The local treatment of wounds

THE LOCAL TREATMENT MALCOM THOMPSON, LOUISVILLE,

B

Y the “Local Treatment of Wounds” is meant treatment as apphed directIy to tissues, the continuity of which has been severed. Genera1 treatment such as the administration of bIood, fluids, chIorides, foods, vaccines and antitoxins wiI1 not be discussed. The influence of disease states such as anemia and diabetes wiI1 purposeIy be omitted. Even with these limitations the subject is Iarge and must necessariIy be confined to the principIes of treatment without reference to specific Iocations of wounds. SpeciaI considerations enter into the treatment of wounds of the pIeura, heart, peritoneum, eye, brain, urinary bIadder, joints and other important structures which makes of each one a subject in itseIf. The principIes underIying the treatment of wounds are the same, however, regardIess of their extent or Iocation. Before studying the treatment of wounds it is proper to inquire into their methods of heaIing. How do wounds heaI? What agencies or factors faciIitate this process and which ones retard it? Most pathoIogists and surgeons speak of wounds as heaIing by first and second intention. The two processes are essentiaIIy the same. By first intention is meant the prompt heaIing of a wound with very IittIe inffammatory reaction, the reaction being so smaI1 that there is no redness and no grossIy appreciabIe sweIIing of the wound and no secretion from it other than cIear serum or norma bIood within the first few hours. HeaIing by second intention is the same process to which is added the phenomena of inflammation. Inffammation is due * DeIivered

OF WOUNDS* M.D.

KENTUCKY

to some injury to the tissues and causes a deIay in the heaIing process. The amount of deIay depends upon the severity of the injury and the abihty of the body to overcome it.‘Once the irritant is removed by the inffammatory process heaIing rapidIy progresses. Since heaIing is due to an actua1 growth of ceIIs anything which prevents the approximation of tissues during the heaIing process and disturbs that process once it is started wiI1 deIay heaIing. To obtain prompt heaIing, or in other words heaIing by first intention, we must excIude from wounds any factor which prevents approximation and any injurious substance. Substances injurious to wounds may be divided into bacteriaI, mechanica1, physica1, and chemica1. The importance of excIuding bacteria from wounds is now generaIIy recognized and the various methods of excIusion wiI1 not be described. Attention is caIIed however to the recent work of Dandy and of MeIeney. Dandy emphasized the importance of adequate steriIizations of suppIies. He has proved that a constant minimum pressure of 20 pounds for at Ieast one hour is necessary to kiI1 bacteria by autocIaving. MeIeney found that members of the operating room personne1 sometimes carried streptococci in their noses and throats which Iead to serious postoperative infections. He reduced the incidence of such infections by covering the nose and mouth of every person entering the operating room. RoutineIy now when postoperative infections occur he makes cuItures of the noses and throats of the entire surgica1 staff to discover if carriers are present.

before the Davies County MedicaI Society, Owensboro, Ky., before the LouisviIIe SurgicaI at LouisviIIe, Ky. and before the Logan County MedicaI Society at RusselIviIIe, Ky.

