727

Carter left the paper as a sequel to one such- episode, but rejoined 25 years later, when thepresent editor, who had been his pupil, consultedhim on certain professional positions whichwere being much discussed before the General IMedical Council, where Carter was sitting as therepresentative of the Society of Apothecaries. Heimmediately gave all possible assistance, andfrom that day until the last decade of his

prolonged life he wrote occasional leading articlesin THE LANCET. i

Christopher Heath, known to four generations of I,students as the author of " Minor Surgery," was.a blunt forceful character. He was essentiallygood-hearted, but made enemies by these qualities.They were displayed in our columns on manyoccasions and led to awkward situations. ButJames Wakley recognised in him a powerfulassistant, and he and Carter for some years exercised igreat influence over the paper.By 1872 the staff of THE LANCET had become ’

considerably augmented ; the size of the paper Ihad increased with the enormous development of imedical knowledge, making it necessary to havedifferent writers able to give authoritative opinions z,on their special subjects. In addition to the Inames mentioned, the staff was now notably Istrengthened by Robert Barnes, James Peddie.Steele, and Jeffrey Marston, while Sir John

Tweedy, who at the time was only just qualified, was admitted to the councils of the paper. * Dr.Thomas Buzzard, whose neurological work has

placed him definitely among the pioneers of modern medicine, was also a much. appreciated leader-writer, for he was a practised journalist, with ’’,a learned and graceful style. Later on, at different ’’intervals, the staff was reinforced by Sir John I

Williams, Vivian Poore, Henry Power, Dr. Sidney iiCoupland, Pearce Gould, W. S. Greenfield, andJohn Curnow. Sir John Tweedy joined the staffimmediately upon his qualification-indeed, to be,accurate, his early contributions were actually iwritten before he had obtained any diploma- and he undertook from the first a very difficultand delicate appointment, namely, to keep thereaders of THE LANCET informed upon matters connected with the Royal College of Surgeons of England, and surgical practice in the metropolitanhospitals.

CONTINUITY AND PROGRESSION.

HE scheme of work which James Wakley II,laid before his staff was twofold. He I- desired to continue and develop the under-

takings of his father-an act of piety which was sometimes embarrassing; and he desired at the same time to keep his columns as open to new Imovements, scientific or professional, as they hadbeen open during 40 years. This was well shown

by the sequels to the Analytical Sanitary Com-mission, such, for example, as the inquiry into theconduct of lunatic asylums, and by the watchful-ness maintained over the actions of the Royalcorporations.

THE LANCET AND THE ROYAL CORPORATIONS.

In 1872 the position of THE LANCET with respectto the Royal College of Surgeons of England wasnot any longer one of open warfare; but the generalfeeling against the constitution of the Collegehad not been abated by the institution in 1843 ofthe order of Fellows. In 1843 a new Charter wasobtained for the College, under which there wasinstituted a class to be called the Fellows,from whom and by whom the Council was to beelected. The number of the Council was increasedto 24, and while the existing members of the oldCouncil were allowed to continue in office for life,provision was made that three elected membersshould retire annually, so that when no more lifemembers were left it would not be possible fora member to retain his seat for a longer period thaneight years without re-election. A further changewas effected by this Charter, for it provided that theexaminers had no longer to be selected from theCouncil, but any Fellow, whether on the Council ornot, became eligible and for a term of not longerthan four years. It will be seen that theCharter, therefore, did meet two of the main

charges brought for so many years by THE LANCETagainst the constitution of the College. Althoughthe Council was only enlarged from 21 to 24

persons, it was no longer self-electing, and theold rule that ten out of this small Councilmust constitute the Court of Examiners wasabolished.

The double reason for the creation of Fellows thusbecame apparent: the new class was to form anelectoral college for the Council and also to providemen up to date in their work to carry on theexaminational duties. The first body of Fellowswas chosen arbitrarily, mainly from among theMembers, but within one year from the date ofthe Charter the Fellowship was closed except byexamination, the tests being graded to provide thatthe Fellows should show by practical and academicacquirements that they were fit men to conduct

College affairs, and particularly to examine andtrain their juniors. THE LANCET admitted that thenew Charter stood for reforming principles, butfound that it was none the less an unsatisfactoryand undemocratic arrangement, in that the Council,while retaining all the power, would be recruitedfrom a special body, in the first instance nominatedby themselves, while no provision had been madefor representation of the Members in general uponthe governing body of their College. The higherI standard of examination laid down for the Fellow-

ship, it was allowed, provided the College imme-diately with a properly equipped body of examiners,and did away with the scandal caused by nona-genarians when found examining lads of the ageof their grandchildren.I, The College continued to come in for criticism

also because of the privacy with which its businesswas transacted, although here the Royal College ofPhysicians of London was much more frequentlyand more logically attacked for its " secreta

collegii." The College, as has been said, escaped thediatribes to which its sister College had to submit

728

in the early issues of THE LANCET, because it Iplayed so small a part in the life of the general practitioner. In Scotland especially, and to some extent in Ireland, it was more usual for the general I

practitioner to have obtained a medical degree, but in England a practitioner practised, as a rule, on his diploma from the College of Surgeons or his Ilicence from the Society of Apothecaries. It wasnot till 1884 that an agreement was entered intoby the Royal College of Physicians of London

establishing a Conjoint Examination Board with the Royal College of Surgeons of England, and until

FIG. 28.-SIR GEORGE BURROWS.

that date the part played by the senior College in general practice was negligible. But officially theCollege of Physicians was of high importance, ’Iand its habit of keeping all its business, whichwas presumably discharged in the interests of the constituency and also of the public, entirely secret led to a good many caustic articles. OnePresident, Sir George Burrows, made a definite attempt to intimidate THE LANCET, to which James - Wakley replied in characteristic style. i

Some information had been published in THE LANCET, through a member of the staff, who wrote the article upon information from persons in

authority who did not consider that the circum-stances were private. The persons who gave theinformation on reconsideration believed that Ino question of privacy arose, and Sir George IBurrows was told that the public apologies upon iwhich he insisted would not be given. Succeeding’Presidents were less susceptible to the dangersof publicity-indeed, from this time forwardcordial relations existed between the College and Ithe paper. (Fig. 28.)

