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 CLINICAL LECTURES 
 
 ON THE 
 
 TREATMENT OF WOU:ffDS 
 
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THE "JOUEKAL PKINTING OFFICES, KEW STREET, BIRMINGHAM. 
 
ON 
 
 THE TREATMENT 
 OF WOUNDS: 
 
 CLINICAL LECTURESil& 
 
 ■o'J^PLl 
 
 ^0 
 
 BY 
 
 SAMPSON GAMGEE, F.R:^:^-^ ^ 
 
 V, 
 
 SUEGEON TO THE QXJEE2:i'S HOSPITAL, BIRMINGHAM; 
 
 HON. FELLOW OF THE SOCIETY OF SUKGERY OF PARIS J 
 
 PRESIDENT OF THE BIRMINGHAM AND MIDLAND COUNTIES BRANCH 
 
 OF THE BRITISH MEDICAL ASSOCIATION. 
 
 WITH ENGEAYINGS ON WO 
 
 J. & 
 
 A, CHTJRCHILL, NEW BURLINGTON STREET. 
 
 1878. 
 
Wa\/ 
 
 " Iravaillons Toujours." 
 
 Velpeau's dying -words addressed to Barth and Nelaton. 
 
 1/ a£/ayo-a^ 
 
 Sox^ 
 
 
TO MY 
 
 Old Fellow Students 
 
 AT THE 
 
 University College and Hospital, London, 
 
 AND TO MY 
 
 Past and Present Pupils 
 
 AT THE 
 
 Queen's Hospital, Birmingham. 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/ontreatmentofwouOOgamg 
 
PEEFACE. 
 
 I liave re-arranged and condensed in tliis 
 small volume, "On tlie Treatment of Wounds/' 
 tlie materials of many of my clinical discourses 
 to Students, and addresses to Medical Societies, 
 delivered during the last ten years. 
 
 Only a small part of tlie materials at my 
 disposal has been utilized. My cMef object, and 
 sincere endeavour, lias been, to illustrate fundamental 
 principles by typical cases, so concisely as not to 
 make too great a call on the time of busy prac- 
 titioners, and yet so clearly as to be intelligible 
 to junior students. 
 
 Observation from various stand-points is 
 essential to the clear understanding of complex 
 truths; and I have therefore deemed it useful 
 to compare, with my own results, those of 
 some distinguished surgeons practising at other 
 times, and undei' different circumstances. 
 
Vlll. PREFACE. 
 
 Scientifically and practically, " The Treatment 
 of Wounds " is a subject of intense interest, 
 deserving, nay urgently calling for, compreliensive 
 study. The great want is a clear understanding, 
 and an exact application, of principles long since 
 demonstrated, but not yet generally or justly 
 appreciated. Another want is a close examination 
 of new methods of treatment, without theoretical 
 bias or hasty generalization, — for or against. 
 
 I hope the facts herein recorded, and the 
 suggestions offered, may, in some measure, help 
 to reconcile differences, to establish simple and 
 safe methods of treatment, and to stimulate 
 investigation in the right direction. 
 
 Broad Street, Birmingham, 
 January, 1878. 
 
CONTENTS. 
 
 Lecttjee I. 
 First principles illustrated by simple cases ... ... 1 
 
 Lecttee II. 
 East, position and pressure, Arrest of Hsemorrliage ... 16 
 
 Lecture III. 
 TVounds penetratirg into joints ... ... ... 35 
 
 Lecture IY, 
 Wounds of the Head— Compound Fractures ... ... 57 
 
 Lecture V. 
 Materials and Apparatus for Dressing Wounds ... ... 80 
 
 Lectuee YI. 
 Drainage, History of Antiseptics ... ... ... 98 
 
 Lecture YII. 
 Professor Lister's practice — The Germ theory ... ... 119 
 
 Lecture YIII. 
 
 The Antiseptic theory and practice. Project and method 
 
 for further enquiry ... ... ... ... 139 
 
LECTURES. 
 
LECTUEE I. 
 
 CONTENTS. 
 
 Introductory Observations on conflicting practices in tte treatment 
 of wounds, p. 1—4 ; Case of strangulated inguinal hernia, 
 p, 4 ; Case of strangulated femoral hernia, p. 5 ; Case 
 of lipoma of the neck, p. 6 ; Case of ovariotomy, p. 
 7 ; superiority of dry over water dressing, p. 8 ; 
 comparative value of silk and metallic sutures, p. 8 ; 
 torsion for medium-sized vessels, p. 9 ; the importance 
 of infrequent dressing, p. 9 ; great diagnostic import- 
 ance of the thermometer, p. 10 ; Case of ovariotomy- 
 escape of bowel the fifth day— rapid re-union of the 
 wound under dry dressing, p. 10 ; contused and 
 lacerated wound of the thumb— healing after super- 
 vention of inflammation, with dry dressing and digital 
 compression, p. 11 ; general considerations on the 
 therapeutic value of pressure, p. 13 — 15. 
 
 Gentlemen, — 
 
 On the Treatment of Wounds, no clinical 
 teacher can be indifferent to the conflicting state 
 of surgical opinion. Progress in this department 
 B 
 
-3 LECTURE I. 
 
 of Surgery lias, in late years, been cliaracterized by 
 divergence from, ratlier tlian by approacli to, 
 nnanimity. Lecturing here in 1867 (^) I told you 
 that I looked upon water dressing, as not niucli 
 better tban a poultice, as favouring suppimation 
 and opposed to liealing. Experience has only added 
 confirmation to tliis opinion; and it is now many 
 years since I applied water dressing, or a poultice 
 to a wound wbicli I wished to heal. Yet, in the 
 last edition of bis work, Mr. Ericbsen seems 
 scarcely less fond of water dressing than (following 
 immediately in Eobert Listen's steps) be was, when 
 Joseph Lister and myself acted as bis earliest 
 dressers, now seven and twenty years ago. (2) 
 
 Once parts have been brought together after 
 
 1 Tlie British Mcclical Journal, Vol. II., 1867, p. 355. 
 
 2 Under tlie head of Dressing of Wounds after Operations, 
 sutures having been introduced, Mr. Erichsen advises ''that a 
 narrow strip of water dressing should then be applied along 
 
 the edge of the incision If union do not take. 
 
 place by adhesion, inflammation and suppuration having com- 
 menced, with much tension and heat about the part, the 
 substitution of a poultice for the water dressing will Be advan- 
 tageous. When suppuration has fairly set in, the applications 
 should be changed at least twice or thrice in the twenty-four 
 houi-s, and the wound may with advantage be washed out twice 
 a day with injections of carbolized water. " — Erichsen : Science 
 and Art of Surgery, 7th Edition, 1877, p. 32. 
 
THE TREATMENT OF WOUNDS. O 
 
 division, tliey cannot be too studiously kept at rest, 
 to whicli infrequent dressing is eminently condu- 
 cive ; yet you will see surgeons, in this and other 
 schools, who dress an amiDutation daily from the 
 first, and sometimes twice and even three times 
 in the twenty-four hours. Pressm^e, gentle, uniform, 
 sustained, I have taught you to look ui^on as an 
 auxiliary of the very first imi^ortance in promoting 
 healing action. Whether it be in the deep-seated 
 lacerations of a violently sprained ankle, or in a 
 compound fracture attended with extravasation, 
 swelling, and blebs; in a clean first incision for 
 ovariotomy; in a subcutaneous division of a 
 tendon ; or in an axe wound severing the insertion 
 of the quadriceps into the patella, and largely 
 laying open the knee-joint, — in one and all such 
 lesions is pressure a therapeutic agent of the 
 most beneficent potency. But very many excellent 
 surgeons would only partially assent to this ]3ropo- 
 sition, many would wholly dissent from it. 
 
 The exclusion of air from a wound has been 
 dwelt upon as eminently conducive to its rapid 
 cicatrization; others teach that air may bene- 
 ficially flood a wound, so long as it is deprived 
 of those noxious germs which are believed 
 
4 LETURE I. 
 
 universally to pervade it. Air, say the disciples 
 of this school, is only injurious because swarming 
 with countless fertile germs; destroy them, and 
 the air loses its maleficence. 
 
 If the germ theory, and the practice based 
 upon it, be correct, the sooner it is accepted the 
 better. But if its foundation be in great part 
 illusory, — if it be unequal to explaining, and be 
 actually inconsistent with, many of the results of 
 practice, — if it be unnecessarily complicated, and if 
 it tend to exclude, or to supersede, without good 
 reason, principles and methods which are demonstrably 
 simple, safe, and sound, — it will be impossible to 
 accord to it the assent which has been claimed for 
 it. Experience must decide the issue. 
 
 To illustrate how simply and successfully an 
 important wound may be treated, let me direct 
 your attention to the case of John Pardo, aged 21, 
 on whom I operated for strangulated inguinal 
 hernia, the 6th September ult. I found it necessary 
 to open the sac, which contained some omentum 
 and a knuckle of intestine, deeply congested but 
 otherwise in fair condition. Bleeding from two 
 vessels was arrested by torsion. The wound was 
 closed by three points of silver suture, and a pad 
 
THE TREATMENT OF WOUNDS. 5 
 
 of dry lint was applied over it, with a gently- 
 compressing spica bandage. One grain of opium to 
 be given every four hours. Milk diet. 
 
 The temperature, which on the day of 
 operation was 101.2° with a pulse of 104, fell in 
 forty-eight hours to 99.5° with a pulse of 76, and 
 respirations 20. The opium was now discontinued, 
 as the patient continued free from pain, and the 
 thermometric chart denoted gradual return to the 
 normal standard of health; the bandage was not 
 interfered with until the seventh day after the 
 operation. The pulse was then 62, respiration 20, 
 temperature 98.2°. I found the pad of lint quite 
 dry; no tenderness or redness around the linear 
 cicatrix, which was solid throughout. The sutures 
 were now removed, another pad of lint applied, and 
 a gruel enema ordered, the bowels not having 
 yet acted. 
 
 The note on September 13th is : — The bowels 
 acted 15 minutes after the enema ; pulse 62, 
 respiration 16, temperature 98.3°. The patient 
 says he feels quite well; is allowed meat diet. 
 He was discharged with a truss the eleventh day 
 after the operation. 
 
 In a case of strangulated femoral hernia, in 
 
G LECTURE I. 
 
 wliicli I operated tlie 15tli May ult., in consultation 
 with Dr. Sawyer and Mr. Cresswell, the wound 
 healed perfectly in fonr days, under a pad of cotton 
 wool and a lightly compressing bandage. The 
 syniptons had existed some days before the 
 operation, and on opening the sac a knuckle of 
 deeply-congested intestine was found within it. 
 The recently pared edges of a hare lip could not 
 have healed more directly and soundly, than the 
 wound in the inguinal region had done. 
 
 Before commenting on these cases, it will be 
 convenient to recall the main facts of two other 
 operations performed in this theatre. In a patient 
 from whose neck I removed a good-sized lipoma, 
 I may remind you, that the tumour extended from 
 the cervical spine and occiput forwards and down- 
 wards on the carotid sheath ; the incision through 
 the integuments was five inches in extent. I put 
 three silver stitches in the upper half of the 
 wound, three silken ones in the lower half, 
 subsequently exercising pressure by pads of dry 
 lint and bandage. The wound, when inspected 
 at the end of a week, was found to have healed 
 directly and firmly, without a drop of discharge 
 of any kind. 
 
THE TREATMENT OF WOUNDS. 7 
 
 AnotTier wound treated on the same principles, 
 and with equally successful result, was presented by 
 Mary Ann Sweet, aged 20, who was sent into the 
 hospital under my care by my friend Dr. Suf&eld, 
 for the performance of ovariotomy. The tumour, 
 being in great part solid, required a free incision 
 (nearly eight inches) for its removal; the pedicle 
 was secured in a carpenter's callipers, and the 
 wound accurately closed with points of silver suture 
 a third of an inch distant from each other ; a 
 superjacent compress of dry lint and bandage 
 completed the dressing. Cicatrization was perfect 
 at the end of a week, when the sutures were 
 removed, transverse strips of adhesive plaster 
 applied, circular bandage and dry pad renewed. 
 The patient made an uninterrupted recovery. 
 
 The wounds in these four cases, though differ- 
 ing in situation, had several features in common. 
 They were all clean cuts of several inches in extent, 
 with sufficient surrounding skin to admit of easy 
 approximation of the edges without tension. They 
 were in parts of the body — two in the abdomen, one 
 in the groin, and one in the neck — which only 
 required the patient to be in the recumbent position 
 to admit of perfect rest; no vessels required ligature; 
 
8 LECTUEE I. 
 
 in neitlier case was the dry dressing touched for 
 several days; and in each was union perfect without 
 a drop of discharge. I attach much importance to 
 the dry dressing. The sponges used at the time of 
 operation were very well squeezed out of clean 
 water ; not a drop was afterwards allowed to touch 
 the wound. Drenching wounds with water during 
 an operation, and washing them with it afterwards, 
 are mistakes. (^) Water favours decomposition, 
 which is the enemy of healing action. In the case 
 of an incised wound, which has only partially 
 healed, let anyone try the experiment of covering 
 one part of the recent cicatrix with dry lint, and 
 the other with water dressing. As a rule, liable 
 to very rare exceptions, consolidation will be found 
 to take place under the dry, and suppuration under 
 the wet part,. 
 
 The sutures used in three of the cases were 
 metallic, in the other case one half of the stitches 
 were of silver, the other half of silk. The fact 
 
 ^ For most instructive observations on this point, and generally 
 on the subject of wounds, the reader is referred to the article " On 
 the Science and Art of Healing AYounds," by Benjamin "W. 
 Eichardson, M.D., F.E.S., in the Transactions of the St. Andrews 
 Medical Graduates' Association, edited by Leonard W. Sedgwick, 
 M.D.— London: Churchill, 1872, p. 37—52. 
 
THE TEEATMENT OF WOUNDS. 9 
 
 that healing occurred at each point and suppura- 
 tion at none, proves that union may be secured, 
 with proper precautions, irrespective of the material 
 of which sutures are composed. None tlie less, 
 it must be admitted, that in the general practice 
 of surgery metallic sutm^es deserve the preference, 
 for one reason above all others, — that they can 
 be left a much longer time with practically no 
 risk of exciting suppuration. 
 
 Eeserving to the next lecture more extended 
 observations on the safest means for arresting 
 haemorrhage from large vessels, I shall here simply 
 observe, that the two vessels which were stopped 
 spouting by torsion, in the case of inguinal hernia, 
 illustrated the rule that, in all such arteries as 
 are met with near the surface of the body, 
 torsion is a successful and perfectly safe means 
 for checking bleeding. 
 
 The fact that in three of the cases under 
 notice the first dressing was left untouched for 
 a week, and in the other case for four days, is of 
 capital importance. Once a recent wound has 
 been nicely adjusted, the less it is interfered with 
 the greater the chances of healing. Under such 
 circumstances, to meddle without good reason is 
 
10 LECTURE I. 
 
 to muddle. In carrying out tlie practice of in- 
 frequent dressing, the thermometer is of the 
 greatest use. To revert for a moment to the 
 inguinal hernia case. With a pulse at 70, 
 respiration 20, and in the absence of pain, it 
 -^^as perfectly justifiable to leave the dressing 
 untouched; when the thermometer fell in forty- 
 eight hours from 101.2° to 99.5°, the evidence 
 in favour of leaving well alone was of the 
 strongest. A glance at the thermometric chart 
 at the head of the bed, is frequently sufficient 
 to assure the surgeon of the x^rogi'ess of a case, 
 without his addressing a single question to nurse 
 or patient. 
 
 ITothing more need be said of the four cases, 
 than that their progress was as absolutely free 
 from pain, as the treatment was simple and 
 successful. 
 
 It is not only recent incised wounds that admit 
 of being so treated. As a striking example I may 
 quote the case of Maria Mason, aged 18, from whom 
 I removed a solid, movable ovarian tumour some 
 years ago. The clamp separated on the fifth 
 day, and everything was proceeding most favourably, 
 when the patient, in the absence of the nurse, left 
 
THE TEEATMENT OE WOUNDS, 11 
 
 her bed and walked about the ward. She was 
 quite unconcerned, when another patient called 
 attention to something hanging below the front 
 of the nightdress. My colleague, Mr. Wilders, 
 who was then our house surgeon, was summoned, 
 and found that several feet of small intestine had 
 protruded through the lower part of the abdominal 
 wound, which had gaped just above the stump of 
 the pedicle. The sutures had not been disturbed 
 since the operation, and it became necessary 
 to remove them, to open up the wound to admit 
 of the boAvel being re]3laced. The edges of 
 the vround were now brought together again 
 with metallic sutures and strapping, covered with 
 a pad of dry lint and circular bandages, l^ot 
 a single unfavourable symptom ensued, the 
 dressing was not disturbed for a week, cicatrization 
 was then complete ; the sutures were finally removed, 
 and the patient was ready to leave the hospital, a 
 fortnight from the day of operation. 
 
 Here is an equally successful case of a 
 different kind, yet confirming substantially the 
 same general principles which should guide you 
 in the treatment of wounds. This youth is the 
 son of one of our principal ivory and bone turners, 
 
12 LECTUEE I. 
 
 •wlio, while practising tlie other day with a fine 
 
 circular saw, nearly cut off the soft pad at the 
 end of his right thiinib. He did not consult me 
 until the third day, when the little flap was 
 swollen, the wound dirty, the whole thumb 
 throbbing and very painful. On compressing the 
 radial artery just above the wrist, the throbbing and 
 pain ceased, and I taught my patient how to obtain 
 the relief, by effecting the compression himself 
 with the left thumb. I then brought the edges 
 of the wound together with narrow strips of 
 emplastrum elemi, leaving slight intervals for the 
 escape of matter ; covered the end of the thumb 
 with a little fine picked oakum, bandaged it so 
 as to effect gentle uniform compression, and 
 supported the hand at an acute angle with the arm. 
 The sling used for the purpose enclosed the elbow, 
 as every arm-sling should do to be efficient. (^) 
 
 ^ "To make such a sling for the right arm of an adult, take 
 a piece of black alpaca or other suitable material 29 1. inches wide, 
 and 35 inches long ; fold it cornerwise with the smallest triangle 
 inwards ; the outer one will thus have about five inches projecting 
 beyond the half square ; the hand rests in the basis of the triangle, 
 the opposite angle is at the elbow, which is efficiently supported by 
 the projecting joortion of the outer layer being carried round the 
 lower end of the humerus, and pinned or stitched to the inner part 
 of the sling ; its two other extremities are carried upwards, on the 
 dorsal and palmar aspect of the forearm respectively, and secui'ed 
 
THE TREATMENT OF WOUNDS. 13 
 
 Eelief was immediate; the dressing was not 
 touclied for four days, and only twice afterwards, 
 at intervals of three days. Yon see the thumb 
 very nearly a match for its fellow, and a linear 
 cicatrix is all that is left of a very ugly wound. 
 
 This case illustrates, like the previous ones, 
 the advantages of compression, with dry and rare 
 dressings, in the treatment of wounds, whether 
 contused or incised; and it further exemplifies 
 the benefits to be derived from digital compression 
 in the treatment of inflammation of the limbs. (^) 
 
 Under water dressing or a poultice, the chances 
 are that this young man's thumb woidd have 
 suppurated, and we should probably have had to 
 deal with burrowing matter, sloughing tendons, 
 and subsequent loss of power, which so frequently 
 follow contused wounds of the hand and fingers. 
 In averting those results, in the case under notice, 
 no influence was more powerful than the uniformly 
 compressing bandage. 
 
 by a strap of the same material at the back of the neck." — On the 
 Treatment of Fractures of the Limbs, hy Saw.jpson Gamgee. London, 
 Churchill, 1871, p. 255. 
 
 ^ Observations on the Treatment of Inflammation by Digital 
 Compression, by Dr. Tito Yanzetti, translated in Treatment of 
 Fractures of the Limbs, by the Author, p. 168 et seq. 
 
14 LECTURE I. 
 
 Of all siiroical asjencies none so beneficent as 
 compression, none reqniriug more delicate manipu- 
 lation, none so inadequately appreciated. Under 
 a smootli and uniformly, while liglitly, compressing 
 bandage, applied to the head, the trunk, or the 
 limbs, extravasations of blood are absorbed, the 
 healing action is promoted, and a soothing influence 
 is exercised. There must be no constriction — 
 only equable adaptation of surface to surface, with 
 the light pressure which always comforts. There 
 must be no squeezing like that of an old college 
 friend's hand, when seen after a long absence; 
 such pressure as that, on tender parts, is intolerable 
 constriction. The soothing surgical pressure is 
 like that which you interchange with the hand of 
 a lady, when the pleasure of meeting her is 
 tempered by a respectful regard. Your hand 
 adapts itself to hers, and gently presses it 
 wherever it can touch it, but nowhere squeezes it 
 for fear of offending. Such pressure, when employed 
 by the surgeon in the treatment of injuries, always 
 soothes and heals. 
 
 To apply a nicely compressing bandage well, 
 you must practise hundreds and hundreds of times. 
 Bear in mind that in surgical, as in all art, 
 
THE TPiEATjMEXT OF WOUKDS. 15 
 
 tlie greatest results are almost always obtainable 
 from the simplest means, provided tliey be em- 
 ployed with, tlie accomplished skill which can 
 only result from the most zealous and patient 
 assiduity. 
 
16 LECTUEE II. 
 
 LECTUEE 11. 
 
 CONTENTS. 
 
 The advantages of compression in checking and removing 
 deep-seated efFasions, p. 16 ; treatment of sprains, p. 
 17 ; Case of sprained ' ankle — swelling and imminent 
 suppuration cured by pressure and rest, p. IS ; treat- 
 ment of wounds after amputation, p. 21 ; amputation 
 of fore-arm, p. 21 ; amputation of thigh, p. 22 ; 
 amputation of fingers, p. 23 ; torsion of arteries, 
 p. 25 ; safety of ligature, p. 27 ; letter from Mr. Syme 
 on ligature of femoral, p. 27 ; acupressure, forci 
 pressure, p. 28 ; need for further enquiry, p. 29 ; 
 pressure and cold in arresting secondary haemorrhage 
 after amputation at the hip-joint, p. 30 ; styptic 
 colloid — its composition and uses — p. 31 ; Friar's balsam, 
 balsamum traumaticum, tinct. benzoin, comp. — their 
 composition and value, 33. 
 
 Gentlemen, — 
 
 It was incidentally remarked in the preceding 
 Lecture, that compression is one of the most 
 beneficent of sm'gical agencies, bnt inadequately- 
 appreciated in principle and practice. A clear idea 
 
THE TEEATMENT OF WOUNDS. 17 
 
 of its advantages is of vital importance to a correct 
 understanding of tlie treatment of wounds and 
 their complications. 
 
 When the edges of a cleanly cut wound 
 through the skin are brought together, it is generally 
 agreed that the contact necessary for healing 
 may be easily maintained by strips of adhesive 
 plaster, a bandage, or a handkerchief to bind the 
 parts together ; but it is a greater and a more 
 methodical application of pressure which is 
 required to prevent subcutaneous effusions, and, 
 when they do occur, to promote their absorption. 
 This is forcibly exemplified in such a case of 
 deep-seated injury as a sprain, without laceration 
 of the skiQ. If the joint be immobilized at once, 
 and uniform compression nicely applied, the 
 subsequent swelling will be very limited indeed. 
 If delay occur, either in the absence of surgical 
 aid, or while fomentations and lotions are beincp 
 prepared, swelling takes place so rapidly, that, in 
 less than twenty-four hours, an ankle may attain a 
 circumference two inches greater than its fellow. 
 Under methodical compression, not only is the 
 further increase of the swelling checked at once, but 
 it very rapidly subsides ; and, at the end of two or 
 C 
 
18 LECTUEE n. 
 
 three days, faint bluisli-green discoloration may 
 Le seen to have extended from the toes nearly to 
 the knee along the shrivelling limb. This diffusion 
 of the extravasated Mood, under the influence of 
 pressure, is the first step to its removal by a 
 widely increased extent of absorbing surface. 
 
