ftMl CIM. COLLEGE OF PHYSICIANS AND SURGEONS LIBRARY Gift of Dr. A, E. S. Lambert Digitized by the. Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/antisepticsurgerOOchey ANTISEPTIC SUEGEEY ANTISEPTIC SURGERY ITS PRINCIPLES, PRACTICE, HISTORY AND RESULTS W. WATSON CHEYNE, M.B., F.K.C.S. ASSISTAXT-SURGEON TO KING'S COLLEGE HOSPITAL DEMOXSTRATOU OF SURGICAL PATHOLOGY AT KING'S COLLEGE Mit^ Illustrations LONDON iSMlTH, EI.DEK, & CO., 15 WATEKLOO PLACE 1882 [All riijhts reserveil ] I PREFACE. The interest which Antiseptic Snrgery has awakened' throughout the profession has led to many j)ublic debates and to the accumulation of a great mass of literature on the subject. The time seems now to have come for a detailed account and discussion of the whole matter, and it is with the view of furnishing such an account that the present volume has been published. The question might have been dealt with in two ways ; either by the discussion of the present standpoint of the principles and practice of Antiseptic Surgery, with but little reference to former literature ; or, as I have attempted to do, by tracing in addition the development of its theory and practice, and following out and criticising the various steps by which the present state of knowledge on the subject has been reached. The former mode might no doubt have produced a shorter work, but it could not have been made complete in the present transitory state of our knowledge, and, taken alone, it would have necessarily raised side issues confusing to readers unacquainted with tlie earlier literature. I have therefore, in addition to tlie discussion (jf the present state of knowledge on the subject, tried to trace out its development, and 1 have done this the more readily because it seems to me that when an attempt is made, almost for the first time, to X riiEFACE. discuss fully a new department of science, the work of those who have chiefly helped by experiment or criticism to build it up should be acknowledged and properly estimated. Such a way of treating the subject will perhaps also supply a want to those who have not the time nor the opportunity of searching out the literature for themselves. Among other facts which have been brought forward here I may draw special attention to the folio wino;, which I think have been now made certain: — Fermentations in wounds occur as the result of the entrance of particles — micro-organisms — from without ; a variety of methods of treatment may be grouped under the heading ' Antiseptic treatment ' ; lives are saved in proportion to the asepticity of the wound, and, when the wound is kept aseptic, infective diseases more especially are avoided ; the aseptic or Listerian method prevents the development of micro-organisins and the occurrence of fermentation in wounds. Portions of this work have been previously published. Some investigations on micro-organisms in wounds and on temperature after operations formed part of my essay Avhich gained the Syme Surgical Fellowship of the University of Edinburgh in 1877. I have since that time repeated and extended these investigations. In the essay to which was awarded the Boylston Medical Prize and the Boylston Gold Medal ^ of the Harvard ' By an order adopted in 1826 the Secretary of the Boylston Prize Committee was directed to publish annually the following votes : — 1st. That the Board do not consider tliemselves as approving tlie doctrines contained in any of the dissertations to which pi-eniiiinis may be adj udgt'd. 2\\(\. That in case of publication of a successful dissertation, tlio autlior be considered bound to print tlie above vote in connection therewilli. TREFA CE. xi University, United States, in 1880, 1 discussed the various methods of Antiseptic Surgery and the best modes of apply mg them to practice. And, in 1881, the council of the College of Surgeons of England awarded me the Jacksonian prize for a discussion of the history, prin- ciples, practice, and results of Antiseptic Surgery. This work is the outcome and development of these essays. The drawings in this book (both the woodcuts and the plates) have been made by Mr. Edgar Thurston, to whom I am much indebted for the great pains which he has bestowed m their preparation. Mr. Groves also kindly took some photographs, from which certain of the woodcuts have been drawn. Dr. Heron has ren- dered me great assistance in revising the proof-sheets and in preparing the Index. In dedicating this work to Mr. Lister I have attempted to acknowledge my great indebtedness to him. W. WATSON CHEYNE. 0 Old Cavendish St., \V. October 1881. CONTENTS. CHAPTER I. THE PARTICULATE THEORY OF FERMENTATION. ON THE FERMENTATION OF BOILED SUBSTANCES. TAGR Definition of putrefaction and fermentation — Chemical fermentations — Living ferments — Various views on fermentation — Lavoisier — Fa- broni — Tlienard — \ppert — Gay-Lussac's experiments and conclusions — Caignard-Latour — Schwann, heated air inert — Schulze — Ure and Helmholtz, nascent oxj^gen inert — Liebig's views— Review of the subject — Schroeder and Dusch, filtered air inert — Schroeder, ozone inert — Schroeder's final views — Pasteur's researches — Lister — Roberts — Tyndall^My own results, carbolised air inert — Conclusions as to the cause of the fermentation of boiled substances .... 1 CHAPTER II. THE PARTICULATE THEORY OF FERMENTATION {continued). ON THE FERMENTATION OF UNBOILED SUBSTANCES. {jVAiiti yncc—Gaif-Liiasa' — Van tier Brocck— Pasteur — Boberts; blood — Van (Icr Broech — Pasteur — Bvrdoii- Sanderson — Lister — 3Iy own re- sults; unboiled urine — Van der Broeelt — Pasteur — Lister — My own results— Boberts — Cazeneure and Liron; milk — Hoppe-Seyler — Bo- hrrts — LAster — My own, experiments ; egg albumen — Van der Liroerk — Gayon — BobeHs — My own experiments; vegetable tissues — Boberts; animal tissues — Billroth — 'Hegel — Burdon-Sanderson — My own ex- periments— C'Mene and Ewart — Meissner — General review of the facts — Behaviour of fluids and tissues in the living body— Principles of aseptic surgery ;{() CHAPTER in. ASEPTU; SUR(;EKY — materials EMPLOYED, Problems to be solved in order to kcoi) a wound aseptic : Carbolic acid - Carbolic lotions - Pure earbolic aeid — Solution in methylated spirit — rarbol/e oil - Carbo/ie aeid and ylyrerine : Spray fjroducers: Catgut CONTENTS. — Carholisrd caffpit- Mr. Litsfcr'a earholtsi'd chromic catf/nt — Dr. J\fac- Ewcn's chromic catf/iit — Caft/iit troiir/h a)id j/ochct caxc: Carbolised silk: Protective: Carbolic gauze — Composition — Method of preparation — Yon lirun\'< gauze : Macintosh : Sponges : Boracic acid — Boracic lotion — Boradc lint — Boracic ointment : Salicylic acid —SalicijUc acid, cream. ■ — Salici/Uc ointment : Chloride of zinc : Iodoform : Carbolised cotton wool 52 CHAPTER IV. ASEPTIC SURGERY [confinned). Example of an aseptic operation : Purification of the skin — Fingers — Instruments: Spray — Precautions— Probable errors, and mode of re- medying them : Guard : Ligature of arteries : Drainage of wounds — India-rubber tubes — Catgut drains —Horse hair — Decalcified bone tubes (Neuber's and MacBwen's) : Sutures: Button stitches — Stitches of re- laxation— Stitches of coaptation — Aseptic strapping — Protective : DeeiJ dressing : Loose gauze : Gauze dressing : Elastic bandage. Changing THE DRESSINGS — Time — Method. Treatment of ulcers : Purifica-* tion of the sore : Boracic dressing : Boracic and salicylic ointment : Boracic poultice 67 CHAPTER V. ASEPTIC SURGERY (cOUtintieJ). Special dressings : Head dressfiiigs : Neck dres.tings : Bread dresKinfiK — Abscess of mamma — Excision of mamma alone — Excision, of mamma, and axillary glands : Axillary dressings : Dressings on the limhs : Dressings for psoas abscess : Lumbar abscess : Hip-joint abscess : Dressings in cases of hernia a7id operations on the scrotum: Excisions of joints. AsejDtic treatment of abscesses. Chief points to be con- sidered in opening abscesses — Method of opening abscesses — Drainage of absresscs— After-treatment of abscesses — Empyema — Perineal and anal abscesses. Treatment of wounds produced accidentally : Problem to be solved— Purification of wound — Further treatment of the n'ound. Special wounds : Compound fractures : Wounds innolring tendons, nerves, <^'c. : Wounds of joints : Compound fr act w'es of the skull: Pene- trating wounds of the thorax: Wounds of the abdomen. Putrid sinuses and wounds. Treatment cf burns. Treatment of gangrene. Treat- ment of na;vi and varicose veins ........ 0(5 CHAPTER VL ASEPTIC SURGERY — MODIFICATIONS. Country practice : How to dispense with the spray during the operation — and during the aft:;-: '^-eatment: How to render the ilreasings less fre- CONTEXTS. XV PAOK quent. Is the aseptic method applicable in war ? 3rr. Lister' s< snggestians : Esmarch's X}liui : Jiei/Jier's method. Development of Aseptic Surgery in Mr. Lister's hands : Compound fractures— Pvre carbolic acid — Formation of crust — Carbolic putty — Lead 2)laster — Imc plaster, syringing wounds with carbolic lotion, protect'n^e, catgut ligatm-es, method in 1870 — Present method in the main introduced in 1871 — Further introduction of wet gauze, steam spray, elastic bandages: abscesses — Method of opening them under carbolic oil : wounds . .120 CHAPTER Vll. ASEPTIC SURGERY {concluded). other methods of carrying out Aseptic Surgery. Substitutes for carbolic acid: Salicylic acid : Thymol: Acetate of Alumina : Eucaltjptus oil. Aseptic surgery by filtration of the air. Subcutaneous surgery . . i.SO CHAPTER Vni. THEORIES OF SPONTANEOUS GENERATION, HETEROGENESIS AND ABIOGENESIS. Principles on which other methods of Antiseptic Surgery act. Organisms are always present in fermenting liquids : their significance. Theory of the origin of organisms independently of a parent. Theories of Needham and Buffon : Needham's proofs. Spallanzani"s experiments : Needham's objections : Spallanzani's replies. Schulze's experiments. Schwann — Schroeder and Duscli — Schroeder. Doctrine of Hetero- genesis. Poiichet's work : his method of test ing the matter : proofs that the source of the organisms in infusions is neither the air, water, nor the putrescible substances : modes of repeating Schulze's and Schwann's experiments : examination of dust. Criticism of his re- sults. Pasteur's experiments : results with ordinary fluids : introduc- tion of dust into sterilised fluids : results with milk and alkaline fluids : the cause in the air which gives rise to the growth of organ- isms is particulate : Pasteur's cultivating fluid : estimate of Pasteur's work. Pouchet's reply : New experiments— Criticism of tliese . . 14") CHAPTER IX. SPONTANEOUS GENERATION {continued). The experiments of Jeffries Wyman : explanation of the results : VVyman's views on the subject. Dr. Uastian's views: Cases in which it is still possible that abiogcnesis may occur : Growth in vacuo— Bastian's ex- periments—my own results — Cohn's facts — Dj- Roberts's ohjection.s, the walls of the ve.s.sels remain impure — Basfian's reply — Objections to the latter — Graitlmiscn's experiments — Pau i.i-rt's results wiili CONTENTS. compressed air — Pouchct looks on a vacuum as preventing spontaneous generation — Paul Bert's results with rarefied air — Ur. Bastian does not always get positive results : Experiments in airless and hermetically sealed flasks raised to a high temperature — Objections— Prof. Huxley's and Dr. Sanderson's statements — Ray Lankester's results — Hartley: expei'imen-ts with alkaline fluids — Roberts's counter-experiment. Mr. Lister's experiments. Experiments by Roberts and Tyndall . .172 CHAPTER X. SPONTANEOUS GENERATION (conchtded). Facts with regard to unboiled fluids and tissues : Mr. Lister's facts with regard to milk : my own experiments with animal tissues. Present state of the question — Dr. Bastian's latest standpoint : Lie- big's doctrine. Can organic molecules derived otherwise than from pre-existing bacteria give rise to bacteria ? Firstly, there is nothing unreasonable in looking on these particles as bacteria or their germs: seeds carried by air : excessive minuteness of the germs of bacteria : Mr. Lister's experience with micrococci. Secondly, there is no direct evidence that organic molecules not derived from bacteria can give rise to bacteria : facts with regard to unboiled fluids and tissues — conclusions from these facts : Paul Bert's experimenTs : Cazeneuve and Livon: Pasteur: Dr. Bastian. Thirdly, there is no evidence that active organic molecules (chemical ferments, &c.) can resist heat more than living things can : effects of heaJt on ptyalin, pepsin, •&c. : my own case of difficulty in sterilising mil'k : Wyman's fact as to an alga living at 208 F I94 CHAPTER XT, RELATION OF MICRO-ORGANISMS TO FERMENTATION. ■Summary of what has preceded with reference to fermentation. Relation between ' vital ' and ' chemical ' fermentations : theories of fermen- tation. Liebig's views. Alcoholic fermentation : Paxte^ir'' » experiments tnid eonchishms. Rfsnmc. Butyric fermentation. Formation of pig- iiTicnt by bacteria. Schroeter : Cohn. Viscous fermentation. Lactic fermentation : Panteur : Lister. Other fermentations, especiaJly tJbe putrefactive: Levi aire ; Cazeneuve and Liron:: Paul Bert. C'onclu- ■sions ............. 20;'i (mAPTER Xn. RELATION -OF MI€RO-ORGANISMS TO THE FLUIDS AND TISSUES OF THE LIVING BODY. Propo.sed mode of cnquir;- — Does the aseptic met liod prevent putref^ac- tion? Does it exclude organisms from wound.s? Kanke's results: CONTENTS. Klebs' objection: Ranke's reply: Demarquay : Fischer: Schiiller : my own method — Results in aseptic wounds — Results in wounds treated otherwise — Koch's method of staining pus — Results in cases not treated aseptically — Examples of complete exclusion of organ- isms in aseptic cases — Examples of the entrance of micrococci in aseptic cases — Detiuition of micrococci — Distinctions between micro- cocci and bacteria. Are organisms present in the healthy living body ? — ' Bistournage.' Are organisms present in the body in states of disease ?— Experiments with ammonia, phosphorus, &c. — The healthy blood and tissues can destroy organisms — Relation of organ- isms to abscesses. How do micrococci enter aseptic wounds 1 Car- bolic lotion a salficient germicide ; Spray, its value — Stimson's experiments ; Gauze dressing as a protection against entrance of organisms ; Carbolic acid as a germicide in albuminous fluids ; Rela- tions of micrococci aud bacteria to fluids containing carbolic acid. Conclusions . . ......... 225 CHAPTER XIII. ANTISEPTIC SURGERY. Complete definition of antiseptic surgery. Varieties of antiseptic sur- gery. Treatment by Antiseptics : Carbolic acid — objections to it : Chloride of zinc : Boracic acid : Sulphurous acid : Chlorinated Soda : Alcohol — Hutchinson's method : Terebene and Sanitas — Bilguer's method — Neudorfer's salicylic powder. Free drainage as an an- tiseptic 3IETHOD. Irrigation and immersion. Open method: Modes in which it acts antiseptically : Bartscher and Vezin's method : Burow's method: Rose's modification. Healing by scabbing: Methods of forming a crust : Bouisson's ventilation method : other modes. Cuerin's cotton-wool dressing. Modes in which THE destructive ACTION OF THE TISSUES ON BACTERIA IS AS- SISTED. Wliy does not fermentation always occur in the blood in wounds in wliich organisms are present ? Best practical methods. Conclusions 265 CHAPTER XIV. HISTORY OF ANTISEPTIC SURGERY. Practice of the ancient writers. Attempts of the ancients to secure im- mediate union of wounds. Pare and Paracelsus : Delacroix : Arcjeus : Progress of wound treatment in the sixtcentli century. Seventeenth century: Magatus: Wiseman: Colbatch : Progress in the seventeenth century. Eighteenth century and the early jiart of the nineteenth : Boerhaave : Col dc Villars : Heister : Bilguer : Benjamin Bell : Abcr- nethy : John Hunter's objections to the views of Bell and Abernethy : John Bell : opinion and practice of other surgeons : Conclusions : Von Kern . . 290 CONTENTS. CHAPTER XV. HISTORY OF ANTISEPTC SURGERY (continued). I'AOB History of the various methods. Incubation : Gu3'^ot. Subcutaneous surgery, preliminary attempts : Stroraeyer : DielTcnbach : Jules Guerin : Langenbeck : Other authors. Occlusion : Jules Guerin : Chassaignac — Eochard's remarks: Pansement ouate — Alphonse Guerin, method and results — Oilier. Substitution of various gases for air: Demarquay and Leconte. Open Method: I'Sartscher and Vezin: Burow: Humphre}-. Healing by scabbing: John Hunter: Xeudorfer : Bennion : Lister : Bouisson : Bonnet, kc. Irrigation and the water-bath : early history : Josse : Berard : Mayor: Amussat : Langenbeck: Valette 317 CHAPTER XVI. HISTORY OF ANTISEPTIC SURGERY (conckuhd). Use of antiseptics: Alcohol — older WTiters — Nelaton — Hutchinson: Glyce- rine—Demarquay : Chlorine: Chloride of zinc: Iodine: Iodoform: Chlorate of Potash : Perchloride of iron, &c. : Coal tar — Corne and De- raeaux — Report of the commission : Coal tar saponine — Lemaire — his views on putrefaction : Carbolic acid — Lemaire — Lemaire"s position n regard to Aseptic Surgery — Lister : Further phases in the historjr of this subject : Objections to Mr. Lister's claim as originator of the Aseptic method — Simpson — Neudorfer. Modifications of the method. Su.bstitutes for carbolic acid. Objections to the Aseptic method . . 347 CHAPTER XVII. RESULTS OF ANTISEPTIC SURGERY. Chief points for consideration. How far do the various methods prevent fermentations in wounds ? How to ascertain the true value of any individual method. The value of the various methods in guarding against infective disease: meaning of the term 'infective disease' Relations of Aseptic Surgery to infective disease. 3/r. Lufrr's remdtn iv fllaariow. The recent Glasgow .tfatiaficK. Mr. Lixter's resvlts in Edinlmrf/h ; re.snlts in sejftic and asej)tio ca^es — 3/r. Sjfcnce's jwactice — Mr. Slime's results — Mr. Lister\'< results at Kinff's Cnlle/je Hospital : — Volkmann — Nmshauni — Socin — Saxtorph — Esmareh. — lluetcr — Czeriiy — Lucas- Cliamqnonnix-re — Gross — LHievant — Panas — Schede— Reyher — Spencer Wells — Keitli^Thornton. TliicrscVs results with salicylic acid. Thymol. The relations of other forms of Antiseptic Surgery to these diseases — Treatment hy Antiseptics — Beyher — lAstcr — Nvlaton — JTutchinson. Occlusion — Jules Gverin — Alphonse Guerin. Treatment hy irrigation and mater hath — Langcnheck — Valette. Open CONT'ENTS. xix PAGE Method — Barischer and Vezin — Bvrmv — Kr'onlein. Results where no antiseptic measures were adopted — Billroth — Malyaigne — Paul — Holmes — Erich&en. Eesults of cleanliness — Mo Vail — Bardenheuer . 365 CHAPTER XVIII. RESULTS OF ANTISEPTIC SURGERY {continued). General considerations. Wounds of, and operations on, healthj* joints. Method of treatment adopted in these cases. Definition of the term 'Aseptic course': Example. Wounds of healthy joints. Operations on healthy joints. Objections to the value of these cases : reply. In- cisions into joints affected with synovitis. Incisions into joints af- fected with pulpy degeneration of the synovial membrane — a without suppuration, b with suppuration. A''oliimann's results : Max Schede : Paul Barth : Saxtorph : Piechaud : Nussbaum : Albert : Hueter : Letievant : Kraske : Eeyher: Bergmann. Comparison of Pieyher's results with those obtained during the Crimean war, and with Heint- zel's. Treatment bj' irrigation. Necessity for observing the minutest precautions as shown by Mr. Lister's case. Piesults of removing foreign bodies from joints without aseptic precautions : Larrej^ : Speuce : Paget 417 CHAPTER XIX. RESULTS OF ANTISEPTIC SURGERY {continued). Compound fractures. Differences between those produced accidentallj^ and those caused by the surgeon : treatment and after-progress of each class. Tables of accidental compound fractui-es treated by Mr. Lister: thigh; leg; liutner us ; forearm ; skull; summary of results. Tables of compound fractures produced intentionally bj' Mr. Lister ; femur ; leg ; clavicle ; humerus ; forearm ; lower jaw. General summary of Mr. Lister's results. Mr ^pence's results. Other operations on bones by Mr. Lister. MacEwen's osteotomies : Volkmann : Max Schede : Bardenheuer : MacCormac. Combined aseptic results: Results br- other methods . Volkmann and Fraenckel : Holmes : St. Thomas's IIosjDital. Rej'her's results in war. Open method: Kronlein. Septic methods 461 CHAPTER XX. RESULTS OF ANTISEPTIC SURGERY {continued). Abscesses connected with di-sease of the vortebne. Best situation for opening psoas abscesses : best time for opening them : after-treatment and after- progress. Table of Mr. Lister'.s results : general summary and remarks on these cases. Comparative statistics are wanting. Sir James Paget 's views . . . 'Al XX CONTENTS. CHAPTER XXI. RESULTS OF ANTISEPTIC SURGERY (concluded). PAGE General consideration of the results. Results of the various methods in saving life. Results in avoiding infective disease. Cleanliness : defi- nition of the term : Mr. Savorj-'s definition and method : cleanliness has not abolished infective disease even in healthy hospitals : cleanli- ness is a complex method : infective disease may appear even in the best hygienic conditions. The source of infective disease. Conclu- sions as to the value of the various methods in preventing infective disease. Deaths from prolonged suppuration after chronic abscesses, compound fractures, &c. Operations on weak or diseased individuals are rendered possible by the aseptic method. Operations otherwise iinjustifiable,but nevertheless necessary for the recovery of the patient, may be safely done by the aseptic method. The patient may be made a more useful member of society: joint cases : tenotomy, &c. : com- pound fracture : dangers of operations of convenience. Local results of wounds treated aseptically : absence of pain, inflammation, &c. : experiments of Yeo and Ferrier : organisation of blood-clot, catgut, sloughs, &c. Histological details of the process : Tillmann's experi- ments. Temperature in aseptic cases : contrast with septic cases. Local and constitutional course of cases not treated aseptically. Objec- tions to aseptic surgery: carbolic acid poisoning: the surgeon is said to neglect the constitutional state of the patient: expense: trouble : necessity for the spray. Conclusion : great principle of wound treat- ment is Rest . 540 Index 603 LIST OF ILLUSTRATIONS. 1. .Schwann's method of admitting heated air to putrescible fluids . . 7 2. Schroeder and Dusch's apparatus for supplying filtered air . .13 3. Pasteur's flask with the bent neck 16 4. Door of Mr. Lister's hot box 18 5. Mr. Lister's hot box 18 6. Mr. Lister's large double-necked flasks 19 7. Method of filling these flasks 20 8. Mr. Lister's arrangement to protect fluids in liqueur glasses from dust 21 9. Mode of filling Mr. Lister's liqueur glasses ...... 21 10. Dr. Roberts's bulbs (copied from Roberts) , 23 11. Prof. Tyndall's pure chamber (copied from Tyndall) . . . .24 12. Dr. Roberts's experiments with grape juice (from Roberts) . . 33 13. Pa.steur's method of obtaining fresh blood (from Pasteur) . . .34 14. Beaker containing unboiled meat and a putrescible fluid . . .46 15. Hand spray producer 54 16. The ordinary steam spray producer . 54 17. Steam spray producer, showing the lamp at present in i;se . . . 55 18. Large steam spray producer with double nozzle for ovariotomy, kc. . 56 19. Trough for catgut 59 20. Lister's pocket catgut holder 59 21. Machine used in the Glasgow Royal Infirmary for manufacturing gauze 63 22. Porcelain trough containing instruments .soaking in carbolic lotion , 70 23. General arrangement of surgeon, assistants, towels, spray, &c., in an operation performed with complete aseptic precautions . . .71 24. To .show the arrangement of towels, &c., in a large operation . . 72 2'>aMcth()(\ of tving vessels in dense tissues ...... 75 xxii LIST OF ILLUSTRATIONS. 25/'.Anotlier method of tying vessels in dense tissues (from Esmarch) . 76 26. Ordinary oblique-ended drainage-tube ready for use . . . .77 27. Drainage-tube with masses of gauze in the loops of tliread . . 77 28. Incision for inguinal hernia, stitched, showing tlie position of the drainage-tube at the outer angle of the wound . . . .78 20. Sinus forceps ^9 .30. Catgut drain ready for insertion 80 31. Operation for stretching the sciatic nerve 82 32. The same wound stitched 83 33. Method of preparing a horse-hair drain for re-introduction . . 84 3-1. Lead buttons for deep stitches 85 35. Wound after removal of mamma and axilliary glands, stitched . 86 36. Excision of the hip-joint 88 37. Dressing in a case of psoas abscess opened above Poupart's ligament 90 38. Method of changing a psoas abscess dressing 92 30. General arrangement of dressings on the neck . .... 97 40. To show the arrangement of the turns of bandage on the head, seen from above 98 41 . Dres.sing applied in a case of abscess of tlie mamma (breast dressing No. 1) 98 42. Breast dressing No. 2 98 43. Dressing after excision of the mamma 99 44. Dressings applied after excision of mamma and axillary glands, to show the arrangement of the dressings and bandages . . . 100 45. Binder applied outside the dressing represented in tig. 44, so as to keep the parts and dressing at rest ...... 101 46. Dressing in cases of operation on tlie axilla alone .... 102 47. Dressing in a case of psoas abscess opened above Poupart's ligament, seen from the front 103 48. Psoas abscess dressing (fig. 47), seen from behind .... 104 49. Dressing in a case of lumbar abscess, seen from behind . . . 101 50. Dressing in a case of hip-joint abscess, with elastic api^lied . . 105 51. Deeper part of the hernia and scrotal dressings 106 52. Dressing in a case of operation for hernia, or on the scrotum on the left side, showing the arrangement of the dressing and elastic bandage 106 53. Dressing in hernia cases or in operations on the scrotum, showing the arrangement of the bandages in the perineum. (Seen from below) 107 54. Si^lint for excision of knee, read}' for application .... 108 LIST OF ILLUSTRATIONS. xxiii nr,. PAGE 5. Splint applied in a case of excision of the knee ..... 108 56. Two forms of sharp spoon.s, a large round one and a .small oval one . 117 57. Esmarch'.s first dressing for the wounded in battle (from MacCormac) 121: 58. Schulze's method of demonstrating that organisms are derived from the air and do not originate spontaneou.sly in liquids . . . 150 59. Pouchet's mode of repeating Schulze's experiment (from Pouchet) . 156 60. Another mode adopted by Pouchet for testing Schulze's views (from Pouchet) 156 61. A simple mode of repeating Schulze's experiments (from Pouchet) . 161 62. Pasteur's mode of introducing dust into flask containing calcined air 165 63. Another mode of repeating Schulze's experiment (from Pouchet) . 169 64. Bacillus subtilis ; without spores; with spores in the rods; free spores; x 600 (after Cohn) ........ 180 65. Deposit in rennet, consisting of a mass of micrococci and spores of bacilli, X 600 (after Cohn) 180 66. Dr. Roberts's experiment with alkaline fluids ..... 192 67. Torula cerevisiaj (after Pasteur) 210 68. Pasteur's experiment on unboiled grape juice ..... 210 69. Bacillus subtilis, x 650 (after Cohn) 212 70. Pigment producing organisms ........ 213 71. Bacterium lactis in pairs and chains . . . . . . .216 72. Flask containing cultivating fluid inoculated from a wound . . 231 73. Thiersch's ichampagne bottle irrigator . 273 7-1. Arrangement for irrigation in the upper limb (after Esmarch) . . 274 75. Arrangement for irrigation in the lower limb (after Esmarch) . . 275 76. Apparatus for continuous immersion (after Esmarch) . . . 275 77. Temperature chart from a case of operation for fracture of the patella. (No. 21, p. 434) 421 Temperature charts of Mr. Lister's cases of wounds and operations on joints (i.-xvii.) 438, 439 78. Temperature chart from a case of compound fracture in which the attempt to eradicate the causes of fermentation was unsuccessful, and which therefore became a septic case. (No. 26, p. 472) . . 463 79. Temperature chart from a case of compound fracture which followed anasopticcour.se. (Case 23, p. 472) 4f,4 Temperature charts of Mr. Lister's cases of compound fracture (xviil.-xxx.) 482, 483 Temperature charts of IMr. Lister's cases of compound fracture (xxxi.-L.) 500, ,501 Temperature charts of cases of psoas and lumbar abscess (li.- LXVli.) 534,535 xxiv LIST OF ILLUSTRATIONS. FIG. I'AGE 80. Temperature cliart. from a case of MacEvven's operation for double genu vulgum ........... 576 81. Temperature chart from a case of compound fracture, in which there was great difficulty in retaining the fragments in position. (Case 27, p. 472) 82. Temperature chart from a case where the ankle-joint was incised in a hajmophilious patient, and where hfemorrhage recurred several times. (Case 16, p. 430) 581 83. Temperature chart from the case of removal of loose cartilage from the knee-joint, in which fermentation occurred. (Case 22, p. 434) 582 84. Temperature chart from a case of operation for recent fracture of the patella. (Case 15, p. 430) 582 Temperature charts of septic cases 584 Temperature charts of aseptic cases 585 ANTISEPTIC SUEGEEY. CHAPTER I. THE PARTICULATE THEORY OF FERMENTATION. ON THE FERMENTATION OF BOILED SUBSTANCES. Definition of putrefaction and fermentation — Chemical fermentations — Living ferments — Various views on fermentation — Lavoisier — Fabroni — Thenard — Appert — Gay-Lussac's experiments and conclusions — Caignard-Latour — Schwann, heated air inert — Schulze — Ure and Helmholtz, nascent oxygen inert — Liebig's views — Review of the subject — Schroeder and Dusch, filtered air inert — Schroeder, ozone inert — Schroeder's final views — Pas- teur's reseai'ches — Lister — Roberts — Tyndall — My own results, carbolised air inert — Conclusions as to the cause of the fermentation of boiled sub- stances. The term ' septic ' so much used in surgery at the present day is derived from the Greek word (X7]ittlkos, which means some- thing that causes putrefaction, the verb (ji!]itw signifying to cause to rot, to make putrid. An 'antiseptic' is therefore, according to this derivation, something w^hich acts against the causes of putrefaction, and ' Antiseptic Surgery ' is surgery directed not against its effects but against its caitses. In deal- ing, then, with the subject of antiseptic surgery, we must first enquire what is putrefoction, and how is it brought about ? Putrefaction is now held to be a form of fermentation ac- companied by the development of offensive odours, and fermen- tation may be defined as ' a new arrangement of the elements of an organic compound (often with the assimilation of the ele- ments of water), and the consequent formation of new products.' (Fownes.) Changes coming under the nbove definition of fermentation B 2 THE PARTICULATE THEORY OF FERMENTATION. have been long known as the result of what is termed Catalysis. Of this perhaps the best example is the change effected in Amygdalin by the action on it of Emulsin. As a result of the contact of these two bodies in presence of water, the amygdalin is broken up into various products, of which the chief are hydrocyanic acid and oil of bitter almonds. This decomposition of amygdalin is, however, not effected by combination with emulsin, for the latter remains unchanged, although its presence is necessary for the chemical action. Similar fiicts are known with regard to the Pepsin of the gastric juice, the Ptyalin of saliva, the pancreatic ferment, &c. But although these ferments undergo little or no change, yet nevertheless it has been clearly proved that they have not the jwwer of self-multiplication. Hence these ferments generally receive the name of ' chemical ' ferments. There is, however, another class of ferments which possess this power of self-multiplication in a remarkable degree. An instance of this may be given in the alcoholic fermentation. Here a minute piece of yeast is introduced into grape juice, or into a sugary solution, and as a result fermentation soon sets in, and goes on slowly till the sugar is decomposed. If we compare this process with the former we see two marked points of difference ; in the first place, in the former the change is rapid and more or less instantaneous; in the latter it progresses slowly and steadily, and requires much more time for its com- pletion. In the former there is no increase in quantity of the ferment ; in the latter the increase is very marked, and when the fermentation has gone on for some time the minutest portion of the fermenting substance added to unfermented material of like composition produces in it a similar series of changes ; and this multiplication of the ferment goes on continuously whenever it is brought in contact with fresh material. As this power of multiplication is a property of living things, the term ' vital ' is usually applied to this class of ferments. In one point the ' chemical ' ferment is allied to the ' vital ' ferment. It is not a substance as yet formed by the "chemist. It is the product of living cells ; and it is quite possible that the yeast plant may act in the same way as the salivary or THE FERMENTATION OF BOILED SUBSTANCES. 3 peptic cells, viz. by excreting a ferment which produces the change in the fermentescible substance, this ferment in neither case possessing the power of self-multiplication. In the case of the salivary ferment the cells which produce it are an integral part of a complex organism, and cannot live apart from the body ; hence the ptyalin, introduced into starch, does not increase in amount. On the other hand, the yeast plant is an independent cell, and grows free in the fermenting fluid, and it is to the growth and multiplication of these living cells, and not to an increase in quantity of the chemical ferment as such, that the multiplication of the fermenting power is due. In the putrefaction of discharges in wounds we have to deal with a ferment belonging to the same class as the alcoholic fer- ments— with a ferment capable of multiplication, which acts slowly and steadily, not suddenly. We must therefore enquire a little more fully into the nature of this class of ferments, into theii- origin and history, in order to obtain some principles to guide us in attempting to prevent their action. In reviewing the history of this subject, the first research of any consequence which it is necessary for us to consider is that of Gay-Lussac* Previous to the publication of this paper at- tempts had been made by Lavoisier, Fabroni, and Thenard to give some explanation of the process of fermentation. Lavoisier's work was in the main carried out with the view of ascertaining the changes which a fermenting liquid under- goes.^ He did not attempt to assign a definite cause for the process. Fabroni,^ writing on the subject of the alcoholic fermentation, concluded that fermentation was a decomposition of one sub- stance by another, 'just as a carbonate is decomposed by an acid, or sugar by nitric acid. The substance which decomposes sugar is a vegeto-animal substance. It is contained in certain utricles in the grape. When the grape is crushed this material, which is of the nature of gluten, mixes with the sugar in the juice, and as soon as these two substances come into contact, effervescence or fermentation commences just as occurs in every • Annates de Cliinrie, Ixxvi. 1810. ^ J'JUtiindit de CMmic, i. 2nd ed. ^ Annalrs de Chimtr, xxxi. 1799. 4 THE PARTICULATE THEORY OF FERMENTATION. other chemical process, as, for instance, when an acid and a carbonate are mixed in the same vessel.' Some years later, but ignorant of Fabroni's views, Thenard published a research on alcoholic fermentation,' in which he showed that gluten had no power whatever of causing the fermentation of sugar. He observed that during the pro- cess of fermentation, a deposit occurred which had the power of inducing a similar change in a fresh saccharine liquid. This substance was apparently the same in a great variety of liquids of different chemical composition, and it presented characters similar to those of yeast. Thenard states that he was unable to determine whether this substance was formed in the course of the fermentation, or whether it was in solution at the com- mencement and became deposited as a result of the changes which occurred. He, however, inclines towards the latter view. Gay-Lussac was led to make his investigations by studying the procedure of M. Appert for preserving vegetable and animal substances.^ Appert's method consisted in placing the materials to be preserved in bottles, very closely corked. These bottles were exposed to the temperature of boiling water for a longer or shorter period of time. They were then packed up and kept for use. There can be no doubt as to the efficiency of this method, for in Appert's work certificates are furnished by several scientific commissions, containing such names as Gay- Lussac, Bordel, &c. Gay-Lussac noticed that, though the sul^stances so prepared could be preserved unaltered for an indefinite period so long as the vessels were kept thoroughly closed, yet, as soon as the vessels were opened, and more especially if the substances were decanted into other vessels, their contents underwent fermentative changes. To ascertain why this occurred, he took a flask of grape-juice which had been preserved for a year unaltered, and which was ac- cordingly quite limpid. Having opened the flask he poured its contents into another vessel, which he closed very accurately and kept at the temperature of 15° to 30° C. Eight days later ' Atuudcs de ChhnU; xlvi. ISOiJ. ^ The Art of Preserving Animal and Vegctuhlc Suhstanees. GAY-LVSSACS EXPERIMENTS. 5 the juice had lost its transparency, fermentation had become established, and it soon became an alcoholic fluid. A second vessel containing gi'ape-juice, prepared by Appert's method, was kept at the same temperatm-e and in the same place, but unopened. This remained pure. This latter flask, the neck of which had been drawn out and sealed, was now taken, and a deep notch having been made with a file, its neck was plunged into mercury and then broken off. A portion of the contents was then introduced into a bell-jar containing no oxygen, and a second portion into one containing a small quan- tity of that gas. The first remained without change for forty days, while the second underwent fermentation very rapidly. In the latter flask all the oxygen had disappeared, but much more carbonic acid in proportion had been produced. Gay- Lussac therefore concluded that, although oxygen is necessary to initiate the fermentation, yet it is not essential for its con- tinuance. The same results were obtained when currant-juice or freshly prepared gi'ape-juice were used. Gay-Lussac further found that, if this juice after being transferred from one vessel to another were again heated after secure corking, it could again be preserved for an indefinite time. He observed that during the boiling the fluid lost its transparency and a deposit took place. He came to similar conclusions as to the necessity of oxygen for the initiation of fermentative processes, in the case of the putrefaction of meats, &c., preserved according to Appert's method, Gay-Lussac concludes from his experiments that oxygen is necessary for the commencement of the fermentation ; that this oxygen combines with some substance in the fermentescible fluid, thus producing the ferment, which can then act without further oxygen ; that the effect of the heat in Appert's method is to decompose any combination already formed, and to make the oxygen which is present unite to form some substance which is not a ferment ; that the product of this union with oxygen is the deposit which is seen to occur on heating these fluids. 1 [e however recognises that fermentation is still a mysterious process, since it occurs slowly and not immediately like other chemical actions. Passing now over a period of some years, we come to the G THE PARTICULATE THEORY OF FERMENTATION. views of Caiguard-Latour, made known in papers presented to the French Academy dming the years 1835-37.' On examin- ing fermenting grape-juice, he found (as indeed had been im- perfectly observed before by Leuwenhoeck and Desmazieres) that it contained numerous globular bodies which he considered to be of vegetable nature, and which he found to possess the power of reproduction, partly by budding and partly, as he sup- posed, by contracting and liberating numerous spores. From several facts — amongst others, from finding that in juices not undergoing alcoholic fermentation these bodies were absent, while they were always present where that fermentation oc- curred— he concluded that they were the cause of the fermenta- tion. He fm-ther found that the de})Osit of which Thenard spoke, and which he had stated to be the ferment, was composed entirely of these bodies. Similar views were announced almost simultaheously by Schwann,'-* and to him rather than to Caignard-Latour must be given the credit of having furnished the first real proof of the view that these cells were the causes of the fermentation. Schwann prepared infusions of meat, fruits, &c., somewhat after Appert's method, but, instead of leaving the vessels com- pletely sealed, he allowed air which had been previously heated to come in contact with the fluids. The following is his de- scription of the method which he ultimately adopted. ' Into a three-ounce vessel a small piece of meat was introduced, and then water was added so that the whole occupied about one- fourth of the capacity of the vessel ; the bottle was then closely corked, the cork being firmly fastened down by wire. This cork was traversed by two small glass tubes, one of which was at once bent downwards on its exit from the vessel, and its orifice dipped into a small beaker containing mercury covei-ed by a layer of oil. The other tube ran at first horizontally and then directly downwards for an inch and a half. There it had two narrow spiral turnings, then it again ran upwards, and finally horizontally, being di'awn out to a fine point at its termi- nation. The cork was covered with several layers of a solution of caoutchouc in linseed oil, rendered thinner by the addition of oil of turpentine. The fluid in the flask was now boiled, and the steam was made to issue from the two tubes till the mercury and oil became so ■ See Annales de CMmie ct de Ph unique, t. Ixviii. 2" seric, 1838. * Pofjgendorf's Annalen, xli. 1837. SCHWANN'S EXPERIMENTS. hot that they no longer condensed the steam. (In order that no organisms might develop in the water which remained between the oil and the mercury, a layer of corrosive sublimate was placed between them.) While the boiling was going on a spirit lamp was placed under the spirals of the second tube, and the heat was continued until the tube began to soften (see Fig. 1). Thedropaof water condensing in the cooler parts of the tubes were dispelled by another lamp. After boiling bad continued for a quarter of an hour it was stopped, and, during the cooling of the flask, air passed through the second glass tube into the vessel, being however j^reviously heated in the spiral part of that tube. After complete cooling of the flask the orifice of this tube was sealed and the portion of the tube between the spiral and the end, containing unheated air, was heated. That being done the spirit lamp was completely removed.' Fig. 1. — Schwann's mkthod. Prepared in this way, the flask contained only boiled meat infusion and heated air. From time to time this air was renewed in the following manner : the spiral part of the tube having been heated almost to melting, the point was broken and fresh air forced slowly in, the old air bubbling out through the mercury. After a time the tube was again sealed with the same precautions as before. By operating thus Schwann succeeded in preserving meat and other substances at a temperature of 63° to 77° F. without any putrefaction, and without the appearance of organisms in them ; while the same materials when exposed to ordinary air underwent putrefactive changes in a few days. 8 THE PARTICULATE THEORY OF FERMENTATION. It was thus evident that there was a something present in the air, other than the gases of the air which had the power of bringing about fermentative changes in boiled liquids, and that this something could be destroyed by heat. Some -further experiments which Schwann performed with reference to the alcoholic fermentation furnish additional evidence against the view that the gases of the air are the causes of putrefaction. A solution of cane sugar having been mixed with yeast, four flasks were quite filled with the mixture and then corked. These flasks were placed in boihng water for an equal length of time (ten minutes each). They were then inverted over heated mercury, and air was introduced so as to displace one-third to one-fourth of the fluid. The flasks were afterwards corked under mercury and kept at a tempera- ture of 63° to 77° F. In two flasks the air thus introduced bad been previously heated, in the other two it had not been so treated. In four to six weeks the flasks which had received the unheated air burst, their contents having undergone alcoholic fermentation. The other two flasks remained unchanged for more than three months. Schwann states that this latter experiment with heated air is generally, but not always, successful, and he explains this by the supposition that after the heating of the mercury, and in the processes of uncorking and corking, organic matter, which had not been previously heated, might very possibly mix with the mercury and enter the flasks. (This view has since been proved to be correct by Pasteur.) It is but fair to refer here to the experiments on spontaneous generation published in 1836 by Franz Schulze. These will be described at a later period. They are, however, of interest here, because Schulze anticipated Schwann in the principle of admitting air previously acted on "in some way or other, in his case chemically, to Appert's preserves. Schwann's experiments were repeated and confirmed by Ure in 1840 1 and by Helmholtz in 1843.^ The latter author, in order to test the oxygen view still further, prepared an infusion in the usual manner in a vessel into which platinum electrodes were fixed. After the infusion had remained unaltered for some ' Journal fiir pralttischc Chemic, xix. ^ Mailer's Archir. 1843. LIEBICrS VIEWS. 9 time a current of electricity was sent through the liquid, decomposing the water into hydrogen and oxygen. But even this oxygen in its nascent, and therefore in its most active state, was unable to produce any fermentation in the fluid. In the meantime Liebig had stepped forward as the oppo- nent of the views advanced by Caignard-Latour and by Schwann. He proposed a theory of a totally different nature.^ After pointing out that organic molecules have a tendency to alter their constitution, to break up and rearrange themselves, he approacVies the question of putrefaction and fermentation. With regard to the cause of these changes he writes as follows : ' Cette cause est la faculte que possede un corps en decomposi- tion ou en combinaison, c'est-a-dire, en action chimique, d'eveiller la meme action dans un autre corps qui se trouve en contact avec lui, ou de le rendre apte a subir I'alteration qu'il eprouve lui-meme.' He compares this sort of action to combustion, and cites several well-known instances of this kind, such as the de- composition of nitric acid by an alloy of platinum and silver, a change which does not take place with the platinum alone ; or the decomposition of peroxide of manganese by oxide of silver, &e., in water containing oxygen. He includes under the term ' eremacausis,' the alterations which organic substances undergo at ordinary temperatures, and as the result of the action of oxygen. When oxygen is excluded, putrefaction occurs. Putrefaction is a combustion of one or more of the elements of the organic substances at the expense of their own oxygen. Where no foul smelling products result, the process is termed fermentation. Putrefac- tion occurs when the equilibrium of the attractions of a complex organic molecule is upset, and it results in a rearrangement of these elements. Non-nitrogenous organic substances do not imdergo this putrefaction spontaneously when they are pure. They must be brought in contact with some substance already undergoing change. This latter substance is therefore termed a ferment. This ferment is a nitrogenous substance under- going putrefaction and eremacausis, it converts the oxygen of the air into carbonic acid, &c. Its activity is destroyed by desiccation, by heat, alcohol, &c. It is the soluble portion of ' Annalex de Chimir ct de Physitpw, 2« serie, Ixxi. 1831). 