In all the developments of medicine which hav.’occurred during our existence it has been our aimto provide news and comment upon that news, torecord all medical discoveries, to give space to thework of those who were engaged in promotingthem, and to hold the balance between those whothought criticism to. be criminal and those who

thought that the world would be no better off forthe new work. To give any summary of theforward movements which in their earlier forms

originated in THE LANCET, or were noticed in it,would be in considerable measure to give a sum-mary of the journal from its issue until to-day.Certain prominent communications which markedthe early years of the paper have been singled outfor notice because they became important in theyears which followed, owing to developmentsalong the indicated lines. But we have now reachedthe era of the greatest medical events of thenineteenth century, which have revolutionisedthe whole of our science-namely, the dis-

covery of bacteria, leading to the introductionof antisepsis, while we have passed by a discoveryof nearly as high a therapeutic importance-namely, the introduction of anaesthetics. The

way in which these great movements were re-

ceived by the paper is a running comment uponits conduct over an extended period, and at thesepoints the summary of our work is brought downto to-day.

ANÆSTHETICS.

Most things that were new in the medical worldwere being sent to THE LANCET for publication atthe time that the anaesthetic action of ether was

revealed-especially was this the case with Englishor French work. The fact that something new wasarriving would emerge from reports from institutionsor from learned societies, when fuller informationwas at once solicited and obtained.

’ The news from Boston of W. T. G. Morton’ssuccessful administration of ether on Sept. 30th,1846, in dental and surgical operations reachedEngland in December of that year, when its practicalimportance was immediately tested and appreciated.In London, on Dec. 19th, James Robinson, in hisdental consulting room, and on Dec. 21st Robert Liston, at University College Hospital, operated onpatients under ether anaesthesia, and lost no timein chronicling their successes, the letter from Liston,published in THE LANCET of Jan. 2nd, 1847, havingbeen written on the very day of the operation.

i That issue of the paper contains some other

interesting documents relating to the early surgicaloperations performed during insensibility; theyinclude, through the courtesy of Dr. Frank Boott,a paper read by H. J. Bigelow before a learnedsociety in Boston, on Nov. 9th, 1846, describing thetechnique and discussing its application, and alsoa detailed description by Boott himself of thei dental operation performed on Dec. 19th in his

presence by Robinson. An editorial pronounce-ment in the same issue of THE LANCET left nodoubt of the fundamental importance of the

discovery, the development in various branches ofmedicine and surgery of " this most valuable dis-

729

covery "

being foretold. An attempt to patent the discovery in the name of its alleged joint inventors, ’C. T. Jackson, a chemist, and Morton, was denounced as preposterous, if not legally impossible, ’,in an editorial article a fortnight later. "The

thing is far too noble to be clogged with a mere commercial transaction," said THE LANCET, which had been already able to chronicle the performance of operations under ether at five London and fiveprovincial hospitals. Illustrations of different formsof apparatus for ether administration appear innearly every issue of THE LANCET during theearly months of 1847, one of the first being that devised by Dr. John Snow, whose subsequent .researches into the physiology of inhalation anees-thesia, published largely in THE LANCET, formed a valuable addition to the early literature of the subject.

It will be convenient to give dated references Ito the communications alluded to. Under the

general heading of "

Operations without Pain," a series of special reports, with full details of cases, from hospitals throughout the countrybegan in THE LANCET of Jan. 16th, 1847, and icontinued for 13 successive weeks. An elaborate questionnaire was prepared and addressed in April, 1847, by Thomas H. Wakley, the eldest son of the Editor and then surgeon to the Royal Free Hospital, to the surgeons of London hospitals, on the grounds that it was " high time I,the profession should be put in a position of authen- Itic information relative to the action of a remedy ’,which has already produced such an unparalleled influence in the practice of surgery in this country."The peculiar applicability of the new discovery to general surgery was early recognised in THELANCET, but, even in January, 1847, attempts toemploy it in medical cases, such as tetanusand rabies, were deprecated on physiologicalgrounds. Its effects on surgical shock werediscussed and its use in operative midwifery prophesied. The prophecy was even then being I,realised, for by February, 1847, ether was alreadyin use in obstetric operations by Prof. J. Y.

Simpson in Edinburgh, by Prof. E. W. Murphy inLondon, and by Baron Paul Du Bois in Paris. (SeeTHE LANCET, 1847, i., 228 and 247.)The unsuitability of ether for cases with

bronchitis was being established by our contributors(1847, i., 1210) and resuscitation by means of

oxygen (ibid., 371) was being practised, while onApril 17th, 1847, we were able to record examplesof the practical application of anaesthetics to

jurisprudence, in distinguishing real from feigneddisease.The attitude of the Editor of THE LANCET, with

regard to the rival claims springing up weekly forthe honour of introducing the new weapon, wasan eminently sane one. In a review (1847, i.,1284) of what was apparently the first book (byJ. Robinson) to be published on the subject in thiscountry, the issue was clearly stated. "

Manypersons have suggested certain sniffings and breath-ings, and have employed them in private in a fewslight cases ; but these we may pass by as unworthyof notice-certainly not detracting in the least

degree from the praise and honour due to theAmerican originator, whether that originator beDr. Morton, Dr. Jackson, or Mr. Horace Wells, thelast claimant." A few weeks after this pronounce-ment we published documentary evidence substan-tiating the claim of Horace Wells for the use ofnitrous oxide gas for tooth extraction prior to thework of Morton. At this time the name of CrawfordLong, who apparently preceded Wells, was stillunknown in this country.

