War Surgery and Medicine
FIRST WORLD WAR
FIRST WORLD WAR
AT the commencement of the First World War army tradition was in favour of conservative and non-operative measures of treatment of abdominal wounds. During the Spanish-American and South African campaigns, and also the Russo-Japanese war, operative measures had been attended by an alarming mortality. Many men had also recovered following wounding by high-velocity bullets when treated without operation. This had so impressed the medical service that operation was given up by the Russians and actually prohibited by the Japanese.
The considered opinion of the British surgeons in the South African War was similar. MacCormac, the consultant surgeon, went as far as to say' a man wounded in the abdomen dies if operated upon, he lives if left alone.'
This was naturally a gross exaggeration, but it does give very clearly the outlook during the South African War. It also reminds us that cases can and do recover under conservative treatment-a fact that is apt to be overlooked by civilian surgeons accustomed to the normal happy outcome of abdominal surgery.
Figures are quoted showing the very high mortality in the different periods and campaigns, but it is essential to be certain of a full enumeration of all cases followed through to complete recovery before comparison can be made. The fact that operation was discarded is sufficient evidence of its lack of success up till the period of the First World War.
At that time the conservative treatment of abdominal infection was popular with some surgeons. Murphy had made well known his treatment by complete abdominal rest, combined with morphia and fluid given by rectal tube. Associated with this he also used a suprapubic stab drain with pelvic drainage and Fowler's position.
On the other hand, there had been a marked development in abdominal surgery prior to the First World War, and early operation had proved to be the most satisfactory method of preventing the onset of peritonitis in cases of appendicitis. Surgeons were accustomed to immediate operation on such cases, and it seemed logical to carry out the same type of treatment in war injuries. The page 224 development of surgery in the forward areas which, in spite of some objections by higher authority at the beginning, quickly came into favour made it possible for early operation to be carried out in abdominal cases. Young surgeons were eager to grasp the opportunity, and their early success was such that a complete change in outlook developed in the British Army.
Once embarked upon, early surgical treatment became the routine in all cases seen at an early stage, and which were deemed fit for operation. The results, though still leaving much to be desired, were much better than those following conservative treatment.
It was recognised at that time that haemorrhage was a serious complication of war wounds of the abdomen, and that this complication demanded early surgery. The treatment adopted consisted of free abdominal exploration with suture of the intestinal injuries, combined as occasion demanded with drainage of the peritoneum. Injuries of the liver were dealt with by packing and suture, those of the kidney by repair or nephrectomy. Bladder and rectal injuries were treated by free drainage. The operative treatment was carried out generally by specially selected surgeons in the Casualty Clearing Stations. Professor Gordon Bell, then attached to the RAMC, was considered one of the leading surgeons in this field.
Overall, a survival rate of about 30 per cent of cases operated on was achieved, though naturally figures varied considerably. At the end of the war early operation had become recognized as the standard treatment of these cases.
Between wars abdominal surgery became still more established and developed.
The treatment of diseases of the colon had attracted much attention, and the conservative method of Paul had been developed further by Devine and others to obviate the dangers of infection. Primary suture of colonic excisions had been proved more dangerous than the conservative methods associated with primary drainage and secondary closure.
Blood transfusion had been developed and was available for resuscitation of the generally seriously shocked abdominal case. Gastric drainage both by Kyle's tube and Abbott's tubes was being frequently employed in cases of threatened ileus. Bio-chemical investigations with regard to water balance and chloride and other mineral balance had become regular methods in clinical treatment.
There was thus available for the treatment of the abdominal wounds in the Second World War well equipped and experienced surgeons and accessory methods peculiarly suited to the conditions to be encountered.page 225