The Art of Primary Union 
OR 
UNION BY ADHESION, IN LARGE 
INCISED WOUNDS 
BY 
FRANK H. HAMILTON, M.D. 
NEW YORK 
Reprinted from The Medical Record, January 2, 1886 
NEW YORK 
TROW’S PRINTING AND BOOKBINDING COMPANY; 
201-213 East Twelfth Street The Art of Primary Union 
OR 
UNION BY ADHESION, IN LARGE 
INCISED WOUNDS 
BY 
FRANK H. HAMILTON, M.D. 
NEW VOR1? 
Reprinted from. The Medical Record, January 2, 1886 
NEW YORK 
TROW’S PRINTING AND BOOKBINDING COMPANY 
201-213 East Twelfth Street 
1886 • THE ART OF PRIMARY UNION, OR UNION BY 
ADHESION, IN LARGE INCISED WOUNDS. 
In the following pages I shall employ the terms “ primary 
union,” “ union by adhesion,” “ union by coagulable 
lymph or by fibrin,” and “ union by adhesive inflamma- 
tion” as synonymous, recognizing no other forms of 
primary union than those which have been thus variously 
designated by different writers, and of which the last 
mentioned is, perhaps, the most representative. 
The conditions requisite to insure “ primary union,” 
or “union by adhesive inflammation,” in large incised 
wounds, are : 
First, a good, or at least an average state of the gen- 
eral health, and especially the absence of any systemic 
infection or dyscrasy, such as pytemic or septicemic in- 
fection, struma, syphilis, etc. 
Second, the removal of all foreign bodies from the 
wound. 
Blood is a foreign body. It must therefore have ceased 
to flow, and such as remains upon the surface must be 
carefully removed. It must be rendered certain, also, 
that it will not again flow after the wound is closed. 
Soon after the infliction of the wound, when the bleed- 
ing has wholly ceased, serum, a product of the first stage 
of reaction, begins to be poured out, and in greater or 
less amount, according to the extent of the surface ex- 
posed, and the degree of the reaction. Equally with 
blood it is a foreign substance. If effused in small quan- 
tities, however, it may be absorbed ; but if effused in 
large quantities it will not be absorbed, and will as ef- 
fectually prevent primary union as the presence of blood ; 4 
and since it often continues to flow for three or four days 
after the wound is closed, it will be necessary, in many 
cases, to provide for its escape by suitable drainage. 
Third, lymph, or as it is also called, coagulable lymph, 
soon begins to be effused, coincident with the second 
stage of reaction. If the reaction does not exceed cer- 
tain bounds it is euplastic, and is the material by which, 
or through which, primary union is to be established. It 
coagulates readily, and its presence upon an open wound 
is usually indicated by the glazed appearance of the sur- 
face. It is advantageous, therefore, to leave the wound 
open until this appearance is presented. 
Fourth, in the cleansing, closure, and dressing of the 
wound every precaution must be taken not to do any un- 
necessary violence to the parts, either by the hands, the 
sponges, sutures, adhesive strips or bandages, or at a 
later day in the renewal of the dressings, since all these 
things tend to increase the inflammatory reaction, and to 
carry it beyond the limitations which are assigned to the 
effusion of euplastic lymph. In short, they precipitate 
suppuration 
The same conditions are requisite for securing primary 
union in contused and lacerated wounds as in simple in- 
cised ; but in consequence of the immediate devitaliza- 
tion of the tissues, resulting in the formation of sloughs, 
or of the excessive inflammatory reaction occasioned by 
the violence done to the parts, the portions of these 
wounds which will be permitted to unite by adhesion 
will be comparatively small; and in some cases the 
promise in this direction is not sufficient to warrant the 
attempt. 
The several conditions above named as necessary for 
the union of large wounds by adhesion are not now for 
the first time declared. Their first enunciation was 
made substantially in the latter part of the last century, 
and were repeated often by systematic writers. They 
were a part of my earliest lessons in surgery, and have 
been taught and practised by me during all my profes- 5 
sional life up to the present time. I believe, also, that a 
strict compliance with these rules constitutes the only 
grounds for the superior success of some surgeons, as 
compared with the success of others, at the present day; 
and if their success is greater than that of surgeons who 
fifty or one hundred years ago practically applied these 
rules—and 1 am willing to concede that it may be, al- 
though it is not proven—it is because they have more 
exactly complied with the conditions named. 
