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2 1986

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GAYLORO

PRINTED IN U. S A.

presented to the
UNIVERSITY LIBRARY
UNIVERSITY OF CALIFORNIA
SAN DIEGO

Harlon W. Harrison, M. D,

LIBRARY

NIVERSITY OF
CALIFORNIA

SAN DIEGO

BM.

CAYuono

PRINTEOtN USA

BY THE SAME AUTHOIl.

With 145 Illustratiou5. 8vo. 21«.

ANTISEPTIC SURGERY

ITS PEIXCIPLES, PRACTICE, HISTORY, AND RESULTS.
EXTRACTS FROM NOTICES BY THE PRESS.

' In the volume Ijefore us lilr.
Cheyiie has made a very vdhiable
addition to surgical literature. The
intimate professional relations of Mr.
Cheyne with Professor I ister give a
special importance and value to this
work ; for while Mr. Lister's results
and views have hitherto been pub-
lished only fragmentarily in journals
and transactions of learned societies,
Mr. Cheyne's book affords a trust-
worthy and complete statement of
them.' Lan'cet.

'Mr. Cheyne has done his work
exceedingly well. No man, except
Mr. Lister, is better qualified to
write on this subject; and he has
done so with a fulness, clearness,
and calmness that leaves nothing to
be desired. The publication of this

work must hasten on the ultimate
universal acceptance of the principles
of aseptic surgery, and lead to
many improvements in its details"
British Medical .Jouknal.
'We have no hesitation in recom-
mending Mr. Cheyne's work to all
who wish to acquire a proper know-
ledge of antiseptic and aseptic
suraery.'
Edinburgh Medical Journal.
' We have at last got a ■« ork worthy
of antiseptic surgery. . . . The whole
volume is admirably got up ; the
woodcuts are numerous and well
done, the printing leaves nothing to
be desired ; the matter is so clear
and so well arranged that it reflects
the greatest credit on Mr. Cheyne.'
Glasgow Medical Journal.

London: SMITH, ELDER, & CO., 15 Waterloo Place.

MANUAL

OP THE

ANTISEPTIC TEEATMENT

OF WOUNDS

FOll STUDENTS AND PRACTITIONERS

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

ASSISTANT SURGEON" TO KING'S COLLEGE HOSPITAL
SURGEON TO THE PADDINGTON Gl'.EEX CHILDllEN'S HOSPITAL, ICTC.

mith Illustrations

LONDON
SMITH, ELDER, & CO., 15 WATERLOO PLACE

1885

PEEFACE

The present manual is written with the view of enabling
students to obtain a thorough knowledge of the practical
details of the best methods of treating Wounds. It is not,
however, intended in any way to be a substitute for the
larger works on Antiseptic Surgery ; for without a thorough
knowledge of the scientific basis of wound treatment, of
its development as shown by its history, and of what it can
do, the best results are not likely to be obtained, nor can
progress be made. In the introductory chapters I have
treated of matters which were not ripe for discussion when
my work on Antiseptic Surgery was written ; and thus I
hope that the two volumes will furnish the reader with
as complete a view of the subject as is possible at the
present time.

W. Watson Cheyne.

H Mandeville Place, Manchester Square, W.
Jaiuiarij 1885.

CONTENTS.

CHAPTER I.

BEPAIR AND DANGERS OF WOUNDS.

Processes of repair — Healing hy first intention — Heallnrj hy scah-
hlng — Healiny hy granulation — Healing hy vnion of granulations
— Healing bi/ organisation of ilood-clot — Comparison of course
of simple and compound fractures — Dangers wliich may follow
wounds I

CHAPTER II.

BACTERIA AND DISEASE.

General description of bacteria, their origin and life liistory —
Causes of septic intoxication — Inflammation and suppuration —
Acute osteomyelitis — Erysipelas — Gangrene — Pj-iemia — Septi-
cemia . . . . . . . . • . • .11

CHAPTER III.

DESTRUCTION OF BACTERIA.

Experiments on disinfectants, carbolic acid, bichloride of mercury,
&c. — Principles of wound treatment — Aseptic and antiseptic
surgery 25

viii CONTENTS.

CHAPTER IV.

ASEPTIC SURGERY — MATERIALS EMPLOYED.

p^GK
Problems to be solved in order to keep a wound aseptic : Carbolic

acid — CarhoUc lotions — Pare carbolic acid — Solution i7i methy-
lated spirit — Ca7'bolic oil — Carbolic acid ami glycerine: Spray
producers : Catgut — Carbolised silk : Protective : Carbolic gauze
— Macintosh: Sponges: Boracic acid — Buracic lotio^i—Horacic
lint — -Boracic ointment : Sj,lic3dic acid — Salicylic acid cream —
Salicylic ointment : Chloride of zinc : Iodoform : Carbolised
cotton wool 36

CHAPTER V.

ASEPTIC SURGERY (continued).

Example of an aseptic operation : Purification of the t-kin — Fingers
— Instruments : Spray — Precautions — Probable errors, and mode
of remedying them : Guard : Ligature of arteries : Drainage of
wounds — India-rubber tubes — Catgut drains — Horse hair — De-
calcified bone tubes (Neuber's and MacEwen's) : Sutures :
Button stitches — Stitches of relaxation — Stitches of coaptation
— Aseptic strapping — Protectic : Deep dressing : Loose gauze :
Gauze dressing : Elastic bandage. Changing the dressings
■ — Time — Method. Treatment of ulcers — Purification of the
sore : Boracic dressing : Boracic and salicylic ointment : Boracic
poultice . . .40

CHAPTER YI.

ASEPTIC SURGERY {continued).

Special dressings : Head dressings : Xech dressings : Breast dress-
ings — Abscess of mamma — Excision of mamma alone — Excision
of mamma and axillary glands : Axillary dressings: Dressings
on the limbs : Dressings for jjsoas abscess : Zumbar abscess : Hijj-

CONTENTS. ix

I'AGK

juint abscess : Dressinr/s in cases of Item i a and operations on the
scrotum: E.rcislon of joints. Aseptic treatment of abscesses.
Chief 2}<''nits to he considered in openin// abscesses — Method of
opening abscesses — Drainage of abscesses — After-ti'catment of
abscesses — Empyema — Perineal and anal abscesses. Treatment
of wounds produced accidentally : Problem to be .wired — Pnri-
f cation of wound — FuHhcr treatment of the wound. Special
wounds ; Compound fractures : Wou?uls invoicing tetulons, nerves,
<5'C. ; Wounds of joints : Compound fractures of the shull : Pene-
trating wounds of the thorax : Wounds of the abdomen. Putrid
sinuses and wounds. Treatment of burns. Treatment of
gangrene. Treatment of nsevi and varicose veins . . .77

CHAPTER VII.

ASEPTIC SURGERY — MODIFICATIONS.

Country practice : Hon- to dispen.^e with the spray during the opera-
tion — and during the after-treatment : How to render the dress-
ings less frequent : Is the aseptic method applicable in war?
Sir Joseph Listers suggestions: Esmarch's plan: lieyher's
method 103

CHAPTER VIII.

ASEPTIC SURGERY (concluded).

Other methods of carrying out aseptic surgery. Substitutes for
carbolic acid : Salicylic acid : jVeuber's permanent dressings :
Thymol: Acetate of alumina: Eucalyptus oil: Bichloride of
mercury : Naphthalin : Iodoform : Aseptic surgeiy by filtration
of the air. Subcutaneous surgery 112

CHAPTER IX.

ANTISEPTIC SURGERY.

Treatment by antiseptics : Carbolic acid — objections to it : Chloride
of zinc : Boracic acid: Sulphurous acid: Chlorinated soda:

X ■ CONTENTS.

PAGE

A hohol — Hutchinson's method : Terebene and Sanitas — Bi Iguers
method — Neudorfer's salicylic jJoivder. Free drainage as an anti-
septic method. Irrigation and immersion. Open method :
Modes in which it acts antisepticallij : Bartscher and Vczin's
method : Burow''s method : Bose's modification. Healing by
scabbing: Methods of forming a crust: Boulsson's ventilation
onethod : other modes. Guerin's cotton-wool dressing. Modes
in which the destructive action of the tissues on bacteria is
assisted. Why does not fermentation always occur in the blood
in ivovnds in whirh oryanisms are i^ifii^t' nt ? Best iwaciical
methods ■ . . . . 125

Index , , 14.5

LIST OF ILLUSTRATIONS.

FIG. PAGE

1. Common forms of bacteria 11

2. Section of kidnej', showing plug of micrococci surrounded

by a clear necrotic layer, and outside this a ring of in-
flammatory tissue. The poisonous material produced by
the micrococci when strong kills the tissue, when more
dilute sets up inflammation . . . . . . .18

3. Section of kidney, showing in the upper corner a mass of

micrococci, a clear necrotic ring and a layer of inflamma-
tion, as in fig. 2. In the centre is the further stage of the
process : the inflammatory cells and the micrococci have
now infiltrated the necrotic ring, and an abscess is the
result. (For further details as to figs. 2 and 3 see ' British
Medical Journal ' for September and October 1884) . . 19

4. Section of skin at the spreading margin of the redness in evy-

sipelas (from a photograph by Koch, x. 700). A lymphatic
vessel is seen containing micrococci, which are also spread-
ing into the tissues around

5. Hand spray producer ........

6. The ordinary steam spray producer

7. Steam spray producer, showing the lamp at present in use

8. Large steam spray producer with double nozzle for ovariotomy

&c 41

0. Trough for catgut . . . . . . . . . 41

10, Lister's pocket catgut holder 42

11. Porcelain trough containing instruments soaking in carbolic
lotion ...... ...

21
38
31)
40

Xll

LIST OF ILLUSTRATIONS.

12.

13.
14.
1.-).

16.
17.
18.

19.
20.
21.

22.
2B.
24.
25.

2^.

27.

28.
29.
30.

31.

32.
33.
34.

35.

PAGE

General arrangement of surgeon, assistants, towels, spray, &c.,
in an oiaeratiou performed with complete aseptic precau-
tions 51

To show the arrangement of towels, kc, in a large operation . 52

Method of tying vessels in dense tissues (after MacCormac) . 55

Another method of tying vessels in dense tissues (from
Esmarch) .......... 55

Ordinary oblique-ended drainage-tube ready for use . . . 57

Drainage tube with masses of gauze in the loops of thread , 57

Incision for inguinal hernia, stitched, showing the position of
the drainage-tube at the outer angle of the wound . . 58

Sinus forceps .59

Catgut drain ready for insertion ...... 60

Mode of using catgut drain as shown in operation for stretch-
ing the sciatic nerve 61

The same wound stitched . 62

Metliod of preparing a horse-hair drain for re-introdaction . 64

Lead buttons for deep stitches 65

"Wound after removal of mamma and axillary glands, stitched 66

Excision of the hip joint. Wound stitched ; protective and
deep dressing applied .68

Dressing in a case of psoas abscess opened above Poupart's
ligament .......... 70

Method of changing a psoas abscess dressing . . . . 72

To illustrate the general arrangement of dressings on the neck 78

To show the arrangement of the turns of bandage on the head

seen from above ......... 79 »

Dressing applied in a case of abscess of tlie mamma (breast
dressing No. 1) .79

Breast dressing No. 2 79

Dressing after excision of the mamma . . , . .80

Dressings applied after excision of mamma and axillary glands,
to show the arrangement of the dressings and bandages . 81

Binder applied outside the dressing represented in fig. 34, so
as to keep the parts and dressing at rest . . . .82

LIST OF ILLUSTRATIONS. xiii

PKi. VXUR

36. Dressing in cases of operation on the axilla alone . . . 80

37. Dressing in a case of psoas abscess opened above Poupart's

ligament, seen from the front 84

38. Psoas abscess dressing (fig, 37), seen from behind . . . 85

39. Dressing in a case of lumbar abscess, seen from behind . . 86
iO. Dressing in a case of hip-joint abscess, with elastic applied . 87

41. Deeper part of the hernia and scrotal dressings . . . . 87

42. Dressing in a case of operation for hernia, or on the scrotum

on the left side, showing the arrangement of the dressing
and elastic bandage . . . . . . . .88

43. Dressing in hernia cases or in operations on the scrotum, show-

ing the arrangement of the bandages in the perineum, seen
from below .......... 8!)

44. Splint for excision of knee, read)' for application . . . 90
4.3. Splint applied in a case of excision of the knee . . .90

46. Two forms of sharp spoons, a large round one and a small oval

one 100

47. (from MacCormac) Esmarch's first dressing for the wounded

in battle 108

48. Thiersch's champagne bottle irrigator 131

49. Arrangement for irrigation in the upper limb (after Esmarch) 132

50. Arrangement for irrigation in the lower limb (after Esmarch) 133

51. Apparatus for continuous immersion (after Esmarch) . . 134

THE

ANTISEPTIC TREATMENT OF WOUNDS.

CHAPTER I.

EEPAIR AXD DAGGERS OF WOUNDS.

Processes of repair — Healing by first intention — Healing hg scahUng —
Healing Inj granvlation — Healing bg union of granulations^ — HeaVuu/
bg organisation of hlood-clot — Comparison of course of simple and
compound fractures— Dangers wliicii may follow wounds.

In order to carry out tlie treatment of wounds with intelligence,
it is essential to have clear ideas of the process of repair, of the
evils which may follow wounds, and of the cause of these evils.
The repair of injuries is well discussed in surgical text-books,
but in the present manual it is necessary for the sake of com-
pleteness to give a short sketch of the subject.

If an incision be made in a frog's foot and the wounded
part observed under the microscope, it will be ssen that the
layer in the immediate vicinity of the injury is in a state of
intense inflammation. In the immediate neighbourhood the
circulation is arrested and the movement of the pigment has
ceased. At the margin of the stasis the blood passes through
the capillaries slowly and with difficulty, while the blood-
vessels in the neighbourhood are dilated, and there is there in-
creased flow of blood. The inflammation goes on to exudation
of serum and migration of corpuscles, and then the process sub-
sides and repair commences. The same thing happens in the
case of wounds in man. The passage of the knife through the

2 ANTISEPTIC TREATMENT OF AVOUNDS.

tissues sets vip an intense inflammation in a microscopic layer of
the whole surface of the wound. This results in the exudation
of liquor sanguinis which coagulates, and of white corpuscles
which become entangled in this coagulated liquor sanguinis ;
in other words, the surface of the wound becomes covered with
lymph. If no other irritating cause comes into play the
inflammation does not go further : retrogression occurs ; blood
begins again to flow freely in the capillaries in which the
cii'culation was previously interfered with ; the cells in the
lymph probably multiply and form fibrous tissue and new
blood-vessels ; the coagulated liquor sanguinis is absorbed ;
from the rete mucosum at the edge new cells are formed bv
budding, and thus the whole wounded surface becomes covered
with epithelium and converted into a scar, which gradually
shrinks and diminishes in vascularity. This process takes
place in healing by first intention, in healing by scabbing,
and in some instances in open wounds under aseptic treat-
ment.

In healing hy first intention the edges of the wound are
brought into accurate apposition, and the deeper parts are thus
protected from further irritation. Organisation of the lymph
rapidly occurs, and the epithelium spreads over the surface in
two or three days.

In healing by scabbing the edges are not brought into
contact, but the superficial layer of the lymph dries up and
forms a crust, which protects the deeper parts from external
irritation ; organisation of the lymph at the deeper parts
occurs, and epithelium spreads over the wound beneath the
crust.

In some cases in open wounds treated aseptically the anti-
septic dressing takes the place of the crust. The process de-
scribed above often occurs to a considerable extent around the
margin of the wound, but the irritation of the antiseptic and
the dressing is generally sufficient, when the wound is of con-
siderable size, to keep up a slight amount of irritation and lead
to the formation of granulation tissue in the centre of the

HEALING BY GEANULATION. 3

wound, and sometimes even to slight supjiuration. It is im-
portant to remember that in all cases the primary inflamma-
tion only aftects a microscopical layer, and the cutaneous
margins of the wound remain quite pale.

When the wound is left open and exposed to irritation from
without, the primary inflammation continues and leads to further
changes, ultimately resulting in the formation of granulation
tissue. Taking up the process at the point where it ceased in
the former case, we no longer find the chief changes in the cir-
culation but in the tissues. The migi^ation of corpuscles goes
on ; the intercellular substance becomes soaked with serum,
softened, and very soon absorbed : probably the connective
tissue cells in the part proliferate, and ultimately we find
nothing but a mass of embryonic cells in part composed of and
derived from the migrated leucocytes, and jjrobably in part also
derived from proliferation of the tissue cells. In this embry-
onic tissue young capillary vessels are soon formed, and at the
surface the new material grows out in the form of l^uds or
granulations; hence the term ' granulation tissue,' applied to all
inflammatory material having this structure. From the sur-
face of the granulations suppuration now occurs, while the
granulations grow and gradually fill up the wound till they
reach the level of the surrounding skin. At the deeper part,
however, the granulation tissue does not remain in the embry-
onic state, but being protected from irritation by the super-
ficial layer, the further progress of the inflammation ceases, and
organisation into fibrous tissue commences. The cells become
elongated and form fibrous tissue ; the walls of the blood-vessels
become thickened from the formation of spindle-shaped cells
around them ; many of the vessels become obliterated, and the
newly- formed fibrous tissue contracts, and the size of the wound
is in this way reduced. When the granulations have reached
the level of the skin the epithelium spreads from the margin,
and as soon as the surface layer of granulation tissue is by that
means protected from irritation, the changes just described as
regards the deeper layer take place up to the surface. This

B 2

4 ANTISEPTIC TEEATMENT OF WOUNDS.

process is termed heeding hy granulation. It may be quickened
if, after granulation is complete, the two sides of the wound are
brought into close contact. In this case the two layers of
granulations protect each other from external irritation, they
adhere, and oiganisation rapidly takes place while epithelium
spreads over the line of union. This process is called healing
hy union of granidations, or healing by the third intention.

There is another method of healing only seen in the case of
wounds where aseptic treatment is thoroughly carried out, or
in some rare instances where a crust forms ; I mean healing by
organisatioyi of hlood-clot. In order to explain this I must
refer to what ballpens to blood-clots and dead portions of tissue
enclosed in the body without access of air and dust. One of
the most interesting and thorough investigations on this subject
has been made by Dr. H. Tillmanns of Leipzig.^ Tillmanns
took portions of the liver, kidney, spleen, and lungs of rabbits,
and hardened them in absolute alcohol for one to three Aveeks
or longer. Pieces of these hardened dead tissues were then
introduced with asejjtic precautions into the peritoneal cavity
of rabbits (in each case^ several pieces were used) ; after some
days the animals were killed and the state of matters investi-
gated. Twenty animals were experimented on, and into their
peritoneal cavities about 100 portions of tissue were introduced.
The animals did not appear the worse for the operation ; the
temperature remained normal, and they seemed well. Of these
twenty animals only two died, both of acute peritonitis : in one
case an error was committed in the treatment, the stitches
were removed too early, and the intestines protruded : in the
other case the animal was suffering before the operation from
chronic peritonitis which afterwards became acute. When the
animals were killed early, in a day or two after the operation,
the masses of tissue were found to be adherent to some part
of the peritoneum, and sometimes two pieces of tissue were

' 'Experimentelle und anatomiscbe Uiitersuchung'en iiber Wunden
del" Leber und Niere : ein Beitrag zur Lehre vou der autiseptischen
Wundheilung,' Vii-claov/'s Archiv, Bd. 78, 187'J.

ORGANISATION OF ELOOD-CLOT. 5

attached to one anotliei\ "Where fourteen days or more were
allowed to elapse, the portions of tissue were found firmly-
adherent and much diminished in size, evidently nndergoing
absorption ; in some places there was only a thick layer of new
material containing a pulpy mass in its interior. In one animal
into whose abdominal cavity a whole kidney had been intro-
duced, and which was allowed to live for forty-seven days, tiie
kidney had entirely disappeared ; the only thing noticeable Avas
that at one part of the omentum there was a thickish tough
spot, where probably the absorbed kidney had been attached.
On investigating the process microscopically the following were
briefly the appearances found : After twenty-four hours the
mass of tissvie is, as I have just said, adherent to the peritoneum
and surrounded by a layer of soft new material — lymph. Any
defects which existed in the margin of the specimen are filled
up with this soft mass. This new material when examined is
found to be composed of countless numbers of cells, which
Tillmanns holds to be white blood corpuscles. If two pieces of
dead tissue lie close to each other, they become adherent to
each other by means of this material. If these tissues are ex-
amined at a later peiiod, say forty-eight or seventy-two hours
after their introduction, the cells are found to have increased in
number and to be no longer confined to the outside of the organ,
but to have penetrated into it where possible, forming, as Till-
manns puts it, streets and pathways of cells through the tissue.
Thus, for example, in the case of the liver these cells penetrate
in the first instance along the streaks of connective tissue
which lie between the lobules, entering first those channels
which are largest, but gradually spreading along the smaller
ones. At this time the cells have already begun to develop to
higher tissue, and not merely round cells, but also elongated
spindle-shaped cells undergoing further development, are found.
This process gradually goes on, the young cells penetrate more
and more among the dead materials, which soon disappear
by absorption, their place being taken by this young tissue
which has come from without. This tissue rapidly undergoes

6 ANTISEPTIC TEEATMENT OF WOUNDS.

further development into fibrous tissue, vessels, <fcc., according
to the well-known processes. The contraction of this young
connective tissue and the further changes which it undergoes
lead to the disappearance of the original mass and the formation
of a cicatrix at its site, which also, as time goes on, tends to
dwindle and disappear.

Where a portion of tissue covered by skin dies as the result
of an injury, as after embolism, it gradually disappears by
absorptioii, and its j)lace is taken by newly-formed fibrous
tissue. The process of absorption of blood- clots when subcuta-
neous is also essentially the same as that described in the ex-
periments jnst mentioned. The blood-clot becomes infiltrated
with young cells which develop into fibrous tissue, the original
blood-clot becoming absorbed, and ultiuiately also much of the
newly-formed material. The essential thing for the due absorp-
tion of blood-clots and sloughs is that they must be uniiritating.
Now the chief irritating causes are mechanical and chemical,
and of these by far the most important are the chemical. A
blood-clot may become chemically irritating by the addition of
some irritating chemical substances fi'om without, or by under-
going fermentative changes. When a blood-clot is subcuta-
neous, the skin protects it from saturation with chemical sub-
stances from without, and also in by far the greater number
of cases from decomposition ; for, as we shall see shoitly,
fermentations in organic fluids are always due to the growth of
minute vegetable bodies in them, these bodies coming from the
air and dust. Of the chemical causes fermentation is much
the most important. The object of aseptic treatment is to
exclude the causes of fermentation, and where this object is
successfully attained the blood-clot, at any rate in its deeper
parts, remains unirritating, In an open wound not treated
aseptically the blood-clot generally putrefies, and, as a result,
breaks down, liquefies, and is washed away with the dischai'ge ;
the surface of the wound grai:iulates and thus healing occurs.
Where, however, the clot remains aseptic, and where it is j^ro-
tected from other sources of irritation, such as the action of the

OEGANISATION OF BLOOD-CLOT. 7

antiseptic emj)loyed, the blood-clot undergoes the same changes
as beneath the unbroken skin. It does not break down but
remains, the Avound being thus filled up with a solid brownish
mass. After some days, if this clot is scratched, it bleeds,
showing that new vessels have been formed in it. Also on lift-
ing up the edge of the clot a broad margin of epithelium will
be found. If the clot is left undisturbed, it frequently happens
that after a time a superficial layer of tough brownish material
(old blood-clot) may be peeled off and a complete scar found
beneath. In some cases, however, organisation occurs in the
clot up to the level of the skin, and cicatrisation spreads for
some distance under the superficial unorganised layer, and then
l>y-and-by the remaining central portion granulates, and we
have a small superficial granulating sore which rapidly heals.
If there is much movement of the wound, or if no prepared
oiled silk (protective) be placed beneath the carbolic gauze, this
organisation may be only imperfectly observed.

The process essentially consists in this : young cells (whether
white blood corpuscles or derived from the connective tissue,
or both, is not yet determined) pass into the blood-clot and
develop into fibrous tissue and also vessels, which become con-
nected with already existing ones, according to the various
well-known methods of vascular formation. This process
gradually extends to the surface till, after some days, as I
have said, the blood-clot bleeds when scratched. When organi-
sation has sufiiciently advanced, the epidermis spi-eads from
the edge. The original blood-clot takes no active part what-
ever in this process : it forms a mould in which the young
cells develop, and is either used up as pabulum for these
cells, or gradually removed by absorption. Here, just as when
subcutaneous, the original blood-clot disappears, and its place
is taken by young tissue which developed in it, not from it.

The objects of wound treatment are to get the most rapid
and favourable healing of the wound with the avoidance of the
various dangers and inconveniences incident to it. The ideal
result is seen in the repair of subcutaneous injuries. One of

8 ANTISEPTIC TREATMENT OF WOUNDS.

the best examples of the course of subcutaneous injui-ies is the
i-epair of simple fractui'es in healthy subjects. Here there is
extensive laceration of tlie soft parts, fracture, and it may be
splintering of the bone and the effusion of a large amount of
blood. And yet, in spite of these extensive injuries, as soon as
the bone has been immovably fixed in proper position, the
pain ceases, the swelling due to the effused blood gradually
subsides, there is no increased rapidity of pulse or elevation of
-temperature, or if the temperature does rise a little it is only
transitory and slight ; rapid organisation of the blood and
lymph and formation of new bone and connective tissue takes
place, while the patient, if strong and healthy, is subjected to
no risk.

Quite difl^erent, however, is the result if the skin over the
seat of fracture is broken and the injured parts communicate
freely with the exterior. The difference is still more marked
if the old method of treatment by the application of water-
dressing or poultices is adopted. However accurately and
firmly the fracture may be put up, the edges of the wound
begin to sw^ell in a few houis, the skin around becomes red
and the part becomes painful ; the blood-clot, filling up the
wound in the first instance, undergoes putrefaction, liquefies and
disappears, and the inflammation in the wound goes on to the
formation of granulation tissue and the occurrence of suppura-
tion. Portions of the lacerated tissues may die, and after a
time come away as sloughs, while the ends of the bones also
very commonly necrose. At the same time the pulse becomes
rapid and tlie temperature high : the patient has traumatic
or inflammatory fever ; this fever lasts for three or four days,
and then gradually subsides. It may be that after separation
of the dead portions of tissue or bone the woimd heals up and
the patient is well. But this is by no means always the case :
the patient is liable to a great variety of inconveniences and
dangers, to which I shall shortly allude. The death of the bone
may not be confined to the exposed j^ortion, but the suppurative
inflammation may extend up beneath the periosteum or in the

DANGEES FOLLOWING WOUNDS. 9

meclulla, giving rise to acute suppurative periostitis or acute
osteomyelitis, in either case leading to death, of large portions
of the bone and very greatly endangering the life of the patient
at tfcp time. Farther, the separation of the dead bone may
occuv rery slowly and imperfectly, while the continuance of
suppuration may lead to the development of lardaceous de-
generation of internal organs, to hectic fever and death from
exhaustion. In other cases abscesses form around the wound
from time to time, leading to very serious consequences.
Again, gangi-ene may occur in the wound and spread with
great rapidity, giving rise to the necessity for amputation of the
limb high up in order to save the life of the patient — traumatic
gangrene. Or the wound may become covered with greyish
or black pultaceous masses, spreading over the skin and tissues
with great rapidity, desti-oying them and accompanied by low
febrile symptoms — phagediena.. Again, a dark redness with a
well-defined margin may spread from the wound over the
skin, accompanied by fever and sometimes by abscesses — ery-
sipelas. If the wound be very large it may happen that on
the second or third day the patient becomes collapsed and dies
in a few hours, with symptoms indicating the absorption of an
intense poison — septic intoxication ; or soon after, it may be
immediately following, the tramnatic fever, severe febrile
symptoms may supervene and continue for a consideiable time,
leading often to the death of the patient — septicoemia. Or
this fever may be of an intermittent type, accompanied by
rigors and the formation of abscesses in internal organs, and of
pus in various joints — pyfemia.

Summing up, then, the evils following compound fracture,
we have traumatic fever, inflammation, suppuration, waxy
degeneration, hectic fever, formation of abscesses, sloughing,
acute necrosis, traumatic gangrene, phagedena, erysipelas,
septic intoxication, septicfemia and pyaemia, all these occur-
ring because there was a communication between the injured
parts and the external air. Before we can pass on to the best
means of preventing these evils, we must shortly consider

10 ANTISEPTIC TREATMENT OF WOUNDS.

why it is that the division of the skin is followed by these
results ; in other words, what are the causes of these various
dangers which follow wounds : and we shall see that they are
almost entirely due to the growth of minute vegetable oi'ganisms
in the dischai'ges from the wound or in the tissues of the body,
these organisms entering the wound from without.

CHAPTER II.

BACTERIA AND DISEASE.

General description of bacteria, their origin and life history — Causes of
septic intoxication — Inflammation and suppuration — Acute osteo-
myelitis — ^Erj'sipelas — Gangrene — Pj'semia — Septicsemia.

I MUST in the first place give a short description of the charac-
ters and life history of these minute organisms, before proceeding
to the consideration of the part they play in the production of
the diseases alluded to at the end of the last chapter. They

^ ©

0\S

-'oaooe t._

/»

Fig. 1.— Common forms of bacteria.
1. Jlicrococci. 2. Bacteria. 3. Bacilli. 4. Spirilla.

are extremely minute masses of jirotoplasm of various sha])es,
and apparently in most cases structureless. They are divided
according to diflerences in shape into four classes (see fig. 1) :
(1) micrococci, or round bodies; (2) bacteria, small oval rod-

12 ANTISEPTIC TREATMENT OF WOUNDS.

shaped bodies, about twice as long as broad ; (3) bacilli, i^ods of
various lengths ; and (4) spirochretfe, or spiral filaments. Some
of them have a cilium at one or both ends, by means of which
they can move actively in fluids ; in some, however, in which
movement is marked, the cilium has not yet been demonstrated.
Others are always motionless, while many are for a time motile
and afterwards become stationary. Often after they have become
stationary they grow in masses, the individual members being
joined to one another by a glue-like material of greater or less
tenacity. This is termed the zoogloea stage, and the masses of
bactei'ia are called zoogloea. Motion seems to be greatly
favoured in most instances by the presence of oxygen, and
is best seen at the edge of a drop of fluid containing the
organisms.

The mode of growth is in all cases by division, though in
some there is also a formation of spores. In the case of rods,
division always occurs transversely to the long axis, but the
micrococci may divide not only transversely to the long axis of
a chain of cocci but also longitudinally, giving rise to the for-
mation of triplets, fours in pairs side by side, &c. The new
cells formed in this way may separate or may remain attached
to each other, forming chains, or in the case of the micrococci
small zoogloea masses. They grow very rapidly, the rapidity
being dependent to a lai-ge extent on the nature of the soil and
the temperature and moisture to which they ore exposed. The
common estimate is that they double their numbers once or
twice in an hour.

Spore formation has only been worked out in the case of
the bacilli. At one or more points in a rod a clear brightly re-
fracting oval body appears, at first ill defined but later becoming
sharp and well marked. At the same time the protoplasm of
the rod gradually disappears till at length the spores are
libei'ated. Spore formation seems to occur when the food of
the plants is nearly exhausted, and it provides for the future
existence of the organism. These spores are very resistant to
heat and chemical agencies ; they retain their vitality for years,

LIFE HISTOEY OF BACTERIA. 13

and when placed under suitable conditions they sprout and
grow into the adult organism.

