1468 MR. AYMARD: GLASS. A SUBSTITUTE FOR LINT IN TREATMENT OF WOUNDS. [

. haem1B.tocolpo.s. With regard to treatment of the flaps ofthe stump by suture, it was obviously the only way inwhich the septic stump could be cut off from the peritonealcavity ; it would have been quite unsafe to have dropped itinto the pelvic cavity and the application of the serre-noeudwas impracticable owing to the adhesions round the cervix.The infection of the kidney was obviously of a septic naturewith the bladder as the focus. I have ventured to reportthis case of prolonged illness because I believe it to beunique and I have been unable to find anything correspondingto it in the literature on the subject.

Brook-street, W. __________ I

GLASS A SUBSTITUTE FOR LINT IN THETREATMENT OF GRANULATING

WOUNDS.BY J. L. A. AYMARD, M.R.C.S. ENG., L.R.C.P. LOND.

THE process of repair in granulating wounds is known tomost of us as very often a long and tedious one. Various

coverings are used to protect skin grafts, but as far as I amaware no rigid form of dressing has been advocated with anyother object. I purposely avoid using the word "new,"knowing well how many have similar thoughts, but in anycase, new or old, the system now advocated is deserving ofmore than passing interest. Lint is of a woolly nature andeven when medicated soon becomes septic, its surface is byno means regular, and every time it is removed from agranulating wound causes irritation if not haemorrhage andpain. In advocating the substitution of lint by a rigid asepticsubstance such as glass or celluloid I have other advantages’to offer which will be set forth in a short history of the casewhich led me to adopt this radical change.The patient was a battery workman, aged 22 years,

.and was admitted into hospital with a large hsematomabeneath the skin on the inner side of the left thigh; thesoft parts had been crushed by machinery and the skin overthe hsematoma was considerably damaged. At the end of thefirst week the hasmatoma had subsided and the wound, treatedwith carbolic oil, presented a very usual appearance, in sizenine inches by five, shallow in some places, deep in others,where two large sloughs had become detached. The wholewound bled freely and was very painful when dressed. In

places the wound presented the typical punched-out appear-ance ; in others over-growing granulations presented them-selves suggesting treatment. The question now arose as tohow. long the wound would take to heal, as probable data hadto be supplied to an accident insurance company. SisterEustace, a very experienced nurse, and I decided that from-six, weeks to two months would be about the time, judgingfrom past experience in somewhat similar cases inJohannesburg Hospital and elsewhere. I decided to coverthe wound with a piece of glass smeared with carbolicoil and to watch the result. I procured a piece of thickwindow glass (cut one inch larger all round thanthe wound), the edges of which were ground on an

ordinary grindstone. The glass was pressed firmly on thewound and absorbent wool was tucked under the edges to

.pack up and absorb discharge ; next a light wood splintwas placed on the outside of the thigh and the whole was’bandaged up, using considerable pressure. On the next

morning upon looking through the glass I was pleased to seethat the wound looked remarkably well and on removing the.glass "without the slightest pain or haemorrhage" I foundthe wound almost entirely flat. Here were three good results;the glass was cleaned and replaced as before for two weeks,when owing to the fact that our analytical chemist, Mr.McLennan, very cleverly bent me a piece of glass in hisfurnace, this was substituted with advantage. The woundkept perfectly level, new skin rapidly formed and crept overquite evenly. It is now three weeks from the commencementof the glass treatment and the wound, is perfectly healed; Ifeel certain in a short time even the site of the wound will bedifficult to detect and scarring entirely absent.

I have treated two minor cases with watch glasses, one avaricose ulcer on the leg and the other a wound on the arm,with similar results.

The advantages, then, are shortly : (1) Perfect levelling ofthe, wound, doing away with all necessityof cauterising over-grewmg granulations ; (2) paBleas, dressing; (3), absent

of haemorrhage ; (4) rapidity of healing process, reducingthe same by at least one half ; (5) an aseptic covering com-pared with lint ; and (6) an extremely cheap dressing, theadoption of which on a large scale would mean considerableeconomy in hospital practice. Further, the glass enablesthe wound to be examined without removal ; a similar resultmight be obtained from transparent celluloid. I am by nomeans certain that it is necessary or advisable to remove theglass so often, but experience will teach, and this suggeststhe application of a glass moulded splint for compoundfractures, leaving a wide field open for experiment.As to the disadvantages, enthusiasts are apt to minimise

the drawbacks of their particular system, but honestly Isee none that will not very readily be overcome in the handsof skilful instrument makers such as Messrs. Down Brothers,to whom I have sent sketches and instructions. When theprofession (after a fair trial with flat glass) pronounce infavour of this system it will not be long before every formof mould is to hand. Flat glass is procurable everywhere andis suitable for many wounds. The accompanying illustration

gives a rough idea of the method of application, but for thosewho may be willing to try this system I will add a few moredetails. I have as yet had no opportunity of trying thisglass treatment on burns but certainlv will do so on the

