Curt Schimmelbusch.

A guide to the aseptic treatment of wounds online

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becomes new growth. We know at the present time that re-
pair ensues only through regeneration of pre-existing cells,
and that everything which interferes with the aglutination of
the tissues retards recovery. Blood, secretions, and separated
tissue particles we regard as useless organic material, which,
it is true, remaining simple, is absorbed, though slowly, but
which, when it becomes the nidus of pathogenic organisms and
decomposes, gives rise to the most serious of wound complica-

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tions. For this reason it is extremely important to control
the hemorrhage with the utmost care, institute drainage, and
avoid laceration of the tissues in operating. A decade ago,
von Bergmann announced that the surgeon who does not in-
sure cessation of the last particle of bloody oozing in operating
must have the results of his aseptic efforts surrounded by un-
certainty. The experience of subsequent years has confirmed
his views. This rule regarding the control of hemorrhage is
observed to-day in the Royal Surgical Clinic, Berlin, as most
essential to union. In mammary amputations and solutions of
continuity produced by trauma, even in minor operations, the
wound is repeatedly inspected to make sure that the smallest
bleeding point has been ligated. The surface must be per-
fectly dry. Where there are large cavities a drainage tube is
always introduced. This form of drainage must be adapted
to the individual circumstances, as a counter-opening is made
for the same purpose in a fold or interdigitation of the skin or
mucous membrane.

The latter is only to be omitted where the wound surfaces
throughout their entire extent can be approximated either by
sutures, pressure of the bandage, or natural tension of the
tissues and accumulation of the secretions thus prevented. In
doubtful cases it should be remembered how little the drain-
age tube interferes with union, and how much risk we run, on
the other hand, by omitting it in lax, sinused, and irregular
wounds. In the one case we have to deal with the danger of
infection, and in the other with delay in union by only a few
days. Where accumulation of bloody transudation occurs
under the rapidly agglutinated edges of a wound, there will in-
evitably be observed a rise of temperature, and, even though
this accumulation be evacuated, healing is retarded. In order
to have the surfaces even and avoid laceration of the tissues in
operating, the original incision through the skin should be

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made freely. This is an important general rule, as only in
widely-gaping, open wounds is exact control of hemorrhage
possible. The conservatism to be observed in individual
cases, just how bleeding is to be controlled and wounds
drained, the surgeon can only learn by experience, and does
not come within the scope of this treatise. The closure of
the wound has been regarded as most important from an anti-
septic standpoint, and this with propriety, as the closed wound
is safer against infection than one which is not. As the heal-
ing progresses from day to day, the danger of infection gradu-
ally decreases. This closure, however, can only act favorably
when there are no foreign substances intervening. Nothing is
more disastrous than the suturing of a wound when pathogenic
organisms are imbedded in its depth in blood and transuda-
tion. Here the closure is antagonistic to repair and conduces
to infection. Where the entrance of infectious germs cannot
be avoided and perfect control of hemorrhage is impossible,
or where previously infected tissues have been the seat of op-
eration, the wound cannot be closed, and must be covered
simply with gauze or packed — tamponed. Here it is difficult
to inaugurate fixed rules applicable in all cases. Only in a
general way will the fundamental principles of tamponing be
alluded to.

In the von Bergmann Clinic three methods of tamponing are
employed :

1. The temporary tampon.

2. The permanent tampon.

3. The continued tampon.

As a rule the only article used for tamponing is iodoform

gauze. In employment of the temporary tampon the wound is

packed throughout its entire extent with this material, which is

allowed to remain for forty-eight hours. It is then removed,

and if the wound is in a proper condition it is treated as recent,

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and the edges approximated and sutured. As a rule, a wound
which has been tamponed for two days with iodoform gauze,
if it were not previously infected, appears fresh and unirri-
tated, as the dry wound does immediately after operation.
Healing also progresses in a similar manner. The actual pur-
pose of the temporary tampon is to check the delayed paren-
chymatous oozing, which occurs usually where large capillary
areas have been opened up, as in case of resections. Here
the gauze pressing upon the bone prevents the escape of blood
until the vessels become closed by thrombosis. It is also of
value where the surgeon is in doubt as to whether or not the
wound, after an operation, is aseptic.

