No. 2782.

DECEMBER 23, 1876.

Clinical LectureON

THE TREATMENT OF WOUNDS.Delivered at the Queen’s Hospital, Birmingham.

BY SAMPSON GAMGEE, F.R.S. EDIN.,SURGEON TO THE HOSPITAL, FOREIGN CORRESPONDING MEMBER OF THE

SOCIETY OF SURGERY OF PARIS.

GENTLEMEN,-Wounds of all kinds must, while you are

surgeons, be the objects of your care. The one greatquestion for you to solve will be, how least painfully, howmost speedily and most safely, you can assist or promotethe natural process of healing.

Teachers, in text-books and hospital wards, differ verywidely on the theory and practice of this fundamental partof surgery. I shall not attempt to enumerate their differ.ences, much less either to confute or reconcile them. Mypresent aim is to place before you the evidence of typicalcases, in support of what I believe to be the first andessential principles which should govern the practice oj

surgeons in treating wounds.I invite your attention to this little old gentleman, whc

has kindly attended here this morning for your instruction,He consulted me about two months ago for a cystic tumour,about as large as a hen’s egg, in the right temporal region.The skin was very red, tense, and painful,and the hat, thougha very soft one, was worn with much difficulty. After

transfixing the growth vertically through the base, and

peeling out the two halves of the cyst, with its bread-sauce-like contents, I dried the interior of the wound witha fine sponge. The edges were then very accuratelyapproximated, and kept so with a few strips of lint soakedin styptic colloid. A few turns of bandage completed thedressing. When I removed it, at the end of five days, therewas not a drop of discharge, adhesion was perfect, andafforded a simple but complete illustration of the surgeon’sfirst intention in treating wounds-to secure direct union.All that is visible of the cicatrix is a very fine, pinkishline, extending upwards about two inches from the rightear.

Please to note-firstly, that the wound was thoroughlydried with a fine sponge; secondly, styptic colloid was usedto keep the edges in contact; thirdly, the parts were notdisturbed until the fifth day, when union was complete andsolid.

Drenching wounds with water during an operation, andwashing them with it afterwards, are mistakes. Waterfavours decomposition, which is the enemy of healingaction.The styptic colloid, used to keep the edges of the wound

together, is the admirable preparation introduced in 1867by my friend Dr. B. W. Richardson.* In removing thestyptic-colloid dressing common water should be scrupu-lously avoided, and a mixture of alcohol and ether em-

ployed, or equal parts of absolute alcohol and distilled

water, warmed to a little above the heat of the body.It has been noted that the dressing was not touched for

five days after the operation. Once divided parts-be theyhard or soft, bones or muscles, skin or nerves-are adjustedwith a view to union, the less they are disturbed the better.

* Styptic colloid, as prepared after the instructions of Dr. Richardson,F.R.S.,by Messrs. Robbins and Co., of Oxford-street, is produced by satti-rating ether entirely with tannin and a colloidal substance, xy!.)iine, orgun cotton. a little tincture of benzoin being finally admixed. (Vide Dr.B. W. Richardson in Mediual Times and Gazette, 1867, vol. i., p. 383 et seq.,"On a new Styptic and Adhesive fluid-Styptic Colloid; Hnd on Heal1D bythe First lutention." Also, by the same author, "On the Science and Artof Healing Wounds," in Transactions of St. Andrews Medical Graduates’Association for 1871. London. 1872. n. 37 et sea.

