Antiseptic surgery; the principles, modes of application, and results of the Lister dressing

Front matter

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NTISEPTIC bURGERY

Chapter XVII

Accidental and Operation Wounds of Joints. — Removal of Foreign Bodies. — Operations for Fractures and Dislocations. — Opening of Joints for Hydrarthrosis — Opening of Diseased Joints. — Opening of White Swellings. — Antiseptic Irrigation of Inflamed Articulations ... . . .... 132

CONTENTS. 7

Comparison of some of the principal Measures of the Metric System with those in common use. — Comparison of Thermometric Scales 230

ANTISEPTIC SURGERY.

Introduction

The first edition of this book was published not long ago, and now the progress of the antiseptic method is so well known that there is no need of long preliminaries to tell how profoundly it has modified, even transformed, the surgical practice of our time.

The reception with which it has met has undoubtedlyvaried : even in England it has difficulty in acquiring the position which is its due ; in Denmark it reigns supreme ; in Germany it has its enthusiasts, since it has undergone changes ; in Austria, Switzerland, Holland, Russia, Italy, and America, we meet eminent representatives of Listerian surgery ; and, indeed, we believe there is hardly a country where there are not some ardent disciples who proclaim its merits.

In France it has gained a firm foothold, and, although we have had some difficulty in acclimating it in the hospitals of Paris, the situation is such to-day that there is small possibility of its being deposed.

10 ANTISEPTIC SUKGEEY.

In 1875, when, in my hospital service, I myself provided the materials for the dressing and the necessary apparatus, and undertook to make the first rigorously precise application, in accordance with what I had learned in Scotland, it met with a discouraging reception from many of my colleagues.

But I had followed the first steps of the method since 1867; had seen it applied in Glasgow in 1868; had described it to the French surgeons in January, 1869 ; had kept it before them in every succeeding } - ear by showing its progress and by introducing into my practice, with great success, the employment of powerful antiseptics. Above all, in 1875, I made at Edinburgh, de visa, an exhaustive study of it. So nothing could discourage me or deter me from faithfully testing it.

Soon some of my colleagues, struck by the remarkable cases which I described to them, and surprised by the growing reputation of the method abroad, asked me to teach them the practice of it ; and Professors Guyon and Verneuil were the first to be convinced by their own experience of its immense value.

It was with difficulty that, even after a year of effort, of personal trouble, we prevailed upon the administration of the hospitals to furnish the materials for the dressing. To-day they can be had for the asking.

This great step having been taken, there was a chance for the propagation of the Lister method; and I was able to introduce it into the services of my colleagues and friends, and those of which I had charge, where it reigns supreme to-day.

In fact, for four years I have had a large personal experi-

INTRODUCTION. 11

ence with the method, and that, too, in varied services, in widely different hospitals, in some of which I found the most deplorable sanitary condition.

Now, what was this experience ? One could tell it in a word : in the Paris hospitals, and in the worst of them, we are obliged to make the most dreaded operations ; we perform them with the same sense of security which we should feel in the country where the air is the most pure. We have thus all the outside advantages of the country, and all the facilities which can be furnished only in a hospital.

Nelaton, who was esteemed one of the most fortunate of operators, was accustomed to say that the man who should discover the means of suppressing purulent infection deserved a statue of gold. If this view of Nelaton's was generally entertained, the statue would be raised to Professor Lister ; for purulent infection has disappeared from the list of wound complications in the services where his method is followed.

Eiysipelas, if not altogether unknown, is infinitely rare. For four years, I have not had a single case after my operations ; and yet I can truly say that, during that time, I have made all the operations which are most liable to be followed by this disease and purulent infection.

But this is not all: security against accidents of this nature is, indeed, the chief advantage of the method, but the others are of great value.

The wonderful regularity of repair and the rapidity of healing are two phenomena of the highest importance. Ask a patient who has suffered amputation of the leg whether he prefers to recover in twenty days rather than in two months ; ask a woman whose breast has been removed if she would like better to be cured after one or two weeks, or remain from six weeks to three months with a gaping wound, — and you will have the response which some surgeons are obstinately bent upon not giving.

