1017 



WOUNDS. 



WOUNDS. 



1018 



granulations, or the throwing out from the wounded parts coagulable 

 lymph, which, becoming organised, unites the edges of the wound 

 together. This latter process is called union by the first intention, and 

 should be the great object of the surgeon in treating wounds. Evident 

 as it may appear, that to heal a wound as quickly a-* possible should be 

 the great object of the surgeon, this universal rule amongst English 

 surgeons is objected to by some continental writers of the present day. 

 It was at one time supposed necessary that wounds should heal only 

 after a long and tedious process of cure by granulation, and lint and 

 tow, bandages, compresses, and a variety of other appliances were 

 made use of to prevent nature from effecting the object in her own 

 way. The remnants of this practice are still found amongst the popu- 

 lace in our own country and some surgeons on the continent. Amongst 

 the Utter, M. Roux, of Paris, has distinguished himself by advocating 

 the cure of wounds made in surgical operations by bringing on the 

 tedious process of granulation. 



When the blood has ceased to ooze from the sides of a wound, an 

 effusion of lymph takes place of a plastic character. Into this lymph 

 vessels are projected by the process of growth from the sides of the 

 wound, and an organised union of the whole wound will frequently 

 take place in the course of forty-eight hours. Even the extent of sur- 

 face laid open by amputation of the thigh is often securely united 

 tlii' iLjhout its whole extent in the space of seventy-two hours. So 

 readily does this process occur, that there are many instances on record 

 of parts of the body having been totally severed, and yet union by the 

 first intention has taken place. Garengeot, in his ' Ti-.iito des Opera- 

 tions,' mentions a case in which a soldier's nose was bit off by one of 

 his companions, and, being restored to its natural position immediately, 

 a permanent union of the separated part was effected. Fioraventi, 

 Blejjny, Balfour, Bosau, and others, have also recorded instances of the 

 restoration of entire union of parts after total separation by accident. 

 Hunter transferred the spurs of a cock to its comb, and the testicles of 

 a cock into the abdomen of a hen, and found in each case that vascular 

 union took place, and the vitality of the transferred part maintained. 

 These instances only illustrated the restorative nature of the process 

 of union by the first intention. It is not often that parts unite after 

 having been once separated. A small vascular connection being pre- 

 served, tends greatly to render this process more likely to occur ; and 

 numerous instances are recorded of fingers and toes being nearly sepa- 

 rated, and afterwards uniting by the first intention. One of the most 

 remarkable examples in which the surgeon avails himself of a know- 

 ledge of this fact, is in what is called the Taliacotian operation. In 

 this operation a new nose is made by paring the edges of the destitute 

 part, and cutting a pyramidal piece of skin from the forehead, its union 

 with the rest of the skin still being maintained at the point, and bring- 

 ing it down upon the face in the form of a nose, when it unites with 

 the pared edges, and a decent substitute for the lost member is thus 

 produced. [TALIACOTIUS, CASPAR, in BIOG. Div.] 



In order to induce wounds to unite by the first intention, the edges 

 ought not to be brought together tin all bleeding has ceased, for the 

 slightest quantity of blood retards and may altogether interrupt this 

 process. When the edges of the wound are ready to be brought 

 together, there are several modes which may be pursued of keeping 

 them in contact. Previous to bringing the edges together, cold water 

 may be applied to the wound upon lint. This will keep down any 

 tendency to over-action or inflammation. It was at one time supposed 

 that the process by which coagulable lymph was thrown out from 

 wounds was one of inflammation, and that it was desirable that the 

 part should be kept warm to encourage this sanatory inflammatory 

 process. But the researches of the late Dr. McCartney, of Dublin, 

 seem to have set this question at rest ; and most physiologists look 

 upon this process as a secretion going on under increased action, but 

 not as an act of inflammation. 



Of the various modes of keeping the edges of wounds in apposition, 

 the application of adhesive plaster is the most common, and certainly 

 applicable to the greater number of ordinary incised wounds. The 

 plaster should be applied in such a manner as to maintain the edges of 

 the wound in contact. There are, however, some wounds which are 

 too extensive for the use of adhesive plaster, and then the suture is 

 used, which consists in bringing the edges of the wound together by 

 sewing them up. [SoTURE.] 



On this subject Mr. Liston remarks, in his ' Elements of Surgery ' 

 (p. 208) : " Of late I have greatly dispensed with stitches and the 

 common adhesive plaster, using, instead of the latter, slips of glazed 

 ribbon smeared with a saturated solution of isinglass in brandy, which 

 is much less irritating and more tenacious than the common adhesive 

 compost. The parts are fixed temporarily with a single stitch, or two 

 at most, and cloths dipped in cold water are placed over the wound. 

 The ribbons are not applied till the adhesive substance has partly con- 

 gealed and the oozing of blood ceased. The divided margins being 

 approximated by the fingers of an assistant, the ribbons are laid gently 

 over and held for a few seconds. Soon after a sufficient number have 

 been applied the stitches are withdrawn, being no longer necessary. 