 Compression acts with equal advantage, when 
 the products of extravasation have undergone 
 change through inflammatory action. Here are the 
 notes of a case in point, in which I was consulted 
 by my colleague Mr. John Clay. His patient, an 
 elderly gentleman, had recently sprained his right 
 anlde in going over a ploughed field. As he had 
 a ]oolicy in one of the Accidental Insurance com- 
 panies, its medical officer saw the case. He 
 advised an incision, for the purpose of gi^^g vent 
 to matter which he thought had formed in the 
 centre of the swelling. In this advice he was 
 sustained by a hospital surgeon of great experience, 
 who was additionally called in on behaK of the 
 company. Mr. Clay, dissenting, invited my attend- 
 ance. I found the right ankle hot, and exquisitely 
 painful. It was so much swollen, that its circum- 
 ference over the heel exceeded that of the 
 corresponding sound joint, by nearly an inch and 
 
THE TREATMENT OF WOUNDS. 19 
 
 a lialf. The skin on tlie outer side of the ankle 
 was especially hot, red, tense, and shining ; palpa- 
 tion in this situation communicated a feeling of 
 elasticity closely simulating, but not amounting to, 
 fluctuation. With Mr. Clay's concurrence and 
 assistance, I enveloped the limb from the toes to 
 the knee in fine cotton-wool, applied well-moulded 
 pasteboard splints on each side, and bandaged 
 with methodically uniform compression. A second 
 consultation was held in the course of three days, 
 when I found the patient very much easier. He 
 had had good nights' rest, had been able to 
 turn over in bed, and could bear the limb lifted 
 and put down again without pain. On opening 
 the apparatus in front, I found the swelling had 
 considerably decreased; the previously red skin 
 was yellowish and shrivelled, like the skin of a 
 late russet apple ; not looking, as at my first visit, 
 like the red shining skin of a prime Blenheim. 
 That shrivelled look is always a good sign. I 
 readjusted the apparatus with firmer pressure. 
 
 Three days later more shrinking was met 
 by fresh paring of the edges of the ap- 
 paratus, and still firmer bandaging. At a con- 
 sultation held a fortnight after the first, the patient 
 
20 LECTUEE n. 
 
 was perfectly easy. ISTo one thought any more 
 about puncturing in search of matter. The Insurance 
 company compromised by paying down a substantial 
 sum of money, and I substituted for the paste- 
 board apparatus, strapping the joint with emplastrum 
 elemi spread on leather ; a Churton's bandage 
 being applied over it with smooth firmness. 
 When I last saw the patient with Mr. Clay, he 
 was walking about his garden with a stick; the 
 plaster had been very properly removed, and the 
 swelling had subsided, the only difidculty to loco- 
 motion being stiffness of the joint. I cracked the 
 adiiesions by using the requisite amount of well- 
 appKed force, and we concurred in advising free 
 use of the joint. In a note which I received 
 from my colleague seven weeks after our first 
 consultation, he wrote : " Our patient is progressing 
 very satisfactorily ; he comes to business every day, 
 walks about a good deal, and does not require 
 surgical supervision." 
 
 In considering the relative value of the thera- 
 peutic agencies in this case, full weight must be 
 given to the perfect rest in which the joint was 
 placed; but experience proves that rest, without 
 methodical compression would have been only 
 
THE TREATMENT OF WOUKDS. 21 
 
 imperfectly and slowly successful, in allaying the 
 inflammatory action, and in removing its products. 
 Besides acting as the most powerful promoter of 
 absorption, smooth circular compression ensures 
 repose, by preventing muscular spasm, which, once 
 excited, is an active cause of constitutional dis- 
 turbance, and often the first link in a series of local 
 troubles — disturbed union, haemorrhage, nervous 
 irritation, suppuration and its sequels. 
 
 The treatment of wounds after amputation 
 affords abundant evidence of the operation of 
 the therapeutic principles, which I have just been 
 endeavouring to impress upon you. 
 
 This youth's right fore-arm having been crushed 
 in a cog-wheel to within two inches of the 
 elbow, I amputated just below that joint, utilizing 
 some of the least damaged skin to cover the 
 stump, which showed bruising of the muscles 
 and effusion of blood into their substance. Two 
 arteries were tied with silk, and some smaller 
 ones twisted. Where the skin was quite sound, 
 the edges were brought together with two points 
 of suture ; elsewhere the parts were approximated 
 with strips of lint soaked in styptic colloid, 
 a drainage tube being left in the lower part of 
 
22 LECTUEE II. 
 
 tlie wound, and tlie ends of tlie ligature brought 
 out at tlie augle Tritli the tube. The stump was 
 covered with a layer of cotton wool, and oakum 
 over it, Eectaugular pasteboard splints, extending 
 from the end of the stump to the shoulder joint, 
 were applied with gently compressing bandage, to 
 ensure perfect immobility and prevent swelling. 
 
 "When the apparatus was opened four daj^s 
 afterwards there was very slight sloughing of 
 the margin of one flap ; but the stump was of 
 good colom^ and healthy temperatiu^e, without 
 tension. I removed the drainage tube, brought 
 the edges closely together by adhesive stra|)ping, and 
 re-applied cotton wool and oakum as dry dressing, 
 with pressure. The lad was discharged on the 17th 
 June, a month within a day from his admission, 
 the stump, then quite healed, ha'vdng been dressed 
 altogether seven times after the amputation. The 
 sutures had been removed at the dressing; on the 
 tenth day, when the arterial ligatures came away 
 with the dressing. 
 
 A parallel case is that of James B., aged six, 
 whom you saw in Ward 6. The soft parts of his 
 left lower limb had been extensively crushed by a 
 wagon, and an attempt had been made to save 
 
THE TREATMENT OF WOUNDS. 23 
 
 the limb. Sloughing and profuse suppuration had 
 been followed by such exhaustion, that the lad might 
 fairly be said to be moribund, when I amputated 
 the thigh in the upper third. The structures in the 
 stump were a good deal swollen, from the interstitial 
 effusion which the severe contiguous inflammation 
 had induced. I dressed with cotton wool, oakum, 
 and pasteboard splints, covering the hip joint and 
 extending upwards to the crest of the ilium ; nicely 
 compressing bandages completing the apparatus. In 
 the forty-seven days which elapsed from the 
 operation to the boy leaving the hospital, in com- 
 paratively good health, the cbessing was only 
 renewed six times. 
 
 We may compare with these amputations of 
 the thigh and forearm, two smaller, but not less 
 instructive ones, performed on out-patients. In 
 the first of these I amputated the middle finger of 
 a mechanic's right hand, because it had become 
 stiff, and an encumbrance, as the result of old injury. 
 I removed it at the metacarpo-phalaugeal articulation, 
 being careful not to wound the palm, and saving 
 enough skin to admit of easy closure of the wound 
 without tension. One bleeding vessel was stopped 
 by torsion* The edges were united by three points 
 
24 LECTUEE II. 
 
 of silver suture, a fine drainage tube was placed 
 in the lower angle of tlie wound, wliicli was covered 
 with a pledget of picked oakum ; a moist pasteboard 
 splint was now bandaged to the palmar aspect of 
 the limb, from the tips of the fingers to the elbow, 
 and the forearm suspended in a sling at an acute 
 angle with the arm. At the end of four days the 
 limb was unbandaged, and the drainage tube gently 
 drawn out. There being no sign of suppuration or 
 heat, the splint was re-applied with smooth pressure. 
 In four days more — eight from the operation — I 
 exposed the part. The oakum was quite dry, and 
 the cicatrix pale and sound ; but on removing the 
 sutures a drop of creamy pus exuded from the 
 opening of the suture nearest the dorsum of the 
 hand. I wiped the drop of pus off with a piece 
 of dry lint, and, keeping the fingers in the extended 
 position, re-bandaged the hand with an intervening 
 compress of cotton wool. The part was not looked at 
 for another week, when the scar was solid through- 
 out, the surrounding skin shrivelled and of healthy 
 colour. 
 
 From the right hand of the man now before 
 you, I amputated the little finger ten days ago, 
 treating the wound precisely as in the previous 
 
THE TEEATMENT OF WOUNDS. 25 
 
 case, except that no drainage tube was introduced. 
 At the end of a week the sutures were removed, 
 the dry pad and compressing bandage renewed. On 
 this, the tenth day, you see the linear cicatrix dry 
 and solid, in the midst of parts as healthy as you 
 ever see in the most successful case of hare-lip 
 operation. The after treatment of these cases could 
 not have been attended with less pain to the patients, 
 or with less trouble to the surgeon ; neither could the 
 process of healing have well been more rapid and 
 solid. Some of the chief amongst the agencies which 
 conduced to this result were, absence of moisture 
 in the dressings, accurate coaptation of edges, 
 immediate immobilizatiou, undisturbed for many 
 days, and steady uniform compression. These 
 therapeutic principles and agents have already been 
 commented upon. 
 
 I now beg the favour of your attention to the 
 means taken for arresting haemorrhage in the cases 
 on which this lecture is based. Torsion has already 
 been noticed as unquestionably safe, when applied 
 to medium-sized vessels. In 1850, while on a 
 visit to the Clinique of Pavia, I saw Professor Porta 
 twist all the vessels in an amputation of the leg 
 near the knee. Torsion had then for some years 
 
26 LECTUEE II. 
 
 been the method which Antonio Scarpa's worthy- 
 successor had constantly employed, in preference to 
 the ligature, in all amputations. The monograph (}) 
 in which Luigi Porta advocated the practice 
 in 1845, will ever remain a monument of wide 
 erudition, careful experiment, and sound clinical 
 reasoning. But in this country torsion gained few 
 desciples, until Mr. Syme adopted it in opposition to 
 Sir James Simpson's acupressure. It has since 
 steadily gained ground ; and Mr. Bryant thus 
 expresses himself in the second edition of his 
 *' Practice of Surgery "(2) — ''The physiological argu- 
 ments in favour of torsion are very great, and the 
 practical advantages seem to he no less. After seven 
 years' experience of the practice applied to vessels 
 of all sizes, the femoral being the largest, I have 
 had no mishap." 
 
 . If increasing experience eventually establish 
 that torsion, applied to large arteries as well as 
 small, is as safe as the ligature, its adoption must 
 
 ^ Delle Alterazioni Patologiclie delle Arterie per la Legatura 
 e la Torsione. Esperienze ed Osservazioni di Luigi Porta 
 Prof, di Clinica Chirurgica Nell' 1. E. Universita di Pavia. Con 
 Tredici Tavole in Rame Milano, Tipografia di Giuseppe Bernardoni, 
 di Giol845. 
 
 2 1876, Vol. I, p. 409. 
 
THE TREATMENT OF WOUNDS. 27 
 
 proportionately become more general; but the first 
 condition must be absolute safety against hsemorrbage. 
 Tliis is practically attained with tlie ligature. In 
 twenty-four years' work as a Hospital Surgeon, I 
 have never lost a patient from litemorrbage in 
 private practice, and only one amongst the 
 thousands who have come under my care in 
 hospital. That was a woman from whose right axilla 
 I had dissected a deeply-seated tumour. The bleeding 
 was checked at the time by ligature and pressure, 
 but, in the course of a week, secondary haemorrhage 
 occurred in the middle of the night, and proved 
 fatal, in spite of the best efforts of our then 
 house surgeon. As an instance of how successfully 
 large vessels may be tied, let me read you a note 
 wliich I had the honour of receiving from the late 
 Professor Syme. 
 
 "No. 1, Shandwick Place, Edinburgh, 
 
 "January 19th, 1867. 
 *' My dear Sir, 
 
 *'I lately tied the femoral artery of a gentleman, 
 "for popliteal aneurism, with complete success, and this 
 " was the thirty-fifth time I had performed the operation 
 "without any unfavourable result; except in one case, 
 "where there had been an unsuccessful attempt by 
 "pressure. 
 
 "Yours very truly, 
 
 "James Syme. 
 "Sampson Gamgee, Esq^." 
 
28 LECTURE n. 
 
 These records of experience, satisfactory so 
 far as tliey go, leave open tlie general question 
 of tlie relative merits of the ligature and torsion, 
 and of vegetable, animal, and metallic substances for 
 the purpose of securing bleeding vessels. (^) That 
 is a wide field of enquiry, to which precise 
 investigations on a uniform plan, and upon a 
 large scale by a number of observers, may be 
 most profitably directed. To be complete, these 
 enquiries should embrace the value of acupres- 
 sure, of which I have little personal experience. 
 The evidence adduced in its support by Sir 
 James Simpson, (^) and the recorded experience 
 of some surgeons who have tried it (^) justify 
 
 ^ American surgeons, to whom Surgery is so greatly indebted 
 in the matter of animal ligatures and metallic sutures, have 
 also accumulated most interesting experience on the use of 
 metallic ligatures for wounded arteries. Vide "A System of 
 Surgery," by Samuel D. Gross. London and Philadelphia, 5th Ed., 
 1872, vol. 1., p. 670, et scq. 
 
 2 "Acupressure, a New Method of Arresting Haemorrhage, and 
 of Accelerating the Healing of "Wounds," by James Y. Simpson. 
 Edinburgh : A. and C. Black, 1861. 
 
 ^ Whilst revising these proof sheets Professor Pirrie, of 
 Aberdeen, has kindly presented me with a copy of the third edition 
 of his " Principles and Practice of Surgery." In an accompanying 
 note he informs me that his decided impressions in favour of acu- 
 pressure remain unchanged after long experience. In all operations 
 odmitting of the surfaces of the wound being brought together, 
 
THE TEEATMENT OF WOUNDS. 29 
 
 furtlier investigation, as does also Monsieur Pean's 
 system of forci-pressure. (^) ISTever lias the saying, 
 that necessity is the mother of invention, been 
 more completely justified, than by the discovery 
 of means for the arrest of haemorrhage. The 
 available information on the subject is more 
 complete and more nearly perfect, than on any 
 other of the great surgical problems. There is the 
 strongest reason for believing, that well-directed 
 and sufficiently extensive experiments, and clinical 
 enquiries, would soon raise our knowledge of 
 haemostatics to the rank of accurate scientific 
 generalizations. 
 
 In estimating the relative value of the means 
 employed for closing a divided artery, it must 
 be borne in mind, that their efficiency is greatly 
 influenced by the general treatment of the wounded 
 part. Any plan, which favours rapid healing of 
 cut surfaces, lessens in direct proportion the chances 
 of recurrent bleeding. It is in this respect that 
 
 Professor Pirrie^ since March, 1864, has invariably employed 
 acupressure, and in no single instance has h.e failed in arresting 
 haemorrhage. 
 
 ^ De la Porcipressure, ou de 1' Application des Pinces a 
 I'Hemostasie Chirurgicale, par G. Deny et Exchaquet, d'apres les 
 Le9ons Professees par M. le Docteur Pean, Paris ; Germer Bailliere, 
 1875. 
 
30 LECTURE IT. 
 
 the results of perfect qniet and uniform com- 
 pression are most conspicuous. 
 
 The most imposing case of secondary haemor- 
 rhage with which I have ever had to deal, 
 occurred in the man whose thigh I amputated 
 at the hip-joint 11th September, 1862 (^). After 
 removal of the limb (which measured 48 inches 
 in maximum circumference, and weighed 991bs), 
 many vessels were tied, including the femoral 
 vein. Everything proceeded favourably until the 
 morning of the fourth day, when arterial blood 
 gushed freely from the centre of the wound, 
 which was nearly all healed. A nurse and dresser 
 had been constantly at the patient's side, with 
 instructions to apply the aortic tourniquet at once, 
 if bleeding occurred ; they obeyed, and I was 
 summoned. On my arrival, in the course of a 
 few minutes, the evidences, that the loss of blood 
 had been considerable, were unmistakable. To 
 open up the vast flaps in search of the bleeding 
 point menaced death. The tourniquet was retained 
 with slight pressure nearly two hours, and a 
 large ox bladder containing three pounds of pounded 
 
 ^ History of a Successful Case of Amputation at the Hip-joint 
 (with Photograplis). London ; Churcliill, 1865. 
 
THE TEEATMEXT OF T\"OUXDS. 31 
 
 ice placed over the anterior flap, to be renewed 
 as rapidly as the ice raelted. 
 
 The bleeding did not recur; at the end of 
 twenty-four hours the ice-bag was discontinued. 
 Pressure was kept up by means of a thick piece 
 of sheet lead, weighing nearly one pound, cut and 
 moulded to the shape of the anterior flap, on 
 w^hich it w^as placed, a piece of dry lint 
 intervening. In the course of a few days the 
 pressure was increased, and the man made a 
 complete recovery. 
 
 Due importance must be attached to the 
 effect of cold in preventing a recurrence of the 
 bleeding, but the perfect state of repose of the part 
 under the pressure, first of the 3 lb. ice-bag, and 
 then of the lead, was most beneficial. 
 
 It was noted in the early part of this Lecture, 
 that styptic colloid was applied, to the fore- arm 
 stump of the youth who was before you The 
 operation, you will remember, w^as necessitated 
 by a machinery crush; the muscular tissue in 
 the stump being a good deal bruised, as was 
 also the skin. The styptic colloid was an effectual 
 means of approximating the edges without tension, 
 of stopping oozing of blood, and, by its antiseptic 
 
32 LECTUEE n. 
 
 properties, of cliecking the decomposition whicli 
 was sure to occur in some degree as the result 
 of the very severe contusion. The effect of the 
 styptic colloid application could not have been 
 more satisfactory. That agent was invented in 1867, 
 C) by my friend Dr. B. W. Eichardson, F.E.S. It 
 is produced by saturating ether entirely with 
 tannin and a colloidal substance, xyloidine or gun 
 cotton, a little tincture of benzoin bemg finally 
 admixed. 
 
 When it has been on for a few days, styptic 
 colloid dressing often peels off easily as a dry 
 shell, leaving the parts beneath perfectly healthy. 
 If the dressing be adherent, care must be taken 
 to remove it so as not to disturb the subjacent 
 parts, and not to give pain. This may be 
 done by dropping on the dry colloid dressing, for 
 a few minutes, a mixture of alcohol and ether, or 
 equal parts of absolute alcohol and distilled water, 
 warmed to a little above the heat of the body. 
 
 ^ Vic/e Dr. B. W. Eichardson, in Medical Times and Gazette^ 
 1867, Vol. I, p. 383 et scq. "On a New Styptic and Adhesive Fluid- 
 Styptic Colloid, and on Healing by the First Intention." The 
 styptic colloid is prepared, after Dr. Richardson's instructions, by 
 Messrs. Eobbins & Co., Pharmaceutical Chemists, Oxford Street, 
 London, 
 
THE TREATMENT OF WOUNDS. 33 
 
 The dressing becomes moist almost directly, and can 
 be taken off lightly, without the patient feeling it. 
 In the absence of alcohol and ether, brandy or whisky 
 will serve to soften dry colloid dressing before 
 removal. 
 
 In advocating the use of styptic colloid, as an 
 excellent prepareition for hsemostatic and retentive 
 purposes, also valuable for its anti-putrescent 
 properties, I do not attempt to define its merits 
 as compared with other spirituous and resinous 
 solutions — e. g., collodion, tincture of benzoin, and 
 the Friar's balsam or Balsamum Traumaticum of the 
 old surgeons, which are one and all excellent prepara- 
 tions. Any of them (^) may be used with great 
 
 1 The Friar's "balsam and the Balsamum Traumaticum are 
 practically identical in composition with the Tinctura Benzoini 
 Composita of the British Pharmacopoeia. The latter contains 
 exactly the same quantity of Balsam of Tolu as the former, and 
 rather more Benzoin, Storax, and Socotrine aloes. The compounds 
 are excellent in surgical use. The appended formula is from the 
 Pharmacopoeia of the London College of Physicians for 1771 : — 
 
 BALSAMUM TRATJMATICUM. 
 
 "R Benzoini P. uncias tres. 
 
 Styracis calamitse colati P. uncias duas. 
 Balsami Tolutani P. unciam unam. 
 Aloes SocotriDse P. unciam dimidiam. 
 Spiritus vinosi rectificati M. libras duas. 
 DiGEEE : — XJt gummi, quantum fieri poterit, solvantur, deinde 
 cola. 
 
 I) 
 
84 LECTUKE n. 
 
 advantage in promoting tlie healing of wounds, as 
 adjuvants to tlie great principles of rest, position, 
 and pressure. 
 
 St}"ptic colloid has the advantage of drying 
 very quickly ; strips or pledgets of lint soaked 
 in it, soon become so dry and firm as to act 
 like splints in preventing motion. I have often 
 treated injuries of the hand and fingers, with 
 successful reliance on lint soaked in styptic colloid 
 to close wounds and immobilize the joints. 
 
THE TREATMENT OF WOUNDS. 35 
 
 LECTUEE III. 
 
 CONTENTS. 
 
 "VVounds penetrating into joints, p. 35 ; Case of incised wound 
 througli quadriceps tendon into knee joint — union by 
 first intention, p. 36 ; Case of incised wound into the 
 patella — union by the iirst intention, p. 41 ; tbe general 
 principles of treatment in the two cases, p. 43 ; "William 
 Iley's experience, penetrating wound of knee joint, with 
 division of rectus tendon — recovery, with perfect ute 
 of the limb, p. 44 ; comparison with Hey's treatment, 
 p. 46; gunshot wound in the elbow joint— recovery, 
 with perfect use of the elbow, p. 47 ; Baron Larrey's 
 ClinicLue — his treatment of open joints, p. 49 ; Case of 
 sword wound into the shoulder joint — recovery, p. 50 ; 
 Case of wound into the knee joint, with division of 
 the quadriceps tendon, p. 52 ; wounds of knee, "with 
 division of the patella — recovery, p. 52 ; Dr. Knowlton's 
 Case of contused and penetia'iDg wound of the knee 
 joint — recovery, p. 53 ; summary of rules for treating 
 open joints, p. 55. 
 
 Gentlemen, — 
 
 Penetrating TvoimcTs of joints are, by common 
 admission, some of tlie most serious injuries wliicli 
 surgeons are called upon to treat; and tliey afford 
 a critical test of the value of therapeutic measures. 
 
!6 
 
 LECTUEE in. 
 
 This patient, George Thomas, aged 48, was 
 admitted into the Queen's Hospital, under my care, 
 20th of July, 1877, with an extensive wound 
 penetrating the left kneejoint. It was self-inflicted, 
 while the patient — a foreman in one of our large 
 factories — was trying the temper of a douhle- 
 handled drawing-knife on a piece of ash. (^) 
 
 Fig. I. 
 
 ^ This and the succeeding woodcuts have "been executed by 
 Mr. R. Paterson, from photographs. 
 
THE TEEATMENT OF WOUNDS. 37 
 
 His knee was bent at the time, and the knife slipped 
 into the limb, while being used with considerable 
 force. On admission the patient was suffering 
 from slight shock. The clean cut wound extended 
 three inches across the thigh, just above the upper 
 border of the left patella ; the tendon of the 
 quadriceps extensor cruris was completely divided; 
 so that the finger could be passed underneath the 
 upper border of the patella into the knee joint ; 
 the outline of the intercondyloid space could be 
 made out ; a thin currant-jelly-like clot was visible 
 in the joint, and slight hsemorrhage was going on. 
 I visited the hospital, very shortly after I 
 received notice of the patient's admission, and 
 found that the assistants had prepared the spray 
 and the requisite dressings, to treat the case on 
 Mr, Lister's plan. 
 
