THE PRESENT POSITION OF 
ANTISEPTIG SURGERY. 
By J. WILLIAM WHITE, M.D., 
Philadelphia, Pa. 
Reprint from Annals of Surgery, Jan.. 1891. THE PRESENT POSITION OF ANTISEPTIC 
SURGERY.1 
J. WILLIAM WHITE, M.D., 
PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA; SURGEON 
TO THE UNIVERSITY AND GERMAN HOSPITALS. 
FOR several years it has been my custom in my lectures 
at the University of Pennsylvania, to pass rapidly over 
the evidence in support of the antiseptic theory of wound treat- 
ment, with the remark that the time for argument had passed 
and that it was merely necessary now to present such facts as 
might serve to make clear the principles involved and to em- 
phasize the enormous benefit that has resulted from the appli- 
cation of those principles to practical surgery. It seemed to 
me that the theory of antisepsis rested upon a mass of corre- 
lated facts, experimental, clinical and bacteriological, sufficient 
to establish it on a firm foundation, and that the only debatable 
ground remaining was that relating to the selection of methods 
and the improvement of details. I considered that the prob- 
lem had been so scientifically stated and that its solution had 
been so thoroughly accomplished that, as regarded the general 
principles, no opposing views worthy of mention remained for 
discussion or refutation. 
I also thought that the whole history of the development and 
establishment of this great theory, while including the admir- 
able labors of hundreds of medical men in all parts of the world 
and constituting one of the brightest chapters in the record of 
human progress, yet centered around the figure of the English- 
speaking surgeon, whose name was identified with it from its 
JA reply to Mr. Tait's recent criticism of Sir Joseph Lister's Berlin Address. 
Read in the post-graduate course of the University of Toronto, December ig, 1890. 2 
J. W. WHITE. 
incipiency, in whose mind the grand conception first took 
practical and definite shape, and whose patient, unassuming, 
conscientious work in elevating his original thought into a 
working hypothesis and in transforming the latter into a 
theory of world-wide acceptance, seemed to me to present per- 
haps the best, and certainly the most important, example of 
the application of purely scientific methods to practical surgery 
to be found in the history of the profession. 
These, I say, have been my views, stated more and more 
dogmatically to successive classes as time went on, and with 
less and less thought of possible error or of contradiction from 
respectable surgical authorities. Of course there are always 
persons in every profession and in every community whose 
brain cells react to new thoughts and ideas as their grosser 
tissues to foreign bodies. A condition of irritation is set up 
followed by the expulsion of the intruder or by its encapsula- 
tion and virtual disappearance. Vaccination for variola has to- 
day its dozens of bitter opponents; for other infective diseases, 
its hundreds of skeptics; the theory of evolution which has 
revolutionized the natural science of this century is still vio- 
lently attacked; and although the laws of gravitation and of 
planetary motion are now quite generally admitted, we have in 
Virginia a colored clergyman who still proclaims his belief in 
the sun's motion. As regards the antiseptic theory we can 
usually afford to turn a deaf ear to this class of opponents, 
many of whom have about as much claim to speak with au- 
thority on surgical or scientific topics as the Reverend Mr. 
Jasper on astronomical subjects. 
When, however, a noted surgeon, a successful operator and 
a vigorous controversialist undertakes to traverse the whole 
line of thought and argument upon which my confident ac- 
ceptance of the theory was founded, denies its basal facts, 
ridicules its logic, jeers at its methods, challenges its records 
and abusively attacks its author and his supporters; and when 
I find such views, so expressed, published and republished in 
the most reputable medical journals of the day, with little or 
no editorial censure, it seems to me proper that those of us 
who are teachers should once more review the evidence, con- 
sider the situation and, according to our conclusions, publicly ANTISEP'1IC SURGERY. 
3 
re-affirm or renounce our faith in the theory and practice of 
antisepsis. 
On the 4th of last August I had the pleasure of hearing 
Sir Joseph Lister deliver before the International Medical 
Congress at Berlin, an address upon "The Present Position of 
Antiseptic Surgery." He evidently did not think it necessary 
in the presence of that vast audience, containing many of the 
most distinguished men in Europe and America, to defend or 
even to re-state his position as to antisepsis, but devoted his 
time to noting the new light which had been thrown on the 
behavior of wounds by the results on the one hand of Koch's 
discovery of the method of cultivating microbes upon solid 
media, and on the other of Metchnikoff's researches into the 
phagocytic action of the migratory or amoeboid cells of the hu- 
man body. According to Lister, Koch's work has rendered it 
possible to study with greater precision than ever before the 
habits and behavior of micro-organisms and he instanced the 
discovery of the cholera microbe as a notable example of the 
results of this method. Detailing some of Metchnikoff's ex- 
periments to prove the antibacteric action of normal leucocytes, 
he called attention to the explanation it offered of much that 
was hitherto mysterious in the relation of micro-organisms to 
wounds, the healing, for instance, of wounds like that made in 
the operation for hare-lip, the posterior edge of which is per- 
petually bathed in saliva containing septic bacteria. The de- 
struction of these microbes by the leucocytes which people the 
lymph at the edge of the wound satisfactorily explains the 
rapid healing which we uniformly obtain after this operation. 
So, too, he thought that in cases where fine silk ligatures are 
used unpurified and left in closed wounds the phagocytic ac- 
tion of the normal tissues may destroy the microbes that have 
gained access to the interstices of the thread and prevent their 
fermentation or putrefactive action on the discharges. 
He then considered the question of drainage and of irriga- 
tion, pointing out the possibility of dispensing with both in 
many wounds, and suggesting that in the new light thrown 
upon the ability of normal tissues to protect themselves, con- 
tamination from atmospheric organisms may perhaps also be 
disregarded, provided no septic matter be otherwise introduced 4 
J. W. WHITE. 
into wounds. In support of this he noted the fact that it had 
been found that the free entrance of air containing microbes 
into the pleural cavity in cases of empyema had produced no 
harmful results in the days when the spray was irrationally de- 
pended upon to sterilize such air, and instanced the transfor- 
mation of the purulent contents of the pleural cavity into a 
rapidly diminishing serous effusion, the closure of the external 
opening, the resumption of the normal functions of the pleura, 
the expansion of the contracted lung through atmospheric 
pressure,2 etc., as a beautiful example of the reparative processes 
of nature when uninterfered with by mischievous agents from 
extrinsic sources. The contrasting course of those cases in 
which in pre-antiseptic days the discharges escaping from the 
wound became infected and underwent putrefactive fermenta- 
tion, is familiar to most of you. 
He then emphasized the need for antiseptic rather than 
aseptic dressings in cases where large discharge is unavoidable 
and concluded with a reference to the double-cyanide dressing 
which he has been using for eighteen months. 
This address seemed to me as I listened to it to be another 
2This statement Mr. Tait critisises (if it can be called criticism) most violently, 
calling on the "shades of Newton and Toricelli" in mock dismay at the disregard 
of physical laws which he thinks it manifests. He misquotes Lister who spoke of 
the closure of "the external opening." This Tait transforms into "closure of the 
affected cavity" and then says that "given a membrane to which the atmosphere 
has free access on both sides, on both of these sides the pressure of the atmosphere 
will be exactly the same"-a self-evident proposition but one which has nothing to 
do with ihe condition of the lung and pleura after the chest wall has become imper- 
vious. He says, also, that when the closure of the pleural cavity is completed "the 
natural dimensions of the affected lung are always remarkably diminished." In 
contradiction of his whole position in this matter I would refer to the following au- 
thorities: West, on Pneumothorax [The Lancet, 1887, vol. 2, p. 353); Williams 
on the use of a Valvular Tube in Empyema [British Medical Journal, May 18 
1889); Reynolds, on Pneumothorax Consecutive to Emphysema [Manchester Medi- 
cal Chronicle, October, 1889); Douglass Powell, on Variations in Intra-ihoracic 
Pressure [Transactions of International Medical Congress, 1^1, vol. 2); Don- 
aldson, on Diseases of the Pleura, [American 8'ystem of Medicine, vol. 3 pp. 522, 
559). The latter author says: "The dilatation of the lung is produced by the disap- 
pearance of the intra-pleural pressure and the pressure in the opposite direction, 
from the bronchial surface." The whole question is, of course, a distinct digression 
but is used by Tait in justification of his assertion that Lister "possesses crude 
notions of logical definition."! ANTISEPTIC SURGERY. 