10 THE PARTICULATE THEORY OF FERMENTATION, the ferment which is active, and this does not act by direct contact, but in consequence of a decomposition which it itself undergoes. The elements of the ferment take no part in the formation of the products which sugar furnishes when fer- mented, though at the same time the ferment is itself under- going destruction. (This latter statement is based on an ob- servation by Thenard, who found that 20 parts of fresh yeast, added to 100 parts of sugar left, after fermentation was com- plete, only '13*7 parts of an insoluble residue. This residue placed in a new portion of sugar became reduced to 10 parts. This last residue no longer exerted any action. Pasteur has since completely disproved the accru-acy of Thenard's results. On the contrary he iinds that yeast increases markedly during fermentation, and in his latest work Liebig admits this.) The ferment is, therefore, according to Liebig, a body undergoing decomposition. If the ferment is too small in quantity for the sugar, when the decomposition of the former is complete the latter ceases to ferment (this statement has since been shown to be quite erroneous), and therefore a sufficient quantity must be present in order that its decomposition may not be completed till that of the sugar has ended. No special substance is, according to this view, required in order to act as a ferment, but merely one which shall be the constant exciter of action in the fermentescible substance. (This statement is also wrong, because putrefying fluids and tissues added to sugary solutions do not convert the sugar into alcohol. This was latterly admitted by Liebig, who was compelled to allow the existence of some relation between the yeast plant and the alcoholic fermentation, a connection which he, however, attributed to the effect propagated from the dead and dying, not from the living, cells.) Liebig sums up as follows : — Organic compounds present two opposite and definite phenomena. 1. They give rise to bodies endowed with new properties, the elements of several molecules of a more simple compound uniting to form one molecule of a more com^ilex nature. 2. Some complex molecules of a high degree of complexity LIEBIG'S VIEWS. 11 break up into one or more less complex molecules of a lower order, in consequence of the destruction of the equilibrium of the attractions of their elements. This equilibrium may be destroyed by heat, by contact with a body of different compo- sition, or by the action of a body which is itself undergoing change. As an example of this Liebig takes the case of urine : ' In fresh urine,' he says, ' if oxygen be entirely excluded there occiu-s no alteration of the urea or of the hippuric acid con- tained in it, but if exposed to the air another substance present in the urine (probably the mucus) undergoes a change of form and composition (eremacausis), which is transferred or com- municated to the urea and the hippuric acid ; the urea is resolved into carbonic acid and ammonia; the hippuric acid disappears, and in its place is found benzoic acid,' He continues : ' When we reflect that the power of exciting putrefaction belongs to bodies of the most different composition, that blood, flesh, cheese, saliva, infusion of malt, emulsion of almonds, &c., acquire this property as soon as, by the chemical action of oxygen, a disturbance in the equilibrium of the attraction of their elements has taken place, all doubt as to the true cause of these phenomena seems to disappear.' (We shall see later that in this Liebig is wrong, that meat, cheese, &c., cause putrefaction not from any inherent tendency to do so or from any state of decay, but because they introduce the necessary particles into the putrescible liquid.) Liebig then goes on to say, with reference to the germ theory of putrefaction, that after the death of fungi and in- fusoria we observe the same putrefactive phenomena as after the death of a larger animal. These organisms, according to him, only appear at a late period of putrefaction, and therefore are not the cause of it, though no doubt by their vital actions they must hasten and modify the change. And now let us pause in the history of this important sub- ject, aud methodise somewhat the views expressed. These may be divided into three sets. Firstly, we have that of Gay- Lussac, who attributes putrefactive and fermentative changes solely to the influence of oxygen in the flrst instance. 12 THE PARTICULATE THEORY OF FERMENTATION. Then come the views of Caignard-Latour and Schwann, refeiTing these changes to the entrance into the fluids of solid particles from without, which may be destroyed by heat. These authors go further, and ascribe the whole fermentative process to the growth of the organisms which are found in the ferment- ing liquids. And, lastly, we have the view of Liebig, who looks on oxy- gen as in so far favouring fermentation that it causes erema- causis, the molecules undergoing this change being now capable of setting up putrefactive and other fermentative changes. The latter changes are therefore due to the presence of some substance itself undergoing change, and to this substance the term ' ferment ' is applied. This ferment may be destroyed by heat. It will be more convenient if for the present we class these views under two heads — the oxygen theory (Gay-Lussac's) on the one hand, and the particulate theory (Schwann's) on the other. At a later period we shall determine whether Liebig's or Schwann's is the more tenable view. I have already mentioned the researches of Schulze, Schwann, Ure, and Helmholtz as tending more or less to upset the views of Gay-Lussac. The next research of importance on this subject is that by Schroeder and Dusch.' Their aim was to see \N]\eihex jiltraiion of the air would be sufficient to prevent the fermentation of boiled fluids. Their apparatus was the following : — A glass vessel containing the material to be tested (meat infvision, &c.,) was closed by a close-fitting cork, which was dipped into hot wax previous to its insertion. This cork had two holes in it wliich gave exit to two tubes bent outside to a right angle, these tubes being also firmly embedded in the cork ; one tube was for the purpose of con- ducting air to the vessel, and the other to suck air out of it. The conducting tube was connected by means of a short piece of vulcanised caoutchouc with a glass tube ; the latter was again attached to a wider tube (1 inch in diameter and 20 inches long) by means of a similar cork to that in the bottle, and at the other end of this tube was a cork with a bit of tubing in it, called the open tube. The wide ' Annalen dcr Chcmic tind Pharmacic, 1854. SCHROEDER AND DUSCH. 13 tube was loosely filled with cotton wool which had been pi-eviously heated for some time in a water bath. The other tube — the suction tube — which in the interior of the flask reached almost to the level of the fluid, was connected by means of a vulcanised india-rubber tube with the upper tube of an ordinary gasometer, this latter tube being provi<led with a stop-cock. The gasometer was filled with water, and on opening the lower tube of this vessel the water flowed out and thus the gasometer acted as an aspirator. (See Fig. '1.) Such was the apparatus employed. The fluid having been introduced into the flask, and all the connections having been Fig. 2.— Scheoedee akd Dusch's appaeatus foe supplying filtered aie. (Till; tulic to tlic left ought to rcacli almost to the level of the liquid.) ascertained to be air-tight, the cock of the aspirator was shut and the substance to be tested was boiled, till all the tubes as far as the cotton wool had been thoroughly heated ; then, the joinings having been again examined, the aspirator was so arranged that water flowed out of it drop by dro}), and thus sucked air slowly through the flask. Meat, boiled in water and ke2)t in a flask of this kind with constant change of air, was preserved for twenty-three days, and wlicji tested at the end of that time was found to lie quite un- altered, vvliile a similar infusion left exposed to ordinary air liad to be removed fioni the laboratory during the second week on 14 THE PARTICULATE THEORY OF FERMENTATION. account of its intolerable stench. This experiment was repeated several times with similar results. Schroeder and Dusch experimented in a similar manner with fresh sweet malt containing hops. After twenty-three days, the fluid being still unaltered, the cotton wool was removed, but the introduction of air — now unfiltered — was continued. The fluid was muddy and covered with fimgi, and had undergone fermentation in a week. These observers were, however, unable to obtain like results with milk, or with meat heated without the addition of water. These substances invariably underwent putrefaction. In a paper published five years later Schroeder returns to this subject.' Having found that white of egg mixed with water, if constantly shaken while boiling, could be preserved for an indefinite time, he tried whether ozone had any power in inducing fermentation. Dilute sulphuric acid was decomposed by electricity, and the ozone thus generated was conducted into a vessel containing pure white of egg. The latter was kept for thirty-eight days, and was at the end of that time unaltered. Schroeder was still unable to succeed with milk or yolk of egg, although the latter, if previously heated in a closed vessel in an oil bath to 160° C. (310° F.) generally remained un- changed, and the milk sometimes also kept pm^e. The special constituents of milk could be easily preserved. He tested casein prepared by precipitation with acetic acid and then washing with water. The whey also which remained after this precipitation could be preserved with ease. When this whey was boiled a deposit occurred, and this was readily kept pure ; and the whey which still remained did not ferment when preserved with the precautions mentioned. Schroeder tried and succeeded with other materials, such as blood, urine, starch, &c. The only substances which failed were milk, yolk of egg, meat heated without addition of water, and occasionally meat infusion. As the result of these contradictory experiments he came to the conclusion that there were two ways in which fermenta- tion might be caused ; firstly, by some solid particle which ' Annalcii der Chcmic zoid PJiarviacie, cix. 1859. SCHROEDER'S VIEWS. 15 can be arrested by cotton wool, and, secondly, by oxygen gas (in the case of milk, yolk of e^g., &c.). Two years later there appeared another j)aper by Schroeder referring to those substances which he had previously failed to preserve, and in this research he has recoiu-se to the use of higher temperatures than formerly-' Yolk of egg, after being heated for half an hour in a closed glass vessel, at a temperature of 130° C. (266° F.), was placed in a flask the neck of which was stuffed when hot with cotton wool, and was again boiled with a little water. This remained for seventy days unchanged. He succeeded in a similar manner with meat and milk, and in the case of the latter he found that prolonged boiling at 100° C. was sufficient. From these facts he gives up his formerly expressed view as to the spontaneous fermentation of organic substances under the influence of oxygen, and concludes that in these fluids spores were present which could resist a boiling temperature, the development of these spores being, according to him, the cause of the fermentation. He further considers that these spores were present originally in the milk, and were not intro- duced from the air, because he finds that milk which has not been Iwiled at all putrefies sooner than pure boiled milk exposed to the air. It may be interesting to mention here that similar difficul- ties were experienced by Appert in his attempts to preserve milk. He succeeded by the following method : ' Condense the milk to two-thirds of its volume, strain it, then put it in the bottle, seal and boil in a water bath for two hours.' In order to prevent the cream from separating he found it well to add yolk of Qgg. This did not increase the difficulty in preserving it. Still fmlher evidence disproving the gaseous theory is fur- nished by Pasteur.^ He repeated Schwann's exiDeriments and was successful with most fluids, but for a time he failed in the case of milk. He, however, succeeded when he boiled the milk under pressure at 110° C. (2.30° F.) for one or two minutes, heated air l)eing then allowed to come in contact with it ; and ' Aimalcti dvr Chemie nnd I'karmacie, cxvii. 1801. - Annalcs dcg Sciences NaUircllcs, scrie iv. t. xvi. 18G1 : Zaolofjic 16 THE PARTICULATE THEORY OF FERMENTATION. he also succeeded if he subjected the milk to prolonged boiling at 100° C. Such milk remains unaltered for an indefinite length of time, but it readily decomposes if unheated dust be introduced into it in the manner to be afterwards described. The most striking of Pasteur's experiments is that of the flask with the bent neck. A flask containing, say, yeast water is heated so as to render its contents pure. Its neck is drawn out and bent, and then, after boiling, the lamp is simply with- FiG. 3. — Pasteur's flask with the bent neck. (From Pasteur.) drawn, the neck being neither heated, sealed, nor plugged (Fig. 3). Nevertheless the fluid does not undergo any change. If, on the other hand, the neck of this flask be sealed during ebullition, a more or less perfect vacuum is thus pro- duced, and then, if the neck be broken after cooling, air rushes violently into the flask, carrying with it its dust. The result is that fermentative changes occur in the fluid. In the same way, if one of the flasks with open necks, the contents of which have remained for some time pure, has the neck broken off short, the fluid in its interior rapidly undergoes fermenta- tion ; or again, if the neck be not bent but be kept straight, so as to allow dust to fall in, fermentation rapidly occurs. The explanation of these results is that in the case of the flask with the long neck the dust is caught in the curve, which in the first inrush of air is filled with water, which filters the air (Mr. Lister's view). Pasteur had supposed that part of the air dust entered the vessel instantly, but that the fluid and the walls of the flask were at that time so hot that any living particles present were immediately destroyed. As will be seen further on. Pastern- also found that it was TYNDALL. LISTER. 17 not necessary to filter the air of its dust, but that if the air were merely left undisturbed for some time till the dust settled, it might then be introduced into flasks without causing any development. These experiments have been repeated by various observers with success, and Mr. Lister has at present in his possession a flask of this kind containing urine which is now thirteen years old, but which still remains unaltered and as limpid as on the day it was prepared. In a lecture on Haze and Dust,^ Professor Tyndall showed that if no dust were present in a flask, a beam of condensed light passed through the vessel in a dark room would only be visible on each side of it, but would be invisible in its interior ; in other words, we see light only because there are particles in the air which render it visible. Were there no particles all would be darkness. Such being the case, Tyndall found that when the air which was admitted to a flask had been previously heated, as in Schwann's experiment, the beam of light was not visible in the interior, showing that all or almost all the particles had been destroyed by heat, or, in other words, were in the main of an organic nature. By the same method Mr. Lister has found that in Pasteur's flasks with the long open necks, no floating dust is present after what was originally there has settled. Another method of excluding dust was published in 1873 by Mr. Lister.^ It seemed probable that the occasional failures which occurred in the attempts to preserve boiled fluids arose from the fact that the steam did not destroy the septic energy of the dust in the necks of the flasks which had not been previously heated. Mr. Lister, therefore, in addition to the precautions as to boiling under cotton-wool caps, &c., subjected his flasks to a high temperature previous to the introduction of the fluid. This is done by keeping them, after the cotton cap has been applied, in an iron box, which is kept at a high temperature for two hours. This box is of a square form, with one of its sides movable so as ' Nature, Jan. 27, 1870. ' Microseojncal Journal iox October 1873; see also Tratix. of Path. Society of London, vol. xxvii. 1878. C 18 THE PARTICULATE THEORY OF FERMEXTATIOK to form a door. ' This door has its circumferential part in tbe form of a groove capable of being packed with a considerable mass of cotton wool (Fig. 4, f). This door can be secured by means of nuts against the edge of the box ; and the cotton wool, having the narrow rim of metal thus firmly pressed against it, serves as an effectual filter of the air that passes in during cooling. But then it is essen- tial that the heat be so equally distri- buted as to avoid heating any portion of the cotton to such a degree as to destroy its physical properties. This uniformity of heat is provided foi- by having three shelves of sheet iron inter- posed between the large Bunsen's burner and the bottom of the box, no as to prevent the heat from acting directly upon it, while at the Fig. 4. — Door of Lister's box. Mr. Fig. 5.— Mr. Lister's hot box. same time the box is covered over with a cover of sheet iron (Fig. 5, k), which reaches nearly to the ground, and, while it checks radiation, compels the heated air to ti-avel over the whole exterior of the box MR. LISTER'S EXPERIMENTS. 19 and escape by holes at the top of the cover, whence it is conducted into a chimney by a tube (l). By these two means combined, the shelves below and the cover round about, we get a uniform browning of the cotton. Into such a box the requisite number of vessels are introduced (Fig. 5). An aperture in the top of the box well packed with cotton wool transmits a thermometer (m), to show us when the temperature of 300° F. has been reached, and when this, or any other higher degree short of 350"- F., has been continued for two hours, the gas is turned off and cooling is allowed to take place ; and when the apparatus is quite cool, the covered glasses may be removed with confi- dence that they are perfectly free from living organisms.' In this manner Mr. Lister purifies his flasks. The larger flasks have two necks, a large vertical one and a lateral one, which is a bent spout, large at its commencement and com- paratively narrow at its shorter terminal part beyond the bend (Fig. 6, o). The large size of the first part prevents it from acting as a siphon, and the result is that when the liqrdd is poured from such a flask and the vessel is afterwards restored to the erect position, the end of the nozzle remains filled with a drop of the liquid, and this guards the orifice so that regurgitation of air can never take place thiough the nozzle. This drop of fluid being sucked away by means of a carbolised rag, a pure cotton cap is tied over the orifice, and the flask is kept for future use. This flask, purified by heat and with each orifice covered with pure cotton caps, is used for the experiments (see Fig. 7). The fluid to be tested is introduced into it by means of a siphon, consisting of two glass tubes (s and T)connected by a tube of india-rubber (u), with a stop-cock (v) in the course of the india-rubber tubing. The siphon is first completely filled with water, the tenqjerature of which should be higher than that of the air, so that there is no dissolved air given off to form bubbles. Place one leg of the siphon in the vessel contain- ing the fluid to be used (w), then turn the tap and permit a sufficient amount of fluid to flow out to ensure that all the water has escaped from the siphon ; then turn off the stop-cock, wash the outside of c 2 Fig. 6.— Mr. Lister's large double-necked flasks. 20 THE PARTICULATE THEOBY OF FERMENTATION. the tube (t) with carbolic lotion, wrap a mass of carbolised rag (y) around its lower extremity, and apply this to the mouth of the flask (x) as soon as the cottou cap is removed, push the tube steadily down to the bottom of the flask through the carbolised rag, turn the stop-cock, and let the required amount of fluid flow into the flask (Fig. 7). When this has taken place the tap is again turned off", the Fig. 7. — Method op filling the flasks. siphon is withdrawn through the antiseptic rag, and a fresh cap of carbolised cotton (the cotton is carbolised by being soaked in a solu- tion of one part of crystallised cai-bolic acid in one hundred parts of anhydrous ether and allowed to dry) is tied over the mouth of the flask when the rag is withdrawn. The fluid is now heated for the desired length of time, and then abandoned under the protection of the caps. In this way Mr. Lister has found that he can preserve turnip infusion, hay infusion, urine, fresh milk, &c., for any length of time without any alteration taking place. To pre- serve milk, the flask containing it is immersed in boiling water for half an hour or more. MR. LISTER'S EXPERIMENTS. 21 Fig. 8. But this is not all, for these fluids can be transfen-ed to smaller vessels without undergoing any fermentation after this transfen-ence. This is done as follows : a liqueur glass (a) is covered by a glass cap (b) (watch glass), and the whole by a glass shade (c), the liqueur glass and the shade standing on a glass plate (see Fig. 8). This an-ange- ment is introduced into the hot box and thoroughly purified. Thus we have a pm-e glass filled with pure air, and the problem is to transfer the fluid from the flask to the glass without con- tamination in the process. To do this, the cotton cap is removed from the nozzle of the flask (Fig. 7, z) and the end of this is instantly slipped into an opening in the centre of half an india-rubber ball (Fig. 9, r) previously steeped in a strong watery solution of carbolic acid. The outer glass shade is then removed, and the watch glass being lifted, the india-rubber cap is instantly applied in its place (see Fig. 9). The required quantity of fluid is then poured into the glass, and the cap and shade immediately reapplied. A fresh cotton cap is now tied over the nozzle of the flask. In this manner any number of glasses may be charged, and these are found to remain as piue and unaltered as the fluid in the original flask. And now observe what such experi- ments teach. In the first place, into the original flask, when cooling, air enters, but this air having passed through a cotton-wool plug is incapable of causing putrefaction. Then in the decanting of this liquid from the flask, fresh air must enter through the large mouth of the flask, but as this passes through a filter of cotton wool it is in like manner incapable of causing fermentation. Further the liqueur glasses are full of air, which lias either been previously heated, or which has been filtered Fig. 9. 22 THE PARTICULATE THEORY OF FERMENTATION. through tlie cotton wool around the door of the hot box. The fluid when poured from the flask into the glass mixes freely with this air, but no change is set up. And, lastly, the loosely- fitting glass cap and shade allow a free interchange of air, but are so placed as to make sure that the air dejDosits its dust outside the glass, thus corresponding in action to Pasteur's flasks with the bent necks. In spite of all these opportunities of admixture with the gases of the air, all sorts of fluids remain unaltered, while, on the other hand, the same liquids exposed freely to unfiltered air rapidly undergo fermentative changes. These experiments are of themselves an absolute proof that the gases of the air alone are unable to cause fermentative changes in organic substances. In 1874 Dr. Eoberts ' demonstrated again that fresh milk and other substances could be prevented from putrefying if kept in a flask with a cotton-wool plug after having been pre- viously boiled. His method was as follows : An ordinary delivery pipette, having on it an oblong bulb capable of containing 30-50 cc, was sealed at one end, and the materials to be experimented on were then introduced into the bulb until it was two-thirds full (Fig. 10, a). The inside of the neck of the bulb was next wiped dry, and a plug of cotton wool was inserted about its middle. Lastly, the neck was drawn out above the plug and sealed in the flame (Fig. 10, b). When the bulb Avas thus charged and sealed it was weighted with a leaden collar, and submerged in tbe upright position (so as to pre- vent the wetting of the cotton-wool plug) in a can full of water. The can was placed over a soiirce of heat and boiled for the re- quired time. The bulb was then withdrawn and, when quite cold, its neck was filed off above the cotton-wool plug (Fig. 10, c). Finally it was set aside in the upright position and maintained at a suitable temperatvire. By exposure to the heat of boiling water for from twenty to forty minutes Koberts was able to preserve those substances with which Schroeder and other observers had foiled, viz., milk, pieces of meat, and egg albumin. In 1876 experiments were published by Professor TyndalP ' PMlosojjhieal Ti'ansactiom, 1 874. " Philomphical Transactiotu, 187C. DR. ROBERTS' EXPERIMENTS. 23 which afford still fmlher evidence on this subject. I have al- ready mentioned the method by which he demonstrated the presence or absence of particles in suspension by passing a powerful beam of light through the air to be examined. He found that ' in order to render air optically pure it was only necessary to leave it to itself for a sufBcient time in a closed chamber or in a suitably-closed vessel. The floating matter gradually attaches itself to the top and sides, or sinks to the bottom, leaving behind it air possessing no scattering power. Sent through such air the most concentrated beam fails to render its track visible.' Fig. 10.— Dn. Roberts' btilbs (copied from Egberts). His method as described by himself is as follows : ' A chamber or case was constructed with a glass front, its top, bottom, back and sides being of wood. At the back is a little door which opens and closes on hinges, while into the sides are in.serted two panes of glass facing each other. The walls of this case are smeared with glycerine in order to make the dust adhere. The top is perforated in the middle by a hole 2 inches in diameter, closed air-tight by a sheet of india-rubber. This sheet is pierced in the middle by a pin, and through the pinhole is passed the shank of a long pipette ending above in a small funnel. A circular tin collar 2 inches deep surrounds the pipette, the space between both being packed with cotton wool mois- 24 THE PARTICULATE THEORY OF FERMENTATION. tenecl with glycerine. Thus the pipette, in moving up and down, is not only firmly clasped by the india-rubbei', but it also passes through a stuffing box of sticky cotton wool. The width of the aperture closed by the india-rubber secures the free lateral play of the lower end of the pipette. Into two other small apertures in the top of the cupboard are inserted, air-tight, the open ends of two narrow tubes intended to connect the interior space with the atmosphere. The tubes are bent several times up and down so as to intercept and retain the particles cari'ied by such feeble currents as changes of temperature might cause to set in between the inner and the outer air (see Fig. 11). ' The bottom of the box is pierced with holes, in which are fixed, air-tight, twelve test tubes, intended to contain the liquid to be exposed to the action of the motel ess air.' The case so prepared is closed and allowed to stand for three or four days, till it is found by the beam of light that all the dust has settled. Then, the pipette being dipped into the test tubes, the fluid to be experimented on is introduced into each in succession. They are then boiled for five minutes in a brine bath. During the cooling, plugs of cotton wool are introduced into the small external convoluted tubes, but these plugs are afterwards withdi'awn. The apparatus is then kept at a suitable temperature and at perfect rest. At the same time a part of the same infusion boiled for the same length of time is placed outside the box in free contact with the air. In this way Tyndall has been able to preserve for an inde- finite time, boiled urine, mutton infusion, beef infusion, haddock infusion, turnip infusion, hay infusion, infusion of sole, liver infusion, infusion of hare, rabbit, pheasant, grouse, codfish, turbot, herring, mullet, fowl and kidney; while flasks contain- ing the same infusions, left exposed to the air after boiling for the same length of time, invariably putrefied in a few days. Fig. n.— Prof. Tyndall's pure CHAMBER (COPIED FROM TyNDALL) TYNDALL. 25 This experiment, though resembling in many respects Pasteur's experiment with the flasks with long bent necks, differs from it materially. In Pasteur's ex]3eriment the whole of the interior of the vessel is acted on by the heat, and thus when the boiling is ended there is no part of the flask, except the neck, which contains any particles capable of causing fermentation. In this case, however, the steam from the tubes, passing into a larger chamber, is not able to destroy the vitality of the dust lining the walls of that chamber, and therefore the infusion is here not only in contact with ordinary air which has not been acted on by heat nor filtered of its dust, but the septic dust itself is present in the same vessel though not in actual contact with the fluids. Tyndall found that as soon as ordinary labora- tory air, laden with dust, was admitted, putrefaction commenced. Tyndall has further shown that the gases arising from ymtrefying substances, however foul smelling, cannot produce decomposition in other fermentescible liquids, although this readily occurs when ordinary dust is admitted. Thus, * on the 30th of November a quantity of animal refuse, embracing beef, fish, rabbit, have, was placed in two large test tubes, opening into a protecting chamber containing six tubes. On December 13th, when the refuse was in a state of noisome putrefaction, infusion of whiting, turnip, beef, and mutton were placed in the other four tubes ; they were then boiled and abandoned to the action of the foul sewer gases emitted by their two putrid companions. On December 25th these tubes were still unchanged. On the same day the end of the pipette was dipped into one of the putrid tubes and then inserted into the turnip, aiid on the 27th a similar speck was transferred to the whiting. These rapidly underwent decomposition, while the remaining two tubes remained unaltered.' By operating in the manner described by Mr. Lister I have succeeded equally well in preserving fresh milk, meat, cucumber or turnip infusion for any length of time. As I shall have to refer at a later period to experiments in which extensive use is made of the ease with which these fluids can be preserved though retaining great readiness to undergo fermentation, I need not say more at present. Not only is air which has been filtered incapable of caus- ing fermentation in a boiled liquid, but air which has been 26 THE FAIiTICULATE THEORY OF FERMENTATION. acted on by carbolic acid is also without effect. I may mention a few facts made out by myself in support of this statement. In the small room in which most of my experiments were done it was almost impossible for me to transfer fluids fi"om one flask to another, by Mr. Lister's method, without contamination and subsequent fermentation, but if I performed the same manipulations in a spray of about 1 to 30 carbolic acid and water I could transfer all sorts of fluids with ease from one flask to another without any risk, even though done in the most leisurely manner. In doing this I have used Mr. Lister's double-necked flasks without the jirotection of the india-rubber cap. I have also in a few instances simply poured the fluid from one single- necked flask to another, and when this was done in a carbolic acid spray without other precaution, the fluid remained pure. That milk once rendered barren by boiling can be readily preserved for any lengtli of time, thougli i-etaining its capability for undergoing fermentation, is shown by the following experiment. On January 30th milk was prepared by boiling for twenty minutes in a flask purified by boiling distilled water in it under a cotton cap, the flnsk being afterwards dried by heat. On the same afternoon three purified tubes with glass caps and shades (just like Mr. Lister's liqueur glasses) were half filled with this milk under the spray. February 6. — The caps were removed under the spray, and a heated needle being introduced, jwrtions of the fluid were taken from each tube for microscopical examination. All the milks were found to present the normal appearance of fresh milk externally and micro- scopically. February 1 1 . — Examined as before. No change. February 19. — No change. March 3. — Still fluid and unchanged in appearance. Two of the tubes were now tested by the addition of a drop of fluid from a tube containing milk which had been left open, and which had putrefled. In three days the milk in these two flasks had separated into two layers, and had lost its normal characters. April 11.- — The milk in the third test tube still remains un- changed. I might multiply instances to show that milk and other fermentescible fluids can be kept in this way for months at a MY OWN EXPERIMENTS. 27 suitable temperature, without undergoing any change. This is not due to any effect of the carbolic acid on the milk, because milk so preserved rapidly undergoes fermentation when exposed to the air. Indeed the minute quantity of the solution which comes in contact with it can have no effect whatever, as is shown by the following experiment performed in 1877. February 1. — Five pure tes^t tubes were taken and into each was introduced 100 minims of boiled milk, along with a certain number of minims of watery solution of carbolic acid, 1-20. To No. I. were added 2 mins., making a proportion of 1-1000. „ II. „ 5 „ „ „ 1-400. „ III. „ 10 „ „ „ 1-200. „ IV. „ 20 „ „ „ 1-120. „ V. „ .50 „ „ „ 1-60. They were then shaken up and left exposed to the air for twenty- four hours, and afterwards covered with very loosely- fitting caps, which were removed at intervals during the following day. February 6. — The milks wei'e beginning to alter in appearance and to separate into layers. This was the case even in No. V. April 19. — They were all much advanced in decomposition. Thus we see that decanting can be safely done in a spray of carbolic acid, the fluid still remaining as putrescible as ever ; while, on the other hand, experience had taught me- that in the particular room to which I have referred, it was very difficult to decant successfully without the spray. The following experiment which I performed some time ago directly proves the efficacy of the spray : — Two flasks containing pure milk were opened in my room, and left open for ten minutes. In both bacteria developed. As soon as these flasks were removed two other flasks similarly charged were put in the same place in a fine cloud of carbolic spray. They were opened and left open for ten minutes. Both of these remained pure, though when inoculated at a later period organisms rapidly developed in them. When they were removed the spray was stojiped, and two fresh flasks were placed in the same position, opened and left open for ten minutes. One of the latter lemained pure ; in the other organisms appeared. (As will be later seen, the presence of organisms is synonymous with the presence of fermentation, and their absence with the absence of such changes.) 28 THE PARTICULATE THEORY OF FERMENTATION. Another experiment proves to demonstration the efficacy of the spray in destroying the putrefactive agents in the air : — Four flasks provided with cotton caps were puiified according to Mr. Lister's method. Into two of these, pure encumber infusion was introduced in the manner ah-eady described. These two flasks were placed for four days in an incubator, kept at the temperature of 98° F. At the end of this time the fluid was unchanged in both. About half of the liquid in one of the flasks was then poured into one of the empty previously purified flasks, in a cloud of carbolic spray, and the caps reapplied. These were then placed in the incubator and they remained permanently unchanged, and without the development of organisms. The same process was gone through with the two flasks without the use of a spi^ay. In both of these organisms developed and putrefactive changes occurred. In this experiment, when the fluid was poured from one vessel to the other it passed through the air, and air also entered into the first flask to take the place of the liquid. When this air had not been acted on by carbolic acid, organisms developed and fermentation took place, but where the air had previously passed through the spray it failed to cause any further change. (1 do not of course mean to imply that the former will be a constant result, for in ordinary air there are but few organisms present, and probably many flasks would escape. This experiment refers to the air of the room in which it was performed, that air being loaded with causes of fermentation.) A very striking proof of the value of the carbolic acid spray which occm'red to me lately may be mentioned. The flasks which I at that time used were purified by heating them to a temperature of about 600° V. in a box like that described by Mr. Lister. The flasks were in the first instance heated without any covering, the cotton caps were then applied under the spray, and the flask with its cap reintroduced into the box, where it was thoroughly dried in order to drive off any carbolic acid which might be adhering to it. As the temperature to which the apparatus was in the first instance raised chars cotton wool, I used asbestos to filter the air as it passed into the interior of the box during cooling. For a while this answered quite well, but after a time portions of the asbestos became detached, and holes were thus formed through Avhich air could (JONCL USIONS. 29 enter without being filtered, and as a result on several occasions I found that all the flasks so prepared were impure. This was obviated simply by directing the spray against the door of the box as soon as the lamp which heats it was extinguished. The box was thus surrounded by spray; the air passing into it first passed through this spray, and, as a result, since I did this, I never failed in any instance in obtaining pure flasks.^ From these researches we learn that the gases of the air, whether oxygen, nascent oxygen, ozone, nitrogen, carbonic acid, emanations from fermenting substances, &c., are powerless to cause fermentation in boiled fluids or tissues. Further, that it is sufficient, in order to prevent this occurrence, that the air be either previously heated, or filtered through cotton wool, or acted on by chemical substances, such as sulphuric acid or carbolic acid, or merely allowed to remain at rest so as to permit the dust to settle outside the substance tested. It is therefore evident that the causes of putrefaction in boiled substances are solid particles present in the atmosphere and on surrounding objects, which may be deprived of their fermentative properties in various ways. When we come to consider the further questions of spontaneous generation and the relation of organisms to fermentative changes, we shall find much additional evidence confirming this view. ' The exact merits of the carbolic spray as a means of purifying the atmo- sphere will be discussed later. What I wish to point out here is, that in ordinary air, in circumstances where we know that particles capable of causing fermentation are present, carbolic acid is able to render these particles inert. 30 THE PARTICULATE THEORY OF FERMENTATION. CHAPTER II. THE PARTICULATE THEORY OF FERMENTATION (continvrd). — ON THE FERMENTATION OF UNBOILED SUBSTANCES. Grape juice — Gaji-Lnssac — Van der Broech — Pasteii/i' — liohcrts; blood — Van der Brocch — Pasteur — Burdoii-Sanderson — Lister — 3Iy awn results ; un- boiled ui-ine — Vaih der Broecli, — Pasteur — Lister — My own results — Roberts — Cazeneure and Livon ; milk — Hojfpe-Seyler — RoleHs — Lister — My own experiments; egg albumen — Van der Broecli — Gay on — Roierts — 3Ty own exjJenments ; vegetable tissues — Roberts ; animal tissues — Billroth — Tiegel — Bur don- Sanderson — My own experiments — Chiene and Ewart — Meissner — General review of the facts — Behaviour of similar fluids and tissues in the living body — Principles of aseptic surgery. While it cannot be doubted that the causes of the fermenta- tion of boiled fluids and tissues are particles which reach them from the air and from surrounding objects, is this equally the case with the unboiled ? Experiments with these substances are apt to yield very contradictory results, for it is a matter of extreme difficulty to prevent their contamination after their removal from the living body. How this has been managed and with what results we must now enquire. I. — Orape Juice. Gay-Lussac in the research mentioned before attempted to ascertain whether unboiled grape juice remained unaltered when oxygen gas was excluded. He took a bell jar and introduced into it small grapes, still intact. The jar was now reversed over mercury, and was filled five times with hydrogen gas in order to wash out all the oxygen. The grapes were then crushed by means of an instrument introduced through the mercury, and the juice thus obtained was kept at a temperature of 15° to 20° C. Fifteen days later, no fermentation having taken place, a THE FERMENTATION OF UNBOILED SUBSTANCES. 31 small quantity of oxygen was introduced, and immediately fermentation commenced. From these experiments he concludes that the oxygen introduced caused the fermentation. But here there are two main fallacies. In the first place, the skins of the grape were left mixed with the grape juice, no sufficient means being taken to destroy any solid particles adhering to them ; and then also the oxygen introduced might have carried in the necessary particles. There can indeed be no doubt, from Pasteur's sub- sequent investigations, that the Torula cerevisise — the cause of the alcoholic fermentation — was present on the skins of the grapes ; and Pasteur has further shown that oxygen is absolutely necessary for the development of the old cells of the Torula, though the young cells may go on developing without the presence of free oxygen. The explanation of Gay-Lussac's experiment is, therefore, that the old Torula cells present could not develop without oxygen, but that when a small quantity of oxygen was introduced, they developed, and fermentation occurred. The next attempt to preserve grape juice of which I can find any record was made by Van der Broeck, and narrated to the ' Provincial Gresellschaft fiir Kunst und Wissenschaft,' Utrecht, January 1858. His method was the following' : — Small beakers were filled with mercury, and then heated in a sand bath till the boiling point of the mercury was almost reached. Fi-om time to time they were placed under the receiver of an air-pump, and at the same time shaken in order to detach any bubbles of gas adher- ing to the side of the flask. This process of heating and exhausting was continued till all the air was removed from the bottom or sides of the glass. These glasses were then inverted in a basin containing previously heated mercury, and were firmly fixed in this position. Ripe and uninjured gi'apes were now passed into the mercury and brought under the orifice of the flask, a portion of the skin of the gi-ape was clipped out by a heated knife, and by gentle pressure some of the juice was made to ascend m the vessel, the rest of the gi-ape being removed. When a sufiicient quantity of juice had been thus introduced the vessels were placed in a room of which the tempei'a- ture was 2.5° to 28° C, and giupe juice thus obtained could l)e kept for months or years without undergoing any change. ' See Annalcn der Chcinie unci Pharniacir, cxv. 18G0. 32 THE PARTICULATE THEORY OF FERMENTATION. In this experiment not only was all air excluded, but the dust adhering to the walls of the vessel and in the mercury was subjected to strong heat, and its fermentative power destroyed. The juice of the grape, in ascending through the mercury, did not come in contact with unheated dust, nor did it touch the skin of the grape. Into some of the flasks containing pure grape juice obtained in this way, pure and fresh oxygen was introduced from a retort containing chlorate of potash and oxide of copper. (The nozzle of the flask was heated previously to its immersion in the mercury, and the oxygen was allowed to stream out for a time sufficient to wash out all the dust.) In none of these flasks was there a trace of fermentation. Into others, atmo- spheric air, passed through a mass of cotton wool, was intro- duced in the same manner, but without producing any effect. Into these vessels containing oxygen, yeast was introduced in minute quantity, and fermentation at once commenced. Into others containing only grape juice, young cells which had never been exposed to free oxygen were introduced by a method which is fully described in his research, and these also caused fermentation ; thus proving that oxygen is not necessary even for the commencement of the change, if only the yeast cells be young (three or four days old). By these experiments it was absolutely demonstrated — 1 That oxygen is not the cause of the fermentation of unboiled gra})e juice ; and 2. That the juice itself contains no ferment. That grape juice contains no ferment was further shown by Pasteur,' who introduced unboiled juice into his flasks with bent necks, containing pure boiled juice. No fermentation occurred, though, as he says, if a single Torula cell had been added, the whole mass would have fermented. Dr. Roberts - likewise succeeded with grape juice. Test tubes were drawn out at their lower ends to capillary points and sealed in the flame; the upper ends were plugged with cotton wool ; they were then passed and repassed through the flame of a spirit lamp until they were quite hot, as shown by the commencing charring of the cotton. (Fig. 12.) ' Eleven sterilised tubes, six empty and Ave containing water, were ' Etudes sur la BVcre. ^ PhM. Transactions, 1874:. PRESERVATION OF GRAPE JUICE AND BLOOI). 33 grape urface charged with grape juice in the following manner : — A fresh was firmly seized with the fiiiger and thumb, and a spot on its s was pi-essed for a few seconds against the flame of a spirit lamp so as to destroy any adhering germs. The point of the sterilised tube, also heated in the flame and quickly snipped off" by an assistant, was then thrust into the grape at the heated spot. Compression was now made on the gi-ape until a sufiicient quantity of the turbid juice was forced into the tube. The tube was then withdi-awn, and its point sealed in the flame. The eleven tubes thus charged remained permanently unchanged, and when examined, at various periods from five to eight weeks, the taste and reaction of their contents were undistin- guishable from that of the fresh grape juice.' II.