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Full text of "The treatment of wounds; its principles and practice, general and special"

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and i" iivt to Im iviuovd frvm llie 
lAbran/ Hifom hy tnuf pr-ivo/i ttr 
under auif itrvivxt winUr-iv.i: 






I ^ 



THE 



TREATMENT OF WOUNDS 



ITS 



% • 



PRINCIPLES AND PRACTICE, GENERAL 

AND SPECIAL 



BX 



LEWIS S. PILCHEE, A.M., M.D. 



miiBH or TB 



PBOICAL SOOUTZ 




WITH ONE HUNDRED AND SIXTEEN WOOD ENORAVINOS 



NEW YORK 
WILLIAM WOOD & COMPANY 

56 & 58 Lapatbtte Place 
1883 






• 
• • 


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• • • 


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* • • • 


• • • 


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• • • • 

• • •'• • 



OORBIOBT 

WnUAlC WOOD & OOMPAMY 
lfi88 



T«ow*s 

PKtNTING AND BOOKBINDING COMPANY 

aox-«i3 Sast Twelfth Street 
Nsw Yonc 



Ffe3 



PREFACE. 



[ Ik the prCBent work I have attempted to state, first, the principles 
L upon which the treatment of wouuds should be based ; then, to de- 
L scribe the means whieli are available to the surgeon for satisfying 
[ the demands of these principles ; and, lastly, to point out the parti- 
I colar modiflcationa which the peculiarities of special wonnds may 
[ require. In the first part of tlie work, the physioiogy of repair, and 
t the character of tlie influences which are capable of disturbing physio- 
I, logical repair necessarily receive attention. A knowledge of tliese 
I mast form the ground-work of all rational wound-treatment. As the 
I result of the more exact methods of research of recent years, while 
[ nmch cliaff, consisting of half truths and incorrectly interpreted obser- 
[ vatione, has accumulated, some facts have undeniably been established, 
I in the domain of physiology and pathology, which will stand the win- 
i novdng process of time aud experience, and will remain as permanent 
, truths that will always require the recognition of intelligent students 
of Nature. Not the least of these are those which have appeared in 
the special fields of wouud-ropair and wound-disturbance. These I 
li&ve endeavored to state in the following pages with an earnest con- 
viction of their truth, and of the great importance attaching to their 
I becoming generally understood and accepted as working-facts. 

It is not necessary that one should blindly follow the theories or 
9 the methods of any one man ; nor, indeed, is it just to select any one 
I name aa the special representative of the present state of the science 
I or the art of wound-treatment. The advances in our knowledge of 
I the therapeutics of wounds, which it would be criminal on tlie part of 
I a Burgeon of to-day to ignore, are the results of the labors of many 



IV PBEFAOE. 

men, in many different fields. In the present work, I have aimed to 

give credit in the proper connection, in the body of the work, to the 

various sources from which material has been drawn for its pages. In 

this place, however, an opportunity is afforded for me to acknowledge 

my indebtedness to my friend, Prof. Roswell Park, of Buffalo, for 

special assistance in the preparation of the chapter on Wounds of the 

Head, and to my colleagues, Drs. Geo. R. Fowler, Jas. E. Pilcher, 

and Glen. R. Butler, for many helps rendered in the course of my 

work. 

LEWIS S. PILCHER. 

4 MoNBOB Stbbbt, Brookltn, N. Y., 
AugQBt, 1883. 



This hooh is the property uj 
COOPER MEDICAL UOLLEGl!, 

SAN FRANCISCO. CAL 
ttltd in tiof f<> hi' rfMfiyd from iflP 

vnder anij pretext u:.\uff>xr. 

CONTENTS. 



PART I. 
IN GENERAL. 



SECTION I. 
THE PRINCIPLES OF WOIIND-TREATMENT. 






CHAPTER I. 

GENEEAL CONSIDERATIONS ON WOUNDS. 

TmpoTtance of Wound -Troatmcnt— Modem MethodA or 8ar([lc!il Study— Contro- 
venie* on Wonoil -Treatment Ooe Hundred Yeara Ago — John Bell — O'Hnl- 
leran — Principiea of Wound- Trefttraect Analjiod— Definitions — Chasifloation 
— InflueDCCB that Modify tbe Ucal!ns of Wouuda 3-20 



IMMEDIATE EFFECTS OF WOUNDS IN GENERAL— THE BE- 
PAIB OP WOUNDS— mTLAMMATION, 



OmttUutional ^JTiwij— Shock— Reactton-Trauniatic Tevei— Local Ef«eU—Im- 
palrment of Function— 0«pra^— Pain— Sfflmorrhage- Active HypBraemta— 

Li'nlon nf TToujHis— Eiudation—V BBCul aril ation— Connective- tiegQO Tmna- 
formation — Cicatriiatioc— Uulon by First Totention— CitaBM of Modified 
Bopaii— X^fct* oj Apj)cnlion—D<ifecli if Pivteetien—D^tcU of NuMtion— 



Modified ybrraal Ilepnir—Eeoiiag by Giaonlntion— Heoliog by Secondarj 
Adhesion— Healing by ScAbbing— Suppuration — DiapoaiUon of Effused Blood 
and Dead Tissue — Deatrvetice DittuThUMta of lispaiT — Inflammation — In- 
fectjoos Wound -Diseasea 21-36 



CHAPTER in. 

THE KELATIOKS OF MICRO- OEGAHI8M8 TO WOUND-DISTUEB- 
ANCEa. 

Eesnite of Defects of Protection — Oaoses of Decomposition of Animal Tissues— 
ReaeataheB of Paatenr and Tyndall — Atmospiierio Organisms— Kegiattng 
Power of Liviug Tissnes — Species acd Generation of Micro- orgauinms — 
Baoteiia — Bacilli — Micrococci— Researcbea of Ogaton, Koch and others^ 
Views of Hant — Summary — Wound- Suppuration — Septiraemia — Pyaemia — 
MiorococeUB-poiBoning — Clinical Deroonstratioca — Besulta of the Practice of 
Lister, Volkmann, and Nnasbaum — ComparBtive StatistiCH of Amputations— 
Mocewen'a Oatcotomies-'TeBtimany of Bands, Stokes, Cheyne, and Little — 
E«Bam^ 37-66 



CnAPTER IV. 

ASEPSIS AOT) ANTISEPSIS-WOUND-OLEANLINESS. 

The SdentiBo Basis of Wound-Treatment- Ptomaines- Sepals- J*«pfli» — Anlt- 
teptit — CfeiJift'ncw— Primary CleauBinff of a Wound— DrHin age— Cleanliness 
of Adjacent Tuaues — ClGanlinesB of Wonnd-DteaatngB— dir-Puriflcatian — 
Antiaeptio Sprays — Practice of Lister — Experimeuts of Stimaon and Dnucan 
—Effects of Sprays 60- 



WOUND-DISIKFEOTION— ANTISEPTIGS. 

Antufpttea in Gfierat: — Comparative Germioidal Strength of Various Agente — 
Strengths Eeqniied to Itestrain OeTm-DevcIopnieut— Local Effect of Anti- 
aaptics on Tiaanes- General Toiio Effects. Spfciiil AntUfptki. -^CoTroaive 
Sublimate- Permang^anate of Potassa — Carbolic Acid— Its AdTantageH- its 
Disadvantages— OatboUo Intoiication — Chloride of Zinc— Baliojlio Acid — 
Bonioio Acid— Acetate and Ace to- Tartrate of Alumina— loJine nnd lodo- 
fom— Iodoform iDtoxioatioa— Naphthalio— Suboitrata of Biantntli 6&-Q0 



OONTKNTS. 



SECTION II. 



THE PRACTICE OF AVOUND-TKEATMENT. 



CnAPTER VI. 

THE AEKE8T OF HEMORRHAGE. 

Spontanwua Bitrnottasui—FhiTgUnl /TamosJow— Eiposnte to Air— Cold —Hot 
Water — Iodine — AJcohol — TaipenXia^^MecJianieai Pifmare — CoiopreBsoa — 
Tampona — Aon praHsnro— Porei proBBure —Ligation— Catgut Liga tures— H«y- 
yinp F«iei»— Torsion— CoagnlmtB — The Oanttsry—litlerrupting Blood-current 
— Poaltion — Forned Flejcion— Digital CompreBaioa— Tonmiqnets — Elastio 
BftndBge — Aeu|>re8H0te— Ligation — Caidioo Sedativoii 83-127 



tt — Anamia — Au to-tmiiBf naion — Transf lis ion — Direct TruDB fusion — Defibrina- 
tion of Blood — Tecbniqua of TiansfaBion — Dan^'ersot Tranafuaion — PerlUmeal 
TrwisfaBion 128-137 



CHAPTER VII. 
THE GENEEAE CONDITION OF THE PATIENT. 



CHAPTER VHI. 
THE CLEANSING OF THE WOUND. 



Samaiilajit) — Sport ging—PnTiRrtttlon of Sponges — Irrigation— ConiJaaoaB Snb- 
meTHion— Irrigating Fluids — Drainage — Natural Drainage -AniScial Drain- 
age— Drainage-Tubes— Absorbable Tabes of Tfeaber, of Maoe wen— Capillary 
Drainage— Catgut Draina — Horso-hnir Drains — Sjinn-glass Drains — Omeral 
ConHderationt it* to Arlifieial Dr'iint—Iiemme — Primary Drainage— Sooond- 
■ry Drwnage— jlwwwi'y Mfit'i* of Wo'iniieiatnUaof—Adjacent Skin — The 

tflnTgeon sud hii Annistanta— InBtromenta and A pplianoes— Compresses and 
Protective Appliancas — Purifloation of the Air — Spray Prodncerii — Clmnting 
Btptic IFoundf-Onrette'i— Disinfecting Lotions. 138-1 



CHAPTER IX. 



APPOSITION OF THE WOUNT>-StniFAOES. 



PetUiM — Birut'iging — Rollers— Com prcBsea— Adheai 
ter— Oold-beater'a Skin— Collodion — Applicatioi 



8 Plttflter— Icthyocolla Plaa- 
of Adhesive Baadtkge— Ob- 




U CONTENTS. 

jootionB to Adhesive Bnndages — ^Fifunnff— Needles— Neodle-hoWera — Thread 

Silk — Catgnt — Silk-wonn-gat— Horse- hair— Metal Wirn — Application of the 

Sjiture — StitcheB of Coaptatian, o! Approiiination, o( Bel aiation— Knot- 
ting — RemoTing the SUtchea^ClaatiJkiiiian of Suturej— Intermpted— Con- 
tinuona— Pin-QaUl— Bead— Buttou— EfiBumS 160-IS8 



CHAPTER X. 
PROTECTION AGAraST DISTUT.BANCEa OP HEAUNO— ANTISEP- 

TIG DBESsraas. 

Cotton TPooi— Bora ted — Salicylated— CarboUtad— Bublimat«_ — iodotormiMd — 
Bismuth — Oaiae — Carbalat«d — lodoformized — NaphthaliDated— Ztnf— Tbu — 
Oakum— Naphthalinated Oakum —Ju (8 — rurZ-Jftit/W*— CAnrawi— Alaminatod 
Ciiaiooal—.Sunrf— Sub li muted Sand— Conf A»ha—Satedu»t— Wood- Wooi—T7i« 
Prcttetivt — TAe SMfnial Impenneabls Enteii>pt^Bandagc» — 77ie Mftlwdof 
Litter— The Iodoform Drating of B^roth—Emmtrch's Turf-Mould Dree- 
ing 18«04 

CHAPTER XI. 
PROTECTION AGAINST DISTURBANCES OF HEALING— tCoNTiNUED). 

REST. 

Potitinn — Compraihn — Immohiliialum — Wire-gauM Splints — Plaster-of-Paria 
Splinta ~ SheUs — Enoirclin^ Plaster-bandaga — FeneatTatod — Interrupted — 
Combined — Change of Dresaiogs — Anodynes £06-317 



CHAPTER Xn. 

THE BELIEF OF DISTURBANCES OF HEALING— INFLAMMATION- 
QANGRENE— ERYSIPELAS- SEITICJEJUA, 

Treatment of Injlammation — Opening tJie Wound — Ifiationt—Iiemorn\ of Ft/r- 
tign Boiiiea — Poeition — Compranon — Seduction of JJeat—OoiA Oompressea — 
Evaporatinj LotionH—Irrigation— Immerai on— Ice- bogs— Cold Water Coila — 
Sflmcatian of Vettdt — Abitraetion of Blood^InierrripUng the Blood-avpplff — 
liituini — TVmCinent of Gangrene — InciBioo*— Conlinaooi Antiiieptio Irriga- 
tion — StimnlMit» — T^reatmmit of iJiT/n^ieiu- AntisoptioH— Snbcutnneooa In- 
jectious of Carbolic Acid— SuperBcial Applioationa— Naphthalin— Tooics and 
StimnlnutH— AntiphlogiBtlcs — Treatment of Sqitieirmla — Local Oisiufection- 
fleueioi Treatment 218-33S 



J 



PART II. 

SPECIAL "WOUNDS. 



SECTION I. 

VARIETIES TKAT HAY OCCUR IN ANT PART OF 
THE BODY. 

CliAPTER Xin. 

SUBCUTANEOUS WOUNDS— INCISED WOUNDS— CONTUSED 
WOUNDS— LACEKATED WOUNDS. 

hibcutaneoiu Ilicniorrhagfe — Restriction, and Abeotptioa of EffuBlona — MoAxage — 
Dry Copping — Sorbe(aoienta — Inflammation^ — Incised Woundi — Kest — C'o/i- 
ttued and Lacerated ITouniii— Peouliaritioa— Secondarj HasmorrliBge — Pri- 
mary neBEHing— Drain age— NecToaia of Tissue — Coaptation — Period of Grao- 
vHaMon—Contutcd Punctured Woandt — Incisions 237-24G 



CUArTEU XIV. 

GUNSHOT WOUNDS. 

^pBonliaritlea of Guaaliot Wonnda — Hjomorrbage — Wouod-cleanlincBB— Imrao. 
diate Antiseptic Occloiion— No Immediate Exploration — ClaBRi&cutioii— Sta- 
tifltioB of Reyber^ — Kon-ocalusive Treatment— Enlaigement, CletmBing, and 

^Ditliifectiaa— PiobeB and Probing — ReuiOTol ol Bull eta— Immobilization. 247-354 
cerna: 



CHAPTER XV. 

NAL WOUNDS COMMUNICATING WITH FRACTUBES OF 
BONES AND WITH JOINT- CAVITIES. 



Feonliarlties — Value of Antiaoptio HsthodH of Treatment— UocCorm no— CI assili- 
cation- — Recent Injurit' toilA Sight ETttmtil Wound — Primary Antiaeptio 
Ocolosion— /fe«n( Injurk* trith Extcmoi Wound of ContUUrable Extent — 



^ 



CONTENTS. 

Prtmar; ExploraUon and Cleansmg — Connter-inciBions — Splinters of Bone — 
Dmin age— Suture — WiriiiuU of Joinlt- — InciiiiuiiB — Partial HcBeotions — Proteo- 
tiTo Drarein^H— ImmotiilkatioD — Atter-trestment— VnjMJiM not HecaiC and 
SrpUe-^'ViKvotahXfi Canes — Cases with PronouDoed Seplio Infsctioo — Disin- 
feotion — Immobilization — Fenestiated uid Interrupted Plutio Splints — Hou> 
eyoomb Plaster Splint 355-2 



SECTION II. 



WOUKDS OF TISSUES COMMON TO ALL PARTS OF 
THE BODY. 

CHAPTEU X^^. 

WOtlNDS OF MUSCLES— TENDONS— NEBVES. 

WoMnii (1/ jVitseirji— Diffioolties of CoapUition— Position — Bandaging^—Bntimng 
— Hest — Protection from Sepsis— Su bo iituneous Ruptureii — Woundt of Ten. 
ff4n«— Healing o( Subcataneoua Wounds— Difficulties oF Open WouDdH— Im- 
portance of Antisepsis, Protection, and Best — Sntuxini^ Teudous— Langu'a 
Cose — Pnuly's CoBB^Woundt of Nn-cei — Importance o( Approximation of 
Divided Ends — HethoilB of Approximation—Sntnring Nerves — Tillman's 
Statiatics— Results reported by Page— Pyo's Cnse^Page'a Case — Ajiplicatiaii 
of the Nerne-raliire—Diteat NerrB-sutore— Peri-neural Suture — The Sntnre 
Matoriftl^ConditioQs Ilequiring NetTe-autura-Neuroplasty— Tubular Suture 
— Contia-t&dicatioua — Bequiaites to Success 366-3 

CUAPTEU xvn. 

WOUNDS OF BLOOD-VESSELS. 

Importance of Wonnds of Blood vessels — Besnlta to bo Secured in Treatment — 
Difflcnl ties— Obliteration o( Vessel B—Belations of Coogulum to Repair— Phys- 
iology of Repair — AppoBitiaii of loneT Serous Surfaces — Means of Compres- 
■ion— The Ligature— Ligation— Gross on Immodemte Violence in Tjinjf a 
Ligatuie— Rules of Procedure — CompUeatioTui of WinindK of Blood- reteelt — 
Primary HiEmorrhiige — Intennediaiy H^Emorrhage — Secondary Ha-morrhage 
— Diffuse Tmomatio Aneurism— Woundt of rriiJ—PeouIiaritieB— Phlebitis 
and PeriphlebitiB— ThrorobofiiH- Efteota of Septic Ligatures — AcujiTessure 
aaxi Forcipressare — J E. Pilcbor's Case — AdvantagoBof Aseptic Ligaturei — 
Bepnir of Vein Wounds — Gross' C use ^Langtn beck's Onse — Lateral Ligation — 
Br»nn"B StatistioB— Seoeauorj Procantiona— Lateral Suture 380-308 



T hia hook is the pnrjh 
OOHTENTS. 

COOPER MEDICAL t'OLLlvGi;, 

SAN FRANCISCO. CAL 
Lihritrij Jhu-.i, I,,} «- .■/ pc-itoi^ tir 

WOUNDS OF s^diif'%-mM^:'-' ''''"''■ 



CHAPTER XVm. 
WOUNDS OP THE HEAD. 



Conrideratidnt—Stiperfieial Wound/ of &a!p— EmiMB and OontuaiOM 
— Fimotaied uul Inoiied Wounds — Exbtmuve Lacerations — Snperfioial Qnn- 
ibot Wounda — Beep Weundi oj Scalp tciCh Injuria to die Cranium — Sign* o( 
CompresdoD ot Brain AbseuC — Fraotuies of Iha Skull— lodiciatioiiB for Tre- 
phining— Frftclmea o( the Base ot tlie Skull — Compreaion of llit Brain — 
Wounds of latra-cnmial Veasels and Sinnses — Injuries to Cruiiiil NenreB— 
Wounds of Brain SabsLance — Hernia Cerebri — Wounds during Birth — Band- 
aging the iLe»A— Trephining — Indications for the Operation — Operativa 
Teohniqae— ExciiiioD of Irregular Fragments — Woundi of Bj/a — Woundtof 
Internal Ear— Wawuit of Clit Faet— Wound* of OnMoutA SOl-SSI \ 

CHAPTER XIX. 

■womros OF the neck and of the thorax. 

of Utt Larj/yui or Trachea — Functnrea — Longitudinal Wounds — Tnmft- 
Teise WoDnda — -Suturing the Trachea — Antisepfiis — Tracheal Conula — Intca- 
tiaoheal Polypi— HffiEnorrh age into Trachea — Wound* of Pharynx or (Etoph- 
Ofvi — Swallowing Intoidicted — (Esophageal Tube— Primar; Impartanoe of 
Deep Union- Longitudinal Wounds— Gunshot Wounds— Transverae Wounds 
— Wi/iind» of the Great Vetaeie of the Neck — Arteries — Vertebral Arteries — 
Internal Jugular Vein— Lateral Ligature — Coses of FarheH, Allis, Oenter, 
Lange, Lidell, and J. E. Piloh<ii—Non.j)enetrating WouiuU of the Thorax — 
Woonds of Internal Mammary' and Interooslal Arteries — Penetrating Woundx 
e^ the Thorax — Heart and Pericardium — Longs — Plenrw— Hemothorax — 
nieainotborax—EinphjrHeuia— Empyema and Hydrothotax — Rfsutn^ 83S'-S 



CHAPTER XX. 

WOUNDS OP THE ABDOMEN—OP THE PELVIS. 

WfeMtrating 'Wottnd*ef Pariela — Arrest of Hmmorrhags— Apposition — Peii»- 
. traling Woundt wiUout Injury to Visnera — The Peritoneal Wound- Pro- 
ion of Tiwera — Intestine— Omentum — Other Tiaoera — PdTMtratfn; 



xu ooirrENTS. 

Wowndi viith If^ury to Viteera — ^Exploration of Abdomen — Diagnosis Positiye 
—Diagnosis Presumpiive — Arrest of Intra-peritoneal HsBmorrhage — Satore of 
' Visceral Wounds — Lembert's Satore— Jobert's — Emmert's — G^y^s— Gossen- 
batter's — Czemy's— The Continaous Intestinal Sntaro — Ciroolar Invagination 
Suture — Primary Cleansing of Peritoneal Canty— Drainage^PeriUmUie and 
Septicmnia — Wounds of the Bladder — External Incisions — Laparotomy — Sut- 
nre of Bladder— Catheterization — Wounds of Anus and Rectum 851-874 



CHAPTER XXI. 

WOUNDS OF THE EXTREMITIES— AMPUTATION. 

Limitations of Conservation — Claasification of Wounds possibly demanding Am- 
putation — Duty in Doubtful Gases — Period for Amputation — Primary, Inter- 
mediary, and Secondary Periods defined — ^Effect of Antiseptics to prolong 
Primary Period — Shock a Centra-indication — Amputation to be done during 
Primary Period—Pcwn^ of Amputation — TrecAment of the Amputation 
Wound. 875-878 

INDEX 879-^1 






PART I. 



IN GENERAL. 



SECTION I. 



THE PKINCIPLES OF WOUND-TREATMENT. 



[TREATMENT OP WOUNDS. 



C'li.U'TER I. 



GENERAL CONBlDBB.iTIONS ON WOUNDS. 



mporuuiue ol Wound- Trentment— .Modem Methods ot Snrgicol Stody — Controveraics 
on Wonud-Treucmeut One Uundted Yeain Ago — .loha Bell — O'Halleians — Prin- 
cipIsHof Woimd-Treatmetit AnalysBd — Defiuitiuns — 'JlassiliuaiUoa — ^InSneiuieH tbat 
Modi^ tbo HeaUiig of Wonudtt. 

fTeB treatmeot of wouuiIb ib uudoubt«(llj- not merely tlie first stone, 

nit nlso the comer-Btone of surgery. By it aui'tj'ery hot) atttuned its 

Mte<(t triumpiiH ; by it our branoU of the profeasiou ImH conferred its 

^test beuefits on mankind ; by it eocli individual Burgeon may liope to 

3 more good th«n in any other way. NeverthelesH it Ims ever been one 

f the c)pprobria of surgei'y ; Uioujjh it was tlie lirst work in which aur- 

eoDB were engaged, it is at the present duy one of the chief questions of 

', and I trust it will remain so till it has attained to perfection." 

Tlieae words by Professor George M. Humphrey, in the Surgical Hec- 

a of the International ^ledical Congress of London, in 1881, do not too 

mgly Ret forth the importance of the subject of the treatment of woumls. 

It has been too much considei-ed the highest esercisg of the akill of the 

sni^eon to make wounds, and the deftness and neatness, i^erhaps the 

brilliancy, with which the mere mefhauical portions of the surgeon's work 

Uy be done liave been considered us more important evidence of merit 

Ura the less sti-iking and more prolonged duties re(|uireil in the after- 

eatment, in the course of which his judgment and the resources of Iiis 

dence are continually being put to their highest test Not only is this 

1 great measure to the fact ttmt the awe and admiration with wliich 



■( 



1 

L 



THE TBEATMKNT OP WOUNDa. 

the laity look upon the deliberate wounds which are maile Iiy a surgeon, 
clothe. miuh procedures with undue imijortance ; but it is also foBtered hj 
the improper methods of surgical iuHtniction, so generally pursued, iu 
which the chief interest is made to centre upon the operatire procednrea, 
and little or no attentiou is directed to the details of dreaung and after- 
treatment 

It may be considered aa one of the heat eTideu<.-e« of the solid chnrHi'- 
ter of the advancement which is claimed tor the surgeiy of to-day, that iu 
its discussions and iu its practice the principles of wound -treatment 1i«t« 
attained an overshadomug importance, while the mechanical details of 
operative surgerj- have been relegated to a minor place. 

That which hiw contributed to this end moat especially ih the apphca- 
tion to surgery of the rigid experimental methods of investigation of 
modem Science, by which general impressions, formed from imperfectly 
noted or understood experience, have been aubstituted by exact demou- 
strutious, guarded by adequate checks and careful precautions, tliat serve 
also to emphasize the limitfttions and variations iu the applications of the 
principles which they demonstrate. 

"While surgery baa tbua iilwaya been a noble art. it may therefore now 
begin to claim, for the first time with aome justice, tlint it is a noble 
science. 

John Bell, in his delightful disioui-sea on the " Nature aud Ciu« of 
Wounds" (Kdiuburgh, 1796), claims that the surgeon "does all bia ser- 
vices by observing imd managing the propertiea of the living Ixwly ; where 
the living principle is so strong and active in every pai-t that by that 
energy alone it regenerates the lost subataucea, or reunites iu a more 
immediate way the more simple wounds." Tlie pictui'C ivbicb Bell pro- 
ceeds to give of the opinions and disuussions among the surgeons of his 
ilay, which is barely one hundred years ago, aa to the treatment of wounds, 
is almost a hui'lesqne upon what is taking plai-o at the present day, with a 
change only in the jiarticular points of ihscunaiou. 

"Thirty yeai's ago, "he aaya, "surgeons had no settled notions that cut 
aurfacea might be made to adliere ; tliey had no motive for saving the 
skin ; or whore they had saved it, they did not know how it sliould be 
used, nor how much it might contribute to a sjieedy cure ; if they extir- 
pated a liunor, they cut away along with it all the surrounding skin ; if 
they performed the trejiau, they performed iu a most regular maimer that 
preliminary operation which they chose to call scalping ; or in iiloiu 



onef 



IN THK EIOBTBBltTH CXNTmtT. 5 

Fterms, tliey cut away six or eight iaclies of that Bkin which Hhould havu 
sftved tlie fractured skull from exfoliation, and should have imniedifttely 
covered and defended the brain ; in performing amputation, they cut by 
one strolie doivii to the boiie ; and even when they performed l!ie flap 
mputation they dressed their stump and flap as distinct sores, 

" An exfoliation of the bone in tiiese older oiierationa was a thing im- 
' avoidable ; so that it was port of their art and skill to procure exfoliation. 
And the filliny up and final healing of their conical stump was so slow a 
process, so imperfect, and so many exfoliation h of the bone, witli other 
H and hindrances, intervened, that it ia no wonder their imagination was 
I much occupied about the di<,'eHling, incaming, and cicatrizing of 
rounrls. ■Whenever a bone was laid bare, they believed that it tnust ei- 
loliate before it could heal ; until they saw this exfoliation perfect, till the 
e had at least thrown off an outer Bcale, tliey would not permit it to 
Ileal ; they would not lay the skin down upon a wound upon the shin- 
bone, or if there was a lacerated scalp, they cut the torn piece off; a 
large part of the Ki.'ulp could not be regenerated in less than neveral weeks 
md w) tliey made good their opinion by their practice ; for 
y generally, in that space of time, the whole, or a part at least, of the 
1 boue, waa thoroughly spoiled. These were a few of the many 
Lkes committed daily by the older surgeons, who were contented with 
Hteir theories about iucamiug and cicatrizing of wounds, too proud of 
llieir own art and too httle inchned to follow the simple ways of natui'e." 
The subject upon which discussion ran high in Bell's time was that of 
^procuring the repair of woimdti by immediate adhesion. Tlie French sur- 
^■geons hud declared, not only that their dap amputation procured an easy 
^Phfl perfect cure, but they affirmed that often in three days the flesh of 
Buch a stump had adhered To this a contemponu-y of Uell, O'Halleran, 
whom Bell characterizes as on excellent and most judicious surgeon^ 
whose doctrine and practice was followed by all the best surgeona of 
tiiat day, had replied : " I would ask the most ignorant tyro in our pro- 
fession whether ho ever saw, or heard even, of a wound, though no more 
_tiun one inch long, united in so short a time ; " adding, " these tjiles ore 
i with, more conlidence than veracity ; healing by inosculation, by the 
tat intention, by immediate coalescence without suppuration is merely 
merical and opposite to the niles of nature." 

Tlie field of controveruy has shifted since that day, but human nature 
8 remained the same, and the same disinclination to accept doctrines 



6 THK THEATMKNT OF WOUNDS, 

which do not agree with precoDceived notions, or that seem to be opposed 
to particular experience, clianictArize the diaoussioas of the present day. 
Many of the dillerences that havti ever existed, or do still exist, have ariaen, 
however, from the tendency to luuke theoretical couaideratdous or indi- 
vidual experience, tlie elements of which have not been accurately ana- 
lyzed and considered, the basis of gGneruliy.atioiiB that are esteemed 
r.omprehenaive. It is not surprising that a catholic and philosophical 
student of the subject of wound treatment, as be retlecta upon the chang- 
ing views and mofhods of the jiast, as lie ob8er\-e8 the improving results 
attained by differing methods tu-day ; and as he remembers the changes 
in his own views and practice at various stages of his experience, should 
hemtate to consider that the lust st«p attained has accomplished that per- 
fection which is the ideal to be striven for. Nevertheless no one will deny 
that there do exist ultiinaf« facts, as to the methods by which the repair 
of injury is accomplished by living tissues aud as to the nature of thone 
influences, which may fuvor or hinder these reparative processes, and that 
these fantfi, when fully understood, will afford a siu-e basis u(>on wliich to 
build a perfect system of wound treatment. 

Nor will it be asserted, in the light of the experience of to-day, that it 
is too much to expect that scientific research may accomplish the satisfac- 
tory and distinct resolution of the problems involved in the search for 
these facts, and estabUsh them clearly mid indisputably. .JuHt iu measure 
as this clear and indisputable estabUshment of these fundamental facts is 
being accomplished, does the ireotment of wounds become emancipated 
from theory and prejudice, and becomes established tipou a liiiol and 
perfect basis. The varj-ing conditions that attend woimils. conditions of 
constitution, of environment, of structure wounded, of agent and manner 
of wound, the presence or absence of needed material for treatment, and 
the measure of perfection iJi the care which may possibly be given to the 
wound will ever be the unknown and vai-iable quantities that will test the 
judgment and skill of the surgeon in the application of priiK^iples to 
practice. 
' Tho prineiples of vx>und Ireaiment, then, are of the highest importance 
08 preliminary to the adoption of rational methoils of practice, and by 
their study only oon any steady and permanent advance in wound thera- 
peutics be made. 

In recognition of this, in the diHCUsnion of the treatment of wounds to 
which the present work is devoted, there will first be considered the 





PLAN OF STUDY DIFINITIOWS. 

jnincipleB upon whioh treatment sbould be fouoded, and from this it will 
be possible to proceed to the application of these principleH in the chotco 
of metbods to be adopted in practice. The plan of sucb a study will 
include: 

Firtt. — The immediate eSecte of a wound upon living tisBuea. 

Second. — The procesBes iuatituted by nature, when undisturbed, for 

repair of the injury. 

Third. — Possible sources of disturbance, and their effects upon the 
reparative processes. 

Faiirtk. — The means by which the natural reparative processes may bo 

it efiectually favored and the action of disturbing agents may be 
minified. 

Before proceeding with this study, certain further general conaidera* 
tions sbould be noticed. These include matters of definition, of classifi- 
cation, and of the modifying influences of a general character that affect 
the repair of woimds. 

DxFiHrnoNs. — A wound ia a division of continuity of the bodily tex- 
ture, produced, either directly or indirectly, by sudden mechanical force, 
Wiseman, "the Father of English surgery," limits the use of the term 
wound to injuries involving division of the skin. In his " ChirurgicaU 
" (1676), p. 331, he thus discourses ; " A wound ia a Solution 

continuity in any Part of the body suddenly made, by anything that 
cuts or tears, with a division of the Skin. This Definition difTera much 
from what is usually delivered by Authors ; and it is fit it should. For 
they generally defining a Wound by a Solution in parte moUi, do thereby 
exclude a Cut mode into a Bone, as that into the Cranium by a Pole-axe, 
etc, which why it should not be called a Woimd I know not. I say, it is 
made by aiujthing that cul» <ir learx. Other Authors define it to be made 
by an external Instrument, etc. How then do they call thaX fmcluram 
cum v'lhiere, a Fracture with a Wound, where the Bone from within 
makes the Wound, and thrusts itself quite through the Fleah. Sennertua 
adds to his definition, that it is to bo done are xtvanlf and acuta: yet he 
reckons those for Woimds that ore made by Bullets, although it be a 
Caonon-ahot. I do therefore think it fit to make my Definition more com- 
prehensive, and to take in whatsoever makes a sudden Solution of con- 
tinuity, at least immediately and by itself, on what Part soever it lightetli. 
80 a Cut into a Bone is a Wound. Tearing the Flesh, Nerve, Sinew, 
Tendon, or Cartilage, by Bullet, Stone, Splinter, etc., is a Wound. Only I 



^_ wous 
ffeif a 



8 THE TREATMENT OF WOUNDS. 

add this restriction, that the Sldn must be likewise divided: by which lii>^t 
woi-del exclude Fractures that come not through the Skin, and Contusions 
if the exterior parts be continuous. But bj the word Sirin I understand 
not only the external Citlis, but also the inwoi'd membranes of the Gullet, 
Ventricle, Gut^, Bladder, I'rethra, and Womb ; all which are capable of 
Wounds from Sharp Instruments, either BWoUowed or thrust into them." 

Though the practical importance of the separate classification as made 
by this delightful old author, of injuries involvicg division of tbe skin or 
mucous membrane is still recognized, yet to make this on important 
element in a general definition is arbitrary and artificial. 

Tlie occurrence of a solution of continuity in any of the solid tissues of 
the body may be due Ui slowly acting causes, as the gradual waste of 
atrophy or the more active disintegration of ulceration, but a breach of 
tissue thus afifected would not be a wound. There is involved in the idea 
the action of a force outside of the tissue itself, which by mechanical 
force has rent or divided its substance. Even in those coses in which 
Bo-cnlled spontaneous rupture of muscular tissue occurs, it is not the oon- 
tniction of the tissues alone that is the cause of the rupture, but the force 
opposed to it cserted through the bony levers into which it is inserted. 

The t«rm wound, tberefore, is susceptible of a very wide range of ' 
application. Contusions, sprains, fractures, subcutaneous as well tm ii 
cutaneous breaches of tissue ore included in the term. In all essential | 
particulars they will be found to be identicnl accidents, involving the same 
methods of repaii* and subject to the Ruuie principles of treatment, their 
apparent differences depending ujtou accidental <liffer€nces of function, 
niitritioD, relation to other parts, extent of traumatism suffered, and of 
exposure to disturbing influences from without. 

These accidental differences are especially marked in the conditions 
which those wounds of bones tliat constitute fractures present. Though 
the method of repair, and the principles involved in treatment are tiie 
same in these wounds as in those of the soft parts, yet the apphcation of 
these principles in the vaiied fractures of the bones of the skeleton in- 
volves so much of detail that, by common consent, these wounds Imve 
been classified apart. In accordance with this general usage, which is 
of practical importance, the consideration of fractures will be excluded 
from the plan of the present treatise. 

CLAssmoATiOK.-The first great division ol wounds is into subcvtaiKOua 
and open wounds, tbe division depending upon their relation to Qie 



uniliet 
fc Op 



CLASSlFIOA-nOK. R 

mmoii coveriug of the body, SubcuUiiifouH woundsi include (ill wliicli 
mpaniedbv breach of the akiti. Pi-oiected by the unbroken skin 
from exteroid jj-ritation und infection, their repair is usually rapid and 
undietorbed by untoward I'oiQpIications. 

Opea noundti, aa a class, include all tcIiicIi exhibit a breach of the 
I, or mucous membrane. Thry may present the widest extrenaes of 
Game-breach, and of lose of substance. Thoae of this class, whose 
exposed surfaces may be quickly brought and kept in apposition, differ 
but little in their gravity from subcubuieouB wounds. Failure to secure 
such apposition, whether by intention or from neeessity, so modifies 
the course and duration of the pro<;eHB of heuling, and so exposes the 
wound to <Iau^-ers of disturbance from without, that such wounds con- 
stitute a well-marked class by themselves. To chmw.teri/* this clasBonly, 
the term open wouml is most commonly employed. 

Wounds are again divided, from the cltaraotfir of the agent or force by 
■which they are produced, into indued, punctured, conliireil, laceivted, gun- 
Act, and poUoimi wounds, according as the wounding agent has been ft 
^B^arp cutting edge, a penetrating point, a dnU and bruising body, a t«ar- 
^^bg force, a projectile impelled by the foi-ce of exploding gunpowder, or 
^^■Bfl which carries with it into the wound a poison. These divisions, with 
^^■M exception of the last, are indefinite general ones for convenience of de- 
^Hfcription. They are all alike in kind, and differ only in the degree of the 
injury sustained. Whatever force or agent produces a breach of tissue, 
occasions hkewiFie death of tissue in the track of the breach. Tlie shaipest 
^auA most delicate tutting edge, when ricwed through a lens of suEGcient 
^bttgnifying power, is seen to be rough and saw-like. Though the extent of 
^Pfce destructive action of an instrument is lessened according to tlie fine- 
Bess of the edge, yet the track of the keenest edge through a tissue is lined 
by disorganized particles that have been killed by its impact. Between a 
slight and clean incised wound, in which the destruction of tissue ia limited 
to the molecules traverned by the cutting instrument, and an extensive 
lacerated wound with roughly torn and contuse<l edges, or between a slight 
bniise and a contusion producing the death and disorganization of large 
masses of tissue, the difference is one of degree, and not of kind. In the 
■tight Bs well as in the severe injury there is dead tissue that must be 
taken care of. 

The important practical difference which has always been recognized 
ni the healing of incised and punctured wounds, as compared with con- 



10 TKK TEEATMKNT OF WOOHD8. 

tused and lacerated 'wouudH, has given importance to these diatinctioiis as 
a basia for a clinical clasaificatiou. Tbeae diB'erencea, howeTer, depend 
Bimply upon the difference in ILe facility with which the devittdized tissue 
is preveuted from becoming a source of disturbance to the healing of the 
wound in the several instances. 

The class of pi/isoned ivounda embraces a much wider range ot injuries 
than its traditional application wau intended to comprehend, and the most 
important practical classification of wounds is baaed upon the presence or 
absence of poisonous Bubstances from a wound. Any substance is a poi- 
son which, in addition to the immediate gross chemical or mechanical ef- 
fects which it ma}- produce, displays a specific subtle quality by which 
the vitality of the tiBSuea with which it comes in contact is degraded, a 
quality which is shown by the production of disturbances of the ntol pro- 
cesses of aa intensity out of all proportion to the immediate injury that 
may have been inflicted. 

Decomposing aulmal matter, certain Becretions of particular animnls, 
conveyed by their bites or stings, and certain vegetable juices, when intro- 
duced into wounds, lu* followed by disturbances in their repair so marked 
that their separate chissilicatiun as poisoned wounds has been natural. 
The nneompUcated effects produced by any traniuutism have been long 
studied in subcutaneous injuries, in the repair of which, even when involv- 
ing much contusion and laceration of soft parts and eTtcnsive effusion of 
blood, as a rule, sloughing, nuppuration, and intlammation do not take 
place, but the effused lii^uids and the dentalized tissues are removed by 
absorption in due time, and no disturbance beyond that inflicted hy the 
original wounding agent is experienced. Similar wounds, to which access 
of ordinary atmospheric air is })L'rmitted by reason of o breach ui the akin, 
invariably have their repair disturbed by putrefaction and sloughing of tho 
devitalized tissues, by decomposition and hquefaction of the blood-clots, 
by inflammation of the wound margins, and by a prolonged process of 
suppuration and granulation in the healing of the wound. Such residts, 
however, do not fake place when tlie air which is allowed access to a woimd 
ia purified of organic particles which are capable of inducing putrefaction 
in animal matter. Such wounds, though oi>en and containing contused 
and devitalized tissues and blood-clots, pursue the same course of repair 
as do subcutaneous wounds. Whenever, therefore, inflammatory, suppura- 
tive, and sloughing conditions arise in an exposed wound it is the result of 
the introduction Into it of foreign matters, which act as poisons in the dis- 



J 




ASBPTIC AND SKPTIO WOUNDS. 



11 



'bancea of the reparative processes that tliey create. The term poisoned 
voumls is thus made to extend in its applicatioQ to the great masH of open 
■wounds, those to which it was originally applied being simply esampleB of 
inoculatioD with special poisons. Upon this fact of the presence or ab- 
sence in a wound of poisonoua foreign material a classification of the 
greatest practical importance is possible, viz., into aseptic and septic wounds. 
Aseptic wounds include all which are preserved from contamination 
by poisonous materials, whether such poison be applied directly to it, or 
be generated in it by the action of germs that gain access to it and find 
it the conditions favorable for their growth. An aseptic condition 
a wound may he obtained either by the pi-otection which the wound 
ivea from the firat against the access of any septic agent, or by the 
er of living tissues to resist nud destroy septic agents, or by tlie appli- 
doQ to the wound of subutaucea which destroy' them. Samples of the 
class ore presented in subcutaneous wounds, and iu operative wounds 
which are inflicted w-ith certain precautioDS ; examples of the second class 
are seen in all open wounds in which union by first intention is secured, 
notwithstanding at the time of their injiictiou they were freely exposed to 
ordinary air ; examples of the third clans ore presented by wounds in 
which the appUcittion of antiseptic substances has been successful in ar- 
resting the action of whatever septic agents may have previously gained 
to them. Asepsis in a woimd is of the highest practical impor- 
As long as it is maintained, no decomposition of the eecretions of 
wound taken place, no slougbiug of killed or partly killed tissue oc- 
When the proper cares to favor the nutrition of the wounded tis- 
re rendered, the healing of the wound progresses without pain, 
imation. or suppuration, and the least possible amount of cicatricial 
lue is produced. To Btciire an aseptic comUtion in a wound, or to ap- 
ih it oa nearly as possible, is the first and most important indication 
vound-treatmeut. .^ 

Septic wounds include all in which nuy agent capable of exciting fer- 
uentatioa or putrefaction lodges and grows. They may present the most 
widely different degrees of wound-disturbances dependent upon the varj-- 
Gondittous which the special wound may present, and upon the char- 
of the treatment which is instituted, but in all cases they are 
ittended with some degree of inflammation and suppuration, and with 
sloughing of dead tissue. Tlie septic agent may be introduced by the 
body that inflicts the wound, or by the dressings that are apphed, or may 



widel 
"atten. 



be among tlie clunt iiarticlea that float iu tLe uir to which it is exiMsed. 
In very rure inatiuices, altto, it in |)Dasible that it may be eunveyed to the 
wouml through the blood of the wouiKled pereou himself. 

JIuBiKYiNo iNfi.rF.M^y.a. — Tlie effects in individual cases which particular 
injiiries produce are nerer the same, aud may widely differ. They &rfl 
tuodilied by idiosyivriifi/, mental utate, age, preoious eonttiiviional condition, 
diaewK, aud hygienic cuHdilioiv. 

Differeucea as to the abihty to bear iujui-iee exist among races, uations, 
fiimiUes, and iodividualB. The Lntin races liave leas resisting jxiwer than 
the German aud Anglo-Baxou. Oriental nations siupaaa the Occidental in 
their tolerance of iiijiuies. Of individuida of apparently ecjually good 
physiijue, and enjoying tlie same liygieuic surromulingB and treatmfcnt, 
one will recover from the most Eierious injury speedily and without serious 
complication, vrhile iu the other an iujiu-y, apparently much leas severe, 
may end fatally or in iirolouged illness. 

The power of resisting the ei&cta of extraneoxis influences to some de- 
gree is a characteristic of all living matter. Its cessation is death, and a 
dead tisane aud a jtassive tissue are synonymous. The quality of the vital 
resisting power inherent in the constitution of an indi%idual cannot ba 
estimated by any known signs. It may be modified by other conditions, 
but in some degree it is always present na a powerful unknown factor 
influencing tlie result of any case. It is a measure of the vital force of the 
l>iirticular individual, aud is what is meant by the term idiosyncrasy aa 
here used. 

Mental states may modify greatly the effects of injuries. The shock 
which attends the reception of an injury is particularly closely associated 
witli mental conditions. Tlie mere apprehension of injury has been 
known to produce death tlirough sliock, aud the ability to rally from the 
physical impression made by an injury is modified by the state of mind 
of the injured person. Tlie reparative pi-owisses likewise are subject to 
the influence of mentid conditions. They are pi-omoted by the emotions 
of hope, joy, espectation, confidence, and resignation, and may be hin- 
dered by fear, anxiety, disappointment, and allied states. This is illus- 
ti-ated on a large scale by the difference which has been remarked in the 
repair of wounds wliich have been sustained by a victorious army and 
those hy a. defeated and dispirited one,' In general, it is important to 

' ** Tbe Infloeiice of the meaCal aondition on the ronnltii uf houdcIh is unileniBble. 
All teporta agree that tho wouodaA of victodoug iroopa, eUted hy the 



INFUTENOE OP AQE OK BEPAIK. 13 



B INI 

Premember that, as it ib esprefwed by Tuke,' "The influence of the minti 
upon the bojy is nu tmusieDt power ; is health it mtiy exalt the eeDBoiy 
fusctions or suspentl them idUigether ; escit* the uenous «j-!ttem bo ae to 
cause the various foiius of t^onvulaive action of the voluntary muscleB, or 
^Mi^ress it so as to render them ^lowerlens ; may stimulate or paralyze the 
Bfcknsrles of organic life, and the proeeases of nutrition and secretion — 
causing even death ; that in disease it may restore the functions which it 
takes awny in health, reinnervating the seuson- and motor nervea, exciting 
healthy vascularity and nervous power, and (iKsistiiig the vis mediualrix 
V to throw off diseased action or absorb morbid deposita." -^ 

The influence of age in modifying the effects of wounds is exerted in 
I threefold way. At the two extremes of life the immediate shock from 
B more liable to be serions, but in the young it is more quickly 
nd completely rallied fi-om, while in the old its development may be 
more slow in its manifestation and ultimately overwhelming in its efiects. 
Secondly, the reparative power is greater in all jmrta of the young than in 
those of the older indiWdiiols of all species. The activity of uiitrition in 
yootii favors repair after injury ; the effects of this favorable inHueuce ore 
notable in the difference between the i-eadiness and completeness of 
repair in childien and tliat in adults. Ijostly, the freedom from pre- 
existing organic disease in early life prevents complications, whidt be- 
come more frequent as age advances. As the result i)f these various condi- 
tions, the general rule may be said to be that, after the age of thirty years, 
tbe ability to resist injnrj- decreases steadily with the increase of years. 
In connection with the influence of age upon the results of wounds, it 
Iny be well to recall the experience of Paget, as given in a clinical lecture 
" The Various Itiska of (.)iieration8."' lie says: " AVe have a largo 




n bravcTj and that of their comTodeB, did better tbnn those of 
i mMt Htrikiiig' example of tbln influeaoe of the mental oon- 
dition it) the successful treatment of wnnndH in modern timeH ia the feturfiil mottAlity 
among the French, after abot wniiudH of oil kiada, in the wui at I8T0-T1. Tbe ex- 
cea-iive tnnrtalitj' of that oumpa^ ira.i imdoubtedly Ini^ely owing to the mental 
dc^ltresslon canHed by u Hitocessioii of reverees rarely met with in the biatory of war- 
fare " (Miilical and Snrgical History of the War of the Rebellioit, Part Third, Surpioal 
Volnme. pnge 8118). ' 

' D. H. Tuke InHi.en™ of tlie Mind on the Body. 

'Clinical LeclnreitaDd BeHayii by Sir Jamen Paget, burl., nditcid liy Howard Monb, 
fc^C.8. Irf)ndOQ, ISTS. 




J 



THE TREATMENT OP W0UKD8. 

number of pricting offices iu the neighborhood of the hospital ; and ever; 
office employs many boys from twelve to sixteen years old ; and hardly a 
week pusses but we have one or more of these boys brought in crushed 
by the printing-machines. Fiugeia, hands, and arms ure thus mutilateil ; 
anil I know of no class of patients that recover more remarkably. Not 
only do they not die, but their wounds heal steadily and ipiiekly ; they 
escape erysipelas and spreading auppurationu and neuondary hiemor- 
rhages ; and often, when, to save any piece of a hand, we leave bits of 
skin that seem as if they could not live, they yet do live and grow good 
Bcara," Again, referring to those advanced Lq life, he continues: "All 
the risks of doing badly are at their maximum in some among the old ; 
but these are some of the risks tor which they will always need your 
especial care. The old are, much more than others, liable to die of shodc, 
or of mere exhaustion within a few days after the operation. They bear 
badly large losses of bk>o<1, long exj)osure to culd, sudden lowering of 
temperature, loss of food. Large wounds heal in them lazily ; and hence 
a prolonged liability to secondary heemorrha^.'e and other mischiefs of open 
wounds. Their convnlescence is often prolonged ; and you may expect to 
meet sometimes with great disajipointment in having your old patients 
die with some slight casual disease, as if exhausted by the long expense 
of vital power in healing large wounds. They get all but well : and 
then, after seeming for some time stationary, they fade imd waste and 
die." 

Under the head uf "Constitutional Conditionn," are to be classed cer- 
tain general states of the blood, or of the nerves, or of the general nutri- 
tion, iu which, «'hile there is not a recognizable disease, there is still n 
departure from a perfe<'t standard of health. It is rare, if ever, that any 
individual would satisfy the strict requirements uf a ^lerfect standard, and 
the varying degree and combinations of departures from this standard, 
which different imlividuals jiresetit, mark the coustitutional difTereuues of 
individuals. It ilifferH from what I have termed idiosynnrasy, in tliat it is 
n measure of the extent to which yitality hits been Mn]>]>e<l iu the tiasueB 
of an individual, while the former refers to the vigor with which the 
tissues are able to resist deterioi-ating influences. Plethora, anfemia, 
obesity, these are gross examples of constitutional differences. I am 
inclined to class here ulsf) the pendiar vulnerability of tissue which con- 
stitutes the scrofulous diathesis. The conditions which result from ad- 
diction to alcoholic stimulants and to gluttouy ; from the exlmustton of 



INPLUENOE OF DKEASK ^HYOIENIO OONDITIOWa 



15 



p-Orerwork, nnderfeediiig, or mental Htraiti ; from viciouM habits, and from 

h&bitual inhalation of \-itiated air : these are some of the more marked 

examples of influences, which, by their effei-t uiwn bodily nutrition in 

{general, aggruvate the efl'ects of injunea by prolonging the period of their 

^uapair, and rendering them more easily afiected by extraneous disturbing 

^Bbiflaences. 

Closely allietl to the conditionB just remarked upon, are well-marked 
diseased states, such as sj'philis, tuberculosis, malaria, diabetes mellitiis, 
■nd Bcurvy. which, by the nutritive defects which they determine, delay 
repair, often arrest it, and subject wounds to the most serious complica- 
tions. The pre-exist€nce of pyicmia, septicemia, erysipelas, phlebitis, or 
any diffiise inliammation, will add special dangers to any superadded 
tnomatism. Diseases of the various organs of the body, and particularly 
CRrdiac, pulmonary, hepatic, and renal diseases, modify the effects of 
wounds both directly, by the constitutional states which they create Uiat 
interfere with repair and diminish the resisting power of the tissues in 
general, and inilirectly, by the reaction of the injury upon the pre-existing 
ictioii, producing' in it temporary exacerbation, or permanent and 

isiTe aggravation, with not infrequently speedy death. 
By their relation to the functions of nutrition in general, hygienic 
mditions also exert an important niodif^-ing influence on the healing 
uds. Food, insufficient in quantity or bad in quaUfy, extremes 
of temperatiu'e, absence of sunlight, depressing chmutic conditions, 
lact of exercise, insufficient and impure air — these not only create pre- 
^^rious constitutional conditions unfavorable to repair, but, when continued 
^Htfter the reception of a wound, <1irectly diminish its activity- Erichsen,' 
^^B discussing diet aft«r operations, remarks : " The soldier or the sailor 
^^k active service is often exposed to serious injuries that necessitate the 
^^pore important operations at a time when his constitutional powers have 
^HDready been broken down by scurvy, dysentery, or some other similar 
nffectioD, resulting as mucli from the deficient quantity as from the un- 
wholesome character of the food with which alone he can be supplied, 
. after the ojieratioa his only available nutriment may be of the 
; chantcter, possibly salted, and imijerfectly cooked. In such 
nimstances ope rati on- wounds Jo not heal, or they assume n peculiar 
mgrenous character ; or the patient sinks from ulceration of the intestinal 



1 tkHence and Art of Surpoy, vol. L, p. 81. Philudelpliia, IBTfl. 



16 THK TREATMENT OP WOUNDS. 

mucous membrane. Tlie mortality of o]>eratious becomes enormouslj' 
increased ; and there can l>e little doubt that tbousauds of deaths which 
have occurred in wars between the most civilized nations and the beat 
appointed aiiuisB may be attributed to these cnuuetj." The important 
influence which diet uiay exert upon repair should not be overlooked in 
the treatment of wounds. An ample supply of fomi, in a digestible form, 
with care observed that the digestive powers of the j)atient should not be 
overtaxed, with due regard to the personal tastes aud instincts of the 
patient, will form the general rule to be followed. The weather, in which 
ore included temperature, hmuidity, atmospheric pressure and movement, 
may also depress or stimulate the general nutrition, and thus influence 
the repair of wounds. Moderately warm weather, if it be not sultiy and 
oppressive, favors repair "Uret'tly, and also indirectly, by encouraging the 
opening of doora and wbidows and thiw permitting free air-supply. A 
dry, clear atmosphere in exhilarating ; a <1tu»p, raw one, depressing. Dr. 
Addinell Hewsou, ' from a comparison of the meteorological records and 
the recoi-ds of operations performed in the Pennsylvania Hospital during 
a period of thirty years, found that with an ascendijig barometer, tlie 
mortality of operations was a little less tlian eleven per cent., with a ata- 
tionary barometer, more than twenty per cent., and with a descending 
barometer, more than twenty-eight per rent. The fjeqnency and moiv 
tolitj' of pyaimia boi-e a direct relation to low barometrical pressure and 
moisture of aii', while the deaths from Hhock occurred in n constant ratio 
with the opposite condition, drjTiess of weather. 

Wales, in liis work on " Surgical Operations and Appliances " (p. 124), 
speaking of the obsen'ations of surgeons in hot cUmates, that wounds heal 
more nuickly uuder an elevated temj^erature than the reverse, says : 
"This is strikingly illustrated in the influence of our high summer heats 
over the adhesive process, which takes place much mure sorely tbau in 
cold weather and damp cool latitudes. The same thiug is observed in 
the coustitution of the Ara.h, whose climate, active habits, and diet pro- 
duce a spare and sinewy frame and a sort of di'y temperament yery 
favorable for tlie quick healing of wounds. 1 hf.ve made the same ob- 
servation in some parts of the East Incbes, where the population is under 
analogous influences. In the Gulf of Mexico the heat during the summer 
is excessive ; and it was during a 2>eriod of tliis sort of weather that I 




IWrLnEHOE OF CLIMATE — SUNLIOHT. 



ir 



Kived into the hospital imder my charge, at tbe mouth of the HiBsia- 
*rfppi Kiver, a large number of the wounded during the naval operations 
agjiinat New Orleans. Though the buildings were crowded with the 
wounded and fever patienta, all of the wounds healed with unusual ra- 
pidity ; aud of fifteen cases of amputation of the thigh and arm, but two 
died, both of them after secondary ojieratious, one of the patients having 
lat a good deal of blood from having hiy knto shattered by a riHe shot ; 
k the other case, disarticulation was performed nt the shoulder for a gun- 
tot wound of both the tuillarj' artery and vein." Rochard, iu speaking 
t the heahng of woimthi in hot climates, saya ; " All of our confreres 
int out the rapidity of their course and the promptitude with which 
J- heal. I h«ve niyselt been able to verify it often in Uliidagasear. The 
1»d guns of which the Sacolnres mnde use, often burst in their hands, and 
I have seen some of these comphcated wounds, for ^'hich I litid proposed 
Uputation. heal with a wonderful facility, iu spite of the most ii'rationiil 
satoient. lutertixipical climates are favorable to the efforts of conseiTO- 
! surgery ; and operations, when it is iiii[}ossible to avoid them, suc- 
eil better there than in Eui-oimj. Tlie same obsonation has been made 
B Oceanica, on the coast of Afnca, in South America, aud in the Antilles. 
I explains the almost constant success of the amputations of naval sur- 
. equatorial stations, aud the remarkable cures that they often 
a when it is possible to abstiun from them." 
The stimulatuig effects of sunlight ui>on nutrition shouIJ also be re- 
a the hygieniii nianagjBJuent of the wounded. Next to the ncces- 
y o! fresh air supply, tlint of simhght has assujued importance in the 
Bent prevailing views as to the arrangement of hospital wards. There 
It an instinctive craving for the light innate in all living beings, which 
m«H more marked whenever, for any renaou, there is a depression of 
1 power. Both pathetic and truthful is the observation of Florence 
llfhtrngale, in her "Notes i>n Nursing," tliat "it is curious to observe 
r almost all patients he with their fai^es turned to the hght, exactly 
I plants make their way toward tlie light. ,A patient will complain that 
I gives him pain lying on that side. 'Then why tin you lie on that 
He does not know, but we do. It is because it is the side 
nvord the window," The effects of sunlight uimu nutritii»u and growth 
l^e an excellent illustratiou iu the hygiene of the growing child. The 
Kial apphcntion of this illufitratiun to the course of woimds in adults 
>eiids upon the fact that in the repair of tUl wounds there ia a return of 



18 THE TBKATMENT OK WOUNDS. 

the local tissues engaged in the repair to tliat condition which marks the 
tissues in general of the growing child. 

Insufiicieitt air is synonymous with impure air, for the purest air, if 
not renewed with sufficient frequency becomes speedily poisoned by tht 
exlialations from the persons of those breathing it. This, which is true in 
health, is still more quickly accomplished when the bodily exlialations are 
rendered more offensive by diseitBe. It becomes therefore more important 
for the well-doing of tlie sick than it is for the welfare of the well that an 
unlimited supply of pme air should be supplied. Wien to the natuml 
sources of air-contamination there is added the emanations of suppurating 
wounds the need of constant change in the surrounding air is more em- 
phatic still, if its piuity is to be preserved. ^Miile much attention lial 
been directed to the impoi'tjuice of the aderiuate ventilation of hospitals, in 
the words of which numbers of wounds are assembled, it should not be for- 
gotten that the same necessity existn for inolated cases in their own homes 
that they do not become sources of infection 1o themselves. Absolutely 
pure air is not attitinable in the ordinary conditions of life. While it ia 
the gi-eat oxygen-carrier for the needs of the livin-j body, it receives in ex- 
change from tlie body the dL-bris of its disintegration. It is the vehicle of 
transportation of an infinite variety of floating matter, the great muss of 
which is organic in character. Putrescible organic matter cannot long b» 
exposed to tiie air without becoming the recipient of puti-efactive germs 
from it. Aseptic wounded surfaces quickly become septic when exposed 
to it by reason of the floating septic particles that it conveys. The best 
BtimuJant to the vital resisting power of a living tissue, by which tlie effects 
of sepsis is antagonized and overcome is perfectly osygenized blood. The 
air thus carries both the bane und the antidote. The practical end tliere- 
fore to be aimed at. in any given air-supply, in that there phnll be as small 
a propoi-tion of the bane and as large a proportion of tlic antidote as pos- 
sible. This uivolves the removal, the suppi'essioii, or the diffusion, as much 
as possible, of all sources of conlaminatiou, and t)ie dilution of that wbicb 
is unavoidable by the introduction of the largest quantity practicable of 
the purest air attainable. The purity and the sufficiency of the air are 
thus seen to have a double relation to the healing of wounds, one a general 
relation, which the lur shores with other hygienic conditions, and the other 
a special relation as a carrier of and an antidote to sepsis. Tliis latter re- 
lation demands further notice. As the sources of infection are multiplied 
and brought near to wounds capable of becoming infected, ^vill the acttoa 



■Mei 



CHARACTEU OP AIR. 

of tike air HH a medium of infection be exempMed in its highest degree. 
This is accompUsUed by the occumiUatiou of numbers of septic wounds in 
one building with limited veutilatiou capacity, Saya Erichsen,' "The 
overcrowding of wounded people, whetlier the wounds be accidental or 
surgical, will inevitably produce one of the four septic diseases, pha- 
geda-na, septicEemio, pyiL'mia, or erysipelas. When the word ' ocercrowd- 
ing ' is used in connection with suryical hygiene, it does not mean the 
heaping together of the sick and wounded in one building beyond what it 
ia intended to hold ; but it means the uccumulation iu one ward or under 
one roof of a greater number of patieotH than is compatible with such 
purity of ah- as to render the septic poison incapable of development or of 
fropitgation ui it." 

The value of ivir as aa antiseptic ugcut is shown by the diioinished pre- 
iptic diseases when those, who by reason of open wounds are 
fiivorable subjects (or their development, are isolated from each other, and 
ai-e supplied with abundance of comparatively pure air. Still the air, how- 
ever great its ijuantity, does not destroy the particles of infection tiiat it 
ililutea. It acta only by increasing the resisting power of the tissues and 
by lessening the amount of the infective material deposited at any one 
time. It is the presence of these infective particles that make it important 
that to a person suffering from an open wound an amomit of ah- should be 
supplied in excess of that required for the ordinary purposes of healthy 
life. Whatever means then may diminish the number or activity of the 
agents of infectloik wlU by that much reduce the importance of an unusual 
air-supply in the treatment of wounds. 

In concluding these paragmi>hs on the general modifying conditions 
it influence the course of wounds, I remark that tlieir i:)ertinency 
upon the trutli that tlie treatment of a iiound involves the treat- 
lent not only of the particidar brencli of continuity, but also of the 
lUnded person as a whole. It is possible that in the special lUi-ection of 
intion to the details of local treatment, matters concerning tlie general 
ite of the ])atient may lie overloiiked or silighted. Too often, perhaps, 
the case. Tlie duty of the surgeon extends, however, beyond the 
icted field of binding up the woimd and keeping it free from ti-rita- 
His ministry to the mental state of tlie wounded may be of the 
lost importance. The ability to excite in the min<lK of those subject to 



'ScfenoeanlArtof 



, p. 33. Philadelphia, 18T8. 



20 THK TREATMENT OF WOXWDa 

his care a feeling akin to tliat of the beleaguered garrison of Metz toward 
Pare, who cried out upon liiK arrival among them, ** We have no longer 
anj fear of dying, even if we should be wounded ; Par6, our friend, is 
among us," may make the difference between life and death. The special 
risks from age, from the previous constitutional condition, or diseases of 
the injured, must be appreciated and met, and the hygienic conditions in 
whidi the wounded man is placed must be made as good as possible, 
before the whole duty of a surgeon is accomplished. 



CHAPTER 11. 



IIATE EFFECTS OF WOUNDS LN GESEKAL— THE HE- 
PAIR OF WOUNDS— INFLiMMATlON. 

hitstitUtlOiuU I^eeU^Rhodk—Reaction—Tnmaatii: Feve.i— I-oad BfeeU—lmpait- 
meiil of Function — Gapiu(t — Paiu — Ilajiaotrbagt)— Active H; persemia-^ f 'nian "f 
Wou n<b— EiQilation— VoBODlurUutiou — Conuocti « e- tisaoe TrauaConn&tlDn — (.'im- 
triatlOD— Union by First Inteutiou— Cunsea ot Modified Rep^^Defrflu of Ap/Ki- 
mlion—VtfecU uf ProUolion—Jifffett </ :f.arit!oii—.}fiifiiJled Iformal Jlrjmir— 
Healing by GnmiilBtion— Healing- by HectiadiLty Adlieaiou— Healing by Scabbing— 
Sappumtion — Diaposition of Effused Blood uud Dead 'ViaBae^I>alruct«>» Dit- 
turbnnc/H •>/ ICepiiir — I ntkmmati on— Infectious Wound- Diseases. 

imaieiliiite ellei.'1-s of n woiiud art twofoki in clinracter, comtilvlioiuil 

CosBTiTPTioNM, Effkitts. — All wounds, of every tl^'gree, produce at first 
depreasiug effect upon the whole body. Tliia in ftct'oinpUshed througli 
nerrous syatom, inny be so ahRht and ti-ansitory as to be unnoticed, 
may be so profound sa to ciiuso lustaut deiitli, This general depression 
istitutea xinK-k: It mumifesta itself most prominently through the 
circDlation by diminution in the ooutiw:tile force of the heart and 
iLTteriee — reflex vjiso-inot^r pandyds. Tlie vjirying degrees of depression 
fiS. nerre-force and of heart-failure which may be pi-oduced by the inflie- 
of a wound cuuae the symptoms of shock to vary from momentary 
llor and mental confusion to a condition of profound prosti'atiou. 
ten the vitnl powers rally fiom this state of depression and the differ- 
ent organs begin to resume tlieir proper fimetions reaction is said to hiive 
taken place. In the most favorable cases reaction is gradual and pro- 
live, though it may ocLUjiy many hom-a. or even days, in its course, 
ituming color to the face and increased powei- in tlie heart's action are 
earliest signs. In certain cases fluctuations in the reaction occur, 
rel^>8e alternating with improvement for a variable time. In some cases 
Ihere is an imperfect reaction, characterized by rapid and weak heart's 



■of ni 

ent I 
taken 

ttasii 
tun 
eai 



-^^"^ ^ 



92 THE TBKATMEWT OF WOrtTDS. 

action, cerebral excitement, muscular tremor, and higU boily temperature. 
Tlie reault of such a condition is doubtful, speedy death or ultimftta 
recovery lifter a prolonged struggle being pouBible. 

The reaction from shock is commonly attended with elevation of the 
body temperature, quickening of the pulee, thirst, derangement of the 
secretions, restlebsneaa, and headache. This fever of reaction may lie »t 
trilling and evanescent as to escape notice ; its grade of severity depends 
chiefly upon the nervous excitability of the patient, liia previous constitu- 
tional condition, and the amount of local irritation produceil by the injury. 
■ Children manifest it most readily. It is of reflex nen-ous origin, makes 
its appearance usually within a few hoiu^ after the reception of an injury, 
and may be expected to decline on or after the second day, Its most 
severe manifestations are seen in cases of imperfect reaction, its combina- 
tion with which produces the condition of excitement with prostration 
which characterizes these cases. It may be dangerouslj- intense, and ia 
then apt to be accompanied by a delirium, which is genei-aHy wild in 
character but temporary- in duration, subsiding witli the restoration of 
the general bodily functions. This reactive fever is to be disfinguishwi 
from the fever which complicntcH the rejiair of injuries, which does not 
develop until two or three days after an injurj-, and is deiiendent upon 
general blooil-infectlon by absorption of septic matters from the injured 
part. The two might veiy properly be designated tui primary and second' 
ar;t traumalic/ever. The secondary is often engrafted upon tlie primary. 

Local Eitects. — All breaches of tissue are produced either by a. force 
of traction, tearing asunder the elemenis fri>m each other, or by direct 
pressure forcing the elements nsundor. The first constitutes a lacerat'im, 
the second a rimtngion. "Wlien a lacenition is iuflicteil a greater amount 
of damage is likely to liave lieen >lone than the particular breach wouLl 
indicate, owing to the wide distribution of tlie effects of the strain, the 
culmination of which at the point of rupture alone is declared by the 
wound. The strains, rents, and raptures of ligaments and cajtsules that 
result from joint- wrenches, distortions, or rlialocations, muscular ruptures, 
the sprains of tendons and tendon-shenths occjisioneil often in violent 
manual efforts, the teaiing away of epiphyses and bony prominences 
through strain upon the muscles or ligaments attached to them, and i-ent* 
in the substance of internal organs, or their separation from their con- 
oeotions by the jar of falls, are examples of subcutaneous lacerations. By 
the prolonged impairment of function whioh they produce they illustrate 



J 



LOCAL EFFECTS OP WOUNDS. 23 

B force of the statement as to the wide distribution of the eSects of 

Btraiii. A contusing force may likewise out as a Incerating force upou the 

tissues beyond the range of ita direct impact, and the moat severe wounds, 

_ as ivgards the difficulties wliich atteml their treatment, are thobo in which 

B^aceratioii and contusion are combined, as in the accidents produced from 

^^le entanglement of limbs in machinery or by their crushing under the 

wheels of cars. In a pure contusion, however, that is a breach produced 

by direct preseui'e only, the traumatism is limited in its estent by the 

area of the impact, Lut the crushing of the tissues may be of any grade, 

Bdbom the imperceptible molecular divisions of n clean incision or a slight 

^BniBe to the pulpitication of large mosses of tissue. 

The local effects of a wound, however proiluced, may be classified under 
the five divisions of, 1, Iin/iairmenl of Funcliuii ; 2, Gaping ; 3, Pain ; 4, 
Htemorrhage : a, AdU-r. fft/iin-ifrmvi. Of these, the foui' first can receive 
here but the briefest mention. The last will exact more consideration, na 
it is the initiid condition upon which is built up the consequent repair 
of the wound, 
^B Impairment of function is the necessary and immediate result of tiasue- 
Hivreach. Its character is detcimined, in a particular wound, by the var>'- 
ing functions and relations of the tissues that have been severed. Its 
extent and duration will depend upon tlie amount of injury, the activity 
and regularity of the processes of repair, the j>er(ection of repair of which 
the tissue is susceptible, anil the amount of new material needed to fill 
up any gap between the dirided tissues that may have resulted from loss 
of substance or gaping. 

Craping depends upon the contractility of the tissues and is due to the 
destruction, by the solution of continuity of the tissue, of the natural force 
by which tliey tirp kept extended. It becomes important when the wound 
is transverse to the direction of the principal fibres of an organ. Tissues 
in a state of tension, tissues in whose structure there is much elastic tis- 
Hipe, as the skin and arteries, and tissue that has the power of contract- 
^Bl& as muscular tissue, when wonnded, exhibit gaping in the most 
marked degree. 

Pain results from the impression made upon the sensory nerves of the 
part, and hence varies with the nerve-supply of the ports. The tempera- 
ment, likewise, of the individual, modifies the amount of pain experienced. 
Mentsl preoccupation or (.-scitemeHt often prevents the i)erception of pain. 
Qteai rapidity In the infliction of a wound diminishes the ^tain resulting. 



L 



24 THE TREATMENT OF WODNDS. 

Extensive operatious with the asaiatance of the "Boi^cal eagine," bj 
which the instruments used are made to revolve with inconceivable rapid- 
ity, may bo done with little or no pain. A temporary benumbing of tlia 
parts ia produced when the injury is instantaneously inflicted. Subsequent 
sensation is one of smarting or burning'. Thia ia esporienced in all wounds, 
and is of short duration. 

The amount of luemorrhage which is provoked by u wound depends 
upon the number, size, and cliarai^ter of the wounded vessels, and the con- 
ditions which either the situation of the wound itself or the art of the 
surgeon supplies to aii-est it. The natural hii;moatatic is the coagida- 
tion of the blood, which spontaneously seals up the divided estremitiea of 
the cnpillaiies and smiJkr vessels, filling theiu as fai" aa to the nest 
branches of the vascular network. In open wounds the eSiised blood, in 
great part, either sijontuneously flows away or may be ^yiped oway ; a 
slight layer of coagulated blood, however, remains, with rare exceptions, 
in tbe interstices of tho wound surfaces. In subcutaneous wounds the 
character of the tissue in which the vessels he influences also the extent 
of blood-effusion. Loose connective tissue favors extensive and rapid intil- 
ti-ution. The cscapu of blood into the cavities of the body may be a dan- 
gerous comphcation both by reason of the possible amount of the hismor- 
rhoge, and from the pi-essure which it may exert u]k>u important organa. 
Blood-clot may interfere with repair, either mechanically, by preventing 
nppoaitioD of the wound-surfaces and maintaining a gstp to be slowlySlled 
Up by new tissue, or by affording a favorable substance for the lodgement 
and development of septic luattcr from ivithouL 

The parts immediately adjacent to a wound si>eedUy swell somewhat, 
and by their increased redness show some capillary turgeacence. From 
the dilated capillaries an amount of plasma is exuded in excess of the nor- 
mal, which infiltrates the tissues adjacent to the wound and appears »8 a 
more or less copious effusion— woimd-aecret ion — upon the free surface of 
the noimd when accurat« apposition is not maintained. The amount ot 
this capillar}- dilatation and of the conseipieut effusion and swelling, can 
be greatly i-estricted by shielding the wound fi-om further irritation, keep- 
ing tho pai-ta at perfect rest, and subjecting them to equable and gentla 
compression. A certain amount of capillary distention in the wound- 
flaps may be passive, the result of the closure of a part of the blood-pathfl, 
by which a less numerous series of channels are provided for the trana- 
nuBslon of the same amount of blood, but the chief element in its produo- 



tion I 



ACTIVB HTPER.GMIA. 3d 

tion has been demoustr!Lte<l to be a quality iiibei'ent in the capiUaiy vea- 
sels of dilating nhen initateJ. The tiret und imuiediato effect of the iiri- 
lAtion of any part ia increased activity of the capillary circulation of the 
affected part. The capillaries dilate and the blood- pressure in them in- 
creases. This »tate iu colled active hyjjdtwmia, or ajfliu:, and occurs only 
as the result of irritation, and in wounds is the direct consequence of 
the local irritation produced by the ti-aumatism that has at the same time 
produced the solution of continuity. In addition to this quality of dilufa- 
iion displayed by tlie vessels themselves, it is probable that in most iuju- 
!B there is present the added influence of the vaso-dilator nerves, affected 
Ih-ectly through the sensory nerves of the implicated region, for it has 
'been observed that excitation of a sensory nerve i)roduce8 increased 
activity of the capillary circulation in the jjart in which the nerve origi- 
This active hypencmia quickly subaides, witJiout having pi'oduced 
marked ii!t«ratiou in normal tissues, when the irritation ceases, if 
has been tempc)rar^-. But when the irritating force has at the same 
le produced a breach of tissue, ihe hyi>enemia is prolonged and 
lickly provokes active tissue-cLanges, These changes consist of ex- 
in and cell-germinaHon. Through tlie conditions which these new 
introduce into the wound, agglutination and ultimate firm 
of the divided tissues by a more or less liighly organized bond is 
d. 
TJmoK or Wousdb. — The preceding description of the capillary condi- 
ins that produce and characterise the active hyperiemia that follows 
ids has been based upon the obaer\'ations of Htricker.' The auc- 
ing statements as to the character of the histological changes that 
snd the process of repaii- lu-e derived from the sume authority. The 
immediate effects of a wound have been traceil to the point where an 
exudation of hquid from the hypertcmic capillaries has taken place. Tliis 
exudation consists of an increased effusion from the vessels of uuti-itive 
planma, or eoagulable lymph, \vith some of the white coi-puscles of the 
blood. The exuded phisnia is appropriated by the cellular elements of 
the tisBUes. Under its stimulus, these normal tissue-cells, which had 
become contractpd and fixed, enlarge, absorb the basis substance iu 
which they are erabediled, multiply by segmentation, and again bepoiue 

Eiboid and capable of development and organization into new tissue, 
DUloibaDccs of Natritioa and Patholog? of laflammatioD. The Intemationftl 
ciDiNEdia of SuTger;, vol. i. New York: William Wood & Co., 




96 THE TREATMEHT OF TTOinTDS. 

being identical in chai-acter with embryonic tissue, the cliaracteristic of 
which is that it is composed of ama:boid cells, aeparat«d by narrow traces 
of intermediate or basis substance, and that these celLj or masses tend to 
multiply actively by segmentation, and by a power of differentiation 
inherent in tbemaelTeH pi-oduce the development and growth of the 
different organs and tisBuen of the body. The older the tissue becomes, 
the greater proportion does the intermediate subutauce actjuire, and th« 
more slender are the cells oud their processes. It ia proper to say, 
therefore, that the divided tissues which are in process of i-eunion return, 
OS a prehrainarj' step, to tlie embryonic state. By the proliferatiou of the 
tiaaue-cells thus revivified new cells are develoj^d, and the process of 
ceU-formutiou continues imtil the breach is tilled. The new mnterinl thus 
formed, consisting of cells embedded iu a slight amount of gelatinous 
uniting substance, blends with the softened reverted tissue on either side, 
and forms a bond of union th.it within twenty-four hours is sufficieutl)' 
formed to agglutinate the divided surfaces. Tlicre follow next, in due 
order, the vaHcularization aud the conuective -tissue transformation of this 
new tissue. Within a few hoiu-s new eapillary loops extend into the cell- 
mass from the surfaces of the i-ecently divided tissue. These inosculate 
freely with each other. 'With the I'estoration of the circulation through 
the new tissue, the active hypern'mia in the adjactiut blooil- vessels sub- 
sides, and u retrugraile iiietaiDor]ihoHiH of the cell-uioss begins. Some 
of the cells become entirely converted into basis, or connective substance, 
while others remain, but contracted aud clmnged in form by a similar 
trnusfonnation of purlious of their moss at their circumference, into ba- 
sis substance. The basis substance speedily becomes quite stiff and fib- 
rinouB, and assumes a fixed character which is influenced by the adjiw 
cent tissue. Tlio fixed character fiually asmimed by tliis bauia substance 
determines the ultiuiate character of the new tissue. As n rule, the 
highest development whicli the new material fonueil can reach is that of 
connective tissue, but a perfect I'egeueration, as regjinla form and firaction 
in the ''-use of nerve, muscle, and Itone tissue may bo attained. The 
capillarv- network formed in the new tissue is at fii-st more abundant than 
that of the adjacent tissue, so that the cicatrix appears as a fine red stripe, 
but in the further history of the tissue a tendency to condensation and 
atrophy is manifested, by which a large proportion of the newly formed 
resaek become converted into soUd, fine connective- tissue strings, and the 
whole cicatricial tissue contracts and pales, becoming more dense and 



PRIMART ADHESION. 27 

t a lighter color than the ndjacent tissue. The repair of all breaches ot 
tissue is aceomplJMhed by esweiitiallj- the same prooeaa, subject only to 
minor differences arising from peculiarities of structure. This process 
conaists — as has been now dcscribed^in a modification simply of the 
^BDnual nutritire processes at the seat of iniui7, by which the tissues to 
^Plie repaired return to their embryonic state, and new embi^onic tissue is 
^lonned between them with which tiiey blend. By the organization and 
development of the new tissue a permanent bond of union is formed. In 
no case is uniou of divided tissue effected without the interposition of 
^uew materiaL l\'heu divided tisKues are at once brought into perfect 
^B|ppOsitiau, and there retained and shielded from disturbance, the amount 
™"of uew tissue required for the accomphahmeut of union will be extremely 
smull, and may be with difficulty recognizable, hut its existence in suffi- 
cient degree is nevertheless imdeniable. 

Wlien rapid and uncomplicated union of divided surfaces takes place, 
1 by Jirgt intpiilion, or by priinarr/ adhesion, is said to have been 
mplished. It ia seen in its idea! perfection in the repair of many 
mple incised wounds, in which, even by the third day, the union may he- 
me so fuTm that extraneous means of retention are no longer necessary. 
B tlus primary adhesion it is necessary that a close apposition 
if the divided wurfaces be effected and preserved, that all sources of irrita- 
'oided, and that the conditions which &vor nutrition in general 
he maiutuined. "WTien any of these conditions fail to be secured, modifioa- 
liona in the typical pi-ocesu take place. The conditions that modify the 
processes of repair, and tend to prevent union by tirst intention may be 
■Mtandfied as 1, difeclir of appomfion ; 2, defect of protection ; 3, defects of 
^KtUhition. An analysis of the various conditions included in each of these 
e!nss«a ia subjoined. Each is of importance in guiding the treatment to 
be adopted in any given case, and will repeatedly reappear for considera- 
tioa in the succeeding pages of this work. 

DxPBOTS or AreoNmoK.^Close apposition of divided surfaces may be 

it>5-- 
a. The natural gaping of the divided tissues in the absence of the 
necessary means of coaptation and retention. 
. The character of the injiiry itself, as in superlicial excoriations and 
bums, and in wounds in which there haa been an extensive 
loss oi aubstance, or by which a large, flat sur&ce has been 
exposed. 



THE TREATMENT OP -WOUITDe, 

c. The accumulation between tbe divided aur&ceH of blood and of 

wound-secretions. 

d. The presence of foreign matter between tlie wouud surfaces. 
Detects of Phutectio.n, — Bj- failiu'e to properly protect a wound tbe 

injured tissues may be exposcKl to continued or repeated irritntiona. TLe 
sources of aucb irritation may be found in : 

a. Motion, by wliicb the apposition of tlie divided eui-faces is dis- 

turlied, rupture uf thu new adhesive material produced, and 
the conditions of the original injury renewed in tissues already 
weakeiietl by that injuiy. 

b. Direct mechanical \iolence, which includes not only rude handling, 

friction, and gross mechanical injuries of every kind, but &lflo 
the less tangible injuries inflicted by minute foreign partides 
that may have been permitted to remain in a wound. 

c. Chemical irritants, including tlie products of the decomposition of 

retained secretions, and of masses or particles of dead tissue. 
it. Infection by jwieonous agents, including the floating organic mat- 
ter of the atmosphere. 

DcFEcra OF NiTTBTTiox. — Tlio causes of defective nutrition may be 
general and local. The genei-al, or constitutional conditions which pro- 
duce defective nutrition have already been considei-ed (see page 14). 
Tlie local conditions ore those which aflect the circulation and the inner- 
vation of the part to be repaired. The primarj' active liypei-iemia may bo 
rendered excessive and prolonged, and nutrition be thus disturbed, by an 
improper position of the injured part or by any impediment to the return 
drculation. The prolonged application of cold impairs nutrition. Ten- 
sion in the wound acts by obsti-ucting the flow of the blood in the 
capillaries, and thus disturbing cell development and formation, a defect 
in nutrition. 

Tlie modifications which these various conditions, separately or in 
combination, may determine, may L^ divided according as the disturb- 
ances which they provoke result simply in prolongation of the healing 
and waste of the repai'ative material, or in an'est of nutrition and necrosis 
of tissue. The former may still be considered as examples of normal 
healing ; the latter introduce disease into the process of healing, the most 
common manifestation of which is tiie cnuditiod of iiijlammalion.' 



' It i» to bH regretted that the terra inflammatioti hiu been sejiorated by recent 
patliologiita from its tniilitioiuJ hm to denote deatroetive dtstuibanoeB of repaii ta 



'i 



HODJFIXD HOBHAL RKPAIB. 



•29 






lirief consideration roust be given to tlie phenomena which these modifj-- 
mg drcumfltances introduce into the processes of repair. 

MorariED Normal Hkp*ik. — In injuries in which a2>position ia imper- 
fect, but in which all sources of further irritation mny be avoided and the 
conditions Uiat favor nutrition con be secured, an apparent modification 
of the healing process results from the greater amount and extent of the 
new tissue required to effect repair, but the process is essentially tlie 
aame. Afflux, exudation, and cell-germ iuati on are continued until the gap 
is filled up ; capillai-j- loops are continuously extended into the new 

kterial as it is formed, and a progressive transformation of it into 
lective tissue, beginning in the portions firat formed, takes place, 
granular eminences appear on the superficial tajer of the new 
tnateiial, from the clustering of the new tissue about the capillary tufts. 
These are gramtlaliotis, in technical nomenclature, and the new tissue is 
designated aa granulation ti^ue. Tiie process of healing thus accom- 
plished is t«nued henlimj by grai>ulalwn, or by necond itilmiiion. In open 
wounds, when the granulations have reached the level of the cutis, or eien 
sooner, they cease to grow ; from the adjacent margins of epidermis a 
proliferation of epidermal cells takes place, which forms a film that grad- 
Q&lly spreads over the granulating surface, forming an epidennal covering 
completes the proccHs of healing. 

If surfaces that ai-e granulating healthily can be brought and retained 

contact with each other, prompt and jiermanent adhesion between 
will take place. Union thus obtained is union by secondary adhesion, 

third intenliiin. 

The conditions necessary for securing tlie undisturbed production and 
organization of granulation-tissue are most frequently secured in sub- 
cutaneous injuries, in whicih cases the integument serves aa a protection 
from further imtation, and especially front that produced by the floating 
organic matter of the air. 

They may also be sometimes secured in o]jen wounds which expose a 
fiat surface by the rapid drying of tlie aubatances effused — blood and 
Ijmph — on the surface, bo as quickly to produce a hard crust that forms a 

-ly impermeable layer, protecting and sealing up the granulating aur- 

68, aud has been extended to oarer, likewise, all the proePHBea which 
teod the repnic oF wonodi^ By tlie preMiit writer it wiil be osed 011I7 in th« 
Mricted clinics,! nifrniflRntiDii wbioh wbh ([Iven to it hy lh« older writen, and with 
lioh it ia «IJ11 used bj prautiml enrgeoru. 



30 



THE TKEATMEXT OF WOUNDS. 



♦ » 



face beneath from further irritation until its cicatrizatioi 
This constitutes healing by scabbing. Though frequent i 
open wounds in animals, the greater sensitiveness to irri 
by the tissues of man make tlus method of hftaling ap] 
wounds of small extent only. The practical difficull 
repair of open wounds is to protect them, from irritati' 
sources of irritation may with care be avoided, the 
wound surfaces or in the wound secretions of sei 
been floating in the air that gains access to it, or i 
fluids or dressings that are applieil to it, usuall; 
The growth of these gorms, under the most faTor:t' 
duces a continuous irritation of the wouBd. A 
irritation, its immediate result is esagrgeiatiou 
hypenrmia, exi^ssive exudation of plasma, and 

onic cell& If the cells be in excess of the nu: 

organized into the new tissue, they are floatc 

thf granulating tissue, susiieudetl in the liqn' 

i<u. bland liquid that bathes the free surf 

s v> ; the process of its formatioii oonsfitu' 

i:: which it appeax^ is a *uppwnaiing wot' 

wa-ste embrvonic tissue cast off from a i: 

tvrfeotly protecteil from irritatkm. Its 

&<x>^:aj"ianim<^i2t of repair, but it is so i 

pr.^:e.-:od s^c* perfectly from all iiTitati< ■ 

t: Vn: coi;s:ue«\i as a nattmd attendant 

ir. wLii?b imion by firsst intention is nc»f 

sls f.-^niif-iL i> important to be secir 

::><^lf a source of di^turl^ttnceif by di- 

::.f TTi^iucts of its decompoeidtion. 

i.vj-Li.-: :lit pus becomes thin ai ^ 

ixpnsed :o desircation the oonrL 

.-.aftitjy t&kfs place under a scab. 
Suppuratioi: inTolree nngto 

.'•r-.i esTAils delay in the coir 

. •riir.ari rvv^rae of xLe healin- 

rhspjisiTio!^ c*r linrsco 
• : r.^ of bKxvl of vazring 



:.i! 



iiiibroken 

:i««l jMutsbr 

. 'II, without its 

;>:Lir of the injury 

::4>orarily the appo- 

.>. or in injnrieB that 

: the dettd partidea or 

..i^lideeompoBition take* 

:ca of the living and dead 



edlsL The new- 

and prodnoes tfans a 

Aedettd parts. The 

nfidity with which a 

die activitT of the 

c die Mpantion of bone 

■Km tanlQT than that 

^ ffxilaces of a woond 

win be aooom- 

vhieh have been 

«« ocnplieated not only 

:^ ^ cwiriml y^okMX. bat 

g^siT. or intofeiee 




_ met 

bofi 



DISFOSmON OF BLOOD-OLOTS. 31 

an injured part presents iis the direct effect of the injury may motUfj the 
process of repair. In subcutaneous injuries blood-cstraTOsations, to some 
degi-ee, are almost always present, and hx the great majority of open 
wounds there remains, at least a slight layer of coagulated blood between 
the wound surfaces. Tlie cavity of an open wound, in many cases, is 
filled with blood-clot, like a plug. Blood-clot muy hinder repair, both by 
AGchanicoUy preveutiug nppositiou and by the irritatiou of the products 
its decomposition and of the development of septic germs, to which it 
y afford a nidus for multiplication. In subcutaneous injuries blood- 
clots neither decompose nor tweome invaded by septic germs. ^Tien the 
blood is infiltrated into the Minnective- tissue meshes it is quickly removed 
by absor^ttiou ; when it remains as a luatiS filling up a. gap between 
'ided tissues it serves as a temporary mould for the support of tlie 
embryonic tissue that is to form the permanent bond of union. The 
Lul&tiou cells ])n)duced at the lx)rders of the dinded tissues invade 
id aj^ropriate its substAnee, capillary vessels follow the invading cells, 
a process of clot-absorption and granulatiou-tissuo development con- 
tinues until the clot hns disappeared and has become replaced by 
cicatricial tissue. In open wounds, when apposition of the divided sur- 
&ce6 con be secured and maintained, any slight film of blood-clot that 
be present will not perceptibly interfere with the repair, but will be 
ly appropriated by tlie germinating tissue-cells, and will disappear. 
VouRils, iu which union by first intention is impracticable, if the 
Beptic germs can be prevented the behavior of the clot is the 
in subcutaneous woimda. The procetm of its invasion and replace- 
ment by granulation-tissue gradually extends toward its surface, till, 
after some days, what appears to bo the clot will bleed when scratched, 
ilore frequently the superficial layer of the clot remains as a somewhat 
dried, dark-colored stratum, that is not invaded by the granulation- tissue, 
but acts as a protective shield to the ileeper partj4 and is finally exfoliated, 
Hcttb-like, when the cicatrization of the tissue underneath is nearly or 
quite complete. In open woimds which are not kept aseptic — and these 
constitute the vast majority of wounds — the blood- clot decomposes, 
liquefies, and is washed away in the discharges from the wound. 

In nil wounds there is devitalized tissue that must be taken core of. 
The removid of all dead tissue, when undisturbed by external agencies, is 
ilished by the same processes of cell-invasion and appropriation as 
been described as the active agents in the disposal of blood-dots. 




J 




83 THK TREATMENT OF WOUNDS. 

The minute particles of ilfod tiasiiie which exist along the track of 
innsed wound, or at the seat of a mild contusion, are quickly abaorbecl, 
and do not perceptibly interfere witli the repair of the injurj'. larger 
masses, likewiae, if they cun he kept from decomposition, and thus from 
becoming irritants, may be gradually removed by the some process and 
tbeir place taken by new tissue. lunsinuch as the active agenta iu the 
production o! decomposition are minute germs that float in the atmm^ 
phere, the exclusion of these germa from access U> the dead tissue is of 
the lirst importance in promoting repair of all injuries. ^Vlien the 
amount of dea<l tissue iH vei? small, and the other conditions for aetire 
repair are supplied, as in incised wounds in wliioli apjiosition, proper 
nutrition, and freedom from iiiitatiou are secured, the constructive power 
of the living tissue is suiHcient to resist the destiiicttve tendency of tlie 
germs that may have gained access to the deail molecides, auil no impedi- 
ment to rapid repair is suCTered. In subcutaneous iaijuties, the unbroken 
skin forming n i>erfect barrier against the infection of the injured parts by 
estenial organisms, the removal of dead tissue by absorption, without it» 
becoming a source of irritation or complicating the repair of the iiijuty 
in any other way thim by mechanically preveotiug temporarily the appo- 
sition of living parts, is the rule. In optu wounds, or in injuries that 
have become such by death of the skin, infection of the dead particles or 
masses and their conversion into irritants througli decomposition takes 
place. The reparative efforts at the line of junction of the living and dead 
tissue are churiicterizcd by undue and prolonged hyperaania, esoesaive 
exudation of plasma, and over-production of embryonic cells. The new- 
formed granulation tissue breaks down into pus. and ijroduces thus a 
solution of the contiuuitj- between the living and the dead jwi-ts. The 
dead port thus cost ol¥ is called a dourjh. The rapidity with which a 
slough may be completely oast off will deimnd upon the actiWty of the 
natural nutritive processes of the particiilai- tissue ; the separation of bone 
or tendon, for example, being accomplished miich more tardily thou that 
of muscle or ordintuy connective -tissue. ^Tien the surfaces of a wound 
have become thus freed from dead tissue, its linid repair mil be accom- 
plished by granulation with suppuration. Injuries which have been 
accompanied with much crushing and tearing are comphcated not only 
by the presence of parts killed outright by the original \-iolence, but 
also by portions of tissue whose vitality is greatly impaired, that are hidf- 
killed. Whatever adds to the irritation of the original iujurj', or interfere* 



J 




POSSIBILITIKS OP NORMAL KEPAIR. 33 

ith the after-nutrition of theHe half-killed parts, endangers still more 
their vitalitj'. and their absolute death may be determined by such subse- 
quent conditions at any period of the reparative process. In subcutaneous 
injurieti, and in open wounds that are kept free from septic infection, the 
gradual return of these balf-kllled tissues to their normal state takes place, 
and the repair of the injur}- is accomplished without the separation of any 
alougli. 

A review of the processes of normal repair which have been described 
showfl thatv when uninterrupted or unimpaired by estemal agencies or 
by unhealthy constitutional conditions, they are competent to remove 
dead tissue, to restore vitality to partially killed tissue, to furnish new 
material to repair breaches of continuity, and to accomphsli the complete 
Tganizatton of this new material into living tissue. In the less favorable 

iditions which those open wounds present in which the access of atmos- 
pheric organisms and the sloughing of dead tissue is unavoidable, as 
long as the free escape of the decomposing particles and of the pus is 
possible, and further injury by external agencies or by unliealthy consti- 
tutional conditions is a%-oided, uninterrupted repair still takes place, but 
with the waste of much reparative material, wtiich escapes as pus from the 
ixposed surfaces. 

Though the processes by which repair is effected ore identical in all 
conditions, the practical results are very different according as repair 
Sb effecteil without orwitli suppuration. AVhen repair without suppura- 
tion is accomplished, a minimum amount of new tissue is required, a 
minimum disturbance of the nutrition and the function of the injured 
part is fiuETered, and the most speedy return of the organ to its functional 
activity is secured. When suppuration attends repair the process of 
healing is prolonged, a greater drain upon the bodily powers is produced, 
prolonged disturbance of the nutrition and function of parts is suffered, 
and throughout danger of disaster from accidental couplications is im- 
niineni ^lien repair is finally accomplished the new tissue is less 
highly organized than that which it has replaced and permanent impair- 
ment of the function of the part is frequent. 

DESTRrcTivR DisTDHBANCEs OP Rep-mr. — The turning-point where the 
processes of normal repair become converted into processes of neci-osis is 
the occurrence of prolonged stasis in the capillaries of the wound mar- 
gina By repeated or prolonged iiTitation of the idready injured tissue — 
the lower the vitality of the tissue the less the IiTitation needed — the area 






mat 
^UK>r 
Bkhk 



expos 

fc . TI 
Hhese 



31 THE TBEATMENT OF WODNDS. 

of the primary active hypenemia ia mcreased, while a graduBl Blowing of 
the blood-curreut takes place in the vessels which are nearest to the point 
of irritation, until finally it ceases altogether, although at the periphery of 
the disturbed region the conditions of vascular dilatation and of accelerated 
blood-flow continue. Simultaneously with the retardation the white cor- 
pusciUar elenientw of the blood — leucocytes— begin to crowd in numbers 
against the walls of the capiUuries, and to penetrate them by their amce- 
boid properties, and to accumulate in the perivascular tissue. An in- 
creaeed transudatiou of liquor sangmnis also takes place, and when stasia 
tinally occurs the vessels remain choked with a crowded masa of red- 
blood disks. These conditions declare themselves by increased redness, 
heat, swelling, pain, and impairment of function in the affected part, and 
by more or less fever. A part presenting these symptoms is said to be 
iuflamed, and the condition, us a whole, constitutes inftammcUion.' 

When stasis has occurred the death of the tissue involved is immi- 
nent, hut if further injury is averted and the general conditious favorable 
to repair are furnished the stasis may shortly be overcome and the 
natural course of the circulation be resumed ; resolution of the inflam- 
mation has been eSected, If, however, irritation be renewed or continued 
the stasis is prolonged and local death, or vecrosia of tissue takes place. 

Inflammation of a wound involves, therefore, not only arrest of normal 
repair, but additional destruction of tissue ; granulation ia replaced by 
ulceration, uud a new element of distiu'bance is introduced by the dead 
tissue which is to be eliminated. In the treatment of a wound, it is 
important that inflammation be preventeil, or that, if it be present to ony 
degree, its resolution be gained, and its destructive effects be hmited. 
Inflnmniation ts always due to some " defect of protection " (see page 28). 
When a wound is inflicted upon a tissue, the injury is done at once ; the 
extent and duration of the nutritive disturbaiices that follow are limited 
by the extent and choi'acter of the immediate injury, and they do not 
repi-oduce themselves in adjoining healthy tissues, except as the result of 
new injuriea The agents of injury may be gross or minute, may produce 
their cfi'ects through meclianical violence or by chemical action, may be 
microscopic germs or subtle poisons, but they all have tlie common effect 
o( impairing the vital quality of — i.e.. injuring— the tissues they come in 
contact with. The practical fact, however, is always to be borne in mind. 




0ADSE8 OF IITPLAMMATION. 35 

that the effect of any particular iiijmy will alwaya be greatly modified by 
ihe pre-existing cooditioD of the tisHue acted upon, and of the inherent 
resisting quality wliich it may possess. While inHammation is present, 
the healing of a wound is on-eated, and if it supervene iu a wound in 
vhich agglutination has already token i^Iace, the new-formed bond uielta 
down and the wound gapes, preBentiiig red, swollen, and everted edgee. 
The local diseases of wounds— eri-sipela a and gangrene — and the geuei'al 
blood states that are dependent upon wouuds^pyiemia and septicEemiu — 
have a common initial lesion in wound-inflammation. 

To prevent or to limit inflammation, or to lessen tlie effects of the dis- 
turbances induced by it, appear, therefore, to be iudiealioua of the gi-eatest 
importance to be met in the treatment that a wound shall receive. The 
conditions of inflammation, however, do not arise sijontaueously, nor do 
they perpetuate themselves. The continuance or the extension of im iu- 
flammation results only from the continued or extending action of i^ome 
irritant. The more gross iriitonts, as motion, friction, or other meohan- 
ical violence, or ordinaiy chemical agents, are readUy detected, nnd, usu- 
ally, as easily guarded against. In the I'cmorks upon clossi^cntion of 
wounds, the difference in tlie behavior of subcutaneous and open woundH, 

* na regarda their liabihty to inflame, waa mentioned, and the inflammatory 
dLstnrbouces likely to result fi-om the access of ordinary air noted. " Of 
the two injuries inflicted in u wound, the mechanical diuturbanco of the 
parts and the exposure to the uir of those tliat were covered, the expo- 
sure, if continued, is the woi'se. Both are apt to excite inQammatiou ; 
but the exposure excites it moat certainly, and in the worse form ; i.e., 
a the form which most delays the process of repair, and which is moat 

I apt to endanger life " (Paget). It was atJll further noted that so great 
s the difference between the behavior of \vcunds in which there waa 
much devitaliaei,! tissue left behind by tlie wounding ageut, and those in 
vbich there waa little, that it constituted a basis for important cliniod 

I classification. That the mere presence of devitalized tissue alone is not 
the cause of these disturbances, however, is shown by the fact that simi- 
lar injuries, if subcutaneous, escape them in great measure. The mere 
presence of ordinary air alone is not the cause of these disturbances, 
as is shown by the harmlessness of siurgical emphysema, and the freedom 
from injury exhibited by animals through whose peritoneal cavity unfil- 
tered ordinary air has been passed for hours. The only conclusion is 
that, in the cases in question, the cause of infianunation, and of the 



1 

I 



J 



36 THK TEKATMKKT OF WOOKDS. 

wound-diseaaeB that are associated nitli it, is to to be found iu the mu- 
tuiil reaction of deWtalized tissue and somfi agent present in tbe air. 
Wound secretions, wlieii accumulat«d in esceas of tbat which can at once 
be converted into living tissue, snd blood-clots, are but forms of devital- 
ized tissue, and display the suine reaction with atmospheric agents. The 
importance, therefore, of securing tlie most complete removal of blootl- 
coogula and of wound-aecretions from wounds that are to be left exposed 
to the air, depends more upon the inflainmation-producing reaction 
wMch they will suffer with agents brought in contact with them by the 
air, than it does by the defects of apimsition which they produce. Sim- 
ple defects of apposition, as has been seen, entail only prolonged repair ; 
the decomposition of dei-italized tissue, of blood-clots, and of wound- 
aecretions introduce continuous and active local irritation, and bathe the 
tissues with produetn, the absorption of which into the circulation poisons 
the verj- fountain of life- 

The inflammation which complicjttes the repair of oi>en ivounds maui' 
tests vorj-ing degrees of intensity, and of tendency to extend in different 
cases. It may be limited to but a small extent of tissue adjacent to 
the wound- margins, and, with the separation and removal of the shreddy 
sloughs fonned by the dead particles of tissue originally in the wound, and 
of the liquified blood-clots, or by the escape of the accumulated secretions, 
may quickly subside and permit the resumption of the healing of the 
wound by granulation. It may difTuse itself upon tbe sJdn, forming a 
superficial erysipelas, or may extend more deeply along the planes of con- 
nective tissue that may have been opened up by the wound, constituting 
a diffuse cellulilis or a phlegmonous crj-eii>elas. The amount of necrosis 
also may present every grade of extent from that of molecular disinte- 
gration upon the surface of the wound to the death of liLrge masses of 
tissue. The amount of constitutional diatiu-bonce produced by the 
abaorittion of matters generated in tbe inflamed tissue varies likewise 
from a slight ephemeral febrile reaction to fatal septica-mia and pyieroja. 
It is not in the scope of this work to discuss in detail tlie vai-ious phases 
of the destnictiTC distiu'bances which may complicate wounds. Sufficient 
only can be [(resented to serve as a groundwork upon which to base a 
rational and comprehensive preventive treatment, for the treatment of a 
wound cannot be considered as accomplished untd all the possible safe- 
gmirds against the disturbance of its repair have been secured. 



. J 



CIIAl'TER III. 

THE RELATIONS OF SnCTtO-ORGANIHMS TO WOUSD-DIKTUIIB- 
ANCTES. 

BMolts at Defects of pTotection — CauBe« of DecoruiKMitiou of Auiinal TiBKues^Uu- 
■euchea of ruteur and Tyntloll — AtaioBiihcm OrgauiBoiH^ILeiiistiiig Power of 
Living Tissues — Species uid Geuoration <jf ^ticcO'OcgaDiHUis — Bacteria —Baa ill! — 
Mlcroooeci— ResewcheB of Ogatou, Kooh uul otbera— Views of Hunt — Sanimar)' 
— Woutid HuppuratioE — SepticiBinia ~- Pjiuinia— MicrocoecuB-poiBouing— Cliiiioil 
DemoiiBtratiODs — Results of the Practice of Lister, Volkmaun, and NuBabaum — 
CompaiatJTe Htatiaticii of Amputationa — Maucwau's OstAotomiea-^TestlnioD; of 
SaodH, Stobes, (.liefne, and Littl« — Eveudii-. 



Thk importance of the considerations wliicti liiLve beeu uD<Ier leview 

in the pracediiijr chapter, as to the inechaiiiuiii of hciiliu^ uu<l of the ilia- 

turhaiK-^eii that may comphwite it luid convert its benetiiwiit conatructiv«j 

ceases iuio those of local einban'SBsuieiit and death, and of possible 

k .geneml danger, have their greatest dentontitration in the aid which they 

Lbave given in directing & iiearch for tbe ultimate cuiiseii of the changes 

i tbat result in disorders of repair. Only with otrcurute knowledge of thes<' 

I CAUses can intelligent effort to prevent their acceHB, to desti-oy them, or to 

I make them liarmless be made. Without such knowledge wound-treai:- 

L meut is au empirical gro])ing ; with it, it beiximeH an exact science. II 

I lias been seen tliat defects of reparative power, constitutional imd local, 

I may hinder repair ; that defects of apposition prolonj^ repair and occauion 

t« of reparative material, but that in defects of pi-otection are found 

P the conditions that produce aiTest of repair and destruction of tissue ; 

that the defects of protection which occasion the moat frei|iient and most 

serious wound-disturbauees are those which permit the access of ntmos- 

' pberic air to wounds ; that those wounds mimifeot these dlBturbonces in 

^Lihe highest degree which present the largest amount of devitalized 

^B xoaterial ; and, finally, that, with the exception of the ti-aiisient iiiflammn- 



38 THE TEBATMENT OP WOUNDS. 

tions due to repented traumatism, the varioUB LuflammiitoTy and septic 
Etccideuts that wounds suffer are due to wouud- decomposition. 

The causes of the decompositiou of animal tissues, and the laws, 
methods, and proilucta of theii- activity, must therefore be regarded by 
the aui-geoc ob mutters of fuiidtuuental im^iortance in all considerations »s 
to the treatment which he shall give to wounds. As to the causes of 
decompotiitioii iu aiiimid tissues, they ore of the name general character 
aa those which detennine decomposition or tenueuting changes in organic 
matter of any kind. The researches of Faateur, of Tyndall, and their co- 
laborers, have clearly and detiuitely settled the scientific truth that no 
decomposition or fermenting change '^vill take place in organic matter, 
except after the introduction into it from without of lining organisms that 
find in its substance piibulum meet for their nutrition, and, as the result 
of their multiplication within it, iuduce its decomposition. The moat 
frequent and universal medium by which these organisms or their germs 
are brought in contact with material susceptible of decomposition is the 
ordinary air, in which they are foimd as a xiart of the organic matter that 
constitutes most of its floating dust. Even the most putrescible sub- 
stances, as urine, and iinimal and vegetable infusions, remain unchanged 
for an indefinite period when they are kept iu an atmORphere which is 
purified from organic particles. It is not the fully developed organism that 
is found in the floating matter of the air, but minute spores or germs that 
require to be planted iu a proper soil, and to be surrounded with certain 
fitvorable accessory couditious for their germination and growth into the 
fully developed organism to take place. The matters secreted by them in 
their development, or the changes inaugurated by their vital activity as 
hving organisms, detennine the changes iu the substances in which they 
multiply which couatitute decomposition, putrefaction, imd fermentation. 

