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V 1 



WOUNDS, ULCERS, AND ABSCESSES. 



THE TREATMENT 



OF 



Wounds, Ulcers, and 
Abscesses. 



BY 



W. WATSON CHEYNE, M.B.Ed., F.R.S., F.R.C.S., 

PROFESSOR OF SURGERY IN KING'S COLLEGE J SURGEON TO KING'S 

COLLEGE HOSPITAL, AND PADDINGTON GREEN CHILDREN'S 

HOSPITAL, LONDON. 




PHILADELPHIA: 

LEA BROTHERS & CO. 

1895. 



PEEFACE. 



In writing this small book I have not attempted to 
discuss the whole subject of the treatment of wounds 
as I formerly did in my book on Antiseptic Surgery, 
nor the various plans which are used by different 
surgeons, but I have limited myself to describing the 
methods which I always employ, which I know to be 
efficient, and which I believe to be the simplest con- 
sistent with certainty in the results. Those who have 
paid particular attention to the treatment of wounds 
will, I have no doubt, agree with the statement which 
I have made, that suppuration occurring in a wound 
made through unbroken skin indicates that the surgeon 
has committed some avoidable error in his methods, 
unless indeed the wound is in the immediate neigh- 
bourhood of or communicates with some mucous 
canal ; it will not do, with our present knowledge and 



viii PREFACE. 

experience, to attribute such an occurrence to con- 
stitutional defects, to bad materials (for, after all, the 
surgeon is responsible for the purity of the materials 
which he uses), &c, it is evident that some error has 
crept into the manipulations, and it is only by honestly 
acknowledging this to one's self, and by searching for 
the fault, that such an occurrence can be avoided on 
another occasion. I believe that a thorough practical 
acquaintance with bacteriological work is of the first 
importance to the surgeon, for in that case the mani- 
pulations necessary to keep bacteria out of his wounds 
become automatic, and he is thus able to concentrate 
his whole attention on the operative details without 
having to fear that he may be omitting some detail 
essential for securing the asepticity of the wound. 

75 Hakley Street, 

London, July 189*. 



CONTENTS. 



TREATMENT OF WOUNDS. 

Classes of wounds — Healing of wounds — Healing by first intention — 
Healing by blood clot — Healing by granulation — Traumatic 
fever — Septic intoxication — Septicaemia — Pysemia — Disadvan- 
tages of healing by granulation — Advantages of healing by 
first intention — Causes interfering with healing by first intention 
or by blood clot — Pyogenic micro-organisms — Their mode of 
action — Different species — Conditions necessary for their action 
— Influence of the number of organisms — Variation in virulence 
— Phagocytosis — Source of pyogenic organisms — Relation to 
culture media — Relation to heat and chemical substances. 

Classes of wounds — Wounds made by the Sukgeon through 

previously unbroken skin where the edges of the 

skin can be brought together. 

Listerian method of treatment — Disinfection of skin — Disinfection of 
instruments — Lotions for use during operation — Irritation — 
Disinfection and use of sponges — Arrest of haemorrhage — 
Ligatures — Stitches, materials, and methods — Button sutures 
— Buried stitches — Drainage — Dressings — Change of dressings 
— Rest in the treatment of wounds — Protective — General treat- 
ment — Aseptic course of wounds — Listerism in private practice 
— Asepsis, methods and objections. 



x CONTENTS. 

Failure of healing by first intention although the 
wounds remain aseptic. 

Accumulation of fluid in wounds — Too tight stitches — Movement of 
wound — Constitutional cause 

Failure of union by first intention due to the 
occurrence of sepsis. 

This is the fault of the surgeon — Symptoms of sepsis — Treatment 
— Treatment where pyaemic symptoms occur — Irrigation. 

Wounds made by the surgeon through previously unbroken 

skin where, however, the edges of the wound 

cannot be brought together. 

Rest of the part — Lotions — Dressings — Methods of obtaining a satis- 
factory blood clot — Thiersch's skin grafting in fresh wounds. 

Sepsis in open wounds. 

Symptoms — Trea-tment — Iodoform in septic wounds — Ointments in 
septic wounds — Lotions in septic wounds — Skin grafting. 

Wounds through the skin which have not been inflicted by 
the surgeon, but which are seen within a few hours. 

Disinfection of these wounds — Lacerated and contused wounds — 
Compound fractures — Amputation in — Wounds of joints — 
Wounds of abdomen — Wounds of thorax — Compound fractures 
of skull — Burns. 

Wounds which have not been made by the surgeon, and in 

which several days at least have elapsed from the 

time of their infliction — open granulating wounds. 

Methods of disinfect ~m and treatment. 



CONTENTS. xi 

Sinus and fistula. 

Simple sinus, causes of — Treatment of — Tubercular sinuses, nature 
of — Treatment of — Iodoform in tubercular sinuses — Fistula, 
definition — Forms of fistula — Treatment of the various forms. 

Wounds which involve not only the skin, but also the mucous 

membrane, ob in which septic cavities which cannot 

be disinfected are opened up. 

Care in making such wounds — Stitches in these cases — Chloride of 
zinc. 



TREATMENT OF ULCERS. 

Definition of ulcer — Classes of ulcers. 

Chronic non-infective ulcers. 

Causes of — Treatment of — Classes of — Simple ulcer — Inflamed ulcer — 
Irritable ulcer — Weak ulcer — Phagedcenic ulcei — Varicose ulcer 
— Callous ulcer — ffcemorrhagic ulcer — Pressure ulcer — Paralytic 
ulcer — Perforating ulcer — Diabetic ulcer. 

Treatment of ulcers in general. 

Principles of treatment — Avoidance of movement — Position of part — 
Massage — Disinfection of ulcers — Iodoform in ulcers — Lotions 
and dressings — Treatment of painful and inflamed ulcers — 
Ointments in the treatment of ulcers — Avoidance of contrac- 
tion — Epidermis grafting — Skin grafting — Thiersch's method 
— Subsequent precautions after skin grafting — Use of the whole 
thickness of the skin as grafts — Additional points in the treat- 
ment of the various kinds of ulcers — Treatment of simple ulcer, 
of inflamed ulcer, of weak ulcer, of irritable ulcer, of phagedenic 
ulcer, of varicose ulcer, of callous ulcer — Blisters in callous ulcer 
— Martin's rubber bandage — Unna's bandage for ulcers — Treat- 
ment after ulcer has healed — Treatment of paralytic ulcers, of 
perforating ulcer, of pressure ulcer. 



xii CONTENTS. 

Chronic infective ulcers. 

Tubercular ulcers — Lupus — Scrofuloderma — Treatment of tubercular 
ulcers — Treatment of lupus — Excision and skin grafting in 
lupus — Scraping in lupus — Treatment of syphilitic ulcers. 

Ulcerating tumours. 



TREATMENT OF ABSCESSES. 

Forms of suppuration in the tissues — Pathology of acute abscesses — 
Seats of acute abscess — Mode in which organisms reach the 
part — Diffuse cellulitis — Subacute abscess. 

Treatment oe acute abscess. 

Method of opening — Dressings — Aseptic course of acute abscess — 
Acute abscess in glands — Empyema — Acute suppurative peri- 
ostitis and osteomyelitis. 

Diffuse cellulitis. 
Appearances of — Treatment of. 

Chronic abscess. 

Pathology of — Methods of treatment — Removal by dissection — Free 
incision and removal of wall by clipping and scraping — 
Scraping, washing out, and subsequent stitching up — Drainage. 



TREATMENT OF WOUNDS. 



WOUNDS, ULCERS, AND 

ABSCESSES. 



TREATMENT OF WOUNDS. 

In considering the treatment of breaches of surface, we 
have to divide thern into two great classes; — first, 
those which have a tendency to heal more or less 
rapidly ; and secondly, those which extend or ulcerate. 
In other words, we have to consider the two groups of 
wounds and ulcers. The treatment of these two classes 
differs radically in the first instance. In the case of 
wounds our efforts must be directed to the avoidance of 
causes which tend to interfere with healing, or which 
may lead to serious constitutional disturbance : in the 
case of ulcers we have to remove the already existing 
causes which interfere with healing, and to prevent 
certain local troubles which take place during and after 
the healing process. Then, intermediate between these 
two classes, we have a group where healing goes on for 



4 TREATMENT OF WOUNDS. 

a time and then comes to a standstill, where the wound 
does not extend— that is to say, does not become an 
ulcer — but where an opening remains on the surface 
from which a channel leads to the deeper parts, which 
channel does not heal for various reasons. This form 
of wound is spoken of as sinus or fistula. 

In the first place, we must consider the processes 
which take place during the healing of a wound. 
Immediately on the infliction of a wound, oozing of 
blood occurs from all the open vessels, and coagulates 
on the surface. At the same time, the injury which 
has been inflicted on the tissues by the knife leads 
to the occurrence of a microscopic layer of inflam- 
mation, which runs through the earlier stages of 
slowing of the circulation, stasis, and exudation of 
lymph. In cases where the two sides of the wound 
are brought into accurate apposition, and where no 
further causes of inflammation come into play, this 
primary inflammation resulting from the action of 
the knife comes to a stop at the point of exudation of 
lymph. The exuded lymph glues the two surfaces 
together, and very soon becomes infiltrated with leu- 
cocytes and plasma cells, the latter of which organise 
into fibrous tissue and permanently unite the two cut 
surfaces, while, at the same time, epithelium spreads 
over the surface. This is the process of healing by 



HEALING OF WOUNDS. 5 

first intention, and, when it occurs, there is little or no 
constitutional disturbance, and little or no pain or 
swelling in the vicinity of the wound. It is true that, 
where the wound is extensive, the temperature may rise 
one or two degrees at the end of the first twenty-four 
or thirty-six hours, but this rise of temperature is not 
accompanied by any serious febrile disturbance, and 
falls again within a few hours to normal. The cause 
of this rise of temperature, which is spoken of as aseptic 
fever, is by no means clear, but it may possibly be in 
part due to reflex nervous disturbance, or in part to 
absorption of fibrinous material from the wound. 

Where the edges of the wound are not brought into 
accurate apposition, or not brought into apposition at 
all, the space between the edges of the cut becomes - 
filled with coagulated blood, and a certain amount of 
lymph is thrown out on the immediate surface in the 
manner just described. Under certain circumstances, 
especially where no further causes of inflammation 
come into play, this blood clot remains in the wound, 
and forms a mould into which leucocytes, in the first 
instance, and subsequently plasma cells, penetrate, the 
latter of which organise into fibrous tissue, while epi- 
thelium after a time spreads over the surface. This mode 
of healing may be spoken of as healing by blood clot ; and 
with regard to the spread of the epithelium over the 



6 TREATMENT OF WOUNDS. 

surface in these cases, it is to be noted that this does 
not begin for some time — in fact not till the blood 
clot has become to a considerable extent organised. 
Further, also, the epithelium does not spread over the 
actual surface of the blood clot, but generally penetrates 
through it at a little distance from the surface, so that, 
when healing is more or less complete, a thin layer of 
old unorganised blood clot can be peeled off, exposing 
the cicatrised part beneath. Here, also, there is no 
serious constitutional or local disturbance. 

In other cases, where further causes of inflammation 
come into play — more especially in cases where the 
edges of the wound are not brought into accurate appo- 
sition — we have healing by granulation. Here, also, we 
have the primary inflammation as the result of the 
action of the knife, and the filling up of the wound 
with blood clot ; but at this point the process diverges 
from those just described. The blood clot and lymph 
very soon undergo liquefaction and disappear, leaving 
the cut surface exposed, and the inflammation in the 
latter continues to the further stage of destruction of 
the normal tissues which were exposed in the wound, 
and the formation of a layer of granulation tissue and 
subsequently of granulations. These granulations grad- 
ually grow and fill up the cavity of the wound, the 
deeper, that is to say the older layers, becoming 



HEALING BY GRANULATION. 7 

organised into fibrous tissue, which contracts and 
gradually draws together the edges, thus diminishing 
the size of the sore, even before the granulations have 
filled up the cavity or epithelium has begun to spread 
over the surface. When the granulations have more 
or less completely filled up the cavity, epithelium 
begins to grow over the surface, and, gradually, when 
the conditions are favourable, completely covers it. 
The superficial layers of the granulation tissue thus 
protected quickly lose their embryonic character and 
undergo organisation into fibrous tissue, which also con- 
tracts, thus reducing greatly the ultimate size of the scar. 
During this process of healing by granulation and 
suppuration, the patient is very often exposed to 
severe local and general troubles, especially during the 
period which elapses before the wound is completely 
covered by granulations, that is to say, within the first 
four to six days, when he is more especially liable to 
the various forms of septic diseases. In the first 
instance, the temperature rises, and generally in the 
course of the first twenty -four to forty-eight hours 
reaches its highest point — about 103 to 104 degrees 
Fahrenheit. It then gradually falls, till, at the end of a 
week — that is to say, when the surface is completely 
covered with granulations — it has generally come back 
nearly to the normal. This is the condition spoken of 



8 TREATMENT OF WOUNDS. 

as Traumatic Fever, and it is due to absorption of 
chemical products formed by bacteria of various 
kinds, more especially pyogenic bacteria, which are 
growing in the fluids contained in the wound and 
in the superficial layers of the tissue. When granu- 
lation has completely taken place, this absorption 
generally ceases, and hence the fall of the temperature. 
Where the wounds are very large, and contain a great 
quantity of decomposing blood, a large amount of 
chemical substances may be rapidly absorbed, producing 
the condition known as Septic Intoxication or Sapraemia, 
a condition in which the patient, after a preliminary 
rise of temperature, passes into a state of collapse, and 
may die. Further, during the early period, the initial 
temperature due to traumatic fever may not fall, or, 
having fallen to a certain extent, may again rise, and 
the condition of Septicaemia sets in, due probably to the 
penetration of pyogenic organisms into the body and 
possibly into the blood, and the poisoning of the blood 
with the products of their growth. Or again, even after 
the complete subsidence of the traumatic fever, the 
patient has a severe rigor accompanied by rapid rise of 
temperature and an equally rapid subsequent fall ; these 
rigors being repeated and the condition of Pyaemia 
developing. 

As regards the local troubles, and, in the first 



SEPTIC DISEASES. 9 

instance, as regards those which accompany the early 
formation of granulations, the edges of the wound 
become swollen, inflamed, and painful, and in a few days 
free suppuration is established from the surface. Fur- 
ther, various local septic diseases may take place, such 
as erysipelas, phagedena, tetanus, &c. In fact, where 
the healing process is that of granulation and suppura- 
tion, the patient has to pass through a variety of risks 
depending essentially on the entrance of micro-organ- 
isms of various kinds into the wound. Various other 
local disadvantages result from this process of healing 
by granulation, such as the presence of unsightly scars ; 
great contraction of the wound pulling on the tissues 
around and causing marked deformity, as is seen in 
burns about the neck drawing down the lower lip, in 
burns about the axillae causing adhesion of the arm to 
the side, after sores in the vicinity of tendons or 
muscles, leading to contraction of these, and so on. 

From this short sketch of the healing process, it is 
evident that in all cases, wherever it is possible, one 
should strive to obtain healing by first intention or by 
blood clot, and to avoid the occurrence of granulation and 
suppuration. By doing so, the patient recovers in a 
few days, instead of after, it may be, many weeks, with- 
out having suffered any pain or constitutional dis- 
turbance, and without having run the risks which I 



io TREATMENT OE WOUNDS. 

have mentioned as incidental to the process of healing 
by granulation, while, at the same time, the resulting 
scar becomes after some months but slightly visible. 

We must therefore now consider more in detail the 
conditions which interfere with healing by first inten- 
tion, or by blood clot. These may all be summed up as 
consisting essentially of conditions which lead to further 
inflammation of the surface of the wound. In order to 
obtain healing by first intention, it is important not 
only to avoid conditions which lead to inflammation, 
but also to bring both surfaces of the wound into 
accurate apposition, that is to say, all blood clot or other 
foreign bodies must be carefully removed and the edges 
of the skin must be accurately united, it being very 
important to see that one edge does not overlap the 
other, otherwise healing may not occur on the over- 
lapping side. But, as is evident from what I have said, 
in order to avoid the risks incidental to wounds, it is 
not absolutely essential that the edges shall be brought 
together accurately, because even when this does not 
occur — provided only we avoid further inflammation — 
healing will take place by blood clot without any local 
or general disturbance. Among the minor conditions 
which come into play we have to avoid ; all actions 
tending to mechanical irritation of the wound, more 
especially movement of the part in which the wound is 



CAUSES OF SUPPURATION. n 

situated, or of the muscles beneath it ; the presence of 
tight stitches pinching the skin and thus causing irrita- 
tion ; the mechanical irritation of the dressings which 
are applied to the wound, or the irritation of chemical 
substances either contained in these dressings or used 
as lotions. 

The essential causes, however, which lead to the 
failure of healing by first intention or blood clot, and 
which expose the patient to the risks which have been 
mentioned, are the growth of micro-organisms, in the 
first instance in the material on the surface of the 
wound, and subsequently in the tissues themselves. 
The organisms which act in this way are essentially 
the pyogenic organisms, namely, the various kinds of 
pyogenic cocci, such as staphylococcus pyogenes aureus 
and albus, and streptococcus pyogenes. These organ- 
isms are almost the only ones which produce suppura- 
tion under ordinary circumstances, the staphylococci 
being more especially concerned in the production of 
typical suppuration, while the streptococci appear to 
have much more dangerous properties and to creep 
insidiously through the tissues, leading to diffuse 
cellulitis without any proper circumscription of the 
pus. These organisms also seem to be responsible for 
the chief forms of septic disease which follow wounds, 
either or both of them being associated with traumatic 



12 TREATMENT OF WOUNDS. 

fever, the staphylococci being especially associated with 
septicaemia and the milder forms of pysemia, and the 
streptococci being the cause of the acute forms of 
septicaemia and of the great majority of cases of 
pyaemia. Where a wound is freely open to the 
entrance of micro-organisms, these are not, however, 
the only ones which may grow in it. The early dis- 
appearance of the blood clot and the occurrence of 
traumatic fever and of septic intoxication are apparently 
also often associated with, and no doubt in part due to, 
the growth of ordinary saprophytic and putrefactive bac- 
teria in the fluids contained in the wound, and although 
these organisms cannot penetrate into or live in the 
body, their chemical products are often intensely 
poisonous and cause very serious effects. 

The mode in which the pyogenic cocci produce sup- 
puration varies and depends essentially on their 
chemical action. In the first place, these cocci are 
powerful peptonising agents, and thus bring about 
the liquefaction of albuminous materials, and in this 
way we have the explanation of the rapid disappear- 
ance of the blood clot and lymph, and of the lique- 
faction of the tissues forming the surface of the wound. 
Further, these organisms during their growth produce 
substances which are very irritating, and which, when 
applied in a concentrated form, as, for instance, in 



CAUSES OF SUPPURATION 13 

the immediate vicinity of a colony of bacteria, lead to 
the peculiar form of death of the tissue which is 
termed Coagulation-necrosis; while in a more dilute 
solution, or at a greater distance from the colony, 
they set up all the phenomena of acute inflammation. 
What the chemical composition of these substances 
exactly is has not yet been satisfactorily determined, 
but it is stated that, among other materials which are 
found, we have, for example, ammonia, and one can 
readily understand how, if there is a constant produc- 
tion of ammonia in the tissues, a state of inflamma- 
tion is kept up and spreads co-extensive with the 
growth of the bacteria, while the peptonising action 
in the centre of the inflammatory area leads to lique- 
faction of the intercellular substance, and prevents 
the coagulation of the material effused from the blood 
vessels, and thus leads to the formation of a fluid, 
namely, pus. These organisms also produce substances 
which, when absorbed into the general system, give rise 
to the phenomena of fever, these substances being no 
doubt similar to those formed by many other bacteria, 
and belonging to the group of albumoses. 

The different action of the staphylococci and the 
streptococci is no doubt partly dependent on the pro- 
ducts which they form, and partly also on their 
mechanical action. As regards their products, it may 



14 TREATMENT OE WOUNDS. 

be mentioned that the streptococci do not have such 
a powerful peptonising action as the staphylococci; 
this perhaps explaining the less rapid formation of 
pus as the result of their growth. The substances 
produced by them also seem to be more potent, both 
in their local and general action, locally leading to 
death of the tissue in their vicinity, and interfering 
with the exudation of leucocytes which would other- 
wise tend to bar their progress. It is possible also 
that the difference in action may depend to some 
extent on the fact that, for some reason or other, the 
streptococci have a special predilection for the lym- 
phatic vessels and lymph spaces of the tissues, along 
which they extend with great rapidity, while the staphy- 
lococci do not seem to have a preference for these 
parts, and very quickly become walled in by a layer 
of leucocytes. The mechanical action of the strepto- 
cocci may also have something to do with their more 
frequent association with pyaemia, for while the staphy- 
lococci when growing in the blood are most usually 
found either singly or in pairs or triplets, the strep- 
tococci tend to grow in long chains, which coil up, 
and entangling with them blood corpuscles, form 
emboli, which stick in various small vessels, more 
especially in the lungs, kidneys, &c, and lead to the 
occurrence of suppuration around. 



CAUSES OF SUPPURATION. 15 

It must be borne in mind, however, that it does 
not necessarily follow that because these organisms 
gain access to a wound, suppuration and the other con- 
sequences must necessarily occur ; on the contrary, we 
know that they must almost certainly have entered 
many wounds, which, nevertheless, heal by first inten- 
tion, though I cannot believe that, should they enter 
wounds where the conditions are not favourable for 
healing by first intention, they will permit the occur- 
rence of healing by blood clot. I should say that 
where these organisms have entered a wound only 
two forms of healing are possible, namely, healing by 
first intention, or healing by granulation and suppura- 
tion. From this we must infer that various conditions 
must come into play which favour or hinder the 
growth and action of these organisms. These con- 
ditions I have already pointed out in my book on 
Suppuration and Septic Disease, and I need not, there- 
fore, do more than refer to one or two of the chief 
points m this place. Perhaps the two most essential 
conditions which favour the growth and action of these 
organisms are, in the first place, the amount of injury 
which has been done to the tissues when the wound 
was made; and, in the second place, the number, 
virulence, and variety of the organisms which enter it 
in the first instance. The relation of pathogenic organ- 



1 6 TREATMENT OF WOUNDS. 

isms to the body is that of a fight between the tissues 
and the invading organisms, and the result of this 
fight will depend on the vigour of either of the com- 
batants. Where the tissues have been much bruised 
at the time of the operation or accident, their vitality 
will have been greatly diminished, and they will more 
readily succumb to the attack of the organisms than 
if the injury done to them had been limited to the 
microscopic layer caused by the action of the knife. 
This is a point of immense importance to bear in 
mind in operating on parts where the entrance of 
organisms cannot be avoided. Under such circum- 
stances the manipulations of the surgeon should be 
particularly gentle, so that the tissues which are 
exposed to the action of the organisms should be in 
as healthy a condition as possible. 

The second point which I mentioned with regard to 
the number of organisms which enter in the first 
instance is also of great importance, for, as the results 
of experiments which I published some years ago, it 
is evident that the effects of organisms depend to a 
very considerable extent on the numbers which enter 
the part in the first instance. Thus, in the case of 
rabbits, it was necessary to inject several millions of 
the staphylococcus pyogenes aureus into the tissues at 
one time in order to produce an abscess ; while some- 



CAUSES OF SUPPURATION. 17 

thing like ten times the number was necessary in 
order to produce a general and fatal infection of the 
animal. And this same law holds good with regard 
to all the pathogenic bacteria which have as yet been 
tested, namely, that in animals not particularly suscep- 
tible to a disease, a small number of organisms may be 
introduced without doing any harm, a somewhat larger 
number will produce a local lesion, and a still larger 
number will be required in order to lead to a general 
infection. And this is no doubt the chief explanation 
of the comparatively good results which are obtained 
by many surgeons at the present day who do not 
employ means to absolutely exclude all organisms 
from the wounds. Although they do not act rigidly 
in this respect, they nevertheless cleanse the parts 
and the instruments, &c, to a considerable extent, and 
thus reduce the number of organisms which are left in 
the wound, and consequently diminish their subsequent 
effect. 

Among other conditions in connection with the action 
of these organisms may be mentioned their virulence, 
for they apparently vary in virulence at different 
times, and the more virulent they are, the smaller the 
number which will be required to produce the effect, 
Further, the entrance of different kinds at the same 

time increases their action, because, even though some 

2 



1 8 TREATMENT OF WOUNDS. 

of those which enter the wound may not be pathogenic 
in the true sense — that is, able to penetrate into and 
live in the tissues — nevertheless, while growing in the 
fluids of the wound, they produce noxious substances 
which may interfere with the vitality of the surface, 
and, if absorbed, with the general vigour of the patient, 
and thus pave the way, so to speak, for the entrance 
and action of the true pathogenic bacteria. Here, 
again, we have an additional explanation of the 
value of simple cleanliness, in that not only is the 
number of organisms which enter a wound diminished, 
but, in all probability, the number of varieties is also 
less. 

The other local conditions which favour the entrance 
of these organisms may be generally summed up under 
the heading of those which produce a depreciation of 
the vitality of the part, such as mechanical injury, cold, 
the action of chemical substances such as carbolic 
acid, &c. Lastly, the local effect depends also to solne 
extent on the anatomical character of the part which 
is the seat of injury. For example, where the peri- 
toneum is opened, organisms, unless in concentrated 
form and of considerable virulence, are apparently 
rapidly destroyed, — much more rapidly than where the 
subcutaneous or muscular tissues are the parts which 
are involved. On the other hand, the lymphatic spaces, 



PHAGOCYTOSIS. 19 

bursae, sheaths of tendons, &c., are regions in which 
these organisms apparently grow with great readiness, 
and produce violent effects. 

As to the mode in which the tissues act in repelling 
the attacks of these organisms, the favourite theory at 
the present time is that of phagocytosis — that is to say, 
it is assumed that the products of certain organisms 
have an attractive action on white blood corpuscles 
and plasma cells, thus explaining the rapid emigration 
of the leucocytes from the blood vessels, and the infil- 
tration of the tissues in the immediate vicinity of the 
organisms. It is then further held that these leuco- 
cytes or plasma cells, or the tissue cells themselves, 
rapidly take up the organisms into their interior by 
means of their amoeboid movements, and there digest 
and destroy them. Athough there are strong reasons 
for believing that in its essential features this theory is 
more or less correct, it is doubtful whether the mode of 
action is quite so simple as I have just mentioned, and 
there are grounds for thinking that, in some cases at 
any rate, the first action on the bacteria is a chemical 
one, and is due to the effect of anti-bacteric substances 
which are present in the serum of the blood and in 
the fluids effused during the inflammatory process, and 
that it is only when the organisms have been weakened 
by the action on them of these substances that the cells 



20 TREATMENT OF WOUNDS. 

are able to take them up and complete their destruction. 
However that may be, it is certain that the tissues of 
the body when in a vigorous state have a great power 
of destroying not only saprophytic, but also pathogenic 
organisms, provided the latter are not present in too 
large numbers. 

It will be evident from what has already been said 
that the essential condition which interferes with 
healing by first intention or by blood clot, and which 
leads to the various septic diseases, is the entrance of 
organisms, especially of the pyogenic cocci, into the 
wounds. I must therefore say a few additional words 
with regard to these organisms, more especially with 
regard to their source and the methods by which their 
vitality and action may be interfered with. The chief 
source of the pyogenic organisms in the absence of a 
suppurating wound is the skin and mucous surfaces of 
the animal body. In former times, before the antiseptic 
era, it is no doubt true that the infection of wounds 
chiefly followed as the result of the direct carrying over 
of pus containing these organisms from one patient to 
another. The principles of cleanliness and disinfection 
were not at that time understood, and, consequently, 
instruments which had been used in a case where sup- 
puration was present retained the infective material, 
and conveyed it to the next case in which they were 



SOURCE OF THE BACTERIA. 21 

employed; and the same was the case with regard to 
the surgeons' and the nurses' hands, and the various 
applications to the wounds. At the present time, how- 
ever, even where strict asepsis is not carried out, such 
wholesale infection of wounds very rarely takes place, 
and, when a wound suppurates, the organisms are most 
usually derived from the skin of the patient in the 
vicinity of the wound, or from the fingers of the 
surgeon or of his assistants. A considerable number 
and variety of bacteria appear to inhabit the skin, 
especially in parts where moisture is present, — as in 
the axillae, perineum, &c, and there is perhaps no more 
certain source of bacteria than in the accumulations 
under the nails ; and among these bacteria, especially 
in parts where moisture is present, the various pyogenic 
organisms are not uncommonly found. In the mouth, 
and along the mucous canals, bacteria also grow in 
large numbers, and among them are organisms which 
are infective both in man and the lower animals, pro- 
vided they obtain the opportunity of entering the body. 
It is less frequent for the organisms to be derived from 
other sources, though, naturally, instruments which 
have been employed in dressing surgical cases, unless 
they are carefully cleansed, may communicate the 
infective material. Similarly, all dust contains bacteria, 
and although it is true that, as a rule, these bacteria 



22 TREATMENT OF WOUNDS. 

belong to the class of saprophytes, and are generally 
bacilli, usually in spore form, yet this is by no means 
always the case, more especially in hospitals where the 
dust may contain recently dried particles of pus, scales 
of skin, &c, in which pyogenic cocci may still remain 
alive, and which, therefore, coming in contact with the 
instruments, hands, sponges, &c, may lead to the infec- 
tion of the wound. Of the older surgical dressings, 
water dressing, lint, charpie, and, above all, poultices 
were also a frequent source of infection. At the 
present time, however, the chief source of these 
organisms is, as I have said, the skin of the patient or 
the surgeon, and also, to some extent, the dust which 
settles on surrounding objects. 

