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Looking Back.FROM

THE LANCET, SATURDAY, July 27th, 1867.

ON A

NEW METHOD OF TREATING COMPOUND

FRACTURE, ABSCESS, ETC.

BY JOSEPH LISTER, ESQ., F.R.S.,PROFESSOR OF SURGERY IN THE UNIVERSITY OF GLASGOW.

PRELIMINARY NOTICE ON ABSCESS.

In anticipation of the more detailed account which I hopewill soon appear in THE LANCET, I will now give a descriptionof a new method of treating abscess, which has affordedresults so satisfactory that it does not seem right to with-hold it longer from the profession generally.

It is based, like the treatment of compound fracture,* onthe antiseptic principle, and the material employed is essen-tially the same-namely, carbolic acid, but differently appliedin accordance with the difference of the circumstances. In

compound fracture there is an irregular wound, which hasprobably been exposed to the air for hours before it is seenby the surgeon, and may therefore contain in its intersticesthe atmospheric germs which are the cause of decomposition,and these must be destroyed by the energetic application ofthe antiseptic agent. In an unopened abscess, on the otherhand, as a general rule, no septic organisms are present, sothat it is not necessary to introduce the carbolic acid intothe interior. Here the essential object is to guard againstthe introduction of living particles from without, at the sametime that a free exit is afforded for the constant discharge ofthe contents. The mode in which this is accomplished is asfollows :-A solution of one part of crystallised carbolic acid in four

parts of boiled linseed oil having been prepared, a piece ofrag from four to six inches square is dipped in the oily mix-ture, and laid upon the skin where the incision is to be made.The lower edge of the rag being then raised, while the upperedge is kept from slipping by an assistant, a common scalpelor bistoury dipped in the oil is plunged into the cavityof the abscess, and an opening about three-quarters of aninch in length is made, and the instant the knife is with-drawn the rag is dropped upon the skin as an antisepticcurtain, beneath which the pus flows out into a vessel placedto receive it. The cavity of the abscess is firmly pressed, soas to force out all existing pus as nearly as may be (the oldfear of doing mischief by rough treatment of the pyogenicmembrane being quite ill-founded); and if there be muchoozing of blood, or if there be a considerable thickness ofparts between the abscess and the surface, a piece of lintdipped in the antiseptic oil is introduced into the incision tocheck bleeding and prevent primary adhesion, which is other-wise very apt to occur. The introduction of the lint iseffected as rapidly as may be, and under the protection ofthe antiseptic rag. Thus the evacuation of the originalcontents is accomplished with perfect security against theintroduction of living germs. This, however, would be ofno avail unless an antiseptic dressing could be applied thatwould effectually prevent the decomposition of the stream ofpus constantly flowing out beneath it. After numerous dis-appointments, I have succeeded with the following, whichmay be relied upon as absolutely trustworthy. About six

teaspoonfuls of the above-mentioned solution of carbolicacid in linseed oil are mixed up with common whitening(carbonate of lime) to the consistence of a firm paste, whichis in fact glazier’s putty with the addition of a little carbolicacid. This is spread upon a piece of sheet block tin aboutsix inches square ; or common tinfoil will answer equallywell if strengthened with adhesive plaster to prevent it fromtearing, and in some situations it is preferable, from itsadapting itself more readily to the shape of the part affected.The putty forms a layer about a quarter of an inch thick ; itmay be spread with a table-knife, or pressed out with the

* See THE LANCET of March 16th, 23rd, and 30th, and April 27th ofthe present year (i.e, 1867).

hand, a towel being temporarily interposed to prevent theputty from sticking to the hand or soiling the coat-sleeve.The tin thus spread with putty is placed upon the skin so thatthe middle of it corresponds to the position of the incision,the antiseptic rag used in opening the abscess being removedthe instant before. The tin is then fixed securely by adhe-sive plaster, the lowest edge being left free for the escape ofthe discharge into a folded towel placed over it andsecured by a bandage. This dressing has the followingadvantages :-The tin prevents the evaporation of the car-bolic acid, which escapes readily through any organic tissuesuch as oiled silk or guttapercha. The putty contains thecarbolic acid just sufficiently diluted to prevent its ex-

coriating the skin, while its substance serves as a reservoirof the acid during the intervals between the dressings. Its

oily nature and tenacity prevent it from being washed awayby the discharge, which all oozes out beneath it as fast as itescapes from the incision ; while the extent of the surface ofthe putty renders it securely antiseptic. Lastly, the puttyis a cleanly application, and gives the surgeon very littletrouble ; a supply being daily made by some convalescent inan hospital, or in private practice by the nurse or a friend ofthe patient; or a larger quantity may be made at once, andkept in a tin canister. The dressing is changed, as a generalrule, once in twenty-four hours ; but if the abscess be a verylarge one, it is prudent to see the patient twelve hours afterit has been opened, when, if the towel should be muchstained with the discharge, the dressing should be changed,to avoid subjecting its antiseptic virtues to too severe a test.But after the first twenty-four hours, a single daily dressingis sufficient. The changing of the dressing must be methodi-cally done, as follows :-A second similar piece of tin havingbeen spread with the putty, a piece of rag is dipped in theoily solution, and placed on the incision the moment the firsttin is removed. This guards against the possibility ofmischief occurring during the cleansing of the skin with adry cloth and pressing out any discharge which may exist inthe cavity. If a plug of lint was introduced when the abscesswas opened, it is removed under cover of the antiseptic rag,which is taken off at the moment when the new tin is to beapplied. The same process is continued daily till the sinuscloses.The results of this treatment are such as correct patho-

