294
SECTION I
GENERAL SURGERY
CHAPTER XII
WOUNDS OF SOFT PARTS
a
Following
the disastrous practice in the early months of the war of abstention
from
surgical intervention, it was for a time considered sufficient to
remove projectiles and
superficially clean the wound channel. Experience soon showed the
inefficiency of these
procedures. This tentative period lasted nearly two years, 1914 and
1915. In 1915 the method
of "débridement" was initiated; in 1916 it was practiced, and in 1917
and 1918 it was elaborated
and improved. This advance was dependent upon careful observation of
the pathological factors involved in wounds produced by projectiles.
In
wounds of the soft parts the muscles offer little resistance to the
impact of a projectile
and are extensively lacerated even in many cases where the external
wound is insignificant.
Pathogenic organisms find an excellent culture medium in the
devitalized tissues. A large
variety of organisms flourish in war wounds and both anaerobic and
aerobic bacteria grow at an
active rate after a latent period of a few hours after the infliction
of the wound. The habitat of
these microorganisms is chiefly in the lacerated muscular masses.
According
to Borst,1 there are three zones in gunshot injuries of
soft parts. The first, or
innermost zone is represented by the wound channel or wound cavity,
which is filled with
necrotic tissue, extravasated blood, foreign bodies, and shreds of torn
muscles. Next comes the
zone of direct traumatic destruction, with cauterization of tissue.
This is of variable width,
according to the physical and morphological peculiarities of individual
tissues and projectiles. Bacteria find the best possible culture-medium
in the necrotic or seminecrotic tissue. In the
third, or outer zone, the tissue is not necrotic, although greatly
reduced in vitality. The fact has
come to be definitely appreciated that all accidental wounds must be
considered as
contaminated, and this is especially true of gunshot wounds. With this
knowledge of wound
pathology it became evident that physical measures would best insure
disinfection and that
chemical measures should be regarded as accessory; also that the
prospects for success from the
use of these measures lie in employing them early, when the organisms
which have been
introduced into the wound are still superficially situated along the
wound tract and have not
extensively multiplied. Physical disinfection consists in ablation of
necrotic tissue and removal
of foreign bodies. This method, known as débridement, constitutes the
greatest advance from a
surgical standpoint that was developed in the recent war. It not only
saved many lives but
enabled many wounded soldiers to return to the front after a relatively
short period of disability.
a The statements made in this and the following
chapter concerning the treatment of wounds of
the soft parts and joints are based upon articles by the writer in:
Surgery, Gynecology and Obstetrics,
Chicago, 1918,
xxvii, 289-311 (with B. J. Lee and P. A. Dineen); Journal of the
American Medical Association, Chicago, 1919,
lxiii, 383-388; Annals of Surgery,
Philadelphia, 1919, lxx, 266-286;
Oxford Surgery, 1921, V, 715-775; Keen's
Surgery, 1921, V11, 557-589.
295
Notwithstanding
the superior results derived from débridement, objections were raised
that valuable tissues might be needlessly sacrificed, and especially
that suppuration often
occurred in spite of excision. Such failures following wound excision
led to the utilization of
other agents in the fight against infection, especially fluids for
irrigation, having in mind both
mechanical, solvent, and bactericidal properties.
All
the customary antiseptics were utilized early in the war. Morestin 2
recommended
equal parts of commercial formol, glycerin, and alcohol. Gaudier 3
utilized methylene blue in
alcoholic or watery solution, 1: 1000.
It
is noteworthy that many antispetic agents which are highly efficient in
the test tube, for
example bichloride of mercury, show less efficiency in the wound.
Moreover, most antiseptic
agents damage not only the bacteria but also the tissues, especially
when used in strong
concentrations, so that the surviving organisms find an excellent
culture medium for their growth
in the changed or necrotic tissues.
The
many antiseptics which were recommended showed striking limitations in
their
efficacy, and great expectations were raised by the introduction of
Dakin's solution, about the
middle of 1915,4 approximately the same time as extensive
débridement began to be used.
Carrel recommended that the new antiseptic be injected into the wound
channel.5 The results
were not highly successful, and thereafter Carrel regarded Dakin's
fluid merely as the
supplement to the operative procedures for the purification of
contaminated wounds. The
success of the Carrel method 5 depends largely upon aseptic
details, espe- cially thoroughness,
gentleness, and cleanliness in dressings, and repeated flushings of the
wound surfaces.
In
many cases a prompt and careful operation is sufficient and need not be
supplemented
by instillation of Dakin's fluid. Yet in infected wounds most surgeons
consider that Dakin's fluid
in continuous irrigations or interrupted instillations constitutes by
far the best method of wound
treatment. But some have not observed superior results from Dakin's
fluid as compared with the
ordinary antiseptics, and consider the bactericidal action of this
antiseptic as exaggerated, the
results being due to the irrigation and the solvent properties rather
than to its bactericidal
properties.
The
ideal treatment of war wounds, as based on experience gained in the
World War,
consists in complete excision of all devitalized tissue, followed by
the application of immediate
suture or secondary suture, according to conditions existing in a given
case. When there is good
reason to believe that little or no cause for infection is left, as
when the whole tract has been
excised and the wound appears healthy throughout, suture may be
applied. This primary suture is
performed either layer by layer or in bulk, the important point being
to leave no dead spaces.
