SUEGERY. 



749 



which the greatest possible care is given to the 

 details of cleanliness, the prevention of putre- 

 faction, the avoidance of any collection of pus 

 in wounds by drainage, and to the securing 

 of absolute rest to injured parts. The extent 

 to which absolute cleanliness may be carried, 

 and the good results of such care, are shown 

 by the answer Volkmann makes to the question 

 whether a surgeon or obstetrician is justified 

 in making an autopsy. His answer is affirma- 

 tive, but with many restrictions which would 

 have seemed ridiculous a few years ago. It is 

 evident that the infection-material which neces- 

 sarily attaches to the surgeon in making an au- 

 topsy can do no good in a wound, and, there- 

 fore, a general surgeon should not come in 

 contact with ulcers, wounds, sensitive mucous 

 membranes, as those of the eye, or make vagi- 

 nal examinations of pregnant or puerperal wo- 

 men, until a suitable time has elapsed since 

 an autopsy, or until he has carefully disinfected 

 himself and the instruments he employs. Since 

 1873 no diseases arising from accidental wound- 

 poisoning have arisen in Volkmann's clinic. 

 Since that time every nurse and assistant has 

 submitted to careful disinfection before touch- 

 ing any breach of surface, no matter how tri- 

 fling. All sounds used for exploration, and 

 even scissors used for cutting sutures in wounds 

 not treated antiseptically, are first disinfected. 

 During this period the slighter forms of phleg- 

 mon have entirely ceased, and erysipelas is 

 only rarely seen in its so-called spontaneous 

 form. Visitors going through his wards and 

 seeing recent wounds on the face treated by 

 the open method, without any inflammatory 

 action being visible, have remarked that the 

 wards must be so entirely carbolized that all 

 wounds heal readily ; or that such cases show 

 what good results may be obtained by the old 

 method. Both conclusions are incorrect, for 

 all the cases were treated on the antiseptic 

 plan, the occlusion dressing alone being omit- 

 ted. In every case, in every part of every op- 

 eration, the causes of putrefaction are exclud- 

 ed. So thoroughly are his best nurses imbued 

 with this idea that they disinfect the scissors 

 with which they cut off the plaster bandage 

 from a simple fracture. His own practice is to 

 use a five-per-cent. solution of carbolic acid 

 freely for washing. He does not consider it 

 necessary to go to the extent of changing the 

 linen ; but, for operations and dressings, both 

 he and his assistants put on white linen coats, 

 and of these he often uses three or four for 

 himself of a morning. He discards the old 

 cloth operating-gowns, and does not approve 

 of the water-proof sleeves and aprons. By 

 this means he is enabled to deliver his course 

 on operative surgery from six to eight o'clock 

 in the morning, during which his hands are 

 constantly in the blood and fluids of fresh and 

 putrid subjects, and then occupy himself im- 

 mediately with operations on the living and 

 with fresh wounds, without carrying infection. 

 He thinks it much better to disinfect a visitor 



and to dress him in a fresh, clean gown, than 

 to trust to his assertion that for a certain num- 

 ber of days he has not been exposed to putrid 

 influences. If it were not possible thus rapid- 

 ly and yet thoroughly to purify one's self, it 

 would be necessary to establish special stations 

 and special assistants for all patients whose 

 wounds were not entirely free from any septic 

 character; for every surgeon is liable to be 

 called from a foul wound or a septic inflamma- 

 tion to give immediate attention to some case 

 particularly susceptible to septic influences. 

 At first he felt great anxiety on this point; 

 the bad cases were all isolated, and their dress- 

 ings were postponed till the last, and, after fin- 

 ishing, his assistant took a bath and changed 

 all his clothes. Now the only cases isolated are 

 erysipelas, diphtheria, and the like. "Where he 

 has a long series of operations, he begins with 

 those in which the danger of infection is great- 

 est, and ends with those already suffering from 

 septic disease. First he opens a peritoneum, 

 then removes a loose body from the knee, then 

 excises diseased joints, and finally comes to the 

 acute progressive inflammation. 



Drainage. One of the most potent influences 

 for evil in wounds is the accumulation of fluids 

 in sacs or pouches of the tissues which may 

 become putrid, and, by being absorbed into the 

 circulation of the blood, produce general blood- 

 poisoning and death. This difficulty has also 

 been in a great measure overcome by the adop- 

 tion of a system of drainage of wounds which 

 has already been referred to. Small soft-rub- 

 ber tubes, with numerous perforations in the 

 end, are introduced into all the deeper parts 

 of wounds, to allow of the constant escape of 

 the fluids. When these do not answer the pur- 

 pose, or can not be introduced into the neces- 

 sary parts of the wound, the latter may be 

 enlarged to permit of their introduction, or 

 entirely new openings in the tissues may be 

 made for no other purpose than to allow of 

 the free escape of matter. For example, in a 

 bad fracture of the thigh by a bullet entering 

 from before, the patient must of necessity be 

 placed upon his back, and all the fluids of the 

 wound tend naturally to gravitate toward the 

 back of the limb and to form pockets and 

 pouches for themselves, where they remain 

 and undergo putrefaction. In such a case it is 

 not uncommo'n to make another opening in the 

 back of the thigh, communicating with the frac- 

 ture, for the sole purpose of discharge. The 

 increased injury is trifling, and the good can 

 not be estimated. 



Under the influence of these two principles, 

 perfect cleanliness and free drainage, almost 

 a revolution has occurred in surgery within 

 the past few years. Operations are performed 

 successfully to-day which three years ago it 

 was considered necessarily fatal to undertake. 

 It is but a few years since a wound of the ab- 

 dominal cavity was looked upon as almost sure 

 to produce an inflammation of the delicate in- 

 ternal covering of that cavity and of the in- 



