 frequently not quite clean. However, if one examines the layer 
 attached to the cover glass, one sees what was in the material ; 
 the fragments which are floating free may consist of all sorts of 
 debris. The specimen is then surrounded with cement. 
 
 The results of these methods of staining are very beautiful. 
 If the staining is not too intense, only the nuclei of the pus-cells 
 and any organisms which are present are stained, and the latter 
 can be recognised with the greatest readiness with a sufficiently 
 high power. 
 
RESULTS OF THESE INVESTIGATIONS. 285 
 
 So much for the method. Plates I. to IV. illustrate the 
 results. 
 
 Let us take first some specimens from wounds which have 
 not been treated aseptically. Here it will be seen that there 
 are always organisms, and that these generally consist both of 
 bacteria and micrococci, though sometimes of one or other alone. 
 Look at any wound not treated aseptically, which has not united 
 by first intention, and which has been somewhat recently made, 
 and you will get this result. 
 
 Case \. — Fig. 2 is a specimen of the discharge taken from a com- 
 pound dislocation of the thumb a few days after the accident. The 
 wound had not been treated aseptically, and it had a very foul smell. 
 (The patient, by the way, died of tetanus.) Here a great variety of 
 organisms will be found — bacteria, bacilli of various kinds, and 
 micrococci. 
 
 Case 2. — Fig. 3 is a specimen of discharge taken from a wound of 
 the scrotum in which a small slough was Ipng. The wound was 
 syringed out daily with carbolic lotion 1-40, and dressed with boracic 
 ointment. The discharge had a very foul smell. Here there are 
 multitudes of minute bacteria, bacilli, and mici-ococci. 
 
 Case 3. — Fig. 4 was taken from a case in the out-patient room, 
 not treated aseptically. There was not much discharge and no jiutrid 
 odour ; rather a slightly rancid smell. Here well-marked liacilli 
 can be seen. Discharge taken on two occasions presented the same 
 appearance. 
 
 Case 4. — Fig. .5 was taken from a case of amputation of the thigh 
 which had been done two days previously, and had been treated by 
 irrigation, though I must say, for the credit of irrigation, not very 
 efficiently. Here there was a slight smell. Bacilli are present. 
 
 Case 5. — Fig. 6 was taken from a case of excision of the hijj-joint 
 where numerous sinuses existed previous to the operation, and whei-e, 
 therefore, there was no hope of eradicating putrefiiction. I dressed 
 this case myself, washing out all the sinuses daily with 1-40 carbolic 
 acid lotion, and applying boi-acic or salicylic acid ointment, and out- 
 side this boracic lint. The specimen figured was taken more than 
 four months after the operation, and contains numerous bactena ; 
 this, observe, although the wound had been treated assiduously for 
 months with antiseptics, but not aseptically. 
 
 At the end of March some pieces of dead bone were fdt, and 
 these were removed on April 1st. The wound and sinuses were 
 thorougldy washed out with chloride of zinc and dressed as before. 
 
230 FERMENT A TION. 
 
 The disoharge, taken two days later (on April 3rd), had a putrid odour, 
 and contained numerous large and small bacteria. 
 
 On the following day (April 4th) it presented the same appearance. 
 Sixteen days after this second operation (on April 17th) there were 
 still numerous bacteiia present 
 
 Case 6. — Take again a case of Syme's amputation performed on 
 March 9th, 1880, for disease of the ankle-joint. Several sinuses were 
 included in the flaps. Free drainage was employed, and salicylic or 
 boracic ointments and boracic lint. This case went on veiy well ; i.e. 
 there was at first a little odour, but this was very slight and soon 
 almost entirely disappeared. The discharge got less, and the wound 
 came to look somewhat like an aseptic wound. 
 
 Fig. 7 (March 15th, from drainage tube) shows chiefly streptococci 
 in pairs ; no typical micrococci, nor the colony form of micrococci ; 
 small bacteria ; a few long rods. 
 
 On March 17th the discharge taken from the drainage tube con- 
 tained chiefly oval bacteria ; also streptococci {i.e. spherical bodies in 
 chains) ; no typical micrococci ; a few long bacteria. 
 
 On April 12th the organisms were much less numerous, there being 
 only a few streptococci and bacteria. 
 
 April 14th, very few organisms — streptococci. 
 
 April 16th, I'ather more organisms than in the last — only strejito- 
 cocci. There had been a little retention of the discharge. 
 
 May 14th, a considerable number of streptococci; also a few oval 
 bacteria : drainage not quite perfect. 
 
 Here we see that organisms were present, but so long as the 
 discharge flowed freely away, they did not develop. When tension 
 occurred they grew. The wound did very well, and forms of micro- 
 cocci were the chief organisms present. 
 
 So much for examples of cases not treated aseptically. In 
 all cases organisms were present, and these were almost always 
 bacteria. The more putrid the discharge, the more numerous 
 and the smaller were the bacteria (Bacterium termo?). The 
 better the progress of the wound, and the better the drainage, 
 the fewer the organisms ; but nevertheless there was always 
 some form of organism present, and had I inoculated infusions 
 from them, I should certainly, according to my former extensive 
 experience, have got bacteria, as well as micrococci, to develop 
 in all cases. The significance of the diminution in number of 
 the bacteria in the last case is a point which I shall not discuss 
 here. I will merely state that in some wounds following a 
 
RESVLTS IN ASEPTIC WOUXDS. 237 
 
 very satisfactory course micrococci only can be found by this 
 method of examination.^ 
 
 Let us now look at cases treated aseptically. I shall only 
 mention a few instances, but I may state that I have examined, 
 in almost all cases, specimens of discharge taken at every dress- 
 ing with the same results as are illustrated here. 
 
 In the first place, I will give two cases which show that all 
 forms of organisms may be permanently excluded by strict asep- 
 tic treatment. 
 
 Case 7. — Take first the most testing case of all — one of em- 
 pyema. Here at each change of the dressings air is sucked in with 
 every inspiration, but when the dressing is done with aseptic pre- 
 cautions, this air has been acted on by carbolic acid. We shall 
 therefore see whether the spray is efficient in destroying organisms. 
 
 The case of empyema to which I refer was one of considerable 
 standing, and was opened aseptically on March 7, 1880. The cavity of 
 pleura was not washed out, and during the whole of the treatment no 
 carbolic acid or other antiseptic was applied to the interior. Hence 
 if organisms got in, they could develop just as freely as in a flask. 
 There were no organisms in the pus when evacuated. The dressing 
 was changed daily. 
 
 Fig. 8 is a specimen taken on March 15th, eight days after the thorax 
 was opened. This contains no organisms of any kind, neither bacteria 
 nor micrococci. Hence for eight days the spray had been efficient. 
 
 Fig. 9 was taken on April 13th, i.e. thirty-seven days after the 
 incision. Specimens examined in the interval were free from or- 
 ganisms, and here it will be seen that there are no organisms of any 
 kind. This result is the more convincing, as for some days there had 
 been a difficulty to the exit of the fluid, and some discharge was pent 
 up in the lower part of the thorax. This was let out on April 13, and 
 the specimen was taken from this fluid. Now my invariable experience 
 has been, that when such accumulation occurs, if organisms were 
 present before, they will be found in large numbers in the retained 
 fluid ; in fact they develop just as freely as if the fluid were in a flask. 
 A specimen taken on April 19th — i.e. forty- three days after the in- 
 cision — was also free from organisms. 
 
 This case seems to me an absolute proof of the efficacy of 
 
 ' In these cases, Ihou.^h iiiicrncocci alone could he found, yet cultivation ex- 
 periments would in all ))robal)ility have revealed the ijrosence oi' bacteria as 
 well. 
 
l>38 FERMENTATloy. 
 
 the spray in destroying the activity of the particles in the air 
 which give rise to organisms and fermentations ; for here the 
 action of the living tissues, to be afterwards discussed, could 
 not come into play — the fluid was under the same conditions as 
 if it had been in a flask placed in an incubator. The conditions 
 exactly correspond with my spray experiments (p. 26 et seq.). 
 
 Case 8. — Take next a case of incision into the knee-joint in a 
 case of gelatinous degeneration of the synovitil membrane before 
 suppuration had occurred. Mr. Lister has found that, in tliese cases, 
 free incisions on each side of the patella, and the insertion of a 
 drainage tube into the joint, olten brings about a cure without sup- 
 duration and without the necessity for further operation. It was so in 
 this instance. The incision into the knee was made, and drainage 
 tubes inserted, on May 10th. 
 
 On May 14th 7io onjanisms were present in discharge taken from 
 the drainage tube. 
 
 On May 16th, same result. Fig. 10 is a specimen taken on May 
 20th from the drainage tube : no organisms. 
 
 A specimen was also taken on May 20th from a plug of lymph 
 in a small chronic abscess beside the knee, opened on May 12th, and 
 here also there were no oiganisms. 
 
 On May 22nd there were still no organisms. 
 
 I might mention a number of cases to show that where the 
 dressing is frequently changed, organisms may remain absent 
 for a long time, or even altogether. Therefore where the 
 dressing is changed frequently, and where the various aseptic 
 precautions are thoroughly carried out, organisms never develop 
 in the discharges. 
 
 As a rule, however, the dressing is not changed so fre- 
 quently, and then, though organisms are absent at the com- 
 mencement of the case, they frequently appear towards its 
 termination. In that case, however, the organisms which 
 appear belong to the group of micrococci. 
 
 The following cases illustrate this. 
 
 Case 9. — I will t;»ke first a case treated strictly aseptically, and 
 following a typical ' aseptic course.' This case illustiates the entrance 
 of micrococci after some days. 
 
 The patient, a young man fet. 26, had suffered for a long time 
 from a sore on his leg, which had now become epitheliomatous. The 
 
MICROCOCCI IX WOUXIJS. 239 
 
 patient was very weak. Amputation was performed through the 
 middle of the thigh. The case followed a typical course. There was 
 no rise of temperature. The patient felt at once relieved by the 
 removal of the disease, and his appetite and strength began to improve 
 from the day of the operation. The wound healed by first intention, 
 except where the drainage tube was. When this was removed the 
 sinus became filled with lymph, and this becoming vascularised, 
 healing took place completely without the occurrence of granulation. 
 The amputation was performed on April 8th. 
 
 Fig. 11 was taken on April 9th (first dressing) from the drainage 
 tube. Xo organisms, but there is a good deal of granular matter. 
 
 Fig. 12, taken on April 10th from the drainage tube (second 
 dressing). No organisms. Less granular matter. Much less dis- 
 charge. The dressing was now left unchanged for two days. 
 
 Fig. 1 3, taken on April 1 2th from the drainage tube. Xo organisms. 
 
 The dressing was again changed on April 14th, and one or two bodies 
 were then seen which might be micrococci, but of this I could not be 
 certain. 
 
 Fig. 14, taken April 16th. A piece of lymph was clipped away 
 and rubbed over the surface of a cover glass. There was almost no 
 discharge. Line of incision soundly healed. The piece of lymph filled 
 up the place where the drainage tube was. (The drainage tube was 
 removed on April 14th.) Distinct micrococci; no bacteria; almost 
 no leucocytes — those that are present being badly formed. The 
 dressing was now left on for three days, and in a specimen taken on 
 April 19th from the little bit of lymph there was nothing hut micro- 
 cocci. No bacteria and no leucocytes. The dressing was now left on 
 for four days. 
 
 In another specimen taken on April 23rd, also from the lymph, 
 which had by this time become in the main vascularised, micrococci 
 were present in gi-eat numbers. No bacteria. 
 
 Here we see the typical result in a case where the ordinary 
 rule was followed of not changing the dressing till the dis- 
 charge comes to its edge. In this case displacement of the 
 dressing was the cause of the frequent changing of the dressing 
 latterly. For six or eight days no organisms appeared in tlie 
 discharge. When they did appear they were micrococci. 
 Bacteria never got in. Further, the micrococci, though lat- 
 terly present in enormous numbers, never caused suppuration 
 nor did they apparently interfere with the healing of the 
 wound. 
 
240 FERMENTATION. 
 
 Case 10. — Case of excision of the mamma and axillary glands for 
 sciirhus, done on March 19th. 
 
 Fi". 15, taken from the drainage tube on March 20th, contained 
 no organisms. 
 
 A specimen taken from the drainage tube on March 21st contained 
 no organisms. 
 
 A specimen taken from the drainage tube on March 22nd contained 
 one or two micrococci. 
 
 These micrococci were more numerous at the next diessing on 
 March 26th, and they were present in large numbers on March 31st 
 and on April 2nd ; no bacteria having appeared, as will be seen in the 
 next specimen. 
 
 Fig. ,16, taken on April 4th, when the wound was almost completely 
 healed. Here there were numeroics micrococci, but no bacteria. 
 
 In this case the micrococci got in earlier than we have yet 
 seen — viz. on the third day after after the operation — but never- 
 theless bacteria never appeared, and the wound did not seem 
 any the worse for the presence of the micrococci. 
 
 That micrococci may get in even earlier than this, if there 
 is but little overlapping and much discharge, is evident from a 
 case of removal of a small epithelioma from the cheek, where 
 only a small dressing was applied, which was left on for two 
 days. The discharge obtained on the second day — i.e. at the 
 first dressing — was found to be full of micrococci. The edges of 
 the wound were not brought together, but it became filled with 
 blood-clot, and healing occurred under this without any sui:>pur- 
 ation at all, and more rapidly than I have ever known it take 
 place in such a wound, and yet numerous micrococci were 
 present even from the first. 
 
 Case l\ also illustrates this. A keloid was removed from the 
 back of a man's neck on March 24th. A small dressing was applied, 
 but there was a good deal of discharge, which reached the edge of the 
 dressing a few hours after the operation. Specimen 17, taken at the 
 first dressing on March 25th, shows a few micrococci. 
 
 A specimen taken on March 28th (third dressing), and one taken 
 on March 31st, showed the presence of micrococci in large numbers, 
 but no bacteria appeared at any time. 
 
 And now I come to two cases illustrating very important 
 points as to the som'ce of these organisms. In these cases I 
 
MICROCOCCI IN WOUNDS TREATED ASEPTICALLY. 241 
 
 have examined the discharge, not merely in the drainage tube, 
 but at some distance from the wound, under the gauze dressing, 
 and I have found that, though there might be no organisms in 
 the wound, yet they might be present at the edge of the 
 dressing, and that micrococci had generally advanced nearer to 
 the wound than bacteria. 
 
 Case 12. — Excision of the mamma and axillaiy glands, done on 
 March 27th. 
 
 A specimen taken on March 28th from the drainage tube (first 
 dressing) contained no organisms. 
 
 Discharge was taken oh March 31st (third dressing) from the 
 dressing, at a considerable distance from the 'iround. The dressing 
 had not been changed for two days, and the discharge had readied 
 the edge some hours before the visit. This specimen contained both 
 micrococci and bacteria. 
 
 A specimen of the discharge taken at the same time from the 
 drainage tube contained 7io organisms. (See Fig. 18, Plate III.) 
 
 Examined again on April 2nd (from drainage tube, fourth dressing). 
 No organisms found. 
 
 Discharge taken on April 4th from the dressing, at some distance 
 from the wound, contains bacteria and micrococci. (See Fig. 19, 
 Plate Iir.) 
 
 Fig. 20 is from a specimen of the discharge taken at the same 
 time from the drainage tube, and contains no organisms. 
 
 A specimen taken from the sinus on April 6th contained no 
 organisms. 
 
 A specimen taken from the sinus on April 8th contained a few 
 micrococci. Wound ahnost healed, 
 
 A specimen taken at the next dressing from a piece of lymph over 
 the orifice of the sinus showed numeroiis micrococci. 
 
 Here we see that on March 31st organisms had penetrated 
 for a little distance under the dressing, but had not yet reached 
 the wound. 
 
 The same was foimd on April 4th ; but on April 8th a few 
 micrococci had got in, and having once got in they multiplied 
 rapidly. Bacteria did not (jet in. There was no change in 
 the appearance of the wound to show that anything hurtful had 
 entered. 
 
 Case 13. — This was a case of disease of the knee-joint treated like 
 Case 7, but hei-e there was necrosis of the patella before operating, 
 and extensive disease of tlio >)ones. As no improvement followed the 
 
 R 
 
242 FERMENTATION. 
 
 incisions, excision was performed on April Snd. The drainage tube on 
 the inner side passed in between the bones, and one was also introduced 
 into a hole gouged in the bone ; that on the outer side passed into an 
 abscess cavity in the soft parts. The case followed the typical course. 
 
 A specimen was taken on April 2nd from some curdy material 
 found in the interior of the joint. (It must be remembered that the 
 interior of the joint had been in communication with the outer world 
 for some weeks by means of a drainage tube, but there had never 
 been any suppuration in the cavity of the joint.) No organisms were 
 found, 
 
 A specimen taken on April 3rd from the drainage tuhe on the 
 inner side contained no organisms. 
 
 Fig. 21, taken on April 4th from the gauze at some distance from 
 the wound on the inner side. One or two micrococci ; no bacteria. 
 
 Fig. 22, taken on April 5th from the inner drainage tuhe, con- 
 tained no organisms. Contrast this with Fig. 21, taken from the 
 gauze on the previous day. In it there were a few micrococci at some 
 distance from the wound, but, as we see from Fig. 22, they did not 
 get in. 
 
 Fig. 23, taken on April 8th from the inner drainage tube con- 
 tained a, few micrococci. They had now reached the inner wound, and 
 in later specimens they were found in large numbers. 
 
 Fig. 24 is a drawing of a specimen taken on April 15th from the 
 outer drainage tube leading into the abscess cavity. This contained 
 710 organisms, although they were present on the inner side of the 
 knee on this same day in large numbers. This shows that the organ- 
 isms could not have come through the blood or developed spon- 
 taneously in the wound ; otherwise they ought to have been found 
 in the outer side as well as in the inner. 
 
 From these results — and these are only a sample of what I 
 have got by this method of investigation — and from my former 
 cultivation results (each method very important in its own 
 way), the difference which I have been led to establish between 
 wounds treated aseptically and those not so treated will be 
 evident. 
 
 Woundi^ treated aseptically are either free from organisras 
 or, if the latter are present, they are only micrococci. The 
 others ahvays contain organisons, and, in the great majority 
 of cases, these organisms are bacteria as ivell as m,icrococci. 
 
 III. If, under any circumstances, organisms do enter wounds 
 treated aseptically, what are their peculiarities ? 
 
PECULIARITIES OF MICROCOCCI. 243 
 
 The facts just stated under the second heading imply that 
 we have to deal in wounds with two great groups of organisms — 
 rod-shaped organisms, or bacteria ; and spherical organisms, or 
 micrococci. 
 
 Some, however, assert that there is no specific difference 
 between micrococci and bacteria ; and these observers would 
 say that the micrococci found in aseptic wounds are simply 
 bacteria altered in form by the new conditions in which they 
 are placed. Prof. Billroth, indeed, has gone so far as to assert 
 that there is only one species, coccos, in the group of Schizo- 
 mycetes ; that this may under varying circumstances assume the 
 form of bacterium or coccos, these two being transmutable into 
 each other. That micrococcus is an organism distinct from 
 bacterium, is denied by Hallier and doubted by Klebs, while it 
 is strongly affirmed by Cohn, Eindfleisch and others. 
 
 I am now thoroughly satisfied that micrococci are really a 
 class of organisms quite distinct from bacteria. I have observed 
 them and worked with them for four years, and I have never 
 yet met with an instance in which a micrococcus has become a 
 bacterium, or vice versa. 
 
 Before considering the evidence on this point, I may define 
 what I mean by micrococci. They are (following Cohn) 
 colourless or coloured round cells, very small, generally under 
 one micro^millimetre in size, with or without movement, grow- 
 ing in pairs, triplets arranged in triangular form, short chains or 
 groups of smaller or larger size, not derived from bacteria nor 
 developing into them. Other living sphericalbodies maybe found 
 in cultivating fluids, such as spores of fungi or, indeed, of some 
 forms of bacteria, as pointed out by Koch ' and Ewart ^ ; these, 
 however, when fresh nutriment is added, develop again into 
 fungi on tlie one liand, and into bacteria on the other. The 
 life history of micrococcus seems only to consist in development 
 from pairs to short chains or groups of larger or smaller size, 
 this cycle being repeated on the addition of fresh ])ahulum. 
 
 1 need not here enter into the general characteristics of 
 these organisms, but I may mention some facts which tend to 
 shew that they are distinct from bacteria. 
 
 ' Beitr'dffe zur Binlo<jie der Pflnnzen, Bd. ii., 1876. 
 ^ Microscojdcal Journal, vol. xviii. 
 K 1 
 
244 FERMENTATION. 
 
 Tiegel ' has pointed out, that if a fluid containing organisms 
 be made strongly alkaline with carbonate of soda, bacteria 
 quickly disappear and only a few micrococci remain, which also 
 ultimately vanish. This indicates a chemical difference between 
 the two forms. 
 
 A similar chemical difference has been incidentally referred 
 to by Koch ^ viz., that while 7)xicrococci are stained by haema- 
 toxylin, bacteria are not. 
 
 I have found that micrococci, when acted on by a strongly 
 peptic solution at the temperature of the human body, remain 
 unaffected, in contrast to ordinary albuminous granular matter, 
 which, as a rule, soon disappears. Many forms of bacteria^ 
 similarly treated, become aggregated into clumps, or may for 
 the most part disappear, only a few irregular rods and granules 
 remaining. Here again a chemical difference is evident between 
 the two groups of organisms. 
 
 Then as to their mode of growth. I have mentioned the 
 triangular arrangement of micrococci, and said that this is 
 typical of these organisms. This is supposed by Cohn to be due 
 to a looseness of the intercellular substance, allowing the cells 
 to become displaced. But then this an-angement is constant, 
 and Mr. Lister^ has by direct observation made out that it is 
 due to longitudinal division of the cells (Fig. 25). This is a 
 method of division which never occurs in bacteria. Here again, 
 then, in their mode of growth we have a marked difference 
 between the two. 
 
 ^Micrococci prefer acid fluids ; most bacteria prefer alkaline 
 or neutral fluids. 
 
 Micrococci grow readily, as we shall presently see, in fluids 
 containing proportions of carbolic acid in which bacteria only 
 grow with difficulty. 
 
 Then, lastly, direct observation has failed to show any trans- 
 formation of one into the other. I have specimens of micro- 
 cocci which have remained in cucumber infusion for ten months, 
 and they were just as perfect micrococci at the end of the time 
 as at the beginning. There was no transformation into bacteria. 
 
 ' Virchow's Arcliir. Bd. Ix. 
 
 - Traumatic infective diseases. 
 
 ' 'Tranxactiiins of flic Iloiial Socictij of Edinhnrf/h, vol. xxvii, 1875. 
 
PECULIARITIES OF MICROCOCCI 245 
 
 I figure three specimens to illustrate the same point, and in 
 the note on the next page I give a table of the series of experi- 
 ments. 
 
 The micrococci were obtained from a case of acute abscess 
 in the groin. When this abscess was opened some of the pus 
 was introduced into flasks containing meat and cucumber infu- 
 sions, but nothing developed. On the third day after it was 
 opened, the dressing having been left on for two days, another 
 flask of meat infusion was inoculated, and in this micrococci 
 developed. From this flask were obtained the micrococci in 
 the series of experiments tabulated below. They were culti- 
 vated for several weeks in a variety of fluids, but always remained 
 micrococci of the same kind and with the same effects on the 
 various fluids. 
 
 Fig. 26 represents the discharge from the wound from 
 which the micrococci were obtained, and is seen to contain 
 micrococci alone. 
 
 Fig. 27 is a drawing of a specimen taken from a flask of 
 vitreous humour, the third in the series, and here we find only 
 micrococci. 
 
 Fig 28 is taken quite at the end of the series (from c 1 7, 
 see note), after the organisms have grown in a variety of fluids 
 (eighteen in all), and yet here we have only micrococci, and 
 these are similar in appearance to the others. There was here 
 no development of micrococci into anything else. (I may just 
 call attention in passing to the proof of the efficiency of the 
 method of experimentation afforded by these results, and also 
 to the numerous arguments which can be drawn from them in 
 favour of the views I am advocating.) 
 
 Such are some of the facts which seem to me to show 
 that micrococci are distinct from bacteria, and they are a 
 sufficient answer to the question as to whether there is any- 
 thing special about the organisms found in wounds treated 
 aseptically. 
 
 It is only one well-defined class of organisms which enter 
 wounds treated aseptically, ivhile in other wounds all forms 
 may he found. 
 
 I will i.ot here enter on the question of the effects of these 
 micrococci nor will I stop to enquire why it is that no bad 
 
246 
 
 FERMENT A TION. 
 
 May 8th, abscess in groin, dresscj after two days, contains micrococci 
 
 I 
 Flask of meat, A, inoculated on May 3rd. 
 
 I May 6th 
 m2(:i) 
 
 I May 8tli 
 
 I 
 am 1 ^noth^ng) 
 
 vl (M) 
 
 Mnvintl 
 
 m 3 (M) 
 
 el 
 (nothing) 
 
 c 2 (M) 
 
 I Mnv 1 2th 
 
 I I I 
 
 e 2 c 4 (II) m 4 (M) 
 
 (nothijig) I 
 
 I May 14th 
 m5 (M) 
 
 I May 15th 
 in 6 (M)" 
 
 Mavl7th 
 
 e3 
 (nothing) 
 
 i I 
 
 c 5 (M) e 4 
 
 I (nothing) 
 
 1 May 19th 
 
 c e (M) 
 
 I May 2l3t 
 c7 (M) 
 
 I May 24th 
 c 8 (M) 
 
 e5 (M) 
 Cucumber (M) 
 
 eG 
 (nothing) 
 
 I 
 clO(M) 
 
 I May 3l3t 
 c 11 (M) 
 
 c 9 (M) 
 
 ^fav 28th 
 
 a c 1 (M) 
 
 I 
 hy 1 (afewM) 
 
 I I 
 
 (nothing) c 12 (M) 
 
 I June 3rd 
 c 13 (M) 
 
 I June 5th 
 m 7 (M) 
 
 I June 7th 
 c 17 (M) 
 
 Lost from having allowed four days to elapse liefore inoculating again. 
 
 In this list m = meat "1 • r • 
 
 J. infusion. 
 „ c = cucumber J 
 
 „ V = vitreous humour of sheep. 
 
 „ e = fresh egg. 
 
 „ am = alkalised meat infusion. 
 
 „ hy = hydrocele fluid (very concentrated), 
 
 „ M = micrococci present. 
 
LOCAL ACTION OF MICROCOCCI. i47 
 
 effects result from their presence. I shall content myself just 
 now with the following remarks. 
 
 It is certain that they do not cause putrefaction, but they 
 always cause a sort of sour, sweaty smell in fluids — a smell which 
 can be recognised in whatever fluid they grow : in other words, 
 they are associated with a peculiar fermentation. Now, the 
 products of this fermentation are but little irritating. They 
 have no acrid taste, nor do they feel pungent when applied to a 
 cut surface. Hence, probably, it is that we find that wounds in 
 which these organisms exist, even in large numbers, appear 
 often unaffected by their presence. 
 
 Nevertheless, they can hardly, under any circumstances, be 
 indifferent, and I think I have observed that, in some cases, 
 after they have got in, the wounds do not behave quite so 
 typically as usual; i.e. there may be a trace of suppuration, or a 
 sinus takes longer to heal than one had any reason to expect. 
 Again, if they get into a wound containing a piece of dead bone — 
 say, not yet loose — they will grow in its canals, produce their 
 sour products, and irritate the parts in the vicinity ; and thus 
 the bone, though not mechanically irritating, because not loose, 
 nor yet chemically irritating if it is quite aseptic, does become 
 somewhat irritating and loses its character of an innocuous dead 
 piece which may be slowly removed by absorption by the neigh- 
 bouring tissues, and becomes a foreign body which must be 
 thrown off. In such cases,- then, it would be of great importance 
 to exclude these micrococci if possible. 
 
 An instance which,! believe, illustrates this, occurred recently 
 in Mr. Lister's practice. We know that formerly, when hempen 
 ligatures were used, they always came away. If, however, they 
 are applied aseptically, they remain without causing suppura- 
 tion, as has been shown in JNir. Lister's cases. The wound heals 
 over them, and they may indeed ultimately disappear. But 
 here, as in the case of the dead bone, a necessary condition for 
 obtaining this result is, that the ligatures be perfectly unirri- 
 tating. In the case I refer to, Mr. Lister excised the thyroid 
 gland aseptically, having previously ligatm-ed the vessels, some- 
 what after Watson's method, with strong hempen twine. The 
 wound healed entirely by first intention, except where the drain 
 was, and this also had almost healed by the tenth day. For 
 
248 FERMENTATION. 
 
 some days previously, however, the dressing had been left 
 unchanged, and about the tenth day the discharge, though still 
 remaining in the main serous, increased in amount. This state 
 of matters continued till one by one the ligatures came away. 
 The ligatm-es, when examined, were found to have a distinctly 
 sourish *• micrococcal ' smell and an acid reaction, and under the 
 microscope their interstices were seen to be filled with micrococci. 
 Here we have a perfectly aseptic course for the first few days 
 till the time came when the dressings were left unchanged for 
 several days — till, in fact, as we have seen, micrococci got in. 
 When these organisms appeared they grew in the interstices of 
 the thread, produced their acrid products, and the thread was no 
 longer a substance which might become encapsuled or even dis- 
 appear by^absoi'ption, but it became an irritating foreign body, 
 which had to be thrown off before healing could occur. 
 
 In the same manner, if micrococci entered a healthy joint 
 where we have a cavity containing nutritious fluid, rather 
 in the conditions of fluid in a flask than in a cavity in the 
 living body, I would hardly regard their presence with satis- 
 faction ; for I should fear that their products would not be 
 altogether neutral to the sensitive synovial membrane, and 
 might, at the very least, cause increased secretion and delay 
 in healing. 
 
 These facts are of themselves sufficient to indicate the 
 advisability of taking all possible precautions to exclude these 
 organisms. Dr. Ogston has recently assigned much more 
 serious consequences to them, but the subject is at present too 
 debateable to be suitable for discussion here. 
 
 IV. Are organisms present or do fermentations occm' in fluids 
 or tissues in the living body which have never been exposed to 
 atmospheric dust ? If they do so occm*, how is their presence 
 to be explained ? 
 
 This question especially deals with the occurrence or not of 
 organisms in the healthy living body. I need not enter at 
 length into this question again ; I have twice already touched 
 on the subject. I have described the experiments by which it 
 has been shown that the blood, urine, and milk of healthy 
 living animals contain no organisms, and possess no inherent 
 tendency to undergo fermentative changes. Then I narrated, 
 
BISTO URN A GE. 249 
 
 both at p. 45 and at p, 196, my experiments on the tissues of 
 healthy living animals. I need not dilate further on this ques- 
 tion, but the conclusions to which we were forced were, that the 
 blood and tissues of healthy living animals do not contain 
 organisms or their spores, and have no inherent tendency to 
 undergo fermentation. But it may be objected that these 
 organs were removed from the living body and placed in flasks, 
 and that the conditions were not the same as if these tissues 
 had been retained in relation with the living body. Such an 
 objection is of no value, because any difference in the condi- 
 tions is in favour of organisms in the flask experiments, for 
 the walls of the flask are neutral to their development, 
 while healthy living tissues are powerful destroyers of bacteria. 
 This we shall see presently. In the meantime, I will now 
 bring forward a piece of evidence which completely sets any 
 such objection at rest. I refer to what is known as the ' ex- 
 perience du bistournage.' ' 
 
 This ' bistournage ' consists in rupturing the spermatic cord 
 subcutaneously by torsion. The testicle is thus separated from 
 its nutritious vessels, and lies loose in its tunics which protect 
 it from the access of the air. It adheres to the tunica vagi- 
 nalis, but the new circulation is insufficient ; the testicle 
 atrophies and disappears. There are no accidents, because, as 
 we have previously shown and shall immediately see, the air 
 with its dust — i.e. bacteria — does not get access to the dead 
 part. 
 
 M. Chauveau who is the author of these experiments, and 
 whose name is sufficient guarantee for their scientific accuracy, 
 proved this in the following way : — If the harmlessness of the 
 o))eration depends on the absence of the putrefactive organisms 
 which would be carried to the testicle by the air, then these 
 accidents ought to occur when the germs are carried to it by 
 the blood. Chauveau accordingly injected organisms into the 
 vascular system of rams. After the fever, sometimes fatal, 
 caused by this injection had subsided, he performed the opera- 
 tion of ' bistournage.' Putrefaction of the testicle occurred in 
 those animals which had been injected with bacterial liquid. 
 
 ' See Jeannel's book. Be VInfcction Pirnilc/ity, from whicli the facts are 
 taken. 
 
L^W FERMENTATION. 
 
 Several objections could be urged against the experiments, 
 and are answered by Chauveau : — ' 
 
 ' 1. Nothing proves that the bacteria in the fluid injected 
 were the active agents. But the experiment repeated after 
 careful filtration of the fluid by special filters — i.e. after removal 
 of bacteria or their germs, remained without effect. 
 
 ' 2. Nothing proves that it was not the infective fever itself 
 which caused the putrefaction of the organ. But of two rams 
 injected with the same fluid and the same dose, putrefaction 
 only occurred in the case where ' bistom-nage ' had been practised. 
 Still fm'ther, if in the same animal ' bistom'nage ' is practised on 
 the left testicle before injection, and on the right after injection, 
 the right testicle is the only one which putrefies : a proof, 
 evident and very ingenious, that it is indeed the penetration of 
 the putrefactive germs into the organ which determines putre- 
 faction ; since the testicle which was separated from the general 
 circulation before the injection remained indifferent, and did 
 not undergo putrefaction, in spite of the infection of the whole 
 body.' 
 
 I have also referred to several similar well-known facts at 
 p. 50 et seq., and Dr. Ogston has tested such fluids as extravasa- 
 tions of blood, haematoma, contents of pathological cysts, the 
 fluids of the natural cavities of the body, &c., by means of 
 Koch's method of staining, and he has failed to find any 
 organisms. I have also referred to Meissner's recent facts. 
 
 From all these considerations we may, I think, conclude that 
 organisms are not present in the fluids or tissues of the healthy 
 living body. 
 
 Are organisms present in the body in states of disease ? (I 
 leave out of account here the infective diseases.) If so, how is 
 their presence to be explained ? 
 
 If we investigate animals suffering from disease, we shall 
 find that in certain cases organisms are present. What these 
 exact conditions are I am not yet able to say, but I will indicate 
 some of the cases. 
 
 I have found that if an acute inflammatory process be in- 
 duced in an animal — say by the injection of ammonia — sub- 
 cutaneously, as pointed out some years ago by Dr. Burdon- 
 ' Quoted from Jeannel. 
 
ORGANISMS IN ACUTE INFLAMMATIONS. 251 
 
 Sanderson, the organs examined b}^ the method I have described 
 may be found to contain organisms. 
 
 I have in three instances produced ab^^cesses in rabbits by 
 the injection of croton oil, and in one case I have found that 
 the pus of the abscess contained micrococci and bacteria, though 
 none were introduced at the time. In one of the others I 
 found only a very few bacilli and in the third I found no 
 organisms. I shall detail the experiments. 
 
 Experiment 1, March 24th, 1881. — Pure croton oil was 
 introduced into a tube. This was then sealed at both ends, 
 placed in a sand bath, which was raised to a high temperature 
 (about 270° F.), and maintained at that temperature for about 2 
 hours. When it had cooled, one end of the tube was carefully 
 opened in a spray of carbolic acid, and a pure syringe being 
 rapidly introduced, some of the oil was sucked up, and at once, 
 in the same spray, half a minim was injected into the dorsal 
 muscles of a mouse. The skin of the mouse was very carefully 
 purified beforehand, and care was taken not to allow any of the 
 oil to escape along the needle track either in introducing or 
 withdrawing the needle. The puncture was dried with a 
 carbolised rag and then touched with collodion. 
 
 A flask of meat infusion was inoculated from the oil at the 
 same time. 
 
 On JNIarch 25th (26 hours later) the animal was found 
 dying, and was at once killed. Great care was taken, in remov- 
 ing the skin from the back, to avoid contamination of the 
 deeper parts. The muscles at the seat of injection were found 
 to be infiltrated with pus, but no trace of the needle track 
 through the skin could be seen. On examining this pus after 
 straining, it was found to contain large numbers of organisms, 
 chiefly micrococci, but a few bacteria and bacilli could be seen. 
 
 The meat infusion remained permanently pure. 
 
 Experiment 2, April 12th, 1881. — A mixture of equal parts 
 of croton oil and olive oil was purified and 3 minims injected 
 into the dorsal muscles of a large rabbit with the same pre- 
 cautions as in Experiment 1. A flask of meat infusion was 
 inoculated with this mixture at the same time but nothing 
 developed in it. 
 
 On April 18th the animal was observed to be ill, and it was 
 
2o2 FERMENTATION. 
 
 therefore killed. A considerable quantity of pus was found at 
 the seat of injection. On examination of this pus I found 
 numerous pus cells, but I have not been able to satisfy myself 
 that there are any micrococci. A very few bacilli were pre- 
 sent. 
 
 Ex'periinent 3, April 20th, 1881. — 2 minims of the croton 
 oil mixture used in Experiment 2 were injected into the dorsal 
 muscles of a large rabbit, with the usual precautions. 
 
 On April 25th, though the animal was perfectly well, I 
 killed it. On examining the seat of injection I found one or two 
 very small cheesy spots (small abscesses). These consisted of 
 pus cells and granular matter, but I have not been able to detect 
 organisms of any kind. 
 
 In each of the experiments the pus was stained with 
 methyl violet, according to Koch's plan, and examined with 
 Zeis's j:8th oil or ^th water immersion objectives. 
 
 Again, I find that if the nutrition of an animal be pro- 
 foundly interfered with, as in slow poisoning by phosphorus, 
 organisms may after some time be found in the blood and 
 tissues. Here, it may be said, inflammation of the intestinal 
 tract has been caused, and the epithelial barrier against the 
 entrance of organisms has been removed. But the blood and 
 tissues, ivheii in a healthy state, have the jpower of themselves 
 of destroying organisms when these are introduced into the 
 body. Thus, if into the veins of four medium-sized rabbits I 
 introduce ^, \, |, and 1 c.cm. respectively, of fluid containing 
 bacteria, keep the animals alive for at least twenty-four hours, 
 then kill them and preserve their organs in the manner described, 
 I shall probably find no organisms in the first three, while in the 
 last they may or may not be present. Where larger quantities 
 of the fluid have been introduced, they will certainly be found. 
 Thus, even though the organisms could gain access to the 
 blood, yet so long as the nutrition of the animal is fairly well 
 carried out, they would be destroyed.^ The reason that they 
 are found where large quantities of bacterial fluid are injected 
 seems to me to be that, along with the bacteria, their products 
 
 ' Similar facts have been made out by Traube and Gscheidlen. See a 
 paper by these authors, ' Ueber Filulniss und den Widcrstand der lebenden 
 Organismen gegen dieselbe,' Berlin. Klin. Wochcnschrift, No. 37. 
 
MICRO-ORGANISMS IN ABSCESSES. 253 
 
 are introduced, that these act in the same way as phosphorus, as 
 poisons, and that thus the resisting power of the animal is 
 diminished. 
 
 The conclusion which I would draw from these facts is, that 
 in severe inflammatory processes, or in great interference with 
 the nutrition of an animal, organisms may pass into the blood 
 without losing their vitality. The organisms usually found are 
 micrococci. 
 
 I have examined a large number of abscesses, in man, when 
 opened. At first I only used cultivating experiments, and 
 this paragraph gives the result of these. In chronic abscesses 
 I have not as yet found any organisms, and in this my results 
 agree with those obtained by Billroth by microscopical examina- 
 tion alone. Of acute abscesses I had up till May 1879 inocu- 
 lated from thirty-two cases. In twenty-five of these no growth 
 of organisms occurred, while from six micrococci were obtained. 
 In no case did I get bacteria (I omit here one abscess in the 
 ischiorectal fossa, where I found both bacteria and micrococci ; 
 and one with faecal odour in the lumbar region, from which I 
 did not inoculate when opened, but in which undoubted 
 bacteria were seen on microscopical examination). 
 
 Professor Billroth has paid special attention to this subject, 
 and he has found organisms in a larger proportion of acute 
 abscesses than I have done. Professor Billroth likewise only 
 mentions the occurrence of micrococci. In acute osteomyelitis, 
 Avhere a communication had not yet been established with the 
 external ah', organisms have been found in the medullary canal 
 or in the pus surrounding the bone by Von Recklinghausen,' 
 Klebs,^ Eberth,^ and Godlee.'* These organisms were as a rule 
 micrococci ; bacteria have but very rarely been present. 
 
 In 1880 Dr. Ogston,-^ of Aberdeen, published an elaborate 
 and careful research on the relation of micrococci to abscesses. 
 In examining pus and discharges for organisms he made use of 
 Koch's method, before described. In the first place, he found 
 as I had done, that micrococci were not present in clironic 
 ' iJnttsche Zeitschrift, Bd. iv. p. L':>;i. 
 ' rffiber Si'hii.<tx)ninde/i, 1871. 
 ' Virchow's ArcJiir, V>d. Ixvi p. .Stl. 
 
 * Lancet, November 2], 187-1. 
 
 * I'lililislied in Lanpenheck's Archir, I'.d. xxv. llefl ,'5. 
 
2b-L FERMENT A TIOX. 
 
 abscesses. In acute abscesses, however, he states that these 
 organisms are always present. This fact, obtained by staining 
 the pus, differs, as will be seen, from my cultivation results, and 
 agrees more with Billroth's results from simple microscopical 
 examination. 
 
 Since this statement was made I have examined a number 
 of abscesses by staining the pus obtained when they were 
 opened, and T now quite agree with Dr. Ogston. Organisms 
 are always absent from chronic abscesses. Micrococci are 
 always present in acute abscesses. 
 
 Fig. 29 (Plate IV.) is a specimen taken from a chronic 
 abscess over the sternum. It contains no organisms. 
 
 Figs. 30 and 31 are taken from acute abscesses — one of the 
 mamma, and the other of the finger. These contain micrococci. 
 
 In one case of abscess in the neck, which had been forming 
 for about three weeks, I could find no organisms. The skin was 
 red over it, and I have entered it in my notes as an acute 
 abscess. In another case, which I have also in my notes as an 
 acute abscess, no organisms were found. This was a case of 
 small abscess in the thigh, in a situation where diseased bone 
 had formerly existed. The patient positively asserted that the 
 abscess had only been forming for fourteen days, but it is of 
 course quite possible that it had existed longer, and had only 
 begun to point for fourteen days. Nevertheless the man's 
 jDositive assertion — for I questioned him again after I saAV that 
 no organisms were present — the redness of the skin, the well- 
 formed pus cells, and the absence of fatty debris make it 
 difficult to assert that this was a chronic abscess. 
 
 Notwithstanding those two doubtful cases, I am ready to 
 accept Ogston's statement and to receive it as a law, that if 
 the pus taken from an acute abscess when opened be examined 
 after staining, micrococci will always be foimd. 
 
 How, then, are my former results to be explained ? By 
 cultivation, from thirty-two cases of acute abscesses I only got 
 micrococci in seven instances, and yet we now know that had I 
 stained the pus I should in all probability have found micrococci 
 in all. 
 
 Well, in my recent investigation I not only stained the pus, 
 but tried cultivation experiments, and I got much the same 
 
MICROCOCCI IX ACUTE ABSCESSES. 255 
 
 results as formerly : in some cases micrococci grew, in others I 
 got nothing. It seems, as far as I can judge from my facts, 
 that if the abscess is opened soon after its commencement 
 micrococci almost always develop. If, however, ten days or 
 a fortnight or more elapse, these organisms do not as a rule 
 grow. Why is this ? Simply, I believe, because the organisms 
 have died. 
 
 I made out early in this investigation, and have often con- 
 firmed it since — sometimes, indeed, to my great inconvenience 
 — that micrococci very soon exhaust the nutritive material in a 
 fluid, and that they then fall to the bottom and die, for they 
 will not grow in any fluid nor increase on the addition of fresh 
 nutriment. In a flask containing say an ounce of cucumber 
 or meat infusion, the micrococci grow rapidly, but they do not 
 live more than three days. Then they fall to the bottom, and 
 the fluid at the top becomes clear and remains so permanently. 
 Take a drop from the flask during the first three days and put 
 it into another specimen of pure cultivating liquid, and micro- 
 cocci develop readily. After the third day or later, in pro- 
 portion to the amount of the fluid, no development occurs 
 whatever one does. The organisms are dead. And so in an 
 abscess they live as long as they find nutriment, and then they 
 die and cannot be obtained on attempting cultivation, though 
 they may still be seen on microscopical examination. 
 
 Ogston relates similar facts, though he apparently does not 
 attach this meaning to them. He remarks that when micro- 
 cocci are cultivated in flasks containing such fluids as urine, 
 ascitic, ovarian or hydrocele fluid, blood, &c., the fluid at the 
 surface remains for months clear, while a slight de2:»osit, which 
 consists of micrococci, is present at the bottom. He concludes 
 that the micrococci are growing away from the air, and that 
 therefore they are anaerobes. This is not the case, for micro- 
 cocci grow with greater rapidity and luxuriance in pure oxygen 
 than under any other circumstances which I have yet tried. 
 The truth, I believe, is, that these organisms were at first not 
 quite dead, but had very little vigour and soon cea?ed to grow 
 and died. They were not growing away from the air. 
 
 His results in cultivation from abscesses confirm mine, for 
 he says: 'Often the micrococci grew luxuriantly, sometimes in 
 
25G FERMJ^NTA TIOX. 
 
 chains and sometimes in groups, but oftener the experiments 
 were unsatisfactory, and it indeed happened that the micrococci 
 which were introduced died altogether.' Now had Ogston put 
 these two facts together, and had he worked for long with 
 cultivation, he would, I venture to think, conclude as I do, that 
 the micrococci which are found in abscesses, but which will not 
 develop in the cultivating fluid, are already dead in the abscess 
 and do not die only on removal from it. 
 
 The following fact may be mentioned as bearing out this 
 view : — 
 
 Fig. 32 (Plate IV.) was taken from a case of acute abscess 
 in the groin, which was opened on April 29th. A number of 
 streptococci will be seen. Nevertheless, a flask of meat and 
 one of cucumber inoculated at the same time remained quite 
 barren. A specimen was taken from the same case at the next 
 dressing, April 30th. There was plenty of discharge in the 
 drainage tube, but this contained almost no organisms. Had 
 the organisms been alive on the 29th, they would probably 
 have been as numerous, if not more so, in the interior of the 
 drainage tube on the 30th. 
 
 So far, then, I conclude, that though micrococci are always 
 present in acute abscesses, yet if the abscesses be not opened for 
 some time, these organisms will be found to have died. I shall 
 not enter here into the question of the relation between 
 these organisms and the abscesses in which they are found. 
 The facts are sufficient for my present purpose. 
 
 It thus seems, that in certain states of low vitality and in 
 acute inflammations, organisms may be present in the blood 
 and tissues of animals. These organisms are generally micro- 
 cocci. 
 
 V. How do organisms get into wounds treated aseptically ? 
 There are three possible explanations which might be offered : — 
 1. They come from the blood. 2. They arise spontaneously in 
 the wound. 3. They come from without through some insuffi- 
 ciency in the aseptic method. 
 
 1. They come from the blood. We have already seen that 
 organisms are not present in the blood or tissues of the healthy 
 living animal, but that they may occur in low or inflammatory 
 states. But a person on whom an o})eration has been performed 
 
MICROCOCCI IN WOUNDS TREATED ASEPTICALLY. 257 
 
 aseptically is, after the effects of the chloroform have passed off, 
 and provided that there has been no great loss of blood, practi- 
 cally as well as before the operation. There is no inflammation 
 and no febrile disturbance — the patient, as far as one can 
 judge, ought to be as able to resist the entrance of organisms 
 into his blood as before the operation. 
 
 If, however, these micrococci did enter the wound from 
 within, they would do so during the first few days after the 
 operation ; but if we look at the cases described, and the same 
 thing can always be found, we see that these organisms do not, 
 as a rule, enter for several days after an operation — not till the 
 dressings are but infrequently changed. 
 
 In the case of acute abscesses opened early, and in which 
 the micrococci are still alive, they of com'se exist from the 
 first ; and so they may occur if for any reason acute inflam- 
 mation attacks a wound. But that this is their mode of en- 
 trance in ordinary cases is against all the evidence. 
 
 2. As to spontaneous generation. We have discussed that 
 at such length at various places that I need not enter into it 
 again. The facts with regard to the absence of organisms 
 imder certain circumstances and the constant presence of a 
 particular form when they do occur, together with the points 
 to be presently mentioned, sufficiently do away with any neces- 
 sity for considering a view which can only be thought of where 
 other and more natural modes of origin cannot be traced. 
 
 3. We must then search for some mode in which they 
 might enter through the antiseptic arrangements. These we 
 may divide into three parts : a lotion in which the various 
 substances are soaked before being brought into contact with 
 the wounds ; a spray to purify the atmosphere ; and a dressing 
 so constituted as to give off carbolic acid to the discharge as it 
 passes under it. 
 
 That the lotion is sufficiently potent to destroy organisms 
 which come in contact with it, will be very evident to any one 
 who chooses to examine the subject. If one places a prepara- 
 tion of actively moving bacteria under the microscope, and 
 allows a little carbolic acid lotion, 1 in 20, to flow under the 
 cover-glass, the movements will be seen instantly to cease ; 
 this, in fact, is the method which I formerly employed when I 
 
 s 
 
268 FERMENTATION. 
 
 wished to draw moving bacteria with the aid of the camera 
 lucida.* 
 
 That the spray is sufficient has already been shown by a 
 nmnber of experiments described at p, 2& et seq. (see also the 
 case of empyema, p. 237). 
 
 An attempt has been lately made by Dr. Lewis Stimson ^ to 
 show that the spray does not act as a germicide, and as his 
 results have been extensively quoted, I must briefly notice 
 them here. Three tubes were filled with urine, boiled, and 
 allowed to cool in the spray and then exposed in it for an hour 
 and a half, the floor being swept to raise the dust. The tubes 
 were then closed with plugs of cotton -wool wet with alcohol. 
 Particles of dust were seen to be caught on the edge of the 
 tube, and a purified glass rod was used to push them into the 
 fluid. In one tube in which this was done bacteria developed. 
 In another case the tube was tilted so as to bring the fluid in 
 contact with the neck, and here also development occurred. 
 The third tube was undisturbed and remained pure. In 
 another set of experiments wide-mouthed beakers were used, 
 and were exposed for three-quarters of an hour. In all of 
 these organisms developed. Test experiments showed that 
 these organisms had entered during the exposure. 
 
 These experiments do not, however, seem to be satisfactory. 
 We are told in the first case that the spray was placed a foot 
 above and 3^ feet distant from the tubes, and that fifteen 
 ounces of carbolic lotion, 1-20, were used. During half the 
 time a board was placed so as to throw the spray back over the 
 flasks. Now if the flasks were only beneath the spray, a foot 
 distant from it, during half the period of exposure — the result 
 cannot be wondered at, for eddies would be produced by the 
 spray which would drive unpurified dust into the vessels. If, 
 however, the spray passed directly over the mouths of the flasks 
 — if these were enveloped by it — it is difficult to conceive that 
 the spray could have played for so long at such a close dis- 
 
 ' Dr. Koch has found that the sjMires of Bacilhis Anthracis can resist 1-20 
 watery sohition of carbolic acid for"a considerable time, though the fully de- 
 veloped organisms are at once destroyed by it. Micrococci, however, are very 
 susceptible to the action of this antiseptic. 
 
 2 Shown to the New York Surgical Society, November 2/5, 1870. 
 
THE SPRAY AS A GERMICIDE. 259 
 
 tance, and that so much lotion could be used without the 
 entrance into the urine of a quantity of carbolic acid more than 
 sufficient to render it sterile. But granting that the method 
 is correct in these respects, Stimson sweeps the floor, raises 
 large masses of dust luhich he can see, and expects that as 
 these fall through the spray they will be soaked through and 
 through, and any organisms in their interior be destroyed ! It 
 never has been asserted that a mass of filth falling through a 
 spray can be soaked completely in a moment by tjie acid. We 
 do not sweep the floors while performing a surgical opera- 
 tion. 
 
 All that I assert is, that under ordinary circumstances the 
 spray is thoroughly efficient. From this point of view it is in 
 the niain a question of size of the particles which the spray meets 
 with. If these are minute and but little compact, they will be 
 disinfected. If they are large and dense, as will be the case if 
 the floor be swept during or immediately before the experiment, 
 one could not expect the spray to soak through them sufficiently 
 during their transit. There is another way, however, in which 
 the spray may act on these larger particles — viz. by bedewing 
 the surface of the wound, and thus keeping up the action on 
 the dust which began during its transit through the spray. In 
 fact, the particle of dust already moistened while passing 
 through the spray, falls into a thin layer of carbolic lotion, and 
 thus disinfection is completed. As a rule, however, particles of 
 dust which are small enough and hght enough to float about in 
 the atmosphere, such particles as are present in ordinary rooms 
 or wards, will, as far as I can judge, be acted on directly in a 
 sufficient manner by the spray, for they will not fall straight 
 through it, but will be carried along with it after being moist- 
 ened with carbolic acid, and thus time is afforded for the 
 thorough action of the antiseptic before they reach the wound. 
 If these organisms got in through fault of the spray, we can 
 hardly imagine that they would always be micrococci. We 
 must, therefore, examine the action of the dressing in order to 
 see if any explanation can be obtained there. We shall see 
 that it can, and that these organisms do enter on account of 
 failure of the dressing to fulfil ail requirements for a lengthened 
 period. 
 
 s 2 
 
260 FERMENTATION. 
 
 As I have already shown, it is generally at a late period in 
 the treatment of a case that these organisms appear ; generally 
 where the dressings have been left on for several days ; or 
 where the discharge has reached the edge some hours before 
 changing it ; or, if they occur early, it is when the discharge 
 which has come through has been considerable, although the 
 dressing has been changed early; and thus I have been able in 
 some cases to prevent the entrance of these organisms by 
 changing the, dressings daily, and, conversely, they are easily 
 enough obtained in any given case simply by dressing it less 
 frequently. This will be readily seen from the cases quoted 
 before. 
 
 If such a fluid as milk be tested with the view of deter- 
 mining the amount of carbolic acid which must be added in 
 order to prevent the development of organisms, it will be found 
 that a large quantity is necessary. Thus, they readily develop 
 in a proportion of carbolic acid and milk, 1-60, and I have 
 grown them in as large a proportion as 1-54. On examining 
 the milk while the carbolic acid is being added, a granular pre- 
 cipitate will be seen to take place. In the same way, if car- 
 bolic acid is added to serum or white of egg^ a white precipitate 
 occurs, and here also a large proportion of carbolic acid is 
 necessary to prevent development. In artificial cultivating 
 liquids — such as Pasteur's fluid — no precipitate takes place, and 
 a much smaller quantity of carbolic acid is required to hinder 
 the growth of organisms. In other words, where carbolic acid 
 is added to an albuminous fluid, a compound is formed which is 
 but little antiseptic. So in the case of the antiseptic dressings, 
 where there is profuse discharge — though the first which comes 
 through may not be putrescible, yet very soon the carbolic acid 
 is not present in sufficient quantity to prevent the develo})ment 
 of organisms ; and, as carbolic acid is very volatile, when a 
 dressing is left on for several days, a considerable amount of 
 carbolic acid will have also escaped by evaporation, and thus the 
 meaning of the following rules of treatment, derived from ex- 
 perience, becomes evident : ' A dressing must not be too small.' 
 ' The dressing must not be left on longer than twenty-four hours 
 after the discharge has appeared at the edge.' ' In no case is it 
 safe to leave a dressing unchanged for more than eight days.' 
 
RELATIONS OF MICROCOCCI TO CARBOLIC ACID. 261 
 
 Experience has shown that any marked disregard of these rules 
 will, in all probability, be followed by putrefaction in the 
 wound. 
 
 But this still leaves unexplained why it is that micrococci 
 only are found in wounds treated aseptieally. At first the only 
 hypothesis which I could think of was that micrococci can grow 
 in j3uids containing carbolic acid in larger quantity than those 
 in which bacteria can develop. I have accordingly performed 
 numerous and elaborate experiments to test this view, but I 
 have been quite unable to find any such difference in the first 
 instance. An observation which I made in the course of these 
 experiments seems, however, to furnish the clue to the mystery. 
 I had previously observed that where one flask was inoculated 
 with bacteria and another with micrococci in like amount, that 
 which contained the bacteria was, as a rule, muddy in from twelve 
 to twenty hours (the quantity of fluid in each flask being 5iij to 
 3iv), while thirty to fifty hours elapsed before the fluid in the flask 
 into which the micrococci had been introduced became opaque. 
 But if carbolic acid, say in the proportion of 1 to 500, be pre- 
 viously added to this fluid, the result is just the reverse : the 
 flask containing the micrococci becomes opaque in twenty-four 
 hours, while that containing the bacteria does not become muddy 
 till a later period. Following out this line of investigation, I 
 have found that if micrococci and bacteria be introduced together 
 into a cultivating fluid containing carbolic acid, the micrococci 
 will develop rapidly, often to the complete exclusion of the 
 bacteria. Where no carbolic acid is present, the result is 
 generally the reverse ; most forms of bacteria grow quickly, the 
 micrococci being often apparently prevented from developing. 
 But, it may be said, in the former case the bacteria became con- 
 verted into micrococci. But if the same bacteria be introduced 
 into a flask containing no micrococci, bacteria alone develop. 
 
 So in the room in which I work, I have never been able, 
 without the aid of the spray, to transfer micrococci from one 
 flask to another. For in the latter flask bacteria almost in- 
 variably developed. But if carbolic acid be previously present 
 in the fluid, the operation may be done in the most leisurely 
 manner, with practically a certainty of obtaining micrococci 
 alone or chiefly in the second flask. 
 
t>fi2 FERMENTATION. 
 
 It is thus apparent that though bacteria and micrococc can 
 grow in fluids containing like amounts of carbolic acid, yet the 
 micrococci find these liquids more suitable for their growth 
 than do bacteria ; indeed, they may grow more rapidly in them 
 than in fluids containing no carbolic acid at all, and therefore, 
 when bacteria and micrococci fall together into discharge con- 
 taining carbolic acid, the latter develop with much greater 
 rapidity than the former, and may thus reach the wound long 
 before them. If, however, sufficient time be allowed to elapse 
 before the changing of the dressing, bacteria also may enter the 
 wound. 
 
 One other observation completes this subject. The largest 
 proportion of carbolic acid in cucumber infusion in which 
 organisms develop is from 1-450 to 1-500. In one of the 
 last experiments performed with the view of seeing whether 
 micrococci could grow in a larger proportion of carbolic acid 
 th:m that sufficient to prevent the development of bacteria, I 
 used micrococci which were growing in a fluid in which a small 
 quantity of carbolic acid was already present. This was done 
 on April 14th. On examining the flasks on April 15th, I found 
 one containing carbolic acid in the proportion of 1-400 quite 
 opaque from the development in it of micrococci, while those in 
 which a larger proportion of carbolic acid was present remained 
 clear. On the same day I inoculated from flask 1-400 a new 
 series containing carbolic acid in the following proportions : 
 C 1-400, C 1-350, C 1-300, C 1-250. On April 16th, C 1-350 
 and C 1-400 were quite muddy from the presence of micrococci ; 
 while C 1-300 and C 1-250 were clear. That afternoon, afresh 
 series, C 1-350, C 1-300, C 1-250, C 1-200, was inoculated 
 from C 1-350. On April 17th, C 1-300 and C 1-350 were 
 muddy. Here the limit seems to have been reached. For 
 though I have obtained slight development in carbolic acid 
 and cucumber 1-275 and 1-250, this is not vigorous. As the 
 micrococci grow in larger proportions of carbolic acid, they 
 become much larger, and the grouping and mode of growth 
 described by Mr. Lister are more evident. 
 
 The facts then seem to be that the discharge, when profuse, 
 or when it arrives at the edge of a dressing which has been left 
 on for some days, does not coatain sufficient carbolic acid to. 
 
MICROCOCCI IN WOUNDS TREATED ASEPTICALLY. 263 
 
 prevent the development of org-anisms in it ; that micrococci, 
 which I find to be more abundant in the ward atrtiosphere 
 than bacteria, find this a particularly favourable medium for 
 growth ; and that as they grow they increase in vigour, and 
 become more able to live in fluids containing a larger propor- 
 tion of carbolic acid, and thus, if time be given them, they will 
 eventually reach the wound. 
 
 Since these investigations were made, I have been able to 
 demionstrate the spread inwards of organisms under a gauze 
 dressing. Look for a moment at Case 12, p. 241. A specimen 
 of the discharge was taken on March 31st, from the gauze 
 dressing near the edge, and was found to contain micrococci 
 and bacteria. No organisms had, however, as yet reached the 
 wound (see Fig. 18, Plate III.). This dressing was removed, a 
 new dressing applied, and the organisms had to begin again 
 at the edge. Fig. 19, taken from the dressing near its edge, 
 and Fig. 20, taken from the drainage tube four days later, 
 illustrate the same thing. Here also the organisms were pene- 
 trating inwards under the dressing, but had not yet reached 
 the wound, and it was not till two days later that the first 
 traces of micrococci appeared in the wound. 
 
 The same thing is demonstrated in Case 13, p. 242. Here 
 Fig. 21, Plate III. is a specimen taken from the gauze near the 
 wound, and it contains a few micrococci : they had not, how- 
 ever, reached the wound, and did not do so till some days later. 
 
 Then, again, I have been able to keep out these organisms 
 simply by dressing more frequently so as to anticipate them 
 before they reach the wound, as may be seen in the case of 
 empyema, &c. And Dr. Ogston does not find micrococci in his 
 aseptic cases, because he dresses much more frequently than 
 Mr. Lister, never allowing the discharge to appear at the edge 
 of the dressing at all. 
 
 It will not, however, be always necessary that the discharge 
 should appear at the edge, for if a dressing be left on for several 
 days sweat accumulates under it, and will serve the same pur- 
 pose as the serous discharge in conducting organisms inwards. 
 
 At the same time it is possible that organisms may oc- 
 casionally enter the wound from the blood, especially in the 
 conditions of interference with the healthy state which were 
 
■Jdi FERMENTATION. 
 
 formerly alluded to ; and it is also possible that they may enter 
 from fault in the aseptic precautions, though I think this must 
 be exceedingly rare. For it is difficult to imagine that in the 
 latter case only micrococci would get in ; indeed, in faulty ex- 
 periments with cultivating fluids, it is almost invariably some 
 form of rod-shaped organism which appears. 
 
CHAPTER Xlir. 
 
 ANTISEPTIC SURGERY. 
 
 Complete definition of antiseptic surgery. Varieties of antiseptic surgery. 
 Tkeatment by antiseptics : Carbolic acid — objections to it : Chloride 
 of zinc: Boracic acid: Sulphurous acid: Chlorinated Soda: Alcohol — • 
 Hutchinson's method : Terebene and Sanitas — Bilguer's method — Neu- 
 dorfer's salicylic powder. Free drainage as an antiseptic method. 
 Irrigation and immersion. Open method: Modes in which it acts 
 antiseptically : Bartscher and Vezin's method : Burow's method : Rose's 
 modification. Healing by scabbing : Methods of forming a crust : 
 Bouisson's ventilation method : other modes. Gtjerin's cotton-wool 
 DRESSING. Modes in which the destructive action of the 
 tissues on bacteria is assisted. Why does not fermentation alwaj's 
 occur in the blood in wounds in which organisms are present ? Best 
 practical methods. Conclusions. 
 
 We have now arrived at the end of our discussion as to what 
 are the particles which cause putrefaction ; what are the exact 
 enemies with which we have to contend in attempting to 
 prevent putrefaction. We have seen that it is from particles 
 falling into fluids or on tissues that organisms develop. We 
 have seen that it is only after the access of particles from the 
 outer world to such fluids and tissues that fermentations occur, 
 and we have satisfactorily demonstrated that the particles 
 which cause fermentations and those which give rise to organ- 
 isms, are one and the same — in other words, fennentations are 
 due to the growth of organisms in fluids or tissues. We have 
 also seen that these same laws, with one exception, to be pre- 
 sently mentioned, hold good when the fluids or tissues are con- 
 fined in the living body, just as when they are in flasks, viz., 
 that the particles which cause putrefaction and other fermenta- 
 tions only rarely enter such substances through the circulation, 
 but generally reach them directly from the air or from sur- 
 rounding objects ; that so long as an animal is healthy, dead 
 
L'GG ANTISEPTIC SURGERY. 
 
 fluids or tissues may remain uufermented in closed cavities in 
 the body, and may even entirely disappear, but that as soon as 
 atmospheric air with its dust is admitted, organisms develop, 
 and fermentations occur. We are now therefore able to take a 
 much wider view of the meaning of the term ' Antiseptic Sur- 
 gery ' than is generally done. It is no longer surgery which 
 only excludes the causes of putrefaction ; we may now include 
 under the term all those methods of ivound treatment in 
 which, luittingly or othertvise, the growth and fermentative 
 action of the lower forms of organisms {bacteria^ are m^ore or 
 less impeded. 
 
 When we come to look at the numerous methods of wound 
 treatment from this point of view, we shall see that there is 
 perhaps none at present employed, with the exception of the 
 poultice dressing so much lauded by Mr. Savory, which does 
 not in some way or other, however imperfectly, interfere with 
 the growth and fermentative action of bacteria, and which does 
 not owe its chief virtues to that cause. 
 
 I shall not enter into details on all these methods, for their 
 number is legion, but I shall discuss the modes in which this 
 interference with bacteric action may be carried out under 
 several headings, and indicate briefly the principles which 
 ought to guide the surgeon in carrying out one or other 
 method. 
 
 The antiseptic methods which merely interfere with the 
 development and fermentative action of organisms on the fluids 
 and tissues in wounds, and which do not aim at their total ex- 
 clusion, may act on various principles. 
 
 1. By the addition of various antiseptics to the discharge, 
 either in the wound, or after it flows out, this discharge may be 
 rendered an unfit soil for the development of organisms. — Use 
 of antiseptics. 
 
 2. The discharge may be allowed to flow away so rapidly as 
 not to have time to undergo fermentation to any extent in the 
 wound itself. — jPree drainage. 
 
 3. This removal of the discharge may be facilitated by 
 washing it away constantly with water alone, or with water 
 containing antiseptics. — Treatment by irrigation or by water 
 buih. 
 
TREATMENT BY ANTISEPTICS. 267 
 
 4. By freely exposing the discharge to air evaporation 
 takes place, and the fluid becomes too concentrated to permit 
 the growth of bacteria, while, at the same time, by supplying 
 these organisms with plenty of oxygen, they have no necessity 
 to break up the albuminous compounds in their search for 
 oxygen, and thus, as shown by Pasteur, their fermenting power 
 is diminished. — Open treatment. 
 
 5. By keeping the parts at perfect rest and by operating 
 only when the patient is in good health, the tissues and the 
 blood are in such a state as to resist the development of bacteria 
 in the thin layer of lymph between the cut surfaces, and 
 union by first intention thus occurs. This is best carried out 
 hy perfect rest and accurate apposition of the cut surfaces. 
 
 Healing hy scabbing acts on the last two principles. 
 
 Although these various methods may be described as acting 
 on these different principles, yet there is no hard and fast line 
 between one and the other. Indeed, at the present day advan- 
 tage is now constantly gained from the use of the various 
 principles combined — as, for instance, by the employment of 
 free drainage, antiseptic irrigation, cS:c., in the open method. 
 As these methods are so very numerous, and as they are gene- 
 rally modified by every surgeon who employs them, few indeed 
 using them on the true principle, I think it will be best 
 merely to make a few remarks under each heading, and then 
 when we come to the historical part we shall be able to fill up 
 blanks in the following description. 
 
 I. — Methods hy ivhich various Antiseptics are added to the 
 Discharge, so as to hinder the Developjment of Organisms 
 in it. 
 
 What are the best antiseptics to use for this purpose ? 
 
 Carbolic acid is the one most frequently employed, but, in 
 my opinion, it is by no means the best in this instance. We 
 have already seen that in vegetable infusions, where carbolic 
 acid is present in the proportions of 1-200 to 1-250 all further 
 growth of organisms is prevented, but that in such fluids as 
 serum, milk, pus, &c., the acid forms a compound with the 
 albumen, and a much larger proportion is required. Thus, in 
 
•2GS ANTISEPTIC SURGERY. 
 
 milk, carbolic acid in the proportion of 1-54 is just enough 
 to prevent development. In accordance with this fact, a very 
 strong solution would be required in the case of wounds, or it 
 must be added in large quantities, in order to prevent the 
 development of micro-organisms. 
 
 And so my own experience of carbolic acid as a disinfectant 
 in the form of a 1-40 watery solution in putrid cases is un- 
 favourable, while, on the other hand, if 1-20 carbolic acid be 
 used, it is very irritating, and interferes with healing. In- 
 jected once or twice a day, the latter destroys the superficial 
 granulation cells, and produces a thin slough in which bacteria 
 develop, and from which it is very difficult to dislodge them. 
 Then its poisonous qualities are objectionable, and are of 
 course much more evident when the acid is injected into 
 wounds or abscess cavities than when used in the manner de- 
 scribed in the chapters on aseptic surgery. 
 
 Further, Dr. Wilhelm Hack,^ in a paper on the power of 
 absorption by granulations, has demonstrated that granulations 
 treated with carbolic acid possess many of the qualities of a 
 recent wound as regards absorption. For instance, apomorphia, 
 which was only absorbed by wounds treated with water dressing 
 during the first twelve hours, was readily absorbed at any time 
 by granulating wounds treated with carbolic acid ; and therefore 
 in the absence of information to the contrary, I should fear 
 that some of the poisonous products of putrefaction might be 
 absorbed with like avidity. Hence, I do not like carbolic acid 
 unless it is used aseptically. 
 
 Chloride of zinc applied to the cut surface has been already 
 alluded to. A single application has the remarkable property 
 of preventing putrefaction in a wound for some time after an 
 operation ; sometimes, indeed, till granulation is nearly com- 
 plete. It is further useful, according to Hack's experiments, 
 in that the slough caused by it does not permit the absorption 
 of substances from the wound. When used in the treatment 
 of wounds, a dilute solution (1 or 2 grs. to the ounce of water) 
 is employed. 
 
 Boracic acid is too weak an antiseptic to be of much service 
 
 ' Ueber das Resorpt ionsvermogen granulirendcr Fliichen. L ipzig, 1879. 
 
TREATMENT BY ANTISEPTICS. 269 
 
 as an injection, but the boracic ointment and the boraeic lint 
 act well as dressings. 
 
 One of the best antiseptic lotions is made with sulphurous 
 acid. This is a powerful germicide. It is also non-irritating 
 and perfectly free from any poisonous qualities. It is used as 
 a solution which is made by mixing together equal parts of 
 the sulphurous acid of the pharmacopoeia and water or glycerine. 
 This may be still further diluted if necessary. 
 
 The chlorinated soda solution is mentioned by Dr. Cabot as 
 standing next to 1-20 carbolic lotion in rapidity of action on 
 bacteria. The strength generally employed is 5ss. to 5J of 
 water. 
 
 Alcohol is not a bad antiseptic, but in order to be effectual, 
 it must be used strong. It has a further advantage, for Dr. 
 Hack has shown that gi-anulations treated with alcohol do 
 not absorb at all or only very slightly ; and to this may be 
 attributed, to some extent, the favourable course of the cases 
 in which wounds are simply washed out with an alcoholic solu- 
 tion, and a rag, dipped in the same solution, applied outside. 
 
 Mr. Jonathan Hutchinson, more especially, has had remark- 
 ably good results from the use of alcohol. His method is as 
 follows : — Having carefully arrested all haemorrhage, chiefly by 
 torsion, he washes out the wound with pure spirit. He then 
 carefully arranges drainage tubes at the most dependent parts, 
 and stitches up the rest of the wound. Thin compresses soaked 
 in a lotion composed of 6 parts of absolute alcohol, a half part 
 of liquor phmibi, and 16 parts of distilled water, are now ap- 
 plied. These compresses are kept constantly moist, either by 
 a nurse or by means of a drop irrigator. The lint is changed 
 daily. In the treatment of important cases, such as com- 
 pound fractm'es and dislocations the rule observed is, never to 
 allow the skin to become warmer than natural. His wounds 
 generally heal by first intention, and septic poisoning is very 
 infrequent. 
 
 In some of these cases no doubt the wound may be aseptic 
 from first to last. To apply an antiseptic to a wound, to stitch 
 up immediately, and then keep an antiseptic dressing con- 
 stantly applied, is really to operate more or less aseptically,. 
 and I believe, with regard to INIr. Hutchinson's cases, that this 
 
270 ANTISEPTIC SURGERY. 
 
 partly explains the good results — the wound being aseptic, at 
 least for a time. Then Hack's results have a strong bearing 
 on these cases, for absoq^tion does not take place readily. 
 Mr. Hutchinson is also very particular to have free drainage, 
 which powerfully helps to maintain the aseptic condition ; 
 and lastly, he carefully selects the cases for operation, only 
 operating, unless in cases of necessity, where the patient 
 is in good health. This selection of cases is a thing not 
 necessary and not done where complete aseptic treatment is 
 employed. 
 
 The method which I should think was the best, acting on 
 this principle, is the following; it is practically what Mr. 
 Lister employs with excellent results, only I would reject the 
 carbolic acid. After the wound has been made, and before any 
 stitches are inserted, the raw surface ought to be thoroughly 
 sponged over with chloride of zinc solution (40 grs. to the oz. 
 of water). In the case of operations on the extremities, this 
 is best done before the tourniquet is relaxed,- so as to ensm-e its 
 thorough application, for otherwise the blood would wash away 
 the solution or dilute it before it has had time to act. Silver 
 wire stitches are then inserted — special care being taken to en- 
 sure free drainage, by the use of large drainage tubes. As a 
 dressing in the first instance, till the bleeding has stopped, 
 several layers of wet boracic lint (wet in boracic lotion) are 
 applied. 
 
 On the day following the operation, the lint is removed, the 
 surface of the wound is thoroughly cleaned with sulphurous 
 acid or chlorinated soda lotions, or with Hutchinson's lotion, 
 and the drainage tubes are washed out with the same, though 
 not removed. The dressing is now a narrow strip of the sali- 
 cylic, eucalyptus or full strength boracic ointments, thinly but 
 evenly spread on calico, and outside this, overlapping it in all 
 directions, one or more broad layers of boracic lint. 
 
 On the second or third day, the drainage tube is removed, 
 and is washed in 1-20 carbolic lotion, the wound being then 
 syringed out with the sulphurous acid or other lotion. After a 
 day or two the ointment over the line of incision is changed to 
 the half-strength boracic, or if salicylic or eucalyj)tus ointment 
 was used, they are retained. These di-essings are changed daily 
 
FREE DRAINAGE, 271 
 
 at first, but when the discharge diminishes, they may be left 
 for two days. 
 
 Terebene and sanitas are remarkably good applications 
 where the smell is bad. 
 
 The results of this treatment are of course not so perfect as 
 those of the aseptic method, for, however carefully one washes 
 out the wound, there are pouches in it into which the fluid does 
 not enter, and pieces of slough cannot of course be disinfected. 
 Thus, prolonged suppurations may occm-, caries may continue 
 without tendency to cure, and even accidental wound diseases 
 (pyaemia, &c.) attack the patient. 
 
 With regard to the use of chloride of zinc, I ought to say 
 that it is well not to apply it to wounds which must, if pos- 
 sible, heal by first intention, as, for instance, in incisions about 
 the lips or face. 
 
 It was on this principle, as we shall see, that Lemaire em- 
 ployed carbolic acid and coal tar ; and his results, though very 
 good, by no means correspond to those obtained by strict aseptic 
 treatment. 
 
 It was also on this principle that good results followed the 
 use of balsams of various kinds in olden times. The most re- 
 markable example of the success of such attempts at rendering 
 the wound secretions incapable of putrefaction by the use of 
 balsams, was that of Bilguer in the last century. No doubt 
 where the wound is shallow, and possesses few recesses, and 
 where the balsam or other antiseptic employed fills up these 
 recesses, we have really an aseptic treatment and an aseptic 
 result. 
 
 By sprinkling powdered salicylic acid on wounds till no 
 more fluid passes out, Neudorfer manufactures a paste under 
 which he says that healing may occur without suppuration. 
 
 II. On Free Drainage as an Antiseptic Method. 
 
 I have already discussed the main principles of drainage 
 under the head of aseptic sui'gery. It is quite clear that, if dis- 
 charge flows away as fast as it is formed, there can be no marked 
 development of bacteria or of their products. The free drains <'-e 
 
272 ANTISEPTIC SURGERY. 
 
 of a wound from which organisms are not from the first excluded 
 is therefore of the utmost importance. I have already de- 
 scribed the use of india-rubber tubes, and I have referred to 
 catgut and horse-hair. Since, in a wound not treated asepti- 
 cally, fermentation, most probably followed by suppuration, 
 generally occurs in the track of the drain, we must provide such 
 a drain as shall permit the free escape of pus. Now, neither 
 horse-hair nor catgut can drain pus, and, therefore, a tube of 
 some kind or other must be used. This may be an india- 
 rubber one, or it may be made of various kinds of metal, per- 
 forated at its sides, and cut flush with the surface. The tube, 
 of whatever material, must be removed from the wound at each 
 dressing and washed with a strong antiseptic lotion, say 1-20 
 carbolic lotion. If this be not done, portions of decomposing 
 tissue, &c., remain inside the wound, and become more and 
 more putrid till very soon they become caustic. 
 
 Where the wound is not treated aseptically, the principle of 
 having the most dependent opening possible must be carried 
 out to the full. 
 
 III. Irrigation and Immersion. 
 
 The principle of free drainage is never of course used alone, 
 other principles act along with it. Of these, one of the most 
 satisfactory is that in which the discharge is not merely allowed 
 to flow away, but is washed away, and the further addition to this 
 principle of adding an antiseptic to the water used for the irri- 
 gation and of thus keeping the wound constantly bathed in an 
 antiseptic fluid. The latter is the form in which irrigation and 
 the water bath are now always employed, viz., by the use of an 
 antiseptic solution. 
 
 Irrigation is, as a rule, only practicable on the extremities, 
 though it may be carried out on the trunk. P'or the latter, 
 however, the continuous water bath is the most convenient. 
 
 The wounded part having been arranged at perfect rest, a 
 sheet of mackintosh is fastened to the limb, and so arranged 
 that the fluid flowing from the wound shall be conducted to a 
 tub ; the vessel containing the fluid is fixed at a considerably 
 higher level than the patient. The form of irrigator most 
 
IRRIGATION AND IMMERSION. 
 
 273 
 
 generally used at the present time is Esmarch's. This consists 
 of a cylindrical leaden or zinc vessel, which has a ring at its 
 upper part to enable it to be affixed to the wall. From the 
 side of this vessel, close to its bottom, a tube passes, and to the 
 end of this tube is fastened a long piece of india-rubber tubing 
 with a nozzle at its end. This nozzle is arranged so as to 
 direct the fluid into the deeper parts of the wound. The fluid 
 used is generally some weak antiseptic solution, such as chlori- 
 nated soda or sulphurous acid, or boracic acid. 
 
 A very good apparatus can be made in an emergency (accord- 
 ing to Thiersch) by knocking the bottom out of a champagne 
 bottle, and having the tube for conveying 
 away the fluid passed through the cork. The 
 bottle is inverted, filled with the solution, 
 and fastened to the wall. The fluid used 
 may be tepid or cold, as we shall see later. 
 There is no advantage in using it very cold, 
 as recommended by some. 
 
 Where the fluid is dropped on to the 
 wound, it is well to place a piece of lint 
 over the part where the drop falls, to pre- 
 vent the constant irritation caused by the 
 concussion. The skin in the neighbour- 
 hood of the wound ought to be coated with 
 palm oil, in order to prevent maceration. 
 
 The continuous bath is either a bath in 
 which the whole patient can be immersed, 
 or one in which the wounded part alone is 
 placed. There are numerous methods of 
 doing this, and the references to these will 
 be given in the history of the subject. 
 
 The advantages of the treatment by con- 
 stant irrigation are, that the discharges are removed as fast as 
 they form, and at the same time, where an antiseptic is em- 
 ployed, the part is kept constantly sweet. Thus, where the 
 cavity is small and uncomplicated, there may be a truly aseptic 
 state of affairs. 
 
 At the same time, where tepid water is used granulation is 
 favoured, while pain and nervous irritation are very much 
 
 T 
 
 Fig. 73. — Thiersch's 
 champagne bottle 
 irrigator. 
 
274 
 
 ANTISEPTIC SURGERY. 
 
 diminished. Fartlier, the parts are kept at absohite rest, the 
 necessity of moving them in order to change dressings, &c., 
 being avoided. 
 
 As an antiseptic means, 1 should think that satisfactory 
 irrigation is lietter than the continuous water bath, for in the 
 latter there is not the same constant change of fluid, nor the 
 same washing away of the discharge. 
 
 Fig. 74.— Aerangemest fou iurigation in the uppek limb. 
 
 (After Esmarch.) 
 
 The favom-able results of constant irrigation in preventing 
 septic diseases are very remarkable, and, in this respect, it 
 probably stands next to strict aseptic treatment. 
 
 The disadvantages of these methods are for the most part 
 the sodden state of the wound and the consequent cedematous 
 condition of the granulations, the constant state of unrest of 
 the wound and the inconveniences attending the application of 
 the method. For the first reason they are discontinued when 
 granulation is complete and has filled up the deeper jjarts of 
 the wound, and when the time for blood poisoning has passed. 
 
IRRIGATION AND IMMERSION. 
 
 275 
 
 That the good results of irrigation and immersion are 
 not due to mere maintenance of temperature, as has been 
 
 Yir,. 7.".— Arrangement for irrigation in the lower limb. 
 
 (After E::maic)i.) 
 
 supposed, is shown by the results of M. Gnyot with his 
 incubation method. Here the wounded part was enclosed in 
 
 Fig. 76.— Apparatus for continuous immersion. 
 
 (After Esmarcli.) (For the e.xtremities.) 
 T 2 
 
276 ANTISEPTIC SURGERY. 
 
 an incubating apparatus, and kept permanently at a high 
 temperature. This method, though much lauded for a time, 
 really seems to have favoured considerably the development of 
 septic diseases. 
 
 IV. Concentration of the Fluids, and their Admixture 
 
 ivith Oxygen. 
 
 The method of treatment which has been the greatest 
 stumbling-block in the way of the acceptance of the principles 
 of antiseptic surgery is the open method, for surgeons have 
 been unable to see how the success of this method could be 
 reconciled with the germ theory of putrefaction. They have 
 looked on it as the antithesis of aseptic treatment, as acting 
 on the very opposite principle to that on which the aseptic 
 method is based. And yet, when we come to consider the 
 matter in the light of the true principles of antiseptic surgery, 
 we find that the open method is an advanced method of 
 antiseptic treatment. Of course other principles, such as that 
 of perfect rest and free drainage, also tell markedly in this 
 ease. 
 
 I have stated that this open method acts antiseptically in 
 two ways, and these I must now briefly consider. 
 
 1. It acts antiseptically in that the discharges dry up, and 
 become more concentrated, and thus become unfit soil for the 
 growth of bacteria. 
 
 Tliat concentrated fluids are not suited for rapid development 
 of organisms is well known. Thus Pasteur pointed out that 
 organisms could not grow in sugary solutions which had become 
 concentrated. This fact is made use of in the arts, in the pre- 
 servation of fruits. Sugar is added in large quantities, and 
 then the fruits can be kept for an indefinite length of time. 
 It is not that the sugar is an antiseptic killing the organisms, it 
 is merely that by its presence in large amount the fluid is 
 rendered unsuitable for development. 
 
 The same pi-inciple is made use of in preserving milk. The 
 milk is evaporated to one-third of its original volume, and a 
 considerable quantity of sugar is added to it. Without the 
 addition of the sugar, the condensed milk may be kept for a 
 
THE OPEN METHOD. 277 
 
 considerable length of time without the appearance of organisms 
 in it ; with sugar it may be kept indefinitely. 
 
 The same is the case with other albuminous fluids such as 
 the discharge from wounds. Concentrate pus, and it will be 
 found that organisms develop in it only with difficulty. 
 
 Then we know the contrast between cases of dry and moist 
 gangrene ; how in the latter putrefaction rapidly occurs, or, in 
 other words, organisms rapidly develop, while in dry gangrene 
 putrefaction does not occur, i.e. organisms cannot develop. 
 
 The same was seen in Cazeneuve and Livon's experiments 
 on minary bladders, mentioned before at p. 37. In that case 
 organisms could not develop in the wall of the bladder, because 
 the fluid was constantly evaporating. 
 
 2. In the open method another antiseptic advantage is 
 gained by the free admission of oxygen to the discharge. 
 
 Some very remarkable effects of oxygen in retarding putre- 
 factive and other fermentations were published long ago by 
 Pasteur. He pointed out that if a sugary solution were freely 
 exposed to air in a thin layer, the yeast plant, though it grew 
 luxuriantly, caused very little fermentation. On the other 
 hand, if oxygen were excluded, only a small development of 
 the yeast cells was necessary for fermentation. And he has 
 bhewn that other plants besides the yeast plant can cause 
 alcoholic fermentation, if only they are deprived of free oxygen. 
 
 With regard to putrefaction he has brought forward similar 
 evidence. The organisms which cause putrefaction are, according 
 to him, incapable of living in the presence of oxygen. If a 
 putrescible fluid be freely exposed to the air in a thin layer, 
 putrefaction does not occur, at least not for a very considerable 
 time. Just as in the butyric fermentation, oxygen not only 
 interferes with the fermentative process, but actually destroys 
 the bacteria which cause it. Hence the free exposure of a 
 putrescible fluid to the air results in comparative freedom from 
 putrefaction, partly because the oxygen interferes with the 
 development of fermentative changes, and partly because the 
 oxygen directly kills the putrefactive bacteria. 
 
 There are two methods of wound treatment which action the 
 principles alluded to above. The first is that introduced by Bart- 
 scher and Vezin, and carried out in the following manner : ' After 
 
278 ANTISEPTIC SURGERY. 
 
 all bleeding vessels have been tied, and after the stump has 
 been cleansed from blood clots by means of a sponge and cold 
 water, the patient, for whom two beds are provided close to each 
 other, is put to bed, the stump is laid on a soft pillow, and over 
 it a piece of gauze or linen is loosely placed in order to keep out 
 the flies, the whole stump being freely exposed to the air.' At 
 the morning visit, the surgeon pushes his hand under the stump, 
 raises it, removes the pillow and applies a new one, or lifts the 
 patient on to the other bed, without further cleansing of the 
 wound. In this method all attempts at union by first intention 
 are given up. 
 
 Bi:u-ow of Konisberg published his method in 1859. He 
 attempted to obtain primary union as far as possible. This he 
 did by bringing the surfaces of the wound into contact after a 
 few hours by means of strips of plaster applied over part of the 
 surface, all other dressings being avoided. 
 
 Rose, whose results of open treatment have been specially 
 published by Kronlein, adheres to Bartscher and Vezin's method, 
 with this exception, that he daily washes out the wound with 
 some antiseptic lotion. Crusts are removed, as they are never 
 complete enough to prevent putrefaction, and only cause tension 
 by their presence, and indeed protect the discharge underneath 
 from the action of the air, or of the antiseptic lotion. Eose 
 farther ventilates very freely, so as to have a plentiful supply 
 of air to the stump. He employs this method in all wounds, 
 except those on the face, where union by the first intention 
 is desirable. 
 
 The open method pure and simple is that introduced by 
 Bartscher and Yezin ; for here, while the discharges are allowed 
 to flow away freely, they are left to the unaided action of the air. 
 The antiseptic effect of this method is no doubt increased by 
 the addition of intermittent antiseptic irrigation. 
 
 Burow's method cannot act nearly so perfectly, for in it dis- 
 charges must accumulate in various parts of the wound, and 
 they are therefore not so conveniently placed for thorough action 
 of the air. 
 
 Among the objections to these methods are the following ; 
 in all, except Burow's, union by first intention cannot possibly 
 occur, indeed no attempt is made to obtain it; as a conse- 
 
HEALING BY SCABBING. .279 
 
 quence of this, a long time is required for healing, while a larger 
 scar is obtained ; the frequent formation of scabs and the con- 
 sequent tension also cause great annoyance. 
 
 Closely allied to the open method stands healing hy scab- 
 bing. This may be brought about chiefly in two ways. The 
 crust may either be allowed to form naturally, or its formation 
 may be aided by artificial means. 
 
 This healing by scabbing acts in two ways. In the first 
 place, the first principle of the open method of treatment comes 
 into play ; the discharge dries up and becomes an unfit soil for 
 the development of organisms. In the second place the fluid 
 underneath it is in such a thin layer that the living tissues in 
 the neighbourhood prevent the development of organisms in it. 
 Of course in many cases no living organisms would be there to 
 develop, for the scab would form an absolute pi'otection against 
 their entrance. 
 
 The natural formation of the crust can only take place effi- 
 ciently in small wounds, and only exceptionally where cavities 
 and recesses are present. For in larger wounds, as we have 
 seen, there is too much discharge for a sufficiently rapid and 
 thorough formation of a crust ; and if the crust is not perfect 
 and rapidly formed, putrefaction takes place underneath it, while 
 at the same time, by confining the discharges, tension and ulcera- 
 tion result in place of healing. 
 
 But though this natural formation of a crust cannot be trusted 
 to in most cases, yet by artificial means a satisfactory one may 
 be obtained. 
 
 The method in which this was done by Bouisson, was by 
 blowing air on to the wound, and thus drying the discharges. 
 This method will be described in the historical part of this work. 
 
 The most common modes are by the application of various 
 powders, such as starch, alum, flour, &c., to the discharge, so as 
 to form a paste. The best substance which can be employed 
 in this manner is powdered salicylic acid, as recommended 
 by Neudorfer, and mentioned before under ' Treatment by 
 Antiseptics,' This is sprinkled on till no more fluid exudes, and 
 it combines the advantages of a thorough crust with those of 
 an antiseptic dressing.' 
 
 ' For clolails of tlicsc various melliods, sec tlie historical part. 
 
280 ANTISEPTIC SURGERY. 
 
 Other attempts have been made to produce a scab by the 
 application of various caustic substances to the surface of the 
 wound. The crust so formed, containing as it does a strong 
 caustic, is unable to undergo putrefaction ; and where the inflam- 
 mation caused by the application is not too great, and does not 
 lead to accumulation of fluid under the crust, an excellent result 
 is obtained. In this case, as no organisms are present under 
 the crust (they were destroyed by the caustic), and as the firmly 
 adhering crust prevents their entrance, we have the typical 
 aseptic result — healing of an open wound without suppuration or 
 granulation. There are, however, various objections to this 
 method of crust formation, the chief of which is the loss of 
 substance involved in the process, while the same disadvantages 
 are present as in the open method proper, viz., slowness of heal- 
 ing and a large scar. 
 
 Closely allied to this method of crust formation is that in 
 which the crust is obtained by the application of the actual 
 cautery. 
 
 Crust formation is seldom suitable unless in the case of 
 superficial wounds without recesses or cavities, for, if these are 
 present, an opportunity is given for the occurrence of tension 
 under the crust. It is a method by no means easy or universal 
 in its application. Where it is employed I should recommend 
 the use of Neudorfer's method, viz., the formation of a crust by 
 the aid of salicylic acid powder. 
 
 Alphonse Gueriri's Cotton-wool Treatment acts partly on 
 the first part of the principle of the open method, but it hardly 
 comes into the category of antiseptic methods. 
 
 As originally used, the wound was simply washed with water, 
 and a large mass of cotton-wool applied around it, and firmly 
 bandaged on. 
 
 At present the wound is washed with some antiseptic lotion, 
 and layers of cotton-wool, containing camphor powder sprinkled 
 in it, are applied. The deeper layer consists of wool moistened 
 in carbolic lotion. 
 
 More details of this method will be found in the historical 
 part ; but I may mention here a point wliich Gruerin considers 
 of great importance. The dressing should not be applied or 
 changed in the ward, but in a theatre or side room, and the 
 
PERFECT REST. 281 
 
 packet of cotton-wool should not be opened till the time of 
 application of the dressing. No doubt these precautions may 
 prevent some infective material present in the ward atmosphere 
 from settling on the wound or on the cotton-wool, but it is only 
 a chance that such will be the case. 
 
 This method can hardly be called ' antiseptic ' in the sense 
 in which we have used the word, for the antiputrescent princi- 
 ples on which it acts are not very powerful. As the result of 
 these dressings, the discharge becomes thick and concentrated, 
 and not a very good medium for development of organisms. 
 Nevertheless this concentration of the discharge cannot occur 
 to anything like the extent which takes place when it is left 
 freely exposed to the air. The second principle on which it 
 acts is that it ensures absolute rest to the wound. By means 
 of this rest the granulations are not lacerated, and neither 
 bacteria nor their products can be admitted into the body. 
 This however is a principle relating to infective disease, a sub- 
 ject which we have not mixed up with the true antiseptic 
 principle, which is solely that of preventing putrefaction in the 
 wound. 
 
 Gruerin's method cannot be recommended except in some 
 exceptional cases of disease of joints with sinuses, and even 
 here the retention of the putrefying discharges, and the conse- 
 quent irritation, render it of very doubtful value. 
 
 I have already described the aseptic applications of pure 
 cotton wool at p. 141. 
 
 V. Assist the destroying Action of the healthy living Tissues 
 on Bacteria. 
 
 This principle may be aided in two ways, viz., by perfect 
 mechanical rest, and by attention to the general health. 
 
 By perfect mechanical rest, when the tissues are in perfect 
 health, and the blood clot is undistiurbed, the tissues and clot 
 may be kept in such a state as to resist the development of 
 organisms. This method, though without recognition of the 
 antiseptic principle, has been long practised, and of late has been 
 specially advocated by Sampson Gamgee.' 
 
 ' On the Treatment of Wounda, 1878. 
 
282 ANTISEPTIC SURGERY. 
 
 It is, of course, a well-known fact that, without any antiseptic 
 appliances at all, wounds, more especially about the face, heal 
 frequently by first intention. How can this take place if blood 
 or lymph, exposed to the air, putrefies as the result of the 
 access of organisms ? For, during the operation, organisms 
 enter the wound both as dust from the air and surround- 
 ing objects, and also from the water in which the sponges are 
 soaked. There is also between the cut surfaces a layer of blood 
 or lymph (which, however, must as a rule be very small in 
 amount, otherwise healing by first intention does not occur) 
 which, if it were exposed between two plates of glass, would 
 probably putrefy in a short time. How is it that union by 
 first intention can occur under these circumstances ? How is 
 it that the blood does not putrefy between the cut surfaces 
 of a wound ? 
 
 Well, to use Mr. Lister's forcible arguments, the fact is that 
 a thin layer of blood, although containing numerous causes of 
 putrefaction, does not as a rule putrefy if it be placed between 
 two healthy living cut surfaces. Or, to state the fact in an- 
 other way, these organisms, which are certainly present, cannot 
 develop in a thin layer of blood or lymph placed between two 
 healthy living freshly cut surfaces. Or, to state the same fact 
 differently (taking into consideration the different results when 
 the same layer of blood or lymph is placed between two plates 
 of glass), the living tissues^ tvhen in a healthy state, have the 
 power of preventing the development of organisms in their 
 immediate vicinity. 
 
 I have already had occasion, in a former part of this work 
 (p. 252), to point out that if into a healthy living animal a 
 small quantity of ordinary bacterial fluid be injected, the 
 bacteria lose their vitality and disa})pear. I have shown how 
 organisms cannot be found in the living healthy body (I except 
 here of course specific pathogenic organisms, such as bacillus 
 anthracis), unless a considerable amount of their products be 
 introduced along with them. On the other hand I demon- 
 strated how, if the animal were out of health, organisms could 
 live in their blood and tissues much more easily. The same 
 is the case in union by first intention. If the part be of 
 high vital power, and in a healthy state, and if there be an 
 
ANTISEPTIC ACTION OF LIVING TISSUES. 283 
 
 extremely small amount of blood or lymph between the cut 
 surfaces, union by first intention will almost certainly occur. 
 If the part become inflamed, or if the patient be in a weak state 
 of health, union by first intention, without aseptic means, 
 becomes a matter of great uncertainty. 
 
 Traube and Grscheidlen ^ have likewise found that blood 
 taken with precautions from a healthy living rabbit into which, 
 24 or 48 hours previously, 1^ c.cm. of bacterial fluid had been 
 injected, could be kept for months without undergoing putre- 
 faction. 
 
 And, further, the facts which I have already mentioned, 
 that the blood and tissues of healthy living animals do not 
 contain Jiving organisms, shew sufficiently that they have the 
 power of destroying them, for otherwise there are frequent 
 opportunities for the entrance of these into the circulation. 
 
 This same principle was made use of by jNir. Lister in his 
 experiments for obtaining unboiled urine (see p. 36). He 
 simply washed the glans penis, and the meatus urinarius. He 
 did not wash out the urethra at all. The urine passed in this 
 way remained absolutely pure, showing that no organisms were 
 present in the urethra. And yet the urethra contains mucus, 
 putrescible outside the body, and there is sufficient time 
 between the acts of micturition for bacteria to spread quite up 
 to the bladder (this was experimentally determined by Mr. 
 Lister); nevertheless they do not penetrate any distance into 
 the urethra. In other words, they cannot develop in this 
 putrescible mucus, when it lies between two healthy living sur- 
 faces. Or, to state the fact otherwise, the healthy living tissues 
 have somehow or other the power of preventing the develop- 
 ment of organisms in their immediate vicinity. 
 
 Now blood clot itself may be looked on as a tissue, though 
 one which is of very low vitality. That it is a tissue is well 
 shown by Mr. Lister's experiments on coagulation of blood ; for 
 he found that a tube or cup of blood clot acted in the same way 
 as regards the prevention of coagulation as the living walls of 
 the vessels. He further found that movement of the clot 
 leading to its laceration destroyed its vital power as a tissue. 
 
 In the ' Dublin Medical Journal ' for August 1879, Mr. Lister, 
 after referring to this subject, mentions the following facts: — 
 
 ' Loc. cit. 
 
284 ANTISEPTIC SURGERY. 
 
 ' I have found, in experiments not yet published, that you 
 may put into such purified glasses' (containing pure blood) 
 ' drops of water of considerable size ; and although every 
 hundredth of a minim probably contains a septic organism, and 
 although the blood that flows into each glass is mixed with this 
 septic water, yet the clot there formed, if protected from any 
 other source of disturbance afterwards, remains sweet and pure 
 for weeks together, proving that even outside the body the 
 blood clot has the power in itself of resisting the development 
 of septic organisms — a most important truth.' After applying 
 this principle to union by first intention in cases of amputation, 
 he says : ' But suppose such a stump attacked by muscular 
 spasm churning up the blood clot, then the septic particles 
 would develop, and then you would have putrefaction and septic 
 suppurations, so that without antiseptic treatment in this kind 
 of case, you are at the mercy of perfect immobility ; and, as I 
 have said before, even with the best means, you cannot secure 
 this.' 
 
 In his recent address at Cambridge, Mr. Lister refers to 
 similar facts, but as he has not yet published them, and as the 
 accounts given in the journals are very garbled, I cannot refer to 
 them. It seems however that he confirmed the experiments 
 just mentioned, and found that blood clot, when kept perfectly 
 undisturbed, did not putrefy, even if 4 drops of tap water were 
 placed in the flask before the blood was introduced. 
 
 A very interesting experiment bearing on this subject is 
 mentioned by John Hunter in his paper on * The living principle 
 of the blood.' 
 
 After pointing out how fresh and living eggs resist putre- 
 faction, and referring to various facts which he thought were 
 indications of the existence of a living principle in blood, he 
 narrates the following remarkable experiment, showing that the 
 blood of young jjersons resists 'putrefaction longer than that 
 of old people ; in other words, that the blood of young persons 
 has greater vital power. 
 
 ' June 24th. — Some blood was taken from a woman twenty 
 years of age, and its surface, after coagulation, was covered with 
 un inflammatory crust. 
 
 ' On the same day some blood was taken from a woman at 
 
BLOOD CLOT DESTROYS MICRO-ORGANISMS. 285 
 
 sixty, when the crassamentum was also covered with an inflam- 
 matory crust. 
 
 * These quantities of blood were set by. 
 
 * The blood from the old woman putrefied in two days. That 
 from the young woman kept quite sweet till the fifth day, when 
 it began to smell disagreeably ; in this state it continued two 
 days more, and then emitted the common odour of putrid blood. 
 
 ' Several experiments were made in the course of the 
 summer of a similar nature with the last, in all of which it 
 appeared that the blood from young people kept longer sweet 
 than that which was taken from the old.' 
 
 That healthy blood clot can resist putrefaction so long as it is 
 kept at rest explains many remarkable cases which would other- 
 wise seem at first sight at variance with antiseptic principles. 
 The following case, showing the contrast between blood clot 
 when kept at rest and when disturbed, is worth narrating.^ 
 
 ' On September 15, 1870, a young officer whose left upper 
 arm had been broken about its middle by a Chassepot bullet at 
 Noisseville seventeen days previously, arrived with an ambu- 
 lance train at the Tempelhof military hospital. 
 
 ' The plaster of Paris apparatus, which had been applied at 
 once on the battle-field, had become soft and broken, and as the 
 patient complained of pain in the arm, probably as the result of 
 the journey, and as it was somewhat swollen, the apparatus was 
 removed, and a careful examination was made of the wound. 
 When I passed my finger into the wound after removal of the 
 crust, I felt numerous fragments of bone, but was, however, 
 astonished to find no trace of pus, only coagulated blood. 
 
 ' After I had removed all the fragments, a plaster apparatus 
 with a window in it was applied ; nevertheless, there now resulted 
 a violent inflainination and suppuration of the wound, which 
 for a time threatened the young man's life.' 
 
 These views sufficiently reconcile the fact of union by first 
 intention in cases not treated aseptically with the germ theory 
 of putrefaction. 
 
 Now in order to have tissues in the state in which they are 
 capable of resisting the development of bacteria in their imme- 
 diate vicinity, they must be as much as possible in a condition 
 
 ' Esmarch, Lanp:cnbcck's Arrliiv, vol. xx., p. lOr*. 
 
286 ANTISEPTIC SURGERY. 
 
 of perfect health. To attain this, the health of the patient 
 must be attended to and kept good, and all causes which irritate 
 and cause the wounded part to inflame or become weaker must 
 be avoided. The causes which weaken the part are various 
 forms of unrest, mechanical or chemical. 
 
 To carry out this principle two things are required, viz., 
 accurate approximation of the cut surfaces, and absolute immo- 
 bilisation of the part. Where accurate approximation of the 
 cut surfaces cannot be obtained, the same principle of absolute 
 rest must be carried out as regards the clot filling up the gap, 
 and it may thus resist the development of bacteria in its sub- 
 stance. Were T compelled to treat any case on this principle 
 alone, I should combine with it the open method, leaving the 
 wound freely exposed to the air. The superficial layer of the 
 clot, by drying up, would thus to some extent form an obstacle 
 to the entrance of organisms. 
 
 I have mentioned this as an antiseptic method, as the 
 principle is of great importance in explaining certain otherwise 
 puzzling cases, but I should not recommend it for adoption, for 
 it is only in a few cases, such as in face wounds, where the 
 vitality of the part is high, that this vital action of the tissues 
 and blood clot can be sufficiently trusted. 
 
 Such are the chief principles on which antiseptic surgery 
 can be carried out. In the class of antiseptic methods to which 
 I have referred in this chapter, the surgeon does not adhere 
 strictly to one or other principle, partly because the principles 
 on which he acts have not as yet been properly understood or- 
 appreciated, and partly beca\ise better results can be obtained 
 by their combination. 
 
 In many minor ways the antiseptic principle may be aided. 
 Thus, by the use of catgut ligatures, we do not have a long 
 septic thread hanging out of the wound, conducting putrefac- 
 tion into its interior and leading to deep-seated suppurations, 
 
 &c. 
 
 The silver suture acts in the same way as compared with the 
 silk. Silver does not absorb the putrescible materials, and thus 
 putrefaction does not occur in it. On the contrary, silk absorbs 
 blood and serum, which putrefy in it, and the silk which was 
 
COXCLUSIOXS. 287 
 
 at first unirritating, becomes very acrid and causes inflamma- 
 tion in its vicinity. 
 
 What are the various means by which the general health 
 and tone are kept up in septic cases, what is the careful 
 selection of healthy individuals for operation, but imperfect 
 attempts at antiseptic surgery ? 
 
 What is ventilation but an antiseptic means ? The air being 
 constantly changed, the foul emanations from wounds contain- 
 ing septic bacteria are diluted and swept away, while at the 
 same time a better state of health is obtained. 
 
 And so I might go on enumerating various minute points 
 which have been, in ignorance of theu' true significance, adopted 
 in the treatment of wounds, all of which, more or less, act on 
 and promote antiseptic principles. 
 