— Blood. Blood is one of the substances which eobeets). have been frequently referred to as having an inherent tendency to decompose, but several experiments have now demonstrated that this is not the case. The first observer who succeeded in preserving blood was Van der Broeck. Van der Broeck procteded as follows: — Having prepared his beakers filled with mercury as formerly described, he introduced one end of a previously heated copper tube into the carotid artery of a dog. To the other end of this a caoutchouc tvibe was connected, while the free end of the lattei- dipped into the mercury and the blood passed along it into the purified beakers. (This caoutchouc tube had been purified by the jjassage of steam through it for some time, and by placing a plug of cotton wool in each end while it was cooling.) The vessels were then kept at a temperature of 25° to 30'^ C. for weeks without the contained blood undergoing any change. Into some of these flasks oxygen or filtered air was intro- duced, but still there was no putrefaction. The minutest por- tion of putrescent or even non-put re scent but unheated substance at once set up fermentation. In 1863, Pasteur ' stated that he had obtained blood from ' Comptcs llcnduv, Ivi. 738. ]) 34 THE PARTICULATE THEORY OF FERMENTATION. healthy iinimals by means preventing contamination with un- heated atmospheric dust, and that this blood had remained free from change. In a later publication ^ he describes the method pursued. ' For this I made use of a flask connected by means of a caoutchouc tube with a brass tube and stop-cock. The two parts of the tube are about twelve centimetres in leugth ; that which is free is filed down like the extremity of a cauula. In order to cleanse this vessel from all living dust the free extremity of the brass tube was connected 'with a platinum tube .strongly heated, a small Fig. 13 (FROM Pasteur). quantity of water having been previously introduced into the flask. This water is then boiled, and the flask allowed to cool, the air which enters during cooling being previously heated. It is well to boil the water in the flask under pressure, to effect which the free extremity of the platinum tube is connected with a glass tube bent at right angles, which dips into a deep vessel filled with mercury. After boiling for some time under pressure, this tube is detached, and boiling is continued at the ordinary pi-essure ; then the flask is allowed to cool and to become filled with heated air. When the flask is cold the cock is shut and the platinum tube detached. Till it is required it is well to hold the orifice of the brass tube down, in order to prevent dust from falling into it. Before being used this portion is heated carefully in the flame of a spiiit lamp. ' A vein or artery of a dog is now opened, the end of the brass tube introduced, and secured in the blood-vessel by a ligature ; the cock is then turned on. Blood flows into the flask, and when enough has been ol>tained the cock is shut and the flask placed in a suitaljle tempei'a-- ture.' As a result this blood does not putrefy, and its odour re- mains quite fresh. There is not even an active absorption of ' Etudes xvr la JJihr, 187G. BLOOD: BURDON-S ANDERSON, ROBERTS, LISTER. 36 oxygen, for after several weeks only 2 or 3 per cent, of that gas was found to have disappeared in a vessel sealed imme- diately after the blood had been introduced. Dr. Burdon-Sanderson • also found that blood taken from rabbits with suitable precautions, and put into purified flasks covered with cotton wool, remained free from change. Dr. Eoberts,^ having purified his tubes in the way described, and having thoroughly cleansed his finger, punctured it, and sucked up about two drops into each tube. Of ten tubes pre- pared in this way, six remained unaltered. This experiment is of little value, partly on account of the imperfect method of experimentation, and partly on account of the small amount of blood obtained. Mr. Lister ^ took blood from the jugular vein of an ox in the following manner : — A large glass tube was fixed in the lai'ge oiifice of one of his double-necked flasks, the interval between the flask and the tube being filled with tightly-packed cottou wool. Over the outer end of this glass tube a cotton cap was applied, and there was a cotton cap as usual over the orifice of the spout. The fiask thus arranged was heated in the hot box. The jugidar vein of an ox having been exposed antiseptically, was divided, the cotton cap removed fi'om the end of the tube, and the end of the vein slipped over the orifice of the tube. Blood thus flowed through a pure tube into a pure flask. When enough had been obtained the vein was removed and a pure cotton cap immediately aj^plied in its stead. Before coagulation had occurred, various liqueur glasses, arranged as formerly described, wei'e charged from the large flask. Blood so obtained remained unaltered in the liqueur glasses and in the flask, though kejit for six weeks. Mr. Lister also found that not only blood, but blood and water — a much more putrescible mixture — remained unaltered. (The water was introduced into a large pure flask, and boiled so as to purify it. A portion of blood clot from one of the liqueur glasses was then spooned into the flask, careful precautions being taken against the entrance of living dust.) In some experiments, performed in a manner to be shortly ' Quarterly Journal of Micraisropiful Sriciicr, xi. J871. - Loc. cit, '■' Mirriixropical Jour mil, 1878. 1) 2 36 THE I'ARTICULATE THEORY OF FERMENTATION. described, I have found that blood, removed from the healthy living body and placed in calcined flasks or in flasks containing infusion of cucumber, maybe preserved for an indefinite length of time without alteration. Hence blood has no inherent tendency to undergo fermen- tative changes, nor can oxygen alone induce such alterations. III. — Urine. Healthy mine was first preserved without alteration by Van der Broeck. The flasks in which it was received were prepared in the manner before described. An animal (dog or sheep) was killed, the abdomen was immediately cut open, and the ureters and m-ethra having been rapidly tied, the bladder was removed and immersed in the mercury. A heated needle was then introduced, and the bladder was torn, the urine then ascending into the glass. This urine remained pure even after the addition of oxygen or filtered air. In the same paper in which Pastern- mentions that he has succeeded in preserving blood he states that he has also obtained pure urine. The method is described in his ' Etudes sui* la Biere.' The flask with its nozzle and stop-cock are prepared as in the case of the blood ; then the free extremity of the brass tube is introduced into the urethra. Urine being passed, the stop-cock is turned, and the urine flows into the flask. Urine thus obtained undergoes no fermentation. ' Elle depose des cristaux en petite quantite, mais sans se troubler ni se putrefier d'aucune facon.' In 1871 Mr. Lister succeeded in obtaining and preserving unboiled urine.' The method he employs is to wash the meatus urinarius and the glans penis with 1-40 carbolic lotion. A prepared flask is then taken, the cotton cap is removed, the glans immediately applied over the orifice, and urine passed into the flask. A fresh cotton cap is then applied. This urine may, like other fluids, be decanted into liqueur glasses. This experiment was apparently constantly successful, no alter- ation occurring in the urine in the flasks or in the glasses. ' Transactions nj the Itvijal Society of Edinhuryh, 1875. URINE: ROBERTS, CAZENEUVE AM> LI FOX. 37 I may here state that I have often repeated this experiment with the view of obtaining pm-e nnboiled urine for other experi- ments, and always with success. I have, however, used the spray, and have thus avoided the necessity of applying the glans penis to the orifice of the flask. The glans having been purified, urine is simply passed in a spray of carbolic acid into a pure flask. This urine passed through the air, but that air, having been acted on by carbolic acid, was inert. Dr. Roberts has also obtained similar results by passing urine into a pure test-tube, and afterwards charging tubes of the form previously described, by breaking oft the capillary end below, and letting the urine flow up. Of eight tubes so obtained, the urine remained unaltered in seven, while in one it putrefied. Cazeneuve and Livon ^ succeeded in preserving urine in the urinary bladder without the occurrence of any alteration in it. A ligature was placed around the prepuce of a dog for five hours, in order to have a considerable amount of urine in the bladder. An incision being made into the abdominal cavity at the end of that time, the ureters and the urethra were ligatured, and the bladder was cut out. The bladder was then suspended in the air at a temperatm-e of about 25° C. The wall of the bladder soon dries, and though liquid slowly transudes, that liquid evaporates immediately, and thus the bladder wall cannot putrefy. Urine may be kept thus for several days without undergoing any change, although if the bladder be opened it becomes ammoniacal in twenty-four hours. I shall return to these experiments at a later period. Thus healthy unboiled urine has no inherent tendency to putrefy, but follows the same law in this respect as boiled urine. IV.— Milk. In 1859 Hoppe-Seyler attempted to preserve milk pure in the following manner: — ^ A small funnel was carefully fastened over the teat of a goat. To the lower end cf this was fastened a piece of caoutchouc tubing, the ' Rcrue Menmclle, 1877, p. 733. ^ Vircliow's Archiv. xvii. (1859). 38 THE PARTICULATE THEORY OF FERMENTATION. other end of which was attached to a glass tube below. This glass tube passed down to the bottom of a glass test tube, the u])per vim of which was provided with a piece of caoutchouc tubing open above. None of the tubes were heated nor in any way purified. The milk was now withdrawn in a continuous stream, so as to flow for a long time over the edge of the caoutchouc tube till it was quite free from bubbles of air. The test tiibe was then lowered, and then, while the milk was still flowing, the caoutchouc tube was firmly tied around a thick glass rod. Milk obtained in this manner, and kept at the ordinary temperature, coagvdated in three days. Hoppe-Seyler therefore concluded that milk when shed contains a ferment. This experiment proves that oxygen is not necessary for the occurrence of fermentation in milk ; in other words, it is not the cause of such changes, and therefore, as the tubes were not purified, the cause must either be in the milk itself or be some- thing adhering to the tubes. As I have just stated, Hoppe- Seyler concluded that the cause was inherent in the milk. Which of these is the true agent is decided by the following experiments performed by Dr. Eoberts : — ^ * A glass tube was drawn out at each end to a narrow orifice. The lesser portion of this was tightly wrapped round with cotton wool and inserted as a plug into a large test tube containing water to the depth of one inch. A cap of cotton wool was also tied over the narrow orifice. The water in the test tube was then briskly boiled, and the boiling was continued almost to diyness. When the apparatus was cold I took it into the cowhouse, and seizing a teat, I pulled ofi" qvuckly the cotton- wool cap and pushed the narrow point into the duct of the teat. Holding it firmly in this position I milked into the test tube until sufiicient milk had been obtained. I then drew away the test tube from the little tulie, pressing in the cotton wool around it as I did so, until the latter was entirely withdrawn from the test tube. ' From the test tube I charged ten empty pure tubes ' (in the manner descril)ed under urine), 'and resealed their capillary orifices : of these ten tubes three remained unchanged, the milk remaining perfectly normal as regards taste, reaction, kc. The other tubes curdled or putrefied in ten days.' ' Loc. cit. MILK: LISTER, MY OWN EXPERIMENTS. 39 The method described here is imperfect, but the fact that three tubes remained unaltered absolutely demonstrates that the cause of the fermentation is nothing inherent in the milk itself, but something which it acquires after it leaves the body — that something being particulate, not gaseous. Mr. Lister ' describes several series of experiments performed with the same aim. In one of these he succeeded in preserving the milk unaltered. A numbei' of little tubes were covered with glass caps and shades, and purified in the usual manner. After a rainy day he washed the udder of a cow and the hands of the milkman with water. A wide glass tube connected with an elastic tube was then placed under the nipple (the glass tube had been heated and the elastic tube boiled). This -was filled with milk, and then each little tube in suc- cession had a small quantity mtroduced by relaxing the elastic tube. Of twenty-four tubes so prepared and charged two remained permanently pure. The results in the other tubes equally demon- strated that the cause of the fermentation of milk is not inherent in the milk, for the milk in each underwent a different change. These experiments will be more fully considered at a later period. While in the Shetland Islands in the summer of 1880 I performed a series of experiments, which consisted in obtaining the milk under the protection of a spray of carbolic acid. A number of flasks with cotton caps and long necks were heated before leaving London. The udder of the cow and the hands of the milkmaid being washed with carbolic lotion (1-20), the flasks were uncorked and filled with milk under the spray. In doing so the mouth of the flask was held as close as possible to the teat. The cow was restive and would not allow me to do the milking, and therefore the experiment was performed by the milkmaid. When the restiveness of the cow, the inex- perience of the milkmaid at antiseptic work, and the dark and draughty cowhouse are taken into account, it will not be sur- l)rising that the milk in a considerable number of the flasks f(;rmented; but nevertheless evidence was got, of tlio same kind as that obtained by Dr. Roberts and Mr. Lister, sufficient ' Micrusccjncal Jourmil, 1878. 40 THE PARriCULATE THEORY OF FERMENTATION. to disprove the existence of a ferment in the milk when with- drawn from the body. In order to transfer these flasks to London I had intended to draw ont and seal their necks, but I found this impossible, and therefore I soaked pieces of cork in carbolic lotion, inserted them into the mouth of the flask, and covered them with tar — a very inefficient method. During the voyage the milk was much shaken, and some of the corks proved inefficient, as shown by the leakage of the milk. The following are the experiments, with their results : — First Experiment. August 5, 1880. — The udder and teats of the cow and the hands of the milkmaid having been Avashed with 1-20 carbolic lotion, and a small spray being directed as well as possible over the part, eight purified long-necked flasks were filled with milk, the milk being drawn directly into each flask, which were held as near the teats as possible. Eash flask was re-covered with its cotton cap, and they were then placed in the upright position in a warm room. Augtist 8. — The milk in these flasks seems unaltered. There is a little cream on the top in each. August 10. — Ditto. August 24. — Four of the flasks have undergone change, the change varying in nature in each flask. The other four are perfectly fluid and present the appearance of pure milk. To-day the corks were inserted. Se2:)temher 21 (twenty-three days after the transport to London). — Only two flasks now remain pure, the other six having undergone alterations of various kinds. October 27. — Examined. The milk in two flasks is perfectly normal. The result of the first experiment was, that after nineteen days four of the milks had undergone alterations of various kinds, while four remained apparently pure. On October 27 — i.e. after two months and twenty-two days — two milks were still perfectly right, in spite of a sea voyage and great disturbance. MILK: MY OWN EXPERIMENTS. 41 Second Experiment. («) August 10. — Two flask?^ were filled after washing the udder of the cow and the milkmaid's hands with carbolic acid (1-20). No spray used. August 24. — The milk in one of these flasks has undergone altera- tions \ the milk in the other Ls perfectly pure. September 21. — Both milks have coagulated and are undergoing changes. (b) August 10. — After the spray employed in experiment (c) had been stopped, two flasks were filled without it. Augiist 24. — I am doubtful whether these are pure or not ; I think they are not. September 21. — Changes have occurred in both. (c) August 10. — Seven flasks were filled under the spray as usual. August 24. — Three of these milks have altered ; four are still apparently pure. September 21. — Three still remain apparently pure : four have undergone change. October 27. — Examined. Three still pure. On December 24 I opened one of these flasks, and found a slightly suety smell but a perfectly sweet taste, and the milk presented the appearance of normal milk. I examined it microscopically — no organisms. I have stained some specimens of this milk (Plate V. Fig. 33), and it will be seen that no organisms whatever are present, and this in unboiled milk kept for moi'e than five months. The result here is that three out of seven of the flasks filled under the sjjray have remained permanently pure, while all of those filled without the spray have ultimately undergone fermentative changes. Third Experiment. (a) August 1 6. — One flask filled without spray and without previous application of carbolic acid to the hands or teats. Aiigust 24. — This milk has coagulated. {b) Aiigust 16. — One flask filled without the spraj' and without washing the teats with carbolic acid. The hands of the milkmaid, were, however, purified. August 24. — This milk has undergone fermentation, having separated into two layere — the upper clear, the lower thick but not coagulated. 42 THE PARTICULATE THEORY OF FERMENTATION. (c) August 16. — Two flasks were filled without the spray, but after washing both the teats and the hands with carbolic lotion. AiKjust 24. — One of these is doubtful, the other apparently iin- altered. Septeiniber 21. — Fermentative changes are occurring in both. {d) August 16. — Six flasks filled under the spray as usual. Aug^ist 24. — All these are appai-ently unchanged. September 21. — Four have undergone some fermentative changes. One is doubtful. One is still pure. Thi-ee of the corks have not fitted perfectly. October 27. — Examined. One still pure. The whole result is, that of twenty-one flasks filled under the spray, six remained permanently unaltered, and that after having been exposed in a manner which sufficiently explained the occurrence of femientation in some of the others. Up till August 24th no less than fourteen of these milks had remained apparently unchanged, while similar specimens taken without any precautions had undergone alteration, I have still in my possession (June 1881) four of these six flasks, and the milk in these still remains perfectly pure and free from fermentative changes. From all the facts narrated I think it is absolutely certain that milk has no inherent tendency to undergo fermentation of any kind, and that the cause of the fermentation is not the gases of the air, but solid particles which the milk meets with after it is drawn from the cow. V. — Egg Albttmen. The difficulty experienced by Schroeder in preserving boiled white and yolk of eggs will be remembered. Van der Broeck introduced an egg into the merciuy ar- ranged as formerly described, broke the shell with a heated iron rod, stirred up the contents with a similar rod, and then allowed them to ascend into the glass. This egg albumen remained pure, even after subsequent addition of oxygen or of filtered air. Gay on ' found that some eggs may be preserved unaltered, while others undergo change. He supposes that in the latter ' C'onijjtvg Itendiix, Ixxvi. Ixxvii. EGG ALBUMEN: ROBERTS. 43 case the causes of putrefaction entered as the egg passed through the oviduct. Such an idea is, however, hardly tenable. Eoberts has shown by experiments similar to those pre- viously described that egg albumen has no inherent tendency to undergo fermentation. He proceeded in the following manner : — Eight sterilised tubes were prepared containing pure water. ' A fresh egg was fixed in a convenient support, and a small piece of the shell was chipped off, care being taken to leave the subjacent membrane uninjured ; then a sterilised bulb was taken, and the capillary portion immersed for a few seconds in boiling water, in order to destroy any adherent septic particles. The sealed end was then rapidly snipped off and the capillaiy portion plunged into the interior of the egg. About 2 gm. of the albumen were then sucked up by the mouth into the bulb. When this was accomplished the bulb was quickly withdrawn and its capil- lary end sealed in the flame.' Six of these eight tubes remained unaltered for seven months. Of a second series of seven tubes similarly charged and kept for two months, five remained unaltered. That is, of fifteen tubes filled, eleven remained pure. I may refer to an experiment which I did for another purpose, accepting as true the view that egg albumen had no inherent tendency to undergo fermentation, aud which proves the truth of that view. On July 7th, 1880, 1 took four purified beakers and four fresh eggs. These eggs were washed with carbolic lotion (1-20), and were then Ijroken, one into each lieaker, under the spray. One of these beakers was covered with its cotton cap, and placed in an incubator kept at the temperature of 98° F. On July 20th no change whatever had occurred. The other flasks were used at once for various experiments. Into one a special form of organism was introduced, and here only this one form of organism developed, with the production only of a special kind of fermentation. Hence egg albumen has no inherent tendency to undergo fermentative changes. 44 THE PAliriCULATE THEORY OF FERMENTATION. VI. — Vegetable Tissues. Dr. Eobei'ts' has also experimented on the solid tissues of the turnip, potato, orange, and tomato, with similar success. The following is his method for turnip : — ' A stei-ilised tube containing- water was nickecl with a file near the base of the capillary part, where the tube had a diameter of about two millimetres, A fresh oblong turnip was then fractui-ed aci-oss, and the tube, snipped off at the nicked jjoint, was quickly thrust into the substance of the turnip. A naiTow cylind-er of turnip about an inch long w'as thus foi-ced into the column of water in the tube. The tube was then detached, and its end sealed with melted sealing-wax.' Of 14 tubes thus chai-ged with turnip 10 were successful; 7 „ „ potatoes 4 „ 8 „ „ orange 8 „ 3 ,, ,, tomato 3 ,, Ferments which induce changes after death are therefore not present in living vegetable tissues. VII. — Animal Tissues. Some years ago experiments were made by Billroth ' and Tiegel^with the view of ascertaining whether the living tissues did or did not contain the causes of putrefaction. Having killed an animal, they opened its body rapidly, and removed with heated implements various portions of tissue such as liver, spleen, kidney, &c., and immediately dropped this into heated paraffin. They supposed that by this means any dust which fell on the tissue in its transit from the body to the flask would be destroyed by the hot paraffin, while this heat would not penetrate into and act on the interior of the tissue. At the same time the organs would be protected from air or dust by the paraffin. They found that many portions of the body preserved in this way, notably the liver and spleen, underwent putrefaction rapidly, and they therefore concluded that the causes of this putrefaction were present in the living blood and tissues. ' CuceohacteHa sejHica. * Virchow's ArcJiir. Ix. ANIMAL TISSUES: MY OWN EXPERIMENTS, 45 These experiments were repeated by Dr. Burdon-Sauderson, who obtained similar results and adopted the same views. If, however, we look at the method, we shall find several objections to it. Thus, heated paraffin must be looked on as dry heat ; it does not moisten solid particles in contact with it. Now it has been shown that dust, if kept dry, may be heated even to 300° F. without losing its power of causing fermenta- tion. Further, paraffin solidifies at about 136° F., or even lower, and therefore paraffin, merely at its melting point, is not likely to be hot enough to destroy all septic particles. Further, during the cooling of the paraffin heavy particles of dust may fall into it and sink on to the tissue. Then, also, on the sides and bottom of the vessel is coarser dust, which likewise may not be destroyed. But, again, paraffin is very apt to crack, and after cooling small cracks may occur which admit moistm-e and dust. To obviate this risk the paraffin has been covered with oil ; but even here the oil becomes laden with dust and passes down through the cracks. And, lastly, the knife, before dividing the tissue, compresses the vessels and forces the blood out of them, and thus, when these vessels are cut, air is sucked in, and this air carries its dust with it quite out of reach of the heat of the paraffin. In December 1877 I commenced a series of experiments on this subject, and these have been continued at intervals since that time. The first experiment was an imitation of those of Billroth and Tiegel (only it was performed antiseptically), and yielded conflicting results. Thus the liver and kidney putrefied, while the spleen, muscle, and mesentery remained unaltered. This being the case, I determined to abandon this method entirely, and to see if some definite conclusion might not be arrived at in some other way. The following is a description of the method I have employed : — A number of beakers, each provided with a cotton cap, were puri- fied by heat, somewhat after Mr. Lister's method, and into each vessel about one-fourth of its volume of pure turnip iut'usioii was introduced from one of the double-necked Masks (Fig 6, p. 1*J). This was done under the spray, and the cotton caps were then reapplied. These beakeis 40 THE rARTICULATE THEORY OF FERMENTATION. were placed in an incubator, and kept at a temperature of 98° F. for three or four days. At the end of that time the turnip infusion was clear and unaltered, and the flasks were therefore considered ready for use. On January 6tli, 1878, four beakers having been thus jirepared, and six beakers containing melted pai-affin being also at hand, a healthy rabbit was iised for the following experiment. The skin and hair of its abdomen having been thoroughly washed with 1-20 carbolic lotion, the animal was killed by a blow on the back of its neck, and the tibdominal cavity was rapidly opened, under a fine spray of carbolic acid, with purified and heated instruments. Portions of its organs and tissues were rapidly cut out and intro- duced into the beakers, which were opened in the spray. Into the four vessels containing the pure turnip infusion portions of liver, spleen, kidney, and muscle respectively were intro- duced, and the caps having been reapplied while the flasks were still in the spray, they were then placed in an incubator (see Fig. 14). Into the six flasks con- taining melted pai-affin por- tions of liver, kidney, spleen, muscle, mesentery, and vena cava, with its blood, were dropped also undei- the spray. The parafl[in was left to solidify, and the vessels were then placed in the incubator. All those portions of organs introduced into the turnip infusion remained ])ermanently puie and free from })utrefaction.' Of the paraffin beakers, two (muscle and vena cava) remained without change ; while the other four (liver, spleen, kidney, and mesentery) putrefied. In this experiment we have in the first case a series of ' On December 24, 1880, I killed a rabbit and preserved its organs in the way described here. Fig. :-54, Plate A^, is drawn from a specimen taken from the beaker containing the spleen, and stained. It will be seen that no organ- isms whatever arc present. ANIMAL TISSUES: MY OWN EXPERIMENTS. 47 beakers heated so as to destroy the activity of the dust adhering to them, and that this was effectually done was proved by the fact that the turnip infusion introduced into them underwent no change, although, as has been amply shown in the fore- going experiments, had ordinary unheated dust been jjresent, this infusion would have undergone fermentation. Further, the portions of the tissue are transferred from the body to the beaker without the possibility of acquiring living dust, for, as we have seen before, a spray of carbolic acid in an ordinary atmosphere is able to destroy the fermenting power of the dust. Such being the case, if the tissue, taken with all pre- cautions undergo putrefaction, it is possible that the causes of this fermentation were present in it while in the living body — the degi'ee of probability depending of course in great measure on the known skill of the experimenter. But if no change occm-s, it is proof positive that there were no causes of change present in the body. In other words, as these unboiled tissues remained unaltered, it is quite certain that they have no inhei'ent tendency to undergo fermentation even when freely exposed to air. I used the turnip infusion partly because I wished to know whether the beakers had been thoroughly purified, and partly in order to keep the tissues moist, for I had found in a former experiment that they dried too rapidly in the open-mouthed vessel if no fluid were present. Since that time I have used cucumber fluid, as being more putrescible. Further, by the use of tliese infusions the conditions favoui- ing fermentation are greater, for we have here a boiled highly putrescible infusion of turnip, and an unboiled, if possible still more putrescible, infusion of meat, as well as the meat itself. It wei'e hardly possible to provide more favourable conditions for fermentation. Nevertheless no change occurred. I may here point out the light thrown by these experiments on the cause of the want of success in the paraffln experiments. In the first attempt which I made with tlie paraffln any of the sup])osed causes of failure might have l)een in 0])erati()n, but in the experiment just narrat(;d the entrance of aii- laden will) septic dust into the blood-vessels is excluded because the opera- tion was done in a spray of carbolic acid. Therefore the failure in 48 THE rARTICULATE THEORY OF FERMENTATION. the four vessels must have been due to dust in the paraffin, or to cracking of this after solidification. But, it may be said, the absence of putrefaction in the beakers was due to the action of the carbolic acid on the tissue. This, however, is not the case, for the following reasons : — In a preliminary experiment I touched the outside of the flask (which was of course covered with impure dust) with one of the portions of the tissue, and afterwards introduced this piece into the flask, and in it putrefaction occurred rapidly. Again, the fact that four paraffin flasks went wrong (the organs being there also subjected to the action of the spray) shows that this had no influence. Again, when the gall-bladder is wounded fermentation often occurs. This latter fact is illus- trated by the following experiment : — A medium-sized rabbit was killed by a blow on the nape of the neck. The abdomen bad been washed beforeliand with 1-20 carbolic acid lotion, and was now rapidly opened under the spray. Into seven beakers containing pure cucumber infusion, two pieces of liver, one piece of kidney, one piece of spleen, one of muscle, and one of mesentery were introduced. In cutting out the liver the gall-bladder was injured. Four weeks later, five beakers were unaltered, the two which had fermented being those containing the pieces of liver, which indeed had undergone fermentation within twenty-four hours. I have since met with sevei-al similar instances. Further, if putrid matter be injected into the jugular vein of the animal a few minutes before death, all the tissues re- moved and preserved in the manner described undergo putre- faction. I have repeated these experiments many times with like results,' and I therefore conclude that the tissues of the healthy ' On two occasions I have found that the apparently healthy living tissues, preserved by the method before described, underwent fermentation and organisms developed in them. In one case the kidney alone of all the organs taken, and in another both kidney and liver, miderwent fermentation with development of organisms, and as I was very careful in performing the expe- riments, I do not think that this could have occurred from any error in experi- mentation, and therefore I conclude that the causes of fermentation (micro- organisms, as we shall afterwards see) were present in the healthy circulating GENERAL CONCLUSIONS. 49 living body, like the fluids, contain no ferment capable of causing putrefaction after death, and remain pure in flasks so long as the dust of the atmosphere is excluded. (In some instances the heart with its contained blood was also removed, and remained, like the other tissues, unaltered. Rabbits and cats were the animals used for the experiments.) Somewhat similar experiments Avere published in 1878 by Chiene and Ewart, and they yielded similar results.' Quite recently,^ Rosenbach mentioned experiments on this subject performed by Meissner. Meissner was able to preserve the internal organs of cats and rabbits in contact with boiled water and pure air, for two to three years, without the occur- rence of any putrefactive change. He was also successful in preserving the blood of mammalia, human urine, and g'oat's milk. The experiments were done with strict aseptic j^recau- tions, and led him to conclusions similar to the above. Such, then, are the chief facts at present known with regard to boiled and unboiled fluids and tissues. We shall add much to them, and to the support which they give to the views here expressed, when we come to consider more minutely what is the nature of the particles which cause putrefaction. On reviewing the mass of evidence before us we have it dis- tinctly shown that boiled fluids and tissues have no inherent tendency to undergo fermentative changes ; that oxygen, whether pure, nascent, or mixed with nitrogen in the proportions present in air, cannot cause fermentation, if only the air be previously passed through such a liquid as sulphuric acid, be heated strongly, be Altered through cotton wool, be made to enter very slowly into the flask containing the fluid or allowed to deposit its dust by gravitation, or be previously acted on by carbolic acid. blfiod. That an orgniiif^jn may be present in an active state in tlic circulating blood need not be a matter of surprise, and need not therefore lead us to the conclusion that they are always or even generally there, especially as one single organism would be sufficient to account for the result in each of these instances. It is indeed surjirising that organisms which must now and then enter the blood arc so rapidly and surely destroyed. ' Journal of Aiuitonnj and I'Jn/Riolofjy. ■ Uvidschc ZcitH'-hrift fiir C/nrurf/ie, xiii. .'544. E 50 THE PARTICULATE THEORY OF FERMENTATION. Thus the material in the air which causes putrefaction is not a gas, for that would be continuous, and would not be re- movable by filtration or by rest ; but it is something discon- tinuous, something heavier than air, something particulate. These particles may be deprived of their power of causing fermentation by the action of chemical substances, such as sulphm'ic and carbolic acids, and also by being subjected to a high temperatm'e. As they are completely destroyed by heat (as shown by Tyndall), they are probably of an organic nature. And it is not that by boiling these fluids an inherent tendency to ferment has been destroyed, for, as we have seen, they possess no such inherent tendency. For not only do unboiled fluids and tissues outside the body fail to putrefy when protected carefully from dust — they also undergo no change, as indeed necessarily follows from the foregoing, when confined in natural or artificial cavities in the living body. Who is not acquainted with the behaviour of blood when ex- travasated into the tissues or cavities of the living body so long as it is not exposed to the outer world ? We all know what a large amount of effused blood may be present about the ends of a fractured bone without decomposition occurring in it, and the same is the case in the hemorrhages into joints in hemophilia, hemorrhages within the skull, &c. And we also know what frequently happens if we cut into any of these extravasations and admit dust-laden air into them. The blood which we found odourless, and it may be clotted, may become in a few hours a foul- smelling liquid ; it has, in fact, putrefied, just as it may do when kept in a flask without exclusion of dust. And just as in the case of blood, so with other fluids. Hy- drocele and serous effusions remain unaltered so long as they are kept from the dust. Examine the pus from a chronic abscess, and even though that abscess be connected with carious bone, it will be found to be odourless and bland, and if carefully received into pure flasks, will, just as in the case of blood, remain odourless and apparently unchanged for an indefinite length of time. (I shall give later on the explanation of the cases where the pus of acute abscesses, when let out, is found to have a foul smell, as is sometimes the case in acute necrosis.) CONCLUSIONS. 51 And not only is this the case with fluids, it is also the case with tissues in the living body. In a fractm-e many portions of the tissue are cut off from their vascular supply, or killed by the violence causing the injury, and yet they do not decompose ; they are not separated as sloughs — they disappear by absorption. Yet if the same injury be not subcutaneous and the injured parts be exposed to ordinary air, they putrefy, and come away in a few days as sloughs. So in infarcts in internal organs, the tissue in the region of the infarct dies, but does not putrefy — does not slough ; while when death of the integuments occurs, putrefaction and slough- ing follow, for here the dead tissue is exposed to the dust of the atmosphere. Similarly, in the case of wounds, when a piece of skin is cut away and an open sore is left, the blood and serum which col- lect in that sore ferment, in all probability putrefy, because the air admitted to them was not heated air, not filtered air, was air which had not been acted on by suitable chemical sub- stances. The causes of fermentation are therefore solid particles, pro- bably of an organic nature, which are present in varying quan- tities in the surrounding air, and which are deposited as dust on all surrounding objects. It is thus evident that in order to prevent putrefaction it is only necessary to prevent the access of these particles, or, if this cannot be done, to destroy their fermenting power in some way or other before they reach the wounds — as, for instance, by the use of carbolic acid. It is on this principle that Aseptic Su7'gery,^- as introduced by Mr. Lister, is based. ' The term ' aseptic ' is the best to indicate this form of antiseptic surgery, because, as we siiall see, there are many different forms of treatment which come under the term 'antiseptic,' while this is the only one which can truly bear the name 'aseptic' In other words, there are many methods by which the occurrence of putrefaction is more or less interfered with, but they all act on a more or less imperfect principle, with the exception of that introduced by Mr. Lister, which, founded on a true principle, attains the ideal of results — viz. a complete absence of putrefaclion— an asepsis. His methcd, then, is best designated by the term expressing its result — Aseptic. E 2 52 ASEPTIC SURGERY— MATERIALS EMPLOYED. CHAPTER in. ASEPTIC SURGERY MATERIALS EMrLOYED. Problems to be solved in order to keep a wound aseptic : Carbolic acid — CarhoUc lotions — Pure carholic acid — SoUttioitin metliylated sjnrit — carbolic oil — Carbolic acid and glycerine: Sj^ray producers: Catgut — Carholiscd catf/ut — Mr. Lister's carholiscd chromic catgut — Dr. MacEwen's chromic catgut— Ca-tguttrough and pocltet caxe: Carbolised silk : Protective: Carbolic gauze — Composition — 3Iethod of preparation — Von Bruns'' gauze: Mac- intosh : Sponges : Boracic acid — Boracic lotion — Boracic lint — Boracic ointm-ent: Salicylic a-cid— Salicylic acid cream — Salicylic ointment : Chlo- ride of zinc : Iodoform : Carbolised cotton wool. Aseptic surgery is based on the piinciple first enunciated by Mr. Lister, and indicated in the preceding pages ; viz. the exclusion of active ferments from the discharges of wounds. Theoretically, this is the ideal form of antiseptic surgery, for here, supposing that the attempt is successful, the causes of putrefaction do not enter the wound in a state capable of pro- ducing fermentation, and therefore decomposition of the dis- charges, or of dead portions of tissue, &c., cannot 2:)0ssibly occur. The problem which Mr. Lister sought to solve may be shortly stated as follows : — On all objects in the external world septic dust is present — on the skin of the patient, on the hands of the surgeon and his assistants, on all instruments, in water, in the air, &c. ; and when a wound is made any introduction of this dust must be carefidly avoided. Then after the wound has been made, care must be taken to prevent its entrance during the after-treatment. Some sort of dressing must be provided which shall prevent its passage in an active state, and at each change of this dressing the problem is the same as at the time of infliction of the wound. Such being the question CARBOLIC ACID. 63 at issue, I must now proceed to the modes in which it has been answered. I shall first enumerate the substances employed in aseptic surgery. Carbolic Acid is the antiseptic employed to destroy the particles in the air and on surrounding objects which give rise to putrefaction. It is obtained in the solid state and of ex- treme purity from Bowdler and Bickerdike, Church, Lancashire, who give it the name of Absolute Phenol. It is used in various forms. The Cai'bolic Lotions used are of two strengths — 1 in 20 and 1 in 40 ; one part of crystallised carbolic acid dissolved in 20 or 40 parts of water respectively. The solution is kept in a stoppered bottle in order to avoid evaporation of the acid. It ought to be quite clear ; when it is not so, and more especially when globules of oily matter are present, it is impure, the oily particles consisting of cresylic acid. It is a mistake to add alcohol or glycerine to aid the solubility of the acid, because these substances hold the acid more tenaciously than water, and it is thus not so potent for producing an instantaneous effect. Undiluted Liquid Carbolic Acid may in some cases be required. This is obtained by liquefying the crystals by the addition of a few drops of water. This is chiefly used for injecting naevi, varicose veins, vtc. A solution of carbolic acid in methylated spirit or in recti- fied spii-it, in the proportion of 1-5, is used for the purpose of purifying wounds inflicted some twenty-four or thirty-six hours before coming under treatment. Carbolic Oil is employed in various proportions, generally 1 in 5, 1 in 10, and 1 in 20, consisting of carbolic acid mixed with olive oil in the foregoing proportions. Carbolic oil 1-5 is but rarely used, tliough it is occasionally applied as a dressing to foul wounds, for the purpose of purify- ing them. It is chiefly known as the solution in which catgut is permanently preserved. Carbolic oil 1-10 is used as a dressing for wounds in the neighbourhood of the anus, penis, &c. Carbolic oil 1-20 is used for oiling catheters or other in- 64 ASEPTIC SUROERY^MATERIALS EMPLOYED. struments before introducing them into tlie bladder. Carbolic acid of this strength does not seem to be too irritating for the Fig. 15.— Hand spray producer. mucous membrane of the urethra, while it apparently secures against the introduction into the bladder of matters which are capable of causing putrefaction. There are various objections to these oily dressings. The chief are, that the carbolic acid is very rapidly washed out by the dis- charge, and that they are very dirty, and soon spoil india-rubber tissues. The latter disadvantage is got rid of by the use of carbolic acid and glycerine in the proportions of 1-5 and 1-10. This is now employed as a dressing in the cir- cumstances in which the oil has been generally used. A sjjray of carbolic acid is generally employed in order to purify the atmosphere. This is obtained by driving a rapid Fig. 16.— The ordinary steam spray producer. CARBOLIC ACID SPRAY. 55 current of air or steam through a horizontal tube so as to pass over the orifice of a more or less vertical one. In this way a vacuum is produced in the vertical tube, and the fluid at its lower end rises, and is expelled from the orifice in the form of spray. We have two forms of spray : one in which air is Fig. 17, Steam spray producer, showing the lamp at present IN USE. It consists of a small flamo, which plays on a plate of metal attached to a hollow central tiibe containing a wick, and perforated by holes at the top. The heat is communicated to tlie wick —the spirit volatilises, and Inirns as it escapes from the top of the tube. The hole in the plate allows the flame of tlje snjall wick to pass up and li^■ht the spirit vapour, which jiasscs out through the holes at the top of the central tube. The cap, which is jjlacfd over the lamp when not in use, and the boiler and vessel for the carbolic acid, are indicated by dotted lines. driven over the vertical tube — hand or foot sprays ; and the other in which steam is employed — steam sprays. The hand or foot sprays produce a somewhat coarse spray, and the force required is such as soon to exhaust the individual employed. They are therefore very uncertain implements, and have now entirely given place to the steam spray.-;, where there is a steady current as long as the water in the boiler lasts. When the hand s])rays are emi)loypd 1-40 solution is placed in the bottle. 50 ASEPTIC SURGERY— MATERIALS EMPLOYED. In the steam spray the 1-20 solution is used because the steam, mixing with the solution, reduces its strength to 1-30 or 1-35. I need not describe here the steam spray apparatus, more especially as it can be easily obtained, of Mr. Lister's pattern, from David Marr, 27 Little Queen Street, Holborn. These sprays consist of the following parts : — A boiler which contains water, and which is heated by a spirit lamp placed beneath it. The steam issues through a tube placed at an angle to another more upright one, through which the carbolic acid lotion 1-20, which is placed in the glass retort, is sucked up. This 1-20 lotion, mixing with the steam, makes a solution of 1-30 to 1-35. The carbolic acid solution passes through a sponge at the bottom of the upright tube, which filters it, and thus prevents the minute orifice of the tube from be- coming choked up by coarse particles. These sprays are of various sizes, and the largest ones have two nozzles, which may be vised singly, or to- gether where the field of operation is large as in ovariotomy. The catgut used for tying the vessels is prepared in the following manner : — Ordinary catgut as obtained from the shops, when introduced into blood-serum, soon swells up and becomes weak. At the same time it is very slippery, and a knot will not hold ; and when placed in the tissues it very rapidly becomes absorbed. With the view of obviating these defects it is prepared by placing it in a solution of carbolic acid in oil (1-5) with a very small quantity of Avater (10 per cent.) diffused through the oil. As the water ultimately falls to the bottom, a few pebbles are placed on the bottom of the vessel, on which the catgut rests. It does not then come in contact with the water. As a result of keeping it in this solution, the catgut first becomes supple and soft, but afterwards harder and firmer, and is then al)le to resist the action of the fluids and Fig. 18.