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The Treatment of Wounds inWar.

THE LANCET.

LONDON: SATURDAY, DECEMBER 19,1911;.

IN recent issues of THE LANCET we have printedsome important communications on the treatmentof the wounded in war, which originated in anaddress delivered before the Medical Society of

London by Sir WATSON CHEYNE; this week we areable to publish a contribution to the discussionfrom Sir ANTHONY BowLBY which derives its greatinterest from the presence of the author with the

Expeditionary Force as consulting surgeon. Broadlyspeaking, the question as promulgated at the

Medical Society resolved itself into a debate as towhat should be done to a recent wound in which

septic germs have become lodged. Is it sufficientfor us to prevent the access of further organisms bythe application of an aseptic dressing, trusting tothe vis medicatrix naticrce or the resistance of

the tissues to deal with those germs which have

already been admitted, or shall we endeavour by theuse of antiseptic substances to destroy the invadingorganisms before they have time to penetrate thetissues bordering on the wound ? This is no new

question. It is that which presented itself to

LISTER some 50 years ago, and it is that which heanswered from the standpoint of knowledge thenreached by his antiseptic treatment. When he

recognised that the cause of suppuration in woundswas the presence of micro-organisms he en-

deavoured to destroy them by the applicationof crude carbolic acid, and the success of his

endeavour demonstrated that it was possible at anearly stage of the infection of a wound to removethe invading germs by chemical means. Hisfirst case2was one of compound fracture, a formof lesion which had up to that time been alwaysfollowed by prolonged suppuration and severe

septic symptoms. After the application of the

carbolic acid the wound healed without sup-

puration and all signs of general sepsis were

absent. This method of .dealing with wounds,somewhat modified by its introducer as his expe-rience widened, was employed by him during thewhole of his active professional life, and it wasfollowed with remarkable success by other surgeonsthroughout the world. Gradually, however, theidea arose that such a strenuous treatment of awound must do great harm to the surroundingliving tissues. The evidence in favour of this

damage was by no means great, and the objection1 THE LANCET, Nov. 21st (pp. 1185, 1200) and 28th (p. 1248), 1914.

2 THE LANCET, vol. i., 1867, p. 326, et seq.

to the use of antiseptics in the wound was almostcompletely based on theory. The advocates of the

aseptic method relied on theoretical considerations;it must be, they contended, harmful to pour a

strong solution of carbolic acid into a wound, for

the damage to the living tissues may be quitesubstantial.

’, Sir ANTHONY BOWLBY’S letter supports the argu-ments employed by Sir WATSON CHEYNE, whoadvocated the maintenance of the Listerianmethods in fitting circumstances, in a remark-

ably direct way. Of his experiences with the

army Sir ANTHONY BOwLBY draws a picture whichshows convincingly that it is upon antisepticprocedure much as LISTER laid down its principlesthat the treatment of wounds in war must

depend. No one doubts that in the case of

a deliberate wound made after the takingof elaborate precautions by an operating surgeonthere is no need to employ antiseptics, for

with care it is possible to keep the woundfree from germs. But the case is utterlydifferent when we have to deal with wounds whichhave already become infected. Here it is not

possible with the very greatest care to prevent themultiplication of the germs which have alreadyentered the wound and the absorption of these

germs or their products. The application of an

aseptic dressing over the wound will not and cannotaffect the septic process going on within. When thewounded fighting man is seen within a few hours ofthe infliction of the injury it may be and oftenis possible to render the wound aseptic. In suchcases the septic organisms are there; but theycan be antagonised, and they may be overcome.And how seldom it happens that in war the woundsof the sufferer can be seen within a few hours; howfrequently the soldier having incurred an injuryof the sort most apt for sepsis abides long hoursin an environment reeking with infection. We

may all of us have known the tragic truth that noamount of forethought, skill, or devotion could

spare our defenders these terrible risks, but SirANTHONY BowLBY’s simple forcible description ofthe conditions must make this more real to us thanever. " There seems to be an idea," he says, " thataseptic’ surgery has been practised at the front,but as far as the clearing stations are concerned,this is entirely a misapprehension. I have myselfnever given up ’antiseptic’ principles and treat-ment, and I was glad to find that in every clearinghospital antiseptics were always used." And heshows that the usual treatment must be inaccordance with the Listerian routine.As a matter of fact the separation of surgery into

the completely aseptic and the completely anti-septic is rather academic. In spite of its disdain

for chemical antiseptics modern aseptic surgery hasnot hesitated to employ a solution of iodine to

sterilise the skin preparatory to surgical operations;but when we hear of wounds in action being treatedby painting the skin with iodine and by applyingan aseptic dressing, while nothing is done to the