Such germinal pai'ticles " abound in every pool, stream, and river. 
AU parts of the moist earth ore crowded mth them. Eveiy wetted sur- 
face which has been dried by the sun or tdr contains upon it the particles 
which the uuevaporated liiguid held in suspension. From such surfaces 
they are detached and wafted awny, their universal prevalence in the 
atmosphere being tlius accounted foi'. They are endowed with a power 
of flotation commensurate with their extreme smnllness and the specific 
Ughtness of the matter of which they ore composefl " (Tyndall), 

Since these agents of decomposition are particles and not gases, they 
are not uuifunuly diffused through the atmosphere, but are likely to be 



f^ thi 



ATHOSPHBBIO OBOAHISHa 3t> 

numerous wherever aotl wbeuever tho conditions that favor tLoir 
growth Diid diasemjuation axe active.* This implies the contrary truth 
also, that at tinieB, uud iu certuiu uouditiona that pi-oniote purity of the 
atmosphere, iudefiuit* volmnes of it may be h-eo from septic germs 
altogether. Particular germs of the same species differ also as regaids 
tlieir readiness for development ; some are fresh, others old ; some nrc dry, 
others moist. The conditions whicJi modify the germinatiou of gross 
Beeds affect in an equal manner these niinute germs. The estemal con- 
ditions of warmth and moisture hasteii their development ; cohl find 
absence of moisture retard it Of tlie greatest importance, however, from 
ite power in limiting their disease-producing effects, iw the power with 
^^whioh the living tissues of the body ore endowed of resisting to a certain 

t«nt the action of these germs, and of destroying tliem. As a consequence 

', this these orgaiuwns are never found in the fluids or tissues of the 
Itealthy living body, notwithstanding they abound in tlie air by which it is 
encompassed ; they rest mid develop in the seiTetions tliat issue on the 
surfaces and gather iu the depressions of the external covering of the 

>dy, and tliey swarm in the secretious and contents of the alimentary 

To this resisting power in living matter is due the fiit't that those 

ms which may have gained access to tlie tisHues esjjosed by a wound, 

J not develop and multiply and produce decomposition in such a wound 
^hen spectly and complete contw^it of it^i surfaces is secureil imd main- 
lunetl. On the cimfniry, whatever gem is niaylie present in such a wound 
are killed by contact mth the living cells tliat ai-e active for its repair. 
Should, however, tlie coaptation of the wound-surfaces be unperfect, no 

P< recesses or cavities remain in which fluid exudates accumulate, the 
I of conditions are afforded at once for tlie development of whatever 
as might have gained actress to them. 
K. Miqnel's experlroenta at tlie observktoiy ht Montaouris In PariH, show that 
llie; Are nioHt nuiuerona in the lovpr atiuta of the aii. While in a cubic metre of 
air at the top of thti Puatbeoa be foand but Iwentj^eiglit of them, tlie uaiiif: quaa- 
tit}" of air in the jmrk of MontHouris contained forty-five, and in the mairie of the 
fourth OTTondiBsement, foor handled and Blxty-two. Great nggloineratloiiH of men 
farntah the most of them. The air in the interior of Paris is nine or ten tinicH richer 
in them thin that in the neighborhood of the fortificationa. The duets proceeding 
from aaUitances in a state of putrefaction, nnhenlthy pas, and the dejeotJonB of the 
nek. ue ohoTKed with them. After two or three days of moist and ratny weather, 
the atmoaphere is in a condition of extreme puritf. 



THB TREATMEMT OF WOUNDS. 

AIucli still remains to lie determined with reganl to the disease-pro- 
duciiig possibilities of the germs that in invisible clouds drift in the at- 
inosphere. We are na yet ouly on the threshold of knowledge with regard 
to them. The extreme minute nesia of the organisms themselves, and the 
still more minute charact*j- of the germs bv which they are disseminatfid, 
make their isfjlnfion and study one of great difficulty, and one especially 
liable to errors. Tlie. moi-e delicate and exact methods of the most recent 
observers— Koch, Pasteur, Tj-ndall, Elhrhch, Ogston, Sternberg, and others 
— with regard to their nature, seem to show that there are many epecies 
of them, each of which has it* own couditi^ms of growth, requiiing, or de- 
veloping beat in, n particular soiL different specieii multiplj-ing in differ- 
ent media, and varying in their susceptibility to different temperatures 
and to different chemical reagents. Appiirenfc identity of form does not 
necessarily indicate identity of nature. They ore not convertible into 
each other ; each species produces only itaelt and is produced by itself 
alone, and, when introduced into a substance that affords a favorable soil 
for its growth, s.lwa™ produces in it the HJiioe results. Tliewe i-esults ore 
not produced suddenly, but are of gradual development, progressing pari 
jxtiva with the slow and steady multiplication of the organism. In addi- 
tion to the immediate and direct effect of the multiplying micro-organism, 
chemicMl changes, for the inauguration of which the organisms were 
necessary', after having been once set in motion by them, may continue to 
advance after the activity of the organism has ceased. 

Tlie species of micrcwirgauiHras that have been identified as capable of 
producing disease in the human lx»dy are comparatively few in number. 
Of these, the ones that are concerned in the production of the inflamma- 
tions and infectious diseases that coinitlioate wounds are I'Tubraced in two 
great groups, \ix. i spherical organisms, or micrococci, and rod-shaped 
organisms, which include bacteria ' and bafnili, the term bai^teria being 
applied to shghtly oval or suusnge-shaped organisms, and bacilli to the 
more slender rods. The chanK-teristic oppejirani-'e of these forms is well 
shown in the accompanj-ing cut (Fig. 1), in which oil three forms appear 
as present in the discharges from a case of compoimd dislocation of the 
thumb, in which no attempt to prevent theii- development had been made 
(see Cheyne, " Antiseptic Snrgerj-," p 235, Case 1). 



' The term btuteriii, though Drigiaallj' applied to rU fomiB of mioro-otgBiLiaii 
beoome reetricted to tbs Hpcoial tona noted In the text. 



MICBO-OROANISMS IK WOUNDS, 



41 



The coDilitioDB in which these different tomm of organiams flourisb dif- 
ler, and the remilta, in general, determuied by them also differ, Iii every 
wound which smella suspicioualy the rod-ehaped orgameiiis are present in 
large numbei-a. ^"hei-e a bagging wound or a deep sinus is present, the 
ilittchai^ is apt to be fetid and contains mostly the rod-t^hnped oi^^aniaiuB ; 
but when an incision converts the pouch into a superficial wound, the 
Kpherical orgaititauH again become predominant (OgBhm') ; and in the dis- 
charges which How from Hut surfaces in general, whei'e stagnation ia 
avoided, the Bpheres exist in preponderating nunabei-a The conclusion is 
lykt the character of the decAmp>FuHous determined by the growth of 




. — Tiifl llIcto-DrEBnlbjnH ol JSepUo 



lAL'hAfE'ni (anlbr^d fnun Ci 



e different raloro-organisms ai-e not identical, but that each, in feeding 
^ the eoila in which they are sustained, generates difi'erent changes in the 
mces where they grow. The bacteria as a class, and some bacilli as 
I, induce the decompositions of putrefaction, i.e., those in wtiich tlie 
taiic«s evolved have an offensive stench. If the contents of an abscess, 
or a fluid where organiwuH have been growing be found to present a pu- 
trid smell, we are absolutely certain to detect in it numerous organisms 
^^lat possess either the sausage-shape of the bacterium or the rod of the 
^^■Hnllns (Ogstonl. The more putrid the discharge the more numerous 
^^pd the amaller the bacteria (Cheyne). The vital energy of these or- 



' Jteport apoD Uicro-OTgaDiBim ir 
Biitiah Hedical Jonmnl, Hacoh 12, : 



inigical Disea^n. By Alexauder Ogaton, H.D. 



I 



THB TREATHENT OF WOUNDS. 

gauisms of putridity is weak ; tliey arc quickly killed by weak antise 
ngeuts ; they do not survive, much less grow iji the blood ; they do 1 
not invade living tiBBue, but attack only dead tissue, and wh^n thev 
ftffect the general system it is by the absorptiou into the blood of the pu- ' 
trid liquids and gnses tliat are generated at the original site of putrebc- 
tion. The nepticremia that is pi-odueed depends for its continuance upon 
the continued activity of the local putrefactive process, and disappears 
when thJH external supply is stopped. Wounds containing much putre- 
liable material, wlien they ai-e at tlie same time of such a character as to 
binder the ready escape of the wouud-secretions, afford the moat perfect 
couditiouB for the lusiuiant develupnient of these orgauisms. The removnl 
of alougha, the opening of aiiiuses, and the estabhshment of free outlets for 
the secretions, tend to banish the organisms by removing the pabulum 
necessary* for their esistenca 

The spherical organisuis — micirococci — manifest chaTaoteristics quite 
different from those diaplayed by the rod-shaped, and exhibit a relation to 
wouud-disturbances much nioi-e extended and difficult to control. Micro- 
cocci are described by Cheyne as colorless or colored round cells, Terj' 
small, generally under one micro-millimetre in diameter, with or without 
moveinent, gi-owing in pairs, short chains, or groups of smaller or lai-ger 
size, this cycle being repeated on the addition of fresh pabulum. In a 
given specimen of pus tliey will not be imiformly distributed, and they will 
varj' iu size, while in different Hpeiiimens their numbers nmy vary greatly. 
One specimen of pus examiued by Ogaton contained forty-five millions 
per cubic millimetre, wliile two others contained iu the same bulk only 
nine huncb-ed. Tlie decomiM)sitionB that tliey imluco are not those of 
(■onmiou putridity. If tliey are introduced into a fluid and there culti- 
vated they produce no offensive stench. In most acut« abscesses where 
they abound no bad oilor is detectable, and in general their presence or 
absence is not indi^'uted by any smell. The obsen-ations of different 
investigators indicate that there are tbfferent species of micrococci, some 
comparatively inn oi'uous, others extremely virulent. "Some ore patho- 
genic and others are not ; some develop in the blood of certain animals 
and othei-s will not. IKfferent species multiply in different media, and are 
destroyeil at different temperatm-es. A nutrient medium which has been 
exhausted for one micrococcus may not be exhausted for another" (St«m- 
berg). Cheyne descrilMs certain micrococci as existing in wounds, even 
in large numbers, without apparent ill effect beyond causing a sort of 



MIOBOOOOOI. 



43 



sour, sweaty emell in ita fluids, Ogstou found micrococci in the jjub of 
all acute abBcesBcs, and in wounde, in amount and actirit)' proimrtiounte ta 
the intensity' o( the suppuration ; but a marked diflference was found to 
result in the results of injections made into the tisguee of mice with the 
puB of absccBses and the pus of wounds. With the first, with rare excep- 
tions, well-marked disease, either rapidly fatal hlood-poisoning, or local 
sphocetus, or acute iuflanimatiou, accompanied by blood-ijoisouing and 




i, followed. With the latter, that of wounds, though rich 

Q micrococci, it was with difBculty that an occasional suppuration 

was produced. This observer further deBcribes' two distinct forms of 

micsrococci, among the more virulent orgouisms, chains and groups (Figs. 2 

and 3), which though often found together, were different organisniw ; the 

chain form never passing into the grouped fonu, uor the groui>ed form into 

the ohain. Both possess the power of cBusiug inflammation endui;; in 

■iRtppuration, and both cause phlegmons. But the more disease api)ro)u:hea 

rfte eryapelatoufl tj-pe and concentrates Itself in the lymphatics, tlie more 

ident does its connection with the chain fonu become ; whOe suppurative 

mation, esjiending itself on the tissues i-ather than on the Ij-mphatics, 

* to be the chflTaeteriatic result of the grouped form. Fehleisen, of 



' NlarooooanB Poiaoiiing. By Alexander Ogaton, H.D. JonnuJ of AuUiiDy and 
r, voli. xiL and xlii. 



THE TKBATMENT OF ■WOUNDS. 

Berlin, has demonstrateil liy clire<!t proof the ayency of chain microcowj 
in the production of eryaipeliia. This observer not only found them 
eiit ia all cases of eryapeJas whidi he exsinined during life, l>ut 
miltivnted them, and with equal succesH inoculated the cultivated o] 
isintt in aiiim alB and in man.' By planting hiubII pieces of the 
erysipelatous aldn in gelatine, he inaugurated a series of cultivations, 







which films consisting entirely of the specific micrococcus were obt 
Of seven men whom he inoculated witli the micrococci thus isolated, mx 
showed, after a period of incul>ation ranjpng from fifteen to sixty h 
^ical erj'sipelaa, setting in with rigors, high temperature, imd i 
the characteristic course. 

Koch ' describes a micrococcus that whenever it was introduced into 
tlie tissues of mice produced a spreading gangrene that extended continaa 
ously until it killed the animals. The in£amxaation, suppuration, i 

' Dis Aetlologlfl des EryripeU. Berlui, 1883. 

' Inventigatioiis ioto the Etiology of Traninatio Infectira DiseBses. Bjr 
Bob«n Koch (WollHt«lal. Traualabed by W. WatAOO Gb«fne, F.B.C.S. London: Th* 

New Sydenhani Buciety. 1860. 



mOROCOOCI AKD SrPPttRATION. 45 

e produced liy mierotxwoi cannot with reason be referred to tiuj- 
[mechanical effect from tlieir presence. Koch explains the gangrene- 
producing effecte of the organiEms investigated by him, ae folIowR : " In- 
troduced bj ino<mlation into living auimal tiaaues, they multiply, and as a 
]Mrt of thtdr vegetative proeen« thej' excrete uoluble HubatanceH which get 
into the tmrrounding tiraues by difEusion. 'niien greatly concentrated, uk 
in the neighborhood of the laicroiwcci, thin product of the organisms ha« 
Kurh a deleterious action on the ccIIh that these perish, and finally com- 
pletely dinappeai-. At a greater ilistance from the micrococci the poison 
Iteeomes more diluteil and acts less intensely, only producing inflammation 
Mid accuninlatiou of lymph i-iirputicleH." 

OgHton, likewise, concludes that it must be by the noxiouH substauees 
generated during their growth that they irritate the tissues, and cause 
iiidammation and suppuration. "It maybe looked upon," he says, ''as 
Iw-ing far from unlikely that the verj- reason why micrococci produce sup- 
jiuration is that they, in growing among the tissues, generate some acrid 
ptumaTnes that nmy correspond pretty closely in their effects .with those of 
injections of tiiri>entiue or other caustic liquiil." 

Belfield,' after referring to the experiments of Posteor, in vi^ch & 
previously harmless cultui-e fluid, when it had become swarming with 
micrococci by the multipUcatiou within it of a micrococcus foimd in 
ordinary water, was invariably followed, in the rabbit, by suppuration 
around the point of injection, the pus and tissues containiug numbers of 
the aame organisms ; and to the observations of Klebs, Zahn, and Tiegel, 
who found that while the injection of jjus from a pywmic absceas or putrid 
fluid was followed by local suppuration and multiple abscess formation in 
the infected animal, the same pus or liquid, after filtration through clay 
cyUnderB — whereby the micro-organisms were separated from the liquid — 
i-ausetl intense general infection, but no sujijuiration, even at the point of 
injection : and to the observation of Koch that infectious suppuration in 
the rabbit after putrid iuocidation was constantly associated with a charac- 
teristic micrococcus, says : " It apx>ears, therefore, impossible to evade 
the conclusion that suppiu:ation can be, and is induced by miiTococci. 
That this effect is induced by one or more specific varieties of tliese organ- 
isms eeems probable from these researches of Klebs, Koch, and Pasteur ; 

'On the Relktlaita of Micro-OrgBnlamB to Diseaae. Bj WiUiam T. BelSeld, M.D. 
The Medical Beoord, Marab S, 1883, p. 338. 



46 -nra treatment of wounds. 

that it ia uut iuducerl by all species in apparent from the fact that colonies 
of micrococci ai-e frequently pi-eaent in the human and other animals' 
(luring variouH morbid procesaea in which suppuration does not occur — hm 
in erj-sii>elaM. An to the mixle hi which this influence ia exerted, there is 
no definite knowledge ; the aHHuniption that the deleterioue efiect results 
fi'om changes in the chemical coustitutiou of the containing medium, as im 
eKseutial feature of the ^^tId activity of these organisms, ia supj^iorted hj 
analogy with the processes of fermeutatiun and puti^facUou, by the phen- 
omena known to attend the hfe of other bacteria, and by tie direct 
observations of Koch and Pasteur." 

The relatiou of micrococci to suppurative inflammations is one of great 
interest and importance in its bearing upon the healing of wounds. While 
— as lias been neen — not all forms of micrococci lure capuhte of excitin-; 
suppuration, nor are micrococci the only agents that are competent to 
excite suppuration, yet the proof seems strong that the suppurations anil 
suppurative diseases that complicate woundw, and the acute suppurative 
inflanuuations that ocirur in man are caused by the \itel activity of some 
form of micrococcus. The observations of Ogstou, in which the pres- 
ence of micrococci in the pus of all acute abscesses, and in tliat formed m 
wounds, have already been referred to. The negative obBervations of the 
same investigator are also to be considered with these, that in wounds in 
which no micrococci cotdd be discovered, no pus was produced, but th« 
discharge remained serous ; and tliat iu all coses in which, by his method 
of di-essing wounds, the accesu of micro-organisms from without wa« 
guarded agEiinst, both micrococci and suppuration remained absent 
When, however, womida nuppurated, tlie intensity of the suppuration wae 
pi-ojwrtionate to the numbers and activity of the micrococci, which not 
only multiplied in the wound-BC'cretiims, but also infiltrateil the adjacent 
tissues, until, by the formation of a dense layer of granulation-tissue, their 
further invasion was limited. The chain of proof that tiie t 
the essential causes of tbe suppuration is rendered nearly complete by the 
results of inoculation experiments, by which it has been shown that paa 
devoid of organiamR, as in Ibat of cliroiiic nbscesaeM, or pus whose organ- 
iarne liave been killed by carbolic acid or high temperatures, is harmlen 
when injected into the tissues of animals, while pus that contained micro> 
cocci, when injected, in doses of a minim or more, invariably occasioMj 
well-marked disease, compriaing, as a general rule, acute local 
tion accompanied by blood-poisoning and ending in abscess. 



HUNT ON MICRO-ORGANISMS. 47 

The experimental proof is coutinuuily accumulating that the various 
inflammatory disturbance b that emboiTasii the heoliog of wouucIh are due, 
with but few— and tbeae easll; recognizable — esceptiona, to the resultB of 
the vital activity of micro-organisms. Noverthelesa, many still demur 
that the proof is uot Bufdcieutly positive that the orgoDisms are the spe- 
cific and primary cause of the irritation that determines the inflammatory 
disturbances, but that a possibility exists that, after all, they may be sim- 
ply tLe concomitants of conditions that have determined the inflammation, 
conditions the exact character of which has as yet eluded our search. 
Perhaps no better putting of such objection has been phi-ased thou that 
of Dr. William Hunt, Senior Surgeon to the Pennsylvania Hospital, in the 
address delivered by him before the Philadelphia Academy of Surgery, 
January 8, 1883. In this address he speaks as follows : ' " Now, are the 
r, j^aguiug micro-organisms, of which we hear so much, any mure tlian con- 
^bttmers of dead material, serving (as we find them everywhere) a beneficent 
^p«Bd so long as they do not get into the UTong places ? Molecular death 
is going on continuously in all living tissues. In the nice balance of per- 
fect health, the residts ai-e removed so completely through the blood and 
lymph channels, and by other means, that there is no accumulation. 
niien, however, disturbances arise, as inflammations, for example, from 
any cause, abundant ttecrotii: pi-oducts are the consequence, and these ac- 
cumulate fftstei- than they can be removed. Then come in the migratory 
micro-oi^anisma. It is a question of food, and is consonant with what 
we know of the movements of hosts of higher animals, posaibly also of 
plants, and sometimes of man himself. As these organiams get into the 
wronff pLices, they, accumulating with great rapidity, help to cholie fur- 
ther and irritate what bos already started on an evil course, and so they 
become aecondmy and very fruitful causes of disease." 

In tiiis view, so attractively and ingeniously set forth, of the relation 
of mid-o-orgauisms to wound disturlmnces, the relation of the micro- 
organisma to the changes in the necrotic products, by which these become 
inflammation-producing agents, is lost sight of, and tJie only evils recog- 
nized as resulting fi-om the presence of the micro-organ iams lire those 
simply which the accumulation of tlie organisms themselves in wTong 
places may be capable of determining. The sequence of events which is 
claimed is : 1, inflanunation, from some cause ; 2, accumulation of ne- 



Medlcal NewB, p. 03, Jtuinaij 27, 






48 TUB TREATMENT OF WOUITDS. 



exotic productB ; 3, micro-orgauisniB. If we test this order by the n- 
(]ueDce o( events which occur iji a wound that has become inflamed, in 
which case the causes of the iDflammation may be followed accuntte^ 
with more ease than in the ('.ane of iutemiil iuflammutioua, the error of the 
view becomes apparent. 

In the case of a wouud. the injury sustained by the wounded tisnie 
does not involve new tissue after the injuring agent has ceased its aotioiL 
The tissues in which vitality remaiuu proceed at once to efforts at repair, 
which process, modified in its activity only by the local and constitu- 
tional vigor of the individual, progresses regularly to its termination, pro- 
vided new sources of injni^ ai'e not added. The presence of the devital- 
ized tissue, resulting from the original injury, embarrasses the process of 
repair only mechanically until it is absorbed, or otherwise removed, as 
long as it is preserved from putrefactive changes. Putrefaction results, 
and resulta only, from the iutroduction into the devitalized tissue of such 
micro-organisms an find in it a suitable medium for their active growth 
and multiplication. As a result of their action the devitalized tissues be- 
come irritants that add neiv tmd continuously acting injuiy to the parts 
with which tbey are in contact, the final outcome of which is the condition 
which a surgeon terms influmnuttion — a condition wliich will jierslst and 
spread until in some way the source of irritation is eliminated or isolated. 
The case, then, as observed iu wounds, may be summed up briefly some- 
what in this way : Inflammation is always the result of continued irrita- 
tion ; devitalized tissue, in itself, in whatever quantities, iit unirritatiag ; 
therefore the accumidation of devitalized tissue is not a cause of inflnnuua- 
tion. Devitalized tinsue in which inicro-orgamsms are growing and multi- 
plying is iiritant, and prone to excite inflammation ; the new and specific 
element which has been added, and from which the irritant quaUties 
spring, are the micixvorguuiems ; therefore, from the point of view of the 
inflanunution, they are its specific and primnry cause. The order, there- 
fore, of the sequence of the conditions which determine inflammation in a 
tissue is not that of the autlior to whom reference has been made, but is the 
exact reverse, viz.: 1, micro-organisms; 2, necrotic products; 3, inflammation. 

It is hardly necessary to obsen-e tliat this discussion applies equally to 
the causes of the suppuration which usually accompanies the healing of 
wounds by granulation, for the production of pus upon a woiuid surface is 
the result of irritation of that surface, and depends for it* continiumce 
upon a condition of the tissues alike in kind, and diffeiiug only in degree 



■fion. 



M1CRO-OK6ANI8MS AND SEPTICJIMIA. 49 

aiitl extent frfini t)iat whicJi foiiHtitiit^ei iiiflimunntioii, in the eurgicul sense 
of the wonL Tlie products of the ordinary micrococcus, a» it multiplies in 
the secretionB of n wound on wboae aurfiice it has been dejtoMited, are but 
little irritatiiifi, (w ha* been whown by ita feebly noxious effect* when in- 
je<-teil into tbe tissues of livinji animoln ; but it is sufficient to proroke the 
prolonged hA-jienenua, the overflow of i>liit«nn, and the excessive produc- 
tion of cells that constitute suppuration. 

Tliiis far in tif c<nisideration of the relations of microorganisms to 

^ntnnd'-disliirbiinr^H, a brief outline oidy of Uie knowledge which has tliua 

accumolateil hk to their local effects has beeu attemptetl. It hns been 

that positive jiiYiof has been fimiishetl that in many cases suppura- 

Vtm, phlegmonous inflammation, j^mgrene. and erisiiielas have been the 

(lirect result of the ^-ital actii-ity of certain forms of micro-oi^janisms, and 

that a strong presumption 1ms been established that the same relation of 

and effect existed iji geiieraL IneideiitjJIy reference has been made 

the effects produced upon the whole s\nlem by the absoriitioa int^j the 

of the noxious pi-odncts or ptoHwYueM that result from the changes 

the pabulum ujion which they feed, to which the genera! term SepHar- 

ia applicable. Tliis deinnnds farther loirsi deration, and also the 

allied state iu which, with a septic condition of the blood, there is 

multiple nbscefwes in viirious organs of the body, P>/n;mia. 

Blood-poisoning and metastatic abscesses claim recognition as the moHt 

ibtable processes tliat cim <Mnjplioflte the healing of wounda Their 

afflociation with fa<tlts of repair in woiuids, and the development of 

djtious in the wound-secretiouH have idwnys been too (ha- 

to &il of recognition, so that the chnical fact tliat these processes 

consequent upon tiie absorption of mixions or septic matters pro- 

iii the wounds, was long appreciated Ijefore esjierimeutal investiga- 

Lttempted to determine and itwibit* the essentijil cause (tf their hiirtful 

Belfield, in liis lectui* on sepsis and itntiseptic surgery,' gives 

'mmman' of tiie experimental researches that Iiave lieen made as to the 

and method of working of the sejitiu elements, the more important 

its of which are those "btaincd hy Pannm. Billroth, Bergmann, and 

which established the fact that the clinical and anatomical fea- 

of septiciemin could be induced by tinorganized substances obtained 

Ute pra<lnet*i of putjefnction, though iu these cases two character- 



50 THE TREATMENT OP WODMDS. 

iatica, frequently observed in the noptic infectiou of human subjects, ver» 
often conspicuously abseiil — tbe staye of iucubatiou and the infeotiousnen* 
of the septic blood and tiuHues ; those of Klebs, by which it was shomi 
that the injection of ijvitrid liquidB containing mjTiadfi of micro-oi^Ba' 
isms was followed by oontiuuouM fever and metastatic abscMaseH, while 
the injection of the Bame hquids after they had been deprived ()f their 
Kohd ))articles, including organismB, by filtering thixiugh day, wits fal- 
lowed by fever just an intense, though inmsient, but never by metastatic 
abscesses ; those of Pasteur, in which, in animals that had become septi- 
cally infected, tlicre were always found present micro-orgamsma in the 
serous sacs, muscles, Uver, and spleen, although the blood may have been 
free from them until death — a ili-op of i>eritoneal serum, or a piece of 
muscle from an animal dead of sejtsis induced in a second animal all the 
appearances, ante- and poBt-mort*m, of tJie original disease, while a ilrop 
of bloorl from the hearfKMivitj', jiroven micrOBCopicaUy to c(mtain no septin 
vibrioM, was innocuous ; and the crowning exjierimenta of Koch, GaSk^, 
and LOISer, in which the particular bacilli of septicemia in mice, micr^ 
<'occi of iipreading gangrene in mice, bacteria of septicteniia in rabbitsi 
and micrococci of pysimia in rabbits, were completely isolated from the 
animal tissues by cultivation upon BoUda, and, thus isolated, reintroduced 
into healthy animals with the reproduction of the some diseases as that 
ivhii'h hail before been produced when the original infected blood was 
inoculated. Tlie author from whom we quote sums up the case as follovra : 
'' A review of the eWdence already considered shows, then, that infec- 
tious diseases, identical in chuical and anatomical api^earances with the 
various forms denominated septicicmia in man, have been induced in the 
mouse and iiibbit by inoculation with animal tissues in vajious stages of 
putrefaction ; that the resulting infection is just as uertjiin if the putrid 
substances be previously boiled and thereby deprived of hving organisms. 
On the other liand, it is certain that jier « iimociious cultiu-e fluids — infu- 
sions of beef, etc.^acquire, after inoculation with u»iuut« ciuuntities of in- 
fected blood or tissue, the siime septic properties, pmrided such blood or 
tissue contain living l»acteria ; it is further certain that Uiis multiplication 
of the septic substance in such hquid is a concomitant of the vital action 
of the organisms therein contjiined : it is further demonstrated tliat these 
organisms can and do, not alone multiply the septic material, but when 
isolated by successive cultures from all the aooompanying animal tissues, 
induce, iudejtendently, fatal infectious diseuses.. The same principle — 




MlCROCOCCUS-POlSONINa. 51 

J activity of bacteria — pervades all these phenomenn ; for the artiftciol 

iniluftion of septic diBeases luw been, in all these experiments, originally 

newjinpliHhed tiy the incoi'porfttiou into the aniinal of jiutricl (issues, with 

tir without bacteria Now, wince putrefaction must be regarded, in the 

present sbite of oiir knowledge, ae impoanible without the presence of 

these organiBuiH, it m evident that sepsis, putrid infe(;tiou, was in every 

otse due, ilirectly or indirectly, to the ai'tion of bactei-ia ; since even the 

boiled substAnceR used by Panum and Ilosenbergor, aiid tlie sepHin ob- 

ined from rotten yeast, by Beryniinui aud Schmiedeberg, had acquired 

r aeptic properties through putrefaction, i.e., through the action of 

eria. Henee we are logically driven, by all thin work, to the belief 

i&t septiaumia implies the inti'oduction into the aniniid either of living 

bacteria, or of a substance which has acquired noxious properties through 

pre%'ioua vital activity of these orgauismH," 

^^L The experiments and obaervatiouM of Ogston, to which reference han 

^Haen made in connection witli iuflammatury iiUstiirbances of wounds at- 

^^■nded with suppuration, led that observer to the uonclueion that septi- 

^Kemia, pytcmia. and septico-pyiLuiia are one and the same disease, and 

^Hpnt tlieir sole and invariable catise bt mkrococcUH-poimming. 

Pufl containing micrococci, obtained from an acute human absceas, 
wfaeo injected by this observer infu the tissues of mice, in nmoimte of half 
k minim or more, produced symptoms of blood-poisoning lasting fivjm two 
^B^ five days, during which time micrococ^d could be detected in the blood 
^^H tlie heart ; the eite of the injection displayed a red infilti-atiou, in which 
^^5>peared micrococci in^-adiug Uie neighboring tissues, penetrating be- 
tween their cells, and in colonies or chains, gratlually decreasing in size, 
poshing their way for a considerable distjiuce into the structures in the 
imtj'. In the centre of tliis infiltrated region would be an abscess. 
e mici-ococci in the heart blood were compumtively few, and somewhat 
ioble in number. Their distribution did not appear to be uniform 
roughout the blood, and their preaenc* was never detected in the lungs, 
er, spleen, kidneys, lymphatic glands, or suprarenal capsules. After five 
a seven days had elapsed, and in some ctujes even earher, the animals ex- 
hibited a change. They Ijecame active aguia, threw off their letliargy, and 
seemed well ; but at the spot where tl^e iniection had been made, there 
was found a fluctuating tiunor, gi-adually increasing in size, and presents I 

ing oil the signs of being an ordinary abscess. When they were killeil I 

^djning this second sti^, micrococci were more rurely found in the heart- J 



62 TUB TttKATMENT OP WOUNDS. 

li!iHj(l, and the infiltration of the or^aimiR into the tisHUPs nrfniiiil tho 
iibsceaa no longer esiHtwl, having iK^eu repWetl l>y a finii thick wall of 
pmniilation-tiHmK', lu which micrococci coiilii Hctilom ^>e■ dctei't^il. and 
which Bwnn'il t<^> act br a haiTier, preventing or <liuiiuiKhiiig their migm- 
tion into the IJood and Hurrouuding HtnictureK. In the ^-iBcem of nniniala 
lolled at this singe no orgaJiimns were detected. Some animuls, howwcr, 
died, overwhelmed I>v Uie lilooil-iK)inoiiiiig, at tlie eai{ of the second or tie 
beginninfr of llie tliird ihiv. In some ciwes the local rem-tion wna ho in- 
tense afl to reHult, not in ftliwpMH, lint in N]ihacelu« of tlie sit* of injectioB 
and overlving skin, in which cwteH the niiiinnls neenied tj-i suffer rather lem 
fn>m the symptoms of hloofl-ixiiHoniug : ainl. when they wei-e kiUed, few 
micrococci were foiiiiil in their IiIoikI. and tJie necnuwsl tissues were Bar-, 
roundeil by a strong tliick wall of gnin illation -lismie, presenting, at ths 
phwwE where the slough was iletiwhed, a wii'fai'e like tliat of nn nicer cov- 
ered with a thin, whitinli, croiipy film, iu whicli the micrococci were grow- 
ing, though in a feehle and wiitt^re*! miuuier. 

In seven eawH of nejitictemia iu man, in which he wan alile t^i exarainci 
Uie hlooti during life by opening a small arteriole or venule, uuder anti- 
septic precautious, the hlood so ohtaijied was foiiiid to cotitnin micrococci 
in even- slide examined. 

In n citsp r)f fatal sejrfjiicmiii, death iM-curring on the «ixtli day after the 
extiqiatiou of the th\Toid gland, the wniuid teemed with niicjtM-iK'et In 
a ease of septicieinia following comjtound dislocation of tlie aukle-joiut. in 
which death was averted liy amputation, the tismies around the murgiu <if 
Uie wounil, and the HulM-utjineims tissue far up the leg, and tJie <'lota in 
and aroimd the ankle-joint were abtmdaiitly infiltmted with mirrocwm. 
Other caaes likewise, he strtt^s. that have come under his observation tell 
the same Btory. He i-oncludeR tliat there is no hucIi iliseam- as se^iticfi'mia 
or pyiemia pT x^, such conilitions being merely secondiivy in tJie order of 
the morbid pro<'ei«, and dcjM-ndent on the existence i>f loeiil fisi of mirro- 
iticcus gi-owtli. For the focus i>f the disease never exists in tlie blood, 
but alwai-s in the tiiwneH, whence the iitouiuTiies geiierated in niicroeoiwal 
proliferation pass into the circuLition to att as poisona or intoxicants, 
though separate indinduals or small groupa i>f the micn>-cirguniians ore 
conveyed by tlie hlooil into other situations, so as to rejiroduee among 
other tissues the diseaae of the iwreiit ffs-us. Li liis ■nwnman- he uses 
the following language: '■ Phlegmonous intlanunation. wpticiemia, pya*- 
niia, and septico-pyocmia ai'e idl luicrococcus [xnaoning, varied, however. 




mcUOOOCCDS-tOIBONlNU. 63 

otHtrding an ptonialiie iubmtiitioii or tlii; locjil tissue reaction becomett 

uoi-e protniueuL Every feverisluierih, friim au iutiiuuwl tlirout. or tmgw, 

is a nepticwtuifi ui ii milil ilegi'ec, iinil muy {tam* into a Hevero form. Ito- 

umlueu iiHBH iiitj) the lilixitl, luid (.'uiucideutly n few individuuJH of the lui- 

y^ 1h) found t(> iiuve WHudered from the local ilitteiiHe mid tii 

ciilatiiig m the Itlood, deud or luilf dead, owiiiy to the luiHiiitubUity of 

t medium where they lU't^, imd the uufavurablu iiiflutiac'Gii of the foi-ecM 

S the timues. If removed fi-om the Llood they nirely grow when jjut into 

ntnible uiedimii. Tliey are all eventually extruded or eouHumed. But if 

B individunl lie (oilijet^ted to ileprerudug iidluenceii, the pt^imalue puiuoii- 

iiig may not lie the iiuly {iheuomeitoti olmerved. An the Mjiuptomii become 

more wvert. and the mici-ocoici more niuiiei-oUH iu the blood, the weak- 

H of the indiiidual beirouieit greater, and the rcsiiiting i>ower of hia tii*- 

R lean, BO tliat the mici'oeoet'i are able to live in tlie blood, where previ- 

y they found tliia imiMiwible. They midtiply aud fomi small (jrouiw 

t increnM iu hIkb luitil they are too large to patw through the eapillaiy 

t-work, aud therefore ai-e caught aud detained iu lun^ liver, or Home 

Iher jiart. Thei-e tliey cimtiuue Uj im-reaiMt during life, perhaps even for 

ptiinr after death, and furnish their i-oiitriUition of iMiifion to the H^-»tem. 

r it may be that, though luiable t^i uudtiply iu the blood, they here and 

I throughout the biKlv &id Hjxitu miitiible for their development, 

) tliey can multiply and form the foci of Huppufatiou that mark tho 

I for which we urnmlly reserve the name pya-mia. The pyicmic aec- 

utnially In luug, or Uver, oi- joint, but may eijually well 

lU' iu lymphatic glands, secreting gljuuls, or even in iionnectivo tisBue." 

In coucludiug the present imiuiry into the rehitious of micnj-organismH 

iir woundHlistiu'bauces, atteutioit should be lUreeted to the resultw wliic^h 

I beeu obtained by metltods gf trentuient that tend to prevent the 

IB of sucli tn'gaiuauw to wounds, or to lessen theu" activity, if alreadv 

Ry tlieiuselveH alone considered these statistical clinical data 

1 tfibrd only presumptive evidence at best ; but when taken in con- 

tian "With the resultw of the careful, nmiute, giuirde^l, expeiimentul iit- 

igadons wliic-h have occupied attention in the precedicg portion of 

thiH vhttpter, they apjiear as the strongest kind of (wntiborative evidence 

of the correctiHTiK of these residts. Every wound treated in accordance 

t the tiieoretical indications exiKrinientally demonstrated becomes a 

k. nptm the currectnesa of tho couclueioiw dediiced from the results 

iued by the experiment 




64 THE TREATMENT OF WOtmDS. 

During tlie pighteeu yeat-H which have elajwed «iiice Joseph Lister, in- 
fluenced by the results of Piuiteur'si iuvestigrttious into the causes of putre- 
faction, began the une of carbolic acid as a genuicide in the treatment of 
wmipound fmcturea in the Glasgow Infirmary, the theorj" that noxious 
germs, conveyed by the ittmoBpbere, were the esaential causee of woimd- 
(listurbanceB, has been tested uimit a vatit scale by many methods and by 
a multitude of independent obHer\'ern. 

In the Oliisgow Intirmai'y, at the time Mr. Lister began liis methods of 
treatment, biiMed upon the principle of antagonizing germ-ftcti\-ity. infec- 
tive diseases were constantly present, and beimme at times so prevalent 
that the wards had tii be closed. Out of thirty-five omputationB, of all 
IdjidB, done by him in (wo years, mxteen died, of which deaths ahniist all 
were duo to iiife<-ti\e iliseiise — thus of the six deaths following amputa- 
tions of the «pi>er extremity, four wej-e due to jiya-iuiii and one to hoi^iitol 
gangrene, .\fter the adoption of his new metbiids. tliough they were 
as yet crude, during thi-ee years, there were but two deaths from py- 
icmia after nmjtutfition, out of forty amputations performed, and in one of 
these the pyjt-mia existed prior to tlie operation. These wei'e the only 
cases of pyiiimia which occurred in Mr, Lister's hoKjrital piwdce during 
these thj'ee years, tliough there wei'e tweufr|--two compound fraetures and 
several compound dislocations treated during thi« time. One case of erj- 
sipelas, and one or two cases of hosi»ital gangrene, of a inild tj"pe, com- 
plete the list of infective diseuHes that occurred during this time. The 
results of Mr- lister's work in the Koyal Lilirmaiy, of Edinbiu'gli, oud iu 
King's College Hospital, of London, from 1^71 to 1880, wei-e of tlie same 
character, Tliey will be found iriwrted at length iu Che_>Tie's work on 
antiseptic mirgprj-. which is the souri'e of the facbi already given, and 
of the following statemeuta as to 3-esult« obtAined by A'olkmanii and 
NuBsbaum. 

In 1877 Professor Tolkmann, of Hidle, I'ejiorted that not a single case of 
pjTPniia or sopticiemia had occurred among patients treated by him aaepti- 
eally during three years, notwithBtamUng the deaths from pyiemia and 
eepticienua had been so numerous previous to the adoption of this par- 
ticular method of treatment that the entire i^lotdng of the hospital for & 
time seemed necessarj'. 

In 1878 Pi-ofesHor Nussbaum, of Munich, tabulated tiie residts of the 
treatment of wounds, in the Gteneiid Hospital under liis care, before and 
after the adoption of aseptic methods, thus : 



■Rjcswra or AimsBPnc theatment. 



fio 



Now. 
a pjtemio. 



No erjT*ipelBa" 



Formerly. 
"InjiirieH of the head, compounil fractures, 
amjiutations and excifiioiiH, iu ftict, nlmoBt all ji^ 
tients in whom boues were iiijured were attacked 
by pyeEsnia. For esaiuple, of seventecti cases of 
iUDputntioii, eleven died from thie cause. Even 
Idents with severe whitlow died of it. 
" Hospital gangrene hud got the upper hand No hospital gangrene. 
D Btich an extent, that in spite of continuous wut«r 
in spite of the use of chlorine water, or the 
cautery, finally ei{jhty per cent, of nil 
mdH and uhiers were attacked, largo arteries 
g opened into. 

"Almofrt eiejT wound was attacked with 
KJpelaa 

In Buomiiug up five years' eaperience, in the last edition of his work on 
■Itttiseptio surgeri-. published in 1880, he goes so far as to say that " any 
recent wound, treated by this metliod is guaranteed against pyceinia, hos- 
pital gsngrene, eiysipelHs, progressive suppuration, and in general against 
Eacddeatdl i-ompliijationB." 
Schede, iu the fasciculus ou aniputfttir>ns anil resections in Pitlut and 
Irotb's "Handbucb," gives coniparative tables of 321 uucouipHcated 
unputationH performed aseptically, and of 377 treated by older methods. 
The firet were under the «ti-e of Bust-h, Si^hede, Soriu, and Volkmann. 
^Xb» latter were furnished by Enins, Bardelelieii. and Billroth. Of the 
HBirptic cases 14 died, or 4.4 per cent. ; of tlie ordinary cases 110 died, or 
^HjLIS per cent. The causes of death were tabidated as follows : 

■ ^ 

w « 






PyiBllua 

Septicwmia. . . . 

Eijrnpelas 

Trismus 

Pyxmm simples 
Htranurrhugf . .^ 
kuetion . , 






Bj EHiOQk. 



G 



66 THE TBEATJIENT OF WOrNDS. 

Williniji Maceweii, of Glaagow, in his work on Osteotomy, publislieil 
in IHHO, re^KirtH H'd5 outeotouiieB of the femur, tibiit, and fibula, which 
were com^wund otweous ilioisioiiH or fi-aetures treated autiseptically. In 
mmiy of the putieuts the general health was tar from, being satisfactory, 
and waa Biich bh would havf precluded most operatiomi. The luajoritj- 
wpi-e in a low atate o( hfiilth; a niimljer wei-e markedly tubercular. 
There were many, however, who wei-e in good general health. With the 
exceptiuB of eight ciises, uU the wounds heuled by organization of Wood- 
dot without pus-production. Of tlie eijrht which 8upp«rate<l tliere were 
recognizable tmuinatic uauses fur the suppm-ation in seven. In one only 
was there no clear reason to be iissigned for the pUH-production. All ulti- 
mately did well, with one ex-reptton, in which case omputatiou was tmBlly 
neoPBsitatetl. 

Pi-ofessor H. li Saiiih*, oi New York, in tlie Xeiv Yorh Meditxtl Journal, 
of Jumiiiry (>, 168.S, declares that in his own experience u wonderful im- 
provement has been wrought in the management of wounds by antiseptic 
surgery. Primiuy union is now the i-ule wliere formerly it wus the exoep- 
tiou ; diffiine inflanintatiou and sujipuratioii are rare even after severe inju- 
ries ; operations once formidable now excite httle apprehension ; and that 
ilreailtul scourge, pya-mia, lias Wen ueai-ly uboUshed. In the sui-gical ser- 
vice of the Eooserelt Hospital, containing seventy-five l>e<lB, no operation 
perfonned duiing tlie last three yeai^s has been followed by septiccemia or 

I'rofesBor William Stokes, of Ireland, ui the " Address in .Surgery," be- 
fore the Biitiah Meilical Association in 1682, claims that one of the beet 
tests, if not the host, for the Milue of antiseptic pnictice, ia resection of the 
knee-joint, as there are so many circumstances that miUtat« against imme- 
diate union being obtained aft«r it. In the first place, as he says, the 
cases requiring so formiilable an operation, are, as a nde, in a condition of 
great physical eshaiistion, consequent on long confinement, and probably 
protracted suffering of mind and bixly, ITie wound is of necessity a large 
one ; the operation occupies a coumderable time ; two large fretifaly cut 
bone Hurfa<?eB are mode, between whicli union is to take i)lace ; and, lastly, 
there is the great iliflGculty of keeping, no matter what appliance be 
adopted, the limb absolutely at rist d\mng the process of miion. Before 
tbe adoption of Listerism the siu^eon anticipated that four, aix, or eight 
months, or longer, woulil elapse before union took place, aud it was alwaya 
u subject discussed at consultations on these cases, previously to operation, 



STOKES — LI8TEB — tlTTLK. 



67 






whether the pationt. vroiilil Imve strength Ut endure so protiacteJ a siippu- 
Btiou. As au illustrntion of how chaiigetl luatterti ore now, he quotes 
«i of fourt«eu coaeu of exeieion uf the knee-joiuf, iu uuie of which 
■ wotmdtj united nitliout a trat-e of pUH-produotiou ; oiul iu anoUier, 
e hut nf the serieH, ouly two lU^siunga were raqiui'ed Kubsequent to the 
me applied at the time of the oi^erutioii, und in Heven weeks after the pa- 
tient woH up uuil },'oint; ahout. K<^ fiurther Htaten tliat iu a reuord of up- 
ward of six hundred operutious performed bv Iiiurtelf und hirt ooUeagueu 
■t the Richmond Surgifal HoHpitnl during' the previous three years, an iii- 
^titutioii which was hjtpenioall.v iu a verv luiBatiafactory comUtion, the 
mortality was 3.fi jier i-eiit.; tliei'e was uot, a Hiuj^'Ie case ui which the 
methuchi of Lister were accurately employed that wan followed by any in- 
fdyo dieeaiie. 

With reganl to the roiu-se of repau- in the wound-site itself, Cheyiie 
wtifies that where wounihs liave Ijeeii treated in accordance with the 
aseptic methods of Mi-. Lister no inflammation owuis ; there is uo swell- 
ing uor rednesH of the ed>i;es, as is so frequently the case in wounds 
mted otherwise. The skin around the woiuid remains as pale and hi\ 
■ it was wheu stitched up at the time of the opemtion ; there is no evi- 
Emce of reaction ; uilliuuumtiou is absent from the dee]>er as well as from 
« superficial parts of the wound. There is no supjiuratiou even when the 
r strui^tuies ore not absolutely m cimtai^t. The discharge from the 
e-tuhe is purely sei-ous, and nipidly diminishes in amoimt so as t« 
luler the ih-ain imnecenaarj- ui a vejy short time. Wounds heal, as ii 
ale, much more rapidly tliau when treated otherwise ; as a result of the 
e of inflaiiimatiou in the dee]ier parte, the scar does not become itd- 
hCTent but i-emaius movable. 

Of the same character is the testimony of Profi^ssor James L. Little, of 
few York, ui remarks made by him before the New York Surgical Soci- 
Ay, November 8, 1881, in which be said that during a period of six yeai-M 
te hail treated nearly three hundred cases of oiien wounds, these uijuries 
cousistiiLg cluefly of wounds of the bands and fingers caused by their 
being caught in tlie cogwheels and other parts of machinery. Iu many 
coses fingers were torn oS, tendons pulled from their sheaths, joints 
opened, and Iiauds often severely crushed and lacei-ated. >Iauy of these 

Epere ui an ludiealthy comhtion, some wifforuig from anicmia, 
I cardiac, disease, phthisis, nud the like. Under antiseptic dress- 
one of these wounds was followed by iuHammatory symptoma 



^ 



68 THE TREATMENT OF WOUNDS. 

Extensive lacer&ted woutiiiii healed, uad dead tissue sloughed away with- 
out giving rise to anv of the so-called symptoniB of inflaiuioatioii. Neither 
pain, redness, heat, Bwelling, uor conBtitutionol disturbance resulted. In 
no case was there reddening of the lymphatics or tenderness of the glaod& 
No counter-openings wei* necessary. Pain was entirely absent, so that 
anodynes were not needed, save in a mngle cnse, and that for one night 
only, to control slight reBtlet«neB& 

Citations of a wniilar character to tlie preceding could be made from 
the testimonies of im iudeGnite number of surgeons on both sides of tlie 
Atlantic. They are alike in their statements that, in proportion as it has 
been possiljle for them to jwrfect methods of wound treatment by which 
the developnieut of micro-orgimisnis <:ould be prevent**! or diminished. 
disturbances of repair have been escaped and healing has been safe and 
Bjteedy aud peH ect ' 

In bringing this chapter to a clone, there confronts us the question, 
What conclusion as to tiie relation of micro-organisms to wound-dis- 
turbances is most cousistent n-ith all the faotn which Irnve thus far been 
established ? Three great groups of phenomena present themselves from 
which to draw jiertiuent observations, itz. : 1, the behaiior of wounds 
which were esjiosed to the ac^.'ess of miiTo-orgtminmH or their germs, ftnd 
which presented conditions favorable for their \it«l activity ; 2, experi- 
mental research as to the nature and the effects proiluced by the difierent 
species of micro-orgaiiisinB ; and, 3, the effei'ts uiwn the course of healing in 
wounds produced by protecting them from germ invasion or by destroying 
or diminishing the activity of such us may have gained access to them. 

In the fu^t class are all open wounds, in which the conditions favor- 
able for the development of activity of genus sown uixm them become the 
more pronounced in pn)portion as the amount of devitalized tissue, and of 
blood-clot, ftn<l the uund>er aud depth of recesses for the reception and 
retention of wound-secretions increase. 

Observation of this elnsa records that invariably their repair is dis- 
turbed by putrefaction aud sloughing of the devitalized tissues, by decom- 
podtion aud Hquofaction of the blood-clotx, by inflammation of the wound- 
margins, and by a prolongeil propess of suppumtion and granulation, and, 
in a certiiui number of cases, by grave sepliciemia, and by pyaemia. 

In the second I'laes stand out the facts that no decomposition or fer- 
mentation takes place in organic matter without the agency of some form 
of microHirgauism ; that when no decomposition of wound-tissues or 



mxVKOY reoM wouin>DisTVBBAiraBS. 



69 



retioiiB takes place no wouud-disturbance occurs ; that certain forms of 
inicro-organiams are alwaj-s found uasociattd with cei-tain forms of woim<l- 
disturbance ; and finally, that theBe mici'o-ftrgujjisma, when isolated and 
introduced anew in sufGcieut amount among tisHues previously healthj, 
I i-apable of exciting here the same diseafled action with which they were 
iiiaHy found tuwociated. 

In the third class are subcutaneous wountla, in which the unbroken 
a fonuK a perfect Hhield against the invasion of noxious organisms from 
mthout ; wounds invuhiug the integument, in which apposition of the 
divided surfaces can be seciu-ed and maintained, and the retention of 
woimd-secretions prevented, and iu which the inherent force nf the con- 
structive power of the healing tissueM is great enough ffl destroy whatever 
I may g^i access while the siu-faeea are exposed ; and wounds of 
class in the treatment of which adequate measures have been used to 
mt the access of germs, or to desti-oy them, or prevent their develop- 
int if presenf. 

Clinical observation records, for idl the members of this third class in 
1 protection from invasion of mJcroHargauisms is secured ui vaiious 
I, a common immunity from wouiid-diHturbances. The repair of suh- 
meous wounds is, as a rule, free from sup^turation, inllanuuafion, and 
sloughing, or other serious complication, even though involnng much 
contusion and laceration of soft parts and extensive effusion of blood. 
Union by first intention, without lUsturbaiice, accident, or delay, is the 
role when the conditions next mentioned are obtaineil ; and, in like man- 
ner, a course of repair free from disturbance and closely approximating 
t rapidity and perfection that of subcutaneous wounds is enjoyed by the 
ivounda. The evidence which each of these groui>s of 
I gives is harmimious and cumulative, and the only conclusion 
bich is contdst«nt with them is that the lontl suppurative and inflamma- 
■, and the general infective di8turbttn<*s which occur in woimds result 
1 the vital activity of micro-organisms, which having been introduced 
a without, find in the wound the conditions that favor their develop- 
mt and increase. 

Other sources of irritation likewise exist and are capable of exciting 
)pnration and inflammation in wounds, but their effects are limited and 
jnent in character, their action is easily recognizable and jireventible, 
I their chief importance fij>rings from the manner in which the con- 
{ttiona create<l by them favor the activity of micro-organisms. 



\ 



CHAPTER IV. 

ASEPSIS AND ANTISEPSIS— WOUND-OLEANLINESa 

The Sdentifio Basis of Wound -Treatment — Ptomaines— Sepsis — Aneptfut — Antisepns — 
Cleanliness — Primaiy Cleansing of a Wound — Drainage— Cleanliness of Adjacent 
Tissues — Cleanliness of Wound-Dressings — Air Purification — Antiseptic Spri^rs — 
Practice of Lister — Experiments of Stimson and Duncan — Effects of Sprays. 

The recognition of the activity of micro-organisms as the essential cause 
of disturbances of repair in wounds supplies a scientific basis for treat- 
ment and a£fords a detioiite principle by which to test methods of wound- 
treatment. It has been seen that it is not the organisms themselves 
that are the irritants that directly cause wound-disturbance, but the pro- 
ducts that are formed in the course of their growth and multiplication, 
either directly secreted by themselves or formed by the decomposition 
of the substances on which they feed« These secondary products — 
ptomaines — are poisons or septic agents, and the results iu general of 
their action upon the living tissues with which they come in contact 
constitute «6;>8t8. Whatever tissue or wound-surfeK^e is uncontaminated 
by these ptomaines is in an aseptic condition, and whatever method or 
means aniagoniases their production, or antidotes, restricts, or removes the 
results of their presence is an antiaeplic. 

The ideal treatment of a wound is that by which a perfectly aseptic 
condition should be obtained and preserved ; where this is impracticable, 
the object of treatment becomes changed to the application of means to 
diminish the activity of the septic organisms, to secure the rapid removal 
of their products, and to increase the resisting power of the wounded 
tissues. 

ASEPSIS. 

Asepsis is present in wounds which are subcutaneous, and iu wounds 
which unite by first intention. The defects of apposition, protection, or 
nutrition which may prevent the accomplishment of union by first inten- 



ASEPSIS AND ATfTISEPSlS. 61 

m in a wound tlo not necessarily exix>8e it to septic infection, Imt sn 
acli do ther increase the diiliciilties of preserving the wound from 
eh infection that the means of reiued^iuj;^ these defects, and of neoiu-iiig 
lion by first intention, when the conditions of the wonnd make it at uU 
issible, iiecome of the highest importance from tlie standpoint of the 
ngere of sepsiB. Tlie methods bj which these defects are to be avoided 
long to the practice of wound -treatment and will be resen-ed for cou- 
leration in that connection. Attention hero must be restricted to 
neral considerations liearing directly upon the prevention or correctiLin 
sepsis. 

Asepsis may he preserved, if the wound is to be inflicte<i by the mir- 
<m himself, by care in permitting access to the wound, at the time of its 
Diction and duriuff its after progress, of no o\>ject which is i;ontaniinated 
■ septic agents. This involves piiriticntioii of the air. instruments, dress- 
ga, and of the hands of tlie surgeon himself, and tlie most minute, 
act, and persistent care throughout the course of the wound until iU 
lal cicatrization. 

In wounds already septic, asepsis may be obtained bv applying to 

sir Burfaces and recesses substances capable of destroying the septic 

^^erniB and organisms present, and by using in their nfter-care diessings 

capable of excluding the further access of septic agents, or of preventing 

their development i/ their exclusion has been iinpussible. 

ANTISKPSJK. 

In wounds in which, for any reason — their looatiuu, their oomplica- 
ttons, the absence of uecessarj- ajipliances, or whatever other cause — 
asepsis is impossible or impracticable, the effects of the septic agents that 
may Iw present may Ije modified and restrained, not only by the appli- 
GStioQ to the wounds, as tlioroughly as possible, of antiseptic substaticea, 
but also by the most perfect reninval fi-<iiii the wound ol devitalized 
rabstHDcee and tbosc prone to decomposition, which if left wouhl be 
rich feeding- ground for raicro-organisras. by the immediate removal of 
the nodous protlucts of the septic condition as fast as pn>diu-ed, and by 
whatever agencies are capable "f jiromoting general reparative euergj- or 
IihaI resisting power in tlie wound-tissues. 

The range ooveretl by this enumeration of the means and methods of 
antagonizing septic conditions iu wounds — antisepsis— is a wide one, and 



63 THE TREATMENT OF WOUNDS. 

includes eTery form of wound-treatmeiit which by experience has been 
found to favorably afTect the healing of wounds. Thoue methods only, 
however, which in a qtecial nianiier luotlify the vital activity of noxious 
micro-organiaras, or nullify the results of auch activity, can be considered 
in this connection. These methods will be considered in the following 
unler r 

FinL — Those that tire required to prevent the accumulation, or to en- 
siu% the removal of whatever substances might aSord a pabuiiuu favorable 
to the growth and increase of septic oi'ganisms ; to facihtate the removal 
of septic prcxluctw, if formed ; and to prevent the introilueition into the 
wound of any substance capable of inducing septic changes in it ; these 
methods are embraced in the single idea, cleanliriee!'. 

St-cond, — Tlie employment of substances as applications to wound-sur- 
facea which are inimical to septic organisms, destroyinj; them or restrain- 
ing their gi-owth — a<iti»fplicit, in the more restricted sense of the term. 

CLEANLINESS. 

That aspect of cleanliness which has to do with the prevention of the 
accumulation, and with the speedy removal of fermentable substances &om 
a wound requires for its accomplishment, at the beginning of treatment, 
the removal of every substance which either itself should foster the growth 
of micro-organisms, or should provoke midue secretion from the wound, 
or that by t!ie mechanical effect of its ])rcHence should delay union. The 
accomplishment of this end constitutes primar;/ cleansing of Ike icound. 
The full performance of tliis cleansing may, however, involve sucli increased 
hazards from the additioual traumatism requireil for its accomplishment 
in some instances, that it may best be ignorf d, as in cascfi of bullets, 
needles, and other boiUes that have j>euetrat«d the tissues, and, becoming 
enejuted, cease to initate, and disturb but Uttlo the function of the parts 
hi which they rest. Again, iu cases in which an awiumulated blood-clot 
M ould appear to i-iulate the rule of cleanliness by its pi-oueness (o decom- 
position an<l by the mechanical effects of its presence, if it can be kept 
aseptic, or if efficient means of antisepsis be a\-ailable, it may, in cases of 
open wounds, with hjss of Hubstaiice so gn'at as to prevent apposition of 
the diWded surfaces, reidly facihtate repair by a&ording jMibulmn, sup- 
port, and pi-otection Ut the foi-raiug gnuiulation-tisHue tliat gradually ti 
its place. In cases, also, in which rapid dr>'ing of a hiyer of blood-dot 



lly takes 
ood-dot 



CtEAflXHTBaa — 'DRAIWAOB. 



63 



that I 



be accomplished, the iuipenueable layer wbicli it fiimis may coueti- 
tute a perfect occlusive aiitisepUf di-eseing for the wound underneath it ; 
but the doing up of a wound " in its o^TIl blood," to be succewsful, requires 
that the other posKible demands of cleauUneBs that may be present or may 
the wound be also regarded. 
Of equal importance \Titli the primarj' cleansing of the wound in the 
prevention of the accumulation within its cavity at any time in it» after- 
liintory of wound-sec retiona and titwue-dtbriH. The abundant serous ex- 
udation which occurs as the iuimediato remilt of the active hypei'iemia 
provoked by a wound, bathes in abundance the free Hui-facea of an open 
wound and gathers in itfi recewes, atid when such wounds are closed ex- 
if exa«t apposition of its deeper pirtn be not alao secured ami 
:tained, separates its surfaces, aiid aa long as it is I'etaiued, not only 
■bs repair by the tension produced, but alao offers the best of pabu- 
promoting the ^ital acti\ity of ferment^producing orgauisma The 
prevention of such aceiuuuljitioo and retention becomes, therefore, of the 
highest important^ in attempts to preserve ar wrmnd from disturbance. 
Again, when suppuration has occurred in a wound, the pus brings into 
wound the same elements of danger which attend the earUer seroua 
idation, with the added condition that septic products are already being 
igled with the wound-secretions. 

The spontaneous escape and draining awiiy of all secretions and tissue- 
iris, (IS fast as exuded or separated, may be provided for either by the 
arrangement of the wouud-surfacea alone, or by the use of appara- 
to drain them away. This portion of the reiiuirements for seeming 
im in wounds is termed drainage. 

u manage a wound as to prevent or to restrain the priniarj- serous 
will diminish the necessity for provisions for drainage. This c 
BCCOtupUsheil in great measure in all wounds iu which such apposition'!! 
the surfaces can be secured an \t> make union bylirst intention possibla I 
This should be the ideal to lie striven for in all such cases. Its acci 
plishment means nuieful and perfect hiemostasis, careful primary deans*'! 
ing, (»reful expression from the wound-carities as its surfaces are being 
brought into apposition of all fluids present, perfect coaptation throughout 
all parts of the wound, deep and superficial, gentle compression, and sup- 
and perfect protection, with infrequent dresaiugu thereafter. With 
perfect nccomptishment of such precautious no accumuhition of serum 
pQwible, and provisions for drainage are unnecessary and objectionable. 



64 TUE TBEATMENT OF WOUKDS. 

Biit whenever neourate coaptation is not secured, iind n ea\-ity exists in 
whirli fluid may accuniukte, it« dmiuoge mu«t be pmridisd lor. 

The hiHt requirement iif ■woimd-clefinhneas, aeeording to nur nnalysis, 
in the prevention of weem to the wound of any mibHtance capable of in- 
ducinff Heptic phangew in it. Prom their relatlou to this requirement must 
be considered : 1, C/eanJiiieng 'if a^occiil (uwite*; % i-livinliiiei« nf vxiiind- 
dreemngK ; and 3, deanlmei^ of the air that comes in contact with the wound. 

Adjacent Tibsuks, — Perfect cleanliness requires not only that the tie- 
Hues immediately ndjiwent tn a wound be iitirifieil of gross iiupuritieB, but 
that they should especiidly be freed from luiy micro-organisms which, 
might, by gaining accetw to the wo»md, make if septic. 

Bxaminatiou of the iJtin on regions much 8iibject«l to frictianB luid 
ablutions, as tlie bunds, frontji of the thighs, anun, and forearms, sliowa 
luicro-orgaiiismB so Mpariiifily tliat ppidenniH removed from thence bv 
scraping may often exhibit few or none. But in iDdi\-iduftlK who, from 
ntiy cause, do not practise frequent ablutions, even in these regions they 
are usually found, wliile in not even the most cleanly per»on does the iu- 
terdigital scurf of the toeit fail to show abunilnnr^* of Imth niicroeoctd and 
liacteria. Tlie scnrf of the scalp coutaina niotrtly fungi tind fimgus spores, 
and is hy no means rich in cocci or bacteria, while the secretion of th© 
imibilicuB fihows l>oth these forms to be present in abundance. 

Micrococci are munerous in the cerumen of the ears and in the mucus 
im the lips, mid tliere exceed in number the other forms of organisms. In 
the ftsdllii, on the otlier lianil, where niiiTo-orgimisms Hre in great plentv, 
tlie bacteria prepundemte, luid in the secretion fi-oni the skin of the nose, 
that is mostly sebaceous, obtJUikcd by gently compressing it« tip. almost 
the only forms met witli are the bacteria, whieh are there, however, innu- 
merable. 

Sebum exiiressed from sorotiil or perineal foUii-les shows multitudinous 
bacteria, slender rods, luid micrococci : the anal I'egion shows thick and 
slender bacilb, bacteria, and micrococci ; while the ftecea and interior of 
the bowels present the appearance of being entirely composed of inliuite 
colonies of all varieties. 

The author ' on whose authority these statements are maile adds : 

"We need not even call into account the soUdN. fluids, and gasea 
around ua in our search for sources of infection when, we jKissess in our 

' Di. Alex. 0|^toD : Mioj-ocixnjua PaiaoDing. .loumul of Auntomj and Phyniologir, 
Vd. XVI.. p. 637. 



DIBINFEOnOH' OF THE SKIN. 



ftrnn fromea so abundant a supply. In relation to surreal qucetions, it ia 

of use to know the extent anil diHtributioii of these yerma on oiu- perBone, 

if our procesacH of disinfection are to be conducted aright. In operative 

procedures on the axilla aiitl Hcrotum, for example, we ought to know that 

^■dl our preUiuinarj- washiugH and diaiiifeetiou are impotent to extermi- 

^Hste the micro-organiama that exist in the openinga of the glanda to a 

^Hepth of oue-fnurtb of an inch and even more. None of the proceedings 

^Btt use in antiaeplie aurgerj- is of any aiiiil to destroy them ; they will 

^^'omtinue to grow and reach the surface, and unless we maintain there a 

Btorehoune of some disinfectant material, frequently renewed, that will 

BufBee to saturate iiU discharges and convert them into aseptii^ fluida, we 

shall assoredly find the organisma growing richly under our dreeaings. 

HSodoform and salicylin acid, which are treaaure-houaes of disinfection, aje 

^Huore ufieful in those regioua than ou the arms, legs, and hands. But even 

in these purer tenitorieH over-confidence is perilous, and where we are 

dealing with akiua not regularly cleaned, aa ia the case, for instance, to a 

large extent in hospital pnu'd(«, we have to add t*> our habitual pi-ecau- 

tiona, and attend both to preliminarj- saturation of the epidermis with 

penetrating ilisinfcctauta nud to the subsequent maintenance of stores of 

K disinfectants on the aurfai-ea where the genua may develop and appear. 

HWoT a coosidemble time bock I have found it advantageous, in any opeiii- 

H^um that inrolveii aerious danger, and that required to be successful at all 

hazards (operations of complaisance, auch aa osteotomies and joint opera- 

tiona), to dress the part for ilays before oiiemtiun in a regular Lister's 

dressiDg. renewing it daily, and aatui-ating the akin with carbolic water, 

Bibeeides washing the part vdth tiu^Kutlue inmiediately liefore making the 

^■fast incision. I do not think I am wrong in sa,'\ing that we are too eaaily 

satisfied with otu* cutaneous disinfection, and that the chief source of 

micro-orgauiams in wounds is from the akin, rather tliau from the air or 

failures in oiu- antiseptic prweiliues." 

The diflii'ulty of securing the desired purification of the adjacent tissues 
becomea almost iusujjerable in woiuids involving the mucous orifices of 
the body, so that unless they are of auch a character that pei-fect apposi- 
tion of the wound surfaces can be secured, and immediate union by first 
intention obtained, tliey inevitably become septic wounds. Such wounds, 
therefore, cannot be treated by occlusive methods ; efibrts must be directed 
to antagonizing the inevitable sepsis and remoriug ita products. But in 
jJl wounds, whether operative wounds at the hands of the surgeon or 




66 THK TEEATMKNT OF WOUKDS. 

wounds accidentally inflicted, in wbidi iittempta at rendering and keeping 
tliem nseptti; oft'er any liope^ of success, all sucli attempts must include 
the pm-ification of that poi-tiou of tlie wkin which is covei-eil in by the dress- 
ings, as much as the wuuud-surfaces thenutelvea Tix> greai core in 
cleansing it cannot be taken. 

WouND-DitEBSiHas. — In this class are to be included everything which 
uecessarily is brought in contact with the wound in the attentions which 
it i-equiies, as well as those mtbstouces which are applied more or lees 
pennanently to the wound to promote its healing. The persons ol the 
surgeon and his assistants, tlie instnimeuts and upphancea of every kind 
that are used in or about the wound, the fluiila that are used for irrigation, 
the drains, the ligatures, tlie sutures, tJie compresses, and protective ap- 
pliances, must each equally comply with that degree of cleanliness which 
shall be necessary to prevent them from becoming the bearers of infection. 

AIR PURIFICATION. 



The more obvious sources uf atmospheric impurity are overtirowding, 
deficient ventilation, the presence of unhealthy suppiirating wounds, the 
presence of infectious diseases, the proximity of walls, be<ls, or other ab- 
sorbent materiala chai-ged with septic emanations, the vicinity of cess- 
pools, sewer-bosiiis, masses of putrefying material, or other fori of 
infection. The mention of these is sufficient to suggest the means of 
remedying fhom. No one of tliem slinuW be overlooked in considering 
the cares to be rendered a wound. To the results which attend their 
neglect, attention has been called in a prerious chapter. 

The air of the countrj- is more free from micro-organisms than is the 
air of a city, and that of the upper floor of a house than that of the lower 
flour. Facts that should be borne in mind when a choice as to where a 
wounded person should be treated is jKWwibla .\fter everj- ordinary pre- 
caution possible bts been taken lo secure a pure atmosphere by clean and 
pure surroundings, isohitioii. and abundant ventilation, what further means 
are necessan' and available for securing absolute air-purity ? 

s bfts been stated in a prerious i-hapter, putrescence invariably follows 

iaent exposure of putrescible fluid to the air, the length of the 

) needed l>eing dependent upon the character of the local sur- 

Dr. Duncan, of Edinburgh,' found tlint in his laboratory a 




and tbe &pr»r- Edlnburg'b Hodioal Jonnia]. Hsrch, 




r 



» 



ASTISSFTIO 8PRAYB. 67 

id preseating n mirface of an inch and a quarter, could be rcpeutedly 
for nearly two hours without infection, and that to be reasonably 
of pub-esoence n surface of three inohee and a <]Uiu-t«r i-equired an 
•xpoMire of twenty uiiunt^s. The volumes of aii- that may bt: free from 
infective genus mAy be considerable in favorable localities, but, as there 
uniformity in the distribution of floating orgHnisms, no given volume 
be relied upon an absolutely pure. 

AsTisEPTic Shr.iys. — With the view i)f prociuiny absolute ijurity, at 

of uH ail' coming in contact with a wound, Mr. Lister has recom- 

ided to fill the atmosphere nbout li wounil, its long as it is eximaetl, with 

spruf of a eai-ljoUc acid Holutiou, IwUevuig that the acid haa the property 

killing whatever germs might lie floating in tJie ail- thus chai-gecL Of 

1 of a spray, however, Mr. Cheyne, in his "Antiseptic Surgerj-," says 

73) : " Of all the precautiouB required by Mr. Lister, that of piuifying 

by means of a ciirboUc. acid spray is the least necessai-y, for there 

but tew aeptic particles present in the atinos])here, and even though 

oome of them fall on to a wound, they intiy be rendered inert by washing 

wound with carbolic lotion. . . . If at the prewent time he were 

ipelled for any reason to give up xume oiie prci'uution, he would at 

throw aside the spray, as that one which w leiwt net.'eMHary, and wliich 

Id be the most readily dispensed with." 

The result-s of observations made by othei's have not confirmed the 
■apposed power of the carbolic acid siirny to kill floating germs. Experi- 
ments made by Stimsou.' of Now York, in 187!), demonstrated that par- 
ticles of atmospheric dust, after liaving paused through a doud of carboUc 
ifac&y, are still capable of exciting putrefaction in hquids upon which 
they lodge. Duncan, of Edinburgh, iu his article on " GenuB lunl the 
Spray," already referred to, reports the results of extended and repeated 
experiments, which definitely prove that, so far as the destruction of flout- 
ing germs in the air Ih concerned, the spray is perfectly incfi'octuaL 
"When we consider the researches published by the German Health 
Bureau, it seems somewhat doubtful whether the carbolic acid spray ever 
killed a single healthy bai.'terium ; the vitality of certain spores is certainly 
not thereby affected " (Belfield '■■). Instead of being beneficial, it is possi- 
ble that a spray directed upon an open wound may be positively harmful 

' Ad Eiperimenlal Incjuii? iDto tbe Value ot tba Carbolio Spray aa a Prevenlive 
or Putrefnctioo. Anier. Joum, Mod. Soiencee, January. 1830. 

'Sepmaaad Antiiteptic Suii^iy. The Medical ItoooFd, Msich 3, 1883, p. 2:n. 



68 THE TBEATJIENT OP WOUNDS. 

by reason of the ftir-cnrrenta which it produces, fur, as Duncau ol)aerTeii, 
if the spray is made to pliiy wojhs ii l>eom of aualight, the floatiug dust 
may be seen in clomlH ruBhing toward and being whirled along with it, 
so that one can liardly doubt that the nutrgin of the spray ih the most 
dangerous poaitioii in which a wound cnn ix placed, and that a slight 
deflection from u current of aii- may renult in tlie entrance of lliis floating 
matter to recesses where tlie Kuhitioii dejwsited by the spray may never 
reach. 

The obBervatiunB of ACquel, at the Montsouris Obsemilory (see page 
83), of the piirification of the atmosithere from floating organiBms pro- 
duced by rain-stonuH, iudicAt«K how the xpray may be made a valuable 
agent in prumotiug tlie ptirity of the air ui any given situue. By means of 
the spray-producer it is possible to liave a local i-aiu-storm, at any time by 
means of wliicli tJie floating matter in the air may Iw mechanic-ally precipi- 
tatecL The temporary comparative piuiticatioii thuH itecurcd would not 
be increased by tlie oiltbtion of a Hiimll iiroportiun of any antiseptic mib- 
stauce to the material imed for the spray, althtmgh Huch aildition would 
not be objectionable. As the spray washes down )ipoii tlie surfacea upon 
which it fallB the floating matter wliich it carries with it, it sliould not be 
used MO as to fall upon a wound. In the case of a surgical o)>eratiou, or of 
the dressing iif a wound, ita uue should be jn-eliuunary to the exposure 
of the wound. 

In most wounds, whaterar germs may l>e deposited on their tturfacea 
from the atmoephei-e may \te readily destroyed by irrigation with aiitlseptio 
litjuids, but in some the deep and irregular recesses which characterize 
them, or the extent of the natural carities into which they ojieu, as iu 
wounds of the great seraus and joint buck, make jierfect inigation imcer- 
Ijiiii. In dealing with such wounds the iidtbtional ]jrecaution uf washing 
the air of the room by means of a preliminai-y sjiraying promises advantage. 



CHAPTER V. 

WOUND-DISINFECTION— ANTLSEPTICS. 

It Gmteral: — Comiiarative Oermicidul Strength of Vuiona AgentH — 
i Bequired to Itestroui Oenu'DeTelopnieDt — Local Effect of Antiseptics 
n TiasuBB— GoQoral ToxJo Effects. S/treial AntuijiUet ; — Corrosive Snblimiita— 
PermuiganaCe of Potussa— Carbolic Acid— Ita AdvantngaB— Its DisadvantageB— 
Cubolio Intoxication— Chlori lie of Zhio— Solioylio Acid— Bonvuio Acid— AaetBt« 
ami Aceto- Tartrate of Alainlua — Iodine oad lodofocm^Iodofonu Intoxication — 
Xaphtballn — Subnitrat« of Binniuth. 



Is additiou to the reHOurtteH of deauliueBB for jtrcHerving wouuili^ fniiii 

becoming the neat of the WtuI airtivity uf iiucro-ort,'tttiiBmH, there atill 1*0- 

8 to the Huryeon the empluviueut of direct nppUfationB to the wouiid- 

s of BubsttmceB which have the [xiwev either tij ilestroj them out- 

r to reati-aiu their yrowtlL lu fjeiiei-al iwrlaiice tlte application of 

e term aniij<i'i/li'-g ia reBtriet«<l t<) tUetie MiiIwtauceM. 

The pot)sil>ility of obtaining antiKeptic remiltN iii a wound by agents 

t simply reKtraiu the growth of Hcptii' orgimisuis, an well uh by thoae 

lat destroy them, i« a matter of great i»racti«il importantie, for it haa in- 

I the number of tnibatAUceri u^-atlable for aQtinepaiH, and since the 

Ppteventive effei'ta of many agents am be accompli Hlied by much smaller 

anwnmtH than their deatnictive efie<-tN, it luw been found possible to obtain 

their autiseptic eSectH with less local initation of the womid itself and le«a 

ility of danger from absorption of poiaonoua quantities of the agent 

tfafiUood.' 



■ This inhibitory action of certain ugenta in Bimilsr to tho effect upon certain pro- 

oeauea of vegetabli? life exhibited by anccachetlcfl. " The addition ot ether to an in- 

fuidau conCainiog j'east, at once aireet? the proeess of fermunladou. On removal of 

■ the aniEBtbetio, by evaporation or by filtration, the activity of the yosit fnngns is re- 

^■iBewed, and fermentation ie agaia resaTaeiL If an ai|uatio plant be placed in a watery 

^l^ohiUoii of ether or chloroform, ita absorptioD of carbonic anhydride and its sxhola- 



70 



TUB TREATMENT OF ITODNDB. 



In estimating the usefulness of any agent ae an antiseptiG application 
in the treatment of womidH, three thiugs have to be token into considera- 
tion. 

1. Its power as a germicide or germ-reatraiuer. 

2. Its immediate local efl'ect on the wound surfaces — neutral, irritant, 
or cauati& 

3. It^ remote constitutiooal effect when absorbeil into the general cir- 
culation. 

Some general considerations under each of these should receive atten- 
tion before taking up Individual antiseptics. 

1. What amounts (if the varioua antiseptic agents are iKceesary to intro- 
duce into a wn^nd, to secure Ike deetruvtion or resist the jnuttiplicatioti of 
whoteoer septic germg maij haue gavied access to it f 

The fact that germs of different ^ecies manifest different degrees of 
vital reaistimce to cliemical reagentH, and that differences in the phyeicttl 
condition of the same species of germs at diffei-ent times likewise cause 
variations in the effects pi'oduced by applications made to them, must 
ftlw^^'s he borne in mind in the clinical application of esperimental re- 
Mitn'hes us affecting the precise strength of an agent needed to antagonize 
possible septic germs. 

The experiments of Dr. George IL Sternberg' give the following 
Muouiitt* as the strengths requii-ed for certain reagents, enumerated, to 
tliwtrov tlie riliJity, or to prevent the development of the miiTococcus of 
IMS. Tlif fli>i<l containing the luicro-oi^anisms, with proper precautious 

matxA ngniiist errors, was subjected by this experimenter to the test 
I for A Bpace of two hours. The following table exhibits the 
■ utKxled t*) destroy the organisms : 



K^^raM 0MW< Tba plftnt does not die ; it merely Bleeps. On replkclug it In 

I (Mt luttn'*^ rospiiBbion U immediately resnnied. The (^naioiitioii at 

k^M ah* I* * dmllftr manner be aitested by .-mrroundtiiK them with on uiieB- 

itiymkii ; Aniextbetics and An^mthetjia ; The tDtamational Baoy- 




400). 
JolMniine tlie Oermicide Valae of u 
^^ t)M U«Uo»l Scieuoea, April, 1883, p. 335. 



u Therapeiitio Age&b. 



1 




AJmssmo AGENTS. 



TABLE OF OEBMIOIDAL STBEKQTHS. 



ESioLent in the 
ReagBOt proporrian ol 

Mercnrif bichloride 20,000 

Potassium permanganate 833 

Iodine 500 

Creosote 200 

Sulphuric a«d ' 200 

Carbolic add 100 

HydrccHorif acid 100 

Zinc chloride 50 

Tinctura ferri chloridi 25 

StJicylic add diriaolved Iiv sodium bonite 25 

Citric add 8 

Chloral hj-drate 5 

The foUowiiig-named rettgents failed in the proportions yiveii below, 
irtiiah vrere au far as the experinibiitfi were cuuduct^d with tlieiii : 

Failed in tbf 
lirupoitioa of 

Fowler's solution (arsenite of pitassii) 40 per cent. 

Sodium hj-poKulphite 32 " 

Sodium sulphite (exwiceated) 10 " 

Ferric mJphate (saturated solution) IB " 

PotasHium iodide 8 " 

Liquor zinci chloridi 8 

Zinc sulphate 20 

Boradc add (saturated solution) 4 

a borate (saturatttl ttolution) 4 

1 salicylate 4 

ffimilar experiments made with the mitTocoi'i-us of goiiorrlupa. the 
micrococcus of aepticit-mia in the rabbit, the bacterium terrao, and ujwn the 
oi^gtmisms developing in broken-down beet-tea which had been freplv ex- 
posed to the air, showed that in general thone reagentit which desti'oyed the 
vitali^ of the micrococcus from piiH are equally efficient when a different 

EaniHui is used. The mout uniform power was dispbtyed in all 
by mercuric bichloride and by iodine, which the author presents 
ride agents of the highest value, giving aa the proportion in 



THE IBEATHENT OF WOUNDS. 

wliitit tJiey would certainly be efficient aa oue part iu five tlioueau*.! for 
roeroiiric bicliloride, and one part iu two hundred for iodine. 

EiperiiiieutH made to determine the miuiniuiu quantity of the reageuts 
named required t*) prevent the development of the various micro-organ- 
iwuB gave rexuit^ which also were found to I>e pretty uniform for the 
three different orgauimua. Am will he Heeii in the subjoined tMble, borocic 
acid, Hodium biborate, and salicyhc acid diasolved by meana of sodium 
biburate, though they hail not been found to iwasesM any germicide valuB, 
even in four i>er cent, solutious, proved to be potent in preventing the 
development of neptic orgnnisniii. This power is more marked in the case 
of the bacterium termo, a putrefactive urganutm, than in that of the 
micrococcus of pus. 

The following table shows the minimum quantity requiretl to prevent 
the development of the micrococcus of pus. 

TABLE OF STRENGTHS liBQUIUED TO EKBTIUIN GEKM-DEVELOPMEST. 

Kmoient in tba 

Uerciuii; bichloride 35,000 

IiKline 4,000 

Sulphuric acid 1,800 

CarboUc acid 500 

Salicylic acid and sodium biborate, eqiml i>ttrt*i 200 

Boracic acid 200 

Ferric eidphate 200 

Hodium biborate 100 

Alcohol 10 

Comparison of the two tables shows that the more potent germicides 
have the power of restricting multipUcation iu quantities considerably less 
ihnn are required to destroy vilahty. ' In the case of iodine, the differencA 

' The folIowiiiK tabid ot reaolta obtatned b^ Koch in tbc laboratory of the ImperisI 
Bourd ol Health at Berlin iMittlidJmigeii. au» dcin kaiitrlirJien GetundheUtamlt, p. 
£30, Berlin, 1881] ma; be coiupareil n-ith the lesQlIa of Sternberg : 



'CD^h Alt rvtgt/nt 



Total destruction of life. 



Fermnnganate <iC potuh, 1 t« 20. . . 
OtMh, 1 to 100.. 



M 



ANTiaEPnO AGENTS. 78 

is eightfold ; in that of corboUc acid, fivefold ; in thitt of aulphuric acid, 
fourfold, etc. 

The substEUirPn included in Huh list tested by Stemlierg include the 
most of the more comuion reagents that have heretofore been in use in 
solution, us Antiseptic lotions, in the treatment of wounds. The results of 
these experimeutA are of great \-alue in giving a standard by wliieh to 
juilge the merits, an antiseptlcH, of \-ariuus agents, and alim b; which to 
determine the strength of the antiseptie solution to l>e used in any given 
instance ; though prudence may require that solutions of considerably 
greater strength than the iiiinituiua quautiticH, determined hh sufficient for 
autisepticH in the fluNku used for these lalxiratory experiuientM, be used for 
_ .the disinfection of actual wounds. 

^B In addition Ut these soluble agents, a new clans of agents, insoluble, 

^Httwerleae. or com^mratively insoluble, has recently been added to the list 

of aoitieeptics. These now include iodoform, naphtlialin, and the subni- 

trat« of bismuth. They remaui to be subjected to a siuiilar series of tests 

to determine the taiuimum strengths in which they must be present to 

Kgaert certaitdy an inhibitory effect upon genu-gron-tL 

^^L 2. 2%e effixt which a intbstance introduced into a toound as an anlis^tio 
^H|^ have on the exposed gur/acet of the tuoHwl must bt laLen into consider- 

W ^.. 

^ Snnclb of MgHil. ^>,p[«ure. ^■''•^'- 

Omiic add, 1 to 100 . 1 iay. Total deatruction of life. 

Ttirp«Dtiiie, oil of Ti dayo. ' ' 

Chlorine water, frealilj made 1 day. " 

Iodine, aloohulic solntiou, 1 to 100 Hiuileicd (growth oalj. , 

Chlorido of lime 5 days. Total deatructiun of lifaii | 

Chloitdeof Inm li dayii. ■■ 

Aisenic, 1 to lOO 10 days. '■ 

SulphurooB add water Very slightly eSoadous, 

Solphiula add, 1 to lOO 10 days. Hindered growth. 

Bondc add. ItoSO Q days. *' 

Borax, I to 20 15 daya. No effeut 

Qalaine, 1 to 100 10 days. Total destrQclion of lite. 

Carbolic add, aqueona BOlution, from 1 to 100 tn 1 to SO, is aaffioieiit to dertroy 
ocganisnu that have not passed into the apore condition. For the aure destructioo of 
thv iporea of Uis anthrax baoilli a stren^b of 1 to 10 is ncoeaaary. 



THX: TBBATHBNT OF WOUNDS. 

alion in chooaing one/or me, as well as its effect upon the germ auj^po&cd lo 
be present. 

A pronounced irritating or caustic effect may render an agent unfit tor 
use upon li\-ing tisBiieB. Even if but eliglitly irritating, the increaaed 
BerouB flow, ^liich its applitution may provoke, wiU seriously embarrsAg 
the attempt to prevent the development of septic cunditionB in it. The 
property of producing upon wound-surfaces a thin film of ijoagulated albu- 
men uncongenial to the growth of germs, as a protection of the surfaces 
covered by it, and which, by pressure, tends to restmia effuaiun, lias ex- 
tended greatly the usefulncHs of so feeble an antiseptic as chloride of one ; 
the freedom from irritation of iodoform imcl bismuth powder, and their 
properties of absorbing moisture and exercising compression \i\xm the 
surfaces to whieli tliey are applied, tlius rentnuuing secretion, add greatly 
to their antiseptic powers. 

3. 77ie poanbilUy of the production of general toxic gymptoms by abeorj}- 
tion of the agents used as local antiseptic ajiplications is always to be borne 
in m%nd at a conmderalion ckecHng the unlimiled use of these agents. 

The amount of danger attending the use of particular agents will 
be considered iii connection with each. In general, however, it may be 
stated tliat the larger the surface exposed to the action of the agent, and 
the moi-e prolonged the exposure, the greater tlie danger of abBorj>tioD 
in toxic qiumtitieH becomes. 

The speuial properties of indiridual imtiseptica will now be considered, 
including, however, only such iis have been found by experience to be of 
value as wound applications. They will be taken up in the following 
order r Corrosicc Subliinale, Permanganate of Polasaa, Carbolic Acid, Chlo- 
ride (f Zinc, Salicylir Acid, Soradc Acid, Acetate of Alumina, Iodine and 
Iodoform, Naphthalin, Subnitrate tf Binmuth. 

CORROSIVE SUBLIMATE 

Though the ef&cient anti-putrefactive properties of the mercuric bichlo- 
ride, or corrosive sublimate, had I>een known for a long time, its employ- 
ment in the treatment of wounds hud lieen prevented by fears of its toxio 
effect through absorption, and olso by tJie ardent advocacy of the sufficient 
merits of other agents. 

The publication of the researches of Koch u]wii tlie bacilli of anthrax^ 
the eporea of which, though they were unaffected by other autiaeptius, wen 



OOBROSIVE SDBLIMATE. 75 

killed in a tew minutes in s solution of corrosive eublimate, 1 to 1,000, and 
■were prevented from developing by a solution of 1 to 5,000, has inspired 
surgeons to trials of this agent, the result« of which have been very aatis- 
factorj-. In the Haiulnu'g General Hospital, during seven tnouths begin- 
ning iritb November, 18B1, Schede and Kilmniell used no other antiseptic, 
Mcept for the sjiray and for the bath for instruments, for wliith purpoaea 
carboUc acid, 1 to 20, was used. These fturgeons employed solutiona varj-- 
ing in atrength from 1 to 100 to 1 to 5.000. Although large quantitiea of 
the stronger solutJoii were uBeil. and the cHses were closely wattihed for 
constitutional tosic sjTuptoms, in only two cases out ot over two hundred 
did any salivation occur.' 

These sui^ieons report that the healing of the wimnds, in the dresBing 
of which the mililiniate is used, is atTomplished with a certainty and uni- 
formity unknown under any other tlresHiug. Enniarth and Neuber, of 
Kiel, have recommended it strongly as an adjuvant to the peat dressing. 
Out of 212 cases of e^tenwve wounds treated by tliem with the sublimate 
and peat dressing, in only 11 cases was the dressing changed more than 
No toxic symptoms were ol^served in any of these cases. 

Weir, in the New York Hospital, has used it with satisfactory re- 



fr. 



The sublimate solution is free from odor, and does not irritate the 
wound. By it*i use the wound-secretions marke<lly decrease, and wounds 
previously offensive bew>me Hpeedily sweet In some instances it pro- 
duces a roughuew* of the Hkin, and in an easily irritated skin an eczema 
may also be provoked. For purposes of inigation a solution of 1 to 1,000 
(about 8 grains to the pint of water) will afford a standard solution of re- 
liable antiseptic streugth A solution of the same strength should be 
used for inmiennng the sponges and compresses, and also for the perma- 
nent preservation of the sulk used for sutures, after they have first been 
Moaked for two liours in a sohitiira of 1 to 100 {7G grains to the pint). 
Any external dressings applie<l may be impregnated \vith the sublimate, as 
pre\-ioualy described. For the disinfection of instruments it cannot be 
_,employed on account of its corrosive action on the metal of which they are 



L Kdmiiiell : Utber «n« neue VtrbandtnetAode, eto. ArMe jUr EUniteiu Chi- 
nrgie, Bandxxm\., Ilrft 3. 

'The Wenk Points in a Iiietor Dreasinf;, and the Adviuitageti of Corrosive Snbli- 
t»ta» H an Aotiseptic. New York Mediool Joomml, Uaf ID, 1883, p. 549. 



TILE TEEATJIENT OF WOUlfDS. 



PERMANGANATE OF POTASSA. 



Since peiiuunganate of ixtfAMsa was brought to the notice of the pro> 
feBsiou by Mr. Condy, iu 1867, its antiseptic powers have been recognized, 
ftnil it has lieen much uaed for piirposea of iiiigation, in aqueous solutiDua 
of imm 5 to 20 piirtH t<) 100, TUe rapidity with whit^h it becomes decom- 
posed when brought into contact with organic substances >u)fit« it for use 
as an agent to secure prolonged autiaeptie effeeta j 

CARBOLIC ACID. 

Tlie use of carbolic acid a« an antiseptic owes its introduction to Le- 
maire, of France, who pubhtihed a ivoik entitled " De I'acide phvnique " in 
1863. Lemaire %ras the first to use corboUc acid, and wax the first to 
realize the ti-uth of the genu theory as api»Ued to woiuids.' Tlie first in- 
terest in tlie use of this agent had in great de^i'ee subsided, inasmuch U 
the lute of it, applied iu the way recommended by liemaire, had failed to 
give satis&f.tory results, when it was taken up by Mr. Lister, iu 1866, in 
his wards in the Boyol Infirmary of Gla^ow, and by hi in brought throng 
various modifications of use until a complete system of wouiid-dresdng, 
based upon its antiseptic properties, bnowu as the Listerian method, ynB 
ultimately elaborated. 

This agent still remains the one in more general use as an antiseptig 
tluui any other, chiefly through tlie impetus i-eceived by the marked and 
certain immunity from septic accidents in wounds which sm-geons wer^ 
for the first time, able tj) secure by its use according to the methods 
prescribed by Mi-. Lister. Whether a more accurate knowleilge of the 
character of the agencies which are capable of lUsturblng the repair of 
wounds, and tlie power of other agents to equally or more certainly coun- 
teract them, shall clause carbolic acid to become measui-ably obsolete in 
tlie future or not, to carbolic acid itseK will always attai^h the interest 
which comes from lia%Tng been tlie agent tlii-ough which tlie posaibili- 
ties of antiseptics iu tlie treatment of wounds were first demonstrated ; 
and whether in future the techniijue of Mr. Lister in the dressing of 
wounds, when antisepsis is desired, shall continue to be adopted or no^ 
to liim will ever i-emaiii the I'redit of liaviug fiiTit apiireciated the full rela- 
tions iif sepsis to wouud^disturbonces, and of liaviug devised a method bj 



^ 



CARBOLIC ACID. 7 1 

which septic infection in n. wound waa lertainly guardecl against, and of 
having inaugurated a new era in wound-treatment in which it was elevated 
&om the potdtion of aii empirirnl art to that of an exact science. 

Carbolic arid is a pn)duct of the ilestruetiTe distiUation of coaL Pure 
carlM>hc at'id is aliBolute phenol, C^,0. It is Kupphed iw a pinkiHli crj-s- 
talline mass, readily soluble in fifteen paila of water at the ordinary tem- 
perature. 'When subjei-ted to idight lieat it hquefieu, and may be made 
jtermanently liquid by adding to it five per cent, of water. 

The ordinal^' commercial acid contiuuit an humolugouK substance, cre< 
mil, which docH nut cryataUize, and. though verj- deliqiieecent, does not 
iliwiolve readily in water. It has equal antiHeptio proiwrtiea, but is more 
irritating and cauwen numbuew} and tinglhig <)f the Hkiii in a much greater 
^d^ree than tlie pure acid does. One i>art of tlie ordinary commercial 
■ttad will diflHoIve with some diilicult;\- in twenty parts of water. 

Carbohe wid i» freely fwluble in glycerine and in alcohol, and readily 
blends with oil in any proportion. The following piw'tii^l remarks on to 
itfl preparations and their ui*et< are mainly from MacCormac's " Antifieptiu 
Surgeri' " : Water posseBHes no veiy Btrong attraction for carbolic acid ; 
the Utter is readily given off by it, hence wateri' wilntionH seem to act 
more intensely on the skin, or any surface to wliicli they are applied, 
the acid does not diasolve in twenty parts of water, but partly re- 
tnmpended in the form of oil-globules, impurity to that eKt«nt is 
indi<nted, and the solution should l>e filtered 1)efore using, as the undia- 
Bolved particles act as a caustic. 

The best way of preijuring either oily or watery mixtures is to first 
jiut a few ounces of oil oi* water into the jar or bottle, and then add the 
full quantity of acid, previously melted by heat. Mis the two thoroughly, 
and afterward add the remainder of the oil or water, otherwise it is diffi- 
cult to properly blend the oil or water with the acid. 

The watery wdutions ai-e of two utreiigths : one being five per cent, or 
1 part in 20, and the other two and n ImU i>er i-eni, or 1 part in 40. The 
five i>er cent solution is employed for purifjing the Imuda of the nurgeou 
Hid his assiHtauts before and <luring au operation ; also to disinfect the 
of that region of the body where the operation is about to he per- 
ifcrmed. and all partes which will be included in the subsequent dressing — 
also f<ir supplj-ing the st«am spray. In a solution of this strength sponges 
are preserved, also silk and drainage-tubea 

The 1 in jO solution is used for the pui^wse of irrigating a wotind. 






TUE TRHATMENT OF WOUNDS. 

waalimg tlie sponges uueil dtuiii^' nu tij)emtinn, sotikiug the gauze whicli is 
first applied to the surface, and for lilliug the tray in which the instrnmeDta 
required are plaeed. Glycerin m equid proportion to tlie earbolie add 
may often be added ivitb advantage to the watery Molution, It helps to 
prevent the too rapid volatilization of the acid, und counteracts to Rome 
extent its irritating properties. 

A solution of t^iirboUc acid in alcohol, 1 to 3, ia used for the purpose of 
purifying wounds inflicted some twenty-four or thirty-sis houTH hefore 
coming under treatment. 

Carbolic acid and glycerin in the proportions of 1 to 5 and 1 to 
10 is used as a dresHing for wounds in the neighborhood of the aaxu, 
peiiia, et«. 

Carbolic oil consists of a mixture of carbolic acid and ohve oil In 
various proportions. The 1 to 5 oil is chieUy known as the solution in 
which catgut is permanently preserved. It has been shown by Koch,' 
however, that solutions of carbolic acid in oil or alcohol ore absolutely 
inert in respect to their action on bacteric life, either on the spores or the 
fully developed orgauisms. .\nthmx spores introduced into oily solutions 
of carbolic acid, of thymol, and of wilicylic acid, in each ut the end of 
three months were still found capable of development. Koch, however, 
remarks that "when the oily solution came in contact with substancea 
containing wat«r, as, for instance, the tissues of the human body in 
wounds, etc., then it undoubtedly gave up part of the acid to these, and 
in this way au antiseptic effect would be pi-oduced. In oil cases, however, 
in which dry substances, mich an silk, catgut, instruments, etc, have car- 
bohc oil applied to them, not the least antiseptic effect is to be expected 
even upou the most vidnerable micro-organisms." 

The possibility of catgut lm\-ing been made from the intestines of ai^ 
thracized sheep renders special caution in its perfect disinfection neces- 
sary. Zweifel, of Erlangeu, Kocher, of Berne, and Volkmaiin. of Halle, 
have idrt-ady reported cases of anthras-iufecUon of wounds by means of 
catguL 

The use of gauze and other materials impregnated with carbolic acid as ft 
wound dressing will be described in n subsequent chapter (Chap. X-}. The 
i-upid deterioration of tlie antiseptic strength of such di'esaings by the volatil- 
ization <)f the carboUc acid has been shown, pvrticulwly by Dr. H, F. Weir,* 

' i'ther Duinftetion. MitCheilungen niia dem ItniterlieAen Gaitndhdtiamte, 1S81. 
* BemBTka oa AntiMptii] DreMfoge. Xew York Medical Joutnal, Jannur, 1880. 



OABBOtrO ACID. 79 

I New York, who found tluit in gauze llut had been imprecated after 
Idster's fonnida, and kept in a tight box wnipjjed up in rubber cloth, 
there remained at the end of tliree montlis but 1.44 per tent, uf (Titrbolio 
_»ad. Another specimen, similarly prepared and preserved, showed at the 
3 of three week^ l.H'A per cent The ordinaiy gauze sold at the shopfl 
B found by Kopff to have but iiue-half of one per cent, of acid. Only 
t which lias b^t ii freshly prepared, therefore, should ever be used 
I AiiVAHT.iaEs OK Cawioi.k! Acid as as AsTisni'ncv — The pro]>erties of 
>oliu acid which eommend it for use as uu iiutiHCptic ore : 
1. Its reliabilitii. Comparatively weak atjueous solutions, 1 to 20 iind 
9 40, may be depended ui)on with certainty to ilestiTjy all micro-organ- 
8 (except such most resistant spores a» the anthrax, w]u<?h need not be 
irily connidered in connection witii woundn), while much weaker bo- 
8 suffice to prevent development us long as the reagent continues to 
b, present. 

^ S. Ita diffasibHity. The miscibility of the reagent-solutions with 
retions, and the absence of any escharotic or coagulutinj; effect 
from the dilute Bohitions used, favor its penetration into all partw of what- 
ever woimd may be treated with it, whereby complet« and thorough dis- 
Kiction of all par1« of the wound is certainly obtained. 
DisADvivTAOEs. — 1. The liical irri/alion which it excites. Carbolic acid, 
m brought iu contact with albuminous fiuida, as serum or pus, forms a 
ooinpound witli the albumen — phenol-albuniiuate — so that its addition in 
larger quantities and in grent#r strength is neceaaary to secure complete 
disinfection of wounds, if they have already become septic. The irrita- 
tion which the use of solutions of the required strength, 1 to 20 to 1 to 
40, produces, determines increased capillary oozing, and an excessive and 
prolonge*! serous flow from the wound surfaceH. Li this respeet its u»e 
riolates one of tlie most importiuit indicatiouH of wound- treatment, to 
rliniinish the amount of putrescible materiid iu a wiiuuti To overcome 
this, greater complesity of ibainage, and of external ilressings to a wound 
are demanded, and the most watclifid care against the possible entrance 
f septic organisms rendered necessary. Eczema anil erythema of the 
D covered by the carbolio tlreasings is not tui infrequent effect. It be- 
■nbs the skin, and is followed by general branny exfoliation of the mi- 
1 layers of epidermis. This is particidai-ly likely to be disagreeably 
I upon the hands of the surgeon using it. 
I 3. Its volatUUif lessens its usefulness bb on agent to secure pern 



80 TUB TEBATMENT OF WOUNDS. 

imtisepBis, maldng frequent renewal of tlie dresamge necessuy. which 
renewals violate imotlier fundamental principle of wound'treatmeDt, that 
of resi UnlesB the ilreseingR are frequently changed, orgflniamB Hpeedil; 
appear in the discharges that accunmlnte under the dressings.' The ne- 
pessity of restraining the Tolatiliziition of tliis antiseptic by enveloping the 
dressings charged with it in an impenuenhle material — macintosh — keeps 
the partA thus contined in a state i)f moist wHnotli, which promotes exuda- 
tion and favors decomposition by Kjaintflining a condition favorable for 
the occurrence of putrefaction as scion as the antiseptic is sufficiently ex- 
hausted By keeping the skui underneath it moistened with retained 
Becretdons it establishes also a favorable cluumel for the introduction of 
organisms from without, Iffl volatility makes absnrlient dressing materials 
that have been (charged with it entirely unreliable for antiseptiit ilresHings 
after they have I»een pi-eiwred for more than a few days. A surgeon in ordi- 
nary practice is thus prevented from keeping it in st*ick for emergencies. 

3. Its foxic (jualitieH. The absorption of carbolic acid in poisonous 
quantities is more frequently obaerved when large cavities or exteosire 
wounds are washed out or are exposed to the action of the reagent under 
a pressure that favors its altsi rjttiini. Some persons seem ]^>eculiarly sus- 
ceptible tu the uitluence of nurlmlic aci<l, and in them quite a small quan- 
tity will suflBce to excite symptoms of poisoiung. Children and women 
seem more eRpedally Uahle to its noxious influence. Many fatal cases of 
poisoning by absorption of cai'bolic tttnd, when itse<I as an antiseptic appli- 
cation, have been recorded. The severe cases are cliaracterized by symp- 
toms of profound coUapse. which sjieedily terminates in death by failure 
of the respiration. In the less sevei'e CAses gastric derangements first 
appear, as loss of ajipetite, frequent nausea, or inceustuit vomiting ; there 
is an increase, often enormous, in the secretion of saliva. More or less 
stupor or giddineHS, noises in the hea«l, or other signs of cerebral disturb- 
ance. The seci-etion of urine is diminished, anil verj- oftwi becomes of a 
dark olive-green color. It may be passed in this cinwlition, or may become 
dark only after standing for monje time. There is. however, no direct 
relation between tlie toxic effects of tlie carbohc acid and the amoont of 
the discoloration. It iti met with when there are no other symptoms ; or 
the urine may be dear, while other well-marked signs of carbolic-acid 
poisoning are present. Abandonment of the use of the acid is at once i| 




H «tmtac 
fecmtac 



OAKBOIIO P0180NIHQ CHLOEIDE OF ZINC. 81 

[aired wbeo toxic Sfiuptoma arise. Little benefit is to be expected 
from any other treatment. 

In Mr. Listers practice, according to Cheyne, carbolic-acid poisoning 
is a thing of very rare occurrence, only two cases having been recognized 
in which serious toxic symptoms were due to it The reason given for this 
immunity is, that Mr. Lister brings carbolic acid as little as possible in 
«tmtact with wounds, applying it freely to everything which may come in 

itact with the wound, rather than to the wound itself. He does not 
Ae wounds, nor inject them, nor even wash away the hlaod and dirt 
from the hue of incision. 

The importance of the disadvantages that attend the use of carbolic 
acid in the treatment of wounds is so great that, with the increasing know- 
ledge of the requirements for preventing the septic infection of woimds, 
and of the value of other agents for that purpose, its use deserves to be- 
come very much circumscribed. Only, perhaps, for use in the antiseptic 
bath for the immersion of metalUc instramenta can it not now be replaced 
by less objectionable substances. 

^B OHLORIDB OF ZINO. 

The germicidal power of chloride of zinc, according to Sternberg, is but 
half that of carboUc acid, a strength of 1 to 50 being required to destroy 
the micrococcus of pua. It is very soluble in water, and its stronger solu- 
tions are powerfully caustic It has been commonly employed in the 
strength of 8 tu 100 (40 grains to the ounce). This, while it destroys with 
certainty all organisms that may be present, forms by its reaction with the 
albumen of the tissue to which it is apphed a white translucent film of 
zinc-albummate, which not only restrains exudation and protects mechan- 
ically the underlying tissue, but also forma to them an antiseptic shield 
that is capable of resisting for many daj-a the development of micro-organ- 

E,' The caustic effect of the reagent unfits it for use on freshly cut 
Eoofaer, in bis paper on the trentmcot of tvouDda olteatl}' refenod to. qaotee the 
rlmenta at Boillat, in wbich a apecimen of thia z[nc- album iuate, oocercd aimply 
with » gltus-receiver and kept at the oTdinary temperature of the room, ebowed the 
flntt avidencea at tho development ol miorococci Ibirtj days later than a cnirespoiid- 
Istg specimen of simple albumen, nlthougli nntlirax aporea liad been kowd direcU; on 
the nrfaoe of the former. A specimen of pheDol-albuminate, prepared like ihe lina- 
annmioate, lemaiDed free from organisma only one day longer than the simple albn- 



82 THE TKEATMENT OF WOUNDS. 

mirfaces, if their union by first intention is desired. In wounds in tie 
vicinity of the mouth and anus, to which protective dressings are inappli- 
cable or in sufficient, its value is especially great. It baa been commonly 
employed in the 8 to 100 strength for the disinfection of woonds that hare 
been for some time exposed to septic influences, or in which septic cbangB 
has already taken place. Kocher speaks in terms of the highest praise of 
the value of very dilute solutions of chloride of idnc, 1 to 500, for irrigatisg 
large suppurating cavities. The absence of poisonous properties in the 
reagent i)erniits its use without limit till every vestige of pus has disap- 
peared. By the use of some antiseptic external dressing to exclude the 
entrance of new infectious material to the cavities, a perfect and rapid 
healing of the cavity may be secured. Oenerally a single irrigation 'with 
the chloride of zinc solution suffices. Only when recuirenoe of high tem- 
perature takes place is a repetition needed. 

