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I ^

THE

TREATMENT OF WOUNDS

ITS

% •

PRINCIPLES AND PRACTICE, GENERAL

AND SPECIAL

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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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

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

■(

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-

ASBPTIC AND SKPTIO WOUNDS.

'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.

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

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.

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

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.

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

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.

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.

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*

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

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,

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.

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.

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.

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.

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.

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.

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,

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-

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.

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..

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.

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.

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,

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

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.

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

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

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-

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.

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

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

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.

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.

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.

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

> Tbe Drainage of WoaudB. Bdtiah Hedioal Joonutl, FebrouT 0, 1881, p. 189.

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

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.

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

^__^^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

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.

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.

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-

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

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

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

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

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

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

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

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.

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

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*

■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-

^Lnady aooeat to the wound can be secured

^^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.

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

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

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.

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.

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-

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.

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.

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

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.

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-

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

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.

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

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

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-

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.

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.

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-

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

■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.

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»-

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

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

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

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

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.

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

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

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

>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.

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.'

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.

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

THK USB OF THX TREPHINE.

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

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

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.

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

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.

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

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

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.

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.

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.

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.

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 '

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 iis7i»£ 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

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;.

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.

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

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

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

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

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

on eiyiipclas, 229

rpnj. 67

HiLLCT, on ligation oF reins, 2110

Nutrition, defects of, analyied, 28

HnjDBi., eiperimentH on the air of PnrlB,

Oakom, lilt

Modifjing inOuenees, repsir of wounds,

Ooclns'on, primary antiseptic, of gursliot

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*-

Potassium iodid", powpr as a gecmicid',

on lelatioa ol nuoTO-orguiiimB

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

•B B means of rest, SOS

of wounds of blood-vessels, 381

in airestinK hicmoribage, 1 19

^^^^^^^^ 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

... 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

^^^^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.

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