152 CASE OF COMPOUND DISLOCATION OF THE ANKLE 



this time undergone softening from putrefaction, so that the nozzle of a syringe 

 could be introduced through it ; and, on injecting some of the watery solution 

 of carbolic acid, I found that it passed freely beneath the integument to the 

 seat of fracture and to the external wound. Whether the skin had been thus 

 extensively detached at the time of the accident, or whether the subcutaneous 

 tissue had been simply loaded with extravasated blood, the spreading of the 

 putrefactive fermentation from the slough exposed to the air was easily 

 intelligible. 



It is therefore essential that every isolated slough which may exist in the 

 vicinity of a contused wound should be dressed antiseptically like the wound 

 itself. But it may be asked. How is it possible to secure this at the time of 

 the first dressing, seeing that there is nothing in the appearance of the skin 

 in the first instance to indicate that vitality has been destroyed ? The simple 

 rule for attaining the desired object is to let the antiseptic plaster first applied 

 overlap the apparently uninjured skin far and wide in all directions. Then, 

 on the following day, let the integument be carefully scrutinized, when any 

 dead portions will be recognized by a dusky discoloration. Every such dis- 

 coloured patch should then be dressed, as if it were a wound, with a piece of 

 protective and well-overlapping lac-plaster. If the protective were omitted, 

 the slough would acquire stimulating properties from the carbolic acid per- 

 petually communicated to it by the lac-plaster, and would excite the neighbouring 

 living parts to granulation and ' antiseptic suppuration '. But if efficiently 

 protected from the antiseptic, as well as from putrefaction, the dead tissues 

 will be absorbed and organized like the clots of blood, new living structures 

 being formed at the expense of the effete but nutritious mass. 



Such was the course pursued in the present case ; and, the oiled silk protec- 

 tive having been used in two, and sometimes three, layers, the results have 

 approached very closely to those which are theoretically attainable. Some of the 

 smaller portions of slough have been entirely removed by absorption, their 

 place being taken by vascular new tissue. Five weeks after the accident, the 

 large slough at the anterior margin of the wound had been considerably reduced 

 in superficial extent, without the formation of any line of separation. What 

 remained of it was of firm consistence, though of yellowish-white colour. In 

 order to ascertain to what extent the process of organization and vascularization 

 had advanced in it, I scratched its central part with the point of a sharp knife, 

 and found that the little incision bled when I reached a depth not above half 

 that of the cutis vera, whereas the original slough had undoubtedly involved, 

 not only the entire cutis, but the subcutaneous fat. The mass of dead tissue, 

 though superficially situated, being protected from the disturbing influence 