These facts are not exceptional ; they are the regular and constant results of this method of procedure, of which we may say further that the subsequent suffering and the traumatic fever are reduced to the minimum.

The wounds unite immediately in the greater part of their extent, and the remainder does not suppurate.

All the dressings are remarkably neat, are required less and less frequently as a case progresses, and we see disappearing from surgery the epithems, the uncleanness of which can only be compared with that of the pus-covered wounds which they were designed to protect.

The results of this new surgery are so remarkable that they have attracted the attention of the most incredulous. These, as is well understood, will not allow themselves to apply the Lister dressing, but each borrows something from it, — perfect apposition, drainage, but, above all, the use of powerful antiseptics. Everything is laid under contribution ; and we see to-day, in all the services in Paris, washing of hands, of instruments, and of patients in carbolized water, — a proceeding formerly unknown.

This kind of thing is not the dressing of Lister ; and yet, such is the value of the principal directions so clearly laid down by him, that the results of the surgery of all these imitators are already vastly improved.

As always happens in such cases, it has been contended that Professor Lister did not invent his own dressing; he has been accused of having pretended to discover antiseptics ;

INTRODUCTION. 13

and there are even those who deny the immense progress which has come from ascertaining the effects of necessary doses of these antiseptics.

Have we not seen a comparison instituted between the dressing of Lister and that of Azam, of Bordeaux? Is it possible to compare the dressing of Azam, which is substantially only the partial apposition in the stumps after amputation, together with drainage (an affair already known), with a method like that under consideration, which at once inflamed the surgical world ? It is well to remember, too, that all publication upon the Azam dressing was subsequent to the announcement of the Lister method, and, better still, that Azam has never laid claim to it at all. With the greatest frankness, in publishing the very remarkable results of his practice, he made known the names of the surgeons who brought to Bordeaux the elements of the amputation dressing : Labat, the deep drain ; Dudon, the double suture ; Denuce", the perfecting of the superficial suture ; and, moreover, each of these elements existed before this dressing.

Doubtless the cause of these quarrels is that the surgical world still considers the dressing of Lister as a procedure, instead of comprehending the fact that it is a method. Any one who has attentively studied or experimented could not make a mistake upon this point. Whoever has followed a service where the antiseptic method is rigorously carried out must have been struck by the fundamental difference in the mode of repair of wounds. It is no longer a question of the more or less perfect healing after a particular operation ; but all surgery is affected.

When one has seen wounds heal without suppuration ; abscesses, as soon as evacuated, dry up and close rapidly ; the great joints, when opened, allow themselves to be roughly handled without resenting it ; clots of blood, instead of interfering with repair, contribute to its perfection, — he comprehends that a new element has entered into surgery. It is not a question of comparing one dressing with others, of making a distinction between various topics. It is necessary to find out by experience whether the advocates of the method haA r e stated facts, or have allowed themselves to be lured away by the promise of novelty.

When we hear it said that this method is a matter of interest only in the great cities, in centres of infection, we regret that it is not better understood. Doubtless it is in the hospital, and the very worst, that it attains the highest degree of interest ; for it succeeds, in a way, in making the place healthy. But much more than this: it has so transformed surgery that its employment is called for everywhere. Perchance, in exceptionally favorable conditions, one may omit some parts of the dressing which are indispensable in bad surroundings ; but the ensemble of the method must remain, and is demanded in the country as well as in town. Certain operations are justifiable only under its protection.

Whatever has been the progress of modern surgery, the antiseptic method came at a time when the surgeon, often disarmed by surgical complications, saw his horizon limited by cruel uncertainties. It was impossible to predict the results of operation, and security was so imperilled that certain conditions appalled the boldest, and certain operations were practically prohibited to the surgeons of cities, who, even though consummately skilful, found themselves unable to produce results equal to those of their far from expert

INTRODUCTION. 15

brethren in the country, where the atmosphere is untainted. The antiseptic method came, and gave an impetus to surgery, for it provided skill with means of success.

