•ON THE / 
' ' 
ANTISEPTIC TREATMENT OF WOUNDS^ 
AND ITS RESULTS. 
BY 
ROBERT F. WEIR, M.D., 
SURGEON TO THE NEW YORK AND ROOSEVELT HOSPITALS. 
PREPRINTED FROM TIIK NEW YORK MEDICAL' JOURNAL, DECEMBER, 1877. 
AND JANUARY, 1878.] 
NEW YOKE: 
D. APPLETON AND COMPANY, 
5 49 & 55 1 BROADWAY. 
1878. ELEMENTS OF GEOLOGY. 
A TEXT-BOOK 
FOR COLLEGES AND FOR THE GENERAL READER. 
By JOSEPH L£ CONTE, 
Author of “Religion and Science,” etc., and Professor of Geology and Natural 
' History in the University of California. 
1 vol,, 8vo. 588 pages. Cloth. Price, $4.50. 
“ I have desired to make a work which shall he both in- 
teresting and profitable to the intelligent general reader, and at 
the same time a suitable text-book for the higher classes of 
our colleges. In the selection of material and mode of presen- 
tation I have been guided by long experience as to what it 
is possible to make interesting to a class of young men some- 
what advanced in general culture and eager for knowledge, but 
not expecting to become special geologists.”—Extract from 
Preface. 
D. APPLETON & CO., Publishers, 549 & 551 Broadway, N. Y. ON THE 
ANTISEPTIC TREATMENT OF WOUNDS, 
AND ITS RESULTS. 
BY 
ROBERT F. WEIR, M. D., 
SURGEON TO THE NEW YORK AND ROOSEVELT HOSPITALS. 
{REPRINTED FROM THE NEW YORK MEDICAL JOURNAL, DECEMBER, 1877, 
AND JANUARY.i 1878.] 
NEW YORK: 
D. APPLETON AND COMPANY, 
5 49 & 551 BROADWAY. 
1878. ON THE ANTISEPTIC TREATMENT OF WOUNDS, 
AND ITS RESULTS.1 
It is only lately that, in America, attention has been given 
practically to the teachings of Lister in respect to the treat- 
ment of wounds. In fact, aside from an article by Schuppert 
in the New Orleans Medical and Surgical Journal, little or 
nothing has appeared in our medical journals relative to the 
results of the so-called antiseptic method. Within the past 
year, however, a change has occurred, due probably both to 
the interest excited by the personal expositions of Lister at 
our late Medical Congress at Philadelphia, and also to the 
satisfactory results that have ensued from this treatment in 
the practice of many German surgeons with large hospital 
experience. The reason why American surgeons—who justly 
have the reputation of being eager to seize upon any improve- 
ment in their art—have been tardy in testing the success of 
this mode of treatment, may, perhaps, be stated as follows: 
1. That the treatment, as enunciated by Mr. Lister, has been 
repeatedly changed in its details; 2. That it was too compli- 
cated, and demanded the supervision of the surgeon himself, 
or, in a hospital, of a carefully-trained staff of assistants; 3. 
That many who had tried it had been unsuccessful in the cases 
where the essay had been made. But the most weighty ob- 
jection which was asserted or entertained, was the positive- 
ness of the enunciation of the germ-theory in explanation of 
the process of decomposition in the secretions of a wound. 
Only the latter reason requires any attention at present, and, 
1 Read before the New York County Medical Society at the meeting 
held November 26, 1877. 4 
as a clearer conception of tlie intent of the many minutiae of 
the dressing may come from a synopsis of this theory, it will 
be succinctly given, notwithstanding the purpose of this even- 
ing’s paper is to present the subject as far as possible from a 
clinical point of view. 
It is, in a few words, this: 1. That in the dust of the at- 
mosphere, and in matter with which it is in contact, there are 
the germs of minute organisms, which under favorable cir- 
cumstances induce putrefaction in fluids and solids capable of 
that change, in the same manner as the yeast-plant occasions 
the alcoholic fermentation in a saccharine solution; 2. That 
putrefaction is not occasioned by the chemical action of oxygen 
or other gas, but by the fermentative agency of these organ- 
isms; 3. That the vitality or potency of the germs can be 
destroyed by heat or by various chemical substances, which 
are called, in surgery, “ antiseptics.” 1 The vpry definition of 
the “ antiseptic system,” as given in the words of Lister him- 
self, is u the dealing with surgical cases in such a way as 
to prevent the introduction of putrefactive influences into 
wounds.”* Nothing need here be added to these statements, 
in their verification or otherwise (though analogy and accu- 
mulating facts seem to lend support to them), except that 
from the standpoint adopted two important statements ought 
to be referred to. I mean those of Thompson,3 Weitzel- 
baum,4 and others, that they had found living bacteria in 
the carbolic solutions as used by Lister, and of Linhart,6 
Fischer,6 Ranke,7 Schuller,8 and Volkmann,8 who, in several 
hundred observations, have found bacteria in the discharges of 
wounds that had been most carefully and satisfactorily treated 
by the antiseptic method. It was noticed, however, that the 
presence or absence of these bacteria (and such were only con- 
1 T. Smith, Lancet, March 25, 1876. 
2 “ Transactions of the International Medical Congress,” Philadelphia, 
1876. 
3 Medical Times and Gazette, November 6, 1875. 
* Wiener Med. Presse, 1876, Nos. 10 and 11. 
6 Schmidt’s “Jahrbucher,” vol. 174, 4. 
8 Deut. Zeitschr.f. Chirur., vol. vi., p. 319. 
7 Idem, vol. vi., p. 63. 8 Idem, vol. vii., 1876, pp. 5, 6. 
8 Schmidt’s “Jahrbucher,” vol. 174, 2, 1877. 5 
sidered as present, when chain-bacteria were found) did not 
influence the progress of the wounds; and Fischer gives the 
opinion, in which many of his countrymen join, that the ob- 
ject of the dressing is not so much to keep the germs away as 
to keep the secretions in such a condition as to be as unfavor- 
able as possible to the development of bacteria, and thus pre- 
vent decomposition taking place. 
It is only justice to append the remarks of Mr. Lister at 
the Congress in respect to these observations, or rather, correct- 
ly speaking, of Ranke’s. They are, textually : “ The statement 
that cell forms have been found beneath antiseptic dressings 
must be received with caution. - I have,” continues he, “re- 
cently met a gentleman who was with Ranke in Halle when 
he found, as he supposed, these organisms beneath antiseptic 
coverings; and when the gentleman pointed out to me the 
bacteria which he called putrefactive, I at once recognized 
them as of the non-putrefactive variety, and the gentleman 
was forced to admit that they differed from those found in 
decomposing masses.” 1 
Passing from these facts (?) of the laboratory, let us con- 
sider those to be used and acquired at the bedside. In prac- 
ticing this method, in order to form a proper judgment of its 
merits, it is essential that Mr. Lister’s plan should be thor. 
oughly known, and be carried out even to its minutest par- 
ticular. The chorus on this point is unanimous among sur- 
geons who have successfully used it. Hagedorn, of Magde- 
burg, says that in every failure the surgeon himself is to 
blame, and not the method; and Lindpaintner,2 representing 
the experience of Munich with nearly a thousand cases treated 
antiseptically, states that it must be considered a precept that 
the minutest directions must be followed, and that he who 
does not get the result (desired) must certainly have made some 
mistake. This opinion is reiterated by all who have achieved 
success by the method, and the number of such is already 
large and increasing.3 A second condition, which really 
1 “Transactions of the International Congress,” 1875, p. 540. 
2 Deut. Zeitachr.f. Ghirur., vol. vii., p. 18. 
3 See Schmidt’s Jahrlucher, vol. 172, 4, and Hirsch’s Jahresiericht, 
1877, for an interesting summary of the antiseptic treatment. 6 
should have come first, is that they who use the method should 
at least provisionally accept the theory on which the dressing 
is based; they should, so to speak, act as if they saw germs- 
on everything. This, however, is not so imperative as tlio 
one just spoken of. 
“ For,” remarks Lister, “ those who are unwilling to accept 
the theory in its entirety, and choose to assume that the septic 
material is not of the nature of living organisms, but a so-called 
chemical ferment destitute of vitality, yet endowed with the- 
power of self-multiplication. . . . such a notion, unwarranted' 
though I believe it to be by any scientific evidence, will, in a. 
practical point of view, be equivalent to the germ-theory, since- 
it will inculcate precisely the same methods of antiseptic man- 
agement. It is important that this should be clearly under- 
stood.” 
For the proper application of the antiseptic dressings to any 
wound made by a surgeon, the following things are necessary : 
1. Three Solutions of Carbolic Acid, duly labeled : (a) 1 to 
40 for the “ protective,” and for the “ loose layer of gauze.”1 
(b) 1 to 30 for the spray. It is intended that the spray itself 
should be of the strength of 1 to 40; by using, however, this 
second solution of 1 part to 30, it will be found that the 
dilution accomplished by the steam will bring it down to the 
desired strength. However, this is a matter that should be 
tested by each surgeon for himself.1 (c) A 1 to 20 solution, in 
which the sponges,8 instruments (the latter for half an hour to 
“ Listerize,” as Yolktnann says, the joints and the teeth of for- 
ceps, etc.), and the drainage-tubes are immersed. This solu- 
tion is also used to wash the epidermis3 adjacent to the pro- 
posed wound, the hands, and particularly the finger-ends, of 
1 For instance, in converting 19 ounces of water into steam, 57 ounces- 
of carbolic solution, of 1 to 30, were used by my present atomizer, giving- 
for the spray exactly the strength of 1 to 40. 
2 Sponges when not in use should, after being washed out thoroughlyr 
be kept constantly in a 1 to 20 solution of carbolic acid. 
3 On the Continent the use of soap and water with a nail-brush, and 
a subsequent washing with ether, are advised prior to using the carbolic-acid 
solution. This appears to be an unnecessary addition to the already great 
complexity of detail. 7 
the surgeon.1 With the same solution injections are made 
into compound fractures, or wounds that have been exposed 
some time to the air ; although, for the former, Mr. Lister has 
lately used a solution of 1 part acid to 5 of spirits of wine, 
employed in a manner to be alluded to shortly. 
