« ForrigeFortsæt »
tage of all the debris and weak granulation tissue. After most thorough scrubbing I dried the surface and then washed it with sulphuric ether; then applied a saturated solution of permanganate of potassium, rubbing it well into the sore, the edges of which were pared at the time of curettage; then applied strong oxalic acid solution until the stain disappeared and then hot water. After drying the wound it and the surrounding skin were washed with alcohol and finally with normal salt solution. I then completely excised the ulcer and all the underlying tissue down to healthy muscle. This left a wound two and a half inches wide by four long which had to be closed. Two six or seven inch incisions, one on either side at a distance of a little more than two inches from the margin, allowed the two edges to be brought together without much traction on the ten sutures introduced. The central wound was then hermetically sealed with iodoform collodion, and the two widely gaping ones closed by Thiersch skin graft from the thigh. Healing by primary union has been secured in the site of the old sore and the "side issues" are nearly well, without one drop of pus and no other sign of inflammatory re
This is an undoubted triumph of antiseptic surgery. The excellent results can be ascribed to nothing else. It required nearly two hours to complete the work, but the success is worth the trouble. It is, however, in cases of minor surgery that I must urge reliance upon antiseptics, together with all possible cleanliness.
Most of the minor injuries with which the railroad surgeon has to deal are inflicted at a time when the surface which is the site of trauma is dirty, often foul; further, in the accident itself septic material is very apt to be ground into the tissues. Here is the condition which calls for the strongest possible antiseptic agents. It will not do to try to rely upon cleanliness alone; it is insufficient. By employing the strong antiseptic remedies after cleaning the wound as thoroughly as possible we may frequently get healing by primary union where it would seem that such a result would be impossible. To illustrate:
March 21, 1896, a boy was brought into my office suffering from a crushed finger. The accident occurred while the hand was very dirty and in such a way that a lot of earth was pressed in among the fragments of bone and injured skin, tendons and muscles; at first glance a wound that would necessitate amputation, but upon careful examination I found the blood supply still good and determined to try to save the finger. With complete anæs
thesia I scrubbed the wound itself very carefully with ethereal soap, itself a good antiseptic; then trimmed away all ragged fragments; then washed with alcohol, rubbing it into all the interstices and between bony fragments; then saturated it with boro-lyptol, the latest germicidal agent, which consists of a five-tenths per cent. solution of formaldehyd in combination with boro-glycerid, eucalyptol, etc., a most valuable association of antiseptic drugs. Using this also to wash away the blood during subsequent procedures, I sutured the skin and other tissues into place with catgut, introduced catgut drains in two or three directions and applied a dressing of bichloride gauze saturated with boro-lyptol. As there was no pain and no fever I did not remove the dressings until the twelfth day, when I found that primary union had occurred. A gauze dressing on a finger with a splint for support to the injured bone constituted the sole remaining treatment.
Now from my observations in the work of those who are treating such cases by "asepsis" alone I am sure I would have lost this finger if I had not employed the strong germicide, or at least antiseptic agents and dressings. The reason is not hard to understand. Howsoever industriously we may labor with soap and water and scrub-brush we cannot rid the wound of the pus-producing germs which have been introduced before the wound is seen by the surgeon. "Nor can we reach and destroy them by antiseptic solutions,” exclaims the exponent of asepsis. That is quite true. We who advocate the use of strong antiseptics do not expect to kill the germs already in the wound-that is not at all the object of their application. Nature can readily take care of the few micro-organisms which have found lodgment upon the tissues. The purpose of the antiseptic agents and the antiseptic dressings is to prevent the development of more germs from those already there. The life history of this species of plant life shows that the pyogenic bacteria increase with an almost incredible rapidity under favorable conditions, and infective troubles arise not from the original seed, but from the wondrous crop that soon follows if the soil and surroundings be propitious. The use of simply sterile gauze or dressings saturated with normal salt solution, as urged by Professor Outten, gives a most favorable soil and surrounding for the development of pathogenic micro-organisms; whereas the application of antiseptic dressings following an antiseptic
operation will completely arrest the growth and propagation of the dreaded germs,—that is, we render them sterile, innocuous. Possibly in the hands of an Outten it may be possible in most cases to secure such perfect cleanness of the infected field so as to give primary union under simply sterilized gauze; but even in his work the employment of the antiseptic plan would do no harm, while in the work of men less careful in practice or where surroundings are less favorable than those in which his patients are placed, it is imperative.