logical knowledge might have enabled us to predict The

pyogenic membrane has no innate disposition to form pus,but does so only because it is subjected to some preter-natural stimulus. In an ordinary abscess, whether acute orchronic, the original cause that led to suppuration is nolonger in operation, and the stimulus that determines thecontinued pus formation is derived from the presence of thepus pent up in the interior. When an abscess is opened inthe ordinary way this cause of stimulation is removed. but inits place is substituted the potent stimulus of decomposition.If, however, the abscess be opened antiseptically, the

pyogenic membrane, freed from the operation of the

previous stimulus without the substitution of a new

one, ought, according to theory, to cease to suppurate,while the patient should be relieved from any local or

general disturbance caused by the abscess, without the riskof irritative fever or hectic.

Such, accordingly, is the fact. Abscesses of large size have,after the original contents have been evacuated, furnished nofurther pus whatever, the discharge being merely serum,which in a few days has amounted only to a few drops in thetwenty-four hours. Whether the opening be dependent ornot is a matter of perfect indifference, the small amount ofunirritating fluid being all evacuated spontaneously by therapidly contracting pyogenic membrane. At the same time,we reckon with perfect certainty on the absence of all consti-tutional disturbance.As an illustration, I may mention the last case which has

come under my care. It is that of a young woman, twenty-five years old, with psoas abscess, which had of late beenrapidly on the increase, and caused a large swelling belowPoupart’s ligament, communicating with a fluctuating mass,dull on percussion, reaching to a considerable distance up theabdomen, the femoral vessels being raised over the communi-cation between them. Six days ago I opened, in the mannerabove described, the swelling in the thigh at the anterior partof the limb where it was nearest the surface, giving exit totwenty-seven ounces of pus, thin, but containing numerouslarge curdy masses. I introduced a piece of lint, dipped in thecarbolic acid and oil, into the incision ; and this prevented anydischarge from escaping during the next twenty-four hours,

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when, on removal of the plug of lint under an antiseptic rag,three ounces of turbid serum escaped. For the next three daysthere was scarcely any discharge, the deeper parts of the in-cision having cohered. On firm pressure, however, the productof seventy-two hours escaped, and amounted to four drachmsof serum. Meanwhile the girl’s general health, which hadnot been interfered with by the abscess, continued perfectlygood, neither pulse, tongue, appetite, nor sleep having beendisturbed.

In this case, though there is no deformity of the spine,there is great probability that caries of the vertebras is

present. But even though such be the case, there is goodreason to hope for a favourable issue. Regarding caries asmerely the suppurative stage of chronic inflammation in aweak form of tissue, I have been not surprised, thoughgreatly rejoiced, to find that it exhibits the tendency ofinflammatory affections generally-viz., a disposition to

spontaneous cure on the withdrawal of irritation. Hitherto,in surgical practice, caries has had to contend against theformidable irritation of decomposing matter, which, undercircumstances of weakness, is often sufficient to cause ulcera-tion, even in the soft parts; yet, in spite of this irritation,caries is often recoverable in the child where the vital powersof all the tissues are stronger. If, therefore, this seriouscomplication can be avoided, there seems nothing in theoryagainst the probability that caries may prove curable inthe adult. And even should portions of necrosed bone bepresent, as is not unfrequently the case, our experience ofthe treatment of compound fracture with carbolic acid hastaught us that dead bone, if undecomposed, not only fails toinduce suppuration in its vicinity, but is liable to absorptionby the granulations around it,*Such were the hopes which I ventured to express several

months ago to my winter class. Since that time I haveopened numerous abscesses connected with caries of thevertebras, the hip, knee, ankle, and elbow, and in all casesI have found the discharge become in a few days triflingin amount, and in many it has ceased to be puriform afterthe first twenty-four hours. Finally, three days ago-viz.,on the 4th inst., (July, 1867,) I had the inexpressible happi-ness of finding the sinus soundly closed in a middle-agedman, in whom I opened in February last a psoas abscess,proved to be connected with diseased bone by the discharge,on one occasion, of an osseous spiculum. For months pastwe had persevered with the antiseptic dressing, although thedischarge did not amount to more than a drop or two ofserum in the twenty-four hours, well knowing by bitterexperience that so long as a sinus existed the occurrence ofdecomposition might produce the most disastrous con-

