466 



NATURE 



[September 17, 1896 



altogether appeared hopeless while we believed with Liebig that its 

 primary cause was the atmospheric oxygen which, in accordance 

 with the researches of Graham, could not fail to be perpetually 

 diffused through the porous dressings which were used to absorb 

 the blood discharged from the wound. But when Pasteur had 

 shown that putrefaction was a fermentation caused by the growth 

 ■of microbes, and that these could not arise de novo in the 

 decomposable substance, the problem assumed a more hopeful 

 aspect. If the wound could be treated with some substance 

 which, without doing too serious mischief to the human tissues, 

 would kill the microbes already contained in it and prevent the 

 future access of others in the living state, putrefaction might be 

 prevented, however freely the air with its oxygen might enter. 

 I had heard of carbolic acid as having a remarkable deodorising 

 effect upon sewage, and having obtained from my colleague Dr. 

 Anderson, Professor of Chemistry in the University of Glasgow, 

 a sample which he had of this product, then little more than a 

 chemical curiosity in Scotland, I determined to try it in com- 

 pound fractures. Applying it undiluted to the wound, with an 

 arrangement for its occasional renewal, I had the joy of seeing 

 these formidable injuries follow the same safe and tranquil course 

 as simple fractures, in which the skin remains unbroken. 



At the same time we had the intense interest of observing in 

 ■open wounds what had previously been hidden from human 

 view, the manner in which subcutaneous injuries are repaired. 

 •Of special interest was the process by which portions of tissue 

 killed by the violence of the accident were disposed of, as con- 

 trasted with what had till then been invariably witnessed. 

 Dead parts had been always seen to be gradually separated from 

 the living by an inflammatory process and thrown off as sloughs. 

 But when protected by the antiseptic dressing from becoming 

 putrid and therefore irritating, a structure deprived of its life 

 caused no disturbance in its vicinity ; and, on the contrary, being 

 of a nutritious nature, it served as pabulum for the growing 

 ■elements of the neighbouring living structures, and these became 

 in due time entirely substituted for it. Even dead bone was seen 

 to be thus replaced by living osseous tissue. 



This suggested the idea of using threads of dead animal tissue 

 for tying blood-vessels ; and this was realised by means of cat- 

 gut, which is made from the intestine of the sheep. If deprived 

 of living microbes, and otherwise properly prepared, catgut 

 answers its purpose completely ; the knot holding securely, while 

 the ligature around the vessel becomes gradually absorbed and 

 replaced by a ring of living tissue. The threads, instead of 

 being left long as before, could now be cut short, and the 

 tedious process of separation of the ligature, with its attendant 

 serious danger of bleeding, was avoided. 



Undiluted carbolic acid is a powerful caustic ; and although it 

 might be employed in compound fracture, where some loss of 

 tissue was of little moment in comparison with the tremendous 

 •danger to be averted, it was altogether unsuitable for wounds 

 made by the surgeon. It soon appeared, however, that the 

 acid would answer the purpose aimed at, though used in diluted 

 forms devoid of caustic action, and therefore applicable to 

 operative surgery. According to our then existing knowledge, 

 two essential points had to be aimed at : to conduct the opera- 

 tion so that on its completion the wound should contain no 

 living microbes, and to apply a dressing capable of preventing 

 the access of other living organisms till the time should have 

 arrived for changing it. 



Carbolic acid lent itself well to both these objects. Our 

 experience with this agent brought out what was, I believe, a 

 new principle in pharmacology — namely, that the energy of 

 action of any substance upon the human tissues depends not 

 only upon the proportion in which it is contained in the material 

 used as a vehicle for its administration, but also upon the degree 

 of tenacity with which it is held by its solvent. Water dissolves 

 ■carbolic acid sparingly and holds it extremely lightly, leaving it 

 free to act energetically on other things for which it has greater 

 affinity, while various organic substances absorb it greedily and 

 hold it tenaciously. Hence its watery solution seemed admirably 

 suited for a detergent lotion to be used during the operation for 

 •destroying any microbes that might fall upon the wound, and 

 for purifying the surrounding skin and also the surgeon's hands 

 and instruments. For the last-named purpose it had the further 

 advantage that it did not act on steel. 



