No. 2861.

JUNE 29, 1878.

Clinical LectureON SOME

MEDICAL USES OF CARBOLIC ACID.Delivered at the Norfolk and Norwich Hospital,

BY PETER EADE, M.D. LOND., F.R.C.P.,PHYSICIAN TO THE HOSPITAL.

GENTLEMEN,-Several cases are now in the hospital undermy care in which you will have observed that carbolic acidhas formed some portion of the medicinal treatment. At thepresent moment three cases of phthisical disease are usingthis drug in the form of inhalation, and one patient sufferingfrom strumous sores is applying it locally in the form oflotion and of carbolised oil. Other cases of medical diseasein which it has been used have also recently been underyour observation, and I have therefore thought this a favour-able time for calling your attention to some of what may betermed the medical uses of this drug, apart from or in addi-tion to its employment in the more purely surgical cases ofdisease or injury. Your familiarity with such surgical usesof carbolic acid I cannot doubt; but beyond these there areso many diseases, in which it is of service, which are eitherpurely medical or at least quite commonly come under thecare of the physician, that I shall not be stepping out of myprovince in choosing carbolic acid as the subject of mylecture to-day.This carbolic acid (or phenic acid, as it was formerly

called) is, as you know, one of the products derived fromthe oil of coal-tar, and has a chemical composition of

C12HsO+HO. It is met with either as an oily liquid or inthe crystalline form, and has an acrid burning taste, anda strong odour closely resembling that of creasote. It is

slightly volatile, and is readily soluble in water, oil, or

glycerine. One of its most valuable properties is that ofpreventing the decomposition of animal tissue-a propertywhich it possesses in common with salicylic, boracic, chromic,and other acids and substances; but it is more generallyuseful than either of these, because it is not only more cer-tain in its action, but may be employed in a more concen-trated form without risk of injuring the parts or tissues towhich it is applied.

Carbolic acid is an antiseptic. It prevents putrefaction,or the destruction and resolution of organised animal tissueinto its chemical elements. But how does it do this? or,rather, in what does this process of change consist? For afull demonstration of the potential causes of putrefaction Icannot do better than refer you to the able addresses ofDr. Roberts of Manchester and Professor Lister of King’sCollege, published last year in the medical journals, in whichit is pretty conclusively shown that the active agent in suchdecomposition or putrefaction is a microscopic vegetablebody called "bacterium." And although Dr. Richardsonhas expressed the opinion that the cause of septic or putre-factive change is a chemical or glandular rather than such avital agent, yet I think the present state of our knowledgejustifies me in telling you that a living and self-reproducingagent is the constant accompaniment and potential cause ofsuch a change. -

Not very much is known about the life-history of bacteria.They are vegetable organisms which under moderate powersof the microscope appear as minute lines, but under higherpowers are seen to be rod-like bodies showing a sort of joint-ing from imperfect transverse divisions, and having usuallya slight vacillating movement. They have been found notonly in decaying animal tissues, but in milk, in the blood,in urine, and in other animal substances. Ehrenberg andothers considered them to be animalcular, but they are nowgenerally believed to be of a vegetable nature, either algoidor fungoid.Now, putrefactive or septic action consisting in a destruc-

tive change brought about by the life and multiplication ofthese little vegetable germs, antiseptic action is the influenceexerted by substances in preventing such life and develop-ment-in either destroying this life or its living power ofmultiplying at the expense of the material which furnishes

its pabulum. Such a property has been found to exist(amongst others) in carbolic acid, and, because of its special

suitability, this agent is the one now generally employed forthis purpose in surgical diseases and operations. It may beused in various ways. It is too acrid, almost too much of a,caustic, to be used in its undiluted form except in the smallestquantities; but dissolved in water, oil, or glycerine, it maybe used of almost any strength that may be thought desir-able. The weakest form of lotion commonly employed con-tains about one part of acid to eighty or a hundred partsof water; and from this dilute solution it may be used for

ordinary purposes of any strength up to that of the glyce-rinum acidi carbolici of the London Pharmacopoeia, whichcontains one part of carbolic acid to four parts of glycerine.For local use in limited quantity, however, it may be usedof much greater strength even than this ; and I am in thehabit (as you have seen) of applying with marked advantagea glycerine solution of the acid to the granular and excoriatedos and cervix uteri, of the strength of four parts of the acidto one part of the glycerine.The efficacy of the acid in checking diseased or septic

action appears to depend upon its being brought into abso-lute contact with the part to be acted on, and it would seemto exert no beneficial effect beyond the exact limit of thepart so touched. The explanation of this is very easy whenwe remember that its action is the destruction of the life ofthe germs living and flourishing in and upon the diseasedpart, and probably also-in the case of a suppurating sur-face-some check to the exuberant growth and developmentof the rapidly-secreted mucus and pus and altered epithelialcells, which have unquestionably a certain amount of inherentindependent life and vitality.But besides its destructive influence upon the vitality of

the bacterium, carbolic acid appears to exercise the samepower of destroying other vegetable germs which are theintimate causes of various diseases in or upon the humanbody. You are aware that a large class of diseases of theskin are now known to be due to the parasitic growth in thecutaneous tissues of different fungoid germs, and in many ofthese carbolic acid has been found to be of signal service.The diseases in which I have found the carbolic acid

especially useful are - 1. All that class of local festering,pustulating diseases of the skin which are at once so com-mon and so difficult to cure. They include all kinds ofpustules, boils, and carbuncle; sycosis, pustular acne, andfestering ringworm. 2. Such strumous sores (especially ofthe neck) as come under the care of the physician. 3. Ex-coriations of the os and canal of the cervix uteri. 4. Phthisisin its second and third stages, and cases of chronic bronchitisaccompanied with more or less purulent expectoration.

