THE DKESSING- OF WOUNDS. 
Read before the Massachusetts Medical Society, June 2, 1874 
It is the business of the physician to know things similar and things 
dissimilar, says Hippocrates, in his Tract on the Surgery ; and one 
may well believe him, in view of the contrariety of doctrines promul- 
gated and enforced in these latter days. Only a few years ago, it was 
dogmatically declared that wounds should be excluded from the air in 
antiseptic dressings. Now comes an equally urgent advocacy of 
leaving them untouched—the open treatment, as it is called ; while 
between these extremes we have every variety of practice, leaning 
toward one or the other method, according as the convictions of the 
practitioner incline him. 
Since such diversities exist in the manner of dressing wounds, 
amounting, apparently, if not in reality, to modes diametrically op- 
posed to each other, it becomes us to consider carefully the various 
methods which their advocates present; to weigh well the results 
claimed, as to whether they are fairly stated, or are intentionally or 
otherwise warped to favor the views advanced; and then to adopt such 
methods in the dressing of wounds as study and experience convince 
us to be best suited to our patients. 
Few physicians are so situated that they can entirely ignore the 
treatment of wounds ; for, although the majority of the profession may 
not claim to make surgery a specialty, and may decline to treat the 
severer injuries or diseases which are classed as surgical, yet almost 
all of us must attend to such as come under the classification of minor 
surgery, which, if mal-treated, may result most unfortunately for the 
patient and the physician. 
Probably, from very early times, it was noticed that in injuries 
where the tissues were so lacerated that the wounds were exposed to 
the air, the condition was vastly more unfavorable for the restoration 
of the integrity of the part, and the rapidity of healing, than where 
the wounds were subcutaneous. Mr. Hunter* divided the injuries 
done to sound parts into two sorts, according to the effects of the acci- 
dent, He says : “ The first kind consists of those in which the injured 
parts do not communicate externally, as concussions of the whole 
body, or of particular parts, strains, bruises and simple fractures, 
which form a large division. The second consists of those which 
have an external communication, comprehending wounds of all kinds, 
Francis TV. Goss, M.D., of Koxbury. 
* Works, vol. iii. p. 240, quoted by Paget. 2 
and compound fractures. The injuries of the first division, in which 
the parts do not communicate externally, seldom inflame ; while those 
of the second commonly both inflame and suppurate.” Mr. Paget* 
states that it hardly seems possible to exaggerate the importance of 
the principle which Hunter has embodied in these sentences. “ For 
of the two injuries inflicted in a wound, the mechanical disturbance of 
the parts, and the exposure to the air of those that were covered, the 
exposure, if continued, is the worse.” 
The recognition of the fact that wounds to which the air has free 
access usually inflame and suppurate, has probably given rise to the 
attempt to render open wounds practically subcutaneous-, by means 
of such dressings as should exclude the air. It is one thing, however, 
to have the tissues unbroken, and the injured parts not exposed to the 
air, and quite another to treat as of this class wounds to which the air 
has once had free admission. Unless we have good reason to believe 
that art can, by its appliances, render practically subcutaneous a 
wound that has once been open, it is better to anticipate the proba- 
bility of inflammation and suppuration, and to provide for them. 
The most prominent advocate of modern times for the occlusive 
treatment of wounds is Prof. Lister, of Edinburgh. Accepting the 
teachings of Pasteur, that the particles of dust which the atmosphere 
contains are germs of bacteria or other allied organisms, and are the 
exciters of the putrefactive changes that occur in wounds, he endea- 
vors by antiseptic dressings to deprive the atmospheric germs of their 
septic energy, so that whatever air reaches the wound shall contain 
no particles capable of exciting septic changes in it. The dressings 
are practically impervious to the air, and are to be applied with scru- 
pulous attention to the minutiae which the author of the system im- 
poses. He claims in this way to bring open wounds approximately to 
the condition of subcutaneous ones. His method is briefly as follows : 
A piece of oiled silk protective is applied to the skin, over the pro- 
tective is laid a quantity of antiseptic gauze, folded in several layers, 
usually eight, while between the two outer layers of gauze a piece of 
waterproof Mackintosh is placed. The whole is retained by a bandage 
of gauze, properly applied. While the part is being operated on or 
dressed, a spray of a solution of carbolic acid is kept constantly play- 
ing over it. Vessels are tied with antiseptic catgut ligature, and car- 
bolized silk is used for sutures. 