 We thus come to the end of our discussion of the Principles 
 and Practice of Antiseptic Surgery. We have seen that anti- 
 septic surgery is simply a struggle with the causes of putrefac- 
 tion. I have not mentioned the germ theory of infective 
 disease at all. That has no essential bearing on the principles 
 of antiseptic surgery. All that is required of antiseptic 
 surgery is to prevent the occmTence of all kinds of fermenta- 
 tion. The germ theory of infective disease is, I say, an inde- 
 pendent view, and not part of those principles at all. It is 
 from mixing up these two theories that the confusion, and 
 much of the difficulty in accepting the principles of antiseptic 
 surgery, have arisen. Thus, for instance, a surgeon who writes 
 a good deal on this subject, after admitting to the full the genn 
 theory of putrefaction, states that he refuses to accept the 
 principles of antiseptic surgery and aseptic surgery in its train ! 
 Speaking of the principles of antiseptic surgery, he says : 
 ' Granting that the same germs which would inevitably produce 
 putrefaction in a dead infusion of beef are constantly admitted 
 to wounds, there is not the slightest particle of evidence that 
 they do produce any change whatever upon Uviiifj tissues, still 
 less is there any evidence that the changes which occur in the 
 numerous varieties of what we call blood poisonings, even when 
 they are of an undoul)ted]y hjcal origin, have the slightest 
 analogy to those seen in a putrefying dead infusion.' 
 
 Such a passage simply shows that the author is confusing 
 
288 ANTISEPTIC SURGERY. 
 
 together the two germ theories —that of putrefaction with 
 that of infective disease. But, as I have already pointed out, 
 the germ theory of puti^ef action is the only vieiu at the basis 
 of antiseptic surgery ; and the author admits the truth of 
 this theory, and yet rejects aseptic surgery ! 
 
 But let the germ theory of putrefaction be once admitted, 
 antiseptic surgery and, where possible, aseptic siu-gery, is 
 the logical, practical outcome. What does it matter for the 
 principles of antiseptic surgery what the precise relations are 
 which fermentations in wounds bear to the bad symptoms after 
 wounds ? These are points to discuss in connection with the 
 results obtained, but they are not the essential points to be 
 considered in determining the adoption or rejection of anti- 
 septic methods. 
 
 Leaving out of view the question of infective disease, and 
 supposing that we deny its connection with fermentations in 
 wounds, I would ask any surgeon who takes the above line of 
 argument, whether he would view with satisfaction the en- 
 trance of causes of putrefaction into the peritoneal cavity ? 
 I venture to say that he would not, and that the following 
 would be the result of his calmer cogitations : ' I do not 
 care at all what relations fermentations in wounds bear to 
 infective diseases, but I would rather not have putrefaction 
 present in the abdominal cavity, and I must insist on your 
 taking all possible precautions to prevent the entrance of its 
 causes. In other w^ords, I believe in the germ theory of putre- 
 faction, and I wish the methods of practice which follow 
 logically from such belief to be fully earned out in this case ; i.e. 
 I wish the strictest aseptic precautions to be employed. If, at 
 the same time, infective disease is also avoided, I shall be very 
 pleased, but I do not understand the causes of it. I do under- 
 stand, however, the causes of putrefaction, and I wish no pre- 
 caution to be spared by which it may be avoided.' 
 
 I venture to think that, with the mass of evidence now 
 existing, there will be very few disbelievers in the germ theory 
 of putrefaction ; and, as soon as a man accepts that view, he is 
 bound, as a rational man, to put his belief into practice on one 
 or other of the lines indicated here. He must do that, I say, 
 whether he believes in the germ theory of infective disease or 
 
CONCLUSIONS. 289 
 
 not, were he indeed ignorant of the existence of such a view ; 
 though no doubt the precise amount of energy which he will 
 bring to bear in carrying out one or other method will to a 
 certain extent depend on the view which he takes of the 
 dangers which may arise from fermentations in wounds, and 
 these we shall have to consider when we come to speak of the 
 results of the various methods. 
 
200 HISTORY OF ANTISEPTIC SURGERY. 
 
 CHAPTER XIV. 
 
 HISTORY OF ANTISEPTIC SURGERY. 
 
 Practice of the ancient writers. Attempts of tlie ancients to secure immedi- 
 ate union of wounds. Pare and Paracelsus: Delacroix: Arceeus: Progress 
 of wound treatment in the sixteenth century. Seventeenth century : 
 Magatus : Wiseman : Colbatch : Progress in the seventeenth century. 
 Eighteenth century and the early part of the nineteenth : Boerhaave : Col 
 de Villars : Heister : Bilguer : Benjamin Bell : Abernethy : John Hunter's 
 objections to the views of Bell and Abernethy : John Bell : opinions and 
 practice of other surgeons : Conclusions : Von Kern. 
 
 Antiseptic surgery being, as we have seen, a very wide 
 term, in endeavouring to take a philosophical view of its his- 
 tory and development, we must trace the development of the 
 methods of wound treatment during the last two centuries at 
 least. In doing so, and in order to avoid repetition when we 
 come to consider the results of the various methods, I shall 
 introduce into this historical part such details of the results 
 obtained as seem to me advisable. 
 
 Without entering into details on the practice of the ancient 
 writers, we may look on their modes of treatment as more or 
 less directed to making the wound heal. Thus, substances were 
 applied to Tnake the flesh grow, others to make the growing 
 flesh firm, and others to make the wound cicatrise. Amid all 
 these attempts, the tendency of the ivound itself toivards 
 healing was almost entirely lost sight of. It was supposed 
 that without these applications all sorts of evil results 
 would take place, and healing would not occur. These ideas 
 reigned paramount for centuries ; and we find them still ad- 
 vocated, not perhaps in such a glaring manner, up till very 
 recent times. 
 
 Nevertheless, there were surgeons who from time to time 
 were bold enough or had insight enough to protest against 
 
EARLY WRITEBS. 291 
 
 these views. Amongst these we may mention Paul D'EdiNETA,' 
 who lived probably in the seventh century. . He proscribes the 
 numerous plasters, by means of which, he says, the action of 
 nature is choked, and he shows himself not ignorant that it 
 is to nature herself that one must attribute the successive 
 changes that wounds present. Eogerius,- in the thirteenth 
 century, also protested against the numerous dressings then 
 , in vogue, and used only wine and honey as local applications. 
 
 The rule at that time was not to attempt to close the 
 wound, even where that was possible, for it was supposed that 
 all sorts of evil humours would be pent up, and cause constitu- 
 tional affections. On the contrary, wounds were distended 
 with tents and plugs, which were covered with all manner of 
 ointments, and imbued with various kinds of medicaments- 
 Attempts were, however, made from time to time to procure 
 union. Among those who made these attempts may be men- 
 tioned Bruno,^ in the thirteenth century, who treated wounds 
 differently according as they were simple incised wounds, or 
 wounds with loss of substance. The former he closed at once, 
 while the latter were made to suppurate, except in cases where 
 nerves were injured, where he thought that 'putrefaction might 
 cause spasm : ' already we see the germ of the idea, which is at 
 present gaining ground, that there is an intim.ate relation 
 between tetanus and septic changes in wounds. Similar views 
 were expressed about the same time by Lanfranc,'* who wrote 
 at length against the dangers of tents, and who states that the 
 immediate union of wounds ought to be the first aim of the 
 surgeon in all cases of simple wounds, except in the case of a 
 bite by a mad dog. 
 
 During the next two centuries, sm-geons seem to have for- 
 gotten, or not to have paid attention to, the teachings of Bnmo 
 and I^anfranc, and to have still continued the practice of 
 endeavouring to remove morbid humours, and of altering the 
 supposed poisonous state of the surface of tlie wound by 
 numerous and varied applications. The most prominent surgeon 
 of tliis time was GuY DE CuAruAf",'' the celelM-atcd surgeon 
 
 ' Soo I'Mrlal'-s JliMnlrc dc V Aiuiloiinc d dc In ('Iiiriirriif, 1770. 
 ^ Ihifi. ■> IhUl.i. 17S. < ////>/. i.l!):5. 
 
 •^ CMrvrfjifi Mai/ua, rct^tituta a L. Joulicrto, 1585. 
 r 2 
 
292 HISTORY OF AXriSEFTIC SURGERY. 
 
 of Moutpellier. He used no less than five different ointments 
 in the treatment of a simple wound. 
 
 At the end of the fifteenth century, or the beginning of the 
 sixteenth century, a new writer appeared in the person of De 
 Vigo,' who for a time exercised a great influence on the progress 
 of sm'gery. It was he who elaborated the dogma that gun- 
 shot wounds are poisonous, and that they must be burnt. He 
 speaks of the contact of the air with wounds as being very 
 hurtful, and for that reason he unites the edges early, taking 
 care not to leave any blood clots between the cut surfaces. He 
 also objects to the unnecessary use of tents, and only introduces 
 into the wounds lint covered with a digestive made with tur- 
 pentine. To the wound itself he applied various powders, some 
 of them containing antiseptic substances, and these no doubt 
 assisted to form an antiseptic crust. 
 
 In 1542 Michel Ais^ge Blondus^ wrote on the treatment of 
 wounds by water. After arresting hsemorrhage, and removing 
 foreign bodies, he applied dressings soaked in water. 
 
 From this period we begin the real history of modern 
 wound treatment. The two men who were most influential in 
 rescuing this department of surgery from the state into which 
 it had fallen, and in laying the foundation for the more modern 
 methods of treatment, were Paracelsus and Pare. 
 
 Philippe-Aureole-Theopheaste-Paeacelse-Bombast 3 was 
 bom in 1493 at Einsiedeln, near Ziirich, and spent the early 
 part of his life at Basle, as teacher of surgery. In his method 
 of treating wounds, he only aimed at aiding nature. He sup- 
 poses that there is a juice, distributed throughout the body^ 
 which keeps the various tissues of the body in good health, and 
 repairs them when they are injured. The whole aim of the 
 surgeon ought to be to prevent alterations in this liquid, result- 
 ing either from its contact with air or from other accidents. 
 Nature alone is sufficient for this, as is seen in wounds of the 
 lower animals, and the essential thing is not to interfere with 
 natm-e. Medicaments are only of use as preserving this juice, 
 and preventing its corruption (puti'efaction). In the treatment 
 
 ' The Must Ea'cellent Warlics of Chirvrgcryc, ifcc, ]54r, 
 
 - Portal's Histoire, i. 381. 
 
 ^ Opei'a Medica Chimica, sire Paradoxa, 1603-5. 
 
PARE. 293 
 
 of wounds he employed silver wire sutures, and bathed or in- 
 jected the wound with a solution of acetate of lead. 
 
 These views were adopted by Ambroise Pare (1509-1584 ?).' 
 He says: — ' Le chirurgien, pour la curation des playes, se doit 
 proposer une commune indication, qui est, union des parties 
 divisees ' . . . ' Or ceste premiere et generale indication est 
 parfaite par nature comme le principal agent, et par le chirurgien 
 comme ministre de nature ; et si nature n'est forte, le chirurgien 
 ne pourra venir a sa fin pretendue.' Pare mentions a variety of 
 topical applications, but his great aim is to keep the part at 
 rest. ' Preserve the temper of a wound by low diet, a little 
 wine, and rest ; avoid venery, contentions, brawls, angers and 
 other perturbations of the mind.' As is well known, he was 
 the first to show that gunshot wounds were not poisonous. 
 He simply enlarged these, and extracted any foreign bodies, and 
 then applied suppurative medicines. He regarded wounds of 
 joints as very fatal, and for the most part deadly, and here he 
 counsels the application of Venice turpentine, and not of sup- 
 purative medicines. His views with regard to air are interest- 
 ing. He looked on pure air as rather beneficial to the wound, 
 and to the patient, but the air of sick rooms, camps, &c., is 
 generally, as he supposed, loaded with miasms, and therefore 
 very dangerous, and it is the miasms in the air rather than the 
 air itself, which are the source of the danger. 
 
 It was chiefly by the writings and teachings of these two 
 men, that the ideas that the wound must be fed, that bad 
 humours must be removed, and that wounds cannot heal 
 without constant meddling, gave place to the true view that 
 natui'e is the only agent in the healing of wounds, and that all 
 that we can or ought to do is to remove anything which inter- 
 feres with its proper action. Pare looked more especially to the 
 constitution. He strengthened the body as a whole, while 
 removing, as far as he knew, any local disturbing causes. The 
 former is, however, the point which he considered the most 
 important. 
 
 Jean Andr^ Delacroix (1573)^ was one of the most suc- 
 
 ' QHuvres Completes, par J. F. 31'algaigne, 18-10. See also The M'orhs of 
 that f anions Chiru/rgion, translated by Thomas Jolinston, 1GG5. 
 "^ Portal's Ilistoire, ii. 41. 
 
L>n4 HISTORY OF AXTISErTIC SURGERY. 
 
 cessful surgeons of that time, and adopted the views just related 
 as to the powers of nature. He used antiseptic substances very 
 largely. Thus he recommends strongly, as applications to 
 wounds, ethereal oils and substances containing alcohol. After 
 the bleeding had been arrested and foreign bodies removed, 
 he washed out the wounds with some ' detergent liquid,' and 
 then applied plasters containing chiefly pitch and oil of tur- 
 pentine. His results were exceptionally good. 
 
 The bad effects of the air were much feared by WiJRTZ,' who, 
 in order to prevent its access to wounds, kept the doors of the 
 sick room closely shut while he rapidly changed his dressings. 
 
 Fallopius ^ also, about the same time, from the same fear 
 of the air, made a number of experiments on healing under a 
 crust. 
 
 The method of treatment employed by P'RANgois Arc^US ^ 
 (1574) was more simple than any of the others used up to that 
 time. Having arrested bleeding, and removed foreign bodies, 
 he washed the wound with alcohol, or with wine containing 
 myrrh or other similar substances, and brought the edges to- 
 gether with sutures, leaving an opening which could be kept 
 open, if necessary, by a piece of lint introduced into it. He 
 then applied a balsam, which afterwards attained great celebrity, 
 and which he describes as follows : — ' Prenez terebenthine claire 
 et baume elemi une once et demie de chacun ; de la graisse d'un 
 animal cliatre, deux onces ; vieille graisse de pore, une once. 
 Faites foudre tons ces ingrediens a un feu modere, et vous 
 aurez un liniment que vous ferez foudre toutes les fois que vous 
 voudrez vous en servir. Vous en oindrez la plaie avec une plume 
 et vous couvrirez le tout avec un emplatre de Vigo.' He had 
 some remarkable results by the use of this method, which really 
 is a fair antiseptic method, and not far removed from an aseptic 
 one. 
 
 ViCARY,'' towards the end of the same century, washed out 
 wounds with a balsamic water, stitched them up, and covered 
 
 ' Practica cler Wuinlarztncij, Basel, lo'.tO. 
 - Opera Omnia, 1600-6. 
 
 3 A 'most JExcellcibt and Covijjcudious Mcthud of ciiriini W'oundcs in the Head 
 and ill other Parts of the Body, translated by John Head, 1588. 
 ■' Tlie A'lir/Hshman's Treasure, <^'c., 1G2G. 
 
^SEVENTEENTH CENTUIiY. 295 
 
 them with various balsams, and he speaks of the excellent 
 results which he obtained in this way. 
 
 The great advance in this century was the reassertion of the 
 part played by nature, and the abandonment of the ideas of 
 feeding wounds or of making flesh. Here also we have the 
 first strong recommendation to apply antiseptics to wounds, 
 and the success of these applications, in the hands of Arcseus 
 more especially, is vouched for by the fame which his balsam 
 afterwards acquired. Nevertheless, as such methods were 
 simply the result of chance, and did not arise from any glimpse 
 of the true principles which were at work in obtaining the good 
 results, they never became established modes of treatment. 
 During this century, two writers more especially, Paracelsus and 
 Wiirtz, looked on the admission of air to wounds as a very bad 
 thing, while Pare went the length of ascribing the harm not 
 so much to the air as to miasms contained in it. 
 
 Seventeenth Century. 
 
 The evil effects of air were, however, most prominently 
 brought forward by Magatus * (1516), to whom also must be 
 accorded the credit of having first thoroughly recognised the 
 importance of rest in the treatment of wounds. He says that 
 the air is charged with miasms, which infect the parts with 
 which they come in contact. He points out as an instance of 
 this, the rapid putrefaction of an egg if a hole is made into it. 
 He also writes strongly in favour of perfect mechanical rest, 
 for he thinks that movement is a frequent cause of the bad 
 results which follow wounds. With the view of obtaining both 
 objects, the exclusion of air and perfect rest, he recommends 
 very infrequent changing of the dressings ; indeed, he only 
 changed them when it became absolutely necessary. He left 
 spaces between the sutures for the escape of pus, but he 
 objected strongly to the use of tents. He did not wipe away 
 the pus from a wound, because he thought that it ultimately 
 formed the cicatrix, and in the meantime protected the wound. 
 
 These infrequent dressings, owing to fear of bad effects from 
 the contact of air with the wound, were, as we now know, the 
 outcome of a wrong theory ; and although Magatus's teaching 
 exercised great influence down to recent times, yet in the case 
 
 ' De rata Midlcatiunc r«^«t'/(t/«, IGIG. 
 
L>9G HIISTORY OF ANTISEPTIC StfRGERY. 
 
 of those who have studied and acted on his views, the reaction 
 has been so great when they have discovered how insufficient 
 they were, that the good points in his method were for a long 
 time Hkewise rejected. 
 
 During this seventeenth century, there was but Httle pro- 
 gress made. The accumulation of dressings, which had been 
 given up to some extent at the commencement of the century, 
 had been again introduced, chiefly as the result of Magatus's 
 teaching on the bad effects of air. These dressings contained, 
 however, balsams and other antiseptics of various kinds, and 
 thus the bad effects which must have arisen from keeping 
 putrid dressings in contact with wounds for a long time, may 
 have been to some extent avoided. 
 
 It is interesting to note, in reference to our future considera- 
 tion of the results of various methods of wound treatment, that 
 Magatus's method by no means did away with the dangers of 
 such injuries as incisions into joints. Thus, to quote from 
 James Cooke's ' Marrow of Chirurgery ' (1685) ; under ' Wounds 
 of Joints,' he says : ' If a wound associate to a dislocation so 
 that the joynt be bar'd and a little thrust out of the skin ; in 
 great joynts 'tis deadly, in all bad : yea, after set, there oft 
 follows inflammation, convulsion, &c., especially if withal there 
 be a fracture near the joynt.' 
 
 That advance was being made, and that the teachings of 
 Mao'atus were not blindly followed, is evident, for example, from 
 the writings of Eichaed Wiseman • (1692). Wiseman's views 
 on the healing of wounds and his methods of treatment were re- 
 markably good. In uniting the edges of a wound, he says that 
 one must not force a pledget of lint between the lips, nor use 
 violence. Unite the parts gently and equally ; then ' preserve 
 the natural temperament of the part, that thereby agglutina- 
 tion may be obtained.' Agglutination is the work of nature 
 alone. Blood is the natural glue, and hence great care must be 
 taken that it is good. Attend therefore to diet and regimen. 
 Support the patient's strength. Do not stop strong drinks, if 
 the patient has been accustomed to them. Do not purge ; but, 
 if necessary, give gentle laxatives. He used as applications to 
 wounds such remedies as turpentine, and outside this he applied 
 1 Chirurgical Treatises, 1G92. 
 
Sm JOHN COLBATCIL 297 
 
 cooling and astringent lotions. Powders of various kinds were 
 sprinkled over the larger wounds. 
 
 At the end of the seventeenth century appeared a most re- 
 markable series of treatises by Sir John Colbatch,' in which he 
 describes results obtained by the use of a medicament, which 
 he unfortunately does not mention, but which gave him results 
 only comparable to the true aseptic results obtained at the 
 present day by the use of the aseptic method. That he 
 should have concealed the name of the substance employed 
 cannot be too much regretted ; but that nevertheless he was no 
 ignorant quack, telling falsehoods simply to sell his wares, is 
 shown by the position which he ultimately attained in his pro- 
 fession. The accuracy of his results are also attested partly by 
 the publicity with which they v/ere obtained, but chiefly by the 
 clearness of the description which he gives of the progress of 
 his cases — a progress which could not at that time have been 
 imagined by any one who had not seen the facts. A typical 
 aseptic course is described, while there is no doubt that he had 
 observed vascularisation of the blood clot, and its replacement 
 by new tissue, just as has been described in the present day by 
 Mr. Lister. 
 
 In his preface he asserts ' that the method of chirm'gery 
 hitherto used is not the best ; that all probes and tents, all 
 digestive and suppurating medicines, all cauterizing and straight 
 ligatures are injurious to the patients, and procrastinate their 
 cure.' His view is, that when a wound is made the ' nutritious 
 juice ' escapes from the vessels. ' Now all the medicines used 
 in the common methods of chirurgery are of such a nature as 
 to relax the divided fibres so much, that they cannot contain 
 the nutritious matter brought to them, but let it pass into the 
 wound, where it is by the same medicines corrupted and turned 
 into that substance we commonly call matter. Now the corrup- 
 tion of the nutritious juice cannot be performed without a sort 
 oi fermentation, and it is the fermenting particles that, fretting 
 the fibres, cause inflammation in wounds, and by entering into 
 the blood, and dividing its texture, cause symptomatic fevers, 
 which frequently prove so fatal.' He then goes on to say that 
 by the medicines in common use surgeons cause suppuration 
 ' Nonnn Lumen chirimjicum, &c., by Sir Julin Colbatcb, 1704. 
 
298 HISTORY OF ANTISEPTIC SURGERY. 
 
 and often mortiticcition, ' and when nature is almost tired and 
 oppressed, weak as she is, they leave her to do her own work.' 
 In the cases where the cavities of the body are wounded, the 
 patient is considered certain to die ; ' for to bring a wound in 
 the lungs, liver, guts, &c., to suppuration is to bring certain 
 death, and to cure a wound without bringing it to suppuration, 
 they don't pretend.' He then refers to the fact that in all 
 wounds the patients were put on low diet, and more often than 
 not blood was taken in large quantities, ' to the great weaken- 
 ing of their patients.' 
 
 As to Colbatch's method. ' Suppose a wound be made with 
 a sword, or other cutting instrument, the length or depth of 
 W'hich signifies nothing, I make a solution of my Potvder in 
 water, for want of which, in urin ; and as soon as conveniently 
 I can — the sooner the better — I either squeeze, or with a syringe, 
 if the wound be deep, inject into the wound some of the said 
 solution ; I then close the lips of the wound together, which, if 
 wide and large, I stitch up. When I have so done, I apply a 
 pledget of fine tow, wet in the said solution, to the wound ; 
 not letting it go into it, but only to cover the edges of it, and 
 lie all over it. And if there chances to be any large artery cut, 
 I hold on the pledget close with my hand till the flux of blood 
 ceases, which will be in a small time, otherwise not ' (he speaks 
 of his medicine as a hsemostatic) ; ' afterwards I bind it on with 
 a very easy ligature, then I give my tincture in wine.' In 
 incised wounds one dressing, or at most two, were as many 
 as were requisite, the second being applied at the end of three 
 or four days. In wounds with loss of substance more dressings 
 were necessary, and these were changed once in four days. 
 
 As to his results, he says : — 
 
 ' First of all, my medicines never cause any pain, unless it 
 be just when the external one is squeezed or injected into the 
 wound, and that pain is little more than what would be caused 
 by using spring water in the same manner. 
 
 ' Secondly, there is no pain afterwards, but the parts are 
 pliant and easy, as if not hurt at all. 
 
 'Thirdly, if there has bin great pain before, according as 
 it has bin greater or less, so it has bin longer or shorter 
 before taken off, but the greatest in a short time. As when a 
 
,SlIi JOHN COLBATCH. i>99 
 
 wound had bin long received, and bad other applications to it 
 before mine, had bin much inflam'd and the parts adjacent 
 much swell'd, and consequently the party in great pain, all 
 these symptoms have bin totally taken off in twenty-four or 
 forty-eight hom's at furthest and many times in such cases the 
 greatest pain taken off in a few minutes. But they have never 
 bin the cause of pain, swelling, or inflammation, which, by the 
 way, is a certain argument they are no caustics, as some mali- 
 ciously and falsely report. 
 
 ' Fourthly, there has never any such thing as a fever, let the 
 wound be ioterual or external, attended any who have used my 
 medicine soon after they have bin wounded ; but several who 
 have bin ill-managed before, and thrown into violent fevers, 
 have in twenty-four hours, by the use of my medicines, bin 
 totally freed from them, and that without blood-letting or ab- 
 staining from flesh or wine, the more of which they drink, so 
 they keep within bounds, I always find them the better. 
 
 ' Fifthly, in all incised wounds, where my medicines have 
 bin soon enough used, and no other applications preceded, 
 they are perfectly cured in a few days without suppuration, and 
 I have frequently observed that at about four days' end, such 
 wounds have bin filled with a substance much like hartshorn 
 jelly, which I have conjectured to be young flesh, and in two or 
 three days I have found my conjectures true, the said substance 
 being converted into good flesh. But where wounds have bin 
 long receiv'd and matter generated, they have bin cured in a 
 small time, without repeating the application above once in 
 three or four days. I have had to do with wounds long re- 
 ceived, which have bin both deep and large, and by the 
 common methods must have discharged a great quantity of 
 matter, but the quantity of matter coming away after using the 
 medicines, has bin so small, that I have good reason to con- 
 jecture it was no more than what was formed before they were 
 applied.' 
 
 These statements correspond very much with what are now 
 made by the supporters of the aseptic method, and they could 
 hardly, more especially where he seems to describe organisation 
 of blood clot, have been imagined at that time. Supposing 
 that this powder were an antiseptic, the method employed is 
 
300 HISTOllY OF ANTISEPTIC SURGERY. 
 
 practically the same as that which I have described when no 
 spray is at hand : fill the wound with the antiseptic lotion ; 
 stitch up and apply your antiseptic dressing. Neudorfer, who 
 also mentions Colbatch, thinks that this powder was a salicylate ; 
 probably, on account of the smell of roses to which Colbatch 
 refers, salicylate of ammonia. 
 
 Thus in the seventeenth century but little real progress was 
 made. The great aim was to exclude the air, and to avoid 
 mechanical causes of unrest ; the chemical causes of unrest 
 were not at all understood. Colbatch's method seems to have 
 been completely lost, no doubt on account of his concealment 
 of the natm-e of the substance used. 
 
 Eighteenth Century and the Commencement of the Nineteenth. 
 
 AuGUSTiN Belloste' (1700) reiterates Magatus's teaching. 
 He fears the contact of the air, chiefly on account of the 
 miasms which it contains, and in order to exclude these, and 
 also in order to obtain mechanical rest, he recommends in- 
 frequent dressings. He fills his wounds with charpie and 
 follows Magatus in not washing away the pus. He advocates 
 immediate union in cases where bones are divided. ' L'expe- 
 rience m'a fait voir,' says he, ' en mille occasions que quand un 
 OS est simplement decouvert, tout consiste, pour en eviter 
 I'alteration, a le defendre des attaques de I'air. Pour cet effet, 
 il faut procurer la reunion de la plaie le plus tot qu'il sera 
 possible, par le moyen des bandages propres et des remedes 
 balsamiques, sans la dilater avec les tentes et les bourdonnets ; 
 par la I'os se recouvre promptement, et on evite I'exfoliation, 
 qui est absolument necessaire quand on a donne le temps a I'air 
 d'y faire ses impressions.' 
 
 In 1706 Parmanus^ speaks of a lotion which he uses for 
 wounds, which ' resists putrefaction, prevents ill accidents, and 
 takes away the inflammation and pain of the wound.' His 
 dressings were kept constantly moist with this lotion, and 
 changed once in two or three days. 
 
 In the same year Anel ^ published an account of a method of 
 
 ' Le cJiirvrgieii d'Hopttal, 1707. * Chirvrgia Curiosa, 1706. 
 
 ^ Portal's Ilistaire, iv. 398. 
 
EIGHTEENTH CENTURY. 301 
 
 evacuating abscesses by aspiration, without leaving an open 
 wound. A similar kind of instrument for the puq^ose of re- 
 moving blood from the thorax had been previously described by 
 Delacroix (1573). 
 
 As we have seen, the dread which surgeons as a rule up, to 
 this time entertained of admitting air to wounds was not so 
 much because it caused putrefaction of the discharges of 
 wounds, but because it contained miasms which were hurtful 
 to the patient. The connection between internal abscesses and 
 wounds had been hardly as yet observed, and it was not till 
 Boerhaave wrote, that this connection was recognised, and that 
 a 'putrid discharge in a wound became a thing to be avoided.^ 
 
 Boerhaave 2 (1720) pointed out the frequency of internal 
 abscesses after certain injuries, and he ascribed this to the ab- 
 soq^tion of pus by the open orifices of the veins of the wound. 
 Boerhaave went further, and ascribed the evil effects to the 
 putridity of the pus. This is very evident in the following 
 quotations, which Jeannel (Pyohemie) gives from Boerhaave's 
 aphorisms : ' Si turn relinquitur (pus) diii in loco clauso, attenu- 
 atur, acre fit, putrescit, augetur, vicina consumit, erodit, mole, 
 pondere et motu sinus fistula sque creat variis locis, varias, 
 pessimas in intestino recto ; ' and also, ' Aut dissipata parte 
 tenuiori reliquum durescens tumores duros, maxime circa glan- 
 dulos creat, vel denique (pus) venis lymphaticis aut sangui- 
 feris, per eroso osculo impressum absorbetur,' &c. Jeannel also 
 quotes passages from Pare to show that he attributed the fever 
 which accompanied wounds to a putrefaction of the jjus. 
 
 Boerhaave's views were adopted by Le Dkan^ and Heister; 
 and, in 1741, we find the necessity of frequent dressings, in 
 order to prevent putrefaction, strongly urged by Col de 
 Villars.'' The latter author advises that if there be much 
 suppuration, the dressing should be changed twice a day. He 
 
 ' Tliat wounds of the skull were apt to l)e followed by abscesses in the 
 liver was long before noticed by Pare and others, but the significance of the 
 fact was not understood. 
 
 - Ajikorixvis concerning flw Kvoirlcdfjc (ind Citrc of iJ'ntcaKc, Xnin&hxXcxX by 
 Delacoste, 1715. 
 
 * Billroth, Ilistorische Stndicu iibcr die Bcvrthdluiifjen dcr Schusm-undcn 
 1859 
 
 •• f'ofirs dc ChirHnjie, ii. 17-41. 
 
302 HISTORY OF ANTISEPTIC SURGERY. 
 
 employed compresses soaked in wine or in Imlsams, sucli as 
 the balsam of Arcaeus, or covered with an ointment consisting 
 of equal parts of wax, turpentine, and oil of hypericum. In 
 order to avoid the contact of the air the dressing was changed 
 as, quickly as possible. 
 
 Heister' (1753) used balsams very extensively, not because 
 he held that they conduced to form new flesh, but chiefly be- 
 cause they removed everything that might hinder that pro- 
 cess, more especially putrefaction. In order to prevent the 
 access of air, which he considered hurtful, ih.& surgeon was in- 
 structed not to remove the old dressings till the new were ready 
 for application. Heister attended to the drainage of his wounds, 
 and, if necessary, he made a counter-opening into which he 
 introduced a piece of lint covered with some sort of balsam. 
 The edges of the wound were brought together either by stitches 
 or by plasters composed of various balsams. 
 
 The most important work, however, in which the action of 
 antiseptics is especially recommended, was Bilguer's^ (1764). 
 His method of treatment in all kinds of wounds consisted 
 essentially in filling all the recesses of the wound with antisep- 
 tics, and laying over the wound a piece of lint dipped in an 
 antiseptic solution. His method is specially described in con- 
 nection with cases of mortification. He makes incisions through 
 the dead parts, which incisions should be large and numerous, 
 but should not touch the living part. He then squeezes out 
 the corrupted humours, and pom's in the following mixture : ' Of 
 frankincense, mastick, sarcocolla, and myrrh finely powdered, 
 true balsam of Peru, and genuine essential oil of cloves — 
 equal parts ; of balsam of Fioraventi, as much as may, after 
 mixing all the ingredients over a very gentle fire, form a thin 
 liniment.' Over this is laid some dry lint, thoroughly sprinkled 
 with a powder composed of ' an ounce of myrrh finely powdered, 
 half an ounce of sal-ammoniac, camphor and nitre — of each a 
 drachm.' If necessary, fomentations may be applied outside this. 
 These fomentations should be com2:)Osed of 'a pint of lime- 
 water, 3 ounces of camphorated spirits of wine, and H ounce 
 
 ' Clcnvral Sjixicvi of Sin-f/tTi/, translalcd 1753. 
 
 - A DiHStoiation on the Invtllif)/ of fhr Atnjmfofiitn of the Linilm, witli 
 notes by M. Tissot, 1764. 
 
BILGUER. 303 
 
 of sal-ammoniac' A variety of other mixtures and methods of 
 treatment are mentioned, but the quotations will show the 
 essential points. 
 
 In this method the thorough application of these sub- 
 stances would no doubt result in complete asepticism ; and the 
 results which he obtained are very remarkable. From his ex- 
 perience, he sets his face strongly against amputation. He 
 says : ' The cutting off a limb being the severest means 
 employed in surgery for the relief of mankind — an operation 
 which every one beholds with horror — I cannot, I imagine, 
 better accomplish my design, or do a greater service than by 
 demonstrating that the cases wherein amputation is necessary 
 are much less frequent than has been hitherto supposed, and 
 that it may even be almost totally dispensed with.' 
 
 With regard to his results he says : ' I have had under my 
 care, during the course of the late bloody war, a great number 
 of wounded limbs, torn and shattered by cannon and musket- 
 balls, by the bursting of bomb-shells and grenades, by grape- 
 shot, &c. I cured them without ever performing amputation 
 . . . although there were bones broken and shattered, large 
 blood-vessels divided, the flesh miserably lacerated, and limbs 
 carried off; others in which the bones were split up as high as 
 the articulation ; all which circumstances might make us rea- 
 sonably apprehend a tedious and difficult cure, too plentiful a 
 suppuration, haemorrhages, violent inflammation, excessive cor- 
 ruption, mortification, and death.' . . . 
 
 ' I had at one time, during the war, in a military hospital, 
 6618 wounded persons, who were all treated according to my 
 direction, and part of whom I attended myself. Of these, 5557 
 persons were perfectly cured, and in a condition to support all 
 the fatigues of the service; 195 were able to do duty in garri- 
 son — what they call " half-invalids " — or to work at any trade ; 
 213 remained incapable of any labour, civil or military, what 
 they call "grand invalids," and 653 died.' 
 
 The 195 and 213 invalids belonged to the class of cases 
 who had their bones bruised, broken, or sliattered. After a 
 calculation which I need not go into, he very reasonably con- 
 cludes that ' much the greater part of these 408 men cured 
 and sent to the Invalidcs would have died if amputation had 
 
,'J04 HISTORY OF ANTISEPTIC SURGERY. 
 
 been performed.' He compares this with the ' prodigious 
 numlier of wounded men who at the beginning of the war had 
 their limbs taken off on account of dangerous wounds, of whom 
 scarce one or two escaped with their lives.' He concludes 
 thus : ' Further, if it be considered that many of those who died 
 might have recovered, had they been taken care of anywhere 
 else than in an hospital, where the air is very bad, and if it be 
 called to mind at the same time, what some very eminent sur- 
 geons have observed, that two-thirds of those die who have 
 their limbs cut off, I hope it will be readily acknowledged 
 that my method of treating wounded limbs by saving them, is 
 highly preferable to that of amputation.' 
 
 As a contrast to this method I may refer to that used by 
 Percival Pott* (1768) in compound fractures. Wliere the 
 limb is treated conservatively, he recommends immediate reduc- 
 tion, and then he mentions two requisites: 1. The mainten- 
 ance of a proper opening for the free escape of discharges — a 
 counter-opening being made if necessary ; and 2. The preven- 
 tion of inflammations in order that the wound may heal, as far 
 as possible, by first intention. His dressing was a piece of dry 
 lint next the wound, and outside this a ' pledget spread with a 
 soft easy digestive.' As the result of this treatment in com- 
 pound fractures, wounds of joints, &c., he thinks that the 
 patient has the best chance by immediate amputation. Thus 
 Bilguer, by his piles of dressings, but these acting more or less 
 completely on aseptic principles, regards compound fracture as 
 a much more favourable accident than does Percival Pott with 
 his simple non-antiseptic dressings. 
 
 Towards the end of this century, the evil influences of air 
 on wounds was brought very prominently forwards, more espe- 
 cially in England. About this time Pkingle ^ published a work 
 on the diseases of the army, in which he speaks of diseases 
 arising in consequence of foul air, and narrates a series of ex- 
 periments made with various antiseptic substances. 
 
 In 1 784 Benjamin Bell ^ published his treatise on the theory 
 and management of ulcers, in which he speaks very strongly 
 
 ' (,'hiriirgical WorTis, edited by Sir James Earle, 1808. 
 
 ^ Ohscrrations on the Diseases of the Arvnj, tliird edition, 17(!1. 
 
 ^ Treatise oti the Theory and ManoAiement of Uleers, 1784. 
 
BENJAMIN BELL. 305 
 
 of the bad effects of air : ' The bad effects of air,' says he, ' on 
 every species of sore are well known to every practitioner, but 
 its pernicious influence on a newly opened abscess is often 
 really astonishing. It first occasions a total change in the 
 nature of the matter, from perhaps a very laudable pus to a 
 thin ill-digested sanies, and afterwards brings on a quickness of 
 piilse, debilitating sweats, and other symptoms of hectic fever, 
 which for the most part, when the collection has been con- 
 siderable, either carries the patient off in a short time, or ter- 
 minates in a confirmed phthisis, which sooner or later proves 
 fatal.' How air acts he does not know, but he thinks that it 
 may stimulate the absorbents to greater absorption of pus, 
 ' and it may likewise, by rendering the matter more putrid than 
 before, give even to the same quantity greater activity in pro- 
 ducing the different symptoms of hectic' On this principle 
 (of preventing putridity) he would account for the operation of 
 many of the remedies commonly employed at that time in the 
 treatment of sores. As a means of avoiding all these dangers, 
 he recommends the introduction of a seton into an abscess, 
 and he thinks that the progress of cases so treated is better 
 than that of those in which the abscess is laid freely open. In 
 hydrocele, however, he found that the use of the seton was 
 followed by great pain and constitutional disturbance. From 
 what has gone before it will be readily understood why such 
 disturbance resulted, and also that, in the case of the abscess, 
 no real benefit was derived. 
 
 Benjamin Bell also used leaden drainage tubes. In incised 
 wounds, after bringing the edges together, he applies ' no 
 dressings except a thin covering of soft lint to protect the 
 parts beneath from cold, and to keep out the air.' 
 
 He is always reiterating the statement that ' nothing proves 
 more hurtful to sores than exposure to the air ; ' and he directs 
 his efforts to excluding the air by closely applied ointments, &c. 
 He also details the disastrous results of wounds of joints, and 
 he says that many authors advise innnediate amputation in 
 such cases. In small wounds, however, he draws down the 
 skin and stitches it in such a position as to make a valvular 
 opening. 
 
 He proposes a valvular incision for the removal of cartilages 
 
 X 
 
306 HISTORY OF ANTISEPTIC SURGERY. 
 
 from joints where the cartilages are quite loose, but where they 
 are attached to any part of the synovial membrane, and the 
 jiain is insupportable, he would advise amputation as ' less pain- 
 ful as well as less hazardous.' 
 
 Similar views as to the bad effects of air on wounds were 
 expressed by Hugh Munro ' (1792) ; and he agrees with Bell in 
 attributing the disastrous consequences following wounds of 
 joints and incisions into psoas abscesses to the entrance of air 
 and the putrefaction of the discharge. 
 
 Alexander Munro '^ (1788) had previously written on the 
 bad effects of air on serous sacs, but he thinks the coldness of 
 the air is their chief cause. 
 
 James Latta^ (1795) gives the teaching of the Edinburgh 
 school, which is essentially that of Benjamin Bell. He says that 
 the admission of air into abscesses ' is immediately attended 
 with symptoms of putridity ; the pus, which at first was white, 
 thick and free from any foetor, becomes instantly thin, foetid, 
 and corrosive ; a quick pulse and hectic sweats come on, from 
 which the patient scarcely recovers, if the collection of matter 
 has been very large.' 
 
 In the Encyclopedie Methodique (1790) Alexander Munro's 
 idea as to the coldness of the air being the injurious factor is 
 upheld, but, at the same time, the impurity of the air is also 
 brought forward, and an attempt is made to prove its influence 
 by citing the different resvdts of am})utations in town and 
 country. 
 
 The advocate of the bad effects of air who succeeded 
 in turning his views to the best account was, however, 
 AbernethV* (1793). He first points out in his 'Essay on 
 Lumbar Abscesses ' that ' whilst the condensed cellular sub- 
 stance which forms the cyst of an abscess remains entire, it 
 continues free from inflammation, and the contained pus suffers 
 no putrefaction, nor evident alteration of quality ; . . . when- 
 ever the abscess is o])ened, either by ulceration or by the hand 
 of the surgeon, a sudden and generally considerable inflamma- 
 tion extends over the whole cyst. This is followed by a cojuous 
 
 ' A Com])en<lioui^ Si/Klem oftlir Thcori/aiid I'racitccvf Mmlvrn Snrf/cry, 1792. 
 - Bwao' Miicosf/; 1788. ^ Practical System of Sim/cry, 1795. 
 
 * Svryical and Pliysiohyical Essays, 1793. 
 
ABERNETHY. 307 
 
 discharge of frequently foetid pus.' Abernethy's writings are so 
 well known, and so well worthy of perusal, that it is unnecessary 
 for me to discuss them in detail. His principle of treatment 
 was to reduce the size of the cavity to as small dimensions as 
 possible by successive tappings of the abscess, and when this 
 was done, the remaining sac was opened. This method was 
 first carried out by drawing off the pus by means of a trocar 
 and canula, but that was soon abandoned for a valvular incision. 
 Several cases are recorded which clearly show the advantages of 
 the method. 
 
 In investigating the reason why air does harm, Abeniethy 
 discusses the views as to whether it is on account of some 
 irritating property which it possesses, or by causing putrefaction. 
 He concludes, from observation of the phenomena eeen in em- 
 physema, and also from Astley Cooper's experiments, in which 
 he inflated the abdomen with air without causing any harm, 
 that the first supposition cannot be correct. Nor does he 
 think that it is the putrid matter which does the harm, for ' if 
 the matter had only an incomplete discharge, if it was confined 
 in a state of putrefaction, and thus applied to the surface of 
 the abscess, it surely would be in some degree injurious, but 
 as the outlet in general is sufficient, and as the former matter 
 is washed away by that which is newly secreted, this is not 
 likely to be a common occurrence.' His belief is that it is 
 partly the primary injury to the cyst when it is opened, but 
 chiefly the constant action of the air. ' The circumstances, 
 however,' he says, ' are different ' (from those in Astley Cooper's 
 experiments). ' When the opening is permanent, a constant 
 renewal of air is permitted ; and the application of a matter so 
 unusual to these sm'faces, I am inclined to believe, does harm.' 
 
 In his ' Lectures on the Theory and Practice of Surgery ' 
 ( 1 830), he speaks of the objects to be aimed at in the treatment of 
 wounds, viz. position, accurate union, avoidance of movement 
 or tension, and prevention and mitigation of inflammation. 
 Stitches are bad, and he uses plasters instead. He approves of 
 leaving wounds open till they become glazed, and then, when 
 the edges are brought together, he covers them very lightly or 
 leaves them quite exposed. 
 
 The dangers of air, and the advantages of the valvular 
 
808 HISTORY OF ANTISEPTIC SURGERY. 
 
 method, were accepted by the leading German writers of this 
 period. 
 
 JoHANN Christian Anton Theden ' (1795) used a lotion for 
 wounds, consisting essential!}' of sorrel water and alcohol. He 
 speaks of washing out wounds with warm wine, then bringing 
 the edges together, and applying compresses soaked and kept 
 moistened in this lotion. He does not regard wounds of joints 
 as so dangerous as other writers have made them out to be ; and 
 he mentions a case of compound fracture of the olecranon from 
 a sword cut, in which there was but little fever and discharge, 
 and the joint was ultimately only somewhat stiff. Three cases 
 of removal of loose cartilages from the knee-joint are narrated. 
 Pressure was made during the operation so as to prevent the 
 entrance of air, and then his lotion was applied. Two cases 
 did well, the third patient got a ' malignioses Fieber ' after the 
 operation, and died. Theden does not think that this bad 
 result was a consequence of the operation. 
 
 August G-ottlieb Eichter (1799)^ advocates the free re- 
 moval of pus by counter-openings if necessary. He used various 
 digestive ointments, and rather tended to the old style of stuffing 
 an open wound without employing any special antiseptic means. 
 It is interesting to note that with him the question of amputa- 
 tion in gunshot injuries and compound fractures is brought 
 prominently to the front. He fears an absorption of pus, if 
 attempts are made to save the limb, and this absorption is, 
 according to him, always followed by death. He advocates 
 Abernethy's method of opening lumbar and psoas abscesses. 
 
 These views as to the bad effects of air on wounds and in 
 abscess cavities were not allowed to pass unchallenged, 'and 
 were especially objected to by John Hunter and John Bell. 
 
 John Hunter (1792)^ ascribes the bad consequences follow- 
 ing a wound to the injury itself, and not to the action of the 
 air. A disposition in the part to inflammatory action may also 
 be superadded. In speaking of the view that air is a cause of 
 snpi)uration, he says ; ' Various have been the opinions on this 
 
 ' Xene Bemerkungen unci ErfaUrwigai zur Bcrcichervng der Wumlarznei- 
 hinst, 171>5. 
 
 - Anfai)(is-grunde der WmidurziieiJnivKt, 17'.)9. 
 
 * John ilunfcr\i WorJis, Vol. III., edited by F. Palmer, 1835. 
 
JOHN HUNTER. 309 
 
 subject ' (the question of inflammation in wounds) ; 'and as every 
 violence committed from without, under the circumstances 
 before mentioned, is exposed more or less to the surrounding 
 air, the application of this matter to internal surfaces has 
 generally been assigned as a cause of this inflammation ; but air 
 certainly has not the least efifect upon those parts, for a stimulus 
 would arise from a wound were it even contained in a vacuum. 
 Nor does the air get to the parts that form circumscribed 
 abscesses, so as to be a cause of their formation ; and yet they 
 as readily suppurate in consequence of inflammation as exposed 
 surfaces. 
 
 'Further, in many cases of emphysema, where the air is 
 diffused over the whole body, we have no such effect — and this 
 air not the purest — excepting there is produced an exposure or 
 imperfection of some internal surface for this air to make its 
 escape by, and then this part inflames. Nay, as a stronger 
 proof, and of the same kind with the former, that it is not the 
 admission of air which makes parts fall into inflammation, we 
 find that the cells in the soft parts of birds, and many of the 
 cells and canals of the bones of the same tribe of animals, 
 which communicate with the lung, and at all times have more 
 or less air in them, never inflame ; but if these cells are ex- 
 posed in an unnatural way, by being wounded, &c., then the 
 stimulus of imperfection is given, and the cells inflame, and 
 unite, if allowed ; but if prevented they then suppurate, granu- 
 late, &c. 
 
 ' The same observation is applicable to a wound made into 
 the cavity of the abdomen of a fowl, for there the wound in- 
 flames and unites to the intestines to make it a perfect cavity 
 again ; but if this union is not allowed to take place, then more 
 or less of the abdomen will inflame and suppurate. 
 
 ' If it was necessary that air should be admitted in order for 
 suppuration to take place, we should not readily account for 
 suppuration taking place in the nose from a cold, as that part 
 is not more under the influence of air at one time than at another ; 
 nor is the urethra in a gonorrhoea affected by the air more at that 
 time than at any other ; these parts being at all times under the 
 same circumstances with respect to air. Therefore, there must be 
 another cause.' Truly there is another cause, as has been 
 
310 HISTORY OF ANTISEPTIC SURGERY. 
 
 already demonstrated, but not the one John Hunter supposed, 
 as we shall see when we consider the results of subcutaneous 
 injuries and subcutaneous operations. 
 
 John Hunter's treatment of wounds is very simple. He 
 wished to allow nature to perform her work herself, simply 
 applying poultices or ointments to allow the protecting dress- 
 ing to come off easily. 
 
 It is in his views on healing by scabbing that we are mainly 
 interested. He observed that when blood dried on a wound, 
 that wound often healed without suppuration ; and hence he 
 concluded that a scab was an obstacle to suppuration, chiefly 
 because it precludes the necessity for the formation of discharge 
 to act as a covering for the exjiosed surfaces. He considered 
 that it was the best practice to let superficial wounds scab 
 over. Many deep-seated wounds also, where the deep parts 
 are in contact, may be allowed to scab. This ought likewise 
 to be done in cases of compound fracture with a small external 
 wound. In large wounds this formation of a scab did not 
 always succeed, but he did not think that there was any danger 
 in trying to get it. In such cases the crust formation could 
 be aided by the sprinkling of powders over the surface, such as 
 chalk or lapis calaminaris. Where suppuration occurred under 
 the crust, he did not even then remove it in the first instance, 
 but pressed out the pus in the hope that the remainder might 
 dry up. When, however, it was evident that harm was being 
 done, he applied poultices and removed the crusts. 
 
 John Bell ' likewise denied that the bad results of wounds 
 were due to the admission of air. In the edition of his ' Prin- 
 ciples of Surgery,' edited in 1826 by Charles Bell, he opposes 
 strongly the idea that air can in any way cause inflammation, 
 and he criticises severely Munro's book on the ' Bursse Mucosae.' 
 He points out that in the case of abdominal wounds or of psoas 
 abscesses air cannot enter the cavity. He further adds : ' That 
 the air which we breathe, and which we feel upon the surface 
 so bland and delightful, should have so opposite a relation to 
 the internal parts, that it should there be a stimulus more 
 acrid and more dangerous than the m'ine or bile, is not to be 
 believed upon slight grounds : this misfortune of inflammation 
 
 Prinrijilex of Siirr/rry, edited by Sir Charles Bell, 1826. 
 
JOEN BELL. 311 
 
 running so quickly round all the surfaces of shut sacs, where- 
 ever they happen to be wounded, proceeds altogether from 
 another source, simple and plain to the last degree. For, in 
 the wound of any shut cavity, where the parts do not adhere, 
 the inflammation spreads and runs its course by a law of the 
 animal economy, which we explain very ill when we call 
 adhesion, the adhesive stage of inflammation, rej)resenting, as 
 the first stage of a most dangerous disease, that adhesion which 
 is a natural and healthy action, the most natural in all the 
 system, and the farthest from disease. Thus, in a wound of the 
 breast or belly, in a joint, or in any shut sac, if the parts, being 
 neatly laid together, should once adhere, then there is no 
 swelling, no pain, no formation of matter, the parts are well 
 and sound in the very moment in which they adhere ; thus it 
 is sometimes in narrow or slanting wounds. But if the wound 
 be broad and open, or if the least thing keeps the lips apart 
 from each other, or if they run into inflammation, then the lips 
 tuna away from each other, matter forms, the wound inflames, 
 and not the wound only, but also the wounded cavity inflames, 
 so that if it be in a vital part, the man dies.' 
 
 In speaking of compound fractures and dislocations, after 
 citing the opinion of French surgeons, chiefly Palfin and 
 Duverney, that amputation should always be performed, he says : 
 ' We do not comply with any such barbarous rule ; ... we know 
 that nature will do wonders, but they are wonders, and we 
 never enter upon the attempt of preserving a limb thus desjDer- 
 ately fractured without awful hesitation, and when we do venture 
 to dilate the wound, and push back the bones, or saw them 
 off, we feel all the responsibility of what we have just done.' 
 
 Of wounds of joints he similarly says :^ ' We here pronounce 
 the opinion which we have too often to deliver in common 
 practice, that openings into inflamed joints are fatal ; and though 
 there are in every book cases of anchylosed joints, we cannot 
 forget that for one that has escaped by anchylosis, thousands 
 have died.' Such are the results of his treatment, founded on 
 the views we have quoted. 
 
 He says, with regard to the methods of treatment : ' When a 
 modem surgeon allows himself to talk about the mundifying, 
 ' Discourses an tJie Nature and Cure of Wounds, 1812. 
 
312 HISTORY OF ANTISEPTIC SURGERY. 
 
 incarning, and cicatrising of wounds, or directs how to fill the 
 wound up with good and sound flesh and keep it to a fair and 
 even level with the adjacent skin, he but proclaims his own 
 ignorance of the properties of the living body.' What we have 
 to do, is to ' save the patient from immediate bleeding, and to 
 lay the wounded parts so cleanly, so neatly, and so evenly in 
 contact with each other, that they may adhere. The rest we 
 leave to nature.' 
 
 Sir Charles Bell,^ although imbued with his brother's 
 teaching, recommends the valvular method in removing loose 
 cartilages from the joints, and states that where the cartilage 
 has escaped into the joint during the operation, the consequences 
 are generally disastrous, on account of the exposure of the joint. 
 
 Such is a short abstract of the views held by the gi-eatest 
 surgeons of our country as to the effects of air on wounds ; but 
 whatever conclusions were come to, the good results of Aber- 
 nethy's valvular method were so evident that it was generally re- 
 commended. As we have seen, Eichter and Theden, and, I may 
 also say, Arnemann,^ adopted and advised it ; and Samuel 
 Cooper^ (1807) says of it : ' I must consider it in the present 
 state of surgery as the only one warrantable.' Cooper also 
 recommends a valvular incision for the removal of loose carti- 
 lages. He does not think that the situation of the incision, a 
 point on which great stress was laid by some at that time, is of 
 any consequence, but he makes it in a valvular manner, brings 
 the edges of the wound accurately together, and keeps the 
 limb extended, and completely motionless. He considers that 
 the dangers of such operations have been much exaggerated, 
 ' but, making every allowance for the influence of prejudice, a 
 man must be very sceptical indeed who does not consider the 
 wound of a large joint like that of the knee attended with 
 real cause for the apprehension of danger.' 
 
 In 1 808 John Pearson ■* wrote against Abemethy's method 
 of opening psoas abscesses, and in favour of allowing them to 
 burst. He says : ' The instances of those who perfectly recover 
 from the empyema psoadicum are few in number when com- 
 
 ' Princijfliis of Surgert/, edited bj'^ Sir Charles Bell, 1 826. 
 
 * System der CMrm'die, 1798. ^ Trcatixe on tlic Diseases of Joints, 1807. 
 
 * Principles of Surgery, 1808. 
 
ASTLEY COOPER. 313 
 
 pared with those to whom it proves fatal." That his results 
 were not so good as those obtained by Abernethy's method is 
 evident from his description of the com-se of psoas abscess. 
 He says : ' Whether the abscess be opened artificially, or be 
 permitted to open by a spontaneous rupture, a very large 
 quantity of purulent matter, of the density of good pus, but often 
 inclining to a cineritious colour, is generally evacuated from its 
 cavity. The daily discharge of pus also greatly exceeds the 
 quantity that might be expected from a tumour of that apparent 
 magnitude. The sore frequently puts on a scrofulous aspect, 
 all the hectical symptoms increase, and the patient is gradually 
 destroyed.' 
 
 Leveille • (1812) advocated the direct incision for removal 
 of loose cartilages. 
 
 In America Wm. Gibson^ (1824) advised valvular incisions 
 in operations for removing loose cartilages from joints. He 
 recognised, however, that 'wounds of the larger joints are 
 among the most dangerous accidents in surgery ; "' and the same 
 may be said of those ' wounds of the smaller articulations, trivial 
 in the eyes of the surgeon, but, in defiance of all calculations, 
 sometimes followed by tremendous symptoms, and even death.' 
 
 Sir AsTLEY Cooper ^ (1819 and 1827) does not seem to 
 have expressed any definite opinion on the effects of air on 
 wounds. His method of dressing consisted in applying a piece 
 of lint dipped in blood along the line of incision. This 
 was fixed by strapping. A cooling lotion was used if there was 
 much inflammation. I may mention here his views on wounds 
 of joints. He advocates immediate and close union of the 
 wound in the skin. Then he applies lint dipped in blood, and 
 over this strapping. He covers the knee with linen soaked in 
 a solution of acetate of lead and spirit and places the limb on a 
 splint. As instances of improper treatment, he says : ■* ' If the 
 patient has a poultice applied, or if the utmost attention be not 
 paid to the immediate closure of the wound, inflammation of the 
 synovial membrane arises, and su})puration ensues. In young 
 
 ' No\irclle Doctrine CMrvroicalc, 1812. 
 
 ^ The Princijdeit and Practice of Svrueri/, 1824. 
 
 3 On iJishcations, 181!). 
 
 •* Lecivres on Snrgcry, oditcd by F. Tyrrell, 1827. 
 
314 History of antisfptic surgery. 
 
 and healthy constitutions, these wounds in the largest joints are 
 recovered from, but in the aged and weak they destroy life. . . 
 Recovery from these injuries, when inflammation has followed, 
 is by adhesion, so as to destroy the synovial surface, or else by 
 granulation, when a partial or general ossific anchylosis is the 
 result.' 
 
 Larrey ^ (1829) does not believe that it is so much the pene- 
 tration of the air into the joint — for that very often does not 
 occur — as the accumulation of blood and consequent tension, 
 which give rise to the bad symptoms. 
 
 BOYER^ ascribes the bad results of wounds to the action of 
 air on them ; but he also considers that putrid pus is a bad 
 application. His method of treatment was accordingly to apply 
 masses of charpie over the wound in the first instance, and to 
 leave this dressing on for several days. In this way he excluded 
 the air till granulations had formed, and he looked on them as 
 sufficient protection of the wound against the influences of the 
 air. He therefore afterw-ards changed the dressings frequently, 
 in order to remove the putrid pus. 
 
 I need not go over his results in compound dislocations, 
 wounds of joints, &c. So far as they are given, they do not 
 differ essentially from the results of others. Thus six cases of 
 wounds of joints are detailed, of which four died, and Phil. 
 Boyer, who edits the work, refers to ten cases, all of which ended 
 unfavourably. 
 
 I have included a few writers of the present century along 
 with those of last century, because they merely speak of results 
 obtained by methods practised at that time. The whole facts 
 as yet stated may therefore be taken as showing the state of 
 surgery up to the year 1809. 
 
 Let us now methodise the results as yet obtained from an 
 antiseptic point of view. 
 
 The bad effects of the air, down to Priestley's discovery, 
 were generally supposed to be due to the temperature of the air. 
 Pare and others had, however, as we have seen, added to this 
 view the further supposition that it carried miasms to the 
 
 ' Cliniqne Chiriirgicale, 1829. 
 
 * Traitv de^ 3/aladii's CMrurgicales, &c., edited bj^ P. Boyer, 1844. 
 
WATER DRESSING: VON KERN. 315 
 
 wound ; while Benjamin Bell first spoke of the bad effects of 
 the gases, more especially of the ' fixed air.' We shall see 
 that this latter view has been more developed in recent times. 
 
 Others, looking on the putrefaction of the discharges as a 
 potent source of evil, attempted to prevent this by the appli- 
 cation of various balsams and other antiseptics ; and, in two 
 instances (Colbatch and Bilguer), with very great success. 
 
 Many surgeons, however, saw in the better results of their 
 time merely the effect of simplification of dressings, and, act- 
 ing on this idea, they reduced their dressings to a minimum. 
 Among those who held this view, and who have not been men- 
 tioned, were Lombaed ^ and Percy,^ who, in 1785, learaed from 
 an Alsatian that he had an infallible remedy for wounds. This 
 turned out to be river water used along with certain magic 
 utterances. Percy and Lombard employed water henceforth 
 in various ways, and became enthusiastic in its praise. 
 
 In 1809 ViNCENZ VON Kern published a little book entitled 
 ' Avis aux Chirurgiens, pour les engager a adopter une methode 
 plus simple, plus natm^elle, et moins dispendieuse dans le 
 pansement des blesses.' In his method the wound was washed 
 with tepid water, left open for eight to ten hours, then united 
 with strips of plaster and covered with light compresses dipped 
 in tepid water. To provide a drain the ligatures were all 
 brought out at one part, or else a piece of oiled lint was intro- 
 duced at one of the angles. U'he wound was cleansed once or 
 twice daily by washing it with tepid water. In some cases he 
 applied poultices. He says : ' Cold water for arrest of hemor- 
 rhage, then warm water for the dressing, some small pieces of 
 lint, absolute rest, and artificial heat : see ! that is all that is 
 necessary for the treatment of any sort of wound.' 
 
 Von Kern held, that the ordinary methods of dressing 
 heated the wound and favoured inflammation and suppuration ; 
 that they iiritated it mechanically and chemically and, in the 
 case of stumps, by their weight, caused retraction of the soft 
 parts. He considers air as not only not hurtful, but in fact 
 useful. ' Folget meinem Beispiele : ' he exclaims. ' Durch 
 
 ' Cliniqve Clnriirgieale relative ait.r Pfaiex, 17i)8. 
 
 2 Manuel (In Chirurgieu (VArmve, 1792. See also Ojnigcules de Medecine, 
 &.C., 1827. 
 
.31G IIISTOBY OF ANTISEPTIC SURGERY. 
 
 Anwendung dieser Grimdsatze werdet ihrden Kriegern unend- 
 liche Schmerzen und dem Staate Millionen ersparen.' 
 
 Von Kern's method, which was essentially water dressing 
 — a septic dressing- — and w^hich I mention chiefly as a matter of 
 history, was adopted by Von Walther in Bonn, and by Fritze 
 in Prague. It was brought to England more especially by 
 LiSTON, and up till 1860 was pretty generally adopted in this 
 country. 
 
 It did not spread much in France ; and here is Eochard's ' 
 explanation, which is well worthy of careful attention : ' Si ce 
 mode de traitement, si rationnel et si economique, n'a pas pu 
 se generaliser en France, cela tient surtout aux conditions hygie- 
 niques des hopitaux de nos grandes villes. Les Anglais, plus 
 favorises que nous, ne voient pas I'infection purulente incessam- 
 ment suspendue sur la tete de leurs malades, et c'est cette menace 
 qui a de tout temps preoccupe les chirurgiens de Paris. Les 
 pansements a Veau ne leiir ont pas offert centre elle une 
 garantie suffisante ; il fallait des preservatifs 'plus certains,^ 
 ou qui du moins parussent I'etre, et a I'epoque a laquelie nous 
 nous reportons (1860) ils se livraient a cette recherche avec une 
 ardeur et une fecondite d'imagination des plus louables.' 
 
 In the further history of this subject we must, up till quite 
 recent times, confine our attention to the progress of wound 
 treatment in other countries. In England, where better 
 hygienic conditions prevailed, this subject was almost entirely 
 neglected ; and the chief aim of the surgeon was to perfect the 
 methods and instruments for operating, and to attain great 
 speed and dexterity in the performance of operations. 
 
 ' Histoire de la Cliirurgic Franqaixi', 1875. - The italics are luine. 
 
THE INCUBATION METHOD. i>l7 
 
 CHAPTER XV. 
 
 HISTORY OF ANTISEPTIC SURGERY — {continued). 
 
 History of the various methods. Incubation: Guyot. Subcutaneous surgery, 
 preliminary attempts: >Stromeyer : Dieffenbach : Jules Guerin : Langen- 
 beck : Other authors. Occlusion : Jules Guerin : Chassaignac — Rochard's 
 remarks : Pansement ouate — Alphonse Guerin, method and results— Oilier. 
 Substitution of various gases for air : Demarquay and Leconte. Open 
 Method: Bartscher and Vezin : Burow : Humphrey. Healing by scabbing : 
 John Hunter : Neudorfer : Bennion : Lister : Bouisson : Bonnet, etc. 
 Irrigation and the water-bath : early history : Josse : Berard : Mayor : 
 Amussat : Langenbeck : Vfdette. 
 
 We mu.st now trace the different modes of treatment to which 
 the ideas as to the cause of the bad effects which often follow 
 wounds have given rise. 
 
 Incubation. 
 
 As has been already mentioned, the view for a long time was 
 that it was the cooling and drying effect of the air on the wound 
 which had to be guarded against. Since Priestley's discovery 
 this idea has been more or less abandoned ; but in 1835 and 
 later, M. Jules Guyot ' studied the effects of cold, and attempted 
 to found a method of treatment on his views. Guyot adduces 
 evidence from Pare and Larrey to shew that wounds cicatrise 
 most rapidly in warm air. Larrey, in his ' Campagne d'Sgypte,' 
 states that the wounds in that hot climate cicatrise with as- 
 tonishing rapidity ; and in his ' Campagne d'Allemagne ' he 
 makes the opposite remark as to the deleterious effects of 
 cold. Guyot accordingly made a series of experiments on ani- 
 mals, and found that when wounds were kept at a temperature 
 
 ' Archives Gencrak'S de Medfcine, Vol. VIII. 183.5. .See also De V Incubation 
 et de soil, Infltiencethcrapcutiqne,Va.x'\ii, 1840; and Z>t' la Chalcnr danslc I'raitc- 
 mcnt drs I'laies, 1842. 
 
318 HISTORY OF ANTISEPTIC SURGERY. 
 
 of about 35° C, they healed with great facility, and much more 
 rajjidly than similar wounds left exposed to the ordinary tem- 
 perature. 
 
 He applied this method to wounds in man. His object was 
 to smTound the part with a uniform and sufficiently elevated 
 temperature (about 36° C, and not below 28°-30° C.) He en- 
 closed the wounded part, without any dressing, in a box, into 
 which a cmTent of warmed air was constantly introduced through 
 a pipe. The box had glass sides, so that the wound could be 
 always seen. This treatment was continued for from ten to 
 twenty days. At first there was a very abundant serous dis- 
 charge and by-and-by pus. The pus dried up, forming crusts, 
 which were removed every two or three days. Guyot says that 
 wounds thus treated heal more rapidly than by any other 
 method, and also that wounds, such as some forms of ulcers, 
 which refused to heal at the ordinary temperature, healed 
 readily at a temperatm-e of 36° C. 
 
 This method only merits the term antiseptic to a limited 
 extent. No doubt the heat made the discharge more concen- 
 trated, and possibly unfit for the growth of organisms, while at 
 the same time mechanical rest was obtained. Nevertheless, the 
 method did not fulfil the expectations of its introducer, and, 
 partly for that reason, and partly also because it was so 
 unwieldy, it has been completely abandoned. 
 
 Subcutaneous Surgery. 
 
 A much more important outcome of the idea of the bad 
 effects of the gases of the air was, however, the introduction of 
 the SUBCUTANEOUS method — a method which has maintained its 
 place up to the present time and will probably always continue 
 to do so to a certain extent. 
 
 Already in the last century, and indeed earlier, the founda- 
 tion of this method had been laid. Delacroix and Axel, by 
 their methods of aspirating cavities containing blood or pus, 
 and more especially Aberxethy, by his valvular incisions into 
 abscesses and into joints, had carried out the principle more or 
 less completely. Nevertheless it is to the introduction and 
 practice of subcutaneous tenotomy that we owe the spread of the 
 subcutaneous method. 
 
SUBCUTANEOUS SURGERY. 319 
 
 In 1807, Sir Charles Bell advised the subcutaneous 
 division of the ligaments by means nf a cataract needle in cases 
 of irreducible dislocation of the thumb. There seems to be no 
 evidence, however, that he ever put his suggestion into practice. 
 
 The first real attempt at conducting an operation under the 
 skin was made by DELPECHin 1816.^ Delpech, in spite of what 
 has been thought and said to the contrary, performed the opera- 
 tion of tenotomy in this way in order to avoid the contact of 
 the air with the divided tendon. Of the air he says : ' Get agent 
 etait au moins un stimulant de plus qu'il paraissait prudent 
 d'eviter ; c'est dans ce dessein que nous avons pratique notice 
 operation, de maniere a ne point interesser la peauqui recouvre 
 le tendon.' The old method of dividing tendons was to make a 
 longitudinal incision over the tendon, expose and divide it. 
 Delpech made a small incision on each side, introduced a narrow 
 knife, and divided the tendon without exposing it. Unfor- 
 tunately suppuration occurred in his first case. 
 
 Probably in this same year Bransby Cooper divided the 
 tendo Achillis subcutaneously. 
 
 In 1817, Benjamin Brodie applied the same principle to 
 a case of varicose veins, which he divided subcutaneously. 
 This operation was at a later period revived by Eicord. 
 
 Astley Cooper, probably looking at division of tendons 
 from the old point of view, objected to subcutaneous tenotomy, 
 but he recommended subcutaneous division of contracted palmar 
 or plantar fascia, and in 1822 Bransby Cooper performed such 
 an operation. Neither surgeon makes any remark about the 
 principle on which these operations ought to be performed. 
 
 In the same year (1822) Dupuytren performed the first 
 subcutaneous myotomy. The muscle operated on was the 
 sterno-mastoid. The account of the operation is not i)ub- 
 lished, so far as I can find, by himself, and the accounts given 
 in various works differ much. It seems, however, to have 
 been a case of contracted sterno-mastoid in a female, and 
 Dupuytren divided the muscle subcutaneously, not from any 
 idea of excluding the air, but simply with the view of avoiding 
 a large scar. Indeed his incision seems to have been more 
 than an inch long, so that only })art of the o})eration was done 
 
 ' JJc VOrthomorphii-, kc, 1828-29. 
 
320 HISTORY OF AXTISEPTIC SURGERY. 
 
 subcutaneously, and it was not at all performed on the sub- 
 cutaneous principle. 
 
 In 1830 DiEFFENBACH^ spcaks of Dupuytren's operation as 
 having been frequently performed with success, and Syme, 
 among others, repeated it in 1832 strictly subcutaneously. 
 
 The various attempts at subcutaneous surgery which I 
 have mentioned remained, however, in the main fruitless, till 
 Stromeyer, and after him Dieffenbach, took up the subject. 
 
 Stromeyer seems to have performed his first operation in 
 1831, and his first publication was made in 1833.^ He only 
 operated on tendons. The object of his operation is distinctly 
 stated to be the exclusion of the air by making as small an 
 incision in the skin as possible. He looked on suppuration and 
 sloughing of the tendon as the consequences were air admitted. 
 He improved Delpech's operation by omitting one of the 
 incisions, simply making a single incision of sufficient size to 
 permit the introduction of a narrow-bladed knife. In his 
 'Beitrage zur operativen Orthopiidie,' published in 1838, he 
 narrates a great number of cases of division of various tendons 
 throughout the body. 
 
 Dieffenbach, who had been perforndng Dupuytren's opera- 
 tion pretty extensively, no sooner heard of Stromeyer's results, 
 than he at once adopted the practice, and his publication in the 
 ' Archives generales de Medecine,' in 1835, narrating numerous 
 cases, excited the greatest interest, and along with Stromeyer's 
 results firmly established the method. 
 
 The most important writer on the subject, though in no 
 way possessing any claim as its originator, was undoubtedly 
 Jules Gu^rin. Though, as I have said, not possessing any 
 claim as originator of the method, he was the first to study, 
 and describe accurately, so far as the state of science at that 
 time permitted, the principles on which subcutaneous surgery 
 was based, and thus he paved the way for the more general 
 application of these principles. In his ' Methode souscutanee,' 
 published in 1841, he describes his views m detail, and gives 
 a number of results. His first operations were performed in 
 1836, and in these he remarked the constant absence of in- 
 
 ' See also (Jchcr die Darchxelinruliiiui dcr Sc/inr/i itnd Miislaln, 18-11. 
 * Uchcr JJurvksclinciduvg dcr Achilles Schnc. linsfs JIutjaziii, Bd. iJ'J. 
 
SUBCUTANEOUS SURGERY. 321 
 
 jflammation, and the rapid organisation of the wound. Com- 
 jmring his results in this respect with the details given by 
 Dieffenbach, Lisfranc and others, in which the frequent occur- 
 rence of inflammation and abscess is mentioned, he came to 
 recognise the principles of subcutaneous surgery to the full, or 
 at least so far as they could be recognised in the then state of 
 science. He was thus led to establish the following law : 
 ' That all wounds made subcutaneously, whatever be their seat 
 and the natm-e of the tissues divided, possess the property of 
 subcutaneous injuries of tendons, that is to say, do not inflame 
 nor suppurate, but undergo immediate organisation.' Both on 
 man and animals he found that the most extensive wounds, 
 such as division of the great mass of the dorsal muscles, were 
 not followed by any trace of inflammatory symptoms. 
 
 He indicates some of the applications to which this principle 
 of making the wound under the skin may be applied. Of these 
 the following are the most important : Incisions into serous 
 pouches ; subcutaneous incision of commencing inflammatory 
 swellings ; subcutaneous removal of exostoses, leaving the de- 
 tached portion to be absorbed, or to be removed after healing 
 of the bone ; opening chronic abscesses ; numerous myotomies 
 and tenotomies of all kinds. 
 
 About this time various operations other than tenotomy 
 were performed subcutaneously. Thus Barthelemy, Mal- 
 GAIGNE and Velpeau (the two former with success) opened 
 ganglia subcutaneously. M. Ricord, as we have mentioned, 
 operated subcutaneously on the veins in varicocele. He pre- 
 ferred to ligature them. 
 
 DuFRESNE Chassaigne, and about the same time, or some- 
 what later, Goyraud and Syme, proposed and carried into 
 effect a subcutaneous method of removing loose cartilages from 
 the knee-joint, by dividing the capsule subcutaneously, expelling 
 the cartilage, and leaving it in a bed in the cellular tissue, 
 from which it could be extracted at a later period. 
 
 In England, William Adams ' published a pamphlet on sub- 
 cutaneous surgery in 1857, in which he shews himself a strong 
 advocate of the subcutaneous method. In support of the 
 generally accepted views as to the principles of subcutaneous 
 
 ' Subcutaneous Siir'jcry, 1857. 
 Y 
 
322 niSTORY OF ANTISEPTIC SURGERY. 
 
 surgery, he quotes the following passage from Paget : ' For of 
 the two injuries inflicted on a wound, the mechanical disturb- 
 ance of the parts, and the exposure to the air of those that were 
 covered, the exposure, if continued, is the worst. Both are apt 
 to excite inflammation ; but the exposure excites it most 
 certainly, and in the worst form, i.e., in the form which most 
 delays the process of repair, and which is most apt to endanger 
 life.' 
 
 As pointed out by Dr. Henry Dick,^ Jules Gruerin, by his 
 operation for removing exostoses, must be looked on as the first 
 to operate subcutaneously on bones. Langenbeck, however, is 
 the man who has popularised subcutaneous osteotomy. The 
 idea first occurred to him during the Schleswig-Holstein war, 
 in 1848, where he had introduced small straight pointed saw^s 
 for section of bones. His first operations were not strictly sub- 
 cutaneous, but in 1852 he practised subcutaneous operations for 
 anchylosis of the knee, and he soon extended his method to the 
 division of rickety bones. Meyer seems to have operated more 
 perfectly for rickety deformities. Gross, in 1859, j^erformed 
 osteotomy for deformity of the femur. This operation was 
 followed by abscess at the seat of fracture, but the patient made 
 a good recovery. 
 
 In 1869 Adams'- extended this principle to division of the 
 neck of the femur for anchylosis of the hip-joint. 
 
 Quite recently Ogston has divided the internal condyle of 
 the femur subcutaneously in cases of genu valgum. Ogston 
 however always operates with strict Listerian precautions, but 
 other surgeons still practise the operation subcutaneously, 
 without bad result. 
 
 Occlusion. 
 
 Attempts have been made at various times to apply the 
 supDosed subcutaneous principle of the exclusion of gases in 
 the treatment of wounds, not in the first instance subcutaneous. 
 I'hus have been produced the various methods of treatment by 
 occliislon. We have already l^ecome acquainted with the at- 
 
 ' Adams' Suhciitaneoux Snrcicrij. 
 
 '■' ^1 Niiw Operation for Bony AnclujJosis of the Iliji- joint, 1871 
 
OCCLUSIOX. 323 
 
 tempts of the ancients to exclude the air, by applying masses of 
 di-essings. I do not refer to these, but to the more recent 
 attempts which have been made since the principles of sub- 
 cutaneous surgery have been discussed. 
 
 In 1839, in a memoir communicated to the Academy on the 
 subject of subcutaneous surgery, Jules Guj^RIN ascribed its 
 good results to the exclusion of the air from the wound. He 
 further enunciates as a proposition : ' Que les applications du 
 phenomene de rorganisation immediate des plaies souscutanees 
 sont de ramener toutes les plaies avec libre communication a 
 Fair aux conditions des plaies souscutanees.' 
 
 From that time he tried various means for the purpose of 
 converting open wounds into subcutaneous ones, such as the 
 application of goldbeater's skin, caoutchouc, &c. ; of these he 
 considers, in 1844,^ that goldbeater's skin gave the best results. 
 In 1844 Laugier also described a similar method of treatment 
 in a paper entitled ' Sur I'heureux emploi du mucilage de 
 gomme arabique et de la baudruche dans le traitement des 
 plaies suppurantes.' 
 
 Chassaigxac- also brought forward an identical method, and 
 claimed priority over Jules Guerin. Chassaignac used the 
 method in abscesses, as well as in wounds. He held that the 
 Avails of abscesses, whether acute or chronic, resembled the 
 surface of a recent wound, and by opening them by a small 
 puncture he hoped to get adhesion of the walls. He covered 
 his puncture with diachylon piaster. (There is here nothing 
 essentially different from Abernethy's method.) Plve years 
 later Chassaignac said that this method had been so successful 
 that he had never observed a single case of erysipelas, of 
 phlegmon, or of hospital gangrene, even in the most unhealthy 
 hospitals, imder this method. Nevertheless, when he began to 
 work at drainage he readily abandoned occlusion. 
 
 Kochard's ^ remarks on Chassaignac's statement are very 
 much to the point, and well worth quoting : ' Ce n'est i)as 
 sans quelque etonnement qu'on voit se produire de pareilles 
 assertions a chaque nouvelle methode qui apparait. En les 
 jircnant an i)ied de la lettre, on serait force d'en conclure que 
 
 ' Gazette Mi'dlcnlc, l^H. ^ Annalcs da ThcrapeKtujiie, \Mi. 
 
 ' IHstoiro de la Chintnjie l'Vaii<;iiixe, 1875. 
 
324 HISTORY OF ANTISEPTIC SURGERY. 
 
 les accidents consecutifs des plaies doivent etre a peu pr^s 
 inconnus dans les hopitanx de Paris, puisque tons les chirur- 
 giens qui y j)ratiquent se flattent de les eviter surement par la 
 methode qn'ils ont adoptee ; mais on ne salt que trop bien a 
 quoi s'en tenir sur ce point, et quant a ce qui concerne les 
 cuirasses de diachylon, Broca rappela qu'il avait vu mourir 
 d'erysipele a Lariboisiere, et dans le service meme de I'inventeur, 
 une femme qui avait ete pansee de cette maniere, a la suite 
 d'une ablation du sein. Chassaignac, du reste, ne tarda pas a 
 modifier son traitement en y introduisant un element nouveau, 
 qui absorbe bientot tout le reste : on comprend que nous voulons 
 parler du drainage chirurgical.' 
 
 Collodion was introduced in America in 1848, as an applica- 
 tion to the surface of the line of incision. 
 
 In 1866,^ Jules Gruerin developed his ideas further, and 
 described a complicated apparatus for the purpose, not only 
 of excluding the air, but also of removing the discharge. He, 
 unlike Chassaignac, had failed in obtaining any very satisfactory 
 results from the methods formerly described, and he thought that 
 this was because, though the impermeable material was closely 
 applied in the first instance, it soon became lifted up by the 
 discharges from the wound, and thus air got in. Then he also 
 feared that by that method there would be accumulations of 
 discharge, and that if these became putrid, their presence would 
 be worse than that of air. I need not enter into a description 
 of his method, which consisted essentially in applying an appara- 
 tus fitting the limb closely, and from which the air was pumped 
 out. In this way none of the gases of the air were in contact 
 with the wound, while the discharges flowed freely out. He 
 stated that in cases so treated there had been no inflamma- 
 tion, or the inflammation had been shortened and reduced in 
 severity. 
 
 An absolutely identical method was brought forward in 1867 ^ 
 by Maisonneuve, as something c{uite new. The only difference 
 was, however, that, instead of pumping out the air once for all, 
 he was continually pumping it out, and he called this ' L'aspira- 
 tion continue.' 
 
 ' Gazette Midicale. '' CoMj?tcs-reu(Ivi<, Vol LXV. 181)7. 
 
OCCLUSION. 325 
 
 Lanxelongue also published a method, in which he used a 
 double-walled india rubber covering, and pumped air into the 
 space between its walls. The inner sac, applying itself closely 
 to the limb and the wound, prevented any air from coming in 
 contact with the latter. 
 
 There seems to be no doubt that whatever credit accrues to 
 any one for the introduction of these methods is due to Jules 
 Guerin ; and as the logical development of the view that the 
 noxious agents in the air are the gases of the air, these 
 attempts, with their failui'es, are of gi'eat interest and import- 
 ance. 
 
 In spite of the glowing terms in which Jules Guerin spoke 
 of his method, it was not found to be of any use in the hands 
 of others, while, what is of more importance, it broke down in 
 the hands of Guerin himself dming the siege of Paris. In a 
 discussion at the Academy of Medicine of Paris, in 1875, 
 on Alphonse Guerin's cotton-wool dressing, Jules Guerin was 
 asked about his results dm'ing the siege. He stated that at an 
 ambulance (I'ambulance des ponts et chaussees), to which he 
 was attached, he had treated only wounds by his method, but 
 wounds which would otherwise have led to amputation. He 
 said that his success was great, and that Nelaton, hearing of 
 it, asked him to apply his method to his (Nelaton's) amputation 
 cases. He tried it in three cases, all of which died, just as the 
 amputation cases treated otherwise did. Jules Guerin then 
 says : ' Cette effrayante mortalite avait sa raison dans I'infection 
 generale de I'hotel, qu'il etait impossible d'aborder sans en etre 
 averti par une odeiu* nauseabonde. . . . Je me borne a dire 
 qu'en presence de telles conditions j'ai refuse d'etendre au-dela 
 de ces trois sujets I'application de mes appareils au traitement 
 des amputations pratiquees dans un milieu aussi profondement 
 infecte.' These remarks are very interesting, as showing how 
 useless this method was to protect against such accidents in 
 situations favourable to their development, and also as showing 
 how very little confidence M. Jules Guerin himself had in it 
 when employed under unfavourable conditions. 
 
 A more important method of occlusion, and one which yields 
 much better results, is the ' PansemeiLt ouaU^ introduced by 
 Alphonse Gui-lmN in 1871. We have already seen (p. 280 
 
32G HISTORY OF AXTISEPTIC SVllGERY. 
 
 that this is really a method of occlusion, and not an aseptic 
 method, as asserted by its author. 
 
 The first publication was made by Hervey ^ in December, 
 1871, and several details of the method and results are there 
 given. I shall, however, refer to this paper later, and in the 
 meantime take some facts from Blanciiard's ' Thesis,' '^ pub- 
 lished in May, 1872. 
 
 The mortality during the siege of Paris was excessively 
 great; indeed, Hervey says that from September, 1870, till 
 February, 1871, A. Gruerin only saved one case of amputation. 
 Gruerin, who had for some time held the view that the cause of 
 pyaemia was a miasm carried by the air to the wound, came to 
 look on this miasm as particulate, though in 1869 he seems 
 to have regarded it as gaseous. Acting on the view that the 
 miasm was particulate, he applied large masses of cotton-wool 
 in the hope of excluding it by filtration. There are two other 
 principles on which this dressing acts, which are mentioned by 
 Blanchard, viz., elastic compression and constant temperature. 
 
 In using this dressing, ordinary rolls of cotton-wool are em- 
 ployed, and cotton bandages. The cotton-wool is applied in 
 such mass as to allow the most energetic compression without 
 pain, say from a half to two kilogrammes of the wool. A region 
 more extensive than the wound must be enveloped in it. 
 The two precautions to which I have referred before must be 
 attended to rigorously, viz. (1) the dressing must not be ap- 
 plied or renewed in the ward, but in an amphitheatre or room 
 at some distance from the wards ; (2 ) the cotton-wool ought 
 not to be opened in the wards, because there the air is always 
 more or less contaminated. Let us suppose that we have to 
 deal with an amputation wound. The ligatures having been 
 applied, are cut short ; the wound is then washed with tepid 
 water, in order to see the bleeding points, and afterwards with 
 some antiseptic liquid such as carbolic or alcoholic water ; the 
 limb is then dried and the cotton-wool is laid over all the 
 surface of the wound, new layers being applied till the stump is 
 completely filled. The limb is now enveloped with rolls of 
 cotton-wool as fiir as the upper part of the thigh. Then the 
 
 ' Pangemcnt a V Oiinte. ArcliivQS Ginu'rales dc Medccine, 1871. 
 - Jitudo snr Ic Panserncnt nvatc, 1 872. 
 
'FANSEMENT OUATE: 327 
 
 bandage is applied, at first lightly, but afterwards more and 
 more firmly. When it is sufficiently tight, the cotton-wool 
 will not yield any more, and the note on percussion is tym- 
 panitic. If the bandage gets loose, apply a new one. If the 
 discharge comes through, apply more cotton-wool outside the 
 dressing. If the smell is very bad, wash the dressing with 
 camphorated alcohol, or with carbolic acid, or place pieces of 
 camphor in the bed. As a rule the first dressing is changed 
 twenty to twenty-five days after the operation. After removing 
 the external layers, the deeper parts are moistened with water ; 
 the wound is then washed with an antiseptic lotion, and a 
 fresh dressing is applied. 
 
 The advantages which are claimed for this method are — 
 suppression of pain, absence of traumatic fever, diminution of 
 suppui'ation, and ease in moving the patient. 
 
 Blanchard states that during the first period, i.e. from April to 
 the end of June, 1871, forty-one cases of amputation and resection 
 wei-e treated in this way, and of these seventeen died. 
 
 Deaths 
 
 1 2 amputations of the thigh .... 6 
 
 11 „ leg' 6 
 
 6 „ upper-arm ... I 
 
 4 „ fore-arm .... 1 
 
 3 disarticulations at the shoulder-joint . . 
 
 h resections ....... 3 
 
 41 17 
 
 3 of these cases died of pyaemia. 
 2 ,, tetanus. 
 
 1 amputation of tlie thigh, from secondary haemorrhage after 
 
 twenty-seven days. 
 1 „ septicajmia ? no metastatic abscesses ; 
 
 1 „ shock. 
 
 1 „ an infant of two months : could not 
 
 be fed. 
 
 Of the remaining eight fatal cases some were not under A. 
 Guerin's care, and, according to Blanchard, were not well attended to. 
 Others died of pyaemia, even after they left the hospital. 
 
 In the following period there were : — 
 
 1 amputation of the thigh ..... ITealcd. 
 1 » Kreat toe 
 
328 
 
 HISTORY OF ANTISEPTIC SURGERY 
 
 1 amputation of the middle and first finger . . Healed. 
 
 1 „ index 
 
 1 resection of a finger 
 
 1 „ metatarsal bone 
 
 1 wound of hand , 
 
 1 ,, index . 
 
 1 „ thumb . 
 
 1 „ extremities of middle and ring fingers 
 
 (Truly a formidable series of cases to aid one in coming to a de- 
 cision on the advantages of the method ! ) 
 
 1 compound fracture of the radius .... 
 1 „ hiumerus 
 
 1 „ olecranon with opening of 
 
 the elbow-joint . 
 
 Further statistics are given by Hervey : — 
 
 1 compound fracture near the knee. 
 Resection, afterwards amputation, 
 exhaustion ..... Death. 
 
 1 amputation of thigh. High tempera- 
 ture and general unsatisfactory pro- 
 gi-ess ; injection of quinine . . „ 
 
 1 amputation of first metatarsal bone Healed. 
 
 Under M. Panas at Saint Louis : — 
 
 1 compound comminuted fracture of 
 both bones of the leg. Gangrene, 
 amputation, rigors . . . , 
 
 1 amputation of foi^e-ai-m for disease of 
 wrist. Advanced phthisis; diarrhoea 
 before opei-ation .... 
 
 1 amputation of the thigh for white 
 swelling ; eight days later 
 
 1 amputation of crushed foot 
 
 1 „ lower third of leg for 
 
 frost bite. Ulceration, necrosis, re- 
 amputation at seat of election 
 
 1 amputation (secondary) for crushed 
 foot 
 
 1 amputation of thigh (limb torn off') 
 
 Healed. 
 
 Death. 
 
 Sudden death. 
 Healed. 
 
 I give these statistics here, but I shall refer to them after- 
 
'PANSEMENT OUATE: 329 
 
 wards. Of course, in judging them, the infected state of the 
 atmosphere must be taken into account. 
 
 In this method no attempt was made to obtain primary 
 union, but in 1875, at the discussion on this method of dress- 
 ing at the Academy,^ M. Guerin stated that he then stitched up 
 his wounds before applying his dressings, and that he frequently 
 got union by first intention. He said also, that in the Hotel- 
 Dieu he had been having good results, but he does not give any 
 statistics which can be used. 
 
 At that discussion, Pasteur and others pointed out that this 
 was not an aseptic dressing, that bacteria and their spores were 
 present in the cotton-wool when applied, and could be readily 
 found in the discharge. Grosselin, who opened the discussion, 
 mentioned similar facts, and he ended by saying that the dressing 
 was good — (I) 'parcequ'il met a I'abri de Tinflammation suppura- 
 tive trop intense; (2) parce qu'il satisfait a cette indication par 
 sa grande qualite d'etre un pansement rare, qui maintient, sans 
 interruption, I'occlusion, la protection, I'immobilite, la tempera- 
 ture imiforme, I'insensibilite, et la satisfaction morale, toutes 
 conditions qui, si la sante anterieure n'estpas trop mauvaise, et 
 si rhygiene atmospherique n'est pas trop defectueuse, condui- 
 sent a ce resultat tres simple, et cependant bien grand, la 
 formation rapide et sans etrave d'une membrane pyogenique ou 
 granuleuse essentielle et promptement reparatrice.' 
 
 Of late Ouerin has wet the deeper layers of the wool with 
 carbolic lotion, and indeed in some cases uses a spray, for what 
 reason it is difficult to imagine. 
 
 Verneuil ^ also speaks very highly of this dressing, and 
 attributes its good results to the absolute immobility which is 
 maintained, for by this means the granulation layer is pre- 
 served intact, and thus neither bacteria nor their products 
 can enter the blood. 
 
 That it is not an aseptic method is evident from the whole 
 description, and that it is not a very powerful antiseptic method 
 is also evident. M. Verneuil, whose good results I have just 
 alluded to, says of it : ' Quelle que soit I'epaisseur des couches 
 entassees, le bandage, au bout de quelques jours, exhale un 
 odeur desagreable. Le pus qui baigne la plaie est d'u7ie 
 ' Bulletin, dc V AcaMnde dc Mcdccinc, 1875. '•' Am^mtutiuns, 1880. 
 
ti-P,0 HISTORY OF ANTISEPTIC SURGERY. 
 
 extreme fetidite. II renferme en quantite des vibrioniens et des 
 bacteries, dont la putridite existe dans les profondeurs du 
 pansement ; et si les gennes du dehors sont arretes au passage, 
 ceux du dedans sont emprisonnes et forment a la blessure una 
 atmosphere constante. Et qu'on ne dise pas que les matieres 
 putrides interieiues sont d'autre nature que les autres ; car il 
 resulte des experiences inedites de ]M. Poncet ' que le pus du 
 bandage inocule a des anvmaux a toutes les proprletes des 
 matieres sejAiqiies.^ He alludes to the following fact of extreme 
 interest : ' Un eleve de mon service, tres bien portant du reste, 
 etait dans ce cas. 11 etait charge du pansement d'un malade 
 atteint d'ecrasement des oiteils, et qui etait traite par I'ouate. 
 Chaque fois que Veleve renouvelait le bandage, il etait pris de 
 Tnalaise et de diarrhee presque subite, exactement comme 
 lorsqu'il faisait la dissection ou I'autopsie d'un sujet putrefie.' 
 
 M. Ollier,^ who soon saw the defects in this dressing, tried to 
 remedy them by soaking the deeper layers of the cotton-wool 
 in carbolic oil. He also applied a silicate bandage outside the 
 cotton bandage. In August, 1872, M. Poncet gave the results 
 of this modification. Of 10 patients operated on, 4 died — 2 of 
 septicaemia, and one of hospital gangrene. 
 
 In 1875, Oilier stated that he had got great benefit from 
 this modification. He said that he had seldom seen a case of 
 erysipelas ; indeed in one winter, when it was very prevalent, 
 only one case dressed in this way had erysipelas, while among 
 the wounds treated otherwise he had 22 cases. He also thinks 
 that when pyaemia appears under this dressing, it is of a mild form. 
 
 Substitution of various Oases for Air. 
 
 Other attempts were made to avoid the supposed evil 
 •effects of the gases of the air on wounds by substituting other 
 gases for them. According to Kochard, these attempts were 
 commenced in Clifton's laboratory while Humphry Davy was 
 there. Perceval, then I^gexhousz, Beddoes, and John Ewart 
 tned to utilise the analgesic properties of carbonic acid on ulcers. 
 These attempts were renewed by Mojon in 1834, and by 
 Simpson and Follin in 1856. 
 
 • Zyo/i J/rd., 187o. 2 CovijJtcs-reiidus, Vol. LXXX. 
 
APPLICATIOX OF CARBONIC ACID GAS. 331 
 
 Two years later Demarquay and Lecunte ^ published a 
 paper giving the results of an elaborate investigation on the 
 effects of injecting various gases into serous cavities, or into the 
 cellular tissue. The gases with which they experimented were 
 air, nitrogen, hydrogen, oxygen, and carbonic acid. They came 
 to the conclusion that none of these gases had any huiiful 
 action when injected into the peritoneal cavity, or into the 
 subcutaneous cellular tissue. 
 
 As to their effects on subcutaneous wounds, they state that 
 subcutaneous tenotomy wounds into which air is blown every 
 day organise much in the same manner and after the same 
 lapse of time as simple tenotomies. Oxygen alone, when intro- 
 duced daily, delays matters somewhat, but it never produces 
 the abnormal vascular conditions caused by hydrogen. Hydro- 
 gen retards the healing for an indefinite time ; indeed healing 
 may be incomplete even after seven and a half months. Carbonic 
 acid favours in a high degree the cicatrisation and organisation 
 of the wounds, and healing is complete in a much shorter 
 space of time than if the wound were left to itself. 
 
 From the result of these experiments they devised an 
 apparatus for the purpose of keeping wounds in contact only 
 with carbonic acid gas. In 1859 they say of the results : ' Many 
 patients affected with gangrenous ulcers, with diphtheritic 
 wounds or with wounds in an unhealthy state, having resisted the 
 ordinary methods of treatment, have been treated by us during 
 more than two years in the surgical department of the " Maison 
 municipale de Sante," and have healed with a rapidity which 
 was truly remarkable.' Similar experiments to those of 
 Demarquay and Leconte were performed by JMalgaigneIu 1844 
 with air, and he also came to the conclusion that air does not 
 impede the healing of woimds. 
 
 At the discussion on the influence of air on wounds in 1857 ^ 
 Velpeau denied that air as such was deleterious, and said : ' II y 
 a longtemps que je me suis attache a demontrer qu'il agitalors, 
 non a la maniere d'un irritant direct, rriais en ralson des 
 decompositions chimiques qu'il provoque dans les liquides. 
 
 ' Comj/frx-rendus, Vol. XLIX. 8cc also EhhuI dc PneuinatoLxjic Mi'd. Paris, 
 
 isor,. 
 
 - JSnllctiii dr V Acadi'-nne da Mvdcciiie. 
 
332 HISTORY OF ANTISEPTIC SURGERY. 
 
 Ge sont ces liquides, et non pas Vair, qui, alUres, denatures y 
 deviennent irritants pour les tlssus qu'lls toucJtent.'* 
 
 Open inethod. 
 
 While these discussions on the influence of the air, and 
 these attempts to exclude the air from wounds, were going on 
 in France, a method of treatment, apparently of the very oppo- 
 site character, was being employed in Grermany with better 
 results. I refer to the open method of treatment. 
 
 Though Von Kern and "Walther's methods were simply the 
 use of water dressing, yet many of their wounds were left quite 
 open. But the first to use the open method properly so called 
 were Bartscher and Vezin. The account of their method and 
 work is published in the ' Deutsche Klinik ' for 1856 by Dr. Vezin. 
 
 Thirty years before that time (aboutl826) Dr. Bartscher asked 
 Vezin to assist him at his first amputation of the thigh. After 
 the operation, the dressings were applied, and the patient was 
 left. During the night, bleeding having occurred, Vezin 
 was called. He removed the dressing, and tried to find the 
 bleeding point, but could not do so. He therefore concluded 
 that the htemorrhage was due to the pressure of the dress- 
 ing, and accordingly he did not apply a new dressing, but 
 simply brought the edges of the wound together by means of 
 strips of plaster. Next morning this plaster had slipped, and 
 the wound was quite open. No further dressing was applied, 
 and the wound healed well. 
 
 They soon found that wounds healed perfectly well, if left 
 to themselves, without any interference on the part of the 
 surgeon ; and ultimately they laid down the following as the 
 best method : — Insert no stitches, apply no dressing, simplj 
 throw over the wound a piece of linen to exclude the flies, 
 and use a cage to keep off the bed clothes. The pillow on 
 which the stump lies is changed daily, but no attempt is 
 made to cleanse the wound. During the first fourteen days little 
 progress is made. The w^ound becomes covered with crusts, 
 which crack and let the pus flow out. Healing is generally 
 complete in eight weeks. Their cases were treated in a small 
 hospital, each patient generally having a room to himself in the 
 first instance. 
 
OPEN METHOD. 333 
 
 Twenty-eight cases were treated in this way, with three deaths, 
 consisting of — 
 
 14 amputations of the thigh . . . No death. 
 
 6 „ leg . . .2 deaths. 
 
 (6 and 36 days after). 
 4 „ upper-arm . . 1 death. 
 
 (28 days). 
 2 „ fore-arm . . No death. 
 
 2 „ great toe, metatarsal „ 
 
 The causes of death are not given. 
 
 In 1859 BuROW ^ published his method, which differed from 
 the other in that the wound was only left open for half an hour 
 or so till all oozing had ceased. The edges of the wound were 
 then brought together by means of stitches and plasters, and a 
 piece of lint was laid over it to keep out the flies. The stump 
 swells up enormously during the first few days, and Burow 
 thought that this was a good thing. He says that healing is 
 much quicker by this method than by any other. In 1866 ^ he 
 gives details of ninety-four amputations performed by himself 
 or his pupils, with only three deaths. (Two further deaths 
 are excluded, viz., one from tetanus which was present before 
 the operation, and the other in which the patient lost a great 
 deal of blood, and where Burow did not himself complete the 
 after-treatment.) 
 
 These cases were 
 
 :— 
 
 
 
 Amputation of thigh (upper third) 
 
 9: 
 
 cases (1 death). 
 
 
 „ (lower third) 
 
 12( 
 
 3ases(2 deaths), 
 
 j> 
 
 leg . . . 
 
 18 
 
 77 
 
 
 metatarsal and tarsal 
 
 
 
 
 bones 
 
 7 
 
 7> 
 
 j> 
 
 close to shoulder . 
 
 4 
 
 )) 
 
 j> 
 
 upper arm (vipper 
 
 
 
 
 third) 
 
 5 
 
 >J 
 
 5> 
 
 upper arm (middle) 
 
 7 
 
 J» 
 
 >J 
 
 „ (lower third) 
 
 7 
 
 >J 
 
 >> 
 
 fore-arm (upper 
 
 
 
 
 third) 
 
 4 
 
 7> 
 
 » 
 
 „ (lower 
 
 
 
 
 third) 
 
 24 
 
 J> 
 
 ' Deutsche Klinilt, 1859. '■' Deutsche Kliinh. Xo. 24. 
 
3.^4 HISTORY OF AXTISEPTIC SURGERY. 
 
 In 1859 Burow discusses tlie causes of death in cases where 
 dressings are applied. He says that the bandages prevent the 
 swelling of the soft parts which was so very noticeable in his cases. 
 Pluofs of blood clot of a certain size form in the veins. When 
 the bandage is removed, the limb swells, and these plugs become 
 too small for the veins, and may be carried away, and cause 
 emboli and pyremia. Burow also refers to the bad practice of 
 using unclean sponges, instruments, &c. 
 
 In a later paper ^ (1876) he speaks of his great success in 
 excision of the mamma. He had operated on 53 cases during 
 the last ten years, without a single death. In these instances, 
 however, he washed out the wounds immediately before stitch- 
 ing them up with a mixture containing chiefly acetate of 
 alumina, which we now know to be a powerful antiseptic (see 
 p. 139). He also dressed suppurating wounds with pledgets of 
 lint soaked in this solution and covered with gutta percha ; 
 and he himself speaks of the powerful effect of the solution in 
 arresting putrefaction. These cases were, therefore, not treated 
 by the open method, but by the addition of an antiseptic 
 substance to the discharge, in many cases, no doubt, by com- 
 plete exclusion of bacteria, i.e., on the Listerian or aseptic 
 principle. 
 
 The chief advocate of the open method in England has been 
 Dr. Humphrey, of Cambridge, whose great success at the 
 Addenbrooke's hospital is well known. In a lecture on the 
 treatment of wounds without dressings (1867),^ he says: 'What 
 is the great requisite — the sine qua non — for the immediate 
 imion of wounds ? Obviously, adaptation of the cut surface. 
 Unless these are placed in apposition, they cannot easily unite. 
 Hence the want of union is commonly })roportionate to the 
 want of apposition of the surfaces ; and one great object in the 
 treatment must be to secure as exact an apposition of the cut 
 surfaces as possible, and to reduce to the minimum all sub- 
 stances, blood, dressings, ligatures, &c., that may intervene 
 between them, and keep them apart. In the case of small and 
 superficial wounds, there is little difficulty about this. Some 
 simple method answers, and they heal at once.' In large 
 wounds, the edges are brought together by means of sutures, 
 
 ' ArcMr fiir Klin. Chir. XX. ^ British Medical Journal. 
 
HEALISG BY SCABBING. 335 
 
 and afterwards no application is employed with the exception 
 of warm water dressing or poultices (rather opposed to the 
 antiseptic element !), which are occasionally applied after a few 
 days. 
 
 On the influence of air on wounds, he writes : ' But I am 
 sometimes asked, is it not better to exclude the air ? Is not the 
 air a source of mischief ? Is not the well-doing of subcutaneous 
 wounds due in great measure to the exclusion of the air ? To 
 this I reply that it is certainly well to exclude air from the 
 interior of the wound, where it keeps the surfaces apart, and 
 promotes the decomposition of the fluids, and perhaps of the 
 solids. On the surface of the wound, however, that is on the 
 skin, it does not act as an in-itant, and we should scarcely 
 expect that it would. We have long been in the habit of 
 leaving wounds of the face uncovered, and they usually heal 
 remarkably well. Why should we not follow the same practice 
 in other parts of the body ? ' Hiunphrey used acupressure 
 instead of ligatures. 
 
 The open method was for a time pretty generally adopted in 
 Germany and Eussia, and to Kronlein's work on the subject I 
 shall have to refer later. Of late, however, it has almost 
 entirely given place to one or other mode of treatment with 
 antiseptics. 
 
 Healinrj by Scahbiixj. 
 
 As we have already seen at p. 279, this is a nearer approach to 
 aseptic treatment than the open method. As I have previously 
 stated (p. 310), John Hlnter made extensive use of this prin- 
 ciple in the case of small wounds. He sometimes applied 
 various powders to aid the formation of the crust. 
 
 Since Hunter's time numerous attempts have been made to 
 carry out his principle of applying powders to aid the forma- 
 tion of crusts, but though they have answered very well in 
 small wounds, they have not succeeded in large. Discharges 
 collect l)eneath them, and tension is the result. 
 
 Among the substances employed in tliis way, have been 
 various antiseptics, and of these may be menti(»ned Nkudorfkk's ' 
 powder. He uses salicylic acid, in tlie foi-)n of a jjowder, 
 
 ' Dir Chirurij'iHclu' Ik'liandhiiHf th r Wiindcn, 1877. 
 
336 HISTORY OF ANTISEPTIC SURGERY. 
 
 mixed with other substances, such as starch, zinc oxide, &c. 
 He dusts the wound with the powder, and rubs it up with the 
 fluids of the wound. Thus a mass is formed, which is again 
 rubbed up with fresh powder till no more fluid comes ; then 
 over the whole some pure salicylic acid is applied, and a bandage. 
 This crust is left on, and if on pressure on it some fluid exudes, 
 more powder is applied. This is generally necessary five or six 
 times during the progress of a case. This method is really only 
 of use in small wounds. The objections to its use in large 
 wounds are that the pain is great, the material is expensive, 
 and there is very apt to be confinement of discharge. Neu- 
 dorfer states that there is no bad smell in the cases treated in 
 this way. Among them he has had no bad case of pyasmia, 
 hospital gangrene or tetanus. He cannot say much about 
 erysipelas. As a rule, in the cases which were attacked, it was 
 generally some other part of the body which was affected. 
 
 Both James Moore and Astley Cooper tried to obtain crust 
 formation by means of char-pie, and the same sort of method 
 was employed by Syme. The latter surgeon, after bringing 
 together the edges of the wound, covered it with a piece of 
 dry lint, which was left on for several days. 
 
 The combination of a piece of lint tuith an antiseptic was 
 the method employed by Bennion of Oswestry. To quote 
 Wm. Adams, who mentions this treatment in his publication in 
 1857,^ Bennion's method in compound fracture was — 
 
 ' 1st. Immediate reduction; and in secm'ing a good apposi- 
 tion of the fractured surfaces, he would frequently employ more 
 force than many surgeons might think prudent, so that he very 
 rarely had occasion to saw off any portion of bone. 
 
 ' 2nd. He cleared away all the blood from the wound, con- 
 siderino' that it interfered with the reparative process, and 
 brought the edges of the wound into apposition. He then 
 covered the wound with a large bit of lint, saturated with 
 compound tincture of benzoin, and bandaged the entire limb, 
 firstly by itself, whilst extension was being kept up by an 
 assistant, and then to a well-fitting splint adapted to the case ; 
 in the lower extremity he used a straight splint. 
 
