164 
NALOIGE, 

becomes a septic dressing immediately after applica- 
tion; that it is, in fact, nothing but a beautifully 
whitened sepulchre full, if not of dead men’s bones, 
at all events of all uncleanness. 
Some aseptic surgeons apply their principle to com- 
pound fractures and rely solely on mechanical means 
for removing dirt from the recesses of the wounds; 
but most, I believe, continue to employ powerful anti- 
septics for this purpose, and in this class of injury 
follow Lister’s instructions. 
I am not so ignorant or bigoted as to suggest that 
so-called aseptic surgery is a bad way of treating 
wounds. I know that first-rate results are constantly 
obtained by means of it. But, I maintain, and here 
I am repeating what Lister often said to me :— 
(1) That it is a troublesome and difficult process, 
involving for successfully carrying it out an amount 
of paraphernalia and an amount of training that puts 
it almost beyond the reach of all except hospital 
surgeons. 
(2) That it is misleading to set it up in opposition 
to the antiseptic system, because most of its advocates 
use chemical antiseptics for one purpose or another, 
and all employ heat with great freedom. 
(3) That infections of the skin and consequent later 
suppuration is more likely to occur than if Lister’s 
methods are followed. 
I will now describe one of Lister’s operations in 
his last years at King’s College. He did not require 
a huge autoclave for sterilising. He did not wear 
gloves, but he purified his own hands and the skin 
of the patient by a most potent antiseptic, which was 
called the strong mixture. It consisted of 1 to 20 
carbolic acid in 1 to 500 corrosive sublimate. Lister, 
fortunately or unfortunately, had a very resisting 
skin; his hands, however, were usually rough, but 
he did not seem to mind. This was not the case 
with many of his followers, who could not, or would 
not, stand the discomfort strong lotions produced. 
This has undoubtedly been one cause of secession. 
The instruments and the sponges (he used marine 
sponges) had been long steeped in strong carbolic 
acid lotion, but during the operation they were wrung 
out of a very weak antiseptic solution. The towels 
placed round the field of operation were also 
carbolised. No irrigation was carried out. When 
the operation was complete, a dressing containing an 
antiseptic substance was applied. 
His treatment of compound. fractures was never 
modified after the first few years. 
The differences you see are these :— 
(1) Lister trusted to a potent chemical antiseptic, 
instead of to mechanical cleansing and heat, for 
sterilising the skin, instruments, and the objects likely 
to be brought into contact with the wound. 
(2) He applied a very weal antiseptic in small 
amount to the wound itself, instead of boiled water 
or normal saline solution. 
(3) Instead of plain gauze he used an antiseptic 
dressing, which has the great advantage of acting 
upon any organisms that, after the operation may 
reach the surface from the sweat and sebaceous 
glands of the patient. 
These differences between the two systems, as thus 
stated, do not appear to be great, but they are im- 
portant. ‘The little more, and how much it is! and 
the little less and how far away!” For in one there 
is simplicity and safety, in the other complication and 
risk. Thus in the first place sterilising by a chemical 
antiseptic involves no special apparatus. It can be 
carried out in the humblest cottage. Secondly, the 
use of an antiseptic during the operation does away 
with the necessity of the surgeon and his assistants, 
young dressers, or busy country doctors, or nurses 
NO 2371,) VOLIO5|| 
[AprIL 8, 1915 

being constantly on the qui vive lest their simply 
aseptic garments should touch some unpurified thing 
and then convey defilement to the wound. Thirdly, 
security is provided for against secondary infection 
from the skin; or secondary infection through the 
dressing, if the discharges should soak through to 
the surface and thus supply a neutral track for the 
germs to travel along. 
When I come to speak of results I must necessarily 
be vague. I have, however, formed the opinion, from 
much observation and long experience, that the 
standard as regards suppuration amongst aseptic sur- 
geons is lower than Lister’s used to be. If a case 
“goes wrong,’ as the common but mischievous ex- 
pression is, it is looked upon as an unavoidable acci- 
dent, not as a disgrace. In recent years the term, 
‘stitch abscess,” has sprung into use. Lister said 
he never had stitch abscesses. Forgive me for dwell- 
ing on them for a moment. The name is applied to 
suppurations occurring about stitches, and they arise 
in this way. Our skin is full of small glands for 
supplying greasy material to the hairs. Organisms 
are present in these glands, and any weakening of 
the tissues gives them a chance of doing mischief, 
the commonest illustration of which is the ordinary 
boil that starts from the fretting of a cuff or a collar. 
A tight stitch, or a not very tight one, may do the 
same. But the risk is very much diminished by 
thorough purification of the skin, which is much more 
effectually obtained by following Lister’s instructions 
than by “aseptic”” methods. It may be granted that 
stitch abscesses do not often lead to serious mischief, 
but they often cause troublesome suppuration in the 
wound itself and involve delay, and the removal of 
important deep stitches, which were intended to be 
permanent. This risk is also lessened by using an 
antiseptic as opposed to an aSeptic dressing. I con- 
fess I have never been able to understand the objec- 
tion to an antiseptic gauze dressing. If the wound 
heals by first intention the antiseptic substance cannot 
possibly act upon the raw .surface of the wound. 
Antiseptic gauze has all the advantages of sterilised 
gauze except that it is slightly more expensive and 
has none of its disadvantages; in fact, I am confident 
that it has only been discarded on purely theoretical 
grounds. 
To what extent, then, should we return? I would 
not urge the use of marine sponges, because they are 
difficult to clean and expensive, and because cotton 
swabs are equally efficient. Nor would I recommend 
the giving up of india-rubber gloves, although I know 
that they have their dangers, and although I know 
that they may safely be dispensed with by an anti- 
septic surgeon. Boiling instruments, I think, should 
be continued. Otherwise I say that it is only fair to 
students to tell them, and show them, that by carrying 
out Lister’s technique, it is more easy to obtain the 
very best results and less likely to fail. 
I have only spoken of civil practice, but I would 
not have ventured to offer you a surgical address, 
and I could not have hoped to attract your attention 
if it had had no bearing upon the war which is now 
raging. 
Lister’s faithful followers had not only watched 
with regret what they considered to be a retrograde 
step in civil practice, but they feared that a war 
would bring out in relief its weak points. 
Wars have occurred of late in distant parts of the 
world, but we paid little heed to the details. It 
required a war in our midst, with our own flesh and 
blood in the trenches exposed to the bullets of the foe, 

and to the pestilence that walleth in darkness, to 
bring the matter really home to Englishmen. And 
} when it came, the reports from the front of almost 


