Manual of Surgery, Alexis Thomson [new books to read txt] 📗

dry and crisp, and is surrounded by a zone of pallor. For the first thirty-six to forty-eight hours there is comparatively little suffering, but at the end of that time the parts become exceedingly painful. In a majority of cases, in spite of careful purification, a slow form of moist gangrene sets in, and the slough spreads both in area and in depth, until the muscles and often the large blood vessels and nerves are exposed. A line of demarcation eventually forms, but the sloughs are exceedingly slow to separate, taking from three to five times as long as in an ordinary burn, and during the process of separation there is considerable risk of secondary hæmorrhage from erosion of large vessels.

Treatment.—Electrical burns are treated on the same lines as ordinary burns, by thorough purification and the application of dry dressings, with a view to avoiding the onset of moist gangrene. After granulations have formed, skin-grafting is of value in hastening healing.

Lightning-stroke.—In a large proportion of cases lightning-stroke proves instantly fatal. In non-fatal cases the patient suffers from a profound degree of shock, and there may or may not be any external evidence of injury. In the mildest cases red spots or wheals—closely resembling those of urticaria—may appear on the body, but they usually fade again in the course of twenty-four hours. Sometimes large patches of skin are scorched or stained, the discoloured area showing an arborescent appearance. In other cases the injured skin becomes dry and glazed, resembling parchment. Appearances are occasionally met with corresponding to those of a superficial burn produced by heat. The chief difference from ordinary burns is the extreme slowness with which healing takes place. Localised paralysis of groups of muscles, or even of a whole limb, may follow any degree of lightning-stroke. Treatment is mainly directed towards combating the shock, the surface-lesions being treated on the same lines as ordinary burns.

CHAPTER XII
METHODS OF WOUND TREATMENT Varieties of wounds —Modes of infection —Lister's work —Means taken to prevent infection of wounds: heat; chemical antiseptics; disinfection of hands; preparation of skin of patient; instruments; ligatures; dressings —Means taken to combat infection: purification; open-wound method.

The surgeon is called upon to treat two distinct classes of wounds: (1) those resulting from injury or disease in which the skin is already broken, or in which a communication with a mucous surface exists; and (2) those that he himself makes through intact skin, no infected mucous surface being involved.

Infection by bacteria must be assumed to have taken place in all wounds made in any other way than by the knife of the surgeon operating through unbroken skin. On this assumption the modern system of wound treatment is based. Pathogenic bacteria are so widely distributed, that in the ordinary circumstances of everyday life, no matter how trivial a wound may be, or how short a time it may remain exposed, the access of organisms to it is almost certain unless preventive measures are employed.

It cannot be emphasised too strongly that rigid precautions are to be taken to exclude fresh infection, not only in dealing with wounds that are free of organisms, but equally in the management of wounds and other lesions that are already infected. Any laxity in our methods which admits of fresh organisms reaching an infected wound adds materially to the severity of the infective process and consequently to the patient's risk.

There are many ways in which accidental infection may occur. Take, for example, the case of a person who receives a cut on the face by being knocked down in a carriage accident on the street. Organisms may be introduced to such a wound from the shaft or wheel by which he was struck, from the ground on which he lay, from any portion of his clothing that may have come in contact with the wound, or from his own skin. Or, again, the hands of those who render first aid, the water used to bathe the wound, the handkerchief or other extemporised dressing applied to it, may be the means of conveying bacterial infection. Should the wound open on a mucous surface, such as the mouth or nasal cavity, the organisms constantly present in such situations are liable to prove agents of infection.

Even after the patient has come under professional care the risks of his wound becoming infected are not past, because the hands of the doctor, his instruments, dressings, or other appliances may all, unless purified, become the sources of infection.

In the case of an operation carried out through unbroken skin, organisms may be introduced into the wound from the patient's own skin, from the hands of the surgeon or his assistants, through the medium of contaminated instruments, swabs, ligature or suture materials, or other things used in the course of the operation, or from the dressings applied to the wound.

Further, bacteria may gain access to devitalised tissues by way of the blood-stream, being carried hither from some infected area elsewhere in the body.

The Antiseptic System of Surgery.—Those who only know the surgical conditions of to-day can scarcely realise the state of matters which existed before the introduction of the antiseptic system by Joseph Lister in 1867. In those days few wounds escaped the ravages of pyogenic and other bacteria, with the result that suppuration ensued after most operations, and such diseases as erysipelas, pyæmia, and “hospital gangrene” were of everyday occurrence. The mortality after compound fractures, amputations, and many other operations was appalling, and death from blood-poisoning frequently followed even the most trivial operations. An operation was looked upon as a last resource, and the inherent risk from blood-poisoning seemed to have set an impassable barrier to the further progress of surgery. To the genius of Lister we owe it that this barrier was removed. Having satisfied himself that the septic process was due to bacterial infection, he devised a means of preventing the access of organisms to wounds or of counteracting their effects. Carbolic acid was the first antiseptic agent he employed, and by its use in compound fractures he soon obtained results such as had never before been attained. The principle was applied to other conditions with like success, and so profoundly has it affected the whole aspect of surgical pathology, that many of the infective diseases with which surgeons formerly had to deal are now all but unknown. The broad principles upon which Lister founded his system remain unchanged, although the methods employed to put them into practice have been modified.