Meanwhile, other gases came into use. In our

foreign news columns, which incidentally givesevidence of service by well-informed correspondentsin various centres of Europe, especially in Paris,we find a report (THE LANCET, 1847, i., 411) ofa discussion at the Academic de Science, Paris,where Baron Flourens demonstrated that hydro-chloric ether (ethyl chloride) had anaesthetic proper-ties similar to those of ether. The next discoveryrecorded was a British one, and took the formof an original article published in THE LANCETof Nov. 20th, 1847, by Simpson (Fig. 29), on

" ANew Anaesthetic Agent More Efficient than Sul-phuric Ether," followed three weeks later by detailsof nine obstetric operations under the saidagent, known as chloroform. Prothero Smithand Murphy also recorded their experiences withchloroform in our columns in November and

December, 1847.While it was obviously much too soon to attemptto assess the relative merits or uses of the rivalanæsthetics-and indeed this task has hardly yetbeen completed-editorial pronouncements at thisperiod left no doubt that differences were alreadybeginning to be recognised. In THE LANCET ofJan. lst, 1848, Thomas H. Wakley was able topublish a record of 100 experiments on differentanimals performed by himself with ether and with; chloroform, with the assistance of Erasmus Wilson,described as " one of the best physiologists of theday," and " that scientific and practical chemist,Mr. Bullock," in whose laboratory the drugs weremanufactured. T. H. Wakley’s conclusions, quotedagain in an editorial comment on the firsthuman death from chloroform, reported inour columns on Feb. 5th, 1847, was that"of the two agents in question assuredly themore dangerous of the two will be found in thevapour of chloroform."

This prophecy was indeed soon realised, and ledto a reaction against the use of the newer drug infavour of ether. During the next 20 years thedisadvantages of pure chloroform were madefurther manifest by many considered articles inTHE LANCET, and in 1864 a committee of the

Medico-Chirurgical Society was set up to considerthe whole question from the physiological, thera-peutical, and toxical standpoints. At this periodwe chronicled the fact that the resident anaesthetist

was beginning to be an institution at the big, teaching hospitals, and that " Mr. Clover’s admirableapparatus," the first to register percentages of

chloroform, was coming into general use, this

apparatus being employed by the Medico-Chirur-gical Society’s committee in their investigations.The report is published substantially in THE LANCET

730

(1864, ii., 49 and 69) and the mixture of chloroform,alcohol, and ether (A.C.E.) recommended bythe committee found favour till comparativelyrecent times, when the alcohol was eliminatedand the C.E. mixture retained in common use.Meanwhile the use of pure ether was brought backinto popularity by the introduction of Clover’sinhaler. John Clover was a prolific inventor, andsuggested the aspiration of the bladder after

lithotrity years before Bigelow. His growing dis-taste for the administration of pure chloroform ledhim to experiment still further, and stimulated bythe revival by G. Colton of the claims of nitrousoxide, he suggested in THE LANCET (1875, i., 33) theuse of nitrous oxide to precede ether, and laterdevised an apparatus to administer successively N20and ether. It was this Colton to whom HoraceWells originally owed his inspiration to use nitrousoxide in 1844. Twenty years afterwards Coltonre-established the gas in fashion in Paris. In 1868we had occasion to comment on a discussionof the properties of nitrous oxide at the Medical Society of London (which met even then on IMondays) and to describe a demonstration of its administration at St. Bartholomew’s Hospital and at the Dental Hospital. Our commentwas that while the agent as used for the processof extracting a tooth was certainly a success,the effects did not give rise to much expectationthat the gas was at all likely to replace chloroform in any but the very shortest of operations. Thisview, indeed, proved correct, since not until 1899,after the publication in our columns by Sir FredericHewitt of a preliminary report on the anaesthesiaproduced by the administration of mixtures ofnitrous oxide and oxygen, did the method comeinto general use for major operations, and not untilthe investigation of Crile and his school in the latenineties did it become really popular.

There was now, by the last quarter of the nine-teenth century, a selection of anaesthetics to choosefrom, and it became desirable once again to

attempt to estimate the physiology of anoesthesiawith special reference to the toxicity of the indi-vidual substance used. A commission with this

object was established by the British Medical Association, who issued a report in 1878, and twoother commissions were financed by the Nizam of Hyderabad in the early nineties. In view of the ’,

extreme complication of our modern views on the Iphysiology of anaesthesia, it is hardly surprising that these reports gave some contradictory results.and were subjected to much criticism from physio- logical experts. It was left to THE LANCET to irevert to the clinical aspect, which had for the time i

being been rather lost in animal experimentation, Iand in the early months of 1893 we were able topublish the outcome of a special LANCET Commis- Ision appointed to investigate the subject of theadministration of chloroform and other anaesthetics Ifrom the clinical standpoint.The history of that investigation was as follows.

