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WHEN THE SKIN DEFENCE IS BREACHED
603
disposition of the connective tissue to hyperplasia have all been considered important factors. FILIPS1 says that keloids can be produced in anyone, quite apart from inborn tendency, if a sufficient amount of the reticular layer of the cutis is destroyed by the high-frequency current. Lesser and more superficial injuries do not produce this reaction, while injuries penetrating the subcutaneous tissue produce a greater reaction. He believes this is because in the deeper injuries a greater number of small blood-vessels are stimuSimilar changes may be lated to proliferate. caustic acids or alkalis, salts of produced by
for X-ray treatment. For excision of a keloid he uses following erythema doses spread over nine weeks, employing 125 kV, with a 5 mA current, and 3 mm. aluminium filter. For large keloids following healing by secondary intention he uses half an erythema dose weekly for eight weeks. Very large keloids may require longer treatment.
cannot sit still
the five
enough
scars
WHEN THE SKIN DEFENCE IS BREACHED
IT is nearly a century since IGNAZ SEMMELWEIS watched his friend KOLLETSCHKA die of septicsemia after pricking his finger when making an autopsy and or electrometals, and it flashed into his mind that it was the same heavy thermocautery if of the reticular is enough cautery, disease as he had seen killing puerperal women layer destroyed. The fact that keloids are so common by the thousand in the Vienna lying-in clinic in the healed areas of large and deep burns before he induced students and midwives to wash makes it not unlikely that infection plays a part their hands with chlorinated lime. That was the in their production, for in the process of healing first clue to the curious defencelessness ’of the hypertrophic granulation tissue is characteristic. human body, otherwise so well protected, when In areas from which razor grafts have been taken its Within its protective envelope is broken. healing may be perfect in one part while in another intact skin and mucous membrane the body can where healing has been delayed a keloid may laugh at the germ life around it; break this develop. It is probable that some degree of pellicle and the laugh is on the other side. The infection is present in many wounds that are germ runs riot in tissues which have had no thought to be healing by first intention. MELENEY2 previous experience of its attack. Since SEMMELhas shown that if a careful postoperative count is WEIS posed this problem JosEPH LISTER has shown taken it will be found that from 15 to 30 per cent. how to solve it with a large measure of surgeons clean " show evidence success for the wounds of wounds thought to be they themselves inflict at of infection. He has also found haemolytic strepto- their own time and place. But in the accidental cocci in the throats of about a quarter of those wound of the post-mortem room and in present in operating theatres, and the work of impromptu injuries of high speed on the road or PAINE3 and WELLS and WELLS4 proves how easy high explosive from the air the die is still heavily it is for a wound to be subjected to droplet infec- weighted in favour of the germ. For the moment tion from such a source. HARThas recorded the at least there is a lull in the wholesale infliction difficulties in eliminating bacteria from operating of wounds and the time seems opportune to contheatres, short of sterilising the air. If infection sider what is known about the prevention and is of any importance the occasional development treatment of wound infection. On p. 608 Mr. of a keloid is not to be wondered at, and this is W. H. OGILVIE begins a series of articles with a a further reason for consummate care in formidable list of questions which are still open. operating. In following issues Colonel L. E. WHITBY will Simple surgical excision and suture is useless set out the fundamental pathology of ideal healing in the attempt to get rid of one of these and what stands in its way, Dr. ROBERT CRUICKblemishes. The new scar will certainly develop SHANK will discuss sources of infection and general another keloid and a worse one because of the preventive measures, leaving Prof. L. P. GARROD tension engendered by the excision. It may to deal with antiseptics and Major G. A. H. occasionally be necessary to replace a large keloid BUTTLE with chemotherapy. A review by Mr. by a graft, but only a direct flap or tube pedicle OGILVIE of surgical methods in prophylaxis and isany use, for with a thinner graft too much treatment will close the series, which, it is hoped, nbrous tissue is deposited in the process of healmay serve as a refresher course to those who in ing. After such an operation radiation must be the event of more active warfare will have to deal, employed from the start, for this is the only agent at home or overseas, with this major problem of that seems to control fibrous-tissue deposition, wound infection. and the newly formed scar is particularly radiosensitive. Radiation is often of value in reducing Miss RUTH DARBYSHIRE, R.R.C., who succeeds Dame the size and colour of a keloid that is unsuitable Joanna Cruickshank as matron-in-chief of the Red for surgery, but long-standing scars do not respond Cross war organisation brings to her task much readily to radiation, and great care is necessary experience and knowledge of nursing in peace and to avoid overdosage, for a radiation burn is much war. Before holding for twelve years the matronship more serious than a keloid. Radium and X rays of University College Hospital she had been in charge of the Derbyshire Royal and St. Mary’s, Paddington, are both used, but FILIPS thinks radium dangerand had spent six years in India as head of Lady ous, and uses it only for small children who "
nursing service. During the last war she was principal matron of the 2nd London General Hospital. She has been vice-chairman of the General Nursing Council and she was, we gratefully recall, a most useful member of THE LANCET Commission on Nursing. Minto’s
1. 2. 3. 4.
