Part 21 (2/2)

Joseph Lister was born at Upton, Essex, England, in 1827, and received Aw general education at the University of London After graduation he studied ery at the University in the latter city

Later he was professor of surgery at Glasgow, at Edinburgh, and at King's College Hospital, London, and surgeon to Queen Victoria He wasin 1893; and was raised to the peerage in 1897, with the title of Baron Lister

Even before the work of Pasteur on fermentation and putrefaction, Lister had been convinced of the importance of scrupulous cleanliness and the usefulness of deodorants in the operating rooh Pasteur's researches, he realised that the formation of PUS was due to bacteria, he proceeded to develop his antiseptic surgical methods The ieneral adoption, with results of such beneficence as to e

ON THE ANTISEPTIC PRINCIPLE OF THE PRACTICE OF SURGERY (1867)

In the course of an extended investigation into the nature of inflammation, and the healthy and morbid conditions of the blood in relation to it, I arrived several years ago at the conclusion that the essential cause of suppuration in wounds is decoht about by the influence of the atmosphere upon blood or serum retained within them, and, in the case of contused wounds, upon portions of tissue destroyed by the violence of the injury

To prevent the occurrence of suppuration with all its attendant risks was an object manifestly desirable, but till lately apparently unattainable, since it seeen which was universally regarded as the agent by which putrefaction was effected But when it had been shown by the researches of Pasteur that the septic properties of the ataseous constituent, but on y to their vitality, it occurred to ht be avoided without excluding the air, by applying as a dressing so particles Upon this principle I have based a practice of which I will now atteive a short account

The material which I have eanic compound, which appears to exercise a peculiarly destructive influence upon low forms of life, and hence is the most powerful antiseptic hich we are at present acquainted

The first class of cases to which I applied it was that of compound fractures, in which the effects of deco and pernicious The results have been such as to establish conclusively the great principle that all local inflaeneral febrile disturbances which follow severe injuries are due to the irritating and poisonous influence of decohs For these evils are entirely avoided by the antiseptic treatly condemned to amputation may be retained, with confidence of the best results

In conducting the treaterms which may have been introduced into the wounds, either at thethe ti the acid of full strength into all accessible recesses of the wound byforceps and dipped into the liquid [Footnote: The addition of a few drops of water to a considerable quantity of the acid, induces it to assume permanently the liquid form] This I did not venture to do in the earlier cases; but experience has shown that the compound which carbolic acid forms with the blood, and also any portions of tissue killed by its caustic action, including even parts of the bone, are disposed of by absorption and organisation, provided they are afterwards kept fro We are thus enabled to employ the antiseptic treatment efficiently at a period after the occurrence of the injury at which it would otherwise probably fail Thus I have now under ow Infir as late as eight and one-half hours after the accident, in whom, nevertheless, all local and constitutional disturbance was avoided by means of carbolic acid, and the bones were soundly united five weeks after his aduard effectually against the spreading of deco the strea the first few days after the accident, when the acid originally applied has been washed out or dissipated by absorption and evaporation This part of the treat the past feeeks The method which I have hitherto published (see Lancet for Mar 16th, 23rd, 30th, and April 27th of the present year) consisted in the application of a piece of lint dipped in the acid, overlapping the sound skin to some extent and covered with a tin cap, which was daily raised in order to touch the surface of the lint with the antiseptic This method certainly succeeded ounds of moderate size; and indeed I may say that in all the many cases of this kind which have been so treated by le failure has occurred

When, however, the wound is very large, the flow of blood and seru the first twenty-four hours, that the antiseptic application cannot prevent the spread of decomposition into the interior unless it overlaps the sound skin for a very considerable distance, and this was inadmissible by theof the surface of the cutis which it would involve

