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

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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$Bie. a: eS TECHNIQUE OF WOUND-EXCISION i The wound has probably been protected by some form of first-aid dressing ; _ the region is now exposed, clothes and bandages being cut off, and the skin cleansed 7 over an extensive area around the site of injury. Soap and water will doubtless be { required, followed by ether or spirit; some variety of antiseptic solution may be } applied to the surface of the skin around the wound. _ Skin rarely requires removal and can usually be adequately and efficiently cleaned without recourse to ablation. Should it be necessary to remove any skin at all, a strip not more than a few millimetres wide should be excised. In facial injuries, skin should never be sacrificed. There must be no hesitation about liberally enlarging the skin-wound in order to secure an efficient exposure of the deeper structures. The necessity for vigorous retraction betokens inadequacy of exposure; anything but the lightest retraction is to be deprecated. Surgical incisions which aim at débridement should be made parallel with the axis of the limb. The tissues of the wound are now excised with a sharp knife or scissors, particular attention being directed to bruised tags of fascia and to the muscles in proximity to the wound-track. Any alteration in the appearance and colour of the muscle, loss of contractility on mechanical stimulation, or failure to bleed demands wide excision of this most vulnerable tissue. Intermuscular spaces containing blood must be opened up, and blood and blood-clot should be removed, since these constitute an ideal pabulum for bacterial growth. Deep fascia should be freely divided in the long axis of the limb in order to permit subsequent swelling of muscles without strangulation and impairment of blood supply. Fragments of bone which are completely detached are best removed; they act as foreign bodies, and in the event of infection will indubitably necrose and become sequestra. At the same time, great caution must be exercised not to remove too - Many loose fragments, lest the future stability of the limb be imperilled. There isa vast difference in prognosis between gun-shot fractures due to mere impact of the missile against the bone and those where the wound-track actually traverses the broken structure; in the former type of injury the risk of infection is trivial if an efficient excision of the soft parts has been performed; in the latter, infection of the bone is inevitable, unless the skeletal injury is thoroughly treated and the medulla adequately opened up. If damaged or doubtful bone requires removal, this must be _ effected by means of careful and skilful use of a rugine; vigorous tearing at partially detached fragments must never be practised, lest valuable and viable bone be wantonly and needlessly sacrificed. No excision of a gun-shot wound is complete without the removal of all retained foreign bodies, e.g. fragments of high-explosive bombs or shells, clothing, mud, dirt, etc. The employment of pre-operative radiography will often shorten the time spent over an operation of wound-excision, and reference to an X-ray film in the operating theatre is an invaluable aid to the surgeon in ensuring the removal of all fragments of metal, estimating the nature of damage to bone, etc. In wound-excision the surgeon must not be oblivious of the future function of the anatomical region with which he is concerned: it is preferable to excise one or more strips of muscle longitudinally, even in the same muscle or group of muscles, rather than to cut ruthlessly across some important muscle, perhaps needlessly sacrificing at the same time much healthy muscle-tissue. The preservation of important nerve and vascular structures is of the utmost importance, and neglect to act on this principle deserves the gravest condemnation ; with adequate exposure these tissues can be thoroughly cleansed. The greatest care must be taken to preserve intact the vessels that remain patent; vascular occiusion may determine non-infective or infective gangrene. Injury to nerves may end in lifelong disability.$