The combination of qualities possesaed by chloride of zinc, of restrain* 
ing the further production of putrefiable material and of rendering what- 
ever material of the kind there may already be present unfit to support 
the life of septic organisms, witli certain germicidal strength, makes it an 
antiseptic agent of the great«st value. 

SALICYLIC ACID. 

Salicylic acid was introduced by Thiersch,' of Leipzig, ns a substitute 
for carbolic acid, the methods of its use being the same. Though of mach 
leas germicidal power than cai-bolic acid, by reason of its comparative 
freedom from toxic qualities, the possibility of ite use in greater quantities 
in many instances is sufficient to make it an efficient antiseptic. Wounded 
surfaces are not irritated by it, nor is the granulating process disturbed. 
The results obtained by it have not been as good oa those obtained by car- 
bolic acid. The experiments of Sternberg show that the solution of sali- 
cylic acid, 1 to 300, that has been used, is practically inert 

It has been more recentiy used as a dry powder-dreasing with more 
decided antiseptic efiects. It is not applicable to fresh wounds in which 
union by first intention is desired, as it acta mechanically to prevent appo- 
sition. It is not efficient in the prevention of erysipelas. It does not ad- 

' Klinuohe Ergtbniut iter LMrr'iehen W'tfirlbuhnntllting and iiber den BnaU der 
Carboltdurt dureh Salieylaauri. ToUcmaim'i Sammlung kUniteher Veiir^gt, New. M 

Mdes. 187^. 




BOEACIO ACID — ACETATE OF ALUMINA. 

a firmly to (he tissues to which it is app!ie<l, and hence is easily washed 
away by any increased sccretioo. When cavities are packed with it, in 
powder, and covered in by salicylic wool, the first dressing may remain 
in place for from one to two weeks without decomposition taking place in 
the wound secretions, and with rapid progress of healing. In general its 
DM in large quantiUea has been imattanded with toxic symptoms. 

^H BORACIC ACm. 

Borsdo acid has been highly praised by the late Willifljn Warren Glreene, 
of Portland, Me.,' as a reliable germicide, cheap, free from all unpleasant 
taste or odor, stable, and devoid of any irritating or poisonous quality 
within the limits of ordinary doses. By Sternberg its value was found to 
consist solely in its ability to restrain the development of organisms, which 
it pOBsesses in a marked degree. By Mr. Lister it is used as an applica- 
tion to superficial granulating surfaces. It may be dissolved in water in 
the proportion of nearly 4 to 100 parts to form a lotion ; but it finds ita 

ratest nse in the shape of borated cotton to afford a permanent antisep- 
protective dressing. 
TbB introduction of acetate of alumina as an antiseptic apphcation to 
wounds is due to Haas, of Freibuj^. It is cheap, unirritating, and non- 
poisonous, but can only be used in the moist form as it decomposes in the 
■^^7 state, If ten parte of hydrat« of alumina are mised with eight parts 
^BF dilate acetic acid, and allowed to stand for twenty four to thirty-six 
^Bonrs, at a temperature of from 68° to 90° F., the filtered solution ob- 
tained will be of fifteen per cent, strength. The hydrated alumina maybe 
obtained by precipitation from a solution of common alum by carbonate 
of soda. 

For application to wounds a solution of two and one half per cent. 
strength is used. Compresses wet with the solution are laid over the 
wound and covered in with macintosh. The amount of wound-secretion is 
usosUy very small, and the dressings required are infrequent The aceto- 
tartrate of alumina is a crystallized salt, soluble in all proportions, and 
i of marked antiseptic properties. It owes its introduction as an 



AOBTATE ANB ACBTO- TARTRATE OP ALUMINA. 




84 THE TBEATMENT OF WOUNDS. 

Hntiseptic to Kllmmell, of Hamburg, ^ho has used it as a three per cent 
and a five per cent. Bolutiou fur purposes of irngaUon with children and in 
all eases in which the toxic qunlities of carbolic acid render tbut agent un- 
advisable. As au antiaeptic dressing one-half to three per cent solutions 
gave very satisfactory reeults. Mixed with charcoal in proportions of three 
parte of the salt to seven of charcoal (thu charcoal having been previoiialy 
baked for several hours), it forma an antiaeptic absorbent powder-dreasing 
of the greatest value for filling in wound-cavities when piimaty union is 
impossible. A first dressing with the aluminated charcoal may often b€ 
allowed to remain undisturbed for one or two weeks. In small wounds 
complete healing will be accomplished as under a scab. It makes an 
exceptionally favorable tlressing for wounds involving the anal region, and 
particulai-lj after operations for extirpation of the rectum, in which cases 
the wound-cavity, after hemorrhage has been controlled, is packed with 
the powder, which is held in place with a layer of cotton-wool, some im- 
permeable tissue, and a T bandage. 

lODIHB AND lODOFOaM. 

Iodine has been long in use as a topical application to wounds. In 
1854 it was praised by I>uroy ; ' in 1871, Eicbardson advocated its use aa 
a most valuable agent in the treatment of wounds, alleging that it deo- 
dorizes, controls discharge, destroys decomposing products, and does no 
systemic injury.' Bryant,' for purifying wound-surfocea has employed 
for years an iodine lotion made by adding twenty drops of the tincture 
to the ounce of water (pouring the tincture into a basin fidl of water, 
until the latter is of a light sherry color, is a suflicient practical guide), 
and prefers it to any other, aa being always at hand, and both simple and 
effectual. A sponge wrung out of this lotion (made with hot water), and 
held to a wound for a minute, completely checks all oozing of blood, 
and tends more thmi anjihing else, except prolonged exposure to the at- 
mosphere, to the formation of that glaze upon the surface of the woujid 
which ao much conduces to satisfactory repair. 

^ Expirieneei et Contidiraliont nouTcBft pour teretr dVhUloire de Piode. Union 
MedicaU, Pari*, T. viiL, 1B57. 

'On the Soieoce ftnd Art o( Healing Woundi. TranmotioQB St. Andrew's Ued- 
ic&l Graduates AaGoaiiition, 1^71, v.. p. 40. 

'latenutioo&l Eocjclopiedia of Borgery, 1B82, il., p. 37. Article on Wound*. 



I0D0F0B3L 85 

The antiseptic properties of iodine, according to Sternberg's experi- 
laents lu-e mauy fold greater than those of ciu-bolic acid—as a ^rmicide 
fire times, and as a germ-reatrainer eight times as great — but they have 
attracted general attention only since the introduction into use, as an an- 
tiseptic, of its comjwund, iodoform, the toriodide of formyl, C,HI„ which 
contains mnety-eix per cent, of iodine, 

lonopoRU, when in solution, imdergoes gradual decompoiation, eTolring 
iodine, so that when a wounded surface is covered with iodoform a kind 
of antiseptic reservoir is estabUshed, which, constantly and slowly giving 
off iodine in a nascent state, effectually hinders putrefactive changes in 
the wound.' The credit of having introduced iodoform as an antiseptio 
dressing, is due to Professor A. Von Mosetig-Moorbof, of Vienna, who 
advocated its use first in a series of articles published in the Weiner Medi- 
cinische Wucheniti-hrifl in 1880 and 1881, and more recently in a clinical 
lecture published in Volkmann'a series,* 

The advanttigea possessed by iodoform caused its immediate and ex- 
Iflnsive adoption ; by it was introduced a new method of antiseptic dress- 
tlie dry-povxler dressing, which more perfectly met the requirements 

R wound-dressing, than any method that had preceded it. It restrained 
woimd-secretion and thus diminished the amount of putrefiable material 

a wound ; it destroyed the vitality of whatever puti-efactive germs were 

^already present in the wound, without itself irritating the wound ; it was 

ible of forming an external, antiseptic, protective dressing ; its decom- 

ition or its volatilization was so slow that the frequency of the dre8»- 
{ngs required was greatly lessened. 

Iodoform is easily soluble in ether, and in both the fixed and essential 
oils, less readily in alcohol, and to a very shght degree in water. It hag 
not the least local irritant action, but exercises an aniesthetic effect upon 
the Burfoces to which it is appUed. On account of its slight solubility in 
vater and in the animul duids it is not adapted for disinfecting instru- 
ments and sponges, the hands of the surgeon, or the adjacent integument, 
or oa an application to surfaces already decidedly septic Upon fresh 
wound-smfacea, or upon surfaces that have been long exposed after they 
hare been disinfected by some other agent, as corrosive sublimate, carbolio 

■ Sanda : On the Value of Iodoform sa a DressiDg for Wounds. The Hriicol Beooid, 
1S82, xxL, p. S09. 

*Der Iodoform- Verband. Volkmum'a kHniseAer Vortrdge, No. 211, January, 



wou 
in a 
ftlrea 



86 THE TREATMEHT OK WOnSDa. 

acid, or chloride of zinc, tlie powdered iodoform amy be lightly dusl«il 
(bom a pepper-box], A slight luyer of iodoform will not interfere vitli 
union by iirst intention wlien appoaition of the surfaces can be obtained, 
In such case, after bringing the wouud-Hurfaces together, with suob pro- 
vieions for drainage an may seem best, the dressing is completed by corer- 
iug the surface with several layers of iotlofonu-gauze, or other aimilar 
antiseptic absorbent substance. Over all a layer of soiue iinpenneable 
tissue, the whole confined by a snugly applied bandage. This dressing 
may be renewed on the second or third day, and afterward every five or 
eight days, or even after longer intervals, as circumstances may determine. 
Pain in the wound, or on elevation of temperatare, after it lias been for 
some time normal, are indications calling for a change of dressing. 

In open wounds tbe cavities, after having been Ughtly sprinkled with 
Uie powder, are lilled with the iodofono^aiize, and the whole covered in 
as before. Such wounds remaiu free from pain, the scanty discharge 
which takes place is serous in character, the surrounding integument re- 
mains free from inflammatory swelling, and the process of granuhiticai 
proceeds rapidly and without interruption. When, however, the repaia> 
tive process ia far advtmced, ultimate cicatrization is hastened by the uae 
of some other agent 

Iodoform is especially adapted for use in the treatment of wounds in- 
volving the mouth or anal region, in which cases plugging the wound 
with iodoform-gauze suffices to keep tt aseptic. Frequent remcival of tin 
dressing even is unnecessary. 

Disadvantages or Iouofoiui. — 1. It ia less abBolute in its power to pro- 
tect wounds against the invasion of eri/sipelaa than against suppuratii 
and putrefactive disturbancea 

2. lis o/lor is pervasive and lasting, and quite disagreeable to most per- 
sons. Musk, Peruvian balsam, various essential oils, as bergamot, clove^ 
and peppermint, have been proposed as corrigents. Mosetig-Moorhof orig- 
inally used Tonquin beau forthe purpose. Schork says that if 0.05 gramma 
of carbohc acid be rubbed up with 10 grammes of iodoform, and 2 drops 
of oil of peppermint be added, the unpleasant odor is entirely covered 
and is not again developed even under a higher temperature, 

3. Its loric qualities early claimed attention on account of the great 
freedom with which the earlier employment of the agent was characterized. 
Various degrees of toxic action have been recorded, and eiperience baa 
demonstrated tiiat Its use must be guarded with certain cautionB, if risk^. 




lODOFOEM INTOKIOATION — NAPHTHALIN. 87 

conaequencea are to be avoided. It acta by absorption into the 
circtilatioii of poisonous quantities from the wouiKl-surfaces. 
doaes cause rapid and feeble beort-oction, coma, and paralyeia 
orgBiiB of respiratioD. Autopaies have demonstrated in Bueb cases 
lesions of meoingitis and fatty degenerations of tbe heart, hver, and 
Leys. But the most remarkable manif eetatious of poiaooing in the hu- 
enbject are due to perverted cerebral action, taking the form of men- 
tal derangement. Every degree of intoxication hae been observed, from 
Kinple exaggeration of nervous excitability to the condition of acute mania. 
la the lighter caaes patients are reBtleas and uncomfortable, complaining 
of headache, loss of appetite, wakefulness, and the constant taste of iodo- 
form. Such symptoms often, but not always, precede those which are met 
.^mih in bad cases, which are nearly identical with the sjTQptoma of delirium 
From aucb a condition many persons recover, while othera die, 
(rften. suddenly, from exhaustion or coma. No antidote to tlie poison has 
discovered, and the only treatment of any avail is that of preventing 
intoxication, and supporting the patient's vital powers by alcoholic 
lolanta until the crisis is past Thus far it haa not been ascertained 
itely what amount of iodoform is necessary to cause poisoning, and 
the susceptibility to its action appears to vary greatly in different casea. 
Old persons ore especially liable to suffer from iodoform-poiaoning, while 
maxsh is not the case with children, as far aa con be inferred from the limited 
■tatifltics thus far publiahed. In the present state of our knowledge it 
should be employed with great caution, and in suck a manner that It cao 
be readily removed from the wound in case symptoms of poisoning should 

According to Neuber,' of Kiel, not more than forty-five grains of iodo- 
a sboold ever be aprinkled upon a fresh wound-aurface, 

NAPHTHALDJ. 

Kaptbidin is a coal-tar product, much resembling paraffin in appear- 

), save that it ia much more crystalline. It is insoluble in water or 

d juices, but readily dissolves in ether, hot alcohol, and varioua fatty 

Fischer, of Straaaburg, first recommended it for use as an antiseptic 

'Ssada. Op. citat, 

' Erfahrangen ubrr lodaform-and Torfnerbdjtde, eto. Ardiio fur kliniteht Cht- 
ii., p. 757. 



further 

ftntimtOa 
Bflbfinitc 



88 THE TREATMENT OF "WOUHDS. 

wound-drsBsing. ' It waa adopted by Professor Lilcke in Ma surgical wards 
in Strassburg, and thence has come into general use. In the United States 
it has been mitdc the subject of study and commeut by Park,' of Chicago, 
and Fowler,' of Brooklyn, 

It is to be used as a dry powder-dresaing, being dusted, in 6ue powder, 
on the surfacea of tlie wound, or packed in quantitiee without limit into 
wound-cavitieB. Oauze impregnated with it may be used for absorbent 
and protective dreBsings. 

Thmtgh itfl antiseptic qualities are inferior to those of carboUc acid or 
iodoform, yet in addition to the general advantages of the powder-dreaong 
wliicli it aharea with iodoform, it has the great ailvantage that no general 
toxic effects ever follow its use, and that it is almost a specific against eiy- 
sipelas. 

It is not adapted for use in wounds the union of which by firat inten- 
tion is desired. To insure its protective action it is important that it be 
introduced into every part of the wound, and care is to be taken that its 
tendency to form crusts does not cause retention of the wound-secretion& 
Its freedom from tosic qualities commends it as a substitute for iodo- 
form in eases in which the use of the latter agent is unadvisable or must 
be discontinued, 

A ])ure article of naphthalin only should be used. Pure naphthiiliii 
remains white permanently ; an impure article turns red. The applioa- 
tion of the impure article is likely to occasion pain and irritation of the 
wound and eczema of the surrounding akin. No such effects attend the 
use of pure naphthalin. 

STTBSITaATE OF BISMUTH. 
The subnitrate of bismuth is advocated by Professor Kocher,* of Berne, 
as an antiseptio i^ent not inferior to any previously employed, and excell- 
ing all in the simplicity of its application, its certain antiseptic effect^ and 

' Unlerruehungeti flier dit Wirkunff det Naphthaiin. Berliner kUniteAa Woehett- 
tehrlft. 1*S3, lix.. p. 118. 

' Nnplithalin M nn Antlaeptia far Surgical Dresainga. The Weekly Medical Beviftw, 
1883, p- M. 

' Naphthalin in the Ttentment of WonDda. Annalaof Au&tomj and Sntgecj, 1688, 
*ii., p. 343. 

'' Vfder die anfaehMtfn MUtd rur Krtidung aner WundhMung dunJi Verklebang 
ohnt Darmrohnn, VolkmBnn'B Htmmltinj kUnUeher Vortrdgi, No. 331. 



SUBNTTBATK OF BKMUTH. 89 

ItB special field is as an application to fresh rounds 
for reBtrainiiig the development of organisms, while for the disinfection of 
hands, inartnunents, surrounding skin, and of wounds tlmt are already sep- 
tic^ other agents must be etnplo3'ed. Its insolubility prevents its effect 
from extending beyond the region to which it is directly applied, there- 
fore, when it is used, special care to prevent accumulation of blood and 
wound-secretion is necessaiy. This Kocher accomplishes by leaving all 
wounds open temporarily, protected by a bismuth dressing, and closing 
them only after the first outpouring of tlie secretions is arrested. The 
bismuth exeroiBeB a desiccating and astringent effect upou the wonnd-sur- 
Caces and assisia in limiting the amount of secretion. Under its use the 
secretion from tie wound-cavity ceases in from twelve to thirty-sis. hours. 
Wounds may then be closed without any further provisions for drainage. 
It is to be used suspended in water ; the salt should have Ijeen flnelj- pow- 
dered, with special care for the purpose ; should then he gradually and 
most ftoroughly triturated with water, till all grittiness has disappeared, 
and an emulsion-like mixture can be produced by simply adding water. 
If a bottle containing such a mixture is shaken, the bismuth will be uni- 
forndy and rapidly suspended through the fluid. 

A one per cent, wateiy mixture, thus prepared, will answer all the de- 
mimds of thorough antisepsiB. In the course of openttions the surfaces 
of tlie wound may be moistened at intervals with the lotion by sprinkling 
I from a bottle, and when the dressings are changed similar manipula- 
] may be repeated. The application of the salt to a fresh wound- 
toiface causes at first a smart burning sensation, but after the first ap- 
plication this is no longer esperienced. After the lips of a wound have 
been brought together, bismuth may be spread upon the line of sutures 
in the form of a thick pa«t« applied by means of a brush. This method 
may also be followed when a woimd has healed to a nairow, supei-ficial 
granulating surface. In recent wounds the dressing is completed by 
^ip^dng a protective covering of gauze or other absorbent material, 
ivhieh haa been dipped in a ten per cent mixture of bismuth, the mois- 
ture being pressed out before being applied ; over this a layer of cotton- 
wool, and some impermeable tissue, the whole kept in place by a roller 

Tumdnp ft. 

tThe Bubnitrate of bismuth should not be applied in unlimited quanti- 
. It is absorbed to some extent by fresh wound-surfaces, and if ap- 
d in large quantities to extensive surfaces will produce toxic ftStecfci, 



otihe 
^bfron 



90 THB TREATMENT OF WOITNDS. 

characterized by acute stomatitis analogous to the chronic form of lead- 
poisoning, intestinal catarrh, and desquamative nephritis. There may be 
alight transient renal disturbances produced, as manifested by a blactish 
discoloration of the urine, with albumen and epithelial casts, unattended 
by other general symptoms. These toxic effects subside rapidly after the 
removal of the bismuth, without leaving any permanent after-effecta None 
of them have been occasioned since the lavish use of strong mixtures and 
the packing of cavities with the undiluted powder has been abandoned. 



PART I. 



IN GENERAL. 



SECTION II. 



THE PRACTICE OF WOUND-TREATMENT. 



CHAPTER VI. 

THE AEREST OF HiEMORTtHAGE. 

Spantantrmt BamoitaiU—SuTgiail iZimuMtnt^f—BjcpOBure to Air— Cold— Hot Water- 
Iodine — Alcohol — Tmpentuie — Mechanical Premari — CompreBaes — TampODS — 
Acnpretnnie — FordpresBaro — Ligation — Catgut Llgntnroa — Plugging FrMied— Tor- 
■ion — CoBgnlaniB— The CaxAeTj—lnteiTvpting Blood-eurrent—Som.Uaa — Foroed 
Flexioa— Digital Compre»aioD— Tonmiqueto— Elmtio Boodago — AcupteaBure — 
LigadoQ — Caidiao Sodativas. 

Tsx. conditions which demand the attention of the surgeon in the case 

I of ereiy wound present themselves to him in the following order : 
1. The arrest of htemorrhage, 
2. The general condition of the patient. 
3. The cleansing of the wound. 
4. The apposition of its surfaces. 
5. The means of protection required to prevent disturbance of the 
del 



6. The relief of disturbances of the heaUng, if any be present 



THE abhebt op H^MOHEHAGB. 



In most wounds hfemorrhage is an immediate symptom, and, in many, 
" demands the instant and actiw interference of the surgeon for its con- 
trol 

Its extent will depend on the number, size, and character of the 
^^ womided vessels ; and the character of the surgical aid demanded will 
^K depend upon the extent to which the natural tendencies to spontaneous 
^V arrest are deficient, the object of the surgeon being simply to supply such 
^H deficiencies in the manner that may cause the least disturbance in the 
^H fatoie repair of the wound. 
^H In every wound a spontoneoufl effort at luemdErtaaiB takes place, in 



94 THE TRKATMBITT OF WOUNDa 

which tlie wounded veasek, the perivasciilftr tissues, and the blood ite^U 
are all engaged. A divided artery contracts and greatly dimioialies its 
lumen and withdraws itself within its sheath. A vein collapses so Uiat its 
walla fall together- Connective-tissue strande and muscular fihrils fall 
over the cut ends of the vessels and tend to entangle the fibrin of the 
escaping blood The irritated njuacular and elastic tissue of the wounded 
region contracts and compresses the vessels that it embracer This spon- 
taneous vascular contraction, aided by the compression exercised by the 
controctioa of the surrounding wounded tissue, suffices alone to check 
hicmorrhage from the capillaries in healthy tissues As the result of the 
action of these iniluences, the bleeding, though very free at the moment 
of the infliction of the wound, qniekly becomes greatly diminished in 
amount When vessels too large to be controlled by such influences are 
wounded, and the heemorrhoge continues untU much blood is lost, the 
force of the heart's beat becomes weakened, until the impulse to the blood 
current which it gives may become too feeble to send the wave of blood as 
far as (lie wounded vessel, and thus the bleeding spontaneously cea«ea 
The blood itself brings the crowning agent for completing the process of 
arresting its own flow, in the coagula that begins to form as soou as the 
first vigorous gush is slackened. These become fixed by the irregular sm^ 
faces of the wound, and, extending into the interior of the severed vessels 
as far as to the first coUateml branches, temporarily plug them up. These 
coagula serve only a temporary purpose, those within tlie vessels becoming 
eventually replaced by the new granulation-tissue which the wounded tis- 
sue of the vessels, and especially their inner tunics, are stimulated to pro- 
duce for the ultimate permanent repaii- of the wound. 

The effective exercise of this quality of coagulation for arresting hem- 
orrhage is thwarted only when the rapidity of the blood current that 
reaches the opening in the vessel is too great to penuit a coagulum to ac- 
cumulate, or its force is so great as to sweep away whatever may have 
already been formetL This latter cause ia especially iUustrated by the re- 
curring hEemorrhages that take place from vessels that had ceased to bleed 
when the heart's action had become faint through shock or loss of blood ; 
with the establishment of reaction the heart^beats become strong again, 
and the impulse of the blood-waves become sufficiently great to sweep 
away the ooagula previously formed ; the hteniorrhage recurs, and though 
it may soon cease, it will continue to recur, unless adequate means to 
prevent it be taken, until the patient dies of anEemia. 



jraANS OF ABBEffTIKG H^MOKRHAQE. 95 

The agencies wbich nature providea for the spontaneous arrest of luem- 
rrimge include, therefore, the following : 

1. Immediate diminution in the size of the opening by the intriiiBic 

coutrftcfaon or collapse of tlie walla of the injured veaaeL 

2. Immediate and direct compression from without by contraetion of 

surrounding tissue, 

3. Secondary diminution in the force and volume of the blood current 

by heart faintuesa 

4. Temporai-y plugging by coagulation of the escaping blood. 

5. Permanent occlusion by the exudation and organization of plastic 

material at the Heat of the noiuid in the vessel 

The agenciea which the surgeon HliewiBe will find of benefit must de- 
nra their value either from the compression they produce, the contraction 
of the vessels they escite, the interference with the blood supply they ac- 
ctHnptisb, or the increased coagulability of the blood they occasion. 

The means for arresting htemorrbage naturally divide themselvea, there- 
fore, into means of direct vagcular contraction, of compresrion, of phigging 
e open orifice of the vessel, and of interruption to the Ijlood current. 

Uxuia or DaiEcr Vascular Contraction, — This class includes contact of 
mo^beric air. cold and hot applications, and such local irritants as 
i, alcohol, and turpentine. 

Expontre to Air.— Tlie contraction of soft pnrta when exposed to the 
air ifl very marked, and the continued exposure of a bleeding surface to 
cool air produces a strong hEsmostfttic effect, which is increased if the air is 
kept in motion as by a fan. When a wound is filled with coagula, underneath 
irhich bleeding is still taking place, the thorough removal of the clots and 
tbe exposure of the bleeding points are often speedily followed by the ces- 
sation of the hwmorrhage. In all cases where there is present hfemorrhage. 
the first duty of the surgeon is, if possible, to fully and clearly expose the 
bleeding point by the removal of whatever clots, compresses, or bandages 
may have previously accumulated in or about the wound. Should the mere 
exposure to the air not be sufficient to cause the hiemorrhage to cease, 
it is in the best position to receive the benefit o£ other apphcations. Where 
the poaaibility of recurrence of htemorrhage in a wound is to be feared, 
the free exposure of the wound-surfaces to the air for some hours furnishes 
the moat rehable means of guarding against it. Though the wound be 
not closed until after many hours, the process of healing may yet continue 
'without material disturbance, and union by first intention be secured. 



THB TBEATMEKT OF WODNDS. 

Cold as a hffiinostatio has always been recognized as of great value It 
may be applied by irrigating the wound with cold water, by applying 
sponges or conipresBes wrung out of cold water, by the application of 
small pieces of ice to the bleeding surface, or by enveloping the part in 
bags Goutolning pounded ice. Although cold, thus appbed, causes the soft 
parts to contract and the blood-veaaels to shrink, its appHcation for any 
length of time tends to increase shock, and to depress tlie vitality of the 
wound-surfucea, luid thus to dimiiitBh the vigor of the subsequent repur 
of the wound. The after-effect of the cold is to lessen the tone of the 
capillaries and predispose them to inflammatory conditions. The use of 
cold applications for hfemostatic purposes is therefore to be resorted to 
only in exceptional cases in default of other resources. 

Hot vxiter is even more efficient as an hfemostatic than cold. Attention 
has but recently been called to its merits by Keetley,' in England, and by 
Hamilton' and Hunter,' in the United States. It combines in an eminent 
degree the properties of stimulating the contraction of the soft tissues of 
the exposed surface, and of esciting the vital contractility of the vessels 
both directly by contact, and indirectly through the vaso-molor nerrea 
It produces a permanently stimuloting effect upon the vitahty of the sur- 
faces to which it is applied; it favors primary union in the wound; and 
in no class of cases is its value more marked than in those of threab- 
ened shock and of exhaustion from hiemorrhage. The temperature of thd 
water should bo as great as can be borne by the hand without pain, from 
125° to 139° F. Hamilton used sponges dipped in hot water at almost a 
boiling temperature, and apphed by forceps to the bleeding points. But 
■3 the water is intended to act as a stimulant, and not mechanically by 
coagulating the albuminoids of the blood, so high a temperature is not 
needed. The most effective means of applying it is by means of com* 
presses of muslin or linen, or towels of size sufficient to cover the whole 
wound-surface, that all parts may experience the effect of the application 
simultaneously. To obtain the full effect, it Is important that one com- 
press be quickly succeeded by another till permanent arrest of the bleed- 
ing is secured. 

Hot water answers the requirements of a wound -application more per- 
fectly than any other agent. The simple precaution to free tt from hurtful 

' London Pruotitioner, Fobrnary, 1879. 

■ Buffalo Medic&l and Sarglcal Journal, April, 1879. 

■ PUladelptiia UedUwl Time*, November 23, 1ST9, 



MEAKS OP COMPBESBIOIT. 97 

P organisms before it is used is alone needed to make it entirety imobjec- 
tionable. 

Iodine added to hot water tacreases its hiemostatio effect, while it also 
I disinfects it. Sufficient of the iodine may be poured into a bualufiil of 
l^imter to make the latter of a light sherry color. A sponge wrung out of 
Pthis lotion (made with hot water), and held to a wound for a minute, com- 
pletely clieckn all oozing of blood, and tends more than anything else, ex- 
cept prolonged exposure to the atmosphere, to the formation of that glaze 
Qpon the surface of the wound which so much conduces to sntiafactory 
repair.' 

Alcohol excites to action the contractility of the vessels and tlie peri- 
▼aacolar tissues, while it acta, in addition, as an aiitiacptic. It may bo ap- 
plied on a sponge pressed upon the bleeding surface. 

Turpentine is strongly recommended by Billroth' as copable of exciting 

a peculiarly energetic contraction of Uie divided capillaries. It may be 

applied on bits of absorbent material pressed against the bleeding points. 

, It is a heroic remedy causing severe pain, and exciting severe inflammation 

a the wound and its vicinity, 

MuNB OF Compression. — Compression may be accomplished by agents 
ut either stimulate the wounded tissues to more energetic contraction, 
' that may exert direct mechanical pressure upon the bleeding sur- 



grw 

Prabt 



The first class of agents includes again atmospheric air, cold and hot 
ilications, and certain irritants, since these agents cause the surround- 
iog tissues to contract with the same energy as they do the bleeding 
veasela. The contraction of the perivascular tisaues la a very important 
element in accomplishing the spontaneous arrest of bleeding. The range 
of application and the value as htemostatics o( the agents which have been 
considered as stimulants to contraction of the vessels directly is thus 
greatly increased by their effect upon the auiTOunding tissues, through the 
itraction of which physiological compression of the vessels is secured, 
supplement thi^ however, means of conipreasion, applied from without, 
are necessary whenever the size of the vessels is too great to admit of their 
control by physiologjcn! means, or the wounded tissues are non- con tractile. 
This 19 supplied by some form of mechanical pressure, the consideration of 
the raiieties of which is next to be taken up. 

' T. Bijant : Article on Wounds. Inteniftt. Encycloptedia of Burgery, vol. i 
■ SniKioa] Palholo^ (Hkckle;, 1871), p. 80. 



98 TEOC TRBATKEHT OF WOUNDS. 

Mechanical PitEBHniiE. — Properly applied preesui'o is sufficient to control 
any brcmorrhage. It muy be applied by means of compresaeu, tampons, 
bandages, the fingers of tlie siirgeou, needles thrust into the tissues, for- 
ceps, and ligatures. The method of its application will depend on the 
character and anatomical relations of the bleeding vessels ; when the bleed- 
ing comes from several points, or when it is a general oozing, which per- 
sists notwithstanding the use of means to excite tissue contractility in the 
wound, a compress is of great value. 

Comprcuses may be maile ot any aubatance that permits of being formed 
into a firm pod of proper size to he introduced into the wound. Folds of 
linen or cotton cloth ore generally available. Sponges and masses of 
charpie are often ujsed. All clots should be turned out of the wound, and 
the first layer placed directly upon tlie orifices of Uie bleeding veseels. 
Each additional layer of the compress should he larger than the preced- 
ing, 08 it is built up till it projects above the suiTounding integument. 
The whole should then be firmly bandaged. In coses where compresses 
are applied to wounds of a limb, the roller-bandage should invariably Girt 
be appUed at the distal extremity of the limb, and be carried up the limb, 
over the compress and above it for some distance. 

Compresses are to be considered only as temporary expedienta, for 
their use is in violation of every principle of wound-treatment except that 
of haimostaais. At the earhest moment they should be removed from the 
wound. If the wounded vessels are of such size as to render a recurrence 
of the hfemorrhage from them likely to take place, they should be secured 
by ligature as soon as the necessary procedures are practicable. 

In wounds of slight extent sufficient compression to control bleeding 
may often be exerted by bringing the surfocea into apposition by sutures, 
and then supporting them by compress and bandage applied upon the 



Tampons are plugs which are crowded into cavities, Ruch as the nares^ 
the rectum, or the vagina, from some part of whose walls bleeding is taking 
place. They act by the direct pressure which they exert upon the bleed- 
ing vessels. 

Hemorrhage from larger arteries and veins is l)e8t controlled by com- 
pression limited to the bleeding vessel, and applied directly to it. The 
finger of the surgeon instinctively appUes itself tor the purpose of making 
such compression upon the orifice of the severed vessel, and, for immediate 
temporary hiemostssis, by its intelHgence, ita power of properly graduating 




ACUPRESSURE. 99 

I fbe coinpreaaioTi to the needs of the case, and the miniinuia amount of 
disturbance which it inflicts upon the adjacent tissues, is employed with 
great advantage. When prolonged compreflsion ie needed, or several 
Tessels require attention, other a(,'ents are required. Tboue that axe eni- 
ployed are needleo, forceps, and hgntures. 

Acuprttf$ure. — Needles or pinu may be thrust into the tissues so as to 
compress the extremity of a bleeding vessel, either by transfixing the 
tissues when in a state of tension, and seouring pressure upon the vessel 
against the needle by the force of the elastic recoil of the tissues, or by 
affording a solid substance against which presaure can be made by other 
agents. 

The attraction of general attention to the use of acupreasiu'e is due to 
SmpaoQ,' of fVlinburgh, who advocated it as a means of diniinishing the 
amount of dead tissue left in a wound, of restricting suppuration, and of 
promoting early union in wounds. By the pressure of the pin the vessel 
is not lacerated, nor the vitality of any portion of it destroyed, and before 
it can become a cause of suppuration the pin may be withdrawn and the 
wound left free from the presence of any foreign body aa an irritant, or 
mechanical impediment to reptur. The compression with pins need not 
be prolonged for more than twenty-four hours upon vessels of small 
calibre, nor upon such vessels as the brachial or superficial femoral for 
more than forty -eight hours. 

Any smooth sharp-pointed pin of sufficient length to transfix the 
tiaaaea suffices for use in the practice of acupressure. A large shawl-pin, 

r"'g. 4, by its smooth, globular, glass head, atoiitneaa, length, and 
eoH, answeiB perfectly for the purpose. 

Fm 

The simplest method of applying acupressure is to pierce the tissuea so 
as to bring the point of the pin out on the surface of the wound close to 
the side of the bleeding vessel, and then, having carried it over the vessel, 

lift its head, bo as to depress strongly the point and thrust it onward 

lea, close to the vessel on the other aide. (See Fig. 5.) The 

force of the pressure exercised by the pin thus applied, will depend 



the* 
Lto li 



> AcapTMmie ; a New Metbod of Aiiettinf Sutgical Hemonhaga Rdinbuigh Hed- 
balJoaTMl, I8C0, v., p. 015. 



J 



TIIE TREATMENT OF WOOKDS. 

Upon the amount aod the elasticity of the tissue transfixed by it, and by 

isting character of the tissue against which the pressure is made. 

It is moot effective when the pin is carried through the slrin, so that itte 




latter is stretched between the points through which the pin paseea, and 
when the Tessel is pressed against a bone. When the skin is transfixed, 
and still the pressure is not sufficient to arrest the hEemorrhage, the con- 
Btriction can be increased by throwing a hgature tightly around the pin, 
on the outside, as in the operation for harelip. When the tissues are lax 
and do not afford sufficient counter-pressure, their resistance can be in- 
creased by twisting them, and by giving the pin different directions in dif- 
ferent parts of its course as it is inserted. Two methods of accomplishing 
this are illustrated in Figs. 6 and 7. 



S— A«ii<nHiiire wlCliT*liit oCriHUn. I. t^ {ntmdnDed panllsl ta ntwl. t. Hn raUUd Ihtooife 



Other variations in the method of applying flCTipressure may suggest 
themselves according to the particular relations of the bleeding vesseL 
FoTcipresaare. — A bleeding vessel may be seized and compressed by 



FORCIPRB8S17RB. 



101 



ilitable forceps, and not only the temporary but also the definitiTe arrest 
of the bleeding be secured without other agenta. The distinctive appel- 
lation of forciijressure was given to thia method by M, Vemeuil,' of Paris, 




I 



in a communicatiou made to the Soci*5tt de Chirurgie in 187G. in which he 
reports twelve observations of hjemorrhageB which he had repressed bj 
of forceps left from two to ten days in the wound. The writings 
and practice of P6m,' of Paris, KoeberK,' of Strasaburg, and of Spencer 
Wella,' of London, have served to establish the value of the practice and 
to attract to it the attention which its merits deserve. The serres-Jinea ' 
(Tig. 8) and eerrvg-forles, or compn'SjnvpiHceUen' (Pig. 0) of previous sur- 



geons, which had been used for the temporary compression of bleeding 
vessels, the elastic recoil of their branches when separated being the force 
relied upon for pressure, had been found inconvenient by reason of their 

' BuUelint el Mimolra de la Soci^U de Cltirurgit. Noauelie Serie. Tome i. 1875. 

' Dtla Foraprtuiire, oiide CiippliealinndapincetdrfiemiMiliuie e/iiruTi/ieale, d'aprh 
let kiOW pro/eat a pendant FaniUe 1874, pnr M. le DocUur Pain. Deny A Eiohkqaet, 
8to, pp. 73. Pari! : Q«nneF Baimdie. 1875. 

' Df rhimottau difinitice par tompreuian tttctatite. Svo, pp. 56. Park: J. B. 
BwlUfie et Fils. 1877. 

* Forcipreasute and Uie Uea ol Preiaura-FarcwpH in Sargaij. BriUiih Itediuol 
.joaznal, Jane 21, 1BT9. 

'Vidal (Ae. CMd«): Traite de PatlioUgU txterne. Tomt i., pp, 71 and KKI. 
Paris, 1031. 

• Angalatoio ; Ueber Camprettivpiaeetten und ihren OeftraueA beAnft tprldiifii/er 
BttiUmung. T. Qraefe & Walchei's Journal der ChiTurgU, zvii., p. 161. Berlin. 
WW. 




108 



THE TBSATMSNT OF WOmTDS. 



small size, and usrcliable from the feebleness and variablenesB of their 
elastic spring. The hiemostatic forceps of Pfan, Koeberlo, and Wella are 
alike in substituting for the uncertain recoil spring of tlie old instruments 
the force of direct pressure exerted through long and strong, though 
elender, leverB as handles, which when closed are locked by an automatic 
catch. Fig. 10 shows the model of Pfiau, fi-om which that of Koeberlfi 
does not differ in any essential respect ; Fig. 11 that of Spenoer WcUa. 







Foroe]!* of Ften. 




ff.ll.. ti 



In seizing a bleeding Tessel irith these forceps no effort need be made 
to exclude fibres of surrounding tissue if the vessel be snialL 

The length of time during which the forceps should Kniain in place in 
order to secure permanent htemostasis vaiies much. Those which have 
been applied upon the arterioles of the skin, connective tissue, and mu»- 
eles, and iipouTeins, except in case of the great venous trunks, may usiially 
be removed in a few minutes after their application. Forceps placed on 
arteries of medium size may be witlidrawn from six to twelve hours after 
the operation. Upon the main arteries of the limbs, including the 



F0KCIPRK99DRE. 103 

femoral, M. Peau advises that they be left from two to four days. In 
opentioii wounda they find their most valuable field by reason of the time 
and blood that they economize tlirouK'' the facility and certainty of their 
inunediate application to each Teasel that is wounded. In large oj>emtions, 




^F as in an amputation of the thigh, or the extirpation of a large tumor, 
though many forceps may have been applied and remain hanging from the 
wound-surfaces, in the majority the hsemostaais will prove to have been 

^ deGnitive by the time the operation is completed, ho that the forceps may 



Appllod (VoeCormas). 



104 TUB TREATMENT OF WOUNDS. 

then be withdravni without need of other means to maintain closure of the 
vessel Fig. 12 shows the manner of their iise for cuntrolling hcemoirbage 
in the courae of operatlona. 

These forceps, when left in wounds, ore eBsily supported by the dreae- 
ings so as not to ilrag upon the tissues : rarely do they cause any distress 
to the patient, who becomes aware of their presence only when tliey are 
uithdrawn. \\'ljen removed they should be taken away one by one with 
care, and, ns soon as it shaU have become certain that the vessels which 
they were compreasing no longer bleed, the dressing should be made as 

The application of such forceps upon tbsuea most prone to resent in- 
terference has not been proiluctive of harm. 

In all cases where the application of a ligature is impracticable or unde- 
sirable, forcipressure may replace ndvaiitageously most of the other means 
available in such cases. It may be used so as to shorten much the dura- 
tion and danger of operations, and, by leaving no foreign body in the 
wound, favors repair by fii'st intention. 

Ligation.— The last method remaining to be noticed which is available 
for exerting compression u}>oii bleeding vessels is tliat of encircling it 
with a thread thrown about its osposed extremity, and tying it firmly mth 
a secure knot. This constitutes ligation. Though it would seem that this 
method should have instinctively suggested itself for controlling the bleed- 
ing fi-om a severed vessel, and though Uivcea of a theoretical knowledge of 
it as a pos-'sible means for controlling haemorrhage are discernible in the 
writings of Galen, Celsus, Avicenna, and Aibucasis, there is no evidence 
that it was ever practised until it was used by Parfi in amputatioiia in th6 
sixteenth centui?.' 



' The fntrodiiat[oii of tho practice of ligntiD|{ bleeding vesgels mnrki the SrsC greax, 
advance mnde m the trentment of woundB iu Ibo history of aurgpr;. During ths' 
ages iiravtouB to the time of Par6 tlie uotuiil caatery hsi) been tho principal mean* of 
Btmnuhing traamatia hmmorrbage. Psil' himself mentions bis prcTious use of the 
cantery os " a thing very horrible and too cruel to he mentioned " [c/iote tri* hont'iU 
ft wueffe leulmnfiit d rneoiitrr, book x., chop. »xvi,). nod, in the same chapter, re- 
IntcB hia own first experimeat in the oae of a ligature ti) oloM tho vesnela after ampu- 
tation of a limb, an foilows: ''Now I ndvine the young snrgeon to sbnndoa mch 
omeity and indnmanity in order Ihe rather to follow tbiH method of minp, with whioh 
It has plfaved God to *oqnainl me without my ever having seen it done hj any one. 
nor spoken of, nor mentioned, except by Galen, in the fifth book of his ifethod, where 
h« UT>ted that It Is necewury to tie the vEBsela on the aide toward their roots, wbiab 



THB UOATUKX OF PARiL 105 

The metJiod of Par6 was to seize the veasela with suitable forceps (a 
Ihiajj uot lUffioult to do— he aaya— because the blocwl uon be seen spouting 
from them), druw them out from the fleah into wliich they have rutractad and 
become hid<Ieo, oiid theji tie them with a stout double thread. Although 
Par6 thus brought this procedure very nearly to the degree of perfection 
that it has now attained, the prejudices of his coutempoiiirieB, and the 
erroneous methods of proetiBiug it followed by his pupils, caused it to 
rapidly fall into discredit, ao thut a hundred ycira Liter the surgeons of 
the Hotel-Dieu were stilJ to be found always emploj-iug the cautery after 
amputations.' The supposed dangers from secoadary hemoiThage, from 
too rapid fall of the ligature, if npphed directly to the vessel, caused Pore's 
most distinguished pupil, Guillemeau, to abaudou the simple method of 
hia preceptor and to practise, instead, mediate ligation, enclosing a mass of 
adjacent tissue, together with the vessel, in the hgature. The effect of 



an the liver and the heart, ri ordei to staunch the greiit tlavr of hlood. How, having 
muij times mad« use of thU way of Berving the veins and arteries in reoent woundB 
which bled, I thought t'lat it woolJ be well to do aa muoh in the extirpation of ft 
limb, Hariog confeited on Ibis matter with Stephen do la KiviSce, Surgeon in Ordi- 
nary to the King, nnd with other sur^oDB from Piiria, and having dedored to them 
IBJ Opinion about this, they advised tliat we should make the experiment on the Gtat 
psUent th&t should be offered, the more sinQe wl' could have the cauteries all reulf 
for lue in cose the ligature ihouM fail. This I piactieed in the spot on euveral with 
verj good result ; and again, soma duj*!! Hler, in tlie perBoa of o poetiliou Hervitor 
from Bnuqaet, named Piron Gaihipr, whose left thigh was amputated four fingera 
above the knee for on iDfiammation which had supervened upon a fracture. 

"In conclusion I counsel the yonnt; surgeon to abandon tbi# miserable wn7 of bnm- 
Ing and roaxtlng ^nnless DOme remnants of gangrene compel itj, admoniehing blm to 
BO longer uy. ' I have read it iu the writings of the ancients, I have wished to act in 
Bocordauce wiih the te:ichings of my old fathers and masters, following whose prao- 
tice I cannot err.' This I t'tant, if thou wilt 'isten to thy goad master, Galeu, iu the 
panuge already alluded to, and to those like it ; but if thou wishest to atop with thy 
father and thy masters for authority for bad practice, being willing to always con- 
tintte therein, doing just the same na is usually done by them in all thinga, thou shalt 
render an acooont for it before Qod, onrl not before thy fathei- or tbv good masters, 
wlio treat men after so cruel a taahion." — Oiucret eompUlet ^AmbroUi Pari, lomt 
Ed. Molgaigne. 

The date at whicli the adopt:on of the practice of ligation was ma<la by Pare U 
1 approximately by Molgaigne to bave been about lS60, since the edition ot fail 
ttka pablished in 1552 mentions only the cnul«ry aa a meaoB of arresting hemor- 
!, and that of 1584 contains tor the firat time mention of the ligatore. 
' Haoec : Tiaxte de la Ligature dea Artira, p. '£. Paris, 1836. 



106 THE TBEATMBRT OV WOUKDS. 

such a procedure was to asaiat the more surely in bringing the use of the 
ligature into disrepute. Excruciating pain, muaculor spasms, and violent 
local inflaiumatious were provoked by ita use in such & v*ay, while the 
speedy loosening of the ligatm-e, as it cut the interposed flesh, in a few 
days, often determined a mortal hiemorrbage. Eight out of eveij ten 
coses of amputation thus treated died. Mediate ligation in its turn, there- 
fore, fell into discredit, and was either abandoned almost entirely or used 
in combination with stj'ptifis and eacbarotics. The surgical world in tlia 
early i>art of the eighteenth century was employed in a search for btrano- 
static agents, but the fear of a recurrence of the bleeding when the ligature 
should become detached still deterred surgeons from its use imtO the 
powerful authority of Shariie,' in England (1760), and of Desault, in 
France (1780), restored it to confidence and brought it uguin among the 
acknowledged resources of wound- treatment. 

"Wide and flat hgatures, their size propoi-tioued to the volume of tlie 
Teasels, were ut first deemed essential, lest tbe vessel should be too rapidly 
cut through. It i-emained finally for the present century to demonstrate, 
by the experiments of Jones,* that a small, round hgaturo was the best 
form to use in all cases for the otrest of bteinorrbage. The conclusions of 
Jones having been accepted and put in practice by Abernethy and Aetley 
Cooper, the stout thi-ead of Parij was restoreil, and tlie original method of 
that surgeon, after a lapse of two hundred and fifty years, became again 
the rule of surgery. Nevertheless, it still remained that the apphcation of 
a hgature, however done, introduced a foreign body into a wound, and 
hence was to be deprecated, on account of the disturbance of the repair of 
the wound which it produced, both directly and indirectly, for its final 
separation and removal from the wound necessitated a x^'^'^'^^^ °^ ulcerative 
absorption of the vessel which it constricted. 

The part of the vessel beyond tbe ligature, when it is apphed upon tbe 
cut extremity, is also deprived of nutrition, and, dying, must be thrown 

' Thii celebrated aargreou to Guy's Hospital, ia bis Critical Enquirj into bba 
Present State of Surgery, (ornmlly ndvocnted the employment of the ligature for tbo 
arreBt of hEcmorrlia^ from wounded arteries, in preferance to slyptin^ or the vautaTj, 
tm tbe ^roand that " it wu not aa yet nmversall; practisad amongst BolgeoiLB reaidiiig 
in the more dUtant coantiei of our kingdom." 

' A Treatise on tbe Method employed by Nature in Bnppressing the Htemorrbaga 
from Puiiutured and Divided Art«riee, and aa the lue of Ligatuiea. Bjr J. T. D> 
I, M.D. Sto. London. 180B. 



THE LIGATTTRB. lOT 

I a slougli. Suppuration is the noceBsaiy attendant of these coll- 
ie a&d when, as is usual, the ligature thread tu left hangini^ from the 
SvntQ the knot has ulcerated itself loose, there ia luniutoined a sup- 
; anna throughout its track which favors the development of 
iou8 septic conditions in the wound- 
Practically the evils resulting from these unfavorable conditions, inci- 
nt to the use of a ligature, are overcome in the great majority of casea 
r the natural reparative powers of the liody, and ultimate healing is 
d after a more or less prolonged period of suppuration and contest 
irith inflammatory and septic accidents of more or less severity. 

On account of the interference with healing produced by the ligatnr^ 
importance has been given to those substitutes for it which in any degree 
diminish the elements of disturbance produced by the means needed for 
tulfilling the supreme indication of arrest of hffimon-hagc. It is this 
which haa given to acupressure and fordpressure, and torsion— a method 
yet to be noticed — their chief importance. No substitute for the Ugature, 
however, has been able (o obtain a permanent jjlace in the confidence of 
sorgeons, and it will undoubtedly always remain the chief resource for 
Brrestiug hiemorrhage from veesels of any size. It is simple and easy of 
ai^liRation, it is certain as a htemostatic, and the materials (or it ore to be 
fonnd in every place. 

Of far greater importance than the attempts at providing a snbstitnte 
for the Ugature have been the results of studies to improve the hgutures 
themaelvea, striving to secure for the use of the Hurge^m a material strong 
and efficient for the compression of the vessel, as long as needed, nnirritat- 
ing while it is performing its work, not hindering immediate imion, and, 
finally, capable of spontaneous absorption by the tissues in which it has 
been buried. 

A thread of any material which can be tied with sufficient finnneeB 
and cIoaene«8 to effectually strangulate a vessel, may be used as a ligature, 
and when the emergency presses there may be no choice left aM to a selec- 
tion. For general use silk thread — round, smooth, well twisted, uucol- 
ored, and suffictently strong to stand comdderable traction— has been pre- 
ferred. In order to reduce to the minimum quantity the amount of tiarae 
to be removed by ulceration, it is import&nt that the thread be no larger 
than ia neeessaiT to give it the strength required to stand the strain pot 
upon it when it is tied. For small Tesads the thread need not ]n: larger 
1 sewing-ealk ; for lai^ger irnncilii. aa Qie lemonl, iliac, or axit 




THE TItEATMKNT OF WOUNDS. 

lary arterieii, a Homewhat stouter thread — saddler's silk — is needed. After 
the ligature has been tied, it hns been customary to clip off one end close 
to the knot, nnd to bring out the other at the nearest angle of the wound, 
or, if that n-:ut too remote, at any more convenient point, wbere it has 
been neeessfli-ir- to permit it to remain until the ligature has become disen- 
gaged from the vessel within by its ulcerative division. To accomplish 
this, a period of from three days to three weeks, according to tlie size of 
tlie vessel, Las been necessarj". The amount and nature o( any other tis- 
sue that may have been included in the ligaturo together with the vesael, 
will also influence the time of its detachment. With the idea of lessening 
the evils consequent upon such a prolonged i-esidence of an irritating 
thread, Physick,' of Philadelphia, in 181-1, began to use ligatures made of 
leather, with tlie especlation that such animal mnterial would be less irri- 
tating, and would undergo softening and absorption. In the year previous, 
1813, Dr. Thomas Young, of Edinburgh, in his " Introduction to Medical 
Literature," wrote : " I have often wished to try ligatures of catgut, which 
might be absorbed," but no record of any such test having been made bj 
Mm is given. 

After Pbysick, Jameson, of Baltimore, adopted the animal 
using buckskin cut into narrow strips and firmly rolled. These, after nu- 
merous experiments and clinical obaervationB, he declared to be decidedly 

' The following Is Pbjsick'a own report of lila use of auiinol ligatursg in a eommn.. 
Bication b; him to The Eclealin Qeperborf, ISIU, vol. vi., p. 380 ; 

" Several jearti ago, Tecollectiag how completely Uather Btraps, apTend with acUie- 
■ivs plaster, and applied over wounds for the purpoeie of keeping their Eides in oon- 
tact, were diiisulved by the lluida dUchnrged from the wouud, it appeared to ma thai 
ligatures mjglit be mode of leather, or of boiqG other animal BUbstonae, with wbioh the 
aides o[ a blood vessel would he comprexfed for a aufBcient time to prevent bemor- 
rbo^ ; that «uch ti^tures would he dissolved after a few daj g, and would be evaea- 
ated with the dLm^harges from the wound. Uodtr thu impreiision I reqaested Dr. 
Dorae; to tr; the experinieat on a horse by using a ligatarc of backskin. This wa* 
found to answer eveiy purpooe and came away in a tew days. 

" Dr. Doraey. in several operations in which I have assisted, has used ligattuea of 
French kid. which he fluLla atrooger than any other Icatber. He baa It out into uut- 
low strips, stretches them, and peels ofl the colored polished surface. So hemoi> 
ibage has taken place in any Instance, and the ligatures are found dissolved at the 
end of two or three days." 

From this period— 1818 — he continued to employ animal ligatures almost exclu- 
sively up to the timo when he left off operating. Memoir of Pbystck, by lUndoIph, 
^8a. 



trea< 



AKIMAL LIGATPKES. 100 

superior to nil other ligatures,' and, before hi>i death, hod applied them to 
(tU the acceaaible arterieH of the body.' Ajiiiiiii! ligatures of various kinds 
were occasionally uaed by other isolated Burgeonfi daring the fifty yeara 
which followed PhyHick. Silk-worm-giit by McSweeney, in 1818,' and by 
Fielding, in 182G ; ' catgut, by Sir Aatley Cooper, and fibres from the 
sinews of the deer, by Ev(>. of Naahidlle, were thus used ; but not until 
1869, when Lister published the results of hia experiments with cat^t 
Hgatoree,' and incorporated them into his method of antiseptic wound- 
treatment, did the full value, and mnge of the use to which animitl 
itnree could be pit become generally recognized. Equally with cat- 
the pantUel strands of connective tissue which make up the tendons 
of different animala have been found to answer an excellent purpose. 
l&rcy,' of Boston, praises those from the moose or caribou, of Maine, 
as most satiKfactor^'. The tendon from the back of the bufiiilo and from 
the wbAle answer equally welL The tendon of the tail of the fox-squir- 
rel of the Southern States gives fibres of much strength and as fine bb 
silk. I have received from Dr. Marcy specimens of fibres from the tail 
of the kangaroo, which excel all others in the qualities desired for a liga- 
ture. Though these tendinous ligatures have the advantjigo of being 
much stronger than catgut, equal weights being used, and of softening 
leas quickly, yet properly prepared and seaeoncd catgut nmy always be 
safely trusted ; and since it is a staple article of commerce, to be had all 
orer the world in abundance, comparatively cheap, and easily prepared 
and manipulated, it has maintained itself as the kind of animal cord best 
ffidxptad for general use aa a ligature, and hence requires more extended 



■jhptioe. 

P at! 



CUgiU lAgatures. — Catgut is the submucous cellular tissue of the in(e»- 
of young Iambs, which, after having been cleansed in an alkaline bath 
and bleached by sulphurous acid, is twisted into a cord and dried, Aa it 

' Gross: Sjtbem o( Surgery, 1883, voL i., p. 557. 

• Agnew'fl Snt^prj. 1878, voL i., p. 173, 

' BxperimentH )□ Favor of a Near Snbatanoe for Tying Arteriea, and tot Satan. 
Edintnirgli Hediiul and Sargioal JonniKl. 1818, vol. xW., p. GD7. 

" On the Dae of a New Substance (Silk- worm -gut) (or Securing Divided ArterleL 
Transactions Metiico-Chinirgioal Society, veL il., p. 340. Edinburgh, 1830. 

' Observations on Ligatnre of Arteries,on the Antbeptio Systam. Lanoet, April 8, 
1800. 

* Atitaal LigBtaien. Anatla ot Anatomy and Snigerf, 1881, vol. It., p. HSH 



110 THE TREATMENT OF WOUNDS, 

comes from tho maker it is ontirelj unfit for use an a ligature, for whtu 
bathed in the secretions of the wound it quickly becomes bo soft and pulpy 
that a knot mil not hold. By suitable prepamtion or seasoning, honerer, 
its qualities may be bo altered that inuncrsioD in blood-eenun mil no 
longer make it pulpy, but that it will continue to retain its form and te- 
nacity for a somewhat prolonged period, during which its removal is being 
slowly accomplished by the gradual erosion of its surface by the active tia- 
Hue-cells by which it is surrounded. Thus compreaaou of the tied vessel 
is insured throughout the whole time that the process of ita repair is 
transpiring. 

Experience has shown, also, that it is possible to over-prepare the cat- 
gut so that it may become too rigid and difficult of absorption, and may 
provoke irritation, and suppuration in the wound. The following ia tha 
method advised by Mr. Lister ' for the preparation of the gut, and which 
he recommends as certain to avoid the evils of over-preparation, whUe it 
obtains all the tenacity and durability needed to fit it for a ligature. A 
solution ia to be made, containing, of 

Chromic acid 1 part. 

Water 4,000 ijartu. 

Carbolic acid 200 parts. 

As soon as the ingredients are mixed, enough of the catgut should be im- 
mersed in it to equal in weight the amount of carhoUc acid used. The 
gut should remain in the solution for forty-eight hours only, at the end of 
which time it shoidd be removed, dried, and then kept for use in carbolic 
oil, 1 to 6, The gut should be kept on the stretch, by tying the ends of 
each hank to two fixed points in a room, while it is drying, otherwise iti 
strength will be seriously impaired by an uncoiling of its twist while 
drying. 

The effect of a longer immersion in the wat«ry solution of carbolio 
acid would bo to " over-prepare " the gut, but after ita immersion in the 
oUy solution it keeps unchanged for an indefinite time.' 

' The Cttgat Ligature. Britvh Mfdionl Jonrnal, Febmair 5, 188t, p. 188. 

' Id the coane of aome lemarhs mftde at k meeting of the I.ODdoD Clnical Society, 
whiafa are reported in the Lancet of Murcll 18, IB82, p 440, Mr. Lister ebaled that he 
had been naing with atlll greater MUaFactioD catgDt prepared bj Koaking it for tiraire 
hours in a one per cent, solution of chrnmic acid, and then for twelve hours more lu 
■DlphuroDs acid (B. P.). Laatl^ it la dried, In whloh aUte It ma; be kept, being aoaked 



1 



CATGUT LIGATTKES. 



Ill 



'Without other application, age done renders catgut less easily softened 
hy blood-serum. 

Inuaeision of catgut in oil of juniper for tweuty-four hours, and its 
inunediate transfer to alcohol, ninety-tive per cent strength, in which it 
should be kept till needed, has been introduced by Kocher, of Beme, as a. 
reliakle method of preparing catgut The gut, thus prepared, is very 
agreeable to handle, ties nicely, and is not absorbed too soon. 

Italian catgut is superior to all others in point of durability and even- 
ness of texture. Harp-strings should be chosen by preference ; No. for 
the finest thread ; No. 1 for medium ; and No. 2 for the heaviest size.' 

After a catgut hgature is applied, the ends are to be cut o£f short, and 
the wound closed without any further attention being paid to the ligature. 
When a properly prepared gut is used nothing more is ever seen of the 
ligature. It is mechanically imirritating and physuologically aseptic, and 
produces no disturbance in the process of repair by its presence, and is 
ultimately removed by absorption in the coiirse of the tissue metamor- 
phoses that are incident to the normal life of the tissues in which it is em- 
bedded. An indefinite number of ligatures may be applied, according to 
the deniaudfi of speedy and ]>erfect htemostasis, in a wound without hinder- 
ing ita union by first intention. By its use one of the greatest hinderauces 
to union by first intention has been removed, and the treatment of wounds 
greatly ramplifiecL The portion of tissue included in the noose of the Hga- 
ture does not die, nor does the external coat of the included vessel become 
divided or ulcerate. It is applicable in septic wounds as well as in those 
that are kept aaeptic. It is only a little less easy to manage than silk. 

When immersed in carbohc oil it improves with age, so that it is 
especially adapted to being kept in stock by the general practitioner for 
occaaional use at indefinite intei'vols.' 

Threads of lunjjlic «i7i- and of vwlal have been used for ligatures, and 
with advantage over the ordinary thread on account of their unirritating 
nature; Their ends having been eut off close, the wound has been closed 



fo; B qojKrter of on hour in & cKrboUa lotion before being med. Cati^t tbas preparad, 

will iriUisUnd tbe action of living tiaBues for three weeks, and after proloDBrcd steep- 

ing in c&ibolic lotion 1b ns strong as in the diy ntnte. 

'These can be prooured In New Tork from L. H. Keller & Co., 64 NasBon Street, 
' The anrKeon who doei not care to prepare the oatgiit for himnelf, can procure it 

in a ver7 convenient shape, and of reliable quality, readj for am, in varioaa aiiea, 
n kUh roller*, and kept in carbolia oil, Irooi C. Am Ende, of Hoboken, N. J. 




113 



THE TRBATSraWT OP 'WOUNDS. 



ftnd the union by first inteutiou of the wound secured, ■while the ligature 
has become encysted. Sucli a favorable result, however, experience has 
shown, cannot be relied upon with any certaiuty in any given case, so thai 
the use of these agents in this way has fallen into general disfavor, except 
for purposes of ligating intniperitoueal vessels, in which caae a more cer- 
tain encysting of the thread can be rehed upon, owing to the nutritivs 
peculiarities of that membrane. 

Silk thread may be made aseptic by boiling it for an hour in a Atb per 
cent solution of carbolic acid, and afterward preserving it for use in a 
fluid of similar strength ; or by soaking it for two hours in a one per cent 
solution of corrosive subhmate, and subsequently keeping it in a weaker 
solution (one-tenth of one per cent). 

Teckniqiie of Ligation. — The bleeding vessel must be seized by a suit- 
able pair of forceps and drawn out from ^e tissues, among which it hai 



retracted, sufficiently to ^lermit it to be isolated and to be encircled by the 
ligature far enough back from its free end to guard against danger of its 
slipping off The htemostatic forceps (Figs, 10 and 11) will probably have 
already been apphed, and none better could be secured to facilitate the 
application of the Ugatui-e when desirable. Zt is essential that whatever 
forceps are used should hold the vessel firmly, and not be liable to become 
accidentally displaced, and that it sliould remain closed automatically when 
once it has been apphed. The form shown in Fig. 13, in which the blades 
cross and arc kept shut by their own spring, ia an excellent model The 
expanded shape of the blades as they near their points facditatca the slip< 
ping down of the noose upon the vessel as the thread is tied, and prevents 
the forceps from being included in the knot. 



r 



A fenaciilum (Pig. 14) may sometimes be used instead of a forceps for 
picking up a vessel when it is embedded in dense tissues that do not per- 
mit its being readily ilrawn out. The sufficient isolation of the veseel 
from other structurea xnay be generally eflfected without trouble ; but this 



MEDIATE LIGATION. 



f aai be practicable when the tiesuea have been matted together bj 
latiOD, OT where the natural density of the tisaues pre- 




" Tenta its being drawn out. Should the vessels be brittle from diBeaee of 
their coats, it raay be best also to tie up with them a cushion of the soft 
part& To accomplish t.hJH a, curved needle, armed wiUi the ligature, maj 
be passed beneath the bleeding point through the tissues so as to include 
with the vessel a sniaU portion of the adjacent tissue, as in Fig. 15 ; a liga- 
ture thuB tied cannot shp, and when catgut is used and the wound ia kept 
^■pM^tic no necrosis of the included portion will take place. 





Fig. 16 will suggest another method of accomplishing the same end. 
The ligature shoidd be tied in a single reef-knot (Fig VTYmYtftlistCTjRa 



114 



THE TBEATKBNT OF ITOtmDS. 



to the eurgeou's knot (Fig. 18) or the common granny-knot It is neces- 
sary to use no more force in drawing the knot than is required to 6rmly 
and aecurely close the vessel, vrhich may best be done by placing the index ' 




Pio. IS.— Tlgbtonlng the Ugatan. 

nngere upon the thread close to the point of application to the veaael 

(Fig. 19) and through them making traction. 

In ligating the larger .arteries the knot should be drawn sufficiently 
tight to cause the internal and middle coats to give way if the common 
sUk Ugature is used ; but this iR less necessary, though unobjectionable, if 
the catgut is used. When the catgut or the aaeptic silk Ugature is nsed, 
the ends should be cut off short, and the knot abandoned to itself ; when 




FroL so ind n.— Lxwulgi 

the ordinary thread is used, one end should be chpped off quite close to 
the knot, and the other brought out of the wound. 

Means of Pluooiko the Vessels. — These include torsion, coagulant^ 
and the actual cautery. 






TOESION. 115 

Tonim, — When the internal tind middle cwite of an arterj' are lac- 
s;parat«d from the outer coat, the elastic quality of the middle 
it to become retracted and incnrved, and thus to block up 
ittore or less completely the lumen of the vesaeL (See Figs. 20 and 21,) 
Arteries that arc torn acrosn. as iu lacerated wounds, may be spontaneously 
closed to such a degree by this cause thai no bleeding will take place from 
them, an entire liiab being torn from the body without any bsemorrhage 
following. 

This retraction and incurvation of the inner coata of an arterj' toay be 
accAmpliehed at will by sharply twisting the cut end of the vessel The 
practice of this manajuvre upon a bleeding Tessel constitutes "torsion." 

The fir^t systematic and inteUigent appUcation of torHion as a means of 
arresting bleeding is to be credited to the French school of surgeons of 
the early part of the present century, of whom Amnssat,' Velpeau,' and 
Thierry,' nearly at the same time appeared as its advocates, each with a 
peculinr method of his own. To the elaborate memoir of Amussat, especial 
mention is due (or the manner in which it developed and illustrated the 
principles on which the practice is to be based. Nevertheless it has never 
guned general confidence except for the closure of small arteries. More 
recently, however, it haa been warmly advocated by Bryant, of London, 
who says ;' "In a physiological point of view there is no method more 
perfect at command for the control of hemorrhage than that of torsion ; 
becaaae, unlike acupressure, which uses one only of Nature's hirmostatic 
processes, or the Ugature, which is a foreign body in a wound, and be- 
comes a source of danger by undoing at a later what has been done at an 
eailier period of the case, it utilizes to the utmost all the physiological 
pcDceases employed by Nature to prevent and arrest bleeding, and places 
the vessel in the most favorable position for them to take effect," To con- 
tinue to quote from the aamo author (p. 302) : " When an artery is closed 
\ij what is termed torsion, the inner coats are ruptured (Fig. 22, B iHid 
I), and the outer (A), when not twisted off, closed by the twists to which 

haa been subjected. But the inner coats, instead of being simply 



I 



Stance dt rAaiflinu'e lioyale d« Medeetne, Jalj 16, 1830. AreAhtt OiniraU* de 

eeint, 1639, tome xx., p. 606. 

Jovrndt univeriai el htbdomadairadx Mideciiu et de Ckirvrgit, eto., 1800, tome t. 



' De la Teriikm da AHirtt, 8vo. Phtw. 
Pnotioe of SnrKeij, p. 806. Philsdelpliia, I8T9. 





united more rapidly and Idndly — primary union being the rule ; there has 
been leas constitutional disturbance after operation, and consequently less 
liftbili^ to trainuatic fever, p^mia, and other compUcationa, Bach a» we 



TOKSION. 



117 



are all too familiiu- with in the practice of surgery. At Guy'a Hospital we 
hxve had two hundred consecutive cases of amputation of the thigh, leg, 
arm, and forearm, in all which the arteries had been twisted (one hundred 
and ten of them having been of the femoral artei^) and no case of second- 
ary hemorrhage." 

To apply torfflon Amuaaat recommended that the artery be drami out 
(or about half an inch by one pair of forceps ; that it then be seized at its 
attached end by another pair of forceps (see Figs. 23 and 24) to steady and 




4 



Fia. U.— TOralmi of in Arter} (Xtnank), 

s while with the first pair of forceps the end be twisted off by about 
* a dozen turns. According to Bryant, the vessel need be simply drawn out, 
as for the application of a hgature, and three or four fibarji rotations of the 
forceps made. In large arteries, such as the femoral, the rotation should 
be repeated till the sense of resistance lias ceased. The ends should not 
be twisted off In small arteries the number of rotations ia of no impoi> 
lance, and their ends may be twisted off or not, as may be preferred. When 
the veesels are atheromatous or diseaeed, fewer rotations of the forceps are 
required, the loner tunics of the vessel being so brittle as to break up at 
once and incurve. 

Torsion-forceps should have jaws brood enough to grasp the whole 
width of the vessel which is to be twisted, and their teeth should be blunt, 
it they cut through the tissue of the vessel which they grasp. 
Forceps after the model shown in Fig. 25, devised by Wight,' of Brook- 
1, answer better the requirements of torsion than the ordinary artery 



Ljestthej 
■ Fore 
^Bbn, ansi 
^Mnwpa. 



FroBMdioga of the Uedioal Sooi«^ of Khsg'v Oonn^, 1 



118 THE TREATMENT OF WOUITOS. 

Coagulayita.—The introduotion into a wound of Bubatonces wMch by 
their combination with the o£fuse<l blood ahall form a firm tenacious ooago- 
liini to act as an efficient pluff to the bleeding vessels is to be resorted to 
only OS a last resource, when other methods are inapplicable or inefQcient. 
Such i-eagents are irritants, the coa^'ula formed act aa foreign bodies, and 
their use destroys any possibiUty of union by first intention. ffheneTer 
used they are to be couibinud with direct compression, if postdble. 
Wounds involving spongy tissues, and cavities or organs, such as the 
mouth, noue, and uterus, where tt ih impracticable to ligate the bleeding 



veBsels, most frequently call fur tlie applicutiou of coagulaulfi. Prerious 
to their application the soft coagida already present should be removed, ^ 
the bleeding surface should be wiped as dry as jtossible, and then a com- 
press saturated with the reagent should be firmly jiressed to the bottom of 
the wound directly iipon the bleeding orifices. The compress so appUed 
should then, if possible, be secured in place by a bandage. Cavities, 
from the walls of which hteraorrhage is taking place, should be packed 
with absorbent plugs saturated with the reagent. Of the multitude of 
substances that have been used an coi^ulants bat two deserve mention, 
the subsulphate of iron (Monsel's salt) and alum, both of which are effec- 
tive antiseptics as well aa coagulants. 

The substdphate of iron may bo used either in powder or in eolution. 
A compress saturated with a lotion mode of the officinal liquor ferri 
subsulphatis, diluted from four to six times with vrater, is a powerful 
haanostatic, while it is less irritating than the stronger solutions. The 
iron produces immediately a dense, firm, and tough coagulum, that con- 
tinues to aliriuk ond hanlen tor some time after its formation. 

Alum is less powerful and instantaneous than the iron salt, but its 
astringent and coagulating effect is great It may be applied in powder, 
or in saturated solution. The powder enclosed in gauze, so as to form a 
small bog, forms an efficient haemostatic tampon, and is particularly suit- 
able for plugging mucous canala. 

27(1! Cautery. — Iron heated to a dull red heat was the potential coutety 
of the aacienta, which alone was relied upon to control arterial luemor- 



I 



ISTBRHTTPmrO THE BWXHMSUHBKNT. 119 

It IB Htill frequently nia<ie use of for the control of bleeding from 
deep-seat«d vessels, and in the course of operative procedures upon very 
vascular pruts, us the maxillary bones, the tongue, the neck, the uterus, 
and the rectum. It in not only a coagulant but a caustic, and destroys 
the tiasaeB to which it is apphed, fonning a thick eschar, which for a 
time effectually seals over the entire wound-surface. When it becomes 
detached as a slough after a few days, hiemorrhage frequently recurs from 
the ulcerated vessels. Care is to be exercised not to heat the cautery-iron 
above a dull red hteat — the bright red or white hot iron consuming the 
eschar and leaving the vessels unsealed. In the emergency which caIIs for 
the cautery, the ingenuity of the surgeon vrill extemporize the needed 
cauting-iroD. In the systematic arrangements for the prevention of hem- 
orrhage by the cautery in the course of surgical operations the ancient 
canting-irons, ^'ith their furnace and bellows, have given place to the 
galvano- and thermo-cauteriea. 

MeA<fa or LvrERBrpriso the Blooi>-Cdrbent. — The force with which the 
Hood-current shall reach the opening in a severed vessel may be modified 
1^ position, by compression of the vessel or it« parent trunk between the 
wound and the heart, and by the internal administration of drugs which 
leeaon the force of the heart's contractions. These means are chiefly 
aviulable as temporary resources until means of direct permanent hnmo- 
be devised. 
Posilion.— The elevation of the limb, so as to add the force of gravity 
the obatacles to be overcome by the blood-current, will materially 
the force of the arterial supply to the more distant parts of the 
It promotes also depletion of the veins. It is a resoui-ce not to be 
^looked in case of wounds of the distal parts of the eitremiUea, 
Ccmprenmon of the Vessel, or its Parent Trunk, between the WoutuI and 
the Bear*. —This may be accomplished by one or more of the following 
ways : Forced flexion, digital compression, the tourniquet, the elastic band- 
age, acupressure, and ligation. 

L Forced Flexion. — When the forearm is strongly flexed upon the arm, 
in a muscular person, the bmchial artery, in addition to heing bent at an 
acute angle, is compressed both between the biceps and brachialis anticua 
mascleB above, as they contract, and at the angle of flexion by Hie mus- 
cular mass there existing, while below, the first portions of its two main 
brancheB are compressed between the contracted muscles of the forearm, 
compression may thus be exerted to completely interrupt the 




TBB TKEATMBNT OF WOUNDa 

flow of blood through the arteries, and to make this &a efficient meauB of 
aseisting in the arrest of hemorrhage fi-om woimda of the distal parts of the 
upper estremity, and particularly from wouuda of the palmar arches.' 

Flexion of the leg upon the thigh hus but a very feeble effect upon the 
arterial current iu the vessels beyoad. By placing a compress in the ham 
and pmctisiug flexion a greater interruption can be produced. By strongly 
extending the foot, its dornal arteiy may be compressed under the anterior 
annular ligament sufficiently to interrupt the current of blood through it 

DigiUd Compression. — When the bleeding is from a -vessel which, either 
itself or its parent trunk, has in some part of its preTious eouiBe passed 
superficially over a bony surface, the pressui-e of the thumb or fingers may 
be sufficient to compress it against tlie bone powerfully enough to i: 
]»letely interrupt the current of blood through it 




Fm, S6.— CompnalDB tb 

The common carotid artery may thus be compressed against the trans- 
verse processes of the cervical vertebrffl by the thumb thrust between the 
larynx and the inner border of the Btemo-cleido-maatoid muscle in such a 
manner as to make pressure downward and inward (Fig. 2G), The facial, 

' AdeloiBan i J}U gexBiUttamt Beugang der Extrtmit&Ua alt BtiUungmnittd bei ttrter- 
itUoi Blutangen dertrHien. ArehivfLr Minuelie Ghirvrgii, 1809. BbqiI xi.. Heft S. 

Fnel: Reeherehei anatomiquet el expirimentalct *ur U ntfeanimne de tAimotlatt par 
diveru* attttudea paHieuUfra dei mfm^ra. BuUetin tt Mmnoirt <k la SoeUU d» Cht- 
rwrgit de Paris, IB82, tomevUi, p. 737. 



J 



COMPRESSION OP ARTERIES. 121 

I ieuporal, supraorbital, and occipitAl bmncbes are all easily compreeaed by 
tbe linger of one fftmilinr with their podtiona. 

Tbe subclavian artery maj be compreeHed, as it passes orer the first rib 
behind the scalenus anticus muscle, by strong protisure maile downward 
and inward into the fossa behind the clavicle at the outer border of the 
stemo-cleido-niastoid muscle. The unaided finger is, however, not strong 
enough to m^ntun the requisite force. A door-key, with its handle wrap- 
ped with doth, is the classical substitute^ 




7 numng the arm and making pressure along the anterior fold of the 
, the axillary artery can be compressed against the bead of the hu- 



The brachial artery may be easily compressed against the humerus, at 
the centre of the arm, by pressure made along the inner border of the bi- 
ceps {Fig. 27). 

The radial and ulnar branches are readily compressed in the lower third 
of the forearm. 

The abdominal aorta, when the abdominal walls ore relaxed and the in- 
testine empty, particularly in thin subjectfl, can be compressed against the 
I woiebne, by pressure upphed a little to tbe left of the middle line at the 



199 THE TBEATMEirr OF WOUNDS. 

level of the umbilicua The fingers of one hand flliovdd be t^inforced bj 
those of the other to supply the requkite degree of pressure. 

The eommon iliac artery may be compressed agiunst the brim of the 
pelvis by the hand introduced into the rectum, or with a lever of wood 
introduced according to the method of Davy, of London (Fig, 28). 




Fid. W.— Corapnalini at 

The femoral artery ia most securely compressed, juat below Poupart's 
ligament, against the ileo-pectineal eminence. It should be made with the 
two thumbs placed the one upon the other (Fig. 29), and the pressure 
should be made upward and backward beneath the ligament upon the i 
pause of the eminence, The thickness of the intervening parts makes 
attempts at compressing the artery against the femur in the middle third 
of the thigh uncertain. 



C01IPKE9SI0N BY TOURNIQUETS. 



123 



The posterior tibial at the inuer ankle, nnd the dorsalis pediB upon the 
dorsam of the foot, are readily compressed by the fingera 

Tounti>^Tiet». — Any spparatuB by means of which Rmduated pressure 
can be made upon a veasel is a tourniquet The ori^al idea, as the 
name indicates, involve<I a twisting or screwing contrivance for graduating 
the pressure, which is the power employed in the instrument most in use 
&t tiie present day, the tourniquet of Jean Louis Petit (1674-1760). This 




insteument (Fig. 30) consists of two metal plates, the distance between 
iriiicb can be regulated by means of a screw, and which are connected by 
r ■ strong silk or hnen strap, which is meant to pass around the limb, and 
which is fastened by a buckle. In using this instrument the lower plate, 
nndcTTieath which a pod or a roll of bandi^e has been placed, should be 
applied exactly over the point corresponding to the artery (t'ig. 31) ; the 
fltrsp that encircles the limb should then be drawn quite light, when the 
screw is turned so as to force the pad down upon the subjacent vessel 
nntil it ceases to pulsate. The tourniquet in use before the invention of 
) instrument of Petit was a simple bond encircling the limb tightly. 




124 THE TRZATHENT OF WOUHDB. 

underneath which a stick was thrust, by the twiafciiig of which powerfiil 
compreBHion coiilil be produced. The same method is hUU often adopted 
with advantage for improvising a tourniquet in ceibcb of emergency. It is 
frequently spoken of as the "Spanish windhiss." A handkerchief or band- 
age, or any similar material, to encircle the limb, and a stick, or rod of any 
kind, to twist it with, being the only essential things for its construction; 
a knot in the handkerchief or a stone enfolded may serve as a compreaa to 
oppl\ directly over the vessel to be compressed (Fig. 32), Another form 




of improvised tourniquet, applicable to the brachial artery is shown in Fig. 
33, in which by means of two eticks, arranged as shown in the figure, 
powerful pressure by leverage can bo exercised on the vessel 

The apphcAtiou of a tourniquet should be discontinued at the earliert 
possible moment, on a«count of the jwiin which it produces, and the inter- 
ference with the venous circulation of the parte beyond, as tlie result of 
which death of more or less of the limb may ensue. It is to be regarded 
only OB a temporary expedient, to be substituted at the earliest practicable 
moment by other means of direct imd permanent hEemD8tasi& 

The. Elat^it: Ilandage. — If a piece of iudia-nihber tubing or bandage 
(Fig. 34) be woimd M-ith strong traction several times round a hmb, and the 
ends be fastened by a knot or clasp, oil the soft parts, and vith them Uie 




COMPRESSION BY ELASTIC COBD. 



125 



), are so firmlj compreased that not a drop of blood con pass through. 
The facility and certainty with which the blood-current can be iutemipted 
by such an elastic band, has caused it to replace, to a very great extent, all 
forma of tourniquets, smce attentiou was drawn to ita advantages in con- 




jHoti with the bloodless method of performing surgical operationa de- 
1 by Esmarch, of Kiel. ' If an elastic bandage be put (no matter how 
[htly) only once round a limb, the preaaiire will not suffice completely to 
mpicfis tlie blood-vessels ; but if it be bound several times round at the 
e point, every tiun so inci'eases the pressure that in a short time no 
e blood can pasa 




AiTupressure. — Those methods of aeupreasure may be used to compresB 
fe TDSsel in its continuity, so as to interrupt the flow of blood through it, in 



' Vdief SintUiiAe BiutXicrt bei Operationtn. Volkmum'it SatH7nlans Sdiiath* 
m Vbrtraoe, No. 58, 




136 THB TRBATMBNT OF WODHTW. 

which, when the tisgues are transfixed by the needle they (ire so put upon 
the stretch that by their elosti^nty they press the needle firmly and continu- 
oubly against the vessel, or in which the needle, having been thrust under 
the vessel, is made the base against which pressure is made by thread 
thrown over the included tissues and about the projecting ends of the 
needle as in the harehp suture. Acupressure may thus be substituted 
\rith advantage in some cases for ligation of vessels in their continuity. 

Ligidion.- — When direct hgation of a vessel ia impracticable on account 
of the depth or inaccessibility of the wound, or because the necessary dis- 
turbance of the wound, or perhaps its extensive cnlitrgement to expose the 
bleeding vessel, is deemed inexpedient, ligation of the vessel in its con- 
tinuity above the wound, or of its parent trunk, will control the luemor- 
rhage definitively. Whenever permanent interruption of the main supply 
current to a port ia neeesaar^-, hgation is to be performed. In the choice 
of material for the hgature, the same reasons exist for preferring ths 
aseptic catgut cord which have been stated in connection with ligation in 
the wound. 

Cardiac Sedatives. — Little is to be expectetl from the action of remediea 
administered int«mally for the immediate staunching of surgical bsemor- 
rhage, but in the aft«i--treatment they may play a more important role, 
combined with other general means. QrosB ' makes the following obser- 
vations on the use of such means : 

" Whatever mode of procedure be adopted for arresting the bleeding, 
it ia an object of primary importance to place the affected part 2>erfectly at 
rest, in an easy and elevated position ; the slightest motion might be inju- 
rious, especially when no ligature has been used, and should, therefore, be 
sedulously guarded against Bepose of the body is equally necessary with 
that of the part, and it is liardly needful to add that mental tranquiUi^ ia 
idso of the greatest moment Cardiac action, too, must be maintained in 
the most perfect quietude, as any perturbing agency of this kind cannot 
fail to favor a return of the hemorrhage and exhaust the system. With 
tliis view a full anodyne should be administered early in the disease, the 
dose being repeated from time to time so as to sustain the soothing influ- 
ence of the remedy. Too much stress cannot be laid upon the use of opi- 
ates in the management of arterial haemorrhage, and it is surprising that 
the remedy is not more generally employed than it seems to be. To allow 



■ B7(t«m of Baig«iT, 1882, vol, 1., p. 075, 



allov J 



t full I 
mid 



OONSTTTUTIONAL TREATMENT. 127 

Uie heart to go riot, or to move imd tose about tumtiltuoiialy, as it is bo 
liable to do after serious loss of blood, while every local precuutioo is 
token for the suppression of the bleeding, is assuredly a stran(,'e iucoutdst- 
eucy, fuid one altogether irreconcilnble with experience and common 
sense. When the bleeding proceeds from a great number of small vessels, 
a restraining influence may be expected from the administration of ergot 
B full and repeated dosea. 

" When high constitutional eicit«ment exists, the effect of the anodyne 
old be aided by the judicious ■use of aconite or veratmm viride. When 
the skin is very hot and dry, a full dose of Dover's powder often answers 
on excellent purpose in calming the heart's action. 

t" The diet should be perfectly bland, and sufficient in quantity to sup- 
the wants of the body. To give less might cause irritabihty of the 
im ; to give more, over-atimulation. The drink must be oold and 
acidulated, and not token so freely as to oppress the stomach, as it will be 
sore to do if the quantity is not carefully restricted, as the thirst is always 
orgeat after the loss even of a comparatively small amount of blood. 
«of ice, or pounded ice, held in the mouth, and gradually swallowed, 
e most grateful and beneficial. The air of the apartment must 
it perfectly cool ; in short, every effort must be made to maintain the 
inqoillity of the drculatioo." 



CHAPTER VII. 

THE GENERAL CONDITION OP THE PATIENT. 

Shock — A n rem ta — Aa to- trnosf oaioa — Tmnaf UBion — Direot Trana f aaion — DeSbrination 
of Blood— Teohciqae of TiaDatuaion— Dangars at TmiBfasiaD — Peritoneal Traiw- 



The lighter degrees of nhoek quickly aud apoDtaneousIy disappear ; in 
the more severe cases the tndicatioDS are for stimulation, free acceas of 
air, recumbent posture, warmth, and reoBsuring words if consciousnesa is 
present. 

If the patient ia able to swallow, brandy or other alcoholic stimulonta 
should be given in small and frequently repeated doses till reaction la 
assured ; if unconscious, these should be injected iter rectum ; if the proB- 
tration ia extreme, hypodermic injections of brandy, in doses of from one- 
half to one drachm, or of ether, in doses of from 15 to 30 minima should 
be administered. Intravenous injections of from 5 to 10 minima of liquor 
ammoruie fortior may also be resorted to. Eepeat the injections every ten 
minutes till the patient is able to swallow. If reaction is delayed, tincture 
of digitalis, in balf-drachm doses, every hour, should be substituted 

Heat and fi-iction to the extremities, hot cloths over the heart and 
stomach, worm blankets to envelop the body are also to be employed. 

If the respiration foils, artificial respiration is to be practised. 

If the shock ia being aggravated or prolonged by the irritation of a 
mangled limb, or the presence among the tissues of a foreign body, or the 
continuance of hwmorrhage, immediate operative interference is needed as 
the less of two evils ; in all other cases operation should bo deferred until 
reaction is secured. 

As reaction comes on, stimulants are to be replaced by supporting and 
anodyne meaflures. Renewed evidences of prostration ai'e again to be met 
by the use of stimulants. 



A UTO-TBA KSFDSIOW TRA N8FD810N. 



AN-EMJA, 

Should loss of blood have l)een »o ^reat as to cause the want of the 
blood t«i be a eouree of iniinediute donyer, tiuto-transfusion should first lie 
performed. 

AuTo-TBAjwrirsioN in iloue when the blood ia forced from Uie extremi- 
tiet* and (.■olleeted iii larger quautiticn ui the vcBselH of the cenb-ol orgiuib. 
It iH easy and expeditious of }>erfoniiauce, aiid free from the dangers aud 
difficulties of trouafusiou, whether of blood or uf milk, iiad offers results 
oL-HTcely inferior to tliowe uf ti-ousfusuiiu itsielf. For its j)erformance, after 
the luemorrbage lia-s been sto]jped, tlie patieut luuut be plaeed with liiit 
feet higher than his heml, in oi-der tliat the bluoil may gi-avitate toward the 
heart and medulla oblongata ; the liuibs are then to be bandaged fii-mly, 
lieginuing at their (listal portiouB; prefembly witJi rubber baudageB^-in 
default of whith. however, onlhiary ones may be used— ao that the limbs 
are rendered comparatively bloodless. If the fainting ia extreme, eom- 
plete iiivenaon of the body, holding bini up by both feet, is the most effi- 
cient method of revivifyinf,' the ex8anguinat«d brain, while rhythmical 
i-ompression of the thonix ^artificial respii-ation — iit the best means of 
stimulating the wtion of the heart and lungs. 

TKASsniBios. — When the loss of blood has been extreme, and auto- 
tnutsfusion is iuodetgimte to insure penoanent rallying, tbe injection of a 
quantity of blood from a healthy person into Uie veins of tlie sufferer ia 
demanded. One great advantage of the pi-actice of auto-transfusion is as 
a temporarj' expedient to gain time for the necessary preparations to be 
e for trail sf union. 

Although tnuisfuHion has Wen pi-actiaed only aw a •/'•rniei- lennori in deM- 
"perata comUtioiiH, tbe results attained by it which lu* recorded have been 
very encoui-aging. WTieii the opemtion has been jwrformed for injuries 
to bliKxl-veBsels or for the ha:murrlmge I'esiUting froni them, the reeoveries 

e fifty-eight per eent ; when jjerfomied in consei|ueuce oi pant-parluni 
wniiage, the recoveries were fifty-six per cent.' 

Tlie operation is wmple, easy t»i jterform, aud \vith careful attention to 

aiu details, Ls free from danger. Sint-e it is au oi>eration of emergency, 

e methods only which are the simplest and demand the least special 

" apparatus are worthy of consideration in connection with it. For its per- 

in ot Blood. AdhbU o( Ihe Auatomluol &nd Sargioal SociaCy, 






' Howe : TtODHtuaii 



130 



THE TIIEATMEKT OF WO0ND8. 



f ect perionnance no other npptiratus is neceasaiy Uion a funnel, a fleiilila 
tube, and a canuK and, in default of these, au ordinarj- sjiinge, if it be 
clean, nud ita nozzle be uot too large to pass into the opened vein, will 
iffice. 

Tlie objections to the use of the syringe are that the repeated introduc- 
tiona of ita nozzle into the rein of the recipient are oft«u <\ifficult and are 
likely to be attended with undesirable violence to the vein and the adja- 
cent tiBBiies, and that the required manipulationa, if prolonged, involve ad- 
ditional clangers of the introduction of clota and of au'. Still these are 
difScultJea that can be surmounted by cjire and skill, and should not be 
permitted to stand in the way of making an attempt with the ayringe if 
better appanitus is not available. 



} 



>s 


* s 




4= ^ 


1- o 3 




I. ■J ,9 


i :■ 


V < g 




« K5 


> 5^ 


^ Sf 


J°4 - 




When the syringe is to be used, the blood to l>e injected is allowed to 
fall into a tumbler or cup tliat stands in a basin of warm water (100° F.}. 
Am hoou an about two ounces liave been drawn, it in sucked up into the 
sjTinge, the nozzle of which in then inserted into the previously exposed 
vein of the patient, and the couteutH slowly and cautiously driven in. 
This is repeated until the I'equired amount of blood has been injected. 

If, however, a suitable funnel, tube, and canula {Fig. 8fi) can be pro- 
cured, the process of ti-ousfuHion becomes less ilifBcult and the result much 
more likely to be satiafatTtory. The principle upon which the efficiency of 
such an apparatus depends is that of hydi'ostatic presBure, The blood from 
the donor is made to flow directly into the funnel as a receiver, and thence is 
troDBmitted through the tube and the canula into the vein of the recipient 



DIBEOT TRANSFDSION. 



131 



;. 36). By elevating or lowering tlie funnel the force of the injec- 
s increaeed or diminished. Such mt injection is gradual and eontinu- 
it little Ukt-ly to be embamiased by the formation of coayuLi, and iii- 
lolves the niininjum amount of time, of inanipulfltion, and of violence to 
fi vein and ite flheath. Pi-erious to inserting the canula in the opened 
1. both it and the tube should be filled with warm water, to which a lit- 
is Holt, or five to ten di'ops of liquor ummonJie have been added. An tbu 




PiB. 36,— Ulnnt Tnuufuiloii by HydiaMaclo 



■aula U being inserted some of this fluid should be allowed to slowly 
K8pe, that all air may witli uertainty be excluded Tlie whole apporatiu 
llDuld have been previously warmed by immersion in blooil-waim water. 
apparatus may be ciuickly extemporized from materials found in every 
tug ahop. Tlie canula may l>e made from a bit of glaes-tubing, the heat 
alcohol-lamp being suf&cieat to enable the surgeon to shape it or 
blHw it down to the necessary size. 

A canula with a stopcock is a convenituce, but even the stopcock may 



J 



THE TREATHEHT OF WOOKDS. 

become n nonrce of erobamiRsment bv introdacing an mt^Tetuiees in the 
interior of the doct that might determine the fomiatioD of cosgula in th« 
pttBOUg blood-cTurreuL 

A piuch(Y)ck mode oul of stiff wire, as in Fig. 38, is a desirable acces- 
Bonr when nibher tnbint; in iu«<l, l>ut max readily be i-eplitced Ig- the 
tbiunb and fint^er of on niwiHtant. 

Collin, of Paris, baa united in one instrument (Tig. 37) n syringe and 
a fnuoel, with a flexible tube and t^auula, which of all the speoial iustni- 
menlH that have been demised desemiti tlie highest mention for its tdm- 
]ilicit_v and it« adaptability to ull the retjuii-ements of blood-tmiisfuaon. 



In tluB instrtuiipnt the funnel acts an a reneiToir for the rt'ireption an<l 
rett'iition of the blootl, which in ilniwn froiri it by the syringe, and ilri%-en 
thence through the tube and cauuLi iuf« tlie recipient vein. The opening 
to the tube is guarded by a ball-valve, which permits only a heavy fluid, 
hke blood, to enter. The entrance of au- is thua guarded against. Tlio 
air originally in the tube should be tii-xt ex^tellM by forcing some of tba 
blood through it, iinniedintely befoi'e iuseriing the cuuuLl into the vein. 
The injection inny then l>e ]>roceeded with, without fear of any fur becom- 
ing muigled with the fluiil injected. 

TMien transfuKJon iw to be perfomieil. a vein in uncovered at the bend 
of the arm, or tdiove the inner ankle, by a free incinion tlmjugh the over- 
lying nkin. When the vein him Iieen clearly evjMJHed. its anteiior wall ia 
to be seized by a fine forceiw, or a tenaculum, and lifted up. wliile a tnms- 




TRANSFt'SION. 



133 

B iuciinon is made with knife or »ciBsors in the vein, extending through 
ttbout two-tbirdit of its wall, bo an to luuke a vnlvului' opening (1-lg. 3&). 
While the dap that has been mtule in uliil held up by the forceps, the 
contila is to bo introduced. Judgment ia neceasory in the selection of ii 
canulo, that too large a one be not citoaen. An a rule, difEculty will l>e 
experienced in inti'oducing into the vqiiis mentioned a cauulii of gi'eat«-r 
diameter tlian three ur three and a half milhmetres. No ligatm-e is neces- 




f to secure tlte i:anidA. It should Niniply be held in place by the 
mtle pressure uf the lingers of an aBsiHtuitt, by which also the diatal part 
e vein should be compressed at the wuue time. 
The blood to 1» injected should be obtained, if posaible, from a young 
and healthy jjermm. and should be ibwvn in a full sti-eam from the vein of 
the donor, thus prolonging tlie peraxl <luring which it will remain without 
tendency to coagulate. To secure this a free opening, at least half an 
inch in extent, should be luiide in the vein selected, which will generally be, 
MB for ordinary venesection, either the median, cephalic, or basilic veina. 



I 



TlIK TRKATMENT OF WOUNDS. 

The blood mtiy be used hh drawn, or may be defibriunted before iising. 
Defibrimitioii baa us ita object the pi-eveiition of dangers from coagulation 
of the blood. It lins been estnbliahed, particularly bv the researches of 
Panuni, of Copenhagen, that blood deprived of its fibiine and exposed to 
tlie ail' for some time is not materially deteriorated for restorative 2>ur- 
poses. Defibriuatiou is ftccomplisbed by tkawiiig the blood into a dean 
vessel, and whipping it, until deprived of its fibriue, with broom wisps, 
those fi-om a new broom, thoi-uugbly cleaused before using, only should 
be used. A bundle of twigs or gliss rods, or a fork, may also be used. 
The fluid remaining should then lie strained through a clean, thick linen ' 
cloth, then again whippeil, and again Bltered through clean white satin, i 
the dressing of which baa been jn-erioiisly removed by washing in distilled 
water.' The filtered bloml flows into a clean, di'y glass veaael, which is 
placed in warm water at 104° F., aud I'emains there till it is required for 
use. \Vhipped blood con be kept for twenty-four hours in a well-covered 
vessel, surrounded with ice, but before the transfusion it must be heated 
by placing it in warai water, and must be satui-nted with osygen by 
repeatedly drawing it iu and out of a s^-ringe. Defibi-iuated blood may be 
tranafused either by the sjTinge or by hydrostatic pressure. Fig. 39 
represents the apparatus for transfusing by hyJi-oatatic pressure recom- 
mended by Eftmarcli, It consists of u gi'aduated glass cylinder which 
holds fi'om ten to twelve fluid oimces (300 to 400 fluid grammes), ending 
below in a rounded and pei-forated point, to which is fastened a foot of 
india-rubber tubing. In tlte lower end of the latter is put a small per- 
forated connecting piece of ^Tilcanite, which accurately fits the counecting 
piece of the cunule. The calibre of these parts must all be of the same 
diameter, so that there is no interiTiption in the interior of the entire 
tube (Fig. 40). 

Into this cylinder is imured the defibriuated blood ; as soon as it flows 
out of the tube it is closed immediately above the end-piece by a clip. 
All the air is removed from the tube by stressing and squeezing in an 
ujjward ilirection. To prevent the blood from becoming cool, the hand 
which holds the cyliniler can press against its outer surface a rubber bag 
fiUed with hot water, as iu Fig. 39, or cloths wrung out in hot watef. 

The end of the tube is then attached to the connecting piece of the 
eanule, which has been meanwhile introduced into a suitable veiu after 





waarcA). Tnutsfiuloo o( Dtrflbriutal Blood. 

rtnoTed, and the coliima of blood is eeen to amk Rlowly in the cylinder 
(Kg. 39). Afl soon as the cylinder is neai-ly empty, the tube is compreased 
with the thumb and dnger, and the cauule ut withdrawn from the vein, 
which is then dressed. 



J 



136 



THE TBEATMENT OF WOUNDS. 



The chief objection to defibmiating the blood is the time occupied in 
the neceasmy mauipvdatioDs. Wben the eiaergency calling for transfusiou 
ia not urgent, such an objection does not hold. When, however, instant 
uutiou is uecettaiu^', the immediate uue of the blood, an it tiows from the 
donor's arm, is impei'ative, 

Tlie dimgera of transfumon lu-e : 1, embmraetdng the enfeebled heart 
by too mpid u supply of new Huid ; 2, the injection of clots that may form 
cmboh ; 3, the entrance of air. 

The tirst danger is to be obviated by introducing the new blood very 
slowly, and by guarding against tlie ti-aiisfusioii of too gi-ent a quauti^. 
Experience has shown that the restorative effects of iiuni six to eight 
ouuceB of new blood are fully us marked as when a larger quantity ia 




traufifuBed. For the purpose of transmitting the blood ia a more even and 
gradual manner to the heart, the methoil of injectiou into an art«ry, as the 
radial or ]>oHt«rior tibial, is the direction of the arterial current, has beeu 
practised (Hueter). 

To obviate the second danger, the interior of the tubes through which 
the blood passes in the prot^css of transfusion, should be as free as possi- 
ble from irregularities, such as projecting shouldei's, abrupt turns, and stop- 
cocks ; the injection should be made instantly, and in a regular and con- 
tinuous flow from its lieginning to its end. When time allows, d^brina- 
tion of the blood may be practised. 

The third danger needs only to be kept in mind to secure the necessary 
cautions in the manipulatioas of the injecting apparatus to exclude the air. 



TUANSFUSION. 



137 



i instrumeDts other thau those here recommended have been 
ilevued from time to time. The origiiml apparatus of Lower (166G) wou 
for direct tnuisfusioii from vein to rein, by means uf silver cauulu; that 
were coimected together by a Hoxible tube made from the carotid iirt«ry of 
a liorse or osu Aveling's iustiTiment (Fif,'- il) is esBentially tliB aame Uiing, 
mbstitutiug a rubber tube, expanded at one point into a bulb, for the ox a 
art«r)- used by lower. Theoi-etically the direct transfusion of blood 
fnoiu the Teia of the douor to that of the recipient ie a more perfect oper- 
ation than the indirect method by sjiiuge or hydrostatic presMure, Prac- 
ticallj, however, the latter method gives eqiuiUy good results, while it is 
"lore easily and certainly accomplished, and places the amount and rapidity 
ot the new blood Hupply mider the full conb'ol of the surgeon. 

I'TUoncal TraiiK/ueitm. — The method of ti-ansfusion (so called) by 

P**iiriug detibrinat*d blood into the peritoneal cavity through a canula, 

ttliber tube, and funnel, proponed by Ponfinck,' though possibly u valu- 

t*le therapeutical measure in cases of anromia of a clironic nature, cannot 

e the place of intra-venous tnmefusiou in cases of acut« oneemia from 

id and excessive loss of blood. 



einfiiehei larfaAre« dei' Traiufu, 
\tBlalUr, 1879, ii., p. S46. 



iwtt beiat Mciuoheit. Wieit Medi- 




Htrmetlaai» — Sjionging — FnriScatlou of S'poagBi^lrTigaluta — Coutmaoaii Submeirion 
— IrrigntinB Fluids — i>i'ni>i«pe— Nutural Drainage — Actifloial Drainage — Draiiu{[(i 
TubcB— Absorbable Tubei of Naiiber, of Macewen — Capillary Drainage — Catgut 
DrailiB — Horeebair Drains — Spuu-Gloas Diaini — QeneriU Coniiidej-iiUoitt a* ta 
Artijieiai JJinini — Uetvnie—Fiiuuuj Drainage — Secondar? Dioin^e — Aeeeaoiy 
Mean* of Wound Cleantinall^XAyuwat Skin— Tha Surgeon and bis AsaJBtanta— 
luatiQinentB and ApplianosB— CompreiiAes and Protective Appliancea — Purifica- 
tion of the Air— Spray Produoeca— CT«iWfli»3 SepUa ICcum/j— fnrettes— Diain- 
fecting LotiooB. 

Afteb Ufemorrhage slmil have been aireated. and the geneml condition 
of the patient shall have received the atteiitiou which it may hai'e required, 
the nest duty of the sui-geon is to proceed to the cJeauaiug of the wound. 
A full fippi-eciation of the extent of the requireinenUi of wound-cleanlineea, 
ami of the minute precautious necessaiy for their fulfilment, is of the ut- 
most imjx)rtauce in deteiiuiiiiiig the futui'e course of a wound. "What 
these i-equirementH ai-e have been discussed in the chapter in the first sec- 
tion on Wound-Cleauliuess. They should have a conti-olliug iuHuence in 
the choice of measures of bicinoBtasiit. For it is important in seeming 
final hfemostoHis tliat those means only be used which do not themselves 
violate Uie i-ule of cleanliness. The fij-st, and one of the most importMit, 
elements of cleansing a wound, indeed — with the esceptioue not«d in 
Chapter IV, — is the perfect arrest of bleeding and the careful remold of 
effused blood. The masses of hardened coagula wliich Btj-jitics leave be- 
hind in a wound, pi-eventing union and speedily becoming uTitauls, make 
their use a violation of cleanliness, and therefoi-e requii-e their rejection. 
Exposure to the ail- and compression alone, or compression with the addi- 
tion of hot iodized lotions, should be relied on to check capilhuy oozing. 
For controlling bleeding from the larger vessels, uniiiitnting ligatures, 



PDKIFICATION OP 8POMUES. 



13» 



whose ends caii be cut ofl) and the ligature itself be left to be absorbed or 
«e.v8ted, should lie used whenever ixissible. In default of Huch ligatures, 
iWKion, forcipressure, aud acupresaure may be reported to, by preference, 
itt the order named. The use of the ordisaiy silken hgature ia a violation 
of every principle of womid-cleanlineHH, mid its emplojTuent ia to be advo- 
i^ted only when, in the absence of otliei' agento, the immediate necessity 
'"i" its use outweighs its Uter disadvantageH. In the further prosecution 
^f the piiniary cleansing of the wound, search is to be made for whatever 
''^T^iga bodiea or particles — aaiid, dirt, fi-agmeuta of bone, pieces of cloUi- 
"ig, of wood, of glass, of metal, etc. — may have been left in the wound. 
■'-llese must, if possible, be removed before the wound is closed. Foreign 
^'^thea of some size nmy most readily l>e removed by the fingei-s or by forceps, 
^^t the more minute particles, as well as the effused blood, aud the wound- 
ions, require the use of careful and gentle sponging, or free irrigation. 
Both in the primary cleansing of the wound and in the after-dressingB, 
^ cardinal principle to be obsen'ed is to abstain from all unnecessary' dis- 
l^*ttbance of the wound-surfaces. Minute care in accomplitJiiHg primaiT^ 
ifdng Yfill make much more simple the after-cjires. The dressing of 
■ound should be so managed that its self -cleansing should l>e eimtinu- 
Oos nutil healing is complete, and all scjueezing and mopping and forcible 
Syringing should be unuecessaiT. 



