Treatment of War Wounds in the Middle East, WWII Tactical and Technical Trends, No. 15, December 31, 1942 (Lone Sentry)

In the course of the six campaigns which have been fought over the Western Desert since September, 1940, British medical officers have had a great deal of practical experience with the treatment of war wounds. The following summary of the surgical conference held recently by the Director of Medical Service, Middle East Forces, and attended by a majority of the experienced surgeons in the Middle East is believed to represent the general trend of surgical thinking in this area on this important subject.

a. Surgery in the Forward Areas

This question brought up several interesting problems. Generally speaking, it is much better to operate where a patient can be retained for a suitable, if brief, post-operative period rather than make him travel within a few hours of the operation. On the other hand, in active desert warfare (and the experiences related were mainly in connection with the second Cyrenaican campaign), the time lag between infliction of the wound and arrival at a forward surgical unit is commonly more than twenty-four hours. Most cases are therefore best passed to the rear early without interference, and the work of the advanced mobile surgical teams becomes mainly that of "life or limb surgery." Into this category fall severe hemorrhage, penetrating abdominal wounds, sucking chest wounds, and devitalized limbs. Primary suture of wounds came in for universal condemnation. The still somewhat prevalent practice of tight plugging of wounds with gauze and an over-liberal dose of vaseline was also deplored. The rest of this discussion was concerned chiefly with the organization and equipment of mobile teams.

b. Penetrating Wounds of Chest

A trend from the more radical procedures of the last war to a more conservative attitude was the most striking feature of the discussion. In hemothorax, although the ideal treatment is early aspiration with air replacement, the best procedure in forward areas under prevailing conditions is simple wound toilet only and evacuation, provided the base hospital is likely to be reached within a week. The great majority of patients with hemothorax do not exhibit dyspnoea at rest and travel well. In a minority, early aspiration is required. The risk of infection is greatly lessened by the oral administration of sulfa drugs along the line of evacuation, and by delaying aspiration until it can be done under optimum conditions at the base. Removal of intra-thoracic foreign bodies is rarely necessary in forward surgery; even for later removal the indications are probably few.

c. Early Treatment of Burns

There was much adverse criticism of tanning procedures in forward areas, since sepsis, often severe, is an almost invariable sequel. Other local applications advocated were sterile vaselined lint strips (with or without dusting of the area with sulfanilamide or sulfathiazole), picric acid, saline compresses, and cod liver oil. Even the value of tanning in base areas was doubted by some. It seems there is little to choose between the various methods of local treatment of first and second degree burns so long as a high standard of cleanliness can be maintained.

d. Open Fractures of the Femur

Not only in this discussion, but in several others there was both great commendation of the value of the Thomas splint and criticism of its not infrequent faulty use and application. The standard Thomas splint technique described in the Royal Army Medical Corps training manual covers all the points raised, but re-emphasis is needed on one or two points. In first aid and during evacuation, only enough extension should be applied to assist immobilization. It is the comfort of the patient, not the reduction of his fracture, that is all-important until he reaches the base. Skin extension strapping should take the place of first aid clove hitches, halters, skewers, and foot clamps, and the sooner the better. A common fault in applying the splint has been looseness and faulty padding of the upper ring. The leather ring should not have superadded padding, and stability must be maintained by a long immovable pad between the outer part of the ring and the thigh. Too often this pad does not retain its position during transport. A long pad of firmly bandaged wool is advised for this. Adequate fixation of splint to stretcher is also highly necessary for proper immobilization. Fixation of limb to splint by encircling plaster of paris bandages is helpful, but sores or worse are apt to develop if the limb is insufficiently padded. Splitting the plaster when set is the safest course. The plaster of paris hip spica was mostly condemned as an immobilizing agent in evacuation.

To return to the compound fractured femur, it still remains one of the greatest problems of war surgery. Treatment of initial shock, provision of ample dependent drainage at the initial operation because of the depth of the lesion, and comfort during evacuation are life-saving measures which far outweigh in importance the position of the bone fragments.

e. Penetrating Wounds of the Knee Joint

Some guiding principles were laid down. In the past, through-and-through gunshot wounds with small entrance and exit apertures were not excised at all; it is impossible to be thorough with the whole tract. More extensive wounds frequently reach the surgeon after a delay which precludes proper debridement. Then the only necessity is to ensure adequate drainage. The surgeon at the base is often confronted with the problem as to whether a joint is or is not infected on the arrival of the patient a week or two after infliction of the wound. Thorough immobilization and expectant treatment for a few days is probably the best course at this juncture. All are agreed on the necessity for extensive incisions once the joint has to be opened. To prevent gravitational spread of pus into the thigh, it is wise to lower the limb till the heel is just off the bed.

