Scand J Plast Reconstr Surg 13: 73-75, 1979
GAS GANGRENE AS A COMPLICATION OF BURNS D. M. Davies
Scand J Plast Surg Recontr Surg Hand Surg Downloaded from informahealthcare.com by Kainan University on 04/24/15 For personal use only.
From the Mclndoe Burns Unit, Queen Victoriu Hospitul. Eust Grinsterid. Sussex, England
Abstrcrcr. Gas gangrene infection in burnt patients is a rare but often fatal complication. It may however, be successfully treated by the use of hyperbaric oxygen and later judicious amputation of dead tissues. Five cases of bacteriologically proven gas gangrene, three of whom survived, occurred out of a total of one thousand and sixtyfour bums patients treated since 1964 in the Mclndoe Burns Unit. and these we describe.
Gas gangrene is a clinical diagnosis for a wound infection or bum complicated by gas formation. The major gas forming organisms are Clostridia but others include anaerobic Streptococci, Escherichia coli or Klebsiella. Clostridia are ubiquitous organisms present in the soil, however, the most important organism, Clostridium perfringens, is a normal inhabitant of the human gastro intestinal tract. There are nearly a hundred species of Clostridia but only a few are pathogenic to man. The clinical features of gas gangrene depend on the spread of an cu-toxin produced by Clostridium perfringens which is only produced in the presence of reduced tissue oxygen tension. The diagnosis may be made when the signs of toxaemia, anaemia, jaundice, severe local pain, together with the never to be forgotten malodour of hydrogen sulphide. The presence of gas in the tissues may be misleading for its presence may be due to previous operation. irrigation of the wound with hydrogen peroxide or other infective organisms (Brightmore & Greenwood, 1974) but the diagnosis may be confirmed by urgent gram stains and later culture. The presence of Clostridium welchii in a wound can be classified into three clinical conditions: I ) Clostridial contamination-the organism is usually found incidentally on routine culture and there is no clinical disease. 2) Clostridial cellulitis-there i s clinical evidence of disease in the absence of dead muscle and little toxin is formed.
3) Clostridial myonecrosis-Clostridia are present with dead muscle. There is marked toxin production and severe clinical disease. The complications of gas gangrene include haemolysis and haemorrhage in 65 5% of cases, toxic psychosis in 45% of cases, acute renal failure in 20% of cases and death in 25-5096 of cases. (The incidences given are only approximate and are taken from two series-Roding, Groeneveld & Boerema, 1972; and Slack, Hanson & Chew, 1969.)
CASE REPORTS Case I P. S. age 12 sustained, as the result of an aircraft accident, 65% full thickness bums of the face, left arm, trunk, and both legs. Eight days post bum dead muscle in the left thenar eminence was found to be infected by Clostridium Welchii. A diagnosis of clostridial cellulitis was made and the patient treated by wide excision of the dead muscle and intravenous penicillin. The patient survived. Cuse 2
G. S. age 42 sustained, in the same aircraft accident, 2 5 % full thickness bums of the face, both hands and both legs. Five days post bum obvious clinical g a s gangrene of the right lower leg was diagnosed (confirmed later by bacteriology). The patient was treated initially with intravenous penicillin and 30 cc’s of antigas gangrene serum also intravenously. The patient suffered a severe anaphylactoid reaction to the serum. Once resuscitated the right leg was amputated through the knee. The patient survived. Cuse 3 M. E. age 48, sustained 45% full thickness bums of the right arm, thigh, side of chest and the whole of the back plus a respiratory bum. Twelve days post bum Clostridium welchii was grown from swabs taken from the right arm. A diagnosis of clostridial cellulitis was made and the patient was treated with penicillin and amputation of the right arm. No further clostridial organisms were cultured. The patient died six weeks later a s a result of her respiratory bum.
74
D . M . Davies
Case 4
Scand J Plast Surg Recontr Surg Hand Surg Downloaded from informahealthcare.com by Kainan University on 04/24/15 For personal use only.
