War Surgery and Medicine
REVIEW OF POSITION AT END OF WAR
REVIEW OF POSITION AT END OF WAR
The position as regards the treatment of war wounds at the end of the war may be summarised as follows:
1 The words ‘surgical cleansing’ have been deliberately chosen because of the obscurity of meaning attached to the name excision, and, to a lesser extent, to the French word ébridement.
Appropriate splinting was applied to all fracture cases, plaster being used in all fractures except those of the femur, when a Thomas splint with plaster strengthening was utilised. The casualty was then evacuated to a General Hospital either by ambulance train, hospital ship, or by air, and given a short period of rest. On about the fourth day, and frequently earlier, the patient was taken to the operating theatre, no dressing having been attemDted since the original operation in the forward areas, the plaster and dressing removed, and, unless definite infection had occurred, the wound was again dusted with penicillin powder and sutured, either by simple salmon gut stitches, taking a deep bite of the tissues, or by figure-of-eight silk stitches. Parenteral intramuscular penicillin was then given for a few days after suture in all severe wounds. No dressings were carried out for from a week to ten days, when at dressing the stitches were removed. Splints were applied to all severe wounds as at the original operation. By this technique about 80–90 per cent of all wounds healed satisfactorily.
If infection of any severity occurred the wound was opened, penicillin tubes inserted, penicillin instilled twice daily, and parenteral penicillin continued. In the rare septic case further blood transfusions were given to combat the associated secondary anaemia which usually developed in these cases. When fractures were present the same routine was carried out, but the penicillin was continued longer, for at least a week after suture of the wound. If sepsis arose, drainage of the wound was often carried out. For those cases in which sepsis contra-indicated delayed primary suture, parenteral and local penicillin was continued till the wound became healthy and allowed of secondary suture, and at times other measures such as the instillation of the hypochlorites were utilised in the penicillin-resistant infections. In the forward areas primary suture of the wound was not attempted, except in page 38 certain parts such as the scalp and face. The performance of delayed primary suture was simple and efficient, and, besides being safer, it brought about a satisfactory distribution of the operative work between the forward and base units. The ideal of primary suture seemed hardly justifiable under the conditions of active warfare, partly because the transportation of the patient would naturally militate against the healing of the wound.
If any loss of tissue had occurred, and especially in burns on the hands, skin grafting was carried out at the very earliest period, and that meant at the time when delayed primary suture was done. If gas gangrene eventuated, radical removal of muscle was called for and a full course of penicillin parenterally. Amputation was necessary only if actual gangrene of the limb itself set in. Diphtheritic infection of wounds, by no means uncommon, was combated by the institution of serum. As a wound application the sulphonamides, except as a medium for the administration of penicillin, had faded from the picture though sulphonamides given by the mouth were still utilised in head cases and in penicillin-resistant infection.
The story of the treatment of war wounds during the 1939–45 War is one of great interest, showing as it does the gradual development of ideas and knowledge till a selected and trained medical personnel was able to devise a technique, with the aid of new antiseptics and antibiotics, that was both simple and very efficient.
The development from the closed plaster technique to the use of the sulphonamides, and finally to the employment of penicillin, and the very early complete closure of the wound, was a triumph for British surgery in which our New Zealand Medical Corps was honoured to be able to participate. The great lesson that was learnt was that no stereotyped method, however hailed as a panacea, should blind one to the truth that there is no finality in medicine, and that we cannot be content till we reach as near perfection as possible.
The closed plaster technique was accepted too readily by out younger surgeons at the beginning of the war, when it really was producing poorer results in many ways than were being obtained at the end of the First World War. Sulphonamides again were expected to do too much to assist the surgeon, and it was not till the dramatic discovery of the remarkable bacteriostatic effects of penicillin on wound organisms that surgeons would turn their attention to the early closure of wounds, and thus approach, and finally improve on, the results actually attained in the First World War. The principles of the removal of soiled and devitalised tissue from the wound, the relief of tension, the provision of page 39 rest to the tissues and the individual, the replacement of lost fluid and blood, the protection of the wound from contamination and finally its complete closure to prevent that contamination and allow of early restoration of function, were not new or strange. They were relearnt slowly, and sometimes laboriously, by a new generation of surgeons. They will have to be learnt again possibly by another generation of surgeons who may have more powerful bacteriostatics and possibly improved techniques in other ways, but the cardinal principles will remain. We can but hope that eventually it will be possible to close wounds completely and safely at the original operation shortly after the wound has been sustained, and thus save subsequent dressing and subsequent infection with so much relief to the patient, and with much lower mortality and morbidity. The severity of the injury may at any time cause death, but if we can ensure the rapid and aseptic healing of the wounds themselves we will save some lives. Undoubtedly many lives were saved in the 1939–45 War by the determined and persistent progress of wound treatment in the British Army, of which we were proud to be an intimate part.page 40
Invalids Evacuated to New Zealand or Discharged in United Kingdom
|2 NZEF 1940–451||1 NZEF May 1916– Dec 1918|
|Fractured tibia and fibula||481|
|Pelvis and hip||100|
|Other wounds of back||174|
|Other wounds of arm||2300|
|Other wounds of leg||2683|
|Total wounded for period||16,456||36,516|
|Also wounded taken PW||1,326|