and another roller, completed the dressing; and a "cradle" was placed upon the neck to check lateral movements which might disturb it. I have described these particulars because I am more and more convinced of the necessity for scrupulous attention to details such as the germ theory dictates, in order to attain anything like uniformity of successful results.

A few ounces of the oily solution were poured daily over the towel for the first week, after which the dressings were left untouched for three days, and then entirely removed. The wound was found quite dry and free from tenderness, and the cloth showed only a superficial bloody stain. The stitches being taken out, a drop of pus escaped from the track of the suture next the head, but this was the only appearance of suppuration in the case from first to last, and on the separation of the scab, a few days later, a sound cicatrix was disclosed. A month (thirty days) after the operation the animal, which had continued in perfect health, was killed, and the soft parts of the neck below to the spine were removed for examination. On dissection I was struck with the entire absence of inflammatory thickening in the vicinity of the vessel, the cellular tissue being of perfectly normal softness and laxity. On exposing the artery itself, however, I was at first much disappointed to see the ligatures still there to all appearance as large as ever. But had I borne in mind what I had observed in some of my earlier cases of compound fracture treated antiseptically, I should have been prepared to find these threads present in appearance, though absent in reality. It may be well for me to quote from the account I have before given of one of these cases. It was a compound fracture of the leg, produced by direct violence, with a wound of considerable size, and a great deal of extravasation of blood into the limb. In accordance with the practice which I then followed, a piece of lint soaked with undiluted carbolic acid had been placed over the wound, and had formed with the blood a firm crust. Nearly three weeks after the accident I was detaching a portion of the adherent crust from the surface of the vascular structure into which the extravasated blood beneath had been converted by the process of organisation, when I exposed a little spherical cavity about as big as a pea, containing brown serum, forming a sort of pocket in the living tissues, which when scraped with the edge of a knife, bled even at the very margin of the cavity. This appearance showed that the deeper portions of the crust itself had been converted into living tissue. For cavities formed during the process of aggregation, like those with clear liquid contents in a Gruyère cheese, occur in the grumous mass which results from the action of carbolic acid upon blood; and that which I had exposed had evidently been one of these, though its walls were now alive and vascular." Thus the dead, but nutritious mass, had served as a mould for the formation of new tissue, the growing elements of which had replaced the materials absorbed, so as to constitute a living solid of the same form.

46

Hence it might have been anticipated that the ligatures of peritoneum and catgut placed on the calf's carotid would, after the expiration of a month, be found transformed into bands of living tissue. Such was, in truth, the case, as was apparent on closer examination. They had, indeed, a deceptive resemblance to their former condition from the persistence in their substance of the impurities of the original materials, the dark adventitious particles being of mineral nature incapable of absorption, so that they had remained as a sort of tattooing of the new structure. Nevertheless a marked alteration in colour had taken place, especially in the distal ligature, where the dirty-grey of the softened catgut had changed to a dirty-pink tint. The twe pieces of catgut which had been tied round the vessel at that part had become, as it were, fused together into a single fleshy band, inseparably blended with the external coat of the artery. The knots were nowhere discoverable, and the only indication of the end which had been left long at the time of the operation was the presence of a black speck here and there upon a delicate thread of cellular tissue in connection with the vessel. The cardiac ligature was in like manner continuous in structure with the arterial wall. The short cut ends had disappeared; but the massive knot was represented by a soft smooth lump, which appeared at first entirely homogone

ous, except that it was speckled with dark particles, as before referred to. On section, however, I discovered in the interior of the mass, and lying close to the wall of the artery, a small residual portion of the original knot, of comparatively firm consistence, and with the three-fold twisted character of the cord plainly visible. It was quite distinct from the living tissue that surrounded it, so that it could be readily picked out from its bed with a pair of needles. A slender and irregular remnant of the noose was also found lying in a sort of tubular cavity, extending about half round the vessel.

Thus the process of organisation had no yet quite invaded the entire thickness of the foreign solid, and it was a h ppy circumstance that the cord had been so constructed that the distinction between the old structure and the new could be plainly recognised.