2. A Steam-spray Apparatus. The best is that devised by 
Lister himself. It is, however, quite costly, ranging in price 
from fifty to seventy-five dollars, and it was to meet this ob- 
jection that the one before you has been constructed. With 
Its diminished cost some of the improvements of Mr. Lister’s 
lamp ,have been sacrificed. It is, however, essentially the 
same. Its hollow wick, readily raised or lowered, affords a 
great and controllable heat. The sprav-tube is in this appara- 
tus fixed, an objection which in the majority of cases is of no 
moment. It will supply spray for over two hours. It there- 
fore requires only that the boiler—containing twenty-two 
ounces—should be, as well as the lamp, full at the beginning 
1 To avoid some of the irritating and roughening effects of the acid, it 
is of service to anoint the hands with carbolic oil, 1 to 10. before exposing 
them to the spray. See Boston Medical and Surgical Journal, September 
14, 1876; British Medical Journal, August 14, 1871, and Lancet, March 12, 
1875. In the first journal, speaking of sponges, instruments, hands, etc., 
he (Lister) says not to introduce anything into a wound not cleansed by a 
1 to 20 carbolic-acid solution. This is also stated in Transactions of the 
International Medical Congress, Philadelphia, 1876. 8 
of the operation; and, with this precaution, it has been found 
practicable to dispense with the expensive and tell-tale win- 
dows of glass belonging to the original imported instrument.1 
The accompanying wood-cut gives a good representation of 
this lamp. 
3. Antiseptic Gauze. This is made of a coarse-meshed cot- 
ton cloth (26 to 30 threads to the linear inch) called “ mull ” in 
Great Britain, but known here as cheese or dairy cloth. This 
cloth is heated beyond 212°, then sprinkled with its own weight 
of a mixture of carbolic acid 1 part, common resin 5 parts, and 
paraffin 7 parts, prepared by melting together the two latter 
in a water-bath, and then adding the acid, by stirring. The 
impregnated cloth is afterward kept under pressure in a water- 
bath box for an hour or two to disseminate equally the liquid, 
when the material is fit for use.2 The resin, it is well known, 
gives off the acid very slowly—that is what is wished for—but 
it would leave the gauze too sticky were not the paraffin joined 
to it. Made in this way, it costs, in the Edinburgh Infirmary, 
unprepared, l£d. a yard, and prepared, 2d. a yard. 
The material from which I have bad it made at the Roose- 
velt Hospital costs 3£ cents per yard, 28 inches wide, at 
wholesale, and is obtained from Id. B. Claffin & Co., and 
costs, when prepared, 6 cents per yard. It is in its preparation, 
however, managed a little differently; for the heated cloth 
is immersed in the melted materials by being carried under rods- 
near the bottom of the hot box containing the mixture, and, 
before emerging from this box, it is passed between two con- 
fronting rubber strips (in fact, weather-strips), which removes, 
the surplus of the mixture; it is then caught on a roller, on 
which are payed at the same time, from another roller imme- 
diately below it, 3 to 5 layers of heated unprepared cloth. 
This tight roll of immersed and dry cloth has sufficient heat 
in it to cause the proper dissemination of the mixture through 
all the layers before it cools. Only occasionally is it found 
necessary to place the roll for further heating in a hot-air 
chamber. The impregnating layer is sometimes found a little 
1 The modified apparatus is furnished in a portable case by Stohlmann 
Pfarre & Co., 67 Chatham Street, at the moderate price of fifteen dollars.. 
* Lancet, March 13, 1875. 9 
too stiff, and is used in the manufacture of bandages. By 
this procedure three hundred and fifty yards of prepared gauze 
can be manufactured at once in a much less space of time than 
by the other precedure. Details of the preparation of this 
and other materials are dwelt upon because mistakes are con- 
tinually occurring; as confirmatory of this, it is necessary 
only to remark that a firm concerned in manufacturing the 
gauze in this city has failed, until recently, to appreciate the 
necessity of previously heating the cloth to insure the thorough 
penetration of the mixture into its substance, with the result 
of the central fibres being found imperfectly charged from 
neglect of this precaution. 
4. The Mackintosh—a thin cotton-cloth with a layer of 
red vulcanized rubber on one side, used as a “ sweat proof,” 
in hats, and deriving its name from the manufacturers in 
Manchester, England. Other rubber-cloth or gutta-percha 
tissue will answer, but whatever is used must be imperme- 
able, and should be held up to the light for the detection of 
holes, etc., before each dressing. 
5. Black rubber tubing, varying in size from that of a 
small quill to that of the little finger, with numerous open- 
ings on the side, each half the diameter of the tube. These 
are for drainage. One or more are inserted, according to the 
size and depth of the wound and the number of its pockets. 
It is better to use two small ones in any given spot than one 
large one, as they will not separate the edges so much. To 
the outer end of these—cut square or beveling, as it may be 
required, to make them lie flush with the skin—are attached 
silk threads to secure them; or they can be prevented slipping 
inward by thrusting, as Volkmann does,1 a fine cambric needle 
across the distal end. A number of threads of catgut are 
sometimes used in lieu of the tube, or in addition to it, so that 
the former can be withdrawn at any desired time, and the 
catgut left in situ. A bundle of horse-hair is also used. 
6. The Protective, technically so called. This is ordinary 
oiled silk, coated on each side by a thin layer of copal varnish, 
to render it impermeable to carbolic acid (which gutta-percha 
1 “Samm. klin. Yortrage,” Nos. 117, 118. 10 
tissue is not), and then brushed over with a mixture of dex- 
trine 1 part, starch 2 parts, and 16 parts of a 1 to 20 car- 
bolic-acid solution. This coating causes the disinfecting solu- 
tion to adhere smoothly to the protective, when it is immersed 
in it prior to an operation. The function of this protective 
is not an antiseptic one; it is really to protect the wound itself 
from the irritating effects of the carbolic acid stored up in the 
antiseptic gauze. 
7. Carbolized Catgut Ligatures, made by putting catgut (or 
silk-worm gut) 1 into a mixture of carbolic acid 1 part, which 
is dissolved in one-tenth its weight of water, and then added 
to 5 parts of olive-oil. Do not mix the acid and oil together, 
and then add water; it spoils the catgut. The ligatures 
should remain in this mixture at least two months, and the 
longer they are kept in the solution the better they are said to 
be.2 This, though quoted from Lister, is not exactly accurate, 
for most of the imported ligatures, even when prepared in Ed- 
inburgh by Gardner, are generally unreliable. Though, when 
successfully made, catgut ligatures generally answer their 
purpose, yet, as they have at times acted as foreign bodies, 
and provoked irritation, Mr. Lister has endeavored to im- 
prove upon this mode of preparation; and, at the Inter- 
national Medical Congress held at Philadelphia last year, he 
announced that he had made more satisfactory ligatures by 
a mixture of carbolic acid, glycerine, chromic acid, spirits of 
wine, and water; the exact formula has not, however, yet 
been given to the public. In this connection it is proper to 
allude to the painstaking endeavors toward perfection that 
have continually prompted the eminent promulgator of the 
antiseptic dressing; his persistent labors are attested by the 
many changes, always for the better, that have marked the 
progress of his treatment of wounds. These improvements, 1 
regret to say, have been misinterpreted by many, as indica- 
tions of unreliability, but they have all been steadily directed 
to the accomplishment of the end in view. 
1 Hirscli’s “ Jahresbericht,” 1870, p. 322. 
* Some marbles or pebbles, covered by a piece of glass, are put in the 
bottom of the bottle, to prevent the gut from touching the water that col- 
lects there. The imported ligatures are generally weak. 11 
8. Carbolized Silk Sutures, made by plunging ordinary 
■surgeon’s silk into melted wax 10 parts, and 1 part carbolic 
acid. After being withdrawn, the surplus wax is removed by 
drawing the silk through a folded cloth. If there is not 
much tension in the part, catgut is often used for sutures. 
Having all these things prepared, and the directions rela- 
tive to the instruments, sponges, hands, and the adjacent 
skin, having been properly complied with, and the sur- 
face of the body not too much exposed, the operation or in- 
cision is begun by directing the spray, made as fine as pos- 
sible,1 upon or a little above the intended wound. The 
management of this is one of the most important duties to be 
intrusted to an assistant. Currents of air may turn away the 
cloud of spray, the position of the limb may be changed, the 
-surgeon may unexpectedly place himself or his hands in the 
way, and thus screen the wound, etc.: all these difficulties 
must be looked after by the attentive lampholder.3 The in- 
cision having been made,3 all bleeding points must be secured 
by the catgut ligatures, both ends of which are to be cut ofi 
short; generally an ordinary reef-knot will secure the ligature 
properly ; if you are in doubt, you may add a third one.4 The 
wound is then to be closed accurately with the carbolized silk 
-or gut sutures,5 and a drainage-tube or tubes placed in the 
1 By contracting or partially plugging the delivery-tube—i. e., the one 
immersed in the carbolized solution—the spray is rendered finer. 
2 It is well to have an extra spraying apparatus accessible. Richard- 
son’s will answer. If the spray should suddenly cease, the wound should 
he at once covered with several layers of gauze wet with 1 to 40 solution; 
this is sometimes called the “ guard.” 
3 If during the operation any instrument has been temporarily laid 
aside, it should be dipped into the 1 to 20 solution, or held a moment or two 
in the spray near the lamp before again being introduced into the wound. 
4 This is particularly advisable when ligating a vessel in its contin- 
uity. 
* Should any traction be required to approximate the lips of the wound, 
a deep relaxation-suture is to be resorted to, and held in situ by perforated 
disks of lead—a procedure similar to that used by Dr. Gurdon Buck, of this 
city, some ten years since, in plastic operations on the face. Adhesive 
straps, if used, should be short enough to be overlapped by the gauze 
-dressing, and should previously be dipped in a bot carbolic solution of 1 
to 20. Personal observation has convinced me that adhesive plaster will, 12 
deepest parts of the wound, so as to drain off all accumulating 
fluids. A small piece of protective, previously dipped in the 
weak solution of 1 to 40,1 but only sufficiently large to thor- 
oughly cover it, is then to be placed over the line of junc- 
tion of the edges of the wound, with openings cut in it for 
the drainage tube.2 Over the wound now covered with the 
protective is to be placed a large and separate layer of 
gauze, which has been dipped in the weak solution of 1 to 
40 of carbolic acid. This is used in order to nullify the 
putrefactive elements that may be deposited in the exposed 
layers of the dry gauze ; which latter is, after stopping the 
spray, then applied in a thickness of eight folds, largely over- 
lapping the wound, and having a piece of mackintosh with 
the rubber side down interposed between the 7th and 8th 
layers. If the discharge is likely to be great, a larger num- 
ber of layers can be used, or extra layers placed where fluids 
would be most likely to gravitate. The mackintosh should 
be about one inch smaller than the gauze, since it is intended 
to convey any discharge that may soak through to it toward 
the edges of the dressing, where it can be detected by the 
surgeon or nurse while it is yet resting in antiseptic material. 
All fluids are thus compelled to permeate the whole dressing, 
and to be constantly in contact with the carbolic acid. 
