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醫學 1867

論外科手術中的防腐原理

約瑟夫·李斯特

傷口腐爛,是因為空氣中的病菌落入其中——殺死病菌,手術便不再殺人。

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In depth · the introduction

在歷史的大部分時間裡,活著被刀切開,也只贏了一半——接踵而來的那道傷口,照樣能要你的命。李斯特弄清了原因,也找到了制止它的辦法。

核心想法

在 1860 年代,外科手術是一場賭博。一台手術也許進行得天衣無縫,可幾天之後,傷口卻會腫脹、化膿、轉為膿毒,病人隨之死去。外科醫生們把這種「傷口膿毒」當作運氣不好,或空氣不潔。格拉斯哥的外科醫生約瑟夫·李斯特,讀到了法國科學家路易·巴斯德的工作——巴斯德已經表明,腐爛與發酵,是由漂浮在空氣中的微小活物(病菌)所引起的。

李斯特由此一躍而悟:傷口腐爛,不是因為空氣本身,而是因為空氣帶進傷口的病菌。在傷口處殺死這些病菌,它便根本不必腐爛。他用石炭酸——一種氣味強烈、當時用來處理污水的化學品——去清潔傷口、敷料、器械與雙手,死亡便止住了。

它是如何誕生的

李斯特是格拉斯哥皇家醫院的外科教授,那裡的病房凶險到,外科醫生有時覺得病人在家裡動手術反倒更安全。在尋找術後感染的根源時,他讀到了巴斯德的論文,認出了別人都不曾畫出的那條聯繫。他之所以選用石炭酸,是因為聽說它能消除施過污水的田地的惡臭——他推想:既然它能在那裡摧毀腐敗的根源,或許在傷口裡也能如此。

他先在最糟的病例——開放性骨折,也就是骨頭刺破皮膚、感染幾乎注定的情形——上試驗。本該被截掉的肢體,竟愈合了。1867 年,他把自己的原理寫成一篇簡短的講稿發表。外科界抵觸了好些年——他那一絲不苟的洗手與換藥儀式顯得小題大做,他的統計數據也遭懷疑——但結果最終讓眾人折服。

它為何重要

在李斯特之前,深入體內動手術幾乎等於自殺;腹腔、胸腔與顱腔幾乎是禁區,因為感染必至。防腐外科,以及由它生長出來的無菌技術,使整個現代外科成為可能——從闌尾切除到心臟移植。那間無菌手術室——連同其中刷淨的雙手、手術衣與器械——就是李斯特的構想;而它所拯救的生命,比醫學中幾乎任何一項單獨的進步都要多。

一個可以想像的畫面

把傷口想像成擱在檯面上的新鮮水果。它腐爛,不是因為空氣碰到了它,而是因為看不見的孢子與微生物從空氣中落下、附著其上、不斷繁殖。你什麼也不必密封——只要讓表面變成一處任何活物都無法立足的地方(就像鹽或醋之於食物),水果就能保鮮。李斯特的石炭酸,對敞開的傷口做的正是這件事:它並不把空氣擋在外面,而是把傷口變成一處讓空氣中的病菌無法存活的表面。

可互動的病房:選擇要做多少例截肢手術,再把李斯特的石炭酸法切換開或關;病床會按李斯特真實記錄的比例(之前約 46% 死亡,之後 15%)標出存活或死亡。

它的位置

李斯特,立在這座圖書館裡兩位巨人之間。巴斯德已經表明,微生物會引起發酵與腐敗;李斯特則把這一想法從酒桶裡取出,帶進了傷口。再早幾年,約翰·斯諾曾把倫敦一場霍亂追溯到一口水泵,主張散播疾病的是一種看不見的因子,而非污濁的空氣——這與從「瘴氣」轉向真實的物理病因,正是同一次轉身。李斯特之後,羅伯特·科赫將證明特定的病菌引起特定的疾病,而弗萊明日後會發現一種能從內部殺死細菌的黴菌。防腐法,正是病菌學說第一次在手術台上兌現的那道樞紐。

The original document
Original source text
Joseph Lister · British Medical Journal 2 (1867): 246–248 · read before the Surgical Section of the British Medical Association, Dublin, 9 August 1867
Addressing the British Medical Association, Lister laid out the reasoning and the results of the antiseptic system he had developed at Glasgow Royal Infirmary. He begins by relocating the cause of wound infection — not in the air itself, but in decomposition set going within the wound:
In the course of an extended investigation into the nature of inflammation, and the healthy and morbid conditions of the blood in relation to it, I arrived several years ago at the conclusion that the essential cause of suppuration in wounds is decomposition brought about by the influence of the atmosphere upon blood or serum retained within them, and, in the case of contused wounds, upon portions of tissue destroyed by the violence of the injury.
The danger, he argues, lies not in the oxygen of the air but in something living that the air carries — and here he turns to Pasteur:
But when it had been shown by the researches of Pasteur that the septic properties of the atmosphere depended not on the oxygen, or any gaseous constituent, but on minute organisms suspended in it, which owed their energy to their vitality, it occurred to me that decomposition in the injured part might be avoided without excluding the air, by applying as a dressing some material capable of destroying the life of the floating particles.
From this followed the remedy: not to shut out the air, but to destroy the organisms it deposits, with a chemical agent applied to the wound and its dressings.
The material which I have employed is carbolic or phenic acid, a volatile organic compound which appears to exercise a peculiarly destructive influence upon low forms of life, and hence is the most powerful antiseptic with which we are at present acquainted.
He then reports the results: compound fractures and abscesses treated on this principle healed without the suppuration and septic fever that had been their usual fate, and the deadly character of his surgical wards was transformed.
[ … ]
Lister stresses that the method is a whole system, demanding scrupulous care at every step, and that its principle — antisepsis — matters more than the particular substance employed.
Glasgow Royal Infirmary · 1867