302

Society

New

SERIES VOL. XXVII,

No. z

Thompson-Wound

That the naturaI protective forces of the body can overcome bacteria in wounds has been demonstrated both cIinicaIly and experimentaIIy. HaIsted showed that the presence of necrotic tissue or foreign bodies in wounds greatIy enhanced the ability of bacteria to muItipIy suffrcientIy to cause infection. He opened the peritonea cavity of thirteen dogs and introduced cuItures of StaphyIococcus aureus. None of the dogs deveIoped peritonitis. In nine dogs “a smaI1 piece of potato covered with a thick growth of StaphyIococcus aureus was introduced into the peritonea1 cavity. AI1 of the dogs died of genera1 peritonitis.” In five dogs “a smaI1 piece of steriIized potato was introduced Peritonitis into the peritonea1 cavity. did not deveIop in a singIe case.” In eight dogs “a smaI1 piece of omentum was Iigated with strong silk. The Iigature and the tied-off portion of the omentum were inocuIated with a drop or two of a bouiIIon cuIture of StaphyIococcus aureus. There was a fata peritonitis in two cases and circumscribed peritonitis in two cases. Four of the dogs recovered without peritonitis.” The obvious deduction from these experiments was that the natural resources of the body were abIe to overcome viruIent bacteria as Iong as there was no necrotic tissue or greatIy injured tissue present. Given the presence of necrotic tissue either in the form of a stranguIated piece of omentum or a piece of potato the bacteria were abIe to overcome the body resistance and cause a fata peritonitis. The commonest cause of necrotic tissue in wounds is suturing with tension and Iigating of Iarge masses of tissue. These cause necrosis by depriving tissues of their bIood suppIy. HaIsted aIso frequently caIIed attention to the fact that in pre-antiseptic days subcutaneous operations usuaIIy resuIted in primary heaIing though the instruments employed were aImost invariabIy contaminated with viruIent organisms. The knives used, however, were sharp and there were no stranguIating Iigatures or sutures and no rough handIing of tissues.

Treatment

American Journal of Surgery

303

Some bIood was present of course but it was not under tension and seldom gave troubIe. In treating wounds injurious factors of mechanica nature are cIamping tissues, Iigating masses of tissues, Ieaving foreign taking unnecessarily large bites bodies, in suturing, suturing under tension, rough handhng of tissues, rough sponging, strenuous retracting, and appIying tight dressings. The teaching of James Paget that “wounds shouId not be rubbed even with agencies sponges ” is stiI1 true. Injurious of a physica nature are excessive heat or coId and dehydration. Injurious chemica1 substances incIude most drugs, particuIarIy antiseptics. Some of these agencies act by constricting the bIood suppIy sufFicientIy to Iead to necrosis whiIe the others cause death of the ceIIs by direct physica and chemical changes. Accurate approximation of wound edges is essentia1 for prompt heaIing. It is aIso important to exclude from the line of union tissues which do not properIy beIong there. This is especiaIIy true of fat as it heaIs poorly and readiIy becomes necrotic. To obtain approximation sutures are necessary. The idea1 suture material is one that wiI1 strongIy support and approximate the tissues, cause no inff ammatory reaction, and when heaIing is compIete, disappear. UnfortunateIy such a suture has never been found. The two great varieties of sutures are the absorbabIe and the nonabsorbahIe. The most commonIy used absorbable suture is catgut while siIk is the most popuIar non-absorbabIe suture. The absorbabihty of catgut is its onIy virtue when compared with siIk. It is difficult to steriIize; wounds sutured with it are not as strong as those made with siIk; it often absorbs too soon; it excites a greater reaction in the wound and it promotes infection to a greater degree than does siIk. Being an anima1 tissue which is easily injured by heat or chemicaIs and being derived from a grossIv infected source makes difficuIt the steriIization of catgut.

304

American

Journal

of Surgery

Thompson-Wound

Treatment

FEBRUARY.

CgJj

Many cases of postoperative tetanus and gas gangrene directIy traceabIe to its use in the operation have been reported. Some

sutured with catgut. Besides, in two of the wounds sutured with catgut separation of the peritoneum had occurred, yet these

Frc. I. Two catgut sutures (00 chromic) and two silk sutures (A bIack) were placed in abdomina1 muscIes of guinea pig. Four days later pig was killed and section of wall removed. Mustration is of peritonea1 surface of sutured muscle showing four sutures having worked toward peritoneum. A, reaction around first catgut suture. B, adherent omentum to second catgut suture. c and D, siIk sutures with practicaIIy no reaction around them.