That the plan is a complicated one is evident. It may be carried 
out in hospitals, but certainly in private practice it can only be fol- 
lowed with extreme difficulty. If the results show it to be superior to 
any other method, no pains should be spared to adopt it. 
Lister, as is well known, claims remarkably successful results for his 
method. One of his disciplesf goes so far as to state that “ the anti- 
septic method itself is not one of the possible modes of managing 
wounds, it is the only possible one, the only one worthy of modern 
surgery.” Passing by the fact that there is good reason to believe 
that the theory of M. Pasteur, upon which Lister bases his treatment, 
is unsound,| some eminent surgeons have by no means met with so 
favorable results as Lister claims to obtain. 
Professor John Wood, in his address, delivered before the last an- 
* Surgical Pathology, pp. 118,119. A 
f Lesser on the Antiseptic System. Edinburgh Medical Journal, march, 1874. 
% The Lancet, Oct. 11, 1873, page 529. 3 
nual meeting' of the British Medical Association, relates his experience 
regarding the antiseptic system of dressing wounds. lie has given, 
he believes, at King’s College Hospital, Lister’s method a fair trial. 
As long as the hospital was healthy, wounds treated by the antiseptic 
method did remarkably well. After a time, erysipelas and its con- 
comitant pyrnmia began to show themselves, “ and the erysipelatous 
blush,” says Air. Wood, "appeared with blameworthy impartiality 
in cases treated in all kinds of ways, and almost as impartially on 
my own antiseptic side of the hospital, as on my colleague Sir 
William Fergusson’s non-antiseptic side.” Air. Wood came to the 
conclusion that, in the generality of wounds, we could not, without 
danger, depart from the old rule of providing a free exit for all purulent 
and offensive discharges, and that for the want of this, the exclusion 
of air was not a sufficient compensation. 
Dr. George Thompson writes* that he had used Air. Lister’s methods 
in his own practice at the Oldham Infirmary, and that at no small sac- 
rifice of time and convenience he had conducted every dressing with 
the utmost care, but had failed to obtain results in any way better 
than he had been accustomed to see in dressing by other methods, 
lie therefore visited Mr. Lister’s wards to ascertain the cause of his 
failures. To his disappointment and mortification, he saw cases look- 
ing very much like what he had been accustomed to see in other hos- 
pitals. In two cases, at least, inflammation and suppuration had oc- 
curred after the application of the dressing, and these were explained 
away in one case by the access of germs, and in the other by the pre- 
mature removal of a drainage tube. Mr. Lister, in his remarks on 
these cases, did not for a moment entertain the bare possibility of 
any failure of the antiseptic system, and the visitors were asked to 
believe that in these cases putrefaction had been absent, and to observe 
M7hat an advantage it was to render, as he did, putrefaction an impos- 
sibility. Dr. Thompson says he left the wards with the last remnant 
of his belief in Prof. Lister dissipated to the winds. 
Such testimony—and more of a similar purport might be cited— 
settles, it would appear, the value of Mr. Lister’s carbolic acid dress- 
ings. Heretofore, he has asserted that the failure of others to obtain 
as favorable results as his own has been due to the fact that they have 
not followed his directions in every particular. Both Professor Wood 
and Dr. Thompson claim to have faithfully complied with Lister’s 
instructions, and to have failed to meet with more success than is ob- 
tained by simpler and well-known methods. 
Another form of antiseptic dressing is that of cotton-wool. M. 
Guerin adopted the theory of Pasteur, and, guided by the experi- 
ments of Tyndall, which showed that the atmospheric germs were 
intercepted when air was made to pass through cotton-wool, he made 
use of this article in the dressing of wounds, hoping thereby to pre- 
vent putrefactive changes in them. But as the subject of cotton-wool 
dressing has been presented in all its bearings to-day,f a passing no- 
tice of Guerin’s method is all that is now needed. 
