A NEW WAY WITH WAR WOUNDS

Evening Star, Issue 23693, 28 September 1940, Page 3

A NEW WAY WITH WAR WOUNDS

Against the evils of war must be set the experience and lessons that it has provided for surgeons (writes the, medical correspondent of the ‘ Spectator ’). It was during the wars of the sixteenth century that Ambroiso Bare realised and impressed upon surgery tlie relative advantages of the ligature over crude and painful cauterisation in controlling hiemorrhage. It was to observations made upon wounded men in the Franco-Prussian War that we are largely indebted for our present-day knowledge of the geography and functions of the brain. Similarly a great deal was learned during the war of 1914-18 about the treatment of deep and soiled wounds, and a good deal more, thanks chiefly to the Spanish surgeon, Trueta, now in England, during the Civil War in Spain. It would, perhaps, he more correct to say that the process, compelled by experience, was rather one of- unlearning. though without in any way disestablishing the underlying principles impressed upon surgery by Lister. It still remains true, as he more than any other man established, that the infection and suppuration of wounds is due to the invasion from outside of pathogenic micro-organisms. This “ outside,” in his days and before, was probably chiefly the hands and garments of surgeons themselves — many of them took a pride in operating in clothes stiff with blood and discharges of a hundred operations—of attendants and nurses, and, in crowded hospital wards, of neTghbouring patients. Lister’s answer was the destruction of those possible invaders by operating in a mist of antiseptics and the use of antiseptic dressings; and his results were so dramatic that' they could not be ignored. There were many discomforts and disadvantages, however, in so operating; and surgery slowly evolved the technique of eliminating their presence altogether. Tlie use of sterilised instruments, sterilised dressings, sterilised operating garments, masks and gloves, became the universally adopted alternative. It was perfected to such an extept that, in considering the advisability of an operation in any part of the body, the possibility of sepsis as a contra-indication had been practically removed from the surgeon’s calculations. Clean operative results, with almost invisible residual sears, were the routine expectation. The surgeon had ceased to expect that his patient’s bodily tissues would he called upon to deal with infection. Ho had perhaps oven forgotten to what an extent they wore capable of doing this. . It began to grow clear, however, in 1914 and 1915 that this procedure was not producing the expected results in a great many war operations, and especially in patients whose wounds had been deep and perhaps associated with fractured bones. Cases in which neatly sown-up wounds broke open again owing to sepsis, or developed various forms of gangrene, were only too common. This was sometimes because some tiny fragment of soiled uniform or other material .had remained undetected in the depths of the wound; or because the bruised tissues had in reality been all the time too devitalised to restore themselves in the normal way. It also became clear that the routine application and reapplicatiou of antiseptics to these bruised tissues tended in itself to their devitalisation.

The practice, therefore, began of a much more thorough exploration of all wounds for foreign particles, of a much bolder excision of doubtful, halfalive tissues, and of leaving wounds tints treated unclosed to heal up from the bottom—a slower hut, as it proved, very much safer process. Greater reliance, too! came to be placed upon the ability of the remaining healthy tissues and their blood supply*to deaf with any hostile organisms that might he present; and simple washing out with water or salt solutions largely took the place of antiseptic applications. The results showed an astonishing improvement both as regards the comfort of the patient and the absence of serious septic complications. In the Spanish Civil War, Trncta carried this process a stop further, realising the great importance of* the added factor of rest in the healing of such wounds. After the exploration, cleansing, and excision of damaged tissues—what is known as “ debridement ” —and the setting, if necessary, of underlying or associated fractures, he merely covered the resultant exposed surface with a light dressing and then completely covered and immobilised the limb concerned in plaster of Paris. Patients so treated could, he found, be transported anywhere in relative! comfort, and wore afterwards simply loft alone. Their general condition, temperature, appetite, and sleep were taken as an index as to whether the unseen wounds were healing satisfactorily.

Taken as a whole, the results were strikingly successful; and this method has already been used with great success in the present war. It has demanded a now proficiency from English surgeons in the art of applying and moulding plaster of Paris casings—an art with which many of them have not yet been very familiar. But there can bo no doubt'about the value of this largely war-born surgical technique.