 ' 3rd. He put the patient at once under the influence of 
 ' Subcutaneous Surgery, 1857. 
 
CRUST FORMATION. 337 
 
 opium, upon which he placed great, reliance, and kept up its 
 action for a considerable time, according to the circumstances 
 of the case. 
 
 '4th. He never disturbed the first dressing or bandage, unless 
 urgent symptoms indicated the necessity for so doing. If such 
 symptoms did not appear, he would allow the first dressing to 
 remain a month.' It seems that Bennion had some very re- 
 markable successes by this method. 
 
 Mr. Lister's first attempts to form a crust by means of 
 carbolic acid have been already alluded to on p. 128. 
 
 Crust formation has been aided by the drying of the dis- 
 charges. This occun-ed in GtUYOt's cases, though he did not 
 aim at it. It was, however, the principle in the often miscon- 
 strued method of Bouisson,i the so-called ' ventilation of 
 wounds.' Bouisson's method consisted in blowing air on to the 
 surface of a wound by means of a caoutchouc bag. He generally 
 directed the patient to do this himself. The ' ventilation ' 
 lasted a variable length of time, according to the extent of the 
 surface and the quantity of fluid. A quarter of an hour 
 generally sufficed for each seance, and this was repeated four 
 or five times a day. The first crust which formed was rarely 
 sufficiently thick or firm, but by-and-by the crust became of 
 sufficient thickness, and when this was obtained, the ventilation 
 was stopped. If the crust seemed to be confining the discharge 
 and doing harm, it was softened and removed, and the process 
 begun again. 
 
 Such was Bouisson's method of obtaining a crust, and as 
 this method has been often quoted as shewing what a slight 
 effect atmospheric dust exercises on a wound, it is interesting 
 to note the advantages he claims for it. These advantages 
 are: 1. A sedative action. Bouisson says that the pain di- 
 minishes so much that the patients often continue the ven- 
 tilation for a long time. 2. Astringent action, so that the 
 vessels are constricted and there is less tendency to inflam- 
 matory congestion. 3. Drying action, i.e. the formation of a 
 crust. 4. This crust exercises a protective action, protecting 
 the wound from the air, and also lessening the quantity of 
 seca'etion. 5. Antiseptic action : from the evaporation and 
 
 ' C'oi>H)tcs-rcndus, t. i7,"1858. 
 Z 
 
338 HISTORY OF ANTISEPTIC SURGERY. 
 
 concentration of the jfluids, decomposition cannot occur. He 
 says : ' Le contact de I'air et de ce liquide ' (the discharges 
 from a woimd) ' sous Finfluence de la chaleur animale deter- 
 mine la formation des produits putrides sulfhydriques ou 
 ammoniacaux, isoles ou combines, et leur abondance contribue 
 a faire naitre des phenomenes typhiques ou ataxiques chez ceux 
 qui se trouvent places dans ces facheuses conditions. La ven- 
 tilation des surfaces suppurantes a necessairement pour effet 
 de prevenir ou d'empecher de pareils resultats, et Ton peut 
 dire qu'a ce titre elle est autant un moyen d'hygiene generale 
 dans les hopitaux qu'un artifice local pom- prevenir la resorption 
 putride.' 
 
 In his conclusions, in which he lays stress on the points 
 already mentioned, he says that wounds and ulcers so treated 
 heal sooner and with fewer accidents, either primary or second- 
 ary, than wounds treated with dressings, or with any sort of 
 medicament. He lays special stress on the avoidance of danger 
 from a septic state of the pus. He recommends the use of 
 this method in all small or medium sized wounds, ulcers, 
 bm"ns, &c. 
 
 The last mode of forming a crust which it will be necessary 
 to mention is by catiterisaticm. This has been resorted to by 
 various surgeons ; first, I believe, by Faire. An exhaustive 
 paper on the subject was published in 1843 by Bonnet,^ The 
 cauterisation may be done in various ways, either by caustics 
 or by the actual cautery. Of caustics Bonnet finds that the 
 Vienna paste or chloride of zinc alone are the best. The latter 
 was extensively used by M. Canquoin and also by M. Gensoul. 
 Bonnet remarks that after its use he has never seen decomposi- 
 tion occur in the wound, or phlebitis and pyaemia. Bonnet 
 preferred the actual cautery for various reasons. He attributed 
 its good effects in the main to desiccation of the tissue, and he 
 used the actual cautery more especially in wounds which had 
 taken on a bad action. 
 
 Irrif/aiion and the Water Bath. 
 
 These are very efficient antiseptic methods, and indeed, I 
 
 believe, stand next in order of efficiency to strict aseptic mea- 
 
 ' See also Troitr 2>^'<it^>l>'<' fJ'' li' C(iuUnsatu>n , d\ij)rv» rcnselgxenient clmlqiir 
 Or A. Bonnet de Lijoii. Par 11. I'ljilipeaux, J8r)6. 
 
IRRIGATION AND THE WATER BATH. 839 
 
 sures, more especially when the water used is impregnated with 
 an antiseptic. 
 
 Without entering into the older history, I may mention that 
 Otius in 550 praises the use of cold water in recent injuries, 
 and in some cases used more or less continuous, irrigation. 
 Again Palatius in the sixteenth century recommends the use of 
 continuous irrigation with cold water, and speaks of having in 
 this way obtained excellent results. 
 
 Two centmies later Smith ^ in England (1725) and Lamorier 
 in France (1732) advocated its use. Lamorier, indeed, pre- 
 ferred prolonged water baths to in'igation. Lombard and Percy 
 used irrigation, and the former also employed water baths 
 pretty extensively. It was not however till the publications of 
 JossE and Berard on irrigation in 1835, and of Mayor on the 
 water bath about 1836, that these methods were fully re- 
 cognised. 
 
 During the further progi'ess of this method, the various 
 questions which have been agitated are, as we shall see, 
 whether the irrigation or the water bath was the best ; whether 
 these ought to be continuous or intermittent ; what the tem- 
 perature of the water should be ; and whether or not some 
 antiseptic substance should be added to the water. 
 
 The first, as I have said, who in recent time called attention 
 to this subject, was Josse ; his work containing his views was 
 edited by his son in 1835.^ His reason for using irrigaticm 
 was, that in this way a continuous and more perfect application 
 of cold could be obtained. He used it in all the larger wounds, 
 and in all inflammatory states. The ap])aratus which he em- 
 ployed was essentially the same as that now in use. 
 
 In the same year Berard' (junior) published, quite indepen- 
 dently, a pa})er on the use of cold water as an antiphlogislic. 
 He also employed irrigation in order to obtain a constant diminu- 
 tion of temperature, which cannot be done, he thinks, by the 
 application of cloths dipped in cold water, even though they 
 are impregnated with substances which volatilise quickly. He 
 
 ' llie C'm-iimfipx of Common Wafe); 172U. 
 2 Mi'lanr/tut de Cldrxmi'te prntiqne, <^'c., 1835. 
 
 ^ Mvmoire tur VimpUn de I'cau froide commc atitijj/iloffi.ttiqiir dans If 
 traitemcnt des maladieg chiriirfficakx, 18H5. 
 
 'A 2 
 
340 HISTORY OF ANTISEPTIC SURGERY. 
 
 mentions several cases which did very well. The only com- 
 plication, which he thinks is really to be dreaded, is death of 
 the tissues from the continuous cold ; but he says that this 
 rarely occurs except in severe contusions. 
 
 In 1838 NiVET ^ published a paper giving some of the results 
 of this method. He mentions, among other cases, nine com- 
 pound fractures so treated, of which seven recovered, five of 
 these without any local or general inflammatory symptoms. He 
 mentions various accidents which may occur, of which the fol- 
 lowing are examples : Pain (this generally soon disappears) ; 
 paralysis (observed in one case); oedema (combat by bandaging); 
 phlebitis (very rare); inflammation of the parts around the 
 fracture ; gangi'ene (generally only where the parts are much 
 injured); anchylosis or stiffness (where the partis kept for a 
 long time in one position). 
 
 About 1834 M. Charles Mayor published his work en- 
 titled ' De la Localisation des Bains sur les diverses parties du 
 Corps humain.' I have been unable to obtain this work, and 
 have had to content myself with a work published in 1846 
 called ' Les Bains sans Baignoires et ramenes a leur belle sim- 
 plicite.' His wish was to provide a permanent warm bath in 
 imitation of nature, for he says : * Is it with pledgets of charpie^ 
 with rags spread with various ointments, with compresses and 
 with bandages, cold and dry, that nature carries out the cure ? 
 Nature, wise and simple nature, contents itself with calling to 
 its aid a warm and permanent bath, which furnishes it plenti- 
 fully with lubricating fluids, thoroughly diffused over the 
 wound, and constantly being renewed.' He points out that 
 this bath keeps up an equable temperature, and that nature 
 uses it after removal of the tonsils, after operations for harelip, 
 after tenotomy, cataract, abdominal section, &c., and it is to 
 supply its place in external wounds that he proposes the use of 
 the permanent warm bath. INIayor described a variety of 
 apparatus for use in different situations. He did not jjlace the 
 whole body in the bath, but merely the diseased or wounded 
 part. His apparatus was so constructed as to permit the 
 renewal of the water without removal of the apparatus. The 
 temperature of the water was about 22°-25° C. The baths 
 
 ' Gazcttr midicale de Paris, 1838. 
 
IRBIGA TION. 341 
 
 were employed for several clays, till in fact there was no fear of 
 the occurrence of accidents. 
 
 The advantages of irrigation were admitted by Nelatox, 
 and more especially by Malgaigne,^ who thought it best to use 
 it intermittingly, and so introduced ' intermittent inigation.' 
 Malgaigne considered that the temperature of the water ought 
 to be regulated by the first sensations of the patient, and 
 that as a rule it ought to be tepid, i.e. about 20° C. Mal- 
 gaigne's term ' intermittent irrigation ' applied, however, more 
 to a sort of water dressing than to irrigation proper, the cloths 
 applied to the wound being soaked in water and changed at 
 fi-equent intervals. 
 
 Although at first the use of water was greatly resorted to, it 
 soon began to go out of fashion, chiefly, it was said, on account 
 of the accidents to which it might give rise, and when Amussat ^ 
 fils wrote his elaborate thesis on this subject in 1850, it was 
 but Httle practised. In this thesis Amussat deals chiefly with 
 the question of the temperature of the water. He and his 
 father, after long investigation of the subject, came to the 
 conclusion that many of the bad effects attributed to the em- 
 ployment of water were due to its being used cold. They found 
 that cold water from 0°-10° C, was a powerful antiphlogistic 
 and sedative, but that it was liable to do harm. Water at 
 30°-35° C. relieves pain in an inflamed part and promotes 
 suppuration : it however tends to cause congestion. Water 
 at 18°-25° C. has all the advantages of cold water without 
 its disadvantages : it abstracts heat, but does not cause con- 
 gestion. They recommend the use of soft water and water 
 containing few salts. Amussat considers that immersion is the 
 most effectual mode of applying water; next to that comes 
 irrigation, and, lastly, a form of water dressing which he 
 describes in detail. 
 
 Looking on imgation and the water bath simply as a means 
 of abstracting heat, Esmarch,^ in 1860, writes very strongly in 
 favour of cold, and he recommends iced water and even ice 
 itself. He mentions several cases in support of his views. 
 
 ' De Viri'u/ation dans les maladies cMrvry'woh's. These de concours, Paris, 
 1842. 
 
 ■' Dc I'emphn de I'eati en chirurgie, 1850. 
 ' Archil} fur kliii Chirurgie, 1860. 
 
342 HISTORY OF AliTISEPTIC SURGERY. 
 
 In 1872 ISAMBERT ' also writes in favour of cold irrigation, 
 but as there is nothing new in his work, I need not refer 
 fiu-ther to it. 
 
 While this discussion as to the temperature of the water 
 was being carried on, others were using the water bath with 
 the view of excluding the air and avoiding putrefaction. I 
 refer especially to the attempts of Stromeyer, Langenbeck and 
 Valette. 
 
 In spite of the writings of Mayor and Amussat, the perma- 
 nent water bath made but little progress till it was taken up 
 by IjANGENBECK. Since 1839 Langenbeck had made several 
 attempts to exclude air from wounds. These attempts resem- 
 bled those of Jules Guerin and others, previously mentioned, 
 but they were not successful in Langenbeck's hands, owing to 
 the confinement of the discharges. Accordingly, dming the 
 Schleswig-Holstein war in 1849, Langenbeck commenced the 
 use of the warm water baths with the view of excluding the 
 air. At the same time also Stromeyer made similar experi- 
 ments. During the next few years Langenbeck perfected his 
 method, and at length, in September, 1855, he published an 
 elaborate paper on the subject.^ 
 
 Just before the publication of Langenbeck's paper, Picard,' 
 who had been visiting Langenbeck's cUiiique, published an ac- 
 count of his practice and results in the ' Gazette hebdomadaire de 
 Medecine et de Chirurgie.' In this paper he speaks very highly 
 of the method, showing how it relieves pain, how there is but 
 little local inflammation or constitutional distiu-bance, how the 
 appetite remains good, how granulations form rapidly, so as 
 indeed at times to be exuberant, how there is no odoiu-, and 
 how this method seems to protect the patient against the 
 chance of pyaemia better than any other. In contrast with this, 
 he describes, in a very graphic manner, the course of a wound 
 treated by the ordinary methods — a course common at that 
 time, and indeed, as I have myself seen, by no means uncom- 
 mon at the present. He says : ' Deja, grace au chloroforme, la 
 
 ' Considerations cliniqnes sttr leu ho/is effets de VirHgati4)n continue et des 
 ajjjjlications froides renouveUes dans le traitement des fractures are jjlaie. 
 Those, 1872. 
 
 2 Deutsche Klinik,'No. 37, 1855. 
 
 ' Gazette hehdontadairc de Mrdeeine et de C/iirnrffie, lSo5. 
 
WATER BATH—LANGENBECK. 343 
 
 douleur disparait au moment decisif; I'homme vivant est 
 insensible sous le bistomi ; ses lamentations ne viennent plus 
 interrompre I'operateur. Mais apres avoir depasse le seuil de la 
 salle d'operation, des que la torpeur anesthesique s'est dissipee, 
 le patient, abattu, affaibli, voit s'ouvrir devant lui tout un 
 avenir de souffrances. La douleur, un moment comprimee, se 
 dechaine avec violence. Plus de repos, plus de sommeil. Les 
 terribles secousses de la fievre inflammatoire epuisent le malade 
 et compromettent le succes de l'opera4-ion. Les tortures quo- 
 tidiennes du pansement viennent aggraver cet etat general. 
 Qui n'a pas eu le coeur serre en entendant les plaintes ar- 
 rachees par le moindi'e mouvement de la partie operee, par le 
 tiraillement des brins de chaqjie agglutines, par la pression 
 grossiere et inegale du bandage, sans compter I'atmosphere 
 infecte dans laquelle le malade et ses voisins sont condamnes 
 a vivre, les souillures des draps et des couvertures ? Enfin, la 
 nature est derangee dans son travail reparateur ; chaque tour 
 de bande change les conditions de la plaie, et le chirm'gien ne 
 pent lui-meme diriger la guerison ' 
 
 Langenbeck placed the wounds in the bath immediately 
 after operation. Where possible, he stitched up the wound, 
 leaving a space at the angle through which discharges passed, 
 and through which the ligatures were brought out. Dming 
 the first twenty-foiu- hours, the limb was simply suspended in 
 a bath, and was not arranged in one of the apparatuses which 
 are apt to constrict the part and cause bleeding. When the 
 edges could not be brought together, charpie and a bandage 
 were applied for the first twenty-four hours to prevent bleeding. 
 
 The permanent bath was continued till granulation was 
 complete, and till epidermic formation had commenced. The 
 limb and granulations were apt to become oedematous, but this 
 subsided in a few hours after the removal of the part from the 
 bath. The apparatus was emptied night and morning, and 
 the walls of the vessel carefully sponged with water con- 
 taining chlorinated soda or chloride of lime. When the stump 
 had been closed at first, the wound was daily injected along 
 the course of the ligatures. The temperature of the water 
 was at first 10°-12° C, but it was raised, as the patient could 
 bear it, to 31°-37° C. The skin of the slump had a thick 
 
344 HISTORY OF ANTISEPTIC SURGERY. 
 
 layer of grease over it, to prevent the action of the water on the 
 epidermis. Where the whole body had to be immersed, the 
 immersion was continued for a half to one hour daily in water 
 at the temperature of 34° C. Water dressing was employed 
 towards the end of the case. 
 
 Langenbeck gives the following as the advantages of the 
 permanent water bath : — 
 
 1. It diminishes pain in the wound, and also does away 
 with all painful dressings. 
 
 2. The intensity of the fever is less. 
 
 3. Stagnation and decomposition of discharges are com- 
 pletely prevented. 
 
 He says that in wounds so treated, union by first intention 
 is rare, though not unknown. 
 
 Among the cases treated in this way he had had, during a 
 period of five or six years, no instance of pyaemia, although, as 
 he says, some of the cases were very well suited for its occur- 
 rence, and although pysemia was prevalent at the same time in 
 other wards and even in cases in the same ward. He says : 
 ' Cooling of the wound, retention and putrefaction of the dis- 
 charge, and miasmatic influences (hospital air) are the causes 
 of pysemia. These noxious agents can be completely excluded 
 by the careful employment of a water bath.' He also believes 
 in the spontaneous occurrence of pysemia, through constitu- 
 tional and blood defects, and he does not think that these rare 
 cases would be prevented. Then, also, decomposition of the 
 discharges in a complicated wound is quite possible, even in a 
 water bath, and might lead to pyaemia. He mentions several 
 (7) cases to show the good results. It is interesting to note 
 that one of these — the only fatal case — was one in which, 
 during the removal of a tumour, the knee-joint was opened. 
 Violent inflammation and suppuration of the joint followed and 
 the patient died on the twenty-first day. 
 
 Langenbeck's paper was followed a month later by one by 
 Dr. FocK.^ He confirmed Langenbeck's good results, compar- 
 ing together cases of Pirogoff's amputations treated by the 
 warm bath, with others treated by the ordinary methods, much 
 to the advantage of the former. He mentions also that Dr. 
 > BenUchc Klinik, Oct. 1855. 
 
WATER BATH—VALETTE. .'345 
 
 Wagner of Dantzic, who had adopted it, reported that formerly 
 i:)ygemia was very prevalent in that hospital, but that since 
 the introduction of the warm water bath it had almost entirely 
 disappeared. 
 
 In a paper in 1856, Picard' mentions that Gosselin and 
 I^AUGIER had adopted this method, and Fock also refers to 
 Ulrich. 
 
 In October 1856, Zeis of Dresden published a note entitled 
 ' Beitrag zur Wiirdigung des permanenten warmen Wasser- 
 bades," ^ in which he advocates the use of a still higher tempera- 
 ture than that recommended by Langenbeck. Zeis finds that a 
 permanent bath below the body temperature is seldom endured 
 by the patient. The best temperature is 37°-42° C. For am- 
 putations 35°-37° C. may be sufficient. 
 
 It is unnecessary for me to pursue the history of Langen- 
 beck's method further. It is the one generally adopted where 
 immersion is employed, and for some time it was very exten- 
 sively used in Grermany. It has of late gone out of use, not 
 because its results are not good, but because it is difficult and 
 inconvenient of application, and because it can now be replaced 
 by more effectual and simpler methods. 
 
 Before leaving this subject, however, I must do justice to a 
 method in which the antiseptic element was more fully recog- 
 nised, and in some respects better carried out, but which has, 
 very strangely, not attained any prominence, probably because 
 the name of its author was eclipsed by the better known name 
 of Langenbeck. I refer to the method proposed, and, while he 
 had opportunity, carried out by Valette of Lyons.^ 
 
 Valette's view was the following : ' The safety of sub- 
 cutaneous wounds sufficiently demonstrates that the presence 
 of the air in the wounds is the primary cause of their bad course.' 
 * How does the air act ? This is a delicate question, but the 
 following is the explanation which appears to me to be the fairest. 
 As soon as the operation is finished the blood and the liquids 
 which collect on the surface of the wound, decompose under 
 the influence of the contact of the air. Sulphuretted hydrogen 
 
 ' Gazcite helxhimadairr, 1850. ^ DeuUrhr KliiriX October, ISoG. 
 
 " Sur vne twiirelle mvthode de panacment des grandes jjlait's {wvt/iode 
 anaf.roplast'ique), Gazette hehdumadaire, 1856. 
 
346 HISTORY OF ANTISEPTIC SURGERY, 
 
 and putrid gases, if you will pardon this expression, are formed 
 and absorbed in part, and exercise a deleterious influence on 
 the body. In a word, there is a true poisoning of the patient, 
 which the constitution often withstands, though not always, 
 especially when the patient is placed in unfavoui'able hygienic 
 conditions, as is the case in the wards of our hospitals. In 
 these cases the phenomena of cicatrisation do not proceed in a 
 favom-able manner, suppurative phlebitis occurs, and pus passes 
 into the circulation ; purulent absorption is an accomplished 
 fact, and death is, one may say, an almost inevitable conse- 
 quence.' 
 
 To avoid these dangers Valette immersed the wounded part 
 in baths containing water impregnated with tincture of benzine, 
 creosote, alcohol, or perchloride of iron. The last gave the best 
 results. There was no putrefaction of this fluid, and he seems 
 to have had great success. He was especially struck with the 
 absence of traumatic fever. 
 
 PuPiER,' who wrote his thesis in 1855 on Valette's method, 
 mentions a number of cases which did well, and states that, in 
 order to prevent the water from getting too warm, it was in 
 one case changed as often as thrice daily. 
 
 Valette had only a limited opportunity for caiTying out his 
 experiments, for after a short time he was placed in charge of a 
 children's ward, where he could no longer practise this method. 
 
 ' U'un traiUvient conseoutif ijjecial des amimtatiom. TMse, 1855. 
 
USE OF ANTISEPTICS. 347 
 
 CHAPTER XVI. 
 
 HISTORY OF ANTISEPTIC SURGERY — (concluded). 
 
 Use of antiseptics : Alcohol — older writers — Nelaton — Hutchinson : Glycerine 
 — Demarquay : Chlorine : Chloride of zinc : Iodine : Iodoform : Chlorate 
 of Potash : Perchloride of iron,&;c. : Coal tar — Corneand Demeaux — Report 
 of the commission : Coal tar saponine — Lemaire — his views on putrefac- 
 tion : Carbolic acid — Lemaire — Lemaire"s position in regard to aseptic 
 surgery — Lister : Further phases in the history of this subject : Objections 
 to Mr. Lister's claim as originator of the aseptic method — Simpson — 
 Neudorfer. Modifications of the method. Substitutes for carbolic acid. 
 Objections to the aseptic method. 
 
 The last point to which we have to refer is the use of antiseptics. 
 As we have already seen, various antiseptics have been in 
 use for many centturies as applications to wounds, and some 
 surgeons indeed have ascribed the good results, derived from 
 their use, in the main to their anti-putrescent properties. In 
 spite, however, of the attempts of surgeons at different times 
 to draw attention to these properties, it was not till the publi- 
 cation of Come and Demeaux's method in 1859 that general 
 interest in the subject was aroused. 
 
 Among the substances formerly employed, alcohol was pro- 
 bably the one in most extensive use, and after the subject of 
 antiseptics came to the front, it was freely employed in some 
 quarters. As I have just said, alcohol was formerly used in 
 great quantities, but then it was generally combined with other 
 substances, though it probably was really the active basis of 
 the compounds so prepared. Thus the balsam of Fioraventi — a 
 celebrated appHcation to wounds — consisted of turi)entine, 
 myrrh, aloes, a large quantity of alcohol, and several unim- 
 portant substances. Many of the various lotions which have 
 been most popular at different times had a similar constitu- 
 tion. 
 
348 HISTORY OF ANTISEPTIC STTUGERY. 
 
 Bataill]^ ' published a little pamphlet in 1859 advocating 
 the use of alcohol, but it was most extensively adopted by 
 Nelaton in 1863, and also by Le Fort. 
 
 Chedevergne^ in 1864 published a detailed account of 
 Nekton's practice with the results which he had obtained. 
 Nelaton's method was to soak chm'pie with camphorated alcohol, 
 and apply it over the wounds in thick layers. These were 
 either kept wet by frequent arrosion, or were covered with an 
 overlapping layer of impermeable tissue, or in some cases the 
 dressing was changed twice daily. Patients treated in this 
 way remain in good health, the edges of the wounds adhere, 
 no granulations are formed, but the wound becomes covered 
 with a layer of lymph under which cicatrisation rapidly occurs. 
 This is the rule, though not an absolutely constant one. In 
 open wounds the granulations can scarcely be seen. There 
 is an abundance of coagulable lymph, almost no appreciable 
 suppuration, and no bad smell. In some cases the charpie 
 becomes embedded in the coagulated albumen, and the whole 
 dries up and forms a crust. 
 
 Chedevergne says that, for more than a year, operation 
 wounds, and injuries, had been treated with camphorated 
 alcohol, or with pure spirits of wine, and that during that time 
 pysemia and other infective diseases had been almost entirely 
 absent. Of forty-eight patients who had undergone severe 
 operations, only three died ; one of tuberculosis, one of hypo- 
 static pneumonia, and one of pysemia. 
 
 RocHARD ^ gives later statistics, in which he shows that there 
 were only two cases of pysemia, and five of erysipelas. Good 
 success in the Hopital des Cliniques ! 
 
 On a pre\dous page (p. 269) I have referred to Mr. Hutch- 
 inson's method of using alcohol. He mixes it with acetate 
 of lead somewhat after the manner of Astley Cooper. 
 
 Glycerine was used pretty extensively in England after 
 1 840, but was introduced in the treatment of wounds mainly 
 by I)p:marquay in 1855.* He first employed it in cases of hos- 
 
 ' iJe Valcool et dcs covqjoscx alcooUqvcs en Chirvrgic. Par JIM. Bataill6 et 
 Juillet, 1859. 
 
 ^ Bulletin general de Therapentiqve, vol. Ixvii. 1864. 
 
 ' Loc.cit. * Gazette des ffdj^itaiix, October, 1S55.' 
 
USE OF ANTISEPTICS. 349 
 
 pital gangrene, and he found that they rapidly began to im- 
 prove under its use. He then extended the treatment to 
 ordinary wounds. He claimed all sorts of advantages for it. In 
 1859, more especially, he stated that it was a specific against 
 erysipelas, pyaemia, hospital gangrene, &c. He thought that it 
 was the best antiseptic substance, and indeed a universal 
 panacea. Since that time it has, however, been extensively 
 tried and found wanting, and has, as Rochard says, for a long 
 time been justly relegated to the modest place in therapeutics 
 which nature had assigned to it. 
 
 Ghlo7%ne and its compounds have been used as disinfec- 
 tants ever since its discovery in 1774. Guyton, in 1795, re- 
 commended its use in hospitals by fumigation, in order to 
 destroy miasms. The Liquor de Labaraque, which attained 
 considerable notoriety as a disinfectant, consisted mainly of 
 chlorinated soda. In more recent times the chlorine com- 
 pounds, more especially chlorinated soda and chloride of lime, 
 have been employed in the treatment of wounds, the wounds 
 being washed or syringed out with the solution, and dress- 
 ings applied which were frequently moistened with the same. 
 Hervieux applied a sponge soaked in the solution to the 
 wound, and this, according to him, not only disinfected the 
 discharge, but also absorbed it. M. Gueesant also used it 
 largely. 
 
 Chalvet ' recommends the introduction of chloride of lime 
 into the superficial layer of the charpie. Chlorine is given off 
 from this, and prevents the decomposition of the discharges. 
 
 We have already mentioned chloride of zinc, which, as we 
 have seen, was extensively employed as a caustic by Canquoix 
 and Gensoul. Bonnet also used it, and remarked on the absence 
 of putridity in the wounds made by it. In more recent years 
 Campbell de Morgan has again used it as a caustic, and also 
 made the same remark as to its antiputrescent powers. It thus 
 came to be employed as a lotion in the treatment of wounds, 
 but it has never become extensively used. The chief use to 
 which it is put nowadays is by Mr. Lister in disinfecting foul 
 ulcers or sinuses (see pp. 65 and IIG). 
 
 ' Bes drxiitfrctants et de Iciir applicatwii, a la Tlivrapcutiqiie ct a I'llijtjihie. 
 Mciiioire do V Academic ivijjcriulc dc Mcdecinc, vol. xxvi. 1863. 
 
350 HISTORY OF AXTISEPTIC SURGERY. ' 
 
 Velpeau in 1859 stated that Iodine had been in use as a 
 topical application for over thirty years. On the contrary, 
 DuKOY asserted that it was only as a consequence of a com- 
 munication made by hira in 185-1 that iodine was first em- 
 ployed in wounds. Iodine has at times been used in the prac- 
 tice of various surgeons. Thus Mr. Spence of Edinburgh at 
 one time painted the surface of stumps with iodine, and 
 thought that he got good results from it ; however, he soon 
 took to painting stumps with other things, and the iodine 
 fell into disuse. 
 
 The only preparation of iodine which is now employed in 
 the treatment of wounds is Iodoform, which is of great use in 
 chancres or foul ulcers. I have already referred to the method 
 in which it is applied in the latter cases (pp. 65 and 94). 
 
 Various metallic salts have been from time to time intro- 
 duced, such as Chlorate of Potash by Milton. This acts very 
 well in ulcers in the mouth, but is not of any very gi'eat value. 
 
 Perchloride of iron was employed as a disinfectant by 
 Deleau, and I have already referred to the use which Valette 
 made of it (p. 346). 
 
 Nitrate of lead, subnitrate of bismuth and other powders 
 have also been spoken of at various times. 
 
 During the middle of the present centmy there had been 
 constant efforts made in various directions to diminish the 
 great mortality in French, more especially in Parisian, hospitals 
 by means of some method of wound treatment. We have seen 
 how at first it was chiefly the action of the air on the wound 
 which was guarded against, but in 1859 it had come to be fully 
 recognised that the chief thing which was required was to 
 prevent decomposition of the discharges. It is therefore not a 
 matter of suqwise that when Corne and Demeaux in that year 
 brought forward a powder which they believed to be capable of 
 attaining this object, attention was at once directed to the 
 subject, and not only did debates occur in the scientific 
 societies, but experiments were also made in the various hospi- 
 tals with this and other antiseptic substances. 
 
 Already in 1815 the antiseptic and disinfectant properties 
 of coal tar had been recognised by Chaumette, and Guibouit 
 (1833) and Siret (1837) also wrote on the subject. In 1846 
 
ANTISEPTICS— CORNE AND DEMEAUX' POWDER. 351 
 
 Bayard introduced an excellent disinfectant, of which the chief 
 ingredient was coal tar. 
 
 In 1858, M. CoRXE took out a patent for a powder which 
 he had for some time employed as a disinfectant, and in the 
 same year Demeaux ' used this powder in the treatment of 
 wounds. The powder employed by Come and Demeaux "^ had 
 the following composition : of ordinary plaster of commerce in 
 very fine powder, 100 parts ; of coal tar (obtained from dis- 
 tillation of coal in the manufacture of gas), 1 to 3 parts. These 
 substances were readily mixed together in a mortar, and then 
 olive oil was added till they acquired the consistence of paste. 
 This paste was applied to wounds, more especially to foul 
 wounds, and it was found that it disinfected (deodorised?) the 
 discharges at once, and that it also absorbed them. They 
 stated that, ' the action of this disinfectant substance seems to 
 arrest the work of decomposition ; it keeps away the flies, and 
 prevents with certainty the production of worms.' Their ex- 
 periments were made jjartly in private practice, and partly in 
 Velpeau's wards. Velpeau observed that in the cases treated 
 in this way suppuration was also diminished. 
 
 In the discussion which ensued at the following meetings 
 of the Academy, various opinions were expressed as to the use 
 of antiseptics in general, and as to the action of this particular 
 powder.' M. Chevreul found that the coal tar powder did 
 not destroy the odour, but rather cloaked it, while, on the other 
 hand, hypochlorite of lime in large quantities made it disapj)ear. 
 He thought however that the coal tar powder would act in 
 preventing putrefaction. M. BusSY called attention to the 
 fact that other disinfectants were in constant use, and were 
 also employed to prevent putrefaction. Such were carbon, 
 chloride of lime, soda or potash, creosote, &c. 31. Kenault 
 stated that as long ago as 1840 he had published a memoir on 
 disinfection of wounds ; for at that time he had come to the 
 conclusion that the putrefaction of blood and discliarges, and 
 the contact of these putrid materials with the wound, were the 
 cause of the bad after-conseqilences. He had found that 
 hypochlorite of lime was the best, though in some cases the 
 
 ' L'ninn mt'dieale, I8(i0. - BitUetin dc I'Aradi'mie dc Mcdecine,\^o^. 
 ' Jhid. : see also Gazette mcdicale de I'aris, 18GU. 
 
35 J HISTORY OF ANTISEPTIC SURGERV. 
 
 disengaged chlorine irritated the lungs. Hence he welcomed 
 the coal tar powder, but he stated that vegetable tar acted as 
 well and had a less disagreeable odour. Calvert had previously 
 shown that carbolic acid, which was present in coal tar, was a 
 powerful disinfectant, and, at a later meeting of the Academy, 
 he stated that it had been used in Manchester in 1857, in the 
 preservation of dead bodies, with success. Dumas had stated, at 
 a jirevious meeting, that carbolic acid was present in coal tar 
 in small quantities and that the least trace of carbolate of 
 soda was sufficient to preserve animal matters. 
 
 After the reading of Corne and Demeaux' paper and the 
 subsequent discussion in the Academy, a commission was ap- 
 pointed by the Academy to enquire into the matter. This com- 
 mission consisted of Chevreul, J. Cloquet and Velpeau. As 
 the result of their investigations, they concluded that this 
 powder was most useful for disinfecting substances, but that 
 it was not a convenient application to wounds, that its odour 
 was disagreeable, that it had often to be renewed and that it 
 soiled the linen. Lemaire also adds that it solidifies and pre- 
 vents the escape of pus. 
 
 The commission tried various other substances which had 
 been mentioned, such as glycerine, sugar, chlorate of potash, 
 &c., but found that they were not much better than ordinary 
 cerates. Tincture of iodine was found to act fairly well, but 
 to cause too much pain ; chlorine and the hypochlorites were 
 good. Sub-nitrate of bismuth or perchloride of iron used in 
 the form of an ointment (8 grains of the liquor to 30 grains of 
 lard), were excellent applications. 
 
 Corne and Demeaux' powder soon disappeared from the list 
 of remedies, but nevertheless attention was attracted by it to 
 the subject of antiseptic applications to wounds. 
 
 Among those who spoke at the debates was Le Bceuf, who 
 in 1850 had found that substances insoluble in water, but 
 soluble in alcohol, could be made into an emulsion by the 
 addition of saponine. Such emulsions were very fine and very 
 stable. Le Ba>uf proposed that coal tar should be emulsionised 
 by the aid of this tincture of saponine. 
 
 Jules Lemaire at once took advantage of Le B«uf s sug- 
 gestion, and in 1860 he published a paper on ' Coal tar sapo- 
 
LEMAIRE—COAL TAR SAPOXINE. 353 
 
 nine.*' The tincture of saponine, to which reference has ju.st 
 iDeen made, is an alcoholic extract of the bark of Quillai/a 
 saponaria and contains other substances besides saponine. A 
 tincture of ' coal tar saponine ' was made by mixing together 1 
 part of coal tar with from 2 to 4 parts of tincture of saponine. 
 With this an emulsion was made by mixing 1 part of the 
 tincture with 4 parts of water. This emulsion retained all the 
 properties of coal tar, and is the substance which was used by 
 Lemaire. Lemaire investigated the "activity of its various 
 constituents, and found that it contained saponine which 
 acts as an antiseptic; alcohol, nlso an antiseptic ; carbolic acid, 
 a powerful antiseptic, but apt to cauterise the tissues ; benzine, 
 which is an irritant ; naphthaline, which is a sedative, and, 
 in Lemaire's opinion, ' modifies and tempers the action of the 
 other substances.' 
 
 Lemaire applied this emulsion very extensively in the 
 treatment of a variety of diseases, and also to putrid wounds 
 and ulcers. The results of its use in the latter cases wer^ — 
 1. Disinfection of the wound; 2. The wound assumes a rosy 
 aspect ; 3. The sloughs become detached with greater facility 
 than usual ; 4. It only exceptionally causes pain. Lemaire 
 also states that it acts powerfully in reducing the quantity of 
 pus secreted. This emulsion was applied in the same manner 
 as other lotions. The wound was washed with it, and then 
 dressed with charpie soaked in the emulsion. I cannot find 
 any case illustrating its use from the time of operation. There 
 is no sort of system described, and I^emaire seems to have 
 used it merely as a disinfectant and as a good apj)]i('ation to 
 wounds. Li fact he treated tlie wound with antiseptics, but 
 not aseptically. Numerous letters from various surgeons are 
 published in Lemaire's book shewing tliat smell was destroyed 
 at the time of the application, but that in some cases the dis- 
 charge became foul before a fresh application was made. 
 
 His views on the germ theory of putrefaction are of the 
 greatest interest, as he was undoubtedly the first who, recognis- 
 ing that theory, applied it to practice. He says, ' the wound 
 which suppurates, as I hope to demonstrate presently, is a 
 secreting surface, the products of which become altered under 
 ' Do coal tar saponine, 186f^. 
 A A 
 
854 HISTORY OF ANTISErVIC SURGERY. 
 
 the influence of air and give birth to a series of phenomena due 
 to one and the same cause, fermentation.' He believed that 
 pus at the commencement is sim})ly serum of the blood con- 
 taining fibrin, that fermentation occurs in this from contact 
 with the air and that pus corpuscles correspond in their nature 
 to yeast cells and are the result of this fermentation. Novs^ coal 
 tar sapouine at once arrests this fermentation and consequently 
 this formation of pus cells. I have already referred to Le- 
 maire's experiments on putrefaction and other fermentations 
 (p. 218). He concludes that the two principal properties of 
 coal tar saponine are disinfection and arrest of fermentations. 
 ' A third important property which seems to me to be the cause 
 of the arrest of the fermentations, is the toxic action which 
 it exercises on vegetables and on the lower animals.' It 
 favours healing by disinfecting the wounds and arresting the 
 fermentation of pus. He concludes that the germ theory of 
 fermentations is true, and that coal tar arrests and prevents 
 fermentation by its toxic effect on the lower organisms which 
 cause them. He says again: 'These facts make me think, that 
 it is on account of its toxic properties on vegetables and on 
 the lower animals that coal tar can prevent or arrest fermen- 
 tations. The opinion of Schwann and of several other physio- 
 logists, a view which in the present day has received great 
 support from M. Pasteur, ap])ears to me to be true.' . . . ' As 
 the ferments appear to be the infusoria and the microscopic 
 vegetable organisms which exist in abundance in the atmo- 
 sphere, and as the " coal tar saponine " destroys them, let not 
 physicians forget this precious property. Perhaps it may 
 ■penn'd them to make imjpoi'tmit discoveries, mid to render 
 a great service to hum^anity.^ ' 
 
 While Lemaire was using this coal tar saponine he was also 
 experimenting with carbolic acid. He found that carbolic acid 
 could form a 5 per cent, solution in water, <ind could also be 
 dissolved in oil and alcohol. He found too that it was much 
 more powerful than coal tar, but that its volatility and its 
 powerful action on wounds were disadvantages. On the other 
 hand, with carbolic acid he had a solution of known and constant 
 strength, which mixed with the discharge and soaked into the 
 ' Tlie italics are mint'. 
 
LEMAIRE— CARBOLIC ACID. 355 
 
 tissues more readily than the emulsion of coal tar. He pub- 
 lished a work on the subject in 1863, called 'De I'acide pheni- 
 que,' and such was the interest excited in France by this work 
 that in 1865 a second edition appeared. 
 
 The greater part of his work is taken up in discussing 
 the germ theory, which he advocates, but the experiments, 
 though numerous and laborious, are so crude and imperfect 
 that I have not been able to make any use of them, 
 though I had much wished to do so, if only for their historical 
 interest. 
 
 In applying carbolic acid to medicine and surgery, he seems 
 to have been guided by no principle or rule, but simply to have 
 applied it empirically. Thus the following is a list of some of the 
 diseases in which he used it : acne, anthrax, asthma, cholera, 
 dysentery, ecthyma, eczema, erysipelas, intermittent fever, 
 typhoid fever, herpes, impetigo, lichen, purulent ophthalmia, 
 pityriasis, phthisis, prurigo, sycosis, cancerous ulcers, taenia, 
 smallpox, &c. In cases where it did good it was supposed to have 
 killed germs. He used it also in ulcers in the same way as 
 the emulsion of coal tar, and where tortuous canals existed, 
 the lotion of the strength of '2 to 1 p. c. was injected. He says 
 very little about recent wounds ; indeed the following is about 
 the only passage I can find. ' Pour mettre les solutions de 
 continuite des tissus a Tabri de la fermentation il suffit de 
 les couvrir des le debut avec des compresses, constamment 
 imbibees d'eau pheniquee. Deux milliemes de I'acide ])henique 
 suffisait dans ce liquido pour obtenir ce resultat.' How ver}' 
 imperfect such a method would be, experience and experiment 
 have since am})ly shown. He only mentions having treated one 
 case of compound fracture, a fracture oftlie fingers, in which he 
 used the emulsion of coal tar. 
 
 Here there is nothing which can b(^ called a melluxl. 
 Lemaire realized what the causes of putrefaction were, but he 
 made no attempt to exclude them, nor indeed did he make 
 any systematic attempts to ei-adicale them after tliey had 
 entered. 
 
 In 186,5 Dkct.at published a work on carbolic acid in which 
 he claimed piiority over Lemaire. This w<tik contains no 
 observations of any value, and liis claim of priority is absolutely 
 
356 HISTORY OF ANTISEPTIC SURGERY. 
 
 without foundation, for Lemaire began his work before Declat, 
 and Declat was well acquainted with Lemaire's work before 
 publishing. 
 
 We must in a few words enquire what is Lemaire's 'exact 
 position in reference to antiseptic surgery ? how much does 
 the present advance of antiseptic surgery owe to him? It is 
 a question which for a time has been much debated and 
 variously answered. 
 
 In the first place we find, as I have already stated, that 
 Lemaire recognised the true basis of antiseptic surgery, the 
 germ theory of fermentation, and also that he was the first to 
 use carbolic acid extensively in the treatment of wounds. But 
 we do not find any method of how best to add the antiseptics 
 to the discharge or how best to exclude organisms altogether. 
 All that we find is that certain results — absence of smell — were 
 attained, and the explanation was that the carbolic acid had 
 destroyed the causes of fermentation. Then, also, look at the 
 aimless way in which he applied carbolic acid to all sorts of 
 diseases. There was no definite plan, no clear purpose, in 
 these attempts. 
 
 On the other hand, we must remember Lemaire's opportuni- 
 ties. He had no hospital appointment as surgeon ; no oppor- 
 tunity, therefore, for seeing a sufficient amount of surgical 
 practice to realise the necessity for systematic action. Would 
 he have elaborated any aseptic, or even thorough antiseptic 
 method had such op})ortunities been given him ? I cannot say, 
 but I doubt it, for his experiments shew the same want of 
 purpose and imperfection in inference, while his views on pus 
 cells, and many other points, show an im})erfect appreciation of 
 the elementary facts of physiology and pathology. 
 
 I am not, however, concerned with what he might have been, 
 but with what he tvas ; for indeed, as Carlyle well remarks, ' it 
 comes that these same would-have-heens are mostly a vanity, 
 and the world's history could never in the least be what it 
 would, or might, or should, by any manner of potentiality, but 
 simply and altogether what it is.^ Lemaire tvas the first to use 
 carbolic acid, and was the first to realise the truth of the germ 
 theory as applied to wounds. lie tuas an advanced treater of 
 wounds with antiseptics, nothing more. 
 
SUMMARY UP TO 1867. 357 
 
 The use of carbolic acid in the treatment of wounds was 
 for some time tried extensively on the continent, and in Eng- 
 land it was also employed by one or two surgeons (Wood, 
 Spence) ; bat, applied in the way recommended by Lemaire, 
 it failed to give satisfactory results and soon began to di'op out 
 of use. Indeed, as early as 1867, Dr. Hingston, who had been 
 travelling on the continent, stated, at the Dublin Meeting of 
 the British Medical Association, that ' he had found that the 
 use of carbolic acid in surgery was now being discontinued in 
 places where it was formerly in vogue.' 
 
 The result of these centuries of work on the subject of 
 wound treatment may be summed up as follows. The old 
 views, that wounds could not heal without active intervention on 
 the part of the surgeon, had been thrown aside, and, after many 
 oscillations of surgical opinion, it had at last become generally 
 recognised that nature was the sole agent in the reparation of 
 wounds ; it had, however, become apparent to most men that 
 the decomposition of the discharges in wounds was a source of 
 danger to the patient so great as to demand active interference 
 for the purpose of preventing it as far as possible. The various 
 attempts which were made with this aim are most interesting 
 and important, although they were all more or less inefifectual. 
 On the supposition that the gases of the air were the active 
 agents, numerous methods (occlusion, crust formation, substitu- 
 tion of other gases, &c.) had been devised for the purpose of 
 excluding the air, but these had all failed in producing any 
 permanent benefit ; it was rendered clear from these researches 
 that the gases of the air were not the injurious elements. 
 Subcutaneous surgery, though based on this erroneous view, 
 had ])ecome firmly established, and it was universally recognised 
 that, if an operation could be done subcutaneously, it was to a 
 great extent free from danger ; unfortunately, the appliealiility 
 of this method was very limited. Then, at first with the view 
 of regulating the temperature of the wound, various forms of 
 irrigation and water-baths were introduced. Some of the 
 surgeons, however, who employed them observed that decom- 
 position was less, and that this was due in great measure to the 
 washing away of the discharges. Drainage had also to a certain 
 
358 HISTORY OF ANTISEPTIC SURGERY. 
 
 extent, though imperfectly, been introduced." On the other 
 hand, it had been found that, by the addition of various 
 substances, hence termed 'antiseptics,' to the discharges of 
 wounds, decomposition could be markedly interfered with, and, 
 at the time to which we refer, in France more especially this 
 idea was the most prominent in the treatment of wounds. One 
 surgeon, indeed, Lemaire, had announced the view that anti- 
 septics acted by destroying ' the vegetables and lower animals ' 
 found in these discharges, and which appeared from recent re- 
 searches to be the active agents in producing decomposition. 
 Lemaire, however, failed to follow out his views, and thus missed • 
 the discovery which was very shortly afterwards announced by 
 Mr. Lister. 
 
 Such was the state of matters when Mr. Lister, who had 
 been working for more than two years independently of any 
 knowledge of Lemaire's e:^periments, published his first papers 
 on aseptic surgery, w^hich at once threw a flood of light on the 
 confused subject of the treatment of wounds. The develop- 
 ment of his system in his own hands has already been traced. 
 Mr. Lister's writings have stimulated surgeons to the study of 
 the whole subject, and have led to the introduction of improve- 
 ments in every detail of wound treatment. These improve- 
 ments, acting on better principles, have brought even the older 
 methods to a high state of perfection, and numerous researches 
 have since been made which have enabled us to reduce to order 
 and show the true principles underlying the various attempts at 
 wound treatment which had been previously carried out. 
 
 It would be hopeless to attempt to follow out all that has 
 been said and written on this subject since that time, and it 
 would not only be hopeless but also profitless, for the greater 
 part of the statements rest on imperfect understanding or know- 
 ledge of Mr. Lister's writings, and imperfect acquaintance with 
 the scientific advances of the present day. In Germany, where 
 science is more advanced than in other countries at the 
 present time, this method has been almost universally accepted 
 and introduced, and some of the leading German surgeons are 
 amongst the most enthusiastic supporters of it. In our own 
 
 ' Cliass,ai_i,mac : Tra'dv jtruiUjve dc la Hitppuruilon ct dti. Drainage CMrvr- 
 (liralr. ISoO. 
 
SPREAD OF ASEPTIC SURGERY. 359 
 
 country on the other hand, the necessity for a protection against 
 infective disease has not been so much felt, on account of the 
 much better hygienic conditions of our hospitals ; while, 
 owing to our so called practical nature, the scientific problems 
 involved have been allowed to fall out of notice and have 
 been imperfectly appreciated when noticed. Perhaps the 
 greatest obstacle to the acceptance of the principles of antiseptic 
 surgery is the confusion which has somehow or other arisen 
 between the germ theory of fermentation and that of infective 
 disease. Indeed at the present time nine surgeons out of ten, 
 if questioned, would give the germ theory of infective disease 
 as the foundation of the principles of antiseptic surgery, 
 while, as we have seen, it in reality has no necessary con- 
 nection with these principles at all. The common argument 
 brought against the aseptic theory is, ' How is it that after 
 such an operation as removal of a finger, or excision of the 
 mamma, not performed aseptically, the patient does not as often 
 die of infective disease as after amputation of the thigh ? ' 
 Now such a question shows the confusion between the two germ 
 theories. The real question to put is ' How is it that putrefac- 
 tion does not occm- in all wounds not treated with aseptic pre- 
 cautions ? ' This I have already explained in considering the 
 princijiles of antiseptic surgery, but I have nothing to do, in 
 looking at these principles, with the former question. In con- 
 sidering the results, I shall demonstrate that the exclusion of 
 bacteria from wounds is followed by the avoidance of infective 
 disease, but I do not care whether any one believes that bacteria 
 are or are not the cause of the infective disease. All I would 
 ask is that bacteria be excluded, because they cause fermenta- 
 tions ; and if this be done, as I shall presently show, the causes 
 of infective disease will also be excluded. If one prefers to 
 go out of one's way to suppose that not the bacteria, but some- 
 thing else, excluded at the same time, are the causes of infec- 
 tive disease, well and good; it does not matter for the _prmci2)^es 
 of antiseptic surgery. 
 
 There are, however, one or two phases in the history of this 
 subject to which I must briefly allude. 
 
 Firstly, attempts have been made to show that Mr. Tester 
 has no claim as introducer of aseptic surgery. Such statements 
 
•MO HISTORY OF AXTISEPTIC SURGERY. 
 
 rest on niisappreciation of the meaning of tliat term. Most of 
 these writers look on aseptic surgery, and the treatment of 
 wounds by carbolic acid as one and the same thing, and then 
 they point out that Lemaire and others used carbolic acid 
 before Lister. 
 
 The first attempt of this kind was made by Sir James 
 Simpson, in the 'Lancet' for 1867. He says: * Mr. Lister in 
 his letter to the ' Lancet,' October 5, states that all his recent 
 visitors to the Grlasgow Royal Infirmary had viewed his treat- 
 ment of wounds, abscesses, comjDound fractures, &c., and " not 
 one," he adds, "had ever expressed the slightest doubt that the 
 system in question was entirely Qiew . . . ! " While I regret 
 the strange and almost incomprehensible want of knowledge 
 with which Mr. Lister charges his professional visitors, I am 
 fortunately not answerable for it, and if Mr. Lister had taken 
 the slightest trouble to search English medical literature alone, 
 he would have easily convinced himself of his own grave error 
 in this respect.' He then proceeds to point out that carbolic 
 acid had been extensively used in siu-gical treatment before Mr. 
 Lister published, and that Lemaire and Declat had also under- 
 stood the principles on which it acted. Had Sir James Simpson 
 underlined the word system, and not the words entirely new, 
 and had he continued the quotation which' runs as follows, 
 'the novelty, I may remark, being not the surgical use of 
 carbolic acid (which I have never claimed), but the methods 
 of its employment with the view of protecting the reparatory 
 processes from disturbance by external agency,' he could hardly 
 have fallen into such a gross blunder. I need not waste time 
 in refuting Sir James Simpson's accusations. 
 
 Several similar mistakes have been committed by other 
 writers ; but the only other one which I need mention, as it is 
 also the most virulent attack of all, is that by Ignaz Neudorfer 
 in 1877.' His work is a very strange one indeed. He rejects 
 the germ theory of putrefaction and supposes that the bodies 
 which fall into wounds and cause fermentation are not bacteria, 
 but ferments coming from previously fermenting substances. 
 St range to say, though holding this view, he rejects also the 
 Lislerian method, which one would think would be as natural a 
 ' Dili clm'uryiic-hc BduDidUiiiij dcr Wiiudeu, 1877. 
 
NEUDORFER AND BARBELEBEN. 361 
 
 sequence of such a view as of the germ theory. He also 
 attempts to show that Lemaire had anticipated Lister in all 
 particulars, but his statements rest on the same fallacious 
 foundation as Sir James Simpson's. He falls into the common 
 error of supposing that Mr. Lister teaches that catgut becomes 
 revivified, instead of, as Mr. Lister has shown, being eaten 
 away and disappearing under the action of the neighbouring 
 living tissues ; and he is very severe on this subject. In- 
 deed here his bitterness against Lister and his teaching crops 
 up in an unwarrantable and most offensive way ; and I will 
 quote his statement here as an example of Neudorfer's writings. 
 He says : ' Es ist auch hier, wie bei der Wundbehandlung, nur 
 die Darstellung Lister's welche ganz einfache und klar zu Tage 
 liegende Verhaltnisse in ein mysterioses Dunkel hiillt, so wie 
 das Bestreben Lister's an die Stelle der wissenschaftlichen 
 Erorterung inspirirte Dogmen als Orakel hinzusetzen, welches 
 die Fachgenossen blenden soil, die seinen sonstigen Ver- 
 diensten nicht wenig Abbruch thut.' 
 
 Mr. Lister's merit in this respect is well stated by Bardeleben 
 in his lectures ' Ueber die Theorie der Wunden.' ' He says : 
 ' Lange schon wusste mandass ein Magnet Eisen anzieht, lange 
 genug auch, dass ein Eisenstab magnetisch wird, wenn durch 
 einen denselben umkreisenden, aber nicht beriihrenden Draht 
 ein galvanischer Strom geleitet wird, aber die Anziehimg des 
 Eisens durch den vermittelst des galvanischen Stromes magnet- 
 isch gemachten Eisenstab fiir die Telegraphic zu benutzen war 
 doch eine Entdeckung.' — ' So steht es auch mit dem segcnsrei- 
 chen P^ortschritte welchen wir Lister zu danken haben. Joseph 
 leister hat weder die Bakterien entdeckt, noch die Karbolsaure ; 
 aber er hat mit eisemer Konsequenz die Thatsache dass 
 Faulniss nicht entsteht ohne Einwirkung von Bakterien, oder 
 wie, er um botanischen Spitzfindigkeiten zu entgehen, lieber 
 sagt, von Keimen (und dass solche Keime in der Luft schweben) 
 er hat diese Thatsache angewandt auf den lebenden und 
 namentlich auf den verwundeten menschlichen Korper. Und 
 das Ergebniss dieser Anwendung war audi eine Entdechung, 
 eine Entdeckung wohl werth den grossten Fortscliritton der 
 iirzl lichen Kunst augereiht zu werden.' 
 
 ' Tlic passage would lose by translation. 
 
362 HISTORY OF ANTISEPTIC SURGEIIT. 
 
 Another phase in the history of this subject to which we 
 must allude is the introduction of various modifications. 
 
 I have ah'eady described the modifications and improve- 
 ments introduced by Mr. Lister. I have also mentioned the 
 newer methods of drainage, more especially the use of ab- 
 sorbable drains introduced by Mr. Chiene, and carried out by 
 him liy means of catgut, and by Neuber by decalcified bone 
 tubes. 
 
 Neuber has made several attempts to obtain a dressing 
 which may be left on for a long time. The advantage of such 
 a dressing is, of course, evident, more especially in the case of 
 compound fractures, &c., and in country practice. He uses 
 bone tubes as drains, and catgut for stitches. The drains 
 in three or four days bec(Hne soft, and in about ten days have 
 generally entirely disappeared. Large quantities of gauze 
 (Kriillgaze) are applied next the wound and fastened with a 
 gauze bandage. Outside this comes a mass of salicylic wool 
 soaked in the lotion, also fastened with a gauze bandage, and 
 then outside this the regular carbolised gauze dressing. The 
 first dressing is left on in the case of large wounds for about 
 two days. Then the gauze and the salicylic wool are removed, 
 the deeper gauze dressing soaked with the lotion, and a fresh 
 dressing applied. This may be left on for ten days or a fort- 
 night, provided no discharge appears at the edge. This is one 
 of many ways in which a similar result may be obtained. Of 
 late Neuber has treated several cases with one dressing alone. 
 
 With the view of cheapening the materials, various modifi- 
 cations have been introduced : thus Brun's gauze, mentioned 
 before, and also a gauze introduced by Miinnich are outcomes 
 of these attempts. MuNNiCH uses glycerine and spirit instead 
 of paraffin. He also in some cases adds stearin. He uses jute 
 instead of gauze. This carbolised jute is much chea^^er than 
 carbolised gauze, and has been extensively introduced. Bar- 
 deleben has used with great success jute soaked with carbolic 
 lotion and kept moist by frequent addition of lotion. This is 
 covered with impermeable tissue. 
 
 INIodifications of the method have been made with the view 
 of applying it in war, and I have described previously the sug- 
 gestions of i\Ir. Lister and Professor Esmarcii. A paper will also 
 
OBJECTIONS TO THE SPRAY. 363 
 
 be found on this subject by Dr. Burchardt in the ' Deutsche 
 militairarztliche Zeitschrift.' 
 
 Various other antiseptics have been introduced as substi- 
 tutes for carbolic acid. Among these I may mention the use 
 of salicylic acid by Thiersch. This I have ab-eady described. 
 Thymol was introduced in 1878 by Dr. Eanke of Halle, and 
 he speaks very highly of its usefulness. It has, however, been 
 tried by several surgeons, among others by Mr. Lister, and 
 has not been found to be a trustworthy antiseptic, (^uite 
 recently H. P^ischer and Professor Maas have advocated the 
 use of acetate of alumina. Maas uses a 2*5 p. c. spray, and 
 after applying protective to the wound, he covers it with com- 
 presses soaked in this solution, and covered with an imper- 
 meable tissue. He says that the cases follow an aseptic 
 course, and that, as the antiseptic causes no irritation, the dis- 
 charge is very slight and the dressings only require to be 
 changed at rare intervals. 
 
 Then of late objections have been made to the necessity 
 for the spray in aseptic work, and Trendelenburg ^ has recently 
 published a paper giving the results of some operations per- 
 formed without the spray. Indeed for four years he has per- 
 formed all operations strictly aseptically, but in none has he 
 used a spray. The mode in which this has been carried out is 
 that indicated before. During and after the operation the 
 wound is washed out with carbolic lotion and, while the wound 
 contains this lotion, it is closed. During the changing of the 
 dressing Trendelenburg adopts Mr. Lister's former method of 
 allowing fluid to flow more or less constantly over the wound, 
 and more especially over the orifice of the drainage tube. I 
 shall discuss this question at a later period. 
 
 Some years ago Mr. Callender published results obtained 
 by a slight modification of Mr. Lister's method, or rather by the 
 use of jNIr. Lister's carbolic oil dressings. I shall also allude to 
 these later. 
 
 With regard to these attempts, we have already seen that 
 the spray is the least essential detail of the system ; and I have 
 described how its use may be done away with with safety. And 
 this brings me to the last point in connection with the history of 
 
 ' Ari-Jiir fill' KHnixchf (liiruiujic. 
 
304 HISTORY OF ANTISEPTIC SURGERY. 
 
 this subject, viz. : that the method has been objected to on 
 various grounds, but chiefly because those who have failed in 
 their attempts have looked on the spray as the essential element, 
 and on aseptic surgery as the performance of operations or 
 dressings in a spray of carbolic acid. There cannot be a more 
 fatal error than this, for the spray is in the great majority of 
 cases merely a convenience, and not a necessity, and those who 
 look on it as a necessity are apt to forget the really essential 
 details, and to trust too much to the spray. I say it is not 
 essential, for if the wound be easily accessible, and be thoroughly 
 washed out during and after the operation, the great probability 
 is that an aseptic result will be obtained. Only it must be 
 remembered that if the spray is not used, this washing out 
 nmst not be neglected. But to deluge the wound with carbolic 
 lotion is an undesirable thing ; and it is for this reason, and also 
 because the feeling of certainty as to the result must be greater 
 when the spray is used than when it is not, that I would advo- 
 cate its continuance. 
 
 Other surgeons look on the gauze as an essential element, 
 and that this is equally an error is evident from a consideration 
 of Mr. Lister's earlier methods, and also from the results at 
 present obtained by the use of other materials. One surgeon 
 has indeed gone so far as to use the term ' spray and gauze 
 method ' as synonymous with Listerian or aseptic surgery ; in 
 other words, to define aseptic surgery by two of its least or even 
 non-essential elements. Aseptic surgery is not treatment by 
 spray, nor by gauze, nor by spray and gauze, nor by carbolic 
 acid, but is any method of treatment whicli aims at and 
 succeeds in excluding the causes of fermentations from 
 wounds. 
 
365 
 
 CHAPTER XVII. 
 
 RESULTS OF ANTISEPTIC SURGERY. 
 
 Chief points for consideration. How far do the various metliods prevent 
 fermentations in wounds ? How to ascertain tlie true value of any individual 
 method. The value of the various methods in guarding against infective 
 disease : meaning of the term ' infective disease.' Relations of aseptic 
 surgery to infective disease. Mr. Lister's results in Glasgnw, The recent 
 Glasgow statistics. Mr. Lister's results in Ediniurgh ; results in septic and 
 aseptic eases — Mr. Sjjences practice — 3tr. Syme's results — Mr. Lister's re- 
 sults at King's College Hospital : — Volhnami — N^usshaum — Socin — iSaxtorjj/i 
 — Esmarch — Hueter — Czerny — Lucas- C/iainpinnuiire — Gros.'< — Lcticvant 
 — Panas — Schede — Meylwr — Spencer Wells^ Keith — Thornton. Thiersch's 
 results with salicylic acid. Thymol. The relations of other forms of 
 Antiseptic Surgery to these diseases — Treatment hy Antiseptics— Beyher — 
 lAster — Nelaton — Hutchinson. Occlusion — Jules Guenn. — Alphonse Guenn. 
 Treatment hy irrigation and water bath — Langenbeck — Valette. Open 
 Met/iod — BaHscher and Vezin — Burow — Kronlein. Results where no 
 antiseptic measures were adopted — Billroth — Malgaigne — Paul — Holmes 
 — Erichsen. Results of cleanliness — Savory — 3Ic Vail — Bardenheuer. 
 
 In looking at the results of the various methods of treatment, 
 the following are the chief points which present themselves for 
 consideration. 
 
 1. Results of the various methods as to saving life 
 {a) by preventing infective disease. 
 (6) by preventing profuse suppurations and con8e(|uent 
 
 exhaustion, 
 (c) in other ways, such as by rendering operations on weak 
 or diseased individuals possible, or by enabling the 
 surgeon to undertake with safety by one method opera- 
 tions which by other methods would be unjustifiable. 
 2. Results according as one or other metliod enables t.he 
 surgeon to render the patient a more useful member of society. 
 
300 JiESUZrS OF ANTISEPTIC SURGERY. 
 
 Here I shall have chiefly to consider the bearing of the various 
 methods on conservative surgery. 
 
 3. Method of healing in various cases, and also the behaviour 
 of sloughs, ligatures, blood clots, &c. 
 
 4. The bearing of the various methods on constitutional 
 disturbance after operations or wounds. 
 
 5. Discussion of the objections against the various methods, 
 and other points. 
 
 Before entering on these questions, I must say a few words 
 as to how far these methods answer the purpose of preventing 
 fermentations in wounds. 
 
 The aseptic method, when properly carried out, does this 
 completely. There is no putrefaction, and no other kind of fer- 
 mentation ; and, as I have shown, organisms can be entirely ex- 
 cluded if it be wished. No doubt in ordinary practice one form 
 of organism does sometimes get in, but this is only generally 
 towards the end of the case, and it does not cause putrefac- 
 tion, while the products of its growth seem to be but little 
 irritating. 
 
 Treatment by antiseptics does not prevent fermentations or 
 the entrance of organisms, unless, indeed, it is so thorough as to 
 render the wound aseptic. The specimens of bacteria which 
 are figured on Plate I. were taken from wounds treated with 
 antiseptics. Although, however, fermentations are not alto- 
 gether prevented, yet from the frequent removal of the organ- 
 isms and their destruction by the antisei)tics employed, fer- 
 mentation does not, as a rule, occur to any great extent. 
 
 The open method hinders the putrefactive fermentation, 
 more especially because the discharge flows rapidly away and 
 also because it becomes too concentrated and too freely ad- 
 mixed with oxygen. Nevertheless, w^henever the discharges 
 are retained, they undergo fermentation, showing that the 
 causes of fermentation are constantly present. 
 
 Treatment l)y irrigation or by water bath is more effectual 
 than the open method, because the discharge is removed still 
 more rapidly and thoroughly ; but, nevertheless, unless a 
 sufficiently strong antiseptic solution be emY)loyed, the causes 
 of fermentation are always present in the wound, and may act 
 if thti-y have opportunity. 
 
MODE OF TESTING THE METHODS. 367 
 
 The various methods of occlusion are the most imperfect of 
 all, and I have already referred to the stench and the state 
 of the pus in wounds treated by Alphonse Guerin's cotton-wool 
 method. 
 
 In determining whether any instrument or any method is 
 safe and suitable for use in the ordinary circumstances in which 
 it will be employed, one does not simply content oneself with 
 using it under such circumstances, but various tests are applied 
 to it, Le. it is subjected to trials greater than those which it 
 will have to undergo in every-day work. A gunmaker is not 
 satisfied with a gun if it does not bm-st with an ordinary 
 charge ; he overcharges it, and if it withstands this test, he very 
 properly concludes that it will be efficient and safe as ordinarily 
 used. A boilermaker does not send out a boiler as trustworthy 
 till he has subjected it to pressure such as it may never have 
 to bear afterwards, but which it might, under rare circumstances, 
 have to endm'e. 
 
 In considering the value of the various methods of wound 
 treatment as protectors against death, we must in like manner 
 consider how they behave in the very worst circumstances, in 
 circumstances in which they may never or only very rarel}' have 
 to be employed ; for a method which is effectual under unfavour- 
 able circumstances ought to be employed in all, unless there is 
 some special and valid objection to its use. The tests, there- 
 fore, which I shall apply to these methods (so far as I can 
 find the reiiuisite material) with the view of determining how 
 far one or other may be depeuded on as a guard against the 
 more serious dangers of o^jerations, are their behaviour in 
 unfavourable hygienic conditions, or indeed, in infected atmo- 
 spheres, and to what extent they protect patients after opera- 
 tions which are peculiarly liable to be followed by serious con- 
 sequences. 
 
 Firstly, then, with regard to Infective DUease. Under this 
 heading I include Pyaemia, Septicaemia, Erysipelas and Hospital 
 Gangrene. Closely allied to these is Septic Intoxication, which 
 I would call, after Matthews Duncan, Saprcemia. For though 
 this is merely the result of a chemical poison, it is a disease 
 which is dependent for its occurrence on fermentation in 
 
368 RESULTS OF AXTISErTIC SURGERY. 
 
 wounds, and it must, therefore, l^e included in this grou)). T 
 do not add Tetanus, because I do not think that there is suf- 
 ficient evidence as yet to justify us in classing it among septic 
 diseases, though several eminent surgeons, more especially in 
 Germany, hold that view. 
 I shall first consider 
 
 The Relations of Aseptic Surgery to these Diseases. 
 
 The first record which I can find — and it is a very striking 
 one — is a paper published by Mr. Lister himself, in which he 
 gives his results in Gflasgow up to the time when he went to 
 Edinburgh. This will be found in the ' Lancet ' for 1870. In 
 this paper he describes the progress of his cases and the state 
 of his wards in the Glasgow Infirmary before and after the in- 
 troduction of aseptic surgery. He tells us that on account of 
 the constant presence of infective diseases in that hospital when 
 he went to Glasgow, he had to diminish the number of beds in 
 each ward, and he states that infective disease was so com- 
 mon, that whenever a case of compound fracture was admitted 
 into his wards, he at once ordered the internal administration 
 of sulphites, which were at that time much used as prophylactics 
 against these diseases. In some of the other wards these 
 diseases became at times so prevalent that the wards had to be 
 closed. 
 
 Mr. Lister gives the following statistical table of his results 
 in amputation cases before and after the introduction of aseptic 
 surgery. The statistics before the introduction of that method 
 include the results of two years' practice (1864 and 1866, the 
 report for 1865 being imperfect). During that time the 
 following amputations were })erformed, with the following 
 results: — 
 
 Cases Deaths 
 
 Through the shoulder-joint :5 2 
 
 ,, upper arm ...... 8 2 
 
 „ elbow-joint ...... 1 1 
 
 „ forearm ....... .5 1 
 
 „ hip 5 4 
 
 „ thigh 10 3 
 
 „ knee-joint ...... 3 1 
 
 „ ankle 5 2 
 
 Total ... 35 16 
 
 A morlality of l.rT p. c. 
 
MR. LISTERS GLASGOW STATISTICS. 
 
 8G9 
 
 The causes of death are not definitely stated, but ahnost all 
 were due to infective disease. Thus of the six deaths following 
 amputations of the upper extremity, four were due to pysemia 
 and one to hospital gangrene. 
 
 In contrast to this, Mr. Lister mentions the results obtained 
 during the aseptic period (1867, 1868, 1869). The following 
 were the amputations performed : — 
 
 Shoulder-joint 
 
 Uijper-arra 
 
 Forearm . 
 
 Hip-joint . 
 
 Thigh 
 
 Knee 
 
 Ankle 
 
 Total 
 A mortality of 15 p. c. 
 
 Cases 
 8 
 3 
 6 
 2 
 •i 
 13 
 9 
 
 40 
 
 The causes of death in all the cases is not given. In two — 
 an amputation at the hip-joint and a double amputation at the 
 knee — death occurred from shock and loss of blood. Mr. Lister 
 also states that two of the deaths resulted from pyaemia, but in 
 one of these the pyyemia existed before the operation (amputa- 
 tion of the forearm), and in only one case (an amputation at the 
 knee) did pyaemia arise after the operation. But further, these 
 were the only cases of pyaemia which occurred in Mr. Lister's 
 hospital practice during these three years, and that in spite of 
 the former frequency of the disease. And among the other 
 cases treated during this time were twenty-two comjjound 
 fractures, and several compound dislocations. 
 
 During the same period only one case of erysipelas occurred, 
 but it did not prove fatal. 
 
 Hospital gangrene attacked one or two wounds, but it was 
 of a very mild type ; and Mr. Lister states that during tlie last 
 year of this period he had no cases of that disease. 
 
 Two other points must also be taken into consideration. 
 Firstly, the annual cleaning of the wards, which had previously 
 been necessary, was not carried out during those three years. 
 Secondly, when Mr. Lister remarked the great improvement In 
 the healthiness of his wards, he increased the number of beds 
 in each. 
 
370 liE^'SUL'ns OF ANTISEri'IC SURGERY. 
 
 Here we have a very valuable piece of Statistics ; and it is so 
 much the more striking as the results were obtained in the 
 early days of aseptic surgery before any of the recent improve- 
 ments had been introduced. During a period of three years, 
 there occurred only two cases of pyaemia, one case of erysipelas 
 and one or tAvo cases of mild hospital gangrene, and this result 
 was obtained in unhealthy wards in which these diseases were 
 previously common, and in wards which, towards the end of the 
 aseptic period, were in much more unfavourable hygienic con- 
 ditions than before the commencement of that period. Looking 
 at only one class of operations, the mortality after amputations 
 was reduced from 45*7 p.c. to 15 p.c, and that reduction was 
 in the main or altogether owing to the abolition of infective 
 disease. I say that these statistics are of the greatest value, and 
 it is strange that they have been allowed to pass unnoticed by 
 those who have cried so loudly for statistics ; for they answer 
 almost all the requirements. They are results obtained by the 
 same surgeon in the same wards in successive years. And the 
 result cannot be ascribed to better hygienic conditions ; for, as I 
 have just pointed out, there was no improvement in the hygienic 
 arrangements during the aseptic period, in fact, rather the con- 
 trary, for the annual ward cleaning was done away with, while 
 an increased number of beds was introduced. Nor can the 
 results be ascribed, as is so much the fashion in some quarters, 
 to cleanliness alone, to the cleansing of the instruments after 
 each dressing, &c.; for long before Mr. Lister had thought of the 
 aseptic method, he had striven to prevent all such contamina- 
 tion, being fully impressed with the evils of putrefaction, and 
 with the necessity of avoiding it, as far as possible. Neverthe- 
 less, though cleanliness had been tried, it had failed. 
 
 While speaking of Glasgow, I may mention here the recent 
 statistics given by Mr. MacEwen in 1879.' They are merely 
 nvnnerical, but nevertheless, they are striking, and when con- 
 sidered along with the other results which will be referred 
 to presently, they will be seen to be of great value. INIr. 
 MacEwen, thinking that pure air was of more value than aseptic 
 treatment, asked the medical Superintendent of the Glasgow 
 Infirmary to compile comparative statistics of cases treated asep- 
 
 ' JJritisk Medical Jaiiriinl, 187U. 
 
MR. MAC EWEN'S STATISTICS. 371 
 
 tically and of those treated in other ways. To his siu-jjrise, the 
 facts showed the opposite of what he had expected. Thus, dui'ing 
 the years 1875, 1876, 1877 and 1878, 1706 cases were treated 
 strictly aseptically under the care of Dr. Cameron, and of these 50 
 or 2*93 p.c. died. During the same period, in the same number 
 of wards, under Dr. Morton's care, 1884 cases were treated not 
 aseptically, and of these 110 or 5*84 p.c. died, the cases in each 
 instance being practically of the same character. And not 
 only was the mortality in the latter case more (it was double) 
 than in the former for the whole period taken together, but a 
 similar difference was found when the results of each year were 
 looked at separately. Thus the percentage mortality during 
 
 1875 was, 
 
 among aseptic cases 
 
 3-29 p. c 
 
 ,, 
 
 „ non-aseptic cases . 
 
 7-63 „ 
 
 1876 
 
 ,, aseptic cases 
 
 3-28 „ 
 
 „ 
 
 „ non-a«eptic cases . 
 
 f>-itl „ 
 
 1877 
 
 „ asefitic cases .... 
 
 3-G8 „ 
 
 „ 
 
 „ non-aseptic cases . 
 
 5-13 „ 
 
 1878 
 
 „ aseptic cases .... 
 
 203 „ 
 
 )j 
 
 „ non-aseptic cases . 
 
 396 ,, 
 
 As is remarked in a leader in the ' British Medical Journal ' 
 on this subject : ' The result, therefore, proves that, under 
 antiseptic treatment, the mortality was, under apparently 
 strictly comparable circumstances, much smaller than under 
 the ordinary mode. . . . This is a case very much to the point, 
 and will meet some of the conditions of comparative statistics 
 rightly insisted on by IMr. Holmes.' Some correspondence 
 followed between Dr. Cameron, Dr. Morton, and JNIr. ]MacEwen, 
 after the publication of these results, but the further informa- 
 tion elicited did not in any way alter the significance of the 
 facts. 
 
 I will now pass on to Mr. Lister's results in the Edinburgh 
 
 Infirmary. These have been already published in his speech at 
 
 the meeting of the metropolitan branch of the British ]\redical 
 
 Association at St. Thomas's Hospital in December, 1879 ; ' and 
 
 some further facts were given by Mr. Lister in his reply, in 
 
 February 1 880, to Mr. Spence's attack.^ I shall not, therefore, 
 
 enter at great length into these general statistics, more espe- 
 
 ' Sec JMacCormacs Avti-icjitir Siirfierif. 
 ■ BrHuh Mrdiriil Journal, 1880. 
 
37:? 
 
 liESULTS OF ANTISEPTIC SURGERY 
 
 oially as I intend presently to allude to some of the facts in 
 detail. 
 
 From the end of 1871 to the middle of 1877 — a period of 
 about five and a half years — Mr. Lister treated 553 eases 
 aseptically. Of these 2, or '36 per cent., died of blood poison- 
 ing. During the same period, Mr. Lister treated 292 cases 
 in other ways, some with antiseptics, some without, and 
 of these 4, or 1*36 p. c, died of blood poisoning. Now this alone 
 is a very striking statistical fact, as it shows that the same 
 surgeon, in the same wards, during the same time, lost four 
 times as many patients from blood poisoning in cases not 
 treated aseptically as in those which were treated on strict 
 aseptic princij)les. And when we look at the nature of the 
 cases in each instance, this difference will become much more 
 apparent. 
 
 Of the 553 cases treated aseptically, 29 died. 
 
 Among these were 80 major amputations, of which 9 died — 6 from 
 shock within a few hours, 1 from diphtheria in the throat nine 
 weeks after operation, when the wound was almost enthely healed ; 1 
 from cerebral hsemorrhage three months after the operation ; and 1 
 from hsemorrhage into the thigh from a malignant tumour of the femur 
 thi-ee days after amputation at the shoulder-joint — the amputation 
 wound was doing well. 
 
 The following is a complete table of M 
 
 r. Lister's 
 
 amputations : — 
 
 
 
 
 For disease 
 
 
 
 
 Primary 
 
 and secondary 
 to injury 
 
 Total 
 
 Cases 
 
 Deaths 
 
 Cases 
 
 Deatlis 
 
 Cases 
 
 Deaths 
 
 Hip . 
 
 
 1 
 
 1* 
 
 2 
 
 2# 
 
 3 
 
 3 
 
 Thigh 
 
 
 
 
 3 
 
 2* 
 
 26 
 
 If 
 
 29 
 
 3 
 
 Leg . 
 
 
 
 
 3 
 
 
 
 5 
 
 
 
 8 
 
 
 
 Ankle 
 
 
 
 
 2 
 
 
 
 16 
 
 n 
 
 18 
 
 1 
 
 Shoulder 
 
 
 
 
 4 
 
 1* 
 
 ] 
 
 ^ 
 
 5 
 
 2 
 
 Upper-arm 
 
 
 
 
 3 
 
 
 
 6 
 
 
 
 9 
 
 
 
 Forearm 
 
 
 
 
 — 
 
 — 
 
 8 
 
 
 
 8 
 
 
 
 
 Total 
 
 16 
 
 4 
 
 64 
 
 5 
 
 80 
 
 9 
 
 * Died in a few hours from shock ; f died from diphtheria ; % from cere- 
 bral luvmoiThage ; § from hemorrhage into the thigh. 
 
 There were akso 21 excisioDS of the larger joints performed asep- 
 
MR. LISTERS RESULTS IN EDINBURGH. 373 
 
 tically without a death (7 of knee, 2 of shoulder, 10 of elbow, 2 of 
 wrist). 
 
 Thirty-seven excisions of the mamma were perfoi^med aseptically 
 with two deaths, both from infective disease. One of the deaths was 
 from septicaemia occurring after the removal of a very large portion 
 of skin and of the whole contents of the axilla. Everything went on 
 perfectly till the tenth day, when a mistake was committed in the 
 dressing ; putrefaction occurred, and septicfemia commenced. On 
 post-mortem examination no abscesses or infarcts or other marked 
 appearances wei-e found. The other patient died of erysipelas. 
 Among these 37 cases there were 24 in which not only the mamma, 
 but also the fat and glands from the axilla were removed. 
 
 There were 27 operations for un-united, or badly united, fractures 
 without a death. These consisted of 8 operations on the femur, 9 on 
 the bones of the leg, 4 on the humerus, 5 on the bones of the fore- 
 arm, and 1 on the clavicle (removal of a projecting splinter of bone 
 in a case of simple fracture, thus converting the case into one of 
 compound fracture). 
 
 There were 14 operations on healthy joints, in which the joints 
 were opened and kept open for some days by means of a drainage 
 tube. No death. 
 
 In 11 cases incisions were made into diseased joints in which 
 suppuration had not yet occurred. No death. These were cases of 
 gelatinous disease. 
 
 There were 39 cases in which abscesses of joints were opened and 
 a drainage tube inserted, none of the diseased parts {bone, synovial 
 membrane, &c.), being removed. Of these, 2 died, both from tuber- 
 cular meningitis confirmed on post-mortem examination. 
 
 An incision was made and a drainage tube inserted in 2 cases of 
 synovitis of the knee-joint. No death. 
 
 There were 4 cases in which operations were performed to relieve 
 old standing dislocations. In some of these the bones were simply 
 replaced. In one case it was necessary to remove portions of the 
 bone before the surfiices of the joint couhl be brought into apposition. 
 No death. 
 
 In 3 cases the femur was divided for knock -knee. No death. 
 
 In 7 cases of ostitis a groove was dug in the bone by a gouge and 
 hammer. No death. 
 
 There were 7 cases of ligature of the large arteries in their con- 
 tinuity, with 1 death. The fatal case is not entered in the note-books, 
 but I remember its occurrence. During attempts to I'educe a disloca- 
 tion of the shoulder-joint of seven weeks' standing, the axillary artery 
 
;]74 llESULTS OF ANTISEPTIC SURGERY. 
 
 was toi'ii and haemorrhage occurred into the axilla. Mr. Lister at once 
 cut down and ligatured the artery, but the patient died the same night 
 from exhaustion, owing to the loss of a large quantity of blood. 
 
 There were 2 cases of excision of the thyroid gland. No death. 
 
 There were 4 cases of excision of the testicle. No death. 
 
 There were 9 cases of strangulated hernia, with 3 deaths. The 
 gut was gangrenous in all the fatal cases. 
 
 There were 30 cases of abscess (psoas or lumbar) connected with 
 disease of the spine. Of these 4 died — 2 from phthisis, 1 from ex- 
 haustion, and in one case the lumbar abscess was almost absolutely 
 healed when a little glandular abscess formed in the neck. This was 
 opened without aseptic precautions, and the wound was attacked 
 with erysipelas, of which the patient died. Though this was an 
 aseptic case, yet the erysipelas did not attack a wound treated 
 aseptically, and therefore the death from infective disease is in- 
 cluded among the cases not treated aseptically, and not among the 
 aseptic ones. 
 
 There were 9 1 cases of acute or chronic abscesses. These included 
 a great variety of abscesses, but they were all more or less extensive. 
 There were 2 deaths ; one death occurred in a case of peri-renal 
 abscess. The patient was in a very low state when operated on, had 
 diarrhoea, &c., and he sank in ten days. On post-mortem examination 
 the typical scrofulous kidney was found. The other death occui-red 
 in a case of abscess in the right lumbar region, but in which there 
 was no disease of the spine. The abscess was opened on May 20, 
 1873, and went on veiy well till July. There was then only a small 
 sinus, and the patient was })ermitted to get up. During autumn the 
 discharge was allowed to putrefy, and it afterwards increased rapidly 
 in amount and became purulent. For some days before her death, on 
 November 15th, the patient had very severe pain in the right iliac 
 region and the right limb, and following this the leg and foot became 
 gangrenous (phlebitis ?). 
 
 There were five cases of empyema. No death. 
 
 There were eight cases of chronic bursitis, in which incisions were 
 made and drainage tubes inserted. No bad result. 
 
 There were twelve cases of removal of exostoses without a death. 
 
 There were forty cases of removal of large tumoui-s from various 
 regions. No death. (There were also a number of cases in which 
 smalUsh tumours, fatty or otherwise, were removed. These are not 
 included among the forty.) 
 
 There were three cases of suprapubic lithotomy, with two deaths. In 
 one fatal case, an adult male, the peritoneum was intentionally oj^ened 
 below the umbilicus, the bladder incised through its peritoneal coat. 
 
MR. LISTERS RESULTS IN EDINBURGH. ;37o 
 
 and the stone extracted. The wonnd in the bladder was then stitched 
 up, as was also the wound in the' abdominal wall. The patient was 
 doing well till the second morning (about forty hours) after the opera- 
 tion, when he got out of bed, or was made to get up. As a result of 
 this exertion the intestines protruded between the stitches. Tbey 
 were returned as soon as the accident was discovered, but the patient 
 died of shock on the same day. In the other fatal case^ a little boy, 
 the peritoneum was also opened, but the stone was not removed. The 
 child cried incessantly after the operation, and in spite of the close 
 stitching of the wound in the abdominal wall, the intestines escaped 
 between the stitches. The patient died on the following day from 
 shock. 
 
 There were three cases of spina bifida, into which minute drains, in 
 two cases horse-hair (two or three threads), and in one a drainage tube, 
 were introduced. The patients apparently died as the result of the con- 
 stant draining away of the cerebro-spinal fluid, although as soon as bad 
 symptoms were evident, the drains wei-e withdrawn. In two cases no 
 macroscopical appearances were found to account for death. (I do not 
 know what the microscopical appearances of the cord may have been.) 
 In one case the sac was congested, and contained a little turbid tiuid, 
 but there was no violent inflammation, and the little which was pre- 
 sent did not apparently spread up the canal. In fact, the appearances 
 found could not explain the fatal result in any of the cases, and there- 
 fore it is possible that the disturbance due to the constant draining 
 away of the cerebro-spinal fluid had something to do with death. 
 The first two cases died in two and nine days respectively. The last 
 died in five days. 
 
 One case of chronic hydrocephalus was treated in this way (by 
 drainage) and died in six days. There was no trace whatever of in- 
 flammation. The ventricles were extremely distended, containing 
 forty-two ounces of clear cerebro-spinal fluid. Apparently the fatal 
 result was due to the same cause as in the former instances, viz., the 
 disturbance consequent on the constant draining away of the cerebro- 
 spinal fluid. 
 
 These are the most impoii:ant of the 553 eases. (Although 
 there were only two deaths from infective disease after aseptic 
 operations, and although that fact was all that was necessary for 
 our present purpose, I have thought it well to mention all the 
 causes of death, and to indicate the sort of cases treated.) 
 
 The 292 cases not treated aseptically contained a very much 
 larger proportion of trivial operations, such as removal of 
 
y70 ItESULTS OF ANTISEPTIC SURQEIiY. 
 
 necrosed bone, Hstula in ano, ha'morrhoids, &c. There were 
 ten deaths, of which two were from pygemia, one from septic- 
 aemia, one from erysipelas, and six from exhaustion (?). 
 
 The cases of pyaemia occun'ed, one after a plastic operation on the 
 nose, and one after amputation of the penis. The case of septicemia 
 occurred after excision of the tongue. The case of erysipelas occurred 
 after the opening of a small abscess in the neck without aseptic pre- 
 cautions; this case is mentioned among the psoas abscesses (p. 373). 
 Onecaseof excision of the hip-joint (a^t. seventeen) died twenty- nine days 
 aftei' the operation, apparently of exhaustion from the profuse discharge. 
 One case of excision of the mamma (set. sixty-three), where putrid sinuses 
 were present before the opei'ation, died in three days of exhaustion. ( May 
 not the fatal result in this case have been due to saprsemia ?) One case of 
 excision of the upper jaw (set. sixty-three), died twenty- three days later, 
 apparently of exhaustion ; there were no marked symptoms during life, 
 and no post-mortem appearances ; there were haemorrhages on various 
 occasions after the operation. One case of excision of the tongue 
 (set. seventy-five) died in ten days without any special symptoms, 
 apparently of exhaustion; no morbid appearances were found on 
 post-mortem examination. One case in which the floor of the mouth 
 was removed for malignant disease (an old woman) died apparently 
 of exhaustion. One case of old standing, necrosis of the ilium (ajt. 
 twenty), died twenty-three days after an attempt to remove the dead 
 bone. He is also said to have died of exhaustion, but there is no 
 record of the post-mortem examination, and he had coffee-ground vomit- 
 ing during the forty-eight hours preceding death. (Several of these 
 cases of exhaustion were probably cases of sapraamia or septicaemia.) 
 
 If we compare the causes of death in the two instances and 
 the nature of the operations, the case in favour of the asej)tic 
 method becomes much stronger than if we simply compare the 
 deaths from infective disease. lu the septic cases the patients 
 either died of septic disease or of exhaustion, the result of pro- 
 fuse suppuration, again the result of putrefaction. If we con- 
 sider the aseptic cases, on the other hand, we get a very 
 different result. Thus, among the deaths after amputation 
 there was not a single case where any method of treatment 
 applied to the wound could possibly have saved the patient. 
 The two deaths from tubercular meningitis, the three cases of 
 hernia in which the gut was gangrenous, and the two cases of 
 phthisis were all independent of the tieafment of the wound. 
 
ItESULTS OF TllEATMEXr WITH ANTISEPTICS. ;J77 
 
 The case of peri-renal abscess was also hopeless, and so also, 
 possibly, the case of abscess in the loin where gangrene of the 
 foot occurred. In the case of exhaustion after psoas abscess 
 the disease was extremely extensive. But suppose we include 
 this case, the two cases of infective disease, the three cases of 
 spina bifida, the case of hydrocephalus, and the two cases of 
 suprapubic lithotomy, we have only nine instances of what we 
 may term preventible deaths. In the last six cases, however, 
 it was rather to the direct surgical interference than to any- 
 thing in the after-progress of the wound, looked at from our 
 present point of view, that the deaths must be attributed ; and 
 here, of course, we are not considering the former point. 
 Leaving then out of view the question of the surgical inter- 
 ference, there are only three cases among these, which can be 
 considered in connection with the method of wound treatment 
 alone. Indeed, I doubt very much if it is fair to include the 
 case of exhaustion after psoas abscess, for the disease was of 
 such a natmre, so very extensive, as to render it doubtful 
 whether recovery was possible under any circumstances.' 
 
 On the other hand, among the fatal septic cases, there were 
 none independent of the after-progress of the operation wound, 
 unless indeed we exclude the case of necrosis of the ilium 
 in which probably waxy degeneration of the internal organs 
 had occurred extensively before the operation. This leaves 9 
 out of 292 septic cases, of which a large proportion were trivial 
 operations in which death occurred on account of the course 
 which the wound followed, while in the former instance, in 
 the 553 aseptic cases, a very small proportion of which were 
 trivial operations, there were only, at the most, three such in- 
 stances. 
 
 During this same period there were treated aseptically in 
 hospital seventy-two cases of injury (wounds, compound 
 fractures, and wounds of joints), of which four died. 
 
 Three of these deaths occurred in cases of compound fracture 
 treated conservatively, and in all death took place within 48 hours. 
 The other death occurred in a case in which the attempt to eradicate 
 putrefaction was unsuccessful, and where the patient is said to have 
 died of bronchitis and caidiac disease. 
 
 ' fciee the list of psoas abscesses, No. 21, Ciiapler XX. 
 
378 ItESULTS OF AXTISEPTIC SURGERY. 
 
 Here again, there is only one ease of possibly preventible 
 death, and that in a septic ease. Among those which were 
 rendered aseptic no death occiuTed which was preventible by 
 any known method of wound treatment. 
 
 We have fortunately the opportunity of comparing these 
 results with those obtained by another surgeon — ]Mr. Spence — in 
 the same hospital during the same time, by the use of methods 
 of treatment which were not aseptic but which consisted 
 sometimes in the application of water dressing, sometimes of 
 boracic lint, and in some cases no dressing was used. I cannot 
 give a name to the method of treatment. It was a mixture of 
 principles, in fact a sort of mongrel method. There were certain 
 differences in the hygienic conditions which will be presently 
 alluded to, but these were all more favourable to ]\ir. Spence. 
 
 Mr. Sj)ence's report extends from October 1872 to April 
 1878 with the exception of the winter session 1874-75.' I 
 regret that I cannot find any report for this session, as dming 
 it there was a virulent epidemic of erysipelas in Edinburgh, 
 and it would have been interesting to know how Mr. Spence's 
 cases progressed during that time. Taking, however, the 
 period so far as it is given, but always remembering that 
 a very testing winter included in Mr. Lister's results is not 
 present here, we find that dming this time 328 more or 
 less severe operations were performed with fifty-eight deaths, 
 and that three cases of compound fracture were treated con-^ 
 servatively with one death. What proportion of these deaths 
 were due to infective disease, we shall, I suppose, never know. 
 In sixteen out of the fifty-eight cases the cause of death is not 
 stated at all ; five died within thirty hours, and may therefore 
 be left out of consideration ; while in eight the fatal result is 
 directly assigned to septic poisoning. In twenty-nine of the 
 cases no distinct causes of death are given, though such state- 
 ments as the existence of irritative fever, unhealthy action in 
 the wound, uncontrollable oozing of blood, &c., lead us to sus- 
 pect that infective disease was also at work in these instances. 
 
 These results form a marked contrast to Mr. Lister's. 
 
 ' See 3Icdical Times and Gazette, March 13, 1875 ; the same journal for 
 October 28, 1876 ; and the November and December numbers of the Edinburgh 
 Medical Juurnaliov 1879. 
 
3fR. SPUNCE^'S RESULTS. 
 
 37U 
 
 Here we have a percentage mortality of nearly eighteen p.c. as 
 compared with Mr. Lister's percentage mortality in aseptic 
 cases of nearly five p.c. i.e. a mortality in septic cases 3'7 times 
 greater than in aseptic ones. And further the cases of death 
 which are distinctly stated by Mr. Spence as having been due 
 to septic diseases were eight in number or 2*4 p.c, that is to 
 say, eight times more than the mortality from similar causes in 
 Mr. Lister's aseptic practice. And, as I have just indicated, the 
 mortality from these causes in Mr. Spence's practice was 
 probably very much greater ; and this difference is not due to 
 greater severity of the operations in INIr. Spence's j)i'actice, as 
 we shall see from the following statement of the nature of his 
 cases. 
 
 During this pei'iod Mr. Spence performed 97 amputations, of 
 which 25, or 25-7 per cent., died. (Compare this with Mr. Lister's 
 mortality of 11 "25 per cent, after amputations performed on aseptic 
 principles.) 
 
 The following table gives Mr. Spence's results in major amputa- 
 tions : — 
 
 
 
 
 Secoudary to 
 
 
 
 Prill 
 
 ary 
 
 iiijury and 
 for disease 
 
 Total 
 
 Cases 
 
 Deaths 
 
 CaKBs 
 
 Deatlis 
 
 Cases 
 
 Deaths 
 
 Hip. .... 
 
 
 
 
 
 3 
 
 1 
 
 3 
 
 1 
 
 Thigh . 
 
 
 
 
 
 5 
 
 .3 
 
 26 
 
 G 
 
 31 
 
 i» 
 
 Knee-joint 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 1 
 
 
 
 Leg. 
 
 
 
 
 
 4 
 
 
 
 9 
 
 2 
 
 13 
 
 2 
 
 Ankle 
 
 
 
 
 
 1 
 
 
 
 24 
 
 2 
 
 2.5 
 
 2 
 
 Shoulder . 
 
 
 
 
 
 1 
 
 1 
 
 3 
 
 1 
 
 4 
 
 2 
 
 Arm 
 
 
 
 
 
 2 
 
 1 
 
 7 
 
 2 
 
 9 
 
 3 
 
 Fore-arm . 
 
 
 
 
 
 2 
 
 2 
 
 2 
 
 2 
 
 4 4 
 
 
 Tot 
 
 al 
 
 
 
 IG 
 
 7 
 
 74 
 
 If. 
 
 00 23 
 
 From this table I have excluded 6 partial amputations of the 
 foot, with 2 deaths, and 1 partial amputation of the hand. These 
 are included by Mr. Spence among his major amputations, but I 
 have already excluded such operations from Mr. Lister's list. 
 
 As to the causes of death in these cases, one patient on whom am- 
 putation at the hip-joint was performed rallied after the operation, 
 but .sank suddenly next day. One case of primary amputation of the 
 thigh died from sliock, and 1 from pyaemia : 1 amputation of the 
 
380 RESULTS OF ANTISEPTIC SURGEItY. 
 
 thigh for disease died of tubercuhir meningitis ; 1 died 5 days after 
 the operation, and it is stated that he had dian-hoea ; in 1 case oozing 
 of blood came on 2 or 3 days after the operation. One secondary 
 amputation at the ankle-joint died from septic poisoning, ana 1 had 
 diarrhcea and tabes mesenterica. One fatal case of amputation at the 
 shoulder-joint had repeated hfemorrhages from the wound. One case 
 of amputation through the upper arm died 2 days after the operation, 
 having had continuous oozing of blood ; in 1 case general oozing 
 began on the 6th day but was arrested by styptics, and the patient 
 died on the 7th day. One primary amputation of the fore-arm died 
 from pneumonia, and 1 had fever, traumatic delirium, diarrhcea and 
 vomiting, and died on the 10th day; 1 died from erysipelas and 1 
 from pleurisy and pneumonia. The causes of death in the other 
 fatal cases (8 in number) are not referred to. 
 
 Among the other cases treated were 57 excisions of various joints, 
 of which .7 died ; 34 excisions of the mamma with 2 deaths ; 10 cases 
 of lithotomy with 1 death ; 44 cases of removal of tumours with 8 
 deaths ; 9 complete or partial excisions of the tongue, 4 deaths ; 
 4 cases of tracheotomy, no death ; 31 operations for necrosis, no 
 death ; 1 operation for badly-united fracture of the femur, no 
 death ; several miscellaneous severe operations, 6 deaths ; 3 excisions 
 of the lower jaw, no death ; 3 castrations, no death ; 2 cases of 
 trephining. 
 
 On comparing these cases with Mr. Lister's we find that 
 the operations were not more severe, and yet the mortality was 
 nearly four times as great. 
 
 Mr. Spence had thirty-one amputations of the thigh against 
 Mr. Lister's twenty-nine, but nine deaths against three. 
 
 The total number of cases in which bones were operated on, 
 such as for ununited fractures, excisions, &c. was greater in 
 Mr. Lister's practice, and yet he had no death as compared 
 with Mr. Spence's seven fatal cases. This difference is the more 
 remarkable when it is remembered that many of Mr. Lister's 
 operations were performed on healthy bones, while the greater 
 number of Mr. Spence's were performed on diseased bones. It 
 is less dangerous to operate on the extremity of a bone than on 
 the dense shaft, especially where the medullary cavity is 
 opened. And the dangers of the operation are diminished if 
 the bone be previously the seat of chronic inflammation, for a 
 chronically inflamed bone is well advanced on the road to 
 
MR. SPENCE'S RESULTS. 381 
 
 granulatiou, and granulation is, therefore, much sooner com- 
 plete after the operation than in the case of healthy bone. In 
 other words, the time during which there is risk of absorption 
 from the wound is shorter in the case of chronically inflamed 
 bone than in the case of healthy bone, while the risk is from 
 the first less, because in the diseased bone a partial barrier is 
 present from the beginning. 
 
 Then, among ]\Ir. Spence's cases there is not a single in- 
 stance of simple incision and insertion of a drainage tube into 
 a healthy joint, a diseased joint or a suppm-ating joint, while 
 Mr. Lister had seventy-six of these cases. 
 
 Then, also, Mr. Spence does not seem to have treated a 
 single case of psoas or lumbar abscess. 
 
 Thus, however we look at the matter, the contrast between 
 septic and aseptic surgery is very markedly in favom* of the 
 latter. This is well seen in Mr. Lister's own hands, in which 
 the results of cases treated aseptically were much better than 
 of those treated in other ways, these results being obtained by 
 the same surgeon, in the same wards, and during the same 
 time. The same contrast in favour of aseptic surgery is shown 
 by the results obtained by another surgeon, in the same hospital, 
 during the same time, and under circumstances in every way 
 more favourable, both as regards the severity of the cases and 
 the hygienic conditions under which the patients were jjlaced. 
 With regard to the latter point, it must be noted that jNlr. 
 Spence's wards were well ventilated and at the top of the build- 
 ing ; Mr. Lister's wards were at the lower part of the building, 
 some on the basement floor. Mr. Spence did not overcrowd 
 his wards ; Mr. Lister had as a rule nearly seventy patients in 
 wards containing fifty beds, and these beds were more closely 
 packed than Mr. Spence's. (The way in which this was 
 managed was, that those adult patients who were well enouoh 
 to be up during the day, slept on mattresses placed in various 
 parts of the ward at night, while children were placed two, three 
 and sometimes even four in a bed.) Then, lastly, Mr. Spence's 
 wards were thoroughly cleaned out once a year ; Mr. Lister's 
 wards, on the other hand, did not, at his own request, undergo 
 this annual process. 
 
 That the wards in which Mr. Lister worked were unhealthy 
 
'S62 RESULTS OF AXTISEPTIC SUIiGERY. 
 
 wards, is shown by the results obtained by jMr. Syme during 
 his last four years. Of amputation cases (120 in number) he lost 
 twenty-five from infective diseases alone, while Eeyher,^ who pub- 
 lished these comparative statistics, states that Mr. Lister, up till 
 the end of 1873, in 123 amputations, had not lost one from infec- 
 tive disease, unless indeed we include a case of tetanus as such. 
 
 These statistical facts fulfil the conditions required by Mr. 
 Holmes in his recent utterances, and they are therefore 
 deserving of careful consideration. 
 
 I shall now pass on to consider JMr. Lister's results in King's 
 College Hospital, from November 1877 till November 1880. 
 During this period there were 207 operations performed asepti- 
 cally, of which fourteen died. All of the operations were more 
 or less serious, and the following is a sample of them, with the 
 causes of death in the fourteen cases. 
 
 Thei'e were 3 amputations at the hip-joint for disease, with 1 
 death. This case died from shock half an-hoiir after the operation. 
 
 There were 4 amputations of the thigh for disease, of which 3 
 died : — 1 got suppression of uriiie on the second day and died ; his 
 kidneys were extremel}'" fatty, and the fact that he had marked albu- 
 minuria had been overlooked before the operation. One case died of 
 pneumonia ; he had a slight cold before the operation, caiight from 
 draughts in the ward ; afterwards he got pneumonia, which was 
 apparently distinctly traceable to exposure during the energetic ven- 
 tilation of the wards in the intense cold of winter. (Such ventila- 
 tion is, I need hardly say, unnecessary in wards where aseptic treatment 
 is carried out ; the comfort of the patients is the point to be attended 
 to rather than the constant flow of a current of aii- through the 
 wards.) A post-mortem examination was not allowed in this case 
 The third case was one of spontaneous gangrene of the foot and leg, 
 where amputation of tlie thigh was iDerformed. Gangrene recurred, 
 and the patient died on the 4th day after the operation. 
 
 There were 2 amputations of the foi'e-arm. No death. 
 
 There were 16 excisions of the mamma and axillary glands, with 
 2 deaths. Both opei-ations were very extensive, and both patients 
 died from shock within 3G hours. 
 
 There were 13 incisions into healthy joints, no death ; 5 in- 
 cisions into joints affected with synovial degeneration, but without 
 buppuration, no death ; 3 incisions into joints affected with synovitis, 
 
 ' Archil- fur KJin. Chirurfiie, Bd. xvii. p. 4',)!i. 
 
J/7i'. LISTER'S RESULTS IX LONLOy. 583 
 
 no death ; 9 incisions into supj)urating joints, 2 deaths, one of which 
 was due to tubercular meningitis, confirmed on post-mortem examin- 
 ation, and 1 occurred in a child admitted with acute abscesses in 
 various joints, in fact with pypemia after scarlet fever ; he died 2 
 days after admission. 
 
 There were 31 operations on healthy bones for deformities, 
 ununited fracture, (tc. No death. 
 
 There were 8 abscesses (lumbar or psoas) connected with disease 
 of the spine. One death. This case putrefied, and the patient was 
 sent home, but died at home from exhaustion a few weeks later. 
 Though not a death in hospital, it is a death in a case treated at the 
 first aseptically, and I have therefore included it. Putrefaction occuri^ed 
 owing to the circumstance that the patient suffered from carbolic 
 acid poisoning, and hence the dressings were left on longer than 
 usual, and thymol dressings were ultimately substituted for the 
 carbolic gauze, with the result that the discharge putrefied. 
 
 There were 4 cases of strangulated hernia with 3 deaths. In one 
 fatal case the bowel was gangrenous ; the gangrenous portion was cut 
 away and the divided ends of the gut vmited by suture ; the patient, 
 who was collapsed at the time of the operation, died in 2 or 3 hours. 
 In one case the patient, an old woman, was in a state of collapse at the 
 time of the operation and never recovered, dying within 24 hovu-s. In 
 one case the gut, which was in a suspicious state at the time of the 
 operation, gave way 60 hours later, and its contents escaped into the 
 peritoneal cavity. The patient died in a few hours. 
 
 There were 3 opei-ations for radical cure of hernia, in which the 
 greater part of the sac was cut away and the mai-gins stitched with 
 cat-gut. No death. 
 
 There were 3 cases of acute necrosis where incisions wei-e made 
 down to the bone and drainage tubes inserted ; the bones were not 
 resected, as Mr. Spence recommends, such a procedure being un- 
 necessary with aseptic management. One of these cases, a child, 
 which was appai-ently in a septicsemic state before the opei-ation, 
 died 5 days afterwards. 
 
 There were 23 large abscesses, among whicli were 6 iliac 
 abscesses, 3 gluteal, 1 pelvic, 2 mammary, 2 in calf, 2 in thigh, 1 
 case in which there were 7 chronic abscesses, 2 cases of suppuration 
 of bruises ; all of them extensive. No death. Two cases of empyema. 
 No death. 
 
 There were 2 cysts of the thyroid gland, which were opened and 
 drained ; no death. Three excisions of the thyroid gland ; one 
 death. In the fatal case tlu; tumour was adherent to tlie trachea. 
 