While speaking of the growth of these organisms in 
wounds, it is of interest to mention one or two points 
with regard to culture media when grown outside the 
body For example, it has been found in the case of 
many pathogenic bacteria that if grown in the presence 
of a large quantity of air or free oxygen, they multiply 
most luxuriantly, but do not produce anything like the 
amount of poisonous material which they do if air is 
excluded. It is further important to note that under 
such circumstances they gradually lose their infective 
properties, so that after a time they are unable to 
infect animals when introduced into the body. The 



ANTISEPSIS. 23 

degree of dilution of the nutrient material also affects 
their growth, and, as a matter of fact, where the 
amount of water present is much under 90 per 
cent, they grow with difficulty, and in more concen- 
trated solutions not at all. Hence, concentration of the 
material in which they are growing, hinders and 
ultimately arrests their development, whether this 
concentration be brought about by evaporation of 
water, ox by the addition of substances such as sugar 
in large amount, as is done in the preservation of 
fruits. 

The most important point, however, which we have 
to consider with regard to the life history of these 
bacteria, is their relation to heat and to various 
chemical substances. Bacteria vary greatly in their 
relation to heat according to their stage of existence. 
If growing rapidiy, and in the adult stage, they are 
readily destroyed at comparatively low temperatures 
but if they have passed into the spore form, they 
become the most resistent living bodies which are 
known in nature. Thus, spores of bacteria may be 
exposed to dry heat considerably above the boiling 
point of water for hours without losing their vitality ; 
while, on the other hand, the same bacteria if in the 
adult stage will be destroyed after a short exposure to 
dry heat of some twenty or thirty degrees above the 



24 TREATMENT OF WOUNDS. 

temperature of the body. Indeed, a thorough drying 
will, in a comparatively short time, even without the 
action of heat, lead to their death. The facts are 
similar with regard to the relation of bacteria and their 
spores to chemical substances. Organisms which in the 
adult stage are readily killed by weak solutions of 
various chemical re-agents, resist the action of the same 
substances to an extraordinary extent if in the spore stage. 
Thus, the spores of anthrax may remain in a 5 per cent, 
watery solution of carbolic acid for nearly twenty-four 
hours without losing their vitality ; while a few seconds' 
exposure to the same solution will suffice to destroy the 
adult organisms. It is fortunate for surgery that the 
organisms which belong to the class of cocci do not form 
these resisting spores, and that it is these organisms 
with which we have mainly to deal. Were it otherwise, 
attempts to prevent infection of wounds would be almost 
hopeless. It is true that certain pathogenic organisms 
which give rise to diseases of wounds belong to the class 
of bacilli and are spore bearing, the chief of these being the 
tetanus and the tubercle bacilli ; but these pathogenic 
bacilli are extremely rare in accidental complications of 
wounds unless directly carried from patients who are 
actually suffering from the disease, and their avoidance 
hardly enters into our calculations in operating through 
unbroken skin. On the other hand, the spores which 



ANTISEPTICS. 25 

may and undoubtedly do often enter wounds, belong to 
the class of saprophytic bacteria, and, unless under very 
special circumstances, are unable to develop in the 
wound or to cause any harm. The pyogenic cocci are, 
as I have said, very quickly destroyed (in a few seconds) 
by the action of a 5 per cent, solution of carbolic 
acid, and the same is true with even weaker solutions 
of this substance (such as 2J per cent.), and of various 
other substances. Of the other antiseptic agents which 
are employed in surgery, the chief is bichloride of 
mercury, in a -joVo or Woo watery solution, and these 
solutions seem to possess about the same rapidity of 
action as the solutions of carbolic acid already men- 
tioned. Many other substances have been introduced 
from time to time into the practice of surgery, but 
these two antiseptics still hold the chief place. 

It must also be noted that although these com- 
paratively strong solutions are required in order to kill 
these pyogenic organisms, the addition of a very small 
quantity to the nutrient substance will interfere with or 
completely inhibit their growth, and it is not, therefore, 
always necessary to employ materials of such concentra- 
tion as to cause the death of the organisms. An 
equally satisfactory effect may be produced provided 
that a quantity sufficient to prevent their growth is 
added to the material. This last is a very important 



26 TREATMENT OF WOUNDS. 

point, because these substances, while they destroy 
bacteria, also exert an injurious, mainly irritating, 
effect on wounds, and are also poisonous to the body 
generally when absorbed in sufficient amount. Another 
point which is of interest, especially as regards carbolic 
acid, is that the addition of a small quantity to the 
nutrient material may diminish the virulence of the 
organisms, and this is one of the methods employed in 
attenuating anthrax bacilli. And this may be in part 
the explanation of the advantage sometimes obtained 
from the use of carbolic acid by surgeons who do not 
employ all the precautions necessary to exclude bacteria 
from wounds. 



In speaking of the treatment of wounds, the reader 
will now understand that the treatment will vary 
according to the various circumstances of the case, and 
we must therefore discuss the treatment under these 
varying circumstances. In the first place, we have two 
great classes of wounds : — (i.) those which are made 
through previously unbroken skin, and which do not 
communicate with mucous surfaces ; and (ii.) those 
which are made through the mucous membrane, or 
which, if made through the skin, communicate with 
some mucous canal. This is an important distinction, 



CLASSIFICATION OF WOUNDS. 27 

because, while, as we shall see, in the first class of cases 
it is comparatively easy to exclude micro-organisms, 
in the second class this is practically impossible, and 
treatment must be directed to minimise their action. 

The first class of wounds — namely, those made 
through the skin, may again be subdivided into (1) 
wounds that have been made by the surgeon through 
previously unbroken skin; (2) those where the wound 
is quite recent, but has not been made by the surgeon ; 

(3) where the wound, also not made by the surgeon, 
has existed for some days, or where, in the case of a 
wound made by the surgeon, sepsis has followed ; and 

(4) wounds of still older date which have assumed the 
form of sinus or fistula. 

Of wounds made by the surgeon through previously 
unbroken skin, we have again two classes : — (a) those 
where the edges of the skin can be brought together ; 
and (b) those where the edges of the skin cannot be 
brought together. Wounds, whether recent or old, 
which have not been made by the surgeon, may again 
be divided into incised wounds, lacerated wounds, con- 
tused wounds, and burns. Of the old wounds which 
have passed into the condition of sinus, we have two 
classes : — one class where we have what may be termed 
a simple, non-specific sinus, which again may be either 
aseptic or septic; and the other where the sinus con- 



28 TREATMENT OF WOUNDS. 

tains some specific new growth in its wall; I refer 
especially to the presence of the tubercular virus. It 
will be necessary, in considering the treatment, to refer 
to each of these kinds of wounds separately. 



Wounds made by the Surgeon through previously 
unbroken skin where the edges of the 
Skin can be brought together. 

In such wounds we must naturally aim at obtaining 
healing by first intention, and in order to get this, we 
have to provide for rest of the part, for the absence of 
any mechanical or chemical irritation, and above all for 
the absence of pyogenic organisms ; in other words, in 
order to make certain of obtaining this result we must 
treat the wound aseptically or antiseptically. I shall, 
in the first instance, describe the various precautions 
which make up the Listerian method of treatment, and 
which I believe to be in practice far superior to the plan 
which has been employed on the Continent, more 
especially by German surgeons — namely, of attempt- 
ing rigid asepsis as opposed to the employment of anti- 
septics. 

In the first place, as the skin is the most common seat 
of these pyogenic organisms,it is absolutely essential that 



LISTERIAN TREATMENT. 29 

they should be thoroughly removed from it, and this 
can only be done by the application to it of suitable 
antiseptic substances ; and the substances which are 
chiefly employed for this purpose are either 1 to 20 
carbolic acid lotion, or a strong solution, 1 to 500 or 1 
to 1000, of corrosive sublimate. These bacteria growing 
on the skin inhabit especially the surface epithelium 
and the outside of the hairs, and penetrate to a slight 
extent into the sebaceous and hair follicles, and care 
must be taken that the antiseptic substances employed 
shall thoroughly impregnate and act on the bacteria 
contained in these parts. At first the method employed 
by Sir Joseph Lister for obtaining disinfection of the 
skin was the simple application to the part for a short 
time before the operation of a 5 per cent, watery solu- 
tion of carbolic acid, and he still adheres to this plan. 
The carbolic acid is certainly much more potent than 
strong corrosive sublimate, because the surface of the 
skin is covered with grease, and the carbolic acid having 
an especial affinity for oily substances, soaks into and im- 
pregnates these fatty materials, while, on the contrary, 
the sublimate solution does not appear to have any such 
effect, and does not reach and act on the deeper parts. 
On the other hand, it has been asserted as the result of 
experiments that this solution of carbolic acid is not 
efficient for the thorough disinfection of the skin ; and 



30 TREATMENT OF WOUNDS. 

this is probably correct in certain regions, such as the 
axillse, where the sebaceous and hair follicles are large, 
and where there is an excessive amount of fatty material, 
but it seems that a sufficiently lengthy application of 
1 to 20 carbolic acid to the skin where there are no 
large hairs or sebaceous follicles, may completely disin- 
fect it. It must be borne in mind that it is compara- 
tively easy to disinfect the surface, of the skin, and that 
thus one may avoid introducing organisms at the time of 
the operation ; the difficulty is to get rid of the bacteria 
from the deeper parts (hair follicles and sebaceous 
glands), and though as a rule these are innocent organ- 
isms, and either do not get into the wound subsequently, 
or if they do, cause no harm, still it is best to take more 
thorough measures, so as to get rid of them altogether. 

Abroad, the disinfection of the skin is a very elaborate 
process, means being taken to remove the fat in the 
first instance, most usually by washing with ether and 
alcohol, to remove the surface epithelium by the use of 
the nail brush, and then to thoroughly saturate the skin 
with various antiseptic materials. In a recent paper 
by Mr. Lockwood, it has been stated that the ordinary 
methods of disinfection of the skin are quite inefficient. 
Mr. Lockwood was not content with the ordinary test 
of scraping portions of the epidermis from the surface 
of the skin after the use of the disinfecting agents, but 



DISINFECTION OF SKIN 31 

actually took pieces of the whole thickness of the skin 
and placed them in various cultivating fluids, and appar- 
ently, if his experiments are correct, even the use of 
very elaborate methods of disinfection failed to answer 
the purpose. I have very recently taken the trouble 
to repeat these experiments with totally different 
results. If only the experiment is done with all 
suitable bacteriological precautions, I have found that 
even Sir Joseph Lister's original simple method of 
applying the 5 per cent, solution of carbolic acid to the 
skin for half an hour before the operation, was, in a 
considerable number of cases, satisfactory on the skin 
of the trunk ; and where a somewhat more elaborate 
method which I shall immediately describe, was 
employed, I see no reason to doubt that thorough 
disinfection of the skin may be relied on. It is quite 
evident that some error in the bacteriological methods 
has crept into Mr. Lockwood's experiments. 

The method which I now always employ for dis- 
infecting the skin is, in the first instance, to shave 
the part to be operated on and a large area around, 
and then wash it thoroughly with soap and a mixture 
introduced by Sir Joseph Lister of 1 to 20 carbolic 
acid lotion containing a 500th part of corrosive 
sublimate in solution. Having washed away the 
greater part of the grease in the first instance in this 



32 TREATMENT OF WOUNDS. 

manner, I then saturate the surface with turpentine, 
and after two or three minutes again wash thoroughly 
with soap and strong mixture, employing a nail brush 
with the view of removing all the loose epithelium from 
the surface. This performance takes about five minutes, 
and is, as far as I can judge, both clinically and 
bacteriologically, thoroughly efficient; but in parts 
where disinfection is especially difficult, as in the case 
of axillae, or where any error in the antiseptic manage- 
ment might lead to very serious consequences, as, for 
example, in operations on healthy joints, I generally 
have the preliminary washing with soap, strong mixture, 
the nail brush and turpentine carried out an hour or 
two before the operation, cloths soaked in the strong 
mixture being then applied and kept on till the time of 
the operation when the whole process is again repeated. 
This repetition of the process is also of advantage, 
because, while doing it, the surgeon at the same time 
disinfects his own hands, perhaps more thoroughly than 
he otherwise would. Hence I always do it myself just 
before the operation. 

Special care must be employed in the disinfection of 
the nails, all the folds about the nails must be 
thoroughly saturated with the solutions and scraped 
and all accumulated epidermis and dirt must be 
removed from beneath the edge of the nail. 



DISINFECTION OF INSTRUMENTS. 33 

All the instruments which come into contact with 
the wound must also be thoroughly disinfected, and 
this is generally quite satisfactorily accomplished by 
immersing them for two or three hours before the 
operation in 1 to 20 carbolic acid solution. Some 
surgeons, however, more especially abroad, are much 
more careful with the disinfection of the instruments, 
and boil them for ten minutes or a quarter of an hour 
immediately before the operation. This is readily 
accomplished by placing them in a perforated tray, 
which is immersed in water containing a considerable 
quantity of salt or soda so as to raise the boiling point 
of the water. When boiled long enough the tray is 
lifted out of the water and allowed to cool under cover. 

For my own part, I believe that except when the 

instruments have been used for some specially infective 

bacillary disease such as tetanus, this is an unnecessary 

precaution ; but, at the same time, it is certainly very 

convenient to have this vessel of water boiling during 

the operation, in case any instrument which has not 

been previously prepared is required, or in case an 

instrument falls on the floor, on a blanket, &c. Such 

instrument can be immersed in the boiling water for a 

few minutes, and then be relied on as being thoroughly 

aseptic. This can, however, be equally effectually, and 

much more rapidly done by dipping the instrument in 
3 



34 TREATMENT OE WOUNDS. 

undiluted carbolic acid for a few seconds, and then 
washing it in 1 to 20 carbolic acid before its use. 
Naturally, the method of boiling the instruments can 
only be employed in cases where the instruments are 
made entirely of metal. I do not myself as a rule boil 
my instruments as I see no advantage in it, nor do I 
think that the minute quantity of carbolic acid 
conveyed to the wound by them when disinfected by 
immersion in carbolic acid does any harm. 

The skin and instruments being in this way 
thoroughly prepared, precautions must be taken against 
any further infection of them during the course of the 
operation, and it may seem superfluous to point out 
that the hands must, of course, remain wet with the 
antiseptic solutions from the time that the disinfection 
has been carried out were it not that one often sees 
surgeons after disinfecting their hands wiping them dry 
on towels or blankets, or anything which is at hand, and 
thus infecting them again. In order to prevent the 
accidental contamination of instruments, hands, and the 
skin of the patient, towels soaked in 1 to 20 carbolic 
acid, or in 1 to 2000 sublimate solution should be 
arranged around the wound, covering the blankets 
in the vicinity, so that any instruments or the 
hands shall only come in contact with this wet 
and disinfected basis. And further, I always like to 



SPONGES. 35 

have at hand a basin containing 1 to 2000 corrosive 
sublimate solution, in which the hands and instru- 
ments are frequently dipped during the course of the 
operation. 

During the progress of the operation also, I, from 
time to time, fill the wound with this same solution by 
squeezing a sponge into it. I do not think that this is 
absolutely necessary — at any rate until one comes to 
stitch up the wound — but, at the same time, it does no 
harm, is no trouble, and forms an additional precaution. 
I seldom employ actual irrigation for a wound, even 
while stitching up, with the exception of cases where 
healthy joints are opened, as, for example, in wiring a 
fractured patella, when I like to have a more or less 
constant stream of warm 1 to 4000 or 1 to 6000 
sublimate solution running over the wound during the 
whole operation. 

As regards the sponges, it is becoming the fashion 
in some hospitals to discard the use of sponges alto- 
gether, and to employ in place of them pads of ab- 
sorbent wool which have been soaked in an antiseptic, 
but this is a plan for which I see no particular object, 
and which I consider to be dangerous. I have often 
seen nurses bring into the room a basinful of these dry 
pads of non-antiseptic wool which have not been dis- 
infected, and then simply rinsing them in weak anti- 



36 TREATMENT OF WOUNDS. 

septic solution, squeeze and hand them to the surgeons. 
Such a plan must be a fruitful source of infection, and 
a further disadvantage seems to me to be that portions 
of wool are often left behind in the wound, which is 
especially dangerous if the wool has not been carefully 
disinfected. On the other hand, I see no objection 
whatever to the employment of sponges if proper care 
is taken, and they are certainly far more efficient for 
the purpose for which they are required. We may take 
it as an axiom that any substance which is thoroughly 
soaked in 1 to 20 carbolic acid watery solution for 
twenty-four or say forty- eight hours is absolutely dis- 
infected, and therefore one need not fear the conveyance 
of infective material by means of sponges if they are 
always kept in these solutions when not in use. As an 
extra precaution, I generally keep three sets of sponges, 
one which has only been used in cases of operation 
through unbroken skin, one which is employed in septic 
cases, and one which is reserved for tubercular cases ; 
but I must candidly confess that I think that this is a 
refinement. After the operation, the sponges are 
thoroughly washed in the first instance in cold water, 
and then allowed to soak for some hours, then they are 
again washed in cold water, subsequently in warm 
water, and then with soap and water, with perhaps a 
little soda in it. They are then placed in a jar contain* 



SPONGES. 37 

ing fresh 1 to 20 carbolic acid solution, which must be 
renewed every two or three days — because the carbolic 
acid very quickly disappears from it — and they are 
afterwards kept in this solution. As a rule, a week 
elapses before they are again employed. When required 
for use, they are wrung out of the carbolic acid and 
washed in 1 to 2000 sublimate solution, and the sponges 
are then placed in a basin containing 1 to 2000 solution, 
which stands, or is held within reach of the surgeon or 
his assistant, who wrings them out whenever he requires 
them. The chief error which is commonly committed 
in the use of sponges is that the nurse wrings them out 
of the antiseptic solution, and places them in a dry basin, 
which very often has not been previously disinfected, 
perhaps she then does something else — makes the bed, 
or what not — -and without disinfecting her hands, gives 
the dry sponge to the surgeon, not uncommonly wiping 
the sleeve of his coat in so doing. All these troubles 
are avoided if, as I have said, the sponges are not wrung 
out of the lotions by the nurses, but are kept at hand 
in soak, and only wrung out immediately before use by 
the surgeon or his assistant. I ought to state that in 
the place of 1 to 2000 sublimate solution for the fingers, 
instruments, and sponges, Sir Joseph Lister has now 
returned to the employment of 1 to 40 carbolic lotion, 
but for my own part I prefer the sublimate solution, 



38 TREATMENT OF WOUNDS. 

more especially because it is less irritating to the hands 
and to the wound. 

As regards the arrest of haemorrhage, I must confess 
that I do not pay such particular attention to it as I 
used to do, or as some surgeons do, because the oozing 
from the smaller vessels is easily stopped by pressure 
which I usually employ as a substitute for a drainage 
tube. As a matter of fact, if, as the operation goes on, 
all the vessels which spout are clamped with pressure 
forceps, it will be found at the end of the operation that 
very few indeed of these vessels bleed ; and if the bleed- 
ing is only a slight oozing, I generally content myself 
with torsion ; in fact, in any case, I generally twist the 
vessels before taking off the pressure of the forceps. 
The result is that only two or three veins, and perhaps 
one or two of the larger arteries require ligature, and 
thus much time is saved where the wound is extensive. 

As regards the nature of the ligature to be employed, 
I fail to see the objections to catgut which are advanced 
by many. Of course, it must be admitted that catgut 
prepared in the old manner in carbolic oil is very often, 
as it comes from the instrument maker, a septic material, 
but it is now a good many years since Sir Joseph Lister 
abandoned the employment of catgut prepared in this 
way, and adopted in place of it catgut prepared by 
sulphurous acid and chromic acid after the manner 



LIGATURES AND STITCHES. 39 

described by him some years ago. This catgut, in 
the course of its preparation, is disinfected, and if 
it is kept in 1 to 20 carbolic acid for some days 
before use, it may be relied on as being thoroughly 
aseptic. The experiments which have been made, 
and which have thrown doubt on the asepticity of 
catgut, were made partly with catgut prepared by the 
oily solutions and partly with dry catgut obtained from 
the manufacturer, which of course must be covered with 
bacteria. But that is not the form under which catgut 
is or should be used. A few days' immersion in 1 to 20 
carbolic acid will remove any living bacteria, and it is 
the rule at the hospital that fresh catgut shall be put 
to soak in carbolic lotion for at least a week before it is 
required. 

Having completed the operation and arrested the 
haemorrhage, we next proceed to stitch up the wound, 
and here various procedures are adopted. At the 
present time, the tendency is to omit drainage of the 
wound as far as possible, and in order to avoid the 
formation of a cavity in the deeper part in which blood 
may collect, some surgeons devote much time and care 
to the insertion of deep stitches of catgut or fine silk, 
with the view of bringing the deeper part of the wound 
together. This may be necessary in some cases, where 
the sides of the wound are formed of more or less rigid 



40 TREATMENT Of WOUNDS. 

material, as, for example, in the removal of an adenoma 
from the centre of the breast, and also where muscular 
fibres have been divided which it is desirable to unite 
again, but, as a rule, I believe that the deeper parts of 
the wound can be brought into effectual apposition by 
means of pressure applied in the dressing, and therefore 
for my own part, in the great majority of cases, I limit 
the stitches to the skin edges. Where there has been 
no removal of skin, there is no difficulty in bringing the 
edges accurately together without any tension, and in 
such cases I generally use a stitch of fine silk applied 
as a continuous suture, after the fashion of the button- 
hole stitch. 

Much has been written and said about the pre- 
paration of silk for use as ligatures, or as deep and 
superficial stitches, and some surgeons take a great 
deal of trouble in the way of boiling and otherwise 
preparing their silk. Such measures are, to my mind, 
absolutely unnecessary. The Chinese twist, as it comes 
from the manufacturer, is almost quite aseptic ; and all 
that is requisite, to ensure its asepticity, is to keep it for 
a few days in 1 to 20 carbolic acid solution. It is too 
often the case that a surgeon pays a great deal of attention 
to the boiling of his instruments and his ligatures, and 
forgets to properly disinfect the skin, or omits some other 
essential step during the performance of the operation. 



STITCHES. 41 

Of other substances which can be used for stitches, 
may be mentioned silver wire, which, I think, is only 
suitable for skin stitches, and not for employment sub- 
cutaneously, as is done by some in the treatment of 
hernia; horse-hair, which is also useful in the skin; 
silkworm-gut, which may be employed both sub- 
cutaneously and superficially; and catgut, especially 
for mucous surfaces. 

In cases where a considerable amount of skin has 
been removed, it is usually necessary to insert an 
additional set of stitches, perferably of thick silver wire, 
with the view of removing the tension on the edges of 
the wound. These have been termed, by Sir Joseph 
Lister, " stitches of relaxation," while those which are 
employed for uniting the edges of the wound are called 
"stitches of coaptation." Where the loss of skin has 
not been great, it is sufficient to put in a few 
stitches of thick silver wire at a little distance from 
the edge, and to tie the wire in the usual manner ; but 
if a large amount of skin has been taken away, it is 
well to employ the silver wire in the form described by 
Sir Joseph Lister as " button sutures " — that is to say, 
the needle carrying the silver wire is entered at a con- 
siderable distance from the edge of the wound and a 
largish flat piece of lead is attached to the end, the 
needle is then carried across the wound and passed 



42 TREATMENT OF WOUNDS. 

out at a corresponding distance from the edge on the 
opposite side, and to this end also a lead button is 
attached. In the case of a large wound, such as after 
removal of the breast, probably two pairs of these 
button stitches will be required, some half-dozen 
stitches of silver wire near the edge of the wound, 
and then a continuous silk suture from one end to 
the other. It must always be remembered that no 
stitch must be drawn tighter than is required to 
secure the object of bringing the edges of the wound 
into contact. To pinch up the wound, in the way 
which one sometimes sees done, is to interfere with 
the circulation in the part, and to introduce an un- 
necessary element of irritation, which may lead to 
failure of union by first intention. 

In speaking of stitches, I may refer to the subject of 
buried stitches, employed with the view of preventing 
the appearance of stitch marks. In many wounds 
which have healed by first intention, the stitch marks 
are more evident than the line of incision itself ; and 
it is sometimes a matter of great importance — especially 
on the face or neck in women — to diminish the scar as 
far as possible, and there is nothing which conduces 
more to this end than the avoidance of stitch marks. 
This can be done by the uniting the deepest portions of 
the dermis by the finest catgut stitches, these stitches 



STITCHES. 43 

not passing through the external surface of the skin at 
all. The edge of the incision is turned outwards, and, 
by means of a fine curved needle, preferably Hagedorn's, 
held firmly in a needle-holder, a stitch is passed through 
the very deepest part of the skin, and subsequently 
through a corresponding part on the opposite side. 
The number of stitches necessary to bring the edges of 
the wound together are, in the first instance, passed, 
and then they are tied, the knot being pushed into the 
fat beneath the skin. In this way the deeper parts of 
the dermis are brought into accurate apposition, and 
the superficial line of incision is readily united by strips 
of gauze fixed with collodion. A strip of gauze is fixed 
along the skin on one side of the wound by means of 
collodion, and, when this has thoroughly dried, the 
edges of the wound are pressed together, and the other 
end of the strip similarly attached to the opposite side. 
The stitches, if of finest catgut, give no trouble ; and 
when this dressing is removed, about a fortnight after 
the operation, the delicate line of incision is often barely 
visible. 

A very important question is that of drainage. In 
the former books which I wrote on antiseptic surgery, 
I laid very great stress on the thorough drainage of the 
wound, and at that time it was apparently a matter of 
great importance. The explanation of that was 



44 TREATMENT OF WOUNDS. 

probably in the first place that the wound was much 
irritated during the progress of the operation by the 
carbolic acid which was constantly poured into it in 
the form of spray and lotions, and consequently an ex- 
cessive amount of effusion took place from the blood 
vessels and collected in the wound rendering an outlet 
necessary; and further, before the introduction of 
corrosive sublimate, and before the necessity for great 
thoroughness in the disinfection of the skin was re- 
cognized, there is no question that organisms did some- 
times enter wounds at the time of the operation or soon 
after, and if these wounds contained a quantity of serum, 
they might grow there and cause disturbance. For two 
reasons, then, drainage was formerly necessary to carry 
off the effused serum, namely, in the first place to pre- 
vent tension in the wound, and in the second place to 
remove the material in which saprophytic or other bac- 
teria might grow. Of late, the use of the spray and of 
carbolic acid as an application to wounds has been 
given up, and we no longer have a large amount of 
serum poured out as was formerly the case; the cor- 
rosive sublimate seems to answer equally well as a dis- 
infectant, not irritating the wounds to anything like 
the same extent ! In the second place much greater 
care is taken in disinfecting the skin, and there is less 
likelihood of organisms entering the wounds at the time 



DRAINAGE. 45 

of the operation. In most cases, if a moderate amount 
of pressure is applied, so as to keep the deep parts of 
the wound in contact, drainage is not necessary. In 
cases, however, where an operation has been conducted 
through unbroken skin, and where there is no reason 
for suspecting infection of the wound, and where pres- 
sure can be satisfactorily applied, drainage is unneces- 
sary. In some cases, however, pressure cannot be 
satisfactorily employed, and in such instances it is best 
to insert a drainage tube for a few days. Such cases 
are, for example, amputations, where pressure cannot of 
course be applied to the flaps ; excision of the breast in 
feeble and spare individuals, where the skin flaps are 
thin ; after removal of half the thyroid gland, where 
pressure cannot be applied on account of interfering 
with the breathing ; where tumours are removed from 
the breast and where the rigid breast substance around 
prevents proper pressure ; in very fat people, and so on. 
But in the great majority of wounds, as I have said, 
drainage is not necessary; and in place of it I introduce 
into the middle of the dressing a sponge, or sponges, of 
sufficient size to press on the whole area of the wound. 
Where drainage tubes are employed, as in the cases 
cited, they need not be left in for more than two or 
three days, so as to allow any blood or serum which 
may have formed in the early period to escape. 



