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

Fig. 1.—Ulcer of back of Hand covered by flap of skin raised from anterior abdominal wall. The lateral edges of the flap are divided after the graft has adhered.

Fig. 1.—Ulcer of back of Hand covered by flap of skin raised from anterior abdominal wall. The lateral edges of the flap are divided after the graft has adhered.

The indirect element of this method of skin-grafting may be carried still further by transferring the flap of skin first to one part of the body and then, after it has taken, transferring it to a third part. Gillies has especially developed this method in the remedying of deformities of the face caused by gunshot wounds and by petrol burns in air-men. A rectangular flap of skin is marked out in the neck and chest, the lateral margins of the flap are raised sufficiently to enable them to be brought together so as to form a tube of skin: after the circulation has been restored, the lower end of the tube is detached and is brought up to the lip or cheek, or eyelid, where it is wanted; when this end has derived its new blood supply, the other end is detached from the neck and brought up to where it is wanted. In this way, skin from the chest may be brought up to form a new forehead and eyelids.

Grafts of mucous membrane are used to cover defects in the lip, cheek, and conjunctiva. The technique is similar to that employed in skin-grafting; the sources of mucous membrane are limited and the element of septic infection cannot always be excluded.

Fat.—Adipose tissue has a low vitality, but it is easily retained and it readily lends itself to transplantation. Portions of fat are often obtainable at operations—from the omentum, for example, otherwise the subcutaneous fat of the buttock is the most accessible; it may be employed to fill up cavities of all kinds in order to obtain more rapid and sounder healing and also to remedy deformity, as in filling up a depression in the cheek or forehead. It is ultimately converted into ordinary connective tissue pari passu with the absorption of the fat.

The fascia lata of the thigh is widely and successfully used as a graft to fill defects in the dura mater, and interposed between the bones of a joint—if the articular cartilage has been destroyed—to prevent the occurrence of ankylosis.

The peritoneum of hydrocele and hernial sacs and of the omentum readily lends itself to transplantation.

Cartilage and bone, next to skin, are the tissues most frequently employed for grafting purposes; their sphere of action is so extensive and includes so much of technical detail in their employment, that they will be considered later with the surgery of the bones and joints and with the methods of re-forming the nose.

Tendons and blood vessels readily lend themselves to transplantation and will also be referred to later.

Muscle and nerve, on the other hand, do not retain their vitality when severed from their surroundings and do not functionate as grafts except for their connective-tissue elements, which it goes without saying are more readily obtainable from other sources.

Portions of the ovary and of the thyreoid have been successfully transplanted into the subcutaneous cellular tissue of the abdominal wall by Tuffier and others. In these new surroundings, the ovary or thyreoid is vascularised and has been shown to functionate, but there is not sufficient regeneration of the essential tissue elements to “carry on”; the secreting tissue is gradually replaced by connective tissue and the special function comes to an end. Even such temporary function may, however, tide a patient over a difficult period.

CHAPTER II
CONDITIONS WHICH INTERFERE WITH REPAIR
Surgical Bacteriology Want of rest —Irritation —Unhealthy tissues —Pathogenic bacteria. Surgical Bacteriology —General characters of bacteria —Classification of bacteria —Conditions of bacterial life —Pathogenic powers of bacteria —Results of bacterial growth —Death of bacteria —Immunity —Antitoxic sera —Identification of bacteria —Pyogenic bacteria.

In the management of wounds and other surgical conditions it is necessary to eliminate various extraneous influences which tend to delay or arrest the natural process of repair.

Of these, one of the most important is undue movement of the affected part. “The first and great requisite for the restoration of injured parts is rest,” said John Hunter; and physiological and mechanical rest as the chief of natural therapeutic agents was the theme of John Hilton's classical work—Rest and Pain. In this connection it must be understood that “rest” implies more than the mere state of physical repose: all physiological as well as mechanical function must be prevented as far as is possible. For instance, the constituent bones of a joint affected with tuberculosis must be controlled by splints or other appliances so that no movement can take place between them, and the limb may not be used for any purpose; physiological rest may be secured to an inflamed colon by making an artificial anus in the cæcum; the activity of a diseased kidney may be diminished by regulating the quantity and quality of the fluids taken by the patient.

