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EXPECTANT TREATMENT OF GAS-GANGRENE
981 of branch
type
block, the
rest of the
complex being a
right ventricle or diphasic T wave. The left-leg potentials have not been included in these charts; but they show that in all of them the loose ends of the lower contour lines at the back should be continued across the left flank (turning back when necessary) to join up with their corresponding numbers in front. To make really accurate charts, many more leads from the front of the chest would be needed and many precautions which are impracticable without special facilities. There should be a time-signal, connected with the pulse, to give accurate synchronisation ; all leads should be taken in the same phase of respiration, the same posture, and at one sitting. Even so there would be other possible sources of error. But the present charts, defective as they are, will suffice to support the main conclusion, that in taking an
electrocardiogram we are tapping a
current
running
round the chest wall and are approximately registering the potential differences between the points of application of the electrodes ; and that these depend on the path of the stimulus and the anatomy of the paths of low electrical resistance from each side of the site of activity to the surface through the precordium, liver, auricles, and great veins. SUMMARY
(1) Charts of the normal T wave show that it develops in successive phases. (2) It is suggested that it is due to a wave of anabolism travelling inwards through the ventricular myocardium with the advance of the returning coronary supply ; and that the normal U wave is a dicrotic T wave. (3) The block
features of the
electrocardiogram
are
common
bundle-branch
discussed.
REFERENCES
Barker, P. S., Macleod, A. G., Alexander, J., and Wilson, F. N. (1929) Trans. Ass. Amer. Phys. 44, 125. Burdon-Sanderson, J. (1879) J. Physiol. 2, 384. (1939) Ibid, Aug. 19, p. 415. Hill, A. (1938) Lancet, 2, 1110. Lewis, T. (1925) Mechanism and Graphic Registration of the Heart Beat, 3rd ed., London, p. 54. —
EXPECTANT TREATMENT OF GASGANGRENE BY H. A.
BRITTAIN, M.Ch. Dubl., F.R.C.S.
patient was a labourer, aged 40, who fell height on to some cement, and sustained a compound fracture of the right tibia and fibula. The wound did not appear to be grossly contaminated, but in view of our recent experiences the following expectant treatment was adopted : Complete excision of the wound was performed, The from a
and a careful " debridement " carried out. The anterior tibial vessels were found to be lacerated at the site of the fracture, and these were sutured. A small protruding fragment of the tibia was removed, and the wound was irrigated with hydrogen peroxide and left widely open. The fracture was reduced by manual manipulation, and a plaster cast was applied The over wool packing extending above the knee. plaster was padded on account of the additional aid to the circulation. A window was cut over the wound, and the plaster was bi-valved. A postoperation radiogram showed a reasonably good reduction. A prophylactic dose of 12,000 units of anti-gas-gangrene serum was given, four times as large as the usual dose, and 1000 units of anti-tetanic serum. The wound was examined every two hours. Twenty hours later a minute bubble of gas was expressed from the lower aspect of the wound, and a faint smell of gas gangrene was present. The patient’s temperature was 99-5°F. and the pulse was slightly fuller. A specimen of the discharge from the wound was taken, and the pathologist reported that B. welchii were present. The wound was explored immediately by a cruciate incision, each limbus of the cross being about six inches long. The corners of the skin flaps were sutured back to the skin. Several muscles were seen to be discoloured, and bubbles of gas were present. The muscles particularly affected were the tibialis anticus and the extensor digitorum longus. These, and all suspicious muscles, were completely excised throughout the length of the wound. A Steinmann’s pin was inserted through the os calcis, and the limb was placed on a Thomas splint. The wound was left widely open and irrigated hourly with hydrogen peroxide alternating with acetic acid, the latter to provide an acid medium and to prevent the formation of an exudate. A fan was also arranged to provide a passage of air and to keep flies away and 16,000 units of anti-gas-gangrene serum were given twice a day. Four hours after the operation there was still oedema along the wound and along the peroneii muscles, but no crepitus could be elicited. Twelve hours later the patient’s general condition had improved. Four days later his circulation was good and there was no evidence of gas-gangrene. The flaps of skin The were viable, and the sutures were removed. wound was cleaned with eusol, and vaseline gauze and plaster were applied. The wound now appears to be granulating well, and there seems no reason to doubt that it will take the usual course of a compound fracture treated by the Winnett Orr method.