A favorite method with some surgeons, particularly in the treatment 
of contused and lacerated wounds of the extremities, is that of immer- 
sion in water; either in that which is kept cold by ice, or in that 
* The Lancet, Sept. 20, 1873. 
t In a paper by Dr, T. B. Curtis, to appear in a future number. 4 
which is warm. Billroth* states that he first saw this plan used by 
his earliest teacher in surgery, Prof. Baum. Billroth himself has often 
adopted this procedure with satisfactory results. He thinks there 
may be considerable latitude allowed as to the temperature of the 
water, adapting it to the feelings of the patient. At first, a lower 
temperature (54°-68° F.); later, a higher one (88°-95° F.). The im- 
mersion is to be continued from eight to twelve days, and after that 
it may be employed at intervals. 
Dr. F. H. Hamilton, of New York, in a paper on “ The Use of Warm 
Water in Surgery,advocates the use of warm water as a surgical 
dressing in preference to cold. In ten cases, embracing a considera- 
ble variety of injuries and diseases that demanded surgical interfer- 
ence, he employed, wherever it was possible, submersion of the wound- 
ed part in water, at a temperature of about 90° F. Otherwise, fomen- 
tations of warm water were applied by means of compresses, and 
covered with cotton and oiled silk. In most cases of submersion, the 
part became considerably, or extremely, oedematous, but in no case 
did any injurious result occur from the pi'esence of the oedema. The 
average duration of the submersion was fourteen days. The results 
obtained by the use of warm water in this way were uniformly good. 
Probably the choice of the prolonged use of warm or of cold water 
should depend on the condition of the patient. A strong man meeting 
with an injury while in full health, in whom we may anticipate power- 
ful reaction, will endure the application of ice-cold water without 
harm, if not with advantage ; while to one who is constitutionally 
weak such an application cannot be beneficially made. In any case, 
the use of cold water should not be too long continued, lest the vitality 
of the wounded part be impaired, and permanent injury be done. It 
is worth consideration whether, for instance, after amputations, the 
application of ice, which is sometimes made to the flaps for many hours, 
may not so diminish their vitality as to favor subsequent sloughing. 
The application of cold water to a wound, as it is ordinarily made, by 
simply laying a cold compress upon it, is soon converted, by the heat 
of the part, into a warm-water dressing, and, if undisturbed, in a little 
time becomes dry. 
Poultices, particularly in hospital practice, are much less used than 
of old. As Billroth puts it,| “Formerly, cataplasms belonged to sup- 
purating wounds as undoubtedly as the lid to the box.,; They are, 
unquestionably, of value in many cases, but experience has shown 
that they are not indispensable in the treatment of wounds. As to 
charpie, which was formerly, if not now, in use in great and unspar- 
ing abundance in Paris in dressing wounds, it is often burdensome to 
the patient from the quantity employed, and in suppurating wounds 
it soon becomes a filthy mass. 
In contrast to the various methods that have been referred to, an 
entirely different practice—that of the open treatment—has, of late, 
been brought to the notice of the profession. In a work by Dr, 
Kronlein, recently published,§ the author relates the results of the 
treatment of wounds during two different periods in the surgical 
wards of the hospital of Zurich. During the first of these periods, 
* Surgical Pathology, translated by Ilackley, page 166 et seq, 
f The Medical Record, Dec. 1,1873. 
J Op, cir,., page 160, 
§ The London Medical Record, April 1, 1874. 5 
from 1860 to 1861, the wounds were covered in the ordinary way ; 
during the second, from 1867 to 1871, the open treatment was pur- 
sued systematically. 
For purposes of comparison, the following classification of cases 
was made : 1. Amputations; 2. Extirpations of the Breast; 3. Com- 
pound Fractures ; 4. Accidental Surgical Diseases. 
The mortality of the two series as regards amputations was :—• 
First period. Second period. 
Thigh, 31 in 36, or 86T per cent. 10 in 28, or 35-7 per cent. 
Leg, 21 in 36, or 58-3 “ “ 2in 11, or 18-1 “ “ 
Foot, 6in 17, or 35’2 “ “ 3in 15, or 20 “ “ 
Upper arm, 10 in 18, or 55-5 “ “ 2in 14, or 14 “ “ 
Forearm, 4in 24, or 16‘6 “ “ 0 0 
Hand, 0 0 0 0 
The cases of extirpation of the breast showed a mortality of 32 3 per 
cent, in the first period, and of 13-6 percent, in the second. The time 
of healing was 43 days in the former, 67 days in the latter. 