This difficulty has, however, been overco (carbonate of lime), mixed with a solution of one part of carbolic acid in four parts of boiled linseed oil so as to form a firm putty This application contains the acid in too dilute a form to excoriate the skin, which it ht desirable, while its substance serves as a reservoir of the antiseptic e continues, the paste should be changed daily, and, in order to prevent the chance ofdipped in the solution of carbolic acid in oil is put on next the skin, andtaken to avoid raising it along with the putty This rag is always kept in an antiseptic condition froer the short ti of the dressing The putty should be in a layer about a quarter of an inch thick, and eously applied rolled out between two pieces of thin calico, which maintain it in the form of a continuous sheet, which may be wrapped in a moment round the whole circuht desirable, while the putty is prevented by the calico fro which is next the skin[Footnote: In order to prevent evaporation of the acid, which passes readily through any organic tissue, such as oiled silk or gutta percha, it is well to cover the paste with a sheet of block tin or tinfoil strengthened with adhesive plaster The tin sheet lead used for lining tea chests will also answer the purpose, and e has ceased, the use of the paste is discontinued, but the original rag is left adhering to the skin till healing by scabbing is supposed to be complete I have at present in the hospital a man with severe co, caused by direct violence, who, after the cessation of the sanibus discharge under the use of the paste, without a drop of pus appearing, has been treated for the last teeks exactly as if the fracture was a si by means of a crust of inspissated blood collected beneath it, has continued perfectly dry, and it will be left untouched till the usual period for re the splints in a simple fracture, e may fairly expect to find a sound cicatrix beneath it We cannot, however, always calculate on so perfect a result as this More or less pus er the wound, the more likely this is to happen And here I would desire earnestly to enforce the necessity of persevering with the antiseptic application in spite of the appearance of suppuration, so long as other syeon is extremely apt to suppose that any suppuration is an indication that the antiseptic treat should be resorted to But such a course would in many cases sacrifice a limb or a life I cannot, however, expect my professional brethren to follow my advice blindly in such a matter, and therefore I feel it necessary to place before theical principles intimately connected, not only with the point we are i, but with the whole subject of this paper If a perfectly healthy granulating sore be ashed and covered with a plate of cleanits surface pretty accurately, and overlapping the surrounding skin an inch or so in every direction and retained in position by adhesive plaster and a bandage, it will be found, on reht hours, that little or nothing that can be called pus is present, merely a little transparent fluid, while at the same time there is an entire absence of the unpleasant odour invariably perceived ater dressing is changed Here the clean metallic surface presents no recesses like those of porous lint for the septic gerranulations has floay undecomposed, and the result is the absence of suppuration

This siranulations have no inherent tendency to form pus, but do so only when subjected to preternatural stin body does not of itself stiranulations to suppurate; whereas the presence of decoanic ly exemplified by the fact that I have elsewhere recorded (Lancet, March 23rd, 1867), that a piece of dead bone free froranulations around it to suppurate, but may actually be absorbed by them; whereas a bit of dead bone soaked with putrid pus infallibly induces suppuration in its vicinity

Another instructive experi sore with so the sound skin extensively; e find, in the course of twenty-four hours, that pus has been produced by the sore, although the application has been perfectly antiseptic; and, indeed, the larger the areater is the quantity of pus formed, provided we avoid such a proportion as would act as a caustic The carbolic acid, though it prevents deco as a cheanic materials (which we know to be chemically acrid) operate in the sa substances are alike; viz, that they induce suppuration by cheuished from what may be termed simple inflammatory suppuration, such as that in which ordinary abscesses originate--where the pus appears to be formed in consequence of an excited action of the nerves, independently of any other stimulus There is, however, this enormous difference between the effects of carbolic acid and those of decomposition; viz, that carbolic acid stimulates only the surface to which it is at first applied, and every drop of discharge that for it; but deco poison, and, if it occur at the surface of a severely injured limb, it will spread into all its recesses so far as any extravasated blood or shreds of dead tissuein those recesses, it will becoy of a caustic sufficient to destroy the vitality of any tissues naturally weak from inferior vascular supply, or weakened by the injury they sustained in the accident

Hence it is easy to understand hohen a wound is very large, the crust beneath the rag may prove here and there insufficient to protect the raw surface fro influence of the carbolic acid in the putty; and the result will be first the conversion of the tissues so acted on into granulations, and subsequently the formation of more or less pus This, however, will be merely superficial, and will not interfere with the absorption and organisation of extravasated blood or dead tissues in the interior But, on the other hand, should decomposition set in before the internal parts have become securely consolidated, the most disastrous results ow a boy, thirteen years of age, who, between three and four weeks previously, ot entangled in aand three inches broad, and the skin was very extensively underenerally soforceps introduced at the wound and pushed directly inwards appeared beneath the skin at the opposite aspect of the li, and a of about three inches of the triceps in al four inches and a half, stripped oftucked in under it Without the assistance of the antiseptic treat else but amputation at the shoulder-joint; but, as the radial pulse could be felt and the fingers had sensation, I did not hesitate to try to save the li the arm from the shoulder to below the elbow in the antiseptic application, the whole interior of the wound, together with the protruding bone, having previously been freely treated with strong carbolic acid About the tenth day, the discharge, which up to that tiht admixture of slimy pus; and this increased till (a few days before I left) it amounted to about three drachms in twenty-four hours But the boy continued as he had been after the second day, free froue, appetite, and sleep natural and strength increasing, while the li, redness, or pain

I therefore, persevered with the antiseptic dressing; and, before I left, the discharge was already so firm I think it likely that, in that boy's case, I should have found s at the end of the three weeks; though, considering the extent of the injury, I thought it prudent to let thenext the skin But I feel sure that, if I had resorted to ordinary dressing when the pus first appeared, the progress of the case would have been exceedingly different

