T H O U G H T S ON W O U N D H E A L I N G AND W O U N D CARE

By A. B. WALLACE, M.Sc., F.R.C.S.E.

Reader in Plastic Surgery, University of Edinburgh

I SHOULD like to develop certain thoughts on wounds, their environment, and care, especially in relation to surgical technique, antisepsis, closure, desiccation, and prevention of cedema.

Locally, in the management of wounds, I try to apply a concept of three clinical phases to the healing process :--

I. A phase of traumatic inflammation in which hypera~mia and leucocytic migration occur: traumatic inflammation lasts in moderate injuries for about five days. The arteriolar and capillary dilatation with exudation of plasma is followed by leucocytic emigration and a little later by dilatation of pre-existing lymphatics and lymphatic capillaries.

2. A phase of destruction or cleansing or demolition when the dead and dying cells are removed and the way is cleared for repair tissue. Autolytic enzymes are liberated from dying cells while leucocytes liberate proteolytic enzymes to aid in the destruction of injured cells, The way is thus cleared for cell proliferation : the third phase. Demolition by phagocytic cells often seems so rapid that the process must be assisted by a variety of enzymes such as proteases, peptidases, lipases, ribonucleases, fibrinolysins, etc. Living cells are protected by appropriate anti-enzymes. In the early demolition the tissue-fluid reaction veers to the acid side. As granulation tissue is formed the wound reaction swings to the alkaline side and another series of enzymes concerned with tissue growth takes over. Here a wide field for clinical research work opens out.

3. A phase of proliferation continues to final healing, fibrous tissue develops, and epithelium regenerates. The stimulus for and regulation of this period are not understood.

The first two phases, although very active, are sometimes grouped together and termed the lag or latent period. It is, however, not the tissues but the surgeon who tends to lag. The length of the period is determined by the time taken by the body and by the surgeon to eliminate necrotic and grossly injured tissue and foreign material. When this is accomplished the wound enters an even more active phase when cell migration occurs and proliferation takes place.

The lag period paves the way for the phase of true repair which, in uncomplicated injury, remains in abeyance until the lag period is nearing its end. Some factors which influence wound healing by extending the lag period can be controlled by the surgeon, e.g., dead tissue, antiseptics, coarse handling, heavy instruments, coarse sutures, tight sutures, irritant sutures, local antibiotics, soft paraffin, inadequate or excessive dressings, waterproof dressings, oedema, too early movement. With these points in mind a surgical technique can be applied to different types of wound, with a view to reducing the lag period.

An open wound can be of the "incised " or " lacerated" or " degloving" type. In the incised wound there is a clean cut, little destruction, and minimal damage of surrounding tissue with slight reactionary oedema. In the lacerated type, however, there is often an element of " crush" damage. Further, there is

x5o

T H O U G H T S O N W O U N D H E A L I N G AND W O U N D CARE 151

in this type a more severe local response with the complications of cedema, extravasation, and hmmatoma. In degloving or avulsion injuries a shearing force has usually been applied at a tangent to a trapped limb. The limb is crushed and the skin and subcutaneous tissue stripped. The base of the avulsed flap is commonly narrow ; the subcutaneous fat often shows thrombosed blood-vessels. Tissue damage is extensive and local responses to injury marked.

The primary aims in the treatment of all acute open wounds are (i) to help tissues to reduce the lag period to its absolute minimum, and (2) to close the wound.

Our protective covers are skin and mucous membrane, and after injury the following biological covers should be made use of :--

i. A plasma pellicle in open and lacerated wounds. 2. An eschar (temporary cover) in wounds with skin death. 3. Granulation tissue and/or grafted skin or mucous membrane in wounds

with skin loss.

In wounds without skin loss the ideal cover is a plasma pellicle, and with skin loss, tissue transplants assisted by a plasma pellicle. Skin is the best surface cover applied either as an autograft or a homograft (living or freeze-dried), and skin of course not only covers but closes a wound. In severe injuries, e . g . , extensive burns, the delayed formation or actual inhibition of a protective granulation layer may predispose to septica~mia and excessive fluid loss, and the employment of extensive freeze-dried homografts, both as protective cover and for closure, can be life-saving.