^^toba 
^■leaui 




The sponge that is to be used upon a wounded surface should be of 
, open cells, and sufficiently elastic to expand readily in the 
X water has been expressed fram it. Tlie whiteness is a matter 
B auoant, unless the bleaching has been carried ho far as to destroy 
t testure. It must be soft and pure. Attention to the character of the 
tonges used is one of the minor details of wound-ti-eatment, which may, 
"llOweTer, make the difference between success or disaster in tlie result. 
The sponges that are to be obtained ordinarily fi-om dmggists in this coun- 
try have undergone no preporatiou after their impoi-tatlon. Even the finer 
qunlitics of Turkey sponge that are sold for sui-gieal uses still contain 
much sand, bits of coral and small shells, and some organic impurities. 
Before they are used, the saud and particles of coral and of shells that 
B lotlged in their interstices should be removed, first by a thorough 
' while the sponge is l.lry, and tlien by prolonged and repeated 
a tepid water— hot water shrivels a Hi>oiige aud sijoils it — mitil 




140 TUE THEATMBNT OF WOUMDS. 

tlie water comes off clear imd free from saud. After they have dried, it 
will be found that a new beatiiig will still dislocl^e Home liaiid. As boou 
lis tlie apongea are aufficieutly freed from soud, tliey sliould be placed in 
It solution of permiingauate of jiotasaa, 1 to 500, for tweuty-four liour& 
Theu they are again waehed in clear water, aiiu placed in a one per cent 
solution of lijiioBulpliit* of soda, to whieh Ib added one-fift!i tlie amount 
of au eight per cent, solution of hydiocliloric at-id (fort.). The sponges 
should remain in tliie Bolution only for a few miuuteB, until (in about 
one-quaiter of au hour) they have become white, being constantly stirred 
with a wooden rod while iu the solution. 

It will not be well to let tliem remain too long in this bath, because 
theii' Bubstance will become injured so that they will lose their elosticitj 
and easily tear. Lastly, they are again washed until they are entii-ely 
scentless, requiring frequent chauges in water duiing two or tliree days, 
and immersed in a five per cent, solution of cai-lx'lif acid for at least four- 
teen days before being ueed. 

After having been used they should be thoroughly purified before be- 
ing again used. For this purpose, after having been washed in wat«r, 
they should be I'epeatedly washed in a solution of carbonate of soda — com- 
mon washing soda — one ounce to the quart of water, to remove any blood 
or matter, theu with water again, and theu iumieraed as before in the fivs 
per cent, carbohc acid solution. 

In procetjs of time, a sponge, after frequent using, will become ao 
clogged with fibriue, that cannot be washed out, that it is useless. In such 
cases the sponges may be allowed to macemte in oi-dinary water fop a 
week or tn-o, until the puti-efactiou of the fibriue has softened it so that it 
is easily washed out Cleansing and immemon of the sponge in five per 
cent, caibohc acid solution, as before, will again fit such sponges to be used. 

"N^Tien sponges have been used upon siu-fiices manifestly impure, or 
about wounds to which any suspicion of infection atlnches, they should b6 
steeped for five minutes, ofter the prdiminary washing, in hquor sodn 
chlorinaUe, diluted with an equal part of water. A longer steeping endan- 
gers the destruction of the sponge itself by the chlorine. 

By tlie use of these measui'es for purifying sponges, they may be used 
repeatedly aud for ou indefinite time. Without these precautions, the re- 
peated use of a sponge is fi-augbt with danger, as it may be the bearer of 
infection from one wound to another. 

Whenever a soft sponge whose purity can be i-elied on is not access!- 




IRRIGATION. 141 

ble, the deansiiig of a irousd sLoutd be attetnpteJ hy enme mibstitute for 
I it, r&ther than by using a sponge of iloubtful cLaract*r, Pieces of cotton 
[ dotl;, old, soft, and absorbent, made clean and pnre at the time of using, 
' nuy be nmile t4> do good service at) substitutes for sponges, and ai'e nearly 
alnnjB a^-aiiable. Dossils of absorbent cotton — cotton from which all groBS 
mi[iuritie8 and fatty matter have been removed, ajid whidi is now abun- 
ilautly supplied by various makers in this eouutr}' — make almost a perfect 
M>b§titute for sponges. They may he wrung out in auy antiseptic liquid 
'■efore tmin g, and, beiug tlu'owu away an fast as usetl, ai'e not Uable to vio- 

("*«^ cleauliness by n second use- 
l mniGATioN. 

The passage of a gently flowing sti-eain nf water over tlie wouud-sur- 

**<»a, or through its cavities and sinuses, if such exist, constitutes irriga- 

_^* ^*" It is especially wlapted for cleansing tlie wound of fluids, and light 

teign matter, and loose bits of tissue of any kind. No complicated ap- 

1 ia necessary for obtaiuiug irrigation. The sti-eam that may be 

pieezed from a sponge, or poured from a buHin or pit«;her, may often an- 

: every purjjose. The stTeam produced by a syringe is objectionable 

a account of its fitfuluess and the micertainty of the force with which it 

*nny strike the wound-surfaces. The appUcatiou of the fo\mtain priu- 

eiple, whenever possible, furnishes tlie most perfect stream for irrigation. 

^^niieneTer a bit of i-ubber tubing, and a utensil that will Ijuld water cim be 

^^Kfed, as a reservoir, a fountaui stream is possible. If from the bottom of 

^BBw reservoir a tulje project, ujhui which the rubber tubing can be slipped, 

it win be convenient ; but if not, if the rubber tube be passed over the top 

of the reservou-, and be mwle into a siphon, it will answer jnst as good a jjur- 

pose. By elevating Mid lowering tlie resenoir, the force of the stream can be 

perfectly gradimted, according to the will and judgment of the surgeon ; by 

replenishing the supply of fluid in the reserioir, as needed, tlie time through 

fwliicli the irrigation sliall be continuetl may be indefinitely prolongetl. 

In the after-progress of the wound, if union by first intention be not 

„ recourse to imgation for the puqwse of cleansijjg it of retained 

cretions, ajid of sloughing tUbrin, may be necessary. In tiiis i-espect it 

rgely aupplements di-ainage, and the measure of its frequency and im- 

■ portauce is the measure of the imperfection of tlie proWsions for drainage. 

The aim should be, in all cases, fii-at, by irrigation to remove all foi-eign. or 

dead, or waste products from a wound ; and second, by drainage to pre- 




142 THE TREATMENT OF WOUNDS. 

vent UieiT renccumulation. Whenever adequate (Iraiiinge has been impRMy 
ticable, continuous inigatiou might becfline of value in preventing aecu- 
niuktion of noxious eubstjmceft Tiie temperature of the water used for 
irrigatiou should always be equal to that of the blood, for a lower t«m- 
perattu« exerts a depressing iufluence on the reiuutttive aaergy of the 
wound. 

C'ontimiouB giihmermoii in worm and hot water ia a form of irrigation, 
and its favorable effect, when experienced, is due to the deansing of the 
wound which it accomplishes, as well iis to its influence in promoting reeo- 
lution of inflamiuatoiy coniplicationa The value of such submersion in 
the treatment, especially of lacerated and contused wounds of the extremi- 
ties, has been wai-mly praised in this country by Dra. Frank H. Hamil- 
ton ' and Da^■id Prince.' Dr. Hamilton states that " no treatment hitherto 
adopted, under his obsenation, has been attended with equally favorable 
results. Under tliis jilan the area of acut« inflammation is exceedingly 
limited ; erysipelatous iiiflmiuiiution has been almost unifoiiuly arrested or 
restrained, when it has actually commenced, and it has never originated 
after submersion ; gangrene has, in no instance, extended beyond the 
parts originally injured, and when progressing, it has, in most cases, been 
s{)eedily arrested. Septiciemia Emd pyeeinia have not ensued in any case 
ill whioh submersion baa been practised from the first day of the accident 
Pmident infiltrations and consecutive abscesses have been infrequent, and 
always limited to the neigbborhoo<l of tlie parts injured, and of small ex- 
tent. Traumatic fever, usually present after grave accidents, when other 
plans of treatment have been pursued, a.s early as the third or fourtli day, 
has seldom been present when this plan has been adopted, and in no case 
has the fever been intense or alarming." The favorable effect of submer- 
sion upon the progress of a wound, as described by Dr. Hamilton, accord- 
ing to my experience, will not be obtained when the character of the 
wound is such that all its recesses 01% not freely accessible to the water, 
and when tlie escape of the wound-discbarges is impeded. It is the dilut- 
ing and cleansing fimction of tlie continuous irrigation that it accomplishes 
to which is due. in great measure, the favorable results obtained ; thuB the 
hot water, though a earner of septic germs, and itself favoring the proceasea 
of fermentation, yet. by its i^ency in removing the necesBory pabulum for 
the development of the ferment, and by diluting and washing away at 

> The Uedical Record. 1874, p. 249. 

' Anoils of Anatomy md Surgery, 1883, vol. v.. p. 1' 



once tlie nosious products of whatever fermentation does occui 
ful in preventing wound-diaturbanceu. As accessory to- this antiseptic in- 
fluence, there shoulcl not be overlookeil, in estinaating the mlionulc of the 
'*eiiefits to be derived frouj this mode of treatment, the favomble effect 
upon the nntrition of the iiumersed part, which the warmth and protection 
'*f Uie hot-water bath exert 

In consequence of the favorable results obtained by the use of immer- 

on in warm nnter, reported by Langenbeck,' of Berlin, in 1855, and by 

,' of I>re8den, in 1850, this method of wound-treatmeiit was for many 

•a extensively used in Germany, but it has now bet^'onie largely replaced 

k that countrj- by moi-e perfect antJKeptic nietlioila 

Icriijating Flvuin. — Since ordinary water in a comiuou veliicle for septic 
S^nns, that which is to he used for iirigating wounds must be sterilized 
■"->j adding to it some antiseptic in sufficient strength to destroy any germ- 
life that may ch&nce to be in it Of the various antiseptics thowe that will 
lae found most generally available and reUable for this* jimijose are corro- 
•sive sublimate in tlie proportion of 1 part to 2,500 of water ; permanganate 
^Gpf jKjtaeh, 1 to 100 ; carlxilic acid, 1 to 40, and tincture of iodine, 1 to 40. 

DHAISAGE. 
ClflHiiBing of the wound is tinally completed by providing means to 
jnvvent the recurrence in the wound of conditions of wound-contamina- 
tion. Of these, the first, and most important, is the establishment of a 
free, short, and direct channel, through which the wound-secretions may 
[freely and continuously flow away. The application of the term " drain- 
nge " to this portion of the management of a wound is happily appropriate, 
mjlat the same physical problem is present for solution as that encountered 
y the farmer who desires to rid his land of undue and hurtful moisture. 
I ditches, canals, imd dnuus, find theu' counterpart in the devices 
Iopt«d by the surgeon to rid wound-cavities of accumulating secretions. 

The pi-ovisions for drainage may be divided into naiuivl and artijiciai. 
f natural being meant whatever arrangement or dressing of the wound 
dtall favor the escape of secretions, apart from the insertion of any appara- 
tus as means of conduction ; by artificial being meant such tubes, setons, 
or tents, as may be necessary to supplement or replace natural means. 
NftTux&L Dbainaok may be secured in many instances. In wounds in 






J>aHUehe Klinik, 1855, ^fo. 37. 



■ UtaueAe KUnik, Ootobec, 165& 



144 THE TBEATMENT OF WOUNDS. 

which gootl coaptation of tlie surfoceB has been possible, and yet in which 
reasoDH exist for sspecting the production of much secretion, the escape 
of such secretion may often be sufficiently prorideJ for by leavtog open 
the most dependent poiiiou of the wound. In other wounds in which 
secretions have accumulated so as to pi'oduce tension, by cutting one or 
more Butures sufficient gnpiug of the wound may be permitted to answer 
the needs of ilrainage. In yft others, the cutting of all stitches, and the 
unrestricted separation of the entire wound-borders may be deemed l>est. 
The " open " method of treating woundH, which has been proven to possess- 
great merits in many instances, is a method in which thorough natui-al 
drainage is provided for, and to this unquestionably a hirge share of the .^^i 
benefits derived from the method are due. The results of diflferent fonua-^^ 
of the "open" treatment show that the chief thing of importance iu itii p i 
management is that free escape of secretions be not pi-eveuted For the ■*^~^ 
purpose of securing this free eacajve wounds are to be enlarged by free-^^3lE 
iutifiions, and counter-openings made wlieiiever requireiL A foi-m of^MiCl 
modified open treatment has recently been practised and advocated bj — «■*» 
Pi'ofesHor Kocher,' of Berne, which he calls tlie metliod by " 
suture," in which natural dimuage is resorted to for the removal of the 
bloody and serous oozing that occurs during the fii-st twelve to twenty-four 
hours aft«r the occurrence of a wound, by learaig the wound open during- 
that period, septic infection being prei-ented hy the use of a bismuth lo- 
tion ; when the farther secretion haa in gi-eat meatiui-e been aiTested, the 
surfaces are brought togetlier and sutured, without any necessity for fur- 
ther drainage. All wounds which ailmit of union by first intention. Pro- 
fessor Kocher recommendh to be subjected to this method of treatment to 
avoid recourse to artificial drainage. 

Abtificial Dkainaoe includes all methods in which foreign substances 
are introduced iuto a wound for the purpose of conducting away its dis- 
cbarges. These substances may act by o«pillarity, sening to keep the 
wound-surfaces apart, and permitting the outflow of Uquid to take place 
along the interstices between their strands, or may provide tubes througli 
which a free flow la secured. The use of various artificial means for drain- 
age is among the ancient resources of surgery. Guy de CliauUac (1300- 
1370) taught that it was necessary to place t«nts and setous "in wounds 
which you would enlarge, cleanse, or from the bottom of which you would 



' Ufber die riafadultii ilillti iin 
!« Dnnnrahren. Volkinnnij'a Siim 



Ertidung einer Wim/i/ieilunii dnrrJi Verld^uug 
nlunq klim/cher Yorlnh/e. No 234. 



T 



DRAINAGE TUBES. 145 

withdraw unj-thing, as in deep woimda wliioh have need of coimter-open- 
Jngs, because of the liquor or the liquid excretion which gathers at the 
I*ottom and in its recesses." Que can ako make use, he aavb, "of a tube 
^f brass or of beaten silver that the ordure may escape from it aud not be 
retained." 

But not until within the present generation has the full impoi'taiice of 
**'tificial means of drainage been demonstrated and its practice been eys- 
t^matized. With the sjBtematic practice of drainage the name of Chas- 
^^guac 19 associated, whose researches were published, in ISoi), in a work 
Entitled, Trailf pToliqiu; de la siipimratian i-t 'In flmirmgr. His method con- 
flated in tntveraing from top to bottom all purulent collections irith vulctui- 
ized rubber tubes pierced with holes along tlieii- sides. Hj demonstrated 
&iid fixed in surgical practice the impoi-tance of preventing the retention of 
t^as, and introiluced a perfect metliod of drainage for purulsnt S'jcretiona 

Tubular DaAiNAOE. — Pus cannot be removed by capiUviry drains ; its 

thickness and tenacity prevent its escape thi-ough such chounels ; a tube 

of some kind or other must be used t*> secure its escape. The iudi.i-rub- 

^B&er Lubes introduced by Chassaignac, being flexible, uninitaluig, easy to 

^Hto&nipulate, nearly always attainable, aud cheap, continue to be regarded 

^^■B the most universally applicable means of drainage. These tubes may 

^^rae obtained of varying diameters, from one-eighth of on inch upward, and 

^Vo( any length. The original tubes of Chaseaignao were made of blade 

rubber, which has been considered objectionable from the liability of the 

Iree sulphur contAined in them to generate sulphuretted liyJi'ogen, and 

thus to produce disagreeable smells. This objection has bsen obviated by 

substituting red rubber for the black rubber in making the tubes. When 

they are to be used for drainage purposes lateral openings should be made 

Pin them at short intervals, the diameter of each hole being about one-third 
of the circumference of the tube. These openings cau bo readily made as 
needed, by simply bending the tube sharply on itself and snipping oflf one 
of the projecting corners at the bend with a pair of scissors. (See Fig, 42. ) 
Tabes of metal, as silver, aluminium, or tin, and tubes of glass may be 

»Babstitut«d for tlie rubber tubes, when the compressible and flexible na- 
ture of Ihe latter is liable to be the occasion of their obstruction by their 
'becoming bent, or from the pressure of the tissues through which they 
pass, or of the dressings that may be applied. 

A drainage tube, of whatever substance composed, is a foreign body, 
; IB it remaina in a wound is liable to prnvoke disturbanca 



146 



TUK TREATMENT OF "WOUNDS. 



Tliey ahoulJ therefore be removed as soon as the period of profuse eecre- 
Uon, which has made their original use aecesaary^ has passed awii}', or as 
Boon aa Uie cavity which they were iiit«nded to drain has become obliter- 
ated. In incised wounds, a tube should not be used at all when the two 
surfaces can be brought accurately together and maintained in apjiosition. 
It is only when care in adjustment, and the use of proper means for reten- 
tion and support and compression prove to be insufficient to secure and 
maintain aocurate adjustment of wound-surfaces that the use of a tube is 
indicated, 




Fid. tt— OntlDuT DmiDUte 



The necessity for the removal of the tube, or its readjustment, if it« - 
continued use is indicated, may be a soittce of disturbance to the progress 
of the wound, and, in any event, as long as it remains in the wound, more 
frequent dressing of the wound, with its attendant dangei-s and disadvan- 
tages, is necessitated. 

For tliis reason a means of drainage which shoidd afFoi-d free escape 
for secretions during the first days, diuing which they are most copiously 
produced, and which should then spontaneously melt away and be absorbed 
is a desideratum. Such a drainage tube would bring into the treatment 
of wounds nn advantage second only to that already gained in the substitu- 
tion of absorbable ligatures for the irritating threads that demanded a con- 
dition of ulceration and suppuration to accomplish Uieir removal 

Ahmrrbtihle tubeJt, made of decalcified bone, have been devised by Dr. 
Neuber,' of Kiel, and used by him as substitutes for the ordinnrj- tubes in 
the primary dressing of wounds. These tubes are prepared from sound 

' Ein Anliieptiic/itr DmitrvFrband iiaeh graiidlieher SluUlillung. AreAiv far 
KUnitchc CMrurgle, zzIt., Beft S; and ucv., Heft 1. 




beco 
Lf it 



ABSOHBABLE DKAINAOE TCBE9. 147 

oz or horse l>one, or ivory, by turning out of them, in a. hkthe, cyhndera of 
proper sizes and lengths, and converting those into tubes by tlriUing holes 
through them. They are then placed in a mixture of one part of hydro- 
chloric acid and two parts of water. After ten hours' immenion the eoi-thy 
matter will have almost completely clifwolveil away, and the tubed, aft«r 
being washed of the superfluous acid in five per cent, carbolic solution, 
are ready for use. Such tubes are absorbed just as catgut is absorbed 
or rephtced. Acconling to Neuber, in dx or seven days the drain will have 
become soft and i>ulpy, and filled with Ivmph. After ten days all traces 

it have diaappeai-ed, except whatever portion may have projected out- 
which will be found lying detached hke a small ring and quite un- 
changed. 

Doctor 'William Macewen, of Glas^O'w, has demouatrated the value of 
the hollow femora and tibiaa of domestic fowls, as substitutes for the ex- 
pensive tubes drilled out of bone, according to the niethoil of Neubor. 
His method of preparation is a« follows : ' The tibiie and femora are 
scraped— bones from fowls which have been cooked for the table being 
used — and steeped in hydrochloric acid and water (1 to 6) until they are 
soft Their articular extremities are then snipped off with a pair of scis- 
•Dts ; the endoateum is raised at one end, and pushed through to the other 
itnity, along with its contents. They ore then reintroduced into a 
solution of the same strengtli, until they are rendered a little more 
itftble and soft than what is ultimately required (as they afterward harden 
little by steeping in the carbolized solution). When thus prepared, they 

placed in a solution of carbohc acid in glycerine — 1 to 10. They may 
be used at the end of a fortnight from the time of introduction into the 
glycerine solution. Holes may be drilled in them, or clipped out with 
Bciusors. Tubes thus formed are semi-transparent, pliable, and elastic, 
capable of retaining for some time their form under the weight of thick 
flape. 

The average duration of the chicken-bone tubes, out of one hundred 
carefully recorded observations, was something over eight daya 

In using them, Macewen directs that they shoidd always be threaded 
with horse-bur to prevent their lieing blocked by blood-clot, and to help in 
tnaintoining the calibre of the tube patent during the first few days, espe- 
cially where the dressings might exercise pressure. After the first few days 



I 



> Tbe Drainage of WoaudB. Bdtiah Hedioal Joonutl, FebrouT 0, 1881, p. 189. 



J^ 



> 



148 THE TREATMENT OF WOUNBS. 

ihe hairs, being no longer of use, are to be removed, and the tulje left pei 
fectly patent, A similar practice of threading the tube with hair when i 
I to be inserted into a recent wound commends itself for adoption witlta^^^i 

any kind of tube. The blocking up of a tube with blood-clot is an acci j 

dent apt to occur, in which case surgeons have been in the habit of^^i 1 
removing the tubes, cleojiing them of clot, and reintroducing them. But -^A I J 
OS the reintroductiou imtates the wound, and, at times, provokes fresh .^cill 
bleeding, it ia to be deprecated. This may be obviated by threadiug them ^c^- 
with hiur, as deacribed, which may be removed es soon as tbe danger of "^t:^ 
cloUformatioQ has passed. 

Certain important pmoticol difficulties, which have been found to ^C^"d 
oppose themselves aa obstacles to the realization of the ideal ad^TUitage «i-i» * tt 
expected to be derived from these bone drains of Neuber and >Iac«wen, _^ 
must be noted. They are likely to suffer untimely collapse, and cease to ^e=V 
act as drains from lack of 8u£Gcient hardness of their walla when immersed .9^ 

he wound-aecreiiona The expedient of forestalling this accident by ~^* 
stuffing them with horse-hair to keep them patent is simply the substitution 
of a non-absorbable drsun, and defeats the sjiecial object — infrequency of 
dreiising — which the bone drains are devised to answer. Again, when not 
too soft, they may become absorbed before the necetiBity for drainage i§ 
over, and by their disappearance determine retention of secretions. Thia 
particularly is liable to occur iu wounds whit-h have not been preserved 
aseptic, and those in which the disi^harge is profuse — conditions in which, 
especially, perfect freedom of drainage is important Lastly, if the drain 
should happen to become surrounded by a eoagulum or by devitalized 
tissue its absorption would l>e indefinitely delayed. These uucertaintiea 
in the behavior of bone di-ains have prevented their use from becoming 
general 

CAPtLtiARY DBARtAOE. — The thin bloody serum, which constitutes the 
. primary secretion poured out from a wound, is capable of conduction to 
the surface by agents that exert upon it a capillaiy attraction. For such 
a purpose those agents only are to be used which are unirrilating, compa- 
ratively non-absorbcnt, and sufGciently fine in testure that the iutorqiaces 
formed when they are made into bundles shall be minute enough to exert 
well-marked capillary attraction, 

Catgvt, aa a means of drainage by capillaritA', was introduced by Pro- 
fessor Chiene, of Edinburgh, who used for tlie purpose very fine catgut. 
His manner of using it, as described by Cheyne, in his work on Antiseptic 



CATGUT DRAINS. 



149 



■ Surgery, is to take a skein of catgut, eontaming say twenty ihreada, und tie 
it at its middle by a Bmglo tiread of the same gut. One end of this thread 
is posaed through a needle {Fig. 43), and by meanH of thia the centre of 
the akeiu is stitched to the deepest part of the wound. The akela is now 
broken up into bundles of five or six threads each. One bundle comes 
out at each angle of the iuclaiou, and the other bundleti at interrals be- 
2en the stitches. (Fig. 44) 




By distributing the threads over various parts of the wound tlie true 
principle of drainage ia caiiied out ; for, as pointed out by Professor 
Chiene, in draining a field one does not have one lai^e drain goiJig from 
one end of the field to another ; on thB contrary, the field ia travenwd by 
^wuuerous small drains. And so in tliis method we have a numbei' of 
J drains traversing the wound in several directions. 

laigat drain ist an dbsorbable drain, and ia exposed to objections 
f to those found to attend the absorbsible tubular drains. Drainage 
l*'i>e needed for a longer period than the few days during which the 
tsaigai stnuids could serve tut a drain. It swells rapidly after being put in, 
and becomes less efficient ns a drain. If found inefficient, and its rcrao\al 
ia desired before it is absorbed, it is likely to have become so closely con- 






150 THE TREATMENT OP W0UND9. 

aected -wUh Hhe neighboriii{j tiamieB that undesirable violence to them is 
indicted by its withdrawal 

Horse-hair presents itself ob an excellent agent for capillary drainage- 
It is always aTuilable, and in unirriiating and non-absorbent The finenesM 
of its threads make the bimdles made of it capable of exerting a HtroD^ 
attractive force on serous Bcci-etiona The credit of its Buggeatioii, aa im 
drain in the treatment of wounds, is given to Mr. "White, of the Notting- 
ham General In£rmarj. Before being used, the hair should be thoroughlj- 
washed in an alkaline solution, to purify it of all foreign matter that may- 
have adhered to it, and afterwards preserved in a five per cent. waf<ry car- 
bolic solution. When useil, it is made into bundles of varying size, whit 
are simply laid in the wound in situations most suitable for drainage. Tt 
(adUtate their management, MacConuuu gives the practical hint to choow 
a sufficient number of hairs, according to the number needed, double tht 
bundle upon itself, and a(t«r fastening them togetlier by a single haii 
wound round them in a spiral form, introduce the convex looped end inU 
the wound. A successive removal of some of the hairs from the burn 
may be made from time to time, as a diminution of the size of the draiii- 
may be thought desirable, before it is fintdly withdrawn. 

Macewen colls attention to the increased efficiency that may be given 
to a horse-hair drain by giving to it a sj'phou action. Ho is of the opinion 
titat when the hair is cut off close to the hps of the wound, when these are 
at a higher level than the int«rioi-, so that the fluid will require to mount 
np, it acts feebly as a drain. By lea%-iug the portion on tlio ouhdde of the 
wound longer than that which remains in the interior the vdsp of hair may 
easily be formed info a sj-phon. The sj-phonage is inaugurated by dipping 
the wisp into a weak carbolized solution before introducing it, and sur- 
rounding it with moistened gauze, T)ie hairs should be tied tt>getlier at 
their outer extremity also when sj-phonoge is desired. 

Span Glass. — Dr. Herman KOmmell, ' of the Hamburg General Hospital, 
has called attention to the supcriorit^t' displayed by spun gloss, as a mate- 
rial for papillary drainage, over any other substance. This material con- 
sista of glass drawn out into tlireads of great tenuity, wluch are perfectly 
flexible and elastic, and feel to the touch soft and smooth like fine wool or 
silk. They are susceptible of being woven into textile fabrics lite vegeta- 
ble and animal fibres, and can be obtained in the shops in strands, even 




sppw-oLAsa DBAnre. IBl 

u feet in length. Tlie author advises that the drEUUB be formed by braid- 
ing together three strandB, each of suitable thickness, and that they be 
kept ready for use in a one per c.mt solution of corrOBive Bubliniate. The 
amolleBt-Bized drain should be about the thiciness of a niateh, it being un- 
desirable to have ajiy greater bulk than is required to carry un the needed 
capillary flov. 

With these glass braids, drainngc can be insured to n greater distance 
without danger from retention, nor is it necessarj- to shorten them by de- 
grees, aa with rubber tubes. They take up but little space, and being flat, 
BeparatA the tissues to a minimum amouni They produce loss irritHtion 
than other substances, never provoke suppuration, and when they are re- 
moved immediate adhesion of the tissue in tlieir track takes place, bo that 
no fiatuUe remain behind. They cannot kink, however great tlie comprea- 
fiion, and never clog. Incisions and counter-incisions to facilitate drainage 
sre unnecessary' when these are used, for the c-ikpillary ntfcra<.'ti<m exerted 
by them acta aa strongly vertically as when assisted by gravitation. Pus, 
blood, and fluids containing much blood, are not removable by these 
dntins any more than by other capillary drains. The prolonged residence 
of theae drains in the tissues is att«nded with the disadvantage only which 
arises from the firmness with which they may become grasped by the 
granulation tissue which may insinuate itself into its interstices. Kiim- 
mell is in the babit of leaving the first dressing undisturbed for Beveu 
days, except in operations of special gravity, in which he changes his dress- 
ing on the fourth or fifth day. In one case in which he left the drain 
undisturbed for fourteen days he waa able to dislodge it only by the aid 
I a cutting instrument. 

Gknebal CosaroEBiTiONS as to Abteficial Drains. — "Drains, of what- 

' erer character, should be so phteed as to carry the secretions from the 

deeper parts of the wound, as well as from any irregularity or recess, by 

the straightest and shortest road practicable to the surface. Many short 

drains, rather than few and long ones, are to be prefen'ed. They are of 

the greatest importance during the first forty-eight hours, and in deep, 

^—.axtensiTe, and irregular wonnda The more powerful the antiseptic Bolu- 

^HHon employed, and the more prolonged its employment, the greater will 

^Hh the amount of after-eecretian, and the greater the necessity for efficient 

^^faminnge. The first dressing la often soaked with bloody serum in twenty- 

^^■Dur hours, or even much earlier. ^Vben it is neceflsar>' to employ drain- 

^Bge tubes for a considerable time they require periodical shortening, or 



nnd 



J 



152 THE TREATMENT OF WODNDSJ. 

must be changed for emaller ones. On the renewal of the dreaeiiig they 
E^ould never bo used for the purpose of syringing the wound, so long its 
it is aseptic The tube should be large in size, rather than suiall, placed 
where it cannot be compressed, and have no elbows. The best time to 
insert the drains is after the sutures have l>eeu introduced, but are not yet 
<lrawn tight. Two tubes, side by side, often work very well. The time 
for their reniova! depends on the amount of secretion. After four to ax. 
days the chuunel in which the drain hea becomes lined with plastic matterv 
and will remain open for a short time after ita removal ; where several. 
drains are present they ought to be taien out, one after the other, after ac^- 
interval. , 

" The tubes should vary in size from that of the little finger to that o^> 
a quilL The ends may be cut transversely or obliquely, so that they ma^ ,, 
always terniiQut* flush with the surface, and never project bpyoud it ; an^ | 
projeolifflg part is pressed on by the dressings, and the otber exlremity- 
wUl thus be forced upon and irritate the wound-surface, and the functioa 
of the tube is impeded. 

" Loopa of carbolized ailfe should be inserted at one end, for the pur- I 
pose of fastening the tube to the slcin. They would otherwise oeciisionally 
shp into the wound-cavity, and might become healed over, or they might 
escape eKtemnlly." ' 

B£suu£. — The two indications to be aceompUshed by drainage of a ' 
wound— to prevent the nccmoulation of ferment pabulum, and to remove 
fluids ah-eady the subject of ferment changes — mean practically the drain- 
age of serum and the drainage of pua The first is primary and preven- 
tive in its nature, the latt«r secondary and corrective, 

Priniarij Drainage. — Since the retention of accumulated serum within 
a wound not only acts as any foreign body to prevent apposition and to 
disturb healing mechanically, but also is prone to rapidly become a fountain 
of poison to the wound, as ferment changes take pLice within it, the prob- 
lem of its remin'al becomes a question of primarj- importance in wound- 
treatment, and ia second to no other involved in the subject of wound- 
cleanliness. The paramount importance of primarj- drainage is one of the 
most prominent points iu8ist*d upon by Mi-. LiBter, to whose teachings 
and practice ite establishment in its proper place in wound-treatment is 
due in great measure. The use of drains, however, is to be regarded 

■ HaoCormBo. AntiHptIo Siug«r7. 



SMCONDABT DRAINAOB. 



153 



I- always as & complication, which, if possible, should be avoided, and to be 
P*dopt«<3 only when other poesible meaoB for limiting the amount of serouB 
ft^iudation luid preventing ita accumulatioD muut be inefficient When 
ins lire unavoidable, they should be removed aa soon ae possible, that is, 
Boon aa tlie tendency to sei-ous exudation ceases, or the obliteration of 
rity drained hy them is accomplished, a period of time varying usu- 
f from one to four days. 

fiecoiidary iMiinagt: — The draina^ of purulent fluids couBtitutes what 

e chosen to call secondary or corrective drainage. For this purpose 

Lpillary drains are inadequate, and tubes miut be used if artificial drains 

equired. This is the fonn of drainage with which the name of Cliaa- 

tao wUl iilwayH be associated. In ita use, the tube, of whatever mate- 

I, must be removed from the wound at each dressing, and washed with 

ing antiseptic lotion. If this be not done, portions of decomposing 

material will remain inside the wound, entangled in tlio openings of tlie 

tube, and will become more and more putrid and noxious. The tubes 

likewise afford a means for irrigating suppur.itiug cavities with cleansing 

lod antiseptic lotiona The use of frequent irrigations with an antiseptic 

Dtion, combined witli tubular drainage and free exposure to the air, has 

sen eystematized by Prof. T. M. Markoe, of the Sew York Hospital, in a 

lethod termed by him " through drainage," ' In this method the wound 

t caused to be traversed by one or more perforated rubber tubes, (he 

mber depending upon the extent and complexity of the wouud. When 

e laeemtioa of tlie deeper jiai-ta bring tlio woumln near to tiio iiit^>giuuent 

Kin the opposite side of the limb, or at a distance from the origiiiiU aper- 

re, counter-openings are made and the tube pasned through so as to 

Lunerge at the new opening. Otherwise the tube is simply passed down 

' io the bottom of the wound and tlie distal end brought out again at a little 

distance bora the point of entrance. A wounded limb, thus traversed, is 

suspended from a fi-amework, so tliat it is raised from the bed, and the 

free discharge of the drainage from the lower opening is secured. Four 

times a day a solution of one-fortieth carbolic acid is thrown through the 

^^ drainage tube l^ith an ordiniuy syringe, and continued until the fluid dis- 

^Lpharged at the lower opening is psrfectly clear. The penetration of this 

^■dBoid to all the recesses of the wouud is desirable, and for this purpose, if 

neceGB,<uy, the lower orifice of the tube is to be pinched sometimes while 



' " Through Drainage" io 
the Medical Scienees, Apiit, 



ibe TreatmenC of Open Waonda, Aimrioan Journal of 
880, vol. Ixiii., p. 305. 



J 



154 THE TREATMENT OF WOUNDS. 

the injection is being made. Professor Markoe adds that every case thus 
treated, of a large number of severe injuries suitable for the treatment; 
chiefly compound fractures, went through its successive stages without in- 
flanmiation at any time sufficient to defeat repair, and that in every case 
the result was equal to the best attained in the most favorable instanoes of 
the given traumatism. 

ACCESSORY MEANS OP WOUND-CLEANLINESa 

Second only to the means used for cleansing the wound-surfaces them- 
selves, are to be regarded those for cleansing the tissues adjacent to the 
wound, and for purifying all substances, such as the hands of the sui^^eoD, 
instruments, retaining and protective dressings, and the air itself, which 
are brought in contact with the wound. These require consideration in 
this connection. 

Adjacent Skin. — All that portion of the surrounding integument which 
is to be included with the wound under the protective dressings must be 
thoroughly disinfected. In the case of operative wounds, inflicted by the 
surgeon, this disinfection should be done before making the wound ; in 
the case of accidental wounds, it should be done before applying the 
dressings. The skin should be shaven, and then thoroughly scrubbed with 
a flesh-brush and with soap and water, or even with ether, to remove fatty 
matters, and finally well washed with a penetrating antiseptic solution (car- 
bolic acid, 1 to 20, or preferably corrosive sublimate, 1 to 1,000), the anti- 
septic solution being allowed to act for some time. Whenever the dress- 
ings are removed, the purification of the surrounding skin is to be repeated ; 
and in the treatment of woimds in specially septic regions, as the axilla and 
perineo-scrotal regions, the dressings should be renewed with more fre- 
quency than in other regions, for the purpose of preventing auto-infec- 
tion. 

The Surgeon and ms Assistants. — The hands of all persons employed 
about a wound should be thoroughly purified. What has already been 
said about the purification of the patient's skin applies equally to the bTHti 
of the hands of those caring for him. Especial care is to be directed to 
the folds of skin about the nails. The nails must be well pared, and 
thorough scrubbing with a nail-brush employed, first using soap and vrater, 
and afterwards an antiseptic lotion — carbolic acid 1 to 40, or corrosive sub- 
limate 1 to 1,000. As the dust and dandruff which may be shaken from the 



CLEANSING OF WOUND-APPLIANCES. 155 



^^P bail of the bead or of flie beard of a surgeon as he bends over a voimd 
■• may be eeptae, it will not seem too great a refinement of ideanliness if their 
/ i>un£i^tion also bo attended to in cases wLere absolute asepsia is of ea- 

fpc-cial importance. The uae of a snugly fitting cap to cuufino the liair 
ooAuneDils itaelf as a cleanly procedure quite ea meet for the mirgeon who 
tQaUes or dresses a wound, as for the tiook who adopts such a device to 
fir-erent mingling the impurities shed from hia hair from falling into the 
^'l^^tuala that he prepares. Close chpping of the beard, or better, its entire 
*~'&juo™l, may not be a point too insignifii-ant to be regm-ded. The eondi- 
*iwn of his mouth and uasal passages in to l>e regarded by a surgeon who 
''^'"oulil protect tlie wounds he cares for from contamination by his breath. 
^SlTie clothing worn should also be scrutinized Clean white "dusters," or 
^ther easily cleansed " over-all " covering, upon which no stains could pass 
'Onitotlced, should be worn. 

The towels and napkins used for wiping the hands should themselves 
1)6 dean and still damp with an antiseptic hquid, out of which they have 
just been wrung. Care is to be exercised that the hands, after haring 
"been in contact with any non-purified substance, be not uued about the 
wound until they have again been purified by dipping them in an antisep- 
tic solution. 

IsBTRCUENTB USD AppLUNCEs. — Eveu though scrupulous cleauhuess, as 
commonly imderstood, be observed with instruments and other apx>liance8 
used about a wound, they may still bear septic dust, and introduce infec- 
tion into a woimd. Surgical cleanliness denuunls, however, that every in- 
strument be absolutely fi'ee from living organisms or their germs when it 
is used. For this piu^se instruments should be immersed in an antiseptic 
solution of sufficient strength (carbolic acid 1 to 20 the l;est ; corrosive 
sublimate solutions coi-rode steel inytrument^, and hence are not avail- 
able) for some time before being used. They ai-e not to bo mei-ely dipped 
in ; tbej must remain in the lotion for some time ; the whole instrument 

»muBi be inmiersed, and so arranged as to peiinit the fluid to come in cou- 
toct with all its parttt. An instnimeat, tlius purified, if laid down on an 
tuipuri£ed surface should be regarded as contaminated, and should not be 
used again until it has been repurified by being dip]>ed in the antiseptic 
lotioo. The dnuns, the ligatures, and the sutures must each have been 
previously immersed in antiseptiti Hquids sufficiently long to have been 
JUsde completely aseptic, and must be retained in an antiseptic lotion 
Mtfl the moment ot nae. Details of the treatment needed to make aeep- 



THE TREATMENT OF WOUNDS. 

tic the different subatances used for these purposes Eire considered in 
other conoeclioDB. 

Compresses and Pbotective Applunceb. — The external dressings whidi 
are applied for the pui-pose of maintaining apposition in a fvound, of ex- 
erdsing compression upon it, and of iiffording protection to it, must sat- 
isfy certain iionditiona of cleaulineaa, if they are not to become agents ol 
harm rather than good to the wounds to which they may be applied. 
While they must be soft and mechanically unirritating, and must be capa- 
ble of absorbing whatever secretions emerge from the wound, and thus 
contribute to the efficacy of drainage, they miist also themselTes be fre« 
from nosious ot^amsme ; and, finally, if they are to answer the most im- 
portant reqiiirement of protection, they must be able in turn to disinfect 
the secretions received by them and the air which filters through them. 
Many substances have been uued which more or less perfectly satisfy tfaess 
conditiona Cotton wool and loosely woven cotton cloth (book-muslin, 
tarlatan, cheese-cloth, gauze), lint, jut«, turf-mould, charcoal, sand, and 
sawdust are the chief agents which are in use for wound-dreaaings at the 
present time. But to fit them to completely answer the requirements of 
wound-cleauliness by acting as efficient protectives against the access of 
noxious orgimiflms, it is necessary that they should ea«h be charged with 
some special antiseptic substance. This will be considered at length in 
Chapter X, 

PuiuncATiOM OF THE Ant. — Means of isolation and ventilation ; the 
choice of a room upon an upper Hoor ; the observation of cleanliness in all 
the surrouuiliugs of the wounded person ; these are the only agendea to 
be rehed upon to purify the air which mxtst come in contact with wound- 
surfaces while they are espoaed. The dressings which are applied to » 
wound should be of a character to purify the air which filters through 
them as long as they are applied. Should, however, in any case, it be 
deemed important to endeavor to secure the possible ailditional purifica- 
tion of the air which washing it by a cloud of spray might produce, s 
steam spray-producer would bo needed to fuminh the necesaaiy volume of 
spray. The ordinary spray instrument of Mr. Lister (Fig. 45) answers aa 
a model for such instruments. In this instrument a current of steam is 
ma<le to rush through a horizontal tube over a minute orifice at the top of 
a more or less vertical one, the lower end of which is dipped in water, or 
a watery solution of the antiseptic, if one be used In this way a vacumu 
is produced in the vertical tube, and the fluid at its lower end rises, and 



AIR PUniFlCATIOS'. 1ST 

rii eipelled from the upper orifice in the form of spray. Tlje fluid used by 
Hr. lister for his spray is a solution of carbolic acid, 1 to 20. After hav- 
ing beeu mixed vrith the steam, it is still further reduced in strength, the 

_j^iniy being estimated to contain the acid in tlie proportion of between 1 
Q BBd 1 to 3S. 




St«aju spray-producers of ■. : 1 1 ■ . : ].■';- Miiich differ from that of Mr. 
Xoster only in minor details, are luude by many instrument manufacturers 
in this country. 

To obtain the full benefit of a spray in purifying the air of a room, the 
Aume of the spray should be large enough to diffiifle it over the whole 
of the room. The une of several instrumenta placed in difierent 
parts of the room would be better than the use of but one, however large. 
The spray should be projected near the ceiling, Uiat it might fall through 
jthe entire maas of air in the room, and should be continued for on hour 
lore the exposure of the wound. 

As the effect of the spray is to mechanically precipitate upon the sur- 
upon which it falls the floating dust of the air, it should not be per- 
mitted to fall directly upon a wound-surface. While the wound is ex- 
poued its use should be suspended, except at a distance to wash currents 
air as they enter the i-<^)om. 






the e 
aces 



CLEANSING SEPTIC WOUNDS. 
If a wound has been exposed for some time and has already become 
lelliug, suppurating, and inflamed, energetic and thorough measures 
r the complete disinfection of the wound are necessary. Although such a 
ind cannot always tie made aseptic, the effort to produce such a condi- 
should be made. In such wounds it is to be remembered that it is not 



THE TREATMENT OP WOUNDS, 



only the diachargeB and the superficial gurfacea in which the septic germs 
eust and must be deatrojed, but that these organisms have intiltrat«d to % 
varjing extent the subjacent tissuea. As a prelimiuaiy to any deansmp 



applications it is important that all wound-caTities and recesses be freely 
laid open, as far as possible. The mere coaveraion of a penetrating or 
sinuous wound-track into a fi'ee superficial wound, is sufBcient of itself to 
rapidly modify the intensity of its septicity and to encourage more healthy 
gmnulation in its cavity. Free exposure of the wound-recesBea hsTing 
been done, all blood-clot and diaorganized tissue ehoulil be removed, with 
any wound-secretions that may have been retained. Should an unhealthy 
granulating surface be esposed, ns ia the case in many chronically suppu- 
rating wounds, the sdft granulation-mat«rial should be acraped away just as 
has long been the practice in dealing with carious bones, and as is most 



O 



O 

O 



^__^^lHf nd p^ectiy done by dentists in the treatment of carious 
Mg^ I^ *i" purpose spoon-ehaped curettes, as tiiose of Yolkmanu, 
^^Mt ^gtvMkSBnuU) Fig. IT, are efficient Tliey scrape away all the 



OLEANBnrO 8TOT10 WOUNDS. 159 

soft inflammatorj- luaterift!, but ore not Eiharp enougli to materially attack 
the healthy soft ports beiieitth. The finger-nail of the aurgeon iu many 
owes Bill answer perfectly the needs of a curette. In addition, when tia- 
es are evidently infiltrated with septic matter, they should be cut awny 
I OTBcarified deeply to admit of the more perfect penetration of antiseptic 
I ^plicationa. 

In all irregular wounds, and in those opening into cavities, iu which it 
k not practicable to freely lay the entire track of the wound open, (.■ounter- 
Wnings should be made ut suitable points to insure free through irrigo- 
iion of aU the recesses of the wound or cavity. 

After this preliminary preparation tbe wound must be irrigated -with a 

**»3ng, germicidal lotion. Every recess of the wound must be reached by 

te ditdnfecting fluid. The lotion must be used in sufficient quantity to 

'**oronglily soak the tissues. Success in rendering the wound aseptic will 

•iepend on the thoroughness with which this final disinfection is done. In 

*>i open wound, under otherwise favorable circumstances, this is usually 

**ot very difficult to accomphsh ; but when septic changes have Iwen going 

*-**> for some time in irregular cavities, or in cases of septic phlegmon ex- 

*«nding into the intermuscular spaces, in suppuration of the articulations, 

^i* in severe compound fractures, it is idways diflficult (MacCormac). 

, Chloride of zinc is to be preferred aa the germicide to disinfect septic 

bounds, because its caustic effect cfluses the disinfection produced by it to 

extend more deeply into the siibjacent tissues, and because the protective 

film, which its combination with the albuminoids of the tissues produces, 

reaiete for so long a time the effects of any septic matters still remaining in 

other parts of the wound or introduced from without. The eight per cent. 

solution (forty grains to the ounce of water) should be used. It may be 

^■Ipplied by irrigatinn, and, in addition, the wound-cavity should be filled 

^^■itb compresses soaked in the fluid. 

^^ Carbolic acid, by reason of its volatility and its diffusibility, may be 
preferred for injecting irregular cavities and narrow sinuses. The stronger 
solution, five per ceut, is to be used until the wound has 1>een rendered 
^—completely aseptic In the after-cares more dilute solutions, whether of 
^Hw rinc or of the acid, may be used. Throughout the future course of 
^Bicb a wound, greater care and watchfulness against the possible redevel- 
^Kfmaent of septicity will be required than would be deemed necessary in 
^Bbe management of a wound aseptic &om the first 




Pt'tUion — Bandaging — RoIteTS — CotnpresBes — AdbestTe Plaoter — Icthjooolla Flatter — 
Qold-beator'a Skin— 'Collodion — Application of AdbeaiTS BaDdage— Objections to 
Adbeaive Bundagea— .SuCunnf — Needles— Needle-holders— Thrcitd — Silk— Catgnt 
-Silk-worm-ent— Horse-hair— Metal Wicn— -IppKcadon of Vie fhitare—Stitottm 
of Coaptation, of Approximation, of Iteloiallon — Knotting — RemoTiug t^e 
&tA.ia^tit~~GI(i»ifieaUoa of Sutura — Intcimptej — Continuoua — Pin— Qaill — Bead 



The appoeitidn of the sepamted aurfuces of a wound is to be i 
pliehed b,y Position, Bandaging, and Suturing. 



The itdTantage to be derived from position becomes apparent -when 
attention is directed to the effect upon the epontaneous gaping of the 
wound of varj-ing attitudeB of the wounded part. A wound over tlie front 
of the knee gapes widely when the knee is bent, though it may show but 
slight tendency to open when the knee is extended. The edges of a tnuw- 
verse wound upon the anterior surface of the neck fall together when the 
head is inclined forward, while a similar wound on the back of the neck iB 
made to gape by the same movement Wounds dividing muscles trano- 
versely gape most widely when positions are assumed in which such mu»- 
clea are put upon the stretch The general nUe, therefore, which is to be 
observetl as to the position of a wounded part, in attempting to secure 
and maintain apposition of the wound -surfaces, is that the part should be 
placed in that position in which the greatest relaxation of the parts can be 
secured. lu this position they should be fixed and held until firm uniou 
lias been accomplished. 



MEANS or APPROXIMATION. 



BANDAGING- 

BandAg^d to approximate aepurated parte may bo either roller band- 
ages encircliDg the entire member, or bonda-res dreased with adhesive 
material— adhesive pluflter — short strips of which, passing across the 
wound and adhering to the skiu on either aide, 
suffice to keep the partH apposed. 

A simple roller-biunlage nifty be all that is 
required to perfectly approsimate longitudinal 
wounds, and woimds in which there is little ten- 
ifency to gape, or in which that t<mileuL-j' liaa 
been overcome by attention to position. By the 
use of the double-headed roller, as iji Fig. 48, 
or tlie invoginated bandage, as in Fig. 41), the 
tissaes may be made to slide toward each other 
from either side, and perfect ajipositiou be se- 
cured in many cases. In all deep woimds the 
. bandage and of compreasea is 

in maintaining apposition of the deepei' parts of tlie 
wound. The compresses should be plac*d on either side of the wound, 
and upon it. in such position that the encircling bandage sliall through it 
produce especial pressure of the deeper surfaces of the wound against 
each other. In the case of certain wounds, as of the face, neck, and 
tnmk, in which the use of a roller bandage is impracticable, relaxation 





and compression of the wounded parts, so as to insure their continued » 
]>o3ition, is beat accomplished by carri-ing broad strips of adhesive plaster 
iicrosa the wound, so as to grasp the tissues for some distance on either 
11 



THB TKBATMBHT OP "ffOUHUB. 

side after these have been crowded up toward the wound by the hands of 
an assistant, so as to take off all tension in the wound itself. Underneath 
these Btrips and upon the wound compresses may be placed, of sufficient 
bulk to insure continued pressure of the wound-surfaces against each 
oUier. When a bandage is applied at any part of a limb so as to encircle 
it, its apphcation must be preceded by careful bandaging of the distal por- 
tion of the limb, from the fingers or toes to the seat of injury, to prevent 
strangulation. 

Roilera, — The matorial out of which the bandages shall be made should 
be soft, strong, and eomewliat elastic, so as to adapt itself snugly to the 
parts to which it is apphed. Cotton cloth — muslin sheeting — that has 
been repeatedly washed and freed from the stiffness of the new material, 
is usually available, and answers well the purposes of a bandage. Matorial 
that has been worn until it is tender should be rejected. The loosely 
woven cheese-cloth, or gauze, when attainable, is to be preferred, in most 
cases, to ordinary muslin. It is lighter, cooler, more elastic, and permits 
the passage of discharges more freely tlirough it. Cloth of any kind 
should always be torn in the direction of its length in making it into 
bandage strips. 

Compreanes. — Purified cotton-wool is the best materia for use as com* 
presses. It is unirritating, light, elastic, and absorbent Folds of gauze, 
masses of charpie, of oakum, or other similar substances may be likewise 
used with advantage. 

Adhegiix Plastic. — The ordinary adhesive plaster consists of moslin 
which has been smeared with a mixture of htharge, olive oil, resin, and 
soap. Tliis mixture, while fluid by heat, is spread over the surface of the 
muslin, and upon cooling forms a thin coating, that becomes soft and 
adhesive whdn again exposed to beat. When it is to be applied, strips 
of suitable size and length are cut from the mualin roll thus prepared, 
observing the precaution to cut the strips lengthwise of the cloth, not 
traasversely, lest they should stretch unduly after having been apphed. 
The most convenient method of heating these strips for apphcation is by 
pressing their unspread siu^ace against a vessel, as a tin cup, a bottle, a 
tea-kettle, or the like, containing boiling water ; they may also be heated, 
but leas conveniently, by exposing them to an open fire, holding them over 
the chimney of a hghted lamp, before a gas-light, etc A form of adhesive 
piaster which does not require to be heated before it is apphed, was intro- 
duced to notice in 1877, by Dr. Heniy A. 1^"''^". of Boston, Maw., vhioli 



ADHESIVE BAITDAOKB. 



163 



K 



revived mucli favor, and, uader the name of " Rubber Plaater," haa 
been since imitated by many makers. The adhesive coating of this plaster 
ia composed of Para rubber, Burgundy pitch, and balsam of Tolu. It ia 
flexible, water-proof, comparatively unirritating, and does not deteriorate 
with keeping, and it Is to be applied at once without any preparation. 

Ichthyocolln and skin plaflters, and collodion may serve as substituted 
for the ordinnrf adherave plaster in the approsimatioii of small and super- 
ficial wonndi 

Ichthijoro/la Pfa.'iler is made by applying to silk a solution of ieinglass in 
ftlcohoL When it is to be applied, it has simply to be moistened by pass- 
ing a damp sponge over its glazed surface. Its adhesive properties aw 
weak, and it cannot be used where there is moisture, so that its use is re- 
icted ratber to the amateur dressings of the laity, to whom its greater 
of appearance and the ease of its application commend it What 
c^led covri platter is a variety of isinglass piaster. 

Gold-beater' B Skin. — A delicate membranous film, made from the intes- 
"of the sheep or the peritoneum of the bullock, when applied to a 
moistened surface adheres with sufficient firmness to withstand considera- 
ble traction. It is applicable particularly to slight wounds of the eyehds, 
as a protective layer over an excoriated surface. 

CoUodion. — A solution of freshly prepared gun-cotton in ether, assisted 

a litUe alcohol, when applied to n dry surface, by the rapid evaporation 
of the ether, leaves a transparent filtn that adheres strongly and contractu 
considerably. It may thus be used for fastening strips of silk or muslin to 
the edges of a wound, in place of other adhesive material, or may be ap- 
plied directly over the wound as the only dressing, or as supplementary to 
other agents in sealing up the wound. It is moat useful as a final applica- 
tion to wouaids that have healed, upon the withdrawal of other dressings, 
apphed over the cicatrix which it protects, giving it a needed support in 
resisting the inevitable tendency to reopening of the wound, which may bo 
more than the fresh and tender new uniting material can withstand. 

Thi^ Application of the adhesive Bandage. — The skin to which a strip of 
.adhesive plaster ia to be applied should be shaven, well washed with soap 
water, and carefully dried, to present a surfece to which the plaster 

adhere, and to save the patient from the pain that would be caused by 
thdr removal if the hair was adherent to the plaster. One end of the strip 
ia then to be pressed upon the skin upon one side of the wound, and while 
tlie edges of the wound are held together by the surgeon, the strip is car- 



^ 




THE TBBATMBNT OF WOT'KDS. 

rieil aoroBS and fastened upon the other dde. Care is to be exercised thiit 
mvereioD of tlie edges r>f the wouod be not occasioned, and equal care that 
suiEcieiitly firm approsiinatioiL ia secured to prevent their after separation. 
The first etrip should be placed across the middle of Uio around, and au 
ii]t«rvid of tram one-quarter to one-half an iucli left betneeu each succeed- 
ing one, to admit o( the escaiie in the i^ter^■als of wound secretions. As 
soon as strips thus applied lose their hold, become sources of irritation or 
obstruct dmiuFvge, they should be removed. But unless some such indica- 
tion esifits meddling ^th them is objectionable, as it tends to do injury to 
the healing of the wound. Tlie cleansing of the wound is to be limited 
to gently wiping from the surface of the wound and of the dreasings what- 
ever secretions may have gathered there. When the removal of tha 
plasters is necessarj-, gentleness of manipulation miust be obaerved ; the 
two ends of eacb strip shoidd be lifted first, and the central port last de- 
tijched from the line of the wound itself, lest by dragging tlie stripe from 
one side to the olber the wound be reopened. 

Objcetions to adhesive Buiuiages. — The use of adhesive bandages for- the 
purpose of producing direct apposition of wound-surfaces is objectionable 
from its interference with wound cleanliness. The muslin strips may 
themselves be carriers of infection, unless they are disinfected with equal 
care with everything else that is allowed to come in contact with the 
woimcL They may favor infection again by sealing up that portion of 
skin upon which they oi-e lai<l fi-om the action of tlie antiseptic dressings 
that may be appUed over them, and thus fostering the creation underneath 
tbem of foci of sepsis from the development of organisms hidden in the 
depressions and follicles of the skin that will have escaped the primary dis- 
infection of the part, however thoroughly done. Still farther, ext«nding as 
they must some distance in every direction from the wound, as soon as 
they become wetted witli the wound-discharges, they become favorable 
media for the propagation from tlie periphery of the dreseinga inward to 
the wound of niicro-orgaiiisms from without In addition to these objec- 
tions, which are of vital impoiijuice in efforts at prcsening asepticity in 
wounds, they are also chargeable with being imrcliable in the support they 
nny give from their tendency to become loosened, with irritating in 
many cases the akin to whicli they are applied, and, finally, with covering 
lip the wound from the inspection of the surgeon. For these reasons, the 
use of adhesive bandages as direct apphcations to wound flaps to secui'e 
their apposition, should be abandoned in the great majority of cases. For 



buthbinq. 163 

i of Bupplementary support, for nae ontaide of the dreesiiigs «p- 
I immediately to the wound, to prevent l«nEdon, to produce compres- 
I, and to insure fixation of the dressings, they are invaluable. 



of ban 
L Th 
Hhilor'i 



The Bntnre is the most certfun, exact, and important of all methods of 
obtaining apposition of divided surfaces. Position and the various metliodK 
of bandaging are chiefly to be employed as supplementary to the anture. 
The apphcation of the suture is simply the use by the surgeon of the 
tor's art to sew together the separated tissues, and by a thread to retain 
0. apposition until their permanent union by a bond of newly-formed 
hving tissue can lie effected. 

Sutures may be appUed superficially and close to the wound-margina, 

simply for the purpose of teeping the cutaneous edges of the wound in 

apposition, such stitches being technically tailed " stitches of coaptation ; " 

UT more deeply and at a greater distance from tho wound-margins to ap- 

I and maintain in apposition the deeper surfaces, "stitches of 

; " or at a greater distance yet from the wound, for the 

purpose of relaxing the adjacent tissues so that the wound-surfaces may be 

brought together, and tension upon the stitches apphed to keep them in 

^>positionmay beprevent«d, these latter ctsnstitute "stitches of relaxation. " 

^L For the practise of the suture there are required needles, thread, and 

^HBi some cases needle forceps for the more convenient insertion of the 

^*eedleB in the tiasuea The peculiarities of the tissues to be sewed makes 

certain qualities important to be possessed by each of these agents ; theae, 

therefore, require consideration here, 

NEEDi.Ea^ — -The density and elasticity of the tissues to be penetrated by 
the surgical needle makcH it necessary that it should differ from the ordi- 
nary sewing needle by having its point flattened, and the edges imme- 
iliately following the point sharp, giving the forepart of the needle the 
shape of a lance (Fig. 50. A). The point should be fine, and the cutting 
edges should extend biit a short distance back from the point, and should 
exceed in its transverse diameter that of the shank or thread extremity of 
the needle. The eye should be as large as possible, to avoid delays in 
threading, and its e<lgc8 should be well rounded, so as not to cut the 
threail Their thickness and length vary greatly, according to the size of 
the thread to be used and the thickness of the tissues to be penetrated. 



166 THE TRBATMBKT OF WOUNDS. 

The shape of the needle must varj with the locality iu which the suture is 
to be applied. Upon a plain or convex surface, when the stitch is to l>e 
introduced but Buperflcittlly, a straight or but shghtly curved needle (Fig. 
50, A and B) is most couveuieut ; where the tissues ore to be deeply pene- 



\ 



trat«d, or the wound involves a coucave surface, as at the inner canthus 
of the eye, or the perineum, strongly curved needles {Fig. 50, C and D) 
become necessary. 

The steel of which they are made should not be too hard, lest they 
break easily. The chief points to be regarded in the choice of needles are 
that they have good points, keen sides, and sufficient temper to prevent 
their yielding to the force necessary to their introduction. 

Needle-holders. — Wben a suture is to be made with a small and mush 
curved needle, or in a cavity, the needle cannot be managed by the fin- 
gers, but must be seized and held firmly in a needle-holder. Any forc^w 
with short stout jaws, and long handles that can be graBi>ed and held 
firmly in the hand, will answer for a needle-holder. The foi-cipressure for- 




ceps of Wells (Fig. 11) are a good model The catch, by means of which 
the branches are fastened when they are closed, adds greatly to their con- 
venience in use. 

Fig. 51 represents the needle-holder of Biefienbach. Fig. 63 that o 
Sands. 



TTEEDLE-aOLDERS, 



167 



Of tte m&ny modele which have been constructed, the writer prefers 
■n aa the "Kus&imi Needle-holder" (Fig. 53), devised by Dr. 
tol de Gaiue, of St. Petersburg. The fimmeae with which it holds the 
le, the ease with which by a eiinple Piechiiniam it can be locked and 




'holdH ol RaadiL 



imloclced, and the shape of its handles, whereby both delicacy and power 
oipulation is secured, constitute its merits. 

The inner surface of the jaws Bhould be cut into stellate grooves, or 
l^jlhould be hned by pewter, into which the needle when grasped may 

[ and be held securely. Many varieties of needle-holders have been 
levlsed to facilitate the introduction of mitures in deep cavities and special 

alities. The requirements for a ueedle-holder are that it shall immov- 
ably grasp the needle, that it shall be of a shape to be- itself securely 
grasped by the hand of tlie surgeon, and that its mechanium shall aecure 
the rapid piclfing up and quick letting go of the needle. 




The Thread. — The suture reqiiires that the thread-material shall be 
\ae and smooth, sufficiently strong to stand a certain amount of strain, 
soft and pliable, so that it adapts itself well to the eye of the needle, easily 
pulled through the tissues after the needle, readily tied into a knot, and 
I^Bosceptible of being removed witli equal readiness The agents that are 
thy of special mention as being in most general use, and as answering 
) purposes of the suture most satisfactorily, are threads of silk, of cat- 
fot. of ailk-worm-gut, of horse-hair, and of metal 

Siii^. — As fine a thread should be chosen as mil bear the strain of the 
(sture, for the observations of Simon ' and Billroth' have shown that the 



' BtpirimenU vber tenehiertene ajibaiaram turWundnalit. Boatook, 1 
■ BniKloal Pattanlogy. Hacklsr. New Toik, 1871. 



1(J8 THE TRBATMENT OP WOUNDS. 

liner the tliread the less irritation ite pressure in the tissues would occa- 
sion, so that very fine ones might cause no irritation whatever, but become 
healed in like metal onea The duest size of what is called, in the instru- 
ment shops, braided ligature silk — size No. 1 — though it is as fine hs h 
hair, is veiy strong — strong enough to bear any tensiou that ought to be 
put on a suture, and does not kink or curl Silk should be mode oseptir 
before using by immersing it in a solution of carbolic acid or of coinwive 
sublimate, aa described ou page 112. 

Catgut. — Properly prepoi-ed and seasoned catgut answers eveiy pur- 
pose of a suture material Only that which has been prepared after the 
methods described for catgut ligatures, jHige 110, should be used for sut- 
ures. In general, after a few days the absorption of the loop embedded 
in the tissues sets free the knot, which is then washed away or picket! 
off without other mauipulatioii for its removal The gut seasoned with 
chromic acid — chromic gut — resists the solvent action of the tissues for 
from ten to twenty days. Being unirritatiug, it may be left undisturbed 
as long as the wound-cicatiix may need support. The catgut, however, is 
not quit« so manageable as the aseptic sjlk ; it ia a little more troublesome 
to tie the kuot^ securely ; it is more difficult to secure with it an exact and 
fine coaptation of the edges of tlie wound ; the material is more expensive 
and the prepaj-ation is more troublesome ; tlic spontaneous melting away 
of the loop in tbe tissues may take place prematurely ; for these reasons it 
has not supplanted the silk thread for general use. 

SiUc-icorm-yul. — This is made from the organ of iha silk-worm wliich 
furnishes the material out of which the cocoon is woven. The threads 
obtained are polished, tranajmreut, and very smooth, and are especially 
distinguished by their great strength in comparison witb their thickness ; 
they are stronger than metal threads, and will remain unchanged in the 
tissues for a month. They produce no irritation, but they have the dis- 
advantage of being somewhat stif^ so tliat some difficulty attends ^dng 
them in a sufficiently strong knot. To render them more pliable they 
should be soaked some time in water {carbolized or sublimated) before 
being used. Sutures of this matexial are most in favor among those sur- 
geons who use catgut but httle. They have been especially praised for 
cases of niptured perineum and vaginal fistula, and fissured palate. The 
improvemenfa made in silk by rendering it aseptic, and in catgut by 
chromicizing it, have lessened the frequency vrith which the silk- worm -got 
is likely to be resorted to. 



^m SITTUKE UATERIALS. IG9 

Hwse-hair. — The pliancy, delicacy, snioothneBs, and non-irritatinp 
cjuolitics of horse-hair make it a deairahle substance for sutures, anil it 
deserves moi'e attention than it has usually received. It is strnag enou^'h 
to keep tlie lips of an ordinary wound in apposition ; a double atrand umj' 
be used if Deceaaaiy. It remains unchanged indefinitely in the tiasuea, 
and may be permitted to remain as long as the support of a suture is re- 
(juired. It t;an be applied with the usual surgical needle, but needs more 
care in making a satisfactory knot than does silk. If there is any t«nBion 
upon it, the lii-st knot needs to be held by a forceps to prevent dipinng 
while the second is being tietb It is easily removed by snipping with a 
pair of scissors, and withdrawal by an onlinary pair of forceps, with abso- 
lutely no discomfort to the patient, being in this respect in marked con- 
trast 'with metallic sutures. Hail's from tlie horse's toil, selected for their 
size and strength, are to be preferred. They should be prepared for use 
by washing in an alkaline solution, aud should be immersed in an anti- 
septic solution before heing introduced. Its abundance and the readiness 
with which it can be obtained, costing nothing but the slight trouble of 
deansing it, together with the advantages possessed by It, as enumerated, 
^«« a suture, would make the use of horse-hair general for all ordinary 
^■toDtmds, were it not that the silk thread is more convenient to tie and to 
^BBoRy by reason of its greater pliabiUty. In default, however, of proper 
^%Qk, it is a most valuable Hubstitute, 

Metal.^-Ywe metallic wires, of lead, of copper covered with gutta- 
percha, of iron, or of silver, and even of other metals, may be used for the 
purposes of a suttu^e ; by their smoothness, pUabUity, and freedom f ram 
irritating properties, they combine in an eminent degree the qualifications 
demanded for such use. They may be introduced with an ordinary sui^ 
gical needle like thread, although a needle whose head, from the eye to 
the extremity, is grooved for the reception of the wire, facilitates their 
introduction ; they are easily fastened by twisting the ends together. 
They are particularly of value for wounds in which great accuracy of co- 
aptation is desired, on account of the facihty with which they can be 
readjusted by simply untwisting the ends, and with which, also, the ten- 
sion they shall exert may lie regulated by the degree to wliich the twisting 
is carried They also tend to support and immobilize the tissues through 
which they pass, and contribute in this way in no mean degree to pro- 
moting early union. The ease with wliich they are fastened adapts them 
KciaUy for use in deep cavities. There is no necessity for their early 




THE TEEATMEHT OF WOtTHDS. 

removal, imd tbey may be left undisturbed till the parts are firmly united. 
Silver wire ie the kind of luetal thread moat fi'equeiitly employed. 'Wire 
made of it nB fine as a hair posaeaaee eufficient strength, and is very ligh^ 
Boft, and pliable. The tirst use of it for suturefi was made by J. MarioD 
Sima,' in the treatment of vesico-vagiiiai fistulffi, in 1849, and liis enthusi- 
astic advocacy of its merits in succeeding publications attracted general 
attention to its use iu genei-al siu-gerj-, lu his " Anuivc-rsary Discourse 
before the New York Academy of Medicine," in 1857, he declares it to be 
hia " honest and heartfelt conWctiou, that the use of silver as a suture iB 
the great surgical achievement of the nineteenth century I " The experi- 
ments of Simon, already alluded to, however, demonstrated that there 
was no diETerence in the amount of irritation produced in the tracks of a 
ver,- fine well-twisteil ailk thread and a fine metal thread during the first 
eight days of their residence iu the tissues. Since both the introductioQ 
and the removal of the wire demands more care than silk on account of 
its inferior softness and pliability, tbey are not so well adapted as the fine 
silk to unite wounds the edges of which are thin. Even in uniting the 
edges of the wound produced in the operation for the relief of vesico- 
vaginal fistula, iu which Sims first used silver wire with so much advantage, 
surgeons of the present day obtain equally good results with silk and cab- 
gut Silk has still maintoiued its plaice, therefore, as the agent most gen- 
erally employed ; but for deep sutui-es, especially those which are applied 
for the purpose of relaxing the wound-borders, and for suturing bones, 
Hud whenever strong tension is to be borne by tlie suture, and when the 
suture must remain in situ, for a long time, an unqualified preference must 
be given to the silver wire. 

Application of the Sutitre. — It is impoi-tant aa the first prelimmoiy, 
when a suture is to be apphed, that the surgeon shall assure lm'i«e lf of thfl 
cleanliness of the suture materials, in the aseptic seuse of the term clean. 
The needles should be immersed in a five per cent, solution of carbolic acid, 
and whatever form of thread is deemed best should have been rendered 
aseptic by previous preparation, tuid should likewise be anew immersed in 
the antiseptic solution at the time that it is to be used. 

Before the introduetion of a suture the wound-borders should be car^ 
fully coapted throughout their whole length, in order that they may come 
evenly togetlier — not having a wrinkle in oue place, aud a projecting eod 

< The Treatment of Teaioo-vagjaal FULula. Ameiioau Journal of the Medioal Sci- 
euoeg, January, I&52. 



i 



APPUCATIOir OP THE SUTURK 



171 



[ 
I 



another. To secure tliia the proper points for entrance flnd exit of the 
iseedle through the skin should he uoted, and when the wound is a long 
<4Be, it will be beet to introduce the first stitch in the centre. If the new 
atitvbes on either aide are likewise placed half-way between the fii-»t one 
^Mad the angles of the wound, the long wound is therehy changed into 
Jour small ones, the peiiect adjustment of whose edge& is much facili- 
tated. 

If sereral sutures are to he applied, it is better to liate the necesaary 
number of needles already threaded and conveniently placed witliin reach. 
.Jlot only is the delay neoes- 
BBTj to newly thread a needle 
the course of the operation 
inconvenient, but it is more 
likely to be attended with 
Borae infraction of the laws of 
cleanliiieB& 

The needle should be 
seized by the right hand e 
that the middle finger nlmll | 
be on the one side and the ^ 
thumb on the other, and the 

index finger by the side of the middle finger where the needle is curved, 
irith both ends of the thread hanging thrown over the backs of the fingers. 
(See Fig. 54.) The border of the wound should then be steadied hy seizing 
it with a forceps or tenaculum, while the needle is made to transfix the tie- 
When the wound flap is sufficiently extensive and free, it may be 
'flxed by grasping it with the thumb and finger of the left hand Upon a 
eouvex Borfoce, or even a Hot surface, when the stitch is to be very super- 
fioial. it is possible to depress the eye end of the needle, and to elevate the 
wound-borders sufficiently to enable the transfixion to be made with a 
[ht needle, but on a concave portion of the surface of the body, as be- 
< and cheek, the palm of the hand, perineimi, etc, a curved 
Deedle is required Since also a curved needle is equally of use on any 
eor&ice, it is the instrument ordinarily and generally used for any suture. 
The needle should pass through the tissues in a line about equal to ibi 
avni curvature ; when but a small amount of tissue is to be included iu 
the suture, tlie needle entering and escaping near the line of intended 
tmioo, ft short and strongly curved needle is needed ; if the suture is to be 




(HKUr). 



wounc 

^ffbaigl 
^Kiweeu 
^" needle 



172 



THH TBEATMENT OF WODNDS. 



introduced at a greater distance from the wound-edge, a longer and lew 

strongly curved needle ia required. 

The dietauce from the edge at which the needle shall be introdaced, 
and the depth to which it shall be carried will depend upon the particular 
function the suture is intended U> discharge. For a stitch of coapta- 
tion, the needlo will be introduced from two to three-sisteenthB of an inch 
from the edgf, and will be tliruut tlirough the skin into the subcutaneous 
connective tissue only. Stitches of approximation will be introduced at a 
greater distance, and will pass more deeply among the tissues. The two 
may be used idtemately. Fig. 65 illustrates the arrangement and reli^ 





tions of these two kinds of stitclieB. When deep sutures are inserted a 
tendency to incurvation of the wound-edges is produced, to overoome 
which requires care to alternately elevate either edge with a tenaculum or 
forceps as the suture is tied. 

When the point of the needle has emerged from the opposite flap ol 
the wound, it is to be eeize<i with the fingers, or forceps, and drawn 
through, canying a sufficient lengtb of thread after it to admit of being 
conveniently tied into a knot The ends are then brought together so m 
to bring the wound -surfaces into apposition and tied into a secure knot 
The various steps of this knotting of the suture are depicted in Pig. 58. 
The suture must not be drawn so tightly as to strangulate the tiasuea em- 
braced in ilfl loop. A suture dravn too tightly will speedily provoke in- 



APPtlOATIOW OF THE SDTURB. 



173 



DimatioD and suppurntioD. Nor must the suture be aukjected to much 
kstic teusion of the tissues, otherwise the tisaues will cut theoaselTes 
the unyielding thretid until the suture becomes loose. When the 
) ore lax the ordinary reef-knot, Fig. 57, should be made as the 
Mt secnre form of a knot. 
£ there exists much tendency to gupinfr in forming the first knot, the 
Qirend may be passed twice through the some noose. Fig. 58, so that the 
adhesion of the threads is increased sufficiently to resist the tendency to 
retraction of the edges until the second simple knot can be tied. This is 
what is termed the " surgical knot" If the two lips oan be held in appo- 
sition by an assiBtaut while the knot is tied, the surgical knot will be 



. mperfli 





Fia. 68.— SniBlc»L Knot 

Tlie knot must not be tieil bo ns to come in the wound-line, but must 
be tied on one side so as to press upon the sound integument, for when 
the knots are permitted to press directly upon the line of the wound they 
_. are liable to produce irritation. 

V The distance between the points of suture must vary according to cir- 
BvnniHtances, depending upon the t«udeo(?y to gape of the tissues, and the 
importance far securing imion by first intention of the most accurate appo- 
sitioii possible. In no cose shoulil there be allowed any gaping in the 
intervals between the stitches. The intervals may vary from one-eighth to 
one-half or three-quarters of an inch. No fixed rule can be laid down, 
either, as to the succession in which the stitches shall be applied, beyond the 
general principle that the stitches of relaxation are to be tirat applied, then 
tlie stitches of approximation, and finally the stitches of coaptation. It is 
Kiaily apparent when the wound-edges are brought together at what point 
the fir^t stitch should be placed. In angular wounds the point of the angle 
should first be secured, and subsequently the stitches should be placed 
elaewhere, so that the borders throughout shall come smoothly together. 



J 



174 THB THKATMENT OF WOUNDS. 

The Btitches may be removed, as a rule, in about three days ; but unless 
their longer residence in the tissuea ia attended with evident disad vantage, 
as shown by a tendency to produce irritation and ulceration, it ia better to 
leave them undisturbed for forty-eight hours longer. "When tliere has 
been much tension necessary to bring the edges of the wound together, 
too early removal of the stitches is esiJecially to be avoided. A week or 
ten days is time enough. By the use of aseptic sutures the necessi^ for 
speedy removal of the thread is overcome, and the needs of the new unit- 
ing tJHBUO for support can be more exclusively considered. 

To remove the stitches, the knot aliould be seized with a dressing for- 
ceps, elevated slightly from the integument, bo that the point of a scissors 
can be insinuated beneath it to cut the thread beyond it The thread is 
then drawn carefully out, while the tissues are steadied by the scissora 
pressing upon them, and traction is made upon the thread in a direction 
toward the line of cicatrix lest the wound be torn open anew by the pro- 
ceeding. The stitches first fo be removed should be those of the least 
importance. In general, they wiU bo removed in the reverse order of that 
with which they were introduced. After their removal, the parts should 
be supported for a time by strips of adhesive plaster, when the wound is 
in a locality where they can be applied, and the line of the cicatrix and 
the immediately adjacent skin should be covered with a layer of collodion. 

CLASsmcATioN op SuTURia. — According to the different methods used 
fbr the successive application of the stitches, or the different devices used 
for exerting pressure upon the tissues, sutures are divided into interrupted, 
continuous, pin, quill, bead, and button sutures. 

Interbupted Suturr — The interrupted suture is formed of a series of 
separate stitches (Fig. 56). It is more generally used than any other form 
of suture ; indeed, the pin, quill, button, and bead sutui-es are but forms 
of this Butiu*. Stitches of relaxation and of approsimation, in all cases, 
require to be of this form. It is the typical suture, and all that has pre- 
ceded with reference to the technique of the suture is particularly appli- 
cable to the interrupted suture. 

CoNTiNuors SuTPRE. — This suture, on account of its similarity to that 
used by the glover, is frequently spoken of as the " glover's suture," The 
stitches of which it is composed are not separate, hut are made with the 
same needle and thread, in continuous succession, by passing the needla 
diagonally from one side of the wound to the other over the surface, and 
tiuough the tissues, until the whole extent of the wound has been tra- 



J 



THE OONTlNnOCa 8DTURB. 

|*iersed (Fig. 59), Though thia form of suture is especially adapted for 
8 of coaptation, it had iintil receutly been almost eutirely discarded, 
^t in the sewing up of woujida of the iut^stines. In nearly all oases, 
wever, it is superior to the interrupted suture tor coaptation purposes 
W'hy reason of its greater siinphcitT, tlie greater rapidity vdth \fhit-h the 
wary coi^tation can be secured, the more even aud accurate appo 
» of the edges which it accomplishes, and the increased support to 
a whole line of the union that it gives. The resulting cicatrix will be 
Bore finely linear than can be obtained in any other way. In applying 
I continuoiiB suture, a compaiatiTely short, fine, aseptic sUk or catgut 
1 should be used, which, with a straight or ciined needle, accord- 
', as the peculiarities of the locality may require, is introduced at one 




m 



Fia. so.— TbaCoDtli] 



\ 



i wound, where it is tied as for the interrupted suture, uid 
I IB carried with oblique stitches along the coapted wound-mar- 
gins to the other end of the line of separation. Here the thread is fas- 
tened fay leaving the superficial loop connecting the last two stitches so 
loose that by cutting it a free end is left which is tied to one end of the 
bat atitch after this has been tied as an ordinary interrupted suture. For 
its removal, each superficial loop should be cut with the point of a scis- 
BOTB, converting it into aa many points of interrupted suture, each one of 
which should then be carefully withdrawn as before described. 

Pnr SurraE. — This form of suture. Fig. 60, known also as the twisted, 
and hare-lip sntore, consists in transfixii^ the apposed margins of a woond 
with metallic pins, and then, while the wound surfaces are kept approxi- 
nuted by pressure from the fingers of an assistant, the two projecting ends 
of the pin are encircled with a thread, which is then carried sereral times 
BTDund the pin. over the line of the wound eUiptically, and in the shape of 
the figure 8, and lastly is secured hv a knot 

Aa a fdn to be used for the jmrpoaes of this sntore, the ordinal; g\am- 



THB TBBATMBMT OB" WOOKDS. 

headed lodiea toilet pin. Fig fal ib not Hurpasaed by any other device. It 
is very sharp-pomt^d, and readilv penehatea the tiseuea ; it is unirritating ; 
it in quickly procurable and is cheap The German inaect-pin, Fig. 60, 
which is made of brass nith a ball head and a flattened, lance-ehaped 
]K>iiit, hkewise makes an excellent af:,eiit Transfixion is effected in the 
same manner as m the (.omnion mtermpted suture, the thumb and finger 
l>eiiig generally qml« sufiicient for the purpose. Tlie pins should be 
thrust as deeply into the tissues as is compatible with bringing them out 
again at a corresponding point upon the surface of the opposite flap. AH 
the pins that are to be inserted should be put in place before the thread is 




Fio 00 — Ths Pin Sntan. Pro. 01.— nn tor TirliUd aotnni. 

applied, otherwise the insertion of tlie becond pin will pull unduly upon 
the first suture. The distance from the woimd edges of the points of en- 
trance and exit of the pins will be from one quarter to lialf an inch. The 
distance between the pins will depend upon the degree to wliich the wound 
borders tend to gape and the amount of motion to which it will be ex< 
posed. Each pin should be aenamtth wound about with the thread, 
which should then be cut and tie I In place of thread, narrow rings of 
rubber may be used to dip over the ends of the pins, and to compreaa the 
wound-borders. The points of the pins should then be cut off with a pair 
of pliers to prevent their sticking into the skin. If there is a tendency 
erident for the ends of the pins to press unduly into the skin, this may be 
protected by a strip of adhesive plaster inserted beneath the extremitiei 



T[IE PIN SUTDBK. 177 

of the pias. The practice of taking; a mucli longer tliread aud carrying it 
from one pin to anottier, making a ci-ohh likewise over the wound between 
the pins with the thread, as it potwes froui pin to pin, has the advantage of 
aiding their coaptation by the gentle premure which it makes upon them, 
but this con be better accompUidied by superficial eutures phteetl between 
the pins, a» in Fig. GO, which may remain to support the titwueH stJU longer 
after the pins have been i\-ithdi-awn. The earlier removal of the pina with- 
out disadvantage is thu8 made possible ; this should be done in from two 
to three days, even earber if the pins show a t^udeiicy to cut their way 
out When they are to be removed the woimd e<lges sliould be gently 
pressed together by the left thumb aud forefinger, applied iip<m the ends 
of the twisted loops, the head of the pin nhould be griwped by an ordinary 
dreeaing-foreepH, hy gentle rotation theii* adhesion in the line of their pen- 
etration loosened, and then withdi-awn. Tlie thread loops, which are glued 
to the skin by drietl blooti, miiy l>e left in place fur a day or two longer, 
an a bond of union, until they become spontaneously detached. All the 
pins may l>e removed at the Haraa time, or ut different times. In the latter 
case, those will first be i-emoved thitt are least usefuL 

The pin suture is eHj)eeiHUy applicable ui cases where there lias Ijeen 
considerable loss of integument, and where considerable strain upon tlio 
tissues is necessary to bring them together. When the parts are verj- 
movable, an in the lips and cheeks, and also when the wound involves skin 
llwt is so thin and las timt the wound edges iiuuiifest a strong tendency to 
roll ill. A much more frequent use of the pin suture might be made with 
advantage than is now usuid. Though primarily it is important as a means 
of approximation when tlie di\ided surfaces aie first bn>ught into apposi- 
tion, its secondaiy effect, to keep immovable and to Bupjxirt the united 
wound is no less important, and mity make its use desirable when the first 
indicatiou does not call for it Tlie results, in general, of attempts to ob- 
tain union by fin^t intention in wounds of any extent will be much more 
uniformly successful by the use of the pin suture, im a matter of routine 
practice, than by relying simply on the ordinary suture and bandaging. 

The Qnu. Sutusk. — This suture consists in the application, on either 
side of the wound, at a httle distance from its edges, and parallel with 
them, of httle rods of some smooth and unirritating substance, as a quill, 
bougie, whalebone, or soft wood, around which tlireads passed deeply 
across the woimd were looped, so tlrnt when they were drawn upon and 
tied, the pressure of the rods would bring and hold together the deep 
12 



h 



JlH. 



178 



THE TKEATMENT OF WOUSDS. 



porta of the wound, and would relax tlie miperficiat parte, which wei-e also 
eecui'ed hy superficial Htitchen of the iiiteiTupted or contiDuouH sutUTf, 
The an-augemenf is shown iu Fi^'. (>2 mid Fly. 63. 

In making tliis Kuture, wvei-al iieedteH nhuuld be tlu'eaded by pa»mig 
both ends of the tlu-ead thiimgh tlie eye of the needle, ho as to form a 
I(K>p on tlio middle of the thrf ml. The double thread is then U> Ite passed, 
as deeply as may l>e ueceHsaiT, through the wound-borders es for an ordi- 
nary inteiTupted Hutui*. A sufBcient number of tbreadH having been 
introduced, instead of ci'ossiug them and tying, a rod in idipped through 
the loops on the one aide of the wound, which are then tightened fi-om the 
other side by drawing on the free ends. A miiiUar rod ia then phured be- 
tween the free eudu of the Ihreanls. and upon tliis they ai-e firmly tied, 




KiO. SL—QdUI Baton. 



beginning rdth thf central tlii-eads, which aiv drawn dount upon the rod 
until by it« prewsiu^ tlie wound Hurfaoes ai-e bixjught mto (-lone np]K>sitioii. 
\ secure knot is then tied, mid the application of the iipparatuB is com- 
plete. This foiTu of sutiu-e wa« used by the older Hurgeous for dosing , 
deep muscular wuundH, as those of the thigh and abdomen ; and by later ' 
surgeons more partieularly for the repair of lacerations of the perineuiB. 
It is efficient both as a suture of approximation and relaxation, but foi' 
ihese puiijoses hiw been mostly supenteded by the beiul and the button i 
suture in some foniL In wounds in situations where the additional nup- 
port of compresses and bandages are impracticable, it wQl, however, always 
i-emain as a device of great value for uecuring primary nccumte deep appo- 
sition and consecutive immobilization and support duiing .the healing of 
the wound. For its removal, aft^r Uiree to five days, the looijs are cut 
with scissors on the one side, and the tlireads drawn out on the other. i 



THE BKAD 8CTDBB. 



irsi 



' The Beau Si;ti;iul — Thin is an inteiTuptetl sutoro in wliicli two suturea ] 
ajx joined in one so that a 1)ea<l at either lateral extremity of the suture I 
has a wire or thi'Pful ptuwiny through the centre of the lieaiL The twist j 
ill the two ends of the wire eualiles the op*>mtor to tighten or loosen the * 
tension after the sutm-e line in closed. This is a very desirable quality of 1 
a stitch ID a aitnation hke that of the interior of the mouth, the stitch ' 
liaving no covering, and the suture line Iiaving no possible support except 
that -of the stitches themselves. This suture is equally applicable to '. 
wounds in the vagina, where any sup 
port to the stitcJies is inipracticnble. It 
is thus described by Dr. David Princ< 
of J,ii.'k-son\ille. HI.' 

The accompanying cut (Fig. 04) rej 
resents the sutui-e in three stages : (1 1 
The completed sutui-e, the beads Irin^ 
upon the natural surface of tJie skin m 
mucous membrane. The tightonijig oi 
loosening of the twist of the ends of the 
nire increases or cUmiiUslies tlie tetimon 
The dotted line indicates the course of 
the wires or tlireads thi-ough the tissues. 
At the bottom of the figure is seen (2) 
the same stitch incomplete. Tlie open 
conditicm of the wound sbuwH the vsiri 
passing thi-oiigh the cut sui^faces. The 
Hutui'e can be so introduced into mem 
branous, or in thin walled piirt«, that thf 
opposite to that upon which the beads i est if it u 
of the foi-ceps, by which the ends of the v 
cut (3). Tlie double-beaded suture, m ■nhnh (in 




J will he upon the am'faco 

i preferred! Tlie position 

i twisted IS seen in the 

:ut) the beads are 



seen to lie in a slit made paiiillel to the suture bnt m ordei to enable the 
opposite surfaces to come into contact wnth eiwh othei The beads smk 
into these incisions, and, as the wires piws through the tissues between the 
surfaces of a tliin wall, there is no folding of the parts to prevent the cut 
surfaces of the suture lijie from being held in close and accurate contnct. 
The object in using two beads on a side is to increase the work done 



i 



The B«ad Suture. AhqiiIb of Anatoiur and Sur);ei7, Murcb, 1 



13. 1.. 142. 



180 THE TREATMENT OF WOUNDS. 

hy two wires, or a single wire bent uiwii itseli, ami t« increftse the scope 
of applied pressure. Iii plikce of two splierieol beads, a single elliptical 
one may be employed. The polialied glaae bead is friendly to the Hur- 
fnees, and, on aecoimt of its HmoothnesB. it in HUperior U> a sphere of lead. 
No attention is required t« niljust spherical beads, and, as they lie loosely 
ujion the silver wii-e, they are I'eady when the wire is cut, at tlie final re- 
moval of the stitches, to slip off nithout difficulty. Tlie manner of intro- 
duction is very simiile aud ea«y. A pilot thread is first canned thiTtugh in 
the situation in which the wii-e in ti l>e subBequently inti-odiiced. A slmi- 
Inr pilot thread is Uien canied tlirough on the opposite side. Bach pilot 
thi-ead is double, and the loop ends we so relate<I to each other that one 
tlirend mny be included in the loop of the other, by wliich it is di'awn 
through. A silver wirs is then dmwii in by the remaining thread. .1 
beail (or two an the case niay lie) is sh^jped upon tlie wii^e, after which it 
is hooked uiwu the loop uf the ne\t thi'ead aud dniUTi in. The two ends 
of tiie silver wire are then on the same side. A bead (or two as the case 
may be) is then slipped nu to one end of the wire, aft*r which the applica- 
tion of Uie forceps m miwle pre2»ariitoi-y to the final twist. In the removal 
of the suture, the wii-e may be cut at either end aud on either aide of the 
bead. The bead straightens Uie ^ire in shpping off, so that traction upon 
the otlier beiul pulls tlie wire out, Appeiu-m}r then iu the shape of a staple. 

Tliere are many situations in which the employment of the beaded 
sutiu:e will be foiuul convenient and efficient The principle of this stitch 
is not new, only the fonn and material of it. AVheii this stitch is em- 
pli)yed upon the soft i»ilate it answers the pm-pose of a suture and a splint 
at tlie same time, and holds in contluuoiut apposition parts that are in mo- 
tion with every act of swallowing and speaking. The »une advanta^ 
exiete in operations for tlie closui-e of rents in the I'agina, where move- 
ments occur in connection with the evacuation of the rectiun and of the 
bladder. 

The Button Si'ti-hk — For tlie purpose of securing relaxation of the 
more distant tLtsues, so tliat the wound surfaces may be approximated and 
coapted, the most efficient device is some foiiu of metal plate, or button, 
placed on either side of the wound at appropriate distances, aud joined 
by silver wire which is passed deeply Uii-ough the tissues from jilate to 
plate across and at the bottom of the wountb Traction ujk>u the wires 
suffices to draw together the tissues pressed upon by the plates and to 
relax the intervening tisiroes. Whenever a considerable (pip exists, such, 



THE BUTTON SUTURE, 



181 



8 are of great ralue in facilitating Itealing, and Hbould generally be 
mployed. Various fonuB of platee have been used. None ore more sim- 
e and efficient than the form devined by 111". Lister, Fig. US, which cou- 




eiste of a fat plate of lead, about onp-tweiiHpth of an inch in tliickneBH, 
ciit nf an oval form, ivith lateral ningo, which are turned up, and iifford 
projecting edges about which the end of the wire is wound in a figure of 
8 form, while the wii-e for tlie suture jifWHem out thi-ough a hole that has 
lieen perforated f.hrouf;]i the centre of the plate. Fig, CG, froni MncCor- 
s "Antiseptic Sm'gery," illuHtrates tbe method of the application of this 




f 



A plate or button. On the one side the wii-e in neen to be secured by 
^winding it about the pi-ojecting wings ns described ; on the other it in 
Bcured by a split shot which has been t'laiuped upon it. Another simple 



ftuil mgeoious method, suggested by Thiersch, of Leipsic, is also figured by 
MiicConnac, from which the accompanying cut (Fig. G7) and descriptioii 
ai'e borrowed. 

Outeide a leaden pl»t« is placed a small perforated glass bead, whic^ 




(listributeB the preRHure, and outaide the bend the n'ire is wound, tiD a 
sufficient degree of tendon ia secured. If the wire becomes loose, one or 
further turns will sufficiently tighten it, or the suture can be relaxed, if it 
be thought desirable. "With a piece of sheet lead, a few beads, a box of 
uitttdies, and some silTer wire, anyone may get ready such sutures with 




Fio. eS. — Amngiimc 



very little trouble. The arrangement and function of the button stitches of 
relaxation is well shown in the fleoompanying illustration from Cheyne's 
"Antiseptic Surgery." (Fig. 68.) 



psmciPLBS OF wouND-APPosrnoN, 183 

In ooncliiSLon, it will be well to repeat that while in different wounds 
different conditions calling for differing devices for obtaining apposition of 
the divided surfaces may be found, the great principles wiU always be the 
same, and must each be regarded, if the best result possible is to be ob- 
tained. These principles are embodied in the three words, relaxation, ap- 
proximation^ and coaptatUm. When these have been secured, the next duty 
of the surgeon in the treatment of a woimd is to protect the injured parts 
from disturbance of every kind till repair is complete. 




CHAPTER X. 



PBOTECTIOS AGAINST DISTURBANCES OP HEALING— ANTISEP- 
TIC UKESSINOS. 

Cotton Waei— Bonted — Sa]ic;lat«d— Coirbolated — SnblimBted— lodoformlzed ~ Bi»- 
math — Ui(U£c— Catbolat«d— lodotonoized -Kaphtbaliimtod— £i>if — 7bu — Oaknm 
— NaphthalinateU Oftkum — JiiU— Turf-Mouiil— (.'AariioaJ— Alumina ted Cfaaroool — 
-Si-iiirf— Sublimated Sand— C'ooi Athea—Sni'^liub—Wuod-'Wool—The Protfctict— 
The Siln-util ImpeiiiieaUe Bnr^e—Bandaget—The Method of LuUr—The lado- 
forin DrcMing of BiOroth — Bttifirr-h's Tarf-Mm/Jd Drtsniag. 

Ls t.lie further liiHtory of n wotiutl, it wU] be iiiH-ewtu'n- that pi-otectise 
di-essingH l>e ajiplied, liy which it nhall be ke2>t fi-om neptic infection, from 
direct luecbftnical violence, aud fi-om luotioii, and l\v which also the com- 
piesfflon and wFirmth ueedeii t<> promote nuti-itiou aball he muintained. 
until healing is complete. 

Septic infection is \o be t,iifU'deil ngoiust hv covei-inj^ the part with soft 
and nbHorlient materials that will I'eceire and keep aaeptic the dischargeB 
that diuiu away from it, ami that will purify from aeptic particles the air 
that pn«HeH tbrouyh them to the wouiiil. For tJiiw purpose many sub- 
stouves may be found useful Among tlione more i-ommouly employed are 
cotton-wool and loosely woven cotton cloth, gaiize and lint, tow, jute, turf- 
mould, charcoal, sand, and sawdust. To the natui-al absorbent properties 
of these materials it is necessaiy only to add the presence throughout 
tlieir Bubstaiiee of a sufficient amount of some ontlseptiu nuitei'ijil to de- 
stroy or to i-euder inert any Keptic germs that may be bi-ought in contact 
with it. Materials Urns prepared constitute arUwi.'plif dressings, the prepa- 
ration of the more important of which will next demand attention. 



ANTISEPTIC DRESSINQS. 
Cotton IFoo?.— Ordinaiy cotton wool should fli-st be piuified and ren- 
dered hygroscopic by washing it in on alkaline solution and drj-ing. It is 
tbua prepared on a large scale by different mnnufacturei-s in this countiy 



ANTISBPTIC COTTON WOOL. 185 

nd Bold 08 "abROrbent cotton." Its preporatiou foi* n ^vouikI dresidiitr in 
completed by chargin}' it with boracic acid, BiUicylic acid, cna-bolic iicid, 
iodoform, corrosive miblimate, or other aiifjseptic 

Boraled Cotton. — Hot water di>utolvex fifteeu per cent of itH weight of 
boracic acid, but on cooling precipitates ail but four per cent. If the cot- 
ton be treated with an ecpuJ weight of a witurul«cl hot Kolutioii of boracic 
acid and then dried, it will remain peiiuanently charged wiUi fifteen per 
cent, of the antiseptic suhstaui-e, wliich in a desirable strength to have to 
insure its antiaeptie pniperties. Berated cotton thus prepared han the 
acid intimately incorporated into the siihetance of its lilin'H and is free 
from loose particJeH of tJie ci-j-stals Ij-iug amontj JtH ineBliew. 

Salici/laled Cotton. — This is usually made of tivo streugUiH, 4 per cent, 
and 10 per cent, ftilicylic acid requires 300 parte of cold water for ita 
eolutiou ; lioiling watei- dianolveH it in the ]iroix»rtioii of 1 1<) 2.'), but much 
fi a given cjuautity of tlie acid is volatilized by tlie heat of mich a solution, 
aking it« permanent HtiTii(^li unreliable. 

Alcohol takett it up in large quantity, and a dilute spirit makes the best 
tamstmum nith which to cliarge a ilressing. Ah the titie cn'stok depos- 

1 in the interaticeH of the wool me liable to shake out, a small propor- 

a of glycerine should also be added. Tlie following fonuula will iiisure 
tie preparation of the 10 per cent, strength : 

Glycerine 2 pai'tH bv weight. 

Water 100 " 

Alcohol 20 " 

Salicylic acid 2 " " 

Cotton wool 20 " " 

The tiolution of tlie acid having been made in tJie nienstruum. with tlie 

of very gentle heat, the mixture should be placed in a fiat vessel, iu 

llliich the wool should be laid in layera, each being thoronglily saturated 

before the next is supei-iniposed. When the whole maen has tlius soaked 

about ten minutes, it is turned upside down, the layers taken off in the 

ler that they were put ou, and hud aside to ib'y, flat, and in a warm 

The antiseptic properties of tlie wool may l>e irtill fai'tlier increased 

l>y dipping a thin layer of it in a fen per cent, solution of the acid in gly- 

toine, applying this first to the wound, and ovei' this a thick layer of the 

aalicylated wool sufficient to extend widely beyond ou all sides. 



the I 



186 



THE TBSATH£HT 01* WOUITDS. 



C'arboluicd Cotton. — Cheyne mentionB a earbolized wool prepared by 
snaking pure cotton wool in n one per cent Bolution of carbolic acid in 
etlier, the cotton to be then diied and used jjnmediat«ly. Its uae is re- 
stricted on account of tlie volatility of tlie agent, and on account of the 
miperiority of the gauze preparation of the same agent 

SuMimalprl Cottoii.—^Coirofave aublimat* may be diffused through cot- 
ton by Batumting it in on alcoholic solution of uot more than one-baU of 
one per cent strength. A stronger solution should not be used lest irri- 
tation of the skin be produced, resulting in eczema and bullte. The fol- 
lowing formula is recommended by KUmmell : 

Alcohol 449 parts. 

Glycerine 50 parts. 

Corrosive sublimate 1 part 

Saturate the cotton, and, having passed it through a clothes-wringer, 
erpose it to dry. 

lodoformized Cotton may be prepared by soaking the wool in an ethe- 
real solution of iodoform, as follows : 

Iodoform 60 parta 

Ether 260 " 

Alcohol 750 '■ 

and permitting the fluid to evaporate, or, estemporaneoualy, by rubbing 
the powder into the cotton, and shaking out the smplus. 

Naphtitalinaled Cotton may be obtained by making a saturated solution 
of uaphtlialin in benzine, and steeping the wool in it for a short time. 
By esjiosing it iu thin layers for a short time, the benzine evaporates per- 
fectly, and leaves the wool charged with the antiseptic. 

Bisjntilh Collfin. — The gubiiitrate of bismuth should be finely pow- 
dered, and then gradually mid verj- intimately triturated with water, in 
proportiouH tf> make a ten per cent emulsiou, in which the i^ottou may be 
dipped, as needed, and used at once after expressing the fluid. 

Cotton wool may be sufficiently charged irith any of the antlBeptic 
powders tor many piuposea by simply rubbing into the meshea of ths 
wool, at the time it is to be used, tlie dry fine powder. 

Gauke. — Loosely woven cotton cloth is more largely used as an absorb- 
ent dressing for wounds than any other material, and is technically kuawtt 



CARBOLATED GAUZK. 187 

"gauze." It is the foundation of the great mass of the antiseptic dreaa- 
ing introduced by Mr. List«r, who drst mentioned it in the British Medical 
Journal for Januftry, 1871. The cloth should first he prepared by boiling 
it ill a weak solution of cai'bonnte of soda and chloride of lime, to thor- 
oughly cleanse aud diaJnfect it This may be done in on ordinary wash- 
boiler. The cloth is then dried, when it will be found to have become 
innch more absorbent than before. Thus pi'epai'ed, it may be impreg- 
ted with various antiseptics, and kept for use. 

Carbolatcd Qaitzi^. — Gauze impregnated with carbolic acid ia the mate- 
al generally employed by Mr. Lister as a dressing to guard against the 
Dtrance of causes of fermentation into a nound after an operation, and is 
D be provided whenever the so-called Lister dressing is to be applied, 
lurbolated gauze cannot be kept for any length of time without deteriora- 
on. by reasou of the evaporation of the carboHc acicL It camiot be kept 
t permanent store. Hence only that which has recently been prepared 
aould be uaeiL "WMle for general use by the surgeon in private pi-actice 
rho desires to have by him a pi^eparatiou of gauze that may be drawn 
ion for occasional dresaiiigH from time to time, some otlier and more 
ible antiseptic is required. A great many different ways of preparing 
ize have been publialied, but, on the authority of Mi-. Cheyne,' Mr. 
lister's colleague and assistant, none are bo good as Uie following, which 
■n be used in any hosjatal, and which was recently employed during 
tie Busao-Turkish War for making fi-esh gauze in camps. The materials 
l^be used ore: 

Crj'Btollized carbolic acid 1 pai-t. 

Common resin 4 parta 

Paraffin 4 parts. 

These materials ore to be mixed together and added to an equal weight of 

the cleansed gauze- The technique of the charging process is as follows : 

The paraffin and fesin are fii-st melted together in a water-bntli, after 

ich the acid is added, and blended by stirring. The object now is to 

diffuse tins melted mixture equally through the cotton-clotli, and for this 

purpose two tilings are requisite, viz., that the cotton be at a higher t«m- 

iture than the melting-point of the mixture, and that it be subjected ia 

kte pressure after receiving it. The doth, a yitnl wide, is cut into 



— the 



188 THB TREATMENT OP WOtnTDS. 

MX yard lenpths, and these lia\'iiig been folded so as to be half a yoiii 
square, lue placed in n, drj- hot chamber, formed of two tin boses placed 
one n-ithiu the other, with an intei-viU to receive water, which in kept boil- 
ing by lii-e or gas beneatli, the upper edges of the boxes being connected 
and provided with an esit^pi]>e for the steam. There is also a glaas pipe 
luranged as a gauge of tlie amount of the water, and the chamber has a 
pi-operly-fitting lid. The bottom of the chamber is strengthened with an 
iniii pliite, to enable it to beai" the weight used for euinpressing the gauze 
when charged. There is a piece of wood almnt twu inches thick, nearly 
fitting the chamber, covered with sheet lead, bo as to make it about aa 
heavy as a man can lift by means of two handles in the upper surface 
The weight in heated along with the cotton, and is put first into the cham- 
ber 80 as to leave the cotton loose for the penetration of the heat, which 
(iccupies two or tln-ee houi-s. The cotton, when heated, i« taken out of the 
chamber along with tlie weight, and placed in a wooden box to protect it 
from the cold. (It would be better to have a second hot chamber for this 
pui-pose, since in cold weather tlie cotton is apt to be too much cooled, in 
spite of the protection of the wooden box.) The heated gauze ia then at 
once charged with the melted mixture of carbolic acid, resin, and pai-affin, 
in quantity equal to the weight of the cotton fabric (or shghtly less) ; and 
iu order to diffuse the liquid an eqinilly as possible, it is sprinkled over the 
gauze by means of a sjiinge with a number of minute perforations in its 
estremit\-, tlie body of the syi-inge and the piston-i'od liaraig each a 
wooden handle to protect the luiuds cf the workman from the heat The 
a\Tinge is constructed to hold hidf the quiuitity of the mixture requii-ed 
for charging one piece of clotli. One folded piece being placed at the 
bottom of the hot chamber, its upper half is rained and turned aside, and 
one B^-ringeful is sprinkled owr the lower half. The upper half is then 
put buck into poHition and another sjTiugeful thrown on. The same 
process is repeated witli all the other pieces of gauze, after which the 
weight is put into the chamber to compress the cbu-ged cotton, and the 
hd apphed. An hour or two are then allowed to elapse, to permit the 
complete diffiision of the liquid, when the material is fit for use. 

In this gauze the carbohc acid is the only ii«tive agent ; the resin ia 
used to prevent the acid from being washed out too soon by the discharge, 
while the paraffin is employed to lessen the adhesiveness of the resin. 
The gauze ought to be kept in a tin box, closing tightly, to prevent evap. 
oi-ation of the carbohc acid. 




lODOFOKUJZBD GAUZE. 1 

All ef&dent gauze miiy be prepared ncconliiig to the fm-muk nf i 
8, by taking 

Ciirlwlir ju-iil 10 piirtM. 

Kesin 40 - 

Cnator oil 8 

Alcohol 200 - 



Tlie resin, powdered, is to be slowly added, with constant stirriny. to 
the alcohol ^VTien the aolutiou in complete the carbolic acid imd the cas- 
tor oil are likewise stirred in. In plac* of the castor oil, glyuerine or 
tnelt«d stearine lany be used, the (iiuintity to lie used beiuj; of equal weight 
with the acid. The alcohol, alwo, may be replnoed by beuziiie, aa a sol- 
vent, and the expense of the prepai'atioii be much reduced. The gauze i» 
to be wmply aoaked iu this mixture, being well kneaded to secure its uni- 
form difiusion, and then hung up to allow the spirit to enipomte. It will 
be dry enough to be ready for use or storing in from five to ten minutex. 
The whole operation demands neither much time nor sldll, nor any partic- 
iJivr apparatus. Gauze thus prepni-ed contains about nine per cent, of 
carbolic nctd. 

In order to mate tlie gauze dressing more reUably antiMeptic, the layers 
of gauze which go next the wound should be ilipped in a watery solution 
of carbolic acid, 1 to 40, iinniedifttoly before being apphed. 