Drainage is injurious rather than useful. Some operators, before
closing the wound, irrigate it
with ether, weak tincture of iodine, or salt solution.
When
there is doubt as to the condition of the wound, primary suture must be
omitted.
The excision having been made as completely as possible, dressings are
applied and suture
performed subsequently if no infection follows
296
The indications for such delayed suture
are to a large extent dependent upon the
quantitative and qualitative estimation of bacterial flor a in the
wound. This is determined by
smear and culture. It has been shown that in the absence of
streptococci and with few other
organisms a wound can usually be sutured safely. According to the time
when delayed suture is done, a distinction is usually made between
"delayed primary suture," if it is done within five
days after the initial operation, and '"secondary suture," if it is
performed a longer time
afterwards. But the real distinction between delayed primary suture and
secondary suture is one
of wound repair rather than of time. Delayed primary suture is one in
which the edges can be approximated and will unite without excision of
tissue. Secondary suture is one in which the
epidermis has grown inward and must be excised for proper union. In
late secondary suture
dense granulation tissue must also be excised.
A
very important point for the successful outcome of primary sutures is
the interval
between the infliction of the wound and the performance of the
operation; this interval should be
reduced to the shortest possible time. In the beginning, wounds were
sutured primarily only
when the wounded were operated upon within the first 12 hours, but
later primary sutures were
successfully applied at the end of 36 up to 48 hours after the
infliction of the injury. At first only
wounds of the soft parts were sutured, then articular wounds, and
finally selected compound
fractures. Immobilization of the damaged region is indispensable to a
successful outcome of the
operation.
It
is generally conceded that the first primary sutures were performed in
July of 1915, by
René Lemaitre.6 From July, 1915, to July, 1917, in 1,046
primary sutures, he had 944 complete
cures, 39 partial cures, and 13 failures. Gaudier,7 in
November, 1916,
also advocated this
method. The procedure began to find more general adoption but not
without giving rise to much
controversy. In November, 1916, Tuffier 8 stated that, on
the basis of official statistics, primary
suture fails in 34 percent of the cases. Dupont,10 in
March, 1917, published 49 cases of primary
suture, including 4 sutures of articular wounds, with only 5 failures,
only 1 of which was serious.
Pierre Duval,10 in October, 1917, sutured 1,058 of 1,230
wounds, with
86 percent of complete
cures in six weeks. For wounds which are not primarily sutured he
recommended suture in three
to five days. By Gross, Tissier, Houdard, Di Chiara. and Grimault,11
759 sutures were applied
from July 23 to September 10, 1917, with 675 primary unions, 47 partial
and 37 total failures; b
i. , 88 percent success. Marquis, Descazals, Luquet, and Morlot 12
published results of their work
during a period of attack; in the four days of this attack they sutured
500 wounds, including 133
bony and 34 articular wounds. The total mortality was 6.5 percent, and
36 percent of the
wounded were discharged as convalescents 50 days after the infliction
of the wounds. From July,
1917, to February, 1918, Lemaitre 6 performed 1,618 primary
sutures, with 1,555 complete
cures, 44 partial cures, and 19 failures.
The
chief methods and agents which were employed for combating infection in
war
wounds are mentioned, although it is not feasible to discuss all of
b
By complete failure is
meant necessity for removing all stitches; by partial failure,
superficial infection necessitating the removal of a few stitches.
297
them in this chapter: Débridenient;13
the Carrel-Dakin method; 5 dichloramin-T;14
hypochlorous acid preparations, Eusol and Eupad;15
hypertonicsolutions or lymphagogic agents
(Sir Almroth E. Wright);16 salt pack (Col.H.M.W. Gray);17
magnesium chloride (Delbet);18
collargol;19 Bipp (RutherfordMorison);20
iodated starch;21 flavine;22 brilliant green;22
methyl
violet (pyoktanin);23 magnesium sulphate; 24
sunlight 25 and ozone; 20 acetozone; 27 vaccine
and
serum treatment of infected wounds; 28 Delbet's pyoculture;
29 introduction of living anaerobes
(Donaldson's method);30 vuzin (Morgenrothand Tugenreich);31
Vincent's powder.32
OPERATIVE
TREATMENT
During
the World War the wounded usually were received at the evacuation
hospitals in
from 4 hours to 24 hours after the receipt of injury, but during
periods of battle activity the delay
was sometimes much greater. They presented various degrees of shock,
hemorrhage, laceration
of the soft parts, and associated lesions. Frequently the wounds were
multiple. They contained
pathogenic microorganisms and in most cases foreign bodies. When
admitted few of the wounds
showed evidence of gas bacillus infection.33
Operative
treatment is indicated for the majority of the wounded as soon as
possible after
the receipt of the injury. Each hour increases materially the danger
from infection. Cases that
could be saved within 14 hours are often lost after 24; wounds that
could be closed successfully
within 8 hours often become the site of infection and gas gangrene,
resulting in amputation or
death if left untreated for 18 hours.