The concept of utilisation of biological covers is not new. It is both stimulating and encouraging to read John Hunter's work and to note the stress which he laid on their formation and maintenance. I should like to quote from his writings (Hunter, 1786-87) :--

" Of Injuries where the Wound Communicates Externally: These may be divided into two kinds, viz., wounds made by sharp-cutting instruments and contusions producing death in the parts injured. Wounds are subject to as great a variety as anything in surgery.

" The aim of the surgeon is to bring and retain the separated surfaces into contact. When the portion of skin is not sufficient to cover the whole wound and the cut edges cannot be brought together, still the skin should be made to cover as much as it can in order to diminish the size of the parts that must otherwise suppurate and form a sore.

" I f the parts, however, continue too long asunder, suppuration must follow and pus is unfriendly to union. To encourage union by the first intention the sides or lips of wound are brought together by bandages, sticking plasters, and ligatures.

" I f any extraneous body should have been left in the wound, suppuration will take place.

"Wounds which are attended with laceration cannot always be united by the first intention because it must frequently be impossible to bring the external parts of skill so much in contact as to prevent that inflammation which is naturally produced by exposure. I f the edges are kept moist they will inflame and the wound suppurate. I f the blood is allowed to dry and form a scab between and along the cut edges then inflammation and suppuration of those edges will be prevented.

" The first and great requisite for the restoration of injured parts is rest, as

152 B R I T I S H JOURNAL OF PLASTIC SURGERY

it allows that action which is necessary for repairing injured parts to go on without interruption.

" Of Scabbing.--The operations which I have described prevent inflammation, especially that sort of it which produces suppuration ; but even where the parts are not brought together, so as to admit of union by the first intention, nature is always endeavouring to produce the same effect. The blood which is thrown out in consequence of the accident and which would have united surfaces brought into contact, is in part allowed to escape, but by its coagulation on the surface a portion is there retained which, drying and forming a scab, becomes an obstacle to suppuration.

" A scab may be defined first, dried blood on a wound, dried pus on a sore ; a slough from whatever cause allowed to dry, mucus from an inflamed surface, as in the nose.

" T h i s might be considered as the first mode of healing a wound or sore; for it appears to be the natural one, requiring no art : proper attention to this has, I believe, been too much neglected.

" M a n y wounds ought to be allowed to scab in which this process is now prevented: and this arises, I believe, from the conceit of surgeons who think themselves possessed of powers superior to nature and, therefore, have introduced the practice of making sores of all wounds.

" The mode of assisting the cure of wounds by permitting a scab to form is likewise applicable, in some cases, to that species of accident where the parts have not only been lacerated but deprived of life. I f the deadened surface is not allowed to dry or scab it must separate from the living parts, by which means these will be exposed and suppuration brought on; but if the whole can be made to dry, the parts underneath the slough will cicatrise and the dried slough will at last drop off. Where this can be effected it is the best practice as it will preclude inflammation and suppuration which, in most cases, should be avoided if possible. This will more readily take place where the cutis is not deprived of life through its whole surface.

" T h i s practice is the very best for burns and scalds." Although this concept of the ntilisation of biological covers is simple and

attractive, unfortunately it has often been misunderstood and misapplied ; for example, exposure of a wound has become synonymous with " open" treatment. This error is not of recent years, and in 1885 was clearly described by Watson Cheyne :--

" T h e method of treatment which has been the greatest stumbling-block in the way of the acceptance of the principles of antiseptic surgery is the open method, for surgeons have been unable to see how the success of this method could be reconciled with the germ theory of putrefaction. They have looked on it as the antithesis of aseptic treatment, as acting on the very opposite principle to that on which the aseptic method is based. And yet, when we come to consider the matter in the light of the true principles of antiseptic surgery we find that the open method is an advanced method of antiseptic treatment. Of course, other principles, such as that of perfect rest and free drainage, also tell markedly in this case.

" I have stated that this open method acts antiseptically in two ways, and these I must now briefly consider.

" I. It acts antiseptically in that the discharges dry up and become more concentrated, and thus become unfit soil for the growth of bacteria.