5 
striking example of Lister's remarkable willingness to receive 
and profit by all new discoveries and all genuine advances 
bearing upon the antiseptic theory. So far as I know he has 
never remained silent in the face of satisfactory demonstration 
that any portion of his method was unnecessary or illogical. 
As he gave up the spray when it became evident that it was 
not accomplishing its work, as he has from time to time dis- 
carded various antiseptics in the search for the ideal one com- 
bining permanency and certainty of action with absence of 
irritating qualities, so he now is willing to minimize the dan- 
gers of atmospheric contamination and to discard washing, ir 
rigation, and even drainage in appropriate cases although for 
years he has been conscientiously emphasizing their import- 
ance. Surely this is the true scientific spirit, as rare as it is 
admirable, and an additional evidence of the single-mindedness 
and absolute fairness of this great investigator. 
On the 27th of last September there appeared in The British 
Medical Journal an article by Mr. Lawson Tait, consisting of 
an address delivered a short time previously and entitled "The 
Present Aspect of Antiseptic Surgery; A Criticism of Sir 
Joseph Lister's Address at the International Congress.'' 
Of the tone, taste and temper of this essay I shall have but 
little to say. It would be difficult to characterize it properly 
and preserve the dignity and decorum which should belong to 
scientific discussion, but which are so conspicuously absent in 
Mr. Tait's paper. So far, however, as concerns our present 
purpose it may be considered from two standpoints: I. As it 
denies the truth of the principles underlying the practice of 
antisepsis, and advances an alternative theory applicable to the 
treatment of wounds. 2. As it attacks the prevailing anti- 
septic methods. 
1. The Principles Involved. Mr. Tait drawsan elaborate 
comparison between the phlogiston theory of Stahl and the 
antiseptic theory, asserting, to use his own words, that we have 
a perfect parallel to the former in "the septic theory of inflam- 
mation and fever which is the favorite hobby-horse of our own 
day.'' He adds "everything at present has a septic origin and 
a septic inception, yet I venture to say that before the 
present generation has run out the word antiseptic will be 6 
J. W. WHITE. 
all that is left to represent the strange structure, just as anti- 
phlogistic was the only word left to represent the phlogistic 
theory in the middle of the present century." He continues 
by asserting a want of logic in the use of the term "theory" at 
all, saying that "instead of the septic or antiseptic fact, Lister 
and his still more illogical disciples talk of the septic or anti- 
septic theory, whereas there is no theory about it at all, but an 
absolute and ludicrous logical error." He then opens his ar- 
gument by denying that the cholera bacillus has been definitely 
isolated or that it can be cultivated with certainty and precision; 
and says that even if it has and if it is potent for production or 
reproduction, the fact that if a thousand people drink the same 
germ-infected water only a hundred or so will be affected, and 
that the majority of these will recover, shows that the facts 
about germs in the human body do not coincide with the facts 
of the germs in the gelatine flasks and that, therefore, they 
cannot stand as the basis of a working hypothesis, far less of a 
theory. 
It is difficult to follow the vagaries of this extraordinary 
paper, but if all this means anything whatever it means that, 
taking the cholera bacillus as a type, all deductions based upon 
bacteriological investigation are denied because the growth and 
reproduction of micro-organisms in the body are so influenced 
and altered by physiological and vital processes as to run a 
course somewhat different from that which they take in flasks 
or test-tubes. For the same general reason and because it 
will not immediately explain the differences among the clinical 
courses of various infective diseases Mr. Tait rejects the 
phagocyte theory, apparently assuming that if it is true there 
should be a uniform destruction of bacilli of all varieties. One 
might as well deny the essential element of conception, the 
fusion of the ovum and sperm cell-possibly an instance of 
phagocytosis-because of the variations in the resulting animal. 
This position is, however, in harmony with his denial of the value 
of vivisection for similar reasons, and illustrates the working of a 
mind which he is pleased to consider "logical." The assump- 
tion that this is what he is clumsily attempting to say is also 
justified by several other paragraphs which will serve at once 
to display his real ignorance of the teachings of Lister and to ANTISEPTIC SURGERY. 
7 
illustrate the character of his address. He says "If the en- 
trance of germs into a wound was the immediate and real cause 
of suppuration and of consequent poisoning the device of the 
spray was the most completely logical appliance that could 
have occurred to the mind of man." "Even if the phagocytes 
are the means by which the tissues resist the omnipotent and 
ever-present germs it is the phagocytes and their conditions 
which must constitute the really important elements of the 
question; keep your phagocytes up to the mark and you need 
never bother about germs." "With the Listerian one germ is 
as good as a thousand." "If it would gratify the phagocytes 
in any way I would stuff the abdomen like pudding with the 
germs or bacilli of decomposition provided there was nothing 
present for them to feed upon." He finally sums up his position 
in the two following paragraphs-Lister's view was "Keep out 
the germs and you may leave blood-clot (and other matters) to 
take care of themselves." My view was and is, "Get out all de- 
composable matter and you can let the germs in freely." "There 
are two factors in the trouble and it can be shown conclusively 
that one, the germs, are wholly inconsiderable without 
pabulum on which to feed; whilst the other, the pabulum is 
sure to breed trouble because it is practically and mechanically 
impossible to keep the germs out; they exist already in the 
blood and elsewhere, and are ever present according to the 
best authorities.7' 
This amount of quotation I was reluctantly compelled to 
make to elucidate his views but we may now ask "what are the 
facts in the case?" 
The evidence necessary to prove the definite etiological rela- 
tion of a particular micro-organism to a specific disease in man 
is as follows: The organism must be unmistakeably recogniz- 
able at different periods of its growth; it must be isolable; it 
must be capable of cultivation alone and free from association 
with other organisms; it must be invariably associated with the 
disease in question; it must be capable by inoculation of pro- 
ducing that disease; it must retain this power through an indef- 
inite series of cultures. If these conditions were fulfilled in 
but a single instance it would be sufficient to demonstrate the 
folly of the general attack on all germ theories contained in 8 
j. w. WHITE. 
Tait's paper,-but at least five well-known examples may be 
mentioned of indisputable relation of cause and effect between 
specific pathogenic microbesand infective disease. Since 1879 
when Koch first demonstrated the connection between definite 
micro-organisms and various wound diseases the evidence has 
steadily accumulated. Ogston in 1881, Rosenbach and Cheyne 
in 1884, Passet in 1885, Zuckermann in 1887, have shown that 
the various staphylococci have as distinct a causative relation 
to acute suppuration as has the yeast plant to the alcoholic 
fermentation. They can be found in and cultivated from the 
pus in every recent abscess; they invariably produce suppura- 
tion when pure cultures are injected, even to the twentieth 
generation. Their effect may or may not be aided by the 
ptomaines which they produce, but as the amount of pto- 
maines is directly proportionate to the number of microbes pres- 
ent and as the ptomaines are never produced at all in the absence 
of the microbes the question as to the relative importance of 
the two has, as Senn long ago said, but little interest for the 
practical surgeon, and can have none at all for the "purely un- 
scientific person'' that Mr. Tait with truthfulness represents 
himself to be. 
Another example is to be found in malignant pustule, the 
specific cause of which, the bacillus anthracis, is readily cul- 
tivated in different media and produces the disease when in- 
oculated in the smallest possible quantity. 