The permanent iodoform gauze tampon, which is often
allowed to remain eight, ten, or even fourteen days, suppresses
hemorrhage not controlled by ligation, or which would not
have subsided under a tampon allowed to remain for two or
three days. These are the hemorrhages which occur from the
large venous sinuses of the brain. The iodoform gauze
tampon should here be placed upon the bleeding point, and
allowed to remain for eight days, or until there has been firm
closure of the sinus by union of its edges. The permanent
tampon has the effect furthermore of affording protection
where infectious material would encounter the wound con-
tinuously or intermittently. Thus it is indispensable after
resections of the upper jaw, removal of the tongue, rectum-
amputations, etc. The iodoform gauze tampon, packed into
the cavity which remains, in these cases becomes firmly im-
bedded without requiring particular fixation, and remains
often for ten days without permitting decomposition of the
absorbed secretions.

The continued tampon is indicated where infected wounds
must be maintained open by reason of long persistence of the
infectious conditions, as often occurs in the treatment of phleg-

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mons, where necrotic tissue shreds continue to be extruded.
When the secretion is very active, and the pus is thick and
tenacious, also where the wound has a relatively great depth,
this method of treatment does not suffice, and after the hem-
orrhage has been controlled by the temporary tampon it is
recommended to introduce the rubber drainage tube early, in
order that the discharge may be better carried off.

One of the most essential features in which the method of
treatment practised at the present time in the von Bergmann
Clinic differs from that frequently employed elsewhere, is in
the non-use of antiseptic irrigation of wounds during and after
operations, and at time of the change of dressing.

To Landerer belongs the credit of first having directed
attention to the superior advantage of the dry treatment of
wounds. A trial of this method was at once begun in a few
cases in the von Bergmann Clinic, and in a short time it
became universal by reason of its manifest superiority. For
some time previously, however, wounds had not here been irri-
gated in the usual manner, injecting into them through a rubber
hose antiseptic solutions under high pressure from an elevated
reservoir. Instead, the fluid was simply poured over the wound
gently from a small hand irrigator. The forcible irrigation of
suppurating wounds is dangerous, as it not simply washes away
the pus and infectious secretions, but tends to force the latter
into the interstices of the connective tissue, and thus dissemi-
nates rather than limits the infection.

When we review the advent of antiseptic wound irrigation,
we must conclude that it never had a really reliable basis,
either experimental or that emanating from surgical experience,
but instead was founded upon hypotheses and assumption.
As surgeons believed in the use of the spray for a time, so also
was the irrigation of wounds regarded as essential. The gen-
eral belief that a wound may be disinfected by means of antisep-

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tic irrigation with the indications laid down for its application,
was, like many other things, the outcome of custom. This
idea was transmitted from one clinician to another, thus find-
ing a fixed place in surgery without due authenticity and
reliability. Consideration of the degree of tolerance possessed
by wounds, on the one hand, and of the disinfecting power of
antiseptic solutions on the other, led of necessity very early to
skepticism regarding the value of irrigation, /. ^., as to whether
or not it really could accomplish all that was claimed for it,
and all that it should. Nowhere are the conditions for the
working of germicidal agents so unfavorable as in the above in-
stance. The essentials for success of the chemical disinfectant,
the necessity for permeation of the substance acted upon,
the avoidance of antagonizing influences, and a sufficient time
for the action, are all wanting here. In recently infected, and
particularly in old wounds, the elements of danger, cocci and
bacilli, are imbedded in the blood clots, tissue particles, and
dried secretions or crusts, and perhaps also in the interstitial
connective tissue, and antiseptics, such as corrosive sublimate
and carbolic acid are incapable, diluted, of permeating these
substances to encounter the organisms.

