SECONDARY ANTISEPSIS
SEPTICEMIA FOLLOWING WOUND INFECTION
=Symptoms.=—After operations performed under the most thorough aseptic or
antiseptic procedure, wound fever, more or less marked, may be expected.
It develops a few hours after operation and subsides in twenty-four
or forty-eight hours. If, however, the wound has not been properly
rendered aseptic, or in which there is reason for irritation or tension,
more serious symptoms may develop about the second or third day. These
symptoms increase with the amount of infection in the wound and result
in septicemia, or septic intoxication, the outcome of the absorption of
ptomains—the product of tissue decomposition.
Inflammatory fever is marked by a sudden rise in temperature, 100° to
103° F., with a full, strong, and rapid pulse, headache, anorexia, coated
tongue, constipation and diminished secretion. If the infection is severe
delirium comes on.
If the symptoms are not relieved promptly the indications of septicemia
assert themselves with an increasing temperature, between 102° and 104°
F., with a rapid compressible pulse gradually becoming weaker. The
respirations are rapid and shallow. The tongue becomes dry and discolored
and the teeth are covered with sordes.
The restlessness disappears and apathy, somnolence, and a low type of
delirium takes its place. Vomiting occurs. There may be a profuse
diarrhea and the urine is passed involuntarily. In other words,
septicemia is but an aggravated continuance of inflammatory fever;
untoward symptoms may come on early, and death may result within
forty-eight hours.
On inspection, the infected wound appears highly inflamed, there is
increasing swelling, with more or less pain in the part. The edges of the
wound appear pale and everted. Serous oozing comes from the wound. If
sloughing is to occur from tension or low vitality of the parts the area
becomes discolored, assuming at first a pale green color, which turns
into bluish brown—and, lastly, brown.
=Treatment.=—The treatment of such wounds is to immediately relieve all
tension by withdrawing the sutures. Flush the wound with peroxid solution
and irrigate thoroughly with a 1-3,000 bichlorid solution, leaving the
wound open for a free drainage.
Then apply iodoform gauze over the wound and change the dressings as
often as is deemed necessary—two or three times a day. In severe cases
open the wound thoroughly, even by further incision, clean out the
contents of the wound, such as foreign matter, bloodclots, exudate, or
perhaps pieces of bone that may have been overlooked, using a small,
sharp spoon curette for the purpose. See that the deeper recesses of the
wound, especially in those about the nasal bones, are thoroughly gone
over.
Next irrigate the wound with a 1-1,000 bichlorid solution. Carbolic
solutions to be of use in the severer cases, are too irritating and
cause an increase of the secretions, hence they are not to be used.
Furthermore, their toxic property is not desirable and ofttimes are not
well borne by the patient.
The wound is now loosely filled (not packed) with iodoform gauze to
permit of perfect drainage. Aseptic absorbent cotton may be placed over
this.
It is not advisable to bring the edges of the wound together; the main
object is to overcome the spread of infection and the toxic absorption of
the wound product.
When the symptoms are severe moist dressings, in the form of compresses
dipped into 1-3,000 bichlorid, are to be preferred, changing them every
hour.
Internally it becomes necessary to reduce the temperature and to overcome
the toxemia.
For the temperature quinin is the best agent. In milder cases it can
be given in tonic doses, associated with antifebrin, with or without
morphin, to quiet the patient. In severe forms quinin must be pushed,
giving as much as twenty grains at a dose, to be repeated as necessary.
A saline purge, magnesium sulphate in full doses, is useful to eliminate
the ptomains.
The strength of the patient must be supported by the free use of
stimulants and frequent small quantities of nutritious food. Milk with
whisky is excellent. Peptonoids and beef juice are given several times in
the day.
Favorable symptoms are heralded by the lowering of the temperature, the
abatement of toxic symptoms, the reduction of the edema, and the deep
redness, as well as the softening of the hard and painful edematous walls
of the wound, followed by the breaking down of more or less tissue with
the production of pus.
GANGRENE
Gangrene in these cases is often due to undue bruising or pressure on
the parts during operation, and otherwise to the tension of sutures. It
is best to allow the gangrenous mass to remain, keeping it aseptic by
antiseptic measures, as it is often found that only the superficial layer
and the edge or edges of the wound have suffered.
