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VETERINARY MEDICINE SERIES 
No. 9 
Edited by D. M. CAMPBELL 


~ WOUND TREATMENT 


BY 
LOUIS A. MERILLAT, V.S., 
E. WALLIS HOARE, F.R.C.V.S., 
AND OTHERS 


Chicago 
AMERICAN JOURNAL OF VETERINARY MEDICINE 
1915 


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PREFACE 


The treatment of wounds in the hands of the average 
veterinarian has not improved as much in the last dec- 
ade as have other branches of purely operative surgery. 
A score of years ago, few veterinarians expected that 
wounds made in the course of their operations could 
be healed without infection. Now, the more successful 
practitioners reproach themselves if a wound of their 
own making develops sepsis. The treatment of acci- 
dental wounds, on the other hand, is much the same 
now in the practice of most veterinarians as it was a 
double decade ago—that is, they are treated by 
washes, ointments, or dusting powders, as the inclina- 
tion of the practitioner may direct, and seldom is a 
real conscious effort made to render them germ-free, 
suture them up, and procure healing by first intention 
without the development of sepsis. 

This average of conditions is not true of the work of 
all, and it is for the purpose of placing the methods used 
by a number of the most successful practitioners in the 
hands of the whole profession that this little volume has 
been issued. It comprises the better articles on the use 
of antiseptics, suturing and treatment of wounds in gen- 
eral, that have appeared in the AMERICAN JOURNAL OF 
VETERINARY MEDICINE during the past four or five years. 
The editor is convinced that the treatments herein given 
are practical for the average practitioner, and their care- 
ful study will prove of much value to him. 


De M.-C: 
Evanston, Illinois, 
September, 1915. 


n 


a 


CONTENTS 


DISINFECTANTS AND THEIR STANDARDIZATION—By 
UT CESS OTT SCTILS Sf) eae INS Mg aa oP EPMO, Ar aE aps a 
BACTERICIDAL PROPERTIES OF COMMON ANTISEPTICS 
AND DISINFECTANTS—By H. Lothe and B. A. 
eee ET sees cha chs oS aig Mee 
ANTISEPTICS, PAST AND PRESENT, IN WOUND TREAT- 
wy He Walls Hoare. : oss... 2 pic oes 
SUPPRESSION OF HEMORRHAGE—By E. Wallis Hoare. 
TREATMENT OF WouNpDSsS—By JL. A. Merillat........ 
Wounp Heauinc—By A. T. Kinsley.............. 
REPAIR OF WoUNDS—By William Brady........... : 
SURGERY IN WOUND TREATMENT—By John Ernst... 
PRACTICAL SURGICAL CLEANLINESS—By Mart. R. 
[SET Gllc, (A GS ee he ek RON re ee 
VULNERARIES—By Douglas H. Stewart............ 
PRACTICAL WOUND APPLICATIONS—By A. W. 
EIU ATE | ey oc! [NRE Ne eal Oe GP UP a ee, vas ae 
ABDOMINAL WOUNDS OF ANIMALS—By J. V. Lacroix 
Weem dOmnrs By ds NI-PTrOst: 2... Shek ee be 
OPEN JoINts—By Mart. R. Steffen............... 
TETANUS FOLLOWING SuRGICAL WouNDS—By Henry 
Ge ly SNE 2 ee Pe ras Bee eae) Sa 
FAVORITE WOUND TREATMENTS—By Several Writers 


65 
125 
131 
137 


145 
149 


153 
155 
165 
173 


LG 


183 


DISINFECTANTS AND THEIR 
STANDARDIZATION 


By WATSON LEWIS, D.V.M., Saint Paul, Minnesota 


An antiseptic prevents the growth of germs, while a 
disinfectant kills them. It is hard to say just where 
antiseptic action leaves off and disinfectant begins, 
for they are so closely allied that the terms are com- 
monly used synonymously. It is a well known fact 
that a substance may cause a marked inhibition of 
bacterial growth and still be of little value as a germ 
destroyer. For instance, turpentine will retard the 
srowth of spores in solutions of 1 to 75,000, while 
carbolie acid only retards in a solution stronger than 
1 to 1,250. This powerful antiseptic action explains 
the high efficiency of turpentine in flatulent conditions 
both in human and in veterinary medicine. 

Nothing is used more frequently in veterinary sur- 
gery than antiseptics and disinfectants, many of which 
are Standardized. However, such is not the case with 
coal tar and allied disinfectants, for here no standard 
has been adopted to protect the consumer against 
fraud. : 

These preparations are now offered on the market 
at prices varying from fifty cents to five dollars a gal- 
lon. The five-dollar preparation may be actually 
cheaper than the fifty-cent preparation, because of its 
germicidal value. Accurate test shows that there are 
preparations fifteen to seventeen times more efficient 
than carbolic acid, but they do not sell for fifty cents 
a gallon. 


5 WOUND TREATMENT 


The question now arises, ‘‘How are we to know 
the real value of a germicide?’’ In the last few years, 
both in this country and in Europe, there have been 
rapid advancements made in the accurate standard- 
ization of disinfectants. It is time that the old state- 
ments in textbooks that bichlorid of mereury kills 
anthrax in so many hours, and Streptococcus pyogenes 
in so many minutes, should be discarded. The results 
depend entirely on the strains of the organisms tested 
and the method used. 


One strain of Streptococcus pyogenes may be killed 
in five minutes while another, by the same method, 
will require twice the time. 

Carbolic acid and the salts of the heavy metals, such 
as silver, copper, and mercury, have been mostly used 
as disinfectants. There is now a tendency to discard 
these for the more easily applied preparations, as their 
general fault lies in their lack of efficiency in the pres- 
ence of organic matter—that is, blood and pus. 


Another group of disinfectants not used to any ap- 
preciable extent but possessing high efficiency, is the 
essential oils. They owe their germicidal value to 
their phenol content, which, in some instances, is very 
high. Thymol, for example, which is a phenol obtained 
from the oil of thyme, is twenty-five times more pow- 
erful than ecarbolie acid. It is unfortunate that the 
expense of these oils and the inconvenience of apply- 
ing them have limited their use, for they are only 
slightly toxic, do not coagulate organic matter to any 
appreciable extent, and are only slightly irritating. 

The germicidal value of most of the commercial 
coal-tar disinfectants is due to the eresols—paracresol, 
metacresol, and orthocresol—which are variable in their 
germicidal efficiency. 


- DISINFECTANTS—STANDARDIZATION 9 


Paracresol and metacresol have much more germi- 
cidal power than orthocresol, and the amount of each 
present in the coal-tar disinfectants may vary mark- 
edly in different lots. Therefore it is necessary to 
determine the percentage of each, in each lot, by frac- 
tional distillation. 

Several methods have been advanced for the testing 
of the germicidal value of disinfectants, and lately 
much work has been done toward standardizing such 
methods. 

The methods of the Lancet commission and Rideal- 
Walker, and that of Anderson and McClintic of the 
United States Public Health Service, have all been em- 
ployed. The Anderson-McClintic method is a modifica- 
tion of the Rideal-Walker method to eliminate some of 
the variations which may be obtained in the use of that 
test. 

In all such tests the great difficulty lies in finding a 
procedure by which the exact value of the disinfectants 
may be determined, and a proper relative standard se- 
cured in the laboratory. 

It must be borne in mind that such a test, no matter 

how painstakingly and elaborately worked out,.is at the 
best but a laboratory test, and is only an indication of 
the relative possibilities of the disinfectants under the 
- varying conditions met with in practice. 
However, it may be said safely that the Anderson- 
MeClintic method gives a basis for successful testing of 
- disinfectants and at the least will enable us to standard- 
ize their action toward the typhoid organism, relative 
to the action of phenol under the same conditions. 

In using the Anderson-McClintic method it is most 
essential that the exact recommendations of the authors 
be carried out to the minutest detail. Lack of attention 
to the different factors concerned in the examination 


10 WOUND TREATMENT 


of: disinfectants is responsible for most of the diserep- 
ancies in results obtained by different workers with 
the same disinfectant. Close attention to the details of 
the method used is the only way in which uniform results 
can be secured. : 

The factors which bring about the greatest variance 
in results obtained, and which must be considered of 
the most importance in the conduct of the test, are (1) 
the organism used, (2) temperature of the experiment, 
(3) amount of culture, (4) amount of disinfectant, and 
(5) the media used in subculture, (6) standardized 
solution of phenol. 

The coefficient obtained by different species, and by 
different strains of same species, May vary greatly, so 
it is essential that one species be adopted and the eul- 
tivation of the strain employed be as nearly standard- 
ized as possible. For this reason the Hopkins strain of 
B. typhosus is best employed. It is cultivated on stand- 
ard extract broth made from Liebig’s extract of beef 
in accordance with the methods adopted by the Amer- 
ican Public Health Association for water analysis. It is 
important that the reaction of the medium be just 11.5. 
One loopful of 4-millimeter platinum loop of the eul- 
ture is carried over every twenty-four hours on three 
successive days. Before being added to the disinfectant 
the culture is filtered through sterile filter paper and 
brought to a temperature of 20 degrees Centigrade in 
a water bath. 

One tenth of a cubic centimeter of the culture is used, 
added to 5 eubie centimeters of the disinfectant dilution 
at a temperature of 20 degrees Centigrade. Measure 
the amount of culture with a pipette graduated to 1-10 
eubie centimeter. 

When the proper dilutions of the disinfectant to be 
tested and the phenol controls have been made and 


- DISINFECTANTS—STANDARDIZATION = 11 


placed in their respective test tubes, all is placed in a 
water bath so that the solutions may be brought to a 
temperature of 20 degrees Centigrade. A standard so- 
lution of pure phenol is made and standardized by the 
United States Pharmacopeia method to contain a five 
per-cent solution by weight. Dilutions are made fresh 
from this each day. When everything is ready, 1-10 
cubic centimeter of the culture is added by the pipette 
to each of the dilutions in the seed tubes. 

The solutions are planted from the seed tubes into 
the culture tubes every two and one-half minutes up 
to fifteen minutes, and for this a 4-millimeter platinum 
loop, United States standard, 23-gauge wire is used. 


In adding the culture to the dilution the best method 
is to tip the test tube at an angle of forty-five degrees, 
lightly touch the pipette against the side of the tube 
below the surface line, and then shake gently. The 
broth tubes are placed in the incubator at 37 degrees 
Centigrade for forty-eight hours. 

The mean between the strength and time coefficients 
is used for determining the coefficient. To determine 
the coefficient, the figure representing the degree of dilu- 
tion of the weakest strength of the disinfectant that 
kills within two and one-half minutes is divided by 
the figure representing the degree of dilution of the 
weakest strength of the phenol control that kills within 
the same time. The same is done for the weakest 
strength that kills in fifteen minutes. The mean of the 
two is the coefficient. 

As has been stated before, the coefficient simply rep- 
resents the germicidal power of the disinfectant tested, 
relative to the power of phenol on the same organisms 
under the same conditions, and should be accepted only 
as such. 


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Fo, 2 oe eel a4 Leeoe ied hoa e 3 
a Vat aa ae 8 ae ‘ 
’ . - S wh a Fea 
< 4 * “} tee 
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Soe See 
PY vs . 
“a 


12 WOUND TREATMENT 

- However, it is ‘the best we have at present, 
francs are due to Rideal-Walker and be 
-McClintie for carrying us this far in obte 
cedure by which we may begin to standar 
fectants. 


<<) ¢ pa ayy ae rte aga 3 é 


BACTERICIDAL PROPERTIES OF COM- 
MON ANTISEPTICS AND 
DISINFECTANTS 


By oH. LOTHE, -.D.V.M., and B. A. BEACH, D.V.M., 
Madison, Wisconsin 


A new era in surgery began with the work of Laster, 
who in 1867 studied the effect of disinfection upon 
wound healing and introduced ecarbolic acid as a dis- 
infectant. As the science of bacteriology developed, our 
knowledge of disinfectants and disinfection increased 
and will continue to increase and may change as new 
bacteriological data are collected that change the 
science of bacteriology. It therefore follows that the 
final word on disinfection has not yet been said, hence 
a conclusive statement of our knowledge of disinfection 
cannot be given. Nevertheless, sufficient experimental 
data have already been collected to determine certain 
fundamental principles upon which scientific disinfec- 
tion is based. Judgment as to the value of any disin- 
fecting agent must, therefore, be made largely from a 
bacteriological point of view. 

As we all know, the fundamental principle of disin- 
fection is the destruction of bacteria by means of chem- 
icals or heat (commonly called sterilization). In this 
article disinfection by means of chemicals only will be 
considered. Chemicals are used for these purposes: (1) 
to render innocuous buildings and other inanimate ob- 
jects that have come in contact with germs of various 
infectious diseases; and (2) to prevent the entrance of 
organisms to the animal body and to kill organisms 


13 


14 WOUND TREATMENT 


that have already gained entrance to the animal body. 
The latter concerns the surgeon, while the former is 
a matter of primary interest to the sanitarian. 
A veterinarian must necessarily act in both of these 
capacities. The fundamental principles of disin- 
fection are the same for both the surgeon and the 
sanitarian, although each has peculiar problems that do 
not concern the other. To the surgeon the question of 
toxicity of the disinfectant to higher animal life be- 
comes an important question, while to the sanitarian this 
is not so important. The ideal disinfectant is one abso- 
lutely non-toxic to the animal body but highly toxie to 
bacteria. Surgeons are still looking for this ideal dis- 
infectant. 


Disinfectant and Antiseptic 


For the sanitarian chemicals that kill bacteria are 
ideal, and are known as disinfectants. Such agents are, 
however, as a rule, too toxic for the surgeon, who uses 
agents that prevent the growth of bacteria and are known 
as antiseptics. The same chemical agent may be both 
an antiseptic and a disinfectant, depending upon con- 
centration. 


Cauterization 


The surgeon occasionally uses agents that are toxic 
to tissues which are known as caustics. These agents 
kill both tissue and bacteria cells, and conditions ob- 
tain at times, such as bites from rabid dogs, when this 
drastic method is of primary importance. 


Factors Affecting the Action of Antiseptics 


There are various factors that affect the action of dis- 
infectants and antisepties, as follows: 


: BACTERICIDAL PROPERTIES 15 


1. Type or OrGANISM.—In the early days of antisep- 
sis, disinfectants were tested bacteriologicaily with the 
idea of discovering some chemical agent that would 
destroy all known bacteria when used in a weak solution. 
No such universal antiseptic has been found. On the 
contrary, it has been found that different antiseptics 
have a selective action upon certain types of organisms. 
For example, bichlorid of mercury is a most powerful 
disinfectant for anthrax, but has only a weak action 
on tubercle bacilli and is much less effective than some 
other drugs (creolin, lysol, aleohol) for superficial dis- 
infection of the skin, while ecarbolic acid is relatively 
ineffective against tetanus bacilli, anthrax spores, and 
tubercle bacilli. It therefore follows that in disinfec- 
tion the different organisms and bacteria must be con- 
sidered individually. In general, it can be said that 
spore-bearing bacteria require stronger disinfectants 
than non-spore bearers. Here again individual differ- 
ences in resistance of species of spores and vegetative 
forms manifest themselves. It is, therefore, difficult to 
make a comparative table of individual drugs. In gen- 
eral, the strongest disinfectants which also destroy spores 
are mercuric chlorid, silver nitrate, iodin, creolin, lysol, 
' liquor cresolis compound and other cresol preparations, 
and formalin. The weaker disinfectants which kill only 
spore-free organisms are coal tar, carboliec acid, salicylic 
acid, dyes, boric acid, and calcium lyes (whitewash) and 
acids. 


Indiwidual Resistance of Organisms.—The individual 
resistance of different organisms varies. Some infectious 
agents are very readily destroyed while others are very 
resistant. For practical purposes disease-producing 
micro-organisms may be divided into two groups on the 
basis of their power to resist disinfection. 


16 WOUND TREATMENT 


1. REQUIRING STRONG DISINFECTANTS: 


Anthrax spores 
Tetanus spores 
Tubercle bacilli 
Blackleg spores 
Rabies virus 


2. REQUIRING WEAKER DISINFECTANTS: 


Glanders bacilli 

Hemorrhagic septicemia bacilli 

Abortion bacilli 

Foot-and-mouth disease virus, and other bacilli 


Pus organisms (Staphylococci and Streptococci) oe- 
cupy an intermediate position. They are more resistant 
than other vegetative forms but less so than spores. 
They, however, require strong disinfectants. 

2. TEMPERATURE.—The higher the temperature the 
greater is the disinfectant property of a given chemical. 
Practical application of this is made by having the 
solution of disinfectants as warm as possible when in 
use. | 

3. CONCENTRATION.—The stronger the concentration 
the more effective is the germicidal action. Creolin, 
however, is an exception to this rule that concentrations 
where emulsification is complete (two to three per cent) 
are most efficient. Concentrations of ten to twenty per 
cent are not relatively as efficient because a great per- 
centage of the creolin is not emulsified and hence not 
entirely effective. Stated in other words, up to con- 
centrations where emulsification is complete, the disin- 
fection coefficient varies directly as concentration, but in 
higher concentration the ratio of increase is smaller— 
that is, a twenty-per-cent solution has not ten times the 
disinfectant properties of a two-per-cent solution. 

4, DuRrATION oF AcTIOoN.—For action, a certain lapse 
of time is necessary, which varies with the-individual 
antiseptic on the one hand and the type of organism 
on the other. With some disinfectants the action on 


BACTERICIDAL PROPERTIES 17 


certain organisms is almost immediate, while with others 
a greater lapse of time is necessary. 


5. PRESENCE OF ORGANIC Matrer.—Under practical 
conditions disinfectants are used in the presence of or- 
ganic matter, and it has been found that considerably 
higher concentration and greater length of time are 
necessary for most disinfectants under such conditions. 
Such organic material as blood, manure, and urine are 
_ often present where disinfection and antisepsis are prac- 
ticed. These contain chemical bodies that unite with the 
antiseptic used, rendering it inert. It is therefore neces- 
sary to use enough disinfectant to combine with the 
organic matter and enough more to act as an antiseptic 
and disinfectant. This factor will naturally vary with 
the kind and amount of organic matter present. 


To summarize, then, we find that the disinfectant 
properties of any given chemical depend upon: 


. Type of organism 
. Temperature at which it acts 


. Concentration 
. Length of time acting 


. Amount and character of organic matter 


Or PO DO eH 


Earlier in this article mention was made of the fact 
that scientific disinfection was based entirely upon bac- 
teriologieal tests. In determining the value of any given 
_ disinfectant it therefore becomes necessary to take into 
consideration each of the five above-mentioned factors so 
that a comparison of different antiseptics can be made 
on the same basis. It is necessary that they all act upon 
the same organism, at the same temperature and con- 
_ centration, for the same length of time, and in the 
presence of the same amount and composition of organic 
“matter. ‘e , 


18 WOUND TREATMENT 


Hygienic Laboratory Phenol Coefficient 


A method of standardizing or testing antisepties has 
been developed and described by Anderson and MeClin- 
tic in Bulletin 82 of the Public Health and Marine 
Hospital Service, Washington, D.C., known as the 
‘‘Hygienic Laboratory Phenol Coefficient’’ method, 
which takes into account all of the above-mentioned fac- 
tors. It is sufficient for our purpose at this time merely 
to state how this method meets these requirements with- 
out going into the details of laboratory manipulations. 


1. Type of organism used is a twenty-four-hour broth 
culture of B. typhosus (the organisin of ie 
fever in a man) 

2. Temperature is 20 degrees Centigrade 

3. Concentrations of various strength ’ 

4, Length of time varies from two and one-half to fifteen 
minutes for each dilution or concentration 

5. Organic matter consisting of two per cent of peptone 
and one per cent of gelatin is used. 


To give more information regarding any given dis- 
infectant, this method prescribes’ that ‘its germicidal 
properties be determined upon typhoid both in the ab- 
sence and in presence of organic matter. 

For purposes of comparison the results are expressed 
in figures known as the ‘‘hygienie laboratory phenol ¢o- 
efficient,’’ which simply means the germicidal proper- 
ties of the disinfectant in question expressed in terms 
of phenol or carbolic acid, reducing the value of all dis- 
infectants to a common language or medium of ex- 
change, so to speak, just as the value of wheat, beef, and 
Sasoline is expressed in terms of dollars and cents rather 
than expressing the value of a bushel of wheat in pounds 
of beef, or pounds of beef in gallons of gasoline. The 
phenol coefficient, then, gives you the bactericidal prop- 
erty of the disinfectant in question compared to phenol. 


BACTERICIDAL PROPERTIES 19 
The table on this page shows the results obtained by 
this method with a well-known antiseptic with which 


many of you are familiar. 


Creolin-Pearson—Results of a Test without Organic 


Matter 
(+ means growth; — means no growth) 
Time culture exposedto - 
action of disinfectant Phenol 
for minutes coefficient 
Sample Dilution 22.5 72 10 123 15 | 200+400 
1:80 | —|—|— —_ —-—— 
Peg S5 S=S 80+ 100 
SC) ee 1:100 | + | +) +/+] + | —|)-———-= 
ze hoc il 2 
1:200 |} —| —}|—}—|—|— | 2.50 + 4.00 
I ec 
Len Se) SS 2 
S00 Se SS 3.20 
Ecole coe. ee we LESS) | See Sse) 9) 
E00 beet ete 
1:450 | +} -+|+|+ ie 
1:500 |+|+/+/+/+]+ 


Results of a Test with Organic Matter 


Time culture exposed to 
action of disinfectant Phenol 


for minutes coefficient 
Sample Dilution 24 5 72 10 12% 15 | 160+ 275 
: 1:80 |—|—|]—|— | —| — |———_-_ ——- 
Tai == ac ee ps | 80+ 90 
eMCUOl ns ose Ge Usi sat Se) Se) Sei sees = 
Peli s=)s= s= s5)s= == 2 
13150 | —| —|—]| — | —] — | 2.00+3.05 
1:160 | —|—]—|—|/—} — = 
1:180 | + | — === = 2 
1:200 | +{|—}—|—|/—|—| Pay 
CSS ee 1:225 | +-4{+ |—/—]—|— 
1:250 £4 a Is — = 
Le2ff s=) 55) 45 == Sar 
[1:300 |+)/+)/+}+)+)4+| 


This table illustrates very clearly the effect of the 
various factors that influence the action of a disin- 
fectant. For instance, in the 1 to 80 dilution of phenol 


20 WOUND TREATMENT 


there was no growth in two and one-half minutes; in 
the 1 to 90, however, there was, showing the effect of 
concentration. The lower table shows the effect of or- 
ganic matter. For example, it took the 1 to 90 dilution 
five minutes to kill against two and one-half minutes 
without organic matter, or just twice as long. The 1 to 
100 dilution failed to kill in two and one-half minutes 
but was bactericidal in fifteen minutes, showing the 
effect of exposure. 

Now the question arises as to what practical caine 
such tables as these have. There are upon the market 
innumerable kinds of disinfectants put up by different 
commercial houses at greatly varying prices, based, not 
upon their efficiency as germ killers, but upon the per- 
centage of profit the manufacturer thinks he ought to 
get. For example, mixtures containing varying 
amounts of ecreolin are upon the market. All have 
the property of forming a white emulsion with water 
and in addition a more or less aromatic odor. The idea 
seems to have gained precedence that odor and disinfect- 
ing properties go hand in hand. The more penetrating 
the odor and the more milky the solution, the better the 
antiseptic, seems to be the belief. There are prepara- 
tions on the market possessing both the latter qualities 
to a superlative degree but having little action other 
than imparting a pronounced odor to your medicine ease 
and clothing. The only true eriterion of the value of 
any given preparation as a germ killer is a bacteriological 
determination. Every practicing veterinarian should in- 
sist upon knowing the phenol coefficient of the antiseptic 
purchased. The time is coming when all commercial con- 
cerns will place the coefficient upon their labels, as some 
houses are already doing. 

When the phenol coefficient and price per gallon of a 
number of disinfectants are known, it is possible to cal- 


: BACTERICIDAL PROPERTIES 21 


culate from the price of pure phenol which will be the 
most economical to buy. It is apparent to any one that 
it is better to pay sixty cents a gallon for disinfectant 
‘‘A”’ than thirty cents per gallon for disinfectant ‘‘B’’ 
if ‘‘A’’ has four times the efficiency of ‘‘B.’’ 

To determine the cost per 100 units of efficiency of any 
preparation as compared to phenol, divide the cost per 
gallon by the cost per gallon of pure phenol; this gives 
the cost ratio of the two. The efficient ratio of the two 
is obtained by dividing the phenol coefficient of the prep- 
aration by the phenol coefficient of phenol, which is al- 
ways 1, since it is the unit. The efficiency ratio is there- 
fore always the phenol coefficient. The cost ratio divided 
by the efficiency ratio (the phenol coefficient) gives the 
cost of the disinfectant per unit efficiency of phenol. 
Multiplying by 100 gives the relative cost per 100 units. 
Thus, 


Cost of disinfectant per gallon coefficient of disinfectant 


Cost of phenol per gallon "coefficient of phenol (=1) 
Cost of disinfectant per unit of efficiency compared to phenol 
=u 
Multiplying by 100 gives coefficient per 100 units of phenol. 
For example, the cost of carbo-campho, with which 
most veterinarians are familiar, is $2.50 per gallon and 
has a phenol coefficient of .57; the cost of phenol is $3.25 
per gallon,t and has a coefficient of 1. Then, 
250 57 
— + — = 1.33. 
3.20 1 
Therefore the comparative cost of carbo-campho per 
unit of efficiency and phenol is 1.33:1; or, multiplying 
by 100, we get 133:100, which means that $1.33 worth 


1The cost of phenol is considerably higher than this at the 
present time, $4.95 per gallon, due to the war conditions abroad, 
but it was deemed best to quote the usual price rather than the 
unnatural one due to the present war conditions. 


22 WOUND TREATMENT 


of carbo-campho will give as much disinfecting efficiency 
as a dollar’s worth of phenol. Likewise, about seven 
cents’ worth of crude ecarbolie acid will give as much 
disinfecting power as a dollar’s worth of pure phenol. 

Such figures as these are of value in determining the 
most economical disinfectant to buy, based upon effi- 
ciency and the price of phenol. 

Naturally these figures will vary as the price of phenol 
and other disinfectants varies, so that a calculation must 
be made to fit market conditions as they exist. What 
may be the cheapest antiseptic to buy to-day may not be 
a month or a year hence. The following table gives fig- 
ures for a number of antiseptics based upon prices to- 
day: | 

Relative cost 
per 100 units 
Efficiency of Efficiency 
Disinfectant Ratio or Compared 


Price per Cost — Phenol with pure 
Gallon Ratio Coefficient carbolic acid 


Crude carbolic acid’........ 60 .1846 2.65 6.9 

FEY PENG ie 2 Oe oe ee oer oa ee .95 .292 3.56 8.34 
Kreseo (PD: & C0552 2 1.15 .003 3.92 9.00 _ 
ZEDONG 8 tanta ote ee 1.25 384 2.25 17.00 
Liquor cresolis compositus.. 2.50 .769 3.00 25.6 
"PEMeFesOl + i.;o6%% ete ce caee 2k 4.00 1.23 2.62 47.3 
CEG ' 355.04: 2 Pie aes es 6.66 2.04 3.25 62.7 
DAWOL 92 x.c.ciely cantein chee sae 5.00 1.52 2.12 71.84 
Carbo-canipho™ de..62 22s 955 2.50 76 .O7 133.3 
Harhohe aed (35. > tatentses 3.25 1.00 1.00 100.0 


In this paper we have endeavored to bring out the fol- 
lowing facts: 

1. That the fundamental principles of disinfection are 
based upon bacteriological facts and not upon physical 
appearance or odors of the disinfectant. 

2. That the action of antisepties is affected by 


1Phenol coefficient determined at Veterinary Science Labor- 
atory, College of Agriculture, Madison, Wis. 

2For phenol coefficient of other disinfectants in this table, the 
writers are indebted to Bulletin 82, Public Health and Marine 
Hospital Service. 


‘ 


BACTERICIDAL PROPERTIES 23 


(a) Type of organism 

(6b) Temperature 

(ec) Concentration 

(d) Duration of action (length of time of action) 

(e) Amount and character of organic matter present. 


3. That there is a method of accurately determining 
the bactericidal properties of any given antiseptic, known 
as the “‘hygienic laboratory phenol coefficient’? method 
and described by Anderson and McClintie in Bulletin 
82 of the Public Health and Marine Hospital Service of 
the United States. 

4. That the phenol coefficient of any given antiseptic 
or disinfectant may, for practical purposes, be defined 
as the figure representing the ratio of the germicidal 
power of the disinfectant to that of carbolic acid, both 
having been tested under the same conditions. 

5. That the only logical method of purchasing disin- 
fectants is upon the basis of their phenol coefficients. 

6. That the relative cost per unit of efficiency can be 
calculated by use of the phenol coefficient. That is, the 
relative cost of any number of antiseptics compared to 
earbolic acid, thus telling you just where you get the 
most for your money. Thus 6.9 cents will buy as much 
disinfecting power in crude carbolie acid as 25.6 cents 
spent for liquid cresolis compositus or $1.33 spent for 
earbo-campho or $1.00 spent for pure phenol. 


ANTISEPTICS, PAST AND PRESENT, 
IN WOUND TREATMENT 
By E. WALLIS HOARE, F.R.C.V.S., Cork, Ireland 


In selecting ‘‘Antiseptics, Past and Present,’’ as a 
theme for discussion, I venture to think it is one that 
will prove of interest to every practitioner; certainly 
there are many points in connection with it which offer 
ample room for an interchange of opinions, ideas, and 
experiences, the result of which is likely to prove useful 
in our daily work. 

I freely confess that one of my reasons for choosing 
this subject is to ascertain as far as possible to what 
extent the principles of aseptic surgery can be applied 
to animals. I am quite aware that in certain quarters 
it is held that aseptic surgery can be applied to animals, 
and that failures in this direction are to be attributed 
to want of care on the part of the practitioner, or to 
prejudice. But in drawing conclusions on matters of 
this kind it is essential to possess a varied experience of 
surgery under conditions favorable and unfavorable, 
both in town and country, and one important point that 
I shall endeavor to demonstrate will be with reference 
to the effects of environment and certain unalterable 
conditiong that exist in connection with the treatment 
of wounds in our patients. 


- PROGRESS IN VETERINARY SURGERY 


I have also another object in view: many medical men 
and not a few of the laity hold the erroneous opinion - 
that veterinarians do not take the trouble to practice 


25 


26 WOUND TREATMENT 


aseptic surgery; we are constantly asked why wounds 
do not heal by first intention, and why we do not adopt 
this or that measure which proves so successful in the 
case of wounds in man. For, owing to the spread of 
popular knowledge, the ‘‘man in the street’’ now pro- 
fesses to know something about surgical technic. Horse 
owners, through reading various popular works on vet- 
erinary science, pretend to know all about antisepties, 
and the suggestions that are often made to us when 
treating wounds are grotesque in the extreme. 

My remarks throughout this paper will be specially 
directed to demonstrate the fact that veterinary sur- 
geons do appreciate the importance of aseptic surgery, 
and endeavor to carry out its principles as far as cir- 
cumstances will permit. 

Let us first of all take a retrospective view of veter- 
inary surgery as applied to the treatment of wounds. 
That marked progress has been made is a fact apparent 
to even the most pronounced pessimist. This advance 
must be attributed to the discoveries of Lister. Although 
the researches of this eminent scientist were directed to 
the perfecting of human surgery, there is no doubt 
whatever but that the application of his principles to 
veterinary surgery has been productive of results which, 
if they cannot be described as brilliant, are at least most 
striking and eminently satisfactory. For, although ab- 
dominal surgery and the surgery of joints are, so far 
as the horse is concerned, as yet in a state of infaney, 
every one will admit that canine surgery has advanced 
by leaps and bounds since the principles of Lister have 
been applied to it. And even in the case of the horse 
we can justly claim that marked advance has been 
made through attention to Listerian principles. Again, 
a knowledge of the principles of wound infection has 
enabled us to prevent the occurrence of those fatal 


- ANTISEPTICS—PAST AND PRESENT 27 


sequelae of wounds, such as septicemia, pyemia, and ma- 
lignant edema, which were formerly so frequently met 
with following accidental and surgical wounds. 

Two factors were instrumental in the erroneous treat- 
ment of wounds that previously existed. One was the 
lack of knowledge concerning wound infection, nothing 
being known with reference to micro-organisms or their 
effects. Another was the prevalent idea that heroic 
measures were essential to promote healing; hence the 
employment of ‘‘black oils’’ and similar concoctions, in 
sublime ignorance of the deleterious effects of irritants 
on wounds, and of the existence of natural means of 
recovery. | 

The researches of Lister may be said to have extended 
from 1865 to 1890, and it is recorded that even up to 
1880 a number of eminent surgeons were incredulous 
as to the value of the antiseptic treatment. Hence it is 
not surprising to find that in veterinary: surgery up to 
this period the Listerian principles are not universally 
adopted. 3 

It may truthfully be said that, as antiseptic treat- 
ment progressed, from stage to stage, In human surgery, 
its value was recognized by veterinary surgeons and its 
principles gradually adopted. The earlier attempts at 
antiseptic treatment would no doubt be considered crude 
in the present day. 


The Work of Lister 


We read in the Lancet that in 1865-1866 ‘* Compound 
fractures were treated by the local application of car- 
bolic acid. The antiseptic was freely applied to the 
interior of the wounds in order to destroy the air-borne 
germs which had the property of causing putrefaction. 
The opening in the integuments was then covered with 


28 WOUND TREATMENT 


lint charged with carbolic acid, and protected by an 
external layer of thin sheet metal. ... In opening 
abscesses a piece of cloth from four to six inches square 
was dipped into a solution of one part of erystallized 
earbolic acid and four parts of boiled linseed oil, and 
then laid upon the skin where the incision was to be 
made. One edge of this cloth being raised, the part was 
incised with a knife previously dipped in the oil, and the 
cloth was instantly dropped upon the skin as an anti- 
septic curtain, beneath which the pus flowed out. 