Though formerly it was supposed that these bodies might
arise spontaneously in organic fluids, as the result of physical
causes such as heat and electricity, it has been conclusively
shown that the experiments on which these views were founded
were erroneous, and at the present time there is no experimental
fact known in favour of the view of spontaneous generation.
It is now perfectly easy to keep any organic material quite
pure for an indefinite time, if the vessel in which it is jilaced
has been sterilised at a high temperature after plugging its
neck with cotton wool, and if the material, after careful intro-
duction into the vessel so as to avoid soiling of the neck, is
heated to a temperature even considerably below the boiling-
point of water for less than an hour every day for several days
in succession.

It is much more difficidt, but still possible, to preserve the
fluids and tissues of the healthy living borly without subjecting
them to heat, the chances of contamination in transferiing the
organs to pur-ified flasks being veiy great. Nevertheless, it has
been amply proved that the thing can be done, and in this way
it has been shown that the fluids and tissues of the healthy
living body are free from micro-organisms.

Mici-o-organisms are present in large numbers in all dust,
in watei', on the surface of our bodies, and in the aii- in various
localities. The introduction into a sterilised organic fluid of a
minute object which has not been sul)jected to heat, or to the
action of chemical agencies, will almost certainly be followed
by the development of micro-organisms, because they are pre-
sent on all surrounding objects. This is a point of the greatest
importance in the treatment of wounds.

These micro-organisms grow on various soils, though some
are more particular than others. The substances essential for
their nourishment are water, phosphates, salts of potash, car-
bonaceous and nitrogenovis organic substances. An important
point is the reaction of the medium, neutral or slightly alkaline

14 ANTISEPTIC TREATMENT OF WOUNDS.

substances being best for mo.st bacteria. Most forms require
free oxygen or gi'ow much more rapidly in it, but there are
some which will not live unless oxygen is almost or entirely
absent. As the result of their vital action these bodies produce
extensive alterations in the materials in which they grow.
They break up the complex organic compounds and reduce
them to simpler' forms. In this way they cause fermentation
and decomposition of organic svibstances. In some instances
well-known chemical sub-stances are thus formed, and the
agency of the micro-organisms is extensively employed in the
manufacture of various articles of food and drink. In other
cases, however, the substances which they produce are extremely
poisonous, and when injected into animals cause symptoms of
poisoning resembling the effect of various alkaloids. There is
one class of organisms which gives evidence to the naked eye of
the changes they occasion in tlie materials in which they grow ;
I refer to the pigment-producing organisms. The spot on
which these organisms are growing assumes a definite colour
when it is exposed to the air. These colours are very
numerous, red, yellow, green, blue, &c., and the same colours
are always produced by the same organism when it grows on a
suitable soil.

Some micro-organisms can grow in the animal body, giving
rise to a variety of diseases. Some are fatal to most animals ;
for example, the bacilhis of anthrax : others again are only
pathogenic in certain species of animals. The diseases caused
by the growth of these bodies in the blood and tissues are
grouped together under the term 'infective diseases.' Of these
there are two kinds, those in which the infection occu)s from a
wound or open surface — traumatic infective diseases — and those
in which no wovnid is necessary, and where the pathogenic
organisms are supposed to be able to enter the body through un-
injured surfaces. It is with the former that we have here to do.

I have already mentioned that some micro-organisms
produce such alterations in organic fluids that the injection of
these fluids into animals is followed by symptoms of poisoning,

SEPTIC INTOXICATION. 15

anfl if in sufficient quantity by fatal results. These symptoms
set in during or soon after the injection (from a quarter of an
hour to two hours). Where a quantity insufficient to cause death
is injected, the temjierature becomes elevated two or three degrees
or more, and this fever lasts for a few hours. Where the quan-
tity used is larger there may be preliminary rise of temperature,
but if death is about to occur it falls below the normal, accom-
panied by collapse and sometimes by diarrhoea and vomiting.
Panum, who first worked at this subject, showed that the symp-
toms were due to a chemical substance and not to multiplication
of bacteria in the body. He boiled these poisonous putrid fluids
for eleven hours and then injected them into animals, and he
found that they were still poisonous, though not quite so power-
ful as before being boiled. He also filtered the fluid, boiled it for
an hour, evaporated to dryness, digested it with absolute alcohol,
and then treated the residvie with boiled water, this watery
extract being also very poisonous. Bergmann states that he -
has been able to extract the poison in the form of a crystalline
substance, to which he has given the name ' sepsin.' From
these experiments it is evident that there is present in putrid
fluids a chemical substance produced by bacteria, which, in-
troduced into the circulation of an animal, acts as a poison,
like strychnia or any other alkaloid. In small quantities this
substance causes febrile symptoms which, however, soon pass
off" unless the dose is repeated, while in larger amount it caxises
death more or less rapidly. The clinical evidence shows that
this material is also poisonous to man. Where a wound is
quite small, or where it has been treated antiseptically, in other
words where the poison is in small amount or entirely absent,
there is no fever or other symptom of poisoning. Where the
wound is larger and antiseptic treatment is not adopted, and
where the wound does not heal by first intention, this mateiial
is absorbed and gives rise, for a few days, to fever — traumatic
fever. Again, when there is a very large raw surface in contact
with putrid discharge, as in a hip-joint amputation, a large
quantity can be rapidly absorbed and produce fatal effects.

16 ANTISEPTIC TEEATMENT OF WOUNDS.

Or, again, when the patient is weakly and when his excretory
organs act imperfectly, as in renal disease, a comparatively
small dose may cause a fatal issue. Hence the danger of
operating in cases of Bright's disease, a danger much
diminished where aseptic treatment is adopted. These
symptoms are now grouped under the title of ' septic intoxi-
cation.' That they are really due to absorption from the wound
is further shown by the fact that as soon as granulation has
occurred the symptoms subside, even althougli the discharge
from the wound be considerable in amount and intensely putrid.
"While the products of the growth of certain bacteria give
rise to general effects — traumatic fever and septic intoxication —
they also act locally on the wound and cause inflammation and
suppuration. The occurrence of inflammation and su^ipuration
in a wound is probably due to various causes, but the chief
causes are the growth of micro-organisms in the discharges
from the wound or in the tissues giving rise to the formation
of irritating substances. In the case of a wound it is not
necessary to suppose that there is only one form of micro-
organism which will cause it to inflame and suppurate. Many
iriitating substances if applied to a cut surface will cause in-
flammation and suppuration, such as croton oil, tartar emetic,
itc, and in the same way many of the products of the fermen-
tation of the discbarges are sufficiently irritating to cause
inflammation and suppuration of the cut surface. For it must
be remembered, as pointed out in the first chapter, that the
superficial layer of a cut surfiice is for a short time in a state
of inflammation as the result of the injury done to the tissues
by the knife, and very slight irritation applied to this inflamed
surface will suffice to keep up the inflammation, lead to the
formation of granulation tissue and the occurrence of suppura-
tion. In treatment with various antiseptics it often happens
that the direct application of the antiseptic to the wound,
especially when it is in strong solution, iriitates the wound
and leads to suppuration. The recognition of this fact led
Sir Joseph Lister to interpose between the wound and the

CAUSES OF SUPPUEATION. 17

dressing a layer of prepared oiled silk, with the view of keeping
the antiseptic from the wound. Again, if from imperfect
drainage the discharge becomes pent np, inflammation is
caused, and if the tension is not relieved it may end in sup-
puration. The efiect of tension is of course greatly increased
if, at the same time, micro-organisms develop in the retained
fluids. Again, inflammation and suppuration may be caused
not merely by growth of micro-organisms in the discharges of
the wound, but also by growth of micro-organisms in the
tissues themselves. This effect is only caused by certain
micro-organisms, for, on the one hand, many micro-organisms
will not grow in the living blood or tissues, but yet growing in
the discharges can produce irritating materials and cause
suppuration ; while, on the other hand, many mici'o-oi^ganisms
grow in the living tissues without causing suppuration. The
micro-organisms which grow in the living tissues and cause sup-
puration belong, so far as is known, almost entirely to the group
of micrococci. They grow in the walls of the wound, and give
rise to irritating products which keep up the inflammation and
suppuration. They often cause extension of the inflammatory
process, or burrowing of the pus, as it is termed, and sometimes
spreading into the neighbouring tissues they give rise to the
formation of al>scesses. This will be presently alluded to, and
the relation of mici'ococci to suppuration will be discussed
more fully. In the meantime I may sum up the causes of
inflammation and suppuration in a wound as follows: 1.
Decomposition of the discharge from the wound. 2. Appli-
cation of irritating chemical substances to the wound, amongst
others various antiseptics. 3. Tension from accumulation of
discharge, more especially when the retained discharges undergo
fermentation. 4. Growth of micro-organisms in the tissues at
the surface of the wound.

I have just stated that when micrococci grow in the walls
of wounds they may spread into the tissues, and there set
up an acute abscess. When the pus of an acute abscess is
examined, micrococci are always found in it, sometimes in large

ANTISEPTIC TREATMENT OF WOUNDS.

numbers, sometimes only few. The relation of the micrococci
to the acute inflammatory process has been much debated,
and in the ' British Medical Journal ' for September and
October 1884 will be found a full discussion of the subject.
The facts seem to be the following. The micrococci associ-
ated with inflammation are of several kinds. Some forms
can cause inflammation, just as anthi'ax bacilli cause anthrax,

iiM4i iiW \

Pig. 2.

Section of kidney, sliowiug plug of micrococci surroundeil by a clear necrotic layer,
and outside this a ring of inflammatory tissue. The poisonous material produced
by the micrococci when strong kills the tissue, when more dilute sets up inflam-
mation.

&c. : there need be no jDrevious injury or disease of the part.
Direct evidence can be obtained with i-egard to some micrococci,
that their injection into animals is always followed by the
formation of abscesses. In Koch's ' Traumatic Infective Dis-
eases,' translated by the Sydenham Society in 1880, an account

ABSCESS FOEMATION.

will be found of a spreading abscess formation in rabbits,
where masses of micrococci were always seen preceding the in-
flammation, the injection of a minute quantity of these micro-
cocci being always followed by the same progressive suppuration.
There seem to be other forms which can cause abscess only if
the part has been previously injured or inflamed. Thus in

^.*"V

Xj-:

■i )

-^ X

"V<.

-S-^ *.

Aa,, v. .a?;'* ^v x«-<*-*^<^ » <- ^

Fig. 3.

Section of kidney, showing in the upper corner a mass of micrococci, a clear necrotic ring
and a lay«r of inflammation, as in fig. 2. In the centre is the further stage of the
process : the inflammatory cells and the micrococci have now infiltrated the necrotic
ring, and an abscess is the result. (For further details as to figs. 2 and 3 see 'Brit.
Med. Journal ' for Sept. and Oct. 1884.)

abscess in the mamma during the early period of lactation the
primary lesion is probably an inflammation resulting from an
injury, cold, &c. ; the micrococci then settle in the part, grow,
and cause suppuration.

c 2

20 ANTISEPTIC TREATMENT OF WOUNDS.

Quite recently * Becker and Krause have worked out the
micrococcus associated with acute osteomyelitis in man. They
have found a micrococcus constantly present in this disease
which forms orange-yellow colonies when grown on gelatinised
meat infusion or on potatoes. The injection of this organism
into the veins of rabbits did not produce any disease of the
bones unless these were previously injured ; but if the bones
had been bruised or broken, the organisms set up abscess under
the periosteum, suppuration between the ends of the bone, and
suppuration sometimes in isolated spots in the medullary tissue,
a result corresponding to the disease in man. We have thus
direct proof that acute necrosis of bone is due to micrococci,
and there is evidence to show that the abscesses occurring in
the neighbourhood of wounds are likewise due to similar though
not necessarily to the same organisms.

Among the most marked results of the growth of micro •
oi'ganisms in the tissues is erysipelas. If portions of the
spreading margin of the redness and of the healthy skin in the
immediate vicinity be excised and cut into sections, it will be
found that in the healthy skin immediately beyond the red
margin the lymphatic vessels contain large numbers of a minute
micrococcus fi^equently arranged in chains (see fig. 4). At the
red margin itself there are inflammatory appearances as well : the
lymph vessels contain not only micrococci but also numerous
leucocytes, and there is a small-celled infiltration around them
and in the skin. The micrococci also extend into the lymph
spaces and canals of the skin. Fehleisen, who has worked out
the subject,^ has succeeded in cultivating these organisms on gela-
tinised meat infusion, solidified blood serum, &c. After disin-
fecting the skin at the spreading margin of redness, he cut out
little bits and embedded them in the cultivating material.
Minute colonies of micrococci grew, and continued growing for
about six days, when they were reinoculated into fresh tubes,

' BeutscJifi Medicinische Wochenschrift, 1883, and Fortschrittc der
Medicin, 1 884.

* B'le jEtiologic des IJrysij?els, 1883.

ERYSIPELAS.

Having in this way obtained a pure cultivation, he inoculated
rabbits at the tip of the ear. In thirty-six to forty-eight hours
the redness and swelling began, and spread from the tip over
the ear and thence over the body. Sections through the
spreading margin showed the same appearances as the sections
of the skin in man : micrococci were present in the lymphatic
vessels. Excision of the whole ear before the redness had
reached the base arrested the process. He further inoculated
man with the cultivated micrococci, and produced erysipelas in
that way. It has been observed that lupus, rodent ulcer and
various malignant diseases often disappear or improve very
much after an attack of erysipelas, and it has been proposed,

•i**.'

Fig. 4.

Section of skin at the spreading margin of the redness in erysipelas (from a photo-
graph by Koch, x. 700). A lymphatic vessel is seen containing micrococci, ■which
are also spreading into the tissues around.

and indeed cariied out in some cases, that, where operation is
not possible, erysipelas should be induced by the inoculation of
pus from a wound affected by erysipelas. Fehleisen treated a
number (7) of these cases with inoculation of the cultivation of
micrococci instead of pus, and produced typical erysipelas by
this means. He also found that a patient was protected for
a short time — but only for a short time — from a fresh attack of
erysipelas.

In Koch's ' Traumatic Infective Diseases ' another very

22 ANTISEPTIC TEEATMENT OF WOUNDS.

interesting set of experiments are described on the production
of spreading gangrene in mice. At the spreading margin of
the gangrene, and preceding the gangrene, he found large
numbers of streptococci in the tissues. The inoculation of these
streptococci on other mice was followed by the development of
the same gangrenous process. Phagedaena and spreading trau-
matic gangrene m man are in all probability in like manner
due to the rapid spread of organisms in the tissues. Indeed,
micro-organisms have been found in these cases, but the rela-
tionship has not as yet been thoroughly worked out. All the
facts point to a similar mode of origin to that of spreading
gangrene in mice, a view much confirmed by the absence of"
these diseases where antiseptic methods of treatment are em-
ployed. I do not, of course, ascribe all cases of gangrene to the
spread of micro-organisms in the tissues; I refer merely to
acute spreading gangrene and phagedsena. Gangrene may
occur as the result of destruction of the tissues at the time of
the injury, or it may occur in enfeebled tissues after an opera-
tion, as, for example, in stumps after amputation for senile
gangrene, or for the i-esult of frost-bite. In this case the tissues
are so weak that they are unable to withstand the inflam-
mation which occurs in the wound. This inflammation is, how-
ever, caused either by growth of micro-organisms in the dis-
charges or tissues of the wound, or by tension. If this patho-
logy is correct, it follows that it is safe to operate early in cases
of senile gangrene and gangrene after cold, provided that micro-
organisms are excluded from the wound, and that the drainage
is satisfactory. Experience with the aseptic method of treat-
ment shows that this is correct. I may thus sum up the
pathology of gangrene after operations or iuj uries : 1 . It may
result from direct destruction of the tissue at the time of the
injury, from injury to large blood-vessels, etc. 2. It may occur
as the result of inflammation in a weak part. In this case the
inflammation is set up by the growth of micro-organisms in the
discharge or tissues of the wound, or by tension in the wound.
3. It occurs as the result of growth of bacteria in the tissues in

PYEMIA AND SEPTICEMIA. 23

a way corresponding to gangrene in mice, seen in pliagedsena
and traumatic gangrene.

Pysemia in rabbits has been sbown to be due to the growth
of micrococci in the blood.' These micrococci are very minute ;
they grow in colonies and tend to adhere to the red blood cor-
puscles. Masses are thus formed composed of colonies of micro-
cocci with included red blood corpuscles. These masses may
adhere to the wall of a blood-vessel, grow and block it com-
pletely, or being swept on in the circulation form emboli in the
smaller vessels. In either case inflammation occurs around,
and an abscess is formed in which are found numerous micro-
cocci : the inoculation on another animal of the pus from these
abscesses, or of the blood containing the micrococci, is followed
by the reproduction of the disease. In man the subject has
not been thoroughly worked out ; but micrococci have been
found in the blood and in the secondary abscesses, and jilugs of
micrococci are often found in internal oi'gans. All the facts
point to this pathology of the disease ; indeed, it is the only
view on which all the appearances can be explained.

Septicseniia is a much more complicated affection, and prob-
ably arises under several circumstances. Continued absorption
of the poisonous material from wounds referred to under the
head of septic intoxication will keep up a feverish state with all
the symptoms of septicaemia, and if long continued may ter-
minate fatally. In other cases the micrococci grow in the
tissues of the wound, and pour their products or ptomaines, as
they are called, into the blood. Here micrococci may be found
in the blood, but the essential seat of disease is the tissues. In
a third form micrococci grow in the blood, and multiplying
there give rise to the symptoms. In a fourth form organisms
grow in the blood ; but they belong to the class of bacilli. The
last two cases correspond to what is found in the lower animals
(mice, rabbits, &c.). In them septicfcmia is caused by more
than one form of organism growing in the blood, and giving rise

' See Koch's Traumatic Infective Diseases.

24 ANTISEPTIC TREATMENT OF WOUNDS,

to symptoms and j^ost-mortem appearances which can only be
classed together as septicaemia. In mice, the most common
form is a minute bacillus found in enormous numbers in the
blood. These bacilli may be cultivated on gelatinised meat
infusion, and their reinoculation on mice produces the same
disease. A small bacterium and other micro-organisms also
kill mice in the same manner.

CHAPTER III.

DESTRUCTION OF BACTEKIA,

Experiments on disinfectants, carbolic acid, bichloride of mercury, &c.
— Principles of wound treatment — Aseptic and antiseptic surgery.

Numerous researches have been published on the subject of the
destruction of micro-organisms by various antiseptic or disin-
fectant substances. With few exceptions these are open to
grave objections, and in what follows I shall therefore only
refer to the most recent and accurate research by Dr. Koch.^
The former experiments were chiefly made by adding varying
proportions of the antiseptic substances to cultivating fluids
containing a variety of forms of bacteria, or by treating a mix-
ture of bacteria with various antiseptics of difterent strengths,
and afterwards testing the power of growth in cviltivating fluids.
In this method no account was taken of possible differences in
the resisting power of difterent bacteria, and the great resisting
power of the spores was more especially left unnoticed. In Koch's
researches pure cultivations of difi'erent organisms were em-
ployed, and special attention was paid to the presence of spores.
The experiments were also carried out on a solid cultivating
material, and thus there was less risk of error from the acci-
dental develojiment of micro-organisms coming from the air.
I may refer in detail to the experiments on carbolic acid.

In the first place, tlie power of carbolic acid in destroying
spores and also non-spore-bearing organisms was tested. For
the former experiment bacillus anthracis containing spores was
employed ; for the latter micrococcus prodigiosus and the bacteria
of blue pus were used. The difference in resisting power

' 3ntthnlun<jeii aus dem h. Gisundhcitsamte, vol. i. Berlin ISSl.

26 ANTISEPTIC TEEATMENT OF WOUNDS.

between bacillus anthracis containing spores and the adult form
of the organism without spores was also tested. The spore-
bearing bacilli, the micrococci, and the bacteria of blue pus were
obtained by soaking sterilised cotton or silk threads in culti-
vations of these organisms and drying them rapidly. The
spores retain their vitality in the dry state indeiinitely, the
micrococci and bacteria only for a few days ; the latter were
therefore always freshly prepared before the experiment. The
non-spore-bearing bacilli were obtained by rubbing up the spleen
of an animal just dead of anthrax with the sterilised threads.
In the spleen the bacilli do not contain spores if taken imme-
diately after the death of the animal.

In the first instance, the resistance of spores to watery
solutions of carbolic acid was tested. A vessel was filled with
watery solutions of carbolic acid of various strengths, and the
spore-bearing threads were left in this fluid for a certain time ;
they were then taken out, in some cases washed with boiled
distilled water, and placed on the solid cultivating materials.
As a result, it was found that the spores of the bacillus were
unaffected after being in a 2 per cent, solution and under for
two days ; they developed more slowly if left for two days in
a 3 per cent, solution ; in a 4 per cent, solution after one day
their growth was slower; and in a 5 per cent, solution after
one day only one or two grew. On the other hand, bacilli of
anthrax which did not contain spores were killed by immersion
for two minutes in a 1 per cent, solution of carbolic acid.
Micrococci and other organisms not containing spores are
similarly desti'oj'ed with great rapidity by watery solutions of
carbolic acid.

It was also necessary to learn what proportion of a disin-
fectant must be mixed with a fluid in order to hinder bacteria
from developing, although their vitality may not be destroyed.
It was found that in meat infusion containing pepton -ji^th to
yijlg-iyth part of carbolic acid was sufficient to prevent the growth
of bacillus anthracis.

The vapour of carbolic acid at the ordinary temperature did

CARBOLIC ACID. 27

not destroy the spores of the ordinary bacilli found in earth,
although allowed to act as long as forty-five days. If, how-
ever, the vaponr acted at a temperature of 75° C, spores in earth
were destroyed in from two to three hours, and even after ex-
})osure for an hour and a half to the vapour at 55° C. only a
few colonies developed, showing that spores are destroyed in
that time, but that some were protected more than others, and
hence not so rapidly affected.

A 5 per cent, solution of carbolic acid in oil did not affect
spores of bacillus anthracis, although they were left in it one
hundred and ten days, and the non-spore-bearing bacilli were
not completely destroyed till after six days, though on the third
day some had apparently been killed. A 5 per cent, solution
in alcohol was also employed without effect on the spores.

The carbolates were much less potent than pure carbolic
acid. Next in power to caibolic acid was the sulpho-caibolate of
zinc, which interfered with the luxuriance of the vegetation of the
spores in one day, and completely destroyed them in five days.

Before going further I shall consider how these results
affect the question of carbolic acid as an antiseptic in the treat-
ment of wounds. When it was first introduced nothing was
known of the existence of resisting spores, and it was thought
that a strong solution (5 percent.) of carbolic acid killed micro-
organisms almost instantly. The results mentioned above, how-
ever, show that while micrococci and other organisms without
resistant spores are killed in a few seconds, spores can retain
their vitality for a considerable time. The experiments do not
show the precise time at which spores are destroyed, for, though
in one experiment development occurred at one part of the thread
after soaking for twenty- four hours, this fact does not imply that
the spores withstood a 5 per cent, watery solution of carbolic acid
for that time, but only that some of them were imperfectly acted
on. There is no evidence of the existence of different resistincr
power of the spores of the same organism, and therefore we
have to find the earliest time in which they are killed. This
has not yet been worked out, but evidently it is considerable.

28 ANTISEPTIC TEEATMENT OF WOUNDS.

In the Lifetermn methcd of treatment, then, the methods of dis-
infecting hands, insti'nments, &c., are sufficient to destroy every-
thing but the resisting spores of some bacilli. Bub as I have
pointed out at some length elsewhere,^ after an operation per-
formed aseptically the discharge will be found to contain no
organisms, or if any are present, they belong to the class of
micrococci. They enter by developing in the discharge beneath
the dressing when the latter is left on for several days, or when
the discharge is profuse. Why, if the spores of bacilli are not
killed by the solution of carbolic acid, are they not found in
the discharge from the wouud 1 Either they do not gain access
to the wound, or if they get in, the circumstances under which
they are placed are unfavourable to their growth. It is prob-
able that on the skin there are but few spores, for the heat and
moisture will I'apidly cause them to germinate, when they will
be readily destroyed by the carbolic acid lotion. The spores in
the air and on the instruments will, if they fall into the wound,
fall into a fluid containing carbolic acid from the spray, a fluid
in which they will be incapable of germinating, while in a very
short time they will be destroyed by the action of the living
tissues ; for, as will be seen in referring to my ' Antiseptic Sur-
gery,' the living tissues can destroy organisms. In all probability
but very few spores fall into a wound, for even where tension
occurs early in cases treated aseptically, I have never found
bacilli in the retained fluid. The carbolic spi-ay, though
practically in my experience of the greatest value, has since the
publication of Koch's research, been regarded as of little use.
The above remarks show that it may be of the greatest service,
not merely in destroying non-spore-bearing organisms and in
keeping the hands, instruments, and skin pure, but also in add-
ing carbolic acid to the fluids of the wound, and thus preventing
the development of spores.

Carbolic oil is also found in practice to act very well as an
antiseptic, but from the fact mentioned above, it does not de-
stroy spores, and only acts very slowly on the mature organism.

' Pathological Transactions, 1879, and ^lntiscj)tic Surgery, 1882.

SULPHUEOUS ACID— CORROSIVE SUBLI.MATE. 29

The difference between the experimental and the practical
results is probably owing to solution of the acid froiu the oil in
the fluids of the wound, thus giving rise to a watery solution.

Sulphurous acid is another disinfectant which has been
much used, but which is apparently not so effectual as has been
supposed. Dry micrococci are killed by a 1 per cent, per volume
vapour in twenty minutes, if moist, in two minutes. Spores
of anthrax, earth and hay bacilli exposed for ninety-six hours
to a vapour of sulphurous acid, at first of the strength of 6'1"/
volume per cent., and after ninety-six hours of the strength of
3"3 per cent., were quite unaffected.

In solution sulphurous acid was somewhat more powerful.
A saturated solution of the gas in water way obtained, and this
was diluted so that four strengths were tested.

The 1st vessel contained 11-4.36 p.c. bj^ weight (4,000 vol. p.c.)

„ 2nd „ „ 5-718 „ „ (2,000 „ „ )

\ „ 3rd „ „ 2-859 „ „ (1,000 „ „ )

„ 4th „ „ -286 „ „ ( 100 „ „ )

In each of these vessels were j^laced several thi-eads contain-
ing anthrax spores, and some of the threads were taken out at
various times and the power of development of the spores tested.
In the first vessel, after one day, development was somewhat
delayed, and after more than one day did not occur at all. In
the second vessel there was also delayed vegetation after one
day, but none of the spores were killed till the third day. In
the third vessel no delay in development till the tliird day, and
apparently none were killed after five days. In the fourth no
apparent effect after five days.

A 5 per cent, solution of chloride of zinc did not kill
anthrax spores after a month's immersion, and chloride of zinc
added to serum in the proportion of 5 per thousand did not
hinder the development of these spores.

Of chemical substances able to destroy spores with great
rapidity, bichloride of mercury is the most potent. Mixed with
the cultivating material in the proportion of 1 to 300,000, the
bacillus anthracis was unable to gi'ow. Spores of anthrax dried

.^0 ANTISEPTIC TEEATMENT OF WOUNDS.

on threads and placed in a watery solution of 1 to 20,000 for
ten minutes were destroyed. Soh^tions of 1 to .5,000 or stronger
destroy all spor-es with certainty in a few minutes; indeed, to
wet the spores with a spray of this solution and then allow
them to dry is sufficient to destroy them.

Of the various other disinfectants employed, only the fol-
lowing were able to kill the spores of bacillus anthracis in less
than twenty-four hours : —

Chlorine water.

Bromine water (1 p.c.)-

Iodine water.

Permanganate of potash (.5 p.c. in water).

Boracic acid (5 p.c. in Avater).

The following acted .slowly and imperfectly on the vitality
of the spores : —

Etlier (incomplete ' destruction after 8 days, complete after 30
days).

Aceton (incomplete after 5 days).

Iodine, 1 p.c. in alcohol (incomplete after 1 day).

Sulphuric acid, 1 p.c. in water (incomplete after 10 days).

Sulphate of copper, 5 p.c. in water (incomplete after 5 daj's).

Boracic acid, saturated watery solution (delayed vegetation after
6 days).

Hydrochloric acid, 2 p.c. in water (complete on the 10th day).

Arsenious acid, 1 per 1,000 in water (complete after 10 days).

Sulphide of ammonium (complete after 5 daj's).

Formic acid, 1-12 specific gravity (complete on the 4th day).

Quinine, 2 p.c. in water (|) and alcohol (f), (incomplete after 1
day).

Tui-pentine oil (incomplete on the 1st dav, complete after 5 days).

Chloride of lime, 5 p.c. in water (incomplete on the 2nd daj', com-
plete on the 5th).

Perchloride of iron, 5 p.c. in water (delayed development on the
2nd day, complete destruction on the 6th).

Absolute alcohol (no effect on the spores after 110 days).

Glycerine (no effect after 110 days).

Chloroform (spores unaffected after 100 days).

' By incomplete is meant that only some spores grew, i.e. where the
solution got free access to the spores it killed them, but where tlie action
was imperfect they still retained vitality.

DISINFECTION BY HOT AIR. 31

Benzoic acid, concentrated watery solution (spores unaffected after

70 days).
Thymol, 5 p.c. in alcohol (spores unaffected after 15 days).

These facts sliow that though the oixlinaiy antiseptics are
sufficient when the virus is a bacterium which is not ppore-
bearing, yet when spox^es have to be dealt with they are in-
sufficient. In using antiseptics there is another point which
must not be lost sight of. Thus, one antiseptic may form com-
pounds with substances in the fluids and lose its properties,
while another, which is in reality weaker, may not do so, and
thus be more effectual. Thus, in recent experiments on the
destruction of tubercle bacilli in phthisical sputum, Schill and
Fischer • found that bichloride of mex'cury solution (1 to 500
in water), added to an equal quantity of sputum, failed to de-
stroy the tubercle bacillus even after twenty-four hours' action,
while a watery solution of carbolic acid (5 per cent.) added to
sputum in the same proportions disinfected it thoroughly in
twenty-four hours. And yet, acting on dry spores of Bacillus
anthracis the bichloride solution is very much more rapid in its
action than carbolic acid. In the case of sputum the result
probably depends on the different chemical affinities of the two
substances, the bichloride either losing its antiseptic properties
by entering into new combinations, or being unable to penetrate
and act on the masses of secretion which contain the bacilli.

Although not directly of use for surgical work, it may be
interesting to refer shortly to the results obtained as regards
disinfection by hot air and steam. Disinfection of masses such
as bedding is not possible with hot air, because, while the outer
layer may be raised to a tempeiature which chars it, the tem-
perature of the intei'ior may not be sufficiently high to destroy
bacteria. I may mention one experiment to illustrate this.
A piece of linen about forty inches long was rolled up tio-htlv
thirty- two comjdete turns being made, in this way giving sixty-
four layers from one side to the other. Maximum thermo-
meters were placed in the middle of the roll and between every

' Mittheilnngen avs dem h. Gesimdheitsavite, vol. ii. Berlin, 1884.

ANTISEPTIC TEEATMENT OF WOUNDS.

fourth turn from within outwards. The whole was placed in
a disinfecting oven and exposed to hot air. The experiment
besan at two o'clock p.m. and lasted for four hours. The
temperature of the air in the interior of the oven was taken at
different times, and was as follows : —

At 2 P.M.

