Alexis Thomson and Alexander Miles - Manual of Surgery

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A dressing may be dispensed with altogether, the grafts being protected
by a wire cage such as is used after vaccination, but they tend to dry
up and come to resemble a scab.

When the grafts have healed, it is well to protect them from injury and
to prevent them drying up and cracking by the liberal application of
lanoline or vaseline.

The new skin is at first insensitive and is fixed to the underlying
connective tissue or bone, but in course of time (from six weeks
onwards) sensation returns and the formation of elastic tissue beneath
renders the skin pliant and movable so that it can be pinched up between
the finger and thumb.

_Reverdin's_ method consists in planting out pieces of skin not bigger
than a pin-head over a granulating surface. It is seldom employed.

_Grafts of the Cutis Vera._--Grafts consisting of the entire thickness
of the true skin were specially advocated by Wolff and are often
associated with his name. They should be cut oval or spindle-shaped, to
facilitate the approximation of the edges of the resulting wound. The
graft should be cut to the exact size of the surface it is to cover;
Gillies believes that tension of the graft favours its taking. These
grafts may be placed either on a fresh raw surface or on healthy
granulations. It is sometimes an advantage to stitch them in position,
especially on the face. The dressing and the after-treatment are the
same as in epidermis grafting.

There is a degree of uncertainty about the graft retaining its vitality
long enough to permit of its deriving the necessary nourishment from its
new surroundings; in a certain number of cases the flap dies and is
thrown off as a slough--moist or dry according to the presence or
absence of septic infection.

The technique for cutis-grafting must be without a flaw, and the asepsis
absolute; there must not only be a complete absence of movement, but
there must be no traction on the flap that will endanger its blood
supply.

Owing to the uncertainty in the results of cutis-grafting the
_two-stage_ or _indirect method_ has been introduced, and its almost
uniform success has led to its sphere of application being widely
extended. The flap is raised as in the direct method but is left
attached at one of its margins for a period ranging from 14 to 21 days
until its blood supply from its new bed is assured; the detachment is
then made complete. The blood supply of the proposed flap may influence
its selection and the way in which it is fashioned; for example, a flap
cut from the side of the head to fill a defect in the cheek, having in
its margin of attachment or pedicle the superficial temporal artery, is
more likely to take than a flap cut with its base above.

Another modification is to raise the flap but leave it connected at both
ends like the piers of a bridge; this method is well suited to defects
of skin on the dorsum of the fingers, hand and forearm, the bridge of
skin is raised from the abdominal wall and the hand is passed beneath it
and securely fixed in position; after an interval of 14 to 21 days, when
the flap is assured of its blood supply, the piers of the bridge are
divided (Fig. 1). With undermining it is usually easy to bring the
edges of the gap in the abdominal wall together, even in children; the
skin flap on the dorsum of the hand appears rather thick and
prominent--almost like the pad of a boxing-glove--for some time, but
the restoration of function in the capacity to flex the fingers is
gratifying in the extreme.

[Illustration: FIG. 1.--Ulcer of back of Hand covered by flap of skin
raised from anterior abdominal wall. The lateral edges of the flap are
divided after the graft has adhered.]

The indirect element of this method of skin-grafting may be carried
still further by transferring the flap of skin first to one part of the
body and then, after it has taken, transferring it to a third part.
Gillies has especially developed this method in the remedying of
deformities of the face caused by gunshot wounds and by petrol burns in
air-men. A rectangular flap of skin is marked out in the neck and chest,
the lateral margins of the flap are raised sufficiently to enable them
to be brought together so as to form a tube of skin: after the
circulation has been restored, the lower end of the tube is detached and
is brought up to the lip or cheek, or eyelid, where it is wanted; when
this end has derived its new blood supply, the other end is detached
from the neck and brought up to where it is wanted. In this way, skin
from the chest may be brought up to form a new forehead and eyelids.

Grafts of _mucous membrane_ are used to cover defects in the lip, cheek,
and conjunctiva. The technique is similar to that employed in
skin-grafting; the sources of mucous membrane are limited and the
element of septic infection cannot always be excluded.

_Fat._--Adipose tissue has a low vitality, but it is easily retained and
it readily lends itself to transplantation. Portions of fat are often
obtainable at operations--from the omentum, for example, otherwise the
subcutaneous fat of the buttock is the most accessible; it may be
employed to fill up cavities of all kinds in order to obtain more rapid
and sounder healing and also to remedy deformity, as in filling up a
depression in the cheek or forehead. It is ultimately converted into
ordinary connective tissue _pari passu_ with the absorption of the fat.