 On hearing the account of the accident, satis- 
 fied that no foreign substance was in the joint, I 
 took no heed of the blood clot, used neither sponge 
 nor lint to the outside, but at once brought the 
 lips of the wound very accurately together, and 
 inserted three points of silver suture. Some strips 
 of lint soaked in styptic colloid were placed 
 lengthways^ after the fashion of adhesive plasters, 
 
38 LECTURE III. 
 
 over tlie wound ; over them a thin layer of 
 picked oakum, and another of cotton wool. The 
 limh, being steadily held in the extended position, 
 v/as immobilized by lateral and posterior paste- 
 board splints, which had been previously moistened ; 
 in bandaging them to the limb I used firm, smooth 
 compression. To give unity to the apparatus, the 
 outside was starched, and long heavy sand-bags 
 placed on each side of the limb. 
 
 July 27th (seventh day after admission). — 
 Has been quite free from pain ; temperature 
 normal; the limb has not been touched. The 
 upper part of the bandages was this morning 
 cut down, in front in the middle line. The skin 
 of the thigh looked so natural, there was such 
 an entire absence of swelling about the knee, 
 and the materials covering it were so dry, that 
 the investing case was not further disturbed, but at 
 once reclosed with compressing circular bandage. 
 
 July 29th. — The case opened throughout in 
 front ; the adhesive strips, with the oakum and 
 cotton wool, easily peeled off, leaving the skin pale 
 and shrivelled; the outline of the knee perfect, 
 and the patella movable ; the wound quite closed, 
 and absolutely dry. I left the sutures, covered the 
 
THE TREATJIENT OF WOUNDS. 
 
 39 
 
 seat of injury witli a pad of cotton wool, and immo- 
 bilized tlie limb in tlie same apparatus. 
 
 August 1st. — On exposing tlie limb every- 
 thing looked healthy — no pain, swelling, redness, 
 or moisture ; sutures removed ; case reapplied. 
 
 August 6th. — The temperature and pulse have 
 been normal throughout. Allowed to get up. 
 
 August 20th (thirtieth day). — Patient dis- 
 charged, with a pale and dry linear cicatrix. 
 
 Fig. II. 
 
40 
 
 LECTUEE III. 
 
 I liave seen this man from time to time 
 since lie left tlie hospital. The apparatus has 
 been gradually reduced piece by piece. He has 
 gone to business for the last six weeks ; and 
 now, barely three months and a half since the 
 accident, he can walk with one stick ; he can 
 bend the knee nearly at right angles; when 
 
 Tig. III. 
 
 sitting, can lift the heel from the ground without 
 help, and when doing so yoa can feel the restored 
 
THE TREATME:t7T OF WOUNDS. 41 
 
 tendon^ at its insertion in tlie knee-cap, of good 
 average development and solidity. 
 
 Here is another case of a similar kind, treated 
 identically, and Vvdtli equally good results: — William 
 Bradley, aged 33, admitted under my care October 
 13tli, 1877, with a clean cut wound, transversely 
 over tlie centre of tlie riglit patella. Tlie wound 
 had been inflicted by a double-liandled draw-knife, 
 which slipped while the workman was shaping a 
 spoke. The incision was two and a half inches 
 in extent, and penetrated into the patella to the 
 depth of one third of an inch. The joint capsule 
 was intact, and haemorrhage had been slight. Our 
 house surgeon, Mr. AYilkins, A^ery accurately adjusted 
 the edges of the wound, and fixed them with two 
 points of silver suture ; a piece of lint soaked in 
 styptic colloid was applied to the front of the 
 knee, and over it some picked oakum. The limb 
 was then immobilized with lateral and posterior 
 pasteboard splints, previously moistened so as to 
 admit of accurate moulding under a smoothly 
 compressing circular bandage. Lateral sand-bags 
 were added. 
 
 October 18th (fifth day). — The wound was looked 
 at for the first time; it was perfectly healed, the 
 
42 
 
 LECTURE III. 
 
 line of cicatrix scarcely visible, and quite dry, as 
 was also tlie surrounding pale skin. Tlie sutures 
 were removed, and tlie limb put up as before. 
 
 October 26th. — There has been no rise of 
 temperature or pulse throughout ; the cicatrix, barely 
 visible, is not adherent to the surrounding parts; 
 
 Fig. IV. 
 
 there is no swelling of the knee, which can be 
 bent at right angles. The patient discharged (a 
 
THE TREATMENT OF WOUNDS. 43 
 
 iortniglit after admission), with a sliort back mill- 
 board splint and circular bandage. 
 
 As I am addressing yon, just tliree weeks have 
 elapsed since tlie accident ; and the man, in ruddy 
 health, can walk without a stick with barely per- 
 ceptible limp. 
 
 You have here two very formidable injuries. 
 In one the knee joint was extensively laid open, 
 and the quadriceps tendon completely divided ; 
 in the other, a wound across the front of the 
 knee penetrated some distance into the substance 
 of the patella. The result in both cases has 
 been complete union by the first intention, without 
 the slightest symptom of local or constitutional 
 disturbance. The two cases were identically 
 treated. Xo water was applied to the wounds, 
 which were at once and completely closed ; very 
 efficient means were taken for immobilizing the 
 limbs ; and, keeping a close eye on the thermometer 
 chart, I waited, and did not interfere Avith the 
 healing process. Nothing could have been more 
 simple, nothing more free from pain, nothing 
 more satisfactory in the issue. 
 
 My general experience warrants me in saying, 
 that in equally severe injuries the same plan of 
 
44 LECTURE III. 
 
 treatment, accurately carried out, will be attended 
 witli tlie same results, with exceedingly rare 
 exceptions. 
 
 In confirmation of the soundness of the 
 therapeutic principles in question, let me read 
 you a clinical record from the work of one of 
 the Masters of Surgery, — a record no less valuable 
 because the case occurred upwards of ninety 
 years ago. I read from Mr. William Hey's 
 " Practical Observations in Surgery." (^) 
 
 "In 1784 a stout young man was brought 
 into the Infirmary at Leeds, with a transverse 
 wound penetrating the knee joint just above the 
 patella. The patient had been working in the 
 woods, and a Avoodman's bill had fallen from a 
 bough above him, and striking the lowest part 
 of the thigh, had made a transverse wound about 
 two inches in length, dividing the tendon of the 
 rectus femoris close to the patella. A wound 
 was made through the capsular ligament, so large 
 that I could easily introduce my finger into the 
 joint. 
 
 " After examining the interior parts of the 
 
 1 Second edition, London, 1810, page 359. The quotation 
 is a transcript, witli only the omission of immaterial details. 
 
THE TREATSIENT OF WOUNDS. 45 
 
 joint with my finger, that no extraneous body 
 might be left there, I united the lij^s of the 
 wound by three stitches of the interrupted suture, 
 taking care to lay hold of nothing with the 
 needle but the integuments. I could not remove 
 all the blood from the inside of the joint, for 
 that continued to flow as long as my finger 
 remained in the wound. E'either could I favour 
 the discharge of that blood which remained in 
 the joint, by any method of placing the limb 
 which would answer my principal intention. But 
 I hoped that, if inflammation could be avoided, 
 the extravasated blood would be absorbed without 
 danger. 
 
 " That I might keep the knee quite steady, 
 and the injured parts in a state of relaxation, 
 I placed the man in a supine posture, with his 
 leg upon a pillow in a hea^y fracture-box, and 
 covered the wound- with ceratum saponis, spread 
 upon a pledget of tow. This method kept the 
 anterior parts of the knee, with the rectus femoris, 
 in a state of the greatest relaxation, and the 
 external air was excluded without making any 
 pressure upon the injured parts. I gave directions 
 that all possible care should be taken to prevent 
 
46 LECTURE ni, 
 
 tlie motion of tlie joint upon any occasion. The 
 patient complained of smarting in the wound 
 for about half an hour after the dressing, but 
 had afterwards no return of pain. The same 
 treatment was continued, and the ligatures cut 
 out upon the tenth day after the accident. The 
 patient recovered so well, that in the space of 
 four weeks he became able to move about in 
 the ward upon crutches. He regained the perfect 
 use of his limb." 
 
 Be good enough to note that in this case, as 
 in mine of George Thomas, the knee joint was 
 extensively opened, and the great tendon comjoletely 
 divided close to the knee-cap. Mr. Hey, like 
 myself, trusted to the extravasated blood being 
 absorbed ; in both cases the wounds were accurately 
 closed and the air excluded, the sutures were not 
 touched for many days, and recovery in both was 
 rapid and complete. One material point of difference 
 in the treatment calls for remark. Mr. Hey observes 
 that he made no pressure upon the injured parts. 
 I steadily and uniformly compressed the icjured 
 joint with a circular bandage, over an intervening 
 pad of j)icked oakum and cotton wool, and applied 
 smooth pressure from the toes to the groin. 
 
THE TEEATMENT OF WOUNDS. 47 
 
 Let me read you anotlier case from Mr. Hey's 
 work. I do so because tlie recovery, after a very 
 severe injury, occurred though poultices were 
 employed ; the treatment differing in this particular 
 from what you see in this Clinique; but 
 fundamentally it was based on the same 
 principles. 
 
 " October 4th, 1798.— Sarah Swordie, aged 18 
 years, was brought into the Infirmary on account 
 of a wound in the elbow joint, which she had just 
 received from the wadding of a pistol, fired very 
 near her, during the rejoicing for Admiral Nelson's 
 victory over the French fleet in the Bay of Aboukir, 
 The wound was made near the olecranon, through 
 the flat tendon of the extensor cubiti. The parts 
 were contused and lacerated. The capsular ligament 
 was divided so as to admit readily the introduction 
 of a finger within the joint. A considerable number 
 of grains of gunpowder were lodged in the integu- 
 ments. I examined carefully the cavity of the 
 joint, but could not find any extraneous substance 
 lodged there. Though it is not probable, from the 
 contused state of the parts, that an union by the 
 adhesive process could be obtained, yet in order 
 to diminish as much as possible the size of the 
 
48 LECTURE III. 
 
 wound and exclude tlie external air, I drew tlie 
 integuments into contact by some stitclies of the 
 interrupted suture. The young woman being put 
 to bed, I placed the arm upon a pillow, in an 
 extended position, that the wounded parts might 
 be kept in a state of relaxation. The arm was 
 covered with a jDo^ltice made of bread and water. 
 An opiate was given immediately, and a gentle 
 laxative the next morning. Tlie young woman 
 was not suffered to get out of bed on any occasion, 
 nor was her arm removed from the pillow, except 
 when gently raised for the purpose of applying 
 the poultice. 
 
 ''The symptoms of inflammation were trifling, 
 and soon went off. The integuments had been 
 so much contused that the ligatures did not 
 retain the wounded parts in contact for a few 
 days. The edges of the wound then sloughed 
 off; but the size of the wound was diminished 
 by the lips having been retained in contact for 
 some days. The arm became quite easy in the 
 course of a few days. 
 
 " On the 14th day I laid aside the poultices, 
 and drew the lips of the wound towards each 
 other with sticking-plaster. The patient regained 
 
THE TREATMENT OF WOUNDS. 49 
 
 tlie perfect use of tlie elbow, and on December 
 5th was discharged cured." (^) 
 
 The successful result of this contused and 
 lacerated wound into the elbow-joint, (duly allowing 
 for the judicious opiate immediately after the 
 accident, and the purgative next morning), was 
 chiefly referable to two conditions — first, to 
 the extended position of the limb, allowing of 
 the nearest approximation of the edges of the 
 wound ; secondly, to rest. 
 
 Mr. Hey has recorded that ^'the arm was 
 covered with a poultice made of bread and water," 
 and that the only movement allowed was in 
 quietly raising the limb to change the poultice, 
 which evidently encircled the whole limb ; it 
 thus exercised a compressing and steadying 
 influence favourable to rest. Several other brilliantly 
 successful cases of extensive joint-wounds are 
 related by Hey, who is clearly entitled to a 
 larger measure of credit than is generally accorded 
 to him, as one of the earliest surgeons who 
 practised excisions of the elbow and ankle. 
 
 In the Surgical Clinique of the elder Larrey, 
 are recorded great advances in many departments 
 
 1 Hey Op. Cit., p. 361, 2. 
 E 
 
50 LECTURE III. 
 
 of surgery, in none more so than in the treatment 
 of woimcls into the larger joints. (^) He clearly 
 understood, and impressively taught, the value of 
 gentle pressure, of absolute rest and of infrequent 
 dressings. In keeping parts at rest he employed, 
 besides adhesive plasters, a retentive apparatus com- 
 posed of compresses and pledgets of tow soaked in a 
 mixture of Goulard's extract, camphorated spirit, 
 and white of egg : bandages externally. He speci- 
 ally counsels that, apart from accident such as 
 haemorrhage or unforeseen displacement, the apparatus 
 is not to be removed before the twenty-first day. 
 He adds, that it is even beneficial to leave it until 
 the cure is completed. 
 
 Let me translate the main facts of one of 
 Larrey's cases: — 
 
 "At the combat of Salahiez, in Egypt, one 
 of our dragoons received, from one of Ibrahim 
 Bey's Mamelukes, -a sabre wound on the shoulder, 
 extending obliquely from the acromion to the 
 anterior border of the axilla. The inner part of 
 the deltoid was divided in almost its whole 
 
 ^ Clinique Chiriirgicale exercee particulierement dans les 
 Camps et les Hopitaux Militaires depuis, 1792, jusq' au 1829. 
 Par le Baron D. J. Larrey. Paris, 1829. Tome Troisieme, 
 371, et seq. 
 
THE TREATMENT OF WOUNDS. 51 
 
 depth, tlie edge of the acromion was notched, the 
 anterior and internal wall of the joint capsule 
 was wounded to the extent of four or five lines, 
 and the head of the humerus was slightly cut. 
 I proceeded immediately after the combat to 
 dress the patient. . . . AVe placed a pad 
 surrounded with tow in the axilla, so as to press 
 outwards against the posterior part of the joint. 
 A circular bandage was then applied to the whole 
 limb with light uniform compression. We united 
 the edges of the wound by means of adhesive 
 straps and an appropriate bandage ; the fore-arm 
 was placed in a sling, and the wounded man 
 was sent to the hospital at Cairo, where we saw 
 him some days afterwards. According to my 
 instructions, the apparatus had not been touched. 
 . . . I removed it myself for the first time 
 on the ninth day. The wound was almost entirely 
 healed without swelliDg or inflammation of the 
 limb. After some weeks care and rest, the soldier 
 went back to duty." 
 
 Let me direct your attention especially to 
 the fact that Baron Larrey himself, chief surgeon 
 to JSTapoleon's army in Egypt, stooped down in 
 the ambulance to dress the wounded dragoon. 
 
52 LECTURE III, 
 
 and followed liim to Cairo, to dress him again 
 the ninth day after he received his sabre wound ; 
 — one of many lessons in which the great surgeon 
 gave proof of his conviction, that surgical success 
 is a question of gentleness and accuracy of surgical 
 dressing, wortliy exercise for a master of his art. 
 
 I must ask you to listen to another abstract 
 from the Baron's clinique : — '' The coachman of the 
 Marchioness de Grouchy, falling from a height on 
 to the edge of a footpath with his leg bent, had 
 cut through the quadriceps tendon at its insertion 
 into the patella, as well as the integuments 
 covering it. We placed the extended limb in an 
 immovable apparatus, and it remained in it for 
 ninety days ; during this time the dressing had 
 only been renewed ten times. The man returned 
 to his employment as a coachman. We have 
 similarly treated with success, in several of our 
 soldiers, wounds of the knee with transverse or 
 oblique division of the patella. These patients 
 having been dressed by us immediately after the 
 accident, the bony fragments have been accurately 
 consolidated, and the movements of the joint have 
 been preserved." 
 
 To pass from old to modern times, from the 
 
THE TKEATMENT OF WOUNDS. 53 
 
 historic battle fields of Egypt, to the virgin forests 
 of far West America, here is another case of most 
 severe and extensive wound of the knee joint 
 treated on what I have taught you to regard as 
 principles of sound surgery: — 
 
 Dr. A. P. Knowlton, of Olmstead Falls, Ohio, 
 records (}) that he was called, December 5, 1872, 
 to see a lad, aged eleven years, who had received 
 a severe wound of the knee. The boy was in 
 the forest with his father, where the latter was 
 chopping wood. The boy had climbed a sapling 
 close by ; the sapling bent over, and the boy 
 slipped and fell, coming down in front of the 
 father just as he was bringing down his axe. 
 The axe struck the left knee of the boy, severing 
 the patella, cutting down on the outside of the 
 knee joint, penetrating the joint, with a cut 
 through the synovial membrane about one inch 
 long. After arresting the h£emorrhage and brushing 
 over the cut surfaces with a solution of per- 
 chloride of iron, they were carefully placed in 
 apposition and secured with silver pin sutures. 
 A figure-of-eight bandage was applied to hold the 
 
 1 American Journcd of the Medical Sciences. PkiladelpMa, 
 1876, Yol. L, p. 413. 
 
54 LECTUEE III. 
 
 fragments of tlie patella in apposition; a long 
 splint was then applied from the axilla down to 
 about six inches below the foot ; an inside splint 
 reaching from the lower part of the upper third 
 of the thigh to six inches below the foot ; cross- 
 piece below the foot, another one just below the 
 knee, and one just above ; a rack was framed 
 around the joint, leaving a chamber from integu- 
 ment to the inside of the rack about one inch in 
 diameter, and this rack was covered v/ith relays of 
 ice-bags. The boy was ordered a one-grain opium 
 pill every fom^ hours ; gentle extension and counter- 
 extension was kept up. This treatment was 
 continued for eight days, when the ice-bags were 
 discontinued and the wound dressed with dilute 
 alcohol and carbolic acid. Primary union had been 
 obtained. At the end of three weeks the splint 
 was removed each day and passive motion practised. 
 The lad made a good recovery, and now has 
 complete use of the leg with perfect motion of 
 the knee joint." 
 
 The opium pill every four hours was a v/ise 
 prescription; the sedative influence of the drug is 
 of great service in keeping patients quiet, after 
 severe injuries and operations. Discrimination 
 
THE TEEATMENT OF WOUNDS. 55 
 
 must of course be exercised, as to close and 
 repetition. 
 
 ISTotliing could liave been more effective than 
 Dr. Knowlton's appliances for securing tlie 
 immobility of tbe limb. Tlie long wooden cradle^ 
 with the bags of ice, precluded all possibility of 
 motion. 
 
 I look upon the dilute alcohol and carbolic 
 acid employed as surplusage, for it is expressly 
 stated that the apparatus and ice-bags were 
 contmued for eight days, when primary union had 
 been obtained. The percliloride of iron solution, 
 which was brushed over the cut surfaces, acted 
 in principle like the balsamum traumaticum the 
 styptic colloid and the allied agents, to which we 
 have already referred. 
 
 To sum up the lessons taught by the cases 
 embodied in this lecture: Wounds into large 
 joints, severing tendons and bony processes, 
 repeatedly, and I beheve as a general rule, do 
 perfectly well, if (in the absence of foreign bodies 
 within them or after their extraction) their edges 
 be accurately approximated, air excluded, and the 
 trunk and limbs kept as nearly as possible in a 
 state of absolute quiet. Once these indications 
 
56 LECTUEE IIL 
 
 are fulfilled, the surgeon cannot be too watchful, 
 or too patient. The dressing of such cases is a 
 work of the nicest surgical art, and a test of 
 that patient confidence which only experience 
 teaches. Act energetically and precisely, at the 
 right time ; watch unceasingly ; and do not meddle 
 without good and sufficient reason. 
 
THE TEEATMENT OF WOUNDS. 57 
 
 LECTUEE lY. 
 
 co:n^tents. 
 
 Wounds of the head, their importance, p. 57 ; Case of removal 
 of cystic tumour from right temporal region, union by first 
 intention, p. 58 ; Case of extensile contused wound of the 
 scalp, with exposure of bone, union by the first intention, 
 p. 59 ; Three cases of compound depressed fracture of 
 the skull without brain symptoms, perfect recovery without 
 trephining, p. 60—65 ; the French and English schools on 
 the trephine, progress of conservative opinion, p. 66; 
 great value of the thermometer to the student surgeon, 
 p. 68 ; Case of compound depressed fracture of the skull, 
 commencing paralysis, recovery without the trephine, 
 p. 69 ; Case of extensive lacerated and contused scalp 
 wound, with double depressed fracture of the skull, perfect 
 recovery without trephining, p. 70 ; compound fractures 
 of the limbs to be reduced to simple ones, p. 72 ; Case 
 of compound fracture of the leg, closure of the wound, its 
 union by the first intention, p. 73 ; Case of extensive 
 compound and comminuted fracture of the thigh, speedy 
 recovery under dry and infrec[uent dressing and immo- 
 bilization, p. 75. 
 
 Gentlemen, — 
 
 Wounds of the head are, for obvious reasons, 
 of the first importance. They have engaged the 
 special attention of leading surgeons in all times 
 
68 LECTURE IV. 
 
 and countries^ and some points connected with 
 their treatment are still matters of keen con- 
 troversy. 
 
 Some wounds of the head — especially those 
 directly, or in their remote issues, affecting the 
 brain — differ materially from wounds in other parts 
 of the body. In this course of lectures, I shall 
 restrict myseK to bringing before your notice a few 
 typical cases of wounds of the scalp, and fractures 
 of the vault of the cranium, unattended with 
 symptoms of organic cerebral injury. 
 
 A simple wound of the head, though of con- 
 siderable extent and in a critical position, was 
 presented by the little old gentleman, who kindly 
 attended in the theatre last term for your in- 
 struction. He consulted me about two months 
 previously for a cystic tumour, about as large as a 
 hen's egg, in the right temporal region. The 
 covering skin was very red, tense, and painful. 
 After removing the cyst with the knife, I dried 
 the interior of the wound with a fine sponge which 
 had been previously well squeezed. The edges 
 were then very accurately approximated, and kept so 
 with a few strips of lint soaked in styptic colloid. 
 A few turns of bandage comjpleted the dressing ; 
 
THE TEEATMENT OF WOUNDS. 59 
 
 when I removed it, at tlie end of five days, tliere 
 was not a drop of discliarge ; adhesion was perfect, 
 and afforded a simple but complete illustration of 
 tlie surgeon's first intention in treating wounds — 
 to secure direct union. All that is visible of the 
 cicatrix is a very fine pinkish line, extending 
 upwards about two inches from, and just in front 
 of, the right ear. 
 
 A more formidable lesion, treated on the same 
 principles and with equally favourable result, was 
 that of Ann Hand, now in Ward 5. She is 55, 
 but looks much older. She had fallen down some 
 steps, on to her liead, into the cellar, when she 
 was brought into the Hospital. Her scalp presented 
 a wound 6 J inches in length, a little to the right 
 of the middle line. The wound was gaping, 
 and the bone was exposed in one small spot. There 
 had been considerable haemorrhage, and the patient 
 was suffering from slight concussion. The edges of 
 the wound were accurately brought together by Mr. 
 Wilkins, and secured by five points of silver suture. 
 A large pad of dry lint supported by carefully applied 
 bandage, with considerable pressure, completed the 
 dressing. The patient rallied in the course of a few 
 hours, took milk and ice plentifully, and was quite 
 
60 LECTUEE IV. 
 
 free from pain. The wound was not looked at until 
 the completion of the seventh day. It was then 
 perfectly healed throughout, the cicatrix appearing 
 as a fine brownish line, movable on the subjacent 
 parts as was also the healthy looking and feeling 
 skin in the neighbourhood. Not the slightest irri- 
 tation was visible at the points of suture, of which 
 four were now removed ; the middle one being left 
 as a precaution. The lint pad and bandage were 
 re-applied. The eleventh day after admission the 
 fifth suture was removed ; it had not produced 
 any irritation. A bandage was lightly applied, and 
 the patient (in perfect health) discharged. 
 
