War Surgery and Medicine
FIRST WORLD WAR
FIRST WORLD WAR
HERE was little recorded experience of the treatment of head wounds in war available to the surgeons called on to treat these injuries in the First World War. As the treatment of other war wounds developed, so did that of the head wounds.
When the New Zealand Division reached France the New Zealand surgical teams attached to British Casualty Clearing Stations learnt how to treat the head wounds, which were being dealt with by the general surgeons responsible for all types of forward surgery. At that time the scalp wound was fully excised and enlarged so as to expose the damaged skull adequately. Bleeding was controlled, sometimes by means of a rubber band round the head just above the ears. During operation use was made of the galea to control bleeding by picking it up on forceps and drawing it back over the cut wound. The skull fragments were removed and the edges of the bony defect smoothed and cleansed by means of nibblers. The wound was irrigated with warm saline, which also tended to wash away the mushed extruded brain tissue. Pieces of bone were picked out of the brain track by forceps and, in large tracks, gentle palpation was sometimes used to find the fragments. Suction bulbs were used to syringe out the tracks. No extensive explorations were made of the brain tracks.
The scalp wound was then sutured, generally in one layer with interrupted stitches, as a rule no drain being utilised. To enable the wound to be brought together without tension much ingenuity was shown in the fashioning of flaps, and to relieve tension small lateral incisions were often made on either side of the wound. It was realised that it was essential to get healing in the main wound. The clean lateral incisions would heal up satisfactorily, and, in any case, mild infection of these would not be of such importance.
The suturing of the wound had been decided on at that time as the best means of preventing infection and herniation of the brain. Though the picture is similar to that of the Second World War there is one main difference—there were no special neurosurgical teams and no specialised equipment.page 137
Later our only New Zealand hospital in France, 1 NZ Stationary Hospital, shifted from Amiens to Hazebrouck, and in doing so took over two British units, one of which had been constituted the Special Head Centre for the Second Army. This unit had had the responsibility of attending to all the head cases in that army. It had no X-ray machine and no specialised surgeon or staff, nor had it special equipment, except a few bone instruments. Our Stationary Hospital set up an X-ray unit in charge of one technician in a building, and had it working just in time to deal with the rush of casualties from the battle of Messines. Our hospital took all the head cases from this battle, and there were well over a hundred of them. We had one young general surgeon who had had some experience whilst attached to a British CCS, and an eye, ear, nose, and throat surgeon with no experience of these cases, but who was called upon to deal with serious cases at a table alongside, both tables being serviced by one sister. Gushing and Crile visited the hospital at the beginning of the rush of casualties. They had just arrived in France. Gushing was shown over the two theatres and he asked to see the instruments. He was shown a very poor and small selection of bone instruments, the only special equipment left by the British hospital, and all they had been supplied with as' the special head centre. His comment was, as might be expected,' But where are the head instruments, you cannot do any work with those.' The answer was to the effect that we had to operate with what was available, and he was then asked to take a table himself. He consented to do so and was at first assisted by a surgeon and a sister. Later he was rather startled when he was left with the sister as the only assistant. But whatever he thought of our surgery, Gushing had the highest admiration for our sisters, who had to cope with a very large number of very serious head cases at that period.
Later in the war more marked specialisation took place, and also some changes in the technique. BIPP (Bismuth lodoform Paraffin Paste) was rubbed into the wound by many surgeons and BIPPed silk used as a suture material. In Gushing's technique the scalp was excised down to the bone and radiating incisions were made so as to adequately expose the fracture. Burr openings were made round the injured bone and the whole area removed en bloc by cutting forceps. The dura was exposed. Local anaesthetic (procaine hydro-chloride) was employed. Coughing and straining were utilised to extricate the debris from the brain track. A soft rubber catheter was then attached to a rubber bulb and suction made in the track, bone fragments and foreign bodies being picked out of the track by means of fine forceps, or by a magnet. Primary closure of the wound was then carried out if operation was performed less than eighteen hours after wounding. If later, the wound was not closed, as the page 138 results of closure were not satisfactory. Brain fungi were covered with guttapercha and gradually receded. Dichloramine was used as an antiseptic in the treatment of infected wounds. It can be seen that the main characteristics of the technique were the block removal of bone and the use of suction through a catheter.