T H O U G H T S O N W O U N D H E A L I N G A N D W O U N D C A R E 153

" That concentrated fluids are not suited for rapid development of organisms is well known. Thus Pasteur pointed out that organisms could not grow in sugary solutions which had become concentrated. This fact is made use of in the arts, in the preservation of prints. Sugar is added in large quantities, and then the print can be kept for an indefinite length of time. It is not that the sugar is an antiseptic killing the organisms, it is merely that by its presence in large amount the fluid is rendered unsuitable for development.

" The same principle is made use of in preserving milk. The milk is evaporated to one-third of its original volume, and a considerable quantity of sugar is added to it. Without the addition of the sugar, the condensed milk may be kept for a considerable length of time without the appearance of organisms in it ; with sugar it may be kept indefinitely.

" The same is the case with other albuminous fluids, such as the discharge from wounds. Concentrate pus, and it will be found that organisms develop in it only with difficulty.

" T h e n we know the contrast between cases of dry and moist gangrene ; how in the latter putrefaction rapidly occurs or, in other words, organisms rapidly develop, while in dry gangrene putrefaction does not occur, i.e., organisms cannot develop.

" 2. In the open method another antiseptic advantage is gained by the free admission of oxygen to the discharge.

" Some very remarkable effects of oxygen in retarding putrefactive and other fermentations were published long ago by Pasteur. He pointed out that if a sugary solution were freely exposed to air ill a thin layer, the yeast plant, though it grew luxuriantly, caused very little fermentation. On the other hand, if oxygen were excluded, only a small development of the yeast cells was necessary for fermentation. And he has shown that other plants besides the yeast plant can cause alcoholic fermentation, if only they are deprived of free oxygen.

" With regard to putrefaction he has brought forward similar evidence. The organisms which cause putrefaction are, according to him, incapable of living in the presence of oxygen. I f a putrescible fluid be freely exposed to the air in a thin layer, putrefaction does not occur, at least not for a very considerable time. Oxygen apparently not only interferes with the fermentative process, but actually destroys the bacteria which cause it. Hence the free exposure of a putrescible fluid to the air results in comparative freedom from putrefaction, partly because the oxygen interferes with the development of fermentative changes and partly because the oxygen directly kills the putrefactive bacteria.

" Closely allied to the open method stands ' healing by scabbing.' This may be brought about chiefly in two ways. The crust may either be allowed to form naturally, or its formation may be aided by artificial means.

" This healing by scabbing acts in two ways. In the first place, the first principle of the open method of treatment comes into play ; the discharge dries up and becomes an unfit soil for the development of organisms: In the second place the fluid underneath it is in such a thin layer that the living tissues in the neighbourhood prevent the development of organisms in it. Of course in many cases no living organisms would be there to develop, for the scab would form an absolute protection against their entrance.

"Alphonse Guerin's cotton-wool treatment acts partly on the first part of the principle of the open method, but it hardly comes into the category of antiseptic methods.

2 E

154 B R I T I S H JOURNAL OF PLASTIC SURGERY

" As the result of these dressings, the discharge becomes thick and concentrated, and not a very good medium for development of organisms. Nevertheless, this concentration of the discharge cannot occur to anything like the extent which takes place when it is left freely exposed to the air. The second principle on which it acts is that it ensures absolute rest to the wound. By means. of this rest the granulations are not lacerated, and bacteria and their products may thus be prevented from entering the body.

"Assist the destroying action of the healthy living tissues on bacteria." " This principle may be aided in two ways, viz., by perfect mechanical rest,.

and by attention to the general health. " By perfect mechanical rest, when the tissues are in perfect health, and the

blood clot is undisturbed, the tissues and clot may be kept in such a state as to resist the development of organisms. This method, though without recognition o f the antiseptic principle, has long been practised, and of late has been specially advocated by Mr Sampson Gamgee (' On the Treatment of Wounds,' 1867).

" Living tissues when in a healthy state have the power of preventing the development of organisms in their immediate vicinity.

" N o w in order to have tissues in the state in which they are capable of resisting the development of bacteria in their immediate vicinity, they must be as much as possible in a condition of perfect health. The causes which weaken the part are various forms of unrest, mechanical or chemical.