46 TREATMENT OF WOUNDS. 

If the case is dressed in say three days, the drainage 
tube may be left out and a permanent dressing 
applied. 

The next point is the sort of dressing which should 
be applied to the wound. The number of antiseptic 
materials in use at the present time is very considerable, 
and several of them are quite satisfactory. The one 
which I now always use is the gauze impregnated with 
the double cyanide of mercury and zinc, which was in- 
troduced some years ago by Sir Joseph Lister. For 
private work I keep this gauze in a jar containing 1 to 
4000 bichloride of mercury solution, and before use 
wring out the quantity required and place it in a 
sponge-bag which has been sponged with 1 to 20 
carbolic acid. It is apparently necessary to wring out 
the gauze thoroughly in some weak solution in order to 
get rid of the quantity of free bichloride of mercury 
which is apt to be present in it, and which, if applied 
to delicate skin, may lead to the formation of blisters. 
I believe that Sir Joseph Lister wrings his gauze out of 
1 to 40 carbolic lotion, which, of course, is equally 
efficient from an antiseptic point of view, but I have 
become very much impressed with the poisonous action 
of carbolic acid on young children, and therefore as the 
mercurial solution is equally satisfactory, and in case 
there should be any mistake, I use the 1 to 4000 or 1 



DRESSING. 47 

to 6000 sublimate lotion. It is necessary, of course, to 
wet the gauze with an antiseptic lotion, before applying 
it to the wound, not only in order to get rid of the free 
bichloride of mercury, but also to disinfect it, because 
this gauze as it comes from the manufacturer and 
reaches the surgeon's hands, after passing through the 
hands of various nurses, &c, is covered with bacteria, 
and, if applied in the dry state to the wound as some 
surgeons do, for reasons which are not very evident, 
these bacteria may very readily be communicated to 
the wound and penetrate into it before any of the anti- 
septic contained in the gauze has been dissolved in the 
serum and been able to inhibit their growth. The 
wound having been stitched up, this gauze is thoroughly 
wrung out of weak lotion (1-40 carbolic, or 1-4000 sub- 
limate) and applied in a large quantity not only to the 
wound, but to a wide area around. One of the most 
common faults which is committed in applying an anti- 
septic dressing is that the surgeon is too economical, 
and limits his dressing to a very small area around the 
wound. The result is that unless it is very tightly 
bound on, the edge of the wound is apt to become ex- 
posed, or, indeed, the dressing may slip off it entirely, 
while, if it keeps its place, the distance between the 
edge of the dressing and the wound is so short, that, as 
I showed years ago, if the dressing is left on for some 



48 TREATMENT OF WOUNDS. 

days, bacteria will be able to grow protected by tbe 
superficial layers of epithelium and reach the wound, 
and may set up trouble. I think that too extensive a 
dressing cannot be applied, though, of course, there 
must be a certain limit to avoid unnecessary waste. 
Having placed a few layers of gauze over the wound 
and the surrounding parts, large sponges, according as 
is necessary, are then thoroughly wrung out of the 
antiseptic solution and arranged over the region of the 
wound, of course, only in cases where no drainage tube 
is employed ; further layers of gauze are then placed 
outside the sponges, and over all a thick mass of salicy- 
lic wool, and then a bandage, put on with fairly firm 
pressure so as to bring the deeper parts of the wound 
in contact. The moisture in such a dressing very soon 
dries, and, in the course of a day or two, it becomes a 
dry dressing, which has certain advantages, in that it 
adheres firmly to the skin, and that the fluids being 
concentrated, bacteria cannot spread inwards. The 
object in employing the salicylic wool is not so much to 
furnish an additional antiseptic layer as to apply a 
material, which, while it permits evaporation, at the 
same time leads to the diffusion of the blood and serum 
over a considerable extent of the cyanide dressing. 
The salicylic wool is never really properly absorbent, 
and the consequence is that the discharges seldom soak 



CHANGING OF DRESSINGS. 49 

into the wool to any extent, but are diffused through 
the gauze. As a matter of fact, however, where 
sponges are employed, the discharge from the wound 
is extremely slight, and seldom reaches the wool 
at all. 

Such a dressing is usually left undisturbed for about 
ten days, unless there is some reason for changing it, 
such as discomfort, fever, or a suspicion of the occur- 
rence of sepsis ; but in by far the great majority of 
cases, no interference is requisite for about ten days. 
The old rule that dressings required to be changed very 
shortly after discharge shows itself, is not now neces- 
sary. As a matter of fact, it is not uncommon with 
the dressings I have described, where no mackintosh 
is used, for blood to appear at the edge of the dressing 
within a few hours after the operation, but this blood 
very quickly dries up, and does not form a cultivating 
medium for the growth of bacteria in the same way as 
it might do if prevented from drying by a layer of 
mackintosh. And further, the double cyanide salt is 
present in the gauze in large amount, and while it is a 
powerful inhibitory agent against bacteric growth, it is 
only slightly soluble, and is not, therefore washed out 
by the first blood which passes through. In the groin, 
neck, and other parts where there is movement, it may 

be well to apply a piece of elastic webbing round the 
4 



50 TREATMENT OF WOUNDS. 

edges of the wound, and also, where it is deep, over the 
sponge. 

When the dressings are changed at the end of ten 
days the wound is found to be soundly healed, the 
stitches are taken out, and a small piece of gauze or 
salicylic wool is fixed over the line of suture for a few 
days by means of collodion. In changing the dressing, 
the lotion which I usually employ is 1 to 2000 
sublimate, unless in the case of wounds such as those 
in the axillae, hernia wounds, varicocele, &c, where it 
is well to wash the surrounding parts thoroughly with 
1 to 20 carbolic solution. I generally use, in order to 
wash the wound clean, a piece of the deeper layer of 
the salicylic wool which has just been removed, and 
which is, being the deeper layer, free from dust and 
aseptic. The region of the wound should be sur- 
rounded by a towel wrung out of an antiseptic solution 
in the same way as during the operation. There is an 
advantage in leaving the dressing undisturbed where 
drainage tubes are not employed, because, as I have 
said, the discharge from the wound very quickly dries 
up, and the dressing adheres firmly to the skin, and 
thus forms a kind of splint which keeps the part at 
rest. If this dressing is removed too early, the wound 
is very apt to be disturbed, and the union between the 
deep surfaces may even be torn asunder. As a rule, 



REST TO THE WOUND. 51 

there is no discomfort on the part of the patient which 
calls for interference, unless it may be that the bandage 
is tight, and this may of course be removed and a looser 
one applied after twenty-four or forty-eight hours 
without disturbing the dressings. 

Such is shortly a description of the treatment of an 
operation wound on the lines which have been laid 
down and developed by Sir Joseph Lister ; but I have 
already mentioned that in addition to the avoidance 
of sepsis, which is the chief point to be attended to, 
the part must be kept at rest and other causes of 
disturbance avoided. Tn cases where the wound has 
been made in the extremities, or over muscles which 
may be frequently called into action, it is well to 
place the part on a splint and fix it for some days. 
In cases where the wo and is in the neck, as, for 
example, after the removal of tubercular glands, it is 
very important, not only in order to obtain a nice 
linear scar, but to get good adhesion of the deeper 
parts, that the neck should be kept completely at rest. 
This is usually quite satisfactorily done if a large mass 
of salicylic wool is applied outside the dressing and 
firmly fixed in its place ; but in very restless children 
it may be desirable to employ a splint somewhat after 
the pattern described by Mr. Treves, which rests on the 
shoulder, is fixed around the waist, and runs upwards 



52 TREATMENT OF WOUNDS. 

towards the head, and ends above in two prongs which 
grasp each side of the head. In the case, for example, 
of excision of the breast with the axillary glands, it is 
of importance to fix the arm to the side for some 
days, and this is done by means of a broad binder 
which surrounds the body, including the arm on the 
affected side, and passes beneath the axillae of the 
opposite side. 

As regards the avoidance of the irritation of the 
dressings, this need hardly be taken into account 
where the wound is closely united and dressed in the 
manner in which I have described, because the blood 
which soaks the dressing lying over the line of 
incision, quickly dries up and fixes the dressing so 
that it does not rub, and if the bandage is sufficiently 
firmly applied, there will be no mechanical irritation of 
the wound from this cause. Where silver stitches are, 
however, applied, it is sometimes desirable to interpose 
a layer of Lister's protective oiled silk between the 
dressing and the edge of the wound, not with the 
original idea of excluding the antiseptic, but in order 
to prevent the ends of the wire catching in the gauze, 
and so fretting and irritating the wound on any move- 
ment of the patient. 

It need, of course, hardly be stated that the general 
condition of the patient must be thoroughly attended 



DIET. 53 

to during the treatment of the wound. As a rule it is 
unnecessary, after the period of chloroform sickness has 
passed off, to restrict the patient's diet in any way 
For the first day or two the patient's appetite is usually 
bad, indeed for the first day he generally retains some 
effects of the chloroform, and during that time fluids 
beef-tea, and milk, are probably all that he cares to 
take ; but on the second or third day, light diet may be 
given — fish, chicken, and so forth, and after the third 
day he may be allowed to have his ordinary food. It 
is somewhat difficult to get rid, even yet, of the former 
tradition of keeping patients on low diet after an 
operation in the hope of diminishing or avoiding 
inflammation, and therefore it is well to mention this 
point specifically. It should also be stated that a laxative 
will be necessary after the operation, and should usually 
be administered on the second or third day. Of course, 
if there is any constitutional conditions present re- 
quiring special general treatment such as diabetes, 
albuminuria, it must be attended to. 

After the various points which I have described 
have been successfully carried out, the wound follows 
what may be termed a typical aseptic course. As 
regards the wound itself, the patient may, and very 
often does experience no pain at all after the opera- 
tion. Where, however, much tension has been employed 



54 TREATMENT OF WOUNDS. 

in bringing together the edges of the wound, and also 
in other cases, especially where sensitive parts have 
been operated on, or when the patient is himself 
hyper-sensitive, there may be some and even consider- 
able pain for the first few hours after waking from 
the anaesthetic, but this gradually and quickly dis- 
appears, so that after twenty-four hours the pain is 
only evident on movement, and after thirty-six or 
forty-eight hours the part is perfectly comfortable. 
The continuance or subsequent occurrence of pain in 
the wound would raise the suspicion that something 
was not quite right. 

If the wound is looked at during the early period, 
it will be found that the skin is of a perfectly natural 
colour, that there is no swelling or tenderness of the 
edges, that, in fact, it presents the same appearance 
as it did immediately after the stitches were inserted ; 
and even at a later period, when the dressing is finally 
removed, unless the stitches have been tight, there is 
no evidence of any irritation of the wound at all. 
In cases where the stitches have been very tight, 
one or other of them may be cutting its way through 
the skin to some slight extent, and around these there 
may be a slight blush of redness and a slight tenderness. 

The constitutional condition of the patient is also 
practically undisturbed. For a few hours, and even in 



ASEPTIC COURSE. 55 

some cases for twenty-four or thirty-six hours, the 
patient is sick or feels uncomfortable as the result of 
the anaesthetic, but after the second or third day, 
especially after the bowels have acted, the appetite 
returns, and the patient feels in his usual state of health. 
The temperature on the evening of the operation is 
usually either normal or slightly above it, or, if the 
operation has been a very severe one, may be sub- 
normal. Towards the end of the twenty-four hours, 
however, in cases of operations of any considerable 
extent, it rises it may be to from 100° to 101° Fahr., but 
it again rapidly falls, so that by the end of the second 
day it has generally returned again to normal, and 
there is no further variation unless some accidental 
disturbing cause comes into play. 

One word with regard to private practice. The 
Listerian method of treatment is quite readily carried 
out in private practice. In most cases a nurse will 
be in the house for some hours at any rate, very 
possibly the night before the operation, and she is 
instructed to wash the skin thoroughly with turpentine 
and the strong mixture and soap some two or three 
hours before the time of the operation ; or, if she is 
in the house to do this on the previous evening, 
leaving a cloth wet with 1 to 20 carbolic lotion, and 
covered with mackintosh over the part after it has 



56 TREATMENT OF WOUNDS. 

been washed, unless in the case of children. As 
regards the lotions, it is not necessary to carry the 
lotions made up to the proper strength, one carries 
some undiluted carbolic acid and a number of com- 
pressed pas tiles of corrosive sublimate, and by means 
of these solutions of the required strength can be 
made in a few minutes. As to the disinfection of 
the instruments I generally thoroughly scrub my in- 
struments with 1 to 20 carbolic acid before putting 
them away after an operation. They are kept in a 
glass instrument press, which is from time to time 
washed out with 1 to 20 carbolic acid, and which is 
almost entirely dust-tight. When required, therefore, 
in a hurry, they are in reality pure, and a compara- 
tively short immersion in 1 to 20 carbolic acid will 
remedy any accidental contamination which may occur 
after they are taken out of the glass press. If, how- 
ever, there is any reason to suspect any particular 
instrument, it is certainly disinfected if plunged into 
the undiluted carbolic acid which is carried by the 
surgeon for the purpose of making his solutions. The 
sponges after an operation are washed as before de- 
scribed, and kept in 1 to 20 carbolic acid. When 
required they are wrung out and carried in a sponge 
bag, which has been thoroughly rinsed in the same 
solution. The dressings are also carried in pure sponge 



ASEPSIS. 57 

bags. The catgut and silk are carried wound on reels, 
which are kept in 1 to 20 carbolic acid in a glass- 
stoppered bottle. Turpentine is obtainable practically 
in any house. In this way the treatment is carried out 
in private practice with the same certainty as in 
hospital, and without any material trouble. 



I have already referred to methods which are em- 
ployed — more especially by certain German surgeons — 
in which the use of antiseptics are as far as possible 
avoided. Their methods are undoubtedly theoretically 
perfectly correct, and practically can be successfully 
carried out by a skilled bacteriologist, but the risks of 
error are so great — and from the absence of antiseptic 
solutions there is no possibility of correcting them — 
that an ordinary surgeon, who has not had a pro- 
longed bacteriological training, will find it a matter of 
the greatest difficulty, indeed, almost impossibility, to 
obtain results which are at all comparable with those 
which he would obtain were he to use the Listerian 
method; and for this reason, although I shall, in a 
few words, mention the methods, I should strongly 
dissuade any one from attempting to employ them. 
To my mind they possess no practical advantage over 
that which I have just described, while, as I have 



58 TREATMENT OF WOUNDS. 

said, they are much more complicated, although, 
from a superficial point of view, apparently much 
more simple. This will be evident in the course of 
my description. 

In this method of treatment the greatest precautions 
are taken to disinfect the skin both of the patient and 
of the operator, it being thoroughly scrubbed with ether, 
permanganate of potash, oxalic acid, and a variety of 
substances, much time and trouble being spent over it. 
Here the use of antiseptics ceases. After the thorough 
disinfection of the skin, the antiseptics are washed 
away, both from the hands of the surgeon and the skin 
of the patient, by sterilised water. The instruments 
are boiled and placed in sterilised water or sterilised 
salt solution ; the ligatures and stitches are boiled and 
also placed in sterilised water. As a substitute for 
sponges, wool which has been sterilised by dry heat is 
usually employed, and the greatest care must be taken 
during the operation not only not to introduce any 
disinfectant into the wound, but also not to infect any 
of these sterilised materials. 

Now it is quite evident to any one who has attempted 
to make cultivations of bacteria that such a method 
of treatment must be carried out under extreme diffi- 
culties in an operating theatre, and, as a matter of fact, 
from the knowledge of these difficulties the precautions 



ASEPSIS. 59 

are in some places carried still further. Separate 
clothes are employed by the surgeon and his assistant, 
the air which enters the theatre is filtered, and indeed, 
in one or two institutions, they have gone the length of 
separating the auditorium from the area of operation 
by a wall of plate glass. In an ordinary theatre, with- 
out these precautions, it is practically impossible to 
avoid infection of the hands, the instruments, the 
sponge pads, and so forth, with dust from the air, 
from surrounding objects, from the breath of the people 
around, &c, and this is still more likely to happen if 
the operator has not had enormous experience in bac- 
teriological work. I do not, of course, mean to say 
that sepsis must necessarily result from such infection, 
for, in my preliminary remarks, I have already referred 
to the various conditions which are necessary ; but, at 
the same time, sepsis must be constantly liable to occur. 
Even in cases where the operator and his assistant are 
enclosed in a glass case, the results are not com- 
mensurate with the trouble, for, after all, no better 
results can be obtained or desired than those got by 
the Listerian method of treatment, and there such extra- 
ordinary precautions are not necessary, because antiseptic 
lotions are constantly at hand to correct any fault of the 
operator, or any accidental infection ; and, after all, the 
irritation of the antiseptics — the avoidance of which is 



6o TREATMENT OF WOUNDS. 

the whole aim of this complex procedure — does not, as a 
matter of fact, interfere with the progress of the wound. 
After the operation has been completed in the 
manner described, the dressing employed is usually 
wool which has been sterilised in an oven by dry heat, 
and which is brought to the side of the operating table 
in unopened cases. Large masses of this wool are 
applied, and subsequently fixed on with bandages. I 
think it is quite unnecessary, after what I have said, to 
take up time and space in describing this method 
which, in my opinion, is really, as regards the great 
majority of operations, a surgical curiosity. No doubt 
in operations on the eye, asepsis, as contrasted with 
antisepsis, is the best treatment; but then, beyond 
proper disinfection of the instruments, there is usually 
no further trouble. 



Failure of Healing by First Intention, although 
the Wounds remain Aseptic. 

It is but seldom that healing by first intention fails 
where the causes of sepsis are excluded, and where the 
wound has been treated in the manner previously 
described ; at the same time, it does occasionally happen 
through accidental circumstances. Perhaps the most 



INTERFERENCE WITH HEALING, 61 

frequent cause of failure of healing by first intention of 
the deeper part of the wound is accumulation of blood 
or serum in it, which distends the wound and separates 
the two cut surfaces. This is usually due to imperfect 
arrest of the haemorrhage at the time of the operation, 
use of too strong antiseptic solutions, or of unequally 
applied pressure afterwards. I have especially noticed 
it also in cases of wounds in very fat subjects, and in 
these persons I generally employ a drainage tube for 
two or three days. Although, however, the deeper 
parts of a wound may be in this way prevented from 
adhering, union by first intention usually occurs along 
the whole line of incision in the skin, and, where the 
accumulation is not great, it may become absorbed in a 
few days. As a rule, however, where it is evident that 
serum has accumulated at some part of the wound, 
time will be saved by gently separating the union of 
the skin in the vicinity by means of a pair of sinus 
forceps, introducing a small drainage tube into the 
cavity containing the accumulation, and leaving it in 
for a few days. 

Another cause which may interfere with satisfactory 
union by first intention is the presence of too tight 
stitches. Where there has been considerable tension 
employed in bringing the edges of the skin together, 
the stitches may cut out and allow the edge of the 



62 TREATMENT OF WOUNDS. 

wound to gape before a sufficiently strong union has 
occurred. Indeed, during the process of cutting out of 
the stitches, there may be so much inflammation in 
the immediate vicinity as to prevent satisfactory union 
at that part. This condition is best avoided by em- 
ploying a large number of thick stitches close together 
where the tension is greatest. In this way the pressure 
is distributed over a considerable area of the skin, the 
irritation caused by the individual stitches is very much 
diminished, and there is not the same tendency for them 
to cut their way out. In connection with this point, 
also, it must be mentioned that in such cases one must 
not take out the stitches too early, that, where the 
tension is considerable as, for instance, in some cases of 
excision of the breast, the stitches should be left in at 
the point where the removal of the skin has been greatest 
for at least a fortnight, otherwise, after they are taken 
out, the wound, which at the time was fairly firmly 
united, may give way and an open sore result. This is 
a matter upon which no definite rules can be laid down, 
but it must be left to the judgment of the surgeon in 
the individual cases. 

Then again, where movement of the part is per- 
mitted, the edges of the wound become irritated and 
to some extent inflamed, and union by first intention 
may not occur. Where union fails in these cases, there 



OCCURRENCE OF SEPSIS. 63 

is usually no objection to putting in fresh stitches 
and bringing the edges of the skin together again ; 
if this is done, healing is often obtained at once, pro- 
vided the part is placed at rest. 

In other instances, though rarely, a cause of the non- 
union may be that the incision through the skin has 
been improperly made (usually obliquely), and that a 
narrow portion of the edge has sloughed ; or again, the 
cause is to be sought for in some constitutional con- 
dition of the patient. In old people union naturally 
does not occur so quickly or so soundly as in young 
individuals, and the same is the case where the patient 
is suffering from some grave constitutional disorder, 
such as diabetes or Bright's disease, or even only 
from extreme weakness. The treatment of these cases 
must of course involve the treatment of the local or 
constitutional cause. 

In none of the cases just alluded to does suppuration 
occur. 



Failure of Union by first Intention due to the 
occurrence of sepsis. 

By far the most frequent cause of failure of union 
by first intention is, however, the failure on the part 



64 TREATMENT OF WC UNDS 

of the surgeon to exclude the pyogenic organisms 
Where we have to deal with unbroken skin at some 
distance from the mucous canals, such failure is practi- 
cally entirely due to imperfection in the methods 
employed by the surgeon, whether it be in his actual 
manipulations or in the asepticity of the materials 
which he employs. In either case, the occurrence of 
suppuration under such circumstances is, as I have 
already indicated, the fault of the surgeon, and such 
failures are naturally diminished by practice in the 
employment of these methods, and are quite uncommon 
occurrences in the hands of those who have had a 
previous bacteriological training. 

In describing the Listerian method, I have here and 
there indicated errors which might occur, but the errors 
which are in reality committed are so numerous, and in 
some cases so extraordinary, that it is quite impossible 
for me to refer to them. When this septic condition 
occurs, we no longer have the typical aseptic course 
previously described. The pain, instead of disappearing, 
increases after the first day, and assumes a throbbing, 
tense character, the edges of the wound become red and 
swollen, and the whole wound becomes distended with 
exudation ; at the same time, the temperature, instead 
of falling after twenty-four or thirty-six hours, goes up, 
and assumes the type of traumatic fever formerly 



SEPTIC WOUNDS. 65 

referred to. The patient, instead of being well after 
the effects of the anaesthetic have passed off, becomes 
ill with loss of appetite and other symptoms of fever, 
and in the course of two or three days, if the wound is 
opened up, pus will be found to be present in it. 

Where these symptoms occur, it is, of course, neces- 
sary to change the dressings in order to ascertain the 
condition of the wound, and if there is any suspicion 
that suppuration has taken place, the necessary stitches 
should be removed from the most dependent part of the 
wound which is then opened up, and a large sized 
drainage tube inserted. As a rule, it is not advisable to 
wash out the wound ; to do so is only to irritate and 
damage unnecessarily the inflammatory tissue, and 
possibly to precipitate, or at any rate to favour, the 
entrance of the organisms into the system. Provided 
there is a free exit for the pus, it is best not to squeeze 
or wash out, or in any way irritate the wound. It is 
well still to retain the antiseptic dressings previously 
described, but they must now be changed daily, till the 
amount of discharge diminishes. Where no general 
infection has or is about to take place, the temperature 
will fall and the other general and local conditions 
improve as soon as a free exit is provided for the dis- 
charge. In the course of a few days the suppuration 

will cease, and the discharge become serous ; and if 
5 



66 TREATMENT OF WOUNDS. 

everything goes on well, the drainage tube may be left 
out in from ten to fourteen days. Where, on the other 
hand, the temperature keeps up, and the other symp- 
toms continue, we must suspect either that there is 
some recess in the wound from which the discharge has 
not been properly evacuated, or that some general infec- 
tion is occurring. In either case, the wound must be 
thoroughly and completely opened up and cleansed, all 
recesses must be freely exposed, and, especially where 
there is no sufficient retention of discharge to account 
for the continuation of the general symptoms, it is well, 
with a sharp spoon, to remove the granulation tissue, so 
as to get rid of any organisms which may be penetrat- 
ing into the body. The wound should then be sponged 
over with undiluted, liquefied carbolic acid, and should 
be stuffed with cyanide gauze sprinkled with iodo- 
form, and, for a time at any rate, made to heal from 
the bottom, the stuffing being renewed daily. If as 
the result of this procedure the temperature falls and 
the general disturbance subsides, one may, in a few days, 
discontinue the stuffing, and after introducing a drainage 
tube, stitch up the wound again. 

Where the general symptoms, especially the occur- 
rence of rigors and sudden elevations of temperature, 
lead one to suspect pyemic infection, one should, on 
opening up the wound, carefully look for some throm- 



SEPTIC WOUNDS. 67 

bosis of veins, and if this is found, the main vein above 
the thrombosed area should be ligatured and divided 
in order to cut off the local source of infection from the 
general circulation. Where, however, the general symp- 
toms continue in spite of this energetic local treatment, 
one can only treat the patient on general principles, 
supporting his strength by stimulants, administering as 
nutritious a diet as he is able to digest, keeping down 
the temperature where it is excessively high by means 
of febrifuges, attending to the state of the excre- 
tions, &c. 

As regards local treatment under such conditions, it 
is probably best to go on with the stuffing of the wound 
with gauze saturated with iodoform; or where the 
wound is extensive, or contains sloughs, or where there 
is a diffuse cellulitis in its neighbourhood, it may be 
advisable to employ constant irrigation with the view of 
washing away the septic material as soon as it is formed. 
In carrying out irrigation of the wound, precautions 
must, of course, be taken against wetting the patient 
by making suitable arrangements of mackintoshes or 
tin vessels in the case of the extremities, &c. The 
fluids used should be tepid and mildly antiseptic. To 
employ strong antiseptic solutions is only to injure the 
granulation layer, and predispose it to the entrance of 
organisms without doing any good; and further, 



68 TREATMENT OF WOUNDS. 

patients in this septicemic condition appear to absorb 
fluids very readily from the wound, and if poisonous 
antiseptics, such as carbolic acid, are employed for 
irrigation, the patient may suffer from general poison- 
ing as the result of their absorption. I believe that the 
best solutions for irrigation of wounds under these 
circumstances are either dilute sanitas or dilute per- 
manganate of potash. The nozzle of the tube which 
carries the fluid to the wound should actually lie in it, 
and the fluid should not be allowed to drop on to the 
wound from a height, such dropping causing in a very 
short time severe pain. In order to prevent the skin 
from being sodden by the fluid, it should be carefully 
oiled; and, further, as the granulations are apt to 
become oedematous from long soaking with the fluid, it 
is well from time to time, especially where improvement 
is taking place, to intermit the irrigation for a few 
hours, and to substitute for it the ordinary gauze 
dressing. 



HEALING BY BLOOD-CLOT. 69 



Wounds made by the Surgeon through previously 
unbroken skin where, however, the edges 
of the Wound cannot be brought together. 

