THE BEST SURGICAL DRESSING 
How to Prepare it and How to Use it 
WITH A CONSIDERATION OF 
BEACH’S PRINCIPLE 
OF 
BULLET-WOUND TREATMENT 
BY 
OTIS K. NEWELL, M. D., 
ASSISTANT DEMONSTRATOR OF ANATOMY AT THE HARVARD 
MEDICAL SCHOOL. SURGEON TO OUT-PATIENTS AT THE 
MASSACHUSETTS GENERAL HOSPITAL, ETC., ETC. 
BOSTON 
CUPPLES AND HURD 
94 Boylston Street 
1888 CONTENTS. 
Page 
Best Surgical Dressing .... 9 
The Use of Iodoform in Surgery : 
Part I. — On the general application of 
Iodoform in Surgery. . . . 17 
Part II. — Iodoform in the treatment of 
fresh and clean (aseptic) wounds, and 
neglected wounds and sores . . 51 
Part III. — Iodoform in the treatment of 
wounds and sores of a specific nature 96 
Beach’s Principle 121 
Beach’s Cases ...... 132 
Other Cases taken from Literature . 137 BEST 
SURGICAL DRESSING. BEST 
SURGICAL DRESSING. 
A somewhat extended and interested 
observation of the subject, among cases in 
private practice and at public clinics, has 
convinced me that but few of us have 
found time to become familiar with the 
true chemistry, physiological action, and 
best surgical use of iodoform. Four years 
ago I had daily opportunities to see results 
of the clinical tests which its use as a sur- 
gical dressing furnished at the clinic of 
Professor Billroth, and with much enthusi- 
asm I translated shortly after the admira- 
ble book by Dr. Mikulicz, so much quoted 
and criticised since its publication, on 10 
Best Surgical Dressing. 
“ Die Verwendung des Iodoforms in der 
Chirurgie.” 
In that part of the book treating of 
gunshot wounds I was greatly pleased to 
find that the method advocated by Mikul- 
icz was exactly that pursued by Dr. H. 
H. A. Beach, in his clinic at the Massa- 
chusetts General Hospital, at the time 
I had the privilege of acting as surgi- 
cal house-officer there, and, moreover, that 
some of Dr. Beach’s cases antedated those 
of Mikulicz and other surgeons quoted by 
him. At that time, however, the value of 
iodoform was in need of further confirma- 
tion, except at the clinics of Billroth, 
Mosetig-Moorhof and some few other 
operators, and the discussion of bullet 
wound treatment, through the Garfield 
case and other sources, had become some- 
what tedious and unprofitable. It was, 
therefore, decided to withhold the publica- 
tion of the present book for further devel- 
opments. Best Surgical Dressing. 
11 
I am now happy to say that the great 
value of iodoform, when properly used, has 
been proved beyond a doubt, and it is 
pleasing to quote from Professor Wolfler’s 
address on the “Progress of Surgery in the 
Last Decennium,” delivered before the 
Society of Physicians at Graz, on the 
26th of November, 1887, the following in 
regard to iodoform: “Iodoform does not 
really fulfil all the requirements of an anti- 
septic as we have named them, it is not 
soluble in water and is also not cheap.” 
“ That it has in spite of this held its place 
speaks all the more for its worth.” “ Un- 
like any other agent it is able to develop a 
continuous action ” (Dauerwirkung). “That 
it produces intoxication when used in large 
amounts there is no doubt, but only in 
quantities which for wound treatment are 
entirely superfluous.” “ It acts as a sort 
of wound-police (Wundpolizei) remaining 
quiet as long as the wound is aseptic, and 
first developing its action when decomposi- 12 
Best Surgical Dressing. 
tion appears.” “ It is thus explained why 
some bacteriologists designated iodoform 
as an entirely inactive agent, while practi- 
cal surgeons were praising it to the skies.” 
“ A strip of iodoform gauze, a wood-wool 
sack, and a bandage over this, is all that I 
use for any wound at my clinic.” “How 
far iodol is able to replace iodoform is as 
yet insufficiently determined.” 
When used to the best advantage, in the 
plain or adhesive gauze as made by Prof. 
Mikulicz, there is no trouble from its odor. 
A square yard of the gauze is sufficient for 
from twenty to fifty dressings. 
It is well to remember that the prac- 
tised surgeon of to-day seldom needs any 
dressing as far as the result in fresh 
wounds of operation is concerned, since 
there he almost invariably has a wound 
which goes on to complete union without 
any suppurative action. When, however, 
the wound comes to him in a septic condi- 
tion, or through some unavoidable accident Best Surgical Dressing. 
13 
becomes in its later progress a septic one, 
then the great desideratum is that form of 
dressing which will, since its insoluble 
basis is not rapidly diluted and washed 
away by the discharge, remain as a perma- 
nent protection to the surface exposed. 
For this purpose nothing thus far discov- 
ered, can stand comparison with iodoform. 
With the hope that I may substantiate 
this fact, for all to whom it will be of inter- 
est and value, I am sure that I can do noth- 
ing better in addition than to give my 
translation of Mikulicz’s book. I must 
apologize for the little revision that I have 
found time to give it, but with the excep- 
tion that the iodoform is now used mostly 
in gauze and but little in bulk, and that the 
tests then made of its antiseptic action 
would not be satisfactory to the bacteriolo- 
gist of to-day, I believe it contains much 
that will be valuable and interesting to 
every practitioner. THE USE OF IODOFORM 
IN 
SU%GE%Y 
BY 
DR. JOHANN MIKULICZ. 
Translated from Wiener Klinik, 1 Heft, 
January, 1882. PART I. 
ON THE GENERAL APPLICATION OF 
IODOFORM IN SURGERY. 
When about sixteen years ago the Lis- 
terian method of wound treatment began 
to be generally known, every surgeon who 
applied it thoroughly, was soon convinced 
that its results were decidedly uncommon. 
Compared with the former progress in wound 
treatment the advance was so great, that it 
is easily understood why there were many 
at that time who were convinced that the 
Listerian method accomplished all that lay 
within the compass of human reason, and 18 
Best Surgical Dressing. 
that further progress would be impossible. 
Science, however, knows no stand-still, and 
as the healing art rests upon a scientific 
basis, it must progress as long as it re- 
ceives the attention of thinking men. 
Those who regarded Lister’s great discovery 
as the creation of a higher genius did not 
venture to interfere with his method, and in 
part still adhere to its every detail. 
In their eyes it was an unwarranted risk 
to attempt changes or improvements. 
Those on the other hand who saw in it only 
the careful work and study of years, were 
convinced from the first, not that they 
honored the great master any the less, 
that the method like every other human 
production could be improved and simplified 
and in time, perhaps, replaced by something 
better. 
Thus it happened that a great variety of 
changes were soon tried. Many of these 
proved useless, but in time modifications 
were found and introduced, which led to Iodoform in Surgery. 
19 
simplification and improvement. First 
of all the silk protective was found to be 
unnecessary. Then instead of the costly 
Mackintosh, cheaper waterproof materials 
were taken, which served the same pur- 
pose. Furthermore, we learned by Bruns’ 
method to prepare the carbolic gauze in 
a more simple and convenient manner. 
Doubt was also raised in regard to the 
indispensability of catgut, and to-day we 
know that antiseptic silk prepared accord- 
ing to Czerny accomplishes in most cases 
the same ends, and in some is even to be 
preferred. 
Eight years ago many eminent surgeons 
began a war against the spray, which until 
that time had been regarded as one of 
the most important facts of the antiseptic 
method. A. Bidder, Trendelenburg and 
Von Bruns announced that they had for 
a number of years operated without spray, 
and obtained results equal to if not bet- 
ter than those of surgeons using it. I, also, Best Surgical Dressing. 
20 
warranted both by theoretical and experi- 
mental study, endeavored at that time to 
demonstrate that the spray might be left 
out of the antiseptic method without 
injury, and I see my conclusions verified 
to-day by an almost two years’ trial on 
Prof. Billroth’s clinic, where since March, 
1880, the spray has neither been used 
at operation nor dressing. Besides this, 
constant efforts were being made to sub- 
stitute for carbolic acid,'to which Lister 
assigned the first place, some other anti- 
septic. Nearly all the antiseptics under- 
went trial with more or less success, but 
still carbolic acid, notwithstanding many 
evil qualities, held its pla£e until recently. 
To thymol and benzoic acid only a very 
restricted application is to-day conceded. 
The chloride of zinc dressings recom- 
mended by Badeleben have as yet made 
no place for themselves. Latterly other 
antiseptics have been tried with very fair 
results, but they too have failed to find Iodoform in Surgery. 
21 
general approval. I will only mention 
the acetate of aluminum dressing recom- 
mended by Burow, and later by Mass, and 
the weak chloride of zinc solution which 
Tucker warmly recommends. 
All these efforts are to-day forced into the 
back-ground through Von Mosetig-Moor- 
hof’s introduction of iodoform in surgery. 
We have found in iodoform an antiseptic 
which, although it does not put carbolic acid 
entirely aside, is superior to it in many 
respects, and has therefore won a place 
in surgery which it will retain until some 
better medium is discovered. Iodoform 
especially replaces carbolic acid where the 
latter was used for dressing purposes, 
and is to-day the antiseptic for wound dress- 
ings. Then the carbolized gauze dressing is 
replaced by a better — the iodoform gauze; 
and of the entire Lister dressing nothing 
remains to-day but the principle, and that 
stands as unassailable as ten years ago. 
But I have anticipated. I will give 22 
Best Surgical Dressing. 
you in the following a summary of the 
experience thus far had with iodoform. 
This consists mostly of observations which I 
have made on the clinic, and under the 
guidance of my highly honored instructor, 
Professor Billroth. Further experience I 
owe to my department in the polyclinic 
and to my private practice. 
The iodoform treatment was introduced 
into Billroth’s clinic in the beginning of last 
year, and I had during that time numerous 
opportunities of making communications 
in regard to it. Once, at the first sitting 
of last year’s surgical congress at Berlin, 
later in a paper read before the Vienna 
Medical Society, and finally in an article 
published in the Berlin Klinische Wochen- 
schrift. That I now feel myself once 
more called upon to speak upon the 
same subject, and more fully, is due to the 
importance which iodoform has recently 
won in surgery. From the general interest 
which iodoform awakens not only in practical Iodoform in Surgery. 
*3 
surgeons, but as it should, in physicians 
also, a connected account of all that is known 
in regard to its application should not be 
without value to you. This splendid remedy 
can be applied in so simple a manner and 
with such satisfactory results in every day 
practice, that I consider it my duty to extend 
its use wherever possible. 
The history of iodoform is brief. It was 
although early known to chemistry, first 
introduced into the healing art some twenty 
years ago, when in 1862, Rhigini published 
the first pharmacological work in regard to 
it. It was first used by Nunn, Besmier, 
Fereol, Bozzi Zeissl and others, and with 
advantage in the treatment of different 
syphilitic sores, and in this direction is 
probably known to most of you as an excel- 
lent remedy. Later, Greenhalgh, Demar- 
quay, Volker and then Hisch and others 
used it for different gynaecological purposes 
and it was also given internally. Still reports 
in regard to it did not agree. In later years, 24 
Best Surgical Dressing. 
Moleschott, ( Wiener Medicinische WocJien- 
schrift, 1878, No. 24 and following,) after 
seeing many brilliant results again drew 
the profession’s attention to it. Neverthe- 
less, the remedy remained but little noticed, 
particularly by surgeons until Von Mosetig, 
by an article also appearing in the Wiener 
Medicinische Wochenschrift, placed it 
definitely in surgical treatment. Von Mose- 
tig at first used iodoform only for those 
wounds which had taken on fungous 
development, and recommended it merely 
as a remedy, which as well as an antiseptic, 
exerted in addition an anti-tuberculous 
action. 
After these announcements Prof. Billroth 
in Jan., 1881, introduced iodoform into the 
clinic, at first only for Von Mosetig’s pur- 
pose, that is the treatment of tuberculous 
wounds. 
We very soon found, however, that apart 
from this specific action, iodoform was an 
excellent antiseptic, and tried it for wounds Iodoform in Surgery. 
25 
of a different nature as well. Here too, it 
was of great service, so that we learned from 
time to time to apply it in ever-increasing 
directions. Since April of the preceding 
year all wounds, and particularly those from 
operation, are treated with iodoform. Von 
Mosetig later announced that he had before 
not only used it in the treatment of fungous 
joint and bone disease, but also with good 
results in the treatment of fresh wounds. 
VonMosetig’s early announcements drew 
forth much doubt and received at first but 
little attention. I was, therefore, on the 
ground of the experience at Billroth’s clinic, 
the first to confirm them. At the time of 
my first communication in regard to it, at 
Berlin, Gussenbauer was the only one who 
had also applied iodoform and he agreed en- 
tirely with me. From that time the remedy 
rapidly gained ground and scarcely ever 
has an improvement in the healing art 
found such rapid and universal acceptance. 
Already numerous announcements from 26 
Best Surgical Dressing. 
other prominent clinics have appeared, es- 
sentially confirming those of the Vienna cli- 
nic. I will mention besides Gussenbauer’s, 
those of Von Konig, Henry, Merkel, Leis- 
rink, Falkson, and Hofftmann. To some of 
these we will incidentally refer; at present 
let it suffice to say that aside from slight 
differences in regard to its mode of action, 
all of the authors give to iodoform the 
highest importance. 
Iodoform is a substance analogous in 
composition to chloroform, and contains 
according to the chemical formula about 96 
per cent of pure iodine. It is readily soluble 
in ether, fats and fluid oils, with more diffi- 
culty in alcohol, and only to a slight extent 
in water and saline solutions. After long 
standing iodine separates in substance from 
the ethereal and fatty solution. The physio- 
logical action of iodoform has thus far been 
investigated only by Moleschott, Hogyes 
and Binz. They have found that by what- 
ever method applied, it is taken into the Iodoform in Surgery. 
economy. Whether through the skin, a 
serous membrane or the subcutaneous 
cellulur tissue, salts of iodine are always 
to be found in the urine. These investiga- 
tors agree that the iodoform becomes dis- 
solved by the fatty substances of the body, 
that free iodine is gradually separated from 
this solution, and that this again becomes 
changed into iodine salts. The action of 
iodoform is then, according to this view, 
nothing but a protracted iodine action; being 
distinguished however, by the fact that 
the iodoform exerts no irritant action on 
the tissues and still acts very powerfully. 
I must here remark that iodoform gets 
into the system not only in the form of 
simple iodine salt but also as an organic 
combination and perhaps as pure iodoform. 
At least Professor Ludwig found in a case, 
to be mentioned later, which terminated fa- 
tally from iodoform poisoning, an unstable 
iodine combination in the internal organs. 
Binz and Hogyes have further found that 28 
Best Surgical Dressing. 
cats and dogs after administration of larger 
quantities of iodoform, die from paralysis of 
heart and respiratory functions, and fatty 
degeneration is found in their internal 
organs. 
Oberlander reports two cases of poison- 
ing in man. Both suffered from weak- 
ness, sleepiness, vomiting, irregular breath- 
ing and other uncomfortable symptoms, 
but recovered finally. I will later speak 
of two cases of iodoform poisoning observed 
on Billroth’s clinic. 
Of the local and general action of iodo- 
form, I can say the following, taken from 
my own observation and experience as well 
as that of others. 
Locally, iodoform is absolutely unirrita- 
ting. Under the iodoform dressing, wounds 
show still less reaction, if possible, than 
under the carbolic. On this account granu- 
lation appears to go on more slowly than 
with other dressings. 
From the time the wound is covered Iodoform in Surgery. 
29 
with iodoform it remains perfectly pain- 
less. I do not mean to infer that this is 
due to a specific anodyne action, as no 
antiseptic wound should be painful during 
the healing process. Iodine combinations 
are very soon taken up from the wound 
and appear to be transferred continually 
and as long as iodoform remains in contact 
with the wound. We have often been 
able, even after a few hours, to detect salts 
of iodine in the urine and saliva, and from 
that time to obtain daily during weeks a 
plain iodine reaction in these secretions. 
Appearances of a general action on the 
organism are completely absent during the 
application of small amounts. After 
applying large quantities to extensive 
absorption surfaces, light symptoms of 
intoxication appear, such as weakness, 
nausea, loss of appetite, and, although 
rarely, vomiting. These however, subside 
after from twenty-four to forty-eight hours, 
and give place to complete eupathy. 30 
Best Surgical Dressing. 