Fehleisen in 1883 showed that erysipelas depended upon a 
streptococcus, inoculation of which when quite pure produced 
the disease in six out of seven cases, the exception occurring 
in a person who had recently had an attack of erysipelas and 
was scarcely more than convalescent. 
Acute osteo-myelitis has until recently been thought to be 
due to the ordinary microbes of suppuration, but the researches 
of Becker and Krause (1883) and others have made it probable 
that a specific micrococcus is the essential element of the 
disease. 
Tubercle furnishes the last of our examples of microbic dis- 
ease and we have just learned that to Koch, who in 1882 dis- 
covered the tubercle bacillus, we possibly owe the equally 
brilliant and infinitely more important discovery of its antidote. ANTISEPTIC SURGERY. 
9 
In the face of this collection of facts, of such transcendent 
importance to surgery and to the world at large, we can afford to 
pass by without further mention the bacilli of tetanus, typhoid 
fever, and glanders, the micrococci of lobar pneumonia and of 
gonorrhoea, and the microbes of cholera and of gangrene, al- 
though it is quite clear to all persons capable of weighing 
scientific evidence that it is a question of time only, when our 
knowledge of these microbes shall be as definite as of those I 
have enumerated. 
In the face of this evidence we may assume that Tait's gen- 
eral and contemptuous rejection stall surgical theories depend- 
ent upon our knowledge of germs is not warranted by the 
facts in so far as suppuration, erysipelas, tubercle, anthrax, and 
osteo-myelitis are concerned, and therefore that there is no 
a priori ground for rejecting every theory involving a belief in 
the potency for mischief of micro-organisms. 
It is more directly to the point, however, to inquire into the 
evidence in favor of the germ theory of septic wound disease, 
and here we must briefly consider some very elementary ques- 
tions. Mr. Tait takes great pains in one portion of his paper 
to emphasize the fact that "such bacilli as cause decomposition 
and such as have specific properties split out from dead organic 
matter some horrid things," i.e. in other words that they act as 
ferments causing that form of fermentation which we know as 
putrefaction. Mr. Tait is as usual inaccurate in his statement 
-as the micrococcus erysipelatosus, for example, which is un- 
doubtedly a microbe with specific properties, does not cause 
any putrid change; but he would have been correct in asserting 
that all organisms produce changes in the materials in which 
they grow, which means that they all cause some kind of fer- 
mentation. 
The antiseptic treatment of wounds might under Mr. Tait's 
ruling be described as a treatment directed against the causes of 
putrefaction in wounds, but a more accurate definition expands 
it, as Mr. Cheyne has suggested, so as to include treatment 
directed against the cause not merely of the putrefactive fer- 
mentation but of all fermentations. Accepting this very 
liberal definition our scientific evidence leads us to the adop- 
tion of the antiseptic theory by the following steps, each of 10 
J. W. WHITE. 
which is as demonstrable as the single rule of three or the 
pons asinorum. 
Fermentation (whether putrefactive or otherwise) in organic 
substances, such as blood clot or serum or pus, or the dis- 
charges from wounds, depends upon the access to these sub- 
stances of micro-organisms. The proofs of this fact are two- 
fold. Experimentally it is shown by the certainty with which 
easily decomposable substances like blood, urine, or beef tea 
may be kept indefinitely sweet by simply protecting them 
from germ contamination. Clinically it forms the basis of all 
subcutaneous surgery; explains the difference between simple 
and compound fractures and, taken in conjunction with another 
fact,-viz., that the fluids and tissues of the healthy living body 
are practically sterile, it also explains the difference between 
the behavior of a case of arterial occlusion affecting a portion 
of the surface of the body and producing gangrene or slough- 
ing, and a case of similar occlusion affecting an internal organ 
and producing atrophy and retrograde metamorphosis. 
The last fact I mentioned-the sterility of the blood and 
tissues-is denied by Mr. Tait, who says "the germs exist al- 
ready in the blood and elsewhere, and are everpresent, accord- 
ing to the best authorites." The elaborate and carefully con- 
ducted experiments of Hauser,3 Watson Cheyne4 and others 
completely contradict this statement, which is really the founda- 
tion of Mr. Tait's argument. As we have seen, the evidence that 
germs cause fermentation is undeniable and it is equally true 
that germs can be excluded from wounds by antiseptic precau- 
tions or can with less certainty be destroyed after they have 
gained access. This statement rests on the one hand upon 
microscopical evidence (microbes being demonstrably absent 
from the discharges of properly sterilized wounds and as con- 
stantly present in suppurating or sloughing wounds); and on 
the other hand upon a mass of clinical testimony familiar to 
every member of the profession. A portion of this testimony, 
in spite of its triteness, it is necessary to recapitulate in order 
to complete the argument: The germ theory of fermentation 
3Archiv. f. Experiment, Pathologic and Pharmacol., bd. 20 p. 162. 
4British Med. Jour., March 3, 10, 1888. ANTISEPTIC SURGERY. 
11 
is undisputed; fermentation in wounds can therefore be pre- 
vented by the exclusion of germs; it has been shown microscop- 
ically that these can be kept out (asepsis) or can be destroyed 
(antisepsis); practically therefore it only remains to show the 
effect upon patients with operative or other wounds of exclud- 
ing or destroying germs to show the value or lack of value of 
antisepsis and the antiseptic theory. By looking back a few 
years to the very beginning of the employment of antiseptics 
we can obtain the most striking and comvincing evidence of 
the effect of treatment directed almost exclusively, though then 
very imperfectly, against the introduction of bacteria. 
The record of the work of Prof. Lister may well begin 
our series of examples: In Glasgow, in 1864, 1865, and 1866, 
Mr. Lister's mortality in a series of operations of all sorts was 
45.7%, largely from septic diseases. About this time he be- 
began to employ, gradually, some antiseptic methods in his 
treatment of wounds and during operations. In 1867, 1868 and 
1869, his mortality fell to 15%. At Edinburgh, having greatly 
improved the details ofhis system, we find that from 1871 to 
1877 he treated 553 grave surgical cases with a mortality from 
septic disease of only .36%, a diminution in the death-rate 
which, when we remember that these different results were ob- 
tained by the same man operating upon the same class of pa- 
tients and for the same injuries or diseases, is so striking as 
to be in itself conclusive. Still later, an opportunity was af- 
forded to compare Mr. Lister's results with those of a col- 
league, Mr. Spence, working in the same hospital, but declin- 
ing to employ antiseptic methods. The total results of their 
major operations showed that Mr. Spence lost just about three 
patients where Mr. Lister lost one, while the deaths from in- 
fective diseases were 2.4% among Spence's cases and one-third 
of 1 % or 8 times less among those of Mr. Lister. When we 
turn to the work of other surgeons we find evidence, if possible, 
still more conclusive of the value of these methods. Nuss- 
baum has shown that during forty years in his clinic under his 
own direction as well as that of his predecessors, among whom 
was Stromeyer, the deaths from wound diseases were so com- 
mon that patients with even the slightest injuries often suc- 
cumbed to them; that erysioelas and abscesses were matters of 12 
J. W. WHITE. 
daily occurrence; that 80% of all wounds and sores were at- 
tacked with hospital gangrene, and that nearly all patients 
with compound fractures died; and he states that immediately 
upon the introduction of the antiseptic system, all these dis- 
eases vanished; and healing by first intention, previously almost 
unheard of in his service, became th'e rule instead of the ex- 
ception. Prof. Volkmann, in an address before the Inter- 
national Medical Congress which met in London in 1881, testi- 
fied strongly and clearly to the results obtained in his own 
practice, selecting two subjects especially, compound fractures 
and major amputations, as evidence of the value in his hands 
of the antiseptic method. He said that the mortality after 
compound fracture had, during the long labors of the sur- 
geons who preceded him as well as during his own, reached the 
sad height of 40%. Immediately before he adopted the anti- 
septic method of treating wounds, his last twelve patients with 
compound fracture had all died of pyaemia or septicaemia. 