Ample as was the evidence afforded to the naked eye of the organisation of these ligatures, it was satisfactory to find it confirmed in the clearest manner by the microscope. A bit of the knot, 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 insterstitial cell-development. At a short distance from the remains of the old thread, the fleshy material which had been formed at its expense proved to be a most beautiful example of fibro-plastic structure, the coarse fibres which mainly constituted it being composed of very large elongated cells, often containing several nuclei, and presenting in their course branchings and thickenings of various forms. Here and there were some fibres more perfectly formed, and also cells of a more rudimentary character. Again, the band which had resulted from the 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 developed form of fibrous tissue, 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. For it is to be remarked that a piece of catgut exhibits under the microscope abundance of perfect fibrous tissue. A more favourable period for the investigation, with a view to establishing the nature of the change which ligatures of animal tissue experience under antiseptic management, could hardly have been selected.

Between the parts tied the calibre of the artery was occupied by adherent coagulum, which was for the most part decolorised, and exhibited under the microscope fibro-plastic cells of irregular forms. A similar clot was present between the distal ligature, and a small branch that arose about a quarter of an inch beyond it. But between the proximal ligature and the heart the formation of a coagulum had been entirely prevented by a large vessel taking origin immediately above the part tied, which had thus borne for a month the full brunt of the cardiac impulse. Yet the vessel, so far from showing any sign of giving way, as it would inevitably have done had it been tied in such a situation without antiseptic precautions, appeared to have derived additional strength from the operation. The encircling ring of new tissue incorporated with the arterial wall must have had a corroborative effect; and within its grasp the inner coats, which seemed to have been but imperfectly ruptured by the soft and substantial ligature, were considerably thickened, and had coalesced so as to form a strong cul de sac, the irregularities of which had been smoothed over by a little fibrinous deposit, which had assumed the characters of a firm fibrous tissue, and presented a free surface undistinguishable from that of the lining membrane of the artery.

At the situation of the distal ligature the structure of the vessel seemed entirely unaffected. The middle coat was seen in longitudinal section as a pink streak between two white lines, representing the external and internal tunics, neither thick. thinner than in neighbouring parts. The catgut

threads had been tied too gently to produce rupture of the internal and middle layers, and their presence and the constriction which they occasioned, whatever may have been their effect in the first instance, had left no permanent marks of disturbance; while the fleshy band that had replaced them, though in time it would doubtless have dwindled to an insignificant filament, was at least a temporary addition to the strength of the artery.

These appearances at the distal ligature are calculated to revive under a new aspect the old question whether it would not be better always to avoid rupture of the internal and middle coats, which could easily be done by using a pretty thick piece of catgut softened by steeping it in a watery solution of carbolic acid. In this way the wall of the vessel would be left from first to last entirely intact. This, however, is probably a matter of indifference. Indeed, judging from the condition of the artery at the cardiac ligature, the injury done to the vessel at the outset by tight tying seems to lead to changes which increase its power of resistance, which was certainly severely tested in the present instance.

It appears, then, that by applying a ligature of animal tissue antiseptically upon an artery, whether tightly or gently, we virtually surround it with a ring of living tissue, and strengthen the vessel where we obstruct it. The surgeon, therefore, may now tie an arterial trunk in its continuity close to a large branch secure alike against secondary hemorrhage and deep-seated suppuration, provided always that he has so studied the principles of the antiseptic system, and so carefully considered the details of the mode of dressing best adapted to the particular case in hand, that he can feel certain of avoiding putrefaction in the wound. For my own part I should now, without hesitation, undertake ligature of the innominate, believing that it would prove a very safe procedure.

Catgut, manufactured from the small intestine of the sheep, may be had at a very low price, from the thickness of a horsehair upwards. In the dry state it is objectionable from its rigidity, and also from a tendency of the first half of the knot to slip before the second half is secured. Water renders it perfectly supple, and as little liable to slip as waxed silk. But if a watery solution of carbolic acid is used for the purpose of making it antiseptic, the protracted immersion requisite to ensure completeness of the effect makes the finer kinds too weak and the stouter too clumsy. The method which I have found to answer best is to keep the gut steeping in a solution of carbolic acid in five parts of olive oil, with a very small quantity of water diffused through it. A larger proportion of the acid would impair the tenacity of the thread. If a mere oily solution is employed, the gut remains rigid, the oil not entering at all into its substance. But a very small quantity of water, such as the acid enables the oil to dissolve, renders the gut supple without making it materially weaker or thicker. And, curiously enough, the presence of this small amount of water in the oily solution gradually brings about a change in the gut, indicated by a deep-brown colour; after which it may be placed in a watery solution for a long time without swelling, as a portion prepared in a simple oily solution does. This is a great convenience; for an oily solution is unpleasant to work with during an operation, and exposure to the air soon renders gut suppled with water rigid from drying. But when it has been treated in the way above recommended, it may be transferred to a watery solution at the commencement of an operation, and so kept supple without having its strength or thickness altered.