— Large steam spray riio- DUCER WITH DOUBLE NOZ/LE FOR OVARIOTOMY, ETC, CATGUT. 67 tissues for a considerable time. It is kept in this fluid for six or eight months, and is then transferred to the ordinary 1-5 oily solution. The longer it is kept in this solution the better it becomes. The rationale of this method will be found in ^Mr. Lister's paper in the ' Lancet ' of Feb. 5, 1881. Quite recently ^ jNL-. Lister has published a new method of pre- paring catgut, by means of which a stronger article is obtained, and one not absorbed nearly so soon as the old kind. It also possesses an advantage over the old kind, in that it disappears by erosion of the surface, and does not become infiltrated with cells, as is the case with the ordinary forms. It thus remains as a firm constricting band, till it is completely replaced by new tissue. I cannot do better than quote JVIr. Lister's description of the method by which this gut is prepared : ' I dissolve one part of chromic acid in 4,000 parts of distilled water, and add to the solution 200 parts of pure carbolic acid, or absolute phenol. In other words, I use a 1-20 watery solution of carbolic acid — only that the carbolic acid is dissolved, not in pure water, but in an exceedingly dilute solution of chromic acid. But, minute as is the quantity of the chromic acid, it exerts, when in conjunction with carbolic acid, a most power- ful effect upon the gut. The first effect of the addition of the carbolic acid to the chromic solution is to change its pale yellow to a rich golden tint. But if the liquid is allowed to stand without the introduction of the catgut, it changes in the course of a few hours to a dingy reddish-brown, in consequence of some mutual reaction of the two acids ; and a considerable amount of reddish grey j)recipitate is formed. If, however, catgut about equal in weight to the carbolic acid is added as soon as the ingredients are mixed, the liquid retains its bright- ness, and the only change observed is the gradual diminution of the depth of the yellow colour; the precipitate, which I pre- sume still occurs, taking place into the substance of the catgut. As soon, therefore, as the preparing liquid has been made, cat- gut equal in weight to the phenol is introduced into it. If you have too large a ]»roportion of catgut, it will-not be suffi- ciently ])repared; if you have too small a (juantity, it may run the risk of being over-prepared. At the end of forty-eiglit ' Lancet, Feb. 5, 1881. 58 ASEPTIC SURGERY— MATERIALS EMPLOYED. hours the chromic element of the liquid has nearly spent itself, and precipitation is complete. The catgut is then taken out of the solution and dried, and when dry placed in 1-5 carbolic oil : it is then fit for use. . . . The preparing liquid causes a certain amount of softening of the catgut, and if it is intro- duced in loose hanks, this will tend to produce a little uncoil- ing of the twisted cord, and a still greater degree of uncoiling will take place during drying. It is of very great importance that this should not occur, because it involves weakening of the thread, and that in different degi'ees in different parts ; and this may lead to the gut giving way when you subject it to a strain. The catgut then should be prepared on the stretch, both when it is put to soak and when it is put to dry. ' I need not enter into the mode in which this can be done by the manufacturer. I may only say this, that the surgeon who wishes to prepare it himself may do it in different ways. For instance, he may take two large test-tubes, one a little larger than the other, and he may wind the catgut on the smaller tube, fixing one end by sealing-wax, winding it round, and then bringing it up again, and fixing the other end with sealing-wax at a higher level than the liquid will reach, putting sufficient liquid into the larger test-tube, and introducing the smaller test-tube with the catgut wound round it, with a little shot to keep it down in the liquid. After forty-eight hours, he takes out the smaller test-tube, and leaves it till the catgut is completely dry. I merely mention this as an illustration, and also as furnishing a hint to some surgeons in private practice who may desire to prepare the catgut themselves ; or a couple of gallipots, one larger than the other, will do just as well. But, as I have said, the principal uncoiling takes place during drying ; and for all ordinary purposes a sufficiently good article is got by putting the catgut loose into the liquid, and making it dry on the stretch by tying the ends of each hank to two fixed points in a room.' Erosion of this catgut does not begin till about a fortnight after its introduction into the tissues. Dr. MacEwen has lately brought forward a somewhat different method of preparing catgut.' ' These ligatures are prepared by making, first, a watery solution of cliromic acid, one ' Britisli Medical Journal, Jan. 2'.), 1881. CATGUT. 59 to five ; then one part of this solution is added to twenty of glycerine. This forms a dark greenish compound, in which the hanks of catgut are inserted and retained for seven or eight months, the bottle containing them being occasionally shaken. At the end of this time the catgut acquires a semi-translucency, and has a dark colour like preserved ginger. It is then ready Fig. 19. — Trough for catgut. for use, and is stored in a solution of carbolic acid and glycerine (one to ten).' Ligatures so prepared begin to soften on an average about the fourteenth day, and are more or less com- pletely absorbed the twentieth day. A very convenient method of keeping catgut for use in hospital is to wind it round reels, say three, each holding a different thickness of gut, which are suspended in a vessel X._^ V ^ ^ ^' -^^^^ Fig. 20. — Lister's pocket catgut holder. A, HoMcr complete. B, The reel on which the catgiit is wound. containing carbolic oil 1-5 (see Fig. 19). The lid of the box is perforated with holes through which the ends of the catgut pass. In this way the gut may be taken directly from the oily solution without any trouble. In order to have a supply of gut always at hand, jNIr. T.,ister has devised the catgut holder shown in the accompanying figure (P^'ig. 20). The gut is wound on a reel which is carried in a German silver case. There is no necessity to fill tin's case with 60 ASEPTIC SURGERY— MATERIALS EMPLOYED. carbolic oil, as is done by some surgeons. Sometimes the case is combined with a caustic holder at the other end. Carbolised Silk is often used for sutures, and is prepared as follows : — Nine parts of beeswax and one part of carbolic acid are melted together. Silk thread of various sizes is steeped for some minutes in this mixture, till it is thoroughly impreg- nated with it. As the thread is taken out, it is drawn through a cloth in order to remove the superfluous wax. The wax holds the carbolic acid, makes the thread more useful, and fills up to some extent its interstices, thus preventing it from becoming soaked with fluids. The carbolised silk thus prepared is kept permanently in stoppered bottles, or wrapped in carbolic gauze. It must- not be steeped for any length of time in the lotion before being used, because the threads become opened out. If the thread be properly kept, the interior is aseptic or even anti- septic, and passing the thread through the fingers moistened with carbolic lotion, or a momentary immersion in 1-20 car- bolic solution, is sufficient to destroy any septic dust adhering to its exterior. In order to protect healing wounds from the irritation of carbolic acid a special material is employed termed the Protec- tive. This consists of oiled silk coated with copal varnish. When this is dry a mixture of one part of dextrine, two parts of powdered starch, and sixteen parts of cold watery solution of carbolic acid (1-20) is brushed over the surface. The rationale of this method of preparation is the following : — Oiled silk alone is better for the purpose of a protective than gutta-percha tissue, because carbolic acid does not so readily pass through it. It does, however, do so, and therefore copal varnish, which is almost absolutely impermeable to carbolic acid, is added. As, however, the fluid collects on this as on a duck's back, leaving intervals between each drop on which dust may fall and escape the action of the acid, the dextrine solution is added, and the result is, that when moistened the whole surface of the protec- tive remains imiformly wet. The use of the carbolic acid in the dextrine solution is not to add any carbolic acid to the pro- tective, but because it is better than water for enabling the dextrine to adhere to the varnished oiled silk. For the same reason the ])owdered starch is added. The original carbolic CARBOLIC GAUZE. 61 acid flies off very quickly from the protective, leaving a material containing no antiseptic in its substance. Garholic Gauze is the material generally employed as a dressing to guard against the entrance of causes of fermentation into a wound after an operation. The gauze used is ordinary fine unbleached tarlatan washed and dried. There are various methods of impregnating this gauze with carbolic acid. I will give Mr. Lister's description of a simple method, w^hich can be used in any hospital, and which was recently employed during the Russo-Turkish war for making fresh gauze in camps. ^ The mixture employed for charging the gauze was originally one part of carbolic acid, five parts of resin, and seven parts of paraffin. Lately the formula has been changed to one part of crystallised carbolic acid, four parts of common resin, and four parts of paraffin. These materials, mixed together, are added to an equal weight of unprepared gauze. ' In order to charge the gauze, the paraffin and resin are first melted together in a w^ater bath, after which the acid is added, and blended by stirring. The object now is to diffuse this melted mixture equally through the cotton cloth, and for this purpose two things are requisite, viz. that the cotton be at a higher tem})erature than the melting point of the mixture, and that it be subjected to moderate pressure after receiving it. The cotton cloth, a yard wide, is cut into six-yard lengths, and these having l^een folded so as to be half a yard square, are placed in a dry hot chamber, formed of two tin boxes placed one within the other, with an interval to receive water, which is kept boiling by fire or gas beneath, the upper edges of the boxes being connected and provided with an exit pipe for the steam. There is also a glass tube arranged as a gauge of the amount of the water, and the chamber has a properly fitting lid The bottom of the chamber is strengthened with an iron plate, to enable it to bear the weight used for compressing the gauze when charged. There is a piece of wood about two inches thick nearly fitting the chamber, covered with sheet lead, so as to make it about as heavy as a man can lift by means of two handles in the upper fjurface. The weight is lieatcd along with the cotton, and is puf, ^rst into the cl;:imber so as to leave ' See Lancet, Marcli 13, 1875. (i2 ASEPTIC SURGERY— MATERIALS EMPLOYED. the cotton loose for the penetration of the heat, which occupies two or three hours. The cotton when heated is taken out of the chamber along with the weight, and placed in a wooden box to protect it from the cold. (It would be better to have a second hot chamber for this purpose, since in cold weather the cotton is apt to be too much cooled in spite of the protection of the wooden box.) The heated gauze is then at once charged with the melted mixture of carbolic acid, resin, and paraffin, in quantity equal to the weight of the cotton fabric (or slightly less), and in order to diffuse the liquid as equally as possible, it is sprinkled over the gauze by means of a syringe, with a number of minute perforations in its extremity, the body of the syringe and the piston-rod having each a wooden handle to pro- tect the hands of the workman from the heat. The syringe is constructed to hold half the quantity of the mixture required for charging one piece of cloth. One folded piece being placed at the bottom of the hot chamber, its upper half is raised and turned aside, and one syringeful is sprinkled over the lower half. The upper half is then put back into position, and another syringeful thrown on. The same process is repeated with all the other pieces of gauze, after which the weight is put into the chamber to compress the charged cotton, and the lid applied. An hour or two are then allowed to elapse, to permit the com- plete diffusion of the liquid, when the material is fit for use. The apparatus above described can be made by a common tin- man for about lOL' Fig. 21 shows the apparatus employed in the Griasgow Infirmary. • As the muslin is the dearest item in the gauze Mr. Lister has suggested that the dressings should be washed and the gauze recharged. The larger dressings are therefore kept and sent back to the manufacturer, who washes and recharges them. This recharged gauze can then be used as loose gauze in future dressings. In this gauze the carbolic acid is the only active agent ; the resin is used to hold the acid — i.e. to prevent it from being washed out too soon by the discharge — while the paraffin is employed to lessen the adhesiveness of the resin. The gauze ' See ' Practical Papers on the JIaterials of the Antiseptic Method of Treatment.' I'y George lieatson. Glastjow Medical Journal, March 1880. CARBOLIC GAUZE. 63 ought to be kept in a tin box, closing tightly to prevent evaporation of the carbolic acid. It is used either in the form of loose gauze or folded dressings and bandages. A great many different ways of preparing gauze have been published, but none are so good as that just described. Von Bruns has lately recommended a gauze containing castor-oil instead of paraffin. His formula is — Carbolic, acid Resin Castoi--oil Spirit 1 part 4 parts 8 „ 20 „ Fig. 21. — Machine used in the Glasgow royal infikjiary for manufacturing gauze. A is tlie receptacle for the antiseptic mLxture of carbolic acid, resin, and paraffin ; E is the tin case in whicli the muslin is heated, impregnated with the mixture, and submitted to pressure. IJ is a pipe whicli conveys steam for heating the apparatus, and E E are stopcocks for turning on or shutting off the steam in connection with either A or B. (From Dr. Beatson's ' Practical Papers on Antiseptic Surgery.') The resin is first dissolved in the spirit, then the carbolic acid and castor-oil are added. The gauze is simply soaked in this, and then hung up to allow the spirit to evaporate. The objection to this gauze is that the castor-oil interferes with the affinity of resin for carbolic acid, and thus the carbolic acid will be sooner washed out, «ind the gauze thereby rendered less trustworthy. In order to prevent the discharge from soaking directly through the dressing macintosh cloth is used. This is cotton cloth with a thin layer of india-rubber spread on one 64 ASEPTIC SURGERY—MATERIALS EMRLOYED. side. It is placed outside the gauze dressing. As a rule one layer of the gauze comes outside it, partly in order to keep it in position, and partly also, in case any hole should exist in the macintosh, to have a little antiseptic material outside. Care is taken that the side on which the india-rubber is spread goes next the wound, for if the other side be placed inwards it absorbs discharge, and, not being itself antiseptic, it becomes in reality a piece of impure cotton in the interior of the dressing, and may thus communicate putrefaction inwards. The macin- tosh itself also gets spoilt when so used. The dressing con- sists of a piece of gauze of sufficient size folded in eight layers, beneath the outer layer of which the mackintosh cloth is placed. Sponges are washed after an operation, and are then kept soaking till required in a jar containing carbolic acid 1-20. During an operation they are washed in 1-40 carbolic acid lotion. These sponges often become filled with fibrin, and thus rendered more or less useless. It is very difficult to remove this fibrin by washing. Mr. Lister, therefore, after an operation places the sponges in a tank containing water. Putrefaction of the fibrin occurs, and after some days the sponges can be easily cleansed. They are then placed till required in the 1—20 carbolic solution. When the wound becomes quite superficial, various prepar- ations of BoKACic Acid may be employed with advantage. Boracic lotion is a cold saturated solution of boracic acid (BgOgSHgO) in water. This acid is soluble in 25 to 30 parts of cold water, and in very much larger proportion when the water is boiling. It is convenient to tinge this solution with litmus in order to distinguish it from the carbolic lotions. Boracic lint is ordinary surgical lint soaked in a hot saturated solution of boracic acid and then hung up to dry. About half its weight consists of crystals of the acid. This is also stained with litmus. Boracic ointment is employed in certain cases. Two strengths are commonly used, called full strength and half strength ; the former being applied to wounds where cavities exist, the latter to superficial wounds which one wishes to heal SALICYLIC ACID. 65 rapidly. The following is the original formula for the full strength ointment : — Boracic acid crystals ..... 1 part White wax ....... 1 „ Paraffin ........ 2 parts Almond-oil ....... 2- „ First mix the wax and paraffin by heating them together, then add the oil ; mix the crystals with this in a warm mortar, and continue the process of mixing till the liquid solidifies. Spread on thin cotton cloth. The half strength contains half the quantity of boracic acid. A much softer and more manageable boracic ointment is now made with vaseline. The following is the best formula : — Make a basis of 2 parts of paraffin to 1 part of vaseline. Take of this o parts „ boracic acid, 1 part. Mix. Salicylic acid cr'eam is used for applying around a wound when a dressing is to be left on for some days. It prevents irritation by the discharge. It formerly consisted of salicylic acid crystals mixed with 1-20 carboh'c acid lotion in sufficient quantity to form a creamy fluid. This is apt to separate into two layers, and therefore it is better to make a cream by mixing salicylic acid with glycerine so as to form a paste. This latter cream remains of uniform consistence, and is easily applied. For this purpose Mr. Lister uses glycerine and carbolic acid 1-10. The' formula for salicylic oinhnent is — Of the same l^ase as is used for boracic acid . 29 parts Salicylic acid ....... 1 part. For the purpose of purifying sinuses, putrid ulcers, &c., a solution of chloride of zinc is used of the strength of 40 grs. to the oz. of water. This is either apjdied on lint to the whole surface of a wound, or it is injected by means of a syringe and catheter into all the deep parts of the wound, care being taken to provide free exit for the fluid injected. If the exit of the solution is obstructed, it may pass into the tissues and cause gangrene. lodofoivi is now applied to the surface of ulcers, and F 66 ASEPTIC SURGERY— MATERIALS EMPLOYED. answers the same purpose as the chloride of zinc solution, while it causes no pain. Carholised cotton ivool is used in some cases of gangrene. It is obtained by soaking pure cotton wool in a 1 per cent, solution of carbolic acid in ether. The cotton is then dried and used immediately. DESCRIPTION OF AN ASEPTIC OPERATION. CHAPTER IV. ASEPTIC SURGERY (continvcd). Example of an aseptic operation : Purification of the skin — Fingers — Instru- ments : Spray — Precautions — Probable errors, and mode of remedying them : Guard : Ligature of arteries : Drainage of wounds — India-rubber tubes — Catgut drains — Horse hair — Decalcified bone tubes (Neuber's and MacEwen's) : Sutures ; Button stitches — Stitches of relaxation — Stitches of coaptation — Aseptic strapping — Protective : Deep dressing : Loose gauze : Gauze dressing : Elastic bandage. Changing the dressings — Time— Method. Treatment op ulcers : Purification of the sore : Boracic dressing : Boracic and salicylic ointment : Boracic poultice. Having described the materials employed in aseptic sm-gery, we must now consider how they may best be employed. Take as an example of an operation the removal of a fatty tumonr. The patient having been brought under the influence of chloroform or other amesthetic, the skin over the tumour, and for some distance in the vicinity, is thoroughly pmified from any active dust by washing it well with a solution of carbolic acid 1-20. The surgeon and his assistants also wash their hands in 1-40 carbolic lotion, while the instruments are put to soak in 1-20. A towel is arranged close to the tumour, gene- rally on the part of the table between the operator and the patient, which towel has been well soaked in 1-20 carbolic lotion, and is meant as an antiseptic basis on which instruments may be laid during the course of the operation without any fear of their contamination. This towel is so arranged as to be within the cloud of spray. A spray being now made to play over the i)art from a convenient distance, the surgeon makes his incisions, removes the tumour, ties the vessels with catgut, introduces a suitable drain, stitches up the wound, and a])i)lies a piece of protective but little larger than the wound — the pro- tective being of course dipped in the 1-40 carbolic solution. p2 68 ASEFTIC SURGERY. Outside this is applied a piece of wet gauze, consisting of several layers of loose gauze which has been soaking for some time in the 1-40 carbolic solution. This wet gauze and pro- tective are called the deep dressing. The wet gauze must overlap the protective in all directions. Then any remaining hollow is filled up with loose gauze, and outside the whole a gauze dressing is fixed. This dressing consists of a piece of carbolic gauze of suitable size, folded in eight layers, and having the macintosh placed beneath the outermost layer, with the india-rubber side inwards. The dressing is fixed by means of a bandage, and when this is accomplished the spray may be stopped. Then around the edge of the dressing an elastic bandage is applied so as to keep the edge constantly in contact with the body, and to allow no interval to occur between the dressing and the skin during the movements of the patient. The elastic is carefully fixed to the edge of the dressing by means of safety pins. In the after progress of the case the dressing is changed according to the amount of discharge, though in no instance is it left longer than eight days. Such is, very briefly, a sketch of the ordinary method of performing operations aseptically. I shall now consider each step in detail, and point out the most frequent sources of failure in carrying out the method ; for it must always be borne in mind that the whole operation, as far as regards the avoidance of putrefaction, requires as much care as if it were an experiment performed in a laboratory on putrescible fluid con- tained in glass vessels. The first thing, then, is to purify the skin in the neigh- bourhood of the seat of operation. This is necessary, because the skin is covered with dust. The natural grease of the skin is not easily removed by simple washing, and it protects the septic particles present beneath it and in the hair or sebaceous follicles. This purification of the skin is carried out by washing it well with 1-20 carbolic lotion, the antiseptic being allowed to act for some little time. It is well, having first washed the neigh- bourhood thoroughly, to apply over the seat of operation a large rag or towel soaked in 1-20 solution, and to allow this to remain on the part for some minutes. Where the epidermis PURIFICATION OF THE SKIN. 69 is thick, or where there is any putrid matter present, it is best to apply this towel about half-au-hour before the operation. It is not necessary to wash the skin with soap and water, or with alcohol or ether, as is often done in Germany. The carbolic acid has a wonderful power of penetrating grease or epidermis ; and if time be given for it to act it is unnecessary to wash off the grease beforehand. If the wound is to be in the neigh- bourhood of hair, as in the axilla or near the pubis, the part must be shaved, and then well soaked with the carbolic lotion. The errors in the purification of the part may be that the skin is not purified at all, or that it is washed with water ; or, as I have seen, the operator simply allows a carbolic spray to play over it for a minute or two, and is satisfied with this ; or he merely rubs the siuface with his wet finger. This purifica- tion must, however, be done thoroughly, for every hair follicle and gland duct may contain causes of putrefaction. Carbolic oil is used by some instead of the watery solution to purify the skin. This is a great mistake, for oil has a much greater affinity for carbolic acid than water has, and therefore the carbolic acid in the oily solution does not act with the same rapidity as the watery solution. Thus 1-20 or even 1-10 car- bolic oil is not nearly so useful for producing an instantaneous effect as 1-20 carbolic lotion. At the same time the operator and his assistants purify their hands. This must also be done thoroughly, and the folds of skin about the nail more especially must be well cleansed with the lotion. In an important operation, as in an o})eration on a joint, it is well to use 1-20 carbolic lotion for this purpose, so as to avoid any chance of a lurking particle ; but in ordinary operations 1-40 is quite sufficient. This purification of the hands is only too apt to be a sham, no care being taken about the nails and folds of skin. The 1-20 is not used in all cases, because 1-40 is really sufficient, and the stronger solution is apt to benumb the hand. The instruments are purified by immersion in 1-20 carbolic lotion before theojjeration. A tin or jxHcelain trough filled with the 1-20 solution is employed for tliis purpose, the instruments being placed in it souk; time liefore an operation (l*'ig. 22). The instruments are not merely dipped ; they must remain in 70 ASEPTIC SURGERY. the lotion for some time, because the carbolic acid requires a little time to act on the grease or dirt on them. For the same reason the teeth of toothed instruments ought to be cleaned thoroughly, and forceps locking by catches ought to be widely opened, so as to allow the solution to come in contact with all parts. The whole instrument must be immersed, for if only the point be purified it may happen that the impure handle is in- advertently brought into contact with the wound during the course of the operation. The errors most likely to occur are either that during the course of the operation an instrument not previously in the tray is used without any attempt at purification, or that the instru- ment is imperfectly purified or only part of it cleansed. I have seen the danger of partial purification more than once exem- FlG. 22. — I'DRCELAIN TROUGH CONTAINING INSTRUMENTS SOAKING IN CARBOLIC LOTION. plified. Thus I have seen the blade of a knife alone purified, and the surgeon in the middle of the operation use the unclean handle to separate the tissues. Other errors in the manipu- lation of instruments will be referred to presently. The spray is very important in many cases, for it provides an atmosphere in which instruments, &c., may be kept without danger of contamination. In order to have a wide and large antiseptic area in which to work, the spray ought not to be too near, about six or eight feet or more being a suitable distance for a good spray. Care must be taken that the spray is not blown off the part by draughts or by people moving about. The spray is most necessary in opening abscesses or in stitching up wounds, for, to take the latter case, as the wound is not syringed SPRAY 71 out after the stitches are inserted, septic air may be inclosed in the cavity of the wound, and may give rise to putrefaction if S ° a g ""'■♦J ° 42 o o ag If - a. « a) a a. s 2 § a S ^ S '^ M ° 9 a S 2 ii-^ J3 f! .a tlic ions e in rah are 11 c ;5 a -*f " >- r: -s ^ j3 ■'J £;g-3|-s -^ ■- •^ 2 of ^ OrC^ C the spray has not been playing over the wound while the stitches were being introduced. During the course of an operation any instrument which has been once purified, if kept in the spray, even though covered' with blood, remains piu*e, and may be introduced into the ASEPTIC SURGERY. wound without hesitation. The same is the case with the hands of the operator or assistants ; and therefore the dresser, in handing instruments to the surgeon, if)iust hand them into the spray (Fig. 23). If in the course of the operation the surgeon reaches his hand or an instrument out of the spray for any reason whatever, it must be repurified before being put into the wound. For this purpose there is generally a Fig. 2i.— To show the arrangement of towels, etc., in a large OPERATION. a a a Are tliree towels which have been soaked in 1-20 rarholic lotion, so that inatruments, &c. may be placed on them without fear of contamination. Tlm^ a small sponse will be seen on the upper one. d is tlie dish containing 1-40 carbolic lotion wliioli alwavs stands before the oiicrator, and in the line of tlie spray. In this he places the instruments which are not being used, and in it lie rcpurifies his hands or instruments if they have been removed from tlie elonil of spray. In tliis particular instance we have a lar^e wound to deal with— one so large that a single spray, unless of large volume, may not cover it completely. Hence a piece of gnai-d soaked in carbolic lotion Is thrown over the front of the wound while the surgeon is attending to the axillary part, or rice versd. basin of 1-40 carbolic lotion placed close to the operator in the line of the spray, in which fingers, instruments, &c., may be re-purified by momentary dipping. When instruments are laid down out of the spray, or, in the spray, on a blanket, they must be repurified before being used again. To provide a basis on which instruments may be laid, the carbolised towel is arranged before the operator as formerly described, and the blankets in the neighbourhood are generally also covered up SPRAY, 73 with wet towels, so as to avoid the chance of the instruments being laid on the blankets (see Fig. 24). Should the operator, during the course of an operation, wipe his hands in a dry towel, or touch any unpurified substance, he must remember to wash his hands in 1-40 carbolic lotion before re-introducing them into the wound. These precautions seem on the one hand self-evident, while on the other they seem so burdensome to remember that they are often neglected by self-sufficient surgeons. And yet it is by the neglect of these, rather than by error in any other part of the Listerian method, that mistakes arise and failures occur. Many people think that the spray is the essential part of the treatment, and neglect the precautions as to constant purification of instruments, &c., and when their cases go wrong they say that the principle is incorrect. And yet one thoroughly acquainted with the Listerian method will readily detect the loopholes, and the general loophole is the omission of some of the precautions with regard to purification of fingers, instruments, &c. Thus I have seen a surgeon with considerable experience in aseptic treatment, during the com-se of a difficult operation wipe his hands with a dry towel and immediately introduce them, covered with the dust from the towel, into the wound. The patient died of septic poisoning. Now many surgeons might have said, ' I used the spray ; 1 used all precautions ; my instruments were soaking ; my hands were purified ; ' for- getting this one little incident. When the point was men- tioned, however, the mistake was at once seen. People are too apt to trust to the spray as sufficient, and to speak of aseptic or Jjisterian surgery as treatment by the spray. This is a great and often fatal mistake. Of all the precautions required by Mr. Lister, that of purifying the air by means of a carbolic acid spray is the least necessary, for there are but few septic particles present in the atmosphere, and even though some of them fall on to a wound they may be rendered inert by washing the wound with carbolic lotion. It must always be remembered that Mr. Lister carried out aseptic treatment for years with great success without any spray ; and if at the present time he were compelled for any reason to give up some one precaution, he would at once throw aside the spray, as that one which is least 74 ASEPTIC SURGERY. necessary, and which could be the most readily dispensed with. At the same time, the spray is an immense convenience in many cases, more especially in abscesses, empyemata, in stitching up wounds, &c. ; and it saves the necessity of applying a great deal of carbolic acid to wounds by irrigating them, with the con- sequent irritation and risk of carbolic acid poisoning. To return to the errors which may arise in this part of the treatment. It may be that the spray is too near, and that thus the cloud is so narrow that the surgeon is constantly getting his hands or his instruments out of it, and forgetting to re- purify them. There are other disadvantages when the spray is too near. Thus it is very wetting, and the hands of the surgeon and the wound are unnecessarily irritated by the carbolic acid. If too near, the opaque spray also obscures the field of vision. On the other hand, where the spray is visible, it may be sufficiently trusted. Other sources of error are that instru- ments may be used which have never been purified, which have been only imperfectly purified, which have after their use lain about outside the spray or on blankets, &c. ; or it may be that the carbolic acid gets exhausted in the spray bottle, or that for some other reason the spray does not act properly. What is to be done should any of these accidents occur ? Suppose that an impure instrument or finger be introduced into the wound, that wound must be at once thoroughly washed out with 1-40 carbolic lotion. This is a bad thing for the wound, because it irritates it, and may prevent lijealing by first intention ; or it may, by causing a much larger quantity of dis- charge than usual, so saturate the gauze dressing as to render it unable to prevent the spread of putrefaction inwards. There- fore it is better to use the spray, and to take all the precautions before mentioned. Should the spray stop, the wound must be washed out just as in the former case, and then, till the spray can be set agoing again, the wound is covered with a piece of rag soaked in carbolic lotion. This piece of rag, called the guard, ought to be always present in the basin by the side of the surgeon, and when there is any indication that the spray is failing, or should it be advis- able to stop the spray for any reason, this is thrown over the wound for the time being. Should any time elapse before the METHOD OF TYING VESSELS. 75 spray is again ready for use, this guard must be repeatedly moistened with carbolic acid lotion 1-40. Where the wound is very large it may be protected during the operation either by having two sprays, or by covering up the part of the wound which is not being operated upon by a guard (see Fig. 24). The arteries are ligatured with catgut. This catgut is generally employed of three different sizes. The largest is used only for large vessels or for stitches; the medium for medium-sized vessels, or for vessels in inflamed or dense tissues where considerable force is required to constrict the vessel, or for stitches ; the small or fine catgut is that ordinarily employed ^-^ Fig. 25a. — Method op tying vessels in dense tissues. (After MacCormac.) for the smaller vessels. The vessel having been securely tied, the catgut is cut short and gives no more trouble. It is well to tie all the visible bleeding points, because a little oozing of blood may give trouble afterwards from tension. If the vessel be situated in dense tissue, so that a ligature cannot be applied around it, a needle carrying a double catgut thread should be passed througli the tissue and tied on each side of the vessel (see Figs. 25a and 2oh). The catgut should be taken direct from the trough containing carbolic oil, and should not be wetted in the lotion. Where the bleeding is from a tear in a large vein, and where it would be dangerous to ligature the 76 ASEPTIC SURGERY vessel, I have seen the following method adopted by Mr. Lij^ter: — In removing some cancerous glands from the axilla, a small vein was torn away from the axillary vein at their junction, making practically a longitudinal rent in the axillary vein. Taking a fine curved needle and the finest catgut, he stitched up the rent by the glover's suture. The patient recovered without the slightest bad symptom. There was no pain in the wound, nor swelling of the arm, &c. In another case, where the longitudinal sinus was injured in trephining the skull, the w^ound was plugged with catgut, and the patient recovered without any untoward symptom. The drainage of an aseptic wound is the point next in im- portance to keeping the wound aseptic. For if the blood and serum which collect in the in- terior of the wound within the first twenty-four or forty- eight hours do not get free exit, they give rise to tension, and tension gives rise to inflammation, and the latter, if allowed to go on long enough, to suppm'ation ; and thus the rapid healing of the TYING VESSELS IN DENSE TISSUES, wouud is prevented, though the (From Esmarch.) paticut is uot as a rulc subjcctcd to any danger to life. To avoid these consequences Mr. Lister has paid very special attention to the drainage of wounds. There are two main ways in which this may be done— drainage through tubes, or drainage by capillarity. The former is the most universally applicable and the most certainly successful. Drainage by means of tubes is that first used by Mr. Lister, and, as just stated, is the form of drainage which is most uni- versally applicable. The tubes generally employed are the india-rubber tubes introduced by Chassaignac, though of late the kind of rubber has been altered, that now used being red rubber, which contains no free sulphur. By the use of these red rubber tubes disagreeable smells and blackening of the X^rotective, which often occurred when the black tubes contain- ing free sulphur were employed, are avoided. These tubes have round holes cut in them at short intervals, the diameter of each Fig. 25&. — Another method of DRAINAGE-TUBES. 77 hole being about one-third of the circumference of the tube. At the outer end the tubes are cut flush with the surface of the skin — straight across if the tube goes directly downwards, or with varying degrees of obliquity according to the direction Fig. 26. -Ordinary oblique-ended drainage-tube ready for use. which the tube takes (Fig. 26). The tube must not project be- yond the surface, for if it does, its orifice gets compressed by the dressing, and the exit of fluid is prevented. To keep the drain- age tube from slipping in, two threads of carbolised silk are Fig. 27.— Duainage-tubk with masses of gauze in the loops of thread. fastened into it at its orifice, and tied in a knot. This knot, held between the dressing and the skin, retnins the tube in ])08ition. In souk; cases, however — as for cxiimple, in ompyeuia — the tube niiglit sli]) in in s})ite of these thrends, and th(n-('f()re it is well to fill u|» (he ]oo])S witli strips of gauze soaked in the 78 ASEPTIC SURGERY. carbolic lotion (Fig. 27). These absolutely prevent the tubes from slipping in. These tubes are always kept in a large vessel containing 1-20 carbolic acid solution, and are thus always ready for use. When a tube is altogether removed from a wound it is not thrown away, but is washed and put into the bottle with the other tubes, and used for another case. These tubes vary in size according to the size of the wound and the amount of discharge expected, and are arranged so as to drain the parts of the wound which form cavities or from which the greatest amount of discharge will come It is not necessary that their orifices be dependent, though it is of course better that they should be so. It is not essential, however, because the fluid, as it forms, wells out, and, not being putrid, that w^hich lies at the bottom of the drainage-tube does not cause irritation. In cases where the most dependent opening would be near sources of putrefaction, it is well to have the drainage-tube in another part of the wound, even though it be not so de- pendent. Thus in inguinal hernia the tube would no doubt be in the most depen- dent part if its orifice were close to the pubis, but as that would be much too near sources of putrefaction, such as the vagina and penis, the orifice of the tube ought to be at the outer angle of the wound (see Fig. 28). In a large wound it is well to have more than one tube; and it is better to have two smallish tubes in any case, rather than HERNIA, STITCHED, SHOWING THE OHC large ouB, bccausc ou the POSITION OF THE DRAINAGE-TUBE day after the operation one of OUTER ANGLE OF THE ^|^ggg ^^j^^g ^^^ ^^ rCmOVCd altogether ; whereas if a large one were pulled out in order to insert a smaller, there would be the gi-eatest difficulty in introducing either. No tube which one wishes to put back again should be removed till the third Fig. 28.— Incision for inguinal AT THE WOUND. BRAIXAGE. 70 day, on account of the difficulty of returning it. By that time, however, it Hes in a channel in the blood clot or Ijonph, and slips back easily. Fig. 29 represents forceps introduced by Mr. Lister, and called ' sinus forceps,' which are of the greatest service in inserting drainage tubes. Generally on the third day half the tube is cut off, and it is reduced in length at subsequent dressings till it becomes no longer necessary. No exact rules can be given for shortening or leaving out the tube. This must simply be a matter of experience, guided by the amount of discharge and the tendency to accumulation or otherwise. Should tension occur, a larger and longer tube ought to be at once introduced. A point which has always seemed to me of great importance in connection with the use of these tubes, and one which has apparently been overlooked, is the following. A tube is taken Fig. 29.— Sikus forceps. out of carbolic lotion at some distance from the spray, is earned through the air, and then directly introduced into the wound. I can hardly believe that when a large tube is taken out of the lotion there would be sufficient vapour of carbolic aoid in it to destroy any septic dust which might get into its interior, for a considerable mass of air must take the place of the fluid, and this amount of hospital air may often, as I have found by experiment, contain causes of putrefaction. Of course when passing through the spray this air may be displaced or purified, and also when introduced into the wound a consider- able amount of it would be forced out ; while at the same time there is a good deal of carbolic acid present, and purification in one way or another would probably occur. And further the purifying power of healthy living tissues, which will be after- wards demonstrated, must be taken into account. But in the case of a cavity, pm'ification in any of these ways may 80 ASEPTIC SURGERY. not happen, and putrefaction may result. In a ease of incision into the knee-joint, which will be afterwards alluded to, in which fermentation and inflammation occurred, this seemed to me the most probable explanation. My suggestion there- fore is always to take the tubes out of the lotion in the spray, and then the air which enters them will be air previously acted on by the spray. Drainage by capillarity was introduced by Mr. John Chiene, who was also the first to enunciate the principle of absorbable drains. For this purpose he uses catgut, and generally the Fig. 30.— Catgut drain ready foe insertion. finest threads. A skein of catgut, containing say twenty threads, is tied at its middle by a single thread of the same gut. One end of this thread is passed through a needle (Fig. 30), and by means of this the centre of the skein is stitched to the deepest part of the wound (Fig. 31). The skein is now broken up into bundles of five or six threads each. One bundle comes out at each angle of the incision, and the other bundles at inter- vals between the stitches (Fig. 32). More than one skein may be required in a large wound. This catgut becomes absorbed, and never requires to be removed. In five or six days the ends which hang out' drop off, and little granulating sores are formed which heal in a few days. In this method the serum escapes by capillarity, and by distributing the threads DEAINAGE BY CAPILLARITY. 81 over various parts of the wound the true principle of drainage is carried out ; for, as pointed out by Mr. Chiene, in draining a field one does not have one large drain going from one end of the field to another ; on the contrary, the field is traversed by numerous small drains. And so in Chiene's method of draining v^rounds we have a number of small drains traversing the wound in several directions. In this method there is no trouble about pulling out the drain, and no necessity for changing the dressing simply to remove a tube ; the drain disappears of itself. It is well to leave the ends of the catgut outside the wound as long as possible, so as to get a siphon action, and care must be taken not to break up the bunches of catgut outside the wound, for the capillary action occurs in the intervals between the threads when they are closely ajjposed. The objections urged against this method are, firstly, that in lai'ge wounds it is not sufficient, and that the catgut becomes a pulpy mass, and when in large quantity takes a long time to organise. Not only may it be insufficient at first, but it may become absorbed too soon — before, indeed, a drain of some kind can be dispensed with. Now these objections rest in great part on the fact that the drain is often improperly employed. If, for instance, it be not stitched to the deepest part of the wound, the catgut may slip and the deeper parts may not be drained ; and again, if a large bundle of it be used, coming out at one part of the wound only, it does become a pulpy mass, and takes a long time to organise. But this is not the method recommended by Mr. Chiene, for he says that only five or six threads ought to be brought out at each place. There is, however, no doubt that in some cases it is absorbed too quickly, and this was the real objection to the use of this method when we had only the catgut prepared by the old method, though even with it, if the gut was well prepared and old, the drainage was often very satisfactory. This difficulty will probably be overcome by the use of the chromic catgut recently introduced ; the only fear, indeed, will now be that the drain may last too long. Mr. Lister, however, thinks that if only the finest gut be used, according to Mr. Chiene's directions, the probability is that it G 82 ASEPTIC SURGERY. will be absorbed with sufficient rapidity. Of course, if neces- sary, the ends of the drain can be cut off, when it has served its purpose, below the level of the skin, and then, even though the internal part be not all absorbed, the wound can heal completely. Catgut can only drain fluids such as blood or serum ; it cannot drain pus. It is, however, unsuitable in cases of chronic abscess, where we have only a serous discharge, because the catgut is absorbed long before a drain can be dispensed with. Fig. ni.