In these cases, also, our chief aim must be the 
exclusion of micro-organisms, and if this is successfully 
accomplished, and steps be taken to keep the part at 
absolute rest, and to prevent, as far as possible, the 
irritation of the dressings, healing will occur by blood- 
clot. Perhaps most commonly where the wound is 
large, healing goes on to a considerable extent by blood- 
clot, and then, as the result of the irritation of the sur- 
face, a small part in the centre may undergo a slight 
degree of granulation before healing occurs. Now, 
however, except in cases where a large cavity is left, as, 
for example, in cases where holes have been gouged in 
bones, one can usually hasten the healing process and 
obtain cicatrisation of the wound almost as rapidly as 
in healing by first intention, by the employment of 
Thiersch's method of skin grafting. Where skin 
grafting is not employed, the treatment is essentially 
the same as that described in speaking of wounds 
where the edges are brought together (page 46, et 
seq.), but special care must be taken, in the first 



7 o TREATMENT OF WOUNDS. 

place, to thoroughly fix the part, so that the 
blood-clot shall not be torn or injured by move- 
ment; and, in the second place, to prevent the 
irritation of the surface of the blood-clot by the anti- 
septics employed, or by the material of the dressing 
itself. To carry out the first essential, the employment 
of splints in the case of the extremities, or of firm 
bandaging where the trunk is the part which has been 
operated on, is requisite, as much of the wound as 
possible being of course stitched up. The exact plan 
must naturally depend on the site of the operation. The 
irritation of the dressing is avoided by interposing be- 
tween the gauze and the surface of the wound a piece of 
protective which has been in the first instance purified in 
1 to 20 carbolic lotion, and subsequently dipped in a weak 
solution of corrosive sublimate. This piece of protective 
must only be slightly larger than the wound, and must 
not reach at all near the edge of the dressing, otherwise 
septic bacteria could spread in beneath it. The lotions 
employed in dressing the wound should also be as non- 
irritating as possible, and for this purpose I generally 
use 1 to 4000 bichloride solution, with which the wound 
is douched, or very gently sponged with a bit of salicylic 
wool as previously described. The surrounding skin, 
however, must be more thoroughly disinfected, either 
with 1 to 2000 bichloride solution, or better, with 



HEALING BY BLOOD-CLOT. 71 

1 to 40, or even 1 to 20 carbolic lotion, care being taken 
that these strong solutions do not run on to the surface 
of the blood-clot. The dressings should be changed as 
seldom as possible, in the first instance probably not for 
ten to fourteen days, and subsequently at intervals of 
eight to ten days. 

In some cases this healing by blood-clot does not take 
place satisfactorily because the cavity is deep and suffi- 
cient blood may not be effused to fill it up, or because 
the clot is not firm enough to remain permanently in 
the part. In such instances, one would not arrest the 
bleeding too carefully, and various materials have been 
employed with the view of entangling the blood and 
leading to its coagulation in the part. For instance, 
fragments of catgut, or loose, irregular coils of catgut, 
may be laid in the wound, and this will form a frame in 
which the clot is caught. In other cases, pieces of 
sponge which have been deprived of their siliceous 
materials and then made aseptic are laid in the 
wound ; or where a cavity has been made in the bone, 
portions of the healthy bone which may have been 
removed may be clipped into small fragments and 
replaced in the cavity. In cases where the blood-clot 
is not sufficiently satisfactory, a certain amount of 
granulation of the wound, or of the partially organised 
blood-clot will occur ; but if the wound has been kept 



72 TREATMENT OF WOUNDS. 

aseptic, there will be no suppuration. This formation 
of granulations will not go on to any material extent, 
and consequently the subsequent contraction of the 
wound or deformity from pulling on neighbouring parts 
will be comparatively slight. 

This process of healing by blood-clot is, however, a 
slow one, depending on the amount of clot which has to 
become infiltrated with new cells and organised, and 
naturally, where there is not a deep cavity, it is much 
better to obtain immediate healing of the wound by 
means of Thiersch's skin-grafts. 

In the method of treatment by skin-grafts, after the 
bleeding from the surface of the wound has been com- 
pletely arrested, the whole surface is covered with 
layers of skin taken from other parts of the body. 
In Thiersch's method, after thorough purification and 
shaving of the skin, long strips, as long and broad as 
possible, and of about half the thickness of the true 
skin, are taken by means of a razor, and immediately 
transferred to the surface of the wound, on which they 
are carefully spread out with the epithelial surface 
uppermost. They are so arranged that each strip slightly 
overlaps its neighbour till the whole wound is covered, 
and at the margin the strip slightly overlaps the true 
skin. After the layers of skin have been applied, strips 
of protective, washed first in 1 to 20 carbolic acid, and 



SEPTIC OPEN WOUNDS. 73 

subsequently in 1 to 2000 sublimate, are placed over 
the wound so as to completely cover the grafts, and 
when placed first on the part, these pieces of protective 
are pressed firmly, so as to expel all blood or bubbles of 
air which may remain beneath the graft, and which 
might interfere with its proper adhesion to the cut 
surface. The ordinary gauze dressing is then applied 
outside the protective, and the dressing is not changed 
for a week or ten days, at the end of which time it will 
be found that the grafts are adhering all over, and that 
the wound has healed. Further details of the method 
of skin-grafting will be found under the treatment of 
ulcers. At first it was thought that these grafts would 
only adhere to a highly vascular surface, such as a 
granulating wound ; but experience has shown that 
they may be confidently applied to the freshly-cut 
surface of a wound, and although no doubt the adhesion 
is more certain and firmer in the first instance if a 
vascular tissue, such as muscle, is exposed, nevertheless, 
in the great majority of cases, unless perhaps in very 
fat individuals, adhesion to the fat exposed in the wound 
occurs perfectly satisfactorily. 



Where these wounds become septic, as a consequence 
of some error in the aseptic treatment, or in the dress- 



74 TREATMENT OF WOUNDS. 

ing, the results, as regards the patient, are not usually of 
a very serious character — unless, indeed, the wound com- 
municates with a cavity in the bone, with the interior 
of a joint, &c. In the latter cases, of course, very 
serious inflammation may follow in these parts; but 
where the wound simply involves the subcutaneous or 
muscular tissues, the disturbance is, as a rule, com- 
paratively slight. The reason for this is that the 
wound being widely open, the septic materials readily 
flow away into the dressing, and only a comparatively 
small quantity becomes absorbed. Nevertheless, even 
here, if the wound is at all large, the temperature rises 
in the first instance, and a varying degree of traumatic 
fever occurs ; the surface and the edges of the wound 
also swell, and become red and painful, and in the 
course of two or three days the surface of the wound 
becomes covered with a layer of granulation tissue, and 
subsequently of granulations, and there is a profuse 
flow of pus from the part. The subsequent history of 
such a case, provided no general infection has occurred, 
is simply that which I have already described under 
the heading of " Healing by Granulation." 

As regards the treatment of such an accident, as soon 
as it is recognised that sepsis has probably occurred, or 
as soon as the rise of temperature and tenderness in 
the part leads one to suspect its occurrence, the dressing 



SEPTIC OPEN WOUNDS. 75 

should be removed, and if it is then evident that the 
aseptic treatment has failed, the surface of the wound 
should be thoroughly cleansed and all adhering portions 
of blood-clot taken away, As to the best method of 
dressing to employ under these circumstances, much 
will depend on the degree of constitutional disturbance. 
If there is much constitutional disturbance, it is well, 
in the first instance, to change the dressings frequently ; 
or, still better, to employ for a day or two continuous 
irrigation with a mild antiseptic solution, in the manner 
formerly described (page 67). In any case, till granula- 
tion is complete, and even afterwards, if the discharge is 
profuse the dressing should be changed twice a day. As 
regards the material to be employed for dressing, I 
think it is best, even although sepsis has occurred, to 
go on, in the first instance, till the wound has thoroughly 
granulated, with the ordinary cyanide gauze dressing. 
These dressings absorb the discharge very readily, and 
growth of bacteria is rapidly arrested in the discharge 
which soaks into them ; while it is probable that a 
certain amount of the cyanide becomes dissolved in the 
liquids of the wound, and thus the amount of decom- 
position in the part is considerably diminished. There 
is a further advantage in going on with the dressings in 
that the organisms which may have entered the wound, 
in the first instance, may be comparatively harmless, 



7 6 TREATMENT OE WOUNDS. 

and, if the dressing is continued, others are kept out ; 
while, on the other hand, if an ordinary water-dressing 
or a poultice were applied in addition to the original 
organisms which entered, others, which might be very 
much more virulent, would gain access to the wound, and 
besides, it is not at all improbable that the organisms 
growing in a wound in which there is a small quantity 
of antiseptic material, may have their virulence very 
distinctly diminished. Indeed, admixture with carbolic 
acid is, as I have already mentioned, one of the methods 
which have been employed for depriving pathogenic 
organisms, such as anthrax, of their virulence. 

Where the suppuration is profuse, or where there is 
regular putrefaction of the discharge, iodoform is of con- 
siderable value. The use of iodoform as an antiseptic 
is a subject which has occupied much attention, and 
about which there are very different opinions, but as 
the result of much debate and many experiments, it 
seems to be pretty clearly established that iodoform 
is not an antiseptic in the ordinary acceptation of the 
term, that is to say, it does not kill bacteria, nor does 
it even interfere with their growth, in the first instance 
at any rate. But it also seems to be established that 
while iodoform does not kill or inhibit the growth of 
bacteria in the first instance, it nevertheless breaks up 
the products of the bacteria, and in doing so, is itself 



IODOFORM. 77 

decomposed, iodine being liberated, and then a certain 
degree of inhibition of the bacteric growth occurs from 
the presence of the free iodine. Thus, while I cannot 
at all approve of iodoform as a dressing in wounds 
made by a surgeon through unbroken skin, where the 
aim ought to be to exclude all bacteria from the wound, 
nevertheless, where a wound has once become septic, 
iodoform is often a very valuable aid in breaking up 
the products of the bacteria, and in subsequently inter- 
fering, to a certain extent, with their growth. I cannot 
but think that a good deal of the sepsis which occurs 
in wounds, and which is attributed to stitches, catgut, 
&c, is really in part due to the way in which these 
wounds are sprinkled with dry iodoform, and in which 
iodoform is trusted as an antiseptic after-dressing. As 
the iodoform has no antiseptic power, it follows that 
when it is kept in bottles exposed to dust, &c, it will 
contain living organisms, and when sprinkled on a 
wound from such bottles will convey these organisms 
to the wound, and this has actually occurred in many 
cases. If iodoform is to be used in recent wounds, it 
itself must be disinfected, either by previous prolonged 
immersion in 1 to 20 carbolic acid, and subsequent 
drying under cover, or in some other way. 

When granulation has completely occurred, the heal- 
ing of the wound will take place more rapidly by the 



7 8 TREATMENT OF WOUNDS. 

substitution of mild antiseptic ointments in the place 
of the gauze dressings, for the gauze itself has a 
mechanical irritating effect on a wound, and is in 
reality an excellent means of promoting granulation 
where this process is sluggish. Among the ointments 
which may be employed in this way, perhaps the best 
is boracic ointment, but if used of the ordinary phar- 
macopoeia! strength it will not unfrequently be found to 
be too irritating, and after a time to interfere with the 
healing of the wound, and therefore it is best, when 
cicatrisation has commenced, to dilute the boracic 
ointment to half or quarter strength ; eucalyptus oint- 
ment, containing from 1 to 10 to 1 to 30 parts of oil 
of eucalyptus, is also an excellent dressing, and appears 
to be specially useful in the case of burns. Where the 
granulations are not cedematous, and where the use of 
ointments is not desirable, Sir Joseph Lister's original 
method of using boracic lint and protective answers 
extremely well : the wound being washed with the 
antiseptic lotion, a piece of protective, dipped in an 
antiseptic, say 1 to 2000 bichloride, is placed over 
the wound, and outside that a much larger piece of 
boracic lint, which overlaps it in all directions. This 
may be changed once or twice a day, according to the 
amount of discharge, and the degree of sepsis. 

As regards the lotions, it is useless to employ strong 



SKIN GRAFTING 79 

antiseptic solutions to the surface of the wound. They 
cannot by any possibility disinfect the wound, because 
the organisms are located in the recesses between the 
granulations and in the surface of the tissue itself, and 
their only effect will be to irritate the surface and 
weaken it, and thus aid the extension of the septic 
process. I believe that the best solution is 1 to 2000 
or even 1 to 4000 bichloride of mercury, but the skin 
around may of course be washed with 1 to 20 carbolic 
acid in order to disinfect the decomposing material. 

Where the wound is large, skin grafting may be 
employed as well, but the sore must previously be 
rendered aseptic. Such granulating surfaces can be 
rendered aseptic by sponging them over with undiluted 
carbolic acid, the skin around being thoroughly scrubbed 
with 1 to 20 carbolic lotion, a dressing soaked in 1 to 
2000 bichloride being subsequently employed. If this 
fails, disinfection will certainly be obtained by scraping 
away the surface layer of granulations, and then apply- 
ing the undiluted carbolic acid as just described. The 
application of Thiersch's grafts to these granulating 
surfaces will be more fully described under the heading 
of ulcers, but it consists essentially in the scraping away 
of the superficial layer of granulations before the appli- 
cation of the graft in order to get a smooth, vascular 
and aseptic surface on which to place the grafts. 



8o TREATMENT OF WOUNDS. 



Wounds through the Skin which have not been 
Inflicted by the Surgeon, but which are 
seen within the course of a few hours. 

The treatment of recent incised wounds which have 
not been inflicted by the surgeon depends, of course, on 
the site and nature of the injury which has taken 
place, but in the first instance we may consider the 
treatment of an incised wound involving the soft parts 
alone. In the great majority of such cases when 
the wound was inflicted organisms were introduced 
at the same time, and this is more especially the 
case where we have wounds, say of the scalp, where 
portions of the hair have been carried in, or of parts 
of the body covered by clothing, where portions of 
the clothing may also have got in. Or, again, it may 
be that a wound which may fairly claim the name of an 
incised wound has been inflicted by a sharp stone or 
some other implement which is covered with earth or 
dust. In any case, we have to do with a wound which 
in all probability contains bacteria varying in number 
and in kind. In many cases, no doubt, where the 
wound has been inflicted by a knife, it will heal by first 
intention if the bleeding is arrested, the wound cleaned 



RECENT ACCIDENTAL WOUNDS. 81 

out, and the edges kept together, but in many instances 
it is not wise to trust to the energy of the body in 
destroying the bacteria which may have entered, or to 
trust that these bacteria may be few in number, and 
therefore, with the view of carrying out the essential 
point in wound treatment, it is necessary to take steps 
to destroy the bacteria which may have entered. This 
is more especially the case where the wounds have been 
made by a stone, where earth is carried in, and where, 
as by no means uncommonly happens, the tetanus 
bacillus has been introduced. It is also very im- 
portant, when the wound is situated on hairy parts, 
such as the scalp, where scurf or portions of hair 
have entered, and will almost certainly lead to septic 
changes. 

In order to carry out the disinfection of the wound, 
it should be held freely open, or, if it is of the nature 
of a punctured wound, the skin incision should be 
enlarged and then, being held freely open, the wound 
must be thoroughly washed out with a strong antiseptic 
solution, preferably 1 to 20 carbolic acid. Where much 
dirt or grease has entered, it becomes a matter of con- 
siderable difficulty to thoroughly disinfect the part, and 
in such cases it may be necessary, in addition to merely 
washing out the wound, to scrub away the earth or 

dirt by means of a nail brush. Of course, for such 
6 



82 TREATMENT OF WOUNDS. 

treatment the patient must be under an anaesthetic. 
In cases where earth has entered, and where, therefore, 
there is very considerable risk of tetanus for instance, it 
is, I believe, safest to sponge the surface of the wound, 
after getting away as much of the dirt as possible by 
means of a nail brush, with undiluted carbolic acid. The 
undiluted carbolic acid does not produce visible sloughs, 
and does not materially retard the healing process, 
while anything less potent will not, with certainty, 
destroy the tetanus organism. Having disinfected the 
wound in one or other of these ways, parts of it may be 
stitched up where the line of incision is fairly clean cut, 
but a drainage tube must be inserted, partly because 
there will be a very considerable amount of effusion 
after the rough handling, and partly lest the attempt 
to disinfect the wound shall have failed and suppura- 
tion after all take place. Otherwise, the method of 
dressing is the same as described on page 46 et seq., and 
should sepsis occur, the treatment must follow the lines 
described on page 65 et seq. I need only here repeat the 
objection which I have to washing out septic granu- 
lating wounds with antiseptic solutions, as being a 
method which does not in any way interfere with the 
vitality or growth of the organisms, while it injures 
the surface of the wound, and may be the very means 
of enabling bacteria to spread into the body. 



LACERATED WOUNDS. 83 

Where we have to do with lacerated or contused 
wounds, the principles of treatment are essentially the 
same, but here we must be still more careful in our dis- 
infection, because, in the first place, the wound is 
irregular, and it is very easy to overlook recesses in it ; 
and, in the second place, the vitality of the surface of 
the wound is much more interfered with, and, if 
organisms have entered it, they very readily grow and 
penetrate into the tissues. In these cases special care 
must be taken to scrub away all the dirt and septic 
material which may have got in, and I think in most 
instances, in the case of lacerated wounds, it is well to 
employ the undiluted carbolic acid. Of course, in 
these wounds, stitches cannot be used unless where 
large portions of skin are detached and where it is 
desired simply to hold them in position, and union by 
first intention naturally cannot be expected. Where 
the disinfection has been satisfactorily accomplished, 
these wounds fill up with blood clot, and the material 
in the cavity is composed of torn portions of tissue 
mixed with this blood clot, and the subsequent mode 
of healing of the wound, provided the precautions 
described under Healing by Blood-clot (page 70 et seq.) 
are carried out with regard to the avoidance of 
mechanical or chemical irritation, will be that of healing 
by blood clot. It thus not uncommonly happens that 



8 4 TREATMENT OF WOUNDS. 

portions of tissue which, were the wound to become 
septic, would inevitably slough, remain undisturbed, 
and either become replaced by new tissue in the same 
manner as the blood clot is replaced, or may regain 
their vitality as skin grafts do. Where the attempt to 
render these wounds aseptic fails, irrigation is probably 
the best method of treatment in the case of lacerated 
wounds if they are extensive, the method being carried 
out as has already been described (page 67 et seq.). J 

The peculiar danger of these wounds not made by 
the surgeon depends very much on the extent of the 
injury, and more especially on the seat of the injury, 
and I may say one or two words with regard to acci- 
dental wounds in reference to their situation. In the 
first place, compound fractures were the earliest wounds 
in the treatment of which antiseptic methods were 
employed, and, in Sir Joseph Lister's first experiments, 
the treatment was to fill these wounds with undiluted 
carbolic acid, which became mixed with the blood and 
formed a sort of paste, and in these cases great success 
was obtained. Where we have to do with a compound 
fracture, it is very essential that no effort should be 
spared to secure the asepsis of the wound, and for that 
reason the patient should be anaesthetised and the part 
thoroughly exposed, the wound being enlarged as much 
as is necessary. I believe that in most instances of 



COMPOUND FRACTURES. 85 

compound fracture it is best to sponge the whole of the 
exposed surface of the tissues, both bone and soft 
tissues, with undiluted carbolic acid. This method is 
much more certain than the injection of the weaker 
solutions, and, as was shown by Sir Joseph Lister's 
earlier work, and as is now our experience, it does not 
complicate the subsequent healing of the wound, seeing 
that union by first intention is not aimed at. 

Where the injury is an extensive one, and where it 
may not be advisable to lay the part so thoroughly 
open as is requisite in order to sponge the whole surface 
with undiluted carbolic acid, one may thoroughly irri- 
gate the deeper parts of the wound with 1 to 20 
carbolic lotion, employing for this purpose a catheter, 
which is pushed up into all the rece: les of the wound, 
care being taken at the same time that there is free 
exit for the solution injected. But even in these cases 
I would certainly advise that the ends of the bones, at 
any rate, be sponged with the undiluted carbolic acid. 
Where this method of treatment is employed many 
limbs, which would otherwise be sacrificed, recover 
completely, and the rules which are found in text-books 
— especially in the older text-books — with regard to 
amputation after lacerated and contused wounds, 
especially with compound fractures, must be very much 
modified. Indeed, in cases of compound fracture, it is 



86 TREATMENT OF WOUNDS. 

practically never necessary to amputate primarily, 
unless, indeed, the limb is torn off, or unless the great 
vessels and nerves are so injured that the part beneath 
must die or be rendered absolutely useless. As regards 
the destruction of the skin, while formerly it was held 
that even although the bones and the nerves and the 
vessels were intact, if the skin of the extremity was 
very extensively destroyed, amputation was necessary, 
seeing that healing either would not occur or, if it did 
occur, would be accompanied by such deformity as to 
render the part useless, yet, at the present time, 
especially with the aid of skin grafting, even very 
extensive losses of skin need not necessitate immediate 
amputation. In such cases, after granulation has 
thoroughly taken place over the whole surface, the 
application of skin grafts by Thiersch's method will 
generally lead to a satisfactory result, and if it does 
not, amputation can always be performed at a later 
period. 

Wounds penetrating the joints or the great cavities 
of the body are also less serious now than formerly if 
only they can be rendered aseptic. As regards wounds 
into joints it is especially necessary to be very thorough 
in the disinfection of the part, and when it is evident 
that the joint has been opened, the wound must be 
thoroughly laid open, and all recesses of the joints 



WOUNDS OF ABDOMEN. 87 

cleansed with 1 to 20 carbolic solution, or even, if much 
dirt has been introduced, with undiluted carbolic acid. 
The freshly incised parts may then be stitched up, and 
drainage tubes introduced at various points so as to 
ensure free exit of the discharge. Once it is evident 
that the attempt at purification has succeeded, these 
tubes may be left out, and a more rapid healing of the 
wound obtained. In the case of joints where sepsis 
occurs in spite of the attempt at purification, it still 
does not become immediately necessary in most cases to 
amputate the part. The great point is to see that the 
drainage is very thorough, and if the symptoms are 
acute, probably irrigation with a mild antiseptic solu- 
tion is the best treatment in the first instance. 

The treatment of penetrating wounds of the abdomen 
will vary according to the injury inflicted on the con- 
tents, and also according to whether or not the viscera 
protrude through the wound. If the asepsis of the 
part cannot be very thoroughly carried out the wound 
itself should be held open and sponged, but I would not 
advise irrigation of the peritoneal" cavity with any strong 
antiseptic solution. In the case of the peritoneum, 
as I have already remarked, sepsis is not so likely 
to occur as in the soft parts on account of the great 
power which the peritoneal cavity has of destroying the 
organisms which may enter it under certain conditions. 



88 TREATMENT OF WOUNDS. 

Of course, apart from the question of the actual 
treatment of the wound, it is now an axiom in surgery 
that if one has to do with a penetrating wound of the 
abdomen, the wound must be enlarged and the condi- 
tion of the viscera thoroughly explored, more especially 
with the view of ascertaining whether any of the intes- 
tinal coils have been injured, and should such injury be 
found, the treatment adapted to the case must be em- 
ployed, treatment which it would lead us too far in the 
present work to consider. Where the viscera protrude 
from the wound they may quite safely be thoroughly 
sponged with 1 to 2000 bichloride solution, or even 
with 1 to 40 carbolic acid, and having been thoroughly 
cleansed, should be returned to the abdominal cavity, 
provided no injury has been done to them. The ques- 
tion whether the wound in the abdominal wall should 
be stitched up, or whether drainage should be provided 
for, is a difficult one, and will depend on the circum- 
stances of the case. Where there has been no injury to 
the intestinal walls, and where there is no reason to 
suppose that any gross particles of dirt have been intro- 
duced with the instruments, I think it is best to stitch 
up the wound completely ; but where injury has been 
done to the intestinal wall, or where there is a suspicion 
that portions of clothing for example have been carried 
in which have not been found, it may be best to leave a 



WOUNDS OF THE THORAX. 89 

drainage tube in the wound communicating with the 
peritoneal cavity for two or three days. These are 
points, however, which I do not propose to enter into. 

Wounds penetrating the thoracic cavity are much 
more difficult to treat. If the lungs protrude through 
the wound, as occasionally happens, the exposed part 
may be sponged and returned, the wound itself being 
thoroughly disinfected, and in some cases the external 
wound may be closed ; but where the wound is ragged 
and dirty, and especially where portions of clothing 
have been carried in, it is best to put in a drainage 
tube, and possibly to make a counter-opening at the 
lowest part of the cavity, because suppuration will 
almost certainly occur. The drainage tube should be 
covered with a piece of protective, as will be mentioned 
in speaking of empyema, so as to valve the opening in . 
order that fresh air may not be introduced, and that 
the air which has already entered may be absorbed, and 
then if suppuration does not occur, these tubes can be 
removed in a few days, the wound will heal rapidly, 
and the lungs will again expand. 

In compound fractures of the skull it is almost 
always best to trephine at once instead of waiting for 
symptoms, because it is almost impossible thoroughly to 
disinfect the wound. The removal of the fractured 
surfaces of the bone does no harm, and enables one to 



90 TREATMENT OF WOUNDS. 

get rid of the septic material, while one may again 
introduce chips taken from the part of the bone away 
from the fractured edge, and thus more or less com- 
pletely fill up the space left by the trephining. Scalp 
wounds, apart from compound fractures, should never 
be closely stitched up, but drainage should always be 
provided for a day or two, the wound being, of course, 
thoroughly disinfected in the usual manner. 

I need not refer to wounds affecting other structures, 
such as tendons and nerves, where, of course, the 
divided parts should be at once brought together. 
What I have already said will be sufficient as exem- 
plifying the method of treatment in different cases. 

In the case of burns, we must also see that the 
surface is aseptic. Where the burn has gone on to the 
extent of producing charring of the skin, the slough is, 
of course, in the first instance free from organisms, and 
and if the surface of the slough is thoroughly washed 
with, say 1 to 20 carbolic acid, and the ordinary 
cyanide gauze dressing is applied, sepsis will be 
avoided. I believe the best dressing for burns which 
have led to complete destruction of the skin is the 
cyanide dressing, used after purification of the part 
with carbolic acid. Where the burn has only gone to 
the second or third degree, then, apparently, antiseptic 
ointments of various kinds are the best, and perhaps 



BURNS. 91 

the most suitable is the eucalyptus ointment, which, 
in the first instance, should be employed of the full 
pharmacopoeial strength, namely, 1 to 5, and can be 
subsequently diluted if necessary. It will be found 
that in the case of burns treated antiseptically, only a 
comparatively small portion of the dead skin may 
separate, the rest acting like the blood clot as a mould 
into which cells penetrate, and which becomes covered 
with epithelium spreading from the adjacent surface. 
Where, however, large portions of slough have separated 
and a granulating surface is left, skin grafting should be 
employed at an early period, because otherwise the 
very greatest deformities are produced, apparently 
greater after burns than after simple lacerated wounds. 
This is probably due to the slower healing of the part, 
and to the excessive production of granulations, leading 
to excessive subsequent contraction. 



Wounds which have not been made by the Suegeon, 
and in which several days at least have 
elapsed from the time of their infliction. 

We may divide wounds of this class into ordinary, 
open, granulating wounds, or still older wounds, 
which present the form of sinus or fistula. These 



92 TREATMENT OF WOUNDS. 

open wounds are practically to all intents and purposes 
to be treated in the manner described under ulcers, 
and unless extensive, or involving some important 
structure, or on the leg or foot, they generally heal 
fairly readily. Where it is important to obtain imme- 
diate asepsis of the part, as, for instance, in the case of 
wounds in the palm of the hand close to or involving 
the tendon sheaths, compound fracture, &c, the only 
certain method of disinfection is to scrape away the 
granulation tissue from the surface of the wound, and, 
when the bleeding has come to a standstill, sponge it 
over with undiluted carbolic acid. Sir Joseph Lister 
often employs for this purpose a strong solution of 
chloride of zinc, 40 grains to the ounce of water, but I 
do not think that this is at all so effectual as the method 
which I have mentioned. Where it is undesirable to 
administer an anaesthetic for the purpose, disinfection 
may be obtained by stuffing the wound with lint or 
gauze soaked in strong carbolic oil, 1 to 5. This 
stuffing is changed night and morning, the surrounding 
skin being washed with 1 to 20 carbolic acid solution. 
The wound will very soon assume a healthy appear- 
ance and lose its foul character, and then a less irritat- 
ing dressing is employed. In cases where complete and 
early disinfection is not so essential, probably the use 
of iodoform is a more suitable method of treatment, and 



SINUS. 93 

where the wounds are superficial, the employment of 
weak boracic or eucalyptus ointment with boracic lint 
outside, answers very well. 

Sinuses may be of two kinds — (a) simple sinuses, 
in which there is no specific virus present; and (h) 
those depending on a special virus, which, in the great 
majority of cases, is of a tubercular nature. 

