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War Surgery and Medicine



The position as regards the treatment of war wounds at the end of the war may be summarised as follows:

The technique of surgical cleansing1 was by no means an excision of the wound. Little or no skin was removed, and then only if ingrained with dirt and devitalised. The same held true with regard to the subcutaneous tissue and fascial layers, but fatty tissue was more freely excised. The nerves and vessels were left intact except when smaller vessels were implicated in the removal of muscle. All dirty and devitalised muscle was removed, leaving only bleeding and fresh coloured muscle. If muscle groups were seriously devitalised and any evidence of anaerobic infection existed, then whole muscle groups were removed. Bone was not removed unless it was dirty and lying quite separate, and not of sufficient size to render non-union or marked weakness of the bone structure probable. The wound was freely enlarged longitudinally to the limb and the fascia opened up to expose the whole depth of the wound, and divided transversely if any tension was present. If necessary counter incisions were made. The wound now being wide open and cleansed of all foreign and devitalised tissue, penicillin powder was dusted over the whole inner surface of the

1 The words ‘surgical cleansing’ have been deliberately chosen because of the obscurity of meaning attached to the name excision, and, to a lesser extent, to the French word ébridement.

page 37 wound and gauze placed over it and used also to keep the surfaces lightly apart. The gauze was either plain or vaselined, or tulle gras could be utilised. The limb, unless the wound was of minor degree, was then encased in a padded plaster which was split after application so as to ensure no interference with the vascularity of the limb during evacuation. Parenteral penicillin was then given four-hourly for a minimum of forty-eight hours, and in all large wounds and fractures for a longer period. Blood transfusion was given to all seriously wounded men according to blood loss and shock. Serum was generally given as well in the proportion of one pint of serum to two of blood. In cases of burns blood serum alone was given, and frequently several pints were necessary to combat the haemo-concentration present.

Appropriate splinting was applied to all fracture cases, plaster being used in all fractures except those of the femur, when a Thomas splint with plaster strengthening was utilised. The casualty was then evacuated to a General Hospital either by ambulance train, hospital ship, or by air, and given a short period of rest. On about the fourth day, and frequently earlier, the patient was taken to the operating theatre, no dressing having been attemDted since the original operation in the forward areas, the plaster and dressing removed, and, unless definite infection had occurred, the wound was again dusted with penicillin powder and sutured, either by simple salmon gut stitches, taking a deep bite of the tissues, or by figure-of-eight silk stitches. Parenteral intramuscular penicillin was then given for a few days after suture in all severe wounds. No dressings were carried out for from a week to ten days, when at dressing the stitches were removed. Splints were applied to all severe wounds as at the original operation. By this technique about 80–90 per cent of all wounds healed satisfactorily.

If infection of any severity occurred the wound was opened, penicillin tubes inserted, penicillin instilled twice daily, and parenteral penicillin continued. In the rare septic case further blood transfusions were given to combat the associated secondary anaemia which usually developed in these cases. When fractures were present the same routine was carried out, but the penicillin was continued longer, for at least a week after suture of the wound. If sepsis arose, drainage of the wound was often carried out. For those cases in which sepsis contra-indicated delayed primary suture, parenteral and local penicillin was continued till the wound became healthy and allowed of secondary suture, and at times other measures such as the instillation of the hypochlorites were utilised in the penicillin-resistant infections. In the forward areas primary suture of the wound was not attempted, except in page 38 certain parts such as the scalp and face. The performance of delayed primary suture was simple and efficient, and, besides being safer, it brought about a satisfactory distribution of the operative work between the forward and base units. The ideal of primary suture seemed hardly justifiable under the conditions of active warfare, partly because the transportation of the patient would naturally militate against the healing of the wound.

If any loss of tissue had occurred, and especially in burns on the hands, skin grafting was carried out at the very earliest period, and that meant at the time when delayed primary suture was done. If gas gangrene eventuated, radical removal of muscle was called for and a full course of penicillin parenterally. Amputation was necessary only if actual gangrene of the limb itself set in. Diphtheritic infection of wounds, by no means uncommon, was combated by the institution of serum. As a wound application the sulphonamides, except as a medium for the administration of penicillin, had faded from the picture though sulphonamides given by the mouth were still utilised in head cases and in penicillin-resistant infection.

The story of the treatment of war wounds during the 1939–45 War is one of great interest, showing as it does the gradual development of ideas and knowledge till a selected and trained medical personnel was able to devise a technique, with the aid of new antiseptics and antibiotics, that was both simple and very efficient.

The development from the closed plaster technique to the use of the sulphonamides, and finally to the employment of penicillin, and the very early complete closure of the wound, was a triumph for British surgery in which our New Zealand Medical Corps was honoured to be able to participate. The great lesson that was learnt was that no stereotyped method, however hailed as a panacea, should blind one to the truth that there is no finality in medicine, and that we cannot be content till we reach as near perfection as possible.

The closed plaster technique was accepted too readily by out younger surgeons at the beginning of the war, when it really was producing poorer results in many ways than were being obtained at the end of the First World War. Sulphonamides again were expected to do too much to assist the surgeon, and it was not till the dramatic discovery of the remarkable bacteriostatic effects of penicillin on wound organisms that surgeons would turn their attention to the early closure of wounds, and thus approach, and finally improve on, the results actually attained in the First World War. The principles of the removal of soiled and devitalised tissue from the wound, the relief of tension, the provision of page 39 rest to the tissues and the individual, the replacement of lost fluid and blood, the protection of the wound from contamination and finally its complete closure to prevent that contamination and allow of early restoration of function, were not new or strange. They were relearnt slowly, and sometimes laboriously, by a new generation of surgeons. They will have to be learnt again possibly by another generation of surgeons who may have more powerful bacteriostatics and possibly improved techniques in other ways, but the cardinal principles will remain. We can but hope that eventually it will be possible to close wounds completely and safely at the original operation shortly after the wound has been sustained, and thus save subsequent dressing and subsequent infection with so much relief to the patient, and with much lower mortality and morbidity. The severity of the injury may at any time cause death, but if we can ensure the rapid and aseptic healing of the wounds themselves we will save some lives. Undoubtedly many lives were saved in the 1939–45 War by the determined and persistent progress of wound treatment in the British Army, of which we were proud to be an intimate part.

page 40
Invalids Evacuated to New Zealand or Discharged in United Kingdom
Wounds in Action
2 NZEF 1940–451 1 NZEF May 1916– Dec 1918
Head 276 440
Eye 216 172
Chest 297 616
Abdomen 202 268
Amputations, leg 307 195
Amputations, arm 80 159
Spine 53 91
Nerve lesions 622
Knee joint 85
Shoulder joint 45
Burns 24
Vascular 55
Fractured feet 245
Fractured jaw 86
Fractured femur 346
Fractured tibia and fibula 481
Fractured humerus 350
Fractured forearm 360
Ear 120
Pelvis and hip 100
Other 259 364
Other wounds of back 174
Perineum 50
Other wounds of arm 2300
Other wounds of leg 2683
Multiple wounds 79
—— ——
TOTAL 4609 7591
Total wounded for period 16,456 36,516
Also wounded taken PW 1,326

1 2 NZEF (IP) not included.