Although, as far as I am aware, dangerous 
symptoms of poisoning from the iodoform 
dressing have not been observed as yet, I 
am familiar with two cases from Billroth’s 
clinic which showed, after application of 
large quantities of iodoform, symptoms 
which were undoubtedly those of chronic 
iodoform poisoning. Both cases were 
weak, reduced children, operated upon for 
suppuration of carious hip-joints. In one 
case Prof. Billroth opened a large abscess 
connected with the joint, in the other I 
made the typical joint resection. The 
wound cavities were filled with iodoform 
(forty to one hundred and twenty gm.) 
The wounds healed splendidly, and the 
children were, during the first three weeks, 
in good condition, had appetite and slept 
well. In the beginning of the fourth 
week, however, slight signs of meningitis 
appeared, apathy, restlessness, staring 
glance, wide pupils, crying aloud, retrac- 
tion of the abdomen, somnolence and light Iodoform in Surgery. 
5' 
clonic cramps. Still there was no signifi- 
cant rise of temperature ; the pulse was 
one hundred and ten to one hundred and 
twenty, the muscles of the neck not con- 
tracted, and no loss of muscular power 
was demonstrable. At the end of the 
fourth week both children died, and the 
post-mortem examinations gave negative 
results. In the second case, as already 
mentioned, Prof. Ludwig found an unstable 
iodine combination in all the internal 
organs. In the first case no chemical ex- 
amination was made. We were con- 
vinced that both cases were chronic iodo- 
form poisoning, and to-day we are con- 
firmed in our opinion, as cases with similar 
symptoms have occurred elsewhere. Henry 
reports two cases from the clinic at Bres- 
lau, and Konig a case from his clinic. 
Henry’s two cases were, which is of spec- 
ial interest, adults, while Konig lost a 
child after a similar hip resection. Lat- 
terly other cases of iodoform poisoning 52 
Best Surgical Dressing. 
have been reported, in some of which 
quite long lasting delirium appeared. 
Since these experiences we have aban- 
doned the use of such large quantities as 
Von Mosetig formerly applied, and par- 
ticularly since finding that the same results 
are attainable with much smaller amounts, 
which from an economical standpoint as 
well, is not to be disregarded. With 
weak children it is particularly advisable 
not to apply iodoform in large quantity. It 
suffices to simply cover the wounds with a 
thin layer of iodoform or to cover or fill 
them with iodoform gauze alone. Al- 
though this here and there necessitates a 
somewhat more frequent change of dress- 
ing it reduces the danger of iodoform poi- 
soning to a minimum. At least I have lat- 
terly seen no signs of a suspicious nature. 
The dressing technique I will later speak 
of in full. 
It is very important for us to know more 
exactly the antiseptic properties of iodo- Iodoform in Surgery. 
form, and as no researches have as yet ap- 
peared in regard to it, I have made in con- 
junction with Dr. Paneth, a series of strik- 
ing experiments. 
33 
Allow me to make you familiar with the 
results of these experiments, as I consider 
it important for us to be familiar with the 
antiseptic action of a remedy before ap- 
plying it extensively. We ought to know 
exactly how far we can rely upon the anti- 
septic action of iodoform ; how far it is 
capable of replacing the antiseptics for- 
merly used—carbolic acid, etc., in order 
that we may assign to this excellent me- 
dium its proper work, and not let ourselves 
be led, through enthusiasm from otherwise 
brilliant results, into requiring more of 
iodoform than it is capable of performing. 
My experiments were proceeded with as 
follows : I took a series of fluids, which 
according to universal experience, form a 
favorite fostering soil for the development 
of germs. These fluids were, Pasteur’s 34 
Best Surgical Dressing. 
solution, one per cent, meat extract solu- 
tion, one per cent, malt solution, one per 
cent, peptone solution, alkaline urine, beef 
water, and diluted blood, (fresh ox blood 
diluted with an equal quantity of water). 
A large number of nutrient fluids was 
intentionally chosen because similar re- 
searches by other investigators have shown 
that different nutrient solutions bear differ- 
ent relations, not only to the germs, but to 
the various antiseptics, so that a very one- 
sided result is obtained if only one solution 
be used. As iodoform is only slightly 
soluble in the decomposable fluids, we had 
more difficulties to encounter than the in- 
vestigators who tested easily soluble anti- 
septics. I first saturated the above solu- 
tions by pouring them several times 
through a muslin filter covered with iodo- 
form crystals. I could assume that in this 
way each of the fluids had taken up as 
much iodoform as possible without carry- 
ing away any of it in substance. Iodoform in Surgery. 
35 
Each of the fluids was now put in a 
glass vessel, and placed in the breeding- 
oven. At the same time a corresponding 
number of glasses containing uniodoform- 
ized solutions — controlling solutions — 
were exposed to the warmth of the oven. 
The result was as follows : In some of the 
fluids, those apparently which had taken 
up a very small quantity of iodoform, 
the antiseptic action was nearly null. In 
others on the contrary, the beef water, and 
blood, namely, which contained more iodo- 
form proportionately, a delay in the devel- 
opment of germs and foulness was plainly 
proved. It is here worthy of notice that 
the characteristic iodoform odor, which 
was at first given out from all the fluids, 
disappeared from those first mentioned 
after a few hours — (iodoform is, as you 
know,a volatile substance), while in the last 
named it was demonstrable after twenty- 
four hours. 
From this series of experiments it fol- 3<> 
Best Surgical Dressing. 
lows that the iodoform taken up by the 
fluids in filtering was capable of exciting 
very little antiseptic action. This prob- 
ably being due to the rapid evaporation 
and decomposition of the small amount 
dissolved. 
In a second and third series of experi- 
ments, I mixed directly with the nutrient 
solutions a large quantity of iodoform. 
The fluids were well stirred every twelve 
and twenty-four hours, and in this way an 
excess of iodoform constantly maintained. 
The result was now essentially different. 
In most of the fluids the development of 
germs was completely arrested, in others 
it appeared only late and sparsely. It is 
important to mention that in all the fluids, 
even where slight germ development oc- 
curred, signs of actual decomposition failed 
completely. The beef water and blood for 
instance, remained constantly odorless, that 
is, they smelled only of iodoform. As is 
well known, the absence of signs of decom- Iodoform in Surgery. 
37 
position with slight development of germs 
is an occurrence often met with in the heal- 
ing of wounds. Germs are even found in 
faultless cases under the Lister dressing. 
They are harmless forms which would only 
be of importance where they might con- 
jointly give rise to decomposition. We can 
therefore say that where iodoform is mixed 
in larger quantities with a decomposable 
fluid, it exerts a weak but constant antisep- 
tic action. Its action is such that wher- 
ever iodoform is in excess, signs of decom- 
position are sure to remain absent. 
This action which answers for many pur- 
poses of wound treatment completely, is 
nevertheless for others wholly insufficient. 
From my experiments as well as my 
clinical experience, I can say that wherever 
it remains for a long time in contact with 
a wound, iodoform acts surely and power- 
fully, and in this direction deserves prefer- 
ence to all other antiseptics. As it does 
not irritate the tissues, it is adapted to every 35 
Best Surgical Dressing. 
form of wound. On the other hand iodoform 
lacks rapid, energetic, disinfecting prop- 
erties, so that in this direction it can never 
displace other powerful antiseptics. For 
many measures of antiseptic wound treat- 
ment, particularly disinfection of the hands, 
the operating field instruments and sponges, 
iodoform is not suited. We cannot there- 
fore, as yet, dispense with carbolic acid in 
the antiseptic wound treatment, and it 
would be a mistake to think of applying 
iodoform alone as an antiseptic. 
Antiseptic precautions before and after 
operation are to be carried out with the same 
care as formerly. Washing, brushing and 
disinfection of the operator’s hands, as well 
as the operating field should be done with 
the utmost exactness. The instruments 
and sponges, and the silk and drainage tubes 
should be disinfected with strong carbolic 
solution three per cent., and I would not, as 
yet, discontinue irrigation of the wound 
with five per cent, carbolic solution. The Iodoform in Surgery. 
39 
iodoform first reaches its application 
after the operation. 
We will now consider the manner in 
which iodoform is applied to wounds, and 
I will first speak of its application in 
general, and then pass to its particular ap- 
plication to wounds. Iodoform comes in 
the market in fine crystals, and can be used 
in that form. As a rule, however, it is 
much more efficient used as a powder, as 
in this form it comes in more intimate con- 
tact with the wound. Besides this, less of 
the powdered iodoform is needed and it is 
thus economical. 
The crystalline form is preferable only 
where it is desirable to directly cover a 
large wound and intoxication is feared; 
Giiterbock properly calls attention to the 
fact that the finely powdered iodoform, 
by its ready solubility and more intimate 
contact with the tissues, becomes much 
more rapidly and abundantly absorbed, 
and therefore gives rise to poisoning 
more readily than the crystalline. 40 
Best Surgical Dressing. 
As is well known, iodoform has a very 
penetrating odor, which to many is quite 
unbearable. Although the physician soon 
accustoms himself to it, it is none the 
less necessary to have regard for the 
patient, and cover or modify it with 
a correctant. According to my experi- 
ence, oil of bergamot is a good de- 
odorant, one drop of which, if thoroughly 
rubbed with ten gms. of iodoform will 
cover the odor decidedly. Von Mosetig 
recommends the Tonca bean for this 
purpose. Two beans split in halves if put 
in an air-tight vessel with about one 
hundred gms. of iodoform will cover its 
odor in a few days with the peculiar Tonca 
bean odor. If it is to be applied in large 
quantities, iodoform can be handled di- 
rectly with a spoon or spatula. If only 
as a thin layer, which suffices for many 
purposes, an ordinary pepper box arrange- 
ment is useful. The perforations should 
be made somewhat larger than usual, Iodoform in Surgery. 
as the iodoform, particularly that treated 
with oil of bergamot, easily stops up small 
ones. Should the object be to dust the 
wound with a very thin layer, it is best 
to use the iodoform duster, invented by 
my friend, Dr. Wolfler, and manufactured 
by Leiter, in Vienna. The same end is 
often accomplished by firmly wiping out 
the wound with iodoform gauze or cotton 
dipped in iodoform. In this way a quantity 
sufficient for many purposes adheres to 
the wound. 
If a completely open wound is in this 
way sufficiently covered with iodoform, the 
further dressing is as a rule very simple. 
An adequate amount of absorbent cotton 
and a piece of waterproof material are 
fastened over it with a bandage. It does 
not matter what sort of waterproof material 
is used. You can use rubber sheeting, 
oiled-silk, waxed-cloth or parchment paper, 
and even the cheap wax and varnish 
papers are sufficient. 42 
Best Surgical Dressing. 
Instead of cotton, ordinary jute may 
be used. In fact, it makes no great 
difference what is used for absorbent after 
the wound has been covered with iodoform. 
This sort of dressing, however, is only 
suited to open wounds which can be di- 
rectly dusted with iodoform, and is not 
adapted to wounds for union by first in- 
tention. If the wound is to unite by first 
intention, it is not covered with iodoform 
but properly drained and sutured, the iodo- 
form to be only embodied in the dressing. 
With small wounds of this kind which 
promise but little discharge, it is sufficient 
to cover a piece of absorbent cotton some- 
what larger than the wound area with iodo- 
form and fasten it on. To large wounds 
however, such as amputations, goitre and 
other large tumor extirpations, it is neces- 
sary to apply an iodoform dressing mate- 
rial which readily absorbs, and permits the 
passage through of the discharge, and is 
not so liable to plug the drainage tube Iodoform in Surgery. 
43 
openings, as the cotton. For this purpose 
iodoform gauze is best suited. 
Whoever has tried cotton exclusively as 
a dressing will have noticed that it only 
absorbs and allows the discharge to pass 
through it to a certain extent. Where 
large amounts of discharge should be ab- 
sorbed by the dressing, even the best ab- 
sorbent cotton refuses to be of service. 
This is clearly due to the fact that it acts 
as a filter. The pus and blood corpuscles and 
fine particles of tissue are retained in the 
close meshes, collect more and more, and 
finally pack together into a thick, impene- 
trable mass. And this happens at the very 
place where the largest quantity of dis- 
charge should pass through, that is, around 
the tube openings. As a result, the latter 
become easily stopped up, and retention 
of discharge is the unfailing consequence. 
The dressing-gauze does not posess this 
disadvantage. Its wide meshes permit the 
passage of all fine particles in the discharge 44 
Best Surgical Dressing. 
and therefore assure its even distribution 
throughout the dressing. It is not exactly 
necessary for the latter to consist of 
gauze alone. It suffices when the im- 
mediate vicinity of the wound is covered 
with a number of folds. This works like 
a wide sieve, and thereby insures a thorough 
distribution of the discharge. It also 
does not appear to me that hydrophyl 
gauze is indispensable, as the function of 
the gauze is not so much to absorb the 
discharge, as to allow it to pass readily 
through its meshes. As a result of these 
facts, since the first of this year all wounds 
intended for primary union, and latterly 
all wounds of whatever nature, at Billroth’s 
clinic have first been covered with a layer 
of iodoform gauze and then with an absorb- 
ent cotton dressing. The preparation of 
iodoform gauze, which by the way, was 
first made on Billroth’s clinic, is very 
simple, and as no particular apparatus is 
needed, can easily be undertaken by every 
physician. Iodoform in Surgery. 
A quantity (2-3 metres) of very loose 
undressed cotton, or gauze, should be loosely 
folded, handkerchief-like together, and laid 
in a washbasin which has been previously 
disinfected with a five per cent, solution of 
carbolic acid. Powdered iodoform should 
then be shaken over this from the powder-box 
and thoroughly rubbed in with the hands, 
which should likewise have been thoroughly 
disinfected. It should be done as if the 
material were being washed. When the 
iodoform has been disseminated as evenly as 
possible, the gauze should be finally shaken 
over the basin so that the superfluous powder 
may fall out. The gauze is now finished, 
and after being folded should be put away 
in closed vessels. Gauze thus prepared 
contains, according to the degree of shaking 
out after manipulation, anywhere from ten 
to twenty per cent, of iodoform. It always 
suffices where it is to serve as an occlusive 
dressing where, therefore, it is to replace 
the Lister. For many purposes, however, as 46 
Best Surgical Dressing. 
in the treatment of wounds connected with 
mucous tracts, it is desirable to use a gauze 
containing more iodoform, for through the 
abundant discharge occurring in some 
places, as in the mouth, it might happen 
that a considerable amount of iodoform 
would be washed out or carried away 
mechanically. For such purposes we have 
from the first used gauze prepared by Bruns’ 
method. First heating it with a solution 
of four parts resin, one part glycerine and 
one part alcohol. It is then dried and 
prepared like the weaker gauze. The 
iodoform adheres here in a much larger 
quantity, from thirty to fifty per cent., and 
more firmly, so that but a small proportion 
of it can be removed mechanically. A sec- 
ond advantage is that it is also somewhat 
stiff and adhesive. As a result of this, the 
strips of gauze used in filling a wound pack 
readily into an adherent mass, which is, 
nevertheless, completely permeable. It also 
adheres to the wound surface which is of Iodoform in Surgery. 
47 
particular advantage in certain localities 
where such tampons are apt to fall out. 
If a large wound is to be dressed, which 
should heal by first intention, a piece 
consisting of from four to eight layers of 
the ten to twenty per cent, gauze should be 
taken, and should be just large enough to 
overlap the wound a little, half an inch to 
an inch, in all directions. Over this comes 
a sufficient quantity of cotton and water- 
proof material and a bandage. This “io- 
doform-occlusion dressing” I will return 
to later. 
Iodoform staffs or suppositories (Bac- 
cilli’i Iodoformi) find extensive application. 
They are prepared by adding to iodo- 
form an adequate amount of cacao butter, 
mucilage and glycerine, or also gelatine. 
Thus : 
i* Iodoformi pulv. io.— 
Mucilag, Gummi Arab. 
Gljcerinse, aa — 
pauxill. ut fiat massa ex qua form baccilli — longit —  Best Surgical Dressing. 
48 
The same formula without glycerine gives 
very hard brittle staffs which are also 
useful. 
R. Iodoform pulv. 5. 
Gelatini 10. 
Form, baccili crassitud—longit— 
R Iodoform pulv. 
Butyri caco. 
aa part, aequ. 
These staffs are extremely useful for 
many purposes, as for instance, where it 
is desirable to introduce iodoform into 
fistulas, deep wound cavities and cavities of 
the body difficult of access, as the uter- 
ine, and that of the urinary bladder. 
As fluid I have applied iodoform in two 
forms. 
I. As etherial solution. 
R Iodoformi 5. 
yEther 25. 
D. ad vitr. cerul. 
In this form I have used it with good 
results as parenchymatous injection in 
fungous inflammation of joints. Iodoform in Surgery. 
49 
II. As suspension. 
ft Iodoformi pulv. 10. 
Ol. olivae 40. 
Glycerinas 80. 
D. S. Shake well before using. 
The suspension I have used for injecting 
into the nares, urinary bladder and into 
previously emptied cold abscess cavities. 