I have said that in order to be effective the carbolic acidmust be brought into contact with the part to be acted on,and I doubt not that in many cases where it has been foundineffective the failure has been due to a neglect to ensurethis contact. In the pustulating and suppurating diseases ofthe skin I have mentioned it is never sufficient to apply thesolution of the acid, of whatever strength, upon or to theoutside of the skin. It must always be introduced into theinterior of the sore or pustule itself, and so as to comesufficientlv in contact with every part of the diseased surface.Of its efficacy thus applied I have now had a very consider-able experience, and so certain am I of its curative powersin these cases that I state with the utmost confidence thatall cases of boils and carbuncles in their earlier stages can beabsolutely aborted and cured, whilst even in later stagestheir further increase can be almost surely prevented. Forthis purpose a very strong glycerine solution should beemployed, and it is best conveyed into the interior of thepustule, boil, or suppurating spot, by a new quill pen dippedinto the solution, and introduced by a rotatory motionthrough its apex, where a sufficient aperture will generallybe found. In carbuncles, which are necessarily larger, andhave often several openings, several such introductions maybe necessary, or, at a later period, threads of lint soaked inthe fluid, may be passed with a probe well into all the sieve-like openings. Occasionally, as when the mass is large andsolid, a watery solution of the acid may be injected with ahypodermic syringe into various parts of the hardenedgrowth. The same plan of treatment is often quite effectivein cases of sycosis, pustular acne, and festering ringworm.And it is doubtless so because it destroys germs which,living in the involntions of the skin, are the essential causeof these various diseases. In the C’1se of acne, and of boilsand carbuncles, the essential dependence of these diseases

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upon vegetable germs has scarcely been demonstrated,l buttheir mode of origin and growth, their whole life-history,and their curability by such local means alone, go far toprove that they, like other skin diseases, are due to thedevelopment in the cutaneous textures or glands of parasiticgrowth. As, however, I have already published in themedical journals several papers on this subject, I will notlonger dwell upon it now. Not long ago it was stated thatthe development of the vaccine vesicle could be prevented bythe application of carbolic acid to the vaccinated sore. Ifthis is so, it would seem highly probable that the same kindof destructive influence would be exerted upon the small-poxeruption if the acid were applied to the pustules before orduring the process of their maturation. The process of intro-ducing a little of the strong acid solution ’into the apex ofeach pimple would be tedious and disagreeable, but, if effec-tive, it might not only save much disfigurement, but possiblyeven life itself. Darkening of the patient’s room, blackeningof the face, covering up the pimples with wet clay (as prac-tised by some savage tribes)-all expedients for preventingthe free development of the local disease, - appear todiminish its virulence somewhat, and possibly this moredirect interference with the special virus might do muchmore to mitigate its severity. Various applications to thegeneral surface have been tried and failed more or less com-pletely, and Velpeau has advised the cauterisation of theindividual pimples with solid nitrate of silver; but I am notaware that carbolic acid has ever been fairly thus tried, andI recommend it to your consideration when cases of this diredisease come under your notice.

2. The healing of strumous sores may be frequently muchexpedited by the bringing into contact with their interior oropen surface a suiEciently strong solution of carbolic acid ;and old stationary sores will often at once begin to healwhen acid is so applied. So, too, when they are first opened,their immediate healing may sometimes be brought about byinjecting into them a solution of the acid, and keeping theopening closed against the admission of air. This methodof treatment, on a larger scale, has been advocated by Mr.Callender in the case of spinal abscesses, and some verysuccessful results have been recorded.

3. In excoriation, or so-called ulceration of the neck ofthe uterus, the strong glycerine solution is a most valuableapplication, and in my hands has been far more efficaciousthan nitrate of silver or other usual caustics. In these casesthe denudation of epithelium is, commonly, not only of thevaginal surface of the os, but it extends up along the canalof the cervix, and often (as Dr. Playfair has shown) into thecavity of the uterus itself. I have found no ill effect fromapplying the strong glycerine solution freely with a camel’s-hair brush within the cavity of the cervix ; and, indeed, it isnot only well and painlessly borne, but is often very effectivein promoting the healing of the " ulcerated surface. Ihave thought it possible that its undoubted efficacy may bepartly due to a power of destroying any bacteria or othergerms living in the uterine mucus, and by their presenceirritating the secreting surface, and so preventing the forma-tion of healthy covering epithelium.