A. A. age 44, an alcoholic, who sustained 45 % full thickness bums of the anterior trunk and all skin below the waist. Twenty-four hours after admission a clinical diagnosis of gas gangrene was made (later confirmed bacteriologically.) The patient was resuscitated with large volumes of fluid but on induction of anaesthetic, for excision of dead tissue, had a fatal cardiac arrest. Post mortem showed the burn had extended through the abdominal wall to involve the large bowel. Case 5
D. L. age 36. sustained 52 % full thickness flame bums of the trunk, arms, face and legs. The flames were extinguished by being rolled over in the earth. Six days post bum he went into acute renal failure and was treated by haemodialysis. On the eighth day post bum obvious clinical gas gangrene of the left arm was apparent and confirmed bacteriologically. The patient was treated with penicillin and metronidazole intravenously, hyperbaric oxygen, the left arm being amputated after two treatments. The patient received ten treatments of one hour duration of hyperbaric oxygen at three'atmospheres pressure, and was dialysed for twenty days. The patient survived. All patients admitted to this unit are given one ampule of Triplopen intramuscularly on admission if not allergic to penicillin, followed by the same dose on following alternate days, plus tetanus toxoid prophylaxis
DISCUSSION Prophylaxis at the time of initial admission to hospital depends upon early adequate escharotomies to burnt limbs and penicillin (Thoresby & Mathison. 1967). However Monafo et al. (1966) bring to attention the fact that escharotomy and fasciotomy open fascia1 planes which allow the clostridial organisms to infect deeper dead muscle. This may be avoided by excising dead muscle at the time of the initial fasciotomy. Once the diagnosis has been made it should be confirmed by bacteriological culture but treatment should not be delayed until this result is available. We feel that burned patients with this complication should be treated as any other injury: 1) Antibiotics. Penicillin should be given in large doses (Slack et al.). Metronidazole may also have a place as it has an antibacterial effect against all anaerobic organisms including the Clostridia (Freeman, McFadzean & Whelan, 1968). Many patients have mixed infections and thus other antibiotics may be required as culture reports indicate. 2) Hyperbaric oxygen. This is life saving in most cases, and in a severely toxic patient should be used prior to surgery in order that the patient's general S C ' t I d J P/tlsl f f t C f J l l , V / rS / l , B
/J
condition may be improved (Brummelkamp. Hoogendyk & Boerema, 1963). However Duff, McLean & McLean (1970) have come to the conclusion that adequate surgery is the most important single factor influencing successful treatment of patients with gas gangrene. In 1961 Brummelkamp, Hogendijk & Boerema, showed that guinea pigs inoculated with clostridia could be successfully treated with hyperbaric oxygen and followed this in 1963 with a series of twenty six cases in which only one patient died directly from gas gangrene. Several other large series have confirmed this theraputic advance (Colwill & Maudsley, 1968; Slack et al.; Roding et a1.L Paul Bert showed in 1878 that exposure of anaerobic organisms to high pressures of oxygen suppressed their growth. The effect Of hyperbaric oxygen is to increase the solubility of oxygen in plasma from 0.3 vol. % to 4 vol. % at three atmospheres pressure. The dangers of hyperbaric oxygen treatment include: ( a ) Pressure changes in the middle ear which may require decompression. ( b ) Oxygen poisoning which is caused by the oxygen interfering with enzyme actions in the brain producing confusion and convulsions. ( c ) The Lorraine-Smith effect which is oxygen damaging the lungs resulting in a diffuse patchy consolidation and severe deterioration in lung function. ( d ) Fire hazards-this is very real and in particular burns dressed with tulle gras have to be thoroughly cleaned before treatment is started. Treatment may be performed in a Heatherwood-Vickers oxygen chamber fiving one hours treatment at three atmospheres pressure with 100% oxygen. Initially treatment is performed twice a day and then daily until three consecutive daily swabs record the patient is free of clostridial infection. These daily swabs should then be continued to monitor any relapse. 3) Operation. Apart from initial escharotomies the theraputic effect of hyperbaric oxygen may be improved by incising dead muscle and eschar. Amputation of dead limbs should be delayed until after several treatments with hyperbaric oxygen which should render the patient more able to tolerate the surgical stress. Obviously in an extensively burnt patient the whole area of dead tissue cannot
Scand J Plast Surg Recontr Surg Hand Surg Downloaded from informahealthcare.com by Kainan University on 04/24/15 For personal use only.
