Similar results were observed in cases of gangrenous infection. Case 454 presented fourteen wounds of the lower limbs, due to the explosion of a grenade. He was operated on six hours after the injury. All fragments of missile were removed, and each wound was furnished with an instillation tube, with the sole exception of a tiny one which was overlooked. The thirteen wounds treated antiseptically developed in normal fashion and were rapidly closed. But the wound which had not been treated was followed by a serious infective complication. This wound was on the external aspect of the right leg. The fragment of grenade was found at a depth of two centimetres in the long peroneal muscle. The track had been carefully exposed and excised, but no instillation tube had been inserted. Next morning, the dressing had an unpleasant odour, and the calf was red, tense, and swollen. Gas escaped from the orifice. A free incision was made on the external aspect, and it was found that the muscles of the front of the leg, as well as the lateral peronei, had been attacked by gas-producing gangrene throughout almost the whole of their extent. Infection had clearly started from the non-irrigated point. Instillation tubes were placed in the wound, which rapidly cleaned up. At the end of six days, the temperature of the case was normal, and the necrosed tissues in a fair way towards elimination. After a second period of six days, the wound was clean and red. Some microbes only remained near the extensor tendons. Twenty-eight days after the injury, the wound was completely closed. The thirteen other wounds had been able to be sutured the twelfth day. Hence in spite of the serious character of the infection, sterilisation only demanded a little more than double the normal time.
Fig. 97. - Case 340. Large infected wound of calf, nth day.
FlG. 99. - Case 433. Fracture of neck of humerus, 15th day.
FlG, 101. - Case 594. Shell-wound of knee: partial fracture of condyle, 6th day.
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Fig. 98. - Case 340. Same wound, the 21st day
Fig. 100. - Case 433. Suture, 17th day.
Fig. 102. - Case 594. Wound became sterile the 16th day and was closed the 20th.
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3rd. Suppurating Wounds. - Wounds which are already suppurating when brought under treatment are readily disinfected. Surface wounds, even when suppuration is abundant, are sterilised in a few days. Usually, when a granulating wound is washed with neutral oleate of soda, and treated either with hypochlorite or chloramine paste, microbes disappear completely from the smears in two or three days.
It is the same with abscess cavities. When a tube is placed in the cavity of an abscess, and the liquid can reach every portion of the surface of the walls, sterilisation takes place with great rapidity. Then, by a compression dressing, the walls can be brought together and the cavity obliterated in a very short time. When the wound is deep and irregular, and contains necrotic tissue, sterilisation is attained more slowly. In a series of fifty-nine wounds, aged from one to twenty-three days at the commencement of treatment, ninety-two per cent. were closed before the twenty-second day. Some of these wounds were sutured the fifth day, as though they had been fresh wounds. The remaining wounds - that is to say, eight per cent. - were sterilised after the twenty-second day.
We may therefore say that all wounds of soft parts respond to treatment by becoming sterile. About ninety per cent. of both fresh and suppurating wounds were closed before the twentieth day. The rest were disinfected at a slower rate, but all attained surgical asepsis. B. Compound Fractures. - Results varied according as treatment was commenced before or after the suppuration stage.
1st. Fresh Fractures. - Experience has taught us that from the point of view of results, fractures should be divided into two classes: in one class, short bones, the smaller long bones, flat bones, radius, ulna and fibula; in the other class, fractures of humerus, tibia and femur. Since the month of December, 1915, we have succeeded in sterilising, in a satisfactory manner from the surgical point of view, all compound fractures of the smaller long bones, short bones and flat bones which arrived at the hospital from five to twenty-four hours after the infliction of the injury, with the exception of fractures of the jaw communicating with the mouth. In the greater number of the cases, fractures of metacarpus and metatarsus, deep wounds of ankle or wrist with laying open of several articulations, have been closed. Fractures of the patella have yielded similar results. We may conclude that these fractures from the sterilisation point of view behave like wounds of the soft parts.
In the majority of cases, sterilisation of fractures of the humerus, tibia and femur has been obtained.
(a) Fractures of the humerus consolidated without its being necessary to make an extensive resection. The possibility of sterilising the seat of fracture allowed the preservation of splinters of orthopaedic value. The greater number of fractures of the humerus, whether implicating or not the articular surfaces, have been able to be sterilised and quickly closed. In highly comminuted fractures, bone fragments which were entirely free were removed, and after sterilisation of the seat of fracture, replaced by Beck's paste. Here is an example of this form of treatment.