Surgery, with Special Reference to Podiatry Part 2

_Staphylococcus pyogenes aureus_-a microorganism producing yellow pus.

_Staphylococcus pyogenes citreus_-a microorganism producing lemon-colored pus.

_Staphylococcus pyogenes albus_-a microorganism producing white pus.

_Streptococcus pyogenes_-a streptococcus producing pus.

(Erysipelas for example).

_Micrococcus gonorrhea_-bacillus of Neisser, or gonococcus.

_Bacillus pyocyaneous_-producing a green pus.

_Bacillus coli communis_-producing intestinal conditions.

(Appendicitis for example).

_Bacillus typhosis_-Eberth's bacillus; producing typhoid fever.

_Bacillus tuberculosis_-Koch's bacillus; producing tuberculosis.

_Bacillus tetani_-Nicolaier's bacillus; causing teta.n.u.s.

_Treponema pallidum_, or _spirochaeta pallida_ of Hoffman and Schaudin-a protoza causing syphilis.

The first six are known as _pyogenic bacteria_, as they all produce pus; in addition to the above there are many more microorganisms, but from a surgical standpoint those mentioned are the most important.

The _staphylococcus pyogenes_ is a spherical coccus of somewhat variable size but averaging about 8 microns; when properly stained it can often be seen to be formed of two separate hemispheres. In pus it is generally found in small heaps containing from two to ten members, but it also occurs singly and in pairs, and even in short chains like the streptococcus, thus rendering diagnosis difficult with the microscope alone. Its cultures are of a yellowish tinge. The aureus type is the most usual cause of abscesses (circ.u.mscribed suppurations) and 77% of acute abscesses are due to the staphylococci.

The _staphylococcus pyogenes aureus_ is a facultative anaerobic parasite which is widely distributed in nature, and is found in the soil, in the dust of air, in water, in the alimentary ca.n.a.l, under the nails, and in the superficial layers of the skin. It forms the characteristic color only when it grows in air. It is killed in ten minutes by a moist temperature of 58C. and is instantly killed by boiling water. Carbolic acid (1 to 40) and b.i.+.c.hloride of mercury (1 to 2000) are quickly fatal to these cocci.

_Staphylococcus pyogenes citreus_, the lemon-colored coccus, is found occasionally in acute circ.u.mscribed suppurations, but far more rarely than the other two forms. Its pyogenic power is even weaker than that of the albus.

_Staphylococcus pyogenes albus_, the white coccus, acts like the aureus, but is more feeble in power. When this organism is found upon and in the skin, it is called _staphylococcus epidermis albus_, an organism which is the cause of st.i.tch abscesses.

_Streptococcus pyogenes_ is found in spreading suppurations and in very acute abscesses. About 16% of acute abscesses contain streptococci. It is easily killed by boiling, and can be destroyed by carbolic acid and by corrosive sublimate. The streptococcus of erysipelas is thought to be identical with the streptococcus pyogenes, but their difference in action is believed to be due to difference in virulence induced by external conditions and by the state of the tissues of the host. The coccus of erysipelas is larger than the ordinary form of streptococcus pyogenes, and infection takes place through a wound, often a very trivial one, or through a mucous membrane. The organism multiplies in the small lymph channels. The streptococcus may cause suppuration in erysipelas, mixed infection not being necessary to cause pus to form.

The _gonococcus_ of Neisser is found both inside and outside of pus cells and mucous cells. The gonococci cannot be cultivated upon ordinary media, but grow best upon human-blood serum. Gonococci stain easily and are readily decolorized by Gram's method.

The _bacillus coli communis_, or the bacillus of Escherich, is invariably found in the faeces. It is believed by many observers to be the cause of appendicitis, peritonitis, and abscesses about the intestine. In cases of appendicitis we can rarely get a pure culture of Escherich's bacillus, but usually find also streptococci and staphylococci.

The _bacillus of typhoid fever_ (Eberth's bacillus) is responsible for some cases of gangrene, for some of embolism and for not a few bone and joint diseases.

The _bacillus tuberculosis_ (Koch's bacillus), the cause of all tubercular processes, is met with especially in dusty air which contains the dried sputum of victims of tuberculosis. This infected air is the chief means of its transmission, though it may be conveyed by the milk of tubercular cows and by the meat of tubercular animals.

Wounds may open a gateway for infection.