Gus gangrene us ri complicution of hrrrns
be excised. Thus only areas with underlying dead muscle are excised and the rest of the burn area is only treated after bacteriological swab reports indicate continuing infection. 4) Antiserum. Van Zyl(1967) reported thirty-one cases of gas gangrene in which the use of antigas gangrene serum had not prevented infection. Rifkind in 1963 reported the common occurrence of hypersensitivity reactions, and this was also our experience with Case 2. 5) Trunsjirsion. Gas gangrene is characterised by severe toxic haemolysis and fluid exudation. Thus fluid replacement becomes even more of a problem in these patients. Hyperbaric oxygen treatment may mask the symptoms of anaemia and thus blood transfusion must be readily available when the patient leaves the chamber. The incidence of gas gangrene at the McIndoe Bums Unit, East Grinstead is five cases out of a total of I064 cases admitted to the unit. Poate & Macafe ( 1962) reported two cases of electrical bums complicated by gas gangrene and treated by amputation, antigas gangrene serum and penicillin. Both cases survided. Monafo et al. reported seven cases of gas gangrene complicating bums all of whom died. Hartford & Ziffren (1971) reported in a series of electrical bums one case complicated by gas gangrene and successfully treated by amputation. Bourke & Ritchie (1972) in a series of twenty patients suffering from gas gangrene had one burns case successfully treated by amputation and hyperbaric oxygen. In Great Britain there are nineteen centres with hyperbaric oxygen units suitable for treating gas gangrene. However only one (other than the case of Bourke & Ritchie) of these has treated a burns case complicated by this infection. A 62-year-old male with diabetes sustained a bum to the right thigh which nine days later was found to be infected by Clostridium welchii and Bacteroidese. He was successfully treated by debridement and hyperbaric oxygen (Morrow, personal communication). Hyperbaric oxygen has been claimed by Hart et al. (1974) that if given within twenty-four hours of thermal injury significantly decreases healing time, and morbidity and mortality, thus having further beneficial effect on the patient as well as combating the infection.
75
CONCLUSION Gas gangrene complicating bums is a rare but senous complication. The sequence of treatment advised is antibiotics, hyperbaric oxygen, and surgery.
REFERENCES Bert. P. 1878. La pression baromttrique recherches de physiologie experimentale. G . Masson, Pans. Bourke, J. B. & Ritchie, H. D. 1972. Treatment of clostridial infections in one man hyperbaric oxygen chambers. J R Coll Surg Edinb 17, 9. Brightmore, T. & Greenwood, T. W. 1974. The significance of tissue gas and clostridial organisms in the differential diagnosis of gas gangrene. Br J Clin Pract 28, 43. Brummelkamp, W. H., Hogendijk, J. & Boerema, I. 1961. Treatment of anaerobic infections by drenching the tissues with oxygen under high atmospheric pressure. Surgery 49. 291. - 1963. Treatment of clostridial infections with hyperbaric oxygen drenching. Lancet 1 , 235. Colwill, M. R. & Maudsley, R. H. 1%8. The management of gas gangrene with hyperbaric oxygen therapy. J Bone Joint Surg 50 B , 732. Duff, J . H., McLean, M. D. & McLean, L. D. 1970. Treatment of severe anaerobic infections. Arch Surg 101. 314. Freeman, W . A., McFadzean, J . A. & Whelan, J. P. F. 1968. Activity of metronidazole against experimental tetanus and gas gangrene. J Appl Bacteriol31, 443. Hart, G. B. et al. 1974. Treatment of bums with hyperbaric oxygen. Surg Gynecol Obstet 139. 693. Hartford, C. E. & Ziffren, S. E. 1971. Electrical injury. J Trauma I I , 33 I . Monafo. W. W. et al. 1%6. Gas gangrene and mixed clostridial infections of muscle complicating deep thermal bums. Arch Surg 92, 212. Poate. W. J. & Macafe, A. L. 1962. Gas gangrene following electrical bums. Br J Plast Surg 15, 17. Rifkind, D. 1%3. The diagnosis and treatment of gas gangrene. Surg Clin North Am 43, 5 11. Roding, B., Groeneveld, P. H. A. & Boerema, I. 1972. Treatment of gas gangrene with hyperbaric oxygen. Surg Gynecol Obstet 134, 579. Slack, W. G . , Hansen, G. C. & Chew, H. E. R. 1%9. Hyperbaric oxygen in the treatment of gas gangrene and clostridial infection. Br J Surg 56, 505. Thoresby, F. P. & Mathison, J. M. 1%7. Prophylaxis and treatment of gas gangrene. J R Army Med Corps 113, 36. van Zyl, J. J. W. 1%7. Hyperbaric oxygen. M. D. thesis. University of Stellenbosch, South Africa.
