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REPRINTED FROM THE " CANADA MEDICAL & SURGICAL JOURNAL."

JULY, 1884.

CLINICAL LECTURE ON THE ANTISEPTIC TREAT-

MENT OF WOUNDS BY DRY AND

INFREQUENT DRESSINGS.

Delivbrbd at the Montreal General Hospital June 28th, 1884,

By FRANCIS J. S HEPHERD^ M .D., CM., M.R.C.S, Eng.,
burgeon to the Hospital.

0-entlemen, — As you are aware, during the last few years
the different methods of treating wounds antiseptically have
attracted much attention in the surgical world, lo Sir Joseph
Lister is due the credit of having revolutionized wound treat-
ment and rendered operations, once formidable and dangerous,
comparatively safe. His method, surrounded by many forms
and ceremonies, which his followers insist on even more than
he does himself, was only slowly taken hold of by surgeons.
Those chiefly who themselves saw the results of Lister's treat-
ment in his own hospital practice at the Infirmary in Edinburgh
adopted his mode of treatment. These disciples earnestly pro-
pagated his doctrines, and Germany was soon converted to
Listerism by enthusiasts such as Nussbaum, Von Bruns, Hueter
and others. From being hotbeds of erysipelas, pyaemia and
septicaemia, German hospitals were transformed into veritable
sanitoriums, and German surgeons became apostles of cleanliness.
Where the mortality had been 50 to 75 per cent, after amputa-
tions, it fell to 5 to 10 per cent., so much did Listerism accom-
plish. The alteration in the mortality of London hospitals was,
owing to careful and cleanly surgery, not so marked, and even
Lister himself could hardly surpass the splendid results attained
by the late Mr. Callender. It soon began to be asked. Why is
Listerism so successful, and is there no way of attaining the
same results by a simpler and less expensive method ? Many
maintained that the success of Listerism merely depended on
the more rigid carrying out of the great principles of wound
treatment, viz. : rest, pressure, cleanliness, and drainage ;
and that everything did not depend on keeping away germs

and bacteria by means of the spray and elaborate dressings.
The spray was first discarded, irrigation taking its place, —
and the results were found to be much the same ; then the
Mcintosh was laid aside, and finally, instead of wet gauze, some
absorbent and antiseptic material was applied to the part.
Many surgeons who at first were ardent Listerites bocame
now meroly antiseptic surgeons. The inspiration was no doubt
owing to Lister and the new methods, which were soon intro-
duced, were in reality merely modifications of his treatment, so
the dry and infrequent form of dressing may be said to have been
evolved from Listerism. Iodoform has played a considerable
part in this, as, owing to its permanency and power as an anti-
septic, it permitted long intervals to ensue before wounds became
septic.

In England the dry and infrequent dressing of wounds was
first advocated by Mr. Sampson Gampee, of Birmingham, and
his published results certainly contributed not a little to direct
surgeons to this form of treatment of wounds. He it was who
first introduced absorbent antiseptic pads.

I, as you know, have practised the dry dressing of wounds
for some time past, and have every reason to be satisfied with it.
I have employed it in various ways and used many kinds of
material, but the principles have remained the same through-
out, viz., antisepticism, cleanliness of instruments, hands, and
wound itself, drainage, the application of some antiseptic,
absorbent material, kept in place by an elastic antiseptic bandage,
and, last of all, infrequent dressings. In detail, the method of
dressing wounds adopted by me is as follows : —

Suppose a leg has to be amputated. The part is first washed
in a solution of mercuric bichloride, 1-1000 ; the hands also
dipped in same after being well cleansed with soap and water
and a nail-brush, and the instruments placed in a 1-20 solution
of carbolic acid (as the bichloride spoils them) for an hour or
two before ; carefully cleaned sponges kept in a 1-20 solution
of acid carbolic are to be used. Thus far you see the proceed-
ings are in strict accordance with Lister's directions. After
the limb has been removed, the wound is irrigated with the
bichloride solution (1-1000), the vessels tied with catgut liga.

