War Surgery and Medicine
SECOND WORLD WAR
SECOND WORLD WAR
At the beginning of the Second World War the technique of primary wound treatment laid down during the 1914–18 War, and continued in the treatment of civilian injuries afterwards, was carried out by the army surgeons. After the surgical cleansing of the wound the closed plaster treatment as developed during the Spanish Civil War was utilised. Very soon the sulphonamides were employed as bacteriostatics, both locally to the wound and parenterally by the mouth and later intravenously and intra-abdominally.
The antibiotic penicillin, when introduced in the later half of 1943, gradually displaced the sulphonamides and with its help the regular delayed primary suture of wounds was introduced. The primary efficient surgical treatment of the wound remained, however, the essential element in wound treatment.
It is necessary to survey the nature of the wounds produced by the different missiles, and the special problems involved in injuries to different parts of the body, before proceeding to discuss the development of wound treatment during the war in some detail, both in regard to the various aspects and also as a chronological account of the conditions present in the different campaigns in which the 2 NZEF fought.
Wounds Produced by Different Missiles
There was a marked difference in the type and severity of the wounds produced by shells, mines, and bullets. Very severe wounds, often multiple, were often caused by shells, mortars, mines, grenades, and booby traps. Unless it struck bone, the rifle bullet was generally less severe in its effect. Fortunately, shell splinters more often caused numerous small wounds rather than severe wounds. Mine wounds were particularly severe and multiple, frequently involving the face as well as destroying the feet.page 7
Types of Wound
The nature of the wound varied a good deal according to the region of the body involved, and especially as to the amount of muscular tissue present.
In the head the penetration of the skull and involvement of the brain called for special equipment, and treatment by personnel trained in neurosurgery. Injuries to the face, apart from the involvement of the eyes, were of importance with regard to the prevention of disfigurement and the associated fracture of the jaw. The neck injuries were often associated with injuries to the large vessels and to the larynx and trachea. Wounds of the thorax were often associated with lethal injuries to the heart and blood vessels, and the sucking wounds presented symptoms demanding immediate relief. The accumulation of blood in the pleural cavity not only interfered with respiration, but also acted as a nidus for infection.
The abdominal wounds were of special importance because of the injuries to the viscera, particularly the hollow viscera, but bleeding in the retro-peritoneal tissues and muscle injury were also of importance.
The buttock and perineum were dangerous areas because of the liability to abdominal, especially to rectal, injuries, and also because of the mass of muscle tissue particularly liable to anaerobic infection.
As regards the limbs, where the bulk of the uncomplicated wounds occurred, the thighs and calves with the bulk of muscle were again prone to serious infection; and vascular injuries were of special importance, especially in the thighs, because of the danger of gangrene.
Injury to bone and joint produced added risk of sepsis and prolonged disability.
Injuries of the larger nerves, though of no importance as regards wound healing, led to the longest period of disability and demanded prolonged treatment.
Traumatic amputation of the limb produced by gross injury proved to be of considerable importance because of the profound and continued shock associated with the extensive tissue damage.
The depth and the extent of the wound naturally varied enormously in degree from a small abrasion to a devastating tissue destruction, and from a perforating wound with two small perforations of the skin, with no swelling of the limb, to a large blowout of skin and muscle leaving a huge hole in a limb or, as commonly occurred, in the buttock.
In uncomplicated wounds the depth and the extent were important factors, but the amount of muscle involvement was of cardinal page 8 importance as it was in damaged muscle that infection, especially dangerous anaerobic infection, was especially prone to occur.
In addition to the missile itself producing in the wound damaged non-vital tissue, there was introduced into the wound foreign bodies of different kinds including dirt, clothing, and portions of the missile itself, all of which acted as irritants to the tissues and potential foci of infection.
The treatment of the wound had to be such as to take all these factors into consideration.
Treatment of the Wound
Before the wound could be dealt with it was necessary to remove any overlying clothing and expose the wound itself and a considerable area around, generally the whole limb in a limb injury, and sometimes the whole body. This exposure was necessitated not only to enable the wound to be adequately treated, but also to ensure that no other wounds were present. Exposure of one area at a time was generally necessary because of the shocked condition of the patient. (The methods of prior resuscitation will be described later.) The skin around the wound was then thoroughly cleansed over a very wide area by soap and hot water and shaved when any hair was present, also shaving a limb on which plaster extension was to be applied. The limb was then dried and painted with iodine solution or other skin antiseptic, and guards adjusted. In ordinary wound operations mackintosh guards were generally utilised in the forward areas so as to save washing.
The surgical cleansing of the wound was then proceeded with according, to a great extent, to the interval that had elapsed since wounding.
Except in the case of wounds operated on very late, and in septic wounds, the thinnest possible slice was taken off the cut surfaces of the skin, and the wound freely enlarged longitudinally so as to open up thoroughly the deeper parts of the wounds. The deep fascia was opened up in the same way and, if necessary, also the muscle planes.