From that time up to the period at which he delivered this 
address he had treated 135 compound fractures without losing 
a single patient from either of these wound diseases; 133 were 
cured; 2 died, one of fatty embolism of the lungs during the 
first few hours, and one, a drunkard, of delirium tremens. As 
to the amputations, he asserted that he now cured each year 
with the antiseptic method more cases of amputation of the 
thigh, for example, than during all the rest of his labors 
before the introduction of the method. In an article on the 
treatment of compound fractures, Prof. Dennis, of New 
York, has compiled further evidence in this same direction. In 
the Pennsylvania Hospital, between the years 1839 and 1851, 
there were treated 116 cases of compound fracture of the leg 
and thigh; excluding those cases requiring amputation there 
were 51 deaths, a mortality of 45%. In the New York Hospi- 
tal, during the same period, there were treated 126 cases of 
compound fracture of the leg and thigh; excluding amputations 
there were 61 deaths, a mortality of 48%. From i860 to 1876 
there were reported from the surgical clinics of Vienna and 
Zurich by Billroth, 180 cases of compound fractures; excluding 
amputations there was a mortality of 41 % from septic disease. 
In the Obuchow Hospital Reports of St. Petersburgh 106 ANTISEP TIC S UR GER Y. 
13 
cases of compound fracture gave a mortality of 68%. In Guy's 
Hospital, from 1841 to 1861, there were reported 208 cases of 
compound fracture with 50 deaths, a mortality of 26%. After 
the introduction of antisepsis this death-rate immediately fell to 
4% from an average of 40 to 50%, and in this article of Dr. 
Dennis, in which he reports 516 cases of compound fractures, 
there was no record of death from septic trouble in any frac- 
ture of the extremities, which was the class of injuries included 
in the above statements. I might easily multiply such evi- 
dence as this a thousand-fold, but it seems unnecessary to re- 
peat what has long been so familiar. And yet it is upon this 
evidence, which I have endeavored to condense, that the anti- 
septic theory rests. The facts and figures could easily be re- 
placed by newer statistical matter but I have selected these 
for the very reason that they show better than more recent ex- 
periences the wonderful changes wrought solely by the employ- 
ment of antiseptics under circumstances otherwise unaltered- 
drainage having been previously used, the amount of "pabu- 
lum" in the wounds remaining the same, the operators and 
surroundings being just as in the days of gangrene and pyaemia. 
Mr. Tait endeavors to break the chain of reasoning by saying, 
1., that the germs are everywhere and cannot be got rid of- 
a misstatement-and 2., that the presence or absence of sepsis 
depends on the presence or absence of "pabulum" i. e., dead 
organic matter, blood clot, serum, etc. It has been one of the 
axioms of antiseptic surgery from the beginning that scrupu- 
lous attention should be paid to haemostasis and to drainage. 
No one has taught this more earnestly than Lister and his fol- 
lowers, and Tait's adoption of it as his "view" is evidence of 
his ignorance of the work of others. To be sure he says that 
Koeberle first taught him drainage in 1875, and gives due and 
deserved credit to Chassaignac for his work in this direction, 
but English and American surgeons have employed drainage 
fully and carefully since the early part of this century and 
Syme (afterwards Lister's father-in-law) in 1826, made the 
importance of providing a free escape for the discharges from 
wounds the subject of one of his most important papers. 
It is easy to say that if you have nothing to decompose there 
will be no decomposition, for that is what it amounts to. 14 
J. W. WHITE. 
"Get out all decomposable matter" he says, "and you can let 
the germs in freely," but in practical surgery this is by no 
means always possible. It is really to be regretted that Mr. 
Tait has not had an opportunity to see some general surgery, 
and particularly to follow Lister's practice at King's 
College Hospital- I am curious to know how he 
would interpret a case which I saw there in 1888 
and described as follows, in a letter to The Medical 
News'. It was a case of operation upon a fractured patella 
with elongation of the quadriceps by Cameron's method, in 
which there had been muscular spasm followed by extensive 
oozing from the cut surfaces. "A large clot formed, produc- 
ing considerable tension, necessitating the removal of the 
stitches, and causing at two points a slight separation of the 
edges of the wound. I watched this for ten days, and instead 
of the flush, the suppuration, the elevation of temperature and 
the alarming symptoms which would usually follow such 
haemorrhage into and about a great joint, the patient and the 
limb both remained perfectly passive, with absolutely no sign 
of either local or constitutional irritation, while the clot itself 
gradually contracted and the knee resumed its normal outline. 
During all this time there was literally not one drop of pus and 
not a trace of offensive odor. A severer test of Prof. 
Lister's antiseptic methods could hardly be devised or 
imagined." 
There was no lack of "pabulum" here, but it gave rise to no 
evil effects, while on the other hand I am sure that there is not 
a practical surgeon in the world to-day, no matter how 
"humble" or "unscientific," who doesn't know what the result 
would have been if the germs had been "let in freely." The 
numerous successful cases of Schede's method of utilizing 
blood-clot in the filling of bone cavities are similar arguments 
and of a most convincing kind. 
Ignorance of general surgery and highly specialized ex- 
perience offer the only explanation of such astounding state- 
ments. 
Mr. Tait deals habitually with a membrane, the peritoneum, 
which has a remarkable power of self-protection. Microbes 
gaining access to the abdominal cavity are exposed to de- ANTISEPTIC SURGERY. 
15 
struction either by the serum which it copiously exudes, or by 
a possible phagocytic action of its enormous numbers of endo- 
thelial cells, or by both. I have thought, too, that possibly the 
extraordinary cases of cure of peritoneal tuberculosis after 
simple laparotomy and flushing of the abdominal cavity were 
due to the stimulation of the membrane (through removal of 
pressure or through contact with the irrigating fluid) to greater 
exudation and of its cells to greater anti-bacteric activity. It 
is merely a supposition, but seems as reasonable as any of the 
explanations I have heard offered. At any rate these prop- 
erties are well known, and if one could anywhere in the body 
depend on the restriction of the amount of "pabulum" rather 
than on the exclusion of the germs it would be here. 
Mr. Tait, after contemptuously discarding all surgical theo- 
ries, including that of antisepsis ventures upon one of his own. 
He thinks the phenomena of sepsis due to the "dose" of dead 
tissue or "pabulum," and of the poison resulting from its de- 
composition and with a momentary forgetfulness of his "hu- 
mility" he actually advances this as an original "working hy- 
pothesis." It would sound very much to the general surgeon 
as if Mr. Tait had never heard of sapraemia, which is described 
by a "Listerian"5 as follows: "Sapraemia or putrid intoxica- 
tion represents that form of septicaemia in which a preformed 
toxic agent is injected into the circulation and in which the 
maximum symptoms are reached as soon as the poison has 
become mixed with the blood. This form of sepsis may be 
caused by any microbe, otherwise harmless, or with only slight 
pathogenic properties, as the bacillus of putrefaction, which 
causes putrefaction in any dead tissue as, for instance, a blood 
clot or contused tissue; and the symptoms arise as the pto- 
maines are absorbed, and are appropriate to the amount ab- 
sorbed, and subside with the cessation of absorption and their 
elimination through some of the excretory organs." 
Mr. Tait's remarks against dosage are further evidences of 
his ignorance of Listerian work and teachings. He says: 
"With the Listerians one germ is as good as a thousand." I 
suppose it is safe to class Mr. Watson Cheyne, whom I have 
5W. Cheyne. 16 
J. IV. WHITE. 
just quoted, as a "Listerian." Indeed, he has for years been 
Lister's assistant and authorized mouth piece. In Mr. 