" To carry out this principle two things are required, viz., accurate approximation of the cut surfaces, and absolute immobilisation of the part. Where accurate approximation of the cut surfaces cannot be obtained, the same principle of absolute rest must be carried out as regards the clot filling up the gap, and it may thus resist the development of bacteria in its substance. Were I compelled to treat any case on this principle alone, I should combine with it the open method, leaving the wound freely exposed to the air. The superficial layer of the clot, by drying up, would thus to some extent form an obstacle to the entrance o f organisms.

" What is ventilation but an antiseptic means ? "

Wound Care . - -The principle of biological cover has been applied to the closure of wounds. As a first step, diagnosis must include diagnosis of structures divided, structures displaced, and structures lost. To cleanse the skin, I per cent. Cetrimide is adequate, the wound being protected from the antiseptic solution by dry gauze. To cleanse the wound, sharp dissection may be necessary; if not,. irrigation may be employed with normal saline, but never with a solution which would cause irritation if injected subcutaneously. This virtually rules out all antiseptics. Lister (1896) wrote : " Of all those who use antiseptics in surgery, I suspect that I apply them least to the wound," and " The irritation of the wound by antiseptic irrigation and washing may therefore now be avoided and nature left- quite undisturbed to carry out her best methods of repair."

Inc i sed W o u n d s . - - A f t e r cleansing of first the surrounds and then the wound,. the divided layers are gently coapted by fine interrupted sutures to allow the body to complete the closure readily with a plasma pellicle. ~In this type of injury with little reactionary oedema and no external wound discharge, an outer dressing is not necessary, but if thought advisable a dry gauze dressing may be applied for protection. Elevation and rest are beneficial.

THOUGHTS ON WOUND HEALING AND WOUND CARE I55

Lacerated Wounds.wWound cleansing is performed by sharp dissection. The dead and/or dying cells are excised, foreign bodies are removed, and bleeding is controlled. Whether the wound is then dosed or closure delayed for three or four days will depend on the extent of contusion of the adjoining tissues. Following sharp-dissection-cleansing and, if indicated, irrigation with normal saline, the wound is either dosed immediately in layers, or it is dressed with liberal quantities of teased-out dry gauze, wool, and bandages and delayed primary closure adopted. Before a dressing is applied, the insertion of a polythene drainage tube through a separate stab and attachment to a mild suction apparatus favours drainage and decompression and eliminates dead space. The employment of carefully controlled suction drainage with modern non-irritant tubes is a definite advance in wound care.

The " delayed emergency" technique or " delayed primary closure" b y allowing the tissues to decompress affords a more ready control of infection and might be adopted more frequently with benefit in crush hand injuries. After closure, immediate or delayed, in some cases gauze wrung out of saline may be applied immediately but not repeated. It is considered that while wet the gauze encourages decompression and that once evaporation is complete the dried gauze encourages the formation of a dry plasma pellicle. Rest and posture are two additional requirements in after-care.

Wounds with Loss and/or Death of Skin.--I f an eschar is present it may be used for some days as a temporary cover. It is removed by the surgeon and the lag period is thus completed to bring the wound to the third phase of healing and to closure with a skin graft or flap. After being dressed, the part is elevated and immobilised. It is essential in all traumatic work to consider early completion of the lag period followed by immediate skin cover. This in turn encourages early function.

Degloving and Avulsion Wounds.--Radical surgery is essential. The flap and all undermined tissues are excised. The wound is closed immediately by tissue transplants or later by a delayed primary technique. Either the flap skin or a split-skin graft may be used for cover. The dressings and care are similar to those for a lacerated wound.

In wounds with extensive skin loss, closure with skin grafts may have to be a staged procedure and granulation tissue accepted as an intermediate protective cover.