For tying an arterial trunk in its continuity, catgut as thick when dry as ordinary purse-silk, will be found best. But for ordinary wounds, where, if one ligature happens to break, another can be easily applied, much finer kinds may be employed, and are convenient from their smaller bulk. For every-day use, a small oil-tight capsule may be carried in the pocket-case, and this can be replenished from a larger stock as may be necessary. I have had a small silver bottle, with well-fitting screwed top, adapted to my caustic-case, and this contains two little rods of wood, with gut of two sizes wound upon them, with a few drops of the antiseptic oil; and now that

torsion has almost entirely superseded the ligature in ordinary wounds, this small supply will probably last me for months.-Lancet, April 3, 1869, p. 451.

42.-ON THE ANTISEPTIC SYSTEM OF TREATMENT IN SURGERY.

By JOSEPH LISTER, Esq., F. R. S., Professor of Surgery in the University of Glasgow. [In compound fracture, as a general rule, healing by scabbing should be aimed at, by leaving the deeper layers of the dressing used to form the scab, and applying the antiseptic externally. If the antiseptic is allowed to penetrate to the wound, it stimulates the tissues to granulation and suppuration.] The advantages of healing by scabbing are so great that it is worth while to endeavor to attain them, and I have been long striving to improve the method of dressing, so as to get rid, if possible, of the attendant risk. A plan which has, in most cases, answered well when the putty has been used, is to make the permanent dressing of two or three layers of lint somewhat larger than the wound, wrung out of a pretty strong solution of carbolic acid in oil, say one of acid to four of oil, and covered with a piece of oiled calico or linen rag extending about an inch beyond the lint in every direction. Over this is applied a stratum of antiseptic putty, which is changed daily, or once in two days, according to the amount of discharge. The blood from the wound soaking into the lint is acted on by the carbolic acid, and changed into a firm substance which consolidates the deep dressings into a crust or scab, and this crust, while sufficiently thick over the wound to prevent the carbolic acid of the putty from penetrating to the raw surface, is so thin at its margins formed by the rag as to be there kept antiseptic through and through. Then, in changing the putty, the first thing seen on lifting up its edge is the thin margin of the calico; and even if this be accidentally raised a little, its antiseptic property prevents any mischief from resulting. The putty is spread on calico, and the calico is applied next to the deep dressing, to prevent adhesion, while the external surface of the putty is covered either with thin block tin or sheet lead, or, what more recently we found to answer quite as well, gutta percha tissue, which, though it permits carbolic acid to escape through it, is not objectionable on that account if the putty be sufficiently thick, while the gutta percha, like the metallic plate, prevents the putty from becoming dry and hard. The putty is made to overlap the permanent dressing well on all sides, and I may remark that, whether the impermeable antiseptic guard be composed of putty or not, it is of the utmost importance that it should extend freely beyond the source of the discharge in every direction, so that the putrescible fluid may have to flow for some distance beneath it before it reaches the atmosphere or any dressing containing active putrefactive organisms. The degree of overlapping of the crust by the external dressing must vary according to the amount of discharge which may be anticipated. When this is large, it should be to the extent of three or four inches. Failures have undoubtedly often occurred for want of attention to this essential point.