In order to place before you satisfactorily my grounds 
for this belief, it will be necessary to recall, briefly, the 
history of this department of surgery. 
As to the best mode of treating large incised wounds 
the opinions of surgeons have differed in different pe- 
riods of the history of surgery. These periods have usu- 
ally been arranged under two divisions, namely, the ear- 
lier period, in which it was taught almost universally that 
they must be left open, in order that they might unite 
by granulation ; and the later period, dating from the lat- 
ter part of the last century, in which it has been taught 
that they should be closed, and encouraged to unite by 
adhesion. 
It will appear, however, that during the latter part of 
the second period, for one reason or another, the prac- 
tice, if not the teachings, of surgeons has at times greatly 
faltered, if it had not at one time, not very remote, gone 
back fully to the practice of the first period. Surgeons 
again preferred to leave their large wounds open, to sup- 
purate and close by granulation. Certainly very many 
practised it, and not a few publicly taught that this was 
the best method. This lapse of faith has happily been 
overcome, and confidence in union by adhesion is to- 
day completely restored. The probable causes of these 
fluctuations of opinion will, perhaps incidentally, be 
made apparent in the following history, although my 
main purpose is to show that the principles underlying 
success are the same now as they always were. 
The first serious attempts to secure union by adhesion 6 
after large amputations were made by Edward Alanson, 
of Liverpool, whose book, entitled “ Practical Observa- 
tions on Amputations,” was published in 1779. His prac- 
tice and opinions soon found acceptance with the large 
majority of surgeons in all parts of the world. They 
were adopted by Hey, Percy, Lucas, Guthrie, Syme, 
Liston, and Bennett, in England ; by Pirrie in Scotland ; 
by Velpeau, Dubois, Boyer, Dupuytren, Delpech, Rich- 
eraud, and Roux, in France, and by most of the German 
and American surgeons. 
In what manner this union was to be accomplished, 
they have constantly, with more or less minuteness of de- 
tail, informed us. 
Alanson speaks of the importance of securing every 
bleeding vessel, of drawing the arteries out with a tenacu- 
lum, so that the ligatures shall not include other tissues, 
and thus form sloughs or delay their removal; of making 
the flaps so long that they will come together without 
strain, and of securing proper drainage. 
Says Velpeau, speaking of incised wounds in general : 
“ In order to attain this end, we must give to the dressing 
more care and time than is ordinarily given to it; the 
section of the soft parts should be neat and regular ; the 
integuments should fall without effort on the front part 
of the stump.” . . . “ All the arteries liable to bleed 
should be immediately tied or twisted ; the sides of the 
wound, freed from foreign substances, should touch 
throughout their whole surlace.’' . . . “The straps 
should do no more than preserve the coaptation, with- 
out pressing or exercising any drawing force.” 
. . . “ The suture should be added to them, or even 
preferred, if the skin is thin or tends to roll inward; the 
diseased parts should be afterward kept in the most 
perfect immobility, and the inflammation should be mod- 
erated by every possible means.” 
When speaking of amputations Velpeau repeats in ef- 
fect the same instructions. 
Most of these surgeons have referred in their writings 7 
to the necessity of waiting until the surface of the wounds 
becomes glazed, before closing them. 
“ After a time,” says Bennett, “ the surface is glazed, 
as it is called; ” and it is at this period that he recom- 
mends the closure of the wound. 
Says Pirrie: “ All oozing having been completely ar- 
rested, foreign matter removed, and the surface having 
taken on a glazed appearance,” we may proceed to close 
the wound. 
Not a few of the most distinguished operators went 
much farther both in their teachings and practice. 
Mr. Syme says wait six or eight hours before closing 
the wound. 
Velpeau says that “in order to arrive with more cer- 
tainty at this result, Parrish, in America, and also a great 
number of surgeons in England and Germany, and Du- 
puytren, in France, have established a precept not to dress 
recent wounds but after the lapse of some hours.” Dr. 
Townsend, in a note to the American edition of Velpeau, 
says that Dr. Valentine Mott “ approves very highly of 
leaving many wounds exposed for some time, even for an 
hour or more.” 
Of those mentioned above, Mr. Syme subsequently 
modified his opinion so much as to permit the dressing to 
be made at the same time as the amputation. 
Even at a date much later than any writer which has 
been hitherto mentioned, Mr. Erichsen has said, “ Hence 
in the dressing of surgical wounds, such as stumps after 
amputation, and in all cases in which it is advisable to 
attempt to procure union by adhesive inflammation, the 
cut surfaces should not be brought together for a few 
hours, until all oozing of blood has.ceased and the fibrin- 
ous layer has been thrown out.” 