The dressing, now completed, requires only to be secured 
in place, which is best accomplished by bandages of the same 
gauze material, as they will not slip. The many-tailed band- 
age is to be preferred tor stumps, since its application will not 
be so apt to displace the protective. If the edges of the dress- 
ing do not tit snugly to the skin, or if they come where the 
in ordinary dressings, frequently interfere with primary union; so that, 
when its employment is demanded, I prefer to interpose a few threads- 
of charpie between its surface and the line of the wound. 
1 In the strong solution of 1 to 20 it is often wrinkled or shriveled up. 
2 If, in an operation for the eradication of tumors, a large pocket is 
formed, or a stump is baggy, or persistent oozing occurs, a large sponge 
dipped in 1 to 20 solution is placed over a good-sized piece of protective, 
and over this the other dressings, secured by a firm bandage. The sponge 
is not generally required after the first dressing. It is also employed after 
opening large abscesses. 13 
natural motions of the body render nicety of application diffi- 
cult, the too free entrance of air can be prevented by either 
stuffing in pieces of crumpled carbolized gauze or salicylic? 
cotton along the edges, or by using a bandage of elastic 
webbing, lightly applied so as not to give discomfort to the 
patient. 
The dressing is changed, as a rule, whether the wound be 
accidental or from an operation, in twenty-four hours, even 
though it is not stained at its edges ; and sooner, if the secre- 
tions are formed in a sufficient quantity to bring about this 
result. This often occurs by reason of the irritating nature of 
the carbolic acid, which increases to a considerable degree the 
secretions of the wound. If the protective is unchanged in 
color, the wound is certainly aseptic; if it is not, it will show 
dark-brownish spots, the result of the action of the liberated 
sulphur upon the lead in the oiled silk. These remarks about 
the protective hold good only of incised wounds. In con- 
tused wounds the changes of color are met with even though 
the wound is doing well. 
To expose the wound, the same precautions as to hands, in- 
struments, etc., are to be taken as at the operation. The spray 
is directed on the dressing, and particularly on its edges, and, 
the encircling bandage having been cut or removed, the folded 
gauze is carefully raised, while the spray is turned into the 
angle between it and the skin. The parts adjacent to the 
wound are lightly wiped by a carbolized sponge or cloth to 
remove the secretion, which is generally a bloody serum. If 
the evidence is favorable, washing out the wound is to be care- 
fully abstained from, and the drainage-tube is not to be re- 
moved ; nor is this to be done until the third or fourth day, 
unless some sign is recognized of its being choked up, as, for 
instance, by tension, etc. Whenever it is taken out it is cleaned 
in the stronger carbolic-acid solution of 1 to 20, and replaced 
previously shortened, if need be, according to the granulation 
or closure of the wound. Lister1 keeps them in until the- 
wound is nearly, if not quite, healed—that is, so long as the 
discharge is more than the mere draiuage-opening will account. 
1 Lancet, April 3, 1876. 14 
for, cutting them off at each dressing, and finding them 
often at the last dressing loose on the gauze, with their track 
healed. 
In a redressing everything is renewed, except the mackin- 
tosh, which can be washed oft’ with the carbolic solution of 
1 to 20, and used again. It is preferable, however, to have 
two pieces, so that the one removed from a soiled dressing can 
be cleaned prior to its being employed again, when it is, of 
course, to be dampened with the strong solution. 
The renewal of dressings, after this one of examination, 
depends on the profusion of the discharge, the sensations of 
the patient, and the temperature elevation. The latter should, 
in a satisfactory case, be either normal throughout or but slight 
in amount, and subside within forty-eight hours or thereabout. 
If nothing wrong occurs, the dressing can be left on for weeks 
.(Lister1 says), if necessary, as it sometimes is in compound frac- 
tures, etc. In one case, by sprinkling the under-surface of 
the gauze with salicylic acid, he kept it on for six weeks, with- 
out either odor or irritation. Generally it is retained from 
two days to a week. 
Such is the management of wounds which can be treated 
ob initio by the antiseptic method. For those coming under 
this treatment some time after their infliction, such as lacer, 
ated wounds, compound fractures, and the like, a somewhat 
■different plan must he adopted. Take, for instance, a com- 
pound fracture. Under the spray the wound is to he explored, 
detached fragments taken away, secundem artern, and a stream 
of carbolized solution 1 to 20—or, better still (Mr. Lister states- 
thougli I have only so far tried the former method), a stronger 
solution, of 1 part carbolic acid to 5 of spirits of wdne (alco- 
hol)—is to be injected into the recesses of the wound, bv means 
of a soft rubber catheter attached to a syringe. Drainage- 
tubes, reaching to the ends of the fractured bone, are to be 
inserted, after which usual dressings are to be applied. 
For suppurating wounds presenting themselves as such, to 
the surgeon, or wounds that have failed to remain aseptic— 
.and experience shows that this can generally be traced to 
1 “Transactions of the International Medical Congress,” p. 541. 15 
some fault in the dressing—another procedure is resorted to.. 
It must be remarked that this failure of a dressing is not shown 
merely by the presence of pus, but by the odor that emanates 
from it as well as by the spots in the protective, for aseptic dress- 
ings will alwrays be without any smell. And here it is well to 
pause a moment to say that the antiseptic treatment will not 
alwa}Ts prevent the formation of purulent matter. This ab- 
sence of pus is to be hoped for; but those who have fairly tried 
the method (Yolkmann and others) freely admit the formation 
of pus. “ It is only just to Mr. Lister,” observes Mr. Thomas 
Smith, in the lecture already quoted,1 “ and essential in order to 
enable one to form a fair estimate of the results of his method,, 
to remember that he is far from regarding putrefaction as the 
only cause of suppuration. On the contrary, he has long since 
pointed out that any antiseptic substance, such as carbolic 
acid, if applied continuously to the exposed tissues of a wound, 
stimulates them to granulation, and the granulations to the 
formation of pus, giving rise to what he calls ‘ antiseptic sup- 
puration,’ due to the direct chemical stimulus of the anti- 
septic.” 
My own experience has shown me that the appearance of 
pus followed, in several of my amputations, the daily flooding 
of the stump with the stronger solution, which promptly and 
markedly diminished when this was stopped, or the weak 
solution used.2 
Hence the avoidance of washing out the wounds when 
they are found proceeding in a satisfactory aseptic manner, or 
simple abscesses when they are first opened. 
But to return from this digression. When such suppurat- 
ing wounds, old ulcers, or “ failures,” are met with, they are, 
previous to the use of the usual dressings, swabbed out with a 
solution of chloride of zinc, 40 grains to the ounce. This rem- 
edy, introduced by Campbell de Morgan to the profession, for 
the proposed destruction of the loose cells in the incision made 
for the removal of cancerous tumors, forms a film over the sur- 
1 Lancet, March 25, 1876. 
3 Lucas-Championnierre, “Chirurgie Antiseptique,” reports the same 
fact, 1876. 16 
face to which it is applied which will remain free from putre- 
faction for several days. Where, however, sinuses exist, leading 
to necrosed or carious bone, etc., it was formerly the custom of 
Lister, after the operation undertaken for the removal of the 
diseased bone, to inject these tracks, and necessarily the wound 
also, with the chloride-of-zinc solution, and then to apply the 
other antiseptic dressings. The anticipation that the zinc 
would entirely eradicate all putrefaction from the wound, 
while a thing to be aimed at, was hardly expected by him, and 
indeed wTas but seldom perfectly satisfactory; and it was only 
on a recent visit to Germany that he learned that Yolkmann 
accomplished much better results by first forcibly and thor- 
oughly scraping out the sinuses with a small, sharp spoon, on 
a long shank (devised by Yon Bruns, of Tubingen), and subse- 
quently injecting them with a carbolic solution of 1 to 20.1 
In the preceding description I have endeavored to give, as 
clearly and accurately as possible, the details of this method, 
inasmuch as considerable difficulty and some confusion will 
be encountered by those who try to study them out in the 
articles that have appeared in the medical journals during 
the past three or four years. Some few points need only to 
be alluded to, such as boracic ointment, made of the strength 
of 1 part boracic acid, 1 part white wax, 2 parts paraffin, 
and 2 parts almond-oil, spread on lint, used in the place of 
the protective to correct the discharges coming from foul cases 
of caries, etc. Boracic lint, dry and wet—i. e., lint2 dipped 
in a saturated boiling solution of the acid and dried, and 
the same dipped in a cold saturated solution and applied 
moist3—is employed in both clean and sloughing ulcers, as 
1 British Medical Journal, December 25, 1876. 
2 Or paper-lint, or loosely-felted paper, is much more absorbent than 
ordinary lint, and makes a very serviceable dressing. 
3 At 212° water takes up one-tbird its weight of the acid ; at 60° it takes 
up one-twenty-sixth of the acid. 17 
a precursor to the cliloride-of-zinc solutions and the usual an- 
tiseptic dressings. In its application, the protective, dipped 
in the watery boracic solution, is placed over the ulcer, and 
outside of this is laid a larger piece of the dry boracic lint 
dampened with the watery solution. This dressing is resorted 
to likewise in skin-grafting, abrasions, putrefying burns, and 
operations about the penis, and, in fact, about those parts where 
it is often impossible to use the more cumbrous gauze-dressing. 
For sounds and other urethral treatments (as suggested by 
Rolleston, in 1868), 1 part of carbolic acid to 20.of oil is used, 
and found unirritating. 
What results have been obtained by this mode of dressing 
wounds must necessarily be a question of absorbing interest 
to surgeons. A considerable amount of material, insufficient, 
undoubtedly, to answer satisfactorily such a question in all its 
branches, has now been accumulated, and at the same time 
ample enough to enable such deductions to be drawn, as to 
render it the duty of every one having the charge of surgical 
cases to diligently try it. 
My own experience dates from March 1st of this year, and 
comprises a period of five months of hospital practice, three 
of which were spent in the Roosevelt Hospital, and two in the 
New York Hospital; both of these institutions, one six years 
old, and the other opened for the reception of patients only 
this year, being magnificently equipped for the care of 
patients. 
The total number of cases which underwent the antiseptic 
treatment, with more and more thoroughness as time passed, 
was 56, 23 of which were under my own charge; and occurred 
both in hospital and private practice ; 9 in the care of Drs. 
Markoe and Mason, who followed me in service at the Roose- 
velt Hospital; and 24 were kindly furnished me by Dr. AV. T. 
Hull, Surgeon to the Chambers Street Hospital, to whom, let 
me state, I am additionally indebted for several valuable sug- 
gestions obtained by him in a recent visit to Edinburgh. This 
total comprises the following injuries and operations : 18 
CHAMBERS STREET 
HOSPITAL. 
1 NEW YORK AND ROOSEVELT 
HOSPITALS. 
Succeeded. 
Failed. 
Succeeded. 
Failed. 
Total. 