‘‘For the subsequent dressings a kind of putty was 
made by mixing common whiting with the carbolized 
oil, and this, spread into a layer about six inches square, 
was laid over the incision.”’ 

From this simple and crude beginning evolved those 
principles which were ultimately destined to revolution- 
ize surgery, and render their discoverer the greatest bene- 
factor to mankind that has ever lived. In 1867, carbol- 
ized shellac plaster was substituted for the putty and 
found more convenient, and during the same period 
ligatures of silk or catgut were introduced, the latter, 
however, not assuming their present form until 1881. 
Even with the above primitive antiseptic measures a 
marked improvement resulted in surgical work, and Lis- 
ter recorded that hospital gangrene, pyemia, and erysipe- 
las disappeared from his wards. 

In 1869 gauze charged with carbolized resin took the 


place of the shellac plaster, and various methods of em- 


ploying carbolized oil and drainage tubes were described 
in articles written by Lister for the Lancet. In these 
articles were also discussed the sterilization and use of 
sponges, and experimental proof was adduced that ‘‘the 
septic ferments were solid particles and not some kind 
of material in solution.’’ | 

The use of boric acid as an antiseptic was also de- 


a eS ae 


_ ANTISEPTICS—PAST AND PRESENT — 29 


scribed. In 1879 improved methods of protective dress- 
ings were introduced, to prevent the carbolic acid in the 
external dressings from reaching the wound, once the 
latter had been rendered aseptic by the primary appli- 
cation of the antiseptic. This protective dressing was 
composed of oiled silk coated on both sides with spe- 
cially thick copal varnish and afterwards covered with 
a layer of dextrin to insure its being moistened when 
dipped into a watery solution of carbolic acid. In 
cases where patients showed special idiosyncrasies to 
carbolic acid, either salicylic jute or gauze charged with 
a mixture of one part of eucalyptus and three parts of 
gum dammar and paraffin, were employed. 

In 1881 Lister delivered two addresses containing what 
seems to be his first published reference to pathogenic 
bacteria as a distinct class of micro-organisms; and in 
1883 he demonstrated the success of wiring the patella 
when antiseptic principles were employed. In 1884 he 
drew attention to the uses of corrosive sublimate as a 
surgical dressing. He pointed out in 1889 that sal alem- 
broth was untrustworthy as an antiseptic, and in the 
same year he introduced the double cyanid of mercury 
and -zine as a reliable agent with which to render gauze 
antiseptic, but pointed out that its germicidal efficacy, or 
ability to destroy existing bacteria, was inferior to its 
power of inhibiting bacterial growth; hence it was ad- 

vised that the dressing should be moistened with a five-_ 
:. per-cent solution of carbolic acid before being applied. 

‘In 1890. Lister announced that he had abandoned the 
use of the carbolic spray three years previously, and 
that he had substituted a solution of corrosive sublimate 
for carbolic acid, having found the former less irritating 
and more efficient; he also pointed out that the double 
cyanid of mereury and zine could be prepared in a 
perfectly definite manner, and although the new prod- 


30 WOUND TREATMENT 


uct contained twice as great a percentage of cyanid | 
of mercury as was present in the substance originally 
used, it had no tendency to cause irritation. 

In 1907, in a note occurring in Sir Hector Cameron’s 
book, On the Evolution of Wound Treatment During 
the Last Forty Years, we find what may be regarded 
as the final utterance of Lister. In this note he ‘‘advo- 
cated the use of the double cyanid of mercury and zine. 
He preferred the use of sponges for the absorption of 
blood or other discharges from an operation wound to 
any. of the substitutes that were proposed, while for 
the purification and sterilization of such sponges, with 
an especial view to the destruction of both the spore- 
less Microcoeci and the spore-bearing tubercle bacilli, he 
preferred carbolic acid (1 to 20) to any other germi- 
cide. For purifying instruments, the hands of the 
operator, and the skin of the patient he used a similar 
solution, except in the case of the eyelids, when a solu- 
tion of corrosive sublimate, being less irritating, was 
preferable. ’’ 

In circumstances where it was impossible to exclude 
septic agencies, such as in operations upon the mouth 
or in putrid sinuses, or in certain compound fractures, 
iodoform might be dusted on the cut surfaces of a 
wound ‘‘after mopping with a solution of forty grains 
of chlorid of zine in one ounce of water.’’ The useful- 
ness of iodoform was, however, rather limited. 

In the external dressing, gauze impregnated with the 
double cyanid of mercury and zine was advised, but be- 
fore being applied to the wound this gauze must be ren- 
dered damp with a solution of carbolie acid. 

To parts where there was very little space between 
the wound and some source of septic contamination, 
the double cyanid powder, mixed with a sufficient amount 
of earbolic solution (1 to 20) to form a cream, might 


_ ANTISEPTICS—PAST AND PRESENT 31 


be apphed with a camel’s-hair brush. In some circum- 
stances the cyanid powder might possibly be used as a 
first-aid dressing by dusting it over wounds by means 
of a tin with a perforated top. 

‘* As regards the changing of dressing, when there was 
a free discharge from a wound he preferred, as a rule, 
to remove the first dressing after a lapse of twenty-four 
hours, but a longer interval ought to be allowed after 
certain amputations.”’ 

I have thought fit to give the above abridged history 
of the evolution of antiseptic surgery, taken from the 
biography of the late Lord Lister that appeared in the 
Lancet. It will assist in the consideration of what 
would appear to be the two schools of surgery of the 
present, one termed the Antiseptic, the other the Asep- 
tic; but, as will be seen later on, the differences between 
them are more imaginary than real, so far as results 
are concerned. 


Terms Defined 


As already remarked, during the course of Lister’s 
career he had to submit to severe and often unjust criti- 
cism, but this is the fate of all who attempt to leave 
the beaten track. One of his opponents pointed out in 
1867 that Lister was not the first surgeon to use carbolic 
acid, but this was already admitted. It is also recorded 
that Sir William Savory (who was president of the Royal 
- College of Surgeons for five years in succession, and full 
surgeon at Saint Bartholomew’s Hospital from 1867 to 
1891), at the meeting of the British Medical Association 
héld at Cork in 1879 delivered the address on ‘‘Surgery”’ 
and spoke in attack or ridicule of the system of anti- 
septic surgery. I introduce this matter in order to show 
that surprise should not be expressed if examples of 
similar opposition existed among veterinary surgeons; 


32 WOUND TREATMENT 


that such did exist I have no doubt, but at present there 
are few practitioners who deny the benefits of Listerian 
principles. 

In order to comprehend the principles of the modern 
treatment of wounds, and to compare the antiseptic 
methods with those designated as aseptic, it is necessary 
to consider briefly the significance of certain terms that 
are employed in connection with the subject. Unfor- 
tunately, it happens that the same term is occasionally 
applied in more senses than one, or has a different 
meaning attached to it by various authors. 

The term septic was formerly applied to wounds of 
an offensive character, which were frequently associated 
with septicemia, pyemia, and similar conditions. But 
as it is recognized now that the above conditions arise 
from the action of pus-producing organisms, the term 
septic is generally applied to all suppurating wounds. 

Recognizing, however, that wounds may be offensive 
and distinctly unhealthy, without any evidences of the 
presence of pus, it is clear that septic can be applied 
to conditions depending on a variety of micro-organisms. 
In many eases the septic condition of a wound depends 
on one pathogenic organism, but in almost every in- 
stance ordinary pyogenic organisms are present, asso- 
ciated with those characteristic of sepsis. 

In practice, however, we are generally inclined to ap- 
ply the term septic to a putrid condition of a wound, 
associated or not with the presence of pus. As a large 
number of accidental wounds in the horse heal by granu- 
lation but not under aseptic conditions, suppuration to 
a varying extent is common, but the pus is not offensive, 
the wound tends to heal with ordinary care, and we do 
not apply the term septic to it, although certainly it 
could not be described as aseptic. As I shall point out 
later on, a large number of accidental wounds in horses 


ANTISEPTICS—PAST AND PRESENT 33 


are already infected before the practitioner gets the 
chance of treating them. 

Aseptic signifies the absence of sepsis—that is, the 
absence of micro-organisms of any kind. The term is 
synonymous with ‘‘sterile,’’ or ‘‘germ-free.’’ 

Antiseptic is a term that is often loosely applied: 
literally it signifies anything opposed to sepsis; in a 
bacteriological sense, it indicates an agent that retards 
or prevents the development of bacteria, irrespective 
of its power of destroying their vitality. But it is 
often erroneously applied as synonymous with germi- 
cide, whereas a large number of agents classed as anti- 
septics are not capable of destroying pathogenic bacteria. 

Disinfectant is a term applied to an agent capable of 
destroying infective micro-organisms, and so far as path- 
ogenic bacteria are concerned it is synonymous with 
germicide. Therefore all disinfectants are antiseptics, 
but not all antiseptics are disinfectants. 

Deodorant is a term applied to substances that are 
capable of destroying or removing offensive or unpleas- 
ant odors, but it does not follow that they possess dis- 
-infecting properties. Many disinfectants, however, are 
also deodorants. | 


Two ‘‘Schools’’ of Surgery 


It will now be necessary to devote a little attention 
to the significance of the terms aseptic surgery and anti- 
septic surgery. : 

To such an extent has the subject: been debated that 
two so-called ‘‘schools’’ have resulted, and even the 
are not in agreement as to the precise sense in which 
the term aseptic should be employed. There is in fact 
a decided antagonism between these schools as to the 
_ technic which is best calculated to bring about success- 


34 WOUND TREATMENT 

ful results, for be it remembered that both aim at the 
prevention of infection in wounds and thus endeavor 
to promote healing in the shortest time possible. Briefly 
speaking, the aseptic system aims at preventing the 
access of pathogenic bacteria to wounds; it embraces all 
the measures adopted to keep the wound aseptic, or free 
from the ill effects of septic organisms, throughout its 
entire course. Antiseptics, except for sterilizing the 
patient’s skin, the hands of the surgeon, or in the 
process of sterilizing ligatures, are rigidly excluded, 


and not permitted to come in contact with operation ~ 


wounds. None of the materials used, such as ligatures, 
sutures, and dressings, contain antiseptics, but are simply 
sterilized. The instruments are sterilized by boiling, 
and are not placed in an antiseptic solution. 

Of course, the aseptic method can be applied only to 
operation wounds made through unbroken skin into 
non-infected tissues. The disciples of the aseptic school 
term the methods in which antiseptics are employed, 
either in solutions or dressings, as antiseptic methods. 
Some even go further than this, for we find one surgeon, 
Mr. Burghard, stating that the term antiseptic, when 
applied to the treatment of wounds, ‘‘should be reserved 
for those measures designed to combat sepsis already 
present in a wound.’’ 

The antiseptic school, however, claim that their meth- 
ods are also aseptic, although as a means of precaution 
they employ antiseptics in addition to the means of 
securing asepsis. Sir Watson Cheyne, one of the ad- 
voeates for this method, states: 

‘“ Aseptic surgery is the method of treatment directed 


to the maintenance of an aseptic condition in the tis-— 


sues of the wound presumably existing at the time of 
operation. ... But on the other hand, antiseptic sur- 
gery has to deal with tissues which have already been 


a a a 


_ ANTISEPTICS—PAST AND PRESENT 30 


infected, with or without a breach of the surface, and 
here the surgeon’s efforts are directed to diminishing 
the effects of already existing sepsis, or it may be in a 
few cases even to eradicating it.”’ 

Mr. Lockwood, who steers a middle course, says in his 
work on Aseptic Surgery, ‘‘Any method of wound treat- 
ment which aims at sterility will be called aseptic.”’ 

The ‘‘bone of contention’’ between these two systems 
would appear to be the question of the employment of 
antiseptics; those of the aseptic school holding that 
these agents, by causing irritation, interfere with the 
normal powers of resistance of the tissues, and thus re- 
tard healing. This weakening of the resisting power 
of the tissues may even enable micro-organisms to enter 
and take effect, in cases where surgical cleanliness was 
neglected, although antiseptics were employed. 

Sir Watson Cheyne, however, points out in the Brad- 
shaw Lecture on the Treatment of Wounds (1908), that 
the Listerian principles in wound treatment include two 
important postulates: 


1. Exclusion of bacteria especially of pathogenic organisms, as 
far as possible during and after an operation. 

2. Avoidance of irritation of the surface of a wound, so as not 

‘to interfere with healing or with the powers of the tissues, 

to prevent the growth of any bacteria which have entered. 


This authority clearly explains that, by the Listerian 
system, every precaution is taken to prevent irritation 
- from the antiseptics employed, and also states that, even 
with adherence to the strict principles of the so-called 
aseptic system, suppuration has occurred when opera- 
tions were carried out in regions other than the peri- 
toneum. He believes ‘‘that of late many surgeons have 
gone to extremes in the avoidance of antiseptic solu- 
tion,’’ and that the aseptic system, so called, is ‘‘only 
carrying to an extreme the principle of avoiding irri- 


36 WOUND TREATMENT 


tation of wounds.’’ He also shows that even the appli- 
cation of plain boiled water to the surface of a wound 
interferes with the integrity of leukocytes and other 
cells, for under the microscope they are found to swell 
up rapidly and become completely disintegrated. In 
summing up his criticism he states that ‘‘the pendulum 
has swung too far in the direction of the avoidance of 
antiseptics, and that the reasonable use of all the means 
at our disposal for securing asepticity of wounds will 
furnish more constant results.’’ He also adds: ‘‘The 
chief point to which I take exception is the employment 
of dressings which do not contain an antiseptic in suffi- 
cient amount to render the discharges which flow through 
them unsuitable for the growth of bacteria.’’ When a 
dressing not containing an antiseptic, although sterile, 
becomes soaked with discharge, the latter may remain 
sterile until it comes near the surface of the dressing, 
but then bacteria will grow into and rapidly spread 
through it and reach the wound, unless the blood has in 
the meantime become so concentrated by drying that 
it is no longer a suitable cultivating medium. 

A second point is the absence of antiseptic solutions 
during the operation, in which hands and instruments 
may be washed from time to time to insure continued 
asepsis. ‘‘The attempt to treat wounds without any 
antiseptics is a very unnecessary complication. In the 
first place, it is ever so much more difficult to secure 
asepticity of a wound under such circumstances than 
if.one takes advantage of antiseptics, and in the second 
place it requires a man who is especially skilled in bae- 
teriological work, to bear in mind the various loopholes 
which have to be guarded against in order to obtain a 
constant aseptic result. ... I confess that I can see 
no reason for this great dread of a drop of antiseptic ma- 
terial getting into a wound; I can only say that my own 


_ ANTISEPTICS—PAST AND PRESENT 37 


results, and those of surgeons who use antiseptics judi- 
ciously, are in every way as good as those obtained with 
the more elaborate aseptic precautions; in fact, seeing 
that we are not troubled with sepsis or stitch abscess at 
all, I venture to assert that they are better, because they 
are more constant and dependable.’’ | 

Rose and Carless, contrasting aseptic and antiseptic 
surgery, in their Manual of Surgery state: 

“Tt is only natural that we who have had the privi- 
lege of working with Lord Lister, and have seen the ex- 
cellent results following the intelligent use of anti- 
septics as mapped out above, should still cling to that 
line of practice which certainly can be carried out with 
more precision under all circumstances, both in private 
and hospital, than the other plan, the objects of which 
may at any moment be defeated by some slight inadver- 
tence or oversight. The theory of asepsis is no doubt 
perfect, but its practical application is often difficult 
owing to the necessity of having sterilizers always at 
hand, a matter almost impossible in cases of emergency, 
in private practice.”’ 


Measures Attempted 


I have deemed it advisable to quote the opinions of 
the above eminent surgeons on the subject of aseptic and 
antiseptic surgery before proceeding to consider how 
far the principles can be applied in veterinary surgery. 
I shall endeavor to show that, although in the case of 
the dog it is possible to carry out perfect aseptic prin- 
ciples under proper surroundings, it is a far different 
matter when we come to deal with equine surgery. I 
suppose it will be generally admitted that in the treat- 
ment of wounds in horses there are certain important 
indications to be fulfilled. 


38 WOUND TREATMENT 


Measures should be adopted which are lkely to in- 
sure the healing of wounds in as short a time as possible, 
so that the animal can return to work. ) 

Steps should be taken to prevent serious complications 
such as septicemia, pyemia, malignant edema, erysipelas, 
bacillary necrosis, and tetanus. 

Measures for the prevention of permanent blemishes 
are of importance, and in the case of wounds affecting 
the limbs, every effort should be made to avoid the oceur- 
rence of conditions likely to interfere with the working 
powers of the animal. 


Human and Veterinary Surgery Contrasted 


Here it will be necessary to compare human surgery 
and veterinary surgery as regards the treatment of 
wounds, both accidental and as the result of opera- 
tions. The distinguishing features that stand out 
pre-eminently are the following. The human surgeon 
has the advantage of a well-equipped hospital with 
all modern conveniences, and a staff of trained nurses 
to carry out his instructions. He is supplied with 
every detail calculated to insure surgical cleanliness 
and to exert a favorable influence on the course 
of wounds. Moreover, in operation wounds, aseptie prin- 
ciples are carried out from start to finish by trained 
hands, and the patients contribute to favorable results 
by obeying the instructions of the surgeon. By complete 
rest the healing of wounds is facilitated, and means ean 
be adopted by which the affected part is rendered as free 
from movement as possible. 

In the case of accidental wounds, early treatment is 
carried out before sepsis has had time to exert its effects, 
even though micro-organisms have gained an entrance. 

The veterinary surgeon, on the other hand, has the most 


ANTISEPTICS—PAST AND PRESENT 39 


adverse circumstances to contend with in his endeavors 
to render wounds, whether surgical or accidental, aseptic, 
and to keep them in this condition. Even in the best 
equipped veterinary infirmaries, so far as horses are 
concerned, it is extremely difficult to carry out aseptic 
surgery. No doubt by the use of iodin it is now possible 
to sterilize the skin, but there are other points to be con- 
sidered. . 

Given an operating table, and a trained staff of assist- 
ants, so that the operator is concerned only with the 
operation, and the certainty that the operator or his 
assistants will carry out the subsequent dressings of the 
wound, then indeed aseptic surgery and healing by first 
intention are possible, provided the technic is carried 
out so that the entry of micro-organisms is prevented. 


Hindrances to Aseptic Surgery 


But in ordinary practice a very different state of 
affairs exists; the patient is cast on a bed of straw, 
skilled assistants are not at hand, so that the operator 
has to attend to the casting, securing, and so forth, 
of the animal, by which means his hands become econ- 
taminated, and even the best directed attempts at asepsis 
are likely to be frustrated by the clumsy actions of the 
assistants. Then again, unless the practitioner is able 
to earry out the after-treatment of the case, his primary 
endeavors will fail, as contamination of the wound is 
certain to occur. 

With reference to accidental wounds, it is quite ap- 
parent that they become infected before professional 
assistance is sought. Contamination occurs at the time 
the injury is inflicted, and also from the treatment 
adopted by the owner or attendant. 

Consider also the surroundings in which horses are 


4() WOUND TREATMENT 


placed; even with the most scrupulous care and atten- 
tion, it is impossible to render the best planned stall 
free from micro-organisms, and every act of the attend- 
ant seems calculated to secure infection of the wound. 
As for the average stable, both in town and country, 
and the erude methods of treatment adopted by the 
owners of animals, the wonder is that serious or fatal 
sequele are not more common. For not only is the 
stall a veritable breeding ground for micro-organsims, 
but also everything brought in contact with the wound 
is teeming with germs. Hands begrimed with dirt, filthy 
sponges, dirty stable buckets, and soiled bandages are 
much in evidence, while often even the water for per- 
forming the perfunctory cleansing of the wound is any- 
thing but pure. How, then, do wounds heal under such 
circumstances? I think you will agree that the explana- 
tion is to be found in the natural powers of resistance 
possessed by the horse. If this vital resistance to the 
action of micro-organisms did not exist, we should meet 
with far more cases of septicemia, pyemia, and similar 
conditions, than we do at present. 

No doubt of late years it is not unusual to find disin- 
fectants in the hands of many owners of animals, and 
these agents are applied to wounds in concentrated solu- 
tions with a total disregard for ordinary cleanliness. 
The result is that instead of promoting healing they re- 
tard it, as they exert a caustic and irritant action on 
the tissues. At the same time the deeper portions of 
the wounds are not cleansed and abound in micro- 
organisms. 

A similar error is committed with reference to the dis- 
infection of stable floors, the dirty surface being allowed 
to remain while disinfectants are scattered thereon. 

Then again, while wounds are being dressed it is not 
uncommon to find the dressings laid on the stable floor 


— | SSS eee 


ANTISEPTICS—PAST AND PRESENT 4] 


for convenience and thus exposed to contamination from 
several sources. 


Varieties of Wound Infection 


It will now be of advantage to consider as briefly as 
possible the measures that can be adopted in order to 
fulfill the indications I have mentioned. In order to 
fully grasp the importance of attention to surgical clean- 
liness, and the judicious employment of antiseptics in the 
treatment of wounds, it will be necessary to consider the 
micro-organisms of wounds, the modes of infection, and 
the means by which these can be overcome. 

With reference to micro-organisms, the most important 
are the pyogenic cocci; these include the following 
Staphylococci and Streptococci: 

Staphylococcus pyogenes aureus is found in acute 
abscesses and is responsible for the majority of suppu- 
rative inflammations. It is occasionally present in gen- 
eral pyemia, and is often associated with other pyogenic 
organisms in suppurative processes. It is very resistant 
to many antiseptics, but is readily detroyed by solutions 
of the more powerful germicides; it is very widely dis- 
tributed, and is found abundantly in the superficial 
layers of the skin of animals and frequently beneath the 
fingernails in man. Experiments have demonstrated its 
power of producing suppuration, both locally and inter- 
nally, and it has been shown that if the vitality of the 
parts experimented on has been previously lowered, or 
the tissues damaged by chemical or mechanical means, 
infection occurs more certainly and readily. 

Staphylococcus pyogenes albus is similar to but far 
less virulent in its action than S. aureus. 

Staphylococcus pyogenes citreus is found only in ab- 
scesses. 


42 WOUND TREATMENT 


.. Streptococcus. pyogenes is another very important or- 
ganism. It is the causal agent in spreading. cellular 
inflammation, and of pyemia and septicemia in many in- 
stances; also of septic metritis, and ulcerative endo- 
carditis. One of its peculiarities is its tendency to invade 
the lymphatics and to induce lymphangitis and cellulitis; 
another is its capability of producing acute suppuration, 
sloughing of the. tissues, and inflammatory wound- 
gangrene. Probably there are many varieties of Strepto- 
cocci, but their characters resemble each other so closely 
that it has not been possible to isolate them. Thus the 
S. erysipelatis, the causal agent of erysipelas, resem- 
bles so closely, both in appearance and cultural charac- 
ters, the S. pyogenes, that many authorities regard them 
as identical. The effects produced, however, are rather 
distinctive, and the S. erysipelatis must be regarded as 
an organism of serious importance in connection with 
the treatment of wounds. 

The powers of resistance of Streptococci must be re- 
garded as feeble when compared with those of 
Staphylococci. 

Bacilli of importance in connection with wound infee- 
tion are the tetanus bacillus, the bacillus of necrosis, 
(B. necrophorus), the bacillus of malignant edema, and 
the bacillus coli communis. Occasionally the bacillus 
tuberculosis and the bacillus (Pseudomonas) pyocyaneus 
may infect wounds. Among other causal agents in 
wound infection we may mention the Botryomyces and 
the Actinomyces, also the Streptococcus equi, the causa- 
tive factor in strangles or colt distemper. 

With such a formidable list of micro-organisms before 
us, it is apparent that the most important part of our 
duties in connection with the treatment of wounds is 
to prevent the entrance of these microbes so far as is 
possible, or, failing in this, to destroy their vitae or 
retard or prevent their development. 


ANTISEPTICS—PAST AND PRESENT 43 


The following modes of infection merit consideration : 
1. INFEcTION By ArIR.—Aerial infection was recognized 
even in prescientific periods. The Listerian principles 
and the carbolic spray were directed against this mode 
of infection, and the air was regarded as containing 
the germs of putrefaction, which were capable of setting 
up septic processes in wounds and their secretions. This 
view has been considerably modified in the present day. 
Experiments have demonstrated that the greater num- 
ber of bacteria present in the air are non-pathogenic, 
that germs exist in the atmosphere only in the form of 
dry dust, that air perfectly freed from dust is harmless 
to wounds, and when the air is kept still, wound infec- 
tion rarely takes place through the atmosphere. But 
when we consider the surroundings of horses, the dust 
raised from a straw bed and during the process of clean- 
ing the stall, we must admit the possibility of infection 
by air containing dust. Indeed, some observers state 
that they have found cocci closely related to the pyogenic 
varieties, and sometimes actually belonging to that class, 
in atmosphere dust, especially when the air is moist. 

2. INFECTION BY WaTeEeR.—Infection by means of the 
water used occurs unless this fluid is sterilized by boil- 
ing or a germicide is added thereto. Ordinary water 
contains a large number of bacteria, usually many hun- 
dred thousand per cubic centimeter. 

3. MIscELLANEOUS Sources.—Other modes of infection 
include infection from the skin of the patient, from the 
hands of the surgeon or those of his assistants, from 
instruments, sponges or their substitutes, hgatures and 
sutures, dressing materials, vessels or utensils, syringes, 
and in other ways. 


Circumstances Predisposing to Infection 


Among the factors which render a given infection 
more likely to prove harmful is excessive injury to the 


44 WOUND TREATMENT 


tissues during an operation, such as rough manipulation 
or bruising or tearing of the structures. By these means 
the vitality of the tissues is lowered and their resistance 
so impaired that the development of micro-organisms 
which may have gained entrance is thereby favored. The 
number and virulence of the infecting organisms, the 
state of health of the animal, and the environment are 
also important in connection with this subject. 


Wound Healing 


Time will not permit me to enter into the question of 
the repair of wounds. As you are well aware, the modes 
of healing are as follows: 

1. Primary UNION or ‘‘UNION By First INTEN- 
TION.’’—This takes place in simple incised wounds under 
favorable conditions—that is, when there is a practical 
freedom from infection, when hemorrhage has been 
arrested, and the surfaces are brought into apposition 
and kept at rest. It is the mode of healing we will strive 
to bring about but so seldom succeed in attaining when 
the horse is concerned. 

2. UNION BY GRANULATION AND CICATRIZATION.—This 
is by far the more common method of healing in horses. 
Formerly there was an idea that the suppuration accom- 
panying the process originated from the superficial layer 
of cells on the recent granulations, which were arrested 


in their development and converted into pus eells, being’ 


east off in the discharge. We know now that the cause 
of the suppuration is the presence of micro-organisms, 
and that union by granulation can occur without sup- 
puration, although admitting that such is not common 
in the horse. 

3. UNION UNpER A Scas.—In this, repair takes. place 
beneath a scab formed by the drying of the discharges. 
This is cast off spontaneously as soon as cicatrization 


a 


ANTISEPTICS—PAST AND PRESENT 45 


is completed underneath. It is a common mode of repair 
in wounds left to heal without any dressing. 


The Technic of Treatment 


We now arrive at the practical application of the 
principles, based on a consideration of the points we 
have considered. Dealing first with operation wounds, 
in the case of healthy tissues in the normal animal, 
there are certain details which, if they do not result 
in bringing about healing by first intention, will at any 
rate assist in the process of repair, and prevent the 
occurrence of serious sequele. . 

I suppose every one will agree that instruments are 
best sterilized by boiling for five minutes in water con- 
taining a teaspoonful of carbonate of soda to each pint. 
The addition of the soda raises the boiling point of water 
to 104 degrees Centigrade, and also prevents the forma- 
tion of rust if the instruments are left in the solution for 
some time; when required for use they are placed in a 
sterilized tray containing a solution of carbolic acid 
(1 to 40). The water should be boiling before the instru- 
ments are placed therein, and the vessel in which they 
are boiled should have a closely fitting lid so that the 
water will boil at a uniform temperature. As regards 
sharp instruments, such as knives, scissors, and needles, 
which become blunt from the effects of boiling, some 
surgeons advise that the edges be protected with a piece 
of gauze or lint, and state that blunting does not then 
occur. This is not my experience, and I prefer to im- 
merse such instruments in undiluted earbolic acid for 
a short time, and then place them in a earbolie solution 
(1 to 20). This method is advised by Sir Watson 
Cheyne, and it is also valuable in case an instrument 
happens to fall on the ground during an operation and 
is immediately required, since boiling takes five min- 


46 WOUND TREATMENT 


utes to sterilize, Indeed, this method is also useful in 
emergency operations, when facilities for boiling are not 
at hand, or an instrument is required for use at a mo- 
ment’s notice. Corrosive sublimate has a most destruct- 
ive effect on metallic instruments, therefore solutions of 
this agent are unsuitable for sterilization purposes. 

As regards the preparation of the patient’s skin and 
the hands of the surgeon, it is not feasible to carry out 
that tedious technic of sterilization adopted by human 
surgeons. Fortunately we have in tincture of iodin an 
agent which renders the skin of the patient and the hands 
of the operator aseptic. Of course the operation area 
should first be shaved before the iodin is applied. Two 
applications are necessary, one about fifteen minutes 
prior to operation and the other immediately before the 
operation. Simple incised wounds are those which are 
most likely to heal by first intention, provided certain 
details receive attention. 


Primary Union Seldom Secured 


Deeper wounds, as already remarked, generally heal 
by granulation, but unfortunately in too many instances 
suppuration occurs in spite of all precautions. But there 
are degrees of infection depending on the number, char- 
acter, and virulence of the infecting micro-organisms that 
gain entrance to the wound; hence the necessity for sur- 
gical cleanliness and the judicious employment of anti- 
septics. 

There are two important points in connection with the 
subject which cannot be ignored. The first is, that in 
operations of all kinds the tissues should receive as little 
damage as possible. Neatness and dexterity in operat- 
ing exert a marked influence on the healing of the 
resulting wounds. This is well exemplified in the opera- 
tion of neurectomy, when a skillful operator exposes the 


_ANTISEPTICS—PAST AND PRESENT 47 


nerve and excises the desired portion with little or no © 
damage to the surrounding tissues. On the other hand, 
an inexpert operator, in his efforts to expose the nerve, 
disorganizes the tissues to a considerable extent. In 
the former case the wound heals by first intention; in 
the latter, even with all attempts at asepsis and antisep- 
sis, healing occurs by granulation often accompanied by 
suppuration. 

The next point is with reference to drainage. Now 
in all wounds of any extent an exudation of serum 
occurs, generally referred to as the ‘‘secretions of the 
wound.’’ Such must not be allowed to accumulate in 
spaces in the wound, and proper drainage is necessary. 
Accumulations of serum not only cause tension in the 
wound, but also favor the growth of micro-organisms. 

The various details in connection with aseptic wounds 
need not occupy us further. For the reasons already 
given, in the case of horses it is difficult to obtain healing 
by first intention; that it is possible even in the major 
operations has been demonstrated by operators who have 
had special opportunities for carrying out the technic. 
But I have yet to learn that aseptic surgery, as con- 
ducted by human surgeons, can be carried out in the 
ordinary operation by the general practitioner. Take 
even the latest surgical feat, the new operation for ‘‘roar- 
ing,’’ where aseptic precautions are rigidly carried out 
before and during the operation, and what is the result? 
Certainly not healing by first intention in any instance, 
and more often than otherwise the wound is septic and 
frequently fetid. Such a condition -would be regarded 
as anything but ereditable in human laryngeal surgery— 
but then the circumstances are different. 

There are some enthusiasts who give details of aseptic 
methods of castration; needless to say, they do not oper- 
ate on many colts and have very little idea of the condi-. 


48 WOUND TREATMENT - 


tions and environment of these animals in the country. 
My experience in the attempt I made at aseptic castra- 
tion carried out by means of ligature was that no sup- 
puration or swelling occurred, but the animal died of 
septicemia and septic peritonitis. Had suppuration and 
‘swelling occurred, probably the case would not have 
resulted fatally. At the same time I believe in all pos- 
sible attention to surgical cleanliness and to antisepsis 
during the operation of castration, although I know full 
well these measures will be frustrated in their results 
by the owner or attendant of the animal. How infec- 
tion occurs in castration wounds is so obvious that I 
need not refer to the subject. 


Treatment of Accidental Wounds 


When operation wounds suppurate or become septic, 
they are in the same category as accidental wounds so 
far as treatment is concerned. 

Every accidental wound may be assumed to be in- 
fected, to a greater or less extent. 

In earrying out treatment, there are certain impor- 
tant procedures necessary, which I shall refer to under 
the following headings: 

1. ARREST OF HEMORRHAGE.—In order to be able to 
explore a wound with any degree of accuracy, to say 
nothing of checking preventable waste of blood, hemo- 
stasis is of prime import. This is to be accomplished 
by means of torsion or compression of all bleeding ves- 
sels or by ligation. 

2. CLEANSING AND DISINFECTING OF THE WOUND.— 
This is carried out by careful washing with an anti- 
septic solution. As to the agent selected it is largely 
a question of choice. The large number of reliable 
germicides that are now on the market render a selec- 
tion comparatively easy. Carbolic acid is still largely 


_ ANTISEPTICS—PAST AND PRESENT 49 


employed for the purpose, although there is consider- 
able difference of opinion as regards its germicidal 
power. Whatever agent is used, a thorough cleansing 
of the wound is essential. 

Unfortunately, we do not often get the chance to 
attend to the first dressing of a wound, as the owner 
or the attendant attempts the process on the occurrence 
of the accident and far too frequently introduces infec- 
tion. In the case of a deep punctured wound, in which 
infection is probably deep-seated, and the external open- 
ing small in size, it is necessary to carefully enlarge the 
latter so as to carry out thorough irrigation. 