The _fascia lata of the thigh_ is widely and successfully used as a
graft to fill defects in the dura mater, and interposed between the
bones of a joint--if the articular cartilage has been destroyed--to
prevent the occurrence of ankylosis.

The _peritoneum_ of hydrocele and hernial sacs and of the omentum
readily lends itself to transplantation.

_Cartilage and bone_, next to skin, are the tissues most frequently
employed for grafting purposes; their sphere of action is so extensive
and includes so much of technical detail in their employment, that they
will be considered later with the surgery of the bones and joints and
with the methods of re-forming the nose.

_Tendons and blood vessels_ readily lend themselves to transplantation
and will also be referred to later.

_Muscle and nerve_, on the other hand, do not retain their vitality when
severed from their surroundings and do not functionate as grafts except
for their connective-tissue elements, which it goes without saying are
more readily obtainable from other sources.

Portions of the _ovary_ and of the _thyreoid_ have been successfully
transplanted into the subcutaneous cellular tissue of the abdominal wall
by Tuffier and others. In these new surroundings, the ovary or thyreoid
is vascularised and has been shown to functionate, but there is not
sufficient regeneration of the essential tissue elements to "carry on";
the secreting tissue is gradually replaced by connective tissue and the
special function comes to an end. Even such temporary function may,
however, tide a patient over a difficult period.

CHAPTER II

CONDITIONS WHICH INTERFERE WITH REPAIR

SURGICAL BACTERIOLOGY

Want of rest--Irritation--Unhealthy tissues--Pathogenic bacteria.
SURGICAL BACTERIOLOGY--General characters of
bacteria--Classification of bacteria--Conditions of bacterial
life--Pathogenic powers of bacteria--Results of bacterial
growth--Death of bacteria--Immunity--Antitoxic sera--Identification
of bacteria--Pyogenic bacteria.

In the management of wounds and other surgical conditions it is
necessary to eliminate various extraneous influences which tend to delay
or arrest the natural process of repair.

Of these, one of the most important is undue movement of the affected
part. "The first and great requisite for the restoration of injured
parts is _rest_," said John Hunter; and physiological and mechanical
rest as the chief of natural therapeutic agents was the theme of John
Hilton's classical work--_Rest and Pain_. In this connection it must be
understood that "rest" implies more than the mere state of physical
repose: all physiological as well as mechanical function must be
prevented as far as is possible. For instance, the constituent bones of
a joint affected with tuberculosis must be controlled by splints or
other appliances so that no movement can take place between them, and
the limb may not be used for any purpose; physiological rest may be
secured to an inflamed colon by making an artificial anus in the caecum;
the activity of a diseased kidney may be diminished by regulating the
quantity and quality of the fluids taken by the patient.

Another source of interference with repair in wounds is _irritation_,
either by mechanical agents such as rough, unsuitable dressings,
bandages, or ill-fitting splints; or by chemical agents in the form of
strong lotions or other applications.

An _unhealthy or devitalised condition of the patient's tissues_ also
hinders the reparative process. Bruised or lacerated skin heals less
kindly than skin cut with a smooth, sharp instrument; and persistent
venous congestion of a part, such as occurs, for example, in the leg
when the veins are varicose, by preventing the access of healthy blood,
tends to delay the healing of open wounds. The existence of grave
constitutional disease, such as Bright's disease, diabetes, syphilis,
scurvy, or alcoholism, also impedes healing.

Infection by disease-producing micro-organisms or _pathogenic bacteria_
is, however, the most potent factor in disturbing the natural process of
repair in wounds.

SURGICAL BACTERIOLOGY

The influence of micro-organisms in the causation of disease, and the
role played by them in interfering with the natural process of repair,
are so important that the science of applied bacteriology has now come
to dominate every department of surgery, and it is from the standpoint
of bacteriology that nearly all surgical questions have to be
considered.

The term _sepsis_ as now used in clinical surgery no longer retains its
original meaning as synonymous with "putrefaction," but is employed to
denote all conditions in which bacterial infection has taken place, and
more particularly those in which pyogenic bacteria are present. In the
same way the term _aseptic_ conveys the idea of freedom from all forms
of bacteria, putrefactive or otherwise; and the term _antiseptic_ is
used to denote a power of counteracting bacteria and their products.