Amputation of thigli 
21 
3 
1 
6 
“ leg 
1 
Is 
2 
4 
11 ankle 
1 
1 
1 
2 
1 
4 
“ fore-arm 
1 
1 
2 
2 
4 
“ “ leg 
5 
1 
1 
7 
“ “ skull 
3 
3 
Ovariotomy, and explorat’y incision 
Strangulated hernia 
2 
2; 
2 
2, 
Loose cartilage of knee-joint 
1 
1 
Ligation of femoral artery 
2 
2 
1 
2 
3 
N erve-stretching 
1 
1 
Abscess 
1 
3 
4 
1 
1 
2 
Abscess and caries of tibia 
1 
1 
Removal of tumor 
1 
1 
Crushed toes 
1 
1 
Bursae 
1 
1 
2 
Wounds 
1 
1 
2 
43 
16 
8 
26 
6 
66 
A glance at this table shows that of the sixteen cases at 
the Chambers Street Hospital there were eight failures, while 
in my own ward the failures were only six in twenty-six 
cases. There is a legitimate explanation for this disparity. 
In the Chambers Street Hospital, from motives of economy, 
the larger pieces of gauze were, as suggested by Lister, or- 
dered to be washed and to be recarbolized. This was poorly 
done—so much so that, when an investigation was made to 
discover why the dressing had failed, the gauze was found 
to have been imperfectly cleansed and unfit for use. 
In almost all the failures taking place under my own obser- 
1 Died from sloughing and secondary haemorrhage on the fourteenth 
day. 
2 A double amputation; died from delirium tremens on the sixth 
day. 
9 Died from septicaemia and extensive sloughing of the wound. 19 
vation, retrospection detected some imperfectly-followed detail, 
such as the too frequent washing out of the wound, bandages 
too loosely applied, defective spray, and (the most common 
cause) dressings left too long in a soiled condition. In none 
of my own failures, save in one case which died from septicae- 
mia (hereafter given in detail), and one where the arm was 
amputated during profound septicaemia, was there anything 
more than ordinary free suppuration, which in itself deter- 
mined the cessation of what was considered at first a trou- 
blesome dressing. Now I should wash such out with the 
strong carbolic or chloride-of-zinc solution, and reapply the 
gauze, etc. 
The most interesting of these cases are herewith presented, 
in more or less brief outline. When not my ow7n, the name 
of the attending surgeon is given. 
Case I.—A Supra-condyloid Amputation of the Thigh 
(Stokes’s) was my first operation under Lister’s method, and 
its result exceeded any that I had ever witnessed in a large 
military and civil experience. It was as follows: 
P. C., aged thirty-two, was admitted to the Roosevelt Hos- 
pital, November 9, 1876, for caries of the lower portion of 
the tibia, of many years’ duration. The diseased bone was 
gouged out with apparent benefit, but subsequently, about 
January, 1877, the granulations had become sluggish and hard, 
and eventually took on an epitheliomatous appearance—a con- 
dition which was confirmed by microscopic examination. This 
gradually extended, with the usual concurrent symptoms, un- 
til the posterior border of the tibia became involved, and a 
false point of motion ensued. Upon the patient’s consenting 
to the amputation proposed, the limb was removed, May 14th, 
under the carbolic spray produced by an ordinary spray-tube 
and bottle attached by a rubber tubing to the steam-pipes of 
the hospital heating-apparatus. This threw a heavy cloud of 
mist, and was in this respect evidently a great improvement 
on the usual spirit-lamp and boiler, but was attended by the 
disadvantage of the steam condensing in the rubber tubing 
(although the steam-pipe had its proper “ blow-off”), which 
caused the emission occasionally of a little jet of warm water 
over the patient and operator. This watery discharge lasted, 
however, so short a time that it did not materially interfere 
with the spray-formation. Unfortunately, I may say that we 
have not yet overcome this difficulty, and in our other cases 20 
were compelled to resort to the lamp previously described.1 
The limb was removed by a long anterior and a very short 
posterior flap. The femur was divided about half an inch 
above its articular surface, and the cartilage of the patella cut 
off by a flat forceps and its bony surface leveled, in order to 
be accurately applied to the face of the sawn femur. This 
done, the synovial ligaments stretching on each side of the 
patella were divided, to allow egress of secretion from the sy- 
novial pouch above, the wound closed after the cessation of the 
haemorrhage by catgut ligatures, by catgut sutures through- 
out, except at the angles whence emerged the ends of the per- 
forated drainage-tubes which traversed the stump. The usual 
protective and gauze bandage was then applied up to the 
trochanter. 
At the next dressing, twenty-four hours later, everything 
was quiet. The shin adjacent to the wound was pale, and 
free from tenderness. The discharge was moderate in amount, 
of a bloody color, and free from any odor. 
The stump was dressed again three days later when the 
tube was removed. Union by first intention had occurred, 
except where the tubes had been lodged. During this time, 
he had surprised me, even at my first visit to him the day 
after the amputation, by the ready and painless way in which 
he used the stump, and on the third day he actually waved 
it about, to show me how easy he was. 
On the third dressing, May 20th, a pale spot half an inch 
across, on the farthest extremity of the anterior flap, showed, by 
its darkening a little, that it was dead, but its separation was 
accomplished with little or no irritation. In short, the patient 
was out of bed in eleven days, and, had my fears permiited 
it, he would have been out by the eighth day. Some of the 
sutures were removed at the fourth dressing, 22d inst., much 
reduced in size, and some were absorbed. The stump could 
then bear firm pressure with the hand. The absolute healing 
of the little ulcers resulting from the drainage-tubes took place 
a short time later. His temperature, the day after the opera- 
tion, rose to and after that did not at any time exceed 
"£°* 
Case II.—A Second Supra-condyloid Amputation of the 
Thigh, wherein failure threatened, but was averted. 
T. M., aged fifty-four, was admitted to the Roosevelt IIos- 
1 Since writing the above, I have witnessed the satisfactory working of 
an ingenious contrivance of Messrs. Angelo and Rundquist, by which, 
through the interposition of a small copper hall in the steam-tubing near 
the spray tubes, the condensed moisture is collected and converted into 
steam by the divided flame of a fine gas-jet. 21 
pital June 6, 1877, with an epithelioma of the left leg, of nine 
months’ duration, which had attacked a cicatrix. The ulcer 
was then two and a half inches in diameter. 
On June 21st, Stokes’s supra-condyloid amputation (a modi- 
fication of Gritti’s) was performed under Lister’s spray. Consid- 
erable oozing occurred, requiring sponges to be applied over 
the stump, secured by bandages, over which the gauze, etc., 
were applied. Drainage-tubes used. Dressing renewed next 
day. Temperature 100|°. Pulse 92. The stump did well, 
with but a little watery discharge. No pain was felt for four 
days, when a slight odor was detected, and the union of the flaps 
retrograded, with an elevation of the temperature to 103°. Bur- 
rowing was found next day to have occurred on the posterior as- 
pect of the thigh, which was arrested by a counter opening, and 
drainage-tube there inserted, after washing the stump and 
track out with the carbolic acid 1 to 20. This arrested the 
inflammatory action, and the temperature fell to 99°, but the 
stump healed by granulation satisfactorily, though slowly. 
Granulations varied from a large and flabby condition to the 
small and irritable. This was relieved a little by applying 
boracic acid to the ulcer, with a continuance of Lister’s treat- 
ment. Final closure hastened by the use of red-wasli. 
Case III.—Amputation of the Arm, performed on a 
youth of seventeen, for a railroad-crush of the hand and fore- 
arm just above the elbow’, by skin-flaps and circular division 
of the muscles, under the carbolic spray. Catgut ligatures used ; 
drainage-tubes inserted into angles of wound ; wound closed by 
carbolized gut sutures, and protective and gauze dressing ap- 
plied to the stump. Union by first intention occurred, save at 
sites of drainage-tubes. No pus formed, only a slight, glairy, 
brownish discharge ; no pain felt, and no swelling seen. First 
dressing twenty-four hours after operation, second on third day, 
and on the fifth day (third dressing) the tubes were withdrawn, 
by which time the union was firm, and at the next dressing 
the little ulcers produced by the tubes were closing rapidly. 
The temperature-table showed some elevation for a number 
of days, but this was due to the free suppuration and burrow- 
ing of a scalp-wound that had been dressed in the ordinary 
way. As far as the antiseptic treatment went it answered 
most admirably. 
Case IV.—Amputation of the Thigh, by Dr. Mason, August 
3,1877, for a railroad-injury which had ground up the leg and 
eaused considerable laceration of the lowrer third of the thigh. 
Circular amputation of the thigh just above its middle was per- 
formed the same evening, under antiseptic spray, with the liga- 
tures, sutures, drainage-tubes, and dressings, as usual. The 22 
femoral vein was also ligated. Temperature on the second 
day rose for a little wdiile to 100-|o, but after that to not more 
than a degree above the normal figure. On the third day 
this was the hospital record: “ Patient passed a comfortable- 
night; has no pain ; temperature 99^°; stump looking beau- 
tiful, and not at all sensitive. There is primary union through- 
out the whole face of the stump, except at corners where the 
drainage-tube projects. The discharge is slight, reddish, and 
inodorous. The sutures (catgut) already seem partly ab- 
sorbed.” lie went on steadily to recovery, without any un- 
toward symptoms. 
Case V.—Amputation of the Leg, by Dr. Markoe, Oc- 
tober 9, 1877, for a railroad-injury involving the ankle-joint.. 
The leg was removed by skin-flaps and circular division of 
the muscles, under the carbolic spray, and dressed after 
Lister’s method. Six dressings were used in eleven days,, 
and the wound healed by first intention, save at the drainage- 
openings. Only a glue-like discharge noted, never purulent.. 
Temperature on second day, 100|°; same evening, 99|°, 
wdiich it did not after this exceed. The result wras emi- 
nently satisfactory. 
Case VI.—Compound Fractures of the Fight Thigh and 
of the Rigid Leg, with a Lacerated Wound of Left Leg, in a girl 
of fifteen, caused by a fall from the roof of a three-story house.. 
The right femur was fractured in its middle third, the wround 
was transverse, two and a half inches long, and on the outer 
aspect of the limb. The tibia and fibula were broken in their 
upper third, and the ends of the fractured bones protruded from 
the wound in front. A laceration, four inches long, existed 
over the left ankle and leg. All dressed antiseptically. On the 
second day dressings changed; again on the fourteenth and 
twenty-seventh days, when only simple granulating ulcers were- 
found, and all closing steadily, AVound of right leg was then 
dressed openly to admit of extension by weight and pulley, and 
subsequently the other wrounds were similarly treated, as it had 
been found, in other cases, that the Lister treatment was open 
to the objection of tardy closure, and that the time had now ar- 
rived when it was better to leave it off, or resort to strapping, 
red-wash, etc. (This sluggishness of repair has been noticed by 
Lister, Dittel, Volkmann, and others, and is met by either 
abandoning the treatment, or by using salicylic acid or boracic 
acid on the wound, or, as I have found serviceable, by using 
the carbolized instead of the ordinary red-wash alluded to> 
above—i. e., sulphate of zinc, grs. ij ; comp. spts. lavender, 3 j; 
water, ss; sol. carb. acid 1 to 20, § ss, the antiseptic dressings 
being continued.) The patient was up and about at the end 23 
■of the ninth week, when she accidentally refractured her 
thigh. Two wTeeks later firm union had taken place. During 
the course of this very encouraging case, the temperature, ex- 
cept on the sixth day, when it rose to 102°, did not exceed, at 
any other time, 101°, and was generally below' that level. No 
swelling or pain was seen or complained of at any time, ex- 
cept in handling the limb. The discharge was purulent, odor- 
less, and slight in amount. 