084 RESULTS OF ANTISEPTIC SURGERY. 
 
 which had become thinned by the pressure, and in removing the 
 tumour the thin membrane gave way. Thus the case was no longer 
 an aseptic one. The puti-id matters passed down the trachea, 
 and gave rise to inflammation of the bronchi. The difficulty in 
 breathing was not relieved by the operation. The patient died 16 
 days after the operation. At the post-mortem examination an open- 
 ing was found in the trachea large enough to admit the tip of the 
 little finger, and communicating with the wound. The lungs were 
 (Edematous, and a small quantity of pus could be squeezed from 
 various parts, but there were no abscesses or infarcts. A lai-ge 
 tumour was found in the thorax surrounding the trachea, and partly 
 also the arch of the aorta. There were no other post-mortem 
 appearances. This is, of course, a septic case, and ought not to be 
 included in this list, but I insert it, as the operation was undertaken 
 with the intention of performing it aseptically, and as it is such a 
 marked contrast to the others. 
 
 Then there were a number of single operations, which it would be 
 too tedious to enumerate, such as 2 cases of nerve stretching, 2 cas- 
 trations, 1 operation for aneurismal varix, 5 varicoceles (veins tied), 
 removal of tumours of various kinds, &c. 
 
 If now we look at the causes of death we find that several 
 were unconnected with the treatment of the wound. Thus the 
 case of shock after amputation at the hip-joint and the two 
 fatal cases after excision of the mamma are quite irrelevant. 
 So also are the three deaths after strangulated hernia, the 
 death from tubercular meningitis, and the death of the little 
 boy admitted with pyaemia. 
 
 How are we to look at the cases of death from suppression 
 of urine, after acute necrosis, and after recurrence of gangrene ? 
 Could these have been prevented by any method of treatment ? 
 The thyroid case was a septic one. 
 
 This leaves us with two cases to consider: the case of 
 pneumonia, which I myself saw, and which I, as well as others 
 who know the facts, firmly believe to have been caused by im- 
 prudent ventilation ; and the fatal case of psoas abscess, which 
 undoubtedly ought to have been avoided, and would in all 
 probability have been so, had not the patient been so sen- 
 sitive to the effects of carbolic acid. 
 
 During these eight years, three wounds of healthy joints 
 and fourteen compound fractures were treated, with one death. 
 
VOLE MANN'S RESULTS. 386 
 
 This death occurred in a case of compound fracture of the 
 skull, the patient being comatose when admitted ; trephining 
 was performed, but he died within twenty-four hours. There 
 were also a number of more or less severe wounds under treat- 
 ment at the same time. 
 
 Looking then at the whole results attained by ]Mr. Lister, 
 we must, I think, come to the conclusion that he is correct in 
 stating, from his own experience, that infective disease is 
 abolished by aseptic treatment, so that, if an operation can 
 be performed aseptically the risk of infective disease may 
 practically be left out of consideration in deciding on the ad- 
 visability of the operation. This view has been amply borne 
 out, as I have shown, by thu-teen years' constant work in three 
 different hospitals — none of them particularly noted for health- 
 iness. 
 
 One of the first surgeons to take up the aseptic method 
 thoroughly, was Professor Yolkmann of Halle ; and he has con- 
 tributed some remarkable testimony to the efficacy of the 
 system. For many years he had used the open method, and 
 during the war in 1866 all amputation wounds were treated in 
 this way. He also employed immersion in water containing 
 carbolic acid : recent wounds of the hands and feet were placed 
 in vessels containing this solution. In his earlier cases the 
 wounds were stitched, drainage being provided for, but for the 
 four years preceding the adoption of the aseptic method — i.e. 
 up till 1872 — he left the wounds quite open. During the first 
 years in which these methods of treatment were carried out, 
 the results were very favourable, and Volkmann was thoroughly 
 conWnced of theu" superiority over the older modes. As time 
 went on, however, and as overcrowding of the wards became 
 necessary, infective diseases also progressively increased, and at 
 last, in the summer and autumn of 1871, the deaths from 
 pvfemia and septicaemia were so numerous that he made up 
 his mind to shut up the hospital altogether for a time. Before 
 doing so, however, he thought that he would try the Listerian 
 method for a few weeks, and it is to the result of tliis trial that 
 I now wish to refer. 
 
 c c 
 
386 RESULTS OF ANTISEPTIC SURGERY. 
 
 T need not go into the details which he gives as to the 
 hygienic conditions of the hospitaL They seem to have been 
 very wretched. There were no proper arrangements for venti- 
 lation ; waterclosets opened into the wards ; there was no place 
 for keeping the dead bodies, which were therefore laid in a 
 cellar situated beneath the surgical wards, and the wards were 
 full of beds. It was under these conditions and in this infected 
 atmosphere that the aseptic method was first employed. 
 
 Volkmann's first report extends from December 1872 to 
 February 1874.^ This was the period in which he was learning 
 the method, and I shall not, therefore, refer at length to his 
 results during this time. Among the cases in which the aseptic 
 method was tried there was one death from pyaemia and one 
 from erysipelas. Erysipelas attacked eight wounds treated on 
 aseptic principles. There were other cases of infective diseases 
 in the hospital during this time, but these were either admitted 
 while suffering from them, or they arose in cases not treated 
 aseptically. 
 
 This remarkable result was obtained in a hospital which, 
 at the commencement of this period, was going to be closed on 
 account of the enormous mortality from these diseases. Surely 
 here there was some benefit derived from the introduction of 
 the aseptic method ! And it must be noted that these two 
 deaths from infective disease occurred in the early period of 
 aseptic practice and, with regard to them and the erysipelas 
 cases, Volkmann states that he could generally point out an 
 error in the manipulations, as a rule, in the mode in which the 
 ■dressing was applied. In a note written in 1875 Volkmann 
 states, that during the last eighteen months,'^ i.e. from the 
 middle of December 1873, there had been no case of pyaemia, 
 and erysipelas had almost or altogether disappeared. With 
 regard to these results Volkmann expressly shows that they were 
 not due to the mere use of carbolic acid as a disinfectant, for 
 carbolic acid had been, as I have just stated, extensively em- 
 
 ' Beitrdgezur Chirurgic, 1875 : ' Ueber den Antiseptischen Occlusiv Verband 
 und seinen Kinflnss auf den Heilungsprocess der Wiinden ; ' Volkmann's 
 Sammlimg, No. 96, 1875. 
 
 - In the Appendix Volkmann states that this holds true for metastatic 
 pyiEmia, but that only fifteen months had elapsed since he had a case of 
 •I'yaimi a simplex.' ^ 
 
VOLKMANNS STATISTICS. 
 
 387 
 
 ployed during the preceding period to irrigate wounds, but 
 latterly without any ap2:)arent benefit. 
 
 In 1877 Volkmann published the continuation of this 
 report,^ and I will refer to it in some detail. The report extends 
 from March 1874 to March 1877, a period of three years. He 
 does not give all the cases treated, but, omitting the septic 
 cases, there is a record of 465 operations performed with aseptic 
 precautions. Of these cases 29 died. 
 
 Among these 465 operations were 157 amputations, of which 15 
 died. On analysing these cases of amputation we find that 139 of 
 them were uncomplicated with other injury or mutilation, and of 
 these only 4 died. Three of these deaths occurred within the first 24 
 hours from shock, and 1 from ' habitual erysipelas.' Omitting from 
 this list 7 partial amputations of the foot, there were 132 major 
 amputations, with 4 deaths, or, leaving out the cases of shock, which 
 were of course independent of the method of treatment, there were 
 129 major amputations, with 1 death. 
 
 The following is the list arranged in a tabular form : — - 
 
 Amputation at the shoulder-joint 
 through humerus . 
 „ forearm . 
 at wrist -joint . 
 „ hip-joint 
 through thigh 
 leg . 
 at ankle (Syrae and Pirogoff) 
 partial of foot 
 
 Total . 
 
 Cases 
 
 Death 
 
 4 
 
 1* 
 
 14 
 
 • — 
 
 23 
 
 — 
 
 3 
 
 — 
 
 2 
 
 1* 
 
 42 
 
 ]* 
 
 2,5 
 
 If 
 
 19 
 
 — 
 
 139 
 
 Died from sliock ; f from ' habitual erysipelas/ 
 
 There were 9 CJises of double amputation.s, with 2 deaths ; 1 died 
 within a few houi-s, and 1 died on the third day (amputation through 
 both thighs) with symptoms of collapse. 
 
 There were also 6 amputations in cases where other severe 
 injuries had been received. Of these 4 died within 24 hours. These 
 were all very severe cases, as for example, amputation at the shoulder- 
 
 ' Vorldiitiijrr lim-irht iihcr die innerhalh drr Iriztfii drei Jahre in der chi- 
 rurginrkrii. Klinik zii JIalle utafiondr odcr jjnlikliuiseh mit Hiilfr der AntUrp- 
 tischen, }[ctlindt' hrhnitdt'Uen xchiccreib Opcratvmen and Kchtvcren Verl.rtzuiigen. 
 By Volkmann and Kraske, Halle, 1877. 
 
 c c 2 
 
388 RESULTS OF ANTISEPTIC SURGERY. 
 
 joint with fracture of sternum and ribs ; fracture of the skull, fracture 
 of ribs, and amputation through both thighs, &c. One case died on 
 the fourth day, never having recovered from the state of collapse ; 
 here amputation through the thigh had been performed, and the 
 patient had also sustained a severe bruise of the abdomen. One case 
 of amputation of the thigh, along with a severe injury to the hand, 
 died of tetanus on the 14th day. 
 
 Lastly, 3 cases died of intercurrent diseases. These were a case of 
 amputation thi'ough the leg, which died of delirium tremens ; an 
 amputation through the femur, from pneumonia, on the 21st day, the 
 wound being practically healed ; and a case of amputation through 
 the humerus, in which abortion occurred, followed by the patient's 
 death from puerperal fever. 
 
 Ninety-one excisions. of joints were performed, with 5 deaths : 
 2 excisions of the hip died from shock ; 1 excision of the hip from 
 haemorrhage 3 j months after the operation ; 1 excision of the hip from 
 thrombosis of the iliac vein two months after the operation : 1 exci- 
 sion of the knee from tubercular meningitis. A-Qiong these cases 
 were 44 excisions of the hip, which recovered. Two cases died from 
 intercurrent disease, viz., 1 excision of ankle-joint from delirium 
 tremens, and 1 excision of the shoiilder-joint from phthisis and 
 haemoptysis. Thus thex-e were in all 93 cases of excision of joints 
 with 7 deaths. 
 
 There were 10 operations for uniinited or badly united fracture 
 withotit a death. Also 50 cases of osteotomy, of which 1, a patient 
 affected with the hoemorrhagic diathesis, died from haemorrhage. 
 
 There were 45 cases of hydrocele treated by opening the sac, stitch- 
 ing it to the skin and introducing a drainage tube. No bad result. 
 
 There wore 119 excisions of the mamma in 110 patients. Among 
 these were 75 cases in which the fat and glands in the axilla were 
 also i-emoved. Of the 110 cases 6 died; 1 from shock, 1 from 
 anthrax, which Volkmann thinks must have been introduced with 
 the cat-gut, 2 from exhaustion in old people, 2 from erysipelas — in 1 
 case arising from a bed-sore, and in the other commencing after the 
 antiseptic dressings had been left off. 
 
 Up to this time Volkmann had treated seventy-three com- 
 pound fractures a:nd twenty-four wounds of joints conservatively 
 without a single death. 
 
 Adding together the whole results, we find that 562 serious 
 operations and injuries were treated, with twenty-nine deaths, 
 not one of these being due to infective disease arising under an 
 
NUSSBAUM. ' 389 
 
 antiseptic dressing, Volkmann further states that not a single 
 case of pyaemia or septica3mia occurred among patients treated 
 asepticallj during these three years. Erysipelas attacked 
 three or four of the cases which were treated on aseptic prin- 
 ciples. 
 
 Here is a piece of evidence which cannot be overlooked. 
 Into an infected hospital the aseptic method was introduced 
 without any other change being made in the arrangements of 
 the hospital. At once the infective diseases, which were attack- 
 ing almost every patient, disappeared in the cases treated 
 aseptically, only one case of pyaemia and about twelve of ery- 
 sipelas occurring dui"ing more than four years, and almost all of 
 these arising at the very commencement of the trial when as yet 
 the surgeon had not had sufficient experience of the working 
 of the method. When this experience was obtained, these 
 diseases practically entirely disappeared. In estimating these 
 results at their proper value, we must also remember that 
 during the aseptic period, operations were performed and limbs 
 preserved in a way impossible in an infected atmosphere. What 
 would have been the result of the 1 50 operations on bones, or of 
 the hydrocele cases, or of the wounds of joints, or of the com- 
 pound fractures in the former infected atmosphere, if they had 
 not been treated aseptically ? What would their result have 
 been in a good atmosphere, such as St. Bartholomew's hospital 
 is said to possess ? Would there have been no infective diseases 
 there ? 
 
 Similar remarkable facts have been published by Professor 
 Nussbaum of Munich, who commenced aseptic treatment two 
 years later than Professor Volkmann. The ' Allgemeines 
 Krankenhaus ' at INIunich, though by no means very deficient in 
 sanitary arrangements, became infected with septic diseases, so 
 that almost every case of open wound treated in the wards was 
 attacked by them. Pyaemia was rife, affecting nearly all cases 
 of compound fracture or Wounds of bones, amputation wounds, 
 &c. ; erysipelas was constantly present. During 1872, hospital 
 gangrene also appeared, and steadily spread in spite of all the 
 precautions which were taken. In 1872, twenty-six per cent, of 
 all the wounds were attacked with hosi)ital gangrene, and during 
 1873 the proportion increased to fifty and ultimately eighty per 
 
390 RESULTS OF ANTISEPTIC SURGERY. 
 
 cent. Erysipelas, too, which in 1872 was comparatively mild, 
 became much more virulent and frequent. All this occurred 
 in spite of the use of antiseptics, of the open method, &c. 
 
 In an address delivered in 1875, at the end of the academi- 
 cal year,' Professor Nussbaum mentions these facts and describes 
 also the results which followed the introduction of strict a^ptic 
 treatment. With regard to his former results, to which I have 
 just alluded, he says that he had employed in the treatment of 
 wounds the open method, various forms of occlusion, continuous 
 water-baths, chlorine water, carbolic acid, salicylic acid in pow- 
 der and solution, Mr. Lister's carbolic paste, and even the car- 
 bolised gauze dressings. ' Alles, alles,' says he, ' war nicht im 
 Stande, den Hospitalbrand, die Pysemie zu bekampfen.' With- 
 out any other change, strict aseptic treatment was used in all 
 possible cases, and then, he says, at once they experienced one 
 surprise after another : everything went well ; there was no 
 more hospital gangrene, though a week or two previously eighty 
 per cent, of the wounds were suffering from it ; pyaemia and 
 erysipelas were only observed in one or two cases, and these 
 disappeared as skill in the use of the method was acquired. 
 Nussbaum adds : ' One might reply ' (to these facts), ' pyaemia 
 and hospital gangrene are diseases which often suddenly attack 
 a hospital without any apparent cause and often also suddenly 
 disappear. But think, my friends, that during the sixteen 
 years in which I have had charge of this hospital pyaemia has 
 not been absent a single month, and yet it suddenly disappeared 
 on the introduction of the Listerian method.' 
 
 A year later. Dr. Lindpaintner, Professor Nussbaum's assis- 
 tant, published a detailed account of Nussbaum's practice from 
 April 1st, 1875, to the end of March 1876.2 j ^^^^\l ^ot enter 
 at length into these results, but there are some points to which 
 I must call attention. 
 
 During this period there were 459 operation or accidental 
 wounds under treatment, and of these twenty-six died. The 
 cases were not all treated aseptically as will be evident when I 
 consider the causes of death, to which I must now allude. 
 
 ' Die Chirimiiitclie Kliriih en Mwichcn im Jahre 1875; Stuttgart: Fred. 
 Enkc, 1875. 
 
 ^ Dcutuclir Zcifschrift far CMritrgie. 
 
XUSSBA UM. 891 
 
 Three cases in which primary amputation was performed died 
 in a few houi's. Other extensive injuries were present in all these 
 instances. 
 
 One patient, ast. 79, died suddenly of cerebral hsemorrhage 31 days 
 after resection of the elbow joint. 
 
 In one case a malignant tumour of the scalp was removed, and 
 the disease was found to have perforated the skull. Recurrence 
 rapidly took place, and the patient died with symptoms of com- 
 pression. 
 
 One case of gunshot wound of the skull and brain went on well 
 for 11 days, and then died suddenly. Cause unknown. 
 
 A large abscess of the mamma connected with caries of the ribs 
 was opened aseptically, and was progi-essing typically, when death 
 occurred suddenly on the 3rd day. Cause unknown. 
 
 One case of large ulcer of the leg, which had healed, died of phthisis 
 nearly 4 months after admission. 
 
 One case of extensive abscess of the knee-joint, which was incised 
 aseptically, died of phthisis 5 months after the operation, the knee- 
 disease having recovered, and the wound having completely healed. 
 
 One case of extensive suppuration in the parotid region died. 
 There was constant vomiting, and on post-mortem examination 
 catarrhal pneumonia was found, 
 
 A very weak, unhealthy subject, suffering from, compound fracture, 
 for which secondary amputation was performed, died 5 days after the 
 operation from thrombosis of the pulmonary arteiy. 
 
 One case of excision of the mamma (set. 72) died, and on post- 
 mortem examinatioti there was found cancer of the lungs, capillary 
 hfemorrhages in the stomach, and extensive aphthous patches in the 
 oesophagus. Death was sudden after the existence of difficulty of 
 breathing for a few hours. 
 
 In one case of excision of the mamma peritonitis set in on the 4th 
 day, though up to that time the patient had been doing well. The 
 peritonitis was found to proceed from a cancerous tumour in the liver, 
 which was breaking down. 
 
 One case of excision of the mamma died on the 1.5th day from 
 unilateral pleuro-pneumonia on the same side. 
 
 One case of large abscess in the neck, died of ' fibrinous i^eri- 
 carditis ' 38 days after the abscess was opened, and after it had 
 healed. 
 
 One case of ovariotomy, in which there had formeily been peri- 
 tonitis, and where extensive adhesions wore present at the time of the 
 operation, died of peritonitis. 
 
392 RESULTS OF ANTISEPTIC SURGERY. 
 
 One case of compound fracture of the leg, which was doing well, 
 died of myocarditis on the 25 th day. 
 
 One case of resection of the elbow-joint died of cedema of the 
 lungs and fatty embolism on the 11th day. 
 
 One case of compound fracture of the femur in which the bone 
 was very extensively comminuted and the knee-joint opened, died of 
 septicaemia. 
 
 The remainder of the fatal cases occiuTed in patients not treated 
 aseptically, and were due to septicajmia, erysipelas, pneumonia, 
 pysemia, phthisis, peritonitis, and shock. 
 
 I have thought it well to mention all the causes of death, 
 and now I shall summarise what Dr. Lindpaintner says as to 
 septic diseases. 
 
 Erysipelas occurred six times during that year, but not in 
 any case which was being treated aseptically. It occurred in 
 four cases of septic wounds, in one case after the Listerian 
 dressings had been left off, and in one case of excision of the 
 mamma treated aseptically but spreading from an inflammation 
 in the neck and never extending under the dressing. 
 
 There was no case of hospital gangrene. 
 
 There were three cases of septicaemia — one after a septic 
 operation (excision of the hip), one case admitted with septic- 
 remia, and one case of compound fracture in which an unsuc- 
 cessful attempt was made to eradicate the causes of putrefaction 
 (alluded to above). 
 
 There were three cases of pyasmia — one occurring after a 
 putrid wound in the thigh, one in a case with putrid sinuses 
 near the elbow-joint, in which no operation was performed, and 
 one after dilatation of a stricture of the urethra which had 
 followed a previous amputation of the penis. 
 
 There was thus only one case of infective disease among 
 the cases treated aseptically — the case of bad compound frac- 
 ture of the femur. Here, of course, the surgeon had not to deal 
 with a wound made by himself, but with one made without 
 aseptic precautions, and it is of course always a matter of un- 
 certainty in such instances whether the wound can be after- 
 wards rendered aseptic or not. The case of peritonitis after 
 ovariotomy and the cases of pericarditis and myocarditis might 
 
NUSSBAUM'S RESVLTS. 393 
 
 no doubt be attributed to failure in the method. Whether or 
 not they were due to such a cause, I do not know. 
 
 This success in the exclusion of traumatic infective disease 
 has continued up to the present time in the cases treated asep- 
 tically, and in a publication of Professor Nussbaum's in 1878, 
 entitled ' Sonst und Jetzt,' he states that there had been no 
 further instance of these diseases. It may be interesting to 
 see what he says : — 
 
 Formerly. Now. 
 
 * Injuries of the head, compound fractures, am- 
 putations and excisions, in fact, almost all patients 
 in whom bones were injured were attacked by 
 pyaemia. For example, of 17 cases of amputation 
 11 died from this cause. Even patients with 
 severe whitlow died of it. .... No pyaemia. 
 
 'Hospital gangrene had got the upper hand to 
 such an extent, that in spite of the open method, 
 in spite of continuous water-baths, in spite of the 
 use of chlorine water or the actual cautery, finally 
 80 per cent, of all wounds and ulcers were attacked, 
 large arteries being opened into. . . . No hospital 
 
 gangrene. 
 
 ' Almost every wound was attacked with erysi- 
 pelas No erysi- 
 pelas.' 
 
 Still later, in the last edition of his work on antiseptic 
 surgery, published in 1880, the same statement is reiterated 
 and Nussbaum now says, that since the introduction of the 
 aseptic method there has been no instance of pya-miu, hospital 
 gangrene or erysipelas among the patients treated in that way. 
 And yet, he adds, no other change has been made ; ' the wards, 
 the furniture, the nursing of the patients and their number 
 remain the same.' 
 
 Indeed, in summing up his five years' experience he goes so 
 far as to say that ' any recent wound, treated by this method, is 
 guaranteed against pyaemia, hospital gangrene, erysipelas, pro- 
 gressive suppuration, and in general against all accidental com- 
 
304 liESUlTS OF ANTISEPTIC SURGERY. 
 
 plications.' And further : ' The fate of a })atient seriously 
 wounded is almost entirely in the hands of the surgeon who 
 applies the first dressing.' Such is Nussbaum's experience after 
 using this method for five years in a hospital in which infective 
 diseases were very prevalent. 
 
 These facts cannot be overlooked, and are of the very greatest 
 value — of much more value than any number of results in 
 healthy hospitals. For here we have an immediate abolition of 
 traumatic infective diseases, only one case occurring in five 
 years, and that after a wound not made by the surgeon ; there 
 was thus not merely a great diminution in the frequency of 
 these diseases but absolute cessation. These facts, when 
 surgeons in this country have deigned to notice them, have 
 been attributed to increased cleanliness alone, the result of the 
 introduction of strict aseptic precautions. It is asserted, and 
 the assertion no doubt holds good in many places, that dirty 
 sponges, dirty instruments, &c., were used in dressing the 
 various cases, and that no care was taken to cleanse the instru- 
 ments after their use, nor to keep apart those employed in bad 
 cases. I venture, however, to affirm that these objections do 
 not apply to the practice of such men as Bardeleben, Esmarch, 
 Hueter, Nussbaum, Volkmann, and many others whom I might 
 mention — men who are at the head of the surgical profession, 
 and who owe their high reputation to their thorough knowledge 
 of physiology and pathology. In Professor Nussbaum's case this 
 objection cannot be upheld for one moment, for he had charge 
 of two hospitals, one in the country placed under good hy- 
 gienic conditions, and the other in town not so well situated in 
 these respects. The same surgeons and the same methods of 
 dressing and nursing were employed in the one institution as 
 in the other, and yet the country hospital remained healthy, 
 while the one in town became infected. Surely the same un- 
 cleanliness would have told, at least to some extent, in the 
 country as in the town. But further it must be remembered 
 that the result of the use of the aseptic system was not "merely 
 the diminution, but the abolition, of these infective. diseases. 
 Now cleanliness, as advocated b}^ Mr. Savory— and I shall refer 
 to this matter again — does not result in the abolition, but merely 
 in the diminution of these affections, and I do not allow that 
 
NTJSSBAUM: SOCIN : SAXTORPH. 395 
 
 the results which Mr. Savory gives were solely clue to clean- 
 liness as distinguished from asepticism. 
 
 Then, again, these diseases disappeared at once, for Nuss- 
 baum tells us that from the day when he began this treatment 
 thoroughly, these diseases never attacked any of the cases so 
 treated. What an extraordinary amount of cleanliness would 
 be required to effect this ! But indeed we are told that clean- 
 liness alone had not been able to abolish these diseases, even 
 after several yeai's'^ practice of it, for Nussbamn says in 1878,* 
 that even then a tracheotomy or other wound which could not 
 be treated aseptically was liable to be attacked by erysipelas of 
 as severe a type as formerly. And, further, Nussbaum had been 
 practising cleanliness before the introduction of the aseptic 
 method; for many of the wounds were irrigated with anti- 
 septics, such as carbolic acid, &c., without any apparent benefit. 
 Cleanliness is, no doubt, a most excellent thing in its own 
 place, but its power as a preventive of infective disease in an 
 infected atmosphere is very limited indeed. 
 
 And lastly, it cannot be said that Nussbaum does not now 
 diagnose as infective disease cases which he would formerly 
 have classified under that heading, for post-mortem examina- 
 tions are made on all the fatal cases by Professor von Buhl, 
 quite independently of Professor Nussbaum, and thus any such 
 error would be corrected. Nussbaum remarks in a note to 
 Mr. MacCormac (' Antiseptic Surgery *), ' the mortality is 
 reduced to one half, and the only cases brought to the 
 postmortem room are those of death by suicide, from severe 
 mechanical injury, in old people, or from cancer and tubercle.' 
 
 Socin of Basle uses language very similar to that of Nuss- 
 baum with regard to the occurrence of infective diseases. He 
 has also observed their complete disappearance under aseptic 
 treatment, and as the result of his experience, he says that, 
 ' Every case of amputation which dies of pyaemia or of erysipelas 
 is a victim of ignorance, of want of skill or of negligence on 
 the part of the surgeon.' 
 
 Saxtorph of Copenhagen has had an experience similar to 
 that of Volkmann and Nussbaum. His results are quoted at 
 considerable length in Lucas Championniere's ' Chirurgie Anti- 
 ' Songt vnd Jctzt. 
 
396 RESULTS OF ANTISEPTIC SURGERY. 
 
 septique,' to which I must refer the reader. I may, however, 
 just mention the following facts. 
 
 Before 1873 Saxtorph had performed 15 excisions of joints, 
 of which 9, or 60 per cent., died. These wounds were treated 
 in the ordinary manner. He then introduced aseptic pre- 
 cautions, but they were very imperfectly carried out. During 
 this period (between 1873 and 1877), he performed 76 ex- 
 cisions of joints with 32 deaths, or a mortality of 42 per cent. 
 The method was then carried out more efficiently, and since 
 1877, 34 excisions of joints (including 15 of the hip and 12 of 
 the knee), have been performed with 5 deaths, or a mortality of 
 17 per cent. Indeed, Professor Saxtorph says that since he has 
 carried out the method with absolute strictness, according to 
 Mr. Lister's directions, he has performed 24 major excisions 
 with 1 death (from tetanus), or a mortality of 4*3 per cent. 
 This result has also been obtained in a bad hospital where 
 infective diseases were common. The increased success, ac- 
 cording as more efficient precautions were taken to exclude 
 the causes of putrefaction, is very interesting and important. 
 
 Another strong advocate of the aseptic method is Professor 
 Esmarch of Kiel. In 1875, he introduced the method into his 
 wards, which had previously been especially liable to attacks of 
 erysipelas. The report of the first year in which Esmarch em- 
 ployed this method is published by Waitz in ' Langeubeck's 
 Archiv ' for 1877, and he states that 536 operation cases were 
 under treatment during that year, and of those treated aseptic- 
 ally only four were attacked by erysipelas (one of these cases 
 died). Two patients who were treated aseptically died with- 
 out any definite symptom except the presence of a continuous 
 high temperature — septicaemia (?). Two cases died of pyaemia, 
 but neither of these tell against the method ; one was a case of 
 acute necrosis where an abscess was opened, but where, never- 
 theless, pyaemia carried off the patient ; the other was a case 
 of herniotomy, in which the gut was found to be gangrenous. 
 
 These results were very good for the first year of aseptic 
 
 work, but as Esmarch and his assistants gained experience, the 
 
 cases of infective disease became fewer and fewer. His report 
 
 for 1878 is alluded to by Mr. MacCormac,' who states that 
 
 ' Antiseptic Surgery. 
 
ESMARCH. 397 
 
 Esmarch had during that year treated 524 cases with 25 deaths. 
 These cases include forty amputations, 27 major resections, 80 
 cases of removal of tumours, &c. Mr. MacCormac gives a list 
 of the causes of death, and among them were two from septic- 
 aemia after excision of the mamma, presumably performed 
 aseptically, though that is not expressly stated ; no facts are 
 given with regard to them. One case of ovariotomy died from 
 peritonitis. In this, as in many other reports, no separation 
 is made between cases dressed aseptically and those treated by 
 other methods. 
 
 Mr. MacCormac states that Professor Esmarch informs him 
 that- his next triennial report will show better results. A part 
 of this report is already furnished by Dr. Neuber, in his last 
 communication on absorbable drainage tubes and permanent 
 dressings.* 
 
 Between the end of April and the beginning of October, 1879, all 
 the cases treated aseptically wei'e di'essed in this way. These were 
 131 in number, comprising 5 amputations of the thigh, 7 amputations 
 of the leg, 1 at the knee-joint, 1 through the humerus, and 1 through 
 the fore-arm ; 2 excisions of the knee-joint ; 4 excisions of the 
 mamma and axillary glands ; 5 excisions of the mamma alone; 16 
 excisions of large lymphatic glandular tumours from the neck varying 
 from 1 to 2 fists in size; 16 excisions of other tumoiu-s, &c. During 
 this period 3 patients treated aseptically died, viz., one case of ex- 
 cision of the hip fi-om shock ; one case of removal of carcinoma from 
 the ear of a patient (jet. 70), in wliich there Avere secondaiy aftections 
 of the glands in the neck, &c., from hypostatic pneumonia; and one 
 patient, who was suifering from septicaemia before his thigh was 
 amputated, and who afterwards died of that disease (not a case in 
 point). 
 
 During the next 2 months 60 additional cases were treated in this 
 way without a death. These comprised am])utations, resections, 
 compound fractures, removal of tumours, &c. Thus during these 8 
 months 191 cases were treated aseptically with 3 deaths, but in no 
 instance did infective disease arise aftei- the operation.^ 
 
 ' Uebir die VerandvnnKjvii dccalcinirter Knochenrohrcn in, Weichtheils- 
 jvuiiden, 4'e. ; Lanyenbeck's Archiv, Bd. xxv. 
 
 2 At the Jnternatioual Medical Congress of this year, Prof. Esniarcli 
 brought forward still more recent statistics. Tlie cases were treated bv 
 >\euber'b method of permanent dressings, the antiseptic chielly employed in 
 
398 RESULTS OF ANTISEPTIC SURGERY. 
 
 Perhaps the earliest in Germany to take up asepticism was 
 Professor Hueter of Grreifswald, and he still looks on it as the 
 best method and the ' greatest advance of modern surgery.' He 
 uses salicylic jute instead of carbolised gauze, not because he 
 believes it to be better, but because it is cheaper. 
 
 Professor Czerny of Freiburg also added his evidence in 
 1876.' The number of cases to which he alluded was not 
 great, but in his address at the end of the summer session, 
 1876, he stated that he had been unable to show his class a 
 single case of pyaemia, hospital gangrene, or septicaemia during 
 the whole year. He had two cases of erysipelas, one of these 
 occurring after sequestrotomy and attempted purification of the 
 sinuses with chloride of zinc. (This was not a case operated 
 on from the first aseptically.) 
 
 Czerny says that in former years, with the exception of 
 1875, during which aseptic treatment had also been employed, 
 he had always had a considerable number of cases of infective 
 disease in the wards. The abolition of these diseases could 
 not, he says, be due to anything in the arrangement or service 
 of the wards, for these remained unaltered. They were as 
 full as formerly, as imperfectly ventilated, and the watercloset 
 arrangements were unaltered. A greater number of patients 
 were treated. The results had steadily improved with in- 
 creased care in carrying out all the details ; and his belief is 
 that 'the favourable results which have followed the intro- 
 duction of this method are to be ascribed to the accuracy 
 with which Mr. Lister's directions have been followed.' 
 
 In France this method was first taken up by Dr. Lucas 
 Championniere, whose text-book and other w^ritings - on the 
 
 the dressings having been Io(loft)rm. They had recently treated 3*J8 cases of 
 major operations and injury with 6 deaths. There was no instance of in- 
 fective diseases. The cases were 146 excisions of large tumours, including 40 
 excisions of the mamma and axillary glands and 14 castrations with three 
 deaths — 1 from pericarditis and old syphilis, 1 from apoplexj', and 1 from 
 fatty heart ; 61 resections ; 51 major amputations (18 of thigh, 27 of leg, 5 of 
 arm, 1 of forearm), with 2 deaths — 1 from shock and haemorrhage, and 1 from 
 delirium tremens; 11 exarticulations 26 necrotomies ; 13 nerve stretchings, 
 including one for tetanus, which was fatal; 8 herniotomies; 21 chronic 
 abscesses ; 12 large wounds ; 4i) compound fractures. 
 
 ' Berlin. Klin. Wockcnschriff, 1876, No. 4:?. 
 
 * ChiTurf/lc Aidiscjjtiqiw. 
 
SCHEDE'S STATISTICS. 39& 
 
 subject, are now so well known. He also finds that pytemia, 
 septicsemia, and hospital gangrene disappear when aseptic 
 treatment is employed. He has at times observed erysipelas 
 under this dressing, but the disease was very rarely present and 
 of a very mild ty|)e. 
 
 As the result of the writings of Lucas ChamjDionniere, 
 several French surgeons have introduced this method, but it 
 has not as yet taken the same hold in France that it has in 
 Germany. Those, however, who have used it properly make 
 the same statements as to complete disappearance of infective 
 disease. Among those who have employed this treatment and 
 who have got these results may be mentioned M. Gross of 
 Nancy, who has written a text-book on the subject. 
 
 M. Letievant, of Lyons, is also an enthusiastic supporter of 
 this system.' He introduced it into his wards during the 
 summer of 1875, and from that time pygemia disappeared and 
 the mortality after operations and wounds greatly diminished. 
 His statements with regard to infective disease are : ' Purulent 
 infection has disappeared. Hospital gangrene has disappeared. 
 Erysipelas is much rarer and less severe.' 
 
 Professor Panas ^ also found that dming a virulent epidemic, 
 those of his patients at the Lariboisiere who were treated 
 aseptically escaped erysipelas and other septic diseases. 
 
 Keturning to Germany, there still remain two pieces of 
 statistics to which I must refer. 
 
 The first is Schede's comparative statement of the results 
 of amputations treated aseptically and of those treated in other 
 ways.'^ The aseptic cases were under the care of Busch, Schede, 
 Socin and Volkmann. The cases not treated aseptically were 
 furnished by Bruns, Bardeleben and Billroth. 
 
 The most important tables give the result of uncomplicated 
 amputations performed aseptically, contrasted with those 
 treated by other methods. 
 
 Uncomplicated amputations treated aseptically : — 
 
 Note sur le paitnemeiit anti»vptique listerien a VHotel-Dieu de Lyon, 
 1880. 
 
 ^ Gazette hsbdomadaire, 1878. 
 
 " Amj)utatiaiirn und Il/'xcctioiwn. Handbiioli dor albjiiiwliu- und sprciclh- 
 Chiruvfju; Tilha und Billroth. 
 
400 
 
 RESULTS OF ANTISEPTIC SURGERY. 
 
 At shoulder- joint 
 
 Through humerus 
 „ fore-arm 
 
 At wrist-joint . 
 
 „ hip-joint 
 
 Through thigh . 
 
 At knee-joint . 
 
 Through leg 
 
 Partial amputations of foot (including 9 Sj'me's"1 
 amputations, 36 Pirogoff's, 15 Cliopart's, 1 ^ 
 Lisfranc, 4 of metatarsal bones)" J 
 
 Cases 
 
 Deaths 
 
 9 
 
 1 
 
 32 
 
 — 
 
 47 
 
 — 
 
 4 
 
 — 
 
 6 
 
 4 
 
 86 
 
 6* 
 
 3 
 
 — 
 
 69 
 
 It 
 
 65 
 
 Total ... 321 ]4 
 
 A mortality of 4-4 p. c. 
 * One of these deaths was due to septicemia ; f from 'habitual erysipelas; 
 § one from ' pytemia simplex.' 
 
 Uncomplicated amputations treated by the older methods:— 
 
 Deatlis 
 
 At shoulder- joint 
 Through humerus 
 
 „ fore-arm 
 At wrist- joint . 
 
 ,, hip-joint 
 Through thigh . 
 
 „ knee-joint 
 
 leer 
 
 Partial of foot (8 Lyme's amputations, 13"| 
 Pirogoff's, 5 Malgaigne's, 9 Chopart's, ^ 39 
 1 Lisfranc, 3 of metatarsal bones J 
 
 15 
 
 8* 
 
 41 
 
 6t 
 
 42 
 
 2 
 
 10 
 
 — 
 
 3 
 
 n 
 
 105 
 
 43§ 
 
 7 
 
 111 
 
 115 
 
 381 
 
 10* 
 
 Total ... 377 110 
 
 A mortality of 29-18 p. c. 
 
 *f All from infective disease; J one from pyEemia; § thirty-eight from 
 infective disease ; || from pyjemia ; 1 thirty-seven from infective disease ; 
 ** nine from infective disease. 
 
 Other tables are given stating the results of double ampu- 
 tations, of amputations with other severe injviries, of amputa- 
 tions in existing septicaemia, pyaemia or tetanus, and of deaths 
 from intercurrent diseases quite unconnected with the operation. 
 I need not, however, go into these, as they would only obscure 
 the point at issue. 
 
 Schede tabulates the causes of death in the two preceding 
 tables as follows : — 
 
REYHERS STATISTICS. 401 
 
 In the septic In the aseptic 
 
 • cases cases 
 
 Pj'Eemia 72 
 
 Septicsemia ....... 19 1 
 
 Erysipelas ....... 2 1 
 
 Trismus ........ 1 
 
 Pyaemia simplex ...... 6 1 
 
 Hasmorrhage ....... 'S 1 
 
 Pjxhaustion ....... 2 1 
 
 yhock 6 8 
 
 Total .... 110 14 
 
 Thus, as Schede truly remarks, if the deaths from infective 
 diseases were removed from the list of septic cases, the death- 
 rate in each would be almost the same — about 5 per cent, for 
 the septic cases, as against 4*4 per cent, for the aseptic. In 
 other words, the aseptic method saved this enormous propor- 
 tion of lives in the main by preventing infective disease. 
 
 The last paper to which I shall refer is Reyher's account of 
 his results during the Russo-Turkish war.' As I intend to 
 discuss these results later I shall just mention the numbers 
 here. 
 
 Eighty-one cases were treated aseptically as soon as pos- 
 sible after the injury, and of these 15 or 18*6 per cent. died. 
 Among these cases were 27 gunshot wounds of joints treated 
 conservatively throughout with 4 deaths ; 1 9 primary resec- 
 tions in cases of gunshot wounds of joints with 2 deaths ; 13 
 primary amputations with 5 deaths ; and 22 compound frac- 
 tui'es with 4 deaths. Of the 1 5 deaths, 5 were due to septic 
 diseases (2 to pygemia, and 3 to septic inflammation and sup- 
 puration). With regard to the deaths from septic diseases in 
 these cases, we must remember that here the surgeon had not 
 to deal with an operation performed by himself, in which the 
 problem is to keep out the causes of putrefaction, for here the 
 causes were in many instances already present. The deaths 
 occurred in cases where these causes were present and were 
 not destroyed because portions of clothing, &c., were present in 
 recesses of the wounds- 
 Contrasted with this were 65 compound fractures and 78 
 
 ' Volkmann's Sainmlitiif/, Nos. 112 and 113: Iflc a/itlnrjHiscfie WuiidbcJiand- 
 litiigindcr Ki-icysckirurgic, 1878. 
 
 n D 
 
402 BESULTS OF ANTISEPTIC SURGERY. 
 
 wounds of joints, in all 143 cases, which did not come under 
 treatment for some time, and in which the generally unsuc- 
 cessful attempt at purification was made. Where these at- 
 tempts are unsuccessful the treatment resolves itself into 
 treatment with antiseptics. Of these 143 cases treated with 
 antiseptics, 71 or 49*6 per cent, had already died when the 
 first part of the report was issued, and 2 more died subsequently. 
 Of these at least 46 cases died of septic diseases. 
 
 Then contrasted with both these sets of cases there were- 
 treated alongside of them 62 wounds of joints, in which no 
 attempt was made to render the wounds aseptic, or even to 
 treat them with antiseptics. Of these, 48 or 77*4 per cent, 
 had died when Eeyher wrote, and amputation or resection had 
 been found necessary in most instances. 
 
 Lastly, I would allude to the results obtained in ovariotomy 
 by the leading ovariotomists of this country. Mr. Spencer 
 Wells and Dr. Keith had for years striven to carry out perfect 
 cleanliness and other antiseptic precautions short of complete 
 exclusion of organisms from wounds, and the results of both 
 were very remarkable indeed. And yet, since they have ex- 
 tended their precautions so as to exclude the causes of fermen- 
 tation, their results have still further improved, and they 
 themselves — and they are the best judges — attribute this last 
 improvement solely to the additional antiseptic precautions 
 employed. 
 
 Mi\ Knowsley Thornton, in his speech at the debate on 
 antiseptic surgery in December, 1879,' gave an analysis of 
 more than 300 cases of fatal ovariotomy, and stated that in 
 more than one-third of the cases septicaemia, pys'mia or septic 
 peritonitis were given as the cause of death, and in nearly 
 another one-third the fatal result was attributed to peritonitis. 
 ]Mr. Thornton pointed out further that the cases of peritonitis 
 were almost entirely due to septic causes, and thus, as he 
 states, two-thirds of the deaths after ovariotomy were due 
 to septic influences, and therefore, if these influences can be 
 eliminated by aseptic surgery, the results ought to improve 
 to a corresponding extent. And he states that this has been his 
 experience, and that the introduction of strict aseptic precau- 
 ' MacCormac's Aiitixcjiflc Surgery. 
 
RESULTS IN OVARIOTOMY. 403 
 
 tions has reduced his mortality by half, and it would have been 
 still less had not putrefaction been present in some of the 
 cases before he operated, owing to previous tapping of cysts 
 by other surgeons without aseptic precautions. 
 
 ]\lr. Spencer Wells, at the same meeting, spoke very 
 strongly in favour of aseptic treatment, and gave the result of 
 the last 168 cases which he had treated in private practice. 
 The first 84 had been treated by his former methods, but yet, 
 he says, ' with all the care I could give to them there were 21 
 deaths.' On the other hand, the last 84 were treated asep- 
 tically, and of these only 6 died, and these deaths occurred 
 among the earlier cases while he was only as yet making 
 acquaintance with the details of the method ; and so ' as I 
 went on and became still more accustomed to the method and 
 details of antiseptic treatment, and avoided mistakes, then I 
 obtained the long run of 38 cases without a single death ; and, 
 adding to that the 5 more of other important abdominal opera- 
 tions, I can record the gratifying and almost incredible result 
 of 43 cases of these great operations without a death.' In a 
 foot-note he adds : ' The run of 38 cases of successfid ovari- 
 otomy was afterwards increased to 41, and then a death 
 occurred where septic symptoms had set in before operation.' 
 
 Dr. Thomas Keith, who had adopted the aseptic method 
 somewhat earlier, and who had previously been getting the 
 best results of the day, states^ that his last 76 cases were per- 
 formed aseptically with only 2 deaths, and these occurred at 
 the couunencement, so that the last 68 cases in succession 
 all recovered. Dr. Keith is equally positive in ascribing 
 these good results to the additional precautions whicli he had 
 taken.^ 
 
 ' See MacCormac"s A/Uin/'ptic Surr/c?'!/. 
 
 ^ At tlie recent International Congress held in London, Dr. Keith is said to 
 have stated that he had discontinued the use of the spray. I have not been 
 able to find a report of his statement, but I can quite imagine that the 
 amount of car})olic acid poured into the peritoneum by the spray in a prolonged 
 operation would l;e injurious both from rendering the patient liable to carbolic 
 acid poisoning, and also from causing an increased amount of fluid in the 
 peritoneal cavity, wliicli, where the details of the aseptic method were not 
 thoroughly carried out, would be liable to undergo putrefaction. Though 
 Dr. Keith lias given up the spray, I have not heard that he has given up the 
 practice of aseptic surgery. (See Chapter XVTII. for remarks on ovariotomy.) 
 
 i» I) 2 
 
404 RESULTS OF ANTISEPTIC SURGERY. 
 
 Salicylic acid, which was introduced b3^ Professor Thiersch ' 
 as a substitute for carbolic acid, has been employed in various 
 hospitals, but the results do not seem to be so good as those 
 with carbolic acid. The following is a specimen of Thiersch's 
 earlier results : — 
 
 From April 1st, 1874, to May 31st, 1875, 109 cases were treated 
 with salicylic acid di^essings, and 51 with carbolic acid. Of the former 
 7 died, of the latter 2. Among the 109 salicylic acid cases were 
 21 major amputations, with 5 deaths ; also a number of resections, 
 compound fractures, abscesses, excisions of tumours, &c. The deaths 
 among the cases treated with salicylic acid were due to the following 
 causes : In one case from haemorrhage from the intestine 100 days 
 after primary amputation of one leg and secondary amputation 
 through the other femur; in one case from hydro thorax 123 days 
 after primary amputation of the leg ; one patient died on the twenty- 
 third day after amputation of the thigh, pus being found in the 
 shoulder-joint ; a case of amputation of the thigh died from ex- 
 haustion twenty-eight days later ; one case of excision of the head of 
 the femur died from uraemia twenty-five days after the operation ; one 
 resection of the wrists-joint, followed by amputation of the fore-arm, 
 died 201 days after the first operation fiom exhaustion. One of the 
 deaths in the cases treated by carbolic acid was from pyaemia. 
 
 Erysipelas attacked the salicylic acid cases seven times, and 
 in one instance proved fatal. 
 
 The general description of the course of these cases is not 
 so good as that of cases treated with carbolic acid, and Volk-' 
 mann and others have tried salicylic acid, but have not found 
 it so trustworthy as carbolic acid. 
 
 Thymol, though at first much praised,^ also soon failed to 
 give satisfaction. The explanation of this probably was that 
 in the first instance the thymol was used in wards free from 
 infective diseases, and therefore good results were at first ob- 
 tained. But these wards had a great tendency to become 
 unhealthy on account of the bad hygienic conditions, and the 
 
 ' ' Klinisc'ie Ergebnisse der Lister'schen Wundbehandlung und iiber den 
 
 Ersatz der Carbolsiinre durch Salicylsiiure ' — VnlhnarDi's Sammlnng, Nos. 84 
 and 85, 1875. 
 
 ^ Jlcher das Thymol und seine Bcuntzuufi hei der antiscptischen Bchand- 
 liinf/ der Wundeii, von Hans Kanke, Volkmatni ■^ Santndunfi, No. 128. 
 
TREATMENT WITH ANTISEPTICS. 405 
 
 thymol was unable to prevent this in the same way as carbolic 
 acid had done. Thus bad results were very soon obtained, and 
 carbolic acid had to be reinstated. 
 
 Here is another strong argument against the idea that 
 cleanliness alone is a sufficient safeguard. In this instance 
 there was of course the same amount of cleanliness when 
 thymol was used as when carbolic acid was employed, but a 
 powerful antiseptic was required in addition to the cleanliness, 
 and, as the experience before the introduction of Listerism 
 into these wards had shown, it was necessary to use this anti- 
 septic on aseptic principles in order to attain the desired object. 
 
 The Eelation of other Forms of Antiseptic Surgery 
 TO Infective Diseases. 
 
 I have found the greatest difficulty in getting records of 
 any value as to the results of treatment with antiseptics not 
 employed aseptically. I have described Bilguer's method and 
 results (see p. 302), and these may be taken as a very fair speci- 
 men of the results obtainable by treatment with antiseptics 
 alone, though it must be observed that in many instances his 
 cases were no doubt treated aseptically. I have also, at p. 401, 
 referred to Keyher's paper giving details of the different results 
 obtained by aseptic treatment and treatment with antiseptics, 
 and this is perhaps one of the best contrasts which could be 
 given. Several of the results which have been published as 
 having been obtained by strict aseptic treatment are in reality 
 nothing of the kind, but are merely the results of treatment by 
 antiseptics and they might very fairly be used as such. And 
 it woidd be seen from these that though infective diseases are 
 often much diminished in frequency, yet they are by no means 
 entirely abolished. Indeed, the rapid manner in which carbolic 
 acid began to fall out of use before Mr. Lister published, shows 
 tliat it was found to be inefficient when used as an antiseptic 
 only and not aseptically. I believe that, employed as an anti- 
 septic only, carbolic acid is inferior to various other substances, 
 for it combines with albumen, and in doing so apparently loses 
 in part its antiseptic virtues (see p. 2(iO) ; and therefore, in order 
 to be efficient, it would require to lie added to tlie discharges of 
 the wound in large quantities. At the same time its in- 
 
lOG liESULTS OF ANTISEPTIC SURGERY. 
 
 efficiency is increased, becanse carbolic acid is very irritating, 
 and causes an increased amount of discharge liable to undergo 
 fermentation. And also, as Hack ' has shown, wounds treated 
 with carbolic acid have greater absorbing power than those 
 treated with other substances. 
 
 The best comparison between aseptic treatment and treat- 
 ment with antiseptics is that furnished by Mr. Lister's own 
 results (see p. 376). The cases which were not treated asepti- 
 cally were, as far as possible, treated with antiseptics. They 
 were frequently syringed with antiseptic lotions and dressed 
 with antiseptic ointments and dressings, and yet it will be seen, 
 that the proportion of deaths avoidable by methods of wound 
 treatment, and especially of deaths from blood-poisoning, was 
 much greater than in the aseptic cases, although the nature 
 of the injuries was much less severe. 
 
 At p. 348 I have referred to the results obtained by the use 
 of alcohol in Nelaton's practice, and I stated that in Chede- 
 vergne's paper ^ mention is made of 48 cases treated in this 
 way, of which only 1 died of pysemia. 
 
 The cases were, however, not very severe. Thus, there was 1 
 case of tumour of the lower jaw ; 3 cases of epithehoma of the lip ; 
 10 partial excisions of the mamma; 2 amputations of the leg; 5 
 cases of removal of fatty tumours, and a number of isolated minor 
 operations. There were also 2 cases of wound of the knee-joint and 
 
 1 of the elbow-joint, all of which recovered. No details of these cases 
 ai-e given, 
 
 Rochard ^ extends these statistics, and states that 97 patients had 
 been treated in this way, and that among these there had only been 
 
 2 cases of pysemia and 5 of erysipelas, 
 
 Chedevergne states with reference to the first part of these 
 statistics that the results obtained were not merely accidental, 
 for two cases which had not been treated with alcohol died of 
 py{x;mia. He attributes the fatal case from pyaemia, mentioned 
 in his paper, to imperfect application of the dressing, pus 
 having been allowed to accumulate in the wound. 
 
 ' Ueher das ResorjJtionsverm'ogen granvlircnder Fliichen, Leipzig, 1879. 
 ^ ' Du traitement des jjlaics cliirurgicales ct traumatiques par les pansements 
 }\ ralcohol,' BulleUn (/eneral de thi'raiu'vtiqve, vol. G7, 1864. 
 
 * Ilistoire de la Chirurgie Fra»qaise au XIX^ Siecle, Paris, 1875. 
 
RESULTS FROM THE USE OF ALCOHOL. 407 
 
 In London most excellent results have been obtained by Mr. 
 Hutchinson by the use of a spirit and lead lotion (see p. 269) ; 
 and in his speech at St. Thomas's Hospital, at the debate on 
 antiseptic surgery,' he referred to his results, and stated that 
 they were as good as those obtained by a colleague who 
 practised aseptic surgery, but he added that he himself had 
 abstained from operations which involved peculiar risk. 
 
 There can be no doubt of the excellence of alcohol as a 
 dressing, and the good results are to some extent explained by 
 Hack's ^ experiments, which show that absorption takes place 
 with the greatest difficulty from wounds treated with alcohol. 
 No doubt, also, as Mr. Hutchinson uses it, many of the cases 
 are treated aseptically. 
 
 With regard to these and other results from the use of 
 antiseptics, I cannot give any tables ; for few surgeons have 
 employed one antiseptic or one particular method of applying 
 them, and in London more especially, where almost every sur- 
 geon uses one or other form of antiseptic treatment, the 
 results from the various methods of treatment are grouped 
 together, and are thus almost absolutely useless for the point at 
 issue. 
 
 Among the best of these mixed results— results obtained no 
 doubt in the main by the use of antiseptics — are the cases of 
 major amputations performed at St. Bartholomew's Hospital 
 for the last ten years (1870-79).^ There were 467 major 
 amputations, of which 7l, or 15'2 per cent., died. These results 
 include, however, the practice of two surgeons who treated their 
 cases in the main aseptically. 
 
 We have already seen in the historical part that the various 
 methods of occlusion, acting on the principle of excluding the 
 gases of the air, have failed to exclude infective diseases. I 
 need only refer to Jules Guerin's experience during the siege 
 of Paris, p. 325, and to his refusal to apply his method in a 
 particular hospital because the atmosphere was ' aussi profonde- 
 7)ient infects.' 
 
 The only method of occlusion which has been of permanent 
 
 ' See MacCormac's Antiseptic Surtjcry. ^ Lq^ ^jj 
 
 * St. Bartholomew^ Hospital licports, 1880. 
 
408 RESULTS OF ANTISEPTIC SURGERY. 
 
 service is Alphonse Guerin's ' Pansement ouate ' (see pp. 280 
 and 325). As we have seen, marked improvement followed its 
 introduction dm'ing the siege of Paris, and good results are 
 still obtained in some of the less healthy Paris hospitals. 
 This method no doubt acts mainly by keeping the layer of 
 granulations at perfect rest, and thus avoiding its laceration 
 and the consequent passage of the putrid material — that ' ter- 
 rible poison,' as Mr. Savory has called it — into the blood. 
 However good its results may have been in some cases, I can- 
 not think that a method of treatment in which fluids, under- 
 going decomposition to a greater or less extent, are retained 
 in contact with the surface of the wound, and in which the 
 patient is only protected from the effects of the absorption of 
 these fluids by maintaining the parts at perfect rest, is one 
 which can be recommended when better means are obtainable. 
 
 The method which perhaps stands next to the aseptic 
 method in its power of preventing infective disease is treat- 
 ment by irrigation or the water-bath. Here also definite 
 statistics fail, but I may refer to Langenbeck's statement (see 
 p. 344), made in 1855, to the effect that during the preceding 
 five or six years no case of pyaemia had occurred among the 
 cases treated by the continuous water-bath. No results are 
 given as to the other infective diseases, but from what I know 
 and have seen of this method, I should think that where the 
 water is frequently changed, especially if an antiseptic is added 
 to it, and where the wound is not complicated, and there is no 
 retention of discharges, these diseases would be more or less 
 completely absent. Langenbeck mentions that dm-ing the five 
 years to which I have just referred, in which he had no case of 
 pyaemia among the cases treated by the water-bath, pyaemia 
 was, nevertheless, prevalent in other wards, and attacked cases 
 treated in other ways in the same wards. 
 
 I referred, also, on p. 345, to Valette's success. He employed 
 antiseptics to a much greater extent than Langenbeck. 
 
 I now come to the consideration of the results obtained by 
 the use of the open method. 
 
 I have already mentioned (p. 332) Bartscher and Vezin's 
 results. They had 28 cases of amputation (26 of these being 
 
OFEN METHOD: BUROW'S RESULTS. 409 
 
 major amputations), with 3 deaths. The causes of death are 
 not given. 
 
 I have also mentioned (p. 333), Burow's results up till 1866. 
 He had 94 amputations (87 of these being major operations), 
 with 5 deaths. The causes of death are not stated. In a 
 later paper (1877), Burow (junior),' gives the results of all the 
 amputations performed up to that time by his father and him- 
 self. Since 1866, 29 major amputations had been performed 
 with 4 deaths, thus giving a total of 123 amputations with 9 
 deaths, or more jjroperly 116 major amputations with 9 deaths, 
 or a mortality of 7'7 per cent. Of the 4 last deaths 2 were 
 due to gangrene of the stump and 2 to pysemia. How many, 
 if any, of the other deaths were due to septic causes we do not 
 know. 
 
 The following is the detailed list : — 
 
 Amputations through thigh 
 .. leg 
 
 „ „ humerus 
 
 „ „ fore-arm 
 
 „ of foot 
 
 Partial of hand 
 
 Cases 
 
 Dtatbs 
 
 as 
 
 6* 
 
 25 
 
 3 
 
 25 
 
 
 
 29 
 
 
 
 9 
 
 
 
 2 
 
 
 
 Total . . . 123 9 
 
 * 2 certainly from pytemia. 
 
 These results are certainly remarkably good. The cases 
 extended over a period of something like forty years, and were 
 treated in a small hospital composed of four rooms containing 
 altogether sixteen beds. These rooms were small and the quan- 
 tity of air for each patient was not very great. A number of 
 operations other than amputations were also performed. Thus, 
 tluring the last ten years given in the paper to which I refer 
 (1866-76), there were treated, besides the 26 amputations, 53 
 excisions of the mamma, 30 cases of fistula in ano, 4 amputa- 
 tions of the penis, 14 excisions of large tumours, 5 excisions 
 of the upper jaw, 8 excisions of the lower jaw, 6 herniotomies^ 
 G tracheotomies, 5 lithotomies, &c. Thus the conditions were 
 not so favourable as might at first sight be supposed. We are 
 not told what the results were in these latter cases, either as 
 to the occurrence of infective disease or otherwise. Burow 
 ' Archivfiir klimschc Chiriirijie. 
 
41U liESULTS OF ANTISEPTIC SURGERY. 
 
 took the most scrupulous precautions as to cleanliness, more 
 especially of hands and instruments ; for example, he never 
 employed sponges which had been used before. Then in many 
 of his cases, notably in the excisions of the mamma, he used 
 acetate of alumina — a very powerful antiseptic — and he specially 
 praises its property of keeping down smell. 
 
 Much more important facts are published by Kronlein ' in 
 his report of the results of the open treatment at Ziirich from 
 18G7— 71. The method employed was chiefly that of Bartscher 
 and Vezin, but it was combined with frequent irrigation of the 
 wound with antiseptic solutions, so that we have here, not the 
 open method pure and simple, but a combination of it with 
 irrigation and treatment by antiseptics. 
 
 Kronlein gives details of the cases of amputation, excision 
 of the mamma and compound fracture conservatively treated, 
 and contrasts the results obtained between 1867 and 1871 with 
 those of the previous 7 years (1860-67). During these 7 years 
 all sorts of methods of treatment were employed. In some 
 cases the edges of the wound were brought together by strips 
 of plaster or by stitches, and covered with compresses and 
 bandages ; in others the wound was left open for several 
 hours, &c. 
 
 Kronlein discusses from various points of view the causes 
 of the difference in the results in the two periods, and at length 
 comes to the conclusion that it is in the main owing to the 
 different methods of treatment employed. I need not enter 
 into all his arguments : I quite agree with his conclusion. 
 
 During the first period (1860-67), 260 important cases 
 were treated, and of these 105 died. These cases included 
 140 amputations, 34 excisions of the mamma, and 86 compound 
 fractures treated conservatively. Of the 105 deaths 59 oc- 
 curred from pyaemia and septicaemia alone. 
 
 During the second period (1867-71), 172 similar cases were 
 treated with 34 deaths. These consisted of 85 amputations, 
 22 excisions of the mamma, and 65 compound fractures. Of 
 the 34 deaths 12 were fiom pyaemia and septicaemia alone. I 
 may just quote his tables : — 
 
 ' Lie offene Wundhehandlung . Ziirich, 1872. 
 
OPEN METHOD: KRONLEINS STATISTICS. 
 
 411 
 
 Amptitations. 
 
 
 1860-G7. 
 
 
 Cases 
 
 Deaths From pyoemia 
 and septicEBiuia 
 
 Thigh 36 
 
 31 16 
 
 Leg 36 
 
 21 12 
 
 Humerus . . . . .18 
 
 10 8 
 
 Fore-arm . . . . .24 
 
 4 2 
 
 Hand 9 
 
 — — 
 
 Foot 17 
 
 6 4 
 
 Total . 140 
 
 72* 42t 
 
 * Or a mortality of 51-4 p. c. 
 
 f Or 30 p. c. 
 
 1867-71. 
 
 
 Cases 
 
 Deaths From pyfemia 
 and septicKmia 
 
 Thigh 28 
 
 10 2 
 
 Leg 11 
 
 2 1 
 
 Humerus 14 
 
 2 2 
 
 Fore-arm 10 
 
 — — 
 
 Hand 7 
 
 — 
 
 Foot 15 
 
 3 1 
 
 Total . 85 
 
 17* 6t 
 
 * Or a mortality of 20 p. o. 
 
 t Or 7 p. c. 
 
 Excic ions of the Mamma. 
 
 1860-67. 
 Cases Deaths From pyiemia and septiciBinia 
 
 34 11* " 4t 
 
 * Or a mortality of 32-3 p. c. t 11-7 p. c. 
 
 1807-71. 
 
 Cases Deatlis 
 
 22 3* 
 
 * Or a mortality of 13-G p. c 
 
 From pyaemia and Beptioa'niia 
 It 
 t 4'5 p. c. 
 
 Compound Fractures treated conservatively to the end. 
 
 1860-07. 
 
 Thigh 
 Leg . 
 
 Humerus . 
 Pore arm. 
 
 Cases 
 7 
 
 Deaths 
 2 
 
 From pyjemia 
 aiid septicaemia 
 
 
 
 . 62 
 
 13 
 
 7 
 
 7 
 
 3 
 
 3 
 
 . 10 
 
 4 
 
 3 
 
 . 86 
 
 22* 
 
 13t 
 
 Total 
 
 * Or a mortality of 255 \p. c. t 151 p. c. 
 
412 RESULTS OF ANTISEPTIC SUIiGEIiY. 
 
 18G7-71. 
 
 Cases Dcatlis From pyaemia 
 
 and septicaiuiia 
 
 Thigh 11 2 
 
 liSg 31 9 5 
 
 Humerus ..... 18 '2 
 
 Fure-arm 10 1 
 
 Total . 65 14* 5t 
 
 * Or a mortality of 21-5 p. c. t 7-6 p. c. 
 
 Kronlein does not give full details of the causes of death 
 during either period, so that one cannot judge for one's self 
 how far they were avoidable or not. He confines his attention 
 to infective diseases. 
 
 If we analyse Kronlein's tables of amputations in the same 
 way as was done on p. 387, for the septic and aseptic tables, 
 i.e., if we only consider uncomplicated amputations, leaving out 
 of consideration double amputations, amputations where other 
 injuries were present, amputations in patients already suffering 
 from septic poisoning, &c., we get the following results in cases 
 treated by the somewhat modified open method described 
 above : — 
 
 Uncomplicated A mputations. 
 
 (1867-71.) 
 
 Cases Deaths 
 
 Humerus 13 3 
 
 Fore-arm 8 
 
 Hand 7 
 
 Thigh 22 5 
 
 Leg 5 
 
 Partial of foot 12 3 
 
 Total . . 67 11 
 
 or a mortality of 16-4 p. c. as compared with Schede's result in aseptic cases 
 of 4-4 p. c. Of these deaths one occurred from shock ; in live no cause of 
 death is given ; four died from pyaemia ; and one from erysipelas. 
 
 Between 1860 and 1867 about 4,000 patients, suffering 
 from all sorts of affections, were treated in the surgical wards 
 at Ziirich, and of these 146 died of pyaemia and septicaemia. 
 
 Between 1867 and 1871 about 2,300 similar cases were 
 treated. Of these only 19 died of pyaemia and septicaemia. 
 
 Among the 4,000 patients of the first period erysipelas oc- 
 
RESULTS OF THE ORDINARY METHODS. 413 
 
 curred 148 times. Among the 2,300 patients of the second 
 period erysipelas occurred 127 times. 
 
 We thus see, that a treatment consisting of a combination 
 of the open method with intermittent irrigation and treatment 
 with antiseptics reduced in a very marked degree the mortality 
 from pyasmia and septicaemia, but did not affect erysipelas at 
 all. What the open method alone would have done we do 
 not know, but these results are very good in a hospital where 
 infective diseases were prevalent. Kronlein himself says 
 that these cases ' sufficiently show that the open method is 
 no absolute guarantee against pyaemia and septicgemia.' He 
 also states that 'the open method does nothing against ery- 
 sipelas ; indeed, during the time in which the open method 
 was employed, erysipelas was more frequently observed than 
 formerly.' 
 
 We have also already seen from the experiences of Nuss- 
 baum and Volkmann, that the open method is not very power- 
 ful against septic diseases in infected hospitals. Thus, for 
 example, Volkmann states that at first he was an advocate of 
 the open method, but that by-and-by, as the hospital became 
 more and more unhealthy, the treatment became of less and 
 less value. 
 
 I may, in contrast to the results of the foregoing methods, 
 give a few statistical tables of cases not treated aseptically at 
 all. 
 
 Billroth's results just quoted in Kronlein's book represent 
 the mortality after operations not treated aseptically. 
 
 Malgaigne's statistics ^ are well known. The following 
 table of amputations represents the results obtained in Paris at 
 the time when he wrote. 
 
 Amputation of thigh 
 » leg . 
 Partial of foot . 
 
 Cases 
 . 201 
 . 192 
 . 38 
 
 Deaths 
 126 = 
 106 = 
 
 y = 
 
 mortality of 62-6 p. c. 
 „ 55-2 „ 
 » 23-6 „ 
 
 yhoulflei-joint . 
 
 . 13 
 
 10 = 
 
 » 76-9 „ 
 
 Humerus . 
 
 91 
 
 41 = 
 
 :, 45 „ 
 
 Fore -arm . 
 
 . 28 
 
 8 = 
 
 „ 28-5 „ 
 
 Total . 563 300= „ „ 53-2 „ 
 
 ' ATc/dv(S (jv III rales ilc Mcih-cinc, 1842. 
 
414 RESULTS OF ANTISEPTIC SURGERY. 
 
 Paul ' has collected a very extensive series of statistics, of 
 which the following is a sample. 
 
 Amputation 
 
 at hip-joint 
 
 222 
 
 159 = ] 
 
 mortal 
 
 ityof 71-6 
 
 )) 
 
 through femur . 
 
 1721 
 
 863 = 
 
 
 „ 50-1 
 
 ,, 
 
 at shoulder-joint 
 
 192 
 
 84 = 
 
 
 „ 43-7 
 
 „ 
 
 „ knee-joint 
 
 49 
 
 24 = 
 
 
 „ 40-9 
 
 ,, 
 
 through leg 
 
 1242 
 
 480- 
 
 
 ., 38-7 
 
 ,, 
 
 „ humerus 
 
 943 
 
 314 = 
 
 
 „ 33-3 
 
 '^ 
 
 „ fore-arm 
 
 391 
 
 73 = 
 
 
 M 18-7 
 
 Total . 5,060 1,997= 39-4 
 
 Mr. Holmes in 1866 - gave statistics of the last 300 ampu- 
 tations performed at St. Greorge's Hospital. Of these, eighty- 
 three or 27*6 p. c. died. In 1874^ he published statistics of 
 the last 500 cases of amputation, and, of these, 158 or 31 "6 p. c. 
 died. It thus appears that of the last 200 amputations per- 
 formed at St. George's Hospital between 1866 and 1874, 75 or 
 37*6 p. c, died. This result shows that but little benefit had 
 been derived from the recent improvements in surgery as 
 regards cleanliness, &c., apart from the use of strict aseptic 
 treatment, because the majority of these cases were treated 
 after attention had been called to the subject by Mr. Lister's 
 writings. 
 
 ]M.r. Erichsen^ says that the mortality after great amputa- 
 tions varies from 35 to 50 p. c. 
 
 The results obtained at St. Bartholomew's Hospital were 
 brought forward by Mr. Savory at the meeting of the British 
 Medical Association at Cork ''in 1879 to show what could be 
 done simply by cleanliness and good ;vir independently of 
 aseptic treatment. The report published in 1880^ shows that 
 of 619 operation cases of all kinds (excluding eye operations) 
 45 or 7*2 p.c. died. Many of these operations were of very 
 minor importance indeed. They included, however, 73 major 
 amputations with 11 deaths; 13 excisions of joints with 4 
 
 ' D'lf conservatire Chirtm/ic dcr (riieder, Breslau, 1854. 
 
 ''■ St. Gcorge\'( Hofiintal Reports, vol. i. ' Ihid. vol. viii. 
 
 * ' On Hospitalism and the Causes of Death after Operations,' 1874. 
 
 "' Brifixh Mcdiciil Journal, August, 1879. 
 
 " St. Bartliohimeir's Ho^jiital R<-pnris. 
 
CLEANLINESS: M'VAIL. 415 
 
 deaths ; 29 cases of removal of tumours of the mamma, no 
 death; 13 cases of removal of tumours of the tongue, 1 death; 
 4 lithotomies, no death ; 32 herniotomies, 6 deaths ; 25 teno- 
 tomies, 1 death ; 74 operations for phimosis ; 36 cases of 
 fistula in ano, &c. 
 
 Among the 45 deaths were 9 from py?emia and four from 
 erysipelas. The causes of death in the other cases are not 
 given. Erysipelas attacked 17 cases operated on, and 11 others. 
 One very striking case is mentioned. The femoral artery was 
 ligatiu'ed with various aseptic precautions for popliteal aneurism. 
 The wound did well till the twelfth day, when haemorrhage 
 occm-red. It was then re-opened without aseptic precautions, 
 and the patient died of pyaemia. 
 
 Thus, by the use of cleanliness alone, infective diseases are 
 by no means banished from St. Bartholomew's Hospital. In- 
 deed, in considering these results, it must be remembered that 
 a considerable number of the cases were operated on aseptically. 
 How many cases were treated by good surgery and cleanliness 
 alone, without aseptic precautions, and with what results, we do 
 not know. 
 
 Very good results obtained by methods which are not very 
 powerfully antiseptic were published in the spring of 1880 by Dr. 
 McVail.^ During the preceding three years 107 operations had 
 been performed of which 50 were major operations. Of these 50 
 cases, 3 died. Among them were 31 major amputations, and 
 the three deaths occurred in these cases ; in one it was due to 
 internal injuries ; in one it followed gangrene of the back, due 
 to contusion ; and in one pyaemia was the cause. The onset of 
 the pyemia in the last case is said to have followed the open- 
 ing of an abscess over the sacrum, and death followed within 
 forty-eight hours — a very rapid course for pyaemia ! Was it 
 simply a case of sapnxjmia, or was the abscess part of the 
 pyaemia? Then there were 3 cases in which joints were 
 opened, viz., one compound dislocation of the elbow, which was 
 reduced, but the local result is not given ; one case of ex- 
 cision of tlic head of tlie radius, resuK not inentioned ; and one 
 case of excision of a metacarpal bone in which some joint was 
 o])ened. 
 
 ' BrUitili J/rdicfi/ Journal. 
 
416 RESULTS OF ANTISEPTIC SURGERY. 
 
 Of course these are a very small number of operations in 
 three years, and they were treated in a country hospital, so 
 that the result is not at all surprising ; but when Dr. McVail 
 attempts to draw extensive conclusions from them, and to 
 show that the method of treatment adopted in these cases is 
 better than the aseptic method, he is using a fallacious argu- 
 ment. All that can be said is that under the conditions in 
 which these operations were performed, aseptic treatment was 
 but little necessary, though even here we find that one out of 
 31 major amputations died of pyaemia. As we have seen, the 
 best surgeons, Mr. Spence or Mr. Savory for instance, even 
 with the use of the most scrupulous cleanliness, cannot reckon 
 on anything like absence of infective diseases. 
 
 After all, these statistics are not nearly so good as the 
 results obtained by Bardenheuer with aseptic treatment in the 
 Cologne Infirmary in one year.' He had no death among 
 133 aseptic operations involving bones. These included, ac- 
 cording to MacCormac — 
 
 41 amputations (17 of thigh) through bones. 
 
 10 ,, at joints (1 at hip). 
 
 53 resections (15 of hip and 12 of knee). 
 
 2H cases of removal of wedge-shaped pieces of bone. 
 
 5 operations for badly united fracture. 
 
 \ case of trephining. 
 
 ' MapCormap's Antigej)tic Surgery, p. 29. 
 
SUMMARY OF THE GENERAL RESULTS. 417 
 
 CHAPTER XVIII. 
 
 RESULTS OF ANTISEPTIC SURGERY {continued). 
 
 General considerations. Wounds of, and operations on, healthy joints. Method 
 of treatment adopted in these cases. Definition of the term ' Aseptic 
 course : ' Example. Wounds of healthy joints. Operations on healthy 
 joints. Objections to the value of these cases : reply. Incisions into joints 
 affected with synovitis. Incisions into joints affected with pulpy degenera- 
 tion of the s^movial membrane — a without suppuration, b with suppuration. 
 Volkmann's results : Max Schede : Paul Earth : Saxtorph : Piechaud : 
 Nussbaum : Albert : Hueter : Letievant : Kraske : Reyher : Bergmann. 
 Comparison of Reyher's results with those obtained during the Crimean 
 war, and with Heintzel's. Treatment by irrigation. Necessity for observing 
 the minutest precautions as showni by Mr. Lister's case. Results of removing 
 foreign bodies from joints without aseptic precautions: Larrey : Spence : 
 Paget. 
 
 So far I have been dealing with general statements; and though 
 these are often not of much use, yet I cannot think that there 
 can be any doubt as to the great value of the facts which I 
 have narrated. Thus, for example, we have had an opportunity 
 of comparing Mr. Lister's results in Glasgow before and after 
 the introduction of aseptic treatment. After be went to 
 Edinbiugh, we were able to trace a very marked improvement 
 following the introduction of the aseptic method; and we 
 also had the opportunity of contrasting the results of aseptic 
 treatment with those of treatment by antiseptics in Mr. Lister's 
 own hands. We were further able to point out that there was 
 a great difference between these results and those obtained 
 during the greater part of the same period, in the same 
 hospital, and under more favourable hygienic conditions, by a 
 surgeon who did not practise aseptic treatment. 
 
 We have fiu'ther had most striking evidence from abroad 
 showing that in infected hospitals the aseptic method has done 
 what other methods, such as the open method, treatment by 
 
 E E 
 
418 RESULTS OF ANTISEPTIC SURGERY. 
 
 irrigation or by antiseptics, could not do. It has not only 
 diminished, but when properly employed, it has abolished in- 
 fective disease. That this result has not been simply due 
 to cleanliness, as has been suggested by some, is shown by 
 numerous facts, such as those mentioned by Nussbaum (p. 394) 
 and Volkmann, and also by the results of the use of thymol 
 (p. 404). 
 
 Nor must I forget to mention the results obtained in 
 ovariotomy, although these are not test cases. For the peri- 
 toneum has a wonderful power of destroying causes of putre- 
 faction, or of rendering them inert by rapidly removing the 
 fluid in which they might grow. Thus, dust-laden air has 
 been injected into the healthy peritoneal cavity without bad 
 results, though, if ascitic fluid were present, or if the peritoneum 
 were unhealthy, there would almost certainly be fermentation, 
 and probably, as a result of this, depending on the amount and 
 natm*e of the irritating products formed, peritonitis. In the 
 healthy peritoneum, which absorbs fluids with immense rapidity, 
 there is no fluid for the organisms to develop in, and thus 
 they are left in contact with active healthy li\dng tissue, which, 
 as we have seen from experiment, rapidly destroys them. 
 Hence the case of ovariotomy is by no means a test. 
 
 There are certain cases, however, to which I must now 
 allude, in which there is not the same tendency to destruction 
 of organisms, but where there is opportunity for them to 
 develop, and where the admission of septic dust is liable, as 
 experience has shown, to be followed by very serious conse- 
 quences. An example of such a case is where organisms are 
 admitted into a healthy joint. Here fluid is present, in which 
 they can develop, and here also all parts of the living surfaces 
 are not in contact, and, therefore, organisms may be present in 
 the fluid of the joint and yet not in contact with healthy living 
 tissues. This is, then, a test case, for here organisms, if ad- 
 mitted, will as a rule grow. We must therefore inquire, how 
 injuries which might involve the entrance of organisms into 
 healthy joints behave under the various methods of treatment. 
 Then, again, in chronic abscesses we have similar conditions. 
 Here the fluid is practically under the same conditions as if 
 it were in a flask ; the walls of the cavity are probably not even 
 
TREATMENT OF WOUNDS OF JOINTS. 419 
 
 healthy. How do such abscesses behave under various circum- 
 stances ? 
 
 And lastly, although this is not such a test case, Ave know 
 that compound fractures, whether made by the surgeon or by 
 accident, are very dangerous, chiefly on account of their great 
 liability to be followed by infective disease. In this instance 
 the destroying action of the blood clot and of the living tissues 
 can come into play, but nevertheless the movements to which 
 the part, is liable are apt to interfere with their action. Blood 
 clot is only of use as a destroyer of bacteria if it be kept at 
 rest. 
 
 Wounds of, and Incisions into, Healthy Joints. 
 
 I have already published the cases which have occurred in 
 Mr. Lister's practice from the end of 1871 up to November 1879,' 
 but I shall introduce these tables here in order to complete 
 the subject. Before, however, discussing the results as a whole, 
 T must mention how the cases have been treated, and what is 
 the usual aseptic course. 
 
 Wounds of joints are treated on the principles described at 
 page 113. If the case is seen very shortly after the accident 
 (within a few hours) the joint is thoroughly washed out with 
 1-20 carbolic lotion by means of a syringe and catheter, the 
 wound being enlarged if necessary; the surrounding skin is 
 well washed with the same lotion, a drainage tube is introduced 
 into the joint, a large gauze dressing is applied, and a splint is 
 arranged so as to prevent movement. This treatment is carried 
 out under a spray of carbolic acid. If the wound does not 
 come under obser\'ation till after the lapse of twenty-four or 
 thirty-six hours, a solution of carbolic acid in methylated spirit 
 ( 1 part of carbolic acid to 5 of spirit) is used. If a still longer 
 time has passed since the receipt of the injury, fermentation of 
 the fluids in the joint has generally taken place, and there is 
 but little hope of eradicating it. An attempt may, however, be 
 made by the use of either of the lotions just mentioned, or of a 
 solution of chloride of zinc (40 grs. to the ounce) or of iodoform 
 suspended in alcohol and water. 
 
 In operating on healthy joints, the various precautions 
 
 ' British Medical Journal, November, 1879 
 E K 2 
 
4:^0 RESULTS OF ANTISEPTIC SURGERY. 
 
 described in the chapters on aseptic surgery must be carefully 
 carried out. As a rule the 1-20 carbolic lotion is used for 
 all purposes. When the operation is concluded, a drainage 
 tube or a horse-hair drain is introduced into the joint so as 
 to provide free escape for the serum, which will probably, for 
 a few hours, be of considerable amount, owing to the irritation 
 of the synovial membrane by the manipulations and by the 
 carbolic acid. The drain can generally be dispensed with in 
 simple cases, such as after the removal of a loose cartilage, in 
 from one to three days. As the residt of these operations, the 
 discharge becomes very slight after the first twenty-four hours. 
 There is no pain nor swelling, in fact no local inflammatory dis- 
 turbance whatever, and therefore, of com"se, no suppuration. 
 Constitutionally the patient remains quite unaffected : he feels 
 well,' eats well, sleeps well, and in fact, thinks it a great hard- 
 ship to be kept in bed for a few days. In the following cases, 
 when I use the term ' aseptic course,' I mean this condition 
 of absence of local or constitutional disturbance. 
 
 Let me take as an example a case of recent fracture of the 
 patella, which was operated on with the view of obtaining bony 
 union. 
 
 W. T. set. 37 was admitted to King's College Hospital on 
 Dec. 13, 1879, suffering from a recent simple transverse frac- 
 ture of the patella. The accident had occurred on December 9. 
 
 Condition on admission. — The knee-joint was much 
 swollen and contained a considerable quantity of fluid. The 
 patella was fractmred transversely and the fragments were about 
 two inches apart. There was a good deal of pain in the joint. 
 
 Ope^'Cition. — On DecL'mber 13, chloroform having been ad- 
 ministered, Mr. Lister made a longitudinal incision about 4 
 inches in length over the patella, the various aseptic precau- 
 tions before described being employed. The knee-joint was of 
 course at once opened. A quantity of coagulated blood and 
 fibrous tissue filled up the space between the fragments, and 
 this was removed. A pair of dressing forceps was then passed 
 into the joint and projected against the skin at the most de- 
 pendent part of the outer side of the joint. An incision was 
 made on the projecting point, and by means of the forceps a 
 horse-hair drain was drawn into the joint. The fragments were 
 
ASEPTIC COURSE. 
 
 421 
 
 then drilled obliquely, avoiding the cartilage, and, a piece of 
 strong silver wire being passed along the drill-tracks, the frag- 
 ments were firmly tied together. The two ends of the wire 
 were then twisted together and left of sufficient length to pro- 
 ject from the wound. A drainage tube was introduced into 
 the incision superficial to the patella and brought out of the 
 upper angle of the wound. The remainder of the line of in- 
 cision was stitched. A large antiseptic dressing was applied 
 enveloping the whole of the thigh, and the limb was placed 
 on a posterior splint. The foot of the bed was raised on 
 blocks so as to make the discharge flow upwards. 
 
 After-'progress. — The after-progress of this case was typical. 
 There was never the slightest pain or constitutional disturbance 
 (see Fig. 77). On the following day (December 15) the dress- 
 
 jnn 
 
 Fig. 
 
 -TEMPERATUUB chart KROM a case op operation FOPv 
 FRACTURE OF THE PATELLA. (No. 21, p. 434.) 
 
 ing was changed and a fresh dressing re-applied ; there was no 
 pain or swelling of the joint. On December 17, the dressing 
 was again changed, and a portion of the drain was removed 
 from the joint. On December 19, the superficial drain and 
 part of the remaining drain for tlie joint were dispensed with ; 
 most of the stitches were taken out. At the next dressing, on 
 December 24, the remainder of the drain and the rest of the 
 stitches were removed. On December 31, the wound was 
 again dressed, and was found to be quite healed, except a minute 
 speck, where the drain for the joint had been. This was found 
 to be quite healed on January 5, when passive motion was l)t gun. 
 The wire was removed on February 9, and bony union was 
 found to have taken place. WliciMlic patient was discharged 
 on February lo, the movements of the joint were perfect 
 through an angle of 45° ; patient could kick vigorously. 
 
422 
 
 RESULTS OF ANTISEPTIC SURGERY. 
 
 
 
 I. Wounds 
 
 No. 
 
 Name nnd Age 
 
 Date of Admission, 
 Operation, and Dis- 
 charge ; with Kesult 
 
 Injury 
 
 1 
 
 Frank K., 29 . 
 
 yl(/,,Nov. 20, 1871. 
 Op., Nov. 20, „ 
 Dis., Dec. 23, „ 
 Result, cured. 
 
 Little finger-joint fractured in various places. 
 Skin over hand contused. Fourth meta- 
 carpal bone laid bare in the greater part of 
 its extent. Fourth metacarpo-plialangeal 
 joint opened. 
 
 2 
 
 George G., GO . 
 
 Ad., June 28, 1872. 
 Op., June 28, „ 
 Dis., Oct. 1, „ 
 Result, cured. 
 
 Compound comminuted fracture of the 
 humerus, caused by the wheel of a wagon 
 passing over his arm. Humerus fractured 
 in two places ; the lower fracture commu- 
 nicating with the elbow-joint. Patient 
 admitted about two hours and a half after 
 the accident. 
 
 •) 
 
 Robert H., 30 . 
 
 Af]., Mav 12, 1873. 
 Op., May 12, „ 
 Bis., July 17, „ 
 Result, failed ; ampu- 
 tation. 
 
 Compound fracture of the carpal bones of the 
 left hand. Extensive laceration of the soft 
 parts. Machinery accident. Patient ad- 
 mitted immediately after the accident. 
 
 4 
 
 Walter S., 42 . 
 
 Ad., May 17, 1875. 
 Op., Mav 17, „ 
 />/*■., May 21, „ 
 Residt, in process of 
 cure. 
 
 Wound of metacarpo-phalangeal joint. 
 
 5 
 
 Francis J. ,48 . 
 
 Ad., Oct. 4, 1875. 
 Op., Oct. 4, „ 
 iJis., Dee. 4, „ 
 Result, cured. 
 
 Compound dislocation of the ankle ; the 
 articular surface of the tibia protruding 
 through a large wound anteriorly. Both 
 malleoli torn off. 
 
 (i 
 
 Henry W. . . 
 
 Ad., June 8. 187(!. 
 Op., June 8, „ 
 Dis., June 13, „ 
 Result, cured. 
 
 Thumb and trapezium nearly torn off, and 
 the carpal joints opened. Gunshot-wound. 
 
 
 David S., 13 . 
 
 Ad., Mav 2, 1877. 
 Op., May 2, „ 
 JJis., after Mr. Lister 
 
 left Kdinl)urgl). 
 Result, cured. 
 
 Large lacerated wound of right knee. Large 
 flap of skin thrown to one side. Mud was 
 ground into the cartilaginous surface of the 
 internal condyle of i he femur. The acci- 
 dent resulted from a wheel of a heavy cart 
 passing over patient's leg. 
 
MR. LISTER'S JOINT CASES. 
 
 423 
 
 OP Joints, 
 
 Little finger amputated ; other parts 
 well syringed with 1-20 carbolic lotion. 
 
 Wound injected with 1-20 carbolic lotion. 
 Some loose pieces of bone were removed 
 from the lower wound. (Xo portion 
 of the articular end of the humerus 
 was, however, removed.) 
 
 Wound injected with a solution of car- 
 bolic acid in rectified spirit (1 in 5). 
 
 Washed out with 1-20 carbolic lotion. 
 
 The wound was injected with 1-20 car- 
 bolic lotion, and an attemjit was then 
 made to reduce the dislocation. This 
 failing, the articular surface of the 
 tibia, was sawn off, the astragalus 
 being left untouched. Foot fixed at 
 right angles to leg. 
 
 The thumb, with its metacarpal bone, 
 was removed ; the trapezium was also 
 dissected out. The wound and the 
 carpal joints, as far as possible, were 
 injected with 1-5 solution of carbolic 
 acid in rectified spirit. 
 
 Shreds of tissue were clipped away, and 
 the cartilage of the condyle was pared 
 with a knife where the dirt was most 
 ground in. The whole of the dirty 
 wound was scruljbed with a nail-brush, 
 and I -20 carbolic lotion, and, in addi- 
 tion, 1-.") spirituous solution of carbolic 
 acid were applied. No stitches were 
 inserted. Tlie limb was ])laced on a 
 posterior splint. 
 
 Some sloughing and suppuration occurred among 
 the contused parts in the hand, and an abscess 
 formed in the forearm. Entirely healed De- 
 cember 23. Passive movements were begun in 
 December, and could be easily performed. 
 
 Putrefaction was avoided ; typical aseptic course. 
 The fracture had quite united on August 10. 
 The wound was quite superficial on August 3, 
 and boracic dressing was applied. On August 
 
 15, erysipelas attacked the wound. This passed 
 off, and the wounds were quite healed on Sep- 
 tember 20. When dismissed, patient was able 
 to flex his arm sufiiciently to enable him to 
 touch the shoulder of the other side. 
 
 Putrefaction occurred in spite of the injection ; 
 and, as fever set in, Mr. Lister operated on May 
 
 16, removing the carpus and fingers, but leaving 
 the trapezium and the thumb. The flaps were 
 left gaping,and carbolic oiled lint (1-10) was 
 introduced between them. Flaps brought 
 together on May 24. Stump was quite healed 
 on June 25. 
 
 Putrefaction was avoided. Treated as an out- 
 patient. Wound followed an aseptic course. 
 
 Aseptic course. The wound was almost abso- 
 lutely healed when the patient was discharged. 
 Joint strong and slighth' movable. The tem- 
 perature was on one occasion as high as 100 deg. 
 
 Aseptic course. Treated as an out-patient after 
 June 13. On June 31, the wound had almost 
 entirely healed. 
 
 The wound became filled with blood-clot, the 
 deeper part of which became organised. On 
 May 27, there was a large granulating surface. 
 The wound was quite superficial on June 26, 
 when boracic ilressing was substituted for the 
 carbolic acid. There was at that time very- 
 considerable movement of the knee-joint, with- 
 out pain. Li August 1878, ' patient visited the 
 hospital, walking without any assistance, the 
 two knees being equally useful, except that the 
 injured one was still somewhat stiff." 
 
424 
 
 RESULTS OF ANTISEPTIC SURGEli^ 
 
 I. Wounds 
 
 Kame and Age 
 
 Ellen M., 12 
 
 Jane D., 50 
 
 Date of Admission, 
 Operation, and Dis- 
 charge ; with Result 
 
 10 Maria L., CO 
 
 Henry B., 22 . 
 
 12 
 
 Samuel M., M 
 
 ArcliiljMl.lK., lU 
 
 Ann P., 08 . 
 
 Ad., Nov. 6, 1877. 
 Op., Nov. (!, „ 
 Dis., Nov. 17, ,, 
 Result, cured. 
 
 Ad., Oct. 1.5, 1878. 
 Op., Oc-t 15. „ 
 Dis., June 20, 1879. 
 Result, wound of 
 joint cured. 
 
 Ad.,'Sov. 12, 1878. 
 Op., Xov. 12, „ 
 I)is.. April 19, 1879. 
 Result, in process of 
 cure. 
 
 Ad.. April 20, 1879. 
 0/j., April 21, „ 
 Dis., May 30, to coir'e 
 
 as out-patient. 
 Result, cured. 
 
 Ad., Julv 8, 1879. 
 Op., Julv 8, „ 
 iJis., Juiy 24, „ 
 Result, cured. 
 
 Ad., Dec. 10, 1880. 
 Dis., Dec. 24, „ 
 Result, cured. 
 
 Ad., Aufi;. 11,1881. 
 0/A, Aug. 12, „ 
 Dis., Aug. 30, „ 
 Result, cured. 
 
 Injury 
 
 Punctured wound of ankle-joint, caused by 
 scissors. The accident happened twenty- 
 one hours before admission. Glairy fluid 
 escaped, and a probe passed into the joint. 
 Foot red and swollen. 
 
 Compound fracture of the lower end of the 
 femur, with splintering of the condyles into 
 the joint. Patient was seen one hour and 
 a half after the accident. (See compound 
 fracture. No. 70.) 
 
 Compound dislocation of the left ankle-joint, 
 with comminuted fracture of the fibula and 
 fracture of the internal malleolus. Skin in 
 the neighbourhood of the wound much 
 contused. 
 
 Patient jumped over Waterloo Bridge ; in 
 his descent, he struck hi.'i left elbow against 
 the side of the parapet. The result was an 
 oblique fracture into the elbow-joint, de- 
 taching the internal condyle. There was a 
 small opening in the skin communicating 
 with the fracture. 
 
 Punctured wound of the left knee-joint, just 
 above the patella. The finger, when intro- 
 duced into the wound, passed into the joint, 
 and felt the under surface of the patella. 
 Synovial fluid escaped. Great pain on 
 movement of the joint. The wound was 
 inflicted about fourteen hours before the 
 patient came to tlie hospital. 
 
 Incised wound of knee-joint. Incision one 
 and a half inch long. 
 
 Compound fracture of the olecranon. The 
 accident happened on August 10. and was 
 iunnediately seen by the house surgeon. 
 
 J 
 
MR. LISTER'S JOINT CASES. 
 
 425 
 
 OF Joints (continued). 
 
 Treatment 
 
 Wound enlarged, and joint injected with 
 a solution of carbolic acid in spirit 
 (1-5). ■ 
 
 The opening in the skin was eulari^ed. 
 The projecting end of the femur was 
 sawn off, and reduction was effected. 
 The wound was washed out with 1 to 
 20 carbolic lotion. An incision was 
 made into the knee-joint on the outer 
 side, and a drainage-tube was inserted 
 into it, to prevent accumulation of 
 huid. 
 
 The detached portions of bone were re- 
 moved; wound syringed out with 1- 
 20 carbolic lotion. Dislocation re- 
 duced. Drainage-tubes inserted. Du- 
 puytren's splint. 
 
 Wound enlarged ; some sm.-jll fragments 
 of bone removed, and the wound and 
 joint syringed out with 1-20 carbolic 
 lotion. Drainaije-tubes inserted. 
 
 Joint wa-shed out with 1-20 carbolic 
 lotion, and witli a solution of carbolic 
 acid in rectified spirit (1-5). Drainage- 
 tube inserted; posterior splint applieit. 
 
 Wound sjTinged out with an emulsion 
 of eucalyptus oil containing iodoform. 
 Surrounding parts washed with 1-20 
 carbolic lotion. 'I'ube introduced into 
 the joint. 
 
 On the lOtli the wound was thoroughly 
 washed out with 1-20 lotion anU 
 treated a^eptically. As there was no 
 bed, patient could not be admitted till 
 the following day. On the 12th the 
 wound wa.s again washed out, and, the 
 opening being enlarged, the fragments 
 were brought to;rethcr by means of 
 strong silver wire. l)rainage-lul)e 
 inserted, wounil stitched, straight 
 splint applied anteriorly. 
 
 The wound had quite healed on November 17. 
 Aseptic course ; dressed four t>mes. When pa- 
 tient was discharged, the ankle was quite nor- 
 mal, with perfect movement. (See Chart I.) 
 
 Aseplic course. The drainage-tulie was removed 
 from tlie joint on October 28, and the wound of 
 the joint had completely healed on November 
 21 : the wound in the thigh healed on December 
 13. As the fracture remained ununited, Mr. 
 Lister injected iodine between the ends of the 
 fragments on February 14. Union not yet oc- 
 curring, Mr. Lister cut off the ends of the bones 
 and wired them together with thick silver wire. 
 The femur is still ununited, but is under treat- 
 ment. (See (yhart IL) 
 
 Aseptic course. Some portions of the skin 
 sloughed. When discharged, the wound was 
 almost healed, but the ankle-joint was stiff. 
 
 Aseptic course. Wound completely healed on 
 June .^0. The movements of the joint were 
 then very good, and have since that time 
 steadily improved. (See Chart III.) 
 
 Aseptic course. The pain on moving the knee 
 ceased a i'ew hours after it had been washed out. 
 The wound was quite superficial when the pa- 
 tient was discharged, an 1 the knee was quite 
 movable. Healing was complete on .July 31. 
 The patient was again seen in October, the 
 movements of the knee being then perfect. 
 
 Typical asejitic course. Tube removed on Decem- 
 biT 17. When discharged the wound had 
 almost entirely healed, and healing was com- 
 plete in a few days. Knee-joint perfectly 
 movable and leg quite strong. 
 
 Aseptic course. Some of the stitches were too 
 tight and caused a little irritation, but this 
 subsided as soon as they were cut. Incision 
 healed and stitches removed on .August 16. 
 Orains entirely removed on August 19. The 
 wound liad (|uite healed when the patient was 
 dischargeil. (The ends of the wire which 
 brought the fragments together were cut short, 
 and the cutaneous margins were brought to- 
 gether over I hem, so that the wire reuuiins.) 
 Seen in middle of September — extension per- 
 fect. l'"le.\ion beyond a right angle, and can be 
 <lone perfectly by passive motion. Arm gain- 
 ing strength. 
 
426 
 
 RESULT !S OF ANTISEPTIC SURGERY. 
 
 II. — Operations on 
 
 No. 
 
 Name and Age 
 
 John C, 46 
 
 David B., .39 
 
 John lilcl., M . 
 
 .John H. 19 
 
 William T., 31. 
 
 France."* G., 54 
 
 Date of Admission, 
 Operation, and Dis- 
 cbarge ; with Result 
 
 Ad., April 5, 1872. 
 Op., April 6, „ 
 Dis., May 9, „ 
 Result, cured. 
 
 Ad., Julv 22, 1872. 
 Op., July 22, „ 
 Dis., Aug. 5, „ 
 Besult, cured. 
 
 Ad., March 13, 1873, 
 Op., March 28, „ 
 Dis., June (>, „ 
 
 Result, cured. 
 
 Ad., May 6, 1873. 
 Op., May 31, „ 
 Dis., Aug. 15, „ 
 Residt, cured. 
 
 ^rf., Xov. 19,1873. 
 Op., Nov. 26, „ 
 Dis., Jan. 8, 1874. 
 Result, cured. 
 
 Ad., Xov. 3, 1873. 
 Op., Feb. 8, 1874. 
 Dis., Sep. 14, „ 
 ResuH, improved. 
 
 Caries of metacarpal bone and first phalanx 
 of ring-tinger. 
 
 Loose cartilage in knee-joint. 
 
 Ununited fracture of olecranon ; fracture ob- 
 lique ; considerable separation of frag- 
 ments. Patient unable to extend the arm. 
 Accident occurred five months previously. 
 
 Dislocation of the lower end of the ulna 
 backwards. The lower end of the radius 
 was much thickened. Suppuration had 
 occurred in the sheaths of the flexor ten- 
 dons. The movements of the wrist-joint 
 were painless, but limited, more especially 
 as regards extension. 
 
 Loose cartilages in the elbow-joint. The 
 movements of flexion and extension were 
 impaired, more especially tlie foimer. 
 Pain on attempting to complete these 
 movements. 
 
 Ununited fracture of neck of right femur. 
 Accident happened IS months before ad- 
 mission. Right limb, 29| in. ; left limb, 
 31^ in. Suffered great pain; could nei- 
 ther sit nor walk. 
 
MR. LISTERS JOINT CASES. 
 
 427 
 
 Healthy Joints. 
 
 Remarks 
 
 Removal of the finger and the whole of 
 the metacarpal bone ; the carpal arti- 
 culations being of course opened. 
 
 Free incision into joint ; cartilage re- 
 moved. 
 
 Longitudinal incision over olecranon, 
 the cartilaginous end of the humerus 
 being at once freely cxpised. Ends 
 of fragments refreshed, drilled, and 
 tied together by strong silver wire. 
 Wound left open. Splint applied so 
 as to keep the arm extended. 
 
 Abscesses opened; end of ulna removed ; 
 drainage-tube introduced into the 
 ■vvrist-joint, which was healthy. 
 
 Longitudinal incision over externa) con- 
 dyle. Joint opened ; loose bodies 
 (about 200 in number) scooped out. 
 Two drainage-tubes were inserted ; 
 wound stitclied. 
 
 The limb having been drawn down to 
 full length bj' pulleys, an incision was 
 made over and above the trochanter, 
 and the ends of the fragments were 
 refreshed with the gouge and hammer, 
 the joint being opened in the process. 
 Drainage-tul)(!s inserted into joint; 
 no stitches ; long splint aiul exten- 
 .sion with weight and pulley apjilied. 
 Length of right leg after operation, 
 30^ in. 
 
 On April 23, the wound had entirely healed ex- 
 cept a small point at the distal end. Aseptic 
 course. 
 
 Wound Avas completely healed on August 5. It 
 had been dressed four times. Aseptic course. 
 Knee freely movable. 
 
 The wound had completely healed on May 2, ex- 
 cept where the wire projected. Dressed ten 
 times. Wire removed on May 19, when union 
 was complete. Passive motion was commenced 
 on April 8, and was performed at each dress- 
 ing. Typical aseptic course. When dismissed, 
 the movements of the arm were almost perfect. 
 In a letter received from the patient some time 
 afterwards, he stated that the one arm was as 
 good as the other. The temperature in this 
 case was irregularlv taken but it was only 
 once above 100° F., and then it was 100-6° F., 
 an evening temperature. 
 
 Xo local or constitutional disturbance followed 
 the operation. When sent to the convalescent 
 home on August 15, there was still a small 
 sinus, but this soon healed. The movements of 
 the wrist-joint were greatly improved. 
 
 Healed on December 17. Dressed seven times. 
 Aseptic course. Arm was paralysed at first, 
 owing to the pressure of the tourniquet ; but, 
 under the use of galvanism, this was cured. 
 When dismissed, the movements were much 
 improved. (See paper by Mr. Sampson Gam- 
 gee in Lancet for January 10, 1871.) The tem- 
 perature in this case was only taken once daily, 
 and was only once above 99° F., viz. on the 
 7norning after the operation, when it was 99*7° 
 F. 
 
 Healed on March 28 ; aseptic course. Extension 
 was maintained till April 3 ; but when it was 
 at length removed, it was discovered that the 
 weight had been too heavy, and that the limb 
 operated on was longer than the other. 
 VVhcn the patient left the hospital, there was 
 not osseous union, but she was al)le to walk 
 fairly and sit. and the pain which she jirevi- 
 ouslv sull'ered had comiiLetelv disappeared. 
 (See Chart iV.) 
 
428 
 
 RESULTS OF ANTISEPriC SURGERY. 
 
 II. — Operations ox 
 
 No. Name anil Age 
 
 Graces., 15 
 
 10 
 
 Agrcs 
 
 Edward R., 59 . 
 
 Alexander — , 26 
 
 11 
 
 12 
 
 James D., KJ 
 
 John D., 64 
 
 Date of Admission, 
 Operation, and Dis- 
 charge ; with Result 
 
 Ad., Maj- C, 1874. 
 Op., May 14, „ 
 Dis., May 27, „ 
 ResiiU, cured. 
 
 Ad., Jnlv 1875. 
 0/>., Jiilv 13, 1875. 
 Dis., Oct. 20, „ 
 Result, cured. 
 
 Ad., Aug. 12, 1875. 
 Op., Aug. 17, „ 
 Dis., Dec. 16, „ 
 Result, cured. 
 
 Ad., Xov. 10, 1875. 
 Op., Nov. 16. „ 
 Dis., Dec. 26, „ 
 Result, cured. 
 
 Ad., Feb. 14, 187 
 Op., Feb. 14 „ 
 Dis., Mar. 20, „ 
 Result, cured. 
 
 Ad., May 18, 187 
 Op., June, 1 ,, 
 i>is., Sept. 8, „ 
 Result, much 
 proved. 
 
 Disease 
 
 Ganglion on the back of both wrists beneath 
 the extensor tendons, which had resisted 
 all treatment; multilocular. 
 
 Ostitis of the tibia; bone much thickened. 
 A sinus was present, leading down to bare 
 bone. 
 
 Enchondroma of scapula. A tumour had 
 been removed from the same region seven 
 years before the patient's admission to 
 hospital. 
 
 Four months before admission, patient met 
 with an accident, causing fracture of the 
 ulna a little above its middle, and disloca- 
 tion of the head of radius backwards. Pro- 
 nation and supination were almost impos- 
 sible. Extension could be carrieil slightly 
 beyond a right angle. 
 
 Patient was run over immediately before 
 admission. Left ankle much bruised and 
 distended with effused bloed. 
 
 Rupture of rectus fenioris and crureus in* 
 both thighs, the vasti being still attached 
 to the sides of the patella. No power of 
 extension ; though, if the leg were ex- 
 tended, it could l)e kept so. If it became 
 at all bent, the patient fell. 
 
MR. LISTER'S JOINT CASES. 
 Healthy Joints {continued). 
 
 429 
 
 Treatment 
 
 Both ganglia were removed, the ten- 
 dons being exposed during the opera- 
 tion and held aside. On the right 
 side the wrist-joint was opened, the 
 articular surfaces of the scaphoid and 
 radius beinor seen. 
 
 Thinking that the case was one of ne- 
 crosis, Jlr. Lister cut down and gouged 
 out a portion of the bone. In doing 
 so, he found the interior of the shaft 
 softened, and converted into a sort of 
 granulation material. In fcraping 
 out this matter, the gouge accident- 
 ally passed into the ankle-joint, which 
 was healthy. Chloride of zinc was 
 applied, and a drainage-tube inserted. 
 
 The whole of the scapula below the 
 spine, the spine itself, and about (^ne- 
 third of the glenoid cavity were re- 
 moved, the upper border of the sca- 
 pula and part of the glenoid fossa be- 
 in^ left. 
 
 Jixternal lateral ligament of the elbow- 
 joint divided and head of radius snip- 
 ped off. DraiiiaKC-tubc inserted into 
 joint. Xo stitches. 
 
 Joint incised and clots evacuated. 
 
 The vasti wore detached from the sides 
 of the patella. The upper border of 
 the patella was rawed, and the vasti 
 were stitched to it-r-a V-shaped por- 
 tion being taken out of the rectus and 
 crureus. Couiiter-ojienings made on 
 each side of the joint and drainage- 
 tubes inserted. Only one knee opera- 
 ted on. 
 
 Remarks 
 
 When dismissed to be treated as an out-patient 
 healing was not complete. On June i', the left 
 wrist was found healed; on June 7, the rii^ht 
 had also healed. Left dressed seven times ; 
 right eight. Drainage-tubes removed Mav 20. 
 Typical aseptic course. Movements of fingers 
 and wrist-joints on both sides were perfect. 
 Temperature irregularly taken. Highest tem- 
 perature was 99'5^ F. 
 
 When the patient was discharged, the wound had 
 completely healed. There was no pain, and the 
 ankle-joint was freely movable. No constitu- 
 tional or local disturbance followed the opera- 
 tion. 
 
 A iwrtion of one of the flaps lost its vitality, leav- 
 ing a lar^e deep hole, at the bottom of" which 
 the articular end of the humerus could be seen. 
 This took a long time to fill up, but was com- 
 pletely healed when the patient was discharged. 
 The rest of the wound healed bv first intention. 
 Passive movement was kept up, and when the 
 patient was dismissed, there was good move- 
 ment at the shoulder-joint. (See (^.hart V.) 
 