A case illustrating the same principles, though on a some-what larger scale, is that of C. H-, aged forty-three, whowas lately in Ward 5, whose right breast I removed on the20th May, with a small hard gland from the correspondingaxilla. Of the operation it only need be said that, accord-ing to my usual practice, I cut down upon the sternalorigin of the great pectoral and dissected it clean, so as tomake sure of thorough removal of the diseased mass. I amconvinced that many so-called rapid recurrences of cancerare only growths of pieces left behind, and that thorough-ness is the very essence of success in extirpation of malig-nant growths. After removal of the breast, the edges of thewound were neatly brought together by numerous points ofsilver suture, and dressed with a layer of fine cotton wooland over it picked oakum. An evenly compressing bandagewas then applied round the chest, and made to include thearm and hand in the flexed position so as to fix them im-movahly to the side. The first night the temperature roseto 101 30, but it never rose afterwards above ]00°.The wound was first dressed at the end of the fifth day

after the operation. A great part of it being healed by thefirst intention, a large number of the sutures were removed,and strips of adhesive plaster applied, so as to keep theedges in apposition ; a pledget of oakum with a compress-ing bandage completed the dressing. On June 1st theremaining sutures were removed. The wound was thennearly all healed, and the same dressing applied. OnJune 3rd (fourteenth day after operation) the entry onthe card is "Patient dressed (as before), and sent homewell."The points in this case to which I wish to direct your

attention are-(a) the numerous sutures; (b) the cotton-wool and picked oakum dressing; (c) the compressingbandage; (d) the rare dressing.

Metallic sutures so very rarely cause any irritation, thatthey may be inserted very near each other with impunity.Sutures far apart, with gaping intervals, are comparativelyuseless. If the cut surfaces are to adhere they must bebrought into contact and kept there, and for this purposemetallic sutures half an inch apart, or even less, are mostedacious. I often apply intervening strips of lint soakedin styptic colloid, but in this case only placed over thewound a layer of fine cotton-wool, and a pledget of pickedoakum. The best cotton-wool for surgical dressings is thatsold for jewellers in thin sheets, about eighteen inches bytwelve, with alternate layers of tissue-paper.* You will

often see claims of priority for cotton-wool dressing. I donot pretend to say who first introduced it, but the credit ofgeneralising its application in the treatment of a greatvariety of surgical injuries chiefly belongs to Burggraeve, ofGbent.tI It has been recorded that the breast case was only dressedthree times, in the fortnight which elapsed between the ope-ration and the patient’s discharge, in accordance with theprinciple of infrequent dressing, of the minimum of dis-turbance to insure the maximum of rest, dwelt upon in thepreceding case, and equally borne out by those to be pre-sently brought to your notice. To the same end thesmoothly and lightly compressing bandage round the chestvery powerfully contributed. Of all surgical agencies noneso beneficent as compression, none requiring more delicatemanipulation, none so inadequately appreciated. Under a.smooth and uniformly, while lightly compressing bandage,extravasations of blood are absorbed, the healing action ispromoted, and a soothing influence is exercised. There mustbe no constriction-only equable adaptation of surface tosurface with the light pressure which always comforts.There must be no squeezing like that of an old Collegefriend’s hand when seen after long absence; such pressureas that, if continued, is intolerable constriction. The soothingsurgical pressure is like that which you interchange withthe hand of a lady, the pleasure of whose meeting is tem-pered by the respectful regard which she inspires. Yourhand adapts itself to hers, and gently presses it whereverit can touch it, but nowhere squeezes it for fear of offending.Such pressure as that, when employed by the surgeon inthe treatment of injuries, always soothes and heals.

It is supplied by S. Jevons, Worcester-street, Birmingham, at 2s. 9d.the lb. parcel.t Chirurgie Simplifige. NoTveau Systeme de Pansements Inamovibles.

Par le Dr. Burggraeve (avec planches). Bruxelles, 1853. Also, by the sameauthor, Le Genie de la Chirurgie. Gand, 1863, p. 26, et seq.