„ .5.30 „
,. 6

227° F.
284° „
293° „
298° „
298° „
302° „
298° „
298° „

When taken out at 6 p.m. the following were the readings of

the maximum thermometers : —

In the middle of the roll
4 turns from the middle
8

94° F.
109° „
126° „
152° „
165° „
17.5° „
182° „
212° „

As a temperature of 280° F. to 300° F. is necessary for the
destruction of bacteria when exposed to dry heat, it is evident
that the proper disinfection even of small mas-ses of clothing,
&c., is impossible in a hot-air chamber.

Superheated steam has also been tested in the same manner
with a similar result. The temperature in the interior of the
mass did not rise sufficiently high to destroy bacteria. This was
also practically tested in these experiments, by placing spores of
bacilli and the much more easily killed micrococcus prodigiosus
fit various parts of the roll ; they were afterwards sown on
suitable cultivating material. In the case of the experiment
mentioned above, these organisms were placed along with the
seven deepest thermometers, and when sown afterwards all grew.

If, however, the steam is not at rest but constantly passes

FERMENTATION IN WOUNDS. 33

over the material to be disinfected, the temperature rapidly
rises and soon attains the same height in the interior of the roll
that it has outside. At the same time a current of steam pass-
ing over spores effectually destroys them, acting in this way like
boiling water. To disinfect bedding, clothes, &c., it is therefore
evident that the best way is to expose them to a current of
steam for about three hours. If the boiling-point of water is
raised by adding salts, it is found that the temperature of the
steam is also above 212° F. In some cases, especially where a
more rapid effect is wanted, this would be an advantage.

We have now considered the modes in which wounds heal,
the diseases which may follow wounds, the causes of these dis-
eases, and the means by which these causes may be destroyed.
We therefore come next to the application of this knowledge
to the treatment of wounds. It is evident that all treatment
must be directed against the causes of wound diseases, care
being taken at the same time to permit the wound to heal. In
other words, all treatment must be antiseptic. As we shall
see immediately, there are various modes in which the principle
may be carried out. The short meaning of the term 'anti-
septic treatment ' is treatment directed against the causes of
putrefaction. But only some of the diseases to which we have
already alluded are connected with putrid changes in organic
matter. The micrococci of erysipelas, for example, do not pi'o-
duce any putrid change. All organisms, however, alter the
composition of the materials in which they grow, that is, all
cause fermentation of some kind or other. We must therefore
somewhat expand the meaning of the term ' antiseptic treat-
ment,' to include treatment directed against tlie causes not
merely of the putrefactive fermentation, but of all fermentations.
That it is sufficient to direct our attention to the matter of
fermentation in wounds I have shown at length in my lai'gev
' work on Antiseptic Surgery, to which I must refer the reader.
It is there demonstrated that it is from particles falling into
oi'ganic fluids or on tissues that micro-organisms develop ;
that it is only after the access of particles from the outer world

34 ANTISEPTIC TREATMENT OF WOUNDS.

to such fluids and tissues that fermentations occur ; that the
particles v,'hich cause fermentations, and those which give rise
to organisms, are one and the same — in other words, that fer-
mentations are due to the growth of micro-organisms in the
fermenting substances; that micro-organisms are not present
in the fluids and tissues of the healthy living body ; that, so
long as an animal is healthy, dead tissues and fluids may re-
main in closed cavities in the living body without undergoing
fermentation, and may even entirely disappear, but that as soon
as atmospheric air with its dust is admitted, organisms deA'elop
and fermentation* occur ; and that it is very seldom that the
organisms gain access through the cii'culation to dead tissues
and fluids enclosed in the animal body. The relation of bacteria ,
to disease I have just described. It is thus clear that precau-
tions that are effective against the causes of fermentation will
equally prevent the dangers due to bacteria.

There are two great principles on which we may carr}^ out
the antiseptic treatment of wounds. A. — We may aim at the
complete exclusion of living organisms from wounds, thus pre-
venting the possibility of their developing there. This is the
principle on which the method of treatment introduced by Sir
Joseph Lister is based, and may be termed for the sake of dis-
tinction the aseptic method. Various surgeons use diflerent
antiseptics and dressings, though still adhering to the principle
of complete exclusion of living organisms. The principle is
generally called the Listerian jyrinciph or Listerism, and the
particular aseptic method on which this principle is carried out
by Sir Joseph Lister, the Listerian method. It does not
necessarily follow because a surgeon does not employ the method
recommended by Sir Joseph Lister that therefore he is not
practising Listerism. That depends on whether or not he acts
on the principle of complete exclusion of living organisms, and
whether his method fulfils that purpose.

B. — We may allow living organisms to enter wounds and
then take means to impede their growth in the discharge and
in the tissues. It is of course at once evident that this is a less
certain plan, and that the result must depend to a great extent

ANTISEPTIC METHODS. 35

on chance : once organisms entei' a wound the result is no longer
completely under our control.

The antiseptic methods which merely interfere with the
development and fermentative action of organisms on the fluids
and tissues in wounds, and which do not aim at their total
exclusion, may act on various principles.

1. By the addition of various antiseptics to the discharge,
either in the wound, or after it flows out, this discharge may be
rendered an unfit soil for the development of organisms. — TJse
of aniiseftics.

2. The discharge may be allowed to flow away so rapidly as
not to have time to undergo fermentation to any extent in the
wound itself. — Free drainage.

3. This I'emoval of the discharge may be facilitated by
washing it away constantly with water alone, or with water con-
taining antiseptics. — Treatment hy irrigation or hij water bath.

4. By freely exposing the discharge to air evaporation
takes place, and the fluid becomes too concentrated to permit
the growth of bacteria, while, at the same time, by supplying
these organisms with plenty of oxygen, they have no necessity
to break up the albuminous compounds in their search for
oxygen, and thus, as shown by Pasteur, their fei-menting power
is diminished. — Opeoi treatment.

5. By keeping the parts at perfect rest and by operating
only when the patient is in good health, the tissues and the
blood are in such a state as to resist the development of bacteria
in the thin layer of lymph between the cut surfaces, and
union by first intention thus occurs. This is best carried out
hy perfect rest and accurate ajJj^osition of the cut surfaces.

Healing hy scabbing acts on the last two principles.

Although these various methods may be described as acting
on these diflferent principles, yet there is no hard and fast line
between one and the other. Indeed, at the present day advan-
tage is now constantly gained from the use of the various
principles combined — as, for instance, by the employment of
free drainage, antiseptic irrigation, &c., in the open method.

D 2

36 ANTISEPTIC TREATMENT OF WOUNDS.

CHAPTER IV.

ASEPTIC SURGERY — MATERIALS EMPLOYED.

Problems to be solved in order to keep a wound aseptic : Carbolic acid

— Carholic lotions — Pure carbolic acid — Solution intnctlinlateds^Arit

— Carholic oil — Carholic acid and glycerine : Spray producers : Cat-
gut — -Carbolised silk : Protective : Carbolic gauze — Macintosh :
Sponges : Boracic acid — Boracie lotion — Borapic lint — Boracic
ointment : Salicylic acid — Salicylic acid cream — Salicylic ointment :
Chloride of zinc : Iodoform : Carbolised cotton wool.

Aseptic surgery is based on the principle first enunciated by
Sir Josepli Lister, viz. the exclusion of active ferments from
the discharges of wounds.

Theoretically, this is the. ideal form of antiseptic surgery,
for here, supposing that the attempt is successful, the causes of
jjutrefoction do not enter the wound in a state capable of pro-
ducing fermentation, and therefore decomposition of the dis-
charges, or of dead portions of tissue, etc., cannot possibly
occur.

The problem which Sir Joseph Lister sought to solve may
be shortly stated as follows : —

On all objects in the external world septic dust is present —
on the skin of the patient, on the hands of the surgeon and his
assistants, on all instruments, in water, in the air, &c. ; and
when a wound is made any introduction of this dust must be
carefully avoided. Then after the wound has been made, care
must be taken to prevent its entrance during the after-
treatment. Some sort of dressing must be provided which
shall prevent its passage in an active state, and at each change

SUBSTANCES EMPLOYED — CAEEOLIC ACID. 37

of this dressing the problem is the same as at the time of inflic-
tion of the wound. Such being the question at issue I must
now proceed to the modes in which it has been answered.

I shall fii'st enumerate the substances employed in aseptic

surgery.

Carbolic Acid is the antiseptic employed to destroy the
particles in the air and on surrounding objects which give rise
to putrefaction. It is obtained in the solid state and of ex-
treme purity fi"om Bowdler and Bickerdike, Church, Lan-
cashire, who ofive it the name of Absolute Phenol. It is used
in various forms.

The Carbolic lotions used are of two strengths — 1 in 20
and 1 in 40 ; one part of ciystallised carbolic acid dissolved in
20 and 40 parts of water respectively. The solution is kept in
a stoppered bottle in order to avoid evaporation of the acid. It
ought to be quite clear ; when it is not so, and more especially
when globules of oily matter are present, it is impure, the oily
particles consisting of cresylic acid. It is a mistake to add
alcohol or glycerine to aid the solubility of the acid, because these
substances hold the acid more tenaciously than water, and it is
thus not so potent for producing a rapid effect.

UndiliUed liquid carbolic acid may in some cases be re-
quired. This is obtained by liquefying the crystals by the
addition of a few drops of water. This is chiefly used for
injecting najvi, varicose veins, itc.

A solution of carbolic acid in methijlated spirit or in recti-
fied spirit, in the proportion of 1-5, is used for the purpose of
purifying wounds inflicted some twenty-fovir or thirty-six hours
before coming under treatment.

Carbolic oil is employed of various strengths, generally
1 in 5, 1 in 10, and 1 in 20, consisting of carbolic acid mixed
with olive oil in the foregoing proportions.

Carbolic oil 1-.5 is but rarely used, though it is occasionally
applied as a dressing to foul wounds, for the purpose of purify-
ing them.

ANTISEPTIC TREATMENT OF WOUNDS.

Carbolic oil 1-10 is used as a dressing for wounds in the
neighbourhood of the anus, penis, &c.

Carbolic oil 1-20 is used for oiling catheters or other in-
struments before introducing them into the bladder. It is well,
however, to lay the instruments in 1-20 carbolic lotion for some
time before using them, especially where there is any disease of
the bladder.

There are various objections to these oily dressings. The

Tig. 5.— Hand Speat Pkoditcee.

chief are, that the carbolic acid is very rapidly washed out by
the discharge, that they are very dirty, and soon spoil india-
rubber tissues.

The latter disadvantage is got rid of by the use of carbolic
acid and glycerine in the proportions of 1-5 and 1-10. This is
now employed as a dressing in the circumstances in which the
oil has been generally used.

A S2)ray of carbolic acid is generally employed in order to

SPEAY FRODUCEES.

purify the atmosphere. This is obtained by driving a rapid
current of air or steam through a horizontal tube so as to pass
over the orifice of a more or less vertical one. In this way a
vacuum is produced in the vertical tube, and the fluid at its
lower end rises, and is expelled from the orifice in the form of
spray. We have two forms of spray producers : one in which
air is driven over the vertical
tube — hand or foot sprays ;
and the other in which steam
is employed — steam sprays.
The hand or foot sprays pro-
duce a somewhat coarse spray,
and the force required is such
as soon to exhaust the indi-
vidual employed. They are
therefore very uncertain im-
plements, and have now en-
tirely given place to the
steam spray producers where
there is a steady current as long as the water in the boiler
lasts. When the hand sprays are eo: ployed 1-40 solution is
placed in the bottle. In the steam spray the 1-20 solution is
used, because the steam, mixing with the solution, reduces its
strength to 1-30 or 1-35.

I need not describe in detail the steam spray apparatus,
more especially as it can be easily obtained, of Sir Joseph
Lister's pattern, from David Marr, High Holborn, W.C.
It consists of the following parts : A boiler which contains
water, and which is heated by a- spirit lamp placed beneath
it. The steam issues through a tube placed at an angle to
another more upright one, through which the carbolic acid
lotion 1-20, which is placed in the glass retort, is sucked up.
This 1-20 lotion, mixing with the steam, makes a solution of
1-30 to 1-35. The carbolic acid solution passes through a
sponge at the bottom of the upright tube, which filters it, and
thus prevents the minute orifice of the tube from becoming

YiG. 6.— The Ordinary Ste.vm Spbat
Producer.

ANTISEPTIC TREATMENT OF WOUNDS.

choked up by coarse particles. These sprays are of various
sizes, and the largest ones have two nozzles, which may be used
singly, or together where the field of operation is large as in
ovariotomy (see fig. 8).

^\\_ ^./•~'"^-'"-rrz

Pig. 7.— Steam Spray Pkoducee, showing the Lamp at Peesext in Use.

It; consists of a small flame, -which plays on a plate of metal attached to a hollow
central tube containing a wick, and perforated by holes at the top. The heat is
communicated to the wick — the spirit volatilises, and burns as it escapes from the
top of the tube. The hole in the plate allows the flame of the small wick to pass up
and light the spirit vapour, which passes out through the holes at the top of the
central tube. The cap, which is placed over the Lamp when not in use, and the
boiler and vessel for the carbolic acid, are indicated by dotted lines.

Carholised catgut is used for ligatures and sometimes for
stitches. Formferly it was prepared by immersion in carbolic oil,
but three years ago ' Sir Joseph Lister introduced anew catgut
made by the use of solutions of chromic and sulphurous acid.s,
which is stronger and not so rapidly absorbed as the older kind.

' Lancet, February 5, 1881.

CARBOLISED CATGUT AND SILK.

The catgut is kept dry on reels in the trough figured below,
and an hour or two before the operation 1-20 carbolic lotion
is poured into the trough,
filling it about half full, 80
that as the reel is turned
ths catgut is immersed in
the lotion.

In order to have a sup-
ply of gut always at hand,
Sir Joseph Lister has de-
vised the catgut holder
shown in the accompanying
figure (fig. 10). The gut
is wound on a reel which is
carried in a German silver
case. The gut is soaked in
1-20 carbolic lotion before
being used. Sometimes the case is combined with a caustic
holder at the other end.

Carholised silk is often used for sutures, and is prepared as
follows : Nine parts of beeswax and one part of carbolic acid

Fig. 8.— Large Steam Spray PRODrcEii
WITH Double Nozzle for Ovariotomy,

riti. 9.— Trough for (Jatgut.

are melted together. Silk thread of various sizes is steeped for
some minutes in this mixture, till it is thoroughly impregnated
with it. As the thread is taken out, it is drawn through a
cloth in order to remove the superfluous wax. The wax holds
the carbolic acid, makes the thread more useful, and fills up to

42 ANTISEPTIC TKEATMENT OF WOUNDS.

some extent its interstices, thus j)reventing it from becoming
soaked with fluids. The carbolised silk thus prepared is kept
permanently in stoppered bottles, or wrapped in carbolic gauze.

' P- M ARR ^^<J B

Fid. 10.— Lister's Pocket Oatgut Holder,
A, Holder complete. B, The reel ou whicli the catgut is wound.

It must not be steeped too long in the lotion before being used,
because the threads become opened out. If the thread be
properly kept, the interior is aseptic or even antiseptic, and a
short immersion in 1-20 carbolic solution is apparently suffi-
cient to destroy any septic dust adhering to its exterior.

In order to protect healing wounds from the irritation of
carbolic acid a special material is employed termed the Protec-
tive. This consists of oiled silk coated with copal varnish.
When this is dry a mixture of one part of dextrine, two parts
of powdered starch, and sixteen parts of cold watery solution
of carbolic acid (1-20) is brushed over the surface. The
rationale of this method of preparation is the following : Oiled
silk alone is better for the purpose of a protective than gutta-
percha tissue, because carbolic acid does not so readily pass
through it. It does, however, do so, and therefore copal varnish,
which is almost absolutely impermeable to carbolic acid, is
added. As, however, the fluid collects on this as on a duck's
back, leaving intervals between each drop on which dust may
fall and escape the action of the acid, the dextrine solution is
added, and the result is that when moistened the whole surface
of the protective remains uniformly wet. The use of the
carbolic acid in the dextrine solution is not to add any carbolic
acid to the protective, but because it is better than water for
enabling the dextrine to adhere to the varnished oiled silk.
For the same reason the powdered starch is added. The

GAUZE AND MACINTOSH. 43

original carbolic acid flies oflf very quickly from tlie protective,
leaving a material containing no antiseptic in its substance.

Carbolised gauze is the material generally employed as a
dressing to guard against the entrance of causes of fermentation.
The gauze used is ordinary fine unbleached tarlatan washed and
dried. This is impregnated in various ways with one part of
crystallised carbolic acid, four parts oF common resin, and four
parts of paraifin. These materials mixed together are added to
an equal weight of unprepared gauze. The larger dressings are
kept after use and sent back to the manufacturer, who washes
and recharges them. In this gauze the carbolic acid is the
only active agent; the resin is used to hold the acid, i.e. to
prevent it from being washed out too soon by the discharge,
while the paraffin is employed to lessen the adhesiveness of the
resin. The gauze ought to be kept in a tin box closing tightly,
to prevent evaporation of the carbolic acid. Jt is used either
in the form of folded dressings, loose gauze or bandages.

In order to prevent the discharge from soaking directly
through the dressing, macintosh doth is used. This is cotton
cloth with a thin layer of india-rubber spread on one side. It
is placed outside the gauze dressing. As a rule one layer of
the gauze comes outside it, partly in order to keep it in position,
and partly also, in case any hole should exist in the macintosh,
to have a little antiseptic material outside. Care is taken that
the side on which the india-rubber is spread goes next the
wound, for if the other side be placed inwards it absorbs the
discharge, and, not being itself antiseptic, becomes in reality a
piece of impure cotton in the interior of the dressing, and may
thus communicate putrefaction inwards. The macintosh itself
also gets spoilt when so used. The dres.sing consists of a piece
of gauze of sufiicient size folded in eight layers, beneath the
outer layer of which the macintosh cloth is placed.

Spo7iges are washed after an operation, and are then kept
soaking till required in a jar containing carbolic acid 1-20.
During an operation they are washed in 1-40 carbolic acid
lotion.

44 ANTISEPTIC TEEATMENT OF WOUNDS.

These sponges often become filled with fibrin, and thus
rendered more or less useless. It is very difiicult to remove
this fibrin by washing. Sir Joseph Lister, therefore, after an
operation places the sponges in a tank containing water. Putre-
faction of the fibrin occui's, and after some days the sponges
can be easily cleansed. They are then placed till required in
the 1-20 carbolic solution.

When the wound becomes quite superficial, various prepar-
ations of BoRACic Acid may be employed with advantage.

Boracic lotion is a cold saturated solution of boracic acid
(BjOySHoO) in water. This acid is soluble in 25 to 30 parts
of cold water, and in very much larger proportion when the
water is boiling. It is convenient to tinge this solution with
litmus in order to distinguish it from the carbolic lotions.

Boracic lint is ordinary surgical lint soaked in a hot satu-
rated solution of boracic acid and then hung up to dry. About
half its weight consists of crystals of the acid. This is also
stained with litmus.

Boracic ointment is employed in certain cases. Two
strengths are commonly used, called full strength and half
strength; the former being applied to wounds where cavities
exist, the latter to superficial wounds which one wishes to heal
rapidly.

The following is the best formula for the full strength : —

Make a basis of 2 parts of paraffin to 1 part of vaseline.
Take of this 5 parts.

,, boracic acid, ] part. Mix. Spread on thin cotton cloth.

The half strength contains half the quantity of boracic acid.

Salicylic acid cream is used for applying around a wound
when a dressing is to be left on for some days. It prevents
irritation by the discharge. It formerly consisted of salicylic
acid crystals mixed with 1-20 carbolic acid lotion in sufficient
quantity to form a creamy fluid. This is apt to separate into
two layers, and therefore it is better to make a cream by mixing
salicylic acid with glycerine so as to form a paste. This latter
cream remains of uniform consistence, and is easily applied. For

CHLORIDE OF ZINC. 45

this purpose Sii- Joseph Lister uses glycerine and carbolic acid
1-10.

The formula for Scdicijlic ointment is —

Of the same base as is used for boracic acid . . 29 parts
SalicyUc acid 1 part.

For the purpose of purifying sinuses, putrid ulcers, kc, a
solution of chloride of zinc is used of the strength of 40 grs. to
the oz. of water. This is either applied on lint to the whole
surface of a wound, or it is injected by means of a syringe and
catheter into all the deep parts of the wound, cai-e being taken
to provide free exit for the fluid injected. If the exit of the
solution is obstructed, it may pass into the tissues and cause
gangren e.

Iodoform is now applied to the surface of vilcers, and answers
the same purpose as the chloride of zinc solution, while it causes
no pain.

Carholised cotton loool is used in some cases of gangrene. It
is obtained by soaking pure cotton wool in a 1 per cent, solution
of carbolic acid in ether. The cotton is then dried and used
immediately.

46 ANTISEPTIC TEEATMENT OF WOUNDS.

CHAPTER V.

ASEPTIC SURGERY — {continued).

Example of an aseptic operation : Purification of the skin— Fingers —
Instruments : Spray — Precautions — Probable errors, and mode of
remedying them : Guard : Ligature of arteries : Drainage of wounds
— India-rubber tubes — Catgut drains — Horse hair — Decalcified bone
tubes (Neuber's and MacEwen's) : Sutures : Button stitches —
Stitches of relaxation — Stitches of coaptation — Aseptic strapping —
Protective : Deep dressing : Loose gauze : Gauze dressing : Elastic
bandage. Changing the dressings— Time -Method. Treat-
ment OF ULCERS — Purification of the sore : Boracic dressing :
Boracic and salicylic ointment : Boracic poultice.

Having described the materials employed in aseptic surgery
we must now consider how they may best be employed- Take
as an example of an operation the removal of a fatty tumour.

The skin over the tumour, and for some distance in the
vicinity, is thoroughly purified from any active dust by washing
it well with a solution of carbolic acid 1-20. This washing is
now generally done an hour or two before the operation, and a
cloth soaked in the 1-20 lotion is bandaged on the Dart. In
very important operations, as in joint operations, opening
psoas abscess, &c., the skin is washed on the previous day, and
a soaked towel is applied and kept on during the night. The
instruments are also placed in 1-20 carbolic lotion, if possible,
for an hour or longer before use. The surgeon and his assist-
ants wash their hands thoroughly in 1-40 lotion, or in
important operations in l-'20. The patient having then been
brought under the influence of chloroform or other anaesthetic,
a towel is arranged close to the tumour, genei"ally on the part
of the table between the operator and the patient, which towel
has been well soaked in 1-20 carbolic lotion, and is meant as

AN ASEPTIC OPERATIOX. 47

an antiseptic basis on which instruments may be laid during
the course of the operation without any fear of their contamina-
tion. This towel is so arranged as to be within the cloud of
spray. A spray being now made to play over the part from a
convenient distance, the surgeon makes his incisions, removes
the tumour, ties the vessels with catgnt, introduces a suitable
drain, stitches up the wound, and applies a piece of protective
but little larger than the wound — the protective being of course
dipped in the 1-40 carbolic solution. Outside this is placed
a piece of wet gauze, consisting of several layers of loose gauze
which have been soakinc: for some time in the 1-40 carbolic
solution. This wet gauze and protective are called the deep
dressing. The wet gauze must overlap the protective in all
directions. Then any remaining hollow is filled up with loose
gauze, and outside the whole a gauze dressing is fixed. This
dressing consists of a piece of carbolic gauze of suitable size,
folded in eight layers, and having the macintosh placed
beneath the outermost layer, with the india-rubber side
inwards. The dressing is fixed by means of a bandage, and
when this is accomplished the spiay may be stopped. Then
around the edge of the dressing an elastic bandage is applied
so as to keep the edge constantly in contact with the body, and
to allow no interval to occur between the dressing and the skin
during the movements of the patient. The elastic is carefully
fixed to the edge of the dressing by means of safety pins.

In the after progi-ess of the case the dressing is changed
according to the amount of discharge, though in no instance is
it left longer than eight days.

Such is, very briefly, a sketch of the ordinary method of
pei'forming operations aseptically. I shall now consider each
step in detail, and point out the most frequent sources of
failure in carrying out the method ; for it must always be
borne in mind that the whole operation, as far as regards the
avoidance of putrefaction, requires as much care as if it were
an experiment performed in a laboratory on putrescible fluid
contained in glass vessels.

48 ANTISEPTIC TEEATMENT OF WOUNDS.

The first thing, then, is to purify the skin in the neigh-
bourhood of the seat of operation. This is necessary, hecause
the skin is covered with dust. The natural grease of the skin is
not easily removed by simple washing, and it protects the septic
particles present beneath it and in the hair or sebaceous follicles.
This purification of the skin is carried out by washing it well
with 1-20 carbolic lotion, the antiseptic being allowed to act
for some time. It is well, as I have said, having first washed
the neighbourhood thoroughly, to apply over the seat of
operation a large cloth or towel soaked in 1-20 solution, and
to allow this to remain on the part for an hour or more if this
is possible. Where the epidermis is thick, or where there is
any putrid matter present, it is best to apply this towel on the
day before the operation. The carbolic acid has a wonderful
power of penetrating grease or epidermis ; and if time be given
for it to act it is unnecessary to wash off the grease beforehand.
If the wound is to be in the neighbourhood of hair, as in the
axilla or near the pubis, the part must be shaved, and then
well soaked with the carbolic lotion.

The errors in the purification of the part may be that the
skin is not purified at all, or that it is washed with water; or,
as I have seen, the operator simply allows a carbolic spray to
play over it for a minute or two, and is satisfied with this ; or
he merely rubs the surface with his wet finger. This purifica-
tion must, however, be done thoroughly, for every hair follicle
and gland duct may contain causes of putrefaction. Carbolic
oil is used by some instead of the watery solution to puiify the
skin. This is a great mistake, for oil has a much greater
affinity for carbolic acid than water has, and therefore the
carbolic acid in the oily solution does not act with the same
rapidity as the watery solution. The inefficiency of the oily
solution for this purpose will be at once understood on referring
to the remarks in the last chapter.

At the same time the operator and his assistants purify their
hands. This must also be done thoroughly, and the folds of
skin about the nail more especially must be well cleansed with

PURIFICATION OF INSTEUMENTS.

the lotion. In an important operation, as in aii operation on
a joint, it is well to use 1-20 carbolic lotion for this purpose,
so as to avoid the chance of a particle escaping ; but in ordinary-
operations 1-40 is quite sufficient. This purification of the
hands is only too apt to be a sham, no care being taken about
the nails and folds of skin. The 1-20 is not used in all cases,
because 1-40 is really sufficient, and the stronger solution is
apt to benumb the hand.

The instruments are purified by immersion in 1-20 carbolic
lotion before the operation. A tin or porcelain trough filled with
the 1-20 solution is employed for this purpose, the instruments
being placed in it some time before an operation (fig. 11). The
instruments are not merely dipped ; they must remain in the

Fig. 11.— Porcelaix Trough costaixisg Instbumexts soaking ix Carbolic

Lotion.

lotion for some time, because the cai'bolic acid requires a little
time to act on the grease or dirt on them. The teeth of toothed
instruments ought also to be cleaned thoroughly, and forceps
locking by catches ought to be Avidely opened, so as to allow the
solution to come in contact with all parts. The whole instru-
ment must be immersed, for if only the point be purified it may-
happen that the impure handle is inadvertently brought into
contact with the wound during the course of the operation.

The errors most likely to occur are either that during the
course of the operation an instrument not previously in the tray-
is used without any attempt at purification, or that the instru-
ment is imperfectly purified or only part of it cleansed. I have

50 ANTISEPTIC TKEATMENT OF WOUNDS.

seen the danger of partial purification more than once exem-
plified. Thus I have seen the blade of a knife alone purified,
and the surgeon in the middle of the operation use the unclean
handle to separate the tissues. Other errors in the manipu-
lation of instruments will be referred to presently.

The spray is very important in many cases, for it provides
an atmosphere in which instruments, &c., may be kept without
danger of contamination. In order to have a wide and large
antiseptic area in which to work, the spray ought not to be too
near, about six or eight feet or more being a suitable distance
for a good spray. Care must be taken that the spray is not
blown off the part by draughts or by people moving about. The
spray is most necessary in opening abscesses or in stitching up
wounds, for, to take the latter case, as the wound is not syringed
out after the stitches are inserted, septic air may be inclosed in
the cavity of the wound, and may give rise to putrefaction if
the spray has not been playing over the wound while the
stitches were being introduced.^

During the course of an operation any instrument which has
been once purified, if kept in the spray, even though covered
with blood, remains pure, and may be introduced into the wound
without hesitation. The same is the case with the hands of
the operator or assistants ; and therefore the dresser, in handing
instruments to the surgeon, must hand them into the sjyray
(fig. 12). If in the course of the operation the surgeon reaches
his hand or an instrument out of the spray for any reason
whatever, it must be repurified before being put into the
wound. For this purpose there is generally a basin of 1-40
carbolic lotion placed close to the operator in the line of
the spray, in which fingers, instruments, &c., may be re-pvirified
by momentary dipping. When instruments are laid down
out of the spray, or, in the spray, on a blanket, they must

> As the result of recent observations it is open to question whether the
spray can really fulfil the object in view of destroying all the bacteria in
the air. It, however, constantly bedews the surface of the wound with
carbolic lotion, so that if living organisms do fall in the action is con-
tinued, while it will hinder their development if they should not be killed.
It also keeps the hands and instruments constantl}^ moist with the lotion.

SPKAY.

be repurified before being used again. To provide a basis
on which instruments may be laid, the carbolised towel is

J2 C S O

^.•S bo—
,^ m t- tK
'a O S -*^

g nS a

F 0) 11 a

<2^ 5 3

X ^-1 en
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S'cu'-S 9
-*- to J5

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,s C) -^-'

" S 9 2

i^S -"^
2gs 3
m «■« >;

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a 2 Si3

.2"^ K o

S >>o-
a) C3 „ a

QQ OJ *

o-^J

+3 — -—

■^ o 2 .2 F'

0) o *^ ^

5f.1 o x ^'
^: 2 g > «"

Q> w o C3

g25g2
t^-g bc"--

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--, fc ^ -s ''

g-2 5f g

Or.

o-e.

2 — T i2 a

3 =. 2 -= m
O C3 +3

arranged before the operator as formerly described, and the
bhnnkets in the neighbourhood are generally also covered up

ANTISEPTIC TREATMENT OF WOUNDS.

with wet towels, so as to avoid the chance of the instruments
being hxid on the blankets (see fig. 13). Should the operator,
during the course of an operation, wipe his hands in a dry towel,
or touch any unpurified substance, he must remember to wash
his hands in 1-40 carbolic lotion before re-introducing them into
the wound.

Fig. 13.— To Show the Arbangemext of Towels, &c., is a Large OrEKAXiON.

a (I (I are three towels wbleli have been soaked in 1-20 carbolic lotion, so that instru-
ments &c., may be placed on them without fear of contamination. Thus a small
sponge will be seen on the upper one. (I is the dish containing 1-40 carbolic lotion
which always stands before the operator, and in the line of the spray. In this he
places the instruments which are not being used, and in it he repurifies his hands
or instruments if they have been removed from the cloud of spray. In this particular
instance we have a Large wound, c, to deal with— one so large that a single spray, unless
of large volume, may not cover it completely. Hence a piece of ffiiard, h, soaked in
carbolic lotion is thrown over the front of the wound while the surgeon is attending
to the axillary part, or rice rersd.