Of the cases of compound fracture, 22 in 86, or 25‘5 per cent., died 
under the ordinary treatment; 14 in 65, or 2P5 per cent., under the 
open. 
Pyaemia and septicaamia occurred less frequently during the second 
than in the first period. 
The time of healing was usually longer during the second period. 
By the open method, healing by the first intention was not attempt- 
ed. Care was taken to secure all bleeding vessels ; cleanliness and a 
free exit for the discharges from the wounds were obtained. Stitches, 
bandages and all dressings were discarded. 
Aside from the reduced mortality asserted to be due to the method 
as practised at Zurich, for purposes of observation and clinical in- 
struction it has great advantages ; because the wounds are so readily 
exposed to full view, and the healing or other processes are so easily 
seen. 
On the other hand, no opportunity is given for the immediate heal- 
ing of wounds, and there is wanting that support afforded by properly- 
applied bandages and strappings, which is in itself a comfort to the 
patient, and an aid to the process of healing. A source of danger at 
once occurs to the mind, as to whether intermediary and secondary 
haemorrhage would not be likely to take place, owing to the want of 
sufficient support to the divided vessels of the wound. In fact, of 
several cases treated at the Middlesex Hospital on the open plan, in 
two this very accident occurred,* 
This question of the open treatment of wounds, or of their closure 
by dressings, is not of recent discussion. From very early times, we 
find it occupying the attention of surgeons. Bonetus, in his “ Guide to 
the Practical Physician,” published two hundred years ago,"I" states 
that “ Gcesar Magnatus and Septalius following him disapprove of the 
old way of curing wounds, used hitherto by all physicians and sur- 
geons who every day, at least once, do cleanse and wipe them, and 
when they have applied new medicines bind them up again. And 
they blame Galen that, passing by the indication of most moment, 
he was only intent upon the lesser, that is, abstersion of the excre- 
ments and filth, the cause that breeds them being neglected, and all 
care of conserving the temperament and innate heat of the part; 
* The Lancet, April 11,1874. 
f London, 1684. Article, Vulnera. 6 
which, and the strength of the part, if they be taken care of, they 
think there will be a far less increase of excrements. And they think 
the heat of it will be cherisht, and strength will be added to it, if it 
be hindered from expiring, and its quality be preserved. Which they 
think they are able to obtain, by making up the defect of a natural 
covering with a Medicine analogous and familiar to the temper of the 
part; by means whereof the heat may be cherished, and its quality 
may be helped by its like. Whence they gather, that for to defend 
this heat, wounds must be seldom opened, lest the ambient Air do hurt 
them. Biit,” continues Bonetus, “ since the same Persons confess, 
that most grievous wounds have been cured by the old way of cure, 
and they cannot deny, but this new one has only place in simple 
wounds, and where the wounded party is of a good habit of Body, 
where great Vessels are not hurt, and the Nerves are whole ; besides, 
there are many wounds, by their own confession, which Nature is not 
able to cure, unless the impediments be removed by a Surgeon, as if 
the Body be Cacochymick, whence comes great store of excrements, 
which cause Pain, Corruption of the Part, Inflammation, Worms, proud 
flesh and the like: Finally, since the exceptions exceed the rule, 
which very rarely allow the use of this new way, we must insist upon 
the old one, approved for many ages.” 
The ancients sometimes had a faith in infallible and quite complicat- 
ed methods of healing wounds, similar to that which is presented in 
modern times, as will be evident from another quotation from Bonetus, 
which will compare well with some equally elaborated formulas of these 
so-called more enlightened days. 
“ This,” says Bonetus, “ cures all Wounds, to a Miracle :* Take of 
Aqua Vitas thrice distilled, and well rectified 2 pounds, St. John’s- 
wort, Hyssop, Millefoil, each 2 handfuls, Frankincense, Myrrhe powder- 
ed, each 8 ounces. Infuse them 4 days, and distill them in Balneo 
or in Sand. Keep it. When you have closed the wound, wet it with 
this water, by pouring it upon the Wound, and laying on Pledgits, 
wet in it, with Powder of Myrrhe, Mastiche, Frankincense, Sarcocolla 
Bole-Armenick, Dragon’s Blood, each equal parts. Make a powder; 
and strew it upon the suture wet with water, and apply upon that a Pled- 
git wet in oyl of Turpentine, and bind it, do not unbind it till the 
fourth day, and once every day foment the Wound as it is bound, and 
wet it with the same Aqua Vitce : On the fourth day loose the liga- 
ture, and you will find the wound healed ; but if you should not find 
the Wound healed, do the same again, and open it not for 3 days, wet 
the Wound every day, as before, then loose it, and cure it as before 
for 2 days.” 