After
the arrival of the patient at the hospital, expedition in the surgical
treatment must be
effected by the help of a well-organized routine. The first essential
is the careful sorting of cases
at the admission tent. Patients presenting a considerable degree of
shock should be left
undisturbed on their stretchers and sent to the shock ward. They must
first be treated for the
shock, and operation deferred until reaction is evidenced by a rise of
blood pressure. The chief
exceptions to this rule are cases with cranial wounds, abdominal
wounds, and sucking thoracic
wounds. Walking cases and slightly wounded cases are referred to the
dressing ward or to the
service for slightly wounded. Of the remainder the majority demand
X-ray examination and
early operation. The dressings are removed and the wounds carefully
examined. Those whose
condition does not contraindicate it are bathed. Cases with active
bleeding, with sucking thoracic
wounds, with penetrating abdominal wounds, with fractures of the femur,
with penetrating
wounds of the knee, and with multiple wounds, receive the first
attention. Cases which have
reacted from shock may be taken at any time. Cases with uncomplicated
wounds of the soft parts
are, in general, cared for after the more urgent cases.
The
success of operation depends largely upon the thoroughness of the
roentgenologist's
examination and the accuracy of his findings. Experience proved that
his report should be made
on the patient's card according to a definite system. It should include
the anatomical site, the size
of each foreign body in millimeters, the depth in millimeters, and the
position of the part at the
time of observation. For example: 1. Right thigh: F. B. 10 by 15 mm.;
298
80 mm. under point marked on skin; limb in
extreme outward rotation. 2.Left leg: no F. B.;
fracture both bones, middle third; much comminution.
The
operator thus visualizes the condition more accurately than if the
report were made
in fractions of an inch, or if some relative term were employed.
"Millimeter" is employed to
avoid error and confusion.
In
times of great activity some cases must be operated upon without X-ray
examination.
They should be selected carefully and should comprise those in which
apparently a foreign body
is not present or in which the foreign body is superficial.
The
patient should always be examined by the surgeon before anesthesia is
begun. In
wounds of the extremities the surgeon should determine whether there is
a nerve lesion and an
arterial pulse. Apparently innocent wounds of the trunk may in reality
be very serious. The
possibility of intrathoracic or intraabdominal involvement should
always be borne in mind.
Cases in which the genitourinary tract may have been injured demand
examination of the urine.
The
preparation of the patient usually is done in the operating room on an
extra table
while the preceding operation is being completed. The wound is
protected with gauze, the part
shaved thoroughly, and scrubbed with soap and water over a wide area.
Application of chemicals
may follow. A common procedure is to cleanse with ether and then apply
tincture of iodine. It is
important to prepare a wide field and, in wounds of the extremities, to
encircle the limb. The part
is draped economically with towels and sheets.
A general anesthetic should be employed except in rare cases.
Nitrous
oxide-oxygen,
administered by an expert anesthetist, is the least harmful. It should
be the anesthetic of choice
for patients in a condition of shock, gassed cases, and thoracic cases.
Ether, however, is
employed in routine cases. Minor operations may often be performed
under primary anesthesia.
Local anesthesia is rarely used.
For
convenience of discussion wounds of the soft parts may be subdivided as
follows: 1.
Wounds by fragments of shells, grenades, or bombs. a. Fragment
retained; penetrating wounds.
b. Fragment not retained; perforating, plaie en séton,
through-and-through wounds, or gutter
wounds. 2. Wounds by bullets-rifle, pistol, or machine gun. a.
Bullet retained; penetrating
wounds. b. Bullet not retained; perforating, plaie en séton,
through-and-through wounds, or
gutter wounds.
A
fragment of shell or grenade is of high velocity, irregular in shape,
and with sharp
edges. In contrast to a bullet it carries with it pieces of clothing
and skin into the tissues. Because
of its irregular shape it exerts a destructive effect upon the tissues
which thus form an excellent
medium for the development of the microorganisms carried in from the
clothing and skin. After
a latent interval of six hours or more both aerobes and anaerobes
proliferate rapidly and
penetrate more deeply into the tissues. The local changes and the later
systemic effects depend
upon the character of the microorganisms and the tissue resistance.
A
bullet at close range exerts a marked explosive effect; during the
major part of its
flight, approximately from 500 to 1,500 yards, it penetrates the
299
soft parts with little destruction of the
tissues; at long range it loses its steady spinning
movement and causes mutilation and laceration. In the majority of cases
of perforating bullet
wounds the missile passes like a stiletto through the clothing and
tissues. Infection may not
result because the projectile carries no clothing into the wound and
penetrates with little
laceration and traumatism of the tissues. When such is the case
operation is usually not required,
since the few organisms which are present have not the proper
environment for growth. Under
certain conditions, however, when the appearance and feeling of the
part suggest considerable
hemorrhage or destruction of tissue, perforating wounds by bullets must
be treated in the same
manner as those made by fragments of shell. The rule is not to operate
upon perforating bullet
wounds with punctate wounds of entrance and exit and with little or no
ecchymosis, swelling, or
tension of the soft parts.
DÉBRIDEMENT
The
general plan or aim of surgical treatment is the prevention or
limitation of infection,
the early closure of the wound, and the preservation or reestablishment
of function. The first
indication is to obtain a clean wound. This is accomplished, primarily,
by débridement c of
tissues--that is, by free incision and excision of injured and
contaminated tissues and by the
removal of the foreign material carried by the missile into the wound.