As demarcation is well established the gangrenous portions may be removed
with the dressing or small seizing forceps. _Walcher’s_ pattern of a
dressing forceps is shown in Fig. 25, a toothed seizing forceps being
represented in Fig. 26.
[Illustration: FIG. 25.—WALCHER DRESSING FORCEPS.]
[Illustration: FIG. 26.—TOOTHED SEIZING FORCEPS.]
The wound from now on may be at first subjected to a rather strong
aqueous solution of hydrogen peroxid, fifty per cent, followed by the
same sublimate solution used throughout.
Iodoform gauze dressing, with or without dusting of iodoform or iodol, is
continued with the purpose of draining the pus secretion thrown off by
the granulating tissue which soon begins to fill the wound, as well as to
exert its antiseptic and stimulating influence upon the granulations.
Lazy or glassy granulations are removed with the curette as they appear,
or a cauterant, in the form of a nitrate-of-silver stick. Gradually the
new tissue contracts, the epidermal edges begin to fold over the surface.
Dry dressing, in the form of aristol or boric acid, may then be used, to
produce ultimate healing under an aseptic scab, or lint moistened with
two-per-cent salicylic oil or boric vaselin is placed upon the wound. A
formula of the latter is made up as follows:
Boric acid 3 parts
Vaselin 5 ”
Paraffin 10 ”
A desirable boric-acid oil for the same purpose is composed of:
Boric acid 3 parts
Cera alba 4 ”
Ol. oliva 20 ”
The latter must be changed daily until cicatrization has been established.
If it is more desirable to cover the granulating area by means of skin
grafts it may be accomplished readily, as later described. This is
usually resorted to when there has been loss of tissue from the result of
sloughing, although a sliding-flap operation may overcome the defect to a
nicety; this is especially true of wounds about the anterior nasal border.
If the resulting cicatrice is no larger than the gaping wound it may be
excised, the skin at either side is undermined and the edges are brought
together, as was originally intended.
ERYSIPELATOUS INFECTION
It sometimes happens that a wound takes on erysipelatous infection. It is
usually of the simple variety, although the cellulo-cutaneous variety is
not rare.
=Causes.=—The predisposing causes are septic infection, lowered vitality,
resulting from alcoholism, poor hygiene, and nephritis. The exciting
cause has been accredited to the erysipelo-coccus of _Fehleisen_, which
is found chiefly in the more superficial channels of the corium and
appearing in chain groups as seen microscopically.
=Symptoms.=—The symptoms locally are the peculiar rosy rash, rapidly
spreading out from the wound with well-defined margins. The affected part
appears smooth and edematous and is slightly raised above the surface,
the patient complains of stiffness and burning pain in the part. Often
vesicles form on the affected part.
The temperature rises suddenly to 102° to 103° F., there is nausea and
vomiting.
=Treatment.=—The wound in such cases must be treated as described in
inflammatory fever. Internally the usual remedies are given. A local
application of sixty-per-cent ichthyol ointment, covered with salicylated
cotton, serves best. The skin may be incised in various places, washed
with an antiseptic (sublimate solution 1-1,000) and the serous exudation
pressed out with the sterilized hand, after which the above ointment is
applied under absorbent cotton (Glück).
Antithermic remedies, as obtained by the application of certain
alkaloids, such as cocain, spartein, solanin, helleborin, have been
successfully used by Guimard and Geley.
Spartein is especially claimed to exert a happy influence.
Lately a product under the name of antiphlogistin has been used locally
with excellent results and its use is to be commended even in local wound
inflammation.
If the subcutaneous tissue is affected and the surface indicates the
breaking down of tissue, hot antiseptic applications are advisable or
the skin is incised down to the deep fascia at such places and iodoform
gauze is packed into the wound for several hours. Constant antiseptic
irrigation is then established by means of drainage tubes inserted
into the various incised places, which are connected to an irrigating
apparatus, so that the antiseptic may reach all parts of the infected
area.
Nontoxic solutions are indicated in this event; of these, hydrogen
dioxid, three per cent, and boric acid, nine per cent, are most suitable.
The solution is allowed to trickle gently through the wound and is led
off by open tubes, that may be connected in such way as to empty into a
receptacle placed beneath the bed.