In view of the conflicting theories, and the various dissimilar prac- 
tices, recently advocated regarding the dressing of wounds, no apolo- 
gy is needed in calling the attention of even a learned body to the 
subject, and in presenting anew some practical considerations that may 
guide us in their proper treatment. 
One point to be aimed at should be simplicity of method. The less 
complicated the dressings of a wound are, provided they fulfil all the 
requirements of the case, the better. The want of simplicity would 
be a fatal objection to Lister’s method, unless it should be proved to 
be greatly superior in its results to any other. In the open treatment 
* Op. cit., page 6GO. 7 
of wounds, we have simplicity of method carried to the extreme ; but, 
not to repeat the seeming objections to the method that have already 
been noticed, it is not probable that practitioners are quite ready to 
entirely discard sutures, strapping and bandages in the dressing of 
wounds. As to the application’ of bandages, it is well to bear in mind 
an old saying of Hippocrates, that it is better to apply a number of 
bandages to insure firmness of dressing, than a single one too tightly. 
Another point of the highest importance, the neglect of which is a 
serious error, is to provide, in the start, for a free exit for the discharge 
of any fluid that may form or collect in a wound. In no case should 
the edges of a wound be so tightly confined, in their whole extent, by 
sutures, or otherwise, that a chance for drainage is not secured. This 
rule holds good for simple incised wounds, even the smallest, and where 
we expect healing wholly by first intention. This provision for the 
drainage of a wound does not preclude the proper coaptation of its 
edges, nor interfere with the promptness of its healing if, fortunately, 
there should be no* accumulation of fluids within it, but will prevent 
suffering, and perhaps disaster, should such an accumulation occur. 
We have heard experienced observers say that they have seen more 
trouble from the neglect of this simple precaution on the part of gene- 
ral practitioners in dressing wounds than from most, if not all, other 
causes put together. As an instance of this neglect, who has not 
known, in wounds of the scalp, pus to burrow extensively, dissecting 
the tissues from the skull in every direction, thereby converting what 
might have been a comparatively slight lesion into one of the gravest 
import ? 
Another point that we should take pains to secure is rest to the wound. 
Especially is this true of wounds resulting from amputations. What- 
ever dressing we may at first apply, whether it is dry or moist, we 
should endeavor, during the first two or three days, to leave the wound 
as undisturbed as possible. If the bandages seem to be too tightly 
applied, they may often be partially cut away to loosen, without mate- 
rially disturbing, the dressing of the wound. In this way, an oppor- 
tunity is given for its early healing, if such will take place, while the 
granulations which form on its edges afford a barrier to the passage of 
septic agents, if such are present in the vicinity of the wound. 
Whatever views we may adopt regarding the possibility of such a mis- 
hap, all of us can but recognize the desirableness that whatever at- 
tempts at repair may be going on shall not be impeded by unnecessary 
interference on our part.* 
The importance of pure air and of cleanliness, equally necessary in 
all methods of treatment, need hardly be mentioned at this time. 
A chief object of this paper, while enumerating some of the more 
recently promulgated, and at times conflicting, methods of treating 
wounds, has been to re-state some of the leading principles sanctioned 
by the most prominent surgeons through all time, which are too apt 
to be lost sight of while maintaining sensational measures and start- 
ling schemes, but which must not be ignored, if the practitioner wishes 
to escape disasters, and to obtain the best results in any case put un- 
der his charge. Though these may be deemed small matters—minor 
surgery, so called—still the subject often involves serious conse- 
* Tide remarks of Messrs. Savory and Callender on Pyaemia, before the Clinical Society 
of London. British Medical Journal, March, 1874. 8 
quences to the attendant as well as to the patient, and has the highest 
classical as well as professional authority for its importance ; for, of 
old, Homer sang : 
“ A wise physician skilled our wounds to heal, 
Is more than armies to the public weal.”* 
* Iliad, xi. 635-6. 
Reprinted from the Boston Medical and Surgical Journal, July 23,1874.