F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
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of sloughs, once they have developed and are demarcated, is necessary. If after removal of
the cutaneous necrosis the underlying fascia is also found to be necrotic and appears to be
infected, it should be incised and sufficiently excised to allow free drainage of the infected
material. In many cases, underneath such a necrotic fascia, pockets of necrotic fat or
abscesses will be found which have to be emptied. The immediate improvement of the
patient's general condition, following such surgical transformation of a closed septic
wound—a sore covered with slough is a classical example of a closed septic wound—
into an open wound is always very striking. The old method, still advocated today, of
leaving the slough untouched until it falls off by itself (Munro, 1952) or becomes liquified
by various conservative procedures, is not only time consuming but most hazardous. It
must be remembered that, in penetrating sores, the deeper tissues underneath the
cutaneous slough are also necrotic and always infected. But, even if the deeper necrosis
were to remain uninfected, the absorption of the dead tissues into the blood stream would
in itself have toxic effects, manifested by listlessness of the patient, loss of appetite, bad
taste in the mouth, and higher degrees of toxaemia may even lead to toxic psychosis.
In one of my patients during the war, admitted with huge sloughy sores, the rapid
disappearance of the psychotic symptoms following excision of the sloughs was most
striking.
Following the excision of necrotic tissues and cleaning the surrounding skin, daily
dressings are applied to the sores, using antibiotics in saline solution, varying in type and
strength according to the type and severity of the infection. In our experience, dressings
of streptomycin-saline (J-J per cent) alternating with penicillin-saline have proved
very effective to combat the local infection of the sore. Before the dressing is applied, the
sore must be thoroughly cleansed with peroxide and saline.
Heavy chemicals are avoided in the local treatment, because they at least inhibit
the growth of granulations and delay rilling in of the defect resulting from the excision
of the slough and may even cause direct damage to the tissues. Flavazole, I : 2,000, or,
in very special cases of heavy proteus infection, i per cent in carbowax, is used for a few
days. Once the infection of the sore has been checked by antibiotics or flavazole, wet
dressings with sterile saline, weak boric solution (3 per cent), or Dakin's solution are
substituted. In this early stage of healing—i.e. filling in the defect by granulations—
dressings with greasy ointments of any kind, including paraffin, are strictly avoided.
Special attention has to be paid to the type of dressing used. The mere covering of
the sore, especially sacral sores, with a thin layer of gauze which is fixed at the outer edges
by thin strips of elastoplast is contraindicated for two reasons: first, such a dressing will
never prevent reinfection of the wound by faecal matter and, secondly, it will crumple
up and act as pressure to the granulating area and will thus not only delay the rate of
healing but will, in fact, produce patches of necrosis in a healing sore manifested by
patches of deep red or bluish discoloration. Therefore, after the wet dressing is applied,
several layers of dry gauze is placed on top and the whole dressing is completely sealed
off by porous elastoplast. Once the granulations have reached the level of the skin and
epithelialization has started, this can be accelerated by pellidol ointment or, if the area
is large, by seed grafts. With these procedures, sores of gigantic dimensions can be
healed completely in a relatively short time (Fig. 2i2a).