In 1889 the Nizam of Hyderabad wrote to THELANCET through the surgeon at the Residency,the late Colonel Edward Lawrie, I.M.S., to askthat a representative of the paper should be sent

out to repeat the experiments upon the adminis-tration of chloroform which had been performedby a committee appointed by His Highness’sGovernment. The Nizam’s Government placedthe choice of a scientific man to repeat the experi-ments, and make any others that might suggestthemselves, in the hands of THE LANCET, andenclosed a fee of £1000, together with an invita-tion from the Government to be their guest in

Hyderabad. Lauder Brunton was nominated,and he accepted the commission in the ratherdelicate circumstances that the work of the

Hyderabad Committee had already come to cer-tain conclusions with regard to the action ofchloroform which were at variance with the viewsexpressed by Brunton in his pharmacologicalwritings. Brunton’s contributions to THE LANCEThad been for many years frequent; indeed, sincehe delivered the Goulstonian Lectures on "Phar-

macology in Relation to Therapeutics" he had

regularly assisted us. All schemes in favour ofnational health, of school hygiene, or of propermilitary training had in him a stalwart advocate.In this last connexion his familiarity with theGerman professional world had led him for someyears to believe that war between this countryand Germany was inevitable, and from a letter

published in THE LANCET it came out that in daysgone by Sir Douglas Haig and Brunton had dis-cussed the circumstances of its occurrence. In the

report of our Commission details of the cases wereset out in tables under appropriate headings, andthough the document was printed 30 years ago,the conclusions, which are set out fully below,would be substantially endorsed by expert opinionat this day. The conclusions were :-

1. That the death-rate under anaesthetics heretoforehas been unduly high, and may by improved methodsand greater care be lowered.

2. That ether, when properly given from an inhalerpermitting graduation of the strength of the vapour,is the safest anaesthetic in temperate climates forgeneral surgery.

3. That nitrous oxide gas should be employed forminor surgery and should replace chloroform in dentalsurgery.

4. That chloroform, when given by a carefullytrained person, is a comparatively safe body, but isnot in any case wholly devoid of risk.

5. That no age or nation is free from danger underanaesthetics.

6. That the perils of anaesthetics, however slight,demand that the undivided attention of a dulyqualified and trained medical man should be given tothe administration of the anaesthetic.

The work appeared in the columns of THELANCET in 1890, being edited with extraordinarycare by Dr. Dudley Buxton, and was afterwardsproduced in volume form. It is interesting to

note that whereas the scientific aspect of the subjectwas altered by the discovery of the occasionallydelayed effects of chloroform poisoning, to whichattention was first called in THE LANCET (1894, i.,193) by Leonard Guthrie, the conclusions reachedby this most exhaustive research into clinicalrecords throughout the Empire over a long periodof time by our Commission have been substantiatedby subsequent experience.

731

Of more recent years the advances in generalanaesthesia have been perhaps less striking. Earlyin this century W. T. McCardie revived interestin the anaesthetic properties of ethyl chloride

by reporting first a few cases and then a series ofover 600 under general anaesthesia induced byethyl chloride, thus bringing to general notice inthis s countryan anaestheticwhich hadhitherto beenused chieflyabroad. Intra-tracheal etherwas introducedin 1909, butdid not come

into general usein this countryuntil a few

years later. Ina review ofvarious meth-ods and appar-atus at the endof f 1911 we

quoted mainlyAmerican andforeign authori-ties, and werethus able to

k e e p Englishworkers intouch with a

valuable tech-

nique.In Europe

scopolamine-morphineanees-thesia (twilightsleep) was alsobeginning tofind favour incertain cases ; ;its merits inlabour were

extolled by C.J. Gauss of

Freiburg, andwere discussedin THE LANCET

by Dr. G. B. Buchanan in 1906. This methodof producing general anaesthesia by means of the hypodermic syringe has advanced inefficiency and popularity, especially for ear,nose, and throat work, but the serious develop-ment of local anaesthesia was dependent on

the perfection of the hypodermic syringe in ;1853 by Alexander Woods. Local anaesthesia by means of surface applications was much older. In June, 1848, T. Nunneley, of Leeds, ,published in THE LANCET the results of attemptsto use ether, chloroform, and certain other volatiledrugs in this way, while a week or two later Simpson irecords in our columns a further series of experi- ments on the same lines. The production of local

FIG. 29.-SIR JAMES Y. SiMPSON.

anaesthesia by means of cold was recorded byJames Arnott in THE LANCET (1847, ii., 98 and287), using ice and salt, but this method was onlycapable of a wide application after the invention ofthe ether spray by B. W. Richardson early in 1866.This was at once recognised by THE LANCET as adevice whose " application would evidently be of

the most valu-able and bene-ficent utility."The discovery

of cocaine in1857 was thenext landmark,but it was notuntil 1884 thatKoller in Viennaused this drugin eye opera-tions. Of this

important event we re-

ceived and

published im-mediate infor-mation, andour readerswere not slowto give the druga trial. Forthe rest of the

year (1884) ourcorrespondencecolumns con-

stantly re-

corded British

experience o fits uses, and,none too soon,of its dangers.In the lastdecade of the

century lesstoxic c deriva-tives of cocainebegan to be sub-stituted, andinfiltration and

spinal methodso f anaesthesia.were evolved.