 Here are the notes of a much more serious 
 case, which has been before you several times. 
 
 The man Thomas Moran, a bricklayer's labourer, 
 aged 55, was admitted to Ward 3 on September 
 15th, 1875. While he was at work just previously, 
 a brick fell from a considerable height upon his 
 head, making a Y-shaped scalp-wound about two 
 inches and a half in length, and situated rather 
 above the middle of the left parietal bone. The 
 flap of the wound being turned back, a Y-shaped 
 fracture became visible, with its centre depressed 
 to one-third of an inch; the sides of the fracture 
 
THE TREATMENT OF WOUNDS. 61 
 
 sloping evenly towards tlie central and most de- 
 pressed point. The man seemed little affected by 
 the accident, and had no idea of its serious nature. 
 The edges of the wound, admitting of easy ap- 
 proximation, were brought together and dressed with 
 dry lint ; and for the first fortnight the patient was 
 kept perfectly quiet in bed, on milk diet, with an 
 ice-basj on his head. ISTo sims of constitutional 
 disturbance appeared, and the man was discharged 
 at the end of seven weeks, to use his own words, 
 '' in as good health as ever he was in his life" 
 The wound was then quite healed, and the area of 
 the depressed bone measured one inch and a half 
 longitudinally, and seven-eighths of an inch trans- 
 versely ; its depth was three-eighths of an inch in 
 the centre. Q) 
 
 I took no notice of the fracture, but proceeded 
 at once to close the wound, which was dressed 
 with dry lint. Local and constitutional rest, milk 
 diet, and an ice-bag on the head constituted the 
 treatment, until the wound was firmly healed and 
 the patient convalescent. 
 
 A more serious case was that of Henry Haddon, 
 
 ^ I saw this patient some montlis after the accident, and he 
 continued in perfect health. 
 
62 LECTURE IV. 
 
 a macliinist, aged 25, wlio was admitted to Ward 
 1 at 11.20 p.m. on the 25tli of September, 1875. 
 A few minutes previously, in a street row, a brick 
 bad been tbrown at bis bead, producing a w^ound 
 an incb in lengtb, over tbe left temporal ridge, in 
 a line above and in front of tbe ear. Tbe bsemor- 
 rbage was considerable. Tbe probe passed into a very 
 abruptly punctured fracture of tbe skuU; tbe 
 amount of depression being balf an incb, and 
 tbe edges of tbe bone, on one side at least, 
 being quite perpendicular. Mr. C. E. Keetley, 
 our bouse-surgeon at tbe time, to whom I am 
 indebted for tbe notes of tbe case, made a 
 memorandum on tbe spot to tbe effect tbat, 
 in Haddon's fracture, a small piece of bone 
 appeared to have been driven rigbt in. Tbe 
 man was quite sensible, tbougb faint from loss of 
 blood. He was put to bed, witb an ice-bag on bis 
 bead. At 8.30 next morning, a little beadacbe was 
 complained of ; tbe pupils were even ; temperature 
 lOlo. A magistrate took tbe patient's depositions 
 at bis bed-side in tbe afternoon. 
 
 September 27tb, morning. Pulse 80 ; tempera- 
 ture 98 dec^. Tbere was a tbin drab fur on tbe 
 dorsum of tbe tongue. Tbe bowels were confined. 
 
THE TREATMENT OF WOUNDS. 63 
 
 He had slept well ; was very liiingry. Tlie wound 
 was healthy. His eyes were slightly swollen. 
 
 The bowels acted the next day. The wound 
 gradually healed, under dry lint dressing. On 
 October 9th (a fortnight after admission) the ice- 
 bag was left off, a flannel cap ordered to be worn, 
 and the man allowed to get up. At the end of 
 another fortnight the man was discharged in per- 
 fect health ; the cicatrix was quite sound, and the 
 depression at the seat of fracture admitted the end 
 of the little finger, which did not seem to touch 
 bone at the bottom. Q) 
 
 The third case of compound depressed frac- 
 ture of the skull which I have to bring before 
 you is that of T. Smith, a joiner's labourer, aged 
 25. He was stooping down at his work, when a 
 brick fell on liis head from a height of thirty feet. 
 When admitted to Ward 1 (4.15 p.m., October 15th, 
 1875), half-an-hour after the accident, he was quite 
 sensible. A wound on the left side of the head 
 was bleeding freely ; corresponding to it was a 
 depressed fracture of the skull, the depressed piece 
 of bone being horse-shoe shaped and situated near 
 
 1 I saw this man seven montlis after the accident, in per- 
 fect health. 
 
64 LECTURE IV. 
 
 the middle of the lambdoidal suture. The depressed 
 surface was about one-eighth of an inch below the 
 surrounding bony level. No head-symptoms. Pulse 
 80; temperature 99°; respirations 24. The edges 
 of the v^ound were approximated and dressed with 
 dry lint. An ice-bag v^as ordered to be kept on 
 the head constantly. 
 
 October 16th. Temperature 99° ; pulse 72 ; 
 respirations 20. Patient perfectly sensible. He 
 had taken plenty of milk. He was ordered to have 
 an ounce of castor-oil. 
 
 October 17th. Has slept four or five hours in 
 the night. The bowels have acted. Temperature 
 lOl'fTf ; pulse 104 ; respirations 22. 
 
 October 18th. Temperature IOI.60 ; pulse 76 ; 
 respirations 25. 
 
 November 19th, morning. Temperature 99.2o ; 
 pulse 84; respirations 22. There were still no 
 symptoms of nervous lesion or constitutional dis- 
 turbance. 7 p.m., temperature 104.4" ; pulse 104 ; 
 respirations 32. He had a rigor half-an-hour ago. 
 The bowels not having acted for some days, a full 
 dose of castor-oil was administered ; the bowels 
 were then freely relieved. The temperature rapidly 
 
THE TEEATJilEXT OF WOUNDS. 65 
 
 fell to the normal standard^ and no other untoward 
 sym^^tom occurred. 
 
 December 8th. The patient had continued 
 perfectly well, and for the last month had acted as 
 assistant porter in the hospital. He was now dis- 
 charged, and I made the following note : — '' The 
 lencrth of the cicatrix is one inch and three- 
 quarters. The depressed portion of bone measures 
 one inch and one-eighth, by seven-eighths of an 
 inch. The depression is deepest in the centre, 
 where no bone can be felt. The man looks per- 
 fectly well, and says that he is so. {}) 
 
 These three cases have several characters in 
 common. In each, the scalp was wounded and the 
 skull broken ; in each, the fractured bone was de- 
 pressed. In all the cases, the offending cause was 
 a powerful one, presumably sufficient to agent con- 
 siderable intra cranial extravasation. Two of the 
 men had each had a brick fall on his head 
 from a considerable height ; in the third a brick 
 had been flung at the temporal region in a street row. 
 
 ^ I saw this patient upwards of twelve months after the 
 accident. He continued perfectly well, and had never missed a 
 day's work. Three small pieces of bone had worked through 
 the cicatrix, which was quite solid, pale, and painless over the 
 depressed portion of the skull. 
 
 F 
 
6Q LECTURE IV. 
 
 In neither of the cases were brain symptoms 
 present. In treating them, I dismissed the 
 fracture from consideration, closed and dry-dressed 
 the wounds, kept the patients at perfect rest 
 with large ice-bags on the head, fed them on 
 iced milk, and watched the thermometer chart 
 closely. Eecovery was practically uninterrupted in 
 each case, and was proved to have continued so, 
 for many months after the patients were discharged 
 from the Hospital. 
 
 As the special object of this series of lectures 
 is to study the treatment of wounds, the histories 
 of cases are condensed with special reference to 
 that point. Many matters of collateral, yet very 
 great, interest are unavoidably passed over; but I 
 must notice, though briefly, the treatment of the 
 fractures, which in point of fact were contused 
 and lacerated wounds of bone. Many surgeons 
 would have trephined in each case ; the majority 
 probably would have done so in Henry Haddon, 
 in whom the brick had driven a small piece of 
 bone right in. 
 
 The use of the trephine in fractures of the 
 skull has been a fertile source of contention 
 amongst the masters of surgery, especially since the 
 
THE TREATMENT OF WOUNDS. 67 
 
 days of Pott and Desault, whicli are amongst the 
 most glorious in the chronicles of surgical science 
 and art. The Englishman was for boring, the 
 Frenchman for watching. In the main, the schools 
 of the two nations were long faithful to their 
 respective traditions — the French one singularly so. 
 But Englishmen, so early as Abernethy and Astley 
 Cooper, hesitated to follow Pott's heroic counsels ; 
 and we have more and more assimilated our 
 practice, in this important department of surgery, 
 to the conservatism of our French colleagues. 
 
 ITearly everyone now admits that in a de- 
 pressed fracture of the skull, without wound and 
 without brain symptoms, the trephine should not 
 be used. Why should the mere existence of a 
 wound make all the difference when it ad- 
 mits of being healed simply and rapidly ? After 
 having seen much of the use of the trephine in 
 my own practice and that of others, after wide 
 reference to the authorities in civil and military 
 practice, while feeling the necessity of precise and 
 extensive statistical study of the question, I am 
 clearly of opinion that in compound and depressed 
 fractures of the skull, without brain symptoms, 
 the trephine should not be used. Prolonged local 
 
QS LECTUEE IV. 
 
 and constitutional rest is tlie most tmstwortliy 
 principle of treatment. 
 
 In approximating the edges, in snch wounds as 
 those under consideration, I am careful not to close 
 them comxDletely ; but to leave a dependent orifice 
 so that any fluid may escape, and not be pent up 
 with the risk of finding its way through the fissure 
 into the cavity of the cranium. 
 
 As usual, I preferred dry dressings, carded oakum, 
 dry lint, or cotton wool, as most favourable to heal- 
 ing. Thermometric observations are of the very first 
 importance in pursuing the line of treatment wliich 
 I have traced out to you. It is impossible to 
 exaggerate, not easy to estimate fully, the clinical 
 value of the thermometer to the student-surgeon. 
 It was noted in one of the cases that the temperature 
 suddenly rose from 99.2° in the morning to 104.4° 
 in the evening ; the patient at the same time had 
 a rigor. The bowels were constipated; so soon as 
 they had been relieved, by a full dose of castor- 
 oil, the temperature fell and all progressed favour- 
 ably. 
 
 The persistent ice-bag and iced milk diet 
 were of the greatest service. Without going into 
 the question of stimulants, wliich is just now 
 
THE TEEATMENT OF WOUNDS. 69 
 
 such a fertile — might Ave not say fashionable 
 — matter of dispute and exaggeration, there can 
 be no doubt that, after severe injuries to the skull, 
 stimulants should be forbidden. 
 
 In further illustration of the therapeutic prin- 
 ciples here enunciated, let me read you from my 
 notebook the histories of two other compound 
 and depressed fractures of the skull, the subjects 
 of which have often been before you. 
 
 On the 22nd ISTovember 1875, Edward Armitt 
 was admitted into the Queen's Hospital under 
 my care. He had a transverse wound about 
 an inch and a half in extent at the back 
 of the head, a little to the left of the middle 
 line, and just below the suture between the 
 occipital and the left parietal bone. The 
 wound, which had been inflicted with a cab- 
 man's metal badge, led directly down to the 
 skull ; this was fissured, and the edges of the bony 
 cleft were distinctly felt to have been driven in. 
 The man was perfectly sensible, but the right pupil 
 was dilated, the corresponding eyelid drooped, and 
 partial paralysis of motion in the right arm was well 
 marked. The treatment prescribed was absolute 
 rest in bed, low diet, close attention to the bowels, 
 
70 LECTUEE IV. 
 
 dry dressing of tlie wound, and application of ice-bag 
 to the liead. At the end of nine days the wound 
 had healed, and the symptoms of compression, after 
 steady decrease, had completely disappeared. The 
 patient was discharged on the 10th December, and 
 resumed work six weeks after the accident. I saw 
 him last week, in perfect health. The depression 
 in the skull is still quite perceptible, but the man 
 has not lost an hour's work, and has shown no 
 symptoms traceable to the injury. 
 
 On May 11th, John Curtis, aged 46, was ad- 
 mitted under my care in our accident ward. He had 
 been thrown out of a cart, in rapid motion, on to some 
 stones. The greater part of the right half of the 
 scalp was turned back, and much periosteum had 
 been stripped from the frontal and left parietal bones, 
 in each of which was a fracture with depression : 
 one fracture, immediately above the parietal ridge, 
 was characteristically punctured and depressed — a 
 circular piece of bone, about the size of a split 
 pea, having been firmly driven in to the depth of 
 one-eighth of an inch. The man was barely con- 
 scious, and could only give a very imperfect account 
 of the accident. When I saw him at 11.10 p.m., 
 about two hours after admission, the pulse was 76; 
 
THE TREATMENT OFWOUNDS. 71 
 
 respirations 22; temperature 99.8-. After carefully 
 cleansing the wound, its edges were brought into 
 contact, except at a small dependent point, with 
 eight points of silver suture ; an oakum dressing 
 and gently compressing bandage were applied, and 
 a large ice-bag all over. 
 
 On the following day (May 12th), 9.30 a.m., 
 pulse 84 ; respirations 22 ; temperature 101. 2o. 
 9 p.m., pulse 108 ; respirations 28 ; temperature 
 103o. After this visit, I noted numbness and im- 
 paired motor power in the left hand, with complaint 
 of headache. Ice-bag to be persistently continued, 
 and an aperient draught prescribed. 
 
 May 14th. Dressing changed; discharge con- 
 siderable, but wound looking very well ; the lower 
 half of it healing by the first intention. Pulse 80 ; 
 respirations 20; temperature 101.2°. Pain in head 
 and numbness in hand gradually decreasing. 
 
 From this date, the progress to recovery was 
 uninterrupted. The man was discharged June 21st, 
 barely six weeks after the accident. He resumed 
 his regular work as a carter in another fortnight, 
 and has ailed nothing since. When I last saw 
 him (September 28th), he was in vigorous health. 
 Two splinters of bone were extracted about two 
 
72 
 
 LECTUEE IV. 
 
 montlis ago from the cicatrix, which throughout 
 is pale and painless, the points where the sutures 
 were inserted being scarcely perceptible. (See Fig. V.) 
 
 Fig. Y. 
 
 That compound fractures should be reduced 
 to the condition of simple ones by closing and 
 
THE TEEATMENT OF WOUNDS. 73 
 
 promoting tlie cicatrization of tlie woiind^ is even 
 more generally true in the treatment of compound 
 fractures of the limbs than of the skull. 
 
 A compound fracture of both bones of the leg 
 from direct violence occurred in the man before 
 you ; and you perceive, from the V shaped cica- 
 trix, what a large flap of skin was turned down 
 in front of the solution of continuity of the tibia. 
 I saw the patient within half an hour from the 
 occurrence, reduced the fracture at once, and fitted 
 the skin-flap into place, keeping it there by strips 
 of dry lint, one of which was successively laid on 
 the other as it became soaked with blood. Softened 
 millboard splints, from the middle of the thigh 
 down to embrace the foot, were the basis of the 
 letentive apparatus ; two similar splints being 
 placed at the back, from the same point above, 
 to within three inches of the heel-bone ; a nicely- 
 compressing circular bandage keeping the whole 
 firmly together. I merely starched the bandage, 
 Vvdiile applying it in front, to keep the case 
 together when it became necessary to cut it open. 
 
 The patient had not a single bad symp- 
 tom ; the apparatus was not touched for ten 
 days, when the wound was wholly healed, 
 
74 LECTURE IV. 
 
 consolidation, of the tlien simple fracture, pro- 
 ceeding in the usual course. Here, repair of the 
 wound in the soft parts and in the bone occurred 
 by one and the same natural process, aided by the 
 same means, — exact co-aptation of the divided 
 surfaces, exclusion of air, and absolute immobiliza- 
 tion persistently maintained. The strips of lint 
 soaked in blood, laid across the wound, and allowed 
 to dry over it, call for comment. The practice 
 is an excellent one ; its origin is often attributed 
 to Sir Astley Cooper, but unjustly so. John 
 Hunter, after calling attention to the healing of 
 small wounds without any dressing, by blood co- 
 agulating and drying into a scab, observes : — 
 "Even compound fractures with a small opening, 
 if suffered to proceed in this manner, will often 
 give but little trouble. (^)" But the merit of 
 establishing the principle in question, as a canon 
 of practice in the treatment of severe compound 
 fractures, belongs to John Bell, " When after a 
 more terrible accident, the limb being torn by 
 machinery, or by carriages passing over it, the 
 
 laceration is great the sides of the 
 
 wound are to be generally supported by laying 
 ^ Jolin Hunter's Works, Palmer's Ed., p. 429. 
 
THE TEEATMENT OF WOUNDS. 75 
 
 small and thin pieces of lint on each side of the 
 wound ; these pledgets of lint are soon soaked 
 with blood, which cakes and adheres to the open 
 part of the wound. By making small rolls and 
 compresses of linen and soft lint, which you lay 
 upon the edges of the wound (at those particular 
 points where you apprehend a gaping of the lips, 
 or where you apprehend that suppuration and 
 cavities will form), you keep the parts very close 
 , . . . you give as much firmness as possible 
 with the many tailed bandage. The steady firm- 
 ness with which you support the parts helps the 
 adhesion, prevents suppurations, and hinders an 
 afflux of blood to the limb." (^) 
 
 As a very striking illustration of the practical 
 soundness of those instructions, and generally of 
 the therapeutic principles embodied in these lectures, 
 let me briefly recapitulate the main facts in the 
 history of the Midland Eailway porter, John 
 Smith, who came in from Selly Oak for your 
 inspection a few days ago. He walked with a 
 slight limp, it is true, but briskly and without a 
 stick, and could bend the knee on the injured 
 side nearly to a right angle. 
 1 The Principles of Surgery, Edinburgh, 1802, vol. L, pp. 653-4. 
 
76 LECTUEE lY. 
 
 I happened to be in the hospital when this 
 man was brought in ; he looked death-hke, was 
 nearly pulseless, and the surface of the body 
 everywhere felt chilly to the hand. (}) The man 
 had been carried up on a stretcher from Kew 
 Street Station, whither he had travelled, partly 
 in a cart on the common road and partly in 
 the guard's van on the line, a distance of some 
 fifteen miles, since a laden coal-truck (weighing 
 about eight tons) had knocked him down and 
 passed over his left thigh, at the junction 
 of its middle and lower thnds. His clothes 
 were torn to rags and soaked in blood, at the 
 seat of injury; they were carefully removed, 
 while hot bottles, wrapped in flannel, were packed 
 along the sound limb and the trunk, warm 
 blankets to cover, and teapoonsfuls of warm tea 
 given to the man, as his head was kept low on 
 the mattress. I ^vas told that the district surgeon 
 of the Eailway Company had sent the man in to 
 undergo amputation of the thigh, and the attendants 
 were preparing the instruments in the theatre, 
 when I interposed. JSTothing could look more 
 
 ^ Precise therm cmetric observation ^Yas not made at the 
 moment of admission. 
 
THE TREATMENT OF WOUNDS. 77 
 
 formidable than the injury — short of actual crush 
 of the whole limb. It lay on the bed helplessly 
 everted, the outer border of the foot flat on the 
 mattress. About three inches above the knee, the 
 thigh was distorted, the soft parts in front destroyed 
 to an extent nearly as large as the palm of the 
 hand ; the bone was crushed into many pieces, 
 which grated loosely on the least touch. The 
 structures in the popliteal space and the knee- 
 joint were sound ; I could feel pulsation distinctly, 
 though feebly, in the anterior and posterior tibial 
 arteries, and I resolved upon an attempt to save 
 the limb. 
 
 After gently straightening the limb (which 
 was nearly three inches shorter than its fellow), I 
 confided the foot to an assistant to make gentle 
 extension, and applied myself to the seat of injury. 
 Manipulating it, and the parts above and below, with 
 both my hands spread out, so as to grasp smoothly 
 and firmly, I moulded the parts into shape ; no piece 
 of bone was taken out; where the skin was least 
 damaged and could be brought together, I secured 
 the edges with points of silver suture, and strips of 
 lint soaked in styptic colloid. "Where the skin was 
 much bruised I left it, and introduced a drainac^e 
 
78 LECTURE IV. 
 
 tube, as thick as a goose-quill, into the seat of 
 fracture through the opening (as large as a half-a- 
 crown), which was left in front, after the parts 
 were approximated as much as possible without 
 dragging upon them. I now packed the seat of 
 injury with a layer of carded oakum carefully 
 teazed out, over it cotton wool which enveloped 
 the whole limb, and mill-board splints from the 
 toes upwards, embracing the pelvis. In applying 
 the outward compressing bandage, care was taken 
 to allow the drainage tube to project outwards. 
 Long heavy sand-bags were then applied on both 
 sides of the limb, and a narrow one, weighing 
 about 31bs., was placed in front, from the groin 
 to just above the seat of injury. 
 
 The man rallied satisfactorily, was kept gently 
 under the influence of opium, and the apparatus 
 not touched for ten days; after that every week. 
 When it was changed, pledgets of lint or cotton 
 wool were employed to remove any discharge from 
 around the wound ; but neither water nor lotion 
 was ever allowed to approach it. Dry dressing 
 was the same each time, carded oakum and cotton 
 wool, nice adjustment of compresses and steady 
 pressure. Progress was uninterrupted, and the man 
 
THE TREATMENT OE WOUNDS. 79 
 
 could walk on crutclies at the end of two months. 
 There is barely an inch shortening, only one small 
 bit of bone has worked through the cicatrix which 
 is perfectly sound and painless. The man can bend 
 his knee and walk long distances. Such a case 
 needs little comment after the other cases which 
 have occupied our attention this morning; it cannot 
 fail to impress itself upon you, as a striking 
 illustration of how satisfactorily surgery may be 
 practised with simple methods and painstaking care. 
 The first essentials for success are, a clear 
 appreciation of proved scientific principles of treat- 
 ment, accuracy, gentleness, and thoroughness in 
 carrying them out. 
 
80 LECTTJEE V. 
 
 LECTUKE V. 
 
 conte:n'ts. 
 
 On splints, p. 81 ; superiority of millboard in their construction, 
 p. 82 ; plaster of Paris splints, p. 82 ; instructions 
 for making millboard apparatus, p. 82 ; sand or earth 
 bags, p. 84 ; sand and water pillow, p. 84 ; picked 
 oakum— its uses and manner of application, p, 85 ; 
 cotton wool — history of its employment in surgery, 
 p. 87 ; Seutin and Yelpeau, p. 88 ; Mayor of Lausanne, 
 p. 88 ; Burggraeve of Ghent, p. 90 ; M. Guerin's 
 theory of the antiseptic properties of cotton wool, his 
 clinique and cases, p. 90; two cases of injuries to fingers 
 and incipient phlegmonous erysipelas successfully treated by 
 position and pressure in cotton wool and millboard apparatus, 
 p. 93-97. 
 
 Gentlemen, — 
 
 Before proceeding further witli an examina- 
 tion of the principles which should guide you in 
 the treatment of wounds, it will be convenient 
 to say something about the materials and apparatus 
 employed in the cases already brought before you. 
 