Carbolated gauze that has Ijeen used may be washed and rechaiged 
with the carbolic acid mixture. It may then be used again. 

lodiifimnixr'l Gauze may be prepared by roughly nibbing the ciystals 
into the meshes of the cloth. Gauze thus prepared constitutes the 
ordinary " absorbent iodoform gauze " of Billroth. In preparing it the 
loosely crumpled gauze should be put into a clean receptacle — a wash- 
biudn rinsed out with carbolic lotiou — imd plentifully sprinkled, by meonn 
of a pepper-box, witli the iodoform powder. This should then be worked 
in with the hands until the whole of the gauze is uniformly yellowed by 
the powder. Then the excess of the iodofoi-m is to be gotten rid of by 
abaking, after which it is ready for uae, It HhoulJ be kept in sealed flat 
glass jars, Tlic luuoiuit of iodoform retained by the gauze after the shak- 
ing wiU be from ten to twenty per cent. An ounce of iotloform will im- 
pregnate thxis between four and tive yards of gauze. 

This form of gauze may be applie<t directly t*) all wotiuds, except those 



190 TIIE TEEATMEHT OF WOUNDS. 

in the caTitr of the mouth. It absorbs very readily, does not endanger 
i-etentioii, does not ii-ritate lite carbolic gauze, and doeH not readily pro- 
voke iodofonii iiitoxicatiou. 

An " adhesive gauze " may be pi^pai-ed by ao&ldng the gauze in an 
filroholif Holution of i-esin, to wliioli glycerine is added, and dustin'; the 
iodoform upon the sticky surface left after it has been wrung out and hall 
dried, just as in the pi-ejjanitiou of the absorbent gauze. For priming the 
^;auze the following formulti is nsed : 

Besin 100 partH. 

Alcohol (95 i»r .-eiit.) 1.200 " 

Glyceiine 50 

Neai-Iy foui- times as much iodofonn is retiiincd by tliis gauze as h\ 
the unprepared fabric. It is of especial value in lU'essing wounds in tlie 
cavity of the mouth, and for application as a comprews upon surfaces fjiim 
which [jaieuchj-matous hetuonhage is taking placa 

Nai>hthnUmU;d Oauzi\ — Five yards of gauze may be charge<l iWth niii)li- 
tludin hy iwiug the following mixture (Fowler) : 

Naphthnlui 1 ounct>. 

Pai'ftflBn 2 ounces. 

tilyceiine 2 onnoea 

Ali'ohol 3 oimoe&:i 



The paraffin in Hitit melted. The glyceiine and alcohol ni-e then mixed ' 
together and added to the melted jMUTiffin ; lastly, the napbtlialiu is 
stiired into the mixtui-e, which is kept heated and well stirred until tlie 
hittei- is all ilissolved. Tlie gauze is dipped into the mixture while flie 
latter ia hot It is then passed imniedhvtely between the rollers of a com- 
mon clothes-wTinger to squeeze out all tlie superfluous fluid. After a few 
iiunutes' exjjosTU'e to allow eraponitiou of the alfohol, it is ready for use. 
It should be kq)t in closely covered tin cwus. 

Another method is to make a saturated solution of nnphtlialiu in ben- 
zine, ui which the gauze is soaked for a few houi-s tor a day or two. The 
material is then himg up on a line to diT until the benzine has all evapo- 
rated (Park). 

A solution maj' hkewise be miLde of tlie naphthalin in four parts ether, 



OAEmt — JD^l. 

I io which an equal quantity of nlt'oliol is added (Fischer), in which the 
gauz« nmy be dipped. 

IjIst may be prepared in luiy of the ways thu^t have been desoribed lis 
Spphctible to cotton-wool. 

»i Tiiw, — Flaxen or hempen tibi'es may aot as siibetitut^B (or the cotton, 
Ind may be ti-eatt^l in tlie eome waya They are inferior in ubsorbent 
QonlitieH, aud are leas soft in t«xture than the cotton. Impregnat«d with 
tar they form ixiktlvi which forms an eseelleDt wound-dressiny in many 
conditions, hut it has only feeble antiseptic proi>ertie8. Oakum may be 
chHrjired with other antiseptics in addition to the tar, and be of especial 
value as a cheap material to form the outer layer of dreasiug& Its fibres 
are too liarsh to luake it a desirable substance to place in immediate cou- 

twith a wound. 
An excellent dreasiuj,' can be qmckly exteuii>orized from the pi-epared 
uiukUm, known us "maiine lint," and uaphthalin, by pickin<; the fonuer 
into loose uiafiseH and tqiriiildiuy it over witli the lattei' and then rubbiny 
the antiseptic well into the meshes of the oakum. The tflr in the oakimi 
causeH the uaphthalin to adhere tirmly to its fibres and in auffieiently 
larpe quantities to an.swer all the pnqjoses of a rigid antisepsis (Fowler). 

JiTTE has bt'en liu-gely used an a woun<!-dresaing on account of its cheap- 
ness and j^reat absorbent power. This is a vegetable fibre obtained chiefly 
from Ben;^ and brought in l;u-ge quantities to the New York market, 
where it is used in the manufacture chiefly of mats and coarse woven stu^ 
It is one of the raoHt cheaply i-aised luid prepared of all fibres Tlie best 
qualities, which alone lU'e suitable for surgical use, have a cleai' white, 
yellowish color, with a tine, silliy luati-e. The fibres are soft and smooth 
to the touch, and ai-e iuie. long, and uniform. Tliey are comiHised of fi-om 
thirty to one hundred fibrillte, flattened in external sliape, and tubulai- in 
the eeutre, which well adapts them for the absorjttiou and retention of an 
antiseptic mediiuu. 

Jute dipi>ed in a ten per cent, solution of cju'bolic acid in spirit dries 
quickly and retflins a large quantity of carbolic acid, as much as six to 
eight per cent, for ten or twelve days. 

Jute may be impregnated with ^-arious antiseptics in tiie same waj-s aa 
have already been described for cottou-wooi It should be cleanetl before 
impregnation. The fluids that drain out of it, when it ia hung up to dry, 
should be again poured over it, until they ai-e all tjiken up. 

TitRF-MouLD. — The dust or mould obtaiued fi-um carbonized turf — peat 




192 THE TKEATMBNT OF WOUNDS. 

— Las been used m a woimd-diessmg witii great adviuitage by EsniBrcli 
iukI Neuber," of Kiel Tlie advantages claimed for it are these : 

1. A given quantity of tlie mould takes up more fluid than jut«, gKUze, 
or cotton wool. If it be lightly moiateued, its abBorbent power is still in- 
creased ; wounds i-emaiii i>erfeirtly drj' under it. 2, It posHesses a great 
jwwer of absorbing pivxlucts of decompomtiou of organic Hubstancen, and 
hence prevents the same from ocemTing, tuid acts even in tJie miprei>ared 
form. 3, The moistened mould is a veri' soft but trtill elastic substance, ao 
that it is easily placed in the i-equii-eii jKwition in the bags before applying 
them to the inequalities of the body. 4. It is the cheapest of known antt- 
septio dressingB, one peun_\-worth sufficing for a dressing, anti will be more 
so when it is found that the prepamtion with some antiseptic can be left 
out. 5, It makes a very suitable pad for all piUTJoses when enclosed in 
gauze. 

To increase ita antiseptic pi-operties, tlie mould may l>e impregnated 
with carbolic acid, chloride of zinc, or iodoform. 

Chakcom- — Powdered charcoal, by its quality of absorption and filtia- 
tioii of fluids, is well fitted for a wound-<IreBBing. It is posaessetf of anti- 
septic properties in its uatuiiil state, and is one of the oldest disinfectants 
used in medicine. 

Aluminaied Cliaraial. — Kdmmel recommends the a^ldition of acetate of 
alumina to charcoal to increase its antiseptic properties. It is to be pre- 
liared by first bitking the finely i>owdei-ed charcoal for sevei-al hours and 
then mixing it witli powdei-ed aceto-tartrate of alumina in the proportion of 

Charcoal 7 parts. 

Aceto-tartrate of uliunina 3 parts. 

If the mixture contains equal parts of the ingredients it produces & 
slight irritation of the t-esli wound-surface, and even in the present pro- 
portions this ii-ritation sometimes occurs. After a few days, however, tlie 
iiTitation disappears, giving place to a healthy gi-anulating sui'face. A 
smaller proportion of the alum would prevent the irritation without dimin- 
ishing the antiseptic properties of the mixture. 

Wound cavities, where primari- union is impossible, may be filled in 
ivith tliis alumiuated charcoal and covered with a few layers of gauze and 
any impermeable material The first dressing may often be allowed to 

' Brfahntngen iher lodafami- und TifrfTtrbAndt in dtr ehir. Klinik da fferm St- 
iiiareh. Bj Dr. G. Neuber, ArthiefUr KUniteht ChinirgU. 18S2, Band xxvii., p. 707. 



BUBLIMATED SAND. 193 

pnmain One to two weeks without n change. In amoU wounds liealing 
8 place 09 under a scab. 

SxsD. — A fine quality of purified sand, common white qnartz-sand, has 

' rfoo been uaed with great adi-antage in the General Hospital of Hamburg 

(KQiumell) as n wouid-dresaing. It in eaailj obtained, is cheap, and can 

readily and quickiy be made aseptic. After having been passed through 

a fine sieve, it should be heat«d several hours in a covered pan. Directly 

nfter cooling it should bo mixed vrith an ethereal solution of corroaive sub- 

limate and be afterward preserved in glass-stoppered bottles. 

^m SMimaied Sand. — An efiScient and reliable antiseptic eand may be 

^Htoade according to the following formula : 

K-150 

r«md. 



Corrosive sublimate 10 parts. 

Ether 100 " 

Sand 10,000 " 



■150 grains of the sublimate being sufficient to impregnate 20 lbs. of 
Mmd. It may be used, like other antiseptic powders, to fill wound cavities, 
being covered with sublimated gauze over which a gauze bandage is fast- 
ened. The use of an impermeable outer covering is objectionable, as 
thereby desiccation is prevented, and healing under a scab impeded. In 
consequence of the fine grain of the sand, it may be instilled into narrow 
fissures and recesses. The dressing may remain in place for weeks till 
healing has taken place, by simply renevring the layers of gauzo as they 
become imprcgnaied with the wound-secretions. Before replacing the 
layers of gauze, the wound should be irrigated with a solution of the sub- 
limate, and the sand, where missing, renewed. The sublimated sand pro- 
motes in a marked manner drj-ness in a wounci This it does by decreas- 
ing the amount of the secretions and by absorbing whatever moisture may 
occur. Frequently it was foimd, upon removal of the firmly dried crust 
of sand, that the wound had healed as under a scab. Barely do particles 
of sand remain in the healed wound. If they do, they are Imrmless. Tha 
sand may also be used as a dressing for wounds that have been sutured 
for primary union, a light layer of lint or wool being first laid over the line 
of suture. 

CoiL-AsHES. — Finely sifted coal-ashes, on account of their lightness, in- 
organic nature, and absorbent properties, are adapted for wound-dressings. 
Their chemical composition consists of elements more or less antiseptic in 
their nature, which may be increased by wetting them with an antiseptio 



L 



x 



THE TltEATMHST OP W0PND9. 

Bolutioii.' Kilmmell haA Rubstitnted sublimated ashes for sand in many in- 
etances. According to this surgeon, the beat ashes for the purpose consist 
of the fine and light powder, called fljing ashes, which settles in large 
quantities behind the fire-boxes of steam hoilerB. Cushions filled with 
UuH latter substance form admirable means of oompression, being soft and 
pliable and readily adapting themselves to the shape of the parts to which 
they are apphed. Cushions filled with the prepared ashes for ordinary 
purposes of woimd-dressing are moistened just prior to being used, in 
order to facilitate their al^orbent action. It is recommended to use sev- 
eral small cushions rather than one lai'ge one in the dressing. 

Sawdcst. — As a cheap and readily obtained absorbent dressing, bags of 
sawdust, impregnated with iodoform, corrosive sublimate or carbolic acid, 
have been used in the New York Hospital and have answered well' 

Wood-wool. — From Professor Bnina, of Tilbingen, we receive a fresh 
addition to our means for carrying out the after-treatment of wounds, in 
the form of a preparation which he caUs " wood-wool," and which he rec- 
ommends to surgeons." Fine-grained wood in the form of splinters and 
shavings, such as are largely employed in paper factories, according to 
Bruns, is the kind of material to he used in preparing the dressing which 
is called wood-wooL Pine wood is preferred, and especiall}' the pinus picen, 
which is poorer in resin and of coarser grain as compared with the wood 
of other pines and firs. The further preparation of the wood shavings and 
splinters consists in their reduction to a state of finer division by being 
rubbed through a wire sieve, then dried, and finally impregnated with 
various antiseptic substances. That considered best is a half per cent, of 
corrosive sublimate and ten per cent of glycerine (the percentage appar- 
ently referring to the ratio between these substances and the wood-wool). 
The advantages of such a dressing are beheved to be manifold. Compared 
with oflhes and turf it is absolutely clean, fresh, and of white color, and Is 
' KQmmeU giveB (be followiug u the average oompoaition of the luli of Engllsli 



Botphurio acid 8.38 

Phosphorio moid. 1. 18 

Silioio aoid 81, 

Lime a 

Oxide of iron lud alamiiu 34.43 

'H. F. Weir: Dieuhisra for Wouuda, New York Medical Joamal, Jauaair 
B3, p. 0. 'BerLlCHn. Woek., 1883, No. M. 







abso 
BVrui 



THE FROTECnVE. 195 

■toft and pliable-like onlinftry wool, nnd witlml of estTOOrdinmy chenpnees. 
It poesesBCB, in virtue of its contaioed resin, ethereal oils, certain antieep- 
tjc propertieB, and is bo easily adapted to the wounded parts, and of such 
elasticity, that a uniform and equable pressure is easily obtained. Its 
principal proi>erty, however, is it« extraordinary power of taking up fluids ; 
in this it excel)! all other forms of dressings ; it absorbs twelve times its 
own weight of fluid, so that ten grama of dried " wood-wool," after eoni- 
plet» saturation, weigh one hundred and thirty grama Simple sawdust 
absorbs only three or four times and a half its weight of water, ashes only 

le-tenths, and sand only four-tenths. This dressing baa been in use by 
for half a year, and be lias every reason to be greatly satisfled there- 
with. With the exception of one case of erysipelas, no secondary accidental 
wound diseases were met with. 

Thk pBOTEcrrvK. — Whenever the direct contact with the wound surfaces 
of these dressings would chemically or mechanically irritate them, as is 
especially the case with those that are impregnated with carbolic acid, it 
is best to apply, over the exposed wound surface, a layer of some aseptic 
neutral and unirritating substance as a protective, over and around which 
the antiseptic dressings shall lie placed. Such a layer will be of use also 
in preventing tlie dressing from sticking to the wound, and in preventing 
the formation of scAbs, and the consequent possible retention of the dis- 
charges. The material so used is, in general parlance, distinguished by 
the technical name of the Prolectiop. 

The special material employed by Mr. Lister, in connection with his 
carbolic acid dressings, consists of oiled silk coated with copal varnish. 
When this is dry a mirtnre of one part of dextrine, two ports of pow- 
dered starch, and sixteen parts of cold watery solution of carboUc acid 
(1 to 20), is brushed over the surface. The rationale of this method of 
preparation is the follo^'ing (Cheyne) : Oiled silk alone is better for the 
purpose of a protective than gutta-percha tissue, because carbolic acid 
does not so readily pass through it It does, however, do so, and 
ttierefore copal varnish, which is almost absolutely impermeable to rar- 
bolic acid, is added. As, however, the flmd collects on this as on a 
duck's back, leaving intervals between each drop on which dust may fall 
and escape the action of the acid, the dextrine solution is added, and the 
result is that when moistened the whole surface of the protective remains 
aniformly wet. The use of the carbolic acid in the dextrine solution 
la not to add any carbolic acid to the protective, but because it is better 



J 



196 THE TREATMENT OP W0UND8. 

than water for enabling the dextrine to adhere to the Tamiahed oiled-alk 
For the same reason the powdered starch is added. The original carbolic 
acid flies off veiy quickly from the protectiye, leaving a material containing 
no antiseptic in its substance. 

This protective should always be dipped in an antiseptic solution (car- 
bolic acid 1 to 40, or corrosive sublimate 1 to 1,000) before being applied 
to the wound surface. 

Although the dextrine-cdpal-oiled silk of Lister is a superior form of 
protective material, it is not indispensable, and, when it cannot be con- 
veniently obtained, may be substituted with very good effects by ordinaiy 
rubber tissue. 

When less irritating agents than carbolic acid, as salicylic and boracic 
acids, are used for impregnating the dressings, the protective is of less 
importance. The powder dressings, as turf-mould, iodoform, naphtha- 
lin, bismuth, eta, are best applied without the intervention of a protectiva 

Cheyne calls attention to the frequent error of putting on too large' a 
piece of protective. There is nothing antiseptic in its substance, and it 
protects the discharge beneath it from the action of the antiseptic in the 
other dressing materiala Therefore if at any part it projects beyond or 
comes close to the edge of the dressing, it allows the causes of putrefaction 
to spread inward beneath it, and prevents the antiseptic from acting on 
this putrefying discharge. It is therefore a very good rule, he remarks, 
having covered the wound with sufficient protective, to look on this pro- 
tective as a wound, and to l)e as careful in having the gauze dressing over- 
lap it in all directions as if it were itself the wounded surfaca Where 
there is very little space for overlapping, no protective ought to be applied. 
It is better to have somewhat slower healing than to have putrefaction 
spread into the wound. 

External IiiPERMEABLE Envelope. — For the purpose of arresting the 
evaporation of the antiseptic when it is volatile, and to prevent the secre- 
tion which soaks through the dressing, if it should come directly to the 
external surface, from being there exposed to atmospheric influence, and 
becoming septic, in close proximiiy to the wound, the dressings may be 
enveloped in some thin impermeable material This is of special impor- 
tance in carbolic acid dressings on account of the volatility of the acid and 
the excessive serous oozing which it provokea The material used by Mr. 
Lister is composed of cotton cloths with a thin layer of india-rubber spread 
on one side, called Macintosh dotL In its use care is to be taken that the 



BAKDAGES. 197 

[lide on which the rubber is spread should go next the wound, and that it 

should be without a rent, pin-hole, or other defect The presence of a 

small opening more or less completely neutralizes the object and endan^^ers 

B-ttie failure of the antiHepsis. As less expensive than the Macintosh cloth, 

bsbber tissue, wased paper or paraffin paper are used au substitutes,' but 

Hhey are less reliably impermeable than the JVIavintosh. The same piece 

of Macintosh, if thoroughly cleaned and disinfected, may be used several 



Tl 
nnarspi 



been 



The use of an impermeable external envelope is open to the very 
iouB objection that it keeps the ekin underneath it moist from retained 
itiou, and by ita moist warmth promotes the activity of whatever 
sources of putrefaction may escape Uie anttseptic cares that have been 
taken. It tends to envelop the wound iii putrefiable material so that the 
more frequent and more copious appUcation of antiseptics is required to 
Becure continued freedom from sepsis. With the introduction of less vola- 
tile and less irritating substances as antiseptics than carbolic acid it has 
been possible to abandon the use of any impermeable covering. 

Baxdaoes. — For the purpose of adjusting and retaining the dressings in 
bandages of various widths ore required. If the case requires their 
direct application upon the deeper parts of the dressing, they should be 
made of antiseptic gauze. Gauee that has been primed with tlie resin 
mixture (page 189) has the advantage that each turn of the bandage made 
of it adheres to the previous one, giving additional security to the dress- 
ing. If carboUc gauze is used, it should always be dipped in carbolio 
—lotion, 1 to 40, immediately before being appUe<L 

^ To fasten down the margins of the dressing in places where the move- 
Hbents of the body tend to loosen the dressing, and thus to allow air to 
penetrate beneath its margins, elastic bondages of ordinary elastic webbing, 
OT of pure rubber tissue (Martin's bandage) serve an excellent purpose and 
in some regions, as the groins, axilla, neck, and head, are indispensable. 
These bandages are most manageable in short lengths, and should vary in 
width from one to two and a half inches, according to the size of the 
dressing, or the region of the body to be dressed. They should not be 
put on too tightly, but stretched just firmly enough to keep everything 

' Codmaa & SbnrtleS, of BostoD, fnmiiii these variouB malerialB at the tollowmK 
pricea: Maeintoah clotb, 1 jQrd wide, per yarij, tl,50; heavy gutta-percha tisane, 3S 
inohet wide, par yard. |1.I)0 ; thio patta-perchft tiflBne, 33 inchea wide, per yard, » 
e>i>te; paraffin paper, 32 InolieB wide, per yard, 6 oeota. 



198 THE TRKATMBNT OF WOUNDS. 

Hecure againBt the movement of the port, or the akifting poeition of tha 
patieut (MacConuac), 



APPLICATION OF THE DBBSSINGS. 

Tbe Method of Listeb. — As the method perfected b; Mr. Lister i?m 
the first in which the iadication for protecting wounds from contaminatioa 
by septic dust, and for keeping their discharges free from putrefaction 
was accepted as the chief end of treatment, and was successfully accom* 
phshed, the details of the ammgement of tbe dressings adopted in this 
method for securing continued protection after the arrest of the luemor- 
rhage, the cleansing of the wound, ite drainage, and the apposition of it^ 
surfaces had been accomphshed, claim the first mention. The foUowing ia 
Cheyne's deucription of the details of the application of tbeee dresaingB 
{"Antiseptic Surgerj-," pp. 87-93) : 

Tbe di'essing employed is the carbobc gauze ; and to prevent iha irri- 
tation of the heahng edge of tlie wound by the carbolic acid, a piece of 
protective is interposed between tbe gauze and tbe wound. This protec- 
tive ia cut a bttle larger than the wound, and it is well to cover the but- 
tons with a bttle bit also, in order to prevent the threads of the gauze 
from becoming entangled in them. This protective need not eitend over 
tbe orifice of the drainage-tube, as its essential object is to protect tha 
healing part from the irritation of tbe carbobc acid. Outside the protec- 
tive a piece of gauze wet in the carbolic lotion (1 to 40) is appUed so as to 
overlap the protective in all directiona Tbe reason for tliis ia that dry 
gauze is apt to receive dust on its surface before being used, while at the 
ordinary temperature of the atmosphere but Httle carboUc acid ia given oflf 
from the gauze, certainly not enough to destroy immediately tbe activity 
of tbe septic particles in tbe dust. But if tbe piece of gauze appbed next 
to the protective be moistened in tbe I to 40 solution, this dust ia at once 
deprived of septic energj', and we apply over the wound a layer of pure 
and powerfully antiseptic material Tbe piece of wet gauze and the pro- 
tective go by the name of tbe deep dressing (Fig. 69). This deep dreas- 
ing may, in some cases, and more especially where catgut stitches and cat- 
gut drains are used, be left for several days undisturbed. If the deep 
dressing be thus left on, it must be remembered that the deep piece of 
gauze loses all its carboUc acid very soon, and that, therefore, it must be 
treated as a wound — te., in renewing the dressing this deep part must ba 



THE t-ISTEB DBE8S1NO. 



199 



I 



lapped in all directions by a piece of wet gauze, nod that again by a 
dressing of suitable siza 

Hanng arranged the deep dreaaing in a suitable manner, any boUowa 
which exist in the neighborhood of the wound are filled up witJi carbolic 
gauze, and special masses of this material are placed where the greatest 
.•mount of discharge is expected Outside this a large gauze ilressing, 
oonsiBting of a piece of gauze of sufficient size folded ia eight layers, be- 
neath the outer layer of which is placed a piece of macintosh cloth, is ap- 
I^ed. The size of this dressing varies according to the amount of dis- 
bharge expected, but in all cases it must extend well beyond the deep 




Q all directions. This dressing is fixed on with a suitable band- 
age of gauze or ordimiry cheap muslin. The dressing is pinned round its 
edge to the bandage. Care must be taken not to put pins through the 
macintosh at any part except at ite edge. To prevent the edge of the 
dressing from becoming separated from the skin, and air passing into the 
space thus formed, the edges of the dressing are surrounded with an elas- 
tic bandage, put moderately on the stretch, its general arrangement vary- 
I Jng with the situation. 

As a rule, the dressing ought tol)o changed entirely on the following 
day, the deep part as well as the superficial. It is well to change the deep 
dressing in order to see that none of the stitches are too tight, and that 
the drains are acting properly. After the first day the deep dressing need 
not be touched, unless the jmtient is complaining of uneasiness, or unless 
the surgeon wishes to see the wound for the purpose of removing stitobeB 



< 



200 



THE TBKATHBirr OF WOUNDS. 



or drain. If the deep drcBBing is not changed, great care must be token 
lo have an efficient spray playing over the pari 

In changing the dressing the spray is used, and also 1 to 40 carbolic 
lotion, in which a piece of luose gauze and protective are put before the 
ilresmng is begun. The elastic bandage is first removed, and then the pa- 
tient or au assistant places his hand over the centi-e of the dressing while 
the bandage is being cut, so as to prevent the dressing being lifted up and 
air pumped in. Then the surgeon, having purified his fingers, and having 
turned on the spray, lifts the edge of the dressing carefully, taking care 
that the spray passes into the angle between the dressing and the skin. 
Having removed the superficial dressing, he again dips his fingers, and 
then removes the deeper parts and exposes the wound. 

If nothing ia wrong, he immediately apphes fresh protective and wet 
gauze, and then washes the pai-ts round about, as far as the discharge has 
extended, with 1 to 40 carbohc lotion. The edge of the wound ia not 
washed or esposod to the action of tlie spray longer than ia absolutely ne- 
cessary. A fresh dressing is applied as before described. 

The next di-essing takes place on the following day at visit, if there is 
any discharge at the edge of the dressing, or if the wound feels uneasy. 
The rule for changing the dressing ia : Change if discharge is through at 
the visit hour, or if there he any other reason lor it ; if not, leave the dress- 
ing tin the next day at visit, and then follow the same rule. 

Never leave a dressing unchanged longer than a week. By that time 
moat of the carboUc acid has passed off by evaporation, and therefore, if 
the discharge once came to the edge, putrefaction could spread inward 
with great rapicbty. And it would not be necessary for the discharge to 
appear at the edge in order to have puti-efaction of the wound, for the 
sweat collecting beneath the di'essiug permits the multiplication of septio 
particles in it, and thus they may reach the wound. 

The Iodoform Dressino op Boxhoth. — According to the practice of Bill- 
roth, of Vienna,' it makes httle difference, in most cases, what kind of 
antiseptic protective material is used for the immediate covering of wounds 
that can be closed, but on account of its less irritating properties, its effect 
to diminish secretion, and its more permanent and intense antiseptic power, 
the iodoform gauze is preferable to the carboUzed gauze. The iodoform 
dressings, however, have their greatest usefulness in wounds that cannot 

' Backer: Anleitung tur AnlUnptiaehen Wu:iitbehandiv,ag noeA der an Prtif. BUt 
retli'i Klialk gebr&weMiehen Mtthoda. Wlen, 1888. 



lODOPOBM DBESSING3. 201 

imited, in wounds of mucous cavities, anil in larger wounds in wluch 
prooessea of decompodtion already exist 

Closed woundg. — Superficial wounds, as, for example, in the fac«, tliough 
they have little need of any dressing beyond the scab formetj by the desic- 
cation of the shght layer of blood and secretion that collects upon the line 
of their union, aa a matter of secimtj', may be covered wth iodoform col- 
lodion ' or iodoform gauze. 

In deeper wounds, do iodoform is apphed to the woimd surfaces, and 
no " protective " is applied over the line of suture. The advantage of an 
(y removal of the dressing material front a wound covered by " protect- 
is surpassed by the advantage of the di-ying of the secretions as 
they come in contact with the gauze, and by the more immediate effect of 
the iodoform upon the secretions as fonned. The sutures are made less 
irritating, also, as evidenced by the fact that suppuration at the points of 
entrance and exit of the needle, when iodoform is used, is very rare. 
Directly upon the wound, after its apposition and suture has been effected, 
from four to sis layers of absorbent iodoform gauze are laid, of sufficient 
idth to extend half an inch beyond the margins of the wound. Over 
plac«d one or more layere of crumpled carboUzed gauze, and over 
Sll a layer of smooth carbolized gauze, or absorbent cotton, or ordinary 
purified gauze. Ihe whole is enveloped in a layer of impermeable mate- 
rial, and, at the margins of the dressing, pads of absorbent cotton or gauze 
■re placed so as to afford compresses over the impermeable material where- 
special pressure seems indicated. The fixation of the dressing is 

implisbed by a common roller bandage. 

Open vxiunde. — No other dressing will give such uniformly good results 
the treatment of open wounds as the iodoform. Nor is any method of 
such cases so simple in its appUcation, or requiring such infre- 
quent changes. 

Open wounds, aft«r being cleansed, are to be simply filled with absorb- 
ent iodoform gauze. In irregular cavities, the first layer of the gauze is cut 
in strips and introduced into all fissures and compartments ; into the remain- 
ing cavity layers of gauze are loosely packed till the space ia tilled to the 
level of the integument. A double layer of iodofoi-m gauze is then placed 
upon it so as to extend over the margins of the wound. The dressing is 
completed by carbolized gauze, impermeable material, and bondages, ex- 



no " 
^«wy 

■^thpv 



ftnridt 






lodotonD oollodion ia a Boluticm of iodoCorm in cotlodion Id the iitopoitioi 
lolO. 



J 



THE TKEATMEItT OF TOtTWDS. 

flctly as in cloBcd wounds, except that no firm compression ia to be pro- 
duced. Healing takes place by granulatioii with but very little suppuiK- 
tioD. The dresaing may be left undisturbed for from eight to fourteen 
day& 

It ia of the greatest importance that every comer and fiasure of a 
wound be brought in contact with the iodoform gauze. 

Change of Dressings. — It is expedient not to permit the dreasinga to 
remain unchanged for a longer period than eight to ten days, on account 
of the eczematouB irritation of the Bl<i" which the gnuzo and the retained 
perspiration is likely to excite, if left unchanged too long, not withstanding 
the antiseptic properties of the dressing may be sufGcient for a much 
longer time. After major operations, it is sometinieB desirable to change 
the dressing on the evening of the same day, or the day following, on ac- 
count of the saturation of the dressing by hit-morrhage. If the oozing is 
moderate, it may suffice to renew only portions of the dressing the first 
evening, as the carbolized gauze, cotton, and impermeable material, Ewd 
defer the complete change until the next day. Aa long as no secredons 
appear on tlie sui-faco the dressing may remain, so that in the treatment of 
very large wounds that may require three or four weeks for h^taling, the 
dressing may bo changed only two or three times. In general, howerer, 
the dressing will be renewed in six to eight days, the time when the diaio- 
age tubes and deep sutures are to be removed WTien complete union by 
first intention is not secured, the drainage tubes must be left in place 
where suppuration exist*, to be gradually shortened before their final re- 
moval. In such wounds a change of dressing is rarely required on account 
of abundant secretions ; the gauze adhering to the wound may remain, 
and it will be only requisite to change the layers of carbolized gauze and 
of cotton. In cases where, aa in compound fractures, it is of the greatest 
importance, for the formation of callus and for the rest of the part, that 
the dressing remain as long ns possible, it may remain fourteen days or 
even three weeks, provided no disturbance manifeats itself. The openings 
left by the draini^e tubes will require a longer time for closure, and will 
leave small cicatrices. 

A change of dressing becomes necesaary whenever the temperahua 
rises to 102° F,, and above, especially when connected with rigore. It is 
dmrable for safety's sake at any time when the dressing is abundantly 
saturated with blood. Mlien the dressing is changed, the drains should 
be injected with a stream of water to see that they ore not clogged ; any 



I 



I 



TUEF-MOTJT,D DKESSIXOS. SOS 

of the sutures may be moderated by the remoral of some of them. 
If the febrile disturbances do not disappear, if the secretions increaae, 
assuming a suppurating character, with a bad odor —a rtkre occurrence 
— the dressing must be changed every day, or every second day. Iodo- 
form gauze should be used sparingly on account of the danger of the 
toxic effects of iodoform. In such coses, forming an exception to the 
general rule, the wound should be irrigated with a strong solution of 
carbohc acid 1-20, or with a solution of chloride of zinc 1-500. In an 
ordinaiy change of dressing, irrigation and pressure to remove detritus is 
not used. 

If, notwithstanding the injections, fever, anoreua, and general weakness 
remain, it is proof that antisepsis has failed. It becomes necessary then 
to remove the sutures, open the wound, and fill its cavity with iodoform 
gauze. If a frequent change of the dressing is imperative, some other anti- 
septic, as acetate of alumina, must be substituted for the iodoform. After 
the wound is perfectly pure, the process of healing may be hastened by 1 
approximating the edges of the wound by secondary sutures of silver wire^ 

strips of iodoform or adhesive plaster may be applied. 

As a rule, the iodoform gauze should be continued only for two or 
three weeks, until a good, healthy, granulating surface has formed, the 
final cicatrization of which will he hastened by the use of zino 'or boraoio 
acid ointment. 

Eshaech's Torf-mocuj Dbessino. — This is used in the following man- 
ner, which has been very successful : Bags of gauze wrung out in 5 per 
cent carbolic solution are prepared of two sizes, 5 and 10 square inches 
respectively. These are filled with turf-mould (or dust), the smaller 
bog with mould containing 2^ per cenL of iodoform, which is laid on 
the wound directly, which has been disinfected with either carboHc solu- 
tion (2J per cent), zino chloride (8 per cent), or, at most, 45 grains of 
iodoform. Over this is laid the larger hag, the mould in which is sat- 
urated with 5 per cent carbohc solution. The whole is kept in place by 
a gauze bcjidage. 

These examples which have been detailed will sufGce to illustrate the 
method of applying practically the principles which will guide the surgeon 
in the use of any of the absorbent, antiseptic, and protective dressings 
which have been described. In the chapters on antisepsis, antiseptics, and 
wound-cleanliness, the indications to be met, and the spe<.nal properties 
of various antiseptics have been carefully detailed. The judgment, por- 



204 THE TREATMENT OF WOUNDS. 

haps simply the conyenienoe or caprice, of the surgeon will determine 
the choice of individtial applications in many casea All other things 
being equal, those applications which are the simplest, the least expen- 
sive, the most readily obtained, and which need the least frequent chang- 
ing, merit adoption for general use. The particular indications which 
special wounds present will be considered in the chapters devoted to 
those wounds. 



I 
I 



CHAPTER XT. 
PROTECTION AGAINST DISTURBANCES OF HEALING— (Continot 



Potition — Compretiion — /mmoAi&ai (fan —Wire-gauze Splints — Plastar-of-Paria Spliute 
— Shells — Encircling Plutitr-baiiils^ — FeneittrBted — JuMrmpWd — -Combinei} — 
Chuiga of Dreaaings — AuodTnea. 

Rfsrr, as nearly absolute (w possible, b of great importance in favoring the 
ondiHturbed and rapid healing of !i wound. This involveB protection from 
motion and from esteniiU mechanical violence, the control of muscular 
spasm, and every means which will tend to insure quietude and comfort 
in the wounded part The means by which rest is to be obtained, include 
Position, Compression, Immobilization, Infrequent aud Careful Dressing 
and Anodynes. 

POSITION. 

That position should always be selected which will W comfortable to 
the patient. An uncomfortable position provokes general restlesaness and 
local muscular spasm. Attention to the comfort of the part canuot be too 
carefully regarded TIuh position will always be one in which the parts ai-e 
relaxed, and the return circulation of the blood to the heart is favored. The 
limbs, if wounded, should I» slightly flexed and elevated. In wounds of 
the lower extremity this is of more importance, and demands more care in 
its accomplishment The foot should be raifwd to a higher level than 
the knee, and the knee than tlie liip ; in eases of severe wounds the limb 
ihould be swung so that movements of the trunk should not disturb tli3 
injured limb. The relations of position to drainage should be kept in 
mind, and in the arranging of the means for drainage, whenever possible, 
the drains sliould be so placed as to be most efficient when the part shall 
havg been placed in the position of the great«3t comfort 



THB TREATMENT OP WOUITDS. 



COKPRESSION, 



Qentle, nniform, &nd continuouB preaeure is of great value in promot- 
ing rapid repair after injury. It reetraiDa excesaive "active hyperiBmJa." 
Uinite edusion, and promotes absorption of effiisions already present When 
properly applied it prevents muscular spaam, and thua becomea a valuable 
auxiliary in aecuring rest to the part, A greater and more metiiodicfll ap- 
plication of pressure tlian is needed for maintaining simple apposition of 
the separated parts is required to obtain the full power of compression 
in favoring the repoli' of a wound. Compression should be smooth and 
nniform, gentle but firm, while any constriction is carefully avoided. In 
moat cases it may be best effected by surrounding the wounded part with 
layers of cotton wool, and applying compression witli roller-bandages. 
The wool moulds itself eiactly to the limb, and by its elasticity tenda to 
evenly diatribut« the compression esercised by the bandage and to keep 
the pressure continuoualy unifoi'm. In cases of wounds of the limbs the 
bandage should be applied first at their distal ends, and carried up evenly 
and carefully over the woauded port, and above it for some distance. 
The means of compression will also be important elements of the means of 
immobilization, in the consideration of which the value of the compression 
itaelf is apt to be lost eight of. Experience, however, baa shown that im- 
mobilization ttiUiout methodical compression is more imperfectly and 
slowly efficient in promoting repair and delaying wound-disturb unces than 
when both are combined. Perfect quiet and uniform l.^ompreBsion are the 
most conspicuous agents which can reinforce the natural reparative energy 
of apart 

IMMOEILIZATIOS. 

Immobility is to be secured by the judicious application of splinte, 
pads, and bondages. A c^lint, whenever applied, should assist in furojsh- 
ing equable and uniform compression and support, as well aa fixation. For 
this purpose the various forms of plastic splints offer great advantages in 
many casea in which, as in penetrating wounds of joints and compound 
fractures, fixation of an entire limb is necessarj-. Such Bijlints accurately 
take the shape of the parts, forming a firm mould that encases and fixes 
the limb without pressing unduly at any one point Aa a result such 
splints are borne with comfort, and thus indirectly contribute still more to 
the well-doing of the wound. It is unnecessary to attempt to enumerBt* 






b 

c 



■WmE-OAOZE SPLINTS, 

fbe mai^ difierent materinls that in cases of emergency m&y be uaed as 
L aplinte. Wherever a woimJ may be received some agent tlmt will serve a 
B temporary purpose for immobilization mil be found. In lieu of bett«r, 
' btrndlea of straw or twigs, or layers of folded newspapers may serve an ex- 
cellent purpose as splints. Upon the battlefield \-arious weapons admit ot 
many most excellent applications as splints. Thin strips of wood, shaped 
i iccording to the requirements of the part to which it b to be applied, and 
I padded with cotton wool, will always be found to make most excellent 
Bplints. ITiere are two kinds of material, however, which from tieir spe- 
cial advantages as agents of immobilization in the treatment of wounds de- 
serve more extended notice. These are wire-gauze and plaster-of-Paris. 

JVire-gauzi^. — Tins materia] is made of wire from one-twentieth to one- 
tenih of an inch in diameter, woven into a fabric, tlie meshes of which are 
from three-tenths to five-tenths of an inch square, or the length of the 
mesh may be greater than the width. After the gauze is cleaned with 
acid, it is put into melted zinc, which covers the wires and fastens them 

» quite firmly together where they cross each other, making a firm and 
■bong fitructore. The material is a common article of commerce, is cheap, 
is to be found in all hardware shops, imd is put to many economic tises. 
Uy attention was first called to the value of this material for surgical pur- 
poses in 1873 when I entered upon duty as adjunct surgeon to the Long 
Island College Hospital, where it had been introduced by my immediate 

t]aedeces8or, Prof. J. S. Wight Its surgical uses have been described by 
VtoL Wight,' us follows ; In the first place, the fabric can be cut into any 
desired shape by a pair of tinsmith's sheai's. The separate wires may 
be cut out by a pair of cutting pliers. The pieces of gauze may be bent 
into any required form by the hands of the surgeon ; and wlien bent it 
will generally have enough firmness and resistance to keep its form under 
aU ordinary circumstances. It is very light — having the same extent of 
surface, it is lighter than wood, tin, zinc, or binder's board, used for 
■plints. It ventilates the part to which it is applied better than any other 
splint material It is verj' desirable where irrigation is needed ; it is non- 
absorbent. At any time it can be removed, disinfected, and reapphed 
yiHh facility. It may be strengthened by fastening to it by small staples 
light strips of wood. It may be used to strengthen plastfir-ot-Paris splints, 

I particularly when they are to be fenestrated. The combination of qualities 
; 



Tba Sargjoal Ukb of Wire-doth. Pioc«ediiii[H at tlio Meditut Society of the 
ConDtjr of Eia^ Janusrj 1801, p. 3^5. 



208 THE TREATMENT OF WOUNDS. 

which have been enumerated — its cheapneas, the readineea with which it 
can be shaped and moulded to a part, its Ughtness, its non-abaorbent 
quflJitiea, and the perfect freedom with which its open-meabed int^iBtices 
permit the passage of moisture tlirough it, make it n material of great 
value for purposes of wound-tlressiDgs. 

Plaster-of-Paria. — Of the various substances that hare been used while 
in a moiat and pliant condition to enrelop a part, a firm mould of which 
they ftfterwanl form by hardening, plaster-of- Paris has proved to possess 
iu the greatest degree the qualities needed for common use. It is gener* 
ally easily and (juicily procurable ; it is cheap ; its manipulation is sim- 
pie ; it quickly hardens and forms a firm and accurate envelope of the 
purt to which it ia applied, so as to insure absolute immobility and uniform 
compression with perfect comforL It is porous, and so does not prevent 
the escape of the natural per^iration from the parts covered by it 
Fine white plaster (dentist's plast«r) that has recently been calcined, is to 
be chosen for use in making an immobilizing apparatus. If it has been 
exposed to mojat air, it will have absorbed sufficient moisture to prevent 
its hardening readily and firmly. If fresh plaster is not attainable, the old 
may be made ^ain fit to use by reheating it For this* purpose it will 
simply be necessary to heat it in an iron pan over a good fire for half an 
hour, or until it ceases to "bubble." 

The part to be immobilized should be wrapped with a layer of cotton 
wool— sheet wadding — or in default of tliis, by strips cut from a woollen 
blanket A stout thread, or bit of cotton twine, wound in a rapid spiral 
over this prehminary layer of cotton or blanket, will be convenient in 
keeping them in place while the piaster is being apphed. 

Three different methods may be used in applying the plaster. 

One method is to cut strips of coarse blanket flannel, crash toweUing, 
or similar strong, open-meshed material, into suitable lengths and shapOE^ 
so that they will partially envelope the part like a cuirass, aa in Figa. 72 
and 73, and dip them into plaater-of-Faris when ndxed with water, so as to 
have the consistency of a rather thick cream. The cloth strips thus im- 
pregnated are then applied to the limb, and while the plaster is still plaetid 
are secured to the hmb by roller bandages. As many layers may be ap- 
plied as may be thought necessary to give the requisite strengtia to the 
splint The Bavarian sphnt (Figa 70 and 71) ia made by fastening two 
pieces of such cloth together by a row of stitching down the centre, and 
pouring the plasteiHTeam between the pieces. 




THE BAVARIAN PLABTER-SPLINT. 209 

"When it is to be employe)! the layers of cloth should be applied to the 

"Bmb so that the row of stitching is at the nether side of the limb j then 

the innermost layer is brought up about the limb and amootbly adapted 

to it, its edges, meeting in front, being secured with pins temporarily. 

len the plaster is poured thickly over the outer surface of this layer, aod J 




baii< 
^%ite 



in the inner surface of the outer layer, being uniformly spread over 
them by the hand of the surgeon. The outer layer is then to be brought 
up to the first, and after having been properly moulded to the hmb by the 
band, is confined by a roller bondage until the plaster has hardened. 

It will then be found that there has been made a splint consisting of 
lateral halves, connected together behind by a cloth hinge, which per- 
its the two halves of the splint to open like a book and expose the in- 
jured parta Wlien anterior and posterior strips (Fig. 72) are used, there 
results two aocurately fitting shells (Fig. 73) either one of which can be 
I 11 



lifted off to facilitate iDspection of the part, while it is atiU supported by 
the other. A great variety of forms of splints, as needed for special loca- 
tions and injuries, can be made from strips of cloth and plaster after this 
method. 

The following practical directions for the preparation of these splinta 
are by MacCormac (" Antiseptic Surgery," p 1S8), and are worth heeding : 
'■ Dressers seldom know the best way to prepare plaster-of-PariB for Tise. 
It is oft«n made too thick, and sets too soon ; 
or, it is too thin, and additional plaster is 
' added at tlie last moment, which makes the 
mixture lumpy and unmanageable. A suffi- 
cient quantity of water for the purpose in hand 
should be first poured into a basin, and then 
the plaster lightly shaken into it, handful after 
handful, or spoonful by spoonful, but without 
stirring, until tlie plaster just begins to float 
on the surface of the water ; then enough of 
plaster has been added, and, on stirring, it 
will quickly blend with the water, and a ho- 
mogeneous mixture, of the proper consisteDce, 
tliat of tliick cream, will be the constant result. 
" In this the flannel strips are dipped, and 
they will take the mixture better, and form 
a stronger and more durable s^ilint if they have 
been pre%iously wetted, all supci-fluous water 
UnwiiorwdPo-- being WTung out." 

Mi'uhiX'tTTM "^'^^ second method consists in the applica- 
tion of roller bandages whose fabric is satu- 
rated with the plaster. These bandages are prenously prepared .by 
rubbing into their interstices tho dry plaster ; when required for vae, 
the bandies, made into loose rollers, are immersed in worm water for 
a short time, until bubbles of air cease to escape, when they are at 
once appheil To reinforce the bandages, plaat«r-eream can be smeared 
over them after they have been applied. Onlinary muslin rollers are not 
well a<1apt«d for use as plaster bandages. A more open-meshed and ab- 
sorbent fabric is needed. The experiments of Dr. Nelson,' of Bo&toD, 




' Flastla Splints in Svxgerj. Anuab of Anfttoiaj' uid Suigerj, t 



., p. 170. 



THE PLASTER-OP-PARIS ROLLER. 211 
have shown that the cheap btcocbed cotton-cloth nsed for printed calico, 
if used before it haa received the dressing, ia a auperior fabric for plaetic 
use*. It is then £re« from oil and is absorbent. It haa the right texture 
to ioke up plaster and retain it. It gives the marinnim of strength, and 
when applied ts very durable. 

The impregnation of the meshes of the cloth with the plaster with the 

same Ume a dir^ and disagreeable process. The simple method suggested 

no. n— Antariot Lag SpllnL ^^^^^| 

L by Eemarch ("Handbook," p. 44) afforda a more satisfactory result in a 
H most convenient manner. It is to put the end of the bandage through a 
H Blit in an upright board (Fig. 74), in front of which the plaster-of -Paris is 
^■"placed ; the bandage is then rolled up in this heap with the fingers, 
^p The third method consists in applying bandages of open-meshed fabric, 
as gauze or mosquito -netting, to the limb, and then smearing them with 
the plaster-cream, adding successive layers of the bandage and of the plas- 
ter until a sufficiently strong splint ia built iifi, A very light, firm and 
^L tough splint can thus be built up. It is a 


^1 method to whic'U 1 uiu laysell very parLud. 
^M Where there are open wounds, open- 


^H 


^Lnady aooeat to the wound can be secured 


mi 


^^BmI bbtt twcape ol the MscieLious may Lake 
^^HfeHtl^^- "^^y These are beat made as 
^^EoD ta the plaster has hardened sufficient 
ment or crumbhng. The material can th 
strong sharp knife. The edges of the teneat 
^H of the spHnt can be rentlUy made impermee 
^fe come in contact with them by brushing the 
^f When the size of the opening required for 
wound is BO great that a connectiiig iathmi 
left, the sphnt may be made in different 


PlB. M, 

y to be cut without dtsplace- 
pn be cut quite easily with a 
nun and the adjacent surfaces 

m over with melted paraffine. 
the necessary exposure of the 
s of sufficient strength is not 
lections, and the two sections 
(Fig. 76). 







THE l^BATMENT OF WOmTDS. 

Plaster-of-Paris may often be combined to excellent purpose witii other 
materials, as wood, metal atiips or wire, or wire gauze, in the construction 
i>f splints for special purposes. A typical example of this is Been in 




rio, 7B,— Wlsdowal P!uUr ot- 



Bandiiga (£>m(ircll). 



Esmarcli's plaster-of-Paris suspension splint for excision of the wriat, which 
is a combination of a wooden or wire splint (Pig. 77), a wire suq>enBion 
bar (Fig, 78), and an interrupted plaster splint. The wooden splint ia 




Fia, TA— Inlsmptcd Flatii 



verj' narrow at the wrist, bent to a right angle at the elbow, and provided 
with a hole for the internal condyle of the humerus. The arm is placed 
upon the splint, wludi is padded with cotton wool and bandaged with 




PLASTER-OF-PAEIS SPLINTS. 



213 



jdaster-of-Paris roDers. Finally, after the suspension bar has also been 
baudaged on with plaster- of-FariB rollers, the arm is euBpended by a rope 
and pulleys, as in Fig. 79. One of the merits of plaster-of-PariB flints, 
aa well as of pinatic splints in general, is the readiness with which they are 
suspended, and tlius faeilititte the movements of the patient without en- 
dangering disturbance of the wound to the degree that la unavoidable 



^'^mieS^ 




when the wounded member lies on an immovable surface. The liuib, 
after having been encased in the splint, should be swung by pieces of rub- 
ber tubing or bands, passed around it at suitable distances from each other 

■ and tied to a bar above (Fig. 80). 

The removal of a plaster bandage may be accomphshed best by using a 

I auitable saw for dividing it. A large-sized Hey's saw makes a veiy con- 




Flo. re,— Wlro 



I Tenient instrument to be used for this purpose. The saw devised by 
Hunter, of Philadelphia (Fig. 81), is an excellent model It is necessary 
that the teeth should be widely set, so that a wide groove may be cut in 
the bandage tor the free pa-ssage of the saw. A powerful pair of shears, 
with one blade flattened so as to be insinuated beneath the splint, will 
Buffiee to sht up many splints. Fig, 82 shows the original model of 

. Seutin, which has not since been Improved upon. 



i 



211 



THE TEBATMHNT OP WOOITDS. 



SuBSEdDBNT DRE8BrMG8.^Too cotIj and too frequent interference with a 
wound may become an obstacle to the highest degree of success in secur- 
ing its undisturbed healing, Infrequent dressing ia eminently conducive 
to that absolute rest whiuh is to be kept in view in whatever method of 




treatment is adopted. When the first dressing of the wound has been 
conducted in accordance with the principles of rational wound- treatment 
which have been descriljed ; when the bleeding has been carefuUj and per- 




manently arrested, the wound-surfaces and recesses perfectly cleansed an 
rendered aseptic, the retention of eei,Tetions and debris provided agaiat 
by efficient means of drainage, the divided surfaces brought together a 



after-cabes. 



215 



far ae poeaible and retained in apposition, and aclequate meone of protec- 
tion against septic infection, mechanic^ injury, and motion, whether paa- 
mve or active, has been provided, its rapid and undisturbed healing will 
certainly take place, with but few changes of di'essings neceaaitated. The 
aft«r-cares from the surgeon will be limited to a watchful oversight of the 
means of protection and immobilization, of drainage and appoeitiou, that 
have been employed, that they be removed, substituted, or reinforced by 
others as soon as they are no longer called for, or have become inefficient. 
The course of the wound in its repair is largely dependent upon the per- 




fection which each one of the great indications for treatment which have 
been dwelt upon may have been met at the first It has been seen that 
the most frequent cause of wound-disturbance, as well as the cause of the 
most perilous of the disturbances that may complicate wounds, is the con- 
junction of the agents and the subjects of decomposition. The prevention 
of access of the one, and the removal, oa fast as formed, of the other, there- 
fore constitute the two great commandmerts of the law of wound-repair, 
each of which, equally, every one who undertakes to treat a wound must 
oomply with to the best of his ability, if be would acquit himself of re- 



^Fproachfo; 
^H the wouni 




h for the results of disturbance that may supervene in the progress of 
8 wound Inflammatory, erysipelatous, gangrenous, or septicEemic com- 
pUcations attacking wounds can no longer be regarded aa unfortunate and 
unavoidable accidents, but must be regarded aa the results of errors or 
failures in the treatment which the wounds have received It is especially 
. in the treatment of fresh wounds that the responsibility of the surgeon is 
[ the greatest, since " the fate of the wounded man depends almost entirely 
I upon the apphcation of the tirst dressiag." When a neglected wound, or 




216 THE TKEATMENT OP WOUNDS. 

one alreatly manifestly aeptic, comes under the care of the surgeon, his re- 
sponeibihty is leBS than in the case of fresh wounds, but his duty BtiU ia 
manifestly to pereietently endeavor to convert the dangerous septic wound 
into one that is aseptic, even if the trial be made in vain. 

"When the first dressing of a wound has been succesefuUj and perfectly 
accomphshed, it may not need to be disturbed for some days; in some 
cases, as lias been mentioned in connection with siwcial methods of protec- 
tive dressing, ten and fourteen days may be permitted to pass without re- 
moving tbe dreBBJngs, by which time the wound may be found to be quite 
or nearly healed. In all cases where the external protective dressings re- 
main dry, as long as the wound remains free from pain and fetor, and 
there is no acceleration of the pulse nor elevation of the temperature, the 
dressings may remain undistarbed. The use of tbe thermometer ae s 
guido to the surgeon is an invaluable aid, a lise of temperature being n 
sign tliat should invite immediate examination of the wound for the begin- 
nings of possible disturbances there, although it may also be occoaioned 
by intercurrent troubles in other parts or organs of the body. 

It is impossible to fix arbitrarily the periods for the renewal of the 
dressings. Each caue must be a law to itself, according as the special con- 
ditions which it may present may determine. The indications which the 
drainage, the sutures, the compresses, the protective appliances may pre- 
sent have been sufficiently set forth, as to the principles that govern their 
use, in the various sections already devoted to their consideration. 

In the changing of the dressings, and indeed in all the monipuktloiis 
required about the wound, the utmost gentleness should he used, coupled 
with a dehberate speed that is possible only when nothing is done without 
a purpose, and every preparation for accomplishing that purpose has been 
made beforehand. When splints are apphed for purposes of immobiliza- 
tion, they should be so apphed that they shall not interfere with the re- 
moval of the immediate dressings of tbe wound when necessary, in order 
that no necessity may arise for the premature removal of the splints. 



The various preparations of opium, by the relief of pain, and the feel- 
ing of genera] well-being and comfort that they create, by their tendency 
to quiet muscular spasm, and to steady the heart's action, may contribute 
in aji important degree toward Becuring the desired rest for a woosd. 



ANODYNES. 217 

They sfaonld be giyen in small and often-repeated doses, according as pain, 
leetleeanesB, irritable pulse, or mnscular twitching may demand for their 
control When an ansasthetic has been given, as in surgical operations, 
the administration of an opiate by suppository introduced into the rectum, 
or hypodermically, should be made while the patient is yet under the in- 
fluence of the ansBsthetic. 




THE REUEP OP DI8TURBAHCES OF HEAUNG— INFLAMMATION— 
QANGBENE— ERYSIPELAS— SEPTICEMIA. 

TVtainienl of Inflammation — Opening Ute Wtmnd — hieiaions — Reniotal of foreign 
Bodiet — Poiition — Compreuion — Reduction ofHeot—CuXA CompteBfleB— Evapomi- 
ing Lotions — Irrigalion — ImmeiBion — Ice-bags — Oold Water CoiU — Relaxation of 
Yeeidt — AbttTaetian of Blood — InUrrwpting Oie Bloodrtupj^y—Riiumi — Treat- 
ment of Oangrene -lacLaiooB — CoBtiunoas AudHsptio Irri^'atiaii— StimDlanta — 
Treatment of ifr^ffpe^f—AcUaeptlcg— Subcutaneous Injectloas of Carbolic Acid 
— SopBrBoial Appticatians—Napb thai in —Tonics and StimulantB — AndphlOKia- 
ttcB — 7'reatmenf of Septieamia — Lockl Diainfeudou — Geneial Treatment. 

INFLAMMATION. 

The treatment of an inflamed wound must be directed both to the removal 
of the cause of Uie inflammation and to the relief or mitigation of the con- 
ditions that attend it, or result from it. The substitution of destnictiTe 
iufLunmation for the constructive processes that make for the repair of n 
wound never takes place, except as the consequence of defects either of 
wound-deanlinesB, or of wound-protection, or, more frequently, of both, 
hence the first duty of the surgeon, when in the presence of an iufluned 
wound, is to seek for its causes and to address himself first to their 
removal 

With but few exceptions an inflamed wound is a septic wound, and 
the cause of the inflammation is the irritation of the products of decom- 
position of retained secretions. It is, accordingly, those wduhiIs in which 
the retention of secretions is most difficult to prevent, as in wounds of 
joints and other cavities, wounds lending down to fractured bones, and 
ileep, irregular-punctured wounds, that severe inflammation is most fre- 
(juently met with. 

To give free vent, therefore, to all wound-secretions that may have 
been retained is the first thing to be attended to in the treatment of Buch 
a wound. This may require nothing more than the cutting of a stitch, so 



TBBATMENT OF IKFLAMMATIOK. 



219 



I 



tiiat the natural gaping of the wouiid may suffice for the required vent, or 
it may reqiiiro counter-incisions and the use of draina 

Whatever means the special couJitioiis of the porta may make neces- 
sary should be thoroughly and syatematically employed until ample pro- 
vision for the entire flowing away of the secrGtioiia as fast aa formed has 
been secured. "In all Bpreading and difiuae indammntions, incision is 
the remedy of paramount utility, because death of subcutaneous tissue 
occurs early — sometimes, indeed, as the initial lesion of the case — and, 
until an avenue of escape is provided for the sloughs, pus formation tends 
to advance progressively beneath the skin, where it is liable to be attended 
by indefinite destruction of tissue. When timely and sufficiently ample 
Openings have been provided, the destructive process is in most iastanuea 
urested at once. Incisions save the integument, which would otherwise 
be destroyed by the spontaneous formation of gangrenous patches — a re- 
mit which, without this remedy, is almost inevitable. In this way, in- 
deed, both the necessity and the great value of early, free, and bold 
incision is demonstrated'" 

Mechanical irritation, motion, and premature use of a wounded part 
may provoke inflammation by preventing or breaking down adhesions, 
inflicting mechanicai violence upon tender tissues, interfering with repair, 
and thus presenting anew the conditions) in which septic changes may be- 
come rife. Tlie search for and removal of foreign substances that may 
bave been left in a wound, as splinters of wood, pieces of glass, rusty 
bits of clothing, detached pieces of bone, etc, must not be over- 
looked in cases where their possible presence may be the cause of the 
btion. 

When the causes of the iudammation liave been removed, all those 
by which perfect rest of the part can be secured become of the 
greatest importance. The part must be phuied in an elevated and coni- 
fiirtabla positioii, and must be immobilized. Then may be used such 
other means to relieve or mitigate the pain, heat, and ewelling of the pai-t, 
iod to overcome the vaacultu' congestion upon which they depend, as the 
conditions of the wound and the judgment of the surgeon may in<licate as 
needful and pi-acticable. The means available for this piu-pose act either 
^by compressing the swollen tissues, reducing the heat, relaxing the ves- 
mhIs, abstracting blood, or interrupting the blood-supply. 

COHPBBSSioN. — The practice of compression with immobilization is at- 

' Van Baren : Inlernatioaal Eacyolopa^dia o( Surgeiy, L , p. (St. 



220 THE TEEATMEHT OF WOUNDS. 

tended with the moet marked advantage in the treatmeDt of inflamed 
n'ounds. All ttiut bos been «ud with reference to their use as protective 
measures to healing woimda applies with j-et more force to an inflameii 
wound. The compression must be even and continuous, and must be 60 
applied as to avoid any constriction. Falu and strangulation, with gan- 
grene, may result from attempts at circular compression in which every 
part from its distal extremity upward is not equally compressed. Properly 
applied compression is attended with comfort, and whenever it produces 
discomfort the means of compression sliould be rearranged or removed al- 
together. An elastic roller bandage of pure rubber (Martin's bandage) 
can be used to make compression with very great advantage, and may be 
adapted to every region of the body. Rollers of soft cotton cloth, or of 
flannel, with layers of cotton wool, enveloping the inflamed part, may be 
used for making pressure. Compressed sponge, confined by a bandage, 
and then supplied with water, may be made the agent of strong and elas- 
tic pressure by its tendency to swell. Bags of water, or of other sub- 
stances that will [lermit on even adaptation of their sur&ce to that of the 
inflamed port, may be Liid upon inflamed port^ so as to exert uniform 



The Reduction of Heat. — The judicious use of cold, locally applied, 
is of especial value in antagonizing the tendency to the excessive active 
hypenemia which marks the earlier phases of inflammatory action. It ab- 
stracts beat, constringes the vessels, and acts as a local sedative. Ita 
power to diminish vascular excitement may be pushed to such an extreme 
that deficient nutrition of the ports to which it is applied may be pro- 
duced, and deficient rejMiir, even local death, result. Its use should be 
confined, therefore, to the control of acut« inflammatory conditions, or as 
an application to wounded parts in which inflammation is both prone to 
occur and to be followed by disastrous consequences, as in wounds of 
joints and of the head. Cold should be so applied as to maintain a con- 
tinuously uniform low temperature, for when applied intermittently each 
application is followed by more or leas vascular reaction which disturbs 
the repair of the wound. 

Cold Compresses. — Cold may be applied by enveloping the part in 
compresses wrung out in cold water, the compresses being frequently 
changed before they have become warmed. This is apt to disturb the in- 
jured part, and is likely to be neglected, so tliat it is an unreliable and 
objectionable method, though the one most frequently adopted. 



APPLIOAHOS' OF COLD, 



321 



Evaporating Lotions. — CompreBsea may also be wetted with & dilute 
Klooholic lotion, the rapid evaporation of tho spirit sudicing to coo! the 
puis. Lotions containing a mixture of equal parts of anunonium chloride 
isal ammoniac) and potn«sium nitrate (saltpetre) lower in a marked de- 
gree the temperature of parts to which they are applieil A strength of 
half an ounce of each salt to the quart of water is the proportion most 
i frequently used. 

Irrigation. — Continuous cold may be apphed to a part by arranging a 
f neeel of cool water above it so that a constant dripping of Uie water upon 
I it may be secured (Figs. 83 and 84), The pai-t should first be covered by 




Via. Kl— IrrlgMlon 



t piece of cloth large enough to extend upon the inf«gument several inches 

Rbeyond the wound, upon which tho water from the irrigator shall fall and 

leu be diffused. The evaporation of the water from the compress is quite 

rapid, and increases greatly the cooling effect of the irrigation, so that it is 

not necessary to employ water of a very low temperature. The water as it 

i away should be caught upon an inclined plane (Pig. 83), or upon 



TIIE TBEATMENT OF WOUNDS. 

some waterproof mnterial benenth the limb (Fig. 84) and guided into a 
receptacle below. The needful appn^ratuB for irrigation may be extempor- 
ized from very simple materials. A common wooden or tin pail, a bottle 
with tie bottom knocked out, an empty fruit-can, a wash-basin, a cup, 
anything that will hold water, and any material that will absorb or convey 
water suffices. The water may be conveyed by making a siphon of a bit of 
rubber tubing (Fig. 8.^), or glass tubing (Fig. 84) or out of a piece of 




candle-wick in g or mmilar absorbent fabric. Tubes may be inserted into 
the bottom of the vessel containing the water, and the amount of the flow 
regulated by the use of suitable plugs in these outlet tubes. 

Immttrmon. — W()nndB of the extremitieH may be immersed in cold 
water, suitable vessels being provided in which the inflamed member may 
be laid. A very low temperature is not needed for producing energetic 
reduction of temperature. The frequent addition of cool water to keep 



tLe temperature of the bath down to the desired point will require watch- 
ful care. 

Ice-bags. — Rubher bagra (Fig. 85), or, when they are not acceesible, 
Uaddeis, may be partly filled with pounded ice and be laid upon a pari 
This method is particularly convenient for the application of cold to the 
head and to the joints. If the direct application of the ice-bag is too cold, 





Wirt 

1: 



kyers of cloth may be laid between the ice-bag and the part An ii;G-biig 
amy be securely closed by wrapping ita closed month about a wooden disc 
or lat^e cork, as in Fig. 85, and tying it by a tape. 

Cold Water Coiln. — Cold may be continuously applied to any jiart of 
liie surface of the body by placing upon them mats formed of rubber 
tubing coiled to the requisite size and shape, the coils being secured by 
wire tape, and by possinj;. pither by fountain or siphon action, a continii- 
current of cold water through the tubing from a reaen-oir placed at a 
.venient height.' Similar mats may be made of soft metal (Tjeiter's 
'tabes). The estremitiea may be encircled by spiral turns of tubing 



' W. M rhamberlii 
n of Body Tempecst 



! The Uses of Hobber Tubin? In tho Theinpeuttos of Eedi 
rj. The Heaicat Becatd, Apnl £9, 1B83, p. 401 



THB TEEATMEST OP WOUNDS. " 

tlirough which the water may flow. Fig. 86, from Esmarch'a "Handbook," 
shows a forearm thus encircled bj a tube, one end of which is placed in & 




vessel filled with ice-water, ^lule the other, hanging down, discharges the 
current into an empty paiL Fig. 87 illustniteB the application of the cold 




fra. ST.— OooUBf Cea t OIU% 



TmtcT coil to the penia. ' The coila of tubing are retained in place by ■ * 
band of cotton or linen cloth. 

Tee Relaxation or Vessels. — Warmth and moisture produce a soothing^ | 

' F. N. Otis : The Cold Water Coil in loflammatlon of tlia Extenwl Hole Oenlbkl \ 
Appumtoa. The Hediml BMord, Jftnuuy 9, 18TS, p. 19. 



POULTICES. BLOOD-LETTING. 235 

md relaxing effect upon an inflamed part directly opposite to that of cold. 
They promote dilatation of the vessels and thus reUeve tenmon by enlarg- 
ing the calibre of the vessels through which the blood is crowding. They 
favor exudation and thus reheve the congested veaaela They relieve pain 
and thus diminish the effect of reflex irritation. Moist heat may be ap- 
plied by compresses wrung out in hot water — fomentations — by poultices 
and by immersion in hot water. The compresses and the poultices should 
be covered over by a layer of impermeable material, na oiled ailk or rubber 
tissue, to retain the heat and moisture and lessen the frequencj' with which 
the application requires renewal For poultices any substance capable of 
being reduced to a soft musliy consistence with hot water may l>e em- 
ployed, but on account of the general facihty of its management and the 
length of time that it retains its heat and moisture, ground flaxseed is to 
be preferred. Poultices should not be made so thick aa to be burdensome 
by their weight, nor should they remain unchanged for a longer period 
than six hours. Immersion in hot water is the most beneficial method of 
procuring vascular relaxation, and is to be chosen whenever practicable. 
It may contribute likewise to drainage anil to wound cleauhness. 

The Abbteactios op Blooo. — Local bleeding may have a very benefi- 
cial effect upon an inflammation by the reUef of tendon which it produces 
I npon the congested tissues and the over-distended vessels. It may he ob- 
I laiued by scarifications, by incisions, by scarifications and cups, and by 
I leeches. The bleeding which may attend the incisions required for the 
more free drainage, and for the relief of tension in inflamed parts is of value 
I in immediately reheving the congestion caused by previous conditions. 

Tee Iktebruption of the Br/ion-strppLV. — The attempt to diminish the 
1' amount of blood supplied to an inflamed part is a logical result of the re- 
cognition of the tact that the active afflux and tindue retention of blood in 
the part is the most prominent factor in the distress and damage which an 
1 part siifiera Against this active hyperemia most of the remedial 
-measures which have been used have been directed. Position, compres- 
Lsion, cold, and blood-letting have been seen to be of benefit either by pre- 
mting the blood from going into a part, or by removing it from it. This 
■■may be yet more effectually accompUshed by cutting off the main stream 
I of Wood from the engorged tia'3ues, by which device the veins ore left of 
Fiheir original cahbre to drain away the superabundant blood, while the 
k volume and force of the arterial current are greatly diminished. As the 
E-neult, the over-distended capillaries soon recover their normal calibre, and 
* 15 



296 THE THEATMENT OF WODHDS. 

the orilinary processea of nutritioii and rep&ir are re-egiablished. Int«i«- 
ruptloa of the blood-supply may be accomplished by the various means 
which have been diAcaeeed In comiection with the arrest of hfemorrhage 
(Chapter Tl), viz.: forced flexion, compression of the main artery by 
meami of the finger, tourniquet or a weig'ht, acupressure, and ligation. 

Forced flexion is particularly applicable to the treatment of inflamed 
■wounds of the forearm and hand, and is easily and well combined with the 
means of elei'ation, compression, and immobilization. The interruption at 
the current through the main trunks of the lower estremity is better ao- 
compliahed by the hgature. A» haa been pointed out by Mr. Maunder,' if 
compression is used to temporarily interrupt the current, and for any rea- 
son should be relinquished too boob, the blood would then not only paw 
to the inflamed spot through the enbu-ged smaller vessels, but also through 
the main channel, and thus an ailditional and injurious supply would re- ' 
suit. The gravity of the proposed operation of hgation will cause this 
means of controlling inflammation to be resorted to only in caaea of de- 
structive and escesHve inflammation. For the first definite formulation of 
the indications for the use of hgation of the main artery of supply, as a 
means of arresting acuf« trainnatic inflammation, and for its practical de- 
monstration by a series of cases, the profession is indebted to Dr. H. F. 
Ciunpbell, of Georgia, under whose direction, in 1862. in the military hos- 
pitals of Richmond, Ta, hgation of the femoral artery in four cases, and 
of the brachial in three cases, was performed for the arrest of riolent and 
uncontrollable inflammation. In all these cases the pain, the swelling, and 
turgeacence were almost immediately reheved, and the most remarkable 
improvement was soon seen in the character of the discharges." Six of 
these cases were reported by him in his chapter on the hgation of arteries, 
in the "Manual ()f MiUtary Surgery," published by the Surgeon-General 
of the Confederate States Army in 1663, in which the author (pp. 104, 
105) states that in all these cases the Hunterian operation was chosea with 
the distinct end in view of combating and checking, if possible, the de- 
utructive progress, and, in some, the septic tendency of the inflammation. 
Dr. D. F. Wright, of Tennessee, reported in 186G ' five other cases, under 

' Bargery of the Arteries, London, 1875, p, 163. 

* Henrv P. Campbell : The Haaterian Ligation of Arteries to Believe and Fteveat 
DeBtractire InflBrnmation. Southern Joamol of the Medical Soiencaa, August, 1866. 

' Thempentio EffecU of the Ligation of ArteriM. ItiobmoDd HedioAl Joaiaa), 
AprU, 1666. 



i 



TEEATMETTT OP GANQEEITB. 

his observation, in vhioli tlie Huiit«nan ligtitioD of the main &rf«riRl trunk 
of a limb had been done for the arrest of aeeondory haemorrhage, and in 
all of which, immediately from the date of ligation. " large tumefaction had 
been superseded by recovery- of the original contour, fetid ichorous dii*- 

I charge by laudable suppuration, and phagedenic gangrene by Tigoronn 

k grnnulationa" 

Mr. Maunder, of London, in hie work on " The Surgery of the Arte- 

\ ries," reports six eases of ligature of arteries for the control of traumatic 

t inflammation, and after discussing the various aspects of the practice, suni- 

f norizes his experience, thus : 

" That ligature of the auperfidal femoral artery has arrested acute in- 

I flamniation conaeqaent on wound of the knee-joint. 

" That ligature of a main artery will quickly diminish profuse suppura- 

I tion and prevent death by exhaustion. 

"That, while it arrests profuse suppuration, it will, by allowing the 

I patient to gain strength, afford an opportimity for amputation at a future 

[ time. 

*■ That gangrene and secondary luemorrhf^e, as the result of ligature, 

I aboulii not be anticipated in the healthy subject." 

S£bi<m£. — The Tarious resources which have been mentioned for antag- 
onizing and mitigating traumatic inflammation are sanctioned by the prac- 
tice $f the past and by the authority of surgical tesichers ; but the more 
accurate knowledge of the present with reference to the essential causes of 
inflammatory disturbances of wounds must relegate them to a less iinpor- 
iant place, while the greatest importance must attach to those measures 

I Triuch may rid a wound of the agents and uubjecta of sepsis. Free ind- 

I flions for the relief of tension and the escape of debris, adequate drainage, 
cleanliness in the aseptic sense of the term, with proper protection and per- 

I feet rest, afford the surest and speediest means of overcoming inflamma- 

I tion, since tliey remove its causes, carry away its products, and favor in 

I ttie highest degree the natural nutritive processes of the part, by means of 

I which recovery from damage already sustained is to be secured, and repair 

T of the original injury is to be accomplished. 

GANGRBNB. 
The appearance of spreading gangrene in a wound calls for immediate 
enei^tic antiseptic treatment to destroy the micro-organisms, the caustic 
products of whose vital activity, as they successively invade new t 







228 THE TREATMENT OF WOUNDS. 

produces the gang;i'enous phenomena. All necrosed tissoe 
removed at once with knife and scissors, and the hving tiiwues exposed 
should be freely and thoroughly cauterized by the eight per cent, chloride 
of zinc solution, which should be injected into eveiy recess and irregu- 
larit^ of the wound. Tlie swollea and infiltrated tissues leading from the 
gangrenous focus, particularly the intermuseular interstices and the sub- 
cutaneous connective tissue, should be opened by numerous small incisions 
through the integument to permit the escape of secretions and of dobria 
and to enable the disinfecting fluid to be introduced into as many places 
as possible. Longer incisions and counter-incisions may Ije made as 
shall be required for the rcbef of tension and for the freest imaginable 
drainage. When gangrene has attacked a wound, the wound must be kept 
exposed, so that its condition may be tmder continuous observation while 
the means of powerful and permanent disinfection are being employed. 
An open method of treatment with contiuuous antiseptic irrigation offers ft 
most effective means which will overcome the most serious eases of sepsis 
when all other precautions have been found insuiBcient. The adjacent in- 
tegument should be freqiiently anointed with vaseline to protect it from 
the macerating influence of the irrigation. 

As an irrigating fluid, a dilute solution of c^rboUc acid (one per cent) 
is adequate. As a substitute for carbolic acid in making permanent irri- 
gation, Bruns,' of Tubingen, advocates the use of weak nolutiona of acetate 
of alumina (one-half of one per cent). This has sufficient antiseptic 
strength, and does not produce eczema or intoxication. The antiseptic ir- 
rigation should be continued until the wound is rendered perfectly aseptics 
Iodoform dressings then will be particularly applicable as protective and 
absorbent dressings. 

The general strength of the patient must be kept up by the hberal use 
of alcohohc stimulants, by nutritious food, by tonics, and by anodynes. 

ERYSIPELAS. 
When the repair of a wound becomes disturbed by erysipelas, the pa- 
tient should at once be isolated. A surgeon or attendant should not pass 
from the care of an erysipelatous case to that of a healthy wound until 
after the most thorough antiseptic precautions for securing cleanliness 

' Dk permanmite Irrigation mit euigiottrw TKanerdt, BarHn. UinMu IFMAm* 

lehrift, 1878. No. 80. 



I 



THEATMENT OF EBYSI^LAS. 229 

have becD obserred. The appearance of erysipelas ia always due to Bome 
defect or neglect in the antiseptic precautiuoH. Greater care is required 
to prevent the occiureDce of erysipelas than of suppurative and putrefac- 
tive reactious in general, but adequate means to keep wounds aseptic have 
beeu proven to be efficient barriere againet its development The remark- 
able experience of Nussbaimi that, although previous to the introduction 
of aseptic methods of treating wounds into the General Hospital of Mu- 
nich, almost every wound was attacked with erysipelaa, and after its intro- 
duction no instance of eryoipelas occurred, has already been referred to in 
a previous chapter (Chapter UL). Similar, though less absolutely perfect 
results, have attended the attempts at aseptic methods of other surgeons. 
The first thing to be recognized, therefore, upon the appearance of ery- 
sipelas in a wound is that it is of specific septic origin, and that it most 
espedaJly calls for those methods of treatment which are ailapted to eep- 
tic wounds. It is no longer correct to say that the pathology of erysipelas 
is still involved in obscurity ; the reiiearches of Fehleisen, referred to in 
Chapter ID., pi^e 44, have definitely demonstrated, what had already been 
inferred by many observers, that erysipelas is due to the infection of a 
wound by a specific micro-organiam, a micrococcua Based upon this, it 
is possible to construct a rational and efficient therapeutics of the disease. 

Treatment may be directed for the purpose of either : 

1. Destroying or rendering inert the specific micrococcus, Anti»!ptics. 

3. Increasing the resisting powers of the invaded tissuea Tonics and 
elimuianls. 

3. Alleviating the local iofiammation and removing its products, 
AtitiphlogUlKS. 

AsTiSEpncs. — The power of antiseptic substances is more readHy exer- 
cised as a preventive means than as a curative resource. The infiltration 
of the tissues with the micro-organisms tends to render them inaccessible 
to antiseptic applications, unless these be of sufficient strength to destroy 
the tissues as welL The germs, according to Fehleisen, spread along the 
lymphatics only, but their dissemination takes place not only along the 
coarse of the lymph stream, but in all directions, without reference to the 
direction of the lymph current. Their destruction, when isolated, by anti- 
eeptic agents, was experimentally demonstrated by Fehleisen with carbolic 
acid and corrosive sublimate. The isolated micrococci, exposed to tlie 
action of a three per cent solution of carboUc add for twenty seconds, 
remained active and potent ; when exposed for thirty seconda, their devel- 



J 



opment was imperfect and retarded ; when exposed for forty-five seconda, 
tliey were destroyed altogether. A one per cent, solution of corrosive 
Bubliraaf« destroyed tliem much more quickly, on exposure of ten to fifteen 
secondH being sufficient to prevent their development. Fischer,' of Straa»- 
burg, claimB for naphtholin that it haa a specific power to antagonize the 
micro-organisms of erysipelas. 

Subcutaneous Infections. — Hueter," of Glreifswald, in 1875 recommended 
the early subcutaneous injections of dilute watery solutions of carbolic acid. 
Hypodermic injections of salicylic acid have also been used with success. 

The use of subcutaneous injections of antiseptic solutions to abort 
attacks of erysipelas has been found to be moat certainly successful when 
employed at the onset of an attack ; later, when the infiltration of the 
pathogenic organisms and the inflammatory reaction has attained a greater 
extent, it becomes less probable that the antidote can be injected so as to 
come in contact with the noxious particles in sufficient quantity and to the 
necessaiy extent Differences in the etage of the disease at which these 
injections are practised, and in the manner in which the injection is per- 
formed, will explain much of the diflerenoes in the results obtained by 
different surgeons. 

The antiseptio to be used must be one that is not too irritating, that 
is diffusible, and that will not coagulate the tissues among which it is in- 
troduced. Carbolic acid, in dilute watery solution, answers these indica- 
tions better than any other agent of equal antiseptic power. Carbohc 
acid was the antiseptic used by Hueter, The method of its use finally 
settled upon by It in ' was to inject three t« five hypodermic syringefuls 
of a three per cent, watery solution of the acid, at numerous points, into 
the healthy subcutaneous tissues along the borders of the erysipelatous 
patch. These injections demand repetition once or twice, according to the 
iat«nBity of the inflammation and its tendency to extend. Even three or 
four repetitions may be needed before the eryaipelas will cease to advance. 
In but few cases will this method of treatment fail to greatly circumacribe 
the disease. 

£. fioeckdl,* of Strassburg, after testing the method in a series of cases, 

' OmtralbtaU f&r Chirurgie, Nov. 28, 1889. &ibgt, p. 3, Congreis of 
Sorseona, 1863. 

' SeiittcJu ZtiUeArift far Chirurgie, 1875, 4 Bd., Hett 5 and 6. 

' SohOIler. JahTttberieht. Dt\fUche ZtUteArift f6r Uhirargit, 1878. 

* QoKtU m^aaU d* Stratbourg, 1S7S, No. 6. 



I 



TREATHENT Of EBTSIPELAS. 291 

concludes that, vhile injections of carbolic acid are cot a paaaceo, jet they 
conatitut« the moet certain remedy which we possess. By iujecting, morn- 
ing and evening, from live to six hypodermic Bi-riugeE>ila of a one and a 
half per cent carboho solution, one-hfth of an inch from the inflamed 
horder, along the entire circumference of the erysipelatous patch, he was 
frequently suoceaeful in arresting a Teiy severe erysipelas within twenty- 
four hours. 

Tillmans,' of Leipzig, is of opinion that subcutaneous injections of car- 
bolic acid have their greatest usefulness in preventing or mitigating a 
threatened outbreak of erysipelas, and that for this end they should bo 
energetically used at the beginning of an attack. He quotes Kdster, of 
Berlin, as alfio of the opinion that, at the onset of an attack, the measure is 
of great value, but that later it is wholly or nearly worthleas. 

To some surgeons it has happened that abscesses have frequently 
formed at the sitea of the injections. This, however, can be easily avoided 
by care that only a clean syringe be used in making the injections, and by 
directing the point of the needle in various directions, so that the fluid 
injected is diffiised over a larger extent of tissue. 

Svper/tdal Applicaiioiis. — The npphcation of antiseptic mbstances to the 
surface of the skin in many cases is of beneflt, but the results are compar- 
atively uncertain and weak. Tincture of iodine, tincture of the chloride 
of iron, tar, strong solutions of nitrate of silver, of sulphate of iron, of sah- 
cylate of sodium, of carbolic acid, and other agents, have been used by 
^'arious surgeons, and in turn have been esteemed as of value and as 
inefficient 

Naphthalin, made into an ointment with vaseline, or other appropriate 
exdpient, in the strength of from ten to twenty per cent, and thoroughly 
smeared over the afibcted surfaces, will cause the unpleasant subjective 
symptoms of erysipelas to disapjwar rapidly, followed by a more slow sub- 
sidence of the swelling or oedema Usually its appUcation beyond the 
limits of the disease will check its further spread, or at least mitigate it 

Tonics ahd Stimulakts. — The general depression and febrile reaction 
which attend attacks of erysipelas are themselves the results of septic in- 
fection by alisorption of the products of the local disease. With the sub- 
sidence of the local disease, the general symptoms also disappear, and yet 
by reason of tiie general depression of tbe natural resisting power of the 



339 THB TEEATMEITT OP WOUKIW. 

body wliicU they produce, they may contribute to the greater severity and 
the prolongation of the local trouble. Those general remedies, therefore, 
will be of value which shall either contribute to general nutrition, or shall 
act as stimulants and roborants. A supporting diet is of importance. The 
use of proper means to keep the digestive and excretive apparatus in actdvs 
condition must be resorted to. Tincture of the chloride of iron, quinine, 
and opium are of great value in many coses. 

AiTFiPHUMisTics. — Since the local inllammatory phenomena which mark 
erysipelas constitute Hb most obvious symptoms, the mitigation of these 
phenomena constitute a very important part of the treatment called for. 
The treatment of the inflammation is to be conducted on the same princi- 
ples and by the same methods which have been discussed in the first part 
of this chapter, ^lien the inflammation is limited to the skin only, thorn 
apphcations which will soothe and protect it find use. A layer of absorb- 
ent material kept saturated n-ith a lotion of lead and opium (Uqoor. 
plumbi subacetatis, 3 j, ; tinct. opii, 3 ss. ; aqusa fervent., Oj.) is an ex- 
cellent appUcation ; or the skin may be dusted with finely powdered 
starch, lycopodium, or subcarbonate of bismuth, and covered by a layer of 
cotton wool ; or it may be anointed with oil or vaseline, either pure, or con- 
taining some antiseptic, or sedative, or astringent substance. 

'When the deeper structures are involved in the inflammation — pM^- 
monous erysipelas — all the resources of art for the control and reUef of in- 
flammation become drawn upon. Position, rest, cold, heat, immersion, 
antiseptic irrigation, multiple incisions, drainage, compression, depletion, 
are to be used, each in accordance with the indications and methods 
already laid down for combating inflammation in general. 

SEPTICEMIA. 

Septicffimia is a generic term that includes every grade of general Bejv 
tic infection produced by the absorption of septic wound-products, from a 
slight febrile reaction to the cases of more intense blood-deterioration with 
the formation of difiused secondary suppurating and septic foci (F^semia). 

LocAi, TaEiTMEST. — AU that has been said as to the treatment of local 
septic disturbances nppUes with equal force to the treatment of general 
blood-infection, for where further new supphes from local septic foci are 
arrested, the return of the blood to its normal state, by the eliminatioa 
and destruction of the septic matters already mingled with the circulating 



TREATMENT OF SEFTIOiEMIA. 2«S3 

fluidfl^ begins at once to be manifest Local disinfection, therefore, is the 
first and most important matter to be accomplished in the treatment of 
traomatic septicsamiai 

Secondary abscesses, whenever they are accessible, should be treated 
.upon the same principles as the primary suppurating d^p6ta 

Besection of joints and amputation of limbs may become necessary in 
some cases when less radical means fail to render the wound aseptic. 

OENsaiL Tbeatmknt. — The indications to be met by general treatment 
axe to mitigate general symptoms, to favor elimination, to counteract pros- 
tration, and to relieve organic complications as they arise. 



PART II. 



SPECIAL "WOUNDS 



SECTION I. 

VARIETIES THAT MAY OCCUR IN ANY PART OP 

THE BODY. 



I 

I 



CHAPTER Xm. 

SDBCTJTANE0U8 WOUNDS— INCISED WOUNDS— CONTUSED 
WOUNDS— L4CEBATED WOUNDS. 

I BabonUneoiu HnmorrhBge— Restiicdon and Absorption of E£FiiBions— Massage— Drr 
Cnplringr—Soibefacientfl—Infl a in Illation— /nFijerf WaUTtdt— Rett— Contused and 
Laeerattd irouTW&— PeouHBrides— Seocradary HffimorrhafB— Primary Cloansing— 
Drainags — Neorosia o( Tiasno— Coaptation — Period of Gtanalation — ContVMd 
Puneturtd Wtntnda — Inciaioua. 

SUBcnTANEOUS WOUNDS. 
Tee perfection of the protection which the unbroken flldn affords to a sub- 
cutaneous wound simplitieg vers' much the treatment which is demande<!, 
while it at the same time diminishes very greatly the dangers fo be appre- 
hended, of disturbancea arising in the course of its healing. As subcu- 
taneous wounds may be of every graile of severity, from a slight bruise to 
ruptures and lacerations of important organs, and the disorgTUiization of 
extenfflve masses of tissue, the amount and character of the treatment 
which they must receive will greatly differ. Mere inspection may not be 
anfiScient to reveiil the amount of damage, the repair of which is to engage 
the assistance of the eui^eon, nor may its ftdl amotmt be recognizable 
nntil after some time, when its subsequent course shall have demonstrated 
nunc tnUy its extent by the degree of functional disturbance which results 
from it 

'[Die most important indications of treatment presented by subcutaneous 
wounds are the control of lucmorrhage, the restriction and absorption of 
effusions, and the maintenance of the injured parts at rest until their con- 
tinuity has been restored with tissue of siiflicient firmness to again endure 
Ihe functional activity of the part. 

StJflccTASEora H-emorrhaqe. — The mutual pressure of the parts among 
which the bleeding point lies is usually sufficient to restrict within moder- 
ate limits subcutaneous heemorrbage. This is still further aided by the 



1 



TITB TRKATKEHT Off WOUITDa. 

^rreguloritieB of tlie rents in the veaeels themselves, which t*nd to entEiiigle 
the libriite of the blood, and to produce clotr-pluge that may seal them ujl 
Haemorrhages into the great cavities of the body, however, having less re- 
straint upon their flow, tend in many cases to speedy death. When large 
arteries are ruptured subcutaneously, it ia necessary to freely expose the 
point of niptare by incision, and hgtite upon both the proximal and the 
distal sides of the rupture. The further treatment of the woimd is then 
removed from the eaf«gorj' of siibcutaneous wounde. The most freijuent 
Bubcutaneoos luemorThsges lu^ those which attend contusions and result 
from rupture of ouhcutaneoua veins and capilhuies, the amount of the 
extravasation depending upon the vascidarity of the pait and the severity 
of the contusion. The connective and muscular tissue interspaces become 
infiltrated with the effused blood, and even more or less distinctly bounded 
cavities containing blood may be formed. The disoolorations produced 
from the wide diffiisiou of extravasated blood, by their extent, mart its 
degree, and persist for a long tiraa 

Special treatment to control haemorrhage of this character is rarely 
caUed for. TVTien the continuance of hiemorrhage ia evident, compresdoil 
by means of an evenly applied bandage, with or without an intervening 
compress, will suffice for its control The appUcation of cold would alao 
be an additional available resource, 

Restiuctios and Absokftion of Eittbioss!. — The arrest of beemorrhage il 
to be followed by the use of means to restrict the amount of active hyper- 
Hunia within the Umita needed for repair. Cold lotions, evaporating 
lotions, or ice-bags, are of value as applications to overcome any tendency 
to excessive afflux, but the most valuable and powerful resource exists in 
immobilization and methodical compression aft«r the methods described 
in Chapter XI IVTien material division of structure, as in the case of 
fractures of bones, or the rupture of muscles or tendons, has taken place, 
this immobilization, in a position that sliall favor the apposition of thft 
divided siu^aces, must be continued imtil complete and firm reunion hag 
been established. 

The absorption of effusions is likewise promoted in a remarkable degree 
by compression. To this should be added, especially in the more severs 
cases of contusion and sprain, tliose means of preventing or overcoming 
the passive dilatation of the blood-vessels prone to remain after the first 
period of active hyperiemia, and of difRising tlie effusion, and thus pro- 
moting its absorption, which are found in methodically rubbing, kneading, 



MASSAOH — SOEBErACIElTTS. 239 

r^percuasiiig, and rolling the soft parte, with passive movements, which con- 
stitute " mftBsage," 

Massage may be used very early after an injury, witliiD the firBt 
twenty-four hours. The akin over the affected part ahould be anointed 
with oil to protect it, for it is the deeper tissues that are particularly to be 
affected by the kneading. The thumbs and fingers ore then to be applied 
with steady and firm preaeure, their force being graduated according to 
the tenderness of the part, so as through the skin to rub, and knead, and 
roll the deeper tisauea, difEiising the exudations present, stimidating the 

» languid circulation, and exciting the absorbents. tThe manipulationB 
riiould be begun beyond the margins of the tumefied and painful spots, 
whieh should be gradually approached. The soothing effect of the rub- 
bing, when patiently and delicately applied, is such that soon pressure and 
novement over the points of chief injury are readily tolerated. By mas- 
sage a more speedy relief from pain and swelling, and an earlier restora- 
tion of the function of the part can be secured in many casea than by any 
other method. It is particularly of value in the treatment of contusions, 

Jdetortiona and sprains of joints, and tbeir sequelte.' 
J}ry Cupping. — The application of dry cups to the siu^ace of the alrin 
over the area of injury will powerfully assist Jn diffusing the eflruaions con- 
iequent upon contuaons of the deeper porta, and will contribute to the 
ooufort and the more speedy restoration of the function of the injured 
|»rl. 
Sorbe/aoienls. — The use of various lotions for their presumed power in 
■Simulating the absorption of effusions, though a popular and common 
resort, cannot, as a rule, be commended as of value. Their power to allay 
the violence of the primary afifluT by their cooling or sedative properties 
is more marked. According to Gross,' the most trustworthy sorbefacient 
is a strong solution of chloride of ammonium with the addition of a small 
quantity of vinegar, applied upon folded flannel, covered with oiled silk, 
and renewed sts or eight times in the twenty-four hoiun. 

Douching a part with hot water, as hot as can be borne without sufFer- 
^_ ing. continued for from twenty to thirty minutes, acta energetically in 
^■jffoducing contraction of the dilated vessels and in restoring tone to the 
^V circulation and nutrition of an injured pait, and in promoting absorption 

' DooeIm GFahnm. M.D. ; The Treatment of SpraiDs bf Uassage. The Hedical 
Beoord, Angnrt H, 1877, p. B04. 

■ STrten o( Bniger; , 1863, vol. i., p. 3S4. 



240 



THE TRBATMENT OF WOUNDa. 



of efitiBions. As an imtne(lia(« application after a oontuBion or eprain, hot 
witter, either ia tiie form of a douche, bath, or by compresses, is preferable 
to cold applications by reason of the diminisbed tendency to pasaive con- 
gestion which follows its use. When the effused blood is collected in 
depots, if ite presence is a cause of discomfort or serious functional di»- 
turbance, it may be removed by aspiration, or tlirough incision made in 
the overlying integument, provided strict surgical cleanliness be used to 
prevent the agents of putrefaction from gaining access to the exposed 
cavitj-. 

Inflammation, complicating subcutasBous wounds, is to be treated in 
accordance with the genei'al principles laid down elsewhere. When sup- 
purative and putrefactive disturbances intervene, free incisions to evacuate 
septic matters must be made, and the general treatment already insisted 
upon for septic wounds followed. 

INCISED WOUNDS. 

The treatment of simple cut or incised Ttrounds presents fewer elements 
of difficulty than do those forms of wounds which ai's accompanied by 
more extended damage to the adjacent tissues. In the arrest of heemor- 
rhage, which in general wiU be accomplished with but little difficulty, the 
means of btcmostasis should be adopted which will not be likely to intro- 
duce sources of disturbojice iu the after-course of the healing. Bleeding 
from all but vessels of considemble size will be arrested by exposure to 
the ail, or by the apphcation of hot water, aided by compression. The 
mutual compreBsion of the wound-surfaces against each other, after ibsy 
have been brought into apposition, serves to restrain any tendency to 
farther beemorrhage. When ligatures are required, only those that are 
aseptic should be employed, the preference being given to those of anlioal 
material that can be spontaneously absorbed. 

The hteniorrliage from incised wounds in which large blood-vessels are 
opened seldom ceases spontaneously ; they constitute the most dangerous 
class of wounds, and quickly torminate fatally from loss of blood. The 
most energetic and instant resort to measures for the arrest of hemorrhage 
is called for in these cases. When a vessel is but partially divided, it ia 
more difficult to stay the bleeding from it than if the di^sion is con^ilete. 
In such cases the first thing to be done is to completo the division of the 
vessel. 



^P nrcisED woTTim?. 341 

^~ The cleftneing of the wound is lesB difficult to accomplisli ; its surfaoea 
are lined with a miniiDuin amount of devitalized tissue, for the absorption 
and removal of which, without disturbance arising from its decomposition, 
the ordinary reporative energj- of the adjacent tissues Is usually quite 
adequate when coaptation is effected, even without minute precautions to 
exclude from contact with it, while exposed, any pathogenic geims. The 
drainage of incised wounds, when proper care is exercised to maintain 
their deeper parts in apposition, is very simple. In the more extenmTe 
wounds, it needs the uae of capillary drains for the first twenty-four hours 
only, during the period of the most energetic aflliix consequent upon the 
wound ; in a large proportion of oases, where compression and immobiliza- 
l|, tion of the wounded part can be etOBoted, no provision for drainage ia 
baquired. 

^^ The apposition of the wound-surfaces should be attended to with the 
ntmost care and minuteness, so that by the use of sutures, compressee, 
bandages, and position, the coaptation of evety part should be perfect, and 
no spaces be left for the coUection of secretions. The reunion of parta 
■uwhich have been almost entirely separated from the body may not infre- 
^Bqaently be secured by minute attention to their coaptation. Albanese, of 
■ Palermo, Italy, reported ' at the session of the International Medical Con- 
gress at London in 1881, a remarkable instance of such reunion. In this 
case the wrist had been almost completely cut through, with the bones and 
the flexor and extensor tendons, so that the hand hung, held to the fore- 
ann only by a slip of skin in the dorsal region about one and a half 
inch wide. The radial and iilnar arteries were ligated, the severed sor- 
Hidbnes were brought into contact with pin sutures, and immobilization was 
HbActed by n plastic splint Slight gangrene a^^ared in the thenar 
region. The temperature and senHibility of the hand and fingers were 
sensibly lowered for a long time. The vitality of the hand as a whole was 
preserved, and its reunion to the forearrn acoom^ished with ankylosis at 
^_tlie carpal Eul^iculation, and mobility at the radio-carpal articulation. The 
^^^gers were at first immovable, but gradually acquired some movement, 
" mtU finally they became quite useful 

The protective dressings required by incised wounds, the coaptation of 

whose surfaces is possible, are very simple. Exposure of the line of suture 

k te the air, so Uiat tlie desiccation of the slight amount of secretion that 



S43 



THE TBKATMBHT OF WOONDS. 



gntheiB there may fonn a protective crust gives esoellent results when the 
conditions of the n'ound are such as to make it practicable. A light, dry, 
clean absorbent dreeaiug of some kind is all that is required at any time. 

The provisions of " rest^" in the case of incised wounds, may and should 
be made absoluUi. 'SVTien proper care has been taken in the other details 
of the treatment of an incised wound, that infraction of itfi rest involved in 
the removal and readjustment of its dressings may be long deferred ; the 
surgeon can consider liia dreesing as having been perfect only when, after 
the expiration of a week or ten days, during which no local discomfort or 
conetitutioDul disturbance having been noticeable, removal of the dresmnga 
and inspection of wound shows it to be healed throughout 

The development of inflammatory disturbance or of septic condition^ 
in the course of the repair of an incised wound, unless the inflammatioti 
and septicity were already present before it came under the care of the 
surgeon, ie a reflection upon the character of the treatment, and calls for 
special explanation upon the part of the surgeon to exonerate himself from 
blame therefor. 

CONTtrsED AND ULCERATED WOUNDS. 

Since the extent of the tissue damage which has been sustained by the 
parts that are the subjects of contused or lacerated wounds lb not to be 
determined by the amount of the apparent injury visible at the first exam- 
ination, it« treatment has to be conducted with a degree of care aud watch- 
fulness, and provision for probable causes of disturbance, that do not 
embarrass the surgeon in the management of incised wounds. The sur- 
face breach is genenJly much less than the breach sustained by the deeper 
tissues, and the wound is comphcat«tl by the presence of much tissue that 
has been damaged by the traumatism, the life of which is to be preserved 
only by great care in fostering its nutrition, and preventing the access of 
infiammatory disturbances. 

The primary htemorrhage from these wounds is less apt to impetatiTely 
demand the attention of the surgeon for its control than in the oaM of 
incised wounds, on account of the favorable condition of the parts for its 
spontaneous arrest produced by the nature of the traumatism, even laz^ 
vessels being frequently spontaneously plugged by the retraction aad in- 
turning of their separated inner tunic, and by the interlacing of the img- 
ular ends of the external tunio and the surrounding connective tissue. 




COHTUSED AND LACEBATED WOFNDS. 248 

On the other hand, secondaty htemorrhages occur with ipore frequency 
on account of the doughing of parts of the wall of a vessel, either becaoee 
ita Wtality had been Bo far destroyed by the original forc«, which had yet 
faUen short of opening it, that it failed to become restored, and so ulti- 
mately necrosed, or because the vessel became involved in destructive 
inflammatory prcsesses compHcating the after-course of the wound. 

The period during which the separation of sloughs caused by the orig- 
inal injury is taking place, is thiis a period of danger. This is usually 
between the sixth and twelfth days after the infliction of the wound. 
Ihiring this time, accordingly, special watchfulness against the occurrence 
of hemorrhage is to be exercised. 

The period of reaction from shock is also particularly liable to be com- 
phcated by haemorrhage in the case of contused and lacerated wounds^ 
since, though the blood-current, while weak from the depressed action of 
the heart, often finds the natural obstructions left behind by the laceration 
of the tissues sufficient to arrest it, yet when it is again driven with more 
energy by a restored heart, it« force may be sufBcient to sweep away these 
comparatively weak obatructione, and to determine copious bsemorrhflge. 

The period of reaction is therefore to be watched witli especial care to 
guard against possible htemorrlmge ; and in the first dressing of a wound 
involving veasela which may possibly bleed, it is the part of wisdom to 
apply preventive ligatures to them, though they may not Ijc bleeding at 
the time, providing this does not involve undue disturbance of the wound 
in other reapecta, Aseptic ligatures should be uHed, and care should be 
ttiken to apply the hgature to a sound poi'tion of the vessel 

Nevertheless, should a surgeon think it beet to defer interference, as 
long as no bleeding takes place, it will be found that in many caees no 
interference will be necesaarj-; but such a course will esact increased 
watchfulness until the repair of the wound has sufficiently far advanced to 
demonstrate the permanency of the spontaneous hfemostasi* When, how- 
ever, secondary haemorrhage haa once occtured, then the application of a 
ligature is imperative, even though the bleeding may have again spontane- 
ously ceased as the heart's action haa weakened, for so soon as the reaction 
again comes on, and the heart beats strongly once more, the hsemoTrbage 
will surely recur. 

The primary cleansing of the wound aliould be conducted with great 
care, the more since the recesses and irregularities, which its surfaces ore 
likely to present, favor the lodgement of irritating matters, and because in 



344 



THB TBEATMENT OF WOUTTDS. 



many inBt&QceH foreign matter is ground into the exposed BurfaoeB at tlie 
moment of the injury. AU detached particles of bone and aoft tisttaa 
should be carefully removed, and tissues into which foreign matter hai 
been bo ground that the complete removal of this dirt la impOBsible should 
be trimmed w-ith sdaaora or knife. Bruised portions of tissue that are still 
attached should be carefully cleansed and replaced, and preserved from 
further traumatism, since much that appears to be hopelessly deatroyed 
may yet be saved in many caaes by care in fostering its nutrition. 

Thorough irrigation of a contused and ln«erated wound with an onti- 
aeptic lotion, imtil no clement of sepsis be left within it, is iinpemtive, for 
all the conditions of such wounds ore such oa to create and present to t 
large degree the material favorable for the rank development of septic 
organisms. The natural resisting power of the tipsuefl, which enables tbs 
surfaces exposed in ordinary incised wounds to resiBt the development ai 
sepsis, and to preserve the minute devitalized fragments of tissue that an 
present from undergoing putrefaction, is no longer to be relied upon in the 
class of woimda under consideration ; in these the bruised wound-surfaces 
have t« struggle to retain their own vitality, and larger masses of devital- 
ized tissue, and more copious effusions of putre&able secretions hava to be 
disposed of. 

The consecutive cleansing of the wound, to admit of the free escape at 
wound debris of every kind during the period of repair, wUl require the 
fullest provision for drainage from all its recesses. All the methods of 
securing this, which have been discussed in the earlier part of this work 
(CJhapter VnL), may find their application in the treatment of these wounds 
and must be applied accordmg to the judgment of the surgeon, so as to 
secore the immediate and full removal from the cavitj- of the wound of bU 
putrefiable material as fast as formed. 

Efforts at accomplishing apposition of the wound-surfaces must be sub- 
ordinated to the needs of drainage anil the provision for the unhindend 
separation of necrotic tissue. In ca^es of severe contusion a degree of 
uncertainly will alvrays eiist as to the abiUty to regain vitali^ which the 
injured tissues may exhibit, and a certain amount of necrosis is to be 
expected and provided for. This necrosis will be reduced to a minimnm 
in proportion as the provisions for making and keeping the wound aseptio 
are thorough and successful. IVTien adequate antiseptic measures are 
practicable, greater efforts at securing coaptation of the nound-surfaoee 
nbould be made, since they will be more likely to be rewarded with a cep- 




PDI^CTUBED WODNDS. 



245 



degree of ptimaiy union Umn wliea antiseptic precautdons are nfl^ 
lected. Special care ahould be observed to avoid all teoHlon of Hxa 
vroimded tiseuea ia endeavoring to approximate them. With this precau- 
tion, and tihoee required for drainage, coaptation may be attempted by any 
tlie means which are at the disposition of the surgeon for that purpose. 

In a large proportion of contused and lacerated wounds there nOl be 
an amount of destruction of tissue that any attempt at closing it to 
primary union will be manifestly coutrsr-iudicated- In such cases 

efibrte of the surgeon are chiefly directed toward protecting the wound 
from sources of disturbance during the time that the separation of the de- 
vitalized tissue and the repair of the breach by granulation is being effected- 
se are the cases in which local septic inflammations, gangrene, ery- 
and general septic infection are most prone to occur. For the pre- 

ition of these accidents the precautions of " antisepsis " and of " rest " 

luld be rigorously observed. 

Contused PDNcruaED Wodnm, such as those formed by the thrusting 
mto the tissues of a splinter of wood, a nail, a bayonet, or any other sub- 
stance which is cajtable of making a deep and narrow wound-track, are 
likely to present difGcutties in treatment by reason of the trouble that thej 
may give in securing their disinfection and drainage. The first thing to 
be attended to, after the removal of the pimcturing substance and the 
stanching of hiEmorrbage. if there be any, is the disinfection and cleans- 
ing of those parts of tlie wound that are accessible, and then placing the 
part at rest. If there has been no septic mat«rial introduced into the 
4leeper parta of the wound at the time the puncture was made, and ade- 
■nute protection be affonled it thereafter, speedy repair without disturbance 
9My be looked for. When, however, from any cause, inflammation of the 
deeper portions of the wound develops, in proportion as it is deep and 
narrow will the inflammatory effusions be pent up, and their putrefaction, 
with attendant local irritation and general septic infection, be likely to 
They are septic wounds and require the immediate and energetic 

iHcation of the means of treatment described as required by such 
Vounds (Chapter VUL, page 157). 

The value of free and early incisions for the relief of pent-up effusions 
cannot be overestimated in such cases. The following strong putting of the 
Tshie and necessity of this measure in such cases is by Bryant, of London.* 



with I 
Kpecur. 
Bfrplic 



THE TREATMENT OP WOCNBS. 