The wounds are not thus disinfected and positive damage
may be done by the poisonous and irritating chemicals. The
sensitive tissue cells are destroyed long before the much more
resisting bacilli and micrococci. Irritation and interference
with the process of repair are ever obvious consequences of
the antiseptic wound irrigation. One concession for this
method of treatment is the removal of blood and purulent
secretions. This may be accomplished, however, better by
means of some non-irritating fluid, — a sterilized physiological
(3/4 io) salt solution, or weak boracic acid solution ; or the
blood and discharges may be absorbed with hydrophile gauze
or some similar material. The latter mode of procedure has

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been in use in the von Bergmann Clinic in all operations under
infectious as well as aseptic conditions, and is exercised in the
changes of dressing. Only in cases of very profuse discharge
is one of the foregoing indifferent solutions employed.

Professional experience with the agents which restrict the
development or modify the damaging influence of bacteria has
been rather confusing and contradictory. A wound which is
covered with green pus cannot be freed from the development
of the bacillus pyocyaneus even by long-continued irrigation
with sublimate solution. We possess in iodoform a better agent
for restricting the proliferation of bacteria and rendering them
harmless, at least in simple suppurating wounds. As iodoform
counteracts the decomposition of absorbed discharges in dress-
ings, so also does it exert an antiseptic influence upon the surface
of wounds, and does not damage the tissues or cause irritation
with increased secretion. Just how iodoform acts antisepti-
cally is not as yet thoroughly understood, but as to its having
this action there is no question. According to the investiga-
tions of Behring and du Ruyter, its effect is principally upon
the ptomaine products of the bacteria. In case of actively
suppurating and offensive wounds, instead of applying iodo-
form gauze it is often better to use gauze saturated with a one
per cent, solution of aluminium acetate. There is no antisep-
tic which counteracts blue pus formation better than the latter

We have already described (Chapter VIII.) how an antisep-
tic dressing is to be applied so as to protect the wound from
infection until the completion of repair. It was stated that
the dressing must form a complete covering of the wound, be
composed of aseptic material, absorb the secretions, and pre-
vent their decomposition. Indications not less important
than the antiseptic dressing for facilitating union are proper
adjustment and immobilization of the injured part and mod-

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erate wound compression. The compression of the wound
has the important effect of preventing the accumulation of
blood and secretions, and of thus perfecting what careful
control of hemorrhage and drainage may have failed to

The original Lister dressing was changed almost daily or
even twice daily. This was necessary, because it was com-
posed of moist layers of carbolized gauze and a waterproof
impermeable covering which acted simply as a Priessnitz
application, " compresses echauff antes," as expressed by the
French. In the absorbed secretions under the moist warm
covering, notwithstanding the saturation with carbolic acid,
bacteria soon develop. The secretion is also more profuse
under this dressing, because warmth and the carbolic acid
irritate the wound very decidedly, even though the latter has
been covered with protective silk or disinfected guttapercha.
The dressing rapidly becomes filled with secretions, taking up,
as it does, more than the dry gauze, and it cannot dispose of
the fluid absorbed, by evaporation. The superiority of the
absorbing dressings consists in our being able to allow them to
remain for long intervals, it being unnecessary to change them
until the completion of repair, unless the discharge has been
excessive. It is objectionable to have to change the dressing,
as every such change exposes the wound to renewed danger of
infection, and disturbs the position of rest and the compression.
Of this we may readily convince ourselves in any case of pro-
gressive suppuration and in localized joint inflammation by
the very decided rise of temperature which often follows.
The aseptic absorbing and well adapted dressing must not be
removed during the whole course of recovery unless there are
urgent indications present. These latter comprise :

1. Inability of the dressing longer to absorb the secretions.

2. Particular soiling of the dressing.

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3. Necessity for removal of the drainage tubes.