 Of the necessity of rest, as nearly absolute 
 as possible, it is impossible to say too much. It 
 is not enough, for a man with an open knee 
 joint, to be put to bed with an ordinary splint 
 
THE TREATMENT OF WOUNDS. 81 
 
 or two, such as a couple of lateral wooden, or 
 leather, or gutta-percha splints extending from 
 mid-thigh to the middle of the caE If the 
 splints do not fit perfectly, or if they he not 
 strong enough, the least movement of the patient 
 in coughing or using the bed-pan, even a trifling 
 muscular twitch, is enough to produce discomfort; 
 this causes the patient to move a little, and 
 induces the surgeon to endeavour to make the 
 apparatus more comfortable: hence more move- 
 ment, pain, constitutional irritation, and the whole 
 chapter of accidents. The first essential for rest is 
 comfort, as nearly perfect as possible ; to ensure 
 this, in the assumed case of open knee, you must 
 fix the entire limb from the toes to the crest of 
 the ilium ; — of open elbow, from the tips of 
 the fingers to the root of the neck. You must 
 fix every joint in the injured limb, especially the 
 one above the seat of injury; you must 
 neutralize every muscle by gentle controlling 
 pressure. For this object you require (after having 
 attended to the wound) to mould to the limb 
 such a case as shall accurately take its shape, 
 and become reliably solid without unduly pressing 
 at any one point. 
 Q 
 
82 ' LECTURE V. 
 
 The limb having been enveloped in cotton 
 wool, plaster of Paris splints and bandages may 
 be applied outside it. A plaster of Paris case 
 admits of being accurately fitted, and of being 
 made strong enough. It is, however, more 
 difS.cult to open, and does not admit of such easy 
 refitting as the millboard apparatus. 
 
 All circumstances considered, I have found 
 millboard the most handy material for immo- 
 bilizing a limb. Take care that it is in the rough 
 state, not rolled and glazed. Do not cut the 
 splints, but bend and break the rough millboard in 
 req^uired lengths and widths over the edge of a table 
 or bench; the ragged uneven edges facilitate the 
 moistening of the material, and bevel off smoothly 
 when moulded by the hand, as the bandage is 
 being applied. The splints are greatly strengthened 
 by putting two thicknesses of millboard together, 
 with an intervening layer of bandage and starch. 
 Starch may also be applied with advantage on 
 the front and sides of the millboard apparatus, 
 while it is being constructed. It gives unity to 
 the case, particularly useful when it is cut up in 
 the middle line in front; the edges admit of being 
 pared and more cotton wool interposed to allow 
 
EHE TREATMENT OF WOUNDS. 83 
 
 for reduction in size, and to keep up even 
 pressure. It is needless to starch the apparatus 
 at the back ; doing so is often a source of 
 discomfort, causing adhesion to the bed-clothes. 
 Starch thus employed is merely an additional 
 means of consolidation; the great instruments in 
 giving immobility are the millboard splints and 
 intersecting layers of bandage sphally applied. I 
 never use reverses, which, though pretty, are 
 unstable, and do not so readily admit of even 
 pressure as can be exercised, by applying a nice 
 soft roller in figures of eight up and down the 
 limb. 
 
 Let me repeat my warning against the 
 deceptive uselessness of starched bandages as such. 
 They are practically powerless in immobilizing a 
 Hmb. 
 
 In the absence of millboard, ordinary bandages, 
 and cotton wool, use tow for padding, paper 
 for splints, and tear up an old sheet for 
 bandages. Fold the paper of the required width 
 and thickness, stick the layers together with 
 paste made by boiling flour and water, and 
 spread the same material between and over the 
 bandages. 
 
84 LECTURE V. 
 
 Sand or earth bags are of tlie greatest service 
 in immobilizing a limb, by being packed closely 
 on eacb side of it. Small bags may also be 
 placed in front of tbe limb lengthways, or across ; 
 tbeir even pressure is very comforting, and bas a 
 great effect in preventing and neutralizing mus- 
 cular contraction. One great advantage of sand 
 or earth bags is that the materials for making 
 them may be obtained anywhere in town or 
 country, and that they require no skill in prepa- 
 ration — very little in application. 
 
 On my suggestion, Messrs. Salt and Son (^) have 
 manufactured an india-rubber pillow, which is 
 of great service and comfort. The pillow is 
 divided longitudinally into three compartments, of 
 which the middle one is filled with water, and the 
 two lateral ones with fine dried sand. A strip of thin 
 board, with straps under the water compartment, 
 admits of the lateral sand partitions being brought 
 close round the limb, and the whole being sus- 
 pended to an ordinary cradle or in a Salter's 
 swing. By means of this pillow, a patient with 
 a broken thigh or an open knee joint may lie on 
 
 ^ This firm is prepared to supply any of the materials 
 recommended in these Lectures. 
 
THE TEEATSIEXT OF WOUNDS. 
 
 85 
 
 an ordinary feather Led, and have a very suitably 
 firm and easy basis of support for the injured 
 limb. The elasticity of the central water compart- 
 ment is a source of great comfort, and the long 
 lateral sand bags give very efficient support. 
 
 Oakum was used in our cases as a 
 compress, according to the practice for which 
 we are indebted to the surgeons of the American 
 Civil "War. Consisting as the material does of 
 picked ship rope, its use is no innovation in 
 
86 LECTURE V. 
 
 principle ; for tow as padding or pledgets, and tar 
 as a dressing, were popular in tlie treatment of 
 wounds ages ago. Setting aside all questions of 
 priority, there can be no doubt tliat picked oakum 
 is a very good dressing ; its anti -putrescent 
 qualities make it specially valuable when wounds 
 are discharging, and the carded oakum pre- 
 pared by Messrs. Southall, and known as 
 Tenax, has the advantage of being softer and 
 more absorbent than the ordinary oakum of 
 commerce. 
 
 To prevent the oakum adhering unpleasantly 
 to a wound or cicatrix, this may first be covered 
 with a layer of gauze or muslin. A good plan is to 
 make muslin bags, which need be only lightly 
 stitched, to hold the oakum ; this must first be 
 well teazed out, as it makes a softer and more 
 absorbent pad when loose. 
 
 If a wound be discharging through a drainage 
 tube, a convenient plan is to leave this rather 
 long, so as to project between the layers of 
 bandage, or through a hole made for it. An 
 oakum pad outside the bandage, and against the 
 end of the drainage tube, catches the discharge, 
 and may be changed, as frequently as necessary, 
 
THE TEEATMENT OF WOUNDS. 87 
 
 to ensure the patient's cleanly comfort without 
 tlie least disturbance. After removal of the 
 breast, for instance, if union by tlie first intention 
 be not complete, a muslin and oakum pad can 
 be placed in the arm-pit, under the night-dress, 
 and changed at any time without even the most 
 trifling displacement. When ladies object to the 
 smell of tar, the muslin bags may be filled with 
 sawdust or tow scented according to taste. 
 
 These injunctions for gentle manipulation 
 and for the patient's comfort may seem tedious, 
 but they are of the very essence of success. 
 
 Cotton wool was employed in nearly all the 
 cases mentioned in these lectures, and it is so 
 very valuable an agent as to deserve special 
 consideration. I have used it for many years, 
 and grown more and more partial to it with 
 increasing experience. M. Alphonse Guerin, by 
 his communications to the Trench Academy of 
 Sciences, and his hospital practice, has greatly 
 contributed to generalize the use of cotton wool 
 as a surgical dressing ; but the claim made on his 
 behalf by M. Eaoul Hervey cannot be conceded, — 
 that to Guerin belongs the merit of discovering a 
 new method for the treatment of wounds, in the 
 
88 LECTURE V. 
 
 application of cotton wool. I am not about to 
 engage in a question of priority for its mere 
 historical interest. It is to an examination of 
 accumulated clinical evidence, wliich has unfor- 
 tunately been almost wholly overlooked, that I 
 invite your attention for its practical surgical 
 interest. 
 
 Seutin and Velpeau, who, Larrey alone 
 excepted, have done more than any other surgeons 
 to demonstrate the value of immovable apparatus, 
 made use of cotton wool many years ago ; 
 but the earliest and best work in point, which 
 has come under my notice, is that of Matthias 
 Mayor. He was enthusiastic in praising the 
 merits of cotton wool for surgical purposes, especially 
 in the treatment of large numbers of wounded 
 persons in great hospitals. He thoroughly under- 
 stood and taught the " resolvent" and anti-phlogistic 
 qualities of the agent, in the treatment of violent 
 contusions and of erysipelas. He was fully alive, 
 also, to the importance of the infrequent dressing of 
 wounds, and to the superiority of cotton wool, in 
 the class of cases above described, over cold 
 lotions, fomentations, and poultices. But Mayor 
 had one misfortime : he lived, worked, and taught 
 
THE TREATMENT OF WOUNDS. 89 
 
 at Lausanne. Scarcely anybody seems to have 
 thought it possible, that a great surgeon of truly 
 original genius could grow up among the chestnut 
 trees of a Swiss valley; and Mayor has been 
 practically forgotten. 
 
 Nearer home, and in more recent times, 
 Burggraeve, of Ghent, Q) became a firm believer in, 
 and a forcible demonstrator of, the surgical advan- 
 tages of cotton wool. "It moulds itself exactly," 
 he said, ''to the limb, and absolutely excludes 
 the air" ('' et entretient I'hermetisme le plus 
 parfait"). "Cotton wool," he added, "admits of 
 methodical compression being applied, and thereby 
 prevents inflammation ; moreover, it exercises a 
 very marked sedative action." Burggraeve further 
 taught the advantages of cotton wool applications 
 after operations on the eye ; and even in so 
 severe a case as a gun-shot wound of the thigh, 
 not requiring immediate amputation, he advised 
 immobilizing the limb in a cotton wool and pasteboard 
 apparatus, and disturbing it as little as possible. 
 
 In one very important particular Biu'ggraeve's 
 practice marks a great advance. A distinguished 
 
 ^ NoTiveau Systemes de Pansements Inamovibles. Bruxelles, 
 1853, Genie de la Chirurgie. Gand, 1853. 
 
90 LECTURE V. 
 
 pupil of, and firm believer in, Seiitin, he put to 
 the best uses the resolvent and antiphlogistic 
 action of compression. 
 
 M. Guerin believes in all those virtues of 
 cotton wool, and something more. He advocates 
 its employment in the treatment of all wounds, 
 whether due to surgical intervention, or occurring 
 as complications of fractures, articular lesions, &c. 
 The doctrine of the absorption of miasms by 
 wounds, as a producing cause of purulent infection, 
 is the busis of M. Guerin's method. Its thera- 
 peutic principle consists in the filtration of air by 
 means of wadding. He attaches great importance to 
 the infrequency of dressings and to the elastic com- 
 pression of which the cotton wool treatment admits. 
 
 In further exposition of M. Guerin's treat- 
 ment I shall translate to you the abstract of a 
 communication which he made to the Academy 
 of Sciences, May 18th, 1874:— "The cotton wool 
 dressing (pansement ouaU) differs from exclusion 
 of ak (occlusion). Cotton wool, while preventing 
 putrid fermentation, does not offer any obstacle 
 to the penetration of ah. In effect, the pus of 
 wounds dressed with cotton wool presents the 
 same chemical and physiological transformations 
 
THE TREATMENT OF WOUNDS. 91 
 
 as pus directly exposed to tlie air ; cotton wool 
 only bars tlie passage to the parasites and other 
 germs of fermentation contained in atmospheric 
 air. M. Guerin does not reject the explanation 
 which M. Pastenr has given of this fact in saying 
 that cotton wool prevents fermentation by absorb- 
 ing the liquid parts of pus." (^) 
 
 M. Guerin lays it down as a rule that a 
 wound once dressed with cotton wool is not to 
 be dressed again until the twentieth or twenty- 
 fifth day. He very much objects to such 
 dressings being carried out in the wards, 
 and m-ges that the operating theatre is the 
 proper place for them. His house surgeon, 
 Monsieur Eaoul Hervey gives, amongst many other 
 cases, one of. gun-shot injury of the shoulder, 
 necessitating amputation at the jomt ; the soft 
 parts were so extensively destroyed that no cover 
 could be obtained. Cotton wool dressing, applied 
 with powerful compression, to the stump and the 
 whole of the chest, was not changed until the 
 twenty-first day after the operation; the second 
 dressiog, nineteen days later. The patient never 
 felt the slightest symptoms of pain or uneasiness, 
 
 ^ ArcMves Genetales de Medecine, Juillet, 1874, p. 117. 
 
92 LECTURE V. 
 
 suppuration was scanty, and recovery perfectly 
 satisfactory. 
 
 Here is another of M. Guerin's cases : — A 
 young man, aged 18, was attacked by the Prussians, 
 September 10th, 1871. He received two wounds, 
 one on the head (parietal region), with depression 
 of one edge of the bony fissure ; the other wound 
 being a clean cut through the olecranon, — the elbow 
 joint was largely laid open and the articular 
 surfaces visible. The patient was carried to the 
 Hospital St. Louis, and M. Guerin attempted the 
 preservation of the arm in a cotton wool appa- 
 ratus. The hand, fore-arm, and arm were 
 enveloped in numerous layers of cotton wool with 
 methodical compression equally distributed over 
 the limb ; the fore-arm was semi-prone, the elbow 
 flexed. No complication occurred in the wound 
 of the head. The patient left his bed the twelfth 
 day (September 22nd), and remained forty-two 
 days in his apparatus without experiencing the 
 least pain or inconvenience. The note on the 
 21st of October is—'' Nearly cured." (i) 
 
 ^ For tlie details of Monsieur Guerin's practice, I am 
 indebted to a series of articles on Pansements a I'ouate, "by Eaoul 
 Hervey, in Arcliives Generales de Medecine, 1872, pp. 319, 417, 
 685, et seq. 
 
THE TEEATMENT OF WOUNDS. 93 
 
 M. Terrier states that the pus and serum, 
 which are situated in the deep parts of the 
 apparatus, undergo chemical, but not putrid, 
 decomposition ; they become oxydised, and do 
 not ferment; they then give rise to odorous 
 gases, which pass through the cotton wool. 
 
 Without entering upon a discussion of M. 
 Guerin's theory, his employment of cotton wool, 
 after the experience of Mayor, Burggraeve, and other 
 eminent surgeons in Europe and America, furnishes 
 additional reason for the more extended trial of 
 cotton wool dressings. They have been employed 
 for many years in this clinique with the greatest 
 benefit; but I have been in the habit of adding 
 millboard splints to ensure immobility; while 
 advocating infrequent dressings, I have not pushed 
 the practice so far, as not to look at a wound 
 into a large joint for many weeks. 
 
 Two cases now in !N"o. 10 Ward are fair 
 examples of the benefits to be derived from cotton 
 wool dressing within an immovable apparatus. 
 Frank Downing, aged 47, attended as an out- 
 patient the 24th ult. A fortnight previously he 
 had severely bruised the end of his right middle 
 finger under an iron weight. He went on with 
 
94 LECTURE V. 
 
 his work for about ten days, when the finger 
 became very painful. He still worked on, but 
 the swelling and severe pain of the hand com- 
 pelled him to stop and seek relief. I found the 
 finger nearly twice its natural size, very tense, and 
 fixed in a curved position, like a baked sausage. 
 It was of a dusky red colour, which extended 
 over the swollen back of the hand to just 
 above the wrist ; the radial and ulnar arteries 
 were very tense, and the man could feel 
 every throb in the end of his finger. 
 He was easy, however, the moment the arteries 
 were compressed. The man was put to bed, and, 
 on my instructions, our house surgeon, Mr. 
 K. B. "Wilkins, covered the hand and fore-arm 
 with cotton wool, bandaged each finger separately 
 and the hand with steady uniform pressure ; a 
 pad having been placed over the radial and ulnar 
 arteries at the wrist, the compressing bandage was 
 then extended to the elbow. With the latter joint 
 bent at an acute angle, the fore-arm semi-prone, 
 and the fingers of the right hand touching 
 the left shoulder, the limb was bandaged to the 
 trunk. The temperature, which was 101.3° the 
 evening of admission, fell in forty-eight hours one 
 
THE TREATMENT OF WOUNDS. 95 
 
 degree; on the seventh day it was at the precise 
 standard of health. Finding on the third day that 
 the bandages were loose, through rapid subsidence 
 of the swelling, I removed them. The fore-arm 
 and hand were pale, shrivelled, and cool; the 
 finger was little more than its natural size, and 
 its joints could be flexed and extended ; the pad 
 at the end of the finger was dark grey over a 
 small circumscribed patch. The limb was again 
 rolled in cotton wool and immobilized in paste- 
 board splints with compressing bandage. Only 
 milk diet had been allowed hitherto ; meat diet 
 now ordered. The seventh day after admission 
 you see the hand perfectly healthy, excepting 
 a small slough in process of separation in the 
 original seat of injury at the tip of the finger ; 
 cotton wool and pasteboard apparatus re-applied. 
 According to very common practice, when I first 
 saw this man an incision would have been made 
 into the tense finger, and poultices applied. 
 How often do the tendons of such fingers slough, 
 the mischief extending to the hand and fore-arm, 
 entailing matting of tendons and life-long disable- 
 ment ! We have relied, with the usual happy 
 result, on rest, pressure, and physiological position 
 
96 LECTUEE V. 
 
 to control the circulation, and promote absorption 
 of extravasated fluids. 
 
 Here is another case, in the same ward: John 
 Eeading, aged 26, was admitted with an oblique 
 wound, of some days' standing, over the first joint 
 of the left index finger. This was swollen, hot, and 
 tense, and so was the hand ; the temperature 
 was 100.4° Under the same treatment as in the 
 above case, confinement to bed, immobilization 
 and compression under cotton wool, pasteboard 
 and bandage, the temperature has fallen in two days 
 to 99°, the swelling of the hand has disappeared, 
 the finger is little more than its natural size, and 
 can be flexed and extended. The same apparatus 
 re-applied, and milk exchanged for meat diet. 
 I shall not trouble you with much comment. If a 
 junior amongst you be disposed to look upon those 
 two cases as trivial, because only affecting fingers, 
 anyone of his seniors in the class can tell him, 
 that such cases often involve the most serious 
 issues to limb and life. A finger is valuable to 
 every man ; injury to it condemns many a working 
 man to the poorhouse, after long but ineffectual 
 struggle with a matted, withered, and useless hand. 
 Such cases afford the most abundant scope for 
 
THE TEEATMENT OF WOUXDS. 97 
 
 gentle, accurate, and successful dressing ; tliey 
 supply some of the most striking results of the 
 happy application to every-day practice, of those 
 principles of simple scientific surgery which I am 
 endeavouring to impress upon you. Q) 
 
 ^ The authoiities mentioned in this Lecture, and not already 
 referred to in foot notes, are — 
 
 Seutin. 
 Methode Amovo-Inamovible. 2nd Ed., Braxelles, 1851. 
 
 Velpeatt. 
 Legons oracles de Cliniqne Chirurgicale. Braxelles, 1841, 
 p. 627. 
 
 Mathias Mayor. 
 La Chirnrgie Simplifiee. Bruxelles, 1842, Article IL, p. 98, 
 "Bu Coton." Article III., p. 104, "De la Mousseline et du 
 Coton." 
 
 H 
 
98 LECTUEE YI. 
 
 LECTUEE YI. 
 
 COE^TENTS. 
 
 Surgical drainage, its history and principles, p. 99 ; Case of 
 necrosis of tibia, drainage, dry dressing, recovery, p. 100 ; 
 Case of collection of pus in the knee, proposed 
 amputation of the thigh, p. 101 ; Drainage, compression 
 recovery, p. 101 ; drainage in pleural effusions, p. 102 ; 
 Case of empyema successfully treated by drainage, p. 102 ; 
 Case of abscess in the breast, with numerous openings, 
 successfully treated by drainage and compression, p. 103 ; 
 chronic mammary abscess (supposed scirrhus) suc- 
 cessfully treated by drainage and compression, p. 104 ; 
 discussion of the history and merits of the antiseptic 
 system, p. 106 ; Personal explanation, p. 106 ; my 
 visit to Professor Maisonneuve in 1867, p. 107 ; Pro- 
 fessor Jjister's first communications on the carbolic treat- 
 ment in 1867, p. 107 ; his unvarying advocacy of the germ 
 theory, p. 108 ; my visit to his clinique in 1873, p. 109 ; 
 the theory and the practice of antiseptics must be separately 
 considered, j). Ill ; Lemaire and Declat's early researches 
 on carbolic (phenic) acid, and advocacy of the germ theory, 
 p. 112 ; its non-acceptance by French surgeons, p. 113 ; 
 enthusiasm of the Germans, Listerism, p. 113 ; clinical 
 report of my visit to Professor Lister's wards in Edinburgh 
 in 1873, p. 113, et seq. 
 
 Gentlemen, 
 Drainage has been employed in very many 
 of tlie cases treated in our wards^ and brought 
 
THE TREATMENT OF WOUXDS. 99 
 
 before you^ from time to time, in these clinical 
 demonstrations. All surgeons are happily agreed, 
 that drainage of wounds and abscesses is a most 
 valuable therapeutic resource. It is curious that 
 so simple and important a method should be of 
 such modern origin, for it is barely three-and- 
 twenty years since M. Chassaignac introduced it 
 to the profession. True it is, that in very remote 
 times surgeons have known the necessity of making 
 openings for the evacuation of matter in dependent 
 positions ; to carry it off with greater facility 
 they have employed setons, tents, and a variety 
 of other appliances ; but these differ widely in 
 principle from, and in practice are far more harmful 
 and less efficient than, M. Chassaignac's drainage 
 tube, of which I hold a specimen in my hand. 
 It is an india-rubber tube, made of different 
 sizes, from that of a probe to the diameter of 
 the little finger, with holes in its walls in 
 different directions, at intervals of half an inch, 
 more or less. 
 
 The essential fact in Chassaignac's system 
 of drainage is, that india-rubber tubes may be 
 made to traverse the muscular or bony structures 
 
100 LECTUKE VI. 
 
 of tlie limbs, tlie large joints, or the great visceral 
 cavities, without producing any irritation. 
 
 I was requested, some time since, to amputate 
 the left leg of a youth, who had had the benefit 
 of experienced professional advice. A number of 
 openings led down to dead bone in all directions, 
 and the patient was much exhausted by long- 
 continued suppuration; but, as he was of healthy 
 parentage, had sound lungs, and the knee and 
 ankle were not yet involved, I could not 
 conscientiously amputate ; consultation resulted 
 in making an incision along the front of the 
 tibia, to within half an inch of the knee 
 and ankle respectively. Uniting the cloacae with 
 a few strokes of the mallet and chisel, an ample 
 channel was made for clearing out the large 
 amount of imprisoned dead bone. A long drainage 
 tube was placed along the bottom of the wound, 
 with its ends depending. With dry and infrequent 
 dressings, and suspension of the limb, convalescence 
 was rapid, and recovery complete. 
 
 In another case Mr. called on me one 
 
 evening to see his wife, who was to undergo am- 
 putation of the thigh the next day, by the urgent 
 advice of the family attendant and of a hospital 
 
THE TREATMENT OE WOUNDS. 101 
 
 surgeon. When I met those gentlemen in consul- 
 tation, I found the right knee joint full of pus, in 
 a delicate woman who had been ill some weeks. 
 She had a clean tongue and cool skin, and was 
 taking a fair amount of nourishment. The first 
 consultant was for amputation at once. I coun- 
 selled at least twenty-four hours' delay, to watch 
 the effect of an attempt to save the limb. This 
 advice having been accepted, I passed a drainage 
 tube, the size of a goose quill, from side to side, 
 through the knee joint, packed it with carded oakum, 
 immobilized the limb with millboard splints and 
 gently compressing bandage, and suspended it in a 
 swing cradle. Improvement was immediate ; there 
 was no need for re-opening the question of amputation 
 at the end of the first twenty-four hours ; the joint 
 gradually emptied itself of a large collection of pus, 
 and the skin covering it changed, from a red and 
 shining appearance to a pale and withered look. 
 Pressure was gradually increased, the drainage tube 
 was withdrawn at the end of three weeks, and not 
 a single untoward symptom occurred. The patient can 
 now walk, — with a limp it is true, but without the 
 aid of a stick. 
 