Cheyne's lectures on "Suppuration and Septic Diseases"6 he 
not only asserted but proved experimentally that the number 
of bacteria introduced modified greatly the intensity of the 
symptoms and even the character of the disease. He ex- 
perimented with cultivations of Hauser's proteus vulgaris, 
finding that one-tenth of a cubic centimetre caused immediate 
death; one-fortieth of a cubic centimetre caused death in six 
to eight weeks; smaller doses produced no effect. Similar 
observations have been made by Passet,7 Pawlousky8 and others 
and are as well known as any in connection with antiseptic 
surgery. 
It is evident that what is original in Mr. Tait's "hypothesis" 
is not true and that what is true in it is not original. 
2. The Prevailing Antiseptic Methods.-It seems ap- 
parent at any rate that, to put it mildly, Mr. Tait is not a safe 
or reliable authority on the general subject of surgical anti- 
sepsis, but towards the end of his paper he ventures on a 
specific fling at Lister's last surgical dressing. After asserting 
that "Listerism" is "as dead as Julius Caesar," he adds: "The 
mischief probably is not at an end, for we hear that the last 
phase of this astonishing craze is that wounds are to be dressed 
with still a new contrivance, one as deadly and dangerous as 
anything that can well be imagined-a double cyanide." I 
am especially interested in replying to this statement for the 
reason that, owing to the kindness of Sir Joseph Lister (who 
during the summer of 1889 gave me confidentially the various 
formulae which he was using and supplied me with the ma- 
terials from his own manufacturers of gauze and chemicals), I 
was the first surgeon in this country to employ the dressing 
in question and because I now have a series of cases in which 
it has been used, large enough to justify publication. The 
history of the steps which led up to the employment of this 
6Brit. Med. Jour., March, 1888. 
'Monatshefte f. Prakt, Dermatol., B. 6, No. 10. 1887. 
8Centralblatt f. Chirurgie, No. 48, 1887. A N TISEP TIC S UR GER K 
17 
material must be briefly mentioned both to explain its selec- 
tion and in reply to the charge of "perpetual shifting." 
The aim of the surgeon after every operative wound is, of 
course, to secure union by first intention. Any persistent 
irritation is a source of trouble in wounds, and the different 
antiseptics which have been employed have not been free 
from the charge of contributing to the occurrence of excessive 
inflammation by their own irritant action. The typical anti- 
septic must, therefore, be as nearly a*s possible devoid of irri- 
tating properties. It must be germicidal-that is, it must 
possess the power of destroying the micro-organisms. It must 
have an inhibitory power-that is, it must prevent the de- 
velopment of such organisms. It must be stable-that is, it 
must not disappear from the dressings after they are made, or 
after they are applied to the wound either by solution in the 
discharges or by volatilization. 
In the old Listerian method carbolic acid was the antiseptic 
employed; but this had the disadvantage of volatility as well 
as great slowness of action as a germicide. Corrosive subli- 
mate, which succeeded it, was stable and acted rapidly, but 
was exceedingly irritating, and, in addition, was precipitated 
by the albumen contained in the serum of the blood. This 
precipitate, it was discovered by Sir Joseph Lister, possessed 
powerful antiseptic properties, with much less power of pro- 
ducing irritation; and he, therefore, devised a form of anti- 
septic dressing called "the sero-sublimate gauze," which con- 
sisted of gauze charged with a solution of corrosive sublimate 
in the serum of the blood. This, however, was difficult to 
manufacture, and produced a harsh and non-absorbent ma- 
terial which was mechanically objectionable. It was suc- 
ceeded, in his hands, by a combination of chloride of ammonium 
and bichloride of mercury, known as sal-alembroth, which, 
while much less irritating, was so exceedingly soluble in the 
blood serum that whenever the discharges from the wounds 
were copious it was washed out of the dressing, leaving them 
without antiseptic property. For these reasons Lister in time 
discarded this material and employed for a considerable period 
a gauze containing 3 or 4%, by weight, of the biniodide of 
mercury. This was less soluble, non-volatile, powerfully an- 18 
J. W. WHITE. 
tiseptic, but, again, extremely irritating, so that the least con- 
tact with the skin produced an intense erythema, even going 
on to vesication. 
Lister was then led to look further for the ideal antiseptic 
and finally to employ the double or mixed cyanide of mercury 
and zinc, which he is now using. Its most evident advantages 
are, first, that it is non-volatile; next, that it is almost entirely 
unirritating; thirdly, that it is insoluble in water and only 
soluble in 3000 parts of blood serum, and, finally, that, while it 
possesses but little germicidal value, its inhibiting power is so 
high that a 1-1200 solution is sufficient to keep animal fluids 
permanently free from putrefaction. This combination of 
qualities is possessed by no other of the antiseptics which 
have been mentioned, and its deficiency in germicidal power 
is easily remedied by including in the manufacture of the 
gauze dressings which are impregnated with this material a 
small percentage (1 in 4000) of sublimate, enough to be germi- 
cidal, but too weak to be markedly irritating. As I have said, 
I was told the details of this method confidentially in the 
summer of 1889. The communication was confidential be- 
cause, while Lister was experimenting with other dressings, 
notably the sal-alembroth, the announcement had been made 
by others that he was using them and they were extensively 
employed at a time when he was quite unprepared for pub- 
lication upon the subject. Until November, 1889, therefore 
I employed the double cyanide only in my private work, but 
since that date, when Lister published his own conclusions on 
the subject, have used it after nearly all my operations at 
the University Hospital. I present herewith in tabulated form 
the results of the most important of these operations, ex- 
clusive of dozens of minor cases which, while as a matter of 
fact they often test severely the efficacy of any surgical dress- 
ing, might be expected to get well under almost any form of 
treatment. 
I have grouped the cases roughly and have avoided un- 
necessary detail for the sake of economy of space, the main 
object in publishing them now being to establish the effi- 
ciency of the double cyanide dressing and its freedom from 
dangerous qualities. ANTISEPTIC SURGERY. 
19 
TABLE OF SURGICAL CASES TREATED SINCE BEGINNING THE USE OF THE 
DOUBLE CYANIDE GAUZE. - September, 1889 to December, 1890. 
1* 
Operations. 
Memoranda. 
Results. 
f Cases. 
I 
2 
'3 
Removal of cervi- 
cal glands for 
tuberculous 
adenitis. 
Trephining of cra- 
nium. 
Wounds varied in length from two 
to six inches; in five cases, the 
dissection was most extensive, 
being carried along the oesopha- 
geal line; in four caseation and 
suppuration already existed. 
Except in the suppurating cases, 
union by first intention along the 
whole length of the wound. Drain- 
age tube usually employed, but 
withdrawn during first two or three 
days. Fever rarely ioo° after 
second day. No deaths. 
3 
For compound 
fracture. 
Wounds already infected by vul- 
nerating body and by dirty fin- 
gers; careful sterilization by 1:500 
sublimate. 
Union of scalp wounds by first in- 
tention, no pus, no fever, no 
deaths. 
3 
4 
For epilepsy. 
Abdominal sec 
tion. 
In every case operation performed 
on account of history of trauma- 
tism. 
In three cases union by first inten- 
tion; one death from suppression 
of urine and uraemia in an old 
alcoholic. 
8 
For removal of 
uterine appen- 
dages. 
In every case 1:10000 bichloride so- 
lution was used for hands and 
sponges and when required for 
irrigation. Tube used in three 
cases. 
Union by first intention except in 
two of the tube cases in which 
stitch abscess occurred; no deaths. 
4 
For intestinal ob- 
struction. 
In two cases there was general pu- 
rulent peritonitis and great dis- 
tention. The obstruction in all 
four cases was from bands. 
In two union by first intention and 
recovery; in the others death with- 
in first 24 hours. 
4 
For peri-typhlitic 
abscess. 
In two removal of vermiform appen- 
dix; in two evacuation of abscess 
and use of drainage tube. 
One death in 24 hours, probably 
from ignorance of nurse, who 
neglected the drainage tube. In 
others rapid recovery without 
fever or other alarming symp- 
toms. 