 He.aling was complete on Deceml)er 8. Dressed 
 six times ; aseptic course. Passive movements 
 were begun on November 18. When dis- 
 charged, the movements in all directions were 
 verj' fair. When seen again in September 1877, 
 all the movements were almos*; absolutely per- 
 fect. 
 
 Aseptic course. On March 10, the wound was 
 quite superficial, and boracic dressing was ap- 
 jiliud. Movements of joint normal. 
 
 Wound went on well for about three weeks, when, 
 owing to the patient pushing his band under 
 (he dressings, the wound putrefied ; l)ut by this 
 time the opening into the joint had dosed, and 
 no harm resulted. When dismissed, the pa- 
 tient could exteml his knee after it had been 
 bent to an angle of 13.5= ; and the other knee 
 being kept c.Nteiided by means of a sjilint, lie 
 could walk withmit fear of falling. (Sec report 
 of case by Dr. Roxburgh in LunccL 1878") 
 (See Chart VI.) ^ 
 
430 
 
 RESULTS OF AXTISEPTIC SURGERY. 
 
 II. — Opkrations on 
 
 Name and Age 
 
 13 
 
 Adam W., 7 
 
 14 
 
 15 
 
 William T., 35 
 (See No. 5.) 
 
 Frauds S., 40 
 
 1(! 
 
 John S., o 
 
 Date of Atimission, 
 Operation, and Dis- 
 charge ; with Result 
 
 Ad., Mav '27, 1877. 
 Op., Julv 6. „ 
 Dis., Auk- 24, „ 
 Result, cured. 
 
 .4(7., July 19, 1877. 
 Op., Julv 25, „ 
 Z>is., Auk. 11, „ 
 Result, cured. 
 
 Ad., Oct. 24, 1877. 
 Op., Oct. 20, „ 
 i>/s.. Jan. 11, 1878. 
 Result, cured. 
 
 Ad., Feb. 6, 1878. 
 Op., Feb. G, „ 
 JJis., Mar. 29, „ 
 .Result, cured. 
 
 Badly united fracture of tlie lower end of the 
 liumor\is, the lower part of the upper frag- 
 ment pmjectiuff backAvards and locking 
 the olecranon, thus causing inability to ex- 
 tend the forearm beyond an angle of 120°. 
 Of some months' standing. 
 
 Return of previous symptoms. 
 
 Transverse fracture of the right patella, pro- 
 duced by striking the bent knee against a 
 bar. Patient was admitted on October 1 2, 
 but insisted on going home, and on being 
 treated by apparatus. As the apparatus 
 did not answer, he now readily consented 
 to the performance of the operation pre- 
 viously proposed. 
 
 Htcmophilia, with elTusion of blood into the 
 right ankle-joint. Stated that he was 
 kicked on the ankle three days before ad- 
 mission. Patient -was suffering great pain 
 and constitutional disturbance. The joint 
 was tense from the presence of fluid, and, 
 as Mr. Lister feared that suppuration 
 might ensue, he incised the joint. 
 
MR. LISTERS JOINT CASES. 
 Healthy Joints (contimted). 
 
 431 
 
 Two longitudinal incisions made on the 
 posterior aspect of the joint : one be- 
 tween the external condyle and the 
 olecranon, the other between the ole- 
 cranon and the ulnar nerve ; these in- 
 cisions, of course, opening the articu- 
 lation. The projecting portion of the 
 humerus was then removed, the at- 
 tachment of the triceps to the olecra- 
 non process bemg left intact, and a 
 hollow was gouged for the reception of 
 the olecranon process. In order to get 
 complete extension, it was necessary 
 to remove the whole of the external 
 condyle ; drainage-tubes inserted. 
 
 Elbow-joint opened ; no loose cartilages 
 found, but a number of bodies at- 
 tached to a fringe of synovial mem- 
 brane were removed. 
 
 A longitudinal incision about three 
 inches in length was made over the 
 patella, when it appeared that the 
 fragments were mutually displaced, 
 and a mass of firm coagulum, mixed 
 with fibrous tissue, interposed between 
 them, so that it would have been im- 
 possible to bring the osseous surfaces 
 into contact except by operative means. 
 This material -was removed, and tlic 
 ends of the fragments were then re- 
 freshed, drilled obliquely and tied to- 
 gether with strong silver wire. An 
 opening was made into the joint on 
 the outer side for the introduction of a 
 horsehair-drain. The wound was 
 clo.scd by stitches, and the limb phiced 
 on a ]iosterior Gooch's splint. 
 
 An incision was made on each .side of 
 the ankle-joint. A qujintity of dark 
 fluid blood escaped. Horsehair-drain 
 passed through the joint. 
 
 Remarks 
 
 The -wounds had quite healed on July 30; 
 dressed six times; typical aseptic course. 
 When discharged, the movements of the elbow- 
 joint were almost abbolutely perfect. fSee 
 Chart VII.) ^ 
 
 Aseptic course. Wound had healed, and the 
 movements were restored when the patient was 
 discharged. (See Chart VIII.) 
 
 The wound had completely healed on November 
 17, except where the wire was. Drain removed 
 from knee on November 4. Incision on outer 
 side of knee healed on November 11. Dressed 
 seven times ; typical aseptic course. Wire was 
 removed on December 21. The splint was left 
 off on January 7. Patella firmly united. There 
 was naturally considerable stiffness of the knee, 
 owing to the limb having lain so long in the 
 splint, but it could be moved with ease through 
 an angle of about 45 deg. Patient would not 
 submit to forcible movement under chloroform, 
 or even to wear an elastic apparatus for gradual 
 flexion. (See Chart IX.) 
 
 Both wounds had healed on March 22. Ha-mor- 
 rhiige occurred from one of the wounds on the 
 morning after the operation, and recurred at 
 intervals during three days, being at length 
 checked by the application of a solution of per- 
 chloride of iron in glycerine. Wounds were 
 quite superlicial on March 12, and l)oracic 
 dressing was therefore applied. No sujipur- 
 ation ; asejitic course. When discharged, 
 there Avas no pain in the joint: the joint was 
 quite movai)le, and the boy was able to run 
 about. Patient was in liospital in September 
 1879, on account of bleeding from his linger; 
 the ankle was then in everv respect q"uile 
 normal. (Sec Chart X.) 
 
432 
 
 RESULTS OF ANTISEPTIC SURGERY. 
 
 II. — Operations on 
 
 No. 
 
 17 
 
 Name aud A.ge 
 
 William B., 45 . 
 
 Date of Admission, 
 Operation, and Dis- 
 charge ; with Result 
 
 ,4rf., March 18,1879. 
 Op., March 20, „ 
 J),s., May 4, „ 
 
 Result, cured. 
 
 18 
 
 Edward W., 12 
 
 Ad., .Tan. .5. 1879. 
 Op., Jan. lb. ,. 
 Dis., June 12, „ 
 Result, in procesa of 
 cure. 
 
 Ununited fracture of the olecranon of nine 
 weeks' standing- Patient could only ini- 
 liertectly extend his furearm. The frac- 
 ture Avas oblique, and, on flexion, there 
 was considerable separation of the frag- 
 ments. 
 
 Badlv united fracture of the lower end of 
 the humerus, with dislocation of both 
 bones of the forearm backward. Accident 
 happened three months before admission. 
 The movementa of the elbow-joiut were 
 very limited. 
 
 19 
 
 James P., 34 
 
 vld.jMarch 19,1879. 
 Op., March 24, „ 
 Dis., April 2.5, „ 
 Result, right cured ; 
 left in statu, quo. 
 
 Loose cartilages in both kuw-joint? 
 
MR. LISTERS JOINT CASES. 
 Healthy Joints (conttnued). 
 
 4:53 
 
 Treatment 
 
 An incision was made on the ulnar side 
 of the postHrior surface of the olecra- 
 non. Ends of fragnients were re- 
 freshed with a chisel and hammer, the 
 joint beini{ of course opened. Fraij- 
 ments were then drilled obliquely and 
 ti'-d tofjether with strong silver wire. 
 Horsehair-drain passed into joini. 
 Wound stitched ; arm placed on a 
 splint in the extended position. 
 
 On the supposition that the case was 
 simplv one of fracture, a longitudinal 
 incisiiiu was made behind the joint, 
 with the intention of excising it ; but 
 the true nature of the ca.se being re- 
 vealed, it was detennined to avoid in- 
 terference with the bones of the fore- 
 arm. A small slice was sawn away 
 from the lower end of the humerus, 
 which was greatly distorted and thick- 
 ened by callus. The lower end of the 
 humerus was then pared and shaped 
 with chisel and gouge, so as to re- 
 semble the natural form of the articu- 
 lar end of the bone, hollows being 
 gouged for the reception of the coro- 
 noid and olecranon processes. The 
 dislocation was then reduced ; drain- 
 age-lubes inserted, and wound stitched. 
 The reason for preferring this opera- 
 tion to complete excision was to avoid 
 the lagging behind in growth of the 
 forearm and hand, which is so apt to 
 occur after that operation in young 
 children. 
 
 Having fixed the cartilage in the right 
 knee. Mr. Lister cut down and re- 
 moved it. Drainage-tube y)ut into 
 joint. Two days afterwards, a free 
 incision was made into the other joint, 
 in search of a very small loose cartil- 
 age, which could not be fixed, but 
 which the patient could generally 
 bring by his own manipuftitions to 
 the spot incised. Protracted mani])u- 
 lations on his own part, carried out 
 under the spray with carbolised liands, 
 failed however to bring the body to 
 the wound; nor could it bcdiscovcrHd, 
 after a long search, with the linger 
 and hooks. 
 
 Remarks 
 
 The wound had entirely healed on April 9, ex- 
 cept where the wire was. Typical aseptic 
 course. Drain and stitches were removed on 
 March 27. Passive motion was begun on 
 March 31 ; wire removed May 11, the union of 
 the fragments b?ing then complete. When 
 discharged, he was able to extend his arm al- 
 most completely. In a letter received from 
 him in October 1878, he stales that his arm is 
 almost as useful as the other, and that he can 
 carry on his trade as a plasterer, which he could 
 not do before the operation. (See Chart XI.) 
 
 Aseptic course. Passive motion was begun on 
 the day after the operation. Pronation and 
 supination were perfect from the first, and al- 
 ways continued so. Owing to the movements, 
 a sore remained over the olecranon till April 
 10, when it had completely healed. Tlie limb 
 was very strong. The movements of extension 
 and fiexion were fair, and were constantlv im- 
 proving when the patient was discharged.* 
 
 Eo'h wounds followed an aseptic course. Drain- 
 age-tultes remove] fr mi eacii the dav after the 
 ojieration. Kight knee healed April 12 ; left 
 knee h.ni li-aled bef.ire the patient left the iios- 
 pital. Mo veil. cuts on both sides unimpaired. 
 
 F F 
 
434 
 
 RESULTS OF ANTISEPTIC SURGEBY. 
 
 II. — Operations on 
 
 Name and Age 
 
 20 
 
 Andrew G., 28 . 
 
 21 
 
 William T., 37 . 
 
 22 
 
 James K., 29 
 
 23 1 .Tosepli R., 24 
 
 Date of Admission, 
 Operation, and Dis- 
 ch irge ; with Result 
 
 Ad., June 6, 1879. 
 Op., June 6, ,, 
 2>is., July 11, „ 
 Result, cured. 
 
 Disease 
 
 Ad., Dec. 13, 1879. 
 Op., Dec. 15, „ 
 Dis., Feb. 15, 18S0. 
 Benult, cured. 
 
 Ad., April 10, 1880. 
 Op., April 12, „ 
 Dis., Sep. 25, „ 
 Result, stiff knee. 
 
 Ad., Sep. 27, 1880. 
 Op., Oct. 22, „ 
 (See No. 25). 
 
 Patient was a medical man. He had suffered 
 from bunion, beside the metatarso-phalan- 
 f^eal joint of the great toe of the right foot, 
 for 14 years. Pads, etc., had been used, 
 but without effect. Patient was unable to 
 walk even short distances without great 
 pain, and he could not enter on the prac 
 tice for which his medical education had 
 now qualified him. 
 
 Recent simple transverse fracture of the 
 patella. The accident happened on Dec. 9. 
 
 Loose cartilage in the left knee joint. 
 
 I 
 
 Ununited fracture of the patella of several 
 months standing. Upper fragment pretty 
 firmly adherent to the anterior surface of 
 the femur. Lower fragment very small 
 Patient cannot walk at all. 
 
MB. LISTERS JOINT CASE'S. 
 Healthy Joints {continued). 
 
 435 
 
 Treatment 
 
 Mr. Lister made a loii<ritudinal incision 
 over the inner side of the joint on the 
 dorsal nspeet. Tlie joint was opened, 
 and the projecting inner end of the ex- 
 tremity of the metatarsal bone cut off. 
 The remainder of the joint left intact. 
 Drainage-tube inserted ; no stitches. 
 
 See description of operation, p. 420. 
 
 The cartilage was removed by a free in- 
 cision, and a drainage-tube was in- 
 serted into the joint. 
 
 Longitudinal incision over the front of 
 the joint, tipper fnigment detached 
 from the femur. Ends of fragments 
 refreshed and tied together with silver 
 wire. Drainage as in the former 
 cases. 
 
 Remarks 
 
 Aseptic course. Wound was quite healed on 
 July 9. When discharged, the joint was quite 
 movable and the swelling from thickening of 
 the soft parts much less. In a note received 
 from him on September 16, 1879, patient 
 Avrites: 'The prominence on the inner side of 
 the foot has entirely disappeared, and I have 
 perfect use of the joint, with entire absence of 
 pain. I can walk ten miles without any in- 
 convenience,' (See Chart XIL) 
 
 Typical course. See p. 420. When the patient 
 was discharged the movements of the knee- 
 joint were perfect through an angle of 45°, and 
 were daily improving. Patient could kick 
 vigorously. (See Chart XIIL) 
 
 On the evening of the day of the operation the 
 knee was very painful, and there was so much 
 discharge that it was necessarv to change the 
 small dressing which had been applied at the 
 time of the operation. On the following morn- 
 ing the temper.iture w,is up to 102-8^F., the 
 knee was swollen and verv painful, and' the 
 dressings were saturated with discharge. There 
 was a blush of redness around the wound. The 
 discharge had no smell. This state of matters 
 got worse, the temperature went still high3r. 
 and for several days varied between 101° and 
 103-6°. The discharge from the joint became 
 purulent and an incision was made on the outer 
 i-iile of the patella into the joint. An abscess 
 formed in the thigh, and was opened. During 
 May matters began to improve, and gradually 
 the discharge diminislied and the various 
 wounds closed. All had healed on September 
 25. The knee was almost stiff, but it was 
 possible to get slight movement (fibrous anchy- 
 losis). The patient was advised to return in a 
 month to have the adhesions broken down, but 
 he did not do so. (See Chart XV.) 
 
 Aseptic course. Stitches removed on October 25. 
 The wounds h-id completely healed on November 
 4. On November 20 the patient wa.s put under 
 chloroform, and an attemjit made to bend the 
 limb. The upjier fragment had, however 
 again become adherent to the femur, and in 
 attempting to bend the limb the wire broke, 
 and the fragments became separated. The case 
 was re-opcr.ited on on November 26 (see No. 25) 
 (See Chart X I V.) ^ ^■ 
 
 F F 2 
 
436 
 
 RESULTS OF ANTISEPTIC SURGERY. 
 
 II. Operations on 
 
 Name and Age 
 
 24 
 
 Martha F., 43 
 
 '25 
 
 Joseph R., 24 
 
 26 
 
 Date of Admission, 
 Operation, and Dis- 
 charge ; with result 
 
 William G., 62. 
 
 Ad., Nov. 5, 1880. 
 Op., Nov. 12, „ 
 Result, cured. 
 
 See No. 23. 
 Oo., Nov. 2G, 1880. 
 Bis., Feb. 5, 1881. 
 Result, cured. 
 
 Ad., June 21, 1881. 
 Op., June 24, 1881. 
 IJis., Aug. 11, 1881. 
 Result, cured. 
 
 Fracture of patella of eight weeks' standing. 
 Patisnt walks with great difficulty and 
 with the aid of sticks. 
 
 See No. 23. Refractured patella. 
 
 Recent fracture of patella, 
 pened on June 21. 
 
 Accident hap- 
 
MR. LISTERS JOINT CASES. 
 Healthy Joints {continued). 
 
 437 
 
 Operation 
 
 Operated on in the same manner as the 
 , others A drainage-tube used for the 
 joint instead of a horse-hair drain. 
 
 Re-operated on as before. No drainage 
 of the joint was necessary. Wound 
 left open in part. 
 
 Treated like No, 21. 
 
 Eemarks 
 
 Aseptic course. No pain, inflammation or con- 
 stitutional disturbance. Drainage-tubes re- 
 moved November 16. Almost healed on Novem- 
 ber 22. Quite healed on November 27. Seen 
 on May 31, 1881. Could then walk comfortably 
 without a stick, could raise the leg from the bed 
 and flex the knee, but the flexion could not be 
 carried quite to a right angle, (See Chart 
 XVI.) 
 
 Aseptic course. On December 8 everything had 
 healed except a small part of the gaping inci- 
 sion where blood-clot filled the wound. On 
 scraping away the superficial laj'er of this clot, 
 cicatrisation was found to have advanced con- 
 siderably beneath it. Seen in April 1881 ; could 
 walk comfortably with a stick. Could not raise 
 leg from bed, but was able to bring it forward 
 in walking. Flexion gradually improving. 
 Union of fragments good ; no separation. (See 
 Chart XVII.) 
 
 Aseptic course. On the morning of the 24th (be- 
 fore the operation) the temperature was 100-2O 
 in the evening 100-6°. On the 25th T. M. 100°, 
 E. 100° ; dressed. 26th, T. M. 100-2° E., 98-6°; 
 dressed. The drain was not acting very well, 
 which probably accounts for the continued 
 elevation of temperature on the 25th ; as soon 
 as that was put rig-ht the T. fell. On the 27th 
 T. M. 99-4°, E. 100-4°. On the 28th T. M. 99-8, 
 E. 99-G. On the 29th tube left out. Dressed 
 again on July 6. Almost entirely healed and 
 spray stopped on July 9. A minute spot un- 
 healed on July 15. The temperature after the 
 28th ranged between 98-8° and 99-8°. Passive 
 motion could be readily performed without any 
 pain. 
 
Tejji'kkatuke Chakts of Mk. lisTKKs Cash 
 
TITT 
 
 _Z7F 
 
 JO" 
 
 Y\'l 
 
 'XV n 
 
 w-tmmtmvmvm\m.y;mam\-mr\wm.vmkiM 
 
 fcWyi,^J:*a.W.M.l:Hl 
 
 !■■■■■■! 
 
 F WOUNUS or, ANIJ Ol'EKATIONS ON, JoiM'S. 
 
 '-'■■■■■■■■■■I 
 
 ■■■■■■■■■■■ 
 
 ■■■■■■■■na 
 
 ...JHflHBHaHm 
 
440 RESULTS OF ANTISEPTIC SURGERY. 
 
 The result, then, is that Mr. Lister has since the end of 
 1871 treated conservatively in hospital 40 cases of injuries of 
 healthy joints without a death, and in only one case (wounds 
 of joints, No. 3), was there any necessity for further operation. 
 This was a case of wound of joint not made by the surgeon. 
 In only one case in which the joint was opened by Mr. Lister 
 did suppuration occur (No. 22), and here, as I shall presently 
 shew, the aseptic method had been imperfectly carried out. 
 
 It has been objected to these cases by Mr. Bryant,' that an 
 equally good series of cases might be found in the case-books 
 of any hospital. It may indeed be that in some instances 
 equally good results have been obtained, but I venture to affirm 
 that no hospital case-book, recording cases not treated asepti- 
 cally, would show that all the cases treated in succession had 
 like results. It is as an integral record of a number of cases 
 in succession rather than as a record of each individual case 
 that these facts are important. There will no doubt be found 
 throughout the journals isolated examples of remarkable 
 results after injuries of joints, but then only the successful 
 cases are published ; we do not have a record of all the cases 
 in the practice of a particular surgeon ; we do not hear of the 
 many cases where failure occurred, or where conservative treat- 
 ment was not attempted. Then, again, the cases ordinarily re • 
 corded in journals have not been treated in the same way as Mr. 
 Lister's. For Mr. Lister not only makes an incision into a 
 joint, but he purposely keeps the communication open for some 
 days by means of a drainage tube, and he does not syringe out 
 the joint with any antiseptic solution. I do not believe that 
 such a thing could be done with a poultice or other septic 
 dressing without the occurrence of suppuration in the joint, 
 and yet among JNIr. Lister's 26 operation cases this only hap- 
 pened in one instance, and in it, as I shall presently point 
 out, we have complete evidence that the requirements of the 
 method had not been efficiently complied with. 
 
 jNIr. Bryant also expressed his astonishment that IMr. Lister 
 should regard the removal of foreign bodies from joints as a 
 perfectly safe procedure on the evidence of 3 cases. But then 
 it must be remembered that every case in which a joint was 
 
 ' MacCormac's Antiseptic Surgery. 
 
MP. BRYANT'S OBJECTIONS TO THESE CASES. 441 
 
 incised, for whatever purpose, proves the assertion that they 
 may be opened for the removal of foreign bodies, and so at 
 the time when Mr. Bryant spoke the evidence rested, not on 
 3 published cases, but on 20 cases of operations and 12 cases 
 of accidental wounds, i.e., not on 3 but on 32 cases. And in 
 reality it rested on many more, for this record only represents 
 Mr. Lister's practice since the end of 1871. For five years 
 previously Mr. Lister had been operating on joints in hospital 
 with success, and the details of some of these cases have been 
 published. And in private practice, also, during all these 
 years Mr. Lister has performed a number of operations on 
 healthy joints. Further, during the same time, many of Mr. 
 Lister's pupils had performed similar operations with similar 
 successes. Thus the evidence in support of INIr. leister's 
 statement is sufficiently ample to justify it. 
 
 It was further stated by Mr. Bryant, that a number of these 
 cases were too trivial to be of value, but I venture to doubt the 
 force of this argument. For I do not suppose that an incision 
 into a car]>al articulation will be regarded as a very trivial matter, 
 and we have in the list only 3 cases where small joints were 
 opened. ■ But I do not regard wounds of phalangeal joints as 
 such a very trivial injury after all. The cases of compound 
 dislocation of the phalanges which I have seen treated conser- 
 vatively but septically have almost all died. It may be that 
 I have had an unlucky experience, but I have seen that ampu- 
 tation is in the great majority of cases performed for these 
 injuries, and that where they are treated conservatively and 
 without aseptic precautions a great risk is run. The only case 
 of wound of a small joint not treated aseptically which has 
 occurred to my knowledge at King's College Hospital during 
 the last four years died of tetanus. 
 
 In speaking of ovariotomy I have said that it was not a test 
 case, because the peritoneum absorbs fluid so quickly that the 
 bacteria, if admitted, have no fluid in which they can develop ; 
 and 1 also added that the test case would be where there was 
 •ascites as well as an ovarian tumour, where, therefore, there 
 was fluid in which organisms may devclo]). Such cases have 
 always been regarded as particularly unfavourable for o})eratiou, 
 
4J2 RESULTS OF ANTISEPTIC SURGERY. 
 
 though surgeons do not as a rule seem to have understood the 
 reason of this. A corresponding condition may be got in the 
 case of joints, more especially in the knee joint in hydrops 
 articuli. The ordinary practice in such cases, if they refuse 
 to yield to the ordinary methods, is to remove the fluid by as- 
 piration. That practice has been found to be perfectly safe ; 
 it is a subcutaneous, in fact an aseptic, operation. In Edinburgh 
 in 2 cases of this kind (chronic synovitis), Mr. Lister made in- 
 cisions into the joints and introduced a drainage tube. In 
 neither case was there the slightest bad result. In the first 
 case the drainage tube was removed on the fourteenth day, and 
 the wound healed a few days later. In the second case the 
 drainage tube was kept in a few days longer, and the wound 
 had completely healed in five weeks. In both instances the 
 disease was cured ; in both the movements of the joint were 
 perfect ; in neither was there any suppuration, inflammation 
 or constitutional disturbance. In King's College Hospital Mr. 
 Lister has made incisions in 3 cases of acute synovitis verging 
 on suppuration, and in all cases with cure without suppuration. 
 In these cases the knee-joint was affected. In 2 the move- 
 ments were good when the patient left the hospital. In the 
 other movement is perfect, but the leg is kept in a silicate 
 apparatus, as the ligaments have not yet regained their firm- 
 ness, and the limb is apt to become over extended. (In this 
 instance the inflammation was much more extensive, affecting 
 the adjacent portions of the tibia and fenmr and producing 
 softening of the ligaments.) 
 
 Then I must mention, that Mr. Lister's practice in cases of 
 synovial disease of joints where the disease progresses in spite 
 of rest, counter-irritants, &c., is to make free incisions into the 
 joints, and introduce drainage tubes into them. This is done 
 at once, without waiting for the formation of abscesses, in 
 cases where the disease is progressing. In 16 cases so treated 
 since 1871 no pus was present, and of these 16 cases 11, or 
 68*7 per cent., were cured without any further treatment (ex- 
 cision or amputation), and there never was any suppuration 
 from the joint. In several of the cases considerable move- 
 ment was obtained. 
 
 The cases were : — 
 
12^ VISIONS INTO DISEASED JOINTS. 443 
 
 8 incisions into the knee-joint — no pus — 7 cured without further operation 
 4 „ „ tarsus „ 2 „ „ 
 
 2 „ „ elbow „ 2 „ „ 
 
 2 „ „ wrist „ „ „ 
 
 None of the cases died. 
 
 Then, as I have said, where suppuration has occurred, the 
 joint is also, in the first instance, simply incised and a drainage 
 tube inserted ; if necessary, further measures can be resorted 
 to afterwards. Of 48 abscesses of joints so treated 27, or 56*3 
 per cent., were cured without further operation ; and in these 
 there was no more formation of pus after the incision. 
 
 These cases comprised : — 
 
 1J» abscesses of the hip-joint— 13 cures without further operation — 1 death 
 
 1 „ 
 1 .. 
 
 11 » 
 
 )> 
 
 knee 
 
 5 
 
 6 
 
 »> 
 
 tarsus 
 
 3 
 
 2 „ 
 
 » 
 
 shoulder 
 
 1 
 
 o ,, 
 
 >» 
 
 elbow 
 
 1 
 
 7 
 
 „ 
 
 wrist 
 
 4 
 
 There were three deaths, all of them from tubercular 
 meningitis, confirmed on post-mortem examination. One other 
 case not included here must be mentioned. A patient, a little 
 child, was admitted into King's College Hospital with pyaemia 
 after scarlet fever. Abscesses were present in various joints, 
 and as they were causing him considerable pain, they were 
 opened. The child died two days later. 
 
 Thus, taking all the cases together, we have 109 instances 
 where joints, healthy or more or less diseased, were opened 
 and drainage tubes inserted ; and of these 109 cases only 3 died, 
 the cause of death in each instance being quite independent of 
 the method of treatment adopted. 
 
 Leaving Mr. Lister's practice we find records of a number 
 of wounds of joints in the practice of other surgeons. 
 
 Volkmann, in his first report, mentions the occurrence of 
 7 wounds of joints and 2 incisions into joints for loose carti- 
 lages without a death. In his last report he adds 24 cases of 
 penetrating wounds of joints making in all 33 cases, distributed 
 as follows, without a death. 
 
444 RESULTS OF ANTISEPTIC SURGERY. 
 
 Cases Deaths 
 
 Knee 15 
 
 Wrist 8 
 
 Elbow 5 
 
 Foot 5 
 
 No details of these cases are given, and we do not therefore 
 know whether any further operative interference was necessary. 
 
 In his paper on compound fractures,^ Volkmann adds the 
 fact that 21 compound fractures passing into joints were 
 treated without a death. With regard to these last 21 cases, 
 we have some further particulars. In 2 instances resection 
 was at once performed ; in 5 resection was performed 
 secondarily ; in 3 amputation was performed secondarily ; in 
 10 there was perfect recovery with freely movable joints ; and 
 in 1 case there was recovery with anchylosis, but the treatment 
 was not commenced in this instance till thirteen days after the 
 injury, and the joint was then already suppurating. In all 
 these cases there was extensive injury of the bones as well as 
 wound of the joint. In 3 cases the secondary operation 
 was performed because the patient was not admitted for some 
 time after the injury, and the joints were already suppurating ; 
 in one case the supervention of gangrene rendered it necessary, 
 and in the other cases the nature of the wound, malposition of 
 the fragments or suppuration of the joint, required it. Of 
 course in considering cases of luounds of joints it must always 
 be remembered, that one can never be certain that all the 
 causes of putrefaction already present have been destroyed, and 
 therefore, the probable result is very different from, i.e. much 
 more uncertain than, that where the surgeon makes the wounds 
 himself, and where, therefore, he has merely to exclude these 
 causes. This is well illustrated in the case of compound 
 fractures. 
 
 Max Schede, in his work on amputations, states that he has 
 treated 15 cases of compound fracture in which joints were 
 opened. Of these 10 were treated conservatively and healed, 
 in 9 instances (5 of elbow, 2 of hand, and 2 of foot) with 
 movable joints, in 1 with anchylosis, where the case was not 
 admitted for some time, and where there was extensive com- 
 
 ' ' Diu Behandlung der complicirten Fracturen,' Yolhmaiiiis Sanimlung, 
 Nos. 117-118. 
 
RESULTS OF VOLKMANN AND SCHEDE. 445 
 
 minution of the tibia, numerous portions of which necrosed. 
 In 2 cases amputation was necessary on account of gangrene ; 
 in 1 case, which was not admitted till ten days after the 
 injury, secondary amputation was performed; in 1 case of elbow 
 injury a partial secondary resection was necessary, and in 1 
 case death occurred from trismus, the patient not having been 
 admitted till the thirteenth day after the injury, when the 
 joint was already suppurating. 
 
 Taken together with Volkmann's 54 cases we have 69 cases 
 with 1 death. With Mr. Lister's 40 cases we have a total of 
 109 cases of injuries to or operations on healthy joints with 1 
 death, a death which ought not to be reckoned at all, for the 
 patient was not treated aseptically from the beginning. 
 
 Both Volkmann and Schede mix up the cases in which 
 treatment was commenced at once with those in which the 
 patient was not admitted for some days after the injm-y, and 
 where the joint was already suppurating. If we separate 
 these cases from the 36 instances of compound fractures with 
 wounds of joints, of which we have details, we find that 28 
 came under treatment within forty-eight hours after the 
 occurrence of the accident, and of these 19 recovered with 
 movable joints ; in 2 cases primary and in 4 cases secondary 
 resection was necessary, and in 3 secondary amputation was 
 performed (twice for gangrene). On the other hand, of the 
 8 cases which did not come under treatment till forty-eight 
 hours or more had elapsed, none recovered with movable 
 joints, 2 recovered with stift' joints, 4 required secondary re- 
 section, 1 secondary amputation, and 1 died of tetanus. Of 
 course in judging of the effects of the aseptic or other method 
 of treatment in preventing the bad effects liable to follow 
 wounds of joints, the latter class of cases, where treatment is 
 not commenced for several days, ought to be excluded. 
 
 Paul Earth ' published in 1877 the results of the cases of 
 wounds of the knee-joint which had been treated in the hospital 
 at Basel since 1873. They were 10 in number. Of these 9 
 recovered with movable knee-joints and one died of exhaustion. 
 The latter was a case of compound fracture of the patella along 
 
 ' Ein Beitrarf zur Behandhmg der pcrforirenden Wunden des Knicgclvniis, 
 by Paul Barth, Basel, 1877. 
 
440 HESULTS OF ANTISEPTIC SURGERY. 
 
 with injury to the right side of the head and fracture of the 
 lower ends of both radii ; the result of a fall from the first floor 
 of a house to the street. For four days things seemed to 
 be going on well, and then the patient began to complain of 
 pain in the knee. The wound on the forehead began to sup- 
 purate, and the bone became bare. The patella also necrosed. 
 An abscess formed in the thigh, and the pus had a foul smell. 
 The patient sank, exhausted from the prolonged suppurations, 
 about six months after the injury. In this case purification 
 had not in all probability been successful in the first instance. 
 Among these 10 cases we have 6 which were seen soon after 
 the injury : the other 4 having come under treatment several 
 days later when suppuration was commencing, or had already 
 begun. The success in purifying the wounds in these 4 cases is 
 remarkable ; they all recovered with movable joints. In puri- 
 fying them, the wound was swabbed out with chloride of zinc, 
 and then irrigated with strong carbolic lotion, several counter- 
 openings being also made. The successful disinfection in these 
 cases was a piece of luck, for one can by no means reckon on 
 anything like such a result. 
 
 Saxtorph of Copenhagen has published the results of his 
 aseptic practice in removing foreign bodies from joints by free 
 incision.' He has had 12 cases, 11 being cured and one end- 
 ing fatally. In this case the patient took off the antiseptic 
 dressing, suppuration ensued, and the patient died. 
 
 Piechaud ^ has collected a number of cases of incisions into 
 joints. He gives 4 cases of hydrarthrosis of the knee-joint 
 which were treated by free incisions and aseptic drainage. 
 They were operated on by Panas, Poinsot, Saxtorph and Lind- 
 paintner. In 3 of the cases there was perfect cure with 
 free movement of the joint. In the fourth case, in a strumous 
 subject, there was some fear that synovial disease was going to 
 develop, and therefore the patient was discharged wearing a 
 silicate apparatus with which he could walk about without pain. 
 
 Piechaud mentions 3 cases of dislocation of the thumb 
 where, in order to reduce the dislocation, free incisions were 
 
 ' Clinique Chirurgicale. 
 
 * De la potiction et de Vincision dans les maladies articidaires. Par le Dr. 
 T. Piechaud, Paris, 1880. 
 
NUSSBAUM: ALBERT: HUETER : LETIEVANT. 447 
 
 made into the joint. All recovered with retention of the 
 normal movements. In a fourth case, the finger, which was 
 otherwise much injured, became inflamed, and amputation was 
 performed on the following day. Piechaud also states, that in 
 the course of the year he had seen in M. Labbe's clinique at 
 the Lariboisiere several similar cases where wounds of the 
 phalangeal joints healed by first intention when treated 
 aseptically. 
 
 Professor Nussbaum,' states in his work on aseptic treatment, 
 that * this method opens up a new field to surgeons. By the 
 aid of these precautions, joints and the cavities of the body may 
 be opened without danger.' This is his experience in an un- 
 healthy hospital. 
 
 Professor Albert ^ of Innsbruck says ; ' Die operative ErofF- 
 nung seroser und synovialer Hohlraumen die bei oflfener Wund- 
 behandlung regelmassig zur Eiterung fiihrt, fiihrt unter Lister 
 nicht zur Eiterung. Man kann Hydrocelen, Cxelenke, Schleim- 
 beutel ohne Gefahr eroffnen.' 
 
 Professor Hueter of Grreifswald says ; ' it is with reason that 
 I said in 1870 that puncture of joints ought to he considered 
 as a dangerous operation ; it is with as much reason that I now 
 affirm (1876) that one can practice this operation without 
 danger. I based my first opinion on the septic accidents con- 
 secutive to the inflammation.' 
 
 M. Letievant of Lyons also says : ^ ' Des tentatives operatoires 
 nouvelles, tres-graves, devant lesquelles on pouvait hesiter, ont 
 pu etre mises en application, et si je n'avais eu la securite que 
 me donnent mes statisques et une pratique deja longue du 
 pansement listerien, je n'aurais jamais ose ouvrir largement des 
 grandes articulations, les luxer pour les nettoyer, remettre les 
 OS en place, drainer et conduire la plaie a guerison.' 
 
 Kraske gives details of all the gunshot injuries of joints 
 treated at Halle aseptically.'* They were 4 in number, and, in 
 all the cases, the knee was the joint involved. In one case 
 the movement was perfect, healing having taken place without 
 
 ' Le pansement antiscptique, 1880, 
 
 ^ Lehrbuch der CJiirurgie, Wien, 1877. 
 
 ' Note sur le Panscjiirnt antiKcptiquf Listerien. Lyon, 1880. 
 
 * Ji?.ngenbeck's Arr/rir, vol. xxiv. 
 
448 RESULTS OF ANTISEPTIC SURGERY. 
 
 the occurrence of suppuration. In a second it was not abso- 
 lutely perfect, but it was almost right, and was improving ; na 
 suppuration. In a third the movements were good as far as 
 a right angle, when the patient left the hospital. In the 
 fourth case the patella was very much broken up by the bullet 
 and portions of the bone afterwards exfoliated. The wound had 
 quite healed in two months. When the patient was discharged 
 about two and a half months after the accident, the patella 
 was freely movable and the joint could be moved by the sur- 
 geon to an angle of 150°. The patient did not return to have 
 the passive motion kept up, and when seen a year after the 
 accident, the joint was anchylosed. 
 
 I have already alluded to the remarkable results obtained 
 by Dr. Carl Eeyher ^ during the recent Kusso-Turkish war, and 
 I must now mention in detail these results in cases where 
 joints were injured. 
 
 Reyher divides the cases treated into * Primary antiseptic 
 cases,' ' Secondary antiseptic cases,' and ' Non-antiseptic cases.' 
 By ' Primary antiseptic ' cases he means those which were 
 treated aseptically from the very first, and which had not been 
 examined beforehand with dirty fingers or instruments, or 
 treated in any way. In these cases Reyher either washed out the 
 wound with an antiseptic solution, removed any foreign bodies 
 present, drained and treated aseptically, or he did not wash 
 out the wound at all, but simply contented himself with purify- 
 ing the exterior and applying an antiseptic dressing. In the 
 latter cases he trusted to Esmarch's idea that the bullet would 
 not carry dust into the interior of the wound. The former 
 practice was adopted where the wound was gaping, and where 
 there was a suspicion that portions of clothing, &c. had been 
 carried in with the bullet ; the latter practice, where the edges 
 of the skin were lying together, and where it was thought that 
 the bullet had not carried any extraneous matters with it. By 
 * Secondary antiseptic ' cases he means those which had been 
 examined or treated in some way opposed to aseptic principles 
 before coming into his hands. In a few cases suppuration had 
 already commenced. He tried to purify these wounds by washing 
 them out with carbolic lotion, but the attempt was seldom 
 ' Volkmann's ,S:r/ww/«/(./7, Nos. H2-14:?, 1878. 
 
GUNSHOT WOUNDS OF JOINTS. 449 
 
 successful. They are, therefore, as I have ah'eady pointed out, 
 cases treated with antiseptics, not aseptically. The ' Non- 
 antiseptic cases ' were treated either with dry dressing, or with 
 some watery or oil}' application containing an antiseptic. 
 
 Eeyher demonstrates completely that all the cases which 
 he mentions were perfectly comparable injuries, and that the 
 results must therefore be due to the different ways in which 
 the patients were treated. Every case, with the exception of 
 very severe wounds caused by shell, was treated at the be- 
 ginning conservatively. 
 
 Forty-six cases were treated by 'primary antiseptics,' and 
 of these 6, or 13 per cent., died. With regard to these 46 
 cases, however, primary resection was performed in 19, and of 
 these 2 died, leaving 27 cases treated conservatively with 4 
 deaths, or a mortality of 14*8 per cent. The following wer3 
 the joints which were injured : — 
 
 Shoulder 
 
 Tutal 
 1 
 
 Uealcil 
 1 
 
 Died 
 
 
 Pcrcentacre 
 
 mortality 
 
 
 
 Elbow . 
 
 2 
 
 2 
 
 
 
 — 
 
 Jlip 
 
 1 
 
 
 
 1 
 
 100 I), c 
 
 Knee 
 
 . 18 
 
 15 
 
 8 
 
 16-6 „ 
 
 Foot 
 
 5 
 
 
 
 
 
 
 
 Total . 21 28 4 11 8 .. 
 
 Eighteen of these cases were treated without washing out 
 the wound ; in 9 the wound was washed out and drained. In 
 none of the 27 was resection or amputation necessary. 
 
 The causes of death in the 4 fatal cases were as follows : — 
 In the injury of the hip-joint acute infl:uiiniation and septic 
 suppuration occurred : here it was found that the bullet had 
 carried in a portion of the clothing. One case of knee-joint 
 injury died fr(jm fatty embolism within twenty-four hours. One 
 knee-joint case died on the fifth day from htcmorrhage from 
 the divided popliteal artery and vein. The fourth case had 
 not died when the rei)ort was issued, but a fatal result was 
 considered certain from hectic fever and diffuse sup])uration ; 
 I have therefore included it among the fatal cases. 
 
 Seventy-eight cases were treated by 'secondary antiseptics,' 
 and of these 48, or 61'5 per cent., died. Of the remaining 30 
 cases, only 8 ultimately retained their limbs, secondary resec- 
 
 G o 
 
450 
 
 RESULTS OF ANTISEPTIC SURGERY. 
 
 tion being necessary in 15 cases, and secondary amputation 
 
 
 Total 
 
 Lived 
 
 Died 
 
 Shoulder- joint 
 
 7 
 
 4 
 
 3 
 
 Elbow . 
 
 . 11 
 
 8 
 
 3 
 
 Hand . 
 
 5 
 
 4 
 
 1 
 
 Hip . 
 
 4 
 
 
 
 4 
 
 Knee . 
 
 . 40 
 
 6 
 
 34 
 
 Ankle . 
 
 6 
 
 4 
 
 2 
 
 Tarsus . 
 
 5 
 
 4 
 
 1 
 
 Total 
 
 78 
 
 30 
 
 48 
 
 Percentage 
 mortality 
 
 42-8 p. c. 
 
 27-2 
 
 20 
 
 100 „ 
 
 85 
 
 33-3 „ 
 
 20 
 
 61-5 „ 
 
 The causes of death were in 17 cases pyemia ; in 16, septic 
 inflammations ; in 4, very acute suppuration of the joint ; in 
 9, hectic ; in 1, carbolic acid poisoning; and in 1 there was 
 jaundice. 
 
 Contrasted with these two sets of cases, there were 62 where 
 no antiseptic precautions were taken. Of these 39, or 62*9 per 
 cent., had died when the first report was issued, but in the 
 Appendix we are told that 9 more had died, the mortality being 
 thus raised to 77-4 per cent. The causes of death in the 39 
 cases were, in 23, from pysemia ; in 6, from septic inflamma- 
 tions ; in 6, from hectic ; and in 1 the cause was unknown. 
 
 The joints involved were (first report) : — 
 
 
 Total 
 
 Healed 
 
 Shoulder . 
 
 7 
 
 
 
 Elbow 
 
 11 
 
 
 
 Wrist 
 
 G 
 
 1 
 
 Hip . 
 
 4 
 
 
 
 Knee 
 
 23 
 
 1 
 
 Ankle 
 
 11 
 
 1 
 
 Total . 
 
 62 
 
 3 
 
 Under 
 treatment 
 
 Died 
 
 Percentage 
 mortalitj 
 
 4 
 
 3 
 
 42-8 p. 
 
 5 
 
 6 
 
 54-5 „ 
 
 3 
 
 2 
 
 33-3 „ 
 
 1 
 
 3 
 
 75 
 
 4 
 
 18 
 
 78-2 „ 
 
 3 
 
 7 
 
 63fi „ 
 
 20 
 
 39 
 
 02-!) 
 
 The amended table a montli or two later would probably 
 
 be 
 
 
 Total 
 
 Healed 
 
 Under 
 treatment 
 
 Died 
 
 Percentafje 
 mortality 
 
 Shoulder . 
 
 7 
 
 
 
 3 
 
 4 
 
 57-1 p. c. 
 
 Elbow 
 
 11 
 
 
 
 5 
 
 6 
 
 54-5 „ 
 
 Wrist 
 
 (; 
 
 1 
 
 3 
 
 2 
 
 33-3 „ 
 
 Hip . 
 
 4 
 
 
 
 
 
 4 
 
 100 
 
 Knee 
 
 23 
 
 1 
 
 () 
 
 22 
 
 l)o-6 „ 
 
 Ankle 
 
 11 
 
 ] 
 
 1 
 
 !) 
 
 81-7 „ 
 
 Total . 
 
 «2 
 
 3 
 
 12 
 
 47 
 
 7.V8 .. 
 
GUNSHOT WOUNDS OF JOINTS. 
 
 4ol 
 
 One additional case died, but I do not know what joint was 
 injured. The number of limbs treated ultimately conserva- 
 tively is not mentioned. 
 
 A similar result is obtained if similar injuries are compared. 
 Thus take the wounds of the knee-joint ; and first the cases in 
 which the bullet became embedded in the bones and in which 
 conservative treatment was tried. 
 
 
 Treated conserva- 
 tively to eiirl 
 
 Intermediate 
 amputation 
 
 Secondary 
 amputation 
 
 
 2 
 > 
 8 
 
 s 
 
 o 
 H 
 
 > 
 o 
 
 S 
 
 
 > 
 
 o 
 o 
 
 o 
 
 ri 
 S 
 
 4 
 5 
 
 o 
 
 5 
 5 
 
 "3 
 o 
 H 
 
 4 
 
 15 
 9 
 
 t'a 
 
 - o 
 
 9H-3 
 100 
 
 Primary antiseptic . 
 Secondary antiseptic 
 Non-antiseptic . 
 
 4 
 
 
 
 
 8 
 4 
 
 4 
 8 
 4 
 
 
 
 2 
 
 2 
 
 1 
 
 
 
 These facts are surely striking enough. Out of 28 cases 
 of wound of the knee-joint where the bullet became embedded 
 in the bones only 5 lived, and of these four were treated asep- 
 tically and retained their limbs. One case recovered which was 
 treated with ' secondary antiseptics,' but only after secondary 
 amputation. 
 
 The results are equally striking if we take all the cases of 
 wound of the knee-joint. 
 
 Primary ~|^ 
 antiseptic / 
 Secondary "\ 
 antiseptic / 
 Non-anti- i 
 septic J 
 
 Treated 
 conserva- 
 tively to 
 the end 
 
 Secondary 
 resection 
 
 Interme- 
 diate ampu- 
 tation 
 
 Secondary 
 amputation 
 
 Total 
 
 Recovered 
 
 6 
 
 (5 
 
 3 
 
 18 
 6» 
 
 o 
 I 
 
 s 
 1 
 
 6 
 'A 
 
 9 
 
 S 
 7 
 
 d 
 
 12 
 13 
 
 s 
 
 6 
 'A 
 
 % 
 5 
 
 so k? 
 
 a « 
 S o 
 
 lfi-6 
 
 sr,- 
 78-2 
 
 -23 
 c « 
 
 ■ s 
 
 15 
 
 'S tn 
 
 18 
 
 19 
 
 9 
 
 9 
 11 
 
 18 
 40 
 23 
 
 3 
 31 
 18 
 
 1 
 
 * II.-ul did ;i( time of report. 
 
 (The last line must be amended, for ultimately only 1 of 
 
 (1 a 2 
 
452 RESULTS OF ANTISEPTIC SURGERY. 
 
 these 23 non-antiseptic cases lived. Hence the percentage 
 mortality was 95 '6. ) 
 
 Thus, of 18 aseptic cases 15 recovered, all with movable 
 joints. The causes of death in the 3 aseptic cases are given 
 on p. 449. 
 
 Of 63 cases treated otherwise, 7 recovered (5 after amputation, 
 1 with a stiff knee, and in 1,1 think, the knee was movable). 
 
 These results are surely convincing. Keyher truly remarks, 
 ' Das scheint mir eben das Bemerkenswerthe zu sein ! Nicht 
 dass Knieschiisse conservativ heilten, sondern dass von 18 
 Knieschiissen welche mir ohne Auswahl auf dem Verbandplatz 
 zugingen und welche an Schwere der Verletzung den andern 
 nicht nachstehen, ein so grosser Procentsatz, uamlich 83*3 pro 
 cent, mit Erhaltung und Beweglichkeit des Gelenkes geheilt 
 ist.' 
 
 Bergmann ^ also got some remarkable results by a smihir 
 method of treatment during the same war. When the wound 
 was valvular he did not wash it out at all, but simply purified 
 the exterior and applied an aseptic dressing. ' After the 
 storming of Telisch and Gorni-Dubnik 15 cases of compound 
 fracture of the knee-joint came under treatment, mere injury 
 of the capsule being excluded from the list. Of these 14 re- 
 covered, 2 after amputation, and 1 died, also after amputation.' 
 (MacCormac.) 
 
 In comparing these results from gunshot injuries with those 
 obtained by other surgeons, INIacCormac says: ' Hennen, l^arrey, 
 and Guthrie all agree that gunshot wounds of the knee-joint 
 demand amputation, as the result is otherwise fatal. Guthrie 
 states in his book that he cannot recollect a case of recovery 
 after gunshot fracture of the articular ends of the bones. 
 Ijongmorfe tells us that in the Crimea not a single man wounded 
 in the knee-joint recovered without amputation.' Such state- 
 ments at once do away with any objection which might be 
 made to Reyher's cases, to the effect that 18 is a vei-y small 
 number of cases; for among these there were no less than 15 
 recoveries with movable joints, a result not obtained at all 
 according to Longmore throughout the Crimean war, and not 
 
 ' Ueber die BclmncUung der Schnsswuiidcu dcs KnictjcJciiks in Krirrjv. 
 Stuttgart, 1878. 
 
GUNSHOT WOUNDS OF JOINTS. 458 
 
 obtained in the 63 other cases mentioned by Eeyher. Indeed, 
 if we were to work out Reyher's tables, we should find that of 
 600 cases of gunshot wound of the knee-joint treated with 
 antiseptics, but not aseptically, only 15 would retain unmuti- 
 lated limbs, and the joints would be stiff. On the other hand, 
 we only require to take 18 cases and treat them aseptically in 
 order, not only to retain 15 limbs entire, but also to retain 
 movement in the joints. 
 
 The proper proportions would perhaps be got by comparing 
 Reyher's aseptic results with those obtained during the Franco- 
 Prussian war, as published by Heintzel.' These cases were 
 treated in a variety of ways; by antiseptics, aseptically, by 
 the water-bath or irrigation, by the open method, &c. Thus 
 the results are by no means so unfavourable as during the 
 Crimean and other wars. The sanitary arrangements were also 
 better. In fact the treatment was much more antiseptic than 
 formerly. Heintzel gives details of 529 cases of gunshot 
 wounds of the knee-joint which were treated at the first con- 
 servatively. In 288 instances amputation was afterwards 
 necessary ; of these 225, or 78*2 per cent., died ; of the 241 in 
 which conservative treatment was carried out to the end, 109, 
 or 45'2 per cent., died. Thus, of 529 gunshot wounds of the 
 knee-joint treated in a variety of ways, generally more or less 
 antiseptically, only 132 or 24*9 per cent, recovered. Compare 
 with this result Eeyher's 83-3 per cent, of recoveries where 
 the aseptic principle is thoroughly and logically carried out. 
 
 I can find no statistics of the results obtained in similar 
 injuries or operations by other methods of antiseptic treatment. 
 We have seen in Eeyher's paper the result of treatment by 
 antiseptics. 
 
 Treatment by irrigation, unless a strong antiseptic lotion is 
 employed, is hardly suitable for these injuries, for there are so 
 many opportunities for retention and fermentation of discharge 
 in the interior of a joint. Treatment by water-bath is no 
 doubt sometimes good, but only as kee-phig dcwn the inflam- 
 mation, not as preventing the suppuration. The only method 
 which prevents inflammation and suppuration is the aseptic 
 ' Deutsche militairarzlliche ZeilKchrift, 1S75. 
 
454 RESULTS OF ANTISEPTIC SURGERY. 
 
 method, whether it be carried out by operating subcutane- 
 ously, or by making a crust, or by the use of antiseptics in the 
 manntu- recommended by Mr. Lister. The latter is, I believe, 
 the only method by which a wound in a joint may be kept 
 widely open for some days without the occurrence of inflamma- 
 tion or suppuration. In order, however, to obtain this result, it is 
 necessary to observe the minutest precautions- before detailed, 
 and to act in the very strictest manner in accordance with the 
 particulate theory of fermentation. It is the omission of this 
 care which leads to the failures which are recorded as failures 
 of the aseptic method, but which are really failures on the part 
 of the surgeon who attempted to carry it out. Surgeons are 
 too apt to regard the omission, of details, such as the purifi- 
 cation of hands or instruments, as 'trifling oversights,' ^ and 
 it is by so doing that they fail to obtain the results they are 
 led to expect, and that we have such an amount of contradictory 
 evidence before us. 
 
 That no precaution is too minute to be attended to, is well 
 illustrated by ]Mr. Lister's case of removal of loose cartilage 
 from the knee-joint (No. 22, p. 434), which was referred to by 
 him at the meeting of the British Medical Association at Cam- 
 bridge in 1880. The case was one of loose cartilage in the 
 knee-joint of a strong healthy man which was removed with 
 aseptic precautions by Mr. Lister. The operation was per- 
 formed on April 12, 1880, and there was no difficulty in its 
 performance. After the cartilage had been removed, a drainage- 
 tube was inserted into the joint, and a small dressing was 
 applied. The same evening the discharge was so profuse that 
 the dressing had to be changed. The discharge had no smell, 
 and I may say that throughout the case it was entirel}' free 
 from odour. 
 
 On April 13, twenty-four hours after the oj)eration, a speci- 
 men of the discharge was taken from the drainage-tube, and 
 after staining with methyl violet, it was found to be full of 
 organisms. These organisms were very small, and on careful 
 examination they were found to be of a distinctly oval form 
 and arranged in pairs. In some parts it was very difficult to 
 
 ' See Mr. Holmes's report of a case in which he operated for ununited 
 fracture of the patella in the St. George's Hospital Iteports for 1880. 
 
NECESSITY FOR THE MINUTEST PRECAUTIONS. 455 
 
 say whether they were round or oval (see Plate V, Fig. 36). 
 There was none of the characteristic grouping of micrococci, no 
 threes in triangles and no pairs side by side. This was seen 
 not to be due to their being all in pairs, for chains of several 
 individuals were found, but nowhere the micrococcal grouping. 
 Again, in a specimen of this pus kept moist on a slide for 
 twenty-four hours, very long chains were found, but no masses 
 or typical micrococcal formation. Hence, from the microscopi- 
 cal examination alone, I concluded that these organisms were 
 not ordinary micrococci, and other evidence will be mentioned 
 immediately which supports this view. They were probably 
 bacteria or micrococci of a peculiar kind not causing -putrefac- 
 tive fermentation, but the products of whose growth were very 
 irritating, for that is the only way of accounting for the profuse 
 discharge from the interior of the joint. 
 
 Redness occurred around the wound, and spread a little 
 distance up the thigh. In the meantime, the patient's tem- 
 perature became high and the constitutional disturbance was 
 considerable. 
 
 On April 15, there was still profuse discharge, now distmctly 
 purulent, but no smell ; and in the stained specimens of the dis- 
 charge taken on this day, the organisms presented exactly the 
 same characters as on the 13th. 
 
 On the 16th, a quantity of pus was pressed out of the joint ; 
 an incision was also made into the inflamed part in the thigh 
 and a quantity of sero-purulent matter escaped. A drainage- 
 tube was inserted into this abscess. 
 
 On April 18, the state of matters continued the same. In 
 the stained specimens of this day's discharge, numerous organ- 
 isms were seen, many of which were distinctly oval in form, 
 but a large number were round (Fig. 37, Plate V). Two flasks 
 of cucumber infusion were inoculated from the wound on this 
 day, but no developfnent occm-red in them. 
 
 In spite of the incision into the thigh, the suppurative in- 
 flammation spread, and a large abscess cavity was soon formed. 
 As the drainage of the joint was not good, an opening was made 
 on the outer side and a drainage-tube inserted. There was 
 distinct improvement after this. The acuteness of the process 
 soon began to abate. 
 
45G RESULTS OF ANTISEPTIC SURGERY. 
 
 On April 22, the discharge from the drainage-tube of the 
 abscess was found to contain organisms of the same characters, 
 though fewer in number than formerly (Fig. 38, Plate V). 
 On this day a flask containing iinieat infusion, and one con- 
 taining cucumber infusion, were inoculated with discharge from 
 this abscess, but no development occurred in either. 
 
 The state of matters continued with but slight improvement, 
 and organisms were always present, though not so numerous as 
 at first. On April 27, a flask containing alkalised cucumher 
 infusion and a fresh egg were each inoculated with discharge 
 from the inner side of the knee, but no development occuiTed 
 in either. And on April 30, two eggs were inoculated with 
 discharge from the outer side of the knee without any result. 
 
 On ]May 9, discharge taken from the abscess cavity showed 
 the presence of organisms few in number but possessing the 
 same characters as formerly. A flask of pure vitreous humiour 
 of a sheep and a flask of ordinary cucumber infusion were 
 inoculated from the abscess cavity. Nothing developed in 
 either fluid. 
 
 With regard to the ultimate result in this case, I may say 
 that improvement now began, and healing was complete and 
 the limb restored to a sound state, during the month of Sep- 
 tember, though there had been very little indeed to heal for a 
 month or six weeks previously. There was a considerable de- 
 gree of fibrous anchylosis. The patella was quite movable 
 laterally, and there was a little movement between the tibia 
 and femur, Avhen the patient was discharged. 
 
 Now, first as to the nature of these organisms. They were 
 certainly not ordinary micrococci, for they had not the same 
 appearance or mode of growth, and also they did not grow in 
 any of the various materials into which they were introduced. 
 The micrococci of which I have spoken in a former part of this 
 work, and, indeed, any which I have as yet come across, would 
 have grown with great readiness in several of these fluids. 
 This was evidently a peculiar form of organism (probably bac- 
 terium), not causing putrefaction, but nevertheless, locally of a 
 very noxious character. Had it not been for the microscopical 
 examination, one might have concluded that no organisms were 
 
2s^ECESSITY FOR THE MINUTEST PRECAUTIONS. 457 
 
 present and been puzzled to explain the phenomena on anti- 
 septic principles, on the supposition that organisms were absent. 
 How did they get in ? If the aseptic method is sufficient, 
 as I have asserted it is, how were these organisms admitted ? 
 As we have already seen, the only organisms which usually get 
 into aseptic wounds are micrococci. Here the organisms 
 differed in many respects from those ordinarily found, and the 
 ordinary forms of micrococci were absent. Hence they probably 
 did not get in in the same way as micrococci usually do, that is, 
 as I have previously shown, through the dressing ; for the ordi- 
 nary forms of micrococci are the first to enter, and would, I 
 think, have been found had that been the explanation. Not 
 only so, but these organisms must have got in at the time of, 
 or very soon after, the operation, in order to be present in such 
 numbers on the next day and also to account for the imusual 
 amount of discharge on the evening of the operation. 
 
 And they did not get in through the circulation, for there 
 also micrococci are found as a rule first, and here there was no 
 disturbance of the general health to accoimt for their existence. 
 
 Whence, then, did they come ? Were they perhaps spon- 
 taneously generated ? Truly an awkward sort of spontaneous 
 generation for the patient ! But why should the mere removal 
 of a loose cartilage from a joint lead to the spontaneous develop- 
 ment of organisms in it ? There was no formation of a 
 vacuum in the joint. There was no change in the physical 
 forces. There was no introduction of cheese a la Bastian into 
 the wound. If organisms were to develop spontaneously in the 
 joint, why did they not do so the day before the operation 
 rather than immediately after it ? I need not pm-sue the 
 many arguments against this view; for we have previously 
 seen that in exact proportion to the care in making experi- 
 ments do the facts supposed to favour spontaneous generation 
 disappear. 
 
 Two explanations therefore remain. Either we had here to 
 deal with some form of resisting spore, or with one which 
 escaped the action of the carbolic acid, or there was some loop- 
 hole in the method. The former supposition I am inclined to 
 reject, for various reasons which I cannot discuss here : we 
 
458 RESULTS OF ANTISEPTIC SURGERY. 
 
 have certainly had no previous experience of bacteria resisting 
 the means employed. 
 
 There was, however, I believe, a very distinct loop-hole in 
 the method as practised at that time. This is alluded to at 
 length on p. 79. I had long thought that the drainage-tube 
 might carry into a wound dust-laden air in its interior, if the 
 air which entered the tube on removing it from the carbolic 
 lotion were not purified by carbolic spray. This is the explana- 
 tion I offer here, viz. that the air carried into the wound by the 
 drainage-tube was not pure air, but contained a particle or par- 
 ticles which gave rise to this particular form of organism. On 
 mentioning this to Mr. Lister, he at once saw the force of the 
 argument, and since that time he takes precautions to prevent 
 the recurrence of a similar accident. 
 
 It is just possible that the fault lay in the fact that a very 
 small dressing was applied at the time of the operation, and 
 that they got in through the dressing. But then they must 
 have got in during or very shortly after the operation, in order 
 to produce the rapid effect which followed. And also, as I have 
 just stated, the ordinary forms of micrococci would probably 
 have been found in that case. 
 
 The only other explanation would be, that there was some 
 error in the manipulations. But though, no doubt, faulty 
 manipulation is almost the constant cause of failure in those 
 commencing the practice of this method and in those who 
 have practised it, when the operation is difficult and requires 
 much thought, yet here there was a simple operation, the im- 
 portance of the aseptic precautions were fully present to the 
 mind, and I do not think that, especially in the case of Mr. 
 Lister and his assistants, this explanation is in this instance 
 the most probable one. Whichever explanation, however, be 
 correct, the case is of great importance, as confirming the views 
 expressed before, as illustrating the necessity of excluding 
 organisms of all kinds, and as showing the results which may 
 follow the admission of bacteria to wounds. It is also of in- 
 terest, because it shows that forms of bacteria may be present 
 without the production of smell, and thus, because a discharge 
 is ' stueet, ' it is not necessarily ' aseptic' The difficulty which 
 was experienced in finding the organisms before the pus was 
 
VALVULAR METHOD OF OPENING JOINTS. 459 
 
 stained also warns us how careful we must be in deciding 
 whether organisms are present or absent from wounds. Cases 
 have been published where disastrous consequences have fol- 
 lowed incisions into joints, but where the surgeon has asserted 
 that the discharge was sweet and free from organisms. Ac- 
 cording to recent investigations, however (p. 253), we know 
 that the pus of acute abscesses and from acute suppurations 
 always contains organisms, generally micrococci ; and therefore, 
 in the published cases in which the assertion to which I have 
 alluded has been made, it is clear that the presence of organ- 
 isms has been overlooked ; for if no other form was present, 
 micrococci were sure to be there. 
 
 Various facts are known as to the removal of foreig'n bodies 
 from joints without aseptic precautions. A number of these 
 have been referred to in the historical part, and I will here 
 content myself with quoting some figures from a paper pub- 
 lished by M. Larrey in 1861. As we have seen in considering 
 the History of Antiseptic Surgery, the valvular method intro- 
 duced a considerable amount of security into these operations. 
 Larrey groups the results of the direct and of the oblique, or 
 valvular incision together, but the details are very meagre. 
 He mentions 132 cases, of which 30 died ; 7 were unsuccessful 
 or uncertain in result; in 10 he mentions the occmrence of 
 anchylosis ; in 2 of hydrarthrosis ; and in 9 of grave accidents 
 not further specified. There are thus left T-i cases which were 
 possibly cured with movable joints, but he expressly states 
 that all the cases of healing in which accidents occurred are 
 not noted, so that the number of cures is really less. Thus, 
 only about one half of the cases recovered without the occur- 
 rence of some serious complication, yet these results, though 
 apparently so bad, are much more favourable than those which 
 had been obtained by several other surgeons, Larrey contrasts 
 with these cases the results of the operation in which a bed is 
 made outside the joint to receive the cartilage. Of these he 
 mentions 38 cases with 19 cures, 15 failures to extract the 
 cartilage, and 5 deaths. 
 
 Larrey's statistics express very well the opinions of the 
 majority of surgeons on the dangers of extracting foreign 
 bodies from joints, even when the valvular or subcutaneous 
 
400 RESULTS OF ANTISEPTIC SURGERY. 
 
 method is employed. If we search the sm-gical text-books we 
 find that there is throughout a fear of such operations or in- 
 jm'ies. Thus, Mr. Spence, in his ' Lectures on Surgery,' says,' 
 * There is no class of operations that I have a greater dread of 
 than the apparently simple one of removing a loose cartilage.' 
 
 I have no statistics of septic cases, comparable to the asep- 
 tic ones, in which wounds of joints have been kept open for 
 some days ; but, as will be seen in the history of this subject, 
 experieuce has up till recently led surgeons to the conclusion 
 that the safety of the limb and of the patient depends on rapid 
 healing of the wound. And yet, as all the facts quoted show, 
 these operations, when aseptically performed, are really devoid 
 of danger. Sir James Paget says : ^ ' I cannot doubt that 
 operations of this kind ' (referring to incisions of joints with 
 closure of the wound), ' which, in the earlier years of my work, 
 were done with great risk, or, with a wise fear of the risk, were 
 left undone, may now, with antiseptic help, be done with an 
 almost complete safety.' 
 
 ' See leading article in British Medical Journal^ April 1880. 
 * MacCorraac's A ntiseptie Surgery. 
 
RESULTS IN COMPOUND FRACTURES. 401 
 
 CHAPTER XIX. 
 
 RESULTS OF ANTISEPTIC SUEGEKY (cO) it I lilted). 
 
 CompDUiid fractures. Differences between those produced accidenlallj' and 
 those caused by the surgeon : treatment and after-progress of each class. 
 Tables of accidental compound fractures treated by Mr. Lister : thigh ; leg ; 
 humerus; forearm ; skull ; summary of results. Tables of compound frac- 
 tures produced intentionally by Mr. Lister ; femur ; leg ; clavicle ; hume- 
 rus ; forearm ; lower jam. General summary of Mr. Lister's results. Mr. 
 Spence's results. Other operations on bones by Mr. Lister. MacEwen's 
 osteotomies : Volkmann : Max Schede : Bardenheuer : MacCormac. Com- 
 bined aseptic results. Results by other methods : Volkmann and Fraeuc- 
 kel : Holmes : St. Thomas's Hospital. Reyhers results in war. Open 
 method : Kronlein. Septic methods. 
 
 I NOW pass on to a second class of cases which are often fol- 
 lowed by most serious consequences : I refer to compound frac- 
 tures occm-ring accidentally or made by the surgeon. 
 
 Compound fractures produced accidentally and those made 
 by the sm'geon differ from each other in various important par- 
 ticulars. In the first class dust is as a rule introduced into 
 the wound before the surgeon sees the case, and, therefore, the 
 problem is to destroy the energy of this dust. VV^hether such 
 an attem])t is successful or not, must of coiu'se always be a 
 matter of doubt ; and hence the results are uncertain. Then, 
 also, the violence is often very severe and complicated with 
 other injuries or with shock, and in this way life may lie lost 
 from causes which could not be avoided by any method of 
 wound treatment. On the other hand, in the second class of 
 cases the surgeon has only the ordinary aseptic problem before 
 him, and if he is justified in other cases in looking with cer- 
 tainty for good results, he ought to be equally justified here. 
 He is also independent of the other injuries and shock which 
 so often comi)licate accidental coni])oun(l fractures, and, there- 
 fore, the mortality ought also to be less. If we remember 
 
462 RESULTS OF ANTISEPTIC SURGERY. 
 
 these differences, we shall be able to form a just estimate of the 
 value of the results. 
 
 The aseptic course in these cases corresponds to that de- 
 scribed in Chapter XVIII. ; and I need only indicate one or two 
 points in the treatment and after-progress of the injury. 
 
 The treatment of compound fractures the result of accident 
 has been already described at pp. 113 and 114. It consists in 
 washing out the wounds thoroughly with a strong antiseptic 
 lotion, generally the 1-20 watery solution of carbolic acid or the 
 1-5 mixture of carbolic acid and methylated spirit. This is done 
 by injecting the lotion through a catheter attached to a syringe 
 filled with the solution, the orifice of the wound being left 
 freely open. In this way, by moving the point of the syringe 
 in various directions, the lotion is introduced with certainty 
 into all the recesses of the wound, while by leaving the orifice 
 of the wound freely open there is no risk of forcing the fluid 
 into the cellular tissue. It is well to clear out all the clots of 
 blood. The skin in the neighbourhood is also thoroughly 
 washed with 1-20 carbolic lotion, the whole being done in a 
 spray of carbolic acid. The wound is left freely open, and in 
 most cases a drainage-tube is passed into the deeper parts and 
 kept in for a few days. In some instances, if there is much 
 tendency to displacement, the ends of the fragments may be 
 tied together with strong silver wire. A large gauze dressing, 
 enveloping the limb, is then applied, and outside it a suitable 
 splint. This dressing is changed on the following day, and 
 afterwards according as it is necessary. After a few days, in 
 compound fractures of the lower extremity, when the discharge 
 has become small in amount, some arrangement like that de- 
 scribed at p. 107 may be employed. 
 
 The after-progress of these cases depends on whether the 
 causes of putrefaction were destroyed or not by washing out 
 the wound. If they were not, then the case becomes one 
 treated with antiseptics, but not aseptically. If the causes of 
 putrefaction were eradicated, the wound follows an ' aseptic 
 course' (p. 421). In cases of compound fracture, more especi- 
 ally from direct violence, the soft parts are often much con- 
 tused and lacerated, and the bones are sometimes comminuted 
 and much injured. The ordinary result in such cases, when 
 
'ASEPTIC COURSE OF COMPOUND FRACTURES. 463 
 
 aseptic treatment is not employed, is, that sloughing of the con- 
 tused and lacerated tissues occurs to a greater or less extent, and 
 very generally portions of the broken fragments of the bone be- 
 come necrosed. This process is accompanied with a considerable 
 amount of suppuration. If, however, the wound is rendered 
 aseptic, and if the irritation of the antiseptic is excluded, this 
 sloughing and suppuration does not occur. The wound be- 
 comes filled with blood-clot ; the interstices between the frag- 
 ments of lacerated tissue also become filled up; the whole 
 remains unaltered for many days, merely assuming a greyish 
 appearance on the surface, but after some days, on scratching 
 this clot, it bleeds, showing that it has become vascularised, 
 and on detaching the superficial layer the greater part, or 
 
 XVTT 
 
 Fig. 78.— Temperatcke Chart from a Case of CoixrouxD Fracture, 
 
 IN WHICH THE ATTEMPT TO ERADICATE THE CAUSES OF FERMENTA- 
 TION WAS UNSUCCESSFUL, AND WHICH THEREFORE BECAME A SEPTIC 
 
 CASE (Case 26, p. 472). 
 
 indeed the whole of the wound, will be found to have become 
 covered with epithelium. (This process will be more minutely 
 discussed hereafter.) There is no suppuration at all from the 
 wound, and no separation either of dead skin or tissue, or of 
 dead bone. If, however, no protective be used, or the wound 
 be deluged with strong carbolic acid, the superficial layer of 
 the clot becomes irritated, and when vascularised, granulates, 
 and suppuration occurs from its surface ; at the same time, the 
 portions of dead tissue being impregnated with carbolic acid, 
 become irritating, cause granulation and su[)puration where 
 they are in contact with the living parts, and are thus separated 
 as sloughs. The sloughing in this instance, however, is not as 
 a rule nearly so extensi\e as in the case of a septic wound. 
 
464 
 
 RESULTS OF ANTISErTIC SURGERY. 
 
 The constitutional condition also depends in the main on the 
 success or failiu-e of the attempt to render the wound aseptic. 
 If the attempt fails, the temperature is generally high, as in 
 other septic cases (see fig. 78) ; if, on the other hand, it is 
 successful, the temperature generally remains normal or nearly 
 so, though it may be high for a few hours after the injury 
 (see fig. 79). (I shall not go into this matter further at pre- 
 sent, as I intend to discuss it more fully in a future chapter.) 
 The general well-being of the patient also closely corresponds 
 to the septic or aseptic state of the wounds ; if the wound is 
 septic and the temperature high, the patient generally feels ill, 
 and has other symptoms of fever ; if, however, the wound is 
 
 BBsaiiii 
 
 I 
 
 mH—8Bai 
 
 Fig. 7'J.— Temperature Chart from a Case of Compound Fracture 
 Which followed an Aseptic Course (Case 23, p. 472). 
 
 rendered aseptic the patient feels practically iu a normal state 
 of health. 
 
 In the case of compound fractures made by the surgeon, the 
 progress of the wound and the constitutional state of the 
 patient are similar to those described as typical of operations 
 on joints (p. 421); and I need not repeat what I said there. 
 In performing these operations a free incision is made down 
 to the bone with the various aseptic precautions ; the bone is 
 chiselled or sawn across, or a portion of bone is removed accord- 
 ing to circumstances ; the bleeding vessels are secured ; a 
 drainage-tube is introduced down to the bone ; as a rule, no 
 stitches are inserted ; and the dressing is applied according to the 
 ordinary rules previously described. In a few hours the wound 
 is filled with blood-clot, which becomes vascularised and organ- 
 
COMPOUND FRACTURES. 465 
 
 ised, and cicatrisation occurs beneath its superficial layer without 
 previous granulation or suppuration. As a proof of this I may- 
 refer to the fact mentioned by Dr. MacEwen, that he had 
 made 835 compound fractures, and that in only 8 of the wounds 
 was there any pus formation, although none of these injuries 
 was subcutaneous. After operations conducted in this way the 
 general state of the patient remains normal. 
 
 In considering the results of compound fractures, it is quite 
 clear that all cases, in whatever way they are treated, whether 
 by primary or secondary amputation or conservatively, must 
 be mentioned and grouped together in the first instance. 
 For the frequency of primary amputation after compound 
 fracture will depend not only on the great severity of the injury 
 and destruction of tissue, but also on the dangers to which, in 
 accordance with the experience of the surgeon in charge, the 
 patient will be afterwards subjected. If the surgeon feels that 
 the method of treatment which he has been accustomed to 
 adopt in these cases is not such as to secure the patient from 
 the after consequences, he will naturally take into frequent 
 consideration the question of primary amputation. If, on the 
 other hand, he has been led to expect that the dangers incident 
 to these injuries are not likely to occur under the method of 
 treatment which he adopts, he will perform primary amputation 
 less frequently. Therefore, in order to judge of the results of 
 any method of treatment in compound fractures, the number 
 of primary amputations and the sort of injuries in which they 
 are performed must be mentioned. With regard to secondary 
 amputation it must be remembered that these, as well as the 
 fatal cases, are those in which the attempt to treat conserva- 
 tively has failed, and therefore it is not sufficient merely to 
 state the results of cases treated conservatively to the end. In 
 the following tables I have attempted to indicate, as fairly as 
 possible, the nature of the injuries and the after-progress of 
 the cases which have occurred in Mr. Lister's practice since 
 1872. In some instances the notes have been deficient, but I 
 have tried to render them complete by tracing out these cases 
 as far as I could. 
 
 II n 
 
466 
 
 RESULTS OF ANTISEPTIC SURGERY. 
 
 I. Compound Fractures, the 
 
 In considering these I have included all Mr. Lister's cases since 
 1871 : those requiring primary amputation as well as those treated 
 
 Comjwund Fractures 
 
 Name and Age 
 
 Date of Admission 
 and Discbai-ge ; 
 with Result. 
 
 Injury 
 
 A ca^e of extensive, compound fracture of the femur where primary amputation was 
 performed at the hip-joint. Tue patient died almost immediately. There is no record o! 
 
 J. S., 45 
 
 George P., 12 
 
 ^f/., .Iune26, 1874. 
 Died., June 26, „ 
 Cause of death was 
 shock. 
 
 Ad., Sept. 29, 1871. 
 Dis., Feb. 14, 1872. 
 In process of cure. 
 
 R. P., 17. . 
 
 (Septic case) 
 
 Mrs. D., 50 
 
 Jd., Nov. 15, 1872. 
 />/W,l)cc. 14. „ 
 Cause of death was 
 bronchitis and car- 
 diac disease. 
 
 .<4rf., Oct. 1.5,1878. 
 Dis., .lunc 20, 1879. 
 Result, healed. 
 
 Extensive conipmind comminuted fracture of 
 the femur, and severe laceration of leg 
 
 Compound fracture of the femur from a fall. 
 Direct violence. 
 
 Two railway trucks jiassed over his le,n, 
 causinj; a' simple commmuted fracture ot 
 both bones of the leg, and a simple commi- 
 nuted fracture of the thigh. The skin 
 over the fracture of the femur sloughed, 
 and the bone protruded on November 22. 
 Patient was sulfering from cardiac disease. 
 
 Compound fracture of tlie femur. 
 
 There were thus five compound fractures of the femur, of which 
 two were amputated primarily, both dying of shock ; and three were 
 treated conservatively, one of these dying of bronchitis and cardiac 
 
 Coiiijioitnd Fractures 
 
 William K., 12 
 
 A. R., 18. 
 
 Ad.. .Tune 17, 1872. 
 Died, same day. 
 Cause of death was 
 shock. 
 
 Ad., April 7, 1874. 
 Din., Sept. 3. 1874. 
 Result, cured. 
 
 Compound fracture of left leg and right thigh. 
 Skin torn off for a considerable distance. 
 Patient in a slate of collapse when ad- 
 mitted. 
 
 Leg crushed l>y a beam. Severe compound 
 comminuted fracture of the leg. 
 
MR. LISTERS COMPOUND FRACTURES. 
 
 4(37 
 
 Result of Accident. 
 
 conservatively or amputated secondarily. I omit the lesser compound 
 fractures of the hand and foot. 
 
 of the Femur (accidental). 
 
 Treatment 
 
 Remarks 
 
 the case in the books, but I know that it occurred. 
 
 Primary amputation just below the 
 trochanters. 
 
 Wound injected -with 1-20 carbolic lotion. 
 Opening enlarged. Drainage-tube in- 
 serted, and splints applied. 
 
 An attempt was made to keep the plough 
 sweet, liut ]uitrefacti(in liad already 
 occurred, and therefore the attempt 
 was unsuccessful. 
 
 See No. n, p. 424, and No. 70. 
 
 Patient was unconscious when admitted, and never 
 rallied. He died in about tAvo hours. Cause 
 ot death was shock. 
 
 The bones had firmly united on November 14, and 
 ihc patient seems to have done well. On 
 January 19 the sinus had not yet closed, and 
 Mr. Lister introduced a pair of sinus forceps to 
 see if there was any loose bone. No precau- 
 tions were used to' disinfect the air which 
 entered (no spray or carbolic lotion), and putre- 
 faction seems to have followed. When the 
 patient was discharged there was still a piece 
 of bare bone to be felt, but he was in perfect 
 health. ^ 
 
 Abscesses formed about the knee and higher up in 
 the thigh. The notes are incomplete, Imt the 
 patientisentered in the hospital books as having 
 died of bronchitis and cardiac disease, from 
 which he was suffering previous to admission. 
 (This was a septic, not an aseptic, case, so that 
 whatever was the cause of death, it does not 
 influence the result in aseptic cases.) 
 
 Aseptic course. The wound healed, but the bones 
 did not unite. (See T. Chart II, p. 438.) 
 
 disease. This last was, however, a septic case, and therefore all the 
 cases (two in numlier) of compound fracture of the femur treated 
 conservatively and aseptically recovered. 
 
 of the Le(j {accidental). 
 
 Primary ami. utation through the upper Patient never rallied, but died in (wo or three 
 i of left leg and upper I of right thigii. hours from shock. 
 
 Primary junputation. (Modified Carden.) 
 
 For some lime Ijir p.i(i(.ni stiO'ered from carbolic 
 poisoning, but after tlie carbolic dressings were 
 left off and boracic dressings were substituted 
 for them, he soon recovered, and the stump 
 healed slowly. 
 
 H H 2 
 
468 
 
 RESULTS OF ANTISEPTIC SURGERY. 
 
 I. Compound Fkactures, the 
 
 No. 
 
 10 
 
 12 
 
 Name and Age 
 
 F. D., 22 . 
 
 James B., 18 
 
 R;H., 25. 
 
 George A., 41 
 
 George S., 24 
 (Septic case) 
 
 13 James D., 24 
 
 Peter M., 22 
 (Septic case) 
 
 15 
 
 Anne L., 60 
 
 Date of Admission 
 
 an<l Discharge ; 
 
 with Result 
 
 Ad., Dec. 12, 1873. 
 />/.s., March 13, 1874. 
 Result, cured. 
 
 Ad., Aug. 3, 1874. 
 Dis., Sept. 13, „ 
 Result, cured. 
 
 ^rf., March 17, 1874. 
 Dis., April 27, „ 
 Result, cured. 
 
 Ad., July 1, 1872. 
 Died, 3n\y 3, ,, 
 Cause of death was 
 exhaustion. 
 
 ^rf., March 15,1872. 
 Died, May 20, „ 
 Cause of death was 
 diphtheria. 
 
 Ad., Aug. 2, 187 
 Dis., Sept. 17, ,, 
 Result, liealcd. 
 
 Ad., Sept. 9, 1872. 
 /-»«., Oct. 31, „ 
 Result, cured. 
 
 Ad., Oct. 28, 1872. 
 Died, on same day. 
 Cause of death was 
 shock. 
 
 Injury 
 
 Railway engine passed over leg, almost sever- 
 ing the foot, and producing a severe com- 
 pound comminuted fracture of the leg. 
 
 Raihvay engine passed over his ankle, crush- 
 ing the bones very severely. A consider- 
 able amount of shock. 
 
 Very severe compound fracture of both bnnes 
 of the leg. Foot drawn through a port- 
 hole of a vessel by an anchor chain. 
 
 Compound comminuted fracture of both 
 bones of the leu. 
 
 Compound comminuted fracture of both 
 bones of the left leg. Fracture of right 
 thigh with very severe bruising. Patient 
 almost moribund. 
 
 The wheel of a cab passed over the leg, 
 causing a compound fracture. Small 
 wound. 
 
 Severe compound comminuted fractnre of 
 both b(mes of the leg. Leg crushed by a 
 heavy stone. 
 
 Compound comminuted fracture of the leg. 
 Also fracture of the pelvis. Patient mori- 
 bund when admitted. 
 
MR. LISTERS COMPOUND FRACTURES. 
 
 469 
 
 Result of Accident {continued). 
 
 Primary amputation through the calf. 
 
 Primary amputation through the upper 
 third of the leg. (Modified circular.) 
 
 Primars' amputation just below the knee. 
 (Modified circular.) 
 
 Wound enlarged and injected with 1-20 
 carbolic lotion. Wound left open. 
 
 Wounds washed out with 1-20 carbolic 
 lotion. (Secondary amputation.) 
 
 Wound enlarged and injected with 1-20 
 carbolic lotion. Wound left open. 
 
 Washed out with 1-20 carbolic lotion. 
 (Secondary amputation.) 
 
 Wound injected witli 1-20 carbolic lotion. 
 
 Remarks 
 
 Haemorrhage occurred on several occasions in 
 connection with a portion of the anterior flap 
 which sloughed, but the rest of the wound did 
 well, and the whole was quite superficial on 
 February 1, and quite healed when the patient 
 was diachargeJ. 
 
 Aseptic course (i.e. no local or constitutional dis- 
 turbance). The wound healed by first inten- 
 tion except where the drainage-tubes were and 
 at the centre of the flaps, where a little gaping 
 occurred. The wound was absolutely' healed on 
 September 18. 
 
 The line of incision healed for the most part by 
 first intention. A slight tendency to gaping at 
 the centre of the incision was easily overcome 
 \>y the use of strapping applied aseptically. 
 Wound was quite healed when the patient was 
 discharged. 
 
 Patient got gradually weaker, and, without any 
 special symptoms, died in forty hours. 
 
 Putrefaction was not avoided, and on March 17, 
 when this was evident, amputation was per- 
 formed through the middle of the thigh. This 
 wound had almost completely healed when, on 
 May 17, he complained of sore throat. His 
 temperature went up ; diphtheritic patches ap- 
 peared on the fauces ; and he died on May 20 
 from diphtheria. (See T. Chart XVIII.) 
 
 Aseptic course. The temperature only once rose 
 above 100° F., and then it reached 101° F., 
 thirty-six hours after the accident. The wound 
 had quite healed, witliout any suppuration, by 
 September 7. The bones were not quite firm 
 when the patient was discharged. He was sent 
 out with the leg in a case of plaster of Paris. 
 
 Putrefaction was not avoided, and as the tem- 
 perature was going up (it had readied 103"^), 
 Mr. Lister thought it better to amputate. This 
 he did through the lower third of the femur on 
 September 13. The stump followed a perfectly 
 aseptic course, and liealed by first intention, 
 except where the drainage tubes were. It had 
 completely healed on October 18. 
 
 Patient died three hours after admission. On 
 ]). m. examination extensive fractures of the 
 sacrum and pelvis were found. 
 
470 
 
 RESULTS OF ANTISEPTIC SURGERY. 
 
 I. Compound Fractures, the 
 
 Name and Age 
 
 William K., 16 
 
 J. M., 32 . . . 
 (Septic case) 
 
 IS 
 
 J. McA. . 
 
 19 
 
 20 
 
 James B., 56 
 (Septic case) 
 
 22 
 
 A. R., 25 . . . 
 (Septic case) 
 
 T. N., 30 . 
 
 Jane L., 36 
 
 Date of Admission 
 
 and Discharge ; 
 
 with Result 
 
 .4tZ., March 26, 1873. 
 7>is., July 12, „ 
 Result, cured. 
 
 Ad., June 16, 1873. 
 Dis.. Sept. 15, „ 
 Result, cured. 
 
 Ad., Aug. 22, 1873, 
 Dis., Dec. 18, „ 
 In process of cure. 
 
 Ad., Sept. 15, 1873. 
 Dis., March 12, 1874. 
 In process of cure. 
 
 Ad., Feb. 18, 1875. 
 D!s., Sept., „ 
 Result, cured. 
 
 Ad., April 26, 1875. 
 Dis., Sept. 20, „ 
 Result, cured. 
 
 Ad., Oct. 18, 1875. 
 Z>is., March 11, 1876. 
 In process of cure. 
 
 Injury- 
 
 Compound fracture of both bones of the leg. 
 A piece of stone fell on his leg. Admitted 
 tweuty-four hours after the accident. 
 
 The wheel of a tramway car passed over li.s 
 leg, causing a compound comminuted frac- 
 ture of both biines. Patient admitted im- 
 mediatelv. 
 
 A stone fell on his leg, causing a compound 
 comminuted fracture of both bones. The 
 patient was admitted two hours after the 
 accident. 
 
 A van ran over his leg, causing compound 
 fracture of both bones, two inches above 
 the ankle-joint. Seen at once. 
 
 Leg was run over. Severe compound commi- 
 nuted fracture of both bones. Admitted 
 two hours after the accident. 
 
 Compound fracture of tibia causid by a 
 wooden beam falling on his leg. Upper 
 end of lower fragment protruding. Acci- 
 dent happened four hours before admission. 
 
 Compound fracture of tibia. Leg crushed by 
 a wooden beam. Lower end of upper frag- 
 ment protruding. Done four hours before 
 admission. 
 
 II 
 
ME. LISTERS COMPOUNI) FRACTUliES. 
 
 471 
 
 Result of Accident (contlvued). 
 
 Wound injected with 1-5 solution of car- 
 bolic acid in methylated spirit. 
 tVounds enlarged. Mdntyre splint 
 applied. 
 
 Wound injected with a solution of cnr- 
 bolic acid in methylated spirit, 1-5. 
 
 Some frapments of hone were remrved. 
 The wound was washed out with car- 
 bolic lotion, 1-20. 
 
 Wound injected with 1-20 embolic lotion. 
 
 Wound injected v ith 1-20 carbolic lotion. 
 
 Wourd injf (ted with 1-20 carbolic lotion. 
 
 Wound wa*-! ed rut with l-fO cnrliolic 
 lotion. 
 
 Remarks 
 
 Putrefaction avoided. A small abscess formed 
 in the leg and was opened on March 31. 
 Afterwards the wounds progressed well, and 
 were sujierfirial on May 16. Boracic dressing 
 was then applied. ErA'sipelas attacked the 
 wound on May 2'6, but it had passed off on Maj' 
 30, and tlie wounds healed rapidly. Tlie bones 
 were fjuite firm and there were onh' two super- 
 ficial spots to heal when the patient was dis- 
 charged. 
 
 Putrefaction was not avoided. The wound suppu- 
 rated freely, and a small piece of bone necrosed. 
 The temjierature was not regularly taken, but 
 for twelve davs it was above IHO^ F., ranging 
 from 100" to l*03-5<-'. The bones had united and 
 the wounds had almost healed when the patient 
 was discharged. 
 
 Putrefaction was avoided. There was a A-ery 
 little superficial ' ,'intiseptic suppuration.' There 
 was no inflammation or formation of abscesses. 
 When discharged the leg was firm, but there 
 was still a sinus leading down to bare bone. 
 The temperature only once rose to 100°, thirty- 
 six hours after the accident. 
 
 Putrefaction was at first avoided, but the pa- 
 tient, during an attack of delirium tremens, 
 tore off the dressings, and the wound jnitrcfied. 
 It was henceforth treated with lint soaked in 
 carbolic acid and glycerine. When discharged 
 there was still a sinus leading down to bare 
 brne, but the bones were quite firm. 
 
 Putrefaction was not avoided. Two abscesses 
 formed, and the wound ard the abscess cavities 
 supjiuratcd. For six weeks the temperature 
 varied from 1(0" to 103" V. Other al)scesses 
 formed, but ultimately the parts began to re- 
 cover, and healing was coniplete at the end of 
 September. 
 
 Aseptic course. The highest tcni])eralure recorded 
 ■was 99-7°. 'J'lie wound liad healed (exact date 
 not given), and the bones had united when the 
 patient was discharged. 
 
 Xo constitutional disturbance, but two Fmall 
 frapments lost tlieir vitality, ai-d were not re- 
 moved till a few (lays before tlie patient was 
 discharged. At that time the bones were firm, 
 and tliere remained only a small superficiHl 
 sore. 
 
47l> 
 
 RESULTS OF ANTISEPTIC SURGERY. 
 
 I. Compound Fractures, the 
 
 Name and Age 
 
 23 
 
 ■24 
 
 25 
 
 26 
 
 James G., 11 
 
 William R., 50 . 
 
 Mary V., 55 
 
 Andrew F., 38 . 
 (Septic case) 
 
 Cornelius N., 34 
 
 28 Maria L., CO 
 
 Date of Adniifsion 
 
 and Discharge ; 
 
 with Rpsuit 
 
 Injury 
 
 Ad., June 23, 1876. 
 Z>/s., Nov. 23, „ 
 In process of cure. 
 
 Ad., Jan. 26, 1877. 
 Dis., March 15, 1877. 
 Besu t, cured. 
 
 Ad., Nov. 9, 1877. 
 Dis., Aug. 14, 1878. 
 Result, cured. 
 
 ^IcZ., March 16,1878. 
 Dis., Dec. 2, 
 Result, cured. 
 
 Ad., May 24, \87i 
 Dis., Dec. 18, „ 
 Result, cured. 
 
 Compound fracture of both bones of the leg. 
 Admitted immediately after the accident. 
 
 Compound fracture of tibia, caused by a kick 
 from a hor<e. Admitted immediately. 
 
 Run over bj' a cart which caused a compound 
 comminuted fracture of both bones of the 
 leg. 
 
 The wheel of a van passed over his leg, pro- 
 ducing a very bad compound fracture of 
 both bones just above the ankle-joint. 
 Great injury to the soft parts. There was 
 also a compound C(Jlles' fracture. See 
 No. 42. 
 
 Leg jammed between a stone and the wheel 
 of a truck, resulting in compound commi- 
 nuted fracture of both bones of the leg. 
 
 Result, cured. 
 
 Compound fracture of fibula, etc. 
 ries of joints. No. 10, p. 424.) 
 
 (See inju- 
 
MR. LISTERS COMPOUND FRACTURES. 
 
 473 
 
 Result of Accident [continued). 
 
 Wound injected with 1-20 carbolic lotion. 
 
 Wound injected with 1-20 carbolic lotion. 
 Wound left open as usual. 
 
 Wound syringed out with 1-20 carbolic 
 lotion. 
 
 Wound washed out with 1-20 carbolic 
 lotion. On the followinic day, in order 
 to get the bones in pnsition, it was 
 necessary to saw off portions and tie 
 the fragments together with silver 
 wire. 
 
 Wound enlarged and pieces of bone 
 removed. Wound washed out with 
 1-20 carbolic lotion. 
 
 Aseptic course. The bone took a long time to 
 unite, and was not absolutely firm, though 
 almost so, when the patient was discharged 
 wearing an immovable apparatus. (See T. 
 Chart XIX.) 
 
 Aseptic course. Beautiful example of organisa- 
 tion of blood-clot, without suppuration. Heal- 
 ing complete on February 28. The tibia was 
 found to be firm on March 6. (See T. Chart 
 XX.) 
 
 Apparently no constitutional disturbance, though 
 the temperature was above 100^ on several 
 occasions. A portion of the skin sloughed. No 
 exfoliation. Put up in plaster of Paris on 
 January 23, 1878. Taken down on March 14, 
 but the bones were not then quite firm. One 
 or two apparatuses were subsequently applied, 
 and when the patient was at length discharged, 
 union was complete. (See T. Chart XXI.) 
 
 The attempt to eradicate the causes of putrefac- 
 tion was not successful, and the Avound sup- 
 purated. The patient had fever. An abscess 
 formed in the leg. The wounds were quite 
 healed on June 5. The wire was removed on 
 July 23. In November the bones were found 
 to be soundly united. (See T. Chart XXII.) 
 
 The greatest difficulty was experienced in keeping 
 the bones in position, and there was conse- 
 quently great pain. The temperature was high 
 for some days, but the pulse was not fast, and 
 the patient seemed well with this one exception. 
 For some days the bones became constantly 
 displaced, but otherwise the wound did well. 
 It remained asei)tic, though as the result of the 
 disturbance theie was suppuration, but only a 
 very little. As the wound got smaller it was 
 found that the bones could be kept in position 
 by a screw pressing on the ui)i)cr fragment. 
 The leg was put up in jilaster of Paris, but on 
 November 29 the bones were found to be still 
 ununited. Eigiit to ten minims of tincture of 
 iodine were therefore injected between the frag- 
 ments. Some swelling and a small abscess 
 resulted, and tlie bones united. When seen on 
 Januarv oO, 187'J, union was complete. (See 
 T. Chart XXIII.) 
 
 Patient did well. 
 
474 
 
 RESULTS OF ANTISEPTIC SURGERY. 
 
 I. — Compound Fractures, the 
 
 No. 
 29 
 
 Name and Age 
 
 Date of Admission 
 
 and Discharge ; with 
 
 Eesult 
 
 Injury 
 
 
 F. C, C . . . 
 (Septic case) 
 
 Ad., Dec. 4, 1878. 
 /J/s., April 20,1879. 
 Result, cured. 
 
 Lei;' run over by a cab. Larj^e wounds on 
 both ^ides of the leg, that on the outer side 
 communicating with a fractured fibula. 
 On the inner side the tibia was bare. 
 
 
 m 
 
 Alfred A., G . 
 
 Ad., Sept.. 12, 1879. 
 />/«., Oct. 19, „ 
 Residt, cured. 
 
 Compound fracture of both bones of the leg. 
 Tibia protruding. Cause not given. 
 
 
 31 
 
 Frederic H., 48 
 
 ^<Z., Nov. 14, 1879. 
 Dis., -Jan. 5, 1880. 
 Result, in process of 
 cure. 
 
 Compound fracture of the lower end of the 
 right fibula and sini|)le fracture of the 
 middle of the right tibia. Result of a fall. 
 
 
 There were thus under Mr. Lister's care during these years 26 
 cases of compound fracture of the bones of the leg, of which 4 died. 
 Three of these deaths occurred within forty-eight hours, and the 
 other was from diphtheria. None of the deaths was therefore pre- 
 ventible by any method of after-treatment of the wound. 
 
 In 5 of the 26 cases primary amputation was necessary. One of 
 these cases died of shock. 
 
 Twenty-one cases were treated conservatively, and of these 3 
 died. 
 
 Of these 21 cases 2 required secondary amputation, of which 1 
 died of diphtheria. Of the remaining 1 9 cases 2 died, both from 
 shock and exhaustion, within forty-eight hours. 
 
 .^2 R. J.. 2;? 
 
 33 
 
 34 
 
 35 
 
 George G., 60 
 
 Henry A., 12 
 
 Henry B., 22 
 
 Ad., March 22, 1872. 
 Died, March 23, „ 
 The cause of death 
 was shock. 
 
 Result, cured. 
 
 Ad., Dec. 28, 1872. 
 Dis.. Aj.ril 17, 1873. 
 Result, cured. 
 
 Result, cured. 
 
 Comjyotmd FracHires of 
 
 The wheel of a railway waggon passed over 
 his shoulder, causing a compound commi- 
 nuted fracture of the humerus and scapula. 
 
 Compound comminuted fracture of the hu- 
 merus. 
 
 Cab wheel passed over arm, causing a com- 
 pound comminuted fracture of the hu- 
 merus. Patient brought to the hospital 
 immediately. 
 
 Compound fracture of the humerus. 
 
MR. LISTERS COMPOUND FRACTURES. 
 
 475 
 
 Result of Accident {contirmed). 
 
 Wound washed out with 1-20 carbolic 
 lotion. 
 
 Wound washed out with 1-20 carbolic 
 lotion. 
 
 Wound enlarged and syringed out with 
 1-20 carbolic lotion. 
 
 Putrefaction was not avoided. Sloughing oc- 
 curred to a considerable extent and the dis- 
 charge had a foul smell. When this was evi- 
 dent, boracic ointment and boracic lint were 
 used. The temperature chart cannot be found, 
 but for some days the tf'm])erature varied 
 from 100'^ to 103'^ F. On March 23, two 
 pieces of dead bone were removed. When dis- 
 charged the wound had healed and the frac- 
 ture united. 
 
 Aseptic course. 
 
 Aseptic course. Wound healed about December 
 20. Fractures found united on December 27. 
 Sent out with a silicate apparatus on. 
 
 In these 19 cases the attempt to eradicate the causes of putrefac- 
 tion was unsuccessful in 4 instances. It was also unsuccessful in 
 both the cases in which secondary amputation was necessary. Thus 
 the attempt failed in 28-5 per cent, of the cases. One case putrefied 
 after some days because the patient tore off the dressings. 
 
 In 2 of the 6 septic cases secondary amputation was necessary ; 
 necrosis occurred in 1, sloughing of the skin took place in 1, and in 
 the remaining 2 there was inflammation and abscess formation. 
 
 In none of the aseptic cases was any operation necessary. In 
 only 1 w^as there any appearance of necrosis, and the course of the 
 others is markedly different in all respects from that of the cases 
 where putrefaction was not avoided. 
 
 the Humerus [accvlpntal). 
 
 Arm removed and also loose portions cf 
 the scapula. 
 
 See Wounds of .J<.ints (Xo. 2). 
 
 Wound wasiicd out witli 1-20 carbolic 
 lotion. 
 
 See Wounds of Joints, p. 121 (Xo. 11). 
 
 The patient was j-utTiring severely from shock 
 when he was admitted, and he never rallied. 
 Died from ^Iiock. 
 
 rutrefaclion was .n voided, but late in the case a 
 little pus escai)ed from tiie wound. On probing 
 it dead bone was felt. This was removed in 
 June, and tiie wound healed raiiidly. The 
 hemes were (irmlv united on Ap;il 11. 
 (SeeT. Chart III., p. 438.) 
 
476 
 
 RESULTS OF ANTISEPTIC SURGERY. 
 
 I. — Compound Fractures, the 
 
 Four compound fractures of the humerus were under treatment 
 with 1 death from shock. 
 
 Of these 1 case was amputated primarily and died, while 3 cases 
 
 Compou7id Fractures of 
 
 Name and Age 
 
 39 
 
 40 
 
 41 
 
 42 
 
 C. B., 40 . . 
 
 J. H., 16 . 
 
 Thomas W ., 17 
 
 Jolm S., 34 
 
 J. F., 30 . . . 
 (Septic case.) 
 
 John O'H., 28 
 
 Andrew Y., 38 
 
 Date of Admission 
 
 and Discharge ; with 
 
 Result 
 
 Ad., June 2, 1874. 
 Dis., Jul}' 6, „ 
 Result, cured. 
 
 Ad., June 8, 1877. 
 Dis., July 16, „ 
 Result, cured. 
 
 Ad., Julv 19, 1872. 
 J)is., Sept. 22, „ 
 Result, healed. 
 
 Ad., July 7, 1873. 
 Dh., Aug. 14, „ 
 Result, cured. 
 
 Ad., Oct. 29, 1875. 
 Dis., Jan. 31, 1870. 
 Result, in process of 
 cure. 
 
 Ad., Dec. 24, 1875. 
 Dis., Feb. 11, 1876 
 Result, in process of 
 cure. 
 
 Ad., March 5, 1878. 
 Result, cured. 
 (SecNo. 2G, p.472.) 
 
 Injury 
 
 A weiji'ht of 30 cwt. fell from a height on to 
 his forearm, completely crushing it. 
 
 Patient's forearm was drawn into a crushing 
 machine and very badly smashed. 
 
 Hand caut^ht in a printing-machine, causing 
 a compound comminuted fracture of the 
 humerus. Kadial artery torn across. 
 Fingers cold and pulseless. Extensive in- 
 jury of the soft parts. Admitted at once. 
 
 Forearm run over hy a vehicle. There was 
 a small wound communicating with a frac- 
 ture of both bones. The accident happened 
 an hour and a half before admission. 
 
 Arm caught in machinery. Compound frac- 
 ture of both bones of the forearm. Kadius 
 much comminuted. Soft parts much torn. 
 
 Compound fracture of the forearm from a 
 piece of wood falling on it. Seen after two 
 or three hours. 
 
 Patient liad a compound CoUes's fracture as 
 well as the fracture of the leg. 
 
 There were thus 7 compound fractures of the bones of the fore- 
 arm without a death. Of these, 2 cases required j)rimary amputation. 
 In one of the 5 cases treated conservatively the attempt to eradicate 
 the cause of putrefaction was unsuccessful. In 2 of the 5 cases 
 union occurred satisfactorily ; in 2 union was delayed, and in one it 
 did not occur on account of the great loss of bone. 
 
 If we sum up the results of compound fractures of the extremi- 
 
MR. LISTERS COMPOUND FRACTURES. 
 
 477 
 
 Result of Accident {continued). 
 
 were treated conservatively with good result. The attempt to eradi- 
 cate putrefaction was successful in each of the 3 cases. 
 
 the Forearm {accidental). 
 
 Primarj' amputaticin thnuigh the lower 
 part of the humerus. 
 
 Primary amputation above the iiiiddle of 
 the humerus. 
 
 Wounds washed out with i-"20 carbolic 
 lotion. Some loone fragments of the 
 broken radius were removed. The 
 wounds were also mopped out with 
 chloride of zinc. Splints applied. 
 
 Wound enlarged and a solution of car- 
 bolic acid in spirit injected. 
 
 Wound washed out with 1-20 carbolic 
 lotion. 
 
 Wound enlarged and injected with 1-20 
 carbolic lotion. 
 
 Wound washed out witli 1-20 carbolic 
 lotion. 
 
 Aseptic course. A minute superficial sore re- 
 mained to heal, where the drainage-tubes were, 
 when the patient was discharged. 
 
 Aseptic course. Wound healed by first intention, 
 except where the drainage-tube was. Here a 
 small superficial sore remained to heal when 
 the patient was discharged. 
 
 The fingers regained their warmth during the 
 first twenty-four hours. Putrefaction was 
 avoided, and the case went on well. So much 
 of the radius was lost that union could not take 
 place. The wounds were quite superficial on 
 August 19, and had healed when the patient 
 was discharged. (See No. 105.) 
 
 Aseptic course. Highest temperature 99-9, pulse 
 82. Date of healing is not gi\Tn, but healing 
 was com|)lete and the bones were strong before 
 the patient left the hospital. 
 
 Putrefaction was apparently not avoided. The 
 wound did very well, but when the patient was 
 discharged it had not quite healed. Bones 
 pretty firm. Patient discharged, wearing an 
 immovable apparatus. (See T. Chart XXIV.) 
 
 Typical cciurse. When discharged to be treated 
 as an out-patient, there was only a small point 
 to Ileal, and the bones were getting firm. (See 
 T. Chart XXV.) 
 
 Followed a typical aseptic course. The arm had 
 healed and the splints were left off on April 12. 
 
 ties produced by accident and treated by jMr. Lister, we get the 
 following facts: — 
 
 Since 1871 there have been 41 patient.s (42 limbs) admitted into 
 hospital suffering from compound fractures of the long bones ; of 
 these 8 died. In 6 the cause of desith was shock and exliaustion, 
 and death occurred within forty-eight hours after the accident ; in 1 
 the cause was diphtheria, and in 1 bronchitis and cardiac disease. 
 
478 
 
 RESULTS OF ANTISEPTIC SURGERY. 
 
 I. — Compound Fractures, the 
 
 Of the 42 limbs injured 10 (10 patients) were amputated prima- 
 rily, and of these four died (all from shock). I need not refer to 
 these again, as they do not concern the point at issue. There were 
 thus 31 patients (32 compound fractures) in which conservative 
 treatment was attempted, and of these 4 died (2 of shock, 1 of diph- 
 theria, and 1 of bronchitis and cardiac disease) ; but then only 1 of 
 these deaths (case 4, which died of bronchitis and cardiac disease) 
 can possibly be supposed to have any connection with the method of 
 treatment of the wound. Hence, for our present purpose, we have to 
 consider 28 cases (29 fractures) treated conservatively with one death. 
 The fatal result in this instance is stated to have been cardiac dis- 
 ease and bronchitis, but the precise cause does not tell against the 
 aseptic results, for in this case putrefaction took place. * 
 
 Of the 32 limbs treated conservatively, only 2 required secondary 
 amputation, and one of these patients died of diphtheria, or we may 
 perhaps put it better, and say that of the 29 limbs (28 patients) under 
 consideration, only one required secondary amputation, and this case 
 recovered. One of the remaining 27 patients died of bronchitis and 
 cardiac disease. 
 