3. REMOVAL OF FoREIGN Bopies.—This is a procedure 
that requires special attention. Wounds in hunters fre- 
quently contain foreign bodies such as thorns, portions 
of gravel, or other substances, and a careful search is 
necessary in order to discover their presence; if they are 
overlooked, serious trouble will occur afterwards. 

4. DRAINAGE.—Efficient drainage is of the greatest im- 
portance. This is well exemplified by contrasting the 
progress made by punctured wounds extending in an up- 
ward direction, with those extending downwards. With- 
out proper drainage, all other means will fail. To carry 
this out efficiently in the case of extensive wounds is not 
always an easy matter, but on it depends success or fail- 
ure. Suitable openings must be made at dependent parts, 
and the selection of drainage materials will depend on 
circumstances. If gauze drainage can be employed, 
eare should be taken that the gauze does not act as a 
plug and prevent the escape of discharge. In extensive 
wounds, india-rubber drainage tubes are to be preferred. 
The old-fashioned seton must be condemned, as it 
causes irritation and increases suppuration. 

5. SuTuRES.—Careful consideration is necessary in or- 
der to decide whether it is advisable to employ sutures. 


50 WOUND TREATMENT 


The frequency with which extensive wounds involving 


the muscular tissues (such as occur in the region of 
the hip) suppurate, and the sutures give way, has led 
some practitioners to leave such wounds open. No doubt 
in the case of a ‘‘squealing,’’ kicking mare, or of an 
unbroken colt, we all have a tendency at times to avoid 
the use of sutures, and it is surprising to find how 
readily such wounds heal. Still, there is no doubt but 
that less blemish is left if the edges of such wounds 
are brought together by sutures, at any rate for a time, 
provided thorough cleansing is carried out and proper 
drainage provided. In extensive wounds of this kind 
occurring in vicious animals, I always cast the patient 
in order to carry out the procedure properly. The 
suture material should be soft in texture, but strong; 
hard material is very likely to cut through the skin. 
In clean-cut wounds, sutures should always be employed. 
It is hardly necessary to remark that in punctured 
wounds, or deep wounds of any kind, and in the ease of 
torn or lacerated wounds with much destruction of tis- 
sue, or in suppurating or: septic wounds, sutures are 
contraindicated. 

Experience has taught me that wounds in the region 
of the head are best treated without sutures, unless such 
cases are in an infirmary under the immediate care of 
the practitioner, so that the early indications of septic 
infection may be observed. Under other conditions there 
is a tendency to the occurrence of erysipelas or allied 
complications. I now paint such wounds with tincture 
of iodin and find the best results therefrom. This may 
be considered as an irritating agent, but the results 
justify its employment. There are instances of sup- 
purating wounds in which suturing should be at- 
tempted in order to avoid permanent blemish. Some 
time ago I saw a case in a foal in which a wound extended 


_ANTISEPTICS—PAST AND PRESENT 51 


from the commissure of the lips up the cheek, exposing 
the first two molar teeth. The accident had occurred 
about ten days previously, and two attempts at suturing 
had been made, but they were unsuccessful. The wound 
was suppurating freely and granulations had formed 
on each of the edges, but there were no evidences of 
union. My first attempt was also unsuccessful. I then 
cast the animal again, removed all granulations with 
sharp scissors, freshened the edges of the skin and 
mucous membrane, removed all debris of food, washed 
the parts thoroughly with peroxid of hydrogen, inserted 
a deep layer of sutures so as to bring the edges of the 
mucous membrane together, the sutures being composed 
of soft silk soaked in peroxid of hydrogen, a superficial 
row of sutures was inserted in the skin, the wound was 
again cleansed with the antiseptic, and then painted over 
with collodion. The foal was removed from the dam 
and fed from a pail, and no further dressings ordered 
except the application of compound tincture of benzoin 
to the edges of the wound after a few days. A few of 
the sutures gave way, but healing progressed satisfac- 
torily and perfect union resulted. 

6. SuretcAL Dressines.—As a general rule, wounds 
should be covered with suitable surgical dressings when- 
ever possible, at any rate in the earlier stages. Whether 
these dressings should be moist or dry must depend on 
circumstances. In suppurating wounds I find the best 
' dressing, in cases where expense is no object, is double 
eyanid gauze soaked in a solution of peroxid of hydro- 
gen (one part of the ten-volume solution to three of 
water). The gauze is then enveloped with a thick layer 
of cotton wool and a bandage. 

As to the frequency of dressing, this will depend on 
the amount of discharge. When the latter soaks through 
the dressing, it is an indication for renewal. If this 


52 WOUND TREATMENT’ 


be neglected the discharges become putrid and a mixed 
infection is likely to oceur. 

For country practice a reliable and cheap antiseptic 
is Hualey’s Liquor Cresolis, in two-per-cent solution. 

As the discharge lessens, the dressing need not be 
changed sooner than the third day, and later on a dry 
antiseptic dressing, such as boric acid with zine oxid, 
may take the place of the moist one. 

In punctured wounds, after drainage has been pro- 
vided for I find it is a good plan to plug the wound 
with gauze soaked in peroxid of hydrogen. This dress- 
ing may be renewed as often as circumstances require. 

In country practice it is useless to expect the owner 
or attendant to apply dressings properly. Therefore, 
unless there are reasons to the contrary, wounds do best 
when left open, being simply cleansed with an antiseptic 
solution and painted with compound tincture of benzoin. 
This latter agent fell into disuse for a time, but in my 
experience it is a most useful. wound dressing for coun- 
try cases, where as little handling of the wound as pos- 
sible is an important matter. 

Carbolized oil, which at one time was so popular a 
dressing, is now known to be absolutely imert as a 
gvermicide. 

In hunters, deep puncture wounds of the front of 
the hind fetlock due to sharp stones are of frequent 
occurrence. The bursa of the tendon may, or may not, 
be opened, but acute inflammation rapidly develops and 
marked pain is present. Attempts to heal such wounds 
quickly do not prove successful, as infection is deeply 
situated; in my experience the best dressing is one of 
the modern substitutes for poultices, which are com- 
posed of kaolin, glycerin, and antiseptic agents, applied 
hot and changed daily. When acute symptoms have 
-subsided, the ordinary dressings may be applied. 


_ ANTISEPTICS—PAST AND PRESENT 53 


Wounds of the sheaths of the flexor tendons are often 
serious in consequence of the infection extending up- 
ward and downward. Free drainage should be provided 
early, and rigid attention to antisepsis is necessary. 

In all wounds in the region of the limbs there is a 
tendency to the formation of exuberant granulations. 
These require early attention in order to avoid perma- 
nent blemishes. I find that the judicious application 
of finely powdered sulphate of copper is the most reliable 
treatment in these cases, old fashioned no doubt, but 
efficient for the purpose required. 

Wounds of the knee, involving the extensor tendons 
in the vicinity of this joint, are not uncommonly followed 
by fibrous ankylosis, accelerated no doubt by keeping the 
horse from lying down. When such a complication 
occurs, the animal should be cast and chloroformed and 
the joint forcibly flexed, otherwise the horse will be 
useless. 

Wounds in the feet due to picked-up nails I shall not 
consider here, as this would form a separate subject for 
a paper. But in hunters, wounds are not uncommon 
in this region as the result of portions of furze (gorse) 
branches entering the foot in the vicinity of the frog. 
Sharp portions of flint not uncommonly enter the foot 
and extend deep into the sole. The detection of such 
foreign bodies is not always an easy matter and requires 
a careful examination of the foot. I believe the best 
- treatment, after the removal of the foreign body and 
the proper enlargement of the wound, is to apply pure. 
earbolic acid or lysol, and a cataplasm composed of 
kaolin and glycerin. 

In my experience the most dangerous wounds are 
those due te punctures from shafts, such as result from 
collisions. The difficulty in obtaining drainage is very 
‘considerable, especially when the wound occurs in the 


o4 WOUND TREATMENT 


region of the hind quarter. But proper drainage must 
be secured at all costs, otherwise treatment will fail and 
septicemia result. If necessary, the animal should be 
east in order to carry out the surgical procedure; after- 
treatment will consist in copious irrigation with anti- 
septic solutions carried out by means of a Winton’s 
syringe provided with a gum-elastic top. Where ex- 
‘pense is not objected to, the wound should be plugged 
with double cyanid gauze soaked in hydrogen peroxid 
solution, the irrigation and dressing being earried out 
daily. 

Time will not permit me to deal with the question of 
open joints, which in reality would require a special 
paper. But I cannot omit drawing attention to the 
dangerous character of punctured wounds in the fore- 
arm, which are not uncommonly followed by purulent 
arthritis of the elbow joint. The septic inflammation ex- 
tends along the sheaths of the tendons, and these ten- 
dons support directly the synovial membrane of the 
elbow joint. Hence wounds of this region should be 
drained as early as possible by a free dependent opening. 


Conclusion 


The practical outcome of a consideration of the sub- 
ject appears to be that, although we can never hope to 
practice aseptic surgery in the strict sense of the term, 
we can at least carry out antiseptic principles, so far as 
is possible under the very unfavorable conditions that 
surround us. 

Improvements in the results obtained are more likely 
to follow strict attention to surgical cleanliness and 
proper drainage of wounds than ecare in the selection 
of the agents we employ as drainage. After twenty-five 
years of ‘‘playing the game,’’ and seeing it played by 


ANTISEPTICS—PAST AND PRESENT a) 


others, I cannot believe that among the host of agents 
that are introduced yearly, one possesses any special 
virtues over another so far as the healing of wounds is 
concerned. 

In conclusion, I think the practical deduction to be 
drawn is that every attsmpt should be made to exclude 
infection from wounds, whenever this is possible, and, 
in the case of wounds already infected, to retard the 
erowth and development of micro-organisms by the judi- 
cious employment of antiseptics. 

But whether in the case of operation or of accidental 
wounds, it is quite apparent that in ordinary practice 
we cannot dispense with antiseptics, and attempts to 
do so are likely to be followed by disaster. 


SUPPRESSION OF HEMORRHAGE 
By E. WALLIS HOARE, F.R.C.V5S., Cork, Ireland 


The arrest of hemorrhage is one of the most important 
points in connection with the technic for the treatment 
of both surgical and accidental wounds. There are two 
reasons why hemorrhage should be controlled: 


1. To prevent a fatal termination from excessive loss of blood. 
2. Hemorrhage lowers the vitality of the animal’s system and 
hence retards the healing of wounds. Also blood clots in a 
wound form a nidus for the development of micro-organisms. 


Fatal hemorrhage, so far as wounds are concerned, 
occurs when a large blood vessel is severed and profes- 
sional assistance is not at hand. But it may result, in | 
spite of the efforts of the practitioner, when one or 
more large vessels are severed that are so deeply situ- 
ated they cannot be ligated. This may occur in the 
case of extensive wounds due to the penetration of a 
shaft between the forearm and the chest, or at any part © 
of the pectoral region, or in the vicinity of the inferior 
aspect of the neck. . 

In such cases but little time is allowed for the effort? 
of the surgeon to prove successful. Very often more 
than one vessel is severed, and unless ligation can be 
employed without delay, a fatal termination will result. 
Plugging the wound with tow is of little or no use when 
the hemorrhage proceeds from a large vessel. In my 
experience the only plan that offers any chance of suc- 
cess is to insert a temporary plug of tow and to cast 
the animal immediately, then seek for the bleeding vessel 


57 


58 WOUND TREATMENT 


(enlarging the wound if necessary), and, having secured 
it with an artery forceps, apply a ligature. In some 
instances it may not be necessary to cast the horse, as in 
consequence of the loss of blood he does not resist the 
necessary manipulation, but the procedure is far more 
easily and satisfactorily carried out when the animal is in 
the recumbent position. 

As already remarked, all our efforts may fail in cases 
where the vessel is out of reach. Plugging with tow may 
succeed when the wounded vessel is not of large size, 
but even in this ease it is not to be advised. Although 
such plugging may temporarily arrest the hemorrhage, 
there is always the risk that secondary bleeding will 
occur and prove fatal in the absence of the attendant. 
It may be laid down as a rule that ligature is the only 
safe method to adopt in the suppression of hemorrhage. 
Only when the vessel cannot be secured should resort be 
had to plugging the wound. 

It sometimes happens that although a vessel may be 
secured by the artery forceps, in consequence of its depth 
a ligature cannot be applied. In many instances, by 
the employment of Schoemaker’s pattern of forceps, in 
which by means of a groove at the point of one of the 
blades a ligature is held in position, a deep-seated vessel 
may be ligated. This is a most useful instrument and 
should be in the possession of every practitioner. 

I have frequently left an artery forceps in situ for 
twenty-four hours in cases where a ligature could not 
be applied. Care should be taken to tie up the animal 
during the interval so that he may not le down and so 
cause the instrument to become detached, or to be driven 
inward by pressure. 

In preparing for major operations, a plentiful supply 
of artery forceps of large and small sizes should be 
provided, as one never knows when a large vessel may 


SUPPRESSION OF HEMORRHAGE 59 


be severed. There are so many patterns of these instru- 
ments now on the market that a selection of the best 
is not an easy matter. Personally, I prefer the pattern 
known as the Mayo-Ochner, which is of the ‘‘rat’s- 
tooth’’ type and very efficient. For ease in getting the 
lhgature to slip down the forceps, Greig-Smith’s pattern 
can be recommended, and the larger sizes are especially 
useful for ligating large vessels. 

As to the ligature material, some prefer silk, others 
eatgut, but I prefer the material known as ‘‘ Chinese 
twist,’’ which can be obtained in all sizes, can be readily 
sterilized, and stands great strain. Nothing is more an- 
-noying when ligating a vessel than to have the ligature 
material break at a critical moment. 

In the case of small vessels, where no ligature is re- 
quired, I have found that Blunk’s hemostatic forceps 
are convenient and reliable. 


Tumors 


There are certain operations in which the question of 
the arrest or control of hemorrhage is of special im- 
portance. Tumors in the region of the shoulder, alsc 
known as ‘‘collar’’ tumors, in some cases depending on 
the presence of Botryomyces but in others having a 
‘doubtful etiology, need special care. 

When ordinary treatment fails—that is, locating the 
abscess by means of a trocar and cannula, free incision, 
euretting the cavity, and plugging with tow soaked in 
tincture of iodin—then excision must be resorted to. 

A knowledge of the anatomy of this region, and of 
the firm consistency of the tumor and its extensive 
attachments, indicates that serious hemorrhage is likely 
to cecur unless care be taken in the technic of the opera- 
tion. The position of the carotid artery should be 
earefully noted, so as to avoid injuring this vessel. But 
in my experience the vessel which is most likely to be 


60 WOUND TREATMENT 


severed is the ascending branch of the inferior cervical 
artery. In many instances I have located and ligatured 
this vessel prior to incising the parts in the vicinity and 
thus saved much subsequent trouble and time. And 
here I may remark that in every instance and in every 
region when we come across a vessel that is likely to be 
severed during the operation, it is a good plan to ligature 
it before proceeding further. : 

Large pressure forceps are useful to hold deep-seated 
portions of the tumor. The growth is severed along 
the edge of the forceps, and any vessels that are cut can 
be seen and readily secured before the structures are 
let go. 

After the tumor has been removed, and all bleeding 
points secured, I advise packing with carbolized tow in 
order to combat any danger of secondary hemorrhage. 
Healing by first intention is not to be expected, and the 
packing ean be removed within twenty-four hours. I 
have met with very serious secondary hemorrhage from 
eases of this kind, and hence I find that firm packing 
immediately after operation is the best plan to adopt. 

When secondary hemorrhage does occur, it 1s very 
difficult to suppress; these tumors have such extensive 
vascular attachments that bleeding may be very profuse, 
and when it occurs at night time, and is not immediately 
observed and checked, a fatal result may ensue. In the 
case of a quiet animal, the bleeding vessel may be located 
and secured, but otherwise it may be necessary to cast 
the patient in order to carry out the necessary pro- 
cedure. 

In less severe cases, firm plugging with tow and deep 
suturing of the edge of the wound will prove successful. 
In the case of all wounds the great objection to firm 
plugging is the extensive swelling that usually results, 
therefore I always prefer, when possible, to secure the 


SUPPRESSION OF HEMORRHAGE 61 


bleeding vessel. Moreover, there are instances in which 
the hemorrhage recurs after the packing is removed, and 
as a result the cleansing of the wound cannot be properly © 
carried out. 


Castration 


Why hemorrhage occurs in some cases after castration 
and not in others, when the measures adopted to secure 


the spermatic artery are similar in each instance, is a 


problem which is not easy to solve. 

Generally speaking, the most serious and annoying 
cases are those that occur some time after the operation, 
say within twelve or twenty-four hours. As my experi- 
ence of castration cases is limited to those operated on 
by torsion, I can deal with the subject only from this 
point of view. This experience has taught me that in 
the vast majority of cases, if torsion is properly carried 
out and the spermatic artery is in a healthy condition 
and the animal healthy, hemorrhage does not occur. 
The exceptions are those cases in which we cannot account 
for the hemorrhage. 

The procedure to be adopted depends on the extent 
of the bleeding. We frequently observe cases that bleed 


profusely after getting up, but this soon ceases without 


any treatment. Obviously, such do not depend on hemor- 
rhage from the spermatic artery, but the bleeding arises 
from the artery of the cord or from a vessel in the 
scrotum. 

When the hemorrhage is profuse and clearly arterial, 
the best plan is to cast the animal, seek for and secure 
the severed end of the spermatic cord, and apply a liga- 
ture. This is far preferable to plugging the inguinal 
canal and scrotal cavity with tow, with its risks of sec- 
ondary hemorrhage when the packing is being removed, 
and the extensive swelling which always results. In the 


62 WOUND TREATMENT 


case of secondary hemorrhage occurring at night, plug- 
ging with tow may be the only practicable measure to 
be adopted under the circumstances. 

In the after-treatment care should be taken to remove 
all blood clots, for otherwise a septic condition is likely 
to result. It must be admitted that in many eases the 
hemorrhage after castration ceases spontaneously. The 
measures adopted, such as throwing cold water over the 
loins or applying cloths soaked in cold water to the same 
region, are of doubtful efficacy. 

That ‘‘weedy’’ debilitated colts are most subject to this 
variety of hemorrhage is well known. Again, aged don- 
keys and mules are very apt to bleed profusely unless 
special care is taken in the performance of torsion of 
the artery. 

I have often observed that castration performed under 
deep chloroform anesthesia is likely to be followed by 
hemorrhage some hours afterwards. This does not occur 
when a lighter degree of anesthesia is employed. 


Epistaxis 

Hemorrhage from the nose occasionally gives rise to 
considerable trouble, especially when arising from in- 
juries about the facial and nasal region. As it is dan- 
gerous to plug both nasal passages of the horse, this 
method of suppressing the hemorrhage is not practi- 
cable. If one nasal passage only be plugged, the blood 
finds its way down the other. 

Local injection of adrenalin proves useful, and rais- 
ing the horse’s head will also assist in controlling the 
hemorrhage, but care must be taken lest the blood gain 
entrance to the trachea. 


Accidental Wounds 


I have already referred to the question of hemorrhage 
arising from injuries due to shafts penetrating the’ body. 


SUPPRESSION OF HEMORRHAGE 63 


But there are many minor injuries in which hemorrhage 
may be a troublesome feature. Wounds received during 
hunting furnish a large number of cases in sporting 
districts. In these the same golden rule applies: always 
secure and ligature a bleeding vessel whenever possible. 
-Avoid plugging and tight bandaging except as an emer- 
gency measure. 

As regards hemostatic agents, they have no effect in 
the case of vessels of any size, and the majority of them 
irritate the wound. 


Deep punctured wounds, in which it is not possible 
to secure a bleeding vessel without making an extensive 
opening, may be plugged with antiseptic gauze. 

Wounds involving the digital arteries in the region of 
the coronet are often troublesome, as it is by no means 
easy to secure the bleeding vessel, especially in the case 
of a nervous, excitable horse. The Mayo-Ochner artery 
forceps will be found useful for cases of this kind. 


When an artery or vein is exposed in an extensive 
wound, but not severed, it is advisable to apply a liga- 
ture, since the walls of the vessel may give way and 
serious hemorrhage result. Should it become necessary 
to apply a ligature to the carotid artery it must be 
remembered that in consequence of the collateral circu- 
lation both the proximal and the distal ends of the 
vessel must be secured. 

As regards the employment of the actual cautery as 
a hemostatic agent, in consequence of tissues it pro- 
duces it is now being discarded. In Great Britain it is 
still employed by some practitioners in the operation of 
castration and also docking. From a humane and scien- 
tific point of view it is to be hoped that the suppression 
of hemorrhage by means of the actual cautery will soon 
be regarded as one of the relics of the barbarous ages. 


TREATMENT OF WOUNDS 
By L. A. MERILLAT 


The treatment of wounds! What a vast subject! 
When the surgeon makes a wound, or meets one acci- 
dentally inflicted, he is immediately confronted with 
the important task of guiding the reparative process 
through and to the successful issue that will not only 
protect the patient against serious complications, but 
which will also leave the once injured body in the best 
possible condition: sound, healthy, and unblemished. The 
word ‘‘guiding’’ is used advisedly, because the first rule 
to lay down in the management of wounds is that wound 
healing is a process of nature that can be guided— 
influenced, but not forced. The surgeon does not heal 
a wound; he merely puts it and keeps it in a favorable 
eondition to heal. The inherent, mysterious, subtle, 
cellular activity that begins as soon as a wound is in- 
flicted and ends in strict obedience to an inexplicable 
law as soon as the breach is filled up with just enough 
new tissue to level off the excavation, is indeed a process 


‘to be guided rather than forced by any outer inter- 


ference. . 

The student of wound healing who first of all learns 
the wisdom of non-interference with this process has 
already laid down a good foundation for wound treat- 
ment. In other words, he who bases his management 
of wounds upon the fact that the new tissue that 
sprouts out from the walls of a traumatic cavity under 
normal conditions grows safely to a useful, mature 
tissue without outside help, is the successful healer, 


65 


66 WOUND TREATMENT 


while on the other hand he who is bent upon constant 
meddlesome interference with the germination, growth, 
and maturing of the reparative elements required to re- 
store the lost elements, invites complications, retards 
the normal activity of tissue construction, and usually 
leaves indelible blemishes as evidence of his harmful 
practices. 

The system of wound treatment in general use in the 
veterinary profession, to be perfectly frank, does not 
entitle us to much credit. Our therapy in this connec- 
tion is severely lacking in the refinement that enables 
the surgeon of human beings to make and manage suc- 
cessfully enormously large wounds. The reader may 
here insist that he has obtained good results from his 
wound treatment. But is this really the fact? Is it not 
more nearly the truth that our successfully treated 
wounds are, after all, trivial wounds, and that our really 
serious wounds, surgical or accidental, are too often 
fatal, or that they permanently disfigure or perma- 
nently disable our animal patients? And is it not 
still a painful fact that the whole veterinary profes- 
sion continues to exhibit a real fear of extensive sur- 
gical wounds because of their bad behavior? And is it 
not still the truth that many of us fear to invade the 
splanchnic cavities and synovials, believing that acci- 
dental wounds of these cavities are fatal and surgical 
wounds very hazardous? Such an impression should 
no longer prevail among us, at least not to the same 
extent as in years gone by. With our knowledge of 
regeneration on the one hand, and of the pathology of 
wound complications on the other, we should approach 
almost any wound with more confidence than formerly ; 
and then by planning various schemes to remove every 
harmful element, inherent and ulterior, a very remark- 
able success may be achieved in the treatment of even 


TREATMENT OF WOUNDS 67 


very serious wounds. It must be borne in mind first - 
of all that the wounds we meet and make, and the 
nature of our animal patients, call for special systems 
of management from the beginning to the end of the 
healing period. After we have followed the general 
principles which should govern the management of 
wounds of all living creatures, there are. still special 
plans, systems, methods, and procedures applicable to 
our patients which must be executed in order to meet 
the requirements needed to obtain the best results. 
The necessity for skillful, scientific, ingenious wound 
treatment is estimated best by those who venture into 
the field of major surgery. Just so long as the surgeon 
restricts his enterprises to minor procedures, the refine- 
ment of technic required to succeed in major work is not 
appreciated, as the minor wound heals in spite of the 
method, while the major wound ends fatally or in some 
other disaster. In short, if we desire to go onward 
with our animal surgery we must first surmount the 
various obstacles due to the fact that our patients be- 
longing to the brute creation are unable to give the 
surgeon any help, are barely worth the expense of 
much surgical work, and are always dirty and are ' 
always kept in dirty surroundings. To do good surgical 
_work even with these obstacles working against us, is 
our task, and it is a task we must in some way master. 
We are no longer compelled to sing the praises of — 
aseptic work; everybody now recognizes its merit, no 
one but the very ignorant ignores it; and as I once heard 
a medical bystander remark: ‘‘Even the horse doctor 
practices it.’’ Ten years ago we were frantically de- 
fending asepsis for animal surgery as a more or less 
practical procedure; to-day everybody knows it can be 
successfully practiced through almost every surgical 
operation and through the postoperative convalescence. 


68 WOUND TREATMENT 


Wound infections of the surgeon’s making, onee the 
rule, are fast becoming the exception. 

During the last two decades the veterinarian has, 
of course, learned much, with the rest of mankind, about 
the nature and behavior of wound infections, and espe- 
cially about the manner wound infections are carried 
into wounds. -We have been painfully slow to acknowl- 
edge the venomous nature of our hands and instruments, 
‘in our well-rooted belief that microbes around a sur- 
gical operation on animals were so abundant and so 
volatile that no system of procedure could cope with 
them. With all of these prejudices out of the way, and 
with every one satisfied that the animal surgeon may 
now, if he chooses, protect his patients against these 
self-made infections, our attention must be directed also 
toward other obstacles. What these are and how we 
may attempt to meet them will be considered in the 


succeeding paragraphs. The object of this article is 


more to bring the modern conception of wound treat- 
ment before the profession in the hope that a better 
system of wound treatment applicable to animals may 
be adopted in the veterinary profession to the decided 
benefit of our onward march toward higher levels; pre- 
cisely as a few years ago it was found necessary to 
preach the gospel of asepsis. That these obstacles are 
formidable, and the recommendations I may be able to 
make inadequate, is hereby acknowledged. ~~ 

The treatment of wounds! Let us understand one 
another. What to rub on a wound or what not to rub 
on a wound is not in our mind in this discussion. On 
the contrary, we are taking the treatment of wounds 
in its fullest sense, ‘‘The curing of the patient by the 
surgeon,’’ for this is what wound treatment is, after 
all. In surgery the healing of the wound is usually 
analogous to curing the patient. It is evident, therefore, 


ee ee ee 


ee Se 


: TREATMENT OF WOUNDS 69 


that wound treatment begins in the preoperative de- 
hberations over a proposed surgical subject, for if the - 
wound will not heal, no operation is indicated. 


Preoperative Treatment of Wounds 


Under this somewhat irrelevant title is included a 
consideration of those systematic conditions which miti- 
gate against the healing of wounds made by the sur- 
geon and those accidentally inflicted; the influence the 
general health will have upon the behavior of a pro- 
posed surgical wound; the condition under which the 
patient must live during healing; and the amount of 
intelligent after-care it will be possible to administer. 

The bearing of the health and especially the vigor of 
a wounded patient upon the healing of a wound has 
too often been ignored. In a large city, where horses 
are often reduced to a pronouned state of general en- 
feeblement from hard work, or from hard work and pri- 
vation combined, the influence of this element in the 
behavior of wounds is most appreciated. The serious 
nail prick, implicating the pedal synovials, for example, 
will respond to active treatment in the vigorous subject, 
but will prove fatal in the weak. In the strong, wounds 
are inclined to have only a local effect, while in the 
weak, bacteria and their metabolic products are almost 
certain to tend to generalize and cause such grave com- 
plications as septicemia, pyemia, and embolic pneumonia. 

The management of wounds must, therefore, begin in 
the preoperative deliberations. We must know first if 
the patient is fit to withstand a given ordeal, and then 
plan accordingly. I know of no one element that works 
so much harm in animal surgery as that of operating 
upon the weak subject. Whether the enfeeblement is 
due to disease or other influences does not matter, the 


70 WOUND TREATMENT 


relations between the patient’s condition and the trau- 
matism is of equal importance. 

The point may be illustrated in fistula of the withers. 
In a young, vigorous subject with a fistula of recent 
origin, before or soon after the first abscess has dis- 
charged its contents the surgeon may proceed fearlessly 
to the most radical steps, with a full assurance of a 
rapid recovery. The trauma may be large enough. to 
cause considerable shock, and the blood loss may be great, 
but in spite of these there is prompt reaction from the 
shock and a prompt healing is soon progressing. On 
the other hand, a subject affected with a sapping fistula 
that has been draining the system for months may be 
too feeble from anemia and chronic septicemia to with- 
stand even a minor operation. The one will recover, 
the other may die. 

Serawny, ill-wintered colts fall victims of castration, 
while the vigorous seldom die. I know of no greater 
hazard than herniotomy or cryptorchidectomy in en- 
feebled subjects. In the case of accidentally inflicted 
wounds, precisely as in surgical wounds, there is this 
same element of vigor working for or against the sur- 
geon, and unless due attention is given thereto, wound 
healing may take a bad turn right from the beginning, 
even if the patient recovers from the shock inflicted. 
Case after case might be related to illustrate this point. 
It should, however, be sufficient to say that the vigor of 
our animal patients has such a marked effect upon the 
results of our surgery that no surgical operation should 
ever be thought of without first giving due considera- 
tion to the influence the general ca ape will have upon 
the final results. 

The remedy in other than urgent cases is to improve 
the patient’s condition by every available and practicable 
means. I have often postponed poll-evil and fistulee 


TREATMENT OF WOUNDS 71 


operations for ten days to two weeks pending an im- 
provement of the patient. The abscesses were lanced 
and irrigated and the patient, previously working per- 
haps, was rested, groomed, fed well, and medicated until 
a better state of health was induced. The loss in time in 
such cases turns to actual gain in the more speedy recov- 
-ery—that is, in the more rapid healing of the wound. 
The hairy, pot-bellied colt, that has subsisted on rough- 
age all winter, should get the invigorating effect of two 
weeks at pasture before it is castrated, and like precau- 
tions should be taken throughout the whole category of 
surgical operations. 

In emergency cases the weak require, as a remedy 
against their enfeebled state, a much more painstaking 
method of procedure to prevent infection, more carefut 
anesthesia, and a more constant and diligent after-care. 
It is here that vaccines find their greatest usefulness in 
animal surgery. Although general systemic enfeeble- 
ment does not always indicate a low opsonic index, our 
observations lead to the conclusion that vaccines wield 
a powerful influence for good in the great majority of 
eases of this type. 

The administration of iron, quinin, and potassium iodid 
to encourage a better behavior of wounds has many 
defenders, and no doubt serves as a more or less valu- 
able adjunct to the feeding, bedding, grooming, and 
general care of weak surgical subjects. 

Another point in the preoperative attention of pa- 
tients is the care of the feet. Any horse about to be 
subjected to a surgical operation, whether the wound is 
intentional or accidental, should be given the benefit of 
good ‘‘underpinning.’’ The shoes should be removed 
and the feet pared and then reshod, so as to give the 
most comfort. This is particularly important when the 
standing position must be maintained day after day. 


(2 WOUND TREATMENT 


In operations upon the feet for disabling lamenesses, 
there is nothing so important as the opposite leg and 
foot, which must now bear the burden of two. While 
the patient is still on the table, the shoeing of the oppo- 
site foot should be scrutinized, and corrected if neces- 
sary. The sound leg, becoming tired, the weak patient 
will often lie down and refuse to rise to bear the weight 
on the aching member. Such cases soon become bed- 
ridden, and seldom recover. 

In fine, it might be truthfully said that no surgeon 
of animals will have success with serious operations if 
he wades into them with a reckless disregard for the 
resistant powers of his patients. The surgeon of human 
beings studies his patient for days. He puts him to bed, 
diets him, purges him, stimulates him, examines his 
urine, his blood pressure, his heart, and then finally de- 
cides to operate. But we veterinarians often wade into 
our patients without a forethought, and then wonder at 
the mortality. 

The operations in which there is an especial need of 
weighing carefully the vigor of the patient in order to 
forestall disaster are more numerous than might at first 
be supposed. The more common are: | 


. Radical operation against poll-evil. 

. Radical operation against fistula of the withers. 

Ablation of scirrhous cords, botryomycomata, shoe boils; 
goiters, nasal tumors, eyeballs, and so on. 

. Radical operations for large hernia-ventraloceles, oscheoceles, 

and exomphaloceles. 

. Cryptorchidectomy. 

Operations upon infected tendon sheaths and articulations. 

. Surgical treatment of large lacerations of the buttocks and 

shoulders. 

. Surgical treatment of abdominal wounds with visceral injury. 

. Amputations following serious accidents. 