! first opportunity and shall be much interested to hear theexperience of others. The glass, if flat, should be what isknown in the trade as "21-ounce." A lighter glass willdo if bent. Upon pressing the glass upon the woundit may be found, especially where there has been a

deep slough, that the glass is not in contact in suchplaces ; provided the glass is in apposition round the

edges this apparently, does not matter, as the granulationssoon grow up to it. I lay considerable stress upon entireabsence of irritation and do not even cleanse the woundwith antiseptic lotion, but simply mop the edges well awayfrom the wound. In my opinion dabbing the raw surfacewith swabs is quite unnecessary and does harm. The same

piece of glass will do until the wound is quite healed,but as the skin heals I consider it requires attention; mymethod is to keep it dusted with boric powder and graduallybring the absorbent wool nearer the centre of the wound.As to the medication for the glass itself, this is certainly ofconsiderable importance and I think should be governed: bythe condition of the granulations, but as a general rule Iwould advise starting with carbolic oil (B.P.) and graduallyreducing until towards the end pure olive oil is sufficient.Any irritation of the skin points to the medication being over-strong. The last point, and one of much importance, iscertainly the question of pressure. The method employedby the sister and myself was to press the glass firmly on thewound (having laid the wool round the edges); we thenplaced a light padded splint on the opposite side of thelimb, next two strips of bandage held the two in position,and then the whole thigh from the knee up was firmly, andtightly, bandaged.PS.-Since sending the above I have had an opportunity

of giving primary wounds some little consideration, andalthough I am not going to advocate the glazing, as. it, were,of every cut, still I can at least think of, one case where itmight be used with considerable advantage. Most of us willrecall the, difficulty of removing the first dressing from anylarge abdominal incision, the abdomen is often intenselytender and the. dressing as a, rule sticks considerably; thisdifficulty is,often increased by the objection,of some, snrgpoMSto, have it’sMtked oS. The applicaftiom,of.&.sitripof-.nattglas&

1469] DR. SPRINGTHORPE : POSITION, USE, & ABUSE OF MENTAL THERAPEUTIOS. I

carbolised should obviate all this besides allowing the wound Ito be readily examined. I would advise any surgeon trying Ithis idea to get 21-ounce glass and to have it at least threeinches wide and longer than the wound itself. I think lateran advantage would be gained by having the top and bottomedge bent slightly outwards, the remainder flat, and a holecan be drilled if necessary for a drainage-tube.Transvaal, S.A.

_________________

THE POSITION, USE, AND ABUSE OFMENTAL THERAPEUTICS.

BY J. W. SPRINGTHORPE, M.A., M.D. MELB.,PHYSICIAN TO THE ROYAL MELBOURNE HOSPITAL; LECTURER IN THERA-

PEUTICS, ETC., TO THE UNIVERSITY OF MELBOURNE; OFFICIALVISITOR TO THE METROPOLITAN ASYLUMS, VICTORIA.

BY his very claim that the aim of his art is to secure the I

mens sana in corpore sano the physician is pledged to arecognition of mind and matter as the fundamental entitiesand he is required to possess some clear understanding oftheir relationship and interactions. But neither medicaleducation nor clinical training as ordinarily experienced iscalculated to give the average medical man anything likean adequate idea of the part played in health and diseaseby the psychical factor and as a result we find the professiongenerally unduly unconcerned and even ignorant as to itstrue position and therapeutic application.The situation may, perhaps, be simply yet satisfactorily

stated as follows. Thanks to recent discoveries we are nowable to trace all forms of matter back to the luminiferousether itself, whilst we find life entering at a certain stage ofmolecular complexity-it matters little whether as a freshkind of movement or a new sort of force. And it is morerational to place purposive thinking mind behind insensatemass than to regard the psychical as progressively evolvedfrom the physical. Omnipresent supreme mind thus comesbefore even illimitable ether and, in ultimate ontology,idealism, the explanation of everything by mind, is more

probable than materialism, the explanation of everything bymatter. But whilst mind may thus exist alone or in someunknown combination, outside the infinite though incalcul-able universe, yet, within known bounds, there is always apsycho-physical parallelism and realism, the explanationof everything by mind or matter, but neither alone is the

only hypothesis that accounts for all present conditions.As to the exact inter-relationship, however, of mind tomatter there is still room for difference of opinion. Accord-ing to the writer of the article on Psychology in the

