Portal de Periódicos da CAPES

A CONTRIBUTION TO THE ETIOLOGY OF SHELL SHOCK.

1916; Elsevier BV; Volume: 187; Issue: 4842 Linguagem: Inglês

10.1016/s0140-6736(01)14500-9

1474-547X

H. C. Wiltshire,

hypertonic solution applied is a 5 per cent.solution, a very little dilution will bring it to the point when blood clotting will no longer be inhibited.(2) When the face of the wound is found covered with a firmly adherent glutinous coating, this has been derived from leucocytes broken down by the direct application of strong salt.The way of avoiding this obstacle-it is, as a matter of fact, a serious obstacle to effective draining and irrigation-is to clean out all pus from the wound before bringing the hypertonic salt solution into application.(3) Where, as very rarely happens, the granulations become oedematous this will be due to the over-prolonged application of concentrated salt solutions.It would seem that here the salt which is imbibed into the granulations is not sufficiently promptly carried off by the circulation, with the result that fluid is drawn into the salt-impregnated tissues, both from the underlying strata, and also (when their salt content diminishes) from the discharges.The remedy will be to discontinue the application of salt, and to apply hot fomentations in order to activate the circulation and promote absorption.;(4) Where the granulations assume a bright coral-red colour, and bleed at the least touch, it will be well to reduce the concentration of the salt solution-in the case where drainage of the tissues is still required to 2'5 per cent., and in the case where no further lymphagogic effect is required to 0 85 per cent.(5) Quite apart from the development of any undesirable secondary effects, it will be well as soon as every trace of induration has disappeared, and all sloughs have been got rid of, to substitute for the hypertonic a physiological salt solution.The rationale of this is, that there will here still remain on the face of the wound, even though it looks to the naked eye perfectly clean.serophytic microbes, which, though quite at home in the serum, can be killed by phagocytosis.In order to kill these-and let us note that they are not killed but only inhibited in their growth by hypertonic salt solution-we must bring leucocytes to the surface of the wound.17.THERAPEUTIC APPLICATION OF PHYSIOLOGICAL SALT SOLUTION.What remains to be done is (a) to destroy the serophytic bacteria-streptococci and staphylococci-which still survive upon the face of the wound; and (b) to reduce the extent of surface lying open to infection, holding before ourselves always as an ideal the closure of the wound by secondary suture.Destruction of the serophytic microbes remaining on the fccce of the wound.-Asurface infection such as we have still to deal with can be effectively combated by keeping the wound wet with physiological salt solution and re-dressing at short intervals.The application of physiological salt solution will, as we have seen, promote the emigration of phagocytes, the frequent re-dressing will prevent the setback that will occur every time that leucocytes die off and set free their trypsin in the wound; and the combination of the two will, in the case where the deeper tissues have been freed from infec- tion, either exterminate the surface infection, or at any rate so nearly exterminate it as to make it safe to embark upon an operation for the closure of the wound.18. FINAL STAGES IN THE TREATMENT OF THE WOUND.' Conditions under which wounds may be olosed by secondary suture.-Secondarysuture may be safely embarked upon when we have favourable bacteriological conditions in combination with favourable anatomical conditions.The bacteriological conditions may be pronounced favour- able when (a) microscopic examination of fluid from the depth drawn out by a " lymph leech " ; or failing this, clinical evidence points to the probability of our having got rid of all the deep infection, and when (b) stained impression preparations made from the wound surface show that we have there large numbers of perfectly well conditioned polynuclear leucocytes, and a complete absence of microbes, or only here and there a stray microbe.The anatomical conditions are favourable when we can, with or without undercutting, bring together the skin edges without putting too great a strain upon the sutures, or leaving underneath any hollow spaces.The operation of secondary suture may be undertaken either before the wound surfaces are covered in with granulations, or sub- sequent to this-the former of these dates being, from the bacteriological point of view, the more favourable, in the respect that there will be less risk of infection lurking below the surface.It will, in every case, be advisable-for the conditions may change within the lapse of a few hours-to let the operation follow immediately upon the examination of the impression preparations.