Of this I will speak later. Besides the 
methods of application already mentioned 
iodoform may be used as an ointment, one 
part of iodoform to ten or twenty parts of 
ointment. 
If it is here also desirable to deodorize, 
a few drops of some aromatic oil should 
be added such as, 01. Bergam., 01. Menthi, 
Lavand, or Cinnam. Auspitz reccommends 
carbolized iodoform ointment, which has 
but little odor. 
ft. Iodoformi pulv. 
Acidi carbol a 20. 
Ung. 150. 
The iodoform collodion recommended by 50 
Best Surgical Dressing. 
Moleschott is very useful and should be 
applied with a brush to the skin. It is 
especially useful for acute and chronic 
gland swellings, for neuralgia, and differ- 
ent kinds of inflammatory exudations. I 
also recommend it for lymphomata. PART II. 
IODOFORM IN THE TREATMENT OF 
FRESH AND CLEAN (ASEPTIC) 
WOUNDS, AND NEGLECTED 
WOUNDS AND SORES. 
Having become acquainted with the 
application of iodoform in general, let us 
now go more closely into its practical 
application to wounds. 
In order to have a clearer view, we will 
divide the different kinds of wounds into 
three main categories, in each of which 
the iodoform will have a different part to 
perform. 
A. Fresh and clean (aseptic) wounds. 
B. Septic, infected wounds and sores. 52 
Best Surgical Dressing. 
C. Wounds and sores of a specific na- 
ture, tuberculous, scrofulous, lupous and 
syphilitic. 
A. Fresh and clean wounds. In begin- 
ning with this category we must divide the 
wounds belonging to it into groups, namely, 
a. open wounds with loss of substance, 
mechanically unsuited for primary union ; 
b. wounds wholly or in greater part suited 
for primary union; c. those communicating 
with the peritoneal cavity; d. those com- 
municating with a mucous tract. To this 
last belong all wounds of the mouth, phar- 
ynx, nares, rectum, vagina and urethra. 
As most operation wounds, as well as 
accidental ones, so important to the practi- 
tioner, belong to these four divisions, I 
must still premise a little in regard to the 
antiseptic measures which should be strict- 
ly observed before putting on the iodoform 
dressing. 
That the spray is to-day to be regarded 
as superfluous, I have already mentioned. Iodoform in Surgery. 
53 
Now, especially, the practitioner can feci 
justified in abandoning its use. The ob- 
servance of all other antiseptic precau- 
tions, however, is so much the more neces- 
sary. 
The surroundings of the wound, and 
everything that is to come in contact with 
it, must be thoroughly disinfected with 
three per cent, carbolic solution, and if 
the wound be one for which the antisep- 
sis is vitally important, the five per cent, 
solution should be used wherever its cor- 
rosive action is not actually harmful. For 
the disinfection of instruments, I advise 
you to use the five per cent, solution. 
The greatest care should be taken with the 
sponges; they should be thoroughly washed 
in warm water, and soaked at least five days 
in five per cent, carbolic solution. If no 
reliable sponges are at hand, use cotton 
wads soaked in three per cent, carbolic 
solution for cleansing the wounds. Drain- 
age tubes should also have lain several 54 
Best Surgical Dressing. 
days in five per cent, carbolic solution be- 
fore being used. 
For ligatures use catgut, or what will 
probably be much more convenient, anti- 
septic silk, which should besides serve as 
the only material for sutures. This 
should be prepared according to CzCrny, 
by winding the surgical silk on spools, 
boiling it one hour in five per cent, car- 
bolic solution, and preserving in solution 
of the same strength. This silk produces 
no inflammatory reaction, and a ligature 
does not interfere with primary union. 
At conclusion of the operation, every 
wound should be irrigated with three per 
cent, carbolic solution. 
Still other details are always to be at- 
tended to, but their consideration here 
would lead me too far. 
Let us now consider the earlier intro- 
duced groups of wounds. 
a. Fresh open wounds. I begin with this 
sort of wound because owing to its sim- Iodoform in Surgery. 
55 
plicity the iodoform dressing can be best 
studied and judged with it. 
Let us imagine that we have removed a 
superficial tumor, and cut away so much 
skin that the wound be not at all, or but 
slightly brought together with sutures. 
You have before you an open loss of sub- 
stance which can only heal by cicatrization 
from the edges. Here the simplest sort 
of iodoform dressing, as I have before de- 
scribed it, is sufficient. A very thin layer 
of iodoform should be applied to the wound, 
and this covered with a sufficient amount 
of absorbent cotton, and then with a piece 
of waterproof material, (protective) and 
the whole fixed with an ordinary bandage. 
This dressing can be left on a week with- 
out causing trouble. If discharge appears 
at the edges during this time, it is simply 
necessary to add fresh cotton. 
At the first change of dressing a moder- 
ate amount of bloody, serous and almost 
odorless discharge is found. The iodoform 56 
Best Surgical Dressing. 
still clings quite firmly to the wound, which 
is not at all irritated and is entirely pain- 
less. The patient is from the time of the 
operation free from fever, never complains 
of pain, and feels well generally. By the 
next change of dressing, which is first nec- 
essary at the end of the second or during 
the third week, the entire wound is plainly 
cicatrizing from the edges towards the 
centre. The secretion is slimy, serous, 
and very small in quantity. The patient 
always thoroughly well. The iodoform 
dressing should now be replaced by an oint- 
ment under which the further cicatriza- 
tion goes on. 
In place of the powdered iodoform, iodo- 
form gauze may be used for the first and 
second dressings as in the following groups 
of wounds. 
In the manner described, I have seen a 
large number of cases, in part severe opera- 
tions, run a completely smooth course, and 
from this experience I can say in regard to 
the iodoform dressing the following : Pages 57-64 missing Iodoform in Surgery. 
65 
in similar cases. The first case was a com- 
pound fracture of the femur in a man of 
about fifty years, who had been kicked by 
a horse. The skin wound was on the 
outer side of the thigh and separated from 
the point of fracture by an enormous ex- 
travasation. As the wound was small and 
the fragments had protruded from it 
neither during nor after the injury, and I 
was on hand one hour after the accident, 
there was no ground for supposing the 
deeper parts to have been infected from 
without. I therefore contented myself 
with washing the wound and its vicinity 
with five per cent, carbolic acid solution, 
and clearing away only the superficial 
parts of the clot. I then dusted the wound 
with iodoform and applied the regular 
gauze dressing. Under two changes of 
dressing the wound was healed, and the 
further progress of the fracture went on 
without interruption in the extension 
apparatus. 66 
Best Surgical Dressing. 
The second case, a patient of eight years, 
was also kicked by a horse, the injury 
being on the front of the leg. I was 
called in consultation by my colleague, 
Dr. Klein, and arrived three hours after 
the accident. Both bones were broken 
at about the centre. Over the anterior 
surface of the tibia was a skin wound 
about seven centimetres long, through 
which both ends of that bone, denuded for 
a long distance of periosteum, protruded. 
The wound was covered with dirt and 
particles of horse manure. The clothes 
were also cut through. It was evident 
that a thorough debridement, according to 
Volkmann should be done. I therefore en- 
larged the skin wound, laid both ends of 
the tibia completely bare, removed bone 
splinters, cut off all projecting points, and 
washed the entire wound with five per cent, 
carbolic acid solution. The ends of the bones 
were then adapted. The skin wound, how- 
ever, only limited by two sutures at either Iodoform in Surgery. 
67 
end, so that there still remained, reaching 
down by the bared bones, an opening five 
centimetres long and one half to one centi- 
metre wide. This I filled with iodoform pow- 
der, and applied the regular iodoform dress- 
ing with a few turns of starch bandage. No 
drainage tube. The course was completely 
aseptic. No fever throughout. The dressing 
was changed but twice (on the ioth and 29th 
days). After six weeks the patient went 
about with splint and starch bandage. 
The third case was a revolver wound of 
the forearm in a boy of about ten years. 
The projectile about seven m.m. in diameter 
had grazed the ulna in the neighborhood 
of the elbow joint and lodged, according to 
my calculations, close to the interosseous 
membrane. 
I proceeded here exactly as in case num- 
ber one. The blood clot obstructing the 
shot canal was only superficially cleared 
away, the wound and vicinity washed with 
five per cent, carbolic acid solution, the 68 
Best Surgical Dressing. 
wound dusted with iodoform, and the regu- 
lar iodoform gauze dressing applied and 
supported by a splint. The first dressing 
remained on fully twelve days. On change 
of dressing, I found a small, cleanly granu- 
lating: wound. Neither local inflammation 
nor general reaction followed. The boy 
had during the recovery no considerable 
pain, and could move the arm quite freely 
after twelve days. 
I call your attention to the fact that the 
projectile was not removed, and also that 
no attempts at removal were made. This 
was intentional, as I think our principles of 
gunshot wound treatment must be with re- 
gard to modern antisepsis, essentially 
altered. First of all, we must hold fast to 
Esmarch’s principle of not disturbing the 
wound. All attempts at probing and ex- 
traction should be avoided. If something 
must be done, the most thorough antiseptic 
precautions should be taken. As all shot 
wounds incline to primary union, and the Iodoform in Surgery. 
69 
projectile does not interfere as a foreign 
body, the advisability of at once making 
attempts at extraction after every shot 
wound is questionable. Through the intro- 
duction of instruments into the wound the 
requirements of first intentions are much 
interfered with and danger is much in- 
creased. Bergmann and Reiher’s experi- 
ence in the last Russian campaign showed, 
that through purely conservative treatment, 
that is, avoidance of attempts at extraction, 
application of an antiseptic dressing, and 
immobilization of the wound in the simplest 
manner, the best results thus far have 
been attained. Bergmann observed one 
case in which even rags carried into the 
knee joint did not disturb the result, but 
healed in without reaction. 
More extensive experience must indeed 
be collected before we can advise universal 
avoidance of attempts at removal. Im- 
mediate extraction of the bullet will be often 
enough indicated. In general, however, I 70 
Best Surgical Dressing. 
would advise you to act according to the 
above principles. At first only pay atten- 
tion to the antisepsis and do not trouble 
yourselves about the projectile. You thus 
take the surest and simplest course. 
Should extraction later prove necessary, it 
is done under much more favorable circum- 
stances when the wound has completely 
healed, as youthen operate in healthy tissue. 
The bloody suffused parts around a fresh 
shot wound, not only make the operation 
much more difficult, but also increase ex- 
tremely the danger of septic and pyaemic 
processes. 
c. Wounds communicating with the 
peritoneal cavity. 
The iodoform treatment again proves its 
value when used after operations necessi- 
tating opening of the abdominal cavity. 
It has been used on Billroth’s clinic after 
numerous ovariotomies, hysterotomies and 
stomach and intestinal operations. As, 
however, laparotomies carried out on the Iodoform in Surgery. 
principles of to-day are but little influenced 
by the dressing, this experience is of slight 
value as regards the worth of the iodoform 
dressing. One of the first principles, as 
acknowledged by most surgeons, is to close 
the cavity completely, when possible, after 
operation. We, therefore, return the pedi- 
cle after ovariotomies and renounce drain- 
age, which, owing to the peculiar relations 
of the peritoneal cavity, is of doubtful 
value. As soon as we have completely 
closed the peritoneal cavity, the patient’s 
fate is decided, and the dressing has as little 
effect upon the recovery as most of the sup- 
plementary measures practised. In a trip 
made for study, three years ago, through 
France, England and Germany, I had am- 
ple opportunity to convince myself how 
important a role the dressing plays in 
laparotomies. With one ovariotomist the 
entire dressing consisted of a small piece 
of gauze, fastened on with two pieces of 
plaster. The other on the contrary applied 
71 72 
Best Surgical Dressing. 
a colossal occlusion-dressing taking in the 
entire abdomen and part of the thighs. 
Everywhere the healing process went on 
equally well, if all antiseptic rules were 
strictly observed during the operation. 
Although iodoform plays a less impor- 
tant part in laparotomies as a dressing, a 
manner of using it first indicated by Prof. 
Billroth, for certain difficult cases of ab- 
dominal operation, is of the greatest impor- 
tance, and may bring about new and great 
progress. 
As is well known, it is a serious compli- 
cation of all laparotomies when large 
wound surfaces are left behind in the peri- 
toneal cavity. Such surfaces are most 
dangerous in the deep portion of the cavity, 
the pelvis, namely. The great danger of 
this complication is recognized by all expe- 
rienced operators, and various measures 
have been adopted to control it, without our 
having found until now, a successful one. 
The danger consists essentially in the fact Iodoform in Surgery. 
73 
that the secretion from the large wound 
surface collects in the deep parts of the 
peritoneal cavity, easily decomposes, and 
leads to “spontaneous infection,” as I have 
named this sort of infection of the entire 
peritoneum. Owing to the peculiar rela- 
tions of the pelvic cavity, the aids other- 
wise applicable for the avoidance of such 
decomposition centres, “dead spaces,” 
namely, drainage and compression, can be 
applied but imperfectly. I published last 
year a detailed treatise in regard to this 
subject to which I refer those of you more 
nearly interested in it.* 
In severe cases of this sort Billroth 
proceeds as follows: After completing the 
peritoneal toilet, the large wound surface 
which often covers the entire small pelvis 
and part of the large, is dusted with a thin 
layer of iodoform, or simply wiped off with 
* I. Uber die Anwendung der Antisepsis bei Laparotomien, mit 
besonderer Riicksicht auf die Drainage der Peritonealhohle, (Von. 
Langenbeck’s Archiv. XXVI.) 74 
Best Surgical Dressing. 
some of the fifty per cent, gauze, whereby 
a certain amount of iodoform is left 
behind. 
The intestines are then immediately laid 
over this and the abdomen completely 
closed. The “ dead space ” thus left in 
the pelvis is supplied with a quantity of 
iodoform, which for a long time prevents 
decomposition, and consequently spotane- 
ous infection of the peritoneum. 
d. Wounds communicating with a 
mucous tract. 
Aside from the method of applying 
iodoform just described, we have as yet 
only considered wounds in which, at least 
as regards the result, the Lister dressing 
has reached the highest degree of perfec- 
tion, so that here a further progress has 
only been obtained through a more sim- 
ple technique, and a safer and cheaper 
dressing material, and we have preferred 
the iodoform dressing on these grounds 
only. Iodoform in Surgery. 
In the group of wounds now to be con- 
sidered, Lister’s method can be not at all 
or only very incompletely applied, as one 
of the principal conditions of the dressing, 
exact occlusion, cannot be carried out. 
As a result, we have until now, either been 
entirely unable to obtain an antiseptic 
wound course with such wounds, or have 
only done so by making use of the most 
complicated, and often untrustworthy, 
means. 
This was the case with most large 
wounds communicating with the mouth, 
nose, pharynx and intestines, and par- 
ticulary with those involving the rectum, 
vagina, bladder and urethra. 
I can say at once that in iodoform we 
possess the means with which to assure for 
wounds of this sort, just as certain an 
antiseptic course as the Lister enables us 
to for those that can be completely 
isolated, and that consequently the iodo- 
form treatment promises for this class of 76 
Best Surgical Dressing. 
wounds the same reform which the dis- 
covery of Lister introduced for the preced- 
ing groups. 
Let us next turn to wounds of the 
mouth and pharynx. 
Every surgeon knows how hard it has 
been to prevent decomposition of the 
saliva and wound discharge, even after a 
small operation in the mouth. What 
operator does not know the great danger 
to which every patient was formerly ex- 
posed, after extensive operations in the 
mouth. Precisely during the first and most 
important days it was hardest to prevent 
decomposition of the discharge, and there- 
with all the dangerous sequelae, such as 
septic phlegmon, wound diphtheria, degluti- 
tion pneumonia, pyaemia, etc. 
Let us now take as a special example, 
extirpation of lingual cancer, a more or less 
typical operation. How dangerous this 
operation formerly was is best told by 
Stromeyer’s familiar speech: “ Humanity Iodoform in Surgery. 
77 
loses nothing thereby if such operations 
are left undone, and surgery is not honored 
by them.” In Billroth’s clinic the mortal- 
ity after extirpation of lingual cancer, 
amounted during the years from 1871 to 
1876, to thirty-two per cent., and Von 
Bruns had during the same period a mor- 
tality of 37.8 per cent. 
Latterly the results appear to have con- 
tinually improved. With the aid of exact 
drainage, by thoroughly coating the mouth 
with permanganate of potassium, and 
frequently syringing day and night, the 
mortality was reduced, on Billroth’s clinic, 
from 1877 to 1880, in fifty-three operations 
to i7’.6 per cent. But still, this 
number was large enough, and the 
complicated after treatment very wearing 
for the patient and burdensome to the 
physician and attendants. The practice 
hitherto followed in the treatment of 
lingual cancer, you will find accurately 
described in an excellent paper by my 7^ 
Best Surgical Dressing. 
friend, Dr. Wolfler, which appeared last 
year in Von Langenbeck’s Archiv. 