— Operation for stretching the sciatic nerve. Catfrut drain stitolicd to the deepest part of the wound, beneath the gluteus maximus, and lirukon up into four separate bunclics. If the wound is very large it is well to introduce tubes as well as catgut drains at first. The tubes may be removed in twenty-four hours. Instead of catgut, horse-hair has been a good deal used. This is simply laid into the wound in the situation where it seems most required. It is diminished by degrees, threads being taken out at various intervals of time. It has an advan- tage over catgut in draining joints, for no part of the drain DRAINAGE BY CATGUT AND HORSEHAIR. 83 remains in the interior of the joint, while portions of catgut do. Further, it is not absorbable. But it has the same disadvantages as the drainage tubes, and it is not readily retained in the deeper parts of the wound. It is preferred by Mr. Lister to the catgut, but there can be no doubt that the catgut, when used strictly according to Mr. Chiene's directions, and of good quality, is a very efficient method of drainas^e. It is easy to re-introduce a horse-hair drain if necessary by proceeding in the following manner : — A sufficient quantity Fig. 32.— The same wound stitched. The h'jnclips of rntpiit cnminp out at intprvals between t)ie stitclies. (Tlie woiintl lias teen exapperated, and the thnails of ratjzut separated, in order to sliow the nietliod more clearly. 'I'lie thnads of catpiit onpht to lie in close apiiositioii, for it is tin: iiitervnls between the threads which act as raiiillary drains'. being taken, the bundle is bent at its middle over a probe, and tied close to the probe by carbolised silk (Fig. 33). In this w^ay, the ])robe being withdrawn, a blunt compact end is oblained, which may be introduced into the wound with ease. Of lute the princi])le of absorbable drains has been applied by Dr. Neuber of Kiel ' in his absorl)al)le drainag(! tubes. ' Ein AnihepHgchcr Daucm-rhand narh fir'dndlichrr Jilutstillnii;/. Von LangenhccJt'x Archiv, Bd. xxiv. Heft. 2. a 9. 84 ASEPTIC SURGERY. These are tubes drilled in long bones, and then decalcified and carbolised. Holes are afterwards cut in the sides, and they are used like ordinary india-rubber tubes. These tubes are said to answer very well, though they are sometimes absorbed too soon, and sometimes last too long. They sometimes get soft and collapse about the third or fourth day, and thus, though not absorbed, become useless as a drain. Dr. INIacEwen ^ has lately somewhat modified Neuber's tubes. He uses chicken-bones, which are already hollow, and decalcifies them. ' The method of preparation is as folloAvs : — The tibia? and femora are scraped and steeped in hydrochloric acid and water (1 to 5) until they are soft. Their articular extremities are then snipped off with a pair of scissors ; the cndosteum is Fig. 33. — Method of preparing a horse-hair drain for re-introduction. raised at one end and pushed through to the other extremity, along with its contents. They are then re-introduced into a fresh solution of the same strength until they are rendered a little more pliable and softer than Avhat is ultimately required (as they afterwards harden a little by steeping in the carbolised solution). When thus prepared they are placed in a solution of carbolic acid in glycerine 1-10. They may be used at the end of a fortnight from the time of introduction into the glycerine solution. Holes may be drilled in them with a punch, or clipped out with scissors.' These tubes are threaded with horse-hair before being introduced into the tissues. This hair helps to maintain the calibre of the tube during the first few days, and also itself acts by capillarity. ' British Medical Journal, Feb. 5, 1881. BUTTON STITCHES. 85 The average duration of j\IacE\ven's tubes in the tissues was something over eight days. If, however, a tube is likely to be required for a longer time, it can be obtained by steeping the decalcified tubes in a chromicised instead of a carbolised solution. These resist the action of the tissues for two or three weeks. The accurate stitching of the edges of the wound is another feature in aseptic surgery. In operating aseptically the same care need not be taken to remove as little skin as possible as is necessary in wounds treated by other methods where swelling and inflammation of the edges are expected. One may take away a wide sweep of skin, such as would seem to render hopeless any attempt to bring the edges of the wound into apposition ; and yet if the edges can only be apposed, and if A c Fig. 34. — Lead buttons for deep stitches. A, The present form, describerl in tlie text. B, Form of button deviscrl by Dr. Ogilvie Will (seen in section). C, The old form, where the wire was fastened by passing it beneatli the button. the wound remains aseptic, union by first intention may be expected along the whole line. Button stitches are employed to relax the edges of the wound, and thus to leave the cutaneous margins free from the irritation which must occur if they are tightly drawn together. These consist of flat pieces of lead cut of an oval form and of various sizes, perforated in the centre by a hole through which silver wire is passed, and provided Avith two lateral wings round which the wire is twisted (Fig. 34). (There are various forms of button suture, but all act on the same principle.) These are a[)})lied some distance on each side of the edge of the wound, and connected by strong silver wire drawn tight enough to permit the edges of the wound to come pretty easily together. The number used varies according to the amount of tension. 8(> ASEPTIC SURGERY. In order to bring the edges of the wound into actual contact, two sets of stitches are employed : silver wire stitches, which take a good hold of the tissues and are placed at regular inter- vals, termed stitches of relaxation ; and in the intervals between these, in order to have the cutaneous margins accurately applied to each other, numerous stitches of coaptation, consisting of carbolised silk, horse-hair, or catgut are inserted (Fig. 35). The speedy healing which occurs when the edges of the wound are accurately brought in contact, while they are at the same time, by the button stitches and the stitches of relaxation, Fig. 35. — Wound after removal oi'^ mamma and axillary glands, STITCHED. To show tlie tliree kinds of stitches. Tlip button .stitchrs will lie at onee recognised ; the tliick stitches, of which three arc represented, are the stitches of relaxation ; and the remainder are tlie stitches of coaptation. freed from any tension, rewards the surgeon for the time spent in inserting a large number of these stitches of coapta- tion. In taking out these stitches it is best to follow a reverse order to that of insertion. The first to be removed are the stitches of coaptation, while the stitches of relaxation are pro- bably cut on the same day. Do not be in a hurry to remove the stitches where there was much tension in bringing the edges of the wound together. A week or ten days is time enough. Should the wound gape, strapping may be employed, even under an antiseptic dressing. To render the stra])ping aseptic, it is immersed in warm carbolic lotion (one part of 1-20 and an equal part of boiling water) before being applied. This both BEESSINGS. 87 renders it aseptic and also takes the place of the hot- water can for heating the strapping. Having proceeded thus far in the aseptic operation — having tied the vessels, aiTanged the drainage, and brought the edges of the skin well together— we must now apply a dressing which shall prevent the occurrence of putrefaction till the case is again seen. In applying a dressing we must in the first place be careful to make it as little irritating as possible to the young epithelium along the Hne of incision. The dressing employed is the car- bolic gauze ; and, to prevent the irritation of the healing edge of the wound by the carbolic acid, a piece of protective is inter- posed between the gauze and the wound. This protective is cut a little larger than the wound, and it is well to cover the buttons with a little bit also, in order to prevent the threads of the gauze from becoming entangled in them. This protective need not extend over the orifice of the drainage tube, as its essential object is to protect the healing part from the irritation of the carbolic acid. The protective is also of use in preventing the dressing from sticking to the Avound, and in preventing the formation of scabs, and the consequent possible retention of the discharge. An eiTor which is frequently made is to put on too large a piece of protective. There is nothing antiseptic in its substance, and it protects the discharge beneath it from the action of the carbolic acid. Therefore if at any part it projects beyond or comes close to the edge of the dressing, it allows the causes of putre- faction to spread inwards beneath it, and prevents the carbolic acid from acting on this putrefying discharge. It is therefore a very good rule, having covered the woimd with sufficient pro- tective, to look on this protective as a wound, and to be as careful in having the gauze dressing overlap it in all du-ections as if it itself were the wounded surface. Where there is very little space for overlapping, as in inguinal hernia, no protective ought to be applied. It is better to have somewhat slower healing than to have putrefaction spre-ad into the wound. As men- tioned before, this protective is di))i)ed in carbolic lotion 1-40 befoi'e being applied. Outside the protective a piece of gauze wet in the carbolic 88 ASEPTIC SUliGEliT. lotion 1—40 is applied so as to overlap the protective in all directions. The reason for this is that dry gauze is apt to receive dust on its surface before being used, while at the ordinary temperature of the atmosphere but little carbolic acid is given off from the gauze, certainly not enough to destroy immediately the activity of the septic particles in the dust. But if the piece of gauze applied next to the protective be moistened in the 1— iO solution, this dust is at once deprived of septic energy, and we apply over the wound a layer of pure and powerfully antiseptic material. Fig. 36.— Excision of the hip-joint. Wound stitclied ; ])rotective anil deep di-essing applied. The piece of wet gauze and the protective go by the name of the deep dressing. This deep dressing may in some cases, and more especially where catgut stitches and catgut drains are used, be left for several days undisturbed. In this way the wound is not irritated by the application of carbolic acid to it every time the dressing is changed. If the deep dressing be thus left on, it must be remembered that the deep piece of gauze loses all its carbolic acid very soon, and that therefore it must be treated as a wound — ^.e., in renewing the dressing this deep part must be overlapped in all directions by a piece of wet gauze, and that again by a dressing of suitable size. DEEP DRESSING. ^9 In some cases it may be desirable to fix down the deep dressing with a piece of gauze bandage. If it be intended to leave on this deep dressing for some time it is well, before applying it, to rub the neighbourhood of the wound with the salicylic cream mentioned before. It sometimes happens that when a dressing is left on for many days together, the discharge becomes somewhat irritating, and the skin around the wound becomes excoriated. This is generally entirely prevented by the use of salicylic cream. Having arranged the deep dressing in a suitable manner, any hollows which exist in the neighbourhood of the wound are filled up with carbolic gauze, and special masses of this material are placed where the greatest amount of discharge is expected. Outside this a large gauze dressing, made as before described, is applied. The size of this dressing varies accord- ing to the amount of discharge expected, but in all cases it must extend well beyond the deep dressing in all directions. Some special examples will be mentioned presently. This dressing is fixed on with a suitable bandage. The gauze bandage is preferable to an ordinary bandage under certain circumstances. It is especially convenient in bandaging a stump next the skin to prevent retraction of the flaps, and also for fixing down the deep dressing. It also increases the amount of antiseptic material outside the macintosh if there happens to be a hole in it. But for ordinary use in fixing on dressings very light and cheap bandages may be made from the ordinary thin muslin which is used as a guard. They do not stick to the skin as the gauze bandage is apt to do. The dressing is pinned round its edge to the bandage. Care must be taken not to put pins through the macintosh at any part except at its edge. Pinholes through the centre of the macintosh simply defeat its object by permitting the discharge to come directly through the dressing. The object of the macintosh is to make the discharge travel through a large extent of the gauze, and thus the same result is obtained as if a mass of gauze were applied over the wound, of the same thickness as the distance from the centre of the macintosh to its edge. If therefore there be a pinhole near the centre of the macintosh, the object of the latter is seriously interfered 90 ASEPTIC SURGERY with. Accordingly, it is always the duty of the i)ersoii who makes the dressings to examine the macintosh with the view of detecting any holes in it. If the dressing is to be used as soon as it is made up, it is well to sponge the surface of the macintosh with 1-20 carbolic lotion before inserting it. The same piece of macintosh may be used for a whole case, or for more than one — so long, in fact, as it does not become worn into holes. Two pieces of macin- tosh are generally provided for each case, and a dressing is always made immediately after the case has been dressed, and is ready for application at any time. Fio. 37.— Dressing in a case of psoas abscess opened above Poupakt's ligament. To show tlie an-angement of tlie elastic bandage along the margins of the dressing. It might happen that, in the movements of the patient, the edge of the dressing might become separated from the skin, and air pass into the space thus formed. To prevent this, the German surgeons as a rule pack in salicylic jute or wool be- neath the edge of the dressing. This may serve the purpose, but it is by no means safe. Mr. Lister some time ago intro- duced the use of elastic webbing, which is of various breadths. It is better not to be too broad. It is put moderately on the stretch, and surrounds the edge of the dressing. Its general arrangement varies of course with the situation. It is not much used on the extremities, because the ann or leg is generally so CHANGING OF THE DRESSING. 91 fixed by means of splints that there is no chance of separa- tion of the dressing. The operation and first dressing ha\iug now been com- pleted, the question arises when the dressing should be changed. It is only extremely rarely that it is necessary to change it the same evening. The only cases in which this is usually done are large empyemata or very large abscesses, and cases of am- putation at the hip-joint, where the discharge of bloodly serum is profuse, and there is but little space for overlapping of the dressing. As a rule, the dressing ought to be changed entirely on the following day, the deep part as well as the superficial. It is well to change the deep dressing in order to see that none of the stitches are too tight, and that the drains are acting pro- perly. After the first day the deep dressing need not be touched, unless the patient is complaining of uneasiness, or unless the sm-geon wishes to see the wound for the purpose of removing stitches or drain. If it is not necessary to disturb it, it may, especially where there is an organising blood-clot, be better not to do so, for that would only be to expose the wound unnecessarily to the irritation of the carbolic acid. If the deep dressing is not changed, great care must be taken to have an efficient spray playing over the part. In changing the dressing the spray is used, and also 1-40 carbolic lotion, in which a piece of loose gauze and protective are put before the dressing is begun. The elastic bandage is first removed, and then the patient or an assistant places his hand over the centre of the dressing while the bandage is being cut, so as to prevent the dressing being lifted up and air pumj)ed in. Then the surgeon, having purified his fingei's, and having turned on the spray, lifts the edge of the dressing carefully, taking care that the spray passes into the angle between the dressing and the skin (see Fig. 38). Having removed the superficial dressing, he again dips his fingers, and then removes the deeper parts and exposes the wound. If nothing is wrong, he immediately applies fresh protective and wet gauze, and then washes the parts round about, as far as the discharge has extended, with 1-40 carbolic lotion. The 92 ASEPTIC SURGERY edge of the wound is not washed or exposed to the action of the spray longer than is absolutely necessary. It is well to apply the deep dressing at once, for in washing the surround- ing parts, one is apt to give the wound a final touch with the rag. Now this rag may contain some gross particles of putrid material (such as a crust of discharge from the exterior of the dressing, faeces, &c.), and thus putrefaction would be com- municated to the wound. There is no necessity for cleansing the edges of the wound. Dirt, so long as it is clean, i.e., so long as it does not contain causes of putrefaction, does no harm ; indeed, it rather aids the action of the protective ; while Fig. 38.— Method of changing a psoas abscess dressing. A Hand of patient holding down tlie dressing over the wound. BB, Hands of surgeon lifting ' the lower^«l?e of th^ dressing (C). D, The spray machine so placed that the spray passes m beneath the dressing as it is lifted. to rub it away is to irritate and injure the healing edge— to produce a state of unrest. A fresh dressing is applied as before described. Where there are two wounds in different situations, so placed that the spray cannot command both, each must be dressed separately, care being taken not to uncover the one till the other is at any rate protected by a deep dressing. The patient or assistant must keep his hand on the dressing over the one wound, while the other wound is being attended to. The next dressing takes place on the following day at visit, RULES FOR CHANGING THE DRESSINGS. 98 if there is any discharge at the edge of the dressing or if the wound feels uneasy. If there is no discharge on the drawsheet and if the wound is free from pain, the dressing is not changed ; and even though discharge should appear a few hours later, the dressing is not changed till next day at visit hour. The rule for changing the dressings is therefore : Change if discharge is through at the visit hour, or if there be any other reason for it ; if not, leave the dressing till next day at visit, and then follow the same rule. Never leave a dressing unchanged longer than a week. By that time most of the carbolic acid ha5 passed off by evapora- tion ; and therefore, if the discharge once came to the edge, putrefaction could spread inwards with great rapidity. And it would not be necessary for the discharge to appear at the edge in order to have putrefaction of the wound, for the sweat collecting beneath the dressing permits the multiplication of septic particles in it, and thus they may reach the wound. Where a dressing is to be left on for a week, it is well to use the salicylic cream in the way before described. Such is the general method of using carbolic dressings ; special modifications will be noticed presently. Let me pass on in the meantime to the general points as to boracic dressings. Let us sup})Ose that a patient is admitted with a foul ulcer of the leg : how is he to be treated ? If he were to be ti'eated with carbolic dressings, the ulcer would very probably remain foul, or even though it ultimately became free from odour, it would heal excessively slowly. Hence, Mr. leister first piuifies the sore, and then dresses it with boracic acid. To purify the sore, chloride of zinc, 40 grs. to the ounce of water, may be used. This is applied tlioroughly to the whole surface of the sore, and at the same time the surrounding skin is well purified by thoroughly washing it with 1-20 carbolic lolion, whieli is em])loyed on account of its special power of jx'uet rating the epidermis. When iliis lias been done, a. jiiece of protective, dii)ped in boracic lotion and slightly larger than the sore, is applied over it, and outside tliis is placed one or two layers of moist or dry (it docs not much matter which) 94 ASEPTIC SURGERY. boracic lint, of sufficient size to cover the protective well in all directions. There is the same objection here to allowing the protective to project beyond the edge of the dressing as in the case of the carbolic dressings. Lately, instead of applying the chloride of zinc solution, which causes consider- able uneasiness, iodoform has been yjowdered over th,e whole surface of the ulcer, and it has been equally successful. The chloride of zinc or the iodoform need only be applied once ; but should putrefaction not be eradicated, the application is repeated. This dressing is changed next day, but aftei-wards, as a rule, if only requires to be changed every two or three days, or indeed at longer intervals, provided that there is not much discharge. That is to say, as there is a very large store of the antiseptic in the lint, and as it is but slightly soluble at the temperature of the human body, the discharge may go through the dressing many times without washing out all the antiseptic. At the same time it is found as a general rule that the wound heals most rapidly when the dressing is changed once in three or four days. At the changing of the dressing no spray is required. The bandage (which may be a common cotton bandage, if preferred) having been removed, the dressing is taken off' and the wound well washed with boracic lotion. Any septic dust which falls on the wound during its exposure is destroyed by giving the wound a final wash with the lotion before applying a fresh piece of protective and boracic lint. This boracic dressing is not used for wounds which are not quite superficial, because the acid is not volatile, and because it is but a feeble antiseptic ; but when once a wound has be- come quite superficial, it will heal more quickly if treated with boracic dressing. In some cases, more especially where the sore is septic, or where the patient dresses it himself, boracic ointment is prefer- . able to protective, and where the sore is healing, the half- strength ointment is the best. Outside the ointment a piece of boracic lint is applied as usual. Of late, salicylic ointment has been used, and found to answer, as a rule, better than the boracic. It is less irritating, and permits healing more readily. B-ORACIC DRESSINGS. 95 A eucalyptus ointment has been employed quite recently, and has given excellent results. VV^hen the effects of a poultice are wanted along with an antiseptic effect, the boracic lint is applied like water dressing. A suitable piece of the lint moistened in boracic lotion is ap- plied, and outside this a larger piece of macintosh or gutta- percha, overlapping the lint in all directions. 96 ASEPTIC SURGERY. CHAPTER V. ASEPTIC SURGERY_(co«^f««frt?). Special dressings : Head dressi/if/s : Ned; dressings : Breast dressiiiffs — Abscess of vKimina — Excision of mamma alone — Excision of inamnia and axillary qlands : Axillary dressings : Dressings on the limbs : Dressings for psoas abscess : Lumbar abscess : Hijf-joint abscess : Dressings in cases of hernia and operations on the scrotum: Excisions of joints. Aseptic treatment of abscesses. Chief xjoints to be considered in opening abscesses — Mi-thod of openi7ig abscesses — Drainage of abscesses — After-treatment of abscesses — Empyema — Perinealand anal abscesses. Treatment of wounds produced acci- dentally : Problem to be solved — Purification of wound — Further treatment of the wound. Special wounds : Compound fractures : Wounds invoicing tendons, nerves, ^'c. : Wounds of joints : Compound fractures of the skull : Penetrating wounds of the thorax: Wounds of the abdomen. Putrid sinuses ■ and wounds. Treatment of burns. Treatment of gangrene. Treatment of na3vi and varicose veins. I SHALL now describe the special methods of dressing and other precautions required in different sitiuitions. In operating on the scalp the hair must be shaved for some distance around the wound, and the hair beyond ought to be soaked with carbolic lotion 1-20. If the incision be in the centre of the scalp, or, in other words, if there be a circle of hair all round it, it is better not to use j^rotective at all. The dressing in such a wound is fixed by the ordinary capelline bandage. Where the wound is more or less to one side, the dressing must extend downwards on the neck, and it is then well to have a narrow elastic bandage along the edges, more especially around the neck. In the neighbourhood of the ears, the various cavities in the ear, and the space behind it, must be filled up with gauze. Nech dressings have nothing very unusual about them. The dressing must be ftistened round the neck. It must be pre- vented from slipping down by a turn passing above the ears BREAfiT DRESSISGS. and around the forehead, and also by two vertical turns over the head, one transverse and the other longitudinal, these various tiurns being pinned together where they cross. To prevent the dress- ing from slipping up, turns are passed under the axilla. A narrow elastic band- age must be applied round the edge of the dressing in this situation, for the movements of the head are extremely a})t to cause an interval between the skin and the dressing (Figs. 39 and 40). Breast dressings are very important ; they are arranged in three different ways according to the size and extent of the wound. No. 1. — Where an abscess of the mamma is opened, or where some small incision, not interfering with the form of the organ, is made, the dressing consists of an ordinary gauze dressing covering Fig. 3"j. the whole mamma, some loose gauze This figme illustrates the genr. being packed in in front and behind. '"' ^'''"■^'^■"^"^ °f '»■•«- This is fixed by turns of bandage passing round the body alternately above and below the organ, with straps over the shoulder. The arm is placed in a sling. by elastic bandage (Fig. 41). No. 2. — Where the mamma has been removed and the dis- charge has become much diminished in amount, there mav remain enough of room between the wound and the axilla for overlapping of the dressing. In order to fix the dressing and keep it well up in the armpit, it is split vertically at the axilla, folded over, and pinned on the top of tlie shoulder. It is then bandaged securely, and an elastic bandage a])i)lir(l around the edges (Fig. 42). No. 3. — Where the mamma and axillary glands have been removed, or for the first few days after excision of the mamma alone, this arrangement is not enough, for it does not leave sufficient room for overlajipiiig. The arm must therefore be nigs on the neck. The ar- rangement shown liero would do for any operation about the region of the stcv- nouia.stoid behind or below the ear. The edges are fixed 98 ASEPTIC SURGERY. included in the dressing. This is accomplished most con- veniently in the following manner : — A large dressing is applied FICt. 40. — To SHOW THE ARRANGEMENT OF THE TURNS OP BANDAGE ON THE HEAD SEEN FROM ABOVE. posteriorly, reaching behind as far back as the middle line, and folding over the arm so as to touch the thorax in front, Fig. 41.— Dressing applied in a case of abscess of the mam- MA (BREAST DRESSING NO. 1). The position of tlip drainage tube is indicated by dotted lines. Fig. 42.— ]5reast dressing- no. 2. the arm being applied to the side. This dressing must be broader than the length of the upper arm from the top of BREAST DRESSINGS. 99 the shoulder to the tip t)f the elbow, the overlapping parts being caught by the turns of bandage passing over the shoulder and round the body respectively. To prevent the internal condyle from suffering from the pressure, a large mass of gauze is applied behind the arm, extending downwards almost to the condyloid region, but not reaching quite so far. A mass of gauze is packed in between the arm and the side, and in front filling up the angle between the arm and the thorax (Fig. 43). A smaller anterior dressing is then applied, narrower than the posterior, reaching as far forwards as the middle line or beyond it, and outwards to the upper arm, the edge of the anterior dressing passing beneath the edge of the Fig. 43.— Case op excision of the mamma. Back dressing lying ready for application ; sliowing also the deep di-cssiug and padding in the axilla and beljind the arm. ])Osterior. Thus the side of the patient is completely encased in a gauze dressing. This is very easily bandaged on. One turn of bandage passes round tlie body outside the arm (Fig. 44, 1); the second also passes round the body, but below the elbow (2), thus catching the portion of the dressing overhang- ing the elbow and also the lower edge of the front dressing ; the next passes roimd the body and over the top of the shoulder on the side operated on, thus catching tlie portion of the dressing projecting above the shoulder (3) ; tlu; bandao-c then passes down beliind but parallel to tlie arm, turns round below the elbow, runs obliquely upwards in front to the top of 100 ASEPTIC SUR(rERY. the opposite shoulder (4), then obliquely back again behind the body (thus fixing the upper angles of the dressing in front and behind) to the middle of the arm, over which it passes obliquely downwards (5), to go under the wrist and end at the top of the shoulder (6) — in this way completing the fixing of the dressing to the arm, and at the same time acting as a sling for the hand. A bandage six yards long generally does this exactly. Pins are now inserted at all the necessary points, more es- pecially where the bandage passes over the shoulder and under the elbow. The arm and dressing are then fixed seciu'ely to the side by a binder of calico, broader than the length of the Ki«. 44— Dressings applfeu aftek excision ov mamma and axillary GLANDS, TO SHOW THE ARRANGEMENT OF THE DRESSINGS AND BANDAGES. The turns of bandage are numbered, and arrows are placed on them to show the direction iu which they run. upper arm, passing round the body, below the axilla of the other side, and pursed up and pinned above the shoulder, and below the elbow of the included arm. Thus perfect rest is procured, and no elastic bandage is required. When the axillary incision is soundly cicatrised, and the discharge has become small in amount, the axillary dressing or the breast dressing No. 2 may be applied, the arm being simply supported in a sling. An axillary dressing must be ap[)lied partly to the chest and partly to the upper arm, and made to fold over the top of the shoulder. It requires an elastic bandage (P'ig. 46). Elastic bandage is not as a rule required for dressings on DRESSING Foil PSOAS ABSCESS. 101 the extremities, because the limb operated on is generally placed on a splint for a few days, in order to procure absolute rest till healing by first intention is complete. Thus the movements which it is the function of the elastic band to neutralise are avoided, and the constriction of the elastic is also avoided. With regard to this constriction, however, the elastic need never be applied so tight as to produce cedema ; indeed, I have more than once seen oedema which was present before an operation subside afterwards, even although an elastic bandage was used. Where the patient is allowed to move the extremity — as, for instance, when he is allowed to walk after a small operation on the lower extremity — an elastic bandage is Fir. 4.").— Bindee applied outside the dressing represented ix FiG. 44, so AS TO keep the parts and dressing at rest. absolutely necessary. In the case of the lower extremity, the padding at the upper part of the splint should be covered with macintosh, and the foot of the bed should be supported on blocks. In this way all the discharge flows upwards, and as it cannot soak into the padding of the splint, it is shed on the draw-sheet soon after it has reached the edge of tlie dressing, and thus one can ascertain accurately whetlier or not it is necessary to change the dressings. The dressing required for psoas abscess opened abo\e Pou- part's ligament is one of the most important dressings, as well as one of the simplest illustrations of the method of applying the elastic bandage. I may say here with regard to this method of opening psoas abscess :>bo\(' P()U))!irt's lignmcnt that there 102 ASEPTIC SURGERY. are two reasons for choosing, this situation. In the first place, the old rule that these abscesses must not be opened early is now done away with, and under truly aseptic treatment, as soon as fluctuation is detected, an operation is performed of a similar nature to that for tying the external iliac artery, and the abscess is opened after a careful dissection. The sooner the abscess is opened the better, for the abscess cavity is thus smaller than if the surgeon waits till the pus has burrowed its way into the thigh ; and, further, so long as the pus is there it irritates by its tension, and thus keeps up the chronic in- FiG. 46. — Dressing in cases ov operation on the axilla alone. In t)iis case an abscess has boen opened and tlie position of tlie draina.s;e tube is Indicated by dotted lines. TLe ed!,'e of the dressing lias also been dotted in. flammation in the si)ine. This, then, is one reason why the opening leading into these abscesses is generally above Pou- part's ligament. Another is, that even supposing the abscess to be pointing in the thigh, it ought to be opened as far as possible from sources of putrefaction, and the most convenient place in this resj)ect, as well as the best for the attachment of a dressing, is the neighbourhood of the anterior superior spine. I shall hereafter discuss the reasons why it is thought best by some surgeons, more especially by Mr. Chiene, to try to get DRESSINGS FOll PSOAS AND LUMBAR ABSCESSES. 10.3 at these abscesses from behind either by perforating the ala of the innominate bone or by getting at the pus above the crest of the ilium. Such a method has advantages both by pro- viding a dependent opening, and also by leaving a shorter channel between the seat of the disease and the cutaneous siu'face. The dressing applied when the opening is in the neighbour- hood of the anterior superior spine extends from the middle line in front to the middle line behind. It reaches as high up as the lower border of the ribs and as low as about three inches below Pou})art's ligament. Special masses of gauze are placed ^ 1 iliVildlH''/ Fig. 47.~Dres3ing in a case of psoas abscess opened above Poupart's ligament, seen from the front. T]ie position of the drainage tube is indicated by dotted lines. in the neighbourhood of the pubis, which is also shaved on that side. The dressing is fastened on by a spica bandage with circular turns around the thigh and abdomen. The elastic bandage is applied accurately to the edge. It begins, say, at the upper and anterior angle of the dressing, runs vertically downwards along the anterior edge ; then, passing back round the inner side of the thigh, it encircles the thigh, thus fixing the lower border ; then it runs vertically upwards behind till it reaches the upper posterior angle ; then, being held there, it is carried round the abdomen. The two ends of the two vertical pieces are fastened to the circular ])iece by pins, and pins are also applied at all the angles and along the edge where neces- 104 ASEPTIC SURGERY sary. In some deformed persons shoulder straps are necessary to prevent the dressing from slipping down (Figs. 47 and 48). Fro. 48. — r^iOAS abscess dre^sixo (Fig. 47), seex from behind. In Inmhar abscess straps must pass over the shoulders to prevent the dressing from slipping down, and between the thighs to prevent it from slipping up (Fig. 49). Vui. 49.— Dressing ix a case of lumbar abscess, seen from behind. Tlie position of tlip rlrainage tube is indicated by dotted lines : the vertical dotted lines at the niiildle of the back indicate the edge of the dressing. In abscess of the hip-joint the arrangement of the dressings is much the same as in psoas abscesses, except that they pass lower down and not quite so high up. As a long splint is I)Iii:SSINGS FOE HERNIA, ETC. ]05 generally in use, an elastic bandage is unnecessary, unless in children (Fig. 50). Where abscesses are opened near the top of the thigh on the inner side, and are thus pretty near sources of putrefaction, large masses of gauze must be applied between the orifice and the perineum, and an elastic bandage carefully fastened along the upper edge. In operations for hernia^ varicocele, and on the scrotum, in the male, there is one form of dressing which is generally applicable. In the first place, no protective is used, on account of the immediate vicinity of sources of putrefaction, as has been previously explained. The gauze applied to the wound, instead Fir. 50.— Dressing in a cask op hip-joint abscess, with elastic APPLIED. The dotted part sliows tlie position of tlie wound. of being merely wet with carbolic lotion, is steeped in 1-5 or in 1-10 solution of carbolic acid in glycerine, and this is wrapped around the penis and over the scrotum. This gauze sticks to the skin and does not become detached with the movements of the body, while it is more powerfully antiseptic than the ordinary carbolic gauze. Then a mass of gauze is rolled into a ball, and this is suspended in the centre of a long strip of gauze. The ball is i)laced in the jjerineum behind the scrotum, and the strip of gauze passes u}) in each groin. This strip retains the pad in position (Fig. 51). The pad serves the double purpose of supporting the scrotum and re- ceiving the discharge, which passes chiefly downwards. The 106 ASEPTIC SURGERY. hollows having been filled np with loose gauze, the general dressing is applied. A hole is cut in this dressing towards the Fig. 51.— Deeper part of the hernia and scrotal dressings. Left side of Bcrotum covered with gauze soaked in carbolised glycerine. Mass of gauze in the perineum enclosed in a roll of gauze. upper border, and the penis is passed through this hole, and thus helps to keep the dressing in position. The dressing „., 'l!£LlmMM/jJ,/Jj^/^/^^^jj^^^ Fig. 52. — Dressing in a case op operation for hernia, or on the scrotum on the LEb'T SIDE, SHOWING THE ARRANGEMENT OP THE DRESSING AND ELASTIC BANDAGE. passes over the scrotum and over the perineal pad, and is fixed bv a double spica bandage (Fig. 52). The pad in the j)eri- EXCISIONS OF JOINTS. 107 neum is fixed there by a St. Andrew's cross. The elastic band- age is applied in the form of a St. Andrew's cross in the peri- neum, and of a double spica (Fig 53). The bandages, dress- ing, and perineal pad are carefully pinned together in the perineum. The methods of managing excisions of joints^ operations for ununited fractures, &c., in the lower extremities, are very im- portant. Here jjerfect rest must be combined as far as possible with the aseptic treatment. For two or three days after an Fig. 53. — Dressing in hernia cases or in operations on the scrotum, showing the arrangement op the bandages in the perineum. (seen from BELOW). operation it is better to change the dressing, which is the ordinary gauze dressing applied round the limb, simply by lift- ing the limb, because there is generally a large amount of bloody and serous oozing at first. After a few days this oozing has become much diminished in amount, and the dressing is then accomplished in the following manner : — A Gooch's splint is padded above and below the situation of the wound, the part opposite the wound being left unpadded. The whole splint and padding is covered with a piece of macintosh cloth, and is firmly fixed to the posterior aspect of the limb above and below the situation of tlie wound. Behind the wound, at the part where tlif jjadding is deficient, masses 10.H ASEPTIC SlTIiGEliY of gauze of sufficient thickness are arranged transversely and superficial to the macintosh. These pieces are three or four or more in number, and they act as padding for the splint, and at the same time as an antiseptic dressing (Fig. 54). When the dressing is changed, a piece of gauze is pinned to each Fig. 5i.— Splint for excision of knee, ready for application. The splint is padded at the upper and lower parts, and tlie splint and padding are covered with a piece of macintosh cloth. The space opposite the knee is filled with masses of gauze arranged transversely and superficial to the macintosh. of the old pieces, and then the old piece being pulled out the new is pulled in, and thus the limb is never left without support (Fig. 55). Over the front of the limb an ordinary gauze dressing of suitable size is applied. Splint applied in a case op excision op the knee. This shows the method of changing the dressing. In the first way described a mass of gauze would be pinned on to the end of the old piece on the other side of the limb, so that as the old piece is pulled out the new is pulled in, or it may be arranged in the second manner de- sc^ribed, and shown in Fig. 54— viz., a piece only extends to the middle line behind, and as soon as each is pulled out afresh piece is pushed in. Another more convenient way in which this may be managed with even less movement is to have each of the masses of gauze mentioned in the former paragraph divided, in the middle line, and thus the half of each mass is pulled out at a time and a new piece substituted (Fig. 54). TREATMEXT OF ABSCESSES. lO'J Another way is to apply a wire splint next the skin, fix it there, and then apply the dressings outside. When the discharge becomes still less the limb may be put up in plaster of Paris, a window being left for dressing. Excision of joints is now, however, rarely performed, for with aseptic treatment an incision into a joint and the insertion of a drainage tube is generally sufficient in cases where formerly excision or even amputation would have been required. Several advantages are thus gained, among the most prominent of these being absence of shortening of the limb (and this is most im- portant in children), and often a certain and even a considerable amount of motion in the joint afterwards. It may be mentioned here that Mr. Knowsley Thornton in ovariotomy cases does not apply a bandage round the abdomen. He fastens the dressing with adhesive plaster, and does not change it for a week, by which time healing is generally complete, except where the stitches are. Such are the chief points as to the application of antiseptic dressings in different situations. I must now say a few words as to the aseptic treatment of abscesses. I have already referred to the question of the necessity for a dependent opening, and I pointed out that, as the discharge from an abscess treated aseptically is not irritating, because not putrid, it does little harm even though left to well out, instead of being permitted to flow ou.t through a dependent opening. In fact, aseptic surgery has altered the relative importance of the questions to be considered in selecting a situation for open- ing an abscess ; and now the chief point to be looked at is not whether the orifice of the tube is in the most dependent position possible, but whether it is at the point furthest removed from sources of putrefaction — i.e.. whether there is the greatest pos- sible space for the overlapping of the antiseptic dressings. Indeed, in some abscesses pointing near such canals as the pharynx, anus, &c., it is better to make an opening in healthy structures at some distance from the abscess, and burrow a channel into it, than to make an incision directly into the abscess cavity. I saw a striking example of tliis iu Kdiubui-gh se\cral vears 110 ASEPTIC SURGERY. ago. A boy was admitted into the infirmary with retropha- ryngeal abscess connected with occipito-atloidean disease. The abscess was on the point of bursting into the pharynx. Mr. John Chiene, who had charge of the case, instead of opening the abscess at the only place where it was pointing, viz., in the pharynx, cut down behind the sterno-mastoid, and burrowed into the abscess cavity from behind. The abscess followed a typical aseptic course, and the patient recovered completely. Thus then the great rule in selecting a situation for opening abscesses is to make the incision as far as possible from sources of putrefaction. When opened, instead of dealing tenderly with the pyogenic membrane as was formerly done under the impression that it was a hurtful thing to injure it, we now empty the cavity thoroughly, especially in the case of chronic abscesses, in order to get out all curdy masses of pus, &c., which may have gravi- tated to the bottom of the abscess. When this is done oppor- tunity is given for, the rapid adhesion of the greater part of the wall of the abscess cavity, and thus in a very short time there is merely a sinus left leading down to the seat of disease. There is no necessity for washing out the cavity of an abscess, as is done in so many quarters. To do so is simply to irritate the pyogenic membrane unnecessarily without securing any corresponding benefit. Indeed, it might give rise to such an amount of oozing from the wall of the abscess as would wash out all the carbolic acid from the dressings in a very short time, and thus lead to the putrefaction of the discharge. The treatment by hyperdistension, while erroneous in theory, is very dangerous in practice, as the fluid may be forced into the cellular tissue, and lead to diffuse inflammation and even gangrene, or to carbolic acid poisoning and death. The greatest care must be taken in the drainage of abscesses. In the case of a large psoas abscess the surgeon should intro- duce the largest sized drainage tube in the first instance. This tube may be changed for a smaller in a few days. It ought not to be removed for the first time till at least three days have elapsed since the abscess was opened, otherwise there may be great difficulty in replacing it. It should not be shortened till it is found to be absolutely impossible to get it in fully. When- TREATMEXT OF ABSCESSES. Ill ever this is the ease a piece must be cut otif from the end. (Here I speak of chronic abscesses, an acute abscess heals in a week or ten days.) In some cases, where the same tube is left in for a week (where the case is only dressed once a week), some difficulty will be found in withdrawing it, owing to the granulations having grown in at the holes and holding it in position. In this instance the guide as to shortening is lost, because the tube cannot be pushed out ; and therefore it will be found best in old cases to use a tube having holes only close to its inner end. This cannot be held, and is gradually pushed out as the sinus heals from the bottom. If on removal of a tube the discharge is found to increase in quantity, the tube must be reintroduced. As the incision into the abscess is merely large enough to admit the tube, there would be no reason for using protective ; and therefore the wet gauze is applied directly over the orifice of the tube. A tube is the only form of drain suitable in these cases. The precautions required in order to ensure an aseptic result are precisely the same as in the case of wounds. In changing the dressings the same rules are followed as were formerly described with regard to incised wounds. Chronic abscesses, more PS]>ecially abscesses connected with diseased bones, are extremely tedious ; but nevertheless, as a rule they ultimately recover. The same care must, however, be taken from first to last. It is never safe to change the carbolic dressing for a boracic one, however superficial the wound ap- pears to be. In the case of spinal abscesses absolute rest in the recumbent posture must be maintained till healing is com- plete ; and as the cases generally extend over many months it is well to warn patient and friends before commencing to treat the case. Whether the rule as to the maintenance of the recumbent posture may not be modified by the use of Sayre's jacket, or even without it, is now a question. Lately in two cases which had been under treatment for a long time, and in which all uneasiness in the spine had passed off, Mr. Lister allowed the patients to get up before healing was complete, and without any bad results. Empyema does particularly \sv\] under this dressing. I 112 ASEPTIC SUllGERY. mention it, in order to state that a metallic drainage tube with a shield like a tracheotomy tube, and with lateral holes, is the best because the india-rubber tube may get compressed between the ribs or be too abruptly bent where it passes into the interior of the pleural cavity. There are some cases in which neither the gauze dressing nor the boracic can be employed, but which may nevertheless be treated aseptically. I refer especially to abscess in the perineum or by the side of the anus. Abscess in the perineum may be treated aseptically with very satisfactory results. The abscess is opened under the spray, and a piece of lint dipped in 1-5 carbolic oil or 1-10 carbolic glycerine is introduced into the cavity to act as a drain. Outside this two or three layers of lint soaked in 1-5 carbolic oil or 1-10 carbolic glycerine are applied, and fixed with a T bandage. Should this become displaced or wet with urine, e^c, the patient pours a little carbolic oil or glycerine over the wound and over the lint, and replaces the dressing. No spray is required in changing the dressings. On the third day a piece of lint dipped in carboHc oil is laid over the wound, and a pair of oiled forceps is slipped under the lint to seize and with- draw the plug ; or the plug may simply be pulled out under the spray. Carbolic oil or glycerine 1-10 is then used for dressino-, and when the wound has become superficial boracic or salicylic ointment is employed. The same method of dressing is employed in abscesses beside the anus. In this case, when the patient defsecates, he holds aside the dressing, defeecates past it, wipes the parts with 1-20 carbolic lotion and then with 1-10 carbolic oil. He then soaks the dressing with the oil, or applies a new dressing. (The glycerine and carbolic acid may also be used.) The result of this method of treating these abscesses is often excellent, fistula in ano being apparently often avoided when the abscess is taken in time. So much for wounds made by the surgeon and their treat- ment. I now come to the consideration of tuounds 'produced accidentally. Here the problem is different from and much more difficult than the former. In the cases we have just WOUNDS PRODUCED ACCIDENTALLY. 