This new power of surgery, it seems to me, can be acquired only by faithful disciples, as I shall explain further on. Approximations to antiseptic surgery, and attempts at imitating it, have everywhere ended in cruel disappointment.

Therefore, I have refrained from explaining in this work the modifications of the method which have been suggested, although I have studied them and know that some of them are of interest. Contrary to what has been said, I believe this surgery to be within the reach of all the world; I believe that every one may be so convinced that he will not deviate from the rules which have been laid down. But one can easily understand that, until it is acknowledged as a matter of surgical duty, only a small number will rigorously follow the necessary practice and attain satisfactory results.

For my part, I write the new edition of this work to-day with a very different personal experience from that of four years ago. Whatever I state, I have tried and observed. I have educated mvself upon all these points, and, confident of success, I have fearlessly performed operations which formerly one would scarcely have ventured on.

I assert more emphatically than ever that we can do no better than to remain faithful to the words of the master ; and that I may deserve to be considered elsewhere, as I am already in the Surgical Society, his apostle, I promise those who shall obey them the following things : —

The disappearance of wound accidents even in the worst circumstances.

A regularity in repair hitherto unknown. Surgery without suppuration.

Union by first intention habitually and without danger. Such rapidity in healing as to surpass all anticipation. The possibility and safety of operations hitherto considered dangerous and even unjustifiable.

This is no vain promise, for these results are obtained daily, and we may be allowed to say with satisfaction that our efforts are crowned with success. A few years ago the hospitals of Paris were reckoned among the worst, even bj r the verdict of some of their own surgeons. To-day their surgery is as fortunate as that anywhere in the world. Even the Csesarean operation is successful.

Chapter I

Progress op Surgery. — Practices designed to protect Wounds prom the Injurious Action of the Air ; Occlusion and Antisepsis in Ancient and Modern Times. — The Method of Lister.

Hardly any advance has been made in natural science without its having been remarked that discoveries of the same kind preceded the announcement of the modern achievements. This is explained by the fact that in the sciences which depend upon observation, the conditions of experimentation are so complex, so disturbed by circumstances of every kind, that one cannot know at once all the elements of progress. He must advance when he catches sight of the truth, retrace his steps when certain circumstances conceal it from him, then advance again and take a longer and surer step, because all previous experience is pointing out the way to him.

The antiseptic method followed the usual course : it did not come complete from the brain of one man ; it would be incorrect to say that it burst suddenly upon surgery like a revelation. The eminent savant who has formulated with so much care the minutest directions concerning it does not deny this, nor does any one of his devoted followers.

If we go back to the earliest history of surgery, we find the idea of the harmful effect of the admission of air to solutions of continuity in the human body. In studying the history of surgery, we are continually catching sight of the constant struggle of art with this action, — an empirical struggle, now abandoned, now renewed with ever increasing success.

Two principal processes have constituted the elements of this struggle, — the occlusion of wounds, and antisepsis, which we venture to believe was unconscious.

Occlusion is, theoretically, the simplest method of protecting wounds fr6m the action of the air ; practically, it is the most complicated. We find the beginning of its history among savages who cover their wounds with sand or mud, and think that their recovery is facilitated by this process.

Two dates, celebrated in the history of occlusion, ought to be especially marked by two names, Magatus and Larrey. Magatus in 1616 not only briefly formulated the directions for occlusion, but wrote an account, marvellous for the age, of the theories of traumatic fever and of septicaemia.

Larrey, with his great military experience, afterwards introduced a valuable method which contrasted with the recognized practice, and shocked the ideas of his contemporaries, but saved many lives. In employing infrequent dressings, he acted empirically, guided by his wonderful clinical instinct. In spite of his natural desire to inspect the wounds, in spite of the dreadful odor emitted by the pussaturated dressings, he persisted in his practice and obtained remarkable results. In analyzing these results, we find points which are difficult to explain ; yet we have a beginning of the interpretation in the science of the infinitely little.

