ii
7. It is difficult from bare figures to prove absolute reduction of mortality in operative
surgery. So many circumstances, which cannot be represented arithmetically, enter into
the question. In 1879 I find that the mortality of operations in the Second Surgeon's
ward, of which I was in charge for nine months, was 18 per cent. In 1880 the mortality
of operations similarly tabulated in the First Surgeon's ward has been about 10 per cent.
I attribute the reduction to the more careful and successful practice of antiseptic
surgery. The operations were not less severe, nor the circumstances demanding them less
serious, in the one period than in the other. The statistics of particular operations support
the general conclusion : 13 amputations, including four of the thigh, two of the shoulder joint,
three of the arm, two of the leg, one of the forearm, and one of the hand,— all recovered. In
some of these cases the conditions—injuries and diseases—necessitating removal of limb were
s e v e r e , a n d t h e c o n s t i t u t i o n a l c o n d i t i o n o f t h e p a t i e n t b y n o m e a n s p r o m i s i n g . T h e
cases in which the antiseptic system succeeded best recovered best and fastest. In one case,
that of a child of two and a half years, in which amputation of the arm was performed for an
enormous sarcoma of the forearm, I allowed the friends to take the little patient home. The
child was brought to hospital every second or third day to be dressed, and the result was perfect
repair in 13 days. There was no death among 10 operations for removal of necrosed and
carious bone, in which the sound bone surrounding was freely divided. In two cases of scirrhus
of the mamma I cleared out the axilla, thoroughly removing all its glands, and both recovered
satisfactorily. I shall not carry the analysis further, as I intend publishing a précis of all the
cases in the Indian Medical Gazette. The general result of the year's experience is greatly
in favour of strict antiseptic surgery.
8. I have already remarked on the great difficulty experienced in keeping the
large wounds resulting from the removal of scrotal tumours aseptic, and the special
proneness of these to become the nidus of septic infection. In 1879 five of these
cases contracted erysipelas, and in 1880 three. I have endeavoured to treat these cases
during the past six months in accordance with strict Listerism. In all cases in which
I have succeeded in arresting putridity, the result has been most satisfactory as regards
rapidity of repair and avoidance of constitutional disturbance. Surgical fevers may roughly
be classed as reactive, irritative, or absorptive. Listerism abolishes the last, which is also
the most severe and dangerous, and this has been remarkably illustrated in these scrotal
operations. Only one case in which septicity was thwarted has died, and that from causes
which I could not associate with the state of the wound. Indeed, so speedy and perfect
was the repair in this instance that I removed the parts after death, and exhibited them to
the Medical Society as a good illustration of rapid repair of a severe injury under antiseptic
precautions. Failures will occur in many of these cases, owing to circumstances which it
is difficult to anticipate or control ; but my experience has taught me that even here
strict antiseptic practice is capable of saving much suffering and some lives.
9. I am not so sanguine as to believe and assert that Listerism is capable of abolish
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ing hospitalism entirely. Septic diseases, according to the most recent doctrines, possess a
threefold causation,—constitutional, hygienic, and local. In so far as the practice of
antiseptic surgery prevents putrefaction and other septic changes in wounds, it removes the
local cause and tends also to minimize the hygienic cause. Over constitutional defects
it exercises less influence. But if secondary fever is added to original constitutional
debility, vital resistance is thereby lowered, and by obviating secondary fever antiseptics
also attack and weaken the third causative factor. It is necessary, however, to guard against
neglect of the personal and hygienic elements of the question in working at and discussing
the local element.
10. On the whole, the experience of the past year has impressed me with a conviction
of the immense value of strict antiseptic surgery in procuring the recovery of persons
afflicted with wounds or sores, and preventing the occurrence of conditions retarding cure
or causing death. I have come to consider it a sacred and imperative duty to endeavour, to
the best of my ability and means, to prevent every breach of surface, whether wound or
sore, from becoming the seat of septic change; and if it has already done so, to correct the
vice and restore it to sweetness. In slight cases the process is easy and inexpensive; in
severe, it requires greater trouble and involves more cost. It is impossible, however, in
the most trivial case, say a small stab, or slight scalp wound, to be certain that septic
contamination of the wound may not result in profound and fatal septic infection; on that
account I teach and practise in every surgical case which I treat as close an approach to
absolute Listerism, which may be called the perfection of surgical cleanliness, as possible.
11. The appliances used are now all prepared in the hospital; and, looking to the
comparatively infrequent change of dressings, the speedier convalescence and the diminished
consumption of alcoholic stimulants, I suspect that the strict pursuance of antiseptic surgery
does not, on the whole, materially add to the cost of treating patients in the surgical wards.
I have very seldom found it necessary to prescribe alcohol in any form to patients during
the past year, and when I have ordered stimulants it has mostly been in consequence of
septic fever having somehow occurred.
Professor of Surgery and First Surgeon.