These precautions se3m on the one hand self-evident, while
on the other they seem so burdensome to remember that they
are often neglected by self-sufficient sui-geons. And yet it is by
the neglect of these, rather than by error in any other part of the
Listerian method, that mistakes arise and failures occur. Many
people think that the spray is the essential pp^rt of the treat-

SPEAY. 53

ment, and neglect the precautions as to constant purification of
instruments, &c., and when their cases go wrong they say that
the principle is incorrect. And yet one thoroughly acquainted
with the Listerian method will readily detect the loopholes,
and the general loophole is the omission of some of the pre-
cautions with regard to purifications of fingers, instruments, &c.
Thus I have seen a surgeon with considerable experience in
aseptic treatment, during the course of a difl&cult operation wipe
his hands with a dry towel and immediately introduce them,
covered with the dust from the towel, into the wound. The
patient died of septic poisoning. Now many surgeons might
have said, ' I used the spray ; I used all precautions ; my instru-
ments were soaking ; my hands were purified : ' forgetting this
one little incident. When the point was mentioned, however, the
mistake was at once seen. People are too apt to trust to the
spray as suflBcient, and to speak of aseptic or Listerian surgeiy
as treatment by the spray. This is a great and often fatal
mistake. Of all the precautions required by Sir Joseph Lister,
that of purifying the air by means of a carbolic acid spray is
the least necessary, for there are but few septic particles present
in the atmosphere, and even though some of them fall on to a
wound they may be rendered inert by washing the wound with
carbolic lotion. It must always be remembered that Sir Joseph
Lister carried out aseptic treatment for years with great success
without any spray; and if at the present time he were compelled
for any reason to give up some one precaution, he would at
once throw aside the spray, as that one which is least necessary,
and which could be the most readily dispensed with. At the
same time the spray is an immense convenience in many cases,
more especially in abscesses, empyemata, in stitching up wounds,
&c. ; and it saves the necessity of applying a great deal of car-
bolic acid to wounds by irrigating them, with the consequent
iriitation and risk of carbolic-acid poisoning.

To return to the errors which may arise in this part of the
treatment. It may be that the spi'ay is too near, and that thus
the cloud is so narrow that the surgeon is constantly getting

54 ANTISEPTIC TEEATMENT OF WOUNDS.

his hands or his instruments out of it, and forgetting to repurify
them. There are other disadvantages when the spray is too
near. Thus it is vei-y wetting, and the hands of the svirgeon
and the wound are unnecessarily irritated by the carbolic acid.
If too near, the opaque spray also obscures the field of vision.
Other sources of error are that instruments may be used which
have never been purified, which have been only imperfectly
purified, which have after their use lain about outside the spray
or on blankets, &c. ; or it may be that the carbolic acid get.«
exhausted in the spray bottle, or that for some other reason the
spray does not act properly.

What is to be done should anj^ of these accidents occur 1
Suppose that an impure instrument or finger be introduced into
the wound, that wound must be at once thoroughly washed out
with 1-40 carbolic lotion. This is a bad thing for the wound,
because it irritates it, and may prevent healing by first inten-
tion ; or by causing a much larger quantity of discharge than
usual, the gauze dressing may be so saturated with the discharge
as to render it unable to prevent the spread of putrefaction in-
wards. Therefore it is better to use the spray, and to take all
the precautions before mentioned. Should the spray stop, the
wound must be washed ovit just as in the former case, and then,
till the spray can be set agoing again, the wound is covered with
a piece of rag soaked in carbolic lotion.

This piece of rag, called the guard, ought to be always
present in the basin by the side of the surgeon, and when there
is any indication that the spray is failing, or should it be
advisable to stop the spray for any reason, this is thrown over
the wound for the time being. Should any time elapse before
the spray is again ready for use, this guard must be repeatedly
moistened with carbolic acid lotion 1-40.

Where the wound is very large it may be protected during
the operation either by having two sprays, or by covering up the
part of the wound which is not being operated upon by a guard
(see fig. 13).

The arteries are ligatured with catgut. This catgut is

LIGATURE OF ARTERIES.

The largest is

generally employed of three different sizes,
used only for large vessels or for stitches ; the medium for
medium-sized vessels, or for vessels in inflamed or dense tissues
where considerable force is required to constrict the vessel, or

Fig. 14.— Method of Tyixg Vessels in Dense Tissues.
(After MacCormac.)

for stitches ; the small or fine catgut is that ordinarily employed
for the smaller vessels. The vessel having been securely tied,
the catgut is cut .short and gives no more trouble. It is well
to tie all the visible bleeding
points, because a little oozing
of blood may give trouble
afterwards from tension. If
the vessel be situated in dense
tissue, so that a ligature can-
not be applied around it, a
needle carrying a double cat-
gut thread should be passed
through the tissue and tied on
each side of the vessel (see
figs. 14 and 15). Where the
bleeding is from a tear in a large vein, and where it would be
dangerous to ligature the vessel, I have seen the following

Fig. 15.— Another Method of Tyixg
Vessels rs' Dexse Tissues.

(From Esmarch.)

56 ANTISEPTIC TEEATMENT OF WOUNDS.

method adopted by Sir Joseph Lister. In removing some
cancerous glands from the axiUa, a small vein was torn away
from the axillary vein at their junction, making practically a
longitudinal rent in the axillary vein. Taking a fine curved
needle and the finest catgut, he stitched up the rent by the
glover's suture. The patient recovered without the slightest
bad symptom. There was no pain in the wound, nor swelling
of the arm, &c. In another case where the longitudinal sinus
was injured in trephining the skull, the wound was plugged
Avith catgut, and the patient recovered without any untoward
symptom.

The drainage of an aseptic wound is the point next in im-
portance to keeping the wound aseptic. For if the blood and
serum which collect in the interior of the wound within the
first twenty-four or forty-eight hours do not get free exit, they
give rise to tension, and tension gives rise to inflammation, and
the latter, if allowed to go on long enough, to suppuration ;
and thus the rapid healing of the wound is prevented though
the patient is not as a rule subjected to any danger to life. To
avoid these consequences Sir Joseph Lister has paid very special
attention to the drainage of wounds. There are two main ways
in which this may be done — drainage through tubes, or drainage
by capillarity. The former is the most universally applicable
and the most certainly successful.

Drainage by means of tubes is the form of drainage first used
by Sir Joseph Lister, and, as just stated, is that which is most
universally applicable. The tubes generally employed are the
india-rubber tubes introduced by Chassaignac, though of late the
kind of rubber h,o,s been altered, that now used being red rubber,
Avhich contains no free sulphur. By the use of these red rubber
tubes disagreeable smells and blackening of the protective, which
often occurred when the black tubes containing free sulphur
were employed, are avoided. These tubes have round holes cut
in them at short intervals, the diameter of each hole being about
one-third of the circumference of the tube. At the outer end
the tubes are cut flush with the surface of the skin — straight

DKAINAGE.

across if the tube goes directly downwards, or with varying
degrees of obliquity according to the direction which the tube

Fig. 1G.— Ordinary Obliql'e-Exded Draixage-Tu-be ready for Use.

takes (fig. 16). The tube must not project beyond the surface,
for if it does its orifice gets compressed by the dressing, and the
exit of fluid is prevented. To keep the drainage-tube from
slipping in, two threads of carbolised silk are fastened into it at
its orifice, and tied in a knot. This knot, held between the

Pig. 17.— Draixage-Tl-be with Masses of Gauze ix the Loors of Thread.

dressing and the skin, retains the tube in position. In some
cases, however — as, for example, in empyema — the tube might
slip in in spite of these threads, and therefore it is well to fill

ANTISEPTIC TEEATMENT OF WOUNDS.

up the loops with strips of gauze soaked iu the carbolic lotion
(tig. 17). These absolutely prevent the tubes from slipping in.
These tubes are always kept in a large vessel containing 1-20
carbolic acid solution, and are thus always ready for use. When
a tube is altogether removed from a wound it is not thrown
away, but is washed and put into the bottle with the other
tubes, and used for another case. These tubes vary in size,
according to the size of the wound and the amount of discharge
expected, and are arranged so as to drain the parts of the
wound which form cavities, or from which the greatest amount
of discharge will come. It is not necessary that their orifices
be dependent, though it is of course better that they should be
so. It is not essential, however, because the fluid, as it forms,
wells out, and, not being putrid, that which lies at the bottom
of the drainage-tube does not cause irritation. In cases where
the most dependent opening w^ould be near sources of putrefac-
tion, it is well to have the
drainage-tube in another
part of the wound, even
though it be not so depen-
^ / I'n dent. Thus in inguinal
hernia the tube would no
m doubt be in the most de-
^ // m pendent part if its orifice
wei-e close to the pubis, but
,, „„ ^ , ,,„ as that would be much too

«a»^ ' / / \ iiear sources of putrefac-

k^r //, // M tion, such as the vagina and

/MK- j| penis, the orifice of the tube

4r V ought to be at the outer

angle of the wound (see fig.
Pig. 18.— Incision fok Inguinal Heenia, iq» t„ „ Ioi.q'p wnnnrl it

STITCHED, SHOWING THE POSITION OF THE ^^)' ^^ ^ ^^^^^ WOUnQ It

Prainage-Tube AT THE Outer Angle OF jg well to have more than
THE Wound.

one tube ; and it is better

to have two smallish tubes in any case, rather than one large

one, because on the day after the operation one of these tubes

DEAINAGE-TUBES. 59

may be removed altogether ; whereas it' a large one were pulled
out in order to insert a smaller, there would be the greatest
difficulty in introducing either. No tube which one wishes to
put back again should be removed till the third day, on account
of the difficulty of returning it. By that time, however, it lies
in a channel in the blood-clot or lymph, and slips back easily.
Fig. 19 represents forceps introduced by Sir Joseph Lister, and

Fig. 19.— Sixus Poeceps.

called ' sinus forceps,' which are of the greatest service in insert-
ing drainage-tubes. Generally on the third day half the tube is
cut ofi", and it is reduced in length at subsequent dressings till
it becomes no longer necessary. No exact rules can be given
for shortening or leaving out the tube. This must simply be
a matter of experience, guided by the amount of discharge and
the tendency to accumulation or otherwise. Should tension
occur, a larger and longer tube ought to be at once introduced.
A point which has always seemed to me of great importance
in connection with the use of these tubes, and one which has
apparently been overlooked, is the following. A tube is taken
out of carbolic lotion at some distance from the spray, is carried
through the air, and then directly introduced into the wound.
I can hardly believe that when a large tube is taken out of the
lotion there would be sufficient vapour of carbolic acid in it to
destroy any septic dust which might get into its interior, for
a considerable mass of air must take the place of the fluid, and
this amount of hospital air may often, as I have found by
experiment, contain causes of putrefaction. Of course when
passing through the spray this air may be displaced or purified,
and also when introduced into the wound a considerable amount

ANTISEPTIC TREATMENT OF WOUNDS.

of it would be forced out ; while at the same time there is a good
deal of carbolic acid present, and purification in one Avay or
another would probably occur. And, further, the purifying
power of healthy living tissues must be taken into account.
But in the case of a cavity, purification in any of these ways may
not happen, and putrefaction may result. My suggestion there-
fore is always to take the tubes out of the lotion -m the spray,
and then the air which enters them will be air- previously acted
on by the spray.

Drainage by capillarity was introduced by Mr. John Chiene,

Fig. 20.— Catgut Draix Ready for Ixsertiox.

who was also the first to enunciate the principle of absorbable
drains. For this purpose he uses catgut, and generally the
finest threads. A skein of catgut, containing say twenty threads,
is tied at its middle by a single thread of the same gut. One
end of this thread is passed through a needle (fig. 20), and by
means of this the centre of the skein is stitched to the deepest
part of the wound (fig. 21). The skein is now broken up into
bundles of five or six threads each. One bundle comes out at
each angle of the incision, and the other bundles at intervals
between the stitches (fig. 22). More than one skein may be

DRAINAGE EY CATGUT.

required in a large wound. This catgut becomes absorbed, and
never requires to be removed. In five or six days the ends
which hang out drop oflT, and little granulating sores are formed
which heal in a few days. In this method the serum escapes
by capillarity, and by distributing the threads over various
parts of the wound the true principle of drainage is carried out ;
for, as pointed out by Mr. Chiene, in draining a field one does

FcG. 21. — OPEiiA'nox FOE Stretchixg the Sciatic Xerve.

•Catgut drain stitclied to the deepest part of the wound, beneath the gluteus maximus,
and broken up into four separate bunches.

not have one large drain going from one end of the field to
another : on the contrary, the field is traversed by numerous
small drains. And so, in Ohiene's method of draining wounds,
we have a number of small drains traversing the wound in
several directions. In this method there is no trouble about
pulling out the drain, and no necessity for changing the dressing
simply to remove a tube ; the drain disappears of itself. It is
well to leave the ends of the catgut outside the wound as long

ANTISEPTIC TREATMENT OF WOUNDS.

as possible, so as to get a siphon action, and care must be taken
not to break up the bunches of catgut outside the wound, for
the capillary action occurs in the intervals between the threads
when they are closely apposed.

The objections urged against this method are, firstly, that
in large wounds it is not sufficient and that the catgut becomes
a pulpy mass, and when in large quantity takes a long time to

Fig. 22. — The same Wound Stetched.

The bunches of catgut coming out .at intervals between the stitches. (The wound has
been exaggerate<i, and the tlireadsof catgut separated, in order to show the method
more clearly. The threads of catgut ought to lie in close apposition, for it is the
intervals between the threads which act as capillary drains.)

organise. Not only may it be insufficient at first, but it may
become absorbed too soon — before, indeed, a drain of some kind
can be dispensed with.

Now these objections rest in great part on the fact that the
drain is often improperly employed. If, for instance, it be not
stitched to the deepest part of the wound, the catgut may slip
and the deeper parts may not be drained ; and again, if a large
bundle of it be used, coming out at one part of the wound only.

DEAINAGE BY HOESEHAIR. 63

it does become a pulpy mass, and takes a long time to organise.
But this is not the method recommended by Mr. Chiene, for he
says that only five or six threads ought to be brought out at
each place. There is, however, no doubt that in some eases it
is absorbed too quickly, and this was the real objection to the
use of this method when we had only the catgut prepared by
the old method, though even with it, if the gut was well pre-
pared and old, the drainage was often very satisfactory. This
difiiculty is lessened by the use of the chromic catgut • the only
difficulty now is that the drain lasts too long. Of course, if
necessary, the ends of the drain can be cut off, when it has
served its purpose, below the level of the skin, and then, even
though the internal part be not all absorbed, the wound can heal
completely.

Catgut can only drain fluids svich as blood or serum ; it
cannot drain pus. It is, moreover, unsuitable in cases of chronic
abscess, where we have only a serous discharge, because the
catgut is absorbed at the surface long before a drain can be
dispensed with.

If the wound is very large it is best to introduce tubes as
well as catgut drains at first. The tubes may be removed in
twenty-four hours.

Instead of catgut, horse-hair has been a good deal used.
This is simply laid into the wound in the situation where it
seems most required. It is diminished by degrees, threads
being taken out at various intervals of time. It has an advan-
tage over catgut in draining joints, for no part of the drain
remains in the interior of the joint, while portions of catgut do.
Further, it is not absorbable.

But it has the same disadvantages as the drainage tubes,
and it is not readily retained in the deeper parts of the wound.
It is, however, preferred by Sir Joseph Lister to the catgut.

It is easy to re-introduce a horse-hair drain if necessary by
proceeding in the following manner : A sufficient quantity
being taken, the bundle is bent at its middle over a probe, and
tied close" to the probe by carbolised silk (fig. 23). In this

ANTISEPTIC TREATMENT OF WOUNDS.

way, the probe being withdrawn, a blunt compact end is obtained
which may be introduced into the wound with ease.

The principle of absorbable drains has also been applied
by Dr. Neuber of Kiel ^ in his absorbable drainage tubes.
These are tubes drilled in long bones, and then decalcified and
carbolised. Holes are afterwards cut in the sides, and they ai'e
used like ordinary india-rubber tubes. These tubes are said to
answer veiy well, though they are sometimes absorbed too soon,
and sometimes last too long. They sometimes get soft and
collapse about the third or fourth day, and thus, though not
absorbed, become useless as a drain.

Dr. MacEwen ^ has lately somewhat modified Neuber's tubes.
He uses chicken-bones, which are already hollow, and decalcifies

Pig. 23.— Method of Peeparing a Hoese-Haie Drain for Re-Ixtroductiok.

them. ' The method of prepai-ation is as follows : The tibife
and femora are scraped and steeped in hydrochloric acid and
water (1 to 5) until they are soft. Their articular extremities
are then snipped off with a pair of scissors ; the endosteum is
raised at one end and pushed through to the other extremity,
along with its contents. They are then re-introduced into a
fresh solution of the same strength until they are rendered a
little more pliable and softer than what is ultimately required
(as they afterwards harden a little by steeping in the carbolised

' ' Ein Antiseptischer Davierverband nach griindlicher Blutstillung,'
von Lavrienicc'k'x ArcMr, Bd. xxiv. Heft 2.
"^ British Medical Joxirnal, Feb. 5, 1881.

SUTUKES.

solution). When thus prepared they ai-e placed in a solution of
carbolic acid in glycerine 1-10. They may be used at the end
of a fortnight from the time of introduction into the glycerine
solution. Holes may be drilled in them with a punch, or clipped
out with scissors.' These tubes are threaded with horse-hair
before being introduced into the tissues. This hair helps to
maintain the calibre of the tube during the first few days, and
also itself acts by capillarity.

The average duration of MacEwen's tubes in the tissues
was something over eight days. If, however, a tube is likely to
be required for a longer time, it can be obtained by steeping
the decalcified tubes in a chromicised instead of a carl^olised
solution. These resist the action of the tissues for two or three
weeks.

The accurate stitching of the edges of the wound is another
feature in aseptic surgery. In operating aseptically the same

Pig. 24. — Lead Buttons for Deep Stitches.

A, Tlie present form, described in the text. B, Form of button devised by Dr. (^ilvie
Will (seen in section). C, The old form, where the wire was fastened by passing it
beneath the button.

care need not be taken to remove as little skin as possible, as
is necessary in wounds treated by other methods where swelling
and inflammation of the edges are expected. One may take
away a wide sweep of skin, such as would seem to render
hopeless any attempt to bring the edges of the wound into
apposition; and yet if the edges can only be apposed, and if
the wound remains aseptic, union by first intention may be
expected along the whole line.

Button stitches are employed to relax the edges of the

ANTISEPTIC TEEATMENT OF WOUNDS.

wound, and thus to leave the cutaneous margms free from the
irritation which must occur if they are tightly drawn together.
These consist of flat pieces of lead cut of an oval form and of
various sizes, perforated in the centre by a hole through which
silver wire is passed, and provided with two lateral wings round
which the wire is twisted (fig. 24). (There are various forms
of button suture, but all act on the same principle.) These are
applied some distance on each side of the edge of the wound,
and connected by strong silver wire drawn tight enough to
permit the edges of the wound to come easily together. The
number used varies according to the amount of tension. In
order to bring the edges of the wound into actual contact,

Fig. 25. — Wound after Removal op Mamma and Axillary Glands, Stitched.

To show the three kinds of stitches. The button stitches will Be at once recogui=cd ;
the thick stitches, of which three .are represented, are tlie stitches of rela.xation ;
and the remainder are the stitches of coaptation.

two sets of stitches are employed : silver wire stitches, which
take a good hold of the tissues and are placed at regular inter-
vals, termed stitches of relaxation ; and in the intervals between
these, in order to have the cutaneous margins accurately applied
to each other, numerous stitches of coaptation, consisting of
carbolised silk, horse-hair, or catgut (fig. 25). The speedy
healing which occurs when the edges of tlie wound are accu-
rately brought in contact, while they are at the same time,
by the button stitches and the stitches of i-elaxation, freed from
any tension, rewards the surgeon for the time spent in insert-
ing a large number of these stitches of coaptation.

STEAPPING; DEESSING. 67

In taking out these stitches it is best to follow a reverse
order to that of insertion. The first to be removed are the
stitches of coaptation, while the stitches of relaxation are pro-
bably cut on the same day. Do not be in a hui'ry to remove
the stitches where there was much tension in bringing the
edges of the wound together, A week or ten days is time
enough.

Should the wound gape, strapping may be employed, even
under an antiseptic dressing. To render the strapping aseptic,
it is immersed in warm carbolic lotion (one part of 1-20 and an
equal part of boiling water) before being applied. This both
renders it aseptic and also takes the place of the hot-water can
for heating the strapping.

Having proceeded thus far in the aseptic operation — having
tied the vessels, ari-anged the drainage, and brought the edges
of the skin well together — we must now apply a dressing which
shall prevent the occurrence of putrefaction till the case is
again seen.

In applying a dressing we must in the first place be careful
to make it as little irritating as possible to the young epithelium
along the line of incision. The dressing usually employed is the
carbolic gauze ; and, to prevent the irritation of the healing edge
of the wound by the carbolic acid, a jiiece of protective is inter-
posed between the gauze and the wound. This protective is
cut a little larger than the wound, and it is well to cover the
buttons with a little bit also, in order to prevent the threads
of the gauze becoming entangled in them. This protective
need not extend over the orifice of the drainage tube, as its
essential object is to jorotect the healing part from the irritation
of the cai-bolic acid. The protective is also of use in j^reventing
the di-essing from sticking to the wound, and in preventing the
formation of scabs, and the consequent possible retention of the
discharge.

An error which is frequently made is to put on too large a
piece of protective. There is nothing antiseptic in its substance,
and it protects the discharge beneath it from the action of the

F 2

ANTISEPTIC TREATMENT OF WOUNDS.

carbolic acid. Therefore if at any part it projects beyond or
comes close to the edge of the dressing, it allows the causes of
putrefaction to spread inwards beneath it, and prevents the
carbolic acid from acting on this putrefying discharge. It is
therefore a very good rule, having covered the wound with
sufficient protective, to look on this protective as a wound, and
to be as careful in having the gauze dressing overlap it in all
directions as if it itself were the wounded surface. Wliere
there is very little space for overlapping, as in inguinal hernia,

Fig. 26.— ExcrsiON op the Hip-Joint.
Wound stitched ; protective and deep dressing applied.

no protective ought to be applied. It is better to have some-
w-hat slower healing than to have micro-organisms spread into
the wound. As mentioned before, this protective is dipped in
carbolic lotion 1-40 before being applied.

Outside the protective a piece of gauze wet in the carbolic
lotion 1-40 is applied so as to overlap the protective in all
directions. The reason for wetting the gauze is that drv gauze
is apt to receive dust on its surface before being used, while at
the ordinary temperature of the atmosphere but little carbolic

DEEP DEESSING. 69

acid is given off from the gauze, certainly not enough to destroy
immediately the activity of the septic particles in the dust.
But if the piece of gauze applied next to the protective be
moistened in the 1-40 solution, this dust is at once deprived
of septic energy, and we apply over the wound a layer of pure
and powerfully antiseptic material.

The piece of wet gauze and the protective go by the name
of the deep dressing. This deep dressing may in some cases,
and more especially whei'e catgut stitches and catgut drains are
used, be left for several days undisturbed. In this way the
wound is not irritated by the application of carbolic acid to it
every time the dressing is changed. If the deep dressing be
thus left on, it must be remembered that the deep piece of
gauze loses all its carbolic acid very soon, and that therefore
it must be treated as a wound — i.e. in renewing the dressing
this deep part must be overlapped in all directions by a piece of
wet gauze, and that again by a dressing of suitable size.

In some cases it may be desirable to fix down the deep
dressing with a piece of gauze bandage. If it be intended to
leave on this deep dressing for some time it is well, before
applying it, to rub the neighbourhood of the wound with the
salicylic cream mentioned before. It sometimes happens that
when a dressing is left on for many days together, the discharge .
becomes somewhat irritating, and the skin around the wound
becomes excoriated. This is generally entirely jirevented by
the use of salicylic cream.

Having arranged the deep dressing in a suitable manner,
any hollows which exist in the neighbourhood of the wound
are filled up with carbolic gauze, and special masses of this
material are placed where the greatest amount of discharge is
expected. Outside this comes a large gauze dressing. In making
the gauze dressing a piece of macintosh cloth with the india-rubber
side uppermost should be laid on a table and sponged with 1-20
carbolic lotion ; the gauze is laid on this. The gauze is folded in
eight layers, or sixteen if much discharge is expected, and a
piece of macintosh cloth of the size of the dressing is placed

ANTISEPTIC TREATMENT OF AVOUNDS.

beneath the outer layer, with the rubber side towards the mass of
gauze. The size of this dressing varies according to the amount
of discharge expected, but in all cases it must extend well be-
yond the deep dressing in all directions. Some special examples
will be mentioned presently.

This dressing is fixed on with a suitable bandage. The gauze
bandage is preferable to an ordinary bandage under certain
circumstances. It is especially convenient in bandaging a
stump next the skin to prevent retraction of the flaps, and also
for fixing down the deep dressing. It also increases the amount
of antiseptic material outside the macintosh if there happens
to be a hole in it. But for ordinary use in fixing on dressings

Fig. 27.— Dressing ix a Case of Psoas Abscess opened above Poufaut's

Ligament.

To show the arrangement of the elastic bandage along the margins of the dressing.

very light and cheap bandages may be made from the ordinary
thin muslin which is used as a guard. They do not stick to
the skin as the gauze bandage is apt to do.

The dressing is pinned round its edge to the bandage.
Care must be taken not to put pins through the macintosh at
any part except at its edge. Pinholes through the centre of
the macintosh simply defeat its object by permitting the
discharge to come directly through the dressing. The object

ELASTIC BANDAGE. 71

of the macintosh is to make the discharge travel through a
large extent of the gauze, and thus the same result is obtained
as if a mass of gauze were applied over the wound, of the same
thickness as the distance from the centre of the macintosh to
its edge. If, therefore, there be a pinhole near the centre of
the macintosh, the object of the latter is seriously interfered
with. Accordingly, it is always the duty of the person who
makes the dressings to examine the macintosh with the view
of detecting any holes in it.

If the dressing is to be used as soon as it is made up, it is
well to sponge the surface of the macintosh with i-20 carbolic
lotion before inserting it into the dressing. The same piece of
macintosh may be used for a whole case, or for more than one —
so long, in fact, as it does not become worn into holes. Two
pieces of macintosh aie generally provided for each case, and
a dressing is always made immediately after the case has been
diessed, and is ready for application at any time.

During the movements of the patient, the edge of the dressing
might become separated from the skin, and air pass into the
space thus formed. To prevent this, the German surgeons as
a rule pack in salicylic jute or wool beneath the edge of the
dressing. This may serve the purpose, but it is by no means
safe. Sir Joseph Lister some time ago introduced the use of
elastic webbing, which is of various breadths. It is better
not to be too broad. It is put moderately on the stretch, and
surrounds the edge of the dressing. Its general arrangement
varies of course with the situation. It is not much used on the
extremities, because the arm or leg is generally so fixed by
means of splints that there is no chance of separation of the
dressing.

The operation and first dressing having now been completed,
the question arises when the dressiug should be changed. It is
only extremely i-arely that it is necessary to change it the same
evening. The only cases in which this is usually done are
large empyemata or very large abscesses, and cases of amputa-

■2

ANTISEPTIC TEEATMENT OF WOUNDS.

tion at the hip-joint, where the discharge of bloody serum is
profuse, and where there is but little space for overlapping of the
dressing.

As a rule, the dressing ought to be changed entirely on the
following day, the deep part as well as the superficial. It is
well to change the deep dressing in order to see that none of
the stitches are too tight, and that the drains are acting propeily.
After the first day the deep dressing need not be touched, unfes
the patient is complaining of uneasiness, or unless the surgeon
wishes to see the wound for the purpose of removing stitches
or drain. If it is not necessary to disturb it, it may, especially

Fig. 28.— Method op CiiAXGiXG a Psoas Abscess Dressing.

A, Hand of patient holdings flown the rlressing over the wound. BB, Hands of pnrgeon
lifting the lower edge of the dressing (C ). D, The spray machine so placed that the
spray passes in beneath the dressing as it is lifted.

where there is an organising blood-clot, be better not to do so,
for that would only be to expose the wound unnecessarily to the
irritation of the carbolic acid. If the deep dressing is not
changed, great cai'e must be taken to have an efiicient spray
playing over the part.

In changing the dressing the spray is used, and also 1-40
carbolic lotion, in which a piece of loose gauze and protective

CHANGE OF DEESSIXGS. 73

are put before the dressing is begun. The elastic bandage is
first removed, and then the patient or an assistant places his
hand over the centre of the dressing while the bandage is
being cut, so as to prevent the dressing being lifted up and air
pumped in. Then the surgeon, having purified his fingers, and
having turned on the sp'"ay, lifts the edge of the dressing care-
fully, taking care that the spray passes into the angle between
the dressing and the skin (see fig. 28). Having removed the
superficial dressing, he again dips his fingers, and then removes
the deeper parts and exposes the wound.

If nothing is wrong, he immediately applies fresh protective
and wet gauze, and then washes the parts round about, as far
as the discharge has extended, with 1-40 carbolic lotion. The
edge of the wound is not washed or exposed to the action of the
spray longer than is absolutely necessary. It is well to apply
the deep dressing at once, for in washing the surrounding parts
one is apt to give the wound a final touch with the rag. Now
this rag may contain some gross particles of jjutrid material
(such as a crust of discharge from the exterior of the dressing,
fseces, &c.), and thus putrefaction would be communicated to
the wound. There is no necessity for cleansing the edges of the
wound. Dirt, so long as it does not contain causes of putre-
faction, does no harm; indeed, it rather aids the action of the
protective ; while to rub it away is to irritate and injure the
healing edge — to produce a state of unrest. A fresh dressing is
applied as befoi-e described.

Where there are two wounds in different situations, so placed
that the spray cannot command both, each must be dressed
separately, care being taken not to uncover the one till the
other is at any rate protected by a deep dressing. The patient
or assistant must keep his hand on the dressing over the one
wound, while the other wound is being attended to.

The next dressing takes place on the following day at visit,
if there is any discharge at the edge of the dressing or if the
wound feels uneasy. If there is no discharge on the drawsheet,

74 ANTISEPTIC TREATMENT OF WOUNDS.

and if the wound is free from pain, the dressing is not changed ;
and even though discharge should appear a few hours later, the
dressing is not changed till next day at visit hour. The rule
for changing the dressings is therefore : Change if discharge is
through at the visit hour, or if there be any other reason for it ;
if not, leave the dressing till next day at visit, and then follow
the same rule.

Never leave a dressing unchanged longer than a week. By
that time most of the carbolic acid has passed off by evapora-
tion ; and therefore, if the discharge once came to the edge,
putrefaction could spread inwards with great rapidity. And it
would not be necessary for the discharge to appear at the edge
in order to have putrefaction of the wound, for the sweat collect-
ing beneath the dressing permits the multiplication of septic
particles in it, and thus they may reach the wound. Where a
dressing is to be left on for a week, it is well to use the salicylic
cream in the way before described.

Such is the general method of using cai-bolic dressings ;
special modifications will be noticed presently. Let me pass
on in the meantime to the general points as to boracic dressings.

Let us suppose that a patient is admitted with a foul ulcer
of the leg : how is he to he treated 1 If he were to be treated
with carbolic dressings, the ulcer would very piobably remain
foul, or even though it ultimately became free from odour, it
would heal excessively slowly. Hence Sir Joseph Lister first
purities the sore, and then dresses it with boracic acid.