ORTHOPÆDIC SURGEON TO NORFOLK AND NORWICH HOSPITAL
difficulty of detecting gas-gangrene under pointed out in a leading article in THE LANCET on Sept. 16 (p. 656). Undoubtedly, if the presence of constitutional signs only determines the removal of a plaster and examination of a wound, it The
THE incidence of gas-gangrene infection varies with the nature of the country. Nitch,1 in Choyce’s " System of Surgery," states that gas-gangrene is practically unknown in desert and mountainous regions, and Truetaencountered only one case of gas-gangrene in treating 1073 fractures during the Spanish war. As Spain consists largely of mountains and arid plains, this is what one would expect. In
low-lying agricultural districts, however, is
common, and in
gas-gangrene
fracture service we have had four cases in the last six weeks. In two of our four cases, amputation had to be undertaken, and the third patient died even after amputation. With the fourth patient a slightly different technique was
relatively
our
used.
1. 2.
Nitch, C. A. R., A System of Surgery, vol. i, p. 217. Trueta, J., Lancet, 1939, 1, 1452.
plaster
was
will be too late to
save
any infected limb.
It is
suggested that forty-eight hours’ expectant treatment, either by constant examination of the wound through a window in a plaster cast, or with the limb on a Thomas splint, may be instrumental in saving some limbs that might otherwise have to be amputated. ... " What do the so-called great things of life end, the fashion of a man’s showing-off for
count for in the
the benefit of his fellows. It is the little things that give its savour or its bitterness to life, the little things that direct the currents of activity, the little things that alone really reveal the intimate depths of personality."-HAVELOCK ELLis in Selected Essays, Everyman Edition, 1936.
type
block, the
rest of the
complex being a
right ventricle or diphasic T wave. The left-leg potentials have not been included in these charts; but they show that in all of them the loose ends of the lower contour lines at the back should be continued across the left flank (turning back when necessary) to join up with their corresponding numbers in front. To make really accurate charts, many more leads from the front of the chest would be needed and many precautions which are impracticable without special facilities. There should be a time-signal, connected with the pulse, to give accurate synchronisation ; all leads should be taken in the same phase of respiration, the same posture, and at one sitting. Even so there would be other possible sources of error. But the present charts, defective as they are, will suffice to support the main conclusion, that in taking an
electrocardiogram we are tapping a
current
running
round the chest wall and are approximately registering the potential differences between the points of application of the electrodes ; and that these depend on the path of the stimulus and the anatomy of the paths of low electrical resistance from each side of the site of activity to the surface through the precordium, liver, auricles, and great veins. SUMMARY
(1) Charts of the normal T wave show that it develops in successive phases. (2) It is suggested that it is due to a wave of anabolism travelling inwards through the ventricular myocardium with the advance of the returning coronary supply ; and that the normal U wave is a dicrotic T wave. (3) The block
features of the
electrocardiogram
are
common
bundle-branch
discussed.
REFERENCES
Barker, P. S., Macleod, A. G., Alexander, J., and Wilson, F. N. (1929) Trans. Ass. Amer. Phys. 44, 125. Burdon-Sanderson, J. (1879) J. Physiol. 2, 384. (1939) Ibid, Aug. 19, p. 415. Hill, A. (1938) Lancet, 2, 1110. Lewis, T. (1925) Mechanism and Graphic Registration of the Heart Beat, 3rd ed., London, p. 54. —
EXPECTANT TREATMENT OF GASGANGRENE BY H. A.
