War Surgery and Medicine
First World War
First World War
At the beginning of the war wound treatment consisted of the removal of foreign bodies, of loose bone, and the institution of drainage. Aseptic dressings were utilised. Numerous antiseptics were employed for wound dressings, the most popular being acriflavine, others being the coal-tar dyes, Di-Chloramine T and Chloralamide. Later came the development of the technique of the thorough excision of the wound, with the removal of the contaminated area of the soft tissues, except naturally the vessels and nerves. At first, excision was restricted to wounds operated on within eight hours of infliction, and the wound was then primarily sutured. This proved generally unsatisfactory, and later the wound was left wide open and drainage instituted as required. Then the common occurrence of gas gangrene, and the realisation that dead muscle was the main culture medium in the wound for the anaerobic organisms, brought about the radical removal of devitalised muscle.
At first dressings were done frequently, with the consequent difficulty arising from shortage of staff. Sir Almroth Wright suggested the application of the principles of osmosis to produce adequate drainage, and further suggested that the wound be packed with dressings saturated in salt, tablets of salt being employed for the purpose. The wound was not dressed for about ten days after the original operation and packing. This treatment had great success in providing rest for the patient and adequate drainage of serum, but produced some difficulty in observation and did not combat anaerobic infection.
Then Carrel carried out his experiments, and advised the hypochlorites as a wound irrigation to combat infection. This became the standard method of treatment throughout the British Army. The wound was radically excised; then small rubber tubes page 4 with lateral holes were inserted freely into the wound, and gauze placed over it. The wound was not drained, but left like an open trough so that the Dakin's solution could lie in the wound and get longer contact with the tissues. Drainage was instituted only if abscess formation developed apart from the wound proper. Dakin's solution was then introduced into the tubes four-hourly by means of a syringe and allowed to be absorbed into the dressings. In large wounds trays were placed under the limb to catch the overflow. Later continuous slow drip irrigation was arranged by means of large glass containers suspended above the bed by wood or metal stands, with rubber tubes, and interposed drip taps, leading to the small tubes in the wound to which glass connections were attached.
Morison of Newcastle developed another technique for primary treatment of the wound. Excision of the wound was carried out and then the wound was packed with gauze impregnated with BIPP.1 This acted as a bacteriostatic and also encouraged lymph drainage of the wound, with generally satisfactory end-results. The method was also employed in the secondary suture of wounds. Apart from some lymph oozing, this method was very successful.
The preparation of the wound for secondary suture was the normal process of wound treatment at the end of the war. Bacteriological examinations were carried out to determine the quantitative infection present, and also to determine the nature of the infection. A scale was compiled showing the number of organisms present which normally would not interfere with satisfactory healing, and the scale was consulted in determining the advisability of operation. At operation the growing edges of the skin were gently excised so as to leave a raw area. The rest of the wound was dealt with by removing any dense scarred area that may have formed over the muscular and subcutaneous areas, and freeing the fascial layer. BIPP was generally rubbed lightly into the wound after its re-excision, and then any excess of the BIPP removed, so that only a thin staining remained. The wound was sutured by means of figure-of-eight sutures of strong silk which had been impregnated with BIPP. The sutures passed through the skin and the fascial layer at intervals of not less than half an inch. The tightening of the suture first brought the fascial layer together firmly, and then the skin. Slight oozing generally occurred between the stitches, but this did not interfere with very satisfactory healing. The BIPPed stitches could be left in for a long time without any irritation to the skin. Some surgeons did not use BIPP, and others employed a simple suture of the wound page 5 without re-excision. The bringing together of the fascial layer, however, had many advantages, especially in the elimination of muscle hernia. Generally, even in very large wounds, the wound could be brought together without great tension because of the wasting of the limb that had occurred since the injury. In cases of difficulty the skin and subcutaneous tissues were widely freed at either side of the wound, and small cuts were made in the skin parallel to the wound after suture, when there seemed to be danger of sloughing of the skin. The cuts relieved both tension and any venous congestion that might be present, and so preserved the vitality of the skin. In cases with marked loss of skin it was a usual preliminary measure to draw the wound together and then attempt suture later. In more serious cases skin grafting or pedicle flaps were utilised. Simple wounds and also compound fractures were dealt with in this way.
The French treated wounds, including wounds of joints and fractures, by excision of the wound (ébridement), by the use of large rubber tubes for dependent drainage and plaster splints for immobilisation. The splints were kept on for weeks, the resultant smell being relieved by the spraying of scent. As a rule, the temperature rapidly subsided, and the progress of the patients was generally satisfactory. Except for drainage the treatment resembled in many ways the Winnett Orr or Trueta treatment.
Most surgeons employed the Carrel-Dakin treatment as a means of controlling infection originally, and many utilised BIPP at the time of secondary suture.
Undoubtedly the Carrel-Dakin system produced excellent results, though it involved considerable nursing attention and somewhat elaborate appliances as methods of continuous irrigation were developed to obviate the four-hourly routine.
There were attempts made at the end of the war to carry out primary suture of wounds when conditions were suitable, and, in many cases, with success. The idea of primary suture was ever before the surgeon, but it was realised that, under ordinary conditions of warfare, the ideal was unattainable.
After the war the techniques of excision of wounds, of Carrel-Dakin treatment, and of Morison's BIPP treatment were all utilised in civilian practice, especially in the treatment of serious accidental injuries.
1 Bismuth iodoform paraffin paste.