In THE LANCET (1901, i., 137) we reviewed

the work of Bier, Corning, and Tuffier in spinalanaesthesia., and our foreign correspondents keptus well posted through the following yearswith developments in this art. The methods ofCrile did not gain much attention in this countrytill early in 1913, when we published an elaboratearticle from his pen. His anoci-association theorytended somewhat to reconcile the two schools ofanaesthetic practice, since he advocates spinalanaesthesia combined with inhalation of nitrousoxide. The last-named gas, combined with oxygen,

proved peculiarly suitable for war surgery, and ledto an extended use of this combination in civil

practice,. Of recent years advances in anaesthetics

732

have been due rather to general improvement intechnique than to any startling changes in drugsor procedure. The improved status of the nuoloroanaesthetist, who is now im an increasing numberof hospitals a valued member of the honorary staff,is a corollary of the development of the specialty.It is hardlv necessary to add that we have

always insistedon, and areeven now againurging (seeTHE LANCET,1923, i., 910),the recognitionof the anæs-

thetist as a

most importantmember of the

operating team,to whom moreconsiderationshould be givenin the event ofa fatality-now, happily,a rare occur-

rence-andmore credit forhis share inthe common

successful issue.

THE FIGHTAGAINST

BACTERIA.

ANTISEPTICS.

THE LANCETwas the journalselected byJoseph Lister(Fig. 30) for thefirst t puhlica-tion, in 1867,of his methodof treatingwounds on

antiseptic prin-ciples. It t is salmost impossi-ble nowadays to realise the conditions of surgicalpractice before these principles were established. ’,In the graphic words of Sir Hector (’aiiiei-oii" Every wound discharged pus freely and putre- i

factive changes occurred in the discharges of all, producing in the atmosphere of every surgical ward,no matter how well ventilated, a fœtid sickening odour. which tried the student on his first intro- duction to surgical work just as much as the unaccustomed sights of the operating theatre. It Iis hardly necessary to add that fatal wounds, diseases, and complications were never absent at

any time from the hospitals of that day.’’ The steps of Lister’s life are well known.

After a distinguished career as a student at

FIG. 30.-JOSEPH, LORD LISTER.

University College Hospital he (jualified in 1852and served as house surgeon to John Erichsen(Fig. 3)) in London, and later to James Symc(Fig. 32) in ’ Edinburgh. He was elected

successively to the chair of Surgery at

Glasgow in 1860, to the professorship of ClinicalSurgery in Edinburgh on the death of Syme in

1869, and toKing’s College,London, in a

similar capacityfrom 1877 to

1893, when heretired fromactive practice,though he livedtill 1912. It twas during hisyears at Glas-

gow that theterrible after-results of surgi-cal interven-

tion, especiallythat conductedin hospitals,led to variousdrastic sugges-t i o n s. Theseincluded (1) de-molition of

hospitals everytwo or three

years, and (2)the treatmentof patients ina constant

draught-thecurrent as-

sumption beingthat it was the

hospital atmo-

sphere whichled to the onsetof redness, swel-ling, heat, andoffensive sup-puration and

sloughing, ifnot actuallypyaemia, which

were almost the normal sequelae of operations.Lister described in THE LANCET (1867, i., 326)

how, pondering over " the frequency of disastrous

consequences in compound fracture, contrastedwith the complete immunity from danger to lifeor limb in simple fracture," and searching for thecause of the decomposition of living tissues exposedto the air without protection, he realised that " aflood of light has been thrown upon this most

important subject by the philosophic researches ofM. Pasteur, who has demonstrated by thoroughlyconvincing evidence that it is not to its oxygenor to any of its gaseous constituents that the airowes this property, but to minute particlessuspended in it, which are the germs of various

733

low forms of life." Applying Pasteur’s discovery to the treatment of wounds, Lister concluded with

I

FIG. 31.-JOHN ERICHSEN.

- admirable logic that " it appears that all that is

required is to dress the wound with some material .capable of killing these septic germs, provided that I.any substance can be found reliable for this purpose ’’and not too potent or caustic." He continued by describing the reasons which had’ induced him in 1865 to choose carbolic acid as the antiseptic tobe tried, its local sedative action being one of thereasons, and gave in this and four subsequentissues of THE LANCET detailed accounts of the- cases of compound fractures, abscess, &c., in whichhe had successfully used this method—his restraint-and absence of self-advertisement in what he rightlyregarded as a most important innovation being ’’,noticeable. In the last of this series he described the application of his treatment to a case of psoas.abscess in a woman, aged 25, explaining that

,," here the essential object is to guard against the.introduction of particles from without, at the same I

time that a free exit is afforded to the constant I,.discharge of the contents." :We have quoted Lister’s actual words in these

papers, because in later controversies on his ’,methods the real issues on which his treatment was based-in essentials the principles guiding surgery to-day-were overshadowed, and even Listerhimself appears to have lost sight of them in the.heat of defence. For example, he resented hotlythe suggestion by Sir J. Y. Simpson (THE LANCET,1867, ii., 546) and others that he was not the:first to use carbolic acid in the treatment ofwounds. Now it did not matter if he had been:anticipated in the empirical use of carbolic acid as I

a dressing of wounds : of the principle guiding itschoice he was the originator. Much more importantthan the previous use by Lemaire and others ofthis dressing was the pioneer work of I. P. Semmel-weiss in 1847-49 on the aetiology and prophylaxisof puerperal fever-work which was unknown toLister for many years after his own researches hadbeen published, but which received generousappreciation from him when it was brought to hisnotice.What did THE LANCET make of Lister’s revolu-

tionary ideas ? In our issue of August 24th, 1867,an editorial article, after setting out his principlesand describing his practice, credits Lister witha " series of observations which, in point of surgicalimportance and fine perception of physiologicalprocesses, deserves the closest attention of all

surgeons and of all physiologists," and states thatif his conclusions should be confirmed by furtherexperiment and observation " it will be difficultto over-rate the importance of what we may reallycall his discovery." This was high praise of sucha heretical doctrine and practice, and was notpopular with many highly placed surgeons. Asthe year 1867 progressed, the principles on whichLister worked became more and more clearlydefined, and two further contributions to our

columns on the Antiseptic Principle in the Practiceof Surgery (1867,.ii., 353) and Illustrations of theAntiseptic System of Treatment in Surgery (ibid.,

