THE ART OF NEGLECTING WOUNDS.
The New York Post-Graduate Clinical Society[2]was recently treated to a moving discourse on the novel subject of “The Art of Neglecting Wounds,” by Dr. Robert T. Morris, one of the instructors in surgery in the Post-Graduate School.
2. The Post-Graduate, Vol.XIII, No. 13, January, 1898.
2. The Post-Graduate, Vol.XIII, No. 13, January, 1898.
The author confined his remarks to wounds made by the surgeon when operating, and hints pretty strongly, though he does not say so, that their subsequent treatment even by the surgeon himself might not inappropriately be called “meddlesome surgery.”
For instance: In incised wounds (the margins of which have not been quite approximated) the capillaries begin to develop granulation tissue in the coagulated lymph deposited upon the surface in a few hours if the trophic nerves have not been much injured. This granulation tissue is extremely delicate and will not bear handling. When such a wound is suppurating freely the strong temptation to wipe away the pus with sponge or gauze should be resisted for two reasons, first, “Granulation tissue suffers traumatism whenever it is touched, no matter how lightly, and, as a result of such traumatism, there will be developed exuberant granulation tissue, which will be poorly supplied with blood-vessels. We have in weak granulations, so to speak, what might be called ‘watered stock.’ It is a very common result of our well-intentioned but ill-directed efforts at keeping the wound clean.”
Gauze upon the granulations will injure the tissue still more, since its filaments entangle the granulations, which on removal of the dressingare broken off in small fragments. The device which prevents this injury is a covering of very soft gutta-percha tissue or Lister’s protective silk. But the surgeon who practices this let-alone method, though backed by sound pathological knowledge and therapeutic principles, will not escape the censure of the family or the nurse, and too often allows his sense of neatness to take precedence of his more sober sense founded upon pathological knowledge.
This “neglect” is particularly desirable when epithelium is shooting across the wound. These hyaline cells are so extremely delicate that the slightest touch will damage or remove them to the detriment of the healing process. The dressing on a suppurating wound should be allowed to remain five or six days. Though the ignorant may find fault with the surgeon for such temporizing, he must insist upon it for the patient’s well-being.
Another illustration is drawn from the operation for appendicitis, in which we have adhesions, pus, and wide infection. Here new pathological factors are met with. The peritoneum throngs with polynuclear leucocytes which are engaged in destroying the bacteria. If time be given these faithful guards to mass themselves in the peritoneal lymph channels, they will prevent the extension of the peritonitis from this point. The surgeon, having evacuated the pus, removed the appendix, and inserted the drainage apparatus, is tempted, because of its bad smell, to wash out the wound. Such a measure would not only give the patient detrimental annoyance, but would inflict a new traumatism upon the tissues. “This traumatism calls out an unnecessary number of leucocytes, and an unnecessary degree of reactive inflammation ensues. If, on the other hand, the colon bacilli are allowed to increase, they will at first produce a very foul odor to the discharge, but in three or four days we will usually find streptococci abundant, and perhaps displacing all other bacteria.” In such cases, leave the drainage apparatus in place and “neglect” the wound. “Repair and destruction of bacteria will go on much better if we leave the wound alone, after having removed the principal mass—the contents of the abscess cavity.”
Another illustration is found in burns of the second degree. Here large blisters have formed and broken, and much skin is denuded of its cuticle. In such a case the author administers an anesthetic, opens the blebs, removes the detached skin, scrubs the parts with an antiseptic solution, covers the denuded surface with strips of gutta-percha tissue, and leaves the case to nature. When a change is made, itshould be of the outer dressings only. And the reasons for this treatment are that in such burns “the serum which is thrown out is germicidal, and is destroying all the bacteria upon the skin very rapidly. This germicidal action will go on so long as the serous exudation is free, but when the coagulation of lymph begins on the surface, this action becomes very much diminished, and the bacteria are then liable to liquefy the lymph and grow very rapidly, as new portions of serum are thrown out. This leads to sepsis and sometimes to the formation of thrombi, with necrosis of the duodenum and perforating ulcer. The patient’s friends complain if the dressings are left long in place, and yet I know of no wounds which do so well when ‘neglected’ as burns.”
In the discussion that followed, the author, being asked what he would do with suppurating sinuses, said “he knew of sinuses that had been kept open week after week and month after month, and had proved veritable gold lodes to the surgeons. If the surgeon had been compelled to go away for a time, these sinuses would have healed long before they did. This might seem like a joke, but it was a fact with which he was brought face to face all the time. His rule was to leave sinuses alone, in the belief that the poorly fed granulations lining them would in time cause approximation of the walls, and healing would occur. It was true that exceptions would have to be made for some sinuses, but that did not affect the rule as given.”
Such considerations give accentuation to the dictum of Velpeau, that “nature is a good physician but a bad surgeon,” and dignify thebon motof Holmes, who, seeing the smoothly healed and finely cushioned stump which resulted in time after an amputation, exclaimed:
“There’s a divinity that shapes our ends,Rough hew them how we will!”
“There’s a divinity that shapes our ends,Rough hew them how we will!”
“There’s a divinity that shapes our ends,Rough hew them how we will!”
“There’s a divinity that shapes our ends,
Rough hew them how we will!”
For the surgeon’s far more than the physician’s successes depend upon thevis medicatrix naturæ, and he who is best versed in physiological and pathological processes, and administers the surgical art accordingly, will secure the best results.
They who neglect their surgical cases from ignorance, carelessness, or a wanton disregard of the great pathological dicta of the day, can find no justification in these teachings, for the truth, as embodied in the author’s closing words, puts all such to shame and confusion: “A good deal of skill is required in order to neglect wounds well. This ‘neglect’ of course implies a proper understanding of the processes with which one is dealing.”