WOUNDS, ULCERS, AND ABSCESSES.
Wounds, Ulcers, and
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
LEA BROTHERS & CO.
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
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*.
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.
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.
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
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.
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.
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.
Appearances of — Treatment of.
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
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
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
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
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
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
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,
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
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
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
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
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
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-
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
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
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
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
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*
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
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-
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.
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
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
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
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
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
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
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
50 TREATMENT OF WOUNDS.
edges of the wound, and also, where it is deep, over the
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
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
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
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
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
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
In none of the cases just alluded to does suppuration
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
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-
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
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
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
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
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
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
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
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
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
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,
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
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
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
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
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
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
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
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-
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
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
These chronic non-infective ulcers are divided into
several classes, according to their appearance and
tendencies, and I must shortly refer to the chief
(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
(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
(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.
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
(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.
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
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
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
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
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
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
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
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-
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
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
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
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
— 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
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
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.
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
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
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
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
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
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
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
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
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-
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
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.
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
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
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
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
(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
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
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
The same principles apply to tubercular empyema,
tubercular peritonitis with suppuration, &c.
Abdomen, wounds of, . . . • • .87
Abscess, acute, aseptic course,
„ „ drainage of,
„ „ dressing of,
„ „ glandular, treatment of,
„ „ mode of formation of, .
„ „ opening of,
„ „ relation to organisms, .
„ „ treatment of,
„ chronic, drainage of,
„ „ iodoform emulsion in, .
„ „ pathology of, .
„ „ removal of,
„ „ scraping of,
„ „ stuffing in, . .
„ ,, treatment of, . .
„ sub-acute, . . .
Abscesses, classes of, . . .
Accidental wounds, disinfection of, .
Acute suppuration, forms of, . .
Anal fistula, treatment of, . .
Arrest of haemorrhage, . . ,
Aseptic course of wounds, . ,
„ fever, . . •
Attenuation, . . .
Blisters in callous ulcer, .
Blood clot, healing by, .
Breaches of surface, classes of, .
1 92 INDEX,
Buried stitches, . . . , . . ,
Button sutures, .......
Callous ulcer, characters of, .... .
„ „ treatment of, .... .
Cellulitis, diffuse, ......
Chloride of zinc, .......
Chronic abscess, ......
„ infective ulcers, ,
Classes of breaches of surface, .
„ wounds, ......
Coagulation necrosis, ......
Co-aptation stitches, ......
Compound fractures, amputation in, . . . .
„ „ of skull, .
„ „ treatment of, ... .
Congenital fistula, treatment of, . .
Contused wounds, treatment of, • . . .
Diabetic ulcer, .......
Diet after operations, ......
Diffuse cellulitis, . . . . . .
Disinfection of accidental wounds, . . . .
„ instruments, . . . . .
, nails, ......
„ old septic wounds, . . .
„ skin, ......
„ sponges, ......
„ ulcers, . . . . . ,
Drainage of wounds, .....
Dressings, antiseptic, ......
„ changing of, . . . . . ,
„ for ulcers, ......
Empyema, acute, treatment of, . . . .
,, drainage in, . . . ,
„ tubercular, . • • . •
Epidermis grafting in ulcers, , . , ,
First intention, healing by, • : •
Fistula, • •
„ anal, treatment of, • ,
„ congenital, treatment of,. . . ;
„ intestinal, treatment of, . . .
„ perineal, treatment of, . .
„ salivary, treatment of, . . . ,
Granulating wounds, treatment of, k >
Granulation, healing by, . . . : .
„ disadvantages of healing by, . ,
Haemorrhage, arrest of, , . . . ' .
Hemorrhagic ulcer, . . . . .
Healing by blood clot, .....
5, 60, 70
„ first intention, .
„ „ conditions interfering with, .
„ „ failure of, . • . .
„ granulation, .
„ of wounds, . ...
Incised wounds, inflicted accidentally, treatment of.
