Notes on the diagnosis and treatment of gas gangrene : with a suggested scheme for the bacteriological investigation of war wounds / War Wounds Committee and Committee of London Sector Pathologists.

Date:
1940
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Licence: Public Domain Mark

Credit: Notes on the diagnosis and treatment of gas gangrene : with a suggested scheme for the bacteriological investigation of war wounds / War Wounds Committee and Committee of London Sector Pathologists. Source: Wellcome Collection.

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    In mixed infections, Cl. welchit and Cl. sporogenes are commonly found together, Concomitant infections with aerobic organisms, such as Streptococci, Staphylococci : i Proteus vulgaris (B. proteus), Pseudomonas pyocyanea (B. pyocyaneus) and coliforms 4 are common. a ; Gas gangrene is a Clinical conception. It is important to realise that bon in the last war and in this, Clostridia have been found, even in large quantities, iz ve infected wounds that have at no time shown any signs of gas gangrene. The clinical diagnosis of gas gangrene may be confirmed by the identification of Clostridia in the wound, especially if they predominate in the specimen or swab, but the f gas gangrene are not fully understood, but infection is more readily established in wounds containing necrotic tissue. Necrotic tissue provides conditions favourable : for the growth of Clostridia. The necrosis may be produced by direct trauma, — by more remote interference in the blood supply, or by the action of injurious chemicals and bacterial toxins or of aerobic pathogenic bacteria. Such anaerobic — foci are readily produced round foreign bodies like pieces of clothing. : From the bacteriological standpoint, gas gangrene may be controlled in two distinct ways :—(1) anti-bacterial (removal of pabulum and introduction of bacteri- cidal substances) and (2) antitoxic measures. Antisera capable of neutralising — toxins of Cl. welchit, Cl. septique and Cl. oedematiens are available, either singly or in mixture, but it should be realised that these agents have no direct effect upon the bacteria or their invasive power; they are purely antitoxic. | Since the war of 1914-18 knowledge of the Clostridium group of bacteria has advanced considerably. The diffusible toxins are, in many cases, better defined, and more powerful neutralising antitoxic sera are available. Under experimental conditions both im vivo and in vitro, many of the bacteria are susceptible to the actions of drugs of the sulphonamide group. Experimental data suggest that the most effective control of fully developed gas gangrene with toxaemia may be obtained by the combined use of surgery, sulphonamide chemotherapy, and anti- _ toxins. Recent work by Legroux has shown, moreover, that heavy infections starting round a foreign body introduced into crushed muscle, may be held in check for several days by local insufflation with sulphanilamide powder, and completely eliminated if the insufflation is accompanied by removal of the foreign body. We are still largely ignorant of the precise roles of organisms of the Clostridium group in the causation of gas gangrene in man; of the parts played by other aerobic and anaerobic organisms; of the relative values of different surgical treatments, and of these treatments combined with chemotherapy, antitoxin, or both chemotherapy and antitoxin. Indications of the best line of treatment will probably come from the records of cases in which therapeutic measures based on a definite plan, or plans, have been carefully checked by repeated bacteriological investigations. (6) Clinical Diagnosis In a typical case of gas gangrene the onset is acute and the infection progresses with great rapidity—so much so that within a few hours of the onset the patient may be im extrenus. Cases have been recorded in which established gas gangrene was present within 3} hours of wounding. The fact that the onset is delayed, as it may be for as long as 4 to 5 days, by no means diminishes the possibility of a severe infection. The commonest site of gas gangrene is in muscle. Usually only single muscles or groups of muscles are involved, but the infection may occasionally involve a whole limb or limb segment, especially where there has been interference with the main blood supply. It usually spreads longitudinally up and down the wounded muscles from the site of the lesion, and has little tendency to spread from muscle to muscle. Gas gangrene may also occur primarily in subcutaneous or areolar tissue where there has been extravasated blood: the best example of this is pe | | | | |