To purify the sore, chloride of zinc, 40 grs. to the ounce of
water, may be used. This is applied thoroughly to the whole
surface of the sore, and at the same time the surrounding skin
is well purified by thoroughly washing it with 1-20 carbolic
lotion, which is employed on account of its special power of
penetrating the epidermis. When this has been done, a piece
of protective, dipped in boracic lotion and slightly larger than
the sore, is applied over it, and outside this one or two layers of
moist or dry (it does not much matter which) boracic lint are

BOKACIC DRESSINGS. 75

applied, of sufficient size to cover the protective well Ib all dii^ec-
tions. There is the same objection here to allowing the protective
to project beyond the edge of the dressing as in the case of the
carbolic dressings. Lately, instead of applying the chloride of
zinc solution, which causes considerable uneasiness, iodoform
has been powdered over the whole surface of the ulcer, and it
has been equally successful. Tlie chloride of zinc or the iodo-
form need only be applied once ; but should putrefaction not be
eradicated, the application is repeated.

This dressing is changed next day, but afterwards, as a rule,
it only requires to be changed every two or three days, or
indeed at longer intervals, provided that there is not much dis-
charge. That is to say, as there is a very large store of the
antiseptic in the lint, and as it is but slightly soluble at the
temperature of the human body, the discharge may go through
the dressing many times without washing out all the antiseptic.
At the same time, it is found as a general rule that the wound
heals most rapidly when the dressing is changed once in three
or four days.

At the changing of the dressing no spray is required. The
bandage (w^hich may be a common cotton bandage, if preferred)
having been removed, the dressing is taken off and the wound well
washed with boracic lotion. A final wash is given immedi-
ately before api>lying the fresh piece of protective and boracic
lint.

This boracic dressing is not used for wounds which are not
quite superficial, because the acid is not volatile, and because it
is but a feeble antiseptic ; but when once a wound has become
quite superficial, it will heal more quickly if treated with
boracic dressing.

In some cases, more especially where the sore is septic, or
where the patient dresses it himself, boracic ointment is prefer-
able to protective, and where the sore is healing, the half
strength ointment is the best. Outside the ointment a piece of
boracic lint is applied as usual. Of late, salicylic ointment has
been used, and found to answer, as a rule, better than the

76 ANTISEPTIC TREATMENT OF WOUNDS.

boi'acic. It is less irritating, and permits healing more readily.
A eucalyptus ointment has also been employed quite recently,
and has given good results.

When the effects of a poultice are wanted along with an
antiseptic effect, the boracic lint is applied like water dressing.
A suitable piece of the lint moistened in boracic lotion is applied,
and outside this a larger piece of macintosh or gutta-percha,
overlapping the lint in all directions.

CHAPTER VI.

ASEPTIC SURGERY — {continued).

Special dressings : Head di'cssings : Keck dressings : Breast dressings
— Abscess of mamma — Excision, of mamma alone — Exoisio7i of mamma
and axillary glands : Axillary dressings : Dressings on the limbs :
Dressings for j'soas abscess : Lumbar abscess : IlijJ-joint abscess :
Dressings in cases of hernia and ojjcrations on the scrotum : Excisions
of joints Aseptic treatment of abscesses. Chitf points to be con-
sidered in opening abscesses — Method of opening ahscesses — Drainage
of abscesses — After treatment of abscesses — Empyema — Perineal and
anal abscesses. Treatment of wounds produced accidentally : Pro-
plevi to be solved - Purification of mound — Further treatment of the
n-ound. Special wounds : Compound fractures : Wounds involving
tendons, nerres, 4'C- '■ Wounds of joints: Compound fractures of the
slivll: Penetrating wounds of the tliorax : Wounds of the abdomen.
Putrid sinuses and wounds. Treatment of burns. Treatment of
gangrene. Treatment of najvi and varicose veins.

I SHALL now describe the special methods of dressing and other
precautions required in diflerent situations.

In operating on the scalp the hair must be shaved for some
distance around the wound, and the hair beyond ought to be
soaked with carbolic lotion 1-20. If the incision be in the
centre of the scalp, or, in other words, if there be a ciicle of
hair all round it, it is better not to use protective at all, and
it is well to powder the hair around thoroughly with iodoform
or salicylic acid. The dressing in such a wound is fixed V>y
the ordinary capelline bandage. Where the wound is more
or less to one side, the dressing must extend downwards on
the neck, and it is then well to have a narrow elastic bandage
along the edges, more especially around the neck. In the
neighbourhood of the ears, the various cavities in the ear, and
the space behind it, must be filled up with gauze.

ANTISEPTIC TEEATMENT OF WOUNDS.

Neck dressings have nothing very unusual about them. The
dressing must be fastened round the neck. It must be pre-
vented from shpping down by a turn passing above the ears
and around the forehead, and also by two vertical turns over
the head, one transverse and the other longitudinal, these

various turns being piniaed together
where they cross. To prevent the dress-
ing from slipping up, turns are passed
under the axilla. A narrow elastic
bandage must be applied round the
edge of the dressing in this situation,
for the movements of the head are
extremely apt to cause an interval be-
tween the skin and the dressing (figs.
29 and 30).

Breast dressings are very important ;
they are arranged in three different
ways according to the size and extent
of the wound.

No. 1. — Where an abscess of the
mamma is opened, or where some small
incision, not interfei'ing with the form
of the organ, is made, the dressing con-
sists of an ordinary gauze dressing co-
vering the whole mamma, some loose
gauze being packed in in front and
behind. This is fixed by turns of band-
age passing round the body alternately
above and below the organ, with straps
over the shoulder. The arm is placed in a sling. The edges
are fixed by elastic bandage (fig. 31).

No. 2. — Where the mamma has been removed and the dis-
charge has become much diminished in amount, there may
remain enough of room between the wound and the axilla for
overlapping of the dressing. In order to fix the di-essing and

Pl(i. 29.

This figure illustrates the gene-
ral arraugement of dressings
on the neck. The arrange-
ment shown liere would do
for any operation about the
region of the sternomastoid
behind or below the ear.

BKEAST DEESSINGS.

keep it well up in the armpit, it is split vertically at the
axilla, folded over, and pinned on the top of the shoulder. It

Fig. 30.— To show the Aeeaxgemest of the Turns of Baxdagk ox the Head

SEEN from above.

Fig. 31.-DRESSING ArrLiED ix a Case Fig. 32.-Breast Dressing Xo. 2.

OF Abscess of the 1U^LMA (Breast
Dressing No. 1).

The position of the drainage tube is indicated by dotted lines.

is then bandaged securely, and an elastic bandage applied
around the edges (fig. 32).

ANTISEPTIC TEEATMENT OF WOUNDS.

No. 3. — Where the mamma and axillary glands have been
removed, or for the first few days after excision of the mamma
alone, this arrangement is not enough, for it does not leave
snflScient room for overlapping. The arm must therefore be
included in the dressing. This is accomplished most con-
veniently in the following manner : A large dressing is applied
posteriorly, reaching behind as far back as the middle line,
and folding over the arm so as to touch the thorax in front,
the arm being applied to the side. This dressing must be
broader than the length of the upper arm from the top of

"'imwi

\i\i\m

^mm

flfWWu

Fig. 33.— Case of Excisiox of the Mamiia.

Back dressing lying ready for application ; showin? also the deep dressing and padding
in the axilla and behind tlie arm.

the shoulder to the tip of the elbow, the overlapping parts
being caught by the turns of bandage passing over the
sliouider and round the body respectively. To prevent the
internal condyle from suffering from the pressui^e, a large
mass of gauze is applied behind the arm, extending downwards
almost to the condyloid region, but not reaching quite so far.
A mass of gauze is packed in between the arm and the side
and in front, filling up the angle between the arm and the
thorax (fig. 33). A smaller anterior dressing is then applied,

EREAST DRESSINGS.

narrower than the posterior, reaching as far forwards as the
middle line or beyond it, and outwards to the upper arm, the
edge of the anterior dressing passing beneath the edge of the
posterior. Thus the side of the patient is completely encased
in a gauze dressing. This is very easily bandaged on. One
turn of bandage passes round the body outside the arm (fig.
34, 1) ; the second also passes round the body, but below the
elbow (2), thus catching the portion of the dressing overhang-
ing the elbow and also the lower edge of the front dressing ;
the next passes round the body and over the top of the
shoulder on the side operated on, thus catching the portion

Fig. 31.— Dbessings Applied after Excisiox of Mamma and Axillary Glaxds
to show the arrangement op the dressings and bandages.

The turns of bandage are numberecl, and arrows are placed ou them to show the direc

tiou in which tliej' run.

. of the dressing projecting above the shoulder (3) ; the bandage
then passes down behind but i^arallel to the arm, turns round
below the elbow, runs obliquely upwards in front to the top of
the opposite shoulder (4), then obliquely back again behind the
body (thus fixing the upper angles of the dressing in front
and behind) to the middle of the arm, over which it passes
obliquely downwards (.5), to go imder the wrist and end at the
top of the shoulder (6) — in this way completing the fixing of
the dressing to the arm, and at the same time acting as a sling
for the hand. A bandage six yards long generally does this
exactly.

ANTISEPTIC TEEATMENT OF WOUNDS.

Pins are now inserted at nil the necessary points, more
especially where the bandage passes over the shoulder and under
the elbow. The arm and dressing are then fixed securely to
the side by a binder of calico, broader than the length of the
upper arm, passing round the body, below the axilla of the
other side, and pursed up and pinned above the shoulder, and
below the elbow of the included arm. Thus perfect rest is
procured, and no elastic bandage is required.

When the axillary incision is soundly cicatrised, and the
discharge has become small in amount, the axillary dressing or
the breast di-essing No. 2 may be applied, the arm being
simj^ly supported in a sling.

Fig. 35. — Binder Applied 011x3101? the Drersixg represexted in Pig. 34, so as
TO keep the Parts and Dressing at Rest.

An axillar]/ dressing must be applied partly to the chest
and partly to the upper arm, and made to fold over the top of
the shoulder. It requires an elastic bandage (fig. 36).

Elastic bandage is not as a rule required for dressings on
the extremities, because the limb operated on is generally
placed on a splint for a few days, in order to procure absolute
rest till healing by first intention is complete. Thus the
movements which it is the function of the elastic band to
neutralise are avoided, and the constriction of the elastic is
also avoided. With regard to this constriction, however, the

DKESSINGS ON THE LIMBS.

elastic need never be applied so tight as to produce cedema ;
indeed, I have more than once seen cedema which was present
before an operation subside afterwai'ds, even although an elastic
bandage was used. Where the patient is allowed to move the
extremity — as, for instance, when he is allow^ed to walk after a
small operation on the lower extremity — an elastic bandage is
absolutely necessary. In the case of the lower extremity, the
padding at the upper part of the splint should be covered with

Pig. 36.— Dressixg is Cases of Operatiox on the Axilla alose.

In this case an abscess has been opened and the position of the drainage-tube is indi-
cated by dotted lines. The edge of the dressing has also been dotted in.

macintosh, and the foot of the bed supported on blocks.
In this way all the discharge flows upwards, and as it
cannot soak into the padding of the splint, it is shed on the
drawsheet soon after it has reached the edge of the dressing,
and thus one can ascertain accuraLely whether or not it is
necessary to change the dressings.

The dressing required {ov 2isoas abscess opened above Poupart's

ANTISEPTIC TEEATMENT OF WOUNDS,

ligament is one of the most important dressings, as well as
one of the simplest illustrations of the method of applying the
elastic bandage. I may say here with regard to this method of
opening psoas abscess above Povipart's ligament, that there are
two reasons for choosing this situation. In the first place, the
old rule that these abscesses must not be opened early is now-
done away with, and under truly aseptic treatment, as soon as
fluctuation is detected, an operation is performed of a similar
nature to that for tying the external iliac artery, and the
abscess is opened after a careful dissection. The sooner the

Psoas Abscess o
;een feoji the Pr

The position of the drainage-tube is indicated by dotted lines

Fig. 37.— Dressing in a Case of Psoas Abscess opexed above Poupart's Liga-
MEXT, seen from the Pront.

abscess is opened the better, for the abscess cavity is thus smaller
than if the surgeon waits till the pus has burrowed its way into
the thigh ; and, further, so long as the pus is there it irritates
by its tension, and thus keeps up the chronic inflammation in
the spine. This, then, is one reason why the opening leading
into these abscesses is generally above Poupart's ligament.
Another is, that even supposing the abscess to be pointing in
the thigh, it ought to be opened as far as possible fi^om sources
of putrefaction, and the most convenient place in this respect,
as well as the best for the attachment of a dressin^^, is the

PSOAS ABSCESS DRESSINGS.

neighbourhood of the anterior superior spine. Some surgeons,
more especially Mr. Chiene, try to get at these abscesses from
behind, either by pei-forating the ala of the innominate bone or
by getting at the pus above the crest of the ilium. Such a
method has advantages, both by providing a dependent opening
and also by leaving a shorter channel between the seat of the
disease and the cutaneous surface.

The dressing applied when the opening is in the neighbour-
hood of the anterior superior spine extends from the middle line
in front to the middle line behind. It reaches as high up as the
lower border of the ribs and as low as about three inches below

s' ill //' ^ '/ ''fTriTiTTnTill||llllinil|ll[[Ti;irTTr!llFTlTiniiT--
FiG. 38.— Psoas Abscess Dressing (Fig. 37), seen fkoji Behind.

Poupart's ligament. Special masses of gauze are placed in the
neighbourhood of the pubis, which is also shaved on that side.
The dressing is fiistened on by a spica bandage with circular
turns around the thigh and abdomen. The elastic bandage is
applied accurately to the edge. It begins, say, at the upper
and anterior angle of the dressing, runs vertically downwards
along the anterior edge ; then, jjassing back round the inner
side of the thigh, it encircles the thigh, thus fixing the lower
border ; then it runs vertically upwards behind till it reaches
the upper posterior angle ; then, being held there, it is carried

ANTISEPTIC TEEATMENT OF WOUNDS.

round the abdomen. The two ends of the two vertical pieces
are fastened to the circular piece by pins, and pins are also ap-
plied at all the angles and along the edge where necessary. In
some deformed jiersons shoulder straps ai'e necessary to prevent
the dressing from slipping down (figs. 37 and 38).

In lumbar abscess straps must pass over the shoulders to
prevent the di-essing from slipping down, and between the thighs
to prevent it from slipping up (fig. 39).

F£G. 39. — DiiESsiXG IX A Case op Lumbar Abscess, seen fhom Behind.

The position of the drainage tube is indicated by dotted lines ; the vertical dotted
lines at the middle of the back indicate the edge of the dressing.

In abscess of the /dp-joint the arrangement of the dressings
is much the same as in psoas abscesses, except that they pa.ss
lower down and not quite so high up. As a long splint is
generally in use, an elastic bandage is unnecessary, unless in
children (fig. 40).

Where abscesses are opened near the top of the thigh on the
inner side, and are thus close to sources of putrefaction, large
masses of gauze must be applied between the orifice and the
perineum, and an elastic bandage carefully fastened along the
upper edge.

In oj^erations for hernia, varicocele, and on the scrotum, in.

DRESSINGS FOR HERNIA.

the male, there is one form of dressing which is generally
applicable. In the first place, no protective is used, on account
of the immediate vicinity of sources of putrefaction, as has been

iiiHinmiii

ilii!l!iilil!illiilliili;iii'lii'IIM^^^

Vui. 40.— Dressing ix a Case of Hip-Joixt Abscess, with Elastic ArrnED.
The dotted part shows the position of the wound.

Fia. 41.— Deepek Paut of the Hekxia and Scrotal Dressings.

Left side of scrotum covered with gauze soaked in carbolised glycerine. Mass of
gauze in the perineum enclosed in a roll of gauze.

previously explained. The gauze applied to the wound, instead
of being merely wet with carbolic lotion, is .steeped in 1-5 or in

ANTISEPTIC TEEATMENT OF WOUNDS.

1-10 solution of carbolic acid in glycerine, and this is wrapped
around the penis and over the scrotum. This gauze sticks to
the skin and does not become detached with the movements of
the body, while it is more powerfully antiseptic than the ordi-
nary caibolic gauze. Then a mass of gauze is rolled into a ball,
and this is suspended in the centre of a long strip of gauze.
The ball is placed in the perinevim behind the scrotum, and
the strip of gauze passes up in each groin. This strip retains
the pad in position (fig. 41). The pad serves the double pur-
pose of supporting the scrotum and receiving the discharge,
which passes chiefly downwards. The hollows having been

Fig. 42.— Dressing ix a Case of Operation for Hernia, or on the Scrotum o\
THE Left Side, showing the Arrangement of the Dressing and Elastic
Bandage.

tilled up with loose gatize, the general dressing is applied. A
hole is cut in this dressing towards the upper border, and the
penis is passed through this hole, and thus helps to keep the
dressing in position. The dressing passes over the scrotum and
over the perineal pad, and is fixed by a double spica bandage
(fig. 42). The pad in the perineum is fixed there by a St.
Andrew's cross. The elastic bandage is applied in the form of
a St. Andrew's cx'oss in the perineum, and of a double spica
(fig. 43). The bandages, dressing, and perineal pad are care-
fully pinned together in the perineum.

EXCISION OF THE KNEE-JOINT.

The methods of managing excisions of joints, operations for
ununited fractures, &c., in the lower extr-emities, are very im-
portant. Heie perfect rest must be combined as far as possible
with the aseptic treatment. For two or three days after excision
of the knee it is better to change the dressing, which is the
ordinary gauze dressing applied round the limb, simply by lift-
ing the limb, because there is generally a large amount of
bloody and serous oozing at first. After a few days this
oozing has become much diminished in amount, and the dressing

'Fig. 43.— Dkessixg ix Hernia Cases or ix OrEUATioxs ox the Scrotum, show-
ing THE Arrangement of the Baxdages in the Perineum, seen from

BELOW.

is then accomplished in the following manner. ' A Gooch's
splint is padded above and below the situation of the wound,
the part opposite the wound being left unpadded. The whole
splint and padding is covered with a piece of macintosh cloth,
and is firmly fixed to the posterior aspect of the limb above
and below the situation of the wound. Behind the wound, at
the part where the padding is de6cient, masses of gauze of
sufficient thickness are arranged transversely and superficial
to the macintosh. These pieces are three or four or more in
number, and they act as padding for the splint, and at the same

ANTISEPTIC TREATMENT OF WOUNDS.

time as an antiseptic dressing (fig. 44). When the dressing
is clianged, a piece of gauze is pinned to each of the old pieces,
and then the old piece being jjulled out the new is pulled in,

Fig. 44. — Si'Lixx rui; Exci.siox of Kxee, ready for Application".

The splint is padded at the upiier and lower parts, and the splint and padding are
covered with a piece of macintosh cloth. The space opposite the knee is filled
with masses of gauze arranged transversely and superficial to the macintosh.

and thus the limb is never left without support (fig. 45).
Over the front of the limb an ordinary gauze dressing of
suitable size is applied.

Pig. 45.— Si'Likt Applied ix a Case of Excisiox of the Kxee.

This shows the method of changing the dressing. In the first way described a mass of
gauze would be pinned on to the end of the old piece on the other side of the limb,
so that as the old piece is pulled out the new is pulled iu, or it may be arranged in
the second manner described, and shown in fig. 44 — viz., a piece only extends to the
middle line behind, and as soon as each is pulled out a fresh piece is pushed in.

Another moi'e convenient way in which this may be
managed with even less movement is to have each of the
masses of gauze mentioned in the former paragraph divided in

ABSCESSES. 9 1

the middle line, and thus the half of each mass is pulled out
at a time and a new jiiece substituted (fig. ii).

In other cases an iron rod beut up over the wound may be
fixed to the front of the limb by plaster of Paris. The limb is
then easily lifted out of the splint by one assistant keeping the
leg and the plaster in contact, and another lifting the thigh and
plaster. In this way the whole of the posterior surface of the
limb is left free for the application of a large dressing, and the
aseptic arrangements are more easily managed.

Another way is to apply a wii-e splint next the skin, fix it
there, and then apply the dressings outside.

When the discharge becomes still less the limb may be put
up in plaster of Paris, a window being left for dressing.

Excision of joints for disease is now, however, rai-ely per-
formed, for with asepHc treatment an incision into a joint and
the insertion of a drainage-tube is generally suflScient, in cases
where formerly excision or even amputation would have been
required. Several advantages are thus gained, among the most
prominent of these being absence of shortening of the limb (and
this is most important in children), and often a certain and
even a considerable amount of motion in the joint afterwards.

It may be mentioned here that Mr. Knowsley Thornton in
ovariotomy cases does not apply a bandage round the abdomen.
He fastens the dressing with adhesive plaster, and does not
change it for a week, by which time healing is generally
complete, except where the stitches are.

Such are the chief points as to the application of antiseptic
dressings in different situations. I must now say a few words
as to the aseptic treatment of abscesses.

I have already referred to th<^ question of the necessity for
a dependent opening, and I pointed out that, aa the discharge
from an abscess treated aseptically is apparently but little
irritating, it does little harm even though left to well out,
instead of being permitted to flow out through a dependent
opening. In fact, aseptic surgery has altered the relative im-

92 ANTISEPTIC TREATMENT OF WOUNDS.

portance of the questions to be considered in selecting a situation
for opening an abscess ; and now the chief point to be looked
at is not whether the orifice of the tube is in the most dependent
position possible, but whether it is at the point furthest removed
from soui-ces of putrefaction — i.e. whether there is the greatest
possible space for the overlapping of the antiseptic dressings.

Indeed, in some abscesses pointing near such canals as the
pharynx, anus, ifcc, it is better to make an opening in healthy
structures at some distance from the abscess, and burrow a
channel into it, than to make an incision directly into the
abscess cavity.

I saw a striking example of this in Edinburgh several years
ago. A boy was admitted into the infirmary with retrophar-
yngeal abscess connected with occipito-atloidean disease. The
abscess was on the point of bursting into the pharynx. Mr.
John Chiene, who had charge of the case, instead of opening
the abscess at the only place where it was pointing, viz., in the
pharynx, cut down behind the sterno-mastoid, and burrowed
into the abscess cavity from behind. The abscess followed a
typical aseptic course, and the patient recovered completely.
I have also had a similar case which healed up in a few weeks
without any trouble. Thus then the great rule in selecting a
situation for opening abscesses is to make the incision as far as
possible from sources of putrefaction.

When opened, instead of dealing tenderly with the pyogenic
membrane, as was formerly done under the impression that it
was a hurtful thing to injure it, we now empty the cavity
thoroughly, especially in the case of chronic abscesses, in order
to get out all curdy masses of pus, &c., which may have gravi-
tated to the bottom of the abscess, and in some cases we scrape
out the pyogenic membrane with a shai-p spoon. When this is
done opportunity is given for the rapid adhesion of the greater
part of the wall of the abscess cavity, and thus in a very short
time there is merely a sinus left leading down to the seat of
disease.

There is no necessity for washing out the cavity of an

DEAINAGE OF ABSCESSES. 93

abscess, as is done in so many quarters. To do so is simply to
irritate the pyogenic membrane unnecessarily without securing
any corresponding benefit. Indeed, it might give rise to such
an amount of oozing from the wall of the abscess as would wash
out all the carbolic acid from the dressings in a very short
time, and thus lead to the putrefaction of the discharge. The
treatment by hyperdistension, while erroneous in theory, is
very dangerous in practice, as the fluid may be forced into the
cellular tissue, and lead to diffuse inflammation and even
gangrene, or to carbolic acid poisoning and death. '

The greatest care must be taken in the drainage of abscesses.
In the case of a large psoas abscess the surgeon should intro-
duce the largest sized drainage-tube in the first instance. This
tube may be changed for a smaller in a few days. It ought not
to be removed for the first time till at least three days have
elapsed since the abscess was opened, otherwise there may be
great difficulty in replacing it. It should not be shortened till
it is found to be absolutely impossible to get it in fully. When-
ever this is the case a piece must be cut off from the end.
(Here I speak of chronic abscesses ; an acute abscess heals in a
week or ten days.) In some cases, where the same tube is
left in for a week (where the case is only dressed once a week),
some difficulty will be found in withdrawing it, owing to the
granulations having grown in at the holes and holding it in
position. In this instance the guide as to shortening is lost,
because the tube cannot be pushed out ; and therefore it will
be found best in old cases to use a tube having holes only
close to its inner end. This cannot be held, and is gradually
pushed out as the sinus heals from the bottom. If on removal
of a tube the discharge is found to increase in quantity, the
tube must be reintroduced.

As the incision into the abscess is merely large enough to
admit the tube, there would be no reason for using protective ;
and therefore the wet gauze is applied directly over the orifice
of the tube. A tube is the only form of drain suitable in these
cases.

94: ANTISEPTIC TREATMENT OF WOUNDS.

The precautions required in order to insure an aseptic result
are precisely the same as in the case of wounds.

In changing the dressings the same rules are followed as
were formerly described with regard to incised wounds. Chronic
abscesses, more especially abscesses connected with diseased
bones, are extremely tedious ; but nevertheless, as a rule, they
ultimately recover. Tlie same care must, however, be taken
from fii-st to laat. It is never safe to change the carbolic
dressing for a boracic one, however superficial the wound ap-
pears to be. In the case of spinal abscesses absolute rest in
the recumbent posture must be maintained till healing is com-
plete ; and as the cases generally extend over many months, it
is well to warn patient and friends before commencing to treat
the case. Whether the rule as to the maintenance of the
recumbent posture may not be modified by the use of Sayre's
jacket, or even without it, is now a question. Lately in two
cases which had been under treatment for a long time, and in
which all uneasiness in the spine had passed oflf. Sir Joseph
Lister allowed the patients to get up before healing was com-
plete, and no harm followed.

Empyema does ])articulai'ly well under this dressing. I
mention it, in order to state that a metallic drainage tube with
a shield like a tracheotomy tube, and with lateral holes, is the
best, because the india-rubber tube may get compressed between
the ribs or be too abruptly bent where it passes into the interior
of the pleural cavity. >

There are some cases in which neither the gauze dressing
nor the boracic can be employed, but which may nevertheless
be treated aseptically. I refer especially to abscess in the
perineum or by the side of the anus.

Abscess in the peiineum may be treated aseptically with
very satisfactory results. The abscess is opened under the
spray, and a piece of lint dipped in 1-5 cai'bolic oil or 1-10
carbolic glycerine is introduced into the cavity to act as a drain.
Outside this two or three layers of lint soaked in 1-5 carbolic
oil or 1-10 carbolic glycerine are applied, and fixed with a

ACCIDENTAL WOUNDS. 95

T-bandage. Should this become displaced or wet with urine,
&c., the patient pours a little carbolic oil or glycerine over the
wound and over the lint, and replaces the dressing. No spray-
is required in changing the dressings. On the third day a
piece of lint dipped in carbolic oil is laid over the wound, and
a pair of oiled forceps is slipped under the lint to seize and
withdraw the plug ; or the plug may simply be pulled out
under the spray. Carbolic oil or glycerine 1-10 is then used
for dressing, and when the wound has become superficial boracic
or salicylic ointment is employed.

The same method of dressing is employed in abscesses
beside the anns. In this case, when the patient defsecates, he
holds aside the dressing, defsecates past it, wipes the parts with
1-20 carbolic lotion and then with 1-10 carbolic oil. He then
soaks the dressing with the oil, or applies a new dressing.
(The glycerine and carbolic acid may also be used.) The result
of this method of treating these abscesses is often excellent,
fistula in ano being apparently often avoided when the abscess
is taken in time.

So much for wounds made by the surgeon and their treat-
ment. I now come to the consideration of wounds jjroduced
accidentally. Here the problem is different from and much
more difficult than the former. In the cases we have just been
considering we had merely to keep out the septic parotides ; in
the present instance these particles have already gained admis-
sion, and therefore we have not only to prevent the entrance of
more, but also to destroy those already present.

This is done by washing out the wound with 1-20 car-
bolic lotion, provided it be recent, i.e., made within twenty-
four hours, and then treating it like a wound made by a
surgeon.

This washing out of the wound must be done very thoi'oughly.
It is best carried out by using a syringe with a gum-elastic
catheter attached to it. The point of the catheter is intro-
duced into all the recesses of the wound and the 1-20 lotion is

96 ANTISEPTIC TREATMENT OF WOUNDS.

injected through it, and thus comes thoroughly in contact with
all parts. There must be no attempt to distend the cavity, as,
for instance, by shutting the orifice of the wound around the
8yx4nge, for the fluid might be forced into the cellular tissue
and lead to inflammation or even sloughing. The opening
must be left perfectly free, and enlarged if necessary. Should
there be any shreds of tissue, they had better be cut off, and if
there be much dii't ground into the tissue, it must be got rid
of by means of a nail brush. The injection and the subsequent
procedures are carried out under the spray.

If the wound was made twenty-four to forty-eight hours
before being seen, a stronger solution is employed, viz., the 1-5
spirituous solution. This is used in the same way as the other.

Having thus got the wound pure the question of stitching
it up arises. The answer to this question varies according to
the parts injured. As a rule, in injury of the soft parts, a
drain is introduced, and the same accurate stitching employed
under the spray as was described on a former page. More
especially is this the rule in scalp wounds, where most brilliant
results may be obtained by the use of catgut drains and accu-
rate stitching. The rest of the treatment is the same as in
oj^ei-ation wounds.

Where the wound is much contused, the same rules apply
as to purification, but it must not be stitched up. After purifi-
cation a drainage-tube is inserted if necessary, the wound is
left open, a piece of protective is placed over it, and the dressing
applied in the usual manner.

I have mentioned the methods to be employed when the
wound is seen within the first forty-eight hours. It may be,
however, that it does not come under notice till putrefaction
already exists. In this case it may be purified by the intro-
duction of iodoform suspended in water by the aid of alcohol,
or if superficial, by stuffing it thoi^oughly with lint dipped in
1-5 carbolic oil. This dressing repeated for several days
generally converts it into an aseptic wound. In most cases it
is best to apply iodoform or the chloride of zinc solution.

SPECIAL WOUNDS. 97

Certain special wounds call for attention.

Compound fractures are the wounds in which aseptic treat-
ment was first applied, and in which excellent results can be
obtained. There are a few special points to be noted. In
purifying the wounds great pains must be taken. Any dirt
must be carefully scraped or scrubbed out. All blood-clots
ought to be turned out as completely as possible. The ends of
the bones are cleaned, and if they cannot be returned or got to
fit, portions should be sawn off. The ends may be tied together
with silver wire. The parts ought to be well kneaded as the
carbolic lotion is injected through the catheter, in order to
difi'use the lotion as much as possible into all the recesses of
the wound. No stitches are inserted, but, on the contrary, free
drainage by tubes is used. The same sort of dressings and
apparatus are employed as in excisions.

Wounds involving tendons, nerves, or muscles, are treated
in the same manner as other wounds, and the ends of the
divided muscles, tendons, or nerves, ought to be stitched to-
gether with catgut, and the position of the part so arranged
as to avoid dragging on these stitches.

Wounds of joints are very important. AVhen recent no
operation (excision or amputation) is required in the first
instance. As a rule the joint may be saved, and perfect move-
ment obtained by washing it out very thoroughly with carbolic
lotion 1-20. The wound in the joint is enlarged if necessary.
Where several hours have elapsed since the accident (more than
eight or ten hours), it is well to employ the spirituous solution
as well as the wateiy. A drainage-tube is introduced into the
joint, bvit no stitches are used. After a few days, when the
discharge has diminished, the drain is removed. In about
three weeks, or earlier, passive motion ought to be begun, other-
wise the adhesions outside the joint may become so strong as
to require to be bi-oken down under chloroform.

Compo^md fractures of the skull ai'e treated in the same
manner as compound fractui-es elsewhere, purification being
attempted with 1-20 carbolic lotion. The dura mater may

98 ANTISEPTIC TEEATMENT OF WOUNDS.

be freely dealt with without fear of inflammation, for the irri-
tation of carbolic acid is only very transient. Bleeding vessels
are secured by catgut. Should one of the great sinuses be
wounded, a graduated compress of catgut arrests the hjBmor-
rhage satisfactorily. This I have known to act very well in a
case of wound of the longitudinal sinus, occurring during the
operation of trephining over the seat of an old injury.

