138 CASE OF COMPOUND DISLOCATION OF THE ANKLE 



I nipped off a portion of it with cutting-pliers,^ and, with the same object, 

 enlarged slightly with scissors the lower end of the rent in the skin, which op- 

 posed a barrier to its passage. But to all intents and purposes the dislocation 

 was simply reduced. The case, however, was treated antiseptically. Watery 

 solution of carbolic acid, as strong as it can be made (one part of the crystals 

 to twenty of water), was thrown into the joint with a syringe, the edges of the 

 skin being held together to prevent its escape and cause its penetration to all 

 the internal recesses of the wound ; and this was further promoted by free 

 manipulation of the injured part while the fluid was still in the interior. There 

 was a time when we should have thought that to introduce an irritating liquid 

 like this into the ankle-joint would be to take an unwarrantable liberty with 

 the articulation. But we now understand that the transient irritation caused 

 b}^ the antiseptic lotion is nothing compared with the abiding influence of the 

 far more acrid products of putrefaction. In the operation which you saw me 

 perform just now [the removal of a fatty tumour], a lotion of half the strength 

 (i to 40) was employed ; experience having proved that this is sufficient to ensure 

 destruction of the putrefactive organisms in a wound just made, and made by 

 the surgeon himself. But when the injury has been received some time before 

 you see the patient, and inflicted, as in the present instance, in a rude way, 

 involving the chance of foreign material having been introduced and mixed, 

 perhaps, with clots of blood lying in inaccessible recesses of the wound, it seems 

 wise to employ as strong a solution as water will produce. And as this will be 

 3^our only chance of acting upon putrefactive particles lodged in the interior — 

 as the work of their destruction must be done once for all at the outset — do 

 not be afraid of dealing very freely with the injured part in introducing the 

 germ poison. [It is a mistake to mingle spirit of wine or glycerine with the 

 watery solution used for injecting the wound. The admixture of either of 

 these materials with water containing a given amount of the acid in solution, 

 gives it a greater hold upon the acid, and renders the lotion more bland, and 

 at the same time more persistent in its action ; and this may, under certain 

 circumstances, be very useful for the purpose of an external dressing. But 

 for the preliminary treatment of the interior of the wound an agent potent for 

 the moment, but transient, is called for, to kill the putrefactive organisms, 

 and, as soon as this is done, to leave the wound as speedily as possible to recover 

 from the inevitable irritation of the antiseptic ; and for this purpose no vehicle 

 seems better for the acid than simple water.^] The liquid introduced having 

 been squeezed out, the process of injection and manipulation was performed 



^ The portion removed was covered at its deeper surface with articular cartilage. 

 ^ The remarks included within brackets were made on another occasion. 



