Milton T. Edgerton

Cleansing the traumatic wound by high pressure syringe irrigation

The purpose of this study was to examine the influence of the fluid dynamics of syringe irrigation on the efficacy of wound cleansing and the infection rate of experimental wounds. The pressure experienced by a surface following wound irrigation was directly proportional to the pressure within the syringe and the size of the needle. High pressure syringe irrigation effectively removed bacteria from the surface of the wound. This reduction in the wound bacterial count resulted in a decrease in the infection rate of tissues. Low pressure irrigation with an asepto syringe did not significantly cleanse the wound of its bacterial contaminants and had no demonstrable clinical merit. On the basis of these studies, high pressure syringe irrigation is being employed routinely in our emergency department for the care of traumatic wounds.

Skull expansion in experimental craniosynostosis

Bilateral coronal suture immobilization was performed in 9‐day‐old rabbits to simulate the brachycephaly deformity characteristic of coronal synostosis. Growth abnormalities were documented by serial radiographic cephalometry. A “corrective” linear craniectomy procedure was performed on the rabbits with an immobilized coronal suture at 60 days of age. The degree of amelioration of the induced abnormalities by the surgery in these animals was compared with a similar group of animals that had the same surgery plus supplemental implantation of a spring expansion device at the coronal suture craniectomy site. The mean marker separation at the coronal suture was significantly greater (5.61 mm ± 0.52 SE versus 2.53 mm ± 0.38 SE; p < 0.05) following spring expander implantation than with linear craniectomy alone. Similarly, induced anterior cranial base shortening and distortion of craniofacial cephalometrics were more significantly improved by the additional use of the spring expansion device.

Mechanical cleansing of contaminated wounds with a surfactant

Mechanical cleansing of a wound with a sponge soaked in a surfactant has prevented the development of experimental wound infection. The surfactant utilized for wound cleansing is Pluronic F-68, a member of a family of block copolymers called Pluronic polyols. Long-term toxicity studies and clinical trials suggest that this surfactant is safe for human use. Pluronic F-68 is a nonionic detergent that does not have any intrinsic antibacterial activity. Although mechanical cleansing with saline-soaked sponges effectively removes bacteria, it damages the wound and impairs its resistance to infection. The severity of the damage to the skin exerted by the sponge can be correlated with its porosity. Sponges with a low porosity are abrasive and exert more damage to skin than do sponges with a higher porosity. The addition of Pluronic F-68 to even the most abrasive sponges ensures that the bacterial removal efficiency of the sponge scrub is maintained, while tissue trauma is minimized. This dual effect of the surfactant results in a dramatic reduction in the infection rate of contaminated wounds. On the basis of these results, a clinical trial with surfactant-soaked sponges would appear to be indicated.

Identification of the wound infection-potentiating factors in soil

Abstract Even the most trivial combat wound is regularly contaminated with soil. Unless this foreign body is adequately cleansed from the wound the risk of subsequent infection is great. The causal factors for this deleterious effect of soil have, until now, been unknown. Results of this study have led to the identification of the factors in soil that potentiate the development of infection. When an injury contained as few as 100 bacteria, the addition of 5 mg of soil led to infection. When this soil sample was fractionated, it was found that the infection-potentiating factors (IPFs) resided predominantly in the clay or organic soil fractions or both. The type of cation adsorbed by the surface of the IPF did not influence its toxic effects on tissues. Silicate clay fractions contain several colloidal clay minerals: montmorillonite, illite, and kaolinite. Montmorillonite clay enhanced the development of infection more than did illite or kaolinite. The IPFs in organic and clay fractions of soil can be characterized by their large surface area and high cation exchange capacity. This physical property of the IPFs ensures an active chemical exchange between the wound and the IPFs which may account for their deleterious effects. Isolation and identification of the factors in soil that potentiate infection will enable us to develop technics for the efficient removal of these agents based on modern pedologic methods.

Automatic disposable stapling devices for wound closure

Specially designed automatic disposable staplers are proving to have an important role in wound closure. Staple closure is accomplished with significantly less damage to the wound defenses than with the least reactive suture. A comprehensive evaluation of the mechanical performance of the commercially available staplers demonstrates that the Premium™ stapler is superior to the other staplers.