113 been considering we had merely to keep out the septic particles ; in the present instance these particles have already gained admission, and therefore we have not only to prevent the entrance of more but also to destroy those ah'eady present. This is done by washing out the wound with 1-20 carbolic lotion, provided it be recent, i.e., made within twenty-four hours, and then treating it like a wound made by a siu-geon. This washing out of the wound must be done very thoroughly. It is best carried out by using a syringe with a catheter attached to it. The point of the catheter is intro- duced into all the recesses of the wound and the 1-20 lotion is injected through it, and thus comes thoroughly in contact with all parts. There must be no attempt to distend the cavity, as, for instance, by shutting the orifice of the wound around the syringe, for the fluid might be forced into the cellular tissue and lead to inflammation or even sloughing. The opening must be left perfectly free and enlarged if necessary. Should there be any shreds of tissue, they had better be cut off, and if there be much dirt ground into the tissue, it must be got rid of by means of a nail brush. The injection and the subsequent procedures are carried out under the spray. If the wound was made twenty-four to forty-eight hours before being seen, a stronger solution is employed, viz., the 1-5 spirituous solution. This is used in the same way as the other. Having thus got the wound pure the question of stitching it up arises. The answer to this question varies according to the parts injured. As a rule, in injury of the soft parts, a drain is introduced, and the same accurate stitching employed under the spray as was described on a former page. More especially is this the rule in scalp wounds, where most brilliant results maybe obtained by the use of catgut drains and accurate stitching. The rest of the treatment is the same as in ojiera- tion wounds. Where the wound is much contused, the same rules apply as to purification, but it must not be stitched up. After purifi- cation a drainage tube is inserted if necessary, the wound is lefto],)en, a piece of protective is placed over it, and the dressing applied in the usual manner. 1 114 ASEPTIC SURGERY. I have mentioned the methods to be employed when the womid is seen within the first forty-eight hours. It may be, however, that it does not come under notice till putrefaction already exists. In this case it may be purified by the intro- duction of iodoform suspended in water by the aid of ;dcohol, or if superficial, by stuffing it thoroughly with lint dipped in 1-5 carbolic oil. This dressing repeated for several days generally converts it into an aseptic wound. In most cases it is best to apply iodoform or the chloride of zinc solution. Certain special wounds call for attention. Compound fractures are the wounds in which this treat- ment was first applied, and in which excellent results can be obtained. There are a few special points to be noted. In purifying the wounds great pains must be taken. Any dirt • must be carefully scraped or scrubbed out. All blood clots ought to be turned out as completely as possible. The ends of the bones are cleaned, and if they cannot be returned or got to fit, portions should be sawn off. The ends may be tied together with silver wire. The parts ought to be well kneaded as the carbolic lotion is injected through the catheter, in order to diffuse the lotion as much as possible into all the recesses of the wound. No stitches are inserted, but on the contrary, free drainage by tubes is used. The same sort of dressings and apparatus are employed as in excisions. Wounds involving tendons, nerves, or muscles, are treated in the same manner as others, and the ends of the divided muscles, tendons, or nerves, ought to be stitched together with catgut, and the position of the part so arranged as to avoid dragging on these stitches. Wounds of joints are very imj^ortant. When recent no operation (excision or amputation) is required in the first instance. As a rule the joint may be saved, and perfect move- ment obtained by washing it out very thoroughly with carbolic lotion 1-20. The wound in the joint is enlarged if necessary. Where several hours have elapsed since the accident (more than eight or ten hours), it is well to employ the sj)irituous solution. A drainage tube is introduced into the joint, but no stitches are used. After a few days, when the discharge has diminished, SPECIAL WOUNDS. 115 the drain is removed. In about three weeks, or earlier, passive motion ought to be begun, otherwise the adhesions outside the joint may become so strong as to require to be broken down under chloroform. Compound fractures of the skull are treated in the same manner as compound fractures elsewhere, purification being attempted with 1-20 carbolic lotion. The dm-a mater may be freely dealt with without fear of inflammation, for the irritation of carbolic acid is only very transient. Bleed- ing vessels are secured by catgut. Should one of the great sinuses be wounded, a graduated compress of catgut arrests the haemorrhage satisfactorily. This I have known to act very well in a case of woimd of the longitudinal sinus, occurring during the operation of trephining over the seat of an old injury. Wounds penetrating the thoracic cavity are much more difficult to treat. Should the wound penetrate the lung, and should the lung protrude, the exposed parts and those around are purified with carbolic lotion 1-20. In deciding as to the returning of the injured lung and the stitching up of the wound, the surgeon must be guided by the circumstances of the par- ticular injury. In some cases, if the wound in the lung were superficial, the edges of the divided visceral pleura might be stitched together with fine catgut, the lung returned, and the external wound closed. Where a large bronchus is injured it might be better practice to leave the limg in the wound, and leave the wound open. Where there is merely a wound of the parietal pleura, and where the lung is not wounded, the external wound only is purified and is closely stitched, in the hope that union by first intention may occur, that the air may be absorbed, and that any septic dust present in the pleural cavity may be unable to cause mischief. Wounds of the abdomen are variously treated, according as there is or is not protrusion of the contents. Where there is no protrusion, and where there is no reason to suspect injm-y of the viscera, the external wound ought to be purified and closely stitched, so as to get primary union throughout, no drain being used. Where the intestines protrude, they ought to be carefully 116 ASErriC SURGERY. bathed in warm carbolic lotion 1-30 or even 1-20, and if there be no injury of them in any part they may be returned. If they are cut, the gut may be stitched with catgut by the glover's suture. If the omentum protrudes, opinions vary as to the treat- ment. When it can be returned do so after thorough purifica- tion, and then stitch the abdominal walls, including the perito- neum, close together. Where, from adhesion or other sufficient cause, this cannot be done, or where the omentum is very dirty, I should, from a research into the consequences of un- . returned omentum by Dr. Kenneth McLeod, of Calcutta, con- sider it the safest practice, especially in the case of a person with strong muscular parietes, to stitch the deepest parts of the omentum to the deep part of the wound, cut off the remainder and close the skin over all. If internal haemorrhage is going on, apparently from the mesenteric vessels, the wound may be enlarged and the bleeding point sought for. Simon advised that in bleeding from the kidney, the injiu-ed organ should be excised ; this suggestion was never put into practice, but nevertheless it is one well worth bearing in mind. Such are the chief points to be attended to in recent wounds ; there remains for consideration the class of cases in which putrefaction has been present for a long time. I refer to cases of putrid sinuses, generally connected with diseased bones or joints. An attempt may be made to purify these during the course of an operation, and sometimes when the sinuses are few and uncomplicated, and where all the dead bone is removed, this attem})t may be successful. The sinus is scraped out with one of Volkmann's sharp spoons (Fig. 56), and all the granulation tissue, as far as possible, removed. The raw surface of the sinus, &c., is then washed out with the chloride of zinc solution, which is applied thoroughly to all parts, and a gauze dressing is used, in the hope that putre- faction has been thus eradicated. The spray should be employed during the whole procedure. If this is successful, well and good. If not, boracic oint- ment (at first full strength, afterwards half) or salicylic oint- TREATMENT OF BURNS. 117 ment, covered with boracic lint, is the best dressing, indeed, it is the best dressing in all cases where strict aseptic measures are inapplicable. The aseptic treatment of burns varies according to the degree and extent of the injury. In any case, unless where the burn is very extensive and where the parts are extremely dirty (necessitating scrubbing of the surface and consequent shock, and also risk of carbolic poisoning), an attempt should be made to purify the surface with 1-20 carbolic lotion. This having been done, if the surface is small, boracic ointment (full strength) and boracic lint form a convenient dressing. When the extent of the burn is greater, wet boracic dressing (wet boracic lint used as water dressing — covered by gutta-percha Fig. 56.— Two foejis op sharp spoons, a large round one akd a small oval one. tissue or macintosh) is the most suitable. The wet boracic dressing is also applied in those cases where, on account of the extent of the burnt surface and the amount cf dirt, purification with carbolic acid is not advisable. Where the surface is thoroughly charred and where the wound is not very extensive, boracic ointment or carbolic oil 1-10 are the best dressings. The objection to carbolic oil, which was formerly used in all cases, is that, when the surface is large, there may be a fatal absorp- tion of carbolic acid. In the after-treatment the sores are dressed with boracic dressings (protective and boracic lint, or better, in the first instance, boracic ointment) just as in the case of ulcers. The rules as to the treatment of gangrene are altered in 118 ASEPTIC SURGERY. aseptic surgery, and this is more especially the case with senile gangrene. Should symptoms of senile gangrene set in, say in the lower extremity, the skin of the foot, toes and leg, are thoroughly cleansed with 1-20 carbolic lotion. This must be done very efficiently. All the folds about the nails, &c., must be carefully cleansed and washed. This having been done, the whole limb and foot are enveloped in a large mass of carbolised cotton wool (carbolised in a 1 per cent, ethereal solution of carbolic acid). This being pure in its substance, and being applied over a pure surface, completely shuts out causes of putrefaction. The carbolic acid soon flies off, and then the cotton wool acts simply as a filter, while it protects the part from unequal pressure and retains the heat. This may be kept on for any length of time, and so long as discharge does not extend to the surface or the gangrene above the limits of the dressing, the part remains sweet, and very often the gan- grene, which in the first instance threatened to involve the whole leg, becomes limited, and there may even be merely a small cutaneous slough. In any case, as a rule, the gangrene does not go on spreading as it does when treated in the usual manner, and for this reason : — Suppose that the part is not treated aseptically, the tissue at the edge of the dried gan- grenous mass becomes putrid, the living tissue in the neigh- bourhood is very weak, the putrid material acts on it like a caustic, destroys its vitality or excites an inflammation which kills it, and so the gangrene goes on spreading, till at length parts are met with of sufficient vitality to resist this action of the putrid materials. Then a line of demarcation is formed. On the other hand, when the gangrenous parts are not putrid, the weak parts in the vicinity, which would to a certainty have died in the former case, retain their vitality and gain strength. Thus also the rule of never amputating in senile gangrene, except to trim a stump formed naturally, is done away with, and it is generally better to amputate as soon as it is clear to what extent the tissue is dead, rather than to subject the })atient to the continual pain and irritation arising from the presence of the dead piece. The same reasoning a])plies to cases of traimaatic spreading gangrene. This is only one instance of how completely many current ideas as TREATMENT OF N.EVI, ETC. 119 to surgical pathology and treatment are reversed, when means are taken to render the dust of the atmosphere inert before it reaches a wound. In treating nasvi great benefit is obtained from the in- jection of pure carbolic acid. The na3vus is first thoroughly- cut off from the circulation by ligatures tightly applied around its base, and then half minims of pure carbolic acid are in- jected into various parts of the tumom-. Ten minutes or so having been allowed to pass, in order to ensure com])lete and firm coagulation, the ligatures are divided and removed, and the punctures are touched with collodion. The surface being left completely dry, any slough which forms becomes absorbed or separates as a crust after some time, the part beneath being found to be a scar. The same method answers excellently in the treatment of varicose veins. A tourniquet having been firmly applied around the upper part of tlie limb in order to arrest the circulation, the vein is punctured at various parts, and half minims of car- bolic acid are introduced into it. The tourniquet is kept on for ten minutes after the injection is completed. Coagulation and a slight degree of inflammation are thus induced, but this, so far as I have seen, never goes to any dangerous extent, and is followed by at least temporary cure. I have not known any case return with reformation of varicose veins. A dissection or post-mortem wound does not give rise to bad results if the wound be instantly purified with 1-20 car- bolic lotion. 120 ASEPTIC SURGERY— MODIFICATIONS. CHAPTER VI. ASEPTIC SURGERY — MODIFICATIONS. Country practice : Hoiv to dispense, with the sjjray diinng the operation — and during the after-treatment : How to render the dressings less frequent. Is the aseiDtic method applicable in war? Mr. Lister's svggestions : Esmarch''s2)lan : Reyher's method. Development of Aseptic S>Trgery in ]Mr. Lister's hands : Conipoimd fractures — Pure carbolic acid — Formation of crust — Carholic p%dty — Lead plaster — Lac plaster, syringing wounds with carVolic lotion, protective, catgut ligat^ires, method in 1870 — Present method in tlis main introduced in 1871 — Fwther introduction of wet gauze, steam spray, elastic bandages : abscesses — Method of opening them under carbolic oil : wounds. Such are the methods usually employed in carrying out the Listerian principle in hospital or in private practice. It is, however, said to be difficult of application to country practice, and we must therefore enquire in what way it can be made easier. The difficulties urged are that the spray is too heavy to carry : that it is not always easy to return a long distance to see a patient on the day after the operation, and that the dress- ings are too expensive for the lower classes. We must there- fore, in some way or other, render the dressings very infrequent, so as to avoid expense and unnecessary visits, and we must try to dispense with the spray. In the first instance in going to perform an operation or to treat a wound, the surgeon takes instruments with him, and he may, without any additional trouble, easily add a spray to the contents of his bag, and this spray may be left at the patient's house, and brought home again after the first dressing. But, suppose the surgeon has not a spray at hand. What is to be done ? Well, he must use all the other i)recautions before described, and wash out the wound frequently with 1-40 carbolic acid lotion during the operation, and while the stitches MODIFICATIONS FOR COUNTRY PRACTICE. 121 are being inserted ; and then, before the piece of wet gauze is applied, he may distend the wound with the same lotion, the wet gauze being applied while this is still flowing out. At the same time I caimot see that, in the great majority of cases, it can be any great hardship to carry a spray to an operation. During the after-treatment a spray is not necessary. The spray may be rendered unnecessary diuring the after-treatment in two ways. In the case where catgut stitches and catgut drains are used a deep dressing may be applied at the time of the operation, and may never require to be changed. This deep dressing is fixed down in some way or other, and is treated as a wound, the gauze being soaked with carbolic lotion every time the superficial dressing is removed, and then a piece of wet gauze larger than the deep dressing, and the general dressing are applied. Should it be necessary to remove the deep dressing, there is no necessity for the spray, if catgut drains be used, because there is no cavity into which air may pass. The deep dressing having been removed, carbolic lotion is allowed to flow over the wound till a guard is applied. Where a tube is used it is more difficult to do without the spray, for in that case there is an open orifice into which dust may fall, and be sucked into the interior of the wound, and further, when the tube is removed, air must enter to take its place. This may be avoided by the use of a syringe which constantly keeps a stream of carbolic acid lotion passing over the wound and over the drainage tube, till a fresh dressing is applied. Should it be necessary to remove the tube it is well, in addition to this constant flow of lotion, to cover the orifice of the tube with a rag dij^ped in the antiseptic lotion. The best way is to take a guard soaked in carbolic lotion and folded in several layers, and place this over the orifice of the drainage tube, extending on each side of it for a considerable distance. The tube is now seized with a pair of forceps through this rag, and as it is pulled out the rag is carefully tucked in around it, so as to compel the air, as it passes in to take the place of the drainage tube, to traverse the moist guard. This seems to me better than the method of slipi)ing in forceps under the guard and pulling out the tube, the guaid being well pressed down on it. In taking out wire or silk stitches, the 122 ASErilV SURGERY— MODIFICATIONS. guard is pulled aside so as to expose the stitch, a little carbolic lotion is then dropped over the suture, and as the latter is withdrawn, a few drops of the lotion are applied to the orifice of the puncture. These methods — the use of catgut stitches and catgut drain, and the employment of a permanent deep dressing, together with the hints in cases where a drainage tube or non- absorbable stitches are employed, suffice to render the operator independent of a spray. Can we now render the dressings less frequent ? This may of course be done to a certain extent by applying a larger amount of gauze, but the best way is to use sponges in the interior of the dressing for the purpose of absorbing and retain- ing the fluid. The deep dressing having been applied and fixed, a large sponge or several small ones are placed outside it, these sponges having just been wrung out of carbolic lotion ; outside the sponges and extending well beyond them is a piece of wet gauze, and then the masses of loose gauze and general gauze dressing. In this way the discharge is retained in the interior of the dressing, and of course so long as it is there, and so long as the discharge has not reached the edge of the dressing, it is as safe from putrefaction as if it were in a pure flask. By the use of these sponges several days may be allowed to elapse, in many cases, before the first dressing is changed, though it is well in every case to change the first dressing on the day after the operation. When the dressing is changed these sponges are squeezed thoroughly, washed in carbolic lotion 1-40, and reapplied. By the use of sponges two or three dressings suffice for the treatment of most operation wounds. By the use of salicylic jute in large masses, the same avoid- ance of frequent dressings may be obtained, but this material is not very trustworthy as an antiseptic. Thoroughly purified cotton wool, which may be obtained cheaply by impregnating it with sulphurous acid fumes, ap- plied in large mass may prevent the necessity of frequent dressing. By the means described, the difficulties in the way of the adoption of this system in country practice may be overcome. APPLICATION IX JVAP. 123 and instead of causing additional expense to a poor patient, it saves expense in many ways. The dressings required are so few that the price of the materials employed is not greater than that which would be necessary even if water dressing were used ; and expense is saved in many other ways, as I shall mention in the latter part of this work, notably in the rapid healing, which is of course of the greatest consequence to the bread winner. Is the Aseptic method applicable in War"? In the 'British Medical Journal ' for September 3, 1870, Mr. Lister describes a method for the use of army surgeons. He suggests that the wound should, as soon as possible after the injury, be thoroughly washed out with 1-20 carbolic lotion, the smTounding skin being at the same time purified. Bleeding vessels are secured by catgut, by torsion, or by car- bolised silk. While the wound is full of lotion, extract the bullet, clothes, &c. Then cover the wound with two or three layers of oiled silk, smeared on both sides with carbolic oil 1-5. Over this apply layers of lint soaked in the 1-5 oil. overlapping the oiled silk for about three inches in every direction, and about a quarter of an inch in thickness. This is covered with gutta-percha tissue, and the whole is fastened on with a bandage soaked in carbolic oil. This is the permanent dressing. Out- side this, another and larger dressing of oiled lint covered by gutta-percha tissue is applied daily. During the first day apply fresh oil to the outer cloth once in six or twelve hours. On the following day the outer dressing is changed, carbolic lotion being introduced under the edge, as it is lifted, by means of a syringe ; or carbolic oil may be poured in. After the first dressing use the 1-10 oily solution, and later the 1-20. On the second day oil is only applied once in twelve hours, after that it is applied daily for five or six days, and then once in two days. Jn compound fractures use a wire splint next the deep dressing, and apply the fresh superficial dressings outside the wire. This s})lint need not be removed till union is complete, the oil being merely poured between the meshes when the dressing is changed. 124 ASEPTIC SURGER Y—MODIFICA TIONS. APPLICATION IN WAR. 125 Esmarch, in Langenbeck's ' Archiv,' vol. xx. p. 171, proposes another plan of treatment. He points out that the new form of bullets passing quickly through the clothes may not carry into the wound any causes of putrefaction. Therefore, if the wound is not examined by dirty fingers or instruments, and if it be seen at once, it may in most cases be regarded as aseptic. Starting on this prin- ciple, he suggests that each soldier should be provided with tampons of salicylic cotton, wrapped in salicylic gauze. Fig. •57 represents the contents of the packet of dressings which Esmarch proposes to supply to each soldier. At the front, when there seems any possibility of saving the limb, these tampons are introduced into the openings, and bandaged on without any preliminary probing or examination of the wound. Any other necessary apparatus is applied, and the patient sent to the rear. At the rear the skin around the orifice is purified with some antiseptic lotion, and if there is any necessity to explore the wound, as for removing bullets, splinters, &c., the tampon is removed under the spray, the wound washed out, and an antiseptic dressing applied. If there is no necessity for exploring the wound, the skin is merely purified, and then a mass of salicylic jute or other antiseptic material is applied without disturbing the tampon. If putrefaction occurs later the wound must be enlarged, and an attempt made to purify it. Conservative surgery being more a})plicable with the aseptic method, the necessity for primary amputation at the front is less frequent, and as a rule exists only in the case of sjnashes from large balls. Esmarch considers that for such cases a sutficient supply of antiseptic materials should be present in the am- bulance. Referring to those cases not treated aseptically which do well, and to the evils of investigating the wound at the first, Esmarch says : ' So weit ich habe in Erfahrung bringen kon- nen sind diejeningen Kalle, welche asei)tisch verliefen, auf dem Schlachtfelde nicht mit dem Finger griindhch untersucht, sondern gleieh verbunden worden, wahrend solche Falle bei denen wiederholte Untersuchungen vorgenommen waren, mir oft einen besonders schlimmen Verlauf zu iiehmen schienen.' Esmarch's method has been put to the test by Dr. Reyher ]2G SEPTIC SURGERY— MODIFICATIONS. during the late Kusso-Turkish campaign. His results were excellent, and will be referred to later on. He carried out the aseptic method in two ways, according to the nature of the injury and the treatment before the case came into the sur- geon's hands. These are, either that the surgeon closes the wound without further treatment, merely disinfecting the sur- rounding parts, or else that he cleans out and purifies the track of the bullet, and afterwards makes provision for free aseptic drainage. In the first instance healing occurs under a crust ; in the second, under a moist and antiseptic dressing. The cases which are suitable for the first method of treat- ment— treatment by a crust — are those in which the wound is small, where no clothing has been carried in with the bullet, where the edges of the wound fall together as where the wound is more or less valvular, and where no examination of the wound by finger, probe, &c., has been made. In such a case the surrounding skin is carefully purified, and an attempt is made to obtain a dry crust either by allowing the blood to dry, or by aiding the drying by applying charpie, gauze, &c. ; or the wound may be covered by a mass of salicylic wool or carbolic gauze. Keyher lays particular stress on the avoidance of probing or draining such wounds. On the contrary, any communication with the outer world should be shut off as soon as possible. In many cases this ' occlusion ' of the wound cannot be depended on, and the bullet track must be washed out, and treated in the way described under compound fracture, free drainage being carefully provided. This is chiefly the case where the missile has been travelling slowly, and where, conse- quently, the wound in the skin is not so small nor valvular, and where there is more likelihood of articles of dress being carried in with it ; where, also, as Eeyher puts it, the wound is open and ' the air has not only entered but must enter again.' This treatment is also necessary in cases where wounds have been examined with unclean fingers or instruments before reaching the ambulance. It is thus evident that the spray is not required for the majority of cases, and indeed by following the lines previously indicated it may be entirely dispensed with. The gauze re- ATTLICATION IN WAR. 127 quired for the dressings can be made in the vicinity, and for this purpose Eeyher carried with him the machine for making gauze described in Chapter III., and had thus a constant supply of the freshly-prepared material. There is not much difficulty, therefore, with regard to the materials ; the real question is how to have the cases treated aseptically from the very first. Eeyher was able to overcome these difficulties by proceeding in the following manner. In the first place, instructions were given that wounds were never to be examined at the front, either with fingers or instruments, nor was any attempt to be made to extract a bullet. The only exceptions to these rules were cases where blood-vessels were injured, though even in these it was generally possible to apply an Esmarch's elastic band to control the haemorrhage temporarily ; and cases where the projectile had passed into the large cavities of the body, and, without wounding the contents, had remained in the wall of the cavity. In such a case the bullet ought to be extracted at once, lest it should fall into the cavity during the transit of the patient. ' For surgeons at the front there is only one line of treatment — to occlude the wound provisionally — to lay the wounded part in a suitable position on the litter, and to render it provisionally immovable. As provisional dressing the sali- cylic balls recommended by Esmarch are the best.' This method is chiefly suitable for cases where the soft parts alone are injured. ]Most of the serious cases can be attended to as a rule at the foremost ambulance. The more surgeons become imbued with the true principles of aseptic surgery, and the more thoroughly they grasp anti- septic surgery in all its developments, so much the greater is the likelihood of obtaining aseptic results. Reyher's results show strikingly what can be done with the methods at present at our disposal. There can be no doubt that with improved methods and increased knowledge and experience, aseptic surgery will soon be universally carried out in war.' It will be interesting now to trace the gradual development ' For a resume of the opinions of army surgeons on the best methods of carrying out aseptic surgery in war, see a little pamphlet by Surgeon- Major H. Melladew, Xvtcson Antincptie Surgery in War. London : Ilanken ."v Co. 1881. 128 ASEPTIC SURGERY. of this system in Mr. Lister's hands. This will not only be interesting but instructive, as showing how aseptic surgery may be carried out in circumstances where spray, gauze, &c., cannot be obtained. • The first cases in which the treatment was tried were com- pound fractures, and the first attempt recorded by Mr. Lister was made in March 1865. This attempt was imsuccessful, as Mr. Lister subsequently believed, from mismanagement.^ The next case was a compound fracture of the tibia, caused by the wheel of a waggon passing over the leg. The external wound in this case was 1^ inch long, and | inch broad. A piece of lint dipped in carbolic acid (which was at that time only got as an impure liquid known as German creosote) was placed upon the wound. Four days later this lint was removed, and the wound dressed with lint soaked in water in which this im- pure carbolic acid was diffused. Five days afterwards a solution of one part of carbolic acid in from 10 to 20 parts of olive oil was used for four days, and then ordinary water dressing was resorted to. The aim in this case was to form a crust consisting of lint, carbolic acid, and blood, which would protect the deeper parts from putrefaction. In this instance, however, the scab came off on the fourth day, and in order to avoid this occurrence, Mr. Lister, in his next cases, applied a piece of lint dipped in pure carbolic acid as before, large enough to overlap the sound skin for a quarter of an inch all round, and covered with oiled paper, applying for the first four days outside this arrangement a piece of lint soaked in pure carbolic acid. The crust was left untouched till the eleventh day, and then water dressing was used. It now became evident that, owing to the volatility of the carbolic acid, means were required to prevent its evaporation. Accordingly, in the next cases a layer of sheet lead or of block fin was applied outside and overlapping the crust. Up to this time there was no attempt made to purify the interior of the wound in the first instance. How was it, then, that no putreftiction occurred ? Probably for the following reasons. It may have been that no septic particles had got ' See numbers of the Lancet for 1867. ITS DEVELOPMENT. 129 into the interior of the wound because the blood flowing con- stantly out would prevent the entrance of solid particles, which would thus only be present if dirt was introduced at the time of the accident, or if much movement of the fragments oc- curred afterwards, with consequent introduction of air. Further, if any septic particles were present they may not have been able to produce any effect in the presence of healthy living blood clot. (This will be discussed hereafter.) Lastly, the strong carbolic acid, though appKed only to the surface, rapidly spreads into the interior even to a depth of one or two inches. The necessity for pmifying the deeper parts of the wound soon became evident. A case was admitted in which, when the tissues around the wound were pressed, bubbles of air escaped along with the blood. Here Mr. Lister squeezed out as much of the clotted blood and air as he could, and then applied a piece of lint dipped in pure carbolic acid, slightly larger than the wound, and over this the piece of block tin. The crust was daily painted with carbolic acid, the tin cap being reap- plied on each occasion. This treatment was continued for three weeks. This purification of the deeper parts was carried out more thoroughly in the next case, in w^hich it was necessary to saw off a portion of the ulna, and here the whole of the interior of the wound was swabbed out with pm-e carbolic acid. In this case Mr. Lister first became acquainted with ' antiseptic sup- puration,' i.e. su})puration due to the irritation of the anti- septic applied. (The evil effects of the piure caustic carbolic acid in causing excoriation of the skin had been already noticed.) Finding that no harm resulted from the free application of pure carbolic acid to the interior of the wound in the last case, the next which came under notice was more thoroughly treated, the contused parts being well manipulated and squeezed, so as to induce the liquid carbolic acid, which was introduced, to penetrate into all the interstices of the wound. At a later period, in order to permit cicatrisation, the crust was chpped away around the margin, and a solution of sulphite of potash (5 grains to the ounce) applied. K 130 ASEPTIC SURGERY. In future, the method of introducing strong carbolic acid into wounds by means of a piece of lint soaked in the undi- luted acid, held in dressing forceps, was adopted. The blood clots were as far as possible removed. In order to obtain a more substantial crust and one less likely to be detached, in cases where there was too little blood, a paste was made use of, composed of starch, moistened with carbolic acid placed outside a piece of calico soaked in pure acid, and applied next the wound. As a rule, however, there is enough blood to form a substantial crust if several layers of calico are used. A great risk of putrefaction was all along experienced, owing to the fact that the pure acid could not be made to overlap the skin around the wound because of the excoriation caused by it. This risk was especially great in the first twenty-four hours, during which there was a profuse flow of blood and serum. Hence attempts were made to obtain some sort of dressing containing the acid in a more diluted form, and the first-fruits of these attempts was the formation of various pastes, of which the chief was long known as carbolic putty. This consisted of a 1 in 5 solution of carbolic acid in boiled linseed oil mixed with common whiting (CaC03), to the consistence of a firm paste or putty. This was then spread on a sheet of block tin, forming a layer of about a quarter of an inch in thickness. A piece of lint dipped in 1-5 oily solu- tion was retained permanently next the wound so as to prevent its exposm-e during the changing of the dressings. The whole dressing was firmly fixed down by means of a continuous series of strips of plaster, which, however, were absent at the most dependent part, so as to allow the escape of discharge, which was received on a towel. After some time it was found better to apply this putty between two layers of calico, and then the block tin outside all. The advantages of this dressing are : the tin applied out- side prevents the escape of the carbolic acid, the acid in the putty is just sufficiently diluted not to excoriate the skin, while the paste serves as a reservoir for the acid during the interval which elapses between the changing of the dressings, the dis- charge, as it flows out beneath the putty, taking up only a ITS DEVELOPMENT. 131 certain amount of the acid in its course. If necessary the strength of the acid in the putty may be reduced. Its disadvantages are that it is clumsy and inconvenient to manipulate, and that it is very apt, when subjected to move- ment, to crumble away, and thus become an uncertain dress- ing. Attempts were therefore made to improve it, and recourse was had to various forms of plasters. The first of these was the lead 'plaster,^ The following is the mode in which this is prepared : — Take of olive oil 12 parts by measure „ ,, litharge (finely powdered) 12 parts by Aveight „ „ beeswax 3 „ „ „ ,, „ crystallised carbolic acid 2^ ,, ,, „ Heat half the oil'over a slow fire ; then add the litharge gradually, stirring constantly till the mass becomes thick or a little stiff. Then add the other half of the oil, stirring the mass as before, till it becomes thick. Then add the wax gradually till the liquid again thickens. Remove from the fire and add the acid, stirring briskly till thoroughly mixed. Cover up close and set aside, and let the litharge settle, then pour ofi" the fluid and spread on calico. The large quantity of litharge in this mixture was introduced for the purpose of preventing the melting of the plaster at the temperature of the body. The wound was dressed with layers of lint soaked in car- bolic oil, and this dressing was covered in all directions with the plaster. This plaster was renewed daily. As with the putty, so here, the deep dressing was apt to be- come displaced, and therefore Mr. Lister used lead plaster as the outermost layer of the deep dressing, in the hope that it would adhere to the skin and prevent lifting of the edges of the dressing. In order to prevent the outer layer of the plaster from sticking to this inner portion, a piece of calico moistened in the watery solution was interposed. But though the plaster does very well for the outside layer, it does not do for the permanent dressing, for it allows the watery solution from the calico to soak through to the wound beneath. At the same time this deep layer, not having formed a crust, is apt to shift its place, and to leave the wound more or less exposed. ' Brit. .Vrd. JiniriKil. Octolicr ;>!, 1878. K 2 J32 ASEPTIC SURGERY. Mr. Lister accordingly tried other sorts of plaster, and at length in shell lac he seemed to have found all that he wanted. This lac mixes in any proportion with carbolic acid, and is more or less fluid or tenacious, according to the quantity of acid present. The shell lac parts but slowly with its acid, and thus forms a good dressing. It is, however, very apt to stick, and in order to prevent this Mr. Lister interposed a layer of gutta- percha between it and the skin. The carbolic acid passes through the gutta-percha with extreme readiness, while the latter prevents the lac from sticking to the deeper parts. Gutta-percha tissue, however, proved apt to crack, and then the discharge got between it and the lac plaster, and thus the fluid beneath it received but little carbolic acid. Hence the same result happens with this cracked gutta-percha as when protective extends to the edge of the dressing — viz., a deep layer of the fluid is more or less protected from the action of the acid, and putrefaction can spread inwards. After several experiments he ultimately employed a solution of gutta-percha in bisulphide of carbon to brush over the surface of the lac plaster. The following is the method of preparing the plaster : — * Take of shell lac ...... 3 parts „ „ crystallised carbolic acid ... 1 part ' Heat the lac with about one-third of the carbolic acid over a slow fire til] the lac is completely melted, then remove from the fire and add the remainder of the acid, and stir briskly till the ingredients ai-e thoroughly mixed. Strain through muslin and pour into the machine for spreading plaster, and when the liquid has thickened by cooling to a degree sufficient, spread to the tliickness of one-fiftieth of an inch. Afterwards brush the surface of the plaster with a solution of gutta-percha in about 30 parts of bisulphide of carbon. When the bisulphide has all evaporated the plaster may be piled in suitable lengths in a tin box without adhering, or rolled up and kept in a canister.' For the permanent dressing in compound fracture adhe- siveness is wanted, and this is obtained by rubbing off the gutta-percha and brushing liquid carbolic acid over the surface. At this time (1868) the necessity for protecting the healing l)arts from the direct action of the carbolic acid was beginning ITS DEVELOPMENT. 1^3 to be recognised, and Mr. Lister first speaks of the use of block tin or sheet lead as a protective. At the same time, having obtained a pmrer carbolic acid soluble in water, he gives up the application of the pure acid to the interior of the wound in compound fractures, and syringes it out with a solution of 1-20 instead. In the 'British Medical Journal' for March 19, 1870, a description is given of the method then used. The wound was in the first instance thoroughly syringed out with 1-20 carbolic lotion. Then oil silk covered with a layer of dextrin was applied iu one or two layers, and outside this the lac plaster. If much discharge was expected lint or a towel was placed outside the lac piaster in order to absorb the discharge. Where the dressing was left undistui'bed for a week two layers of plaster were used. Where a small piece of lac plaster was applied as a deep dressing, and where consequently the gutta-percha was rubbed off to allow the plaster to adhere to the skin, the gutta-percha was left at one part so as to afford a channel for the escape of discharge. In changing these dressings a solution of carbolic acid 1-20 was thrown over the wound by means of a syringe, as the dressing was raised, and then a guard soaked in the lotion was applied. In 1869 catgut ligatures were introduced. The objections to the lac plaster are that the discharge putrefies outside the plaster and irritates the skin, that the lac keeps the surface beneath it moist with what is really a film of watery solution of carbolic acid, and this again makes its way under the protective and irritates the woimd. Very shortly after the use of the aseptic method in the treatment of compound fractures it was a})plied to abscesses. The first publication on this subject appeared in the 'Lancet' for July 27, 1867. The method of opening the abscess and of changing the dressings employed with the means at that time at disposal are very important with reference to the question of operating and dressing without a s})iay. A piece of rag dipped in 1-5 carl)olic oil is laid on the skin where the incision is to be made. The lower edge of this rag being raised, a knife dipped in the oil is at once plunged into the abscess, and the rag immediately dropped over the orifice through which the pus is pressed out. A piece of lint 134 ASEPTIC SURGERY. soaked in the oily solution is then introduced into the opening in order to stop bleeding and to prevent it from closing. This is done by slipping the strip of lint under the antiseptic rag. With regard to the dressing, the putty is here described and used outside a deep dressing of carbolic oiled lint, a layer of calico being interposed between the putty and the deep dressing to prevent them from sticking together. The putty is changed once in twenty-four hours, or oftener if necessary. In doing so a rag dipped in the oily solution is placed over the wound or the deep dressing the instant the old putty is removed. If a plug of lint has been introduced in the first instance it is after a time (two or three days) withdrawn by pushing oiled forceps under the piece of oiled rag, seizing hold of the plug and pulling it out, the oiled rag being pressed thoroughly around the forceps. If a probe is introduced it must be oiled and then slipped in between the folds of the oiled rag. As the various means described under compound fracture were introduced they were applied to abscesses on the principles already described. The first example of efficient aseptic treatment in the case of wounds published by Mr. Lister will be found in ' The British Medical Journal ' for October .31, 1868,^ The case narrated is one of operation for badly united Pott's fracture. ' On the 11th inst. (April, 1868), the man being under the influence of chloroform, I made a curved incision behind and below the prominent end of the tibia, a solution of carbolic acid in four parts of olive oil being dropped into the wound during the progress of the operation. I detached the soft parts from the bone sufficiently to enable me to insinuate behind the callus one blade of a pair of cutting pliers smeared with the same oil, and then having placed pieces of lint soaked with the oil around the blades of the pliers, so as to prevent the chance of septic air entering the joint when the bone gave way, divided the callus, and at once covered the wound with the antiseptic lint. . . . The wounds were then dressed with a weak oily solution of carbolic acid, and covered with the anti- septic (lead) plaster. Fresh plaster was applied daily.' I need not repeat the various modifications in the treatment ' Reports published during the same year by Drs. Heron and Malloch will be found in the Glasgow Medical Jonrnal. ITS DEVELOPMENT. 