CHAPTER VISECONDARY ANTISEPSIS
Symptoms.—After operations performed under the most thorough aseptic or antiseptic procedure, wound fever, more or less marked, may be expected. It develops a few hours after operation and subsides in twenty-four or forty-eight hours. If, however, the wound has not been properly rendered aseptic, or in which there is reason for irritation or tension, more serious symptoms may develop about the second or third day. These symptoms increase with the amount of infection in the wound and result in septicemia, or septic intoxication, the outcome of the absorption of ptomains—the product of tissue decomposition.
Inflammatory fever is marked by a sudden rise in temperature, 100° to 103° F., with a full, strong, and rapid pulse, headache, anorexia, coated tongue, constipation and diminished secretion. If the infection is severe delirium comes on.
If the symptoms are not relieved promptly the indications of septicemia assert themselves with an increasing temperature, between 102° and 104° F., with a rapid compressible pulse gradually becoming weaker. The respirations are rapid and shallow. The tongue becomes dry and discolored and the teeth are covered with sordes.
The restlessness disappears and apathy, somnolence, and a low type of delirium takes its place. Vomiting occurs.There may be a profuse diarrhea and the urine is passed involuntarily. In other words, septicemia is but an aggravated continuance of inflammatory fever; untoward symptoms may come on early, and death may result within forty-eight hours.
On inspection, the infected wound appears highly inflamed, there is increasing swelling, with more or less pain in the part. The edges of the wound appear pale and everted. Serous oozing comes from the wound. If sloughing is to occur from tension or low vitality of the parts the area becomes discolored, assuming at first a pale green color, which turns into bluish brown—and, lastly, brown.
Treatment.—The treatment of such wounds is to immediately relieve all tension by withdrawing the sutures. Flush the wound with peroxid solution and irrigate thoroughly with a 1-3,000 bichlorid solution, leaving the wound open for a free drainage.
Then apply iodoform gauze over the wound and change the dressings as often as is deemed necessary—two or three times a day. In severe cases open the wound thoroughly, even by further incision, clean out the contents of the wound, such as foreign matter, bloodclots, exudate, or perhaps pieces of bone that may have been overlooked, using a small, sharp spoon curette for the purpose. See that the deeper recesses of the wound, especially in those about the nasal bones, are thoroughly gone over.
Next irrigate the wound with a 1-1,000 bichlorid solution. Carbolic solutions to be of use in the severer cases, are too irritating and cause an increase of the secretions, hence they are not to be used. Furthermore, their toxic property is not desirable and ofttimes are not well borne by the patient.
The wound is now loosely filled (not packed) with iodoform gauze to permit of perfect drainage. Aseptic absorbent cotton may be placed over this.
It is not advisable to bring the edges of the wound together; the main object is to overcome the spread of infection and the toxic absorption of the wound product.
When the symptoms are severe moist dressings, in the form of compresses dipped into 1-3,000 bichlorid, are to be preferred, changing them every hour.
Internally it becomes necessary to reduce the temperature and to overcome the toxemia.
For the temperature quinin is the best agent. In milder cases it can be given in tonic doses, associated with antifebrin, with or without morphin, to quiet the patient. In severe forms quinin must be pushed, giving as much as twenty grains at a dose, to be repeated as necessary. A saline purge, magnesium sulphate in full doses, is useful to eliminate the ptomains.
The strength of the patient must be supported by the free use of stimulants and frequent small quantities of nutritious food. Milk with whisky is excellent. Peptonoids and beef juice are given several times in the day.
Favorable symptoms are heralded by the lowering of the temperature, the abatement of toxic symptoms, the reduction of the edema, and the deep redness, as well as the softening of the hard and painful edematous walls of the wound, followed by the breaking down of more or less tissue with the production of pus.
Gangrene in these cases is often due to undue bruising or pressure on the parts during operation, and otherwise to the tension of sutures. It is best to allow the gangrenous mass to remain, keeping it aseptic by antiseptic measures, as it is often found that only the superficial layer and the edge or edges of the wound have suffered.