Wounds with Granulation Tissue Cover.--Granulation tissue of itself acts as a mechanical barrier and as a physiological filter to invading organisms and controls to some extent fluid loss. Unfortunately the cleansing treatments applied to granulation tissue are many and varied and have no real purpose except to kill micro-organisms. Most applications are antiseptic solutions, or antibiotic powders or creams directed against infecting organisms often already present because of the wet state of the dressings, and little thought or assistance has ever been given to the natural protective properties of granulation tissue. Wardill's procedure of a daily slunge followed by routine exposure has much to commend it. There are no real indications for the application of antiseptics to a biological protective layer : they irritate and disturb. A more rational procedure is daily mopping of the surface with saline swabs for a few days followed by the application of skin grafts and exposure. The surface does not require to be sterile for the application of skin, and within two hours of the application of a skin cover the infecting organisms

156 B R I T I S H J O U R N A L OF P L A S T I C SURGERY

rapidly decrease in number and fluid loss is also reduced. It is of considerable interest that living and freeze-dried homografts appear to have similar beneficial immediate effects. Much more investigation of this approach is required.

Dressings and their Historical Background.--Dressings are intimately associated with wound care. They can either encourage or prevent the closure of a wound, and they can precipitate the reopening of a wound already closed. The present fashion is for too many small tidy dressings and for airtight dressings. Airtightness is of less importance than desiccation.

It is of particular interest to note that the value of absorption and desiccation of wound exudate has been stressed through the ages. The Talmud (4 B.C.) mentions the use of dried shell of gourds--a method still used by some primitive tribes. John Woodall (1617) wrote : " Follow the general rule, let the dry be more humected and the humid more desiccated," and in 1848 James Syme stated: " The surgeon shall apply dry lint over the wound as often as the least moisture is perceived." Schimmelbusch (1894) wrote: " T h e open method of wound treatment introduced into practice in the pre-antiseptic period by Kern was attended by more favourable results than all methods previously used. Burow, who had lost 5o per cent. of his patients upon whom amputation was performed, had a series of ninety-four cases treated by the open method, i . e . , without any dressings, which gave a mortality of only 7"5 per cent.

" In superficial cutaneous wounds, nature dries the secretions, forms a crust, and provides a protective covering. The experiments of constantly irrigating wounds with solutions or of keeping them continually submerged in a water bath during the entire process of repair are only of historic interest."

Lister also taught that desiccation of exudate was essential to prevent putrefaction, and Cameron (19o7) stated : " One characteristic of the early methods, soon to be changed, was that the dressings were purposely made unabsorbent and impervious to the discharges.

" It became the practice in some quarters to dress wounds with oakum, carefully selected and teased and good reports were given. It was the use of this substance which suggested to Lister the employment of gauze, a form of dressing which would absorb the fluids of the wound. The material selected was a cheap muslin---' book muslin.' This was charged with resin, paraffin, and carbolic acid. Lister was anxious to bring carbolic acid as little into contact with wounded surfaces as possible, and therefore equally anxious to give up the washing of the wound prior to stitching it."

Listerism has been defined in many ways. To use his own words (Lister, I868), it was " t h e systematic employment of some antiseptic substance so as to prevent the occurrence of putrefaction, as distinguished from the mere use of such an agent as a dressing."

There has been little change or advance in the type and form of dressing. Schimmelbusch (1894) wrote: " The present requirements of dressing are essentially three. The dressing must: (I) absorb well the wound secretions ; (2) be free from pathogenic organisms; (3) work antiseptically, i . e . , prevent decomposition of the absorbed secretions.

" The dressing must not take up its maximum quantity of fluid at one time, but rather absorb continuously and dry out promptly by evaporation.

" Materials like blotting paper, silk, lint, and absorbent cotton once filled with fluid are no longer absorbent and are inadequate for dressings.

THOUGHTS ON WOUND H E A L I N G AND WOUND CARE 157

" Next to gauze, sphagnum moss is the best material, then wood fibre and wood wool."

This viewpoint was expressed some years previously by Gamgee (1867), who considered that wet dressings were not much better than poultices, that they favoured suppuration, and were opposed to healing. In addition, he taught that pressure, gentle, uniform, sustained, was an auxiliary of first importance in promoting healing action. He wrote: " There must be no constriction, only equable adaptation of surface to surface with the light pressure which always comforts. The soothing surgical pressure is like that which you interchange with the hand of a lady, when the pleasure of meeting her is tempered by a respectful regard. Your hand adapts itself to hers and gently presses it wherever it can touch it, but nowhere squeezes it for fear of offending." Surely this is the classic description of a pressure dressing.