FIG. 2. Proper method of treating avuIsed Aaps. Picture taken one week after highway accident showing Iiving flap and wound free from inflammation. Had wound been completely cIosed flap would aImost certainIy have become necrotic as it was impossibIe to approximate edges without avuIsed skin becoming white and avascular from tension.

of these have resuhed fataIIy. In 1931, MeIeney and ChatfieId reported: “In a recent study of 174 specimens of catgut sent us by tweIve different surgica1 cIinics, scattered throughout the country and either taken from their stocked suppIy or purchased from the open market, twentytwo, or 1296 per cent, were found to yieId spore-forming bacteria, including the common gas gangrene organisms.” AImost certainIy there have been many simiIar infections from catgut which have not been reported. That more have not deveIoped speaks we11 for the resisting powers of the average human body. That wounds sutured with catgut are not as strong as those sutured with siIk has been experimentaIIy demonstrated by Dr. E. L. Howes of New York. He studied the strength of wounds made in the gastric and abdomina1 waIIs and sutured with catgut and silk. Of wounds made in abdominal waIIs “the resuIts showed that in every instance the wounds sutured with silk were stronger than those

and a11 of the other wounds appeared to have heaIed per primam externaIIy.” Of the gastric wounds, the ones sutured with siIk regained their origina strength and became stronger than the stomach waI1 in Iess time than did those sutured with catgut. The premature absorption or digestion of catgut has been observed many times. This is manifested by disruption of the wound, a serious postoperative accident in which the entire wound compIeteIy comes apart. The prevaIence of disruption in dehydrated patients has been known cIinicaIIy for many years. It was particuIarIy feared foIIowing operations for pyIoric stenosis and recentIy Bird and MacKay have shown experimentaIIy that dehydration greatIy deIays healing. H. S. Andrews of LouisviIIe reported that he had seen disruption of wounds several times foIIow operation for pyloric stenosis when they were sutured with catgut but has never seen it foIIowing the use of siIk. I have seen severa cases of disruption

New SERIES VOL.. XXVII,

No.

2

Thompson-Wound

following the use of catgut but up to the present time have never seen it in a wound sutured with siIk. My experience with siIk has been fuIIy as extensive as that with catgut. Cases of disruption foIIowing siIk have been reported, however, in the Iiterature. The disruption of an abdomina1 wound with the expuIsion of abdomina1 contents is a terrifying accident. The proper way of treating this condition is to repIace as gently as possibIe and without any attempt at cIeansing, the abdomina1 contents and suture the abdomina1 waI1 IooseIy with interrupted throughand-through sutures of silver wire or silkworm gut. That catgut excites greater reaction in a wound than does siIk has been demonstrated many times. This was done by palpating wounds sutured with the two materiaIs. Other factors being the same there was aIways more sweIIing, more induration, and more tenderness in the wounds made with catgut. SiIk when properIy used in cIean wounds gives a lower percentage of infections and a higher percentage of primary union than does catgut. Beginning in 1925 I made a study of wounds at the Pitt Community HospitaI in GreenviIIe, North CaroIina. The resuIts were pubIished* and were briefly as foIIows: Using a non-absorbabIe suture (siIk or Iinen) 95 per cent of wounds resulted in firm primary union. Using catgut onIy 90 per cent of wounds resuIted in primary union. In this study any discharge of serum or pus regardIess of how smaI1 in amount or any separation of wound edge, no matter how sIight, was counted as sufficient to consider the case one of fauIty union. In 1924, Goff of the Woman’s HospitaI in New York gave the foIIowing figures in a study of 2755 clean abdomina1 incisions. Of these, 1645 incisions cIosed by absorbabIe sutures resuIted in extensive infections in 4.7 per cent of cases and sIight infections in 5.3 per cent; I I IO incisions cIosed by non-absorbabIe sutures * Sourbern Med. CYSurg., JuIy, 1927.