The results of the treatment in the First World War were better than were expected at the time, especially in the prevention of wound infection. The immediate mortality was heavy. There are German figures available showing that half of the deaths on the battlefield were due to wounds of the head and neck. The Germans stated that 15 per cent of all wounds at the RAP level were head injuries. There are French records available showing an immediate mortality of 48 per cent and later the loss of 33 per cent of the remainder. Gushing stated that there was a mortality of 32.4 per cent in head wounds at the CCS level, and that in penetrating wounds involving the brain mortality was 45 per cent, infection accounting for 88 per cent of the total.
There were certain late complications, although many of the serious cases with gross brain injury made remarkable recoveries. They came under three main categories: infection, epilepsy, and cranial defects.
Infection: This generally was shown as a brain abscess associated frequently with retention of debris, often a piece of in-driven bone. It was found that metallic fragments, especially if of small size, seldom gave rise either to any subsequent disturbance or to infection. On the other hand, bone fragments frequently caused brain abscess, and on this experience was founded the operative procedures of the Second World War.
Epilepsy: This proved a common and very serious sequel of head injuries during the First World War. The epilepsy was, as a rule, generalised in form and not Jacksonian. It was most commonly associated with wounds penetrating the brain, especially when infection had been present. Cairns noted a close correlation between delayed wound healing, a manifestation of sepsis, and the development of epilepsy, with the highest incidence following brain fungus. The incidence of epilepsy in wounds penetrating the dura was given by Wagstaffe as 18.7 per cent; by Rawling as 33 per cent to 54 per cent; and by Ascroft as 45 per cent.
Ascroft stated that 11 out of 34 traced cases operated on by Gushing in the First World War developed epilepsy. When there had been no penetration of the dura the incidence was much less, and Ascroft gives a percentage of 23 in a group of pensions cases investigated by him.page 139
Ascroft's figures were taken from a random sample of pension files about twenty years after the war. He showed that if epilepsy came on shortly after wounding it had a tendency to disappear, whereas if it came on two or three years afterwards it then became permanently established. The figures are, in our opinion, unduly pessimistic and this view is confirmed by the New Zealand War Pensions survey at the end of this article.
When large numbers of gunshot wounds of the head are surveyed there is still, however, an important incidence of epilepsy. Sargent quoted 4.5 per cent in a series of 18,000 cases.
Cairns made the interesting observation that the incidence in cases with a retained foreign body was much less than in those cases which had had a foreign body removed, namely, 38 per cent as against 53 per cent. He ascribed this to possible brain trauma.
Our New Zealand experience in regard to the incidence of epilepsy since the First World War, in the opinion of those associated with War Pensions for long periods, is that there has not been a high incidence of epilepsy in these cases. Head injuries in general give rise to much less disability than one would expect, and a few years after a war large numbers cease to draw pensions. In some cases the epileptic fits tend to cease.
It was clearly established, however, that there was a marked incidence of epilepsy following gunshot wounds of the head, especially those penetrating the brain and those associated with sepsis. The routine administration of sedatives for long periods was therefore advised in all serious head injuries. Relief was sometimes obtained by excision of the scarred area of the brain.
Cranial Defects: When large defects are present certain organic symptoms arise, such as giddiness on stooping. More commonly the symptoms are psychopathic in type, associated with the thought of possible injury to the unprotected brain. Following the First World War many large defects were closed by a number of different techniques. Metal plates were first used, composed of ordinary steel, and later of rustless steel and vanadium. Repair by cartilage and bone was also instituted. First grafts were cut to shape from the cartilaginous end of the lower ribs alongside the lower end of the sternum. These were fitted in beneath the rim of the defect. Then shaped arcs of the outer table of the skull were slipped over the defect from a contiguous part of the skull. Again, pieces of bone were taken from the ribs, tibia, and also later from the region of the crest of the ilium, the edge of the defect being freshened so as to allow of bony union. Increasing success was achieved by the different methods.