"In the treatment of oU punctured wounds, the mirgeoD haa only to 
remember that, as their danger consists in the difficulty of providing effi- 
cient drainage, so their treatment turns upon this deficiency being reme- 
died ; and the surgeon who, on the first appearance of local or general 
symptoms indicative of the presence of retained fluids, makes an outlet by 
one or other of the means which have been suggested^even when the out- 
let is only for the escape of pent-up serum — will be more suecessful than 
another who, from timidity or other cause, leaves the ease to run its 
course, till a large inflammatory abscess has formed from the irritation 
caused by the fluids which should have been evacuated. In all punctured 
wounds, which do not heal quickly by primary union, and in which eecon- 
darj- inflammation occurs, with ita necessary efFiision, it is the surgeon's 
duty to find an outlet for the fluids of the part as soon as the fact of their 
retention is clear. The artificial formation of a free vent for these fluids 
will be followed by reUef, both locally and generally, and will almost 
always save tissue ; whilst delay in adopting this practice is not only locally 
deleterious, but may even prove dajigeroua to life. When thecse of ten- 
dons, fascial and fibrous coverings, as of bones, are involved, the neceasty 
of adopting this practice is more important, if possible, than when the 
softer tissues are implicated ; and an incision into the deep parts for the 
evacuation of even simple serum, by reheving tension, will oft£n prevent 
the extension of the inflommatiou, and prevent destruction of tissue." 





FMnUaritiM ot Oonsliot Wotmcis — Htemorrhme — Wonnd-aleBnUnuB— Iromeduta 
AntUeptio OoduBioQ— No Immudiale Explolatioa—Claasificatioa— SUtiitioB of 
Seybtc — Non-ocnlusive Tieaiinent — fnl&TgeineDt, Clmnung, uid DiamfectioD — 
Probm and Probing — EemoTal of Bullets— Im mobilization. 

OmaBOT wounds are contuBed and punctured wounds, but bare a special 
character by reason of the length to which their track may attain, the ex- 
tensive concealed injurieB they are likely to present, the difBculties, both 
near and remote, which the frequent lodgement of the missile among the 
tissues is prone to create, and the circumstances in which, upon the battle- 
field, most of such injuries are sustained. 

The principles of treatment wliich are applicable ia contused and pimo- 
tured wounds in general find their most important apphcation in the treat- 
ment of gunshot wounds, and by their scrupulous observance the repair of 
these wounds will he greatly facilitated and the occurrence of the wound- 
disturbances, which are prone to manifest themselves as the sequela? of 
gunshot wounds, will he avoided. 

H£UOKBHAo& — Special interference for the arrest of haemorrhage is only 
likely to be demanded in the case of wounds of vessels of considerable 
■ice ; in such coses the rule is imperative to enlarge the wound, expose the 
bleeding vessel and ligate it upon both the proximal and distal side of ita 
wound. Should the vessel not have been ah-eady completely severed by 
the ball, it should be divided between the ligatures after their application. 

When the wound-track is in the vicinity of a large vesael, the possibil- 
ity of secondary hemorrhage should be borne in mind, and special watch 

kept upon the case till its repair has sufBciently advanced to make such 
;er no longer to be apprehended. 

WoumwJLKAKLDSESS. — The cleansing of the wound involves the meaaurea 
for its exploration, the removal of tlie missile and other foreign 
matter that may have been carried in with it, and the destruction of Bepaia. 



ilj-of 



SIS 



THE TEEATMKNT OP WOFKDS. 



The relative importance of these measures appears from the fact that 
the iliaastrouB rcxutte of guiubot wounda, which are not quickly fatal from 
the vital importouce of the parta damaged, are always couBequeut upon in- 
flammatoiy, suppurative, and infective disturbances which complicate their 
repair. These disturbances have their origin in septic ccmtaminatioa of 
the wound-track, and gain their aggravated proportions from the natural 
obstftdes which the woimd-track presents to the escape of the septic mat- 
ters afforded by the contaminated wound-secretions and debris. 

TTte preifcntion of the spjjtic conlamirtatton of the woimd-tract, therefore, 
is to be considered as of the greatest importance to be observed in all the 
manipulations to which it may be subjected, and is to be kept in view 
from the first moment that the wound is received. The presence of the 
missile, or other foreign substancea carried in with it, or splinters of bone, 
are less to be feared than the subsequent admission of septic elemeDt& 
As MacCormac ("AutiBeptic Surgerj-," p. 268) has remarked, "Gunshot 
wounds, in general, present many features of what are called subcutaneous 
wounds. There is a small external opening which bears no proportion to 
the extent of the damage within, and it has been long observed that some 
gunshot fractures, and wounds of joint« even, may heal just as simple 
fractures do, and the inference is that they healed because of the closure of 
the external wound, and the absence of suppuration depended on the non- 
admission of septio elements, at all events in suiUcient quantity to excdt« 
decomposition. " 

Immediate antiseptic occlusion, that is, the application to the external 
wound, or wounds, of tampons of absorbent antiseptic material, as early u 
possible after the infliction of the wound, should be done ; for no period of 
time, no matter how small, can be safely allowed to elapse between the 
reception of the injury and its protection from septic invasion. Absorbent 
cotton impregnated with iodoform, salicyho acid, or boracic acid may be 
selected for such immediate occlusive purposes. The antiseptic balls 
recommended by Esmarch to be supplied as a part of the outfit of a soldier 
are made of salicylic wool and jute, contained in sahcyhc gauze, and en- 
closed in a square of oiled paper. The tampon to be invariably applied 
directly to the wound, and the oiled paper used as an external coraring. 
The whole secured with a bandage. 

Jute impregnated with chloride of zinc has been recommended for 
such tampon as more powerfully and certainly antiseptic in its action. It 
may be applied in the same way. 




GUNSHOT WOUNDS. 249 

When no antiseptic protective subetajice i» immediately attainable as a 
covering to the wound, it Hlioold be left exposed to the air without any 
ooTering whatever, iuasmuch as the air is less likely to be septic thEui any 
ordinary dressing which would otherwise be applied. By such exposure, 
also, desiccation of the secretions about the wound aperture would be 
found, and a protective crust thus he formed. 

When the necessity of interference with the wound for the arrest of 
hiemorrhage ia present, its urgency may compel the disregard of every 
other precaution ; but, with that exception, it should be considered an 
absolute rule that nothing should be brought into contact with it for any 
purpose which has not been previously rendered aseptic, and that all 
interference of any kind Is to be abstained from until it is possible to but- 
round it nith the necessary provisions against sepsis. 

When no septic matter has been carried in with the bullet, and no 
septic matter has been introduced by the surgeon in explorations or efforts 
at removal of the missile, and early sealing of the external wound has 
been accomplished, either by the scab formed by the desiccation of its dis- 
charges, or by occluaion with on antiseptic tampon, the wound ia reduced 
to a subcutaneous injury, and the greater port of the difficulties in its 
treatment become eliminated. 

Tlie chief obstacle to the general adoption of the practice of primarily 
sealing up the external aperture of a gunshot wound lies in the unilue im- 
portance which has been attached to the early removal of the missile, when 
embedded, as if the foreign body in itself was the exciting cause of the 
disturbances of repair that mark the usual course of the healing of suoh 
wounds. 

On the contrary, as Esmaroh expresses it, "the damage done by the 
bullet ia caused by it in its course ; the harm that is added comes mostly 
from the examiner's finger." 

Beyher,' in detailing the remarkable reeulta obtained, under his direo- 
tion, in the Busso-Turkish war, remarks : " I have never explored for the 
purpose of extracting bullets; never even, for this sole purpose, aft«r 
patients had rea.ched the hospitoL In the hospital I have only removed 
them when their removal seemed imperative on account of inflammation 
or suppuration in their immediate vicinity. In a large number of cases, 
then, the parts have healed around the bullet, in spite of the generally 

' J)i4 AnliieplkAe WundbfhaniHung in dtr KrUgnMrwgie. ToUcnuum's SammL 

. Vvrtrdge^ So. 142, AojcuBt, 1878. 



d 



250 THE TREATMENT OK WOUNDS. 

accepted ideas of practice to the contrary. It is not impossible that in 
some of these cases the foreign body may prove a source of future irrita- 
tion, but its extraction subsequently in private practice will be much less 
dangerous than in the infected atmosphere of a military hospital, while its 
removal, then, will be from tissues which are no longer infiltrated, and 
from which all blood-extravasation has long been absorbed," 

The mere lodgement of a bullet, therefore, in the tissues, is not of itself 
a sufficient indication for opening up the wound-track by an exploring 
finger or probe, and exposing the wound to the dangers of septic contam- 
ination which sucb a manceuvre would entail, nor, even if the exploration 
was done with adequate antiseptic precautions, would it be justi£abte to 
disturb the wound by the new traumatism of the exploration, until dis- 
tinct evidence had appeared that the missile was seriously disturbing the 
repair of the wound by its presence. 

Imuediate Exploration of a gunshot wound is called for only in cassa in 
which the manifest nature of the wound is such, by reason of the extensive 
laceration and destruction of tissue present, that its occlusion is impracti- 
cable, and the (juestiona of excision and amputation require to be decided 

Classifichtion or Gitnshot Wounds. — Gunshot wounds thus divide them- 
selves, from the standpoint of treatment, into two classes: 1, Those which 
ore capable of primary occlusion of the external wound, and of conversioa 
into practically subcutaneous wounds ; and, 2, those which must be treated 
aa open wounds throughout. 

By immediate provision for the protection of the wound from septio 
contamination from without, and by careful abstinence from any explora- 
tions of it, until the symptoms of inflammatory disturbance declare that 
interference is necessary, an aseptic course of the healing of the wound 
may be secured in a large proportion of coses, Beyher, in his observstiona 
before alluded to, has recorded the following valuable statistics of the com- 
pantive safety and value of such attempts to occlude gunshot wounda 

Out of twenty-eight cases of gunshot wound of the knee with bullet 
embedded in the part, the four which were treated in accordance with these 
principles, from the oxUsel, recovered with movable jointa ; eight, in which 
antiseptic precautions were not adopted until the next day, died, as well aa 
four which had no such treatment at all ; while of the remaining twelve, 
which had no primary antiseptic treatment, and required either interme- 
diate or secondary amputation, eleven died. Of forty-six cases of wounda 
of different joints treated as above, six died — mortahty 13 per cenL ; of 




PEIMAET AimaEPTIC DEOLUSION. 







tiiese, nmeteen required primary resection, of which only two died — 10,6 
per cent. Of seveiity-eight cases aimilur in other respects, but in which 
antiaepsis was a secondary consideration, or from which bullets had been 
extracted, forty-eight died — G1.5 per ceni Of another series of sixty-two 
shot wounds of joints without primary precautions, thirty-nine died — 63 
per ceni So in cases of shot fractures of long bones, of sisty-five treated 
from the first, only five died — 7.6 per cent Of twenty-nine not so treated, 
eight died— 27 per cent In a neighboring hospital to his own, during 
the campaign in the Caucasus, Beyher saw seven cases of uncomplicated 
«-oundH of soft parts die of pyiemia ; under his own primary antiseptic 
measures he lost but one such. In another series of sixty-five fractures 
treated secondarily by antiseptic rales, twenty-three died— 35.3 per ceni 
As illustrating the reduced number of cases of pyEcmia, altogether of 
eighty-one cases of miscellaneoua wounds treated primarily, only five died 
from blood-poisoning — 6. 1 per ceni ; whereas, of one hundred and for^'- 
three not so treated, forty-six died — 32. 1 per cent Of fifty-seven various 
wounds of skull, buttocks, and soft parts, all treated antiseptically from the 
start, not one died. 

With all his cases, Reyher saw erysipelas but three timea There were, 
moreover, but two cases of tetanus, and none of gangrene. The number 
of lives saved by the adoption of this method by Reyher was, therefore, in 
proportion, from three to four times as many as were saved under the 
older methods. Out of the for^-six cases of gunshot wounds of joints it 
was only necessary in /our cases to depart from the system of primary 
occlusion without interference ; whereas, of seventy-five cases of similar 
wounds treated by secondary antisepsis, drainage, etc., in fifty-four of them 
resections or amputations were required. 

The second class of cases, which must be treated as open wounds, in- 
clude those in which the extent of the estemal wound is too great to give 
Wty hope of securing its primary occlusion, those in which these attempts 
been made but have failed, and those in which such attempts have 

in deferred or omitted until the wound has become manifestly septic, 
by reason of its exposure, its having been subjected to tincleanly and pre- 
mature explorations, or tJie application to it of contaminated dressing. 

Even in this second class of cases, all explorations and other operative 
should be deferred until they can be done with the necessary 
.ations against septic contamination, or can be accompanied by ade- 
protective antiseptic dressing. 




^Aj^^J 



2j2 THE TREATMENT OF WOONDS. 

TjtaiTMKNT OF Open Gunshot Wotsps. — The treatment of this claas of 
eunfihot wouDds ehould be conducted with scrupulous attention to tlw 
thorough disinfection of every acceaaiblB rocess of the wound and to per- 
fect freedom of drainaga The appearance of high fever, inflammatory 
Hwelling, progressive infiltration, gangrene, tind other evidences of progres- 
sive septic contamination, call for the energetic and thorough application 
of all the reBources for the deatmction or control of sepsis which are within 
the command of the surgeon. 

The primary examination and clm.nging oi the wound should be coo- 
ducted with the view of making it aseptic. Frequent partial cleaning 
should be avoided ; repeated probinga, cuttings, irrigations, and squeezinga 
for the purpose of evacuating wound-eecretions and debris, which keep up 
a continual irritation of the wound, should be replaced by a thorough pri- 
mary examination and cleansing. Thin must be conducted with deUbera- 
tion and minute attention to the ultimate object in view — the destnictioo 
and prevention of sepsla An anaesthetic should be administered, and 
everything brought in contact with the wound slioidd be carefully disiii- 
fected as used (see Chapters IV. and "ViLL). 

The eitemal wound should be freely enlarged, when necessary, so as 
to permit the introduction of the cleansed and disinfected finger for pur- 
poses of exploration. For the purpose of enlarging the deeper part of the 
track, if the vicinity of important organs or the dangers of bsmorrhage 
make the use of the knife undesirablo, it may be enlarged with blunt in- 
Htrumenta, as dressing forceps introduced closed and then opened and 
withdrawn, thus acting as a dilator. The ordinary glove-streteher sug- 
gests itself as a model for such a dilating forceps. 

Bullets, aphnters of bone entirely detached, pieces of clothing, and 
other foreign bodies, which are fotmd during the examination, should be 
carefully extracted. 

A bullet not infrequently, after having is the early part of its course 
inflicted injuries which require to be treated by the open method, eon- 
tiunes its course in such a manner that the second part of its track may 
heal primarily bcJiind it, and the bullet remain shut off from the first port 
of the wound, and then, becoming encysted, permanently remain without 
inducing further mischief. 

The treatment of such a deep wound-track should be conducted on the 
same principles aa those which control the treatment of the more superfi- 
cial wound. It should not be probed, nor irrigated, nor in any manner in- 



I 



PROBES AND rnoBiiTO. 253 

terfered with, until evidenccB of inflammatory disturbance of its walk ap- 
pear. No search should he made along it for the bullet, much leas should 
tiie mere presenpe of the bullet at its bottom be considered an indication 
for an attempt at its removnl. The disinfection and drainage of the super- 
fieial portion of the wound should be conducted witli all care and thor- 
oughness. Should disturbances of the ile^er portions of the wound maui- 
fest themselves, the exploration, cleansing, and drainage of that portion of 
tiie wound would then be re<iuired. Enlargement of the aperture of com- 
munication with the superficial wound, and free counter-incisions to the 
extent required for it« easy and perfect drainage, and for the removal of 
anv foreign and irritating bodies along its track will be necessary. 

Probes. — For the exploration of wounds, the depth or course of which 
is snch as to make tliem inaccessible to the finger, probes must be used. 
' For probing, a blunt-pointed, flexible rod ehould be used ; the probing 
extremity should be sufficiently lai^e, so that it should not easUy make a 
passage for itself among the tissues ; tlie shaft should be flexible, so that it 
may be adapted to the particular course of the track that is being ex- 
plored, and should be long enough to admit of being easily and definitely 
controlled by the hand of the surgeon. 

Boda of copper, silver, or i>ewter, a foot in length, with bulbous ex- 
tremities of the diameter of an ordinary goose-quill, ofier themselves as 
mutable material for probes. In an emergency the ingenuity of the sur- 
geon win not fail to find some material from which a probe may be extem- 
porized, although adherence to the rules which should guide the treatment 
of wounds, as given above, will remove explorations altogether from the 
Itst of operations of emergency. 

Probing a wound should be done with all possible gentleness and care. 
The probe should be carefully cleansed and disinfect«d at the time of 
being used. It cannot be too strongly impreased on the mind of the sur- 
geon, however, that all probing of a wound should be abstained from until 
such time as the final thorough examination and dressing of the wound 
ean l>e performed, when, once for bU, the use of the probe may be required 
in accordance with the restricted indications for its use which have been 
toentdoned. 

The Removal of Bullets. — When relegated to its proper place as a minor 
part of the general provisions for obtaining wound-cleanliness, the search 
for and the removal of the bullet calls for less consideration as to the 
methods by which it may be accomplished, and the apparatus needed for 




TH£ TBBATIIXNT OF WOUNDS. 



ad4 

its technique, tlian when it was esteemed in itself an indicfttion of first 
importance to be met. Forcepa with alender and firm jaws, with aligbtl; 
projecting teeth iiiat may increEise the security of tlie grasp of the forceps 
upon the bullet, will facilitate the removal of a bullet when exposed. A 
blind groping for a bullet at the bottom of a deep ainua ahould not be 
attempted ; the enlargement of the estemal aperture, and the dilatation of 
the deeper track, as required for the purposes of cleansLng and drainage 
of a woimd, or the comit^r-in<:iBionB made when the length and location of 
the track demand it, should be ample enough to permit the sufiicient 
exposure, and ready seizure of the biUlet, if it is to be removed at alL 

When the ball is suspected of having become impacted in a bone, or to 
have penetrated a joint, it is not to be interfered with, nor is ao exploration 
for the purpose of determining the fact to be made, unless the wound, for 
other reasons, demands treatment as an open wound, or the efibrts to 
secure primary occlusion have failed. If, upoD exposure, it is loosely held, 
it may be readily removed ; if fimdy impacted, it may be loosened by 
means of an elevator or chisel, and then removed. 

LaroBUJZATioN of parts which are the subjects of gimshot wounds is of 
extreme importance. Means of immobilization should be adopted as a 
port of the fiint dressing, it should be made continuous and absolute, and 
will prove a powerful accesaoiy to the local antiaeptio dressings in securing 
pennanent primaiy occlusion of a wound. 

Aside from penetrating wounds of the cavities of the body, and injuries 
of the large vessels, the great majority of those gunshot wounds which are 
likely to be compUcated by dangerous wound-disturbances are those which 
involve bones and joints. The further consideration of the special methods 
of averting or controlling the dangers incident to such wounds belongs 
naturally to the discussion of that class of wounds in general 





I 



jitiei — Talae of Antiseptio MeCbodn ol Treatment— MBcCormfto—CIasBificnticni 
—SccerU Injurirs loith SiigU Exttrnal TVeund— Primary Antiseptio OocIumoo— 
BeeerU Injuria ujiW External Wound of Contiderable ffir((in(— Primary Explon- 
tioD and CI Ban ring— Counter- inciflioQa — Splinters of Bono— Drain ags^ Suture — 
Woit/ufi of Joints — Inoiaions — Partial RcBeotioDS— Protective DteBaingH — Immo- 
biliiation— After-treatment— in;u7TW not Recent anil Septic — Favorable Casea— 
Caaea with Prononncod Septio Infection — Disinfection— Immobilization — Fenes- 
tmted and Intemipted Ploatio Splints— Honeycomb Ploater Splint. 

Thk conditions presented b3' those lacerated anil contused wounda, which 
are complicated by fractures of bones communicating with the wound, are 
Buch as are very favorable to the development of septic disturbances in 
their most aggravated foi-m. Phlegmonous inflammation, prolonged aup. 
puTBtion, more or less sloughing of the contused and lacerated tissues, and 
DAcrosis of bone, are the ordinary attendants of the healing of such 
wounds when adequate precautions against sepsis are not observed in their 
treatment ; while in this class of injuries, more than in any other, have the 
more formidable septic complications of erysipelas, gangrene, se|jticflsmia, 
and pyiemia been rife. 

The special feature possessed by these woujids which tends to aggra- 
vate the difSculties attending the treatment of severe lacerated and con- 
tused wounds in general, is the irritation of the wound by the movements 
of the bone fragments within it The law of rest is thereby continually 
being violated, and a favorable condition for the development of septic 
disturbances maintained. 

The treatment of these cases should be conducted from the 6rst in such 
ft way as to prevent, if possible, septic contamination, or to destroy or con- 
trol it, when efforts at primary prevention have not been mode, or have 
.^uled. 



J. 



THX tbkatheut of wowtss. 

"In no kiad of surgical injury," to borrow the language of MacCormiw: 
("Autiseptic Surgery," p. 180), " have the results accompliahed by the anti- 
Hfiptic method been more thoroughly ratiafactory and complet* than in 
compound fracture. In future we miiy expect to eave the lirab of tlie 
patient in dl cases in which the extent of damage to the Boft parts, TCMOo la, 
and nerves is not such as to nbBolutely forbid the attempt. Even in cases 
where the expectation of saving the limb is not great, we are justified in 
giving the patient tlie benefit of the doubt, aa we do not endanger his life 
by HO doing ; and should gangrene or any necessity for operation occur, 
we may then ampntat* without increased risk 

"Pyiemia and septicicniia, which liave hitherto caused half the deatlis 
among the fatal cases, should no longer occur ; but only death bom un- 
avoidable causes, such as fat>«mbo]iRm, delirium tremens, tetanus, senile 
bronchitis — causes not directly dependent upon the wound nor its 
treatment." 

The difficulties which will attend the treatment of these cases will 
depend on the extent and character of the traumatism which has been 
inflicted, and upon the time at which they came under the care of the 
surgeon. 

For purposes of convenient consideration they may be classified into 
three groups : I. Cases in which the injury ia recent, and in which tlie 
external wound ia a slight puncture only of the skin. 2. Cases in which the 
injurj- is recent, and in which the external wound is of considerable extent 
>l. Cases which are not recent, and which have already become septic. For 
each of these groups of cases n different mode of procedure offera the 
best results ; for the first, primary occlusion, as in gunshot wounds ; for 
the second, thorough primary disinfection of the whole extent of the 
wound, removal of blood-clot« and loose B]>linter3 of bone, drainage, and 
finally occlusion by a closely fitting and evenly compressing antiseptic 
protective dressing : for the last, abandonment of occlusive dressinga, and 
the substitution of open methods of treatment, with antiseptic irrigatioii. 

Each of tliese groups requires consideration more in detail 

HECENT INJUHIES WITH PLIGHT EXTERNAL WOUND. 

When but a short time — an hour or two — has elapsed since the recep- 
tion of the injury : when the wound through the integument is small ; 
when there is no subcutaneous cavity filled with coagula, and the adjacent 



OOMPOtnTD FRACTURES. 357 

tiasuea are not swollen and infiltrated, there is eTery reason to expect that 
by cleaniung tlie external wound and the odjaceut akin, by occluding th» 
wound with an absorbent antiseptic dreasin^,', and by keeping the parts at 
perfect rest, ondisturbed and speedy healing of the external wound would 
be secured and the deeper injuriee be reduced to the condition of subcu- 
taneons injuries. All explorations of such an injury should be carefully 
retrained from. 

The comminution of the bone, and the presence of splintered fragments 
at the bottom of the wound la not in itself sufficient to constitute an ex- 
ception to this practice. Examples of such comminution of bone, with 
amall external wound, are confined almost entirely to cases of gunshot in- 
juries. BmuB,' in connection with this subject, remarks that even when 
splinters liave become entirely detached and robbed of their periosteum, 
they will grow together again, provided suppuration is prevented and 
primary nnion of the external wound is secured. A splinter, even if the 
source of mechanical irritation, is not to be regarded as in itself an element 
indocing inflammation. The aspect of the case would, however, be 
i^d if the foreign body, which had produced the splintering, had 
lught with it septic germs so as to infect the wound. The rule laid 
down for the treatment of gunshot wounds in general, that, where the in- 
jury is not such as to manifestly require primary amputation, the wound 
should be treated from the beginning by antiseptic occlusion and perfect 
without exploration and enlarging, applies equally to wounds compli- 
id by fracture of bone, however extenaive the comminution may be. 
The treatment required should be begun by a careful cleansing and 
disinfection of the skin over a large area anrrounding the wound. Carbolic 
acid or corrosive sublimate lotions may be used for this pmpose. The 
external wound should bo irrigated with the same lotion, and shoidd then 
bo covered with thick layers of antiseptic, absorbent, and protective mate- 
rial (Chapter X.). Iodoform absorbent gauze, or cotton wool, presents the 
greatest ailvantagea for this dressing ; but many other substanucfi, as the 
carbolic, naphthalin, and corrosive sublimate dressing will liliewise be 
efficient The dreSRing will be completed by a bandage of fixation and 
compression, and the application of an immobilizing apparatus. 

Ah long na no symptoms, general or local, of wound disturbance moni- 

Iat themselves, the dressing shoultl be left undisturbed. When sufficient 
' Die aligfituine Lehra von den Kiuie/u-nlmieAen, DeaUcha Chirurgie, Litf. 37, 
mVtf, p. 35S. 
^_ 



indu' 






THE TREATMEWT OF WOtTSDS. 

time for complete healing of the wound hae elapsed, the wound-dreaangB 
may be removed, and the further treatment of the case be as for a Bunple 
fracture. 

Should inflnmmator} dieturbajice in any degree manifeHt itself, the 
attempt at primary occlusion must be abandoned, and the cleauaing, dis- 
infection, and after-treatment of the wound be conducted as in the more 
severe cases next to be dieuussed. 



BEOKNT INJURIES, WITH EXTEKSAL WOUND OF CONSIDERABLE 

EXTENT. 

Tlie painful and protracted character of the manipulationa required in 
tlie first dressing of tliis class of cases make the administration of an an- 
lesthetic indispensable. Every portion of the ekin which will be included 
in the subsequent dressings must bo thoroughly cleansed de n'gueur (Chap- 
ter VllX.), Mith soap and water, brueh and razor, and finally piuified with 
a carbohc acid or corrosiTe subhmate lotion. The wound cavity ia next to 
be disinfected. If the existing opening ia not lai^ enough to permit the 
full exploration of the wound by the finger, and by retraction of its mai^ns 
to permit inspection of all parts of the wound-CAvity, it must be enlarged 
by tlie knife. All coaguln and foreign matter are removed, and the wound 
cavity is then thoroughly irrigated with an antiseptic solution. The follow- 
ing more detailed directions for accomphshing the complete diainfecUon 
of the wound are given by Bruns (loc. cit.), from whose work, also, the 
greater part of what follows in the present chapter has been appropriated. 

If long sinuses and pockets are present, counter-incisions should be 
made, so as to open tliem at their farther end, and secure through drain- 
age in them. If extensive detachments of the skin are detected, numerous 
am^ incisions are recommended for the insertion of small dnuns. If the 
wound-opening is unfavorably situated for its enlargement, so that satia- 
factory disinfection of the breach, caused by tlie fracture, is hindered, as 
is the case sometimes in gunshot fractures, a drain should be introduced 
at the original aperture, and a counter-incision made into the wound-track, 
where it is most superficial, through which the disinfection may bo pet- 
fotmed. If it is discovered, on digital examination, that beyond the frag- 
ments pockets have formed, the bone at the point of fracture must be bent 
and its fractured ends forced up tluough the wound sufficiently to permit 
nch deep recess to be irrigated. Excision of badly lacerated and contused 



I 



I 



COMPOUND FKACTUKE3. 259 

portions of soft tiflsuo may, in some' cases, be done with the scissors, when 
it IB probable that Uie healing of the wound will be accelerated thereby. 

An splinters and fragments of bone which have become completely de- 
I from the soft parte, or which are held only by a small strip of peri- 
or muscular fibre, as a rule, should be removed, idnce those frag- 
; obsfruct healing whenever suppumtion and sepsis infest the wound, 
Bn occurrence whicli cannot always be avoided. When drainage will be • 
lacihtated, fragments of bone may be removed, even when more exteii- 
eively adherent to the soft tissues. In this case the periosteum should be 
carefully preaerv'ed by using a periosteid scraper to detach the bone. 
Portions of periosteum, thus saved, will be of great value as sources of 
callitB. All fragments of bono ftdheriiig to wide strips of soft tissue should 
be replaced in their normal position ; fheii- union may be expected with 
certainly if the wound bo kept asoptip (Iming its healing, 

Neit follows the drainage and the suture. Multiple short, drains should 
be introduced into the wound ; those in the principal wound should rea^i 
down to the point of fracture in the bone, but should never penetrate be- 
tween the fragments. All the drainage-tubes should l)e chpped to the 
surface of the akin, and fixed by a s-ifetj-pin transversely inserted. All 
the woimds of counter-incision, as well as the princiiial wound, should 
then be sutured close to the drainage-tubes, whenever healing by first in- 
tention appears possible. 

The treatment now detailed is to be employed not only when the wound 
communicates with a fracture of tlio shaft of a bone, but also when a joint 
cavity ia opened into by the wound. 

If the joint is not opened by a direct penetrating wound, but only by a 
fissure through tbo articular eitremities of the bones forming the joint — 
an occurrence which may be verified by the hemorrhage into the joint — 
the joint cavitj- should l>e openetl by ;v free incision at a suitable point, and 
should bo emptied of nil serum and coagula, disinfected and drained. In 
given cases, the procedure amounts to nothing more nor less than a partial 
and irregular resection of the joint, the features of which will suggest thera- 
Belves in the special conditions which these woimds will present in which 
antiseptic conservative methods i^-ill hereafter be more frequently adopte<l. 
Total resection will be limited, henceforth, to ven- grave cases. 

After this primary cleansin<j and disinfection of the wound has been 
thoroughly accomphahed, a protentive antiseptic dressing should be applied 
with great care, and made to extend widely in every direction beyond the 



260 



THE TREATMENT OF WOUNDS. 



woimd. Oauze, or other absorbent material, impregnated with carbolic 
acid, iodoform, corrosive Bubhmate, naphthalin, or other antiseptic oub- 
Btanoe (Chapter X. ), should be apphed, crumpled and in multiple laj-eiB, 
and confined with an accurately applied roller bandage, eo as to act aa a 
means both of protection and compreaaion. 

Difficulties will arise if the wound is in Bucb proximitj' to the thorax 
that the dresrangs extend upon it, since tbe movements of respiration will 
loosen the dressing. Afartin's pure rubber bandage will be of et^>eciBl 
service in Buch cases, accomplishing both tbe esduaion of air and oom- 
preseion. 

The part is finally immobilized by the apf^catioa of a proper splint 
The after-treatment is very simple, provided thorough aeepms has beeo 
obtained. In favorable cases, where healing by first intention is secured, a 
single change of dressing, after six }o eight (lays, for the removal of su- 
tures and drainage-tubes, is all that ia necessarj-. The second dressing re- 
ivoins to the time of complete heaUng. In ordinary cases, where the 
wound does not show a tendency to primary union, the dressing is changed 
in from two to four days, according to the dischor^ ; later, when the se- 
cretions become of a thick creamy consistence, the intervals between the 
dressings wUl be longer. Each change of dressing should be executed 
with rapidity, and yet with the greatest care. Exquisite caution should be 
exercised in the examinations and irrigations of the wound. The manipu- 
lations should be restricted lo simply cleaning the surrounding integument 
with a pledget of absorbent cotton moistened with an antiseptic lotion, 
being careful not to disturb its relations. The drains should be remored 
as soon as the secretions cease to flow through them. The dresungs 
should be renewed till the wound is filled ivith granulations up to the lerel 
of the surrounding stdn. It will then suffice to apply a more simple pro- 
tective dressing, covered by a plastic splint, as in subcutaneous fractures, 
till oonoolidation has taken place. 



INJURIES, NOT BECENT, AND SEPTIC. 
As injnrira which are " not recent " ore to be comprehended those 
which come under treatment after the lapse of twenty-four hours. The 
tflsk to establish an aseptic course in these cases is obviously much more 
difficult ; each patient, however, will present its special conditions, so that 
we hare hn^, also, to diSerentiate between favorable and unfavonUe 
cases, each kind requiring difierent treatment 




t 



BEPTIO COMPOnND FRACTDRES. 261 

The more favorable cases are titose which do not Bhow an extended 
luud-reactioij, even though immiBtakable signs of decompoeitioa of the 
>und-secretions are present According to pa«t eTperience, an aseptic 
course may, even under these conditions, be obtained— ^t.e., an undisturbed 
healing by granulation, though frequently with increased suppuration, and 
often with necrosis of the ends of the fractured bone. The method to be 
pursued in these cases is virtually the same as in recent wounds — namely, 
enlargement, esploratioD, and disinfection of the wound, with subsequent 
antiseptic, protective, and ouclusire dressings. 

Contrasted with these favorable cases are to be plac^ those in which 

pronounced picture of local sepsis ia presented, either in consequence 
of neglect of antiseptic treatment, or of the inefficiency of that which has 
been employed. In these cases will be observed positive signs of decom- 
poeitiun of the wound-HCcretions. real ichorous discharge, more or less in- 
flammatory reaction in the surroiindingB of the woimd, in some cases gan- 
grene of the badly contused soft parta, and progressive infiltration of the 
connective tissue with pus and giu. 

Energetic disinfection is agnin demanded in these cases, though unde- 
niably attended with greater difficulty, and not in all cases possible to be 
absolutely attained. All septicoUy infected tissues must be freely laid 
open by incisions, so as to give entrance to the disinfecting substance ; all 
gaDgrenouB tissues must be removed with knife and sctssorK. long inci- 
uons and counter-incisions should be mode to open up the torn and infil- 
trated intersticea of the muscubr tissue. Where there is extensive subcu- 
taneous infiltration of blood, as well as in those cases in which there is 
■Iready present phlegmonous infiltration, numerous small incisions should 
be made, in addition, through the integument, for the removal of blood, 
pus, and gases, and to enable the disinfecting fluid to be introduced In aa 
many places an possible. These multiple scarifications will render impor- 
tant service in opening the spaces between the long incidona They abould 
■U be subjected to thorough antiseptic irrigation, and be kept open by 
fflnall drainage-tubes. 

Neither occlusion nor compression of the wound can be adopted in 
•nch cases, while it is further important that the changes which may be 
going on in it be capable of being observed at any time. For these rea- 
sons an open treatment, with permanent antiseptic irrigation is required 
(Chapter XIL). 

This treatment should be continued ontH the wound has been rendered 




THE TREATMENT OF WOUNDS. 

perfectly aseptic, when it iobj be replaced hy oouluaive and compreaBiTe 
antiseptic dressings. 

IMMOBILIZATION OP THE INJURED PABT8. 

Means of iiniuobilization mtist be resorted to both for tlie protection 
of the injured uoft iiarta, and for the retention of the bone-fragmenta in 
proper position until consohdation baa been accomplished. The presence 
of an open wound introduces elements of greater difficulty into the prob- 
lem of immobilization than when a simple fracture is being dealt with, for, 
either the fracture-dressing must be i^emoved every time the wotmd is ei- 
amiucd, and then renewed, or must be so constructed as to leave exposed 
the wound and its surroundings. The latter plan is to be preferred, but 
is attended by greater technical difficultjes, which grow with the circumfer- 
ence of the woimd, and may be insurmountable in very estenaive or multi- 
ple wounds. 

The difficulties attending the employment of permanent dressings is 
quite apparent when antiseptic dressings also are to be used, and the ques- 
tion may have to be decided which of the two factors, antisepsis or immo- 
bilization, is of the greater importance, and which shall be infringed upon 
in their combination. 

Slight motion of the extremities of the fractured bone, during a change 
of dressing, ia not followed by any reaction when the parte are kept 
aseptic. Antisepsis, therefore, is the first requirement to be observed, 
especially in the earlier period of the case, until the fracture and the 
wound in the soft parts ore covered with gnmulationa Antisepsis should 
be maintained scrupulously, even if it becomes necessaiy to remove the 
fracture-dressing from the Umb to change the antiseptic dressing. 

Except in the more simple and favorable cases the use of a permanent 
plaster- of -Faris dressing, applied so as to encircle the limb, and fenestrated, 
is not compatible with the requirements of the antiseptic dressing of the 
wound during the earlier days of its course. After Uie first critical period 
has passed, however, and the wound has become covered with granulsr- 
tions, and the amount of its secretions have somewhat diminished, such a 
dressing will be applicable- In cases of fractures occurring in patients 
suffering from delirium tremens, tbis dressing is indispensable. 

During the first period of the treatment of tbese injuries, only such a 
means of immobilization should bo employed as will allow the wound to 
be enwrapped with ou antiaeptic dreaaiug that will extend over a wide cii- 



IMHOBILIZIITO COMPOUND PRAOTUBBS. 268 

* emuference about it. Not always the same kmd of dresaiiig will answer ; 
Ktat of the fracture, and the special conditloiis of each case ehould be 
our guide. 

Plastic splints ore to be recommeDded in most cases. Splints made of 
pasteboard, felt, or plaster-of -Paris are eapedally applicable, as thoy can 
be adapted to any part of the body. The width of the splint should ex- 
tend over about one-tlur<l of the circumference of the limb. In general, 

: Ifae splint is applied over the antiseptic dressing, if possible, on that side 
of the limb where it will be least soiled by the wound-secretions. They 
diould be secured by moist starched bandages, eo that the tui-ns, when dry, 
will firmly adhere to each other. For suspending the limb, holes may 
bo punched iu the splint, and cords for suspension drawn through 
them. 




Such splints can easily be removed at each change of the dressing. In 

e cases, however, in which the wound ia not too large, and is favorably 
located, the splint might be enclosed within the antiseptic dressing, so 
iliat it might remain when the latter is changed. In such a cose, the 
q)lint should be nan-owed opposite the wound, and wrappeil in impermea- 
ble tissue or lined with antiseptic cotton. It may then be placed directly 
upon that part of the limb opposite the wound, next to the skin. Over all, 

^_tbe antiseptic dressings are to be apphed, and the whole secured as before 

^■Bcommended. 

^^^ Another way to avoid removal of the splint, when the wound-dressing 
U changed, is to have a O-ahaped arch formed on the splint, opprisite the 
wound (Fig, 88), so a« to render tlic wound and its smroundins'.'i accessible 
Q annmd. Such a splint would need to be reinforced by a strip of hoop- 




TttK TKEATMBMT OF WOUNDS. 

iron, beat in the same way, and indoaed in th« plaster. Such a splint 
resembleB much the iiiterrupt«d circulaj' spUnt (Figs. 76, 79). 

Concave Hplints of wood, tio, or wire, applied over the wound -drsseing, 
may be used to advautage ia many cases. 

Some kind of BuspeDsion-spliiit, with extension by means of adhesive 
plaster stxipH, a weight and pulley, affords, as a rule, the best advantages 
for earning out the antiseptic treatmeat of a wound complicated with 
fracture. 

The fenestrated or interrupted pla8t«r-of-PariB encircling ^Unt maj 
be employed with advantage as Boon as the prooess of healing haa Boffi- 



I 







eiently advanced to exclude danger from sepsiB and inflammation. This 
period may nrrive within two or three weeks, if the conditions are &toi^ 
able, but may be delayed for a much longer time. When the secretitma 
have nearly ceased, tbe woimd is covered with granulations, and the ind- 
■ioQS have either healed or have become supeiticial granulating surfaoea, 
the perfect immobilization of the fracture assumes Rreat«r importODOB 
than the rigid antiseptic treatment of the external wound. No method 
faucture -dressing can secure the desired immobility of the bone-fragmenta, 
and yet permit the necessary attentions to the wound, but the encirdill^ 
I^Mter ephnt, fenestrated or interrupted. 



inoi- 
taoea, 
tODOB \ 
odof I 
jentfl, J 




FENESTRATED PLASTER SI'LIITTS. 265 

The RppliGotion of the plaat«r-dres8iBg io these cases requires grsat 
eve and e^rperience to preserve the continaation of the antiseptic treat- 
ment. If the wound is smalt, feQestration of the splint will suffice ; if it 
ie extenaive, or if seTerol wounds coexist, it must be interrupted. 

Apptieatinn of (he FenenlrtUed Splitit. — The fenestrated plast«r-of-Pahs 
a^int is applied as follows : The wound and its immediut« vicinity, to the 
extent of one to two inches, are covered t«niporaril}' with a number of 
IbldB of antiseptic gauze or cotton, which will afterward form a projection 
in the plaster casing, by which the location of the fenestrum will be 
marlied. As a basis for the plaster dressing, the whole limb, aft«r having 
been well cleansed with an antiseptic lotion, should be wrapped in anti- 
septic cotton. The plaster bandages should then be implied in the usual 
my (Chapter XL, p. 211). The plaster bandage may be reinforced by the 
a between its layers of one or more longitudinal strips of sheet-iron. 




-lAt>i-i,-y|>ii»iii >J;>liDt at rimgoff (finiorcJI). 



As aoon as the plaster is sufficiently hard, the fenestrum is made, and 
fte temporary antiseptic dressing is removed through the window. The 
■paces at the margins of the opening are filled thoroughly with antiseptic 
pute (ten per cent carbolized oil and common chalk or whiting). Finally, 
the whole space within the fenestrum is filled with antiseptic protective 
UiBt^ial ; over all a layer of impermeable tissue is placed which shall 
Oterlap the circumference of the fenestrum from two to three inches, being 
•ecnred in place by a gauze bandage. 

The limb should then be suspended. 

If it becomes necessary for the fenestrum to be so large that the splint 
IB materially weakened by it, a wooden strip might be placed longitudinally 
over the limb, crossing the window, as in the " Lath-gypsum " dressing of 
Pirogoff (Fig. 90), In this dressing of Pirogoff, after a strong plaster-of- 



Sod the treatment ok wottkos, 

Paris splint of coarse Backcloth, soaked in plaster crBam, hua been applied 
to the celt, two large balls of tow, saturated with Uie plaster cream, are 
placed upon the anterior surface of the leg ; a wooden lath is then fastened 
upon the tow witli broad utrips of linen, which 
are al»o impregnated with the plaster cream. 

The interrupted plaster dressing (Chapter 
XL, p. iJ12) is suitable in estenmve injuries of 
the soft parts, or in multiple incisions and 
counter-incisions. The bridges ^Fig. ill), pre- 
ferably of sheet-ii'on, which connect the two 
piecea of the dressing should extend along the 
whole length of the sections of the dressing 
I into nhich they oie inserted, and should be 
upphed one externally and the other intentaUy, 
k) the limb. They should be fastened by a 
sufScient number of turns of plaster bandage 
to give the apparatus sufficient strength. The 
margins of the dressing in the neighborhood 
of the wound should be filled in with the anti- 
septic paste, and the antiseptic dressing ap- 
plied to the wound as usuoL 

The form of interrupted plaster dresBiDg, 
called by SzjTuanowski the honeycomb plaster 
dressing, may be easily improvised and applied 
in cases where extensive or multiple injuries ex- 
ist It consiata of applying first as many sepa- 
rate plaster rings as the requii'ed interruptions 
mnecting these with narrow wooden strips, which 
are fastened to the plaster rings by other turns of the plaster bandage until 
the whole is cousohdated ^vith su£B.cient firmness to secure absolute immo- 
bility to the enclosed parts. The interspaces between the wooden strips per- 
mit a thorough dressing of the wounds and frequent renewal of the same. 

If either the fenestrated or interrupted plaster dressing, in any form, is 
used, it must remain iu place till the wound is covered by skin. Ab bj 
antiseptic methods of ti-eatment Utia will .have happened long before con- 
solidation of the fracture has oenurred, a close piaster di-esaiug should be 
substituted for the open one during the period that will yet remain before 
flzm union of the bone is occomphshed. 




make necesaory, and then c< 



PART II. 



SPECIAL "WOUNDS 



SECTION J I. 



WOUNDS OF TISSUES COMMON TO ALL PARTS OF 

THE BODY. 




I 



I 



Woiuui* t^ ifuM^t— Diffianlties of CoaptatioD— PoBition_Baiids«iDg— Sutimne-' 
Rest— Proteotioa from Sepsis— SuljcutoneouB Bupturea— Wounrf* of Tmdoru— 
BealiDg of Subcatan 1:01111 Wunndi— Diffioattiss of Open Wonods — Importance of 
Antbepaia, Protection, and Real — Snturing Tendona — langc's Case— PiiQly'i 
Cue— Wouttdi of Nerva — Importance of Approximation of Divided Ends- Meth- 
ods of AppToximation— Saturing Necvea- Tillman's Statistics- Reanlts reported 
by Page— Pye'a Caae— Page'a Ct»e—AppUtation of thf Ntrrvetritiin—Jiiniot 
Kerre-anture — Peri-nsaral Suture- The Soturo Matarial— Condition* Itaqnitin|{ 
Ncrre-Butare—Neacoplaaty- Tubular Suture— Contra-indioationa—Reqiiiaitea to 

WOUSDS OP MUSCLES. 

The retractile nnture of the musciilar tissue, by its t«Ddeiicy to causa 
wide separatioD of the divided ends of an injured muscle, occasions specisj 
difficultieB in the treatment of wounds of these organs. In order to bring 
the wound-BurfaceH into apposition it is necesaary that the part be placed 
in a position of complete relaxation, in which it must be kept during the 
course of the healing', till firm union boa taken place. Wien it is a muscle 
of one of the exb-emitiea that is wounded, the continued relaxation of 
either portion will be promoted by the application of two roller bandages, 
applied in opposite directions, each beginning at that part of the muscle 
most distant from the wound, and approaching the wound as they are 
^>plied. Thus the contraction of the fleshy fibres may be controlled, and 

approsimation of the retracted ends favored. 

The permanent fmit^tiomil impairment which is entailed by a failiire to 
secure approximation and union of the divided ends of a muscle, lends im- 
portance to everj- meann which can be adopted which will prevent such 
fiulure. Sutures should be applied — sutures of relaxation and of coapta> 
tioD — the deeper sutures being carried through nearly the whole thicknees 



270 TUE TIIEATITENT OF WOUNDS. 

of the muscle. Best by meajia of podtion, conipreesion, and tmmobilixa- 
tion should be mamtainecl with great care. When adequate protection 
against the Pauses of inflammation is negletrted. iipproxinjation by sutures 
will be of little t-alue, since the softening of the tissue, even to some little 
distance from the surface of the wound, consequent upon the inflommatary 
changes, will cause them to be easily torn out. Every precaution, tliBre- 
fore, of wound-cleanliness and of antiseptic di'es^g should be obserred in 
the care of this class of wounds, to prevent the production of inflammataty 
or septic disturbances. 

In the treatment of subcutaneous ruptiwes of muscles, when the muscle 
is one whose function is of importance, and is so situated that it is accessi- 
ble without endangering more important organs in the operation, the pro- 
tection of the unbroken skin sliould be sacrificed, and Uje wound converted 
into an open one, in order that the more ini|X)rtant indication of bringing 
the retracted ends into coaptation by sutures may be accomplished. 
Shotdd the edges of tJie wound across the muscle prove to be ragged, they 
should be trimmed sufficiently to permit of close apposition of the surfacea. 

Subcutaneous muscular niptures which are too deep seated, or which 
are complicated with other injuries that make their exposure by incision 
inidvisable, should be treated in accordance witli the general methods 
described for the management of subcutaneous injuries. 



WOUNDS OF TENDONS. 

Approximation of the dinded ends of a severed tendon must be fovored 
by placing the part in that position which ivill fully relax the attached 
muscle ; appropriate means of immobilization and compression must then 
be used to prevent retraction and separation during the period of repair. 
The healing of subcutaneous woimds may be expected to progress undis- 
turbed without other treatment, it these precautions be obsen'ed. Divided 
tendons, in which the injurj' has been accomp-mied by a simple punctured 
wound of tlie skin, as in the operations of tenotomy for orlliopscdic pur- 
poses, ill which immediate occlusion of the external woun<l is accompanied 
by its healing by primarj- union, require the some simple treatment aa if 
the wound had been absolutely subcutaneous from the Itrst. 

Open wounds exposing divided tendons present conditions especially 
favorable fur the development of woimd-disturbonces, which conditionB are 
still more aggravated in those cases in which a synovial sheath for the ten- 






^^Son is UkewiBG opened. The retraction of Uie t^ndou-frogiDeDts prevents 
^prosimatioii and primiuy onion, and leaves recesses for the iiecuniula- 
tioa and retention of secretioua ; the ^^ovial shenths offer favorable mate- 
rial and surfaces for tlie development of sepsis, and in llieir absence the 
connective-tiRsue that ensheaths the tendon affords a favorable tissue for 
the development and extension of phlegmonous inflaiamationB. A strict 
obeervBlnc* of every detail of wound-cleanliness and disinfection is there- 
fore necessury in the treatment of open wounds of tendons. Perfect arrest 
of hfemorrfaage must be accomplished. The primarj- cleansing of the 
KMroimd must 1)e scrupidous, and adequate means for drains^ must be 
Hqvorided. The ends of the divided tendons must bo sought for, and their 
coaptation effected and maintained by sutures. It in less essential what 
tlie exact kind of suture it is that is employed, than that it be aseptic and 
of sufficient durability to maintiin the coaptation till the imion ahoU be 
firm. The suture stiould be passed tlmjngh tlie tendon sufficiently far 
from its edge that it shall not be easily torn out. The extermil wound 
_, ahould then be closed, with due attention to drainage. Protective dresa- 
^■li^ and provisionB for rest sliuuld be applied with miniit« core. 
^P The treatment of wounds involving tendons, in which suppuration or 
inflammatory disturbances Iiavo already declared themselves mu3t be con- 
ducted in accordance with the methoils governing tlie treatment of such 
wounds in general. The sutnrc of the tend on -fragments will have to be 
abandoned or omitted in such cases, and their direct union left to be 
accomplished by operative measures at a later period, after dcatrizatiOQ 
of the wound has been effecied. 

^Vlicn marked impairment of function remains long oft^r the wound 
has henled, as the result of a gap which persists between the retracted 
ends of a divided tendon, whether the original injury liave been a subcu- 
taneous rupture or an open wound, the parts should be exposed by n free 
indflion, the ends of the tendon-fragments freed from any new attach- 
ments, freshened, and, having been brought, if possible, into coaptotion, 
sutored together. If the end of the proximal fragment cannot be found, 
or cannot be brought down to the distal fragment, the freshened end of 
the latter may be attached to a contiguous tendon, with the result of re»- 
toration of some power over the supplied part. If the matting of the end 
of the distal fragment in the cicatricial tissue at the point of injuiy is so 
extensive as to make its isolation unwise, the end of the proximal frag- 
ment may be brought down and bkewise attached to the cicatrix, with the 



WOUNDS OF TENDONS. 271 



979 THE TREATMEBT OF WOUNDa 

result of increaHing the amount of voluntary' control over the parts beyond. 
As an example of the resultB which may be obtained from exposure and 
suture of divided t«ndonB gubsequent to the healiufj of the primary wound, 
the following case may be quoted : At the meeting of the New York Sur- 
gical Society of March 13, 1883. Dr. F. Linge presented n kdy patient 
who, about two months previously, had faUen from a considerable height, 
and sustained a wound, cutting the tendons nf the exteneor ni\isde8 uf tbe 
left foreaiTu. He saw the patient two weeks afterward, when the wound 
was almost healed, and there was extensor paralysis involving the tHrd 
and fourth fingers, only the last two joints moving through the action of 
the interosset. About two weeks lat«r Dr. Longe nuide a longitudinal iD' 
cision, and found that three of the est«nsor tendons had been divided, 
namely, those belonging to the third and fourth fingers, and to the index 
finger. The extensor indicis proprius was not injui-ed, for the action ol 
the index existed. The divided tendons of the extonsors were separated 
to a distance of ahnoet one inch and a half. They were brought together 
and sutured with antiseptic silk. The hand was then put in a position of 
superextension, and an antiseptic dressing applied. The sutures were re- 
moved at the end of one week. The result was that the movements of the 
fingers could already be quite etttiefactorily performed, and it was probable 
that improvement would still continue. 

The residts of the immediate suture of a divided tendon, with proper 
after- treatment, are exemplified in the following case, reported by Pauly,' 
of Posen. It is also quoted by MacCormac, in his Antiseptic Surgery. 

A boy fell fro:n the top of a hay wagon, with the left heel right ocroas 
the blade of a scythe. 

A wound four inches long, extended transvcisely &om one malleolus to 
the other, completely dividing the tendo Achillis, and opening the auUe- 
joint from behind. The tuberosity of the oe calcia, \n\h the jaeoe of 
tendo Achillis attached to it, about an inch in length, was comple[«ly sev- 
erod from the rest of the bone, to which it remained connected by soft 
parts alone. Antiseptic treatment was adopted. The detjw^hed tuberosity 
was fastened in its place by a common ntidl, and while the foot was main- 
tained in the equinus position, the divided surfaces of the Achilles tendon 
were united together by catgut sutures inserted alternately deeply and 
superficially into the substance of the tendon. 



I 



WOUITDS OK JTEBVBS. 378 

In nineteen days a complete recovery waa accomplished, and one year 
Afterward, the report states tliat the function of the limb was pierfectlj 
normal 

WOUNDS OF NERVES. 



While it is true that, in general, wounds of nerves should be treated on 
'the same general principles as wounds of otter Btructnres, yet special at- 
tention is demanded to the methods and results of attempts at securing 
approximation of the divided ends in those cases in which important nerve- 
tronks are severed. 

The regeneratioB of nra^e-tisBue through a cicatrix, and thus the 
spontaneous restoration of the function of a. nerve that baa been divided, 
even when considerable loss of substance, or retraction from each other of 
the divided ends has been present, has been observed to occur with suffi- 
dent frequency to render not altogether hopeless any recent case of paraly- 
m» resulting from section of a nerve ; as a rule, however, the re-estabUsL- 
ment of the functions of a nerve never takes place when its extremities 
have been allowed to become separately cicatrized ; but in such cases an 
after-history of abolished function, neuralgic and trophic disturbances is 
entailed. When, however, the ends of the divided nerve can be brought 
into early apposition, and primary* union of the wound can be secured, 
speedy restoration of function in great part may be confidently counted 

The indication is imperatiTe, therefore, to secure and maintain the 
closest possible approximation of the cut surfaces of a divided nerve dur- 
ing the healing of the wound, that the amount of cicatricial tissue may be 
reduced to a minimum, and that the more speedy and certain restoration 
of function may be favored- 

A. degree of approximation may be secured by the position of the 
iTOuiided port, by keeping it in such a position that the nerve-trunk shall 

P relaxed, and by those means of approximation which may be applied to 
ore coaptation of the surfoceH of the wound in general ; but the intrinsio 
raction of the fragments of the nerve-trunk itself will still cause, in most 
iances, more or less of a gap to remain between them. 
In contused and lacerated wounds, and in wounds in which there is 
appreciable loss of substance, it is unhkely that even approximate apposi- 
tion of the ends of divided ncn-cs could be effected without the use of 
Bpedal means. The natural resource in such cases, in addition to the gen- 



J 



274 THE TEEATMEBT OP WOmtD3. 

eral means of relaxation and approximation already referred to, would be 
to isolate the separated ends of the nerve-fragmentfi, draw them down into 
apposition with each other, and keep them apposed hy suturing t h e m to- 
gether. 

The knowledge of the eril effects frequently due to punctures of nerves 
and to their inclusion In Ugatures, the fear of tetanus and of inflammatory 
complications, has, however, rendered surgeons cautious in resorting to 
nerve^uture. A more frequent resort to it has, however, marked the prac- 
tice of surgeons of late years ; in none of the reported cases have untoward 
comphcations occurred, and the marked benefits secured by its practice 
have now established it as a regular surgical procedure, the neglect of 
which, in the cases caUing for it, would be censurable. 

In a paper devoted to the subject of wounds and suture of nerves, by 
Tillmans, ' of Leipsic, in 1881, out of 12 coses of nerve-suture, in general, 
which he tabulates, in 22 cEises the application of the primary suture is 
stated to have been made. In 13 of these the result, as regards restoration 
of function, is stated to have been succeesful ; in one, only, unsuccesKful ; 
the remaining eight beiog classed as questionable. In eight other instances 
sufficient data for determining whether the suture was primary or not) is 
not given. Four of these resulted successfully, one unsuccessfully, and 
three were questionable. In 12 instances at various lengths of time after 
cicatrization of the wound had taken place, the separated nerve-ends were 
exposed by proper incisions, and their refreshed ends, having been brought 
together, were sutured. Of these cases of secondary suture, six resulted 
snccGSsfuUy and six are classed as questionable. Herbert W. Page,' of 
Xjondon, has related four successful cases of primary suture not included in 
Tillmans' tables, two from the practice of Mr. Favell, one from Mr. Pye, 
and one case of his own. More recently Mr. Page has reported ' the ulti- 
tnate results of two cases of secondary suture, one having been completely 
Buccessful, the other but partially sa 

The cose of primary suture of Mr. Pye, and that of seeondaiy suture of 
Mr. Page may be detailed as fair examples of the two classes of procedure. 
In the first instance, a lad, aged 14, caught bis arm in a printing-machine 

' Ueter NervetwerltUungen «nd NervmnaM, ArtMv fUr Klinudu CAirvrgie, 
rvJL 1. 

* The Immediate Sntare of Divided Nerves. Britisb Medical Jonntiil, Maf 7, 
1881. p. 717. 

■ Coae of Seoondat; Bntare ot XJInMT Nerve Six ModUu >f (er ita Divlaioa Biitidl 
Moduli JoQmal, June 33, 18H3, p. 1223. J 



|£u 



NEEVE-SLTCKE. 275 

ind received a Incemted wound beliind and on either dde of the left elbow- 
joint, exposing the internal and anterior aupecte of the capsule of the joint 
with the brachial artery, tettring the tendon of the triceps, and chipping off 
part of the internal condyle of the humerus. The median nerve was torn 
completely aeroaa The ends of the nerve were brought together, ns nearly 
as possible, by catgut sutui-ea passed through the substance of the nerve 
and through its sheath. The wound was lightly dressed with carbohc acid, 
and the arm was placed la an angular splint. During the first week there- 

the motor and sensory paralysis appeared complete in the hand and 
the muscles of the forearm supplied by the nerve. Then there began 

pricking and tingling of the forefinger, soon followed by commencing 
power of flexion. The return of sensation, once started, progressed rapidly 
and was neai'ly complete by the end of the montL The ball of the thumb 
and the radial side of the middle finger remained insensitive throughout 
The return of muscular power was fairly good, but was more difficult to 
estimate in consequence of the cicatrization of the wound. 

The example of secondary suture which I desire to quote was the case 
of a man, aged 25, who six months previously hod received a severe wound 
of the left wrist from glass, which was a month in healing. From that 
time he had extreme pain in the cicatrix, his ring and littte fingers became 
bent and useless, and he was obliged to carrj- his arm in a sling. T,\Tien 
admitted for treatment, the wouind cicatiis was excessively tender, he had 
lost the power of extending the two last phalanges of the ring and little 
fingers, and, to a less extent, of the other fingers also, and the thenar and 
hypothenar eminences, together with the interossei, were markedly waited. 
Sensation was very defective, though not entirely absent, in the ring and 
httle fingers, more especially on their palmar eurfacea The whole hand, 
indeed, was somewhat aniesthetic and withered from disease. It sweated 
constantly and profusely ; the little finger was blue and slightly swollen, 
and the tmil was much misshapen. 

b April 4, 1881, Mr. Page cut down on (he site of the ulnor nerve, and 
%ith much difficulty found the separated end& The upper end of the 
lower portion was found turned downward and inwanl, and ended in 
thick cicatricial tissue on the under surface of the tendon of the flexor 
carpi ulnaria It was not enlarged, and a transverse section of it, when 
freed from the cicatrix, showed the appearances of healthy nerve. The 
lower end of the upper portion was swollen to about three times its natural 
size, and ended in a firm bulbous nodule, which also was bound in cica- i 



2T6 Tira TBEATMENT OF WOVWDB. 

incial tissue. From this it was dissected, and a third of on inch had to be 
roiuov^ before the section looked natural It was necessary to dissect the 
upper part of the nerve free for a couple of inches, before the two ends 
could be brought into comfortable appoaition ; they were then joined by 
three fine cat^t sutures passed through both sheath and nerre. The 
wound healed by first intention. As early as the tenth day the anscstheaia 
was less marked. At the eud of three weeks, sensation hod decidedly im- 
proved, the cicatrix was free from pain, and some return of the power of 
extension of the last phalanges of the ring and little fingers was evident. At 
the end of twenty-two months, during the first year of which appropriate 
galvanic and faradio treatment had been persevered in, his hand was as 
useful as it had ever been. Tliere was no sign of trophic disturbance ; 
sensation was normal; there was no wasting; be, however, experienced 
occasional pain in the cicatrix on change of weather, and was unable to 
perfectly extend the last phalanx of the little finger, 

Appucation of the Neh^-e-sdtcre. — For the piu^se of securing Kppon- 
tion of the two ends of a cut nerve, sutures may be introduced either 
through the substance of the nerve-tnmk itself or simply through the con- 
nective-tissue that acts as a sheath to the nerve, including, perhaps, tha 
neuiilemma. The former constitutes "direct nerv€>-euture," the latter "in- 
direct" or "peri-neural" suture. 

Direct Nerve-gulure. — This is the form of suture which has been r&- 
sorted to in the greater number of the published cases of nerve-suture. 
By means of a fine needle the thread is made to traverse the body of tho 
ner%'e and embrace ita substance in the knot which is tied. By some thfi 
nerve has been pierced through and through ; others have brought out the 
thread at the lower, or at the middle part of the cut surface. The latter 
method is more likely to secure accurate and steady coaptation, but if there 
is any strain upon the suture, it will be more quickly cut out In tha 
fonner method greater care will be required to obtain exact adjustment 
and avoid angular deviation of the ends when the knot is tied, but it gives a 
greater security against subsequent gaping by retraction. One thread only 
will euifice, unless a large trunk, as the great sciatic, is under treatment 

Perineural Suture — The insertion of the sutiu^a through the peri-neu- 
ral oonnective-tisBue, when, by «> doing, sufficient traction on the nerve- 
fragments can be effected to overcome the gaping at the iwint of divi- 
sion, recommends itself by the fact that by ita practice the nerve-bundles 
neither receive injury by the needle puncture nor by the after-etroin of 



THK TraBVE-BUTUBB. 377 

) thread. For its application two sutures are reqiiired, one at either 
side of, and close to, the nerve. When the sutuixs are drawn up and care- 
fully kBotted, coaptation of the cut surfaces of the nerve may be obtained 
'Kith even more accuracy than when the direct suture is employed. The 
results obtained by the use of the indirect suture have been very ^tisfac- 
tory. In seven of the cases reported by Tillmans, was this method of 
coaptation used, with a successful result in all but on& 

Both the direct and the indirect methods may be employed in the 
same case, when the conditions seem to require it, the one great indication 
to be met being esact and stable coaptation of the cut surfaces. 
I The Suture Material. — The choice of tho thread for the suture is of im- 
portance, for the highest success of the suture can be obtained only by 
securing union by first intention. No material should be used for the 
stttuie which will interfere with primary union of the wound. Aseptic 
catgut, silk, or silver wire may be used, but the catgut is to be preferred, 
as by its subsequent spontaneous absorption it is not bo likely to become a 
source of future irritation. By the use of catgut, and the indirect method 
of suture, no hesitancy need be felt in the apphcation of the suture in 
every case of complete division of a nerve-trunk. 

CoyDrrioHS Reqoihiso Nebvb-suture. — A recent wound, in which a 
nerve'irunk has been severed, requires the separate suturing of the ends 
of the divided nerve, as one of the elements of securing proper " wound- 
apposition." Some latitude of practice and judgment may be allowed in 
cases in which the external wound is quite restricted, and in which httle 
tendency to retraction may be supposed to exist, and by position and the 
general measures instituted for the appirosimation of the wound-surfaoefl, 
ita primary union ih probable. 

When the external wound is considerable, even though the retraction 
of the divided ends of the nerve Is not great, the suture should be 
ployed. 

I When decided separation of the divided ends of the nerve exists, either 
■ M the result of retraction or of loss of substance, the suture must not 
■ omitted. The amount of separation which can be overcome, so that 
fnds of the nerve -fragments can be again apposed, may be considerabh 
Nclaton brought together the ends of the median nerve after having 
ezsected two and one-third inches of ita continuity ; von Langenbeck ob- 
tained union between fragments of the great sciatio nerve that had been 
eepaiated by a distance of two inches. If, however, it is foimd impossible 



we«, 
tioa^^^fl 

ther 9 

t be 1 

the I 



278 THE TEBATKEHT OP WOTTWDS. 

to bring the divided ends together, one of four expedients may be fidopted. 
First, if several nerves have been divided, the expedient of Hourens may 
possibly be resorted to, that of uniting the lower end of the naost impor- 
tant nerve to the upper end of another. Second, if such less important 
nerve be not already divided, if it be accessible, a sufficient portion of ita 
GUI-face may be freshened, and the lower end of the divided nerve sutured 
thereto, \irtually grafting it in. A succesaful instance of this kind is re- 
ported by Marchand," from the clinic of Deprca. A lacerated wound of 
the left arm had torn the median nerve. Depr^s found it impossible to 
bring the central end of the torn nerve down so as to eutm-e it to its corre- 
sponding fragment He therefore esposed the ulnar nerve, and having 
separated its fibres by tearing them apart mih a pair of dressing forceps, 
into the interspaces insert«d the fibres of the peripheral end of the median 
nerve. The procedure was crowned with success, and the patient recov- 
ered a useful band. 

The two remaining expedients are those of "nenroplas^," or transplan- 
tation of nerve-tissue to fill the gap, and of "tubular suture." These are 
still matters of physiological experiment, but deserve mention in this con- 
nection. They are referred to by Nieaise," as follows : " Gluck, of Berlin, 
has resected in chickens three or four centimetres (1 to IJ inch) of the 
sciatic nerve, which he has replaced by a piece of the sciatic nerve of s 
rabbit, sutured at both of its extremities. The chickens thus operated 
upon walked as well as those upon which direct suture of the sciatic had 
been practised, while section of the sciatic without suture or autoplasty 
produced a paralysis of this nerve which was still complete at the end of 
ten weeks. This procedure is yet in the domain of physiology. When 
the separation of the ends of the nerve ia considerable, and they cannot be 
brought in contact, the tubular guture of Gluck and Vaulair may be tried. 
The aim of this is to prevent the obhteration of the space which sepa- 
rates the two segmente by the interposition of a Neuber's osseine tube. 
Qluek has only obtaine<l negative results, but Vaulair has seen, he says, 
after a delay of four mODths, the regeneration of a nerve-trunk measuring 
five centimetres (2 inches). He has determined that the regeneration ia 
effected by oentrifugal granulatioas arising from tba oectral end, as has 



' GiutU BtbSomadairt ia Medteine et dt CMrvrgie, 1876, Ifo. S. 

' lojutiea and DiMBneB of Nerves, lulematloQal EncycIopiDdia of Surgery, vol 



\ 



THE NEKVB-aUTURK 279 

like^nse been shown by Eichlioret, Ranvier, and Hahn. He addB that a 
entail portion only of tlie new fibies unite trith the degenerated fibres of 
the peripheral end." 

When the section of the nerve ia the result of a contused wound, the 
disintegrated or badly contused portions of the exposed ends should be 
resected until surfaces capable of primai^ adhesion ai-e reached, which are 
then to be brought together. In cases of severe contusion of a nerre- 
trunk, without actual solution of ite continuity, the propriety of exsecting 
the contused portion and suturing the eitremitieB which remain, is worthy 
of conmderation in view of the frequent, prolonged, and severe loss or dis- 
turbance of function following nerve oontusions, and the good results ob- 
tained by nerve-suture. 

The suture is contrar-lndicated when the wound is no longer recent, 
but has begun to suppurate. In such oases, general measures of approxi- 
mation must alone be relied on until cicatrization has token place, after 
which, if necessary, operation for secondary suture may be instituted. 

The approsimatioQ and suturing together of the divided ends of a 
nerve should be done as early as possible after the wound has been in- 
flicted. It is important that primary union be secured ; minute observ- 
ance of every requirement of wound-treatment should mark the care of a 
wound involving a nerve-trunk. 




Importanoe of Womuls ot Blood-veuels — Keanlti to be Secured In Treatment— Diffl- 
cntliei— Oblitenttioti of VesMli— BsUtioiu of Coogalnm to Repaii— PhjaLologj 
of Bapali — Appoiitioii of Inner SerouB Bnrfoces — Meuu of CompieuioD — TI1& 
Llgatore — Ligtttioa — Groaa or Inuaoderate Yiolenoe in T^iug m Ligature— Bolea 
of Prooedme — Complieatiotu of Woundi of Blood-veudi — Primuy HaiinarrbBg« — 
Inteimediuj HiemoiTluiKa — Secoadaij HEemoniiage — Diffuse Traumatic Aueii' 
tiKa — Woand*ofVein* — Peonliaritiea— PWebitia andPeriplilubitia— Thromboaia— 
Effeota of Septic Ligatnrei — Acnpremure and Foroipressare— J. E. Pileher'a Ca*a 
— Adiantagea of Aaeptio Iiigatoret — Repair of Vein Wounds — Groaa' Caiae — 
Langenbeck's Case — Lateral Ligation — Braon'a StAtiatica — Ifeoessai7 Pzecau- 
tiona — Latetal Sutnce. 

A'-'' wounds involve wounds of blood-veBsela, and the mdications for treat- 
ment which the resulting hfemoirbage presents have claimed attention in 
connection with each of the general claases of wounds that have been con- 
Bidered. There remain, however, certain special considerations with regard 
to wounds of tliese organs to which further examinatdon should be 
directed. 

It is impossible to exaggerate the importance of tvounds of blood- 
vesHels ; \h.% treatment which is demanded, when vessels of any size are 
involved, must be instantoneouHly apphed, in default of which quick death 
is inevitable. It is the opinion of Lidell ' that more lives are lost bx)m tlie 
hfemorrbage resulting from wounds of blood-veBsek, eitlier directly or in- 
directly, than from all the other consequences combined which flow from 
wounds. In support of this assertion he states that of the slain in battle, 
of whom he had personal observation during our War of the Bebellion, a 
very large share, about one-half, possibly even more than that, perished by 
haemorrhage from wounds of the large blood-vessels of the neck, chest, 
abdomen, groin, etc, or from wounds involving vital organs like the bnis 

'Injnile* of Blood-veuela. InteiuBtioual Eocydopeedla of Suiger;, 10I. ilL, p. 40. 



WOUHUe OF BL00D-VES3ELS. 281 



^Mid lungs, the bleeding vbereof caused deadly compreaaion of these 
organs before succor could be afforded. 

The treatment, again, must be effectual for Uie pennsneiit obliteration 
of the open orifices in the wounded veesel, otherwiae reneved peril from 
the escape of blood will supervene. 

The treatment of the wounded Teasel should, if possible, be conducted 
iu such a wBj as to avoid introducing sources of disturbance into the heal- 
ing of the other wounded tissues ; thereby, also, its own undisturbed repair 
will the most certainly be secured. The elements of treatment which 
wounded blood-vessels require do not differ from those required by other 
tissues. Hsemorrhage must be arrested, the wound must be cleansed and 
brought into apposition, protection againeit disturbance from without must 
be supplied, and rest must be secured until repair is perfected. 

The practical difficulties which complicate the treatment of these 
^ununds spring from the peculiar fimction and anatomical character of the 
^Hrgan. The blood-pressure within them is a constant force tending to 
Vtaparate the edges of the wound, while the escape of this vital fluid con- 
stitutes a danger which must be prevented at the sacrifice, if necessary, of 
the functional activity of the organ itaeif. The th'^t walls of the organ do 
not afford sufficient surface, when wounded, for securing perfect and 
reliable apposition of the edges of the wound, in antagonism to the press- 
BTB of the column of blood which they enclose, and to the intrinsic ten- 
dency to gaping from the contmctiUty of its own tissue. Longitudinal 
wounds of veins, however, in many instances form an exception to this 
■talemeni The readiness with which the internal tunic of blood-vessels 
responds to irritation by the production upon its surface of plastic 
material, suffices, when taken advantage of, to supplement the reparative 
deficiencies of the cut surfaces. From this source granulation tissue ih 
produced that by its organization obhterates that part of the vessel filled 
by it, and pei-mits the undisturbed organization of the reparative material 
produced from the wound-surfaces themselves. The coagulum which 
forms within the last portion of the caool of a severed vessel, and blocks It 
iq>, not only serves as a temporary plug to prevent the escape of blood, but 
H stimulates the vascular timic, with which it is in contact, to an increased 
cdl-activity that results in new tissue that not only assists in forming a 
permanent seal to the vessel, but also invading the clot, substitutes for it 
cicatricial tissue that converts the now unused portion of the vessel into a 
fibrous cord. The result i^ a total loss to the economy of a portion of its 



iJ.^ 



383 THB TBEATMBNT OP WOirNDS. 

Bubstnuce, and the permanent impairment of fimction of an organ. The 
importance of this loss and impairment will depend upon the importance 
of the pftrticulflr vessel and upon the ability of other vessels to supplement 
the defects of the injured one by increased development and labor. Per- 
manent impairment of function, cedema, and gangrene are not infrequent 
results of the obliteration of vascular trunks. 

The presence of a coagulum, however, is not essential to the inaugura- 
tion of the processes by which a wounded vessel is to lie sealed up, and ite 
presence is an embarrassment, rather, to the repair when the needful sap- 
port and rest to the part can be secured while its repair ia in progresa 
The e^-'.'cts of the original traumatism by which the vessel has been 
wounded suffice to stimulate that portion of the internal tunic adjacent to 
the wound to the needed nutritive activitj-, and if the effort of the surgeon 
is successful in keeping the proliferating surfaces of this tunic in contact 
until Gnu adhesion has taken place by the organization of the new m&terial 
supphed by it, the beat result wiU be obtained. 

Apportion of the wound-surfaces, therefore, in the caae of wounds of 
the blood-vessels, with exceptions that will be mentioned, should be sub- 
stituted by apposition of the surfaces of that part of the inner tunic of the 
vessels which is immediittely luljacent to the wound. 

The ti'(!atment of wounded blood-vessels in this respect involves the 
same principles aa those which hereafter will be found to govern the treat- 
ment of wounds of thin-walled membranous organs, as the pericardium, 
alimentary canal, or urinary bladder, the walla of which present on one 
side a serous surface, the apposition of which, rather than of the wound 
edges themselves, affords the most rapid and secure means of closing a 
penetrating woimd of their substance. 

Some means of compression will be required in every case for beeping 
the inner surfaces of the vessel in contact until firm adhesion, adhesion 
firm enough to resist the impulse of the blood-current, and the tendency 
to gape of the walls of the vessel itself, has token place. This will be 
afforded by the means which have at once been adopted for restraining the 
escape of blood. The various resources which are at the command of the 
Burgeon for this purpose have already been considered at length in the 
chapter devoted to arrest of haemorrhage (Chopter TL), "Whatever 
method, however, may have necessarily been adopted in the emergen- 
cy of the primary hcemorrhage, if the wounded vessel prove to be of a 
size that its prolonged compreeaion is necessar)', it should be substituted, 



TVOUN'DS OP BLOOD-VESSELS, 983 

i the earliest practicalile moment, by the application of an aseptic 




^BDm; 



ligature dischai^es two functions, th*t of a means of bfemostasis 
of appoHition. In its application for the first purpose, it is eBsentlal 
it should be drawn with sucli tightness that its gni^ of the Tesael 
be so finn that it shall not slip off a«ciiientally. It is not uecessary, 
'er, that it should rupture any of the coats of the vesBel, or that the 
portion of the vessel should be strangulated. 
The purposes of apiKiaition require a force of ligation no more power- 
ful than the preceding. The additional traumatism of ruptured coats is 
not reqiiired for exciting or reinforcing the reparative effort, while such 
apphcation of a ligature as shall determine a process of ulcerative inflftpi- 
mation in the tissues grasped by it, ia to be deprecated as the possible d&- 
termiuing cause of secondary hiemorrhage. 

In thia connection I cannot refrain from repeatiug the following ex- 
clamation of Gross : ' " Nothing is more unseemly, or moi-e truly reprehen- 
sible, in a surgeon or his assistant, than to pull a hgature by fits and jerks, 
or so violentiy as to break it, or, perhaps, lacerate and tear off the artery 
itsell With a little care and gentleness, a comparatively weak ligature 
may be thrown around a vessel so as to answer the intention most fully. 
I dwell upon this point with some degree of empbama, because it haa hap- 
pened to me to witness a very unusual number of these Herculean feats 
with khe ligature, the men often pulling aa if they had hold of a rope and 
piece of wood, instectd of a delicate thread and artery. 

It is important, as the first step in the treatment of a wounded blood- 
vessel — it being understood that in all cases vessels whose size or relations 
are such as to require special treatment are being referred to — that full 
exposure of the wound in the vessel is secured. In the case of superficial 
wounds, and of deeper wounds with -extensive division of the more super- 
ficial structures, such exposure of a wounded vessel is eaaUy and sponta- 
neously accomplished. In deep wounds, with restricted external wound, 
punctured and gunshot wounds, this full exposure of the wounded 
vessel is equally imperative. Plugging of such a wound with tampons, or 
preseion of the main trunk on its cardiao side, if it be on artery, may 
resorted to as means of temporary arrest of bleeding ; but as soon as the 
conditions permit the methodical dressing of the wound, the vessel must 



384 THE tbbatmknt of WOrNDS. 

be laid bare at tlie injured point, and permanent ligation be practisecL 
For this purpose free incisions must be made througli the skin and orer- 
Ij-ing tisEues, always making tbem of sufficient length so that the struct^ 
ures at the bottom of the resulting wound shall be distinctly exposed and 
readily accessible to manipulation. As Hsmarch remarks (Intomational 
Medical Congress, London, 1881), "when life is concerned, it matters ht- 
tie whether the incision be an inch or a foot long ; as, if it succeed in 
checking hemorrhage, and be conducted thoroughly aseptically, a long 
incision heals just as well as a short one." 

Care to first render the limb bloodless, in the case of wounds of vessel') 
of the estremities, by the use of an elastic bandage, after the method of 
Emnarch, will greatly facihtate the making of the required inciajons. Li 
other cases, a finger thrust into the wound so as to reach and compress the 
wound in the vessel, will both control the hemorrhage for the time being, . 
and will serve as an invaluable guide for the incisions. As the incisions 
are made, all blood-clots should be thoroughly and carefully removed by 
sponging and scraping, and perfect cleansing of the wound from fluid 
blood and debris of every kind should be done. When the wound in the 
vessel has been found and exposed sufficiently to enable its entire extent lo 
be seen, the vessel must be isolated, and a hgature apphed to a healthy 
part of it both above and below the woimd. The hgatures must be asep- 
tic — catgut or mil.- — luid after having been securely tied, should be cut off 
close. If, by misfortune, no aseptic material for ligatures can bo obtained, 
necessity will compel the use of an ordinary thread. In tliin case, one end 
having been cut off near the knot, the other should be brought out at thv 
most dependent angle of the wound 

Esmnrch colls attention to the difficulty that may be experienced in dis- 
tinguishing veins, when bloodless and collapsed, from cords of connective- 
tissue. As a means of overcoming this, he advises the preliminary forma- 
tion of a reservoii- of blood below the wound by placing a ligature around 
the hand, for instance, before appljing the elastic bandage to the arm.' 
Aftern'ard, on elevating the limb and removing the ligature, the blood 
flows out of the injured vein, if the vessel have been such. 

If the vessel have been only partiaUy divided by the original injuij-, 
after the hgatures have been apphed on either side of the wound, the divi- 
sion should be made complete, and the two ends allowed to retract 

The direction to apply a hgature to the distal as well as the proximal 
aide of a vessel-wound is especially applicable to wounds of arteries, and is 




I 



■W0CKD9 OF BLOOD-VESSELS. 285 

to be observed whether the distal extremity bleeds when exposed or not. 
If left TmaecTired, immineut risk is incurred from intermediary heemor- 
rhage as the full natural force of the circulation begins to be again felt, or 
from secondary btemorrhage after a more free collateral circulation shall 
Uare become established. 

The same reasons conti-a-indicate the practice of ligating the tnmk of 
the artery above the wound, except in those instances in which the bleed- 
ing artery is inaccessible, as the internal maxillary, and, in some instances, 
the lingual 

In the treatment of wounds of small vessels Ij'ing at the bottom of deep 
cavities, and, in more superficial wounds, where a general bleeding from 
many small vessels persists, in which the application of hgatures is imprac- 
ticable, the methods which have been described are impracticable, and the 
use of the tictiial cautery, a^d of tampons is necessitated. 

Every effort should be made to secure primary union in wounds that 
are comphcated by wounds of important blood-vessels. The greatest safe- 
guBJ-d against the occurrence of secondary dangers from wounds of the 
vessels is secured by preventing disturbances in the healing of the general 
wounds of which they form a part. Every precaution against sepsis which 
ifl within the command of the surgeon should be practised in the dressing 
and after-treatment of these wounds. 

OOMPIICATIONS OF WOTWDS OF ELOOD-TESaELS. 

The oomphcations which are so especially related to wounds of vessels 
as to demand conside ration here, are the losses of blood which are liable 
to attend these wounds. Those losses which follow immediately upon the 
infliction of the injury constitute jirimary lujmiorrlmge ; those which attend 
the period of reaction, constitute iniermediary hcemorrhage ; and those 
which take place after the establishment of suppuration constitute second- 
ary liamftrrhage. The extensive effiisions of blood which follow upon the 
subcntoneous rupture of large blood-vessels, knovm as traumalic ajwuritmin, 
tmand, also, some consideration. 

Psnuny Hsmobrhaoe. — The treatment demanded for the control of 
this complication has been fully considered in the first part of this treatise. 
Chapter VL, to which reference shotdd be made. 

IsTERMEDiABT Hjmorrhaqe. — The treatment of intermediary hEemorrhi^e 
must be conducted on the same principles as those which guide the treat- 



286 THE TREATMBNT OF W0DND3. 

ment of primary hemorrhage. Its occurrence is an evidence of the ineffi- 
ciency of the means which had been previoudy instituted, and would 
hardly take place in any case if the directions which have been given for 
the full exposure of wounded Tessels, their careful hgation in a sountl part 
of their structure on eithei' side of the wountl, the complete division o( the 
vessel, if previously but partially dividefl, and the reinovol of coagula and 
debris from the wound. It is impossible to dwell with too much etress 
upon the importance of care and thoroughness in the application of the 
first dressing as a preventive of subsequent coniplicatious. This is illus- 
trated by the list of causes of int«rmediary hcemorrhage which the medical 
historian of the War of the BebeUion gives as discernible in the cases^ 
eeventy-seven in number, ■which apiiear in tlie records of the Surgeon-Gen- 
eral'e office of the army. ' The report states that " the earlier coses of 
hEBmorrhage were due to the force of the blood-current in the returning 
circulation diuing re-action ; to commencing inflammatory action, in which 
the swelling bad been sufficient to force out the protective coagulum ; to 
weakened arterial walls, and to a depraved condition of the blood in per- 
sons suffering from eshausting or depressing diseases. Not unfrequentlj 
the hiemon'hage of tlie earlier days bad ita source in the injury of some 
Teasel of considerable size, unnoticed in the primary examination of the 
wound. Cases have been cited in which no excessive htemorrhage waa 
noticed imtil attempts were made to effect the removal of a lodged missile 
or foreign body, which had prevented bleeding by acting as a plug or 
tampon." The first three causes in this list ore the result of failures to 
primarily expose and hgate the vessels. The last two to vrant of thorough- 
ness in the primary examination of the wound. Other frequent causes of 
intermediary hcemorrhage, such as the inabih^ of the vessel to retract by 
reaaOQ of its incomplete ilivision, the imperfect compression of the vessel 
by a large coagulum which baa been permitted to accumulate over it, act- 
ing the rather as a poultice upon it to keep it relaxed, and disturbance of 
the parts by muscular spasm, motion, or external traumatism, all alike are 
examples of infractions of the primary principles of wound-treatment 

The occurrence of intermediary hiemorrhage demands at onoe r new 
dressing of the wound, ah initio. It must be opened, enlarged if necessary, 
cleansed, explored, the vessels secured as already described, and its primaiy 

■ Uedioal and Botgloal HUtOTy of tbo War of tlie BebelliocL Part Third, Toluma 
a., Soiyicnl HUtoty, p. SOS. 




I 

I 



SKCONDABT HjEMORRHAOE, 287 

drefiaiDg and after-treatmect conducted scrupulously in accordance with 
the general priDciples and methods of wound-treatment already described. 

Ligation of the maim trunk, the uee of the actunl cautery and the tam- 
pon are resources to be used in conditions noted on a previouB page in this 
ahapt«r. 

Secondabi H^mobbeaok — Under this head are to be ensbroced aH losses 
of blood from wounded vessels occurring after the establiahment of sup- 
puration. Eeferring again to the "Medical and Surgical History of the "War 
of the JRebeUion" {Inc. cU.), we find the statement that by far the greater 
Diunber of coses of secondary hremorrhage are due to the separation of a 
■lough, the result of a contusion of the walls of the vessel and the iiiflani- 
matory action consequent upon it Identical in nature with this class of 
cases is that group in which the luemorrbage takes place where the ulcera- 
tion of the vaacolor coafa, produced by the constriction of an irritating 
Hgatore, is accomplished, withont the previous obliteration of the adjacent 
portion of the vessel by adhesive inflammation. 

Yet other cases have their origin in the breaking down of adhesions, or 
the progressive ulceration of tissue due to the changes effected in the 
wound by destructive inflammatory and septic processes. 

I^eglect to secure, by ligature, the distal orifice of a severed vessel may 
"be the cause of a later hfemorrhage, after the collateral circulation shall 
liave become sufficiently free to restore the strength of the blood-current 
in that portion of the vessel. 

Faulty application of the ligature in the priomry dressing ; Bubeeqnent 
increase of blood-pressure as the result of venous thromboaiB, or inflamma- 
tory engorgement, or improper position of the wounded part ; interference 
irith repair by muscular spasm, motion, or external traumatism ; constitu- 
tional conditions that interfere with repair ; these should be added to the 
list of causes that may determine a secondary heemorrhage. 

This statement of the causes of secondary hEemorrhages is a record of 
failures either to institute or to carry out the primary principles of wound- 
treatment; It enforces the injunction ah-eady given to observe with scru- 
pulous core, in the treatment of wounds involving the opening of large 
blood-vessels, every precaution which shall prevent the access of diaturb- 
anoe in its repair, and shall foster the most rapid union throughout its 
extent 

The appearance of secondary hEemorrhage from a wound, even though 
it at £r8t be small in amount, should at once engage the effort of the Bui^ 



288 THE TEEATMBHT OF WOUKDS. 

geon for tie application of efficient menns for orreBting it and preveiitiiig 
its renewal Only the moet radical measures should be employed. Even 
though the hfiemorrhflge, either spoutaneoualy or as the result of Baperfi- 
cial applications, have ceased at the time, ita recurrence again and again is 
certain, luless adequate proceedings for its control be at once instituted. 
The opening in the vessel must be sought for and exposed, and ligatures 
placed on both its distal and proximal sides at points where the vascolar 
tissue is sound. This rule is subject to those exceptions only which hxvo 
already been noticed in connection with the treatment of intermediary 
hiemorrhage. 

Diffuse Tsadhatio Abetbisu. — The same principleB which are applies* 
bie to open wounds apply also to the treatment of rapidly extending effu- 
sion of blood from subcutaneous wounds of large blood-veeaels. Nor 
should the treatment be delayed till the effusion has attained a threaten- 
ing magnitude. The surgeon should proceed at once to expose the wound 
by external incisions, ligate, cleanse, dress, and immobUize, as in the oaee 
of other wounds. 

WOUNDS OP VElNa 

In some instances the treatment of wounds of veins may justifiably 
vary from that which would be imperative for wounds of arteries of the 
some importance. Such variations are dependent upon the differing 
anatomical and physiological conditions of the two classes of blood-vessels, 
and also upon the dififerent course which, in consequence, their repair 
may take, 

The tendency to gaping of the wound, in the case of a vein-injury, ia 
less than in a similar wound of an artery ; the greater thinness of the waUa 
of veins causes them, as tubes, to be more flaccid and to collapse sponta- 
neously when empty, while the more languid and even flow of blood 
through them, and the freer collateml circulation, reduces greatly the force 
with which they are distended by their contents. From these circum- 
stances apposition of divided surfaces is more readily secured and main- 
tained in them, aa a class, than in aimilar wounds in arteries, and the 
provisions of " rest " during repair are less likely to be violated. As a con- 
sequence, the repair of vein-wounds is often rapid and perfect, and union 
of incomplete wounds may even be accomplished in many instances with- 
out obliterating the canal of the vessel Buch a result, aa a rule, is ob- 
tained in cases of longitudinal wounds of superficial veins, when Oia 



WOUITDS OF TKINS. 289 

treatment is confined to the applicatioa o( sunple external compreamon. 
The pressure of the compreBB suffices to exclude the column of blood from 
the wounded region until adhesion of the edges of tlie wound in the wall 
of the vein has taken place. Upon the withdrawal, then, of the compres- 
■ion, Uie blood renews its course through its previous channel 

In the case of wounds partially dividing a large and deep-seated vein, 
the size of the vessel and tlie fiaccidity of its walls may permit the edges 
of such an incomplete wound and some of the inner tunic adjoioiag to be 
brought together and held in apposition by ligatures, sutures, or clamps, 
until firm adhesion has taken place, without interruption to the flow of 
blood through the vein at any time. No such thing is possible in the case 
of any arterial wound. 

The direction of the blood-current in the veins toward the heart, and 
the continually increasing calibre of the channels tlu^)ugh which it passea 
cause the occurrence of disturbances of repair in wounds in which veins 
are involved, or even exposed, to be attended with special dangers, either 
from dislodgement of a loosened clot or mass of fibrinous exudate, or from 
the production thereia of more liquid and septic secretions tliat tlow into 
and mingle with the general mass of the blood. 

The loose connective-tissue in which veins are embedded, and which 
forms for them a kind of sheath, has been observed to afford most favorable 
conditions for the development and difiusion of septic phlegmonous wound- 
infiammations, in the course of which the tunics of the vessels themselves 
become involved, and disastrous phlebitis may ensue. 

Mr. Benjamin Travers, in his essay on " Wounds and Ligatures of 
Veins," which was published in ISll, seems to have been the first to draw 
special attention to the dangers attending injuries of veina He speaks of 
the "fatal catalogue of tied veins," and snys that he has observed some- 
thing like that superstitioiis alarm which is excited by events that we do 
not expect and cannot explain, when such a catalogue is compared with the 
generally successful cases of tied arteries. In the period immediately pre- 
cedii^ the time when Travers wrote, there had been an entire absence of ap- 

I prehension of danger in dealing with veins, so that, in the language of that 
writer, they were attacked witli singular rudeness, pricking, cutting, tying, 
and burning them, without ever adverting to any other than the mechan- 
ical effects of such operations upon the diseases for which they were insti- 
tuted. 
This author was successful in awakening attention to the fact that di»- 



J 



290 



THE TRBATMKNT OF WOnNDS. 



Bfltrous indaiuiDatory complications often followed iDJmics of reins; that 
they sometimes followed a puncture, sometimes a division, a Ugature encix- 
ding the tube, or including only a port of it ; or that they sometimes arose 
Eipontjmeously from an inflamed surface, of which tlie vein formed a part. 
The practice of phlebotomy, though luvolving only a aimple longitudinal 
wound of a superficial vein, by the great frequency with which it was per- 
formed, afforded many examples i»f the accidents that might follovr such 
wounds. Trousseau and Pigot, in 1827, testified ' that every year they 
witnessed fatal inflammatorj- complications supervening upon phlebotomy. 
By many surgeons veins came to be regarded aa vessels especially lutoler- 
rant of int«rfereDce, and prone to the development of unexpected and un- 
controllable complications. Ligation of veins, in particular, became con- 
sidered OS hazardous. Manj' of the surgical writers of the second quarter 
of the present century, including Rous, Lisfranc, langenbeck, Miller, and 
Pirogoff, taught that it was attended with great danger, and to be avoide<l 
by all possible means. Dupuytren' spoke of phlebitis as " that inflamma- 
tion BO grave, ao diflicult to master, which has caused so great a number 
of persona to perish whose veins have been ligated," Chassaignac' taog'bt 
that ligation was one of the most dangerous operations of surgery, uid 
more recently, Erichsen,' that the upphcation of a ligature to a van 
" should, if possible, always be avoideth" 

A numerical majority of surgeons, however, have always held that the 
dangers of the ligation of veins were not sufficiently imminent to prevent 
its adoption as a measure of convenience in the treatment of a wound. 

No difference of opinion has existed, however, as to the hazards attend- 
ing the ligation of veins whose tunica were diseased, as in tlie case of vari- 
coee veins. 

The occurrence of tlux>mbo9tB and suppurative peri-phlebitiB has been 
obseryed as particidarly likely to be provoked in instances in which i 
have been contused or denuded. In three instances, one surgeon — Oilier, 
of Lyons — is reported ' to have seen death follow in from eighteen to thirty- 
six hotufJi after the beginning of a thrombosis comphcating a wound of 
this character. From this experience he concluded that extensive denude 



■ Archive* GeniraUi rU Midecint, 1837. 

' Le^om OraUt dt CUaique CAinirgieah, 1830. t. iii., p. 851. 

' Traiti Clinique ct Pratigue dei Operatiom CMmrgieaUa, X. 

* Soioncs and Art of Surgery, 1878. vol. I, p. 378, 

' KioaiM : Du Plaitt etdtta Ligature de» Veintt, 1872, p. 'ti 



WOUNDS OF TEIN8. 291 

tion of ft reis is more dangerous than ligation ; and that in coses in wbJcL 
Inunediate ttDion is not obtained aft«r such denudation, vhen sloughing of 
the fiapa that cover the veins occurs, when, in a word, the veins remain es- 
lx)sed at the bottom of a suppurating wound, all the accidents of an exten- 
nie and progressive thrombosis are likely to occur. These complications, 
are not the inevitable consequences of denudation and contusion, 
for such injuries, in the greater number of inetancea^ progress to recovery 
without their development 

Physiological experiment has fully demonstrated that the tunics of a 
vein do not possess a special intolerance that renders them liable to de- 
Btructive inHommation more quickly an<l upon less irritation than other 
iissuee. The more frequent connection of woimds of veins, than of their 
companion vessels, tlie arteries, with diffuse suppurative iuflammations and 
profound and rapid general intoxication, is not a myth, nevertlieless. It 
Tesulta from the readiness with which the connective-tisHue that ensheafhes 
■fhe veins permits the progressive invasion of raicro-orgoniBms, and from 
the fact that the resulting peri-pblebitis determines the formation of coagula 
Q the involved vein, which, in their turn, are likely to be speedily invaded 
Ijy raicro-organiBms, and thus Income converted into poison-depots, from 
which ptomaines, pus, and emboh ore diachorged directly into the circu- 
lation. 

These dangers require to be consideretl, and to engage the careful 
k effort of the surgeon for their prevention in all cases of wounds of veins. 

The effect of the constriction of a vein by a ligature does not introduce 
I gay new danger into the wound. The evil effects which have been noted 
a prone to occur in wounds in which hgation of a vein has been perfoi-med, 
lise only in those cases in which the niat«rial of the ligature is irritating. 
and is so applied as to become the means of tlie introduction or retention 
of septic matter in the wound. Whenever an ordinary Hgatiu-e is applied, 
liie constricting thread is an irritating foreign body in the wound, and 
invariably excites along its traok an inflammation which persists until its 
removal is permitted by the division, by ulceration, of the walls of the 

I constricted vein — a period of time extending upon an average from one to 
two weeks, according to the size of the vein. Union by first intention is 
Qius prevented, along the track of the ligature at least. The thread, satur- 
■ted with the secretions of the suppurating sinus which it has created, 
becomes the best media for transmitting septic germs to the deepest part 
of the wound. The irritation of its presence puts an additional strain upon 



I 



392 THE TREATMENT OF WOUNDS. 

the reaistuig power of the tissueB among which it lies, and to this extfint 
lesBens their ability to reaiet inTSsion when septic germs find aooeas to the 
wound. 

The natural resisting power of the tiaaueB is sufficient to limit, in the 
great majority of cases, the amount of disturbance resulting from an ordi- 
nary ligature to a circumscribed inflammation, which simply mats together 
the tissues adjacent to the ligature, and confines the destructive processes 
to necrosis of the tissue grasped in the loop of the threa^L But in cases 
in which original defective resisting power exists, as notably in tissuefl 
whose nutrition has been interfered with by the varicosity of their veins, 
and in those in which some general cachexia pre-exists, an unchecked dif- 
fusion of the disturbances introduced by such a ligature would be likely 
to take place. 

These considerations, as to tlie sources of the disturbances which have 
been obsesTfed to complicate vein-wounds, show the importance of elimin- 
ating them, not only in cases where veins already diseased exist, but also 
in all cases in which vein-wounds demand special means for the control of 
heemorrhage and the maintenance of the wolls in apposition. Tliey justify 
the dread of ligation which haa been felt by many surgeons, practised, as 
it has been, with an irritating thread, and they emphasize the importance 
of employing substitutes for such ligatures, so that full compliance with 
the requirements of surgical cleanliness and of wound-protection may be 
accomplished in the treatment of this class of wounds. 

Acupressure and forcipressure both present great advantages over tlie 
common ligature as methods for controlling venous hiemorrhages, and 
few conditions will be found in which one or other of them may not b« 
substituted for the Ugatnre. The ret«ntion of the compressing needle or 
forceps is rarely necessary for a longer period thou a few hours. Their 
smooth metallic surfaces do not irritate the woimd ; they may be enclosed 
in the antiseptic protective mat«rial that may be available for dressing the 
wound ; and their early withdrawal removes the mechanical obstacles to 
primary union that they cause during their residence in the wound. 

The value of forcipressure is illustrated by the following ease : 

Case. — Wow\d of Jnlem^d Jugvlar Vein — IxUeral fhni'prrggitre — Se- 
moery. — In November, 1881, W. B., aged about 45 years, stabbed himself 
in the neck with a small dagger. The weapon was thrust into the right 
side of the neck, passed through the stemo-cleido-mastoid, grazed the in- 
ternal jugular, in which it inflicted a small lateral wound, and finally pen»- 




WOUJTDS OP VEINS. 

I ^ated the tracliea. The wife, who wits at his side in a moment, restrained 
die hemorrhage by throwing her arm arouad hie neck so ob to compress 
the wound. Dr. Jamea E. Pilcher was at the side of the patient in a few 
minut«B. He enlarged the wound suffideiitlj to identify the vessel and 
expose the opening into it, which was a simple alit in. its anterior wall, a 
quarter of on inch in length. He first apphed a lateral ligature ; but exteu- 
Blon of the neck, caused by the falling back of the patient's bead, as he was 
being placed in bed, caused this to slip oS. Htemostatic forceps were then 
applied, which, perfectly controlling the hffimorrliage, were left to produce 
permanent obHteration of the wound in the vein. On the second day 
thereafter they were removed. No further luemorrhflge took place. The 
wound healed by granulation, and a perfect recovery was accomplished. 

In this case the forceps were kept in mtu for a period of about thirty- 
Bii hours ; but in most cases in which I have used them, as in wounds of 
veins in the axilla or in the neck, I have been able to remove them in a 

I anuch shorter time. 

I In general, however, a more excellent way stiU is available to the sur- 

geon in dealing with wounded veins. For, as acupressure needles and 
luemostatic forceps excel the ordinary ligatures, so they, in turn, ore ex- 
celled by the aseptic animal hgaturo and antiseptic protective dressings, by 
vhich, with a perfect luemostatic, easily and universally appbcable, that 
revokes no irritation by its presence in the tissues, and that is sponto- 

B^eonsly removed by absorption when no longer needed, security is also 

Kgnaianteed against the access from without of agencies that might disturb 

kTepair. By the use of such an aseptic ligature, it becomes possible to 
noid the sources of disturbance that have thus far been recognized in 

I wounds of veins, and to make the application of a hgature safe in all cases. 
For the purpose of obtaining more definite data upon which to base 
e employment of the hgature in treating vein-wounds, I made a number 
S experiments during the year 1882 upon goats, using aseptic catgut My 
experiments included three hgations of the internal jugular vein, and two 
of the femoral vein, ' Union by first intention of the operation wound was 
secured in each instance. As the result of these operations I secured 

Lqiecimens illustrating the condition of repair upon the second, fourth, 

ftpinth, fourteenth, and twenty-fourth days after ligation. Examination of 
1 demonstrated that marked proliferation of the tiasue-cells of the 

[ tunica interna had been excited, the activity of this proliferation being 



SSi THE THKATMBNT OF W0DND3. 

greater as the point where the vein walls were coiifitricted and approxi- 
mated by the hgature was approached. The aecumidation and conflueuce 
of the mass of cells in the cul-de-sac formed by the Tein-conatriution, the 
subsequent exteoeion of capillaries Into tliem, and the consequent conver- 
tiion of the new tissue into connecti've-tissue, were the successive steps hy 
which permanent closure of the tied Teins was eflfected. In none of these 
experiments did a thrombus form on either side of the ligature, except in 
one case, in which special effort was made to secure one by applj-ing a 
second hgature to the vein, swollen with blood, a little more than an inch 
above the lirat one. Tlie part of the vein between the two ligatures having 
been left filled with blood, a thrombus was thus obtained. The specimen 
was removed on the ninth day. In this case the clot was found to have 
simply mechanically distended the tunics of the vessel, making the study 
of the conditions presented by the tunics more easy, but not modifying the 
character of the reparative process. It was an unirritating injectdon-maaa 
that was awaiting to be invaded and appropriated by active cells from the 
adjacent tissue. 

The reparative changes which had been provoked by the application of 
the ligature may be regarded as having had, as their first object, the resto- 
ration of function in parts whose nutrition had been disturbed by the orig- 
inal application of the ligature. But the agent which had disturbed the 
nutrition of the tunica interna, and provoked a more active metamorphosis 
and proliferation of its cell-elements, had at the same time held the vein- 
■waila in coaptation until the confluent plastic material formed had become 
eufficiettt in amount and tenacity to permanently unite them together. 
Essentially the process is that of the formation of a cicatrix, and in ita 
course the ligature plan's the same part as does the suture in ordinary 
wounds — that of maintaining coaptation until firm adhesion is secured. 
There may be seen in this, also, the same process as that by which a sim- 
ple longitudinal aht in a vein-wall may be repaired without obstruction to 
the current of blood through the vessel, the edges of the sht themselves 
furnishing the material for ita repair, the amount of which material, if only 
further in-itation or traumatism be withheld, being strictly limited to the 
reparative needs of the injured structurea 

The two following cases, from Lidell,' may be quoted as involuntaiy 
experimental demonstrations on the human subject of the repair of vein 



' iDJurisB of Blood -Teaiels, Intemfttional Encycloptcdift of BjitgVTj, 111, IIB s 



J 



I 

I 
I 



TUE REPAIR OF VKIN-WOUNDS. 395 

wotmds, when imdisturbed The first case occurred lu the practice of 
Professor S. D. Groua : 

Cask I — A strumoua lad, nged 14, was wounded in the neck by an ao- 
eidental discharge of a fowUng-piece, loaded with large-sized squirrel-shot, 
which entered the neck at four or five different points. The casualty was 
attended with but httle hemorrhage, and the symptoms of shock eoon 
passed away. The wounds healed without any application, and everything 
went well until thirteen daj's after the accident, when the patient was 
seized, suddenly and without warning, by a protracted epileptic convul- 
sion, affecting chiefly the left side, and died the followiug day, without re- 
tiuTi of consciousness. Autrrpay. — One shot had perforated the subclaviau 
artery, and had lodged in the first rib. The caUbre of the vessel was un- 
impaired, and the apertures were closed by small clote extending around 
the exterior of the vessel, upon the removal of which the margins of the 
wounds appeared as if they had just been in^cted. The artery presented 
no marks of inflammation. 

Another sliot had perforated the anterior wall of the right internal 
jugular vein, and had lodged on the inner surface of the opposite wall, 
where it had become completely encysted. The vein bore no erideuce of 
inflammation. The opening in the anterior wall was ixirfecUy closed, and 
there was no eitemal nor internal clot The lumen of the vein, however, 
was somewhat dimininhed by the projecting cyst 

Case IL — Professor Langenbeck, while removing an epithelial cancer, 
wounded the internal jugular vein, and tied the lardiac end only, there 
being no h:pmorrhage from the distal end. The common carotid artery, 
being involved in the tumor, was tied with two threads and divided. 
When operated on, the man had bronchitis, from which he died on the 
twelfth day. A nrcroscopy showed the vein completely healed, as if by the 
first intention, without the shghest trace of redness, thickening of its walls, 
or formation of a clot 

LATERAL LIGATION. 

The considerations which have been described, as to the process of re- 
pair after Ugation of veins with unirritating ligatures, find an important 
practical appUcation in determining the propriety of substituting a lateral 
ligature, or a latcraJ suture, for ligatures encircling the entire vessel in the 
treatment of wounds involving but a portion of the waU of a great vein. 

The use of lateral ligatures ha.a been strongly condemned by many 



1 



296 THE TEBATMKNT OF WODNDS. 

gurgical writ«ra Malgaigne ' saj^ " tlie lateral ligature will be an opera- 
tion always to be condemned," and that "for verj extensive wounds of 
venoufl trunks, where compresaiou is insufficient, the only resource is the 
ordinary ligature." The objection of this author was founded on tiie 
erroneous belief that permanent hsemoBtasiB after a vein-wound depended 
upon the formation of a clot sufficient to occlude the entire lumen of Uie 
wounded vessel InoHmuch, therefore, ae the lat«ral ligature in some cases 
might fail to provoke the formation of euch a clot when the ligature should 
come away, in euch cases secondary hsemorrhage would be inevitable. The 
objection of nU surgeons who have rejected this measure as a justifiable 
proceeding, has arisen from the frequency with which secondary luemoi^ 
rhage has occurred in the cases in which it bus been employed. 