4. In cases of phthisis which have passed their earlieststage, and in which the sputum is of a muco-pnrulent cha-racter, you have almost daily opportunities of witnessingthe efficacy of carbolic acid inhalations. In three patientsnow in the hospital the cough has been greatly lessened byits use, whilst at the same time the secretion of purulentmucus has been greatly diminished in quantity. As youhave seen, we employ it in the simplest fashion. We givethe patient a solution of the acid in water containing tengrains to the tablespoonful. We tell him to add this to

half a pint of hot (not boiling) water in a narrow-mouthedjug surrounded by a towel or handkerchief, and then to in-hale this for about ten minutes ; and we order the inhalationto be repeated three, four, or five times in the twenty-fourhours, according to the necessities of the case. The inhala-tion can of course be made through any ordinary inhaler, orit can be used with the acid in more concentrated solution,or in the form of spray ; but I have found the above methodnot only simple and always available, but perfectlyeffica-cious. In these cases, as in others, I believe the carbolic

1 Mr. Startin has written that in a few cases of boils and carbuncleshe has found cryptogamic vegetation like to that seen in sycosis ; and Ihave recently had a case of small carbuncle, in which, amongst themasses of plastic and other cells obtained from its interior, I observed,on pressure, a cloud of small rounded granules suddenly to diffuse them-selves in the fluid in the field of the microscope, which were undistin-guishable from those of the Achorion Schonleinii.

acid to act entirely by its local influence. The vomica of aphthisical lung contains two elements : (a) the muco-pusalready secreted, and lying more or less free in the cavity pand (b) less perfectly formed and separated mucus, stillattached to the pyogenic or secreting surface. As atmo-

spheric air laden with germs is constantly entering with thebreath into these cavities, and as this animal mucus is afertile soil for these germs to develop in, it is almost certainthat such tendency to settle and multiply upon it existsand the power of carbolic acid to prevent such life andgrowth would well explain its efficacy. But it is also knownthat carbolic acid does in some way prevent the rapid pro--duction of new pus and mucus cells, and in this way, too,some of its good influence may be exerted. But, whateverthe explanation, there is no doubt that the use of carbolicacid in the form of vapour is a distinct addition to our thera"peutical resources in the treatment of this disease. Manyyears ago tar-vapour was in much repute for the same pur-pose. The greater efficacy of carbolic acid is probably duepartly to its purity, and partly to the greater concentrationin it of the active detergent principle, upon the presence ofwhich the beneficial influence on the disease depends.

I will only detain you further to-day by mentioning oneother form of medical disease in which carbolic acid is ofsome small help to us : I allude to those disorders of thestomach v hich are not only accompanied with fermentationand the flatulence induced thereby, but which show theactual presence of another form of low vegetable life. Inthe decomposing contents of the stomach in some of thesecases may be detected by the microscope immense numbers.of a small vegetable growth called Sarcina ventriculi. Theselittle bodies are observed in clusters of adherent cells ar-ranged in squares, each square containing four, or somemultiple of this number, and they often present an appear--ance which may be roughly likened to that of corded wool-packs. In cases of this singular disease, some advantage isoccasionally derived from the administration by the mouthof carbolic acid in doses of one or two grains ; but as thepresence of these bodies is usually, unfortunately, only theresult and accompaniment of other and more serious change,its efficacy is generally proportionately slight.

I may mention to you that when carbolic acid is veryfreely applied to the surface of the body for any length oftime, the urine is apt to become stained of a dark or blackishcolour. But although this symptom is one which at once-challenges attention, it appears to be of no real or seriousimportance, and at once disappears on the withdrawal of theproducing cause.

ON VARICOSE ULCER AND ITS TREATMENT.BY JOHN GAY, F.R.C.S.,

SENIOR SURGEON TO THE GREAT NORTHERN HOSPITAL, ETC.

I DO not think that a clear notion exists either as to the

specific distinction between varicose and other ulcers onthe leg -the favourite seat of ulceration from a varietyof causes-and the means of their diagnosis ; or as to the-precise relation, in respect of cause and effect, between the-pathology of such an ulcer and the especial condition of thevein to which the morbid processes associated with it are-due. A general impression prevails that an ulcer on a

limb, the veins of which are either simply tortuous and en-larged, or actually varicose, is related to such veins as effectto cause; and many a vein has been needlessly mutilatedthrough this misapprehension. Moreover, in order to bringabout a reconciliation of this view with the- conflictingtestimony of results, ingenuity has been rife in devisingvarious modes of treating such veins -caustics, ligature,extirpation, &c.-as though, in despair of a principle, aspecial charm was to be discovered in some particular modeby which their destruction is to be accomplished.

I believe we must seek for other principles in order toestablish our claim to having satisfactorily dealt with thequestion as to varicosity and its bearing on the process ofallied ulceration.A case is now under my care in the Great Northern Hos-

pital, which I will briefly relate, together with the treatmentand the reasons for its adoption.