As regards simple sinus, various things may tend to 
interfere with the complete healing of the wound ; for 
example, movement of the part. Where the wound has 
penetrated among muscles, the continued action of these 
muscles may interfere with the complete closure of the 
wound. Again, early contraction of the external orifice 
may lead to continued accumulation of fluid in the 
deeper part, which distends the wound, sets up irrita- 
tion, and prevents its closure for a long time. This is, 
of course, especially the case where suppuration is 
taking place, and in such instances it w T ill often be 
found that rapid healing will occur if the external 
wound is freely opened and proper drainage established. 
Then, again, a simple sinus will not heal on account of 
some foreign body being present, such as a piece of dead 
bone, a piece of sponge, septic ligature, &c, and till this 
foreign body has been removed either by nature or by 
the surgeon, healing will not occur. The treatment, of 



94 TREATMENT OF WOUNDS. 

course, in such instances depends in the first place on 
the cause which leads to the continuance of the sinus ; 
for example, putting the part at absolute rest, so as to 
stop the movement of the muscles ; free dilatation of 
the canal and proper drainage, where imperfect evacua- 
tion of discharge is the cause ; removal of foreign bodies, 
&c. I do not think that it is advisable to inject these 
sinuses as is so frequently done, for the reason which I 
have previously mentioned as contra-indicating injec- 
tions into wounds. As regards the dressing to be 
applied to the orifice of the sinus in these cases, if the 
wound is aseptic, of course the ordinary gauze dressing 
should be used ; where the wound is septic, this is pro- 
bably an unnecessary expense, and the various oint- 
ments, especially the strong boracic ointment, with 
boracic lint outside, will form a perfectly satisfactory 
dressing. 

In other cases, the cause of the continuance of the 
sinus is the presence of some specific disease, more 
especially the presence of tubercular disease of the wall. 
In such cases the whole track of the sinus is composed 
of tubercular material which undergoes caseation, and 
has only a very slight tendency to heal. The treatment 
of a tubercular sinus will depend entirely on the condi- 
tion of the patient. Very often these tubercular sinuses 
lead to foci of tubercular disease in bones, joints, glands, 



TUBERCULAR SINUS. 95 

&c., and the healing of the sinus is prevented not only 
by the tubercular condition of its walls, but also by the 
disease which is going on at the deeper part. The treat- 
ment of these sinuses consists essentially in complete 
removal of all the tubercular material ; that is to say, 
the sinus itself should be cut out where that is anatomi- 
cally possible, and the part from which it takes its 
origin, as, for example, carious bone or caseating glands, 
should also be removed. If that is done, a clean cut 
surface is left behind which readily heals. Where it is 
not possible to excise the sinus along with the bone or 
gland disease, if any, which may be present, the next 
best thing to do is to lay it as freely open as possible, 
and with a sharp spoon to scrape away the lining mem- 
brane and all disease which can be reached, and then, 
instead of introducing a drainage tube and dressing the 
external wound as was formerly done, it is, I believe, 
best to leave the wound open, and stuff it with gauze 
which has been dusted with iodoform. Where the 
wound is septic, or where it is known that tubercular 
material is left behind, it is, I think, advisable, as soon 
as the bleeding has stopped, to sponge the interior with 
undiluted carbolic acid. This method of stuffing the 
wound with iodoformed gauze seems to act very much 
better than any other plan short of complete removal 
of the tubercular disease. The gauze is mechanically 



96 TREATMENT OF WOUNDS. 

irritating, and leads to more or less luxuriant growth of 
granulations, while the iodoform may possibly have 
some an ti- tubercular action. It has been supposed that 
iodoform acts better where oxygen is not present, and 
that, when injected into tubercular abscesses, it has a 
definite anti-bacteric action which is much favoured by 
the fact that it is in a closed cavity ; and the reason, 
therefore, that it has been so much advocated for the 
stuffing of wounds of this kind is that it is assumed that, 
in the deeper part of the wound so stuffed, oxygen will 
be absent and the iodoform may thus exert its action. 
However this may be, I am quite satisfied that the 
results obtained by stuffing in this way are very 
much superior to those obtained by injecting iodoform 
and glycerine into these wounds, as I used formerly 
to do. 

Fistula, as I have said, is a condition where there is 
an opening in the skin and an opening in the mucous 
membrane with a canal between them. It occurs in 
various parts of the body, especially around the orifices 
of the mucous canals. Thus we have salivary fistula 
where there is an external opening into a salivary duct, 
this duct leading again into the mouth ; intestinal 
fistuke, where there is a communication between the 
intestinal canal and the surface of the skin, resulting 
from disease or injury, as after gangrenous hernia, 



FISTULA. 97 

colotomy, &c. ; anal fistulas, where an abscess forms 

under the mucous membrane of the rectum, and finds 

its way into the ischio-rectal fossa, opening both 

externally and internally ; perineal fistulas, where there 

is a communication between the urethra and the 

perineum ; congenital fistulas in the neck, which are 

the remains of the branchial clefts, or in connection with 

the intestine, the result of a congenital malformation, &c. 

The chief reason why these fistulas do not heal is the 

constant passage of saliva, fasces, urine, &c, through 

them, and, in addition, in the case of congenital fistulas, 

the fact that the whole canal is lined with epithelium. 

The treatment of the various fistulas can hardly be 

considered here, depending as it does on various local 

conditions which would require full consideration ; but 

the treatment consists essentially in preventing the 

flow of foreign materials along the track, and bringing 

the surface of the fistula into a healthy condition. In 

the case of salivary fistula a more direct opening is 

made into the mouth for the saliva, and the external 

opening pared and stitched up. Similarly, in the case 

of intestinal fistulas means are taken to make it more 

easy for the fascal matter to pass along the intestinal 

tract than to make its way out through the fistulous 

opening. Thus, where faecal fistulas has resulted from 

gangrene after strangulated hernia, the contents of the 
7 



98 TREATMENT OF WOUNDS. 

upper part of the bowel cannot find their way into the 
lower part, on account of the spur of the mucous 
membrane which valves the orifice and the lower part 
of the canal, and steps must be taken to remove this 
obstruction, either on the principle of Dupuytren's 
enterotome, or by resection of the ends of the bowel 
and immediate union. In the case of an anal fistula 
the only satisfactory method is to lay it freely open, 
scrape or cut away the wall of the fistula, especially if 
it is tubercular, and then stuff the wound for some days, 
and make it heal from the bottom. In the case of 
perineal fistula, by curing the stricture one often gets 
healing of the fistula without further treatment. 
Where we have to do with congenital fistulae nothing 
short of complete removal of the whole track by dis- 
section will effect a cure ; attempts at destroying 
the mucous lining of the canal by scraping or caustics 
usually fail, probably because islets of epithelium are 
left behind. 



WOUNDS. 99 



Wounds which involve not only the Skin, but 
also the mucous membeane, or in which 
Septic Cavities which cannot be Disinfected 
aee Opened Up. 

In these cases, strict asepsis cannot be obtained, 
because in the case of a wound, say in the mouth, it is 
impossible to exclude the bacteria which are everywhere 
present in the fluids, and therefore the problem in such 
instances is not to exclude bacteria from the wounds, 
but to diminish their action in every way possible. In 
the first place, the vitality of the tissues must be 
interfered with to as slight a degree as possible during 
the operation, the manipulations being gentle, and 
pinching and rough treatment of the wound being 
avoided. Further, wherever it can be managed, union 
by first intention should be aimed at, and in order to 
obtain that the bleeding must be very thoroughly 
arrested, care must be taken that no foreign material 
whatever is left between the edges, and care must also 
be taken that the whole cut surface of the wound, and 
not merely the mucous surface, is in accurate and close 
apposition. 

In bringing these wounds together stitches must be 



ioo TREATMENT OF WOUNDS. 

employed which are not themselves porous, and will 
not therefore form a nidus for the growth of bacteria. 
Silk is consequently out of the question. Probably the 
best stitches, where they are strong enough, are those 
of horse hair, which, like silver wire or silkworm-gut, 
does not become soaked with fluids, and which, there- 
fore, does not, like silk, become a putrid foreign body. 
Where stronger material is required, silkworm-gut in 
most cases will answer all purposes, and it is less rigid 
and consequently less disagreeable to the patient than 
silver wire. 

No dressing is of course possible in these cases, but 
frequent washing of the surface with antiseptic solutions 
should be carried out. For example, in operations about 
the mouth, it is well to provide the patient with a 
quantity of some weak antiseptic solution, such as 
sanitas or weak Condy's fluid, and to instruct him to 
rinse out his mouth — or to gargle, if the incision is far 
back — at repeated intervals. 

In cases where the edges of the wound cannot be 
brought together, and where, therefore, healing must 
take place by granulation, it is of great importance to 
avoid, if possible, septic decomposition of the surface of 
the wound during the first two or three days. After 
that time there is usually such a marked invasion of 
cells in the deeper part of the wound, that bacteria find 



WOUNDS OF MOUTH. 101 

considerable difficulty in entering ; indeed, the chief 
bacteria which are able to penetrate under such circum- 
stances are either the streptococci, giving rise to 
creeping, diffuse cellulitis, or such organisms as the 
diphtheritic bacilli, which settle on the wound and 
grow in the superficial tissues. For this purpose Sir 
Joseph Lister has, for many years, employed a solution 
of chloride of zinc, 40 grains to the ounce, and he 
regards it as, so to speak, pickling the surface of the 
wound for a day or two after it has been made. It is 
certainly a fact that after a thorough application of 
chloride of zinc to a cut surface exposed to the elements 
of putrefaction, decomposition does not apparently 
occur so early as where the wound is abandoned to 
nature, and therefore this method is one which may be 
strongly recommended. In some cases I have employed 
instead undiluted carbolic acid, and I think that with 
it the results are probably equally good, while the after- 
pain is distinctly less. It is especially in these cases 
that iodoform is of value, and it is well after having 
sponged the cut surface with chloride of zinc or 
undiluted carbolic acid, to powder, it thoroughly with 
iodoform crystals, and to repeat the application once or 
twice daily as these crystals are washed away by the 
discharge. Once the wound is granulating, mild anti- 
septic washes are in most cases all that is necessary ; 



102 WOUNDS OF MOUTH. 

but the condition of the wound must be watched and 
other applications, if required, must be made. For 
example, should the granulations tend to become too 
prominent, the application of nitrate of silver or 
sulphate of copper to the part is indicated, and if, on 
the other hand, they tend to become ceclematous and 
weak, some astringent lotion such as alum or sulphate 
of zinc, &c, should be used in place of the ordinary 
antiseptic fluid. 



TREATMENT OF ULCERS. 



TREATMENT OF ULCERS. 

An ulcer may, in the first instance, be roughly defined 
as any breach of the surface of the skin or mucous 
membrane which does not heal. This definition 
includes not merely ulcers proper — that is to say, 
an inflammatory process — but also ulcerative processes 
occurring in tumours. True ulceration is an inflam- 
matory process, and a more accurate definition of an 
ulcer is an extending loss of substance in the skin or 
mucous membrane in a part which has been previously 
the seat of inflammatory changes which have gone on 
to granulation, this continued loss of substance being 
due not to death of visible pieces of tissue, but to 
degeneration of the cells or death of microscopic 
portions of tissue, — what is spoken of as molecular 
death. 

Of ulcers proper we have two great classes : — (i.) 
those which are not due to any specific virus, but which 
are caused by various local troubles, such as alterations 
in the circulation or innervation of the part, which I 



106 TREATMENT OF ULCERS. 

shall immediately allude to. This class may be spoken 
of as the chronic non-infective ulcer. There is, how- 
ever, a second large group of ulcers, where a specific 
virus is at the root of the ulcerative process, by far the 
largest number of these ulcers being the result of 
syphilitic or tuberculous disease. In these cases there 
is, preceding the ulcerative process, a formation of new 
tissue which has a special tendency to degeneration, 
either syphilitic gummatous tissue or tubercles which 
undergo caseation, and the ulcerative process is the 
result of the degenerative changes which take place 
in this new tissue. 



The Chronic Non-infective Ulcees. 

Before proceeding to the consideration of the treat- 
ment of these ulcers, we must, in the first instance, make 
ourselves familiar with the various causes which lead to 
the ulcerative process. These causes are mainly local, 
and among the chief of them are those which tend to 
interfere with the normal circulation of blood in the 
part. For example, in the dependent position of the 
part there is a certain difficulty to the return of blood 
and consequently an imperfect nutrition in the inflamed 
tissues, and hence it is that the great majority of 



CAUSES OF ULCERS. 107 

ulcers affect the lower extremity, even when no disease 
of blood vessels interferes with the circulation. A 
patient who has a granulating wound on the leg is very 
apt to become the subject of an ulcerative process if he 
continues to stand, or walk about much on the leg or 
even to hang it down. 

Perhaps one of the most frequent causes of these 
ulcers is the presence of varicose veins, more especially 
where the veins which are varicose are the small vessels 
in the skin. Under such circumstances there is a very 
marked obstacle to the return of the blood, and con- 
sequently great stagnation of blood in the part. Then 
again, the presence of atheroma of the arteries will act 
similarly in that there will be a smaller quantity of 
blood brought to the part ; and if, in addition to the 
presence of this disease of the arteries, the dependent 
position is superadded, the ulcerative process may go 
on rapidly. "Where the inflammatory process has led 
to a considerable amount of exudation into the tissues 
around, this exudation presses on the blood vessels lead- 
ing to the surface of the sore, and interferes with the 
supply or the return of blood in the part. This is more 
especially the case where the sore is situated over loose 
connective tissue, the meshes of which very readily 
become distended with lymph, and which is but sparely 
supplied with blood vessels. 



108 TREATMENT OF ULCERS. 

In addition to these causes depending on defects in 
the circulation, ulceration is greatly favoured by a weak 
condition of the tissues, more especially as the result of 
old age. A wound on the leg in a young patient, even 
although he may have varicose veins, and although he 
continues to walk about, is not nearly so likely to lead 
to an ulcer as a similar injury in an old person; and 
this is to a large extent owing to the greater vitality 
and recuperative power of the tissues in the young. 
A similar result is brought about by severe and con- 
tinued cold, which, short of producing gangrene, causes 
the formation of chilblains, and subsequently it may be 
of ulcers. Another local cause which leads to ulceration 
is movement of the part. For example, where a sore is 
situated immediately over a muscle, and more especially 
when it is adhering to it, or where it is situated over a 
fascia which is in frequent movement, that sore is much 
more likely to ulcerate as a result of the movement of 
the muscles beneath than a sore which is situated else- 
where. Again, where a sore cannot contract, the ulcer- 
ative process is very apt to be set up. As I have 
previously said in speaking of healing by granulation, a 
considerable share in the healing process is taken by 
the contraction of the newly-formed fibrous tissue, and 
if this contraction cannot occur and the sore is large, a 
time will come when healing will cease and ulceration 



CAUSES OF ULCERS. 109 

take place. The constant effort of the new fibrous tissue 
to contract without success seems to irritate the part 
and arrest the healing. This inability to contract may 
simply result from the great size of the sore, as, for 
instance, after burns, where the greater part may heal, 
but a portion in the centre may refuse to heal and 
subsequently ulcerate. Here contraction goes on till at 
length no further contraction is possible, and then 
healing ceases. 

In such cases, no doubt, there is another fact which 
must be taken into consideration, viz., that as the result 
of the contraction of all the marginal and deeper parts 
of the sore, the blood vessels leading to the centre 
become compressed and the circulation is rendered im- 
perfect ; but, nevertheless, apart from interference with 
the circulation the contraction of the sore itself seems 
sufficient to put a stop to the healing process. Another 
case in which contraction cannot occur is where a 
sore is situated over and adherent to a bone. In that 
case, also, if the sore is of considerable size, not 
only will healing not occur, but after a time ulcera- 
tion will take place, especially if the parts around 
become cedematous, and the circulation is thus inter- 
fered with. 

Again, irritation of the sore will lead to its conversion 
into an ulcer, — irritation, for example, by mechanical 



no TREATMENT OF ULCERS. 

action, as by pressure too long continued, by rubbing of 
dressings, &c, or from the presence of certain chemical 
substances, such as carbolic acid, which is often and 
very wrongly applied to ulcers, or decomposing secre- 
tions, more especially where the secretions have 
partially dried and formed crusts over the surface of 
the wound underneath which the decomposing and 
irritating pus is retained. In wounds secreting septic 
pus, and which are healing, it is not uncommon to find, 
after a crust is allowed to form on the surface, that on 
peeling it off not only has the healing process come to 
a standstill, but actual ulceration is taking place 
beneath. 

Then, again, the ulcerative process may be set up by 
accidental contamination of the wound, leading to too 
violent inflammation of the part, or by some specific 
infection of the wound, more especially diphtheritic or 
phagedenic infection. Lastly, we have ulcers occurring 
in parts in which the innervation is deficient, — for 
example, after paralysis, this being due in part, no 
doubt, to the fact that, accompanying the loss of sensa- 
tion, the patient is very apt to press unduly on some 
one spot, and thus lead to inflammation and ulceration, 
but in part also to a distinct interference with the 
nutrition of the tissue and trophic changes as the result 
of the loss of the nervous supply. Ulcers also occur in 



RISKS OF ULCERS. in 

connection with certain constitutional conditions, such 
as diabetes, scurvy, &c. 

The proper treatment of ulcers and their rapid cure 
are matters of great importance, because a patient who 
is afflicted with an ulcer of the leg is not only more or 
less incapacitated from his work, but is liable to various 
accidents which may render him a permanent cripple, 
or even lead to the loss of his life. For example, where 
we have an ulcer on the leg, especially over the 
muscular part of the leg, the muscles beneath are very 
apt to become inflamed and infiltrated with exudation, 
and so to lose their function, and the patient may be 
crippled from his inability to move these muscles 
properly. The same may be the case where the ulcer 
is situated over the tendons, where adhesion takes 
place between the tendons and the tendon sheaths, 
or between the tendons and other structures in the 
immediate neighbourhood, leading to loss of action of 
the muscle. Perhaps the most common disability 
resulting from the presence of the ulceration is the 
result of the contraction which goes on in the efforts 
at healing. Where an ulcer is situated over a joint, 
for example, during the healing process so much con- 
traction may take place as to completely flex the joint 
and interfere with its further mobility. Or, again, 
where we have an ulcer completely surrounding the leg, 



ii2 TREATMENT OE ULCERS. 

if it should heal, the contraction is apt to be so great 
as to constrict the vessels leading to the part below, 
and thus cause great oedema and often complete useless- 
ness of the foot. A further risk of an ulcer is that the 
veins in the neighbourhood are apt to become inflamed, 
and that there may be an extensive, simple, or septic 
phlebitis leading from the part, and this is more likely 
to occur where the veins are varicose. Further, 
the patient is subject to all the ordinary septic diseases, 
more especially to the occurrence of erysipelas, which 
may prove very serious. Again, I may mention that 
in cases where ulcers last a long time, it not uncom- 
monly happens that an epithelioma develops at the 
margins, and the patient may die of this cancerous 
growth. 

These chronic non-infective ulcers are divided into 
several classes, according to their appearance and 
tendencies, and I must shortly refer to the chief 
groups. 

(1.) The Simple Ulcer. — These are sores which are 
kept from healing by various local causes, such as 
pressure, friction, muscular movements, inability to 
contract, either from their great size or from their 
situation, &c. In these simple ulcers the surface of 
the sore is nearly on a level with the surrounding skin; 
it is covered with yellowish or brownish red granula- 



CLASSES OF ULCERS. 113 

tions, the margins are sharp, and the surroundings are 
(Edematous and firm. These sores are generally situated 
about the middle of the lower third of the leg, and they 
may extend fairly rapidly where no proper care is 
taken. In certain cases these and other ulcers may 
become the seat of an acute inflammation, and we 
have — 

(2.) The Lnflamed Ulcer. — This is an ulcer which has 
become the seat of acute inflammation, as the result of 
some mechanical or chemical irritation, bad methods of 
treatment, and so forth. In these cases the surface of 
the ulcer becomes intensely red, bleeds readily, secretes 
large quantities of pus, extends with great rapidity, 
and is not unfrequently covered with little pieces of 
actual gangrenous tissue. The skin around is also 
bright red and cedematous, and the borders are irregular 
and eaten away, and it is not uncommon for fresh 
ulcers to develop rapidly around the margins of the 
original sore. These ulcers are generally acutely 
painful. 

(3.) Irritable Ulcer. — This form of ulcer is one which 

occurs especially in neurotic women. It is generally 

in the form of a small sore with a somewhat elevated 

surface, and is intensely tender to the slightest touch. 

It is usually associated with menstrual disorders. It 

usually occurs above the external malleolus. 
8 



ii4 TREATMENT OF ULCERS. 

(4.) Weak Ulcers. — The simple ulcer, or the healing 
sore, is very apt to become a weak ulcer as the result of 
defective blood supply, either from too small a quantity 
of blood being sent to the part, as in cases where the 
vessels are diseased, or from deficient quality of the 
blood, for example, during the progress of some con- 
stitutional disease. In this form of ulcer the granula- 
tions become smooth and somewhat yellowish, the 
secretion thin and small in amount, and very apt to 
scab, and the edges pale and flat. In other cases of 
weak ulcer the granulations become oedematous, and 
this is more especially the case where there is some 
general cause of cedema, or some local interference with 
the circulation, such as the presence of varicose veins, 
compression of veins from the contraction of the 
sore, &c. Or again, we have another form of the weak 
ulcer, — where the granulations show excessive growth. 
This is chiefly the case where the ulceration is due to 
inability of the sore to contract. In such cases the 
granulations become prominent, vascular, soft, and 
bleed readily, and we have the condition which is 
popularly spoken of as " proud flesh." 

(5.) These simple ulcers again may become attacked 
with some specific septic virus, more especially with 
the diphtheritic virus, or the other virus, the nature of 
which is not exactly known, and which leads to what 



VARICOSE ULCER. 115 

is called the Phagedenic Ulcer. In the latter case, the 
ulcer becomes covered with a greyish pulpy material, 
which rapidly infiltrates the surrounding skin and cel- 
lular tissue, and extends both superficially and deeply 
at the bottom of the sore, leading to extensive and very 
rapid destruction of the part, and not uncommonly to 
the death of the patient 

(6.) The Varicose Ulcer — This is a form of ulcer which 
originates as the result of varicose veins. As a rule, if 
only the larger veins are varicose, ulceration is not so 
apt to occur ; but where, in addition to the varicosity 
of the large veins, the smaller venules in the skin are 
affected, ulceration is not unlikely to take place, especi- 
ally in old people. This condition of varicosity of the 
smaller veins leads to imperfect nutrition of the skin, 
to the formation of an excessive amount of epidermis, 
and ultimately to a local dermatitis. This dermatitis 
goes on to eczema, and we have the condition known 
as varicose eczema. The patient then scratches the 
eczematous part, and produces a wound, which becomes 
inflamed, and, if the patient continues to walk about, 
rapidly develops into an ulcer. In other cases inflam- 
mation occurs around a varicose vein (periphlebitis), 
and an abscess forms, which bursts. A little sore is 
thus produced, which extends by ulceration. However 
produced, these varicose ulcers are usually in the first 



n6 TREATMENT OF ULCERS. 

instance small and superficial ulcers, with oedema 
around, and sometimes prominent, soft, or perhaps 
©edematous granulations. If the patient continues to 
walk about with a varicose ulcer, the condition gradually 
passes into that of — 

(7.) The Callous Ulcer. — As the result of the con- 
tinued interference with the venous return, oedema of 
the part takes place, exudation of coagulable lymph goes 
on into the interstices of the cellular tissue, which thus 
become much distended, with the result that the 
arterioles are pressed upon, and the nutrition of the 
sore is much interfered with. This exuded material 
coagulates, and to a considerable extent becomes 
organised ; the result is that the skin and subcutaneous 
tissues around the ulcer become very much thickened, 
so that the surface of the ulcer comes to lie at a con- 
siderably lower level than its edges, and at first sight it 
looks as if the ulceration had extended in depth, and 
ultimately the callous condition is produced ; the. char- 
acteristics of the callous ulcer being a sore at a deeper 
level than the surrounding skin, the surrounding parts 
hard and firm, the surface of the sore devoid of granu- 
lations, pale yellow, and secreting only a small quantity 
of thin fluid. 

(8.) Then again, in certain cases we have what is 
known as the Hemorrhagic Ulcer, occurring more 



PRESSURE ULCERS. 117 

especially in patients suffering from scurvy, where we 
have an ulcer which bleeds readily, the surface of the 
sore being swollen and red, and the blood sometimes 
coagulating on the surface, and forming a projecting 
clot. 

(9.) Ulcers as the result of pressure. — These especially 
occur on the sole of the foot, and they result from long- 
continued, but not necessarily severe, pressure. In the 
first instance, this pressure leads to thickening of the 
epidermis and the formation of a callosity. Under- 
neath this callosity inflammation and suppuration 
occurs, and when the thickened epidermis is separated, 
an ulcer is seen, the character of which is a deep sore, 
with great thickening of the epidermis around the sides. 

(10.) Lastly, we have the ulcers which occur in con- 
nection with deficient innervation. In limbs which are 
paralysed, it is not uncommon to find atonic ulcers, 
which are painless, sometimes multiple, and quite 
superficial, as a rule with very imperfect granulations 
on the surface. These ulcers especially occur about the 
phalanges of the fingers and toes; they also occur on 
the sole of the foot, but in this place they are gener- 
ally ascribed to pressure, and assume the form which 
is described under the head of pressure ulcers. In con- 
nection with these pressure and paralytic ulcers, I may 
specially mention — 



n8 TREATMENT OF ULCERS. 

(11.) The Perforating Ulcer of the foot, which occurs 
at the parts of the foot where there is marked pressure, 
more especially under the heads of the metatarsal 
bones, chiefly of the great toe. These perforating ulcers 
generally attack men over forty, who are always work- 
ing, and they are not necessarily associated with any 
paralytic condition of the limb, but they are supposed 
to result more especially from a peripheral neuritis. 
This perforating ulcer begins as a callosity, with 
inflammation beneath, and the formation of an ulcer 
resembling in all respects a pressure ulcer in the first 
instance. This ulcer then extends in depth, becoming 
funnel-shaped, and may penetrate as far as the bone. 
The bone may become the seat of rarefying osteitis, and 
may completely disappear at that part ; the base of the 
ulcer is generally covered with reddish, warty granula- 
tions, and the secretion is of a very foul character. 
The cavity of the ulcer is filled up with dense masses of 
epidermis, the epithelium having spread down the sides 
of the ulcer, and there being great proliferation of the 
epidermis. It is most likely that these perforating 
ulcers are in the main pressure ulcers, starting in the 
first instance like the ordinary pressure ulcer, with the 
formation of a callosity. The pressure is kept up by 
the epidermic growth down the sides of the ulcer, 
which forms a hardish mass and presses on the deeper 



PERFORATING ULCER. 119 

parts. At the same time, it must be acknowledged 
that the exact pathology is not thoroughly made out. 
Whatever the pathology may be, these cases are very 
chronic, and they will not heal even although the 
patient is kept in bed for a long time ; the reason why 
they do not heal being the presence of this growth of 
epidermis down the sides of the ulcer, which prevents 
the adhesion of the sides to one another. 

(12.) In certain constitutional states, such as diabetes, 
ulcers may form. In diabetes, inflammation and ulcera- 
tion may follow a slight scratch or cut, and the characters 
of a diabetic ulcer are its rapid spread, the presence of 
considerable inflammation around, and often of sloughs 
of tissue. The rapidity of spread and the inflammatory 
changes arise especially in connection with the endar- 
teritis, which occurs in diabetics, and the special 
liability of the tissues to septic infection. 



Treatment. 

The conditions which are necessary for the healing 
of ulcers are the same as those which are necessary in 
the case of wounds. As I have previously mentioned, 
in speaking of granulating wounds, the chief essentials 
are that the surface of the sore must become level with 



i2o TREATMENT OF ULCERS. 

the surrounding parts, that the margins of the sore 
must be movable in order to permit its contraction, and 
that the granulations on the surface must be healthy. 
We have three principles to attend to in the treat- 
ment of ulcers; namely — (i.) to get rid of the various 
causes which are keeping up the ulceration, the 
most important of which I have already mentioned; 
(ii.) to improve the condition of the surface and the 
margins of the ulcer ; and (iii.) to further healing in any 
other way possible. 

The first essential in the treatment of all ulcers is 
rest. As I have already said, any movement of the 
part will tend to keep up the ulceration, consequently 
the patient must be absolutely prohibited, if it is desired 
to get the ulcer to heal quickly, from walking about, 
and the movement of the neighbouring joints must also 
be prevented by the application of splints which control 
and fix them in the proper positions. In the case, for 
example, of ulcers in the leg — the most frequent seat 
— it is well to apply one or two lateral splints grasping 
the leg and the knee, and fixing the ankle-joint and 
keeping the foot at right angles to the leg. 