 Of the 30 limbs treated conservatively in patients who did not 
 die within forty-sight hours, the attempt to eradicate putrefaction 
 
 Compound Fractures 
 
 43 
 
 Name ami Age 
 
 William S., 18 . 
 
 Date of Admission 
 
 and Discliarnc ; with 
 
 Result 
 
 Injury 
 
 Ad., Jan. 29, 1872. |Coni])oiiii(I dpprcsscrl fracture of the right 
 Dis., May 30, ,, i tcm|i(>ral bone. Patient quite sensible on 
 Result, cured. admission. 
 
MR. LISTER 8 COMPOUND FRACTURES. 
 
 479 
 
 Result of« Accident (continued). 
 
 was successful in 22 instances, and none of these required fuilher 
 measures ; all healed. But in 8, or 26-6 per cent., the attempt was un- 
 successful ; of these 1 died, in 2 secondary amputation was necessary, 
 one of which patients also died of an independent disease, while in 
 some of the remainder the further progress of the case was unsatis- 
 factory This is a striking fact, as showing the difference in results 
 between cases treated aseptically and those treated with antiseptics. 
 These figures do not, however, rightly represent the present prob- 
 abilities of rendering compound fractures aseptic, for the majority of 
 the failui-es occui-red early in the treatment, while of late the greater 
 number of attempts have been successful. Thus from the end of 
 1871 till the end of 1875, 18 cases were treated, and of these 6, or 
 33"3 per cent., ftiiled. On the contrary, from the end of 1875 till 
 1880, 12 cases were treated, only 2 of which, or 16-6 per cent., 
 failed. The chief improvement which has led to this greater success 
 is no doubt the method of washing out the wound thoroughly by 
 means of a catheter attached to a syringe — a method introduced 
 since 1875. The chance of success depends, however, almost entirely 
 on the nature of the wound and the amount of dirt in it. If it be 
 complicated and dirty the result is doubtful ; otherwise success is 
 almost certain. 
 
 of the Skull {accidental). 
 
 Treatment 
 
 Clots removed, and the wound syriiij^ed 
 out with 1-20 carbolic lotion. Gauze 
 dressing applied. 
 
 The wound remained aseptic, but in a few hours 
 the patient became restless and comjilained of 
 pain in his head. He soon became unconscious. 
 Trephiuin^was tiierefore performed on January 
 ol, the depressed bone elevated and some frag- 
 ments of the internal tabic removed. Patient 
 recovered consciousness after the operation, and 
 progressed rapidly towards recovery, the blood- 
 clot lying- exposed in the wound. At one part, 
 at the time of the ojjeratiou, the bone was felt 
 bare for some distance, but none separated, and 
 it was all completely covered on February 22. 
 The Wound had completely healed cm Mav 2. 
 Wiien the jialient was discharged, tlie j)ulsa- 
 tioiis of the brain could be seen to raise tiic 
 cicatrix. (Sec T, Chart XXVI.) 
 
480 
 
 RESULTS OF ANTISEPTIC SURGERV. 
 
 I. — Compound Fractures, the 
 
 Name ami Ap 
 
 44 
 
 A:> 
 
 George S., 18 
 
 J. MeC. (adult) 
 
 46 
 
 J. McK., 7 . 
 
 48 
 
 49 
 
 51 
 
 52 
 
 William L., 32 
 
 Andrew P., 7 . 
 
 G. W. E., 12 . 
 
 Gcorj^e II., 3fi . 
 
 David McC, 30 
 
 A. C, 15 
 
 Thomas G., 32 , 
 
 Date of Adniissioii 
 
 ami Discharge ; with 
 
 Result 
 
 Ad., Feb. 12, 1872. 
 Dis., Feb., 18, „ 
 Besult, in process of 
 cure. 
 
 Ad., March 4, 1872. 
 Dis., ISIay 2, „ 
 Result, cured. 
 
 Ad., June 14, 1872. 
 ])h., July 22, „ 
 Besult, in process of 
 cure. 
 
 Ad., Nov. 15, 1872. 
 Died, Nov. 17, „ 
 The cause of death 
 was injury to the 
 brain substance. 
 
 Ad., Sept. 15, 1.S7G. 
 Dis., Oct. 8, 
 Result, cured 
 
 Ad., April 2, 1878. 
 7>/s., April 15, ,, 
 Ncsiilt, cured. 
 
 Ad., M:iy 14, 1878. 
 Died, May 15, „ 
 The cause of death 
 
 wasfracture of the 
 
 skull, &.C. 
 
 Ad., Oct. 3. 1880. 
 iJis., Oct. 1 8, „ 
 Result, cured. 
 
 Ad.,.Ur\. 22, 1880. 
 Dis., Feb. 9, „ 
 Result, in process of 
 cure. 
 
 .4 rf., April 9, 1! 
 Di.i., April 20, 
 Result, cured. 
 
 Injury 
 
 Compound fracture of the os frontis. 
 depression. 
 
 No 
 
 The handle of a windlass struck patient on 
 the forehead, causing a depressed compound 
 comminuted fracture of the os frontis. 
 Fracture of nasal bones. The patient was 
 conscious when admitted. 
 
 Depressed compound fracture of temporal 
 bone. 
 
 Patient fell from a heii>ht of 20 feet, sustain- 
 ing a compound fracture of the skull. 
 Patient insensible, pupils dilated, surface 
 cold, had several convulsive fits before 
 admission. 
 
 Compound fracture of temporal and frontal 
 bones. Bleeding" from the ear and nose. 
 Run over by the wheel of a c.nb, head 
 markedly flattened. 
 
 An iron gate fell on his head detaching 
 nearlj^ half the scalp, which was hanging 
 down. Bone fissured. 
 
 Patient fell 10 feet, striking his head and 
 causing an extensive compound ('ommi- 
 nuted fracture of the skull. Patient insen- 
 sible, but muttering and restless. 
 
 Struck on the head by a bottle, causing two 
 incised wounds and fissure of the skidl. 
 Patient drowsy, but sensible. 
 
 Fell on his head from a height of 35 feet. 
 Large scalp wound, fracture of parietal 
 bone, and other injuries, no depression. 
 Patient quite insensible when admitted 
 into hospital. 
 
 Fell 68 feet, and struck his forehead, receiv- 
 ing a compound fissure of the frontal bone. 
 Patient sensible ; other bruises present. 
 
MR. LISTERS COMPOUND FRACTURES. 
 
 481 
 
 Result of Accident [continued). 
 
 Wound injected with 1-20 carbolic lotion, 
 and for the most part stitched. 
 
 Wound injected with 1-20 carbolic lotion, 
 depressed bone elevated, and portions 
 of loose bone and of the internal table 
 removed. 
 
 Wound injected with 1-20 carbolic lotion, 
 and left quite oi)en. 
 
 Comminuted portions removed, and de- 
 pressed bone elevated. Wound 
 washed out with 1-20 carbolic lotion. 
 
 Wounds injected with 1-20 carbolic lo- 
 tion. Ears stufl'ed with gauze. 
 
 Wound thoroughly washed out with 1-20 
 c.irbolic lotion, catjfut drain and numer- 
 ous horsehair stitches. 
 
 A portion of loose bone was rcmovdl, and 
 the wound was syrinj;cd out, and left 
 open. 
 
 Two small pici'csdf the outer tabic were 
 rcnujved and the wound was washed 
 out with 1-21) carbolic lotion. 
 
 A portion of bone was loose, and was re- 
 moved, wound washed out witii 1-20 
 carbolic lotion. 
 
 WoHinl washi'd out wiili 1-20 carliolii 
 Inii. n. 
 
 Aseptic course. No suppuration, the wound heal- 
 ing bv first intention and organisation of blood 
 clot. ' 
 
 Aseptic course- The Avound had quite healed on 
 March 16. As there was slight redness and 
 pain at one part of the scar, it was opened up 
 on March 27, and one or two minims of jnis 
 escaped. This had soundly healed by April 19. 
 There was an elevation of temperature on 
 March 7, apparentlv due to derangementx>f the 
 bowels, as it subsided at once on administering 
 a laxative. (See T. Chart XXVII.) 
 
 This case followed an aseptic course till July 12, 
 when, probably owing to the restlessness of 
 the patient and consequent displacement of the 
 dressings, the wound was found to have be- 
 come putrid. By tliis time, however, the 
 deeper parts had closed. When discharged 
 there was stiU a small suppurating wound, and 
 a portion of the os frontis could be felt to be 
 bare. 
 
 Absolute insensibility, with occasional convulsive 
 attacks, continued till his death, about 36 hours 
 after the injury. 
 
 Aseptic course, except that an abscess formed on 
 the side of the head behind the eye. Everj'- 
 tliing had healed, and was apparently sound 
 when the patient was discharged. 
 
 Aseptic course. The woimd healed entirely by 
 tirst intention, except at one point where a 
 little piece of horsehair draiti was employed. 
 On April 12, there -were just three tiny points 
 to heal. A collodion dressing was ap])lied. 
 (See T. Chart XXVIII.) 
 
 Th" patient never recovered consciousness, and 
 died about 27 hours after the accident. The 
 skull was found to be very extensively frac- 
 tured and ha'niorrliage had <icciirr('d in various 
 places but no lesion of the brain was found. 
 
 As ptic course. On Octolter \'i\ two additional 
 |ii('ces of bone were rtnuivcd. (See T. Chart 
 XXIX.) 
 
 Aseptic course. The wound had .'dniost healed 
 when the patient was dischargeil, to be treated 
 as ati out-|iatient. (See T. Chart XXX.) 
 
 Aseptic cour.se. Tiui wound h.id qnile iie.iled 
 when the patient w.is discli.irucd. 
 1 I 
 
482 
 
 BESVLTS OF ANTISEPTIC SURGERY 
 
 xvm 
 
 
 XK 
 
 XZ 
 
 m 
 
 :m em em em em em em em e 
 
 
 M EM EM EM EM EM EM EM Et 
 
 XXI 
 
 xxu 
 
 Tkmperatitkk Charts oh' Mr. Listek's Cases op Compound Fractukk. 
 
MR. LISTERS COMPOUND FRACTURES. 
 
 J 83 
 
 M EM EM EM EM EM E 
 
 —■■■— ■■■■■■■ 
 
 MilililMIBHilHWMIHIIlllW 
 
 IHljHHSMHI 
 
 XXV 
 
 XXMIL 
 
 xjLvar 
 
 EM EM EM EM EM EM eH tM 
 
 ^■■■■■■■■■■■■■■^ 
 ■■■■■■■■■■■■■■^ 
 
 {■■■^■■■■■■■n 
 
 m^m^mmm^m 
 
 MX 
 
 :■■■:«:■ 
 
 mwmmmmmmmmwk 
 
 L'KMPERATrUE CUAIiTS OF M R. LiSTEKS C'ASE< OF COMPOUND ]• ItACTlKE ( <Y////.) 
 
 1 I 2 
 
484 
 
 RESULTS OF ANTISEPTIC SURGERY 
 
 There were thus 11 cases of compound fracture of the skull with 
 two deaths, both due to the nature of the injury, and both occurring 
 within forty-eight hours. In all the 9 cases which survived putre- 
 faction was avoided, and the result was good. 
 
 The whole result of iNIr. Lister's hospital practice in regard to 
 compound fractures produced accidentally since 1871 is therefore as 
 follows : — 52 cases of compound fracture of the skull and long bones 
 (53 fractures) were treated with 10 deaths. 
 
 Leaving out of consideration here all the cases which died within 
 forty-eight hours, we have 44 cases (45 fractures) with 2 deaths, 
 
 1 from diphtheria and 1 from bronchitis and cardiac disease. 
 
 Or, taking the facts in another way, and, as is generally done, 
 leaving out cases requiring primary amputation, Ave have 42 
 cases (43 fractures) treated conservatively with 6 deaths ; and 
 omitting also cases which died within 48 hours, and which 
 have no bearing on the point at issue, we have 38 cases of 
 compound fracture of the skull and long bones (39 fractnres) with 
 
 2 deaths, 1 of these deaths being certainly independent of the wound. 
 
 In 31, or 81'5 per cent., of these cases the attempt to eradicate the 
 causes of putrefaction was successful, and all of these cases re- 
 covered, i.e., 31 compound fractm^es of the skull and of the long 
 bones were treated aseptically without a death and, in the case of 
 the limbs, without necessity for further operation. 
 
 I now propose to consider the compound fractures made by the 
 
 II. Compound Fractures 
 Compound Fractures of 
 
 54 
 
 Name 
 
 and Age 
 
 James 
 
 M., 
 
 13 . 
 
 Alexander 
 
 W., 
 
 37 
 
 
 
 Frances (J. 
 
 , 54 . 
 
 Date of Admission, 
 
 OpiTatioii and Dis- 
 
 cliarge ; with Result 
 
 Ad., Jan. 22, 1873. 
 Date of discharge 
 
 not given. 
 Result, cured. 
 
 Op., June 18, 1873. 
 Result, healed. 
 
 See No. 6, p. 42(). 
 Result, healed. 
 
 Injury 
 
 Anchylosed knee-joint. Knee bent at right 
 angles. 
 
 Ununited fracture of the femur-joint above 
 the knee-joint. 
 
 Ununited fracture of the nnck of the femur. 
 
MR. LISTERS COMPOUND FRACTURES. 
 
 485 
 
 surgeon, and I would remark that Mr. Lister's osteotomies were in 
 no sense of the word subcutaneous. They were real compound 
 fractures ; the wound in the bone communicated freely with the 
 external world and a drainage-tube in most cases kept up this 
 communication after the operation. In some instances the bone was 
 simply chiselled partly through and then broken ; in others, portions 
 of the bone were removed. I have not included in this list exci- 
 sions of joints for disease, partly for the reasons stated on p. 380, and 
 also because in almost all the cases of diseased joints, sinuses are 
 present before the patients come into hospital, and therefore the cases 
 cannot as a rule be treated aseptically : 1 or 2 cases where a 
 joint was anchylosed, and where a wedge-shaped piece of bone was 
 removed, in other words where a compound fracture was produced on 
 a healthy bone, are included. 
 
 From these cases the element of shock is excluded, and there- 
 fore we ought to have results comparable to the 38 cases of compound 
 fracture with 2 deaths ; and if these deaths were really independent 
 of the wound, we ought here to have no deaths at all. Here also 
 the certainty as to the ultimate result ought to be greater and the 
 character of the results better ; for here we have merely to exclude 
 the causes of fermentation, whereas in the other cases we had to 
 destroy those ivhich had entered. In other respects they are 
 comparable injuries, and, therefore, at the end I shall sum up all the 
 compound fractm'es together, whether they have been made by the 
 surgeon or have occurred accidentally. 
 
 MADE BY THE SuilGEON. 
 
 the Fenntr (^Surcjeon). 
 
 A wcili,'c-sli;ij>cd piece of lione was re- 
 llioveil, anil tlic, le;;' was Ijrinijilit 
 straitclit. Iiicisiou made over the seat 
 of fracture. 
 
 Ends of bones refreshed by KOi'o'^ '""1 
 lianiincr. Wound left open. 
 
 Operated on. 
 
 Ty|iii'al aseptii; tdurse. On Filiruary 'l all the 
 stitches were removed, and every thinj; was 
 healed, except wliere the ihainaj,a'-tube was. 
 All soundly healed (ni Feliniary 11. 
 
 Aseptic course. Cimipletely healed during 
 Auf;ust. The temperature was taken once 
 daily, and was only once up to 100"^. iNo 
 union. Sec Nos. 57 and 58. 
 
 Aseptic cour.se. (See T. Chart I A'.) 
 
486 
 
 RESULTS OF ANTISEPTIC SURGERY. 
 
 II. Compound Fractures 
 
 Name and Age 
 
 58 
 
 59 
 
 ()0 
 
 01 
 
 (i2 
 
 G3 
 
 r,4 
 
 Alexander VV., 
 38 ... . 
 
 Alexander W., 
 38 ... . 
 
 Thomas D., 37 
 
 Richard K., 12 . 
 
 Peter M.,30 
 
 C. VV. Y., 9 
 
 Date of Operation 
 
 aud Pischarftx' ; 
 
 with Result 
 
 Thomas D., 38 . 
 
 Mary McD., Ifi. 
 
 Op., March 6, 1874. 
 Result, healed. 
 
 Op., July 17, 1874. 
 Dis., Sept. 21, „ 
 Result, cured. 
 
 Op., July 23, 1875. 
 Dis., Nov. 23, „ 
 Resiilt, healed. 
 
 Op., Oct. 4, 1875. 
 Bis., Dec. 14, „ 
 Result, cured. 
 
 Op., Feb. 19, 1876. 
 Bis., July 27, „ 
 Result, cured. 
 
 Op., March 14, 187G. 
 
 Dis., Oct. 14, 
 
 In process of cure. 
 
 Op., July 19, 1870. 
 Bis., Sept. 20, 1877. 
 In process of cure. 
 
 0/5., July 15, 187r). 
 Bis., Feb. 7, 1877. 
 Result, cured. 
 
 Injury 
 
 See No. 55. Fracture still ununited. 
 
 See No. 57. Fragments still ununited. 
 
 Ununited fracture of femur about its middle, 
 
 of eleven months' standing. Various me- 
 thods of treatment tried. 
 
 Aggravated knock-knee on one side. 
 
 Ununited fracture of the femur about ten 
 inches belov/^ the great trochanter. Of ten 
 mouths standing. 
 
 Badly united fracture of the left femur just 
 below the trochanters. Fracture occurred 
 eighteen months previously. If inch short- 
 ening. 
 
 Sec No. 59. Fracture still ununited. 
 
 Double knock-knee. Patient coulil hardly 
 walk. The deformity commenced two 
 years previously, after a fever. 
 
MR. LISTER'S COMPOUND FRACTURES. 
 
 487 
 
 MADE BY THE SuRGEON (contimied) . 
 
 Similar operation to the former. Frag- 
 ments drilled in two places and iron 
 pegs driven in. Two wounds made. 
 Drainage-tube inserted. 
 
 A similar operation was again performed, 
 and the leg was put up in plaster of 
 Paris at once. (Intermediate amputa- 
 tion). 
 
 Ends of bone gouged, 
 inserted. 
 
 Drainage-tubes 
 
 An incision was made above the con- 
 dyles of the femur down to the bone. 
 Periosteum detached, and a wedge- 
 shajied piece of the femi;r removed. 
 Drainage-tubes inserted. 
 
 Incision on outer side of thigh. Ends of 
 botie removed. Bones drilled and tied 
 together with silver wire. 
 
 Incision on the outer side of the thigh 
 over the seat of fracture; bone divided ; 
 limb brought straight. Ends of bone 
 refreshed and tied together with silver 
 wire. 
 
 Ends of bones refreshed and tied together 
 with silver wire. 
 
 A wedge-shaped piece of bone was taken 
 out of each femur on the same day. 
 (Sec No. 60.) Drainage-tubes in- 
 
 : sertcd. 
 
 Remarks 
 
 The pegs became loose and were removed on ^lanh 
 16. The wound on the inner side healed April 
 29, and the other soon afterwards. Limb kept 
 in plaster till -June 8, and put up again till 
 July 16, but still no union. The temperature 
 was once up to 100° (100-1), on the moiniug 
 after the operation. 
 
 Putrefaction occurred here probably during the 
 application of the plaster. As the temperature 
 was going u|), Mr. Lister thought it best to 
 amputate. This Mas done on July 22, and 
 the wound followed a typical aseptic course, 
 healing entireh' by first intention except where 
 the drainage-tube was. 
 
 Aseptic course. The blood-clot became organised 
 as usual, and the gaping wound had completely 
 cicatrised on September 12, without any pus- 
 formation. Union had not occurred when the 
 patient left hospital, wearing an immovable 
 apparatus. (See T. Chart XXXI.) See No. 63. 
 
 Tj-pical aseptic course. No suppuration. Wound 
 completely healed on November 14. Highest 
 temperature was 99"6°. When seen some 
 weeks after his discharge the femur was quite 
 firm and the limb straight. 
 
 Aseptic course. Put up in plaster of Paris in 
 April. Apparatus taken down on July 5. 
 Bones united. Wire removed. (See T. Chart 
 XXXII.) 
 
 A good deal of constitutional disturbance followed 
 the operation ; the wound suppurated and ab- 
 scesses formed. When the patient was dis- 
 charged a small sinus remained unhealed. The 
 femur was quite firm and the leg straight, and 
 only ^ in. shorter than the other. One or two 
 small pieces of bone came away. Ultimately 
 healed. 
 
 Aseptic course. Patient was kept in hospital 
 having various immovable apparatuses applied 
 at intervals, but when discharged there was 
 still a little mobility. The silver wire was left 
 in, and the fragments ultimatelv united without 
 further operation. (See T. Chart XXXIII.) 
 
 Aseptic course. The right leg had completely 
 healed at the end of -Vugust, and the loft almost. 
 Fioth limbs uere put u|> in plaster of Paris on 
 August MO. This was taken down on November 
 oO, when both hones were found to be united 
 (See T. Chart XXX IV.) 
 
488 
 
 RESULTS OF ANTISEPTIC SUROERF. 
 
 II. Compound Fractures 
 
 Name and Age 
 
 60 
 
 68 
 
 09 
 
 70 
 
 72 
 
 Adam S., 6 . 
 
 JohnT.. 11 . 
 
 Emma P., 9 
 
 George E., 12 
 
 Thomas E., 35 
 
 Jane D., 50 . . 
 
 Beatrice J., 14 . 
 
 Frank J., 7 
 
 Date of Operation 
 
 and Discharge ; 
 
 with Kesult 
 
 Op., Aug. 1, 1876. 
 iJis., Dec. 4, „ 
 Result, cured. 
 
 0/)., June 29, 1877. 
 Z>/»-. durin.i^ autumn. 
 Result, cured. 
 
 Op., Nov. 20, 1877. 
 IJis., July 27, 1878. 
 Result, cured. 
 
 Op., Jim. 29, 1.S79. 
 Dls., Dee. 14, „ 
 Result, healed. 
 
 Op., March 19, 1879. 
 J)is. May 15, „ 
 Result, cured. 
 
 Op., April 9, 1879. 
 Uis., J une 30, „ 
 Result, healed. 
 
 Op., May 16, 1879. 
 IJis., July 8, „ 
 Result, cured. 
 
 Op. May 21, 1879. 
 Dis., J lily 8, „ 
 Result, cured. 
 
 Injury 
 
 Aggravated knock-knee on one side. 
 
 Both knee-joints ancliylosed at an acute 
 angle — tiie result of j)revious disease. 
 
 Left knee-joint anchylosed nearly at a right 
 angle. 
 
 Ununited fracture of the neck of the femur 
 of six weeks' standing (extracapsular). 
 
 Double iSL'ini valgum. 
 
 Ununited fracture of the femur. 
 
 Genu valgum on the right side. 
 
 Genu valgum on both sides. 
 
MR. LISTERS COMPOUND FRACTURES. 
 
 489 
 
 MADE BY THE SuRGEON {continued). 
 
 Treatment 
 
 Similar operation to No. 64. Drainage- 
 tube inserted. 
 
 Left leg operated on. Only so much 
 bone removed as was necessary to ob- 
 tain a straight position of the limb. 
 
 Portions of the end of the femur were re- 
 moved, and the leg was got straight 
 after division of the hamstring ten- 
 dons. Horsehair drain. 
 
 A long incision was made on the outer 
 side of the thigh over the great tro- 
 clianter. The fragments refreshed and 
 two drainage-tubes inserted. Long 
 splint. 
 
 MacEwen's operation on both thighs at 
 the same time. Drainage tubes in- 
 serted. 
 
 Ends of fragments refreshed and tied 
 together with silver wire. 
 
 MacEwen's operation on the right thigh. 
 Drainage-tubes inserted. 
 
 MacEwen's operation on both limbs on 
 the same day. Drainage-tubes in- 
 serted. 
 
 Aseptic course. Wounds quite superficial and 
 almost healed on September 1. The femur was 
 quite lirm on September 4, but there was still 
 slight divergence outwards. This was due to 
 want of caie in adjusting the splints during 
 the holidays. 
 
 Aseptic course. The greater part of the wound 
 healed by tirst intention, but two sinuses were 
 still unhealed in the beginning of September 
 when Mr. Lister left Edinburgh. I hear that 
 the patient left the hospital soon afterwards, 
 with the woimds quite healed and able to move 
 his knee very slightly (a movable knee-joint 
 was aimed at in the first instance). 
 
 Aseptic course. Wound healing by first intention 
 except where the drain was. The drain was 
 removed on January 12. A small abscess 
 formed on the outer side of the knee, and was 
 opened on February 5. A minute sinus remained 
 here for a long time, the wound being soundly 
 healed and the bones firm. It healed a few 
 days after the patient was sent to a convalescent 
 home. 
 
 There was considerable constitutional disturbance 
 after the operation, and the temperature at 
 times Avas as high as 101'G°. A little suppura- 
 tion occurred from the wound, but the greater 
 part healed by first intention. A little bit of 
 loose dead bone (apparently a chip from the 
 operation) was removed on November 11, and 
 then the sinus at once closed. Union did not 
 occur. From the high temperature and the 
 suppuration it is probable that some ferment 
 had got in, but the discharge was not examined, 
 and it never had anv smell. (See T. Chart 
 XXXV.) 
 
 Aseptic course. Both wounds had healed at the 
 end of April. Union was then complete. 
 Patient began to walk on Mav 5. (See T. 
 Chart XXXVI.) 
 
 Aseptic course. No suppuration. Wound healed 
 about May 15. Patient was discharged wearing 
 an apparatu.s, but union did not occur. 
 
 Aseptic course. Healed about .June 5. Splints 
 removed and bones united on June 2^. Began 
 to walk on June 29. (See T. Chart XXXVII.) 
 
 Asc])tic ciiurse. l?olh wounds had healed by 
 Jun:; 10. Union jicrfcct on Juik' 'M). Joints 
 freely movable. (See T. Chart XXXVIII.) 
 
400 
 
 RESULTS OF ANTISEPTIC SURGERY. 
 
 II. Compound Fractures 
 
 No. 
 
 Name and Age 
 
 Date of Operation 
 
 and Discharge ; 
 
 with Result 
 
 Injury 
 
 
 73 
 
 Lydia \V., 9 . 
 
 Op., July 9, 1879. 
 Dis., Aug. 19, „ 
 Result, cured. 
 
 Genu valgum on right side. See also No. 87. 
 
 
 74 
 
 Ethels., 5 . . 
 
 Op., Oct. 15, 1879. 
 Dis., Dec. 14, „ 
 Result, cured. 
 
 Double genu valgum. 
 
 
 75 
 
 John M., 15 . 
 
 Op., Oct. 22, 1880. 
 Dk, Jau. 3, 188L 
 Result, cured. 
 
 Genu valgum on the right side. 
 
 
 76 
 
 Henry D., 17 . 
 
 Op., Nov. 5, 1880. 
 Dis., Jan. 7, 1881. 
 Result, cured. 
 
 Bony anchj-losis of knee-joint of eight years' 
 standing : leg at right angles to the thigh. 
 
 
 We have thus 23 cases in which compound fractures of the femur 
 have been made by the surgeon (27 compound fractures). In all 
 but 3 cases there was a typical aseptic course, i.e., the patient ate as 
 well and was as well in every respect as if he had not been operated on, 
 while there was no suppuration from the deeper parts of the wound, 
 
 Corajwuncl Fractures 
 
 77 John C, 44 . . Op., Aug. 28, 1872. Ununited fracture of both bones of the leg. 
 Result, healed. 
 
 79 
 
 80 
 
 81 
 
 John C, 45 , 
 John C, 45 
 
 Eliza L., 23 , 
 Eliza L., 21 . 
 
 Op., July 30. 1873. 
 Result, healed. 
 
 Op., Jan. 15, 1874. 
 JHs.. Sept. 3, „ 
 Result, cured. 
 
 Op., June 6, 1874. 
 J)is., Aug. 1.3, „ 
 Result, cured. 
 
 Op., March 17, 1«75. 
 
 Exact date of dis- 
 charge cannot be 
 ascertained. 
 
 Result, cured. 
 
 Former case (No. 77). Still ununited. 
 
 Former case (Nos. 77 and 78). Tibia still 
 ununited. 
 
 Badly united Pott's fracture. Leg much 
 everted. 
 
 Patient (Ni). 80) had used her foot loo freely, 
 and there was some return of the deforniit\'. 
 
MR. LISTER'S COMPOUND FRACTURES 
 
 491 
 
 MADE BY THE SuRGEON (continued). 
 
 MacEwen's operation, 
 inserted. 
 
 Draiuai;e-tube Aseptic course. No date of healinsr. Allowed to 
 get up fur the first time on August 12. Union 
 then perfect and wound healed. 
 
 M.icEwen's operation on both sides. 
 Drainage-tubes inserted. 
 
 MacEwen's operation on the right side. 
 
 Wedge-shaped piece of bone removed. 
 Horse-hair drain. 
 
 No local disturbance, but the temperature rose a 
 little for a day or tAvo, being once as high as 
 101°. The child, however, was quite well. On 
 November 6 one wound Avas healed and the 
 other ne 'riv so. Both legs seemed to be firm 
 at that time. (See T. Chart XXXIX.) 
 
 Aseptic course. Wound superficial on November 
 10, and boracic dressing applied. Patient got 
 up on December 4. (See T. Chart XL.) 
 
 Aseptic course. On December 9 all healed except 
 two spots where the drain was. Patient got up 
 on January 2. Seen last on March 20, when he 
 could walk well without anv support. Bones I 
 quite firm. (See T. Chart XLI.) I 
 
 and as a rule none at all from the superficial part. In one case 
 where putrefaction occurred, secondary amputation was performed as 
 being the safest treatment and also the best when the difficulty in 
 getting union and the shortening of the limb were taken into 
 account. 
 
 of the Leg [Surgeon). 
 
 Ends of the bones refreshed and l)rought 
 into good position. Wound left open. 
 
 Similar operation. 
 
 Similar operation. Iron 
 driven into the tibia. 
 
 pegs were 
 
 Fibula divided obliquely. Foot brought 
 straight. Wound left open. Dupuj- 
 tren's splint. 
 
 Similar treatment. 
 
 Aseptic course. On November .5 the limb was 
 put up in plaster of Paris. This was reapplied 
 several times till July, 1873, but union did not 
 take place. See No. 78. 
 
 Aseptic course On September .5 the wound was 
 small and quite superficial. The fibula united, 
 but the tibia did not. See No. 79. 
 
 Aseptic course. On March 12 union was found 
 to have occurred, and the pegs were removed. 
 The rest of the wound had healed. The patient 
 was, however, kept in ho.spital for some time. 
 
 Aseptic course. Wound had herled and the 
 bones were apparently firm when the patient 
 was discharged. 
 
 Aseptic course. Kept loiigor in an apparatus. 
 On this occasion the cure was permanent. (See 
 T. Chart XLI I.) 
 
4!)2 
 
 RESULTti OF ANTISEPTIC SURGERY. 
 
 II. Compound Fractures 
 
 82 
 
 83 
 
 84 
 
 85 
 
 80 
 
 88 
 
 89 
 
 90 
 
 Name and Age 
 
 Martlia C, 28 
 
 William M., 3(3 
 
 Martha C, 28 
 
 FinlayMcD.,29. 
 
 Date o" Operation 
 
 anil Discharge ; 
 
 with Result 
 
 Alexander A., 23 
 
 Lydia VV., 9 
 
 Henrv B., 32 
 
 Frederick A., 2G 
 
 Joseph B., 2. 
 
 O/)., All-. 18, 1875. 
 Din., Oct. 2, 1876. 
 Result, healed. 
 
 Op., Dec. 21, 187o. 
 DIs., March 2, 1876. 
 Result, cured. 
 
 Op., Feb. 27, 1876. 
 Result, cured. 
 
 0/j., Jan. 16, 1877. 
 Dis., June 9, „ 
 Result, cured. 
 
 Op., July 19, 1877. 
 Dis., Oct. 13, „ 
 Result, cured. 
 
 Oj>., July 9, 1879. 
 Di.^., Aus. 19, „ 
 Result, cured. 
 
 0/3., Dec. 12, 1879. 
 Dis., March 31, 1880. 
 Result, cured. 
 
 Op., Nov. 0, 1879. 
 Dis., Dec. 16, 1879. 
 Result, cured. 
 
 Oj>., June 18, 1880. 
 His., July 15, 1880. 
 Result, eured. 
 
 Injury 
 
 Congenital deformity of right foot. Invcr- 
 f-ion of foot, the inner surface of which 
 formed an angle of 140° with the axis of 
 the leg. 
 
 Badly united fracture of the leg with dis- 
 lilaccment of the font backwards. Of 
 fourteen mouths' standing. 
 
 See case No. 82. 
 
 Badly united fracture of both bones of the 
 leg, just below the tuberosity of the tibia. 
 Leg bent inwards. 
 
 Ununited fracture of both bones of the leg at 
 the junction of the middle and lower thirds. 
 Cf fourteen weeks' standing. 
 
 Rickety deformity of one leg 
 73. 
 
 See also No. 
 
 Badly united 
 everted. 
 
 Pott's fracture. Foot much 
 
 Patient was admitted a fortnight previously 
 with simple fracture of both bones of the 
 leg. A fragment of the tibia projected 
 under the skin, causing great pain and 
 threatening to protrude. 
 
 Rickety deformity of both legs. 
 
MR. LISTERS COMPOUND FRACTURES. 
 
 493 
 
 MADE BY THE SURGEON {continued). 
 
 Treatment 
 
 Remarks 
 
 Fibula cut through and a wedge-shaped 
 portion of bone removed from the tibia. 
 Extensor tendons divitled. Bones tied 
 together 'iv silver wire. Foot brougtit 
 into straight position. 
 
 Tiljia and fibula divided bv lateral inci- 
 sions. Foot brought straighL Du- 
 jjuytren and horseshoe splints. 
 
 End-s of fragments refreshed. Similar 
 after-treatment to that formerly 
 adopted. 
 
 Fibula cut across. Wedge-shaped piece 
 of bone removed from tl'C tibia. A 
 portion of the fibula cut away. Leg 
 straightened, and wounds left open. 
 
 Incisions over each bone, and the frag- 
 ments refreshed. Iron pegs driven 
 iuto the fragments of the tibia. 
 
 Incisions over the bon^^s which were then 
 cut across. Drainage-tubes inserted. 
 No stitclies. 
 
 An incision was made over the site of the 
 former fracture, and the libula divided 
 obli(|uely. Foot inverted by means of 
 pulleys. Drainage-tubes inserted. 
 Dupuylren's splint. 
 
 Mr. Lister cut down on and removed the 
 projecting portion, thus causing a com- 
 pound fracture. 
 
 Incisionn over the tibia and fibula. 
 Hones divided. Wounds left r)peri. 
 ]5oth legs oper.ated on. 
 
 Aseptic course. Wounds superficial on September 
 18. When seen in Februarv, 1876, the b(me 
 was still ununited. See No. 84. (See T. Chart 
 XLIII.) 
 
 Aseptic course. Bones firmlj' united and only a 
 little speck to heal on February 1. 
 
 As?ptic course. On this occasion imion took 
 place, but the dates of union and discharge are 
 not given in the note books. 
 
 Aseptic course. Tibial wound found healed on 
 March 1, and the fibular on March 3. Plaster 
 of Paris removed on March 10, and the bones 
 found to be firm. It was reapplied till 
 May 1, when it was finally left otf. the bones 
 being quite firm and strong. (See T. Chart 
 XLIV.) 
 
 Aseptic course. The temperature rose on one 
 occasion as high as 99-8°. Iron pegs removed 
 on September 1, and wounds healed a few days 
 later. On October 4 the bones were lound to 
 be quite united. 
 
 Aseptic course. Date of healing not given. Pa- 
 tient allowed to get up for the first time on 
 August 12. Union then perfect and the wounds 
 quite healed. 
 
 Aseptic course. Wound i|uite suiterficial and 
 boracie dressing ajjplied on January' IG. Splint 
 left off anfl patient allowed to get up on Feb- 
 ruary 24. There was a little ])ointing of the 
 toes, which was overcome by elastic force. (See 
 T. Chart XLV.) 
 
 Asejitic course. On Xoveuiber 17 the wound was 
 quite suiicrlicial, and boracie <lressing Wii-s ap- 
 I)lird. riic wound was healed and the bones 
 firm when the patient left the hospital. 
 
 Aa-'ptic course. No date of healing. Wounds 
 quite healed and the bones firm wlicn tiie i)a- 
 tiiut was disciiarged. (.See T. Chart XL VI.) 
 
494 
 
 21ESULTS OF ANTISEPTIC SURGERY 
 
 II. Compound Fractures 
 
 No. 
 91 
 
 Name and Age 
 
 Date of O))eratioii 
 
 and Discharge ; 
 
 with Result 
 
 Ill jury 
 
 
 Jessie C, 2\\ . 
 
 Op., Oct. 29, 1880. 
 DIs., Dec. 20, „ 
 Result, cured. 
 
 Bad rickety deformity of both leg.*5. 
 
 
 Fifteen patients with compound fracture of the leg were treated 
 without a death; and in these cases there were 31 separate compound 
 
 92 
 
 93 
 
 94 
 
 Henry F., 1(5 
 
 William A., 71 
 
 Elizabeth H., 22 
 
 Op., Feb. 4, 187.5. 
 Dh., March 2, „ 
 Result, cured. 
 
 Op., June 1, 1877. 
 L>is., Aug. 6, „ 
 Result, cured. 
 
 Op., Feb. 12, 1879. 
 Ms., April 12, „ 
 In process of cure 
 
 Compound Fractures of 
 
 Simple fracture of the clavicle ; a fragment 
 projecting under the skin, cau.sing great 
 pain and interfering with the adjustment 
 of the fracture. 
 
 Unreduced dislocation of the acromial end of 
 the clavicle. Of ten weeks' standing. 
 Patient cannot use the arm well. 
 
 Cervical rib pressing forward the brachial 
 plexus and causing great pain. Patient 
 very hysterical. 
 
 There were 3 compound fractures of the clavicle without any bad 
 
 9o 
 
 90 
 
 Alexander S.,r)0 
 
 Jame.s McB., 48 
 
 John 15., 14 
 
 Op , Feb. 9, 1872. 
 JJis., Sept. 5, „ 
 In process of cure. 
 
 Op., Feb. 12, 1872. 
 DLs., Oct. 10, „ 
 Result, cured. 
 
 Op., Dec. 6, 1872. 
 DIs., Feb. 11. 187.S. 
 Result, cured. 
 
 Compound Fractures of 
 
 Ununited fracture of the humerus of two 
 years' standing. Various methods of treat- 
 ment had been previousl}* adopted. 
 
 Ununited fracture of the humerus .at the 
 junction of the upper and middle thirds. 
 Of si.x months' standing. 
 
 Fracture of lower end of humerus with dish 
 cation. Of five months' standing. 
 
MR. LISTER'S COMPOUNL FRACTURES. 
 
 495 
 
 MADE BY THE SURGEON [continued). 
 
 Both bones in both legs divided, and 
 wedjre-shaped portions removed from 
 the tibia. On the ri^ht side the bones 
 were divided in two places. 
 
 Aseptic coarse. Wounds superficial and spray 
 stopped on November 6. Exact date of healing 
 not given ; it was apparently about the end of 
 November. Splints removed and the patient 
 allowed to walk on December 14. (See T. 
 Chart XLVII.) 
 
 fractures made. In no instance did any local or constitutional 
 disturbance follow the operation. 
 
 the Clavicle (Stirgeon). 
 
 Mr. Lister cut down and removed this 
 loose portion, thus converting the case 
 into one of compound fracture. Drain- 
 age-tube inserted. 
 
 Articular surfaces removed and the ends 
 of the bone tied together with silver 
 wire. Wound left open. 
 
 Mr. Lister cut down and divided the 
 clavicle. Drawing aside vessels, &c., 
 he removed the rib, which was attached 
 to the sixth cervical vertebra, and arti- 
 culated with the first and second ribs 
 in front. Clavicle tied with silver wire. 
 Drainage-tubes inserted. 
 
 Aseptic course. The wound had healed and the 
 bone firmly united on March 6. 
 
 Aseptic course. Wire removed on July 1.5. 
 Healed on July 24. Union was perfect and the 
 movements were greatly improved when the 
 patient left hospital. (See T. Chart XLVII I.) 
 
 Aseptic course. Wound healed by first inten- 
 tion, except where the drainage-tube was. 
 Wound quite healed on March 12. The clavicle 
 did not unite firmly till September. Wire re- 
 moved during November. (SeeT. Chart XLIX.) 
 
 symptom. 
 
 the Humerus (Surgeon). 
 
 Ends of fragments s.awn off, bones tied 
 together by silver wire. Wound left 
 open. 
 
 Ends of fragments refreshed and tied 
 together with silver wire. Drainage- 
 tube inserted. 
 
 Excision of elbow-joint b}' a longitudi- 
 nal incision. 
 
 Aseptic course. Wire removed during March, and 
 the wouikI quite healed on April 4. The bone 
 was almost, but not absolutely, firm, and the 
 patient was discharged wearing a silicate appa- 
 ratus. 
 
 Aseptic course. The greater part of the wound 
 healed typicaliy, but a sinus remained around 
 the wire leading down to bare bone. On June 
 3, osseous union was com|)]('te. Wire removed 
 on Auirust 2.'?. When discharged tliere was 
 still a sinus leading down to bare bone. 
 
 No constitutional disturbance. A smjill abscess 
 formt'd on the outer part of the limb, and was 
 opened on December 20. It h.-id healed on 
 January 20. The opera! ioti wound had en- 
 tirely healed on January (>. except a minute 
 su])erfi<'ial crack with the healing of whicli the 
 movement of the arm seemed for some time to 
 interfere. The movement was good when pa- 
 tient was discharged. 
 
496 
 
 MESULTS OF ANTISEPTIC SURGERY. 
 
 II. Compound Fractures 
 
 98 
 
 99 
 
 100 
 
 101 
 
 102 
 
 103 
 
 Name and Ago 
 
 Peter B., 1 1. 
 
 Donald McL. 45. 
 
 James J., 24 
 
 John N., 15 
 
 Jessie S., 14 
 
 Edward W., 12 
 
 Date of Oijeration 
 
 aiirl Discharge ; 
 
 with Result 
 
 0/j., Dec. 2, 1872. 
 7>?s., Feb. 11, 1873. 
 Result, cured. 
 
 Op., Nov. 14, 1874. 
 IHs., Feb. 28, 1875. 
 Result, cured. 
 
 Op., Dee. 15, 1875. 
 iJis., June 8, 1876. 
 In proce-^s of cure. 
 
 Op., Nov. 27, 1875. 
 iJis., Jan. SI, 1876. 
 Result, cured. 
 
 Op., Mis. 21, 1875. 
 Date of discharge is 
 
 not given. 
 Result, cured. 
 
 O/)., Jan. 15, 1879. 
 In process of cure. 
 
 Injury 
 
 Similar injury to that in No. 97. 
 
 Ununited frapture of humerus a little above 
 its middle. Of fifteen months' standing. 
 
 Fracture of loAver end of humerus, with 
 inability to use the arm. Done six weeks 
 previous!}". 
 
 Badly united fraeture of the humerus, about 
 its middle, the arm being bent inwards. 
 
 Osseous anchylosis of the elbow-joint in the 
 straight position, the result of old frac- 
 ture. 
 
 Badly united fraeture of humerus. See 
 Operations on Joints, No. 18, p. 432. 
 
 Thus we have 9 compound fractures of the humerus without 
 
 Comj)ound Fractures of 
 
 104 
 
 105 
 
 106 
 
 107 
 
 108 
 
 John McI. 34 
 
 Thomas W., 14. 
 
 Alexander — , 26 
 
 J. McJ., .30 
 
 James S., 53 
 
 Result, cured. 
 
 Op., May 3, 1873. 
 JJis., Nov. 20, „ 
 Result, cured. 
 
 Op., Nov. 10, 1875. 
 Result, cured. 
 
 O/}., Jan. 15, 1876. 
 JJIs., April 13, „ 
 Result, cured. 
 
 O/)., Jan. 26, 1877. 
 ])is, June I '.I, „ 
 Result, cm 0(1. 
 
 Ununited fracture of olecranon. See Opera- 
 tions on Joints, No. 3, p, 426. 
 
 Ununited fracture of radius. See No. 38, p. 
 476. 
 
 Dislocation of the head of the radius back- 
 war Is. See 0|)erations on Joints, No. 10, 
 p. 428. 
 
 Ununited fracture of the radius : of sixteen 
 months' standing. Had been previously 
 operated on by ancither surgeon. The ends 
 of the bones were not in contact. 
 
 Ununited fracture of llie radius : oftwenty- 
 
 twii weelis' standintc. 
 
MR. LISTERS COMPOUND FRACTURES. 
 
 407 
 
 MADE BY THE SURGEON {continued). 
 
 Exci>ion of elbow-joint by a longitudinal 
 incision. 
 
 Ends of fragments refreshed and tied to- 
 gether witli silver wire. Wound left 
 open. 
 
 Excision of elbow-joint by longitudinal 
 inci:jiou. 
 
 Bone divided by hammer and chisel and 
 brought into proper pi sition. Drnin- 
 age-tulie inserted and plaster of Paris 
 applied at once. 
 
 Exc'.-ion of elbow by H-incisiou. 
 
 Remarks 
 
 Aseptic course, except that the drainage was 
 not good for the first day or two. The wound 
 had completely healed on January 27. Move- 
 ments good wtien discharged. 
 
 Aseptic course. Wound quite healed on Decem- 
 ber 27. Union was complete and wire removed 
 on February 27. 
 
 The woimd went on well till the Christmas holi- 
 days, wlien it putretied. After that an abscess 
 formed in the upper arm. In Marcli onl}' two 
 sinuses remained to heal. It is not stated 
 wiiether the.-e had com] letely healed when pa- 
 titrnt was discharged. Movements fair. 
 
 Aseptic course. The wound had completely healed 
 on .January Iti. The bones were lirui when 
 patient was discharged. 
 
 Aseptic course. The incisions were quite 
 healed on September 2o. Movements good. 
 (See T. Chart L.) 
 
 Aseptic course. 
 
 any bad results. 
 
 the Forearm ( Suryeon). 
 
 A piece of bone was cut out of the ulna 
 to allow the ends of the radius tocirme 
 into contact. Tlie ends of tiie radius 
 were refreshed Fragments tied to- 
 gether by silver wire. Lett open. 
 
 Ulna divided aixl a portion removed. 
 The ends of tlie radius refreshed. 
 Fragments tied togetlier witli silver 
 wire. Wounds left open. 
 
 Ends of radius refreshed. A piece cut 
 out of the ulna. Fragments tied to- 
 getlier with silver wire. Wounds left 
 open. 
 
 Aseptic course. 
 
 Aseptic course. Plaster of Paris applied on July 
 28, when both wounds were healed. Uenioved 
 on November 17, when union was complete. 
 Wires also i-emnveJ on that day. Seen again 
 in March, 1874, when the arm was strong, 
 and in every way perfectly useful. 
 
 Aseptic course. 
 
 Aseptic course. The wounds had healed and 
 union was complete when the patient was dis- 
 charged. 
 
 Aseptic course. Both wounds had healed in six 
 weeks without any pus formation whatever. 
 Plaster of Paris was a|)plied on March 3. 
 Apjiaralusremoved on June 2, wlien union was 
 complete. Wires removed on that dav. (See 
 T. Chart LI.) 
 
 K K 
 
498 
 
 RESULTS OF ANTISEPTIC SURGERY 
 
 II. Compound Fuactures 
 
 109 
 
 110 
 
 Name and Age 
 
 William B., 45 
 
 Johu H. 28 
 
 Date of Operation 
 
 anil Discharfre ; 
 
 with Result 
 
 Op., March 20, 1879. 
 Result, cured. 
 
 Op., Jan. 14, 1881. 
 iJis., March 5, „ 
 Result, cured. 
 
 Injury 
 
 Ununited fracture of the olecranon. See 
 Operations on Joints, No. 17, p. 432. 
 
 Ununited fracture of both bones of the fore- 
 arm, the result of a machine accident 
 eleven months' previously. 
 
 In all there were 7 cases of compound fracture of the fore-arm with- 
 
 in 
 
 Maggie C, 17 
 
 0/>., April 1, 1875. 
 
 l)is.. May 12, „ 
 
 Result, improved. 
 
 One ease of com- 
 pound fracture of 
 the lower jaw, 
 which did well. 
 
 Coiripound Fracture of 
 
 Anchylosis of one side of the jaw. Jaws 
 tlrmlv closed. The result of old necrosis. 
 
 Following the example of most writers who discuss the 
 results of compound fracture, I shall now leave out of consider- 
 ation the cases in which primary amputation was performed, 
 and also those which died within forty-eight hom-s. The 
 following result will then be obtained. Since the end of 
 1871 up to the present time Mr. Lister has had under bis care 
 95 ^ patients affected with compound fractm-es ; of these 95 
 patients only 2 died. (The number is apparently 97, but 2 
 patients are each counted twice.) I may tabulate the result 
 as follows : 
 
 Tart injured 
 
 No 
 
 of cases 
 
 No. of ileaths 
 
 Femur . 
 
 
 26 
 
 1 
 
 Bones of leg 
 
 
 34 
 
 1 
 
 Clavicle 
 
 
 3 
 
 — 
 
 Humerus 
 
 
 12 
 
 — 
 
 Fore-arra 
 
 
 12 
 
 — 
 
 Skull . 
 
 
 9 
 
 — 
 
 Lower jaw 
 
 
 1 
 
 — 
 
 Total No. 
 fracture 
 
 of 
 
 Secondary 
 
 amputations 
 
 1 
 
 50 
 
 
 2 
 
 12 
 
 
 _ 
 
 16 
 
 
 — 
 
 9 
 
 
 — 
 
 1 
 
 
 — 
 
 Total . 
 
 97 
 
 121 
 
 A patient on whom an operation has been performed, whose wound has 
 healcil, and on whom a second operation has then been done, is, of course 
 reckoned as two separate cases 
 
 
ME. LISTER'S COMPOUND FRACTURES. 
 
 49i> 
 
 MADE BY THE SURGEON {continued). 
 
 Treatment 
 
 Remarks 
 
 Incisions over each bone. Fragments 
 refreshed and tied together with silver 
 ■wire. Wounds left open. 
 
 Aseptic course. (See T. Chart XI., p. 439.) 
 
 Wounds superficial and spray discontinued on 
 Januarj' 31. Silicate apparatus applied on 
 February 7. Wires removed March 16. 
 Union satisfactory. (See T. Chart LII.) 
 
 out any bad result. (There were 11 distinct compound fractures.) 
 
 the Lower Jaio {Surgeon). 
 
 An incision was made behind the ramus 
 of the jaw on the anchylosed side, and 
 the condyle of the jaw was cut through. 
 
 The wound was almost absolutely healed on April 
 21, when boracic dressings were applied. A 
 Avedge was kept between the teeth, and when 
 the patient was discharged she could open her 
 mouth without aid for half an inch. When 
 seen in July her condition had much improved. 
 
 It may, perhaps, be more convenient if I separate the 
 cases of accidental compound fracture from those made by 
 the surgeon. The following is the list of the accidental ones : — 
 
 Boue 
 
 No 
 
 of cases 
 
 Xo 
 
 of death 
 
 Femur 
 
 
 3 
 
 
 1 
 
 Leg . 
 
 
 19 
 
 
 1 
 
 Humerus . 
 
 
 3 
 
 
 — 
 
 Fore-arm . 
 
 
 .5 
 
 
 — - 
 
 Skull . 
 
 
 9 
 
 
 — 
 
 Secondary 
 amputations 
 
 Total 
 
 39 
 
 The following is the list of those made by the surgeon:—- 
 
 Bone 
 
 No. of cases 
 
 No 
 
 of fractiu-cs 
 
 No. of deaths 
 
 Femur 
 
 23 
 
 
 27 
 
 — 
 
 Leg . 
 
 L") 
 
 
 31 
 
 — 
 
 Clavicle 
 
 3 
 
 
 3 
 
 — 
 
 Humerus . 
 
 9 
 
 
 9 
 
 — 
 
 Fore-arm . 
 
 7 
 
 
 11 
 
 — 
 
 Lower jaw 
 
 1 
 
 
 1 
 
 — 
 
 Secondary 
 
 amputations 
 
 1 
 
 Total 
 
 82 
 
 K K 2 
 
xw 
 
 
 agmi 
 
 jiH 
 
 
 I^Hfi 
 
 jaH 
 
 
 8BBMI 
 
 HH 
 
 
 bhbb 
 
 ■S 
 
 
 iBBB 
 
 h|| 
 
 
 ■BBB 
 
 ■H 
 
 an 
 
 ESBH 
 
 MB 
 
 HK 
 
 jIBBHH 
 
 IB 
 
 
 ^IhB 
 
 ^Mum 
 
 ■ 
 
 
 ■1 
 
 ■ 
 
 Bl 
 
 JULY 19 ?0 21 ?^ i3 ;4 il 
 
 i !m e 
 
 M E 
 
 M E 
 
 M E 
 
 M E 
 
 ^ E 
 
 M t 
 
 1 '"*' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^- 
 
 
 
 
 
 
 J J 
 
 \ 
 
 ^ 
 
 n 
 
 
 
 
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 Temperature Charts of Mr. Listers Cases of Compound Fracture (ty/i^ /(/«</;. 
 
502 MESULTS OF ANTISEPTIC SURGERY. 
 
 Some writers have a fancy now-a-days to group tlie cases 
 according to age. The following are the facts in these 95 
 cases : — 
 
 0-9 years 10-19 20-29 30-39 40-49 50-59 60-69 70-79 
 12 cases 25 19 20 8 7 2 1 
 
 (In one case the age is not known.) 
 
 If we again subdivide these into accidental and intentional, 
 we find the following : — 
 
 Accidental. 
 
 0-9 years 10-19 20-29 30-39 40-49 50-59 60-69 70-79 
 
 4 10 (1 death) 7 (1 death) 9 2 3 2 
 
 (In one case the age is not known.) 
 
 Intentional. 
 
 0-9 years 10-19 20-29 30-39 40-49 50-59 60-69 70-79 
 S' 15 12 11 6 4 1 
 
 It is thus evident that the results are not due to absence 
 of old patients. 
 
 The result exactly confirms the anticipations expressed on 
 p. 461, that where the element of shock is excluded, and where 
 the surgeon has merely to keep out the causes of fermentation, 
 not to eradicate them, the mortality would fall and an element 
 of certainty be introduced into the results. 
 
 In order to get comparative statistics similar to those given 
 in Chapter XVII., I have looked through Mr. Spence's account 
 of his work from 1872 to 1878, given in the papers to which 
 reference has already been made (p. 378), and the following 
 seem to be the facts : — 
 
 I find mention of 16 primary amputations during this 
 period, and of these 7 died. In only 1 of these cases is it 
 stated that death occurred within forty-eight hours, and thus 
 we have to consider 15 primary amputations with 6 deaths. 
 Then I find 5 secondary amputations with two deaths, neither 
 within forty-eight hours. Also 1 secondary excision which re- 
 covered. And then only 2 cases of compound fracture treated 
 conservatively, both of which recovered. Whether these are 
 all the cases of compound fracture treated conservatively, I 
 
MR. SPENCE'S COMPOUND FRACTURES. 503 
 
 cannot say, but as these 2 are mentioned, I presume that had 
 there been any more, they would also have been stated. Hence, 
 in Mr. Spence's list of cases treated during the greater part 
 of the period referred to, and in the same hospital as Mr. 
 Lister's cases, we find traces (for they are not grouped) of 23 
 compound fractiu-es w^hich lived for more than forty-eight 
 hours, and of these 8 died, some of the deaths being due to 
 infective disease. These facts are also interesting as showing 
 what a large proportion of compound fractures are amputated 
 primarily in the practice of a surgeon not treating his cases 
 aseptically, and also the large proportion of secondary opera- 
 tions. For of 23 compound fractures 15 were amputated 
 primarily (6 deaths), 5 were amputated and 1 excised second- 
 arily, and only 2 were treated conservatively. And even if 
 Mr. Spence has not published all his cases of compound frac- 
 tures the facts remain equally striking, for, with a much 
 smaller number of patients than Mr. Lister and with less 
 hospital accommodation, Mr. Spence has performed a larger 
 number of primary and secondary operations. 
 
 But from these papers I glean the following facts which 
 are free from any objection. During this time (1872-78), 6 
 compound fractm-es seem to have been made on healthy bones 
 by Mr. Spence, and of these 2 died. One case, however, died 
 in 36 hours, and therefore, following our rule, we have 5 
 intentional compound fractures of healthy bones with 1 death. 
 These were, 1 excision of the head of the humerus in a case 
 of unreduced dislocation — death in thirty hours ; 1 excision of 
 the knee for bad anchylosis ; 1 operation for badly united 
 fracture of the femur ; and 3 excisions of the elbow for anchy- 
 losis — 1 of these cases subsequently underwent amputation and 
 died, apparently of septicaemia. 
 
 Before leaving Mr. Lister's results, I may refer to some 
 operations on bones which have the same dangers as com- 
 pound fractures, though the bone is not fractured across. 
 
 Tlius the removal of exostoses is a serious matter. Mr. ' 
 Tiister has operated for exostoses thirteen times (from the end 
 of 1871 till Octol)er 1880), four times on the femur, and twice 
 on the tilna, without any ])ad result. 
 
 Ill chi-oiiic osteitis not yielding to treatment, Mr. Lister 
 
504 RESULTS OF ANTISEPTIC SURGERY. 
 
 cuts down, exposes the bone for a considerable extent, and 
 then digs a long deep trough in it with the gouge and hammer. 
 This treatment at once relieves the pain, and generally cures 
 the disease. Mr. Lister has performed 10 such operations 
 (from the end of 1871 to October 1880), without the slightest 
 bad result in any instance. 
 
 And then there are a number of operations in which, as in 
 the removal of tumours, portions of bone have been cut away 
 without any bad result. 
 
 By including all these operations together the number of cases 
 could be very much increased without the addition of any bad 
 result. I have preferred, however, to adhere rigidly to the 
 cases of compound fracture, meaning by that not subcutaneous 
 division of the bone, but a large wound open and communicating 
 freely with the bone, generally by means of a drainage-tube. 
 
 I shall now consider the results obtained by other surgeons, 
 and I shall take first, as being the most remarkable results as yet 
 published, the statements made by Dr. MacEwen in the ' Lancet ' 
 for September 18, 1880. He there gives the result of all the 
 cases in which he has made compound fractiu-es aseptically. 
 He points out that these cases were really compound fractures, 
 and not in any sense could they be called subcutaneous opera- 
 tions. The wounds varied in length from | inch to 1^ inch, 
 and the edges of the wound were held aside so that the bone 
 was freely exposed, and purified air had free access to the 
 divided fragments. In this way he has operated on 330 
 .patients affected with various deformities. Of these 220 had 
 knock knee (367 limbs), 64 had bow legs (104 legs), 40 had 
 tibial curves &c. (80 legs), and 6 had osseous anchylosis of the 
 hip or knee The bones were either simply divided by the 
 chisel and hammer, or wedge-shaped portions were cut out. 
 Although he only operated on 330 patients, he produced com- 
 pound fractures on 557 limbs. And as he often produced 2 
 or more separate compound fractures on the same limb, it 
 came about that he had in all made and treated aseptically no 
 less than 835 compound fractures. 
 
 What were the local results ? Here we have to consider 
 835 compound fractures, and here Dr. MacEwen tells us that 
 only in 8 out of these 835 wounds did suppuration occur, even 
 
MacEWEN'S compound fractures. 505 
 
 though union by first intention was impossible. In one case 
 there was no apparent cause for the suppuration ; in the other 
 
 7 cases some cause was present. In 3 instances irritation and 
 inflammation were set up by the pressure of the splint, &c. ; 
 in 3 cases there was bruising and laceration of the soft parts ; 
 and in 1 a piece of muscle was severely injured in adjusting 
 the bones. In each of these 8 cases the occiu'rence of suppur- 
 ation was preceded by elevation of temperature. 
 
 What was the result as regards the necessity for further 
 operation? Here we have to speak of ^51 limbs ; 557 cases in 
 which secondary amputation might have been necessary. 
 Secondary amputation was, however, only necessary in one 
 instance, although some of the limbs had as many as four or 
 five compound fractures. The operation in this case was neces- 
 sary because, owing to an accident, the bandages had become 
 displaced, and gangrene of the foot occurred. This patient 
 recovered perfectly. 
 
 What were the results as regards life ? Here we have to 
 consider 330 lives which might have been lost, and in con- 
 nection with this it is to be remembered that many of these 
 patients had multiple comj^ound fractures, in some instances as 
 many as 10. And yet of these 330 cases only 3 died, and not one 
 of these deaths was in any way due to the operation. MacEwen 
 describes these 3 cases in detail, and I may state that the 
 causes of death were diphtheria, tubercular meningitis, and 
 pneumonia contracted before the operation. 
 
 To sura up Dr. MacEwen's results, we find that of 330 
 patients only 3 died, in each case the fatal result being inde- 
 pendent of the disease : of 557 limbs affected with compound 
 fracture only 1 required secondary amputation or other opera- 
 tion, and this from a cause independent of the wound ; and 
 lastly, of 835 compound fractures, suppuration only occurred in 
 
 8 wounds, though primary union was impossible in all. 
 
 These results are the more striking when it is remembered 
 that many of the patients operated on were not in good 
 health, ' On several occasions,' says Dr. ]MacEwen, ' the patients 
 were so weak that there was considerable hesitation about 
 administering an anaesthetic. Many have been carried to the 
 wards by their friends, as they were unable to walk exce[)t by 
 
506 RESULTS OF ANTISEPTIC SURGERY. 
 
 the aid of crutches, and that for a very short distance.' It is 
 indeed strange that such facts are allowed to pass entirely un- 
 noticed, and that in spite of them surgeons continue to assert 
 that equally good results may be obtained by cleanliness, good 
 ventilation, &c. These injuries will be generally acknowledged 
 to be grave ones, and there is no record whatever of anything like 
 similar results from other than aseptic methods of treatment. 
 In reference to the statistical value of such cases, Mr. Holmes 
 justly remarks : ' Of all wounds, perhaps those of compound 
 fractures of the leg are the best adapted for studying the effect 
 of different ways of dressing. Amputations and other major 
 operations depend so much more for their success on the health 
 of the patient and the previous course of the disease, that it is 
 hardly possible to draw^ from their results any absolute con- 
 clusions as to the effect of the system of dressing. This 
 objection applies, of course, to compound fractures to some 
 extent (as indeed it does to every surgical affection) ; but much 
 less than to amputations, especially when the severer accidents 
 which call for immediate amputation, or which prove fatal from 
 other injuries, are left out of account.' 
 
 Professor Volkmann has published a detailed account of all 
 the compound fractures treated by him conservatively since he 
 introduced the aseptic method. These are 73 in number (75 
 fractures), and of these 73 patients not one died.^ In one or 
 two cases of injury to joints, primary resection was practised. 
 These, of course, still remained compound fractures, and are 
 very properly included here. The following is Volkmann's 
 list: 
 
 Seconrlai-y Rocoiifliry Death 
 
 resection anii)utation 
 
 Part injured 
 Femur 
 
 No. of 
 cases 
 
 1 
 
 No. treated 
 conserva- 
 tively 
 1 
 
 Patella 
 
 3 
 
 3 
 
 Leg . 
 
 43 
 
 36 
 
 Humerus . 
 
 8 
 
 8 
 
 Fore-arm , 
 
 20 
 
 14 
 
 75 G2 n 8 
 
 ' In hi.s address at the recent meeting of the International Medical Con- 
 gress in London, Volkmann said: 'When I adopted the anti.septic treatment of 
 wounds my last 12 patients, with compound fracture of the leg, had all died 
 of py;emia or scptici\3mia. From that time up to tlic ])rcscnt day I have 
 
VOLKMAAWS COMPOUND FRACTURES. 507 
 
 Now, in considering these facts we have first to notice, that 
 no less than 48 patients were injured by direct violence, and 
 that in 20 cases the bones were extensively shattered. A 
 number of the cases were machine accidents, and Volkmann 
 says with regard to these, that it was at first a very difficult 
 matter to decide whether any attempt ought to be made to save 
 these limbs. In 19 of the cases joints were involved in the 
 injuries : of these 5 were resected and 3 amputated secondarily, 
 while 1 1 were treated conservatively to the end. In 2 cases 
 primary resection of the joint was performed, once at the 
 shoulder -joint and once at the elbow-joint. 
 
 The following are the ages at which these accidents oc- 
 ciured : 
 
 61-70 
 
 1-10 
 
 11-20 
 
 21-80 
 
 31-40 
 
 41-50 
 
 51-60 
 
 5 
 
 13 
 
 14 
 
 17 
 
 10 
 
 9 
 
 With regard to the cases of secondary amputation and 
 resection, Volkmann expressly states that they chiefly occurred 
 soon after the treatment was first introduced, and that with 
 increasing experience of the aseptic method these cases have 
 become more and more infrequent ; and he states that 3 cases 
 of secondary amputation would have been unnecessary if the 
 injuries had been, in the first instance, properly diagnosed and 
 treated. In speaking of the results of his cases he rightly 
 divides them into two sets, the first being those which occurred 
 during the first year, while they were learning the method ; and 
 the second, those treated during the remainder of the period 
 (three years or more) after they had learned the method. In 
 the first set they had always suppuration and sometimes gan- 
 grene of portions of the skin ; here they injected a strong 
 solution of chloride of zinc at first, and afterwards they washed 
 out the wound daily with carbolic lotion. When they found 
 that chloride of zinc ought not to be used, and that it was 
 unnecessary and hurtful to wash out the wound, they got very 
 different results. Then they found, and this was the case in 
 
 treated, one after anotlier, 135 compound fnictures. and not a single patient 
 has succumbed to either of those accidental wound diseases ; 133 were cured, 
 two died, one of fat embolism of the lungs during the first few hours, and 
 one, a drunkard, of delirium tremens.' Luncef, August 13, 1881. 
 
503 RESULTS OF AXTISEPTIC SURGERY. 
 
 about the last 60 cases, that the fracture and wound behaved 
 as if they were subcutaneous, there was no suppuration nor 
 gangrene of the tissues, but, on the contrary, rapid heahng. As 
 a rule, also, necrosis did not occur, though in one or two cases 
 small detached fragments, which had been left at first, were 
 picked out of the wound afterwards. Volkmann describes the 
 course of the cases as follows : ' Grleich von Anfang an tritt 
 keine ortliche Reaction, keine Jauchung, kein Wund-reinigungs- 
 stadium auf ; das Markgewebe verjaucht nicht in der Umgebung 
 der Bruchspalte ; die geofFnete Markhohle und das blossgelegte 
 spongiose Grewebe werden sofort wieder durch Blutcoagula 
 verdeckt und abgeschlossen, die so lange liegen bleiben, bis sie 
 durch organisirte Grewebswucherungen ersetzt sind. Es ent- 
 stehen keine fissuralen (Bruchspalten-) Eiterungen, keine 
 inter-muscularen, subperiostealen und parossalen Phlegmonen, 
 keine Eitersenkungen und Eiter-retentionen, keine grosseren 
 Necrosen. Die antiseptische Methode gestattet die Heilung der 
 complicirten Fracturen gewissermassen unter dem feuchten 
 Schorf.' In only three cases did Volkmann fail to eradicate 
 the causes of fermentation. 
 
 Max Schede has also treated a number of compound frac- 
 tures aseptically. There were 37 cases admitted soon after the 
 infliction of the injuries, and only 1 did badly, and that case is 
 said to have suffered in the first few days from fatty embolism 
 and delirium tremens. No patient died. In 4 cases intermediate 
 amputation was necessary, thrice on account of gangrene due 
 to the direct violence of the injury, and once on account of 
 gangrene in the case just alluded to, where the patient moved 
 the limb violently and tore the posterior tibial artery, the 
 anterior tibial having been destroyed by the injury. All these 
 cases were the result of direct violence. 
 
 Taken along with Volkmann's 73 cases we have a total of 
 110 cases treated, in the first instance conservatively, without 
 a death. Of these, 12 required secondary amputation and 6 
 secondary excision, leaving 93 which recovered without fmlher 
 interference. 
 
 Max Schede adds the following interesting facts : — Seven 
 cases came under treatment between the second and the 
 sixteenth day after the injury ; these cannot of course be in- 
 
VOLKM ANN'S COMPOUND FRACTURES. 509 
 
 eluded in the same category as those which came under treat- 
 ment within a few hours after the accident. Of these, 2 died — 
 1 admitted on the ninth day with tetanus and 1 admitted on 
 the sixteenth day with extensive suppuration ; 1 underwent 
 secondary amputation, and 4 were treated conservatively. As 
 I have previously pointed out, these cases illustrate the result 
 of treatment by antiseptics, because it is hardly possible to 
 render such a wound aseptic so long after the injury. 
 
 Before leaving Volkmann's results I shall refer to the com- 
 pound fractures made by himself. He has produced 71 com- 
 pound fractures on 59 patients. One of these cases died. 
 This occurred in the case of a bleeder who died of anaemia 
 about twenty-four hours after the operation — a case of excision 
 of the knee for anchylosis. Leaving out of consideration, then, 
 according to Mr. Holmes' rule, this case which died within 
 forty-eight hours, we have 58 patients on whom compound 
 fractures were produced without any fatal result. After the 
 70 compound fractmres which we have to consider, secondary 
 amputation was onl}^ necessary twice ; in 1 case a central 
 enchondroma in the tibia was found to be the cause of the 
 deformity, and the limb was therefore amputated ; in the other 
 case* there was very severe genu valgum in consequence of 
 arthritis deformans, but the exact reason for amputation is not 
 given. As to the bones affected, we have mention of 16 com- 
 pound fractures produced on the femur and 45 on the bones 
 of the leg. The other operations were for ununited or badly 
 united fractures, but the bones affected are not mentioned. 
 
 In comparison with these results Volkmann says, that the 
 journals of the surgical wards at Halle for former years contain 
 notes of 1 1 compound fractures of the thigh, of which 6 died, 
 and of 64 compound fractures of the leg, of which 26 died. 
 The proportion of cases which required secondary amputation 
 is not mentioned, but it is stated that many of the injuries 
 were very simple and the result of indirect violence. 
 
 During the year 1878-79 Bardenheuer, operating aseptically, 
 made 28 compound fractures on healthy bones without bad 
 result. He also performed 53 resections — 15 of the hip and 
 12 of the knee-joints — without a death. 
 
 MacCormac gives the results of the aseptic practice in 
 
610 BESULTS OF ANTISEPTIC SURGERY. 
 
 St. Thomas's Hospital. There were 16 cases of compound 
 fracture treated (2 of the femm-, 3 of the upper extremity, and 
 1 1 of the tibia) without a death, and in only one instance was 
 secondary amputation necessary. He contrasts these results 
 with those obtained in the former six years during which 
 5-i cases of compound fracture were not treated aseptically, 
 and of these 12 died (4 from pyaemia and 4 from erysipelas); 
 one case required secondary amputation on account of gangrene j 
 and in several there was suppuration or erysipelas and a pro- 
 tracted recovery. 
 
 MacCormac also referred to 45 compound fractm-es made 
 by the sm-geon (since the address the number has risen to 57), 
 without a death. Thirty of these involved the knee-joint, and 
 though the wound in the soft parts was comparatively small, 
 yet it was ' quite large enough in many instances to allow 
 serious inflammation and putrefactive changes to take place 
 in it.' In no single instance did any serious result follow. 
 
 If, now, we sum up the facts already obtained and, following 
 Mr. Holmes' suggestion, exclude all cases of primary amputa- 
 tion, and of death within forty-eight hours after the injury, we 
 get the following remarkable results : — 
 
 /. Accidental Compound Fractures. 
 
 Adding together the results of Lister, Volkmann, Schede, 
 and MacCormac, we find that there were 164 cases of com- 
 pound fracture treated conservatively, in which an attempt was 
 made to purify the wound,' and of these 2 died, giving a 
 mortality, after accidental compound fractm-es, of 1*2 per cent. 
 But then one death certainly, and the other probably, was 
 independent of the injury. Among these are included a few 
 cases of compound fracture of the skull, but if w^e take limbs 
 alone, we find tliat 158 limbs were affected with compound 
 fracture, and among these secondary amputation was performed 
 in 15 cases and secondary excision in 5, leaving 138 limbs 
 which were cm-ed without operative interference. 
 
 ' The numbers would be larger now, see note on p. 506. 
 
GENERAL RESULTS IN COMPOUND FRACTURE. 511 
 
 //. Intentional Compound Fractures. 
 
 Adding together the results of Lister, Volkmann, MacEwen, 
 Bardenheuer and MacCormac, we have 530 patients affected 
 with 1,072 compound fractures, and of these only 3 died, giving 
 a mortality of '56 per cent., the causes of death being in each 
 case quite independent of the operation. Looking at the 
 results to the limbs, we find that 766 limbs had 1,068 compound 
 fractures, and that among these secondary amputation was 
 only necessary in 4 instances, or '51 per cent. 
 
 Adding together the cases of accidental and intentional 
 compound fractures, we iind that 694 patients ivere affected 
 with 1,239 compjound fractures treated aseptically, and of 
 these 5, or '72 per cent., died. 
 
 Or looking at the results as regards the limbs, we find that 
 924 limbs were affected luith 1,226 compound fractures, and 
 of these 902 recovered ivithout further operaiion, ivhile 19 
 required secondary amputation and 5 required secondary 
 excision. 
 
 In contrast with these results we have the following facts : 
 
 Volkmann and Franckel ^ found a record of 885 compound 
 fractiures of the leg in the reports of the German and English 
 hospitals, and, of these, 339, or 38*5 per cent., died. In the 
 above 694 cases treated aseptically, I have not been able to 
 give the exact numbers as regards the bones affected, but by 
 far the greatest number of bones injured were those of the 
 lower extremity, the injuries of the thigh and leg being about 
 equal in frequency, the femur being perhaps most often 
 affected. However, as the mortality after compound fracture 
 of the femur is greater under ordinary circumstances than the 
 mortality after compound fracture of the bones of the leg, the 
 comparative value of these statistics is increased. 
 
 Bauin in (ioUingen- lost ;i8 p. c. after compound fracture of the leg. 
 
 liillroth in Zurich - 38-7 „ ,, „ 
 
 In P.reslau '' iOo „ „ „ 
 
 In Halle '^ 406 „ 
 
 In Bonn- 418 „ „ „ 
 
 ' \o\kmiinn'ti Sam iidtnif/, 117 118- ^ Ibid. 
 
512 RESULTS OF ANTISEPTIC SURGERY. 
 
 Mr. Holmes' states that in St. George's Hospital, from 
 1865 till 1878 inclusive, after excluding cases of primary- 
 amputation and deaths within forty-eight hours, there were 
 treated by the ordinary methods 162 cases of compound frac- 
 ture of the leg, of which 40, or 24*6 per cent., died. A con- 
 siderable proportion of these cases was treated during a period 
 in which cleanliness, good ventilation, &c., were greatly in 
 vogue, and by surgeons who were much impressed with their 
 necessity. Among these 40 deaths were 21 from pyaemia 
 alone, and several of the remaining deaths were due to other 
 sejitic diseases. 
 
 I have previously, at p. 510, given the results in St. Thomas's 
 Hospital, the mortality there being 22*2 per cent. 
 
 These records correspond with the expressed views of sur- 
 geons of all ages as to the dangers of compound fractures pro- 
 duced accidentally or of operations in which compound fractures 
 are made On the other hand we have also the generally 
 acknowledged fact that subcutaneous osteotomies are practi- 
 cally free from danger, and the subcutaneous method is, as we 
 have previously seen, a form of aseptic treatment. The fore- 
 going facts show that it is not necessary to have recourse to 
 subcutaneous operations to ensure safety, but that the Listerian 
 method is equally, if not more efficacious, while the free access 
 to the bone is in many cases a great advantage, indeed in some 
 an absolute necessity. 
 
 I must now again refer to Carl Eeyher's results in the 
 Russo-Turkish war (see p. 401, et seq.) During this war he 
 treated 22 cases of compound fracture of the extremities 
 aseptically (by ' primary antiseptics,' as he terms it), and of these 
 4 or 18 p.c. died, secondary amputation being only necessary 
 in one instance. The following list shows the cases and the 
 results : — 
 
 Healed with 
 
 retention of 
 
 limb 
 
 4 
 
 2 
 
 12 
 
 Part injured 
 
 
 No. of cases 
 
 Died 
 
 Secondary 
 amputation 
 
 Humerus . 
 Fore-arm , 
 Thigh 
 Leg . 
 
 
 4 
 3 
 
 3 
 12 
 
 1 
 3 
 
 1 
 
 Total 
 
 • 
 
 22 
 *0r 81-8p. c. 
 
 4 
 
 1 
 
 ' St. 1 
 
 Gvorgi; 
 
 :'« HosjAtal Reports, 
 
 vol. ix. 
 
GUNSHOT WOUNDS OF BONE. 513 
 
 During the same time he had 62 fractures of the long bones 
 treated with antiseptics or, as he calls it, with ' secondary anti- 
 septics,' and of these 23, or 35*3 p.c, died. The following is the 
 table : 
 
 ■r. X • • 3 ewnnHnvv Ut'alud with 
 
 Part injured No. of cases Died amm°"itiin retention of 
 
 ^ ' limb 
 
 Humerus ... 12 5 3 5 
 
 Fore-arm ... 3 — — 3 
 
 Thigh 
 
 No. of cases 
 
 Died 
 
 Secondary 
 amputation 
 
 12 
 
 3 
 
 •35 
 
 
 5 
 
 3 
 
 
 13 
 
 5 
 
 22 
 
 
 5 
 
 2 
 
 
 
 
 
 62 
 
 
 23 
 
 10 
 
 "Or 69-6 
 
 p. c. 
 
 
 
 12 
 
 Leg .... 22 5 2 17 
 
 Total . 62 23 10 37* 
 
 He also refers to 27 similar fractures not treated antisepti- 
 cally at all, but he gives no details of them, and only states 
 that up to the time of writing 8 had died of pyjemia. 
 
 The following are the fatal cases where aseptic treatment 
 was attempted : — 
 
 One compound fracture of the thigh died of fatty embolism • it 
 is not mentioned how long after the injury the patient died : in 
 this case the femur was completely shattered throughout its whole 
 extent, the wound of entrance being near the pubis. One compound 
 fracture of the thigh died from exhaustion, the residt of profuse 
 suppuration. One compound fracture of the thigh died from septic 
 suppuration. One compound fracture of the forearm — a shell injury 
 — -died of pyaemia. 
 
 With regard to these cases I need merely point out the 
 extreme difficulty of thoroughly disinfecting the wound and of 
 removing all portions of clothing from the wound. Reyher 
 refers to this i)oint, and it seems that in 3 of the 4 fatal cases 
 in which the aseptic method was tried, disinfection was not 
 successful. This is of course only what might be expected. 
 There is nothing m;igical about the injection of an antiseptic 
 into wounds, and unless the fluid reaches all the recesses of the 
 wound, and destroys all the causes of fermentation which have 
 been introduced into it, the wound cannot be expected to follow 
 an aseptic course ; it is not an aseptic l)ut a septic wound, and 
 the consequences of such a wound will be those of a septic not 
 of an aseptic one. 
 
 L L 
 
514 RESULTS OF ANTISEPTIC SURGERY. 
 
 In considering the results of other forms of antiseptic 
 treatment, the only detailed account to which I can refer is 
 Kronlein's report of the results of the open method in Ziirich 
 (see p. 410). Kp'inlein states that between 1860 and 1867, 
 160 cases of compound fracture were treated, and of these 67 
 died ; 86 of them being treated conservatively with 21 deaths. 
 Between 1867 and 1871, 102 compound fractures were treated, 
 of which 27 died ; Q5 of these being treated conservatively with 
 14 deaths. 
 
 Though Kronlein tells us the number of cases amputated, 
 and the number treated conservatively to the end, he does not 
 tell us the number of primary and secondary amputations. 
 Now, of course, in considering the results of compound fractures, 
 we must divide them into those amputated primarily, and those 
 in which conservative treatment was tried ; the latter group 
 being subdivided into those which required secondary amplita- 
 tion and those which were treated conservatively to the end. Of 
 course the cases treated conservatively to the end are the most 
 favourable class, because they did not require secondary opera- 
 tion. But in judging of the success of consei'vative treatment, 
 it is necessary to know in what proportion of cases that treat- 
 ment failed and secondary operation was required. Now it is 
 only of the former — the successful cases — that Kronlein gives 
 us infonnation. With the view of getting a coiTect impression 
 on this point, I have gone over his statements, and the follow- 
 ing are the facts, so far as I have been able to gather them. 
 
 Of the 160 cases treated between 1860-67, 38 were ampu- 
 tated })rimarily, with 19 deaths ; 21 were amputated secon- 
 darily with 17 deaths ; and 15 were amputated, but whether 
 primarily or secondarily, I have not been able to ascertain ; of 
 these 9 died. 86 were treated to the end conservatively with 
 22 deaths. Now according to our I'ule the primary cases are 
 omitted. As to the 15 amputations with 9 deaths, I don't 
 know what they are, and therefore we shall put them in a 
 group by themselves. This leaves us with 107 cases in wliicli 
 we are certain that conservative treatment was attempted, and 
 of these 39, or 30*4 per cent., died. The result then, so far as 
 we know it, is — 
 
OPEN TREATMENT OF COMPOUND FRACTURES. 515 
 
 No. of cases 
 
 Death; 
 
 107 
 
 39 
 
 (certain) 
 
 
 Secondary 
 amputation 
 
 21 
 (certain) 
 
 Recovered without 
 
 mutilation 
 
 64 
 
 (or 59-8 p. c.) 
 
 Looking at the results of the open method from 1867 to 
 1871, we find that 102 cases in all were admitted, and of these 
 27 died. Of these 19 were amputated primarily with 5 deaths ; 
 9 were amputated secondarily with 4 deaths ; 9 were amputated, 
 but whether primarily or secondarily I do not know, with 4 
 deaths; 65 were treated conservatively to the end with 14 
 deaths. Treating these cases like the former, we may say that 
 74 cases were certainly treated conservatively, and of these 18, 
 or 24'3 per cent., died. Thus — 
 
 No. of cases Deaths 
 
 74 IS 
 
 (certain) (certain) (or OS'D p. c.) 
 
 It is to be remembered in both cases that some of the 
 doubtful amputations were probably secondary, so that these 
 results are the most favourable. I may give further details of 
 the cases which we know about accordinsf to the limbs affected. 
 
 Secondary 
 
 Recovered with 
 
 amputatlou 
 
 mutilation 
 
 9 
 
 51 
 
 Total 
 
 Cases treated Conservatively. 
 (1860-67.) 
 
 art affected 
 
 No. 
 
 , of cases 
 
 Percentage of 
 cases treated 
 conservatively 
 
 Deaths 
 
 Secondary 
 amputations 
 
 Recovered 
 without 
 mutilation 
 
 Femur . 
 
 
 8 
 
 61-5 
 
 3 
 
 1 
 
 .5 
 
 Leg . 
 
 
 77 
 
 81 
 
 26 
 
 15 
 
 49 
 
 Humerus 
 
 
 9 
 
 47-3 
 
 4 
 
 2 
 
 4 
 
 Fore-arm 
 
 
 v^ 
 
 39-3 
 
 6 
 
 3 
 
 6 
 
 107 
 
 66-8 
 
 39 
 
 21 
 
 64 
 
 Cases treated Cunservativel//. 
 (Open Method 1867-71.) 
 
 Part affected 
 
 No. 
 
 of cases 
 
 Percentafrc of 
 cases treated 
 conservatively 
 
 Deaths 
 
 Se( 
 ami 
 
 .'ondary 
 )utation 
 
 Recovered 
 without 
 nuitilation 
 
 Femur 
 
 
 12 
 
 70-5 
 
 3 
 
 
 1 
 
 
 9 
 
 Leg . 
 
 
 38 
 
 84-4 
 
 12 
 
 
 7 
 
 
 22 
 
 Humerus . 
 
 
 14 
 
 51-3 
 
 2 
 
 
 1 
 
 
 11 
 
 Fore-arm . 
 
 
 10 
 
 62r) 
 
 1 
 
 
 — 
 
 
 9 
 
 Total . 
 
 
 71 
 
 69- 1 
 
 I, L 2 
 
 IS 
 
 
 9 
 
 
 51 
 
ol6 RESULTS OF ANTISEPTIC SURGERY. 
 
 It will thus be seen that some improvement followed the 
 introduction of the open method, but this in no way corresponds 
 to that effected by the aseptic method. 
 
 The causes of death are not given, but of the 39 deaths of 
 the first period, at least 27 were from pyaemia and septicaemia 
 (14 of the cases treated to the end conservatively and 13 of 
 the secondary amputations). Of the 18 deaths of the second 
 period at least 8 were from pyaemia and septicaemia (5 of the 
 cases treated conservatively and 3 of those amputated secon- 
 darily). As I have said, this is the most favourable statement 
 possible, and it does not include those which died of other septic 
 diseases. 
 
 I do not find any facts of statistical value, with regard to 
 the results with other forms of antiseptic treatment, but the 
 good results of irrigation and the water bath and of crust forma- 
 tion are well known, and have already been alluded to in the 
 history of the subject. The whole tendency of the facts 
 published in recent times is, however, to show that success 
 increases according as the method adopted fulfils more and 
 more the requirements of the aseptic principle; and the same 
 is evident if we look at the history of the subject and see the 
 successes obtained by the use of balsams, of crust formation, 
 of irrigation and the water bath, and of subcutaneous surgery. 
 
SPINAL ABSCESSES. 517 
 
 CHAPTER XX. 
 
 RESULTS OF ANTISEPTIC SURGERY — {continued). 
 
 Abscesses connected with disease of the vertebrse. Best situation for opening 
 psoas abscesses : best time for opening them : after-treatment and after- 
 progress. Table of Mr. Lister's results : general summary and remarks on 
 these cases. Comparative statistics are wanting. Sir James Paget's 
 views. 
 
 Before discussing these results, I think that it will be most 
 convenient to consider the last group of cases to which I intend 
 to refer, viz. cases of abscesses connected with disease of the 
 vertebra?. The cases which I give here were treated by ]Mr. 
 Lister between the end of 1871 and 1879 ; and I will mention 
 all the cases which occurred dm-ing that period. I have been 
 careful to take oidy those abscesses which were unmistakably 
 connected with disease of the vertebrae, as indicated by curva- 
 tm'e, by the history of the case and the symptoms present, and, 
 in several instances, by the presence of pieces of bone in the 
 pus. Of course this list, like the others, does not represent all 
 the cases which 'Mr. Lister has ever treated asejitically, for he 
 had several cases under his care before this period, and both 
 before and during it, he has treated a number of similar ab- 
 scesses in private practice. Here, as in other instances, his 
 results have been better in private practice than in hospital, 
 because the cases were attended to either by himself or by 
 skilled assistants, while in hospital it was often nece.-;sary to 
 leave the changing of the dressings to students. 
 
 In the treatment of these abscesses the general principles 
 of aseptic surgery are carried out in the manner before de- 
 scribed, and I need not recapitulate the point:^ here. I must, 
 however, say a few words as to the best situation for opening 
 psoas abscesses. An abscess which has passed into the thigh, 
 
518 RESULTS OF ANTISEPTIC SURGERY. 
 
 and which is pointing in the neighbourhood of the lesser 
 trochanter, is usually, under the ordinary modes of treatment, 
 opened at its most prominent situation at the upper and 
 inner part of the thigh. Now if the aseptic method is adopted, 
 it is quite evident that an incision in that situation leaves very 
 little space, only two or three inches, for the overlapping of the 
 dressings, while the edge of the dressing, being near the anus 
 and genito-urinary organs, is very liable to get soiled with the 
 excretions. Case No. 1 is an example of this, and hence it is 
 well, if possible, to avoid this risk ; indeed, these abscesses are 
 now never opened in that situation. Almost all the psoas 
 abscesses have up till the present time been opened above 
 Poupart's ligament, and the results have been very satisfactory. 
 An incision is made near the anterior superior spine of the 
 ilium, much in the line for tying the external iliac artery, and 
 the muscles are carefully divided as in that operation. When 
 the transversalis fascia is reached, the pus can generally be 
 made to bulge beneath it, and then a pair of dressing forceps 
 are pushed into the abscess cavity, the opening dilated, all the 
 pus squeezed out, and a large-sized drainage-tube introduced. 
 Though this opening is not dependent, yet, if the tube be large 
 enough, the drainage is perfectly satisfactory, and there is no 
 accumulation of discharge. The cavity in the thigh drains 
 upwards into the iliac fossa and closes entirely in a few days. 
 The after-treatment has been already described ; after a time, 
 in these cases, a drainage-tube without holes except at its 
 upper extremity, is most useful. 
 
 Mr. Chiene advocates the opening of these abscesses above 
 Hie crest of the ilium behind by means of an incision at the 
 outer border of the quadratus lumborum. The advantages 
 which he claims for this method are the following : the orifice 
 is dependent, and thus the drainage is most satisfactory ; the 
 incision is made into the upper part of the aljscess, and thus 
 the whole of the cavity in the iliac fossa closes rapidly by 
 adhesion of the gr^n^ilations, so that, after a few days, there is 
 only a short sinus eading directly to the seat of disease. This 
 situation is an advantage, more especially in the after-j^rogress 
 of the case, when the sinus becomes too narrow to admit a 
 drainage-tube, for if a sinus is long and tortuous, the drainage 
 
TREATMENT OF SPINAL ABSCESSES. 519 
 
 of the discharge from the seat of disease is of course more 
 likely to be imperfect than if the sinus is short and leads 
 directly to the diseased bone ; further, the orifice of the drainage- 
 tube is still more distant from sources of putrefaction in this 
 situation than when the incision is in front ; the dressing can 
 also be very securely applied and fixed. 
 
 These abscesses ought to be opened as soon as they are 
 detected. The spontaneous absorption of abscesses is a very 
 rare occurrence, and the treatment by repeated aspiration is very 
 apt to be unsatisfactory. The earlier the abscess is opened, 
 provided that it is done aseptically, the better, and this for two 
 chief reasons. In the first place the longer the pus is left, 
 the larger does the abscess cavity become ; and thus for the 
 first few hours after it is opened there will be, corresponding 
 to the extent of the abscess, a proportionate amount of serous 
 oozing, which, if great, will severely tax the efficiency of the 
 gauze dressing ; there will also of course be a larger cavity to 
 heal. In the second place the pus being pent up in a cavity, 
 tends, by tension and consequent nervous disturbance, to keep 
 up and even aggravate the chronic inflammation of the bony 
 tissue, and therefore, so long as the pus is there, the chronic 
 inflammation is kept up and the disease of the vertebrae pro- 
 gresses instead of improving. On the other hand, when the 
 pus is let out, and care is taken that causes of fermentation 
 are not admitted, a great source of disturbance is removed, 
 and an opportunity is afforded for the cessation of the disease. 
 For these reasons, therefore, the abscess ought to be opened as 
 soon as possible. I do not of course mean to advise the early 
 opening of these abscesses where the aseptic method is not to 
 be used, or where the surgeon has not had sufficient experience 
 of that method to be able to rely with considerable certainty 
 on excluding the causes of fermentation. But if the surgeon 
 considers that he can exclude these causes, then I believe that 
 the best thing for the patient is to open the abscess as soon 
 as possible. 
 
 The after-progress of these cases is exceedingly satisfactory. 
 For some hours after the abscess is opened, there is a profuse 
 discharge of bloody serum, due no doubt to the effect of the 
 diminution of pressure on the vessels in the granulation tissue 
 
Gi'O RESULTS OF ANTISEPTIC SURGERY. 
 
 lining the abscess cavity. This discharge rapidly diminishes, 
 and in a few days beconaes very slight. After the original pus is 
 evacuated there is no more pus formation from the abscess cavity, 
 provided that the drainage is efficient and that the discharge 
 is kept aseptic. There may be a little suppuration from the 
 granulations surrounding the orifice of the drainage-tube, which 
 are irritated by the direct application of the carbolic acid, but 
 there is no suppuration from the deeper parts. As a conse- 
 quence of the slight amount of discharge the dressings are not 
 often changed, and generally, in a few weeks after the abscess 
 has been opened, the case is only dressed once a week, and 
 then not because discharge has reached the edge of the dress- 
 ing, but, for the reasons given on p. 93, because it is considered 
 that the dressing is no longer sufficiently antiseptic.^ A sinus 
 often remains for a long time, sometimes for months, and the 
 weekly dressings must be continued till it finally closes, the 
 greatest care in carrying out the minutest aseptic precautions 
 being required till healing is complete. Never be tempted, how- 
 ever slight the discharge, or however apparently superficial the 
 sore, to give up the aseptic method or to substitute boracic for 
 carbolic dressings. During the whole treatment of the case the 
 patient must be kept absolutely recumbent, whether lying on 
 his back or on his side is of little consequence, and must never 
 be allowed to raise his shoulders for any reason whatever. 
 Grenerally, after the sinus has healed, it is well to maintain the 
 perfectly recumbent position for at least six weeks longer, so 
 as to ensure that the bones are sound before the weight of the 
 body is allowed to tell on them. The maintenance of absolute 
 rest is essential for success. 
 
 The constitutional state of the patient rapidly improves 
 after the abscess is opened. If hectic fever is present before- 
 hand, it generally rapidly subsides (see T. Chart LIV), and the 
 temperature becomes normal, and remains so throughout ; and if 
 the temperature is normal before the abscess is opened it does 
 not rise nor assume a hectic type, as is so common when the 
 
 ' I may just recall the fact alluded to on p. 89, that when dressings are left 
 on for a week, there sometimes occurs a little irritation beneath them, and that, 
 therefore, it is well to rub a little of the salicylic cream on the skin around 
 the wound before applying the dressing. 
 
ASEPTIC COURSE OF ABSCESSES. 521 
 
 discharge is allowed to putrefy. The general condition of the 
 patient corresponds entirely to this state of the temperature : if 
 he has been weak and sutfering before, he rapidly regains 
 strength, loses his pain, and puts on flesh ; his appetite returns, 
 and he soon feels in a state of perfect health. The reason for 
 this is evident ; the patient is not exhausted by the daily loss 
 of a large quantity of discharge, while he is relieved from the 
 presence of the abscess. Cod-liver oil and iron are, of course, 
 given throughout, but stimulants are rarely necessary, at least 
 after the first week or two. Although these cases remain so 
 well, and although the discharge is soon practically nil, yet 
 they are as a rule very tedious, and it is well not to reckon on 
 cure in less than six or eight months ; some cases indeed last 
 much longer. It is expedient, therefore^ to warn the patient's 
 friends of this before the abscess is opened, for otherwise they 
 may get discom-aged and take the patient away ; and if aseptic 
 treatment is not continued to the end, the chances of recovery 
 are almost as slight as if it had never been employed. 
 
 A number of examples of the ' aseptic course ' of these 
 abscesses just described will be found in the following table, so 
 that I need not detail a case here. 
 
522 
 
 RESULTS OF ANTISEPTIC SURGERY. 
 
 Psoas and 
 
 Xanie ami Ajre 
 
 Jane T., 38 
 
 Donald T., 24 
 
 Thomas G., T) 
 
 William L., 4;") 
 
 Thoiiins M., 02 
 
 Peter L., 3.' 
 
 Date of Operation and 
 Discharge ; with Result 
 
 Op., Dec. 21, 1871. 
 Dis., Jan. 31, 1872. 
 Result, putrelied. 
 
 Op., Feb. 10, 187 
 />/«., Felj. 1.S73. 
 Rfxiilt, cured. 
 
 Op.. April 2, 1872. 
 liexitlt, unknown, pro- 
 bablv cured. 
 
 Op., April 1872. 
 ni.f, April 3, 187; 
 litsiilf, cured. 
 
 Op., Julv 4, 1872. 
 IJis., April 2, 1873. 
 /i fsiih, died of an in- 
 dependent cause. 
 
 0/>, Se|)t. 1872. 
 />/.s., Oct. 21, 1873. 
 Result, cured. 
 
 Disease. 
 
 Larjije p.soas abscess forming a buljjing tu- 
 mour in the thigh and extending high up 
 in the abdomen. First noticed six months 
 previously, pain in back, &c. 
 
 Lumbar abscess. Patient hurt his back two- 
 and-half years ago, pain in back, &c. 
 
 Pso.is abscess in connection with advanced 
 spinal disease. A lumbar abscess appeared 
 later. 
 
 Lumbar abscess. Curvature of spine, &c. 
 
 Lumbar abscess. Patient first noticed a 
 swelling three months previous to admis- 
 sion. There was no curvature but great 
 jiain on pressure over the spine in the hnn- 
 bar region. 
 
 Psoas abscess with marked curv;iture of the 
 spine about the lower dorsal region. Ab.scess 
 pointing in the thigh. Disease began 
 nine years previously'. Suffered great ])ain 
 and had been getting weaker and thinner. 
 
MR. LISTER'S SPINAL ABSCESSES. 
 
 Lumbar Abscesses. 
 
 Abscess opened in thi^h and 40 oz. 
 pus evacuated. Drainaije-tvibe 
 serted. 
 
 Opened, 10 oz. of pns evacnated. Drain- 
 age-tube inserted. 
 
 Opened, drainage-tube inserted. (The 
 lumbar abscess was opened in Octo- 
 ber). 
 
 Abscess opened. Drainage-tube in- 
 serted. 
 
 Oponed. Drainage-tnTie inserted. 
 
 0|)cned. Drainage-tulje inserted. Tlio 
 material evacuated was verv thick. 
 
 On December 26, it. was found that the menstrual 
 flow had soaked the dressings and the dis- 
 charge had a disagreeable odour. On Decem- 
 ber 28, a large piece of bone came away. As 
 the abscess was undoubtedly putnd, and as the 
 patient was very anxious to go home, she was 
 allowed to do so. At that time there was pro- 
 fuse discharge and the patient was getting 
 weaker. 
 
 The discharge rapidly decreased in amount, be- 
 ing in tlie main serous though occasionally 
 somewhat purulent. The abscess had com- 
 pletely healed on October 24, but on November 
 11 the cicatrix gave way and a sinus was re- 
 established. This he.iled jK^rmanently about 
 the end of January. 
 
 After opening the first abscess the discharge was 
 considerable and purulent, but there was no 
 smell. Many fr.agments o( bone came away 
 during the course of the summer, and in Octo- 
 ber a lumbar abscess was found and opened. 
 The case is not completed in the note liooks, 
 the last note having been taken on April 20, 
 1873, to the etlect that there was very little 
 discharge, and that the general healtii was good. 
 1 should think that the case was in all proba- 
 bility cured. 
 
 Aseptic course. The wound was found healed on 
 August 11, but the scar again opened. Healed 
 again on October 13 ; again the scar gaA-e way. 
 Healed permanently on December 10. For 
 some time the patient could not do without a 
 spinal support, but in July 1877 he showed 
 himself, and was then perfectly well and strong 
 and able to do any kind of work. 
 
 On November 28, some cui-vature of the spine 
 was noticed. In February the dressings were 
 changed weekly, there being only a small 
 sinus, which at the end of March had almo.st 
 absolnteh' healed. At this time a small glan- 
 dular abscess formed in the neck and was 
 opened and dressed with boracic lint. On 
 Marcli 23, erysipelas attacked this wound and 
 quickly spread over the head and neck. The 
 patient got npidly weaker, and died on April 
 2. (This is really a case of cured lumbar 
 abscess dying of another cause before leaving 
 hospital.) 
 
 Aseptic course, tlie discharge being jiurely ser- 
 ous and very slight in (inantiiy. Healed in 
 September 1873. 
 
524 
 
 BUSULTS OF ANTISEPTIC SURGERY. 
 
 Psoas and 
 
 No. 
 
 Name and Age 
 
 Date of Operation and 
 Discharge ; with Result 
 
 Disease 
 
 
 7 
 
 T. H., 9 . . . 
 
 Op., Feb, 8,1873. 
 7>/s., Mawh §, 1873. 
 Result, in process of 
 cure. 
 
 Three lumbar abscesses. Curvature in the 
 dorsal regiou. Patient weak and thin. 
 
 
 8 
 
 Helen T., 24 . 
 
 Op., May 7, 1873. 
 JHs., Dec. 22, ,, 
 Result, cured. 
 
 Psoas abscess, Avhich had passed into the 
 thigh. Patient began to feel weakness in 
 the back about six months previously. 
 She had noticed the swelling in her thigh 
 for three months. 
 
 
 9 
 
 Donald R., 2G . 
 
 Op„ June 2, 1873. 
 JJis., Jan. 23, 1874. 
 Result, cured. 
 
 Psoas abscess pointing in the thigh. Curva- 
 ture in the lower lumbar region. 
 
 
 10 
 
 Jane R., 27 . . 
 
 Op., July 2, 1873. 
 JJis., Feb. 2, 1876. 
 Result, cured. 
 
 Patient was admitted in June 1873 on ac- 
 count of suppuration of the sheaths of the 
 flexor tendons of the hand following an in- 
 cision into a bursitis of these tendons not 
 performed aseptically. On July 2, a psoas 
 abscess was found in the right iliac fossa. 
 Had suffered from pain in her back for 
 about a year, and for some time from ab- 
 dominal tenderness. 
 
 
 11 
 
 Anne McK., 22 
 
 Op., Aus- 21, 1873. 
 JJis., Spring 1875. 
 Resu t, cured. 
 
 Lumbar abscess with well-marked curvature 
 of the lower dorsal vertebrai. A second 
 abscess formed later. 
 
 
 12 
 
 — W., 32 . . 
 
 Op., Sept. 2, 1873. 
 JJied, Feb. 3, 1874. 
 The cause of death 
 was phthisis. 
 
 Psoas abscess pointing in the thigh. Curva- 
 ture in the lumbar region ; great pain in 
 the back. Advanced phthisis. 
 
 
 13 
 
 Eliza M., 30 . 
 
 Op., Feb. 19, 1874. 
 JJis., Nov. 10, „ 
 Jiesult, in process of 
 cure. 
 
 Dorsal abscess. Great tenderness on pres- 
 sure over the whole dorsal vertebrai and 
 curvature of the middle ones. Patient 
 ver}' weak and anaimic. The pain began 
 a year ago. Patient half-witted. 
 
 
MR. LISTERS SPINAL ABSCESSES. 
 
 625 
 
 Lumbar Abscesses {continued). 
 
 Opened. Drainage-tubes inserted. 
 
 Opened. Drainage-tube inserted, 30 oz. 
 of pus were evacuated. 
 
 Opened above Poupart's ligament. 
 Drainage-tube inserted, 23 oz. of pus 
 evacuated. 
 
 Abscess opened above Poupart's liga- 
 ment, 20 oz. of pus containing pieces 
 of bone were evacuated. Drainage- 
 tube was inserted. 
 
 Opened, 10 oz. of pus evacuated. 
 Drainage-tube inserted. 
 
 Opened, "24 oz. of pus 
 Drainage-tube inserted. 
 
 evacuated. 
 
 Opened, 24 oz. of pus 
 Drainagc-tul)e inserted. 
 
 evacuated. 
 
 On Feb. 23, the two smaller abscesses had closed. 
 The drainage-tube was removed from the other, 
 and by March 8, the discharge was very slight. 
 The parents were very anxious to take the 
 child home, and they were allowed to do so 
 after having been instructed in the method of 
 dressing. The general health was at that time 
 improving. 
 
 Aseptic course. After .June 3, the case was 
 dressed every second A&y, and after July 6, 
 every three days. Healed about the beginning 
 of November. 
 
 Aseptic course. No more pus. Found healed on 
 October 10. Patient allowed to get up for the 
 first time on December 6. 
 
 The discharge rapidly diminished, and the case 
 was soon dressed only once a week. Aseptic 
 course, the discharge being purely serous. On 
 December 2, 1874, abscesses were found in con- 
 nection with the elbow-joint and opened, the 
 patient's health being then good and the psoas 
 abscess almost healed. When the patient left 
 hospital everything was sound. When heard 
 of in 1877, she was well and strong and had a 
 fairly movable elbow-joint. 
 
 Aseptic course. Quite healed on July 31, 1874. 
 On September 1.5, 1874, she was allowed to sit 
 up for the first time, but aftenvards felt great 
 pain in the dorsal vertebrae. She again sat up 
 on October 3, but again had pain. On October 
 22, a small abscess was opened at the side of 
 the former one. This healed during the spring 
 of 1875, and the patient was discharged cured. 
 (The exact dates of healing and discharge can- 
 not be ascertained.) 
 
 Till the middle of November the case went 
 on well, and the general health seemed to im- 
 prove, but from that time tlie lung disease 
 rapidly got worse and the jiaticnt gradually 
 became weaker. Diarrlioea set in in January. 
 During the last two or three weeks there was a 
 considerable increase in the amount of the dis- 
 charge, which became purulent. 
 
 The abscess went on as usual, the discharge 
 diminishing, and the i)atient's health improv- 
 ing when, on April 0, she tore off the dressings. 
 Ne.xt day there was a slight .smell, and the 
 wound was injected v.ith 1-20 carbolic lotion. 
 The discharge thereafter was odourless. No 
 notes are given from the end of April till 
 Novcml)er 10, when she is said to have been 
 ' discharged in process of cure' (See T. Chart 
 LV.) 
 