886

To apply a nicely compressing bandage well, you mustyra,ct,ise hundreds and hundreds of times, bearing in mind- Mtd in surgical, as in all art, the greatest results are

. @ffuen obtainable from the simplest means, provided they be".11!II!éi!ployed with the skill which can only result from themost patient assiduity.These principles are illustrated by the two patients who

’:have undergone amputations, and who are now before you.I amputated the middle finger of this man’s right hand

in the course of my clinical lecture last week. As the resultT3’f old injury, the finger was bent and stiff, so as to be in the

- w&y. I therefore removed it at the metacarpo-phalangealM’ttcaltion, being careful not to wound the palm, andizteluding in the elliptical incision so much of the covering.of the phalanx as to admit of easy closure of the woundover the big knuckle. The edges were united by threepoints of silver suture, a fine drainage-tube placed in thelower angle of the wound, which was covered with a pledgetof picked oakum ; a moist pasteboard splint was now

b%adaged to the palmar aspect of the limb from the tips of i

’tke fingers to the elbow, and the forearm suspended in a I.Hag.

This othpr patient, aged sixteen, was admitted to Ward 3,’&e 18th May ult., with his forearm crushed by machineryTbs within two inches of the elbow. As the bones were not,slrlit into the joint I amputated just below it, utilising somed the least damaged skin to cover it. Where the skinW3:,S quite sound the edges were brought together with two,points of suture, elsewhere the parts were approximatedwith strips of lint soaked in styptic colloid, a drainage-tubebeitig 1.-fs in the lower part of the wound. The stump waswavered with a layer of cotton-wool and oakum, and rec-- ts.ngular pasteboard splints were applied with gentle pres-sure to ensure perfect immobility and prevent swelling.7NEen the apparatus was opened four days afterwards there-was very slight sloughing of the margin of one flap, butthe stump was of good colour and healthy temperature,without tension. The same dry dressing with pressure wasapplied, and the lad was discharged on the 17th of June, anicut,b within a day from his admission, the stump, thenquite healed, having been dressed altogether seven timesafter the amputation.A parallel case is that of James B aged six, dis-

charged the other day from Ward 6. The soft parts of his’left lower limb had been extensively crushed by a waggon,and an a-ttempt had been made to save the-limb. Slough-ing and profuse suppuration had been followed by suchexhaustion that the lad might fairly be said to be moribundwhen I amputated the thigh in the upper third on the 22ndof April. I dressed with cotton-wool, oakum, pasteboardsplints, and nicely compressing bandages, and the lad wa.Rdischarged with a sound stump and in good health on the

’ 15th of June. In the forty-seven days which elapsed from, ’lke operation to his leaving the hospital the dressing wasonly renewed six times.

Not to go over the ground already trodden in commentingon the other cases, I shall only remark on the splints andthe drainage-tubes employed in these amputations.

Coapt,ation of divided surfaces once effected, absolute restis the first essential to the healing process. That rest isbest secured, in the case of amputations, by moulding tothe stump well-softened pasteboard splints, and fixing themwith evenly compressing bandages. As in the case of

fractures, the joint above the injury should be included inthe splints, and great contributory benefit may be derivedfrom the nice adaptation of sandbags.

Of Chassaignac’s drainage-tubes in the treatment of’wounds it is impossible to speak too highly; but useful asthey are after amputations, removal of tumours, and such-like operations, it is in such cases as this breast that theiradvantages are perhaps most conspicuous.When this woman was before you last week, her pale,

drawn face betokened suffering and exhaustion; the big,pendulous, and exquisitely tender left breast dischargedmatter through half a dozen openings, the result of post-partum mammary abscesses and linseed poultices. J

passed a long probe from the lower aperture on the outeIside, under the mammary gland, obliquely upwards and’ awards, out at the uppermost aperture near the sternumA ligature secured to the eye of the probe enabled me t(carry a good,sized drainage-tube along its track, and I leftit there with. both ends depending, covering the breast witt

a good pledget of dry oakum, and Ruapendirtg and com-

prressing it with an evetdy cmpressing bandage. The poorwoman was easy at once, her app(,tilo improved, and sheslept well. When the dressing wn.s removed, after a lapseof four days, the breast was soft and much diminished insize; the openings other tha.n those traversed by the drain-age-tube were heating rapidly, and the woman is nowcheer-ful and rapidly convalescent.Here it an equally successful case of a diifcrpnt kind, yet

