534 



NATURE 



[August 30, 191 7 



THE TREATMENT OF WAR WOUNDS.^ 



II. 



Treatment of Wound Infections. 



T F you have now quite clearly apprehended the sig- 

 •*■ nificant distrnction between a live space and a dead 

 space, you will with that have mastered the first great 

 principle governing the treatment of all local bacterial 

 infections. If you are dealing with infection m live 

 spaces you can often mend matters by bringing (that 

 is the rationale of hot fomentations) a larger blood 

 supply — that means more lymph and more leucocytes 

 — to the focus of infection ; and again you can often 

 mend matters by improving the quality of the lymph — 

 that is the rationale of vaccine therapy; or again, you 

 may apply both these procedures concurrently. i3ut 

 when you are dealing with an infected dead space you 

 cannot in these ways mend matters. You might just 

 as well take a test-tubeful of infected fluid ..nd try 

 by these means to influence it. Where you have in- 

 fected dead spaces your remedial agent is the knife. 

 You have to evacuate your dead space as I emptv 

 this test-tube. 



Now that is the whole purpose and meaning of tlie 

 surgery of the wound as carried out at the front. That 

 can be summed up in two propositions. Every in- 

 fected dead space must be cut down upon and evacu- 

 ated. And, as a prophylactic measure, every space 

 which would, if left to itself, become an infected dead 

 space — that means every space occupied by an infected 

 projectile or pieces of infected clothing' or infected 

 foreign bodies or devitalised infected tissues — must 

 likewise be laid open and cleaned out. That exhausts 

 the treatment of buried infections. 



But it is only the beginning of the treatment of the 

 wound. There is still the surface infection. The 

 situation you have to face is just the same as that 

 produced by emptying an infected tube ; you have got 

 rid of the infected contents, you have left the infection 

 on the walls. 



I now turn to the problem as to how best to deal 

 with this infection. And here again inevitably we 

 must establish distinctions. We must distinguish be- 

 tween the naked tissue surface made by the act of the 

 projectile, or section with a knife, and the granulating 

 defensive surface, which after a time clothes the naked 

 tissues. In the former we have a non-vascularised sur- 

 face, and in this a system of lymph spaces left without 

 mechanical or "biological protection other than that 

 furnished by the emigration of leucocytes and (until 

 that stanches) by the outflow of lymph. And the 

 naked -tissue surface is not only ill-defended against 

 microbic attack, it is also peculiarly liable to damage 

 and to physiological deterioration of the kind which 

 opens the door wider to such attack. Such a surface 

 readily dries up; and drying means the closing down 

 ot the capillary circulation. Again, a naked-tissue 

 surface, seeing that it is nbn-vascularised, readily takes 

 cold, and by that both lymph outflow and emigration 

 are arrested. And. lastly, a naked-tissue surface, if 

 kept . wet, will, so soon as the discharges become 

 tryptic, readily undergo erosive digestion. Against all 

 these forms of physiological degeneration special pro- 

 vision should always be made. 



A_ granulating surface offers much greater protection 

 against microbic infection, and is much less subject to 

 <lamage. The tissues are covered in by many lavers 

 of protective cells, the lymph spaces are sealed over, 

 and there has been laid down immediately below «he 



1 \^^ Sir Almroth E. Wright, C.B., F.R.S. In its original form this 

 lecture was delivered at the Royal Institution on March 9. It was supple- 

 mented by additional matter relatins to antiseptics and the method of Carrel, 

 and was printed in full in the Lancet of Tun^ 23. Parts of the lecture of : 

 purely technical interest have been omitted. Continued fro n p 51S 



NO. 2496, VOL. 99] 



surface in newly formed vessels a very abundant blcod 

 supply. All this is protection against massive microbic 

 invasion from the surface, against the wound taking 

 cold, and against erosive digestion. In short, there is> 

 with an infected granulating surface much less danger 

 of a set-back than with an infected naked-tissue 



surface. 



I 



I The Natural History of the Wound with a Nakcd- 

 j tissue Surface Left to Itself. 



Let us consider the natural history of the untreated 

 wound with 'an infected naked-tissue surface. I will 

 take the case of an open shell wound left without 

 I treatment. According as it is wet or dry the evolu- 

 i tion of this wound will be entirely different. Let is 

 i suppose that it is allowed to dry. Under the original 

 , dry dressing the blood and lymph flow from the sur- 

 face will gradually stanch, and we shall then have a 

 naked-tissue surface with a coating of coagulated blood 

 and lymph. In this will be incorporated" elements of 

 moribund tissue, other elements of foreign matter, and 

 always a certain number of microbes. Little bv little 

 the coating of coagulated blood and lymph upon the 

 surface of the original wound, or of the surgeon s 

 incisions, will dry up, and by that the capillarv circu- 

 lation will be closed down. And all the while the scro- 

 phytic microbes will be proliferating. As a result of 

 all this the superficial tissues will die and become 

 gangrenous, and the originally clean naked-tissue 

 surface will gradually be transfoimed into a drv, 

 greenish-black, excessively foetid, slough-covered sur- 

 face pullulating with microbic growth.- Under the 

 sloughs will then be formed infected dead spaces, and 

 from these the infection — I am here thinking in par- 

 ticular of a gangrene infection — will invade the neigh- 

 bouring live spaces, converting these in their turn into 

 dead spaces until we have to cope with large areas of 

 gangrene and a general intoxication. 



That, of course, will happen only with very heavv 

 infection or extreme physiological deterioration. With 

 lighter infection or less adverse physiological condi- 

 tions the invaded organism will have recourse to 

 measures of defence. Gradually the superficial 

 sloughs and gangrenous portions of the deeper tissues 

 will be demarcated and then amputated from the 

 living tissues — the amputating agent being, no doubt, 

 the trvptic ferment in the dead spaces. And at the 

 same time there will have been organised in the living 

 tissues some little way back a defensive front built 

 up on the same plan as a granulating surface. 



Let me now tell you also what will happen if the 

 infected surface is simply kept wet. Here," also, the 

 microbes which have been incorporated in the clot 

 would grow out. Then there would supervene leuco- 

 cytic emigration, and upon that would follow a break- 

 ing down of the leucocytes with a setting free of 

 trypsin ; and after that any and every m.icrobe would 

 pullulate in the cavity of "the wound and on the de- 

 vitalised wound-surface. Finally, if treatment were still 

 deferred there would be reproduced in an aggravated 

 form (for there would in the open wound be a varied 

 and more formidable infection) the evil train of events 

 which is associated with infection in a buried dead 

 space. When you reflect that an open wound cavitv 

 filled with tryptic pus is physiologically equivalent to 

 an unopened abscess sac, you will see that erosive 

 action will enlarge and deepen its cavity; that <:his 

 will enable the microbic infection to burrow every- 

 where deeper into the walls; and that bacterial poisons 

 will be absorbed. 



All I have been saying in the last few minutes can be 



2 Let us note in connection with this that the albuminous substances of 

 our tissues when no longer bathed in lymph, are immediately degnided to 

 the rank of unprotected native albumens. 