The second principle, which is of the greatest import- 
ance in the treatment of ulcers, is to favour the return 
circulation. I have already referred to the great 
importance of the interference with the return cir- 



TREA TMENT B Y REST. 1 2 1 

culation in the formation of ulcers, as a primary cause — 
for example, in the occurrence of simple ulcers or 
varicose ulcers — and as a secondary cause leading to the 
formation of a callous ulcer; and so long as provision 
is not made for the proper return of the blood from the 
part, so long will the ulcer refuse to heal. This may 
be brought about in various ways, but the most 
efficient of all is to place the part at a higher level than 
the heart ; and in the case of ulcers of the leg, to place 
the patient in bed and elevate the leg on a pillow. 
Even in a bad case of callous ulcer, without any further 
treatment, the oedema of the leg will very soon begin 
to go down under this treatment, and coincidently with 
that, the surface of the sore will become covered with 
granulations, and in the course of two or three weeks 
will begin to heal at the edge. This is a result which 
is not obtainable so rapidly by any other method of 
treatment where the vertical position is permitted. 

The return of the blood and lymph from the part 
may also be favoured by massage, but that also should 
be combined with rest in the elevated position. 
Where massage is employed, the kneading should begin 
at the upper part above the ulcer, and by and bye, as 
the skin gets softer in that region, the area which is 
subjected to treatment is increased downwards. Other 
ways in which the return circulation is favoured — for 



122 TREATMENT OF ULCERS. 

example by pressure, will be spoken of when we come 
to discuss the question of the treatment of callous ulcer. 
A third great point which is common to the treat- 
ment of all ulcers is to get rid of all causes of irritation 
of the surface of the sore. The substances which may 
cause irritation may act either mechanically or chemi- 
cally; mechanically more especially in the form of 
dressings and bandages, or chemically chiefly in the form 
of sepsis. Of these the most important are the chemi- 
cally disturbing causes. The presence of decomposing 
discharge on the surface of an ulcer will interfere very 
materially with the healing process ; and it is, therefore, 
one of the most important points at the commencement 
of the treatment to remedy, as far as possible, the septic 
condition. In order to do this, the following is the 
best method of procedure. In the first place, the skin 
for a considerable area around the ulcer, should be 
thoroughly disinfected, because, of course, to disinfect 
the surface of the ulcer alone and leave the skin septic 
would simply mean that in the course of a few days the 
ulcer would again become foul. In the first instance, 
then, the skin around is thoroughly washed with soap 
and water, and all hairs are shaved off. It is then 
disinfected in the same way as the skin is disinfected 
before proceeding to an operation through unbroken 
skin, that is to say, after washing and shaving the skin, 



DISINFECTION 01 UICERS. 123 

turpentine is applied so as to dissolve the fat, and then 
the part is thoroughly scrubbed with a nail brush and 
the strong mixture of carbolic acid and sublimate, soap 
being employed with the view of removing the tur- 
pentine. As regards the surface of the ulcer, it is not 
always an easy matter to complete the disinfection at 
one sitting. Sir Joseph Lister's first method of dis- 
infecting ulcers was to apply a solution of chloride of 
zinc, 40 grains to the ounce, thoroughly to the surface 
of the ulcer, repeating it in two or three days, If it is 
evident that the disinfection has not been successful, 
I believe that in the long run the most satisfactory 
results will be obtained by applying undiluted carbolic 
acid. As a matter of fact, the destruction of the super- 
ficial layer of granulations on the ulcer is a matter 
of absolutely no moment, because at the time that the 
treatment of the ulcer is taken in hand, these are 
generally unhealthy, and are best got rid of by this 
summary procedure. In fact, in cases where the 
granulations are at all exuberant, or the sore a " weak " 
one, I believe it is still better in the first instance to 
scrape them away, and then to apply the undiluted 
carbolic acid to the scraped surface. 

Another method which may be employed, when it is 
not desirable to administer an anaesthetic, or to cause 
so much pain to the patient as would be produced by 



i2 4 TREATMENT OF ULCERS. 

chloride of zinc, or immediately on the application of 
carbolic acid, is to employ strong carbolic oil, 1 to 5. 
Lint dripping in 1 to 5 carbolic oil should be carefully 
packed into all the recesses of the ulcer, and if this 
dressing is changed every day, it will be found that in 
a few days the sepsis has been completely got rid of. 

As to the use of iodoform in ulcers, it is, of course, 
inefficient as a means of disinfecting them completely, 
and only acts by diminishing the evil effect of the already 
existing sepsis. As, however, I consider it of very great 
importance at the initial stage in the treatment of an 
ulcer to obtain an aseptic surface, I think one does much 
better to employ either the undiluted carbolic acid or 
the carbolic oil in the first instance, in preference to 
iodoform. Usually for the first two or three days after 
the preliminary disinfection of the wound, I have applied 
the cyanide gauze directly to the surface of the ulcer, 
the gauze being soaked in 1 to 2000 bichloride of mer- 
cury solution, and having been only imperfectly squeezed, 
so that there is a considerable amount of solution actually 
kept in contact with the surface of the ulcer. In a few 
days, however, sepsis having been got rid of, we must 
adopt means to avoid any further irritation of the sore, 
either by the chemical antiseptics employed, or by the 
dressings, otherwise the sore would not heal, although 
it were aseptic, and although the limb were placed at 



DRESSINGS FOR ULCERS. 125 

rest and in a suitable position. It is too often the 
custom to employ carbolic lotion and lint dipped in 
carbolic acid as a dressing for ulcers. This, as far as I 
have seen, is far too irritating a dressing, and will of 
itself interfere with the healing of the ulcer. 

The method which Sir Joseph Lister employed, and 
which is still in most cases probably the best, is to use 
an absolutely non-irritating antiseptic, such as boracic 
acid, as the application to the wound, and to prevent 
the mechanical irritation of the dressing by interposing 
between it and the surface of the sore, % piece of the 
oiled silk protective. The method is, after having got 
rid of the sepsis completely, to take a piece of the 
oiled silk protective — which is oiled silk covered with a 
layer of dextrine, in order that the antiseptic solution 
in which it is placed may not run off the surface, but 
may wet it uniformly — slightly larger than the wound, 
and having first dipped it in 1 to 20 carbolic acid lotion 
in order to disinfect it, to place it in the saturated 
watery solution of boracic acid. This protective is then 
applied over the surface, care being taken that it shall 
overlap the edges in all directions, but shall not extend 
above a quarter to half an inch beyond them. Outside 
this, two or three layers of boracic lint which have been 
wrung out of the solution are applied over the protec- 
tive and over a large area of the skin around, and fixed 



126 TREATMENT OF ULCERS. 

on with a bandage. In cases where the surface of the 
sore is extensive, and where there is a good deal of 
secretion, it is well to clip a few holes in the protective, 
so as to prevent the discharge being confined beneath 
it ; but in the case of a small sore, this is hardly neces- 
sary. This dressing is changed daily, the surface of the 
wound being washed with boracic lotion, and the sur- 
rounding skin with 1 to 20 carbolic lotion, care being 
taken that the carbolic lotion does not run over the 
wound ; and, further, the skin around is shaved at least 
once a week so as to prevent the growth of the hairs, 
which would otherwise entangle the discharge in them, 
and tend to act as centres for bacteric growth. 

In cases where the ulcers are painful, or where there 
are sloughs on the surface, it is well to employ the bor- 
acic lint wet, without any protective, the lint being 
used in the same way as a water dressing ; that is to 
say, the boracic lint, soaked with boracic lotion, is ap- 
plied over the ulcer and a little beyond it, and outside 
the boracic lint, overlapping it in all directions, is fixed 
a piece of mackintosh which has been disinfected in the 
carbolic lotion. This wet boracic dressing, or boracic 
poultice, as it is sometimes called, should be changed 
twice daily, and should not be continued after the 
irritable condition of the sore has ceased, or after the 
sloughs have separated. If this water dressing is too 



DRESSINGS FOR ULCERS. 127 

long continued, the granulations are very apt to become 
cedematous, and one form of weak ulcer is thus estab- 
lished. On the other hand, where the granulations 
become oedematous, dry dressings — the boracic lint well 
wrung out of boracic lotion, without the interposition 
of any protective — are probably the best. 

The other method of dressing ulcers is the use of 
various ointments, of which those chiefly employed are 
boracic ointment, eucalyptus ointment, or iodoform 
ointment. As a rule, I do not think that the wounds 
heal so kindly, when they are at all extensive, under oint- 
ments as they do under the protective and boracic lint 
dressing, and certainly they do not heal well under bor- 
acic ointment of the ordinary pharmacopoeial strength. 
Where the wound is healing rapidly and boracic oint- 
ment is used, the pharmacopoeial ointment should be 
diluted to about a half or a quarter of its strength, pro- 
bably the best is about a quarter strength. The strong 
boracic ointment seems to interfere with the epithelial 
growth, and is therefore unsuitable in such cases. It 
acts, however, very well in the early stage of the treat- 
ment of ulcers, before epithelial growth has begun at 
the edges of the wound. 

A fourth object in the treatment of ulcers, which is 
common to all, is that attempts should be made to get 
rapid healing with as little contraction as possible, and 



128 TREATMENT OF ULCERS. 

to obtain a scar which shall subsequently be sound. 
In the case of ulcers affecting the lower extremity, 
especially in oldish people, the scar obtained, where an 
ulcer is allowed to heal of itself, is usually weak, and 
commonly breaks down again if the patient afterwards 
has much standing or walking, the result being that he 
has, every now and then, to give up his work in order 
to get the ulcer healed, or else to be content to employ 
means which only interfere with the extension of the 
ulcer and which relieve him of his discomfort 

Where, however, a sound scar is desired, and where 
it is important to avoid any great contraction, it is 
necessary to employ the methods of skin grafting, 
and of these the best is that introduced by Thiersch. 
There are three plans in which the rapid epidermic 
covering of the sore may be brought about, the earliest 
being Eeverdin's method, which, however, is more 
properly termed epidermic grafting than skin grafting. 
In his plan minute portions of the superficial layer of 
the skin are shaved off; pieces of about the size of a 
pin's head are then planted on the surface of the granu- 
lations at short distances from each other. The result 
is that epidermic growth occurs from each of these 
little points, and numerous little islets of epithelium 
are thus formed over the surface of the sore. If these 
grafts are close enough together, and the other condi- 



EPIDERMIS GRAFTING. 129 

tions of healing are favourable, these islets of epidermic 
growth soon coalesce, and in this way rapid cicatrisa- 
tion of the sore is brought about. It is necessary in 
this method that the grafts should not be too far apart, 
because, as a rule, it seems that they have only a 
limited power of reproduction. Usually a minute graft 
the size of a pin's head will give rise to an islet of 
epidermis about the size of a sixpence, and then further 
growth seems to come to a standstill; therefore, in 
order to get rapid healing over the whole surface, the 
grafts should not be further apart than the diameter of 
a sixpence. 

The result of this method of epidermis grafting is 
that rapid healing of a sore is obtained in many cases, 
more especially in burns and sores on the trunk, where 
contraction of the deeper part is readily possible, and 
no doubt the subsequent contraction is considerably 
diminished, because less granulation tissue is formed 
than if the sore has to heal altogether from the margin. 
Nevertheless, a considerable amount of contraction does 
occur in sores in which healing has been obtained in 
this way, and the resulting scar is in reality not materi- 
ally stronger than the scar which is obtained by per- 
mitting the sore to heal from the edge. 

With the view of obtaining a sounder scar, much 

more extensive and thicker portions of skin must be 
9 



130 TREATMENT OF ULCERS. 

taken, and they must be applied close together. There 
are two ways of doing this, either by using the whole 
thickness of the skin, or, still better, by employing 
Thiersch's method, in which about half the thickness 
of the skin is shaved off. Whichever of these plans 
is employed, the preliminary portions of the treatment 
are the same. The skin which is to be used as the 
grafts must, in the first instance, be thoroughly dis- 
infected in the usual manner, and must also be care- 
fully shaved ; the presence of hairs in the grafts seems 
to materially interfere with the union. 

The sore itself must also be prepared beforehand. 
In the first place, the ulcer must be got into a healthy 
condition, and this is best indicated by the occurrence 
of healing at the edges. As a rule, if one attempts to 
graft a sore which is still ulcerating, the graft will fail 
to take, and the result will be unsatisfactory; hence 
the first thing to do as a preparation for skin grafting 
is to act on the principles which I have already men- 
tioned, and to wait till the surface of the sore has 
become covered with healthy granulations, and till the 
commencement of epithelial formation at the margin is 
evident. Some surgeons wait still longer, and the 
usual time given is about six weeks after the com- 
mencement of the treatment, and further, they prepare 
the surface of the sore in an elaborate manner with the 



SKIN GRAFTING. 131 

view of getting a firm, vascular basis of fibrous tissue ; 
this is chiefly clone by repeatedly cauterising the surface 
with nitrate of silver. I have not, however, found that 
this preliminary treatment of the sore is necessary, nor 
that it is desirable to wait longer than till the tissues 
have passed into a healthy state and healing has 
commenced. 

Having got the sore into this condition one should 
make sure that it is aseptic, and then, the patient 
having been placed under chloroform, the granulations 
over the whole surface should be scraped away, taking 
care not to go through the deeper layer of newly formed 
fibrous tissue and into the fat. The result is that a 
surface which is quite smooth, highly vascular and 
firm is left, on which the grafts are laid, this surface 
consisting of the deeper layers of granulation tissue 
which have already become organised into new fibrous 
tissue. 1 consider it also of the very greatest im- 
portance in the case of ulcers of the leg to remove the 
portions of the sore which have already become covered 
with epithelium. One is tempted to limit the skin 
grafting to the actual unhealed portions of the sore, 
and, in the earlier cases in which I employed this 
method, I did so. The result was very disappointing, 
for while, if a patient walked about, the region which 
was skin grafted remained perfectly sound, the interval 



132 TREATMENT OF ULCERS. 

between the skin grafts and the healthy skin, which 
had become covered by epidermic formation previous 
to the performance of the skin grafting operation, broke 
down. Thus, instead of a complete recurrence of the 
ulcer, a narrow line of ulceration was left surrounding 
the central area which had been skin grafted, this line 
of ulceration being extremely difficult to treat. That 
experience in several cases has led me to do as I have 
recommended above, namely, in all cases to cut away 
the whole healed part of the sore right on to the 
healthy skin so as to cover the whole surface with the 
skin grafts. 

Having in this way prepared the surface of the sore, 
the bleeding must be completely arrested before the 
skin grafts are applied, and this is done by taking a 
large piece of protective, dipping it in 1 to 20 carbolic 
acid so as to disinfect it, and subsequently in weak 
sublimate solution or in boracic lotion, and applying it 
over the whole surface which has been scraped. Out- 
side this sponges are placed on which an assistant keeps 
up pressure, or, if there is no assistant, a bandage is 
applied firmly over the part. The object of the pro- 
tective, which was introduced by Halsted, of Baltimore, 
is to avoid the occurrence of the bleeding when the 
pressure is taken off. If the sponges or dressing are 
applied directly to the wound with the view of exer- 



SKIN GRAFTING. 133 

cising pressure, the bleeding for the time ceases, but 
the sponges or dressing become adherent to the surface 
of the wound, and, on pulling them off, the bleeding is 
reproduced. If, however, a piece of protective is inter- 
posed between the sponges or dressing and the surface 
of the sore, no adhesion takes place, and the pressure 
can be removed without starting the bleeding again. 

While the bleeding is being arrested by pressure, the 
surgeon may proceed to cut his skin grafts. In 
Thiersch's method of skin grafting the grafts may be 
taken from any part of the body, but, as a rule, they are 
most conveniently cut from the extremities, and I most 
usually take them from the thighs. The skin having 
been prepared in the manner previously described, it 
is put vertically on the stretch by an assistant, and the 
surgeon grasps the thigh behind and makes the skin 
tense and prominent by pushing the muscles and skin 
forward from the bone, and in this way gets a more or 
less flat surface. The razor, which should have a broad 
blade, is dipped in boracic lotion or a very weak sub- 
limate solution, and is kept constantly wet with this 
solution while the graft is being cut in the same way 
as a razor is kept wet in making microscopical sections 
of fresh tissues ; if this is not done, the graft tends to 
adhere to the razor and, in a very short time, the base 
of the graft is cut through. The razor penetrates the 



i 3 4 TREATMENT OE ULCERS. 

skin to about half its thickness, and then, by a sawing 
motion, the grafts are cut as broad and as long as 
possible. After a little practice one can cut grafts from 
1 to 2 inches in breadth, and of the whole length of the 
thigh. I generally leave the graft lying on the slightly 
bleeding surface from which it has been taken till it is 
required for use. I think that is better than placing it 
in a warm antiseptic solution (boracic lotion) or a solu- 
tion of salt and water ; sufficient warmth is communi- 
cated from the limb, and the graft remains bathed in 
blood and serum. 

One goes on cutting fresh grafts till enough have 
been obtained, and then, the bleeding having been 
arrested as formerly described, the graft is transferred 
bodily to the surface of the ulcer. If the graft is 
too long, it is cut across with fine scissors at the 
requisite point. These grafts should be applied quite 
in contact with each other, — in fact, the thin edges of 
the grafts should overlap each other, and they should 
also overlap the margin of the ulcer, so that when the 
process is completed the ulcer is entirely covered with 
pieces of skin, and one should not be able to see any 
part of the raw surface. While the grafts are being 
spread out in this way bubbles of air are apt to be 
caught under the deeper surface, and, at the same time, 
a little bleeding may occur ; consequently it is neces- 



SKIN GRAFTING. 135 

sary, having arranged the grafts in the manner 
described over the whole surface of the wound, to 
apply pressure again in order to squeeze out the air 
and blood which may have accumulated underneath. I 
generally do this by taking a narrow strip of protective 
— which has been rendered aseptic as formerly de- 
scribed — and, holding it at each end, place it gently 
over the grafts, gradually increasing the pressure as it 
is wrapped round the leg so as to squeeze out anything 
underneath it. It is then simply left in position, and 
fresh strips are applied in the same manner, overlapping 
the edges of the former. In this way the whole surface 
of the ulcer is covered with protective. Outside this 
protective, and overlapping it well in all directions, I 
generally apply a thick mass of cyanide gauze, with 
some salicylic wool outside the gauze, and then a fairly 
firm bandage. 

The dressing should not be changed for at least five 
days after the operation, and it may in most cases be 
quite well left for a week. When it is removed, it will 
almost always be found that if the operation has been 
properly carried out, the whole of the grafts have taken, 
and the surface of the ulcer is practically healed. Care 
must of course be taken not to detach any of the 
grafts in changing the dressing, because, although they 
have become adherent, the adhesion is still comparatively 



136 TREATMENT OF ULCERS. 

slight. The surface of the grafts having been washed 
with weak sublimate solution (1-4000 or 1-6000), fresh 
protective and gauze is applied for another week. In 
about a fortnight, I generally substitute weak boracic 
ointment for the former dressing, and go on with this 
for some three or four weeks, not that the wound is not 
healed, but to avoid the drying up of the surface of the 
grafts which is apt to occur. With regard to the 
part from which the skin has been taken, the best 
dressing is weak boracic ointment covered with boracic 
lint and a bandage. This may be left on for about ten 
days, when, as a rule, the whole, or, at any rate, the 
greater part of the surface will be found to have healed 
over. In the course of time, the region from which 
the skin has been taken assumes a more and more 
normal appearance, so that after a year or two fresh 
grafts might if necessary be taken from the same 
surface. 

Where an ulcer has been made to heal in this way, 
it is of great importance to prevent the patient walk- 
ing too soon. In the first instance, of course, the 
graft is only attached to the deeper parts by lymph,, 
and subsequently by new cell growth, and the complete 
reorganisation of the graft, and the complete and 
intimate union of it with the deeper parts — especially 
the formation of elastic tissue passing from the deeper 



SKIN GRAFTING. 137 

parts into the graft, is a process which is not com- 
pleted for several months, and if the patient is allowed 
to walk about too soon, hemorrhage is very apt to 
occur between the grafts and the deeper parts and 
lead to their detachment. Hence it is well after an 
ulcer has been healed in this way, to tell the patient 
not to hang down the leg or to walk about on it for 
from three to six months. If he follows that advice, 
one may reckon that a large proportion of ulcers, even 
although they may have been intractable or in an 
unhealed condition for years, will remain permanently 
sound. This being the case, I consider that skin 
grafting is a procedure which should always be em- 
ployed in ulcers of the leg. 

As regards the method of skin grafting by using 
the whole thickness of the skin, I employed that at 
one time in a number of cases, and no doubt where 
these grafts were applied and took, the result was 
extremely satisfactory. The objection, however, to this 
plan is that, in the first place, the grafts do not take 
with at all the same certainty as Thiersch's grafts 
take. As I have already said, one may almost reckon 
on success with Thiersch's method, if only the opera- 
tion has been properly carried out on the lines which 
I have described ; but where the whole thickness of 
the skin is employed, however careful one is, whole 



138 TREATMENT OF ULCERS. 

grafts or portions of the grafts will almost certainly 
die. It is not at all unfrequent in such cases to obtain 
union of the graft as a whole, but to find that a 
small slough forms in the centre of the graft, and 
probably this is because the skin tends to curl up. and 
although applied flat over the surface of the sore, the 
centre becomes raised and does not acquire proper 
adhesion beneath. Another objection is that where 
the whole thickness of the skin is employed, great care 
must be taken that all the fat is removed. The actual 
deeper layer of the dermis must be in contact with the 
surface of the ulcer, and this is a procedure which 
takes a considerable amount of time, and which it is 
not at all easy to carry out properly. A further objec- 
tion to the employment of the whole thickness of the 
skin is that the skin retracts, so that what in the first 
instance was a large piece of skin, by the time it has 
been prepared and made ready to apply to the ulcer, 
has become a comparatively small piece, and it is sur- 
prising how much skin one must use in order to 
completely cover a comparatively small ulcer. On the 
whole, I believe that an equally satisfactory ultimate 
result is obtained by Thiersch's method as by employ- 
ing the whole thickness of the skin, while the operation 
is much more satisfactory and more easily performed. 
I may now mention one or two points with regard to 



INFLAMED ULCER. 139 

the treatment of some of the forms of ulcers which 
I have previously referred to. As regards the simple 
ulcer I need not say anything. The simple ulcer is one 
which is prevented from healing by various local causes, 
and if these causes are removed, and the limb placed 
at rest in a suitable position, the sore will quickly heal. 
Where, however, the sore has become inflamed, and we 
have the condition of inflamed ulcer, it is necessary to 
take measures with the view of combating this inflam- 
mation, and these must consist in the first place, and 
most essentially, in the elevation of the part, and 
secondly, in the employment of warm compresses, the 
best being the boracic poultice which I have already 
described ; or, where the inflammation is progressing 
very rapidly, the use of cooling lotions such as lead and 
opium lotion. In the case of inflamed ulcer, also, con- 
siderable benefit will be obtained from making incisions 
into the inflamed tissues, and this is more especially 
the case where there are several ulcers which are 
separated by narrow bridges of skin. By cutting across 
these bridges the tension will be relieved, local depletion 
will be carried out, and the exuded material underneath 
is enabled to escape, and in this way narrow bridges of 
skin, which would otherwise almost certainly slough, 
will be saved. This treatment by boracic poultices or 
by lead and opium lotion must not of course be con- 



140 TREATMENT OF ULCERS. 

tinued once the inflammation has subsided, otherwise 
one is apt to get a weak ulcer. Once the inflammation 
has come to a stop, the treatment must be conducted on 
the lines already described. 

In the case of the weak ulcer, the cause which is 
leading to the weakness must be sought for and removed, 
especially difficulty in contraction of the surface of the 
ulcer, general anaemia of the patient, &c. Stimulant 
applications are usually advised for these ulcers, such as 
weak solutions of sulphate of zinc (red lotion), sulphate 
of copper, nitrate of silver, &c. Where it is due to 
difficulty in contraction, means must be taken to permit 
this to occur, as, for example, by lateral incisions. 
When the sore is adherent to bone, portions of bone 
have been removed, or even joints excised, to relieve the 
tension. In the case of the irritable ulcer, occurring 
above the malleolus in neurotic women, the best treat- 
ment is to thoroughly cauterise the ulcer by nitrate of 
silver, so as to destroy its base completely, and subse- 
quently to carry out the treatment on the principles 
previously mentioned ; the menstrual functions must 
more especially be attended to. The phagedenic ulcer, 
of course, requires energetic destruction of the gangrenous 
tissue. It may be carried out either by the actual 
cautery, which is apparently the best method, or by 
caustic potash, which, however, is apt to do more than 



CALLOUS ULCER. 141 

is required, or by nitric acid, which, on the contrary, 
seldom penetrates sufficiently deeply. Subsequently to 
the application of the strong escharotic, pure carbolic 
acid may be sponged over the surface, and then a dress- 
ing of strong carbolic oil applied. The varicose, ulcer 
must be treated on the lines already mentioned, and, in 
addition, steps must be taken to improve the condition 
of the veins by operation. It is, on the whole, best to 
defer the operation for varicose veins (excision of 
portions of the vein) till after the wound has thoroughly 
healed. Operations for varicose veins, should the 
wound become septic, are of course extremely dan- 
gerous, and, while the wound remains open, it is always 
possible that the asepsis'may not be complete and that 
the operation wounds might become soiled. 

The ulcer with regard to which we need speak most 
in detail is the callous ulcer. Here, as I have already 
said, the obstacle to healing is the callous condition of 
the surrounding parts, and our first efforts must be 
directed to getting rid of this condition. As a matter 
of fact, if the part is put at rest, the leg being elevated 
and the sore rendered aseptic, this callous condition 
will comparatively quickly subside, so that in the 
course of two or three weeks the sore will present a 
healthy appearance and healing will commence. Where 
it is desirable to expedite matters, or where the 



142 TREATMENT OF ULCERS. 

thickening of the tissues does not disappear rapidly, 
various plans have been employed. Of these I may 
mention, as perhaps the most efficient, blistering. The 
effect of a blister applied over the thickened parts is to 
set up an increased circulation of blood through the 
part, and consequently an increased circulation of 
lymph ; and the result of the blister is usually in a few 
days very great improvement as regards the thickening 
of the tissues. As a rule, the blisters should only be 
applied to the skin around the ulcer, and should not 
extend over the surface of it. A number of the patients 
who suffer from this form of ulcer are also the subject 
of kidney disease, and if the blister is applied over the 
surface of the ulcer, a considerable quantity of the 
cantharides may be absorbed and lead to congestion of 
the kidneys and serious consequences. Another method 
which is very much employed is pressure. This may be 
employed' either in the form of strapping, the strips of 
plaster beginning below the ulcer and crossing in front 
of it, a hole being cut at the lower part to allow the 
escape of discharge from the cavity of the ulcer ; or 
again, an elastic bandage, more especially Martin's 
elastic bandage, may De employed with advantage. 
Massage will also speedily get rid of the effused 
material, the rubbing being employed, in the first 
instance, at the upper part of the leg in the way 



CALLOUS ULCER. 143 

which 1 have already mentioned. Again, lateral 
incisions have been recommended with the view of 
allowing the escape of the exudation into the cellular 
tissue, and of permitting the edges of the sore to 
contract. On the whole, however, I think that the 
best plan is usually to remain content with elevation 
and rest, or, if time is a matter of consequence, to apply 
blisters. 

The callous edges having been got rid of, and the sore 
having assumed a healthy condition, skin grafting should 
be employed, and if, when the swelling of the parts has 
completely subsided, varicose veins are found, they 
must be operated on after the wound has healed. 

Callous ulcers occur more especially in the very poor, 
who are unable to submit to the necessary treatment, 
and it is often a matter of great difficulty to persuade 
them to come into the hospital or to remain away from 
their work for the length of time which is requisite in 
order to effect a complete cure. Hence, one has often 
to treat them as out-patients, and, in that case, one can 
hardly hope for a cure. The utmost that one can 
expect is alleviation of the pain and discomfort, with 
possibly a gradual improvement in the condition of the 
sore. If the patient is to be allowed to walk about with 
a callous ulcer, the first essential, after having rendered 
the sore aseptic, is to give the part adequate support, so 



144 TREATMENT OF ULCERS. 

as to aid the return circulation when the patient 
assumes the vertical position. For this purpose 
bandages are necessary, and as an ordinary bandage 
practically affords no support, one must employ either 
an elastic bandage or else ordinary bandages which are 
stiffened by gelatine or other material which solidifies. 