526 
 
 RESULTS OF ANTISEPTIC SURGERY. 
 
 Psoas and 
 
 14 
 
 15 
 
 IG 
 
 18 
 
 10 
 
 21 
 
 Name and Age 
 
 Margaret M., 7 
 
 Marfiaret S., 20 
 
 Susan J., 12 
 
 William M., 6 
 
 William L., 25 
 
 Tlionias M., 15 
 
 Mary C, 4 
 
 Margaret W., 24 
 
 Date of Operation and 
 D ischarge ; with Result 
 
 0;^., July 1874. 
 IJis., Jan. 1875. 
 Result, cured. 
 
 Op., Aug. 3, 1874. 
 TJis., Sept. 2, 1875. 
 Result, cured. 
 
 0/j.. Aug. 17, 1874. 
 Dis., April 17, 1875. 
 Result, putretieii. 
 
 Op., Sept. 14, 1874. 
 Dis., Nov. 7, 1876. 
 Result, cured. 
 
 Op., Jan. 10, 1875. 
 IJIs., June 10, „ 
 Result, left hospital 
 
 before healing was 
 
 complete. 
 
 Op., .July 4, 1875. 
 Result, cured. 
 
 Op., Nov. 18, 1875. 
 Dis., June 27, 187(5. 
 Result, putrefied. 
 
 Op., Nov. l(i, 1875. 
 7>/Vf/, March 17, 1877 
 Result, died of ex- 
 haustion. 
 
 Psoas abscess, angular curvature in the lum- 
 bar region. Began six months before ad- 
 mission. 
 
 Dorsal abscess. Angular curvature in the 
 dorsal region. Symptoms began eighteen 
 months before admission. Patient thin, 
 without appetite, and had cough and 
 ha:moptysis. 
 
 Psoas abscess, 
 gion. 
 
 Curvature in the lumbar re- 
 
 Psoas abscess, which had not yet passed into 
 the thigh. Curvature in the lower dorsal 
 region. 
 
 Psoas abscess, 
 gion. 
 
 Curvature in the lumbar re- 
 
 Lumbar abscess. Patient was admitted in 
 May with an abscess connected with a 
 carious rib. 
 
 Psoas abscess with disease of the vertebrw. 
 
 Psoas abscess pointing in the thigh. Acute 
 curvature in the lumbar region. The ab- 
 scess extended all round the thigh. 
 
MH. LISTERS SPINAL ABSCESSES. 
 
 627 
 
 Lumbar Abscesses {continued). 
 
 Opened, 1-4 oz. of pus evacuated. 
 Pieces of bone in the pus. Drainaye- 
 tube inserted. 
 
 Opened, 5 oz. of pus 
 Drainatre-tube inserted. 
 
 evacuated. 
 
 Opened, 8 oz. of pus evacuated. No 
 dr;iinaire-tube was inserted. 
 
 Opened by a dissection as if to tie the 
 external iliac artery. Drainage-tube 
 inserted. 
 
 Opened like No. 17, lo oz. of pus eva- 
 cuated. 
 
 Opened. The spinous process of one of 
 tlie lumbar vertebr.t was felt to be 
 bare. l)rainjiLre-tube inserted. 
 
 O] enodlike Xo. 17, above l'"Upart's liga- 
 ment. Drainage-tube inserted. 
 
 0]>ened, .lO oz. of jais evacuated con- 
 taining pieces of bone. 
 
 Aseptic course. Healed November 20, 1874. 
 Allowed to sit up on January 9, 1875. Exact 
 date of discharge not given. 
 
 Asefitic course. Healed in August 187.5. Patient 
 rapidly picked up Hesh and regained her appe- 
 tite after the abscess was opened. When she 
 was di>charged she was stout and well. 
 
 On September 8, this wound had healed, but a 
 collection soon reformed, which, on evacuation, 
 was found to consist of clear yellow serum. 
 During the month of February the case seems 
 to have p)utrefied, and on March 22, aseptic 
 measures were stopped and wet boracic lint 
 applied. Sent home. 
 
 Aseptic course, but the patient was extremely 
 restless, and it was very difficult to prevent him 
 from sitting up. To this is possibly due the 
 long delaj' in healing. This abscess was found 
 healed on Septetnber 15, 1876. A second ab- 
 scess formed on the opposite side and was 
 opened during t)ctober 1875. This had healed 
 before the patient was discharged. 
 
 The wound was doing well, but the patient got 
 tired of hospital, and wouLl not t-tay longer. 
 The tube was therefore removed and he was 
 taught how to dress the wound asepticalh'. 
 When he left his urine was albuminous, but its 
 state on admission is not given. 
 
 This ciise seems to have followed an aseptic course ; 
 the ]>atient left the hospital healed and cured. 
 But the notes are abotninably taken, and tlure 
 is no note either of the date of healing or of the 
 date of dismissal. 
 
 This case did wel till the Christmas liolidays, 
 when putrefaction seems to have occurred. 
 After that time there was profuse jiurulent 
 discharge, tliough for the most ]iart odourless. 
 The child was getting thinner and weaker, and 
 the parents wished to take her home. 
 
 All through the ca.se there was great difticulty in 
 getting free drainage, and consequently there 
 was an unusual amount of discharge, the ca.se 
 rer|uiring dressing about every .second day. 
 Laticrh" tlie patient sulii-red stvere jiaiu in tiie 
 thigii, leg, and liacU, with constant vomiting. 
 On posl-niorlem exaiiiin.ition tlie lumbar verte- 
 bnvj were found to be completely disorganised, 
 cavities containing cheesy material being found 
 in the bodies, transver.se and spinous jirocesses 
 of the vertcbriu. The bodies of two vertebraj 
 were absent. Tlie liver, spleen, kidneys, and in- 
 testines were in a state of waxy degeneration. 
 For T. Chart ju^t before death, see No. LIU. 
 
528 
 
 RESULTS OF ANTISEPTIC SURGERY. 
 
 Psoas and 
 
 Name and Age 
 
 Date of Operation and 
 Discharge ; with Result 
 
 Disease 
 
 22 
 
 23 
 
 EUea S., 32 . 
 
 John D., 18. 
 
 24 
 
 25 
 
 John D., 24 
 
 Eliza T., 19 , 
 
 Helen E., 60 
 
 Op., Nov. 14, 1875. 
 JJis., Feb. 3, 187G. 
 Result, cured. 
 
 P/)., March 22, 1876. 
 Dis., March, 1878. 
 Result, cured. 
 
 Op., April 4, 1876. 
 Died, Oct. 2, „ 
 The cause of death 
 was phthisis. 
 
 Op., Aug. 1, 1876. 
 ])is., July 1880. 
 Result, cured. 
 
 Op., Nov. 16, 1876. 
 Dis., Sept. 4, 1877. 
 Result, cured. 
 
 Largo lumbar abscess, 
 spine. 
 
 Curvature of the 
 
 Psoas abscess pointing in the left groin. Cur- 
 vature of the spine. Patient had been ill 
 for a year. He was in an extremely weak 
 and emaciated state. At a later period an 
 abscess formed in the right thigh. 
 
 Psoas abscess. Curvature of the spine in the 
 lumbar region. Patient was very weak, 
 and had advanced phthisis. 
 
 Admitted with a psoas abscess on the left 
 side, which had not j'et reached the thigh. 
 Great tenderness and curvature of the 
 spine in the lumbar region. At a later 
 period a psoas abscess formed on the other 
 side and also a lumbar abscess. 
 
 Patient injured her back a year before ad- 
 mission. It had been very weak and pain- 
 ful ever since, and when admitted there was 
 a psoas abscess pointing in the thigh. 
 Patieut was very weak. 
 
 I 
 
MR. LISTEES SPINAL ABSCESSES. 
 
 629 
 
 Lumbar Abscesses [conthiued). 
 
 Opened. Drainage-tube inserted. 
 
 Abscess opened above Poupart's liga- 
 ment. Drainaire-tube inserted. 
 
 Opened above Poupart's ligament. 
 Pieces of bone escajied with the pus. 
 Drainage-tube inserted. 
 
 Opened above Poupart's ligament, 20 oz 
 of pus evacuated. Drainage-tube in- 
 serted. 
 
 Abscess opened above Poupart's liga- 
 ment, 18^07. of pus evacuated. Drain- 
 age-tube inserted. 
 
 Aseptic course. Healed November 20, 1876. 
 (See T. Chart LVL; 
 
 The psoas abscess went on very well. A large 
 abscess formed in the othpr thigh, and was 
 opened on February 11. The patient was re- 
 moved to a private house in October 1877, and 
 placed under Dr. Bishop's care. Dr. Bishop 
 writes as follows in tlie British Medical Journal 
 for Januiry 31, 1880: 'John D., healed in 
 March 1878. Left Edinburgh in May. When 
 last heard of he was able to v/alk without sup- 
 port, and was feeling quite strong.' (For T. 
 Chart for some days after the second abscess 
 was opened, see No. LIV.) 
 
 The discharge seems to have remained aseptic, 
 though latterly it increased somewhat in 
 amount, necessitating a change of dressings 
 every two or three days. His cough got worse, 
 he became weaker, and died of phthisis. 
 
 Aseptic course, but the case was extremely tedi- 
 ous. A psoas abscess formed on the right side, 
 and was opened on January 16, 1878. In 
 March, after a gymnastic performanre in her 
 bed, she felt great pain in her back, and a lum- 
 bar abscess formed and was opened on April 
 17, 1878 ; bare bone was felt by the finger. 
 The case went on with almost no discharge, the 
 dressings being changed only once a week, till 
 August 1879, whf-n the first sinus healed. In 
 the beginning of October this opened up again. 
 On November 22 the right psoas ab.^cess was 
 found healed, and on D;'cember 27, the lumbar 
 abscess had healed. Although the original 
 sinus had not yet henled, the patient was al- 
 lowed to get up in Februar}' 1«80. This sinus 
 healed in June 1880, and the patient went 
 home in t!ie be,i:inning of July. During the 
 whole time the ])atietit had been in good health, 
 and her rosy cheeks (not hectic) and appear- 
 ance of perfect health rendered it difticult to 
 persuade any one that she was suffering from 
 disease of the spine with two psoas and one 
 lumbar abscess. (See T. Chart LVII. taken at 
 the time when the second abscess was opened.) 
 
 Asejjtic course. Healed July 5, 1877. Before 
 her discharge she was able to walk about. 
 (See T. Chart LVIII.) 
 
 M M 
 
530 
 
 RESULTS OF ANTISEPriC SURGERY. 
 
 Psoas and 
 
 Name and Age 
 
 27 
 
 John R., 10 
 
 '28 
 
 Hugh McL., 6, 
 
 29 
 
 Michael C, 21. 
 
 30 
 
 John B„ 25 
 
 31 
 
 John D., 29 
 
 Date of Operation and 
 Discharge; with result 
 
 Op., Nov. 20, 187G. 
 Din., Aug. 5. 1877. 
 Result, cured. 
 
 Op., Jan. 29, 1877. 
 Dig., Aug. 1878. 
 Result, improving. 
 
 Op., Jan. 28, 1877. 
 Din., May 1878. 
 Result, cured. 
 
 Op., Fel). 11. 187 
 Vis., Feb. 1878. 
 Result, cured. 
 
 Op., Oct. 12, 1877. 
 Uis, Jan. 1878. 
 Result, died. 
 
 PsoaG abscess pointing 
 ease of the spiue. 
 
 in the thigh. Dis- 
 
 Psoas abscess on the left side pointing in the 
 thigh. Extensive disease of the vertebrae 
 and curvature of the lower dorsal and 
 upper lumbar vertebr». An ab.scess formed 
 on the other side at a later period. 
 
 Lumbar abscess on the right side. Pain in 
 the back. A second lumbar abscess 
 formed. 
 
 P.soas abscess which had not passed into the 
 thigh. Had been treated for spinal dis- 
 ease for eighteen months. Patient very 
 weak. 
 
 Psoas abscess which had passed into the 
 thigh. The curvature of the spine began 
 at the twelfth dorsal and the most promi- 
 nent part was at the second lumbar verte- 
 brse. Patient much emaciated and very 
 weak. 
 
 1 
 
MR. LISTERS STIXAL ABSCESSES. 
 
 53 1 
 
 Lumbar Abscesses (contiuued). 
 
 Treatment 
 
 Oi)ened in the thipjh. A sound was then 
 passed under Poujiart's liiz;anient, the 
 point projected against the skin and 
 cut out. The lower wound was then 
 stitched. Drainage-tube inserted into 
 the upper. 
 
 Opened like No. 27. Very thick pus 
 containing pieces of bone was evacu- 
 ated. 
 
 C)pened. Drainage-tube inserted. 
 
 Absce.'ss opened above Poupart's liga- 
 ment. Drainage-tube inserted. 
 
 Opened, 8."( oz.of pus evacuated. Drain- 
 age-tube inserted. 
 
 Aseptic course, soundly healed June 1877. The 
 w ound in the thigh healed in a few daj's, but pus 
 reaccumulated there, and it was necessarj- to 
 open the sear. (The object of the procedure was 
 to obtain an opening above Poupart's ligament 
 as far away from the pubis as possible with- 
 out the difficulty of a special dissection. It 
 was hoped that the wound in the thigh would 
 heal by tirst intention, and that the part of the 
 abscess in the thigh would drain into the abdo- 
 men.) (See T. Chan LIX.) 
 
 For some time the case went on very well, but it 
 was a matter of extreme difficulty to keep on 
 the dressings owing to his deformity. An ab- 
 scess formed on the opposite side and was 
 opened in May 1877. Putrefaction occurred 
 during the summer. Of this patient Dr. 
 Bishop writes: 'His father removed him in 
 August 1878 to the West of Scotland. He 
 was then considerably improved, having youth 
 on his side to resist the septic influences ; and 
 when he was last heard of he was running 
 about.' 
 
 Aseptic course. The second abscess was opened 
 February 25, 1877. Dr. Bishop says, 'Michael 
 C. healed in March 1878. Left in May. In 
 July 1878 he was able to go to Peterhead to 
 the herring fishing. He returned to the fishing 
 in 1879.' (See T. Chart LX.) 
 
 Aseptic course. Dr. Bishop says : ' John B., 
 hceiled in December 1877 ; left in FebruMry 
 quite strong and well. When last heard of, he 
 was employed as a colporteur.' (See T. Chart 
 LXI.) 
 
 The patient a|)i)arently suffered from carbolic 
 l)oisoning, and therefore the dressings weie 
 left on for a long time and were made very 
 small, and creosote and ultimately thymol were 
 substituted for carljolic acid. .\s the result 
 <if these changes, putrefaction occurred. The 
 discharge became foul and exceedingly jirofuse 
 and the patient l)ecanie rajiidly w(!akcr. As 
 he exjiressed a desire to go home, lie was 
 allowed to do so. He died about a mouth after 
 he got home. 
 
 ii M 2 
 
532 
 
 RESULTS OF ANTISEPTIC SURGERY. 
 
 Psoas and 
 
 No. 
 32 
 
 Name and Age 
 
 Lucy S., 22 , 
 
 33 
 
 34 
 
 35 
 
 Marv R.. 
 
 Sarah P., 21 
 
 Catherine C, lo 
 
 36 
 
 37 
 
 Henry W., 24 
 
 Mary P, 25, 
 
 Date of Operatii n and 
 Discharge ; with Result 
 
 0;>., July 23, 1878. 
 Dis., June 1879. 
 Result, cured. 
 
 Op., Oat 11,1878. 
 Dis. MMy 17, 1879. 
 Result, cured. 
 
 0/j., May 5, 1879. 
 Dk., Ai)ril 1880. 
 Result, cured. 
 
 Op., Feb. 6, 1880. 
 ])is., Sept. „ 
 Result, cured. 
 
 0/j,, June 2n, 1879. 
 Dis., .luly ]«S(). 
 Result, in proce.ss of 
 cure. 
 
 Op., Oct. 7, 1880. 
 Result, cured. 
 
 Large psoas abscess. Also a collection of 
 flui'l in tlie f^ltiteal rcijioji. Curvature of 
 the lower dorsal vertebrae. 
 
 Psoas abscess, ■which had not yet passed into 
 the thigh. Considerable angular curva- 
 ture of the lower dorsal and upper lumbar 
 vertehne. 
 
 Psoas abscess pointing in the thigh. Had 
 noticed pain over the second and third 
 lumbar vertebne for twelve months. 
 
 Curvature of the spine chiefly in the lumbar 
 region. Psoas abscess. Pain in back. 
 
 Patient was admitted with disease of the 
 elbow-joint. Had suffered from pain in 
 the back for some time. An abscess was 
 found in the left lumbar region. 
 
 Psoas abscess. Prominence of first lumbar 
 vertebra. Great pain and tenderness over 
 that part ; she could not be touched or 
 moved without crying out. General health 
 verv bad. 
 
MR. LISTERS SPINAL ABSCESSES. 
 
 :33 
 
 Lumbar Abscesses {continued). 
 
 Treatment 
 
 An incision was made into the abscess 
 above the crest of the ilium, and six 
 ])ints of clear fluid were evacuated. 
 The fluid in the buttock was evacu- 
 ated by the same incision. Wound 
 stitched up. 
 
 Opened like Xo. 17. Dniinage-tube in- 
 serted, 14 07.. of pus with pieces of 
 bone escaped. 
 
 Opened above the crest of the ilium 
 about its middle ; oO oz. of thin pus 
 e;caped. Drainage-tube inserted. 
 
 Opened like Xo. 17, 8 o/. of thick mor- 
 tar-like pus escaped containing? pieces 
 of bone. Drainage-tulje inserted. 
 
 Opened. Drainage-tube inserted. 
 
 Abscess opened and 24 oz. of pus con- 
 tHining a piece of l)one evacuated. 
 Drainage-tube inserted. 
 
 The fluid reaccumulated in the buttock, and in 
 the beginning of August, 17 oz. of serous fluid 
 were removed bj' the aspirator. There was 
 again reaccumulation, and 18 oz. were with- 
 drawn on August 22. On September 4, the old 
 cicatrix was opened and a drainage-tube in- 
 serted. The tube got blocked, and there were 
 reaccumulation and high temperature. (The 
 patient was also menstruating at the time.) 
 As soon as free exit was provided for the 
 fluid, the tem]ierature fell. The case then 
 followed a typical course and the wound healed 
 during April 1879. She went home quite 
 well and strong in the beginning of June. 
 When the fluid was let out on September 4, it 
 had a peculiar odour and contained numerous 
 bacilli. These, however, disappeared in a few 
 daj's, being apparently either dead already or 
 incapable of developini; in the serous discharge 
 from the wound. (See T. Chart LXII.) 
 
 Aseptic course. Wound healed on March 4, 
 1879. Patient was in excellent health through- 
 out the whole treatment. (See T. Chart 
 LXIII.) 
 
 Aseptic course. Healed completely on February 
 25, 1880. Patient improved in general condi- 
 tion from the day of the operation. (See T. 
 Chart LXIV.) 
 
 For some days this mortar-like stuff containing 
 fragments of bone could be pressed out. Bv 
 February 24, the discharge was serous and the 
 case thenceforward followed a typical aseptic 
 course. The elevation of temperature on Feli- 
 ruary 9, and the following days coincided with 
 the patient's first menstruation. Healed during 
 July 1880. (See T, Chart LXV.) 
 
 .Vseptic course. In the summer of 1880, as tliore 
 was no discharge, even though the sinus had not 
 healed, the patient was allowed to walk about. 
 When the hosjiital was closed in July 1880, the 
 sinus was still unhealed. He was sent lionie to 
 be treated asepticallv by his own doctor. (See 
 T. Chart LXVI.) " 
 
 Aseptic course. The pain in the back di-ap- 
 peared in a few days and tin; patient's health 
 rapidly improved. Found liealed on June 16, 
 1881. Patient tlien well and strong and quite 
 free from jiain or tenderness. (See T. Chart 
 LXVII.) 
 
m smamm immmam^mM 
 
 ■ 
 
 ziv 
 
 TEMriHA'II (!K CHAHTS OF CASKS OK I'SOAS AND LUMBAR ABSCESS. 
 
 I 
 
T.YTT 
 
 XXL 
 
 zjnrr 
 
 7, XIV 
 
 LXV 
 
 ,Im rwEM EiMElM E ME MEM EM E M E M HM EM EM E 
 
 I ■■■■■■■■■■■■ 
 ■■■■■■■■■ ■■■ 
 
 Bptap 
 
 Lxvr 
 
 L.\\7f 
 
 'J';;.\ii'EiiATrKi'; Chauts n\- ('asks op I'shas and Lr.viHAit Ausckss (^(■(intiiHird ). 
 
636 RESULTS OF ANTISEPTIC SURGERY. 
 
 Another case was admitted during these years, a little child 
 with psoas abscess. This was opened aseptically, but the parents 
 insisted on removing the child 3 days after the oj)eration, for no 
 apparent reason. As of course such a case could not be of any 
 value in regard to the effects of treatment, I have not included 
 it in the list. 
 
 We have thus 37 cases of abscess connected with disease of 
 the spine treated by free incision and the insertion of a drainage- 
 tube under strict aseptic precautions. Of these 23, or 62*1 p. c, 
 were certainly cured. This figure does not however represent 
 all the cases which recovered, for several of the patients left 
 hospital continuing the aseptic method, and I see no reason why 
 these did not also recover. I would thus consider that 4 other 
 patients (Nos. 3, 7, 18, and 36) were probably also cured, giving a 
 total of 27 cures, or 72*9 per cent, of cures. 
 
 Of these 37 cases 4 died in hospital, and 1 is known to have 
 died soon after leaving hospital, giving 5 known deaths in 37 
 cases, or a mortality of 13*5 p. c. But it may be said : 'The 
 cases which putrefied and were discharged also died ; ' and no 
 doubt some of them did. Reckoning these cases therefore as 
 also cases in which a fatal result ultimately occurred, we should 
 have 9 deaths in 37 cases, or a mortality of 24*3 per cent. We 
 know however that this percentage is too high, for the boy 
 No. 28 was improving in general condition when he was last 
 heard of, and he very probably recovered, and the result in 
 No. 16 was by no means certainly fatal. 
 
 If we enquire into the causes of death we find, that some of 
 them must necessarily be present in a certain number of these 
 patients. Thus Nos. 12 and 24 died of phthisis, while No. 21 
 died of exhaustion, and on post-mortem examination there was 
 found most extensive disease of the spinal column, so extensive 
 and of such a nature that the chance of recovery under any 
 circumstances was exceedingly minute, if indeed it can be said 
 to have existed at all. No 5 died of a cause quite independent 
 of the lumbar abscess ; indeed this case ought to be reckoned 
 as one which was cured of the lumbar abscess, but which died 
 from another cause before leaving hospital. The case shows 
 very well the dangers of a septic as compared with those of an 
 aseptic wound ; for for months the patient had had an open 
 
MR. LISTER'S SPIA'AL ABSCESSES. 637 
 
 wound treated aseptically without any bad result, but he did 
 not have a septic wound many days before it was attacked by 
 erysipelas, of which the patient died. 
 
 The cases in which putrefaction occurred show very well the 
 contrast between the course of cases where the aseptic method 
 has failed (in other words the course of septic cases), and of 
 those where the aseptic method has been successfully carried 
 out. If we look at the causes of failure we shall see that in 
 one or two cases there was good reason for it. Thus in No. 1 
 the abscess was opened at the upper and inner part of the thigh 
 quite close to sources of putrefaction. It was this case which 
 showed the danger of incisions in this situation, and led to the 
 much better plan of opening psoas abscesses in all cases above 
 Poupart's ligament. The immediate cause of putrefaction in 
 this instance was that the menstrual discharge soaked the 
 dressing and conveyed putrefaction to the wound before the 
 accident was detected. Here also it must be noted, that the 
 application of an elastic bandage along the margin of the 
 dressings had not yet been introduced, and hence the edge of 
 the dressing was not always in apposition with the skin. That 
 putrefaction occurred under these circumstances is not a matter 
 for surprise. No case will go wrong from this cause in future. 
 Then in No. 28 the dressings slipped owing to the extreme 
 deformity of the patient and the difficulty in retaining them 
 in position, but this will probably also be avoidable in the future 
 by careful management. In No. 31 we had the complication 
 of carbolic poisoning — a complication happily extremely rare — 
 and by the use of one or other of the powerful antiseptics now at 
 our disposal we may, I think, reckon that if a similar case should 
 occur again, there will be no necessity for such treatment as 
 would involve the risk of putrefaction of the abscess. Then 
 we have two cases in which no explanation is given (Nos. 1 6 and 
 20). These were likely due to the carelessness of the dressers ; 
 one (No. 20) occurred during the Christmas holidays, when most 
 of the dressers were away, and when those who were left had 
 generally more work than they could do without hurrying 
 over it. Altogether, I believe that in future the chances of 
 a case going wrong are very small, as indeed we already see 
 from the more regular progress of the last cases. For, if we 
 
538 RESULTS OF ANTISEPTIC SUItGERY. 
 
 look at the results since 187/), we find that 73*3 per cent, of 
 the cases were certainly, and 80 per cent, probably, entirely 
 cured, as against 59 per cent, of certain, and 72*7 per cent, of 
 probable, cures in the preceding four years. But this does not 
 yet give a true idea of the present probabilities, for of the two 
 cases which proved fatal since 1875 one died of an unavoidable 
 cause — phthisis — while in one putrefaction occun-ed under 
 circumstances which would not now happen, viz. the absence of 
 a ftiirly trustworthy substitute for carbolic acid. The results of 
 the last few years, both in hospital and private practice, shew 
 that in a patient not affected with phthisis or other dangerous 
 malady a cure is in the highest degree probable. • 
 
 If we look at the cases which recovered, we see that what 
 I stated at p. 519 is true — that the effect of opening a large 
 abscess aseptically and keeping it freely open by means of a 
 drainage-tube is not a severe attack of fever, nor profuse 
 suppuration, nor hectic fever, but is the relief of the patient 
 from any hectic symptoms from which he was previously 
 suffering, and his rapid return to a normal state of health 
 without any suppuration from the abscess cavity. The change 
 wrought in these patients is very remarkable. Some have been 
 brought into hospital in a very feeble and emaciated condition, 
 apparently rapidly dying, and yet in a few days after the abscess 
 was opened they recovered their appetite, they rapidly put 
 on flesh, and soon gained an appearance of robust health. The 
 cases which were cured were not cured after a weakening con- 
 finement to bed, but, when they left their beds, they were in 
 
 ' With reference to all the cases mentioned, I need hardly point out that 
 the results obtained during a number of j'ears in which a method is being 
 developed do not give the jiresent jyrobahilH.ies of success. The asep'ic 
 method is much more perfect at the present time than in 1872, and therefore 
 the failures in the earlier period reduce the average results. It is only by 
 failures that advance is made, and the failures in the earlier period have led 
 to improvements which avoid these errors in future. For a very simple 
 example of this look at Case 1 of the psoas abscesses, where the failure led to 
 the selection of a better position for making the incision. In the same way 
 other failures led to the wetting of the deepest layer of gauze, to the use of an 
 elastic bandao-e, &c., and it is only the results since these improvements which 
 shew the present state of matters and which now give those who employ this 
 method great confidence in it. 
 
SPINAL ABSCESSES NOT TREATED ASEPTIC ALLY. 539 
 
 good health and strong, while when they were admitted they 
 were in some cases miserable, weak, emaciated creatm'es. 
 
 This success after opening spinal abscesses aseptically has 
 been obtained by several surgeons who have used the method 
 carefully, while, on the other hand, surgeons who have been 
 apparently successful with other wounds have failed in tliese. 
 This is the case in which perhaps of all others faulty manipula- 
 tion becomes evident. For in an ordinary wound, as we have 
 seen, the healthy tissues may destroy causes of fermentation 
 should they accidentally enter the wound, but in an abscess 
 cavity like this, such destruction will not occur, and therefore a 
 slight error which might not matter and might escape notice in 
 the case of a wound, will entirely upset the result here. These 
 cases are really tests as to whether a surgeon is thoroughly 
 versed in the details of the aseptic method ; and till a surgeon is 
 able to reckon on success in these instances, he ought not to 
 ventiu'e on operations of convenience, such as many operations 
 on joints, &c., in which failure is apt to be followed by grave 
 consequences, nor ought he to bring forward his own experience 
 as telling for or against the aseptic system. 
 
 When I come to look for comparative statistics on this 
 subject I find none. During the Edinburgh period I do not 
 find mention by Mr. Spence of a single case of this kind, nor do 
 ] find reference to them by other statisticians. I have, however, 
 in the history of this subject referred at length to the views of 
 surgeons on the dangers of opening these abscesses, and we have 
 seen that when they were freely opened and kept open, death 
 was looked for in the vast majority of cases. The only methods 
 which yielded any sort of satisfactory results were the valvular 
 method and the method by aspiration. 
 
 At the meeting at St. Thomas's Hospital, to which reference 
 has been already made. Sir James Paget said, 'A few years ago 
 I believed that I had never seen a patient recover after the 
 opening of a lumbar or a psoas abscess with a free incision ; I 
 could not remember one who had not died before the opened 
 abscess had healed. Of late years I have known such abscesses 
 opened with complete impunity under antiseptic treatment ; and 
 there has seemed nothing but this treatment to account for ihe 
 difference of results.' 
 
540 RESULTS OF ANTISEPTIC SURGERY. 
 
 CHAPTER XXI. 
 
 RESULTS OF ANTISEPTIC SURGERY — (concluded). 
 
 General consideration of the results. Results of the various methods in saving 
 life. Results in avoiding infective disease. Cleanliness : definition of the 
 term : Mr. Savory's definition and method : cleanliness has not abolished 
 infective disease even in healthy hospitals : cleanliness is a complex 
 method : infective diseases may appear even in the best hygienic condi- 
 tions. The source of infective disease. Conclusions as to the value of the 
 various methods in preventing infective disease. Deaths from prolonged 
 suppuration after Chronic abscesses, compound fractures, &c. Operations 
 on weak or diseased individuals are rendered possible by the aseptic method. 
 Operations otherwise unjustifiable, but nevertheless necessary for the 
 recovery of the patient, may be safely done by the aseptic method. The 
 patient may be made a more useful member of society : joint cases : 
 tenotomy, &c. : compound fracture: dangers of operations of convenience. 
 Local results of wounds treated aseptically : absence of pain, inflammation, 
 &c. : experiments of Yeo and Ferrier : organisation of blood-clot, catgut, 
 sloughs. &c. Histological details of the process : Tillmann's experiments. 
 Temperature in aseptic cases : contrast with septic cases. Local and con- 
 stitutional course of cases not treated aseptically. Objections to 
 aseptic surgery : carbolic acid poisoning : the surgeon is said to neglect 
 the constitutional state of the patient : expense : trouble : necessity for 
 the spray. Conclusion : great principle of wound treatment is Rest. 
 
 We are now in a position to consider the points referred to at 
 pages 365 and 366, and first as to the results of the various 
 methods in saving life. 
 
 In Chapter XVII. I have brought forward a mass of evidence 
 to show what are the results of the various methods in avoid- 
 ing infective disease, and I must now refer to this evidence 
 very shortly. We have seen that the aseptic method, when 
 efficiently carried out, has practically abolished infective dis- 
 eases, and that this result has been obtained whether the 
 hospital was one in which these diseases were only present in 
 small amount, as in Pklinburgh, or whether it was one in which, 
 from some cause or other, they were rife ; where the hospital 
 
ASEPTIC METHOD PREVENTS INFECTIVE DISEASE. 541 
 
 was, as it is said, infected. We have also seen that none of the 
 other forms of antiseptic surgery give the same certainty as 
 regards the result, and that the absence of infective diseases 
 increases in direct proportion to the increase in asepticity of the 
 wounds. I have merely to recall the facts from Mr. Lister's 
 own practice, which show the difference in the results of aseptic 
 treatment and treatment by antiseptics carried on by the same 
 surgeon, in the same wards, during the same time, in cases 
 more or less severe. (I cannot say ' of equal severity,' because 
 the cases treated aseptically were, taken as a whole, much more 
 severe than those treated with antiseptics.) The proportion of 
 infective diseases was four times as great in cases treated with 
 antiseptics as in those treated aseptically. But it must further 
 be noted, that the two cases in which the aseptic method was 
 employed and which died of infective diseases, were both 
 cases in which, through error in the manipulations, an aseptic 
 result was not attained ^ ; they were, in fact, septic cases. And 
 so it may be truly stated that in no case in which the aseptic 
 method was efficiently carried out., i.e. ivhere fermentation and 
 micro-organisms were absent from the ivound, did the patients 
 suffer from blood-poisoning. In other words, the aseptic 
 method, luhen efficiently carried out, was, in Mr. Lister^s prac- 
 tice, effectual in entirely preventing infective diseases. 
 
 Similar evidence is furnished by Volkmann, Nussbaum, and 
 others to the effect that in the very few cases in which infective 
 diseases occurred, faulty manipulation could be shown, and this 
 is further proved by the facts that these cases occurred at the 
 commencement of the trial of aseptic treatment, while as yet 
 the surgeons were learning the method, and that since they 
 have become thoroughly versed in its use these diseases have 
 disappeared.'^ 
 
 ' That two cases in which the aseptic method was applied died of infective 
 disease does not prove that the keeping of a wound aseptic is not sufficient 
 to prevent those diseases, because in neither of these cases was tlie wound 
 kept aseptic, a failure due entirely, as has been previously abundantly shown, 
 to faulty manipulation. 
 
 2 It appears to be generally the opinion of those who have had much expe- 
 rience in aseptic treatment, that while pyiemia and septica;mia are readily 
 enough got rid of, greater caie is required to prevent the occurrence of ery- 
 sipelas. The following is the explanation which J would give of this fact. 
 
542 RESULTS 01 ANTISEPTIC SURGERY. 
 
 The other methods of antiseptic surgery are powerful in 
 this respect chiefly in so far as they prevent or interfere with 
 the occurrence of fermentation in the discharges of wounds. 
 And hence it is that among the best means, not entirely aseptic, 
 for accomplishing the purpose aimed at, are treatment by irriga- 
 tion and the water-bath, or the very free use of suitable anti- 
 septics. The open method and free drainage are also useful, 
 though to a less extent. 
 
 It has been asserted by some writers, more especially by 
 Mr. Savory, that the good results following the use of aseptic 
 methods were due to cleanliness, and that equally good results 
 are obtainable by cleanliness, combined with good ventilation, 
 &c., as are got by the Listerian method. By the term cleanli- 
 ness, as ordinarily employed, is meant the cleansing of in- 
 struments and sponges, in some cases the use of new sponges 
 at each operation and of fresh instruments in the dressing of a 
 case, plenty of water to wash the wound with, the use of fresh 
 and clean dressings, and great care in the ventilation of the 
 wards. Combined with these is careful nursing, good surgery, 
 good hygienic conditions, &c. Mr. Savory, however, defines it 
 as 'the prevention or removal or destruction of all matter 
 which may prove poisonous,' and this definition corresponds to 
 some extent with the meaning of the term ' antiseptic surgery ' 
 as employed in this work, though I have limited it to the 
 methods which inteifere ivith the ^production of these poisonous 
 substances, rather than to those which neutralise their effect 
 after they are formed ; and I have also defined more clearly 
 
 There seems to be little room for doubt that erysipelas is a disease due to the 
 growth of micrococci in the skin and subcutaneous tissue, more especially in 
 the lymph channels. Now, as we have seen, one form of micrococcus enters 
 aseptic wounds comparatively readily, more readily than other forms of 
 organisms. We have no absolute evidence, however, that it is only one 
 form of micrococcus which can get in in the manner described in Chapter XII. 
 and it is by no means improbable that the form which causes erysipelas 
 might enter with considerable facility. Where, therefore, a wound is guarded 
 altogether against organisms, erysipelas is avoided ; but where care is suffi- 
 ciently relaxed to let in micrococci, it is possible that the micrococcus of 
 erysipelas may also enter, though the causes of other infective diseases are 
 excluded. That they cannot enter so easily as the micrococci previously alluded 
 to is proved by the absence of erysipelas in the practice of those who use 
 this method most carefully. 
 
MEANIXG OF THE TERM ' CLEANLINESS: 543 
 
 what the nature of the enemy is with which we have to contend. 
 The mode in which Mr. Savory proposes to meet the require- 
 ments of his definition is the following : ' Taking a case, say, 
 of amputation through the thigh, or of excision of the breast, 
 I should treat the wound in the way following. Having care- 
 fully arrested all hemorrhage, using most probably the car- 
 bolised catgut ligature, and having gently removed any 
 particles of blood-clot that may have lodged on the surface, 
 employing only clean water or sponges just rinsed out of it, I 
 should, without any further interference with the surface of the 
 wound, bring the edges together, adapting these as nicely as 
 possible with silver-wire sutures. I should not in any way 
 attempt to close the wound completely, but I should leave 
 spaces between the sutures, perhaps from one to two inches 
 long. Then, over the course of the wound and for some distance 
 on each side of it, I should place a layer of folded lint which 
 had been previously well soaked in olive or almond oil contain- 
 ing one part in about 50 of carbolic acid. Over this again I 
 should place two or more layers of dry lint, either with or with- 
 out cotton wool ; so arranging this as, by gentle and equable 
 pressm'e, to secure without any violence, as far as practicable, 
 the accurate adaptation of the surfaces of the wound through- 
 out, avoiding thus any considerable cavity in the interior. I 
 should secure all this by strapping or bandage, or both, so 
 adjusting these that they may be hereafter removed with the 
 least disturbance. I should place the patient and the wound 
 in the most comfortable position possible, having especial 
 care to the fact that fluids, as they form, may flow outwards. 
 ... As a rule I do not disturb this arrangement for forty-eight 
 hours, although very often I change the dressing and inspect 
 the wound after twenty-four. . . . The dressings are removed 
 with the utmost gentleness, and the state of the wound carefully 
 inspected. Especially is attention directed to whether there is 
 any tendency to the lodgment of fluid ; whether that which 
 forms can escape freely ; whether there is much tension of the 
 edges. ... If the wound presented no other evidence than 
 that of satisfactory repair, I should dress it as before, and pro- 
 ceed in this fashion, dressing and examining it daily or less 
 frequently, according to circumstances. But if at the flrst 
 
544 RESULTS OF ANTISEPTIC SURGERY. 
 
 dressing, or at any time afterward, the discharge became at all 
 profuse, or the surfaces did not remain in contact, or there 
 were much tension or a blush at the edges, I should forthwith 
 substitute a bread and water poultice for the previous dressing, 
 and probably continue to employ this until at least all the 
 deeper portion of the wound had closed. When I dressed the 
 wound, I should wash it probably from the first with tepid 
 water, perhaps containing some permanganate of potash in the 
 form of Condy's fluid, or other potent antiseptic of the least 
 irritating kind. I should accomplish this, washing out, if I 
 thought fit, portions or even the whole of the interior by the 
 use of a syi'inge, avoiding contact of sponges or other substances 
 with the wound. I aim here at the utmost possible cleanliness, 
 having at the same time due regard to the avoidance of any 
 unnecessary disturbance, that the process of repair be not in- 
 terrupted. And withal I endeavour, by means I need not 
 indicate, to secure for my patient the most complete rest and 
 the purest air.' Such is the way in which Mr. Savory proposes 
 to carry out the ' prevention or removal or destruction of all 
 matter which may prove poisonous.' I do not intend to discuss 
 whether or to what extent this method will succeed in fulfilling 
 these requirements ; I leave that for the reader of the preceding 
 pages to decide. I quote it as showing what the best surgeons 
 mean by the term ' cleanliness,' and it will be seen that Mr. 
 Savory's description of treatment by scrupulous cleanliness 
 does not materially difier from what is ordinarily understood by 
 that term. 
 
 I must now proceed to inquire whether this cleanliness ' is 
 
 ' It is too much the fashion at the present time to assert that cleanliness, 
 as the term is now emploj'ed, existed long ago, and to speak of it as an ex- 
 planation of the results of the aseptic method which has been overlooked 
 by Mr. Lister. On the contrary, cleanliness as at present understood is one 
 of the leading developments of Mr. Lister's writings. The disinfection of 
 instruments, sponges, &c., is the leading feature of his system, and was not 
 attended to before he wrote. The avoidance of silk ligatures by the use of 
 catgut ones is due entirely to him, for, though catgut had been tried before, it 
 had failed, and it was not till Mr. Lister discovered how to prepare it that it 
 was of any use. Drainage also, though introduced long ago, and again brought 
 into notice by Chassaignac, was very imperfectly used till Mr. Lister worked 
 with it, showed its importance, and demonstrated the best mode of employing 
 it. Cloanliness in the common acceptation of the term is not a feature of 
 
CLEAyLINESS teksijs INFECTIVE DISEASE. 545 
 
 really as etfectual in preventing infective diseases as the 
 methods of treatment founded on the Listerian principle. If 
 we look at the evidence on this point we shall find, that no 
 amount of cleanliness, ventilation, &c., has succeeded in 
 abolishing infective diseases to the same extent as the aseptic 
 method. This is at once evident if we again look at the com- 
 parative results in Mr. Lister's own. hands of cases treated 
 aseptically, and of those treated with antiseptics, &c., i.e. by 
 scrupulous cleanliness (p. 376). It is still more strikingly evi- 
 dent if we contrast the results obtained by Professor Spence 
 (p. 378) with those got by Mr. Lister in the same hospital and 
 during the same time. For there we find that the total mortality 
 in JNIr. Spence's practice was very much greater than in Mr. 
 Lister's, whether we take the results of individual operations or 
 the total results in the two cases. It will also be seen from 
 jNIr. Savory's statement at Cork,^ and still better from the 
 Eeport of St. Bartholomew's Hospital for the following year 
 (p. 414), that infective diseases are far from abolished by the 
 use of the ' most scrupulous cleanliness ' apart from truly aseptic 
 means.^ This is the result in healthy hospitals. 
 
 But, supposing that it were the case that these diseases are 
 abolished in healthy hospitals by cleanliness, free ventilation, 
 &c., there is abundant evidence to show that these remedies 
 are but feeble in hospitals which are unhealthy or, as it is 
 termed, infected. Look for instance at Professor Volkmann's 
 results before and after the introduction of the aseptic method 
 (]). 385). Before he employed it he had used cleanliness in its 
 best sense, that is to say, he had irrigated his wounds with 
 water and with antiseptics, treated them with the water-bath, 
 treated them with antiseptics, &c., and yet infective diseases 
 increased to such an extent that he had resolved to close the 
 hospital altogether. Nevertheless, as soon as the aseptic 
 method was introduced these diseases disajjpeared. Perhaps 
 the most striking piece of evidence on this subject derivable 
 
 Mr. Lister's method, for he is glad to allow accumulation of l)lood and dirt 
 around the margin of the wound, so long as micro-organisms do not enter this 
 dirt, because it protects the wound from tliu irritation of the antiseptic 
 employed. 
 
 ' Jiritixk Medical Jintriidl, August I), 187i). 
 
 '^ See also the results of amputations in 8t. George's Hospital, p. 114. 
 
 N N 
 
646 RESULTS OF ANTISEPTIC SURGERY. 
 
 from Volkmann's experience, is that with regard to the use of 
 thymol (p. 404), showing that where the antiseptic employed 
 was inefficient the surgeon mi^ht take the most scrupulous pre- 
 cautions with regard to cleanliness and yet fail to exclude 
 infective diseases. 
 
 Similar evidence was brought forward by Professor Nuss- 
 baum (p. 393), and his testimony is the more striking as it is 
 clear from his results in the country hospital that he really had 
 been treating his cases with 'scrupulous cleanliness' before he 
 introduced the aseptic method, and yet his patients were dying 
 in large numbers from infective diseases in the hospital in town. 
 Nevertheless as soon as the Listerian method was introduced 
 these diseases at once ceased. That in his practice ' scru- 
 pulous cleanliness ' when thoroughly carried out was without 
 effect is still better shown by the fact to which he alludes, viz. 
 that even after years of aseptic work with absence of infective 
 disease, these diseases, of as violent a type as formerly, were 
 apt to attack wounds not treated aseptically. ]M;my other facts 
 bearing on this subject will be found in Chapter XVII., and I 
 need not recapitulate them here. 
 
 It follows from what has gone before, that a method which 
 is ineffectual under unfavourable circumstances has only a limited 
 usefulness when they are favourable ; for, as soon as from any 
 cause, accidental or otherwise, the circumstances become 
 unfav(Mirable, the method becomes ineffectual. In truth 
 cleanliness alone is no method. To be effectual it must be 
 combined with careful nursing, efficient ventilation, good 
 hygienic conditions, careful medical treatment, good surgery, and 
 so fortli. Eemove one of these conditions, and in proportion to 
 the importance of the factor displaced does the treatment become 
 ineffectual. What the aseptic method does is to substitute a 
 unity for a complexity, and thus to render the patient indepen- 
 dent of any disarrangement of a number of factors. Exclude 
 the causes of fermentation from wounds and, as the evidence I 
 liave brought forward abundantly proves, you at the same time 
 exclude the causes, whatever they may be, of infective disease. 
 
 With the exception of a few extremely rare cases which may 
 be left out of discussion, the causes of infective disease enter 
 the body through a wound. If therefore these causes be 
 
CLEANLINESS versus INFECTIVE DISEASE. 547 
 
 excluded from the wound, they may be abundantly present in 
 the surrounding air, and the patient may be in a fit condition, or 
 in other words, may be a favourable soil for their reception, but 
 nevertheless he will remain safe. And thus the surgeon has a 
 feeling of certainty that in spite of the condition of the sur- 
 rounding air, or the receptivity of the patient, the latter is safe 
 so long as the means employed to exclude the causes of infec- 
 tive disease prove effectual. On the other hand, aim merely at 
 rendering the causes of infective disease inert by a number of 
 isolated precautions, and the failure of any one of these from 
 causes overlooked or imknown renders the j^atient liable to be 
 attacked. There is no certainty, no security, in such a method. 
 That a patient is liable to be attacked by pyaemia and other 
 infective diseases, even under the most favourable circumstances, 
 when he is not treated aseptically, is most beautifully shown 
 by jNIr. Holmes' experience at the Wimbledon Hospital, and I 
 do not think that I need apologise for quoting his words in 
 detail.^ In order to test whether operations would succeed 
 better in the country than in the town, Mr. Holmes operated 
 on two patients at Wimbledon. ' I commenced,' says he, ' with 
 two cases which seemed to me to be very appropriate for the 
 experiment. One was a middle-aged man suffering from chronic 
 disease of the tarsal bones, a perfectly healthy individual who 
 had never, as far as I could find, had any serious disease in his 
 life, and certainly never suffered from erysipelas. The other 
 was a man broken down by all kinds of dissipation, and, no 
 doubt, to a certain extent a bad subject for an amputation, but 
 otherwise there was nothing very remarkable about the case. 
 1 sent these two men down to Wimbledon, and performed 
 amputation on both on the same day, a few days after their 
 admission into the hospital. They were treated in separate 
 rooms, neither room having been used before ; one was in one 
 of the wards of the hospital, the other in one of the private 
 rooms. They were separate from each other, but attended by 
 the same nurse ; otherwise they were in exactly the same con- 
 ditions as a man would be in private practice. The rooms were 
 entirely free from all possibility of contamination. They were 
 not attended by medical students at all, but by the resident 
 • t5cc the debate on Pyiumia. Transactions of the Clinical Socictij, 1871. 
 
 N N 2 
 
648 RESULTS OF ANTISEPTIC SURGEEY. 
 
 medical officer of the hospilxil. There were no other cases in 
 connection with them whatever, and all the other cases in the 
 hospital were simply convalescent cases. I never saw two cases 
 more likely to do well. One of them was certainly a case of 
 amputation which anyone would have expected to recover, 
 merely Syme's amputation for chronic disease. Both of these 
 people died, one of pya?mia, the other of erysipelas. The 
 erysipelas did not attack the stump at all, but simply the head. 
 This appeared on the fourth or tifth day, and was followed 
 shortly afterwards by sloughing of the skin of the back to an 
 enormous extent, a piece as large as a soup-plate sloughing a 
 few hours before his death. The patient died on the fifth day 
 after amputation. The other man died on the seventh day from 
 pyaemia.' Argue over these cases as you like, they simply shew 
 that the contention that cleanliness, isolation, and so on, are 
 sufficiently protective against infective disease is incorrect, for 
 by these methods some unknown factor may be overlooked and 
 the patient become infected. 
 
 Dm-ing the debate at the Clinical Society, evidence to the 
 same effect was brought forward by a number of speakers. 
 Thus the president, Mr. Prescott Hewitt, mentioned the occur- 
 rence of pyaemia in his private practice in twenty-three cases. 
 Mr. Hutchinson also brought forward evidence to show ' that 
 pyaemia is extremely common amongst the lower animals, and 
 it occurs amongst them when they are not crowded in the least, 
 but tuhen they are placed under the most jjerfect hygienic con- 
 ditions.^ Mr. Charles Hawkins mentioned that an outbreak of 
 phagedsena occurred in St. George's Hospital in the ward at 
 the top of the house, ' in the best ventilated and best placed 
 ward in the hospital.' Sir James Paget stated that pyaemia 
 was as common in private as in good hospital practice. He 
 says, after enumerating several cases : — ' I therefore come to 
 the very clear conclusion that there is really nothing, I will not 
 say in any hospital, but nothing in a well-managed hospital, 
 which contributes to the production of pyaemia.' Dr. Barnes, 
 who had been for some time physician to the ' Dreadnought,' 
 referred to a great improvement which had followed the aban- 
 donment of sponges, and the substitution of fresh tow for the 
 cleansing of each wound, and tlie avoidance as far as possible of 
 
VLEAyLINESS vEERrs INFECTIVE DISEASE. 549 
 
 the transference of any contaminating material from one patient 
 to another. Mr. Croft, who had been surgeon to the ' Dread- 
 nought,' said with regard to the permanent effect of these 
 improvements : — ' I know that after some alterations had been 
 made in the state of the hospital, an improvement took place 
 in the number of cases of erysipelas, pyaemia, and phagedaena, 
 but, after a time, while Mr. Tudor was there — I am sure if he 
 were here he would bear out what I say — both pyaemia, 
 erysipelas, and hospital gangrene were rife.' 
 
 I need not quote other facts mentioned there and elsewhere 
 to shew that cleanliness, free ventilation, &c., are not by any 
 means perfect protectors against pyaemia, but are liable to 
 become ineffective from a variety of causes. I do not of course 
 mean to deny or detract from the value of cleanliness and good 
 hygienic conditions.^ On the contrary, they are most excellent 
 and do much to abolish infective diseases, more especially if 
 they are associated with free drainage, and chiefly, I believe, 
 with the open method and antiseptic irrigation. ]My argument 
 merely is, in the first place, that however well carried out, they 
 do not even in the most favourable cases protect the patients 
 entirely from risk, more especially in operations, such as on the 
 bones, which are particularly liable to be followed by pysemia ; 
 and in the second place, their success is so much at the mercy 
 of numerous disturbing causes, many of them unknown and 
 therefore to a great extent unavoidable, that they cannot form 
 anything like a guarantee against the occurrence of infective 
 disease. No one could say of any individual case so treated : 
 ' I have no fear that you will die of infective disease, unless you 
 are one of those rare individuals who apparently get pysemia 
 spontaneously : indeed you need not take the danger of infective 
 disease into consideration.' On the other hand, with the ase])tic 
 method, whether the operation be conducted in an 'infected' 
 hospital, or performed on parts particularly liable to be fol- 
 lowed by blood-poisoning, there is practically, as the evidence 
 
 ' I do not of course mean to den}' that good ventilation is useful even 
 where aseptic treatment is carried out. Good ventilation has been shown to 
 be essential for health, and it therefore ouglit to be carried out as far as 
 possiljle in everj' case. I speak here of vent ilal ion, kc., as .tiihsiifiitr.t for 
 aseptic treatment. 
 
550 RESULTS OF AXTISEPTIC SURGERY. 
 
 brought forward abundantiy shews, security against its occur- 
 rence. 
 
 The explaiiation of these facts has been furnished by various 
 writers, and as Mr. Savory has, in his sj^eech during 
 the debate on Pyaemia and at the meeting of the British 
 Medical Association at Cork, summarised the points which are es- 
 sential for understanding the modus ojjerandi of antiseptic sur- 
 gery, and for showing the necessity for truly aseptic treatment, I 
 may quote what he says : ' We may take a decomposing fluid, 
 inject it into the blood, and produce all those effects which are 
 generally recognised as the effects of pygemia.' The poison ' is 
 formed during the decomposition of animal fluids, animal fluids 
 in connection with the living human body.' ' Decomposition is 
 unquestionably hastened by exposure ' to air. ' Most of all, the 
 introduction of other matter in a state of active decomposition 
 increases vastly the rate of decomposition of the original fluid.' 
 This decomposing fluid ' can, by a syringe, be introduced at 
 once into the blood of an animal, and produce the most terrible 
 forms of blood-poisoning.' ' As we have been already told, the 
 not unhealthy pus, normal pus, may be injected into the circu- 
 lation, and you do not get as a necessary result, by any means, 
 pyaemia. But pus is an animal fluid, which, of all fluids, is 
 most likely to be found in contact with wounds, and, obeying 
 the law of exposed animal fluids, is exceedingly likely to 
 undergo decomposition ; and then pus, undergoing decomposi- 
 tion, will produce pyaemia, as any other fluid will produce 
 pyjTemia which is in a state of decomposition.' 'Take pus ; you 
 do not want to go to decomposing vegetable and other animal 
 fluids; you may do it with them, but take pus, and with it I 
 could make a case of py;iemia or septicaemia according to order, 
 by the length of time which I kept the pus before I injected it ; 
 and I know very well, in experimenting on this subject, one 
 may produce all degrees of the disease, and may say that the 
 chances of getting secondary abscesses are in direct ratio to the 
 length of time an animal lives after it has become inoculated with 
 the poison. When the poison is thoroughly septic, when you 
 have that terrible substance which Dr. Bm'don-Sanderson has 
 shown us how to get in the peritoneal cavity of an animal, the 
 blood h(;comes so poisoned and spoilt that it kills outright, and 
 
RESULTS OF FERMENTATION IN WOUNDS. 651 
 
 there is no time for the secondary effects to supervene.' And 
 then how is it that this fluid can be in contact with granulating 
 siu-faces, and yet the patient be free from all symptoms ? 
 Simply because the granulations protect the patient against 
 the absorption of the ' terrible substance ' in contact with them. 
 There are other reasons which I need not mention here, but 
 the most powerful is that which I have just stated. I again 
 quote Mr. Savory : ' The best work done in late years in this 
 direction are those, experiments which Billroth and other 
 persons have performed, showing that where granulations are 
 healthy, when they exist in their integrity, they offer a decided 
 obstacle to the passage of the material from without to within ; 
 liut when these granulations become destroyed, either mechan- 
 ically or by other means, whereby they are brought into an 
 unhealthy state, these fluids pass with fatal facility through 
 them and so gain entrance into the blood.' I have already 
 demonstrated that the decomposition of organic fluids and 
 tissues was dependent on the introduction of particles into them 
 from the outer world, and that these particles are bacteria or 
 their spores. The latter point is not absolutely essential for 
 the question at issue, indeed Mr. Savory sums up the essential 
 points as follows in his address at Cork. ' I turn away from 
 any farther inquiry as to the natiu-e of these septic particles. . . 
 It is enough for us that they are septic; that they can pro- 
 duce and promote putrefaction ; and further, that fluids so 
 changed by them may provoke those terrible effects tvhich are 
 only too well knoivn as blood-poisoning.^ ' 
 
 T do not pledge myself to all Mr. Savory's conclusions, more 
 especially where he states that he can get pysemia and septi- 
 caemia according to the length of time that the decomposing 
 fluid has been kept or that the animal has lived after inocula- 
 tion ; but the statements taken as a whole reflect fairly well the 
 present state of knowledge on this subject, and are sufficient ex- 
 planation of the results of the different varieties of antiseptic 
 surgery in regard to infective disease. They shew that no pre- 
 cautions which do not entirely prevent the growth of organisms 
 in wounds can be trusted to remove the patient altogether from 
 the risks of blood-poisoning, for if organisms are not entirely 
 ' The it.ilics are mine. 
 
562 RESULTS OF ANTISEPTIC SURGERY. 
 
 excluded from wounds, aud if these wounds are not very care- 
 fully drained, fluids may be confined in the deeper parts of the 
 wound and there undergo decomposition. The use of a bread 
 and water poultice greatly facilitates the putrefaction of the dis- 
 charge ; and thus it comes about that a patient so treated is 
 practically only protected from the ' terrible poison ' in his 
 wound by a thin and delicate layer of granulations. If these 
 remain whole and healthy all may be well,' but if from ■ some 
 injudicious movement this layer is ruptured, or if from some 
 other cause the granulations lose their vigour, then the patient 
 is liable at any moment to the entrance of the poison into his 
 circulation, and to the consequent dangers. 
 
 Mr. Savory considers that the term ' antiseptic surgery ' is 
 synonymous w4th the term ' good surgery.' I would ask, if it is 
 good surgery to leave a patient subject to the risks just mentioned, 
 and dependent for his safety on a number of factors, any one of 
 which may fail to act and upset the remainder; or whether it 
 is not better surgery to keep away altogether from the wound 
 the causes of the formation of this ' terrible substance,' and 
 thus make the patient independent of the numberless accidents 
 which might render him liable to the absorption of the poison, 
 if it were already present. Cleanliness, isolation, ventilation, 
 poultices, drainage with gutta-percha tissue, &c., may be very 
 excellent when suitably combined and carried out, but, as I 
 have already pointed out, this is a system so complex and so im- 
 practicable as to be incapable of providing a satisfactory safe- 
 guard against infective disease ; it is not the simple thing 
 which some hold it to be. The true simplicity, I again say, is 
 where there is only one factor to be considered, as in the aseptic 
 method. 
 
 I do not intend to enter in this work into the discussion of 
 the germ theory of infective disease at all. To do so thoroughly 
 would require much more space than I have at my disposal ; 
 and further, its discussion might tend to obscure the real prin- 
 ciple which is at the basis of antiseptic surgery ; for, as I have 
 already pointed out, the tendency in the present day is to bring 
 
 ' This does not by any means always follow, for some forms of micro- 
 orfi;anisms may be able to j)enetrate through healthy granulations, and produce 
 infective disease. 
 
MICRO-ORGANISMS AND INFECTIVE DISEASE. 553 
 
 prominently forward the germ theory of infective disease, and 
 thus lose sight of the real points at issue. For my own part, 
 I consider that the evidence in favour of the germ theory of 
 infective disease is overwhelming, and I constantly admire the 
 temerity of those who, often through ignorance of the present 
 state of knowledge on this subject, ridicule it and speak of it 
 as far from proven. It is sufficient, however, for our purpose 
 to recognise that when the precautions taken to exclude 
 micro-organisms are successful, the causes of infective disease 
 are also excluded. This is an absolute rule. Look at any of Mr. 
 Lister's cases which went wrong ; they only did so after fer- 
 mentation had occurred in the wound, after the aseptic method 
 had failed to exclude micro-organisms. And so we may draw 
 this rule, that if organisms are absent from a wound, that 
 wound having been properly examined, the patient is prac- 
 tically safe from the occurrence of infective disease. If, how- 
 ever, organisms are present, he may become liable to these 
 affections from causes depending on a variety of accidents 
 which we cannot consider here. This we may accept without 
 in any way adopting the view that bacteria are the causes of 
 infective disease, for all that we need hold is, that the pre- 
 cautions necessary to exclude bacteria are sufficient also to 
 exclude the causes of infective disease. 
 
 That the aseptic system, of all the methods of wound treat- 
 ment, is the most certain and perfect protector against infective 
 disease, is perhaps even more strikingly shown by the results 
 of operations on healthy joints and bones, which are, under 
 other systems, particularly liable to be followed liy infective 
 disease. Such operations have been justly looked on as pecu- 
 liarly dangerous, and as only warranted under exceptional 
 circumstances, while it is also pretty universally conceded that 
 if they can be performed subcutaneously, i.e. more or less 
 aseptically, the danger becomes much less. No other system, 
 however, not even the most scrupulovis cleanliness and the 
 most ])erfect ventilation, has ever enal)led the surgeon to cut 
 freely into healthy joints or to operate on healthy bones, and 
 \o keep up a communication between the external air and the 
 injured bone; or joint, witliout incurring tlie greatest danger to 
 the patient, and that danger cliiefly from infective disease. 
 
.')r>4 RESULTS 01' ANTISEPTIC SURGERY. 
 
 And yet the reader has only to turn to Chapters XVIIT. and 
 XIX. to see that such operations can be done with safety under 
 aseptic precautions. As I have already discussed these facts 
 in detail, it would be mere repetition to dwell on them here. 
 
 We have thus applied crucial tests to the various systems, 
 with the view of ascertaining to what extent they may be de- 
 pended on as barriers against infective disease, and we have seen 
 that the aseptic method is the one which has done most in this 
 direction, and, indeed, that under certain circumstances it is the 
 only one which can be depended on at all. It follows from 
 this that, as it protects against pysemia, even in the worst cir- 
 cumstances, it will be equally certain under more favourable 
 conditions ; and as we have seen that no other method of treat- 
 ment is anything like an absolute safeguard against infective 
 diseases in cases liable to be attacked by it, and as these 
 diseases may occur, as we have just shown, even though rarely, 
 under the most favourable conditions, it follows that unless any 
 sufficient reason exists against its use in any particular instance, 
 Listerism ^ ought to be employed, as far as possible, in all 
 cases, and where it is not applicable the most strenuous at- 
 tempts ought to be directed to the limitation as far as can be 
 of fermentation in the wounds, and to the avoidance of any 
 distiu"bance such as movement, or anything which tends to 
 make the granulations unhealthy and thus render the patient 
 liable to the absorption of the products of fermentation. 
 
 But death after operations and wounds is not only due to 
 infective disease, it may occur as the result of exhaustion, 
 hectic fever, e^c. Among these the most important are the 
 deaths which ensue as the result of prolonged suppurations, 
 most strikingly seen after opening chronic abscesses connected 
 
 ' I need hardly repeat what I hope I have already made sufficiently clear, 
 that there is a difference between the terms ' Listerism ' and the ' Listerian 
 method.' Listerism is the great jJ7-i)icij}le of wound treatment introduced by 
 Mr. Lister, a principle which may be applied in various ways. The best mode 
 of application of this principle is that worked out by Mr. Lister himself and 
 known as the Listerian metliod. Some surgeons have introduced various 
 modifications of the method, but they still practice Listerism, though not 
 strictly the Listerian method. Tliat the Listerian method is the be.st mode at 
 present known of carrying out Listerism cannot be doubted. 
 
DEATHS FROM PROFUSE SUPPURATION. oc5 
 
 with carious vertelirne. In this case we have a chronic disease 
 of the bone, which has led to the formation of an abscess in 
 connection with it. The cause — the chronic disease of the 
 bone— which primarily led to the formation of the abscess, was 
 not very active, and thus the abscess was chronic in its com- 
 mencement, i.e. not attended with any marked symptom of 
 inflammation ; the causes — the chronic bone disease and the 
 tension exercised by the pus already formed on the walls of the 
 abscess cavity — which induce the continued formation of pus 
 act very slightly, and thus the abscess increases but slowly, 
 and if tlie inflammation of the bone cease and the pus be not 
 very tensely confined in a sac, it may become a cheesy mass or 
 even be entirely absorbed. As a rule, however, there is suffi- 
 cient tension on the walls of the sac to lead to continuance of 
 the pus formation, steady though slow increase of the abscess, 
 and maintenance of the bone disease. So long as the skin re- 
 mains unbroken this abscess increases very slowly. If now the 
 pus be withdrawn by means of an aspirator or by a trocar and 
 canula, and no causes of fermentation be admitted, it may 
 happen, though in truth very rarely, that there is no reaccumu- 
 lation of pus, the residue which was not removed by the aspi- 
 rator is absorbed, the cavity closes, and the disease is cured. 
 In some cases repeated aspirations are necessary to secure this re- 
 sult, but in the majority of instances the abscess steadily increases 
 in size and must at last be opened, or bursts externally. And 
 now if no care be taken to exclude the causes of putrefaction, 
 the state of matters becomes very different from that which 
 existed before the skin was broken. As we have already seen, 
 and as the behaviour of the chronic abscess so longf as the skin 
 is unbroken abundantly shews, pus has no inherent tendency 
 to undergo fermentation. We also know that the gases of the 
 air cannot induce fermentation, but that particles in the air 
 and deposited on surrounding objects can. If the abscess is 
 opened without sufficient aseptic precautions, of whatever kind 
 they be, these particles must gain admission into the pus in 
 the abscess cavity, and as there can here be no destructive 
 action of the living tissues on these particles, fermentation 
 occurs. And this fermentation may or may not be putrefactive, 
 but whatever it be, its products are always more or less chemi- 
 
ooG RESULTS OF ANTISEPTIC SURGERY. 
 
 cally irritating ; and the effect of the appHcation of irritating 
 chemical substances to granulations is to cause them to suppu- 
 rate. P'urther, these irritating chemical substances — the pro- 
 ducts of this fermentation — are not transiently applied but are 
 constantly present day after day in contact with the granula- 
 tions, for as we have seen, the ' vital ferments ' have an in- 
 definite power of multiplication, and thus there is a constantly 
 fresh supply of the irritating products. The result is the pro- 
 fuse suppuration which constantly follows free incisions into 
 these abscesses, and the consequence of this prolonged and free 
 suppuration is hectic fever, exhaustion, waxy infiltration and 
 degeneration of various internal organs, and ultimately, in the 
 great majority of cases, death. On the other hand, prevent the 
 entrance of micro-organisms, as I have shewn can be done by 
 the aseptic method, and the pus remains as unirritating as 
 formerly There is no more reason for great formation of pus 
 after than before the abscess was opened ; indeed, the granu- 
 lations are relieved from the tension of the pus, and are there- 
 fore less irritated than before and secrete less. And then in 
 a few days tlie greater part of such an abscess cavity closes by 
 adhesion of the granulations, and only a sinus is left leading to 
 the seat of disease. But the granulations lining this sinus do 
 not suppurate because they are not irritated, and hence all 
 that happens is a slight transudation of serum, perhaps not a 
 couple of minims in a week, and this continues till the disease 
 is cured and the sinus can close. Thus, during the treatment 
 the patient is not exhausted by profuse discharge, while he is 
 relieved from the presence of the abscess, which by the tension 
 of its contained pus was keeping up the chronic inflammation 
 of the bone and was a source of constitutional irritation. And 
 thus we constantly see that, where such abscesses are opened 
 aseptically and ke^tt aseptic, the patient's health at once begins 
 to improve. 
 
 That these are not mere theoretical speculations, but that 
 they are fair deductions from the facts, will be evident to any 
 one who will carefully weigh tlie facts brought forward in the 
 history of antiseptic surgery and in Chapter XX. For there we 
 see that the only method of treatment which could be said to 
 be of any service at all in these cases, excepting the Listerian 
 
DEATHS FROM PROFUSE SURPURATIOX. 557 
 
 method, was Abernethy's mode of punctm'ing with a trocar and 
 canula, or of making a valvular incision into the abscess. On 
 the other hand, we have the much better results of aseptic 
 treatment, results not obtainable by the so-called simple 
 methods of cleanliness, free ventilation, &.c. I need not go 
 into the discussion of these results again ; the facts have been 
 sufficiently given in the last chapter. 
 
 Though this is the most striking instance in which profuse 
 suppuration leads to loss of life, yet in many other cases great 
 danger is caused by its occurrence. Thus in many injuries of 
 bone, such as compound fractures, very profuse and prolonged 
 suppuration often follows which may endanger the life of a 
 weakly patient, or may even in the case of a healthy patient 
 lead to amyloid infiltration and degeneration of the internal 
 organs. This is chiefly the case where necrosis of portions 
 of the fractured bone occurs ; the necrosis may be due to the 
 injury directly, a portion of bone being deprived of vitality or 
 separated from its vascular connections at the time of the 
 accident, but more frequently it is the result of acute in- 
 flammation of the bone, acute suppurative osteitis, which 
 supervenes on the injury, and which is due, as is at once evident 
 from comparison with the behaviour of a simple fracture, to 
 the existence of a communication between the injured bone 
 and the external air, and the consequent occmTence of fer- 
 mentation and formation of irritating products in the wound. 
 But, if the wound is kept aseptic the fracture behaves exactly 
 as if it were a simple one, the danger which results from the 
 external wound being completely avoided. There is therefore 
 no acute inflammation either of the soft parts or of the bone, 
 and hence no necrosis from this cause ; the process of repair 
 at once commences. And, just as in the simple fracture, in 
 the way which will be described more minutely presently, 
 portions of bone detached from their vascular supply do not 
 therefore give rise to suppuration, and indeed, by no means 
 require removal, but become encroached on and removed by 
 the surrounding new tissue. Here also this result depends on 
 the asepticity of the wound, however brought about, whether 
 by the aseptic method, or in rare cases by absolute immobilisa- 
 tion or the formation of a crust. If once fermentation occm".s 
 
658 lii:SULTS OF ANTISEPTIC SURGERY. 
 
 in the wound, suppuration takes place, detached portions of 
 bone are always separated, and frequently necrosis of living 
 bone results. An abundance of facts which prove these views 
 have also been brought forward. The same remarks apply to 
 lacerated wounds, though in these cases the suppuration is not 
 often so great, or at least so long continued, as to endanger life. 
 
 Wounds of joints also, though perhaps most frequently fatal 
 in the iirst instance from saprsemia, septicaemia or pyaemia, yet 
 when these dangers have become slight, are still serious from 
 the prolonged suppuration which follows. We have fully de- 
 monstrated that these dangers are all avoidable by taking 
 measures to prevent the occurrence of fermentation in the 
 joints (see Chapter XVIII.) 
 
 There are many other cases, which I need not consider, in 
 which the avoidance of profuse and prolonged suppuration is a 
 matter of the greatest importance, sometimes even of life and 
 death. I shall just mention one example more — acute osteo- 
 myelitis. In this disease, if the patient escapes the primary dan- 
 gers from infective diseases (see definition of the term in Chapter 
 XVII.), he is certain to suffer from prolonged and very profuse 
 suppuration, on account of the death of the bone to a greater 
 or less extent. To avoid these risks amputation is frequently 
 resorted to, but recently Mr. Spence has recommended the 
 excision of the inflamed bone, and has had some good results 
 from this procedure. Neither of these operations are, however, 
 necessary if the case be treated aseptically. It is generally 
 merely requisite to open the abscess freely, wdth the necessary 
 aseptic precautions, and to attend to free drainage, and as a 
 consequence suppuration ceases at once or is very slight, and 
 sometimes the wound heals up without any separation of dead 
 bone whatever, or if this occurs it is generally merely a super- 
 ficial exfoliation. Mr. Lister has had several excellent cases 
 treated in this way. The case of osteomyelitis is of course by 
 no means so typical as the other instances which I have men- 
 tioned, because, as we have seen, micro-organisms are always 
 present in the pus of the abscess in connection with the bone ; 
 but nevertheless its course, if treated aseptically, is often 
 markedly different from that which it follows when treated 
 otherwise, and this, and the fact that some cases do better than 
 
OPERATIONS ON WEAK INDIVIDUALS. 559 
 
 others, may be explained by tlie other fact previously mentioned 
 (p. 256), that in many acute abscesses the micro-organisms are 
 probably dead when the pus is evacuated. 
 
 Then again, if we consider the case of necessary operations 
 on weak or diseased individuals, we shall find that the aseptic 
 method more than any other has diminished their risks, and 
 indeed, with regard to many, alone renders thek performance 
 possible. The good health of the patient is one of the many 
 conditions necessary in the sort of treatment which we have 
 just been considering under the head of cleanliness, free ventila- 
 tion, &c. If the patient be in a weak state, his resisting power 
 to septic influences is less, and the protecting layer of granula- 
 tions is less potent to resist the entrance into the system of the 
 * terrible substance ' in contact with it. Let the patient be 
 weak, and he can, for a shorter time, endure the exhausting 
 suppuration which may follow the operation, a time too short, it 
 may be, to permit of recovery from it.^ This is a point of view 
 from which the subject has been regarded by most surgeons 
 who have adopted the aseptic method thoroughly. Thus Mr. 
 Wood, at the meeting of the British JNIedical Association at 
 Cambridge in 1879,^ said of the aseptic method, that one great 
 reason for employing the Listerian method was ' that it saved 
 a considerable percentage of weakly constitutions, upon whom 
 it was absolutely necessary to operate, and who would die unless 
 for its precautions.' Among these instances may be mentioned 
 cases of amputation in patients suffering from phthisis. The 
 difference uf opinion which exists on this subject is of com"se 
 well known, and many surgeons refuse to operate where marked 
 
 ' Operations on patients suffering from albuiuiniu-ia scorn to be les:; 
 dangerous if treated a-septically than a wound is when treated in other ways. 
 This is easily intelligible, for when not treated aseptically there is frequently 
 absorption of products of fermentation from the wound. In a healthy person this 
 may not be of much consequence, the poisonous materials being probably got rid 
 of in great part by the kidneys. Where, however, the kidneys are diseased 
 this material may not be got rid cf, but may accumulate in the blood and 
 poison the patient, or may act on the kidnej's and cause them to stop work- 
 ing and lead to the patient's death from uncmic poisoning. Both these 
 dangers arc avoided if the case is treated aseptically, for in that case this 
 material is not formed in the wound. 
 
 - British Medical Journal, vol. ii. IbTii. 
 
560 HESULTS OF ANTISEPTIC SURGERY. 
 
 phthisis is pieseut. Of course, where a wound is not treated 
 aseptically, and where healing does not occur by first intention, 
 suppuration takes place, and where the patient is weak this 
 reduces him still further, and, if the wound is large, may only 
 hasten his death. In these cases also the irritative fever which 
 occurs is particularly dangerous. Where, however, union 
 by first intention occurs, irritative fever and suppuration are 
 absent, and the removal of the disease is a relief to the patient. 
 As the aseptic system not only favours union by first intention, 
 but also prevents the occurrence of fever and suppuration in 
 cases where union by first intention cannot take place, am- 
 jiutation in cases of phthisis is a much more hopeful procedure 
 than formerly. Several of jNlr. Lister's cases have been striking 
 examples of this. 
 
 And fui'ther, operations can now be performed which may 
 be necessary for the recovery of the patient, but which would 
 have been almost certainly fatal under the former methods of 
 treatment, and which were therefore considered unjustifiable. 
 This of course follows from the facts narrated in the three 
 preceding chapters, for if an operation such as the incision of 
 a healthy joint may be safely performed for the removal of an 
 inconvenience, it must be equally safe when performed for the 
 removal of something which, if left, would imperil the patient's 
 life. I may quote two facts from Professor Volkmann's speech 
 at the recent International jNIedical Congress.' ' For a large 
 enchondroma in the cortal pleura that occupied the left wall 
 of the thorax. Professor Fischer removed a large piece of the 
 chest wall and ribs, so that the heart and lungs were exposed 
 and an opening as large as a child's head was made, and yet the 
 patient was able to be discharged from the hospital after four 
 weeks.' ' In the case of a large echinococcus of the liver, 
 which in front and at the side was covered with thick layers of 
 liver tissue, and which i)rojected into the thoracic cavity, after 
 resection of the seventh rib, I opened the healthy pleural 
 cavity, which was free from adhesions. The thorax was freely 
 opened, the thinned diai)hragm cut into, the echinococcus sac 
 opened, the animal bladder extracted in toto, and the patient 
 recovered without complication. A similar operation with like 
 results was conducted by ]Mr. Israel of Berlin.' On this point 
 ' Si'C Lancrt, AuiTiist 18, 1881. 
 
■LISTERISM AIDS CONSERVATIVE SURGERY. 561 
 
 also Mr. Wood says : ' ' And another point from which he ' (Mr. 
 Wood) ' had been in the habit of considering it ' (the aseptic 
 system) ' was this : that it extended the aim and scope and 
 value to the community of surgical skill in eases on which it 
 would be too risky to operate without the extreme precautions 
 which antiseptic surgery affords. There were a great many 
 operations which they were doing at the present time which 
 would have been considered wild, and which were now by many 
 considered unjustifiable, otherwise than with their improved 
 means.' 
 
 There are, however, a great many other points which have 
 to be attended to in the treatment of wounds besides the saving 
 of life ; we have to look to what Sir James Paget calls the ' w^ell- 
 doing ' of the patient. Now as the aseptic method allows the 
 performance of operations which would otherwise be considered 
 unjustifiable, it is evident that it must in many cases enable 
 the surgeon to render the patient a more useful member of 
 society than he would otherwise be. Take, for instance, any 
 interference with the movement of joints from some cause (say 
 the presence of an exostosis) which would involve the o})ening 
 of a great articulation in its rectification ; here the aseptic 
 method permits an o})eration which would not otherwise be 
 possible. Look at Mr. Lister's list of joint cases, and see 
 whether or not some of the patients have been rendered more 
 useful members of society by the aseptic method. 
 
 Take the simple operation of tenotomy. How impossible 
 it was till the subcutaneous method was introcUiced ; but as 
 soon as a method was found by means of wliicli the causes of 
 fermentation were excluded from the wound, tliese operations 
 became frequent, and they certainly daily increase the use- 
 fulness of many patients. And what was im})ossible in this 
 department in former days by means of free incision, is possible 
 n<jw ; arid if for any reason one wislies to see the tendon to be 
 divided, it may be exposed aseptically without fear of the result. 
 And further, in cases of ruptured tendons, cases so a})t to leave 
 inii»aiied power behind, one may cut down and sew the ends of 
 the tendon togetlier with catgut and in this way get perfect 
 
 ' Lie. rit. 
 
562 BESULTS OF AXTISUrTIC SUEGEEY. 
 
 union and a complete restoration of power. This has been 
 done in a number of eases with perfect success, and I may refer 
 to Eschenburg's thesis, published in 1877, for the history of 
 these attempts and their results. I may quote two passages 
 from this thesis which shew a striking contrast between the 
 results of septic and aseptic surgery. The first is taken from 
 Eavoth, who says : ' Selbstverstandlich wird man die Sehnennaht 
 vermeiden, wenn keine Hautwunde gleichzeitig vorhanden ist.' 
 On the other hand, Kiister writes as follows : ' Es ist nun eines 
 der Hauptverdienste der antiseptischen Wundbehandlung dass 
 sie den Kreis unserer operativen Indicationen wesentlich 
 erweitert hat, dass sie dem Chirurgen mit ruhigem Gewissen und 
 ohne die mindeste Besorgniss an eine Anzahl von Operationen 
 zu gelien erlaubt, welche sonst entweder gar nicht, oder nur 
 unter ganz besonders giinstigen Bedingungen unternommen 
 werden durften.' And among these operations are those of 
 stitching ruptured tendons. 
 
 This is only one example of the numerous applications to 
 which a method can be put which renders operations practically 
 subcutaneous. Look also at all the operations for ununited and 
 badly united fractures, and for deformities of bones, operations 
 to aid the reduction of dislocations, more especially when of 
 old standing, radical cure of hernia, and so on. These instances 
 are so numerous and varied that I cannot detail them here, but, 
 in the practice of the operating surgeon, cases are constantly 
 occurring in which the advantages gained by means of the 
 aseptic method are of the greatest importance. 
 
 While the scope of the operating surgeon is so much 
 increased by the aseptic method, the cause of conservative 
 surgery is also greatly advanced. I have at p. 442 shewn that 
 in cases of disease of joints a cure may be obtained in a large 
 proportion of instances, without resorting to any further ope- 
 rative procedure than the free incision of the diseased articula- 
 tions. By this treatment not only is the limb retained without 
 any shortening, but also there is frequently a considerable 
 amount of movement in the articulation, a result of the greatest 
 importance to the patient. In the treatment of compound 
 fractures, also, there is much less necessity than formerly for 
 amputation, either primary or secondary. This is hardly a 
 
. LISTERISM AIDS CONSERVATIVE SURGERY. 563 
 
 point which can be treated by statistics, but my own experience 
 — and it is the same as that of others who have practised careful 
 aseptic treatment, and a careful perusal of the cases in Chapter 
 XIX. will demonstrate it — is, that the necessity for these mutila- 
 tions is very much less than when other methods are employed. 
 A limb must be very badly injured indeed before it is necessary 
 to perform primary amputation : it must not be merely that a 
 joint is opened, or that the bone is extensively comminuted or 
 the soft parts badly lacerated: the questions really are, whether 
 the part beyond will retain its vitality, whether if it does so it 
 will be useful, and whether there is a fair probability of purify- 
 ing the wound. If the last is probable the chance of 
 recovery should be given, and if afterwards it is found that 
 purification is not successful, and if otherwise the injury is one 
 which, without aseptic management, would demand primary 
 amputation, the operation can be performed in two or three 
 days after the injury — as soon, in fact, as it becomes evident 
 that aseptic treatment is impossible.^ Again, where primary 
 amputation is necessary it need not be performed above the 
 injiu-ed parts, but, with the view of getting a longer limb, 
 where that would be an advantage, bruised and even lacerated 
 parts may be included in the stump ; for inflammation will 
 not occur in the flaps, and hence the sloughing which would 
 otherwise take place is avoided. I have myself seen limbs 
 amputated in the practice of septic or semi-antiseptic surgeons 
 which I know could have been easily saved by aseptic manage- 
 ment ; and I have, on the other hand, known the surprise of 
 surgeons when amputation has been performed through the 
 bruised parts in order to get a longer stump or to save an 
 important joint, and their expectation that the injured parts 
 
 ' This statement may seem contrary to the well-known facts as to the 
 dangers of secondary amputations, but here the case is different ; for under 
 ordinary circumstances the (question of secondary amputation does not arise 
 till it is found that tliere is danger to the patient if conservative treatjnent is 
 persisted in. Here, however, I do not advise that one should wait till the 
 patient is in a dangerous state ; I merely say that attempts may be made to 
 save limbs which would otherwise be certainly amputated, and that if it is 
 found that fermentation has not been avoided, then the limb ouglit, in the 
 majority of these severe cases, to be amputated as soon as it is evident that 
 the attempt to purify the wound has failed, without waiting for the appearance 
 of any constitutional symptoms. 
 
 o o 2 
 
6G4 RESULTS OF ANTISEPTIC SURGERY. 
 
 would slough 'when inflammation came on.' But fortunately 
 inflammation is not likely to come on if the wound has been 
 properly treated. 
 
 I need not discuss this matter further. If one remembers 
 that an incision, supposing it can be made aseptically, provided 
 also that the wound is kept at rest and otherwise properly treated, 
 is not followed by any local reaction nor by constitutional dis- 
 turbance, one can readily realise how many little operations 
 of convenience may be performed with benefit and increased 
 usefulness to the patient. It may be argued against such 
 operations of convenience that man is fallible, and that a failure 
 of the method might prove a serious matter to the patient. 
 This is to a certain extent true, but the chances of failure in 
 experienced hands in any given case are very small indeed. 
 The performance of such operations by those just learning the 
 method cannot be too much discouraged. It is too much the 
 fashion nowadays to begin aseptic work with some of these 
 daring procedures, such as opening joints ; but such operations, 
 however simple they appear, ought not to be lightly under- 
 taken ; indeed they ought not to be attempted till one has had 
 extensive experience in the aseptic treatment of wounds, and 
 more especially of chronic aliscesses.' 
 
 Exjjerience is needed in aseptic work just as in every other 
 department of surgery. Why does the student devote so much 
 of his time to learning anatomy and to acquiring manual dex- 
 terity in the use of the knife? Simply in order that he may 
 be able to operate with safety to the patient. Take the opera- 
 tion of ligature of an artery or lithotomy or any other great 
 operation in surgery. When performed by an experienced 
 surgeon it seems very simple and easy of performance, but the 
 young operator finds that nmny ditficulties have to be over- 
 come and many little arts acquired before it can be done 
 in the same way as by the ex})erienced surgeon. One would 
 never dream of allowing a man who had never handled a knife 
 
 ' Surgeons are loo apt, even without liaviiig had any experience of the 
 aseptic method, at once to introduce luoditications wmch generally are illogical 
 and hurtful. Volkniann {Lancet, August K'>, 1881) makes the following true 
 remark on this point : ' Most of tlie unfavoinable judgments,' says lie, ' passed 
 nn this metliod afe due to the fact that surgeons who have not yet learnt to 
 experiiuent ivitli it have already made it the .siihjcut of their experiments.' 
 
EXPERIENCE NEEDED FOR ASEPTIC WORK. 565 
 
 before to commence with one of these operations on the living 
 human body. It is just the same with aseptic surgery. For 
 its proper practice are required a scientific training, and more 
 especially, a training in experimental work with its consequent 
 acquirement of patience and dexterity. Let the beginner com- 
 mence its practice in simple wounds where but little harm will 
 result from his failures, or, better still, let him try some experi- 
 ments on fluids contained in flasks. Then, just as the operator 
 feels his way to more serious operations, so the surgeon operat- 
 ing aseptically extends the application of his method ; and just 
 as the experienced operator may proceed with confidence to 
 operations which in the hand of an inexperienced man would 
 be very doubtful procedures, so the surgeon practising Li sterism 
 may with confidence in its protection perform operations which 
 would otherwise be unjustifiable, such as many of the opera- 
 tions of convenience of which we have been speaking. He has 
 then chiefly to consider whether the advantage to be derived 
 from the operation is worth the inconveniences attending its 
 performance. Of course if one has to deal with a large num- 
 ber of cases one cannot say that all of them will do well : in 
 some one or other the experiment may fail. Where there is a 
 large number of cases or a continuous run of successes the sur- 
 geon may become less particular than in any special case which 
 he has determined to keep right, and an accident 7::aight occur. 
 But we may fairly put the matter in this way : given any 
 single case, say of incision into a joint, the surgeon may reckon 
 with certainty that in that particular instance no harm will 
 result from the operation. When, therefore, the surgeon under- 
 takes one of these serious operations he should realise the 
 dangers which are run and the means of avoiding them, and 
 should devote his most careful attention to the case in ques- 
 tion throughout the duration of the treatment. If this is done 
 it is right to undertake such operations if their performance 
 can increase the usefulness of the patient. 
 
 I have said that operations performed aseptically, where the 
 wounds remain aseptic and wliere they are properly treated 
 otherwise, are not followed by any local or constitutional dis- 
 turliance, and I must now say a few words on tins point. And 
 
56G RESULTS OF ANTISEPTIC SURGERY. 
 
 first with regard to tlie local progress of a wound treated asep- 
 tically. 
 
 Where the wound is treated aseptically by the method 
 formerly described (where the drainage is efficient, where the 
 stitches are not too tight, and where tliere is no other local 
 cause of initation, such as movement), no inflammation occurs ; 
 there is no swelling nor redness of the edges, as is so frequently 
 the case in wounds treated otherwise. The skin around the 
 wound remains as pale and as lax as it was when stitched up at 
 the time of the operation ; there is no evidence of reaction. 
 Thus it comes that such wounds are quite painless, and their 
 edges may be pressed and handled without occasioning the 
 patient any uneasiness. Hence even after the most extensive 
 operations the patient remains free from pain ; indeed, the opera- 
 tion being performed under an anaesthetic, and there being no 
 inflammation afterwards, the whole treatment from beginning to 
 end is unattended by any suffering. Patients constantly express 
 their astonishment that the pain which they perhaps mostdreaded 
 is absent ; and this astonishment is the greater if the patient 
 has been previously operated on and treated by the older 
 methods. • 
 
 Then, as the result of this absence of inflammation, the scar 
 is linear and soon becomes hardly apparent. One or two sur- 
 geons have stated that the scars after wounds treated aseptically 
 were conspicuous, and that therefore the method was unsuitable 
 for wounds on exposed parts. This statement must, however, 
 rest on some mistake — either protective has not been used or 
 some other error has been committed ; for my own experience, 
 which is now very extensive, is, that an inconspicuous and 
 linear scar is one of the most striking results of the treat- 
 ment. 
 
 But not only is there absence of inflammation along the cut 
 edges of the skin, it is also absent from the deeper parts of 
 the wound. Thus there is no suppuration even where the deep 
 structures are not absolutely in contact. The discharge from 
 the drainage tube is purely serous and rapidly diminishes in 
 amount so as to render the drain unnecessary in a very short 
 time. 
 
 The importance of this absence of inflammation in the 
 
PROGRESS OF WOUNDS TREATED ASEPTIC ALLY, mi 
 
 deeper parts of the wound has been well shewn by the advan- 
 tages gained by the application of the method to experiments 
 on the lower animals. This is perhaps best illustrated by the 
 experiments recently performed by Professor Gerald Yeo on 
 the brains of monkeys. 
 
 In Dr. Ferrier's former experiments on the brains of mon- 
 keys for the purpose of investigating the function of the 
 various parts of the brain, no attempt was made to keep the 
 animals alive after the operation, because, as the result of ex- 
 perience, encephalitis was looked on as a certain consequence. 
 The attempts which were made failed owing to the occui'rence 
 of encephalitis, with the exception, I think, of one animal 
 which lived for some time. It was therefore deemed useless to 
 attempt to preserve the animals, for the after effects of the 
 injury done at the time of the operation were so complicated 
 by the effects of the inflammation which succeeded, that results 
 of any value could only be obtained from observations made at 
 the time of the operation. 
 
 Lately, however (1878-80), Gerald Yeo has performed 
 a number of these operations with aseptic precautions, and the 
 results were extremely striking, and yielded very definite and 
 valuable information. Twenty-six operations were done. In 
 the first case great difiiculty was found in retaining the 
 dressings in position, and this animal tore off the dressings. 
 It died in a short time of encephalitis, and was the only one out 
 of the twenty-six in which inflammation occurred. Afterwards 
 a very convenient and satisfactory mode of fixing the dressings 
 was devised, and this accident did not happen again. In the 
 other twenty-five cases no inflammation whatever occurred, as 
 was confirmed on post-mortem examination of the animals 
 which died shortly after the operation, or which Avere killed 
 after a sufficient length of time had elapsed. As no inflamma- 
 tion occurred, the symptoms which were manifest after the 
 operation were due to the lesion caused at the time, and thus 
 valuable and definite facts were elicited. The gain to physio- 
 logical observation indicated by these experiments cannot be 
 over-estimated. 
 
 Of the twenty-six cases operated on seven dit'd, the 
 remainder surviving the operation permanently, without ever 
 
508 RESULTS OF ANTISEPTIC SURGERY. 
 
 presenting any symptoms except such as were due to the 
 cerebral lesion. Of the seven deaths, one — the first case, in 
 which the animal tore off his dressings — died of encephalitis ; 
 two died soon after the operation, one from chloroform and one 
 from shock ; one died six days after the operation from cerebral 
 hemorrhage, and here there was no trace of inflammation ; 
 three died apparently from the intense cold of winter, one of 
 these surviving the operation for thirteen days without a trace 
 of inflammation. The wounds always healed by first intention, 
 and the dressings were dispensed with in about a week. 
 
 As a result of this absence of inflammation in the deeper 
 parts the scar does not become adherent but remains movable. 
 This is of greatest importance after amputations where so much 
 inconvenience is often caused by the adhesion of the scar to the 
 divided end of the bone. 
 
 This absence of inflammation is also well seen after opening 
 bursse or hydroceles. Of late it has become very much the 
 fashion in Germany to treat hydrocele by making an incision 
 into the sac aseiitically, stitching the tunica vaginalis to the 
 skin by means of catgut, and inserting a drainage tube. No 
 inflammation follows this procedure ; the discharge becomes 
 very slight, the drainage tube is removed in a day or two, the* 
 wound heals, and the hydrocele is cured. (The violent inflam- 
 mation which follows incisions into hydroceles without aseptic 
 precautions is well known.) Similar residts are obtained in 
 cases of bursitis, more especially of bursitis in connection with 
 the sheaths of tendons. Incisions may be made into these, 
 the fluid and solid material evacuated, and a drainage tube 
 inserted, without fear of bad result, and with ultimate cure of 
 the disease without any adhesion of tendons or other accidents 
 which commonly follow such attempts. 
 
 In cases treated aseptically the wound heals as a rule much 
 more rapidly than when it is treated otherwise ; for where the 
 edges can be brought into contact, healing by first intention 
 is the rule, and even where there is a sj)ace left, this becomes 
 filled up with blood clot which rapidly undergoes organisa- 
 tion. 
 
 "^riie organisation of the lilood clot is one of the most marked 
 features in aseptic treatment. That blood clot may become 
 
ORGANISATION OF BLOOD CLOT. 669 
 
 organised under certain circumstances is no new fact in medi- 
 cine or surgery. We all know what happens in subcutaneous 
 injuries. Blood clot and lymph are thrown out, they are gradu- 
 ally removed by absorption, or their place is taken to some 
 extent by new tissue. In a simple fracture blood clot and 
 lymph are present between the ends of the fractured bone. 
 The effused material gradually disappears, and its place is taken 
 by new tissue which ultimately ossifies. So after tenotomy ; 
 the space between the ends of the divided tendon is filled up 
 with blood clot and lymph, and these become organised, and 
 thus imion again occurs. I need not bring forward other 
 examples to show that blood clot in the living body, when 
 protected by the skin, is gradually removed and its place taken 
 by new tissue. In an open wound not treated aseptically the 
 blood clot generally putrefies, and, as a result, breaks down, 
 liquefies, and is washed away with the discharges ; the surface of 
 the wound granulates, and thus healing takes place. Where, 
 however, a wound is aseptic, and where it is protected from 
 other sources of irritation, such as the action of the antiseptic 
 employed, the blood clot in it undergoes the same changes as 
 it would under the skin, for the aseptic method renders wounds 
 practically subcutaneous. Thus it does not break down but 
 remains, filling up the wound with a solid brown mass ; no 
 granulations are seen, nothing but this brownish solid material. 
 After some days, if this clot be scratched, it will be found to 
 bleed, implying that new vessels have been formed in it, and 
 on lifting up the edge of the clot a broad margin of cicatrix 
 will often be found. If the clot is left undisturbed it fre- 
 quently happens that after a time a superficial layer of 
 toughish brownish material (old blood clot) may be peeled off 
 and a complete scar found underneath. In some cases organ- 
 isation occurs in the clot up to the level of the skin, and 
 cicatrisation spreads for some distance under the superficial 
 unorganised layer, and then by-and-by the remaining central 
 portion granulates, and we have a small superficial granulating 
 sore which rapidly heals. The occurrence of granulation may in 
 this case, I think, be due to the entrance of micrococci, which as 
 we have seen sometimes occurs at a late period of the case. If 
 there is much movement of the wound, or if no protective 
 
570 RESULTS OF ANTISEPriC SUliGEIiY. 
 
 be employed, this organisation may also be imperfectly or not 
 at all observed. The organisation of blood clot has been de- 
 monstrated by several writers, and therefore I need not describe 
 it minutely. The process essentially consists in this : young 
 cells (whether white blood corpuscles or derived from the con- 
 nective tissue, or both, is not yet determined) pass into the 
 blood clot and gradually form fibrous tissue and vessels, which 
 become connected with already existing ones, according to 
 the various well-known methods of vascular formation. This 
 process gradually extends to the surface till, after some days, 
 as I have said, the blood clot bleeds when scratched. When 
 organisation has sufficiently advanced, the epidermis spreads 
 from the edge. The original blood clot takes no active part 
 whatevier in this process : it forms a mould in which the young 
 cells develop, and is gradually either used up as pabulum for 
 these cells, or removed by absorption. Here, just as when sub- 
 cutaneous, the original blood clot disappears, and its place is 
 filled by young tissue which developed in it not from it. 
 
 Sloughs are served in the same way. When a part under 
 the skin dies, as is frequently the case where infarcts occur, 
 it does not necessarily separate, it is gradually removed by 
 absorption and its place is taken by new tissue. In the same 
 way a slough of the skin if kept aseptic, and not imbued with 
 carbolic acid or otherwise rendered irritating, does not separate 
 but goes through the same process as the blood clot. The 
 ordinary process of separation of sloughs is the occurrence of 
 inflammation at the line of junction of the living with the 
 dead tissue owing to the irritating character of the latter. 
 (The slough causes inflammation because it is undergoing de- 
 composition, for the products of decomposition are irritating.) 
 But if the slough is not chemically irritating it does not 
 cause this inflammation ; it does not irritate the living parts 
 around. Then the young cells pass into it as into the blood 
 clot, and the whole process is exactly the same. Thus in 
 lacerated wounds, if rendered aseptic and kept free from the 
 irritation of the antiseptic employed, suppuration and sloughing 
 do not occur: the raw surfaces and the interstices between 
 the torn pieces of tissue become filled up with blood clot, the 
 process of organisation just described goes on, and the whole 
 
ORGANISATION IN CATGUT. 571 
 
 or the greater part of such a wound may heal without the 
 occuiTence of granulation, suppuration, or sloughing. A similar 
 process has been observed in dead bone kept aseptic and not 
 loose : the granulations gradually encroach upon it, and it soon 
 entirely disappears by absorption. 
 
 The same process occui's in catgut introduced into a wound, 
 whether for the puq^ose of ligaturing vessels or as a drain. 
 The young cells gradually infiltrate the catgut from without 
 inwards,' develop into fibrous tissue, remove the original cat- 
 gut, and take its place. The ordinary process of separation of 
 a silk or hempen ligature is, that fermentation occurs in the 
 discharge which has soaked into it ; the ligature thus irritates 
 the walls of the vessel on each side of it ; these granulate, and 
 then suppuration takes place at the point of contact of the 
 dead part included in the loop of the ligatm-e with the living 
 tissue. When suppuration has occurred all round on both 
 sides the ligature is loose and may be pulled away. Secon- 
 dary hemorrhage results when the portion of the vascular wall 
 which has undergone degeneration into granulation tissue as a 
 consequence of this process is not strong enough to resist the 
 blood pressure. If, however, a hempen ligature be applied 
 around a vessel and the wound be kept aseptic, the ligature 
 remains chemically unirritating and may never separate at all. 
 I have seen this well illustrated in a case of amputation where 
 the surgeon operated aseptically, but tied the vessels with hem- 
 pen ligature and left the ends hanging out: the ligatures 
 would not separate but had to be broken short inside the wound. 
 If now catgut be employed it is a material which is rapidly 
 removed by the young cells which, as I have previously said, 
 infiltrate it, and its place, as a ring round the vessel, is taken 
 by this young tissue, which rapidly becomes organised and 
 replaced by a ring of newly formed fibrous tissue. Thus where 
 a catgut ligature is employed there is no ulceration of the 
 
 ' The great advantage of the new catgut prepared with chromic acid is 
 that the cells have a great difficulty in peneti'ating it, and therefore onl}' erode 
 its surface, and thus a stitch which luis been left in the wound for some days, 
 though narrower where it has been in the tissues, is still firm and free from 
 cellular infiltration. With catgut prepared by the older uiethod cells infiltrate 
 it in a few days. With unprepared catgut the cell infiltration and tlie 
 absorption of the thread is a very rapid process. 
 
572 RESULTS OF ANTISEPTIC SURGERY. 
 
 coats of the vessel, but after a time a ring of newly formed 
 fibrous tissue will be found in the situation of the original 
 ring of catgut. For these reasons also the risk of secondary 
 hemorrhage is reduced to a minimum. 
 
 The facts with regard to the organisation of the catgut liga- 
 ture were described by Mr. Lister in his first publication on 
 the subject as long ago as 1869,' and as some of his state- 
 ments have been misunderstood I may quote what he says. It 
 has been supposed by some that he held that the dead blood clot 
 and that the dead catgut became revivified in the tissues. Such 
 an idea is of course utterly absurd and was never entertained 
 nor expressed liy Mr. Lister. Indeed, he speaks as follows as 
 regards the blood clot, and applies his remarks to catgut : ' Thus 
 the dead, but nutritious mass, had served as a rtiottld 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.' Mr. Lister tied the carotid artery of 
 a calf in two places with a ligature of catgut (in one place with 
 two ligatures), and a month later he killed the calf and ex- 
 am^ined the parts. He says : ' The two pieces of catgut which 
 had been tied round the vessel at the distal 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 ojieration was the 
 presence of a black speck ' (the original material contained 
 dark mineral impurities) ' here and there upon a delicate thread 
 of cellular tissue in connection with the vessel. The cardiac 
 ligature was in like manner continuous in structure with the 
 arterial wall. The short ends had disappeared ; but the mas- 
 sive knot was represented by a soft smooth lump, which ap- 
 peared at first entirely homogenous, 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 threefold 
 twisted character of the cord plainly visible. It was quite dis- 
 tinct from the living tissue, so that it could be readily picked 
 ' Lancrt, April 3, 18C0. 
 
ORGANISATION OF CATGUT. 573 
 
 out from its bed with a pair of needles.' Here almost all the 
 original catgut had been removed, but it had served as a mould 
 for the development of new tissue Avhich had taken its place, 
 and which retained the form of the mould in which it had 
 grown. Mr. Lister describes the microscopical appearances as 
 follows : ' A bit of the residue of the peritoneal thread, having 
 been teazed out with needles in a drop of water, presented, like 
 a fresh piece of peritoneum, 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 
 fieshy 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. Here and there were some fibres more per- 
 fectly formed, and also cells of a more rudimentary character. 
 Again, the band which had resulted from the organisation 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 deve- 
 loped form of fibrous t,ssue, consisting of coarse fibres rather 
 than of elongated cells, being thus intermediate between the 
 merely fibro-plastic material of more recent growth and the 
 completed texture of the original thread.' 
 
 A number of writers have described the changes which 
 blood clot and portions of dead tissue undergo in the process of 
 organisation. One of the most interesting and thorongli inves- 
 ligations on this subject has been made l)y Dr. H. Tillmanns of 
 J/cipzig.' Tillmanns took portions of the liver, kidney, spleen, 
 
 ' Experimeiitcllc imd aiiatomischu UnlLa-sucliuii^cn iilier W'umUni (lor Leber 
 und Niere. Ein iieilraj^ ziir Lcluu V(jii dur anli.supli.schcn Wundbcilunj^. 
 Virchow's Archir. Ud. 78, IbT'J. 
 
674 liESULTS OF AUTISEPTIC SURGERY. 
 
 and lungs of rabbits, and hardened them in absolute alcohol 
 for one to three weeks or longer. Pieces of these hardened 
 dead tissues were then introduced with aseptic precautions 
 into the peritoneal cavity of rabbits (in each case several pieces 
 were used) ; after some days the animals were killed and the 
 state of matters investigated. Twenty animals were experi-. 
 mented on, and into their peritoneal cavities about 100 por- 
 tions of tissue were introduced. The animals did not appear 
 the worse for the operation ; the temperature remained normal, 
 and they seemed well. Of these twenty animals only two died, 
 both of acute peritonitis : in one case an en-or was committed 
 in the treatment, the stitches were removed too early, and the 
 intestines protruded : in the other case the animal was suffer- 
 ing before the operation from chronic peritonitis which after- 
 wards became acute. When the animals were killed early, in 
 a day or two after the operation, the masses of tissue were 
 found to be adherent to some part of the peritoneum, and 
 sometimes two pieces of tissue were attached to one another. 
 Where fourteen days or more were allowed to elapse, the por- 
 tions of tissue were found firmly adherent and much diminished 
 in size, evidently undergoing absoqjtion ; in some places there 
 was only a thick layer of new material containing a pulpy mass 
 in its interior. In one animal into whose abdominal cavity a 
 whole kidney had been introduced, and which was allowed to 
 live for forty-seven days, the kidney had entirely disappeared ; 
 the only thing noticeable was that at one part of the omentum 
 there was a thickish tough spot, where probably the absorbed 
 kidney had been attached. On investigating the process micro- 
 scopically the following were briefly the appearances found : 
 After twenty-four hours the mass of tissue is, as I have just 
 said, adherent to the peritoneum and surrounded by a layer of 
 soft new material — lymph. Any defects which existed in the 
 margin of the specimen are filled up with this soft mass. 
 This new material when examined is found to be composed 
 of countless numbers of cells, which Tillmanns holds to be 
 white blood corpuscles. If two pieces of dead tissue lie close 
 to each other, they become adherent to each other by means of 
 this material. If these tissues are examined at a later period, 
 say forty-eight or seventy-two hours after their introduction, 
 
ABSORPTIOX OF DEAD TISSUE. 575 
 
 these cells are found to have increased in number and to be 
 no longer confined to the outside of the organ, but to have 
 penetrated into it where possible, forming, as Tillmanns puts it, 
 streets and pathways of cells through the tissue. Thus, for 
 example, in the case of the liver these cells penetrate in the 
 first instance along the streaks of connective tissue which lie 
 between the lobules, entering first those channels which are 
 largest but gradually spreading along the smaller ones. At 
 this time the cells have already begun to develop to higher 
 tissue, and not merely round cells, but also elongated spindle- 
 shaped cells undergoing further development, are found. P^ig. 39, 
 Plate v., represents this : to the right is seen the old liver cells, 
 and to the left the new cells which have penetrated along the 
 interlobular connective tissue ; at the upper part these cells 
 have already become spindle-shaped. This process gradually 
 goes on, the young cells penetrate more and more among the 
 dead materials, which gradually disapjjear by absorption, their 
 place being taken by this young tissue which has come from 
 without. This tissue rapidly undergoes further development 
 into fibrous tissue, vessels, &c., according to the well-known 
 processes (see fig. 40, Plate V.). The contraction of this 
 young connective tissue and the further changes which it 
 undergoes lead to the disappearance of the original mass and 
 the formation of a cicatrix at its site, which also, as time goes 
 on, tends to dwindle and disappear. 
 
 Thus the replacement of blood clot, sloughs, and other 
 dead tissues, in the living body by new material — their organ- 
 isation, as it is commonly called — is no longer a fact resting on 
 clinical experience alone, but is a process which has been traced 
 step by step under the microscope. What at first sight seems 
 remarkable, what is certainly something new, is, that this 
 process occurs in an open wound. But when the whole facts 
 are carefully considered, it will be seen that this ftict is only 
 one which might have been expected, and that it is quite in 
 accordance with well-known facts in pathology. 
 
