A. Don
1916 BMJ (Clinical Research Edition)  
TEN months in a casual y dclaring station gives one an opportunity of trying the various methods of dressing wounds as they have been from tilmie to time suggested, and of comparing their efficacy in cleaning damaged tissues, in preventing the spread of infections, and in (adding to the comfort of tlle patients. If, as happens in my case, the surgeon is not identified witlh any of the newer disinfectants, a fair trial may be assured for each of them. The surgery of wotunds, as distinct from the
more » ... s distinct from the method.of dressing, is not meantime under consideration, but it must b3 stipulated that, for real comparison, the surgical technique should not clhange coincidently with the methAd of dressinig. To clhange botlh at the same time introduces two factors, eitlher of wllich may alter the whole picture. In published writings on the treatment of wounds in the present war one meets with assertions that aiitiseptics have failed rs; that previous experience in, say, South Africa, does net lhelp us; and even the suggestion that the dressing of wounds is more tlhe province of the plhysician than of the surgeon; and, furtlher, that all previous know. ledge of the treatment of wounds must be a bar to success out here. Such statements must be taken cum grano salis, even though the writers are experienced and men of note. It is tr-ue that a surgeon's mnetliols in civil practice become more or less stereotyped. Older men unlearn old methods with difficulty and assimilate new ones with diffid n.e, but one is still left witlh the feeling that the surge( n of ecperience whio possesses the virility to be at the fr nt, s a valuable a. set to thle army. Hiis civilian dogmas get a rude slhock at first, and hiis confidence in hiis well-tried methods may be slhaken, but lie sooIn recognizes the new elen'eets lhe has t) contend wvitl, and will certainly I a e me; theem b(fo:e, if rarely -or at least will be Iamiliar witlh most of them from his knowledge of tl:e history of u gery. Tlje fact is that it is merely his memory that needs refreslling, and his fixed habits that need reforming. Few even of the older surgeons have seen hospital gangrene, and they do ii )t always recognize that this serious scourge of surgery tlhrove on a lack of scientific ktiowledge of bacteriology and antiseptics, wlichl is now tauglht to and understood by every medical student. The present gas gangrene is identical with the old hospital gangrene, and the mixed infections we see so frequently were in olden times, as somnetirnes even now, introduced in tlle dressings tlhemselve3. The greater number of slhell wounds, .and the high-velocity rifle bullet at close range, produce effects that are of daily occurrence lhere, but were new at first to surgeons who had been tllrouglh the South African campaign. But all there effects have been met with before, and are, in fact, m-latters of hiistory. Tlhe one new featur( is the trenclh warfare, and its effects on wounds. ThJe soldier s skin, clotlhing, hair, every part of him which a missile lhas to traverse, is covered witli mud, whicli is carried to tlle deptlhs of every wound. Higlily fertilized soil may contain every conceivable patliogenic and putrefactive organism. Sucll germu-laden wounds are unusual in civil life, and vere sb also in the Soutlh African war. They are, lhowever, met wvitli in accidents from agricultural districts, whlliel are admitted mostly to small provincial hospitals, though they are also seen by surgeons attached to mnedical sclhools. Tlle badly damaged and (lead tissues at once putrefy and smell badly, and their treatment becomes more a question of sanitary science than of modern surgery, and hias been more suLecessfully dlealt witlh by tlle disinifectants used in sanitationi than by tlle commooner surgical antiseptics. To get rid of tlle smnell and putrefaction in tlle wound lhas been to get rid of the unusual in tlle disease. Whlat is new, tlhen" in the surgery of this causpaign is old in sanitary scienice, and older still in tlle Ihistory of surgery, wlliclh, being the older science, lhad dealt witlh the grosser infections muclh earlier. Among the many methods of dressing wounds one comes across, none are really new, but one recognizes many an old -friend in new war paint, lhabilitated witlh elaborate wordapainting more or less accurate and conVInCiDg. A dip into a good textbook of su-rgery in use, say, about the early part of last century will convince any sceptic, thouglh ib is