Pilips, L. Med. Rec. 1939, 150, 379. Meleney, F. L. Surg. Gynec. Obstet. 1934, 59, 358. Paine, C. G. Brit. med. J. 1935, 1, 243. Wells, W. F. and Wells, M. W. J. Amer. med. Ass. 1936, 107 1698, 1805. 5. Hart, D. Arch. Surg., Chicago, 1937, 34, 874.
disposition of the connective tissue to hyperplasia have all been considered important factors. FILIPS1 says that keloids can be produced in anyone, quite apart from inborn tendency, if a sufficient amount of the reticular layer of the cutis is destroyed by the high-frequency current. Lesser and more superficial injuries do not produce this reaction, while injuries penetrating the subcutaneous tissue produce a greater reaction. He believes this is because in the deeper injuries a greater number of small blood-vessels are stimuSimilar changes may be lated to proliferate. caustic acids or alkalis, salts of produced by
for X-ray treatment. For excision of a keloid he uses following erythema doses spread over nine weeks, employing 125 kV, with a 5 mA current, and 3 mm. aluminium filter. For large keloids following healing by secondary intention he uses half an erythema dose weekly for eight weeks. Very large keloids may require longer treatment.
cannot sit still
the five
enough
scars
WHEN THE SKIN DEFENCE IS BREACHED
IT is nearly a century since IGNAZ SEMMELWEIS watched his friend KOLLETSCHKA die of septicsemia after pricking his finger when making an autopsy and or electrometals, and it flashed into his mind that it was the same heavy thermocautery if of the reticular is enough cautery, disease as he had seen killing puerperal women layer destroyed. The fact that keloids are so common by the thousand in the Vienna lying-in clinic in the healed areas of large and deep burns before he induced students and midwives to wash makes it not unlikely that infection plays a part their hands with chlorinated lime. That was the in their production, for in the process of healing first clue to the curious defencelessness ’of the hypertrophic granulation tissue is characteristic. human body, otherwise so well protected, when In areas from which razor grafts have been taken its Within its protective envelope is broken. healing may be perfect in one part while in another intact skin and mucous membrane the body can where healing has been delayed a keloid may laugh at the germ life around it; break this develop. It is probable that some degree of pellicle and the laugh is on the other side. The infection is present in many wounds that are germ runs riot in tissues which have had no thought to be healing by first intention. MELENEY2 previous experience of its attack. Since SEMMELhas shown that if a careful postoperative count is WEIS posed this problem JosEPH LISTER has shown taken it will be found that from 15 to 30 per cent. how to solve it with a large measure of surgeons clean " show evidence success for the wounds of wounds thought to be they themselves inflict at of infection. He has also found haemolytic strepto- their own time and place. But in the accidental cocci in the throats of about a quarter of those wound of the post-mortem room and in present in operating theatres, and the work of impromptu injuries of high speed on the road or PAINE3 and WELLS and WELLS4 proves how easy high explosive from the air the die is still heavily it is for a wound to be subjected to droplet infec- weighted in favour of the germ. For the moment tion from such a source. HARThas recorded the at least there is a lull in the wholesale infliction difficulties in eliminating bacteria from operating of wounds and the time seems opportune to contheatres, short of sterilising the air. If infection sider what is known about the prevention and is of any importance the occasional development treatment of wound infection. On p. 608 Mr. of a keloid is not to be wondered at, and this is W. H. OGILVIE begins a series of articles with a a further reason for consummate care in formidable list of questions which are still open. operating. In following issues Colonel L. E. WHITBY will Simple surgical excision and suture is useless set out the fundamental pathology of ideal healing in the attempt to get rid of one of these and what stands in its way, Dr. ROBERT CRUICKblemishes. The new scar will certainly develop SHANK will discuss sources of infection and general another keloid and a worse one because of the preventive measures, leaving Prof. L. P. GARROD tension engendered by the excision. It may to deal with antiseptics and Major G. A. H. occasionally be necessary to replace a large keloid BUTTLE with chemotherapy. A review by Mr. by a graft, but only a direct flap or tube pedicle OGILVIE of surgical methods in prophylaxis and isany use, for with a thinner graft too much treatment will close the series, which, it is hoped, nbrous tissue is deposited in the process of healmay serve as a refresher course to those who in ing. After such an operation radiation must be the event of more active warfare will have to deal, employed from the start, for this is the only agent at home or overseas, with this major problem of that seems to control fibrous-tissue deposition, wound infection. and the newly formed scar is particularly radiosensitive. Radiation is often of value in reducing Miss RUTH DARBYSHIRE, R.R.C., who succeeds Dame the size and colour of a keloid that is unsuitable Joanna Cruickshank as matron-in-chief of the Red for surgery, but long-standing scars do not respond Cross war organisation brings to her task much readily to radiation, and great care is necessary experience and knowledge of nursing in peace and to avoid overdosage, for a radiation burn is much war. Before holding for twelve years the matronship more serious than a keloid. Radium and X rays of University College Hospital she had been in charge of the Derbyshire Royal and St. Mary’s, Paddington, are both used, but FILIPS thinks radium dangerand had spent six years in India as head of Lady ous, and uses it only for small children who "
nursing service. During the last war she was principal matron of the 2nd London General Hospital. She has been vice-chairman of the General Nursing Council and she was, we gratefully recall, a most useful member of THE LANCET Commission on Nursing. Minto’s
1. 2. 3. 4.
Pilips, L. Med. Rec. 1939, 150, 379. Meleney, F. L. Surg. Gynec. Obstet. 1934, 59, 358. Paine, C. G. Brit. med. J. 1935, 1, 243. Wells, W. F. and Wells, M. W. J. Amer. med. Ass. 1936, 107 1698, 1805. 5. Hart, D. Arch. Surg., Chicago, 1937, 34, 874.