It needs to be said that, following the example of Mr. 
Syme, after a time most surgeons relinquished the prac- 
tice of waiting several hours before closing the wound, 
both because of its inconvenience and because in most 
cases the glazed appearance was found to be present 8 
sufficiently early to enable them to do so without com- 
promising the desired result. 
Alanson, Syme, Liston, and probably all the system- 
atic writers of this period, taught the necessity of not 
only stopping all bleeding, but also of providing for 
the escape of serum by suitable drainage. Mr. Syme, in 
1825, wrote a paper in which he spoke of the flow of 
serum as “ invariable,” and of the absolute necessity, 
therefore, of providing for its escape. 
Let us now inquire what were the results of this plan 
of treatment, which was substituted for the open treat- 
ment, and which found favor with so many—nearly all, 
indeed—of the most practical surgeons at the close of the 
last century and up to a late period during the present 
century. 
Alanson declares that, under his improved treatment, 
of 35 cases of amputation of the leg and thigh, at the 
public hospital in Liverpool, he did not lose one, while 
of the preceding a6 amnutations he had lost to 
Mr. Liston, a pupil of Syme’s, says, that of the last 20 
cases of amputation of the thigh for chronic disease, 
which he had seen performed by Mr. Syme under this 
plan of treatment, not one died ; and this although some 
of them seemed in a nearly hopeless condition at the 
time of the operation. 
Of 92 soldiers treated in this manner on the field of 
battle by Percy, 86 were cured in twenty-six days; and 
of 70 cases thus treated by Lucas only 5 died. 
It is true that Pelletan, who did not favor the practice 
of attempting union by adhesion, lost 5 out of 6 treated 
by himself; but it is sufficiently apparent that he had not 
complied with two of the most important conditions of 
success, when he declares that in all the fatal cases the 
autopsy showed the presence of blood, as well as of pus, 
between the surfaces of the wounds; and that in the only 
case in which recovery took place the accumulated pus 
forced off the adhesive straps. He had neither secured 
the bleeding vessels properly, nor provided for drainage. 9 
What treatment, either ancient or modern, has pre- 
sented a better record than this furnished by Alanson, 
Syme, Liston, Percy, Lucas, and, so far as we know, 
by the faithful disciples and distinguished advocates of 
their practice ? 
It is scarcely necessary to remind you that these re- 
sults were obtained before the introduction of anaesthet- 
ics or of antiseptics. 
In the face of these remarkable and universally con- 
ceded successes, which contrasted so strongly with the 
slow and uncertain results of the earlier practice, it is 
hard to understand how any steps backward could have 
been taken ; but this is what actually happened, the 
retrograde movement commencing even before the distin- 
guished advocates of the new system had died. Here 
we enter that point in the history of the treatment of 
wounds to which I have already referred, as that in which 
the practice of attempting to obtain union by adhesion 
“ faltered,” and surgeons were everywhere returning to 
the practice of leaving their large incised wounds to sup- 
purate and granulate. Of the fact as now slated there is 
no question. How this change was brought about I will 
now attempt to explain, and also how, through the agency 
of one man, Mr. Lister, the practice of union by adhesion 
was happily restored. 
In the first place, to comply with all the conditions 
demanded for union by adhesion requires time and pains- 
taking. It demands scrupulous attention to the most 
minute details. To omit one of the many conditions 
named is, in most cases, as fatal as to omit the whole. 
Celerity is here inconsistent with success. Surgeons, 
therefore,who wish to acquire a reputation as “brilliant” 
operators, are likely, especially in their public or hospital 
exhibitions, where their example can do most harm, to 
fall short of the requisition, and then, by their failures, to 
bring discredit upon the system they teach and are at- 
tempting to follow. 
Second, war is unfavorable to this department of sur- IO 
gery. The exigences of the battle-field do not supply the 
time, nor the appliances necessary for the application of 
all the principles involved in primary union. There are 
many occasions on the field of battle when the demands 
upon the surgeon to save the life of the patients tempor- 
arily, must be paramount to all other considerations, and 
in which, as Armand has said, the only precept is, cite, 
citissime. 
Macleod says, speaking of his experience in the Cri- 
mean War, “ I never saw one case among our most nu- 
merous amputations in which primary adhesions took 
place throughout the whole surface of the flaps.” 