Wounds penetrating the thoracic cavity are much more
difficult to treat. Should the woijnd penetrate the lung, and
should the lung protrude, the exposed parts and those around
are purified with carbolic lotion 1-20. In deciding as to re-
turning the injured lung and stitching up the wound, the
surgeon must be guided by the circumstances of the parti-
cular injury. In some cases, if the wound in the lung were
superficial, the edges of the divided visceral pleura might be
stitched together with fine catgut, the lung returned, and the
external wound closed. Where a large bronchus is injured it
might be better practice to leave the lung in the wound, and
leave the wound open.

Where there is merely a wound of the parietal pleura, and
where the lung is not wounded, the external wound only is
purified and is closely stitched, in the hope that union by first
intention may occur, that the air may be absoi'bed, and that
any septic dust present in the pleural cavity may be unable to
cause mischief.

Wounds of the -abdomen are variously treated, according as
there is or is not protrusion of the contents. Where there is no
protrusion, and where there is no reason to susj^ect injury of the
viscera, the external wound ought to be purified and closely
stitched, so as to get primary union throughout, no drain being
used.

Where the intestines protrude, they ought to be carefully
bathed in warm carbolic lotion 1-30 or even 1-20, and if there
be no injury of them in any part they may be returned. If
they are cut, the gut may be stitched with catgut by the glover's
suture.

PUTRID WOUNDS. 99

If the omentum protrudes, opinions vary as to the treatment.
When it can be returned, do so after thorough purification, and
then stitch the abdominal walls, including the peritoneum, close
together. Where, from adhesion or other sufficient cause, this
cannot be done, or where the omentum is very dirty, I should,
from a research into the consequences of unreturned omentum
by Dr. Kenneth McLeod, of Calcutta, consider it the safest
practice, especially in the case of a person with strong muscular
parietes, to stitch the deepest parts of the omentum to the deep
part of the wound, cut off the remainder and close the skin over
all.

If internal haemorrhage is going on, apparently from the
mesenteric vessels, the wound may be enlarged and the bleeding
point sought for. Simon advised that in bleeding from ruptured
kidney, the injured organ should be excised ; this suggestion
was never put into practice, but nevertheless it is one well worth
bearine: in mind.

Such are the chief points to be attended to in recent wounds ;
there remains for consideration the class of cases in which putre-
faction has been present for a long time. I refer to cases of
putrid sinuses, generally connected with diseased bones or
joints. An attempt may be made to purify these during the
course of an operation, and sometimes when the sinuses are few
and uncomplicated, and where all the dead bone is removed,
this attempt may be successful. The sinus is scraped out with
one of \^olkmann's sharp spoons (fig. 46), and all the granula-
tion tissue, as far as possible, removed. The raw surface of the
sinus, &c., is then washed out with the chloride of zinc solution,
which is applied thoroughly to all parts, and a gauze dressing
is used, in the hope that putrefaction has been thus eradicated.
The spray should be employed during the whole procedure.

If this is successful, well and good. If not, boracic ointment
(at first full strength, afterwards half) or salicylic ointment,
covered with boracic lint or salicylic wool, is the best dressing,

100 ANTISEPTIC TREATMENT OF WOUNDS.

ndeed, it is the best dressing in all cases where strict aseptic
measures are inapplicable.

The aseptic treatment of burns varies according to the
degree and extent of the injur}'. In any case, unless where the
burn is very extensive and where the parts are extremely dirty
(necessitating scrubbing of the surface and consequent shock
and also risk of carbolic poisoning), an attempt should be made
to purify the surface with 1-20 carbolic lotion. This having
been done, if the surface is small, boracic ointment (full sti-ength)

Pig. 46.— Two Fobms op Sharp Spoons, a Large Round One and a Small Oval

One.

and boracic lint form a convenient dressing. When the extent
of the burn is greater, wet boracic dressing (wet boracic lint
used as water dressing — covered by gutta-percha tissue or
macintosh) is the most suitable. The wet boracic dressing is
also applied in those cases where, on account of the extent of
the burnt surface and the amount of dirt, purification with
carbolic acid is not advisable. Where the surface is thoroughly
charred and Avhere the wound is not very extensive, boracic
ointment or carbolic oil 1-10 are the best dressings. The
objection to carbolic oil, which was formerly used in all cases,
is that, when the surface is large, there may be a fatal absorp-
tion of carbolic acid.

In the after-treatment the sores are dressed with boracic
dressings (protective and boracic lint, or better, in the first
instance, boracic ointment), just as in the case of ulcers.

The rules as to the treatment of gangrene are altered in
aseptic surgery, and this is more especially the case with senile

TREATMENT OF GANGRENE. 101

gangrene. Should symptoms of senile gangrene set in, say in
the lower extremity, the skin of the foot, toes, and leg are
thoroughly cleansed with 1-20 carbolic lotion. This must be
done very efficiently. All the folds about the nails, &c., must
be carefully cleansed and washed. This having been done, the
whole limb and foot are enveloped in a large mass of carbolised
cotton wool (carbolised in a 1 per cent, ethereal solution of
carbolic acid). This being pure in its substance, and being
applied over a pure sui-face, completely shuts out causes of
putrefaction. The carbolic acid soon fiies off, and then the cotton
wool acts simply as a filter while it protects the part from un-
equal pressure and retains the heat. This may be kept on for
any length of time, and so long as discharge does not extend to
the surface or the gangrene spread above the limits of the dress-
ing, the part remains sweet, and very often the gangrene, which
in the first instance threatened to involve the whole leg, becomes
limited, and there may even be merely a small cutaneous slough.
In any case, as a- rule, the gangrene does not go on spreading as
it does when treated in the usual manner, and for this reason :
Suppose that the part is not treated aseptically, the tissue at
the edge of the dried gangrenous mass becomes putrid, the
living tissue in the neighbourhood is very weak, the putrid
material acts on it like a caustic, desti-oys its vitality or excites
an inflammation which kills it, and so the gangrene goes on
spreading, till at length parts are met with of sufficient vitality
to resist this action of the putrid materials. Then a line of
demarcation is formed. On the other hand, when the gangren-
ous parts are not putrid, the weak parts in the vicinity, which
would to a certainty have died in the former case, retain their
vitality and gain strength. Thus also the rule of never ampu-
tating in senile gangrene, except to trim a stump formed natu-
rally, is done away with, and it is generally better to amputate
as soon as it is clear to what extent the tissue is dead, rather
than to subject the patient to the continual pain and irritation
arising from the presence of the dead piece. The same reason-
ing applies to cases of ti-aumatic spreading gangrene. This is

102 ANTISEPTIC TREATMENT OF WOUNDS.

only one instance of how completely many current ideas as to
surgical pathology and treatment are reversed, when means are
taken to render the dust of the atmosphere inert before it
reaches a wound.

In treating nfevi great benefit is obtained from the in-
jection of pure carbolic acid. The nsevus is first thoroughly
cut off" from the circulation by ligatures tightly applied around
its base, and then half minims of pure carbolic acid are in-
jected into various parts of the tumour. Ten minutes or so
having been allowed to pass, in order to insure complete and
firm coagulation, the ligatures are divided and removed, and
the punctures are touched with collodion. The surface being
left completely dry, any slough which forms becomes absorbed
or separates as a crust after some time, the part beneath being
found to be a scar.

The same method has been employed in the ti-eatment of
varicose veins. A tourniquet having been firmly applied around
the upper part of the limb in order to arrest the circulation, the
vein is punctured at vai'ious parts, and half minims of carbolic
acid are introduced into it. The tourniquet is kept on for ten
minutes aft^Sr the injection is completed. Coagulation and a
slight degree of inflammation are thus induced, but this^ so far
as I have seen, never goes to any dangerous extent, and is
followed by at least temporary cure.

A dissection or post-mortem wound does not, as a rule, give
rise to bad results if the wound be instantly purified with 1-20
carbolic lotion. In many cases the organisms introduced are non-
spore-bearing, and are thus very readily destroyed by the solu-
tion. Even anthrax does not produce spores in the living body,
and thus the bacilli are rapidly killed by the carbolic lotion.

103

CHAPTER YII.

ASEPTIC SURGERY — MODIFICATIONS.

Country practice : How to dispense ivitli tJie sjn-ay during tlte operation
■ — and during the after-treatment : Hojc to render the dressings less
frequent : Is the aseptic method applicable in war 1 Sir Josejih
Lister's suggestions : Esniarch's j)lan : Iteyhcrs method.

Such are the methods usually employed in carrying out the
Listerian principle in hospital or in private practice. It is,
however, said to be difficult of application to country practice,
and we must therefore inquire in what way it can be made
easier. The difficulties urged are that the spray is too heavy
to carry : that it is not always easy to return a long distance to
see a patient on the day after the operation, and that the dress-
ings are too expensive for the lower classes. AVe must there-
foi'e, in some way or other, render the dressings vei-y infrequent,
so as to avoid expense and unnecessary visits, and we must try
to dispense with the spray.

In the fii'st instance, in going to perform an operation or to
treat a wound the surgeon takes instruments with him, and he
may, Avithout any additional trouble, easily add a spray to the
contents of his bag, and this spray may be left at the patient's
house, and brought home again after the first dressing. But,
suppose the surgeon has not a spray at hand. What is to be
done 1 Well, he must use all the other precautions before
described, and wash out the wound frequently with 1-40
carbolic acid lotion during the operation, and while the stitches
are being inserted ; and then, before the piece of wet gauze is
applied, he may distend the wound with the same lotion, the

104 ANTISEPTIC TREATMENT OF WOUNDS.

wet ganze being applied while this is still flowing out. At the
same time I cannot see that, in the great majority of cases, it
can be any great hardship) to carry a spray to an operation.

During the after-treatment a spray is not necessary. The

spray may be rendered unnecessary during the after-treatment

in two ways. In the case where catgut stitches and catgut

drains are used a deep dressing may be applied at the time of

the operation, and may never require to be changed. This

deep dressing is fixed down in some way or other, and is

treated as a wound, the gauze being soaked with carbolic lotion

every time the superficial dressing is removed, and then a

piece of wet gauze larger than the deep dressing, and the

general dressing are applied. Should it be necessary to remove

the deep dressing, there is no necessity for the spray, if catgut

drains be used, because there is no cavity into which air may

pass. The deep dressing having been removed, carbolic lotion

is allowed to flow over the wound till a guard is applied.

Where a tube is used it is more difiicult to do without the

spray, for in that case there is an open orifice into which dust

may fall, and be sucked into the interior of the wound, and

further, when the tube is removed, air must enter to take its

place. This may be avoided by the vise of a syringe which

constantly keeps a stream of carbolic acid lotion passing over

the wound and over the drainage tube, till a fresh dressing

is applied. Shduld it be necessary to remove the tube it is

well, in addition to this constant flow of lotion, to cover the

orifice of the tube with a rag dipped in the antiseptic lotion.

The best way is to take a guard soaked in carbolic lotion and

folded in several layers, and place this over the orifice of the

drainage-tube, extending on each .side of it for a considerable

distance. The tube is now seized with a pair of forceps through

this rag, and as it is pulled out the rag is carefully tucked in

around it, so as to compel the air, as it passes in to take the

place of the drainage tube, to traverse the moist guard. This

seems to me better than the method of slipping in forceps

under the guard and pulling out the tube, the guard being well

COUNTEY PRACTICE. 105

pressed down on it. In taking out wiie or silk stitches, the
guard is pulled aside so as to expose the stitch, a little carbolic
lotion is then dropped over the suture, and as the latter is
withdrawn, a few drops of the lotion are applied to the orifice
of the puncture.

These methods — the use of catgut stitches and catgut drain,
and the employment of a permanent deep dressing, together
with the hints in cases where a drainage tube or non-absorbable
stitches are employed — sviffice to render the opei'ator independent
of a spray.

Can we now render the dressings less frequent 1 This may
of course be done to a certain extent by applying a larger
amount of gauze, but one of the best ways is to use sponges in
the interior of the dressing for the purpose of absorbing and re-
taining the fluid. The deep dressing having been applied and
fixed, a large sponge or several small ones are placed outside it,
these sponges having jast been wrvmg out of carbolic lotion;
outside the sponges and extending well beyond them is a piece
of wet gauze, and then the masses of loose gauze and general
gauze dressing. In this way the discharge is retained in the
interior of the dressing, and of course so long as it is there,
and so long as the discharge has not reached the edge of the
dressing, it is as safe from putrefaction as if it were in a pure
fiask. By the use of these sponges several days may be
allowed to elapse, in many cases, before the first dressing is
changed, though it is well in every case to change the first
dressing on the day after the operation. When the dressing
is changed these sponges are squeezed thoroughly, washed in
carbolic lotion 1-40, and reapplied. By the use of sponges two
or three dressings suflice for the treatment of most operation
wounds.

By the use of salicylic jute in large masses, the same avoid-
ance of frequent dressings may be obtained, but this material
is not very trustworthy as an antiseptic. If it is used it is best
to 2)lace no macintosh outside it. In this way the discharge
dries up beneath the dressing, and we have a combination of

103 ANTISEPTIC TREATMENT OF WOUNDS.

dry and antiseptic di-essings. I have often, after osteotomies
where the wound was left open and no drainage-tube inserted,
applied a large mass of salicylic cotton and left it unchanged
for weeks, till in fact the wound had quite healed. Of course
if the wound becomes painful the dressing must be removed
and the cause of the pain investigated. I would not use the
wool in cases of lar-ge chronic abscesses, such as psoas abscess,
nor do I think it good if suppuration occurs in a recent wound.
By the means described, the difficulties in the way of the
adoption of this system in country practice may be overcome,
and instead of causing additional expense to a poor patient, it
saves expense in many ways. The dressings required are so
few that the price of the materials employed is not greater
than that which would be necessary even if water dressing
were used ; and expense is saved in many other ways, notably
in the rapid healing, which is of course of the greatest conse-
quence to the bread winner.

Is the Asejdic method a^yplicahle in War ?

In the 'British Medical Journal ' for September 3, 1870,
Sir J. Lister describes a method for the use of army surgeons.
He suggests that the wound should, as soon as possible after
the injury, be thoi-oughly washed out with 1-20 carbolic lotion,
the suiToundin^ skin being at the same time purified.
Bleeding vessels are secured by catgut, by torsion, or by car-
bolised silk. While the wound is full of lotion, extract the
bullet, clothes, &c. Then cover the wound with two or three
layers of oiled silk, smeared on both sides with carbolic oil 1-5.
Over this apply layers of lint soaked in the 1-5 oil, overlapping
the oiled silk for about three inches in every direction, and
about a quarter of an inch in thickness. This is covered with
gutta-percha tissue, and the whole is fastened on with a bandage
soaked in carbolic oil. This is the permanent dressing. Out-
side this, another and larger dressing of oiled lint covered by
gutta-percha tissue is applied daily. During the first day apply
Iresh oil to the outer cloth once in six or twelve hours. On

ASEPTIC TREATMENT IN WAR. 107

the following day the outer dressing is changed, carbolic lotion
being introduced under the edge, as it is lifted, by means of a
syringe ; or carbolic oil ma)' be poured in. After the first
dressing use the 1-10 oily solution, and later the 1-20. On
the second day oil is only applied once in twelve hours ; after
that it is applied daily for five or six days, and then once in
two days.

In compound fractures use a wire splint next the deep
dressing, and apply the fresh superficial dressings outside the
wire. This splint need not be removed till union is complete,
the oil being meiely poured between the meshes when the
dressing is changed.

Since the introduction of corrosive sviblimate into surgical
practice, methods are being devised for applying it in war.
These methods are as yet incomplete, and have not been
practically tested, but there can be no doubt that it will prove
to be one of the best and most easily used antiseptics for the
purpo.se.

Esmarch, in Langenbeck's * Archiv,' vol. xx. p. 171, proposes
another plan of treatment.

He points out that the new form of bullets passing quickly
through the clothes may not carry into the wound any causes
of putrefaction, or if any pass in with the bullet they may also
be carried out by it. Therefore, if the wound is not examined
by dirty fingers or instruments, and if it be seen at once, it may
in most cases be regarded as aseptic. Starting on this prin-
ciple, he suggests that each soldier should be provided with
tampons of salicylic cotton, v.^rapped in salicylic gauze. Fig.
47 represents the contents of the packet of dressings which
Esmarch proposes to supply to each soldier. At the front, when
there seems any possibility of saving the limb, these tamf)ons
are introduced into the openings, and bandaged on without
preliminary probing or examination of the wound. Any
other necessary apparatus is applied, and the patient sent to
the rear. At the rear the skin around the orifice is purified
with some antiseptic lotion, and if there is any necessity to

esmaech's method. 109

explore the wound, as for removing bullets, splinters, &c., the
tampon is removed under the spray, the wound washed out,
and an antiseptic dressing applied. If there is no necessity
for exploring the wound, the skin is merely purified, and
then a mass of salicylic jute or other antiseptic material is
applied without disturbing the tampon. If putrefaction occurs
later the wound must be enlarged, and an attempt made to
purify it.

Consei'vative surgery being more applicable with the aseptic
method, the necessity for primary amputation at the front is less
frequent, and as a rule exists only in the case of smashes from
large balls. Esmarch considers that for such cases a sufficient
supply of antiseptic materials should be present in the am-
bulance. Referring to those cases not treated aseptically which
do well, and to the evils of investigating the wound at the first,
Esmarch says : ' So far as I can learn, those cases which
followed an aseptic course were not examined with the finger
on the field of battle, but were dressed at once, while those
cases in which repeated examinations were made appeared to
me often to run a particularly unfavourable course.'

Esmarch 's method has been put to the test by Dr. Reyher
during the late Russo-Tiirkish campaign. His results weie
excellent. He carried out the aseptic method in two ways,
according to the nature of the injury and the treatment before
the case came into the surgeon's hands. These are, either that
the surgeon closes the wound without further treatment, merely
disinfecting the surrounding parts, or else that he cleans out
and purifies the track of the bullet, and afterwards makes
provision for free aseptic drainage. In the first instance heal-
ing occurs under a crust ; in the second, under a moist and
antiseptic dressing.

The cases which ai'e suitable for the first method of treat-
ment — treatment by a crust — are those in which the wound is
small, where no clothing has been carried in with the bullet,
where the edges of the wound fall together, as where the wound
is more or less valvular, and where no examination of the

110 ANTISEPTIC TREATMENT OE WOUNDS.

wound by finger, probe, &c., has been made. In such a case
the surrounding skin is carefully purified, and an attempt is
made to obtain a dry crust, either by allowing the blood to dry,
or by aiding the drying by applying charpie, gauze, &c. ; or the
■\yound may be covered by a mass of salicylic wool or carbolic
gauze. Reyher lays particular stress on the avoidance of
probing or draining such wounds. On the contrary, any com-
munication with the outer world should be shut off as soon as
possible.

In many cases this ' occlusion ' of the wound cannot be
depended on, and the bullet track must be washed out, and
treated in the way described under compound fracture, free
drainage being carefully provided. This is chiefly the case
Avhere the missile has been travelling slowly, and where, conse-
quently, the wound in the skin is not so small nor valvular,
and where there is more likelihood of articles of dress beins
carried in with it ; where, also, as Reyher puts it, the wound is
open and ' the air has not only entered but must enter again.'
This treatment is also necessary in cases where wounds have
been examined with unclean fingers or instruments before
reaching the ambvilance.

It is thus evident that the spi^ay is not required for the
majority of cases, and indeed by following the lines previously
indicated it may be entirely dispensed with. The gauze re-
quired for th*:^ dressings can be made in the vicinity, and for
this purpose Reyher carried with him the machine for making
gauze described in ' Antiseptic Surgery,' Chapter III., and had
thus a constant supply of the freshly. prepared material. There
is not much difl&culty, therefore, with regard to the materials ;
the real question is how to have the cases treated aseptically
from the very first. Reyher was able to overcome these difli-
culties by proceeding in the following manner. In the first
place, instructions were given that wounds were never to be
examined at the front, either with fingers or instruments, nor
was any attempt to be made to extract a bu'let. The only
exceptions to these rules were cases where blood-vessels were

THE ASEPTIC METHOD IN AVAR. Ill

injured, tliougli even in these it was generally possible to apply
an Esmarch's elastic band to control the bfemorrhage tempo-
rarily ; and cases whei-e the projectile had passed into the large
cavities of the body, and, without wounding the contents, had
remained in the wall of the cavity. In such a case the bullet
ou^ht to be extracted at once, lest it should fall into the cavitv
during the transit of the patient. * For surgeons at the front
there is only one line of treatment — to occlude the wound pro-
visionally, to lay the wounded pai^t in a suitable position on
the litter, and to render it provisionally immovable. As
provisional dressing the salicylic balls recommended by
Esmarch are the best.' This method is chiefly suitable for
cases where the soft parts alone ax-e injured. Most of the
serious cases can be attended to as a rule at the foremost am-
bulance.

The more surgeons become imbued with the true principles
of aseptic surgery, and the more thoroughly they grasp anti-
septic surgery in all its developments, so much the greater is the
likelihood of obtaining aseptic results. Reyher's results show
strikingly what can be done with the methods at present at
our disposal. There can be no doubt that with improved
methods and increased knowledge and experience, aseptic
surgery will soon be universally carried out in war.^

' For a resume of the opiuions of army surgeons on the best method
of carrying out aseptic surgery in war, see a little pamphlet by Surgeon-
Major H. Melladew, T^^'otes on Antiseptic Surgery in War. London :
Eanken & Co. 1881.

112 ANTISEPTIC TEEATMENT OF WOUNDS.

CHAPTER YIII.

ASEFTIC SURGERY — {concluded).

Other methods of carrying out aseptic surg-er3\ Substitutes for
carbolic acid : Salicylic acid : Neuher's 'permanent dressings : Thymol :
Acetate of Alumina: Eucalyptus oil: Bichloride of mercury:
Na2>hthalin : Iodoform : Aseptic surgery by filtration of the air.
Subcutaneous surgery.

These are the essential details of aseptic surgery as introduced
and practised by Sir Joseph Lister. The disadvantages arising
from the irritating and poisonous qualities of carbolic acid have
led some to seek other antiseptics as substitutes for carbolic
acid. These attempts have not as yet, however, succeeded in
producing any substance possessing so many advantages as that
acid. The most successful substitute up till quite recently was
salicylic acid, which is used on exactly the same principles, but
not with the same constant aseptic results.

The use of salicylic acid was first advocated by Professor
Thiersch, of Leipzig, and the following is a short abstract of
his method of using it.

Salicylic acid is chemically nearly related to carbolic acid.
Its formula is C7H(;03, differing therefore from that of carbolic
acid in containing in addition the atoms of carbonic anhy-
dride. (The formula of carbolic acid is C^HgO.) Salicylic
acid is not poisonous, but it affects the hands in the same way
as carbolic acid. It is absorbed, and may be found in the urine
of patients whose wounds are dressed with it.

A lotion of salicylic acid is employed. This is a saturated
solution of the acid in water at the ordinary temperature, and

SALICYLIC ACID. 113

its strength is about 1 part of salicylic acid to 300 parts of
water.

Two materials are u'^ed as dressings — viz., salicylic wool and
salicylic jute.

Salicylic wool is cotton wool impregnated with salicylic acid
in the proportions of 3 and 10 per cent, by weight.

The 3 per cent, wool is made by dissolving 750 grammes of
salicylic acid in 7,500 grammes of spirit (83 sp. gr.). This
solution is then diluted with 150 litres of water at the temper-
ature of 70°-80° C. : 25 kilogrammes of pure cotton wool are
saturated with this mixture.

The 10 per cent, wool is obtained by dissolving one kilo-
gramme of salicylic acid in 10,000 grammes of spirit (S3 sp. gr.),
the solution being then mixed with 60 litres of water. Ten
kilo^^rammes of pure cotton wool are soaked in this solution.

This soaking is best done in a large wooden vat, in which
the layers of cotton wool have plenty of room. It is best to
place only small quantities of wool (two to three kilogrammes)
in this vat at a time, in order to get an equal distribution of
the acid. Thin layers of cotton wool are introduced into the
salicylic solution under light pressure, fresh layers being added
only when the former have been thoroughly soaked. When
the whole quantity has been introduced the mass is turned
over, so that the undermost layer becomes the uppermost, and
then it is left for about ten minutes, so as to have equable
distribution of the fluid. The wool is then taken from the vat
and spread out in layers. On cooling, the acid crystallises out,
and the layers are made up into small parcels, not exceeding
two to three kilogrammes each. After twelve hours this wool
is spread out to dry in a moderately warm place. It should
not be hung up, lest the acid should become unequally
distributed.

The 10 per cent, wool is coloured with carmine for the sake
of distinction.

It is important to note that Thiersch, in speaking of 3 per
cent, and 10 per cent, wool, means wool soaked in the solutions

114 ANTISEPTIC TREATMENT OF AVOUNDS.

of the strength described. The wool does not contain that per-
centage of salicylic acid.

This cotton wool does not absorb fluids readily, and therefore
Thiersch now uses jute. This is made from the bark of various
species of Gorchorus grown in Bengal, and is cheaper than
cotton wool, and at the same time more absorbent. It is used
of two strengths — 3 and 10 per. cent, prepared in the same way
as the salicylic wool.

Glycerine is added to the solution in order to prevent the
crystals of salicylic acid from falling out, because they are apt
to produce violent sneezing, coughing, itc.

In order to obtain the 3 per cent, jute 2,500 grammes of
jute are put into a solution of 75 grammes of salicylic acid
in 500 grammes of glycerine and 4,500 grammes of water at
70^-80° 0.

, In the glycerine jute the acid is more equally distributed
than in the cotton wool. In the case of the latter the cotton
is frequently so imperfectly charged that it is necessary to place
a layer of 10 per cent, cotton next the wound, and then outside
this the 3 per cent. wool. In the case of the glycerine jute a
4 per cent, material is sufficient for the whole dressing.

As to the spray, Thiersch does not care whether it is 1-50
carbolic acid or 1-300 salicylic acid. Carbolic acid is to be
preferred, because it causes less coughing and sneezing, and it
does not adhere to the clothes.

Salicylic acid is best in some cases, as it irritates the wound
less than the carbolic.

For disinfecting the hands and skin, carbolic acid or salicylic
acid may be used, but for the instruments carbolic acid must
be employed, because the steel becomes oxidised in a solution
of salicylic acid.

The sponges are washed in carbolic acid.
No protective is required, because the salicylic acid is but
little irritating.

Macintosh is also unnecessary.

In order to enable the dressing to peel off and to let the

SALICYLIC ACID. 115

discharge get away moie easily, a layer of gutta-percha tissue
or of oiled silk riddled with holes and covered with a piece of
gauze is applied next the wound.

This treatment may be illustrated by a case of amputation.

The patient having being chloroformed and Esm arch's elastic
bandage applied, the part is shaved, washed with soap and
water, spirit and turpentine oil, and then with salicylic acid
lotion, or with the 1-20 carbolic acid solution. It is also
scrubbed with a nail-brush for a few minutes (quite unneces-
sary). The operation is carried out with the usual aseptic
precautions. After arresting the ha;morrhage the wound is
closed with deep and superficial stitches. A drainage-tube is
then introduced into each angle, and the wound is washed out
with salicylic acid solution till the fluid which comes out is
clear (ixnnecessaiy). A piece of perforated gutta-percha tissue
aud three finger-breadths of carbolic gauze are then applied ;
over this comes one finger's thickness of the strong salicylic
wool, and outside this two fingers' thickness of the weak wool.
The whole is then fastened on with a bandage.

If the patient complains of pain the dressing is changed and
the wound examined. If not, it is left till the eighth or tenth
day, when it is changed, in order to remove the drainage-tube.
If any discharge comes through in the first instance, fresh wool
is put outside the dressing. The second dressing is left till
healing is complete.

Large compound fractures are treated at first by irrigation
W'ith salicylic acid. In order to protect the skin from irrita-
tion, it is from time to time rubbed with salicylic cream. After
all risk of abscess formation has passed off" and the wound is
granulating well, one may apply dry salicylic dressing as before
described. As I have already pointed out, this is an excellent
dressing for recent wounds but not for abscesses, nor would I
use it in cases of incision into joints.

Where there is a tendency to inflammation, more especially
where there is imperfect drainage with progressive abscess

116 ANTISEPTIC TEEATMENT OE V/OUNDS.

formation, wet salicylic dressing should be applied. This is
ordinaiy salicylic dressing, which is from time to time soaked
with salicylic lotion.

In some cases wounds are filled up with powdered salicylic
acid and salicylic wool applied outside. This is said to purify
wounds already septic. In some cases, however, there is risk
of salicylic acid absorption and poisoning.

In connection with the salicylic dressing, I may draw
special attention to the permanent dressings advocated more
especially by Neuber. For ligatures he uses catgut, for drain-
age absorbable tubes of decalcified bone, and in his first method
he fastened layers of gauze over the wound, filled xvp the hollows
with salicylic wool, then fastened on a mass of salicylic wool,
and then outside all a carbolic gauze dressing. Such a dressing
may be left till the wound heals. Later he used 10 per cent,
carbolised jute wrapped in carbolic gauze. When the iodoform
dressings were introduced he then used iodoform wool or jute,
and of late he has employed peat mould mixed with iodoform
and made up in gauze bags. This peat mould may also be im-
pregnated with bichloride of mercury in the same way as wool
(see below).

Thymol as an antiseptic application to wounds was introduced
some years ago by Ranke of Halle, and was much lauded on
account of its non-poisonous and non-irritating qualities.

The thymol gauze was made on the same princii3]es as the
carbolic gauze, spei-maceti being, however, employed. A thymol
solution of the strength of 1-1000 is made by the addition of
alcohol and glycerine.

This antiseptic has not answered the expectations entertained
at first. It does not prevent putrefaction, and has been jvistly
abandoned in aseptic work.

Acetate of alumina has been lately used by Maas. He
applies lint dipped in the solution (2^ per cent.) to the Avounds,
over a piece of protective, and covers this with macintosh.

EUCALYPTUS OIL. 117

The edges of the dressing are surrounded by salicylic wool.
The strength of the spray is also 2^ per cent.

He says that this is a powerful antiseptic, and that with it
he gets typical aseptic results. The substance is unirritating,
non-poisonous, and very few dressings are required.

Euccdij'^tus oil has recently been strongly advocated by Dr.
Schulz of Bonn.' Its antiseptic properties were shown by
Bucholtz in his paper on Antiseptics. He found that it was
three times as strong as carbolic acid, for while carbolic acid
prevented putrefaction when present in the proportion of 1 in
200 parts, the eucalyptus oil only required to be present in
the projDortion of 1 to G66"G parts to produce the same effect.

Siegen also showed that eucalyptus oil prevents putrefaction
and alcoholic fermentation better than carbolic acid. He found
that blood to which ^ per cent, of eucalyptus oil had been
added was quite odourless ten days later. Bing states further
that it hinders the passage of white corpuscles out of the vessels,
and that therefore, on Cohnheim's theory, it is an agent capable
of arresting suppui-ation.

With regard to its iisefulness, its smell is more pleasant
than that of carbolic acid. It dissolves readily in alcohol or
in oil, and mixes perfectly with pure paraffin.

Schulz also states, from Siegen's experiments and from his
own, that the eucalyptus oil is not jjoisonous. The tree from
which the oil is obtained grows in large numbers in Australia,
and the oil can be obtained in large quantities and very cheap.