Case YII.—Another Compound Fracture of the Thigh, 
with Simple Fracture of the JJlna, was admitted to the Roose- 
velt Hospital July 25,1877. It occurred in a boy of fourteen, 
and wras caused by a fall of about twenty feet. The ends of the 
femur protruded through the anterior part of the thigh, about 
jts middle. The bone wras found comminuted, and a fragment 
■one inch long, and involving more than one-half the shaft, 
was removed. The w'ound was dressed antiseptically by the 
injection, by means of a soft rubber cathetre, of a 1 to 20 so- 
lution of carbolic acid, and the other steps of the method car- 
ried out, excepting that,through misconception on the part of 
the house-surgeon, a drainage-tube was not introduced. The 
next day—26th—his temperature was 101°, and he was deliri- 
ous. On examination, I found that the wound wras closed, and 
that a collection of several ounces of bloody inodorous serous 
■discharge had occurred. The wound wras therefore enlarged, as 
.its edges had been strongly approximated by the swel ing that 
had ensued, a drainage-tube of good size introduced, the cavity 
well washed out with the strong solution, and the dressings 
reapplied. The same evening the temperature had fallen to 
99|°, and although it rose the next day to 102|°, with a con- 
tinuation of the delirium, yet after that time it sank to 99|°, 
above w'hich it did not again pass during the further progress 
•of the case. The subsequent discharges wTere slight, without 
■odor, and non-purulent, until the seventh day, when pus ap- 
peared. The swelling also disappeared, and the limb had an 
uninjured appearance. By the twentieth day only a simple 
granulating ulcer remained with a short drainage-tube, which 
latter was done away with on the thirtieth day. As far as the 
wound w'ent the patient did very well, but in this instance 
non union occurred, which has continued up to the date of the 
last record of the case, October 1st. 
Whether this was a condition that might have happened 
under any treatment, or whether it resulted from the destruc- 
tion of at least one inch of the bone, cannot, of course, be 
determined. Volkmann1 reports that this result—non-union 
“Samin. klin. Yortriige,” Nos. 117, 118. 24 
— has obtained several times (three times in seventy-five- 
cases) in the fractures treated antiseptically by him, and that 
it is probably due to the total arrest of the inflammatory 
oedema, which is always present even in a simple fracture, 
and which plays so important a part in the process of re- 
pair. What, in addition, materially contributes to the non- 
appearance of the oedema with him, is the quite firm pressure 
with which he purposely secures the antiseptic dressings. He 
therefore deems it advisable, as soon as possible, to immobilize 
the fractured limb, and preferably by coaptation-splints. 
Cases VIII. and IX. were respectively operations for the 
relief of strangulated femoral (omental) and inguinal (intesti- 
nal) hernias. One, the femoral, required opening of the sac, 
and the exposure of quite a large extent of omentum to 
the influence of the spray, and the other was reduced with- 
out dividing the peritoneum. Both did extremely well, 
with entire union of the wounds on the seventh and fourth 
days. 
Case X. Ovariotomy, for multilocular cyst weighing 
thirty-eight pounds. The carbolic solution used for spraying 
with in this, as in other cases, was made from absolute phenol,1 
which is less irritating2 and more soluble than any other form, 
and is the only kind used by Lister. In this operation—first 
done antiseptically, it may be stated, by Nussbaum in 1875, 
and subsequently by Keith, Olshausen, and others—it will be 
remembered, it is customary to place a sponge or cloth over 
the intestine when passing the abdominal sutures, in order to- 
absorb the blood effused by the needle. In this instance, a 
cloth wet with a 1 to 40 solution was resorted to for this 
purpose, and remained several minutes in situ without giving 
rise to any inflammatory reaction. The wound was closed 
with catgut sutures and without a drainage tube, and the 
other dressings applied, with numerous extra layers on each 
side of the clamp, so as to make firm pressure with the band- 
ages. The strong salicylized cotton was stuffed in all places 
1 Obtained at Caswell, Hazard & Co.’s, New York. 
5 The less irritating salicylic spray, 1 to 300, might be used if deemed 
advisable. No special risk of carbolic-acid poisoning is met with in ovari- 
otomy, as was supposed by Funk. This poisoning rarely occurs. Volk- 
mann, however, had one fatal case from this cause, but Bardeleben be- 
lieves that it arises from the use of impure acid. The acid has been de- 
tected several times in the urine by its black coloration in patients who 
were otherwise doing well. 25 
needing protection, as over pubes, and adjacent to bony points, 
etc. The patient did very well, and was out of the house on 
the twenty-first day. 
Case XI. An Exploratmp Excision through the Abdomi- 
nal Walls for a doubtful Ovarian Tumor, by Dr. Mason.— 
The case was ascertained to be one of hydatid tumors, and the 
incision, three inches long, was closed bv catgut sutures—all’ 
done after the antiseptic method. Primary healing took place 
promptly in the principal portion of the wound, but some gap- 
ing occurred in its upper part from the early melting of the 
catgut sutures. In fact, wherever there is likely to be tension, 
or the support is to be given for any length of time, the 
carbolized silk or the wire “ relaxation ” suture should be 
employed. 
Cases XII. and XIII. Two Ligations of the Femoral Ar- 
tery in Scarpais Triangle for Popliteal Aneurism, by Dr. 
Ma/rkoe, at the Roosevelt Hospital, with Primary Union of the 
Incision.—Dressing complete, except that the drainage-tube 
was not used. 
Some recent observations reported at the Clinical So- 
ciety in London,1 by Mr. Bryant, show that the catgut liga- 
ture accomplishes the division of the internal and middle 
coats, like the silk ligature, and that, where the wound is 
treated openly, sloughing of the outer coat can also occur. In 
four cases where a post-mortem examination was made, this 
latter was met with once. In the cases that died on the 
twelfth, thirteenth, and nineteenth days, the ligature had 
melted away, and in the last instance a small knot was the 
only part left. In a case wherein I ligated, with a fatal result 
the carotid and subclavian arteries simultaneously for innom- 
inate aneurism, employing a triple knot to secure the ligature, 
I was unable to distinguish, on the fourteenth day, any trace 
of the catgut used, and the vessels were found satisfactorily oc- 
cluded bv the divided middle and internal coats. Only rarely 
does the ligature give way in a few hours, as has been remarked 
by Callender, Spence, Smith, and others. Probably this is by 
the slipping of the ordinary reef-knot; as, in one of Mr. Bry- 
ant’s cases, in which death occurred fourteen hours after the 
ligation, the catgut was found intact, and the vessel occluded 
1 Lancet, October 20, 1877. 26 
above and below. If, joined to this reliable obstruction of 
the artery, we can have, by the aid of the antiseptic dressing, 
primary or rapid union, secondary haemorrhage and other 
risks can be almost done away with. 
Case XIV. Unsuccessful Nerve-stretching for Tetanus.— 
The incisions, each two inches long, for exposing and stretch- 
ing the sciatic and anterior crural nerves, were made under the 
antiseptic spray and hy the usual dressings. These were 
changed on the sixth day, and the wounds were found healed, 
except at the points of exit of the drainage-tubes. These lat- 
ter .were removed, and a few days later, when exposed, the in- 
eisions were healed. The amelioration of the tetanic spasms 
and trismus lasted for nearly eight days, when they recurred, 
and the case terminated fatally on the fourteenth day after 
the operation. 
Case XV. Exsection of the Fourth Metatarsophalangeal 
Joint, for severe neuralgia of the foot and leg, was done on a 
girl of twenty-two, July 26, 1877, after the method suggested 
by Dr. Morton, of Philadelphia, viz., by an incision two and 
half inches long on the dorsum of the foot, and under the 
antiseptic plan. The wound healed by first intention, save, as 
usual, at the drainage-opening, which closed August 13th, no 
general or local reaction having at any time shown itself. 
She was discharged from the hospital, free from pain, August 
21st. 
Case XVI. Unsuccessf ul Attempt to reunite Old Divided 
Tendons.—I should not have undertaken this operation, except 
that mv previous satisfactory experience with Lister’s dressing 
had given me the confidence that I should not submit the 
patient to any risk of further impairment by the operation. 
The man had had the proximal phalanges of the middle and 
ring fingers of the left hand cut across the middle of the 
palmar aspect by a knife, some eight weeks prior to his ad- 
mission to the hospital. The wound, he said, healed readily, 
but he found he had lost the power of flexing the fingers more 
than 10° to 15°. Under the spray I made a longitudinal in- 
cision in each finger, and found the proximal end of the deep 
tendon just within the palm, and the distal end above the first 
phalangeal joint, leaving a space of quite an inch in which 
there was total absence of tendon, nothing but a reddish 
friable band being found there. It was impossible to approxi- 
mate the ends, and the operation was therefore abandoned. 
Under the gauze dressing, applied as usual, but enveloping 
the whole hand and a portion of the forearm, the wound healed 
by first intention, and the drainage-openings closed on the 27 
tenth day. The man was discharged, with his condition as be- 
fore the operation. 
Case XVTL—This, with the next case, is an example of 
the conversion of an old suppurating wound into an aseptic 
one. It occurred in a man who had had his right wrist-joint 
opened by a hook tearing into it, several months prior to his 
entrance in the hospital. General arthritis of the carpal joints 
followed, with the formation of several sinuses. On Septem- 
ber 17th, excision of the wrist-joint was performed according 
to the mode of operation known as Lister’s—though, lately, 
he is reported as having abandoned the radical removal of the 
whole carpus, with the ends of the metacarpal bones, and those 
•of the radius and ulna,1 for the more simple gouging out of the 
diseased parts under the antiseptic spray and dressings. Not 
being able at that time to obtain the details of the new 
method, I followed the older one. The parts were removed 
according to rule, and the sinuses leading to the diseased bones, 
and necessarily the wTound also, were injected with the chloride 
of zinc solution (40 grains to the ounce); and as the oozing of 
blood was difficult to control from the combined cause of spray, 
zinc, and Esmarch’s bandage, the cavity of the wound was 
filled with carbolized sponges (1 to 20) secured by a wet gauze 
bandage, and the usual gauze dressings with the mackintosh 
put on over this, so as to cover the whole hand and forearm. 