But though this method will, with proper care, generally succeed, it would be very desirable, if possible, to get rid of the trouble involved in it. At one time I hoped this might be done by means of the plaster above mentioned, by employing a layer of it instead of the calico as the upper part of the permanent dressing, so that the adhesiveness of the emplastrum might keep the whole deep dressing securely applied to the skin, except at limited spots where the discharge might ooze out; another layer of plaster being used instead of the putty, with calico moistened with a watery solution of the acid interposed to prevent adhesion of the two layers of plaster. My anticipations, however, have not been verified in this respect. For the plaster, though it answers extremely well for an external antiseptic guard, whether in compound fracture, incised wounds, or abscesses, has proved

unsuitable for the permanent dressing. The substance of the emplastrum becomes softened by the solution of carbolic acid used to moisten the calico, and permits it to enter beneath it and soak into the lint below, and stimulate the raw surface to granulate and suppurate, and this was what occurred in the case of displaced foot above mentioned. At the same time the lint is kept moist, instead of forming a dry crust, and hence it may gradually shift its place along with the plaster that covers it, involving the risk of leaving the wound insufficiently overlapped. if not exposed. I have experienced this inconvenience in two cases of compound fracture which have been treated in this way. One of these was an old lady, of 75, in whom the os humeri was severely comminuted just above the elbow-joint, with a considerable wound from which six loose fragments were extracted; the other, was a boy, 12 years old, whose right thigh was much contused as well as broken by machinery. These cases, indeed, have done well; osseous union having occurred as early as if the fractures had been simple ones. But in both of them the

wounds healed by granulation instead of by scabbing.

With the view of getting over these difficulties I sought to obtain some kind of antiseptic cement, by which a portion of dressing might be glued down firmly upon the skin. Among other materials I tried shell-lac, and, in so doing, I accidentally hit upon a substance which appears preferable to the plaster for almost every purpose. I found that this resin could be mixed with carbolic acid in any amount by aid of heat, the result, when cooled, varying, according to the quantity of the acid, from brittleness to fluidity, the intermediate proportions giving a firm but flexible solid with a certain degree of elasticity, approaching to some extent the characters of caoutchouc. It further turned out that the lac thus associated with the carbolic acid retained it with great tenacity,* so that a thin layer spread on calico may be used to store up a large quantity of the antiseptic, forming an application which retains its virtues for days at the temperature of the body, and at the same time, fails to irritate the skin. It has also this great advantage over the lead plaster, that it cannot be softened by either a watery or oily fluid. The only imperfection which it appeared to shew, when used in practice as an external antiseptic guard, was that when long applied to the skin it adhered to the surface, whereas it is desirable that such a dressing should adhere very slightly if at all. This objection to it I attempted to obviate by spreading it upon gutta percha tissue which, though insoluble in carbolic acid, allows it to travel through its substance. The lac when thus lined with gutta percha proved none the less efficient as an antiseptic, and, being perfectly devoid of adhesiveness and of smooth surface, shed the discharge in a most perfect manner, greatly excelling, in this respect, the lead plaster. But it had one fault, viz., that when subjected to much bending, as at the fold of a joint, the gutta percha cracked and admitted the discharge, which, gradually insinuating itself, detached the gutta percha more or less extensively, and introduced an element of risk through the interposition of a layer of liquid between the antiseptic lac and its lining. This fault has been got rid of by reducing the gutta percha to a mere film, incapable of affording lodgment for fluid, by brushing over the antiseptic lac with a weak solution of gutta percha in bisulphide of carbon, which, rapidly evaporating, leaves a coating of microscopic thinness, yet effectual for preventing adhesion. We have now given this lac dressing a sufficient trial in wounds and abscesses to entitle me to recommend it with confidence.t

In this respect, lac differs altogether from India-rubber, which, though it may be impregnated with the acid to any degree, parts with it rapidly.

+ This plaster is supplied at a very moderate price by the New Apothecaries' Company, Glassford Street, Glasgow, to whom I am much indebted for the interest and pains they have taken in bringing it to perfection. The following is the mode of its manufacture:--Take of shell-lac, 8 parts; crystallised carbolic acid, 1 part. Heat the lac with about a third of the carbolic acid over a slow fire till the lac is completely melted; then remove from the fire and add the remainder of the acid and stir briskly till the ingredients are thoroughly mixed. Strain through muslin, and pour into the machine for spreading plaster; and, when the liquid has thickened by cooling to a degree ascertained by experience, spread to the thickness of about one-fiftieth of an inch. Afterwards, brush the surface of the plaster lightly with a solution of gutta percha in about thirty parts of bisulphide of carbon. When the sulphide has evaporated, the plaster may be piled in suitable lengths in a tin box without adhering, or rolled up and kept in a canister.