Schulz recommends that for the spray the glass bottle should
be filled with the pure oil or with oil dissolved in alcohol. The
steam would then pick this up and make an emulsion.

As a lotion it might be used in the form of an emulsion.

Schulz proposes that the wounds should be dressed with lint

saturated with a 10 per cent, solution of eucalyptus or olive oil.

Outside this, or instead of it, may be used Lister's gauze dressing

containing eucalyptus oil instead of carbolic acid. A gauze

' Ccntralblatt far CJilrurgie, January 21, 1880.

118 ANTISEPTIC TEEATMENT OF WOUNDS.

■which contains even 50 per cent, of eucalyptus oil may be made
with paraffin. Dr. Schulz has not himself, however, used this
method.

Sir Joseph Lister has for some time been making an exten-
sive trial of eucalyptus oil in the treatment of wounds. A
gauze has been prepared similar to the ordinaiy gauze, but
containing eucalyptus oil instead of cai'bolic acid. Dammar
has also been substituted for the ordinary resin. So far this has
proved very satisfactory. It seems to be fairly trustworthy as an
antiseptic, and can be used tinder circumstances where carbolic
acid is apt to cause irritation, as in dressings on the scrotum, or
in patients whose skins are liable to be irritated by carbolic
acid. Being non-poisonous, it may also be substituted for car-
bolic acid in cases where constitutional effects are apt to follow
the absorption of the latter. Indeed, of late. Sir Joseph Lister
has used eucalyptus gauze almost to the exclusion of carbolic
gauze. On account of the great volatility of the oil the gauze
is, however, very uncertain in quality, and is, therefore, not so
safe as the carbolic gauze.

It has also been emjiloyed as an ointment in the proportion of
one part by measure of the oil to four parts by weight of the same
base as is used for the boracic and salicyhc ointments (p. 44).
This ointment is employed in the cases for which boracic and
salicylic ointments have up to the present been used, and it
possesses the advantage over the latter in that the oil not only
renders the di">charge pure as it passes over it, but also, on
account of its volatility, bathes the parts in an antiseptic
vapour. Hence it will probably be especially useful in the
treatment of burns (see p. 100). Its non-poisonoiis qualities
are also a great point. As yet no experiments have been
made with the view of substituting it for carbolic acid in the
lotions used in the spray, in washing wounds, purifying instru-
ments, ifec.

Among the more recent antiseptics the bichloride of mercury
deserves special notice. Since Koch's research on disinfection

COKROSIVE SUBLIMATE. 119

it has been largely used in Germany, Bergmann, however, has
employed it since 1878. Max Schede has done a great deal of
work with it, and I will refer chiefly to his methods.

There are two solutions employed : a weak watery solution
of Jyth percent, strength, and a strong watery solution of -j\^th
per cent. These are used for disinfecting the skin and as lotions
for the wound, &c. For the spray and the disinfection of instru-
ments carbolic acid is still employed. The catgut is laid in the
first instance for twelve hours in a 1 per cent, watery solution,
and then kept in a^ per cent, alcoholic solution containing 10
per cent, glycerine. An antiseptic powder is formed by mixing
sand which has been subjected to a high temperature with a
1 to 10 solution of bichloride in ether. A -^Qth. per cent, and a
ith per cent, make a good powder for sprinkling over wounds.
In the case of superficial wounds this powder is first sprinkled over
them, and then a dressing of sublimate gauze or wool is applied.
This dressing is made by soaking unprepared gauze or wool in
the following solution : corrosive sublimate 10 parts, glycerine
500 parts, and alcohol 4,490 parts.

In the case of wounds united by stitches a layer of glass
charpie is first applied, made of spun glass, which is always kept
in a 1 per cent, watery solution. Over this the sand is sprinkled
and then the sublimate wool, the whole being fastened by a
bandage. Capillary drains of this spun glass may also be used.
The dressings may be left unchanged for weeks.

Some surgeons do not use the sand loose but enclose it in
disinfected bags, or instead of sand coal ashes may be used con-
taining ^^th per cent, sublimate. The ashes are lighter than
the sand.

Von Bruns employs wood wool impregnated with ^ per
cent, sublimate and 5 per cent, glycerine. He first washes the
wound with the ^^th per cent, watery solution, then stitches it,
uses the spun glass a.s a drain and covers the whole with the
wood wool.

Very excellent aseptic results are obtained in this way, but
sometimes severe irritation and eczema has been obsei'ved, and

120 ANTISEPTIC TEEATMENT OF WOUNDS.

also in several cases salivation. From what I know of the
results I doubt if they are so constantly good as with car-
bolic dressings, and except in the matter of permanent aseptic
dressings I do not as yet see much advantage from the use of
the sublimate.

In the ' Lancet ' and ' British Medical Journal ' for October
1884 will be found a paper by Sir J. Lister on corrosive sub-
limate as a surgical dressing. He finds that if combined with
serum it loses to a great extent its irritating properties. He
proposes to make a gauze impregnated with a mixture of 1 part
of sublimate to 100 of serum. He is, however, still working
at the subject, and iL is somewhat premature definitely to re-
commend a particular sublimate dressing.

Naphthalin (C,oHg) obtained from coal tar has also been
extensively used by E. Fischer of Strasburg. He found that
while a powerful antiseptic it was not poisonous to man.
Foul wounds powdered with it were soon purified.

In the case of open wounds, Fischer fills them with
powdered naphthalin and then applies a mass of absorbent wool
or gauze, a piece of macintosh and a bandage. The dressings
are impregnated with naphthalin either by spiinkling a
quantity of the powder in them, or by soaking them in a
strong solution of naphthalin in alcohol and ether, and allowing
the alcohol and ether to evaporate.

An ointment of equal parts of naphthalin and vaseline is
also employed. Fischer also uses an ethereal solution for the
disinfection of foul wounds. It is either brushed or sprayed
over the surface of the wound.

In an American review of my 'Antiseptic Surgery,' I was
sevei'ely blamed for not mentioning or laying stress on iodo-
form as a substitute for carbolic acid in the treatment of wounds.
I omitted it intentionally, for I did not consider that it was a
good antiseptic, nor did I think that it would be used for any
length of time. This view has proved correct. Iodoform is

PILTRATION OF AIR. 121

not a powerful antiseptic, and is not now nearly so much em-
ployed as it was two or three years ago. It has been found
that in a considerable number of cases severe symptoms of
poisoning have followed its use, while it does not even prevent
the occvuTence of erysipelas. In the clinique of Max Schede
and others who may be trusted to observe all the necessary pre-
cautions for antiseptic work, severe epidemics of erysipelas have
occurred in wounds treated by iodoform, and they have for this
reason, and on account of its poisonous qualities, given up its
use.

Wounds are powdered with the iodoform, a gauze or wool
containing 10 to 20 per cent, of iodoform is applied, the piece of
the dressing placed next the wound being, however, soaked in the
1-20 carbolic lotion. Carbolic acid is also used for disinfection
of skin and instruments and for spraj'. There is no doubt that
many good results are obtained, especially if no macintosh is
applied outside the wool, but the results are not so constant as
with carbolic acid, and in corrosive sublimate, salicylic acid,
acetate of alumina, &.C., we have much better substitutes for
carbolic acid.^

So far we have been considering modes of pi-eventing putre-
faction in wounds, based on the fact that the septic particles in
the air and on surrounding objects may be deprived of their
power of causing fermentation by contact with some suitable
chemical substance. But it is also sufficient for the avoidance
of fermentation in flasks to keep the dust out mechanically, as,
for instance, by means of cotton wool. This fact was made use
of by Sir Joseph Lister some years ago in the following manner.
I may quote his remarks, which are given in a foot-note to his
article on Amputations in Holmes' ' Surgery,' vol. v. p. 619,
published in 1871.

' Among i^ecent contributions of fact to the elucidation of

> Full details with regard to the use of iodoform will be found in
E. Fischer's Handhiich der allgeineinen Verhandlchrc, tStuttgart, F.
Enke, 18Si.

122 ANTISEPTIC TREATMENT OF WOUNDS.

this question (the germ theory) may be mentioned Professor
Tyndall's simple but beautifal proof of the existence of organic
particles of dust of excessive minuteness in the air by means
of a condensed beam of light, and the equally clear ocular
demonstration afforded by the same method, that even the
finest particles ai-e ca^oable of being removed from the air by
causes which Pasteur, in some of his experiments, inferred must
clear it of suspended organisms, such as the action of gravity
and filtration by cotton wool. The fact last named seemed to
promise valuable results in antiseptic surgery, and experiments
made with this view have afforded further evidence in favour
of the germ theory, which it may be well to mention here. I
found that if cotton wool impregnated with either chlorine or
sulphurous acid gas, or with the vapour of benzine or carbolic
acid, was placed upon a wound or granulating sore, after
washing the surface with a solution containing the same agent,
although the volatile antisejytic left the cotton in about a day,
the blood or pus still effused beneath the cotton remained free
fi'om putrefaction for an indefinite time, provided that the dis-
charge was not sufficiently copious to soak through the cotton
and appear at the surface, in which case, the meshes between the
fibres affording ample space for microscopic organisms to develop
in, putrefaction spread within a few hours throughout the
moistened part of the mass. This circumstance greatly inter-
fered with the practical utility of the dressing, and it has since
been superseded by the antiseptic gauze to be described in the
text, but the facts seem to me important with regard to the
germ theory. The cotton wool, though it loses all chemical
antiseptic virtue in a day, yet will keep out putrefaction for a
month or more. It cannot possibly keep out any atmospheric
gas, which is necessarily diffused freely between its fibres, and
gets in for the same reason that the volatile antiseptic gets out.
That which it does exclude can only be suspended particles of
dust. It follows, therefore, as a matter of certainty, that the
cause of putrefjiction through atmospheric influence of blood or
pus, or, in other words, such materials as the surgeon has to

EILTKATION OF AIE. 123

deal with in treating vrounds, are not the atmospheric gases,
but dust, and the fact that this dust is deprived of its pvitrefac-
tive energy by agents which are chemically so unlike as chlorine,
sulphurous acid, benzine, and carbolic acid, but which agree in
having a common hostility to animal or vegetable life (I used
benzine because I knew that the entomologist employs its vapour
to kill insects), this' fact confirms the view that the putrefactive
particles are really organisms. I commend these simple experi-
ments with cotton wool to the candid jvidgment of the reader,
because, whatever may be thought of their bearing upon the
allied subject of spontaneous generation, they must be allowed
to aflbrd absolute demonstration of the truth which is the
foundation of the antiseptic system, viz., that the putrefaction
of blood or pus under atmospheric influences is caused not by
the gases of the air, but by suspended particles, which can be
deprived entirely of their septic energy by the vapour of an
agent like carbolic acid.'

It will thus be seen that what Sir Joseph Lister used here was
not an antiseptic application but an aseptic one, and that the
only mode in which this dressing acted was by mechanically pre-
venting the particles from reaching the wound. For the reasons
quoted, this method has not been turned to practical account,
though, as we have seen, it is still used in cases of gangrene in
order to protect the weak parts from all sources of irritation.

Mr. Barker, of University College Hospital, has tried a
similar method in one or two cases. He purified cotton wool
by heat, and applied between it and the wound a layer of lint
dipped in carbolic oil. This method, however, seems to be im-
practicable, for after the wool has been heated, but before it
is applied, dust would very probably gain access to it unless
very complicated precautions were taken. I believe that if
pure cotton wool is used Sir Joseph Lister's method is the only
practicable one.

I have mentioned these experiments more as confirming the
theory of aseptic work than for the purpose of recommending
the method for adoption. I believe that thoroughly satisfactory,

124 ANTISEPTIC TREATMENT OF WOUNDS.

and indeed the best, results may be obtained by the use of suit-
able chemical means.

Subcutaneous surgery is another way in which the aseptic
principle may be carried out. Here the wound is made under
the skin and away from the air dust altogether. If, however,
the instruments used are not thoroughly disinfected, it may
happen that micro-organisms capable of living in the tissues
may be carried in with them and lead to suppuration or some
other mishap.

125

CHAPTEE IX.

ANTISEPTIC SURGERV.

Treatment by antiseptics : Cariolic acid — objections to it : Chloride of
zinc: Boracic acid : Sulphin'oiis acid : Chlorinated soda, : Alcohol —
JTiitch in son's method: Terebene and Sanitas — Bilr/ner's metliod —
Kendoiifer's salicylic powder. Free drainage as an antiseptic method.
Irrigation and immersion. Open method : Modes in which it acts
antiseptically : Bartscher and Vezin's victhod : Bnro?v's method:
Rose's modification. Healing by scabbing: Methods of forminf/ a
crvst : Bouisson's rentilatio?i method : other modes. Guerin's cotton-
wool dressing. Modes in which the destructive action of the tissues
on bacteria is assisted. Why does not fervientation. ahvays occur in
the blood in mounds in which organisms are present ? Best practical
metliods.

I. — Methods hy which various Antiseptics are added to the Dis-
charge, so as to hinder the Develo2}ment of Organisms in it.

What are the best antiseptics to use for this purpose 1

Carbolic acid is the one most frequently employed, but, in
my opinion, it is by no means the best in this instance. In
vegetable infusions, where carbolic acid is present in the pro-
portions of 1-300 to 1-350, all further growth of organisms is
prevented, but in such fluids as serum, milk, pus, &c., the acid
forms a compound with the albumen, and a much larger propor-
tion is required. Thus, in milk, carbolic acid in the proportion
of 1-54 is just enough to prevent development. In accordance
with this fact, a very strong solution would be required in the
case of wounds, or it must be added in large quantities, in
order to prevent the development of micro-organisms.

And so my own experience of carbolic acid as a disinfectant
in the form of a 1-40 watery solution in putrid cases is un-
favourable, while on the other hand, if 1-20 carbolic acid be

126 ANTISEPTIC TEE.ITMENT OF WOUNDS.

used, it is very irritating and interferes with healing. Injected
once or twice a day, the latter destroys the superficial granula-
tion cells, and produces a thin slough in which bacteria develop,
and from which it is very difficult to dislodge them. Then its
poisonous qualities are objectionable, and are of course much
more evident when the acid is injected into wounds or abscess
cavities than when used in the manner described in the chapters
on aseptic surgery.

Further, Dr. Wilhelm Hack,' in a paper on the power of
absorption by granulations, has demonstrated that granulations
treated with carbolic acid possess many of the qualities of a
recent wound as regards absor'ption. For instance, apomorphia
which was only absorbed during the first twelve hours by wounds
treated with water dressing, was readily absorbed at any time
by granulating wounds treated with carbolic acid ; and therefore,
in the absence of information to the contrary, I should fear
that some of the poisonous products of putrefaction might be
absorbed with like avidity. Hence, 1 do not like carbolic acid
unless it is used aseptically.

Chloride of zinc applied to the cut surface has been already
alluded to. A single application of an 8^ per cent, watery
solution has the remarkable property of preventing putrefaction
in a wound for some time after an operation ; sometimes, in-
deed, till granulation is nearly complete. It is further useful,
according to Hack's experiments, in that the slough caused by
it does not permit the absorption of substances from the wound.
When used in the treatment of wounds, a dilute solution (1 or
2 grs. to the ounce of water) is employed.

Boracic acid is too weak an antiseptic to be of much service
as an injection, but the boracic ointment and the boracic lint
act well as dressings.

One of the best antiseptic lotions is made with Sulphurous
acid. This is a powerful germicide. It is also non-irritating
and perfectly free from any poisonous qualities. It is used as

' Ueier das Hesorptlonsverimgen granidlrender FlucJien, Leipzig,
187i).

TREATMENT BY ANTISEPTICS. 127

a solution which is made by mixing together equal parts of the
sulphurous acid of the Pharmacoposia and water or glycerine.
This may be still further diluted if necessary.

The Chlorinated soda solution is mentioned by Dr. Cabot as
standing, next to 1-20 carbolic lotion in rapidity of action on
bacteria. The strength generally employed is 5ss. to ^j of water.

Alcohol is not a bad application to wounds, but in order to
be effectual it must be used strong. It has a further advan-
tage, for Dr. Hack has shown that granulations treated with
alcohol do not absorb at all or only very slightly ; and to this
may be attributed, to some extent, the favourable course of the
cases in which wounds are simply washed out with an alcoholic
solution, and a rag, dipped in the same solution, applied outside.

Mr. Jonathan Hutchinson, more especially, has had
remarkably good results from the use of alcohol. His method
is as follows : Having carefully arrested all haemorrhage,
chiefly by torsion, he washes out the wound with pure spirit.
He then carefully arranges drainage-tubes at the most depen-
dent parts, and stitches up the rest of the wound. Thin com-
presses soaked in a lotion composed of 6 parts of absolute
alcohol, a half part of liquor plumbi, and 16 parts of distilled
water, are now applied. These compresses are kept constantly
moist, either by a nurse or by means of a drop irrigator
The lint is changed daily. In the treatment of important cases,
such as compound fractures and dislocations, the rule observed
is never to allow the skin to become warmer than natural. His
wounds generally heal by first intention, and septic poisonii.g
is very infrequent.

In some of these cases no doubt the wound may be aseptic
from first to last. To apply an antiseptic to a wound, to
stitch up immediately, and then keep an antiseptic dressing
constantly applied, is really to operate moi'e or less aseptically.
and I believe, with regard to Mr. Hutchinson's cases,
that this partly explains the good results — the wound being
aseptic, at least for a time. Then Hack's results have a strong
bearing on these cases, for absorption does not take place

128 ANTISEPTIC TKEATMENT OF WOUNDS.

readily. Mr. Hutchinson is also very particular to have free
drainage, which powerfully helps to maintain the aseptic con-
dition; and lastly, he carefully selects the cases for operation,
only operating, unless in cases of necessity, where the patient is
in good health. This selection of cases is a thing not necessary,
and not done where complete aseptic treatment is employed.

The method which I should think was the best, acting on this
principle, is the following ; it is practically what Sir Joseph
Lister employs Avith excellent results, only I would reject the
carbolic acid. After the wound has been made, and before any
stitches are inserted, the raw surface ought to be thoroughly
sponged over with chloride of zinc solution (40 grs. to the oz.
of water). In the case of operations on the extremities, this
is best done before the toui-niquet is relaxed, so as to insiire its
thorough application, for otherwise the blood would wash away
the solution or dilute it before it has had time to act. Silver
wire stitches are then inserted — special care being taken to insure
free drainage, by the use of large drainage-tubes. As a dress-
ing in the first instance, till the bleeding has stopped, several
layei's of wet boracic lint (wet in boracic lotion) are applied.

On the day following the operation the lint is removed, the
surface of the wound is thoroughly cleansed with acetate of
alumina, sulphurous acid or chlorinated soda lotions, or with
Hutchinson's lotion, and the drainage-tubes are washed ovit
with the same, though not removed. The dressing is now a
narrow strip of the salicylic, evicalyptus, or full strength boracic
ointments, thinly but evenly spread on calico, and outside this,
overlapping it in all directions, one or more broad layers of
boracic lint or a mass of salicylic avooI.

On the second or third day the drainage-tube is removed ,
and is washed in 1-20 carbolic lotion, the wound being then
syringed out with the sulphurous acid or other lotion. After a
day or two the ointment over the line of incision is changed to
the half-strength boracic, or if salicylic or eucalyptus ointment
was used, they are retained. These dressings are changed daily
at first, but when the discharge diminishes, they may be left
for two days.

DKAINAGE; lEEIGATIOX AND IMMEKSION. 129

. Terehene and sanitas are remarkably good applications where
the smell is bad.

The results of this treatment are of course not so perfect a'?
those of the aseptic method, for, however carefully one Avashes
out the wound, there are pouches in it into which the fluid does
not enter, and pieces of slough cannot of course be disinfected.
Thus prolonged suppurations may occur, caries may continue
without tendency to cure, and even accidental wound diseases
(pyaemia, &c.) attack the patient.

With regard to the use of chloride of zinc, I ought to say
that it is well not to apply it to wounds which must, if possible,
heal by first intention, as, for instance, in. incisions about the
lips or face.

It was on this principle that Lemaire employed carbolic
acid and coal tar ; and his results, though very good, by no
means correspond to those obtained by strict aseptic treatment.

It was also on this principle that good results followed the
use of balsams of various kinds in olden times. The most
remarkable example of the success of such attempts at rendering
the wound seci-etions incapable of putrefaction by the use of
balsams, was that of Bilguer in the last century. No doubt
where the wound is shallow, and possesses few recesses, and
where the balsam or other antiseptic employed fills up these re-
cesses, we have really an aseptic treatment and an aseptic x'esult.

By sprinkling powdered salicylic acid on wounds till no
more fluid passes out, Neudorfer manufactures a paste under
which he says that healing may occur without suppuration.

II. — Free Drainage as an Antiseptic Method.

I have already discussed the main principles of drainage
under the head of aseptic surgery. It is quite clear that, if dis-
charge flows away as fast as it is formed, there can be no marked
development of bacteria or of their products. The free drainage
of a wound from which organisms are not from the first excluded
is therefore of the utmost importance. I have already described
the use of india-rubber tubes, and I have referred to catgut

130 ANTISEPTIC TEEATMENT OF WOUNDS.

and horse-liaii". Since, in a wound not treated aseptically,
fermentation, most probably followed by suppuration, generally
occurs in the track of the drain, we must provide such a drain
as shall permit the free escape of pus. 'Now, neither horse-hair
nor catgut can drain pus, and, therefore, a tube of some kind
or other must be used. This may be an india-rubber one, or it
may be made of various kinds of metal, perforated at its sides,
and cut flush with the surface. The tube, of whatever material,
must be removed from the wound at each dressing and washed
with a strong antiseptic lotion, say 1-20 carbolic lotion. If
this be not done, portions of decomposing tissue, &c., remain
inside the wound, and become more and more putrid till very
soon they become caustic.

Where the wound is not treated aseptically, the principle of
having the most dependent opening possible mvist be carried
out to the full.

III. — Irrigation and Immersion.

The principle of free drainage is never of course used alone ;
other principles act along with it. Of these, one of the most
satisfactory is that in which the discharge is not merely allowed
to flow away, but is washed away, and the further addition to this
principle of adding an antiseptic to the water used for the irri-
gation and of thus keeping the wound constantly bathed in an
antiseptic fluid. The latter is the form in which irrigation and
the water bath are now always employed, viz., by the use of an
antiseptic solution.

Irrigation is, as a rule, only pi'acticable on the extremities,
though it may be carried out on the trunk. For the lattei',
however, the continuous water bath is the most convenient.

The wounded part having been arranged at perfect rest, a
sheet of macintosh is fastened to the limb, and so arranged
that the fluid flowing from the wound shall be conducted to a
tub ; the vessel containing the fluid is fixed at a considerably
higher level than the patient. The form of irrigator most
generally used at the present time is Esmarch's. This consists

IRRIGATION.

131

of a cylindrical leaden or zinc vessel, which has a ring at its
upper part to enable it to be affixed to the wall. From the
side of this vessel, close to its bottom, a tube
passes, and to the end of this tube is fastened
a long piece of india-rul)ber tubing with a
nozzle at its end. This nozzle is arranged
so as to diiect the fluid into the deeper parts
of the wound. The fluid used is generally
some weak antiseptic solution, such as chlori-
nated soda, or sulphurous acid, or boracic
acid.

A very good apparatus can be made in
an emergency (according to Thiersch) by
knocking the bottom out of a champagne
bottle, and having the tube for conveying
away the fluid passed through the cork. The
bottle is inverted, filled with the solution,
and fastened to the wall. The fluid used
may be tepid or cold : there is no advan-
tage in using it very cold, as recommended
by some.

Where the fluid is dropped on to the

wovind, it is well to place a piece of lint over

the part where the drop falls, to prevent the

constant irritation caused by the concussion. The skin in the

neighboui"hood of the wound ought to be coated with palm oil,

in order to prevent maceration.

The continuous bath is either a bath in which the whole
patient can be immersed, or one in which the wounded part
alone is placed. There are numerous methods of doing this, but
I shall only refer to Langenbeck's and Valette's methods.

Langenbeck placed the wounds in the bath immediately
after the operation. Where possible, he stitched up the wound,
leaving a space at the angle through which discharges passed,
and through which the ligatures were brought out. During
the first twenty-four hours, the limb was simply suspended in

Fig. 48.— Thiersch's
Champagne Bottle
Irrigator.

]32

ANTISEPTIC TEEATMENT OF WOUNDS.

a bath, and was not arranged in a- special apparatus which
is apt to constrict the part and cause bleeding. When the
edges could not be brought together-, chai'pie and a bandage
were applied for the first twenty-four hours to prevent bleedin<y.
The permanent bath was continued till granulation was
complete, and till epidermic formation had commenced. The
limb and granulations were apt to become cedematous, but this

Fig. 49. — Arrangement for Irrigation in the Upper Limb.
(After Bsmarch.)

subsided in a few hours after the removal of the part from the
bath. The apparatus was emptied night and morning, and the
walls of the vessel carefully sponged with water containing
chlorinated soda or chloride of lime. When the stump had
been closed at first, the wound was daily injected along the
course of the ligatures. The temperature of the water was at

IRRIGATION AND IMMERSION.

133

first 10°-I2° C, but it was raised, as the patient could bear it,
to 31°-37° C. The skin of the stump had a thick layer of
grease over it, to prevent the action of the water on the
epidermis. Where the whole body had to be immersed, the

Fig. 50. — Arrangement foe Irrigation in the Lower Limb.
(After Esmarch.)

immersion was continued for a half to one hour daily in water
at the temperature of 34° C. Water dressing was employed
towards the end of the case.

To avoid the dangers resulting from fermentation of the

134

ANTISEPTIC TREATMENT OF WOUNDS.

fluid in the bath and in the wound, Yalette impregnated the
water with tincture of benzine, creosote, alcohol, or perchloride
of iron. The last gave the best results. There was no putre-
faction of this fluid, and he seems to have had great success.
He was especially struck with the absence of traumatic fever.

The advantages of the treatment by constant irrigation are
that the discharges are removed as fast as they form, and at
the same time, where an antiseptic is employed, the part is kept
constantly sweet. Thus, where the cavity is small and uncom-
plicated, there may be a truly aseptic state of affairs.

At the same time, where tepid water is used granulation is
favoured, while pain and nervous irritation are very much

Fig. 51.— Apparatus fob Continuous Immersion.
(After Esmaxch.) (For the extremities.)

diminished. Fuither, the parts are kept at absolute rest, the
necessity of moving them in order to change dressings, &c.,
being avoided.

As an antiseptic means, I should think that satisfactory irri-
gation is better than the continuous water bath, for in the
latter there is not the same constant change of fluid, nor the
feame washing away of the discharge.

The favourable results of constant irrigation, especially
when antiseptic fluids are employed, in preventing septic
diseases are very remarkable, and, in this respect, it probably
stands next to strict aseptic treatment.

The disadvantages of these methods are for the most part
the sodden state of the wound and the consequent (Edematous
condition of the granulations, the constant state of unrest of
the wound and the inconveniences attending the application

OPEN METHOD. 135

of the method. For the first reason they are discontinued
Avhen granulation is complete and has filled up the deeper parts
of the wound, and when the time for blood poisoning has passed.
That the good results of irrigation and immersion are not
due to mere maintenance of temperature, as has been supposed,
is shown by the results of ]M. Guyot with his incubation method.
Here the wounded part was enclosed in an incubating
apparatus, and kept permanently at a high temperature. This
method, though much lauded for a time, really seems to have
favoured considerably the development of septic diseases.

IV. — Concentration of the Fluids and their Admixture

with Oxygen.

The method of treatment which has been the greatest
stumbling-block in the way of the acceptance of the principles
of antiseptic sui-gery is the open method, for surgeons have
been unable to see how the success of this method could be
reconciled with the germ theory of putreftiction. They have
looked on it as the antithesis of aseptic ti'eatment, as acting
on the very opposite principle to that on which the aseptic
method is based. And yet, when we come to consider the
matter in the light of the true principles of antiseptic surgery,
we find that the open method is an advanced method of anti-
septic treatment. Of course other principles, such as that of
perfect rest and free di-ainage, also tell markedly in this case.

I have stated that this open method acts antiseptically in
two ways, and these I must now briefly consider.

1 . It acts antiseptically in that the discharges dry up, and
become more concentrated, and thus become unfit soil for the
growth of bacteria.

That concentrated fluids are not suited for rapid develop-
ment of organisms is well known. Thus Pasteur pointed out
that organisms coidd not grow in sugary solutions which ha I
become concentrated. This fact is made use of in the arts, in
the preservation of fruits. Sugar is added in large quantities,
and then the fruit can be kept for an indefinite length of time.

136 ANTISEPTIC TKEATMENT OF AVOUNDS.

It is not that the sugar is an antiseptic kilhng the organisms,
it is merely that by its pi'esence in large amount the fluid is
rendered unsuitable for development.

The same principle is made use of in preserving milk. The
milk is evapoi-ated to one-third of its original volume, and a
considerable quantity of sugar is added to it. Without the
addition of the sugar, the condensed milk may be kept for a
considerable length of time without the appearance of organisms
in it ; with sugar it may be kept indefinitely.

The same is the case with other albuminous fluids, such as
the discharge from wounds. Concentrate pus, and it will be
found that organisms develop in it only with difficulty.

Then we know the contrast between cases of dry and moist
gangrene ; how in the latter putrefaction rapidly occurs, or, in
other words, oi'ganisms rapidly develop, Avhile in dry gangi-ene
})utrefaction does not occur, i.e. organisms cannot develop.

2. In the open method another antiseptic advantage is
gained by the free admission of oxygen to the discharge.

Some very remarkable efiects of oxygen in retarding putre-
factive and other fermentations were ^Dublished long ago by
Pasteur. He pointed out that if a sugary solution were freely
exposed to air in a thin layer, the yeast plant, though it gi-ew
luxuriantly, caused ver}^ little fermentation. On the other
hand, if oxygen were excluded, only a small development of
the yeast cells was necessary for fermentation. And he has
shown that other plants besides the yeast plant can cause alco-
holic fermentation, if only they are deprived of free oxygen.

With regard to putrefaction he has brought forward similar
evidence. The organisms which cause putrefaction are, ac-
cording to him, incapable of living in the presence of oxygen.
If a putrescible fluid be freely exposed to the air in a thin layer,
putrefaction does not occur, at least not for a very considerable
time. Oxygen apparently not only interferes with the fermen-
tative process, but actually destroys the bacteria which cause
it. Hence the free exposure of a putrescible fluid to the air
results in comparative freedom from jDutrefaction, partly because

OPEN METHOD. 137

the oxygen interferes with the development of fermentative
changes, and partly because the oxygen directly kills the putre-
factive bacteria.

There are two methods of wound treatment which act on
the principles alluded to above. The first is that introduced by
Bartscher and Vezin, and cai-ried out in the following mannei' :
' After vessels have been tied, and after the stump has been
cleansed from blood-clots by means of a sponge and cold water,
the patient, for whom two beds are provided close to each other,
is put to bed, the stump is laid on a soft pillow, and over it a
piece of gauze or linen is loosely placed in order to keep out the
flies, the whole stump being freely exposed to the air.' At the
morning visit, the surgeon pushes his hand under the stump,
raises it, removes the pillow and applies a new one, or lifts the
patient on to the other bed, without further cleansing of the
wound. In this method all attempts at union by first intention
are given up.

Burow of Konisberg published his method in 1859. He
attempted to obtain primary union as far as possible. This he
did by bringing the surfaces of the wound into contact after a few
hours by means of strips of plaster applied over part of the
surface, all other dressings being avoided.

