War Surgery and Medicine
OTHER ASPECTS OF WOUND TREATMENT
OTHER ASPECTS OF WOUND TREATMENT
The story of the development of the Blood Transfusion Service is given elsewhere, but it is necessary to stress the great importance of blood, plasma, and serum in the resuscitation of the wounded man and in wound repair.
There was a very severe loss of blood in many large wounds, especially of the limb. Lieutenant-Colonel Grant, RAMC, estimated that a loss of 50 per cent of the total blood volume was common in such injuries, so that up to five pints of blood was required to make up the loss.
At first the use of blood was confined to the primary treatment of the severely wounded man, in order to replace blood loss and so sustain the general circulation and combat shock. This led to the direct saving of many lives and enabled operative treatment to be safely undertaken. Later, blood was used at the base hospitals to combat the Secondary anaemia which was almost invariably present, often to a marked degree, in patients with severely infected wounds. Often haemoglobin was down to 50 per cent or less, and the red cells to 3,000,000 or under in these cases. As much as three pints of blood was often required to bring the haemoglobin and red cells up to a satisfactory level. Fresh blood carefully cross-typed had to be used and given slowly, as severe reactions were common, especially in those cases who had already been transfused in the forward areas.
As the war progressed it was realised that a marked protein deficiency was present in all severe casualties, and that blood plasma or serum transfusions were of great value in counteracting it. It was realised that biochemical changes had a very great effect on wound infection and healing. During the latter half of the war, not only protein deficiency but deficiency of chemicals and vitamins were recognised as being of the utmost importance. It was recognised that the wound healing depended on the general metabolism of the body and that adequate food, particularly those foods of high protein content, and adequate fluid were necessary, especially in the presence of infection.
Plasma and serum were of particular value in all cases of protein deficiency and were generally given as a daily routine in the early stages of the most serious cases.page 20
Effect of Transportation on Wound Healing
The evacuation of wounded men from the forward areas shortly after or without operation was found to interfere seriously with wound healing. This was especially marked following transport over the roadless desert, but even on good road surfaces ambulance transport was harmful, and swelling of the limb often occurred. If primary suture had been undertaken, this swelling led to tension and tearing of the stitches. Plaster splints caused dangerous constriction of the swollen limb, and this led to the padding and splitting up of the splints in the forward areas.
Treatment of the Wound after Primary Operation
At the beginning of the war, when the closed plaster treatment was carried out for all the large wounds, the original plaster with its underlying vaseline gauze dressing remained untouched for a period generally of two to three weeks. The plaster was then removed and the dressing and plaster changed, still using vaseline gauze unless frank sepsis called for different treatment. When sulphanilamide was adopted as an application to the surface of the wound it was reapplied when the original plaster dressing was removed. Later it was ascertained that the local application of sulphonamides to the wound often led to the patient becoming sensitised to sulphonamide, and also that the sulphonamide locally had little effect on ingrained infection. In consequence, the local application of the sulphonamides was discontinued, reliance being placed on the administration of sulphonamides by mouth for the first five to seven days after wounding, and later for the treatment of sulphonamide-sensitive infections such as that due to the streptococcus, with strictly regulated dosage for a limited period.
During this period, if definite sepsis arose it was countered by methods of treatment for infection as ordinarily applied in the pre-sulphonamide period. Drainage has been mentioned, and associated with that was the free opening up of the infected area by incision and the removal of any slough or gangrenous or avascular muscle, as well as the evacuation of any collection of pus. Treatment was instituted by antiseptic lotions such as the electrolytic hypochlorites, which were often instilled into the wound following the methods of the First World War. Acriflavine was also used, as was dichloramine T. Saline baths were sometimes used.
When penicillin was available it was applied locally in a sulphanilamide base at the original treatment of the wound, and thereafter was applied locally by instillation into the wound, and in addition it was given parenterally. For infection which was page 21 resistant to penicillin the older methods of treatment were again resorted to. The treatment of established sepsis depended on the type of infection and on the organisms responsible.