My personal experience in our own late Civil War was 
that primary union after large amputations was the excep- 
tion ; and that toward the close of the war army sur- 
geons were everywhere returning to the practice of open 
dressings. This lack of success in' their attempts to se- 
cure primary union upon the field induced, it is fair to 
suppose, on the minds of many who did not sufficiently 
consider the causes of their failures, a general lack of 
confidence in the plan, which led them to reject it even 
after they returned to civil practice. 
If Percy had better success as an army surgeon in 
securing primary union than most other surgeons have 
had, it was because he was better able to comply with 
the conditions. 
Third, the introduction of anaesthetics has had no incon- 
siderable influence. My own experience has not fur- 
nished me with any evidence that general anaesthesia has 
appreciably delayed the union of tegumentary wounds, or 
of the majority of small wounds, when they occur in 
most of the other tissues of the body. What the fact 
may be in this regard, I am unable to say, nor would it 
perhaps be very easy to determine ; but in reference to 
its effect in large muscular wounds, or in major amputa- 
tions, and especially where muscular flaps are made, I 
have no doubt their union has been thereby delayed and 
often prevented. II 
I practised surgery some years before the introduction 
of anaesthetics, and soon after I began to use them it 
became a matter of common observation with me, and 
of comment, that the same measures did not so often in- 
sure primary union as before. I think also that Mac- 
leod’s experience in the Crimean War, already referred 
to, goes further than proving that amputations made un- 
der these circumstances do not usually comply with the 
conditions of success. He says that “ chloroform was 
almost universally used in the British army.” If, then, he 
was unable to meet with a single case of complete prim- 
ary union, it seems fair to charge a part of this result to 
the general use of chloroform. 
But aside of any specific testimony upon this subject, 
let me appeal to the reader’s intelligent judgment. When 
large flap amputations are made while the patient is com- 
pletely under the influence of an anaesthetic, in addition 
to the total loss of sensibility—for which both operator 
and patient have reason to be thankful—we observe 
that the muscles do not quiver and retract under the knife, 
that they hang apparently lifeless from the wound as they 
do when made upon the cadaver, and that they do not 
wholly resume their normal contractility and position un- 
til some hours after the operation is completed. The 
arterial blood is dark, and can scarcely be distinguished 
from the venous, showing that it is imperfectly oxidized. 
The surface of the wound has a dark, grumous look, 
wholly unlike the appearance presented under other cir- 
cumstances. 
Is it reasonable to suppose that the effusion of lymph, 
so as to give a glazed appearance to the wound, and 
which is essential to primary union, will not, under these 
circumstances, be delayed ? and that this delay will not 
often extend beyond the period when primary union is 
possible ? For myself, if I were asked this question, 
and no evidence were presented on either side, I would 
say it must necessarily be delayed. 
I have been speaking thus far of the circumstances 12 
which seem to explain why surgeons for a while faltered 
in their faith in primary union. This explanation, how- 
ever, which may or may not be correct, was not neces- 
sary to the historical sketch which I proposed to make. 
The material point is, that for a time surgeons did actu- 
ally treat wounds as if they had forgotten the conditions 
of success, or had lost faith in the earlier teachings. 
In attestation we have only need to recall what we have 
often witnessed in the public amphitheatres in this city 
and elsewhere during the last twenty or thirty years ; 
large flap amputations, made dexterously, but afterward 
the surfaces of the wound rudely handled, fretted by 
rough sponges, the wounds closed before the blood had 
ceased to flow, then hermetically sealed by adhesive 
straps, without provision for drainage, and hurried from 
the amphitheatre to make way for another brilliant 
operation. 
To one who has only observed the results of this 
method of treatment, without having given attention to 
the means by which they were brought about, the sole 
conclusion must be, that it would be far better to return 
to the old practice of leaving the wounds open, since 
nothing short of a miracle could secure primary union ; 
and this is precisely the conclusion to which, within a 
few years, some surgeons have arrived. 
We have now reached the period in the history of 
surgery when Mr. Lister interposed, and turned back the 
tide. He taught that under a most thorough system of 
antisepsis primary union could be secured; and he 
demonstrated that it could be secured even after the 
most profound anaesthesia. This was the great lesson 
which he had in his mind, and which he successfully 
taught; but he taught also, incidentally, that the wound 
must be handled gently, all foreign substances must be 
removed, the blood must cease to flow, and provision 
must be made for drainage. In short, if you will look 
carefully into his teachings and practice, and the practice 
of his disciples, you will see that they omit nothing 13 
which, in the opening of this paper, I declared essential 
to success; and I venture to say, that if they did, no 
amount or quality of antisepsis would secure union by 
adhesion. 