The next class of cases to which I have applied the antiseptic treatment is that of abscesses Here also the results have been extreical principles indicated above The pyogenic ranulations of a sore, which it resembles in nature, forms pus, not from any inherent disposition to do so, but only because it is subjected to some preternatural stimulation In an ordinary abscess, whether acute or chronic, before it is opened the stimulus which maintains the suppuration is derived from the presence of pus pent up within the cavity When a free opening is ot rid of, but the at access to the contents, the potent stienerated in greater abundance than before But when the evacuation is effected on the antiseptic principle, the pyogenic membrane, freed from the influence of the former stimulus without the substitution of a new one, ceases to suppurate (like the granulations of a sore undera be dependent or not, rapidly contracts and coalesces At the same time any constitutional symptoms previously occasioned by the accuhtest risk of the irritative fever or hectic hitherto so justly dreaded in dealing with large abscesses

In order that the treatment may be satisfactory, the abscess must be seen before it is opened Then, except in very rare and peculiar cases [Footnote: As an instance of one of these exceptional cases, I may mention that of an abscess in the vicinity of the colon, and afterwords proved by post-mortem examination to have once communicated with it Here the pus was extremely offensive when evacuated, and exhibited vibros under the anisms in the contents, so that it is needless to introduce carbolic acid into the interior Indeed, such a procedure would be objectionable, as it would stienic membrane to unnecessary suppuration

All that is requisite is to guard against the introduction of living aterms from without, at the same time that free opportunity is afforded for the escape of the discharge froiven elsewhere a detailed account of the method by which this is effected (Lancet, July 27th, 1867), that I shall not enter into it at present further than to say that the means employed are the sa of co dipped into the solution of carbolic add in oil to serve as an antiseptic curtain, under cover of which the abscess is evacuated by free incision, and the antiseptic paste to guard against deco in the streaed daily until the sinus is closed

The ical point of view have been afforded by cases where the formation of pus depended on disease of bone Here the abscesses, instead of foreneral class in the obstinacy of the suppuration, have rese discharge, and frequently the production of pus has ceased froinal contents Hence it appears that caries, when no longer labouring as heretofore under the irritation of decoery, and recovers like other inflammatory affections In the publication before alluded to, I have edin diseased bone, in whom the sinus finally closed after months of patient perseverance with the antiseptic treatment Since that article ritten I have had another instance of abscess equally gratifying, but the differing in the circumstance that the disease and the recovery were more rapid in their course The patient was a blacksmith, who had suffered four and a half months before I saw hie in the left elbow These had latterly increased in severity so as to deprive hiht's rest and of appetite I found the region of the elbow greatly swollen, and on careful exa point at the outer aspect of the articulation I opened it on the antiseptic principle, the incision evidently penetrating to the joint, giving exit to a few drachentleow) supervised the daily dressing with the carbolic acid paste till the patient went to spend two or three weeks at the coast, when his as entrusted with it

Just two months after I opened the abscess, he called to show e had been, for at least teeks, as little as it was then, a trifling ht be accounted for by the little sore caused by the incision On applying a probe guarded with an antiseptic rag, I found that the sinus was soundly closed, while the lih he had not attempted to exercise it h a considerable angle Here the antiseptic principle had effected the restoration of a joint, which, on any other known system of treatment, must have been excised

Ordinary contused wounds are, of course, amenable to the same treatment as compound fractures, which are a complicated variety of thele instance of this class of cases In April last, a volunteer was discharging a rifle when it burst, and blew back the thumb with its e at the trapezial joint, which had evidently been opened, while all the soft parts between the h I need not insist before ly character of such an injury My house- surgeon, Mr Hector Cameron, applied carbolic acid to the whole raw surface, and co as if for compound fracture The hand re, and with the exception of a shallow groove, all the wound consolidated without a drop of matter, so that if it had been a clean cut, it would have been regarded as a good exa surface soon healed, and at present a linear cicatrix alone tells of the injury he has sustained, while his thurasp

If the severest forms of contused and lacerated wounds heal thus kindly under the antiseptic treatment, it is obvious that its application to simple incised wounds ood deal of attention to this class, but I have not as yet pleased ether with any of the o so far as to say that a solution of carbolic acid in twenty parts of water, while aany septic ger the perfor the subsequent introduction of others, the paste above described, applied as for coives excellent results Thus I have had a case of strangulated inguinal hernia in which it was necessary to take away half a pound of thickened omentum, heal without any deep-seated suppuration or any tenderness of the sac or any fever; and a one immediately below the knee, have remained absolutely free from constitutional symptoms