Oo NAM FP wre 


A review of these procedures, and there are many 
others, shows clearly that major operations of a serious 


1 
—_ = 


ER ee a ee a a er 


TREATMENT OF WOUNDS 73 


character—serious on account of the magnitude of the 
traumatism—are indeed numerous. They include the 
surgical operations of animals that are actually worth 
the trouble and expense entailed in their performance 
and after-care, because the salvage is always consider- 
able and in most cases amounts to the full value of the 
individual afflicted. The existence of animal surgery 
therefore depends largely upon our ability to work out 
plans of wound treatment that will carry such patients 
safely and promptly through the period intervening be- 
tween the completion of the operation and the final 
cicatrization of the wound. In short, to make animal 
surgery actually worth while we must make, and then 
manage, large wounds better than we have done hereto- 
fore. 3 
Previously in this article we endeavored to show that 
the initial fault in wound treatment is the lack of 
effort we make in the preoperative examination of our 
surgical subjects. To wade recklessly into a patient be- 
fore weighing carefully its ability to bear the effect of 
the traumatism we are about to inflict seems to be a sin 
we continue to commit. In view of the other obstacles 
under which wound healing in animals must proceed 
it is plainly important to start out with the best phys- 
ical condition it is possible to produce. Every means 
at our command should be drawn upon to accomplish 
this end. | 

I shall repeat that our best surgical subjects are 
those well cared for, well fed, and worked enough to 
keep them muscular, and the poorest risks are those 
badly fed, worked hard, and housed in poorly venti- 
lated stables. To the latter may be added animals sick 
and enfeebled from the disease for which they are to 
be operated upon. The former stand surgery well, while 
the latter are victims of complications; the former need 


74 _ WOUND TREATMENT 


only a preparatory dieting to avert operative accidents, 


while the latter are seldom fit for major surgery until © 


the lost vitality has been restored. A physical examina- 
tion for pulmonary, cardiac, digestive, and locomotory 
disorders is particularly demanded. Urine analysis, 
blood counting, and bacteriological tests of discharges 
and secretions are less called for in animal surgery than 
in surgery of human beings, and in fact are only sel- 
dom of sufficient importance to warrant one in resorting 
to them, but the knowing animal specialist comes to 
conclusions about the physical condition of his patients 
by their general appearance and the lives they have 
previously led. ; 


The Cost of Better Wound Treatment 


The question of cost always enters into any detailed 
dissertation on surgical operations. It is usually thought 
imprudent to add still more to the already high over- 
head expense of our surgical work. To eliminate the 
necessity of referring to this feature again, we shall 
state flatly that the actual value of our surgical opera- 
tions is not reflected in the prices in vogue to-day. The 
veterinarian should make them more valuable by doing 
better work. This is the pure and simple solution of 
the ridiculously low prices we receive for our surgical 
services. A scale of prices should be an elastic scale. 
We must do what the surgeons of human beings do: 
operate upon the poor for nothing, and claim a reason- 
able fee where the cost is less an object. In veterinary 
surgery we should operate upon cheap animals for less 
than upon those where the salvage is great. Five, ten, 
fifteen, or twenty dollars may be ill spent for an opera- 
tion that ends unsuccessfully or in a long convalescence ; 
while twice these amounts for operations that promptly 


: 


ee ee i te hed fi i ati 


TREATMENT OF WOUNDS 75 


restore useless animals to their full value would be re. 
garded as good investments. 

Operations upon cheap animals, performed with a thor. 
oughness that makes for good results, will always amply 
pay the surgeon in experience if not in money; and this 
experience can always be turned to good use when con- 
ditions are more favorable for the collection of a good 
fee. Any attempt to arrange prices on any other basis 
is destined to failure. It is becoming more and more 
evident that better surgery offers us the best oppor- 
tunity to increase our incomes. 


A Few Words on Asepsis 


The precautions for preventing the contamination of 
wounds while making them, or while treating those 
accidentally inflicted, have revolutionized the surgical 
art. To-day the surgeon must work religiously 
throughout an operation to prevent the soiling of tis- 
sues with infection, and this has greatly complicated 
surgical technic. The mere cutting process is often 
much simpler than that of preventing the open tis- 
sue from becoming contaminated with pathogenic bac- 
teria. Surgery includes to-day not onlv the classical 
incisions, resections, and dissections, but also a compli- 
eated prearranged plan for performing these opera- 
tions without depositing harmful bacteria into the 
trauma. The fact that bacteria are harbored upon and 
within all objects directly and indirectly connected with 
the procedure, calls for preventive measures that are by 
no means easy to carry out. The prevention of opera- 
tive infection requires knowledge of bacteriology and 
- pathology that is not possessed by the charlatan, and. 
it is here that the educated practitioner can find the 
greatest weapon to use against his charlatan competitor. 


76 WOUND TREATMENT 


There are a certain definite number of objects that 

touch wounds, and aseptic surgery might be correctly 
defined as the art of preventing these from inoculating 
bacteria into them. 
- The air, the instruments, the surgeon’s hands, the 
assistant’s hands, the surgeon’s clothing, the assistant’s 
clothing, the operating place, the sponges, the solutions, 
the containers of solutions, the sutures, the dressings and 
bandages, the surroundings of the wound (surgical field), 
and the patient’s habitat include all of the objects ca- 
pable of conveying infection. Aseptic surgery dictates 
a rigid handling of all of these objects. None must be 
ignored; each must be made absolutely harmless, or at 
least as nearly harmless as is possible and practicable. 
To make a sane effort to prevent wound contamination 
from each of these conveyors in every operation is a 
modernism that should no longer be neglected in vet- 
erinary practice. The methodical handling of these to 
this end, in a surgical operation, is an exhibition of 
knowledge and of skill—a spectacle deserving of praise 
and sure to win applause from intelligent judges, and a 
means of accomplishing the best results. The veteri- 
narian should realize there is also a legal side to this ques- 
tion: that he may be made accountable for infections 
of his own making, when precautionary measures have 
been disregarded. 


Air as a Conveyor of Infection 


Except where patients can be taken out into the open, 
on a clean grass plot away from the dust of trodden 
corrals, roads, or tilled fields, the air is capable of convey- 
ing dangerous infections. The air itself acts only as a 
carrier of particles which in turn carry bacteria. When 
there are no particles suspended in the air it is harm- 


{ 
| 
: 
: 
‘ 
7 
: 


TREATMENT OF WOUNDS 77 


less; when it is laden with suspended or flying particles 
it must be reckoned with, and is probably more often 
the source of mysterious wound infections than we at 
first supposed. 

- In my earlier teachings I was inclined to make light 
of the possibilities of wound infections from this source, 
just as the surgeons of human beings were doing after 
they demonstrated the fallacies of Lister’s historical 
‘*phenicated cloud.’’ But a wider experience has taught 
me that the air of stables, and especially of veterinary 
hospitals, is quite different in this regard from that of 
hospitals for human beings. — 

- While it is no doubt a fact that most of our infections 
come from other sources, the air of our operating 
rooms is not to be entirely ignored. Such rooms are 
usually dust laden, the dust originating from badly con- 
taminated floors, and even when measures are taken to 
allay dust, the room may become recontaminated around 
the surgical field with dust raised from the patient’s 
body. The body of a struggling animal may thus be- 
come a veritable pest. Dust and hairs loosened by strug- 
gles and then whirled about by drafts often create very 
dangerous conditions. and are difficult to manage. We 
would be making a poor start toward perfection in asep- 
tic practice were we to continue to disregard these 
dangers. 

Refined nosocomial work demands special care to al- 
lay suspended room dust by spraying, and to prevent 
the raising of dust by mopping and flooding floors in- 
stead of sweeping, and by wiping furniture and titen- 
sils instead of dusting them. When these precautions 
have been taken the patient itself might be brought in, 
well groomed and moistened with a damp cloth to re- 
duce to the minimum the amount of dust raised from 
the body. This latter recommendation is particularly 


78 WOUND TREATMENT 


important aeouan the surgical field. These environs — 
even be well soaked with water. 

For the outdoor operation the trodden corral and 
tilled field are particularly dangerous, for the dust from 
these sources is ridden with bacteria of the most harm- 
ful sort, and usually there is wind to whirl about the 
particles raised by the patient’s struggles. 

Youngsters, either equines or bovines, shedding the 
long shaggy winter coat, are about the most miserable 
surgical prospects imaginable. In operations upon such 
animals great clouds or even’ bunches of hairs are some- 
times swept into wounds, and if there is added to this 
the dust from a bare paddock the condition is abom- 
inable and strictly unfit for any kind of surgical work. 

The use of any kind of litter as an operating bed may 
likewise be condemned. There is no fit litter for sur- 
gical work. A ban might as well be put on all kinds 
of loose beddings used to make a soft place for re- 
strained animals to lie upon during operations, for it is 
positively impossible to maintain a decent state of sur- 
gical cleanliness with loose particles whirled or trailed 
into or near the wound at every movement. Whenever 
the weather is too inclement for outdoor work it is bet- 
ter to cast animals upon a bare floor, protecting the 
head and hips with blankets if thought necessary. The 
actual difference between a bare floor and a floor bedded 
with two or three inches of straw is not great, measured 
from the standpoint of the patient’s comfort. Beddings 
are usually pushed aside and the body rests upon the 
floor before the operation is far advanced, and about the 
only good accomplished by the bedding is the psycho- 
logical effect it has upon the audience. Shavings prop- 
erly moistened can be controlled better than any other 
bedding, but these are seldom available and are none 
too safe. It is better to abandon entirely the use of 


TREATMENT OF WOUNDS 79 


litter as a surgical appurtenance, and thus dispose of 
one of the sources of air contamination. 

In short, air is a prolific source of wound infection 
in animal surgery that should be dealt with consistently. 
It is not so dangerous as Lister taught before the days 
of bacteriology, but more dangerous for veterinarians 
than for the surgeons of human beings, who operate 
under much more favorable conditions than is ever 
possible for us. 


Instruments as Conveyors of Infection 


As instruments come into direct contact with wounds 
they are more certain to inoculate them than the other 
objects used in wound treatment. The metallic instru- 
ments used in surgical work (knives, forceps, and so 
on) become progressively more dangerous day after day 
unless submitted to an effectual sterilization. That is, 
instruments used from the pocket case or from shelves 
of the instrument case soon become very dangerous. 
They will infect every raw spot ans touch with appal- 
ling certainty. 

Wound infection from this source is Eviidable under 
all circumstances in veterinary as in human surgery, 
and should therefore be entirely eliminated. There is 
absolutely no excuse for wound infection from instru- 
ments. They can and should be sterilized before every 
operation and then so handled during an operation as 


| _ to prevent them from becoming contaminated. Veteri- 


narians who continue to operate without first sterilizing 
their instruments are fortunately fewer than formerly, 
but I regret to say they are still legion. 

Boiling is by far the easiest as well as the safest 
method of making instruments safe. To assure safety, 
metallic instruments should be boiled ten to fifteen min- 


80 WOUND TREATMENT 


utes. Cutting instruments are harmed somewhat by - 


repeated prolonged heating; our present plan is to pick 
up the knives from the boiling water after two or three 
minutes and complete the sterilization by placing them 
in a jar containing denatured alcohol. Alcohol steriliza- 
tion alone for scalpels and bistouries is depended upon 
by many, and if the immersion is long it may be regarded 
an appropriate and safe expedient for the particular 
purpose of assuring the best sterilization possible with- 
out injuring the keen edges of sharp knives. 

Rubber goods (gloves, catheters, drainage tubes, 
syringes) may be subjected to a certain amount of 
boiling without injury, and as these are not as a rule 
very costly, such injury as they do sustain is unim- 
portant. Costly instruments of this class ean also be 
made safe by immersing them for some time in strong 
solutions of mereuric chlorid. 

The resoiling of instruments during operations must 
be prevented by taking care that they do not come in 
contact with soiled objects. If they become infected by 
contact 'with pus or other infected substances they 
should be set aside and not placed upon-or near clean 
instruments on the tray. The use of a little caution 
and plenty of common sense is needed in handling in- 
struments, for otherwise the whole plan of clean operat- 
ing will be futile. 


The Surgeon’s and the Assistant’s Hands 


The hands as carriers of infection into wounds we 
treat deserve more than ordinary consideration, because 
the hands of surgeons practicing among animals are 
always hable to infect wounds. In short, the hands 
belong to the first rank as infection carriers, not only 
of ordinary pyogenic infection but also of infections of 


x 


a ey 


TREATMENT OF WOUNDS 81 


more serious import. Working continually among in- 
fected objects and infected structures of the body of 
diseased animals that must be handled manually, the 
veterinarian who indulges in major surgical work, or 
who desires to have nice results from his minor work, 
must learn first of all that his hands are dangerous 
and unless managed properly will defeat his every other 
precaution to perform aseptic operations. The hands 
that remove a putrefied placenta or decomposed fetus are 
not fit to handle internal organs or raw wound sur- 
face for some time, even when careful washing precedes 
the operation, for no washing, no matter how carefully 
done, will immediately rid them of infectious material. 

The exact truth in this connection is that bare hands 
are never safe. Even the hands of the human surgeon 
are not so regarded, and his work is by no means of 
such a filthy character as that of the veterinarian. 
Just before operating, the veterinarian is often engaged 
in much dirty preparatory work—casting or otherwise 
securing his patient. The paraphernalia used around 
a veterinary surgical operation is dirty in the surgical 
sense and abominably contaminated with the dirt of 
preceding operations. As these must be handled with 
the hands, there is little chance of the veterinarian ever 
having hands that are fit to handle tissues or instru- 
‘ments that must come in contact with tissues. And 
since the wearing of sterilized, skin-tight rubber gloves 
is not practicable for ordinary operations, it would 
seem that we here meet an insurmountable obstacle. 
- The truth is, however, quite different, for if we prac- 
tice the art of avoiding the digital manipulation of raw 
surfaces the obstacle is at once removed, no matter how 
dirty the hands are. Ablutions of soap and water fol- 
lowed by a rinsing in mercuric chlorid are all that is 
needed to prevent infection from the hands when han- 


82 WOUND TREATMENT 


dling the tissues with the fingers can be avoided. While 
such hands still harbor and deposit infections, they 
touch only the handles of instruments; the blade of the 
scalpel and the jaw of the forceps are not soiled, and 
thus do not convey hand contaminations. By exercising 
a little care to prevent the handles of instruments thus 
soiled from touching the parts of other instruments on 
the tray that will be subsequently used on the raw 
tissues, the infection of wounds with the hands becomes 
negligible in veterinary surgical operations in spite of 
the fact that they are all the while badly contaminated 
with bacteria. In addition, however, we must not forget 
the assistant’s hands. These come into even closer con- 
‘tact with the wound while baling blood than those of 
the surgeon himself. In handling sponges the assistant 
must endeavor throughout to keep the part of the sponge 
he touches with the fingers from touching the wound— 
a plan easy of execution—and under no circumstances 
should he bring his fingers directly into contact with 
the wound. When he hands instruments to the surgeon 
he should touch only the handles or convey them with 
forceps. The rules we have put into operation to pre- 


vent wound infections from the hands are as follows: 


1. Avoid all unnecessary handling of raw tissues with the 
fingers. 


2. Rinse the hands with mercuric chlorid (1 to 500) after wash- 
ing them with soap and water. During the operation rinse 
them frequently in a deep basin provided for the purpose. 

3. Wear gloves while scouring the patient. 

4. Touch only the handles of instruments that contact raw sur- 
faces, and so arrange them on the tray that the handles will 
not come into contact with the blades of knives or jaws of 
forceps that will subsequently be used on the raw surfaces. 

5. Handle needles and sutures with the read only, or wear 
sterilized skin-tight gloves while suturing. 

6. Soak sutures previously sterilized in tincture of iodin so that 
soiling will be less harmful. 

7. Where digital manipulations are needed, as in spaying. or 
ridgling castration, the hands cannot be "made entirely safe, 
Washing with water, rinsing in mercuric chlorid solution, 


TREATMENT OF WOUNDS 83 


rubbing them with alcohol, and then painting the fingers in 
weakened tincture of iodin combines the best resources we 
have. The latter—the iodin—is objectionable, because of 
the staining and because it blunts the tactile sense, so much 
depended upon when digital work is actually necessary. 


Wearing clean gloves while doing the preparatory 
work, the washing and rinsing of the hands as above 
proposed, avoiding unnecessary manipulations with the 
fingers, and wearing sterilized, skin-tight gloves while 
suturing are just so many practical means of averting 
wound infection from the hands, and when these simple 
means are resorted to hand infections are comparatively 
rare. There remain the unavoidable infections when 
the bare hands must be used. 


Sponges 


Absorbent cotton is the best sponging material for 
general use in veterinary practice, especially where a 
large number of sponges will be needed during a given 
operation. Gauze comes second, and while decidedly the 
safer, absorbent cotton is delivered in clean packages 
and is easily sterilized whenever absolute purity is de- 
manded. Our plan of handling cotton for important 
operations is to place a sufficient amount in the sterilizer 
with the instruments and when well boiled cool it off in 
a basin of mercuric chlorid solution (1 to 1,000) made 
with sterile water. This is then the assistant’s basin. 
During the operation he takes his sponges from this 
basin as fast as they are needed and of course casts 
them aside when soiled. This plan tends to keep the 
assistant’s hands safer by their repeated contact with 
the antiseptic solution containing the cotton. 

Where there are plenty of especially assigned assist- 
ants to look after the surgical paraphernalia, as in 
college clinics, sterile gauze sponges used in the same 


84 WOUND TREATMENT 


way are preferable. These may be resterilized for future 
use. 

Sponge sponges are very effectual in absorbing blood 
from wounds, and on this account are defended as best 
by some veterinarians. By keeping them in a strong 
antiseptic solution they can of course be sterilized, but 
unless these are used like the gauze and cotton sponges, 
being cast aside when soiled, their use cannot be recom- 
mended under any circumstance. It is best to dispense 
entirely with the sponge and at once eliminate a very 
common source of wound infection. 


Solutions and Their Containers 


There is no material about veterinary surgical opera- 
tions more erroneously used than the antiseptic solution. 
I find that veterinarians are still placing too much 
dependence upon the microbicidal value of ‘chemical 
substances dissolved for surgical use. Unless the water, 
the basin, and even the drug are sterilized, no antiseptic 
solution is safe. In fact, antiseptic solutions are one 
of the commonest sources of wound contamination. They 
soil more than they are capable of disinfecting. They 
carry bacteria into wounds where none previously ex- 
isted, and they are ineffective against bacteria lodged in 
the tissues. The statement that pathogenc bacteria are 
more viable than the cells of the body cannot be too often 
repeated. The explanation of the stubbornness of wound 
infections against antiseptics is found therein. The 
simple truth is that antiseptics injure, devitalize, and 
even kill cells to the advantage rather than to the dis- 
advantage of bacteria growth. 

From these facts it is evident that the antiseptic solu- 


tions we use should be more intelligently prepared and 


handled than is customary in veterinary surgical opera- 


EEE 


TREATMENT OF WOUNDS 85 


tions. Water from the well or hydrant brought in the 
milk pail or stable bucket, no matter how clean looking 
it may be, is a sure carrier of infection. To add to this 
water an antiseptic drug does not improve matters as 
‘much as is generally supposed; the solution is still an 
infection carrier of the most certain sort. HExperimen- 
tal studies of the viability of various microbes in the 
different solutions used in surgical operations tell plainly 
enough why wound infection from this source is so com- 
mon. Sterilized water held .in a sterilized basin. without 
any antiseptic drug is much safer than medicated water 
that is laden with bacteria, as almost all waters are. 

Analyzing the reason why sterilized water is still so 
rarely found in veterinary operations, I find that the 
principal argument against the use of this valuable and 
very inexpensive product is that water boiled just as 
the animal is about to be operated upon is always 
brought to the scene of the operation too hot to be 
handled, and as it does not cool very fast there is always 
an inclination, in the haste of getting through with the 
work, to cool it off with cold water. This of course 
spoils everything; and knowing this, the country vet- 
erinarian soon abandons his effort to stick strictly to 
this product as a menstruum for his solutions. 

It is, however, worth while insisting that every drop 
of water to be used in any important operation should 
be boiled for fifteen minutes and brought out in the 
original vessel. The time allowed for it to cool is time 
well spent. In my rural operations I frequently fill the 
large wash boiler with water, place in it the basins, 
dipper, bandages, and sponges to be used, and then boil | 

all together for fifteen minutes. In the meantime the 
instruments are being boiled in the regular instrument 
sterilizer—an apparatus that every veterinarian should 
carry with him everywhere. It requires about fifteen 


86 WOUND TREATMENT 


to twenty minutes for these to cool off, and this time 
can be utilized in preparing the patient. 

This is a general plan that every country practitioner 
should follow sacredly. The unfortunate sequences of 
many of my country operations during past years I 
attribute to this source of infection. Suppuration ga- 
lore, surgical septicemia, malignant edema, tetanus, peri- 
tonitis, and other consequences following operations that 
one has taken especial pains to do well may often be 
traced to bad judgment in providing the solutions. 

The best plan the country veterinarian can lay down 
as a start for better surgery is the use of the housewife’s 
wash boiler in the manner mentioned above. 


In hospital operations sterilized water is more easy to 


procure. It can be stored in large bottles ready for use, 
and the instrument sterilizer should be large enough to 
sterilize the basins into which the water is poured. Too 
much dependence must not be placed in the hot water 
from the hot-water tank even though it comes out steam- 
ing hot. Tank water whose temperature is maintained 
around 200 degrees Fahrenheit for hours is, however, 
safe enough for ordinary surgical work. 


Sutures 


The certainty of wound infection from unsterilized 
sutures is due largely to the fact that they sojourn so 
long in the injured tissues. The bacteria they carry 
always find a favorable environment for growth in the 
enfeebled tissues they hold together, and even when 
sterilized and placed with exceptional eare, stitch sup- 
puration may develop from skin bacteria that cannot 
be dislodged in the preparation of the surgical field. 

On these accounts sutures in veterinary operations 
call for special methods of handling. They must first 


ee = 


TREATMENT OF WOUNDS 87 


be boiled for at least fifteen minutes, bathed in pure 
tincture of iodin, and then so handled as to prevent 
contamination through trailing over unclean places or 
from the soiled hands. 


We defend the use of antiseptic sutures instead of 
aseptic sutures chiefly on the grounds of expediency. 
Such sutures can be handled more carelessly with the 
bare hands, they are less apt to get soiled from acci- 
dentally trailing over soiled places on the patient, and 
stitch suppuration from skin bacteria is made negligible. 
The nature of our operations demands this expedient. 
This applies, of course, only to removable sutures, that is, 
sutures for the skin. Buried sutures for the underlying 
integuments need not be so treated, but should always be 
purchased sterilized and in sealed containers. The veter- 
inarian has no way of safely sterilizing raw gut, and 
therefore should not undertake to do so. 


In suturing wounds the needle is held in the needle- 
holder, and the end of the thread that is handled may be 
eut off when the needle is threaded. The assistant. may 
then keep the dangling end from trailing over the pa- 
tient by holding it up with forceps as it is drawn 
through; or the surgeon may at this stage of the opera- 
tion put on a pair of sterilized, skin-tight rubber gloves 
’ and handle the needle and thread with the fingers, keep- 
ing the thread in the palm of the hand to prevent trailing. 
Either of these plans will answer. 


There is no use in practicing other aseptic precautions 
if any carelessness whatever in handling sutures is al- 
lowed to creep in, because here we have a certain infec- 
tion carrier. A wound may sometimes escape infection 
‘from contaminated air, instruments, or hands, but never 
from sutures that are not absolutely aseptic and carefully 
handled. 


88 WOUND TREATMENT 


Wound Packing, Drainage Wicks, and Draining Tubes 


Inasmuch as we continue to use compression packs to 
control copious bleeding after some of our operations, 
these are capable of acting as carriers of bad infections. 
A soiled wound-pack sewed up tightly in a traumatic eav- 
ity is a mighty dangerous object. In twenty-four hours 
it is fetid, and in forty-eight hours, if not removed or the 
sutures loosened to admit air, malignant edema is very 
likely to have developed. The large cavities of ridgling 
castration, of fistule of the withers, of poll evils, and of 
large tumors are to be feared in this connection. Re- 
cently a case of this kind came to my notice. A ridgling 
castrated after some difficulty was packed with cotton 
that, was simply disinfected in mercuric chlorid solution 
made from well water and contained in a milk pail. The 
wadding was held in place by snapping the edges of the 
wound with a clamp forceps. When removed forty-eight 


hours later the wadding was fetid, the scrotum was swol-. 


len, and the patient stiff and sick. There was a per- 
ceptible emphysema in the loose areolar tissue along the 
inguinal canal. Two days later the patient was swollen 
with an emphysematous edema along the ventral surface 
of the body as far forward as the elbows. Death oc- 
curred a few hours later. I have had similar results from 
operations upon fistula of the withers where soiled pack- 
ings were injudiciously allowed to remain sewed up too 
long. These infections are wound-packing infections, and 
must be reckoned with in wound treatment. 


- The best wound packing is sterilized oakum, sterilized 
by boiling and not alone with antiseptics. Oakum is bet- 
ter than cotton for this purpose because the latter stub- 
bornly mats into raw tissues and stays there for two or 
three days. An oakum pack comes out en masse, leaving 
no particles behind. 


ES ee 


a ee —————EEeEE 


SS ee 


TREATMENT OF WOUNDS 89 


For wicks to act as drainage in counter openings, or in 
the lower commissure of wounds, sterilized antiseptic 
gauze is most suited. Drainage tubes should be boiled 
before being fixed into a wound. : 

Protective Dressings as Conveyors of infection 

Bandages, absorbent cotton, oakum, collodium, dust- 
ing powders, and wound varnishes are the objects used 
as protective dressings. The truth about wound treat- 
ment in this connection is that a wound closed without 
having been infected in the process of treatment is not 
apt to become infected later. Postoperative infection I 
know is often a very convenient cloak to cover up oper- 
ative infection. The castrator, in all the seriousness of a 
minister, chastises the owner of a dying colt for having 
allowed it to inhabit a dirty stall when in fact the infec- 
tion responsible for the stricken animal’s condition was 
deposited with his own hands or his own unsterilized or 
half-sterilized emasculator, at the time of the operation, 
and this example explains the mystery of nearly all our 
wound infections. 

Collodium, dusting powders, and wound varnishes sel- 
dom convey infections because they are clean, antiseptic, 
and drying. Bandages and cotton, however, placed over 
a wound, require attention as infection carriers. I ama 
believer in antiseptic wraps for wounds, and depend 
upon aseptic wraps only when renewal is frequent. An 
aseptic bandage that becomes soaked with wound serosity, 
or that holds wound discharges against the skin around 
a wound, is not so good as one that contains iodoform, 
mereury, or carbolic acid, because the serum in such a 
bandage does not putrefy as soon as in an aseptic wrap. 

It is our practice to dust a powder of iodoform, bis- 
muth subiodid, or boric acid over the wound and then 
cover this with cotton and a bandage soaked and rinsed 
* out of mercuric chlorid solution (1 to 200). With these 


90 WOUND TREATMENT 


simple precautions protective dressings are deprived of 
all harm. 


The Surgical Field as a Conveyor of Infection 


A good liberal zone around a wound or proposed seat 
of a wound must be submitted to the classical cleansing 
process, now regarded as standard for this purpose. It 
consists in washing with water and soap, clipping, shav- 
ing, rinsing, and rubbing briskly with mercuric chlorid 
(1 to 500), and then painting with tincture of iodin. 
This does not positively sterilize the skin of a hairy ani- 
mal, but it combines the best means of producing the 
safest possible field for a cutting operation. 

The surgical field conveys infection during the opera- 
tion by being directly at the wound, and after the opera- 
tion by the growth of bacteria on the serum-soaked skin. 
It is therefore evident that any laxity or omission here 
1S serious. 


Postoperative Conveyors of Infection 


As mentioned in the foregoing paragraphs, postoper- 
ative infection is not so common as is generally supposed 
or, better still, not so common as the surgeon would have 
his clients believe. That there are postoperative infec- 
tions is of course admitted, but the search for causes will 
usually be more successful if the operative methods are 
serutinized. 

It is, however, plain that the same careful handling of 
everything that prevailed during the operation must be 
continued during the after-care, especially during the 
first’ four days. It is a misfortune to be compelled to 
turn over the after-care of wounds to untrained hands, 
but if we plan our after-care with this in view we can 


: TREATMENT OF WOUNDS 91 


generally succeed in keeping our really aseptic wounds 
from harm. 


e 


The postoperative conveyors are the patient’s bed and 
stall and the attendant’s hands, syringes, solutions, pow- 
ders, and dressings. 

The patient’s habitat is made safe by keeping the 
wound covered, keeping the patient in the standing posi- 
tion, and keeping up a sensible state of cleanliness in 
the surroundings. 

The handling of wounds by attendants should be 
avoided. They might be entrusted with the dusting of 
powder on a sutured wound, applying a clean piece of 
gauze or cotton and wrapping a bandage over all, but 
this is as far as any untrained hands should be trusted 
in the treatment of aseptic wounds. A wound requiring 
irrigation and renewal of drainage wicks or tubes re- 
quires also the intelligent assistant or surgeon, as these 
means are sure to infect. 

Syringes and solutions in wound treatment should be 
given into the hands of others only in the treatment of 
suppurating cavities where refinement is unnecessary. 

I would summarize the plans of handling the various 
conveyors of infection as follows: 


1. Operate in an atmosphere that is free from dust, and prevent 
objects from being whirled about by the patient. Avoid 
loose bedding, and moisten the patient to keep the hair 
from flying. 

2. Boil instruments for fifteen minutes and so handle them dur- 
ing the operation as to prevent contamination. Call for 
other instruments to replace those soiled. 

3. Avoid touching the wound with the fingers. Use tissue for- 
ceps, tumor forceps, and needle holders. It is seldom neces- 
sary to touch wounds with the fingers. When digital work 
is necessary, wash the hands, rinse them in mercuric chlorid 
(1 to 500), and coat the finger tips with tincture of iodin. 

4. Use only sterilized water and sterilized basins. 

5. Prepare a large surgical field in the manner above recom- 

- mended. 

6. Use sterilized sutures and bathe them in tincture of iodin. 

Keep them from trailing over the dirty body. Handle them 


92 _ WOUND TREATMENT 


with the needle holder, or else wear sterilized, skin-tight 
gloves while suturing. 
7. Protect wounds with antiseptic dressings instead of aseptic. 
8. Attend yourself to the after-care of wounds instead of trust- 
ing it to untrained hands. 
9. Prevent wounds from coming into contact with the stall, bed- 
ding, or ground. 


Classification of Wounds 


The time-honored custom of classifying wounds into 
incised, lacerated, punctured, and so on, although almost 
consecrated by usage, serves no useful purpose and might 
therefore be entirely discarded in the study of wound 
treatment. These names reflect only the character of the 
causative instrument, and that without giving a hint 
about the particular treatment they might require. As 
a basis for a detailed description of wound treatment 
these names are useless unless prefixed with simple, per- 
_ pendicular, complex, superficial, oblique, deep, trans- 
verse, soiled, mutilated, sheltered, venomous, or some 
other descriptive adjective that would indicate oe plan 
of management. 

Take for example an incised wound, the basis of nearly 
all surgical operations. That it was made with a sharp 
instrument is less important in the treatment than the 
fact that it was made with a dirty knife, that its direction 
is such that it cannot be drained, or that it is located in a 
place where muscular movements cannot be controlled. 
These are a few of the elements that call for special man- 
agement of animal wounds, and it is upon these that a 
classification should be based. 

The classification that appeals most to the writer is one 
which at once indicates a particular plan of manage- 
ment, as follows: 


1. Aseptic incised wounds; wounds without loss of tissue or in 
which the loss is not great. 
2. Wounds with loss of underlying tissue which can be bridged 


—” 


: TREATMENT OF WOUNDS 93 


over with the skin-and whose cavity can be drained by 
gravitation of the discharges. 

3. Wounds that cannot be drained by gravitation of the dis- 
eharges. Open wounds. 

4. Venomous wounds. 

5. Punetured wounds. 

6. Gun-shot wounds. 


Aseptic Incised Wounds 


These are always surgical wounds, made in a prepared 
field with a sterilized knife and touched only with steri- 
lized objects—sponges, hands, solutions, and. so on. In- 
cised wounds accidentally inflicted. must never be placed 
in this category, as the sickle, razor, scythe, saber, or dag- 
ger capable of inflicting them are not aseptic and there- 
fore soil the tissues in the process of making.’ Although 
' these instruments may seem clean, they are actually 
poisonous in many instances, depositing infections. that 
make the wound behave badly, and when closed with 
sutures with no provisions for drainage they may often 
end in a threatening if not fatal septicemia. ai 

-TREATMENT.—The handling of this class of aoa is 
indeed. very simple. The first step is to close them up 
completely with sutures so arranged as to bring and 
maintain perfect apposition of all of the integuments— 
skin, fascia, and muscle. Hach integument—usually only 
the skin is involved—is brought into very accurate con- 
tact without, however, tightening any part. sufficiently 
to cause stitch necrosis. Sutures that havebeen boiled 
fifteen minutes and then bathed in pure tincture of 
iodin are the only sutures we use for this purpose. As 
we have previously mentioned, these are recommended 
because they are seldom soiled in’ the handling. 

_ The second step is the protection against infection dur- 
ing ‘the succeeding seven or eight days. The best method 
is a varnish of collodium applied layer after layer as 


94 WOUND TREATMENT 


soon as the wound and environs can be dried of blood 
and moisture. Collodium serves the double purpose of 
protecting against soiling and of supporting the sutures. 
On the limbs where bandaging is feasible, smothering 
such a wound with iodoform or bismuth subiodid, pure or 
mixed with boric acid, is a still better plan than the 
appheation of a wound varnish. The powder should be 
held against the wound with cotton. As bandages are 
apt to bind or become disarranged, the dressing can 
be renewed every second day without, however, disturb- 
ing the sutures or the powder encrusted around them. 
The redressing amounts to a renewal of the powder 
that falls off when the cotton is removed. The delicate 
fibers that will eventually mature into a firm union of 
the two edges are not to be disturbed by any handling, 
for if these are once broken there will be no primary 
union, even if there is no infection. 

During these days special efforts are made to provide 
against mechanical injury due to the patient’s lying upon 
the wound or rubbing it against the stall, or from move- 
ments of the limbs and body. This can usually be done 
in large animals by simply preventing decumbency for 
eight days. It is impossible to protect a wound against 
the strong movements of a horse’s getting up and lying 
down, no matter where the wound is located about the 
limbs and trunk. 

The standing position for horses, and strong thick 
wraps for small animals, is the best we can do to provide 
against mechanical injury. 