#General Characters of Bacteria.#--A _bacterium_ consists of a finely
granular mass of protoplasm, enclosed in a thin gelatinous envelope.
Many forms are motile--some in virtue of fine thread-like flagella, and
others through contractility of the protoplasm. The great majority
multiply by simple fission, each parent cell giving rise to two daughter
cells, and this process goes on with extraordinary rapidity. Other
varieties, particularly bacilli, are propagated by the formation of
_spores_. A spore is a minute mass of protoplasm surrounded by a dense,
tough membrane, developed in the interior of the parent cell. Spores are
remarkable for their tenacity of life, and for the resistance they offer
to the action of heat and chemical germicides.

Bacteria are most conveniently classified according to their shape. Thus
we recognise (1) those that are globular--_cocci_; (2) those that
resemble a rod--_bacilli_; (3) the spiral or wavy forms--_spirilla_.

_Cocci_ or _micrococci_ are minute round bodies, averaging about 1 [micron]
in diameter. The great majority are non-motile. They multiply by fission;
and when they divide in such a way that the resulting cells remain in
pairs, are called _diplococci_, of which the bacteria of gonorrhoea and
pneumonia are examples (Fig. 5). When they divide irregularly, and form
grape-like bunches, they are known as _staphylococci_, and to this
variety the commonest pyogenic or pus-forming organisms belong (Fig. 2).
When division takes place only in one axis, so that long chains are
formed, the term _streptococcus_ is applied (Fig. 3). Streptococci are
met with in erysipelas and various other inflammatory and suppurative
processes of a spreading character.

_Bacilli_ are rod-shaped bacteria, usually at least twice as long as
they are broad (Fig. 4). Some multiply by fission, others by
sporulation. Some forms are motile, others are non-motile. Tuberculosis,
tetanus, anthrax, and many other surgical diseases are due to different
forms of bacilli.

_Spirilla_ are long, slender, thread-like cells, more or less spiral or
wavy. Some move by a screw-like contraction of the protoplasm, some by
flagellae. The spirochaete associated with syphilis (Fig. 36) is the most
important member of this group.

#Conditions of Bacterial Life.#--Bacteria require for their growth and
development a suitable food-supply in the form of proteins,
carbohydrates, and salts of calcium and potassium which they break up
into simpler elements. An alkaline medium favours bacterial growth; and
moisture is a necessary condition; spores, however, can survive the want
of water for much longer periods than fully developed bacteria. The
necessity for oxygen varies in different species. Those that require
oxygen are known as _aerobic bacilli_ or _aerobes_; those that cannot
live in the presence of oxygen are spoken of as _anaerobes_. The great
majority of bacteria, however, while they prefer to have oxygen, are
able to live without it, and are called _facultative anaerobes_.

The most suitable temperature for bacterial life is from 95 to 102 F.,
roughly that of the human body. Extreme or prolonged cold paralyses but
does not kill micro-organisms. Few, however, survive being raised to a
temperature of 134.5 F. Boiling for ten to twenty minutes will kill all
bacteria, and the great majority of spores. Steam applied in an
autoclave under a pressure of two atmospheres destroys even the most
resistant spores in a few minutes. Direct sunlight, electric light, or
even diffuse daylight, is inimical to the growth of bacteria, as are
also Rontgen rays and radium emanations.

#Pathogenic Properties of Bacteria.#--We are now only concerned with
pathogenic bacteria--that is, bacteria capable of producing disease in
the human subject. This capacity depends upon two sets of factors--(1)
certain features peculiar to the invading bacteria, and (2) others
peculiar to the host. Many bacteria have only the power of living upon
dead matter, and are known as _saphrophytes_. Such as do nourish in
living tissue are, by distinction, known as _parasites_. The power a
given parasitic micro-organism has of multiplying in the body and giving
rise to disease is spoken of as its _virulence_, and this varies not
only with different species, but in the same species at different times
and under varying circumstances. The actual number of organisms
introduced is also an important factor in determining their pathogenic
power. Healthy tissues can resist the invasion of a certain number of
bacteria of a given species, but when that number is exceeded, the
organisms get the upper hand and disease results. When the organisms
gain access directly to the blood-stream, as a rule they produce their
effects more certainly and with greater intensity than when they are
introduced into the tissues.