Tne influence of Mr. Lister, backed by his specious 
theories, secured a return to the old practice of the ad- 
vocates of primary union in all its essential details, and 
to this it added antisepsis. Fortunately, antisepsis 
carried with itself, inseparably, one thing more, namely, 
the agency of a moderate stimulant and astringent, which 
served materially to resuscitate the tissues and the capil- 
lary vessels which had been temporarily paralyzed by 
the general anaesthesia, and thus in some measure to 
counteract its deleterious effects. 
As to his practice of removing carefully and effectually 
all foreign substances before closing the wound, and 
providing for the escape of the serum or blood which 
might subsequently be effused between the cut surfaces ; 
and as to his practice of applying industriously, so long 
as the wound was open, a moderate stimulus to the cut 
surfaces in the form of spray or lavements of dilute car- 
bolic acid—these are facts which admit of no dispute. 
But as to his declaration that the results which he ob- 
tained were due to the destruction of certain micro- 
organisms constantly floating in the atmosphere, and 
which being received and propagated upon the raw sur- 
faces prevent primary union, or which being conveyed 
into the system by absorption cause septicaemia—this is 
only a theory, and one which is far from being universally 
accepted. It has not been conclusively shown that 
the formation of pus depends in any case upon the 
presence of germs. When suppuration takes place in 
closed cavities these germs are generally absent; but as 
if to show how impossible it is to prevent their pernicious 
intrusion—in case it be admitted that they can or do 
cause suppuration—they are occasionally found in great 
numbers in cavities which have never been open to the 
air. 14 
If germs are so readily absorbed by open surfaces, and 
distributed through the system, of what possible use is it 
to commence the application of the antiseptics one or 
several hours after the reception of a wound, or months 
after the skin has been destroyed, and then apply it with 
so much assiduity, so long as the knife of the surgeon or 
his hands are in the wound ? 
If, on the other hand, the germs are not so easily ab- 
sorbed, and only nestle upon the surface of the wound, 
why, instead of using the antiseptic from the beginning 
to the close of a surgical operation, is it not sufficient to 
apply it thoroughly just before closing the wound ? 
There is one quality or property of antiseptics to 
which allusion has not yet been made, namely, their power 
to prevent the decomposition of blood, of pus, and of 
serum ; the decomposition of either of which changes 
these otherwise comparatively innocuous fluids into an 
irritating ichor. But when employed for this purpose 
they can serve no useful end, except when blood, serum, 
or pus are actually present. To apply them, therefore, 
immediately preceding the closure of the wound, and 
whenever subsequently blood, serum, or pus present 
themselves, or seem likely to present themselves, is 
rational, and would justify their employment also, 
within certain limitations, in all cases, after the closure 
of the wound and until the end of the treatment; but it 
supplies no argument for the adoption of all the compli- 
cated procedures with which Mr. Lister and his disciples 
preface and encumber their operations. 
The conclusion to which we are brought is, that while 
we are indebted to Mr. Lister for having restored confi- 
dence in union by adhesion, it seems equally certain 
that his excellent results have been obtained, not by a 
literal compliance with the rules which are the logical 
deduction from his theories, but by his strict enforce- 
ment, in the practical application of his theories, of cer- 
tain other conditions, which he seems to regard as acces- 
sory and incidental, rather than of paramount importance. 15 
If this conclusion is correct, then there is not sufficient 
reason why the air of a room in a private house, or even 
in a public hospital, not suspected of being infected by 
some contagious or infectious disease, such as diphtheria, 
scarlatina, erysipelas, etc., should be disinfected before 
an operation is performed, or why all persons present 
should have been previously disinfected, or that they 
should be required to breathe through disinfecting respi- 
rators, or should wash their hands in carbolized water, 
or search beneath their nails for concealed germs, or why 
they should carbolize their instruments, or why, indeed, 
they should pour a constant stream of carbolized water or 
of spray upon the wound while operating, except, as I have 
already stated, for its utility in closing the capillary ves- 
sels, and its power in restoring tone to the paralyzed 
tissues when anaesthetics have been employed. 
The various manipulations and devices for the purpose 
of excluding the germs above enumerated have at one 
time or another been suggested by Mr. Lister or his dis- 
ciples, and, in my opinion, they are all necessary if Mr. 