It will be noted that I have advised the use of sublimate gauze as the dressing for all infected wounds. This has been done purposely, for the use of iodoform gauze has become entirely too common. Iodoform gauze is not strongly antiseptic; in fact iodoform powder is not germicidal at all, though it does act advantageously in preventing the rapid proliferation of pus organisms by its drying. (and other) properties; so while it is a most valuable dressing for aseptic wounds, particularly when a considerable amount of wound secretion is anticipated, it is practically valueless in a wound already infected. But bichloride gauze not only sterilizes the little air which passes through to the wound surface, but effectually prevents the increase in the number of the microbes which may be in the serum escaping from the seat of injury.
Now please understand the position I take. In every wound made by the surgeon himself (under favorable circumstances) asepsis is perfectly safe and should be invariably practiced, as it is the ideal method, and gives the best results in careful hands.
But in every accidental wound and in operations where it is impossible to secure and maintain perfect asepsis (such as operative procedures in already infected tissues as well as in the rectum, etc.) reliance must be placed upon antiseptic agents.
In conclusion, I wish to repeat that however fascinating it may be to see a Joseph Price simply scrub his hands with soap and water, prepare the field of operation in the same way, use nothing but boiled water upon his sterilized instruments, and apply only sterilized gauze as a dressing,-in other words, relying upon perfect asepsis to secure perfect results,it will not do to follow his example in managing the cases which usually come to the
railroad surgeon. To use the words of the title of my paper: "Railroad surgeons should not try to practice aseptic surgery in emergency work," because better results can be obtained by recourse to antiseptics.
DISCUSSION OF DR. LANPHEAR'S PAPER.
Dr. Geo. W. Crile: I do not know that I can add anything new to this subject, but I wish to say a few words relative to some of the points brought out by the essayist. With reference to what has been said on the question of asepticism and antisepticism, I will say that it is necessary for the competent surgeon to use one or both, although many will try to reach asepticism through the agency of antisepticism. First of all, I would say that we must not lose sight of the fact (in the process of repair) that the tissues repair themselves by their cellular action and reproduction, and cells can only repair themselves when properly nourished. The only proper food for the cell is the serum of the blood. I maintain that in our efforts to carry out asepticism we should in all cases avoid the uses of douches, of using water and saline solutions. If we use normal saline solutions on a wound we dilute the food upon which the cells live, and the ideal method of repair in a wound is by making use of the normal food--the blood plasma. It is better, in my judgment, to dry the wound, make absolutely perfect hemostasis and leave no so-called dead spaces in the tissues. Do not douche the parts with saline solution.
As to antisepsis the same thing holds true. Bichloride of mercury in strong solution will precipitate the food upon which the cells depend and will certainly do much damage in the hands of one who is inexperienced with its use. In infected cases use bichloride of mercury, but use it in small quantities.
Dr. W. H. Elliott: I believe in this matter Dr. Lanphear has taken the correct position, and were it left to me for decision, I would state the case in these words: Asepsis when you can; antisepsis when you must.
Dr. Fulton: I am not on my feet to discuss the paper, for I believe there is nothing to disIts title was misleading. He gave us a title but did not follow it out. The practice of antisepsis in railway surgery is always a necessity. The practice of antiseptic surgery in Mr. Tait's practice to which Dr. Lanphear referred is not necessary; that is to say, antisep
tics are not necessary in the practice that Mr. Tait follows. He is not dealing with the kind of cases that railway surgeons encounter, and when we discuss a question like this we probably discuss it from one standpoint. If we discuss it from the standpoint of Mr. Tait's work, we will practice asepsis, but if from the standpoint of the railway surgeon, who cannot get his patient in an aseptic condition prior to operation, he must, in addition to aseptic precautions, practice antiseptic surgery. Everybody knows that, and there is no dispute upon that point.
Dr. S. S. Thorn: It seems, from the investigations and researches of Lister, Pasteur and other biologists, from whom we have learned so much, that the germs are not autogenetic. They must be planted in order to be there. do not believe that railway dirt, such as oil and other stuff that comes from the cars and track, is necessarily pathogenic. If we have pathogenic germs we should treat our cases antiseptically. If we have not, then all that work is unnecessary, and not only that, but positively injurious. We have all seen the pendulum swing to the other side, and we have followed it there. That pendulum is back again and is going the other way. I do not for a moment deny the benefits that have come to railway surgery from the antiseptic work which has been done, for we all know that we were surrounded by filth from head to foot at one time, and surgeons then were not so particular about cleanliness of person as they are now. At present we go into our cases reasonably clean. I am opposed to any cast iron rules. There are no cast iron laws to govern our manipulations and treatment.
tic we cannot prove that they are not so. We should treat them as septic cases. What has made surgery what it is to-day? Antiseptics. As we learn more and more of these things, we resort to antiseptics in order to make ourselves aseptic. It is impossible to perform an aseptic operation without the aid of antiseptics. I hope no gentleman here will go away from this meeting and try to render injured limbs aseptic without the use of antiseptics.