f. Emergency Amputations

The indications for primary amputation (i.e., on or about the first day) are quite straightforward and generally agreed upon. But they are not so easy at a later date. Amputation for infection is a most difficult decision. Greater risks can be taken in upper limb cases, firstly, because the upper limb is so much the more precious, and secondly, because septic absorption is so much less marked than in the lower. There was some little disagreement in the discussion as to whether secondary hemorrhage should be such a relatively frequent indication for secondary amputation. There are infrequent cases of secondary hemorrhage unassociated with bone damage and with but slight sepsis. For these, local ligature at the most is sufficient. In the more common form, associated with gross bone or joint sepsis, one point of view was that amputation is too quickly resorted to, the other was that lives are lost by undue delay. A general working rule adopted by most was as follows: expectant treatment, with minor local measures, for any initial small hemorrhage; local, or if impossible, proximal, ligature for the first large hemorrhage; and amputation for a second large hemorrhage. Stressed and restressed by speakers was the necessity for saving every possible inch of limb on amputation. There is no telling how much the inevitable sepsis in war conditions will eventually further shorten the limb. Sites of election do not exist in war surgery. To anticipate the sepsis, most prefer not to perform the guillotine operation, but to cut flaps and either sew these back temporarily or insert stitches which may be tied after a few days. Early skin traction is useful. When decisions have to be taken regarding the upper limb it is well to remember that a few stumps of thumbs and fingers are better than the best prosthesis.

g. Wounds of the Upper Face

The audience at this meeting was reminded that the skin of the face is too precious ever to be excised in wound treatment and that because of this, and to avoid possible later powder and tattoo marks, such wounds must have a more thorough cleansing than others. Any piece of bone with soft tissue still attached must be retained, firstly because its recovery is probable, and secondly because its removal causes deformity. Suturing of facial wounds is indicated only where the wound is recent, where there is no loss of time, and where fine needles and sutures are available. Otherwise it is best simply to apply a sulfanilamide, tulle gras, and saline dressing, and to transfer the patient to a plastic surgery center. In plastic surgery, any attempts to close a gap where there is loss of tissue must be resisted. Big stitches under tension lead to serious sepsis and irreparable scars.

Protection of the cornea is the principle underlying treatment of wounds of the eyelids. A sulfanilamide dusting, tulle gras and saline dressing is advised, and twice daily the eye is irrigated with normal saline and liquid paraffin drops instilled. Vitreous loss is the greatest danger to the future integrity of the eye after penetrating wounds. Such patients should be kept lying and not treated as walking wounded. The risk of sympathetic ophthalmitis in eye wounds is almost negligible up to nine days, and patients therefore should be sent back to have major operations in the best possible surroundings.

h. Wounds of the Head

When head wounds are seen early (up to about thirty-six hours after receipt), closure is advised after cleansing with a stab drain down to the bone only. In heavily infected cases, seen several days later, gentle cleansing should be done; the removal of any superficial pieces of bone then will also help remove highly infective material such as hair and dirt, which also prevent drainage. Although more a matter of argument, there is a good case for the closing of these late wounds also; since protection of the brain is so important. The large potential space for effusions between scalp and bone is a great safety factor, and the scalp has tremendous powers of healing. Routine lumbar puncture on the second or third day not only relieves pressure but gives a good idea of what is happening within the skull. Only a minority of indriven fragments and metal causes abscesses; interference with these should therefore be limited.

i. Treatment of Infected Wounds

Great tribute was paid to the value of blood transfusion for patients with severely infected wounds, especially in the chronic suppurative stage, and also even earlier. Such transfusions must be large, even massive, in amount. Most agree that one large transfusion is better than repeated small ones. The loss of plasma proteins in copious discharges raises the question of making good its loss, and this was described as best accomplished by a T.B. diet with fresh fruit and plenty of fluids.

A case was presented for less conservation in dealing with these infected wounds and for a return to irrigation procedures. The solution advocated is 0.25 percent electrolytic sodium hypochlorate. This is diluted ten times for continuous irrigation, only twice for intermittent lavage. Many of those present seemed content with dressings consisting usually of a powdering of sulfanilamide, a layer of tulle gras, and a covering of saline gauze.

There is some evidence to suggest that improved drainage plus Proflavine (powder) has been instrumental in clearing up resistant infection (usually staphlcocci) in late stages.