SOME ASPECTS OF BRITISH SURGERY IN FRANCE. BY

James Swain, M.S., Lt.-Col. R.A.M.C.;

M.D. London.,

Consulting Surgeon

to

F.R.C.S.,

the Southern Command.

It may be of interest to those at home to know some of the principles of treatment applied to cases of gunshot wounds within the first few

days

of their occurrence, for the

problems

which confront the surgeon abroad are very different from those which occur in England. This is largely owing to the fact that a

practically

condition of

necessitates the

all wounds

urgent use

in

acutely septic condition, paramount importance, which

are

and

an

of free incisions for the relief of tension

adequate drainage of the wounds. Much of the work at the casualty clearing stations and base hospitals consists in energetically combating this sepsis, and without the results and

thus obtained many of the cases would die of acute toxic poisoning, or would suffer more severely from the extension of the

septic

mischief

during

their transference to

The treatment of well-marked same

in all the

Surgeon It is

hospitals

"

England. "

is the gas gangrene I visited while Acting-Consulting

in France, viz. circular

impossible

has arisen with

to enter here

regard

amputation without flaps. upon the controversy which

to this form of treatment.

It must

suffice to say that any form of flap is more than likely to a further development of the bacillus perfringens

lead to

with extension of gangrene, and I am in agreement with those who consider the flapless amputation for gas gangrene to be a life-saving operation. The

"

straight

"

amputation

should be done above the-

SOME ASPECTS OF BRITISH SURGERY IN FRANCE.

tissues ;

gas-infected and I have

but

this is sometimes

seen cases recover

I2g

impracticable, amputation

where the line of

necessarily passed through the infected area. It is of the greatest importance not to confuse gas gangrene with the local varieties (gaseous cellulitis, etc.) of infection with

gas-forming

bacilli.

The treatment of these local infections differs

according

the views of the surgeon. Some operators practically excise the whole wound, so as to expose healthy muscle and to

skin.

Such

lacerated

an

operation

muscles

must

in

a

cause

deep

wound with

considerable

would also suppose that the exposure of such a surface to infection might lead to serious toxic but it is said that this has not been found to others these

pocketing

One fresh

large absorption, result. By

successfully treated by drainage and only, being taken that no tension or is allowed to remain. Sometimes a deeply-

cases are

free incision "

widely-

shock.

"

care

invaded muscle is removed, but there is the whole wound

as

previously

no

referred to.

such excision of It

seems

clear,

therefore, that it is unnecessary to submit the patient to the shock of a free excision of wounds accompanied by local infection with

following

gas-forming

bacilli.

A

case

in

point

is the

:?

Private W. was wounded on July ist, and admitted to hospital on July 4th with a shell wound and extensive spreading sepsis of the upper part of the right thigh reaching on to the abdomen. The general condition was most unsatisfactory, and A large shell fragment was removed from gave rise to anxiety. a stinking abscess cavity full of gas. There was sloughing of the subcutaneous and intermuscular tissues. Very free multiple incisions were made, and the wounds were dressed with salt tablets. Two days later further incisions were made. The condition rapidly improved. On July 17th the wounds were healthily granulating, and on July 19th he was sent to England. As

there is

regards a

the treatment of

considerable

septic wounds generally divergence of opinion as to what is

DR.

130

JAMES SWAIN

best after the inevitable incisions for the relief of tension. At

hospitals

some

the wounds

with gauze

lightly packed

are

wrung out of five per cent, saline solution and covered with wool and

bandage, at others eusol is used, sometimes mixed equal parts of ten per cent, saline solution, in a similar

with

In both

manner.

daily,

and

solution

the wounds

cases

at the time of

irrigated

are

dressed

twice same

dressing

or

with the

once

that used for

as

wetting the gauze. again, the treatment of

At other

septic wounds hospitals, consists in packing them with gauze, enclosing tablets of salt, each tablet containing sixteen grains of salt and three grains

of citrate of

used

are

by placing

about three as

potash.

or

Large

them

of gauze the gauze so twisting The wound is then covered with on

four inches

to enclose the tablets.

numbers of these tablets

two to four

wide,

layers

and

gauze, wool and bandage, or dressed with eusol or saline solution as referred to above. Pain is caused for about an

dry

hour, and the tablets

forty-eight is left

by

are

not

wholly

dissolved for about

Afterbeing dressed in this way the wound surgeons for a week or longer according to

hours.

some

circumstances. The advocates of this last method maintain that it is unnecessary to dress these cases frequently, and that leaving them alone you save the patient from much pain

quite by

and shock. of about

a

Cases

are

commonly

week from the

dressed after

primary dressing,

as

an

by

interval

this time

the gauze easily floats off with the pus which has accumulated beneath. If, however, during this period the temperature rises

or

pulse is accelerated, and particularly if painful, a further exploration would be

the

becomes "

the wound made and

"

any pocketing or tension relieved. It is needless to say that decomposition occurs, but the patients appear to prefer to put up with the foul odour of

putrefaction

rather than to bear the

pain

of

frequent

SOME ASPECTS OF BRITISH SURGERY IN FRANCE.

The smell

dressings.

frequently changing

can

be

the outer

partly kept

dressings,

131

under

without

by more interfering

with the part of the dressing next to the wound ; for those who prefer this form of treatment regard the frequent removal of the whole

dressing as deleterious to both wound and patient. As examples of infrequent dressing of wounds surrounded by stinking pus without appreciable harm

resulting

the

following I

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