The _bacillus tetani_ (Nicolaier's bacillus), an aerobic organism, is found especially in the soil of gardens, in the dust of old buildings, in street dirt, and in the sweepings of stables. Spores develop at the ends of these bacilli. This organism is capable of producing toxins of deadly power. Its spores are hard to kill.

CHAPTER III

+ASEPSIS AND ANTISEPSIS+

Before the introduction of Lister's methods of treating wounds, it was considered proper, in accidental and operative wounds, to have profuse suppuration, pyemia, erysipelas, etc., and it was not remarkable, therefore, that the mortality following accidental and operative wounds was very high. Lister's method of wound treatment was largely based upon the conception that the infection of wounds occurred from contact with the air which contained spores and germs, and his method of treatment therefore, was directed chiefly to their destruction. The air can be a medium of wound infection to a certain extent, and dry air contains more spores and bacteria than moist air, but Koch demonstrated the fact that atmospheric microbes were chiefly of innocuous character, and wound infection usually could be traced to bacteria or spores being brought into direct contact with wounds, by the clothing, or by the skin of the patient, or by the hands of the surgeon, or by unclean surgical instruments and dressings. The antiseptic qualities of the blood serum and cell activities in healthy tissues, are sufficient to destroy or remove a certain number of microorganisms, and suppuration occurs only when the tissues are completely overwhelmed by the number of these organisms or when their power of resistance is lessened by injury or disease.

+Sepsis.+ Sepsis is due to the entrance and multiplication of microbes, or to the absorption of their products in the body. Local inflammation and marked const.i.tutional symptoms characterize sepsis.

+Asepsis.+ Asepsis aims at thorough sterilization of the parts and of all the objects brought into contact with the wounds, and the exclusion of germs by the use of occlusive bandages and dressings.

+Antisepsis+ is that method of wound treatment which keeps germicidal agents continuously in direct contact with the wound. Its object, therefore, is to produce asepsis. It is the duty of the surgeon to guard against the contact of microorganisms in the wound and to employ whatever means science has evolved for their destruction. He must, however, be careful to employ means of disinfection or destruction that will not have an injurious effect upon the normal tissues.

Mechanical disinfection does not apply to wounds but is employed as a preventive measure by the operator and his a.s.sistants for instruments and for the skin surrounding the wounds. Mechanical disinfection is accomplished by the use of soap and water and a friction brush; germicidal solutions of one kind or another are also employed.

In the modern aseptic operating room germicides and antiseptics do not play so important a part as they formerly did. This is largely due to the fact that heat is used wherever possible in the preparation of sutures, ligatures, dressings and instruments, and to the farther fact that in uninfected tissues no antiseptic solutions are employed. It must also be remembered that the germicidal agents possess the disadvantage of exercising a more or less destructive action on the body cells, and consequently their use is not warranted in clean wounds. We still, however, sufficiently often meet with infected wounds that render the use of these agents necessary.

+Heat+ is the most valuable of all sterilizing agents, its only drawback being that it is not universally applicable. Wherever possible it should be employed in preference to chemical agents. It can be employed either dry or moist. Moist heat is a much more efficacious germicide than dry heat, for it destroys the organisms at a much lower temperature. Boiling water at a temperature of 212F. will destroy nearly instantaneously all pus-producing organisms. Spores, however, require a moist heat of 284F. kept up for at least a half-hour. A dry heat of 212F. will not destroy pus-producing organisms under an hour and a half of treatment, and spores will live for three hours at a dry temperature of 284F.

Although moist heat is very much quicker and more satisfactory in its action, yet it is often inconvenient to employ it in the sterilization of gowns, towels, operating suits, etc. However, sterilization by heat has been greatly facilitated by the introduction of the autoclave, by means of which a very high temperature under pressure can be obtained.

This is the most satisfactory method of sterilizing dressings, towels, sheets, operating suits and ap.r.o.ns. A similar and less expensive method of sterilizing these articles is by the use of one of the simple steam sterilizers which are sold by all dealers. In an emergency, an ordinary bake oven can be employed as a sterilizer. It is best, however, where the temperature cannot be estimated, to boil the articles and dry them between sheets moistened with b.i.+.c.hloride solution.

+Disinfection or Sterilization.+ Sterilization of a wound, or of the substances coming in contact with it, may be accomplished by using the aseptic or antiseptic method; by combining these two methods we obtain the best results. The aseptic method, which employs antiseptic substances for the purpose of sterilization of objects coming in contact with the wound when their disinfection by heat is impossible, is the method perhaps most generally favored by modern surgeons.

