[REPRINT! FROM “ THE CANADIAN PRACTITIONER,” TORONTO, 
SEPTEMBER, 1884.] 
Later Antiseptics in Private 
Surgical Practice. 
By TUB. 
• EDGAR, ONT. Later Antiseptics in Private 
Surgical Practice, 
IN discussing the treatment of wounds, a 
subject confessedly the most important in 
the whole domain of surgery, we have no longer 
to ask, “ Shall* antiseptics be used V’ That 
question has been answered, and in its place have 
arisen the queries “ What antiseptics shall we 
use V’ and “ How shall we use them so as to 
obtain for our patients the greatest safety and 
benefit, and for ourselves the least trouble and 
expense V’ The principles which underlie their 
scientific use, and with which for all future time 
the honored name of Sir Joseph Lister will be 
associated, briefly stated, are:—1st. That in the 
air, in fluids, and in the dust around us there 
exist particalate living bodies which may gain 
access to any wounds not subcutaneous. 2nd. 
That entering a wound they are the active 
agents in setting up putrefactive fermentation 
in its discharges. 3rd. That if they are abso- 
lutely excluded or are rendered innocuous, fer- 
mentative changes, with their frequently disas- 
trous consequences, will not ensue. These 4 
principles the surgical world has, either in 
words, or in actions that speak louder than 
words, accepted as proven. Founded upon 
them we had till recently only that system 
worked out by the father of all antiseptic sur. 
gery, and known by the name of Listerism. It 
aims to prevent the entrance of germs into 
wounds, and to keep these wounds strictly 
aseptic. Volkman modified this by washing 
the germs from the wound while it was exposed, 
and then protecting it from them by a dressing 
similar to Lister’s. Billroth disregards the 
entrance of germs into wounds, ’Or tbeir presence 
in discharges, but depends on destroying their 
power for evil by the presence of an antiseptic 
powder. While carbolic acid remained the only 
or the chief antiseptic, no modification of Lis- 
terism was advanced suited to the requirements 
of private practice. The original method of 
Lister, befogged with spray and enshrouded in 
the folds of a mysterious gauze, the proportion 
of antiseptic, in « hich might be anywhere from 
5% to b of 1%, poisoning the patient or keeping 
his wound sodden and in an unfavorable state 
for rapid healing, irritating the wound till its 
discharges soaked through the thickest dressings, 
intricate, troublesome and expensive, had but 
one thing to commend it to the general prac- 
titioner. That one thing was the success at- 
tending its full and careful use. My practical 
experience with it began in 1873, in the treat- 5 
ment of a compound fracture. Ever since then 
I have followed, sometimes perhaps afar off, the 
practice of the Lister school. By doing so I 
have reached some results that by ordinary 
methods, I could not have hoped for. Of these 
I shall mention here only one series : Five pene- 
trating wounds of the knee-joint, chiefly axe- 
cuts, recovering perfectly and promptly. It is 
but just to say that ice supplemented the action 
of the antiseptics in each of these cases. In 
the treatment of less grave wounds, I have like 
others been seeking constantly for simpler, safer 
and less costly methods. The spray I long since 
abandoned for the douche, and the unstable 
carbolized gauze for that prepared at the time 
of use with Von Brun’s solution. But it is only 
since the later antiseptics appeared and their 
value was demonstrated tlat I have felt the 
slightest danger of becoming a contented rout- 
inist. 
Named in the order of their importance these 
are : The bichloride of mercury, iodoform, 
boracic and salicylic acids. Within the last 
four years they have been employed by num- 
berless careful observers, and conclusions as to 
their safety and relative value have been reached. 
The most exact and extensive of these observa- 
tions have been made in Germany. Based upon 
the methods of their use in that country, as de- 
scribed in recent literature, or as followed or 
modified in the New York, Roosevelt, Mount 6 
Sinai, and German hospitals of New York city, 
where I have lately had opportunity of studying 
them, I wish to describe a method of wound 
treatment particularly adapted to the needs of 
private surgical practice. At the same time I 
do not wish to go on record as advising that any 
one method of treatment be used for all classes 
of wounds. The shoemaker who works on a 
single last is not the one who fits his customers 
most exactly. 
