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医学 1867

论外科手术中的防腐原理

约瑟夫·李斯特

伤口腐烂,是因为空气中的病菌落入其中——杀死病菌,手术便不再杀人。

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In depth · the introduction

在历史的大部分时间里,活着被刀切开,也只赢了一半——接踵而来的那道伤口,照样能要你的命。李斯特弄清了原因,也找到了制止它的办法。

核心想法

在 1860 年代,外科手术是一场赌博。一台手术也许进行得天衣无缝,可几天之后,伤口却会肿胀、化脓、转为脓毒,病人随之死去。外科医生们把这种「伤口脓毒」当作运气不好,或空气不洁。格拉斯哥的外科医生约瑟夫·李斯特,读到了法国科学家路易·巴斯德的工作——巴斯德已经表明,腐烂与发酵,是由漂浮在空气中的微小活物(病菌)所引起的。

李斯特由此一跃而悟:伤口腐烂,不是因为空气本身,而是因为空气带进伤口的病菌。在伤口处杀死这些病菌,它便根本不必腐烂。他用石炭酸——一种气味强烈、当时用来处理污水的化学品——去清洁伤口、敷料、器械与双手,死亡便止住了。

它是如何诞生的

李斯特是格拉斯哥皇家医院的外科教授,那里的病房凶险到,外科医生有时觉得病人在家里动手术反倒更安全。在寻找术后感染的根源时,他读到了巴斯德的论文,认出了别人都不曾画出的那条联系。他之所以选用石炭酸,是因为听说它能消除施过污水的田地的恶臭——他推想:既然它能在那里摧毁腐败的根源,或许在伤口里也能如此。

他先在最糟的病例——开放性骨折,也就是骨头刺破皮肤、感染几乎注定的情形——上试验。本该被截掉的肢体,竟愈合了。1867 年,他把自己的原理写成一篇简短的讲稿发表。外科界抵触了好些年——他那一丝不苟的洗手与换药仪式显得小题大做,他的统计数据也遭怀疑——但结果最终让众人折服。

它为何重要

在李斯特之前,深入体内动手术几乎等于自杀;腹腔、胸腔与颅腔几乎是禁区,因为感染必至。防腐外科,以及由它生长出来的无菌技术,使整个现代外科成为可能——从阑尾切除到心脏移植。那间无菌手术室——连同其中刷净的双手、手术衣与器械——就是李斯特的构想;而它所拯救的生命,比医学中几乎任何一项单独的进步都要多。

一个可以想象的画面

把伤口想象成搁在台面上的新鲜水果。它腐烂,不是因为空气碰到了它,而是因为看不见的孢子与微生物从空气中落下、附着其上、不断繁殖。你什么也不必密封——只要让表面变成一处任何活物都无法立足的地方(就像盐或醋之于食物),水果就能保鲜。李斯特的石炭酸,对敞开的伤口做的正是这件事:它并不把空气挡在外面,而是把伤口变成一处让空气中的病菌无法存活的表面。

可交互的病房:选择要做多少例截肢手术,再把李斯特的石炭酸法切换开或关;病床会按李斯特真实记录的比例(之前约 46% 死亡,之后 15%)标出存活或死亡。

它的位置

李斯特,立在这座图书馆里两位巨人之间。巴斯德已经表明,微生物会引起发酵与腐败;李斯特则把这一想法从酒桶里取出,带进了伤口。再早几年,约翰·斯诺曾把伦敦一场霍乱追溯到一口水泵,主张散播疾病的是一种看不见的因子,而非污浊的空气——这与从「瘴气」转向真实的物理病因,正是同一次转身。李斯特之后,罗伯特·科赫将证明特定的病菌引起特定的疾病,而弗莱明日后会发现一种能从内部杀死细菌的霉菌。防腐法,正是病菌学说第一次在手术台上兑现的那道枢纽。

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