To return to the importance of absorptive dressings over wounds with much discharge, in 1828 Dr D. S. Anderson of Glasgow recommended in burns the immediate application of finely carded cotton-wool disposed in narrow fleeces so thin as to be translucent and applied in successive layers. His results were good in comparison with later methods used in Glasgow (see table).

TABLE

Mortality Statistics of Burns and Scalds in the Glasgow Royal Infirmary from 1833 to 1934

Time Period.

18,33 to 1844 1844 to I854 1854 to 1868 1868 to 1885 1885 to 1899

1899 to 191o

191o tO 1918 1918 to I929 1929 to 1934

Local Therapy.

D r y cotton-wool Dry cotton-wool Dry cotton-wool Carbolic oil Sodium bicarbonate followed

by boracic or picric acid Sodium bicarbonate followed

by picric acid Alnminium acetate Paraffin wax Tannic acid

Mean Mortality.

Per cent. 17"2 17"1 13 "3 16.2 24.8

37 "6

30"5 22 "9 20.6

I '96 x Standard Error of Period

Mortality.

Per cent. 2.2 2- 4 2. 9 i .88 2 "86

2.84

2 ' I 4 2' 7 5 '46

(From Dunbar, 1934.)

The rising mean mortality figures illustrate in my opinion the misinterpretation of Lister's teaching. Halford (1928), who was brought up by strict Listerian discipline, encouraged in wounds the formation of an artificial scab and in areas with skin loss the desiccation of sloughs and the drying up of surface discharges, promoted when necessary by the application twice daily of methylated spirit in the form of a coarse spray to all parts of the dressing, which was of plain sterilised gauze and cotton-wool, at first bulky, but later reduced to as thin a layer as possible to encourage evaporation. The dressing was never completely removed--only the portion sodden with discharge---to allow of spraying and the reapplication of dry dressing.

I58 BRITISH JOURNAL OF PLASTIC SURGERY

Lister emphasised that any original infection in a traumatic wound slowly but surely was subdued by the natural resistance of the tissues so long as putrefaction of the discharges was prevented. " I f the discharge happened to be sufficiently copious to soak through the cotton-wool and appear at its external surface, putrefaction occurred throughout the entire mass of the moistened part down to the wound, even within the first twenty-four hours after the dressing, if the fluid were sufficiently copious to penetrate within that period. It is only when dry that cotton-wool can arrest the progress of microscopic organisms, which have ample room to develop among its meshes when filled with a putrescible liquid.

" For preventing the access of putrefactive fermentation the agent which we now commonly use is what we have termed the antiseptic gauze. The gauze is also extremely convenient in the form of bandage--an antiseptic bandage---which is put on to hold the main dressing in position ; and instead of being a nidus for putrefaction, as a cotton bandagc would be, it increases at every turn the antiseptic efficacy of the dressing " (Lister, I87I ).

The function of a dressing should be complementary to the natural healing process, and I have already stressed the importance of biological wound covers. I believe that if dressings are to be employed they should encourage in incised and lacerated wounds the formation and preservation of a dry plasma pellicle, and they should keep, in wounds with skin death or loss, eschar or granulation tissue as dry as possible. They must encourage first absorption of discharge and then its desiccation or evaporation. I f this does not happen the dressing and outer bandages become sodden and infection readily passes in. Plaster of Paris, strapping, and elastoplast hinder evaporation. Lister appreciated this danger and stressed the importance both of the desiccation of discharge from a wound and the protection given to the inner absorptive dressing by an outer bandage impregnated with antiseptic.

In incised wounds with little discharge, dressings are not necessary, but in a lacerated wound with much soft tissue damage, dressings can be of extreme importance. They must absorb and continue in the absorbent state or be immediately changed. An absorptive dressing should if possible be completely surrounded by circulating air to allow constant evaporation and desiccation to take place. Turning bed frames are essential for patients with encircling wounds and wounds of buttock to permit evaporation from all aspects of the dressing, yet how few turning beds are available in medical and surgical wards. Present-day evils are the fixation of bandages by strapping and the use of waterproof or plastic covers on pillows and mattresses because both encourage the moist compress effect which leads to maceration, infection to and from blankets, cross-infection, etc. This weakness in surgical care, in my opinion, is common to the surgical and medical wards of most hospitals.