GAS GANGRENE AS A COMPLICATION OF BURNS D. M. Davies
Scand J Plast Surg Recontr Surg Hand Surg Downloaded from informahealthcare.com by Kainan University on 04/24/15 For personal use only.
From the Mclndoe Burns Unit, Queen Victoriu Hospitul. Eust Grinsterid. Sussex, England
Abstrcrcr. Gas gangrene infection in burnt patients is a rare but often fatal complication. It may however, be successfully treated by the use of hyperbaric oxygen and later judicious amputation of dead tissues. Five cases of bacteriologically proven gas gangrene, three of whom survived, occurred out of a total of one thousand and sixtyfour bums patients treated since 1964 in the Mclndoe Burns Unit. and these we describe.
Gas gangrene is a clinical diagnosis for a wound infection or bum complicated by gas formation. The major gas forming organisms are Clostridia but others include anaerobic Streptococci, Escherichia coli or Klebsiella. Clostridia are ubiquitous organisms present in the soil, however, the most important organism, Clostridium perfringens, is a normal inhabitant of the human gastro intestinal tract. There are nearly a hundred species of Clostridia but only a few are pathogenic to man. The clinical features of gas gangrene depend on the spread of an cu-toxin produced by Clostridium perfringens which is only produced in the presence of reduced tissue oxygen tension. The diagnosis may be made when the signs of toxaemia, anaemia, jaundice, severe local pain, together with the never to be forgotten malodour of hydrogen sulphide. The presence of gas in the tissues may be misleading for its presence may be due to previous operation. irrigation of the wound with hydrogen peroxide or other infective organisms (Brightmore & Greenwood, 1974) but the diagnosis may be confirmed by urgent gram stains and later culture. The presence of Clostridium welchii in a wound can be classified into three clinical conditions: I ) Clostridial contamination-the organism is usually found incidentally on routine culture and there is no clinical disease. 2) Clostridial cellulitis-there i s clinical evidence of disease in the absence of dead muscle and little toxin is formed.
3) Clostridial myonecrosis-Clostridia are present with dead muscle. There is marked toxin production and severe clinical disease. The complications of gas gangrene include haemolysis and haemorrhage in 65 5% of cases, toxic psychosis in 45% of cases, acute renal failure in 20% of cases and death in 25-5096 of cases. (The incidences given are only approximate and are taken from two series-Roding, Groeneveld & Boerema, 1972; and Slack, Hanson & Chew, 1969.)
CASE REPORTS Case I P. S. age 12 sustained, as the result of an aircraft accident, 65% full thickness bums of the face, left arm, trunk, and both legs. Eight days post bum dead muscle in the left thenar eminence was found to be infected by Clostridium Welchii. A diagnosis of clostridial cellulitis was made and the patient treated by wide excision of the dead muscle and intravenous penicillin. The patient survived. Cuse 2
G. S. age 42 sustained, in the same aircraft accident, 2 5 % full thickness bums of the face, both hands and both legs. Five days post bum obvious clinical g a s gangrene of the right lower leg was diagnosed (confirmed later by bacteriology). The patient was treated initially with intravenous penicillin and 30 cc’s of antigas gangrene serum also intravenously. The patient suffered a severe anaphylactoid reaction to the serum. Once resuscitated the right leg was amputated through the knee. The patient survived. Cuse 3 M. E. age 48, sustained 45% full thickness bums of the right arm, thigh, side of chest and the whole of the back plus a respiratory bum. Twelve days post bum Clostridium welchii was grown from swabs taken from the right arm. A diagnosis of clostridial cellulitis was made and the patient was treated with penicillin and amputation of the right arm. No further clostridial organisms were cultured. The patient died six weeks later a s a result of her respiratory bum.
74
D . M . Davies
Case 4
Scand J Plast Surg Recontr Surg Hand Surg Downloaded from informahealthcare.com by Kainan University on 04/24/15 For personal use only.
