War Surgery and Medicine
FIRST WORLD WAR
FIRST WORLD WAR
During the First World War considerable progress was made in the treatment of peripheral nerve injuries. Sir Robert Jones was indefatigable in the institution of special orthopaedic centres, and surgeons trained by him or chosen by him were appointed to look after these cases.
Great enthusiasm was evoked, with the result that the quality of the work performed reached a very high standard, and the surgeons associated with the centres later became the leaders of orthopaedic surgery in Great Britain in the period between the wars, and also in the Second World War. One of them, Brigadier W. R. Bristow, was consultant orthopaedic surgeon to the British Army throughout the 1939–45 War.
During the First World War there were the same two schools of thought with regard to the operative treatment of nerve injuries as there were during the Second World War, in fact as still exist.
One school considered that there was a much better chance of recovery of function if no operation was performed, and that no case should be subjected to operation till ample time had been allowed for spontaneous recovery to take place. This school was influenced very much by the teaching of the famous Frenchmen, Leriche and Tinel, the name of the latter having been perpetuated by the sign he advised to evaluate nerve recovery. Leriche at that time taught that nerve tissue was very readily damaged even by gentle handling, and that operation in itself would inevitably cause injury to the nerve tissue, with the inference that the nerve had much better take its chance of recovery without the added insult of the surgeon. Cases were therefore not referred for surgery till as a rule some months after injury, and the bias was against exploration.
The other school was in favour of exploration in all doubtful cases after the wound had been soundly healed for some weeks, and when there were signs of complete loss of function. It was pointed out that nerve tissue was very vital tissue, as shown by its survival in septic wounds and amputation stumps, and its wonderful powers of regeneration. The danger of damaging nerve tissue during operation, as stressed by Leriche, was not believed in, especially as, in page 167 any case, the damaged and scarred area had to be excised before suture was undertaken. It was held that nerve recovery was more satisfactory the sooner the suture was performed, and that if the operation was delayed for long the chances of success were minimal.
The knowledge of the signs of nerve injury developed rapidly, and many masseurs were trained to test the muscles by means of electrical reactions, both faradic and galvanic, and also to evaluate changes of sensation. The reaction of degeneration in paralysed muscles was utilised fully, and the physiotherapists became highly skilled in both diagnosis and treatment. Regular stimulation of muscles, both by faradic and galvanic current, was instituted, and massage employed to encourage circulation in the part. Splints were used and much ingenuity displayed in designing splints to combine an optimum position with preservation of mobility. The objectives aimed at were:
Prevention of stretching of paralysed muscles.
Prevention of deformities at joints due to overaction of non-paralysed muscles.
The utilisation of elastic tension to produce the optimum position and yet allow of muscular action and joint movement.
Examples of positions and appliances were:
Cock-up splint for musculo-spiral paralysis, combined with elastic bands to the fingers, keeping them in light tension.
Plaster or papier mache splint keeping little and ring finger extended in ulnar paralysis.
Shoulder abduction splint for paralysis of shoulder girdle.
Plaster or tin splints to dorsi-flex the ankle in paralysis of peroneal nerve.
The splints were removed daily during the physiotherapeutic treatment by massage and electricity. The relative greater importance of voluntary movement as against electrically stimulated movement was well understood.
New Zealand Forces
Well organised and equipped physiotherapy departments were attached to the hospitals in England, especially the hospitals at Brockenhurst and Walton-on-Thames, and the Convalescent Depot at Hornchurch. The personnel in charge were well trained and highly skilled in the treatment of nerve injuries. Lieutenant-Colonel M. Macdonald was appointed to take charge of the physiotherapeutic work in England and was stationed at Brockenhurst. He had had special experience of the work and had been attached to Leriche's and Tinel's clinics in France for some time, and he brought to his page 168 work unbounded enthusiasm and energy, as well as sound judgment in the evaluation of the cases. All New Zealand personnel were admitted to our own hospitals from France and were not evacuated to New Zealand till the condition was stabilised. This allowed of ample time to evaluate the prospects of recovery in nerve lesions, and to submit suitable cases to operation. A knowledge of, and experience in, the treatment of nerve injuries was thus gained by the neurologists and surgeons in 1 NZEF that their successors in 2 NZEF were unable to obtain owing to the early evacuation of patients to New Zealand in the Second World War.