■The sponges were removed the next day, a large drainage-tube 
placed across the exsected portion and the dressings renewed, 
this time with the protective, etc. These were changed every 
third day. On the fourth day, the splint constructed by Lis- 
ter for such cases was applied over the dressings ; and although 
this only imperfectly permitted the carrying out of the injunc- 
tion to frequently use passive motion, vet the performance of 
this, when the dressings were renewed, allowed a very good 
result to be obtained. No reaction occurred about the incis- 
ions, and but very little pus was formed. By October 8th 
{date of last report) the cavity of the wound had completely 
filled up, except a sinus due to the drainage-tube, and run- 
ning across from one side to the other. 
Case XVIII. An Old Suppurating Palmar Ganglion, 
with Sub facial Inflammation involving Palm and Forearm, 
was admitted to the New York Hospital, August 8th, 1877. 
An incision was made in two boggy points, one above the wrist 
and one in the palm, and drainage-tubes were put in after 
syringing out the tracks gently with the chloride of zinc 
solution. The antiseptic dressing was then applied. This was 
1 Boston Medical and Surgical Journal, October, 1876. 28 
changed on the 11th, 16th, 20th, and 25th, when healing 
occurred. The patient did remarkably well, and very little 
suppuration ensued. 
Case XIX. was a failure that terminated in death. A 
boy of twelve received an extensive laceration of the soft 
parts of the calf by being run over by a heavy cart, Septem- 
ber 1, 1877. It was determined to try the effect of the anti- 
septic dressing upon the case, with a view of avoiding amputa- 
tion. This was done, and the patient progressed very well for 
a week, when the dressing was discontinued, and thick layers 
of salicylized jute substituted, for the reason that the sero- 
purulent discharges were so profuse as to require redressing 
twice a day, and in the last twenty-four hours became offensive 
from unavoidable neglect in changing the gauze, etc. During 
this whole time there was no oedema of the parts above, and 
but very little elevation of the temperature. With the putre- 
factive changes the thermometer rose, and swelling of the 
limb ensued. The patient rapidly developed septicaemia, and 
died September 14th. 
As a full description of all the cases antiseptically treated, 
while of interest to those who may be engaged in carrying 
out this treatment for themselves, would occupy too much 
space for a paper of this description, I shall occupy but a 
short time in further referring to a few cases of interest that 
occurred in the charge of Dr. Bull. They are as follows: 
Case XX. A Compound Fracture of Right Tibia and, 
Fibula in its Middle Third, produced by a fall, was brought 
into the Chambers Street Hospital March 20th, 1877. It was. 
put up in Lister’s dressing after the wound had been washed out. 
At the end of the first week (i. e., sixth dressing) the wound had 
been converted into an ulcer without any formation of pus, 
only a serous sanguinolent discharge having been observed. 
Temperature at no time exceeded lOl^-0. Plaster-of-Paris 
splint was applied one month later, and on May 18th the pa- 
tient was discharged cured. 
Case XXI. Compound Fracture of the Fibula, One Inch 
above the External Malleolus, with Fracture of the Internal 
Malleolus opening into the Ankle-joint.—The foot was reduced, 
the wounds freely injected with a carbolic solution of 1 to 
20, and the antiseptic dressings applied with an external 
boot-shaped splint. No local reaction occurred, nor was any 
pain felt. The temperature did not exceed at any time 
during the progress of the case, except on the fourth day, 29 
when delirium tremens developed itself. Only a very little 
pus was formed at any time. The wounds were reduced to 
simple ulcers on the fortv-ninth day, but the final cicatrization 
was slow. Discharged witli good motion in the joint. 
Case XXII. Compound Fracture of the Tibia and Fibulay 
Middle Third, with a wound admitting the little finger. In- 
jected, and antiseptic dressings applied, but no drainage-tube. 
No reaction ; only a slight serous discharge. Six dressings in 
eighteen days, when wound closed. Put up then in plaster 
splint, and discharged. Union firm on thirty-seventh day. 
Case XXIII. A Bursa over the Patella, and of the size 
of half a lemon, was opened by a small incision, under car- 
bolic spray; one ounce of fluid evacuated, and a small drain- 
age-tube inserted after the cavity had been injected with a 
1 to 20 solution of carbolic acid. A carbolized sponge was- 
then applied as a compressor, and over this the antiseptic 
dressings. Primary union of serous surfaces occurred, and the 
patient was out of bed on the third day, and was discharged 
on the fourth day, with a sinus half an inch long, which 
healed in a week. 
Case XXIV. Removal of a Loose Cartilage from the 
Right Knee-joint bg Direct Incision.—This was accomplished 
under the carbolic spray, by a wound one and a half inch 
long, which was then closed by catgut sutures and the rest of 
the antiseptic dressing applied, except that no washing out or 
tube was used. The limb was put on a long posterior splint. 
Considerable pain was experienced for six hours, but from that 
time the progress of the case was completely satisfactory. 
No swelling or tenderness of the joint, or temperature eleva- 
tion, followed. Forty-eight hours after the operation the dress- 
ing was changed, and the wound found closed by primary 
union. A little bloody serum was seen about the wound. 
The patient was discharged from the hospital on the seventh 
day, walking about. 
While the foregoing list of cases does not embrace the 
whole number treated according to Lister’s method, yet it 
shows quite a uniformity of success in a variety of operations 
and wounds. The feeling of certainty as to the result, which 
those older in the method refer to, has, speaking personally,, 
decidedly augmented with the increase of experience. The 
total number—fifty-six—is, however, palpably insufficient for 
statistical inference; and, for the purpose of duly impressing 
you with the advantages of this method of treatment, I must 
bring before you the testimony of others who have been able- 30 
"by it to overcome the most serious obstacles met with in sur- 
gical practice. 
Saxtorph, of Copenhagen, who was the first on the Conti- 
nent to follow Lister’s teachings, says “ that it has completely 
-changed his principles of pathology and his surgical prac- 
tice;” and in respect to another point of interest, he states 
that “ he is equally sure that if he does not carry out the anti- 
septic treatment to its full extent, it is of no use whatever to 
apply carbolic acid to a wound, at least as regards the dangers 
that always accompany putrefaction.”1 
Nussbaum, in a report of the surgical cases treated in his 
•clinic at Munich, in a very bad hospital where, prior to 1872, 
80 per cent, of the wounds were attacked with hospital gan- 
grene, says that “since then, to the year 1875 (the date of his 
last report),3 there has not been a single case of this disease.” 
To accomplish this, he tried the open treatment, the occlusion 
dressing, the water-bath, irrigation with chlorine or carbolic- 
acid solutions, salicylic acid in solution and in substance, and 
the putting on of Lister’s antiseptic materials, such as the car- 
bolic-acid paste, etc., but all were unable to combat hospital 
gangrene and pyaemia. “ But when we applied,” he continues, 
“ to all our patients the newest antiseptic method, 7iow in many 
respects improved by Lister, and did all operations according 
to his directions, we experienced one surprise after another; 
everything went well; not a single case of hospital gangrene 
occurred, . . . and pyaemia and erysipelas completely disap- 
peared”—a statement that time has shown not absolutely true, 
though very near to it; for Lind pain tner,8 his assistant, has 
lately published a list of 459 cases of severity, treated anti- 
in which eighty deaths occurred, three of which were 
from pyaemia. In all these cases, only six cases of erysipelas 
were met with. 
Thiersch, of Leipsic, the first surgeon in Germany to use 
the Lister method, declares that, “ although the technical 
•details may be modified, Lister’s postulate”—exclusion of the 
ferments from the wound—“ will certainly never 
1 British Medical Journal, December 25, 1875. 
3 Idem, and “Die chirurg. Klinik zu Munclien im Jahre 1875.” 
3 Deutsche Zeitschr.f. Chirurg., vol. vii., p. 187. 31 
again be lost sight of.” lie it was who, in endeavoring 
simplify the antiseptic treatment, brought into use salicylic- 
acid. This disinfectant was employed by him in spray, while 
performing an operation, the wound of which was closed by 
antiseptic sutures, drained by rubber tubes, and covered by 
an inch layer of salicylized cotton of 10-per-cent, strength, over 
which a second layer, two inches thick, of 3-per-cent, salicylized 
cotton was placed, extending about a hand’s breadth above 
the stump, for instance, and secured by a bandage without 
any mackintosh. Later on in his experience, he used jute, 
salicylized to a similar strength, in place of the cotton.1 
(This substance, which is a veritable addition to the surgi- 
cal armamentarium, is the inner bark of a Bengal plant 
[corchorus capsularis], and from it the gunny-bags of com- 
merce are made. It is very absorbent, and makes an excel- 
lent dressing for freely suppurating wounds.2) This dressing 
was changed for the first time at about the tenth day, when 
the tube was removed. Healing of the wound was expected 
at the second or third dressing. lie reports the trial of this 
and Lister’s antiseptic treatment in one hundred and sixty 
cases, among which were fifty-one cases <>f major amputa- 
tions, resections, and compound fractures, and of which only 
1 “German Clinical Lectures,” Sydenham Society, p. 63, et seq. 
2 The 10-per-cent, salicylic cotton, the only kind required in the Lis- 
ter dressing, is made hy putting five pounds of hygroscopic cotton (a 
cotton deprived of its oiliness by being boiled in a 4-per-cent, solution of 
caustic soda, and recarded)1 in a solution of eight ounces of salicylic acid 
and two and a half quarts of alcohol of 0.830 sp. gr., diluted with four gallons 
of water at 150° Fahr. The soaked cotton is piled up, not hung, to dry. 
It is customarily stained w7ith carmine, to distinguish it from the 3-per-cent. 
cotton.2 The jute is salicylized to a 4-per-cent, strength, which lias, by 
reason of its permeability, been found sufficient. It is prepared by being 
immersed in a solution of two and a half ounces of salicylic acid, one pound 
of glycerine, and ten pounds of water, raised to a temperature of 158° to 
1760.3 This amount will suffice for five and a half pounds of jute. Jute 
is obtained at the Dolphin Manufacturing Co., 65 Duane St., N. Y., at 
eight cents per pound, and costs in hospital, when salicylized with Merck’s 
acid, about forty cents a pound. 
1 Bruns, Chirurg. Prax., p. 145. 
2 Girard, Circular No. 3, Surg. Gen. Office, 1877. 
Thiersch, op. cit. 32 
seven proved fatal. The results, the greater part of which 
were from the salicylic dressing, though ver}r brilliant, have 
been so much surpassed by the Lister treatment, that, since 
the publication of Thiersch’s statistics, it has been announced 
that he has given up salicylic acid and now uses Lister’s method 
altogether.1 Thiersch makes the statement that, however much 
the idea may be ridiculed, he entertains no doubt that failure 
often results from an under-estimation of the technical in- 
structions ; and those surgeons who regard the whole thing 
a priori as a kind of fashion, or even delusion, run a risk, on 
that very account, ot attaining bad results. 