Another source of interference with repair in wounds is irritation, either by mechanical agents such as rough, unsuitable dressings, bandages, or ill-fitting splints; or by chemical agents in the form of strong lotions or other applications.

An unhealthy or devitalised condition of the patient's tissues also hinders the reparative process. Bruised or lacerated skin heals less kindly than skin cut with a smooth, sharp instrument; and persistent venous congestion of a part, such as occurs, for example, in the leg when the veins are varicose, by preventing the access of healthy blood, tends to delay the healing of open wounds. The existence of grave constitutional disease, such as Bright's disease, diabetes, syphilis, scurvy, or alcoholism, also impedes healing.

Infection by disease-producing micro-organisms or pathogenic bacteria is, however, the most potent factor in disturbing the natural process of repair in wounds.

Surgical Bacteriology

The influence of micro-organisms in the causation of disease, and the rôle played by them in interfering with the natural process of repair, are so important that the science of applied bacteriology has now come to dominate every department of surgery, and it is from the standpoint of bacteriology that nearly all surgical questions have to be considered.

The term sepsis as now used in clinical surgery no longer retains its original meaning as synonymous with “putrefaction,” but is employed to denote all conditions in which bacterial infection has taken place, and more particularly those in which pyogenic bacteria are present. In the same way the term aseptic conveys the idea of freedom from all forms of bacteria, putrefactive or otherwise; and the term antiseptic is used to denote a power of counteracting bacteria and their products.

General Characters of Bacteria.—A bacterium consists of a finely granular mass of protoplasm, enclosed in a thin gelatinous envelope. Many forms are motile—some in virtue of fine thread-like flagella, and others through contractility of the protoplasm. The great majority multiply by simple fission, each parent cell giving rise to two daughter cells, and this process goes on with extraordinary rapidity. Other varieties, particularly bacilli, are propagated by the formation of spores. A spore is a minute mass of protoplasm surrounded by a dense, tough membrane, developed in the interior of the parent cell. Spores are remarkable for their tenacity of life, and for the resistance they offer to the action of heat and chemical germicides.

Bacteria are most conveniently classified according to their shape. Thus we recognise (1) those that are globular—cocci; (2) those that resemble a rod—bacilli; (3) the spiral or wavy forms—spirilla.

Cocci or micrococci are minute round bodies, averaging about 1 µ in diameter. The great majority are non-motile. They multiply by fission; and when they divide in such a way that the resulting cells remain in pairs, are called diplococci, of which the bacteria of gonorrhœa and pneumonia are examples (Fig. 5). When they divide irregularly, and form grape-like bunches, they are known as staphylococci, and to this variety the commonest pyogenic or pus-forming organisms belong (Fig. 2). When division takes place only in one axis, so that long chains are formed, the term streptococcus is applied (Fig. 3). Streptococci are met with in erysipelas and various other inflammatory and suppurative processes of a spreading character.

Bacilli are rod-shaped bacteria, usually at least twice as long as they are broad (Fig. 4). Some multiply by fission, others by sporulation. Some forms are motile, others are non-motile. Tuberculosis, tetanus, anthrax, and many other surgical diseases are due to different forms of bacilli.

Spirilla are long, slender, thread-like cells, more or less spiral or wavy. Some move by a screw-like contraction of the protoplasm, some by flagellæ. The spirochæte associated with syphilis (Fig. 36) is the most important member of this group.

Conditions of Bacterial Life.—Bacteria require for their growth and development a suitable food-supply in the form of proteins, carbohydrates, and salts of calcium and potassium which they break up into simpler elements. An alkaline medium favours bacterial growth; and moisture is a necessary condition; spores, however, can survive the want of water for much longer periods than fully developed bacteria. The necessity for oxygen varies in different species. Those that require oxygen are known as aërobic bacilli or aërobes; those that cannot live in the presence of oxygen are spoken of as anaërobes. The great majority of bacteria, however, while they prefer to have oxygen, are able to live without it, and are called facultative anaërobes.

The most suitable temperature for bacterial life is from 95° to 102° F., roughly that of the human body. Extreme or prolonged cold paralyses but does not kill micro-organisms. Few, however, survive being raised to a temperature of 134½° F. Boiling for ten to twenty minutes will kill all bacteria, and the great