The
principle of this procedure may be visualized by considering a typical
case of a
wound of the soft parts with a tract from the skin to the interior of
the muscles, containing a
fragment of shell and pieces of clothing along its course, and having
for its walls lacerated
muscle. Pathogenic organisms are present throughout this tract. The
devitalized, pulpified walls
of the tract furnish an ideal medium for the growth of bacteria. One
can readily imagine that
immediate wide excision of such a tract as a whole, including removal
of the devitalized skin,
subcutaneous tissues, aponeurosis and muscle, together with the shell
fragment, clothing, and
microorganisms contained within the tract, will leave a healthy aseptic
wound, provided the skin
adjacent to the wound has been properly prepared and the operator has
employed a technique
comparable to that used in clean operations. To obtain an aseptic wound
is the ideal desired,
though it is doubtful whether this is actually achieved in any case.
But, however skeptical one
may be as to the total eradication of microorganisms under the
conditions which prevail in
these wounds, many wounds after operation undergo repair as if aseptic,
and cultures and smears
made from them are often sterile.
Even
during times of greatest activity débridement should be properly
carried out and
the best possible technique observed. The temptation to relax in these
respects during periods of
stress should be resisted. The time saved by careless work is not
sufficient to warrant the
additional risk incurred; only rarely is it justifiable to substitute
incision and drainage for d ebridement in recent wounds.
The
closure of the wound may be carried out by immediate or primary suture,
delayed
primary suture, or secondary suture.
c
This term is used
to signify both the incision and excision of devitalized tissues, and
removal
of foreign body.
300
TECHNIQUE
The
skin incision, when possible should be made parallel to the long axis
of the limb.
This permits wide exposure of the underlying tissues and renders
subsequent suture less difficult.
A transverse incision should rarely be employed. In the case of a deep
transverse perforating
wound it is better to make two longitudinal incisions and work inward
from each rather than
make a transverse incision with division or excision of considerable
muscle tissue. In the former
case suture is usually readily done at an early date, whereas in the
latter primary suture is often
impossible because of the difficulty of uniting the severed muscle.
Even when this is
accomplished the sutures frequently tear out and allow retraction of
the muscle with resulting
dead space and breaking down of the wound. When the transverse wound
has not been closed
primarily, or has reopened, secondary suture is delayed and is more
difficult. The functional
result is also less favorable on account of the transverse section of
the muscle.
Transverse
incisions should be employed in the extremities only in superficial
wounds
involving the subcutaneous tissues or with very superficial involvement
of muscle. In the gluteal
region and on the trunk the incisions, in general, should be in the
direction of the fibers of the
underlying muscle. Occasionally, as in deep, transverse,
through-and-through wounds of the
calf, a long median incision may be employed advantageously; the tract
is exposed in the middle of its course and débridement is carried out
from this region in both directions. The skin wounds
of entrance and exit are excised by small elliptical excisions and the
wound edges
approximated.
The
operation itself consists in the free excision of all tissues with
which the foreign
body has come into contact and all devitalized tissue, except
structures such as nerves, large
vessels, and bones, whose removal would interfere with the function of
the part and cause
permanent disability. Free excision, however, does not mean ruthless,
blind butchery of the
parts, but rather, careful, intelligent dissection, with liberal
removal of such parts as should be
removed, and with equally scrupulous preservation of such parts as may
be left with safety.
The
wound itself, with all contused skin, is excised by removing an
elongated ellipse of
skin. No healthy skin should be sacrificed on the sides of the ellipse,
as it is important to
conserve as much skin as possible in the transverse plane of the limb
to facilitate suture. This is
especially important in the forearm. There is no advantage in
attempting a débridement through
a short incision. A deep débridement demands a long incision. The skin
incision must always
be vertical to the skin surface; the tendency to bevel the incision
should be avoided, as this
interferes materially with satisfactory suture.
Lemaitre6 prefers to begin with a short
incision, say of 5 or 6 cm.,
and to increase it as
the need arises. He does not hesitate to extend the ends inward or
outward or to transform the
incision into a flap.
When there are
two wounds one or two incisions may be employed as
already described. Similarly when the foreign body has taken a
transverse or oblique course,
penetrated a considerable distance, and lodged in the tissues,
301
two incisions may at times be used to
advantage, one over the foreign body and one to excise the
wound of entrance, both being used for excision of the tract.
After
excision of the skin wound the instruments should be discarded or
washed in
alcohol. The skin edges are widely retracted and the subcutaneous
tissues removed as far as there
is evidence of laceration or contamination. It is not necessary,
however, to remove all blood-infiltrated subcutaneous tissue. In
general, the fingers are kept out of the wound and the
dissection made with instruments. Good exposure of every plane by
retraction is essential, the
edges being rolled outward with toothed retractors or some form of
clamp, such as the Allis
forceps.
FIG. 159.-
Débridernent. Excision of the
external wound
FIG. 160.- Débridement. Excision of the
aponeurotic wound layer
The
aponeurosis is treated in the same manner as the skin-that is, by a
long straight
incision with removal of the wound by a relatively narrow ellipse.