Resistance of the surgical wound to antimicrobial prophylaxis and its mechanisms of development

Summary The effectiveness of antimicrobial therapy in the prevention of wound infection is markedly reduced by postponing antimicrobial treatment and delaying wound closure. In experimental contaminated wounds, immediate treatment with antibiotics was superior to delayed treatment. In addition, the effectiveness of delayed treatment with antibiotics was more apparent in the wound closed immediately after injury than in wounds subjected to delayed closure. These findings suggest that exposure of a wound leads to a sequence of events that limit the therapeutic value of antibiotics. Insight into the dynamics of these events has been derived from histologic, biochemical, and physiologic measurements of the primarily closed wounds and wounds subjected to delayed closure. When a wound is left open, its vessels exhibit a marked increase in vascular permeability. Fluids from the intravascular space extravasate to fill the wound crater. The exudate is rich in a wide variety of blood proteins containing high concentrations of sialic acid and hexosamine. It is our belief that this fibrinous coagulum surrounds the bacteria and protects them from contact with the antibiotic. Application of a proteolytic enzyme to the surface of the contaminated wound disrupts this coagulum, allowing the antibiotic to destroy the bacteria and prevent the development of infection.

Airless paint gun injuries: Definition and management

Abstract A standardized model has been developed to provide insight into the definition and management of airless paint gun injuries. With this model, the structure of paint materials has been correlated with their toxicity. Soya alkyd, a paint vehicle, elicited a greater inflammatory response than did any other material. The solvents mineral spirits, xylol, and turpentine were less destructive to tissue than was soya alkyd, followed by the vehicle acrylic latex and the pigment titanium dioxide. The ability of paint components to potentiate infection was studied by injecting them into tissues contaminated with S aureus . Acrylic latex and titanium dioxide were the only components of paint that potentiated infection. Once a component of paint was injected into tissues, it was extremely difficult to remove. Incision and drainage of the paint injury did not remove enough foreign material to minimize its deleterious effects. Supplemental irrigation of the incised paint injury was of no demonstrable value. Antibiotics appear to have an important place in the care of a patient with a paint injury. Antibiotics markedly reduced the number of bacteria in contaminated paint injuries and minimized the destructive effects. Treatment of the animals with steroids shortly after the paint injury limited the severity of the inflammatory response to certain components of paint. The difficulties encountered in treating paint injuries confirm the necessity for safety regulations and standards for all high pressure injection devices and the need for use and development of the least toxic paint materials.

Barrel Stave Osteotomy for Correction of Turribrachycephaly Craniosynostosis Deformity

The “barrel-stave” osteotomy procedure addresses the characteristic excessive height and reduced anteroposterior projection of the turribrachycephalic skull in one operative procedure. Four quadrant craniectomies are followed by barrel stave-Rke osteotomies in the parietooccipital region. The parietooccipital bone undergoing osteotomy is displaced posteriorly, thereby opening up the posterior fossa and effectively increasing the potential volume of the cranial vault. This increased capacity allows for notable reduction in skull height and reshaping of the skull along the anteroposterior axis.

Rapid Management of Persistent Seromas by Sclerotherapy

Postoperative lymphoceles and adventitious bursae are common occurrences. They are slow to resolve and often persist when traditional techniques of prolonged drainage, multiple aspirations, and local pressure are used. Tetracycline sclerotherapy provides a rational nonoperative alternative treatment that is simple and without major complications and provides a rapid resolution of persistent seromas. Based on our favorable limited experience we believe that this technique should be studied in patients with persistent seromas in a randomized prospective fashion.

Evaluation of vocal pitch in male transsexuals.

A 49-year-old male-to-female transsexual was administered voice therapy following surgery. Tape recordings were made of her speech prior to and each week during therapy. Selected sentences from these reocrdings were analyzed. Results indicate that changes in both fundamental frequency and perceptual judgments of femininity were statistically significant and supportive to the client. The voice of the client was still discernible from that of a female speaker, although less so than before therapy. It is suggested that a composite treatment program combined with laryngeal modification through surgical intervention may be necessary.