4. Evidence of infection.

Secretions of fresh wounds are taken up very well by
dressings composed of gauze and moss. When the secretions
penetrate to the upper surface of the dressings it suffices for
preserving the aseptic character of the latter to apply addi-
tional layers of gauze, or simply provide for the contact of
the air with the saturated areas. The object of the latter is
to cause them to become dried. When the entire dressing is
saturated with discharge the upper layer should be removed,
the deeper remaining undisturbed. Frequent changes are
necessary in ichorous and offensive wounds, because even the
gauze absorbs with difficulty the tenacious pus, and the latter
stagnates under the dressing. Here a change, at intervals of
twenty- four, forty-eight, or seventy- two hours, is required.
Especial precaution must be taken against outward soiling of
the dressing in regions of the rectum and genitalia. When in
the latter situation the gauze and bandage become saturated
with urine or soiled with faeces, this portion must be removed.

In the von Bergmann Clinic the drainage tubes are removed
on the sixth or eighth day. As a rule, union is then complete,
so that the greater number of sutures can be dispensed with.
The drainage tubes are removed in toto at one time, and not
gradually shortened. The small fistulous tracts remaining,
close in the course of a few days. The presence of the tube
after the end of a week is unnecessary, it having at this time
no further function to perform, and it prevents the complete
closure of the wound. It must not be supposed, however, that
a tube left for a longer time would be a source of danger.
Through error this once occurred in the von Bergmann Clinic,
a drainage tube being allowed to remain for five weeks, and,
notwithstanding, no particular disturbance was occasioned.
After its removal the wound healed rapidly throughout its en-

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tire extent. The extraction of the drainage tubes with the
change of dressing is the simpler and better method. Allow-
ing them to protrude through the gauze, or attaching threads
to them to facilitate their removal in course of a few days, is
not to be recommended, as the position and aseptic character
of the dressing are thus jeopardized. A direct external com-
munication is created. The frequent changes of dressing in
the former Lister method was regarded as necessary in order
to enable the surgeon to determine early whether infection had
anywhere taken place. Necessity for this seems very apparent.
With the occurrence of infection most energetic measures are
to be adopted. All, or the greater number of the sutures
should be removed, the wound laid open, packed with iodo-
form gauze, and drained. In the permanent dressing of to-
day the direct " control " of the wound is excluded, and so
much the more thoroughly must the surgeon study the symp-
toms which indicate to him, without such inspection, the
presence of infection. It is very essential to understand the
normal process of recovery. In case of the mammary ampu-
tation referred to, sensitive patients will complain of some
pain on the day of the operation. On the following day, if the
course is aseptic, this is substituted by simply a feeling of dis-
comfort, due to the dressing. As the effect of the chloroform
passes off, vomiting and headache subside, and the appetite and
normal sleep return, so that in the course of thirty-six to forty-
eight hours a quite natural condition is resumed. The char-
acter of recovery under the Listerian dressing led surgeons to
suppose that where there is no reaction in wounds the patient
is always free from fever. This is incorrect. Every experi-
enced clinician will endorse the following statement of Volk-
mann ; " It will very nearly be a true representation of the
facts to assume that of one thousand cases of severe injury,
properly treated, with all the aseptic precautions, only one

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third are free from rise of temperature, another third have a
moderate elevation, and the remaining number very decided

The so-called aseptic fever often reaches 39° and 40° C.
like the septic. Typical illustrations of aseptic fever are
afforded by nearly every large fracture. Von Volkmann studied
in his clinic fourteen successive cases of fracture of the femur.
Of these just three were entirely free from fever. The greater
number showed 39° and 40** C. for several days, and in two
cases the temperature was at this point for ten days, in one for
eleven, and in one for sixteen days. This form of fever begins
immediately after the operation ; often when the patient has
been operated upon in the morning, on the evening of the
same day there will be a rise to 39°. The temperature may
continue to increase, and attain a considerable height, then
gradually decline. Almost never is that fever aseptic, which
begins on the second or third day after the operation ; here
we have to do with infection. Usually in two or three days in
uninterrupted repair, the temperature has returned to the nor-
mal, although it may remain high for a longer time, finally
declining gradually.