Braua' has compiled from published records twenty-four cases in 
which a lateral hgature was apphed, and three cases of lateral forciprees- 
ure. Of these nine died from pytemia and from secondary hsBmorrhage. 
In one case the hgature shpped, and the hfemorrhoge hod to be controlled 
by other means. In Uiirteen of these cases, the internal jugular vein was 
the vessel wounded. Lateral ligature was applied in twelve instances, and 
forcipreasure in one. Three deaths resulted from secondary hfemorrhage. 
In seven instances the femoral vein was involved. Lateral ligature was 
applied in five cases, and forcipressure in two. There was one death from 
secondary hemorrhage, caused by the slipping ofT of the ligature, and five 
deaths from pytemia. Five coses in which the axillary vein, one in which 
the subclavian, and one in which the external jugular were involved, all 
recovered. 

The deaths from pyiemia were all due to septic hospital infiueucee, and 
ore not to be attributed in any way to the special method of ligation 
adopted. The proportion of cases of secondary hfemorrhoge, however, is 
so great that, unless the danger of such a comphcation can be shown to be 
avoidable, the practice must be condemned, since its dangers outweigh any 
advantages that might otherwise attach to it 

These disasters, however, have occurred in connection with the nee of 
ordinary hgatures, the dangers of which, even for use in ligations of the 
whole circumference of a vein, have been dwelt upon, and such use depre- 
cated. Much more imminent is the danger which their use entails when 

' Mideeine Operatoirr^ ed, 1861. p^ 114. 

' Ueber dtn teiUie/ien YertcMuf Km Vanwivundm. ArcAirfUr kliaiicht chirureU, 
1682. uvlii., eft4-«72. 




LATBRAL LIGATION OP VEINS. 29 1 

applied to the side of a vein. In many casea, as Malgaigne feared, no clot 
vould have formed to act aa a plug to the hole in tlie vein produced by 
the separation of the slough grasped in the loop of the ligature, nor would 
a auEQcient amount of plastic exudate have gathered on the interior of the 
packer, at the site of the hgature, to substitute a wall of new tissue for 
that carried away by the slough. Secondary haemorrhage, in such coses, is 
inevitable. lateral ligation, therefore, shoidd not be employed when the 
surgeon must make use of an ordinary thread for his hgature. In such 
cases the entii'e vesBel must be included in the ligature, which must be 
apphed both above and below the wound, and complete division of the 
vessel between the ligatures be done. 

The use of aseptic materials for ligatures, which may be cut short, and 
over which speedy union of the entire wound by first intention may, with 
much certaint}', be secured, places the subject of lateral hgature upon on 
entirely different basis. Care is first nec«Bsiuy- that the ligature is securely 
applied, lest the acoident of its aUpping off should expose to disaster. 
Then the rent in the wall ia virtually transformed into an extravascular 
injury, and the tissues of the puckered wall of the vein, in the grasp of the 
ligature, are placed in the same condition as that which characterizes veins 
when ligated in their whole circumference. No thrombus is required, nor 
formed, by ite insufficiency or its disintegration, to become a source of 
danger. There is no ulcerative process to extend unduly, and to leave an 
opening in the vein-wall when the hgature comes away. That the process 
of the exudation and complete organization of the plastic material that Gils 
in and e£kces the irregularity produced by the apphcation of the hgature 
should proceed undisturbed to its conclusion, demands, simply, that the 
general precautions for securing wound-repair be observed. The hgature 
acts as an unirritating reinforcement that prevents the rupture of this new 
tissue during the yielding period of its history, and itself is finally disinte- 
grated, and is removed in the course of the ordinary tissue changes of the 



In 



n«ctued with aseptic materials — catgut or silk — with antiseptic pre- 
cmtiono, lateral hgature is a safe and valuable means of treatment in 
wounds of the lateral walls of veins. It should especially he employed in 
the case of wounds of the main veins at the roots of the extremities, as the 
axillary, subclavian, and femoral, the complete closure of which would be 
likely to seriously disorder the circulation of the limb of whose blood it ia 
the channel of return to the heart. 



THE TREATMENT OP WOUSBS. 



LATERAL SUTURE. 

The application of a suture auggest§ itself aa a resource in lateral 
wounds of large veins, when such wounils are too long or extensive to admit 
of being dosed by a lateral ligature. Cheyne relates ' the following caae, 
in which this pi-ocedure was adopted by Mi\ Lister : In removing some 
cancerous glands from the axilla, a small vein was torn away from the axil- 
lary vein at their junction, making, practically, a longitudinal rent in the 
axillary vein. Taking a fine curved needle and the finest catgut, he stitched 
up the rent by the glover's suture. The patient recovered without the 
slightest bad symptom. 

Braun (op, dtat ) relates that Czemy performed this operation upon 
the internal jugular vein, but hiemorrhage recurred so that acupressure 
became necessary, Schede was more fortunate. He stitched the femoral 
vein with a fine needle and the finest of catgut. He then sutured also the 
sheath of the vessel Union by first intention followed. 

The same considerations are appUcable to the lateral suture which have 
been elaborated in connection with the lateral ligature. When it is per- 
formed, the edges of the wound in the vein should be brought out so that, 
as the thread is drawn up, the internal surfaces of the divided vein flaps 
shall be brought in contact. Upon a large vein hke the internal jugular, 
it might be found practicable to hold the wound-edges together by a 
" through-and-through " continuous stitch, instead of by the ordinaiy 
" over-and-over " glover's stitch. This would bring the surfaces of the 
intima into more certain aud extensive contact, and therefore would be 
preferable. Silk — aseptic — is to be chosen for the suture material on ac- 
count of the greater ease and certainty with which it may be manipulated. 
A very fine strand ia to be used. The ordinary round sewing needle of the 
sempstress should be employed for introducing the suture, since the punc- 
ture which it makes will be more perfectly filled by the thread that ia 
drawn after it than when a needle with cutting edges is used. 



PART II. 



SPECIAL "WOUNDS 



SECTION III. 



WOUNDS OF SPECIAL REGIONS. 




■WOUNDS OF THE HEAD. 



Atialomieal ConxiderationM—Saprrfieial W/nindt of Seaip—BraiMs and Contmiona— 
PDnatnml and loouMd Wouoda — Extemuve LaceratiooB — Superfiolal Gunshot 
Woonda — Deep Woundi of Sealp aitA lajuriei to the Cntnium — ttigus of Comprea- 
rion of BraiA Abaant— Pmetores of Che Skull— Indicationa for Traphining-— Frao- 
uureaof the Base of the altaW^Compremm of the Brain — Wounds of Intrnctatiisl 
Veaaeli and Sino sea^ In jnriea to Cranial Nerves— Wounds of Brain Subalance— 
Harnia Cerebri— Wounds during Birth— Bandaging the KbaA— Trephining — Indi- 
oationa for the Operation— Operati to Technique— Eioision of Irregular Frag- 
mexLiM—WmmdaofEyt — WvuniUof Internal Ear —Woaniitof the Fat*— Woandi 
of the MovtA. 



I 

I 



ANATOMICAL CONSIDEHATIONS. 

Tbere are many pointa in the anatomj of the skull whicli are of paramount 
importauce in conaidermg the nature and occurrence of wounds of its com- 
ponent bony parts and of injuries to the auliatance of the brain ; but thoBe 
especially concerning us when comiiderlng the treatment of these lesiona 
are comparatively few, and can be covered in a few words. The perios- 
teum of the cranium — usually colled the pericranium — is Wn but quite 
Btrong and resisiani Except over the sutures and at the great foramina it 
can be easily stripped off, or even made to glide over the bone. In old 
people itfl connection with the bone is more finn. It is nourished princi- 
P^y by veBselo from the bone. Concerning the bones themselves it 
should be remembered that the diploii is wanting both in young as in 
advanced life. 

Of great importance are the connections which the veins of the super- 
ficial soft parts enjoy with the sinusee of the bony cavity and the veins of 
the diploe through the emissoria Santorini. The most important of these 
anastomoses are : 1 . Among the occipital veins, which connect through the 
Ptastoid foramen with the lateral siiiua. 2. Along and around the inter- 



302 THE TREATMENT OF WOUNDS. 

parietal Buture, especially its posterior eitiemity, where numerous open- 
ingB connect wifh the superior longitudinal sinus. 3. The ophthalmic 
veins, according to Sesemann's investigations, empty as well into the ca- 
vernous sinus as into the filial vein& By this it will be seen that the 
sinuses of the brain have their overflow outlets, or " waste weJrs," in what 
would seem to be abundance. On the other hand, t.liia freedom of venous 
connection enhances the danger from pyiemic or thrombotic trouble in 
cases of erysipelas or phlegmon of the external soft parts. 

SUPERFICIAL WOUIiDS OF THE SCALP. 

It will be well at tlie very outlet of our consideration of this subject to 
give the greatest possible prominence to the classical dicttmi, " No injurv 
of the head in too alight to be desi>ised, nor too severe to be despaired of ; ' 
a statement only strengthened by time and experience. The temptation 
is very great to ignore trivial wounds, to insufficiently cleanse them, to 
careiessly dress them. If nothing else teaches the danger of care1e§ene8S 
in these cases the experience gathered from the sword duels of German 
studentfi should be convincing, since each year several deatlis are caused by 
apparently trivial or commonplace wounds. 

We may divide injuries to Uie scalp and adjoining soft parte into 
bruises and contusions, penetrating or incised wounds, tuid extensive lac- 
erations, and discuss their treatment accordingly. 

BarisEs Asn Costubions. — A mild bruise or contusion, which may have 
caused some abrasion, but no other solution of continuity nor any harm to 
bone, may be dressed with ordinary evaporating lotions, or cold applica- 
tions either in bladders or ice-bags, or by compreBses frequently wet In 
cold woter. If there be any superficial abrasion some antiseptic should !» 
used, a httle alcohol or some tincture (e.g., tr. arnica or Bi>ta. camph.), or 
carbolic acid or iodoform. Any ordinary efFiision of blood l>etween scalp 
and bone will be checked and Oxen rapidly reabsorbed under this treat- 
ment The hair may be cut short, or shaved if occasion require. If effu- 
sion be very great, and apparently not checked after prolonged trial witii 
tdmpler measures, then it may be well by free incision to turn out the more 
or less fluid blood, search for bleedinp vessels, twist or tie them with cat- 
gut, cleanse thoroughly, wait until all bleeding has stopped, and then 
neatly approiiinat£ the edges of the wound with fine silk or catgut, wiUi 
the insertion of a few threads of horse-hair for drainage, and over oil a firm 



WOUNDS OF THE SCALP. 303 

Of course all this should \>e done with antiseptic precautione, 
meaning thereby irrigation with carbolized water, cluan instruments and 
sponges, and dressing with some absorbent antiseptic niat«rial {Chapter 
X.). Rest and avoidance of esimsure must then be enjoined. 

PrNCTTjRED OK Incihed Wousds. — A smttll punctured wound, as made by 
some sharp instrument, should be treated by careful cleansing and then by 
antiseptic occlusion, as with borated, salicylated, or iodoform cotton, A 
small knife-blade, the point of a foil, or other pointed instrument may 
pierce the soft parts over the course of some vessel, and without doing 
material injury to the bone sever or wound an artery or vein. Several 
cases of aneurism of terminal vessels have been reported as occurring in 
this way. From such a wound lioemorrhage would be free, while it would 
be easy to recognize whether an artery or vein, or both, had been injured. 
If a vein, pressure will in moat cases be mifficient ; this presaure should be 
made a part of the antiseptic occlusion, being maintained by an elastic 
bandage or some mechanical device, an by including in the bandage a 
piece of oompressed sponge which ^lall later be moistened with cu-bolized 
water. 

But if an artery be wounded and such pressure be insufficient, the next 
measure should be the introduction of a needle threaded with silk, which 
should be passed, close to the wound, under the vessel and then out ; the 
thread can then be tied in a simple knot or over a compress tight enough 
^■^ constrict the same. A hare-lip pin or even a common pin may be used 
^Ebiatead, a thread being tightly tnisted over it in a figure of eight If this 
measure be required it should be done on either side the cut, which should 
be then cleaned and occluded as before. Or, if required, the wound may 
be freely extended with a scalpel, the hair having been removed, and then 
the bleeding vessel caught and secured. Aft«r this careful cleansing, ap- 
proximation and occlusion as before. 

Extensive Lacerations. — Extensive lacerated or complicated incised 
wounds are often inflicted, by accident or through homicidal intent, which 
may even strip the pericranium off the bone, yet vrithout causing any more 
dangerous aj-mptoms than a temporary concussion or "stunning." In 
these cases, after having satiflfied himself that no fracture of the bone has 
occurred, at leaat none CEdling for operative procedure, the surgeon should 
first attend to every oozing point or spurting ^-essel, and clip short the 
hair about the region of the wound. He should then, witli sponge and 
forceps, address himself to the removal of every particle of dirt and every 



304 THE TBEATMEIIT OF 17017111)8. 

loose hair. Any shred of tisauo about whose vitahty there is the least 
doubt bftd better be chpped oft All bleeding being checked it renuuns 
now to close the wound ; but one cannot be too careful to couTince him- 
Belf that every speck of duat ie removed. If now the pericranium have 
been stripped up, ita edges may be approximated with iine catgui Or if 
its edges closely correspond with those of the scalp, they may all be in- 
cluded in one stitching, tt is well to omit a stitch at each angle or end of 
the wounds to allow for escape of pus, should any form ; though if all 
these precautions have been observed one may expect union per primam in- 
lentionem. 

Bather fine silk iB perhaps the best material for these sutures ; it maj 
either be carbolized or prepared with a carbolized wax, wliich makes it 
stronger. Stitohes should not be more than a quarter-inch apart, and may 
be either continuous or interrupted, according to the fancy of the surgeon ; 
excellent results may be achieved with either. If drainage seem to be indi- 
cated, it may be accomplished by a few horse-hairs, or o bundle of two or 
three silk or catgut threads, laid especially in those angles of the wound 
which are to be dependent. It has been suggested to use the natural haira 
of the part for the approximatioQ of the hps of on incised wound of the 
scalp ; but it is difficult to make a knot tied with hair hold firmly enough 
to anEiwer the purpose. Still, it may be tried in trivial cases; in mora 
severe ones it is hardly to be odopted. 

The wound being neatly closed, on excellent dressing is the following': 
A narrow strip of protective, moistened witli a solution of corrosive subli- 
mate, 1 to 500, is first laid over the wound ; then a few layers of gauze, 
preferably naphthalin gauze (for reasons elsewhere stated, vide p, 305); 
then a layer of borated or sahcylated cotton to give elasticity to the com- 
press ; then a few lai^er pieces of gaiize, a piece of macintosh, gutta-percha 
paper or waxed paper, and over all a roller bandage so applied as to make 
adequate pressure. The writer prefers the protective slip applied imme- 
diately over the line of the wound, because it does not permit dressingB to 
dry and stick to the wound or to the ends of stitches, and thus permits 
change of dressings without discomfort to the patient. 

This dressing need not be changed for from two to six days ; earlier, if 
provision have been made for drainage ; later, if not If thought beet an 
ice-bag may be appUed outside of its mass. 

In those cases which occasionally occur where some port, or nearly the 
whole, of the scalp has been torn of, or loose, ae by machinery or " aea^ 



EKTSIPELAS OF THE 8CAXP. 305 

tt," if tbe patient be seen in time, on eSbrt should be made to replace the 
looae portion. Some aatomsliing succeBseB in theae cases have been re- 
ported, and at least no harm is done if tbe trial fail. The general rules 
already given are'safficient to guide the reparative e&brt; accurate approxi- 
uuitioo and judicious pressure being the important canons of treatmeut 
along with careful antisepsis. Should the effort partially succeed or fail, 
if the loss of Bubstanco be small, a plastic operation may be attempted; 
otherwise the bare or raw surface must be kept clean, healthy granuiationa 
stimulated by some such application oa amorphous boracic acid, and, 
when attained, the healing process still further assisted by skin grafting, 
OT the newer "sponge grafting." The sponge nmy be applied in fine flecks, 
tti in larger but very thin slices. No esse of this kind which is not speed- 
ily and primarily fatal need be despaired of. 

The possibihty of occ\irrence of erj'aipelas in all these cases should b« 
home hi mind, and for that reason additional attention should be paid to 
enforcing perfect rest, and this by sedatives, when necessary, as during aa 
attack of delirium tremens, and to securing a soluble condition of the 
bowels, combating fever, keeping up the strength, etc. Any reasonable 
medicinal means for attaining any or all of these conditions are justifiable. 
Moreover, the use of naphtlialin, in gauze or in fine powder, as a local antir 
septic, is recommended, especially because of the peculiar properties which 
it seems to possess as op])osed to, or preventing, erysipelas. 

It may ha])pen that we have a case to deal with which has already be- 
come inflamed, or perhaps erj-sipelulous, either through bod attention or 
lack of any. We should then proceed as follows : The region of the 
wound should be carefully shaved, or the lioir clipped short as possible. 
If the appearance of the part, or the general condition of the patient, indi- 
cate any septic process, the wound Bho;dd bo opened, and ita interior 
freely exposed to view, while a most painstaking disinfection of its entire 
surface should be made. Suppurating or foul spots or surfaces may be 
treated with an eight per cent solution of zinc chloride, or with strong 
carbolic acid, new openings made for drainage in most dependent part^ 
and, according to circumstances, the edges reunited, the whole left mor» 
or less open and drained, or putrefyini^ and necrosed tissue removed with 
knife, scissors, or curette. Instead of tlie zinc chloride, or after it, an 
ethereal solution of iodoform or naphthalin may be used. Abscesses 
should be freely laid open, and tlieir cavities scraped out if necessary. If 
8 have supervened, the whole scalp may be covered with antiaeptio 



306 THE Tfi£ATHEHT OF WOUNDS. 

potdtioes; it may be kept well smeared with a fifteen to twenty per cent 
ointment of naphthalin, or the old-faahioned treatment of white-lead paint, 
mbbed up with a little turpentine, may be resorted to. (It will be remem- 
bered that turpentine is a Tery &ir antiseptic.) Few surgeons would fed 
justified in making ice applications to an erysipelatous scalp, unless cere- 
bral complications were extremely seyera Of course, when we bear in 
mind the anatomical connection of the scalp and deeper parts {vide first 
paragraph of this chapter), it will be understood that all attacks of erysi- 
pelas about the scalp are at least serious. 

When called to treat the later results of former injuries in the line of 
granulating or sluggish ulcers, or exposed and carious or necrotic bone, 
there are no indications in their case calling for dififerent treatment than 
similar conditions elsewhere on the body. A healthy ulcer may be ooTered 
by akin or sponge grafts, or by a plastic operation ; an imhealthy one should 
be first rendered healthy, and this best^ perhaps, by aid of boracic acid and 
an occasional stimulating with caustic. All dead or dying bone should 
be removed with curette or chisel, and the surface then allowed to heal by 
granulation, or covered by a plastic operation, or botL • 

Superficial GtJN-sHor Wounds should be treated on the general princi- 
ples above enunciated ; but it must be remembered that a buUet may not 
only pursue a devious and tortuous path, but may cany in foreign matter. 
Such a wound should either receive primary antiseptic occlusion (p. 248), 
or its track be carefully cleansed and drained, being laid open for this 
purpose if necessary ; after thorough disinfection it does not differ from 
any other wound of the scalp, so far as indications are concerned. Bullets 
may be left untU a subsequent convenient time for their extraction, or they 
may be searched out at once and removed, with due antiseptic precautiona 

DEEP WOUNDS OF SCALP, WITH INJURIES TO THE CRANIUM. 

Those in which there are no Signs of Compression. — The first proce- 
dures in these cases are not dififerent from those already mentioned. An 
antiseptic cleansing of external surfaces, and a removal of hair in the 
neighborhood of the lesion, are first to be effected. Next should follow a 
checking of all hsemorrhage, as before described. Then a careful examina- 
tion of the wound should be made. Should it appear that a small extern 
nal wound conceals more extensive injury or laceration beneath, then free 
incision should be made in order to expose every part to sight or touch 



I 



INJURIES TO CEAKIUM. 307 

According to the extent of these deeper lesioiiB should the supra^cial 
.iround, as now extended, be revmit«d or not. 

It may happen that one or more pieces of the external table may be 
mtirely separated from their bony surrouudingB, and held only by their 
connections with the periosteum and soft parts. Not forgetting that they 
may be etiU nourished by these connections, it is, on the whole, the safest 
plan to remove them. But should n prominent process of bone be thus 
detached from its seat— as. for instance, a part of tho supiTi-orbitol ridge, or 
margin of the orbit, or even tho mastoid process' — it would only be good 
jssctice to make every endeavor to save it Buch a fragment may bo held 

place possibly by pressure, by stitching together edges of periosteum, 
<^ by drilling and insei-ting catgut suturea But pieces of bone that lie 
entirely loose must be unhesitatingly removed, even if the dura mater or 
brain bo thereby exposed. 

Should hemorrhage from a denuded external surface of bone, or oozing 
from the deeper portion occur and delay the surgeon, it may be checked 
by irrigation or sponging either with ice-water or water as hot aa can be 
borne ; preferably the latter. . After it has been once fully checked it is 
Bot likely to recur after tho parts ore closed in from the air, as when tho 
cbessing with suitable compressiou has been made. 

Aside from leaden projectiles a variety of foreign bodies may not only 
injure the cranial bones, but parts of them may even bo embedded ; work- 
men's pointed tools, knife-blades, bayonets, sword or foil points, arrow- 
beads, hatchet or tomahawk points, pieces of glass, etc In pixtportion as 
these penetrate deeper, the gravity of the wound and the possibility of de- 
pression or perforation of the inner table are greater ; but the indications 
do not differ greatly so far as the therapeutic meaaures ai-e concerned. 
Obviously their removal is called for, in most cases at least, and this should 
be accomplished with the least possible disturbance. If a simple pull be 
inBufficient, enlargement of tho ext«rnal wound and instrumental aid must 
be resorted ta Strong forceps, a pointed elevatorium, a removal of sur- 
'Xounding bone by moans of chisel or gouge, and possibly even the trephine, 
may in succession be colled for. Tho more recent tho case the better, as a 
rule, the results. If any pointed instrument should evidently have pene- 
trated the cranium, it should be removed by the moat direct pull in the 
direction of the line of its entrance, so that farther injury' to brain tissue 



■ BtmUit. Th^iw de Paru, 1878. Dupvgtrta^ Lefons onlei, t. L, p. GB. Btrgmann, 
I KopfveiletEnng^n, p. 262. 



3D8 THE TBEATME^T OF WOUND8. 

or coverings ma; be avoided. As more or lees beemorrhai^ ma; take 
place from the wound in the tablee of the skull immediately after removal 
of the body, especially if it have penetrated, absorbent cotton should be 
plugged into the wound, or the head at leaat placed in sunh a ]iositioa that 
bleeding into the cavity of the cranium may not take place. 

In every case where Bolution of continuity of the out«r table has oi*- 
curred, the surgeon ahoiild bear in mincJ what a vantage ground the diploS 
offers for the lodgement of septic germs and for the development of in- 
flammatory and septic thrombotic processes which may greatly militate 
against the safety of the patient ; and he should in such coses omit no pre- 
caution which may t«nd to avert their destructive agency, Higid antisep- 
sis, or preferably, if it can be put into practice, rigid asfjjgix must be the 
motto; without it no such wound can be properly treated To quote 
Bergmami (L c, p. 83). "We have leai'oed to appreciate that every wotmd, 
eveiy contusion of tlie head fares better in the poorest privat« dwelling 
than in the richest hospitaL And if this protection [antisepsiB] is indi- 
cated in private practice, it certainly does not come amies in the vorat 
hospitaL" 

If instttad of finding some portion nf bone chipped off, or some foreign 
body embedded or loose, wo find simply Unea of cleavage indicating Unear 
fracture, different hnes of treatment should be pursued, accoi-ding to what 
we judge the character and extent of the fracture to be. If symptoms 
of compression uidicate protrusion inward of some bony fragment of tha 
inner table, the trephine >a called for, as will be subsequently considered 
when discussing the indications for trephining. If, on the other hand, no 
sign of intra^^iranial trouble be manifest, and no loose piece of bone demaiul 
removal, the case should be treated much as if no such serious lesion wen 
present, save that the antisejiBiB should be rigid, and absolute and pro- 
longed rest be insisted upon. 

It will be as appropriate here ns anywhere to discuss the treatment of 
any severe contusion of the skull, which from the history of the injury or 
the inherent features of the case has in all probabihty produced botba 
fracture of the cranial viiult. Such a fracture is to be considered from the 
same point of view as a simple fracture of an}- bone, deriving special im- 
portance only when there is concomitant or subsequent injury to the 
cranial contents. Notwithstanding the internal table is often vety exten- 
sively injured, many cases of simple depressed fracture proceed to per- 
t recovery without any active treatment and without alarming head- 



SIHPI^ FRACTDRES OF &KVLh. 309 

PiJQnnptoiaa at aoy time in their courae. In all cueea of aimple fracture, 
whatever the depresaion, or however great the couuniuution of the bone, a 
conservative hue of treatment should be adopted, and the simple fracture 
converted into a compound one b^- iuciaiou of the soft parts covering it, for 
Uie purpose of the upphcittion of a trephine or the remov&l of detached 
l^ihnt^rB of bone, only when prolonged or alarming eymptome of intra- 
cranial mischief render it imperative. As to the conditions in which imme- 
diate resort to the trephine, in cases of simple fracture, is imperative, in 
^^ .liie opinion of Sands, of Sew York, there are but two, of which he speaks 

^H "One of these is the case in wliich the fracture isof limited extent, and 

in which there is reason to think, from its situation, or from the occurrence 

of monoplegia, monospasm, or hemiplegia, that a sphnter from the inner 

lahle may have penetrated the motor tract of the cerebral cort«t. But, as 

^LtVe have seen, the fractures which are attended with such displacement of 

^HjjEBgments of the inner table are usually of small extent, and are almost in- 

^^Lnriably compound. The other case is the one in which compression of 

^^bftic brain is caused by an accumulation of blood between the dtura mater 

^Vfind the cranium. Such an accumulation may result from a wound of one 

of iitB larger venous sinuses, but in a large majority of instances it depends 

on a wound or a laceration of the middle meningeal artery. The accident 

is most frequently accompanied by a compound fracture ; but it may be 

net with in cases of simple fracture, and occasionally when no fracture is 

present When there exists a compound fracture, the blood usually escapes 

through the external wound, thus rendering the diagnosis ea*rj' ; but when 

tike fracture is simple, or when the aitery alone is injured, the extravasated 

blood separates the dura mater from the cranium, and may be poured out 

IB auScient quantity to cause fatal compression of the brain. The amount 

fd blood thus extravasated may be as much as half a pint. Wlien the 

^^ btaiu has not sustained severe injury, and the symptoms of concussion may 

^^4fB but shgh^ the signs of the arterial lesion may be quite charm;teriatic. 

^BAfter a blow has been received, usually in the teroporo-pariefal region, the 

patient, although perhaps shghtly stunned, soon regains consciouaneas, and 

axhibits no marked signs of cerebral injury. But aft«r the lapse of a few 

iiiinut«B, or possibly several hours, symptoms of compression appear, and 

' The Qaestioa of Trephiniog In InjoriM of tbe Head. AuekIs of Aiutaitij and 



^ 



THB TREATMENT Or WOCHDa. 

BooD become very marked, the ptttdent often dj-ing within twenty-four houn 
from the time of the accideut Hemiplegia aoiuetimes occura before insen- 
BibUity is complete ; and ita detection is imiwrtant, for the reason that a 
blow upon one side of the head has been known to cause a rupture of the 
artery on the opposite Bide. The accident affords a clear and poaitiTe in- 
dication for the appHcation of the trephine ; yet there tire but few recorded 
toacB of the operation." 

Should destruction of soft parts be so extreme, should laceration be so 
extensive, that it eeems best to remove more or less tissue, fearing that its 
vitaUlj is lost, the surgeon need not hesitate to make a plastic operation to 
cover the defect, provided it seem advisable. And even if the bone liavo 
been denuded, nay, even if the dura mater be laid bare, as will happen 
after certain injuries as well as operative procedures, unless something else 
contra-indicate it, plastic operations may still be mode. The writA baa 
repeatedly succeeded — like every surgeon who has tried it — in making 
skin flaps atihere, per prinuim inteiilioncm, to poilions of the cranial vault 
whose external table hail been removed ; while Biiry;ical literature contains 
abundant reference, which coincides with penjonal experience, to cases in 
nbich they have adhered equally well to the dura mater. 

In case of a short fissiu*e or circumscribed depression of the outer table 
the surgeon Ims but little to do l^eyond careful dressing, and may almost 
limit his use of inBtrumcuts to the needle. 

Should a sequestrum exist underneath a granulating mass, as may re- 
sult during the course of some of these eases, it should be removed like a 
similar foreign mass elsewhere in the body. 

Wounds are occasionally inflicted ^-ith sawn, as in the following case re- 
lated to the writer. A laborer in a saw-mill fell in such a way that hia 
head was thrown up against a saw in rapid motion. A clean cut was made 
through scalp, skull, ond an uncertain distance into the brain ; the line 
being fUong to one side of the superior longitudinal sinus. The n 
nt once removed to his home and medical aid summoned ; but there mu 
very httle to do and he waa treated symptomatically. 

Considerable discussion arose as to what extent it would be yropae to 
sow up the external wound, etc, and the home tjilent finding this too 
knotty a problem to decide called counsel from a neighboring large dty. 
But while the surgeons were discussing the pros and mi» of this question 
the patient progressed rapidly, and by the time the matter was final]; 
settled he was evidently out of danger. 




BIHPLE FHACTl'EE OF SKULL. 311 

Should the reader meet such a case, his best pohcy would be to ab- 
stain from any active interference, to ahave the parts, to approximate the 
edges of the acalp wound, save at certain pointti for drainage, to use anti- 
septics and probably ice applicatioua. If any serioua hccmoiThage were in 
progress the case would fall under the head of injuries to the vessels and 
sinuses of the cranium, to be considered in another paragraph. 

The gunshot wonnds made by modem projectile are noted for the 
numerous splinters around the edge of the lesion they cause. These splin- 
ters being loose or almost so, should be carefully removed. 

It should not be forgotten that children have no frontal fdnus, and 
that consequently the brain lies close to the front Hence a fracture 
of the OS fronlis in children should not be indifferently probed, nor even 
such an examination mode as may sometimes be penuitted in an adult, 
nor need it cause surprise if the dura mater seem very close to tha 
surface. 

Fistulous openinga may remain long after injuries such as we have 
been considering have apparently or for the most part healed. Their 
treatment is the conventional one, i.e., free exploration with removal of all 
tuberculous di^bris or diseitsed bone. 

Fractures of the Ba*^ of th; Si-all, and Diantasia of Sutures. — It happens 
rarely that cases of fi-actui'e of the base of the skull which are really amenable 
to treatment come under the surgeon's care. Too many of these cases are 
either dead by the time of the surgeon's ^isit, or are past help and die un- 
conscious. Nevertheless cases which there is every reason to diagnose as 
fractures of the base do once in a while recover, and it should always b6 
the rule to treat even the most desperate case as if there were at least a 
possibility that appearances would prove deceptive. 

It there be bleeding from the nose it would be well to use a douche of 
some kind, either quite cold or quite warm water, which should be iodin- 
ized The stj-ptic effect of hot water in cpistaxis is as well known as is 
its power over hiemorrhage elsewhere, and it should be made use of in 
these coses. 

Bleeding or serous oozing from the ear should be treated similarly with 
quite warm iodinized water, and after the injection the meatus should 
be filled with boracic acid in amorphous powder, or a httle iodoform 
should be blown in, and then a plug of antiseptic cotton inserted ; all this 
to be repeated as often as may he needed. 

Any injury of soft part« or cranial vault that may be discovered should 



313 



THE TREATMENT OF WOPND8. 



be treated in accordance with those rules abeady laid down at sufficient 
lfng*li 

The balance of the treatment must be ^mptomatic and largely medici- 
saL If collapae be imminent, local and general stimulation in moderation, 
not to excess, lest with vigorous reaction come undesirable conseijuencea. 
If the heart's action be weak, a sponge wrung out of hot water and sopped 
over the cardiac regiAo, or heat and raid alternated, with hypoilermicB of 
ether, or of atropia (y^g^ to ^^ grain). Wbsn once the pulse and respiration 
are satisfactory, and the Iwwels cleared out, the rest must be left largely 
to time. Ice apphcations to the head may be indicated — will be, in fact, if 
temperature rises or meningitin occur. ArtiSciol nourishment will be re- 
quired as unconsciousness, paresis, or paralysis complicate the case. Tbia 
may be administered by the long tube either into the stomach or rectum, 
as seems best in each case. 

TREATMENT OF COMPEESSION OF THE BRALV. 

Treatment of tJiis condition cannot be separated from that of the oauao 
that produces it Obviously the first measure must be, after cleansing and 
exploration, the removal of the compressing fragment, if such there be. 
Neit may be considered the advisabiUty of the withdrawal of a ccrlain 
amount of blood, either by venesection or arteriotomy, for the sake of 
weakening the heart's action and diminishing the amount of blood in the 
system. In this connection one shotdd take into consideration the result 
of Althann'a investigations; he found that after bleeding, even though its 
volume was reduced, the blood could better pass through the capiUaries. 
Nevertheless, remembering, too, that jMitients often recover quicker from 
apoplectic attacks after bleeding, we may regard venesection as a proper 
meastire, at least when pressure or congestive symptoms are severe. The 
return of blood from the head may also be hastened, and its access hin- 
dered by having the head well raised, or the patient in an only partially re> 
cumbent posture. Saline catliarlics ore indicated, or any other meaaa 
wbich shall tend to drun the blood of its serum, and so compel reab- 
Borption of the effused fluids. Any means also which may persuade the 
arteries to contract, i.e„ vaso-motor stimulante, stich as ergot or small doees 
of atropia, may be useful later. To the same end the constant galvanio 
current may be employed. 

Cold applicatioos ure also of undoubted but rather uncertain value in 




WOUMOS OF nrrHA-OBAinAL VES8EM. 313 



I 



L 



cases. Pirogoff has recommended a continual dropping of cold water 
on the head, or Bomething like a very mild cold douche ; others also have 
noticed a rapid return to coneciousnesa after this had been tried. The 
Beceaaary appaxatuB for this purpose may be easily mode v 
douche or fountain syringe. When they are at hand the skull-cap of 
koden tubes, as made by Leiter, or a coil of rubber tubing supported by a 
wire frame, Uurough which ice-water shall coutinuaUy flow, will be found 
perhaps equally effective. 

So much of the operative treatment of these coses as has not already 
considered will faU under the head of trephining, to be dealt with 



WOUNDS OF INTEA-CRAJ*IAL VESSELS AND SINUSES. 

Tbeae woiinds most often involve the longitudinal and trunsverso si- 
and the middle meningeal artery. It occasionally happens that these 

A^nred during the operation of trephining, but these are by no means 
ly fatal ; in fact, in more than one case the effect was that of vene- 
aection, and was gooii If by a small penetrating wound a superficial uinus 
be punctiired, on antiseptic compress may be sufficient to check bleeding ; 
over this an ice-cold apphcation should be made. The cases are numerous 
ill which rapid recovery has followed this simple measure. Death is in 
Buch cases unusual, and results rather from other comphcations, such as 
injury to the brain, or partial escape of blood into the cninial cavi^', or 
from septic processes. Genzmcr ' has related a fatal case from Volkmann's 
oUnic of entrance of air into a sinus during estirpation of a sarcoma from 
the bone and dura mater. But un<ler most conditions this would never 
faa|)pen. Wounds of the cavernous sinus through the orbit have always 
fieai fatal 

When a sphnter of bone or a foreign body has perforated a sinus wall 
the blood may escape at once or only after its removal These cases are 
rare. The hsEmorrhage may be checked by tampons, with ice applications, 
or the sinus walla may be sewed together, as in the following unique 
OMG reported by Professor C. T. Parkes,' of Chicago. In June, 1882, 
he was called to treat a man who had received a compound commi- 
Buted fracture of the skull, with depression ; the fractui-e was just in front 



1 

>ter I 

ave I 

l^e I 




' Verhan^. d. deulnAai aettiUchafl f. ChitiirgU, 1877, ii 
• Annala of Anatomj ud Snigerjr, 1883, vlll,, 118. 



814 THE TREATMBNT OT WOUNDS, 

of tlie middle of the sa^ttal suture, extending into and inTolving the right 
parietal bone. The depreBsed portion was fully an inch in longest diam- 
eter, and extended a little to right of median line. He had paralyais of left 
side, hut no head nymptoms. An anEDsthetic having been given, Professor 
Parkes endeavored to remove the fragments. After removal of two or three 
a terrific haemorrhage set in, so that he was compelled to occlude the open- 
ing by a pad of antiseptic gauze. Nest morning he removed the compreaa 
and found the hcemorrhage to at once recur. As rapidly as possible he re- 
moved the fragments, exposing the dura nmter, when he found a large 
opening in the upper wall of the longitudinal sinus, from which the blood 
poured in a stream. He packed tlie opening with sponge, and, clearing 
out all diibris, smoothed off the roughened edges of bone. Finding the 
dura entire, with above exception, be removed the sponge and united the 
edges of the rent with three fine catgut sutures. Bleeding was checked at 
onoe, and the man made an excellent recovery. The opening in the sinus 



These wounds of sinuses usually heal well, with only a thickening of 
wbUb ; but entire obliteration of a single channel is of no great import, as 
Schellmann's researches ' have shown. The principal danger comes from 
softening of thrombi. 

Holmes,' Gnmgee, and Gross,' along with others, have related caaea of 
penetrating woimds which have injured the middle meningeal artery. It 
has several times happened that this vessel required Hgation during re- 
moval of fragments after severe injury ; while during our civil war the 
common carotid was seven times ligated for this same purpose, with three 
recoveriea. When gradually increasing symptoms of compression lead us 
to fear a rupture of this vessel, although there be no open wound, the pro- 
priety of trephining over its course with a view to its ligation may then be 
discussed. In 1839 Eeate removed a depressed piece of bone and caught 
it in its course v?hUe spurting, Tatum, Beck, Hueter, Physick, Bird, 8o- 
cin, and others have done this or similar operations with success. Should 
such a measure be decided upon, the coagula should be as far as possiblo 
removed, and everything should be done under aseptic precautions. A 
case of Parker's ' will be instructive in this connection. In this there n 
no extemul wound of soft parts ; nevertheless he trephined over the artery 

' Utber VerUUiing der nimriiULt ; Distertat., Oieoeo, 

' Treatise oo Kargery, 1876. * Am. Jont. Med Scl, July, 1873. 

•H^. Times, 1677, L, p. 91. 



■k>( 



IHTBA-CRANTAL UTJURIES. 815 

side, but found no lesion ; he then trephined over the artery on the 
other aide, but found uo coagulum outside the dura ; but since tlie latter 
had a distended and bluish appearance he incised it and removed a con- 
Biderable amount of blood. In three days the patient became conecious, 
id then quicily recovered. 
Injuries to the cerebral portion of the internal carotid are much rarer 
than thoae to the meningeaL Xiongmore relates that a bullet penetrated, in 
one case, through the orbit into the petrous bone and lodged there, but 
led to erosion of this trunk and fatal hemorrhage. Some injury of thiB 
kind might, if not rapidly fatal, lead to the formation of an orterio-venouB 
aneurism calling for hgalion of the common trunk. 

The treatment of woiinds of vessels in the substance of the brain can- 
not differ from that already laid down. Could hEemorrhage in the sub- 
dural space be diagnosed, it would be good practice to trephine and open 
the dura. One such case was reported during our war (vide Gross, L c). 
*' There are 100 cases of hsemorrhoge from the middle meningeal artery 
known. Of these 17 recovered ; in 12 of tliese 17 the blood escaped 
;h the estenial wound. Of the remaining 5 one recovered without 
ktion ; the others recovered after trephining and evacuating the blood 
lUgh the opening. In Hueter's case the bleeding vessel was secured by 
ligature " (Sands). 

INJUBIES TO CRANIAL NEB\-E3. 
The treatment of injuries to these uerves inside the cranium cannot be 
other than symptomatic. Should a depressed fragment or a foreign body 
press upon a nerve-trunk, removal of the some would meet tlie principal 
indication, and, provided tlie inj'uiy were not too se^-ere in other respects, 
the nerve might regain more or less of its fimctlon. When it is certain 
that a nerve-trunk outside the cranium is severed, it would be good prac- 

r*^ ~ to dissect down upon it and unite the severed ends with a fine carbo- 
d catgut suture, just as should be done elsewhere in the body. 
Inasmuch as tliese are inevitably complicated with thoae of parts ex- 
ternal, we can draw no abrupt therapeutical distinction, Obviously, if 
antiseptic meaaures are indicated for more superficial injuries, they are 
titally essential here. We wish to emphasize, also, more fully in this con- 



WOUNDS OF BRAIN SUBSTANCE. 



I 



316 THE TREATMENT OF WOUNDS. 

Dcction, wfafit has already received mention in this vork, and tliat is, the 
futility — we are alreoirt tempted to aay the homicidal effect — of careless or 
inedectiml probing for bullets, emce most of tliese wounds are mode bj 
projectiles. The array of cases set forth by German military- surgeons, in 
which most dangerous wounds, such aa when treated by old methods of 
proniiBcuous bullet-bunting, were surely fatal, primarily and antiBeptioally 
occluded, and never probed nor inveBtigatdd, have gone on to speedy re- 
covery — this array ahould be most convinoing as to the merits of thia 
pmctice. ' 

Probing disturbs clots and all reparative efibrt, and too often introduces 
septic gemia into deep porta Suppose we know a bullet has entered ft 
head, and are able to follow its track with a piobe two inches deep into 
the brain, what good have we accomplished, what valuable knowledge 
gained ? We knew that it had penetrated ; we could have made a guarded 
if not a very grave prognosis without the probing ; we have gained noth- 
ing, but, on the contrary, may have introduced new and disturbing ele- 
meute. The practice, then, which will commend itself is the following ; 

If, aff«r a gunshot or small perforating wound, there be no symptoms 
uidicating a serious luemorrhage or compreBsion, as from a depressed 
fracture calling for operation, the treatment is most simple, and coosista of 
antiseptic cleansing and occlusion of the external woimd, cold applications 
to the head, free evacuation of the bowels, and absolute rest The occlu- 
sion should be made with simple iodoform cotton, or something of the kind. 
tl, after the lapse of hours, ^inptoms of compression or intracranial lenon 
Bupervenc, then the trei>hine will be called for. When once decided on, 
the earlier it is used the better, and of course with all antiseptic precau- 
tions. If, on removal of the disc of bone, it shall appear that depression 
caused the trouble, after it is reheved no further operation is needeA If 
a clot be found between dura and skull it should be carefully removed, if 
necessar)- by removal of other buttons of bone. If o pouting and dark 
appearance of the dura make it probable that there is subdural hsemor- 
rhftge, an incision throug^h it should be made, and blood removed as l>efore. 
If, during these manipulations, the foreign body be recognized, it would 
be well to remove it as gently as possible ; but the circumstances must be 
very rare which shall justify random exploration in the brain for a bullet 
Even if a b\illet were touched at the depth of on inch, its removal would 
be attended by risk of hemorrhage such as might be difficult to master. 

'Vide Anoala of Anatomy uid Sargeij, 1883, vii., 114. 



HERNIA CEKEBIU. 



317 



Ebreover, many recorded cases prove with what apparent freedom brom 

I consequencea patienta maj recover with euub foreign masses an 

in their braina Not a few men are to-day at work, who are known 

' to be earning some small mass of lead embedded in their braina. The 

flttfest mie to follow, then, is to absiain from aU operative measurea v^ten 

Ike indicaiians become obncure. 



HERSUl CEBEBBL 

When from a recent wound, or one of a few days or wet 
rotruBion — hernia cerebri — takes pLice, it may seem doubtful whether it 
feronld be bett«r to excise the pixttruding mass or to endeavor to replace it 
Id pressure. Of course the careful surgeon will dress all fresh 
a with such a judicious amount of pressure as shall guard against thia 
condition ; but he may be called on to treat it after it lias bapijoned. If 
the hernial mass has commenced to slough, there can be no question ; es< 
ciaion must be practised and haemorrhage carefully watched for and 
checked ; twisting or tying any Uttle spouting vessel — pressure, or the 
not too hot cautery on oozing piints, will usually govern this. When 
the mass appears healthy, gentle but continuous pressure will usually 
cause the disappearance, within the cranium, of its proper contents. If 
this cannot be accomplished during the time of an ordinary' dressing, com- 
presses and bandages should be arranged so as to exert an uuintermitting 
pressure. After reduction a lead or caoutchouc plate may be adnpl«d to 
the shape of the part and appHed extemoJly as a portion of the bandage 

^ technique. 
Cauterizing or hgating the protruded mass is almost us dangciMus as 
excising ii 

If an abscess tmderlie it, as may be ascertained by the liypodermic 
syringe needle when suspected, its contents should of course be evacuated. 

» Adams has reported a case of irreducible heniia cerebri, in which he 
■Uccee-ded in covering the hernial mass with a flap of skin by a plastic 
operation,' and Kusmin another similar, except that he resorted to akin 
gmfting.' 



k. 



Luioel, 187G. No. 11. 

Bt. Petetaburg. Med. WoeroKlift., 1878, No. 17. 



THE TREATMENT OF "WOinTOS. 



WOUNDS DURING BIETH. 

With reference to those mjui-ies to the fcetal head which may happen 
during natural or artificial delivery, it ie neceaaary to add but little. Even 
large extravaaationa of blood are usually absorbed ; in estreme cases, 
after waiting a few dajB, it might be well to incise them and turn out the 
clots. Excoriations and bruiseu made by instruments need only conven- 
tional trentment. Fatal phlegmonous inllammation hoft been known to 
result from such injury done by forceps, hence the necessiij for antisepsis 
and attention to detail. Symptoms arising from the compression caused 
by the forceps will usually subside as the head resiuies its shape. Should 
positive fracture take place, it will probably run its course uninfluenced by 
therapeutic measures. Perfect rest and cool applications will constitut« 
about all that can be done. The prognosis must be bused on tlie amount 
of injury. 

BANDAGES FOB THE HEAD, 

Apposition of wound-surfaces, compression, and the retention of drea*- 
ings in their place require much ingenuity In the application of proper 





Fia, IR,— BueltLiI BuiKligs. 

bandages in the case of head-injuries. The following figures, copied, to- 
gether with their descriptions, from Eemarch'a " Surgeon's Handbook," 
will servo to indicate those methods of bandaging most likely to be of 
service. 

The double-headed roller (Fig. 92) is applied by placing the centre of 
the bandage opposite to the seat of injury, and carrying the two heads put 



BANDAGES FOB THE HEAD. 819 

h other with gradually iQcreaamg traction upon the wound ; these turns 
I then brought back again to the atarting-point, and the saoie process 
;|epeat«d several times. 

The sagittal handago, (Fig. 93), a ^-bandage, is especially suitable for 

mds of the scalp. 
The halter bandage (Fig. 94). The first turn begins on the top of the 
I, crosses the cheek by passing under the chin, and returns to the %'er- 





SX. From here the second turn runs backward round the occiput ; it is 
fiien earned from the nape of the neck to the front, round the anterior 
of the chin ; btetly, it returns to the nape of the neck, and ascends 
to the vertes. After these have been repeated two or three times, 





third turn brings it to a concInsioQ by forming a circle from forehead 
to occiput 

The capeltine (Fig. 95) is a double-headed bandage, the end of which 
jarnim round the head from forehead to occipu^ and fixes the turns of the 



^ 



S90 



THE TREATMENT OF WOtTKDS. 



r the right and left parietal bone. 



Tectangulor handkerchief, 
T ends. The figures ahow 



other end, which ia carried alternately o 
each turn overlapjiiug the preceding one. 

The four-tai/ed cap (Figs. 96 and 97) ii 
three times as limg as broad, and ^t at its n; 
the method of its use. 

The hetul-net (Figs. 98 and 99) may he made of coarse cotton twine. 
A. narrow linen ribbon, drawn through the meshee of its lower border, will 
fix it in a circular manner round the forehead, temples, and occiput A 





U*Rl for Pliiiv m an IeB«w. 



second ribbon, which ia tie<I beneath the chin, keeps the net down, and a 
third contracts the net upon the vertex like the string of a purse. It may 
thua be made to adhere firmly to the surface of the head without esercimng 
too much pressure or causing heat. 



TEEPHINI.VO. 

Tndkationsfar Vie Operation. — As ProfesBor H. R Sands has remaiked 
in the paper already alluded to. read before the New York Surgical 
Society : " For agea past no surgical procedure has been the subject of 
keener controversy, Euid the diversity of opinion which still prevailB 
concerning it suffices to prove that the question of its value is yet 
unsettled, and that it is one of inherent difficulty and obscurity." In the 
opinion of this surgeon, trephining is, however, plainly indicated in all 
compound fractures of limited extent accompanied with depression and 
comminution of the bone, even though not attended vrith any eigns of 
serious injury to the brain. He says : " Many lives which would oQuO' 



js well 
pompc 



nmiCATioss fob teephining. 821 

e be lost ure saved by the operatiou, wliich by elevating depressed fray- 
ments, by reino%'iiig fragments that are looae or sbttrp, aud by permittiDu 
thorough autiseptic irrigatiou o( the wound, reduces to a minimum the 
risk of intracranial inflammation, so gi-eiitly to be dreaded in this claaa of 
cases. To insure succesa, however, the operation should be performed 
soon after the injury, and with strict antiseptic precautioiia. I recall an 
iostonee in which, many yeare ago, I unfortunately delayed the operation 
until the third day, in consequence of the entire absence of bead 
symptoma When these occurred I trephined, but lost the patient, who, I 
believe, might have been saved by earlier interference. If trephining has 
not been performed soon after tlie accident, and the wound seems to be 
doing well, I should consider it objectionable to disturb it at a later period, 
unless the operation was indicuted by the occurrence of decided symptoms 
pointing to intracranial mischief. I have seen cases of recovery from com- 
pound depressed fractures in which the bone was not elevated ; but I do 
not remember to have met with such an instance, except in children, who, as 
fB well known, bear head injuries much better than is the case with adulta 
" While belieWng that trephining Is to be recommeaded in all cases of 
mpound fracture in which the depression is marked, but of no great 
~ superficial extent, and in all cases of punctured fracture, when there is 
reason to suspect that the internal table is extensively splintered or de- 
pressed, I am strongly opposed to active interference when the fracture is 
of great eitent, and when the depression is not hmited or abnipt It is 
true that these cases ore usually fatal ; but I am sure that nothing can be 
gained by the extensive operative procedure that would be involved in any 
attempt to remedy the displacement Aside from those coses in which the 
brain has suffered irreporoblo damage, I think that in future many suc- 
cesses will be obtained by careful antiseptic treatment of the wound, audi 
as recommended by Lister in the management of compound fracture of 
the bones of the extremitie.^. The most scrupulous cleansing of the 
woimd, the arrest of hsmorrhage, the removal of foreign bodies, loose 
fragments of bone, and of detoclied portions of brain matter, if present, 
followed by proper drainage and dressings, is, in my judgment, the only 
means which, with our present knowledge promises any benefit In this 
nearly desperate class of injuries." 

tot those who advocate more free resort to this operation. Professor 
Jgs, of Nashville, has more recently written.' In this paper he calls 



323 THE TEEATMENT OF WOTJIIDS. 

attention to the frequency, and alinost impunitj, with which it was done 
Ly the ancients and by strolling charlatans in the middle agea With 
respect to its adoption he divides surgeons into three classes— (1) tl 
who reject it, (2) those who only practise it when imperatively demand:- 
ed, and (3) those who recognize it as a valuable prophylactic The 
mortality after it ia certainly high ; but how many of those dying are 
reaUy killed by the trephine ? The well-known case of the Count of 
Nassau, wlio was trei^hined twenty-seven times by Chadboum, proves 
the operation, as such, to be no more dangerous than otlier capital 
nperatious. The South Sea Islanders scrape through their skulls with 
pieces of glass. Among the Comiiih miners the operation is, according to 
IVCchel,' one of daily occurrence. The chief danger in depressed fractures 
ia not the compression, for the brain rapidly adapts itself to tliat, but the 
irritation set up by the depressed bone. His motto is, " The early trephine 
is gold, the late trephine is lead," The risk of converting a simple fract- 
ure of the skull into a compound one can by no means equal the positive 
harm that threatens the integrity of the brain and its meninges if no 
operative steps are taken. Acting on this plan, that if cerebral irritation 
clearly point to a local focus the exploratory trephine should be used, he 
has never had occasion to regret this matter, dreaded by many, of makiDg 
a compound out of a simple fracture. 

Summing up, then, and gi^'ing due consideration to the opinion of ths 
oilier masters in aurgerj' as well an the more recent (Bell, A. Cooper, 
Brodie, Hewitt, N^ton, Bergmann), we may make out the list of indict 
tions for the trephine about as foUon-s : 

Simple fracture, with loss of function from penetration of cerebral 
oortex by splinter from inner table, or with compression from 
wound of a meningeal vessel 

Compound fracture, with depression, even without symptoms of com- 
pression, except over the frontal sinus in adults. 

Punctured fractures, even without symptoms. 

Coma, with signs of compression, with bruising of soft parts, but with- 
out fracture of the external table. 

Hemorrhage, either to tie a vessel or remove a clot This is mon or 
lees indaded in the above. 



' Am. Jour. Hed. BcL, Oot., 187B. 



OPEEATION OF TBEPHINING. 323 

Other mdicationa not so directly coutieut«(l with our aubjeiit are ; 
AbaceaeeB of braiu. 
Epilep^ or mental aberration following a bead injury, when the 

lesion can be localized. 
Bone abscess (frontal eiuus, mastoid, et«.). 
Purulent meningitis ? ' 

Lin diBcusaing this part of the subject, the t«rm trephining has been 
1 aa including not only removal of a disc of bone, but also the use of 
the bone elevator and Hey's saw. Ihe facts of the fractured area covering 
a relatively great extent of surface, or the depression not being limited or 
abrupt, are usually held as count«r'indicationB for operation ; yet here, as 
everywhere else, the surgeon must be guided by general couBiderations and 
by the special features of a given case, and be prepared to use that judg- 
ment without which he can in nowise be considered to be a surgeon. 

The Operation. — For the operation are needed, bewdes the ordinary 
scalpel, forceps, etc., one or more conical trephines, a bone elevator, and a 
Hey's saw. Sponges, autiseptica, aasiaUmts, and the spray being ready, the 
scalp should first be cleanly shaved. If the }>atieut be uncouscioiitt no 
amesthetic will be retjuired, at all ei'euta at first ; otherwise he should be 
aneesthetized. An existing wound should be enlarged ; else the bone must 
be exposed by a crucial, curved, or X-i^pd incision ; the pericranium is 
also raised from that poi'tion where it is intended to perforata. All bleed- 
ing vessels should be caught and tied as cut Hiemorrhage being checked 
the surgeon plants the trephine on the place selected, the centre-pin 
protruding, and turning it gently, one way and then the other, sinks the 
pin-point HIl the teeth have cut a circular groove. The centre-pin is then 
withdrawn till it no longer appears on a level with the teeth. The trephine 
is now worked vrith gentle motion, withdrawing it frequently to brush the 
groove in the bone, and its teeth, with the UtUe brush that should always 
accompany the instrument. Complete division of the outer table and 
entrance inte the diploG will be recognized by the more yielding sensation 
to the hand guiding the instrument, and the altered, more bloody character 
of the detritus thrown up by the saw. The surgeon must never forget 
that children and aged peraons have no diplou, their crania being therefore 



_.Q, 



Am. Jour. Med. Rci., July, 18X5, p. 00. If tha ^rofficologist can open the 
Ltonekl cavity tor acute peritODitia vilh Ruoceu. as Tait hu done, whjr cannot tha 
m Dpen the meDiugeal uutUj' for the same rcoaoii, to let out pua 7— (F.j 



324 THE TKEATMENT OF WODNDS. 

8o mucli the thiimer. As the instrument is made to cut more deeply- it 
must be the ofteuer withdrawn and the groove explored with a blunt 
probe, by which one will be able to diBtinguiah between the bone snd the 
more elastic and yielding dura mater. If the probe go through on one 
side, lie must be very careful to press the trephine only on the other sid^ 
and to avoid lacemting tlie dura witii its teeth. Extreme caution is now 
reqiiiretL On account of irregularities of the inner surface of the skull it 
maj' be impossible to cut everywhere through the whole thickness of bona 
without endangering the part^ beneath. In this case, even at the risk of 
causing spiculse of bone, the disc must be broken out. 

The trephine having been carried aa f ar as deemed judicious, one end 
of the elevator is inserted under the disc^ and with the margin of the sound 
bone as a fulcrum it ia pried out of place, tlie elevator point being 
troduced at several points around its circumference if need be. When 
loose from bony attachments the elevator and the forceps will facilitate 
its removaL Sometimes the combined action of two levers may be d6- 
cessary. 

With this removal of a disc of bone the prime object of the operation 
is attained, and pus or blood may be evacuated, or depressed portions of 
bone may be raised to theii' proper level by prying them with the elevator. 
Before closing the wound all shiu^) jxiiuts should be removed and rough 
edges smoothed off with suitable instruments. If a coagulum is to be ex- 
tracted it may be broken down with the bent probe and washed away with 
tt stream of tepid carbolized water. It ia a favorable sign when the dun- 
risea in proportion os clot is removed. 

We have described above the tj-pical operation. In 
nuted fracture it may be poasible to remove the fragmenta with the 
tor and forceps, without the necessity for making a prior opening. 8ome> 
times a projecting piece of bone may be removed with a Hey'a saw without 
requiring the trephine ; this fragment thus removed, an opening is 
just as if the trephine had been used. 

Certain cautions must be <lihgently observed. 

I^ace of Applying the Trephirw.—^lt must be rested by its centre-^pUl 
upon sound bone. That portion of broken bone, or edge, which is 
pressed always carries with it a larger portion of the inner table than 
swere to the diameter of the hole in the outer table. Hence the 
for observing this rule. Moreover, to trephine the depresaod portion might 
be to depress it still more during the operation. 



m 



THE V9E OF THE TREPHmE. S35 

Fointg to which the Trephine should neoer be Applied. — The line of the 
longitudinal sinus, the occipital bone over the course of the large sinueea, 
the frontal over the frontal irinua, and the parietal over the course of the 
middle meningeal artery— at least its lower portion. A point an inch and 
b* qnartra-, or half, back of the external angle of the orbit marks the site of 
r:ttie artery. If neceaaity arise for application of the trephine over the fron- 
tal sinus, the outer table should he first removed and then the inner. 

Should the circumetaticeB of the case, the bidgiiig of the dura mater 
and its discoloration lead to tlie supposition that pus or blood be present 
beneath it> it would then be legitimate to incise it and remove whicherer 
might present 

Whenever removal of one disc proves insufficient for the elevation of 
hone or removal of clot the surgeon is justified in removing a second am? 
a third even, selecting his points in accordance with the rule above given 
Tlie following plates, Figs. 100 aud 101, taken from Charles Bella 
■■Illustrations of the Great Operatious of Sui-gery" (London, 1821), with 
their commentoty and explanation, will serve to illustrate, much better 
—jtfaan a long description, some of the practical points in the operation. 

Afler-treatment. — There is little to be said with reference to the after- 
treatment Perfect repose, hght diet, and sedatives, pro re nata, in the 
way of therapeutics. The wound shoidd be dressed strictly ontLseptically, 
with a few catgut threads for drainage in one or two comers of the wound. 
p'A reasonably firm compress inuat be made over the site of the cperation, 
loth to repress any tendency to hernia dune or hernia cerebri, and to keep 
the pericranium and scalp in proper apposition with the parts beneath. 
The scalp-wound, of course, is neatly closed with sutures. But if pua 
liave been evacuated from within the cranium, it will be necessary to make 
^^•n open wound, and to place the head in the most favorable position pos- 
^■lible for drainage. 

H ENLARGISG OPENLVCa IN THE CALVARIA. 

^P For the purpose of enlarging openings which already exist in the bones 
■ of the cnmium for the elevation of depressed fragments, the extraction of 
splinters of bone or foreign bodieS; and to provide for the adequate cleans- 
ing and drainage of penetrating wounds of the skull, gouge-forceps may be 
conveniently used, as in Fig. 102 by means of which the edges may be 
gnawed away, and the opening quickly enlarged in any direction. Es- 
LVch, in his "Hindbook," p. 281, recommends that the sawing out of s 






H'Are. 

Bboth 



i 



THK USB OF THX TREPHINE. 



I 



Etflahation or Fia. 100. 

1. A Bkall showing Tarioun eiamplea □( fracture. A, a trlangiilar portion of tbe 
OS froDtis, frscCnTed and depressed. B, tbe three perforstiena tonnd neoeaaarj' for il» 
alevatinn and extmotion. The edge ot the inner table bein^ taaad to shelve tirxfT 
the sound bone mnila the eecond aud third perforation neoeasary. Thia wag a uiia- 
tnke, bnt one which ma; happen. D, a point, where the trephine was emplojed for a 
fissnre and fra<^are of the 03 frontis repissented at ils right side ; a aeoand perfora- 
tion was made on the aoand bone a little higher np, Btill the bone conld not be ex- 
trocled *. tbe trephine waa then applied ut E, and the bone lifted up. It ahoald have 
been applied at E in the first place. F ie a frnctare with depression at the lower 
angle. The trephine was placed at O. It oug-bt to have been a lar^ ods. and placed 
>t H, by which a portion of bone would have bepn s^ved and a more favorable toini 
of opening obtained. By perforating at O an acute angle of bone woa left between 
Oand F. 

3. Represents the piece of bone removed from A, with its inner table projecting 
beyond the outer 

4. Tbe button of bone removed in order to elevate the fragment represented in 3. 
nere, b; careletts work, the surgeon might have pressed on the depressed portion with 
tbe trephine, and Ihos depressed aed chafed the dnra. 

S and 7. Buttons ot bone having inequalltiee on their lower surfaoeB, showliig the 
uecesiitf for extreme caution during tbe operatSen. 

6. Another button, having conBiiierable inner table attached to it, as occurs when 
the surgeon is obliged to break up the ciicalnr portion. 

In I. instead of the trephine, a Bey's saw might have been used to cut acroM the 
base of tbe fragment at H, but tbpre is alwuya more danger of wounding the dura 
[ the MW, and it is more difficult to introduoe the elevator. 




Fio. ini— « Pmctimd Bkntlattn Ihs Ai<p11(!Uir 

1. BhowH the parts after the application of the trephine and remoral of tbe tr»g- 
meiilA. A, B, the flap* oF inteEameat ; C, tbe cnmitiTn ; and D, the dura mntor . 
eipOF<ed. 

2. Sketch of the fractured bone. A, B, C. tbe three portioDa of fractured bono, 
with depressed edges, which, being shaj^, are itritatirg the dnm ; they roust. theiO' ' 
■fore, be removed. Thej nre. moroover, to nepatated from their attacbments OB to 
huTB lost their vitalily. There being no " purchane" (ot the elevator, the ttephine 
IS applied at D, and the broken pieces elevated and picked ikway. 

3. Two diECB of hone cut by the trephine, ahowioi; the vntying thickneu of tha 
sknll. 

4. ElxfolinCion of bone after use of the trepTiine. 

5. Shows tbo two bibles of the sknll, with the d.ploc between. 



ENLAROINO 0PENIH08 IN SKULL. 329 

circular piec* o£ bone by the trephine be resorted to only in those cases in 
irhich there is no opening in the skull. If there is but a narrow fissure 
which hoB to be m^lened, he would use a gouge, a common carpenter's 




Fio. ID9~DiUnii o9 tho Edge of Bone, In k?nctfino( thaFlmll, with fiongo-fatwpi ( E^mnrcA). 

chisel, and a wooden mallet, with which sroall, sharp blows Hbonld be dealt 
ujxm the chisel obliquely placed upon the bone (Fig. 103). When the 
opening has been sufficiently widened, the gouge-forceps can be vised for 





BnlirEc u Oi> 



its farther enlargiop, as may be necessaiy. ^Vhen the object is sufficiently 
exposed, it is raised by an elevator, grasped with forceps, and carefully cx- 
traoted. 



The TRBATMETIT OF WOmWW. 



WOUNDS OF THE FACE. ETC. ^^™ 

Wounds of the eye are usually relegated U> the speoifllist in tliat depart- 
ment, yet it is essential that every practitioner should at least know what 
" first help " to render. No eareleaa efforts should be made to remove 
penetrating partit^les or bodies, but the eye should be carefully cleansed, a 
few dropu of a 2 to 4 grain solution of atropia be instilled to dilate the pupil 
and allay jwiin and irritation, the hd should then be lightly bandaged 
down, the patient put absolutely nt rest, and cold apphcations uiade, 
with, perhaps, the administration of a cathartic. For further informatioii 
the reader is referred to any of the standard treatises on ophthalmology. 

Wounds of the interior of llie ear should first be treated with warm 
water ; in fact, warm water is tbe only fluid that ever should be used in flie 
ear except by direction of the professed aurist. If pain be extreme, 
though, a few drops of a solution of morphia, with a little atropia in glyce- 
rine may be instUleii Beyond this nothing but hot water, made antiseptic, 
and possibly alkaline, should ever be used. 

Innned ux>nnds if the eyelidg may be united like other wounds. The 
approximation should be as neat as possible that the resulting scar may be 
slight. Fine silk should be used. 

A variety of pertelratijig Kmmds of lite fare may be met with. Knif^ 
blades and metallic instruments occasionally enter to tlie depth of an inch 
or more. If no wasel be severed, repair usuoDy goes on speedily. The 
leas such a wound is disturbed, as by probing, the better. A little wnd 
of antiseptic cotton bound on, or occlusion made by iodoform collodion, 
over which cold may be applied, will probably be all sufficient. If com- 
pression do not check hieraniThage a hare-hp pin, or cur\'ed needle witli a 
figure of eight ligature, or a deep stitch on either side the opening, may 
be reBorte<l te, both needle and sUk having been carbolized. If serious 
hiemorrbage indicate tlie division of some arterial trunk, the wound must 
be enlarged enough to permit application of a ligature to each end of the 
divided vessel, or posaibly a ligature below the wound may be required. 
Advantage may also be taken of the styptic powers of hot water. 

Should fracture of the nasal bones comphcate a case, the parte may be 
supported by tampons of cotton from within the nose, or, better still, accord- 
ing to the method recommended by Mason, ' they maybe supported upon a 
strong needle passed under them from one side to the other. Should ae- 

'AnnaU of Anmtomy Rod Snrgery, 1881, iii, 107, 197. 



WOTTNDB OP TKE FACE. 



831 



vere epiBtBiiB ocCTir, a douche of water as warm aa can possibly he toler- 
ated should be given, after which cold may be applied to the hacb of the 
head and the hands raised above it 

In any of the great i-ariety of punshot woundB that may occur, the rule 
EJiouId be &8 follows : If no serious symptoms iudicate a lesion incapable 
of spontaneous recovery, a simple antiseptic ocelusion of the wound will be 
all that is required; iio probe ahoiild be introduced. Any symptom of 
really grave import can be recognized without the probe. Should, on the 
contrary, the general and particular features of the case indicate some 
operative measure, it should be, if possible, postponed (of courae not ttm 
long) till everything is ready — the patient's accommodationa, the anies- 
thetic, instruments, and antiseptic dressings, as well aa assistants and 
nurses. And all probing and investigating should liave been omitted until 
then, when all can be done at one sitting and with belter results. 

The same will hold good with regard to injuries by liu-ger or foreign 
bodies, as, e.g., fragment*) of gla^s, bomlw or nbell, or splinters of wood. 
Primary antiseptic occlusion on the battle-field, or place where injiu^d, and 
all operative measures later when they can be carefully attended to. 

Intractable bleeding sometimes occurs after extraction of teeth, espe- 
daDy in so-called "bleeders." In these cases hot water may serve the pur- 
pose, but it will probiibly be necessarj' to pack the cavity with some styptic, 
and then moke compression by stuffing that side of the mouth and binding 
the jaws together. 

It may be possible to replace a tooth that has been wrenched or knocked 
out of its socket, provided the alveolar process be not badly broken, and to 
fasten it by wire or silk to other teeth or by binding the jaws together. 

When fracture of any of the larger bones of the face occurs along with 
an external wound, making a compound fracture, the general rules govern- 
ing the treatment of such injuries should be observed ; — approximation of 
fragments, perhaps by ^ire or chromic catgut, disinfection of the entire 
wound, provision for drainage, accurate adaptation of superficial wound, 
ftnd Buitable inter-dental or external support 

In wounds cutting through the entire thickness of lip or cheek it should 
be the effort to coapt the surfaces of mucous membrane as carefuDy as 
those of the integument Otherwise there are no particular indications 
about wounds of the soft parts of the face or external car differing from 
those in other parte of the body. If, however, the surgeon particularly desire 
to avoid acarting, he may do as Fancoast has suggested with reference 



J 



THE TRBATMEWT OF WOtTITDS. 



ilidea ' 



lo incimons made during plastic operatioua about the fac« — he may 
a little more time and 6ewi the udgfis, so that one ehall tend to lap or slide 
little way under the other, thus making the cicatrix a mere li 

"We may add that portions of the cartilaginous part of the external ear 
'nhich have been entirely removed may be replaced, provided not too long 
an interval have elapsed, with expectation of reunion in quite a large pro- 
portion of cases. 

Wounds of the 3/(in( A. '^Wounds opening into the buccal cavity, as after 
extirpation of the tongue, etc, should be lightly packed with iodoform- 
gauze. The adhesive gauze is here particularly valuable, because by its 
adhesive properties it attaches itself to the waUs of the wound, thereby 
preventing its being swallowed or causing sufibcation, while the iodoform, 
adhering to the gauze, is not apt to ba removed by the secretions of tlie 
mucous membrane. The gauze, cut in strips one-half to three-fourths 
of an inch in width, should bo brought into intimate contact with the 
wound-surfaces, so as to fill all fissures and recesses, and, if necessary, 
should even be fastened by stitches. In -wounds to which the gauze can- 
not be tliua applied, as, for example, those of the tliroat and palate, the 
iodoform in powder should bo daily inauiHuted. Drainogo is called for 
only after extirpation of the tongue and other wounds invoh-ing the floor 
of the mouth, in which there ii already an external opening. Parenchy- 
matous luemorrhogc is controlled by the gauze. Saruni, which at first may 
ooze through, may be absorbed by sponges fastened on sponge-holders 
firmly pressed against the dressings. 

The gauze, which vrill form in time a sohd moss with the various Becr&- 
tions, should remain in ititit 8 to 14 days, till it is spontaneously detached. 

Secondary btemorrhago is prevented, and cleansing of the buccal carity 
and teeth, formerly carefully attended to, in of less importance. 

If the filling of the wound-cavity has been performed with exactneae, 
there will be no reaction, secretions will be at a minimum, the patient will 
feel well, will experience no pain, and the mouth will be free from unpleas- 
ant odor. Only the superficial layers of the gauze will need a renewal, as 
soon as they are soiled by food, saUva, etc., or if the iodofoi-m in any con- 
oiderable quantity is washed away, the powdered iodoform should be 
duflt«d upon the dressing, more particularly where the gauze has separated 
from flie edges of the wound. 

' Woifler : WvndMmndluns Im Mun^t, Areliie far ktiaitehe Chii-urgit, xxrli., 
41a. BaclMt : AnkitUTig nr anOttptlMhen Wundbehandlung, p. 31. 



CHAPTER XIX. 

WOUNDS OF THE NECK AND OF THE THORAX. 

Wound* of the Larynx or JVobAw — PnncCurca — LongitadiiuJ Wounds— Trftnsrawe 
Wounds— Suturing- the Trachea— Ad tiKpsia — Tracheal Cauula— Intra tnoheol 
Polypi — Hnmorrhatje into Trachea — VioujuU of I'haryni or ffi«i;)/iapu»— Sw«l- 
lowiDg loMrdicted — OEsophBgeal Tube— Primaiy Importanca of Deep tTnion- 
Longitudinnl Wounds- Gunshot Wounds— TranBvetBe Wouodi— ir<ttiiirf» of Uie 
Qreat V*»»di of Ihe ^Vecjl— Arteries- Vert«brBl Arteries- Internal Jugular Vein— 
Iiat^ral Ligature — Cases of Paikes, Allis, Gerater, Lauge, Lidell, and J. EL Pil- 
cher — Nmi'penet rating Woultdt of Uu Thorax — Wounds of Inteniul Marainai? and 
IntercoBlal Arteries — PfnetraCi/ig Woumla of Iht TVioruar— Heart and Pericaid.um 
— Lungs — Plenno— Hffiraothorni— Pncuinothoroi— Emphysema- Empyema and 
Hjdcothorax— EeHOm^ 



WOUNDS OF THE NECK. 

The wotmda of the neck wMch present peculiarities that demand special 
examination are those deep wounJu whidi penetrate the larj-nx or trachea, 
the pharynx or (esophagus, or inyolve the yreat Teasels of the neck. 

Wonsna of tbb Labyns ob Trachea. — Siniple puuctures of the air-tube, 
as in cases of stab-wounds, usually unit« by first intention, without intro- 
ducing any complication in the course of the more superficial wound. 
Spontaneous apposition of the edges of longitudinal wounds of the trachea 
may be depended on by reason of the reHiHtanc« to separation exercised by 
the cartilaginous rings of its waU. The closnre of such a wound by pri- 
mary adhesion is the ride. Transverse wounds may be made to gape by 
extending the neck. In such cases the head should be depressed toward 
the chest sufficiently to bring the sides of the wound in contact, where it 
should be kept either by the occipito-stemal handkemhief of Mayor (Fig. 
104), or by some other apparatus acting on the same principle. Coaptation 
of the tracheal wound, in transverse wounds, may be assisted, if the case 
seem to require it, by introducing sutures through the peritracheal fascia, 
that enaheathes the tube ; this peritxacheal fascial sheath has suffident body 



.'J34 



THE TKBATMENT OP WODNDS. 



to make its auture in such cases a valuable resource in making accurate 
adjustment and in steadying the wound-edges in their proper relations to 
each other in those comparatively rare instances in which the trachea or 
liirynx has euitei'ed transverse division through a large part or the whole 
"f its circumference. If catgut is iised for such a purjjose, it should be 
cut off short in the wound. If mil;, oue end should be brought out through 
the supertidfll wound, and the suture regarded in the light of an ordinaiy 
ligature. 

Close ftpprosinmtion of the more superficial wound-surfaces, and their 
Duturing, should not be practised to a degree that would embarrass the 
free escape of any air, or mucus, or blood, that might be forced out of the 




Flf. IM.— OccipLtD-nsrul Handlutctalat lor Appcoilmntlng Truu> 

trachea through the wound in its wall by cough or in ordinary expiration. 
Approximation, with efforts to obtain primar}- imion, ahoultl, however, be 
made of all portions of the wound, with the exception named. 

The entrance of sepsis into wounds involving tlie air-tube cannot be 
prevented, bo that vigilant effort ia reqiiired to antidote its effects. The 
tree escape of all secretions should receive oareful attention that it be per- 
fectly secured. As an antiseptic appUcation the biBmuth lotions of Kocher 
(p. 89), are partictilarly ap])licable. By their use, the secondary suture, 
as practised by that surgeon, may be employed on the second or third day 
with the result of hastening greatly the period of repair in favorable cases. 



■W0USD3 OF THE TRACHEA. 



3rs5 



I 



In caaee in which there ia considerable losa of substance of tho wall of 
the larynx or trachea, great care must be eserciaed to prevent the entrance 
into the trachea of septic secretiona. One of the most frequent and fatal 
complicationB of such injuries, as well as of similar injuries of the niouth, 
is broncho-pneumoma, from the inhalation of septic matters from tlie 
wound. For the prevention of such a compheation, a suitable couula 
should be kept in place in the tracheal opening, and the surrounding 
wonnd-cavity should be kept packed lightly with adhesive iodo form-gauze, 
until its cicatrization is well ad>-anced. The \ise of a similar canula will 
also be required for purposes of respiration, if that portion of the air-tube 
abore tlie wound should become stenoeed from any cause, na inflammatoiy 
csdema, diphtheritic exudate, or cicatricial contraction. 

The opening of the conula should be kept covered by a moist and warm 
sponge to purify and moderate the temperature of the inhaled ur, and 
thus to guard against bronchial irritation from cold or dust-laden air. 

Exuberant granulations, forming poljiKnd escrescences projecting into 
the tiBchea, not infrequently form at one angle of a wound in the trachea 
which has been kept distended by a canula. They are formed by the ex- 
ceesive development of the granulations, which spring up to fill in the 
angles of the tracheal wound not filled by the canula. Their presence may 
be a source of dangerous embarrassment to the reHpiratiou when the canula 
is removed. They should be destroyed by the apphcation of caustics, or 
by avulsion, followed by cauterization of their bases. Whatever operative 
procedure may be necessary to nudie them aceesaible to the required appB- 
catioos should be done. Whenever a prolonged use of & canula is re- 
fiuired, watch should be kept for any signs of their development, and their 
f^rowth repressed from the first 

The escape of blood into the trachea, to the extent even of producing 
.'lufibcation, ia a compheation that should not escape the thought of the 
surgeon in the cares wliieh he gives to the wound. It is to be prevented 
by thoroughness in the primary hsemostofiia, and by the non-closure of the 
external wound. When blood in any quantity has already been poured 
into the trachea, it should be removed at once by fordbly compressing 
the chest while the patient is held with head and neck hanging down, and 
l.>y the introduction of forceps, armed with sponges, into the trachea 
through the wound, which may be enlarged, if necessary, to admit of 
being cleansed. A syiinge, if at hand, may also be used to suck out the 
blood. 



33C THE TREATMENT OF WOCKDS. 

Wounds of the Phartox, or the CEIsophagob. — The pharyni, or the 
ossophagUB, may be womwled from within, or from without. In the former 
oaae, portiona of the iDgeala, in the act of eating or drinldng, may escape 
into the connective-tissue of the neck, and produce purulent infiltratioD of 
ita loose substance. If the wound is in the posterior wall of the tube, the 
suppurative gatheringB may burrow into the posterior mediastinum below. 
These dangers, and the requirements of " rest " for the wound, make it 
necessary that the functions of the eanid in swallowing food shall he held 
in abeyance for a time. The patient must fast for the first days, until ad- 
hesion of the wound-edges has taken place. He should be sustained by 
nutritive enemas, whici alone may be sufficient to sustain him during the 
lieriod required. Great thirst may he alleviated by rinsing the moutli with 
lemon-juice or ice-water, but all attempts at swallowing should be rigor- 
ously interdicted. If the rectal alimentation be insufficient or impracti- 
cable, a flexible tube should be introduced into the cesophagus to a point 
beyond the wound and nutritious fluids be euppUed to the stomach through 
this. Such a tube, introduced through the nose, has been left iii aiiti for n 
long time, and the prolonged support of the patient successfully accom- 
plished through it. This physiological rest of the oesophagus should 1>c 
observed in all wounds of ils walls. Coses in which a wound from with- 
out has reached and opened the pharynx or the issoplmgiiB, are less liable 
to be attended by phlegmonous infiltration of the tissues of the neck, or 
by ottier septic accidents, The wound in the alimentary canal is, or, in 
many other cases, may be made accessible to treatment to secure its pri- 
mary imion, and the external woimd, by the drainage that it affords, is a 
aifeguard against the i-etention of irritating matters. 

The chief end to which treatment must be directed is to secure, first, 
imion of the wound in the ph.irj'ngeal or the cesophugeal wall. A simple 
longitudinal wound, as that inflicted in the operation of ocsophagotomy, 
presents httle difficulty. There is no tendency to gaping, coaptation is 
apontajieous and perfect as long as no attempt at swallowing food Is made, 
the external wound is approximated and treated according to the require- 
ments of incised wounds in general, and primary union results. 

Gunshot wounds of tliia tube do not admit of primary antiseptic oc- 
clusion. They should be treated by enlargement of tJie external wound, 
and adequate pro\TBlon for free escape of wound-secretions and debris 
from the deeper ports of the wound. Drainage tubes should be used, and 
UiQ wound, after thorough priniary disinfection by a carbohc acid lotion. 




WOUNDS OF VESSELS OK NECK. 

should be kept lightly stuffed with iodoform gauze and be made to " heal 
from the bottom." 

TronaverBe incised wounda should be sutured, whenever the wound in 
fJie tube ia acceasilile, or can be rendered so by a proper enlargement of 

the external opeDing. Aseptic silli: thread will make the most convenient 
tnaterial fur the suture. The sutures should not include the mucous mem- 
braue, but only the submucous and muscular coats. The int«rrupted form 
Bkould be used, luiJ tlic intervale should be BmoU, not exceeding the fourth 
of an inch. They should be cut off close. The eitemal woimd should bo 
cleansed and disinfected, and approximated with a view to secure union by 
first intention throughout The head should be kept in a position to relax 
the wounded structures and prevent gaping. 

WouKDS OF THE Gbeat VESsELa OF THE tiBOL—Arieries. — Should either 
of the main arterial trunks of the neck be wounded, the rule to expose the 
wounded vessel and to llgate it above and below the wound is imperative. 
If large collateral branches be cut, the same rule should be followed, if 
practicable, and the practicabihty of the procedure will largely depend 
upon the anatomical knowledge and the operative dexterity of the surgeon. 
The following comment on the subject of hEemorrhage and Ugations in 
wounds and injuries of the neck occurring during the War of the Bebel- 
lion, is by its surgical historijm. ' 

" Grouping the ligations of the large vessels of the neck, performed on 
account of gunshot wounds of the face or of the neck, we have a total of 
seventy-five hgations of the common carotid, with a mortahty of seventy- 
eight per cent . . . Nowhere else, not even in wounds of the forearm 
or legs, in which the brachial or femoral may have been tied, does the 
operation of Anel appear to greater disadvantage. Tying the common 
trunk for injuries of the smaller vessels of the head or neck is an operation 
based on a fallacious interpretation of tlie anatomical and physiological re- 
lationa of the region. Nothing that is not corroborative of Guthrie's 
admirable suggestions is found in the preceding cases. If the indolent 
or timid surgeon, who, to control bleeding from minor branches of the 
carotid, prefers to stuff the wound with styptics, or to perform the easy 
operation of tying the common trunk, rather than to seek in the difficult 
anatomy of the maxillaiy and thyroid regions to place double hgatures at 
the bleeding point, he may temporize, or may associate his name with the 

■ OUb : Hed. Knd Sur^. Hiatory of the W&r ot the Bebetlioa. Part I , voL U., 
Sarpoal HUtorr. p. 428. 



J 



838 TirE TREATMENT OP WOUNDS. 

necrology of ligationEi ; but if hie patient recover, it will generally be found 
to be under circumstancea in whioli the surgeon's operative intervention 
was uncalled for." 

Ferlebral Arlfries. — An exception to the preceding statements is to bo 
made in the case of wounds of the vertebral arteries. The difficulties 
which surround the treatment of wounds of these vessels are very great. 
Almost all the recorded cases, and their number is not small, have proved 
fatal We quote the following observations from Lidell : ' " Ligature of 
the vertebral artery fof practical purposes ia impossible except in a portion 
about two and three-eighths inches long, between its origin and its entrance 
into the transverse foramen of the sixth cervical vertebra. In this part of 
its course it has been successfully tied by Smyth, of New Orleans, for r^ 
gurgitating hemorrhage ; in this part, also, it has been tied, together with 
the inferior thyroid art«ry, by Maisonneiive, in order to arrest liiemorrha^ 
attending a shot wound of the neck — with success as far as stopping the 
hicmorrhage and extracting the ball was concerned, though death occurred 
from infiltration of pus into the spina! canal, and consequent inflammation. 
But these successes, complete and partial, afford some encouragement. 
Having determined by esploring the wound with a finger, or by any other 
means, that the vertebral artery is punctureii in this part of its course, the 
bleeding point should at once be laid bore, and a Ugature should be put 
round the artery on each side of the aperture. But when the exploration 
showB that the artery is wounded above the ^joint where it enters the fora- 
men of the transverse process of the sixth cervical vertebra, how can we 
suppress the bleeding and save the patient 7 We cannot tie llie artery in 
the wound ; and to tie it in the first part of its course, on Anel's plan, 
muld fail, because the two vertebrals unite to form the basilar artery at 
Hut base of the brain, and therefore regurgitating hiemorrhage would occur 
in the woimd whenever the direct hsemorrhage might be stopjjed in this 
W^T. Distal ligature of this arterj-, between the occipital bone and the 
hAm^ as mi^ested by Dietrich, would be both difficult in pcrformanoe and 
atwtiiiii in result There remains, then, only the operation of plugging 
Mb* wwuid*^ artery, a measure which has been successfully employed in 
iMM cwv by Dr. Kocher, of Bern. 

" Oi dilating the wound in the neck by suitable incisionB, both longi- 
tat^Mi »nd transverse, and removing the coi^uhi, the blood was seen to 
iiMH» ttVM a iKunt between the transverse processes of two vert«bre, ap- 

> luteniatiaDftl KucyclopatJU o( Surgery, iii., 118. 



WODMDS OF INTEBNAL JUGULAR VEUT. 339 

parentlj ihe fifth and sixth. Arterial blood escaped from both the central 
and peripheral jMrtioiiB of the art«ry ; and the bleeding was arrest«d by 
presaure against the transverse processea, either from above or from below. 

a ligature could not be applied, a plug of charpie of the size of a pen, 
I in Bolution of perchloride of iron, was introduced between the 
B processes, and left there as soon ue it had been ascertained th.at 
Uifi bleeding was suppressed. The external wound, having been closed bj 
sutures, was covered vvith charpie dipped in carbohzed gljcerine, Lister's 
carboho acid paste was apphed, and the dressing was retained in place by 
a bandage. The heod was kept fixed by a stiff collar. The plug in the 
deep part of the wound was removed on the fourth day after the operation, 
partly by means of a stream of water, partly by forceps ; no bleeding fol- 
lowed. Excepting n shght attack of erysipelas, the patient progressed 
steadily toward recovery, and was dischoi^ed cured a httle more than five 
weeks after the operation. 

" But in order to secure the success of this operation of plugging the 
vertebral art«ry, it is essential that the bleeding point shall be exposed to 
view, that the ping sbidl he placed exactly in the open canal of the vessel, 
which it must completely fill, and that the patient's head shall be held 
fixed, and the neck immovable, by a stiff collar." 

Inlernal Jugular Vein. — Wounds of this veaeel, when treated by expos- 
ure of the vessel and the application of a hgature above and below the 
wound, result happily in a great majority of cases. The free collateral 
circulation, through the intracranial venous sinuses, the superficial veins of 
the head and neck, and the sinuses of the spinal canal, prevent serious dis- 
comfort from being exp«rienced by the obliteration of so large a channel 
as the internal jugular vein, when the character of the wound renderu such 
a proceeding necessary. Lateral wounds of this vessel should be closed 
by the lateral hg.iture, if the wound is small : by lateral suture, if the 
wound is long. The advantages of this procedure ore that it may be more 
quickly done ; it demands less extensive dissection and disturbance of the 
neighboring tissues ; it increases the prospects of obtaining union through- 
out the wound by first intention ; and, finally, it preserves intact the func- 
tion of the vessel 

Of the tliirteen cases of lateral closure {12 by ligature and 1 by forci- 
pressure) of the internal jugular vein included in the statistics of Braun, 
before referred to (p. 296), there were ten recoveries, in one of which, how- 
ever, the ligature slipped off and other means were then resorted to, 



840 THE TREATMENT OF WOUNDB. 

Tfaero were three deathn from secondary luemorrhage. In addition to 
these cases, Dr. Parkea of Cbicagi),' baa reported three cosea of ktenl 
ligation of wounds of the internal jugular vein, followed by recovery iu 
eacli cose. In one of these cases the coustnutiou of the calibre of the i 

vessel caused bj the ligature amounted to one-third, and in another to one- i 

half its extent. No untoward syiuptoms followed in either case. . 

Dr. Allis, of Philadelphia, reported,' also, a cose in which he hod 
applied a lateral ligature to the internal jugular vein on account of a 
wound inflicted in it during the removal of a tumor from beneath the 
atemo-oleido-maatoid muscle. The recovery was rapid and permanent 

Dr. Gerster, of New York,' in a cose iu wliich a long longitudinal slit 
was made in the internal jugular vein, during the removal of a multiple 
lymphoma of the neck, succeeded in closing the rent by the applicatiou 
laterally of a row of catgut ligatures. Primary union followed the opera- 

Dr. Lange, of New York,' applied a lateral ligature, of antiseptic eilk, 
to a wound of the internal jugular vein, accidentally indicted in on attempt 
to tie the common carotid artery for secondary htemorrhoge. Recoveiy 
took place, 

lidell reports' another successful case, in which, the internal jugular 
vein having been punctured while a deep-seated tumor of the neck was 
being dissected out, the margins of the puncture were drawn together 
and raised up by a Liston's forceps, and a ligature was tied around them 
on the side of the vessel 

Dr. J. K PUcher's successful case of lateral forcipressure, reported in 
Chapter XVH. (p 292), should also be recalled is this connection. These 
eight recent attempts at securing lateral closure of a wound of the intenuj 
jugular vein were all attended with success, and serve to demonstrate the 
feaaibihty of the practice. 

The chief source of danger, which may threaten the success of an at- 
tempt to secure lateral closure of a wound of this vein is the normal 
lateral pressure of the column of blood in the vessel ; whenever the head 
is elevated, whenever the free entrance of the blood into the thoracio vea- 

' ProoradJDpi ot ibe Philadelphia Ooontj Mediud Sodetj, taeetini; of Manih B, 
18aa. m tbB Philpd. Med. TiroM, July. ISsa. 

' Proceed in^i ot Lhe New York Surgical Society. mneCing of Feb. 27, 18B3. ll«di- 
Okl Nai*>. Phlla.. 1S8». ilii., 378. 

* International EnojdopKdU o( Sargeij, iii, 109. 




WOUNDS OP THE THORAX. 341 

eela is impeded, aa in cougliing or straining at atool, this normul pressure 
is intensified. The contraction of tlie muscles of deglutition, oud of the 
moBclea which croaa it lower in the neck— the platyama, tLe etemo- 
deido-mastoid, and the omo-hyoid — may also affect the freedom with 
which the current through the vein shall pass, 

After any wound of the internal jugular Tein, and especially in tboeo 
instances in which a lateral hgature has been applied, the recumhent 
position must be maintained until firm union of tlte wound in the vessel 
has taken place. All movements of the neck must be restrained by the 
mass and the stiSness of the external dressings applied to the wound, 
bnmobilization and compression, as far as practicable, should be secured. 

The material used for all ligaturea of the internal jugular vein should 
be aseptic, and the treatment of the wound should be scrupulously anti- 
septic, that, if possible, primary union of the wound may bo secured. 

Lateral hgature of thia vessel should be attempted only when Eiseptic 
thread, catgut or silk, is obtainable and the subsequent course of the 
wound can be kept aseptic. In none of the recorded cases has secondary 
hromorrhage or other accident disturbed the course of the healing after lat- 
eral ligation when these precautions of antiaepais have been obaerved. The 
danger of secondary hEemorrhage should deter from resort to lateral liga- 
tion of this vessel when ordinary ligatures are used and the wound cannot 
be kept from septic contamination- When secondary heemorrhage occurs, 
it must be treated by exposure of the vessel and the application of a hga- 
ture both above and below the bleeding aperture, 

WOUNDS OF THE THOEAX 

Wounds of the thorax arc subject to the same general divisions aa 
those affecting other ports — they may be incised, punctured, or gunahot, 
contused or lacerated— and are silbject to such variations in treatment as 
may be appropriate to these varietiea More important, however, in tiia 
region is the division into non-penetrating and penetrating wounds. The 
former class includea those wounds which affect the thoracic wall only, 
without opening tiie pleural sac. The latter includes all those which 
involve injury to the contents of the thorax. 

Nox-PESETRiTDfo WonjDS. — Superficial wounds of the thorax present 
DO peculiarities requiring special consideration, except the difficulty which 
attenda efforts to secure the advantages of immobility in their treatment) 



343 THE TREATMENT OF WOUNDS. 

on account of tbe continual rising and falling of the chesL-walls in respira- 
tion. As the result, when union I)j first intention fails to be secured, the 
healing by granulation is apt to be retardeil in its course. This mobility 
of the thoracic walls may be restricted by surrounding the thorax with s 
broad, tightly drawn baniloge, which will restrain the movements of the 
riba, and make the breathing more abdominal in its character. 

Deeper wounds of the thoracic wall may involve fracture of the ribs or 
costal cartilages, and wounds of the internal mammary and intercostal 
arteries. The methods detailed in Chapter XV. should be applied to the 
treatment of wounds complicated by bone injuries. 

Wounds o( the arteries should be treated, whenever practicable, hj 
their exposure, and the application of a ligature to both the proximal and 
distal ends of the vessel The external wound should be enlarged by in- 
cision, if necessary, until the bleeding point is brought into view. Ceilain 
Hpeeial points in connection with each of these arteries reqiure mention. 

Internal Mammarij Artery. — The results of wounds of this vessel have 
Iteen disastrous in most of the recorded cases. Of the five cases in which 
it was distinctly recognized, and treatment attempted, during the War of 
the Rebellion, all terminated fatally, Wlien— as is most frequently the 
case — the wound which has severed this vessel has also penetrated more 
deeply and has opened the anterior mediastinum, the cavity of the peri- 
cardium or of the pleura, the dangers of intra-thoracic and concealed 
hatmorrhage are added. Acconting to Tourdes,' as quoted by the sur- 
gical historian of the War of the BebeUion, more than half the cases are 
accompanied by section of the costal cartilages, and this section always 
occurs when the vessel is wounded below tlie fourth rib by on incised 
wound, Tliere may be external hiemorrhoge, and internal, into the 
anterior mediastinum, into the pleural cjivity and into the pericardium. 
The diagnosis may be very difBcult, for the signs of intra-thoracic extzavo- 
sation ore often equivocal In continuation, Otis quotes the observatioiis 
of N^aton,' that if the htemorrhage is suspended at the time of examina- 
tion, anatomical condderations may afford presumptive evidence, and that 
every deep wound near the margin of the sternum, from the first to the 
seventh rib, should be viewed with suspicion. External arterial hemor- 
rhage decides the point ; but this sign is often absent. The diagnosis may 

' De» Hetiura de Farlirt mammaire iitternt tovM t« point de vae midioihligat, Bad*, j 
1849, p. 41. 

'£lemeni de Pathotogie cMrurgieaU, t lil, p, 430. 



^f be compl 



I 



WOUNDS OP INTEENAL MAMMARY AKTEBT. 34S 

be complicated b^ bleeding from woiinded lung, and the iuteruid haemor- 
rhage then offonla no decisive idgii, the ponition uf the nound alone sug- 
gesting the prcHuiuptiua tliiit the iutermd luamuiar)- tu't«rj' is lutefciited. 
The vessel is often of sufficient calibre to fufnish blood very freely, and 
death may result either from the profuuiou of the bleeding or from 
asphyxia from hemothorax. If the blood paswe into the pericardium, tbe 
heart's movement is impeded and soon arrested ; if it enters the pleural 
cavity or mediastinimi, there ia room for mortal hemorrhage ; and if the 
patient escape these primary accidents he is exposed to those of putrid de- 
composition of the extravasated blood.' 

In all cases, therefore, of deep wounds of that ix>rtion of the anterior 
vail of the thorax, in which the internal maumary artery runs, its exter- 
nal enlargement, sufficiently to permit de^uite determination of the fact 
vrhether this vessel is wounded or not, should be mada The enlargement 
of the wound should be mode by incisions directed slightly obliquely to 
the axis of the body, from above downward, and from without inward, so 
that the centre of the incision should be tliree or four lines external to the 
margin of the sternum, and in the original wound. All the superficial 
structures shoiUd be freely incised, so as to fully expose the wounded 
intercostal space. The anatomical difficulties which may embarrass the 
exposure of the vessel now present themselves. They consist of the shel- 
ter which the costal cartilages and the adjacent border of the sternum give 
to the vesaeL In the upper three or four intercostal spaces, sufGcient 
room between the cartilages may be found for the dtiiriiiement needed to 
expose the vessel ; in the lower spaces, resection of a portion of one or 
more of the cartilages may be needed, and should be promptly and boldly 
done. The primary and imperative indication is to expose the bleediog 
vessel, and no superficial structure ehoidd be permitted to arrest the eSbrt 
till its end has been accomplished. 

The task is more difficult in cases of secondary luemorrhage, where the 
adjacent soft tissues have become swollen and infiltrated, and the vessel 
lacerated and displaced. The attempt to secure it in the wound, however, 
should be mode ; failing in that, the tampon might be resorted to, after the 
plan of Desault This consists in placing over the wound a fine compress, 
four or five inches square. The centre of this is pressed through the 
wound so as to form a glove- finger-like sac projecting into the thoracic 

> Medical and Bmgioal HUtoi; of the War of tbe Bebellioo, Put 1., vol vL, Sur- 
gical Biatorjr, p. S25. 



M4 TKK TKKATlCEIfT OF WOTTRDS. 

ssd^ "Daa u O^ Bbdied fimlT with lint ; tiie angles of the c 
^ As oaAnl* n« tboi bnmght together, and the intra- thoracic pad or 
liBaf Bat Ib Aiawa gcntlv outward, and mode to compresB the wounded 
^■■d aganHt tba itntiuiu or ribs. To keep the pad in place, the com- 
fnw ngqr be ttad like a purse, and the ligature Becured around ft roller or 
oAwcaneaieiit crlinder. According to Otis, this is the best reaonrce, if 
Ae ^hunil to Sgate the Teasel fails. The hazard of exciting inflammatioD 
te fte |JwMa and long is leas to be dreaded than the danger of hEemo- 
Ttw risks of exciting inflammation of the intra-thoradc parte 
m leasened b; u^ng antiseptic materials in making this tampon, 
r pwt bring made of antiseptic gauze, and antiseptic cotton, jute, 
> being uaM] for the stuffing. 

i Artery.— la recent wounds, properly directed attempts to 
» intorcoistal artery by enlarging the wound should meet with 
■O i M ori i wan table difficulty. As the location of the wound recedes from 
I, the trouble which may be experienced will be likely to be- 
ing to the greater thickness of the external soft parte, 
the greater protection exercised by the projecting edge of the rib under- 
amth which it mns, and the larger size of the vessel, and the consequent 
mon proftwe bleeding from it. In the later history of a wound, when 
Mcooditry bsmorrhage from the artery requires to bo arrcst<>d, the swol- 
In And infiltnteil condition of the parts would still furtlier increose the 
Aificolttee of exposing it and ligating it directly. In such case, should 
•Sbtte at direct ligation prove imsatlafactory, the tampon of Dcsault might 
be rMorted to, as described in connection with the internal mammary 
If Uiis sliould prove inadequate, mediate ligation of the artery, by 
iMlvtilin^ it in the loop of a ligature thrown around the adjacent rib, may 
This method of securing this artery is described as follows by 
,' who hu invented an instrument for facilitating its practice : " A 
^ ehaipty curved needle, with a blunt point having in it an eye for 
tte Utnwd, should be taken. Having introduced a strong thread (silk, 
Mfamt, tx* niter) through tliis eye, prolong the wound n little posteriorly, 
Met dippii'g ^ point of the needle under the lower edge of the rib, fol- 
Inw tldnriy tb tnsar muiice, and, by depressing the handle of the instm- 
__4 iMike tbe pOiDl present, covered by the integuments, at the upper 
^^^^ ^ ^ jibk An inoiuon should now be made so as to uncover the 
^^. ^ ^ iidranent and enable the operator to remove the thread from 
• TM rriw»tt«* *^ PncLlce oC Sursery, 1878, L, 339. 



r 



PENETEATIIfQ WOUNDS OP THORAS. 345 

its eye, after which the instrument should be withdrawn. The ends ma; 
be disposed of by tj-ing them together over a roll of lint, or by passing 
them tlirough the openings in a bone button, and then securing the knot, 
Another plan of dealing with the ligature, after thus encircling the rib, ia 
to pass the end which was removed from the eye of the instrument through 
an ordinary good-sized needle, slightly curved at its extremity, and, rein- 
serting it at the puncture made at the upper part ot the rib, carry it be- 
tween the integuments and the external surface of the ribs, bringing it 
out at the original wound. This, which is c[uite easily accomplished, coD- 
etitutes a subcutaneous Ugation without the inclusion of soft parts. The 
upper puncture should then be closed with an adhesive strip. Xigatures 
applied in this way unavoidably compress artery, »ein, and nen-e. 

Peketoatino Wounds. — Wounds which pierce the pleural sac may either 
simply open the pleural cavity or may involve the organs eontnined within 
the chest to a varying extent. The most numerous class of penetrating 
wounds of the chest are gunshot wounds. Next to these in frequency are 
punctured and ineised wounds. 

The prognosis of penetrating gunshot wounds is very grave. Out of 
8,715 cases tabulated in the " Medical and Surgical History of the War 
of the Rebellion" (Part 1, vol. ii., p. 606), 5,260—62.6 per cent.— died. 
Out of 1,609 cases collected from various authors, and tabulated in the 
flune history, l,0i9 — 05.2 per cent.— ^lied. The course of incised and 
punctured wounds is much more favorable. Of 291 cases reported by 
Albanese.' of Palermo, only 24 — 8.2 per cent — resulted fatally, 8 of which 
were wounds of the heart, and i wounds compUcated with wounds of the 
abdomen, the peritonitis from which caused the fatal result. The great 
fatality of chest-wounds depends upon the vital importance of the organ 
wounded and the extent of the wound. Of the intra- thoracic organs, 
wounds of which may be in any degree affected by treatment directed 
especially to tliem in any case, the lungs and the pkiu-a demand most 
extended notice. Brief notice must be given to possible opportunities 
that may present for interference in i-are cases of heart-wound. Wounds 
of the thoracic portion of the (esophagus, of the thoracic duct, and ot the 
nerve-trunks that descend through the thorax are beyond the reach of the 
sorgeon. Wounds of the great blood-vessels are quickly and hopelessly 
mortoL Examination of the opportunities for treatment presented by the 
heart and its sac, by the lungs, and by the pleuree, vUl fij-st be made, after 




THE TEEATMENT OF WOUNDS. 

wliich tlie general caies demoDded by penetratiiig cheHt^wounds, as a 
whole, will be coDaidered. 

3eart aiid Pericardium, — Not evety wound of the heart results fatally. 
The statistics of Fischer,' for which we are indebted to quotation by Otis 
(op. citat, p. 530), Btat« that out of 452 cases analyzed, 7I> — 10.3 per 
cent, — recovered. Many instances ore recorded of death occurring some 
hours or days after the reception of a wound of the heart by a gradual 
leakage from it, the blood escaping into the pericortliuiu, and also, in sonie 
cases, into the pleural cavity through a pericardial wound, aud producing 
death either by the loss of blood, or by the embarrassment to tbe heart 
occasioned by the accumulating efiusion in lis investing eac If sucli 
cases could be recognized before death, with any degree of certainty, their 
otherwise hopeless course would justify an esaection of the overlying car- 
tilages, an incisiou into the pericardium, the evacuatioa of the eSiised 
blood, and an attempt to suture the rent in the heart-wall. That the peri- 
cardial cavity cau be opened for a short time with impunity in the human 
being, Eoenig's case of excision ot the sternum,' in the course of which 
both pleural cavities and the pericardium were opened into, has demon- 
strated. In this case the openings were at once occluded with antiseptic 
gauze. The dressing was not disturbed for twelve days. Ultimate recov- 
ery waa secured. Block ' has farther shown that in dogs, not only can the 
pericardial cavity be opened with impunity, but the heart may be seized at 
its apex, and held still sufficiently long for the introduction of a suture, 
and still have it resume it« piUaations. It is not impossible that heart- 
suture may yet be successfully performed in the human subject. 

Lungs. — The wounded lung will collapse more or less closely, accord- 
ing to the size of the aperture in the thoracic wall, and the freedom with 
which air con pass into the cavity of the chest tlirough it. lu rare in- 
stances protrusion of a portion of the lung through the external wound 
has token place. The lung-wound may bleed, may become inflamed, may 
be complicated by the retention within it of a foreign body. The bleed- 
ing from a lung-wound will exhibit itself both by a bloody expectoration, 
and by efiusion into the pleural cavity. It« arrest must be procured by 
general measures ; absolute quiet and silence ; ice, swallowed, and also 

> D(t Wunden dot Etrieru nnd dtt IlenbeuleU. Archivfur kUniKhe 
Ii., 571, 

' AOgmuint Wiener mediolni*Ae Zeiturig, September 33, 1883. 
• OMttU Hidioale it Slraiieurs, Ootobu 18, 1882. 






TTOtnrDS OF THE zmtQB. 347 

applied to the aurface of the cheat ; ergotiae, hypodermically adminis- 
tered ; opium ; heat and coimtor-irritanta to the extremitiea. The man- 
agement of aectiiD Illations of blood in the pleural cavity will be considered 
in another connection. Trauiuatic pueumonin does not involve large por- 
tions of the lung structure, as in the idiopathic variety, but is limited to 
the vicinity of the wound track. The inflammatory exudation may be 
at^orbed, may be diachsrged through the bronchial tubes, or may accu- 
mulate in the cavi^ of the pleura. From the latter cavity they will need 
o be evacuated by incision and drainage. 

Foreign bodies embedded in the substance of the lung are not to be 
eeorcbed for, but left to their spontaneous course. Should the patient 
survive, and continued ill effects be experienced from the foreign body, the 
propriety of exploratoiy operation, and of resection of a portion of the 
limg may yet become a matter of consideration. The experiments of 
Block," upon animals, in ivhich recovery and survival, in apparently good 
health, was secured after the removal of from one to four pulmonary lobes, 
are sufficiently encouraging to suggest the hope that such an operation 
may be proven to be available for the reUef of otherwise hopeless cases of 
prolonged suppuration and irritation from the retention in a lung of o. for- 
eign body. 