illustrating aurr,t wtimliy the same general principles whichshould guide you in the treatment OF all wounds. Thisyouth is the son of on of our pl’incipfll ivrry and brmeturners, who, while practising the other day with a finecircular saw, nearly put. off the 80ft pad at the end of theright thumb. He did r;ot consult- me until the third day,when the little flap was swollen, the wound duty, thewhole thumb throbbing and being" very painful. On com-

pressing- the radial joint a,1’ove the wrist, the throbbing andpiiin ceased, and I taught. my p atient, how t,) obtain therelief by affecting the compression himself with the leftthumb. I then brought the edges of the avntsrd togetherwith narrow strips (f e’11plfistrum eltmi, leaving slightintervals for the escape of matter, covred the end of thethumb with a litt1,. fine picked oakum, bandaged it. so as toeffect, gentle unitorm compression, and supported the handat an acute ang’e with the arm, by means of a. sling snp-porting the foream an inclosing the elbow, as every sling,t’) he efficient, sho’llrl do. Redef was immediate ; the dress-irg was not t(1)Chf’d for four days, and only trice afterwards, at intervals f f ’hi’t’e d eys. You see th- thnmh very nearlya match for its fr-liow, and a linear en atriE is all that is hftof the ugly wound.

This case illustrates, like the previous ones, the advan-tages of direct compression, with dry and rare dressings,iu the treatment of wounds, and it further exemplifies thebenefits to be nerived ttom digital f’ompresaion in thetreatment of inflammation of the limbs*

In proof of the 8tate!lJént that. the pa,me principles of £treatment are applicable, whether the wounded partshe soft. or hard, skin, hones, or muscles, or all combined,you have here two very striking case,-. Tr.i=! carter (seefigure) was brought into the accident ward with the scalp

torn from the greater part of the rigbt side of the head,and with two compound and depressed fractures in theparitatal and frontal bones resppctivdy. The large flap was

* Observations on the Treatment of Inflammation hp Digital Compres-sion, by Dr. Tito Vanzetti. on Treatment uf Fracrures of [he Limbs, bySampson Gamgee; London, Chulclkill, 1871 ; p. 16s, et seq.

887

cleansed, replaced, and united by eight points of suture,picked oakum and a light bandage applied, and an ice-bagover alL The greater part of the wound united by the firstintention. The’cicatrix is now quite solid, and the man isdoing his usual laborious work without ache or pain.The last case which I shall now bring before you is that

of a porter on the Midland Railway, who was brought tothe hospital, a distance of fourteen miles, with the leftfemur literally smashed just above the knee-,joint, a fully-laden coal-truck having gone over the limb. The soft partswere extensively torn, but both tibials pulsated, and I feltjustified in the attempt to save the limb. Reductioneffected and the edges of the wound approximated, a largedrainage-tube was passed into it, and a pledget of lint,soaked in styptic colloid, placed over it. The limb wasnow accurately encased in a pasteboard apparatus fromthe crest of the ilium to the toes. The apparatus was notopened for ten days, and once a week afterwards. The manbarely limps in walking, and is now doing duty as a signal-man at Selby-cut. One and all these cases illustrate myfavourite maxim, that REST, POSITION, and PRESSURE are thetrinity of healing surgical graces.

THE

EFFECT OF PROLONGED MUSCULAR EXER-CISE UPON THE URINE IN RELATIONTO THE SOURCE OF MUSCULAR POWER.

BY F. W. PAVY, M.D., F.R.S.,PHYSICIAN TO, AND LECTURER ON PHYSIOLOGY AT, GUY’S HOSPITAL.

(Continued from p. 850.)