The form of elastic bandage which is usually employed 
now is Martin's pure rubber bandage. Originally it was 
applied directly to the sore without any dressing inter- 
vening, and the instructions given were to take it off at 
night, thoroughly wash it, and hang it up to dry, and 
then in the morning, after having washed the sore, to 
re-apply it before getting up, without using any dressing 
whatever. In applying the bandage, it must be put on 
loosely, otherwise, if the turns are applied tightly, the 
pressure accumulates, and thus, especially towards the 
upper part, a very tight constriction may be brought 
about. The bandage should be simply rolled round the 
leg loosely and evenly. After the patient has stood a 
short time, the leg begins to swell, and the bandage 
becomes firm and helps to resist any further distension. 
The original Martin's bandage was imperforated, and the 
result was that the sweat could not escape, and if a con- 
dition of varicose eczema was present, this was very apt 
to become exaggerated. Now, however, these bandages 
are perforated so as to permit of the drying up of the 



CALLOUS ULCER. 145 

sweat. I do not myself approve of the method of 
applying the bandage over the ulcer without any inter- 
mediate dressing. It interferes with the aseptic treat- 
ment of the sore, and the discharge accumulating 
beneath it very soon becomes extremely foul, and con- 
sequently very irritating ; hence, I always apply an 
antiseptic dressing to the sore before putting on the 
bandage, the best being the protective and boracic lint 
previously described. It is well to avoid greasy sub- 

l 

stances such as ointments, because they spoil the rubber, 
and then fresh bandages must be obtained at frequent 
intervals. There is no question that great benefit is 
derived from the use of Martin's bandage, and in a 
certain number of cases the sores may even heal. 

Unna has introduced, in preference to the Martin's 
bandage, an arrangement by which ordinary bandages are 
stiffened, and do not slip down. His method is shortly 
this. In the first place, he thoroughly disinfects the 
skin, washing it with soap and water, and subsequently 
with antiseptic lotions, and powdering it and the sore 
with iodoform. He then takes a double-headed band- 
age, and commences from the middle of the sore, making 
one end of the bandage go upwards and the other down- 
wards. This bandage is a porous one, and over it he 
applies a mixture of gelatine and glycerine, 10 parts of 

gelatine to about 40 parts of water and 40 parts of 
10 



146 TREATMENT OF ULCERS. 

glycerine, to which some oxide of zinc is added in order 
to make it stiffer. This is melted and rubbed into the 
bandage, and before it has set, another bandage is taken, 
dipped in hot water, and applied over it. The whole 
thing solidifies, and forms a firm support to the leg, 
while, at the same time, it has not the weight or the 
dense hardness of plaster of Paris, and, further, some of 
the disadvantages of Martin's bandage, especially the 
irregularity of the pressure, are avoided. This dressing 
is renewed according to the amount of discharge, usually 
at first every other day, but as the discharge gets less, 
at less frequent intervals. It is readily removed by 
putting the patient's leg in a tub of warm water, which 
melts the gelatine, and allows one to unwind the band- 
age quite easily. Those who have compared the effect 
of Martin's bandage and Unna's method, speak most 
highly in favour of the latter. 

When an ulcer has healed, whether it is by skin 
grafting or naturally, it should be supported for some 
time with a light bandage and pad, or even with Unna's 
bandage. Massage should also be used if the scar is 
fixed and hard, and the muscles are atrophied. The leg 
should be frequently placed in a warm bath, and lano- 
line should be rubbed into the skin. 

In the case of the paralytic ulcers, stimulant applica- 
tions should be used in addition to the ordinary methods 



CHRONIC INFECTIVE UICERS. 147 

of treatment, more especially the application of spirits 
of wine to the parts around. As a dressing, balsam of 
Peru sometimes acts as well. In the case of perforating 
ulcer of the foot, very radical measures are necessary in 
order to obtain healing. One may place such a sore at 
rest and in an elevated position for a long period of 
time, without obtaining the slightest attempt at healing, 
the reason being, as I have already pointed out, that the 
epithelium has spread down the sides of the funnel, 
hence, in order to obtain healing, it is necessary to cut 
away the edges and the sides of the ulcer. The orifice 
of the ulcer, and the whole of the sides down to the 
bottom, should be completely and widely excised. The 
bottom of the ulcer should then be scraped, and the 
whole cavity stuffed with cyanide gauze sprinkled with 
iodoform. In the case of the pressure ulcer, also, it is 
necessary to remove the callosity on each side of the 
ulcer. 

The Chronic Infective Ulcees. 

There are several infective diseases which lead to the 
formation of ulcers, but there are only two which I need 
refer to, namely — tuberculosis and syphilis. Without 
going into minute details, tubercular ulcers of the skin 
may be roughly described under three forms, namely — 
the ordinary tubercular ulceration, which generally 



148 TREATMENT OF ULCERS. 

occurs after the bursting of an abscess which has formed 
under the skin either primarily or secondarily to sup- 
puration in a deeper seated gland. This form is charac- 
terised by discoloration of the skin around, thin under- 
mined edges, and a soft, pale, unhealthy base. These 
ulcers do not heal on account of the presence of the 
tubercle, and also because the undermined skin is so 
thin that there is no possibility of its adhering to the 
deeper parts ; indeed, in some cases, the skin has become 
so thin that the deeper parts of the hair follicles and 
glands have been opened into, and epithelium has spread 
from these points over the under surface, so that even 
although the conditions of healing became more favour- 
able, the thin skin could not adhere to the deeper part, 
because it has already become covered with epithelium. 
Secondly, we have the tubercular ulceration of skin 
resulting from lupus vulgaris, where tubercles have been 
deposited in the superficial layers of the dermis, leading 
to the formation of typical lupus nodules, which break 
down, forming an irregular ulcer with soft nodular base, 
and w T ith nodules around the margin. Intermediate 
between these two, we have the condition of scrofulo- 
derma, where the tubercles have probably become 
deposited in the deeper layers of the dermis, and so 
lead to an ulcer presenting an appearance intermediate 
between that of the tubercular ulcer of the skin and of 



TUBERCULAR ULCERS. 149 

the lupoid ulcer ; that is to say, in some parts there is 
a tendency to nodular formation, while in other parts 
there is an imperfect undermining of the skin; the 
ulceration extends more rapidly than that of lupus. 

The treatment of these tubercular ulcers consists 
essentially in the removal of the tubercular material. 
They must no longer be looked on as due to a constitu- 
tional taint only, and the efforts to obtain healing must 
not be limited to the treatment of the general condition. 
They are essentially local affections, depending on the 
growth of tubercles in the part, and their treatment 
must be essentially local, and consist in the removal of 
these tubercles. This may be effected in various ways, 
the choice of the method depending, in the main, on the 
extent and situation of the disease. In cases of true 
tubercular ulceration — which is not usually very exten- 
sive, and which is more often situated on the neck or 
the extremities than on the face — the best treatment 
is complete excision of the whole area, with, at the 
same time, removal of tubercular glands, if present, of 
carious bone, &c. Such a wound, after complete re- 
moval, may, in some cases, be brought together by 
stitches, the edges of the skin being loosened ; or, if the 
wound is too large, healing can be rapidly obtained by 
skin grafting. 

Where, for some reason or other, such as the size or 



ISO TREATMENT OF ULCERS. 

situation of the sore, excision is not advisable, the 
undermined skin must be thoroughly slit up (though not 
necessarily removed) in various directions, and the 
surface of the sore must be scraped, with the view of 
getting rid, as far as possible, of all the tubercular 
growth. In the case of the tubercular ulcer, it gener- 
ally suffices, after scraping away all the surface, to 
apply undiluted carbolic acid, and then subsequently to 
treat the sore on the lines already laid down in speaking 
of ulcers. Such sores are, however, very apt to become 
weak ulcers, and whether from constitutional debility, 
or not uncommonly from fresh tubercular infection, 
considerable difficulty is often experienced in getting 
them finally to heal. One must change the dressings 
and the method of application from time to time. For 
a time, immediately after the scraping, one may use 
cyanide gauze sprinkled with iodoform; this again may be 
changed for gauze impregnated with balsam of Peru; or 
again, it may be changed for ointments of various kinds. 
In the case of lupus, our choice lies between excision 
or destruction of the lupus nodules in some less 
effectual manner. The most satisfactory manner is by 
excision, but in some cases the lupus is so extensive 
that one hesitates to carry out this method of treat- 
ment. Where there is a small group of lupus nodules 
on the face — provided they are not on the tip of the nose 






LUPUS. 151 

— excision will lead to less deformity than any othei 
method, and will, at the same time, give a more satis- 
factory result as regards cure ; the patch is enclosed in 
an oval incision, and the edges of the skin brought 
together again, possibly with buried stitches, and thus 
a delicate linear scar will result. Where the lupus is 
more extensive, excision and subsequent skin grafting 
yield very excellent results, and I have carried out this 
treatment, even in cases where there has been most 
extensive disease of the face, with remarkable success. 
Soon after the treatment the newly grafted areas seem 
hard, and show the scar to a greater extent than after 
scraping; but as time goes on the scar becomes soft 
and movable on the deeper parts, and the deformity 
becomes comparatively slight, while, at the same time, 
the whole or the greater part of the diseased area is 
radically cured. Further, the contraction resulting 
from this method is very much less than after scraping 
the wound and allowing it to heal by granulation, or 
tha 1 in cases where the lupus has recovered of itself ; 
consequently this plan is to be specially recommended 
where the lupus patch is in the neighbourhood of the 
eyelid, where, during the healing process, the lid might 
be seriously drawn upon. 

Where it is decided to employ scraping, this must be 
very thoroughly done, the greater part of the disease 



152 TREATMENT OF ULCERS. 

being removed, in the first instance, with a large sharp 
spoon, and then with finer spoons, the whole surface 
being ultimately gone over with a very small spoon, 
such as is used in the treatment of meibomian cysts, so 
as to clear out all the small recesses of the fibrous 
tissue. After the bleeding has been thoroughly arrested, 
the raw surface must be cauterised, with the view of 
destroying any tubercles which may have been left 
behind, and I believe that the best caustic for this 
purpose is nitric acid. Mtnc acid should be freely and 
thoroughly applied to the whole surface, and after 
about five minutes have elapsed, its action may be 
arrested by pouring on a saturated solution of carbonate 
of soda. When effervescence has ceased, it is evidence 
that the nitric acid has been neutralised, and if the 
nitric acid has been thoroughly neutralised, the sub- 
sequent pain is but slight as compared with that where 
this neutralisation has not been completely accom- 
plished. Pieces of boracic lint soaked in the carbonate 
of soda are then placed on the surface for some hours, 
and later on this is changed for boracic ointment, in 
the first instance of full strength, and subsequently 
diminished in strength as the sore tends to cicatrise. 
With this method more rapid healing could be obtained 
after granulation has occurred by the use of skin graft- 
ing, and possibly with less contraction, but I do not 



SYPHILITIC ULCERS. 153 

think that it is a matter of very great importance, 
because it is seldom that one eradicates the disease 
completely, however thorough the scraping and cauteri- 
sation, and the result is that a tubercular deposit forms 
under the skin graft, and the condition is reproduced. 

I do not propose to go fully into all the methods of 
treatment of lupus, and have only referred to the two 
chief methods which I should myself employ in most 
cases of lupoid ulceration. In cases where we have to 
do with isolated nodules of lupus, I believe the employ- 
ment of Unna's salicylic and creosote plasters according 
to his directions — that is to say, using the strong 
plaster for two to three weeks, and subsequently 
allowing the wound to heal under the mild plaster — is 
probably preferable to the method of scraping out the 
individual nodules and burning the cavity with nitrate 
of silver, or to the other methods, such as scarification, 
&c, which are sometimes employed. 

As regards the condition of scrofuloderma, the treat- 
ment must be similar, but in most cases I think that 
scraping and cauterisation yield a fairly satisfactory 
result. 

As regards syphilitic ulcers, I need say practically 
nothing. Their treatment, of course, is the treatment 
of the constitutional condition, and they will usually 
heal rapidly if only large enough doses of iodide of 



154 TREATMENT OF ULCERS. 

potassium are administered, the fault generally com- 
mitted being that the physician rests content with 5 or 
10 grains of iodide of potassium at a dose, instead of 
going up to 25, 30, or more. Where healing is slow, 
especially where the ulceration is not due to the presence 
of a gummatous nodule, but is the superficial form of 
ulceration occurring at the early stage of the ter- 
tiary period, the application of emplastrum hydrargyri, 
renewed every day, will aid the action of the iodide of 
potassium. In some cases, in feeble individuals, Gibert's 
syrup gives excellent results. It is seldom that one 
scrapes or removes a syphilitic ulcer, but I must say 
that I see no objection to doing this in cases where the 
ulceration is obstinate ; on the contrary, I believe that 
great advantage will thereby be obtained, more 
especially where the bone beneath is also involved 

Ulcerating- Tumours. 

As regards ulcerating tumours, the treatment here, 
of course, is not carried out with the view of getting 
the ulcer to heal, but with the view either of eradi- 
cating the disease, or of alleviating the troubles of 
the patient. The eradication of the disease naturally 
means the removal — preferably by excision — of the 
whole malignant tumour, and the decision with regard 



ULCERATING TUMOURS. 155 

to that must depend on its site and the possibility of 
such removal. As regards the discomforts which it is 
necessary to alleviate in such cases, they are chiefly 
the foul condition of the ulcer, and the great pain 
which sometimes accompanies it. It is an excessively 
difficult thing to get rid of the foul condition of the 
ulcer, and it is important in trying to get rid of it not 
to employ irritating antiseptics, because these will only 
lead to more rapid extension of the growth. Frequent 
washing of the surface with sanitas, peroxide of hydro- 
gen, Condy's fluid, &c, powdering it with iodoform, and 
applying iodoform ointment and boracic lint, will, in 
most cases, answer best. Where the smell of iodoform 
is objected to, the sepsis can also be very considerably 
diminished by the use of the powdered double cyanide 
of mercury and zinc, which is employed for impregnating 
the cyanide gauze. This powder may either be dusted 
over the sore, or, still better, may be mixed up into a 
paste with a weak sublimate solution, and this paste 
introduced into all the crannies of the ulcerated surface. 
Where there is much pain, the antiseptic ointment 
may be alternated with ointments containing cocaine or 
morphia, and, of course, in cases where the disease 
cannot be operated on, there can be no objection to 
injections of morphia subcutaneously, repeated when- 
ever the pain recurs and becomes severe. 



TREATMENT OF ABSCESSES. 



TREATMENT OF ABSCESSES. 

Suppuration in the substance of the tissues must be 
divided into acute and chronic, and as the pathology 
of these two forms is quite different, and as con- 
sequently the treatment is not the same, we must 
consider each form separately. 



Acute Abscess. 

In this case, suppuration occurs under two forms : — 
(a) the pus is contained in a well defined cavity — the 
ordinary circumscribed acute abscess ; (b) the pus 
infiltrates the cellular tissue, and there is, in the early 
stage at any rate, no well defined limit or wall sur- 
rounding it — diffuse cellulitis. 

Acute suppuration in the tissues is always due to 
micro-organisms, and by far the largest number of 
abscesses owe their origin to the growth of the pyogenic 
cocci to which T have already referred, the circum- 



160 TREATMENT OF ABSCESSES, 

scribed acute abscess most commonly containing staphy- 
lococcus pyogenes aureus, or albus, while the diffuse 
cellulitis is practically constantly due to the strepto- 
coccus pyogenes. The mode in which the acute abscess 
is formed is best seen if one studies the development 
of abscesses in connection with pysemic emboli. In 
these cases, what first happens is the deposit of a mass 
of pyogenic cocci in the part, and the tissue immediately 
surrounding this mass in the first instance passes into 
the condition of "coagulation necrosis," while that 
which is further away, and in which the irritating 
products of the bacteric growth are more dilute, show 
the signs of inflammation. This inflammation goes on 
to the formation of granulation tissue, and ultimately, 
as the result of the action of the micrococci, of an acute 
abscess. 

It is not necessary that all acute abscesses should 
commence with the deposit of cocci in the tissues ; it 
is probably not an uncommon occurrence that in the 
first instance, as the result of some injury or other 
irritating cause, the early phenomena of inflammation 
occur in the part, and that then pyogenic cocci, which 
are present in the blood, or which are carried to the 
part by the lymph stream, &c, settle there, and set up 
the further changes which result in an acute abscess. 
However that may be, as I have already said, an acute 



FORMATION OF ABSCESS. 161 

abscess, or a diffuse cellulitis, is always due to the 

growth of pyogenic micro-organisms. 

We may trace the pathological changes very shortly, 

as follows : — In the first instance, we have all the 

phenomena which accompany the early stages of acute 

inflammation, namely, increased rapidity of the flow of 

blood, with subsequent slowing and possibly ultimate 

stasis, dilatation of the blood vessels, and exudation of 

white corpuscles and liquor sanguinis. The cause of 

the inflammation continuing to act, or, as I indicated 

in the second supposition mentioned above, fresh causes 

of inflammation coming into play, the process goes on 

to the complete destruction of the tissue which is the 

seat of disease, and the formation of a new, embryonic 

tissue, which is termed granulation tissue, and thus we 

come to have in the affected area a mass of embryonic 

granulation tissue. The irritant still continuing to act, 

we find that towards the centre of this granulation 

tissue liquefaction occurs, and fluid containing numerous 

cells in suspension is formed, in other words, pus. 

Once an acute abscess has formed in this way, the 

process extends, till ultimately the abscess reaches 

some free surface and there discharges itself, and the 

law which governs the direction and extension of the 

abscess is that it spreads along the tissues which are 

of greatest vitality. Thus, if an abscess forms beneath 
11 



i62 TREATMENT OF ABSCESSES. 

a dense fascia, the suppuration spreads along the planes 
of the cellular tissue beneath (burrows as it is termed), 
for long distances instead of passing directly through 
the fascia, and a considerable time must elapse before 
an opening occurs in the fascia either as the result of 
granulation of the dense fibrous tissue, or as the result 
of sloughing of the fascia. Thus, in the case of abscesses 
occurring in the deeper seated tissues, we generally find 
that we have not to do with a globular cavity but with 
one which shows recesses in various directions, and 
this is a point of excessive importance to bear in mind 
from the point of view of treatment. For if one in 
such a case contents oneself with a simple incision 
through the skin, the great probability will be that the 
pus will not escape freely from some of these deep 
recesses, and as a result, the discharge of pus will 
continue from the opening which has been made, and 
further burrowing of the pus takes place in con- 
nection with the imperfectly drained cavities. This 
is perhaps best seen in cases of suppuration in 
the mamma, where the abscess cavity is practically 
multilocular, on account of its subdivision by the 
lobules of the breast, and where, consequently, unless 
special care is taken when the abscess is opened to 
break down the various septs which subdivide the 
cavity, suppuration may go on, and fresh sinuses form. 



ENTRANCE OF ORGANISMS. 163 

Acute abscesses occur in any part of the body, the most 
important regions — as implying differences of treatment 
— being the skin, the subcutaneous tissue, beneath 
fasciae, in glands, in connection with the periosteum 
and bone, about the anus, in tendon sheaths, and in 
various serous cavities, more especially the pleurae. As 
to the causes which set up acute abscess, as I have 
already said the essential cause is the presence of pyo- 
genic organisms, but these can only produce the result 
under special circumstances such as I have already 
indicated when speaking of suppuration in connection 
with wounds. 

These organisms may reach the part in which the 
abscess subsequently forms either by (i.) direct exten- 
sion through the tissues from some neighbouring abscess, 
or from some free surface such as the skin, or by 
spreading up ducts as in certain cases of suppuration of 
the breast, where they spread up the milk ducts; or 
(ii.) through the lymphatic vessels ; or (iii.) through the 
blood vessels. As to the mode in which they gain 
entrance to the blood we are not as yet thoroughly 
acquainted. Most usually they get into the blood at 
some part distant from the abscess, where an ulceration, 
or at any rate, a weak spot has been formed. For 
instance, where the patient is the subject of a boil, the 
organisms may enter the blood, and, reaching some weak 



1 64 TREATMENT OF ABSCESSES. 

part at some distant part of the body, may there set up 
an abscess. Similarly, they may enter from wounds or 
leers in the mouth and throat. Kocher is of opinion, 
however, that most often, especially in cases of acute 
periostitis or osteomyelitis, they enter from the intes- 
tine, because in these diseases there is generally a 
history of some intestinal derangement, usually diar- 
rhoea, for a few days preceding the onset of the disease. 
The second form of acute suppuration, namely, 
diffuse cellulitis, is a very much more serious disease 
than that which we have just been considering. In 
this case the organisms spread with great rapidity, 
probably along the lymph spaces and lymphatic vessels 
in the cellular tissue, and no proper wall of leucocytes 
is formed, at any rate in the early stages. As a result, 
the tissues become infiltrated with a small quantity of 
pus, which it is impossible to get rid of by compara- 
tively small incisions ; and not only are the tissues 
infiltrated with pus, but those which are least vascular, 
at any rate, die to a considerable extent, and conse- 
quently, when incisions are made, we have an escape 
not only of pus, but also of sloughs of fascia, fat, &c. 
The great danger of this condition lies in its rapid 
extension, and more especially in the entrance of these 
streptococci into the blood, setting up the condition of 
pyaemia. 



SUBACUTE ABSCESSES. 165 

As, to some extent, intermediate between the acute 
and chronic abscesses, we have a certain number of 
cases where the abscess does not spread with the same 
rapidity, but, at the same time, is not at all chronic in 
its course and character, forms which may be spoken of 
as subacute abscesses. These subacute abscesses are 
also generally due to pyogenic cocci, more especially 
to the less virulent varieties, and it is in them, as a 
rule, that the rarer pyogenic cocci and pyogenic bacilli 
are found. In actinomycosis, also, the suppuration 
which occurs is generally of this subacute variety, but 
this form of suppuration is rare; it is perhaps most 
often seen about the jaws, and the condition is usually 
recognised by the presence of yellow or orange -yellow 
grains of actinomyces in the pus. Subacute, or even 
acute abscesses may also be due to the bacillus of 
glanders. 

Treatment. 

The treatment of an acute abscess consists in the 
first instance in the earliest possible evacuation 
of the pus. Once the signs of acute inflammation 
have existed for four or five days, even though one 
cannot make out distinct fluctuation, pus will almost 
certainly be found on opening up the hardest part of 
he swelling, and therefore I think it is well, under such 



1 66 TREATMENT OF ABSCESSES. 

circumstances, to make an incision without further 
delay There is no object whatever in waiting for the 
presence of fluctuation, because to do so is simply to 
allow the abscess to extend further, while even though 
pus is not found, or only in an extremely minute 
amount, free incisions into the part will usually arrest 
the process. Hence, I should lay down the rule that 
in cases where it is evident that we have to do with 
inflammation going on to suppuration, the earlier an 
opening is made into a part the better. 

Where an acute abscess is opened, the skin incision 
— unless in situations such as the face or neck, where 
the size of the scar is a matter of importance — should 
be free, — sufficiently free, at any rate, to allow the 
surgeon to introduce his finger. Having made the 
incision into the abscess, the surgeon introduces his 
finger with a view of breaking down the septa, to which 
I have previously referred as present in deep-seated 
abscesses, and of making sure that all the recesses in 
the cavity are freely opened up. This cannot be satis- 
factorily done without the aid of touch. In cases, 
however, where the abscess is superficial, or in cases 
where, as in the face, a scar is of great importance, a 
small incision may be made only sufficiently large to 
admit a small drainage tube, and the recesses of the 
abscess may be opened up by introducing a pair of 



OPENING OF ABSCESSES. 167 

dressing forceps through the incision and expanding 
the blades in all directions. In certain cases, such as 
in the neck, many surgeons use Hilton's method, in 
which the skin only is incised, and then, with a pair of 
dressing forceps, the deeper tissues are bored through 
till pus is reached. No doubt this plan is sufficiently 
satisfactory in many cases, but I think that with care 
it is but seldom necessary, and even where it is em- 
ployed I should strongly advocate the subsequent 
introduction of the finger for the purpose already 
mentioned. 

Having freely opened the cavity of the abscess, the 
pus which it contains should be thoroughly squeezed 
out, and then a drainage tube, which should always be 
of fairly large size — in fact, the larger the better in the 
first instance — should be introduced. For my own 
part, I object strongly to the washing out of these 
acute abscesses as is done by some surgeons. I do not 
think that it does any good, while, as I have already 
repeatedly said, it is apt to damage and depress the 
vitality of the abscess wall and favour the extension of 
the process. 

In opening an abscess all the usual antiseptic pre- 
cautions should be taken, the skin, &c, being purified, 
and cyanide dressings being employed in the manner 
which I have already fully described. At first sight 



1 68 TREATMENT OF ABSCESSES. 

this might seem an unnecessary precaution, because 
these abscesses being clue to pyogenic cocci already 
contain causes of suppuration. In practice, however, it 
is found that it is of the greatest importance and benefit 
to treat the abscess strictly antiseptically, It is found 
that when an abscess is opened antiseptically, suppura- 
tion ceases from that time. On removing the dressing, 
say on the following day, one may no doubt find a small 
quantity of pus, which, however, is only the residual 
pus that was present in the abscess at the time of 
opening, but one cannot, as a rule, squeeze out anything 
but a little serum, and on the following day there is 
usually no further pus. On the other hand, if an 
abscess is not dressed antiseptically, and all the pre- 
cautions which I have already described are not taken, 
if, for example, a poultice is applied after the abscess is 
opened, it will be found that the suppuration goes on, 
and that days will elapse before this suppuration ceases, 
and the healing of the abscess will be slower than in 
cases where the wound has been treated antiseptically ; 
while not uncommonly the process extends and fresh 
fluctuation becomes evident and fresh openings form. 

The explanation of this I take to be the follow- 
ing: — In the pus, and in the granulations forming 
the wall of the abscess, in the first instance, pyogenic 
cocci are present in large numbers, and, in the early 



DRESSINGS. 169 

stage at any rate, of complete activity. As the result, 
however, of the opening of the abscess, a quantity of 
serum is poured out which, in part, sweeps away the 
cocci and in part destroys them as the result of the 
largely increased amount of antibacteric material which 
is thus brought in contact with them. The consequence 
is that in a day or two the abscess cavity is free from 
organisms, or if they are present, they are very much 
diminished in virulence. The wound being treated 
antiseptically, fresh organisms do not enter, and the 
result is that we have in this way to do with an aseptic 
wound. If, on the other hand, a poultice, for example, 
is applied, while no doubt there is the same pouring 
out of serum and the same destruction of the bacteria 
already present in the abscess, fresh organisms at once 
spread in, and proceed to act and keep up the suppura- 
tion. That it is not entirely a question of free drainage 
is evident in cases where we have suppuration taking 
place in a wound which is more or less completely open, 
and where the pus has not been confined in a cavity. 
In such cases, if we open up the wound completely and 
introduce a drainage tube, we have not the same pouring 
out of serum which occurs when we open a tense, acute 
abscess, and we find that for days after the drainage 
tube has been introduced, pus can still be squeezed out. 
Whether this explanation is the correct one or not, the 



170 TREATMENT OF ABSCESSES. 

practical fact remains, as I have already stated, that if 
an acute abscess is opened antiseptically, and all the 
septa present in the cavity broken down, and free 
drainage provided, there will, in by far the greater 
majority of cases, be no further extension of the pro- 
cess. 

As regards the further treatment of these acute 
abscesses, the dressing should, as a rule, be changed the 
next day, when it will be found that already the swell- 
ing has considerably subsided, and that the tube, which 
was at the time of the operation of the proper length, 
is now projecting from the wound. In most cases it 
is best not to disturb the tube at this period, because 
there may be considerable difficulty in replacing it ; it 
is sufficient to clip off the portion of the tube which 
projects externally, so as to leave it again flush with 
the skin. As to when the dressing should be again 
changed, that will depend on the amount of discharge. 
Usually it can be left a couple of days, and then, 
depending on the size and depth of the abscess and on 
the amount of discharge, the drainage tube may either 
be left out on that occasion, or kept in till the next 
dressing two or three days later. 

I may refer very shortly to one or two points in con- 
nection with abscesses in special regions. As regards 
acute suppuration in glands, it sometimes happens, if 



GLANDULAR ABSCESSES. 171 

the abscess is simply opened, that healing does not 
occur very readily, because, in the gland, there may not 
only be the large abscess cavity, but there may be one 
or more small foci of suppuration present, and if the 
large collection is simply opened, these foci may sub- 
sequently give trouble ; and further, in the case of acute 
suppuration in a gland, it is not uncommon for other 
glands in the vicinity to contain commencing deposits ; 
in my experience this is very likely in cases of subacute 
suppuration in the glands in the groin. Hence, in the 
case of acute glandular abscess, I always make it a 
point, in addition to opening the abscess freely, to 
remove the whole of the gland, which is usually readily 
done with the finger introduced into the abscess cavity. 
In cases where more than one gland is enlarged, and in 
cases of subacute suppuration in the groin, I think it 
is best to make quite a free incision, and to remove not 
only the gland which has suppurated, but also the other 
enlarged glands in the vicinity. It is so often the case 
in these suppurations in the groin, especially after 
chancroid, that while the original abscess does well, 
fresh suppuration occurs in the other glands, and the 
case becomes a long one, and a source of disappoint- 
ment to the surgeon, and not uncommonly of loss of 
confidence on the part of the patient. This is avoided 
by removing the various enlarged glands as I have just 



172 TREATMENT OF ABSCESSES. 

mentioned. The same holds good with regard to glands 
elsewhere, certainly, at any rate, as regards the origin- 
ally affected gland, bnt, curiously enough, in my experi- 
ence, the multiple subacute, non-tubercular suppuration 
in glands has been practically limited to cases affecting 
the inguinal region. 