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wound itself, we cannot endorse the reasoningwhich underlies. This may be aseptic surgery, butit is not wise. The case is, indeed, different whenmany hours have elapsed since the infliction of thewound; then the germs have had time to penetratedeeply into the tissues forming the sides of the

wound, so that an antiseptic cannot follow them.What shall be done in such cases ? The essentialelements in the treatment here are the removal of

disintegrated structure where the circumstances

point thereto, and the employment of adequatedrainage. It may be asked whether the employment ofan antiseptic in a wound never damages the tissues.Certainly this does happen, but the damage inflictedon the tissues by one application of even a verystrong antiseptic will do little mischief, and whatmischief is done is rapidly repaired by the tissues.What is really harmful is the repeated applicationof even weak antiseptics to healing tissues. Manywho would shrink from applying a strong solutionof carbolic acid to a recent wound will not ihesitate to irrigate a wound day after day with iantiseptic solutions which can do little more thanserve to irritate the parts. Sir RICKMAN GODLEE I

prophesied recently that the time would come whensome surgeon would rediscover Listerism. We

cannot believe that such rediscovery will be

necessary at any rate until our science takes someunforeseen step forward. As long as wars are con-ducted as at present Listerism will be the only soundmethod to follow in dealing with the wounded in thefield. The pendulum has swung far in the oppositedirection, but only to return. Sir RICKMAN GODLEE

quoted recently LISTER’S saying that if he shouldever write a book on surgery he would choose as itsmotto the words of Psalm xxxviii., " My woundsstink and are corrupt, because of my foolishness."Much unnecessary sepsis exists to-day in civil

practice because of the unwise neglect of the

teaching of LISTER. Sir ANTHONY BOwLBY’S vividcommunication indicates how hopeless any otherroutine would be in military practice.

Quackery and a Ministry of PublicHealth.

THE Unqualified Practice Prevention Committeeof the General Medical Council submitted recom-mendations at the recent meeting of the Councilafter it had considered the report of the SelectCommittee of the House of Commons on the sub-

ject of so-called patent medicines. These recom-

mendations/ which were adopted by the Council,suggested that the approval of the Select Com-

mittee’s report by the General Medical Councilshould be expressed under two headings. In the

first place, there should be conveyed to the

Lord President of the Privy Council an expres-sion of the General Medical Council’s completeagreement with the recommendations of the SelectCommittee; and in the second place there should

1 THE LANCET. Dec. 5th, 1914, p. 1314.

be a representation to the Government, throughthe Lord President, of the necessity for the imme-diate creation of a Ministry of Public Health. It

will be remembered that the Select Committeerecommended that the administration of an im-

proved, reconstructed, and coordinated law relatingto the advertisement and sale of patent medicinesshould be entrusted to one department of State,and that this should be the " Ministry of PublicHealth, when such a department is created."

The Select Committee considered the possibilityof legislation to regulate the trade in patentmedicines preceding the institution of a Ministryof Public Health, and suggested that the LocalGovernment Board should undertake " mean-while " the proposed departmental duties. TheGeneral Medical Council has now by resolutionurged the desirability of proceeding first to createthe department without waiting for this particularsection of its probable future duties to be brought,into being. This appears to be a wise and reason-able course, and it is to be hoped that the Govern-ment may be able to find the time and theoccasion to carry into effect the advice of the

t representative body of the medical profession,: charged with the standardising of our educationi and the proper maintenance of our statutoryi Register.

For the passage of controversial measures in-

volving conflicting commercial interests there isnot likely to be an early opportunity, and legislationon the subject of patent medicines will involvethe disturbance of vested interests, whose repre-sentatives will certainly wish to secure a full

hearing for their case, and to invoke protectionwherever they can find it. At the present time 9,large number of Members of both Houses of

Parliament are on active service, and are likelyto remain so for many months-a fact which,combined with the other circumstances of a gravenational position, renders it probable that only a.

very small amount of domestic legislation willbe attempted in the near future. In the case

of a large and flourishing trade, if not in most

shapes a desirable one, no Bill affecting it is

likely to be introduced at present, and neither theadvocates of such a measure, nor its opponents,would wish to have it discussed under any unsuit-able conditions. The formation of a Ministry ofPublic Health, however, is a different matter. It isnot the result of a proposal made by the SelectCommittee on Patent Medicines, which has merelysuggested the creation of certain duties for a Statedepartment, which naturally would be assigned tothe Ministry of Public Health if it existed. It doesnot exist, but its creation has been asked for anddesired for a long time by all interested in thenational health and welfare. Incidentally it wouldbe very convenient if, on the passing of a new law

to regulate the trade in patent medicines, the

department were there ready to carry it into

. effect, but the formation of the department hasbeen urged upon other grounds. The formation