The aseptic condition, close approximation, 
drainage, the elastic pressure of dry and absor- 
bent dressings, rest and protection, these are 
what we should aim to secure, and through them 
by the method now to be described, we may 
expect most wounds to heal without suppuration 
and under a single dressing. Under an essen- 
tially similar method, Esmarch and Neuber of 
Kiel, found it necessary to change the dressings 
more than once in but 11 out of 212 cases of 
extensive wounds. Made, closed and protected 
in this way, one may leave, as I frequently have 
left, wounds to await a convenient hour for 
further attention at any time within ten days. 
Pain, fever, or the appearance of discharges are 
to be reported by the friends of the patient at 
once, and are the indications for the renewal of 
the dressings. 
It will be convenient to suppose that a tumour 
of moderate size, situated on the fore-arm, is to 
be removed at a country farm-house. The arm 7 
of the etherized patient is brought through an 
opening in a rubber sheet, and the upper part of 
this opening is drawn closely and secured by a 
safety-pin, or is laced or contracted by a purse- 
string of elastic tubing. The folds of the sheet 
are then so disposed as to convey fluids into 
anything convenient, placed on the floor to re- 
ceive them. Next comes the thorough cleansing 
and disinfecting of the part to be operated on, 
and of the hands of the operator and his as- 
sistant. Soap, hot water, and a nail brush first, 
and then a solution of the bichloride of mercury, 
1 : 1000 should be freely used. 
At the New York hospital, in the service of 
Dr. Weir (to whom personally and to whose 
writings I am much indebted), the field of 
operation is also bathed with turpentine and 
alcohol, 1 to 7. The standard antiseptic solu- 
tion may be prepared easily and with sufficient 
exactness when and where wanted by dissolving 
an 8 gram sublimate powder in each pint of 
water. I am in the habit of carrying these 
powders in a hard rubber pocket match safe. 
The recent discovery by Sir Joseph Lister that 
sublimate is soluble in 1| times its weight of 
glycerine, may furnish a still more convenient 
mode of preparing our solutions. Such a glyce- 
ole would doubtless diffuse in water more 
rapidly and uniformly than a powder could dis- 
solve. The 1 : 1000 .solution is to be mixed 
with an equal measure of hot water, for use in 8 
cleansing sponges and douching the wound. A 
tank, a fountain-syringe, or Esmarch’s inverted 
and bottomless bottle, arranged as I show you, 
may be used, but most convenient and portable 
of all is the syphon douche now presented. 
This consists of a sinker weighing 3 oz., attached 
to one end of a tube of thick rubber 4 or 5 feet 
long, on which has been slipped a clip to close 
the tube when desired. These replace the short 
afferent tube and light sinker of any good syringe 
made after the Davidson pattern. Any pitcher 
will do for a reservoir, and the thick tube 
comiDg over its edge will form a curve instead 
of an angle, which would occlude it partly or 
completely. A fine nose tip of hard rubber is 
convenient during operation, but a tapered tube 
must replace it to inject the drainage tube and 
the deeper parts of the wound. Constant irri- 
gation, though not required, is harmless. Since 
the mercuric salt acts injuriously on instruments, 
rusting and dulling them, and loosing its strength 
in doing so, we have yet to use for their disin- 
fecting a saturated 1 : 20 aqueous solution of 
carbolic acid. In this strength carbolic acid 
benumbs the fingers dipped frequently into it; 
hence it is well, when one is his own assistant, 
to place a towel wet with bichloride solution, 
when the instruments in use can be for the 
moment laid down, instead of being returned to 
and fished out from the carbolic lotion as wanted. 
The cutting instruments can be conveniently at 9 
hand on a plate or platter, while a bowl makes 
a bath for the forceps. Of these last, since the 
securing of every bleeding point is so important 
when the effoit is to gain entire primary union, 
I make mention of the exceptional value cf Sir 
Spencer Wells and Pean’s pressure forceps, and 
of the torsion forceps of Fricke. Good models 
of these are shown, since bad ones are common. 