FIG. 32.-JAMES SYME.

p. 668) contain many suggestions, founded on basicconceptions of the germ theory of disease, thatmight well find a place in any modern text-book.The discredit which it was attempted in certainquarters to throw on Lister’s theory, when manyyears later he discarded after a lengthy trial the

734

carbolic spray, was unfair indeed in the light ofhis early complete grasp of the essential facts ofinflammation, as set out in the second of thepapers. He says : " Admitting, then, the truthof the germ theory, and proceeding in accordancewith it, we must, when dealing with any case, i

destroy in the first instance once for all any septic organism which may exist within the part con- cerned ; and after this has been done ourefforts must be directed to the prevention ofthe entrance of others into it. And provided I,that these indications are really fulfilled, theless the antiseptic agent comes in contact withthe living tissues the better, so that unnecessary disturbance from its irritating properties may be Iavoided."From the beginning Lister, bearing principles

well in mind, was constantly modifying his practice.He soon found, for example, that undiluted carbolic acid in the purification of a recent wound caused superficial sloughing, and after testing anddiscarding an oily solution 1 in 4, found that a5 per cent. watery solution was strong enough. In view of the antiseptic-aseptic controversy, it is interesting to observe that Lister recognised the evils of antiseptics in damaging the tissues, and in1868 was attempting to meet them with the exclusion of germs by mechanical means, such as,rubber, or at least to protect the wound by oiled silk. In the search for suitable dressings he dis- ’,carded in turn putty made from carbolic oil andchalk, paraffin wax and lac plaster, all designedto hold the carbolic acid and prevent its beingwashed away by discharge, for those which freelyabsorbed discharges. The first of his absorbent

dressings was carbolised gauze, and later cyanidegauze was favoured. The facts will be found inTHE LANCET as they occurred.

Lister’s methods did not gain ground in Londonwith rapidity, and we allowed ourselves someeditorial sarcasm at the expense of London surgeons who had no success therewith. Mr. P. R. Cresswell

reported in THE LANCET of August 29th, 1868, that " the use of carbolic acid in the treatment of wounds has created quite a revolution in the surgical practice at Dowlais Iron Works," where 8500 men I

were employed. We commented the next week on Mr. Cresswell’s excellent results, adding : "And yet Mr. Lister’s treatment does not find muchfavour in London. Are the conditions of suppura- ,,tion different here from those in Glasgow or Dowlais? or is it that the antiseptic treatment is not triedwith that care without which Mr. Lister has always pointed out that it does not succeed ? " .As Thomas Wakley had done in the matter of

anaesthetics 20 years previously, the son now acted.James Wakley was not long satisfied with impres- Isions, but took steps by inquiries at various London hospitals to ascertain the opinion formed by surgeons on its use. As a result of these inquiries, by IINov. 14th, 1868, he was able to record that Lister’smethod, " sometimes with modifications at the

fancy of the surgeons, has been pretty extensivelytried at the London hospitals." It does not

surprise us nowadays that at St. George’s Mr. Rouse" finds the proportion of one part to forty of water

too strong as an application for chronic ulcerationof the legs. It appears to inflame the neighbouringskin. He now orders a lotion composed of twodrachms of carbolic acid to one pint of lead lotion,which he finds very useful." Surgeons at St.Bartholomew’s, Guy’s, Middlesex, and King’sCollege Hospitals submitted varying reports inthe concluding months of the year 1868, someenthusiastic, others damaging.

Meanwhile, suppuration being so much reducedin his hands, Lister’s own attention was beingturned to ligature material, for with the controlof sepsis and .absence of sloughing, the conceptionof reliable ligatures which would eventually beabsorbed and organised began to intrigue him.In 1869 he published in THE LANCET a note onthe Ligature of Arteries on the Antiseptic Principle,wherein he described his reasons for experimentingon these lines, the preparation of antiseptic catgutand its advantages as ligature material. We

pointed out in an editorial comment (1869, i., 503)that whereas it was the custom to regard theligature as a foreign body, more or less irritating,exciting suppuration and only fit to be roughlyremoved by the surgeon, " Prof. Lister’s experi-ments lead us to think of a ligature as capable ofbeing absorbed as dead tissues are absorbed, or

encapsuled as a metal bullet might be, or incor-porated with the tissue of the artery." We calledattention in the same article to the discrepancybetween Lister’s own results and those of certainothers attempting to use his methods. This wasa useful comment, as it inspired Mr. E. R. Bicker-steth, of Liverpool, among others, to recount inour columns his own good results, and to recordthe first cases in which the antiseptic catgutsuture had been successfully used on the humansubject for tying an artery in its continuity.(THE LANCET, 1869, i., 743, 811.) Various reportsfollowed in which the inefficient action of catgutligatures was mentioned. These caused much con-

troversy. Failure was attributed by the friendsof Listerism to imperfect preparation of the catgutsupplied, and the reports were useful in that

they stimulated Lister to study and improvemethods for the sterilising and preparation ofcatgut.A reformer of Lister’s outstanding honesty could

not fail sometimes to offend. The resentmentaroused by his not altogether tactful Edinburghlecture entitled On the Effect of the AntisepticSystem of Treatment upon the Salubriety of a

