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War Surgery and Medicine
Operative Treatment
Operative Treatment
This was undertaken some weeks after the wound had healed, when physiotherapeutic examination had shown that there was a complete nerve block showing no signs of recovery. The period allowed for recovery naturally depended on the judgment of the neurologist and the surgeon, but generally in England operation was not delayed very long, and, following the introduction of secondary suture of wounds, the waiting period was very much shortened.
Our New Zealand routine was a reasonable compromise between the conservative attitude of the neurologist and the enthusiasm of the surgeon. A large number of nerve sutures were performed in both our main hospitals, the technique being that adopted by the leading British orthopaedic surgeons. This technique consisted of:
| (1) |
Careful skin preparation before operation. |
| (2) |
Extensive skin incisions with excision of scar. |
| (3) |
Definition of the nerve trunk well above and below the site of the injury, and placing of a tape under the nerve to allow of gentle traction. |
| (4) |
Careful dissection of the nerve from above and below towards the damaged area, dissecting the densely scarred neuromatous tissue between the normal portions of the nerve as part of the common nerve track. |
| (5) |
Freeing of the nerve well above and below the site of the injury. |
| (6) |
Evaluation of the damaged and scarred area of nerve. If excision deemed advisable, then resection by a sharp knife (generally a tentatome) till normal looking nerve tissue showing nerve bundles was shown and hard scar was no longer present—and a healthy nerve sheath was available. The general appearance of the scarred area, the density of the scar, and the probability that complete division had taken place, were all taken into account. With experience the surgeon had confidence in his page 169 judgment, which, of course, was backed by the opinion of the neurologist, founded on frequent and meticulous examinations beforehand. |
| (7) |
Before dividing the nerve, fine stay stitches were generally introduced so as to retain the normal line of the nerve, and as far as possible reconstitute it in perfect apposition, allowing the nerve fibres to grow again in their original sheath in the peripheral part of the nerve. |
| (8) |
Freeing the nerve again above and below to allow of suture without tension, help being given by flexion of the joint. |
| (9) |
Suture by separate fine thread stitches in the nerve sheath. Stay stitches were also inserted in the sheath above and below to counteract tension. No stitches were placed in the nerve itself. |
| (10) |
The sutured nerve was placed in as healthy a bed as possible, all scarred tissue being removed and a muscle bed being preferred. (Many different methods were used to protect the nerve from adhesions. The junction was wrapped in many materials, both foreign and tissues from the body such as fascia, fat, or muscle. These were all given up as they proved unsatisfactory. They were never used in New Zealand hospitals.) |
| (11) |
The wounds were sutured, healthy tissues being drawn over the nerve when possible. |
| (12) |
The limb was splinted in a position allowing of no tension on the nerve. This generally meant the placing of the joint in flexion, sometimes fairly extreme flexion. This position was corrected gradually in the course of some six weeks till normal position could be attained without risk to the union. |
After operation the splinting and physiotherapeutic treatment by galvanism, massage, and joint movements was regularly carried out till function returned—a long, tedious business.
The results obtained during the 1914–18 War were only moderately satisfactory, and varied considerably in the different nerves. This was dependent on several factors:
| (1) |
The time of suture after the injury. It was determined that very late sutures gave little hope of any success. |
| (2) |
The extent of damage to the nerve, especially the length of nerve involved. |
| (3) |
The extent of the muscular atrophy, especially in relation to the smaller muscles such as the intrinsics of the hand. |
| (4) |
The condition of the joints and the presence of any deformities. |
It was found that the sensory nerves recovered on the whole better than the motor nerves, but that it was rare to get complete recovery. Motor recovery was frequently rendered impossible by the complete atrophy of the involved muscles, especially those of small size.
When nerve repair was impossible or had been unsuccessful, some functional activity was restored by means of tendon transplantation and arthrodesis. This was found especially useful in paralysis of the radial nerve, and tendon transplantation gave, as a rule, such good results that nerve suture was abandoned in cases of extreme difficulty. Tendon transplants in the foot, on the other hand, did not give the same success, largely because of the extra strength required. Arthrodesis was found of use in the ankle.
At the end of the 1914–18 War the surgery of peripheral nerves had reached a very high standard.
Between the wars the development of orthopaedic and neurological specialism continued steadily, but no very marked changes occurred in treatment or in knowledge.