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The Treatment of Minor War Injuries
Medical Clinics of North America November, 1941
THE TREATMENT OF MINOR WAR INJURIES JOHN
H.
GIBBON, JR.,
M.D.
MAJOR, MEDICAL RESERVE CORPS, UNITED STATES ARMY; SURGEON, PENNSYLVANIA HOSPITAL, PHILADELPHIA
AND
CLARE C. HODGE, M.D. CAPTAIN, MEDICAL RESERVE CORPS, UNITED STATES ARMY; ASSISTANT SURGEON, PENNSYLVANIA HOSPITAL, PHILADELPHIA
THE wounded in war may be roughly divided into those cases which require transportation on a stretcher and those wounded soldiers who are able to stand, sit or walk, the "walking wounded." This classification arises from the fact that military surgery, as opposed to civilian surgery, must concern itself with the early transportation of the injured, and those who can stand, sit or walk can be most easily moved away from the battle area to general hospitals. More of these patients can occupy an ambulance or railroad car, and also such patients can usually be brought with greater rapidity to the place where their injuries are first treated than the wounded who must be borne on a stretcher. DEFINITION
It is proposed in the present discussion arbitrarily to define minor war injuries as those casualties which do not require transportation by stretcher, i.e., the "walking wounded." They comprise burns that do not produce shock or serious disability, flesh wounds of the upper extremities and minor flesh wounds of the 4ead, neck, trunk and lower extremities. Compound fractures of the upper extremity are included, as patients with such injuries frequently are able to sit or stand after debridement of the wound and immobilization of the part in plaster of Paris. 1829
1830
JOHN it. GIBBON, jR., Cl.AR~ C. llOnG~
ORGANIZATION
It would be meaningless to discuss the treatment of war injuries without at least a very brief mention of the facilities for applying the treatment proposed. Warfare in the past five years has reverted again to one of movement, as opposed to the more or less fixed trench warfare of 1914-1918. The development of the airplane has eliminated safe areas, twenty or thirty miles back of the fighting line. In modern total war, high explosive bombs can wreck hospitals well to the rear of the fighting area. The war of movement and of the airplane, consequently, has resulted in inevitable and necessary changes in the handling of wounded soldiers. The Surgical Team. of the Spanish War.-In the Spanish Civil War, 1937 to 1939, the medical organization of the Loyalists for the care of the wounded underwent considerable modification during the course of the war. The basis of the Spanish Republican medical organization was a "surgical team," which was self-sufficient and equipped with its own means of transportationY The "team" consisted of fourteen people; two surgeons and two anesthetists and the appropriate number of nurses, orderlies, etc. Transportation was provided by an "autochir," a large truck which carried the operating room equipment, autoclave, generator for electric current, and other accessories. In addition, there was an ambulance for the transportation of the personnel. When the team was established for work the ambulance was used to evacuate the wounded. This group could go to a forward position close to the front line, and be ready to take care of wounded in a few hours. Several of these groups could be combined to form, with other personnel, general or evacuation hospitals. The division of the medical organization into such teams made for efficiency because the individuals were accustomed to working together. In a special article in the Lancet15 the advantages of this system are mentioned and the elimination of unnecessary advanced dressing stations is recommended. Evacuation of the Wounded.-Rapid evacuation of the wounded from the scene of the fighting is of the utmost importance. All unnecessary halts before reaching the place where first definitive surgical treatment is undertaken should be
THE TREATMENT OF MINOR WAR INJURIES
1831
eliminated. l4 Transportation of the wounded by airplane is probably only of value under special circumstances, i.e., where the enemy has either lost control of the air or is rapidly retreating. Such circumstances obtained during the German operations in Poland and have been described by Schmidt.26 Jollyll emphasizes that the care of the wounded should be based upon the time factor, rather than the distance from the scene of the fighting, the object always being to render adequate surgical care at the earliest possible moment. The efficiency and adaptability of these basic surgical teams provided with their own means of transportation were admirably shown under the test of war conditions in Spain. BURNS
