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