The so-called aseptic fever does not belong properly to the
aseptic course of repair. Like the septic, it is an absorption
fever, being dependent upon the taking up of the ferment
which the disintegrated tissue produces in the wound. These
tissue shreds, and more especially the fluid or coagulated
blood — the fibrin ferment (von Bergmann and Angerer) — cause
the whole phenomena. This explains why the fever begins im-
mediately after the operation, and herein lies the differentia-
tion of this from the septic fever. The cause of the aseptic
rise of temperature, the fibrin ferment, is produced with the
formation of the blood clot and the disintegration of tissue.
The ptomaines and toxines which are the cause of the septic

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fever by their absorption, develop gradually with the prolifera-
tion of the bacteria. One germ or a number of germs pro-
duce no effect. Suppuration and fever — ^the consequences of
the bacterial toxines — are manifested only when these products
are manufactured in large quantities in the wound. There is
always a period of incubation in infection therefore ; prior to
the second day noticeable symptoms are almost never to be
expected. Thus the first twenty-four hours following the
operation affords little aid in the prognosis, and not until the
second or third day are we presented with definite information.
Later than this the occurrence of infection is not to be ex-
pected. If on the second day there is no constitutional or
local disturbance, it is evident that during the operation no
infection occurred, and we can reasonably calculate on a
favorable termination. Only rarely does this form of compli-
cation develop subsequently under the permanent dressing,
and according to the weight of experience we have here rather
to deal with a secondary inception of bacteria. The symptoms
of beginning wound infection are local and constitutional —
fever. The objective evidences of inflammation in the wound?
the redness and swelling, are concealed from our view by the
dressing, which, when possible, we allow to remain undisturbed.
The pain of which the patient complains however, is often
very distinctive. It is almost always present to a greater or
less extent in inflamed wounds, and may be very severe. This
symptom is more valuable when it was not present on the day
of operation or on the first day afterward. Even though the
wound cannot be inspected, usually its surroundings can, and
the latter afford us valuable information. Nothing in this
connection is more important than the condition of the lym-
phatics, and the first thing to be observed when sepsis is sus-
pected is the character of the lymph glands in the vicinity,
with a view to determining whether or not they are swollen.

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The constitutional disturbance and fever in septic infection
do not conform to any fixed rule. Infection is dependent
upon a number of varied organisms, which form dissimilar
toxines and affect the body differently. The height of the
fever, which is non-septic, corresponds with the quantity of
blood poured out in the wound, and with the extent of the
destruction of tissue, while in the dangerous forms of sepsis
the local disturbance may almost escape notice, everything
being dependent upon the quality of the bacteria. The
severest cases can also run a course unattended by particular
elevation of temperature, and there only remains the abnor-
mally hard or readily compressible character of the pulse, or
the general condition of the patient, to indicate to the clinician
the gravity of the prognosis.

Usually a patient affected with sepsis is depressed, or at
least feels that he is ill. This sensation, however, may be
absent in severe cases, and it is important to know that there
may be an abnormal feeling of well-being, and yet the indi-
vidual die in the course of a few hours, greatly to the astonish-
ment of the bystanders.

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The Examination of Fresh Wounds with Fingers and Probe is Unpardon-
able — So also is the Irrigation with Water — Control of Hemorrhage —
The Dressing — Occlusive Bandage Applied to Small Wounds — Gunshot
Injuries and Complicated Fractures — Injuries Involving Large Wounds
— Improvisation.

One of the most persistent of former evils is the examina-
tion of fresh wounds with fingers and probes. In no particular
does the ancient and modern treatment present greater con-
trast. The wound proper has been thought to be the chief

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Online LibraryCurt SchimmelbuschA guide to the aseptic treatment of wounds → online text (page 15 of 19)