Because of the great number of gasoline-propelled vehicles in.modern warfare, and the increasing use of incendiary bombs, it is likely that there will be an increasing incidence of burned patients. The systemic treatment of extensive burns does not lie within the province of this paper. We shall consider only the local treatment of burns of such extent that they do not produce shock. The greatest change from civilian practice has been the elimination of tannic acid in the treatment of burns of the hands and face. 16 • 25. 29 The tendency of the stiff eschar to crack over areas frequently moved, as the fingers and face, opens up avenues for infection. Furthermore the tan may interfere with the blood supply of the fingers and produce necrosis of the distal phalanges (Figs. 230 and 231). Minor Burns.-The War Wounds Committee of the Medical Research Council in England has published an outline of the treatment of minor burns,16 which is an excellent summary of current methods. It advises cleansing minor burns with soap, water and ether. Thorough cleansing and debridement are essential. The mechanical element in cleansing is important but must be done with a minimum of trauma. The skin surrounding the burned area should also be cleansed carefully, adjacent hair shaved for some distance from the margin of the burn and meticulous care taken to remove overhanging bits of devitalized tissue along the edge of the burn. Special attention
1832
JOHN H. GIBBON, JR., CLARE C. HODGE
should be given to nails as these serve as potent sources for subsequent infection.4 Following the soap and water toilet and the debridement the area is thoroughly washed with saline solution and dried. Sterile vaselinized gauze is then applied to burns of the face and hands. Tannic acid jelly or 1 per cent gentian violet jelly is used for burns on other parts of the body. When these jellies are used, no dressing is applied.
Fig. 230.-Third degree burn of hand treated with tannic acid. Terminal necrosis of the fingers can be seen. (Wakely, "The Treatment of War Burils," SUrgery, Vol. 10, p. 207, 1941.)
Severe Burns.-More extensive burns are similarly cleansed and then dusted with sulfanilamide powder. Except in burns of the face, hands, wrists, or feet, some coagulant is then applied. Those commonly used are ( 1) 10 per cent silver nitrate, (2) 10 per cent tannic acid, (3) 10 per cent silver nitrate and 5 per cent tannic acid, used alternately, (4) "triple dye" (gentian violet, 1 :400, brilliant green, 1 :400, and neutral
THE TREATMENT OF MINOR WAR INJURIES
1833
acriflavine, 1: 1000, equal parts of each). The coagulants are best applied with a gauze mop. Great care should be exercised if circumferential tanning is used, for fear of interfering with the blood supply. On those parts where coagulants cannot be used the burns are cleansed, dusted with sulfanilamide powder
Fig. 231.-Skiagram of hand depicted ill Fig. 230, showing necrosis of the terminal phalanges. (Wakely, "The Treatment of War Burns," Surgery, Vol. 10, p. 207, 1941.)
and covered with tulle gras, which is in turn covered with six or eight layers of gauze soaked in salt solution. Tulle gras consists of squares of curtain net (mesh 2 mm.) impregnated with soft paraffin, 96 gm., and balsam of Peru, 2 gm., and then autoclaved. When treating extensive burned ·areas with sulfanilamide powder, the total amount used should not exceed 20
1834
JOHN H. GIBBON, JR., CLARE C. HODGE
or 30 gm., in order not to produce excessive concentrations of the drug in the blood. 9 Morphine should always be used liberally in severely burned patients, and antitetanic serum administered prophylactically. If infection occurs beneath the tan, the tan must be soaked off with salt solution and treatment continued by saline baths and dressings. The recent development by Bunyan2 of waterproof envelopes which entirely enclose a limb and which are filled at intervals with electrolytic sodium hypochlorite for irrigation, may be of value in the later treatment of some burns after evacuation of the patient from the front line area. The method is better adapted for use in hospitals 7 than in advanced stations for the treatment of wounded. FLESH WOUNDS