The plan of going down for a bleedirg vessel, 
and lifting into view successively deeper and 
deeper portions of tissue with a pair of dissecting 
forceps held in each hand, is worth referring to 
in this connection. Sponges should be kept and 
carried in a sublimate solution. Dr. Weir 
showed me a rubber ice-cap, with large hard- 
rubber screw top, which made a very convenient 
receptacle for them. Not less than three basins 
of warm 1 : 2000 solution should be provided 
for the cleansing of the sponges. Passing through 
these in rotation, they reach the operator clean 
and dry. This point I should hardly have men- 
tioned if I had not seen sponges so often thrown 
into and taken from the same basin during an 
entire operation. Many surgeons, who would 
not think of using dirty water for their own 
faces, apply it without stint to their patient’s 
wounds. The tumour removed, every bleeding 
point is to be secured by torsion or the catgut 
ligature so as to leave a dry wound. At present, 
in New York, catgut which after preparation, 
has been kept in oil of juniper or in absolute 10 
alcohol, is used almost entirely. It ties and 
keeps its knot better than that preserved in car- 
bolized oil. In ligating arteries, I use now only 
the two larger sizes, as the smaller ones are not 
strong enough to stand being tied, as Robert 
Liston said ligatures always should be, “ devilish 
tight.” For sutures, however, and in particular 
for the “ sunken sutures” of the Germans—those 
by which we close together muscle to muscle in 
the deeper parts, tying the knot far below the skin 
and obliterating the wound, they are excellent. 
The lines of drainage shonld be next arranged, 
and in them placed one or more absorbable 
tubes. I show you those of Neuber, imported 
from Germany, and those of MacEwan, made 
by my assistant, from the femora and tibiae of 
chickens. Since the one form has with me suc- 
ceeded as well as the other, and since the natural 
tubes can be bought in the flesh for about the 
same price as the drilled and turned ox-bone in 
oil, my decalcified tubes in future will, I think, 
be after-dinner considerations. If the wound is 
to be dressed again within a week, either rubber 
tubes, horse-hair, or Ghiene’s chromic-acid catgut 
may be used. The two last I have not found to 
drain pus well, though they are excellent for the 
early serous discharges. For closing the wound, 
catgut should be preferred. Horse-hair answers 
for adjusting the edges of the skin, and silver 
wire secured by lead buttons may be needed to 
sustain tension. If silk be used at all, it should 11 
have been prepared by boiling for an hour in a 
5% carbolic lotion, and should have been kept 
in one of the same strength. The line of union 
is to be dusted with iodoform, and then covered 
with several handkerchiefs of 10% iodoform 
gauze, or | of 1% sublimate gauze, over which a 
roller of the latter material is to be applied. 
The dressing is completed by the adjustment of 
bags or pads filled with some one of the absor- 
bents presently to be spoken of, by a second 
roller, and a splint to secure perfect rest to the 
part. Cheese cloth, boiled in a soda solution to 
remove fatty matters, and then washed in water 
to get rid of the alkali, answers for the prepara- 
tion of the handkerchiefs, the bandages, and the 
pad covers. Iodoform gauze is made with this 
very simply, by Billroth’s plan of rubbing the 
crystals into the meshes of the cloth. From 10 
to 20/ will be retained. Another method is to 
saturate the cheese cloth in iodoform 50 parts, 
ether 250 parts, alcohol 750 parts, and allow the 
fluids to evaporate. This gives a 10% gauze. 
Iodoform is always a dessicating dressing, hence 
it is important to bring the ends of the drainage 
tubes through the layers in contact with the 
wound. Neglect of this in one case where I had 
drained a compound fracture extending into the 
elbow joint, caused the end of the drain to be 
sealed in the antiseptic scab, the serous discharge 
to be retained, and the temperature to rise to 
103° F. All went well again when the mistake 12 
was corrected. The great value of iodoform 
lies in its permanence. It constantly evolves 
an antiseptic influence, as penetrating and as 
persistent as its own odor. Being non-irritant, 
a moderate quantity between the lips of a cut 
will not prevent union by the first intention. 
Neuber warns us that not more than 45 grains 
should be applied at any one time to a raw sur- 
face. When first introduced, large wounds, as 
after hip excisions, were filled with it, and 
deaths followed. Now we have the authority 
of Lister, Macormac, Longman, Billroth, Sands, 
and many others, for considering it to be the 
best-known antiseptic for direct application to 
wounded surfaces. 