135 of wounds, as they are similar to those just described under compound fractures. In the 'British Medical Journal' for January, 1871, JMr. Lister first mentions the gauze dressings, and also refers to the use of oakum. The spray is also tried. In August, 1871, this method has been established, the present protective was com- pleted, and macintosh was substituted for gutta-percha tissue below the outer layer of the gauze. The drainage tube is first mentioned in August, 1871, in the treatment of wounds, though it had been used for a short time previously in the case of abscesses. At that time the piece of gauze next the wound was not wet. It was some two or three years later that the necessity for wetting the deep layer was recognised, and since that time the results have been much more constant. With the introduction of the steam spray, of the elastic bandage, of the improved gauze, &c., there has been a marked improve- ment in results, and the avoidance of putrefaction, in cases where the wound is made by the surgeon, is now reckoned on as a matter of course. 130 ASEPTIC SURGERY. CHAPTER VI r. ASEPTIC SURGERY — {concluded). Other methods of carrying out AsejDtic Surgery. Substitutes for carbolic acid: Salicylic acid: Thymol: Acetate of Alumina: Eucalyjrtiis oil. Aseptic surgery by filtration of the air. Subcutaneous surgery. Such are the essential details of aseptic surgery as introduced and i^ractised by Mr. Lister. The disadvantages arising from the irritating and poisonous qualities of carbolic acid have led some to seek other antiseptics as substitutes for carbolic acid. These attempts have not as yet, however, succeeded in producing any substance possessing so many advantages as that acid. The most successful substitute up till quite recently was salicylic acid, which is used on exactly the same principles, but not with the same constant aseptic results. The use of salicylic acid was first advocated by Professor Thiersch, of Leipzig, and the following is a short abstract of his method of using it. Salicylic acid is chemically nearly related to carbolic acid. Its formula is C^HgOy, differing therefore from that of carbolic acid in containing in addition the atoms of carbonic anhy- dride. (The formula of carbolic acid is CgHgO.) Salicylic acid is not poisonous, but it affects the hands in the same way as carbolic acid. It is absorbed, and may be found in the urine of patients whose wounds are dressed with it. A lotion of salicylic acid is employed. This is a saturated solution of the acid in water at the ordinary temperature, and its strength is about 1 part of salicylic acid to 300 parts of water. Two materials are used as dressings — viz., salicylic wool and saHcylic jute. TREATMENT BY SALICYLIC ACID. ]37 Salicylic wool is cotton wool impregnated with salicylic acid in the proportions of 3 and 10 per cent, by weight. The 3 per cent, wool is made by dissolving 750 grammes of salicylic acid in 7,500 grammes of spirit (83 sp. gr.). This solution is then diluted with 150 litres of water at the temper- ature of 70°-80° C. 25 kilogrammes of pure cotton wool are saturated with this mixture. The 10 per cent, wool is obtained by dissolving one kilo- gramme of salicylic acid in 10,000 grammes of spirit (83 sp. gr.), the solution being then mixed with 60 litres of water. Ten kilogrammes of pure cotton wool are soaked in this solution. This soaking is best done in a large wooden vat, in which the layers of cotton wool have plenty of room. It is best to place only small quantities of wool (two to three kilogrammes) in this vat at a time in order to get an equal distribution of the acid. Thin layers of cotton wool are introduced into the salicylic solution under light pressure, fresh layers being added only when the former have been thoroughly soaked. When the whole quantity has been introduced the mass is turned over, so that the undermost layer becomes the uppermost, and then it is left for about ten minutes, so as to have equable distribution of the fluid. The wool is then taken from the vat and spread out in layers. On cooling, the acid crystallises out, and the layers are made up into small parcels, not exceeding two to three kilogrammes each. After twelve hours this wool is spread out to dry in a moderately warm place. It should not be hung up, lest the acid should become unequally distributed. The 10 per cent, wool is coloured with carmine for the sake of distinction. It is important to note that Thiersch, in speaking of 3 per cent, and 10 per cent, wool, means wool soaked in the solutions of the strength described. The wool does not contain that per centage of salicylic acid. This cotton wool does not absorb fluids readily, and therefore Thiersch now uses jute. This is made from the bark of various species of Corchorus grown in Bengal, and is cheaper than cotton wool, and at the same time more absorlient. It is used of two strengths — 3 and 10 per cent, prepared in the same way as the salicylic wool. 138 ASEPTIC SURGERY. Grlycerine is added to the solution in order to prevent the crystals of salicylic acid from falling out, because they are apt to produce violent sneezing, coughing, &c. In order to obtain the 3 per cent, jute 2,500gTammes of jute are put into a sohition of 75 grammes of salicylic acid, in 500 grammes of glycerine and 4,500 grammes of water at 70°-80° C. In the glycerine jute the acid is more equally distributed than in the cotton wool. In the case of the latter the cotton is frequently so imperfectly charged that it is necessary to place a layer of 10 per cent, cotton next the wound, and then outside this the 3 per cent. wool. In the case of the glycerine jute a 4 per cent, material is sufficient for the whole dressing. As to the spray Thiersch does not care whether it is 1-50 carbolic acid or 1-300 salicylic acid. Carbolic acid is to be jjreferred, because it causes less coughing and sneezing, and it does not adhere to the clothes. Salicylic acid is best in some cases, as it irritates the wound less than the carbolic. For disinfecting the hands and skin, carbolic acid or salicylic acid may be used, but for the instruments carbolic acid must be employed, because the steel becomes oxidised in a solution of salicylic acid. The sponges are washed in carbolic acid. No protective is required, because the salicylic acid is but little irritating. Macintosh is also unnecessary. In order to enable the dressing to peel off and to let the discharge get away more easily a layer of gutta-percha tissue or of oiled silk riddled with holes and covered with a piece of gauze is applied next the wound. This treatment may be illustrated by a case of amputation. The patient having been chloroformed and Esmarch's elastic bandage applied, the part is shaved, washed with soap and water, spirit and turpentine oil, and then with salicylic acid lotion, or with the 1—20 carbolic acid solution. It is also scrubbed with a nail-brush for a few minutes (quite unneces- sary). The operation is carried out with the usual aseptic precautions. After arresting the haemorrhage the wound is TREATMENT BY ^SALICYLIC ACID. 139 closed with deep and superficial stitches. A drainage tube is then introduced into each angle, and the wound is washed out with salicylic acid solution till the fluid which comes out is clear (unnecessary). Three finger-breadths of perforated gutta-percha and of carbolic gauze is then applied ; over this one finger's thickness of the strong salicylic wool, and outside this two fingers' thickness of the weak wool. The whole is then fastened on with a bandage. If the patient complains of pain the dressing is changed and the wound examined. If not, it is left till the eighth or tenth day, when it is changed, in order to remove the drain- age tube. If any discharge comes through in the first instance fresh wool is put outside the dressing. The second dressing is left till healing is complete. Large compound fractures are treated at first by irrigation with salicylic acid. In order to protect the skin from maceration by the fluid it is from time to time rubbed with palm oil. After all risk of abscess formation has passed off and the wound is granulating well, one may apply dry salicylic dressing as before described. Where there is a tendency to inflammation, more especially where there is imperfect drainage with progressive abscess formation, wet salicylic dressing should be applied. This is ordinary salicylic dressing, which is from time to time soaked with salicylic lotion. Thymol as an antiseptic application to wounds was intro- duced some years ago by Eanke of Halle, and was much lauded on account of its non-poisonous and non-irritating qualities. The thymol gauze was made on the same principles as the carbolic gauze, spermaceti being, however, employed. A thymol solution of the strength of 1-1000 is made by the addition of alcohol and glycerine. This antiseptic has not answered the expectations entertained at first. It does not prevent putrefaction, and has been justly abandoned in aseptic work. Acetate of alumina has been lately used by Maas. He applies lint dipped in the solution (2^ per cent.) to the wounds, 140 ASEPTIC SURGERY. and covers this with macintosh. The strength of the spray is also 2^ per cent. He says that this is a powerful antiseptic, and that with it he gets typical aseptic results. The substance is unirritating, and very few dressings are required. Eucalyptus oil has recently been strongly advocated by Dr. Schulz of Bonn.' Its antiseptic properties were shown by Bucholtz in his paper on antiseptics. He found that it was three times as strong as carbolic acid, for while carbolic acid prevented putrefaction when present in the proportion of 1 in 200 parts, the eucalyi^tus oil only required to be present in the proportion of 1 to 666*6 parts to produce the same effect. Siegen also showed that eucalyptus oil prevents putrefaction and alcoholic fermentation better than carbolic acid. He found that blood to which ^ per cent, of eucalyptus oil had been added was quite odourless ten days later. Eing states further that it hinders the passage of white corpuscles out of the vessels, and that therefore, on Cohnheim's theory, it is an agent capable of arresting suppuration. With regard to its usefulness, its smell is more pleasant than that of carbolic acid. It dissolves readily in alcohol or in oil, and mixes perfectly with pure paraffin. Schulz also states from Siegen's experiments and from his own that the eucalyptus oil is not poisonous. The tree from which the oil is obtained grows in large numbers in Australia, and the oil can be obtained in large quantities and very cheap. Schulz recommends that for the spray the glass bottle should be filled with the pure oil or with oil dissolved in alcohol. The steam would then pick this up and make an emulsion. As a lotion it might be used in the form of an emulsion. Schulz proposes that the wounds should be dressed with lint saturated with a 10 per cent, solution of eucalyptus or olive oil. Outside this, or instead of it, may be used Lister's gauze dressing containing eucalyptus oil instead of carbolic acid. A gauze which contains even 50 per cent, of eucalyptus oil may be made with paraffin. Dr. Schulz has not himself, however, used this method. ' Ciidnilhlultfiir Chvrimjit', Jannury 24, 1880. USE OF COTTON WOOL. 141 Quite recently .Mi-. Lister has been making an extensive trial of eucalyptus oil in the treatment of wounds. A gauze has been prepared similar to the ordinary gauze, but containing eucalyptus oil instead of carbolic acid. Dammar has also been substituted for the ordinary resin. So far this has proved very satisfactory. It seems to be trustworthy as an antiseptic, and can be used under circumstances where carbolic acid is apt to cause irritation, as in dressings on the scrotum, or in patients whose skins are liable to be irritated by carbolic acid. Being non-poisonous, it may also be substituted for carbolic acid in cases where constitutional effects are apt to follow the absorption of the latter. It has also been employed as an ointment in the proportion of 1 part by measure of the oil to 4 parts by weight of the same base as is used for the boracic and salicyHc ointments (p. Q5\ This ointment is employed in the cases for which boracic and salicylic ointments have up to the present been used, and it possesses the advantage over the latter in that the oil not only renders the discharge pure as it passes over it, but also on account of its volatility bathes the parts in an antiseptic vapour. Hence it will probably be especially useful in the treatment of burns (see p. 116). Its non-poisonous qualities are also a great point. As yet no experiments have been made with the view of substituting it for carbolic acid in the lotions used in the spray, in washing wounds, purifying instruments, &c., and indeed the whole matter is only for the present under trial. So far we have been considering modes of preventing putrefaction in wounds based on the fact that the septic particles in the air and on surrounding objects may be deprived of their power of causing fermentation by contact with some suitable chemical substance. But we also saw in the preliminary considerations that it sufficed for the avoidance of fermentation in flasks to keep the dust out mechanically, as, for instance by means of cotton wool. This fact was made use of by Mr. Lister some years ago in the following manner. I may quote his remarks, which are given in a foot-note to his article on Amputations in Holmes' ' Surgery,' vol. v. p. 619, published in 1871. 142 ASEPTIC SURGERY. ' Amonar recent contributions of foct to the elucidation of this question (the germ theory) may be mentioned Professor Tyndall's simple but beautiful proof of the existence of organic particles of dust of excessive minuteness in the air by means of a condensed beam of light, and the equally clear ocular demonstration afforded by the same method, that even the finest particles are capable of being removed from the air by causes which Pasteur, in some of his experiments, inferred must clear it of suspended organisms, such as the action of gravity and filtration by cotton wool. The fact last named seemed to promise valuable results in antiseptic surgery, and experiments made with this view have afforded further evidence in favour of the germ theory which it may be well to mention here. I found that if cotton wool impregnated with either chlorine or sulphurous acid gas or with the vapour of benzine or carbolic acid, was placed upon a wound or granulating sore, after washing the surface with a solution containing the same agent, although the volatile antiseptic left the cotton in about a day, the blood or pus still effused beneath the cotton remained free from putrefaction for an indefinite time, provided that the discharge was not sufficiently copious to soak through the cotton and appear at the surface, in which case the meshes between the fibres affording ample space for microscopic organisms to develop in, putrefaction spread within a few hours throughout the moistened part of the mass. This cir- cumstance greatly interfered with the practical utility of the dressing, and it has since been superseded by the antiseptic gauze to be described in the text, but the facts seem to me important with regard to the germ theory. The cotton wool, though it loses all chemical antiseptic virtue in a day, yet will keep out putrefaction for a month or more. It cannot possibly keep out any atmospheric gas, which is necessarily diffused freely between its fibres, and gets in for the same reason that the volatile antiseptic gets out. That which it does exclude can only be suspended particles of dust. It follows, therefore, as a matter of certainty, that the cause of putrefaction through atmospheric influence of blood or pus, oi-, in other words, such materials as the surgeon has to deal with in treating wounds. USH OF COTTON WOOL. 143 are not the atmospheric gases, but dust, and the fact that this dust is deprived of its putrefactive energy by agents which are chemically so unlike as chlorine, sulphurous acid, benzine, and carbolic acid, but which agree in having a common hostility to animal or vegetable life (I used benzine because I knew that the entomologist employs its vapour to kill insects), this fact confirms the view that the putrefactive particles are really organisms. I commend these simple experiments with cotton wool to the candid judgment of the reader, because, whatever may be thought of their bearing upon the allied subject of spontaneous generation, they must be allowed to afford absolute demonstration of the truth which is the foundation of the anti- septic system, viz,, that the putrefaction of blood or pus under atmospheric influences is caused not by the gases of the air, but by suspended particles, which can be deprived entirely of their septic energy by the vapour of an agent like carbolic acid.' It will thus be seen, that what Mr. Lister used here was not an antiseptic application but an aseptic one, and that the only mode in which this dressing acted was by mechanically preventing the particles from reaching the wound. For the reasons quoted, this method has not been turned to practical account, though, as we have seen, it is still used in cases of gangi-ene in order to protect the weak ^Jarts from all sources of irritation. Mr. Barker, assistant surgeon to University College Hospital, has tried a similar method in one or two cases. He piuified cotton wool by heat, and applied between it and the woimd a layer of lint dipped in carbolic oil. This method, however, seems to be impracticable, for after the wool has been heated, but before it is applied, dust would very probably gain access to it unless very complicated precautions were taken. I believe that if ])ure cotton wool is used Mr. Lister's method is the only practicable one. I have mentioned these experiments more as confirming the flask experiments described before than for the purpose of recommending the method for adoption. I believe that tho- roughly satisfactory and indeed the best results maybe obtained by the use of suitable chemical means. 144 ASEPTIC SURGERY. Subcutaneous surgery is another way in which the aseptic principle may be carried out. Here the wound is made under the skin and away from the air dust altogether. This method will be better understood when we come to trace the history of antiseptic surgery. PARTICLES WHICH CAUSE FERMENTATION. 145 CHAPTER VIII. THEORIES OF SPONTANEOUS GENERATION, HETEROGENESIS AND ABIOGENESIS. Principles on wliich other methods of antiseptic surgery act. Organisms are always present in fermenting liquids : their significance. Theory of the origin of organisms independently of a parent. Theories of Needham and Buffon : Needham's proofs. Spallaazani's experiments: Needham's objec- tions : Spallanzani"s replies. Schulze's experiments. Schwann — Schroeder and Dusch — Schroeder — Doctrine of Heterogenesis. Pouchet's work : his method of testing the matter : proofs that the source of the organisms in infusions is neither the air, water, nor the putrescible substances : modes of repeating Schulze's and Schwann's experiments : examination of dust. Criticism of his results. Pasteur's experiments : results with ordinary fluids : introduction of dust into sterilised fluids : results with milk and alkaline fluids : the cause in the air which gives rise to the growth of organisms is particulate : Pasteur "s cultivating fluid : estimate of Pasteur's work. Poachefs reply : New experiments — Criticism of these. 8uCH are the methods by which that form of antiseptic surgery which aims at the total exclusion of septic ferments may be best earned out. But ' Antiseptic Surgery ' in its broad sense includes another class of methods of treatment acting on a totally distinct principle, and interfering more or less perfectly with the occurrence of fermentations. These all act on the principle of rendering inert the causes of jjutrefaction after their entrance into the luownd, of offering obstacles, more or less co')nplete to the fermentation ivhich these pai^ticles would other- luise occasion. In order to understand these methods, to see on what ja-inciples they act, to decide which are the best, and to carry them out with the greatest success, it is necessary to take up our discussion of the causes of putrefaction at the point wliich we have already reached, and to consider what is the nature of the particles which we fotind to be ihe causes of L 146 SPONTANEOUS GENERATION. fermentative changes, and how it is tlmt they bring about these changes. As is well known, micro-organisms of some form or other (bacteria, toruUie, &c.)are always present in fermenting liquids, and the view which is now almost universally held by scientific men is that these bodies are the initiators of the chemical change. We have nlready seen that fermentation occurs only after the access of particles from the outer world, and it is asserted by the supporters of the germ theory of fermentative changes, that these particles aire organisms or their spores, and that it is by the growth of these organisms in the fermentescible material that the latter undergoes alteration. Soriie, however, assert that these organisms are only acci- dental accompaniments of the process of fermentation ; in fact a few still maintain that they arise in fermenting substances from agglomeration of the molecules of that material, that in feet they are generated anew and are not necessarily derived from a parent. It is therefore necessary for us, before discuss- ing the germ theory of fermentation, to consider what are the real focts with regard to this matter of abiogenesis. The first views of which we must take notice, as being the first founded on experiment and observation apart from mere philosophical speculation, are those of Needham and Buffon, published in the middle of the eighteenth century.' Needham's ' It may be of interest to quote Needham 's own words somewhat in detail. Referring to Spallanzani's criticisms of his viOT:]<i{Xnurvlles liecherches sitr Ics litres wicroscojnqiies, by Spallanzani, translated by M. I'Abbe Regley, 1769), he savs (vol. i. p. 142) : ' II (Spallanzani) sait trrs-bien par toute la tenenr de mes observations raicroscopiqnes que je ne donne aucune autre puissance h la mati^re que celle qui produit la pure vitalite denuee de toule sensation, et qui derive, comiue son existence primitive, de la seule Divinite ; que cette vitalite est un compose materiel de la force resistante et de la force expansive, dont les premiers principes ont ete donnes a la matiere par le Crc'ateur au moment de la creation : que tout corps, ou partie organisee, est une proces- sion ou prolongation d'un corps organise, soit vegetal ou animal, qui doit nrcessairement preexister, et dont la soucheiDrimitive sort immediatement des mains de Dieu ; que cette procession ou prolongation insensible, que doit donner ce germe nouveau, dont la petitesse est indetinie, pour se conformer A, toutes les circonstances possibles, se fait moyennant une espece de reduction dirigee par les forces plastiques, et une concentration des parties specitiqucs, (lui tendent, en les attenuant, vers nn point determine ou un certain foyer commun, de mrine u ]ieu ]ir(\s que Tccil est au monde visible, un centre ou les NEEDHAM. 147 theory was, that there is in matter a force charged with the formation and government of the organic world, which force he rayons viennent s'arranger de toutes parts, sans confusion, dans le mcme ordre qu'ils re9oivent de I'harmonie preetablie de I'univers ; que quant aux premiers principes de cette vitalite purement materielle, il y a une mati^re indubitable- meut demontree par des experiences constant es, trfe-attenuee, tr^s-exaltee , etheree selon Newton, electrique selon les idees presentes, tres-elastique par sa nature intime, toujours prete iidonner lebranle a la mati^re brute et rusistante, et qui penetre substantiellement la masse enti^re ; que par consequent ces deux especes de mati^re, melees dans toutes les proportions possibles, peuvent fournir les temperaments necessaires pour tout degre de vitalite quelconque, et pour tons les grands phenomenes on changements physiques de I'univers en partant d'un seul principe ; que cette vitalite, n'etant autre chose qu'un esprit tres-subtil et trfes-actif, agissant dans une matiere brute, tenace et ductile, pour former, selon les forces specitiques de chaque corps vital, un nouveau systeme organise, est tr^s-dilferente, selon mes idees, du principe seiisitif, qui ne pent etre compose, et encore plus distinguee du principe intellectuel et sptrituel, I'ame de rhomme.' Further on (p. 150) he reiterates his view that these beings are distinct from the higher classes of animals which possess sensation. ' En general, toute substance quelconque, animale ou veg6tale, se decompose, selon moi, en etres que j'appelle Hte?/.a; pour les distinguer des animaux parfaits a qui la Divinite a ajoute par surcroit les puissances purement sensitives, ou sensi- tives-intellectuelles.' Again (p. 172), ' L'auteur (Spallanzani) croit que j'ai parle de la force ordinaire vegetante des plantcs, par laquelle elles develop25ent en feuilles, en branches et en racines. II n'est rien de tout cela. Quand il s'agit de la pro- duction de ces corps organiques, je considere an contraire la plaute dans un etat de corruption comma jilante : car c'est alors qu'elle perd absolument sa forme primitive et, quapres avoir ete depouillee de ses sels, de ses huiles, et des autres principes constitutifs, ce qui reste devient une matiere gela- tineuse et loute tilamenteuse qui vegete par elle-meme en branches vitales et se partage en corps ronds animes ou pousse au-dehors des globules mouvants.' ' Voila en jjeu de mots le vrai tableau, voilii le raisonnement de M. de BiifTon et le mien. II y a certainement un principe de vitalite materiel dis- tingue du principe sensitif, seul constitutif de la stricte animalite, qui se dis- pose organ iquement, et qui, subordonne aux lois generales etablies jDar la Divinite, vegete dans les corps animaux qu'il forme conime dans les vegetaux, en les animant ^ la fa(;on ordinaire ' (p. 166). ' Ce principe de vitalite est le seul principe d^conomie et d'action dans lea vegetaux, et dans une certaine classe de ces Ctrcs qui, paraissant scnsitifs sans Fetrc, servent i\ lier ensemble le vegetal et I'animal sensitif ' (p. 166). 'Mais j'ai toujours reconnu comme necessaire pour completer le vrai animal, qui doit etre sensitif, un principe de sensation, une time qui n'est pas coniposee comme le systeme organique, et qui, quoique aneantie avec le corps selon le bon plaisir de son cn'atcm-, est ni'anmoius superieure ^ la vitality, et hors de toutes les puissances du la matiere la plus exaltee.' Bullon {IlisUmr Xaturcllc, vol. ii. p. 420, 171'.)) says : ' Tous les aniruaux L 2 148 SPONTANEOUS GENERATION. calls force vegetatrice. He imagines that this force, by setting into motion all the particles of matter, excites in some of them a sort of vitality distinct from sensation, and produced by the union of two other forces, which he terms fo7xe resistance and force expansive. The proofs on which Needham bases his views as to the spontaneous origin of these minute organisms are of three distinct kinds. The first discussing the different phenomena furnished by different infusions, more especially the enormous variety of forms arising in them ; and the second alluding to the behaviour of infusions after being subjected to heat, dependent as these arguments are on microscopical examination, need not be con- sidered here, because the construction of the microscope was at that time so imperfect as to make it of little or no use for such observations. The third, and indeed the only experiments which require to be noticed, are those in which infusions, contained in vessels hermetically sealed, are subjected to the action of heat for a prolonged period. In infusions treated in this way by Need- se nourrissent de vegetaux ou d'autres animaux, qui se nourrissent eux-memes de vegetaux ; il y a done dans la nature une mati^re commune aux uns et aux autres qui sert a la nutrition et au developpement de tout ce qui vit ou veg^te; cette matiere ne peut operer la nutrition et le developpement qu'en s'assimi- lant k chaque partie du corps de I'animal ou du vegetal, et en penetrant in- timement la forme de ces parties, que j'ai appelee le moule interieur. Lorsque cette matiere nutritive est plus abondantequ'il ne faut pour nourrir et develop- per le corps animal ou vegetal, elle est renvoyee de toutes les parties du corps dans un ou dans plusieurs reservoirs sous la forme d'une liqueur ; cette liqueur contient toutes les molecules analogues au corps de I'animal, et par consequent tout ce qui est necessaire a la reproduction d'un petit etre enti6rement sem- blable au premier. Ordinairement cette matiere nutritive ne devient sura- bondante, dans le plus grand nombre des especes d'animaux, que quand le corps a pris la plus grande partie de son accroissement, et c'est par cette raison que les animaux ne sont en etat d'engendrer que dans ce temps. ' Lorsque cette matiere nutritive et productive, qui est universellement repandue, a passe par le moule interieur de I'animal ou du vegetal, et qn'elle trouve une matrice convenablc, elle produit un animal ou un vegetal de meme espece ; mais lorsqu'elle ne se trouve pas dans une matrice convenable, elle produit des etres organises difl'^rents des animaux et des vegetaux, comme les corps mouvans et vegetants (jue Ton voit dans les liqueurs seminales des ani- maux, dans les infusions des germes des plant es, kc' SPALLANZAIK. 149 ham and boiled for many minutes organisms developed very readily. Spallan5^ani ' repeated these experiments, and he found that though some infusions could be sterilised after boiling for a short time, yet it was necessary to keep others at the boiling temperature for an hour or more before they would remain permanently sterile. Spallanzani's method was to heat his flasks, then to pom- in the liquid, hermetically seal the flask, and place it in a water bath. The error in this method is probably that the impure fluid when poured into the flask, soiled the neck which he had previously purified by heat. To these experiments Needham objected that Spallanzani had much enfeebled or perhaps destroyed the force vegetatrice of the infusions by keeping them exposed to the action of heat for so long a period of time as an hour. This objection was at once met by Spallanzani, who showed that organisms rapidly developed in these same infusions, if they were left exposed to the air after this prolonged boiling ; and he truly says that, if the organisms only come from the fluid, and if the power which this possesses of generating these beings is destroyed by heat, they would remain absent whether the flasks were open or shut. He even went further and heated the vegetables very strongly before infusing them, but even in this case organisms developed in the fluids so prepared. Needham, however, said that the small quantity of air re- maining in the flasks was completely altered by the exhalations from the fluid and by the heat of the fire, and that thus the force vegetatrice could not act. This objection cannot be said to have been in any way met by Spallanzani. In some cases, indeed, he succeeded in preventing the appearance of organisms by boiling the fluid from a half to two minutes, but in many cases minute organisms appeared. In order to prevent their occurrence in all instances, it was necessary to prolong the heat for at least three-quarters of an hour. As an answer to Needham's last objection the experiments of Schulze ^ form a most important step in advance. The ' Opvsciiles de Physiqve animale et vegetale ; traduits par Jean Senebier, Geneve, 1777. * See translation in Microgcnpical Jmirnal, 1841. 150 SPONTANEOUS GENERATION. following was the problem which he proposed and the method adopted to solve it. Query : ' If the access of atmospheric air, light, and heat to substances in flasks included of itself all the conditions for the primary formation of animal or vegetable organisms ? The difficulties to be overcome consist in the necessity of being assured first, that at the beginning of the experiments there was no animal germ capable of development present in the infusion, and secondly, that the air admitted contained nothing of the kind.' His method of procedure is described by himself as follows : — ' I filled a glass flask half full of distilled water, in which I mixed vai'ious animal aud vegetable substances. I then closed it with a Fif4. 58.— Schulze's method of demonstrating that organisms are DERIVED FRO.Vr THE AIR AND DO NOT ORIGINATE SPONTANEOUSLY IN LIQUIDS. good cork, through which I passed two glass tubes, bent .it right angles, the whole being air-tight. It was next placed in a sand-bath and heated vintil the water boiled violently, and thus all parts had reached the temperature of 212° F. ' While the watery vapour was escaping by the glass tubes I fastened at each end an apparatus which chemists employ for collect- ing carbonic acid ; that to the left was filled with concentrated sul- phuric acid, and the other with a solution of potash. By means of the boiling heat everything living and all germs in the flask or in the tubes Avere destroyed, and all access was cut off by the sulphuric acid on the one side and by the potash on the othei-. I placed this easily moved apparatus before my window, where it was exposed to the action of light, and also, as I performed my experiments during SCHULZE. 151 the summer, to that of heat. At the same time I placed near it an open vessel with the same substances that had been introduced into the flask, and also after having subjected them to the boiling tempera- ture. In order now to I'enew constantly the air within the flask, I sucked with my mouth several times a day the open end of the apparatus filled with solution of potash ; by which process the air entered my mouth from the flask through the caustic liquid, and the atmospheric air entered the flask from without through the sulphuric acid (Fig. 58). The air was of course not at all altered in its com- position by passing through the sulphuric acid in the flask, but if sufficient time was allowed for the passage, all the portions of living matter or of matter capable of becoming animated, were taken up by the acid and destroyed. From May 28 till the beginning of August I continued uninterruptedly the renewal of the air in the flask, without being able, by the aid of the mici-oscope (magnifying glass ?), to perceive any living animal or vegetable substance, although during the whole of the time I made my observations almost daily on the edge of the liquid ; and when at last I separated the dififerent parts of the apparatus I could not find in the whole liquid the slightest trace of infusoria, of confervse, or of mould. But all the three pre- sented themselves in great abundance a few days after I had left the flask standing open. The vessel which I placed near the apparatus contained on the following day vibriones and monads, to which were soon added larger Polygastric Infusoria, and afterwards Eotatoria.' By these experiments the fears entertained by Needham as to an alteration in the air contained in the flask being the cause of the sterility of the infusion, were completely set at rest ; for here air, which had not been subjected to heat, and which was constantly changed, was present in the vessel in which no development occurred, while the second open vessel showed that the power of the liquid to nourish organisms had not been lost by boiling. It was therefore clear that in this instance the organisms which grew in the outer vessel came in some way or other from ])articles in the atmos})here, which could be destroyed by sulphuric acid. Whether or not both modes of origin might not exist, and whether the bodies falling into the fluid from the atmosphere were organisms or their spores, or merely albuminous matters which gave rise to organisms, was as yet in no way determined. And the results of the experiments of Schwann, mentioned ]52 SPONTANEOUS GENERATION. before, leave us in the same position. In his case the heating of the air was substituted for Schulze's method of passing it through a chemical substance, but no further evidence was obtained. Advance was no doubt made by his results in that the objection which might have been urged by some against Schulze's experiments, viz., that particles of the sulphuric acid were carried over with the air, or that the air was in some way or other altered, are entirely removed,' while at the same time it was then known that heating air joroduced no alteration in the gases of the air. Schwann himself explained his results by supposing that the spores of infusoria and other smaller organisms are present in air, and are destroyed by heat ; and he held that putrefaction and other fermentative changes are brought about by these organisms abstracting materials for their nutrition from the fluids in which they grow, and leaving the compounds thus broken up to form new combinations. One most important fact he does mention, viz., that blood can be received into and preserved in a flask with certain pre- cautions, without the development in it of any form of life. Further evidence with regard to boiled substances was brought forward by Schroeder and Dusch, and later by Schroeder alone. Their method of experimentation by filtration of the air through cotton wool, and their results, have been already referred to (p. 12, et seq.), and it will be sufficient to add here that in those cases where putrefaction occurred, organisms were present, while in the flasks, in which no change took place, organisms were absent. By their method, meat, meat infusion, and malt were preserved after boiling without any appearance of organisms. Difficulties were experienced with milk and yolk of egg, but these were finally overcome either by heating them to the temperature of 130° C, or by prolonged heat at 100° C. These experiments are of the greatest importance, as with the method ' This objection that the air is altered in passing through sulphuric acid is not urged by Pouchet, who indeed states that no alteration occurs, and that organisms can develop as readily when such air is admitted as in presence of ordinary air. Schulze's experiment also proves that the barrenness of the liquid was not due to the entrance of sulphuric acid into it, for the liquid became full of life after having been exposed for a few days to ordinary air. POUCHET. 153 employed no objections can be raised as to any alteration in composition of the air. When, then, we look at Needham's two objections, which have been urged against experiments with boiled fluids, and when we compare with them the answers furnished by all observers, but more especially by Spallanzani to the first, and the progressively strong replies to the second by Schulze, Schwann, and Schroeder and Dusch, we must, I think, come to the con- clusion that they have been completely met. Hence in order to retain the theory of spontaneous generation it became neces- sary for the heterogenists to change their ground. They had to admit that there were present in the air and on surrounding objects particles (not necessarily bacteria or their germs, though very probably so) which, falling on suitable soil, gave rise to the development of bacteria ; but they still held that under certain circumstances heterogenesis may also occur, though possibly more rarely than propagation from a parent. They attempted to support this view in two ways : firstly, by denying the accuracy of the former experiments, by pointing out that they do not always succeed, and that organisms develop in some materials, even after prolonged exposure to a high tem- perature ; and secondly, by reference to the results of attempts to preserve unboiled fluids and tissues. In 1859 there appeared the work of one of the most ardent supporters of the theory of spontaneous generation — Pouchet — and it is necessary for us to examine his views and facts some- what in detail.' Pouchet does not look on these organisms as originating from dead matter through the action of some mysterious force, as has been since advanced by some heterogenists. Their sources are, according to him : ' Des particules organiques, debris des anciennes generations d'animaux et de plantes, qui se trouvent combinees aux parties constituantes des mineraux. Selon cette doctrine ce ne sont done pas des molecules minerales qui s'orga- nisent, mnis bien des particules organiques qui sont appelees a nne nouvelle vie.' He further states that though he believes that it is the contact of different bodies which gives rise to the ' Heterogenie im Traitr de hi Gl-ncrotwn spontant'c hasr siir des nourcllcs experiences. Pjiris, 1859. 1.34 SPONTANEOUS GENERATION. development of proto-organisms, yet he does not think that their origin is due to affinity alone — vital force must also come into play. This vital force owes its manifestation to certain unknown concomitant circumstances ; thus fermentative or catalytic phenomena precede all spontaneous generation. In connection with these views he describes the development of ova in what he terms the proligerous pellicle, or scum on the surface of fermenting fluids. With regard to this he says : ' La generation primaire ne produit jamais un animal de toutes pieces, mais seulement elle engendre des ovules spontanes dans le milieu proligere absolument sous I'empire des memes forces qui fa^onnent des ovules dans le tissu de I'ovaire.' The essentials for the production of new forms are, according to him, a putrescible body, water, and air, while heat, light, and electricity considerably favour the result. Having shown that the first three are essential, though they need not necessarily be present in large amount, he proceeds to state the problem in a very fallacious manner : ' Si I'on admet,' says he, ' que dans nos experiences la generation ne pent s'operer qu'a I'aide de trois facteurs, et que c'est I'un d'eux seul qui recele les germes des proto-organismes, il est evident que si Ton prend chacun de ces trois corps en particulier, sans s'inquieter nuilement alors des deux autres, et que Ton demontre successivement que ce n'est aucun d'eux qui contient ces germes, il faudra bien, en somme, reconnaitre quand le fait aura ete strictement etabli pour chacun isolement, que ce n'est done aucun de ces trois coi-ps qui pent servir d'asile aux oeufs ou aux seminales introu- vables des etres divers qu'on voit s'engendrer sous les yeux.' He tests the question in the following manner: 1. With regard to the first point he says that it is evident that the putrescible material does not contain the germs of the proto- organisms since, even though it is charred previously to its employment, the water in which it is placed becomes rapidly filled with microzoaires and cryptogams. Experiment. — 10 grammes of any of the following seeds, maize, peas, beans or lentils, were placed in an iron spoon and completely charred ; then the pi'oduct was placed in a glass vessel containing 500 grammes of distilled water and covered with a bell jar. In twenty days the fluids were found to contain micro-organisms and cryptogams. POUCHET. 155 2. He next points out that it is not the water which con- tains the germs because, if one places organic substances in an artificial water, animalculge and cryptogams still develop. To show this an artificial water was obtained in the following manner : — ' Into a large flask with two orifices, water and fragments of zinc are placed : one of the orifices transmits a tube terminating in a funnel by means of which sulphuric acid may be introduced into the flask ; the other orifice is attached to a large horizontal tube filled Avith asbestos, which leads to a small tube drawn out at its extremity, and terminating close to the outside of a metal vessel filled with cold water. The sulphuric acid having been introduced, hydrogen gas is disengaged, and is lit at its exit from the tube. The flame being close to the metal vessel, moistens its walls with watery vapour, the result of the combination of the oxygen of the air with the hydrogen from the apparatus : and this vapour, being condensed, is caught in a platinum vessel. The apparatus having been maintained in this state for three days, 200 gi'ammes of water were obtained, and were employed in the two following comparative experiments.' Half of this water was boiled for a quarter of an hour, in order to kill the germs which might have fallen into it, although he does not consider that to be necessary. This water was then introduced into a ves.sel with 5 gi^ammes of hay, which had been raised to a tempera- ture of 200° C. The vessel was placed in a basin containing a little water, and the whole was covered with a small shade. In four days there was a granular pellicle and two species of Paramecia. The other portion of distilled water was not boiled, and to it was added hay which had not been heated; the result was absolutely identical. 3. Lastly, Pouchet states that it is evidently not the atmo- sphere which disseminates the germs, since he has seen organisms appear in flasks containing only artificial air, or in flasks con- taining air which had been heated or which had passed through sulphuric acid. He next takes up Schulze's experiment, and jiresents the following as a counter experiment and as a complete disproof of the former :^ A vessel of the capacity of one litre was half filled with water, to which 5 grammes of hay were added. The cork of the vessel was traversed l)y two tubes each bent at right angles, five centimetres above the place of exit ; one, the afii^rent, did not descend into the interior 156 SrOXTANEO US GENERA TION. of the vessel lower than its neck, the other, the efferent, reached to within one centimetre of the liquid, in order the better to remove the heavy stagnant gases. To each of the tubes was attached Liebig's bulbs filled with sulphuric acid. To the efferent was further attached Fig. 5f».— Pouchet's mode op kepeating Schulze"s experiment. (FROM POUCHET). a water aspirator, which was kept constantly acting (Fig. 59). The cork, &c., were all luted with copal. The fluid was then boiled for an hour. In twenty-six days spirilla, vibriones, and penicillium were present in the fluid. In order, as he supposes, to have more rigorous conditions than those of Schulze, he introduces the following method of procedure : Fig. 60. — Another mode adopted by Pouchet for testing Schulze's views (from Pouchet). A flask is used having the capacity of one litre, and having three necks. This is quite filled with concentrated sulphuric acid. The first neck contains a bent tube, which by one extremity communicates with an air pump, while the other extremity passes down to the rOUCHET. 