Hernia of the lung should be treated by carefully cleansing and disin- 
fecting the protrusion, and, it possible, returning it into the thoracic 
oavi^, enlarging as much as may seem prudent the original wound, in 
order to favor the return. According to Otis (op. citat, ii., 518), there 

I is, however, but a single instance of successful reductiou of a traumatic 
pneuroocele without previous hgntion of the tumor at its base and excision 
of the distal portion. If the first attempt to reduce fail, either ligation 
and excision may be done, or no interference be attempted beyond pro- 
tecting the protrusion during the course of its becoming adherent to the 
margins of the wound and its ultimate cicatrization. In most of the re- 
corded cases the fonncr haa been done, and without bad results. The 
material for the ligature should be aseptic, and the stump, after having 
been disinfected, may be returned to the pleural cavity without hesitation. 
PleurtE. — By the peuelratiou of the pleural sac, air and blood enter its 
cavity ; air escaping again through its external opening may become dif- 
; 



I 
I 



' Erperimentdifi tur Lungenracetion. DeuUehe med, Woohtiuahrift, B«iUii, I 



348 



THE THBATHETIT 0!" 'WOnlTOS. 



fused among the interstices of the subcutaneoue connective-tieaue ; and, 
finally, Bcptic inflammation of the pleural membrane itoeU, with accumula- 
tion of inflammatory productfi in its cavity, may follow. 

In genornl the mere fact of the presence of air and blood in the pleural 
cavity does not call for active interference unless they accumulate in such 
quantity as to embarrass the action of the soiind lung. The escape of 
blood to such an amount would be fatal from the loss of blood alone. 

RcBinothorax, — Signs of an increasing accumulation of blood in the 
pleural cavity call for a renewed examination of the wound in tlie parietes, 
to exclude a posaible hEemorrhuge from a superficial vessel If such should 
be found, it should be secured by ligature at once. If not, the opening 
into the thorax should be made sufficiently free, so that the blood being 
effused into ita cavity may escape externally, while the general meaaureB 
for arresting the Lfflmorrhage, which have been referred to in connection 
with bleeding from the lungs, should be adopted. Sffiuuons of blood 
which have been retained in the pleural cavity and have undergone decom- 
position ore to be removed by incisions through the wall of the chest, and 
by antiseptic irrigation. 

Pneumothorax. — The rehef of troublesome pneumothorax is to be ao- 
CompUahed by dilating the external wound so that the escape of air from 
the wounded cavity may meet with no obstruction. 

Emphi/Rema, rare after gunshot wounds, and more frequent after 
oblitjus afab wounds, is due to a want of parallelism between the tniperficial 
tmd the deep portions of the parietal wound. The wound should be en- 
larged Bufficlently to make the whole track free and direct. The swoUen 
tissues should be compressed by a bandage ; punctures and scarifications 
may be mode if needed, but will rarely be required. 

Empyistna and ffyJrolhorax. — Accumulations of fluid, the results of 
traumatic pleurisy, require thoracentesis for their removal Simple ae- 
TOua exudation may be removed by aapiration ; sero-purulent and sanguineo- 
purulent collections should be evacuated by free incision of the thoracic 
wall, irrigation with antiseptic lotions, and drain^e until obliteration of 
the purulent cavity is accomplished. Etsection of a portion of a rib may 
be done, if necosaary to give the required freedom to the opening, The 
opening shoidd be free enough to admit a finger easily, and to permit the 
escape of any fibrinous shreds, masses of gangrenous tissue, or foreign 
bodies that may be loose in the pleural cavity. In resecting a rib, the 
method of procedure should be as follows : Make an incision for two inohea 




I 

I 

I 

I 



TREATMENT OF EMPYEMA. 34'J 

or more directly over the rib aelected, and join this, at ita miJ point, by 
KBotber an inch long, carried downward at right angles to it Thia should 
be deepened until the rib has been completely exposed throughout the 
length of the first incision, and then the periosteum divided in a, direction 
parallel to the long axis of the bone. Then raise it by means of a perios- 
teum-elevator, which iti aUiO passed beneath the rib so as to separate it 
from the deep surface, a manosuiTe which is rapidly and easily accom- 
plished. A curved elevator ia then slipped completely beneath the rib 
wliich ia thus raised slightly from those immediately above and below 
it, and a piece, from one to two inches long, is removed either by cat- 
ting pUers alone, or after first dividing tlie bone half through with a small 
Buw. This is all completed before the pleura, or indeed the deep part of 
the periosteum, are in any way interfered with. The soft pajHs being held 
aside with hooks, the pleura is then incised at leisure, and the opening ia 
enlarged by expanding the blades of a pair of dressing forcepa The risk 
of wounding the intercostal artery is thus absolutely avoided, and if any 
vessel be dirided, either in the superficial or the deeper structures, it is 
easily seen and readily secured. Such an opening wUl admit the finger, if 
it be thought advisable to introduce it, and in the subsequent progress of 
the case the removal of the portion of the rib leads to no incouvenienca 
Antiseptic dressing of the drainage-wound (Chapter X- ) should be carefully 
performed, as directed in the nest section for the original wound. 

An efficient drainage-tube may be readily improvised in the following 
manner : ' Take a piece of pure ludia-i'ubber sheeting, -j*; inch thick and 
about 1} or 2 inches square, and cut a round bole in its centre. Then 
take a piece of tubing, of the size required, and without boles, and of a 
length merely sufdcient to project into the chest cavity, being fixim IJ to 
2^ inches long — according to the thickness of the chest waU. Spht this at 
one end into four pieces, which are then drawn through the hole in the 
flat piece of rubber, tume<l down upon it, aud fixed in position by stitches 
of fine silver wire. The completed tube is shown in Fig. 105, Such a 
tube will adapt it^telf to a sinus leading in any direction, aud ivill require 
no special mancBuvros to prevent its slipping into the chest ; it may be left 
beneath an antiseptic dressing for many days at a time, in confidence that 
it will work well all the time. 

Oeneral Regume. — If the external woimd is small, with no or only 

* R. J. Oodlee, The TreatmBut of Enipjema. Annali of Anatomy and Sncgerj, 
Jnly. 1888, vUt, 13. 





THE TREATMENT OF WOUNDS. 

slight splintering of the bones, and is adapted for primary closure, imme- 
diate antiseptic occlusion should be done 

If the wound is extensive, not suitable for primaij closure, and compli- 
cated hy an estenaiTe bone-splintering, it should be enlarged and carefully 
cleansed by the removal of the splint- 
ers of bone, tissue-shreds, clot«, or 
foreign aubatanee§ that may be en- 
tangled in it ; sufficient counter-open- 
ings should be made to affiird effective 
. drainage, and thorough disinfection 

Iof the wound and ita Buiroondingv 
should be made. Then thicli and ex- 
tensive layers of antiseptic protective 
material (Chapter X.) should be ap- 
plied, with adequate drains in the 
wound and in the counter-openings 
The whole should be secured in place 
with bandages applied so as to strong- 
ly compress the thorax and restrict its 
movements. To prevent the access of air imder the edges of the tlreBBiugs, 
an elastic bandage should be carried around ite upper and lower borders ; 
to prevent shpping of the dressings up or down, a muslin bandage should 
1m carried once or twice over one shoulder and down under the perineum, 
and up over the shoulder again, and secured by pins to the upper and 
lower imiia of the dressing, in front and behind. The antiseptic dressings 
should cover the whole nidth of the thorax, from neck to navel 

Changes of dressing should be made as rarely as possible. Should 
occlusion not be successful in preventing copious suppuration in the 
wound-track, more frequent changes of the dressings will be required. 

In the primarj- cleansing of the wound, if fi>reign bodies present them- 
selves, they should be removed, but no search by probing for a foreign 
body should be made. 

The arrest of luemorrhage will be attended to as a part of the primaiy 
cleansing of the wound which has been described. 



a. lOS,— Dr»lM«i>Tulic 




CHAPTER XX. 

WOUNDS OF THE ABDOMEN-OF THE PELVIS. 

Ifim-penelTating Woundt of ParitU* — AtrsHt ot HBemotrhage— AppoaitEon— PfJMtruMnff 
Wound* tcU/iotit Injury to Yiieera — The Periloneal Wound — ProiruBion o( Vi«- 
oera — Inteatine — Omentum — Other Viaoem — Feiiet rating Wouada ait/i Injury to 
ViMtrii^Exploralioa of Abdomeo—DingDOeU Foutive — Diagnoaia PreBuinptive^ 
Aireal: of Intra]>eritoDeEJ HKrooirboge — Suture of Viscrral Woondii — Lemberlr'a 
Satura — Jobert's — Eramert's — G^^Ij'h— Gussenbauer's— CEemj'a — The Coutinuoua 
iDleatianl Sntn re— Circular InvoginBtion Satute—Primart/ Cleaiuiag of Perito- 
neal CaTily— Drainage— PeriCaiiilU nnii Sejilkamui — Woundu of Me Bliiddfr — 
Eztsmal InoisionB — LapBrotomj— Suture of Bladder— Catbeterixation—VIViundt 
of Anu* and Reetum. 

Wounds of the aMomen may involve aimply the abdominal wall, without 
penetration of the peritoneal sac ; they may penetrate the peritoneal eac 
without wounding any abdominal viscera ; they may involve wounds of 
any of the viscera. Cach clase presents certain features in treatment 
which require special consideration. 



NONPESETRATING WOUNDS OP THE PAaiETEa. 

Abkebt of Hxmorbbaoe.— When arteiial bleeding is present, the gen- 
eral rule, that the bleeding vessel shall be exposed in the wound, and a 
proximal and distal ligature be applied to the divided ends, is imperative. 
The internal epigastric, the internal mammary, and'the internal circumflex 
iliao arteries, when wounded, may retract within the muscles among which 
they lie, and cause trouble in securing them ; should attempts be mode 
by compression and styptics to control the bleeding, extensive interstitial 
extravasation would be endangered, entailing suppuration and sloughing, 
even though the hiemorrhage be primarily checked. Punctured wounds 
of these vessels are hable to the same danger of hidden extravasatioti. 
In cases of penetrating wounds, the blood may flow into the peritoneal 
cavity and be concealed. In case of a. deep wound of the abdominal pari* 



359 THE TREATMENT OK WOUNDS. 

etea, involving the muscles, the surgeon should be sure tbat perfect and 
definite hieuiostasis has been secured before tlie wound be closed. Evety 
arterial branch that bleeds should be tied, aud double hgature of the 
larger trunks must not be neglected. 

Should extravasation of blood among the intermuscular or interapo- 
□eurotiu spaces have already taken place, the clots should be removed as 
far as poawble, and thorough dieitJection of the parts be made. Should 
the case have proceeded to the poist of cIot-decompositiDn and suppura- 
tion, free incisions, antiseptic irrigations, and drainage should at once be 
made. 

Apposition. — Wounds in the abdominal parietea require that careful 
apposition of all the divided structures should be secured, to prevent pre- 
mature weakening of its structure. Otis remarks, "I^ter experience 
attests the utility of deep sutures ; it was generally observed during the 
lata war that ventral protrusions were only to be prevented, aJter ex- 
tended division of the abdominal walls, by exact coaptation of the divided 
muscular tissues. The quUled suture answered the best purpose, redu- 
cing the extensible cellulo'fibrous cicatrix to the narrowest dimensions. 
Twice by this means I secured firm cicatrices, without protrusion, in ex- 
tensive incised wounds in the bellies of horses, whore the difficulty of 
exact reunion is great." The possibiUty of the regeneration of muscular 
fibres, and thus the ultimate perfect j-estoraUon of the integrity of the 
wounded part, is an adihtiounl reason for great care in securing coaptation. 
A position whicli should relax the wounded sti'uctures, together with the 
compression and support of ample protective dressings and a bandage, 
should not be neglected. 



PENETRATING WOUNDS OF ABDOMIN.VL WALL WITHOUT ISJURT OP 
VISCEHA 

Wounds which penetrate the peritoneal cavity, without injuring any 
contained viscus, may not differ from non-penetrating woiuids, except in 
the addition of the wound in the peritoneum ; they may bo complicated by 
protrusion through tlie wound of some of the abdominal contents ; they 
may be comphcated by the entrance of foreign matt«r or blood into the 
peritoneal cavity. 

The pFJirroNEAL WouNn. — This should be closed by being included in 
the deep sutures introduced for the purpose of closing the wound in gen- 



PErrETRATHTG "WOTINDS OP ABDOMKfT. 



353 



I 



eraL These ileep suturea should be inserted rather more than an inch 
from the border of the wound, and should tdope toward the inner surface, 
yet so as to inciude, upon either side, a narrow strip of peritoneum. When 
the BUtures are tightened, the included peritoneal surfaces are brought 
into apposition, and adhere with great rapidity. Whenever edges or sur- 
faces of peritoneum are divided or separated, they should, if possible, bo 
reunited. Peritoneum must be apposed to peritoneum ; the edges should 
be inverted so tljat two aei-ons surfaces shall be pressed together, the exact 
opposite of the conditions required for the union of skin or mueous mem- 
brane, union of wounds in which is prevented by inversion of the akin or 
membrane into the wound. The reparative processes in the serous mem- 
brane of tlie abdomen are identical with those described for the intima of 
blood-Tesaels. When the peritoneal margins of a wound are brought and 
held in opposition by sutures, the effused lymph quickly adheres, tills up 
the angle of union, and may make so smooth a surface as even to render 
undistinguishable the line of luiion. In wounds of the parietal peritoneum, 
ve have the best roaeons, clinically, why we should always reunite the 
severed edges of the peritoneum. As has been pointed out by Sims,' if 
the edges of the peritoneum are not embraced in the sutures that close the 
abdominal sectioD, a raw surface is left on the inner face of the wound, 
which immediately aiilheres to the subjacent parts. If it happens to ad- 
here to the omentum, well and good ; but if to intestine, the result may or 
may not be fortunate. For, if the adherent inteatine happen to be con- 
voluted in such a way as to obstruct the bowel, a fatal result may follow. 
Sims relates that he has seen three cases in which, while the parietal 
wound gaped open widely, the peritoneal edges were firmly united. In 
these CAses, if the peritoneum had not been closed, there would have been 
no union whatever in the line of the abdominal incision. 

Pbotkdbion or ViacEBA.^The viscera most frequently met with protrud- 
ing through wounds of the abdominal parietes are the small intestine and 
the omentum. Instances of protrusion of the stomach, hver, sjJeen, kid- 
neys, and bladder have been noted. Many instances of recovery from 
the most extensive and aggravated wounds of this character, under very 
unpromising circumstances, are on record, so that no case of the kind 
should be despaired of. The follo«-ing recent cases may be quoted in 
iUuBbation of the truth of this statement : 



334 



THE TREATincm OF WOFNBS. 



1. Case reported by Simpson,' of Michigan, Male, 30 yenrs of age, 
cut liis abdomen open with a razor, while in the woods. Seen by the sur- 
geon four hours after the occurrence. Was then covered by an old bed- 
quilt, which was adherent to the protruding intestines. Wound was in 
middle line, eight inches in length, esteuding from the enaiform cartilage 
to a point below the umbilicus. Through this a mass of intestiues, con- 
sisting of eight inches of transverse colon and twelve feet of small intes- 
tine and omentum protruded ; the intestiues were dry and wrinkled, cov- 
ered with diiders, dust. sand, and a variety of foreign matter which had 
been rubbed in as the man had rolled over and over on the ground in his 
agony. Under cldoroform, the loi'ger bits of foreign matter were picked 
off, and the intestines washed in water from a neighboring brook, and 
the protruding viscera returned. A qurtntity of blood effused into the 
peritoneal cavity was mopped out with a handkerchief. The wound was 
closed by a continuous suture ajjpUed so as to include the whole thickness 
of the wound-edges. Difficulty was experienced in preventing the omen- 
tum from protruding while the suture was being apphed, and in the lower 
half of the wound it became adherent to and unit«d with the lips of the 
wound. The man was then removed in a lumber wagon four miles to a 
town, and placed on & dirty cot bed in the city fire-engine house. Rapid 
recovery without an imtoward symptom tool; place, so that he was dis- 
charged from treatment on the fifteenth day after the occurrence. 

2. The second case ' is very similar to the first. A male, 55 years of 
age, attempted suicide, and cut into his abdomen with a large knife four 
successive times. When first seen, three hours Eifter the accident, the pa- 
tient was found lying on the dirty floor of a cattle-hut, in a fainting state, 
with all the small intestines and the whole omentum majus i^rotruding 
out of a clean-cut wound which extended from the scrobiculus cordis far 
bdow the umbihcus. Tliere were seen also three other smaller wounds, 
•Q of them perforating the abdominal wall. The protruded parts, which 
««re covered with mud and blood, were washed with tepid wat«r and re- 
ined, and then all the wounds closed with silk sutures, and dressed with 
caU water. Three weeks later the patient left the hospital, having recOT- 
9tid without any complication except a small abscess in the abdominal 
wmi Mar the largest wound. 

OM of 307 cases of penetrating incised wounds of the abdominal CftT- 

' 3(«dK!ftl Q»»Btt«. New York. 1882. p. 22.^. 

• ;^«niiataJ:,*, Vraclirbiiisa Viiidumotti, St PeterBbntg, 1882, Ho. 18. 



PROTRUSION OF nsCKRA. 366 

ify reported by Alboneee,' of Palermo, in only G instoncea did death result 
from aimple diffuse peritonitis. lu these cases, protrudiDg intestinal loops 
were always carefully washed with carbolated water, and any wouiide in 
the inteatinea sutnred before the protrusion was returned. 

In general, the rule of treatment in thta class of oases is to cleanse and 
disinfect the protruding tiscus as carefully as j)OBsibIe, and return it into 
the abdominal cavity, after which the wound should be treated as one 
without protrusion. Attention must be dire<?ted, however, to modifica- 
tions of this rule demanded in certain circumstance a. 

Inleeline. — So large an nmount of intestine may Lave escaped through 
the wound that It con no longer be passed back through the opening by 
which it escaped. In such a case the wound must be enlarged until the 
return of the protruding intestine is possible ; care should be taken to 
moke the intusions at those portions of the wound which resist distention 
and act as agents of constriction. The return of tlie intestine should be 
followed by insertion of the finger to determine with certainty that the 
gut has been replaced in its proper cavity, and not crowded between the 
peritoneum and the superficial tissuea. 

The difficulty in reduction may depend on the distention of the bowel 
by flatus. If so, an attempt to press it back into the portion of intestine 
■within the abdomen should be made. If this is unsuccessful, and the pro- 
trusion is great, with excessive distention, the bowel should be punctured 
with an aspirating needle through which the gns may escape. 

The intestine may have been strangulated by the constriction of the 
wound through which it has been forced. If, after the constriction has 
been rehoved. the circulation in the previously strangulated loops resumes 
its natural course, reduction of the gut, and closure of the wound should 
be mode. If gangrene is already present, or if the feeble and imperfect 
retiun of the circulation, after dividing the stricture, indicate that it is 
inevitable, the bowel should be left in the wound, \o the margins of which 
it will have contracted adhesions, an incision should be made into the 
liowel and an artificial anua created. 

Omentum. — Protruding omentum, which cannot be readily replaced, 
should be ligated at its base and cut off; if an aseptic Ugature has been 
employed, the stimip may be dropped back into the abdomen, and the 
abdominal wound may he closed ; if an ordinary ligature be used, the 

' TraaskotioiiB of ths IntematioDAl Medical CongreBa, Londoa, 1381, il,, 487. 



1 



356 



THE TEEATMEHT OF WOUNDS, 



omentuiQ muat be left in tbe wound, and henling by granulation awaited. 
Protruding omentum that is very dirty, that is congested in any degree, 
or into wbose substnnce eitraTOsations of blood Imvo taken place, should 
be excised. If the size of tbe omental moss, that is to be excised, be con- 
siilerable, a double thread should be passed through its base, and each 
littlf tied separately. 

Protnmon of other Vvtcera. — Pi-otrusions of tbe stomach are to be 
treated in accordance with the rules for the intestines. 

In cases of protrusiou of tbe bladder, evacuation of tbe urine sbould 
first be secured by the introduction of a catheter, after which its reposi- 
tion may be effected without difficulty. 

Protrusions of portions of the spleen, or of the liver have occurred. 
The general treatment of such protrusion should be the same as that 
given for protruding omentum. 



Two cases of complete protrusii 
recently been recorded.' In both c 
pedicle formed by the vessels and i 
covery ensued. 



a of a kidney through a wound have 
ses a ligature was thrown around the 
reter, and the kidney removed. Re- 



PBNETEATING WOUNDS OP THE ABDOMINAL WALL \\1TH INJITRY OF 

VISCERA 

In the treatment of this class of wounds, the surgeon will need to 
specially consider tbe subjects of exploration of the abdominal cavity, 
arrest of intraperitoneal heemorrhage, suture of visceral wounds, primary 
cleansing of the peritoneal cavity, secondary cleansing or drainage, and 
secondary inflammatory and septic complications. 

Exploration of the Abdominal CAvrrv. — The evidences that an abdom- 
inal viscus has been wounded may be either positive or presumptive. The 
escape through the opening in the pnrietes of tbe contents of the aliment- 
ary tube, of tbe bile or of the urine, or the protrusion externally of the 
wounded viscus, so that the woiuid is sabject to actual inspection, alone 
can be considered as positive proof of visceral injury. When any of these 
conditions are present, the duty of tbe sui^on is, clearly, to enlarge the 
opening in the abdominal wall, or to make a new one in a more favorable 
location, sufficiently to admit of examination of the ^-iscerii iu the track of 



■Bnndt: Wifjurr 3ffd. Woelitiuefirf/t, l»j7.1. Uurtuid: lUaveH d» Mim. d* Xti. 
de ChirvTg , etc., 187S, xxxL, SOS. 




I 



WOUNDS OP ABDOHINAI. VISCERA. 357 

tlie wound, to detect aud ligat« bleeding vesaela, to suture intestinal rents, 
and to thoroughly cleanse the peritoneal cavity of extravasated matters. 

In the great majority of cases of visceral wound, however, positive 
evidence is wanting, and simply a more or leas strong presumption of the 
fact of the wouud exists. In these cases it should first be established, by 
Buperfiditl esploration, that penetration of the peritoneal cavity hus taken 
place. In this respect nn exception should be made to the general rule 
given in the case of gunshot wounds to abstain from all primary explora- 
tion of their track. Gunshot wounds of the abdominal walls should be 
explored in ail cases, as soon as the necessary requisites of aseptic cleanli- 
ness can be complied with, suMciently to determine whether they do or do 
not penetrate the peritoneal cavity. 

The fact of peneti-ution having been established, the further course to 
be pursued becomes a matter of grave consideration, whenever signs of al- 
ready impending dissolution do not absolve the surgeon from all responsi- 
bility. With but few exceptions, this class of wounds are gunshot wounds. 
A pohcy of non-interference, and of expectant treatment by rest, cold, and 
opiates has been pursued in the post in the treatment of the cases under 
discussion. Notwithstanding this treatment, 87.72 percent, of all pene- 
trating gunshot wounds of the abdomen, during the war of the Rebellion, 
terminated in death. During the Crimean war, 91.7 per cent, of the cases 
among the Frendi, and 92.6 per cent among the English, died. Of the 
cases that recover, the larger proportion are among those in which the 
protrusion of the \-iscera, or the adhesion of the morons of the internal 
Tisceral wound to the margins of the external wound so that the contenta 
of the viscus escape externally, reheve the surgeon from all doubt as to the 
course he should pursue. Of the few cases that remain, in some the re- 
covery has taken place though positive evidence of visceral penetration has 
been given by the subsequent voi'ling of the bullet per anum, and in yet 
others in which the symptotns have afforded strong presumptive evidence 
of visceral wound, as in the following case, reported by Schapps : ' a male, 
aged twenty years, was a<lmitted into St, Vincent's Hospital, New York, in 
the sen^ce of Dr. Chas, Phelps, May 26, 1880, having been shot by a pis- 
tol at a distance of three feet. The bullet penetrated the abdominal wall 
two and a half inches above and to the left of the umbihcus. General con- 
dition when admitted fair, but within half an hour experienced great de- 



338 



THE TBEATMEMT OF WODHDS. 



presBion of vital poweni. and TomitcHl conmderftble blood. Ice, stimulants, 
luid opium were given. He was discharged on the twenty-second day 
thereafter, cured. 

It should also be remarked that instances have been recorded in which 
the abdominal cavity has been traversed by a bullet, or transfixed by a 
weapon, without injury to any of its viscera. 

In any individual case, the possibility that it may prove to be one of 
the rare exceptions to the genei'al rule of fatality, will have its uifiuence on 
the decision of the wirgeon as to the course which be shall pursue. 

The cause of death in the fatal cases is either shock, hiemorrhage, sep- 
ticiemia, or septic peritonitis. Death fi-om the first two causes is speedy, 
so that, except iu rare instances of slowly accumulating blood-extravasa- 
tions, they do not require special consideration bera The two latter causes 
of death, septicEcmia and septic peritonitis, are more slow in their opera- 
tion, and hence engage the more particular sohcitude of the surgeon in 
the treatment that he nmy give. Most important of all would be their 
prevention, but in these injuries the cause is inherent in the wound Iteeli^ 
from the extranisation of the septic contents of the wounded organs into 
the peritoneal cavity. Fi-ee incision, exploi-ation, disinfection, and drfunage 
constitute the treatment for similar conditions in other regions of the body 
and would be resorted to in all cases of penetrating wounds of the abdomi- 
nal cavity were it not for the special dangers which such practice involvea 
These are the shock of the incision and the handling of the abdominal 
contents, the danger of awakening fatal inflammation by the operation 
itself, the possibihty of disturbing repair which if left alone would haye 
accomplished recovery, and finally, the possibihty of overlooking wounds 
from which subsequent extravasationa would occim 

In forming his final conclusion as to the course which he should pursue 
in the treatment of those cases in which presumptive evidence only exists 
as to the occurrence of visceral injiuy, these dangers attending the pro- 
cedure of incision of the abdominal waU, exploration and cleansing of its 
cavity, are the only conditions that can weigh for much. They have been 
BUfficient, heretofore, to deter from its practice. The great proportion of 
recoveries, however, which have followed the free abdominal incisions, and 
the prolonged manipulations, and the often great traumatism, inflicted 
upon the abdominal riscem, in the operation of ovariotomy, as performed 
by many surgeons, has demonstrated that lens danger attends mere trau- 
matic injuries of the peritoneum than had been supposed ; the dangers of 




XXPLOBATION OF PKBTTOKEAL OAVITT. 359 

' septic infection hare also been more clearly defined by the experience of 
ovariotomiats. In view of tlie more accurate knowledge now posaessetl as 
to the management of peritoneal wounds, encouragement ifi given to a 
more ready and frequent resort to immetliate ventral incision for purpoeea 
' of exploration and cleansing in caaea where the symptome establish a 
Btrong presumption of visceral injury. The danger that by such proced- 
ure adhesions would be broken up, which if let alone would have accom- 
plished spontaneous recovery, is too infinitesimal to be permitted to have 
any weight ; while the final danger that posBilily some wound might fail to 
be detected and Bccured, as the result of which all that bad been done 
would be useless, should stimulate rather to increased thoroughness in the 
exploration than to refusal to attempt it at all In this connection the 
I following language of J. Morion Stms ' may be quoted : — 

"I have the deepest conviction that there is no more danger of a man's 
dying of a gunshot or other wound of the peritoneal cavity, proj>erly 
ti'eated, than there is of a woman's didng of an ovariotomy, properly per- 
formed. Ovarian tumors were invariably fatal, till McDowell demonstrated 
r of cure, which has now reached such jierfection that we euro 
from 90 to 97 per cent of all cases. And by the application of the same 
principles that guide ua in ovariotomy to the treatment of sliot wounds 
penetrating the abdominal cavity, there is every certainty of attaining the 
same success in these that we now boast of in ovariotomy." 

In any exploration of the peritoneal cavity, the surgeon must observe 
every precaution lest he liimsplf, in his manipulations, introduce septic 
matter. Every precaution of aaepsts should be rigidly observed in the 
persons of the surgeon and of his assistants, and in his sponges, instru- 
ments, and appliancea The external surface of the abdomen must be 
carefully cleansed and disinfected, and the subsequent dresstngs should be 
antiseptic in character. 

Abbest of luTKiiPERrroBKu. Hmmoebhaoe. — Whenever evidences of intra- 
peritoneal bicmorrbage are present, there is but one resource, the en- 
largement of the estemal wound, or the making of an inirislon through 
the abdominal wall in a more suitable situation, and the exposure and 
ligation of the bleeding vessel Aseptic silk or catgut should be used ; 
the ligature should be cut short and left in the peritoneal cavity. 

Psrencbymatous htemorrhage from the tissue of a wounded liver, 
spleen or kidney should be arrested by the actual cautery. 



360 THB TBBATMKinr OF WOUNDS. 

Suture of Vbcebm. Wodnds. — In Buturiug intraperitoneal wounds of 
the aliuieutary caual or of the urinary or gall bladders, the apposition of 
the serous surfacea adjacent to tlie woimd edgee, rather than of the wound 
edges tLemBelves, ie of the greatest importance. An eOectual method of 
accomplishing this in ordinary wounds is the method of Lembert,' Imown 
as " Lembert's suture " (Fige. 106 and 107). 




Fia, lOT.— Lembnt'iiSnCiiniu AppUM 



The suture is applied as follows : at a point about one-third of an inch 
from the edge of the wound the ]>eritoneal coat is pierced from without 
inwards (Fig. 107, a), the needle is then caused to glide between the serous 
and mucous coat for one-half the distance between the point of entrance 
and the wound-moi-gin, it is then brought out through the serous coat 
again (Fig. 107, b), carried across the wound, and entered on the other 
side (Fig. 107, cj, at a similar distance from the wound margin and the 
same manoeuvre repeated in reverse order. When the loops are tied, the 
tension causes the edges to be inverted as a natural consequence, and the 
serous surfaces are held in secure apposition. The stitches should be in- 

' Lesibett : Sur reiUnvrhapAU. JltperUwe ianaL, dep/ij/iM. paUmL, 18S7. 



I 



I 



lexbert's SUTXTRE. Sfil 

troduced quite closely together, at interrols not exceeding a, quarter of au 
inch, in order that, ehould diBt^ntion of the bowel bj gas occur before 
firm adhesion of the bowel has taken place, no gaping even then should 
be possible. The thi'eads should not be drawn so tightly as to constrii-t 
the tiBBuea, and cut them thi'ough, but simply firmly enough to keep the 
parts in apposition. The threads become imbedded in the plaatic exudate 
that forms the new boud of union, and give no further trouble. 

The choice of a material for the suture, providing it is aseptic, may be 
either silk or catgut. Surgeons differ in the preference to be given to 
these materiuls. Czerny, Billroth, Miulelung, Bauui, Bouilly, and others, 
consider silk na the best. Dittel, Schede, Julliord, Rydigier, and others 
prefer catgut.' The speedy softening of catgut has been charged with ex- 
posing wounds in which it was employed to the danger of being left with- 
out support too early, but without sufficient reason, if it has been fastened 
in the first place with care, for so rapidly does the adhesion of the serous 
aurfaces take place, that uo danger is to be feared fi-om the softening of 
the catgut The disasters which have taken place have been due either 
to lack of care in the knotting of the suture, or to sloughing of the in- 
testinal weII. Those who advocate the use of silk tind their chief reasons 
for the preference in the fact that its application is more easy, and a 
finer needle may be employed with it, points which, though apparently 
trivial, are of much practical importance. 

Ordinary round sewing needles, neither flattened nor with cutting 
edges, should be used for introducing the suture, in order that the wound 
made by the needle may be as small as possible, and free from hmmor- 
rhage. 

During the application of the suture, it would be best that, if possi- 
ble, the wounded jmrt be drawn out of the abdomen, and the wound in 
the parietes of the abdomen kept closed as much as jxMsible by the hands 
of an assistant, or lietter, by a sufficient number of temporary deep 
sutures to lessen the amount of exposure of the abdominal contents. 

Modifications of the suture of Ijembert have been proposed by Jobert, 
Emmert, Qcly, Guasenbauer, and Czemy. 

Jobert carried his needle through the mucous, as well as the serous 
ooat of the viscua, puncturing the inverted edges of the wound in their 
whole thickness (Fig. 108, A, B, C). 



'BonlUy and ABaokj' ; De ti rUeetim eireaiairt el dt la miure d» CitUettin, 

tetle CMnrgic, 1883, p. 833. 




^J 



363 THE TRKATMEITT OP TVOFIfDS. 

When an b-ritating thread must be used, and it ia wisted tbat the 
suture may cut through and ultimately fall into the lumen of the viacuB, 
this method is to be adopted, and the sutures should be drawn very 
UghUy. 

Emmert's suture was devised to overcome a presumed objectioo to the 
suture of Lembert that it did uot have sufficient hold upon the tissues, 
and that the cicatrix projected too much into the interior of the viscus. 

The method of its application is shown in Fig. 109, The threads are 
carried through the wLote thickness of the visceral wall. A series of in- 




terrupted stitches result by ^^g together the opposite threads, a, a and 
d, d. It ia mora intricate and tedious of application than the suture of 
Lembert or of Jobert, while these have been found to be sufficiently seour& 
The suture of G61y {Fig. 110) is executed with a long thread, each ex- 
tremity of which is armed with a needle. The whole thickness of the wall 
of the viscus is pierced about one-third of an inch from the wound-mar^ 
gin, at one end of the wound (Fig, 110, a) from without inward, the 
thread ia then carried kterally and parallel with the edge of the wound 
for about one-third of an inch, and then brought out again the same dis- 
tance from the wound mni-gin as before (Fig. 110. b). This procedure ifl 
repeated with the second needle on the opposite edge, at "c" and "(£;'■ 
this done, the threads are crossed over the gaping wound ; the needle 



INTESTINAL SUTCKEB. 



363 



wliich found an exit at "/i " is now introduced nt the point "U" of Ibe oi>- 
j poute aide, and rice versa with the other needle. Tbus the surgeon con- 

fiiiueB, till the entire wound is closed ty the suture. The extremities 
L Iianng been drawn tight, the knot in tied and out short The result is 
( excellent^ but the same criticism is applicable to this as to the suture of 
I Emmert. 

Czemy'a suture. If, in addition to the ordinary Lembert suture, the 
I cut edges of the peritoneal coat be first sutured together by a row of fine 
I Butures, one of which is seen already placed in Fig. 107, and then the in- 





vagination and suture of the more distant portion of the serous coat be 
done as usual, the sealing up of the wound will be doubly insured. This 
is the suture of Czemy. 

Fig. Ill gives a diagrammatic representation of a transverse section of 
ft bowel to which this suture has been applied. 

Qnasenbauer's suture is essentially the same, differing only in that 
I both the internal and external stitches are made with the same thread, the 
I in and out course which the thread is made to take, causing a figure of 8 
to be described by it, are seen in the diagram, Fig. 112. 

More simple, and more quickly and easily executed than any of the 

methods which have been described, and in all ordinary longitudinal 

wounds of the intestine or bladder, sufficiently secure and reliable, is the 

I ordinary continuous suture (Fig. 113), applied with an over and over 



364 



TllK TREATMENT OP WOUNDS. 



stitcb, care being taken to tuck in the edges so as to invert the aerouM 
edges, and bring a line of serous inembraue into appositiou as the thread 
is drawn tight. In many of the accidental wounds which may demand 




fT^ 



Via. 111.— Cienij'i Intsalnal SnloK. Fia. lH.—Oiincabngn'i InMatlnkI Solnn. 

the application of an intestinal Buture, the conditiouB may be such as to 
make the more complicated sutures difficult, if not impossible, of practice. 
In such cases the continuous suture may be used with every con^denoe of a 
good reeult. Naasbaum ' expresses a decided 
preference for the simple continuous suture, as- 
serting that it IB applicable in transverse, as well 
as in longitudinal wounds, and that, even where a 
complete solution of continuity of the intestinal 
tube exists, it answers all demands, being easily 
executed, and in its results not inferior to any of 
the other methods. 

The suturing together of the divided portions 
of an intestine, when complete division of the tube 
has occurred, requires further consiileration. If, 
in a given caee, which is the upper and which 
the lower portion of the tube cou be positively 
settled, Nuusbaum advises that the end of the 
upper tube be invaginated into that of the lower, 
whose edge is first turned in so tliat serous sur- 
face shall be apposed to serous surface, and the 
. two be secured after the method of Jobert. Fig. 
" ™ "■ 114, A, B, shows the relation of the two ends to 

each other when invaginated. The steps of the procedure ore thus 
described by Nussbaumt — First, the two divided extremities, "as" the 



,*^ 



' Ifie VerleUangea da Untffrleihta. Deultche Vlarargie, Lirf. 44, p. I£B. 



THE IKVAOINATION SUTURE. 



863 



r upper pOTiion, and " y " the lower portion, are dissected up from tlie 

niesentery ; secondly, tbe upper portion, "x," ia invaginnted by means 

of two sntures into the lower tube, " y " (see Tig. 115). The upper tube 

is supplied with sutures, affixed to opposite ddes (Fig. 115, a a), about 

two-thirds of an inch from the edge of the wound. Each extremitj of the 

Bnture is armed with a needle, each of which are then made to pierce tbe 

doubled-in lower portion, "y" (Fig. 115, b, c, and d, e, the punctures b 

I ftnd c, and d and e, being situated from one-third to one-half an inch 

I from each other). The nest step ia the tying of the sutures, b and c, 

I whereby the intestine "x" ia drawn into the lumen of the tube "y." At 




[ 



tbe points d and e, the procedure is repeated. Tlie tension should bo 
moderate, otherwise the nutrition of the surrounding tissues will be dis- 
tiu'bed, and gangrene result. The operation is completed by the inti-o- 
duction of the necessary number of sutures to keep the ends of the Iwwel 
in position and prevent extravasation. Tlie continuous, or some form of 
the interrupted suture may be used. EouiUy and Assaky (op. citat.) reject 
tbe method by iuvagination, as lonp, difficult of execution, and liable to 
be followed by symptoms of intemsl obstruction, and express their bebef 
that the suture of Lembert is sufficient in every case, provided the threads 
are sufficiently near together. From them may be quoted the following 
practical directions In perfomiinf; tbe operation : 

One or two points of suture should be first applied upon tbe lips of the 
triangular wound in the mesentery, two suffice usually to approximate these 
parts up to the concave border of the intestine. It is well to place a point 



see THE TREATMENT OP WOtOTDa. 

of suture nt the place where the mesentery ia to te attached to the intes- 
tine and to secure it to the intestinal wa!L The first point of intcatiiial 
suture, the highest, is placed quite near the new mesenteric insertion ; 
immediately oftem-ard the second thread is placed at a point diametri- 
cally opposite, that is, on the convex border of the intestine. These two 
' threads, in position and knotted, hold the intestinal ends well in the posi- 
tions which they should occupy and facilitate much the introduction of the 
other threads ; thene are successively introduced, working from the con- 
cave border to the convex. To reach the posterior surface, it is necessary 
to raise up the loop already sutured. The introduction of the posterior 




Fie. 1U.-Tb( 

series of threads is particulaily difficult near the insertion of the mesentery, 
where, indeed, special care should be exercised. Each thread should be 
tied as it is put in place. l"he number of points of suture should be eon- 
_ siderable. The threads shoidd be very near togetJjer. for points separated 
by an interval of one or two lines, where the intestine ia collapsed, would 
be found to be distant from each other a quarter of an inch and more 
when that state of tympanitis occurs, whicli always follows, though per- 
haps only temporarily, everj- intraperitoneal operalion. The neeiUe should 
not pierce the intestinal tissues more than a third of an inch away from ' 




I 



CLEANSING THE PERITONEAL CAVITT. 367 

the out morgm. Should a decided difference in the calibre of the two 
euda esist, the larger might bo retrenched by the removal ot a longitudinal 
gore from ita wiill and then the apposition and suture of the two enda be 
eSTected, or the union of the two might be sccompliahed as far as possible, 
and then the gaping portion left be secured in the eitemal wound and a 
temporary artificial anus formed. 

Pbihary CLEjiNsisa of the PERrrosE,u. Cavitv, — In all wounds attended 
with extriivasation into the peritoneal cavity ot matter, either septic or 
prone to become septic, the most thorough and scrupulous cleansing of 
tlie cavity must be practised. The external wound must be enlarged, if 
necessary, sufficiently to admit of the complete performance of this duty. 
After all hiemorrhage has been absolutely and deiinitely arrested, and 
suture of the visceral wounds has been accomplished, all foreign matter, 
blood and serum must be removed. For this purpose irrigations and 
spongings may be usecL The irrigatirg fluid should be blood-worm, and 
should be made to approximate the specific gravity of the serum of the 
blood, by the solution in it of a small quantity of common salt. The no^ 
zle of the irrigating tube should be introduced deeply into the peritoneal 
recesses both of the abdomen and of the pelvis. While the irrigation is 
being practised, the position of the patient can be changed so as to facil- 
itate the free escape of the irrigating duid. Sponging should be done by 
soft and pure sponges, secured to a aponge-holder or grasped in a forceps, 
by which they are carried down to the farthest recesses of the peritoneum. 
No loose sponge should be thrust into the abdominal cavity, ou account of 
the danger of its being overlaid by the intestinal foldn and left in the 
cavity. The aponging should be continued until the peritoneum is clean 
and dry. In the absence of the desired purified sponges, sponging roust 
not be dispensed with, removal of intra- peritoneal efiusions must in all 
cases be made as perfectly as possible, with the best means at the com- 
mand of the surgeon. 

Drajnaoe. — The conditions which the peritoneal cavity presents are 
Buch as to alter the relations of artificial drtunage In the cose of wounds 
within it. As has been pointed out by Mr. Lister," the large size of the 
cavity prevents the occurrence of tension within it, though copious secre- 
tion may take place. The absorptive powers of the seroua lining suffice, 
in many cases, to rapidly remove effljsiona, and thus to prevent their 
accumulation and putrefaction. The natural great vital resisting power 

' TmuacUoufl latenuLtioaal MedioiLl Cougieu, 1881, voL il., p. 370. 



808 THK TREATMENT OP WOUNDS 

of the peritoneum enables it to control and overcome septic inflnencesto 
a certain degree. On the other hand, special disadvantages attend the 
use of artidcial drains in wounds of the abdominal cavity. They hsfe 
been tummarixeil by Knowsley Thornton * as follows : 

L Dangers of admitting infective material through the tube. 

2. Danger from the removal of serum and blood from the peritonenm 
in an exhausted patient Aseptic peritoneal contents are reabsorbed and 
feed the patient 

9L The tube oauaes a weak spot in the ventnl wall for sobsequaii 
heinia. 

4. Tlie slow beaHng of the tube-opening prolongs copva lo se cno e , and 
expooe* the patieni to the additi€«&al risks of an open wtNmd. 

The pvactksJ coDdisiioii may be acc^epled that when tbosoagii ptimary 
neaescir of the caviir has been doiwu the wwnzid may be dosed wifli 
every cxpc««a2k>£ of f:;n2re frNiiooi fnwsi wpbc izilMkm. The 
of Spenrcr Weu^ * ». thttX is h» oa»w of sKkcLxnal smvubl anee lie 
u(?pccd a&&Kf<ir pr«ca;:^730cts. cdiher iainhWftwwml ftBda» 3o 
or. if iher ^ i^t >!;> 3»x raa^ft ^ bnt an^ aSKv^M widms din^ mmj 
harsL, Tht rue ji3.^coiMt Vy K«tife^* sa v-smw cf c«KirG^*iicy. ia %» ■■» ft 



-^^HL wiH see z<!C 3ifti aHe» wvil ^«::taiu^ftc .^isttrnmc " r^h; x^^wsnrvBKi 

mhtiSL aisy le iis7iȣ 3i nantam ' I ?<tc :atf iintm^g<tiun : jjLHUiA 
ahrtnrnmal ^vaiL Ir 3» a awL ^csmw ,pia» Wl«ft. iicii^^ 

L &fti jtjw ± :» -rrmc m "ioi r«scQEmt. ia\i a t >^ -ssaiBiui^r ' Jfuswia . I dnft ik 

,ip % jtdit nt : WBT :t T»aa i 9M^ «xI ^«ip 3J*c a to ^ ^ 

ttiikk iiiT iiiMiiiiii '■ DtmK "iast ^wtf ^ju -Sfeiv *%Hsc ssriLn ti^ a 

jUiC % 'imp •wRapt la. *3» nHMnac ir "sto* itik^ i ? 

,|K,TXt£fc r flBHmnfc -aaaHr. -miim ^our jt »•• J^^itt^. ^^ ^^ I 






I 



WOUNDS OF THE PELVIS. 369 

iglit and morning. I formorly kept the drainage-tube in six days or a 
, till the serum got quite sweet and pure ; but now I take it out gen- 
illy within forty-eight hours. If the amount cornea down to a drachm 
or two, I don't mind taking the tube out, and that without any kind of 
precantions, After all, though, you must be governed by the quantity 
that comes." 

>, The application of the fruits of the experience of ovaidotomy wounds 
|h> the treatment of accidental penetrating wounds of the abdomen is di- 
Wct and immediate. Whenever from the nature of the wound, or the cir- 
cumstances attending it, all fiuiils likely to become septic are not removed 
in the primary cleansing of the peritoneal cavity, their subsequent escape 
by drainage must be provided for. The drainage-tube may be inserted 
either through the original aiicidental wound, or through one mado by the 
surgeon, as the conditions of the special caee may dictate. 

pEBrrosiTis AND SEPTicEMtA, — The so-called traumatic peritonitis is in 
all cases & septic uiflammation, and kills quickly by the rapid absorption 
of the abundant septic products— ptouiiiinea — -which are drunk uji quickly 
by the serous membrane aa they are generated in the copious inflamma- 
tOTj secretions. Tlie one imperative thing to be accomphshed by way of 
treatment is to secure the immediate removal of the poisonous exudations. 
This may require a reopening of the abdomen, repetition of the imgations, 
and more effective provisions for drainage. The presence of diffuse peri- 
tonitis is not a counter-indication to such opening and cleansing, but, on 
tlie other hand, is a condition that directly calls tor it 

WOUNDS OF THE PELVIS. 

The wounds of the pelvis of which special mention must be made are 

of the bladder, and those involving the rectum and anus. 
Wounds of the Bladdeb. — The wounds of this organ may be caused 
internal rupture without estemal wound ; may be eomphcated by ex- 
wound ; may be iutlictetl by the surgeon. Special indications to be 
fulfilled in their treatment centre about the preveuUon and treatment of 
the disturbances caused by the extravasation of the contents of the organ. 
They are: (1) To remove, as soon as possible, extravasated urine. {2) To 
prevent further escape of urine into surrounding connective-tissue or peri- 
toneal sac. (3.) To meet such symptoms of shock, peritoneal inflamma- 
tion or urinary infiltration as may appear. The coui'se to be pursued in 



■Zi 



370 THE TREATMENT OF WODNDS. 

meeting the two first indications will vary according as tlie wound is extra- 
OT intra-peritoneaL 

In extra-peritoneal wounda, the remoTal of extravafiated urine requires 
free aud deep incisions into the infiltrated tissues. 

In intra-peritoneal wounds, the conditions are identical with those al- 
ready diBCuaaed in connection with wounds of the hollow viscera of the 
abdomen, and the same method of procedure must be adopted, free exter- 
nal int-iaion of the abdominal wall, suture of the rent in the ^^scus, and most 
careful cleansing of the peritoneal cavity of all extravaaated matters. The 
well-known case reix»rt«d by Walter,' of Pittsburg, illustrates the value of 
laparotomy and cleansing of the peritoneal sac, although it is not beyond 
oriticisra, since the suture of the vesical wound was neglected, happily, 
however, without evil result in this instance, owing to the location of the 
wouud iu fbe fundus, and the continuous use of the catheter. In this 
case a man 22 years of age, had received a blow on the hypogastric l-e- 
gjon and immediately felt a sharp pain with an urgent desire to urinate, 
which he could not accomplisL After some hours, the belly began to 
swell, the pulse became small and frequent, and the respiration rapid. A 
catheter brought away a minute quantity of bloody urine. Ten hours 
after the injury, no urine passing by the catheter, the aMomen waa 
opened in the linea alba by an incision beginning one inch below the um- 
bilicus aud terminating one inch above the puhes, to the extent of six 
inches. The intestines were found inflated, their peritoneal coat, as well 
.as that lining the interior of the abdominal walls, already showing evident 
marks of congestion. A soft sponge was then cautiously introduced into the 
abdomen, with which the extravasated fluid, amounting to nearly a pint^ 
consisling of urine and blood, was carefully removed from the pelvis, and 
between the convolutions of the Ijowels. A rent was found at tJie fundus 
of the bladder, two inches in extent. The cjivity of the abdomen being 
cleansed of the noxious agent, the wound of the bladder was left to itself 
BB no urine was seen to escape from it The abdominal wound was closed 
by strong Carlsbad needles, secured by silver wire (only skin and fascia 
being stitched, while the peritoneiun waa left untouched) ; a flannel band- 
age encircled the wliole abdomen. The patient awakening from the anaes- 
thetic sleep, felt relieved of pain and the desire to urinate, so distressing 
before the operation ; vomiting did not retura ; opium in one-grtun doses 
was orderf>d; abstinence of drink and perfect quietude of body, with 



WOUHDS OF THli BLADDEi;. 



71 



retention of the catliGt£r, were Btrictly insisted upon. He soon begun to 
doze, had a comfortable niglit, was free from pain the nest momiug, com- 
plaining only of soreness in the abdomen without tympanites, sickness or 
calls to urinate ; thirst leas urgent. The treatment being vigorously con- 
tinued, for drinks, iced barley-water, wat«r only in very small quantities 
with pieces of ice, being allowed. No unpleasant symptom followed ; urice 
in small quantities, but free of the admixture of blood passing by the 
catheter. On the third day the intervals between the doses of opium were 
lengthened to two hours; on the fifth, to three, and thus gradually de- 
creased, AS all signs of inflammation had passed. At the end of a week 
the abdominal wound appeared to be closed by tirat intention ; the stitches, 
however, were not removed till a week later. The gum-elaetic catheter 
was replaced by a new one everj- two days, and was not withdrawn for two 
weeks after the iiijuiy had been received, and then only for a short time. 
At the expii-ation of two weebt, with the absence of all pain and tender- 
neae, opium was omitted. The intestines were reUeved by warm water in- 
jections on the tenth day, when mild nourishment was ordered. Between 
the second and third week, the catheter was permanently withdiawn and 
introduced only every four hours for tlie evacuation of urine. After the 
third week, the patient left his becL The recovery was permanent, so that 
he returned to his work, feeling no embarrasament in the urinary funo- 

In two other recorded instances,' abdominal incision has been done for 
the removal of urine extravnsated into the peritoneal cavity. In both these 
cases, however, tlie operation was delayed much longer than in the case of 
Walter, until dangei-oua symptoms were well developed. Willett operated 
thirty hours, and Heatli forty-two and a half hours after the injury. In 
both cases suture was attempted, but, as the result proved, was done im- 
perfectly. In the case of "WiUett, the patient having died twenty-three 
hours after the operation, the autopsy showed " the opening in the bladder 
everywhere well closed except between the two posterior stitches where 
tliere was an orifice through which water injected per urethram. escaped 
very freely." Heath's patient Uved more than four days. A continuous 
cot^t suture had been employed. Autopsy showed that it bad given way 

' A. Willett : Abdominal Section in a Cose of Ruptured DUidder. St. Banbolo- 
men'B Hospital Ilepoita, ISTtl. xii.. pp, 309-333. U. Heatb : On Iba Dia^osis and 
Treatmeat of Rnptore of (he Bladder Medtao-CbuuTgUul Traasactioiia, ItJTD, Ixii , 
P.-83S. 



373 



THE TREATMENT OF WOUNDS. 



lit its lower end, and permitted the wound in the bladder to gape tlirougli- 
out the lower third of its extent 

The advantttgea ofifered by lapurotomj in cases of wouuds of the intra- 
peritoneal portion of the bladder ai* thus enumerated by Vincent : ' 
* ■ With laparotomy a complete examination of the wounded region ciai be 
niaile, and the existence, the locjition, the extent, and the conformation of 
tlio solution of continuity experieueed by the urinary reservoir deter- 
mined ; the existence and nature of complications can be seen, if a vesical 
arteiy is wounded, or any of the vuaoular truiJta of the region have been 
torn, they can be ligated ; if intestinal loops have been perforated, they 
can be sutured, with or without enterectomy ; if the rectum has been per- 
foi-ated — a frequent event— the breach which is found can be sutured ; if 
n splinter, from a fracture of one ot the pelvic Ijonea, projects against the 
bladder and is tearing it, it can be extirpated, resect«d, or reduced, as the 
case may be ; if a foreign body has remained in the peritoneal cavity, it 
can be taken away ; if the wounding agent has lodged in the walls of the 
bladder, or has fallen into its interior, or has become fixed in the walla o( 
the pelvis, it may be extracted at once, which will prevent those fistula^ 
tliose suppurations, those Uthic concretions which, when they do not in- 
duce death, necessitate later, sometimes after many years of suffering, re- 
course to the knife, the hthotrite, or the hthotome. With laparotomy the 
urine can be completely removed, together with the effused blood, all the 
liquids and dots which may be found in the peritoneal cavity, everything 
which has been soiled by the urine can be tlisinfected ; in a word, a com- 
plete antiseptic toilet of the peritoneum con be made ; with laparotomy, 
finally, the source of luinary extravasation can be absolutely suppressed 
by careful suture of the bladder ; a catheter retained in the bladder cns- 
not replace the suture, this is evident." 

As a final estimate of the necessity and vaJne of lajmrotomy when ex- 
travasation of the urine into the peritoneal cavity has taken place, the fol- 
lowing is the conclusion of Stein :' 

" Both clinical and experimental experience teach that the danger to 
hfe is not in the laparotomy, but in the presence witliin the peritoneal 
cavity of a decomposable and septic fluid, and. when this is removed 

I.L.p. 



' Plaia penilranU* trUrapfrilontaiti <fo la POiit. StPU» d» Chirurgie, 



- A Slnd; of Bnptnn of the Bladder, eto. Annola of Anatomy vaA SDigecj-, 188S, 




SUTURE OF THE BLADDER. 373 

ahortlv after such extravasation has occiuTeii, laparotomy may be practised 
with almoat a certainty of success. The ilispositioii of the hladder-woimd 
1 is so great that it may be regarded as certain if the edges of the 
aame are accurately brought together, while the danger to lite from 

[ wounding of the peritoneum is In iteelt very slight" 

When on intraperitoneal wound of the bladder has been suffered, the 

I more speedily the removal of the intraperitoneal extravasations by lap.v 
rotomy, and the closure of the wound by suture, is eSected, the gi-oater 

1 win be the probabihties of a successful issue. Though it should have 
been delayed until severe inflammatory and septic conditions havo already 
developed, the incision of the abdominal wall, the removal of effusinns 
already present, free irrigations and adequate drainage, may still affoi'd a 

I. posaibtlity of recovery from what would otherwise pursue an inevitably 

' &tal course. 

Suture nf the. Blad/ler. — The unfortunate result of the attempts at 
suture in the cases of "Willett and of Heath may serve t^ enforce the neces- 
sity of caution and thorouglmesa in applying the sutxu'e to a bladdcr- 

I wound. Vincent (op, citat,) urges the adoption of the method of a double 

' row of sutures, one at the edges of the wound, hut excluding the mucous 
coat, and another row which pierces the serous coat a little distance from 
the edges of the wound, by which a more extensive turning in and appo- 
sition of the serous membrane is accomplished. This is the method 
already described on a previous page (i363) as Czerny'a modification of 
Lembert's suture, which see. 

The double row of sutures closely set should be employed, but the 
iggeation of Nuasbaum, in connection with intestinal wounds, to apply 

1 the suture as a continuous suture hi each i-ow, should be followeil, on ac- 
count of the greater certainty, eoae, and speed with which it can be applied 
to a deep-seated part like the bladder. Aseptic silk should be used for 
the hgature material 

The number of cases has already become considerable in which suture 
of the bladder has been done, with recovery, in cases of wounds of the 
Ijladder inflicted by surgeons during the removal of pelvic and abdominal 
neoplasms. 

CiTHETBEizATiON.^Free and uninterrupted drainage of the bladder by 
continuous retention of a catheter in the bladder through the urothr.i 
should be maintained for a week or t*n days aft«r the iiijury. TiiO 
catheter should be soft and flexible, open at the end, and its end should 



374 



THE TBEATMENT OF WOUITOS. 



reach just within the vesical orifice. It should be removed, waahed, and 
returned once dtuly during the period of retention. For some time, a 
week or more, after its continuous residence in the bladder is dispensed 
with, it should yet be iised several times daily to remove the urine, 
durisf^ which time no efibrt to urinate should be made by the unaided 
coutmction of the bladder. 

WorsDS OF AxiTs and Rectum. — Wounds involving the lovrer end of tho 
alimentarr canal must be treated as open wounds. In order to preserve 
them from sepsis it Is necessary that the wound cavity be kept packed with 
onergeticaHy antiseptic absorbent material and that the function of defsc«- 
tion be kept in abeyance. The lower bowel should be thoroughly washed 
out with a carboho or corrosive sublimate solution, and tho movements ot 
the bowels checked by opium. The woiuid itself should be freely irri- 
gated with an eight per cent solution of chloride of zinc, after which the 
antiseptic absorbent selected shouUl be lightly packed into the wound so 
as to reach every recess. Iodoform gauze, b^s of aluminated charcoal or 
sublimated coal ashes, may be selected according to the convenience of 
the aiu-geon. These should be covered in by a plentiful layer of purified 
cotton wool, o^-er which a layer of impermeable tissue should be placed, 
the whole kept in position by a "^-bandage. Whenever a movement of 
the bowels becomes necessary, sufficient of the dressings must be removed 
to permit the issue of the fiecol matter, after which the bowel should be 
cleansed and the wound redressed as at iirst, Wieu the wound has 
become a superficial granulating surface, the rigid antiseptic efforts may 
be relaxed and the sore be kept smeared simply with boracic ointment. 




i 



WOUNDS OF THE EXTRESnTIES— AMPUTATION. 



LimiUitioM of ConiemUiim — OlasHificatiou q( Wounda poBiibly demaiKliug Amputa- 
tion — Duty in Doubtful Cases — Prriod for Ampula[ion~-'pT\mary, In tecraeil iaty, 
wid Secondary Periods defiued—EffecC ot Autiaeptio^ to pioiong Primary Period 
— Shook B Coutra-indicBtion— Ampnttttion to be done daring Primary Period — 
Paint of Amputation — Treatment oftha Amputation Wuund. 

X^RE remain tor presentation Home coueiderations as to the management 
of lacen*ted, contused, or gunshot wounda of the estremities in which the 
damage is so extensive as to compromise the ritality of tlie parts bej-ond 
the wound and to cause tlie question of amputation to be entertained. 
Intereet centres about three poiuts, viz. : — To what extent should attempts 
at coBservation be pushed, and, if amputation is imperative, when and at 
what point should it be done ? 

LiMiTATiciNa OF CoNBEBVATiuN. — In deciding to what extent attempts at 
conservation should be pushed, two considerations must influence the 
Burgeon. These are : 1. Can the vitality of the distal portions of the 
limb be preserved ? and, 2. If preserved, will the hmb be a useful member 
or a useless incumbrance ? 

For purposes of sj-stematic consideration the wounds in question may 
be divided into five general classes, as follows : — 

L Injuries in which the whole moss of the limb, to a variable distanoe 
from its end, is mangled and pulpified, or torn nearly away. 

2. Injuries in which, at a limited part of the continuity of a limb, all 
the tissues in it« whole tliickness have been crushed. 

3. Injuries of less extent but in which the great vesaels of an extremity 
have been lacerated. 

4. Injuries characterized by open wounda communicating with exten- 
sively comminuted bones or with large joint cavities. 

Injuries characterized by extensive stripping away of soft parts, ab 
integument and muscles. 



3i6 THE TEEATMENT OF WOUNDS. 

In the two first of these cJaasea the duly of the BUrgeon is plain ; prim- 
lay amputation must be performed ; but omputatiuu in tlieae cusea is to be 
regarded less as a loiinal operation than as a pai't of the general proced- 
xa-e of the i)riniBty cleansing of the wound which reijuirea that devitalized 
tdsBiiea shall be removed aa perfectly and speedily as possible from every 
wound. 

In the remaining three groups, the propriety o( attempts at conseiTa- 
tion must depend on the facihties at the comniand of the surgeon for pre- 
serving the wound from septic infection aud secuiing to it perfect rest 
during repoii', and upon the probable future usefulness of the part, if am- 
putatiun ij iivoiiled. The mere wound of the great vessels, unless it be 
attended with sucli extensive laceration of the adjacent soft parts as to 
render tha nutrition of the distal portion of the limb by the collateral cir- 
culation obvioimly improbable, does not call for immediate amputation. 
Wountls of the joint cavities and compound comminuted fi'a*;txires, in tlifl 
great majority of coses, can be conducted to recovery by adequate meosuiee 
of disinfection, drainage, and immobflizatiou. The extensive stripping 
away of soft parts, although ultimate cicatiization of the wound may lie 
possible, may nevertheless be a suificient cause in some cases, for primaiy 
amputation, on account of the deformity or uselesaness of the part which 
wouhl be left. 

Cases will present themselves in which the question, whether the vital- 
ity of the distal jwrtions of the limb can be preserved or not, must be a 
doubtful one, and will depend on the prevention of inflammatorj' disturb- 
ances in the wound, and in placing the endangered portion of the limb in 
conditions that ahall favor its nutrition as perfectly as poBsible, It would 
be incumbent on the surgeon, in such a case, to make the effort at ooa- 
servation, and to resort to amputation only when it had become plain that 
the efforts at protection were unsuccessfid, or that the ritaUty of the taar 
dangered tissues was hopelessly destroyed, 

Peuiod run Amputation. — Wounds in which (he accession of septic con- 
ditions is not prevented, have tlieii' history divided into three period^ 
primary, inlcrmcdianj, and secondary, the primary being that short period 
which intervenes between the reception of the wound and the appoanince 
of the secondary traumatic fever caused by the development of septic in- 
flammation in the wound, a period generally of from thirty-sis to fortj- 
eigbt hours ; the intermediary period being the period during which pro- 
gressive local inflammatory infiltration and general fever prevail, a period 



THE QUESTION OF AMPUTATION". 



377 



extending over a variable time ; the secondary beginning with the subsi- 
dence of ike intermediary stage, as marked by limitation and diminution 
of the infiltration and fi-ee suppuration fi'om the wound surfaces. 

When adequate antiseptic measures are employetl, the primary stage is 
indefinitely prolonged, infinmmatoiy infiltration and secondary ti-aumatic 
fever are prevented, and an opportunity afforded for the full display of the 
reparative resources of the injured part. 

When the necessity ot amputation is lui questionable, it should, if possi- 
ble, be done before the mipervention of the intermediary stage. If this baa 
been impracticable, it should be deferred to the secondary i>eriod, unless 
progressive gangrene of the wound develop, when amputation, through 
tissues yet sound, should be done as quickly as possible. Amputation 
should never be done, in any case, until full reaction from tJie shock of the 
original injury has been secured, and, if such reaction ia delayed until the 
primary stage has passed, the operation must be deferred yet longer, until 
the secondary stage has been reached. 

The prolongation of the piimary stage by antiseptic treatment — -con- 
tinuous antiseptic irrigation being the method which, in general, is best 
adapted to tiie treatment of these cases— makes it possible for the surgeon 
to delay amputation until such time as, in his judgment, the patient will 
be in the best con<lition to bear the operation. In some caaes it will hap- 
pily have served to demonstrate the possibility of recovery without ampu- 
totion. In cases, Uie possibility of saving which manifestly depends 
entirely upon tie success of tlie effoiHa to prevent their being invaded by 
septic infection, as soon as it ia evident tliat these efforts have not been 
successful, amputation should be proceeded with before the full local and 
constitutional symptoms of the sepsis have developed. 

Point of AiirDTATins. — The choice of the point at which the amputation 
shall be ma<le may be greatly influenced by the facihties at the command 
of the siu-geon for keeping the wound aseptic. If these be adequate for 
the purpose, the section may be made at whatever point may be desirable 
to give the patient the most useful stump, even though bruised and lacer- 
ated parts be included in the flaps. These are preserved from inflammatoi-y 
disturbance, their full vitaUty is regained, and they participate in the for- 
mation of tlie stump without disaster from sloughing. Wheu, for any rea- 
son, the wound cannot receive adequate antiseptic treatment, amputation 
will, if possible, bo mode at a point sufficiently far above the injury to ex- 
clude all bruised and lacerated tissue from the flaps. 



878 THE TREATMENT OF WOUNDS. 

Treatment of the Amputation- Woumd. — ^In the treatment of the 'wounds 
made by amputation, scrupulous attention should be paid to all the details 
of treatment which have been dwelt upon in the chapters on the *' Practice 
of Wound-Treatment " in the first part of this work. Absolute aseptic 
cleanliness of everything — ^hands» instruments, dressings, — ^that is brought 
in contact -with the wound ; perfect arrest of hsemorrhage by catgut^ cut 
short after being securely knotted ; ample provision for drainage from the 
deepest recesses of the wound ; thorough dismfection of the wound sur- 
faces ; careful apposition of the flaps by both deep and superficial sutures ; 
protection, support, and compression by external antiseptic dressings ; an 
elevated and comfortable position for the stump and protection of the limb 
from motion or external traiunatism of any kind, these constitute the in- 
dications to be observed. The various means by which they may be met 
have been suf&ciently pointed out The adaptation of the particular 
agents to each special case must be left to the judgment of the surgeon. 



^^^^B ^H 


ABKRKBTBr, on ligatnrea, 106 


Alms, 0. H., on lateral ligation ot intet- 




ual jugular vein, 340 


Abdomiual viacara, protrusion ot, 353 


Alum, as an haiiuostutic. IIU 


AbaoesKH. metastatic, 40 


Alumina. aceUte and aceto-tartrata, as 






Absorbent cotton, 184 


Alumiuated cbnrcoflJ, in3 


gume, 188 






AutlsSAT, on torsion, 115 


AohiUes-UiQrion. Eutune. 273 


AmpatatioQ. 375 


Aoapressute, 99 


Amputations, corapamtivB table of septic 




and aseptic cases, 55 


to oorapre'B TesseU in theuc 
eoatinoity. 125 
Adfaesioii, union by primarj. 37 


Ansmia from bmmorrhiige. 129 


Anajsthetics, pamllel between, and anti- 


union bj Becondaty, 30 


septics. OS 


Adhesive gnuze, ISO 


Anal region, micro- orgnniams infesting, 81 


plaster. 1G3 


wounds ot, use of alaminated 


Affluic. physiolDKy of. 24 


charcoal in, 84 


Age, uiodifjing the effeots of wounds. 13 


Aneurism. diEFuao (raumatio. 388 


AONUW. D. H., on modiato ligation at an 


Animal ligatures, 108 


intercostal artery, 344 


Anodynes, 218 


Air, both an antiseptic and a carrier of 


after htBrnorrhage, 1S6 


contagion, 18 


Anthrax infection from catgat, 78 


exposure to, as an hinmoi-tatic. 0.1 


Antisepsis, Gl 


impure, efFect of, on wounds, 18 




of Parie, germs in, 3U 


ances, IS.T 


purifluation, 66, 68, loO 


dreasioga. 184 


Tatying decrees of purity of, ill differ- 


sprays, (57 1 


ent lociliUes. (JO 


tampons. 348 ] 




treatment, teanlts of, 54, C7 






of Ihe chest. 345 


deSnition of, 80 


on treatment of incised vroandi, 




341 


Anna, wounds of, 374 


Albuminate", lino and phenol, 81 








Btreo^th required to rwtiain 


in wounds of abdominal pari- 




. etea,3S2 



380 



INDEX. 



Apposition, in wounds of blood-ve88el8,282 

peritoneum, 353 
of contused and lacerated 
wounds, 244 
divided nerves, 273 
divided tendons, 271 
incised wounds, 241 
wound-surfaces, 160 
Appi^oximation stitches, IGo 
Arrest of hssmorrhage, 93 
Arsenic, power as a germicide, 73 
Arsenite of potossa, power as a germicide, 

71 
Arteries, effects of torsion on, IIG 
wounds of, 280 

carotid, 315, 337 
intercostal, 344 
internal mammary, 

342 
middle meningeal, 

314 
vertebral, 338 
Artery forceps, 112 
Asepsis, 60 

how obtained, 61 
Aseptic ligatures, 112 

in vein-wOwinds, 293 
spoDgea, 139 
wouuds defined, 11 
Atmospheric organisms, causes of decom- 
position, 38 
Auto-transfusion of blood, 121) 
AvELiNG, apparatus for direct transfusion 

of blood, 136 
Axilla, micro-organisms infesting, 64 
^xillary vein, lateral suture of, 298 



Bacilli, 41 

Bacteria, 41 

Bandage, elastic, tourniquet, 124 

Bandages, 197 

adhesive, application of, 163 

adhesive, objections to, 164 

for the head, 318 

in the treatment of inflamma- 
tion, 220 

plast r-of Paris, 211 
Bandaging, as a means of apposition, 161 
Base of the skull, fractures of, 311 
Bath, antiseptic, for instruments and ap- 
pliances, 155 



Bavarian splint, 206 
Bead suture, 179, 182 
Bklfikld, on effects of mioro-orgaxusmaiy 
45 
on the causes of septicssmia, 49 
Bell, C, illustrations of trephining, 326, 

328 
Bell, John, discourses on wounds, 4 
Beromann, on the causes of septicaemia, 49 
BiLLBOTH, method of dressing wounds, 200 
on causes of septicaemia, 49 
on suture thread!*, 167 
on turpentine as an haomoBtaUc, 
97 
Birth, wounds during, 818 
Bismuth cotton, 186 

intoxication, 89 

subnitrate of, as an antiseptic, 88 
Bladder, protrusion of, 356 
suture of, 373 
wounds of, 369 
Bleeding in head-injuries, 312 
Block, on resection of the lungs, 347 

on surgical interference with the 
heart, 346 
Blood, abstraction of, in inflammation, 225 
Blood-dots, how disposed of, 31 

when to be left undisturbed, 
62 
Blood-poisoning, 49 

Blood-supply of inflamed parts, how in- 
terrupted, 225 
Blood-vessels, wounds of, 280 
BcECKBL, E., on hypodermics of carbolic 

acid in erysipelas, 230 
BoiLLAT, experiments with zinc, and 

phenol albuminates, 81 
Bone drainage-tubes, decalcified, 146 
Boracic acid, as an antiseptic, 83 

power as a germicide, 71 
power in restraining germ- 
development, 72, 73 
Berated cotton, 185 

Borax (biborate of sodium), strength re- 
quired to restrain germ-developmeut, 
72,73 
Bowels, micro-organisms infesting, 64 
Brain, compression of, 312 

wounds of, 315 
Braun, on lateral ligation of veins, 296 
BiiiOGS, W. T., on trephining, 321 
Bromine, power as a germicide, 78 



INDEX. 381 1 


Bruhs. p., on ttoetftte of olninina (or 


CnAFi.iAC, GcT DE, On draioflgo, 144 


contlnaoaa irrigntiuQ, 338 


CttEYNB, descripcion ot Lister's method 


on treatmeiit of compound 


of wound -drenaing. 108 


frmitares. 257 


on oorbolated gauze, 187 


Bbukb, ton, on oarbolated ganze, 180 


OB different spacien of micro- 


i-poon ooTetteii. 168 




on wood-wool, 104 


on " Che protective," lOO 


Bhyant, T., on iodine, 84 


results of antiseptic treatment. 


ont.r>don, 115 


57 


on treatmeiit of ponctnred 




woan(j«, ma 


CitlENE, on catgnt drains, 148 


BaSolo-tendoLi lignturea. 100 


Chloral hydrate, power as a germicide. 


BullBtB. removal of, 240. 252, 253 


71 


Bnttoa suture, 160 






Chlorine, power na a genuioide, 73 


Campbkll, K p., on ligation of artery of 


Cliromiciied catjtut ligatures. 110 


supply in treating inflummaLion, 220 


OieaUiiatioo, physiology of, 20 


Canola. tracheal, 335 


Citric acid, power aa a germicide, 71 


Capeliine bnndige, 310 






of gunshot wo QDds, 260 


Carbolated cutton, 160 


of wounds, 8 


gttuio. 187 




^^ CarboUo acid, aa mi ontiBeptio, 7(i 


scope of the tenn, 03 


^L hypodermii;B of, in eryaip- 


Cleansing compiund fractures, 857, SS8 


^M elas.230 




^H intoxication, 80 


243 


^H local irritation caused by, 70 


gnnsliot wounds. 247 


^H lotions, 77 


peritoneal cairity, 367 


^^M i<ow«r na a germicide, 71 


primary, of wounds, 03 


^^M stren^^th reiiiired to restmin 


wounds, 138 


m Ber,n.development,73 


Cloth for plaster-of-Parls splints, SU 


H rolBtility of, 70 


Clothing of snrgeon, to be purified, 16S 


^1 Caibollo gaTtte. rapid deterioration of, 70 


Coagulant-, 118 


■ 


Conl-ashes, 1S3 


^M Bprays, 67 




H CardUc tedatiTea, ISO 


Coils, water, in in flam ma lion, 323 


^f -Caribou-teodon ligaturea. 109 


Cold, application of, in the treatment of 


Carotid nrteriea. woumlB ot, 337 


inHammation, 22Q 


Corotid artery, internal, wounds of, 315 


as an baimostatio, 00 


Catgnt, anthrax infection from, 78 


COLLIH, instrument for tranafuaiug blood, J 


drains, U8 


133 


M ligatures, 100 


Collodion, 163 


■ snt,.reB, 108 


iodoform, 201 


^P Catheteiiiation in wounds ol the bladder. 


Compound tructnrei, 2.15 


■^ !173 




Couteiy. 118 




Cell germiaation, physiology of, 25 


materials for. 103 


Cerebri, hernia, 317 


worm and moist. In inflam- 




mation, 225 


H Charcoal, 193 


Compression, as an bremcwtatio, 07 


^1 CnASSAiartAO, on di-sinnge, 145 


in the ireatment of Inflam- 


L ""'""" 


mation, 219 







382 INDEX. 1 


Compression, in tbe treatnieiit of wounda, 




acMi 




in wounds of blood- venB^ls, 


Disease, pre-existing, us modifying tlie ef- 


282 


fects of wounds, 15 


oltha brain. 313 


DtsinfecUon of skiD, neceoHity for, 65 


of paieaC tmalc to arrest 


DisturbanofiB of healing, relief of. 218 


luBraurrhnge, llfl 


of re[>aii, deEtmctive, 33 






the efTects of wonnila, 14 


230 


CoiurtitutioDal effBoto of wounda, 31 


Drwnage, 143 




artificial. IW, IBI 


Contused pnoDturcd wounds. 215 


EipiUarj. 148 


Contused wounds, 242 




Conluaions, 33 


in compound fractures, SS9 


of the Bcalp, £03 


natanil, 14.1 


of the skull, 808 




Co<,linB coils, 324 


wounds, 344 


CooPBH, Ahti,kt, od lifatnres, 106, 108 


of inoised wotutds. 241 






of, 74 


of piBoral cavity, »49 


powBc OH a germi- 


primary .103 


eido. Tl. 73 


secondary, 103 


httengih required to 


tubulnr. 143 


leotnuo g«rm-de- 


when unnecessary, 88 






Cotton wool, 184 


for empyema. 849 


Court plaHter, IfiS 


Dr«!<aing8, antiseptio, 184 


Cranial nerves, injurie* to, 315 


eztema). to b« puriGed, ISO 


Ctjminm, injur.es to, 307 


iodoform, of BUlcotli, 200 


CieosDDe, power bh a germicide, 71 


Lister's method, 108 




of wonnd, defined. Oil 


in subcutaneous mjuTies, 239 




CsKRNY. c.tM of lateral Hutuie of Intenftl 


turf- mould of Esmaiob, 203 


jagular vein, 208 


DcNCAN. John, observations of impuritiea 


OMmy's satDrs, 3G3 


in the ail, 07 




DupuvTREK, on ligation of veins, 290 




DrROY. on iodine, 84 


Davy's lrver for completing ilioo artery 


Dnst,38 


tbroDgh the rectum, 122 




Dead tissue, how dis|>oned of, 31 


Ear, wonuds of. 380 




Ean, mIcTo-orgwiiara< infesting, 61 


cansea o(, 38 




Deer-sinew ligatures, UiO 


Embryonic revrrsion of tissue, « 


Defects i.t upiTO-ition analyied. 87 


Emmert's s<iture. 3U2 


ofuntrition muilyiecl, 2S 


Emphysema. 348 


of protection analyied, 28 




Defibrination of blood. i:M 


Ebiciiben, on the effenta of diet on th« 


Dedumon of wounds, 7 


repair of woaada, IS 


Dbbaitlt, on lipitures. lOfl 




torn poll of, 34il 


on ligation of reins. 200 


Diastasis of cranini untnrHH. 311 


Erysipelas of the scalp. SM 


JtamvoACB, needlB-hoIder of. IM 


treatment of, 228 


^V — ■ 



INDEX. 383 1 


tewABCH, BppBrntaa for trnnrfuain^ by 


Fractures, nf Ihe Bkull, 3O0 1 




FuncHon, impairment of, 23 1 


on antiseptic uxe of comialTe 




sublimate, 75 






■ Gajke. a. »., Neodle-holdor of, 167 1 


Tarla, 325 


GAFf KV, on the relnlion of micro-organ- 1 




1 isms to septioaimia, 61) 1 


veBBPlH, 2H 


Qangrene, Bpreadiog, canse of, 40 J 


211 


treatment of, 227 
Gapiog, 23 


the turf moBld draaHiog, 20:t 


Game, 180 


use of ela-itio bnndage to com- 




pnaa blood-ve«eU, 135 


Gely, the auture of, 863 


Eraporating [otions, 231 


GnKZMEn, on entrance of air into intra- 




craniai ainua, 313 




Gorma, 38 


pair of vein-woirnds, 2«a 






re agentH required lo realraia, 73 


of gunshot woandB, 2^0, 233 




Extremities, woaodi of, 875 


71 




GeksteR, a. Q., on lateral I igatiotj of ia- 


Eje. wound- of, 330 


temal jugnlar vein, 340 


Ejellda, woimda of, 330 


Glover's antiire, 174 






Pace, wouud* of, arjO 


Gold-beater-sskio, 103 


Fehleiskn, oa microcLH^i of eryaipelns, 


Grafting, nerve, 378 


44.330 




Femoral yuln, lateral sutare of. 208 






OraunbttoDs, 2U 


Fever of renotion, 33 


Gkpj;ne, W. W., oa botaoic aoid, 83 


trnnnialio, 23 


Gross, H, D., case ot wonnd of internal 


PlELDtNo, on silltworm-gut ligatareB, 100 


jugular vein. 20j 


FiBCiiBn, E, on nnpbthalin, h7 


on after-treatment lu caaes 


FlecuBR, on wounds of the henrt, S46 


of hiemorrbage, (26 


Flexion, forjed, in treating inlUmraation, 


on ligat^ng a wounded 


238 


artery. 2S3 


to arcent hffimon-hngB, lit) 


Oi;n.i,KMKAii. on the nae of the ligature. 


Fmurbsb, on nerre grarting, 278 


in.-; 


Plnjda, irrigatinB, 143 


Gunshot wounds, 247 




claraiflontion of. 250 


Food, afi modi^iTng the effecte of woonds. 


of nblomen. 357 


«5 


of brain. 316 




of oheat. ;i45 


torsion, 117 


of face, 331 


Forcipressure, 100 




in Tem-wonndii, 203 


of acalp. 306 


Fonr-Uiled cap bandnge. 320 


GussBNiurEB, the auture of, 883 


FoWLKn, Q. R,, on naphthalin, 88 




in naphthnlinated gauM. 100 


H.BUORKnACE after extmctlon of teeth, 


Foi-teil-lenJon ligatures, lOS 


m 


Ftactnres, componod, 2Sn 


arreat of, 03 


of QBMl bonw, 880 


._ 



384 



INDEX. 



Hsemorrhage, general considerations on, 

24 
intermediary, 285 
in abdominal wounds, 351 
in contused and lacerated 

wounds, 242 
in gunshot wounds, 247 
in incised wounds, 240 
intraperitoneal, 359 
into pleural cavity, 348 
into trachea, 335 
primary, 285 
secondary, 287 
subcutaneous, 237 
Hsemostasis, spontaneous, how effected, 

94 
HsBmostatic forceps, 102 
Hsemothorax, 348 
Halter bandage, 319 

HA3iiLTON, F. H. , on continuous submer- 
sion in hot water, 142 
on hot water as an 
hemostatic, 90 
Hands of surgeon, method of purifying, 

154 
Hare-lip suture, 175 
Head, bandages for, 318 
-net, 320 
wounds of, 301 
Healing by first intention, 27 
by granulat'on, 29 
by scabbing, 80 
by second intention. 29 
disturbed, means of relief, 218 
Heart, wounds of, 346 
Heat, reduction of, in the treatment of 

inflammation, 220 
Heath, C. , case of laparotomy for wound 

of bladder, 371 
Hernia cerebri, 317 

of the lung, 347 
Hewson, Addinell, on the effect of the 

weather on wounds, 16 
Honeycomb plaster splint, 266 
Horse-hair drains, 150 
sutures, 169 

Hot climates, healing of wounds in, 16 
Hot water douches, as a sorbefacient, 

239 

HuETER, on arterial transfusion, 136 

on hypodermics of carbolic acid 

in erysipelas, 230 



HuMPnRET, 6. M. , on the importance of 
wound-treatment. 3 

Hunt, Wm., views on micro-organism, 47 

HuNTEB, C. T., on hot water as an ha> 

mostatic, 06 
saw for removing plaster splints, 
215 

Hydrochloric acid, power as a germicide, 
71 

Hydrostatic pressure as a means of trans- 
fusing blood, 131 

Hydrothorax, 348 

Hygienic conditions, as modifying the ef- 
fects of wounds, 15 

Hyperaemia, active, physiology of, 24 

Hypodermics of carbolic acid in erysipelas, 
230 

ICE-BAGB, in inflammation, 223 

IchthyocoUa plaster, 163 

Idiosyncrasy as modifying the repair of 

wounds, 12 
Immersion, in inflammation, 222 
Immobilization, 206 

in compound fractures, 

and joint-wounds, 262 
in gunshot wounds, 254 
in inflamed wounds, 219 
Impairment of function, 23 
Impermeable envelope, external, 196 
Incised wounds, 240 

of the scalp, ^03 
Incisions, in the treatment of inflamma- 
tion, 219 
in inflau'.ed punctured wounds, 
246 
Inflammation, causes of, 35 

note as to use of the term, 

28 
of incised woundp, 242 
of subcutaneous wounds, 

240 
pathology of, 34 
treatment of, 218 
Instruments, how purified, 155 
Intention, union by first. 27 

union by second, 29 
union by third, 29 
Intercostal artery, wounds of, 344 
Intermediary haemorrhage, 285 
Interrupted plaster splints, 212, 266 
suture, 174 



INDEX 



385 



Interruption of blood-BuppIy to inflamed 

parts, 225 
Intestin**.! wounds, suture of, 360 
Intestine, protrusion of, 355 
Intra- cranial vessels, wounds of, 313 
luyaginated bandage, 161 
Invagination suturo of Jobert, 364 
Iodine, as an antiseptic, 84 
as an haemostatic, 97 
lotions, 84 

power as a germicide, 71, 73 
power in restraining germ-develop- 
ment, 'J2 
Iodoform, as an antiseptic, 85 
collodion, 201 
cotton, 186 
dressings, 200 
g^uze, 189 
intoxication, 86 
Iron, chloride of, power as a germicide, 73 
tincture of, power as a germicide, 71 
subsulphate, as an haemostatic, 118 
sulphate, power as a germicide, 71 
power in restraining germ-develop- 
ment, 72 
Irrigation, 141 

continuous, of septic wounds, 

228 
cool, in inflammation, 221 
fluid! for, 143 

of contused and lacerated 
wounds, 244 

Jameson, on ligatures of buckskin, 108 
JoBEKT, the suture of, 361, 364 
Joints, wounds of, 255, 259 
Jones, J. F. D., on haemostasis, 106 
Jugular vein, internal, wound of, 292, 

205, ^98, 3^9 
Juniper, oil of, for catgut ligatures. 111 
Jute, 191 

Kanoaroo-tail-tendon ligatures, 109 

Kbatb, ligation of middle meningeal ar- 
tery, 314 

Keetlet, on hot water as an haBmostatio, 
96 

Keith, on drainage of peritoneal oavify, 
368 

Kidney, protrusion of, 356 

Klebs, experiments on suppuration and 
septicaemia, 45, 50 



Knee-joint, antiseptio exdaiouB of, by 

Stokes, 57 
Knots, suture, 173 

Koch, micrococcus of gangrene in mice, 
44,50 
on carbolic oil, 78 

results of experiments with gemd- 
cides, 72 
KocHEii, anthrax infection from catgut, 78 
on irrigation with dilute solu- 
tions of chloride of zinc, 82 
on oil of juniper for catgut liga- 
tures, 111 
on plugging a wounded vertebral 

artery, 338 
on secondary suture in treatment 

of wounds, 144 
on subnitrate of bismuth, 88 
KoBBEBLf:, on forcipressure, 101 
Koenio, case of excision of the sternum, 

346 
KoPFF, deterioration of carbolic add 

dressing, 79 
KCmmell, H., on aceto-tartrate of alu- 
mina, 84 
on antiseptic use of corro- 
sive sublimate, 75 
on preparation and use of 
aluminated charcoal, 192 
on spun-glass drains, 150 
KCsTER, on hypodermics of carbolic add 
in erysipelas,- 231 



Lacbratbd wounds, 243 

of the scalp, 303 
Lacerations, 22 
Lanob, F. , case of t«ndon-suture, 272 

oaseof lateral ligation of inter- 
nal jugular vein, 340 
LANaBNBBCK, caso of wound of internal 

jugular vein, 295 
effects of immersion of 
wounds in warm water, 
143 
on ligation of veins, 290 
Laparotomy, explorative, for intraperiton* 

eal wounds of bladder, 873 
for wounds of abdominal 
viscera, 356 
Larynx, wounds of, 333 
Lateral ligation of veins, 395 



386 



INDBX. 



Lateral Hgfatnre of internal jugular vein, 

339 
Lateral suture of veins, 29S 
Jjeid suture-buttons, 181 
Leeches, in inflammation, 225 
Lbitbr, tubes for water co'ls, 223 
Lemairr, the first to employ carbolic acid 

in wounds, 76 
Lbmbbrt, suture of, 360 
LiDBLL, on deaths from haemorrhage, 280 
on lateral ligation of internal jug- 
ular vein, 340 
on wounds of the vertebral ar- 
teries, 838 
Ligation of artery of supply, in treating 
inflammation, 226 
of bleeding vessels, 104 
of veins, 290 

of vessels in their con tinnity, 126 
technique of, 112 
Ligatures, aseptic catgut, 110 
aseptic silk, 112 
in wounds of blood-vessels, 283 
lateral, of internal jugular 

vein, 339 
materials for, 107 
substitutes for, 107 
Lime, chloride of, known as a germicide, 

73 
Lint, 191 

Lips, micro-organisms infesting, 64 
Lister, J., and carbolic acid, 76 

case of lateral suture of ax- 
illary vein, 298 
on catgut ligatures, 110 
on drainage of peritoneal 

cavity, 367 
on lead suture -buttons, 181 
on method of dressing 

wounds, 198 
on primary drainage, 152 
on ** protective" material, 

195 
resnlts of antiseptic treat- 
ment, 54 
use of spray to purify air, 
67 
LrgFRANC, on ligation of veins, 290 
Ltttlb, results of antiseptic treatment, 

57 
Liver, protrusion of, 355 
Local effects of wounds, 22 



LOfflsr, on the relation of micro-orgaa- 

isms to septictemia, 50 
LoDgritudinal sinus, wound of, 313 
Lower, apparatus for transfusion, 137 
Lungs, resection of, 847 
wounds of, 346 

Maab, on acetate of alumina, 83 
Mac Cormac, on compound fractures, 256 
on drainage-tubes, 152 
on gunshot wounds, 248 
on horsehair drains, 150 
on the preparation of plas- 
ter-of-Paris splints, 210 
Macewen, on chicken-bone drainage 

tubes, 147 
on horsehair drains, 150 
results of osteotomies, 56 
Macintosh doth, 196 
Malgaionb, on lateral ligation of veins, 

296 
Mammary artery, internal, wounds of, 94.Z 
Marcy, H. O., on animal ligatures, 109 
Marine lint, 191 

Markoe, on *^ through drainage,*' 153 
Martin, H. A., adhesive plaster, 162 

rubber bandage, 197 
Mason, L. D., method for fracture of 

nasal bones, 330 
Massage, 239 
Maonder, on ligation of artery of supply 

in treating inflammation, 227 
McSwEENEY, on silkworm-gut ligatures, 

109 
Median nerve, suture of, 275, 277 
Mediate ligation, 105, 1 13 
Meningeal artery, middle, wounds of, 314 
Mental states, as modifying repair of 

wounds, 12 
influence of, over body, 
13 
Mercuric bichloride, antiseptic uses of, 

74 
power as a germi- 
cide, 71, 72 
power in restrain- 
ing germ -devel- 
opment, 72 
Metal sutures, 169 
Micrococci, 41 , 42 

and suppuration, 46 
Microooocus-poisoning, 51 



JUDEX. 387 1 




NirAiaE, on neuroplarty, 278 


of the body, Hi 


NionTiNdAi.E, Fl-oHiMOE, on the effeota 


ralaLioiiB of, to AisetuK.V, 


of Buulight. 17 


reltttioDa of,to wound dia- 




tnrbances, 58 




fpeciea of, 40 


53 




on eiyiipclas, 229 


rpnj. 67 




HiLLCT, on ligation oF reins, 2110 


Nutrition, defects of, analyied, 28 


HnjDBi., eiperimentH on the air of PnrlB, 




3a 


Oakom, lilt 


Modifjing inOuenees, repsir of wounds, 


Ooclns'on, primary antiseptic, of gursliot 


12 


wounds, 348 


MosSBi., theBiltof, 118 


(EHophagus. wounds of, 338 


MoMe-tCDilon ligatarea, 100 


Ogbtos, a., on differnnt apocioa of micro- 




organisms, 41, 43 


Month, woundB of, 333 


on miorocooonB-poisoniDg, 52 


MucooB orifleea, wounds of, difficulty iu 


OB the relation of raioroooooi 






Muriate of ammonia lotion as a 9orb«fa- 


O'ltALLEKATf, on healing of woanda, 5 


cient. 239 


Oi-LitLR, en thrombosis of reins, 300 


Muscles, wounds of, 300 


Omeutum, protrus-on of, 355 




Open mcth->d of treating wounds, 144 


Nafetiialin, lis an antiaprtic, 87 


Open wounds defined, 


In eijulpelas, ^1 


iodoform dresaing of,30t 




Opiates, 21S 


gauze, !00 


Opium after hicmorrbagB, 138 


oakum, 191 


Osmio ftoid, power aa a germicide. 73 


Kaaal bonas. fnwt res of, 330 


Ostiotoroy— Mace wen's resulls in, 56 


Nation nlity, as modifying repair of 


Otis. G. A., on the ure of sutures in 


wounds, 13 


wounds of the abdominal parietes, 35S 


Neck, wonnds of, 333 




Necrosis, 34 


Page, H. W., on suturing nerres, 275 


^^ Keedle-holdera, IGfi 


Paget, o^ exposnre to nir as a canse of 


H Needles, aoupresxnre, 09 


inflammation, 85 


^B for suturing, 103 




^V N£r.ATON, oa wounds of Intemal mam- 


wounds, 13 


mary artery, 313 


Pain, S3 


NBI.eo\, R N., on cloth fabric for plaHtic 




■plints, 311 


on value of deGhrinated blool for 


Nerre grafting, 27S 


tranrfosion, 184 


^K mture. 374, 270 


Paraffine paper, 107 


^m Nerves, cranial, injuries to, 319 


Par6, at the siege of Met*, 30 


^H wonnda of, STS 


on the use of the ligntnre. 104 


^m Net for bead, 330 








■ '^. 






artery, 314 


■ sublimate, 7.1 


Fabkes. 0, T,, case of wonnd of longitu- 


■ on iodotcim, B7 


dinal sinus, 313 


H on use of turf-mouM, 1!)3 


on lateral ligation of in- 


|„. 


ternal jngnlM vein, 340 







^dS^^^ INDEX. ^^^B 


PmrticloH, ^nolnaJ. B8 


Position, in the trpntment of inflamin*- 






45 


Potassium iodid", powpr as a gecmicid', 


on lelatioa ol nuoTO-orguiiimB 


71 








tic, 70 


»8 


permanganate, power as a ger- 


Padlt, casB of tendon-aotore, 373 


micide, 71, 73 




PonKicea, 225 


Pelvis, Moundaof, 3B9 


Practice of wound -trentment, 91 


PerloBnliam, wounds of, S4S 


Priroiry hiGmoirhaBO. 285 


Peti-DstinLl Butnrc, STQ 


Primarj ampulaciomi. 377 


Peripblebltui, 2B1 


Pkikcb, D., on bead sutDre, 170 




on continuous subnenion. 




142 


eiplocntioa of, 359 




trwwfnsiOD, 137 


of wound- treatment, 1 


Peritoneain, woondn of, 'JS^ 


Probes, 253 


PeritonitiB, 358. 3U!1 


Probing. 233 


Pktit, J. L., tourniquet of, 123 


Protection, defects of, analyiec!. 28 


Phorj'DX, Buture of, 3:}7 


Protective, the. IBS 


wounds of, 338 




Pblebltifl, 201 






Ponctnred wonnds, 245 


PlLCBER, J. E., coEB at woiuid ol inWrLal 


of flcnlp, 303 


jngalnr vein, 2B3, 340 


Pnrifioation of air. (ifi, (i.H, IM 


Pin fiuture, 173 


of spoDges, 130 


Pmcutteo, compreBsiv-, 101 


Pub. 30 


Pin?, acnprcBsure, 00 




PiBOQOKi', lath-gypsum splint, 263 


Pjiemia, 49 


ou ligaUon of veins, 200 




PIOBter, adhesive, UVJ 


Qrii-L sutnro. 177 


icbtbjocolla. 1G3 


Qoinine, power us a geniiicide, 73 


Flaatei-of-Paiis, how prepared for nse. 




210 


Beactiok. 21 


splmtB, 208 


Iteotum, aluminated charcoal na a drew- 


eplinta in compound frac- 


itig after eitiipation of, S4 


tures. 263 


wounds of, 374 


PlBniie,woiHidB of, 344, 347 


Iteef-knot, 173 


Plnremg blood-vEBBeK mennB of, 114 


EolaiaUonof vesaels-in treatment of in- 




flammation. 224 


PneamoUiomx, S4S 




Poiaoncd wounds defined. 10 


tiOQ, 100 




Stitches. 105 


bj oarbolio acid, 80 


Removal of piaster i^ptinta. 213 


by iodoform, 88 


Bepair, destriiotive disturbances of, 83 


Polypi, from einbfrant grnnulationa pro- 


modified normal, 29 


jecting into trnchea, a;i5 


normal, power of, 33 


PONi'lllCK. on peritoneal transfusion, 137 


of woQuds, modifying influences, 


Position, as a means of appositioD, 1«0 


13 


•B B means of rest, SOS 


of wounds of blood-vessels, 381 


in airestinK hicmoribage, 1 19 




I 


^ 







^^^^^^^^ HTDEx. 389 V 


B E«rt,205 


Serres-fiaaa, hiranoatatic, 101 


^" ttltet indsed wounds, 842 


Serres -fortes, hsemoatatic, 101 


in inflamei] wounda, 21U 


SEOTtN, piaster shears of, 215 


EevorsioQ of tissue, embryonic, 3S 


Shaiipk, on ligatures, lOS 


Bether.oq eiploring gunshot wounds, 249 


Shock, 21, 128 


Eiba, reaection of, 348 


SUlc Ugaturea, how made aaeptic, 119 


BiCRABDsaN, on iodina. 84 


for sutures, Id? 


BoCQARD, ou healing of wouuds in hot 


Silkworm-gut ligatures. 109 


climates, 17 


sutures, 108 


BoUer bMidagea, 161, 16S 


SUver wire sutures, 170 


don bis-headed, for head, 


Simon, on a utu re- threads. 107 


318 




plaater-ot- Paris, 211 


Simpson, I., case of penetrating wound of 


Bonx, on ligation of voina, 290 


abdomen. 3S4 




SMS, J. M., on silver wire sutorcs. 170 


in treatment of inflam- 


on suturing poritoneal 


matioa, 320 


wounds, 3G3 


oord tonmiquat, 125 


on treatment of gunshot 


tissue, 107 


wounds of peritoneal cav- 


tubing for water-ooila, 323 


ity, 350 




Sinns, wound of longitudinal, 818 


S^SiTTAi. bandi^ce, 310 


Smnsos, intraorosial, wounds of, 813 


8a]ic;lated cotton, 185 


Sfcm, method of purifying, 164 




precautions in diamfeoting. 66 


poweif B8 a germicide, 71 




power iu restraining germ- 


organiama, 64 


development, 72 


Skull, contusions of. 308 


Basd aa a wound-dreadng, 193 


traoturea of, 809 


Eauds, H. B., antiseptia results of, OS 


Sloughs, 33 




Sodium, sulphite, hypo-mlphite, borate 




and salicylate, power aa germicides, 71 


on trephinmg, 309, 330 


Sorbefacients. 239 


Saw-dnat as a wound-dresfling, 1B4 


Spanish windlass, 124 


Scabbing, healing by, 30 


Spleen, protmaion of, 3M 




Splints, 206 


wonnds of. S02, 800 


plastic, in compound fractures, 


SoatiQcationa of inflamed tiaenes, aS5 


293 




Sponges, 13D 


shot woond of abdomen, 357 






inflammation, 220 


vein, 30B 


Spray, how most elective, 167 


table of ameutationa, 55 


producers, 156 


Bciatia nerve, auture of, 377 


Spraja, antiseptio, 67 




Spun -glass drains, ISO 






^^ heemonhagD, 287 


intra-peritoneal wounds of bladder, 372 


^1 Buture, Kocher'a method of, 144 


STnnNBBiiG, G. M., experimcBts with 


H Sepsia, what constltates, 60 


genutcidea, results of. 70 


■ Septionmia, 49 


StimsoN, L. a., obaarvations on antiseptio 


H treatment of, 332 


value of carbolic apray, 67 ^ 


■ Septio wounds deSned, U 


Stokes, antiseptio rsialts of, 66 


k 


... J 







^V 390 INDEX. ^^^^^1 


^B BtraogulDted iuteiitine, »55 


Tampons, antiseptic, 248 ^^^^H 


^H StuicK£1(, on repair of woiudB, 25 


hffimOHtutic, D8 


^H Styptics, lis 


Teeth, hteroorrhage after eitracting, 381 


^H Subculaoeous effusions, 338 


Teuaoulum, 112 


^H ho^morrliage. 237 


Tendo-AchiUea, suture of, 273 


^M wounds, ZSl 


Tendon-ratui-B, 271 


^M SubliioBted cotton, l&i 


Tendons, wounds of, 270 


^M BBDd, 1S3 


Tonaion. effect of, 28 


^H Bubmenion, uoutinuona, 143 




^H Sulpboria moid, poner as a germicide, 7t, 


of wounds, 210 


■ 


Thierry, on torsion. US 




TuiBitBCU, bead suture of, 182 


development, 72 


on salicylio acid, 83 


Sulphnrons ncid, power aa & gfrmicide. 73 




Sunlight, effect of, ou tbe wounded, 17 


Thoracic duct, wounds of, 844 


Buppuiotion, 30 


Tboran, drainage of, 348 


and taiorocoooi. iS 


wounds of, 341 


SuiBioal knot, 173 


TnoiiBTOK, KSOWBLEY, on drainage of 


Bupendoo at HplintB, 318 


peritnneal cavity. 808 


Guturo, bead, 179 


Thread for Butniea, 167 


buttou, 180 


Througli-dnuiiaee. Markoe's method, 158 


couHnoonB, 174 


TiBOEi., experiments on suppuration and 


Cierny'ii. 363 


septicaemia, 4S 


EmmerfB, 303 


TiLLMAHs. on bypodctmics of carbolic 


Oily'«. 802 


acid in eryaipclaa, 331 




on Bntnring ueivea, 374 


Interraptad. 174 




Invoginstion, Jobert's, 864 


Torsion, 115 


Jobert-fl, 8G1 


Torsion- forceps, 117 


lembert'B, 860 


ToDRDES, on woanda of internal mam- 


Of bladdet, 373 


mary artery, 843 




TourniqnetB, 123 


of nervea, 274, 276 


Tow, IBl 


Of peritoaeam, SOS 


Towels, to be purified, 155 


of pharyni, 837 


Trachea, suture of, 333 


ot Btomaoh. 300 


wounds of, 333 


of tendoni, 271 


Tracheal cunulaa, 388 


Of tmohaa, 333 




Of vaiu. IftMnl, 388 


Tranraatic fsver, 22 


peri-neural. 376 


TnAVEKs, B. , on wonnda ot veins, 2S9 


pta,173 


Trephining, 330 


1 _ qBlU, 177 


Tropical cliraatea. healing: of wotinds in. 


^^mm l^lai nerve. S78 


17 


^^^^H||^ ilipUoatioii of, 1S5, 170 




^^^^^^MHa,ua 


(fiction. 2!)0 


^^^^^^^H^M^nde of abdominal parletea, 


Tubes, drninngo, 145 




Tubulnr drainage. 145 


^^^^^HHIpb tor, 107 


nerve-auturB, 879 . 


^^^^™tSi« < IT-t 


Tnrf-mould as a wound -dregalner, 191 ^^^^H 




dressings of Esmarcb, 208 '^^^^^| 






^K^MpneaMMll, S43, 344 


power as a germlode, 78 ^^^^^| 



I Tarpentine, use in diBiuIecting Bkin, 03 
I Twisted 8u tare, 175 

f Tykdall, renesfcheB an cuaaea of decom- 
pomCiou, 38 



\ TAecCLAn relaxation, means of prodn- 

ciuf;, to relieie inflammation, 3S1 
I TaOLAIK, on tubular nerve-sntnre, 278 
J Vein, int«TQal jugulnr, woundB of, 830 
I Veins, lateml ligation of, 305 
lateral Butnre of, 398 
woande ot, 288 
Velpeau, on toraion, 115 
TeneaeotioQ in head-injuriei, 313 
Ventilation, necesBity for, 18 
VEiiSBm., on fortipTCBHore, 101 
Vertebral arteriea, wounds of, 3U8 
VesaelB, intra- oriinial, wonnds ol, 313 
VrscBNT, on advontngea of lapnrotomy in 
Imra-p'iritoiieal wounds of bladder, 373 
Voi.EMAMM, autbraz infection from cat- 
gut, 78 
BUtiscptio resulla of, S4 
Bpuon-cnrctlca of, IQ8 

I tfALEB, P. S., on healing of wounds in hot 

oli mates, IQ 
I Waltbr, onaeof iutra-peritonealwoundof 

bladder, 370 
I Water-coils, in inflammation, 233 
[er. hot, BB an ha;mo8tatJc, 00 
I Wnxed-paper, aa a wound dressing, 197 
I Weather, effect of, on repair of wounda, 16 
' WkIR, R. F., on antiaeptio nMs of corro- 
flive aublimate, 75 
on deterioration of oarbolio 
aaid dceasings. 79 
WitLLB, Spkhckb. on drainage ot peri- 
tooEal caTitj, 388 
on toroiprasauie, 101 
f Whitb, on horse-hair drains, 150 
WlOHT, J. 8., Hrt«ry foroepB, 117 

on wiFo-gBUEe splints. 31)7 
WlLLUTT, A., case of laparotomy for in- 

tra-peritoneal mpture of bladder, 371 
Windows in ploater uplints, 21 1 
Wira-Kanze splints, 207 
WiazHAN, K., deSnitiOQ of wonnds, 7 



Wood-wool, as a woond-dressitig, 1S4 
Wound-disinfection, OH 

diaturbances and micro- organismB, 

58 
dresainga defined, 06 
dreaaings, Lister'a, 1Q8 
Eecietions. importance of prevent- 
ing their nccumulatiou, (t3 
Wounds, aseptic. deSued, 11 
claasificalion of, S 
contmuuicating with bons-frao- 
turea, ot opening jolnt-CBrHiee, 
265 
oonstitutionol effects of, 21 
contnaad, 343 
definition of, 7 
gunshot, 347 
tuciaed, 240 
lacerated, 249 
open, defined, 
open, effects of inflammation in. 

80 
of mucous orifices, difficulty in 

preaerviug aaeptio, 05 
of special regions, 399 
poiaone'i, deGned, 10 
septic, defined, U 
septic, how cleansed, 157 
physiology of repair of, 25 
pnnctured, 245 
special, 235 
saboutaneouH, 337 
subcutaneous defined, 9 
BQppurating, 30 
WtirGHT, D. F., on ligation ot artery of 
supply in treatment ot inflammation, 330 
Wriat, case of incised wound of, 341 

YoDNo, TnOB., on ligatures of catgut, 108 

Zaiht, experimenta on auppurBtion and 

septiraemia, id 
Zrir, effecta of immersion of wounds in 

warm water. 143 
Zinc, chloride of, ns on antiseptic, 81 

power OS an application 

to septic wonncln, 109 

power OS a germiclile, 71 

sulphate, power ai a geimiaide, 71 

ZwBiFEi., authrojc infection from catgat. 



V 



LANE MEDICAL LIBRARY 



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