Dr. James T. Jelks: It is an accepted fact among modern surgeons that the micro-organisms of inflammation are everywhere, in the dust we breathe, and in the dirt beneath our feet. It must be a fact that the dirt of the railroad track and the oil with which it is mingled, is septic. We have acted on that basis for thirty years, and the results have been marvelous in modern surgical work. One gentleman has said that the pendulum is swinging the other way, and that we are attempting to foist upon the profession aseptic surgery in septic cases. septic cases. If we have an operation to do in a clean peritoneal cavity, it is an accepted fact that we should not pour antiseptics into that delicate cavity. We all know that, and hence should not bring Tait's dictum, or that of Joseph Price into a congregation of railway surgeons. All of our cases are septic. Antiseptic precautions in lacerated, infected wounds are the only road to safety.
Dr. Lanphear (closing): I am astonished at the unanimity of opinion of this association after hearing the paper of Dr. Outten last night and the enthusiasm which it seemed to provoke. I wish, first of all, to give attention to the remarks of Dr. Fulton. He says there is no dispute about this subject. Surely he is not familiar with the work of men in this city, or he would have heard the cry of those who are clamoring here, there and everywhere throughout the land for the hot salt solutions exclusively. Men are advocating in this city the use of nothing but hot water and soap and brush in preparing for operations. The same thing is being done in Chicago. It is being done in Junction City, where Dr. Daugherty lives. It is being done everywhere and it is a dangerous thing.
In reply to the assertion of Dr. Thorn that we must have no cast iron rules in operative surgery, I will say that we are dealing with cast iron laws as fixed and immutable as the
laws of the Medes and Persians-those laws which govern the life history of micro-organisms and which are known to bacteriologists and the experienced surgeons of to-day. We must perforce adopt cast iron laws, and the rules which I have enunciated in my paper are the ones upon which we can safely rely in the treatment of infected wounds. No man advocates the use of antiseptics (except for preparation) in the treatment of wounds which are to be produced by the surgeon himself. The surgeon who understands his business knows this. It is to oppose the use of asepsis in accidental surgical work that I am here to-day.
Lastly in reply to the remarks of Dr. Crile. He has told us that blood serum is the best germicide in the world. Very true when it is in the blood vessels but when the blood serum is upon an injured surface, it constitutes an ideal culture field for the growth and development of micro-organisms, and unless we can counteract the microbes which are there; unless we can render the germs sterile, incapable of reproduction, we will have mischief in 99 cases out of 100 infected wounds. We must rely upon antiseptic agents.
And now, in conclusion, I want to say that if with my paper I have caused one little doubt about the propriety of relying upon asepsis alone to linger in the minds of the members of this association, over which they will ponder as they wend their way homeward, and will put their thoughts into practice in their work I will have been amply repaid for my time and trouble. (Applause.)
INFLAMMATION OF BONE.
BY ANDREW L. FULTON, M. D., KANSAS CITY, Mo.
In discussing inflammation of bone tissue. it will doubtless be suggested by some of the members of this society, and with some degree of truth, that I cannot refrain from showing my heretical tendencies in attempting to pervert the true faith, inasmuch as I propose to take issue with well recognized authorities some points regarding this particular inflammation. I invite, and shall expect, adverse criticism, which, however severe, I hope will be kindly.
Inflammation of bone tissue presents the same phenomena characterizing inflammation
of other tissues, and the same pathological changes, and there is no particular difference in the cause, all inflammations depending upon a pathological condition. Although the focus of infection is usually in the medullary canal or medullary substance in the cancellous tissue, the entire structure, medulla, bone and periosteum, is soon involved in the process. It is of little consequence, therefore, where the focus of infection is from a clinical standpoint; but from a medico-legal and an etiological consideration it is of paramount importance to the railway surgeon and corporation whose rights he is supposed to protect from the too often unscrupulous claimant.