The operative treatment of flesh wounds remains the same as in the first World War, with the addition of the use of chemotherapy. We shall only consider here flesh wounds of the upper extremity and nonpenetrating wounds of the head and trunk. Debridement.-With the exception of small through-andthrough bullet wounds which require no special care, the treatment is debridement, which ideally consists of surgical excision of the entire wound. 24 The possibility of employing this procedure under wartime conditions, with extensive, lacerated, contused and disrupted wounds, does not always exist. The ideal, however, should be approached as nearly as possible under the existing circumstances. Most gunshot wounds received in warfare are badly lacerated and contused. After proper anesthetization the wound is covered up to its edges with a plain gauze pack and the surrounding skin carefully shaved and thoroughly cleansed with soap and water and some fat solvent. The skin then, if desired, may be painted with an antiseptic up to the wound margins. The skin edges are then excised. Skin should not be unnecessarily sacrificed; frequently l,4 inch is all that needs to be removed around the margin of the wound. Often the injury is more extensive than that of the skin wound itself, in which case adequate exposure must be obtained by further skin incision. This should be made in the longitud-
THE TREATMENT OF MINOR WAR INJURIES
1835
inal axis of the limb. All dirty and contaminated tissue and devitalized muscle must then be excised, preferably en masse. In wounds of the face the excellent blood supply permits a limited debridement, and mechanical cleansing should take the place of radical excisionY Important nerves and blood vessels must be preserved whenever possible. Primary nerve or tendon suture should not be attempted under war conditions. 5 Secondary repair of these structures can be un~ertaken a,t a later date with far greater likelihood of success, especially if infection has been avoided during the primary treatment. Successful nerve suture may be performed up to two years after the original injury.l Foreign bodies are located and removed, preferably by digital exploration. Eloesser5 has pointed out that the use of x-ray in advanced stations is impracticable. Hoffman8 agrees with this and states that it has been used in less than 5 per cent of cases. Packing and Immobilization.-After excision of all dead and damaged tissue and removal of all foreign bodies,· the wound should be thoroughly irrigated with normal saline, packed open, and the extremity immobilized in the position of function by the use of plaster. The only possible exceptions to this rule of avoiding primary suture are minor wounds of the head, hand, foot and wrist.1> Minor wounds of the scalp may be sutured per primam provided a very thorough debridement has been performed. Otherwise such wounds are best left undisturbed until definite treatment can be given. 18 The packing used in the wounds may consist of plain gauze, vaselinized gauze, or gauze smeared with some form of antiseptic paste, such as "Zisp." This is made up of equal parts of zinc peroxide, iodoform and sulfanilamide powder, with enough paraffin in to make a thin paste.8 The use of gauze saturated with cod liver oil has also been favorably mentioned. 23 ANESTHESIA
In mobile warfare dependence should be placed upon the simplest and most easily transportable anesthetic agents.17 Ether and chloroform both fulfill these requirements, while anesthetic gases which must be transported in heavy cylinders
183'6
JOHN H. GIBBON, JR., CLARE C. HODGE
should not be relied upon. For extensive wounds requiring prolonged operation, general inhalation anesthesia will probably be necessary. Brachial plexus block in injuries to the upper extremity has been found by Eloesser 5 to be useful. Ten to 30 cc. of 1 per cent novocain containing 2 minims of 1: 1000 solution of epinephrine hydrochloride to the ounce, is injected in and about the plexus by passing the injecting needle posteriorly 2 cm. above the middle of the clavicle. For other minor injuries pentothal sodium intravenously has been found satisfactory. Six to 8 cc. of a 5 per cent solution is injected intravenously for induction. A total of 16 to 18 cc. is necessary for a satisfactory anesthesia. 25 The use of 2.5 per cent solution of the drug is probably safer than the stronger solution. CONTROL OF HEMORRHAGE
