1st. Influence of Secondary Closure on the Duration of Treatment. - Wounds of the soft parts, both fresh and suppurating, were closed in the proportion of 90 per cent. from the fifth to the twentieth day, in whatever stage of the wound the treatment may have been commenced. Wounds not sutured in this period were also sterilised, though in a slower manner. If the wounds thus closed during the first twenty days of treatment had been treated by the usual methods, they would have needed from one to six months to cicatrise. By early suture a reduction by about two-thirds of the duration of treatment was obtained.
In compound fractures of flat bones, short bones, and long bones such as the fibula, radius, and ulna, sterilisation was produced as quickly as in the wounds of soft parts. The saving in the length of time needed for treatment was therefore very considerable, because these compound fractures, treated in the ordinary way, often suppurated for several months. It is well known how slowly deep wounds of the tarsus, for example, recover when they are infected. One cannot estimate exactly the diminution produced by sterilisation in injuries of the humerus, tibia, and femur. But this diminution is considerable. In fact, compound fractures of the humerus, when sterilised, are often closed after the lapse of from twelve to twenty days, when similar cases, treated by the ordinary methods, are still suppurating after six, seven, or eight months. It is also evident that the closure of compound fractures of the femur after fifteen, twenty, or twenty-five days constitutes a great advance.
A considerable reduction in the duration of the treatment has likewise been effected in other branches of surgery. The possibility of sterilising and closing purulent pleurisies,1 as MM. Tuffier and Depage have done, very greatly diminishes the length of the patient's stay in hospital. For the treatment of mastoiditis M. Mahu 2 has, by means of chemical sterilisation, reduced the term of treatment to one-third of what it used to be. At Pittsburg, Mr. Sherman3 has almost entirely suppressed the infection of wounds due to industrial accidents. These wounds are sterilised more readily than wounds received in war, and the saving which may thus be effected is considerable.
2nd. Influence of Early Anatomical Repairs on the Duration of Treatment. - Sterilisation of the wound allows us to practise operations quite early in the case which formerly had to be put off until after cicatrisation was complete. Thus bone-grafting or wiring, reunion of muscles or tendons, or nerve suture, before to-day, could only be practised after the healing of the infected wound. This cicatrisation often was only obtained after the lapse of several months. To-day, we set about these reconstructions as soon as the wound is sterile, that is to say, from the eighth to the fifteenth day.
1 Tuffier and Depage, C. R. Societe de Chirurgie, March 27, 1917.
2 Mahu, Presse medicale, 1917.
3 Sherman, Surgery, Gynecology and Obstetrics, January, 1917.
Case 433 presented a section of all the tendons and the median nerve just above the right wrist. He was brought to the hospital three and a half hours after the injury. The wound was immediately cleansed and provided with instillation tubes. After ten days it was sterile. On the eleventh day, all the tendons and the median nerve were sutured, and seven days later, the skin wound was closed without drainage. Healing took place by first intention. This case had at the same time an inter-articular fracture of the right elbow, and a fracture of the left humerus, which were sutured at the same time, and likewise united by first intention.
Reparation of bone tissue may be made with equal safety at an early date. Case 518, aged 23, had a fracture of the vault of the cranium with a large wound of the hairy scalp. Phenomena of compression disappeared as the result of a craniectomy, in the course of which a fragment of bone the size of a crown-piece was removed. Four days later, the wound having become sterile, M. Woimant made good the loss of bone substance by an osteoperiosteal flap taken from the internal surface of the left tibia. The scalp was closed hermetically, and union took place by first intention. The case was examined anew forty days later. It was found that the graft had exactly adapted itself to the cranial wall.
3rd. Diminution of the Cost of Treatment. - The expenses of treatment are considerably lessened, since its length is so much less than by other methods. The saving thus realised is from about 50 to 70 per cent. Besides, the substances used in the treatment are not costly. The net cost of Dakin's solution is three centimes the litre,1 whilst ether, alcohol, peroxide of hydrogen and balsam of Peru are very much dearer. Suppuration being done away with, the dressings are but slightly soiled, and almost the whole of the gauze may be saved again for subsequent use. The cost of the appliances for instillation is recovered in a few days from the saving due to the exclusive employment of a substance of such trifling cost as hypochlorite of soda.
In the greater number of injuries, eventual incapacity is the result of infection. As the sterilisation of wounds permits the avoidance in many cases of amputations and resections, there results a considerable diminution in the amount of pensions payable to the wounded men by the State. It is also well known that the presence of infection in a compound fracture of a leg or thigh, raises the positive incapacity rate from 5 or 10 per cent. to 25 or 50 per 1 Net cost of ten litres of Dakin's solution:-
200 gr. chloride of lime at I fr. 10 centimes .
100 gr. carbonate of soda (Solway) at O fr. 40 centimes .
800 gr. bicarbonate of soda at 0 fr. 60 centimes . .
Net cost of 10 litres.................
Therefore the net cost of a litre is 3 centimes (rather less than a halfpenny per quart).
cent, and more. The gain from the suppression of infection is therefore very evident. In successfully treating fractures without extensive removal of bone substance, considerable shortening of limbs and pseudarthroses are frequently avoided. Sinuses are scarcely ever seen in cases thus treated. The recovery is all the more complete, for a case of compound fracture of the tibia, the femur or the humerus, sutured after the lapse of a few days only, presents neither the muscular atrophy, the retraction of tendons, nor the joint-stiffness, which, after long periods of suppuration, reduce limbs to the verge of impotence.
Sterilisation of wounds is equally successful in securing, more readily than by the other methods, healing of deep wounds of the soft parts. In reality, since tendons and muscles can be sutured as soon as the wound is sterile, the unions are stronger. Nerve suture likewise is done under excellent conditions. In wounds of muscle, the deep and painful cicatrices, which so hamper the usefulness of a limb, are not produced. It is quite certain that the economies in the amount of pensions paid by the State, obtained by means of the sterilisation of wounds, are very considerable.