tures and the ends cut short. After all bleeding has stopped a
little iodoform may be dusted over the wound, and then the
edges of the wounds should be brought accurately together by
means of a few deep silver wire, or silk sutures, dipped in 1'40,
with intermediate sutures of carbolized catgut, a drainage
tube is then inserted into the most dependent part of the wound.
Now comes the special form of dressing which is called "Dry."
I sometimes use a layer of washed absorbent gauze and place it
directly over the wound, having previously dusted it with iodo-
form, and also dusted the wound itself with the same material.
Now h applied a square or oblong pad, such as I show you,
of some antiseptic absorbent material, covered with washed ab-
sorbent gauze. This pad varies in size and shape, according to the
size of limb to be encased or wour ' o be covered, and may be
made at the time of operation. I generally dust the pad over freely
with iodoform before applying it, and now place it directly on the
wound instead of first putting on a layer of gauze. It is to be
applied as accurately as possible, and by means of cuts made in
the sides or ends of these pads they may be fitted closely to any
part. The material of the pad may be of various kinds. I first
used Gamgee's pad, which is of salicylic absorbent cotton wool
enclosed in washed gauze, I have used peat, asbestos and
oakum, but the material I prefer to all others is finely carded
jute rendered antiseptic by mercuric bichloride, naphthalin or
carbolic acid. It is elastic, absorbent and antiseptic. Well,
the antiseptic pad having been applied, it is kept in place by an
evenly and firmly applied antiseptic gauze bandage. Here I
have used the ordinary carbolized gauze furnished by the Hos-
pital, but in private practice I generally make use of a bandage
of washed cheese-cloth, or book-muslin which has been rendered
antiseptic by soaking in a solution of bichloride and methylated
spirits, one grain to the ounce, and then, by exposing to the air
and evaporating the spirit, the bandage remains charged with
bichloride. In this way a very good antiseptic dressing may
be made, cheaply and quickly. The dressing is now com-
plete, the patient is placed in bed and the limb put on a pillow
or swung from a cradle. If the amputation has been near a
joint, as, for instance, the knee, I generally, over the gauze

bandage, apply a pasteboard splint, made pliable by dipping in
hot water, and which is kept in place by another bandage. In
the last amputation of the leg you saw me perform, I made use
of bone drains instead of rubber, hoping by this means to do
away with the necessity of taking off the dressing to remove or
shorten the tubes ; but in this case the tubes collapsed, being
too sof;, and the eflFused serum, being confined to the stump,
caused an elevation of temperature and interfered with primary
union somewhat by distending the flaps. I removed the dress-
ings on the third day, and replaced the bone drains by rubber
ones. The temperature fell immediately, and the patient from
that time did well, going out in a Uttle over three weeks.

If there is much oozing and the dressings are stained, they
had better be changed on the second day, the tubes very much
shortened and the dressing reapplied as before, and, as a rule,
the case will now go for a week or ten days without needing
change of dressing. At the next dressing, the silver wire
sutures and tubes should be removed altogether, and the wound,
if everything goes well, needs only one or at most two dressings
more. Of course, we must be guided as to our change of
dressings by the condition of the patient. If there is elevation
of temperature and the patient complains of distention and pain
about the wound, it should be immediately examined. I have
now treated over a hundred wounds and injuries of all kinds by
this method with, as you know, most satisfactory results. The
method is simple and the materials used easily obtained ; it is
also comparatively inexpensive. Many of you, after you receive
your degrees, will practice in country or other places where it
will be difficult or impossible to carry out the elaborate ritual of
Listerism in all its entirety ; in dry dressing, however, you have
a method of wound treatment that may be employed with as
much success, and the materials for which may be carried in
your breast pocket.

I might now call your attention to a few cases which were
under treatment in my wards during last winter, and which are
examples of the good results obtained by dry and infrequent
dressings. Most of you remember the case of amputation of
the arm for severe injury, which was in Ward 31, and