BRITTAIN, M.Ch. Dubl., F.R.C.S.
patient was a labourer, aged 40, who fell height on to some cement, and sustained a compound fracture of the right tibia and fibula. The wound did not appear to be grossly contaminated, but in view of our recent experiences the following expectant treatment was adopted : Complete excision of the wound was performed, The from a
and a careful " debridement " carried out. The anterior tibial vessels were found to be lacerated at the site of the fracture, and these were sutured. A small protruding fragment of the tibia was removed, and the wound was irrigated with hydrogen peroxide and left widely open. The fracture was reduced by manual manipulation, and a plaster cast was applied The over wool packing extending above the knee. plaster was padded on account of the additional aid to the circulation. A window was cut over the wound, and the plaster was bi-valved. A postoperation radiogram showed a reasonably good reduction. A prophylactic dose of 12,000 units of anti-gas-gangrene serum was given, four times as large as the usual dose, and 1000 units of anti-tetanic serum. The wound was examined every two hours. Twenty hours later a minute bubble of gas was expressed from the lower aspect of the wound, and a faint smell of gas gangrene was present. The patient’s temperature was 99-5°F. and the pulse was slightly fuller. A specimen of the discharge from the wound was taken, and the pathologist reported that B. welchii were present. The wound was explored immediately by a cruciate incision, each limbus of the cross being about six inches long. The corners of the skin flaps were sutured back to the skin. Several muscles were seen to be discoloured, and bubbles of gas were present. The muscles particularly affected were the tibialis anticus and the extensor digitorum longus. These, and all suspicious muscles, were completely excised throughout the length of the wound. A Steinmann’s pin was inserted through the os calcis, and the limb was placed on a Thomas splint. The wound was left widely open and irrigated hourly with hydrogen peroxide alternating with acetic acid, the latter to provide an acid medium and to prevent the formation of an exudate. A fan was also arranged to provide a passage of air and to keep flies away and 16,000 units of anti-gas-gangrene serum were given twice a day. Four hours after the operation there was still oedema along the wound and along the peroneii muscles, but no crepitus could be elicited. Twelve hours later the patient’s general condition had improved. Four days later his circulation was good and there was no evidence of gas-gangrene. The flaps of skin The were viable, and the sutures were removed. wound was cleaned with eusol, and vaseline gauze and plaster were applied. The wound now appears to be granulating well, and there seems no reason to doubt that it will take the usual course of a compound fracture treated by the Winnett Orr method.
ORTHOPÆDIC SURGEON TO NORFOLK AND NORWICH HOSPITAL
difficulty of detecting gas-gangrene under pointed out in a leading article in THE LANCET on Sept. 16 (p. 656). Undoubtedly, if the presence of constitutional signs only determines the removal of a plaster and examination of a wound, it The
THE incidence of gas-gangrene infection varies with the nature of the country. Nitch,1 in Choyce’s " System of Surgery," states that gas-gangrene is practically unknown in desert and mountainous regions, and Truetaencountered only one case of gas-gangrene in treating 1073 fractures during the Spanish war. As Spain consists largely of mountains and arid plains, this is what one would expect. In
low-lying agricultural districts, however, is
common, and in
gas-gangrene
fracture service we have had four cases in the last six weeks. In two of our four cases, amputation had to be undertaken, and the third patient died even after amputation. With the fourth patient a slightly different technique was
relatively
our
used.
1. 2.
Nitch, C. A. R., A System of Surgery, vol. i, p. 217. Trueta, J., Lancet, 1939, 1, 1452.
plaster
was
will be too late to
save
any infected limb.
It is
suggested that forty-eight hours’ expectant treatment, either by constant examination of the wound through a window in a plaster cast, or with the limb on a Thomas splint, may be instrumental in saving some limbs that might otherwise have to be amputated. ... " What do the so-called great things of life end, the fashion of a man’s showing-off for
count for in the
the benefit of his fellows. It is the little things that give its savour or its bitterness to life, the little things that direct the currents of activity, the little things that alone really reveal the intimate depths of personality."-HAVELOCK ELLis in Selected Essays, Everyman Edition, 1936.