I. It is well known that nearly all the wounds resulting from explosions of shells, torpedoes, and bombs are septic; and that the methods employed up to the present in the treatment of these wounds are generally impotent to check the progress of the infection. To be convinced of this, one has only to be present at the arrival at a base hospital of a convoy of wounded, who have been operated on in the dressing-stations or the hospitals near the front. Then one grasps the danger of those paradoxes upheld by surgeons who still deny the universality of infection.
That the septic character of wounds is disastrous is also well known. During the early hours, or the first few days, the wound is exposed to the danger of gas-producing infection. Later are developed the various infections, which, either in the seat of fracture, in joints laid open, or in extensive lacerations of soft parts, sometimes give rise to lesions leading to amputation or to death. At the hospital of the Maison Blanche, M. Tufrler, as a result of the examination of a large number of cases of amputation, found that about 70 per cent. of the operations were needed because of the presence of infection, and were not due to the extent of the anatomical lesions.
Even when the patient has had the good fortune to be operated on close to the scene of action by a competent surgeon, and has escaped the serious infections of the early stages, suppuration still occurs, and continues indefinitely. Sometimes it becomes a danger to life or limb, and almost always brings about adhesions between muscles, aponeuroses, tendons, nerves and vessels. After healing, the patient has scars of large area, often painful, which prevent the limb from resuming its normal functions. Tendons remain gripped in fibrous fetters. Nerve extremities which have been bathed for weeks in pus, sclerose. Deep in infected bones, osteo-myelitis springs up. For months, maybe years, the limb still suppurates. Joints ankylose, muscles atrophy, and the wounded man becomes unfit, not only for being a soldier, but for work of any kind.
The suppression of wound infection would protect a large number of men from incapacity or death, and would bring about the rapid restoration to health of the greater number of those whose anatomical lesions are compatible with life. Such progress would result in great saving in money and men.
It would seem, however, that hitherto practically no really systematic research has been carried out with the object of discovering the procedure needful to bring about this improvement in treatment of wounded. As a matter of fact, attempts have been made by isolated individuals and often with extemporised equipment. Experimenters have attempted, working alone, researches which needed the co-ordinated efforts of chemists, pathologists, bacteriologists, trained in scientific technique. Proceedings of learned societies are laden with reports, based for the greater part on experiments and observations, incomplete, vitiated by faulty methods. No results of value were obtained. Despite the academic toil of many surgeons, wounds suppurate to-day as freely as ever.
It is known, however, that, under certain conditions, infected wounds can be rendered sterile. Lister, undoubtedly, by the aid of carbolic acid, succeeded in disinfecting compound fractures, at a time when such an injury was of the gravest import. Nevertheless, modern surgeons disregard these facts. Not only have they despised the road opened up by Lister, but they even question the possibility of applying the principle of antiseptics to war-wounds.
The throwing-over of Lister's ideas came about, not so much from the inadequacy of his method, as from the carelessness with which it was applied. In clinical researches, the basic principles of scientific investigation were forgotten. Methods utilising measurements were rarely employed. In the wounds investigated, it was never sought to estimate exactly the relations which exist between the number of microbes present, their nature, and the rapidity of cicatrisation. Any substance which possessed the property of destroying microbes in vitro, was looked upon as an antiseptic, and used in the treatment of wounds, every man to his taste. Substances which coagulated proteids, which lost their bactericidal power in the presence of serum, or which were actually harmful to the tissues, were all used. What degree of concentration of a bactericidal substance was to be used at the surface of a wound, how this degree of concentration was to be maintained - such details were never sought. The period during which this substance should remain on the surface of the wound, at a given concentration, was never determined. No careful study was made of the quantitative modifications, produced by the antiseptic agent, of the microbial flora, modifications which can only be revealed by daily bacteriological examination. The action of antiseptics on tissue repair was ignored, although it was important to learn how much the substances employed would impede the progress of cicatrisation. In a word, in the therapeutics of septic wounds, we may attribute the stagnation we have experienced to the lack of precision in clinical research.
However, Lister's method was held responsible for technical inadequacies, and surgeons raised to the position of a dogma the teaching that antiseptics had no real efficacy. In a memorandum on the treatment of wounds in war,1 MM. Burghard, Leishman, Moynihan and Wright, wrote in April, 1915, that "the treatment of suppurating wounds by means of antiseptics is illusory, and that belief in its efficacy is founded upon false reasoning." The principal adversary of antisepsis was Sir Almroth Wright. He believed that Lister's method was not applicable to war-wounds, and that the microbes, being carried by projectiles and fragments of clothing deep into the tissues, were beyond the reach of antiseptics. Chemical sterilisation of a wound seemed to him impossible of realisation. "In fact," he wrote in 1915, "if it were ever to come about that an antiseptic sterilised heavily infected wounds, that would be a matter to announce in all the evening and morning papers." l