Inflamed ulcer, ......
„ treatment of, . . . .
Inhibition of growth of micro-organisms, .
Instruments, disinfection of,
Intestinal fistula, treatment of, .
Iodoform in recent wounds, .
„ in septic wounds, .
„ in ulcers, .
Irrigation, during operations, . . . .
„ of septic wounds, . . . .
Irritable ulcer, ......
„ treatment of, . • • •
Joints, wounds of, .... .
Lacerated wounds, treatment of, . . • •
Listerian method, , • .
Listerism in private practice, . - . .
Lotions for septic wounds,
„ 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,
Perineal fistula, treatment of,
Periostitis, acute suppurative, treatment of,
„ „ treatment of, .
Position in the treatment of ulcers,
,, „ treatment of,
Private practice, Listerism in,
„ treatment in,
Pyogenic cocci, how they act, .
„ ,, inhibition of growth,
,, „ relation to chemical substances,
, t „ H „ culture media, .
Pyogenic micro-organisms, relation to heat,
„ „ „ source of,
Relaxation stitches, . . ,
Rest in the treatment of ulcers, .
,, „ „ wounds,
Rib, chronic abscess in connection with,
Sapraemia, . .
,, treatment of,
Sepsis in wounds, treatment of,
„ open wounds, treatment of,
Silk for stitches, .
Silkworm gut, . .
„ „ 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,
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,
„ „ 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, .
epidermis grafting in,
painful, treatment of,
treatment of, .
tubercular, treatment of,
Unna's dressing for,
Varicose ulcer, .
„ treatment of,
„ treatment of,
Wounds, classes of,
„ drainage of,
„ of abdomen,
„ mucous membrane,
treatment of, .
• « ■
n rest in the treatment
• » 1
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FOX (TILBURY AND T. COLCOTT). EPITOME OF SKIN
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FULLER (EUGENE). DISORDERS OF THE SEXUAL OR-
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FULLER (HENRY). ON DISEASES OF THE LUNGS AND AIR
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GANT (FREDERICK JAMES). THE STUDENT'S SURGERY. _ A
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HABERSHON (S. O.). ON THE DISEASES OF THE ABDOMEN,
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In one octavo volume of 554 pages, with 11 engravings. Cloth, $3.50.
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HARD A WAY (W. A.). MANUAL OF SKIN DISEASES. In one
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HILLIER (THOMAS). A HANDBOOK OF SKIN DISEASES.
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HUDSON (A.). LECTURES ON THE STUDY OF FEVER. In one
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LUCAS (CLEMENT). DISEASES OF THE URETHRA. Preparing.
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LUDLOW (J. L.). A MANUAL OF EXAMINATIONS UPON
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LYMAN (HENRY M.). THE PRACTICE OF MEDICINE. In one
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LYONS (ROBERT D.). A TREATISE ON FEVER. In one octavo
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MITCHELL (JOHN K.). REMOTE CONSEQUENCES OF IN-
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MORRIS (HENRY). SURGICAL DISEASES OF THE KIDNEY.
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NORRIS (WM. F.) AND OLIVER (CHAS. A.). TEXT-BOOK OF
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OWEN (EDMUND). SURGICAL DISEASES OF CHILDREN.
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PARVTN (THEOPHILUS). THE SCIENCE AND ART OF OB-
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THE SYSTEMATIC TREATMENT OF NERVE PROSTRA-
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POWER (HENRY). HUMAN PHYSIOLOGY. Second edition. In
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REICHERT (EDWARD T.). A TEXT-BOOK ON PHYSIOLOGY.
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SMITH (STEPHEN). OPERATIVE SURGERY. Second and thor-
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14 Lea Brothers & Co.'s Publications.