where there was primary union, the man going out cured in ten
(lays with two dressings ; also the man Hoskins, whose thigh I
amputated for tumor, and in whom, with two dressings, the
wound had all healed except where the drainage tubep had
been. This case was a good example of the bad effect of drain-
age tubes left in too long, as the sinuses caused by them after
the rest of the stump had completely healed were most difficult
to close. Also the man Smith, in 31 Ward, whose leg I ampu-
tated for railroad injury, and who went out in three weeks with
the stump healed by first intention. These were the most
favorable examples, perhaps, you will say ; but still they fairly
show, I think, results that may be obtained by the dry dressing.
This mode of treatment is suitable to all forms of wounds and
injuries. You have lately seen several cases of severely crushed
hands thus treated by dry and infrequent dressings with
remarkably good results, and have also seen knee-joints opened
and afterwards put up in this way and do exceedingly well.
Abscesses also may be easily and successfully treated in the
same manner. You may, perhaps, remember a case of large
gluteal abscess in VVard 31 last winter, where, after opening it
at the most dependent point and evacuating several pints of pus,
and inserting a drain, I treated with iodoform and dry dressing,
and where the progress to recovery was uninterrupted. I
might here mention to you a point with regard to the after-
treatment of abscesses, and also wounds. It is this :— After
evacuating an abscess or whilst dressing a wound, never inject
them with an antiseptic solution unless they are in a septic
condition ; drain freely, if you like, but do not disturb the newly-
formed tissue by forcing in a stream of water and so delay heal-
ing. Of course I do not wish to make this rule an absolute one,
I do not mean to decry the external washing of wounds and irri-
gation, but, when everything is going on well with a wound,
leave something to Nature, and remember that meddlesome
surgery is bad surgery.*

As this is the last time I shall have the pleasure of meeting

nK1^^nJ7ij^"M°'lJ?"^''^T^"«®'^«^ % t^« ^ mode of dreBsing wounds may be
obtainadfromMr. W. A. Dyer, chemist, 16 Phillip square, Montreal.

the ciass during the aession, I shall read to you a table which
will show the operative work done during the last your, with the
results obtained.

Operations performed in Dr. Shepherd's ivards at the Montreal

General Hospital for year ending June 1«<, 1884 :

AmpiUatiom: Cured. Died. Total.

AJ"^''' 2 .. 2

J^«K 4 .. 4

root — Syrao's l ., j

Chopart's i . . j

Lisfranc'a l , . j

Great Toe i , j

UpporArm o .'. 2

r orearm i , . j

Hand 2 '.'. 2

Fingers 2 . ! 2

Total 17 .. 17

Of the above operations, 7 were performed for disease and 10
for injury. The following list will show the cases more in
detail : —

Pnmary Amputations for Injury: Cured Died. Total.

Leg 1 ., 1

Great Toe 1 . . i

Arm 2 .'. 2

Hand 2 '.', 2

Fingers 2 . . 2

Secondary for Injury :

Leg 2 .. 2

For Disease :

Thigh 2 .. 2

Leg. 1 .. I

Syme's 1 .. i

Chopart's 1 . . i

Lisfranc's 1 . ' i

Forearm 1 , . j

Total 17 .. ^

Excisions of Joints :

Ankle 1 .. 1

Excision of Diseased Bones :

Partial of Fibula l . 1

" " Tibia 1 .. .1

" " Femur 1 .. 1

" " Radius 2 .. 2

" " Clavicle l .. 1

Ligature of Arteries :

External Carotid 1 . . 1

Anterior Tibial 1 , . 1

Ulnar 1 .. i

Removal or Tumours— Cancer ; Cured.

Lip 2

Side of face and neck 2

Tongue 1

Floor of mouth and submaxillary

gland I

Soft palate and tonsil 2

Sarcoma :

Neck 2

Nori'malignant Tumours :

Glandular of neck 4

.... 1

groin ,

Neuroma of arm

Large polypoid of nose. . ,
Bursal of patella

Beparative Operations:

Imperforate Anus 1

Tenotomy 2

Drilling femur for ununited frac-
ture 2

Incinon and drainage of large ahscesnes :

Gluteal region and thigh 2

Ischiorectal 4

Perineal 2

Parotid 3

Bursal • ■ • 3

Connected with diseased spine

and ilium 3

Various Operations :

Ovariotomy

Colotomy

Incision and drainage of chest. . !
Incision and drainage of knoe-

joint

Radical cure of hydrocele

Drainage of cystic bronchocele ... 1

Fissure of rectum 3

Fistula in ano 4

Removal of toe nail 2

Circumcision j

1
1

2
1

Died. Total.

1 2

1
2

4
2
1
1
1

1
2

2
4
2
3
3

1
1
1

2
1
1
3
4
2
1

86 2 80

There were two deaths— one after excision of tongue, from
gangrene of the lung following erysipelas, and one from shock
after ovariotomy. In the two cases of excision of the tongue,
the lingual arteries were ligatured previous to the excision of
that organ. In one case of excision of large tumor of neck, the
internal jugular vein was ligatured.