In our modern surgery we find a multitude of occlusion processes. Each of these has been thought to deserve the name of a new method, according as it was more or less complicated, more or less ingenious. In all of these methods there was a common principle, which explains their success : they prevented the circulation and stagnation of air in and

OCCLUSION PROCESSES. 19

about the wounds, perhaps simply by isolation, perhaps by exhaustion of the air and the altered fluids.

Serious difficulties of application prevented the continuance of these methods, excepting the wadded dressing of Alphonse Gue"rin, which has rendered services so remarkable, although this eminent surgeon made it known only a few years ago (1871). This does not exclude the air, as the occlusion dressings pretended to do, but filters it, and consequently renders it harmless to the wounded organism. It fulfils yet other conditions, which are of less importance but advantageous to wounds, and constitutes one of the most powerful methods in surgery. We hasten to add that it is no longer an empirical dressing, but is based upon a serious scientific theory of the accidents of wounds, and is now always combined with antiseptic precautions.

Ancient empiricism combated the harmful action of the air by proceedings much more powerful than the occlusion of wounds. There seems to have been a constant effort to change the injured surfaces, so as to avoid the immediate results of the fermentation and putrefaction of dead parts and organic fluids. The instruments by which the modification was produced were various : the actual cautery, boiling liquids, above all, antiseptic substances have played the chief part in the treatment of wounds.

Modern surgery has erred in not holding in greater esteem the prescriptions of the ancients, and in not admitting that so remarkable observers could not have acted without discernment, and without depending upon the mighty facts of experience.

What do we see, in glancing through the surgical pharmacopoeia, if not the constant employment of powerful antiseptic substances ? Undoubtedly, man does not correctly interpret his own actions ; undoubtedly, superstitious practices induce surgeons to put together substances which are more or less extraordinary, such as serpents, earthworms, and human fat. But, although in his opinion the effect of these substances is largely due to their supernatural power, he takes good care not to use them alone ; he always unites them with antiseptics.

These are manufactured products, such as turpentine, wine, brandy, alum, common salt, etc., and many vegetable substances, among which we find aloes, the leaves and shell of the walnut, figs, and many other substances quite as valuable.

Cataplasms even are of infinite variety, and contain antiseptic, aromatic, and other substances. It is only in our time that a panacea has been found in linseed pulp, a fetid topic and natural receptacle of all injurious organisms.

Surgeons do not even neglect the atmosphere, for they advise the employment of aromatic substances, and disinfectants suitable for the fumigation of the sick-chamber.

The most ridiculous and mysterious of their formulas, after all, depend only for their activity on antiseptics, often combined with oily substances which serve as vehicles and to isolate the wounds.

The famous oil of puppies, the secret of which cost Ambroise Pare" two years of entreaty, was only a mixture of oil, brandy, and turpentine, in which living puppies and earthworms played the necessary role of mystery.

The commander's balsam, an alcoholic compound of benzoin, is a type of the antiseptic substances, and its employment has recently been recommended anew.

At a more modern date, and in the most classic works, we also find prescriptions as neat as this of Dionis : " Oil} 7 and putrid remedies are of no use in wounds of the head ; the balsams and spirits are there of the most advantage, for which one ought to keep white balm and spirit of wine."

UNCONSCIOUS ANTISEPSIS. 21

If we go from medical works to the histories of chivalry, in which there is no lack of recipes for infallible balms, we again find the employment of antiseptics.

Since the confidence inspired by these substances has continued for ages, it is probable that they have some real action, that their reputation is partly deserved, and it is surprising that surgery should all at once have the vanity to say, " Our fathers were entirely mistaken ; " and henceforth surgery is done with lint, cerate, linseed-meal poultices, and hot and cold water.

Is it necessary to attribute this abrupt change largely to the influence of physiologism, to the doctrine of inflammation, to the work of men whom Velpeau called antiphlogistiqueurs, even while he was constantly under their influence?