In the few remarks I desire to make on osteo-myelitis I shall confine myself to the discussion of the so-called spontaneous suppurative osteomyelitis and to the tubercular variety of osteo-myelitis. As to the cause of these classes of inflammation there have been differences of opinion which seriously affect the right of both corporations and individuals. There is scarcely any dispute regarding the etiology in cases of direct traumatic, suppurative osteo-myelitis, and it is generally conceded that the cause of spontaneous osteomyelitis is the arrest of infected micro-organisms that have made their way into the circulation from a more or less remote suppurative process or abscess cavity, a metastasis as it is called, or, through the intestinal tract or mucous membrane of the respiratory tract. Consistent with this I have for several years held to the opinion as a reasonable and logical conclusion that the tubercular type of inflammation has its origin in and is conveyed to a locus minoris resistentiæ from an antecedent pathological condition. I shall further assume, and not without good clinical evidence, that the suppurative and tubercular character of inflammation respectively present the same anatomical features and like conditions as to the age of the patient and the point of infection. I thus briefly outline the basis of argument, that if the one is not due in any sense to a slight trauma without a wound, the other, namely tubercular osteo-myelitis, will justify the same conclusion.
Acute spontaneous suppurative osteomyelitis is almost exclusively confined to children and young adults prior to the bony union of the epiphysis with the diaphysis, and next to
the tubercular inflammation is most frequent of all inflammatory disease of bone. The point of departure of the disease, or the focus of infection, in these cases is either in the medullary substance in the canal of the long bones or in the same substance in the diaphysis near the epiphyseal line. The anatomical peculiarities of bone in children favor the development of the disease. The large, dilated capilaries, active circulation and what seem to be terminal or end vessels of the diaphysis at its junction with the epiphysis are anatomical conditions favorable to the arrest of the infected leucocytes or emboli; the morbid process having originated in this way in the medullary tissue, extends to the bony structure or adjacent bone tissue, then to the periosteum and para-periosteal tissue, and forms an abscess which marks the progress of the disease. Aside from the cases in which we have direct infection from compound fractures or wounds, the cause of the suppuration is obscure. It is a well known clinical fact, however, that exposure to cold from bathing in cold water, over-heating and rapid cooling, lying on damp, cold ground and the like, may cause apparently healthy children to suddenly contract suppurative osteo-myelitis. I may add in this connection that there seems to be something still unknown regarding the character, origin and cause of pus formation where there is no external wound open, fracture or preexisting suppuration elsewhere. We know from clinical experience, however, that acute attacks of suppurative osteo-myelitis may occur at any time without the slightest apparent cause, running a rapid and very destructive course. The reason for the entrance of the pus microbes into the general circulation is at matter of great wonder, but the fact that the micro-organism is carried to a particularly vulnerable issue is not so strange.
The following clinical features usually constitute the picture of a typical case of suppurative osteo-myelitis. The Child, or young adult in ordinary good health, is suddenly seized with severe pain at or near the epiphyseal line of a long bone; a chill almost immediately follows. The pain increases and becomes excruciating and is of a throbbing character, and while the pain is not exclusively confined to the focus of infection, it is sufficiently limited to direct our attention to the
area involved, knowing, as we do, that as a rule the primary infection is at or near the distal side of the epiphyseal line, where there is a positively well-defined point of tenderness on pressure, marking the involvement of the periosteum. All the symptoms of inflammation will not be observed until the soft parts are involved on account of the infected focus being walled in by the bony structure surrounding it. In the cases where we have neglected surgical interference, or have been mistaken in the diagnosis, we will be guided by the continuous rise of temperature and the distressed appearance of the patient (typhoid symptoms), symptoms that should always be looked upon with suspicion. The swelling, redness, etc., are absent in the early stage of the disease on account of the primary inflammation being located in the interior of the bone, but as soon as the inflammatory product has tunneled through the osseous tissue, all the other symptoms of inflammation and suppuration are at once manifest. These symptoms should never be allowed to supervene unprotected by surgical recourse. I have frequently observed these clinical features developing rapidly in children who had been exposed to cold, and terminating in the formation of large pus cavities, without suspicion of anything except ordinary malarial fever. In these cases there was positively no assignable cause, except the spontaneous development through the agency of the pyogenic cocci. No history of injury of any kind having been observed.
Tubercular osteomyelitis, while much more common than suppurative inflammation, often terminates in the same way that acute suppurative osteo-myelitis does. It is, however, essentially chronic in its nature. The only real difference between the two diseases is a pathological and an etiological one. Instead of the destructive pyogenic cocci incident to suppurative myelitis, we observe the tubercle bacilli which transform the normal connective tissue cells into embryonal or granulation tissue cells. The subsequent course after the focus of infection is established depends much upon the extent of the inflammation and rapidity of its course. The tubercular disease may pursue a course quite like suppurative osteomyelitis when the inflammatory product far exceeds the resorption capacity of the granu-