All seriously traumatised tissue was now removed from the internal wound surface either by knife or scissors. Special attention was given to muscles, all avascular discoloured muscle being removed so that a fresh bleeding surface was presented. Tags of fascia and damaged subcutaneous tissue were removed, and all foreign tissue such as dirt and clothing were removed by instruments, wiping, and washing. All bleeding was stopped, the suction apparatus being of great value in the catching of the bleeding points and also in removing blood and clot from the wound. page 9 Blood vessels and nerves were preserved, as was bone. The extent of the removal of tissue would depend on the amount of tissue damage and partly on the interval since wounding.
At first in North Africa the removal of skin was excessive, so much so at times as to interfere with the subsequent healing of the wound. It was then stressed that skin was a very vital tissue which was seldom the site of infection, and excessive removal was discontinued.
The extent of removal of tissue in the deeper parts of the wound also varied during the different periods. This was especially so when the scene changed from the relatively non-infective terrain of North Africa to Italy, where more severe wound infection was noted and more radical wound toilet was called for.
Great tension in the wound was found at times, especially in the thigh and sometimes in the calf. This was relieved by free incision in skin and especially in the deep fascia, which was, if necessary, divided transversely.
After all the wound had been cleansed, tension relieved, bleeding dealt with and the wound surface dried, the whole surface was lightly covered with powder, at first sulphanilamide and later penicillin in a sulphanilamide base.
Gauze dressings were then applied so as to keep the wound open without plugging. At first sterile vaseline gauze or tulle gras was used so as to ensure an atraumatic dressing, which would not produce pain and trauma on redressing. In Italy, when delayed primary suture became the routine, plain gauze was substituted for the vaseline gauze as it was found that this dressing left a healthier surface for suture, and as the gauze was removed under the anaesthetic the question of pain did not arise. Cotton wool, gamgee, etc., were used as outer dressings.
In all fracture cases and in all large limb wounds splints were applied, in the great majority of cases of plaster, or with plaster incorporated with a Thomas or Kramer splint.
Removal of Foreign Body
Foreign bodies were removed if located during the process of wound cleansing, or if their position was known and the foreign body was large enough to warrant the exploration. It was seldom that X-rays were taken for this purpose, and in the Field Ambulances X-ray was not available. Hunting for foreign bodies in the seriously shocked cases was in general not warranted, especially if this entailed the opening up of fresh tissue planes. It was recognised, however, that the removal of foreign bodies was desirable, and a much larger proportion were removed during the page 10 latter part of the war. The smooth bullet was less prone to produce sepsis than the jagged pieces of shell which often introduced clothing.
The wound, as already stated, was always left wide open and kept open by a gauze dressing, and this ensured some wound drainage. In large wounds of the thigh and often of the calf dependent drainage was generally instituted by making incision in the back of the limb, especially in the earlier period of the war. and before penicillin became available. When sepsis developed, free drainage was provided by large incisions.
Closed Plaster Treatment
At the beginning of the war the closed plaster technique was adopted practically universally and all limb wounds were treated in this way. The wound treatment as described was employed for all large wounds. Vaselined gauze was then applied to the cleansed and enlarged wound and the limb enclosed in plaster. The results were very good. The patients travelled comfortably. The temperature tended to subside satisfactorily, and little toxaemia was present in the majority of the cases. There was little strain on the staffs of the hospitals as dressings were infrequent.
Certain disadvantages were evident, and these became more obvious as time went on, but the treatment had obtained such a grip on the imagination of the medical officers that the disadvantages were prone to be overlooked, especially in those who had had no previous experience of war wounds. The first disadvantage noted was that there was a grave danger of interfering with the blood supply of the limb if a closed plaster was applied, without padding, shortly after wounding. Some limbs were lost because of this. Instructions were then issued by Army that padding should always be used for the primary plaster, and that the plaster should also be split before the case was transferred to another unit.
The second disadvantage was that the plasters became very stained by the secretion from the wound, and also very offensive. Much ingenuity was displayed to obviate this, and carbon dressings and deodorants applied, but without much success.
The most important disadvantage, however, was the long period generally required to promote healing, with the resultant serious wasting of the limb and loss of functional activity. This was naturally noticed only as time went on. It was also noted that secondary infections arose, notably by B. Pyocyaneus. Finally it was agreed that the principle of primary immobilisation of the wounded limb was sound, but that, after the first ten days, further page 11 complete immobilisation was unnecessary and undesirable in the majority of the non-fracture cases, and that more rapid healing and return of function should be aimed at. Changes were soon made in attempts to clean up the wounds more rapidly and close them by secondary suture. Many methods were utilised, including the Carrel-Dakin method, but generally simple dressings with acriflavine and other antiseptics were used. Comparatively little was done in 2 NZEF, however, as our policy of evacuating the seriously wounded to New Zealand as soon as a hospital ship was available removed the patients from our hospitals in the Middle East before their wounds were ready for suture. This was contrary to what occurred during the First World War, when it was the routine procedure to hold cases in England till after the wounds had been sutured and healed. The closed plaster technique, however, continued to be utilised throughout the war in the treatment of below-knee fractures till delayed primary suture of wounds was carried out in all suitable cases, the plaster splint being reapplied after suture. The same applied generally to the treatment of arm fractures.