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INTRODUCTORY NOTE

JOSEPH LISTER was born at Upton, Essex, England, in 1827, and received his general education at the University of London. After graduation he studied medicine in London and Edinburgh, and became lecturer in surgery 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 was made a baronet in 1883; retired from teaching in 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 room; and when, through Pasteur's researches, he realized that the formation of pus was due to bacteria, he proceeded to develop his antiseptic surgical methods. The immediate success of the new treatment led to its general adoption, with results of such beneficence as to make it rank as one of the great discoveries of the age.

ON THE ANTISEPTIC PRINCIPLE OF THE PRACTICE OF SURGERY

I

(1867)

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

To prevent the occurrence of suppuration with all its attendant risks was an object manifestly desirable, but till lately apparently unattainable, since it seemed hopeless to attempt to exclude the oxygen which was universally regarded as the agent by which putrefaction was effected. But when it had been shown by the researches of Pasteur that the septic properties of the atmosphere depended not on the oxygen, or any gaseous constituent, but on minute organisms suspended in it, which owed their energy to their vitality, it occurred to me that decomposition in the injured part might be avoided without excluding the air, by applying as a dressing some material capable of destroying the life of the floating particles. Upon this principle I have based a practice of which I will now attempt to give a short account.

The material which I have employed is carbolic or phenic acid, a volatile organic compound, which appears to exercise a peculiarly destructive influence upon low forms of life, and hence is the most powerful antiseptic with which we are at present acquainted.

The first class of cases to which I applied it was that

of compound fractures, in which the effects of decomposition in the injured part were especially striking and pernicious. The results have been such as to establish conclusively the great principle that all local inflammatory mischief and general febrile disturbances which follow severe injuries are due to the irritating and poisonous influence of decomposing blood or sloughs. For these evils are entirely avoided by the antiseptic treatment, so that limbs which would otherwise be unhesitatingly condemned to amputation may be retained, with confidence of the best results.

In conducting the treatment, the first object must be the destruction of any septic germs which may have been introduced into the wounds, either at the moment of the accident or during the time which has since elapsed. This is done by introducing the acid of full strength into all accessible recesses of the wound by means of a piece of rag held in dressing forceps and dipped into the liquid.' 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 from decomposing. 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 my care, in Glasgow Infirmary, a boy who was admitted with compound fracture of the leg 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 admission.

The next object to be kept in view is to guard effectually against the spreading of decomposition into the wound along the stream of blood and serum which oozes out during the first few days after the accident, when the acid originally applied has been washed out or dissipated by

1 The addition of a few drops of water to a considerable quantity of the acid, induces it to assume permanently the liquid form.

absorption and evaporation. This part of the treatment has been greatly improved during the past few weeks. 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 well with wounds of moderate size; and indeed I may say that in all the many cases of this kind which have been so treated by myself or my house-surgeons, not a single failure has occurred. When, however, the wound is very large, the flow of blood and serum is so profuse, especially during the first twenty-four hours, that the antiseptic application cannot prevent the spread of decomposition into the interior unless it overlaps the sound skin for a very considerable distance, and this was inadmissible by the method described above, on account of the extensive sloughing of the surface of the cutis which it would involve. This difficulty has, however, been overcome by employing a paste composed of common whiting (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 may be made to cover to any extent that may be thought desirable, while its substance serves as a reservoir of the antiseptic material. So long as any discharge continues, the paste should be changed daily, and, in order to prevent the chance of mischief occurring during the process, a piece of rag dipped in the solution of carbolic acid in oil is put on next the skin, and maintained there permanently, care being taken to avoid raising it along with the putty. This rag is always kept in an antiseptic condition from contact with the paste above it, and destroys any germs which may fall upon it during the short time that should alone be allowed to pass in the changing of the dressing. The putty should be in a layer about a quarter of an inch thick, and may be advantageously applied rolled out between two pieces of thin calico, which

be wrapped in a of a limb if this prevented by the is next the skin.

maintain it in the form of a continuous sheet, which may moment round the whole circumference be thought desirable, while the putty is calico from sticking to the rag which When all discharge has ceased, the use of the paste is discontinued, but the original rag is left adhering to the skin till healing by scabbing is supposed to be complete. I have at present in the hospital a man with severe compound fracture of both bones of the left leg, caused by direct violence, who, after the cessation of the sanious discharge under the use of the paste, without a drop of pus appearing, has been treated for the last two weeks exactly as if the fracture was a simple one. During this time the rag, adhering by means of a crust of inspissated blood collected beneath it, has continued perfectly dry, and it will be left untouched till the usual period for removing the splints in a simple fracture, when we may fairly expect to find a sound cicatrix beneath it. We cannot, however, always calculate on so perfect a result as this. More or less pus may appear after the lapse of the first week, and the larger the wound, the more likely 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 symptoms are favorable. The surgeon is extremely apt to suppose that any suppuration is an indication that the antiseptic treatment has failed, and that poulticing or water dressing 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 them, as shortly as I can, some pathological principles intimately connected, not only with the point we are immediately considering, but with the whole subject of this paper.

If a perfectly healthy granulating sore be well washed and

In order to prevent evaporation of the acid, which passes readily through any organic tissue, such as oiled silk or gutta percha, it is well to cover the paste with a sheet of block tin, or tinfoil strengthened with adhesive plaster. The thin sheet lead used for lining tea chests will also answer the purpose, and may be obtained from any wholesale grocer.

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