Eose, whose results of open treatment have been specially
published by Kronlein, adheres to Bartscher and Vezin's
method, with this exception, that he daily washes out the
wound with some antiseptic lotion. Crusts are removed, as
they are never complete enough to prevent putrefaction, and
only cause tension by their presence, and indeed protect the
discharge underneath from the action of the air, or of the anti-
septic lotion. Hose further ventilates very freely, so as to have
a plentiful supply of air to the stump. He employs this method
in all wounds except those on the face, where union by the first
intention is desirable.

The open method pure and simple is that introduced by
Bartscher and Yezin : for here, while the discharges are allowed
to flow away freely, they are left to the unaided action of the

138 ANTISEPTIC TEEATMENT OF WOUNDS.

air. The antiseptic efiect of this method is no doubt increased
by the addition of intermittent antiseptic irrigation.

Burow's method cannot act nearly so perfectly, for in it dis-
charges must accumulate in various parts of the wound, and
they are therefore not so conveniently placed for thorough action
of the air.

Among the objections to these methods are the following :
in all, except Burow's, union by first intention cannot possibly
occur, indeed no attempt is made to obtain it ; as a consequence
of this, a long time is required for healing, while a larger scar
is obtained ; the frequent formation of scabs and the consequent
tension also cause great annoj^ance.

Closely allied to the open method stands heeding hj scab-
bing. This may be brought about chiefly in two ways. The
crust may either be allowed to form naturally, or its formation
may be aided by artificial means.

This healing by scabbing acts in two ways. In the first
place, the first principle of the open method of treatment comes
into play ; the discharge dries up and becomes an unfit soil for
the development of organisms. In the second place the fluid
underneath it is in such a thin layer that the living tissues in
the neighbourhood prevent the development of organisms in it.
Of course in many cases no living organisms would be there to
develop, for the scab would form an absolute protection against
their entrance.

The natural formation of the crust can only take pla(*e effici-
ently in small wovmds, and only exceptionally where cavities
and recesses are present. For in larger wounds, as we have
seen, there is too much discharge for a sufficiently rapid and
thorough formation of a crust; and if the crust is not perfect
and rapidly foi'med, putrefaction takes place underneath it, while
at the same time, by confining the discharges, tension and ulcei'a-
tion result in place of healing.

But though this natural formation of a crust cannot be trusted
to in most cases, yet by artificial means a satisfactory one may
be obtained.

HEALING BY SCABBING. 139

Bouisson's method consisted in blowing air on to the sur-
face of a wound by means of a caoutchouc bag. He generally
directed the patient to do this himself. The ' ventilation '
lasted a variable length of time, according to the extent of the
surface and the quantity of flviid. A quarter of an hour
generally sufficed for each seance, and this was repeated four or
five times a day. The first crust which formed was rarely
sufficiently thick or firm, but by-and-by the crust became of
sufficient thickness, and when this was obtained, the ventilation
was stopped. If the crust seemed to be confining the discharge
and doing harm, it was softened and removed, and the process
begun again.

The most common modes are by the application of various
powders, such as starch, alum, flour, &c., to the discharge, so as
to form a paste. One of the best substances which can be
employed in this manner is powdered salicylic acid, as recom-
mended by Neudijrfer, and mentioned before under ' Treatment
by Antiseptics.'

Neudcirfer uses salicylic acid in the form of a powder mixed
with other substances, such as starch, zinc oxide, &c. He dusts
the wound with the powder, and rubs it up with the fluids of
the wound. Thus a mass is formed, which is again rubbed up
with fresh powder till no more fluid comes; then over the
whole some pure salicylic acid is applied, and a bandage.
This crust is left on, and if on pressure on it some fluid exudes,
more powder is applied. This is generally necessary five or six
times during the progress of a case. This method is really only
of use in small wounds. The objections to its use in large
wounds are that the pain is great, the material expensive
and there is very apt to be confinement of discharge. Neu-
dorfer states that there is no bad smell in the cases treated in
this way. Among them he has had no bad case of pypemia,
hospital gangrene or tetanus. He cannot say much about
erysipelas. As a rule, in the cases which were attacked, it was
generally some other part of the body which was affected.

Other attempts have been made to produce a scab by the

140 ANTISEPTIC TREATMENT OF WOUNDS.

application of various caustic substances to the surface of the
wound. The crust so formed, containing as it does a strong
caustic, is unable to undergo putrefaction ; and where the inflam-
mation caused by the application is not too great, and does not
lead to accumulation of fluid under the crust, an excellent result
is obtained. In this case, as no organisms are present under
the crust (they were destroyed by the caustic), and as the firmly
adhering crust prevents their entrance, we have the typical
aseptic result — healing of an open wound without suppuration or
granulation. There are, however, vaiious objections to this
method of crust formation, the chief of which is the loss of
substance involved in the process, while the same disadvantages
are present as in the open method proper, viz., slowness of
healing and a large scar.

Closely allied to this method of crust formation is that in
which the crust is obtained by the application of the actual
cautery.

Crust formation is seldom suitable unless in the case of
superficial wounds without recesses or cavities, for if these are
present an opportunity is given for the occurrence of tension
under the crust. It is a method by no means easy or universal
in its application. Where it is employed I should recommend
the use of Neudorfer's method, viz., the formation of a crust by
the aid of salicylic acid powder.

Alplwnse GuerirCs Cotton-wool treatment acts partly on
the first part of the principle of the open method, but it hardly
comes into the category of antiseptic methods.

As originally used, the wound was simply washed with water,
and a large mass of cotton wool applied arovmd it, and firmly
bandaged on.

At present the wound is washed with some antiseptic lotion,
and layers of cotton-wool, containing camphor powder sprinkled
in it, are applied. The deeper layer is of wool moistened in
carbolic lotion. The dressing should not be applied or changed
in the ward, but in a theatre or side room, and the packet of
cotton-wool should not be opened till the time of application

HEALTHY TISSUES AND BACTEEIA. 141

of the dressing. No doubt these precautions may prevent
some infective material present in the ward atmosphere from
settling on the wound or on the cotton- wool, but it is only a
chance that such will be the case.

This method can hardly be called ' antiseptic ' in the sense
in which we have used the word, for the anti-putrescent princi-
ples on which it acts are not very powerful. As the result of
these dressings, the discharge becomes thick and concentrated,
and not a very good medium for development of organisms.
Nevertheless, this concentration of the discharge cannot occur
to anything like the extent which takes place when it is left
freely exposed to the air. The second principle on which it
acts is that it insures absolute rest to the wound. By means
of this rest the granulations are not lacerated, and bacteria and
their products may thus be prevented from entering the body.

Guerin's method cannot be recommended except in some
exceptional cases of disease of joints with sinuses, and even
here the retention of the putrefying discharges, and the conse-
quent irritation, render it of very doubtful value.

I have already described the aseptic applications of pm-e
cotton wool at p. 121.

V. — Assist the destroying Action of the healthy living Tissues

on Bacteria.

This principle may be aided in two ways, viz., by perfect
mechanical rest, and by attention to the general health.

By perfect mechanical rest, when the tissues are in perfect
health, and the blood-clot is undisturbed, the tissues and clot
may be kept in such a state as to resist the development of
organisms. This method, though without recognition of the
antiseptic principle, has been long practised, and of late has been
specially advocated by Mr. Sampson Gamgee.^

It is, of course, a well-known fact that, without any antisej^tic
appliances at all, wounds, more especially about the face, heal

' On the Treatment of Wuunds, 1878.

142 ANTISEPTIC TREATMENT OF WOUNDS.

frequently by first intention. How can this take place if blood
or lymph, exposed to the air, putrefies as the result of the
access of organisms 1 For, during the operation, organisms
enter the wound both as dust from the air and surround-
ino- objects, and also from the water in which the sponges are
soaked. There is also between the cut surfaces a layer of blood
or lymph (which, however, must as a rule be very small in
amount, otherwise healing by first intention does not occur)
which, if it were exposed between two plates of glass, would
probably putrefy in a short time. How is it that union by first
intention can occur under these circumstances 1 How is it that
tlie blood does not putrefy between the cut surfaces of a wound ]

Well, to use Sir Joseph Lister's forcible arguments, the/act is
that a thin layer of blood, although containing numerous causes
of putrefaction, does not as a rule putrefy if it be placed between
two healthy living cut surfaces. Or, to state the fact in an-
other way, these organisms, which are certainly present, cannot
develop in a thin layer of blood or lymph placed between two
healthy living freshly cut surfaces. Or, to state the same fact
difierently (taking into consideration the different results when
the same layer of blood or lymph is placed between two plates
of glass), the living tissues, ivhen in a healthy state, have the
power of preventing the development of organisms in their
immediate vicinity.

That healthy blood-clot can resist putrefaction so long as it
is kept at rest explains many remarkable cases which would
otherwise seem at first sight at variance with antiseptic princi-
ples. The following case, showing the contrast between blood-
clot when kept at rest and when disturbed, is worth nar-
rating.^

'On September 15, 1870, a young officer whose left upper
arm had been broken about its middle by a Chassepot bullet at
Noisseville seventeen days previously, arrived with an ambu-
lance train at the Tempelhof military hospital.

' Esmarch, Langenbeck's Archlv, vol. xx. p. 1G9.

GENERAL CONSIDERATIONS. 143

' The plaster of Paris apparatus, which had been apphecl at
once on the battle-6eld, had become soft and broken, and as the
patient complained of pain in the arm, probably as the result
of the journey, and as it was somewhat swollen, the apparatus
was removed, and a careful examination was made of the
wound. When I passed my finger into the wound after re-
moval of the crust, I felt numerous fragments of bone, but was,
however, astonished to find no trace of pus, only coagulated
hlood.

' After I had removed all the fragments, a plaster apparatus
with a window in it was applied ; nevertheless, there now re-
sulted a violent inJI animation and sujii^uration of the tuotmd,
which for a time threatened the young man's life.'

These views sufliciently reconcile the fact of union by first
intention in cases not treated aseptically with the germ theory
of putrefaction.

ISTow in order to have tissues in the state in which they are
capable of resisting the development of bacteria in their imme-
diate vicinity, they must be as much as possible in a condition
of perfect health. To attain this, the health of the patient
must be attended to and kept good, and all causes which irritate
and cause the wounded j)ai't to inflame or become weaker must
be avoided. The causes which weaken the part are various
forms of unrest, mechanical or chemical.

To cany out this principle two things ai'e required, viz.,
accurate approximation of the cut surfaces, and absolute immo-
bilisation of the part. Where accurate approximation of the
cut surfaces cannot be obtained, the same principle of absolute
rest must be carried out as regards the clot filling up the gap,
and it may thus resist the development of bacteria in its sub-
stance. Were I compelled to treat any case on this principle
alone, I should combine with it the open method, leaving the
wound freely exposed to the air. The superficial layer of the
clot, by drying up, would thus to some extent form an obstacle
to the entrance of organisms.

I have mentioned this as an antiseptic method, as the

144 ANTISEPTIC TEEATMENT OF WOUNDS.

principle is of great importance in explaining certain otherwise
puzzling cases, but I should not recommend it for adoption, for
it is only in a few cases, such as in face wounds, where the
vitality of the part is high, that this vital action of the tissues
and blood-clot can be sufficiently trusted.

Such are the chief principles on which antiseptic surgery
can be carried out. In the class of antiseptic methods to which
I have referred in this chapter, the surgeon does not adhere
strictly to one or other principle, partly because the principles
on which he acts have not as yet been properly understood or
appreciated, and partly because better results can be obtained
by their combination.

In many minor ways the antiseptic principle may be aided.
Thus by the use of catgut ligatures, we do not have a long
septic thread hanging out of the wound, conducting putre-
faction into its intei'ior and leading to deep-seated suppu-
rations, &c.

The silver suture acts in the same way as compared with
the silk. Silver does not absorb the putrescible materials, and
thus putrefaction does not occur in it. On the contrary, silk
absorbs blood and serum, which putrefy in it, and the silk,
which was at first unirritating, becomes very acrid and causes
inflammation in its vicinity.

What are the various means by which the general health
and tone are kept up in septic cases, what is the careful selec-
tion of healthy individuals for operation, but imperfect attempts
at antiseptic surgery ]

What is ventilation but an antiseptic means 1 The air being
constantly changed, the foul emanations from wounds contain-
ing septic bacteria are diluted and swept away, while at the
same time a better state of health is obtained.

And so I might go on enumerating various minute points
which have been, in ignorance of their true significance, adopted
in the treatment of wounds, all of which act^ more or less, on
and promote antiseptic principles.

INDEX.

ABD

AuDOJiEN, wounds of, aseptic treat-
ment of, 98
Abscesses, after-treatment of, 94

— aseptic drainage of, 93

dressing of, 94

treatment of, 91

— liacteria and, 17

— formation of, 9, 19

— lumbar, 86

— near anus, aseptic treatment of, 95

— of liip joint, 8(3

— perineal, aseptic treatment of, 94

— psoas, 83

— retropharyngeal, aseptic treatment
of, 92

— spinal, recumbent position in, 94

— thoracic. See. Empyema, 94

— when and where to open, 84, 92
Accidental wounds, 95

Acetate of alumina, IKi, 121
Acute necrosis, 9

— osteomyelitis, 9

— spreading gangrene, 22

Air, nitration of, through cotton-wool,

121, 124
Alcohol as an antiseptic, 127
Hutchinson on method of

using, 127
Anal abscess, aseptic treatment of, 95
Antiseptic methods, 142-145

free drainage, 130

irrigation and immersion, 130-

134

open method, 135-138

rest, 143

ventilation, 145

Antiseptics. See Disinfectants

— treatment by, explained, 33, 125,
et seq.

Arrangement of towels, 52
Arteries, ligature of, 54

ASE

Aseptic operation, 46-50

duties of dresser in, 50

errors in, how corrected, 49-53

example of, 46-50

ligature of vessels in, 55

use of oarbolised towel in, 46,

51
use of guard in, 54

— surgery, detined, 36

materials employed in, 36, et seq.

-. principles of, 36

— treatment in country practice, l03
-106

in war, 106-111

of abscess, 91

of accidental wounds, 95

of burns, 100

of compound fractures, 97

of compound fractures of skull,

of contused wounds, 96

of dissection wounds, 102

of gangrene, 101

of gunshot wounds, 106-111

— — of wounds of abdomen. 98

of wounds of intestines, 98-99

of wounds of Joints, 97

of woimds of muscles, 97

of wounds of nerves, 97

of wounds of tendons, 97

of wounds of thorax, 98

substitutes for carbolic acid in,

112-129

use of acetate of alumina in, 116

of eucalyptus oil in, 117

of iodoform in, 120

of salicylic acid in, 1 13-116

of thymol in, 1 16

— wounds, 36, et seq.

drainage of, 56

stitching of, 65, 96

146

ANTISEPTIC TREATMENT OF WOUNDS.

ASB

Aseptic wouuds, strapping of, 67

use of cotton wool, 121-123

Axilla, aseptic dressing of, 78-82

Bacilli. See Bacteria, 11
Bacillus anthracis, 25-26
Bacteria and abscess, 17

acute osteomj'elitis, 20

carbolic acid, 25

disease, 14-24

erysipelas, "21

gangrene, 22

healthy tissues, 141, 144

heat, 32

inflammation, 17

phagedena, 22

pyaimia, 23

septicasmia, 23

septic intoxication, 15

spontaneous generation, 18

suppuration, IG

— — traumatic infective diseases,
14

— classification of, 11

— Becker and Krause on, 2(1

— Bergmann's experiments on, 15

— cultivation of, 13

— description of, 11-14

— destruction of, 25, 32

of by health} tissues, 141-144

— diseases caused by, 14-24

— Felileison on, 20

— Fischer on, 31

— general description of, 1 1

— growth of, 12

— hoAV to assist tissues to destroy,
141-144

— Koch on, 25

— life history of, 12

— Lister, Sir J., ou, 120. 142

— mode of growth of, 12

— of blue pus, 25

— Panum on, 15

— poison produced by, 15

— products of, 14

— Schill ou, 31

— spores of, 25

— temperature necessarv to destroy,
32

— vitality of various, 26

— why they do not always cause
feriuentation, 142

Bandage, carbolic gauze, 43, 67

— elastic, 71

— muslin, 70

Bandaging of gauze dressing, 70

CHI

Barker, Mr., ou filtration of air, 123
Bartscher and Vezin's open method,

138
Becker on bacteria, 20
Bergmann's experiments on bacteria,

15
Bichloride of merciir}-, 29, 119

Bruns, Von, on, 110

Lister, Sir J., on, 120

Schede's results, 1 19

Blood-clot at rest and disturbed, con-
trasted, 143

— healing by organisation of, 4, 5
Bone, death of, 8

— decalcified tubes, 116
Boracic acid lint, 44
lotion, 44

ointment, 44

— lint dressings, changing of, 75
use of, 75

wet in place of poultice, 76

— ointment as a dressing, 75
Bouisson's method of crust formation,

139
Bright's disease, operating in, 16
Bruns, Von, on bichloride of mercury,

119
Burns, aseptic treatment of, 100
Burow's open method, 137
Button stitches, 65
Buttons, lead, for deep stitching, 65

Capillarity, drainage by, 60
(Carbolic acid, Lemairc on use of, 129

oily solutions of, 37

poisoning, 126

solution of. in glycerine, 38

substitutes for, 112-129

undiluted, 37

use in treatment by antiseptics,

125-128

watery solutions of, 37

Carbolised catgut, 40

— gauze, 43

— silk, 41

— wool, 45

Catgut, carbolised, 40
chromic (Lister's), 40

— chromic (MacEweu's), 64

— drainage by, 60

— Lister's pocket holder, 41, 42

— trough for, 41

— use as a ligature, 40, 55
Chassaignac's drainage tubes, 56
Chiene on catgut drains, (iO
retropharyngeal abscess, 92

INDEX.

147

CHI

Chiene on situation of opening in psoas

abscess, 85
Chloride of zinc, solution of, 45-126
Chlorinated soda, 127
Comparison of course of simple and

compound fractures, 8
Compound fracture, aseptic treat-
ment of, 97

course of, 8

Conservative surgery, bearing of

aseptic treatment on, 109
Contused wounds, aseptic treatment

of, 96
Cost of aseptic treatment, 103, 106
Cotton wool, A. Gue'rin's dressing,

140-141

aseptic use of, 121-124

carbolised, 45

Countrv practice, aseptic treatment in,

103-106

mode of dressing in, 103-106

Cream, salicylic acid, 44
Crust, Bouisson on, 139

— formation of, 2-7, 138-140

— healing by, 2

— Neudorfer on, 139

— treatment by, 138-140

Dangers following wounds, 8
Decalcified bone tubes, 64
Definition of aseptic surgery, 36
Degeneration, waxy, 9
Disinfectants, 25

— acetate of alumina, 1 16

— alcohol, 127

— bichloride of mercury, 29, 118,
119

— boracic acid, 126

— carbolates, 27

— carbolic acid, 25, 28, 112-129
oU, 28

— chlorinated soda, 127

— eucalyptus oil, 117

— iodoform, 120

— Koch's experiments on, 25

— Lister, Sir J., on, 118

— naphthalin, 120

— Neudorfer's salicylic powder, \2'.>

— salicylic acid, 112
powder, 129

— sanitas, 129

— Schulze on, 117

— sulphurous acid, 127

— terebene, 129

— thymol, 116

— varicQG, 80

EMP

Dissection wound, aseptic treatmen

of, 102
Drain, catgut, 60, 63

— horsehair, 63

re-introduction of, 63

Drainage as an 'antiseptic method,
56

— aseptic, of abscess, 93

— bv capillarity, 00
catgut, 00, 63

Chassaignac's tubes, 56

decalcified bone tubes, 04

horsehair, 63

india-rubber tubes, 56

— Chiene's method of, 60

— importance of, 56

— of aseptic wounds, 56

— tubes, absorbable, 60-62, 65
position of, in aseptic wounds,

67-59

use of, 56

Drains absorbable, 60-62, 65
Dressing, aseptic, axillary, 78-82

— boracic, 44, 75-76

— breast (three methods), 78-82

— changing of, 71-73

— deep, 68

— errors in use of protective, 67-08

— excision of joints, 39

— fixing of, 70-71

— general gauze, 43, 47, 69

— loose gauze in, 43, 47, 69

— lumbar abscess, 83

— method of changing, 72-73

— neck, 78

— of hernia, 86

— of hip-joint abscess, 86

— of limbs, 83

— ovariotomy, 91

— psoas abscess, 83

— scalp, 77

— scrotum, 86

— time of changing, 71-72

— use of pins in, 47, 70-71

of protective in, 67

of wet gauze in, 47, 08-69

— water, 8, 100

Dressings, aseptic, in country practice
105-106

permanent (Xeuber's), 116

use of sponges in, 43-44

with salicylic acid, 44, 113

Elastic bandage, 71

Empyema, 94

— aseptic treatment of, 94

148

ANTISEPTIC TREATMENT OF WOUNDS.

Errors in aseptic operations, how

avoided, 49
Erj'sipelas, 9

— micro-organisms of, 20
Esmarch's arrangement for irrigation,

131
Eucalyptus gauze, 118

— oil, Buclioltz on, 117

Scliulz on, 117

Siegen on, 117

— ointment, 118 ^
in burns, 118

Example of aseptic operation, 49
Excision of joints, aseptic dressing

of, 39
Experiments on disinfectants, 25

Fermentation, cause of, 6, 33, 34

— chemical, 6

— in wounds, 33

— Pasteur on, 13G
Fever, hectic, 9

— traumatic, 9

First intention, healing b}', 2
Fischer on naphthalin, 120
Forceps, sinus, 59
Fractures, compovind, 8, 97

— simple, 8
Free drainage, 35

Gangrene, acute spreading, 22

— aseptic treatment of, 101

— Koch's experiments, 22

— patliology of, 22

— senile, ioi

— traumatic, 9

— treatment of, 101

Gauze, carbolic, bandage, 43, 67

use in deep dressing, G9

general dressing, 43, 47, G9

loose, 43,47, 69'

— dressing, how to make a, 69

— eucalyptus, 118

— sublimate, 119

— thj'mol, 1 16
Granulation, healing by, o
Granulations, healing by union of, 3
Guard, use of, in aseptic operations,

54
Guerin, Alphonse, on cotton wool,

140, 141
Gunshot wounds, aseptic treatment

of, 106-111
Guj-ot, results of his incubation

method, 135

LIS

Hack, Dr., on absorption from

wounds, 127
Hands, purification of, 48
Healing by first intention, 2

granulation, 3

organisation of blood-clot, 4

scal^bing, 2, 138-140

union of granulations, 4

Hernia, aseptic dressing of, 86

Hip joint, aseptic dressing of abscess

of 86
Horsehair drains, 63

re-introduction of, 63

Hutchinson on method of treating

wounds, 127

Immersion, treatment by, 130-135
India-rubber drains, 56
Inflammation, absence of, in aseptic
wounds, 28

— bacteria and, 16
Injuries, repair of, 1-8
Instruments, purification of, 49
Intestines, wounds of, aseptic treat-
ment of, 98

Intoxication, septic, 9, 15

Iodoform, 45, 120

Iron, perchloride of, as a disinfectant

132
Irrigation and immersion, loO

— as an antiseptic, 130

— Esmarch's arrangement for, 131

— Langenbeck and Valette's methods
of, 132

— treatment by, 35
Irrigator, Thiersch's, 131

Joints, excision of, 39

— wounds of, treatment of, 97

Jute, salicylic acid, 114

Koch on bacteria, 25

gangrene, 22

traumatic infective diseases, 18,

21, 23

Ligature of vessels with catgut, 40,

55
Limbs, aseptic dressing of, 88
Lint, boracic, 44
Lister, Sir J., on aseptic treatment in

war, 106
use of corrosive sublimate.

119

INDEX.

149

Lis

Lister, Sir J., on cotton wool, 121

destruction of bacteria by

healthy tissues, 142

; eucalyptus oil, 118

Lotion, boraeic, 44

— carbolic, 37

Lumljar abscess, aseptic dressing of, 8(1

Maas on acetate of alumina, IIC
MacEwen's absorbable drainage tubes,

Co
Mackintosh, use of, in gauze dressing.

Mamma, dressings after operations on.

78-82
Mechanical exclusion of dust, 121.

124
Melladew on aseptic treatment in

war, 111
Micrococci. See IJacteria, 11
Micrococcus prodigiosus, 2.5
Muscles, wounds of, aseptic treatment

of. 07'

N.EVi, treatment of, 102

jSTaphthalin, 120

Necrosis, 9

Nerves, wounds of, aseptic treatment

of, 97
Neuber's absorbable drainage tubes,

Ob.tections to aseptic treatment,

103
Oiled silk, 42
Ointment, boraeic, 44

— eucalyptus, 7G

— salicylic, 45, 7')

Open method of treatment, .Sf), 135
Operation, aseptic, duties of dresser
in, 50

— example of, 46
illustrated, 50

— ligature of vessels, 55

— probable errors in, 49

— spray in, 50

— towels in, 52

— use of guard in, 54
Organisation in blood-clot, 5

— of dead tissue, Tillmanns on, 4
Osteomyelitis, 9

Ovariotomy, aseptic dressing of, 9 1
Oxygen and bacteria, 12, 14, 135
Pasteur on, 136, 137

SAL

Pasteur on fermentation, l.^C

org.anisms, 122, 136, 1.37

Pathology of gangrene, 22
Perineum, aseptic treatment of ab-
scess of, 94
Periostitis, cause of, 9
Phagedicna, 9

Pigment formed by bacteria, 14
Pins, use of, in gauze dressing, 47, 70,
71

precautions in, 70, 71

Poisoning with carbolic acid, 126
Precautions in operations, 49-51

— spray least necessary of, 53
Principles of aseptic surgery, 36
Probable errors in aseptic operation,

49
Processes of repair of injuries, 1-8
Protective, errors in use of, 67-68

— preparation of, 47

— use in aseptic dressing, 47, 67
Psoas abscess, .aseptic course of, 91-94
dressing of, 83-6

situation of incision, 83-85, 92

Purification of hands, 48

instruments, 49

recent woimds, 95-96, 103

septic wounds, 74, 75, 95-96, 103

skin, 46, 48

Putrefaction, dangers of, 8

— theories of. See Fermentation, 6,
33, 34, 136

Putrefactive fermentation, 33, 136-137
Putrid wounds, 99

Pyjemia, relations to fermentations in
wounds, 9, 23

Ranke on thymol, 116

Rest as an antiseptic, 35, 141, 144

— fundamental principle of wound

treatment, 141-144
Results of A. Guerin's dressing, 141

.antiseptic surgery, 28, 109-111

aseptic treatment, 28, 91, 109-1 1 1

irrig.ation, 132-135

occlusion, 107-110

open method, 136-138

water bath, 132-135

Retropharyngeal abscess, 92

lleyher on aseptic treatment in

war, 109
Rose's open method, 137

Salicylic acid, aseptic use of, 112
cream, 44

150

ANTISEPTIC TEEATMENT OF WOUNDS.

SAL

Salicylic acid, dressinsrs with, 111,
112-lir.

jute, 105, 113

lotion, 1 12

ointment, preparation of, 45

uses of, 44

wool, 113

Sanitas, 129

Scabbing, healing by, 2, 138-140
Scalp, aseptic dressing of, 77
Schede on iodoform, 121

— on bichloride of mercury, 119
Schulz on eucalyptus oil, 117
Scrotum, aseptic dressing of wounds

of, 86
Sepsin, 15

Septic intoxication,
causes of, 15

— treatment, results of, 15

— wounds, purification of, 74, 75, 95-
96, 103

Septicasmia, 9

Silk, carbolised, preparation of, 60

Silver wire stitches, 66

Sinus forceps, 59

— putrid, treatment of, 99
Skin, purification of, 46, 48

Skull, compound fractures of, aseptic

treatment of, 97
Sloughing, 9
Soda, chlorinated, as an antiseptic,

127
Spinal abscess, 94

recumbent position in, 94

Spirilla. See Bacteria

Spirocha3ta3. See Bacteria

Sponges, purification and preservation

of, 44

— use of, in dressings, 71
Spontaneous generation, no experi-
mental fact known in favour of. 13

Spoons, Volkmann's sharp, 99
Spores, carbolic acid and, 25

— expei-iments on, 2()

— formation of, 12

Spray, carbolic acid, as germicide, 28

— errors in use of, 53

— how to dispense with, 103-106

— one of the least necessarv pre-
cautions, 53

— producers, hand, 38
steam, 39-40

— use of, 38, 53, 73
Stitches, button, 65

— of coaptation. 66

— of relaxation, 66

— removal of, 67

VES

Stitching of aseptic wounds, 65
Strapping of aseptic wounds, 67
Streptococci, 22
Subcutaneous surgery, 124
Substitutes for carbolic acid, 112-129
Sulphurous acid as an antiseptic, 127
Suppuration, causes of, 17
— not always due to micro-organisms.

16
Surgery, aseptic, definition of, 36

materials employed in, 36

principles of, 36-37

Sutures, 65

Temperature necessary to destroy

bacteria, 32
Tendons, wounds of, 97
Thiersch on salicylic acid dressings,

112

irrigator, 131 '

Thorax, wounds of, 98
Thjnnol, aseptic use of, 116
Tillmanns on organisation of dead

tissue, 4
Tissue, healthy, resists bacteria. 141-

144
Towel, carbolised use of, in aseptic

operations, 52
Traumatic gangrene, 9

— fever, 9

— infective diseases, 18, 21, 23
Treatment, antiseptic, explained, 3;!

— aseptic, 46

— by perfect rest, 35, 141, 144

— Listerian, 35

— of abscesses, 78, 83, 86

— of accidental wounds, 95

— of gangrene, 101

— of noBvi, 102

— of putrid sinuses, 99

— of ulcers, 74

— of varicose veins, 102

— open method of, 35, 135

Ulcer, purification of, 74

-^ treatment of, with boracic acid,

74-75
Union of granulations, healing bj', 4

Ventilation as an antiseptic means,

145
— of wounds, 139
Vessels, method of tying, in dense

tissues, 55

INDEX.

151

VEZ

Vezin and Bartscher's open method,

137
Volkmann's sharp spoons, 99

War, aseptic treatment in, 106-111
Water dressing. See Dressing
Waxy degeneration, 9
Wool, cotton, aseptic use of, 120-
124

— Gue'riu's, 140-141

— salicylic acid, 113

Wounds, accidental, aseptic treatment
of, 95

— antiseptics in, U! .

— aseptic treatment of. See Aseptic

— bacteria in, 10-24

— causes of irritation in, 6, 10

— contused, 96

— course of, outline of, 1-8

— dangers following, 8

— dissection, aseptic treatment of,
102

— drainage of, 56

— fermentation in, 33

— Gamgee, Mr. S., on treatment of,
142

ZOO

Wounds, gunshot, aseptic treatment of,
106-111

— how to keep aseptic, 36

— mechanical exclusion of air from,
120-124

— micro-organisms in, 10-24

— of abdomen, aseptic treatment of, 98

— of intestines, aseptic treatment of, 98

— of joints, aseptic treatment of, 97

— of muscles, aseptic treatment of, 97

— of naivi, aseptic treatment of, 97

— of parietal pleura, aseptic treatment
of, 98

— of skull, aseptic treatment of, 97

— (jf tendons, aseptic treatment of, 99

— of thorax, aseptic treatment of, 98

— processes of healing of, 1-8

— ]iurification of, 74, 76, 95, 96, 102,
lO.H

— putrid, 99

— stitching of, 63, 96

— strapping (aseptic) of, 67

Zinc, chloride of, 45
— sulphocarbolaie of, 27
Zooglsea. See Bacteria, 12

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