A. A. age 44, an alcoholic, who sustained 45 % full thickness bums of the anterior trunk and all skin below the waist. Twenty-four hours after admission a clinical diagnosis of gas gangrene was made (later confirmed bacteriologically.) The patient was resuscitated with large volumes of fluid but on induction of anaesthetic, for excision of dead tissue, had a fatal cardiac arrest. Post mortem showed the burn had extended through the abdominal wall to involve the large bowel. Case 5
D. L. age 36. sustained 52 % full thickness flame bums of the trunk, arms, face and legs. The flames were extinguished by being rolled over in the earth. Six days post bum he went into acute renal failure and was treated by haemodialysis. On the eighth day post bum obvious clinical gas gangrene of the left arm was apparent and confirmed bacteriologically. The patient was treated with penicillin and metronidazole intravenously, hyperbaric oxygen, the left arm being amputated after two treatments. The patient received ten treatments of one hour duration of hyperbaric oxygen at three'atmospheres pressure, and was dialysed for twenty days. The patient survived. All patients admitted to this unit are given one ampule of Triplopen intramuscularly on admission if not allergic to penicillin, followed by the same dose on following alternate days, plus tetanus toxoid prophylaxis
DISCUSSION Prophylaxis at the time of initial admission to hospital depends upon early adequate escharotomies to burnt limbs and penicillin (Thoresby & Mathison. 1967). However Monafo et al. (1966) bring to attention the fact that escharotomy and fasciotomy open fascia1 planes which allow the clostridial organisms to infect deeper dead muscle. This may be avoided by excising dead muscle at the time of the initial fasciotomy. Once the diagnosis has been made it should be confirmed by bacteriological culture but treatment should not be delayed until this result is available. We feel that burned patients with this complication should be treated as any other injury: 1) Antibiotics. Penicillin should be given in large doses (Slack et al.). Metronidazole may also have a place as it has an antibacterial effect against all anaerobic organisms including the Clostridia (Freeman, McFadzean & Whelan, 1968). Many patients have mixed infections and thus other antibiotics may be required as culture reports indicate. 2) Hyperbaric oxygen. This is life saving in most cases, and in a severely toxic patient should be used prior to surgery in order that the patient's general S C ' t I d J P/tlsl f f t C f J l l , V / rS / l , B
/J
condition may be improved (Brummelkamp. Hoogendyk & Boerema, 1963). However Duff, McLean & McLean (1970) have come to the conclusion that adequate surgery is the most important single factor influencing successful treatment of patients with gas gangrene. In 1961 Brummelkamp, Hogendijk & Boerema, showed that guinea pigs inoculated with clostridia could be successfully treated with hyperbaric oxygen and followed this in 1963 with a series of twenty six cases in which only one patient died directly from gas gangrene. Several other large series have confirmed this theraputic advance (Colwill & Maudsley, 1968; Slack et al.; Roding et a1.L Paul Bert showed in 1878 that exposure of anaerobic organisms to high pressures of oxygen suppressed their growth. The effect Of hyperbaric oxygen is to increase the solubility of oxygen in plasma from 0.3 vol. % to 4 vol. % at three atmospheres pressure. The dangers of hyperbaric oxygen treatment include: ( a ) Pressure changes in the middle ear which may require decompression. ( b ) Oxygen poisoning which is caused by the oxygen interfering with enzyme actions in the brain producing confusion and convulsions. ( c ) The Lorraine-Smith effect which is oxygen damaging the lungs resulting in a diffuse patchy consolidation and severe deterioration in lung function. ( d ) Fire hazards-this is very real and in particular burns dressed with tulle gras have to be thoroughly cleaned before treatment is started. Treatment may be performed in a Heatherwood-Vickers oxygen chamber fiving one hours treatment at three atmospheres pressure with 100% oxygen. Initially treatment is performed twice a day and then daily until three consecutive daily swabs record the patient is free of clostridial infection. These daily swabs should then be continued to monitor any relapse. 3) Operation. Apart from initial escharotomies the theraputic effect of hyperbaric oxygen may be improved by incising dead muscle and eschar. Amputation of dead limbs should be delayed until after several treatments with hyperbaric oxygen which should render the patient more able to tolerate the surgical stress. Obviously in an extensively burnt patient the whole area of dead tissue cannot
Scand J Plast Surg Recontr Surg Hand Surg Downloaded from informahealthcare.com by Kainan University on 04/24/15 For personal use only.
