Keep them as neat and clean as possible, and disturb them as little as you can; so far as may be practicable, exclude the air; favor healing under a scab; and do not give the patient a lowering diet, but feed him as you would a woman recovering from her confinement.
According to von Gurlt, Wuertz attached relatively small importance to healing by first intention, and only in rare cases did he make special efforts to secure this result. On the other hand, he availed himself of every opportunity to enter his protest against some of the bad tendencies which had somewhat suddenly made their appearance in the practice of surgery in his day, and more especially “against the almost universal employment of caustics and the red-hot iron for arresting bleeding; against the uncalled-for and positively harmful habit of repeatedly probing a wound; against the unreasonable practice of inserting tents into wounds; against the uncontrolled application of mushy poultices to wounds; and against the excessive employment of bloodletting in the treatment of wounds.” He exhibited his conservatism in still other ways. Thus, for example, he was very slow in reaching a decision to amputate a limb or to remove splinters or larger portions of loose bone from a wound, for he put greater trust in the reparative powers of Nature than did most of the surgeons of that day. Wuertz was also slower than were most of them in resorting to the operation of trephining the skull. His ideas with regard to the nature of gunshot wounds were not very clear, for he still believed that the projectile caused some burning and a certain degree of poisoning of the wound; but he condemned all unnecessary efforts at extraction, especially by means of complicated instruments. It was better, he said, to wait until the bullet or other missile manifested its presence at some easily accessible spot in the body.
The statements made above bring out some of the good features of Wuertz’s treatise. This work, however, says von Gurlt, also contains not a few bad features, and among them he mentions the fact that it abounds in repetitions and in evidences of the author’s superstitiousness.
Some of Wuertz’s comments on the symptoms which occasionally develop in cases of injury to the head, and the suggestions which he makes as to the treatment that should be adopted, throw considerable light upon his mode of procedure in the presence of certain surgical phenomena. The following clinical lesson is based upon three hypothetical developments in a case of cranial injuries:—
(1) The patient’s wound in the head, let us suppose, has to all appearances healed, when it unexpectedly becomes swollen and painful and begins to discharge again. What measures are indicated under these circumstances? The wound should at once be freely reopened, for it may confidently be assumed that such a lighting up of the local symptoms is due either to a loose splinter of bone that is trying to escape or to the presence of a small area of bone caries. If, under these circumstances, you should not establish a free opening a large abscess will surely collect in that region and will soon make for itself a new outlet.
(2) If the patient complains that he has constant pain in his head on the same side as that on which the injury was originally inflicted, that the pain is steadily increasing in severity, and that in addition he feels a sensation of pulsation in his head; and if, furthermore, you inspect closely the site of the original wound, and pass your finger cautiously over the spot, but fail to discover any appreciable external swelling, you may feel almost certain that a splinter or a spicule of bone projects from the inner table of the skull cap into the substance of the brain. Then, when the surgeon believes that the condition as just described truly represents the existing intracranial lesions, he should not hesitate to make an opening in the calvarium over the affected spot and remove the offending splinter.
(3) If the patient, after the external wound has healed, complains of a throbbing and roaring in his head, not merely in the region of the actual injury but involving the entire head, and if the symptoms tend rather to increase than to diminish, and eventually become so severe that the patient is almost beside himself with the pain, then is the surgeon justified in believing that a clot of blood is imprisoned somewhere beneath the cranium and is gradually being converted into an abscess or a condition of ulceration. And if at the same time some swelling appears in the vicinity of the eyes, or if a bloody and purulent discharge begins to flow from the nose or the ears, he may not merely entertain a belief that his diagnosis is correct, but may assert with positiveness that the lesions just named really exist. And then the proper treatment for him to adopt is [in essentials] the following: The head having first been shaved over the site of the original wound, make a crucial incision through the scalp and pericranium, turn the flaps back, apply a strong, sharp-edged chisel to the surface of the bone, and remove enough of the cranium to afford a satisfactory view of the underlying parts. [Among the effects first observed] probably pus will well up into the opening, and the patient will then experience relief; and if a spicule of bone comes into view, remove it forthwith. The plan of treatment here suggested is the only one which can be trusted to effect a cure in a case like that which is now being considered.... If a boring instrument is employed for making an opening in the bone, be careful not to allow any of the chips made by the borer to enter or remain in the cranial cavity. Some surgeons teach that, if pus be not found at the first opening, a second one should be made at the distance of a finger’s breadth from the first, and that the intervening bone should be broken down with a strong and sharp knife so as to convert the two into a single opening. [Wuertz adds that he had never found it necessary to act in accordance with this advice.] After the pus or clot of blood has been removed, one may as a rule readily discover the true cause of the pain and other symptoms. As a final step, suitable dressings should be applied to the wound.
Another important department of practical surgery, in which Wuertz appears to have gained special distinction, is that which relates to wounds and certain diseases of the abdomen. Owing to lack of space it will not be practicable to reproduce here any histories of the cases of this nature which came under his observation, but I believe that the following brief extracts from his remarks upon the best way of treating them may in some measure answer the same purpose:—
Penetrating wounds of the abdomen are universally admitted to be very dangerous, no matter what organs (stomach, intestines, liver, gall-bladder, spleen or kidneys) be involved in the injury. In the case of a wound of the liver or spleen it is not advisable to employ sutures; instead, one may use some kind of sticking plaster for bringing the edges of the wound together. Proper regulation of the diet plays an important part in the treatment of these conditions, and so also may venesection. When an intestine is the organ wounded I adopt the plan of treatment recommended by most authorities; that is, I stitch together the opposite edges of the wound and I cleanse the surface of the bowel carefully with milk that has been well saturated with the juice of anise seeds.
In his remarks about the treatment of suppurative processes involving the thigh in the vicinity of the knee, Wuertz gives the following advice:—