Surgical Hospital, which reflected rather seriouslyon the work of some of his former colleagues atGlasgow, was ventilated in our correspondencecolumns during 1870. It was impossible to doubtwho had the best of the argument. On Jan. 15th,1870, we pronounced that " Prof. Lister hasdone good service in publishing his experience ofthe antiseptic system in the Glasgow wards," and

we published during that year a series of importantpapers illustrating his current work. In January,1870, Lawson Tait began in our columns the

first of a long series of attacks on Listerism,and we returned to the endeavour to ascer-

tain to what extent these methods were being

735

" fairly and crucially tried" in London and IBirmingham, the reports received being on thewhole favourable. The modifications of the antiseptic technique

introduced by Lister in the early seventies were,however, to test severely the faith of those of hisadherents who failed to distinguish between theprinciples and the current practice of his system,and, moreover, caused much discomfort to his surgicalteam and possibly some harm to the unconsciouspatient. We reported the address at the meetingof the British Medical Association in 1871, in whichhe first described the spray method, wherebyoperators worked in an atmosphere permeatedwith carbolic acid. For well over ten years this iuncomfortable method was bravely persisted in byLister, until, indeed, the non-pathogenicity of thebacteria in the air was definitely established.Other innovations of this period were of more

permanent value, notably the rubber drainage-tubeand the substitution in certain cases of carbolicacid by the milder boracic lotion. The drainage- tube adapted by Lister from that used by Chas-saignac in 1859 was illustrated in THE LANCET of March 27th, 1875, and is almost exactly likethe tube in use to-day. As to boracic acid, " the new antiseptic

" discovered in Sweden, he found it (THE LANCET, 1875, i., 604) in the form of watery solution,

"

highly efficient and much less irritating than carbolic acid." Already he did not use the spray for every case. For example, he wrote on June 5th, 1875 (p. 788), " I need hardly remark that to operate under the spray when the woundcommunicates with a septic buccal cavity would Ibe an absurdity. The use of carbolic lotion should also be avoided on account of the irritation which it occasions to the tissues. There is, how- ever, no objection to having the sponges rendered ’Ipure by wringing them out in mildly acting boracic ilotion."

The acceptance of Lister’s doctrines abroad was much more prompt and enthusiastic than in thiscountry. We recorded on June 19th, 1875, thathis progress through the university towns ofGermany has " assumed the character of a triumphalmarch." His cause received a setback in London i

through an unfortunate incident. In the earlymonths of 1877 Lister made a speech in Edinburghwhich was not intended for publication, but found its way into the lay press, containing a somewhat tactless depreciation of the methods of London schools of surgery. This gave rise to acrimonious

correspondence in THE LANCET and to somewhat severe editorial rebuke. The occasion of the

speech was the acknowledgement of a testimonial I,received from his students, on the rumour thathe had been invited to leave Edinburgh for London,and should perhaps have been regarded as privi-leged. Lister showed no resentment at theeditorial attitude, for he continued to send hispapers to THE LANCET and, indeed, later in aclinical lecture published in our columns (THELANCET, 1878, i., 5) confesses that his strictureswere founded on misconception of the present Imethods of the London schools, and expresses hissincere regret that certain expressions used " should

have seemed capable of casting the remotest

possible slur on the surgeons of the Metropolis."His inaugural address to the students of King’sCollege on the nature of fermentation offered clearexperimental evidence of the groundwork on whichthe antiseptic theories were based. In editorialcomment on the address, which is well summarisedin our columns, we call attention to the skill withwhich Lister used diagrams and experiments to

illustrate his arguments, unusual in those days,and express our conviction that the scientificworld would thank him for his lecture. Laterin the year he developed the subject in a

" remark-

ably lucid and well-reasoned address " on LacticFermentation and its Bearing on Pathology (THELANCET, 1877, ii., 9, 21), presented to the Patho-logical Society of London, where he was receivedwith cordial welcome by a packed meeting of hisscientific colleagues. Charles Murchison presided,Burdon Sanderson and Charlton Bastian were mostcordial.

Nothing less than a revolution was broughtabout from this period onwards by the gradualspread of accounts of Lister’s successful cases

among London surgeons. The attitude of therapidly diminishing opposition is well shown byan anecdote quoted by Sir Rickman Godleein his Life of Lister. In October, 1877, Lister

performed an " open operation " on a broken

patella by wiring the two fragments together,then a novel procedure; and a well-known

surgeon said: " When this poor fellow diessomeone should proceed against that man for

malpraxis."A clinical lecture on a Case of Excision of the

Knee-joint, published in THE LANCET of Jan. 5th,1878, caused considerable sensation, and anotherlecture on Antiseptic Surgery, published in ourissue of Dec. 20th, marked what may be termedthe close of the period during which Lister’s basicprinciples were regarded by responsible peopleas under any doubt. In a leading article wereviewed the situation and expressed ourselves

finally convinced that " Listerism is destined to bethe surgery of the future." The battle againstprejudice was won. Of the publications of Lister,subsequent to this lecture and until his retirementfrom active practice, a good proportion were pub-lished in our columns, as may be seen in the manybibliographies of his works.

THE DISTINCTION BETWEEN PATHOGENIC ANDNON-PATHOGENIC BACTERIA: ASEPSIS.