Lister’s theory be correct. If it be not correct, they serve 
no other purpose than do the walking, talking, and gestures 
of the prestidigitator. They abstract the attention, and 
conceal the adroit manipulation by which the trick is 
actually performed. 
I say this with all respect for the integrity of the dis- 
tinguished surgeons who hold strictly to Mr. Lister’s 
opinion and practices, since in one particular they differ 
from the class to which I have compared them. The 
prestidigitators are not deceived, but deceive their audi- 
ences ; while Mr. Lister and his disciples deceive both 
themselves and their audiences. 
It will be observed that I have thus far spoken only of 
carbolic acid as an antiseptic, since it is that which was first 
used by Mr. Lister, and still continues to be more com- 
monly used than any other; but I am aware that surgeons 
have lately substituted many other things for carbolic acid, 
and with equally satisfactory results ; and that many who 16 
continue to prefer carbolic acid have rejected ihe con- 
tinuous spraying, and in several other particulars have 
modified the treatment. At the present moment a weak 
solution of the bichloride of mercury is the most active 
contestant of the alleged superior virtues of carbolic acid. 
In a paper read before the New York County Medical 
Association in February, 1885, Dr. Theodore R. Varick, 
surgeon to St. Francis’ Hospital, Newark, N. J., states 
that he has for nearly six years substituted hot water, or 
water a little below the boiling-point. Immediately 
after the larger vessels have been tied, he applies the 
water freely and continuously to the raw surfaces until 
all oozing has ceased and “ the parts are thoroughly 
glazed.” The effect of this is, as claimed by Dr. Varick, 
to coagulate the albumin in the serum, by means of 
which the open vessels are closed against the admission 
of germs, and to impart a moderate stimulation. 
In a private letter Dr. Varick informs me that of 
thirty-nine major amputations thus treated, mostly in 
cases of railroad accidents, only two terminated fatally, 
one by hemorrhage and one by cardiac disease ; and that 
in all of the various operations performed by him there 
has been no case of septicaemia or of pyaemia, “although 
in several instances the hygienic surroundings have been 
of the worst kind.” 
Dr. Varick attributes his remarkable success, which is 
probably equal to that obtained by those who adhere to 
the use of carbolic acid, or of the bichloride of mercury, 
to the power of hot water to close hermetically the ca- 
pillaries, and thus to prevent the admission of germs. 
Since, however, in most of his cases—railroad injuries— 
there must have been extensive exposure of the vessels 
by laceration, it is again difficult to understand, as I have 
before suggested, how they can be excluded when the 
door has been left open for some hours before the patients 
came under his notice. In short, while I fully approve 
his practice, and have myself often adopted it, I do not 
accept his theory. 17 
Mr. Lawson Tait, in reporting “ a series of one hun- 
dred and twelve consecutive cases of consecutive opera- 
tions for ovarian and parovarian cystoma without a 
death,” and in which no antiseptics were employed, says : 
“ I tried the so-called antiseptic system in all its ever- 
varying details in as complete and unprejudiced a series 
of experiments as I believe it possible for man to under- 
take.” . . . “I finally came to the conclusion that 
my patients were being poisoned by the use of carbolic 
acid, thymol, and various other substances, which were 
being used by others as well as myself for the purpose of 
destroying the germs which were supposed to do so much 
harm,” . . . and he adds, that his experience had 
proven to his own satisfaction conclusively that he “could 
do better without Listerism than with it; that, in fact, the 
only tendency of this so-called antiseptic system was to 
mar ” his success. 
In the light of all that has already been said upon this 
subject no one familiar with Mr. Tait’s careful and pains- 
taking mode of operating, will fail to see where lies the 
seal secret of his hitherto unparalleled success, and which 
he himself says is due to “ increased personal experi- 
ence, increased attention to all the minute details which 
go to create success, and inattention to any one of which 
may defeat the best-laid plans.” “ In every case,” he 
adds, “ where there has been a tendency to ooze, or 
where the patient has been advanced in life, I have used 
the drainage-tube, an addition to our means of saving 
life of which it is impossible to speak too highly.” 