However it may be, the reaction has come about, and is to be explained first and foremost by an empirical return to antiseptics. A great number of substances of recent production have been extolled, and everybody has been able with reason to praise the favorable influence of a new dressing. Carbolic acid, an entirely modern production, has been recommended by many. We have seen several surgeons employ carbolic-acid dressings, freely using weak solutions of it, and also, what is still more important, sprinkling carbolized water about for the purpose of counteracting the poison of wounds. By these means the wounds heal more rapidly, and the healthfulness of the wards is improved.

But alcohol has attracted the most attention. Ardently advocated by Bataille" and Le Cceur, this dressing had the good fortune to be adopted by Nelaton. Bataille" saw in it the final suppression of purulent infection. Le Cceur, with his dressing, actually returned to the ancient practice, recommending with the alcohol much neglected articles.

This dressing had an advantage over others in being based upon a theory which was revived by Neudorfer some years afterwards for carbolic acid. Alcohol coagulates albuminoid substances, and makes them imputrescible ; it contracts the minute blood-vessels, and renders them incapable of absorption.

Whatever there may be defensible in this explanation, there has been rapid progress in this modern period. All antiseptics, from pure alcohol to dilute caustics, have been employed with varying success, but always with success.

We have seen, then, substances which were formerly thought to be irritant come into ordinary surgical use, hastening and insuring the healing of wounds instead of retarding it.

Doubtless the action of each dressing was capable of an explanation, but sufficient evidence was not adduced to establish it. It was thought that some modified the wound, that others acted upon the secretions, that others afforded protection from the action of the air. It was easy to see that great progress had been made, for surgery was already much improved ; but it was difficult to give the reason.

Furthermore, success, though actual, was far from being constant. Although accidents were less frequent and the progress of repair was more regular, still with the failures astonishing discrepancies were observed, which the theories previously advanced did not explain.

Antiseptic surgery, with its constant achievements and its scientific interpretations, begins a new period, marks an important triumph. The regularity of the work of repair, almost without regard to tissues and media, bringing all points of the economy under a common law, is what chiefly attracts the attention of the observer.

The method which Professor Lister has taught since 1866 is evidently connected with the great progress which we record.

THE LISTER METHOD. 23

This surgeon protects the organism against the hurtful action of the air, at least against those parts of it which are poisonous.

He gives the theory of the action of antiseptics.

He directs and assures the regular course of repair.

He imparts to the organic elements their greatest possible reparative power, by removing everything which he had ascertained to be obstructive to their functions of renewal.

Physiological study, we may say, of the healing wound agrees with the theoretical ideas which he has advanced as necessary conditions. In my opinion, this will be the true criterion of the value of the method, and of the importance of the discoveries to which it will give birth.

The method of Lister is an immediate result of the discoveries of Pasteur. This eminent savant explained the cause of the injuriousness of the air. He showed that fermentation is impossible in pure air. But at the same time he demonstrated that everywhere air is impure ; that it is surcharged with germs in densely populated localities ; that the number of germs is less in country places ; and that when we come to the summits of high mountains the scarcity of germs is remarkable, but still there are germs.

Now, according to Lister, as we shall see later, it is not the air itself which is hurtful to wounds, but the germs in the air are the source of their putrefaction and infection, and the cause of accidents.

It is still very difficult to explain the exact mechanism of these accidents. But the researches of Pasteur and his pupils, of Davaine, of Lister, of Bert, of Tyndall, have awakened the study of the evolution of germs in infectious maladies, septicaemia, pyaemia, and even puerperal fever. The pursuit of the micro-organisms, to use Sedillot's happy expression, is made every day, and every day we study

24 ANTISEPTIC SURGEEY.

more accurately the conditions of their existence and resistance.

We are beginning to understand that, in the microcosm of the vibrios, all the beings are not equally baleful ; how it is that the appearance of certain of them coincides with the disappearance of certain others ; how the presence of fresh air, frequently renewed upon a denuded surface, is less favorable to their development than a dressing which imperfectly covers a wound.