sequences ; and at length our patience has been crownedwith success.Hence I no longer feel any hesitation in recommending

the early opening of such abscesses, because, while theyremained unopened, the disease of the bone is necessarilyprogressive, whereas when opened antiseptically, there is

good ground to hope for their steady, though tedious,recovery.The putty of the strength above recommended, though it

generally fails to excoriate the skin, sometimes producesthis effect when long continued. In such case it may bereduced in strength so that the oil contains only one part tofive or six without disadvantage when the discharge is verysmall in amount.The application prevents the occurrence of cicatrisation in

the little sore caused by the incision, and perpetuates a

trifling discharge from it. Hence it is impossible to judgewhether or not the sinus has closed, except by examining itfrom time to time with a probe, which should be dipped inthe antiseptic oil, and passed in between folds of the anti-septic rag. This may seem a refinement, but if we couldsee with the naked eye a few only of the septic organismsthat people every cubic inch of the atmosphere of an hos-pital ward, we should rather wonder that the antiseptictreatment is ever successful than omit any precautions inconducting it.The putty used in treating abscesses has proved very

valuable in simplifying the treatment of compound fracture,and enlarging the range of its applicability, and also indealing with incised wounds on the antiseptic principle.But I must defer a notice of these matters to a futureoccasion.

Glasgow, July, 1867.

* See THE LANCET of March 23rd, p. 359

ROYAL COLLEGE OF PHYSICIANS OFLONDON.

Elcetion of President.AN extraordinary Comitia was held on March 25th, Sir

RICHARD DOUGLAS PowELL, Bart., K.C.V.O., the President,being in the chair.The PRESIDENT announced that the Sir Gilbert Blaine

medals had been awarded to Staff-Surgeon J. W. W. Stanton,R.N., and Surgeon Bernard Ley, R.N.The PRESIDENT then delivered the usual annual address, in

the course of which he offered congratulations to those Fellows,Members, and Licentiates of the College upon whom Royalhonours had been bestowed during the past year, and healso referred to the awards, medals, prizes, and scholarshipsconferred or awarded by the College. He next mentionedthe lectures which had been delivered before the College.The gifts presented to the College were likewise gratefullyacknowledged. The President laid stress on the servicesrendered by the Harveian librarian (Dr. J. F. Payne) inimproving and maintaining the library of the College inevery way. He then read short obituary notices of thoseFellows who had died during the year: Henry AugustusGoodrich, Sir Willoughby Francis Wade, John Henry Bryant,John Henry Bridges, John Cameron, Thomas Harris, GustaveIsidore Schorstein, Edmund Symes-Thompson, and ArthurErnest Sansom. The President then referred to the con-gresses held during the year to which the College hadsent delegates, and to the communications which hadtaken place with various departments of State. Thefinancial position of the College, separate and conjoint, wasthen reviewed. In conclusion, he expressed his thanks forthe kindly courteous consideration shown to him by theCollege during his year of office, and he thanked all theofficers, notably the Registrar (Dr. E. Liveing), for theassistance which they had given to him.

Dr. F. W. PAVY proposed a vote of thanks to SirRichard Douglas Powell for the address which he had justdelivered and for the services which he had rendered to theCollege during his year of office and added a request thatthe address might be printed.

Sir RICHARD DOUGLAS POWELL returned thanks to the

College and acceded to the request to have the addressprinted. He then vacated the chair.The REGISTRAR read the by-laws relating to the election

of President. The ballot then took place and Sir RichardDouglas Powell was re-elected by a very large majority asPresident for the ensuing year.The charge was delivered by the SENIOR CENSOR (Dr.

F. T. Roberts) who delivered to Sir Richard DouglasPowell the insignia of office and the PRESIDENT pledged hisfaith to the College.

Sir RICHARD DOUGLAS POWELL then thanked the Collegefor the honour accorded to him in so cordially re-electing himas President.The following communications were received : (1) From

the secretary of the Royal College of Surgeons of Englandreporting proceedings of its Council on March 14th ; and(2) from Mr. A. Forbes Sieveking requesting that he mighthave access to the records of the College in compiling abiography of his father, the late Sir E. H. Sieveking. The

request was granted.A report from the committee of management dated

March 4th was received and adopted. The committee recom-mended that the following institutions should be added tothe list of those recognised by the Examining Board in

England for instruction in chemistry, physics, and biology :Ley’s School, Cambridge, and Trent College, Long Eaton.The quarterly report of the examiners for the Licence on

the results of the January examinations was received andadopted.The PRESIDENT then dissolved the Comitia.

WEST CORNWALL MINERS’ AND AVOMEN’S HOS-PITAL.-On March 23rd Lady Clifden formally opened inthe presence of a large gathering a new operating theatrewhich has been added to the Miners’ Hospital at Redruth.The theatre, which is fitted up with all modern improve-ments, has been erected at a cost of R1460, the whole ofwhich sum has been subscribed.