(Fig. 160.) The aponeurosis is
of great value in secondary sutures in the lower extremity and
shoulder, and, therefore, should
not be ruthlessly sacrificed. It must be emphasized that liberal
excision of aponeurosis or skin
is not necessary because it is not in these tissues that infection
ordinarily originates or develops. The aponeurosis should be widely
retracted and muscle planes exposed. It is this tissue that
favors infection. All traumatized and devitalized muscle must be
removed. This demands
excision for a distance of 0.5-1 cm. on all sides of the tract. The
dissection is made parallel to
the fibers of the muscle; a long, relatively narrow ellipse is removed
so that the sides tend to
fall together after the excision. The dissection should be made by
planes, muscles should be
identified, and the situation of nerves and large vessels should always
be borne in mind. The
tract should be followed by sight, not by probing; for this pu rpose a
reflecting headlight is
indispensable.
302
If the tract is lost between muscle planes,
often slight flexion
or extension of the limb
will bring it into view. Careful hemostasis is necessary at all stages.
Sponging of blood should
be done by pressure and not by rubbing, because the latter method may
carry organisms from
an infected to a clean part of the wound and may cause a small tract to
be lost to view.6 The
foreign body should not be extracted until reached in the dissection,
otherwise the parts fall
together and the tissues immediately beyond the body, which often
contain clothing, may not be
adequately excised. When the excision is complete all exposed muscle
must look healthy,
contract when pinched with forceps, and ooze when snipped with
scissors; otherwise its vitality
has been diminished to such a degree as to favor gas bacillus
infection. At times the finger must
FIG. 161.- Débridernent.
Excision of injured
muscles
be introduced to search for the foreign body,
but, as a rule, in cases where the track is lost or
where for other reasons difficulty arises in locating the foreign body,
fluroscopy should be
employed.d If this fails, the
tissues should not be
blindly torn up, but after a careful search one
should desist, leaving the wound open and removing the foreign body.
subsequently, after more
careful X-ray localization or under the screen. When the deep tissues
are so markedly infiltrated
with blood as to suggest the possibility of constriction of the muscles
under the overlying fascia,
this fascia must be incised so as to free the muscles from internal
pressure.
When
the fragment or tract is in proximity to a large vessel, as, for
instance, the brachial
vein, the vessel should be inspected and, if traumatized, should be
treated by ligation and
excision of the contused portion; otherwise
d
The Bergoni vibreur was used to advantage
at La Panne and elsewhere.
303
secondary hemorrhage is likely to occur. If
there is danger of gangrene resulting from ligation a
primary suture should be performed and the case watched with particular
care. In the case of a
small lateral wound Lemaitre 6 advises repair of the vessel
wall by suture if the neighboring
tissues are healthy. Ordinarily, however, it is best to ligate the
vessel about 1 cm. above and
below the vascular wound and to excise the intervening portion. Though
sudden and unexpected
hemorrhage will occasionally confront the surgeon, the absence of an
arterial pulse below the
lesion and the widespread infiltration of the soft tissues about the
wound usually warn the
operator in advance of the presence of a vascular lesion. The
importance of having a tourniquet
at hand at all times is obvious.
Care
should be taken to avoid injury to nerves by careless dissection. A
severed nerve
should be united, and if possible the nerve should be buried within
muscle tissue. When
preliminary examination shows that a nerve
FIG. 162.- Change of
position of wound tract
from changed position of limb
has been injured, it should be exposed above
or below the tract early in the operation to avoid
traumatization during d ebridement.
When
the excision has been completed all hemorrhage should be controlled. As
little
catgut as possible should be buried. The wound should be irrigated with
saline or Dakin's
solution. Ether has been extensively employed for irrigation of wounds
after d ebridement, but it
probably has not sufficient merit to warrant its use. Lemaitre6
employs 5 percent tincture of
iodine, after drying the wound, to fix the superficial microorganisms.
One of its disadvantages is
the slight secretion of turbid serum due to its action upon the
superficial cells of the wound. We
have not been able to note any advantages from its use.
If
the wound is left open vaselined gauze is placed over the exposed skin
edge and
subcutaneous tissues in order to prevent the dressing from adhering and
to lessen oozing and
pain when the dressing is removed. Gauze soaked in Dakin's solution is
placed loosely in the
wound in such a way as not to cause retention of secretions. Dry gauze
is applied over this and
the dressing kept in place with a bandage. This is the routine
treatment for cases which are to be
304
evacuated early. Cases which are to be
retained may be dressed similarly, or Carrel-Dakin
treatment, if indicated, may be begun at once.
The
indications for Carrel-Dakin treatment may be summarized as follows: If
the
operator feels that d ebridement is satisfactory and that the wound is
likely to be susceptible of
suture in a few days chemical disinfection is unnecessary and
Carrel-Dakin treatment is not used.
If, for any reason, such as incomplete excision of tissues or the large
size of the wound, it seems
probable that the wound must be left open for a week or more,
Carrel-Dakin treatment is advisable. Even clean wounds that are left
open for a considerable time always become infected,
but the use of Carrel-Dakin treatment will prevent or limit the
infection. When infection has
occurred the use of Dakin's solution will do much to control and
terminate it. Under these
conditions the treatment is essential.