XXVI. 
In Billroth’s clinic the iodoform treat- 
ment has latterly been carried out in 
eighteen cases of extirpation of the tongue, 
in part very extensive ones, all of which 
consecutively recovered ; a result until now 
unheard of. Their progress was absolutely 
aseptic and recovery occurred without 
complications, which from the extreme 
simplicity and convenience of the treat- 
ment, is of all the more significance. 
The after treatment is as follows: 
After the operation is completed, and all 
bleeding has been arrested, the mouth is 
syringed out with one per cent, carbolic 
acid solution. The wound is then filled 
with narrow strips of iodoform gauze, and 
these so well packed in that they adhere as 
a firm tampon. I have already remarked 
that the strong iodoform gauze, fifty per 
cent, previously impregnated with resin and Iodoform in Surgery. 
79 
glycerine is best adapted to this purpose. 
These gauze tampons cling closely to the 
wound from eight to ten days, and should 
be allowed to remain during this time. No 
drainage of the mouth is needed, no syring- 
ing, and no other treatment whatever. 
After eight or ten days the tampon becomes 
loose and is ejected by the patient entire, 
or in pieces, whereupon the wound should 
be again similarly tamponed for six or eight 
days. At the end of the second week a 
clean granulating wound is obtained. The 
course as stated, is a perfectly smooth one; 
above all the patients have no pain from 
the time of operation, and excepting dif- 
ficult deglutition, no serious inconvienence. 
If the operation was not too extensive, 
the patients are able in spite of the tampon 
to drink without hindrances, and even take 
solid nourishment. The majority are able 
to leave their beds as soon as the second or 
third day. There is absolutely no decom- 
position of the discharge, no trace of odor 80 
Best Surgical Dressing. 
from the mouth, no surrounding inflamma- 
tory action, no important rises in tempera- 
ture, and no bronchitis or pneumonia; in 
short such an ideal course as had, with such 
simple methods, scarcely ever been seen. 
A similarly smooth course is obtained 
with the iodoform treatment after all oper- 
ations in the mouth, namely, after resection 
of the upper or lower jaw, and further after 
operations in the pharynx, larynx and 
oesophagus. Here, too, the entire treat- 
ment consists in tamponing the wound with 
iodoform gauze, which mostly remains as 
long as after the already described tongue 
operation. I should remark that in many 
locations, as in the tonsillar region the tam- 
pons adhere less tenaciously and become 
easily loosened through efforts at swallow- 
ing. In such cases they should be fastened 
with thread and loops externally to prevent 
their being swallowed. If they become 
loosened they should be replaced by new 
ones every second or third day. Iodoform in Surgery. 
81 
The certain asepsis which iodoform 
assures in the nasal cavities as well, I ob- 
served in the following case : 
A patient with a very vascular sarcoma 
of the upper jaw was admitted into Bill- 
roth’s clinic. During examination of the 
nares, into which the ulcerated, readily 
bleeding growth protruded, such an abun- 
dant hemorrhage suddenly came on, that it 
was necessary to tampon. In attempting 
after several days to remove the tampons, a 
similar hemorrhage occurred so that tam- 
poning again became necessary, and this 
was similarly twice repeated. We could no 
longer afford to expose the extremely 
anaemic patient to the danger of further 
hemorrhages. I therefore allowed the tam- 
pons to remain fully two weeks without be- 
ing disturbed, until the patient had partially 
recovered from loss of blood. When I 
finally removed them, there had been no 
hemorrhage in the meantime, the iodoform 
gauze saturated with blood and slime was 82 
Best Surgical Dressing. 
entirely free from odor and had produced 
no inflammatory action. 
No less favorable are the results obtained 
with iodoform after operations on the rec- 
tum. Before all I recommend the remedy to 
you for the after treatment of the so frequent 
anal fistula (rectal fistula). In several 
cases, where it is necessary to make very 
extensive and high division, it is of partic- 
ular advantage. In all cases the fresh 
wound should be packed with the fifty per 
cent, gauze, and this allowed to remain from 
five to eight days, during which time the 
stools should be controlled with opiates. 
At the end of the first week the original 
gauze strips are passed with the first stool, 
and the dressing must then be changed after 
every movement. The strips remain odor- 
less and every sign of inflammation is absent. 
It must be very evident that patients in 
this way suffer scarcely any pain, and feel 
much more comfortable than when the 
dressing is changed daily. As soon as the Iodoform in Surgery. 
8i 
wound granulates well it is best to replace 
the iodoform with a salve dressing. 
Iodoform is also used with the best 
results after the serious and involving 
operations for cancer of the rectum. It 
would lead me too far to go more closely 
into the after treatment of these operations, 
which belong to the most difficult chapter 
of operative surgery. I will only remark that 
here the essential part of the iodoform treat- 
ment is to fill the spacious wound cavity 
with iodoform gauze tampons, and allow 
them to remain a long time, even over 
a week. This, too, without seeing the anti- 
sepsis disturbed, in spite of the passage 
of faeces. 
Two instructive cases from Billroth’s 
clinic show that an almost absolutely asep- 
tic course may also be obtained by the 
iodoform treatment in wounds connected 
with the urinary tract. They concern 
two patients with far advanced cancer of 
the penis. In less advanced cases Professor 84 
Best Surgical Dressing. 
Billroth had used the Thermo-cautery 
alone, but it was here necessary to dissect 
out the penis nearly as far back as the 
origin of the corpora cavernosa, and re- 
move the latter with the Thenno-cautery. 
A cuff-like skin flap was left, and there 
remained a circumscribed wound, sur- 
rounded for the greater part by loose 
cellular tissue, in the depths of which lay 
the urethral orifice. In both cases this 
cavity was simply filled with gauze, which 
in the second remained over a week. In 
the first case a catheter was used on 
the third day, and in the second none 
during the entire progress. The urine 
was from the first passed spontaneously 
by the patients, and drained through the 
gauze. Here also, all signs of decom- 
position, odor and inflammatory action 
were absent. The patients were able 
after a few days to leave their beds, and 
in the second week the wounds were filled 
with clean granulations. Iodoform in Surgery. 
Finally, belong in this category, wounds 
following gynaecological operations. In 
Billroth’s clinic, the after treatment of a 
series of uterine extirpations was also 
carried out with iodoform, and throughout 
an almost entirely smooth progress obtained. 
Iodoform is also valuable after other 
gynaecological operations. 
B. Septic Wounds and Sores. 
While the application of iodoform to 
fresh wounds is entirely new, it has been 
used by many surgeons and with the best 
results in the class of wounds now to be 
spoken of. Notwithstanding the fact that 
it presented eminent advantages for so 
many such cases in daily practice, the 
remedy obtained no general recognition. 
I will be permitted, therefore, to dwell 
somewhat longer than otherwise upon this 
group of wounds. 
Iodoform can be used for every septic 
wound, every ichorous sore, with great 
advantage, as it is able to arrest decom- 86 
Best Surgical Dressing. 
position in the shortest time. If you 
have such a wound or sore before you, 
it is only necessary to powder it with 
iodoform or cover it with the gauze, 
in order to check in the shortest time, 
often in a few hours, all local septic pro- 
cesses, and therewith cause all symptoms 
produced by them to disappear almost 
as rapidly. 
While as we know iodoform only acts 
locally, we must carefully observe that 
it comes in contact with all parts of the 
ichorous surface. Although it is a relatively 
weak antiseptic it works where this can 
be done as a result of the constancy 
of its action, more surely and rapidly than 
all other ever so powerful antiseptics, and 
at the same time offers the great ad- 
vantage of not irritating the tissues like 
the stronger ones. 
Iodoform is next to be recommended 
for all neglected wounds after accidental 
injury. The wound should be laid open, Iodoform in Surgery. 
$7 
cleansed, and dusted with it, and over this 
the iodoform dressing applied. As a rule 
on the following day every trace of odor 
has disappeared, the discharge lessened, 
and the pain mostly subsided. 
Particularly striking is the action of 
iodoform on gangrenous wounds. The 
demarcation and separation go on under 
its influence entirely without odor, even 
when putrefaction has preceded. The 
following case from Billroth’s clinic, was 
very instructive to me. 
A woman was bitten in the index finger 
by a squirrel, whereupon a phlegmon de- 
veloped within a few days, which extended 
to the forearm. After eight days the entire 
hand and part of the forearm were intensely 
swollen, and the index finger gangrenous 
up to the middle of the first phalanx. The 
patient had suffered intense pain for 
several days which refused to cease even 
after I had made abundant incisions and 
evacuated the foul smelling discharge from 88 
Best Surgical Dressing. 
the suppurating tissues. Two days after 
this I dusted the gangrenous finger as 
well as all the incision wounds with iodo- 
form, and after twenty-four hours all odor 
and therewith the pain had disappeared. 
The phlegmon was arrested and separation 
of the gangrenous finger went on without 
interruption. 
I treat the daily occurring felons and 
other paronychia, in the same way with the 
best results, and also subcutaneous phleg- 
mon of the extremities. In deep phlegmon 
iodoform strewn superficially upon the 
wound can exert no influence. In such 
cases after deep and free incisions, strips 
of iodoform gauze should be introduced 
into the deep-lying pus cavities. I would 
also advise, in addition, the use of that old 
and reliable remedy the poultice, and not 
to forget elevation of the extremity. 
In furuncle and carbuncle the incision 
openings should be filled with iodoform 
powder or packed with thin strips of the Iodoform in Surgery. 
89 
gauze. If the surrounding parts are much 
infiltrated a poultice should also be applied. 
In a case observed on Billroth’s clinic, of 
anthrax of the chin and under-lip, recovery 
took place very rapidly under this treat- 
ment. I have further cured a phagedenic 
ulcerative process in a man of sixty years, 
which involved half a finger and part of the 
skin on the dorsal surface of the hand, and 
had resisted all other treatment. (Repeated 
cauterization, anti-syphilitic cures, etc.). 
Experience fails me as to whether iodo- 
form is capable of bringing once started 
erysipelas and wound diphtheria to a stand- 
still. As it only acts locally it can exert 
but little influence on the first named. 
In the treatment of neglected ulcers 
of the leg, iodoform is of great value. I 
saw it used for this purpose two years and 
a half ago by Lister, who described it as 
the most powerful and certain antiseptic 
for these cases. The ulcer should be pow- 
dered with iodoform or covered with the 90 
Best Surgical Dressing. 
gauze, and the requisite amount of absorb- 
ent cotton fixed over this with moderately 
firm compression. As a rule a clean ulcer 
will be obtained after several days, and this 
without the patient keeping his bed. This 
is the chief object of the iodoform treat- 
ment in these cases. The formation of a 
firm cicatrix must be aided by other means, 
principally mechanical. I have latterly 
used for this purpose, Martin’s bandage al- 
most exclusively. It is splendidly adapted 
to the out-patient treatment of this com- 
mon trouble. 
The use of iodoform is further to be 
recommended for foul new growths, such as 
carcinomata of different regions, which on 
account of the abundant secretion of a 
foul-smelling discharge are often such an 
affliction to the patient as well as those 
about him, and of the greatest trouble to 
the physician. The disinfection of such 
inoperable cases of cancer of the breast, 
penis, tongue and elsewhere, may be ac- Iodoform in Surgery. 
9i 
complished by using the iodoform powder 
or gauze. For rectal, uterine, and vaginal 
cancer, suppositories and pessaries of iodo- 
form and But. Cacao, or gelatine with addi- 
tion of morphia are useful. Within twen- 
ty-four to forty-eight hours the offen- 
sive odor and in part the pain disappear, 
which is a great relief to the patient and 
all concerned. Here you must also be sure 
that the iodoform actually comes in contact 
with the wound surface. The iodoform 
odor also may be covered with ethereal oils. 
The preceding is not only to be rec- 
ommended for inoperable cases but also for 
operable ones, as preparatory disinfection. 
Efforts at preparatory disinfection of the 
operating field in the neighborhood of foul 
tumors, as in the mouth, vagina, etc., were 
also successful formerly but never in so 
simple a way as with iodoform. 
Finally, a description belongs in this 
place of the application of iodoform to cav- 
ities of the body which have become the 92 
Best Surgical Dressing. 
seat of inflammatory and suppurative pro- 
cesses. I first recommend it to you in the 
operative treatment of pyothorax. You 
will best understand the manner of using 
and the action of iodoform in this disease 
by the introduction here of two cases which 
I will now describe. 
One case from my private practice was 
a high degree of empyema which ap- 
peared spontaneously in a boy of ten years 
after a left-sided pleurisy. The patient 
was, after a ten weeks’ duration of the dis- 
ease, extremely reduced, and thoracentesis 
thrice performed by another surgeon, had 
had no effect upon it. Called in consulta- 
tion by Dr. Wonka I performed, according 
to the rules which through the efforts of 
Konig are established for the present, re- 
section of a part of the seventh rib in the 
axillary line, drained and applied an iodo- 
form dressing. In addition to this, how- 
ever, I introduced into the pleural cavity, 
twice weekly, an iodoform staff prepared Iodoform in Surgery. 
93 
after a previously given formula. The se- 
cretion diminished continually, after the 
second week lost its pussy character entire- 
ly, and was always odorless. The patient, 
before always feverish, remained from the 
time of operation without fever. After six 
weeks the opening was completely closed, 
the highly compressed lung again mostly 
expanded, and the heart previously much 
pressed to the right, once more in its nor- 
mal position. The patient gained during 
this time about five and one half kilos. I do 
not mean to infer that recovery would not 
have occurred in this case without the use 
of iodoform ; the certainty of the course is 
however, according to my convictions, de- 
cidedly assured by it. 
The second case from Billroth’s clinic, 
was a pyothorax of six years’ standing, re- 
sulting from a stab wound. When the pa- 
tient came to the clinic there was a sinus 
which had existed during this time and 
which led into a spacious cavity filled with 94 
Best Surgical Dressing. 
foul-smelling secretion. A long incision 
was also made in this case, the rib resected, 
drainage applied, and iodoform staffs simi- 
larly introduced twice a week. The dis- 
charge had become free from odor even 
after forty-eight hours. Complete recovery 
did not indeed take place here so rapidly ; 
but that was scarcely to be expected after 
the long duration of a cavity with unyield- 
ing walls. The case only goes to show 
that even under such unfavorable circum- 
stances, iodoform can develop its rapid and 
energetic action. 
I have further made use of iodoform in 
two cases of purulent cystitis. After other 
remedies had been followed by no great re- 
sults, I introduced a small iodoform staff 
through the urethra into the bladder. With 
females this can be done directly with the 
aid of small dressing forceps, in males the 
staff is to be pushed in by the after follow- 
ing catheter. In both cases the previously 
ammoniacal urine became on the third or Iodoform in Surgery. 
95 
fourth day free from odor and acid in reac- 
tion. 
Finally, it may be mentioned that iodo- 
form staffs are used for the uterine cavity 
by obstetricians and gynaecologists. The 
staff is introduced through the cervical ca- 
nal into the uterine cavity, where it soon 
liquefies, so that the uterine walls are every- 
where brought into contact with iodoform. 
This application for prophylactic purposes 
should also be followed by good results af- 
ter obstetrical and gynaecological opera- 
tions, and also in already existing endome- 
tritis. PART III. 
IODOFORM IN THE TREATMENT OF 
WOUNDS AND SORES OF A 
SPECIFIC NATURE. 
C. Wounds and sores of a specific na- 
ture. (Tuberculous, scrofulous, lupous and 
syphilitic.) 
Thus far we have studied iodoform only 
as an antiseptic, and for this property alone 
have given it preference as a dressing 
material. We now come to a class of 
wounds upon which, besides its antiseptic 
action, it exerts a more or less decided 
specific, healing influence, an advantage 
which has not been shown in so striking a 
manner by any other antiseptic. That iodo- Iodoform in Surgery. 
97 
form acts remarkably well upon sores in 
syphilitic tissue, and brings about recovery 
more quickly and surely than many of the 
remedies formerly used, syphilologists have 
already acknowledged, so that fresh evi- 
dence in this direction is scarcely needed. 
I refer you to the already mentioned arti- 
cles by Nunn, Besnier, Ferial, Lazansky, 
Bozzi, Zeissl, Maracek and many others. 