"Encyclopaedia Britannica," the theory with which we mustat present rest content is " that the physical and the

a psychical are not independent and closed’ against eachother, but that in certain circumstances-e.g., in perception-physical changes are the occasion of psychical, and thatin certain circumstances-e.g., in purposive movements-psychical changes are. the occasion of physical, neither alonebeing explicable from the other." The same writer representsthem further as "both keeping invariably and exactly inline in development and in emciency, in intensity and com-ple$ity." and ’’ even structure to be regarded as partly shapedand perfected by function rather than function as solely deter-mined by structure itself mechanically evolved." Thus, justas amidst all mental and moral operations there is a physicalfactor always present, often dormant, and potent even whereumsuspected, so also amidst all physiological and patho-logical processes there is a psychical factor, equallyoperative, though unrecognised by material science. Butwhilst, under existing conditions, there is no possibilityof the physical factor being overlooked or of its claimsbeing neglected, the psychical factor is too often bothignored and unused. It has no place in the ordinarycurriculum of study, it has only a few half-friends in thewards, it is not found in the post-mortem room, and it isuncultivated, if not unknown, in most everyday practice.And yet it has claims which demand the most serious con-siderations, ramifications that are wider, and effects that aremore remarkable, than those of any other branch of thera-peutics.

In its essence the psychical factor in each one of us maywell be assumed to be. akin to ,the omnipresent suprememind, a particulate entity thereof, so to speak. And thoughthe deep-thinking East has decided differently it probably

enters each human cortex inherently free from materialstain. It has unquestionably some power of choice, though,its independent action seems limited like that of a player byhis instrument or like the movements of the epicycle by thegeneral sweep of the Ptolemaic orbit. Rightly, too, astheology may hold it to be ultimately destined after trialand testing, ever and always to choose in harmony with thesupreme, still, at present, it is heir to a material inheritancewhich it cannot alter, open to physical influences which it-

may not control, and operative through physical channels.And yet it initiates change, modifies function and environ-ment, regulates organs, is a final court of appeal in manysystematic disturbances, and plays a fundamental part indisease, structural as well as functional, physical as well aspsychical.The systematic utilisation of this psychical factor in the

maintenance of health and in the cure of disease constitutesmental therapeutics. Even proverbially contentment is greatgain, we laugh and grow fat, joy stimulates, fear depresses,worry disturbs, and fjight acts like a shock. And of neces-sity the physician himself and his hygienic, dietetic, andmedicinal assistants always exercise some psychical, overand above the necessary physical, influence. But theseordinary sporadic and almost automatic attempts donot deserve the name of mental therapeutics or placethis line of treatment in the unique position to whichit is rightly entitled. To do this we have to makeit our aim systematically to arouse in our patient all thepowers of auto-suggestion. This demands a mixture ofinsight, knowledge, and confidence, but no special or super-natural powers. In theory this means that we have to seizethe psychological moment, to employ the most appropriatesuggestion, and to apply it in the aptest manner. And thebest procedure is similarly both personal and natural. Wesecure the patient’s confidence by making him believe thatwe understand his case, that we sympathise with him, andthat we can and will do the best for him. If therefrom hecan create-as he frequently can-the certainty of cure,cure, if possible, is at hand. Everything else, environmentand attendants, are also to be then utilised to convey notonly their ordinary physical cargo but the special thera--peutic suggestions, which are often of much greater import-ance and which at times may deserve to be called specific.Hence, for example, the superior value of "spa" treatmentas compared with the home drinking of the -same waters andthe frequent transformation of failure into success when

patients are removed from home surroundings or placed inspecially trained and experienced hands. But how seldom isany such sustained and systematic attempt made in everydaypractice. The necessary result is that those physicians whomake no such attempt fail to reap even anything like theregular crop of good results which they otherwise might obtain,whilst they leave entirely to others those exceptional harvests-which astound the unenlightened and make the fame and for-tune of quacks. And this regrettable failure must continue solong as medical education continues to be considered onlines that practically ignore the psychical factor and so longas disease is arbitrarily divided into physical and psychicaldepartments, to be treated in different places, by differentpeople, in different ways.

It is thus coming to be seen that psychical means alone do>not suffice for the treatment of those whose affliction we cal]>mental. Hence the modern treatment of the acutely insane-is in a thoroughly up-to-date hospital, with all the physical!and scientific appliances that the term implies, and not.in’an asylum, which is the last development of the doctriae-efdetention and safe custody. Even in the ordinary wards øf a.

general hospital, such as the Royal Melbourne, which. has-many drawbacks from this special point of view, some 30"cases of melancholia have recovered after an average treat-ment extending over from four to six weeks without certifica-tion to any asylum. In a suitable mental hospital evensuperior results would no doubt be attained. Similarly,where there is inability in an asylum to provide individualand the desirable physical treatment cases of necessity doless well than in private where both are available. Thus,recently a young man who was drifting towards dementia.during his six months’ asylum treatment recovered within six;weeks in a private establishment. And the same is found toapply mutatis 9?iittandis to cases which are not acute. Hel’1c-the universal movement in favour of placing the feeble--minded, the epileptic, and the chronically insane in suitable-farm and industrial colonies. -,

But a commoner error with the profession is that -ofignoring the psychical factor in the diagnosis and treatment