DÉBRIDEMENT of WOUNDS

The first use of débridement, the surgical excision of necrotic or infected tissue and the removal of foreign bodies from contaminated wounds, appears to have been made by a French medical officer, Dr P. Riche, in October 1914. ("Official History of Australian Army Medical Services, 1914-1918" Colonel A. C. Butler, Australian War Memorial, Vol II, page 326). However, in 1914, Major E. T. C. Milligan, an Australian MO working with the RAMC and Colonel Gray, RAMC, were independently experimenting with this technique.

Prior to the introduction of débridement, all but simple incised wounds were treated by surgically opening the wound, removal of obvious foreign bodies and then irrigated with sterile salt solution or oxidisers such as Hydrogen Peroxide in an attempt to sterilise the lesion. The wound was left open and freely drained or was packed with gauze, and then it was immobilised by suitable splints if necessary. Discharge of pus was treated by drainage tubes made of glass or rubber. ("Manual of Surgery" Vol. 1, by Thompson & Miles, 1913, Oxford Medical Publications)

Milligan, after nine months experience, published his results: "The Early Treatment of Projectile Wounds by Excision of Damaged Tissues" in the British Medical Journal, 26th June 1915, and Gray published his results as "Treatment of Gunshot wounds by Excision and Primary Suture" in the Journal of the Royal Army Medical Corps, June 1915.

Below is Dr Milligan's paper, taken from the "Official History of Australian Army Medical Services, 1914-1918" Vol II, page 326-7.

Dr M. Geoffrey Miller, editor

"The Early Treatment of Projectile Wounds by Excision of Damaged Tissues";

BMJ., 26th June 1915.

"After eight months of experience of the early treatment of projectile wounds . . . I desire to place on record a method of treatment which has given most gratifying results, and which if practised thoroughly, will materially lessen the time a wounded man is absent from the firing line. In a modern projectile wound we have to deal with a varying amount of devitalised tissue and a varying amount of ingrained infected material, both of which are always present The devitalised tissue varies in different wounds from a microscopical amount, through all quantities, to the gross obvious slough. The ingrained infected material is inseparably fixed to this devitalised tissue, and nothing short of the complete removal of the tissue can possibly get rid of the infected matter. Cleansing measures are placed at a great disadvantage, for only those organisms which are spread loosely broadcast on the surfaces can be removed or inhibited in growth by antiseptics. The more important natural protective powers of the healthy body in which these wounds occur are also placed at a great disadvantage, for no vigorous opposition can be offered by devitalised tissue, and the healthy tissue is separated from the loosely scattered infected material on the surface of the wound by the layer of devitalised tissue hounding the wound, and this tissue also acts as a perfect culture medium.

"The Method. This consists in the extirpation of the devitalised tissues. An anaesthetic is given where indicated [local or general].... The wound of the skin, is boldly cut out with a sharp scalpel. It should be so completely removed that a clean healthy incised wound replaces the contused and infected wound made by the projectile. There should be nothing of the old wound remaining. The wound of the superficial and deep fascia should be treated in the same way. The wound of the muscle is dealt with in the same fashion. It presents, however, more difficulties because of the retraction of severed fibres, and because of the distance of the depths of the wound f rom the surface of the body. This latter difficulty can be happily overcome in many cases by making larger incisions.

"Removal of loose and fixed bits of obvious foreign, and dead matter is, of course, essential. Ample exposure and drainage of the wound is necessary, and those wounds which are too extensive after the above treatment to retain a drainage tube do better than those in which a tube is necessary on account of their depth and narrowness. By this procedure the wound is put in the best possible conditions for the bactericidal actions of the tissues and the outpoured lymph. It is important to remark that it is not wise to impair the resisting and offensive powers of the artificially obtained healthy tissue surfaces by the use of strong or injurious antiseptics.

"Results. This method, when combined with the surgical essentials of perfect rest, cleanliness, and frequent suitable dressings has resulted in the healing of projectile wounds, without any appearance of pus in wounds of the skin and of the superficial fascia. In many wounds of muscle and bone, also, this gratifying result has been attained. In the treatment of some wounds of bone and muscle anatomical problems have prevented these principles of treatment from being thoroughly carried out, so that the results have not been as good. There have been no cases of generalised blood infection, nor of any spreading infection in the neighbourhood of the wound."