We will, therefore, at once consider the 
action of iodoform upon wounds and tumors 
in tuberculo-scrofulous tissue, and first 
of all in cases of scrofulous joint and bone 
inflammations. As is well known, fun- 
gous bone and joint diseases are regarded 
to-day according to the prevailing view, 
that of Volkmann, as local tuberculoses, 
which are simultaneous expressions of a 
general tubercular dyscrasia. Although 
the discussion held over tuberculosis at 
last year’s Berlin surgical congress proved 
the views in regard to this question to be 
still far from clear, the fact still remains 98 
Best Surgical Dressing. 
that these joint diseases stand in very close 
relation to tuberculosis. Modern en- 
deavors to hasten recovery through opera- 
tive interference, that is, extensive resec- 
tion and scraping out of the parts, are 
therefore a priori completely justified; since 
the introduction of the antiseptic wound 
treatment we have been able to undertake 
such measures with little danger, and have 
therefore hoped with the aid of the Lister 
dressing, to cure bone and joint tuberculo- 
ses in the earlier stages, more quickly and 
certainly. 
Unfortunately these early expectations 
proved to be unwarranted. Konig was the 
first to prove by his experience with a large 
number of cases that extensive resection of 
tuberculous joints did not in general lead 
to brilliant results. He communicated, in 
the last but one of the Berlin surgical con- 
gresses, 117 cases of extensive tuberculous 
joint resections performed antiseptically, 
in the course of four years. He watched Iodoform in Surgery. 
99 
the further progress of the cases not only 
for the following months, but during 
several years, and came to the conclusion 
that the operation performed antiseptically 
exerted no essential influence upon the 
later course of the disease, and especially 
that the carbolic acid did not act upon the 
tuberculously diseased tissue. 
Unfortunately, every surgeon must agree 
with Konig’s decision. Who has not again 
and again experienced, that under the car- 
bolic dressing the healing starts brilliantly, 
but that after a few weeks, and even as early 
as a fortnight, the granulations become fun- 
gous in character, or the young cicatrix 
breaks down to make way for fungous 
masses springing up from beneath. 
Furthermore, Konig proved, as far as his 
limited number of cases warranted a conclu- 
sion, that the antiseptically performed op- 
erations produced no effect on the mortal- 
ity. The number of patients who died later, 
of tuberculosis and other resulting diseases, 100 
Best Surgical Dressing. 
was for the short period so great that it, at 
least, corresponded with Billroth’s record of 
mortality for victims of joint caries. 
As regards the question of local cure as 
well as that of general infection, Konig’s ex- 
perience appears to speak decidedly against 
early resection, much as we would wish 
through it to prevent general infection by 
the earliest possible elimination of the tu- 
berculous process. Considering the old 
experience that in so many fungous bone 
and joint diseases, especially in children, 
spontaneous recovery occurs, we must des- 
ignate the necessity of early operation, at 
least for a series of cases, as doubtful; and 
indeed I believe that iodoform also can 
hardly cause any essential change in this 
particular. Where and to what extent fun- 
gous joints should be resected will best be 
decided in the future, after learning wheth- 
er the later function of the limb is best after 
resection, or purely conservative treatment. 
In Billroth’s clinic for years, all cases where Iodoform in Surgery. 
IOI 
operative interference was not absolutely 
indicated, have received only conservative 
treatment; that is, spontaneous recovery 
has been aided by mechanical helps, such 
as extension, immobilization, supports, etc. 
The relations are different, however, in 
those cases where abscesses threaten to 
break through, or have already done so ; 
where sinuses exist, or extensive disturbance 
in the bone and joint is evident. Here, 
even the surgeon devoted to purely conser- 
vative treatment must interfere in some 
way. Still such cases have unfortunately 
thus far given no great satisfaction. In 
spite of the strictest antisepsis, primary 
union of the soft parts very often fails to 
take place, and extensive operation there- 
fore promises but little success, and often 
becomes dangerous. In addition, is the fact 
that with weak patients, children namely, 
there is danger of intoxication from a too 
intense action of the carbolic acid. Thus 
it happened, that we limited ourselves in 102 
Best Surgical Dressing. 
these cases mostly to curetting and re- 
moval of sequestra. In short, to slight op- 
erative measures, and as our former anti- 
septics did not affect the character of the 
tuberculous granulations, and a cavity sur- 
rounded by bony walls was from mechani- 
cal causes able to heal but very slowly, we 
were often driven in the end to amputation 
as the only radical aid. 
To-day the state of affairs is essentially 
changed, as we possess in iodoform a medi- 
um, which in its antiseptic action exerts a 
special influence on tuberculous tissue, and 
brings about the development of healthy 
granulations which heal like those in nor- 
mal tissue. 
There can no longer remain any doubt 
as to the very favorable action of iodoform 
upon tuberculously diseased tissue, as to- 
day, besides Von Mosetig’s original obser- 
vations and the experience on Billroth’s 
clinic, other harmonious communications 
from prominent surgeons lie before us, and Iodoform in Surgery. 
103 
I can therefore omit the introduction here 
of a series of striking cases as proof thereof. 
Differences of opinion are only possible in 
regard to the explanation of this peculiar 
action. Konig,* for instance, does not be- 
lieve that iodoform exerts any specific anti- 
tuberculous action upon the granulations, 
but that the influence is due to the general 
and peculiar antiseptic action of the drug. 
Which explanation is correct, will have to 
be decided by further research. From a 
purely practical standpoint, however, this 
is of little importance, and we may satisfy 
ourselves, meanwhile, with the generally rec- 
ognized fact that iodoform is at present the 
best dressing for fungous bone and joint 
diseases. 
Through Von Mosetig’s discovery, many 
cases of this disease have become amen- 
able to treatment, and by such simple means 
that every practical physician can make use 
of them. The simplicity does not refer to 
* Centralblatt fur Chirurgie, 1881, No. 48. 104 
Best Surgical Dressing. 
the technique of the dressing alone, but to 
the operative measures as well, the proper 
performance of which depends neither upon 
close attention to fine anatomical points nor 
particular manual dexterity. 
Let us imagine one of the most fre- 
quent cases of this sort — a fungous 
disease of the ankle joint. At one point 
the skin is bluish red and thin, beneath 
it is found a plainly fluctuating abscess. 
The instruments needed for operation are 
a scalpel, curved scissors, two retractors 
and a large and small curette, and it is 
well to keep at hand for emergency, artery 
forceps and ligature director, hooked 
forceps, dissecting forceps, dressing for- 
ceps, and needle with suture; still, as a 
rule, they will not be needed. 
The patient is anaesthetized and it is 
also well to empty the extremity of 
blood, as everything can be much better 
seen, and the entire operation performed 
without losing a drop of blood. To anaema- Iodoform in Surgery. 
/05 
tize it is not necessary to envelop the 
entire extremity with an elastic bandage, 
it suffices to suspend it from three to 
five minutes until it becomes entirely pale, 
and then bind it securely at the proper 
place with an elastic bandage. Antiseptic 
precautions must here also be strictly ob- 
served by washing the operating field 
with soap and water, and then disinfecting 
with three to five percent, carbolic solution. 
The operator’s hands should be similarly 
treated. Instruments should come from 
a five per cent, carbolic solution. For 
cleansing the wound it is best to use 
cotton wads which have been soaked in 
three per cent, carbolic solution and then 
squeezed out. 
You now open the abscess throughout 
its extent, let the wound flaps be held 
back with retractors, and at once take 
in hand the curette, which is the main 
instrument in this operation. With it 
you scrape away from the bone and soft Best Surgical Dressing. 
106 
parts all fungous matter, until you come 
everywhere upon sound tissue. You 
need not fear removing too much with 
the curette as only the diseased tissue 
gives way to it. Healthy tissue resists 
this instrument, and it is therefore 
very easy to define with it the boundary 
line between healthy and diseased tissue 
in bone, as well as in soft parts. If the 
primary incision was too small do not 
hesitate to enlarge it upon the director 
in the required direction, as you thus get 
a clear view of the entire diseased mass 
and can reduce the wound later with 
sutures. Now take the curved scissors 
and cut away all ragged pieces in the 
wound cavity as well as the thin edges 
of the skin flaps. If you find a small 
sequestrum in the wound, which is often 
the case, remove it with the curette or 
dressing forceps. 
If you have a sinus and not a closed 
abscess to deal with, enlarge the wound Iodoform in Surgery. 
from it as a starting point, and proceed 
in the same manner. 
If the wound was very extensive, unite 
it at the ends only, with one or two 
stitches, and always leave an opening 
corresponding in size to the wound 
cavity. 
The course of the operation is essen- 
tially the same whether you undertake 
to scoop out a small circumscribed mass, 
or remove disease involving the whole 
joint. Extensive surgical measures are 
only necessary in advanced degeneration of 
the larger joints, and they then consist 
as a rule of the typical resections, and 
require a sure operative technique. 
The after treatment also is the same. 
If you have a small wound before you, 
it is best to fill it with iodoform powder. 
Large cavities on the contrary, I advise 
you only to tampon with strips of iodo- 
form gauze and allow the ends to pro- 
trude from the wound. Drainage tubes 108 
Best Surgical Dressing. 
are mostly superfluous. Entire filling of 
the wound cavity with iodoform powder 
would too easily expose the patient to 
•the danger of poisoning. 
The remainder of the dressing consists 
of absorbent cotton, a water-proof material 
(protective), and a bandage. If you have 
operated under local anaemia, you must 
put on the dressing with considerable 
compression before loosening the elastic 
bandage, and suspend the extremity from 
one fourth to one half an hour, whereby 
you can almost always prevent serious 
after bleeding. 
The further progress is very simple. 
Above all the healing process is entirely 
aseptic, which can scarcely surprise you 
now that you know iodoform sufficiently 
as an antiseptic. Excepting slight rises 
of temperature in the first few days, the 
local and general reactions are practically 
null. In the first dressing you find the 
discharge to be quite abundant and bloody, Iodoform in Surgery. 
but it is afterwards very moderate, serous 
in character and free from odor. The 
patient suffers no pain and feels generally 
well. The dressing needs to be changed 
at most but once a week. In short, the 
wound healing goes on almost as in normal 
tissue. You now notice from one dressing 
to another that the gauze is being grad- 
ually pushed out of the wound, which is 
correspondingly filled with granulations. 
At first the iodoform and gauze cling quite 
firmly to the wound surface, but can how- 
ever, as a rule, be easily removed by the 
second week, and we find beneath them 
clean beautiful granulations. According to 
its size the wound is filled in from two to 
six weeks, and recovery is in most cases 
thereby assured. Here, too, the iodoform 
dressing is generally replaced towards 
the end by a salve dressing and ad- 
equate stimulation. 
The rapid filling of cavities in carious 
bone under the iodoform treatment is Best Surgical Dressing. 
110 
particularly astonishing. Formerly al- 
though superficial defects of bone healed 
readily by drawing in and fixation of 
the surrounding soft parts, central cavities 
in carious bones and joints defied all 
methods, and the most favorable cases 
lasted months and even years before re- 
covery ensued. Under the effect of iodo- 
form, however, such cavities often fill 
rapidly so that here also recovery follows 
as if the defect were in normal tissue. 
With similar results iodoform can be ap- 
plied to other tuberculous and scrofulous 
diseases amenable to surgical treatment. 
Next of all, in superficial cold abscesses 
in different regions. These should be 
thoroughly opened, the abscess scraped out, 
the cavity dusted with iodoform, sewed up 
in part, and an iodoform dressing applied, 
drainage being inserted in large cavities. 
You proceed similarly and with like results 
with suppurating lymph glands, tuberculous 
masses in the testicle, in the neighborhood 
of the rectum, and elsewhere. Iodoform in Surgery. 
Ill 
After such experience it is easily under- 
stood why most surgeons are inclined to be- 
lieve that iodoform exerts a specific action 
on tuberculously diseased tissue, that is, 
changes it into healthy tissue, and thus acts 
to a certain extent as an anti-tuberculotic. 
The objection might now be offered, that 
as in nearly all cases the fungous masses 
were first removed by operative means, 
there could be at most allowed to iodoform 
the property of preventing quick recurren- 
ces. At Billroth’s clinic we also indulged 
at first in the same reflections, and on that 
account applied iodoform directly to fun- 
gous granulations and tuberculous abscess 
membranes, without preparatory curetting. 
A specific action was shown nevertheless 
here, as clean granulations formed very 
soon under the iodoform. 
That this method of treatment is not ad- 
hered to is owing to the fact that recovery 
occurs more slowly without previous me- 
chanical removal of the fungous masses. 112 
Best Surgical Dressing. 
The action of iodoform is, in fact, accord- 
ing to my experience only local, that is, 
exerted only upon that tissue with which it 
comes in direct contact. Von Mosetig in- 
deed observed in some cases a distant 
action, that is an influence upon distant 
diseased masses, but I have not yet been 
able to confirm this. On the contrary, I 
observed in several cases the appearance 
of new fungous masses even in the imme- 
diate neighborhood of the applied iodoform, 
which speaks decidedly against its having 
any general action. We were also unable 
at Billroth’s clinic to verify any general 
anti-tuberculous action. During the iodo- 
form treatment one individual died of pul- 
monary tuberculosis, and another of tu- 
bercular meningitis. 
The specific action of iodoform as well 
as being purely local is limited as to time. 
The remedy acts only as long as it remains 
in contact with the tissue, and, as I have 
unfortunately experienced, does not surely Iodoform in Surgery. 
"3 
prevent recurrences. I say unfortunately, 
because we at first indulged in the hope 
that by the iodoform treatment every fun- 
gous process would be ended once and for all. 
I must also not conceal from you the fact 
that there are many cases of severe caries 
which resist the iodoform treatment en- 
tirely. Improvement indeed shows itself 
at first, clean granulations develop, and the 
discharge lessens, but absolute healing 
does not take place. I emphasize this in 
order that you may not allow yourselves to 
be misled by your faith in iodoform into 
treating a joint entirely disorganized by 
caries, conservatively, instead of amputat- 
ing at once. Even the iodoform treatment 
has its limits. 
In conclusion, gentlemen, I should like to 
describe a twofold method of applying 
iodoform, first introduced by me, which 
does not relate to its use as a dressing, but 
more to its anti-tuberculous action. My 
purpose was, mainly, to make use of the 114 
Best Surgical Dressing. 
specific action of iodoform in inflammatory 
tuberculous processes which had not yet 
led to external opening. The results of my 
efforts have thus far been so favorable that 
I can give you my method in brief and 
recommend it to you. 
I first had in mind the early stages of 
fungous joint inflammations, which manifest 
themselves through diffuse or circumscribed 
spongy infiltration, and are followed later by 
serious and lasting disturbance of function. 
Should it succeed to inject iodoform in a 
suitable manner into such infiltrations, it 
ought to be possible to thus bring the pro- 
cess to an early termination, or at least pre- 
vent its further progress. I, therefore, 
made parenchymatous injections of iodo- 
form and used the etherial solution, (1-5) of 
which, half a hypodermic syringeful was in- 
jected twice a week into the fungous masses 
and the joint itself. The injection produced 
a brief, sharp pain, and was as a rule, accom- 
panied at first by slight local reaction, in- Iodoform in Surgery. 
"5 
creased swelling and tenderness. After the 
fourth injection, I noticed in three cases 
rapid diminution of the tumor and decreased 
tenderness. In four or five weeks the joints 
were much less swollen, but little tender, 
had slight motion, and as far as my obser- 
vations reached, remained so afterwards. 
Let me here say that, according to my 
view, this sort of treatment is only suited 
to fresh cases of tumor albus where the fun- 
gous masses are still solid and sufficiently 
vascular to admit of absorption of the dis- 
integrated or liquified tissue elements.' 
When the fungous masses have already be- 
gun to soften, or even abscesses are present 
I believe the parenchymatous injections to 
be no longer suitable. At least, in three 
such cases where I made the experiment, I 
observed that the process as such was not 
influenced, but on the contrary, accelerated. 
In such cases it is surely more judicious 
to at once decide upon opening, scraping 
out, and the open iodoform treatment. 
My second experiment was made in the 116 
Best Surgical Dressing. 
treatment of cold abscesses with iodoform, 
and I had above all to deal with the typical, 
and unfortunately, not rare abscess of the 
thigh, connected with suppuration in the 
pelvis. Although the abscesses become 
very burdensome by their often immense 
size, it is on good grounds that we reluc- 
tantly decide to open them. With the ab- 
scess the patient can get about after a 
fashion, but with the antiseptic dressing 
after opening, not at all. 
In the first case of this kind, I proceeded 
as follows: I punctured and emptied as 
thoroughly as possible, with Dieulafoy’s as- 
pirator, an abscess larger than a child’s 
head, situated on the inner side of the thigh, 
beneath the genito-crural fold, and injected 
one hundred gm. of the earlier mentioned 
suspension of iodoform in glycerine and oil, 
(Iodorf. io., Glyc. So., Oil olive, 40.) Over 
this was applied a firm compression band- 
age of adhesive plaster. The patient who 
was treated as an ambulant, felt from the Iodoform in Surgery. 
