Manual of Surgery Volume I Part 2

_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--Cla.s.sification of bacteria--Conditions of bacterial life--Pathogenic powers of bacteria--Results of bacterial growth--Death of bacteria--Immunity--Ant.i.toxic 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 cla.s.sical 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 const.i.tuent 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 a.n.u.s in the caec.u.m; the activity of a diseased kidney may be diminished by regulating the quant.i.ty 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 const.i.tutional 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 ma.s.s 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 ma.s.s 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 cla.s.sified 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 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 gonorrha 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, teta.n.u.s, 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 a.s.sociated 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 pota.s.sium 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 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 circ.u.mstances. 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 teta.n.u.s and erysipelas, and certain of the pyogenic bacteria, show little tendency to pa.s.s 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 pa.s.s 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, a.s.sociated 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 teta.n.u.s, or the paralyses that follow diphtheria.

_Death of Bacteria._--Under certain circ.u.mstances, it would appear that the acc.u.mulation 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 Pa.s.sive 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 pa.s.sive 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 _ant.i.toxins_. 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--_ant.i.toxic 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 b.u.t.tock, 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 ca.n.a.l, _e.g._ anti-tetanic serum. The immunity produced by injections of ant.i.toxic 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 const.i.tutional 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.

The vaccine treatment has been successfully employed in various tuberculous lesions, in pyogenic infections such as acne, boils, sycosis, streptococcal, pneumococcal, and gonococcal conditions, in infections of the accessory air sinuses, and in other diseases caused by bacteria.

PYOGENIC BACTERIA

From the point of view of the surgeon the most important varieties of micro-organisms are those that cause inflammation and suppuration--the _pyogenic bacteria_. This group includes a great many species, and these are so widely distributed that they are to be met with under all conditions of everyday life.