4 
I 
For removal of 
tumors of ab- 
dominal wall & 
cure of ventral 
hernia. 
Hypogastric sec- 
tion and cystot- 
omy. 
Operation very tedious and pro- 
longed involving much handling 
of tissues. Wound brought to- 
gether by sutures en etages. Pa- 
tient old and infirm. 
Extensive "aseptic suppuration," 
i e., without fever, pain or other 
symptoms thought to b® due 
to traumatism to the thick layer 
of subcutaneous fat. Recovery 
with good, firm cicatrix. 
I 
For exploration. 
No satisfactory explanation found 
for violent and persistent vesical 
symptoms, which had lasted for 
29 years. 
Rapid healing, no suppuration. 
4 
For removal of 
calculus. 
Three stones weighing over two 
ounces. One small oxalate cal- 
culus. 
All recovered without suppuration. 20 
J. W. WHITE. 
TABLE.-Continued. 
Group. 
\No. of Cases. 
Operations. 
Memoranda. 
Results. 
4 
i 
For prostatec- 
tomy. 
Very extensive operation, removal 
of large portions of the prostate. 
Death on eighth day from uraemia 
and suppression of urine. Kid- 
neys almost completely disorgan- 
ized. 
For exploration 
and drainage. 
An enormous prostate with absolute 
retention. Patient old and fee- 
ble. 
Lived a year in comparative com- 
fort. 
S 
2 
Excision of vari- 
cose long saph- 
enous vein. 
Veins extremely long and tortuous. 
Patient disabled Incisions 18 and 
>914 inches in length. 
Rapid union. No suppuration. 
6 
14 
Excision of breast 
with removal of 
axillary glands. 
In all complete removal of breast, 
opening of axilla and removal of 
axillary glands 
Not a single suppurative case. 
Average time of healing and dis- 
charge from hospital n _ days. 
Average number of full antiseptic 
dressings, three. 
7 
3 
Arthrectomy o f 
knee. 
In all of them most extensive re- 
moval of synovial membrane liga- 
ments, cartilages and osseous foci 
of disease. All tubercular. 
In all rapid primary union of skin 
wound. lu two persistent suppu- 
ration in track of drainage tube, 
but final healing. In one at this 
date (eight months after opera- 
tion) re-opening of sinus. In oth- 
ers apparentcure. 
8 
I 
Removal of for- 
eign body from 
knee-joint. 
A portion of a needle found partly 
within, partly without synovial 
cavity. 
Primary union under first dressing. 
9 
3 
Removal of su- 
perior maxilla. 
All three cases of malignant tumors. 
Primary union of skin incision; all 
recovered from the operation. 
IO 
I 
Removal of both 
superior maxillae 
with a portion 
of the malar 
bone. 
For osteoma of both maxillae. 
Primary union of skin. Entire re- 
covery from the operation. 
II 
2 
Removal of a por- 
tion of the in- 
ferior maxilla. 
For osteo-sarcoma. 
Primary union of skin. Prompt re- 
covery. 
12 
2 
Excision of elbow. 
For tuberculous 
arthritis. 
Patient had already undergone sev- 
eral operations upon other joints. 
Union by first intention under two 
dressings except in track of drain- 
age tube. Entire union in three 
weeks. All movements of elbow 
preserved. 
For bony anky- 
losis. 
The anchylosis was the result of an 
old fracture; the arm was extended 
and useless. 
Primary union throughout whole 
wound under two dressings; func- 
tioanl result excellent. ANTISEPTIC SURGERY. 
21 
1 
|No. of Cases. 
Operations. 
Memoranda. 
Results. 
13 
Amputations. 
8 
Finger. 
Six from lacerated wounds in crush- 
ing accident; two from result of 
felon. 
All healed by first intention under 
one dressing. 
I 
Forearm. 
From tubercular arthritis of wrist 
and carpus. 
Primary union under two dressings. 
I 
Arm. 
In old ununited fracture at the up- 
per third. 
Primary union. 
2 
Foot. 
One malignant tumor of foot, one 
for crush of foot, both Choparts. 
One healed by first intention, Sec- 
ond recent. 
3 
Leg. 
All for railroad injury. 
Primary union in all. 
2 
Thigh. 
One for malignant growth of lower 
end of femur. One for tubercular 
osteitis of knee. 
In 1 antiseptic suppuration in track 
of drainage tube which was left in 
situ or an unnecessarily long 
time. Final healing. In other 
primary union under 2 dressings. 
14 
3 
Radical cure of 
hernia. 
Inguinal. 
All of these cases were strangulated, 
all were seen and operated on 
early. In the inguinal cases 
Barker's method was used; in the 
femoral a modification of that 
method. 
All recovered from the operation. 
In two there were fever and sup- 
puration along the track of the 
catgut drainage. In one there 
is already a return of the hernia. 
In the others the cure seems per- 
manent. 
2 
Femoral. 
15 
2 
Parotid tumor. 
Both cases were examples of tumors 
over the parotid originating in 
the lymphatic rather than true 
tumots of the parotid itself. 
Primary union in one. In the other 
a little aseptic oozing for a week. 
16 
I 
Osteotomy and re- 
fracture of bones 
of the forearm. 
For angular deformity following 
badly treated fracture. Open 
wound. 
Primary union under two dressings. 
Cure. 
>7 
I 
Myotomy of ad- 
ductor, sartorius 
& tensor vaginae 
femoris. 
For contractures of long standing. 
Primary union. 
18 
Removal of tu- 
mors. 
II 
From scalp. 
In eight cases the operation was for 
the removal of sebaceous growths. 
In three, included here for con- 
venience, a painful scar was ex- 
cised for supposed traumatic epi- 
lepsy. 
In every case there was primary 
union except (in three ilong the 
track of the drainage tubes. In 
no case was there fever sr suppu- 
ration. 
3 
From neck (exclu- 
sive of tubercu- 
lous glands). 
Hydrocele of the neck; two malig- 
nant growths of neck. 
TABLE.-Continued. 22 
J. W. WHITE. 
$ 
| fn/w) 
of Cates. 
Operations. 
Memoranda. 
Results. 
18 
4 
From back. 
Three fatty tumors; one large cyst. 
I 
From thigh. 
One large fatty tumor, 
2 
From tongue. 
One cyst; one malignant growth. 
2 
From tonsils. 
For hypertrophy. 
There were no deaths. 
19 
I 
Ligation of brach- 
ial at two points 
For ruptured traumatic aneurism, 
old operation. 
Some sloughing from pressure 
previous to operation. Slow 
healing afterward with aseptic 
suppuration. Case ran an afeb- 
rile course to entire recovery. 
20 
Sequestrotomy. 
In these cases the cyanide gauze 
was used freely as packing and 
was found to work excellently 
well. As the bone cavities slowly 
granulated, the discharges re- 
mained sweet, and were serous 
rather than purulent. 
Recovery in each case. 
2 
Of femur: 
2 
Of tibia. 
I 
Of cranium. 
21 
Ununited fracture 
Both of these cases were operated 
on by wiring. In the former the 
implantation ef sterilized bone 
was tried, but was not successful. 
One failure. One recovery. No 
suppuration or fever in either 
case. 
I 
Of humerus. 
I 
Of tibia. 
22 
Abscess. 
In all of these antiseptic irrigation 
with bichloride was used, and re- 
cently with peroxide of hydrogen, 
always followed by packing with 
either cyanide or iodoform gauze. 
All recovered. Profuse suppura- 
tion ceased almost immediately 
and the cavities rapidly closed 
during a moderate serous oozing. 
6 
Acute. 
5 
Chronic. 
2 
Ofbone. 
2? 
Perineal section. 
In all the retained catheter was 
used and the wound was treated 
in accordance with the antiseptic 
methods described in this paper. 
Cyanide gauze packing was em- 
ployed when necessary. 