117 
time of puncture much relieved, and was 
able at once to go on with his work. The 
adhesive bandage was thrice renewed, and 
after four weeks the patient wore only a 
simple bandage. The abscess cavity did 
not entirely disappear, but remained re- 
duced to about the size of an apple, and re- 
mained so as long as the case was under 
observation (seven weeks). 
The second case, a similar one, presented 
an abscess almost twice as large, which a 
former nurse from Billroth’s clinic had car- 
ried on her thigh for nine months. The 
proceeding was here gone through with 
three times, at intervals of about four weeks. 
The abscess grew considerably smaller af- 
ter each puncture and iodoform injection, 
and since the last one, the original cavity, 
twice as large as a child’s head, has been 
reduced to the size of the first, and has not 
increased during five months. The patient, 
who up to that time was unable to work, 
now performs light duties about the clinic. 118 
Best Surgical Dressing. 
During the treatment I noticed that after 
each injection the patient had nausea, 
which however, disappeared after an hour. 
In two other cases, this method of treat- 
ment, as far as I am able to judge in the 
short period for observation, seems to es- 
tablish itself. I chose the fluid form of io- 
doform for injection in these cases, as I 
think we are best able in this way, with the 
help of compression to obtain the greatest 
action of the remedy upon the abscess mem- 
brane, and where possible, upon the origi- 
nal seat of the disease. On this account I 
wish to lay great stress upon the after com- 
ing compression, which should force the 
iodoform against the abscess walls and 
thereby produce a more powerful action. 
I purposely took glycerine and oil as 
constituents of the suspension. The first 
becomes more quickly absorbed, so that 
later only oil and iodoform remain, of 
which I was able to convince myself in 
the second case, when I made the later 
punctures. As iodoform is quite readily Iodoform in Surgery. 
119 
soluble in oil, and the latter only with diffi- 
culty taken up by the abscess membrane, 
an even and prolonged action of iodoform 
upon the abscess walls is assured. 
Thus I am at the end of my remarks. 
I have tried, gentlemen, to give you a 
view of the present state of our knowl- 
edge in regard to iodoform, and endeavored 
to indicate in what manner you may be able 
to apply this excellent remedy in the differ- 
ent cases of your private practice. 
With the rapid advances in surgery, to 
which we are accustomed at present, the 
iodoform treatment may in the shortest 
time experience further development, and 
much that we at present consider as valu- 
able, perhaps give place to something bet- 
ter. We are already indebted to iodoform 
for a progress so important, that we must 
look upon its introduction into surgery as a 
far-reaching reform through which, it above 
all else becomes possible for the antiseptic 
wound treatment to be the common prop- 
erty of all. BEACH’S PRINCIPLE 
OF 
BULLET WOUND TREATMENT. BEACH’S PRINCIPLE. 
It is a great pleasure for me to be able 
to claim for Dr. Beach the establishment 
of the principle of bullet-wound treatment, 
the value of which I shall endeavor to 
prove in the following remarks and quota- 
tion of cases. 
It is also gratifying, in this connection, 
to see that surgeons are pretty generally 
agreed upon the course to pursue in the 
treatment of bullet wounds of the abdo- 
men and chest. In other instances, how- 
ever, they appear, as a rule, to disregard 
the following principle of bullet-wound 
treatment: “Never disturb a bullet wound 
unless there are positive indications of the 124 
Bullet Wound Treatment. 
necessity of so doing. A bullet entering 
the body in the usual manner is as harm- 
less as a tooth filling and soon becomes 
encysted.” 
There is, perhaps, no better and briefer 
way of proving the soundness of this 
theory than by considering the cases con- 
tained in the following pages. If we go 
back to the time of Guthrie, or no later 
than the war of the rebellion, for instance, 
we can imagine if not estimate the great 
difference that thorough antisepsis would 
have made in the results. To the surgeon 
of to-day, judging from a standpoint so 
vastly different from that of but a few 
years ago, it seems to me that the collected 
cases must read with all the interest of a 
romance. The mere performance of lapa- 
rotomy is no great feat for him, and there- 
fore nothing of which he thinks with any 
particular apprehension, but he fully real- 
izes that the best surgery teaches how to 
avoid an operation when that is possible Beach’s Principle. 
and advisable. In connection with bullet 
wounds of the abdomen the following 
summary from a leading article in the 
Medical Analectic for February, 1888, ap- 
peals to one’s reason: 
“The present views of the majority of 
surgeons in regard to bullet wounds of the 
abdomen, gathered from the literature of 
the past few months, seem to be as fol- 
lows : 
“First. A person having received a pen- 
etrating bullet wound of the abdomen, with 
probable wounding of a viscus, may recover 
without operation. 
“Second. The wound in the abdominal 
wall should not be explored, unless one is 
prepared to perform laparotomy, if the 
wound proves to be a penetrating one. 
“ Third. Long-continued shock is a con- 
tra-indication. Peritonitis is not a contra- 
indication, but it renders the operation 
much more difficult. 
“Fourth. If laparotomy is performed the 126 
Bullet Wound Treatment. 
incision should be a free one in the linea 
alba. 
“As the shock of the operation is due 
largely to the exposure of the intestines to 
the air, care should be taken to have as 
small an amount as possible out of the 
abdominal cavity at any one time. 
“The more practice the operator has had 
with intra-abdominal manipulations, and 
the more efficient assistance at hand, the 
better are the chances of a successful 
result.” 
If inquiry went to show that the bowels 
were probably empty, or not filled with 
fluid contents at the time of wounding, 
there would be no reason to expect danger 
from escape of fecal matter. Where, 
however, there was reasonable evidence 
that this accident, or hemorrhage, had 
occurred, there should not be a moment’s 
hesitation to avoid their possible effects by 
immediate operation. 
A bullet wound differs in nature from Beach’s Principle. 
127 
any other in that its character is very much 
determined by the rapidity with which it 
is produced. For instance, in the cele- 
brated Warren Museum crowbar case, an 
injury resulted which, if imitated by any 
slower process of pushing the crowbar 
through, would without doubt be fatal. 
Again, the difference between pulling a 
cloth from beneath objects placed on a 
table with a rapid twitch or by a slow move- 
ment. In the one case the objects are left 
on the table; in the other they are pulled 
off with the cloth. Or between dropping 
and drawing a pin through a soap bubble. 
All this of inertia and other laws of physics 
is familiar to us, and may have its applica- 
tion here. Certain it is that bullets have 
been known to pass through tissues where 
no trace of cicatrix has been found at the 
autopsy. How many veterans of the 
Grand Army are not only carrying bullets 
about with them, but in them, to-day ? 
What quieter resting-place has a musket 128 
Bullet Wound Treatment. 
ball ever been found in than when it has 
been discovered on sawing through an ele- 
phant’s tusk? Naturally, when a ball 
has carried in with it more septic material 
than the economy can take care of, it be- 
gins to create trouble and proves an ex- 
ception to the rule. But more often the 
trouble comes because some bullet, harm- 
lessly lodged in a bed of soft parts or bone, 
has been fruitlessly and septically, to a 
greater or lesser degree, searched for with 
probe or other instrument. 
This same principle can be no more 
clearly stated than in the following eight 
propositions taken from a very able paper 
on the “ Early Treatment of Gunshot 
Wounds,” by Roswell Park, A. M., M. D., 
Professor of Surgery Medical Department 
University of Buffalo, published in the 
Physician s Magazine for August, 1885. 
“ i. The injury which a bullet may inflict 
is done by it as it passes in its course ; in 
other words, instantly; any subsequent Beach’s Principle. 
129 
harm usually comes from unwarranted 
interference. 
“ 2. It is so heated in its passage out of 
the weapon and through the air that it kills 
any germs which may have found lodgment 
on it; i. e., it enters the body in an antisep- 
tic condition. 
“ 3. Even when its wound of entrance and 
the direction of its path from outside the 
body are known, it is absolutely impossi- 
ble to predict where it maybe found within 
the body. 
“4. A leaden bullet imbedded in the tis- 
sues is, per se, an innocuous and inoffen- 
sive substance; that this is true is proven 
by innumerable experiences of military and 
civil surgeons. 
“5. Unless other and poisonous material 
has been carried into the tissues, nothing 
has entered which, except from aesthetic 
motives, needs to be removed or is likely 
to do harm. 
“6. Supposing that shreds of clothing or 130 
Bullet Wound Treatment. 
impurities of any kind have entered ; they 
are seldom to be discovered, much less 
removed, by mere probing. 
“ 7. By the act of probing, Nature’s oc- 
clusive blood clot is broken up, and the 
entrance of air permitted ; a dirty probe 
not rarely made to serve as a carrier of in- 
fection; and last, but not least, it is ten to 
one that no real information is gained as to 
the position of the bullet. Hemorrhage 
which had spontaneously ceased is often 
provoked afresh, and may not be easy to 
check a second time. 
“8. General observation of the patient’s 
condition will show whether a vital part 
has been injured or not; pulse, respiration, 
amount of shock, hemorrhage, peritonitis, 
pleuritis, coma, hemiplegia, as well as vari- 
ous other objective features, will give 
vastly more reliable information and of 
greater extent than can possibly be ob- 
tained by the probe.” 
I will not add further argument of my Beach’s Principle. 
*3* 
own, but will submit the following cases, 
preceding them with those taken from 
among Dr. Beach’s, as furnishing the most 
typical and valuable evidence. I would lay 
stress upon the fact that there is no attempt 
to make of a principle an invariable rule, 
but to establish the principle. That this 
has elsewhere not been done, in this coun- 
try at least, the daily accumulating news- 
paper evidence that “the doctors probed 
for the ball” will readily testify. 132 
Bullet Wound Treatment. 
DR. BEACH’S CASES, WITH THE EX- 
CEPTION OF CASE I., TAKEN 
FROM THE RECORDS OF THE 
MASSACHUSETTS GENERAL HOS- 
PITAL. 
Case i. Reported in the Boston Medical 
andSitrgicalJournal,1876, vol. xciv., p. 238. 
Case seen in consultation with Dr. Bemis 
of Medford. Patient, a man of twenty- 
seven years, attempted suicide with pistol 
fired over heart. “ An examination of the 
injured region disclosed a small wound be- 
tween the fifth and sixth ribs of the left 
side, in a vertical line, and two and a half 
inches below the nipple of that side. The 
skin for two inches around was blackened 
by powder.” “If the location of the ball 
had warranted explorations, his weak con- 
dition forbade it.” There were symptoms 
of spine injury, paralysis of motion and sen- Beach’s Principle. 
133 
sation in the left leg, but the patient, con- 
trary to the expectations of consultant and 
attending physician, ultimately recovered. 
July 30, 1879, G. E. F. B., a policeman, 
while on duty was shot in the eye. The 
ball penetrated the globe and sight was de- 
stroyed. The eye was enucleated, and it 
was then found by careful probing that the 
missile had penetrated further backwards 
and downwards. No attempts at its re- 
moval were made and the patient was dis- 
charged well at the end of two weeks. 
Aug. 21,188 r, F. K., twenty-one years of 
age, single, an artist, attempted to end his 
life by shooting himself. The ball, a twenty- 
two calibre, entered (on the right side) be- 
tween the cartilages of the sixth and 
seventh ribs, about three and one half inches 
from the median line. There was no dis- 
charge from the wound. It was undisturbed, 
and the body surrounded with an antiseptic 
dressing of phenyle gauze. During the 
first four days there was severe pain in J34 
Bullet Wound Treatment. 
the neck and shoulder on the wounded 
side, and also some abdominal tenderness 
and tympanites, but this was controlled 
with morphia, and the patient made a good 
recovery, and was sent home at the end of 
twenty-two days. 
Aug. 11, 1881, M. L., female, set. 23years, 
married, was accidentally shot in the back 
with a twenty-two calibre revolver. The 
ball entered about fcur inches above the 
posterior superior ileac spine, two inches 
to the right of the median line, and pene- 
trated deeply. No attempts at removal 
were made and the parts were surrounded 
with a phenyle gauze dressing. Recovery 
was complete in twelve days, although there 
was much pain in the hip and thigh for the 
first forty-eight hours and two bloody dejec- 
tions on the sixth day. 
Oct. 3, i88i,W. F. D., a glass worker, 
set. 41 years, came to the hospital, having 
been wounded three days before with a 
twenty-two calibre revolver. The wound Beach’s Principle. 
was scabbed over and extended, as evi- 
denced by tenderness and induration on 
careful palpation, inwards beneath the 
pectoral muscles towards the sternum. 
The parts were kept quiet in bed, and the 
wound left, as upon his entrance, covered 
with adhesive plaster. Owing to a slight 
discharge on the second day the parts were 
thoroughly enveloped in phenyle gauze. 
There was considerable tenderness and in- 
duration, but the patient was discharged 
without further treatment in nineteen days. 
Oct. 14, 1881, S. W., boy, fifteen years 
of age, accidently shot himself in the hand 
with a twenty-two calibre pistol. The ball 
entered the palm between the pisiform and 
trapezoid bones. Had been probed for but 
not found before entering the hospital. 
The wound was thoroughly anteseptized 
and was done up in phenyle gauze. 
Recovery was complete and there were no 
signs of disturbance at the end Qf nineteen 
days. 136 
Bullet Wound Treatment. 
Oct. 17, 1881. Chas. O’C., also acci- 
dentally shot himself in the palm of the 
hand with a twenty-two calibre pistol. 
The ball entered midway between the bases 
of the first and third metacarpals. The 
hand was done up in phenyle gauze without 
disturbing the wound and the patient made 
a good recovery. Eighteen days after acci- 
dent there were no signs of disturbance. 
Oct. 25, 1882. M. B., a lad of 12 years, 
accidently shot himself in the chest with a 
twenty-two calibre revolver. The ball 
entered on the right side between the third 
and fourth ribs about one inch from the 
sternum. Hemoptysis followed, but had 
ceased when the patient was brought to 
the hospital one hour later. The wound 
was not examined, and the parts after 
thorough phenylization were enveloped 
in phenyle gauze. There were no bad 
symptoms later on and recovery was per- 
fect, patient being convalescent in sixteen 
days. OTHER CASES 
TAKEN FROM LITERATURE. OTHER CASES. 
Cases taken mostly from recent literature on this sub- 
ject AS BEING OF SPECIAL VALUE FOR THE PRESENT PUR- 
POSE. The accounts are mostly direct quotations. 
The italics are mine. 
Case I. 
(From “Guthrie’s Treatise on Gunshot Wounds,” 
published in 1827.) 
“A soldier of the ninety-second regi- 
ment, forty years of age, was wounded 
by two musket-balls in the right hand and 
wrist, on the 25th of June. On the 5th 
of July, the arm was swollen above the 
elbow, the hand oedematous, the discharge 
profuse and fetid, countenance sallow 
and dejected, the skin hot, bowels confined, 
tongue loaded, pulse ninety. 6th. The 140 
Bullet Wound Treatment. 
bowels opened by medicine, tongue cleaner, 
skin cool, pulse eighty, wound discharges 
profusely, patient much debilitated. 8th. 
The arm amputated above the elbow. 
(The whole forearm lost in consequence of 
the operation having been delayed, and the 
extent of the swelling and inflammation 
which ensued). 9th, 10th, and 1 ith. A 
little increase of fever, the bowels being 
kept open, and saline medicines admin- 
istered. 12th. Had a paroxysm of inter- 
mittent fever, which he has been subject 
to since the expedition to Walcheren. 
On removing the dressing, the edges of 
the stump were retorted, the discharge 
copious and fetid, respiration hurried, com- 
plains of thirst, skin hot, pulse ninety, skin 
tinged of a yellowish color. 14th. Had 
a return of the paroxysm this morning, 
respiration still hurried, pulse ninety,bowels 
open, head affected in consequence of the 
long continuance of the hot fit. Stump 
very irritable, and discharging profusely. Other Cases. 
141 
Calomel and antimonial powder were 
given every three hours ; saline draughts ; 
the bowels kept open. 15th. Complains 
to-day of fulness and pain in the left 
side, pulse one hundred, skin tinged of a 
deeper color, a sense of suffocation in 
the horizontal position. A blister was 
applied to the whole of the left side. 
16th. The blister rose well, but did not 
relieve the pain in the side. Was delirious 
during the night, vomited frequently, and 
about the usual period of the attack of 
the intermittent he became insensible, and 
died in the evening. 
Dissection. On opening the chest, the 
lungs were found to adhere to the pleura 
costalis in several places, had lost their 
usual spongy texture, and were dense like 
liver; a quantity of serum and coagulable 
lymph was contained in the left side, suf- 
ficient to prevent the dilatation of the lung, 
in which a small abscess had also formed. 