Treatment

American Journal of Surgwy

305

resuIted in extensive infections in onIy 2. I per cent and sIight infections in I .9 per cent. There was a 6 per cent decrease in

FIG. 3. X-ray before operation of extensive injury of ankIe extending into joint. Shadows near lower end of fIbuIa are of gravel imbedded in tissues and iIIustrate importance of thorough debridement.

infected cases when non-absorbabIe sutures were used. It is interesting to note that their figures are aImost identica1 with the ones at the Pitt Community HospitaI. More recentIy MeIeney of the Presbyterian HospitaI in New York made this statement foIIowing an extensive study of wound infections : Certain types of operation seemed to favor wound infection. Up to 1929, a particularly high incidence of infection occurred in radica1 thyroids, open reduction of mastectomies, fractures, recurrent and ventral hernias, double operations and excision of Iipomas. There seemed to be a pIausible expIanation for al1 but the thyroids. In this group we were getting

306

A mericnn Journal of Surgery

Thompson-Wound

not onIy a high incidence of infection but many hematomas. Most of the thyroids were being done by the two surgeons connected with the thyroid clinic. In the summer of 1929, in the absence of one of these surgeons, one of the staff, who had recentIy come from another cIinic where silk was being used more generally, operated on five thyroids and used silk instead of catgut. The soft, cIean heahng of these wounds was seen by the second thyroid surgeon and he decided to try it. He operated on IO cases with silk and then on IO with catgut. The siIk cases a11 heaIed cleanIy and the catgut cases had four hematomas and two infections. Then he changed over entirely to the use of siIk and a Iittle Iater in May, 1930 the other thyroid surgeon foIlowed his example. Since then practicaIly a11 of the thyroids have been done with silk with marked reduction both of hematomas and infections. This striking improvement in thyroid cases Ied to the greater use of silk in hernias and open reductions with equaIIy gratifying resuhs when the figures were completed for 1931. The incidence of infection in open reduction feI1 from 26 per cent to 2 per cent and aIthough there were some other changes in technic this seemed to be due aImost entirely to the substitution of siIk for catgut. We believe that this favorabIe response is probabIy due to the minima1 tissue reaction which siIk produces, to the greater security of hemostasis with silk and to the gentIer handIing of tissues which the use of silk requires. Since coming to LouisviIIe, the incidence of primary union of wound in my private practice has been studied. There is incIuded in this study onIy wounds made under aseptic conditions, not previousIy infected and cIosed without drainage. Of wounds sutured with siIk 96.3 per cent resuIted in compIete primary union and none of them suppurated. As Iong as sutures are not too tight and the tissues are not approximated under tension it does not seem to make much difference whether interrupted or continuous sutures are used. In cIosing cavities (stomach, bIadder, peritoneum, etc.) the continuous suture is often preferabIe as the suture-Iine becomes water-tight more quickIy. In other pIaces (fascia, muscIe,

Treatment

FEBRUARY,1935

skin) the interrupted sutures are probabIy better. With the interrupted suture one may use fine materia1 which wiI1 break if tied too tightIy, whiIe with the continuous suture a stronger strand is necessary and there is danger of inadvertentIy having it too tight. ShouId one of severa interrupted sutures give way IittIe or no damage resuIts while hernia or non-union is more IikeIy to ensue if a continuous suture breaks. The interrupted aIso permits fluids to escape from a wound easiIy, thereby decreasing any tendency to tension within the wound. Sutures are sometimes pIaced in the subcutaneous fat in an attempt to prevent stretching of the cutaneous scar. They seIdom are of any usefuIness, however. Fat heaIs poorIy and its nutrition is so readiIy jeopardized that it shouId not be sutured unIess there are cIear indications. For the same reason though to a Iess degree muscIes are but rareIy sutured as proper approximation can usuaIIy be obtained by suturing their fascia. CIean wounds are no Ionger drained. The drain prevents proper union at its point of insertion and it permits the entrance of bacteria into the wound. A steriIe bIood cIot is Iess dangerous ordinariIy than a drain. If within cIean wounds there are fIuids such as biIe or urine which need to be withdrawn, then drainage is indicated. HertzIer has shown that rubber in wounds is irritating and shouId not be used unIess it is desired for the wound to remain open sometime. Most wounds shouId be dressed. A dressing serves severa purposes. It protects the wound from clothing, bacteria, coId, heat; it absorbs discharges; it heIps to immobiIize. Tight dressings are injurious because they jeopardize the suppIy of bIood. Extensive and snug abdominal dressings frequentIy embarrass respiration and promote the deveIopment of ateIectasis. Many different materiaIs have been used to dress wounds. SteriIe cotton gauze is the most popuIar. The use of aIcoho1, iodine, bismuth powder, and other irritants

