« ForrigeFortsæt »
and which exhibit great vital energy. bert considers it probable that the lymphogenic-leucocytes with single nuclei are capable of taking part in the construction of new connective tissue, by helping to cover over the lymph cavities and space with endothelium. So then the cicatrix of a wound is formed of fibrillar connective tissue, which is formed from fibroblasts." Tillman still further states that "the formative cells are at first round and then enlarged and look like large round epithelium cells, or they are more elongated or possess one or more processes, some becoming spindle-shaped, others club-shaped, or they may form branch cells or polynuclear giant cells. The processes repeatedly anastomose with each other. The number of large formative cells then rapidly increase, and in certain localities they lie close together. The fibrillar tissue is formed in part directly from the protoplasm of the formative cells themselves, and is consequently intracellular in its origin, or it comes from a homogeneous intercellular ground substance or stroma, which has previously developed from the formative cells. In the intracellular fiber formation, fibers make their appearance on one or both sides of a cell, or at one extremity, or in a process of it, and unite with the fibers of the adjoining cells. The nucleus, together with a portion of the protoplasm of the formative cell, persist as a fixed connective tissue cell. The direction taken by the fibers is usually the same over a considerable area, the formative cells playing no part in determining the direction of the fibers. The size of these remaining cellules subsequently diminishes, the fibrous tissue becomes thicker and the cicatrix is complete." Again, it is asserted that in the first stages in the repair of a wound the fixed tissue cells receive their nutriment from the blood plasma, from the vessels in the immediate vicinity, but this supply in cell nutrition is only temporary, the formation of new blood vessels being necessary to further growth and repair. The repair of wounds comes then mainly and essentially from mesoblastic elements; original fixed connective tissue cells and endothelium of vessels are the source and elements creating and hastening repair in wounds. Any element which is competent to hasten the granulation of wounds must be based upon the principles of aseptic
wound treatment and the application of mesoblastic elements to granulating surfaces. This is true, not only as regards the process of Riverdin, Thiersch, Wölflers, mucous transplantation, the root sheath of hair, but in the direct transplantation of skin itself. Experience has taught the surgeon that in healing by second intention or granulation, particularly in those wounds where we have contused and lacerated tissue, modern methods are defective, even unto the most careful use of aseptic or antiseptic wound treatment; that where it is not possible to obtain approximation of the surfaces through extent of injury, situation or loss of substance, such wounds are subject to infection and the formation of pus is a frequent attendant. The utter inutility of attempting to destroy pus foci when once resident in the interior of tissue and vessels by applying antiseptics to the surface has been demonstrated by Schimmelbusch and others. These microbic forms are endowed with life and procreative power and fulfill their function under the favorable conditions in which they are placed. Microbes may be destroyed upon the surface of a wound by antiseptics, but those chiefly protected and in fertile soils thrive constantly beneath antisepticized surfaces. We may lessen the number of pathogenic microbes in their less favorable situations, but we certainly do not and cannot decrease the vigor of them in localities favorable to them. Again, the best and most perfect antiseptics are disease producers themselves, begetting local and systemic effects. We are all well aware of the poisonous effects of corrosive sublimate, iodoform and carbolic acid. These so-called cures are at times dangerous disease producers and therapeutic fallacies. If pain be nature's signal of distress and ease is but rest, and rest is indication of normal function, it appears but a just conclusion that the non-irritants as exemplified in the application of asepsis, should be justly considered as nature's ideal form of cure. Antiseptics are all irritants, and the use of irritants, we maintain, are within the realm of danger, as their management depends upon the interpretation of divers conditions, which of necessity are not always evenly determined. Pain is but a nerve's distress and its waste and the loss of just so much vital force; hence in the application of asepsis this waste, dis
tress and loss of force is averted; but it is ultimately always engendered in the application of antiseptics. The great worth of asepsis is in its honest simplicity, while the danger of antisepsis comes from its natal error and the assumption of experimental truth. The value of asepsis has been established by truthful investigation and delay, while antisepsis has prospered by unwise, misleading precipitancy. Absolute cleanliness or effective studied prevention is but asepsis; irritant and disease-producing uncertainties picture antisepsis. It is but natural to believe that with the accumulation of time, experience and results, all wound treatment will be based upon the principle of asepsis. The virtue which seems manifest in antisepsis plainly comes from those elements of asepsis contained in the technique of antisepsis. The great and real value of all wound treatment comes in the true realm of prevention. Asepsis is but a name for ideal prevention, ideal rest, as it prevents infection and unrest, and these are the real germs of cure. Zeidler of St. Petersburg has for the past seven years doubted the sense or desirability of attempting to disinfect wounds which are suppurating, or localized foci, or diffuse suppurative cellulitis. He has practiced in such wound condition or diseased condition asepsis in preference to antisepsis. In 1889 he recorded about one hundred cases treated without antisepsis in the most satisfactory manner, and his observations have now swelled up to many hundreds. His method of treatment is as follows: The field of operation is prepared as usual; the wound is thoroughly opened up and all tissues infiltrated with pus carefully dissected out. It is then wiped out with sterilized gauze, and if necessary irrigated with a 6 per cent saline solution. It is lightly but carefully packed with sterilized gauze, over which is placed another layer of gauze covered by wool and firmly bandaged on. Zeidler is greatly in favor of dry rather than wet dressings, believing that thereby secretion is diminished and the formation of healthy granulations assisted. Neither iodoform nor any of the usual antiseptic reagents appear to his mind to have any salutary influence on the course of the case, and indeed he considers that they are really harmful. The dressing is often left on for eight days without being changed and he has never
noticed any objectionable smell arising from decomposition of the secretion. Should the effusion be great and soak through the outer layers, this may be removed and replaced without touching the deeper parts.