FIG. 163.- Wound by
shell fragment two weeks
after débridement and primary suture
PRIMARY AND SECONDARY SUTURE
There
are two conditions under which war surgery is performed at the front:
First,
relatively quiet periods; second, times when military activities are
acute. In quiet times a thin but
fairly continuous stream of wounded are passed back to the forward
hospitals, but only
occasionally, as after a raid, does congestion occur. The wounded
usually can be operated on
almost as soon as they are received; there need be no hurry, and the
patients may be carefully
watched after operation. The aggregate of such cases along a wide
sector in quiet periods reaches
formidable figures.
The
ultimate aim of treatment is to restore the soldier to full activity,
with complete
restoration of function, in as short a time as possible. Obviously, one
of the conditions of such
restoration is the repair of the wound. During quiet times early
closure of the wound may be
undertaken successfully in a large proportion of eases. Great benefit
thereby accrues both to the
patient
305
and to the service. But the long relatively
tranqluil periods also are of use inaffording an
opportunity for study and demonstration as to what may be done and what
should be done under
the varying conditions of war surgery. As a result of such study of
technical methods and tissue
repair, rules may be formulated and safely enforced for the treatment
of the wounded during
periods of greater activity.
It
must be recognized, therefore, that local conditions such as the
degreeof battle activity,
alter materially the indications for suture, particularly forprimary
suture, in the advanced area.
The following
is an outline of the general principles and technic of the
three varieties of suture of
war wounds, namely, primary suture, delayed primary suture, and
secondary suture in wounds of
the soft parts:
FIG. 164.- Perforating
shell wound,
left thigh, the same missile penetrating
right thigh
and
fracturing right femur. All wounds closed by primary suture. (Heuer,
Keen's Surgery)
PRIMARY SUTURE
Débridement having been completed, the choice of
treatment lies
between primary
suture and leaving the wound open. If ideal conditions, that is, early
and thorough debridement,
have been approximated and the case can be watched for some days,
primary suture may be
made. Otherwise, the wound is left open and sutured subsequently.
Obviously, the decision in a
given case, as to whether primary suture may be made, must be attended
with much uncertainty;
a mistake may be costly to the patient. In active periods, as in an
offensive, when there are many
wounded, the exigencies of a service demand haste in the primary
operation, and the patient
must be evacuated, passing from the operator's control soon after the
operation. Under these
conditions, primary suture should not be considered. It may be
employed, therefore, only in quiet
periods and in hospitals where patients may be retained for observation
306
FIG. 165.- Multiple,
penetrating wounds
of back, soft parts, closed by primary suture. Lower left
wound "failure." (Heuer)
FIG. 166- Long
performing would of
thigh, with opening of knee joint, closed by primary suture.
(Heuer)
307
The
advantages of primary suture are obvious; the disadvantages
consist chiefly in the
danger of closing within a wound, especially within a wound imperfectly
débrided, noxious
microorganisms, particularly anaerobes of the types which produce gas
gangrene. A resulting gas
bacillus infection or a
FIG. 167.- This
and Figure 168 show perforating
wounds of forearm
with fracture (see fig. 169),
two weeks after dibridement and primary suture
pyogenic infection in a
few cases will
counterbalance many successful closures. The only means of rendering
primary suture safe is by
extreme operative care
FIG. 168
and thoroughness, thoughtfulness and judgment
in the selection of cases, and, finally, scrupulous
watchfulness for some days after the operation.
When
the circumstances are such as to warrant primary suture the following
considerations must be weighed in each case in deciding whether or not
308
suture is indicated: (1) The interval between
the receipt of the wound and the operation; the type
of tissue and situation of the wound. Thus, wounds involving the
muscles of the calf, thigh, or
gluteal regions should not be closed as a rule after a longer interval
than eight hours. In these
muscular arts gas bacillus infection is prone to occur and to result
disastrously. In other muscu- lar parts the time often may be extended
to about 12 hours. In wounds not involving muscles the
time may be further extended. It must be understood, however, that such
rules based on the time
between the injury and the operation are not absolute and have been
advanced only as a
suggestive working basis. Wounds of the face and scalp are regularly
sutured. Wounds of the hands should, ats a rule, be sutured. Extensive
wounds of the feet should, as a rule, be left open,
treated by the Carrel method, and closed subsequently.
FIG.169.-
Outline of
X-ray, Figure 167
(2) Extensive laceration of the soft parts or
the presence of a large shell fragment or of
considerable clothing in the tissues shortens the time within which
primary suture may safely be
made. (3) Conditions which demand haste in the operation, and therefore
militate against
thorough and painstaking d bridenient, preclude primary suture; for
instance, multiple wounds,
condition of shock, or period of a rush. (4) Diminution of the vitality
of the parts, especially as at
result of vascular lesions, precludes closure; for instance, wounds of
the calf with the lposterior
tibial artery sectioned, or marked infiltration of the tissues with
blood. (5) As has been
emphasized, primary suture must not be made unless the patient can be
watched carefully for
days thereafter. Accordingly, it was a general rule in the American
Expeditionary Forces that
during, active periods no primary suture of wounds of the soft parts
should be made except in
wounds of the scalp, face, or hands, as enumerated above.
TECHNIQUE
Thorough
débridement is essential, and aseptic technique must be observed
throughout
the operation. Hemostasis must be complete. The wounds
309
should be washed sufficiently to remove blood
clots and loose fragments oftissue. Many
operators, after drying the wound apply ether to the wound surfaces;
this, however, is empiric.