Unfortunately, time will not permit me to quote the opin- 
ions of ali the well-known surgeons who have tested and have 
approved the antiseptic treatment. I need only refer to An- 
nandale, a colleague of Lister; Heath, of the University Col- 
lege Hospital, London ; Pick and Holmes,2 of St. George’s 
Hospital; Croft, of St. Thomas’s; Thomas Smith, of St. Bar- 
tholomew’s, where Callender has had such good results by 
other methods of treatment to be described hereafter; to Es- 
march, of Kiel, as well as to many other distinguished men, as 
indorsers of the efficiency of this method of treating wounds. 
It has been thought that some points might be omitted 
from the at first troublesome minutice—-some simplification of 
the method made; this, perhaps, will be accomplished as time 
advances and experience widens. Trials have already been 
made in this direction by Thiersch. Bardeleben,3 too, has 
been carrying on a modification of the antiseptic treatment 
in his clinic, but he finds he cannot omit the most annoy- 
ing feature of it—that is, the spray—though he weakens 
it to a per cent, solution. He uses, however, as a 
variation, the silkworm gut carbolized, and employs wdiat he 
calls jute-cake, or jute rolled into flat masses, which are 
soaked in a 1 to 20 carbolic-acid solution, and secured by a 
bandage without any mackintosh. But his results are not so 
good as those afforded by the Lister method, though in the 
treatment of several hundred cases he reports that pyaemia and 
1 “Transactions of the International Medical Congress,” p. 537. 
2 “ Treatise on Surgery,” p. 50. 
8 Deutsche med. Wochenschr., Nos. 22, 23, 1876. 33 
septicaemia did not occur, and erysipelas only once. At- 
tempts to do away with the spray, by simply washing out the 
wound with the carbolic-acid or chloride of zinc solutions, 
have not proved satisfactory with him. 
The most encouraging statistics presented by a modified 
antiseptic treatment are those furnished by Mr. Callender, of 
St. Bartholomew’s Hospital,1 and by Mr. Spence, an associate 
of Lister himself. Mr. Callender has given a report of forty- 
four amputations performed by him in the course of three 
years with only one death, or 2.27 per cent, (viz., twenty thigh 
amputations, one death ; sixteen of the leg, no deaths; two of 
the arm, no deaths; and six of the forearm, no deaths).2 
Callender’s method of treatment3 is, briefly, to tie bleed- 
ing vessels with carbolized catgut, he having formerly used 
torsion to arrest haemorrhage. He then washes out the stump 
with a carbolic solution of 1 to 20, or chloride of zinc 1 
to 12, and, after inserting for drainage two pieces of car- 
bolized gutta-percha tissue, loosely tied together with car- 
bolized catgut, which straddle the bone and allow the gutta 
percha to emerge from the angles of the wound, he closes it 
with silver sutures taken some distance from the edge of 
the wound. Over this are now placed three layers of lint 
dipped in carbolized oil 1 to 16, covered by gutta-percha tis- 
sue and a thick covering of cotton wool, all fastened by a 
bandage. Rest is secured by a stump-splint, hinged to allow 
ready redressing. The bandages, etc., are changed from one 
to three or five days. The catgut, dissolving in two or three 
days, permits the withdrawal of the drainage-tents. 
Spence4 has had not so happy a result,having had twenty- 
six amputations and six deaths—23 per cent. His most 
recent method is, after washing the wound out with car- 
bolic water and inserting a drainage-tube, to close it with 
sutures or straps, and to apply lint soaked in a saturated 
1 “St. Bartholomew’s Hospital Reports,” vols. ix. and x. 
3 These cases, it must be stated, are confessedly carefully-selected 
ones, many amputations being rejected for injuries that would probably 
be operated on by other surgeons. 
3 British Medical Journal, March 18, 1876. 
4 Medical limes and Gazette, October 28, 1877. 34 
boracic-acid solution, or in carbolized oil 1 to 20. The whole 
is then covered with waxed paper. 
Holmes has performed after Lister’s method, save using 
the spray, thirty-two amputations, and had only three deaths— 
9.3 per cent.1 All these cases make a total of one hundred and 
two amputations and ten deaths, or 9.80 per cent, of mortality 
by the modified antiseptic treatment. This mortality should, 
be compared with the results attained in the same hospitals- 
in years previous to the adoption of the present mode of 
treatment. In St. Bartholomew’s, for instance, there had 
been, from 1853 to 1868, seven hundred and nineteen amputa- 
tions and one hundred and fifty-four deaths—21.4 per cent, 
mortality; and in St. George’s, in five hundred amputations 
of all kinds, there were one hundred and fifty-three deaths- 
—30.6 per cent, mortality—of which seventy-five were case& 
of pyaemia. 
This omission of the spray, with the observation of the 
other directions of Mr. Lister, has not, so far as my researches 
go, been systematically resorted to to any great extent except 
by Mr. Holmes, though one would think, from the results ob- 
tained in the treatment of compound fractures, and wounds 
exposed for a moderate length of time to the air, that it 
might be successful. Nevertheless, a number of trials have 
been made with antiseptic dressings differently applied, such 
as those of Pozzi in Paris,2 where no spray was used, and, 
instead of the antiseptic gauze, carbolized cotton was em- 
ployed, and over this was placed carbolized hygroscopic 
cotton ; and instead of protective, gold-beater’s leaf was 
substituted; and for the mackintosh, ordinary oiled silk. 
Seven cases of operation are given as the result of this- 
treatment, only one of which was of magnitude, viz., an 
amputation of the leg in which union by first intention 
occurred. The imperfection of such reports constitutes at 
present the difficulty of comparing their results with those 
attained by Lister’s method. 
If wTe now take compound fractures of thigh, leg, arm, and 
forearm, which, together with amputation-wounds, are by com- 
1 “ St. George’s Hospital Reports,” vol. viii. 
2 London Medical Record, March, 1877. 35 
mon consent resorted to to test the value of any new method 
of treating wounds, and for obvious reasons, we find that Cal- 
lender had forty cases of such injuries, with but one death— 
viz, 2.5 per cent, only of mortality. Spence reports so few 
cases of this sort—only three compound fractures, with one 
death—that they are useless for our present purpose. 
There are two other modes of treating wounds that should 
be considered a moment, before endeavoring to appreciate by 
comparison the statistical value of Lister’s dressing. I refer 
to the open treatment, and the cotton-wool dressing of 
Guerin. The open treatment is indicated by its name. The 
stump of an amputation is not closed; it is simply left exposed 
to the air, covered lightly by a cloth to protect it from flies, 
etc., and under it is placed a saucer to catch the secretions. 
It was introduced to notice in the early part of this century 
by Kern, a Vienna surgeon, whose name is sometimes attached 
to the method. It was, however, revived in 1856 by Vezin, 
of Osnabruck, as well as by Burow, Bartscher, and Hum- 
phrey. Latterly, the success that can be attained by this method 
has been made known to us by Dr. James R. Wood, of this city, 
who has published, through his house-surgeon,1 fourteen cases 
of amputation treated in this way without a single death. An 
excellent resume of the results of this treatment is given in an 
able article by Kronlein in the Archiv fur Idinisehe Chirurgie 
for 1875. He there compares the results obtained by it with 
those furnished by the antiseptic method. In presenting them 
to you for comparison, only the amputations or compound 
fractures heretofore referred to—to wit, of the thigh, leg, arm, 
and forearm—will be considered. From a number of amputa- 
tions by the open method, furnished by Kronlein—viz., fifty- 
three, with fourteen deaths—the mortality from this method 
is shown to be 26.4 per cent. ; and, of sixty-five cases of com- 
pound fractures likewise treated, the mortality was fourteen, 
or 21.5 per cent. ; though, if he included, as he should have 
done, those fractures wherein amputation or resection was ne- 
cessitated by the progress of the case, the mortality would 
have been 25.4—i. e., one hundred and two cases, with twenty- 
six deaths. Erysipelas was more common, also, in the open 
1 Dennis, New York Journal of Medicine, June, 1876. 36 
treatment than by the antiseptic method. The duration of 
the treatment, again, was in favor of Lister’s method, as two 
is to one—e. g., for thigh-amputations by the open treatment, 
the duration in hospital averaged 118.2 days ; by the antisep- 
tic treatment, 61.2 days ; for leg amputations, open treatment, 
87.5 days; antiseptic, 47 days; arm, open, 57.7 days; anti- 
septic, 28.7 days. 
In respect to the cotton dressing of Guerin, we learn from 
Hervey 1 that the mortality of the amputations treated by this 
method amounted to 46.1 per cent. 
How, naturally to meet such figures as have just been 
given, and especially those of Callender, one turns, for the 
facts required, to Lister himself. Unfortunately, he has pub- 
lished but few cases, and those mainly to illustrate his method. 
The condemnation, therefore, for not making his results known, 
passed upon him in the discussion upon the subject of antisep- 
tic dressingsin the Clinical Society of London, is, so far as the 
English language is concerned, correct. But in 1874, in Lan- 
genbeck’s Archiv fur Tdinische Chirurgie, Reyher published 
a careful comparison between the results of treatment of Lis- 
ter and his predecessor in the same hospital, the great Syme. 
These are extremely interesting in themselves, as well as 
for the purpose of contrasting with the statistics of others. 
Reyher collected one hundred and twenty amputations per- 
formed by Syme, in which there were twenty-eight deaths—a 
mortality of 28.3 per cent. ; or, in leaving out the hand and 
foot amputations, there were seventy-five major amputations, 
with twenty-six deaths—a mortality of 33.3 per cent.; and, of 
these, there were sixteen from pyaemia and four from septicae- 
mia. The number of amputations performed by Lister was 
one hundred and twenty-three, in which there were twenty- 
one deaths, or a mortality of 17 per cent. Taking out the 
foot and hand amputations, as in the preceding case, there 
remain sevent}r-six major amputations, with twenty deaths, 
or a mortality of 26.3 per cent, as against 33.3.2 Only one of 
1 These de Paris, Sur le pansement ouatg. 
2 Expressed differently: Syrne, for pathological amputations, had 26.8 
per cent, mortality; for injuries, 41.1 per cent. Lister, for pathological 
amputations, had 15.9 per cent.; for injuries, 40.6 per cent, mortality. 37 
Lister’s deaths occurred from a wound complication. Inas- 
much as it has been asserted that the deaths charged by Lister 
to anaemia really resulted from diseases due to wound-poison- 
ing, I have taken the trouble to examine his table of deaths, 
and find that, of the fourteen cases assigned to this cause, one 
had a secondary haemorrhage, and died two days after it; one 
died between forty-eight and seventy-two hours after the opera- 
tion, from other injuries, and twelve died within twenty-four 
hours—too early, therefore, for septic effects. Lister’s wards, 
it must be remembered, are small—of a capacity of fifty-five 
beds, but often containing seventy-five patients—and are al- 
ways over-crowded. The absence of pyaemia and septicaemia 
is therefore all the more striking in these figures of Reylier. 