The viscera of the abdomen were sound, 142 
Bullet Wound Treatment. 
with the exception of the liver, which 
was enlarged to twice its usual size. 
Dr. Hennen, page 272 of his valuable 
work on Military Surgery, has related 
the particulars of a case, which was com- 
municated to him by staff-surgeon Hughes, 
of an abscess of the liver taking place 
nine days after secondary amputation of 
the thigh, and destroying the patient on 
the fourth day from the appearance of the 
attack." 
(From “ Surgical Observations,” by J. Mason 
Warren, 1867.) 
Case II. 
“Case 336. Wound of chest from 
pistol balls. Death eight years after. Pis- 
tol balls suspended within the chest by the 
pleura. In a fit of jealousy, a man shot his 
mistress, coming behind her while she was 
sitting on a low bench, and firing down 
upon the chest. He then placed a pistol 
to his heart and pulled the trigger. In the 
act of discharging the pistol the muzzle Other Cases. 
143 
became elevated, so that the bullets just 
escaped the heart and great vessels in 
their passage through the chest. Both 
these patients came under my care at the 
time. 
The woman lived three days and then 
died in great agony. On a post-mortem 
examination it was found that one of the 
bullets had passed through the cavity of the 
chest, and lodged in the body of a dorsal 
vertebra. This vertebra I now have with 
the ball deeply imbedded in it. A second 
bullet struck the first rib, was cut in two by 
it; one half traversing the top of the rib, 
the other traversing the lung, being found 
loose in the cavity of the chest. The hem- 
orrhage produced by this wound filled the 
chest, compressed the lung, and was the 
immediate cause of her death. The third 
bullet entered the neck, and its course 
could not be traced. 
The man, immediately on being wounded, 
had great emphysema of the walls of the 144 
Bullet Wound Treatment. 
chest, followed by entire flatness on per- 
cussion of that side. After a very severe 
illness, he recovered sufficiently to be 
brought to trial ; and, being convicted, was 
sentenced to the State prison for life. 
I saw him at the prison about four years 
after. He then had a constant, dry cough. 
On auscultation, the respiration was found 
rough on the left side, and somewhat bron- 
chial. There was no rale. Percussion re- 
vealed nothing abnormal. His health was 
otherwise good. 
He died suddenly eight years after the 
crime was committed. On examination, it 
was supposed by Dr. Morris, surgeon to the 
prison, that some disease of the heart 
would be found to explain his death. No 
sufficient disease, however, could be de- 
tected. The valves of the heart were thick- 
ened, but not enough to impede their action. 
In the upper lobe of the left lung a cica- 
trix, showing the course of the balls, was 
distinctly visible. The balls, having tra- Other Cases. 
!45 
versed the lungs had lodged in the side of 
the chest. From this place they had be- 
come gradually detached, and were found 
suspended from the sides of the chest, like 
cherries hanging from a tree, having carried 
the pleura before them and being enveloped 
in that membrane.” 
Case III. 
(From the Brit. Med. Journal, 1880, p. 735. 
Walter Buchanan, M.R.C.S.E., etc.) 
“ I was called to J. E., who had attempted 
to commit suicide, by firing a revolver into 
his mouth. On examining him I found a 
very little blood on the mouth. On wash- 
ing it out, I found the right side of the 
tongue charred, and an opening through 
the right tonsil about the size of a goose 
quill. On exploring this my director took 
an upward and backward course, to the 
transverse process of the first cervical ver- 
tebra and then towards the left. I could de- 
tect the bullet firmly impacted in the body of 146 
Bullet Wound Treatment. 
that bone. The man seemed none the worse 
for the injury. I held a consultation, and 
we decided that it would be injurious to at- 
tempt to remove the bullet. He was com- 
mitted to prison and thus I lost sight of 
him for ten weeks. He is now in perfect 
health and in no way suffers from the bullet, 
which has never been removed. 
Case IV. 
(From the Brit. Med. Journal, 1880, p. 53. 
Herbert L. Bernaj, M.R.C.S.) 
“At the post-mortem examination, the 
bullet was found in the liver, but not at the 
spot where it pierced the skin. It had 
glided over the smooth surface of the liver 
to the right side ; there it appeared to have 
struck a rib, rebounded, and entered the 
liver to the depths of about three-quarters 
of an inch. There were about three ounces 
of old blood clot, probably effused at the 
time of injury, and a fair amount of 
partially organized lymph around the Other Cases. 
*47 
wound. The small cavity where the ball 
lay was lined with very well organized 
lymph. Nowhere was there any sign of 
abscess. The functions of the liver were 
well performed to the last. All the other 
organs were healthy. The child certainly 
did not die from the presence of the ball in 
the liver but simply from exhaustion from 
not taking sufficient nourishment. 
Case V. 
(From the New Orleans Med. and Surg. Journal, 
1880, p. 1031. Read before Attakapas Medical 
Association, March 4, 1880.) 
Paul F. was accidentally shot in the 
shoulder with a 32-calibre Smith & Wesson 
revolver. The ball had entered the shoulder 
at the anterior edge of the deltoid muscle ; 
there was very little hemorrhage. A No. 8 
female catheter used as a probe passed read- 
ily into the wound and struck denuded bone, 
evident from roughness and peculiar feel 
on probing. Crepitus was distinctly felt, 
and examination showed fracture of surgi- 148 
Bullet Wound Treatment. 
cal neck. The ball was not found and it 
was concluded to dress the wound with the 
best obtainable Lister dressing gauze, wet 
with 1-50 carbolic acid solution, and post- 
pone the projected resection of the head of 
the bone until the morning. “Together 
we visited our patient the next morning 
with instruments, etc., all ready, but much 
to our surprise our patient presented little 
or no local or constitutional disturbance; 
was cheerful and bright.” 
The shoulder was eventually done up in 
a fenestrated plaster-of-Paris bandage and 
recovery was complete “ with no deformity.” 
Case VI. 
In the British Medical Journal for Oct. 18, 
1884, Mr. Herbert Parsons reports the case 
of a Uruguay girl, thirteen years of age, who 
received a revolver wound of the brain. “ The 
ball passed through the mastoid process 
of the temporal bone and took a course in- 
wards through the convolutions of the brain, Other Cases. 
149 
with a slight downward direction. She fell 
down unconscious, but recovered complete 
consciousness one hour later. The wound 
was examined with a bullet probe, and then 
the orifice filled with iodoform. There was 
never any fever or nervous disturbance be- 
yond hemiplegia. She became perfectly 
well and had remained so eighteen months 
later. The ball was of very small calibre.” 
Case VII. 
In the New York Medical Journal of June 
io, 1885, Chas. A. Powers, M. D., writes 
an interesting article from which the follow- 
ing is quoted: “At this hospital, the local 
treatment of pistol wounds is essentially the 
same in all cases, but slight attempts at 
probing are made ; no endeavors are made 
to hermetically seal the aperture; a slight, 
but thorough antiseptic dressing is applied, 
which in many instances is left on until the 
wound is entirely closed.” 15° 
Bullet Wound Treatment. 
Case VIII. 
C. L., thirty-eight years of age, a Ger- 
man silversmith, was shot in the left chest 
with a 44-calibre revolver. “ Examination 
revealed a punctate wound, four centi- 
meters below the middle of the clavicle, 
which admitted the end of the little finger.” 
A probe gently introduced passed easily 
backwards, inwards, and somewhat down- 
wards, and being arrested, was withdrawn 
and no further attempts were made with it.” 
There was one attack of haemoptysis, but 
no recurrance of it. Recovery was com- 
plete. 
Case IX. 
Also, T. J. C., fifty-four years, married, a 
bank porter, was shot by a man ten feet 
away, firing upon him in full front. The 
ball, a forty four calibre, entered between 
the cartilages of the third and fourth 
ribs, two centimetres to the right of the 
Sternum. “ The ivoundfreely admitted the Other Cases. 
75/ 
end of the little fingerThe ball was 
not removed and recovery was complete in 
thirty-seven days. Later on, the ball which 
was at first to be felt in the infrasapinous 
forsa of the scapula, was removed. 
Case X. 
In the London Medical Press and Circular 
for Jan. 7th, 1885, Mr. W. F. Smart, 
F. R. S. C. I., reports the case of a 
coolie, admitted to the Demarara hospital, 
with a bullet wound over the sixth 
rib, one inch from the sternum. Bullet 
eighty grains weight, fired at a distance 
of three yards. Believing the ball to 
have penetrated the abdomen, S. operated 
after giving fifty drops of laudanum and 
one ounce of brandy. An exploratory 
incision, two and one half inches long, 
was made over the cartilage of the eighth 
rib, through the skin and subcutaneous 
cellular tissue. This was further carried 
down into the substance of the liver and the 152 
Bullet Wound Treatment. 
ball removed. The operation was followed 
by a “ state of utter collapse.” After 
a most critical illness the patient recovered. 
The author says in conclusion : “ I merely 
bring this case forward in the hope that 
it may elicit the opinions and experience 
of others on the utility of iodoform as an 
antiseptic.” 
Case XI. 
In the British Medical Journal for Feb. 
21,1885, Mr. T. Fred Gardner, M. R. C. S. E. 
and L. R. C. P., London, reports a case of ac- 
cidental wound of the skull, occurring Aug. 
13, 1884, with a smooth bore gun, firing a 
one and one-half ounce ball. The wound 
was over the left eyebrow, round and 
smooth, “ admitting the finger, and bleeding 
freely. The brain was felt pulsating through 
it. Seven weeks later the patient was dis- 
charged, Dec. 12. The intellect was clear 
in every particular, and there was not the 
slightest trace of paralysis anywhere, nor of 
any symptoms of irritation of the brain.” Other Cases. 
153 
Case XII. 
In the Australian Medical Journal for 
March 15, 1885, Mr. E. S. Jackson, M. B. 
Ch. B., reports the case of a boy, aged 
eight years, who was accidentally shot by a 
schoolmate in the left malar region. “ On 
admission there was a small blackish scab 
over the wound, and some swelling around 
it. The patient was partially conscious, 
extremely restless, and occasionally wan- 
dering. Pupils dilated, no paralysis. The 
scab was poulticed off and revealed a sinus, 
extending through the malar prominence 
backwards, slightly inwards and upwards. 
At a consultation with the visiting sur- 
geons a long probe was passed along the 
sinus right to the back of the brain, but no 
bullet was met with. The wound was then 
dressed with carbolic oil daily, and the 
patient kept in quiet and darkness, with 
occasional doses of bromide of potash and 
chloral and an ice bag to his head. ” Five 154 
Bullet Wound Treatment. 
days after admission a note was made to 
the effect that he was much quicker and 
more conscious than when first admitted. 
He had been passing water without assist- 
ance. O11 the 19th day of July, twenty- 
four days after admission, his only symptom 
was a slight loss of memory, and he was 
able to sit up in bed a little each day. He 
was then allowed to get up, and from that 
time continued to improve as before, until 
his discharge on Aug. 23d, when he was in 
perfect health, but still had a sinus in the 
cheek, at the bottom of which, at a distance 
of about one and one half millimeters, some 
small pieces of bare bone were to be felt. 
Case XIII. 
Also, J. H., aet. 29 years, a bullock 
driver, accidental revolver wound of right 
knee, which was in a flexed or semiflexed 
position. “ On examination there was a 
slight swelling of the right knee on the in- 
ner side of the joint just over the promi- Other Cases. 
nence of the internal condyle of the femur. 
There is a small bullet wound leading by a 
sinus about one half inch long straight into 
the osseous tissue and not communicating 
with the joint which was slightly distended 
with fluid. No bullet could be discovered 
with the probe, which was used with the 
least degree of violence. The patient was 
ordered to be kept in bed and the knee 
fomented. 
On the first day of August, eleven days 
after the injury had been inflicted, he had 
done so well that he was allowed to get up. 
He limped slightly and complained of stiff- 
ness in the knee. 
A week after last date, Aug. 8, he was 
discharged, at his own urgent request, with 
the wound healed, and was able to walk 
with little or no limp. There was still, 
however, slight impairment of the power 
to flex the limb.” i$6 
Bullet Wound Treatment. 
Case XIV. 
Also, M. P. H., set. 28 years, cook, mar- 
ried. September 5, 1884, attempted to 
shoot his wife, and then to commit suicide 
by shooting, and finally by cutting his 
throat with a razor. There was a small 
wound above the right frontal eminence. 
On probing this bone could be felt, and 
between the skull and scalp, an inch and a 
half back to the right side, a lead mark was 
obtained with the Nelaton probe. “There 
is bleeding from the right ear and within 
it a blackened pistol wound, through which 
a probe can be passed slightly downwards 
and inwards into the throat, where the 
probe point can be distinctly felt through 
the soft tissues by the finger introduced by 
the mouth. On pressing the right tonsil 
the probe can be moved slightly out of the 
ear. His throat being also wounded, explo- 
ration was not persevered in, as it seemed 
likely to set up bleeding from the patient’s Other Cases. 
'57 
attempts to vomit. The throat wound, 
which has been made with a sharp instru- 
ment, is about three one-half inches long, 
extending transversely above the thyroid 
cartilage and at its central part into the 
pharynx, the posterior wall of which can 
be distinctly seen through the wound. 
Liquids pass through the wound upon 
arrival in the pharynx. He is, however, 
still able to swallow liquids when the wound 
is closed and the head slightly flexed. His 
consciousness is complete. A consultation 
was held, at which it was considered inad- 
visable to explore further for the bullets, 
till more urgent symptoms developed. 
The wound in the throat was thought to 
add to the danger of the patient’s being 
anaesthetized. Treatment consisted in syr- 
inging the ear daily as necessary with a dis- 
infectant solution. Throat wound brought 
into opposition by flexing the head; no 
sutures were used ; dressed with a clean 
towel, changed as often as necessary. 158 
Bullet Wound Treatment. 
“September 21. A note is made, that 
beyond slight earache he has not had a 
bad symptom and can hear a watch ticking 
with his right ear. Wound of throat 
closing fast. 
“ November io. He was handed over to 
the police and entered in the ward-book 
discharged, improved. 
“ The medical officer of the penal estab- 
lishment in which he is now undergoing a 
life sentence, informs me that the throat 
wound is quite healed, also that in the fore- 
head. There is still some discharge from 
the ear.” 
Case XV. 
In the British Medical Journal for 
April 4th, 1885. Mr. Richard Barwell 
reports three interesting cases of gunshot 
wound, among them : Case 3d. Carl F. shot 
himself in the mouth and in the ear with 
a revolver just a quarter inch bore, Oct. 
24th, 1884. The wound first named was 
on the left side of the soft palate, and the Other Cases. 
159 
ball penetrating that part, inflicted another 
wound in the posterior wall of the pharynx. 
The bullet had never been found, and had 
given no trouble. It was probably encap- 
suled among the deep muscles on the left 
of the spine. The other bullet passed for 
three-quarters of an inch through the audi- 
tory meatus without injuring it on either 
side, then continuing its directly trans- 
verse course, it left that channel by a small 
wound at its posterior part. A probe passed 
in here touched a substance, which Mr. 
Barwell believed to be metallic, exactly two 
inches from the margin of the meatus. 
The depth and the direction of the wound 
caused abstention of any attempt at extrac- 
tion, because it appeared to Mr. Barwell 
that the projectile must lie in a very dan- 
gerous proximity to the lateral sinus. 
After 48 hours, abundance of clear serum 
became mixed with the blood discharged ; 
it was either cerebro-spinal fluid, or liquor 
contunii; the admixture of blood then of 160 
Bullet Wound Treatment. 
pus prevented any testing for sugar. The 
man, who was singularly apathetic, pro- 
gressed favorably, with the exception that 
a week after the infliction of the wound, 
the parts about the angle and ascend- 
ing ramus of the jaw swelled and short- 
ly after suppurated. On December 4th, 
there was sufficient disturbance in those 
parts to indicate that the projectile was pro- 
ducing considerable irritation and ought 
to be, if possible, removed. Moreover, if, as 
seemed possible, the lateral sinus had 
been injured the wound would in the five 
weeks have healed. With some difficulty, for 
it was rather large, Mr. B. passed a Nela- 
ton’s probe sufficiently far to obtain the 
lead-mark. Making a curved incision be- 
hind the pinna he trephined the mastoid 
process to the depth of three-quarters of 
an inch ; finding a small track leading still 
deeper, he again got on the Nelaton’s probe 
the lead-stain, but at a distance from the tre- 
phining hole of more than an inch. The Other Cases. 
161 
track was cautiously enlarged with a gouge 
and a pair of sinus forceps was passed 
down to the bullet, which, although very 
firmly fixed in the bone, was successfully re- 
moved. After this operation, the man had 
no bad symptoms, the abscess in the jaw 
was opened, the trephine hole rapidly filled, 
and by the middle of December he was 
well. 