As regards suppuration occurring in serous cavities, 
I may say one or two words on the question of empyema. 
In cases of acute empyema, the collection should be 
opened as early as possible, and if the pus has not been 
allowed to remain in the chest till the lung has got 
firmly bound down by adhesions, the recovery will 
usually be very rapid provided the operation is properly 
done, and provided the wound is kept aseptic. In the 
first instance, the incision into the chest should be free, 
so as to permit the complete escape of the pus, and also 
of the masses of fibrinous material, which are so often 
present. This involves, in the case of children at any 
rate, the removal of a portion of the rib. In the 
case of adults, it is possible, in a considerable number 
of cases, to obtain sufficient access to the cavity of 
the chest through the intercostal spaces. The chest 
having been opened, and as much of the pus having 
escaped as will do so in the first instance, the patient 
should be allowed to recover to some extent from 
the anaesthetic, when he will usually commence to 



EMPYEMA. 173 

cough, or if he does not cough at once, he will do so on 
introducing the finger in contact with the lung. The 
finger being kept in the opening, this coughing on the 
part of the patient should be encouraged, because the 
result is that air is forced from the sound lung into the 
collapsed lung, which is thus gradually expanded. In 
doing this, the finger should be kept in the opening 
which has been made so as to prevent the entrance of 
air, being from time to time removed so as to allow the 
exit of the pus. In a comparatively short time, in 
recent cases, the lung will be felt to have more or less 
completely filled the cavity, and to project close to the 
opening. Beyond seeing that the cavity is as empty as 
possible, more especially of the fibrinous masses, I do 
not think that it is advisable to wash it out, unless in 
cases where we have to do with tubercular empyema. 
A drainage tube is then introduced which must 
efficiently extend into the thoracic cavity, but need 
not go for any considerable distance ; and then, outside, 
over the orifice of this drainage tube, a piece of protec- 
tive is placed which acts as a valve, allowing the exit 
of pus, but preventing the entrance of air, and thus, 
when the patient coughs, as he should be encouraged to 
do for some time after the operation, the expansion of 
the lung can go on. 

The dressing in such a case will very likely require 



174 TREATMENT OF ABSCESSES. 

changing, in the first instance, within about twelve 
hours, and a fresh piece of protective must be imme- 
diately placed over the orifice of the drainage tube on 
removal of the former piece. In the last case in which 
I opened an empyema in an adult, I left out the tube 
on the third day, and the result was that the patient 
was quite well, with a completely expanded lung, in a 
month, although when the empyema was opened, the 
chest was completely filled with pus, and the lung 
absolutely collapsed. In a number of cases at Padding - 
ton Green Children's Hospital, the tube has been left 
out at the end of twenty-four hours with equally satis- 
factory results ; and it is quite evident from our ex- 
perience that it is a great mistake in the majority of 
instances to continue the drainage, according to our old 
rule, till the discharge has become slight in amount. 
By doing so, one is very likely to have a sinus left 
behind, the healing of which is very troublesome. I 
need not go further into this matter, but I may refer the 
reader to the excellent papers which have been recently 
published in the Lancet on the pathology and treatment 
of empyema by Dr. G. A. Sutherland. 

The only other form of acute abscess to which I need 
especially allude are the abscesses which occur in con- 
nection with bone, cases of acute suppurative periostitis 
and osteomyelitis. In these cases, early incision through 



SUPPURATIVE PERIOSTITIS. 175 

the periosteum is a matter of the very greatest import- 
ance, and should be carried out as soon as the signs of 
inflammation of the periosteum and bone have mani- 
fested themselves. The incision should be free, both 
through the skin and through the periosteum ; and in 
cases where we have the typical grave signs of acute 
suppurative periostitis or osteomyelitis, if one fails to 
find pus under the periosteum, one should trephine the 
shell of the bone, and open the medullary cavity. In 
cases where the incision has not been made so early, and 
where the periosteum has been extensively stripped from 
the bone, it becomes a question whether one might not 
hasten matters by removal of the exposed portion of 
bone ; but if the wound is treated antiseptically, in most 
cases the greater part, and sometimes all the exposed 
bone, will recover ; and, therefore, unless in a case 
where the whole shaft of the bone is involved, and 
where the epiphyseal lines are destroyed, and where 
therefore it may be advisable to remove the detached 
shaft, I think it is best to wait till one sees whether 
the bone will not recover. In such cases, however, I 
think that the shell of the bone should be trephined 
and the medullary cavity opened, and if there is pus in 
the medullary cavity, this should be done in several 
places over the exposed area. 



176 TREATMENT OF ABSCESSES. 



Diffuse Cellulitis. 

The other form of suppuration in the cellular tissue 
is that known as diffuse cellulitis, where the pus is not 
contained in a definite abscess cavity, but infiltrates the 
tissue. This condition is, as I have already said, due 
to the streptococcus pyogenes, and these organisms not 
only lead to this diffuse infiltration of the tissues with 
pus, but also very often to death of shreds of tissue 
which come away afterwards as sloughs. This condition 
is a much more grave one than that of acute abscess, in 
bad cases the patient soon passing into what is known 
as the typhoid state. 

As regards the local appearances, the inflammatory 
condition spreads with great rapidity, the skin becoming 
red and brawny, and as suppuration occurs, boggy, but 
in the early stages at any rate, it is very difficult to 
make out any definite fluctuation. At a later period, 
it is not uncommon to find in addition to the infil- 
tration of the tissues with pus, that somewhere or other 
there is a distinct fluctuating cavity. The infective 
material spreads along the lymphatic vessels and 
not uncommonly bursts through the walls of these 
vessels at various parts of their course, leading to 



DIFFUSE CELLULITIS. 177 

multiple patches of inflammation ; and it is not 
uncommon for the condition to end in pyaemia. 

The treatment of this condition must be very 
thorough, and consists in permitting free and early 
exit for the pus and sloughs. A small incision will do 
no good whatever in this state, because the pus being 
infiltrated through the tissues would not escape and 
the process would go on spreading. It is absolutely 
essential that very free incisions should be made as 
soon as possible, these incisions extending right through 
the whole of the inflamed area, and if one incision 
does not suffice to lay the whole part open, additional 
incisions must be made till the whole inflamed area 
is exposed to view. After the incision in the skin has 
been made, the part should be gently squeezed, and 
any recesses from which pus wells up, should be 
thoroughly opened. When one is satisfied that all the 
recesses have been fully opened, I think it is well, after 
sponging the wound, to touch the whole surface with 
undiluted carbolic acid with the view, if possible, of 
destroying all the micro-organisms, and the results in 
such cases are sometimes extremely satisfactory. As 
regards the after treatment, where it can be conveniently 
carried out, irrigation with a weak antiseptic solution in 
the manner formerly described is the best form of treat- 
ment in the first instance till the wound has become 

12 



178 TREATMENT OF ABSCESSES. 

covered with granulations. Subsequently, the treat- 
ment must be carried out on the lines already suffi- 
ciently laid down. 

The gravity of this condition depends partly on the 
constitutional effect of the poisonous products of the 
organisms and partly on the situation of the disease. 
Diffuse cellulitis is most common in the upper arm, 
the organisms entering through scratches about the 
fingers or hand, and the inflammatory process un- 
fortunately does not always remain limited to the 
subcutaneous cellular tissue, but is apt to extend into 
the tendon sheaths and lead to very serious interference 
with the usefulness of the hand should the patient 
recover, these interferences being due partly to sloughing 
of tendons, to matting together of the muscles, and to 
adhesion of the tendons to the tendon sheaths. It is 
very important in these cases that as soon as the 
inflammatory condition has passed off, the movement 
of the fingers and wrist should be encouraged in order 
to prevent, as far as possible the formation of adhesions, 
and subsequently when the wound has healed, it is 
absolutely essential to employ massage, for a long 
period, and sometimes also occasional forcible movement 
under chloroform. 

In certain cases where the inflammation is very 
extensive and involves the tendon sheaths to a large 



CHRONIC ABSCESS. 179 

extent, and where the condition of the patient is very 
grave, it may be necessary to perform amputation, but 
this can only be done provided the amputation can be 
carried out well above the inflammatory area. 

Another region where this affection sometimes occurs 
is in the deep cellular tissue of the neck — the condition 
known as Angina Zudovici. Here the organisms enter 
from the tonsils and spread in the sub-fascial tissues 
with great rapidity, and very often with fatal results. 
It is of great importance that these cases should be 
recognised early, because almost the only hope for the 
patient's life is free and extensive incisions into the 
inflammatory area. 



Chronic Abscess. 

Chronic abscess is practically always due to tuber- 
culosis, and the pathology and treatment of the disease 
is therefore totally different from that of the acute 
form. To illustrate the pathology of a chronic abscess, 
I may describe the method of formation of one in 
connection with the cellular tissue. The earliest 
commencement is the formation of a mass of tubercles. 
These tubercles gradually extend, leading to the 
occurrence of inflammation around, and the formation 



180 TREATMENT OF ABSCESSED 

of a nodule, which, in the first instance, is firm in 
consistence, and more or less freely movable on the 
surrounding parts. As the nodule increases in size, the 
older tubercles in the centre undergo caseation, the 
caseous mass acts as an irritant, fluid is poured out, and 
also some leucocytes; and thus we come to have a 
nodule containing a softened centre, the material in 
this centre being fluid with degenerated fragments of 
cells and tissue and some leucocytes, while the firm 
tissue outside constituting the wall of the abscess con- 
tains tubercles. Once formed, the natural tendency is 
for the abscess to increase in size, fresh tubercles being 
constantly formed in the tissues around, while the 
older tubercles caseate and break down, the degenerated 
remains falling into the cavity of the abscess. On 
making a section of such a chronic abscess, therefore, 
one finds that the wall is composed of tubercles and 
imperfectly formed granulation tissue, and, while it is 
fairly well limited externally, the inner surface of the 
wall in contact with the abscess is ragged and irregular, 
and is composed in the main of caseating tissue. Hence, 
it follows that by simply opening such an abscess and in- 
serting a drainage tube, one merely evacuates the material 
which has already undergone degeneration, and does 
not in any way radically attack the essential disease. 
It is true that by removing the tension of the wall 



CHRONIC ABSCESS. 181 

due to the presence of the fluid contents, one does, to 
some extent, remove a cause of inflammation, but, 
nevertheless, one leaves the greater part of the curative 
work to be done by nature. That nature will in most 
cases prove equal to the task, provided only that the 
wound is kept aseptic, and that no fresh cause of 
inflammation enters in the shape of pyogenic organisms, 
and that the general health is kept up, is amply 
proved by the results which have been obtained in 
cases of abscesses connected with spinal disease which 
have been treated by simple aseptic drainage, as was 
the method employed by Sir Joseph Lister for many 
years. I have elsewhere given the statistics of cases 
treated in this way, from which it appears that over 
70 per cent, of psoas and other abscesses connected 
with spinal disease have completely recovered under 
this treatment. Nevertheless, even in these cases, the 
period during which the patients were under treatment 
was exceptionally long, on an average, something like 
eight months, and during that period the patients were 
absolutely confined to bed, and at any time an unskilful 
dresser might make a mistake in his aseptic work and 
allow the entrance of micro-organisms, thus rendering 
the former trouble futile. 

Since the pathology of chronic abscesses has been 
more clearly ascertained, and we know that we have to 



182 TREATMENT OF ABSCESSES. 

reckon not only with the contents of the abscess but 
also with the wall, methods have been introduced which 
render the treatment of these cases much more precise 
and satisfactory, and the ultimate results more certain 
than was previously the case. These methods may be 
summed up as three in number. (1.) The lirst and 
ideal plan is to dissect out the chronic abscess in the 
same way, or even more carefully, than one would 
dissect out any cystic tumour. This method of treat- 
ment can be carried out in many cases, more especially 
where we have to do with subcutaneous chronic 
abscesses, which are not at all infrequent in children, 
and which are termed by the French, " scrofulous 
gummata." In these cases a free incision is made over 
the abscess, and if the skin itself is involved, the 
affected portion of the skin is included between the 
incisions, and the whole of the abscess is dissected out, 
care being taken to avoid, if possible, opening into the 
cavity or leaving any portion of the wall behind. If 
this is done properly, a clean cut wound is left which 
heals by first intention, and in this way the whole 
process may be cut short, and the patient cured in the 
course of a few days. This method of dissecting out 
chronic abscesses is not limited to subcutaneous 
abscesses, it is equally applicable in many cases to 
abscesses connected with tubercular glands, where, of 



CHRONIC ABSCESS. 183 

course, in addition to removing the abscess wall, the 
gland from which it spread and all the enlarged glands 
in the neighbourhood are also taken away, and although 
one has to make a larger scar than would be necessary 
simply to open the abscess, the scar is linear instead of 
presenting the puckered, disfiguring appearance which 
so often follows spontaneous opening, or even drainage 
and scraping in these cases. 

In cases also where the abscess is connected with 
bone, it is possible in a certain number of instances to 
employ this radical treatment, more especially I would 
refer to chronic abscesses in connection with tubercular 
disease of the ribs, cases which do not do at all satis- 
factorily, or, at any rate, not at all rapidly, under any 
other plan of treatment. In such instances, I always, 
where the abscess is at all of moderate size, dissect out 
the abscess wall completely, and remove the whole of 
the carious part of the rib, taking care to cut through 
the healthy rib beyond. In such cases, it is true, one 
cannot remove absolutely the whole of the abscess wall 
by cutting, because there is practically always pus 
beneath the rib between it and the pleura, and that 
portion has to be dealt with by thorough scraping; 
but I have never yet failed in these cases to get 
healing by first intention, and satisfactory and per- 
manent cure. Where also abscesses are connected with 



1 84 TREATMENT OF ABSCESSES. 

other bones, or even with joints, and where they are 
not of large size, the same method of treatment may 
be adopted. 

(2.) Where it is impossible, on account of the large 
size of the abscess, or on account of its intimate rela- 
tions to important structures, to dissect out the wall 
in the manner which I have described, the next best 
thing to do is to lay it as freely open as possible, not 
merely making an incision into which one can introduce 
a finger or instrument, but such an incision that one 
can hold apart the sides of the wound and look into the 
interior; not uncommonly, one can make an incision 
extending over the whole length of the abscess. 
Having exposed the interior of the abscess in this way, 
and having evacuated the fluid contents, one then 
proceeds to remove the wall as thoroughly as possible, 
cutting it away at the superficial parts, either with a 
knife or with scissors ; or at the deeper parts, where 
cutting is not advisable, scraping very thoroughly with 
a sharp spoon, this scraping being much more satis- 
factorily accomplished where one can in this way look 
into the interior and see what one is doing than where 
one has to do it through a small orifice. Here, also, 
one can not uncommonly get rid of the wall completely 
and again obtain a wound which heals by first inten- 
tion. If, in such cases, the abscess has originated from 



CHRONIC ABSCESS. 185 

bone, one is also able to see and define the extent of 
the disease, and to chisel or gouge away the affected 
tissue. Where one does not feel absolutely certain 
that all the disease has been removed, I think it is 
advisable to fill the wound, before putting in the 
stitches, with iodoform and glycerine emulsion, which 
consists of glycerine, to which is added a small pro- 
portion of bichloride of mercury (yoV or pW part), 
and which contains 10 per cent, of iodoform in suspen- 
sion. Although I do not place any very great reliance 
in iodoform as an antitubercular agent, still I think, 
looking over one's whole experience, that it is not 
without a certain amount of value. In cases, on the 
other hand, where a considerable amount of tubercular 
material is unavoidably left behind, it is best not to 
stitch up the wound, but to pack it with cyanide gauze 
which has been thoroughly powdered with iodoform. 
This packing is left in, in the first instance, for some 
days, and then subsequently should be renewed daily. 
Once the wound has become completely covered with 
healthy granulations, the packing may be left off and 
% stitches inserted, a drainage tube being of course used. 
Union will then occur in a considerable number of 
cases at once. 

(3.) Lastly, we may have to do with cases where it 
is impossible, from the situation and connections of the 



1 86 TREATMENT OF ABSCESSES. 

abscess to treat it in either of the above mentioned 
ways. These are chiefly cases of abscesses connected 
with the spinal column, more especially cases of psoas 
abscess. In such instances it is impossible to lay open 
the cavity in such a way as to make the whole, or even 
the greater part, of its extent visible without, at the 
same time, damaging the strength of the abdominal 
walls very materially, and therefore we must resort to 
a less severe method. This consists in making a 
smaller incision into the abscess, in the case of psoas 
abscess best in front of the anterior superior iliac 
spine, and thoroughly squeezing out the cheesy con- 
tents. The abscess should then be washed out with a 
weak antiseptic solution, for which purpose I generally 
employ a 1 to 6000 sublimate solution, at the tempera- 
ture of the body, and then the wall must be as 
thoroughly scraped with a sharp spoon as possible. 
The washing out and scraping is best performed by 
means of the flushing spoons introduced by Mr. Barker, 
care of course being taken in scraping the inner part 
of the wall not to perforate the peritoneum or to injure 
the vessels. 

After the wall has been thoroughly scraped and the 
contents washed out, it is well to complete the process 
by introducing rough sponges held on long dressing 
forceps, with the view not only of soaking up and 



CHRONIC ABSCESS. 187 

removing the remains of the sublimate solution, but 
also of detaching any cheesy material or tags which 
may have escaped the action of the spoon. Having 
in this way dried the abscess cavity, it should be filled 
with iodoform and glycerine emulsion (usually from 
one to two ounces), a considerable part of which sub- 
sequently runs out, and then the external opening 
must be closed by means of stitches. In a large pro- 
portion of cases the external wound heals by first 
intention. In a small number it may heal in the first 
instance, and subsequently break down. In a certain 
number of cases, although the external wound heals 
by first intention, there is found, after a few weeks, 
a small collection of fluid, and it is well to evacuate 
this collection again, repeating the whole process at the 
the same time. As a rule, this fluid is a brownish 
glairy material, and contains a certain quantity of 
iodine. 

In the great majority of cases permanent healing is 
obtained either after one operation, or most commonly 
after two or three. In any case, the length of treat- 
ment is short as compared with that required for 
drainage, while the patient is not subjected to the 
same risk of sepsis. It is needless to remark that 
this operation must, of course, be carried out with all 
the precautions which I have previously mentioned. 



1 88 TREATMENT 0I> ABSCESSES. 

In a certain proportion of cases, after the wound 
heals by first intention, a small sinus forms, and 
remains open. In some instances it heals again soon, 
but in other cases, if nothing further is done, it remains 
open for a considerable time. In most cases where 
this takes place, if the sinus does not close in two 
or three weeks, I dissect away the surrounding portion 
of skin, and open up the canal, and scrape it afresh, 
injecting iodoform and glycerine, and bringing the 
edges together after loosening them by lateral dissec- 
tion through the fat. Such a performance is generally 
successful, but in a few rare cases, even though it is 
repeated several times, a sinus again forms, and if 
that occurs, one must have recourse to the old plan of 
drainage. 

The same principles apply to tubercular empyema, 
tubercular peritonitis with suppuration, &c. 



INDEX. 



INDEX 



^ 








PAGE 


Abdomen, wounds of, . . . • • .87 


Abscess, acute, aseptic course, 






168 


„ „ drainage of, 








167 


„ „ dressing of, 








168 


„ „ glandular, treatment of, 








171 


„ „ mode of formation of, . 








161 


„ „ opening of, 








166 


„ „ relation to organisms, . 








163 


„ „ treatment of, 








165 


„ chronic, drainage of, 








188 


„ „ iodoform emulsion in, . 








187 


„ „ pathology of, . 








179 


„ „ removal of, 








182 


„ „ scraping of, 








186 


„ „ stuffing in, . . 








185 


„ ,, treatment of, . . 








182 


„ sub-acute, . . . 








165 


Abscesses, classes of, . . . 








159 


Accidental wounds, disinfection of, . 








81 


Acute suppuration, forms of, . . 








159 


Anal fistula, treatment of, . . 








98 


Antiseptics, .... 








25 


Arrest of haemorrhage, . . , 








38 


Asepsis, ..... 








57 


Aseptic course of wounds, . , 








54 


„ fever, . . • 








5 


Attenuation, . . . 








26 


Blisters in callous ulcer, . 








142 


Blood clot, healing by, . 


• • 




5 


Breaches of surface, classes of, . 




• 




3 



1 92 INDEX, 






PAGE 


Buried stitches, . . . , . . , 


42 


Burns, ......,, 


90 


Button sutures, ....... 


41 


Callous ulcer, characters of, .... . 


116 


„ „ treatment of, .... . 


141 


Catgut, ........ 


38 


Cellulitis, diffuse, ...... 


176 


Chloride of zinc, ....... 


101 


Chronic abscess, ...... 


179 


„ infective ulcers, , 


147 


Classes of breaches of surface, . 


3 


„ wounds, ...... 


27 


Coagulation necrosis, ...... 


13 


Co-aptation stitches, ...... 


41 


Compound fractures, amputation in, . . . . 


85 


„ „ of skull, . 


89 


„ „ treatment of, ... . 


84 


Congenital fistula, treatment of, . . 


98 


Contused wounds, treatment of, • . . . 


83 


Diabetic ulcer, ....... 


119 


Diet after operations, ...... 


53 


Diffuse cellulitis, . . . . . . 


176 


Disinfection of accidental wounds, . . . . 


81 


„ instruments, . . . . . 


33 


, nails, ...... 


32 


„ old septic wounds, . . . 


92 


„ skin, ...... 


29 


„ sponges, ...... 


35 


„ ulcers, . . . . . , 


122 


Drainage of wounds, ..... 


43 


Dressings, antiseptic, ...... 


46 


„ changing of, . . . . . , 


49 


„ for ulcers, ...... 


125 


Empyema, acute, treatment of, . . . . 


172 


,, drainage in, . . . , 


173 


„ tubercular, . • • . • 


188 


Epidermis grafting in ulcers, , . , , 


128 



INDEX, 


193 




PAGE 


First intention, healing by, • : • 


4 


Fistula, • • 


96 


„ anal, treatment of, • , 


98 


„ congenital, treatment of,. . . ; 


98 


„ intestinal, treatment of, . . . 


97 


„ perineal, treatment of, . . 


98 


„ salivary, treatment of, . . . , 


97 


Granulating wounds, treatment of, k > 


73 


Granulation, healing by, . . . : . 


6 


„ disadvantages of healing by, . , 


9 


Haemorrhage, arrest of, , . . . ' . 


38 


Hemorrhagic ulcer, . . . . . 


116 


Healing by blood clot, ..... 


5, 60, 70 


„ first intention, . 


4 


„ „ conditions interfering with, . 


10 


„ „ failure of, . • . . 


61 


„ granulation, . 


6,9 


„ of wounds, . ... 


4 


Incised wounds, inflicted accidentally, treatment of. 


83 


Inflamed ulcer, ...... 


113 


„ treatment of, . . . . 


139 


Inhibition of growth of micro-organisms, . 


25 


Instruments, disinfection of, 


32 


Intestinal fistula, treatment of, . 


97 


Iodoform in recent wounds, . 


77 


„ in septic wounds, . 


76 


„ in ulcers, . 


124 


Irrigation, during operations, . . . . 


35 


„ of septic wounds, . . . . 


67 


Irritable ulcer, ...... 


113 


„ treatment of, . • • • 


140 


Joints, wounds of, .... . 


86 


Lacerated wounds, treatment of, . . • • 


83 


Ligatures, ...... 


38 


Listerian method, , • . 


28 


Listerism in private practice, . - . . 


55 



13 



194 



INDEX. 



Lotions for septic wounds, 
Lupus, .... 

„ scraping of, 

„ skin grafting in, . 

„ treatment of, 

Martin's elastic bandage, . 

Massage in the treatment of ulcers, 

Mercuro-cyanide gauze, . 

Micro-organisms, conditions favouring the action of, 

Mucous membrane, wounds of, . 

Nails, disinfection of, 

Number of organisms, importance of, 

Ointments in the treatment of wounds, 

„ in ulcers, 

Old septic wounds, 
Osteomyelitis, acute suppurative, 



Paralytic ulcer, . 

„ „ treatment of, 

Perforating ulcer, 
Perineal fistula, treatment of, 
Periostitis, acute suppurative, treatment of, 
Peritonitis, tubercular, 
Phagedenic ulcer, 

„ „ treatment of, . 

Phagocytosis, 

Position in the treatment of ulcers, 
Pressure ulcer, 

,, „ treatment of, 
Private practice, Listerism in, 
Protective, 
Pyaemia, .... 

„ treatment in, 
Pyogenic cocci, how they act, . 

„ micro-organisms, 

„ ,, inhibition of growth, 

,, „ relation to chemical substances, 

, t „ H „ culture media, . 



INDEX. 



195 



Pyogenic micro-organisms, relation to heat, 
„ „ „ source of, 

Relaxation stitches, . . , 

Rest in the treatment of ulcers, . 
,, „ „ wounds, 

Rib, chronic abscess in connection with, 

Sapraemia, . . 

Scrofuloderma, 

,, treatment of, 

Sepsis in wounds, treatment of, 
Septic intoxication, 

„ open wounds, treatment of, 
Septicaemia, 
Silk for stitches, . 
Silkworm gut, . . 

Simple ulcer, 

„ „ treatment of, 

Sinus, causes of, . 

„ classification of, 

„ treatment of, 

„ tubercular, . 

Skin, disinfection of, 

„ grafting in recent wounds 

„ „ Thiersch's, in ulcers, 

„ „ subsequent dressing, 

„ „ with the whole thickness of the si 

Skull, compound f ractures of, 
Source of pyogenic organisms, 
Sponges, disinfection of, . 

„ use of, in dressings, 
Staphylococci, streptococci, differences in action 
Stitches, . . . 

„ buried, . 
„ of eo-aptation, . 
,, of relaxation, . 
Strapping in callous ulcer, 
Suppuration, acute, causes of, 
„ forms of, 



PAGE 

23 
20 

41 
120 

51 
183 



148 

153 

63 

8 

73 

8 

40 

41 

112 

139 

93 

93 

94 

94 

29 

72 

129 

135 

137 

89 

20 

35 

48 

14 

39 

42 

41 

41 

142 

160 

159 



196 



INDEX, 



Sutures, . . 

„ button, • 

Syphilitic ulcers, . 



Thiersch's method of skin grafting, 
Thorax, wounds of, 
Towels, aseptic, . . 

Traumatic fever, . 
Treatment of open wounds, 
Tubercular sinus, nature of, 

„ „ treatment of, 

„ ulcers, 

„ „ treatment of, 

Tumours, ulcerating, . 

Ulcer, callous, . 

diabetic, . , 

hemorrhagic, . ' 

inflamed, . . 

irritable, . . 
„ paralytic, . 

,, perforating, , 

,, phagedenic, . 

,, pressure, . . 

„ simple, . . 
,, varicose, . 

,, weak, . . 

Ulcers, causes of, 

„ chronic infective, 

,, ,, non- infective, 



classes of, . 

definition of, 
epidermis grafting in, 
painful, treatment of, 
syphilitic, 
treatment of, . 
tubercular, 
tubercular, treatment of, 
Unna's dressing for, 



classes of, 



INDEX. 


197 








PAGE 


Varicose ulcer, . 


. 


• • 


115 


„ treatment of, 


• 


• • 


141 


Weak ulcer, 


_ 


• • 


114 


„ treatment of, 


. 


• . 


140 


Wounds, classes of, 


. 


• • 


27 


„ drainage of, 


. 


. 


43 


„ of abdomen, 


. 


• 


87 


„ joints, 


. 


• 


86 


„ mucous membrane, 


treatment of, . 


99 


„ thorax, 


. 


• « ■ 


89 


n rest in the treatment 


of, 


• » 1 


51 



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16 Lea Brothers & Co.'s Publications. 



VISITING LIST. THE MEDICAL NEWS VISITING LIST for 1895. 
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