War Surgery and Medicine
Finally it can be stated that the results achieved in the final stages of the war were very satisfactory, and that sepsis, the most serious complication of the surviving cases, had been reduced to a very small percentage of the total (3.3 per cent in our own Italian cases).
The majority of deaths from chest injuries in war are the result of severe irrecoverable injuries for which no treatment will probably ever be available. Over four-fifths of our fatal cases died in the first twenty-four hours and 74 per cent died in the Field Ambulances. On the other hand, there were very few deaths at the base hospitals. It would seem that any reduction in mortality must come from the protection of the individual from the missile, and efforts to introduce protective shields were made during the war.
An investigation of 100 fatal and 100 non-fatal gunshot wounds of the chest in a civilian population by Hardt and Seed of Chicago showed that in the fatal wounds the heart or great vessels were penetrated in 85 per cent of the cases. They concluded that a shield covering the anterior portion of the chest approximately 24 cms. square would have prevented 63 out of 66 fatal wounds entering the anterior part of the chest.
A survey made of deaths from wounds in 2 NZ Division in Tunisia shows the high immediate mortality from chest wounds. In 82 men killed in action or dying almost immediately from wounds, the regional classification of the main injury was: chest 32, head 26, abdomen 12, and other areas 5, with multiple wounds 7. This shows how vulnerable is the region of the chest in battle, and some fatal wounds of the chest are caused by small pieces of metal which could be deflected by a body shield. If such a shield were made of light material it would inconvenience the wearer only slightly.page 219
Perhaps in another war some protection will be devised for the chest and abdomen just as the helmet has been introduced to protect the head.
Summary of Important Points:
Reduction of mortality by the introduction of protective shields.
Special chest units to be sited at forward base hospitals.
Sucking wounds an urgent problem calling for immediate closure by pad or temporary suture, by wound excision and closure, by muscle suture at the forward operating centre, and by delayed primary suture of the skin later.
Haemothorax treated by early and repeated aspiration till dry, penicillin being injected into the pleural cavity after each aspiration.
Conservative primary surgery restricted to wound treatment, removal of superficial foreign bodies and thoraco-abdominal injuries.
Pleural infection dealt with by:
Foreign bodies if in the chest wall or pleural cavity removed at first operation; if in the lung removed later if over 1 cm. in diameter in two dimensions.
Blood transfusions restricted to the replacement of actual blood loss.
Severe cases not evacuated till stabilised, generally seven to ten days after wounding.
Breathing exercises and the encouragement of coughing a regular routine in all cases.