Contents

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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.

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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

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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.

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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.;

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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

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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.

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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,

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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.

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 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.

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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

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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

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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

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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)

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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

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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

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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 101^0. 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.

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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

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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

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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

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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

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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.

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REFERENCES

(1) Borst, Max: Pathologisch- anatomische Erfahrungen über Kriegsverletzungen. Sammlung klinischer Vorträdge begrandet von Richard von Volkmann, Leipzig, 1917, n. s. no. 735, Chirurgie No. 201, 299.
(2) Morestin, H.: De l'emploi de forinol dans le traitement des plaies très septiques et des gangrènes gazeuses. Bulletins et mémoires de la société de chirurgie de Paris, March 24, 1915, xli, 740.
(3) Gaudier: Cited by Delbet in Discussion of article by Le Grand: De l'emploi d'un fixateur colorant avant la desinfection mecanique. Bulletins et mémoires de la société de chirurgie de Paris, June 2, 1917, xliii, 1347.
(4) Dakin, Henry M.: Au sujet de l'emploi de certaines substances antiseptiques dans le traitement des plaies infectées. Presse médicale, Paris, September 30, 1915, xxiii, 377.
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(8) Tuffier: Traitement des plaies de guerre. Bulletins et mémoires de la société de chirurgie de Paris, November 8, 1916, xlii, 2452.
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(11) Gross, Georges, Tissier, H., Houdard, L., di Chiari, F., and Grimault, L.: Primary Suture of War Wounds (Translated and abstracted from the Bulletins et mémoires de la société de chirurgie de Paris, October 10, 1917, xliii, pt. 2, 1086). Medical Bulletin, A Review of War Medicine, Surgery, and Hygiene, Paris, 1918, i, No. 5, 383.
(12) Morquis, Descazals, Luquet and Morlot: Suture of War Wounds in Time of Attack (Translated and abstracted from the Bulletins et mémoires de la société de chirurgie de Paris, December 19, 1917, xliii, pt. 2, 2281). Medical Bulletin, Paris, 1918, i, No. 5, 388.
(13) Riche, P.: A propos des blessures de guerre. Bulletins et mémoires de la société de chirurgie de Paris, October 14, 1914, xl, 1110.
(14) Skillern, Penn G.: A Series of War Wounds Treated with Dichloramine-T. Annals of Surgery, Philadelphia, 1919, lxix, No. 5, 498.
(15) Fraser, John, and Bates, H. J.: The Surgical and Antiseptic Values of Hypochlorous Acid (Eusol). Edinburgh Medical Journal, 1916, n. s. xvi, No. 3, 172.
(16) Wright, Sir Almroth E.: Memorandum on the Treatment of Infected Wounds by Physiological Methods. British Medical Journal, London, June 3, 1916, i, 793.
(17) Gray, H. M. W.: Remarks on the General Treatment of Infected Gunshot Wounds. British Medical Journal, January 1, 1916, i, 1.
(18) Walther and Delbet: Sur l'action de la solution de magnesium. Bulletins et mémoires de la société de chirurgie de Paris, February 13, 1918, xliv, 283.
(19) Boese, Karl: Ueber Collargol, seine Anwendung und seine Erfolge in der Chirurgie und Gynäkologie. Deutsche Zeitschrift fur Chirurgie, Leipzig, 1921, clxiii, Nos. 1-2, 62.
(20) Morison, Rutherford: The Treatment of Infected Suppurating War Wounds. Lancet, London, August 12, 1916, 268.
(21) Berczeller, L.: Ueber Iodstärke. Biochemische Zeitschrift, Berlin, 1922, cxxxiii, 502.
(22) Browning, C. C., Gulbransen, R., Kennaway, E. L., and Thornton, L. H. D.: Flavine and Brilliant Green Powerful Antiseptics with Low Toxicity to the Tissues; their Use in the Treatment of Infected Wounds. A Report to the Medical Research Committee. British Medical Journal, London, January 20, 1917, i, 73.
(23) Gaudier: A propos de l'emploi d'un fixateur colorant avant la désinfection mécanique. Bulletins et mémoires de la société de chirurgie de Paris, July 11, 1917, xliii, 1528.
(24) Alston, James: The Treatment of Inflammatory and Suppurating Lesions by Magnesium Sulphate. Medical Press, London, April 2, evii, 258.
(25) Leriche: De la stérilisation par le soleil des plaies infectées. Bulletins et mémoires de la société de chirurgie de Paris, May 16, 1917, xliii, 1063-1072.
(26) Stoker, George: The Surgical Uses of Ozone. Lancet, London, October21, 1916, ii, 712.
(27) Gore-Gillon, G., and Hewlett, R. T.: Acetozone as a General Surgical Antiseptic. British Medical Jonrnal, London, August 18, 1917, ii, 209.
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(29) Delbet, P.: Pyoculture et index opsonique. Bulletins et mémoires de la société de chirurgic de Paris, July 28,1915, xli, 1601.
(30) Donaldson, Robert, and Joyce, J. Leonard: A Method of Wound Treatment by the Introduction of Living Cultures of a Spore-Bearing Anaerobe of the Proteolytic Group. Lancet, London, September 22, 1917, 445.
(31) Morgenroth, J.: Ueber chemotherapeutische Antisepsis. I. Zur experimentellem Begrüdung der Vuzin Tiefenantisepsis. Deutsche medizinische Wochenschrift, Berlin, May 8, 1919, xlv, 505.
(32) Bazin: Recherchles expérimentales sur le pouvoir antiseptique du mélange boro-hypo-chlorité de Vincent. Comptes rendlus des séances de la société de biologie, Paris, February 9, 1918, lxxxi, 122.
(33) Crile, G. W.: Lectures of Army Sanitary School, A. E. F., No. 109. On file, Historical Division, S. G. O.