 Of the advantages of drainage, in the treatment 
 
102 LECTURE VI. 
 
 of efpLisions into the pleural cavities^ there is no lack 
 of proof. The case to which I am about to refer is 
 a striking instance in point. I was urgently sum- 
 moned one morning to Gr. Madge, aged 25, re- 
 cently admitted under my care to Ward 3. I 
 found him propped up in bed, with sunken cheeks, 
 open mouth, and widely staring eyes, a leaden 
 hue, big drops of cold sweat on the forehead, 
 breathing forty times in the minute, and with barely 
 perceptible pulse. He had a history of phthisis 
 of two years' standing. Some weeks pre- 
 viously he had been carried into the operating 
 theatre of a hospital, with a view to tapping of 
 the chest ; but the operation was not performed, 
 as I subsequently learned, on account of diffused 
 pulsation over the left chest. I found this side 
 much enlarged, the intercostal spaces bulging, per- 
 cussion-dulness absolute. The heart's apex beat 
 under the right nipple. Pulsation could be felt over 
 a great part of the left chest wall ; presuming that 
 it was due to a recoil wave — seeing that the 
 man was actually moribund — I passed a long 
 silver probe, carrying at its end a medium-sized 
 drainage tube, through the chest, from front to 
 back, in the sixth intercostal space, and a little 
 
THE TEEATMENT OF WOUNDS. 103 
 
 outside the line of tlie left nipple. Creamy pus 
 came out freely from both ends of the tube. The 
 left chest was lightly packed with oaknm, and a 
 circular flannel bandage applied loosely. The pulse 
 rallied, the face became animated, the man was 
 able to lie on his back in a few hours, took 
 food well, and lived 18 months — ^more than half 
 the time with the tube in his chest. 
 
 Such cases as this, of abscess of the breast 
 also illustrate, in a very marked manner, the 
 advantages of Chassaignac's drainage tubes. When 
 this woman was before you last week, her pale 
 drawn face betokened suffering and exhaustion; 
 the big, pendulous, and exq^uisitely tender left 
 breast discharged matter through half a dozen 
 openings, the result of fost partum mammary 
 abscesses and linseed poultices. I passed a long 
 probe from the lower aperture on the outer side, 
 under the mammary gland obliquely upwards and 
 inwards, and out at the uppermost aperture near the 
 sternum. A ligature, secured to the eye of the 
 probe, enabled me to carry a good-sized drainage 
 tube along its track, and I left it there, with both 
 ends depending, covering the breast with a thick 
 pad of carded oakum, and suspending it with a 
 
104 TECTURE VI. 
 
 smootMy-compressing bandage. The poor woman 
 was easy at once, her appetite improved, and she 
 slept well. When the dressing was removed after 
 a lapse of four days, the breast was soft and much 
 diminished in size, the openings other than those 
 traversed by the drainage tube were healing 
 rapidly, and the woman is now cheerful and in 
 advanced convalescence. The drainage tube was a 
 chief cause of the improvement in this case, 
 draining the dependent and soddened breast, on 
 much the same principle as a farmer drains a piece 
 of boggy land with an earthenware pipe. 
 
 Mrs. T., aged 42, from Evesham, lately con- 
 sulted me with a view to removal, from the right 
 breast, of a tumour which was supposed to be 
 scirrhous. From the history and physical signs I 
 suspected deep-seated chronic abscess. An incision 
 with a straight narrow bistoury revealed the pre- 
 sence of pus. I introduced a drainage tube the 
 size of a crow quill into the aperture, and passed 
 it along to the bottom, by a gentle spiral or cork- 
 screw movement. A layer of gauze over the 
 breast, a soft pad of carded oakum, and a bandage 
 carefully applied, so as to compress the breast and 
 suspend it, completed the dressing. The patient 
 
THE TREATMENT OF WOUNDS. 105 
 
 returned into the country at once. When I saw her 
 at the end of five days the discharge had permeated 
 the bandages, hut these and the oakum were 
 quite dry. Tlie tube was lying against tlie cica- 
 trized opening, the breast having shrunk away 
 from it. Tliere was no pain and no discomfort, 
 and I have since heard that the patient has per- 
 fectly recovered. 
 
 In these breast cases the india rubber tube 
 was not the single beneficent agent ; the raising 
 and compressing of the breast were most powerful 
 accessories. In the case of suppurating syno- 
 vitis, immobilization, suspension, and compression 
 had greatly contributed to the result in which 
 the drainage tube was an important factor. 
 The great value of surgical drainage is, that 
 it admits of compression, rest, and infrequent 
 dressing, carrying off matter as rapidly as it is 
 formed, and thus preventing its decomposition and 
 attendant irritation. The latter is especially the 
 object which makes drainage of such exceptional 
 value in the estimation of those who advocate 
 antiseptic dressings. 
 
106 LECTUEE VT. 
 
 It has been my object tbrougbout tbese 
 lectures, to demonstrate to yon by typical cases 
 the fundamental principles and simple methods, 
 by which, wounds may be successfully treated. 
 Here and there, touching on some disputed point, 
 reference to dissentient opinions has been inevit- 
 able, but controversial matters have, so far as 
 practicable, been avoided. This is no longer pos- 
 sible in discussing the history and merits of the 
 antiseptic treatment, which is advocated as an 
 innovation on surgical practice based on special 
 scientific grounds. The theory and the practice of 
 the antiseptic system must be separately consi- 
 dered. The subject is so important, it has 
 engaged the attention of so many able men here 
 and abroad, and has been the theme of such 
 keen controversy, that it is no use looking at it 
 in a casual manner. It is a searching and com- 
 prehensive examination, that is demanded by the 
 circumstances and merits of the case. 
 
 I must first trouble you with a few words of 
 explanation, which I hope may reach a larger 
 class of students than that I am immediately 
 addressing. "When visiting Paris in 1867, I found 
 Professor Maisonneuve at the head of the clinical 
 
THE TREATMENT OF WOUNDS. 107 
 
 wards in tlie old Hotel Dieu. He was enthusi- 
 astic on the beneficial effects of what he 
 called his anti-putrescent lotion, composed of 
 one part of carbolic acid to one hundred of 
 water. It was said to cleanse the wounds, 
 promote healing, and prevent pyeemia. The 
 matter was not treated as a novelty, but as 
 the outcome of theoretical studies and practical 
 investigations of six years' standing. It was in 
 March of that year, that my friend Professor 
 Lister published the first of his series of papers 
 on a new method of treating compound fracture, 
 abscess, &c., with observations on the condition 
 of suppuration. (}) The treatment advocated was 
 the free use of carbolic acid, and M. Pasteur's germ 
 theory was put forward as the key to the explana- 
 tion of the antiseptic effects. I visited Professor 
 Lister's clinique in Glasgow in 18G8, and on two 
 subsequent occasions, in Glasgow and Edinburgh, 
 enjoyed the fullest opportunity of examining his 
 cases. I was uniformly struck with the ad- 
 mirable precision of the dressings, which were 
 daily superintended, and in great part carried out 
 by the Professor himself. Pure carbolic acid did 
 
 1 Lancet, 1867, vol. I., p. 326, et seq. 
 
108 LECTURE VI. 
 
 not long hold its ground; it was diluted and 
 variously prepared as putty, oil, and lotion ; but 
 Pasteur's germ theory has never varied, as the 
 basis and explanation of Professor Lister's 
 practice. In evidence of the importance which 
 he still attaches to the maleficent potency of 
 atmospheric dust, I shall read you an extract 
 from the BritisJi Medical Journal, (}) in which 
 an account is given of an operation for psoas 
 abscess, at King's College Hospital. All the 
 instruments to be used had been placed in 
 carbolic acid lotion an hour before the time of 
 operation; the dressing forceps had a little grease 
 in the teeth, so that when drawn over a 
 towel they soiled it; but, as they had been well 
 soaked, Mr. Lister considered them perfectly 
 antiseptic, and used them without fear. Clean 
 and dry towels were placed around the patient, 
 the pubes being carefully covered up, and the 
 clothes drawn out of the way. A continuous cloud 
 of carbolic spray was produced by a hand steam- 
 spray producer, and directed over the seat of opera- 
 tion, carbolic lotion (1-20) was placed in the bottle 
 of the ax3paratus, and by dilution with the steam this 
 1 October 27, 1877, p. 572. 
 
THE TKEATMENT OF WOUNDS. 109 
 
 was reduced to about 1-30, before it fell upon 
 tlie skin. The bistoury to be used had of course 
 been soaked in carbolic lotion, but, when taken 
 out, the water collected on its polished surface in 
 dew-like drops, and, as tlie operator pointed out, 
 " the blade was no longer antiseptic, as dust might 
 fall upon it, together with septic particles ; to keep 
 it antisejjtic, the knife must be freely exposed on 
 both sides to the carbolic spray, and kept there 
 till the conclusion of the operation." 
 
 From first to last, I freely confess that 
 the germ theory, in its application to practical 
 surgery, has not carried conviction to my mind. 
 Anxious to solve it, I made a proposal in 
 December, 1873, to Professor Lister, who accepted 
 it, to visit his wards, and publish my observations 
 for the benefit of the profession, with such remarks 
 as I deemed just, and calculated to be interesting 
 and instructive. Upon the facts, no question could 
 arise ; for I submitted the notes to my friend, and 
 accepted the very slight alterations which he thought 
 it necessary to make in them. I was not so fortunate 
 with the commentary, for which I was solely 
 responsible. In it occurs this passage : " Students 
 of science know that a theory may be tem- 
 
110 LECTURE Yi. 
 
 porarily useful in the pursuit of truth, though 
 proved fallacious on the attainment of fuller 
 knowledge ; but, unless demonstrably true, a theory 
 becomes embarrassing, to say the least, when, 
 having once been adopted, it is made to fit all 
 difficulties, and is itseK maintained immutable in 
 the presence of a succession of very varying facts. 
 Pasteur's theory may be true or not, but since to my 
 mind it only affords an incomplete explanation of 
 the phenomena witnessed in the antiseptic treatment 
 of wounds, I propose considering the facts themselves 
 entirely apart from their theoretical explanation." 
 
 To my very great regret, Professor Lister 
 regarded this passage as containing a grave charge 
 against his professional character. ISTothing was 
 further from my intention. It has been my good 
 fortune to be personally acquainted with a very 
 considerable number of the distinguished surgeons 
 of this generation, and I have never known one in- 
 spired by purer motives, or more devoted to his 
 work, than Professor Lister. 
 
 But the progress of truth would be more rapid 
 and less €hequered, if self-sacrifice and lofty aims 
 could dispense with logical accuracy and severity. 
 History is full of examples of the judgment 
 
THE TKEATMENT OF WOUNDS. Ill 
 
 of the most honourable and Mglily-endowed 
 men being biased by preconceived notions. The 
 vast superiority of the inductive over the old 
 scholastic philosophy chiefly consists in this, — that 
 in the former fact, and in the latter theory, is 
 supreme. If an observer collects his facts, and 
 reasons from them, step by step from particulars 
 to generals, he has comparatively little difficulty in 
 retaining the position of a dispassionate interpreter. 
 But once he sets out upon an enquiry under the 
 dominion or fascination of a governing hypothesis, it 
 is very difficult for him to prevent himself seeing 
 what he believes, rather than believing what he 
 sees. It is not enough for the interests of truth, 
 that what an observer sees should be the truth ; it 
 must be the whole truth, and nothing hut the truth. 
 Partial truths are often great errors ; and* whole 
 truths, combined with error of fact or wrongly 
 interpreted, are apt to be most deceptive when 
 made the basis of generalization. 
 
 The whole of this question of the treatment 
 of wounds antiseptically, has been seriously embar- 
 rassed by the pre-acceptance of Pasteur's germ 
 theory; and I must adhere to the soundness of my 
 suggestion, already quoted, to consider the facts 
 
112 LECTUEE VI. 
 
 themselves, entirely apart from the theoretical ex- 
 planation of the germicide action of the antiseptics. 
 It is the germ theory, and its practical applica- 
 tion to surgery, which is the innovation and the 
 professed basis of the new system, and which specially 
 calls for examination. About the value of agents 
 endowed with the power of preventing or checking 
 decomposition, a large amount of evidence has 
 accumulated for generations. Earth and tar, 
 spirituous solutions of gums and barks, the tere- 
 binthinates, a great variety of acids and salts, 
 medicated tow, oakum and cotton wool have 
 been employed, under the various names of 
 detersives, antiputrescents, disinfectants, and anti- 
 septics. None of those agents, however, has 
 acquired such wide repute as carbolic acid, which, 
 without for a moment calling in question Professor 
 Lister's belief in the novelty of his teaching, was 
 first introduced to the profession as a parasiticide 
 (phenic acid) by Lemaire and Declat. A claim 
 of priority has been contested between those two 
 gentlemen, but, without engaging in it, I shall 
 translate and condense from Declat's work." (}) 
 
 ^ Nouvelles Applications de 1' Acide Phenique en Medecine 
 et en Cliirurgie. Par le Docteur G. Declat. Paris, Adrien 
 Delaliaye. Octobre, 1865. P. 21, et seq. 
 
THE TREATMENT OF WOUNDS. 113 
 
 "On the 30tli of November, 1861, M. D^clat 
 was summoned by Count Paul Demicloff to a 
 gentleman who was thrown from his horse against 
 a tree while hunting. Paralysis ensued, and, in 
 spite of the utmost care, the soft parts over a 
 number of the bony eminences by- and -by 
 became gangrenous. The smell was so offensive 
 that the bedroom became uninhabitable, though 
 spacious and well ventilated. In this state the 
 gangrenous parts were tanned, by being brushed 
 over with a solution of one part of carbolic acid 
 to ten of common oil. The smell disappeared, the 
 soft parts ceased to mortify, and the patient rapidly 
 recovered; a carbolic lotion was injected into some 
 purulent tracks along the muscular sheaths. 
 
 "From this date (1861), M. Maisonneuve 
 having witnessed the surprising result in this 
 patient, has not ceased to employ carbolic acid at 
 the Hotel Dieu as a common dressing. Accordingly 
 his wards are made healthy, and the results are 
 most satisfactory and remarkable. Alcohol and 
 camphor, like carbolic acid, act as parasiticides, 
 and in some way as poison antidotes. It is by 
 an analogous action that they prevent purulent 
 infection, hospital gangrene, &c. 
 I 
 
114 LECTUEE VI. 
 
 " The fine researclies of M. Pasteur clearly 
 explain these unexpected phenomena. Everywhere 
 where there is decomposition of an organic liquid 
 or substance, such decomposition is caused by the 
 physiological action of living beings, the germs 
 of which pullulate in the air. Everywhere, where 
 a wound is made, air penetrates, and with the 
 air, germs, which have the power of developing 
 themselves even in the interior of the blood- 
 vessels where the circulation carries them. Hence 
 result inflammations of the lymphatics and of the 
 veins, erysipelas, gangrene, &c. The more cutting 
 is the instrument with which the operations are per- 
 formed, the more freely are the vessels divided, 
 the better do the germs penetrate, the more easily 
 do microphytes and microzoa cause complications, 
 especially in loose and vascular tissues .... 
 It is to-day well proven that carbolic acid and 
 its compounds prevent the development of, and even 
 partially destroy, the germs in the air. One can 
 thus easily understand the favourable action of 
 that acid in wounds of all kinds, in burns, and even 
 in midwifery practice." 
 
 This public teaching of Declat, in 1865, founded 
 on experiments conducted in 1861, is unmis- 
 
THE TREATMENT OF WOUNDS. 115 
 
 takably Pasteur's germ theory applied to sior- 
 gical practice, with carbolic acid as tlie parasiticide. 
 But, curiously enough, on Pasteur's own ground, 
 and with his countrymen generally, the theory 
 found very little favour. It probably would have 
 been forgotten, but for its enthusiastic adoption 
 and untiring advocacy by a distinguished British 
 surgeon, and but for the admiring approval of 
 Yolkmann, von Nussbaum, Konig, and others of our 
 German confrkes. It is they who have added 
 the term Listerism t® surgical language. At present 
 it is with Professor Lister's practice that the germ 
 theory is identified, and it is his practice, based 
 on that theory, that we have to consider. 
 
 I think I cannot give you a more faithful picture 
 of what that practice is, than by reading you 
 the bedside notes which I made in his wards, 
 in the Eoyal Infirmary of Edinburgh, in December, 
 1873. Those notes embody the cHnical appearances 
 which came before me, and Mr. Lister's remarks 
 in explanation of his method of practice. Since 
 he was good enough to revise those notes, and 
 I accepted at once the slight alterations which 
 he made in them, the^ accuracy is beyond 
 question. 
 
116 LECTURE VI. 
 
 Matthew E , thirty-five years ago, 
 
 received a gun-shot wound on the inner and back 
 part of the right leg, at and just below the ankle. 
 The result was a sore, which never healed. He 
 was admitted on the 19th November last, with 
 a very ill-conditioned ulcer. Though healing rapidly, 
 it is still several inches in extent. On admission, 
 the sore was sweetened with a chloride of zinc 
 lotion (forty grains to the ounce). The epidermis 
 around was cleansed with a carbolic acid lotion 
 (one part to twenty of water). The latter lotion 
 acts best on the epidermis, the former on the 
 raw surface. The wound, once sweetened, was 
 enveloped in antiseptic gauze, and next day 
 dressed with boracic lint, which is prepared by 
 dipping lint in a hot saturated solution of 
 boracic acid, then taking it out and letting it 
 dry. The lint is then loaded with crystals of 
 the acid, and these crystals are unctuous, not 
 harsh. If you applied the boracic lint next to 
 the sore, you would stimulate it too much with 
 the acid — you would have too much suppuration, 
 too little cicatrization, and, on removing the dry 
 lint, you would peel off the epidermis, and the 
 discharge might irritate by tension by accumulating 
 
THE TEEATMENT OF WOUNDS. 117 
 
 under the lint ; so we interpose between the lint and 
 tlie sore a ''protective/' consisting of oil-silk var- 
 nished with copal varnish, and coated with dextrine 
 to permit it to take a watery solution of the anti- 
 septic. The object of the copal varnish is to 
 prevent easy permeation by carbolic acid when 
 that acid is employed. Carbolic acid is used in 
 applying the dextrine, but it soon goes, and the 
 protective is not antiseptic itself; its object is to 
 keep out the antiseptic; but it must be put on 
 in an aseptic state, and must, therefore, be dipped 
 in antiseptic lotion before application. This lotion 
 is a saturated solution of boracic acid, with the 
 addition of a few drops of litnius to distinguish 
 it from colourless carbolic lotion. The sore having 
 been washed with the boric lotion lightly, the 
 protective, dipped in lotion, is put on the sore 
 and the tender epidermis around, with boracic 
 lint outside. If we were to put it on dry, we 
 should put on a septic lint, because boracic acid 
 is not volatile, and septic particles — organisms, 
 I may say — are not deprived of septic energy by 
 it in the dry state; so we dip the boracic lint 
 in boracic lotion^ and then we are sure it is free 
 from anything septic. Boracic acid is little soluble 
 
118 LECTURE VI. 
 
 in cold water, and at tlie temperature of the 
 body the discharge may go through boracic lint 
 without carrying off all the acid. Boracic lint 
 consists of equal weights of lint and boracic acid, 
 and under such lint there is no sore but would 
 keep sweet twenty-four hours. 
 
 Matthew E 's wound was at first dressed 
 
 every day, then only once in two days, with 
 two layers of the boracic lint, and a gauze 
 bandage. Lister does not care much about pres- 
 sure in such cases. The wound in this case and 
 the surrounding parts, looked beautifully clean 
 and rosy, were perfectly free from odour, and 
 cicatrization was advancing rapidly. The wound, 
 which on admission was intensely painful, had 
 now become quite free from pain. 
 
THE TREATMENT OF WOUNDS. 119 
 
 LECTUEE VII. 
 
 CONTENTS. 
 
 Professor Lister's cases continued ; Case of extensive burn of the 
 scalp and skull successfully treated with borax, in lint 
 lotion, and ointment, p. 119 ; Case of caries of the foot, 
 p. 121 ; ;pickUng the wound in fistula in ano and after 
 lithotomy, p. 122 ; Case of ligature of the femoral artery 
 for popliteal aneurism ; suppuration attributed to omission 
 of drainage tube, p. 122 ; Case of loose cartilages (200) 
 in the elbow joint removed under carbolic spray, no 
 constitutional disturbance, healing without suppuration, 
 p. 124 ; Commentary on the practice and critical examination 
 of the germ theory in its surgical applications, p. 129 — 138. 
 
 Gentlemen, 
 
 I shall conclude the reading of my notes 
 taken in Professor Lister's Clinique; before com- 
 menting on the practice. 
 
 Donald M'C , eight months ago, while 
 
 in an epileptic fit, fell on the fire, destroying a 
 large part of the scalp on the right side^ largely 
 exposing and burning the bone, destroying the 
 external ear and the zygoma and much skin on 
 the back of the neck and shoulders. The wound 
 
120 LECTUEE vn. 
 
 is dressed every otlier day in tlie same way as 
 in the former case. Tlie protective is applied on 
 the granulating and cicatrizing parts, not on the 
 bone, which is covered directly with the boracic 
 lint. Though nearly the whole bony wall of the 
 right side of the head is exposed, there is no 
 putrefactive smell whatever. The wound is dressed 
 as in the former case, with the exception that 
 on the granulations adjacent to the bone is ap- 
 plied boracic ointment, consisting of one part of 
 boracic acid to ten parts of axunge and one part 
 of glycerine. At first we saw the entire zygoma. 
 sticking out as dead bone ; we then saw gTanu- 
 lations growing over tlie bone. The bone, just 
 before being quite covered from each end, be- 
 came pink, showing that the scale of dead bone 
 had become thinned by absorption from within ; 
 and now it is all covered without exfoliation. 
 With the dead bone, as with the catgut in the 
 antiseptic ligature, the dead tissue is absorbed 
 by the living tissue near it ; for if the dead 
 tissue do not become acrid by putrefaction, it is 
 as good for living tissues to feed upon as 
 clotted blood. I said, " What about the septic 
 particles, as the vast wound is lying exposed 
 
THE TREATMENT OF WOUNDS. 121 
 
 during this instructive discourse ? " " Oh/' replied 
 the Professor, "they are lying in abundance upon 
 it ; we destroy them by washing with the boracic 
 lotion." The vast wound was beautifully clean 
 and quite odourless, and the granulations could 
 be seen encroaching upon, and adhering to, the 
 edges of the bone, and in several places as little 
 rosy buds projecting above or shining through 
 and just under the dry bony surface. The man 
 was in excellent health, and quite free from pain. 
 
 In applying antiseptic gauze dressing, the 
 deepest layer of gauze as well as the protective, 
 must be dipped in carbolic lotion before apply- 
 ing it, because septic particles adhere to it, and 
 carbolic acid is given off so slowly by the 
 gauze at the ordinary temperature of the body 
 as to kill the septic particles. 
 