NEW SERVES VOL. XXVII,

No. z

Thompson-Wound

is contraindicated. Professor Mont Reid of Cincinnati dresses cIean wounds with wet saIt gauze which encourages the exit of

Treatment

American

Journal

of Surgery

307

should not be placed in saline solution as it delays coaguIation between the graft and the wound. If a graft is unnecessary

FIG. 4. TypicaI temperature chart folIowing debridement and primary cIosure without drains for extensive Lacerated and contaminated wound. Dressings not disturbed for nine days. Temperature remained normal after fifth

serum and Iessens the tension within the wound. I employ one strip of vaseIine gauze next to the wound and appIy over that a few layers of dry gauze. The vaseIine is non-irritating and prevents the gauze from adhering to the wound. Rest of a heaIing wound is necessary but it shouId never be obtained at the expense of blood suppI)-. During the World War a much larger percentage of primary union of sutured wounds resuIted in the ones which were not transported immediately following operation than in those which were transported. Dr. H. Winnet Orr of LincoIn, Nebraska has emphasized the importance of adequate rest for a11 wounds. Dressings of clean wounds shouId not be disturbed until heaIing is we11 advanced. Any dressing of any wound entaiIs the hazard of possibIe contamination with viruIent bacteria. When the edges of a wound can not be approximated without tension Ieading to anemic necrosis it is preferable to forego compIeteIy cIosing the wound. If the defect is extensive a graft of some kind wiII be necessary. Th e prrnciples ’ of treating grafted wounds are exactly the same as those for sutured wounds. Approximation of the graft to the wound must be accurate and for this an elastic dressing such as a sea sponge is sometimes needed. Grafts

the same principIes are to be observed as if a graft were used. This latter fact is frequently overlooked as one often sees a clean wound with a smaI1 defect which has been dressed daiIy with irritating applications. Each time a dressing is removed some of the deIicate young ceIIs which are attempting to close the wound are either kiIIed or damaged and union delayed. Many cases can be cited to ihustrate the injuriousness of frequent dressings. A recent one is that of a healthy child who had an uIcer of the Ieg of ten weeks’ duration. Dressings had been applied once or twice each day and the uIcer was getting Iarger. HeaIing was obtained within a few days simply by permitting each dressing to remain at least five days. Zinc oxide adhesive pIaster makes an exceIIent dressing for such wounds. It has satisfactorily and frequently been used for skin grafts. Tannic acid crusts make suitabIe dressings for cIean wounds. They are non-irritant, protective from one the and remove temptation to change the dressing too frequently. For the dressing of beds from which grafts have been removed tannic acid is highly recommended by W. G. Maddock of Ann Arbor. Before Ieaving the subject of cIean wounds permit me to say to those of you

308

American

Journal

of Surgery

who are not accustomed more words concerning Should infection ensue

Thompson-Wound to using it, a few the use of siIk. or shouId there

Treatment

FEBRUARY.