It remains only to note the alteration in technique-for it was no alteration in principle-which ledfirst to the abandonment of the carbolic spray andlater to the gradual replacement of antiseptic byaseptic surgery.The fundamental change was brought about by

the discovery that the bacteria in the air were

mainly, if not entirely, non-pathogenic, and thatif scrupulous cleanliness were adopted in everyinstrument, dressing, or finger allowed to touchthe wound, incisions into tissues not alreadyinfected might be expected to heal by first inten-tion. This ideal was developed by the aseptic

736

school founded by von Bergmannl in 1885-86,till it reached the stage well known in modernoperating theatres, and there is no sign at presentthat in civil surgery this procedure is likely to bereplaced. In war surgery, however, the antisepticsystem still largely prevails. The Carrel-Dakin(THE LANCET, 1916, i., 880, and 1916, ii., 800)and the bipp method (THE LANCET, 1916, ii.)of antiseptic treatment were but extensions ofthe Listerian ideal, and, in fact, only one (thehypertonic saline treatment introduced by AlmrothWright, THE LANCET, 1915, i., 847) of the manymethods of treating war wounds which we had

occasion to describe and assess during the war wasfounded on physiological principles other thanthose elaborated by Lister. The search for Lister’sideal antiseptic which penetrates the tissueswithout damaging them, and yet is potent to destroypathogenic bacteria, is not yet ended.We have gone very fully into the story of

antiseptics because some writers in summarising the magnificent work of Lister have consulted ourcolumns partially and have come to the unjustifiableconclusion that, after having supported Listerenthusiastically at first, we -later made his course ’,difficult. It was impossible that the swings back ’,of the pendulum, as they occurred, should not be ireflected in our columns, but there was never any iattack upon Lister, and many quotations from our columns, made to give colour to the mistaken ’,view, would be found on consultation to be extracted from the reports which had to be pub- ’,lished, if true information was to be given, andnot from editorial articles.

PUBLIC AFFAIRS AND MEDICAL

JOURNALISM.HUNDRED years of medical events cannot be told without overlapping or repetition’unless regard for dates gives way to the

claim for a consecutive story, when big things-such things as make epochs by their revolutionarybearing-are in question. In writing of anaesthetics Iand antiseptics the wish to complete a sectionrecording the relations of THE LANCET to thesebig things has brought up to the days in whichwe live a narrative broken off under the editorshipof James Wakley. I

DISRESPECT FOR PERSONAGES.There was a side to that editorship to which I,

attention should be paid as furnishing an example of the influence of circumstances upon a journal founded to remedy the ills under which general practice lay and to raise the doctors of the people ito the place which their responsibilities should give Ithem. From the beginning this programme had I,been carried out with fearlessness and fierceness,

1 Von Bergmann celebrated the twenty-fifth anniversary ofhis career as a surgeon in 1885 when he was director of theKœnigliche Chirurische Universität Klinik in Berlin. In con-gratulating him we noted the fact that he was engaged on a series of investigations " which are principally a continuationof Lister’s inquiries into antiseptics " (THE LANCET, Dec. 5th,1885), and in the course of the next few years were able tochronicle his invention of steam sterilisation and the world-widespread of his doctrine and practice of asepsis.

with the result that much tyranny and back-slidingin high places had disappeared. It was no longertheir official lapses, as presidents or professors,which offered to the leaders of medicine oppor-tunities day by day for demanding apologies or forstarting libel actions ; instead, strictures were metedout to them for their behaviour in public affairs.The ethical rather than the official demeanour wasmade the subject of investigation, and James

Wakley’s aspirations for peace were thwarted bythe bitter comments which appeared in his columnswhen social happenings brought the manners ofdistinguished persons under the criticism of certainof his editorial writers. It will be sufficient to

give two or three examples in illustration.Shortly after the arrival of Napoleon III. in

England a consultation took place between BaronCorvisart, his medical attendant. and Sir HenryThompson, when the condition of vesical calculuswas diagnosed and the question of operativeinterference discussed. But the symptoms abated,and it was not. until Jan. 2nd, 1873, a year andnine months later, that Sir Henry Thompsondecided to operate with the general medical andsurgical support of Sir William Gull and Sir JamesPaget. Chloroform was administered by Cloverhimself and lithotrity was performed. Three dayslater there were indications that further operationwas necessary, but before this could be performedthe Emperor died. The post-mortem examinationrevealed a condition which it was suggested inTHE LANCET could have been better met bylithotomy, while excerpts were published from theback files of the Union Médicale showing that atleast three years before the disastrous Franco-German War the Emperor’s medical advisers hadbeen perfectly aware of his ominous state. These

quotations led to disrespectful comment on thewording of the post-mortem report, inasmuch asthe very first sentence contained a suggestion thatthe conditions found at the autopsy were unsus-pected, and could not have been ascertained in thecourse of ordinary diagnosis. Now Sir William Gulldissented from the finding of the other signatories,and his conduct in so doing was considered byTHE LANCET to have been a pretence to a superiorwisdom, which had only been obtained after thetragedy, and the professional attitude adopted wasbluntly condemned.

Later the same physician came in for severecriticism because of certain contradictory statementsi which he had made in the Bravo case, the stages ofwhich were reported in THE LANCET. That case

was, and for experts in criminology remains, ofextraordinary importance, and, during the whole ofthe protracted inquest with which the proceedingsterminated, the daily journals gave prominence tothe matter, and made of it a story of standinginterest. A quarrel arose between Sir WilliamGull and Sir George Johnson with regard tothe way in which Gull gave his evidence ; the

allegation of Johnson was that Gull, having beeni called into consultation because poisoning was

i suspected, and having been definitely told byJohnson and his colleagues why he was being con-sulted, suggested in his evidence that the suspicion