Means taken to Prevent Infection of Wounds.—The avenues by which infective agents may gain access to surgical wounds are so numerous and so wide, that it requires the greatest care and the most watchful attention on the part of the surgeon to guard them all. It is only by constant practice and patient attention to technical details in the operating room and at the bedside, that the carrying out of surgical manipulations in such a way as to avoid bacterial infection will become an instinctive act and a second nature. It is only possible here to indicate the chief directions in which danger lies, and to describe the means most generally adopted to avoid it.

To prevent infection, it is essential that everything which comes into contact with a wound should be sterilised or disinfected, and to ensure the best results it is necessary that the efficiency of our methods of sterilisation should be periodically tested. The two chief agencies at our disposal are heat and chemical antiseptics.

Sterilisation by Heat.—The most reliable, and at the same time the most convenient and generally applicable, means of sterilisation is by heat. All bacteria and spores are completely destroyed by being subjected for fifteen minutes to saturated circulating steam at a temperature of 130° to 145° C. (=266° to 293° F.). The articles to be sterilised are enclosed in a perforated tin casket, which is placed in a specially constructed steriliser, such as that of Schimmelbusch. This apparatus is so arranged that the steam circulates under a pressure of from two to three atmospheres, and permeates everything contained in it. Objects so sterilised are dry when removed from the steriliser. This method is specially suitable for appliances which are not damaged by steam, such, for example, as gauze swabs, towels, aprons, gloves, and metal instruments; it is essential that the efficiency of the steriliser be tested from time to time by a self-registering thermometer or other means.

The best substitute for circulating steam is boiling. The articles are placed in a “fish-kettle steriliser” and boiled for fifteen minutes in a 1 per cent. solution of washing soda.

To prevent contamination of objects that have been sterilised they must on no account be touched by any one whose hands have not been disinfected and protected by sterilised gloves.

Sterilisation by Chemical Agents.—For the purification of the skin of the patient, the hands of the surgeon, and knives and other instruments that are damaged by heat, recourse must be had to chemical agents. These, however, are less reliable than heat, and are open to certain other objections.

Disinfection of the Hands.—It is now generally recognised that one of the most likely sources of wound infection is the hands of the surgeon and his assistants. It is only by carefully studying to avoid all contact with infective matter that the hands can be kept surgically pure, and that this source of wound infection can be reduced to a minimum. The risk of infection from this source has further been greatly reduced by the systematic use of rubber gloves by house-surgeons, dressers, and nurses. The habitual use of gloves has also been adopted by the great majority of surgeons; the minority, who find they are handicapped by wearing gloves as a routine measure, are obliged to do so when operating in infective cases or dressing infected wounds, and in making rectal and vaginal examinations.

The gloves may be sterilised by steam, and are then put on dry, or by boiling, in which case they are put on wet. The gauntlet of the glove should overlap and confine the end of the sleeve of the sterilised overall, and the gloved hands are rinsed in lotion before and at frequent intervals during the operation. The hands are sterilised before putting on the gloves, preferably by a method which dehydrates the skin. Cotton gloves may be worn by the surgeon when tying ligatures, or between operations, and by the anæsthetist during operations on the head, neck, and chest.

The first step in the disinfection of the hands is the mechanical removal of gross surface dirt and loose epithelium by soap, a stream of running water as hot as can be borne, and a loofah or nail-brush, that has been previously sterilised by heat. The nails should be cut down till there is no sulcus between the nail edge and the pulp of the finger in which organisms may lodge. They are next washed for three minutes in methylated spirit to dehydrate the skin, and then for two or three minutes in 70 per cent. sublimate or biniodide alcohol (1 in 1000). Finally, the hands are rubbed with dry sterilised gauze.

Preparation of the Skin of the Patient.—In the purification of the skin of the patient before operation, reliance is to be placed chiefly in the mechanical removal of dirt and grease by the same means as are taken for the cleansing of the surgeon's hands. Hair-covered parts should be shaved. The skin is then dehydrated by washing with methylated spirit, followed by 70 per cent. sublimate or biniodide alcohol (1 in 1000). This is done some hours before the operation, and the part is then covered with pads of dry sterilised gauze or a sterilised towel. Immediately before the operation the skin is again