I agree fully with Mr. Tait, that this simple narrative of 
his personal experience, the accuracy of which is assured 
by his acknowledged integrity, and by abundant collat- 
eral testimony, ought to “ dispose forever of the much- 
discussed question of Listerism in abdominal surgery ” 
Incidentally I will add that it ought to furnish a beam 
of light to those surgeons who, during the last three or 
four years—ever since the death of President Garfield— 
have been prophesying the brilliant future of gunshot 18 
wounds of the belly under a “ strictly antiseptic treat- 
ment,” according to whom the time was near, if it had 
not actually arrived, when, under the protective influence 
of antisepsis, surgeons would open the belly freely, un- 
ravel the intestines and close their wounds, search care- 
fully through every pocket of the peritoneal cavity, and, 
if need be, dissect and explore the regions outside of the 
peritoneum, and, having found and removed the lost ball, 
they would wash out the fecal matter and the blood 
which had necessarily escaped into the peritoneal cavity, 
and close the abdominal wounds, with a reasonable 
probability of restoring the patient to life and health. 
The fact that the vertebras had been penetrated and 
were crumbling would constitute no bar to success ; and 
indeed nothing would interpose a serious obstacle, ex- 
cept that the missile had lacerated some important blood 
vessel, or had buried itself in some solid viscus, a fact 
which perhaps nothing but an ante-mortem or post-mor- 
tem dissection could determine. 
These inspired revelations, uttered sometimes with a 
certain tone of regret for the lamentable ignorance of 
those who have lived before them—generally by men 
who have had little or no personal experience in the 
treatment of such wounds, and who certainly never prac- 
tised successfully what they foresaw in their prophetic 
vision—still wait for fulfilment, notwithstanding the 
many thousand opportunities which both civil and mili- 
tary experience have since furnished. 
I am not prepared to say that surgeons have not exag- 
gerated sometimes the dangers and difficulties of search- 
ing for balls which have entered the cavity of the belly ; 
but I do not think so ; and I believe that all surgeons 
who have had much experience in this class of injuries 
will agree with me. I only intend to say that antisepsis 
has in no degree abated these dangers and difficul- 
ties. 
Before dismissing this subject it seems necessary to con- 
sider briefly certain relatively modern suggestions, other 19 
than antisepsis, which have been made for the purpose 
of securing the primary union of large incised wounds. 
“ Bruising ” the vessels, first suggested by M. Briot, 
and “ torsion,” which owes its introduction to M. Vel- 
peau, are both still practised upon the small vessels with 
a certain degree of success, but in my personal experi- 
ence both have more often failed. 
Veitch, in 1806, used for the ligation of both large and 
small vessels very fine silk, and cut off the ends, leaving 
the knot in the wound to become encysted ; but as small 
abscesses subsequently formed in many cases, Ruysch, of 
Germany, and Physic, of this country, substituted animal 
ligatures, and treated them in the same manner. Valen- 
tine Mott says, like the silk ligatures they often formed 
abscesses, and after a short time their use was almost en- 
tirely abandoned. 
At the present time we see the practice of using the 
animal ligature revived, but only, for the most part, in its 
application to small vessels upon the surface of the 
wound. In this manner they are now used quite freely, 
and no doubt serve the purpose of shortening the period 
we may have to wait before closing the wound, and of 
giving additional security against secondary hemorrhage 
during the early period of reaction. Notwithstanding the 
statements made to me by some surgeons, that they have 
seen no abscesses follow their use, this has not been my 
experience. In at least two cases out of the few in 
which I have adopted this practice very small abscesses 
have formed. I must, therefore, consider the method as 
still under trial. 
The substitution of cloth or a towel for the sponge, as 
a means of removing the blood from the surface of the 
wound, made, as I understand, for the purpose of pro- 
tecting the patient against septic germs, is subject to the 
criticism that it is illogical. If germs can be destroyed 
which lie exposed upon the surface of a wound, or upon 
instruments, they can equally be destroyed when they lie 
secreted in sponges, by a thorough saturation with some 20 
disinfectant, or by boiling water; and if they cannot be 
so disinfected, neither can the towel be. I observe, 
however, that in using the towel it is only laid upon the 
surface, not drawn roughly over it, and in this practice I 
see a positive gain. When a sponge is drawn roughly 
over the quick and sensitive wound, in the case of a pa- 
tient who is not anaesthetized, it causes most acute pain; 
and although when the patient is insensible it can no 
longer cause pain, it can fret and partially disintegrate 
the surface as when rasped by a file. If surgeons’ assist- 
ants cannot learn how properly to use a sponge, let them 
use a towel. 