Recovery in every case but one in 
which nephro-pyelitis probably 
occurred. Exploratory neph- 
rotomy was recommended, but 
refused and the patient, a child, 
passed from under observation. 
3 
Rupture of ure- 
thra. 
TABLE.-Continued AN! ISEP TIC S UR GER Y. 
23 
TABLE.-Continued. 
Group. 
No. of Casos. 
Operations. 
Memoranda. 
Results. 
23 
2 
False passage. 
I 
Traumatic stric- 
ture . 
24 
Plastic operation. 
Union by first intention in all ex- 
cept two, in which tension caused 
separation of line of flaps. In 
those union by granulation took 
place. 
Recovery. 
I 
To make upper 
lip 
2 
To make lower 
lip. 
I 
To remove epith- 
elioma of cheek 
and lower lid. 
25 
Anal and rectal 
operations. 
In these cases either the cyanide or 
the iodoform gauze was used in 
packing. 
Recovery in every case. Afebrile 
course. No suppuration. 
8 
For fissure. 
6 
For haemorrhoids. 
10 
For fistula. 
1 
For rectal fibroids. 
26 
Compound frac- 
tures in which 
drainage and 
antiseptic dress- 
ings were used. 
In these cases sterilized iodoform 
was used in addition to the gauze. 
Recovery in every case. No fever. 
No suppuration, exceptin last case 
when the injury was crushing 
and the damage to tissues exces- 
sive. 
3 
Skull (included 
under trephin- 
ing. 
♦ 
I 
Humerus. 
I 
Humerus & both 
bones and fore- 
aim. 
6 
Tibia. 
4 
Both bones ofleg. 
3 
Tarsus and meta- 
tarsus . 24 
J. IV. WHITE. 
It will be observed that there are but five deaths in this list, 
two of them due to pre-existent and chronic disease; the 
other three were abdominal cases, operated on with the pa- 
tients almost in extremis, with swollen bellies, intestinal paresis, 
and in one case with suppurative peritonitis. The surgeon 
who has not lost such as these in spite of his best efforts and 
most careful application of antiseptic and operative methods 
has, indeed, been fortunate. 
I can truthfully say that in the whole list there have not 
been six freely suppurating cases, and that there have been no 
cases of septic trouble and no deaths from any form of blood- 
poisoning. 
The majority of these cases have been observed from begin- 
ning to end by sections of the University class, and have been 
under the daily care of my residents at the University Hospital. 
Of most of them I have elaborate clinical reports, made by 
members of the third year classes, and handed in to my assist- 
ants at the completion of the case. 
Upon others I have operated in private for well known 
physicians. I am sure that all who have seen these cases, 
whether students or practitioners, will corroborate my state- 
ments both as to the harmlessness and the efficacy of the 
method in question. 
I am glad to be able to give this positive testimony in favor 
of the latest Listerian method, which, while it may not be per- 
manent (as there are yet many opportunities for improvement 
before the ideal dressing is reached), is obviously undeserving 
the epithets of ^deadly and dangerous," applied to it by Mr. 
Tait, without, I will venture to say, his having taken the trou- 
ble to watch its effect in a single instance, to calculate the 
quantity of cyanide in a single dressing, to consider the im- 
probability of absorption, or indeed to give the matter any 
serious consideration whatever. For an example of the un- 
scientific spirit which Mr. Tait justly claims for himself, and 
for absence of the humility which he unjustly pretends to as- 
sociate with it, as well as for absolute recklessness of state- 
ment, commend me to the paragraph I have quoted about the 
cyanide dressing. 
I must not be understood in my eulogies of antisepsis as ANTISEPTIC SURGERY. 
25 
meaning to depreciate efforts made to attain the surgeon's 
ideal condition of operative wounds, i. e., perfect asepsis. 
There is no opposition between them. On the contrary, asepsis 
is the outcome of antisepsis, but I must confess to grave 
doubts of the efficacy of many of the means advocated to this 
end, and of some of the testimony in relation to it. These 
doubts are founded on a comparison between published re- 
sults and observed cases in the hands of some eminent Eu- 
ropean surgeons-the almost uniform effect upon my mind of 
such opportunities of comparison having been a distinct loss 
of confidence in the statistical reports. I saw, for example, a 
series of cases of excision of the breast, with pigmented irrita- 
ble scars, with suppuration, with dressings that were percepti- 
bly stinking, shown to a distinguished surgical audience, the 
operator and lecturer being a vigorous advocate of asepsis as 
opposed to antisepsis, and having in his clinic elaborate ap- 
paratus for the sterilization of dressings by steam heat under 
pressure, admittedly the best of all the non-chemical sterilizing 
methods yet discovered. These cases were in such marked 
contrast to what I had read of the results obtained at this 
clinic that the experience was a great shock to my faith in 
current surgical literature, a shock from which it has scarcely 
yet recovered. 
It cannot be disputed that in the light of modern science the 
operator has a two-fold duty, viz., to prevent the entrance of 
living pathogenic microbes into the wound and at the same 
time to preserve the vitality of the tissues themselves. tWe 
have already spoken of the phagocytic theory of Metchnikoff9, 
and in addition we have learned through Waterhouse's exper- 
iments10 and through the clinical experience already spoken 
of, of the anti-bacteric power of the peritoneum. Bouchard and 
others have observed the destruction of bacilli by the spleen 
and their elimination by the kidneys, as in typhoid fever. 
Buchner and Lubarsch11 have shown the bactericidal power of 
blood-serum or of some substance such as the fibrin ferment 
9Fortschritte der Medizin, Bd. 2, 1884, No. 17 
10Virchow's Arch., Bd. 119, heft 3, p. 342. 
nVersammlung Deutsch Naturforsch und Aerzte, Heidelberg, 1889. 26 
J. W. WHITE. 
contained therein. We have abundant reason, therefore, to 
believe in a general antagonism between the body cells and 
the micro-organisms of disease, even if, with our friend, Pr. 
William Osler12, we are compelled to consider the question of 
phagocytosis as still an open one. It follows that the theoretical 
propriety of non-interference with these tissues cannot be 
doubted, and Lister plainly admitted and accepted this new 
view when he said that the floating particles of the air having 
been shown to be less harmful than was supposed, we may 
possibly dispense with antiseptic washing and irrigation, "pro- 
vided always that we can trust ourselves and our assistants to 
avoid the introduction into the wound of septic defilement 
from other than atmospheric sources." 
When this method is adopted it is evident that all strong an- 
tiseptic solutions which might compromise the vitality of the 
tissues must be discarded; instruments, silk, ligatures, sponges, 
etc., must be sterilized by heat, hands must be washed clean 
in sterilized water (after previous chemical disinfection), and 
the same is true of the skin over the field of operation. If an- 
tiseptic solutions are used at all they must be very feeble- 
1:60 carbolic for instruments (after previous sterilization by 
heat), i: 10,000 sublimate for sponges, etc. 
In the meantime, however, while waiting for further im- 
provement in this direction I have felt and still feel that it is 
safer in a large general clinic, with several assistants and with 
numbers of students actively participating in the operative 
work, to depend upon full antisepsis rather than upon asepsis, 
and I have in the cases above cited and in large numbers of 
others, not of enough importance to include in the table, em- 
ployed the following methods, substantially based on those 
of Lister himself, as described to me in a private letter of last 
January. They represent, therefore, the latest views made 
public before the Berlin address. 
I need not detain you with a description of the preparation 
of the gauze itself. This can be found in detail in The Lancet 
for November 9, 1889, and January 4, 1890. 
Immediately over the wound is placed a portion of the cya- 
12Medical News, April 13 and 20, 1889. ANTISEP 7IC S UR GER Y. 
27 
nide gauze, washed in a solution of carbolic acid to get rid 
of the bichloride of mercury in the dressing in contact 
with the wound. For this purpose one part of carbolic 
acid to twenty of water is safer than any weaker solution. 
