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 purified in the same way.
The iodine method of disinfecting the skin introduced by Grossich is simple, and equally efficient. The day before operation the skin, after being washed with soap and water, is shaved, dehydrated by means of methylated spirit, and then painted with a 5 per cent. solution of iodine in rectified spirit. The painting with iodine is repeated just before the operation commences, and again after it is completed. The final application is omitted in the case of children. In emergency operations the skin is shaved dry and dehydrated with spirit, after which the iodine is applied as described above. The staining of the skin is an advantage, as it enables the operator to recognise the area that has been prepared.
If any acne pustules or infected sinuses are present, they should be destroyed or purified by means of the thermo-cautery or pure carbolic acid, after the patient is anæsthetised.
Appliances used at Operation.—Instruments that are not damaged by heat must be boiled in a fish-kettle or other suitable steriliser for fifteen minutes in a 1 per cent. solution of cresol or washing soda. Just before the operation begins they are removed in the tray of the steriliser and placed on a sterilised towel within reach of the surgeon or his assistant. Knives and instruments that are liable to be damaged by heat should be purified by being soaked in pure cresol for a few minutes, or in 1 in 20 carbolic for at least an hour.
Pads of Gauze sterilised by compressed circulating steam have almost entirely superseded marine sponges for operative purposes. To avoid the risk of leaving swabs in the peritoneal cavity, large square pads of gauze, to one corner of which a piece of strong tape about a foot long is securely stitched, should be employed. They should be removed from the caskets in which they are sterilised by means of sterilised forceps, and handed direct to the surgeon. The assistant who attends to the swabs should wear sterilised gloves.
Ligatures and Sutures.—To avoid the risk of implanting infective matter in a wound by means of the materials used for ligatures and sutures, great care must be taken in their preparation.
Catgut.—The following methods of preparing catgut have proved satisfactory: (1) The gut is soaked in juniper oil for at least a month; the juniper oil is then removed by ether and alcohol, and the gut preserved in 1 in 1000 solution of corrosive sublimate in alcohol (Kocher). (2) The gut is placed in a brass receiver and boiled for three-quarters of an hour in a solution consisting of 85 per cent. absolute alcohol, 10 per cent. water, and 5 per cent. carbolic acid, and is then stored in 90 per cent. alcohol. (3) Cladius recommends that the catgut, just as it is bought from the dealers, be loosely rolled on a spool, and then immersed in a solution of—iodine, 1 part; iodide of potassium, 1 part; distilled water, 100 parts. At the end of eight days it is ready for use. Moschcowitz has found that the tensile strength of catgut so prepared is increased if it is kept dry in a sterile vessel, instead of being left indefinitely in the iodine solution. If Salkindsohn's formula is used—tincture of iodine, 1 part; proof spirit, 15 parts—the gut can be kept permanently in the solution without becoming brittle. To avoid contamination from the hands, catgut should be removed from the bottle with aseptic forceps and passed direct to the surgeon. Any portion unused should be thrown away.
Silk is prepared by being soaked for twelve hours in ether, for other twelve in alcohol, and then boiled for ten minutes in 1 in 1000 sublimate solution. It is then wound on spools with purified hands protected by sterilised gloves, and kept in absolute alcohol. Before an operation the silk is again boiled for ten minutes in the same solution, and is used directly from this (Kocher). Linen thread is sterilised in the same way as silk.
Fishing-gut and silver wire, as well as the needles, should be boiled along with the instruments. Horse-hair and fishing-gut may be sterilised by prolonged immersion in 1 in 20 carbolic, or in the iodine solutions employed to sterilise catgut.
The field of operation is surrounded by sterilised towels, clipped to the edges of the wound, and securely fixed in position so that no contamination may take place from the surroundings.
The surgeon and his assistants, including the , wear overalls sterilised by steam. To avoid the risk of infection from dust, scurf, or drops of perspiration falling from the head, the surgeon and his assistants may wear sterilised cotton caps. To obviate the risk of infection taking place by drops of saliva projected from the mouth in talking or coughing in the vicinity of a wound, a simple mask may be worn.
The risk of infection from the air is now known to be very small, so long as there is no excess of floating dust. All sweeping, dusting, and disturbing of curtains, blinds, or furniture must therefore be avoided before or during an operation.
It has been shown that the presence of spectators increases the number of organisms in the atmosphere. In teaching clinics, therefore, the risk from air infection is greater than in private practice.
To facilitate primary union, all hæmorrhage should be arrested, and the accumulation of fluid in the wound prevented. When much oozing is anticipated, a glass or rubber drainage-tube is inserted through a small opening specially made for the purpose. In aseptic wounds the tube may be removed in from twenty-four to forty-eight hours, and where it is important to avoid a scar, the opening should be closed with a Michel's clip; in infected wounds the tube must remain as long as the discharge continues.
The fascia and skin should be brought into accurate apposition by sutures. If any cavity exists in the deeper part of the wound it should be obliterated by buried sutures, or by so adjusting the dressing as to bring its walls into apposition.
If these precautions have been successful, the wound will heal under the original dressing, which need not be interfered with for from seven to ten days, according to the nature of the case.
Dressings.—Gauze, sterilised by heat, is almost universally employed for the dressing of wounds. Double cyanide gauze may be used in such regions as the neck, axilla, or groin, where complete sterilisation of the skin is difficult to attain, and where it is desirable to leave the dressing undisturbed for ten days or more. Iodoform or bismuth gauze is of special value for the packing of wounds treated by the open method.
One variety or another of wool, rendered absorbent by the extraction of its fat, and sterilised by heat, forms a part of almost every surgical dressing, and various antiseptic agents may be added to it. Of these, corrosive sublimate is the most generally used. Wood-wool dressings are more highly and more uniformly absorbent than cotton wools. As evaporation takes place through wool dressings, the discharge becomes dried, and so forms an unfavourable medium for bacterial growth.
Pads of sphagnum moss, sterilised by heat, are highly absorbent, and being economical are used when there is much discharge, and in cases where a leakage of urine has to be soaked up.
Means adopted to combat Infection.—As has already been indicated, the same antiseptic precautions are to be taken in dealing with infected as with aseptic wounds.
In recent injuries such as result from railway or machinery accidents, with bruising and crushing of the tissues and grinding of gross dirt into the wounds, the scissors must be freely used to remove the tissues that have been devitalised or impregnated with foreign material. Hair-covered parts should be shaved and the surrounding skin painted with iodine. Crushed and contaminated portions of bone should be chiselled away. Opinions differ as to the benefit derived from washing such wounds with chemical antiseptics, which are liable to devitalise the tissues with which they come in contact, and so render them less able to resist the action of any organisms that may remain in them. All are agreed, however, that free washing with normal salt solution is useful in mechanically cleansing the injured parts. Peroxide of hydrogen sprayed over such wounds is also beneficial in virtue of its oxidising properties. Efficient drainage must be provided, and stitches should be used sparingly, if at all.
The best way in which to treat such wounds is by the open method. This consists in packing the wound with iodoform or bismuth gauze, which is left in position as long as it adheres to the raw surface. The packing may be renewed at intervals until the wound is filled by granulations; or, in the course of a few days when it becomes evident that the infection has been overcome, secondary sutures may be introduced and the edges drawn together, provision being made at the ends for further packing or for drainage-tubes.
If earth or street dirt has entered the wound, the surface may with advantage be painted over with pure carbolic acid, as virulent organisms, such as those of tetanus or spreading gangrene, are liable to be present. Prophylactic injection of tetanus antitoxin may be indicated.