Between the seventh and the tenth days the sutures 
may be removed. Sutures that are doing no good because 
of having eut through one edge should be removed at 
once, but otherwise hasty removal is inadivsable. Ten 
days is often soon enough to remove sutures of the skin 
over the large muscles (buttocks and shoulders). At 


TREATMENT OF WOUNDS 95 


ten days the wound varnish or powder used to protect 
the wound will be desquamating and can easily be re- 
moved to gain a good view of the sutures. These are 
removed without pulling the outside dried part through 
the needle tract. Lifted from the surface with the tissue 
forceps, they are cut with the scissors and then pulled 
through from the other side. 

The aseptic incised wound is now healed. It requires 
no further attention. What a goal to strive for! What 
a reward for good work! And what a wonder it is not 
oftener sought! To find a wound healed when the sutures 
are removed is a good surgeon’s pride. To have them 
‘‘kick up’’ is a nightmare—a reflection on his cautious- 
ness, his skill, or even his knowledge. 


Wounds with Loss of Underlying Tissues 


This type of wounds, that can be bridged over with 
the skin and whose cavity ean be drained by gravitation 
of the discharges, is one of the very commonest encoun- 
tered in veterinary practice. It is much more common. 
than the incised wound without loss of substance. This 
class includes the wound of many surgical operations 
as well as almost all of the accidental traumata sus- 
tained about the legs, trunk, neck, and head. Whenever 
a tumor or other object is excavated from the body the 
‘surgeon always plans to bridge the excavation over with 
the skin, or in the case of an accidental wound it is 
always desirable to bring the skin and other integuments 
into apposition over the underlying cavity. The aim 
here is to reduce corporal blemishing to the minimum 
by prompt surface healing, and to avoid the dangers of 
anaerobic infections by keeping (in surgical wounds) 
or making (in accidental wounds) the tissues thus coy- 
ered over perfectly aseptic. _ 


96 WOUND TREATMENT 


This wound distinguishes itself therapeutically from 
the incised wound because provision must be made for 
the escape of the serum that will exude from its walls, 
which would fill up the cavity to the physical detriment 
of the healing process and the decided advantage of in- 
vading microbes.. Even though a wound is aseptic it must 
never be allowed to harbor its secretions in any consider- 
able quantity. Wounds of animals filled with serum be- 
come putrid despite everything. 

TREATMENT.—If such a wound is surgical, every effort 
is made to prevent soiling of the tissues during the opera- 
tion. If any are soiled by contact with dirt or flowing 
pus, these are trimmed off with the scissors or scalpel 
rather than depending upon any form of chemical ablu- 
tion, the aim being to have at the end of an operation a 
traumatic cavity that is absolutely free from micro-organ- 
‘isms. The surroundings having been previously shaved 
and disinfected, the wound is now ready to cover over by 
suturing. An opening at the end of the cavity, or a 
counter opening especially made, is provided for the 
escape of the serosity that will exude more or less 
copiously during the succeeding week. If the orifice thus 
provided is simply kept open so that every dram of the 
discharge will flow out, there is no other treatment re- 
quired except that of maintaining a suitable protection 
of the sutured portion against external contamination 
and injury. If infection of the cavity is prevented dur- 
ing the first five days there will be less chance for any 
suecessful invasion of microbes thereafter. That is, the 
first few days, while the tissues are still weakened from 
the injury they have sustained and before a protective 
reaction has developed, is the time during which special 
care must be taken to prevent them from being inocu- 
lated with the gauze, the syringe, the fingers, or any 
object that may be needed to keep the orifiee working 


TREATMENT OF WOUNDS of 


as a drain. At the end of ten days the sutures may be 
removed, but as the traumatic cavity will require another 
week, or even a fortnight, to cicatrize, the drainage must 
be continued. In wounds whose cavities have consider- 
able size three weeks should be sufficient time to heal 
them. Infected wounds of the same size require six weeks 
to two months or even longer for healing. 

The accidental wounds of this class interest the prac- 
titioner most. They include almost every bodily injury 
that animals sustain accidentally by contact with objects 
capable of lacerating the skin and underlying muscles. 
Kicks on the buttocks, the thigh, the shoulder, the breast; 
wire cuts in the heels, the forearm, the hock; and almost 
all manner of traumatism from collisions, nearly all 
belong to this class. 

The veterinarian here is confronted with the problem 
of healing up an ugly wound often of considerable di- 
mensions, not infrequently invading the muscles deeply— 
that is, bruised, torn, and soiled. The desiderata are to 
heal the wound quickly and to leave behind as little 
blemish as possible. The ugly scars that mar the bodies 
of so many splendid horses attest the poor initial treat- 
ment such wounds have received. 

I am bearing fully in mind the obstacles that con- 
front the country practitioner arriving on the scene of 
such an accident. The patient is often intractable, the 


- surroundings are not inviting, help is scarce, and last 


but not least the character of the work required to give 
the wound a strictly refined treatment is not compre- 
hended by those in charge. ‘‘I guess you had better sew 
it up, doc,’’ is the usual idea of the treatment required. 
There is seldom any conception of what this suggestion 
entails if followed out in strict accordance with the rules 


of modern surgical procedure. 


With this prevailing notion of things the rent is 


98 WOUND TREATMENT 


usually patched up with needle and thread after a per- 
functory ablution with an antiseptic solution. Four days 
later it is an open wound again, more seriously and more 
deeply infected than if it had been left entirely to the 
mercies of nature. To change this order of affairs is now 
our serious duty, and in view of the fact that it is exceed- 
ingly easy to show the difference between good wound 
treatment and poor wound treatment the objection to put- 
ting a stiff initial cost on the treatment of such a wound 
will not be long lived. We have done it in a city prac- 
tice and I am sure the country practitioner can do 
likewise. | 

Formerly we treated accidental wounds of all kinds, 
except enormous ones, in the stables. We secured the 
patient with the twitch and sideline, washed the wound, 
sewed it up after more or less of a running fight with 
the patient, and then applied whatever protection best 
suited. In the usual four or five days we were always 
called again to do the work over. ‘‘The stitches have 
broken out,’’ was the usual ery. Sometimes a second at- 
tempt at closure was made, but more often the dangling 
skin was trimmed and open-wound treatment applied 
during the remaining long process of cicatrization. In 
such cases there was the cost of the first treatment; of a 
number of periodical visits during the succeeding six 
weeks; of antiseptic lotions, astringent lotions, and pow- 
ders, without accounting for the costly days of disability. 

To-day we bring such patients to the hospital, devote 
two or three hours to the initial treatment, keep the 
patient in the hospital eight days, and usually return it 
to work at the end of two weeks, or in three in cases of 
extensive wounds. In the former cases the sear was large, 
indelible, conspicuous; in the latter there is often no 
plain evidence that a wound has ever existed. The cost 
to the client is about the same in both cases, but in the 


TREATMENT OF WOUNDS 99 


latter the money is earned by skill while in the former 
it was not earned at all; the patient would have been 
about as well off without any expert (?) interference; 
common everyday home treatment would have done just 
as well. In the former the patients were marred for 
life, while in the latter their full value is restored. In the 
former the patients were disabled two months, in the 
latter two to three weeks. Our plan of handling acci- 
dental wounds of the body is as follows: 

1. Restraint.—Even tractable patients always put up 
a pretty vigorous opposition against interference with a 
wound recently inflicted. They especially object to the 
suturing, and as wounds are often located where there 
is danger of the veterinarian sustaining personal injury, 
it is difficult and tedious to carry out the treatment 
without some form of effectual control. Much the best 
plan is to use the operating table. Removal to the hos- 
pital should be insisted upon where the distance is not 
too great. Here the patient will be well controlled and 
well positioned to carry out every detail from beginning 
to end. For outdoor work the standing position will be 
found better than casting harnesses. In the latter 
- almost every wound is in an awkward position near the 
ground, difficult of access and in tiresome position for 
the operator to work so long. Some form of improvised 
stocks to keep the patient from lunging about, supple- 
_ mented with a sideline or breeding hopples, may be made 
to answer the purpose. Then the operation may be made 
less painful by wiping the internal surface of the skin 
with two-per-cent cocain solution as far from the edges 
as the needle points will be located. This will greatly 
but not entirely control the pain of suturing. This same 
form of anesthesia may also be used-when the patient is 
secured on the operating table. It prevents annoying 
struggles which raise dust and otherwise interfere with 


100 WOUND TREATMENT 


the work. Respiratory anesthesia is not applicable be- 
cause the operation is of too long duration. 

For wounds on the legs we have found the casting har- 
ness better than the standing position because the legs 
are never well immobilized standing, and the surgeon 
is forced into a very uncomfortable bending position, par- 
ticularly if the wound is about or below the knees. or 
hocks. 

In every form of recumbent restraint some care must 
always be exercised in letting the patient up without 
inflicting violence to the sutured wound. The forcible 
movements of the legs may stretch a sutured wound wide 
open by tearing either the sutures or the skin in which 
they are inserted. In taking from the operating table 
a horse that has just been sutured about the buttock, or 
which has been operated for shoe boil, we always keep 
the foot of the affected leg in the hopple until it lands 
safely to the floor and supports weight. Otherwise a 
swing might do much harm. For wounds of the legs 
treated in the casting harness ample protection can al- 
ways be given against such injury by using plenty of 
bandaging material, and by helping the patient promptly 
to its feet without unnecessary struggles. 

2. DISINFECTION.—We always try to begin this part of 
the treatment before securing the animal, by giving the - 
body a thorough cleaning. Dried mud on the legs, 
feathers, and abdomen must always be curried and 
brushed off. Otherwise a veritable halo of dust will 
cloud the whole atmosphere when the patient is strug- 
gling during the operation. A good brushing and then 
a wiping of the whole body with a wet towel are essen- 
tial. A preoperative bath where there are accommo- 
dations for such treatment would of course be better, but 
as animal bathrooms are not usually available, the above 
method of cleaning must answer the purpose. 


TREATMENT OF WOUNDS 101 


The patient once secured, the first step is to shave the 
region about the wound. A good liberal field is shaved, ' 
not merely a narrow strip along the edges. As shaving 
requires previous washing of the hairs to soften them, 
the wound itself will become additionally soiled in this 
process by the lather and hairs falling into it, but as 
subsequent treatment will attend to this, little harm will 
be done. It is, however, not advisable to be unduly care- 
less in this matter. By shaving first a narrow strip along 
the margin, drawing the razor away from the edge, much 
of this hair-soiling may be avoided. MHair-soiling can 
also be prevented somewhat by wadding the cavity with 
cotton while the shaving is being done. 

In a large wound this shaving is no small undertaking, 
but in no case must it be omitted or slighted on that 
account. 

The next step is to disinfect the shaved skin. Brisk 
friction with mercuric chlorid solution (1 part to 500 of 
sterile water) comes first, then it is painted with tincture 
of iodin, or, what is still better, a solution of iodin erystals 
in ether. Two drams of iodin to one pound of ether is 
the solution we are now using for skin disinfection. It 
seems to assure a better skin disinfection than does the 
aleoholic solution. It penetrates into the recesses of the 
skin better than the tincture, and thus effects a deeper 
disinfection. 

The surroundings having been thus prepared, atten- 
tion is now directed to the raw tissues. Here we find 
torn muscle tissue, shreds of fascia, nerves, vessels, sub- 
cutaneous areolar tissue, all more or less soiled. Every 
part of this motley surface is infected and there is no 
way of disinfecting it with chemicals if the wound must 
be closed. Strong disinfecting chemical substances that 
would be capable of killing the microbes now harbored on 
and within this anfractuous surface would also cauterize 


102 WOUND TREATMENT 


it and thus produce a lot of debris that would have to 
be east off by the healthy elements beneath. Such treat- 
ment is of course out of reason where the cavity must be 
bridged over with the skin. Ordinary antiseptic ablu- 
tions are inadequate; they never actually disinfect any- 
thing. Every attempt we have ever made to bring this 
surface of wounds into a safe state for suturing with so- 
lutions has ended in disappointment. Disastrous suppu- 
ration ensued and primary union of the skin was pre- 
vented in every case. So uniform was this result that 
we, like many others, fell back on open-wound treatment 
for a time as much the best and safest plan of treating 
practically all accidental wounds. It gave better results 
than the closing of wounds that were harboring infected 
tissues beneath the sutured integument. For a long time 
we only sutured accidental wounds for policy’s sake—to 
appease a request—knowing all the while it was a use- 
less procedure, and we always prepared for the inevi- 
table breaking open a few days later, at which time the 
real treatment of the wound began. 

We are now submitting such wounds to a mechanical 
disinfection we have called ‘‘uncarpeting.’’ That is, we 
trim off all of the surface sheet-like, beginning above and 
omitting nothing save possibly a synovial capsule, large 
blood vessel, or an important nerve. These are, how- 
ever, seldom encountered in wounds of this class. A 
sharp scalpel, scissors, and tissue forceps are used, and 
as the surface is loosened, the loose pieces are washed 
off by a stream of sterilized water poured from a pitcher 
_ by an assistant. The edges of the skin must be turned up 
where it is loosened from the body and its under surface 
submitted to the same trimming. Where there is nothing 
loose to trim off, the wound is scraped with the scalpel 
as the stream of water washes off the scrapings. The 
edges of the skin must be included. Sometimes simply 


TREATMENT OF WOUNDS 103 


scraping them, at other times trimming them straight 
with the scissors, may be thought best, depending upon 
their condition. 


A wound thus mechanically disinfected is a pure 
wound, as aseptic as a wound of the surgeon’s own mak-_ 
ing, and it has a large, clean, disinfected field around it. 
In short, it is a fit wound to close up, and if closed prop- 
erly it will behave in the manner that will please. 


The wound cavity, having thus been ridden of all 
microbe-laden tissues, is a safe cavity to bridge over with 
the skin, but to prevent subsequent contamination provi. 
sions must be made to prevent accumulation of the serum 
that will exude from the walls. That is, the cavity must 
be drained. Serum must not be allowed to remain even 
momentarily in a wound cavity, for if this microbe food 
is offered, putrefaction of the serum, followed by infec. 
tion of the living walls, is sure to follow. The certainty 
with which microbes creep into favorable places for their 
esrowth is now well known to students of aseptic surgery 
The favorable environment is as certain a source of in- 
fection as manual soiling. Mutilated, bruised, weakened 
tissues are prey for microbes, and when these are soaked 
in a serosity a few otherwise innocuous organisms may 
soon develop a formidable infection, while strong and 
only slightly injured tissues would destroy them. In 
short, when we create a favorable medium and an incu- 
‘bator, the microbes are usually there to do mischief, 
while on the other hand if we create unfavorable soils 
for microbian growth infections become negligible. 
These are laws in wound treatment, and they must be 
obeyed as sacredly as the laws relating to the sterilization 
of infection carriers, bands, instruments, and so on. 
Whether these infections of bruised wounds are endoge- 
nous or exogenous is less important to the practitioner 


104 WOUND TREATMENT 


than the fact that they are very certain to occur in a 
large percentage of cases. 

To better illustrate this point, the prevailing contro- 
versy in the medical profession over the open treatment 
of fractures might be mentioned to advantage. During 
the last few years the old, time-honored method of treat- 
ing fractures of long bones by simple reposition and 
retention has been discarded by many surgeons for the 
new open method. That is, an invading incision was 
made into the traumatic cavity and the segments fitted 
together and retained with screws, nails, or plates. With 
asepsis as a protection against complications, it at first 
seemed this apparently sensible method would soon be- 
come the universal one for the treatment of fractures. 
Subsequent developments, however, proved that the plan 
was not entirely harmless. Many cases became infected 
with disastrous results. Why? Because a fracture with 
its injured tissues, blood-clots, outpoured serum, and im- 
paired circulation is a favorable field for infection. 
To-day, on this account alone, the open method is being 
abandoned except in special cases. In veterinary prac- 
tice the wound of castration might be used to illustrate 
the same point. The crushed spermatic cord, the aeeumu- 
lated clot and serum, and the closed incision combine 
conditions especially favorable for microbian growth. In 
fact, if any bacteria are deposited they are prone to 
develop a serious infection very rapidly. 

We must, therefore, plan as perfect a system of drain- 
age as possible in all wounds of this class, for otherwise 
our other good work will be useless. During the trim- 
ming process—that is, the mechanical disinfection re- 
ferred to in the preceding paragraph—special care is 
taken to groove channels toward the proposed drainage 
orifice. This done, the skin fiap is ready to be sutured. 


TREATMENT OF WOUNDS 105 


Suturing the Skin Flap 


At this stage of the procedure the veterinarian should 
don a pair of sterilized skin-tight gloves or else handle 
needle and thread with the needle-holder, with the aid of 
an assistant to keep the dangling end from trailing 
about over soiled places. ‘T'he former method—the wear- 
ing of gloves—is the better, because suturing can then 
be done much faster and also more accurately. The first 
effort is to baste the flap with crucial sutures arranged 
somewhat loosely and about one inch apart, some care 
being taken to bring the flap to the place it actually 
belongs in order to prevent wrinkling and to avoid ten- 
sion. This basting process is of great importance, be- 
cause if it is well done the rest is a mere routine. The 
edges themselves are not yet approximated; there is a 
gap along the entire flap. An accurate approximation is 
now effected with interrupted sutures placed one quarter 
of an inch apart and about three sixteenths of an inch 
from the edges. Every fourth or fifth stitch of these 
interrupted sutures is made longer—about a quarter of 
an inch from the edges, or even more. The latter sutures 
are retaining sutures, like the crucial sutures, while the 
short ones are the real approximating media. The short 
sutures tend to prevent the infolding of edges that is sure 
to be produced by the longer ones. Infolding of the 
- edges must be corrected at every point, as union is impos- 
sible unless the raw edges are brought into contact. 
Every part is thus closed up except the place planned 
for the drainage orifice. The size of the orifice or counter 
opening specially made must harmonize with the size of 
the traumatic cavity. A large wound will require a 
larger opening than a small wound, because a free outlet 
is essential. 


106 WOUND TREATMENT 


In the short, interrupted sutures, which only pinch up 
the very edges of the skin, lies the secret of success. The 
greatest error of suturing wounds of anmals seems to 
have been that of putting in long wmterrupted sutures. 


These prevent union by blocking the circulation, while. 


the short sutures, which pick up only little bits of skin, 
permit the circulation of the blood freely to the very 
edges, where it is most needed. ¢ 

The wound is now well repaired, and the skin flap is 
neatly approximated to the other edge of the wound with- 
out stretching. That is, there is no strain on the flap; 
it lies comfortably in the place where it properly belongs. 
There is, however, still some danger of damage from 
movements of the underlying muscles, despite this perfect 
apposition of the edges of the skin. This danger we re- 
duce to the minimum by fixing the skin down to the 
body with Mayo’s running loop, put in from one to three 
inches apart, according to the amount of strain to which 
the flap will be subjected by movements and edema. On 
prominent convexities of the body, such as buttocks or 
shoulder, there will be more strain than in flat places like 
the forehead or costal surface. In the former these loop 
sutures are placed close together; in the latter, they may 
not be needed at all. It is our judgment after several 


years of trial, in many wounds treated, that the resort — 


to the use of Mayo’s running loop is the greatest boon 
to wound suturing in animals. Without them we have 
failed even when everything else was done well and con- 
ditions were favorable. Since resorting to them we sel- 
dom fail to heal these wounds promptly. 

For those readers who are not acquainted with this 
special suture, and especially for those who have no access 
to literature in which it is deseribed, the following de- 
scription is given: 

‘‘Mayo’s running loop’’ is a series of continuous loops 


TREATMENT OF WOUNDS 107 


that cross the wound line at a right angle. They are 
made to extend from about three inches on one side to 
about the same distance on the other. <A full curved 
needle is armed with about two feet of single thread. Be- 
ginning say three inches from the wound line, the 
needle is passed subcutaneously or even deeper toward 
the wound, coming out three quarters of an inch from 
the point of entrance. One foot of the thread is drawn 
through. The dangling end is then tied with a double 
knot at the exit point, the knot lying upon the hole. 
Letting the end dangle again, the needle is now in- 
serted through the exit point and brought out again 
three quarters of an inch toward the wound, where 
the dangling end is again tied in the same way. These 
are continued across the wound to about the same dis- 
tance on the opposite side. The loops are not tied tight 
enough to block circulation but just tight enough to 
lie straight. When one is completed another is put in, 
one, two, or three inches away, and so on, until the whole 
field of skin is firmly recarpeted to the body. 

It is almost a physical impossibility for a skin flap so 
fixed to break away from the body. Even when active 
inflammation follows, the flap stays fixed. 

The drainage orifice, provided by leaving a dependent 
part unsewed or by making a counter-opening, is now 
wadded with an aseptic gauze wick. The first wadding 
should be tight so as to dilate the orifice. Subsequent 
waddings must be more loosely arranged to allow outflow 
of discharges. 

We now ‘‘touch up’’ the sutures along the wound 
with tincture of iodin and then varnish the whole field 
with four or five successive layers of collodion. These 
thick applications of collodion play an important role in 
supporting the sutures, and they also afford a perfect 
cloak to keep out external soiling. 


108 WOUND TREATMENT 


The patient must now be placed under restraint that 
will protect the wound against injury. Standing for 
ten days is always a part of this restraint, as there is no 
way to prevent stretching, tearing, and bruising a wound 
if the patient is allowed freedom. If the wound is lo- 
cated around the hips, thighs, hocks, buttocks, or croup, 
switching the tail must be prevented by sacking or tying 
it to one side. For wounds about the forequarters, 
neck, or head, it is best to back the patient into a single 
stall, fasten the head on the pillar reins, and feed from a 
hammock. Slings may sometimes be thought necessary 
to assure the desired state of repose that makes for good 
healing. ; 

The after-care of the wound consists of daily attention 
to the orifice. This must be kept from damming up the 
discharges. A loose wick pushed up two or three inches 
is the best way to keep the drain working well. 

At the end of ten days the collodion will be shedding. 
It will be found adherent here and there, but easy enough 
to remove by passing blunt scissors beneath it. The 
sutures are now removed along the edges, and if it is 
found there are some places not united, the loops are 
not disturbed for several days more. 

If there is any doubt about the firmness of the union 
the patient must be kept in the standing position until 
the danger of breaking open the wound has passed. In 
twenty days such a patient is usually ready for the har- 
ness. A longer time may, however, be required where 
the traumatic cavity was large or when the wound is 
located at a flexion surface. 

The reader might also be reminded that the treatment 
of such a wound is never complete without the adminis- 
tration of an immunizing dose of antitetaniec serum. The 
closing up of a wound of this character creates a tetano- 
genic field, and as this certain preventive is available, 


5 TREATMENT OF WOUNDS 109 
we are not justified in depending entirely upon our 
mechanical disinfection to prevent tetanus. 


Wounds That Cannot Be Drained by Gravitation of 
the Discharges—Open Wounds 


This group includes both the surgical and the acciden- 
tal wounds located at the summit of a region. The trau- 
matic cavity points upward and its bottom is too far 
from the surface of the body to drain downward. It 
includes the surgical wound of radical poll-evil opera- 
tions and some operations for fistula of the withers, quit- 
tors, and all the accidental wounds of the back, loins, 
croup, and heels. Almost all other wounds besides these 
can be drained and treated by the method previously 
deseribed. The surgical wounds of this kind are often 
invasions of badly infected places, but the aim of the 
operation in each case is to remove en masse the microbe- 
laden structures. 

Thus in poll evil, although we start with a badly 
infected mass of tissue and tracts carpeted with infected 
eranulations, when the operation is properly done all of 
these are safely removed and the cavity resulting, if not 
entirely sterile, is in a fairly good state for the easy 
destruction of the infection that remains. The same 
may be said of all operations of this character. The 
operation itself is the mechanical disinfection needed to 
promote healing, and the performance of the operations 
must be carried out with this end in view, for if we leave 
our surgical wounds, made in infected structures, with- 
out disposing of the original infection, or deposit more 
in operating, these wounds will be difficult to manage. 
They will heal slowly. The fact that we are operating 
upon infected structures is never an excuse for unclean 
surgery. These operations should be as clean as those 


110 WOUND TREATMENT 


made in perfectly sound flesh, and in working through 
such operation we should keep in mind that the desired 
goal is to leave at the completion of the operation an 
aseptic traumatic cavity. With this accomplished, the 
subsequent management consists of disposing of the dis- 
charges which gather in the cup-like cavity as fast as 
they accumulate. What gravitation does in the wound 
previously described, we must now do by absorption. 
A large traumatic cavity will pour out an enormous 
amount of serosity between the second and fifth days. 
To dispose of this accumulation during these days is 
the prime factor in the treatment of such wounds, and 
as the healing period will be materially shortened if 
infection is controlled it is well worth while to work dili- 
gently at the task of absorbing discharges during this 
period—the first five days. Thereafter, as the exuda- 
tion will gradually diminish and the walls will have pro- 
tected themselves against invasion, this diligence may be 
somewhat relaxed. It is, however, well to keep all wound 
cavities as dry as possible until they are level. 

The best method we have found to take care of dis- 
charges in large cavities is by smothering them with borie 
acid and iodoform (95 to 5 per cent). The cavity is filled 
with this powder, and it is renewed three times a day 
if it becomes soaked. While this vigilance may seem to 
be considerable trouble, it is always rewarded by prompt 
healing, and is much less trouble than that almost im- 
possible task of handling the copious flow of pus over 
the surface of the body, sometimes encrusted an inch 
thick from withers to heels, constituting about the most 
unsavory postoperative condition imaginable. The diffi- 
culty in handling this latter condition is enormous com- 
pared with the little trouble necessary to prevent occur- 
rence by diligent, initial attention, lasting four to five 
days. Furthermore, traumatic cavities of this nature 


TREATMENT OF WOUNDS ele Ta 


that are not allowed to become infected, never overfill 
with exuberant granulations—when the cavity is filled 
the granulations are already maturing into firm tissue. 

The use of gauze for the purpose of absorbing secre- 
tions in wounds that cannot drain has not given us the 
same satisfaction as the absorbent powder above men- 
tioned, and is applicable only in small wounds and espe- 
cially in wounds of small animals. 

Borie acid will take up large quantities of eid 
discharges and may be depended upon to preserve from 
putrefaction any serum it thus absorbs, while iodoform, 
kept continuously in contact with the walls of a wound 
cavity, will disinfect them better than any other known 
chemical, 4 

In accidental wounds of this group the piacbones 
should choose one of two lines of treatment. The first 
begins with mechanical disinfection as described for 
wounds preparatory to closure and is followed up by 
keeping the wound aseptic with boric acid and iodo- 
form while the cavity is filling up. If the granulations 
threaten to overgrow, there is nothing better to control 
them than piain white lotion. 

The second method begins with a disinfection with a 
strong chemical substance that will not only destroy the 
microbes but will also cauterize the tissues into a firm 
protective coating of dead elements. Both of these plans 
are good because each first disposes of the surface infec- 
tions that would soon do mischief. The former is the 
more refined, the latter the more practicable for veteri- 
narians. Whenever a veterinarian cannot or will not 
for any reason surgically disinfect an accidental wound 
that he decides to treat as an open one, he should apply 
to it a chemical substance that will do something and 
not merely delude himself into believing that any ordi- 
nary antiseptic wash will be of material benefit. Strong 


112 WOUND TREATMENT 


proprietary liniments often gain wide reputations as 
wound medicines because they are actually germicides. 
The fact that they temporarily retard healing by cauter- 
izing the surface is in their favor because they destroy 
everything they touch, and because they produce a leath- 
ery coating that gives protection against subsequent in- 
fection. Wounds thus treated escape the surrounding 
phlegmonous condition of infection, and when the eschar 
desquamates, the cavity is found paved with a layer of 
rosy, healthy granulations that need but little further 
attention beyond a weak antiseptic powder or mild 
astringent. : 

What chemical substance should the veterinary prac- 
titioner select for this purpose? In other words, what 
is the best application for an open wound? Pure 
phenol, butter of antimony, and chemically pure nitro- 
hydrochloric acid are strong substances to consider in 
this connection, but they are exactly the kind of chem- 
ical to use. Applied with a brush, with precautions 
against overflow, these substances will do no harm. A 
little discretion to avoid the cauterization of synovials, 
nerves, and large blood vessels should of course be prac- 
ticed in the use of such radical measures, just as the 
surgeon would avoid cutting these with the scalpel. 

A good lotion, less potent than the above but one that 
will, however, answer the purpose, consists of one ounce 
of permanganate of potash and two ounces of sulphate of 
zine, dissolved in a quart of water. This can be applied 
two or three times daily until perfect disinfection is 
assured, or a wad of cotton, soaked in the solution, may 
be bound to the wound and renewed frequently. 

Kerosene is a mighty good disinfectant of raw sur- 
faces if applied frequently during the first few days, 
and it is perfectly safe if it does not touch the skin. 

In fine, open-wound treatment must begin with disin- 


/ 


TREATMENT OF WOUNDS 113 


fection of the exposed raw tissues. If this is not done 
surgically, in the manner prescribed for mechanical dis- 
infection, then let the veterinarian throw precedent to 
the winds and ‘‘go at’’ his wounds with chemicals that 
will do this work for him. 


Venomous Wounds 


This term is coined to meet the requirements of the 
particular scheme of treatment already laid down in the 
preceding paragraphs. By it we wish to distinguish 
wounds in the active stage of inflammation. A venom- 
ous wound is one invaded with bacteria and envenomed 
with their toxins. The term ‘‘infected wound’’ is some- 
what different, since a wound is infected as soon as bac- 
teria have lodged upon it; it is, however, not envenomed 
until these bacteria have injected it with their poisons. 
The term is used to designate that period of infection 
intervening between the time the tissues begin to react 
against the bacteria and their poisons and the final cessa- 
tion of the active inflammation. In short, it applies to 
all wounds in the siege of active inflammatory processes. 
When the inflammation subsides, cicatrization proceeds 
normally, unless there is some permanent damage done 
to a bone, a tendon, a ligament, a cartilage, or an un- 
drained cavity has formed. These events may cause a 
chronic suppurative process—a fistula. When the active 
inflammation ceases, or a chronic state of suppuration 
supervenes, the term ‘‘venomous wound’’ no longer 
applies. 

When a wound is soiled (infected) and before there 
is any inflammation—that is, during the first twenty- 
four or even forty-eight hours—we have recommended 
the unceremonious trimming off of the bacteria-laden 
tissues. That is, we have advised the immediate crea- 
tion of an aseptic wound from a badly contaminated 


114 WOUND TREATMENT 


one. ‘To resort to the same measures in a venomous 
wound would be an error fraught with much hayoe. 
Surgical interference with a wound in the active stage of 
inflammation (a venomous wound) is capable of doing 
harm by opening up new channels for invasion and thus 
exciting rather than subduing the inflammatory process. 
The mechanical disinfection — uncarpeting — previously 
referred to for soiled wounds is not recommended in the 
treatment of venomous wounds. When bacteria have 
already injected the tissues with poisons and have them- 
selves invaded more or less deeply into the tissues, me- 
chanical disinfection is no longer indicated. That is ta 
say, when a wound already shows a pronounced local 
reaction of swelling, pain, redness and probably a sys- 
temic febrile reaction, it is too late to transform it at 
once into an aseptic wound. We must now manage it in 
another manner. Radical extirpation or amputation 
may be called for when a venomous wound actually 
threatens life, but such measures are rarely expedient 
in animal surgery. 

The evacuation of purulent collections, from the hot- 
bed of the infected center, and the trimming off of ele- 
ments actually dead, are the only surgical treatments 
to which a venomous wound should be submitted, and 
_ these measures should be carried out carefully so as to 
inflict as little injury to the inflammatory surroundings 
as possible. If we meddle too much with an inflamed 
wound a more and more serious state is produced. An 
aggressive attack upon an inflamed trauma is always 
harmful. When such a wound has been evacuated of its 
purulent collection and the accessible dead elements have 
been removed, the advancing process must be left largely 
to the reactive forces of the body. Antiseptie packs 
covering the wound and the swollen environs is a stand- 
ard treatment. In humans it is never omitted, and the 


: TREATMENT OF WOUNDS 115 
antiseptic, that is now receiving the most favor, is a 
saturated solution of aluminum acetate. Borie acid so- 
lutions and lead acetate solutions are also highly recom- 
mended. There is little doubt that such packs are 
_ helpful in animals as well as in human beings, but 
with us they are seldom renewed often enough to 
be of real service; when a wound is discharging copi- 
ously, they tend more to do harm than good, unless 
the packing material is changed as often as it becomes 
soaked with pus. Furthermore, the wrapping must not 
be so tight as to dam up the discharge. To apply an 
antiseptic pack upon a badly discharging foot, for ex- 
ample, and leave it to become soaked with serosity during 
the succeeding twenty-four hours, is not good treatment. 
On the other hand, if the entire covering were changed 
three or four times a day, a certain amount of good 
would accrue from such treatment. Hot antiseptic baths 
—a popular sort of treatment in the veterinary profes- 
sion—are seldom continued long enough, or done clean 
enough, to be of much service. Jn short, I doubt very 
much whether any form of local antiseptic treatment 
with solutions as they are usually used on animal pa- 
tients ever turns the course of any local infection. The 
process goes on in spite of such treatment, and the 
patient sinks or swims on its own inherent vitality. It is 
therefore evident that the best recourse we have is the 
surgical measures above recommended. For example, 
we could bathe the scrotum in cases of castration- 
funiculitis hour after hour, and day after day, without . 
any good effect, but the moment the incision is opened 
and the collection of pus drained out, the patient’s tem- 
perature falls, and it is soon on the high road to recoy- 
ery. This is the case with practically every venomous 
wound with which we have to deal; analogous cases may 
be cited ad infinitum. 


116 WOUND TREATMENT 


In discussing the management of venomous wounds, 
along this vein of non-interference, I was once chided by 
a student for performing the radical operation for infec- 
tion of the navicular sheath from a nail prick, on the 
ground that my arguments and practices were discrep- 
ant. When the objects of this operation are analyzed, 
however, it is made plain that the whole procedure is 
nothing more than the drainage of a pent-up sero- 
purulent collection in the sheath cavity. The apparent 
radical part of the operation is the invading dissection 
required to reach the hot-bed of the infectious wound. 