First aid control of hemorrhage should always be attempted by direct pressure over the wound combined with elevation. Only in the rare cases where this is inadequate should a tourniquet be used. If a tourniquet is applied, it should be released every twenty minutes. Should the hemorrhage recur, it can then be reapplied. Where the patient has reached facilities for direct treatment of the wound the hem or rh age will of course be controlled by direct ligation of the bleeding vessels. Under unusual circumstances it may occasionally be necessary to control hemorrhage by packing the wound. If this is done tightly there is a great danger of subsequent infection, particularly as under these circumstances debridement has probably not been adequate. If tight packing is used, it should be removed at the earliest possible moment. It is also dangerous to apply tight circumferential bandages over a wound in a limb for hemostasis. Such a bandage will later produce severe pain and great edema in the distal portion of the limb. 19 LOCAL AND ORAL CHEMOTHERAPY
The report of Jensen and coworkers1o in 1939 on the local implantation of sulfanilamide in compound fractures was a great stimulus to the local use of sulfanilamide in many situations, particularly, in traumatic wounds and compound fractures. The local use of the drug does not eliminate the neces-
THE TREATMENT OF MINOR WAR INJURIES
1837
sity for very adequate and thorough debridement, but it probably is a useful adjunct to such a procedure. The drug is absorbed into the general circulation and eliminated; consequently, it is advisable to supplement the local use with administration by mouth. An initial dose of 4 gm. should be taken orally as soon after the injury as possible. This should ' be followed by 1 gm. every four hours, for one week. In cases without evidence of infection the dosage may be diminished after two or three days. Where infection occurs larger doses will be required. Not more than 15 gm. should be placed in the wound. Five to 10 gm. are usually sufficient. Other sulfonamides may prove to be more efficient and less toxic, but their general use will have to await further study. Chemotherapeutic agents are undoubtedly most efficient when used prophylactically and in the early stages of infection. S Sulfanilamide powder in the amount of 5 to 10 gm. can be sprinkled on a wound when the first aid dressing is applied, and the initial dose taken by mouth at the same time. When the wound is debrided, sulfanilamide powder can again be placed in the wound and the administration by mouth continued. Such use of sulfanilamide was found to be of considerable value in diminishing the incidence of streptococcal infection during the evacuation from Dunkirk20 and in the fighting in Libya. 19 Ross and Hulbert25 do not routinely employ sulfanilamide either locally or generally. However, 50 per cent of their wounded were aviators in which cases the contamination seen in wounds of the infantry soldier from soil and dirt must have been largely absent. COMPOUND FRACTURES OF THE UPPER EXTREMITY
Closed Plaster Dressings.-Probably the greatest change which has occurred in the treatment of war wounds has been the use of closed plaster dressings for compound fractures. Following the publication of Orr's book on this subject in 1929,21 the closed plaster method was slowly adopted in the United States in the treatment of osteomyelitis. The remarkable results which could be attained by this method in the treatment of compound fractures were not generally appreciated
1838
JOHN H. GIBBON, JR., CLARE C. HODGE
Fig. 232.-Wound of upper third of humerus, produced by aerial bomb and not treated for twenty-four hours. Extensive debridement was performed before application of plaster. (Trueta, "Treatment of War Wounds and Fractures." Courtesy of Hamish Hamilton Medical Books, London, England.)
Fig. 233.-8ame patient as in Fig. 232, seventy-five days later. Fracture had united but wound had not completely healed. Plaster was again applied. (Trueta, "Treatment of War Wounds and Fractures." Courtesy of Hamish Hamilton Medical Books, London, England.)
THE TREATMENT OF MINOR WAR INJURIES
1839
Fig. 234.--Same patient as in Figs. 232 and 233, after application of final plaster. (Trueta, "Treatment of War Wounds and Fractures." Courtesy of Hamish Hamilton Medical Books, London, England.)
Fig. 235.-End-result in case illustrated in Figs. 232 to 234. (Trueta, "Treatment of War Wounds and Fractures." Courtesy of Hamish Hamilton Medical Books, London, England.)