FROM all these considerations, then, even allowing a largemargin for any error in the principle of calculation, theevidence points in unmistakable language to the utter im-possibility of the power manifested by muscular actionbeing due to the oxidation of muscular tissue. Traube has

gone so far as to invert the doctrine of Liebig, and to con-tend that in the performance of muscular work non-

nitrogenous substances alone are consumed. The meta-

morphosis of the organised constituents of a muscle, heasserts, is neither involved in nor increased by its action.In this proposition, however, it may be premised that weare carried beyond what is true, for the results before usshow an increased elimination of nitrogen during the per-formance of muscular exercise apart from the influence offood. It is not, indeed, surprising, looking at the increasedactivity of the circulation and respiration, that there shouldbe an increased metamorphosis of nitrogenous matterthroughout the system, and therefore an increased wear andtear of the muscles as a part of the general action occurring.The oxidation of nitrogenous, like that of non-nitrogenousmatter, furnishes, it must be remembered, a source of force,for, after the separation of its nitrogen as urea, an oxidisableresidue remains, but this has no intrinsic association withthe view which ascribes the source of muscular power to thedirect oxidation of muscular tissue.

Dr. Flint, from his observations upon Weston in America,has arrived at a diametrically opposite conclusion from thatwhich I have endorsed. He says: "If these facts be

accepted, and, leaving the widest margin for inaccuracy inthe estimates, they cannot involve any considerable error,it is impossible to come to any other conclusion than thatexcessive and prolonged muscular exertion increasesenormously the excretion of nitrogen, and that the excess ofnitrogen discharged is due to an increased disassimilation ofthe muscular substance."*

Dr. Flint’s observations were conducted upon a pedestrianfeat of five consecutive days’ duration, in which a distanceof 317½ miles was walked. An investigation was made, ex-

* On the Physiological Effects of Severe and Protracted Muscular Exer-cise. Reprinted from the New York Medical Journal" for Jane, 1871,P. 78.

tending over five days before, the five days during, and &vc"days after, the walk. The results summarised are :-

It will be seen that Dr. Flint has taken account of the-nitrogen contained in the faeces, and reckoned this in thenitrogen eliminated. He has left out of consideration iathis estimate the nitrogen of the uric acid. The uric acidin Flint’s analytical results, however, is so small as scarcely,to be worthy of note, and there is reason to believe that thequantity fails to be correctly represented. Upon one occa-sion it amounted only to 014 grain for the twenty-fourhours, and for the most part ranged under 3 grains, once-only rising as high as 9 21 grains. The estimation was-effected, we are told, by " concentrating the urine, treatimg-it with nitric acid for twelve hours, and collecting andweighing the crystals." As I shall subsequently show, whendescribing the analytical processes adopted in obtaining myown results, the nitric is an objectionable acid for use, as itfails to give as large an amount of crystalline deposit as ie,yielded by the hydrochloric; and moreover the period oftwelve hours allowed is insufficient for the complete sepa-ration of the uric acid. This I only allude to in passing to-account for the great discordancy which may be wonderedat as existing between the amounts of uric acid obtained byDr. Flint and myself. Under any circumstances theamount is not sufficient to affect the deduction concerningthe source of muscular power.

Dr. Flint mainly grounds his argument upon the relationbetween the nitrogen ingested and that eliminated. Iiwsays, " During the walk of 317½ miles in five consecutivedays, for every 100 parts of nitrogen taken in with thefood, there were discharged in the urea and fseces 174-83parts, against 95 53 parts per 100 for the five days beforethe walk, and 91-93 parts per 100 for the five days after the-walk."There is in these figures considerable error, based upon a

wrong principle of calculation having been adopted. Hegives the daily relation of nitrogen eliminated to 100 partsingested, and estimates from these the average relationfor the respective five-day periods. Clearly, to give rs--

correct representation, he should have taken the total-nitrogen ingested and eliminated during the five days of-the periods, and have drawn the relation for the period fromthese figures instead of framing the average from the=:separate daily relations.During the five days before the walk, the total nitrogen’

ingested amounted to 1697 28 grains, and that eliminatedin the urea and faeces to 1575’43 grains. These figures give-to every 100 parts of nitrogen ingested 92.82 parts