Antiseptics
Joseph Lister introduced the idea of antiseptics and a sterile surgical environment to lessen the risk of infections in 1867. During the first world war (1911-1918) surgeon Rickman Godlee, nephew of Lister and his biographer, delivered a Discourse entitled ‘Back to Lister’ in 1915.
In the talk he discussed the merits of his uncle’s work, and the risk of infection that injured soldiers faced on the battlefield. Antiseptics were a momentous surgical advancement, however they weren’t used without problems. if undiluted the effect of powerful agents like carbolic acid (phenol) on surgeons’ ungloved hands and patient’s exposed skin could produce damaging effects to their tissue.
Unlike Lister who created an antiseptic spray, Godlee did not believe germs came from the air. In war the injured were largely treated by fellow soldiers in unsanitized environments, such as the battlefield. Godlee believed these circumstances posed a big risk to the wounded.
‘land and water attacks were far more dangerous. The germs on the skin of the patient, the dirt on the hands of the surgeon, the unpurified sponge, the dried clot on a badly cleaned instrument – these were the dreadnoughts and submarines, the howitzers and hand-grenades; these were the sappers and miners that really decided the fate of the campaign.’
Quoting another military surgeon, Godlee continued, ‘In this trench warfare you must remember that, if a man is hit, he often falls into filthy mud and water… and the water is hopelessly polluted, and soaks his clothes and his wound.’
Godlee summed up during war ‘Antiseptics are being very largely used though with most disappointing results.’ However, ‘Undiluted carbolic acid is, according to our present lights, the antiseptic most likely to be practically useful in the rough-and-tumble practice of the battlefield.’
Click and collect
Meanwhile, James Mackenzie Davidson, a radiologist who consulted at military hospitals, was also trying to help wounded soldiers. He came to the Ri in 1916 to deliver a Discourse on ‘Electrical Methods in Surgical Advances’. The potential of X-ray was recognised from the moment of
discovery in 1895, but it usually only depicted a view of the body in two dimensions, a limitation which would remain for another 50+ years.
‘Having ascertained the position of the bullet in the body we have at hand, fortunately, other electrical aids for the surgeon when he comes to deal with the problem of its extraction. One of the most useful of these adjuncts is the telephone probe… It consists of a telephone to one terminal of which may be attached to the surgeon’s steel, silver or nickel-plated instrument, while a carbon plate is attached to the other terminal which is applied to the patient’s skin, moistened… When any of the instruments come into contact with embedded metals, such as lead, nickel, copper, iron, or the iron alloys used in shell manufacture, a loud click is elicited…’
Alternatively, ‘a large electromagnet is excited by an alternating current and held over the suspected part. If the magnetic field which is thus created embraces the embedded projectile, a vibratory motion is induced in the projectile… The surgeon palpates the part, and becomes instantly aware of any vibration of the tissues.’
Dressing to kill
Almroth Wright was a pathologist and immunologist, who spent much of his career at t St Mary’s Hospital in Paddington, even supervising Alexander Fleming.
In a 1917 lecture Wright discussed the healing, infection and dressing of wounds, including the normally mildly antibacterial action of blood serum. This led to laboratory experiments with Fleming’s ‘artificial war wound’, a curious piece of glassware, made with deep pits or ‘diverticula’ representative of real bullet and shrapnel wounds.
‘To imitate the conditions obtaining in the actual war wound we fill both the tube and its diverticula with an infected trypsinised serum.’ Meaning a degraded serum typically found in wounds.
‘We now empty the tube, leaving behind of necessity in the diverticula a certain amount of the original infected fluid. We then fill with an antiseptic; and the future of the infection will now depend on the penetrating power of the antiseptic. If the antiseptic penetrates into the infected fluid sterilisation will be obtained; if it fails to penetrate microbes will survive. To test our result we empty out the antiseptic, refill with trypsinised serum, and incubate.’
Wright’s studies indicated that healing was helped by the easy migration of white blood cells into a wound to fight infection, which was prevented if the wound dried up, or was burnt by antiseptics, which could kill the patient.
‘The first thought of every man would probably be that the wound should be most carefully disinfected at the outset. But what happens in burns shows that to start in open wounds with a sterile surface avails nothing. A burn is at the outset absolutely sterile, and quite notoriously… it tends to become very rapidly septic… It is just the same with war wounds. These become heavily infected even when they are drenched at the outset with undiluted carbolic acid.’
To clean the wound, and to keep the wound dressed and wet, with a 5% salt solution was his advice.
Shock horror
Injured soldiers could still die in the battlefield from a mysterious condition called surgical shock.
Surgical shock was caused by a significant loss of blood. The condition was alleviated only late in the war by physiologist William Bayliss and others who investigated it further. In 1920 after hostilities ended, Bayliss came to the RI to discourse on The Volume of the Blood and its Significance.
Bayliss, a professor at University College London, joined the Royal Army Medical College staff when war broke out. The volume of blood ‘came especially into prominence in connection with the explanation and treatment of the state known as “surgical shock” but which occurred with an alarming frequency in men wounded in the war. ‘
‘Much difficulty was found in distinguishing between this state, even when attended by very little loss of blood, and that resulting from very great loss of blood unaccompanied by serious injury.’
Bayliss’ experiments in 1916 pointed to an effective treatment which was eventually introduced, but he was initially reluctant to recommend a remedy, meaning many may have continued to die unnecessarily.
‘Blood has not actually been lost, and it should be possible to keep up an effective circulation by some other liquid until the poison is got rid of and the pooled blood returned to circulation. An innocuous fluid seemed to serve practically as well as blood, and had the advantage of being always at hand.’
Just before the end of the war Bayliss and colleagues were able to avoid deaths from shock with another ‘dose of salts’, a simple mixture of saline solution, and gum which raised the osmotic pressure of the solution close to that of real blood.
Learnings
On reflection there were significant advancements in the treatment of the injured during the first world war, which led to future improvements in treating wounds throughout the century. The work of Godlee, Wright and Bayliss was instrumental in learning more about handling and treating wounds. However sadly, often many of these principles couldn’t be employed on the battlefield because of the urgency and immediate threat to those already injured and those treating them in a dangerous environment.
Laurence Scales leads London tours featuring the history of science, invention and medicine. He is a graduate in engineering who has worked in various technological industries.