1840
JOHN H. GIBBON, JR., CLARE C. HODGE
until the Spanish Civil War (Figs. 232, 233, 234 and 235). The best summary of this method and its results is to be found in Trueta's book.27 The technic of the application of the plaster is excellently described by Eloesser. 5 He stresses the importance of placing plaster splints in position before applying the circular turns. Casts constructed in this manner are stronger and lighter than those made entirely by circular turns. It is also easier to split these casts longitudinally, which should always be done if patients must be evacuated shortly after the application of the plaster. The operative treatment of the wound itself is similar to that outlined above in the treatment of flesh wounds. In addition, any loose bits of bone unattached to periosteum are removed. The bones are placed in proper alignment by traction and manipulation and held in place while the primary plaster splints are applied, followed by the complete circular cast: All the wounds are packed open. Dry gauze was used in Spain but vaselinized gauze, "Zisp," cod liver oil, or gauze saturated with a sulfanilamide paste may be used. Wallis and Dillworth 30 have recently recommended gauze soaked in a 12 per cent solution of lactose for packing these wounds. Because fermentation takes precedence over putrefaction, they state that these casts do not develop a foul odor for periods up to four weeks. Streptococcal septicemia was the most common cause of death in the wounded during the war of 1914-1918. In the bacteriologic studies of the closed plaster cast during the Spanish Civil War, streptococci could be grown from the wounds at almost any stage in the healing process,22 but streptococcal septicemia was an extreme rarity. This appears to indicate the effectiveness of complete immobilization in preventing absorption from raw surfaces. 21 . 28 Immobilization of Fractures.-Abduction plaster casts for fractures of the humerus should not be used in advance stations. 5 • 6 The arm in the abducted position interferes with transportation and exposes the part to injury. Immobilization by binding the arm to the chest is useful in emergencies. When possible a cast should be applied with the arm slightly abduc-
THE TREATMENT OF MINOR WAR INJURIES
1841
ted and in slight anterior flexion. The forearm should be at right angles to the arm and directed forward. 12 Splints.-:-Except for actual litter work on the battlefield, plaster of Paris is the ideal modern splint for use in the care of the wounded. 13 Plaster weighs more than other splints, but is less bulky and easier to transport. Furthermore, plaster can be adapted' for use in any situation, whereas when other material is used a variety of splints for different purposes must be kept on hand and returned to the forward areas when they are removed from the patient. Finally, the immobilization achieved by plaster during the transportation of the wounded, cannot' be obtained by any other means. SUMMARY
1. In modern warfare a medical organization will be most efficient when it is built up of small surgical units which possess their own means of transportation and supplies. Such units can be set up quickly to take care of casualties close to the scene of action'. When many units are combined they may serve as an evacuation or general hospital, in association with other specialty units. 2. Burns of the hands and face should not be treated with tannic acid. 3. Debridement, ideally wound excision, is stilI the essential basis of treatment of gunshot wounds. 4. Primary suture should never be employed in contused, lacerated gunshot wounds. 5. Sulianilamide, locally and generally, should be employed in all patients with traumatic wounds. 6. The closed plaster of Paris dressing has been proved to be the ideal primary treatment of compound fractures and extensive flesh wounds. BIBLIOGRAPHY 1. Bristow, N. R.: Peripheral Nerve Injuries (Report of Societies). Brit. 1: 373, 1941. 2. Bvnyan, J.: Envelope Method of Treating Burns. Proc. Roy. Soc. 34: 65, 1940. 3. Buttle, C. A. H.: Chemotherapy of Infected Wounds. Lancet, 1: 890, 4. Cohen, S. M.: Treatment of Burns; Tannic Acid versus Saline. Brit. 2: 754, 1940.
M.
J.,
Med., 1940. M. J.,
1842
. JOHN H. GIBBON, JR., CLARE C. HODGE
5. Eloesser, L.: Treatment of Compound Fractures in War: Report of Prac. tical Experience in Spanish Civil War. J.A.M.A., 115: 1848, 1940. 6. Ernst, M.: Preparation of Wounded for Transportation from Front Line Hospitals. Miinchen. Med. Wchnschr., 87: 1377, 1940. 7. Hannay, J. W.: Treatment of Burns by Envelope Irrigation. Brit. M. J.,
2: 46, 1941. 8. Hoffman, S. J.: Treatment of Air Raid Casualties. Brit. M. J., 1: 785, 1941.
