War Surgery and Medicine
FIRST WORLD WAR
FIRST WORLD WAR
In the First World War bleeding was dealt with by first-aid methods in the field units, and by operative treatment at the CCS stage. The high incidence of anaerobic infection in France led to the thorough excision of wounds, even those of no great severity, and especially of those associated with any swelling or tension. This ensured that injuries to the large vessels were explored and the vessels, if found damaged, were ligatured, the wound being left widely open. There could have been little in the way of expectant treatment in cases of serious vascular injury. Gangrene following page 325 ligation of the main limb vessels was common, and subsequent amputation often necessary.
Makins stated that gangrene occurred in 25 per cent of femoral, 41 per cent of popliteal, and 25 per cent of brachial ligations. Short of gangrene, there often developed fibrosis of muscle, liquefaction of muscle, especially in the leg, and general ischaemic changes. Makins laid down at that time principles of treatment which have been followed ever since:
The main vein should be ligated at the same time as the artery to delay emptying the limb of blood and to retain vasodilator substances in the limb circulation.
Operation on aneurysm should be delayed till the collateral circulation became satisfactorily established.
There was danger of secondary haemorrhage in cases with primary damage to the vessels, especially where infection was present. Secondary haemorrhage, largely arising in previously damaged vessels, was a very common complication during the First World War.
Late Results of War Injuries: The number of cases seen in New Zealand between the wars with complications following vascular injuries sustained in the 1914–18 War was not large. Aneurysms, both arterial and arterio-venous in type, gave rise to symptoms demanding operative treatment at times. In many cases, however, the symptoms were so slight that no treatment was necessary or deemed advisable. The increase in size of the aneurysm and interference in the circulation of the limb, however, often necessitated operative treatment, which generally consisted in the quadruple ligation of the artery and the vein. If this was carried out a considerable period after the original injury, there was little danger of gangrene.
When the vessels affected were main vessels near the heart, cardiac changes generally developed. Surgical treatment, if practicable, was accorded such cases in which sudden cardiac dilatation causing death sometimes took place.
Research Work: The utilisation of arterial suture to reconstitute the main vessels was developed to some extent following research work on animals. Research work was also done on the sympathetic control of arterial tone and spasm following the work of Leriche. Heparin had been utilised to prevent the clotting of blood and so render arterial patency following suture more certain. Research, though considerable, was not sufficiently advanced to bring about any marked advances in vascular surgery by the beginning of the Second World War.page 326