For an external dressing the watery solution was not adapted, 

 as it soon lost the acid it contained, and was irritating while it 

 lasted. For this purpose some organic substances were found 

 to answer well. Large proportions of the acid could be blended 



NO. 1403, VOL. 54] 



with them in so bland a form as to be unirritating ; and such 

 mixtures, while perpetually giving off enough of the volatile salt 

 to prevent organic development in the discharges that flowed 

 past them, served as a reliable store of the antiseptic for days 

 together. 



The appliances which I first used for carrying out the anti- 

 septic principle were both rude and needlessly complicated. The 

 years that have since passed have witnessed great improvements 

 in both respects, of the various materials which have been em- 

 ployed by myself and others, and their modes of application, I 

 need say nothing except to express my belief, as a matter of long 

 experience, that carbolic acid, by virtue of its powerful aflinity 

 for the epidern\is and oily matters associated with it, and also its 

 great penetrating power, is still the best agent at our disposal for 

 purifying the skin around the wound. But I must say a few 

 words regarding a most important simplification of our pro- 

 cedure. Pasteur, as we have seen, had shown that the air of 

 every inhabited room teems with microbes ; and for a long time 

 I employed various more or less elaborate precautions against the 

 living atmospheric dust, not doubting that, as all wounds ex- 

 cept the few which healed completely by the first intention 

 underwent putrefactive fermentation, the blood must be a 

 peculiarly favourable soil for the growth of putrefactive 

 microbes. But I afterwards learnt that such was by no means 

 the case. I had performed many experiments in confirmation 

 of Pasteur's germ theory, not indeed in order to satisfy myselt 

 of its truth, but in the hope of convincing others. I had ob- 

 served that uncontaminated milk, which would remain 

 unaltered for an indefinite time if protected from dust, 

 was made to teem with microbes of different kinds by a very 

 brief exposure to the atmosphere, and that the same effect was 

 produced by the addition of a drop of ordinary water. But 

 when I came to experiment with blood drawn with antiseptic 

 precautions into sterilised vessels, I saw to my surprise that it 

 might remain free from microbes in spite of similar access of air 

 or treatment with water. I even found that if very putrid blood 

 was largely diluted with sterilised water, so .as to diffuse its 

 microbes widely and wash them of their acrid products, a drop 

 of such dilution added to pure blood might leave it unchanged 

 for daj's at the temperature of the body, although a trace of the 

 septic liquid undiluted caused intense putrefaction within twenty- 

 four hours. Hence I was led to conclude that it was the grosser 

 forms of septic mischief, rather than microbes in the attenuated 

 condition in which they existed in the atmosphere, that we had 

 to dread in surgical practice. And at the London Medical 

 Congress in iSSi, I hinted, when describing the experiments I 

 have alluded to, that it might turn out possible to disregard 

 altogether the atmospheric dust. But greatly as I should have 

 rejoiced at such a simplification of our procedure, if justifiable, I 

 did not then venture to test it in practice. I knew that with 

 the safeguards which we then employed I could ensure the safety 

 of my patients, and I did not dare to imperil it by relaxing 

 them. There is one golden rule for all experiments upon our 

 fellow-men. Let the thing tried be that which, according to 

 our best judgment, is the most likely to promote the welfare of 

 the patient. In other words. Do as you would be done by. 



Nine years later, however, at the Berlin Congress in 1890, I 

 was able to bring forward svhat was, I believe, absolute demon- 

 stration of the harmlessness of the atmospheric dust in surgical 

 operations. This conclusion has been justified by subsequent 

 experience : the irritation of the wound by antiseptic irrigation 

 and washing may therefore now be avoided, and nature left 

 quite undisturbed to carry out her best methods of repair, while 

 the surgeon may conduct his operations as simply as in former 

 days, provided always that, deeply impressed with the tremen- 

 dous importance of his object, and inspiring the same conviction 

 in all his assistants, he vigilantly maintains from first to last, 

 with a care that, once learnt, becomes instinctive, but for the 

 want of which nothing else can compensate, the use of the 

 simple means which will suffice to exclude from the wound the 

 coarser forms of septic impurity. 



Even our earlier and ruder methods of carrying out the 

 antiseptic principle soon produced a wonderful change in my 

 surgical wards in the Glasgow Royal Infirmary, which, from 

 being some of the most unhealthy in the kingdom, became, as I 

 believe I may say without exaggeration, the healthiest in the 

 world : while other wards, separated from mine only by a passage 

 a few feet broad, where former modes of treatment were for awhile 

 continued, retained their former insalubrity. This result, I need 

 hardly remark, was not in any degree due to special skill on my 