193~

Through clinica experience surgeons have Iearned that after a contaminated wound is tweIve to twenty-four hours old it is no

FIG. 5. FIG. 6. FIG. 3. Chronic osteomyelitis of radius with muItipIe sinuses. FIG. 6. Same as Figure 5 folIowing Orr treatment. AI1 sinuses heaIed. Good function. First dressing six weeks after operation. Subsequent dressings every two weeks.

be a serous discharge from the wound, do not be alarmed concerning the fate of the siIk. If fine strands have been used they may or may not be extruded from the wound. Most frequentIy they wiI1 not be extruded but wiI1 become encapsuIated and wiI1 not deIay union. Many times fine siIk has been purposeIy used in infected wounds (appendicia1 abscesses, etc.) in which drainage tubes were used and the wounds have heaIed niceIy around the tubes. ParticuIarIy in the treatment of hernias does the user of siIk have an advantage over one who uses catgut. He not onIy has fewer infections but there is the added security of not having premature absorption of the suture Ieading to recurrence. Those who use siIk in hernias never need sutures made of fascia a refinement of technique which to me has aIways been cumbersome and unnecessary. Amputation stumps are noted as frequent sites of infection and deIayed heaIing. In them, whenever possibIe, one shouId use throughand-through non-absorbabIe sutures very IooseIy tied and make no attempt to get a Iinear approximation of the skin. AIso, drainage of amputation stumps shouId not be practiced as drainage tracts are sIow to hea1. If infection is feared Ieave the stump open and practice secondary suture at a Iater date. TREATMENT

OF

CONTAMINATED

WOUNDS

Pathogenic bacteria are so prevalent that any wound not made under aseptic conditions shouId be considered contaminated.

Ionger safe to consider it as mereIy contaminated but should then consider it infected. We speak then of the first twentyfour hours as the period of contamination and any time subsequent to that as the period of infection. There is a difference in the treatment of the two periods. Under tweIve hours unIess grossIy soiIed with pus or feca1 materia1 it is safe to consider a11 as mereIy contaminated. Between tweIve and twenty-four hours one must reIy upon appearance of the wound. If there are no signs of reaction it is usuaIIy safe to consider it just contaminated. In treating contaminated wounds the depths of the wound shouId be exposed, foreign bodies shouId be removed, necrotic tissue excised and hemorrhage stopped. The principIes of gentIeness as eIucidated under the treatment of aseptic wounds shouId be observed carefuIIy. If the wound can not be made grossIy cIean by these measures, irrigation with saIine but not with antiseptics may be done. I personaIIy rarely use any irrigation as there is danger of carrying bacteria into the recesses of the wound. Whenever possibIe hemorrhage shouId be stopped by pressure with dry gauze as Iigatures increase the chances of infection. The measures just described were brought to a high degree of efficiency by the French surgeons during the WorId War. They empIoyed the terms debridement, excision, and extraction as descriptive of this treatment. Debridement means IiteraIIy an unbridIing of the wound and the French meant by it a wide exposure of the wound. Our usage of the word in the

NEW

SERIES

VOL. XXVII,

No.

2

Thompson-Wound

United States has come to mean a11 three procedures (debridement, excision, extraction). The mechanica cIeansing of the wound must be thorough though structures such as vessels and nerves necessary for function or Iife must be preserved carefully made to protect them. an d an effort Following this cIeansing, the wound shouId be IooseIy sutured provided suture can be accompIished without putting any of the tissues upon tension. Immobilization of the part is then required unti1 heaIing is complete. During the hearing of muItipIe wounds and wounds other than very small ones the patient shouId have absoIute rest in bed. Here again the experience of the war was vaIuabIe as the transported wounds did not heaI as we11 as those which were kept quiet. If it is necessary to transport the patient or if it is impossibIe to cIose the wound with sutures, the wound shouId be IooseIy packed with vaseIine gauze, amply dressed with dry gauze, and properly immobiIized, pIaster casts being sometimes required. Provided the patient is free from pain and the temperature norma and remains promptIy reaches there, wounds treated by this method of packing shouId not be disturbed unti1 heaIing is compIete or at least weIIadvanced. The time of heaIing depends on the depth and extent of the wound and the condition of the patient. If the wound is superficial the first dressing shouId be done at the end of seven to ten days. If larger or deeper, the dressing shouId not be disturbed for two to six weeks depending upon the size of the wound and the If the odor should patient’s condition. become offensive or the dress unsightly the outer layers may bc changed. EarI?; changing of the inner dressing Ieads to infection. Orr has repeatedIy emphasized this fact and I know from persona1 experience that he is correct. TREATMENT