STDLLE (ALFRED). CHOLERA; ITS ORIGIN, HISTORY, CAUS-
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THERAPEUTICS AND MATERIA MEDICA. Fourth and
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STILLE (ALFRED), MAISCH (JOHN M.) AND CASPARI
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STIMSON (LEWIS A.). A TREATISE ON FRACTURES AND
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A MANUAL OF OPERATIVE SURGERY. Second edition. In
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STUDENT'S QUIZ SERIES. A New Series of Manuals in question and
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STURGES (OCTAVTUS). AN INTRODUCTION TO THE STUDY
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SUTTON (JOHN BLAND). SURGICAL DISEASES OF THE
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TUMORS, INNOCENT AND MALIGNANT. Their Clinical
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TAIT (LAWSON). DISEASES OF WOMEN AND ABDOMINAL
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Lea Brothers & Co.'s Publications. 15
TANNER (THOMAS HAWKES). A MANUAL OF CLINICAL
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ON THE SIGNS AND DISEASES OF PREGNANCY. From
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TAYLOR (ALFRED S.). MEDICAL JURISPRUDENCE. Eleventh
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TAYLOR (ROBERT W.). A CLINICAL ATLAS OF VENEREAL.
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TAYLOR (SEY3JOUR). INDEX OF MEDICINE. A Manual for
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THOMAS (T. GAILLARD) AND MUNDE (PAUL F.). A PRAC-
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THOMPSON (SLR HENRY). CLINICAL LECTURES ON DIS-
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THE PATHOLOGY AND TREATMENT OF STRICTURE
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TODD (ROBERT BENTLEY). CLINICAL LECTURES ON CER-
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TREVES (FREDERICK). OPERATIVE SURGERY. In two
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A MANUAL OF SURGERY. In Treatises by 33 leading suiv
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THE STUDENTS' HANDBOOK OF SURGICAL OPERA-
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SURGICAL APPLIED ANATOMY. In one 12mo. vol. of 540 pp.,
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INTESTINAL OBSTRUCTION. In one 12mo. volume of 522
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TUKE (DANIEL HACK). THE INFLUENCE OF THE MIND
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VAUGHAN (VICTOR C.) AND NOVY (FREDERICK G.).
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16 Lea Brothers & Co.'s Publications.
VISITING LIST. THE MEDICAL NEWS VISITING LIST for 1895.
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WALSHE (W. H.). PRACTICAL TREATISE ON THE DISEASES
OF THE HEART AND GREAT VESSELS. Third American from
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WATSON (THOMAS). LECTURES ON THE PRINCIPLES AND
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enlarged English edition, with additions by H. Hartshorne, M. D.
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WELLS (J. SOELBERG). A TREATISE ON THE DISEASES OF
THE EYE. In one large and handsome octavo volume.
WEST (CHARLES). LECTURES ON THE DISEASES PECULIAR
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ON SOME DISORDERS OF THE NERVOUS SYSTEM IN
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WHARTON (HENRY R). MINOR SURGERY AND BANDAG-
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WHITLA (WILLIAM). DICTIONARY OF TREATMENT, OR
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"WILLIAMS (CHARLES J. B. AND C. T.). PULMONARY CON-
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WILSON (ERASMUS). A SYSTEM OF HUMAN ANATOMY.
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THE STUDENT'S BOOK OF CUTANEOUS MEDICINE. In
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WINCKEL ON PATHOLOGY AND TREATMENT OF CHILDBED.
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WOHLERS OUTLINES OF ORGANIC CHEMISTRY. Translated
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YEAR-BOOK OF TREATMENT FOR 1895. A Critical Review for
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YEAR-BOOKS OF TREATMENT FOR 1891, 1892 and 1893, similar
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YEO (I. BURNEY). FOOD IN HEATH AND DISEASE. In one
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A MANUAL OF MEDICAL TREATMENT, OR CLINICAL
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YOUNG (JAMES K.). ORTHOPEDIC SURGERY. In one 8vo.
volume of 475 pages, with 286 illustrations. Cloth, $4; leather, $5.