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bleeding to be controlled at the time. It is hardly necessary to state that every bleeding point should be securely tied. The application of hot water to an operation wound is to be condemned unless there appears to be no other means of controlling the hæmorrhage, owing to the large amount of inflammatory exudation it afterwards causes.
Wounds should be dressed as seldom as possible. The every-day dressing of a clean operation wound which is going on well is to be most strongly condemned. The way some surgeons treat wounds reminds one of the little child who sets a seed in his garden and digs it up every day to see if it has sprouted. If the temperature goes up to beyond 101° F. the wound should be dressed at once, taking care if it looks all right, to leave it uncovered as short a time as possible. If an unabsorbable drainage tube has been used it should be removed not later than the third day after the operation. If no tube has been used, and all has gone on well, at the end of the fifth or sixth day the wound should be dressed and some at least of the stitches removed. Silkworm gut, well soaked in warm lotion, will generally be found of most service as suturing material. It is strong, clean, fairly pliable and not too readily absorbed. Wounds which are not suppurating should not be syringed out or irrigated. The force used in irrigating a wound separates the wounded surfaces and so often. in great measure prevents that union by first intention which it is our great object to secure. Brass syringes are a perfect nidus for germs. Much may often be done to lacerated and dirty wounds by carefully cleansing with soft soap and the nail brush ; the dirty edges should be pared, and hopelessly lacerated and injured pieces of tissue removed with scissors and scalpel. The wound should then be thoroughly irrigated with corrosive sublimate (1 in 1000), but as before stated it increases the exudation and necessitates the use of an efficient drain. The treatment of lacerated wounds by a constant bath has been adopted by some surgeons. It has this advantage, that you are not cutting away any tissue which may perhaps recover, and the more one sees of
lacerate parts the less one feels inclined to condemn those parts, however seriously they may be injured, as any sort of a crook is better than none at all.
The treatment of suppurating wounds differs according to their situation, character, and extent. Some operation wounds which have been treated with the greatest care, in which all aseptic procedures appear to have been adopted with the utmost rigidity, will suppurate, and whatever we may say or do, we cannot get over this fact. Perhaps it may be from blunt instruments having been used; the vitality of the tissues is lowered, and healing is interfered with. "In early life, in old age, and in atonic states, when the resistance to disturbance is lowered, in parts distant from the centre of the body, and especially when the circulation in these parts is hindered by degeneration of the arteries, healing often takes place with difficulty, and suppuration results." This power of the tissues to resist disturbance is a factor that cannot be neglected. Who will expect an amputation wound in a case of senile or diabetic gangrene to heal by first intention, however careful an antiseptic surgeon he may be? On the contrary, no danger results from attempting to secure primary union and sewing up wounds in such cases, if extra precautions are taken to prevent infection. In some wounds we must have pus formed, as in fistula operations and in operations about the mouth and anus generally How common it used to be for patients to die of septic pneumonia after removal of the tongue. Now it is much less common. In abdominal operations it is better not to flush the peritoneal cavity, unless there is a good reason for it. The fluid so used
should consist of either boiled water or a solution of boracic acid. Boracic acid lotion is unirritating to the peritoneum, and there can be no doubt that it possesses valuable powers of preventing decomposition, although it is of little or no use as a germicide. By no means use any other antiseptic lotion for the peritoneal cavity.
Antiseptics have been defined as "substances directed against the growth and life of those micro-organisms which cause the
decomposition of animal tissues and fluids." Let me state, with Mr. Jacobson, that "no perfect antiseptic is known as yet. An antiseptic that is reliable-one that will not irritate and is not liable to poison-is as yet unknown. No use of antiseptics, however elaborate, is, per se, sufficient to secure success; as unremitting attention to details as ever must be carried out. Keep your wound clean, and then the need of powerful antiseptics will not be essential in order to obtain union by first intention.
I should like here to recall your attention to the fact that Alanson, of Liverpool, a century ago stated that he had performed 35 amputations without a single death; that Syme ligatured the femoral artery 35 times with 34 successes.
