(b) In the second category of cases, the number of microbes contained in the secretions diminished rapidly at first, then at the end of a few days the bacteriological curve became a horizontal line. The quantity of microbes observed in each field varied from about five to fifty. But they never got below one. When the microbial curve forms a plateau at the level of or above the line indicating five microbes per field, experience has shown that there exists in the depths of the wound either a sequestrum or a patch of osteitis which would justify surgical interference. Even in those cases where complete sterilisation could only be obtained by resorting to a secondary "cleaning-up," suppuration dried up in a few days and the general condition of the patients changed greatly for the better.
Fig. 114. - Trans-trochanterian fracture of femur. Case 618.
The following example demonstrates how the dura-tion of treatment may be lengthened if a compound fracture of the thigh be allowed to suppurate even slightly.
Case 496, aged 25 years, arrived at the hospital forty-two days after having received a shell-wound which had caused a highly comminuted fracture of the right thigh. A few drops of pus came from the opening. Instillation tubes were put in position and the pus disappeared almost completely. But on the surface of the track four or five microbes per field of the microscope persisted. Four months later, slight sero-purulent oozing came from the seat of fracture, from which numerous fragments were removed. Two months later the sinus was still not closed. This persistence of suppuration shows how important it is to sterilise these compound fractures at the outset, to the degree when they contain no microbes at all. In the present case the fracture had consolidated rapidly enough. But care had not been taken to dry up the suppuration in an early stage. The consequence was that the patient, instead of recovering as though he had only a simple fracture, still suffered from a small sinus six months after the infliction of the injury.
When fractures are treated early, even if they are freely suppurating, the results observed are much better.
Case 642, aged 21 years, had a shell-wound causing fracture of the middle of the right femur. The projectile was extracted in an ambulance at the front five hours after the injury. Two large drainage tubes were placed in the posterior wound and the end of one of these tubes came out by the internal wound. A long anterior wound was plugged with gauze compresses tightly packed in, and almost completely closed by suture over the compresses. The result of this therapeusis was disastrous. When we received the case at the hospital two days after the operation the thigh was swollen and very painful. The plaster apparatus and the dressings were soaked in an extremely foetid discharge. The stitches were immediately removed. The tissues were found almost black, covered with sanious pus, stinking. Microbes in infinite number were contained in these secretions. Three irrigating tubes were placed in the posterior wound, three in the anterior, and four in the internal wound. Next day the bad smell had quite gone, suppuration likewise. The following day the general condition of the patient was much improved, although the thigh was still swollen. Six days later, the swelling of the thigh had greatly diminished, and the wound had become red. Eleven days afterwards, some of the tubes were removed, for healing was proceeding rapidly. Twenty-three days after the patient's entrance into hospital, the internal wound was isolated from the seat of fracture, and the posterior and external only communicated with it by a narrow track. Two days later, two of the wounds were sterile, and the third only contained a few microbes. The evolution of this fracture was then comparable, in a certain measure, with that of a fresh compound fracture treated before the onset of suppuration.
In highly comminuted fractures, it was usually impossible to disinfect the wound without surgical interference.
Case 617, aged 28, had received a torpedo wound which had pounded up the tibia at its upper part. After some hours it was operated upon in an operating post, where free splinters were removed, and where, very wisely, they had carefully preserved several large plates of bone adherent to the periosteum of the internal surface. The seat of fracture was disinfected and dressed with ether, and the limb immobilised in a metallic gutter-splint. This patient arrived at the hospital three days later. The limb looked well and the temperature was 38.5° C. (101°Fahr.). But the surface of the bone was dark in colour and extremely infected. Examination of the pus showed that the microbes there were innumerable. Two instillation tubes were placed in the cavity, and after four days the temperature fell. Pain and swelling of the limb also disappeared. Nevertheless, after twenty-five days the number of microbes gathered from the surface of the wound was still high. Surgical cleansing of the surface of the bony cavity was carried out, and several small sequestra removed, preserving the periosteum. Instillation tubes were placed in the cavity. Sharply the microbial curve dropped, and reached the level which indicates surgical asepsis.
Even in those cases where the extent of the lesions and the gravity of the general condition do not permit of an integral application of the method, still we can obtain sufficient disinfection to transform both the local and general conditions of the patient.
Case 635, aged 34 years, had a large wound of the right thigh with fracture of the femur. He was operated upon in a field-hospital, where a plaster apparatus had been applied. But a very abundant suppuration set in, and during the weeks which followed, he had seven secondary haemorrhages. This patient reached us forty-six days after the injury. He was in a very serious condition. The thigh presented an anterointernal wound and a posterior wound. The denuded extremity of the superior fragment stuck out into the wound. Pus in large quantity poured from the seat of fracture, and rapidly soiled the dressings. The patient was very depressed; his evening temperature was 38.5° C. (1010 Fahr.). The urine contained albumen. Haemoglobin was reduced to 30 per cent. of its normal quantity. Systolic arterial pressure was 12.5 and diastolic pressure 8. In addition the patient suffered from intractable diarrhoea. Because of the gravity of the general condition, we limited our action to slipping four instillation tubes along the bony fragments in the seat of fracture. But the whole of the infected region could not be reached in this manner. As the patient was not in a condition to stand an incision, we were content to irrigate those parts of the infected area we could reach. At the end of a week the general condition had improved, and suppuration had almost completely disappeared. But the diarrhoea changed into dysentery, and the general condition changed for the worse. By way of compensation the local condition rapidly improved. Granulations covered the bare bony surfaces. Pain had disappeared. But microbes remained in considerable numbers. Twenty days after the arrival of the case about 500 grammes of blood were transfused. His general condition improved, and the dysentery, which had been treated by Dopter's serum, disappeared little by little. Twenty-five days after arrival, his temperature was normal and the wounds rapidly healing. Suppuration had not reappeared. This case is a striking example of the possibility of suppressing suppuration, and of thus ameliorating, to a very real extent, the condition of a patient who, treated by the usual methods, would have suffered amputation and probably have died.