War Surgery and Medicine
FIRST WORLD WAR
FIRST WORLD WAR
IN the early stages of the First World War chest injuries were treated conservatively and little was done apart from the treatment of the external wound. The wound itself was not treated by radical excision in the same way as wounds of the trunk and buttocks, as there was not the same danger from anaerobic infection of muscle.
Chest surgery, as we now know it, had not been developed. The mortality from chest injuries was high (it still is for that matter), but infection was a common and dangerous complication. During the bloody and prolonged battle of the Somme, with its heavy and continuous casualties, the problem of sepsis in relation to penetrating wounds of the chest became an insistent one, and Cask, then working in a CCS at Heilly, came to the conclusion that an attempt should be made to treat wounds of the chest and lung by full exposure and radical excision on the same principles as that applied to other gunshot wounds. He courageously tackled the problem and developed a technique of early operation which consisted of excision of the wound of the chest wall, opening the chest, freely excising wounds of the lung, and removing foreign bodies and blood from the pleural cavity. He closed the chest by suture and aspirated afterwards. His capacity as a surgeon enabled him to get satisfactory results, especially as regards the prevention of infection, but the mortality was naturally high. Chest cases were then sent to him from the whole area—the first development of a forward chest centre. The necessity for special training of the surgeon, special anaesthetists, and equipment restricted the development, and the majority of surgeons continued to treat the chest cases conservatively.
Gask, however, continued his work and undoubtedly gave a great stimulus to chest surgery. Moynihan at the end of the war was convinced that chest surgery had a great future before it and that marked progress would be made as a result of experience in war. His vision has proved correct. It was strange perhaps that experience in the Second World War showed that early radical exploration of the chest was undesirable, and that the best results were obtained by conservative methods.page 195
During the First World War there was much severe and prolonged sepsis with chronic empyemata. Treatment by the instillation of the hypochlorites was undertaken with beneficial results when the Carrel-Dakin treatment was introduced. (Thoracoplasty. was required later in some of the cases.)
In the First World War the New Zealand forces had no special chest surgeon, nor did they have one during the 1939–45 War. They relied when necessary on the British centres.
Between the Wars
The after-results of war wounds of the chest were evaluated as time went on. There were serious disabilities left behind by chronic infection, with lack of expansion and so of function of lung.
The retention of foreign bodies in the lung was found to give rise to complications, especially if the foreign body was large and irregular, though the large majority of the smaller foreign bodies caused no trouble. Haemoptysis sometimes occurred and there were some cases of bronchiectasis and also of abscess of the lung.
These cases so impressed the Pensions authorities in New Zealand that eventually the Pensions Boards decided to grant a 10 per cent pension to all ex-soldiers who had a retained foreign body, irrespective of the presence of any symptoms or disability. This decision seems to be founded on possibly undue pessimism, and the principle of granting a pension when no disability was present for what might be called a potential disability is open to criticism. The experience of trouble following retention of foreign bodies after the First World War influenced treatment during the Second World War.
A specialised branch of surgery with its own equipment and anaesthetic technique sprang up between the wars and major chest operations became a routine in civilian practice.