Wiping out venomous wounds frequently. with clean 
wads of cotton, keeping the surroundings free from desic- 
cated discharges and dusting freely and often with an 
antiseptic (non-astringent) powder I have found to be 
the best, and the most practical treatment. 

The resort to bacterins should not be ignored; the best 
surgeons are using them. In one of the largest surgical 
clinics in Chicago. a bacterin is made in every pus ease, 
and as this practice is now of some years’ standing, it is 
very evident that benefit is derived from the bacterins, 
for otherwise the practice would long since have been 
discontinued. 

Whenever suppuration continues beyond the active in- 
flammatory stage, after all local and systemic phenomena 
attending the process have ceased to exist, then the 
wound treatment must be directed toward the underlying 
cause. Foreign bodies, sloughs, sequestra, exposed liga- 
ments, tendons, cartilage and tooth roots, channels be- 
tween layers of muscles, or outer integument extending 
in a downward direction, are a few of the many things 
capable of perpetuating a suppurative process. It is the 
surgeon’s duty to ‘‘hunt these out’’ and to correct mat- 
ters whenever any of these elements are found to exist. 

Treating suppurating tracts day after day and week 


TREATMENT OF WOUNDS ny 


after week with antiseptic infections is useless, until the 
cause of the suppuration is removed. This, of course, 
is elemental and well known, but is well worth repeat- 
ing. Sometimes it is not advisable to operate too early 
after the acute inflammation has receded because the 
process of sequestration may not have progressed far 
enough to enable one to cut out all that will eventually 
amputate itself from the living tissues. Thus a suppura- 
tion supervening a calked coronet points to quittor, but 
if we operate at once there is found no guide to the 
area of necrosis in the cartilage. After a little procras- 
tination the necrotic area will become distinguishable 
from the healthy surrounding and can be removed suc- 
cessfully. The same may be said of suppurating 
processes due to exfoliation of bone particles. If a hasty 
reaction is made, separation is not complete, and a second 
operation will be required. 

Approaching the final stage of healing, venomous 
wounds do not behave as well as aseptic wounds. The 
eranulations of an aseptic wound grow safely and evenly 
to maturity like a healthy tree, while those of infected 
wounds are erratic in their behavior. Some may become 
indolent and others exuberant. Indolent granulations 
(ulceration) are rare in animal wounds except from im- 
proper treatment—treatment that stunts them. The 
continued use of strong antiseptics or the too early resort 
to astringents (alum powders, for example) are very 
harmful to wounds. They prevent the cells from grow- 
ing toward a healthy maturity and delay healing. 
Astringents are not indicated until the granulations are 
level with the surface of the body; then they are needed 
to prevent the formation of a protruding scar. Com- 
mon white lotion or white lotion with the addition of a 
small amount of copper sulphate is hard to improve upon 
as an astringent for the last stages of sclerogenesis. 


118 WOUND TREATMENT 


Methylene blue, tannic acid, or alum are also effectual, 
but these are not indicated in eavities. They do no 
2ood in such locations and often do much harm. 

The growing custom of using alum mixtures indiserim- 
inately as a stock healing powder is not good practice, as 
such strong astringents applhed to wound cavities pre- 
vent instead of encourage the formation of new tissue. 
Alum or any other astringent application is indicated 
only as above mentioned, to prevent overgrowth of 
eranulations. 

Another element of no small importance in the treat- 
ment of venomous wounds is absolute rest of the inflamed 
part. Movements of inflamed wounds is disastrous, while 
quietness is very helpful. Keeping animals tied up 
instead of giving them the freedom of a paddock; tying 
them up instead of exposing wounds to the movements 
of getting up and lying down, applying immobilizing 
bandages or leg braces, are just so many means of pre- 
venting harmful movements of infected regions. When 
a human surgeon puts a patient with an infected foot 
to bed, or places an infected hand or arm in a sling, he is 
doing a service that he knows is more beneficial than all 
the other treatment he is able to devise. The same must 
not be forgotten in the treatment of brutes that never 
show any inclination whatever to protect their wounds 
against movements or even serious violence. 

Internal treatment for venomous wounds is usually di- 
rected at the fever, the pain, the emunctories, or the 
infection itself. This calls for antipyretics, analgesics, 
diuretics, purgatives, and internal antiseptics, When a 
venomous wound threatens to be mortal, a simple line of 
such internal medical aid should be carefully planned. 
In the early stage when the pulse rate is high and the 
character full and bounding, a few doses of aconite has a 
helpful quieting effect on the circulation; later quinin 


TREATMENT OF WOUNDS 119 


in small repeated doses seems best. I have never actually 
discerned any benefit from ecchinacea or any other in- 
ternal antiseptic. Potassium iodid, in an article entitled 
‘‘The Systemic Handling of Wounds,’’ by Prof. W. L. 
Williams, is highly lauded as helpful in controlling the 
ravages of infections. Analgesics are seldom called for 
in animals. Given in sufficient dosage to allow suffering 
patients a few hours of rest, they are always apt to pro- 
duce delirium or a blunted state that is prone to do more 
harm than good by causing the animals to inflict physical 
injury to the infected region. Purgatives must be ad- 
ministered cautiously, as an uncontrollable diarrhea may 
ensue upon the administration of a purge or even an 
oleaginous cathartic in herbivora. In ecarnivora a good 
saline is always indicated, and in these animals it may 
be preceded with a cholagogue of calomel with good 
results. Among the diuretics best suited for this purpose 
is acetate of potassium given once a day during the 
period of active inflammation. As for internal antisep- 
tics for wound sepsis, ‘‘there ain’t no such animal’’ so 
far as the writer is aware. A drug that would actually 
destroy focal bacteria, inhibit their activity, or in some 
way dispose of their metabolic products, would be a 
blessing par excellence, but unfortunately agents capa- 
ble of performing this feat are yet undiscovered. 


Punctured Wounds 


A punctured wound is always more dangerous, or 
rather more treacherous, than one with a wide open 
cavity, because anaerobic infection is more grave, or at 
least more uncertain in its terminations, than facultative 
or aerobic infections. The punctured wound is also grave © 
because of the inaccessibility of its remotest point to 
direct treatment. If the bottom of a punctured wound 
could be reached for an effectual trimming that would 


120 WOUND TREATMENT 


bring out every vestige of the soiled tissue, it would be 
no more dangerous than other wounds, and when the 
invading incision required to accomplish this mechanical 
disinfection seems feasible, much the best plan of pune- 
tured wound treatment is to get right down to the bot- 
tom of things and clean out the whole tract at once. 
When this is not feasible, the tract should be opened 
as far as possible and the rest cleaned out with the curette 
and then submitted to a prolonged irrigation with a 
weak antiseptic solution or else cauterized with a ear- 
bolic swab. Cauterization should, however, never be 
practiced unless it is positively assured that the very bot- 
tom will be reached, because such treatment may actually 
form a better cloak for anaerobes that survive beneath 
the eschar. A splendid example of punctured wound 
eauterization is the application of muriatie acid to nail 
punctures of the feet of horses. If the tract is shallow, 
and the acid reaches its depth, the wound heals promptly 
and the plan (generally carried out by horseshoers) is 
given a boost. On the other hand, when the tract is 
deep and therefore only partly cauterized, a serious sup- 
purative or gangrenous inflammation is sure to super- 
vene, and if the patient escapes these, tetanus may follow 
later. 

For the punctured wounds of large dimensions pene- 
trating the large muscles of the chest, buttocks, and 
neck of animals, usually sustained by collisions \:ith 
broken stalls, fences, or vehicles, the best form of steri- 
lization is a prolonged irrigation. The tract of such a 
wound contains torn muscle, shreds of fibrous tissue, 
blood clot, and hairs and dirt carried in with the wound- 
ing object. It is impossible to manage these because of 
their inaccessible location except by washing out every- 
thing that is loose and cleaning everything that is at- 
tached, by a diligent irrigation. An attempt should be 


TREATMENT OF WOUNDS 121 


made to deposit a hose, small enough to allow reflux, 
back to the very bottom of the tract, and then with a 
fountain. syringe or hydrant irrigate the tract for sev- 
eral hours. Pure water, physiological saline solution, or 
a weak antiseptic should be used. A perfunctory treat- 
ment of this kind will not do much good, but a prolonged, 
carefully done irrigation may perfectly sterilize such a 
wound. : | 

The following case serves to illustrate: A horse sus- 
tained a puncture by a broken shaft of a single wagon, 
extending from the breast to the level of the olecranon. 
Having determined the location of the bottom with a 
long sound, a counter-opening was made through the 
skin behind the elbow. A hydrant hose was placed in 
the counter-opening and a good stream was turned on 
for four hours. Besides peppering the two wounds with 
an antiseptic powder several times a day, no other treat- 
ment was given after this one irrigation. In spite of the 
ereat dimensions of this wound there was never any sup- 
puration and the patient returned to work in exactly 
three weeks, entirely healed up. The success here was 
due to the perfect sterilization by the long irrigation. 
Whenever such irrigations are attempted, provisions must 
always be made for a free reflux of the water by using 
a hose of smaller caliber than the tract, otherwise in- 
fected material might be driven into the tissue spaces far 
beyond the original wound. 

For smaller punctured wounds that can not easily be 
mechanically disinfected, a loose antiseptic wick should 
be inserted along the whole tract and changed fre- 
quently. This may be preceded by injections of hydro- 
gen peroxide. , 

Finally, a dose of antitetanic serum is given in all 
punctured wounds to prevent tetanus. The dose should 
vary from 500 to 1,500 units, according to time of ad- 


(Oe WOUND TREATMENT 


ministration. On the first or second day 500 units will 
answer, but when the wound is older, 1,000 units to 
1,500 units will be required to assure immunity. 


Gunshot Wounds 


We shall not attempt to describe a treatment for all of 
the various wounds capable of being inflicted by fire- 
arms. Their varieties forbid in a short review of wound 
treatment, and the writer, like probably all American 
veterinarians except a few in our army who saw service 
in the Philippines, must plead inexperience. As the 
fund of information in this connection is about to be 
enlarged by the untold range of experience and observa- 
tion of our European confreres, it would be presump- 
tuous for one in my position to venture into this domain 
at this particular moment. 

In peace times veterinarians only rarely encounter 
wounds made by firearms, and when they are met they 
are generally from low-power guns or shotguns. These, 
of course, inflict wounds of a different character than 
those of high-pressure rifles used by modern armies, say- 
ing nothing of shrapnel, shells, bombs, grenades, ete., in- 
cluded in their ordnance. It is the wounds of these 
modern arms that interest us most to-day, and as peace 
may not always be our good fortune, it stands us in hand 
to acquaint ourselves with the present experiences of the 
able veterinarians of the European armies now in the 
field. 

At present I shall content myself with a few simple rec- 
ommendations. The old custom of immediately search- 
ing for a bullet imbedded in the body has long since 
been abandoned. It is only the plainly felt subeutaneous 
bullet that is removed to-day. Those lodged deeper, even- 
though they may have been located by the Réntgen 
rays, are left strictly alone to become encysted or to form 


‘ TREATMENT OF WOUNDS 123 
an abscess. In the latter event, the bullet is removed 
when the pus of the well matured abscess is evacuated. 
‘*Do not search for bullets unless they can be clearly felt 
through the skin, but leave them to the tissues where they 
will either be tolerated or expelled by suppuration.”’ 
(Cadeac.) Thus Cadeac in a word says about all there 
is to be especially said about extraction of bullets. The 
tract of the bullet is not irrigated, nor is there any effort 
made to explore its depths. Local antiseptic treatment 
of the orifice to avert secondary infection is, however, 
faithfully followed and the patient is watched continu- 
ously for febrile complication and for the abscess that 
will disclose the location of the bullet. Antitetanic serum 
is always indicated, and should never be omitted, in the 
management of firearm wounds. 


ye 


‘WOUND HEALING 
By A. T. KINSLEY, MSc., D.V.S. 


The subject of wound healing is not new. It has been 
discussed by eminent pathologists and surgeons for hun- 
dreds of years. This, like some other problems in patho- 
logie surgery, appears to especially attract the attention 
of the general medical profession periodically and spas- 
modically. Thus Lister’s principles of antiseptic dress- 
ings and aseptic surgery caused marked modifications of 
methods in wound treatment and resulted in a great ad- 
vancement of surgery. Yet Listerian principles are not 
so universally employed by veterinarians as they should 
be. The reason for the existence of this state of affairs 
is difficult of explanation. | 


- 


_ Bacterins an Aid in Wound Treatment 


Recently, following the lead of medical investigators, 
another advancement has been made in the knowledge of 
wound healing. This newer method consists of increas- 
ing the animal’s resistance to infection by the stimula- 
tion of its tissues to form specific opsonins. Opsonic 
therapy is and has been increasing the possibilities of 
surgery and rendering all major operations less 

hazardous. 


Wounds and Their Classification 


A wound may be defined as an interruption of the 
continuity of tissue or tissues. Some have restricted’ the 
term to those conditions resulting from traumatism. 
Others have confined it to injuries of soft tissues, while 


125 


126 WOUND TREATMENT 


still others maintain that wounds occur only upon the 
surface. There are no good reasons for these restric- 
tions, because thermic and chemie influences produce 
interruption of tissues which are not unlike and are not 
distinguished from wounds mechanically inflicted ; again, 
a fracture is a break in the continuity of osseous, tissue 
and is repaired in exactly the same way as is a wound 
in soft tissue; and further, a rupture, as of the liver or 
spleen, is characterized by tissue destruction and inter- 
ruption of the continuity of the integral parts of the 
injured organ, all of which are conditions not easily dif- 
ferentiated pathologically from wounds. Usually the 
term ‘‘wound’’ is restricted to those injuries that are 
produced by sudden violent action; thus ulcers and ne- 
erotic tubercular centers are not wounds. <A bruise may 
or may not be a wound, depending upon the nature of 
the lesion; that is, whether or not an interruption of the 
tissue has been effected. 

There are a variety of ways of classifying wounds, of 
which the following will serve for discussion: Etiolog- 
ically, wounds may be traumatic, chemiec, or thermic; 
topographically, wounds may be surface or subsurface, 
and again they may be facial, cervical, thoracic, abdom- 
inal, and so on. According to character, wounds may 
be incised, punctured, lacerated, contused, as produced 
by a stab, shot, or bullet, or a bite. As to condition, 
wounds may be infected or non-infected. 


How Wound Healing Is Accomplished 


Wound healing is the simultaneous regeneration of the 
tissue of an area in which there has been previous destrue- 
tion. Traumatic wounds usually heal more readily than 
wounds resulting from thermic or chemic causes, be- 
cause traumatisms are the result of mechanical force : 


WOUND HEALING 127 


only, and the destructive influence ceases immediately 
upon removal of the cause, whereas the influence of 
thermic, and especially chemic, causes continues for a 
variable period. 

Many methods of wound healing have been described, 
such as immediate union, primary union, secondary 
union, tertiary union or intention, healing under a scab, 
and so on. When the exact conditions are understood, 
it is found that practically all wound healing is of one 
or the other of two types, primary union or first inten- 
tion, and healing by secondary union or granulation. 

The process of healing by primary union embraces 
coagulation of the hemorrhagic extravasate, agglutination 
of the wound margins, hyperemia, inflammation, vas- 
cularization, fibrous formation, disintegration of the 
hemorrhagic extravasate and inflammatory exudate, 
cicatrization, epithelization, and substitution, the time 
required for the latter being much greater than the 
former. 

The other type of healing—that is, by granulation— 
is the type usually observed in the majority of wounds 
in the domestic animals. It is this type in which there 
is a continued infection and a continual destruction of 
the newly generated tissue, thus necessarily increasing 
the length of time required for the wound gap to be 
filled with new tissue. This type of wound healing can 
be obtained by any one and under any conditions sur- 
rounding it. It is certainly no credit to a veterinarian 
to have under his care several cases of wound healing i in 
which the method of healing is by granulation. 


Prevailing Methods Deplorable 


Healing by primary union is desirable in all wounds. 
Unfortunately, this method of wound healing is not ob- 
tained as frequently as it should be in veterinary practice. 


128 WOUND TREATMENT 


The majority of practitioners have thus far not 
attempted to obtain primary wound healing in any 
except small surgical wounds. Often surgeons do not 
properly prepare their fields of operation and do not 
give the proper care and after-treatment of surgical 
wounds to favor this type of healing. This is deplor- 
able, and is one of the most frequent causes of condemna- 
tion of veterinarians. Why veterinarians take no more 
pains than they do to observe antiseptic precautions 
in their surgical operations is difficult to explain. Most 
practitioners make the plea that they have not the time 
to do aseptic surgery, and that their clientele will not 
pay for this kind of operation. Such surgeons are 
really to be pitied, for it is indicative of improper under- 
standing of aseptic surgery, as well as showing that they 
have failed to impress their clientele by their surgical 
efficiency. 


Advantages of Good Surgery 


If a surgeon will successfully perform two or three 
aseptic surgical operations, in which the wounds heal 
by primary union, he will have no difficulty in obtain- 
ing future cases and a good fee for aseptic surgical 
operations in the same community. It is not an impos- 
sibility and, further, it is not difficult to obtain primary 
wound healing even in large lacerated wounds. Cer- 
tainly, time is required to prepare the wound, but after 
the first dressing little, if any, attention is required, 
and the advantages obtained more than offset the extra 
time required in placing the wound in such a condition 
that it will heal by primary union. This type of healing 
is rapid, and seldom leaves an unsightly sear; thus the 
animal is back in service in a very short time. The 
value of the animal is not then depreciated by unsightly 
scars, and the actual time required of the surgeon is 


WOUND HEALING ~ 129 


less than it would have been had he permitted the wound 
to remain infected and thus require daily treatments. 


Aseptic Surgery and Wound Dressing 


Large lacerated wounds are properly prepared by first 
shaving the hair from all adjacent tissues, then thor- 
oughly cleansing the wound and marginal tissues and 
removing all fragments of tissue, after which the wound 
margins are brought in apposition and maintained in a 
fixed immobile position. The method of procedure that 
should be resorted to in cleansing a wound prior to 
bringing the various parts of it in apposition with sutures 
or otherwise, should be determined by the nature of the 
wound. In a lacerated wound in which there has been 
introduced filth, such as dirt, fecal matter, and hair, the 
parts should be thoroughly washed with physiologic salt 
solution until the filth has been entirely removed. The 
tissue shreds should then be removed by the use of 
sterile instruments, and some disinfectant used in further 
cleansing the part. The application of the disinfectant 
should be again followed by washing with sterile physio- 
logic salt solution, for be it remembered that if disin- 
fectants are applied tissues are destroyed, the extent 
of which will depend upon the strength of the disin- 
-fectant and the duration of its application; the purpose 
of the application of the disinfectant is to insure the 
destruction of all infectious agents, and the object of 
the application of the salt solution after the disinfectant 
is to wash away all excess disinfectant. 

Such treatment of a wound will necessarily require 
considerable time. I have seen some such wound treat- 
ment, and in one instance I remember where the irriga- 
tion with the salt solution was continued for four to five 
successive hours. In this wound some thirty sutures were 


130 WOUND TREATMENT 


taken, the wound healed by primary union, and the 
animal was back in service within a week. 
If a lacerated wound is fresh and clean, thorough 


irrigation for from thirty minutes to two hours with a~™ 


salt solution is preferred without the application of a 
disinfectant. 

After the wound is thoroughly cleansed, the various 
parts of it may be adjusted, the kind of suture and the 
method of suturing depending upon the nature of the 
wound, always selecting that type of suture which will 
hold it in the best position with the least destruction of 
tissue. When a wound is sutured, especially if it is of 
large size, it 1s necessary to provide it with drainage. 

In the treatment of granulation wounds of long stand- 
ing, it is possible in many instances to render them 
aseptic and bring the wound margins in apposition, thus 
inducing primary union. In some instances, however, 
there is so much tissue destroyed that it is impossible 
to obtain immediate union, even though the wound is 
thoroughly cleansed. 


Antiseptics Often Misused 


There is no question but that the application of anti- 
septics as frequently practiced is harmful, and that the 
tissues are often injured and wound healing retarded 
by the application of such agents. Wounds are pro- 
tected by the inflammatory exudate which usually oozes 
to the surface, thus favoring granulation, which ulti- 
mately results in the filling of the gap and completing 
the union of the tissues, the time required being much 
less than if tissues are repeatedly destroyed by the 
frequent application of antiseptics. 


a. 


NE a, 


REPAIR OF WOUNDS: 
By WILLIAM BRADY, M.D., Elmira, New York 


The general management of wounds should be based 
on a practical knowledge of the physiology and path- 
ology of repair. With a thorough understanding of the 
process of healing the young tyro may bring about the 
cure of old varicose or other ulcers which his senior col- 
leagues have perhaps pronounced incurable after years 
of empirical tinkering with various highly recommended 
ointments. Without going into details, a brief considera- 
tion of certain features of the healing process may be 
of interest. 

In a wound not aseptic, inflammatory symptoms are 
apt to appear on the second day. Every case should 
therefore be seen at this time, whether the dressing is to 
be disturbed or not. It is often wise to leave a strand 
of silkworm or gauze in the lower angle of an acci- 
dental wound of whose asepsis there is: much doubt, 
and to remove it on the second or third day if the 
wound is clean. The best dressing for such a case is the 
wet normal salt gauze, which is undeniably superior to 
dry gauze or ointments as a medium for drainage for 
exuding serum. | 

Sutures, if inserted, should be removed on the fifth day 
if there is no tension upon the edges of the wound. If 
tension is unavoidable, the sutures should remain until 
about the tenth day. It is generally well to reinforce, 
or even replace, suturing by adhesive strapping to relieve 
undue tension. A wounded extremity is always more at 


Reprint from Medical Summary.. 


131 


132 WOUND TREATMENT 


rest in a flexed position, if such position does not cause 
gaping of the wound. Absolute rest is best attained by 
means of suitable splints, or firm bandages in wounds 
of sufficient importance to require it or make it advisable. 

The floor of a deep laceration, as of the perineum, 
becomes covered after several hours with a varnish-lke 
glazing of coagulated fibrin from the exuded serum. 
Suturing at this stage will ofttimes give first-intention 
union even better than primary suturing. 

If not closed, an open glazed wound becomes covered 
in two or three days with a dirty grayish membrane, 
which separates after a few days and is discharged with 
the pus, leaving a base of bright red granulation tissue. 
Granulation tissue is the vascular framework upon which 
cicatricial tissue grows. When it reaches the level of the 
skin, a transparent, delicate film appears around the 
edges and extends gradually out toward the center of 
the granulating surface, like ice freezing over a pond. 
This film is, of course, new epithelium, though I have 
seen nurses and doctors carefully wiping it away with 
wet gauze or cotton in the blissful notion that it was 
foreign material. 

New epithelial cells are as readily destroyed by chem- 
ical antiseptics as are pyogenic bacteria. There is not 
only no excuse for washing a healing wound with germi- 
cides, but positively a contraindication to such maltreat- 
ment. Asepsis, not antisepsis, is the goal to strive for. 

Granulation tissue in large wounds or ulcers aids re- 
pair also by contracting and drawing the edges closer 
together. This gives us a valuable hint for the use of 
adhesive plaster about larger granulating surfaces. As 
to strapping directly upon the granulations, personally 
I have had only unpleasant results. 

A wound whose edges are not approximated may still 
heal without suppuration if it be filled with aseptic blood 


a ee a, ee 


Pa 


SST 


: REPAIR OF WOUNDS 133 
clot, and kept aseptic—that is, left alone. A clean clot 
is an excellent culture medium for embryonic epithelial 
cells. As healing progresses, a portion of the unab- 
sorbed clot is pushed out by the granulating tissue and 
dries in a scab which protects the surface of the wound. 
Aseptic clot repair occurs typically in simple fractures, 
subcutaneous tenotomes, internal rupture of organs, and 
healing of bone cavities following the radical operation 
on sequestra. It is nature’s peerless method, and one 
that we should endeavor to imitate whenever the con- 
ditions permit. No other packing is as good as clean 
blood clot. No other wash is as good as blood serum. 

Given a recent wound of accidental nature, how shall 
we render it aseptic? In ordinary cases one thorough 
cauterization with iodin is usually sufficient, all subse- 
quent dressings to be without antiseptics of any kind. 
In wounds which give rise to the fear of tetanus or 
rabies, however, pure phenol is preferable. If the wound 
has a cavity, the phenol should be poured in after moist- 
ening the surrounding skin with alcohol, and allowed to 
remain one minute. It may then be removed with a 
dropper, and alcohol applied. If it is a puncture wound, 
the phenol must be applied on a cotton-wrapped probe, 
opening the track of the puncture if necessary to permit 
access to the farthest point. If it be a freely-bleeding 
wound, and still bleeding, I believe cauterizing is un- 
necessary under any conditions. 

Many authorities are now reporting happy results from 
leaving granulating wounds and ulcers freely exposed 
to the air, under a wire netting for protection against 
insects or injury. Some writers report excellent results 
from treating skin grafts in this manner. 

Brewer’s yeast is a remedy I have found very useful 
for hastening the separation of old sloughs and stimu- 
lating granulations. It smarts a trifle, but patients do 


134 WOUND TREATMENT 


not object to it, especially when they find they ean 
obtain it for the asking. I have also given it in doses 
of one to two ounces internally, though with doubtful 
effects. 

For painful wounds and ulcers generally a simple 
dressing kept wet with warm normal saline solution. 
seems most useful. The patient appreciates it better if 
he is given normal salt tablets (which, by the way, make 
real imitation plasma), rather than being directed to 
dump a teaspoonful of common salt into a dish of 
water. 

For ugly, painful old varicose ulcers a boon to the new 
doctor on the case is orthoform, applied either as a dust- 
ing powder or in five-per-cent ointment. Some patients 
will develop erythema from orthoform, much lke those 
formerly common when iodoform was in use. 

For exuberant granulations—‘‘proud flesh,’’ as pa- 
tients seem to call it—I like the scissors. It can usually 
be trimmed off without discomfort. If this is not per- 
missible, then firm pressure is the next method of choice. 
My experience with silver nitrate has been uniformly 
unsatisfactory. So far as I can see, silver nitrate merely 
musses up the field of operations and stimulates the gran- 
ulations to renewed activity. The clean, prompt, effect- 
ual way to remove proud flesh is to cut it down. 

Carbolic acid, in any other role than as a cauterant, 
is to be mentioned only to be condemned. There is 
nothing known to domestic surgery that will delay heal- 
ing of a simple wound like carbolic salve, unless it be a 
fresh and reeking poultice of genuine cow dung. 

Antiseptics, other than cauterants or recognized disin- 
fectants, might well be discarded from the office al- 
together. We have little use for them. Once having 
asepticized a wound, I am sure the best policy from that 
point on is to avoid antiseptics and depend wholly upon 


REPAIR OF WOUNDS 135 


simple cleanliness, with due regard to the all-important 
consideration of the patient’s opsonic immunity and gen- 
eral condition. 

Vaccine therapy and internal medication are chapters 
by themselves. Our chief duty is to stand by fully armed | 
while nature does the work. 

In dry old varicose ulcers, carbuncles with little fluid 
drainage, and indurated swellings of various kinds in 
which incision is not productive of the usual benefit, 
the engorgement and coagulation of lymph in the ves- 
sels about the lesion is probably preventing free access 
of fresh opsonins or antibodies to the site of infection. 

Wright and others report good results in such cases 
from the use of citric acid internally in sixty-grain doses 
every three hours until a freer exudation of serum is 
obtained from the wound. The local use of citrate of 
sodium and salt solution is also advised—one tenth of - 
one-per-cent citric acid and four-per-cent sodium chlorid 
wet dressings. 

One case of Ludwig’s angina, reported by Sir Alm- 
roth Wright, seemed hopeless despite free vertical inci- 
sions in the neck and a measured opsonic index of 1.8, 
there being serious physical prostration and insufficient 
exudation from the incisions to enable Wright to ‘‘fill a 
platinum loop’’ for culture. Yet two or three doses of 
citric acid, as mentioned above, resulted in free oozing 
from the incisions and immediate institution of convales- 
cence. As Wright says, it was not the patient’s lack of 
resisting power, not his need of vaccine treatment (as 
shown by the opsonic index), but merely the choking of 
the lymph vessels about the induration which prevented 
his ample supply of antibactericidal bodies from reach- 
ing the Streptococci in the wound or lesion, and bring- 
ing about recovery. 


SURGERY IN WOUND TREATMENT’ 
By JOHN ERNST, D.V.M., Salt Lake City, Utah 


Wounds are generally understood as being a solution 
of continuity. They belong to the division of medical 
science known as surgery. This does not allude to oper- 
ative surgery alone, but includes such medical agents as 
may be or are applied, with a view or for the purpose of 
accomplishing certain specific results. It is said that 
“it ought to be, as a matter of course (perhaps it is so 
in point of fact) that no one of intelligence and integrity 
will assume the duties and responsibilities of surgical 
practice without the due preparation and equipment, 
which is only to be acquired by conscientious study and 
complete knowledge of medical science at large.’’ 

Especially and indispensably, a surgeon must be an 
accomplished anatomist. Huis knowledge must be thor- 
ough in the several divisions of anatomical science. He 
must possess a familiar acquaintance with descriptive 
anatomy; he must be fully instructed in surgical anat- 
omy or the anatomy of regions; he must have mastered 
the last chapter in pathological anatomy; and if there 
are any other kinds of anatomy he must master them all, 
and then he will have become an anatomist in fact and 
qualified to practice surgery. Yes; a surgeon must be 
an anatomist, and it ought to go without saying that 
only a surgeon should practice surgery, whether his pa- 
tient be biped or quadruped. No untrained layman 
should presume to wield the knife and the cautery with 
their associated arsenal of weapons and their appli- 


1Read at meeting of the Utah Veterinary Medical Association. 
1 Si7/ 


138 WOUND TREATMENT 


ances for the subjugation of the enemy whose assaults 
it is the special provision of the surgeon to repel. An 
ignorant operator may easily become, himself, a more 
dangerous ‘‘lesion’’ than some of those which we pre- 
sume to treat. The man who can cut into the living and 
usually hypersensitive flesh of suffering animals, with- 
out knowing what tissues or organs he is attacking, 
what arteries he is likely to sever, what nerves to wound, 
what organs to lacerate, what functions to paralyze— 
such a man, if he be found, should simply be subjected 
to an odium which should ostracize him from honorable 
and equal association with other of his species, besides 
being held criminally amenable to the law providing 
penalties for the perpetrators of cruelty to animals. 

These reflections may be unnecessary, but it is all too 
true that our domestic animals too often become the 
victims of worse than brutal masters, who take advan- 
tage of their helplessness and inferiority to inflict upon 
them ecruelties so gross and aggravated that right-feeling 
men are often compelled to blush to call them fellows. 
It is no excuse for this that it is done through the 
agency of a pseudo-surgeon; such a plea merely doubles 
the number of the wrongdoers. 

With the skill of the expert anatomist must be asso- 
ciated, of course, the necessary mastery of therapeutics, 
and a familiar knowledge of special and general path- 
ology, and all should be supplemented by a knowledge 
of the theory and practice of the farrier. 

The science and the application of the laws of hygiene, 
so generally, indeed almost wholly, ignored by our fa- 
thers, and so largely a discovery of the present time, 
should never be overlooked or depreciated by the gen- 
uine surgeon. The fullest attention to the theories and 
applications of what may be denominated the science of 
antisepsis, now so universally and unintermittently an 


SURGERY IN WOUND TREATMENT 139 


adjunct to all medical and surgical practice and so 
utterly indispensable in the departments of dressing and 
nursing, and so often an available and valuable aid in 
the very act of operating, must be considered to have 
become an incorporated and constituent department of 
the domain of surgery and medicine as well, and the 
eultured veterinarian will, of course, so regard it in his 
practice. 

Besides the special scientific attainments to which we 
have referred, there are many other qualifications which 
must enter into the character of the good and skillful 
surgeon, in order to round it into true symmetry and 
proportion. Bouley remarks that ‘‘he must not only be 
a man of science, but a man of art,’’ meaning, we sup- 
pose, that he should not only possess knowledge but know 
how to make it available. First, he must possess the 
faculty of knowing how to gauge the necessity of his 
interference, with its manner and its duration; or, on the 
other hand, whether any interference is necessary, and 
whether the true indication is not to refrain from active 
measures. The result of his decision will afford a good 
test and gauge of the extent to which he has profited by 
his clinical and theoretical study. He is a wise philoso- 
pher who can wisely determine when to let alone in oppo- 
sition to the temptation to do something. Courage and 
coolness, with patience, are essential qualities of tem- 
per in an operating surgeon. To become alarmed and lose 
his balance on the occurrence of some untoward inci- 
dent, or the appearance of some unlooked-for abnormal 
development or complication, or to give way to a spirit 
of impatience because of unexpected delay, or, especially, 
to resent the fractious movements of the suffering ani- 
mals writhing under the knife or the glowing cautery, 
is both unprofessional and unmanly. The terms, cour- 
age, coolness, patience, and kindness should. describe 
his state of mind while operating. 


140 WOUND TREATMENT 


Every movement of the surgeon should be prompt and 

precise. Indeed, by operating rapidly he shortens the 
duration, and consequently the sum, of the pain, and 
thus diminishes the anguish of a long and torturing 
infliction on behalf of the patient. The maintenance of 
his own self-possession will make him master of the 
situation, and assure a neat, artistic finish to his task, 
with no unnecessary division of tissues, no mistaking of 
locations, and generally with no betrayals of doubt and 
hesitation or awkward and aimless manipulations, such 
as mark the attempts of the tyro and the novice. 
- The confidence and facility with which each move is 
accomplished will not fail to impress favorably those 
who are spectators of the operation, and to react fa- 
vorably and profitably for the operator. The operative 
function of veterinary surgery requires, on the part of 
the man who practices it, a certain corporeal vigor, asso- 
ciated with sufficient agility to be able effectually to over- 
come the resistance of animals under torture, and coun- 
teract the efforts and avoid the injuries they are always 
so prompt and often so dexterous in inflicting upon 
those who are causing them pain. The veterinary sur- 
geon must be cool-blooded and patient, never losing his 
presence of mind while directing the manipulations, 
often so difficult and dangerous, which are necessitated at 
his hands, especially when the large domestic animals are 
under treatment. He must then—always, in fact—be 
prepared for all difficulties and eventualities that may 
arise, whether before, during, or after an operation, and 
he must inspire confidence in his assistants by using full 
precautions for their safety and for his own, in his de- 
fensive dispositions against the dangers to which they 
are exposed. 