We have seen that certain substances, employed as topics and called antiseptics, arrest the evolution and the multiplication of these germs.

We already explain the apparent inconsistencies of the theory and the practice. We know how; dressings as different as the wadded, the antiseptic, and even the open dressing act in the same direction ; it is by the total or partial destruction or sterilization of micro-organisms. And although the germ theory leaves so many points to be studied, so many obscurities to be lighted up, it certainly draws a decided confirmation from the practices and theories of modern surgery.

Science advances ; till now we have destroyed the germ without seeing it, almost without knowing it. Thanks to modern observers, we have caught the vibrio in the process of evolution ; we study it, and every day new proofs are added to the experiences upon which are based the theory of the harmfulness of the air and the practice of antiseptic surgery.

CHAPTER II. Theoretical Views on which the Practice of the Dressing

is BASED.

The antiseptic method is founded upon a certain number of theoretical ideas, of which the first and most important is that of the existence of germs.

It was in hospital practice, among the perpetual failures of surgery in a thoroughly infected hospital (Glasgow), that Lister conceived the idea of the method which has made him so famous. He had struggled ceaselessly and in every possible way with insalubrity, and was constantly vanquished by its fatal influences.

Persuaded that the atmosphere about the wounded is especially pernicious in its effects, he thought that these should be attributed to the numerous germs which Pasteur was studying in all the media which surround us. He became a convert to the doctrines of the eminent French chemist. This was in 1865, — that is, a short time after the first publications of that illustrious experimenter. Lister made for himself numerous experiments which demonstrated the presence of germs in the atmosphere, and their influence upon fermentation and putrefaction, and then proposed to enter into a struggle with the disturbing elements. The atmospheric germs, he said, provoke suppuration ; they excite putrefaction of the blood and other animal fluids, and, by this process, produce complications in wounds.

Thus the germs or microzymes are, according to him, the cause of the infectious accidents of wounds ; and, if they are destroyed, if their development is prevented, we shall be guarded against the complications which harass surgery.

The germs, like the vibrios which they engender, are infinitely varied : all are not equally harmful ; it is even certain that there are some which destroy those more harmful than themselves. But they exist always in the atmosphere, deposited upon the surface of all objects, and especially in all putrefied and putrescible matters which remain on the instruments, the hands, and the pieces of dressing.

It being impossible to discriminate between the good and the bad, the surgeon should seek the suppression of all. The direct or indirect destruction of all these living beings and of all germs has been practised by Lister.

The result has been the disappearance of the accidents of wounds ; he has seen purulent infection and hospital gangrene absolutely put to flight. Hospitalism is no longer a cause of mortality.

The ensemble of conditions practically necessary to the disappearance of the germs put the wounds into a peculiar state, and little by little Lister was led to study exhaustively the conditions of their repair. He very soon saw that to insure the healthiness of wounds not only must the micro-organisms be kept away, but it was also necessary to study certain conditions which are favorable, even essential, to the regularity of the reparative process, if one wished to achieve more perfect surgical results.

These conditions are subordinate in comparison with the prime importance which must attach to the destruction of germs, but yet they play a prominent part in practice.

When the conditions are most favorable to the repair of tissues, as in subcutaneous injuries, there is no suppuration. Contrary to many of the received ideas, it must be admitted that suppuration is not a necessary phenomenon. It implies

CAUSES OP SUPPURATION. 27

a difficulty, an obstacle to repair. It appears when the vital ity of the newly formed elements is lowered. It is necessary to seek for the cause of the irritation which is produced, the source of the trouble. Lister recognized the fact that three conditions produce this untoward result : —

Excessive tension in the tissues.

Direct irritation of the living tissues, and the presence of a foreign body.

Direct irritation by the atmosphere charged with germs.

What is excessive tension ? It is the phenomenon accompanying all local inflammations, liable to lead to suppuration. In a phlegmon, in a dropsy, in a considerable effusion of blood, there is excessive tension.