OF

INFECTED

WOUNDS

of treatment infected For purposes wounds mav be divided into two cIasses: the acutely” infected and the chronicaIIy infected. The first essentia1 in treating an acuteIy

Treatment

American JvornaI of Surgr.r.v

309

infected wound is rest. This can best be obtained by means of cases, spIints, suspension, traction, bandages, adhesive strapping, braces, and rest in bed. Whatever method is used to be sufficient it must overcome muscIe spasm. John B. Murphy constantIy stressed the vaIue of traction in treating infection of joints because it was the most adequate method of putting joints at rest. In the words of Hugh Owen Thomas rest must. be “continuous, proIonged and uninterrupted.” The next essentia1 of treatment is to reIieve tension within the wound. This is ordinariIy spoken of as drainage but more than simpIe drainage by_ tubes or gauze is necessary as the entlre Iength and breadth of the wound must be open. In obtaining this exposure care must be exercised not to carry infected materia1 into norma tissues and if a spreading Iymphangitis is present it is usuaIIy wise to wait unti1 IocaIization has taken place. If the wound is free from sloughs, packing IooseIy with vaseline gauze is nearIy aIwags sufficient. If sIoughs are present Dakin’s soIution (surgica1 soIution of chIorinated soda) or Wright’s soIution (hypertonic saIine) are used to digest them, my preference being Wright’s soIution. Great credit is due Wright and FIeming of EngIand for demonstrating the utter useIessness and even harmfuIness of the ordinary antiseptics in treating infected wounds. The.y aIso showed that the virtue of Dnkin’s solution Iax not in its antiseptic properties. They beheved that the good resuIts of Dakin’s soIution were due to its exerting an action simiIar to that of the hypertonic saIine soIution. The action of this saline soIution in wounds was thoroughry studied and it was shown that the saIine soIution was superior to Dakin’s soIution and other antiseptics. Its beneficent action was shown to be due to its causing serum and Ieucocytes to enter the wound. The saIine solution destroyed Ieucocytes which Iiberated tryspin. The trypsin digested the necrotic tissue. WhiIe this was in progress the serum diIuted the saline suffrcientIy to stop its destructive action and permit mo1-e Ieucocytes to

310

American Journal of Surgery

Thompson-Wound

enter the wound. With each application of saIine this process was repeated. I empIoy these soIutions by a modified One or more sinaII CarreII technique. rubber tubes are Ied to the depths of the wound. The tubes are secured with adhesive tape or cotton bandage and the wound IooseIy and abundantIy dressed with gauze. A smaI1 quantity of warm but not hot soIution is gentIy introduced into the tubes every two hours during the day and three hours at night. The dressings are changed every four to five days and the tubes are not removed unti1 it is intended to Ieave them out entireIy. When the wound appears to be free from sIoughs, granuIations grow in and the temperature remains norma for four days, the interva1 between irrigations is inSoon the irrigations are discreased. continued. The condition of the wound and the genera1 condition of the patient rather than bacterioIogic studies are relied upon to determine this time of stopping the irrigations. If stopping them does not resuIt in an elevation of temperature the tubes are removed, the wound IooseIy packed with Vaseline gauze, dressed and permitted to hea with as IittIe interference as possibIe. After the infection in these wounds has disappeared secondary suture of them has been practiced by some. Smears were made from the wound if there were no streptococci and fewer than six other bacteria per fieId upon three successive days secondary suture was considered safe. My own experience with secondary suture has not been happy so I no Ionger practice it. In chronicaIIy infected wounds I foIIow the method of Orr. Necrotic tissue is gentIy removed, the wound packed with vaseLe gauze and absoIute rest obtained. No sutures, no tubes, and no foreign bodies other than the gauze are used. The first dressing is done two to six weeks Iater. Such satisfactory resuIts have been obtained with this method that I have not used maggots or bacteriophage. In wounds which do not hea promptIy, and this particuIarIy appIies to uIcers, bacterioIogic studies shouId be made.