Case XVI 
Another case was that of a gentleman 
who shot himself with a pistol less than a 
quarter inch bore. The wound was within 
the areola of the left nipple; but the weapon 
must have been held obliquely, for the bullet 
missing the heart by probably very little 
passed through about eight inches of the 
left lung, and lay outside the chest near the 
lower angle of the scapula. There was 
very considerable hemorrhage from the 
wound and coughing caused the blood to be 
driven out several feet. There was also a 
good deal of hemoptysis. Strict quietude, 162 
Bullet Wound Treatment. 
ice, acetate of lead, and opium, subdued 
in about fifteen hours the external hemor- 
rhage, but the hemoptysis continued for six 
days. Pneumo and hemothorax together 
with surgical emphysema, were very 
marked. Pneumonia came on, on the 
seventh day. After the lapse of three 
weeks, during which he had been in a very 
precarious condition, improvment set in 
which steadily and rapidly progressed. On 
the 35th day, Mr. Barwell removed the bul- 
let, which he had hitherto avoided, wishing 
the wound of exit from the chest to become 
previously closed. Seven weeks after the 
injury the man was discharged from care, 
somewhat weak, but quite well. 
Case XVII. 
In the Transactions of the N. Y State 
Medical Association for 1884 is reported, 
on Nov. 10, by Dr. John H. Hintor, a case 
of pistol shot wound through the stomach 
followed by recovery. The patient was a Other Cases. 
163 
young man of twenty-one years. The ball 
entered over the tenth rib about five inches 
to the left of the spine, and could be felt 
under the skin in front, two inches from 
the median line, three inches from the um- 
bilicus. Wound in the back was closed with 
adhesive plaster. “ Within three hours 
after the shooting, I removed the ball from 
under the skin, and I ascertained by explo- 
ration with the point of the little finger, 
that the ball, a conical 32-calibre, had passed 
through the cartilage beneath. This fact, 
taken in connection with the vomiting of 
food and blood, showed that the ball had 
passed entirely through the stomach. Flax- 
seed poultices were applied over the ante- 
rior and posterior wounds, and he was 
ordered to have no food by the mouth, ene- 
meta of milk being given every four hours. 
During his illness, the patient vomited 
blood several times, and had numerous 
bloody dejections, but was discharged well 
at the end of forty-one days. 164 
Bullet Wound Treatment. 
“That we might in some wise imitate 
such an injury, I directed my house officer 
to fill the stomach of a cadaver with water 
to about the quantity of an ordinary break- 
fast and then to shoot it from behind. The 
ball entered the body at about the same 
place as in the case related above, and by 
the dissection, it was shown that it passed 
through both walls of the stomach and 
lodged in the anterior abdominal muscles. 
The posterior wound of the stomach was 
guarded by a valvular flap of mucous mem- 
brane which prevented the escape of liquids. 
The anterior wound had no flap as might 
have been supposed, yet the wound was al- 
most closed, which in all probability would 
be the case in living tissues.” 
Case XVIII. 
In the Pacific Med. and Surg. Journal 
for July, 1885, A. B. Stuart, M. D., of Santa 
Rosa, California, reports the following case. 
“Joseph Elliot, aged about twenty-five Other Cases. 
'<$5 
years, American born, of German extrac- 
tion, farmer by occupation, while engaged in 
conversation with a friend at a railroad sta- 
tion waiting for the incoming train, was acci- 
dentally shot, the pistol, a 32-calibre, being 
in the hands of a physician deeply under the 
influence of liquor. How or why the pistol 
was discharged no one knows ; but that it 
was unintentional on the part of the doctor 
everyone present believed. The ball struck 
the left parietal bone about midway between 
the temporal and occipital bones, and three 
inches from the lower portion of the mas- 
toid process of the same side, passing 
through the skull and taking a slightly up- 
ward course, in the direction of the centre 
of the upper border of the temporal bone on 
the opposite side. About an inch and a 
half from the external wound, I detected 
with a probe what I supposed to be the 
bullet, but when removed it proved to be 
only a thin ring-like portion, such as you 
would expect to see from forcing a leaden 166 
Bullet Wound Treatment. 
ball through a hard metal tube rather too 
small to admit it. Believing that the 
greater portion of the bullet yet remained 
in the brain, I again introduced my probe, 
which passed easily and unobstructedly 
four inches from the external surface, where 
it met with a slight resistance, but not oc- 
casioned by the ball, or any other foreign 
substance, and fearing that I might do un- 
justifiable injury to the brain, I withdrew 
the probe and discontinued further manual 
examination. Having no drainage tube, a 
tent was substituted, passing it in just far 
enough to give vent to a slight bloody dis- 
charge then present, applied cotton, wet in 
carbolized water, externally, and recom- 
mended the attending surgeon to open the 
bowels with a saline cathartic and put the 
patient upon opium, bromide of potassium 
and aconite.” * * “I am told that the 
tent was removed next day; external wound 
soon healed, and our man had a speedy get- 
ting up, but was never again his former Other Cases. 
i6j 
self, either in mind or body.” * * “He 
is now dead, having died of typhoid fever 
about two years after the injury just re- 
ported.” No autopsy! 
Case XIX 
In the Transactions of the American 
Medical Association, Drs. Edward and E. 
Wyllis Andrews report some interesting 
revolver wound cases, from which I quote 
the following: 
“ The first wound was made by a twenty- 
two calibre bullet, which entered on the 
linea alba, between the umbilicus and 
the xiphoid cartilage, traversing directly 
backwards. The stomach was empty, con- 
siderable shock ensued, but no vomiting. 
The patient was treated by opiates and 
starvation. On the tenth day he passed 
the bullet per anus. He recovered with- 
out signs of peritonitis.” 
“ A second case had a thirty-eight calibre 
bullet shot completely through the body on 168 
Ballet Wound Treatment. 
nearly the same line as the previous one. 
Laparotomy was proposed to him, but he 
refused it. His stomach had no food in it 
at the time of the injury, but he had taken 
considerable beer. As he rejected the 
operation he was placed upon starvation 
and opiates, and recovered without a single 
symptom.” 
“ The third case, not ended at the time of 
reporting, was shot with a thirty-eight 
calibre ball, which went in through the bor- 
der of the cartilages or the ribs upwards, 
and to the left of the umbilicus, and came 
out at a point behind about opposite. 
On his arrival there was a slight eleva- 
tion of temperature, and pressure detected 
a diffuse tenderness of the abdomen ex- 
tending down to the iliac region on the 
right side; the pain, however, was moderate, 
and the decubitus was not that of decided 
peritonitis, as he showed no desire to draw 
up the knees. Laparotomy was deemed 
advisable and performed ; but no signs of Other Cases. 
i6g 
perforation were discovered. The inci- 
sion which had been made antiseptically 
was closed, and the patient treated by star- 
vation and opiates. On the sixth day the 
patient had recovered from signs of peri- 
tonitis, but was suffering from delirium 
tremens, due probably to his * being daily 
accustomed to imbibe fifteen glasses of 
beer.’ 
“It is clear that the first two patients suf- 
fered nothing from the omission of lapa- 
rotomy, and it is not clear that the third 
derived any benefit from it. True, there 
was removed some bloody serum, but 
blood which has not been exposed to the 
septic germs of the atmosphere by laparo- 
tomy is often absorbed without trouble.” 
Case XX. 
In the New York Medical Record of 
Aug. 22, 1885, Dr. Wilis Butterfield of Bel- 
viclere, 111., reports “an interesting case of 
a little girl, Gertie M., 10 years of age, who iyo 
Bullet Wound Treatment. 
was standing talking to a companion, and 
suddenly sunk down to the ground, appar- 
ently lifeless. Her playmates heard a 
queer noise, which was the spud of the bul- 
let which struck the girl’s head an inch 
above and behind the right ear. When 
Dr. B. saw her a few minutes later, she 
was wholly unconscious, and on the walk 
where she fell was a pool of blood, contain- 
ing about a teaspoonful of brain substance. 
Within half an hour an ecchymotic swell- 
ing appeared above the eyeball in the 
outer part of the right orbit. Blood had 
flowed from the nose immediately after the 
injury was received. Dr. John Best of 
Arlington Heights was called in consulta- 
tation. The opening in the skull was 
round and clean cut on the outside, but 
splinters of bone could be felt projecting 
from the inner table. An elastic catheter 
about the size of the external wound was 
used for purposes of exploration, as being 
less likely to injure the sound tissue. Other Cases. 
171 
This passed about two and one-half inches 
into the brain and pointed in the direction of 
the right orbit, but the ball could not be 
detected. On account of the swelling and 
discoloration about the eye, it was thought 
that the ball had fractured the orbital 
plate, though no foreign body could be felt 
in the orbit. The wound was carefully 
dressed antiseptically, all spiculse of bone 
projecting from the inner edge of the 
cranial wound being removed. The prob- 
ing and removal of bone fragments caused 
no pain, but the patient moaned whenever 
the scalp wound was touched. Two or 
three hours later the child spoke a few 
rational words and the mental faculties 
were gradually restored. The temperature 
did not at any time rise above one hundred 
and one degrees. There was no paralysis 
and slight headache was complained of 
during the first few days only. In three 
weeks the child was out doors at play. 
The right eye remained more prominent / 72 
Bullet Wound Treatment. 
than the other, and at times there was 
double vision. After having made a number 
of examinations without result, Dr. B. at 
length discovered the ball in the right orbit 
between the inner wall and the globe of the 
eye. The patient being anaesthetized an inci- 
sion was made in the conjunctive, and a thir- 
ty-two calibre ball extracted. The eyesight 
soon became normal and the little girl 
attended school the following autumn with 
all her mental faculties unimpaired.” 
Gunshot Wounds of Knee. — Sir Wil- 
liam MacCormac comments as follows 
upon two successful cases, published in 
detail in the Lancet, Feb. 27, 1886, p. 
389. The two cases recorded are strik- 
ing from the similarity of the injury in each. 
“The bullets causing the damage were 
almost alike in size, although one was dis- 
charged from a rifle and the other at close 
quarters from a pistol. The ball traversed 
the expanded portion of the condyles 
transversely, in both cases from within out- Other Cases. 
*73 
wards, in each instance very near to the 
articular surface, lodging in the bone in 
both, and in both remaining undiscovered 
for a considerable time. In both, too, 
there were symptoms of inflammation in 
the knee-joint, some pain, fever, swelling, 
and subsequent stiffness, which passed off. 
It is difficult to believe that in either the 
injury could have been wholly extra- 
articular. Conical bullets such as these, 
and capable of penetrating the bone to so 
considerable a depth, would be very likely 
to cause fissures which would almost cer- 
tainly extend to the joint surface, while the 
continued presence of the foreign body 
could scarcely fail, one would suppose, to 
excite articular mischief. Nevertheless, in 
neither of these two cases has any perma- 
nent ill-result followed, and the function of 
the joint is in both perfectly restored. 
There is a strong presumption, without, I 
admit, any positive proof, that the knee-joint 
was implicated to a greater or less degree in 174 
Bullet Wound Treatment. 
each of these cases, yet recovery has ensued 
with a freely movable articulation, and cer- 
tainly without, in either case, any special 
advantage in regard to treatment. Per- 
haps, after all, a gunshot injury of the knee 
may not be always so disastrous as it was at 
one time assumed to be. Langenbeck 
told me that he had met with at least one 
hundred cases of penetrating wound of the 
knee-joint followed by recovery during the 
Franco-German war. Many cases of re- 
covery after a bullet had traversed the joint 
and fractured the bones are recorded by the 
Surgeon-General of the United States 
army ; and then there are remarkable re- 
sults published by Bergmann and Reyher 
obtained after antiseptic occlusion in the 
Russo-Turkish and other campaigns. Dur- 
ing the American war, 338 cases of unmis- 
takable fracture involving the bones of the 
knee-joint made good recoveries after an al- 
together expectant plan of treatment—that 
is, both life and limb were preserved. Many Other Cases. 
775 
of the cases, beside the one which I have 
first quoted, are most remarkable, but for the 
details I must refer to the Surgeon-Gen- 
eral’s report. A conservative treatment, 
whenever it is possible to adopt it, is prob- 
ably by far the most promising one for gun- 
shot injury of the knee-joint, and it has 
proved the most successful, especially in 
recent campaigns. Excision of the knee 
for gunshot injury in time of war has hither- 
to been disastrous, while amputation has 
been very fatal also.” 
In the Gazette Hebdomadaire de Medi- 
cine et de Chirurgie for Sept, n, 1885, 
Paul Reclus, in an article entitled “ Trait- 
ment des blessures par balle de revolver,” 
ably argues in favor of this treatment and 
quotes the following five cases from his 
practice. 
i. A boy of fifteen years received an 
accidental revolver wound with a ball of 176 
Bullet Wound Treatment. 
9 m. m. calibre, which entered the right 
hypochondrium, pierced the liver, and 
lodged, as indicated by symptoms, at the 
base of the thigh in the depths of the 
proas muscle. The case when seen had 
already been probed to the depth of 10. 
cm. But, says the writer, “ nous mettons 
fin a cette exploration dangereuse.” The 
wound was dressed antiseptically. The 
patient made a perfect recovery without 
further symptoms. 
R. then states that all surgeons, however, 
seriously abstain from exploring wounds 
of the cranial, thoracic, and abdominal 
cavities, but doubts if the conduct of 
several of his colleagues would have been 
similar to his in the four remaining cases. 
2. A major of artillery, while fooling with 
a small pocket revolver, shot himself in 
the left index finger, close to the meta- 
carpo-phalangeal joint. The ball, a very 
small one, lodged in the bone. It was 
left in the wound, as the patient’s wife ob- Other Cases. 
177 
jected to its removal on the grounds that 
she “ne voulait pas d’un mari infirme.” 
Three months later the patient was seen, 
and had been without symptoms, and ex- 
cepting a linear cicatrix there was nothing 
to indicate a former injury. 
3. A girl, shot by her rejected lover 
with a revolver of small calibre, received 
a wound in the left breast. The ball 
penetrated beneath the muscles along the 
chest wall and appeared under the edge 
of the pectoralis major. A direct incision, 
a few centimeters in depth, would have 
sufficed to extract it, but it was let alone, and 
under an antiseptic dressing recovery was 
complete. The ball became thoroughly 
encysted. 
4. A law student, shot by his mistress 
who supposed herself deserted, was 
wounded in the posterior cervical region. 
The ball penetrated the muscles and 
lodged against the occiput, as far as 
could be determined by superficial exam- 
ination, palpation without stilet or sound. 178 
Bullet Wound Treatment. 
The patient insisted on its extraction but 
R. absolutely opposed this. The wound 
was covered with iodoform and the parts 
immobilized with a stiff bandage. In 
several days cicatrization was complete, 
and at time of reporting case the most ex- 
tended movements could be made without 
trouble. 
5. Was an accidental wound of the 
thigh. The ball pierced the internal saphe- 
nous vein at the upper part of the limb 
and buried itself in the popliteal space. 
After being assured that the large vessels 
and nerves were intact, and as hemorrhage 
had ceased, the wound was dressed with 
iodoform and immobilized. The cutaneous 
orifice was a little long in healing, but on 
the twelfth day the patient was about his 
work. 
Case XXI. 
“The patient died of septic infection of 
the blood. It was blood-poisoning, whether 
called pyaemia or septicaemia. Other Cases. 
179 
“The source of this infection is the 
subject of inquiry. 
“‘The ball entered the body on the right 
side, at a point three inches and a half 
from the spinous process of the first lumbar 
vertebra. It fractured the eleventh rib, 
was then deflected downward, fracturing 
the twelfth rib, and passed across the axis 
of the body through the spinal column, in 
front of the spinal cord. It fractured the 
body of the first lumbar vertebra, and drove 
a number of small fragments into the adja- 
cent soft parts. And it lodged about two 
inches and a half to the left of the spine, be- 
low the pancreas and behind the perito- 
neum, where it was found completely 
encysted.’ 
“The post-mortem showed that the ball 
was, and had been for a long time, com- 
pletely encysted. It was, therefore, harm- 
less, and must be eliminated from the list 
of agencies supposed to have produced the 
septic condition of the blood.” MEDICAL WORKS 
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LEGENDS OF THE RHINE. From the German of Prof. Bernard. 
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A SELECTION FROM THE POEMS OF PUSHKIN. 
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RALPH WALDO EMERSON, Philosopher AND Seer. An Estimate 
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SOLOMON MAIMON: An Autobiography. Translated from the Ger- 
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HANDBOOK OF PSYCHOLOGY. By Prof. J. Clark Murray, 
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AALESUND TO TETUAN. By Chas, R. Corning. A Volume of 
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