It can be safely said that the most progressive surgeons of the day use asepsis almost to the entire exclusion of antisepsis. Success in connection with operative treatment and wound treatment depends upon studious, well directed attention and care in the preparation of a patient, the cleanliness of the operative surroundings of the surgeon and assistants, and the proper aseptic preparation of every element used in dressing entering into the treatment of the case. It has been said that asepsis is the scientific form of wound treatment, while antisepsis is an empirical form. We have found after some experience that with the normal saline solution-a 6-10 or 7-10 per cent solution-and proper sterilized substances, that we obtain better and more comfortable results than was obtained by antiseptics. In our earliest experience with antiseptic wound treatment the following technique was pursued: As is well known, particularly in railway surgery, more than ordinary septic conditions are engendered. Not infrequently at the time of injury the parts are bedraggled in cinders, dirt and doubtful filth and not infrequently are covered with grumous oils. Under these conditions the parts were thoroughly scrubbed and cleaned, shredded and doubtful tissues are removed; then the parts were irrigated with a corrosive sublimate solution, ranging from one in one thousand to one in fifteen hundred; then the surface was covered with iodoform, then iodoform gauze; then above this corrosive sublimate gauze covered the wound; then absorbent cotton applied; then above this a mackintosh and more gauze and a spica bandage.
In amputation additional elements were applied in the shape of a plaster-of-Paris bandage covering the outer dressing. We not infrequently found that we obtained the best results where rigid filtration of air was thus accomplished, but once when pus manifested. itself, our irritant irrigations seemed incompetent to hasten result. It is true that by this means we have always avoided septicæmia and pyæmia, but still infection remained. We have tried both asepsis and antisepsis in
granulating wound treatment, and while heartily in favor of aseptic wound treatment, still we find that in injuries inflicted on the railways we have many halting stages, particularly in large granulating wound surface. Anyone who has tried antiseptic and aseptic dressings will soon find out that there is a period in the healing of granulating surfaces in which there is a positive non-effect of any application on the granulation. They not only become tolerant, but show a tendency toward retrogression; that is, they apparently become rebellious to the continuous application of any single agent or dressing used. This is certainly true regarding the normal saline solution, corrosive sublimate, iodoform, carbolic acid, etc. But there is this in favor of the saline solution and aseptic dressings: their continued application does never engender systemic effects and we obtain more satisfactory curative results. Again, we believe that when the necessity arises for the repeated erasement of the granulations, there is greater loss of tissue, and the resulting cicatrix is even more unstable than when saline solution is used. Hence, we believe that skin grafting in some form should be used more or less in many large granulating wounds, as it lessens the time incurred in the healing process and in preventing consequent cicatricial contraction. Yet experience has taught us that skin grafting is at times an unstable form of cicatrization. It has been demonstrated beyond a doubt that the Thiersch method is pre-eminently the superior form of skin grafting, as the Riverdin method is imperfect, while in the Thiersch method conditions are intelligently interpreted and met. Of course, skin transplantation presents elements far superior to any process of skin grafting, but the many elements of difficulty in its application debar the possibility of broad and extended use. Again, in the treatment of granulating wounds the use of the normal saline solution does not debar us from using these elements of skin grafting which hasten cicatrization. We have succeeded in many instances of obtaining grafts by placing the graft direct upon the granulations without scraping away the granulations. Schwenninger and Nussbaum have attempted to implant hair by strewing it over a granulated area, where there has been a loss of skin. If the root sheath still remain attached to the
hair, it became adherent and formed a center from which cicatrization proceeded, but the hair itself fell out after a few days. Hairs without their root sheath did not become attached at all. (Tillmann's.)