 While there is this absence of local disturbance in wounds 
 treated aseptically, the constitutional state of the patient re- 
 mains good ; in fact, if he has not lost much l)lood during the 
 
576 
 
 BESULTS OF AyTISEPTIC SURGERY 
 
 operation, or if the operation has not caused shock, he is, on 
 recovery from the effects of the chloroform, practically as well 
 as before. His appetite is perfect, and I may say here that 
 after operations performed aseptically there is no reduction of 
 diet even for a few days ; an hospital patient remains on full 
 diet, and a private patient may have anything he fancies pro- 
 vided it is wholesome, and the more nutritious the food the 
 better. Indeed, after the opening of a psoas abscess, or after 
 an operation which rids the patient of some depressing disease, 
 such as a carious joint, the appetite which was previously 
 very imperfect returns in a few days, and hunger becomes the 
 
 jBBSEBEflEB 
 
 jJBb 
 
 Fig. 80. — Temperature Chart. 
 
 Temperature chart from a ca-ie o£ ilacEweii's operation for double genu valgum (Case 69, p. 488;. 
 
 patient's chief trouble. At the same time there is no fever, as so 
 frequently occurs after operations treated otherwise. I do not 
 propose to discuss here the subject of temperature after opera- 
 tions ; to do so would require much space, and our knowledge 
 of the origin and regulation of temperature changes in the 
 living body is as yet so imperfect that we could not come to 
 any definite conclusions. I shall therefore content myself with 
 referring to the following facts. 
 
 After an operation performed aseptically, and in which there 
 is no cause of elevation of temperature, such as tension, the 
 temyjerature remains normal ; or if the operation has been at all 
 extensive, the following changes are obsei'ved, of which Chart 
 XXXVI., fig. 78 (Case 69, p. 488), is a very good example. 
 In this case both femora were divided, i.e. a compound fracture 
 of each femur was made, on the same day : the temperature 
 previous to the operation was 99° F. : on the evening of the 
 
TYPICAL TEMPERATURE IN ASEPTIC CASES. 577 
 
 operation it had fallen to 96'8° : on the following morning it 
 was 100-6°, and then it again rapidly fell to the normal, being 
 on the same evening 99'3°. As a rule the temperatin-e after 
 operations performed aseptically resembles this example : the 
 temperature is below the normal on the evening of the opera- 
 tion, it then rises to or above 100°, reaching its highest point 
 on the following morning or evening, and then rapidly falls to 
 the normal line again. In some cases before reaching the 
 normal it fluctuates for a day or two between 99° and 100°, but 
 this fluctuation is not within the range of fever temperature 
 but within the normal rauge.^ It is very seldom that the 
 pulse rises in equal proportion, indeed it generally remains 
 normal. 
 
 This normal^ temperature may be disturbed for various 
 reasons, but especially when tension and retention of secretions 
 occur. The elevation of temperature which follows imperfect 
 drainage is often very marked. Among the cases narrated in detail 
 there is no good example of elevation of temperature from tension: 
 I may therefore quote the following instance. A little boy had an 
 unreduced dislocation backwards of the bones of the forearm of 
 six weeks' standing. On December 9, 1876, Mr. Lister cut 
 down on each side of the joint, opened it, and succeeded, after 
 detaching the muscles from the condyles of the humerus, in 
 reducing the dislocation. The parts were very tense after 
 reduction, and the primary rise of temperature reached 101° on 
 the day following the operation, and remained at that level for 
 thirty-six hours ; it then fell rapidly as usual. On December 
 14th Mr. Lister moved the joint for the first time. That even- 
 ing there was profuse hemorrhage, which ceased on removing 
 the dressing. A fresh dressing was applied, but the hemor- 
 rhage went on into the limb, which was next day very much 
 swollen and distended with blood. The temperature rose 
 rapidly and continuously till it reached 104*4°. On December 
 16th incisions were made into the arm to evacuate the blood 
 
 ' It has been pointed out by Wunderlich that after disturbance of the 
 temperature the curve often fluctuates for a day or two before regaining the 
 normal. 
 
 - Mere elevation of ten^pcrature without other symptoms cannot be called 
 fever. Fever is indicated by a combination of symptoms, and an elevated 
 temperature is only one, though the most striking, feature of the febrile state. 
 
 P P 
 
678 
 
 RESULTS OF ANTISEPTIC SURGERV 
 
 clots ; on the following day the temperature began to fall, and 
 on the morning of the iHth was 100-8°. After some oscilla- 
 tions about this height it rapidly fell to normal. Here in the 
 first instance, coinciding with tension of the parts after the 
 operation, the primary rise reached 101°, and did not fall at 
 once, but remained for some hours at that height. Then it 
 fell ; but the parts became greatly distended with blood, there 
 was great tension, and coincidently with this the temperature 
 rose rapidly and to a consideral^le height, and again fell when 
 the tension was got rid of. The pulse at the same time in- 
 creased in rapidity, being on one occasion 144. 
 
 XXIII 
 
 Fig. 81. — TEilPEKATLfKE FROM A CASE OF COMPOUND FRACTURE, IN WHICH 
 THERE WAS GREAT DIFFICULTY IN RETAINING THE FRAGMENTS IN 
 
 POSITION (Case 27, p. 472). 
 
 Why it is that the accumulation of discharges and the con- 
 sequent tension should be accompanied by rise of temperature, 
 often very rapid and high, is a very debateable question, and 
 one which can hardly as yet receive an answer. At first the 
 impression was, that this rise of temperature was due simply 
 to the effects of the tension on the nervous system; that it 
 was, in fact, a nervous phenomenon. There can be no doubt 
 that several instances of elevation of teinjieratiu-e in children 
 and hysterical women after operation are in some way or other 
 reflex phenomena. Thus in a child the presence of a tight 
 stitch may be accompanied by a rise of temperature, which 
 subsides as soon as the offending cause is removed. Probably 
 this is the reason for the rise of tem])erature in Case 27, p. 472 
 (see fig. 79). In this case great difficulty was experienced in 
 keeping the u]>per fragment in position and there was therefore 
 
FErEll DUE TO TEysIOX. 670 
 
 constant disturbance of the parts. At the same time, it must 
 be observed that the pulse rate had not increased in rapidity 
 in projjortion, and the patient did not feel out of sorts ; with 
 the exception of the elevated temperature there was no other 
 symptom of fever. Here there was no fermentation in the 
 wound and no retention of discharges, and therefore it seems 
 probable that it was a nervous phenomenon. On the other 
 hand, there are cases in which there may be great tension, 
 as after subcutaneous bruises, or local disturbance of the parts 
 as in some forms of joint disease, without an elevation of 
 temperature at all corresponding to that which occurs when 
 the discharges of wounds are retained. And also, the weight 
 of evidence derived from experiments on animals seems to go 
 against the view, that mere disturbance of the nerves of a 
 part is a frequent or probable cause of the marked elevation of 
 temperature which sometimes occurs in cases where there is 
 retention of discharge. Indeed, according to Wunderlich,^ the 
 application of external irritants has the effect of lowering the 
 general temperature rather than of raising it, and the same 
 author states that Heidenhain has found that iiTitation of 
 sensory nerves constantly and suddenly lowers the temperature, 
 except after division of the medulla oblongata from the spinal 
 cord or when fever is present. On the other hand, it has been 
 demonstrated that the products of inflammation (the serum of 
 pus, &c.), when introduced into a healthy animal, cause a rapid 
 rise of temperature, which soon passes off if no further injections 
 are made.^ It is thus quite possible, that when discharges are 
 retained by the blocking .of a drainage tube or for any other 
 reason, the fever which follows is due, at least in part, to absorp- 
 tion into the circulation of the retained materials. (In most 
 cases of elevation of temperature from tension the pulse is 
 
 ' On Temperature in Diwase. 
 
 ^ That the products of inflammation should cause fever is not surprising. 
 For, in inflammation, not only do liquor sanguinus and corpuscles pass out of 
 the blood-vessels, but the tissue cells, which are constantly taking material 
 from the blood and altering its constitution — in fact acting as ferments — are, 
 I think there can be no doubt, stimulated to increased activity; their func- 
 tion is also probably perverted, and the changes which they produce in the 
 nutritive materials with which they are supplied may be different from those 
 which occur in health, and may lead to the formation of substances which, 
 when absorbed into the circulation, cause fever. 
 
 p p 2 
 
580 RESULTS OF ANTISEPTIC SURGERY. 
 
 correspondingly quick, and the patient feels ill — in fact, he 
 has fever. On the contrary, where it is a merely nervous 
 phenomenon, I think, though perhaps I may be hasty in this 
 conclusion, that the pulse does not increase in rapidity to a 
 corresponding degree.) This is, to my mind, the most pro- 
 bable explanation of the high temperature which occm's after 
 ovariotomy in Mr. Thornton's practice.^ Mr. Thornton does not 
 drain the peritoneal cavity, but stitches it closely up. The 
 consequence is, that the fluid effused from the divided pedicle 
 or from other injured parts is absorbed by the peritoneum, and 
 although ]Mr. Thornton's wounds are aseptic, yet he has fever 
 in many cases. This fever, however, is not fatal, for as the 
 pedicle heals the discharge diminishes and the temperature 
 falls. Here tension cannot be at work ; and further, surgeons 
 who di'ain the peritoneal cavity, and who at the same time treat 
 their cases thoroughly aseptically, do not meet with this high 
 temperature. Which of these two is the cause of the elevated 
 temperature in tension, or whether both may not play a part, 
 are questions which cannot as yet be definitively settled. 
 
 Though tension is the most important cause of elevation of 
 temperatm-e in aseptic cases, there are other minor causes, such 
 as retention of fgeces, the occm-rence of menstruation, &c. 
 
 What the meaning of the transitory rise of temperature after 
 aseptic operations is, it would be difficult to say. In some cases 
 no doubt, where much blood has been lost, it is merely the rise 
 which normally occurs in these circumstances. It seems to be 
 established in the case of the lower animals, that after blood- 
 letting, though the temperatm-e may fall in the first instance, 
 it generally rises to a considerably higher level than that at 
 which it stood before the blood was taken. Similar facts have 
 been observed after blood-letting in man. This rise of tempera- 
 tm-e after loss of blood is probably the explanation of the curve 
 in Case 16, p. 430 (see fig. 80). Here the ankle joint of a 
 hsemophilious child was opened and hemoi-rhage occurred from 
 the cut surface on various occasions diu-ing the following three 
 days ; there was no fermentation of the discharge and no 
 tension. Nevertheless loss of blood cannot always be the 
 cause, for what we may call the ' asej)tic curve ' occurs in 
 ' Medico- CMrurgical Transactions, 1881. 
 
TEMPERATURE IN CASES NOT TREATED ASEPTICALLY. 5S1 
 
 cases where little or no blood is lost. In aseptic cases it is 
 probably a nervous phenomenon, more especially as the pulse 
 rate in no way corresponds. I cannot discuss this matter 
 further, as much space would be required, and we do not yet 
 know enough about the origin and regulation of the tempera- 
 ture of the body. One fact is, however, apparent, that besides 
 the ordinarily recognised elevations of temperature after opera- 
 tions there is a transitory elevation tuhich occurs soon after the 
 operation and as an infiniediate result of it, and which can be 
 readily recognised when all other disturbing causes are excluded. 
 I have not met with any instance of the high temperature 
 which Volkmann has after a large proportion of Ids operations, 
 and which he has termed ' aseptic fever,' and I do not under- 
 stand it at all. 
 
 Fig. 82. — Temperature Chart from a Case where the Ankle Joint 
 was incised in a hyemophilious patient, and where hemorrhage 
 
 RECURRED SEVERAL TIMES (CASE 16, P. 430). 
 
 If one compares the temperature in cases which are treated 
 aseptically with that of those which are not, the contrast will 
 be found to be very marked. I do not of course by any 
 means intend to say, that the temperature is always high after 
 operations which are not treated aseptically ; far from it. 
 Many wounds not treated aseptically heal by first intention, and 
 in these there is, of course, no elevation of temperature or merely 
 the * aseptic curve.' Further, in many wounds in which fer- 
 mentation of the discharges occurs the discharge is drained 
 off and but little can be absorbed ; and in other cases the 
 wounds are small, or the conditions for absorption are not 
 favourable. In tliese instances there will often be no marked 
 elevation of temperature. But in a great numlier of severe 
 
582 RESULTS OF ANTISETTIC SURGERY. 
 
 operations treated by the ordinary methods of cleanliness, as 
 described at p. 542, there is marked elevation of temperature — 
 traumatic fever — and in some cases this passes into a septicsemic 
 or pyaemic temperature. Look at the temperature chart of 
 Case 22, p. 434 (see fig. 81), and contrast it with that of Case 
 
 :rr 
 
 1 
 
 IITBIHM ^■■^■■^■■^i ^^ ^. ^j».*^i-M'-^ir»^Mr^j.^a»-t,^^^» 
 
 BB ^^BBWWBi^B^^B^^B^^B^^M^^B^^Bi^B^^B^^B^BiB^^BB>«ft wB^BBBI 
 
 11 
 
 
 Fig. 83.— Temperature Chart from the Case of removal op loose 
 Cartilage from the Knee-joint in which fermentation oc- 
 curred (see Case 22, p. 4;54). 
 
 15, p. 430 (see fig. 82). In the former case we have a small 
 operation performed on a joint, but fermentation occurred in 
 that joint. As a result we have a severe attack of fever. 
 (Here it is interesting to note that there was no ^putrefactive 
 
 7T 
 
 a ct. w fci i;i it g 
 
 jQQffij^QS^R^E^BEKQE^B 
 
 bbb:hii 
 
 wmmmmsm 
 
 Fig. 84.— Temperature Chart from a Cise op operation for recent 
 fracture of the Patella (Case 15, p. 4:?0). 
 
 fermentation.) In the latter case we have an operation of 
 greater severity, but the causes of fermentation were excluded, 
 and there is a correspondingly normal temperature. The 
 difference between aseptic and septic temperatures is also often 
 very marked after serious injuries or ojierations such as com- 
 
TEMTEHATVliE IX SEPTIC CASES. 583 
 
 pound fractm-es. Contrast the temperatures in the cases of 
 compound fracture. In eight cases of compound fracture pro- 
 duced accidentally putrefaction occurred. In four of these 
 (Cases 14, 17, 20, 29) it is stated that the temperature ranged 
 for several days after the injury between 100° and 103° or even 
 higher. In one case (No. 4), though there is no statement as 
 to the temperature, there can be no doubt, from the description 
 of the case, that it was high. The temperatiu'e charts of three 
 cases are given here, and in two of them (Cases 12, 26) it 
 will be seen that traumatic fever was present, while in only one 
 (No. 40) was there a normal temj^erature. In one case (No. 
 58), in which putrefaction occurred after operation, amputa- 
 tion was jDerformed chiefly because the temperature was rising 
 rapidly ; and in another, of which the chart is given (Case 68, 
 Chart 35), there is little doubt but that some form of organism 
 got in, and here also we have a high temperature. Contrast these 
 with the highest temperatiires in cases of compound fracture 
 produced by the surgeon and treated aseptically. The differ- 
 ence is so marked that I need not dwell on it.^ 
 
 If we contrast the, local and constitutional course of wounds 
 which are not kept aseptic with the foregoing description of 
 aseptic wounds, we see a very marked difference. 
 
 Look at the cases treated with antiseptics but not aseptically 
 in the foregoing tables. In one case of wound of joint (No. 3) 
 putrefaction was not avoided, and the case therefore became, 
 as I have previously pointed out, one treated with antiseptics 
 but not aseptically. Here fever and inflammation set in, and 
 threatened to be so serious in their results that it was considered 
 advisable to amputate. In one case of operation on a healthy 
 joint (No. 22) the wound was not kept aseptic, and thus the 
 case became one treated with antiseptics but not aseptically. 
 (It was dressed throughout with the ordinary gauze dressing, 
 
 ' With regard to the temperature charts published in this work, I wish to 
 state that they have not been in any way selected ; I publish all the tempera- 
 ture charts which I have been able to obtain. Till 1877 temperature charts 
 were not in use in Mr. Lister's wards ; the temperatures were noted on a card, 
 and it was seldom that the clerk took the trouble to copy them into the books, 
 unless, indeed, the case was a serious one, and the temperature high. Hence 
 the average of the temperatures in the charts is probably higher tiian it ought 
 to be. * 
 
584 RESULTS OF ANTISEPTIC SURGERY 
 
 XVIII 
 
 xnr 
 
 jxn^ 
 
 TlOME'ERATUllE CJIAKTS UK SEPTIC CASES. 
 
TEMPERATURE CHARTS OF ASEPTIC CASES. 585 
 
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 TK.MI'F.RATrUE ClIAUTS Ol' ASKI'TIC CasIO 
 
o8G RESULTS OF ANTISEPTIC SURGERY. 
 
 and the spray and carbolic acid were employed with the view 
 of preventing the entrance of other mischievous particles.) 
 In this case inflammation and fever occurred. Contrast the 
 progress of these two cases treated with antiseptics with that of 
 the others which were treated aseptically. The same marked 
 difference will be seen if we look at compound fractures in 
 which fermentation was not avoided. The constitutional 
 results in these cases have been considered in a preceding 
 paragraph, while locally necrosis, inflammation, and suppuration 
 are recorded in several instances. I do not say that these 
 are the constant results in cases treated with antiseptics, but 
 they are the results in the series of severe operations which 
 we have been considering, and if they occur in these severe 
 operations there is no security whatever that they will be 
 absent from others which are less severe. That these results 
 often follow simpler wounds, will be evident from a perusal of 
 the foregoing chapters. 
 
 If, again, we take the open method, we find also a marked 
 contrast between the local and constitutional consequences of 
 wounds so treated and of those treated aseptically. Burow, as 
 we have seen at page 334, speaks of the great swelling of the 
 edges of the wounds, and Kronlein also tells us of the 
 inflammation and necrosis which so frequently occur. The pain 
 which must accompany this inflammation, and the exhaustion 
 produced by the prolonged suj)puration, are very marked features 
 of the open method. Kronlein,^ in his report of Eose's practice, 
 states that it was found best not to seek primary union after 
 amputations. He further states, that the first effect of the 
 wound is great swelling of the flaps, which goes on increasing 
 for some days, till, in fact, granulation is complete ; this is 
 inflammatory swelling. Kronlein also points out, that in 
 Burow's, or any other method in which the edges of the flaps 
 are brought together by stitches or plasters, the result of this 
 swelling is frequently gangrene of portions of the flaps. In- 
 deed, he says that in 58 cases of amputation treated by 
 the method before described (no attempt being made to bring 
 the flaps into contact) gangrene — not hospital gangrene — 
 occurred in six instances, or in 10*3 i)er cent of the cases, 
 
 ' Luc. c'it. 
 
PROGRESS OF WOUNDS UNDER OPEN TREATMENT. 587 
 
 simply as the result of the swelling of the flaps, combined in 
 one or two instances with injm-y to them. Kronlein also states 
 that necrosis of the end of the divided bone occurred very fi-e- 
 quently — in 19 out of the 58 cases, i.e. in 32*7 per cent. This 
 happens less often in the cases where the edges of the wound 
 are brought together, but Kj'onlein tries to make out that this 
 is chiefly because many of the patients in whom it would have 
 occurred die before it has time to take place. This explanation 
 is, however, to a great extent, incorrect ; for the true expla- 
 nation of the absence of necrosis in many cases where primary 
 union is aimed at is that primary union has occurred over the 
 bone, and hence the acute suppurative inflammation of the 
 bone due to the contact of irritating materials, which results in 
 acute necrosis, does not take place. The aseptic method, by 
 preventing this inflammation, renders it a matter of indifference, 
 from this point of view (the chance of necrosis), whether 
 primaiy union occurs or not. 
 
 Further, in cases treated by the open method there is 
 generally more or less fever, showing that absolution is occurring 
 from the wound in spite of the free escape of discharge, or 
 indicating the presence of inflammation in the wound. Kron- 
 lein does not enter into details on this subject, but he mentions 
 the fact, that in only six, or 8*7 per cent., of the amputation 
 wounds treated (67 in number) was there no rise of temperature ; 
 the temperature in these six cases hardly ever went above 
 100° F. This small proportion of cases in which there was no 
 fever contrasts markedly with the results after aseptic operations. 
 
 The open method also possesses other disadvantages which 
 make the contrast with the results of the aseptic method still 
 more marked. Thus there is a constant tendency to the for- 
 mation of crusts, which are apt to lead to retention of fluids and 
 their fermentation beneath the crust ; thus the wound loses 
 the advantages of the open method. Other disadvantages have 
 been previously alluded to. 
 
 The local results of treatment by irrigation and the water- 
 bath are also not so good as those after aseptic treatment, and 
 these methods possess several disadvantages. These disad- 
 vantages have been previously mentioned, and I need now only 
 allude to one or two. Thus the water is apt to run into the 
 
588 RESULTS OF ANTISEPTIC SURGERY. 
 
 bed and wet the patient ; in order to avoid this, in the case 
 more especially of local baths, the apparatus must be so firmly 
 fixed to the limb that swelling is apt to occur. P'urther, the 
 maceration of the epidermis and the sodden state of the granu- 
 lations are great inconveniences. Also where the water used is 
 cold or where ice is too long ajDplied there is great danger of 
 gangrene in weak parts. Then, in the case of the water bath 
 more especially, where the wound is deep the swelling of the 
 granulations from imbibition of water is apt to block up the 
 orifice and confine the discharge ; and also pus coagulates 
 in contact with the water and frequently forms a thick layer 
 over the wound. 
 
 I need not dwell further on the points in which the other 
 forms of antiseptic surgery are inferior to the aseptic method. 
 Many of them are self-evident and have been already alluded 
 to. The results, both local and general, of all methods which 
 do not bring about an aseptic state of the wound are uncertain, 
 aind the results of these cases being uncertain the surgeon must 
 always have a feeling of anxiety corresponding in degree to the 
 severity of the operation and the interest which he takes in his 
 patient. 
 
 I have previously said, that on account of the various bene- 
 fits which are obtainable by the use of the aseptic method, 
 it ought to be employed wherever possible, unless, indeed, 
 special drawbacks attend its use. Several disadvantages, 
 to which I must now allude, have been attributed to this 
 method. 
 
 Firstly, it is said that there is a risk of carbolic acid poison- 
 ing. This, however, is not an objection against the method ; 
 it is an objection against the antiseptic employed, and is 
 equally valid when a wound is treated w^ith carbolic acid, though 
 not aseptically. Indeed, the risk of carbolic acid poisoning is 
 greater where wounds are not treated aseptically, for it is then 
 employed in large quantities to wash out the wound. Where the 
 aseptic method is carried out as formerly described, the wound 
 not being deluged with carbolic acid either at the time of the 
 operation or by injecting it afterwards, the risk of poisoning is 
 very slight. The occuiTence of dark coloured urine due to 
 
CARBOLIC ACID POISONING. 589 
 
 absorption of carbolic acid is not very rare, but this is not 
 poisoning. Unless a remedy is taken in such quantities that 
 the patient's health or life are jeopardised by it, we do not say 
 that the patient has been poisoned. In the same way. unless 
 the absorption of carbolic acid has been so great as to produce 
 serious symptoms, we have no right to say that the patient is 
 suffering from carbolic acid jooisoning. 
 
 The subject of carbolic acid poisoning has been worked 
 out by Kuster, and Nussbaum,' who has had some experience 
 of it, has written a very interesting chapter on the subject. 
 According to them, carbolic acid kills by causing paralysis of 
 the respiratory centre. The heart continues to beat even after 
 the respiration is arrested, and the temperature also falls. In 
 severe cases all the symptoms of collapse are present, low tem- 
 perature, ' at first superficial and stertorous respiration, later 
 great pallor and, finally, sudden death by arrest of respiration.' 
 In less severe cases the following are the symptoms according 
 to Nussbaum : — ' They present at first gastric symptoms, which 
 must really be looked on as cerebral symptoms. These are loss 
 of appetite, frequent nausea or incessant vomiting ; there is 
 also an increase, often enormous, in the secretion of saliva, 
 which is very frothy. The urine diminishes in quantity ; 
 indeed, it has been said that it sometimes contains albumen, 
 but I have never observ^ed this.^ There may also be dysphagia, 
 immobility of the pupil, and the patient may have a certain 
 feeling of oppression or anxiety. The patients often lie abso- 
 lutely tranquil in their bed, as if they were prohibited from 
 moving, and they have difiSculty in spitting out the saliva 
 secreted. Fever is never absent till, in serious cases, the tem- 
 perature falls just before collapse sets in.' In addition to these 
 symptoms the urine on standing acquires a dark olive green 
 colour, though it may have been of normal apj)earance when it 
 was passed. This is due to the presence of indican. 
 
 The alleged presence of fever in cases of supposed carbolic 
 acid poisoning is a very puzzling circumstance ; for the evi- 
 dence derived from experiments on the lower animals does not, 
 
 ' f.eitfddeti zur antisejJtischen Wvndhrhandlitvff. ]881. 
 * Dr. Keith stated, at the recent meeting of the International Medical 
 Congress, that the urine in some of his cases contained albumen. 
 
590 RESULTS OF AXTISEPTIC SURGERl'. 
 
 so far as I am aware, lead to the conclusion that fever is one of 
 the results of poisoning with carbolic acid ; on the contrary, 
 it seems to be followed by depression of temperature. Under 
 the imjiression that fever was one of the symptoms of carbolic 
 acid poisoning, and wishing to produce fever in rabbits, I at 
 one time injected carbolic acid subcutaneously at frequent in- 
 tervals into a series of rabbits, but without obtaining the wished- 
 for result. So satisfied have some physicians become of the power 
 of lowering temperature possessed by carbolic acid that it has 
 been employed as an antipyretic in place of salicylate of soda. 
 These facts throw grave doubt on the view that elevation of 
 temperature is a symptom of carbolic acid poisoning, and lead 
 us to question whether many of the alleged cases of carbolic acid 
 poisoning are so in reality. 
 
 Many of the cases which have been published as cases of 
 carbolic acid poisoning are undoubtedly instances of septicaemia 
 occurring in patients who have been treated with spray, gauze, 
 and carbolic acid, but not by the Listerian method, i.e. 
 asejitically. In these cases there is a high temperature, and it 
 is said that carbolic acid has been found in the urine. The 
 temperature is often distinctly septicaemic in character, while 
 the presence of carbolic acid in the urine does not prove that 
 these are cases of carbolic acid poisoning. On the contrary, 
 Brieger,' who has investigated the subject of the formation and 
 excretion of carbolic acid in the living body, states that carbolic 
 acid is constantly present in the urine of septicsemic patients, 
 often in considerable quantities, even though no carbolic acid 
 has been brought in contact with them. 
 
 I do not wish to deny that this fever may be sometimes due 
 to carbolic acid, but, as far as I can judge, such a view is against 
 the evidence, though more facts are required before we can 
 come to a decision. That there is something different in the 
 result of administering carbolic acid internally and applying 
 it to a wound is evident from the fact which Nussbaum mentions, 
 that olive-colom-ed urine only occurs after the external use of 
 carbolic acid, and not when it is administered by the stomach 
 or inhaled into the lungs. Surgeons ought, however, to be 
 
 ' ' Ueber Phenol-Ausscheidung bei Krankheiten,' Ccntralblatt f. d. Med. 
 Wissensck. 1878, No. 30. 
 
TREATMENT OF CARBOLIC ACID ROISOXING. 591 
 
 very careful in attributing elevation of temperature in their 
 cases to carbolic acid poisoning. 
 
 In ]Mr. Lister's practice, and in that of many other surgeons 
 who use carbolic acid freely, but who operate aseptically, carbolic 
 acid poisoning is a thing of very rare occurrence, indeed I only 
 know of two cases treated by Mr. Lister in which serious 
 symptoms were present.^ The reason of this is that Mr. Lister 
 brings carbolic acid as little as possible in contact with .wounds, 
 but acts strictly in accordance with the aseptic principle, and 
 applies it freely to everything tvhich may come in contact luith 
 the ivound rather than to the wound itself. He does not irri- 
 gate wounds, nor inject them, nor even wash away the blood and 
 dirt from the line of incision. The surgeons who see the most 
 numerous examples of carbolic acid poisoning are those who, 
 led away by the dogmatic statements of eminent men to the 
 effect that the good results of Listerism are solely due to 
 cleanliness, apply this view to the treatment of their cases, 
 irrigating and washing wounds freely with carbolic acid, to the 
 great detriment of the wounds and the patients. 
 
 In the treatment of carbolic acid poisoning the first thing 
 is of course to remove the carbolic acid. This may be done 
 without at the same time abandoning the aseptic method. By 
 the use of eucalyptus gauze,'^ or by the use of salicylic or 
 iodoform di'essings, the patient may have the benefit of the 
 exclusion of organisms without the risks of poisoning. In 
 severe cases Nussbaum advises the subcutaneous injection of 
 three milligrammes of sulphate of atropia, which he says has a 
 beneficial effect on the vomiting and salivation ; he also advises 
 
 ' In both of these cases there was elevation of temperature, bat it does not 
 necessarily follow that it was due to carbolic acid. The discussion of this 
 subject., and the speculations in which one might indulge with regard to it, are, 
 however, not suited for the present work. 
 
 * I have examined, by means of Koch's method of staining bacteria, a 
 number of wounds treated with eucalyptus gauze, and in a very considerable 
 proportion of them bacilli were found. I therefore cannot recommend the 
 eucalyptus dressings as being etjual to those with carbolic acid. As we have 
 already seen, micro-organisms are not found in wounds treated with carbolic 
 acid, or, if present, they are only micrococci. I have not found bacilli under 
 carbolic dressings. On the contrary, with eucalyptus oil, though sometimes 
 no organisms are present, yet in a considerable number of cases bacilli may 
 be found ; micrococci are but seldom seen. 
 
5JJ2 RESULTS OF ANTISEPTIC SURGERY. 
 
 that the patient should be packed. Where collapse is present 
 
 Nussbaum has derived benefit from the use of the following 
 
 means : friction of the chest, of the hands, and of the soles 
 
 of the feet with a brush, and the subcutaneous injection of 
 
 ether and camphor. In milder cases, besides the removal of 
 
 the carbolic dressings, he advises the use of sulj)hate of soda as 
 
 follows : — 
 
 Sulphate of Soda o parts. 
 
 Distilled Water 100 parts. 
 
 Syrup of Raspberries .... 25 parts. 
 
 Two tablespoonfuls of this mixture are given every two hours. 
 This method of treatment was proposed by Baumann, who found 
 that carbolic acid was not excreted by the kidneys as carbolic acid, 
 but in the form of a non-poisonous compound with sulphuric 
 acid. It is with the view of obtaining this non-poisonous 
 compound that the sulphate of soda is administered. It is 
 said not to do much good. I have myself had no experience 
 of it. 
 
 The so-called ' carbolic eczema ' has been brought forward 
 by some writers. I have already referred to it, and mentioned 
 the use of salicylic acid cream as a preventive. It has been 
 attributed alternately to carbolic acid, to the paraffin and to 
 the resin in the gauze, but as I have already exj)lained, it seems 
 to me in some cases more probably due to a fermentation of 
 the discharges caused by micrococci (see p. 232). 
 
 In tw^o cases I have known a carbolic acid dressing blister 
 the skin in a few hours and have to be abandoned. Here, 
 however, as I have before said, it was merely carbolic acid, not 
 the aseptic method, which was abandoned ; another antiseptic 
 was used in its stead. 
 
 Another argument has been brought forward against the 
 aseptic method, viz., that it distracts the attention of the 
 surgeon from the constitutional state of his patient. Such an 
 argument has no foundation in fact. Are the precautions 
 necessary to attain the single object of the exclusion of micro- 
 organisms from wounds more likely to divert the surgeon's 
 attention from the constitutional state of his patient than the 
 numerous cares as to ventilation, nursing, and so forth, with 
 which the surgeon who trusts to cleanliness alone is harassed ? 
 
EXPENSE OF ASEPTIC TREATMENT. 693 
 
 In the great majority of simple fractures no attention is paid to 
 the constitutional state of the patient ; the limb is placed in 
 splints, full diet is ordered, and the patient is left till the bones 
 unite. Why is it thought necessary to attend to the constitution 
 of the patient when the bone is divided by an incision through 
 the skin ? Because under ordinary circumstances inflammation, 
 suppuration, fever, and other hurtful consequences are apt to 
 occur. But, as we have seen, the aseptic method avoids all 
 these dangers and makes the wound practically subcutaneous. 
 Where, then, is the necessity for attending to the constitution 
 more than in the case of simple fracture ? ^ But fm'ther, as 
 Mr. Lister himself has pointed out, such an argument is of no 
 weight in presence of the facts ; for, if Mr. Lister gets such 
 avowedly good results (better than those obtained by surgeons 
 who jjay great attention also to the constitution), and at the 
 same time, as is however wrongly alleged, neglects the con- 
 stitutional state of his patients, such a fact would be an 
 additional argument in favour of aseptic treatment, and only 
 prove the great efficiency of the method. 
 
 Then it is said that the method is costly, and therefore 
 not applicable in the case of poor patients. Now no doubt 
 each individual dressing is costly — costing at the most \Qd. or 
 Is., though generally much less — but then these dressings, after 
 the first two or three days, require to be changed only at rare 
 intervals, and I have calculated that in most cases, with of 
 course some exceptions, the dressings are really in the long run 
 cheaper than water dressing changed once or twice daily. But 
 further, the aseptic method saves expense in many other ways. 
 As the patient has no pain nor fever, it is only in a few cases 
 that a trained nurse is required ; any sensible friend or servant 
 can attend him quite well. And as he is not suffering fi'om 
 fever nor weakened by profuse discharges, he fre(]uently does 
 not require stimulants or tonics, indeed in Mr. Lister's practice 
 these are seldom ordered ; this advantage is no doubt to some 
 
 ' It must not be supposed from this that I would advise the neglect of the 
 constitutional state of the patient. On the contrary, every care ought to be 
 taken to attend to hj'ij^ienic conditions, and by means of good diet to support 
 his strength, or by suitable drugs to attempt to remedy any constitutional 
 defects. 
 
 Q Q 
 
594 RESULTS OF ANTISEPTIC SURGERY. 
 
 extent counteracted by the fact that the patient has an excel- 
 lent appetite. Further, wounds heal on an average more quickly 
 than when treated by the ordinary methods, and as the patient 
 is not weakened by the presence of fever or discharge, the 
 period of convalescence is shorter. This is, of coru-se, of the 
 greatest importance to the bread-winner, for he is well and 
 back at his work while the patient who has not been treated 
 aseptically, and whose wound has not united by first intention, 
 is still undergoing treatment or recruiting his powers in the 
 country. Thus in numerous ways, of which these are a few 
 examples, ex[^ense is saved, and on the whole this treatment 
 is from this point of view the one most applicable to poor 
 patients. 
 
 Lastly, it has been said that the aseptic method gives the 
 surgeon a great deal of trouble. Now there is no doubt that 
 at first each operation and each dressing requires care and 
 thought, but then the dressings are unfrequent, and by-and-bye 
 the method becomes more or less instinctive. This argument 
 of trouble could not, however, be seriously upheld for a 
 moment, for if a system is good it must be carried out in spite 
 of the trouble involved. Why does one take so much trouble 
 in perfecting one's anatomical, physiological, or practical know- 
 ledge but simply with the view of being able to treat his 
 patients better ? For the same reason the trouble ought to be 
 ungrudgingly expended here. And if there were no other 
 reason (such as the safety and well-doing of the patient), the 
 relief from anxiety on the part of the surgeon, and the feeling 
 of certainty as to the result, are of themselves a sufficient 
 reward for all the trouble bestowed. The chief point which is 
 laid stress on as giving rise to increased trouble is the use of 
 the spray. I have already discussed this question at pp. 73, 
 120, and 364, and I have also pointed out the methods by 
 which treatment without the spray may be carried out. As 1 
 have said, the spray is the least necessary of all the precau- 
 tions, because fewer micro-organisms are present in the air 
 than on surrounding objects, and, therefore, the purification of 
 the air is the least important : further, if any particles do fall 
 on the wound from the air, they may be readily destroyed by 
 washing the surface of Ihe wound with an antiseptic lotion. 
 
PRAY NOT ESSENTIAL FOR ASEPTIC TREATMENT. 595 
 
 I have already pointed out that the spray can be dispensed 
 with, and that operations can be performed without it ; it can- 
 not, however, be safely abandoned without a substitute being 
 provided m the shape of frequent irrigation of the wound. In 
 proof that aseptic surgery may be carried on without the spiay, 
 we have Mr. Lister's work of several years — and very successful 
 work it was too — before he introduced the spray ; but then 
 while he performed the operation he constantly poured carbolic 
 oil or carbolic lotion into the wound, and in dressing the case 
 he had a current of the oil or lotion flowing over the wound. 
 Then further, we have Mr. Callender's experience. He prac- 
 tically employed,' with some modifications, Mr. Lister's original 
 method with carbolic oil, and his results were good. And, 
 in 1879, Trendelenburg ^ published the results which he had 
 obtained without the use of the spray. He employed the 
 method of continually irrigating the wound with carbolic lotion 
 while he performed the operation and while he dressed the 
 wound. And his results are, in the main, as indeed was only 
 to be expected, aseptic results. He mentions eighteen cases 
 where hydroceles were opened and successfully drained ; eight 
 cases where the sheaths of tendons or ganglia were opened 
 without local reaction ; twelve cases in which joints were 
 opened, in only one of which was there inflammation; and 
 five osteotomies, of which one died of tetanus, the others 
 doing well. The spray, however, has advantages which seem 
 to me far to outweigh its disadvantages. In the first place, I 
 think it is really less trouble to have a spray playing over a 
 part than to be continually irrigating it with carbolic lotion. 
 Further, there is a feeling of certainty attending an operation 
 conducted under the spray (see p. 259;, for if no s^miy is used 
 septic particles may fall into the wound and escape the action 
 of the lotion ; this is most likely to be the case while the 
 wound is being stitched uj), and these particles may be })ro- 
 tected by the blood clot from the action of tlie carbolic acid, 
 and may not be destroyed by the clot or the living tissues, 
 but may develop and cause fermentation in the wound. Lastly, 
 the spray has this great advantage over irrigation, that less 
 cai'bolic acid is applied to the wound, and thus there is less 
 
 ' Lnc. rit. 
 
596 RESULTS OF ANTISEPTIC SURGERY. 
 
 irritation of the cut surface and less chance of absoiption of 
 carboHc acid into the system. It cannot be a good thing 
 either for the patient or for the wound to be constantly 
 deluging it with strong carbolic lotion. 
 
 The whole principles of wound treatment may be summed 
 up in the one word — Rest. This has been urged by many 
 writers, from Magatus downwards, and indeed before the time 
 of Magatus ; but it is only within the last few years that science 
 has so far advanced as to enable us to grasp the whole signifi- 
 cance of that term as applied to the treatment of wounds. 
 The causes of Unrest may be mechanical or* chemical.' The 
 mechanical causes consist of movement of the parts, of the 
 presence of foreign bodies, of tension in the wound, and so on ; 
 and they are, as a rule, easily avoided by the use of suitable 
 apparatus, by the removal of mechanical irritants, or by providing 
 against the occurrence of tension ; and inasmuch as they are 
 easily avoided they are comparatively unimportant. The most 
 importa;nt and the least easily prevented are the chemical causes 
 of Unrest, and these may be divided into two great classes : 
 1. Where the chemical substance is merely something — a salt, 
 or an acid, or an alkali — added to the wound from without, 
 such as carbolic acid. Such a chemical cause will act only in 
 proportion to the amount added, to its irritating property, and 
 to the length of time that it remains in contact with the surface 
 of the wound. When the original quantity is exhausted the 
 
 ' IMr. Lister long ago divided the causes of supjjuration into three great 
 groups : 1. Putrefactive suppuration where it was due to the presence of 
 putrid materials; 2. Antiseptic suppuration where it was due to the presence 
 of some chemical substance, such as the antiseptic employed in the treatment 
 of the wound ; 3. Suppuration the result of nervous disturbance, as intension. 
 This classification still, I think, holds good, notwithstanding the recent work 
 of Dr. Ogston referred to at pp. 248, 251), who has expressed the opinion that 
 all acute abscesses are due to micro-organisms. The observations which I 
 liave published at p. 251, and others which I brought forward at the recent 
 meeting of the International Medical Congress, seem to me to go against this 
 view. At the Congress Mr. Lister also pointed out a number of clinical facts 
 which proved that other causes of acute inflammation and suppuration exist 
 besides the action of micro-organisms. I do not, of course, deny that micro- 
 organisms are the cause of many of the acute absce.sses in winch they are 
 found, but I think that in some they are accidental, and that suppuration 
 may be induced othervvise than liy their action. 
 
REST, THE PRINCIPLE OF WOUND TREATMENT. 597 
 
 chemical irritation ceases. 2. The other cause of chemical 
 Unrest is where the chemical substance is being constantly 
 formed in the wound. Here we have much the most formidable 
 cause to deal with, for there is no exhaustion of the substance, 
 but, on the contrary, continued formation of fresh material so 
 long as the causes of this formation are present in the wound ; 
 and, as we have seen, the eradication of these causes, once they 
 have entered, is a very difficult matter, and thus these causes 
 of Unrest are the most important. To interfere with these 
 causes of Unrest is the main object of antiseptic surgery. The 
 prevention of their entrance is the special aim of aseptic treat- 
 ment. The prevention of the entrance of micro-organisms is, 
 as we have already seen, apparently much more easily and 
 better accomplished than their destruction after they have 
 entered. And further, in attempting their destruction after 
 their admission, the wound is subjected in a marked degree to 
 chemical Unrest of the first class. The ideal wound is a sub- 
 cutaneous one, kept at perfect rest. We have not yet attained 
 this ideal, for even with the aseptic method there is a certain 
 amount of Unrest caused by the antiseptic employed, by the 
 stitches, by the apparatus for drainage, and by the dressing 
 itself. Nevertheless, the essential elements of Unrest have 
 been abolished by this method, and the disturbances from the 
 antiseptic, from the stitches, and so forth, have been reduced to 
 a minimum, and now hardly make themselves evident. That 
 art will still fm-ther perfect the treatment of wounds there can 
 be no doubt ; but whatever development occurs in the future, the 
 great principles of Listerism, the exclusion of the chief causes 
 of chemical Unrest, and the reduction of the action of the other 
 causes to a minimum, must form the groundwork of any system. 
 In conclusion, I cannot too strongly express my conviction 
 that the scientific basis of wound treatment should hold the 
 most prominent place, and that it is only by a thorough know- 
 ledge of natural phenomena in all their bearings that the best 
 practice can be carried out and the best results obtained. 
 Loose observations and loose and vague ideas as to probabilities 
 wliich have no foundation on the facts of nature, cannot 
 advance art in any way. Natural phenomena are generally 
 found to differ from the conception which man in his ignorance 
 
598 EESULTS OF ANTISEPTIC SUIIGERY. 
 
 is apt to form of them ; and therefore any statements on any 
 subject, to be of value in the development of that subject, 
 must be founded on knowledge and rigid application of the 
 facts of nature, whether or no these facts seemed at first sight 
 probable or sufficient explanation of the phenomena. That 
 advance can only be blind and imperfect till the true law of 
 nature is discovered is well illustrated by the history of wound 
 treatment in former years. Through the darkness which then 
 reigned glimmers of light had at times penetrated, but no 
 true and lasting progress was made till quite recently, when, 
 chiefly by the scientific labours of two men — Pasteur and 
 Lister — a flood of light has been thrown on one of the most 
 obscure subjects in nature, and the foundation of rational 
 methods of treatment on rational and scientific principles has 
 been followed by inestimable advantages to mankind. 
 
Plaiel 
 
 
 r 
 
 
 
 Edgar Thur stop. dd. 
 
 MmtEmBxos sc 
 
FlahK 
 
 
 FIG 12. 
 
 d) 
 
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 Fid IS. 
 
 Edgar Thurstcm. 3*1 
 
 Min.t.em. Bros sc 
 
FlateUI 
 
 FIG 17- 
 
 Ed^ar ThurstcD dd. 
 
 Tihntem Bros sc 
 
Plcd&. T/. 
 
 cL 
 
 / Vo 
 
 
 i •' . 
 
 FIG. iy. 
 
 
 F 1 G ^^. 
 
 Eiga-r ThurstoTx del. 
 
 MinVem Bros s<.- 
 
PloU V. 
 
 *# 
 
 ■04 
 
 .M^-f^ 
 
 ^%. 
 
 C 34-, X670. 
 
 F 1 G ^6. X7250. 
 
 F '. C. 37. xiaoo 
 
 FIG. 38. X1200 
 
 Edgar Ttarstoi! li 
 
 ■ OCi X (5/0 ' 
 
 lynnleiT- Br 05 sc 
 
 ■ OOl X 2300 >- 
 
EXPLANATION OF THE PLATES. 
 
 These sjjccimens have been drawn by the aid of the Camera Lvcida, and Zeii^ 
 water-itmnersion or oil-immersion lenses were those chiejiij emjdoyed. 
 
 PLATE I. 
 
 PIG. PAGE 
 
 1. Micrococci, from a wound treated aseptically, growing in infusion 
 
 , of cucumber. x 14.50 ......... 231 
 
 2. Specimen of discharge taken from a case of compound dislocation 
 
 of the tliumb not treated aseptically. Contains numerous micro- 
 organisms. X 1450 235 
 
 3. ISpecimen of the discharge from a case of wound of the scrotum not 
 
 treated aseptically. Contains numerous micro-organisms, x 1450 235 
 
 4 Discharge from a case not treated aseptically. Bacilli and pus 
 
 cells. X 1450 235 
 
 5. Discharge from a case of amputation treated by irrigation. Red 
 
 blood corpuscles, leucocytes, a few bacilli, x 1450 . . . 235 
 
 6 Discharge from a case of excision of the hip-joint treated with anti- 
 septics. Micro-organisms and blood-corpuscles, x 1450 . . 235 
 
 7. Discharge from a case of Syme's amputation treated with antiseptics. 
 
 Pus corpuscles and micro-organisms, x 1030 .... 236 
 
 8. Discharge from a case of empyema treated aseptically. Leucocytes : 
 
 no micro-organisms, x 1030 ....... 237 
 
 PLATE II. 
 
 9. Discharge from a case of empyema treated aseptically ; taken at a 
 
 later period than that in the specimen from which fig. 8 was 
 drawn. No micro-organisms, x 1030 ..... 237 
 
 10. Discharge from a case in which a diseased knee-joint was incised 
 
 aseptically. No micro-organisms, x 1030 238 
 
 11, 12, 13, and 14 are from specimens taken at different times from a 
 
 case treated aseptically. The first three specimens are free from 
 micro-organisms ; the last contains micrococci, x 790 . . 239 
 
600 EXPLANATION OF THE PLATES. 
 
 FIO. PAGE 
 
 15 and 16. Taken from a case of excision of tlie mamma treated with 
 aseptic precautions. Fig. 15 contains no micro-organism.s. x 790. 
 Pig. 16 contains numerous micrococci, x 550 .... 210 
 
 PLATE III. 
 
 17. Specimen from a case of operation performed with aseptic precau- 
 
 tions. Contains a few micrococci, x 10.30 240 
 
 18, 19, and 20. Specimens to illustrate the mode of entrance of micro- 
 
 cocci into wounds treated aseptically. Fig. 18 sliows discharge 
 talcen from the drainage tube on March 31. No micro-organisras. 
 X 790. Fig. 19 shows discharge taken from the edge of the 
 dressing on April 4. Micro-organisms are present x 1030. Fig. 
 20, taken from drainage tube on April 4, contains no micro-organ- 
 isms. X 1030 241 
 
 21, 22, 23, and 24, illustrate the same point. Fig. 21, taken from the 
 gauge on April 4, contains a few micrococci. Fig. 22 taken from 
 the inner drainage tube on April 5, contains no micro-organisms. 
 Fig. 23, taken from the inner drainage tube on April 8, contains 
 one or two micrococci. Fig. 24, taken from an outer drainage 
 tube leading into an abscess cavitj'', on April 15, contains no 
 organisms. Figs. 21, 23, and 24 al30 illustrate the fact that the 
 leucocytes found in exudations from wounds treated aseptically, 
 frequently do not appear as healthy pus cells, but seem to be de- 
 generating, ot, if derived from the tissue corpuscles, perliaps to 
 have been imperfectly developed. All the specimens are x 1030 2*42 
 
 PLATE IV. 
 
 25. Growth of micrococci as observed under the microscope by Mr. 
 
 Lister, a. Group at 855 a.m. b. Same group at 9-4 a.m. 
 
 c. Same at 9-30 a.m. d. Same at 1036 a.m 244 
 
 26, 27,'and 28 represent micrococci growing in various materials. Fig. 
 
 26, discharge from the wound from which the micrococci were 
 taken, x 600. Fig. 27, the same micrococci growing in vitreous 
 humour, x 1030. Fig 28, the same growing in cucumber infusion 
 after having previously lived in meat infusion, x 1030 . . 245 
 
 29. Pus taken from a chronic abscess, contains no micro-organisms. 
 
 X 1030 254 
 
 30. Pus taken from an acute abscess of the mamma when opened, con- 
 
 tains micrococci, x 1030 ........ 254 
 
 31. Pus taken from an acute abscess of the finger, contains micrococci. 
 
 X 1030 254 
 
 32. Pus taken from an acute abscess of the groin when opened, contains 
 
 streptococci, x 1030 256 
 
EXPLANATION OF THE PLATES. 601 
 
 PLATE V. 
 
 FIO. PAGE 
 
 33 to 38 were kiiKlly examined for me by Mr. E. Nelson, whose skill in 
 microscopical work, and more especially in the uses of illumina- 
 tion, is so well known. These specimens have been drawn from 
 his microscoiDe. 
 
 33. Specimens of milk which had been preserved without boiling for 
 
 several months. Contains no organisms ..... 41 
 
 3i. Specimen of the deposit in a beaker containing cucumber infusion, 
 into which the spleen of an animal had been drojaped some days 
 previously. No micro-organisms ....... 4G 
 
 35. Specimen of dust collected and stained with meth}-! violet. One or 
 
 two bodies are present which are indistinguishable from micro- 
 cocci and bacteria, and have taken up the stain . . . .198 
 
 36. Specimen of discharge taken on April 13, from a case of removal 
 
 of loose cartilage from the knee-joint in whicli supjiuration 
 occurred. Contains oval organisms ...... 454 
 
 37. Specimen of discharge taken on April 18, from the same case . . 455 
 
 38. Discharge taken on April 22, from the same ..... 45G 
 
 9. Piece of liver introduced into the abdominal cavity with aseptic 
 precautions, examined 24-48 hours later. Leucocytes have jsene- 
 trated between the lobules of the liver, and at the upper part of 
 the figure have already become spindle-shaped (Hartnack 2 eye- 
 piece, 7 objective). From Tillmanns ...... 575 
 
 40. Piece of dead liver after 17 days in the abdomen; organisation of the 
 leucocytes into fibrous tissue, vessels, &c. (Hartnack, 2 eyepiece, 
 7 objective). From Tillmanns . . . . . . . 575 
 
INDEX, 
 
 ABD 
 
 4 BDOMEN, wounds of, aseptic treat- 
 1\. ment, 115 
 Aberncthy on treatment of wounds, 
 
 306 
 Abiogenesis, theories of, 145 
 Abscesses, acute micro-organisms in, 
 
 25H 
 
 — significance of micrococci in, 255 
 
 — Anel on aspiration of, 300 
 
 — aseptic drainage of, 110 
 -- aseptic treatment of, 109 
 
 — chronic, effects of air on, Aheriuttky 
 on, 30G 
 
 B. Bell on, 306 
 
 ^1. Mniiru on, 30(> 
 
 H. Mnnru on, 306 
 
 — relation of micro-organisms to, 253 
 
 — treatment of, Pearson on, 312 
 • Bidder on, 303 
 
 — lumbar. See Lumbiir abscess. 
 
 — near anus, aseptic treatment of, 112 
 
 — near pubis, dressing of, 105 
 
 — of hip-joint. See Hip-joint. 
 
 — of joints, aseptic treatment of, 443 
 
 — perineal, aseptic treatment of, 1 1 2 
 
 — psoas. See Psoas absce-ss. 
 
 — retropliaryngeal, aseptic treatment 
 of, 110 
 
 — spinal, recumbent position in, 1 1 1 
 
 — thoracic. See Empyema. 
 
 — valvular, treatment of, Ahernetlni on, 
 307 
 
 — vertebral, absence of statistics of, 
 530 
 
 — — aseptic course of, 51'.), 5.18 
 pathology of, 555 
 
 results of, 517 
 
 time for opening of, 51 'J 
 
 Absorption by granulations, Ilavli on, 
 
 268, 26;», 407 
 Adams on subcutaneous surgery, 321, 
 
 322 
 
 ANT 
 
 Air, effects of, on wounds, Ahernethj 
 
 on, 306 
 
 Benjamin, Bell on, 305 
 
 Jolm Bell on, 310 
 
 Demarqnay and Lecontr 
 
 on, 331 
 
 ■ Humphrey on, 334 
 
 • John Hunter on, 308 
 
 Malgaigne on, 331 
 
 ■ ~ Ale.v. Munro on, 306 
 
 ■ Hugh Munro on, 306 
 
 — Pringle on, 305 
 
 • Vali'tte on, 345 
 
 -^ Veljjeav on, 331 
 
 — ~ examination by the Author, 198 
 Pasteur, 165 
 
 Pouchet, 163 
 
 — filtration of, through cotton-wool, 
 12 
 
 — &A«vf//«'.vexperimentswithheated, 6 
 Albert on operation on joints, 447 
 Albuminuria, operations in, 559 
 Alcohol as an antiseptic, 269, 348 
 
 — results of treatment with, 40G 
 Alcoholic fermentation, 209 
 Alumina, acetate of, use in aseptic 
 
 treatment, 139, 363 
 Amputation in phthisis, 559 
 AniMsmt on irrigation, 341 
 Anal abscess, aseptic tre;itment of, 112 
 Anel on aspiration of aV)sccsses, 300 
 Animal tissues boiled, fermentation of, 
 
 14,22,24 
 
 unboiled, fermentation of, 45 
 
 Antiseptic, definition of term, 1 
 
 — derivation of term, 1 
 
 ■ — surgery, history of, 290 
 
 in sixteenth century, 292 
 
 seventc(!nt h cent ur3% 29G 
 
 eighteenth century, 300 
 
 • present centurj', 317 
 
 meaning of term, 1, 145, 265 
 
G04 
 
 INDEX. 
 
 ANT 
 
 Antiseptic siirgeiy, points in testing- 
 result, 367 
 
 principles of, 288 
 
 relations to fermentations in 
 
 wounds, 366 
 
 relations to infective disease, 540 
 
 results of, 365 
 
 summary of views on, up to 1800, 
 
 314 
 
 varieties of, 265 
 
 Antiseptics, Beiinion on use of, 336 
 
 — Bilguer on use of, 302 
 
 — Colhatch on use of, 297 
 
 — in common use, 348 et seq. 
 
 — treatment by, 265, 267, 583 
 
 history of, 347 
 
 Lister s results in, 376 
 
 ■ relation to fermentation 
 
 in wounds, 366 
 
 relation to infective disease, 405 
 
 Rei/hersi results in, 401 
 
 Ajyjjerfs method of preserving fruits, 
 &c., 4 
 
 milk, 15 
 
 Arncpus's method of wound treatment, 
 
 294 
 Aryicmann, treatment of wounds, 312 
 Aseptic cases, table of temi:)erature 
 
 charts of, 585 
 Aseptic coiirse of chronic abscesses, 
 519, 638, 555 
 
 compound fractures, 462, 563 
 
 operations on joints, 421 
 
 wounds, outline of, 566, 575 
 
 Aseptic method, does it exclude micro- 
 organisms from wounds ? 227, 454 
 
 does it prevent fermentations in 
 
 wounds ? 226, 366 
 Aseptic operations, diet after, 576 
 
 duties of dresser in, 72 
 
 errors in, how corrected, 74 
 
 example of, 67 
 
 ligature of vessels in, 75 
 
 on joints, results, 426 
 
 temperature after, 576 
 
 use of carbolised towel in, 67, 72 
 
 use of guard in, 74 
 
 Aseptic surgery, definition of, 51 
 
 general results of. See Statistics. 
 
 principles of, 51, 52, 359 
 
 relations to infective disease, 368, 
 
 540 
 Aseptic temperature curve, 580 
 Aseptic treat mcnt, advantages iDCCuliar 
 to, 561 
 
 bearing on conservative surgery, 
 
 562 
 
 AUT 
 
 Aseptic treatment, cost of, 593 
 
 development of, 128 
 
 example of failure of, 454 
 
 experience essential in, 504 
 
 in country practice, 120 
 
 in war, 123 
 
 objections to, 588 
 
 of abscess, 109 
 
 accidental wounds, 112 
 
 bursitis, 568 
 
 burns, 117 
 
 compound fractures, 114, 461, 
 
 563 
 
 of skull, 1 1 5 
 
 contused wounds, 113 
 
 dissection wound, 119 
 
 gangrene, 117 
 
 — gunshot wounds, 123 
 
 — hydrocele, 568 
 
 wounds of abdomen, 115 
 
 intestines, 115 
 
 — joints, 1 14 
 
 results, 422 
 
 muscles, 114 
 
 nerves, 114 
 
 tendons, 114 
 
 thorax, 115 
 
 relation to erysipelas, 541 
 
 trouble connected with, 594 
 
 use of acetate of alumina in, 139 
 
 — eucalyptus oil in, 140 
 
 thymol in, 139 
 
 salicylic acid in, 136 
 
 Aseptic wounds, AvfJuir on micro- 
 organisms in, 229 
 
 drainage of, 76 
 
 micrococci in, 243, 256 
 
 stitching of, 85 
 
 strapping of, 86 
 
 substitutes for carbolic acid, 136 
 
 Aseptic use of cotton wool, 141 
 
 salicylic acid, results of, 404 
 
 thymol, results of, 404 
 
 Avtlior, examination of air, 198 
 
 — experiments on destruction of bac- 
 teria by healthy tissues, 252, 283 
 
 — experiments on fermentation, 25 
 of blood, 36 
 
 micro-organisms in aseptic 
 
 wounds, 229 
 relation to living body, 
 
 205 et seq. 
 spontaneous generation, 193, 
 
 195, 200, 202 
 
 — on fermentation of boiled urine, 25 
 
 — unboiled animal tissues, 45 
 
 egg albumen, 43 
 
INDEX. 
 
 C()5 
 
 AUT 
 
 A^Mor, on fermentation of unboiled 
 milii, 3'J 
 
 — urine, 37 
 
 Axilla, aseptic dressing of, 100 
 
 BACILLI in wounds treated with 
 eucalj'ptus gauge, 591 
 Bacteria, formation of pigment by, 212 
 
 — Koch's method of staining, 233 
 
 — under A. Guerin's dressing, 329, 330 
 Bandage, carbolic gauze, 89 
 
 — elastic, 90 
 
 — muslin, 89 
 
 Bandaging of gauze dressing, 89 
 Bardelchen on Listerism, 361 
 JBardenheuer, results with aseptic treat- 
 ment, 416 
 
 — statistics of compound fractures, 509 
 Jjarher on use of cotton wool, 143 
 Barnes on results of cleanliness, 548 
 Barth's statistics of wounds of joints, 
 
 445 
 Burtschcr and Vfziii's ojDcn method of 
 
 treatment, 277, 332 
 Bastiaii on spontaneous generation, 
 
 176, 181, 187, 191, 196 
 BataiUe. on dressings with alcohol, 348 
 Bell, Benjamin, on action of air on 
 
 wounds, 305 
 
 — — on drainage tubes, 305 
 
 — • — on wound treatment, 304 
 
 Brll, Sir ('., on removal of loose carti- 
 lages, 3 1 2 
 
 subcutaneous division of liga- 
 ments, 319 
 
 Bell, John, on effects of air on wounds, 
 310 
 
 treatment of com[H)un(l frac- 
 tures, 31 1 
 wounds of joints, 31 1 
 
 _ . vvound treatment, 312 
 
 Bclloste on treatment of wounds, 300 
 
 Jienfiion on wound treatment, 336 
 
 Jifrard on irrigation, 339 
 
 Benimunn ongunstiot woimds of joints. 
 452 
 
 Jicrt on fermentation, 220 
 
 — — spontaneous generation, 184, 185, 
 201 
 
 BiUjuer on results of con]i)ound frac- 
 tures, 302 
 
 — — wound treatment, :i02 
 Billruth on micro-organisms, 243 
 in abscesses, 253 
 
 — statistics of sej)tic treatnuiil, 41i) 
 
 Billroih and Tiiyel on fermentation of 
 
 unboiled animal tissues, 44 
 lUstournage, 249 
 
 Blanchurd on A. Guerin's-dressing, 326 
 Blondiis on treatment of wounds, 292 
 lUood, fermentation of, 33 
 Blood clot, organisation of, 568 
 Boerhaave on putrefaction of pus, 301 
 Boiled substances, fermentation of, 1, 
 
 29 
 Bone, gunshot wounds of, results of, 
 
 512 
 
 — organisation of, 571 
 
 Bon net on. cauterisation of wounds, 338, 
 
 349 
 Boracic acid lint, 64 
 
 lotion, 64 
 
 ointment, 64 
 
 -— lint dressings, changing of, 94 
 
 use of, 93, 268 
 
 wet, in place of poultice, 95 
 
 — ointment as a dressing, 94 
 Bouisson's method of ventilating 
 
 wounds, 279, 337 
 Boi/er on treatment of wounds, 314 
 Brodie, B., on treatment of varicose 
 
 veins, 319 
 Brims on carbolic acid gauze, 63, 362 
 
 treatment of wounds, 291 
 
 Bryant on Lister's operations on joints, 
 
 440 
 Buff on on spontaneous generation, 147 
 Burdo a- Sanderson on fermentation of 
 
 blood, 35 
 unboiled animal tissues, 
 
 45 
 micro-organisms in living 
 
 body, 250 
 
 — sjionlaneous generation, 188 
 
 liurns, asejitic treatment of, 117 
 Biiron-, open method of treatment, 278 
 - on results of the open method, 333, 
 
 409 
 liursitis, aseptic treatment of, 568 
 Jiussji on use of coal tar, 351 
 Button stitches, 85 
 Butyric fermentation, 2J2 
 
 r^AIiOT^m elilniiiialcl soila, 269 
 ^ Cmiinttrd- Liitimr nn yeast cell.s, 6 
 Cullender's method nf woiukI treatment , 
 
 363, 595 
 Ciilrert on carbolic; acid, 352 
 Cameron's statisti(;s, 371 
 Camjiioiii. on crust formation, 338, 349 
 Carbolic acid, Lema'irc on use of, ;{54 
 
606 
 
 IXDEX. 
 
 Carbolic acid, oily solutions of, 5o 
 
 poisoning, 588 ct seq. 
 
 solution of, in glycerine, 54 
 
 substitutes for, 136 
 
 • undiluted, 53 
 
 use in treatment by antiseptics, 
 
 267 
 watery solutions of, 53 
 
 — eczema, 232 
 
 Carbonic acid gas, treatment by, 330 
 Cartilages, loose, removal of, B. Bell on, 
 305 
 
 <^r C. Bell on, 312 
 
 Sam. Cooper on, 312 
 
 Chassai(i)w on, 321 
 
 Gibson on, 313 
 
 — Larrey on, 45!) 
 
 Levdllc on, 313 
 
 Spencc on, 460 
 
 'llu-dcn on, 308 
 
 Catalysis, 2 
 
 Catgut carbolised, 56 
 
 chromic (Lister's), 57 
 
 — chromic (MacE wen's), 58 
 
 — drainage by, 80 
 
 — Lister's pocket-holder, 5"J 
 
 — organisation in, 571 
 
 — trough for, 51) 
 
 — use as a ligature, 75 
 
 Cazeiieuve and Li con on fermentation, 
 
 218 
 
 — of unboiled urine, 37 
 
 on spontaneous generation, 
 
 l'J5, 201 
 Chalvet on use of lime chloride, 349 
 Championn'iire on results of aseptic 
 
 treatment, 3!)8 
 Cliasmi/inac on occlusion, 323 
 Chassaigne on subcutaneous surgery, 
 
 321 
 Climdiae, Gnij dc, on treatment of 
 
 wounds, 2!)1 
 Chnuveau on bistournage, 24!) 
 llii-dererqne on dressings with alcohol, 
 
 348, 406 
 Clieniical fermentation, 2 
 (lievrcul on use of coal tar, 351 
 Chienc on catgut drains, 80, 362 
 
 retropharyngeal abscess, 110 
 
 situation of opening in jisoas 
 
 abscess, 102, 518 
 
 — and Ewart on fermentation of un- 
 boiled animal tissues, 49 
 
 Chlorinated soda as an antiseptic, 26!) 
 f 'Iilorine as an smtiseptic, 34!) 
 Chivicle, compound fractures of. See 
 Compound fractures. 
 
 CON 
 
 Cleardiness, definition of, 542 
 
 — McVaiFs results with, 415 
 
 — Nussbaum's results with, 390, 394 
 
 — results of, 544 et seq. 
 
 — Savory's results with, 414 
 
 — treatment l)y, 542 
 
 — value of, 546 
 
 — Volkmann's results with, 385, 405 
 Coal tar. Come and Demeaux on, 350 
 Lcmaire on, 350 
 
 Colin on pigment bacteria, 212 
 
 spontaneous generation, 179 
 
 ColhatclCs method of wound treatment, 
 
 297 
 Cold in wound treatment. See History 
 
 of Irrigation. 
 Collodion, nse of, 324 
 Compound fractures, accidental, general 
 
 aseptic results, 510 
 
 aseptic course of, 462 
 
 treatment of, 114, 461, 563 
 
 J. Bell on, 311 
 
 eradication of putrefaction in, 
 
 478 
 intentional, general aseptic re- 
 sults, 511 
 
 Lister's, summary of, 484, 498 
 
 made by surgeon, 464 
 
 of clavicle (surgeon), 494 
 
 femur (accidental), table of, 
 
 466 
 
 (surgeon), table of, 484 
 
 forearm (accidental), table of, 
 
 476 
 
 (surgeon), table of, 496 
 
 humerus (accidental), table of, 
 
 474 
 
 (surgeon), table of, 494 
 
 of leg (accidental), table of 
 
 464 
 
 — (surgeon), table of, 490 
 
 limbs (accidental), summary of, 
 
 478 
 lower jaw (surgeon), summary of, 
 
 498 
 
 Pott's results in, 304 
 
 results of asejjtic treatment of, 
 
 461 
 
 — Bilguer in, 303 
 
 open method, 514 
 
 of skull (accidental), summary of, 
 
 478 
 
 aseptic treatment of, 1 15 
 
 Condensed beam of liglit, use of, by 
 
 Prof. Tyndall, 17 
 Conservative surgery, bearing of aseptic 
 
 treatment on, 562 
 
INDEX. 
 
 607 
 
 CON 
 
 Constitutional state after aseptic opera- 
 tion, u75 
 
 Contused wounds, aseptic treatment of, 
 113 
 
 Coolie, Jas., on danger of joint wounds, 
 2;)6 
 
 Cooper, Sir Astleij, on subcutaneous 
 tenotomy, 319 
 
 wound treatment, 313 
 
 Cooper, Bransiij, on subcutaneous teno- 
 tomy, 319 
 
 Cooper, Sam., on removal of loose carti- 
 lages, 312 
 
 Come and Deineaux's powder, 351 
 
 Cost of aseptic treatment, 593 
 
 Cotton wool, aseptic use of, 141 
 
 carbolised, 66 
 
 A. Guerin's dressing, 280, 325, 408 
 
 Country practice, aseptic treatment in, 
 120 
 
 — — mode of dressing in, 122 
 Croft on results of cleanliness, 549 
 Crust, formation of, 335 
 
 Bouisson on, 279, 337 
 
 Fallopius on, 294 
 
 J. Hunter on, 310, 335 
 
 Neudorfer on, 271, 279, 335 
 
 treatment by, 279 
 
 Czerny on results of aseptic treat- 
 ment, 398 
 
 J^iUJLAT on use of carbolic acid, 355 
 J-^ Delacroix on treatment of wo und s , 
 
 293 
 Deleaic on perchloride of iron, 350 
 Delpcch on subcutaneous tenotomy, 319 
 JJemarquay on micro-organisms in 
 
 wounds, 228 
 
 — on treatment by glycerine, 348 
 
 — and Lecontc on carbonic acid gas, 
 331 
 
 Demeaux and Corne's powder, 351 
 
 iJesinazieres on yeast, 6 
 
 JJU'ffenbacli on subcutaneous surgery, 
 
 320 
 Diet after aseptic operations, 570 
 Dissection wound, aseptic treatment of, 
 
 119 
 Drain, catgut, 80 
 — ■ horse-hair, 82 
 
 ■ reiutroduction of, 83 
 
 Drains absorbable, 80 
 Drainage as an antiseptic method, 271 
 - aseptic, of abscess, 1 10 
 
 — by capillarit}', 80 
 
 — of aseptic wounds, 7(J 
 
 EGG 
 
 Drainage tubes absorbable, 83 
 
 — B. Bell on, 305 
 
 — position of tube in aseptic wotinds, 
 78 
 
 — ttse of, 76, 458 
 
 Bran, Le, on putrefaction of pus, 301 
 Dresser, duties of, in aseptic operation, 
 
 72 
 Dressing, aseptic, axillary, 100 
 
 boracic, 93 
 
 of breast (3 methods), 97 
 
 changing of, 94 
 
 deep, 68, 88 
 
 errors in use of protective, 87 
 
 excisions of joints, 107 
 
 fixing of, 89 
 
 general gauze, 89 
 
 of hernia, 105 
 
 hip- joint abscess, 104 
 
 limbs, 101 
 
 loose gauze in, 89 
 
 of lumbar abscess, 104 
 
 method of clianging, 91 
 
 of neck, 96 
 
 ovariotomy, 109 
 
 psoas abscess, 101 
 
 scalp, 96 
 
 scrotum, 105 
 
 time of changing, 93 
 
 use of pins iir, 89 
 
 use of protective in, 87 
 
 wet gauze in, 88 
 
 — water, 292, 315 
 
 Dressings, aseptic, in country practice, 
 
 122 
 
 permanent, Keuher on, 362 
 
 -— — use of sponges in, 122 
 
 with salicylic acid, 136 
 
 Dumas on carbolic acid, 352 
 Duncan, Matthcics, on saprjemia, 367 
 Dupuytrcn on subcutaneous myotomy, 
 
 319 
 Duroij on use of iodine, 350 
 Duscli and Schroeder on fermentation, 
 
 12 
 of boiled animal tissues, 
 
 14 
 
 milk. 1 4 
 
 • " spontaneous generation, 
 
 152 
 
 I^X'ZKMA, carbolic, 232, 592 
 J Egg albumen, boileil, llohirts 'm 
 ferment al ion of, 22 
 
 - Schrneder on fermentation of, II, 
 15 
 
608 
 
 INDEX. 
 
 EGO 
 
 Egg allmmen, unboiled, fermentatidn 
 
 of, 42 
 Egineta, Paul d\ on healing of wounds, 
 
 291 
 Empyema, aseptic treatment of, 111 
 E)icyclopcdie MHho/Uqne on purity of 
 
 air, 306 
 Eremacai;sis, definition of, 9 
 Enchsen on niortalitA* after amputation, 
 
 4U 
 Errors in aseptic operations, how cor- 
 rected, 74 
 Erysipelas, relationto aseptic treatment, 
 
 541 
 Esmarch, aseptic treatment in war, 
 
 125 
 
 — in'igator, 273 
 
 • — on use of iced water, 841 
 
 — statistics, 396 
 
 Eucalj'ptus oil, aseptic use of, 140, 591 
 
 - — ointment, 141 
 
 Excision of joints, aseptic dressing of, 
 
 107 
 Exhaustion, deaths from, 554 
 Exostosis, aseptic treatment of, 503 
 
 TpABROXT on fermentation, 3 
 ■-*- Fallooiug on healing under a crust, 
 
 294 
 Eaurc on crust formation, 338 
 Femur, compound fractures of. See 
 
 Compound fractures. 
 Fermentation, alcolujlic, 209 
 • — always due to particles coming from 
 
 without, 50 
 
 — and eremacausis, 9 
 
 — Jicrt on, 220 
 
 — of blood, 33 
 
 boiled ('g£i- albumen, 14, 15, 22 
 
 milk, 14, 15, 20. 22, 25 
 
 animal tissues, 14, 15, 22, 24 
 
 substances. 14, 22, 24, 29 
 
 —urine, 24, 26 
 
 ■ — buiyric, 212 
 - — cause of, 51 
 
 — causes not gaseous, 50 
 
 — Cazenciirt! and IJvoth on, 37, 218 
 
 — chemical, 2 
 
 — definition of, 1 
 
 — gaseous theory of, 4 
 
 — in wounds, is it prevented by the 
 aseptic method ? 226, 366 
 
 relations of aiitis('ptic surgery 
 
 to, 366 
 
 — lactic, 214 
 
 — Lvinairc on, 218, 353 
 
 GAY 
 
 Fermentation, lAeiig on, 9, 197, 208 
 
 — particulate theory of, 1 
 
 — Pasteur's theory of, 223 
 ^— pigment, 212 
 
 — prevention of, 51 
 
 — putrefactive, 218 
 
 — relation of micro-organisms to, 205 
 
 — summary of views on, 17 
 
 — of tissues in the living body, 50 
 
 — of unboiled animal tissues, 44 
 
 egg albumen, 42 
 
 — grape juice, 30 
 
 milk, 37 
 
 substances, 30 
 
 urine, 36 
 
 vegetable tissues, 44 
 
 viscous, 214 
 
 vital, 2, 206 
 
 F'erments, theories of actions of, 205 
 
 Ferrier and Yco's experiments on mon- 
 key, 567 
 
 Fiorarcnti, balsam of, 347 
 
 FiHcher, E., on micro-organisms in 
 wounds. 228 
 
 — //., on use of alumina acetate, 363 
 Fooli on immersion, 344 
 
 Forceps, sinus, 79 
 
 Fore-arm, compound fractures of. See 
 Compound fractures. 
 
 Fractures, compound. .See Compound 
 fractures. 
 
 Fraenckcl and Volkniann.'s septic re- 
 sults of compound fracture, 511 
 
 Franldand on Bastian's experiments, 
 189 
 
 Fritm on water dressing, 316 
 
 GANGRENE, aseptic treatment of, 
 117 
 Gaseous tlieory of fermentation, 4 
 Gauze, carbolic, bandage, 89 
 
 general dressing, 89 
 
 loo^e, 89 
 
 Miinnich, 362 
 
 use in deep dressing, 88 
 
 — carbolised, preparation of (Lister's), 
 61 
 
 (Von r.run's), 63 
 
 — dressing, liow to make a, 64 
 
 — eucalyptus, 141 
 - thymol, 139 
 
 Ciiiil-fjinotdi- on fermentation, 4 
 
 of unl)()iled grape juice, 30 
 (iaijon on fermentation of unbuiled egg 
 albumen, 42 
 
INDEX. 
 
 609 
 
 GEL 
 
 Gelatinous degeneration of joints, asep- 
 tic treatment of, 442 
 Generation, spontaneous, theories of, 
 
 145 et seq. 
 Gensoul on crust formation, 338, 349 
 Genu Valgum, MacEwen on, 504 
 
 Ogston on, 322 
 
 Gibson on removal of loose cartilages, 
 
 313 
 Glycerine, treatment of wounds by, 348 
 Gossdin on A. Guerin's dressing, 329 
 Guyraud on subcutaneous surgery, 321 
 Granulations, absorption by, 268, 407 
 Grape juice boiled, Gaij-Lussac on, 5 
 
 ■ unboiled, fermentation of, 30 
 
 Gross on subcutaneous osteotomy, 322 
 — M., on aseptic treatment, 399 
 Grmthuisen on spontaneous generation, 
 
 182 
 Gschidlen and Trauhe on destraction 
 
 of bacteria by healthy tissues, 283 
 Guard, use of, in aseptic operations, 74 
 &ueri>is, Aljihrnse, cotton wool treat- 
 ment, 280, 325, 408 
 Guerin, Jules, on occlusion, 323, 324, 
 325 
 
 subcutaneous surgery, 320 
 
 Gnersant on use of chlorinated soda, 
 
 349 
 Gunshot wounds, aseiJtic treatment of, 
 123 
 
 of bone, results of, 512 
 
 -^ ■ joints, 447 
 
 Guyot on treatment by incubation, 317 
 Gvyton on chlorine as a disinfectant, 
 349 
 
 fTACK on absorption by granula- 
 -*i tions, 2G8, 407 
 Hands, purification of, 67, 69 
 Hartley on spontaneous generation, 189 
 Hawliins, Chas., on occurrence of phage- 
 
 da;na, 548 
 Jlcintzel's statistics of gunshot wounds 
 
 of joints, 453 
 Heister on wound treatment, 302 
 Helviholtz on fcrrncmtation, 8 
 Hernia, aseptic dressing of, 105 
 Heron, early reports of Listerian me- 
 thod, 134 
 Hervey on A. Guerin's dressing, 326 
 Hervienx on use of chlorinated soda, 
 
 349 
 Heterogencsis, theories of, 145 
 Hewttt, Prescott, on pya;mia in private 
 practice, 548 
 
 Ilingston on use of carbolic acid, 357 
 HijD joint, aseptic dressing of abscess 
 
 of, 104 
 History of antiseptic surgery, 290 
 Lister's earlier aseptic methods, 
 
 128 
 Holmes on the gei-m theory, 225 
 results with cleanliness, 547 
 
 — statistics of amputations, 414 
 
 compound fracture, 512 
 
 Hoppe-Seyler on fermentation of un- 
 boiled milk, 37 
 
 Horse-hair drains, 82 
 
 reintroduction of, 83 
 
 Hospital, St. Bartholomew's, major am- 
 putations at, 407 
 
 Hueter on aseptic surgery, 39 S 
 
 puncture of joints, 447 
 
 Hidzinga on spontaneous generation, 
 181 
 
 Humerus, compound fractures of. See 
 Compound fractures. 
 
 Humphrey on the open method, 334 
 
 Hunter, J., on bad etfects of air, 308 
 
 crust formation, 310, 335 
 
 resistance of blood to putrefac- 
 tion, 284 
 
 • wound treatment, 310 
 
 Hutchinson, method of using alcohol, 
 269, 348 
 
 — on pya;mia in lower animals, 548 
 
 — results with alcohol, 407 
 
 Huxley on spontaneous generation, 188 
 Hydi'ocele, aseptic treatment of, 568 
 
 IMMERSION, history and results of. 
 See Irrigation. 
 
 — treatment by, 272 
 
 Incubation, treatment by, 317 
 
 Infective diseases, definition of, 367 
 
 germ theory of, 552 
 
 relations of aseptic surgery to, 
 
 368, 540 
 
 relation of treatment with anti- 
 septics to, 405 
 
 Tnllamuiafion, absence of, in aseptic 
 wounds, 56(; 
 
 Instruments, purificalion of, 67, 69 
 
 Intestines, wounds of, aseptic treat- 
 ment, 115 
 
 Iodine, use of, as an antiseptic, 350 
 
 Iodoform, 65, 350 
 
 Iron perchloride, as a disinfectant, 350 
 
 Irrigation, course of wounds treated 
 by, 587 
 
 -- history of, 338 
 
 11 R 
 
GIO 
 
 INDEX. 
 
 Irrigation, its relation to fermentation 
 in wounds, 366 
 
 — treatment b.y, 272 
 
 • — and immersion, results of, 3-14, 316, 
 
 406 
 Isamhcrt on irrigation, 3-12 
 
 TAW, lower, compound fractures of. 
 See Compound fractures. 
 Joints, abscess of, 443 
 
 — dangers of wounds of, 296, 30.5, 308, 
 311, 313, 314, .558 
 
 — excision of. See Excision. 
 
 — gelatinous degeneration of, 442 
 
 — gunshot wounds of, 447 
 
 — operations on, 305, 312, 446 et seq. 
 
 — healthy, results of aseptic treatment, 
 426 
 
 wounds of, aseptic course of, 421 
 
 treatmeni;, 114, 419 
 
 Joly on spontaneous generation, 172 
 Josse on irrigation, 339 
 Jute, salicylic acid, 138 
 
 'jy'EITH, aseptic ovariotomy, 403 
 -*1- Kcrii, Vincenz von, on wound 
 
 treatment, 315 
 Klcha on micro-organisms in wounds, 
 
 228 
 Koch, method of staining bacteria, 233 
 
 — on micrococci, 244 
 
 Kraske on gunshot wounds of joints, 
 
 447 
 Krbnleiii, results from open treatment, 
 
 410, 586 
 
 — statistics of compound fracture, 514 
 
 LABARAQUE, Liquor de, 349 
 Lactic fermentation, 214 
 Lamaner on irrigation, 339 
 Lanfranc on immediate union of 
 
 wounds, 291 
 LaiKjcnheek on the permanent water 
 bath, 342 
 
 subcutaneous osteotomy, 322 
 
 Laiiltestrr, E. Ray, on spontaneous gen- 
 eration, 189 
 Lannelonyue on occlusion, 325 
 Larrey on wounds of joints, 314 
 — statistics of operations on joints, 459 
 jMtta on psoas absce.ss, 306 
 Laufjier on occlusion, 323 
 LavdiHicr on fermentation, 3 
 Le B u: II f on tincture de saponine, 352 
 
 LIS 
 
 Lccontc and Dc mar quay on carbonic 
 
 acid gas, 331 
 Le Fin-t on dressings with alcohol, 348 
 Leg, compound fractures of. See Com- 
 pound fractures. 
 Leiiiairo on ' coal tar saponine,' 352 
 
 fermentation, 218, 353 
 
 use of carbolic acid, 354 
 
 Lcticvant on operations on joints, 447 
 
 results of aseptic treatment, 399 
 
 Lcutvenhoeck on yeast, 6 
 
 Lex-eilU on removal of loose cartilages, 
 
 313 
 Liehig on feimentation, 9, 197, 208 
 Ligature of vessels with catgut, 75 
 Limbs, aseptic dressing of, 101 
 
 — - compound fractures of, summary of, 
 478 
 
 Lime, chloride, in wound treatment, 
 
 349 
 Lindpaintner on Nussbaum's statistics, 
 
 390 
 Lister, compound fractures, summary of, 
 
 484, 498 
 
 — earlier aseptic methods, 128 
 
 — on asejJtic treatment in war, 123 
 use of cotton wool, 141 
 
 causes of suppuration, 596 
 
 — — crust formation, 128, 337 
 
 destruction of bacteria by healthy 
 
 tissues, 282 
 
 -- — eucalyptus oil, 141 
 
 fermentation, 17 
 
 — of blood, 35 
 
 boiled milk, 20 
 
 urine, 20 
 
 unboiled milk, 39 
 
 — urine, 36 
 
 lactic fermentation, 215 
 
 organisation of the catgut liga- 
 ture, 572 
 
 — originator of aseptic system, 359 
 et scq. 
 
 — on spontaneous generation, 192, 194, 
 199 
 
 treatment by cleanliness, 544 
 
 use of zinc chloride, 349 
 
 — operations on joints, summary of, 
 440 
 
 — results of aseptic treatment in Edin- 
 burgh, 371 
 
 Glasgow, 368 
 
 London, 382 
 
 treatment by antiseptics in 
 
 Edinburgh, 376 
 
 — summary of spinal abscesses, 536 
 
 — table of compound fractures, 466 
 
INDEX. 
 
 611 
 
 LIS 
 
 Lister, table of operations on joints, 
 
 421 
 
 spinal abscesses, 522 
 
 Listerian method, development of, 127 
 
 358 
 
 materials emploj'ed in, 52 
 
 Listerism, definition of, 554 
 
 — principles of, 51, 359 
 lAston on water dressing, 316 
 
 Liron and Cazcneiive on fermentation, 
 
 218 
 
 of unboiled urine, 37 
 
 on spontaneous generation, 
 
 195, 201 
 Lomhard on treatment of wounds, 315, 
 
 339 
 Lotion, boracic, 64 
 
 — carbolic, 53 
 
 Lumbar abscess, Abernethy on, 306 
 
 aseptic dressing of, 104 
 
 ■ results of. See Vertebral abscess. 
 
 l{/rAAS on acetate of alumina, 139, 
 -LfuL 863 
 
 MacCormac on gunshot wounds of 
 
 joints, 452 
 statistics of compound fractures, 
 
 509 
 MacEwev, 3Ir., Glasgow statistics, 370 
 
 — Dr., absorbable drainage tubes, 84 
 
 operations on bones, 504 
 
 Mackintosh, use of, in gauze dressing. 
 
 03, 90 
 Mafiatus on wound treatment, 295 
 JMalgairfne ou effect of air on wounds, 
 
 331 
 irrigation, 341 
 
 — statistics of septic treatment, 413 
 Maisoiincnvc on occlusion, 324 
 jMalloch, early reports of Listerian 
 
 method, 134 
 
 Mamma, dressings after operations on, 
 97 
 
 2Iatiiegazza on spontaneous generation, 
 172 
 
 Maijiyr on immersion, 340 
 
 McVaifx statistics, 415 
 
 Meat, fermentation of. See Animal tis- 
 sues. 
 
 Mi-issner on fermentation of unboiled 
 animal tissues, 49 
 
 Mt'lladcw on aseptic treatment in war, 
 127 
 
 Mcijcr on subcutaneous osteotomj', 322 
 
 Micrococci, l')illroth on, 243 
 
 — characteristics of, 244 
 
 NEL 
 
 Micrococci, definition of, 243 
 
 — in wounds treated asepticallj-, 243, 
 247, 256 
 
 — Kocli on, 244 
 
 — Lister on, 244 
 
 — mode of growth of, 244 
 
 — relations of, to carbolic acid, 261 
 
 — their significance in acute abscess, 
 255, 596 
 
 — Tiegel on, 244 
 Micro-organisms, are they excluded 
 
 from wounds by aseptic treatment 1 
 227, 454 
 
 — Author on relations of, to living body, 
 205 et seq. 
 
 — destruction by healthy tissues, 252, 
 282 
 
 — in acute abscesses, 253, 597 
 
 — in chronic abscesses, 253 
 
 — in wounds treated asepticallj", 227 
 ct seq. 
 
 — in wounds treated with eucalyptus 
 gauze, 591 
 
 — not present in body in healtli, 248 
 
 — relation of, to fermentation, 205 
 living body, 205 et seq. 
 
 — resistance to heat of, 203 
 
 — their presence in disease, 250, 597 
 
 — relation to spontaneous generation, 
 145 et seq. 
 
 Milk, Appert's method of preserving, 15 
 
 — boiled, fermentation of, 14, 15, 20, 
 22,25 
 
 — unboiled, fermentation of, 37, 38, 39, 
 214 
 
 3/ilton on use of potash chlorate, 350 
 Morfjan, Cmnphell de, on use of zinc 
 
 , chloride, 349 
 Morton's statistics, 371 
 Mihmieh's carbolic gauze, 362 
 3[miro, Alex., on bad effects of air, 306 
 
 — Hugh, on bad effects of air, 306 
 Muscles, wounds of, aseptic treatment, 
 
 114 
 Mtisevlv.^ on ammoniacal fermentation 
 
 of urhie, 207 
 Mvsset on spontaneous generation, 172 
 ]\lyotomy, subcutaneous, 319, 320 
 
 N^VI, treatment of, 119 
 JSeck, aseptic dressing of, 96 
 Necrosis after compound fracture, cause 
 
 of, 557 
 Aeedhavi on spontaneous generation, 
 
 146, 149 
 Ai'Iatoii on dressings with alcohol, 348 
 
 R 11 2 
 
612 
 
 INDEX. 
 
 NEL 
 
 Nt'laton on irrigation, 341 
 
 Nerves, wounds of, aseptic treatment, 
 
 lU 
 Neuher, absorbable draina<je tubes, 83, 
 
 362 
 
 — on Esmarch's statistics, 307 
 
 permanent aseptic dressing-, 362 
 
 Nnidarft'T on crust formation, 271, 279, 
 
 335 
 
 Listerism, 360 
 
 Nivet on irrigation, 340 
 
 Nitsshaum. on carbolic acid poisoning, 
 
 589 
 operations on joints, 447 
 
 — results of cleanliness, 390, 394, 546 
 
 — statistics, 389, 393 
 
 OBJECTIONS to aseptic treatment, 
 588 
 Occlusion, liistory of, 322 
 
 — its relation to fermentation in 
 wounds, 367 
 
 — results of, 323, 407 
 
 Ogston on absence of micro-organisms 
 
 from healthy body, 250 
 micro-organisms in abscesses, 253 
 
 — wounds treated aseptically, 
 
 263 
 
 — subcutaneous osteotomy, 322 
 
 Ointment, boracic, 64 
 
 — eucalyptus, 141 
 • — salicylic, 65 
 
 Oilier on A. Guorin's dressing, 330 
 Open method of treatment, 276 
 
 general course of wounds, 586 
 
 history of, 332 
 
 relation to fermentation in 
 
 wounds, 366 
 
 results of 333, 408 
 
 in compound fracture, 514 
 
 Operations, aseptic, diet after, 576 
 
 on healthy joints, 420 
 
 • — — results of, 426 
 
 — aseptically performed, duties of 
 dresser in, 72 
 
 example of, 67 
 
 ligature of vessels, 75 
 
 use of guard in, 74 
 
 — towel in, 67, 72 
 
 — necessary, more fre<|uent]y justifi- 
 able with Listerigm, 559 
 
 — on the weak and diseased, 559 
 Organisation in blood clot, 568 
 bone, 571 
 
 catgut, 571 
 
 dead tissue, Tillmaiivs on, 573 
 
 PRI 
 
 Organisation in sloughs, 570 
 Osteitis, aseptic treatment of, 503 
 Osteo-myelitis, treatment of, 558 
 Osteotomy, subcutaneous, ' history of, 
 
 321 
 Otius on water treatment, 339 
 Ovariotomj', aseptic dressing of, 109 
 
 "pA GET on operations on joints, 460 
 
 -*- pysemia in hospital, 548 
 
 results of psoas abscess, 539 
 
 Palatius on irrigation, 339 
 Panas on aseptic treatment, 399 
 
 A. Guerin's dressing, 328 
 
 ' Pansement ouate.' See Wool cotton, A. 
 
 Guerin's method. 
 Pasteur on alcoholic fermentation, 209 
 
 — on butyric fermentation, 212 
 
 — cultivating fluid, 167 
 
 — examination of air by, 165 
 
 — on fermentation, 15 
 
 of blood, 33 
 
 boiled milk, 15 
 
 unboiled grape juice, 32 
 
 urine, 36 
 
 A. Guerin's dressing, 329 
 
 SDontaneous generation, 164, 191, 
 
 195, 202 
 
 — theory of fermentation, 223 
 Paracelsus's views on wound treatment, 
 
 292 
 Pare, views on wound treatment, 293 
 Parmanita on wound treatment, 300 
 Particulate theory of fermentation, 1 
 PanVs statistics of septic treatment, 
 
 414 
 Pearaon on treatment of psoas abscess, 
 
 312 
 Percy on wound treatment, 315, 339 
 Perineum, aseptic treatment of abscess 
 
 of, 112 
 Phthisis, operations in, 550 
 Picard on immersifm, 342, 345 
 Piechand on wounds of joints, 446 
 Pigment, formation of, by bacteria, 212 
 Pins, use of, in gauze dressing, 89 
 Poisoning with carbolic acid, 588 et seq. 
 Poncet on A. Gu('rin's dressing, 330 
 Potash chlorate, 350 
 Pdit, Perciral, on wound treatment, 304 
 results of compound fractures, 
 
 304 
 Povchet, examination of air hy, 163 
 
 — on spontaneous generation, 153, 168, 
 196 
 
 i Pi-ingle en effects of foul air, 304 
 
INDEX. 
 
 613 
 
 PRO 
 
 Protective, errors in use of, 87 
 
 — preparation of, 60 
 
 — use in aseptic dressing, 87 
 Psoas abscess, asejjtic course of, 519 
 dressing of, 101 
 
 early incision of, 519 
 
 probabilities of putrefaction in, 
 
 537 
 
 results of, 305, 30fi, 312, 517 
 
 situation of incision, 102, 517 
 
 Pupier on immersion, 346 
 Purification of hands, 67, 69 
 
 instruments, 67, 69 
 
 recent wounds, 112 
 
 septic wounds, 93, 114 
 
 skin, 67, 68 
 
 Putrefaction, definition of, 1 
 
 — dangers of, 551 
 
 — eradication of, in compound frac- 
 tures, 478 
 
 — of pus, Bocrliaare on dangers of, 301 
 
 — theories of. See Fermentation. 
 Putrefactive fermentation, 218 
 Pyaimia in good hygienic conditions, 
 
 548 
 
 — relations to fermentation in woimds, 
 550 
 
 ~DANKE on micro-organisms in asep- 
 -*^ tic wounds, 227 
 RenaxCd on use of anti.septics, 351 
 Rest, MagatuB on, 295 
 
 — mechanical, as an antiseptic method 
 of treatment, 281 
 
 — llie fundamental principle of wound 
 treatment 596 
 
 llosults of antiseptic surgery. See Anti- 
 septic surgery. 
 aseptic treatment. See Aseptic. 
 
 — general aseptic, summary of, 417 
 
 — of A. Guerin's dressing. See Wool 
 cotton. 
 
 irrigation. See Irrigation. 
 
 occlusion. See Occlusion. 
 
 open method. See Open method. 
 
 treatment by antiseptics. See 
 
 Antiseptics. 
 
 water bath. See Water bath. 
 
 Retropharyngeal abscess, aseptic treat- 
 ment of, 110 
 
 Rpyher on aseptic treatment in war, 
 • 126 
 
 gunshot wounds of bone, 512 
 
 joints, 448 
 
 Syme's statistics, 382 
 
 — results in war, 401 
 
 SCH 
 
 Richter on wound treatment, 308 
 Ricord on treatment of varicose veins, 
 
 319 
 Roberts on fermentation, 22 
 
 of blood, 35 
 
 boiled animal Tissues, 22 
 
 ■ — egg albumen, 22 
 
 milk. 22 
 
 unboiled egg albumen, 43 
 
 grape juice, 32 
 
 milk, 38 
 
 ■ urine, 37 
 
 vegetable tissues, 44 
 
 spontaneous generation, 181, 191, 
 
 192, 195 
 Rochard on dressings witli alcohol, 348 
 
 occlusion, 323 
 
 water dressing, 316 
 
 Rogeniig's applications to wounds, 291 
 Ruse's open method of treatment, 278 
 
 QALICYLIC acid, aseptic use of, 136 
 
 O cream, 65, 89 
 
 dressings with, 138 
 
 — — jute, 137 
 lotion, 138 
 
 ointment, preparation of, 65 
 
 — uses of, 117, 270 
 
 results of treatment with, 404 
 
 wool, 137 
 
 Sanderson, Jas., on resistance of seeds to 
 
 heat, 203 
 Sanitas, 271 
 
 Saponine, tincture of, 352 
 Saprajmia, definition of, 367 
 Saconj on causes of pyemia, 650 
 treatment by cleanliness, 542 
 
 — results witli cleanliness, 545 
 
 — statistics, 414 
 
 Saxtorph's results of operations on 
 joints, 446 
 
 — statistics, 396 
 Scabbing, healing hy, 279 
 Scalp, aseptic dressing of, 96 
 
 Scars not adherent after aseptic ampu- 
 tation, 568 
 ScJude, comparative statistics, 399 
 
 — on wounds of joints, 444 
 
 — statistics of compound fractures, 508 
 Schroeder on fermentation, 14, 15 
 spontaneous generation, 152 
 
 — and Ditsch on fermentation, 12 
 spontaneous generation, 
 
 1.52 
 Schrorter on pigment bacteria, 212 
 
614 
 
 INDEX. 
 
 SCH 
 
 SeJnVler on micro-organisms in wounds, 
 
 228 
 Schnlz on encalyptus oil, 140 
 Sehiilzc, experiments on spontaneous 
 
 generation, 8, 149 
 ScJtwann on fermentation, 6 
 
 spontaneous generation, 151 
 
 Scrotum, aseptic dressing of wounds of, 
 
 105 
 Septic, definition of term, 1 
 
 — derivation of term, 1 
 
 — cases, table of temperature charts, 
 584 
 
 — treatment, results of, 399, 402, 413 
 
 — wounds, purification of, 93 
 
 temperature after, 581 
 
 Silk, carbolised, preparation of, 60 
 preservation, 60 
 
 Silver sutures as an antiseptic means, 286 
 
 — wire as stitches, 86 
 
 Sim2?so)i, Sir Jas., on Listerism, 360 
 Sinus forceps, 79 
 
 — putrid, treatment of, 116 
 Skin, purification of, 67, 68 
 
 Skull, compound fractures of, aseptic 
 treatment of. 115 
 
 — results of. See Compound fractures. 
 Sloughs, organisation in, 570 
 
 Smith on irrigation, 339 
 
 Socin on results of aseptic treatment, 
 
 395 
 Soda, chlorinated, as an antiseptic, 269, 
 
 349 
 Sjiallanzani on spontaneous generation, 
 
 149 
 Spence, compound fractures, 502 
 
 — on operations on joints, 460 
 
 — results with cleanliness, 545 
 
 — statistics, 378 
 
 Spinal abscess, a test of skill in aseptic 
 treatment, 539 
 
 recumbent position in, 111 
 
 results of, 517 
 
 want of statistics of, 539 
 
 Sponges, purification and preservation 
 ■ of, 64 
 
 — use of, in dressings, 122 
 Spontaneous generation, theories of, 145 
 
 et scq. 
 Spoons, Volkmann's sharp, 116 
 Spray, carbolic acid, experiments test- 
 ing efficacy of, as germicide, 26, 258 
 
 — how to dispense with, 120 
 
 — errors in use of, 74 
 
 — objections to necessity' for, 363 
 
 — one of tlie least necessary precau- 
 tion.s, 73, 364, 594 
 
 Spray, use of, 70 
 
 — Ijroducers, hand, 54 
 steam, 56 
 
 Statistics of aseptic treatment, 368 et 
 
 seq. 
 Stimson on efficacy of carbolic spray, 
 
 258 
 Stitching of aseptic wounds, 85 
 Stitches, button, 85 
 
 — of coaptation, 86 
 relaxation, 86 
 
 — removal of, 86 
 
 Strapping of aseptic wounds, 86 
 Stromeyer on immersion, 342 
 
 subcutaneous surgery, 320 
 
 Subcutaneoiis surgery, 144, 318 
 Sulphurous acid as an antiseptic, 269 
 Summary of views on fermentation, 1 1 
 Suppuration, causes of, 596 
 
 — not always due to micro-organisms, 
 596 
 
 Surgerj'-, aseptic, definition of, 51 
 
 materials employed in, 52 
 
 principles of, 51, 52 
 
 — subcutaneous, 144, 318 
 
 Syme, method of wound treatment, 386 
 
 — on subcutaneous surgerj-, 320 
 
 — statistics, 382 
 
 Synovitis, aseptic treatment of, results, 
 442 
 
 TEMPERATURE after aseptic opera- 
 tions, 576 
 
 comi^ound fracture, 463 
 
 septic wounds, 581 
 
 wounds of joints, 421 
 
 — charts after compound fractures 
 (accidentaP, 482, 500 
 
 — opening psoas abscess, 534 
 
 wounds of joints, 438 
 
 of aseptic cases, 585 
 
 septic cases, 584 
 
 — curve septic, 580 
 
 — during tension in a wound, 577 
 
 — in carbolic acid poisoning, 589 
 Tendons, wounds of, aseiDtic treatment, 
 
 114, 561 
 Tenotomj', subcutaneous, 319, 561 
 Tension, elevation of temperature dur- 
 ing, 577 
 
 — theory of elevation of temperature 
 during, 579 
 
 Ti('(icl on micrococci, 244 
 Tillmamn on organisation of dead 
 tissue, 573 
 
IXIJUX. 
 
 G15 
 
 TIS 
 
 Tissues, unboiled animal, fenuentation 
 of. See Animal tissues. 
 
 vegetable, Ruhertx on fermenta- 
 tion of, i-i 
 
 TJieden on wound treatment, 308 
 
 Thenard on fermentation, 4 
 
 Theories of action of ferments, 205 
 
 fermentation. See Fermentation. 
 
 spontaneous generation. See 
 
 Spontaneous generation. 
 
 Tkitrscli on salicylic acid dressings, 136 
 
 — results with salicylic acid, 404 
 Thorax, wounds of, aseptic treatment, 
 
 115 
 Thornton, aseptic dressing in ovari- 
 otomy, 109 
 
 — on aseptic ovariotomy, 402 
 Thymol, aseptic use of, 139 
 
 — treatment with, results, 404 
 
 Tiegel and Billroth on fermentation of 
 
 unboiled animal tissues, 44 
 Towel carbolised, use of, in aseptic 
 
 operations, 67, 72 
 Trawhe and Gsoheidleii on destruction 
 
 of bacteria bj'' healthy tissues, 283 
 Treatment, aseptic. See Aseptic. 
 
 — by antiseptics. See Antiseptics. 
 
 — of dissection wound, 119 
 neevi, 119 
 
 putrid sinuses, 116 
 
 varicose veins, 119 
 
 Trendelenburg on operating without the 
 
 spray, 363, 595 
 Tytidall on fermentation, 23 
 spontaneous generation, 192, 203 
 
 — use of condensed beam of light by, 
 17 
 
 ULCER, purification of, 93 
 — treatment of, with boracic acid, 
 93 
 Unboiled substances, fermentation of, 
 
 30 
 Unrest, causes of, 596 
 Vre on fernientation, 8 
 Urine, boiled, 20, 24 
 — unboiled, fermentation of, 36 
 
 'TZALETTI'J on immersion, 345 
 '^ Van der Broeck on fermentation 
 of blood, 33 
 ■ unboiled egg albu- 
 men, 42 
 
 grape juice, 31 
 
 urine, 36 
 
 WOU 
 
 Van der Broeck on spontaneous genera- 
 tion, 195 
 
 Varicocele, Bicord on, 321 
 
 Vegetable tissues, unboiled, Boherts on 
 fermentation of, 44 
 
 Veins, vari ;ose, treatment of, 119, 319, 
 321 
 
 Velpeau on eiiects of air on wounds, 
 331 
 
 — on use of coal tar, 351 
 
 iodine, 350 
 
 Ventilation as an antiseptic means, 287 
 
 — in treatment of wounds, 549 
 
 — of wounds, Boiiisson on, 279 
 Verneuil on A. Guerin's dressing, 329 
 Vezin and Bartsclters open method of 
 
 treatment, 277, 332 
 Vicary on wound treatment, 294 
 Vigo, De, on treatment of wounds, 292 
 Villars, Col de, on wound treatment, 
 
 301 
 Viscous fermentation, 214 
 Vivisection, advantages of Listerism in, 
 
 567 
 Volkmann and Fraenchel, septic results 
 
 of compound fractures, 511 
 
 — on aseptic fever, 581 
 
 — results with cleanliness, 385, 405, 
 545 
 
 — sharp spoons, 116 
 
 — statistics, 385 
 
 of compound fracture, 506 
 
 wounds of joints, 443 
 
 TI/AITZ on Esmarch's statistics, 396 
 
 Walther, F«/i, on water dressing, 
 
 316 
 
 Warm bath. See History of Irrigation. 
 
 War, aseptic treatment in, 123 
 
 — results of aseptic treatment in, 401, 
 
 448, 512 
 Water dressing. See Dressing. 
 IVcUk, Sjjcneer, on aseptic ovariotomy 
 
 403 
 Wiseman, treatment of wounds, 296 
 Wood, John, on advantages of aseptic 
 treatment, 559, 561 
 
 use of carbolic acid, 357 
 
 Wool, cotton, aseptic use of, 1 4 1 
 
 A. Guerin's method, 280, 325 
 
 results of, 327, 408 
 
 bacteria under, 329, 330 
 
 salicylic acid, 137 
 
 Wound treatment, fundamental prin- 
 ciples of, 596 
 history up to 1867, 357 
 
610 
 
 INDUX. 
 
 Wounds, ai-cp1ic. (See Af-o) tic. 
 outline of course of, 5(J(i 
 
 — contused, aseptic treatment of, IIH 
 
 — dissection, aseptic treatment of, 1 19 
 
 — gunshot, aseptic treatment of, 128 
 
 — micro - organisms in. See Micro- 
 organisms. 
 
 — of abdomen, 115 
 intestine, lln 
 
 joints, aseptic treatment of, Jl-J, 
 
 419 
 
 gunshot, 447 
 
 results of, 422 
 
 muscles, 114 
 
 nerves, aseptic treatment, 114 
 
 tendons, ase^Dtic treatment of, 114 
 
 — thorax, 115 
 
 ^ produced accident ally, aseptic treat- 
 ment of, 112 
 
 Wounds, septic, purification of, 93, 114 
 
 W'iirtz, bad effects of air on wounds, 
 294 
 
 Wpnan, Jcffrii'S, on spontaneous gene- 
 ration, 1 72, 203 
 
 — Morrill, on spontaneous generation, 
 175 
 
 YEAST-PLANT in alcoholic fermen- 
 tation. 209 
 Yeo's experiment s on monkeys, 567 
 
 ZEIS on immersion, 345 
 Zinc chloride, C5, 116, 268, 271, 
 349 
 
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