It is especially as therapeutic measures that opera- 
tions are necessitated in the treatment of diseases and 


SURGERY IN WOUND TREATMENT 141 


injuries, as, for example, in the case of the removal or 
extirpation of diseased or altered parts whose morbid 
action injuriously affects the general health or pre- 
vents recovery from a pre-existing disease. This class of 
operations includes the opening of abscesses, the extirpa- 
tion of gangrenous parts, or of necrosed or carious bone; 
or again, for the modification of the nature of a trau- 
matic lesion in order to stimulate cicatrization, as in the 
opening of a fistulous tract, or the resection of an ul- 
cerated surface, or when the tissues are to be relieved 
from the presence of a foreign body or the abnormal prod- 
uct of a natural function, as in case of esophagotomy, 
or of calculus of the bladder, or of the salivary ducts. 
Operations have also their prophylactic uses, especially in 
the various forms of inoculation and vaccination as 
anticipatory and preventive of infectious diseases. They 
find their further obvious indications, again, in remedy- 
ing physical lesions when a’pplied to fractures, disloca- 
tions, deformities, and the endless list of accidental in- 
juries, wounds, and hurts of every kind and degrees. 
And finally, they have their justifiable use in mutilating 
the larger domestic animals designed for purposes of 
labor as beasts of burden or draft in improving their 
adaptability by castration or spaying, or, as it 1s com- 
monly termed, ‘‘altering.’’ 

Thus the general purpose of an operation is to palliate, 
cure, or assist in the recovery of surgical diseases; to 
prevent disease, and to so modify the condition of the 
domesticated animals as to enhance their usefulness and 
value to their human owners. 

To accomplish these ends we do not depend upon 
surgery alone, but also employ such agents as setons, 
sutures and bandages, drainage tubes, and antiseptics. 
To the mechanical appliances we need not devote any 
time, as all veterinarians are familiar with their use, but 


142 WOUND TREATMENT 


the use of antiseptics and biological products differs 
greatly in the practice of veterinarians. 

The use of medical agencies in the treatment of wounds 
depends upon the character of the wound and the nature 
of the bacteria that may have or that have gained access 
to the wound. A solution of continuity may be of almost 
any shape or form imaginable and from:a clean incision 
to a ragged, dirty, lacerated wound, located in any 
region, tissue, or organ of any part of the organism. 

These variations make it imperative on the part of the 
operator or veterinarian to exercise wide judgment in 
connection with his theoretical training, since various 
complications (such as exposed tendons, open joints, a 
puncture into the abdomen or thoracic cavity) require 
treatment peculiar to the extent and character of the 
lesion. The wound, being made, the operator recalls the 
ways by which the pathogenic bacteria may enter into it, 
—hy the air, by the hands and clothing of the operator,— 
or by means of foreign bodies (stone, sand, nails, wood 
splinters, pieces of earthenware) which enter the wound 
simultaneously with the wounding. Then the resting 
place of the patient, either during the operation or after- 
wards, may be such as to infect the wound, or infection 
may come by means of the instruments and bandaging 
material, or from the region surrounding the wound 
(skin, hair, nails, hoof). 

If an operator makes a fresh wound, he first considers 
by what mode and by what means he can prevent the 
infection of the wound, and if the wound has been pre- 
viously made, he considers how he is to remove an infee- 
tion already existing in it. 

Therefore we have two different subjects to consider, 
according to whether the wound is already infected or 
not. If our aim is to protect a wound against infection 
we speak of aseptic treatment of wounds, while disin- 


SURGERY IN WOUND TREATMENT 143 


fecting or antiseptic treatment of wounds is referred to 
when an already infected wound has to be liberated 
from the infection—that is, disinfected or made aseptic. 
We therefore should not be surprised that the rem- 
edies used for the prevention of wound infection are 
entirely different from those used for the removal of an 
infection already present; hence the remedies used in the 
treatment of wounds are divided into two groups: first, 
bandaging material; and second, disinfectants. Bandage 
materials should possess certain qualities to obtain the 
desired effect. First, they must be porous so as to . 
absorb the discharges of the wound; second, they must 
be free from infectious germs, so as not to be a source of 
infection to the wound; third, they must be soft, elastic, 
and flexible, so as not to cause pressure on the wound, 
and must adapt themselves to the corresponding parts of 
the body without forming any gaps. If there are no 
infectious germs already present in the wound their in- 
troduction is most liable to take place from the outside. 
To avoid this, the bandaging material should be impreg- 
nated with some reliable disinfectant so as not to per- 
mit of infections gaining access to the open surface of 
the wound. By this means the germs that may gain 
access into the bandage material are destroyed or find 
that the discharges absorbed by the bandages are unfit 
as a nutritive medium for their development. 
Disinfection means nothing else than the removal or 
destruction of the germs or infection. Disinfection of 
wounds, or of an instrument, or of the operating field, 
the air, hands, and clothing, ligature and drainage tubes, 
stable and resting places, means making innocuous the 
infectious germs located in the respective media that 
may bring them in contact with the wound. Most dis- 
infectants act simultaneously in two or more ways, and 
we may divide the methods into three groups: First, 


144 WOUND TREATMENT 


physical disinfection agents; second, chemical disinfeec- 
tion agents; and third, biological disinfection agents. 

Among the physical agents we class all surgical instru- 
ments by the aid of which we can remove infected ma- 
terial in a purely mechanical way, such as the knife, scis- 
sors, or sharp spoon; also the high degree of heat in the 
form of the firing iron or thermocautery, and finally the 
withdrawal of moisture—namely, exsiccation and perma- 
nent irrigation. 

The chemical agents hostile to the development of 
micro-organisms are principally mercuric chlorid, iodin, 
iodoform, iodol and iodin trichlorid, carbolic acid, creolin, 
salicylic acid, boric acid, chlorid of zine, camphor, tar, 
turpentine, bismuth subnitrate, salol, and many other 
similar mediums and prepared preparations. 

The biological products or bacterins help in disinfect- 
ing a wound by assisting the animal organism in destroy- 
ing the infectious bacteria. This once accomplished, the 
tissues proceed to make repair, and in the course of due 
time, if new formations foreign to the part do not 
develop, the desired effect will be accomplished. 


PRACTICAL SURGICAL CLEANLINESS 
By MART R. STEFFEN, V.S., M.D.C., Brillion, Wisconsin 


There 1s now an apparent tendency among surgeons, 
both human and veterinary, leading in the direction of 
a sane, practical balance in the conception of surgical 
cleanliness. 

As with many other good things, so also with our 
ideas of sepsis and asepsis, extremes have been developed 
and accepted which we are now endeavoring to adjust. 
The treatment of fresh, accidental wounds seems to afford 
the best field for the application of new and improved 
-thought along these lines, and the main point which 
nearly all writers attempt to carry in recent articles is, 
that the assumption of microbian contamination in all 
wounds of an accidental nature is erroneous.t Almost. 
without exception the various contributors to medical 
and surgical papers dealing with this subject condemu 
the doctrine which has, until recently, been generally ac- 
cepted and which held that all accidental wounds were 
to be treated as infected wounds. The result is that the 
treatment of wounds is undergoing a change, especially 
as regards the excessive washing and irrigating with anti- 
septic solutions. It is pointed out that such washing and 
irrigating is detrimental for two chief reasons; one, that 
it always devitalizes the -tissues; the other, that it 
mechanically removes the bacteriolytic exudate that ap- 
pears almost instantly on all wounds—nature’s means 
of controlling whatever infection might be present. Dr. 

1See also the chapter on nae joints in my book, Special Veterinary 
Therapy,p.19. © 

145 


146 WOUND TREATMENT 


W. W. Grant, speaking of handling wounds that accom- 
pany fractures, says: 

‘* At the present time it is not considered advisable to 
enlarge the wound or to irrigate, unless dirt or some in- 
fective material is in the wound. The old maxim, which 
considered every compound fracture as infected, is not 
sound nor borne out in practice.”’ 

In an article on wound and skin sterilization Dr. Lile 
says, In the International Journal of Surgery: ‘‘The 
plan adopted by the writer in all cut, bruised or lacer- 
ated wounds is never to wash, but before allowing any- 
thing to come in contact with the wound to swab it off 
with the five-per-cent tincture of iodin and cover with 
sterile gauze.”’ 

“While the foregoing remarks are mainly in reference 
to human surgery, veterinary surgeons can afford to pay 
some attention to them. Excessive washing of wounds 
is the rule in veterinary practice, and no doubt works 
as adversely in our patients as it does in human beings. 
One hindrance to an ideal handling of wounds in our 
patients, especially equine patients, is the tendency to- 
ward exuberant granulations, or ‘‘proud flesh,’’ as it is 
commonly called. It is my opinion, formed through prac- 
tical experience, that this tendency is aggravated by 
much washing or other applications, such as irrigating 
with antiseptic solutions. 

Referring to the sterilization of the unbroken skin for 
surgical incision, Dr. Lile says in the same paper, ‘‘In 
operating where the skin is unbroken the surface is first 
painted with gasolin or benzin, then dried with sterile 
gauze or a towel, and painted with the standard iodin 
solution, and the patient is ready.’’ He also remarks 
that to Grossich is due the credit of bringing iodin dis- 
infection to its present scientific basis and that he has 
‘‘ealled attention to the fact that thorough sterilization 


PRACTICAL SURGICAL CLEANLINESS 147 


could be obtained only when the iodin solution was ap- 
plied to a dry surface.’’ 

From personal experience with this method of steriliz- 
ing the skin previous to surgical operations I can say 
that it is equally safe and sufficient in veterinary prac- 
tice if the hair is first shaved off. 


VULNERARIES ' 
By DOUGLAS H. STEWART, M.D., New York 


The days before antisepsis, treatment of wounds, so 
far as dressing was concerned, made its demands upon 
the patient’s own healing powers, which were to be aided 
by vulneraries. Then came the Pasteur-Lister methods, 
which aided the patient not at all, considered the wound- 
healing application of small account, but did interpose a 
shield between the patient and extraneous infection. 
About the year 1895 there appeared the experimental 
work of some German surgeons, who claimed that the 
use of antiseptics in infected wounds was of no benefit. 
For centuries there had been in use a plant known as 
bruisewort. Modern men were experimenting with pla- 
cental membranes. Now the consensus of opinion is that 
wounds require both the shield of the dressing and the 
reinforcement of the patient’s bactericidal products. 

The value of the vulnerary begins where the surgeon 
leaves off, and bruisewort, or comfrey, had been more 
or less in use for ages. Nor can any one who has had 
experience with this plant be persuaded that it does not 
possess tissue-building powers. Neither is it strange that 
those powers should be sought for in embryotic tissues, 
because the active principle of placental membranes as 
well as of Symphytum officinale (that is,. comfrey) is 
allantoin. German literature treats approvingly of that 
plant as a wound-healer, and personal experiment con- 
firms the good results claimed therein. The Americans 
claim that comfrey will cause the disappearance of sar- 


1Reprinted from The American Journal of Clinical Medicine. 


149 


150 WOUND TREATMENT 


coma. I do not believe, because I do not know; but, not 
knowing I have not the recklessness to say, ‘‘ Impossible.’’ 

Nature’s usual first step in healing an incised wound 
is to discharge a thin serous fluid. Attempts at aiding 
this first step are made by using an ‘‘osmotic pump’’; 
that is, by applying some substance of high specifie grav- 
ity in which an antiseptic is dissolved, and anticipating 
that germs carried out of the tissues will be killed as are 
those of external origin. Hence, glycerin and its combi- 
nations were used, and later sodium chlorid was similarly 
employed. This salt regulates osmosis and imitates some 
of the functions of blood serum. Other sodium or potas- 
slum salts were mixed with the sodium chlorid until 
finally Wright, of England, mentioned the advantages 
of the citrate. , 

Wright’s solution has been widely and successfully 
used; but it is really a wound-healer, pure and simple, 
and is devoid of any germicidal value. It compares well 
with allantoin, and, in view of the raging European war, 
is much more accessible. It does seem as if the vulnerary 
had come into its own again, after all; at the same time, 
the lessons learned from the wave of antisepsis are many 
and important. 

Suppose one were to secure a vulnerary which was at 
the same time a germicide, yet free from the drawbacks 
ealled irritation. Suppose a mixture existed which was 
sedative to tissues and attacked neither skin nor instru- 
ment. Suppose this preparation would take care of 
vaginal or dormal injuries so far as redness, heat, pain, 
swelling, and discharge were concerned. Suppose a sur- 
geon could employ it equally well to treat vaginal gonor- 
rhea or a septic or an aseptic wound, or use it on his 
own face after shaving. Then it might well be called 
the surgeon’s own powder, especially if it were odorless. 

There is such a combination, which, when it is brought 


VULNERARIES 151 


in contact with an animal fiuid or discharge, at once 
breaks up into Wright’s solution, plus aluminum acetate, 
plus insoluble white lead; and its results are exactly what 
any one would imagine they would be when backed up 
by the most powerful osmotic pump known; namely, cane 
sugar, which compares with glycerin as 1,600 to 1,250 or 
less. 

The experimentation which led up to this combination 
of wound-healer and protector would make many papers 
such as this one. There seems to be some difficulty in 
making the preparation; however, the power machines 
experience no trouble. Consequently it would appear to 
be a question of trituration. Its formula for general use 
should be as follows: 


SMEEECES Cho cto) wisi p SIR Ig oe wkd he) over WS ca vies AGS grs. 2 

SLD ee ee eC cca i PS grs. 40 
SL LIP PETE ar) C0 as 0 SRE uA a grs. 240 
ME REB ret ego cra ha aa (are Sat ore cae 6 Sis 2 elk owe md grs. 180 
ED OE Re A Oe ad ee ee ee grs. 360 
pueAr CHOURH LO MAKC 2). soe Secon ts oe a see e's ozs. 16 


Since writing the above, I have heard that some are 
using this compound either before or after the usual 
hand-cleansing procedure, as it keeps the operator’s 
hands soft and pliable. Personally, after returning home 
from an operation I make it a habit to take a teaspoonful 
of the powder in my hands, rub it in thoroughly (it gets 
wet by rubbing), leave it on for five minutes, and then 
wash it off with cool water. 


PRACTICAL WOUND APPLICATIONS. 
By A. W. WALDRON, JR., D.V.S., Tullahoma, Tennessee 


While aseptic surgery is ideal it is far beyond the at- 
tainment of the country practitioner in a location such 
as this, where the farmers clean their stables but once a 
year. : 3 . 

Undeniably, all antiseptics irritate wounds and retard 
healing; but their use is imperative, and furthermore the 
dressing must be as simple as possible to apply, and 
should require but little of the attendant’s time. For as 
a rule elaborate directions will not be followed. 

Each year I use less bichlorid and more tincture of 
iodin, which is I think the best application for the great 
majority of wounds, both surgical and accidental. Ap- 
plied once a day with a swab or syringe, and later every 
second or third day, its effects are most satisfactory. 
The pain its application occasions is ephemeral. By its — 
use we obtain most of the benefits of iodoform, without 
the offensive odor and at far less expense than we could 
use the powder. An application of 100 parts fish oil, 
50 parts oil of tar, and 1 part carbolic acid, or the com- 
mon ‘‘black oil,’’ a petroleum product, will protect the 
wound from flies. Either one is both inexpensive and 
effective. Paint around the wound with one of the 
above three times a day. 

Jodin is most excellent for the general purposes of the 
country practitioner, whose methods must almost always 
be more or less rough and ready. It is a useful applica- 
tion to the points of sutures, for sterilizing a line of in- 
cision, and as an application to many forms of contused 


153 


154 WOUND TREATMENT 


as well as lacerated, punctured, and incised wounds. 
This refers alike to wounds in muscular, tendinous, and 
osseous structures. Under this treatment large and deep 
wounds will remain practically dry if made under rea- 
sonably good aseptic precautions. 

For wounds in the oral, abdominal and the other nat- 
ural cavities, hydrogen dioxid is my favorite antiseptic, 
either full strength or diluted and used ad libitum. 

For surface wounds, and where it is desirable to pro- 
duce a dry seab as quickly as possible, as in ‘‘broken 
knees,’’ there is nothing equal, I believe, to tannoform; 
for persistent urachus this is also very valuable, often 
relieving the condition in forty-eight hours, if applied 
every three hours to the umbilicus in sufficient quantity 
to cover the area rather thickly. 

For surface wounds where the cost of the dressing is 
more of an object, an absorbent mildly antiseptic and 
astringent, dusting powder often answers well. All of 
the above dressings are most efficiently and economically 
applied by means of the small insect-powder blowers to 
be obtained from druggists. 

Pulverized copper sulphate quickly destroys the exces- 
sive quantities of granulation tissue so frequently found 
in old and neglected wounds. 

As a protective dressing to open wounds that are sup- 
purating but little in seasons of the year when flies are 
bothersome, the following prescription does very well. 
It is particularly applicable to wire cuts and other lacer- 
ated wounds. 


OZ. 
PHENOL, 3. 'oc wz «8 ce aie de = a0 5b le eee ee 1 
Guam “Cam phow. oie ois ois 64,4 teas eee de ee ee 5 
RESID 9. oss Gi << Sa deere wip sierp 0k at win ples ac 1 
Methylated spirits”... << a.sis .swe eos tale oe ce 15 


M. Sig. Paint on wounds three or four times a day. 


» 


ABDOMINAL WOUNDS OF ANIMALS'! 
By J. V. LACROIX, D.V.S., Kansas City 


Under abdominal wounds of animals may be included 
a wide range of conditions wherein divers factors are to 
be reckoned with. In this brief treatise we shall con- 
sider the subject in a general way only, mentioning spe- 
cific instances in the way of case reports merely for 
emphasis. 

Our domestic animals are all, because of the manner 
in which they are kept, subject to injuries of the abdo- 
men. In a general way the horse and mule are more 
frequently affected than are the other animals. The 
fact that horses, used as they are in all kinds of service, 
exposed to various injuries in the way of runaway acci- 
dents, kicking one another when shod with calked shoes; 
together with the anatomical construction of the abdom- 
inal wall, accounts for their being frequently injured. 
The abdominal wall of the horse is more tense than is 
that of other animals, and being very agile and quite 
likely to struggle whenever any vulnerable object con- 
tacts the abdomen, they are often seriously injured. The 
ox, under the same conditions, would suffer little or no 
harm. | 3 

Cattle receive abdominal wounds rather infrequently. 
They are subjected to contusions probably more fre- 
quently than to any other mode of injury. Having thick 
skin and a rather loose and pliable abdominal wall, punc- 
tures and lacerations are of comparative infrequency. 

1Read at the 50th annual meeting of the American Veterinary 
Medical Association. 


155 


156 WOUND TREATMENT 


Sheep have loose abdominal walls, and in addition the 
skin is protected by wool. Abdominal fat is usually 
quite abundant, and as sheep are not inclined to greatly 
resist confinement in any position, they seldom suffer 
from injuries of the abdominal walls. 

Neither are swine frequently the victims of abdominal 
wounds, though brood sows with large, pendent abdomens 
receive lacerations of the mammary glands occasionally, 
and various complications may ensue. This is the most 
frequent form of injury among these animals. Swine 
may wound one another in combat, or receive wounds 
from dogs or wolves, but this is not of frequent oceur- 
rence. Having more or less fat underlying the skin, they 
may receive extensive and deep wounds without making 
eventration imminent or necessarily a sequel, the result 
of a post traumatic necrosis of tissue. 

Abdominal wounds are classified variously by different 
authorities. We shall for convenience here consider 
them under four classifications, as follows: 

1. Contusions with subsurface solution. 
2. Lacerations without eventration. 


3. Wounds with eventration and without visceral perforation. 
4. Penetrant wounds with visceral perforation. 


Contusions with Subsurface Solution of Continuity 


Contusions with subsurface maceration of tissue fre- 
quently occur in horses and mules. This type of injury 
is occasioned by any heavy blow that is sufficiently force- 
ful to sever any one of the several layers comprising the 
abdominal parietes. Contusions are so directed as to dis- 
place relations of the various layers of the abdominal 
wall, by rupturing tissue, allow of considerable extrava- 
sation of blood and serum. Such injuries are accom- 
plished by falls or kicks, or by, the animal being crowded 
against door jambs or gate posts, or bunted by cow’s 
horns. . 


~ ABDOMINAL WOUNDS OF ANIMALS = 157 


Manifestation of such injuries may be evident within 
a few hours after they occur, or they may pass unno- 
ticed until much subsurface extravasation or discharge 
of fluids has taken place. In some eases, only a small 
amount of blood escapes into the tissues, little swelling 
occurs at first, and not until infection has taken place is 
there marked inconvenience manifested by the subject. 
Abseesses occurring in this manner often contain large 
quantities of pus, and it is a noticeable fact that such 
conditions may persist for weeks at a time without per- 
foration of the abdominal wall from necrosis. 

To differentiate between abscess of the abdominal wall 
where there exists a large cavity filled with fluctuating 
detritus, and hernia, is not easy in certain cases. In 
vicious horses, where the condition is painful, little is 
to be learned by palpation while the subject is standing. 
By casting such animals and placing them in such a posi- 
tion that the swelling is located uppermost, one can ex- 
clude hernia by absence of perforation of the underlying 
structures, and failure at reduction of the mass. Finally, 
by using an exploratory trocar or needle, hernia can be 
excluded. 

Where such abscesses involve one or more floating ribs, 
necrosis is likely to result in perforation of the abdom- 
inal wall, and being situated nearer the superior part of 
the abdomen, swelling is not so extensive and it is more 
_ defined. 

Treatment of such cases consists in evacuation of all 
pus and the removal of shreds of necrotic tissue. Such 
abscesses should be so opened that perfect drainage may 
take place and little after-care be necessary. 

_ An extreme case of this kind was treated by the writer 
in 1906. The subject was a gelding weighing eleven hun- 
dred pounds. He was very vicious, and the owner had 
given him little or no attention. Not until the swelling 


158 WOUND TREATMENT 


had gradually increased for about six weeks was any 
attention given the case. Location of the enlargement 
was in the left flank, and it extended from the umbilicus 
to near the anterior iliac tuberosity. The fluctuating 
center was about twelve inches in diameter. It was not 
possible to determine the exact nature of the condition 
without casting the animal. After properly confining 
the subject, diagnosis was not difficult. The abscess was 
drained of a large quantity of pus and the cavity irri- 
gated with a weak antiseptic solution. The subject was 
allowed exercise, but in about a week it became necessary 
to enlarge the opening made for drainage. The animal 
being hard to handle, no further treatment was given 
him, and complete recovery resulted in about a month. 

Traumatisms immediately resulting in hernia, with 
more or less subsurface laceration of tissue, are met with 
frequently in all animals. Contusions produced by 
means of blunt objects often result in hernia because the 
skin is freely movable, and quite capable of withstanding 
injuries which do violence to the underlying tissues. 
Subcutaneous rents result in hernia where a sufficient 
opening in the abdominal wall is produced. Strangula- 
tion of intestine may occur, and unless cared for, results 
fatally. Strangulation usually occurs where the injuries 
involve the region of the groin. Non-strangulated 
herniz are often found involving the floor of the abdo- 
men anterior to the inguinal region. 

No great difficulty is experienced in rolieael a diag- 
nosis of such eases, as they occur in connection with some 
injury and the skin usually bears evidence of violence, 
even though it be left intact. By rectal examination 
those parts of the abdominal wall that are within reach 
may be palpated and the nature of the swelling deter- 
mined. . Where strangulated hernia exists, diagnosis is 
not so easily made as in cases of non-strangulated hernia. 


"9 oak oe 


ma a re 


~ ABDOMINAL WOUNDS OF ANIMALS 159 


Treatment is imperative in cases of strangulated hernia 
and consists in confinement and anesthetization of the 
subject. The skin over the swelling is shaved and 
cleansed with soap and water, dried, and painted with 
tincture of iodin. A free incision is made, exposing the 
strangulated loop of intestine and the ragged edges of 
the subcutaneous wound. Reposition is effected by ma- 
nipulation, after having drained a quantity of fluid with 
a small trocar. If little fluid is contained, it may be 
necessary to enlarge the opening slightly. After reduc- 
ing the hernia, approximation of the wound margins is 
effected by means of sutures. 

In a ease of strangulated hernia occurring in a twelve- 
hundred pound mule, the animal had kicked over a par- 
tition and become impaled upon an upright timber. In 
his struggles a sufficient amount of tissue had been torn 
and badly mutilated to allow a hernia of the floating 
colon. Separation of muscular layers had taken place to 
an extent sufficient to permit of the incarceration of 
about twenty inches of intestine. 

The writer was called about four hours after the acci- 
dent occurred. At that time there existed in the left 
fiank just anterior to and below the anterior iliac spine 
an enlargement ten or twelve inches in diameter, which 
was edematous in its periphery. Manipulation of the 
mass caused pain to the subject. By rectal examination 
_it was possible to outline the irregular borders of this 
abdominal rent. The animal was very restless, and it 
was decided that immediate surgical intervention was 
the only recourse. 

With assistance, the subject was cast, and anesthetized, 
the field prepared, and by means of a free incision the 
strangulated loop of bowel was exposed and replaced. 
The wound was prepared and the various tissue layers’ 
were sutured separately. The mule was allowed the free- 


160 WOUND TREATMENT 


dom of a small blue-grass pasture, and beyond some sup- 
puration which later necessitated drainage, a complete 
and uneventful recovery resulted. 


« 


Laceration Without Eventration 


Laceration of some part of the abdominal wall without 


eventration is of common occurrence and is caused in 
numerous ways. Because of the fact that fibres of the 
several muscular layers of the abdominal wall are dis- 
posed in various directions, large wounds occur without 
complete perforation. This is particularly true when the 
offending implement is not possessed of a keen edge or a 
sharp point. Horses are kicked by others that are wear- 
ing sharp calked shoes, receiving extensive lacerations, 
but it is unusual for the victims of this mode of injury 
to suffer eventration at the time of accident. In jump- 
ing over and upon fences, lacerations of the abdominal 
wall oceur; but unless the animal strikes an upright body 
capable of penetrating the abdomen, extensive lacerations 
usually take place without immediate eventration. 

Lacerations of the abdominal wall are characterized by 
visible solution of continuity, fragmentary protrusion of 
margins, and more or less hemorrhage. Because of the 
facility with which separation of tissue layers takes place, 
sacculations are to be found under the margins of the 
wound; these extend in various directions, and where 
gravitation or pressure does not interfere, they are filled 
with blood. 

Where such wounds are not too deep, and conditions 
make impracticable other and more elaborate treatment, 


they may be cared for by trimming away all macerated: 
tissue, controlling the hemorrhage, and fare dressing. 


them as open wounds. 
Where such lacerations are deep and involve so mueh 


= _— 


- ABDOMINAL WOUNDS OF ANIMALS _ 161 


tissue that eventration threatens, coaptation of the wound 
margins in some manner is necessary. 

In the handling of such cases in large animals, the 
first problem which confronts the operator is that of 
restraint. Certain it is that the subject must be con- 
fined, and unless the wound is high up on the side, a 
recumbent position is necessary. .As a precautionary 
measure it is well to apply a temporary bandage to pro- 
tect and support the parts until the animal is placed in 
readiness. If much suturing is to be done, complete 
anesthesia 1s imperative. Local anesthesia would suffice 
were it not that the subject usually resists confinement 
even more than the pain inflicted by the process of 
suturing. 

Since the treatment of such wounds constitutes emer- 
gency surgery, there is no time for the preparation of 
the subject, and one must count on an occasional loss 
from anesthesia, delirium, or shock. 

Careful attention must be given to cleansing the skin 
bordering the wound. A liberal area should be shaved, 
all macerated tissue removed, and the wound thoroughly 
cleansed by mopping with gauze or cotton moistened with 
a mild antiseptic solution, or with sterile water. After 
hemorrhage has been controlled, all parts should be 
moistened with tincture of iodin. Particularly is this 
essential if the wound has taken place several hours 
_ prior to its being treated, or if it has contained much 
dirt or filth. 


Approximation of the wound margins, with the excep- 
tion of the skin, may be brought about by means of con- 
tinuous sutures of chromic gut. Each of the several 
layers of tissue comprising the abdominal wall should be 
sutured separately, then the skin should be sutured with 
a heavy material either of silk or linen. Mattress sutures 


162 WOUND TREATMENT 


serve very well. Reinforcing sutures in the skin and sub- 
cutem are useful in some cases. This method of suturing 
is applicable in all cases where coaptation is attempted. 
Some suppuration occurs in the majority of cases, and 
drainage should be provided for by means of a tube or 
by inserting at some pendent part of the wound a suture 
that is readily removed. After-care consists in keeping 
the parts clean and restricting exercise. Plenty of time 
should be allowed that complete repair may take place, 
else hernia is likely to occur even three or four months 
after the wound has completely healed. The parts may 
be supported by means of heavy bandage material during 
the process of treatment, but it is doubtful if this is of 
real service if the wound has been properly sutured. In 
large animals wounds so treated are completely united 
within thirty days unless swelling persists and consider- 
able necrosis results. 

A lacerated wound of the abdominal wall in a mule, 
the result of a kick with a sharp calked shoe, was treated 
at the Kansas City Veterinary College in January, 1911. 
The injury was located in the right lower abdominal re- 
gion about eight inches from the median line and twelve 
inches anterior to the pubic brim. All of the structures 
except the peritoneum were lacerated. The wound ex- 
tended almost at a right angle from the spinal axis, and 
was about five inches in length. Much dirt and filth had 
been carried into the depths of the wound, and there was 
extensive maceration of tissue. 


The animal was placed upon an operating table and 
the wound treated as just outlined. Union of the parts 
had taken place in about three weeks, and the patient 
was then dismissed from the hospital. She was put to 
heavy work at a grading camp, and a hernia resulted. 
However, this did not interfere with her usefulness, but 


ABDOMINAL WOUNDS OF ANIMALS 163 


was the direct result of an insufficient length of time 
being allowed for complete repair to have taken place 
before putting the animal in service. 


Wounds With Eventration and Without Visceral 
Perforation 


Wounds with eventration and without visceral per- 
foration occur in all animals, the result of direct in- 
juries of various kinds. The agent inflicting such in- 
juries is not sharp enough to perforate viscera imme- 
diately upon coming in contact with them, even though 
driven with great force. This type of wound occurs in 
horses that are gored by bovines, or become impaled 
upon upright posts or implements of various kinds. The 
writer has observed fatal eventration in the horse where 
a rent at least eight inches in length was inflicted by a 
Jersey cow’s horn. Where much of the intestine pro- 
trudes it is likely to become injured beyond repair, un- 
less it is given immediate protection in some manner 
until reposition is effected. Even though successful 
reposition of the intestine is effected, there is danger 
of peritonitis, and considerable shock always attends in- 
juries of this kind. Where such wounds involve the 
floor of the abdomen there is likelihood of hernia re- 
sulting unless it is possible to secunaly approximate the 
wound margins. 


Treatment consists first, in protection of -the exposed 
viscera and appropriate confinement of the subject. 
After thoroughly cleansing the visceral organs, reposi- 
tion is attempted. In the large animals, if there is much 
struggling or straining, complete narcosis is needed. 
Reinforcement and protection of the wound with dress- 
ings and bandages is helpful in small animals, and may 


164 WOUND TREATMENT 


be of some advantage in the large animals. However, 
where such wounds are kept covered they remain moist, 
and are prone to suppurate unless frequently redressed. 


Penetrant Wounds With Visceral Perforations 


Visceral perforation occurs occasionally in any of the 
domestic animals and is the result of gunshot wounds, 
thrusts with sharp implements of any sort, or where ani- 
mals become impaled upon sharp projecting bodies. In 
the smaller animals tooth wounds sometimes penetrate 
the intestine. ‘ ) 

Where the perforation is large in animals that resist 
manipulation of the peritoneum, it is possible to close 
the intestinal wound by means of bowel anastomosis or 
by approximation of its margins with sutures. Spon- 
taneous marginal adhesion of serous membranes with the 
production of fecal fistule is not of uncommon oceur- 
rence. | 

Where small puncture wounds involve the bowel in 
numerous places, allowing the escape of intestinal con- 
tents into the peritoneal cavity, there is no effectual 
means of intervention except such as occasions laparot- 
omy ; therefore the repair of this form of injury is often 
impracticable. 


—~ «4 pow Od 


OPEN JOINTS 
By J. N. Frost, D.V.M., Ithaca, N. Y. 


The literature in regard to suppurative arthritis 
seems to be a minus quantity so far as veterinary sur- 
gery is concerned, and the case reports are few. As one 
medical work states, ‘‘Our knowledge of joint disease is 
so imperfect that no opportunity should be lost by which 
clinical data may be added.’’ 


CAuSES.—The causes of open joints are kick wounds, 
nail punctures, and the like, which not only open the 
joint capsule but are liable to carry infection to the 
joint cavity, where synovia serves as a favorable medium 
for the development of the bacteria. Another cause is 
the extension of necrosis from neighboring areas of in- 
fection, such as tendon sheaths or burse. Likewise, it 
may result by the process of metastasis from some dis- 
tant suppurating foci. | 

The severity of articular wounds is not due to the 
lesions produced, but to the inoculation of the wound 
with bacteria. When pyogenic organisms gain entrance 
to a joint cavity they lead to inflammation of all the 
structures of the joint, followed by suppuration, and, 
unless overcome, to the destruction of the joint cartilage 
and its discharge in the form of pus, leaving the ends of 
the bones bare and rough. Naturally, this leads, in 
those joints where the movement is limited, to ankylosis 
or stiffness of the joint. 