Erysipelas has been with him, as well as with many of his fol- 
lowers, reduced to a rarity. 
While the opinions and data just given show very clearly 
the advantages of the antiseptic treatment, and while the gen- 
eral impression of all surgeons witnessing that treatment in 
Lister’s own wards has been favorable to the method, yet the 
statistics themselves do not equal those presented by Callen- 
der. It is difficult to make such a contrast as perfectly as 
could be wished, because of the want of sufficient details. It 
is desirable, for example, to know, in Callender’s table, how 
many were pathological amputations, or what complications ex- 
isted, if any, at the time of the operation, etc.; for, in an expe- 
rience the most important yet offered to the profession on the 
subject of antiseptic dressings, these points are strictly elabo- 
rated by the reporter, Dr. Volkmann, of Halle.1 This emi- 
nent surgeon has had, since the year 1874, excluding cases of 
ligature of arteries, operations on tumors, severe injuries of 
the hand, operations in which the abdomen was opened, etc., 
about ten thousand cases under the antiseptic treatment, 
rigidly carried out according to Lister’s directions. Of this 
number, he states, more than a thousand were great opera- 
tions and severe injuries. The amputations amounted to one 
hundred and eighty-three in one hundred and pa- 
1 Congress of the Society of German Surgeons, London Medical Record, 
June 15, 1877. 38 
tients, of whom twenty-three died—equal to 13.3 per cent.;1 
but twenty-three cases, with sixteen deaths, should be de- 
ducted to place them fairly in relationship to Callender’s, and 
then the mortality would descend to the low rate of 2.87 per 
cent. !—only snrpassed by Callender’s 2.27 ! If the foot-ampu- 
tations were cut off, as they should be—forty-two cases, with 
no deaths—the percentage would rise to 3.09. These results, 
whether Callender’s or Volkmann’s, are truly wonderful. Of 
the two methods—one strictly and the other the modified an- 
tiseptic method—-judging from personal observation, that of 
Lister’s is the most likely to afford the best results in inexperi- 
enced hands, and has an advantage in not requiring the dress- 
ings to be so often disturbed. 
On this point Mr. Holmes, who, be it remembered, omitted 
with marked success the carbolic spray, says, in his “ Treatise 
on Surgery ” (1875), that, “ allowing for this (that is, the 
effects of cleanliness, well-managed hospitals, etc.), I cannot 
but express my strong conviction of the value of the method 
of dressing wounds which Mr. Lister has introduced. I have 
frequently pointed out the perfect immunity from traumatic 
fever, which in some cases follows even the gravest injuries 
or operations thus treated ; and, although I quite admit that 
a similar immunity follows after other methods of dressing, 
yet I think it is more common after that which is called the 
‘ antiseptic system ’ than any other, and on that account I 
advocate the use of that system, as wrell as on account of its 
utility in hospital practice, as necessitating the dressing of 
important cases by the surgeons or house-surgeons themselves, 
and almost excluding the possibility of any subsequent inocu- 
lation.” 
Turning again to the results secured by the Lister treat- 
ment in compound fractures, with which we only have the open 
and the modified antiseptic treatment to compare it, even more 
encouraging figures are presented. Volkmann (not to allude 
to his other great successes) has had seventy-five compound 
fractures in seventy-three patients under his charge, and, with 
the aid of the antiseptic treatment, has not lost a single one, 
1 Compare with statistics of St. George’s and St. Bartholomew’s Hos- 
pitals, ante. 39 
although amputation became necessary in eight of them. Add 
to this, as occurring at the same time in his hospital, fifty 
operations of osteotomy in thirty-eight patients, with only one 
death (from the haemorrhagic diathesis), and you have a suc- 
cess that is unparalleled ! The compound fractures included : 
thigh, one ; knee, four ; leg, forty-two ; arm, six ; elbow, five ; 
forearm, fifteen. 
The osteotomies were performed on the femur thirteen 
times, and on the tibia thirty-seven times. Resection for false 
joints was also done nine times successfully.1 The comparison 
of these results of seventy-five cases and no deaths with the 25.4 
per cent, of mortality by the open method or with the 38 per 
cent, of mortality by the ordinary treatment,® is too striking 
for comment. It will only bear association with Callender’s 
forty cases and one death.3 Many of these compound frac- 
tures of Volkmann’s were machinery-accidents, and many had 
the lacerated muscles hanging out of the wound, and in several 
cases the skin was torn off from the knee to the ankle. As 
his experience grew, the resort to amputation became more 
and more seldom. This treatment also received a severe test in 
those cases of compound fractures where the large joints4 were 
involved, which occurred in twenty-one cases, with the result of 
eleven times preserving the limb, with anchylosis taking place 
in only one case ; which result, he says, surgery in former times 
can show nothing analogous to. He corroborates a statement 
made in the earlier part of this paper, that irrigation of a wound 
is to be avoided after the first dressing, as it disturbs the 
coagula, etc. By not doing this, and by removing the drain- 
age-tube early, he has had primary union, without any re- 
maining sinus, in hip, knee, shoulder, and elbow resections in 
four, eight, and sixteen days from the date of the operation. 
The early removal of the tube—in which point he differs from 
1 “ Sammlung klinischer Vortrage,” Nos. 117, 118. 3 Idem. 
3 In the Boston City Hospital, for the five years ending 1874, were 
one hundred and fifty-seven compound fractures, of which sixty-five died 
—41 per cent. From the Roosevelt and St. Luke’s Hospitals I have notes 
of twenty-one cases and seven deaths—33.3 per cent. 
4 When this complication was encountered, the joint itself was opened, 
washed out with the carbolic solution, and drainage-tubes inserted. 40 
the teachings of Lister—may he done from the second to the 
eighth day, or as soon as it is seen that no fluid flows out on 
moderate pressure. 
As his results have been so good and his experience 
So large, it will perhaps be of service to shortly sketch 
his manner of treating compound fractures, especially as 
we have but little in English concerning the antiseptic treat- 
ment of these injuries. Since, with him, the first dressing 
decides the fate of the patient and the progress of the wound, 
much care must be spent on it. All counter-incisions, sawing 
off of the ends of the bones, extraction of loose splinters, adjust- 
ment of fragments, and disinfection, must be attended to at this 
dressing. As he believes it is necessary that the ends of the bones 
should be seen, he often widens the wound and scoops out the 
clot, so that the irrigation (with a 1 to 20 solution) can be thor- 
oughly made against the fractured portions, and especially in or 
against the fissures caused by the injury. By this exposure of 
the bone, also, any portions of intervening muscles, etc., can 
be removed. Counter-openings are to be made if the wound is 
deej); and, if the fracture cannot be reached through the original 
wound, it is to be cut down upon by a free incision at the near- 
est point. After the irrigation, the drainage-tubes, small and 
numerous, are inserted to the fracture, not between it, and in 
all pockets, with their projecting ends trimmed off and held 
externally by a needle traversing them, and the wound finally 
closed up to the tubes by sutures. A second irrigation is now 
made, and the surplus fluid gently pressed out. No protec- 
tive is employed, but from fifty to one hundred (sic) small 
layers of the gauze are placed over the wound, and then the 
usual piece of eight layers, with the interposed mackintosh, is 
firmly bandaged on with a wetted gauze bandage. All crevices 
and ill-fitting edges are stuffed with salicylized cotton, for he 
considers it an hermetically-closed dressing. This is removed 
the next day, and, as previously stated, as soon as the discharge 
ceases, the tube is withdrawn. If, at the second dressing, the 
bone is yet exposed, he scrapes the sides of the wound to make 
it bleed, so as to hide the bone by a coagulum to be organized 
under the dressing. When the wound becomes glassy-red 
the protective is to be used. The dressing is to be continued 41 
until the granulations have filled the wound. If necrosis 
occurs, the wound will close over it until it is loosened, when 
it will be discharged, or be dissolved in transitu. Immobility 
of the fracture should be obtained early by outside splints and 
by a plaster-of-Paris bandage. When the latter is applied, he 
places over the wound a piece of cotton soaked in the carbolic 
solution 1 to 20 ; then he covers the rest of the limb with anti- 
septic dry cotton, and applies the plaster bandages. The 
fenestra is cut out under the spray, and antiseptic cotton is 
tucked under the edges and the gap filled up with the gauze. 
If the fenestra is large, the splint is put on in the usual 
way, and salicylic cotton is forced under the edges of the 
opening, etc., before the gauze is applied. 
In his last sixty cases, by the constant improvement that 
has gone on in his dressings, the results he states have become 
almost ideal, and his severest cases have united like simple 
fractures. 
Volkmann says of himself, that he only gradually got into 
the way of using the dressing properly—a statement likely 
to impart comfort, I hope, to a surgeon more than half dis- 
couraged by failures often inexplicable to him. 
But one word more need be said, and that is in reference 
to the cost of this dressing. I have computed that the six 
dressings probably required for a successful thigh-amputation, 
allowing six yards of gauze to each dressing, two pieces of 
mackintosh, with the other materials, will average about sixty 
cents per dressing. 
In concluding this long, and, I fear, from its necessary 
minuteness, fatiguing description of the antiseptic treat- 
ment of wounds, with the results that have been obtained, 
I trust that the experience presented will have been sufficient 
to convince the most doubting of its practical efficacy, and 
to induce them to put it into immediate use. Moreover, the 
vast saving of life, which a reduction in mortality such as is 
shown in this little table means, should, if continued, as it 
probably will be, entitle any one who has been the instrument 
in the accomplishment of such results to a high place in 
the list of man’s benefactors; and it seems to me that 
among them the name of Joseph Lister must outrank in 42 
medicine all of liis century, not excepting the discoverer of 
anaesthesia. 
MORTALITY TABLE. 
From 
Ordinary- 
Treatment. 
From 
Open 
Treatment. 
From 
Modified 
Antiseptic 
Treatment. 
From Strict 
Antiseptic 
Treatment. 
Amputa- 
tions 
f Thigh "I 
Leg 
Arm 
Forearm 
-per ct. 
21.41 
28.002 
26.43 
2.274 
9.805 
3.096 
10.911 
Compound 
Fractures 
Thigh 
Leg 
Arm 
Forearm 
- per ct. 
38.00s 
26.49 
2.5010 
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