As demarcation is well established the gangrenous portions may be removed with the dressing or small seizingforceps.Walcher’spattern of a dressing forceps is shown inFig. 25, a toothed seizing forceps being represented inFig. 26.
Fig. 25.—Walcher Dressing Forceps.
Fig. 25.—Walcher Dressing Forceps.
Fig. 25.—Walcher Dressing Forceps.
Fig. 26.—Toothed Seizing Forceps.
Fig. 26.—Toothed Seizing Forceps.
Fig. 26.—Toothed Seizing Forceps.
The wound from now on may be at first subjected to a rather strong aqueous solution of hydrogen peroxid, fifty per cent, followed by the same sublimate solution used throughout.
Iodoform gauze dressing, with or without dusting of iodoform or iodol, is continued with the purpose of draining the pus secretion thrown off by the granulating tissue which soon begins to fill the wound, as well as to exert its antiseptic and stimulating influence upon the granulations.
Lazy or glassy granulations are removed with the curette as they appear, or a cauterant, in the form of a nitrate-of-silver stick. Gradually the new tissue contracts, the epidermal edges begin to fold over the surface.
Dry dressing, in the form of aristol or boric acid, may then be used, to produce ultimate healing under an aseptic scab, or lint moistened with two-per-cent salicylic oil or boric vaselin is placed upon the wound. A formula of the latter is made up as follows:
A desirable boric-acid oil for the same purpose is composed of:
The latter must be changed daily until cicatrization has been established.
If it is more desirable to cover the granulating area by means of skin grafts it may be accomplished readily, as later described. This is usually resorted to when there has been loss of tissue from the result of sloughing, although a sliding-flap operation may overcome the defect to a nicety; this is especially true of wounds about the anterior nasal border.
If the resulting cicatrice is no larger than the gaping wound it may be excised, the skin at either side is undermined and the edges are brought together, as was originally intended.
It sometimes happens that a wound takes on erysipelatous infection. It is usually of the simple variety, although the cellulo-cutaneous variety is not rare.
Causes.—The predisposing causes are septic infection, lowered vitality, resulting from alcoholism, poor hygiene, and nephritis. The exciting cause has been accredited to the erysipelo-coccus ofFehleisen, which is found chiefly in the more superficial channels of the corium and appearing in chain groups as seen microscopically.
Symptoms.—The symptoms locally are the peculiar rosy rash, rapidly spreading out from the wound with well-defined margins. The affected part appears smooth and edematous and is slightly raised above the surface, the patient complains of stiffness and burning pain in the part. Often vesicles form on the affected part.
The temperature rises suddenly to 102° to 103° F., there is nausea and vomiting.
Treatment.—The wound in such cases must be treated as described in inflammatory fever. Internally the usual remedies are given. A local application of sixty-per-cent ichthyol ointment, covered with salicylated cotton, serves best. The skin may be incised in various places, washed with an antiseptic (sublimate solution 1-1,000) and the serous exudation pressed out with the sterilized hand, after which the above ointment is applied under absorbent cotton (Glück).
Antithermic remedies, as obtained by the application of certain alkaloids, such as cocain, spartein, solanin, helleborin, have been successfully used by Guimard and Geley.
Spartein is especially claimed to exert a happy influence.
Lately a product under the name of antiphlogistin has been used locally with excellent results and its use is to be commended even in local wound inflammation.
If the subcutaneous tissue is affected and the surface indicates the breaking down of tissue, hot antiseptic applications are advisable or the skin is incised down to the deep fascia at such places and iodoform gauze is packed into the wound for several hours. Constant antiseptic irrigation is then established by means of drainage tubes inserted into the various incised places, which are connected to an irrigating apparatus, so that the antiseptic may reach all parts of the infected area.
Nontoxic solutions are indicated in this event; of these, hydrogen dioxid, three per cent, and boric acid, nine per cent, are most suitable. The solution is allowed to trickle gently through the wound and is led off by open tubes, that may be connected in such way as to empty into a receptacle placed beneath the bed.