5.5 Significance of WF for experiments in surgery

• New techniques in the treatment of wounds and infection:

  Problem faced by RAMC: dealing with infections from gas gangrene.

  It was not possible to perform aseptic surgery in Dressing Stations and Casualty Clearing Stations, due to the contaminated conditions and because of the large numbers of wounded men needing treatment.

  Because of this, other methods of treatment had to be found.
• This led to much disagreement in the medical profession between those medics who were facing the frontline conditions on a daily basis, and those who were back in Britain, unfamiliar with what medica in the trenches were facing.
• ·      Wound excision or debridement: infected tissue was cut, and the wound closed by stitching. Needed to be done quickly as infection could spread.

  ·      The Carrel-Dakin method: Sterilised salt solution in the wound through a tube. The solution only lasted for six hours and so had to be made as it was needed. This could be difficult, especially when large numbers of wounded men needed treatment at the same time.

  ·      Amputation: By 1918, 240,000 men had lost limbs- many of them because it was the only way to prevent the spread of infection and death.
• The Thomas Splint:

  In 1914 and 1915, men with a gunshot or shrapnel wound to the leg only had a 20% chance of survival. This was because these wounds created a compound fracture where the broken bone pierced the skin. It was particularly serious if the femur (thigh bone) was fractured, because a large amount of muscle would be damaged. This meant there was likely to be major bleeding into the thigh.
• The splint that was in use as the wounded man was transferred from the frontline did not keep the leg rigid. By the time the wounded man arrived at the Casualty Clearing Station, where he could be operated on, he would have lost a great deal of blood, was likely to be in shock and might already have developed gas gangrene in the wound. This combination of factors reduced his chances of surviving an operation to the wound. Many of those who survived did so because their wounded leg was amputated.
• It was clear that a way of improving the survival rate for men with this type of injury was needed. In fact, the solution, which only came into use in 1916, had been available since well before the start of the war.

  In the late 19th century, Robert Jones worked with his uncle, Hugh Thomas, in his medical practice, where his uncle had designed a splint to stop joints from moving. When the war broke out, Jones was 57 years old. He offered his services immediately to the war effort. He worked with disabled soldiers in a hospital in London and started to make use of his uncle’s Thomas splint.
• As a result of this, in December 1915, he was sent to Boulogne to instruct medical practitioners on how to use the Thomas splint. The introduction of its use from this time increased the survival rate for this type of wound from 20% to 82%.
• X-rays were used from the start of the war. Their main use was to identify shell fragments and bullets in wounds, which, if not removed when the person was wounded, could cause infection. Two x-rays would be taken from different angles and this helped the surgeon to identify quite accurately the location of shrapnel and bullets in the body.
• Problems with x-rays on the Western Front.

  ·      X-rays could not detect all objects in the body e.g fragments of clothing.

  ·      long length of time for x-ray could cause problems depending on the wound.
• · The tubes used in x-ray machines were fragile and overheated quite quickly. This meant that x-ray machines could only be used for about one hour at a time and then had to be left to cool down. This posed a problem when there was a major offensive going on and large numbers of wounded men were being brought in.
• The solution was to have three machines which would be used in rotation. When a machine became too hot to continue working, it would be replaced by another one. There had been an advance made in the technology of tubes in the USA by William Coolidge in 1913, but this was not available to the RAMC on the Western Front until the USA entered the war in 1917.
• The Base Hospitals and some of the larger Casualty Clearing Stations had static (unmoving) x-ray machines as part of their equipment. Those that did not have them could call on a mobile unit. There were six mobile x-ray units operating in the British sector on the Western Front.
• Setting up the equipment from the mobile unit took some time. A tent was attached to the back of the van with a table where stretchers could be placed. The x-ray machine was set up next to this table and linked to the engine of the van, which was used to power the x-ray machine. The equipment for processing the x-ray films were set up inside the van.
• Although the quality of the x-rays taken by the mobile units was not quite as good as that taken by static units, it was sufficient to identify shrapnel and bullets and prevent infection for many of the wounded soldiers.
• Blood transfusions:

  • Use of blood transfusions pioneered by a Canadian doctor, Lawrence Bruce Robertson, 1915.
  • indirect method: where a syringe and tube was used to transfer the donor blood to the patient. The purpose of this was to stop the patient going into shock through blood loss before surgery.
  • As blood transfusions proved so successful at the Base Hospital, it was decided to extend their use.
  • Therefore, by 1917, blood transfusions were being administered in the Casualty Clearing Stations as a routine measure in the treatment of shock.
• Geoffrey Keynes, a British doctor and lieutenant in the RAMC, designed a portable blood transfusion kit that was used to provide blood transfusions close to the frontline. Despite Robertson’s pioneering work, this kit did not use stored blood because of the difficulties in keeping the blood fresh when there was no refrigeration available. Keynes added a device to the blood bottle to regulate the flow of blood which helped prevent clotting. In 1915, Keynes used the new method in a Casualty Clearing Station on the Western Front. By his own accounts, it saved countless lives. 
• The blood bank at Cambrai

  The identification of blood groups and the use of blood type O as a universal donor blood type meant that the risk of being transfused with the wrong blood group was reduced. The problem of clotting remained, and there was never enough blood on hand to meet demand. However, as the war continued, some advances were made in the storage of blood.
• ·      In 1915, American doctor Richard Lewisohn discovered that by adding sodium citrate to blood, the need for donor-to-donor transfusion was removed. Blood transfusions could be done indirectly, with patients not needing to be in the same room. 