a thankless task to recommend such a perusal. The names of drugs are less mystifying, but a good description of the treatment of foul wounds with chlorine, iodine, and saline compounds, and even of gas gangrenie itself, will be found and will well repay the ardent stuident. Attention lhas already been drawn to tllis by otlher writers. Thle cruder drugs produced then, as now, in a short time very candidly stated, a clean surface from whiclh exuded laudable pus-that transition in the discharge from the nauseating putrefactive d4bris of decaying tissues to the odourless creamy pus, then, as now, considered laudable. This pus comes from living tissues in which are to be found the ordinary pyogenic germs alone. PuLtrefactive organisms can attack only dead tissues or those weakened by pyogenic processes or mechanical traumatism. To get rid of the putrefactive organisms and to prevent the ingress of thle pyogenic has been the problem of wound treatment for surgeons in the present campaign, and it is yet to a great extent unsolved. Towards tlhis objective I offer my experiences in a casualty clearing station. I. Hypertonic Solutions. Wright's saline treatment lhas received perhaps more praise than any other. In tlheory it seemed excellent, but in practice the re4ults are various. When used properly and in suitable cases they are good, but tlle cases require careful selection, and its application requires more skilled watching than can usually be given witlh the means at one's disposal so near tlle front. Tlle method and choico of cases cannot be left to the discretion of a dresser or eveni to the average medical man attachled to a casualty clearing station, and if used as a routine dressing the results are more often positively bad than passably encouraging. In tlle majority of places where hypertonic salines are used as a routine dressing they are either too long continued for bad lacerations or are applied to many cases almost clean, where they are unsuitable. To living tissues strong salt solution is extremely irritating, and causes pain for a very considerable period after each application. This does not depend on tllh patients. The action of salt on wounds was well knowni in history, wlhen it used to be rubbed into tlle cuts made by the laslh, not for its lhealing power be it noted. I hlave personally experienced its smart, for it was a favourite dressing in hypertonic solution in my boylhood. I owe tlhe preservation of a perfect finger joint to its use, yet I well remember the lhappy change to a soap and sugar ointment whiclh comnpleted the treatmiient. The lhypertonic metlhod does well for joints, wlhen they lhave not been laid open too freely, and probably laceratecl wounds wlhere the explosive force of the missile hias killecl the tissues for a considerable distance beyond the bullet track. The salt preserves tlhese dead tissues fromn putre faction (a well-known use of salt), for it is an absolute bar to tlie growtlh of putrefactive organis8ms, while its irritating effect on the living tissues sets up a mnore or less severe dischlarge, wlhichll lelps to .prevent tlle inigress of pyogenic germs. But suchl a dressitng slhotuld not be covered by non-permeable tissue, wlichl will check entirely such. outward flow of sertum. Tlle tabloid and gauze pack is perlhaps the best for dirty wounds in casualty clearing stations, as it can be left for a considerable time witlhout attention. There is at first practically no pain following its application, for even the tissues that will ultimately live are rendered analgesic by tlhe blow. But once the. dead tissue separates, and the hypertonic dressing beconies painful, it soon produces purplislh, waterlogged, slhining granulations, wlhicll at one and the samue tim:le form a barrier to the exit of disclharges, and to any feeble antiseptic action it miglht exert on the cooped-up pyogenic germs below. Absorption begins, and abscesses in the deptlhs are not unusual. How often are these pyoaenic organisms present from the start 2 I am inclined to believe tllat even nowadays they are sometimes introduced much as they wvere by the surgeons in pre-antiseptic days. I lhave seen in ilospitals out here the pernicious lhabit, wlliclh lhad almost disappeared in the best civil lhospitals, of wringing gauze from antiseptic solutions witlh the bare lland. The result is that all tlhe germs present in -the previously dressed cases, are inooulated into thQ wound. Rubber gloves LMAY 6, rgif,
doi:10.1136/bmj.1.2888.648 fatcat:hxjxyxindvdwfm3s5e6pxdzote