Gus gangrene us ri complicution of hrrrns
be excised. Thus only areas with underlying dead muscle are excised and the rest of the burn area is only treated after bacteriological swab reports indicate continuing infection. 4) Antiserum. Van Zyl(1967) reported thirty-one cases of gas gangrene in which the use of antigas gangrene serum had not prevented infection. Rifkind in 1963 reported the common occurrence of hypersensitivity reactions, and this was also our experience with Case 2. 5) Trunsjirsion. Gas gangrene is characterised by severe toxic haemolysis and fluid exudation. Thus fluid replacement becomes even more of a problem in these patients. Hyperbaric oxygen treatment may mask the symptoms of anaemia and thus blood transfusion must be readily available when the patient leaves the chamber. The incidence of gas gangrene at the McIndoe Bums Unit, East Grinstead is five cases out of a total of I064 cases admitted to the unit. Poate & Macafe ( 1962) reported two cases of electrical bums complicated by gas gangrene and treated by amputation, antigas gangrene serum and penicillin. Both cases survided. Monafo et al. reported seven cases of gas gangrene complicating bums all of whom died. Hartford & Ziffren (1971) reported in a series of electrical bums one case complicated by gas gangrene and successfully treated by amputation. Bourke & Ritchie (1972) in a series of twenty patients suffering from gas gangrene had one burns case successfully treated by amputation and hyperbaric oxygen. In Great Britain there are nineteen centres with hyperbaric oxygen units suitable for treating gas gangrene. However only one (other than the case of Bourke & Ritchie) of these has treated a burns case complicated by this infection. A 62-year-old male with diabetes sustained a bum to the right thigh which nine days later was found to be infected by Clostridium welchii and Bacteroidese. He was successfully treated by debridement and hyperbaric oxygen (Morrow, personal communication). Hyperbaric oxygen has been claimed by Hart et al. (1974) that if given within twenty-four hours of thermal injury significantly decreases healing time, and morbidity and mortality, thus having further beneficial effect on the patient as well as combating the infection.
75
CONCLUSION Gas gangrene complicating bums is a rare but senous complication. The sequence of treatment advised is antibiotics, hyperbaric oxygen, and surgery.
REFERENCES Bert. P. 1878. La pression baromttrique recherches de physiologie experimentale. G . Masson, Pans. Bourke, J. B. & Ritchie, H. D. 1972. Treatment of clostridial infections in one man hyperbaric oxygen chambers. J R Coll Surg Edinb 17, 9. Brightmore, T. & Greenwood, T. W. 1974. The significance of tissue gas and clostridial organisms in the differential diagnosis of gas gangrene. Br J Clin Pract 28, 43. Brummelkamp, W. H., Hogendijk, J. & Boerema, I. 1961. Treatment of anaerobic infections by drenching the tissues with oxygen under high atmospheric pressure. Surgery 49. 291. - 1963. Treatment of clostridial infections with hyperbaric oxygen drenching. Lancet 1 , 235. Colwill, M. R. & Maudsley, R. H. 1%8. The management of gas gangrene with hyperbaric oxygen therapy. J Bone Joint Surg 50 B , 732. Duff, J . H., McLean, M. D. & McLean, L. D. 1970. Treatment of severe anaerobic infections. Arch Surg 101. 314. Freeman, W . A., McFadzean, J . A. & Whelan, J. P. F. 1968. Activity of metronidazole against experimental tetanus and gas gangrene. J Appl Bacteriol31, 443. Hart, G. B. et al. 1974. Treatment of bums with hyperbaric oxygen. Surg Gynecol Obstet 139. 693. Hartford, C. E. & Ziffren, S. E. 1971. Electrical injury. J Trauma I I , 33 I . Monafo. W. W. et al. 1%6. Gas gangrene and mixed clostridial infections of muscle complicating deep thermal bums. Arch Surg 92, 212. Poate. W. J. & Macafe, A. L. 1962. Gas gangrene following electrical bums. Br J Plast Surg 15, 17. Rifkind, D. 1%3. The diagnosis and treatment of gas gangrene. Surg Clin North Am 43, 5 11. Roding, B., Groeneveld, P. H. A. & Boerema, I. 1972. Treatment of gas gangrene with hyperbaric oxygen. Surg Gynecol Obstet 134, 579. Slack, W. G . , Hansen, G. C. & Chew, H. E. R. 1%9. Hyperbaric oxygen in the treatment of gas gangrene and clostridial infection. Br J Surg 56, 505. Thoresby, F. P. & Mathison, J. M. 1%7. Prophylaxis and treatment of gas gangrene. J R Army Med Corps 113, 36. van Zyl, J. J. W. 1%7. Hyperbaric oxygen. M. D. thesis. University of Stellenbosch, South Africa.