  ·      In the same year, Richard Weil discovered that blood with sodium citrate could be refrigerated and stored for up to two days.

  ·      In 1916, Francis Rous and James Turner found that by adding a citrate glucose solution to blood, it could be stored for a much longer period- up to four weeks.
• The use of stored blood was clearly demonstrated in 1917 at the Battle of Cambrai. Before the battle, Oswald Hope Robertson, a British-born American doctor, stored 22 units of universal donor blood in glass bottles. He built a carrying case for the bottles in ammunition boxes which he packed with ice and sawdust. He called this a ‘blood depot’.
• During the battle, he treated 20 severely wounded Canadian soldiers with the 22 units of blood, some of which had been collected 26 days before use. They were so badly affected by shock that none of them were expected to survive. In fact, of the 20 wounded men, 11 survived.
• Robertson’s work at Cambrai was the first time stored blood was used to treat soldiers in shock, and, although it was only on a small scale, demonstrated its potential to save lives. This was important, because during times of heavy fighting, only the most severely wounded were taken to the Casualty Clearing Stations. The less severely wounded, who were normally the men who gave blood for transfusions, would not be taken there. Therefore, the availability of blood stored in a number of blood depots made a huge difference to men’s chances of survival.
• The attempts to deal with increased numbers of head injuries:

  About 20% of all wounds in the British sector of the Western Front were to the head, face and neck. This was part of the body that was most exposed in the trench warfare of the Western Front. Injuries of this nature could be caused by both bullets and shrapnel.
• Injuries to the brain were very likely to prove fatal at the start of the war because:

  ·      The issue of infection applied just as much to head injuries as it did to wounds to other parts of the body

  ·      There were difficulties involved in moving men with head injuries through the chain of evacuation, as they were often unconscious or confused

  ·      There were very few doctors who had experience of neurosurgery* before the war.
• Despite the inexperience of doctors in dealing with head wounds, observation quickly led to improvements in methods of treatment.
• Harvey Cushing, an American neurosurgeon, developed new techniques in brain surgery on the Western Front. He experimented, for example, with the use of a magnet to remove metal fragments from the brain. He also used a local anaesthetic* rather than a general anaesthetic* when operating. The reason for this was that the brain swelled as a result of general anaesthetics and this increased the risks of the operation.
• Harvey Cushing:

  His methods became more effective as he learned more through observation. He operated on 45 patients in 1917 with an operation survival rate of 71%, compared to the general survival rate of 50% for brain surgery.
• Harvey Cushing Observation 1:

  Men who were operated on quickly were more likely to survive.

  Specific Casualty Clearing Stations became chosen as centres for brain surgery. For example, during the Third Battle of Ypres, all head injuries were moved to the Casualty Clearing Station at Mendinghem.
• Harvey Cushing Observation 2:

  It was dangerous to move men too soon after an operation.

  Patients remained at the Casualty Clearing Station for three weeks after surgery.
• Harvey Cushing Observation 3:

  Injuries that looked fairly minor could be hiding more severe injuries.

  All head wounds were always carefully examined.
• Plastic Surgery:

  The development of plastic surgery: Harold Gillies. In civilian life, he was an ENT (ear, nose and throat) surgeon. He was sent to the Western Front in January 1915. There he met Charles Valadier, a French man who had been working for the British Red Cross as a dentist since October 1914. Head injuries that might not kill, could cause severe disfigurement. This led Gillies to become interested in facial reconstruction. As he had no background in this type of surgery, he devised new operations to deal with problems as they confronted him.
• The intricate operations and recovery that were required in plastic surgery could not be carried out in France. Men who needed this surgery were returned to Britain. From August 1917, the key hospital providing this type of surgery was the Queen’s Hospital in Sidcup, Kent. Gilllies was involved in creating the design for the hospital so that it exactly matched his needs.

  By the time of the end of the war, just over a year after the hospital opened, nearly 12,000 operations had been carried out.
• What led to the use of new techniques to treat wounds on the Western Front?

  The type and extent of injuries
• How did the number of casualties affect medical practices during WWI?

  It allowed doctors to perfect their methods
• What method revolutionized the treatment of infection on the Western Front?

  The Carrel-Dakin method
• What was the basis for the Carrel-Dakin method?

  Based on Lister's work on antiseptics
• What existed before the First World War that was effective on the Western Front?

  The Thomas Splint and X-rays

  
• How did the environment of the Western Front demonstrate the effectiveness of the Thomas Splint and X-rays?

  It showed their utility in treating injuries

  
• What significant progress was made in blood transfusions from 1915 to 1916?

  Developments in blood transfusions occurred
• What was the RAMC's struggle regarding infections on the Western Front?

  They struggled to treat infections like gas gangrene
• Why was aseptic surgery difficult to achieve on the Western Front?

  Overcrowded dressing stations and CCSs