 William H . Three days ago the Professor 
 
 removed a quantity of carious bone from the right 
 foot. He removed the ends of three metatarsal 
 bones and a good deal of the adjacent tarsus. After 
 gouging, he applied the sulphuric acid (Pollock's) 
 treatment. The large wound is clean, odourless, 
 and without pus; and there is neither pain nor 
 constitutional disturbance. 
 
122 LECTXJEE VII. 
 
 In fistula in ano, and in lithotomy and other 
 wounds in the vicinity of the anus, as well as those 
 communicating with the mouth, or a putrid sinus, 
 Mr. Lister applies forty grains of chloride of zinc 
 to the ounce of water, to ;picTde the wound, so to 
 speak ; the fact being that chloride of zinc has the 
 remarkable peculiarity of rendering the cut surface 
 incapable of putrefaction for two or three days, 
 though in contact with septic material. 
 
 Ward No. 5. — William E , aged forty-two. 
 
 Temperature 98-2'^ ; pulse 84. On Thursday last, 
 for large popliteal aneurism, the femoral was tied 
 just below the apex of Scarpa's triangle ; the opera- 
 tion was performed antiseptically, and with the 
 prepared catgut. Three carbolized silk sutures were 
 put in. Metallic sutures are not used, because 
 aseptic silk is softer and easier to manage, and 
 antiseptically equally safe. The dressing consisted 
 of — ^firstly, protective ; secondly, a sponge squeezed 
 out of carbolic acid lotion ; and, thirdly, gauze 
 dressing overlapping that. No drainage-tube was 
 used. That was a mistake. The drainage-tube is 
 more important with antiseptic treatment than 
 without it, because the antiseptic treatment irri- 
 
THE TREATMENT OF WOUNDS. 123 
 
 tates tlie cut surface, and in the first few hours 
 there is more serous effusion than without it. 
 With the three stitches and no drainage-tube 
 inflammation occurred, and the man complained of 
 pain on the second day, when we removed the 
 dressing and found redness, tension, and already- 
 some pus. The lips of the wound having become 
 adherent externally, the serous oozing from the 
 parts could not find its way out; it irritated, not 
 chemically but by its tension, affording an example 
 of inflammatory or nervous suppuration, as dis- 
 tinguished, on the one hand, from antiseptic sup- 
 puration, due to the direct action of the antiseptic 
 on the tissues as a chemical irritant ; and, on the 
 other hand, from septic suppuration, due to the 
 acrid products of putrefaction, which resemble an 
 antiseptic salt in acting on the tissues as chemical 
 irritants, but differ in the all-important circum- 
 stance that they are perpetually multiplied by the 
 septic fermentation which spreads wherever it meets 
 with a favourable nidus. In this case it was 
 purely inflammatory or nervous suppuration. When 
 two stitches were removed the man was easy. (He 
 is in no pain. I saw antiseptic dressing removed ; 
 no smell ; a little pus on the surface, but none 
 
124 LECTUEE vn. 
 
 came up on deep pressure). Professor Lister does 
 not use carbolic oil, because dirty. 
 
 William T , aged thirty-one, a farm-servant, 
 
 and a powerful man, was admitted November, 
 19th, 1873. Two years and a half ago he began 
 to suffer the inconvenient symptoms in the right 
 elbow for which he now sought relief. Both 
 flexion and extension were very imperfect. When 
 the elbow was bent to about a right angle a 
 sudden check was experienced, and when extension 
 was attempted great pain was felt in the joint. 
 So long as he kept his hand in his pocket he 
 was perfectly easy; but when he let it hang by 
 his side intolerable uneasiness ensued, so much so 
 that he had been off work for twelve months, 
 and had been subjected to various treatment with- 
 out any arrest of the complaint. 
 
 On examination of the limb nothing was 
 found wrong with the posterior aspect of the 
 elbow, where the bony prominences had their 
 natural appearance unaffected by any thickening 
 of the soft parts. But anteriorly, on careful mani- 
 pulation, there was felt a distinct abnormal pro- 
 jection from the humerus, on a level with the 
 external condyle, and therefore in the region of 
 
THE TREATMENT OF WOUNDS. 125 
 
 the joint. That the growth, of whatever nature, 
 did extend into the articulation was further in- 
 dicated by the great pain on extension, which could 
 not be accounted for by mere stretching of fibres 
 of the brachialis anticus, but was readily to be 
 understood if the anterior ligament of the joint 
 was put on the stretch over it. 
 
 Knowing that pedunculated exostoses occa- 
 casionally grow from the humerus in the immediate 
 vicinity of the elbow, Mr. Lister was inclined to 
 think that the present case was of that nature 
 Two alternatives presented themselves in the way 
 of operative procedure — ^viz., excision of the joint, 
 and removal of the tumour alone. The latter 
 necessarily involving opening the articulation, 
 would have been, in Mr. Lister's opinion, alto- 
 gether unjustifiable without reliable antiseptic 
 measures ; but with these it was believed to be 
 perfectly safe, and likely to leave a stronger and 
 more useful limb than excision. 
 
 Accordingly, on November 26th, the skin 
 having been purified with 1 to 20 carbolic-acid 
 solution, and a spray of 1 to 40 lotion playing over 
 the part, an incision was made about five inches 
 long over the outer condyle and supra-condyloid 
 
126 LECTUEE VII. 
 
 ridge and the external aspect of the joint. Tlie 
 supinator longns and neighbouring extensors being 
 then detached from the intermuscular septum and 
 from the condyle, and the external lateral ligament 
 exposed, the muscles were drawn aside with a 
 spatula from the front of the joint, and on intro- 
 duction of the finger into the wound the promi- 
 nence before detected through the soft parts was 
 distinctly felt. On the joint being opened, how- 
 ever, instead of an exostosis, a large number of loose 
 cartilages were discovered, most of them, about 200 
 in number, being about an eighth of an inch in 
 diameter or less, while six were larger, varying 
 from one fourth of an inch to an inch and a half 
 in gTcatest diameter. They were very irregular in 
 form, the larger appearing at first sight like aggre- 
 gations of the smaller ones, but in reality, as seen 
 on section, consisting in the interior of true bone 
 and medullary tissue, with a cartilaginous external 
 layer and synovial investment, to which small 
 cartilaginous bodies were attached by narrow 
 peduncles. The larger of these bodies were most 
 of them still connected by synovial bands to a 
 prominent ridge of bone, across the front of the 
 humerus ; but the smaller ones were generally free 
 
THE TREATMENT OF WOUNDS. 127 
 
 in the articTilation. In order to extract the 
 larger ones it was necessary to divide the 
 anterior ligament with a probe-pointed knife to 
 the extent of abont an inch and a half, after 
 which the ridge from which they sprang was 
 removed with the gouge. The very numerous small 
 ones were successively brought into view by free 
 alternate flexion and extension of the joint; and 
 as they continued to appear time after time when 
 these movements were executed; and as it seemed 
 right to endeavour to extract them all, the joint 
 must have lain open exposed to the spray and 
 sponging for full half an hour. The operation 
 was performed in the bloodless manner, which has 
 been practised by Mr. Lister for several years, by 
 freely elevating the limb, and then screwing up 
 the common tourniquet as rapidly as possible, so 
 as entirely to arrest circulation. Some small 
 arterial branches having been secured, two drainage- 
 tubes, each about one fourth of an inch in dia- 
 meter, were introduced fairly down to the open 
 joint, their outer extremities being kept on a level 
 with the cutaneous margins of the wound, which 
 were elsewhere accurately stitched, after which the 
 usual dressing of antiseptic gauze was applied, a 
 
128 LECTURE VII. 
 
 piece of protective being interposed between it and 
 tbe wound. 
 
 The patient experienced no symptoms of irri- 
 tation of the joint, nor any constitutional disturb- 
 ance as the result of this procedure. For the first 
 three days the dressing was changed daily, as the 
 discharge of serum was still considerable ; but after 
 this, as the serous oozing diminished in amount, 
 the intervals between the dressings were extended 
 to three days, four days, five days, and six days 
 respectively. Of the two drainage-tubes, one was 
 removed the second day after the operation, and 
 the other eight days later, when, the wound else- 
 where being entirely healed, the stitches were 
 extracted. On the 17th December, when I wit- 
 nessed the dressing after an interval of six days, 
 and just three weeks after the operation, the place 
 where the two drainage-tubes had originally been 
 was contracted to a very small size, and all that 
 remained to heal was a grey patch, about one 
 eighth of an inch in diameter, of the original 
 blood-clot altered by organization ; the neighbouring 
 parts looked pale and healthy, having cicatrized, 
 I was informed, not only without the appearance 
 of a particle of pus, but without the occurrence of 
 
THE TKEATMENT OF WOUNDS. 129 
 
 granulation. Meanwhile the object of the oioeration 
 had been so far attained that the elbow could 
 be extended to almost the full degree without 
 occasioning uneasiness. (^) 
 
 Collectively and separately considered, these 
 results are admirable ; others equally so have re- 
 peatedly been witnessed by visitors to Professor 
 Lister's clinique, or by surgeons who have 
 practised his method. In endeavouring to account 
 for those results, care must be taken to distinguish 
 between essentials and accessories in the chain of 
 therapeutic causation. It would surely be a mistake 
 to magnify the importance of the carbolic spray, to the 
 exclusion of the influence of delicately painstaking 
 and cleanly manipulation, with materials admirably 
 suited for accurate dressing. I have seen a case, 
 a type of a large class, in which a surgeon prided 
 himself on the antiseptic treatment of an excision 
 of the knee. The carbolic spray had certainly 
 been used; but a good deal of constitutional dis- 
 turbance, and not a little suppuration, had followed. 
 When I saw the patient, matters were progressing 
 
 ^ The above notes are a reprint from my papers on tlie Treat- 
 of Wounds by the Antiseptic Method, published in the Lancet, 
 1874, Vol. I., pp. 9, 50 et seq. 
 
 K 
 
130 LECTURE VII. 
 
 favourably ; but for some weeks the limb had been 
 immobilized in plaster of Paris, and suspended in a 
 Salter's swing ; very considerable pressure being at 
 the same time employed, with gauze bandages, in ap- 
 plying the dressings to the knee. A success under 
 such circumstances is perfectly explicable in accord- 
 ance with the proved priaciples of scientific surgery, 
 without importiQg any hypothesis about germs.. But 
 whatever be the explanation of the phenomena in 
 successful cases under the carbolic spray, many 
 surgeons, and even patients, might be utterly careless 
 about. They might say, " We care nothiag for the 
 rationale; we are quite satisfied with the plan, if 
 such are its results." 
 
 It is, however, a very important matter not 
 to encumber surgery with an erroneous doctrine. 
 No less important is it to discard all complica- 
 tions of operative procedure, unless absolutely 
 essential to saving pain or life. Scientifically 
 considered, the truth or error of the germ 
 theory, in its surgical application, is a question 
 of the greatest interest ; practically, no less so. 
 A surgeon exceptionally placed in public and 
 private circumstances, with the resources of a 
 great hospital at his command, and a class of 
 
THE TKEATMENT OF WOUNDS. 131 
 
 enthusiastic students to do his bidding, may be 
 able to carry out with comparative ease a com- 
 plicated course of treatment ; but on the field of 
 battle or at the mouth of a coal mine, in 
 a parish infirmary or on a twenty-mile round 
 in a country practice, hand and steam sprays, 
 gauze and protectives, with the minute injunc- 
 tions for their successful use on the antiseptic 
 theory, become serious complications, if not absolute 
 impossibilities, — hence the scientific and practical 
 reasons for critically examining the matter. 
 
 In discussing the comparative merits of dif- 
 ferent plans of treatment it must be remembered 
 that man is so constituted, his organism so framed, 
 his functions so co-ordinated, as to enable him to 
 live in the arctic region and in the torrid zone. 
 That fact is no proof that either extreme is best or 
 safest for a mean duration of useful life. Wounds have 
 healed times out of number under dirty poultices 
 and clean dry earth, under bland glycerine and 
 stimulating turpentine, under dry dressings and 
 carbolic washes. These facts are no answer to the 
 question, what is the easiest, the quickest, the least 
 painful, and the safest treatment of wounds ? The 
 solution of the problem must be the outcome of 
 
132 LECTUEE VII. 
 
 experience. It cannot be predicated on the basis of 
 any hypothesis, however fascinating by its novelty 
 and ingenious in its application. While conceding 
 that I have witnessed admirable results under 
 Professor Lister's treatment, I have never seen 
 it secure such absolutely painless, rapid, and firm 
 healing as can be obtained by dry and infrequent 
 dressing, by absolute rest, easy position, and smooth 
 pressure. 
 
 It has been urged that, for the perfect success 
 of the antiseptic system, its conditions must be 
 accurately fulfilled, and that it is owing to their 
 violation that failure occurs. Professor Lister shows 
 his class a number of long flasks, containing a 
 variety of organic fluids, and having their mouths 
 well plugged with cotton wool. The vessels have 
 been filled with special precautions and exposed to 
 great heat; their contents have remained clear 
 for months. Admit air to one of these flasks, 
 inoculate it with a ferment, and troubled action, 
 turbidity, and stink soon follow. In the laboratories 
 of scientific men these experiments have been the 
 matter of much contention, not merely as to their 
 theory, but as to the facts themselves. I am quite 
 willing to admit the facts of the flasks and their 
 
THE TEEATMENT OF WOUNDS. 133 
 
 clear and tiirbid contents, jnst as they may be 
 stated by the most ardent advocate of the germ 
 theory. What do the facts amoimt to in their 
 snrgical application? Is not the whole history of 
 physiology and surgery full of examples, to prove 
 the fallacy of arguing from the demeanour of 
 organic parts removed from the body, to what 
 occurs in the living system ? 
 
 Here are ten operations — 1, hare-lip ; 2, peri- 
 neoraphy ; 3, rhinoplasty ; 4, ligature of femoral ; 
 5, amputation of fore-arm ; 6, Syme's ampu- 
 tation at the ankle ; 7, excision of the elbow ; 
 8, excision of the knee ; 9, excision of the lower 
 jaw ; 10, removal of cystic tumours from the scalp. 
 The selection is made as an average representation 
 of so-called major surgery. Most of those operations 
 I have performed many times, some only occasionally. 
 I have never lost any one of the cases. Other 
 surgeons can doubtless say the same. Where 
 were the maleficent germs ? Take the whole field 
 of ophthalmic or orthopaedic surgery practised so 
 successfully by many surgeons. They all use 
 clean knives, certainly ; but I am not acquainted 
 with any who take special precautions against 
 atmospheric dust; yet how rare is suppuration 
 
134 LECTURE VII. 
 
 after iridectomy and cataract extraction ? Whoever 
 heard of it after division of the tendo Achillis? 
 Where are the germs when the globe of the eye and 
 the tendinous sheaths are opened? An answer is 
 supplied by a passage in Dr. William Eoberts's 
 recent address on the Contagium Yivum. He warns 
 us that — 
 
 "Before we can understand the pathology of 
 septicsemia we must have clear ideas on the rela- 
 tion of septic bacteria to our bodies. We see in 
 our laboratories that dead animal tissues, when 
 exposed to ordinary air or ordinary water, in- 
 variably breed septic organisms ; in other words, 
 contact of the septic germs with the dead tissues 
 never fails to produce successful septic inoculation. 
 But it is quite otherwise with the same tissues 
 when alive and forming part of our bodies. You 
 cannot successfully inoculate the healthy tissues 
 with septic bacteria. It has been proved over and 
 over again that these organisms, when separated 
 from the decomposing medium in which they 
 grow, can be injected in quantity into the blood 
 or tissues of a healthy animal, or applied to a 
 sore on its skin, without producing the least 
 effect. The healthy living tissues are an unsuit- 
 
THE TREATMENT OF WOUND S. 135 
 
 able soil for tliem ; they cannot grow in it ; or, 
 to put it in another way, ordinary septic bac- 
 teria are not parasitic on the living tissues." 
 
 I submit, with much deference, that this 
 passage, from one of the ablest advocates of the 
 germ theory, concedes expressly and fully the 
 basis of my contention against its surgical appli- 
 cation, — throws upon its advocates the whole onus 
 prohandi. Take, amongst all the cases recorded 
 in these lectures, that of George Thomas, whose 
 knee joint was fully laid open. Air and germs 
 had flooded it for an hour at least, and it con- 
 tained a blood clot; but union by the first inten- 
 tion was prompt and lasting without one moment's 
 constitutional irritation, the wound having been 
 closed and the limb compressed and accurately 
 immobilized. Dr. Eoberts says it was because 
 the healthy living tissues were not a suitable 
 nidus for the germs, that they did not pullulate. 
 It follows that practical surgeons need not trouble 
 about germs, when they operate upon healthy 
 living tissues, and have at command the simple 
 means which are necessary to secure the conditions 
 for physiological repair. 
 
 Admitting, as we have done, that organic 
 
136 LECTTJRE Vn. 
 
 fluids in vessels closed with cotton wool may 
 be sterilized by great heat, I am not aware 
 of any facts being at hand to prove that air 
 can be deprived of fertile germs by washing with 
 boracic lotion, or by working a carbolic spray. A fine 
 crack in a closed flask is said to be sufficient to 
 fertilize its previously sterilized organic contents. 
 If so, what are the probabilities that one or two 
 spray producers can sterilize the ah, while a thigh 
 is being amputated and dressed? Professor Lister, 
 and those who believe with him, may contend that 
 the proof is supphed by their treatment of woimds. 
 That is precisely the question at issue. 
 
 Against their explanation may be quoted this 
 passage from Professor Dittel's " Experiences on the 
 Management of Wounds after Lister." (i) " The 
 theory of the antiseptic efficacy of the Lister bandage 
 has been thoroughly upset in the clinique at Halle, 
 which, according to Volkmann's publications, enjoyed 
 the best results. Eanke proved by a hundred 
 careful microscopic examinations that in the secre- 
 
 ^ Erfahningen liber die 'Wundbeliandlung nach Lister von. 
 Prof. D. Dittel, 1877, p. 150. This Monograpli is published 
 as an appendix to the Aertzlicher Bericht des k. k. allgemeinen 
 Krankenbauses zu Wien vom Jabre 1876, Wien, 1877. 
 
THE TREATMENT OP WOUNDS. 137 
 
 tions beneath the Lister bandages, under the most 
 favourable circumstances, aH those forms of 
 minutest organisms occur, wliich are said to be 
 kept away, by the Lister materials {Listerstoffe) 
 and their methodical employment. 
 
 " Birch-Hirschfeld's results concur in this 
 opinion against the antiseptic theory, Ernst 
 Fischer, in Strassburg, has proved by his investi- 
 gations the existence of all forms of septic coc- 
 cobacteria and of colonies of micrococci beneath 
 aU the layers of the Lister bandage. He con- 
 cludes that the Lister bandage does not prevent 
 the appearance of micrococci and bacteria." 
 
 With aU respect for the distinguished his- 
 tologists who have arrived at these significant 
 results, I do not ask you to accept them as con- 
 clusive evidence against Professor Lister's theory. I 
 am very weU aware that as an authority on micro- 
 graphy he is deservedly held in high esteem, and it is 
 only right to suspend judgment on the statements of 
 his German critics, untH he shall have had an 
 opportunity of revising them. But taking into 
 account the controversies on the germ theory 
 between leading scientists, in this country and 
 abroad, the German authorities, which I have just 
 
138 LECTUKE VII. 
 
 quoted, furnish very strong reasons why that 
 theory should not yet be accepted as the foundation 
 of a new system of surgical practice. 
 
THE teeatme:nt of wounds. 139 
 
 LECTUEE VIIL 
 
 CO:^ENTS. 
 
 Antiseptic theory not proved, p. 139 ; examinations of the merits 
 of antiseptic practice, p. 140; objections to it; Dr. 
 CMene's proposed modifications, p. 141 ; Case of en- 
 chondromatous tumour removed from right cheek, union 
 by the first insertion, p. 145 ; need of experimental 
 enquiry without theoretical pre-occupation, p. 146 ; Con- 
 cluding remarks to my old fellow students, and past 
 and present pupils, p. 148. 
 
 Gentlemen, 
 
 Our discussion of the germ theory in the 
 preceding Lecture, resulted, in substance, in this 
 conclusion: that, in its applications to surgical 
 practice, the theory is not proved. Setting aside 
 the theory, let us ask ourselves whether it be 
 not possible, that the doctrine may be wrong, and 
 the practice founded upon it right ? It is an 
 admitted fact that William Harvey did not know 
 the existence of the capillaries; and that he was 
 wrong in his theory of the manner in which the 
 
140 LECTURE VIII. 
 
 blood reached the veins from the arteries ; but, 
 that error notwithstanding, Harvey's exposition of 
 the general circulation was right, and Malpighi's 
 discovery of the capillaries only supplied the 
 link in the chain, which never can be broken. 
 
 It is the antiseptic practice with which we 
 have now to deal. I must recall to your recollection 
 the remark made in a previous lecture, that for 
 successive ages a long list of substances has been 
 employed, with a view to prevent decomposition 
 in wounds, to arrest it when it occurs, and 
 to promote healing. It is also worthy of re- 
 mark, that the carded oakum, the styptic 
 colloid, the Friar's balsam (Tinct. Benz. Comp.), 
 and the adhesive plaster (Emplastrum Elemi 
 Southalls), which I em^^loy, contain substances 
 of undoubted antiputrescent potency; while 
 Professor Guerin claims for cotton wool that its 
 beneficen effect is due to its power of filtering 
 the air of noxious particles. 
 
 In the present state of knowledge, particulars are 
 wanting to enable us to generalize on the modus 
 operandi of those and other agents employed in the 
 treatment of wounds. What is needed is precise 
 information, derived from observation, in a suffi- 
 
THE TKEATMENT OF WOUNDS. 141 
 
 ciently large number of cases under a variety 
 of circumstances, to prove tlie relative value 
 of so-called detersives, antiputrescents, or antiseptics, 
 not as the foundation of a surgical system, but as 
 useful accessories to surgical practice. 
 
 The merits of Professor Lister's particular 
 system are a question apart. It is open to the 
 objections of being expensive, and requiring more care 
 than is practicable under ordinary circumstances ; 
 it necessitates frequent movement and is, in this 
 respect, opposed to the great principle of rest ; 
 when long continued, the frequent ablutions and 
 sprays with carbolic water tend to retard healing. 
 Assuming these facts admitted, it is still com- 
 petent for Professor Lister, and those who think 
 with him, to say that the question of the superior 
 merits of his practice remains open. If we con- 
 cede their position, the omcs prohancU of their plan 
 still rests with them as its advocates. 
 
 Some interesting evidence in point has just 
 seen the light. 
 
 Dr. John Chiene, a distinguished member of the 
 Edinburgh school, has lately published an article 
 "on the antiseptic dressing of wounds," (^) in which 
 ^ Edinburgh Medical Journal, December, 1S77, p. 509. 
 
142 LECTUEE VIII. 
 
 he puts this query — "Is there any way in which 
 the surgeon may dress his wounds without the 
 constant aid of the spray-producer? Can we in 
 any way so alter the external conditions of our 
 deep wounds that they will resemble a superficial 
 wound?" I quote Dr. Chiene's reply. 
 
