CICATRIZATION OF WOUNDS : IX. INFLUENCE ON THE HEALING OF WOUNDS OF VARIATIONS IN THE OSMOTIC TENSION OF THE DRESSING.

In the study of the action of non-antiseptic substances on the rate of cicatrization, the chief obstacle encountered is the facility with which wounds become reinfected under an aseptic dressing. At the beginning of Experiment 1 the wound was sterile. It was subjected to flushing with distilled water for 2 hours, then to flushing with 30 per cent sodium chloride solution for another 2 hours. During that time no special precaution was taken to sterilize the wound and the dressing was left intact until the following morning. It was then found that the wound contained from 30 to 50 bacteria per field. The following day, after the wound had been subjected to the same treatment, the number of bacteria had increased to 50 and 100 per field, and as an immediate consequence the surface of the wound increased from 12 to 12.6 sq. cm. in 2 days. The wound was then dressed antiseptically and was found to be sterile 3 days later. Reinfection again took place the following day in spite of antiseptic dressing with chloramine paste 4 parts per 1,000, which was applied for 20 hours. In Experiment 2 similar results were observed. After 2 days of flushing with distilled water, the number of bacteria had increased to 50 per field. The wound was thereupon sterilized, but new reinfection ensued a few days later. Another wound on the same patient became reinfected under the same conditions after 1 day of sterile dressing. In none of the patients could the wounds be kept in a sterile condition throughout the whole experiment. It was impossible to maintain the sterility of a wound under aseptic dressing. Dakin's solution was therefore injected every 4 hours, or less often, according to the degree of infection, or chloramine paste was applied during the night. If there were 3 or 4 bacteria per field, the experiment was discontinued in order that the wound might be sterilized again. The cicatrization and bacteriological curves of Experiment 4 show that by the application of chloramine paste a wound may be maintained in an appropriately bacteriological condition for carrying out an experiment. Nevertheless, in spite of the antiseptic precautions taken, it was necessary to interrupt this experiment on two occasions, on December 13 to 15 and on December 18 to 22, in order that a complete sterilization of the wound might be effected. When the sterilization was performed as soon as the bacteria were discovered, little retardation occurred in the process of cicatrization. Moreover, the reinfection from the skin was often due to fine bacilli which have but mild retarding action on the rate of healing. The use of at least six flushings in 2 hours with Dakin's solution or of 12 hours' dressing with chloramine paste 10 parts per 1,000, was necessary to keep the wound in a condition of surgical asepsis. The action of distilled water was studied in Experiments 1, 2, and 3. In Experiment 1 the wound was subjected to flushing with distilled water first for 2 hours, then 4 hours, and later for 8 hours per day. The wound was maintained in a condition of mild infection. No marked modification, either acceleration or retardation, was noted in the rate of repair during the period that the treatment was applied. From November 21 to 25 the wound was almost clean and the observed curve remained parallel to the calculated curve, showing that distilled water did not retard the rate of healing. In Experiment 2 the wound was subjected to uninterrupted flushing with distilled water, first for 2 and 8 hours, then for 24 hours. It was continued from November 24 to 30; viz., for 112 hours out of 120, without the occurrence of any marked modification of the course of healing. The bacteriological curve showed that from November 22 to 27 inclusive the wound was kept aseptic. The slight retardation which occurred afterwards was probably brought about by the infection. In Experiment 3 the wound was subjected to flushing with distilled water, first for 2, then for 4, 6, and 8 hours, a total of 20 hours in 4 days. From November 21 to 24 the wound remained surgically aseptic. No modification in the rate of healing occurred. The action of the hypertonic sodium chloride solution was studied in a similar way. In Experiment 4 the wound was flushed at first with 40 per cent sodium chloride solution, from December 4 to 9 for 12 hours a day, and from December 10 to 13 for 24 hours a day, making a total of 144 hours out of 240 hours. At the end of this time the surface area of the wound coincided exactly with the calculated area. Owing to reinfection the experiment was suspended. From December 24 to 29 the wound was kept in contact with 50 per cent sodium chloride solution for 54 hours, and after December 30 flushing with 80 per cent solution for 24 hours a day was resorted to. The total amount of time involved in the above treatments was 174 hours with 40 per cent solution, 72 hours with 50 per cent solution, and 120 hours with 80 per cent solution. On January 1, the surface measured 11 sq. cm. and the calculated surface was 11.3 sq. cm. On January 5 the. surface observed was 10 sq. cm. and the calculated surface was 9 sq. cm. It should be noticed that on January 5 the bacteria numbered 4 per field, which might account for the difference. In Experiment 5 the wound was flushed for 24 hours every day with 50 per cent sodium chloride solution from December 11 to 18, a total of 192 hours. From December 18 to 24 the wound was dressed with agar-agar cakes containing 40 per cent sodium chloride. The concentration was raised to 50 per cent from December 24 to 27. The cicatrization curve indicates only a slight retardation of the repair which can be attributed to infection when both cicatrization and infection curves are compared. The temporary acceleration on the 13th may have been due to the influence of the dressing, but as it did not occur again an experimental error is probably the cause of the change observed in the curve. In Experiment 6 two practically identical wounds at a distance of but a few centimeters from each other were located on the right thigh of Patient 721. The areas of the wounds were respectively 40 and 33 sq. cm. One of the wounds was flushed with distilled water only. The other was subjected to the action of 40 per cent sodium chloride solution. From December 20 to 25 both wounds were in a condition of surgical asepsis. However, the cicatrization curves show that in spite of the difference of treatment the rate of healing was not modified. The rate of healing of the wounds did not therefore apparently undergo any measurable modification under the influence of distilled water or hypertonic salt solution. It is well known that the osmotic changes of the medium have a marked influence on tissues deprived of circulation. But it seems that a tissue with normal circulation is protected by it against the changes of the osmotic pressure occurring at its surface. The above experiments show that apparently the conditions of the tissues of a wound are not modified by the changes of the osmotic pressure of the dressing. The beneficial effects of hypertonic sodium chloride solution on the sterilization of wounds and on the rate of healing recently described by various surgeons are possibly an illusion due to lack of precise technique.