So in the healing of granulating wounds, we have acted upon this suggestion as stated by Tillmann and found that by the implantation of single hairs we could readily hasten cicatrization, but that a hair without a root-sheath was of no use. We have succeeded with hair implantation, and there is always an abundance of hair around, their preparation and application is readily and easily accomplished without all the attending elements of worry and care necessitated in the preparation of skin grafts. Hair from the head is always used. It being pulled forcibly and rapidly out, those possessing the root-sheath are put into a 7-10 per cent saline solution at a temperature of 140 degrees F. After they have been sterilized they are then applied directly to the granulations. The root-sheath is pressed along with the attached hair rather firmly into granulations, and about one-third of an inch from the edge of the cicatrizing wound. These are held in position by the application of sterilized gold or tin foil and hot salted gauze applied direct to granulation, and over foil holding root-sheath grafts. At about the eighth or ninth day the foil is removed; the hair is permitted to remain until it comes away. We generally find at this period a pearlly pellicle tissue, which indicates the adhesion of the graft. We do not see why this should not be done in almost every granulating wound. We have found the saline solution thoroughly soothing and not infrequently where a corrosive sublimate solution has produced more or less pain, that a change to the saline solution was followed by undoubted ease and rest. The only objection which we have found regarding the saline solutions thus far has been the necessity of applying them oftener than when we were in the habit of applying antiseptic dressings, and this tendency toward non-action or toleration by the granulations, which we attributed to septic infection. Hence we have conceived that if we could by any means sterilize or filter the surrounding air, we would be enabled to accomplish more successful results. We have already stated that in our early application of antiseptics we not infrequently
had healing by first intention, and this we interpreted had arisen by obtaining a rigid exclusion of contaminated air. There is no doubt but that all wounds, particularly granulating wounds, require in their healing process the presence of pure sterilized air; likewise there is no doubt that too much heat retented by dressings is hurtful. While we realize that the generally accepted idea is that absorbent sterilized cotton is a perfect germ filtrant, still at the same time we believe that it is a great heat producing and heat retaining agent. Hence, if we can obtain dressings which will admit sterilized air to the wounds and which will absorb any excess of the exudations and still not retain or impart heat to the treated parts, we may be able to obtain a more perfect process of healing. While we realize that in many instances we cannot completely get rid of wound infection, yet we believe that along with the aid of the process of phagocytosis and the prevention of continual external infection that the best of results will accrue. In the treatment of contused and lacerated wounds, where nature has to heal by granulation, our failures have been constant and unceasing, and it has occurred to us that the great desideratum in the treatment of wounds is the perfect filtration of external air, the non-retention and production of as little heat as possible engendered by dressings and by the absorption of exuded materials accomplished by drainage and absorption. We have at our command some of the best forms of antiseptics, which owing to their irritant character we are unable to use, either upon the granulating surface or the cutaneous surface. We have recently used the mild and unirritating elements of asepsis in the shape of warm sterilized salt solutions, aseptic salted gauze bandages, and in addition thereto crinoline gauze of No. 7 make, steeped in a strong antiseptic mixture, for the purpose of filtrating the air and preventing any ingress of microbes. Crinoline gauze has large meshes, which permit the entrance of air. This gauze is treated in the following manner, with the aim of filtering the air prior to its coming in contact with the wound: Onefourth of an ounce of the best calf's foot gelatine is boiled in a pint of water for half an hour or more, and to this thoroughly boiled gelatine there is added a quarter of a drachm
to the ounce of this gelatine mixture, of either the oil of cassia or the oil of mustard. A bandage of crinoline gauze of such width as desired is thoroughly steeped in this mixture of gelatine and one of these essential oils, and if desired can be put on in their hot condition, or they can be thoroughly dried in a sterilizer and when needed for use can be steeped in hot sterilized water and thus readily softened for application.
The manner of application consists of the following technique: The wound is thoroughly cleansed, all doubtful and shredded tissues removed, the surface around the wound. treated by permanganate of potash solution or oxalic acid, and then irrigation is applied to the surface, generally 6-10 or 7-10 per cent saline solution at about 140 degrees F.; the surface is then dried; then gauze steeped in hot sterilized salt solution is applied direct to the wound, three or four layers being used to thoroughly protect the wound; then a single bandage of this sterilized gelatine bandage is applied on the salted gauze; then more salted gauze is applied above this, and another layer of the gelatine gauze is then applied, to be covered up by a sterilized spica bandage.