 " If this can be done, then the spray will 
 not be required as long as these conditions are 
 kept up. During the last two months I have 
 attempted in several cases to comply with these 
 conditions. My success has been such that 
 I feel justified in stating the simple method 
 adopted. The cases were a parotid tumour, an 
 excision of an epithelioma tons tumour of the arm, 
 an amputation of a great toe, and excision of the 
 elbow-joint. In these cases a permanent deep 
 dressing was applied on the day after the opera- 
 tion, and fixed in position either with a bandage 
 or with some sticky material, such as Canada 
 balsam, or solution of gutta-percha in chloroform. 
 From the experience I have had in these cases, 
 I am of opinion that if the dressing is so arranged 
 as to be perfectly porous, and if an absorbable 
 method of drainage is used, as catgut, it will not 
 be necessary to remove the deep dressing until the 
 
THE TEEATMEXT OF WOUNDS. 143 
 
 wound is superficial. As long as the deep dressing 
 is in position, the spray will not be required. 
 All that is necessary is to remove the outer 
 dressing when the discharge reaches its edges ; 
 to damp with carbolic lotion and salicylic 
 paste the deep dressing, and to apply anew an 
 external dressing. It must be remembered that 
 the deep dressing has lost its antiseptic 
 qualities, while it remains, as it is covered by 
 the outer dressing, perfectly aseptic. It must, 
 therefore, be thoroughly damped with carbolic lotion 
 whenever it is exposed to the atmosphere, in order 
 to destroy any mischief that may have fallen upon 
 it during the exposure, and in order to render it 
 actively antiseptic, so that when the dry gauze 
 dressing is applied over it no mischief may pass 
 from it through the deep dressing into the wound. 
 The spray is used at the operation and at the first 
 dressing, and afterwards only when the deep dressing 
 is removed. This method has another advantage : 
 it approaches more nearly to the perfection of 
 healing bj ' scabbing/ and the wound is not irritated 
 by the carbolic spray when exposed by the usual 
 method." 
 
 Dr. Chiene's permanent deep dressing with 
 
144 LECTURE VIII. 
 
 Canada balsam, or solution of gutta perclia in 
 chloroform, was substantially the same in cha- 
 racter as the dressing with Balsamum Traumaticum 
 or the Styptic Colloid; but why did he apply 
 it the day after the operation, instead of the 
 next minute ? He remarks that the deep dressing 
 has lost its antiseptic qualities, while it remains, 
 as it is covered by the outer dressing, perfectly 
 aseptic ; and he advises damping the deep dressing 
 with carbolic lotion, whenever it is exposed to the 
 atmosphere, to destroy any mischief that may have 
 fallen upon it during the exposure, and in order 
 to render it actively antiseptic. I submit, with 
 the most friendly feeling, that this is language 
 which is not warranted by the facts, and which 
 begs the whole question at issue. What mischief 
 can fall on the deep dressing? If germs are 
 referred to, who has ever proved, or seriously 
 attempted to prove, that atmospheric dust can 
 influence a wound through a well applied dressing 
 of Canada balsam, or a solution of gutta-percha in 
 chloroform ? Why expose the deep dressing at all 
 if the patients feelings, the pulse, and the thermom- 
 eter point to ''all right?" 
 
 Just glance at the case of Mrs. Bradshaw, in 
 
THE TREATMENT OF WOUNDS. 145 
 
 Ward 5. Only a week ago I removed an en- 
 chondromatons tumour, the size of a pigeon's 
 egg, from beneath the right zygomatic arch. 
 The covering skin was loose, but the deep part 
 required careful dissection, to separate the ad- 
 hesions without injuring the contiguous nerve. 
 After bringing the edges in close apposition, 
 and securing them with three points of silver 
 suture, our house surgeon, Mr. Wilkins, covered 
 the part with a small pledget of lint, soaked in 
 styptic colloid, dry oakum, and a compressing 
 bandage. There has not been the slightest pain 
 or constitutional irritation, the dressings have 
 not been touched until this morning; they are 
 quite dry. The surrounding skin is of natural 
 colour, the sutures have been taken out, the 
 linear cicatrix is firm, and the patient is dis- 
 charged quite well. I say dismiss the germs and 
 atmospheric dust, and experiment without theo- 
 retical pre-occupation. Those who are clean, light- 
 handed, and painstaking dressers, and watchful 
 clinical observers of the constitutional state, will 
 have abundant opportunities for studying nutrition 
 and repair, without troubling themselves about 
 fermentation and putrefaction. They will find that 
 
146 LECTURE VIII. 
 
 the great majority of wounds, wlien well treated, 
 heal kindly and without complications. " How could 
 this be so if atmospheric dust were as powerful for 
 evil as Professors Lister and Tyndall insist ? The 
 mere fact that we were at first told to rub pure 
 carbolic acid into the innermost recesses of a com- 
 pound fracture to destroy Pasteur's germs, and that 
 now a solution of one part of Thymol in two thou- 
 sand of water is said to be sufficient for the purpose, 
 is surely pregnant with suggestiveness as to the 
 fallacy of the new doctrine. But its leading advocates 
 have never wavered ; their faith in the germs 
 has hitherto remained immovable. Are they 
 right, or are the old principles of scientific surgery 
 true ? 
 
 The important issue is one which only rightly 
 conducted experiment and rigid induction can 
 decide. The necessary investigation involves no 
 less a matter than a revision of surgical prac- 
 tice. It demands something more than deU- 
 cate and patient manipulation, and cannot be 
 conducted to a successful issue, without a wide 
 and conscientious examination of the results 
 obtained by other surgeons with other methods. Such 
 
THE TEEATMENT OF WOUNDS. 147 
 
 statistics as those of Spence (^) and Callender {^) 
 and the critical teaching of Billroth {^) and Dittel (*) 
 deserve the closest attention, and I confidently 
 ask for most careful experiment with dry and 
 infrequent dressing, with efficient means to secure 
 absolute and easy rest, and to exert steady uniform 
 compression. Oakum is unquestionably a cheap, 
 handy, and very useful dressing for general pur- 
 poses, while cotton wool possesses advantages 
 which must win the favour of any surgeon who 
 gives it impartial and extensive trial. Valuable 
 
 ^ Statistical Eeport of Operations in tlie Eoyal Infirmary, 
 Edinburgh, performed by Professor James Spence, from April 3rd, 
 1875, till Sept. 30, 1876, witb remarks. — Medical Times and 
 Gazette, 1876, vol. 2, p. 612, et se(i. 
 
 2 Note on tbe Death-rate after Amputations in Hospital 
 Practice, by George W. Callender, F.K.S., giving a total of 25 
 consecutive Amputations, 21 of which were at the thigh or leg, 
 without a death. St. Bartholomew's Hospital Eeports, 1871, 
 p. 179. In the succeeding volume of the same Eeports, Mr. 
 Callender's 30 amputations, *' of which 13 of the thigh and 18 
 of the leg without a death." In vol. 10 of the same reports, 
 Mr. Callender's " Surgical Notes on Wounds and Ulcers," comprise 
 43 Amputations, of which 19 of the thigh and 16 of the leg, with 
 only one death. 
 
 ^ Lister 'sche Wundbehandlung, in Die Allgemeine Path- 
 ologic und Therapie von Dr. Theodor Billroth, achte vermehrte 
 Auflage, Berlin, 1876, p. 108 et seq. Untersuchungen iiber die 
 vegetationsformen von Coccobacteria Septica von Dr. Theodor 
 BUlroth, Berlin, 1874. 
 
 * Op. cit, ante. 
 
148 LECTURE VIII. 
 
 as drainage is, a large number of wounds heal 
 perfectly well without it, and it is important to 
 determine by careful experience the rules for its 
 employment. What agents should be used as deter- 
 gents or antiseptics, and under what exceptional cir- 
 cumstances, must also be the outcome of careful 
 investigation. Whatever be the particular results, 
 whatever therapeutic generalizations may be arrived 
 at, of this I am very confident, that there is 
 vast scope for improvement in surgical dressings 
 as generally applied, and that the mortality from 
 surgical operations recorded in the text books is 
 in very great measure avoidable. 
 
 To my old fellow students, and to my past 
 and present pupils, to whom I dedicate these 
 lectures, I would address a fev/ supplementary 
 remarks. 
 
 ISTo one can be better aware than I am, of 
 the imperfections of this small volume. It is 
 not a treatise; but a collection of facts, thoughts, 
 and suggestions, which I hope may prove a help 
 in practise, and a theme for wider and deeper 
 study. 
 
THE TEEATMENT OF WOUNDS. 149 
 
 If there be something ahnost discouraging in 
 the very vastness of the enquiry projected, there 
 is much that is comforting in a cursory retrospect. 
 Only a hundred years ago primary union of 
 wounds after amputation was scarcely dreamt 
 of. The ligature for arresting haemorrhage was 
 only partially, and very imperfectly, em- 
 ployed; and dressers sat up all night to stem 
 out-flowing life, by flouring the faces of stumps, 
 in which skin, muscle, and bone had been 
 ampu.tated on one level. 
 
 Alanson, Mynors, Hey, White, and Park, were 
 at that time, and shortly after, laying in our 
 provincial Hospitals, the foundations of the great 
 revival in British surgery which John Hunter 
 promoted on independent grounds. The dawn and 
 the first quarter of the century saw the surgeons 
 in the van of medical progress. The Bells, 
 Astley Cooper, Abernethy, Lawrence, and Brodie 
 had few rivals. For the present genera- 
 tion of surgeons to prove themselves worthy 
 of their great inheritance, they must advance in 
 the intellectual race, by observing the conditions, 
 cultivating the resources, and developiQg the powers, 
 which enable distinguished men to go to the fore 
 
150 LECTURE vni. 
 
 in other walks of life. Surgery is as deeply interest- 
 ing as it ever was ; it offers a wider field than ever 
 for investigation, and never made sucli great demands 
 on the resources of those devoted to its study 
 and practice. 
 
 A John Hunter to-day is an impossibility. 
 The untrodden expanse before him was so wide, 
 that the career of an original explorer could 
 be persevered in with the disregard, almost 
 amounting to ^contempt, which he cherished for 
 the labours of others. But surgery has progressed 
 since his day, nearly as much as in the 
 whole time before him. If an enquirer in 
 organic chemistry is not allowed to ignore 
 the early labours of a Berzelius or a Gmelin, 
 if a physiologist, aspiring to a first position, is 
 assumed to know the works of Eedi and Spallan- 
 zani, as well as those of Bernard and Ludwig, 
 why should a surgeon ignore the works of those 
 early masters who traced the lines, and laid the 
 foundation, for surgical progress through all time ? 
 Equally important is it to keep abreast of con- 
 temporary progress, and never to tire in seeking 
 the truth in facts, as superior to theories and 
 systems; as on the one hand the surest anti- 
 
THE TEEATMENT OF WOUNDS. 151 
 
 dote to the paralyzing influence of prejudice, 
 and, on the other hand, as the healthiest stimulus 
 to appetite for more and purer knowledge. 
 
 The day is gone by, never to return, when a 
 hospital surgeon could carve his way to eminence 
 and fortune, could affect to despise erudition, and to 
 be superior to the niceties of accurate clinical 
 observation. He must now and hereafter consent 
 to be a student of science, to read widely, to 
 experiment accurately, and to reason closely. 
 Surgeons will always have to use the knife ; 
 but in • doing so they must never forget the great 
 dictum of the old surgical academicians, "the 
 operation is only one point in the practice of 
 surgery." Given average manual dexterity, surgical 
 success has come to be, in great measure, a 
 question of accurate and painless, simple and watch- 
 ful wound dressing. 
 
INDEX 
 
 • 
 
 
 
 - 
 
 PAGE 
 
 ABERNETHY 
 
 67, 
 
 149 
 
 Acupressure 
 
 
 
 28 
 
 Alanson 
 
 
 
 150 
 
 Alcohol 
 
 
 
 113 
 
 Amputation, wound after 
 
 
 
 21 
 
 ir of finger 
 
 
 
 24 
 
 II of fore-arm 
 
 
 
 21 
 
 II at hip joint 
 
 
 
 30 
 
 II of thigh 
 
 
 
 23 
 
 Aneurism of femoral artery ... 
 
 
 27, 
 
 122 
 
 Ankle, sprain of 
 
 
 
 18 
 
 Antiseptic system, history of... 
 
 
 
 106 
 
 II theory and practice of 
 
 110- 
 
 -139 
 
 If objections to theory 
 
 
 147 
 
 Antiputrescent lotion 
 
 
 122 
 
 Antiputrescents 
 
 
 
 112 
 
 Arteries, ligature of... 
 
 
 
 26 
 
 II torsion of ... 
 
 
 
 25 
 
 Astley Cooper 
 
 
 . 67, 74, 
 
 149 
 
 BACTERIA 
 
 
 
 135 
 
 Balsam, Friar's 
 
 
 
 33 
 
 Balsamum Traumaticum 
 
 
 
 33 
 
 Bell, John ... 
 
 
 
 74 
 
 Benzoin, Tinct. Comp. 
 
 
 
 33 
 
 Billroth 
 
 
 
 147 
 
 Birch — Hirschfeld ... 
 
 
 
 127 
 
 Blood dressing 
 
 
 
 74 
 
154 INDEX. 
 
 PAGE 
 
 Boracic acid ... ... .. ... 116 
 
 „ lint 116—119 
 
 ti ointment ... .. ... ... 120 
 
 Brodie ... ... ... ... ... 149 
 
 Bryant on torsion of arteries ... ... 26 
 
 Burggraeve ... ... ... ... 89 
 
 Bum of scalp and skull ... ... ... 119 
 
 CALLENDER, statistics of Ms practice ... 147 
 
 Camphor ... ... ... ... ... 113 
 
 CarboHc acid 107—112 
 
 Cases — 
 
 Amputation of fingers ... ... 23 — 24 
 
 It of fore-arm ... ... 21 
 
 II at hip joint ... ... 30 
 
 II of thigh ... ... ... 23 
 
 Bum of scalp and skull ... ... 119 
 
 Caries of foot ... ... ... 121 
 
 Cystic tumour of scalp ... ... 58 
 
 Crushed finger, inflamed hand ... ... 93 
 
 Contused wound of scalp ... ... 59 
 
 Compound fracture of leg ... ... 73 
 
 II of skull ... 60, 61, 63, 69, 70 
 
 II of thigh ... ... 75 
 
 Chronic mammary abscess ... „. 104 
 
 Diffused n ... ... 103 
 
 Empyema ... ... ... ... 102 
 
 Enchondromatous tumour ... ... 145 
 
 Gunshot wound .. ... ... 91, 116 
 
 Hernia, strangulated femoral .. ... 5 
 
 II inguinal ... ... 4 
 
 Ligature of femoral artery ... ... 112 
 
 Lipoma ... ... ... ... 6 
 
 Loose cartilages in elbow ... ... 124 
 
INDEX. 
 
 155 
 
 Cases (continued) — 
 
 Necrosis of tibia 
 Ovariotomy ... 
 Sprained ankle 
 Suppuration of knee joint 
 "Wound of elbow joint 
 of finger 
 of kead 
 
 of kead and arm 
 of knee joint 
 of patella 
 of skoulder joint 
 of tkumb 
 Ckiene, Dr. 
 Ckassaignac 
 Ckloride of zinc 
 Coccobacteria 
 
 Cold 
 
 Collodion ... 
 Compression 
 
 It digital ... 
 
 II for efi'usion 
 
 Contagium vivum 
 Copal varnisk 
 Cotton wool 
 Cystic tumour, removal of ... 
 
 100 
 
 7—10 
 
 18 
 
 101 
 47 
 96 
 57 
 92 
 36, 44, 52, 53 
 41 
 60 
 11 
 
 141 
 99—103 
 
 122 
 
 135 
 31 
 33 
 ... 14, 16, 101 
 13 
 17 
 
 134 
 
 117 
 93 
 58 
 
 78, 87, 90, 
 
 DECLAT on pkenic acid and germ tkeory 
 
 Desault on fractures of tke skull 
 
 Depressed fractures of skull ... 
 
 Detersives ... 
 
 Digital compression ... 
 
 Disinfectants 
 
 Dittel on antiseptics 
 
 112 
 
 67 
 
 60—70 
 
 112 
 
 13 
 
 112 
 
 136, 147 
 
156 INDEX. 
 
 PAGE 
 
 Drainage ... ... ... ... ... 98, 101, 105 
 
 Drainage tube ... ... ... ... 99 
 
 11 of breast ... ... ... ... 103 
 
 II of knee ... ... ... ... 101 
 
 ti of pleura ... ... ... ... 102 
 
 Dressing ... ... ... 8, 9, 59, 63, 68, 100 
 
 It with Hood ... ... ... 74 
 
 EARTH-BAGS 84 
 
 Elbow joint, wounds into ... ... ... 47 
 
 Empyema ... ... ... ... ... 162 
 
 Emplastrum Elemi (Southall's) ... ... 140 
 
 Encbondromatous tumour ... ... ... 145 
 
 Ericbsen on water dressing ... ... ... 2 
 
 EEMORAL artery, ligature of ... ... 27, 122 
 
 Finger, amputation of ... ... ... 22, 24 
 
 II contused wound of ... ... ... 93 
 
 " incised wound of ... ... ... 96 
 
 Fischer ... ... ... ... ... 137 
 
 Fistula in ano ... ... ... ... 122 
 
 Fore-arm, amputation of ... ... ... 21 
 
 Forci-pressure ... ... ... ... 29 
 
 Friar's balsam ... ... ... ... 33, 140 
 
 Fracture, compound, of leg ... ... ... 72 
 
 Fractures of skull ... ... ... ... 60 
 
 GAUZE, antiseptic ... ... ... ... 121 
 
 Germ theory ... ... ... ... Ill — 114 
 
 It commentary on ... ... ... 129 — 138 
 
 Gu^rin 87—90 
 
 Gross ... ... ... ... .•• 28 
 
 Gunshot wound ... ... ... ... 47 
 
INDEX. 
 
 H^MOREHAGE ... 
 
 ti secondary 
 
 Head, wounds of 
 Hernia, femoral 
 II inguinal 
 Hervey, Raoul 
 Hey, W. ... 
 Hip joint, amputation at 
 Hunter, John, on blood dressing 
 
 II disregard of learning 
 
 ICE-BAG ... 
 
 Ice diet 
 Immobilization 
 India-rubber pillow 
 II tubes 
 
 Intestine, protrusion of 
 
 JOINTS, treatment of open 
 
 KNEE-JOINT, wounds of 
 
 II pus in 
 
 Knowlton, Dr. 
 Konig 
 
 LAREEY .. 
 
 Lawrence . , . 
 
 Lead, sheet, for pressure 
 
 Leg, compound fracture of 
 
 Lemaire on phenic acid 
 
 Ligature of arteries ... 
 
 Lister ... 2, 107, 109, 110, 
 
 Listerism . . . 
 
 Lithotomy wound 
 
 157 
 
 PAGE 
 
 9 
 
 30 
 
 57 
 5 
 4 
 
 87 
 
 44, 150 
 
 30 
 
 74 
 
 150 
 
 30, 68, 70 
 68 
 
 17, 74, 78 
 
 . 85 
 
 99 
 
 11 
 
 49 
 
 36, 44, 52, 53 
 
 101 
 
 53 
 
 115 
 
 49, 51 
 
 149 
 
 31 
 
 73 
 
 112 
 
 27 
 
 113, 127, 132, 137 
 115 
 122 
 
158 
 
 INDEX. 
 
 PA.GE 
 
 MAYOR 
 
 
 88 
 
 Maisonneuve 
 
 106, 
 
 113 
 
 Metallic sutures 
 
 
 9 
 
 Millboard splints 
 
 . , 73, 82, 
 
 101 
 
 Micrococci ... 
 
 
 135 
 
 Microphytes 
 
 
 114 
 
 Microzoa 
 
 
 114 
 
 Muslin bags 
 
 
 86 
 
 Mynors 
 
 
 149 
 
 NUSSBAUMYON ... 
 
 
 115 
 
 OAKUM, carded and picked... ... 78 
 
 , 85, 101, 
 
 104 
 
 Oiled silk ... 
 
 
 117 
 
 Ointment, boracic ... 
 
 
 120 
 
 Ovariotomy 
 
 7, 
 
 10 
 
 PAPER splints 
 
 
 83 
 
 Paralysis after head injuries ... 
 
 69, 
 
 71 
 
 Park 
 
 
 149 
 
 Paste for splints 
 
 
 83 
 
 Pasteur 
 
 91, 
 
 107 
 
 Patella, wound into 
 
 
 41 
 
 II division of ... 
 
 
 52 
 
 Pean on forci-pressure 
 
 
 29 
 
 Perchloride of iron ... 
 
 ... 
 
 55 
 
 Phenic acid 
 
 
 112 
 
 Philosophy, inductive and scholastic ... 
 
 
 111 
 
 Picked oakum 
 
 
 85 
 
 Pillow, sand and water 
 
 
 84 
 
 Penetrating wounds of joints 
 
 
 35 
 
 Pirrie on acupressure 
 
 
 82 
 
 Pleural efifusions 
 
 
 102 
 
 Pott, Percival 
 
 
 67 
 
 Porta, Luigi, on torsion 
 
 
 25 
 
INDEX. 159 
 
 PAGE 
 
 ressure .. ... ... ... ... 3, 14, 132 
 
 Protective ... ... ... ... ■ ... 117 
 
 QUADEICEPS tendon, division of ... ... 44 
 
 KANKE on germs in antiseptic dressings ... 136 
 
 Eest 80 
 
 Rest, position, and pressure ... ... ... 132 
 
 Reverses in bandaging ... ... ... 83 
 
 Rectus femoris tendon divided ... ... 44 
 
 Richardson, Dr., F.R.S. ... ... ... 8, 32 
 
 Roberts, Dr. William, on contagium vivum ... 134, 135 
 
 SAFD-BAGS 84 
 
 Scalp, burn of ... ... ... ... 119 
 
 ir contused wound of ... .. ... 59 
 
 It wound, with fracture ... .. ... 70 
 
 Secondary hgemorrhage ... ... ... 30 
 
 Seutin, Baron ... ... ... ... 88 
 
 Septicsemia , . . ... ... ... ... 134 
 
 Shoulder joint, wound in ... ... ... 50 
 
 Silk sutures ... ... ... ... 9 
 
 Silver ,. ... ... 9 
 
 Simpson, Sir James, on acupressure ... ... 28 
 
 Skull, fracture of ... ... ... ... 60—69 
 
 Sling for arm ... ... ... ... 12 
 
 Spence, Professor, statistics ... ... ... 147 
 
 Spiral bandaging ... ... ... ... 83 
 
 Splints generally ... ... ... ... 80 
 
 It millboard ... ... ... ... 82 
 
 It paper ... ... ... ... 83 
 
 It plaster of Paris ... ... ... 82 
 
 Sprains ... ... ... ... ... 17 
 
 Starch ... ... ... ... ... 82 
 
 Starched bandages ... ... ... ... 83 
 
160 INDEX. 
 
 Stimulants ... 
 
 Styptic colloid 
 
 Sutures 
 
 Sword wound in shoulder 
 
 Syme, James 
 
 TAR 
 
 Tenax 
 
 Terrier 
 
 Thermometer 
 
 Thigh, amputation of 
 
 II compound fracture of 
 Thumb, wound of 
 Tibia, necrosis of 
 Torsion of arteries 
 Tow 
 
 Trephine 
 Tumour in axilla 
 
 If cartilaginous 
 
 II cystic, of scalp 
 
 If fatty 
 
 YANZETTI on digital compression 
 
 Yelpeau 
 
 Volkmann ... 
 
 WATER dressing 
 White 
 
 ZINC, chloride lotion of 
 
 PAGE 
 
 69 
 31, 140 
 
 8, 122 
 50 
 27 
 
 86 
 86 
 93 
 10, 68 
 23 
 75 
 77 
 
 100 
 
 9, 25 
 
 83 
 
 66 
 
 27 
 
 145 
 56 
 
 13 
 
 88 
 115 
 
 2, 8 
 149 
 
 116 
 
 Note.— I have to thank my friend and pupil Mr. Edward 
 Johnstone for valued help in the preparation of this Index. 
 
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