Absorptive dressings over eschars are similarly of great importance. Dry eschars separate off at an earlier date than those in a moist state. At one time in my unit eschars were removed by scalpel about the twelfth day. I f kept dry, even extensive eschars can be removed within three weeks by scissors with little blood loss.

Dressings and Hospital Cross Infection.--With the present-day frequency and fear of hospital wound infections the proposal to " return to Listerism " is often heard, but it is not appreciated that this would involve personal supervision by the surgeon of all dressings.

THOUGHTS ON WOUND ~ H E A L I N G AND WOUND CARE 159

The cross-infection of wounds gave trouble in Lister's time. In 1893 he wrote: " T h e 'Staphylococcus pyogenes aureus--a very common cause of suppuration--is very resisting. Now it has been shown that in such solutions as would be used in surgery carbolic acid destroys this organism much more rapidly than bichloride of mercury does.

" For dressing the wound in the absence of chemical antiseptics, dry substances such as absorbent cotton-wool or old linen (preferably boiled before use) are far better than anything kept permanently moist like water dressing. The blood and serum oozing into a dry dressing, becoming more or less inspissated by evaporation, are in proportion a less favourable soil for microbic development.

" A n external antiseptic dressing, to be ideally perfect, should have four essential qualities. It should contain some thoroughly trustworthy antiseptic ingredient ; it should have that substance so stored up that it cannot be dissipated to a dangerous degree before the dressing is changed; it should be entirely unirritating ; and it should be capable of freely absorbing any blood and serum that may ooze from the wound--even if it be a wet dressing ; it must be absorptive - -no t sloppy."

In conclusion, I would stress the importance of reduction of the lag period, utilisation of biological covers, and, to combat hospital infection, a return to Lister's principle of complete desiccation of wound discharge and the application of an outer protective antiseptic bandage.

Perhaps we shall gain encouragement or consolation from William Clowes ( I 5 9 I ) : - -

" Hippocrates in his aphorisms, as Galen writeth sure, Saith four things are needfulto every kind of cure : The first faith be, to God belongeth the chiefest part, The second to the surgeon, who doth apply the art, The third unto the medicine that is Dame Nature's friend, The fourth unto the patient with whom I here will end. How then may a surgeon appoint a time, a day, or hour, When three parts of the cure are quite without his power."

R E F E R E N C E S

ANDERSON, D. S. (1828). Glasg. med. y., x, 205. CAMERON, H. C. (19o7). " O n the Evolut ion of W o u n d Trea tment during the last For ty

Years." Glasgow : James Maclehose & Sons. CHEYNE, W. W. (I885), "Ant i sep t ic Trea tment of Wounds . " London : Smith, Elder & Co. CLOWES, W. (1591). " Profitable and Necessarie Booke of Observations." DUNBAR, J. (1934). Glasg. med. ft., I22 , 239. GAMGEE, S. (I867). " Trea tment of Wounds . " London : J. & A. Churchill . HALFORO, A. C. F. (1928). " Lister Redivivus." Brisbane : Sapsford Bros. HUNTER, J. (1786-87). " Lectures on the Principles of Surgery." See Palmer ' s edition of

" The Works of Jotm Hunte r , " vols. I and 3, I837. London : .Longmans, Green & Co. LISTER, J. (1868). Brit . med. J . , z , 53. - - ( i87I). Brit. reed. ft., u, 225. - - (1893). Brit. med. J . , i , I6I . - - ( I 8 9 6 ) . Presidential Address to British Association for Advancement of Science,

Liverpool. SCHIMMELBUSCH, C. (1894). " T h e Aseptic Trea tment of Wounds . " London : H . K .

Lewis. SX'ME, J. (I848). " Principles of Surgery." London : John Murray. WOODALL, J. (I617). " T h e Surgeon's Mate . "