DISCUSSION ON DR. OUTTEN'S PAPER.
Dr. Emory Lanphear: I feel that I cannot allow the assertions of Dr. Outten go by, without challenging them in certain respects, at least. I believe in this audience there are too many careful observers and thorough surgeons, who have seen too many cases recover under strict antiseptic surgery, that would have terminated fatally under the method advised by Dr. Outten, to disbelieve in antiseptic surgery. In the first place, he makes the statement that the insertion of the hand into the hair, and then putting the hair into a solution of common salt-seven-tenths per cent-at 140 degrees F., will sterilize the hair which is taken from the septic head. This is absolutely absurd from the standpoint of the bacteriologist. I put water at 140 degrees into my wounds purposely to check hemorrhagedo I sterilize my hands in 140 degrees of com-mon salt? By no means. The hairs after being put in that solution of common salt are just full of disease-producing bacteria.
The second point to which I would take ex
ception, is the assertion based upon Dr. Roswell Park's experiments with mustard. It is true that mustard and the oil of mustard may be regarded as one of the most valuable of disinfectants. As Dr. Outten says, after you have been holding a post-mortem-yea, more, after you have been handling iodoform-if you will take simply some mustard meal and thoroughly rub your hands with it, the foul smell disappears. But, howsoever thoroughly you might wash your hands in mustard meal, as advised by Park, if you will immediately take a needle and insert it beneath the finger-nails, or even rub the surface of the finger upon a proper culture field, you will find that the finger is still dirty beneath the nail and on the skin you will find dirt which is pregnant with danger to the patient-dirt which contains the staphylococcus or the streptococcus of pus, and Park himself is said to have admitted quite recently that he does not now recommend this process of sterilizing the hands by disinfectants. It certainly does not disinfect, as has been proven by abundant experimentation in the last two months.
Dr. Outten seems to imply in his remarks that granulation tissue is always infected tissue. I want to say in reply that I can take you through the hospitals of this city to-day, and show you wounds made two or three weeks ago, that are granulating without the least sign of inflammatory trouble, pus, or infection, as a result not of asepsis, but of the most careful antiseptic treatment possible.
We have been told that iodoform is an antiseptic or a germicide. It is nothing of the kind. No intelligent man nowadays will claim that iodoform is germicidal. It is scarcely antiseptic. Powdered chalk would do almost as well. It is simply by the drying process that we get beneficial results from iodoform and not from its smell or its tendency to destroy germs, but from the fact that it prevents proliferation of the germs that are there and the development of new ones. In that one point lies the great secret of success in the use of iodoform. Any dry powder of equally absorptive power would probably be as good as iodoform.
Dr. P. Daugherty: A good many years ago -soine ten years at least-I think the late Professor Gunn said that he did not know whether there was anything in antiseptics or not, but
one thing he did know, and that was that since he commenced the use of carbolic acid he had much better success with his wounds than he did before. Now, gentlemen, I do not know whether there is anything in iodoform or not, but I must say that since I began its use I have had better success than I did before, and I believe it was from Dr. Outten that I got the idea of using it, and using it plentifully. Some years ago when the M. K. & T. was under the control of the Missouri Pacific, I happened to be on a visit in St. Louis, and, of course, went to the hospital. Dr. Outten had a man with a gun-shot wound in the gluteal region, upon whom he was operating that day. He made quite an extensive exploration, but failed to find the bullet, and in dressing the wound he kept putting in his iodoform continuously, and said to me, "I use it very freely," and I got the idea of using it from him. Since then I have had better success than before. But there is another thing of which I feel firmly convinced, that antisepsis is fast giving way to asepsis. and the time is coming when cleanliness will supersede antiseptics.
Dr. Broughton: In the past two years I have discarded what we call antiseptics. I used to employ them, and I believe that while it is not universal, the majority of surgeons are now discarding antisepsis and adopting asepsis. I am not personally acquainted with Dr. Outten, but I believe he is a man who will learn by experience, and he has learned that iodoform is of no good.
Dr. W. S. Hoy: The question of antisepsis and asepsis is one in which the profession are particularly interested at this time, and sooner or later we will have to draw a marked distinction between the one and the other; either discarding one or accepting the other. We have witnessed from time to time the gradual growth of certain materials that were offered to the profession as kind of hobbies, not only from manufacturers, but physicians themselves. While I love Dr. Outten as dearly as my own father and respect him for his ability and characteristics as a man, I think sometimes he takes opposite views in this association in order to get the members fighting. I would just as soon dust a wound with dry clay and expect good results from it as to use iodoform.
As regards the treatment of wounds asepti