The bichloride gauze is made by simply satur- 
ating the cheese cloth with bichloride of mer- 
cury, 20 parts, water 4,480 parts, glycerine 500 
parts, and allowing it to dry as far as the 
glycerine will admit. Its active agent, besides 
being the most powerful antiseptic of which we 
have any knowledge, is always at hand, is safe, 
permanent, pleasant to handle, and is only irri- 
tating to the extent of producing an occasional 
slight dermatitis. 
We come now, and finally, to the absorbents 
which may be used to scak up and keep harm- 
less all fluids which our internal drainage has 
brought to the surface. Of these I show you 
hygroscopic cotton and the same containing 15% 
of boracic acid. They will each take up, as I 13 
have found by experiment, 16 times their own 
weight of water; wood-wool, 14 times; german 
peat, 12 times ; and jute, 8 times. Dr. Weir is 
now testing the ordinary moss of our woods as 
an absorbent. After drying it in an oven to 
kill the insects it may contain, he finds it soft, 
elastic, and able to soak up about four times its 
weight of water. The New York Medical 
Record of last week contains a letter from Dr. 
Lydstone, of Chicago, advocating the use of punk 
or spunk, a substance used by dentists to dry 
out cavities in teeth. I show you a piece, part 
of which, when tested, was found to absorb 11 
times its weight of water. I have not been 
able to obtain wood-wool from the paper makers 
here. That shown and also the peat came from 
Germany. Both are exceedingly cheap, costing 
only six or eight cents per pound in original 
packages. Specimens of each are shown as they 
come to us, others impregnated with equal parts 
of corrosive sublimate and glycerine in 200 parts 
of water, and still others, sewed in bags of sub- 
limate gauze ready for use. The wood-wool is 
made from pine of non-resinous character, is 
soft, cottony in texture, elastic, and clean to 
work with. I prefer it to any thing excepting 
the cottons, which cost many times as much, or 
peat which costs about the same. Wood-wool 
collapses when thrown into or saturated with 
water. On this account the roller first applied 
should not cover any dressings containing it, or 14 
the pressure may not be maintained and the 
result may be compromised. It has. as was re- 
cently pointed out by Lister, in the discussion at 
Woolwich on antiseptic field surgery, the same 
composition as cotton rags, which may replace 
it if used in sufficient mass. Dr. F. Lange, who 
is perhaps the best exponent of German antis- 
eptic surgery in this country, is partial to berated 
cotton arranged in thick sheets and covered 
with sublimate gauze. I show you a “com- 
pound borated dressing ” prepared as he directs. 
The story of the introduction of turf, mould 
or peat, may be new to some here present. 
About four years ago a man applied to Dr. 
Neuber, assistant to Esmarch, in Kiel, relating 
that ten days before he had, while working on 
the moor, sustained a severe injury to the fore- 
arm. To this had been at once applied a thick 
coating of mould and a rude splint. On exam- 
ination the wound was found free from sup- 
puration and either united or granulating well, 
though there had been compound fracture of 
both radius and ulna, rupture of the wrist joint 
and extensive laceration of the soft parts. 
Neuber followed up this broad hint as to the 
value of peat, and its use has been attended by 
rapid and satisfactory healing of the parts it 
protected. A special advantage of peat is its 
power to absorb the gaseous products of decom- 
position, such as ammonia. Used as a litter for 
horses the same beds have, according to Dr. 15 
Ernest Hart, been in use for two or three 
months. It absorbs best when slightly damp- 
ened, is soft, as you see, and very elastic. 
In conclusion, I do not propose to enter into 
any recital of cases or statement of results. 
The method advised is one of the antiseptic 
methods, and results obtained by it belong to 
that system, the beneficient influence of which 
can be as little questioned as can be the good to 
mankind that followed the discovery of the 
haemostatic use of the ligature, or the anaesthetic 
use of sulphuric ether. The materials required 
can all be carried in a small satchel, and all be 
purchased with what would be only a fair fee 
for their first use.