INCARCERATED SEPSIS

AlbertE. Morison
1918 The Lancet  
535 the dressings need be touched before the seventh day are very few, and at that dressing, as a rule, every second stitch is removed, the remainder being cut on the tenth day. Analysis of Cases. Of 290 consecutive gunshot cases during the past six months, 36 were sutured within five days of being wounded. Five of these were not up to suture standard and were closed tentatively. The remaining 31 cases-10-7 per cent. of whole series-arrived at the base up to suture standard. Of the 36 cases
more » ... Of the 36 cases sutured, 16 had wounds of soft parts only, 13 complete fractures of long bones, 5 partial fractures, and 2 wounds of joints. The proportion of wounds of soft parts to other wounds is a little greater in those sutured than in the whole series, and this is not surprising considering the relative ease with which wounds of soft parts can be completely excised. Of the 36 cases. 29 had been wounded by shell, 2 by shrapnel ball, and 5 by bullet. Those who have been less enthusiastic with regard to the free excision of wounds have suggested that many of the surgically clean wounds arriving at the base were bullet wounds which would have healed quietly without surgical intervention. The above figures do not bear this out. Although the majority of cases had been treated by the Carrel-Dakin method, a few had been freely excised and then treated with Bipp, flavine, or soap. Ilesults of Sllt1{re. Of the 31 cases up to suture standard when closed 28 made a perfect recovery, being healed on an average of 10'5 days from the date of suture. The remaining three cases were partially successful. In one case of compound fracture of scapula, treated with Bipp, there was great physical difficulty in closing wound. Several of the sutures gradually cut out and left a wound about half original size. A second case with compound fracture of tibia and fibula also presented difficulties when the question of closure arose. In spite of considerable undercutting there was great tension in one of the wounds and several stitches gave. Both these cases serve to illustrate the importance of conserving as much skin as possible in the primary excision. The third case was one of compound fracture of tibia. For no obvious reason the extremity of one wound opened after removal of stitches on twelfth day. In no case was there any constitutional disturbance nor any local signs of inflammation. The five cases not up to suture standard all looked clean to the naked eye and presented low bacterial counts. Only one was really successful and this was healed on the fifteenth day after suture. In three cases there was partial success, the wounds being healed respectively in three, five, and seven weeks. In one case there was lighting up of infection with marked general reaction and all the sutures had to be removed. It is thus seen that Carrel's bacteriological standard was of the greatest value in the choice of wounds for delayed primary suture. It is rapid and easily carried out with the simplest laboratory equipment. Cultures were made to determine the micro-organisms present in the sutured wound. Aerobic cultures in broth and on agar slopes and anaerobic cul,ures were taken, and in special cases the organisms were isolated and subcultured. A great diversity of bacteria was encountered staphylococci, streptococci, Gram + and Grambacilli, diphtheroids. and others occurred either singly or in various combinations. In a small series of observations with sunh a varied infection it is impossible to draw definite conclusions ; but at this stage in a wound, so far as can be seen at present, the dose of organisms is of more importance than their nature. Three cases proved to be sterile on culture. The importance of suture precoce cannot be overestimated. At no period is a wound so easily closed as it is before the onset of cicatrisation and fixation of tissues in abnormal positions. Not only does closure of a wound obviate the danger of secondary infection and the expense I and pain of many dressings, but leads to the quickest and most perfect restoration of function. To be able to close wounds of soft parts and to convert compound into simple fractures is the ideal of military surgery. That this has been attained in 10 per cent. of cases recently arriving from the Front is a tribute to the work of the casualty clearing. stations. In conclusion, it seems proved that an important advance has been made in the treatment of wounds with a minimum ' ' , disturbance of our present methods. The bacteriological I examination of all wounds that seem in the least degree i hopeful will repay the surgeon. When we commenced to I suture wounds in the first few days, we were astonished to uud wounds suitable which in that stage of our experience seemed quite out of the question. In the past we cannot help feeling we have subjected such cases to weeks, perhaps I months, of repeated dressings which now prove to have been I quite easily avoidable. The saving in expense and labour and hospital accomi modation is too obvious to require elaboration,
doi:10.1016/s0140-6736(01)26041-3 fatcat:tiyviwginjcsnkcdktlg2p63cu