A very pure acid should be used, because, if impure, it is not 
completely dissolved, and the undissolved particles are need- 
lessly irritating to the surgeon's hands. When a dressing is 
changed this piece of gauze is applied over the wound before 
the surrounding parts are cleaned with the carbolic solution. 
The carbolic acid soon flies off from the washed gauze, leav- 
ing nothing in it in contact with the wound but the unirritat- 
ing cyanide. 
By proceeding in this way it is not necessary to use "protec- 
tive." The amount of unwashed gauze to be applied 
will depend upon the amount of discharge anticipated. In 
the early stage of a wound, where we expect much sero- 
sanguineous oozing, it is desirable to use a considerable mass, 
say an inch in thickness, and extending on all sides be- 
yond the wound. Further, it is well, where free discharge 
may occur, to place over the dressing a piece of thin mackin- 
tosh with the caoutchouc side (antiseptically washed) next the 
dressing. This is for the purpose of preventing the discharge 
from coming directly through the dressing. It should not, of 
course, overlap the gauze, nor need it even extend to its edge. 
When the part operated on is placed on a splint, as after resec- 
tion of the knee, the padding of the splint is lined with such a 
piece of mackintosh. 
It is unnecessary to purify bandages or elastic bands that 
are placed outside of dressings, but if a bandage is used in 
the interior of a dressing, as in bandaging a stump next the 
skin, it is purified sufficiently by soaking it thoroughly with a 
solution of corrosive sublimate i:2OOO. For purifying the skin 
1:20 carbolic acid in 1:500 sublimate solution is used. The tow- 
els placed around the seat of operation are wrung out of 1:2000 
sublimate lotion, and this is also used for the sponges during 
the operations. The carbolic solution is also used for purify- 
ing the instruments before an operation. At the end of an 
operation, before beginning to stitch, the wound may be 
washed with 1:500 sublimate lotion, and irrigated with 1:4000 
during the stitching. 28 
J. W. WHITE. 
But where a joint, such as the knee, is opened the use of the 
strong sublimate solution, which is seriously irritating to the 
synovial membrane should be avoided; and in that case it is 
better to irrigate through the whole operation with 1:4000. 
As to rendering wounds aseptic which have been infected, 
that is, speaking generally, a thing on which we can never 
reckon with absolute certainty; in recent wounds, like com- 
pound fractures, the chance of success is, of course, always 
greater the^ shorter the time that has elapsed after the in- 
fliction of the injury. 
If the skin and wound are greasy, oil of turpentine is of 
great value for cleaning away the dirt, and the use of a 
nailbrush with carbolic and sublimate solutions, after the tur- 
pentine (or without it if there be no special occasion for its 
use), is very valuable. In many cases where septic sinuses are 
present, it is hopeless to try to extirpate the septic 
mischief; but very great advantage is gained by washing the 
cut surfaces in an operation under such circumstances with a 
solution of chloride of zinc, forty grains to the ounce of water. 
This is done once for all at the conclusion of the operation, and 
prevents putrefaction during the critical early days. The 
same solution is used where the wound communicates 
with a septic cavity, as after the removal of a portion 
of a tongue, or of a jaw; and under these circumstances 
it is also useful to apply iodoform to the cut surface after the 
chloride. In cases in which the septically infected part is of 
very limited extent, as, for example, where a suppurating 
strumous gland has discharged without an antiseptic dressing, 
complete disinfection may often be obtained by applying undi- 
luted liquid carbolic acid, after scraping away the degenerated 
glandular or other tissue with a sharp spoon. 
I have recently learned to value peroxide of hydrogen very 
highly as an antiseptic especially in suppurating cases and 
am using it more largely than ever before. 
This address has already assumed an inordinate length on 
account of the necessity for free quotation, but I cannot con- 
clude it without a protest against the tone of Mr. Tait's paper 
and against the personal virulence of its references to Lister. 
There is, unquestionably, room for legitimate differences of ANTISEPTIC SURGERY. 
29 
opinion as to the treatment of operative wounds; there are 
many problems relating to the principles involved which are 
yet unsolved; the precise comparative value of the different 
factors, which taken together, have given modern surgery its 
scientific exactness, is yet to be determined; argument and dis- 
cussion are not only excusable but highly desirable and, con- 
ducted in a proper spirit, could scarcely fail to be productive 
of great benefit to surgery and humanity. But this is not to 
be brought about by invective or by personal detraction. Mr. 
Tait discloses his real animus when he complains that for 
twelve years he has been "ignored" by Lister, and his contro- 
versial writings show that he probably belongs to that class 
of persons who feel far more deeply injured by neglect than by 
assault. 
It is doubtless true that he and his work, carried on in a 
special line and under special conditions, have not in the con- 
sideration of the whole subject been elevated into the promi- 
nence which he thinks they deserve; but how many of us in this 
world are taken at our own valuation, either personally or 
professionally? 
Lister's work since he took his first degree in 1852 has been 
of a character to command the respect and admiration of the 
scientific world. Receiving the first prizes in botany and an- 
atomy when he passed the M. B. examination, he won the 
gold medal and the scholarship in surgery in the final examin- 
ation. His papers on the minute anatomy of the skin, the 
physiology of the lacteal current, the contractility of the iris, 
the microscopic anatomy of involuntary muscular fibre, the re- 
lations of the inhibitory system to the visceral nerves, the 
regulation of arterial contraction by the nervous system, the 
early stages of inflammation, the coagulation of the blood, 
etc., stamped him at once as an original investigator of the first 
rank, and as one of his biographers says "would have sufficed 
to make his career memorable if he had never applied anti- 
septic measures to the treatment of disease." I have heard 
Prof. Louis Agassiz years ago and later Prof. Joseph 
Leidy say that, viewed from the standpoint of abstract science, 
his work had been of the very highest order and the appreci- 
ation of his labors by the best minds in our own profession 30 
J. W. WHITE. 
has been enthusiastic and almost universal. Nearly every 
great surgeon in the civilized world has put on record his ad- 
miration for Lister's teachings, his acceptance of the general 
principles involved and his sense of almost personal obligation 
to the author of the antiseptic theory. 
That Mr. Tait should speak of such a man as having "lived 
in the clouds of his spray for the last twelve years," as "want- 
ing in logic," having "crude notions of logical definition," 
making "illogical blunders," "falling away from his own faith," 
promulgating an "absolute and ludicrous logical error," etc., 
and should make a boast of having "laughed at" and 
"ridiculed" him and his doctrines and disciples, is, it seems to 
me, evidence of his unfitness by temperament or training (or 
from lack of the latter) for the serious discussion of broad surgi- 
cal principles. I am quite sure that the vast majority of general 
surgeons will be found to have no sympathy with either his 
views or his manner of expressing them, and it is a relief to 
find that in his own special line there are operators of equal 
eminence whu repudiate both. In an address on "Abdominal 
Surgery, Past and Present" recently delivered before the 
Medical Society of London, its President, Mr. J. Knowsley 
Thornton, said: "I am not ashamed still to use the spray and 
all the precautions which have advanced my results in ovariot- 
omy to 1.88% mortality (as against Bantock's 4 and Tait's 
3.3%) and I find increased practice and a steady adherence to 
methods which have yielded me good results in the past in- 
crease in like ratio my success in all abdominal operations. 
Every operator of prominence improved his results enormous- 
ly as soon as he adopted Listetism; then having learnt how 
to be surgically clean, he has found for himself ways of attain- 
ing this end with more or less success by methods differing 
from those of Lister. '1 he sum and substance of it all is, that 
if we had never had Lister to teach us true cleanliness, we 
should never have used antiseptics, flushings or drainage tubes 
to attain it. The great advance is due to the antiseptic sys- 
tem, the minor details are merely the different ways of attain- 
ing the same end-asepticity. Time alone will show what is 
worth retaining and what we may safely cast aside."