Treatment

FEBRUARY. 1935

Many unsuspected infections of blastoactinomycosis and other Iess mycosis, frequent infections wiI1 be discovered. A most instructive case of this nature was shown to me Iast year by Dr. CIyde McNeiII. A physician had an intractabIe wound of the hand the exact nature of which was not known unti1 Dr. McNeiII demonstrated Donovan bodies by anaerobic cuItures under helium. REFERENCES I.

2.

3.

4.

5. 6. 7. a. 9. IO.

BIRD, C. E. and MACKAY, E. M. The

healing of wounds: an experimental study to show the inBuence of body dehydration. Surg. Gynec. Ohst., 54: 872, 1932. CLOCK, R. 0. The fahacy of chemical sterilization of surgica1 catgut sutures. Surg. Gvnec. Obsr., 56: 149, 1933. DANDY, W. E. The importance of more adequate sterilization Drocesses in hospitals. Bull. Am. Coil. Surg., 46: I I, 1932. FLEMING, A. The action of chemicx1 and physioIogical antiseptics in a septic wound. Brit. J. Slug., 7: 99, 1gr91g20. GOFF. B. H. An anaIvsis of wound union in 3000 abdomina1 incisions. Am. J. Obst., 7: 342, 1924. HALSTED, W. S. ColIected Surgical Papers. Bait., Johns Hopkins Pr., 1924, 2 ~01s. HERTZLER, A. E. The new conception of wound healing as applied to practica1 surgery. AM. J. SURG., n.s. 7: 293, 1929. HERTZLER, A. E. The principles of the technique of skin nrafting. InterstateM. J.. Vol. 20. 1913. Howas~ E. L. The strength of wounds s&red with catgut and silk. Surg. Gynec. Obst., 57: 309, 1933. MADWCK, W. G. The use of a tannic acid dressing for OIIier-Thiersch graft beds. J. A. M. A., 97: 102, 1930.

I I. MELENEY, F. L. and CHATFIELD, M. How can WC insure the sterility of catgut? Surg. Gynec. Obst., 50: 271, 1930. 12. MELENEY, F. L. and CHATFIELD, M. The sterility of catgut in relation to hospita1 infections. Surg. Gynec. Obst., 52: 430. 1931. ‘3. MELENEY, F. L., HUMPHREYS, F. B., and CARP, L. An unusua1 fatal operative wound infection yielding a pathogenic anaerobe of the gas gangrene eroun not hitherto described: with direct &ft=r&e to catgut as a source. Surg. G~nec. Obst., 45: 775. 1927. 14. ORR, H. W. Persona1 communication.

15. ORR, H. W. The treatment of osteomyeIitis and other infected wounds by drainage and rest. Surg. G,ynec. Obst., 45 : 446, 1927. 16. KEICHERT, F. L., and HOLMAN, E. The fate of the . . sutures as observed rn mtestina1 anastomosis and in the heaIing of wounds. Bull. Johns Hopkins Hosp., 36: 212, 1925. 17. REID, M. R. A genera1 consideration of bIood supply in the practice of medicine and surgery. SOUL~J. M. J., 26: 107, 1933. 18. WHIPPLE, A. V. The use of siIk in the repair of clean wounds. Ann. Surg., 98: 662, 1933. 19. ANDREWS, H. E. Persona1 communication.