Lemaitre 6 applies tincture of iodine to fix residual
microorganisms. It is questionable, however,
whether the ether or the iodine are factors of importance. The muscles
and aponeurosis are
approximated with interrupted catgut. As little and as fine catgut
should be introduced as will
approximate the tissues and obliterate dead spaces. The skin
andsubcutaneous tissues are closed
with interrupted silkworm gut. Drainage should be avoided. If employed,
the drain should be
removed as soon as possible, in general, within 24 hours. In some
cases,
especially in deep
wounds of muscular parts, a few strands of silkworm are advantageous as
a means ofobtaining
subsequently a culture from the interior of the wound. At the first
dressing the silkworm should
be removed and cultures taken, and if hemolytic cocci are found the
wound should be reopened.
After the dressing has beenapplied the part should be immobilized.
Partial
primary suture of wounds of the soft parts has nothing to recommend it;
it is often
harmful; it should therefore rarely be employed.
A
wound which has been closed by primary suture should be examined within
24 hours;
moreover, the general condition of the patient should be carefully
watched. These precautions
can not be too strongly urged. If they are observed, there is not much
danger of fatal infection; if
they are neglected, avoidable fatalities will occur. It is, in general,
the failure to recognize the
development of gas bacillus infection or pyogenic infection as early as
one should, and the
unwillingness to admit failure of the primary suture and the necessity
for complete reopening of
the wound and free excision of gangrenous muscle, that cause the
fatalities.
When
gas bacillus infection develops after primary suture its onset is
suggested usually
by local tenderness or spontaneous pain in the wound after 12 hours, or
by changes in the general
condition of the patient which should be watched for and immediately
recognized. These
changes can be noted, as a rule, in about 18 to 24 hours after the
operation. They are rapid pulse,
peculiar gray appearance of the face, and moderate rise of temperature,
for instance, to 1010.
The condition, if left, rapidly becomes worse, and six hours later the
systemic symptoms are
often greatly accentuated. The patient becomes profoundly toxic, with
high temperature,
delirium, and dyspnea. Locally, in typical cases, the part is swollen,
tender, tense, and often
bronzed in patches; the face, however, may look and feel normal. A
tympanitic note on finger percussion, as emphasized by Lemaitre,6
can often be demonstrated. Crepitation is frequently
present. On opening the wound, or perhaps not until the aponeurosis has
been opened, bubbles of
gas and thin, brownish fluid exude; the typical rotten meat smell is
noted, and the involved
muscle shows the characteristic appearance and lack of vitality,
notably, an unhealthy salmon
color, friability, and failure to contract on pinching. Cultures in
these cases show various
anaerobes, especially B. welchii (perfringens), often
associated with pyogenic organisms.
310
DELAYED PRIMARY SUTURE
The
distinction between delayed primary suture and secondary suture is one
of tissue
repair rather than of time. Delayed primary suture is one in which the
edges can be
approximated and will unite without excision of tissue. Secondary
suture is one in which the
epidermis has grown inward and must be excised for proper union. This
is, in general, about one
week. In late secondary sutures dense granulation tissue must also be
excised. The determination as to when a wound may be sutured depends on
bacteriologic findings and clinical
observation. It must be emphasized that the cooperation of a
bacteriologist is indispensable in
making a decision as to the indications for delayed primary and
secondary sutures. The practical
function and indisputable importance of the bacteriologist in war
surgery lies in this. In the
FIG. 170.- Large
penetrating shell wound,
internal aspect of leg, closed by retarded primary suture.
consideration as to whether a wound is
suturable or not reliance must be placed chiefly on
cultures, the important feature being the determination of the presence
or absence of hemolytic
cocci. For this a routine blood-agar examination is essential.
Bacterial
counts are far from exact, yet they give an indication as to the degree
of
bacterial contamination of a wound, especially the progress from day to
day, and are of value
especially for one untrained in estimating clinically the indications
and contraindications for
suture.
From
18 to 24 hours after the original operation of d bridement or excision
of tissues the
wound is dressed and a culture and a smear are made. A report is
returned as soon as possible. If
no organisms are found, suture is indicated. If hemolytic cocci are
present, suture is not
considered. In the absence of hemolytic cocci, if the wound is
clinically suturable, the presence
of a few
311
anaerobes or other organisms (approximately
one in two fields) does not contra-indicate suture.
A considerable number of organisms of any kind indicatesthe necessity
for caution. Suture, in
that event, should be delayed and aculture and a smear repeated at the
following dressing.
Delayed
primary suture is usually made within six days after the primary
operation. The
advantages of this method are the practical elimination of the danger
of
gas bacillus infection and
the marked lessening of the danger of pyogenic infection. The
disadvantages are the possibility of
postoperative contamination of the open wound and the subjection of the
patient to a
second operation, with the attending discomfort and danger of
postoperative complications, such
as pneumonia. These disadvantages, however, do not equalize the risk
incurred by primary suture
in doubtful cases.
FIG. 171.- Large
perforating wound of thigh,
closed by primary suture. (Heuer)
TECHNIQUE
All
dressings of wounds after the primary operation should be made
according to the
Carrel-Dakin technique. The anteoperative preparation of the wound for
delayed primary suture
consists in painting the skin with tincture of iodine, after thorough
cleansing as in the routine
dressing. Some operators also paint the wound surfaces. The details of
suture are the same as for
primary suture.
