Page:On the Antiseptic Principle of the Practice of Surgery.djvu/3

] with strong carbolic acid. About the tenth day the discharge, which up to that time had been only sanious and serous, showed a slight admixture of slimy pus, and this increased till, a few days before I left, it amounted to about three drachms in twenty-four hours. But the boy continued, as he had been after the second day, free from unfavourable symptoms, with pulse, tongue, appetite, and sleep natural, and strength increasing, while the limb remained, as it had been from the first, free from swelling, redness, or pain. I therefore persevered with the antiseptic dressing, and before I left, the discharge was already somewhat less, while the bone was becoming firm. I think it likely that in that boy's case I should have found merely a superficial sore had I taken off all the dressings at the end of three weeks, though, considering the extent of the injury, I thought it prudent to let the month expire before disturbing the rag next the skin. But I feel sure that if I had resorted to ordinary dressing when the pus first appeared, the progress of the case would have been exceedingly different.

The next class of cases to which I have applied the antiseptic treatment is that of abscesses. Here, also, the results have been extremely satisfactory, and in beautiful harmony with the pathological principles indicated above. The pyogenic membrane, like the granulations of a sore, which it resembles in nature, forms pus, not from any inherent disposition to do so, but only because it is subjected to some preternatural stimulation. In an ordinary abscess, whether acute or chronic, before it is opened, the stimulus which maintains the suppuration is derived from the presence of the pus pent up within the cavity. When a free opening is made in the ordinary way, this stimulus is got rid of; but the atmosphere gaining access to the contents, the potent stimulus of decomposition comes into operation, and pus is generated in greater abundance than before. But when the evacuation is effected on the antiseptic principle, the pyogenic membrane, freed from the influence of the former stimulus without the substitution of a new one, ceases to suppurate (like the granulations of a sore under metallic dressing), furnishing merely a trifling amount of clear serum, and, whether the opening be dependent or not, rapidly contracts and coalesces. At the same time any constitutional symptoms previously occasioned by the accumulation of the matter are got rid of without the slightest risk of the irritative fever or hectic hitherto so justly dreaded in dealing with large abscesses.

In order that the treatment may be satisfactory, the abscess must be seen before it has opened. Then, except in very rare and peculiar cases, there are no septic organisms in the contents, so that it is needless to introduce carbolic acid into the interior. Indeed, such a proceeding would be objectionable, as it would stimulate the pyogenic membrane to unnecessary suppuration. All that is necessary is to guard against the introduction of living atmospheric germs from without, at the same time that free opportunity is afforded for the escape of discharge from within.

I have so lately given elsewhere a detailed account of the method by which this is effected, that it is needless for me to enter into it at present, further than to say that the means employed are the same as those described above for the superficial dressing of compound fractures—namely, a piece of rag dipped in the solution of carbolic acid in oil, to serve as an antiseptic curtain, under cover of which the abscess is evacuated by free incision; and the antiseptic paste, to guard against decomposition occurring in the stream of pus that flows out beneath it: the dressing being changed daily till the sinus has closed.

The most remarkable results of this practice in a pathological point of view have been afforded by cases where the formation of pus depended upon disease of bone. Here the abscesses, instead of forming exceptions to the general class in the obstinacy of the suppuration, have resembled the rest in yielding in a few days only a trifling discharge; and frequently the production of pus has ceased from the moment of the evacuation of the original contents. Hence it appears that caries, when no longer labouring, as heretofore, under the irritation of decomposing matter, ceases to be an opprobrium of surgery, and recovers like other inflammatory affections. In the publication before alluded to I have mentioned the case of a middle-aged man with psoas abscess depending on diseased bone, in whom the sinus finally closed after months of patient perseverance with the antiseptic treatment. Since that article was written I have had another instance of success, equally gratifying, but differing in the circumstance that the disease and the recovery were both more rapid in their course. The patient was a blacksmith who had suffered four and a half months before I saw him from symptoms of ulceration of cartilage in the left elbow. These had latterly increased in severity, so as to deprive him entirely of his night's rest and of appetite. I found the region of the elbow greatly swollen, and on careful examination discovered a fluctuating point at the outer aspect of the articulation. I opened it on the antiseptic principle, the incision evidently penetrating to the joint, giving exit to a few drachms of pus. The medical gentleman under whose care he was (Dr. Macgregor of Glasgow) supervised the daily dressing with the carbolic-aidacid [sic] paste till the patient went to spend two or three weeks at the coast, when his wife was entrusted with it. Just two months after I opened the abscess he called to show me the limb, stating that the discharge had for at least two weeks been as little as it then was—a trifling moisture upon the paste, such as might be accounted for by the little sore caused by the incision. On applying a probe guarded with an antiseptic rag, I found that the sinus was soundly closed, while the limb was free from swelling or tenderness; and, although he had not attempted to exercise it much, the joint could already be moved through a considerable angle. Here the antiseptic principle had effected the restoration of a joint which on any other known system of treatment must have been excised.

Ordinary contused wounds are of course amenable to the same treatment as compound fractures, which are a complicated variety of them. I will content myself with mentioning a single instance of this class of cases. In April last a volunteer was discharging a rifle, when it burst, and blew back the thumb with its metacarpal bone, so that it could be bent back as on a hinge at the trapezial joint, which had evidently been opened, while all the soft parts between the metacarpal bones of the thumb and forefinger were torn through. I need not insist before my present audience on the ugly character of such an injury. My house-surgeon, Mr. Hector Cameron, applied carbolic acid to the whole raw surface, and completed the dressing as if for compound fracture. The hand remained free from pain, redness, or swelling, and, with the exception of a shallow groove, all the wound consolidated without a drop of matter, so that if it had been a clean cut, it would have been regarded as a good example of primary union. The small granulating surface soon healed, and at present a linear cicatrix alone tells of the injury he had sustained, while his thumb has all its movements and his hand a firm grasp.

If the severest forms of contused and lacerated wounds heal thus kindly under the antiseptic treatment, it is obvious that its application to simple incised wounds must be merely a matter of detail. I have devoted a good deal of attention to this class, but I have not as yet pleased myself altogether with any of the methods I have employed. I am, however, prepared to go so far as to say that a solution of carbolic acid in twenty parts of water, while a mild and cleanly application, may be relied on for destroying any septic germs that may fall upon the wound during the performance of an operation; and also that for preventing the subsequent introduction of others, the paste above described, applied as for compound fractures, gives excellent results. Thus I have had a case of strangulated inguinal hernia, in which it was necessary to take away half a pound of thickened omentum, heal without any deep-seated suppuration or any tenderness of the sac or any fever; and amputations, including one immediately below the knee, have remained absolutely free from constitutional symptoms.

Further, I have found that when the antiseptic treatment is efficiently conducted, ligatures may be safely cut short and left to be disposed of by absorption or otherwise. Should this particular branch of the subject yield all that it promises, should it turn out on further trial that when the knot is applied on the antiseptic principle, we may calculate as securely as if it were absent on the occurrence of healing without any deep-seated suppuration; the deligation of main arteries in their continuity will be deprived of the two dangers that now attend it—viz., those of secondary hæmorrhage and an unhealthy state of the wound. Further, it seems not unlikely that the present objection to tying an artery in the immediate vicinity of a large branch may be done away with; and that even the innominate, which has lately been the subject of an ingenious experiment by one of the Dublin surgeons on account of its well-known fatality under the ligature from secondary hæmorrhage, may cease to have this unhappy character, when the tissues in the vicinity of the thread, instead of becoming softened through the influence of an irritating decomposing