Drainage-tubes made of bone, from which the mineral 
structure has been removed, and which, therefore, may 
become dissolved or even absorbed, present no possible 
advantage over the ordinary india-rubber flexible tube, 
except that, if by any accident they should escape into 
the wound, they will take care of themselves and prob- 
ably do no harm. The objection to them is, that they 
are short and inflexible, and cannot be made to follow a 
long and tortuous canal. 
In closing the wound some modern surgeons have 
given the preference to metallic sutures, others to the 
animal sutures, or to horsehair, for each of which it 
is claimed that they cause less irritation than silk, and in 
this way improve the chances of primary union. 
Any suture, no matter of what material composed, will 
cause irritation and suppuration at the points of pressure, 
if it is employed upon tegumentary tissues for the pur- 
pose of drawing the lips of the wound together forcibly, 
as when, owing to a deficiency of structure, they could 
not otherwise be made to meet; but I have elsewhere 
explained that this is not, in tegumentary wounds, and 
but rarely in any wound, the proper function of a suture. 
In the class of cases now under consideration, where 
we desire prompt primary union, the suture is intended 
only to place the edges of the wound in accurate apposi- 
tion, and to prevent inversion. For this purpose the 21 
finest silk suture, introduced as near the margin of the 
wound as possible, and tied lightly, is the best. It will 
cause no more irritation than the wire or horsehair, is 
much more flexible and adjustable, and is, therefore, 
much more easily and painlessly introduced and re- 
moved. The accuracy of these statements I have fre- 
quently verified by employing the two materials on dif- 
ferent parts of the same wound. 
The value of the animal suture consists solely in its 
being spontaneously removed. If it be claimed that its 
value, as now generally employed, consists in its being 
carbolized, the reply is, that the silk may be treated in 
the same way. The only objection which I have to its 
use is, that it is less flexible that silk and is not so fine 
as the finest silk. 
Hot water, as a means of imparting a healthy stimulus 
to paralyzed tissues, of arresting capillary hemorrhage, 
and of removing the blood from the surface of the 
wound, has long been employed by me, applied by means 
of a sponge. The suggestion of Dr. Varick, to apply it 
in an interrupted stream from the nozzle of a pipe 
connected with a reservoir, in the same manner in which 
the antiseptic solutions are now often employed, com- 
mends itself theoretically and by its results. A current 
of hot water, falling with moderate force upon the wound, 
not only removes the blood from the surface, but also 
washes it from the tissues where it has accumulated 
around the bleeding orifices of the small vessels, exposes 
them to view, and enables the surgeon to apply a ligature 
if required. It also coagulates the albumin, and for this 
reason, if for no other, it ought to be satisfactory to 
those who believe that by the interposition of this shield 
the vessels are protected from the intrusion of germs; 
while it is absolutely innocuous, a quality which is not 
possessed by any of the antiseptics, so called, now in use. 
The occasional toxic effects of carbolic acid and of the bi- 
chloride of mercury, in their surgical application, are 
known and admitted by all the advocates of antisepsis. 22 
Dr. Varick recommends that the water have a temper- 
ature “ slightly below the boiling-point.” This might do 
if one were to apply it by means of a sponge, and then 
only for an instant, as I have often done to close a bleeding 
arteriole ; but if employed continuously, or by irrigation, 
through the nozzle of a tube, it ought not to exceed in 
temperature 1120 or 1150 Fahrenheit, or the temperature 
which may be easily borne by the naked hand. 
Finally, I wish to say that while it seems to me capa- 
ble of demonstration that the real secret of Mr. Lister 
has lain concealed under a series of complicated man- 
ipulations, my confidence in the intelligence of my pro- 
fessional brethren is such that I believe they will soon 
abandon all those procedures which are irrelevant and 
wholly unnecessary to success. This is what they have 
already begun to do. In addition to those whose names 
I have mentioned, Mr. Keith, Mr. Callender, Mr. Savory, 
and Mr. Bryant, have publicly declared their non-accept- 
ance of the doctrines of Mr. Lister, as have also a con- 
siderable number of equally distinguished French and 
German surgeons; and the number of those who have, 
after a fair trial, substantially ceased to practise them ac- 
cording to his theory, is constantly increasing. Let us take 
care, however, that in severing our attachment to certain 
theories and practices, we do not loose our hold upon 
anything, whether new or old, which is really useful. 
Antiseptics have their position and function in a great 
variety of wounds, including large simple incised wounds, 
under certain circumstances, and at certain stages of 
their progress. What this position is in the latter class 
of cases—whether it be dominant or subordinate—I have 
sought to explain.