As to the best antiseptic, I believe none is better and more efficient than corrosive sublimate (1 in 1000) for washing the skin before and after operations. If carbolic acid be used, it should be of at least 5 per cent., as that is the only strength of use in killing spores. Carbolic, too, is the best antiseptic for keeping instruments in during the operation. Perchloride lotion is far more preferable than carbolic for irrigation purposes. As a dressing, sal alembroth gauze may be used with safety; it is cheap, soft, antiseptic, and, from its blue colour, readily shews how far the discharges have penetrated. It is urged against it that it is irritating and causes eczema, a condition which does sometimes occur in warm weather, Blue wool does not absorb anything like so rapidly as ordinary absorbent wool. Iodoform gauze is more than double the cost of sal alembroth, and where this is of no moment, will generally be found preferable to it It has been said that in using iodoform we are only substituting one stink for another. This I do not believe. Iodoform has a most marked effect in preventing putrefaction. I have come to this conclusion after using it pretty freely for the past seven years. When iodoform is mixed with pus at the temperature of the body, the micrococci decompose it and liberate iodine, than which no stronger antiseptic can be wished. I do not believe in dusting or rubbing iodo
form into a clean wound, as by doing so a foreign body is needlessly introduced, harmless in itself though that body may be. For a tubercular wound, and one which is undoubtedly infected, nothing answers better than well dusting and rubbing in iodoform. Iodoform emulsion (100 per cent.) injected into a tubercular cavity will often cause it to take on better ways and heal up.
The operating theatre should be kept at a temperature of from 65° to 70° F., well ventilated and well lighted. The walls and floor of such a material that they can easily be washed down, The operator and his assistants—there are very few operations which require more than one assistant-should wear a white washable gown which reaches from the chin to the feet. The nails and hands should be well cleaned and scrubbed, then soaked for a couple of minutes in corrosive sublimate (1 in 1000) or carbolic lotion (1 in 20); it is no use to merely dip them in the lotion. It is better for the patient to have a warm bath the day before operation, after which any hairy parts are shaved. Too little attention is paid to nail brushes, they should always be kept in an antiseptic solution. Before making the incision the skin around should be well scrubbed with soap and water; I prefer soft soap. After the scrubbing, again wash the surface with one of the before mentioned antiseptic solutions. Any exposed parts of the body should be well wrapped up, particular attention being paid to the chest. No blankets that may possibly get soiled should be left uncovered. The operation table may be made so that it can be warmed by hot water; in prolonged operations and abdominal sections this is to be particularly desired. Five minutes before the operation the instruments are covered with carbolic lotion (1 in 20). This may then be poured off, and plain boiled water substituted. Mops made of absorbent cotton wool and covered with gauze are better than sponges for general use. Sponges, if used, require the most careful cleansing. The mops should be kept in carbolic lotion, and wrung out before use in plain boiled water. No one, except the operator and his immediate assistant, should
touch any part of the wound, or handle any sponge or instrument. No antiseptic need then be used during the operation ; but after it is over and the wound sewn up, the skin may be washed over with sublimate lotion before the dressing is applied. By this method of asepticism, rather than antisepticism, results will be obtained by which all interested in the case will be satisfied and but little will be left to be improved upon, and not much will then be heard of wound fevers.
"Who would not give a trifle to prevent that which he would give a thousand worlds to cure?" - Younge's Night Thoughts.
NOTE ON THE EMPLOYMENT OF
BY ROBERT SAUNDBY, M.D. EDIN., F R.C.P. LOND.
IN a recent number of the British Medical Journal Professor A. E. Wright, of Netley, published a very interesting paper* in which he described a simple method of testing the relative coagulability of the blood by drawing it into capillary tubes and noting the time in which it clots in the tube so as not to be expelled by blowing, and further related the results obtained by this method in a case of hæmophilia treated by calcium chloride. I may briefly recall that he shewed the normal coagulation time to be between 4' 50" and 5', its prolongation in hæmophilia to be 12 to 14', reduced after the administration of one gramme of calcium chloride three times a day to 5′ 15′′ or 5′ 30′′; but unfortunately his experiments were brought to an end by the departure of the patient.
* On a method of determining the Condition of Blood Coagulability for Clinical and Experimental purposes, and on the effect of the administration of Calcium Salts in Hæmophilia or in actual or threatened Hæmorrhage. By A. E. Wright, M. D. Dubl. --Brit. Med. Journ, 1893, vol. ii., p. 223.