SECONDARY SUTURE
The
following routine is generally followed: After 48 hours, at the daily
dressing, a
culture and a smear are made. The first report, therefore, contains the
approximate number of
organisms per field and the varieties of organisms. Thereafter, a smear
is made every two days.
It is also advisable to make a culture occasionally. Care must be taken
not to touch the skin
surface in making the smear, since skin contamination vitiates the
value of the report. From the
smear a bacterial curve may be plotted according to Carrel's plan. When
the organisms in two
successive counts are few, that is, approximately one per two fields,
and a culture shows an
absence of hemolytic cocci, the wound is considered susceptible of
secondary suture, except
when the wound has contained hemolytic cocci at any time. In that case
careful cultures are
made
312
from granulation tissue and from the
discharge from all parts of the wound; and absence of
hemolytic cocci should be established by two successive negative
cultures before suture is
made. It has been observed that streptococci are prone to lie dormant
in small numbers but to
flare up and cause virulent infection after closure of the wound.
FIG. 172.- Wound,
posterior aspect,
right thigh; compound comminuted fracture of femur. Two
weeks after débridement. Treated by Carrel method
TECHNIQUE
The preparation is the same as
for delayed primary suture.
Lemaitre 6 distinguishes two
varieties of secondary suture: (1) Secondary suture of the skin. The
incision surrounds the new
epidermis along the wound edges. A healthy normal skin edge must be
present for successful
suture. The skin is freed by undermining in all directions as far as
necessary in order to approximate the edges with the minimum tension.
This separation is made in the plane immediately
superficial to the deep fascia. Only dense scar tissue or
313
projections of granulation tissue are removed
from the wound. The deep fascia is then
approximated with interrupted catgut when possible; usually this may be
done in the thigh and
shoulder, but rarely in the leg, arm, and forearm. The skin and
subcutaneous tissues are closed
with silkworm gut.Considerable tension may be allowed, far more than we
are in the habit
of permitting in civil practice. If little skin was removed at the
original operation
FIG.
173.- Same wound
as that shown in
Figure 172, two weeks after secondary suture
the skin stretches in a short time, tension
is relieved, and good union results. The result of suture
is directly proportionate to the degree of tension. If there is extreme
tension infection may be
expected. It is surprising, however, how well most of these wounds do,
even after some
infection. After the suture is completed a dry dressing is applied with
considerable pressure and
left undisturbed, if conditions warrant, for about eight days, after
which sutures are removed 7. (2) Secondary suture
reconstruction. The granulation tissue
314
and scar tissue are removed from the entire
wound and all layers are reconstructed by suture. When two longitudinal
wounds are on the same transverse plane, with considerable loss of
tissue
in each, one wound can usually be closed completely and the other
closed in part. A dry dressing
is applied and the wounds are left for about eight days, after which
the sutures are removed. The
unclosed portion then presents a flat, clean, granulating surface.
WOUNDS OF THE FACE
Wounds
of the face must be considered independently. However severe,
extensive, and
dirty the wound, virulent pyogenic infection and gas gangrene are not
prone to develop. This
feature makes it possible by timely operative intervention to avoid in
most cases the gruesome
mutilations which were so often allowed to occur in the early days of
the war. The rule which
may be safely followed is to repair wounds of the face as soon as
possible after the receipt of the
injury without general excision of tissues. The wound is cleaned
thoroughly, and only such
tissue is removed as is definitely devitalized. The mucous membrane is
then closed and the skin
wound sutured. Such wounds unite quite regularly. Secondary plastic
operations are made in
order to improve unsightly scars, to reconstruct the angle of the
mouth, etc. The frequently
associated fractures of the maxillie should be treated by a
surgeon-dentist. In his absence the
original operator should conserve as far as possible all fragments of
bone.
WOUNDS OF THE HAND
In
general, the soft parts should be studiously conserved; when conditions
warrant,
primary suture should be made and early active motion enforced Wounds
by shell fragments
with retained foreign bodies should be operated upon. Wounds caused by
very small fragments
may be left unopened, especially if bone, tendons, or joints are
uninvolved:
In
extensive wounds of the hand slow, painstaking cleansing by
conservative
debridement is necessary. Tendons are cleaned carefully; unopened
tendon sheaths should not be
entered. If practicable, divided tendons are sutured. If suture is not
possible, severed tendons
should be united with others so as to obtain the best functional
result. Even extensive wounds of
the hand should be closed if they have been carefully and thoroughly
treated. If a dead space is
present a drain should be introduced. Plastic operations with sacrifice
of a finger and excision of
a metacarpal are advisable if the danger of infection can thus be
diminished.
WOUNDS OF THE FOOT
Ample
longitudinal incisions are necessary except for perforating wounds near
the
margin of the foot, in which case a transverse incision is employed,
laying open the whole track.
In the anterior part of the foot it is best to expose the whole track
by incision through the web
between the toes. Conservation of the digits is not necessary to the
same extent as in the hand.
Usually primary suture may be made in slight wounds. Extensive wounds
of the foot should be
left open and treated with Dakin's solution.
315
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