‘Symproms.—If the wound of the joint is small, and 
made. by a clean instrument, the only symptom may be 
the discharge of synovial fluid. In most cases there will 


165 


166 WOUND TREATMENT 


be, however, some infection which results in signs of irri- 
tation, such as swelling of the joint, increased synovial 
fluid, or tenderness on palpation. If the infection is 
severe there will be edema, fever as high as 104 to 105 
degrees, with pulse and respiration increased. The pa- 
tient holds the swollen, painful articulation in a posi- 
tion to relieve the pain as much as possible, touching 
only the toe to the floor. Frequent convulsive move- 
ments are made with the leg, indicating pain in the 
part. The tissues surrounding the joint are inflamed 
and swollen, and there is a discharge of synovia from 
the wound, which at first is a slippery, transparent, 
straw-colored liquid. Synovia may be recognized by its 
tenacity if the finger which touches the fluid is slowly 
withdrawn. This is a sure sign that the fluid has come 
from a synovial bursa, or, in other words, that it con- 
tains mucin. 

As inflammation of the joint advances, the synovia 
is discharged in thick, heavy clots. After the synovial 
membrane becomes infected, its secretion is greatly aug- 
mented, and the discharge is a thick yellow mixture of 
pus and synovia, which is thrown off in large quantities. 

The loss of flesh is exceedingly rapid, even though the 
appetite remains good. Due to long periods of decu- 
bitus, sore and infected areas develop on the skin over 
the external angle of the ilium, the shoulder, and the 
supra-orbital process of the head. 

The differential diagnosis between a suppurative ar- 
thritis and suppurating tendon sheath is not always easy, 
as the discharge from each has the same general appear- 
ance and around most of the joints there are tendon 
sheaths which may become opened more readily than the 
joint. There is usually a difference in the degree of 
lameness. The animal with open tendon sheath does 
not ordinarily show as great pain upon movement or 


Sha 


: OPEN JOINTS 167 
upon bearing weight on the part as does the animal 
with open joint. 

By probing we can usually make our diagnosis posi- 
tive. We are told by many that probing should not be 
resorted to, and this no doubt is true if it cannot be 
done in an aseptic manner. We fail to see, however, 
why there should be danger if we are careful to dis- 
infect the wound and then use a thoroughly sterilized 
probe. After probing we are in a position to give a 
more accurate prognosis and treatment. 

TREATMENT.—The treatment of suppurative arthritis 
is highly unsatisfactory, necessarily of long duration, 
and in a great percentage of cases unsuccessful. The 
death rate has resulted in the trial of drugs, with poul- 
tices, blisters, continual irrigation with weak antiseptic 
solutions, ointments of camphor, alum, calomel, and cor- 
rosive sublimate. 

In the treatment of open joints, they may be divided 
into two groups: 

1. Open joints, such as the stifle, shoulder, or elbow, where 
ankylosis cannot occur, or, occurring, would destroy the use- 
fulness of the animal. 

2. Open joints which, if ankylosed, would not seriously impair 
the value of the animal, such as the smaller tarsal joints of 
the corono-pedal joint. 

The first question to be decided when a joint is in- 
volved in acute suppuration is whether an attempt 
should be made to prevent ankylosis or whether the 
process should be favored. 

Taking the first group, which comprises the more im- 
portant joints and in which ankylosis would be dis- 
astrous to the usefulness of the animal, we find it im- 
possible, or at least impracticable in the larger animals, 
to bandage these parts. If the joint is not infected by 
the object causing the injury, it is almost certain to 
become infected by exposure. In treating these cases 


168 WOUND TREATMENT 


we must prevent too great an infection, which causes 
an inflammation and destruction of the capsule and ear- 
tilage, and thereby results in ankylosis. We must also 
be careful that our antiseptics are not so strong as to 
cause some irritation to the joint capsule and cartilage, 
producing inflammation as well as increasing the chance 
for infection and in so doing hasten the destruction of 
the part. 

It is a known fact that most of our antiseptics cause 
irritation to the tissues even in a strength which is too 
mild to harm bacteria. Our antiseptic then must be one 
that not only prevents the growth of bacteria but also 
that does not produce irritation of the tissues. 


We have found pure glycerin to be an agent which 
produces no visible irritation of the tissues, and we have 
also found that bacteria fail to multiply upon it. Ac- 
cording to Rideal on Disinfection and Preservation of 
Food, bacteria and insects are killed by undiluted 
olycerin, since, having a very low diffusive power, it 
causes death by desiccation. Spores with thicker en- 
velopes resist it indefinitely, and on dilution of the 
glycerin begin to grow immediately. Cultures made in 
the laboratory of Streptococcus and Staphylococcus, and 
mixed cultures from cases of fistulous withers, fail to 
make any growth on glycerin. The injection, under 
aseptic conditions, of pure warmed glycerin into the 
hock or stifle joint of a horse causes the animal no dis- 
tress, and is followed by no increased heat in the part, 
no pain upon pressure, and no change in the gait of the 
animal. 

We find also that when we inject, under aseptie con- 
ditions, one part of Lugol’s solution to four parts of 
olycerin, or in other words, twenty-per-cent Lugol’s solu- 
tion in glycerin, it fails likewise to cause irritation. 


— eT ee 


PS Ad 0 pine ee as ee een, ee oY Ae ee 


OPEN JOINTS 169 


In order to determine the amount of irritation pro- 
duced by glycerin, we injected two ounces, slightly warm, 
into the joint capsule of a horse. Twenty-two hours 
later the animal was killed. It had shown no signs of 
irritation, and the capsule of the joint failed to show 
any congestion. Another animal, treated in the same 
way, was killed forty-eight hours after injection, and 
failed to show any symptoms, and the joint capsule re- 
mained normal. Two other animals were injected in 
the stifle joint in the same manner. One was killed on 
the third day; the other, at the end of two weeks. 
Neither showed any ill effects from the injection, and 
the joint capsules remained normal. In all, fourteen 
horses were injected, and none showed any signs of a 
disturbance in the joint. 

Later, injections of twenty-per-cent Lugol’s solution 
in glycerin were made in the same manner, and the ani- 
mals killed at intervals of four, eighteen, and forty-eight 
hours, and three weeks. In all, we were unable to see 
that any irritation had been produced. 

The treatment recommended by us for open joints, in 
which we wish to prevent ankylosis, is, first, to shave all 
hair from the area surrounding the wound, following 
with a thorough cleansing of the skin and disinfection 
of the wound, and then to inject a twenty-per-cent Lu- 
gol’s solution in glycerin into the wound. This should 
be repeated two or three times a day, each time enough 
of the solution being injected to fill the joint capsule, 
thereby securing the flushing effect. As this solution 
does not cause irritation to the tissue and yet is a strong 
antiseptic, it serves to shorten the period of congestion 
and inflammation and to overcome the infection without 
causing a destruction of the secreting membrane until 
the external wound has had time to heal. The injection 
of this solution seems to retard the excessive secretion of 


170 WOUND TREATMENT 


synovia. The larger the joint capsule and the smaller 
the external wound, the longer our antiseptic will re- 
main in contact with the inflamed tissues as the glycerin, 
being thick, does not flow through a small opening. 

In treating the second group of open joints, those 
joints in which ankylosis does not impair materially the 
value of the animal, we believe the treatment should be 
much the same in the beginning as for the first group. 
If we find the secreting membranes are highly infected 
and cartilages are becoming eroded, ankylosis is bound 
to occur, and we should direct our treatment toward 
hastening the process. | 

In this group we can use the bandage and antiseptic 
pack to good advantage, as all of these joints may be 
readily bandaged. The application of a 1/100 corrosive 
sublimate or other antiseptic pack should prevent fur- 
ther infection to the part. In making the pack, we have 
found it advisable to use gauze in place of cotton, as 
the gauze allows the secretion to pass through and thus 
drain away, while the cotton has a tendency to dam 
back the secretions and hold them in eontact with the 
wound, thus preventing the flushing action produced by 
the secretion of synovia. The free discharge of synovia 
acts as a flushing agent and thus carries out infection 
and pus from the joint cavity. The proper applica- 
tion of the pack and bandage constitutes the first prin- 
ciple in the treatment of inflammation—namely, rest to 
the part—by preventing or lessening the motion of the 
joint. Motion results in irritation to the tissues and 
promotes infection. We may render the joint immoy- 
able by the use of splints, shoes with a brace, or tar 
bandages and heavy packs. That this greatly lessens 
the infection and pain is shown by the unusual amount 
of weight the animal will bear on the part. 


- OPEN JOINTS | 171 


By making a free opening into the joint, we may be 
able to curette away the joint cartilage and thus hasten 
the process of ankylosis. Then, too, by increasing the 
size of the opening into the joint, we have a better oppor- 
tunity to disinfect thoroughly the joint cavity, overcome 
the infection, and thus prevent fatal sepsis. Abscesses 
in the periarticular tissue should be opened wherever 
they occur and their cavities thoroughly drained and 
disinfected. 

For the purpose of disinfection we have found long 
narrow strips of gauze saturated in tincture of iodin 
to be of great benefit. The iodin also serves as more or 
less of an irritant, and causes a destruction of the se- 
ereting membranes and joint cartilage which must take 
place before we may hope for recovery. 

In the human being and in the smaller animals there 
is another operation which may be resorted to—ampu- 
tation. When the infected area is great and there is 
danger of death from septicemia, the removal of the 
distal portion of the member allows of thorough disin- 
fection of the joint, as well as the removal of the in- 
fected area which is producing the sepsis. 

We do not favor the use of slings in disease of the 
articulations, believing that the animal, if worth treat- 
ing, is able to get up and down readily if given a box 
stall with sufficient room. Certainly a horse, if given 
a proper amount of dry bedding to prevent decubical 
gangrene, rests more comfortably in a large stall than 
in a stiff pair of slings. Another point which is often 
ignored is the removal of the shoes from a horse which 
is spending much of its time in a recumbent position. 
The bruising of the pectoral region from the front shoes, 
and the resulting infection, may be sufficient to over- 
come an animal that is fighting to withstand the attack 
of septicemia resulting from suppurative arthritis. 


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OPEN JOINTS 
By MART R. STEFFENS, V.S., M.D.C. 


This subject will be considered in two parts—open 
joints of recent origin in fresh wounds, and those of a 
chronic or subacute and infected character. 


Fresh Wounds Lacerating a Capsular Ligament 


It frequently happens as the result of accidents that 
an articulation is involved in the trauma. While all 
accidental wounds in veterinary patients are to be con- 
sidered surgically unclean, it is well not to carry this 
theory too far. Unless much extraneous matter, such 
as hair, chaff, etc., has entered directly into the articula- 
tion do not allow antiseptic solutions to penetrate to the 
synovial surfaces when you clean up such a wound. 

Swab the surroundings as clean as possible with a cot- 
ton swab, but do not allow any of the solution to reach 
the joint. Nothing seems to irritate a synovial joint 
more than water. 

After the surrounding eee are thoroughly Sead 
and dried with clean, dry cotton, the wound cavity is 
completely filled with chemically pure powdered sodium 
‘bicarbonate, some of which is even gently pressed so as 
to enter the synovial cavity. It is important that 
enough be used. A thin layer of cotton is now made 
to cover the lesion and is retained either with col- 
lodion or bandages. 

This dressing is allowed to remain for twenty-four 
hours. At the end of that time it is removed and 
the wound carefully inspected for synovia. No instru- 


173 


174 WOUND TREATMENT 


mentation is permissible; the inspection is confined to 
looking into the wound for traces of synovia. If no 
synovia is to be seen the wound is treated along regular 
lines. 

If synovia is present in the wound the treatment is 
repeated as on the first occasion and again left on for 
twenty-four hours. More than two such applications are 
seldom necessary, and unless the wound has been very 
large and is very severely infected, good, healthy granu- 
lations and no synovia are present after the first twenty- 
four or forty-eight hours. 


Chronic, Infected, Purulent Joints. 


The treatment of these is radical. While it happens 
now and then that cases of this kind recover with dila- 
tory methods of treatment, it is only by radical pro- 
cedure that prompt and positive results can be ob- 
tained. 

The various articulations of the equine present vary- 
ing degrees of severity and obstinacy in this affection. 
The elbow joint stands at the head of the list of fatal 
terminations. JI would class the coffin joint second. 
Next in order I would place the hock; last, the stifle. 

The following method of treatment is always suc- 
cessful in cases in which the patient has not become 
greatly emaciated and still retains the greater part of 
his vitality and good spirits. It is successful in fifty 
per cent of the latter cases, but it is of no avail (nor is 
any other treatment) in cases where the patient is down 
and refuses to eat. Such cases rally occasionally for a 
temporary period, only to go down again later and die. 
If the surgeon will select for this treatment cases which 
are, while moderately grave, still in good general con- 
dition, or even fair, he can promise his client good 
results. 


é OPEN JOINTS 175 


To carry out this treatment properly it is essential 
to cast the patient either on the ground or on the 
table. The following procedure is then adopted: 

Thoroughly cleanse the region of the joint involved, 
shave and scrub. Irrigate the joint cavity for at least 
ten minutes with a solution of hydrargyrum chloridum 
corrosium (1 to 3,000) at body temperature. This must 
be done with the utmost antiseptic precaution and great 
delicacy. If the opening in the joint is in such a posi- 
tion that good drainage cannot be vubtained, another 
opening is to be made surgically at-the desired point. 

Having thoroughly flushed the joint cavity with the 
solution, for which purpose a fountain syringe is best, 
it is now again flushed for a considerable time with 
sterile physiological saline solution at body tempera- 
ture. These washings are to be discontinued only when 
the fluid comes out clear and free from pus, flakes, or 
detritus. It may take a half hour of continuous irri- 
gation to accomplish this. When this has been accom- 
plished the interior of the joint may be considered sur- 
gically clean and it is now injected with the following 
suspension : 


year lidd © Gulles oe eo i es Biv. 
Mie Oy Ce IEA Cig Shore sen aie ee aoe ae aia et Ziv 
M. Sig. Shake before using. 


This is to be injected into the cavity slowly after 
plugging up all openings except the one through which 
it is to be introduced. The entire quantity is injected 
so as to be sure every portion of the interior comes in 
contact with the suspension. As soon as this is done 
the entire joint is swathed in clean cotton held in place 
by such bandages or retaining appliances as the surgeon’s 
ingenuity may devise. This dressing is to remain in 
place for two weeks. | 


\ 


176 WOUND TREATMENT 


In nine out of ten cases a complete cure will have 
been effected when the dressing is removed at the end 
of this time. In rare cases it may be necessary to repeat 
the treatment. It is very important that the entire 
joint be heavily swathed in cotton which must be held 
snugly, yet not tightly, in place. | 

The patient must be-kept as quiet as possible until 
the two weeks have elapsed, and during this time should 
receive a dram of hexamethylenamin in a pail of drink- 
ing water three times daily. 

Hexamethylenamin is of much value in various forms 
of arthritis; it has been found that it is excreted by 
serous membranes and it has been demonstrated to be 
present in synovial cavities within an hour or two after 
administration. Its antiseptic action is due to formal- 
dehyde, which is liberated during the process of elimi- 
nation. 


— 


TETANUS FOLLOWING SURGICAL 
WOUNDS 
By HENRY SMITH, V.HS. 


Up to the present time tetanus following operation 
has been put to the charge of the surgeon. The impli- 
cation has been that he introduced the tetanus through 
suture, lotions, dressings, instruments, sponges, or from 
his own hands or those of his assistants—not a very 
comforting refiection for the surgeon. Why should this 
tetanus occur in spite of the utmost care on the part 
of the surgeon? I believe that the reason is explained 
by Sir David Semple’s paper. An anaerobic area has 
been left—the sine qua non for the development of 
tetanus from tetanus spores. Sir David Semple has 
shown that the spores of tetanus are frequently present 
in the human intestine. He has shown that when tetanus 
spores are injected into a given area of a guinea pig, and 
quinin injected into a different area of the same guinea 
pig, tetanus bacilli are to be found in the anaerobic 
slough produced by the quinin and nowhere else, and 
that a control guinea pig which has similarly received 
an equal number of spores, but has not received any 
- quinin, is not affected by tetanus. How do the spores 
reach the anaerobic area in this case? I can explain it 
only on the supposition of some of them traveling 
through the blood circuit and eventually becoming 
stranded in the area of dead anaerobic tissue, where 
they develop into toxin-producing tetanus bacilli. 


177 


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FAVORITE WOUND TREATMENTS 


Applications for Successful Wound Treatment 


If a wound is to be stitched, it is washed out with 
boiled water to which has been added one dram mercuric 
chlorid and one-half ounce hydrochloric acid to the pint. 
Then it is stitched and covered with plain sterile gauze, 
kept moist with five-per-cent solution of carbolic acid in 
boiled water. The wound is dusted daily with a mix- 
ture of boric acid and iodoform. On wounds not closed 
by sutures I use the following: 

Powdered aloes, one ounce; denatured alcohol, four 
ounces, and linseed oil as much as will suffice to make 
one pint. 

These treatments or applications are made daily. As 
far as results are concerned, I believe I get primary 
union as often as any of the general practitioners in 
the rural districts, and more often than most of them. 

In open wounds the aloes-alcohol-and-linseed-oil mix- 
ture is a sure winner. I have found poor animals bound 
with all kinds of mechanical devices (most of them 
cruel and all of them unnecessary), to keep from gnaw- 
ing and biting their wounds. I have never seen a wound 
or sore—surgical, accidental, or constitutional—that the 
animal would lick, gnaw, or bite after the above dressing 
had been used twice in twenty-four hours. 

ar Poke ASH: 
Centerville, Iowa. 


179 


180 WOUND TREATMENT 


Nail Pricks 


Open the puncture thoroughly to allow good drain- — 


age, then cleanse the parts well with a good antiseptic, 
such as a 1-5000: bichlorid solution, and in severe cases 
apply the following freely, twice daily: 

fodin' cystals. . 62%). S esas « s\0's a wlan es 5 nnn div 


-» Sulphuric ether... 55% < f.0 sis see <a 7 5vili 
Protect the wound from dirt by covering with cotton 


and a bandage, and as an external protector, a piece of 
burlap. 
I have given this treatment a good trial on cases 


where pus had burrowed under the sole considerably, — 


and have had the best of results. 
Always be sure to give free drainage, and to pro- 


tect the wound from dirt afterwards. The ether in the 


above evaporates rapidly when it is applied and leaves 
an even coating of iodin over the wound, which pro- 
tects it from infection, thus allowing rapid healing to 
take place. 

I have used this treatment in cases of nail prick where 


the swelling extended most of the way up the leg, and > J 


have seen a rapid subsidence of all swelling after a few 
applications. W. P. BossENBERGER, D.V.M. 


Williams, Iowa. 


Wound Dressings 


When I make an incision, other than for the opening 


of a sinus or an abscess, I use a dressing of boracie¢ 
and tannic acids, for two reasons: I want to protect 
the wound against outside infection and I want the skin 


and stitches dry so that, barring infection while operat- | 
ing, I shall have healing by first intention. The same — 


applies to accidental wounds that are fresh and can be 
advantageously stitched. 


- FAVORITE WOUND TREATMENTS 181 


Where there is pus already in the wound, I use no 
antiseptics or dressings, except possibly for the first 
cleansing, or rather washing out, and then my hobby: 
is a light, wine-colored solution of potassium perman- | 
ganate or a normal salt solution. In this class of wounds, 
bacterins or nuclein, or both, get me the results, and I 
let the wounds alone: I simply cleanse around. the 
wound, taking care to keep the discharge from getting 
in and on the hair as far as possible. 

‘In the case of freshly punctured wounds, if deep, I 
give antitetanie serum, and, of course, bacterins, but 
let the wound alone after having secured as good drain- 
age as it is possible to give it. _ 

Occasionally a wound with exuberant granulations 
needs tannic acid or some styptic even as strong as 
- stibium chlorid to hold it in check. 


E. M. Bronson. 
Hartford City, Ind. 


Things I Have Noticed About Wounds 


1. Wire cuts do better in the summer than in winter. 

2. I have received very little benefit from the use of 
bacterins in the treatment of wire cuts. | 

5. If the periosteum is injured the recovery is greatly 
retarded. 

4. Peroxid of hydrogen does more harm than good. 

5. All unnecessary digital manipulation should be 
avoided. 

6. Wounds across the face heal more rapidly than 
in any other part of the body. 

7. Rope burns are harder to heal than wire cuts. 

.8. The majority of wire cuts come after an electrical 
storm. 


182 WOUND TREATMENT 


9. Wounds do better with a dry dressing than with 
liquid applications. we 
10. Bandages as a rule are a hindrance rather hee i 
a help toward rapid recovery. i 
11. The use of slings is very beneficial in the treat. i ‘ 
ment of open joints of all kinds. Re 
12. Ointments of all kinds are filth gatherers. oa 
13. The common barn sponge has no place in the 
modern wound treatment. a 
_ 14. And lastly, the teats in cows are practically the! 4 
only part of their anatomy that becomes injured from 
barbed wire, and beware, young man, when treativg — $s 
them. F. H. Burt, M.D.C. : 
Chenoa, Ill. 


22, TILES ORT DG SoC alae ae a ae eS ee 155 
ee EER eA A SEE Cs OS wo ws 8 Se ee weet Be oa ant ataataene My eke 75 
eee MOR MIBEE UNDE RELIEF ia 25 25) = wa 7 dee eva Se etapa a SEN we slate ne o's 33 
2 DE TUDE TIGTS 2G S00 1G 5 ie eee aC aed ee 93 
ee NEMEC PIED en src sis Fret. -fienc @ o's os ius ahe a aig Babe's Od GAR 33, 129 
PIE ONMESerY. HIndrances £0. 4... <j. oss sess Sas eens sice 39 
ue TE WEE RENCE ono sce case's oe oF afi S ocacain a «c's ae Ghee Ba eS 48, 62 
EPAMEIERME SS, Ne Seale cor eas PE PS ie ate Saf vren ces soso ak Mineo’ ce 42 
pee CORVEYVOr Of INTCCEION.:. . . 2/2 2 6 fib. i ae ose Sue weieslees 76 
Pena UCC TIMNEIC: TCLHOU oie nee es cs so nie v's va von a Sloe eens oie 9 
PUUUMMMDICSES ERI haat Woe Siang wie wie > Gime new Le Sie S slate bales clas 167 
PRIME UREA ist eas foe aaa tia ails x) ve Wes coe i> Soe iw ests, She mel Mace". 7, 33 
muse ptics, factors affecting action Of... 2.2 sic. sce ee e's 14 
Antiseptic surgery ....... eect Rte a. , aa eee eee en: 33 
eater eCOl COMMMUENIS. a). ofan ass tats wk es nl + oe ye ow eee 42 
eeeteees opr MAOH ANG COCMIA 2 oie cs 2S oc Zine 0 tun Se ein © baie a6 42 
eR SE AAC CE OSES OFS Oto ol 6 MS ho aid ea. 3’ Sia See eee wee Seas 42 
EVM MOC Y NOUS. ocho) s'0'S - bis aie eg eciets Sia i's 8% Ries 6 Naish ere. ssU0 42 
Ee seer OFS LOLAMUSs 2%. ovis eos’ sy eo toe gS a Se eRe oP Patents 42 
ICO EEE CUIOSIS 60. oo ahece soe the ors 21M Pete os Sa lage hop a Soa wes 42 
BAartenns tn wound treatment. 2%). 2 dni. bade see ss oo 8 ee 125 
ES ERMOMNYCER A, Noe Aspe aie 2 are ieie dn See al ccn's suds whale Ve Ae sted Sor ote 42 
SEE DIPSET ES oe er lho gl arse ae aes erties NS ig a ea 21 
(2EE TCLIG EGG oie A i Sas na ee ee ge mee ete 8 
EMM RMU ois ter aes pa ae, wy cic o Bw oleae won os 6 Shave Sn etnies oye 'o'e ee 61 
ERR RPA O TN he ace? Gans get als Sibi kale cies Scie VSS bows ene S 6 14 
SuEOiHic an ceLed, purulent JOIMUS As. BU. oe eee alee och e's 174 
Striscecatiouror wounds: !s..c.00. sl soe Shee Shee a 92, 125 
Cleansine and disinfecting Wounds... : 1. 6 <i. eactwke cele case 48 
Contusions with subsurface solution of continuity........... 156 
183 


184 WOUND TREATMENT 


Cost: of better wound treatment... ....5 26. ..:0. 00 sae walle wee 74 
Greolin- Pearson. 3. i sp ov ost ow ese Ae , «= 9s laa 19 
Deodorant =. sic. ooo 5:5 staf suelg 0 Gee aon ae» btalieee ten aie 33 
Disinfectants)... +. os s/ac.¢s’uw sso 0 o's wa me oes elas hn en 7, 33 
Disinfection. 2 pieces + siedareiend bee dee t/ntytale br 48, 100, 143 
Drainage Of WOUndS. 64/0 <0. i6 .+s,0 es da. cle nes a» Seen 49 
Draining tubes... < .. ssa’ « « 0's" 0018 6 p= 0 ain clei a s ae 88 
Drainage “Wick... 05 ss. cs «os «ns o/disie'he 0 a 00 5 ote «a 88 
Dressings as conveyors of infection....:.......+..0sssaeese 89 
Dressing ‘for nail pricks» .\.5 <4. «26s /0s.4 pls bel 180 
Dressing for open joints... 0... .se 5. os eter 175 
Dressings ‘Lor WOUnGBES , is). o5'70.0.0 css sn ~ ks ole een 153, 180 
E/pistaxig 22s. 2 i745 ciclo slica nels nese oe 0'e » bieiele,ackoa ent ous 62 
Eventration without visceral perforation............++.0:: 163 
Exuberant granulation ...........6-seeceeseeeeeeees ‘ae ane 134 
Fetlock wounds) 23.0) o s:<-pis 3a s 0s 00's ovine» said skin 52 
Flexor tendon sheath wounds...... .°.2, =<». +» «5 saan 53 
Foot; Wounds ye. see us sieie 2 vs 02's, 6,9 m9 6 0 5 9 2 0 53 
Foretgn bodies so. 62s bo\ee ply oes ede uo ote voy ors lw ate 49 
Formule for wound dressings................ 153, 175, 179, 180 
Glycerin a8 AN aANnTISephic, 2... 062 2d «0's clvin's o ok ge 168 
Gunshot wounds. 2:0... 2 e204. 0s sieie's.e eles vis 5 0s 5 Sie 122 
Hands, surgeon’s and assistant’s. ....... .:.....s 5000 80 
Healing of Wounds. © 2.0 ia: . 0%. ele eas so siue's 0s yo ae i eee 149 
Healing of wounds, how accomplished...............+--00- 126 
Hemtorthage® 2 ois 2.6. eietes. vies ¥ 2-0)a elas we! = oo ala ag 48, 57 
Hexamethylemamin: 2.6... s0s)0 se «0 sis o's 30 0 wo ln 176 
Human and veterinary surgery contrasted..............-.- 38 
Infection: by aif 1... 24's. si aa © vere 2 a0.cpelo cin epee 43, 76 
Infection by dressings «<i. «<<. o'ea «06 © ean wes 89 
Infection by instruments... .).....'04 22s «us oss ween 79 
Infection. by. Wafer... 6)... < o,3.0\0.6% oa. o\e'e-0)e)e sk 45 
Infection, circumstances predisposing.........2.-sssseessese 43 
Infection from miscellaneous sources. .........e.-eceeesses 43 


Infection from the surgical field... 0.3... ....¢.00es seen 90 


MPECE RIO POSLOPEL ALIVE: s.'a)s 2 Oe cisieta che !e a oo ee Bin se, ole w Rleee epee 90 
Mie rCEPOM, | WARLCTICS (OL s (20/6 nix. Satasecye' x Grace bbe eos ever e trate ele! e sine’ 41 
Pe aMELEFUMENLS BS /CONVEYOIS Of INLECHION, ¢ 6. boca 'an ee dlen ei ees 7k 


Kerosene as a disinfectant 


RS My on a | ovate A A oe 12 
EMU EEENEL Ses eS cate te tat ct oa cid Gyo teeter n ceolavive rede. wea ate Wow ews 53 
Lacerations of capsular ligaments............. cece cee eee 173 
Lacerations without eventration........ PMS i eine 160 
we) LDIF SELPERI DENS SSE Se Sr a RO eer eg oa aT Se 
Mem NV OIC TO Pore eon otek oothes oie Sa elas Sraisbe le ece-e eles Woe path 
ere I SOUIELA OT elt oie whe plete oe oie owe ais civ os Smieie gees Ss Fate 168 
Dn BTEC IYEREY 051 3 RP ei ha A ee 9 
WOE BERT LE yea a ae ccc cit oy nie alin 6) aise) oe a “wi ovaea & > EA aiseegon a eile 180 
Cope: Pasa See Re Cee ee 165, 173 
Marae SMMUOCIIIIN ELE «ala sh cha jor acale atone’ cia accde «aoe Sv de cave fevers oto hist ate at 8 109 
EMMI Se EESISTANCOD Obs talers crake. wicies v's Sale ob a de eee e Wee Pe 15 
SOR RaPT Ea Heep IGRL IRE tet teh nis TL MO al oN CSE TS oe Soe h eek I at 134 
Packing EOE SAM OMIUG Sete kt ua aoe solos che e'aiy os Op een te ces 88 
eae ECSU Mae hae nti ral SNe eR ELS Te NS wrcu sath eka Sie ooh SD GaSe oer a ts 9 
ER COC TRGVC TEC sta rere 96 ako ane e eae, tho ee he hd Sie ae Nk 18 
SEO GIVE INL CCLIOUs 002 °5 5 joints cislerelale os she, jee lstateleie e's eh tes 90 
Poashoperative treatment. of Wounds. ss. in. s0s fae hic ees «ne 69 
Penmcitire “WOUMdS ace sie be h ks t ton oe ee Mme, 52, 119 
ESE OAT SI Sie rs 5 stoi) ao be) seat oe site! ate a sweaty mie a wietelsia ccs 2 ¢ 16 
Hare ease NADIR S 2 ea. aes ians Stata da atest nls “of oeca ae! ais aioe e sis spe eka. o' 131 
PES ACCT OL \OTMMSING 2, fas eu, vc 2 elelese)e ose es sale bate a 2s 15 
Bigisd eo Serr 8 Si tor ia gobi eM ci Vii gir age a sd SRN My ia AERO A Oe 99 
TEsiicd vSeees aN I here aera a4 ol CHOY ke ae arate NN, ADE Ne ed Sa a ee 9 
SMO OIE (SUT ROLY: sxe ais a lak sotes fo cob a pts aayohe ae G aPalenn © Stee alee ale 33 
SSE EC PMV OUI Gee onc y, Pers os cl caete feo ic Sn iste! alan a eet talte a Wledy shee eGerd ove 32 
a besdibsl opie RUDI NCU rosetta aba ale ete rane teNara! ake aha Go lcohee w'a: weer ave. oi bp BS t's, © 139 
Skin, suturing the....... Pei cae EE aaa AN eG, bese erans 105 
Soluhsonscanayt herr. Combaimerscercicesc Neco os a ohet cs ot 06 ecb lec eueee.e 84 


~ 


186 WOUND TREATMENT 


Sponges 2. sous eae oe od oc sla selerela seid eam © Bale ae 83 
Staphylococeus pyogenes albus. ...........+.+sen+ss yee 41 
Staphylococcus pyogenes aureus... .........+s0<085 5 see 41 
Staphylococcus pyogenes citréus.......6.. 4.00.06 seu eee oo 41 
Sterilization < oo). seis avo eo ew oie a wd ee a hg © et 146 
Sterilization of instruments... ....../4:.+...++ «snes ee . 45 
Streptococcus ‘GUL. yo.05's o.c. 5 wie:sim en's 2 bonis os 6 bie wae ee 42 
Streptococcus erysipelatis. ..05 . 0s. <j.40.. 2+ ss sneer 42 
Streptococcus Pyogenes.. 06... sess es sass aes ee -- 42 
Subsurface loss of. tissues... - 2.5... 2-35 de. <2 wo ate 95 
Suppurative arthritis ~.20)5..4s0k 2. shes +6 ones a 165, 173 
Surgeon’s and assistant’s hands................ vos 80 
Surgical Aressings 5 2s gis'a6) sins s einsse och «8 aoe 2 0 0 oe 
Surgical field as a conveyor of infection............sseneamn 90 
Gabares if. sjo ke orzo G haere dare sd 050s 6a oie, 5 Ve ee 49, 86 
Suturing the skin flap iis os ws. 5. cc vce wdw a © ome hn 105 
TPeGawUs pisos ais iolais.g e tieee a \elge we aes sic 58.8 se goatee 177 
Thymol Oo kecs a peepee sneaks eo ée ota eec ce ah ben 8 
TUMOG? ans Le oo. york Web as iw aiele «cia iar w 2 i 59 
Union. by first mbemtion. 6... 6. ote 's oe ssw died oo eis pn 44 
Union by granulation and:cicatrization. .......).....s «seen 44 
Union ander a seals = ge. soc 6. ote o's sje +e 0ide sate 44 
" Waricose. wees. 23..)\o hae ccc uae v wien ve blown ae een 134 
Venomous, Wonndss so5.7 0b. eR oe ee ae buxte's sce ~ LIS 
Veterinary and human surgery contrasted.............+.0. 38 
Veterinary Surgery, PrOPTESS iD... os. sss ew oo ce ss ee 25 
Vaseeral, perforations... ens. > oe as ee 5 Oh one en ‘wd bee 164 


Wire © CUTE. acid Sede 2 bic idl Lin shan’ 9 mine cio bie bie w oun aa 181 


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