+Antiseptic Method.+ In the antiseptic method, the field of operation, the hands of the operator and of his a.s.sistants, and the instruments, must be treated in germicidal solution and, in addition, the wound should be frequently irrigated during the operation with a solution that has germicidal properties.

Recent investigations show that many germicidal substances have not the power that was formerly attributed to them. Furthermore, substances which are really active germicides very often produce a marked toxic effect upon the patient and produce a very decided irritation of the skin with which they come in contact.

+Aseptic Methods.+ The aseptic method for the treatment of wounds admits of the use of germicidal solutions and heat upon the field of operation, upon the hands of the operator and of his a.s.sistants, and upon the instruments employed. After this has been accomplished, placing absolute dependence upon this sterilization, no germicidal or antiseptic substances are brought into contact with the wound, sterilized salt solution or plain sterilized water being used, if necessary, to flush the wound, the dressings employed having been sterilized by dry heat or moist heat.

+Sterilization of the Hands.+ Experimental investigation has shown that the failure of the surgeon's efforts to render his hands absolutely aseptic, has been the productive cause of infection in many wounds.

The hands and finger nails may be best sterilized by first rubbing them with spirits of turpentine; then scrubbing them with soap and water; and then using a sterilized nail brush freely. The scrubbing should be done for several minutes. The hands should then be rinsed to remove the soap, and then soaked for about ten minutes in a solution of b.i.+.c.hloride, strength, 1 to 2500. If turpentine has not been used before was.h.i.+ng with the soap, strong alcohol or ether should be well rubbed over the hands before they are immersed in the b.i.+.c.hloride solution. Perhaps the best way of rendering the hands sterile is to scrub them with green soap and water, then mix a tablespoonful of commercial chloride of lime and half a tablespoonful of carbonate of soda with enough water to make a paste. When this has a.s.sumed a thick creamy consistency, it should be rubbed into the hands until the grains of lime disappear and the skin feels cool; then rinse the hands in sterile water.

+Sterilization of Instruments.+ Instruments may be sterilized by boiling them for fifteen minutes in water in which a tablespoonful of was.h.i.+ng soda has been added for each quart. This prevents rusting of the instruments and also makes the water a better solvent for any fatty matter which may be upon the instruments, thus increasing the sterilizing effect of the heat.

+Sterilization of the Feet.+ As most patients do not apply water as freely or as frequently to the feet as to other portions of the body, there is usually present an excessive amount of thickened epidermis, which is very difficult to render sterile. For operations in chiropody the feet should be thoroughly moistened with soap and water, scrubbed vigorously with a brush, then soaked in a solution of b.i.+.c.hloride of mercury of 1 to 1000 strength, and then wrapped up in a towel soaked in the same solution while waiting for the operator.

+AGENTS EMPLOYED TO SECURE ASEPSIS+

+b.i.+.c.hloride of Mercury+ is used for the disinfection of the hands and skin and for the irrigation of wounds. Biniodid of mercury is extensively employed and in the same strengths as the b.i.+.c.hloride. It is, however, a more powerful germicide, while being less irritative, and neither forms a mercuric alb.u.minate nor tarnishes metal instruments.

+Carbolic Acid.+ This acid is derived from coal tar, and although known as early as 1834 as the first antiseptic recommended and used by Lister, is not so popular since the discovery that b.i.+.c.hloride of mercury possesses more germicidal action.

Gangrene of the skin and subjacent tissues has often been traced to the long continued use of dilute solutions of carbolic acid or of ointments containing small quant.i.ties of the drug. Gangrene of the fingers and toes is by no means infrequent as a consequence of its use. Another condition frequently seen is the systemic poisoning through absorption. One of the first symptoms noticed from such absorption is irritation of the urinary tract and carboluria. This poisoning is more apt to take place when the weaker solutions are used than when the pure acid is used, as the destruction produced by the pure acid prevents its absorption.

The effect of carbolic acid upon the urine (See Chapter II, "_Carbolic Acid_") is to cause it to become smoky a short time after it is voided. The urine shows a complete absence or diminution of the sulphates, and alb.u.min is generally present. When these symptoms present themselves, the use of carbolic acid should be withdrawn, and the administration of sulphate of soda and atropin begun. If the condition has existed for any length of time and the patient is weak and exhausted, stimulants are indicated.

+Lysol+ is a saponified phenol, and possesses some germicidal power. It is used in strengths of 1 to 3 per cent. solutions.