 No other dressing is required, unless suppuration occur ; the ribbons 

 will adhere firmly till the completion of the cure, and thus the pain 

 and irritation caused by frequent dressing is avoided. Even the largest 

 wounds, as after amputation, are treated in this manner with the most 

 satisfactory results. Of late years a plaster, made by coating oiled silk 



with a solutiou of isinglass, has been used instead ; the glazed surface 

 of the slips is moistened and applied as here directed." Surgery is 

 deeply indebted to Mr. Liston for the bold and fearless manner in 

 which he has carried out a simple and natural treatment of incised 

 wounds. 



AVouuds, however, under the best of treatment will not always unite 

 by the first intention : the consequence is, that the parts which do not 

 unite at once will suppurate, and granulations will be formed. This is 

 called union by the second intention. [INFLAMMATION.] When this 

 process takes' place, then all applications to procure union by the first 

 intention must be abandoned, and all attention must be given to curing 

 the wound by the process of granulation. Plasters, sutures, and ban- 

 dages must be removed ; and where the inflammation is great, every 

 means should be taken to arrest it. Suppuration should be encouraged 

 by warm fomentations, by poultices, and above all by the warm-water 

 dressing, which consists of nothing more than pledgets of lint dipped 

 in warm water, and then covered over with oiled silk to prevent evapo- 

 ration and cooling. When the inflammatory action is subdued and 

 granulations are forming, gentle pressure should be employed for the 

 purpose of avoiding the formation of more new matter by granulation 

 than is absolutely necessary. The dressings at this period should bo 

 light. Some surgeons are fond of ointments, which may always be 

 dispensed with ; but in some cases of languid granulation a stimulating 

 ointment is useful. Lotions are generally better. A weak solution of 

 sulphate of zinc or nitrate of silver may be mostly employed with 

 advantage. The wound itself does not require the washing aud 

 sponging and dabbing to which it is so frequently submitted ; but the 

 skin about the wound cannot be kept too clean and free from impurities 

 of every kind. 



Punctured Wounds. These wounds are dangerous from their depth, 

 and the internal effusion of serum and blood which usually attend 

 them. In consequence of this, these wounds are frequently followed 

 by severe inflammation and suppuration. These results used to be 

 attempted to be obviated by the practice of dilatation. This, however, 

 is severe practice, and only justifiable in cases of the existence of a 

 foreign body. Setons are recommended by the French surgeons for 

 these wounds, but there are so many objections to them, that they are 

 seldom used by surgeons in this country. Whether these wounds 

 unite by the first or second intention, they require to be healed upon 

 the same general principles as incised and gunshot wounds. 



Contused and Lacerated Wounds. These result from the collision of 

 blunt, obtuse, hard bodies, being forcibly driven against the living tex- 

 tures. Although these wounds may occur independent of gunshot, 

 it is in the class of wounds called gunshot that the best examples of 

 lacerated and contused wounds occur. The rapid introduction of 

 powerful machinery into the manufactures of this country renders 

 contused and lacerated wounds of very frequent occurrence in our large 

 towns. In these wounds there is seldom much bleeding, arising from 

 the coats of the arteries becoming twisted and doubled up by the force 

 of their retraction. They are much more liable to have foreign bodies 

 in them than incised wounds. Such wounds seldom unite by the first 

 intention, but in their treatment this object should always be kept in 

 view, as frequently portions of the wound may be induced to unite. 

 During suppuration and granulation, the same plan of treatment should 

 be pursued as when these processes occur iu incised wounds. The 

 constitutional symptoms arising from these wounds are generally more 

 severe than from any others, and require attention. Symptomatic 

 fever must be treated according to the same general principles laid 

 down for the treatment of fevers. [FKVERS.] Another consequence 

 of these wounds is that dreadful state of the nervous system called 

 tetanus [TETANUS], which often resists all kinds of treatment. 



P'lisoned Wounds. The principal forms of this class of wounds seen 

 in this country arise from the bites of rabid animals, pricks and cuts 

 received in dissection, and the bites of vipers and the stings of insects. 

 The bites of rabid animals are unfortunately too common, and often in 

 this country require the attention of the surgeon. When the poison is 

 introduced into the system, it produces the fearful disease known by 

 the name of hydrophobia, for which medical science has not hitherto 

 found a remedy. [HYDROPHOBIA.] Where persons have been bitten 

 by cats, dogs, or wolves in a rabid state, the wound should be imme- 

 diately excised, and the nitrate of silver (lunar caustic) applied to the 

 wound. 



Dissecting Wounds. Under this head may be included not only the 

 punctures aud cuts to which medical men are exposed in the examina- 

 tion of the dead human body, but all those wounds after which ill 

 consequences ensue, in which there is reason to suppose some poison 

 generated in an animal organisation has been introduced into the 

 system. It is still sometimes discussed in books on surgery, as to 

 whether the effects following these wounds are produced by a peculiar 

 poison or are only the result of a slight wound in a constitution pre- 

 disposed to disease. The frequency of the ill effects of these wounds 

 amongst medical men, as compared with other classes of persons, 

 equally liable to pricking and cutting their fingers, must decide this 

 question in favour of the existence of a poison. It is not, however, as 

 is generally supposed, that putrescent bodies and those advanced iu 

 decomposition are most injurious, for it is generally found that the 

 worst consequences follow wounds from recent bodies, especially of 

 persons who die of puerperal peritonitis, The consequences following 



