War Surgery and Medicine
Primary Suture of Wounds
This was attempted during the First World War and met with some success in the latter part of the war under certain ideal conditions. Under ordinary conditions of warfare in France, however, it was not successful, and the routine treatment was to leave the wound open, counteracting infection by the Carrel-Dakin method until the wound was fit for secondary suture at the Base.
During the Second World War, in the early period in North Africa, primary suture was carried out on abdominal and head wounds, usually with the introduction of temporary drains. Face wounds were at first sutured in the forward areas, but later any large wound was left to be sutured at a facio-maxillary centre at Base, as primary suture had often produced unsatisfactory cosmetic results. During the second Libyan campaign amputations carried out at the sites of election were primarily sutured by some of the forward surgeons, especially in Tobruk, but the results at Base page 26 were found to be unsatisfactory and the practice was discontinued. Suture of sucking chest wounds was also performed as a primary operation, but gave place to delayed primary suture for skin, although muscle suture was carried out at the primary operation. Primary suture of wounds of the scrotum was often undertaken to protect the testes and to prevent contamination.
Generally, however, primary suture was discouraged, as under war conditions it proved unsatisfactory. Late in the war in northern Italy success attended an experiment in which lesser wounds were referred to a CCS for primary suture during a quiet period when the patients could be held until the wounds were healed, with a resultant saving of much time in convalescence. In the future it should be possible to undertake primary suture in a large proportion of uncomplicated wounds when casualties can be rapidly evacuated to hospitals, where the patients can be held, and where there are sufficient surgeons to attend to the minor, as well as the serious, wounds. Careful wound cleansing, together with administration of antibiotics from the earliest opportunity after wounding, and the provision of rest to the injured area should ensure that primary suture will be successful.
Delayed Primary Suture
During the First World War the French reported successful suture on the fourth day after wounding. The use of the closed plaster technique precluded early suture at the beginning of the Second World War. The penicillin trials in Tripoli proved that in many cases wound suture could be successfully carried out within a few days of wounding with the help of penicillin.
In Italy careful wound toilet in the forward areas, and the application of penicillin powder in a base of sulphanilamide to the wound surface, enabled the wound to be successfully sutured on the fourth or fifth day at the base hospital when the original splint and dressing were removed. Later when penicillin became available in ample quantity it was administered parenterally from the earliest opportunity after wounding until delayed primary suture was undertaken, and generally for several days afterwards. This ensured success in the great majority of cases and greatly improved the results in fracture cases. The early healing of the wound prevented secondary infection with its associated serious illness, and greatly shortened the period of hospitalisation and convalescence. It was proved conclusively that with adequate primary surgery, under suitable conditions, and with the use of penicillin, early wound suture was not only practicable but also highly successful.page 27
The technique of suture consisted in freshening the skin edges, applying penicillin powder, and the simple drawing together of the wound surfaces by deeply placed skin sutures of either salmon gut or silk at about half-inch intervals.
Suture of a wound after the first week or ten days has been described as secondary suture. This was the routine procedure at the end of the First World War, when the Carrel-Dakin treatment was used to render the large wounds fit for suture. The operative technique often entailed the removal of the granulating area of the wound, the freshening of the skin edges, and the freeing of tissue layers, which could then be brought together separately by figure-of-eight silk skin sutures.
A relatively small number of cases were dealt with by secondary suture in the Second World War. This was due to the use of the closed plaster technique under which the wound was allowed to heal slowly without suture, and also to the early evacuation of the heavy cases to New Zealand. In the latter part of the war the success of delayed primary suture rendered secondary suture unnecessary in most cases, but it was performed on a few cases after their treatment in saline baths or by the hypochlorites or other antiseptics.
This was carried out by the plastic surgeons in certain large wounds which could not be sutured, and in which it was important to obtain a covering of solid skin. This particularly concerned fracture cases with bare bone exposed in the wound, injured areas on the flexor aspects of the elbow and knee where tissue contraction was to be feared, and areas on which pressure was exerted such as knee, elbow, and heel. Sliding and pedicle grafts were used.
This was more commonly adopted as the war progressed. The techniques were developed especially to deal with the raw areas so common in burns cases, but were frequently used for the healing of gunshot wounds. Early grafting was done in special areas such as the face and fingers, but on the large wounds grafting was at first performed at a comparatively late stage to bring about skin cover when suturing was impossible. When delayed primary suture became established as the routine method of treatment for wounds, skin grafting was carried out at the same time (on the fourth day) to cover any raw areas which could not be dealt with by suture.page 28
Skin grafting was often employed as a temporary dressing to prevent infection and contraction or to facilitate a final repair of the wound by suture or more permanent grafting later. The dermatome proved invaluable when any large area of skin was required for grafting.