157 bottom of the acid; through the middle neck passes a siphon, which commences in the flask at the level of union of the uppei' and middle thirds, while its other end passes into an empty vessel. The third orifice contains a tube passing down to the bottom of a second vessel, but only originating in the first vessel at the very top. This second vessel, of the same capacity as the other, had been filled with boiling water ; the first neck allowed the passage of the tube from the first vessel ; through the central one passed a siphon similarly arranged to that in the first vessel : while from the third opening a tube led into a third vessel. This third vessel had the same capacity as the others, but had only two openings, the fii'st receiving the tube from the second flask, which, however, did not pass down to the bottom of the third flask as in the other two cases ; and the second giving exit to a siphon arranged as before (Fig. 60). A strong decoction of boiling hay having been introduced into the third vessel so as to fill it exactly, the whole apparatus was luted with the greatest care, and thus the apparatus contained only this decoc- tion, the sulphuric acid and the water which had been previously boiled. Air was then forced slowly into the sulphuric acid, and traversing the acid, it collected at the toj), forcing the sulphuric acid through the siphon ; this air then passed on thiough the second flask, passing through the water and forcing the water through the siphon ; and from the second into the thiid vessel, forcing some of the decoction through the siphon ; then the apparatus was abandone J to itself, and a quantity of the same decoction was placed outside for compai-ison. In twenty days the hay infusion, both in the appa- ratus and in the vessel outside, contained * mucor ' and bacteiia. A second experiment was done by introducing into the thiixl flask 5 grammes of hay, which had been exposed to the action of steam for five minutes. The vessel was then filled with boiling water. A similar lesult was obtained. Again, he introduced into the third flask filtered water, and 10 grammes of hay exposed for thirty minutes to a temperature of 200° C. Nevertheless, monads and vibriones weie found. A similar experiment to Schwann's was also perfonned, the air in the apparatus just described being passed over a heated tube instead of through sulphuric acid. Nevertheless, organisms (penicillium and vibriones) developed. Two flasks (instead of three) were used, the first being filled with boiling water (this flask having the three necks as usual, one receiving the heated air, one for the siphon, and the third leading into the second 158 sroyTAXJSOUS GENERATIOX. flask), and the second containing boiled decoction of hay and ha\dn2: two necks. He states that he succeeded more often in obtaining organisms when filtered, unboiled water was sub- stituted for the boiled water ; and, as he has already proved, as he thinks, that water does not contain organisms, he considers it a matter of indifference whether the water has been boiled or not ! Similar experiments with artificial air yielded the same results. A new objection is then brought forward, viz., that if the atmosphere be the universal disseminator of germs, the greater the mass of air in contact with a fluid, so much the greater ought to be the number of organisms which grow in that fluid. This he has not found to be the case, and he also points out that in flasks containing the same fluid, placed close to each other at the same time, different forms of organisms may de- velop, a fact which he does not consider capable of ex- planation on the theory of Panspermism. Pouchet further examined air dust microscopically, and he admits that he finds spores of fungi and other microscopic organisms, but he does not think that they are ever present in sufficient quantities to explain the numbers which are found in an infusion, for he states that the bacteria themselves do not increase in number by fission (or but very slowly), but that on the contrary each is spontaneously generated. To prove thut organis)iis do not in tlie main come from the air he took five gi'ammes of dust from the I'oof of the Ruuen Cathedral, and placed it in 100 gi'ammes of distilled water. Then in another similar vessel he placed 100 grammes of distilled water, containing tive grammes of the dry stalks of China aster, previously exposed for two hours to a temperature of 200° C. These two vessels were placed under the same glass shade. Eight days later the first contained vibriones, monads in small numbers, and a few kolpodes. The second was full of monads and kolpodes. During a later research Pouchet examined the dust which collected in the lungs and bones of birds, and he states that there can always be found evidences of the locality in which the birds lived. For instance, this dust in the case of forest CRITICISM OF rOUCIIET'S EXPERIMENTS. 159 birds contains fragments of wood, leaves, starch, &c. He says that -he never found spores of plants nor ova of microscopic animals nor encysted animalculge. That he should not have found spores of fungi, which one would think are more nume- rous in the forest air than starch granules, is inconceivable, unless it is supposed that there is a special provision in the animal economy which prevents their entrance into the lungs, though permitting the admission of starch granules. The probability is that he did not recognise them. Not only does Pouchet sup})ort the doctrine of the spon- taneous generation of bacteria and the lowest foi^ms of animal or vegetable life, but he is also prepared to accept the spon- taneous origin of fleas, acari, and cysticerci ! If, now, we carefully examine these experiments, we shall see that they are full of the grossest blunders. Take, for in- stance, his experiments to show that organisms are not present in putrescible substances, in water or in air. The first experi- ment is simply absurd. Some seeds are charred and introduced into a vessel containing distilled water, and covered with a bell jar ; organisms develop. What does this prove ? Does it prove that organisms were not present and may not constantly be present in putrescible substances exposed to the air ? No. It merely proves that this cannot be their only source ; for here the water and the air were not heated or otherwise purified, and therefore the organisms might be easily communicated through them. Again, to prove that water does not contain them, an artificial water is prepared, boiled for a quarter of an hour, placed in an unpurified vessel containing some hay, which had been pre- viously heated and exposed to ordinary air. What does this show ? Certainly not that ordinary water does not contain organisms. Even admitting that this specimen of water did not contain them, there was ample explanation of their 2:»resence from the fact that the fluid was put into an impure vessel, and that the air had access to it. Nor is Pouchet more successful in liis attempt to show that the air is not the vehicle. In considering the question as to the presence of organisms or their spores in the air Pouchet puts forward the idea that if 160 SFONTANEOUS GENERATION. organisms were present in the atmosphere in sufficient numbers the atmosphere would be totally obscured. But it has been asserted and shown by Pasteur and others (as we shall see later on) that organisms are by no means so numerous in the atmo- sphere as was formerly supposed, but that they are generally derived from dust which has settled or from water. Further, Tyndall has shown, by means of the beam of light, what numbers of minute particles fill the air around us, and up to a certain point, instead of obscuring it, really render the light visible. In his repetition of Schulze's experiment it must be admitted that Pouchet has a stronger case, but even here the flask and the tubes were not purified, the quantity of fluid as compared with the size of the flask was very small, and there is always the possibility of a flaw in the cork or in the joinings of the various tubes. And further, this experiment loses its force when Pouchet admits that he does not always get organisms, and states, on the contrary, that, when a simple apparatus is employed, a negative result is obtained. Thus to quote his own words : ' Dans un appareil a simple rentree d'air ' (this consists of a flask having only one tube passing through its cork, to which tube Liebig's bulbs are attached, see Fig. 61 ), ' et dont les boules de Liebig contenaient de I'eau, on remplit le tiers du ballon de colle de farinelegere: que I'ony tient quinze minutes en ebullition a I'aide d'une lampe. Celle-ci eteinte. Pair rentra dans I'appareil en traversant I'eau peu-a-peu. L'appareil fut abandonne deux mois a une temperature moyenne de 14 degi-es, et pas la moindre moisissure ne se declara a la surface de la colle durant tout ce temps. ' Au contraire un criterium, place a cote et en contact avec I'atmosphere, avait au bout de cinq jours toute sa surface envahie par des champignons. ' Une experience enterprise le meme jour et dans les memes conditions, mais dans laquelle Pair est introduit dans l'appareil en traversant des boules de Liebig remplies d'acide sulfurique, donna absolument les memes resultats.' Thus Pouchet showed that not only was Schulze's experi- ment successful, when performed with a simple apparatus, but he fiu-ther demonstrated that it was not necessary that the air CRITICISM OF FOUCHET'S EXFERIMENTS. 161 should pass through sulphuric acid ; if it were merely tuashed in water it was sufficient. Again, ' Dans notre appareil a simple rentree d'air, et dont les boules etaient remplies d'eau, on mit 175 grammes d'urine humaine et on I'y tint en ebullition pendant un quart d'heure. Ensuite Fair rentra en traversant I'eau et I'appareil fut abandonne sous I'influence d'une temperature moyenne de 12 degres. Deux mois apres, I'urine etait encore parfaitement limpide et pas la moindre moisissm-e ne s'etait declaree a sa surface. Un criterium place a cote, au bout de huit jours, etait envahi par une abondante vegetation crypto- gamique. ' Une experience est faite le meme jour et absolument dans les memes circonstances, seulement Fair ne rentre dans I'appareil qu'en traversant des boules remplies d'acide sulfurique. Le resultat est absolument le meme que dans I'experience precedente : I'm-ine est intacte.' Such are exainples of Pouchet's general results with this simple ap- paratus, and, when he states that with the more complicated arrangement, even with much more prolonged boil- ing, he generally obtains cryptogamic vegetation, I do think that I am only drawing a fair inference when I sup- pose that there was something defective about his apj)aratus. Nor is he more fortunate with Schwann's experiment. Referring to Pasteur's results — that when he (Pasteur) per- formed Schwann's experiment of having in contact with fer- mentescible substances only previously' heated air, he obtained neither fermentation, nor yeast, nor infusoria — he says : ' L'air calcine a ici encore arrete la fermentation et les i)roduits organiques qui en derivent ; cet air est done egalement iiiipropre au developpement de phenomenes chimiques, comme il Test a celui des phenomenes vitaux. L'experieuce de M M l( Inaiiiiiiiiiiuiiiiiiniiil \\ Fia. 61. — A PI3IPLE MODE OF REPEATING SCHULZE'S EXPERIMENTS (FROM POU- CHET). 1G2 SPONTANEOUS GENERATION. Schwann, et celles qui ont ete calquees siir elle, sont done absolument insignifiantes.' Truly a strange interpretation of the facts, more especially as he had previously attempted to demonstrate that calcined air and air which had previously passed through sulphuric acid were equally incapable of pre- venting the development of organisms, and as in the ' more rigorous " conditions under which he performed the experiments he found that organisms always developed ! Looking more closely at these so-called ' more rigorous ' conditions, we find that they contain a sufficient number of loopholes to explain the result. What are we to think of the third experiment to show that the air is not the vehicle of these organisms ? An impure vessel is taken, containing dust, and unboiled filtered water is introduced into it along with some heated hay. Is it any matter for surprise that organisms are found here, however pure the air ? The dust in the vessel contained plenty of their spores, the various tubes passing into it contained dust and impure air, while the water itself was teeming with organisms or their spores. And similar objections may be urged against, the first and most rigorous experiment. Boiling hay infusion is intro- duced into a vessel containing dust ; no attempt is made to destroy the septic properties of this dust or to purify the air and the dust in the tubes leading to and from it. Air is now forced into the infusion, carrying along with it the organisms which Pouchet ought to have known were theoretically present in the air in the last connecting tube, as well as on the walls of that tube. This is the ' rigorous ' experiment, which is sufficient ' to overturn the experiments of Schwann and Schulze.' It is needless to pursue the criticism of such methods. The following experiment is stronger, and he considers it sufficient to upset those of Schwann and Schulze. A flask was introduced to the bottom of a vessel containing a decoction of barley, which had been kept boiling for six hours. The flask being completely filled with this fluid, was brought to the sur- face and corked, and then the circumference of the cork was surrounded by varnish. On the sixth day a deposit of yeast was seen, and the flask burst on the seventh. Here an impmre vessel, cork, &c., were used, and the heat rOUCHET. 1G3 was not applied to them for a sufficient length of time. Fur- ther, the fluid cannot have been boiling when the vessel was introduced and corked, otherwise, if he had done it efficiently, the operator would have scalded his fingers. It is, moreover, noteworthy that Pouchet only got organisms in one experiment of this kind. In his ' Micrographie Atmospherique,' Pouchet falls into the great error of assuming that organisms do not subdivide quickly enough to account for their rapid appearance in infu- sions. Now it has since been made out by several observers that organisms do divide with sufficient rapidity, and of this I may mention two instances from Mr. Lister's work. In the course of observations on a form of micrococcus, which he terms ' Granuligera,' he found that in little more than an hour and a half they had trebled their numbers, a fact which he made out by observing the subdivision of a little group. And with re- gard to the Bacteriuvi lactis, he found definitely by nume- ration that it doubled by fission in an hour, so that given one BacteriuTYi lactis there would be in twenty-four hours no less than 8,388,608 bacteria ; and other forms of organisms deve- lop even more quickly. Then, again, Pouchet objects that with free access of air, a greater variety of forma ought to be found, but it must be remembered that what may novu-ish one form may not be good for another, and that the products of the growth of the form which in the first instance was most vigorous and most nume- rous, may interfere seriously with the growth of other varieties ; and in the experiment which he mentions it is quite evident that in the vessel to which the dust was added there is little or no nutriment compared with that contained in the stalks of the China aster. And lastly, when he 2)laces similar infusions, similarly treated, in flasks of the same size, under the same glass shade, and in similar conditions, and finds that the organ- isms which appear differ in form in the two flasks, he does not obtain, as he supposes, a proof of spontaneous generation, but the contrary. For on that theory the same infusion, in the same conditions, ought to give rise to the same species of organisms ; and the occurrence of different forms can only be explained by su})posiiig that different spores gained access to M 2 164 SPONTANEOUS GENERATION. the various infusions, a view quite in accordance with the theory of Panspermism. Appearing shortly after Pouchet's work, and leading to diametrically opposite conclusions, were the researches of M. Pasteur, which have by many been considered as administering the death-blow to the theory of heterogeny. Pasteur,^ in his account in the ' Annales des Sciences naturelles,' begins by attempting to demonstrate the exist- ence of spores in the atmosphere, a fact which Pouchet had previously admitted. Such attempts are, however, very un- satisfactory, partly from the difficulty of recognising what are and what are not spores, and also from the fact that if spores do exist they must be so excessively minute as to be in many cases invisible under the microscope. Professor Tyndall has shown, by means of the condensed beam of light, the existence of innumerable solid particles in fluids, in which but few could be detected by the microscope. Pasteur certainly demonstrated, and this is generally admitted, that spores of fungi do occur in the atmosphere. It is not necessary, however, to have this demonstration of the existence of spores, for the matter can be set at rest by experiment alone, and it is these experiments, and not the demonstration of the existence of spores of fungi in the atmosphere, which give the value to Pasteur's work. Operating with an albuminous saccharine fluid, in the man- ner described below, Pasteur always succeeded in preventing the growth of organisms in that liquid, in presence of heated air. ' J'ai certainement eu I'occasion de repeter plus de cinquante fois I'experience, et, dans aucun cas, cette liqueur, si alterable, n'a donne vestige de productions organisees en presence de I'air calcine.' Into a flask with a capacity of 250 to 300 com. were introduced 100 to 150 com. of the saccharine albuminous fluid. The neck of this flask, which had been drawn out, was then connected with a platinum tube in which the air could be raised to a very high temperature. The fluid was boiled for two or three minutes, and then the calcined air allowed to enter. Although the experiment succeeded in the case of the Annales des Sciences naturelles, surie 4, t. xvi. 1861. PASTEUR. 165 saccharine albuminous material, and some other fluids, it did not succeed with milk. Leaving milk out of consideration for a moment, it was shown that other fluids which, although pre- viously boiled, when exposed to ordinary air, rapidly become the seat of development of organisms, remain barren when exposed to heated air. (It has been remarked by several authors, especially by Pouchet, that Pasteur was unable to succeed, in many cases, in repeating Schwann's experiment with calcined air. This is true : but the experiment which failed was the one where the flask is inverted over mercury, and the calcined air then introduced, and Pasteur has pointed out that it is from the mercury that the source of contamina- tion is derived.) It remained to enquire further what happened when dust which had not been heated was introduced into the Fig. 62.— Pasteur's mode of introducing dust into flask con- taining CALCINED AIR. h, the fla.sk containing the infusion sealed after being filled witli heated air. a, piece of asbestos containing dust. When the tube in which this rests lias been purified and filled with heated air, tiie neck of the flask 6 is broken at c, and the dust slipped in. The neck of the flask is again sealed. (From Pasteur.) fluid in presence of heated air. This was done ; the air coming in contact with the boiled fluid was, as in the former case, pre- viously heated, and the fluid had remained barren for one or two months; then precautions being taken that no unheated air was introduced, unheated dust was put into the flask (Fig. 62), and, as a consequence of this, development of organisms rapidly occurred, and these organisms were of the same kind as those which appeared in fluids freely exposed to air. Thus Pouchet's objection to Schwann's experiment (viz., that heated air interfered with the growth of organisms) was completely up.set. Fresh urine behaves in exactly the same manner when treated in the two ways described. In the case of Tnilk Pasteur was, however, unsuccessful when the boiling temperature was maintained for only two or 16G SPONTANEOUS GENERATION. three minutes (a length of time quite sufficient in the former cases) ; and this want of success he believes to be due to the fact that in this fluid organisms can resist the boiling tempera- ture for a longer period than in other liquids. Two or three minutes of a temperature of 110° C, or a prolonged tempera- ture of 100° C, werej however, sufficient to sterilise milk. This resisting power he considers to be due to the alkalinity of the fluid, for he finds the same difficulty if he renders his sugared yeast water alkaline by the addition of carbonate of lime. In the case of milk and of the latter fluid, thus purified and pre- served unchanged for some weeks, the addition of the atmo- spheric dust, in the way described, produces the same results as in the fluids previously referred to. But it is not necessary to use calcined air, ordinary air will be equally inert, if only it has had opportunity to deposit its dust before being admitted into i\ie flask. This he showed to be the case by his well-known experiments with flasks with bent necks. Into a flask a suitable quantity of the fluid to be ex- perimented on is introduced, the neck is then drawn out long and bent in various directions (Pasteur only figures one long curve) so as to present obstructions to the entrance of solid particles along with the air (see Fig. 3, p. 16). The fluid is then boiled for the requisite length of time, and, the lamp being removed, ordinary air is allowed to enter. Fluids may be prepared in this way, and preserved for any length of time de- sired. On the other hand, if the neck be straight, so as to allow the dust to fall readily into the flask, organisms appear, however long the neck. In the same way, if the neck be broken off short, so that there is no obstruction to the entrance of dust, organisms rapidly develop. In the case of milk the boiling point must be raised to about 110'" by heating the fluid under pressure, or the milk must be boiled for a long time. That the cause of the growth of these organisms is not continuous, as would be the case were it some known or un- known force, but that it is the advent to the fluids of solid particles floating in the atmosphere, is likewise demonstrated by the following experiment. Flasks containing the saccharine yeast solution were j)repared, and sealed during boiling. These PASTEUR. 1C7 jQasks being opened in different places, with certain precautions against the admission of dust from its neck, &c., air rushed in, carrying with it any suspended dust. The neck of the flask was again sealed, so as to prevent any further entrance of dust. It was thus found that the air in some places and under some conditions contained none of the particles which give rise to organisms, while, on the other hand, when they were present the organisms might be of very various kinds. One of the situ- ations in which such flasks could be opened without any de- velopment of organisms, was in some cellars which had not been entered for a long time, and in which the dust had there- fore settled. Precautions were of course taken that the operator neither introduced the particles himself nor stirred up the dust of the cellar. I may quote one experiment : I^e 14 aout 1860 j'ai ouvert et renferme dans les caves de TObservatoire dix ballons contenaut de I'eau de levure de biere, et onze autres ballons de la meme preparation dans la cour de I'etablissement. ;\ 50 centimetres du sol, par un vent leger. Tous ont ete rapportes le merae jour dans I'etuve de inon laboratoii-e, dont la temperature est de 25 a 30 degres. J'ai conserve jusqu'a ce jour tous ces ballons. Un seul de ceux ouverts dans les caves renferme une production vegetale. Les onze ballons ouverts dans la cour ont tous fourni des Infusoires ou des vegetaux du genre de ceux que j'ai deja decrits.' But the greatest blow was given to the views of the hetero- genists when Pasteur demonstrated that albuminoid materials are not necessary for the development of bacteria and fungi, but that they can be replaced by crystalline salts, such as phosphates and salts of ammonia. He prepared a fluid of the following composition, in which these organisms readily grew : — Eau pure 100 grammes Sucre canrli ........ 10 ,, Tartrate d'ainmoniaque . . . . . 2i\5 „ Cenrlrcs fondues de levure de bii'^re . . . 4 „ ' Si Ton seme dans cette liqueur, en presence de I'air cal- cine, les poussieres qui existent en suspension dans Fair, 1G8 SPONTANEOUS GENERATION. on y voit naitre les Bacteriums, les Vibrions, les Mucedinees &c." Here there is no question of albuminoid particles com- bining to form an organism. If they develop here sponta- neously they must be built up from mineral salts. Such is Pasteur's first work — the work which is considered by many to have struck the final blow at heterogenesis. Let us see what it really does prove. It shows that a certain number of boiled fluids prone to the development of organisms can be preserved, without any growth of organisms in them, in the presence of calcined air, or of ordinary air, the dust of which has been allowed to settle ; that the introduction of dust into these flasks is the only con- dition requisite for the development of organisms ; that the source of organisms is something discontinuous — particulate ; that organisms are not necessarily the result of changes in albuminoid materials, for they grow vigorously in an artificial mineral fluid. Further, Pasteur has shown that among the particles present in the dust of the atmosphere there are spores of fungi and bodies which may be bacteria or their spores. This is all that is proved by these experiments ; and how does Pouchet answer them ? By asserting that these solid par- ticles are not bacteria or their spores, but lifeless particles, which under certain conditions become vivified, and appear as various forms of organisms ? The only possible theory, one would think ! No. Pouchet disputes the facts. He does not, it is true, take the trouble to repeat Pasteur's striking experi- ment of the flask with bent neck. He simply says : ' C'etait une erreur.' Further, ' Nous avons refuse de repeter les ex- periences de M. Pasteur parce que, logiquement, rationnelle- ment, pour des physiologistes, du moment oii il est reconnu ' It may be mentioned here that, since Pasteur published, other simihir fluids in which organisms can grow have been cmploj'ed. Tlius Cohn uses the following: — Distilled water Tartrate of ammonia Pliosphate of potash Crystallised sulphate of magnesia Tribasic phosphate of lime 20 c.cm. •2 grammes •1 „ •1 •01 POUCHET'S REPLY. ]69 que celles de Schwann * sont absolument erronees, et je pense que pas un seul de ceux-ci ne voudrait aujoiurd'hui le contester, les experiences du chimiste de Paris sont consequemment frap- pees de la meme nullite.'^ Pouchet again retiu'ns to the simple experiment in repeti- tion of Schulze's, which we have previously quoted, but now his statement is directly opposed to that formerly made. He now says, ' En employant dans cet appareil ' (a simple rentree d'air) ' de la colle de farine extremement legere, de I'albumine, de I'urine, de la biere, du foin, ou de la noix de galle, constam- TYient on voit apparaitre des microphytes ou des microzoaires apres un temps fort court.' How is this contradiction to be reconciled ? Is not the former experiment most likely to be correct ? Fig. 63. -Another mode op repeating Schulze's experiment. (FROM Pouchet.) He then goes on to describe an experiment ' much more ' rigorous ' than that of M. Schulze. 'Dans un ballon dont le col place horizontalement siipporte un robinet, je mets une certaine quantite d'eau ordinaire. Un corps fermentescible renferme dans un gvos tube de veri-e, et qui a ete prea- ' I previously pointed out that Scliwann's experiment, whicii was occasion- ally unsuccessful in Pasteur's hands, was not that to which M. Pouchet alludes, but that performed over mercury ; and Pasteur has abundantly demonstrated the fallacy here and liow it can be overcome. ^ ijee Nouvelles Ej.-pcHenccs sur la (reiteration spontanee. 170 SPONTANEOUS GENERATION lablemeut cliauffe k 150° C. pendant cinq beures, est plac6 a I'interieur du col de ce ballon : ce tube est ferme par un opercule rode a I'emeri et scelle hermetiquementavec lui par line substance facilement soluble dans I'eau. Le ballon communique avec irois tubes en U et des boules de liiebig. L'un de ces tubes contient de la ponce sulfurique, tin autre de la pota,sse causti(|ue, et le troisieme du coton carde. ' Les boules de Liebig sont remplies d'acide sulfurique concentr6. ' A I'aide d'une lampe on met I'eaiT du ballon en Ebullition pendant dix minutes, et ce n'est qu'ensuite qu'on articule les tubes en U a I'extremite du tube de Liebig. Enfin on eteint la lampe, et, tandis que I'appareil se refroidit, I'air extei-ieur y rentre en traversant I'acide sulfurique, le coton, la ponce sulfurique et la potasse. Quand I'appareil est parvenu a la temperature ambiante, on fait tomber le tube dans le liquide, et loi-sque celui-ci a dissous la substance soluble qvii lute I'opercule, ce dernier s'ouvre et I'eau envabit I'interieur de ce tube. * Peu de temps apres, constamment on voit la liqueur du ballon se peupler de v6getaux et d'animaux microscopiques, selon les substances que Ton a confinees dans le tube. Jamais en suivant ce proced6 I'experience ne manque.' Such is the experiment which is more rigorous, certainly much more complicated than Schulze's. Nevertheless there are numerous loopholes in it. Thus this little tube containing the fermentescible material is cold, and may be covered with dust when introduced into the neck of the flask. It is certainly strange that, in order to be certain that organisms should develop, it is necessary to heat the great bulk of the water used, and the putrescible material in a small quantity of water separately, and then to unite them in the manner described. For Pouchet himself admits that he does not always get organisms with Schwann's simpler method. Then, again, it is no easy task to cork thoroughly a vessel heated to the boiling point of water ; and the cork used was in no way purified. It is true that steam passed over it for a short time, but then steam is dry heat, and it is generally admitted that dry heat at the temperature of boiling water is not sufficient to destroy all organisms. This argument also applies to the dust on the wall of the vessels. And then in tilting the vessel to introduce the tube into the water, the joints, unless very securely fixed, may oj^en, or living dust may be shaken into the POUCHETS REPLY. 171 fluid from the neck or cork, leaving out of consideration the fact that it is in all probability carried in with the small tube. Pouchet looks on this experiment as completely disproving those of Schulze, Schroeder and Dusch, and Pasteur, and why ? Because with this apparatushe constantly obtains organisms. How then does he explain Pastem-'s results ? Pasteur boils his fluids for two or three minutes, and finds that they remain barren. This experiment can only be answered by Pouchet (so long as he adheres to this line of argument) by supposing that Pasteur is making a false statement, or that by boiling his fluid he has destroyed its power of producing organisms spontaneously. As regards the first, a committee composed of the first scientific men in France confirm the truth of what Pasteur asserts ; while the second can have no force when looked at in the light of Pouchet's own experiments ; for we find that the latter obtains organisms after keeping his fermentescible material at a tempe- rature of 110° C. for several hours, and boiling the water for from 30 to 60 minutes. Such a method of reasoning and of experimentation would not have deserved so much notice were it not for the great in- fluence which Pouchet's work has exercised and does still exer- cise on those who have not read or studied it. And I have felt it the more necessary to consider his work in detail as he is one of the last observers who has maintained a more or less complete heterogenesis, and also as I am not aware of any work in which his experiments have been subjected to a searching criticism.' ' Pouchet's experiments and conclusions were objected to by Mihie- Edwards, Payen, Quatrefages, Claude Bernard and Dumas, who examined them, and also those of Pasteur. 172 SPONTANEOUS GENERATION. CHAPTEE IX. SPONTANEOUS GENERATION {continited). The experiments of Jeffries Wyman : exi^lanation of the results : Wj'inan's views on the subject. Dr. Bastian's views: Cases in which it is still pos- sible that abiogenesis may occur : Growth in vacuo — Bastian's experiments — my own results — Cohn's facts — Dr. Roberts's objections, the walls of the vessels remain impure — Bastian's reply — Objections to the latter — Gruit- huisen's experiments — Paul Bert's results with compressed air — Pouchet looks on a vacuum as preventing spontaneous generation — Paul Bert'sresults with rarefied air — Dr. Bastian does not always get positive results : Ex- periments in airless and hermetically sealed flasks raised to a high tem- perature— Objections — Prof. Huxley's and Dr. Sanderson's statements — Ray Lankester's results — Hartley: experiments with alkaline fluids— Roberts's counter-experiment. Mr. Lister's experiments. Experiments by Roberts and Tjmdall. Other writers, chiefly French and Italian, among whom may be mentioned Joly, Musset, and Mantegazza, have sn])ported Pouchet, but as their experiments furnish little or no additional evidence nor new argument I think it unnecessary to discuss them. Those of Joly and Musset will be found in the ' Comptes Kendus de I'Academie des Sciences,' about the same period as the papers of Pasteur and Pouchet. I must, however, refer at length to the experiments of Professor Jeffries Wyman, of Cambridge, U.S. These have been largely quoted by the supporters of heterogenesis, as proving their view, though it ought to be borne in mind that Wyman himself expressed no such opinion. It must be confessed that at first sight the experiments seem difficult of explanation on the Panspermic theory, and it is the more necessary to scrutinise them carefully, as he has evidently approached the subject with a perfectly unbiassed mind, and has therefore simply recorded his facts without attempting to force any definite conclusion on this question from them. JEFFRIES WYMAN. 173 The following are the facts which have been adduced by supporters of spontaneous generation as favouring their views. Flasks were prepared in three ways : 1. 'The materials of the infusion were put into a flask' (the general relation between the quantity of fluid and the capacity of the flask was, that about 20 c.cm of fluid were introduced into flasks of about 500 c.cm. of capacity) ' and a cork through which passed a glass tube drawn out to a neck was pushed deeply into the mouth of it. The space above the cork was filled with an adhesive cement composed of resin, wax, and varnish. The glass tube was bent at a right angle and inserted into an iron tube and cemented there with plaster of Paris. The iron tube was filled with wires, leaving only very naiTow passage ways between them.' Into these flasks such fluids as sugar, gelatine, and hay infusion — cheese, sugar, and gelatine — flesh, sugar, and gelatine, &c., were introduced, and boiled for periods varying from fifteen minutes to two hours, while at the same time the ii'on tube, filled with wires, was heated to redness. On withdrawing the lamp from the flask, the air which entered passed over these heated iron wires. When cold the flasks were sealed with the blow-pipe. Fourteen vessels were prepared in this way. and in ten of these, when opened after the lapse of various periods of time, organisms were found, generally vibriones and bacteria. The other four remained barren. 2. In a second set of experiments the cork in the neck of the flask was avoided, the neck itself being drawn out and bent at right angles, and into the orifice of this tube the iron tube was cemented. The other conditions were the same as in No. 1. Similar fluids were used here as in the former case, such as gelatine and sugiir with a few drops of urine and milk, beef infusion, &c. Thirteen flasks were treated in this way, and in all organisms appeared. 3. In others the flask was sealed at the ordinary temperature of the room, after the fluid to be tested had been introduced, and then it was submerged for a variable period in boiling water. This was a repetition of the experiments of Needham and Spallanzani. In :ill llic flasks so treated organisms de- velo])ed. 174 SPONTANEOUS GENERATION. Four experiments were made under pressure, and of these two gave evidence of life (' monads and vibrios '), the other two remaining barren. Such facts coming from an accurate and totally imjirejudiced observer cannot be dismissed lightly. It is quite evident, on reading Wy man's paper, that the facts are accurately narrated, and we must therefore see whether any flaw can be detected in the method of experimentation, and we must attempt to find some explanation of results so diametrically opposed to those obtained by Pasteur which are, it must be remembered, equally indisputable. Now, if we compare this method with that adopted by Pasteur, we shall see that with one exception the essential details are the same. This exception is, however, an extremely important one, and is probably the explanation of the diverse results obtained by several honest workers, and even by the same worker at different times. Pasteur takes a flask having a capacity of 250 to 300 c.cm., and into this 100 to 150 c.cm. of the liquid are introduced. Wyman uses flasks varying from 500 to 800 c.cm. in capacity, and into these he puts 12 to 40 c.cm. of the liquid. (In neither case was there any attempt at preliminary purification of the walls of the flask or of the air in the interior.) In Pasteur's experiments the fluid occupies ^ or more of the capacity of the vessel ; in Wyman's only -J^ to -3^ part. Such is the only important difference between their methods ; and this affords, I believe, sufiicitsnt explanation of the opposite results. For in Pasteur's flask only a proportionally small part of the wall of the flask has to be purified by the steam, and the extent of this part is of course much diminished, by the ebullition of the fluid during boiling. There is also in Pasteur's flask only a very small quantity of air, Avith its dust, to be acted on. It is thus not to be wondered at that a barren result was obtained. But in Wyman's experiments by far the greater part of the flask and of its contents is impure, and can only be purified by the steam. Now steam, as heat, must be looked on as dry heat, and it is stated by Wyman, in a later publication,' that certain forms of organisms may ' American Journal of Science, vol. xliv. 18C7. JEFFRIES WYMAN. 175 resist the prolonged application of even a higher dry tempera- ture than 212° F. Wyman also points out that the tempera- ture of the air even half an inch above the surface of boiling water is many degrees below the boiling point. How much lower then will this temperature be at the orifice of this large flask during the greater part of the time in which the fluid is boiled ? But even admitting that steam is moist heat (what I am by no means disposed to allow) several remarkable instances of vegetable growth at high temperatm'es are produced by Wyman, in one case even at a temperature of 208° F. Such is the explanation I would give of Wyman's results, and that this is a true explanation will be very evident when I come to the consideration of the method of experimentation adopted by ]\Ir. Lister. This explanation accords in every way with my own experience, in which I could point to several similar instances. As I ?iave said, Wyman is generally quoted in support of the theory of spontaneous generation, and at one time I thought that he had entertained that view, but the following facts brought to my notice by his brother. Dr. JMorrill Wyman, show that he never gave any expression of opinion on this point, and that he appreciated the possibility of such an explanation of his results as I have given. His first article is entitled ' Experiments on the formation of infusoria in boiled solutions of organic matter enclosed in hermetically sealed vessels and supplied with pure air,' ' and his second, ' Observations and experiments on living organisms in heated water.' ^ With regard to the object of his research he says, ' The observations and experiments contained in this com- munication have not been brought together either for sustain- ing or refuting the doctrine (spontaneous generation) just referred to, but partly with the view of testing the accuracy of the experiments formerly made, and chiefly for the puri)Ose of determining how far the life of certain kinds of low organisms is either sustained or destroyed in water which has been raised to a high temperature, a result which must be readied before spontaneous generation can be either asserted or denied.' ' >Sillimft/i'.i Jiiin-nal, vol. xxxiv. 1SG2. - Ihid, vol. xliv. 1S(;7. 176 SPONTANEOUS GENERATION. With regard to his experiments he says, ' In the first experiments the red hot tube, beyond a question, destroys all organisms contained in the air which enters the flask through it, but is without effect on such as may be contained in the solution, or adhere to the inner surface of the glass. These come in contact only with boiling water or steam, and unless destroyed by one or the other of these would be sufficient to vitiate any experiment, however careful the adjustment and heating of the tube may have been. We therefore believe that the tube is an unnecessary and useless complication of the apparatus.' In another set of experiments it was shown ' That if the boiling of the flasks was continued for four hours, the infusoria may appear nevertheless — though in other cases it has happened that life ceased to be manifested if it was continued only for two hours.' ' In pushing the experiment still further, we have not found that infusoria appeared in any instance if the boiling was prolonged to five or six hours.' Several experiments, in which many flasks were used, were tried, but ' the result was uniformly the same. Thus a limit to the development of infusoria in boiling water was reached.' Dr. Wyman tells me that in the summer of 1880 he examined one of these flasks, which is marked as having been prepared in June, 1867, and which has remained unopened ever since. ' Judging by the signs above given ' (absence of scum, of muddiness, or of fer- mentation) 'there is no evidence of infusorial life.' The last defence of heterogenesis which it is necessary to consider is that by Dr. Bastian.' He gives up the theory of organic molecules derived from previously living molecules, and attempts to demonstrate that vital force and living matter may arise de novo under the action of the ordinary physical forces — heat, light, electricity, &c. This change of front on the part of the heterogenists is clearly brought about by the over- whelming evidence produced against Pouchet's views, and more especially by Pasteur's success in cultivating organisms from dust in fluids containing no organic matter. A further admis- sion is made which somewhat simplifies the question, viz., that organisms have the power of self-multiplication. ' The BcfjinniiKjs of Life, 1872, &c. BASTIAN. 177 The limitation of cases of spontaneous generation, which has been gradually taking place, is exceedingly instructive. Beginning with the higher animals, it became gradually more limited, frogs, flies, &c., being by degrees excluded, till now it is only in the case of the lowest forms of life that the doctrine is asserted, and even there only in certain instances. The cases which are yet doubtful are given by Eastian in the work quoted, and may be grouped into three divisions. I. The first division relates to the development of organisms in various fluids, more especially m vacuo — a condition which Pouchet looked on as inimical to life ! Into flasks portions of various infusions were introduced. The latter were then boiled for from ten to twenty minutes, and hermeti- cally sealed while still boiling. The fluids used were turnip and hay- infusions, o.nd also solutions of certain salts, chiefly citrate of iron and ammonia coutainiug portions of wood, cheese, &c. The conditions of the first experiment mentioned are very striking and unusual. ' A closed flask containing a very strong infusion of hay (boiled for five minutes), to ivhich had been added 7,\th part of carbolic acid, was opened twelve days after it had been hermeti- cally sealed.' Bastian states that this flask contained organisms of a peculiar form. Such a statement as this, that a saturated solution of carbolic acid (for a watery fluid at the ordinary temperature containing -Jjjth part of carbolic acid is saturated) can jjerinit the growth of organisms, is absolutely opposed to all experience and ex- periment. In experimenting with turnip infusion, cucumber infusion, &c., I have never been able to grow any sort of organ- ism in these fluids, when they contained a larger proportion of carbolic acid than 7, y- th part, even though several drops of fluids swarming with bactt'ria were introduced. Further, I liave lately jicrformed the following experiment : — In January 1880 I intro- duced carbolic acid into flasks containing strong unboiled hay infusion so as to have a strength of the acid present, varying from 1 in 20 to 1 in 200 [)arts. Tlu'se flasks were then covered with cotton-wool caps, and placed in an incubator. When examined six weeks later, there had not yet appeared in any one of them N 178 SFONTANEOUS GENERAriON. any sort of organism. And lastly, tliis statement, that organ- isms can develop in acid fluids after boiling, is contrary to the whole tenor of Dr. Bastian's later remarks, for his strong point is the develo})ment of organisms in alkaline — not in acid — fluids after })ro]onged boiling. Bastian also employs turnip and hay infusions (without carbolic acid) and solutions of such salts as citrate of iron and annnonia, and he finds that a slight sediment occurs which contains organisms. He generally has to introduce such things as deal wood, cheese, &c., in order to get this result. With regard to experiments on such fluids as hay infusion and turnip infusion without cheese, I may state that I have quite lately repeated them with exactly op})osite results. At first I proceeded to repeat them, following closely Dr. Bastian's directions, in the expectation of getting organisms, and looking out for some explanation of their occurrence. The physical forces, or whatever else it may be, were, however, not favourably disposed for spontaneous generation at the time and place where I performed those experiments, for to my surprise I was unable to obtain any development of organisms. I tried several modifications, in the hope of finding the cause of their absence, but whichever of these vegetable fluids I used I was able, with proper precautions, to preserve them with the greatest ease. Some specimens were very difficult to filter, and in some a slight muddiness occurred on boiling, and the granular de])Osit might very readily be mistaken at first sight for organisms, though some care and experience would easily prevent such an error. But I have boiled the fluids for a few minutes and then filtered them under pressure (I could not in this way remove any of Dr. Bastian's supposed physical forces) , and having thus obtained a perfectly clear liquid, 1 treated it like the others. There was now no deposit, and nothing which could be mistaken for organisms. No doubt other observers have produced evid