Further, the virulence of an organism is modified by the condition of
the patient into whose tissues it is introduced. So long as a person is
in good health, the tissues are able to resist the attacks of moderate
numbers of most bacteria. Any lowering of the vitality of the
individual, however, either locally or generally, at once renders him
more susceptible to infection. Thus bruised or torn tissue is much more
liable to infection with pus-producing organisms than tissues clean-cut
with a knife; also, after certain diseases, the liability to infection
by the organisms of diphtheria, pneumonia, or erysipelas is much
increased. Even such slight depression of vitality as results from
bodily fatigue, or exposure to cold and damp, may be sufficient to turn
the scale in the battle between the tissues and the bacteria. Age is an
important factor in regard to the action of certain bacteria. Young
subjects are attacked by diphtheria, tuberculosis, acute osteomyelitis,
and some other diseases with greater frequency and severity than those
of more advanced years.

In different races, localities, environment, and seasons, the pathogenic
powers of certain organisms, such as those of erysipelas, diphtheria,
and acute osteomyelitis, vary considerably.

There is evidence that a _mixed infection_--that is, the introduction of
more than one species of organism, for example, the tubercle bacillus
and a pyogenic staphylococcus--increases the severity of the resulting
disease. If one of the varieties gain the ascendancy, the poisons
produced by the others so devitalise the tissue cells, and diminish
their power of resistance, that the virulence of the most active
organisms is increased. On the other hand, there is reason to believe
that the products of certain organisms antagonise one another--for
example, an attack of erysipelas may effect the cure of a patch of
tuberculous lupus.

Lastly, in patients suffering from chronic wasting diseases, bacteria
may invade the internal organs by the blood-stream in enormous numbers
and with great rapidity, during the period of extreme debility which
shortly precedes death. The discovery of such collections of organisms
on post-mortem examination may lead to erroneous conclusions being drawn
as to the cause of death.

#Results of Bacterial Growth.#--Some organisms, such as those of tetanus
and erysipelas, and certain of the pyogenic bacteria, show little
tendency to pass far beyond the point at which they gain an entrance to
the body. Others, on the contrary--for example, the tubercle bacillus
and the organism of acute osteomyelitis--although frequently remaining
localised at the seat of inoculation, tend to pass to distant parts,
lodging in the capillaries of joints, bones, kidney, or lungs, and there
producing their deleterious effects.

In the human subject, multiplication in the blood-stream does not occur
to any great extent. In some general acute pyogenic infections, such as
osteomyelitis, cellulitis, etc., pure cultures of staphylococci or of
streptococci may be obtained from the blood. In pneumococcal and typhoid
infections, also, the organisms may be found in the blood.

It is by the vital changes they bring about in the parts where they
settle that micro-organisms disturb the health of the patient. In
deriving nourishment from the complex organic compounds in which they
nourish, the organisms evolve, probably by means of a ferment, certain
chemical products of unknown composition, but probably colloidal in
nature, and known as _toxins_. When these poisons are absorbed into the
general circulation they give rise to certain groups of symptoms--such
as rise of temperature, associated circulatory and respiratory
derangements, interference with the gastro-intestinal functions and also
with those of the nervous system--which go to make up the condition
known as blood-poisoning, toxaemia, or _bacterial intoxication_. In
addition to this, certain bacteria produce toxins that give rise to
definite and distinct groups of symptoms--such as the convulsions of
tetanus, or the paralyses that follow diphtheria.

_Death of Bacteria._--Under certain circumstances, it would appear that
the accumulation of the toxic products of bacterial action tends to
interfere with the continued life and growth of the organisms
themselves, and in this way the natural cure of certain diseases is
brought about. Outside the body, bacteria may be killed by starvation,
by want of moisture, by being subjected to high temperature, or by the
action of certain chemical agents of which carbolic acid, the
perchloride and biniodide of mercury, and various chlorine preparations
are the most powerful.

#Immunity.#--Some persons are insusceptible to infection by certain
diseases, from which they are said to enjoy a _natural immunity_. In
many acute diseases one attack protects the patient, for a time at
least, from a second attack--_acquired immunity_.

_Phagocytosis._--In the production of immunity the leucocytes and
certain other cells play an important part in virtue of the power they
possess of ingesting bacteria and of destroying them by a process of
intra-cellular digestion. To this process Metchnikoff gave the name of
_phagocytosis_, and he recognised two forms of _phagocytes_: (1) the
_microphages_, which are the polymorpho-nuclear leucocytes of the blood;
and (2) the _macrophages_, which include the larger hyaline leucocytes,
endothelial cells, and connective-tissue corpuscles.

During the process of phagocytosis, the polymorpho-nuclear leucocytes in
the circulating blood increase greatly in numbers (_leucocytosis_), as
well as in their phagocytic action, and in the course of destroying the
bacteria they produce certain ferments which enter the blood serum.
These are known as _opsonins_ or _alexins_, and they act on the bacteria
by a process comparable to narcotisation, and render them an easy prey
for the phagocytes.

_Artificial or Passive Immunity._--A form of immunity can be induced by
the introduction of protective substances obtained from an animal which
has been actively immunised. The process by which passive immunity is
acquired depends upon the fact that as a result of the reaction between
the specific virus of a particular disease (the _antigen_) and the
tissues of the animal attacked, certain substances--_antibodies_--are
produced, which when transferred to the body of a susceptible animal
protect it against that disease. The most important of these antibodies
are the _antitoxins_. From the study of the processes by which immunity
is secured against the effects of bacterial action the serum and vaccine
methods of treating certain infective diseases have been evolved. The
_serum treatment_ is designed to furnish the patient with a sufficiency
of antibodies to neutralise the infection. The anti-diphtheritic and the
anti-tetanic act by neutralising the specific toxins of the
disease--_antitoxic serums_; the anti-streptcoccic and the serum for
anthrax act upon the bacteria--_anti-bacterial serums_.

A _polyvalent_ serum, that is, one derived from an animal which has been
immunised by numerous strains of the organism derived from various
sources, is much more efficacious than when a single strain has been
used.

_Clinical Use of Serums._--Every precaution must be taken to prevent
organismal contamination of the serum or of the apparatus by means of
which it is injected. Syringes are so made that they can be sterilised
by boiling. The best situations for injection are under the skin of the
abdomen, the thorax, or the buttock, and the skin should be purified at
the seat of puncture. If the bulk of the full dose is large, it should
be divided and injected into different parts of the body, not more than
20 c.c. being injected at one place. The serum may be introduced
directly into a vein, or into the spinal canal, _e.g._ anti-tetanic
serum. The immunity produced by injections of antitoxic sera lasts only
for a comparatively short time, seldom longer than a few weeks.

_"Serum Disease" and Anaphylaxis._--It is to be borne in mind that some
patients exhibit a supersensitiveness with regard to protective sera, an
injection being followed in a few days by the appearance of an
urticarial or erythematous rash, pain and swelling of the joints, and a
variable degree of fever. These symptoms, to which the name _serum
disease_ is applied, usually disappear in the course of a few days.

The term _anaphylaxis_ is applied to an allied condition of
supersensitiveness which appears to be induced by the injection of
certain substances, including toxins and sera, that are capable of
acting as antigens. When a second injection is given after an interval
of some days, if anaphylaxis has been established by the first dose, the
patient suddenly manifests toxic symptoms of the nature of profound
shock which may even prove fatal. The conditions which render a person
liable to develop anaphylaxis and the mechanism by which it is
established are as yet imperfectly understood.

_Vaccine Treatment._--The vaccine treatment elaborated by A. E. Wright
consists in injecting, while the disease is still active, specially
prepared dead cultures of the causative organisms, and is based on the
fact that these "vaccines" render the bacteria in the tissues less able
to resist the attacks of the phagocytes. The method is most successful
when the vaccine is prepared from organisms isolated from the patient
himself, _autogenous vaccine_, but when this is impracticable, or takes
a considerable time, laboratory-prepared polyvalent _stock vaccines_ may
be used.

_Clinical Use of Vaccines._--Vaccines should not be given while a
patient is in a negative phase, as a certain amount of the opsonin in
the blood is used up in neutralising the substances injected, and this
may reduce the opsonic index to such an extent that the vaccines
themselves become dangerous. As a rule, the propriety of using a vaccine
can be determined from the general condition of the patient. The initial
dose should always be a small one, particularly if the disease is acute,
and the subsequent dosage will be regulated by the effect produced. If
marked constitutional disturbance with rise of temperature follows the
use of a vaccine, it indicates a negative phase, and calls for a
diminution in the next dose. If, on the other hand, the local as well as
the general condition of the patient improves after the injection, it
indicates a positive phase, and the original dose may be repeated or
even increased. Vaccines are best introduced subcutaneously, a part
being selected which is not liable to pressure, as there is sometimes
considerable local reaction. Repeated doses may be necessary at
intervals of a few days.