9. Hooker, D. H. and Lam, C. R.: Absorption of Sulfanilamide from Burned Surfaces. Surgery, 9: 534, 1941. 10. Jensen, N. K., Johnsrud, L. W. and Nelson, M. C.: Local Implantation of Sulfanilamide in· Compound Fractures; Preliminary Report. Surgery, 6: 1, 1939. 11. Jolly, D. W.: Field Surgery in Total War. Paul B. Hoeber, Inc., New York,
1941. 12. Key, J. A. and Conwell, H. E.: Fractures, Dislocations and Sprains. St. Louis, C. V. Mosby Co., 1934. 13. Lancet, Editorial: Surgical Lessons of Heavy Fighting, 1: 1052, 1940. 14. Lancet, Editorial: Evacuation of Army Casualties, 1: 573, 1941. 15. Lancet, Special Article: Medical Organization in the R.AM.C. and Spanish Republican Army, 1: 579, 1941. 16. Lancet, Special Article: Treatment of Burns, 1: 425, 1941. 17. Macintosh, R. R. and Pratt, F. B.: Anesthesia in War Time. Brit. M. J. 2: 1077, 1939. 18. McKissock, W. and Brownscombe, B.: Apparently Trivial Head Injuries. Lancet, 1: 593, 1941. 19. Mitchell, G. A. G., Logie, N. S. and Handley, R. S.: Casualties from the
Western Desert and Libya Arriving at a Base Hospital. Lancet, 1:
713, 1941. 20. Ogilvie, W. H.: Treatment of the Infected Wounds. Lancet, 1: 608, 1940. - - - :Surgery of Infected Wounds. Lancet, 1: 975, 1940. 21. Orr, H. W.: Osteomyelitis and Compound Fractures. St. Louis, C. V. Mosby· Co., 1929. 22. Orr-Ewing, J., Scott, J. C. and Gardner, A. D.: The Bacteriological In23. 24. 25. 26. 27. 28. 29. 30.
vestigation of Wounds Treated by the Closed Plaster Method. Brit. M. J., 1: 877, 1941. . Palser, J. E. R.: Closed Plaster Technique for Infected Fracture and War Wounds (letter to the Editor). Brit. M. J., 2: 764, 1940. Reid, M. R. and Carter, B. N.: The Treatment of Fresh Traumatic Wounds. Ann. Surg., 114: 4, 1940. Ross, J. A. and Hulbert, K. J.: Treatment of 100 War Wounds and Burns. Brit. M. J., 1: 6, 8, 1941. Schmidt, F.: Transportation of the Wounded by. Plane. MU. Surgeon, 87: 136, 1940. Trueta, J.: Treatment of War Wounds and Fractures. New York, Paul B. Hoeber, Inc., 1940. Trueta, J. and Barnes, J. M.: The Rationale of Complete Immobilization in Treatment of Infected Wounds. Brit. M. J., 2: 46, 1940. Wakeley, C. P. G.: The Treatment of War Burns. Surgery, 10: 207, 1941. Wallis, A. D. and Dillworth, M. J.: Lactose for Prevention of Odor in the Closed Cast Treatment of Compound Fractures. Brit. M. J., 1: 750, 1941.
THE TREATMENT OF MINOR WAR INJURIES JOHN
H.
GIBBON, JR.,
M.D.
MAJOR, MEDICAL RESERVE CORPS, UNITED STATES ARMY; SURGEON, PENNSYLVANIA HOSPITAL, PHILADELPHIA
AND
CLARE C. HODGE, M.D. CAPTAIN, MEDICAL RESERVE CORPS, UNITED STATES ARMY; ASSISTANT SURGEON, PENNSYLVANIA HOSPITAL, PHILADELPHIA
THE wounded in war may be roughly divided into those cases which require transportation on a stretcher and those wounded soldiers who are able to stand, sit or walk, the "walking wounded." This classification arises from the fact that military surgery, as opposed to civilian surgery, must concern itself with the early transportation of the injured, and those who can stand, sit or walk can be most easily moved away from the battle area to general hospitals. More of these patients can occupy an ambulance or railroad car, and also such patients can usually be brought with greater rapidity to the place where their injuries are first treated than the wounded who must be borne on a stretcher. DEFINITION
It is proposed in the present discussion arbitrarily to define minor war injuries as those casualties which do not require transportation by stretcher, i.e., the "walking wounded." They comprise burns that do not produce shock or serious disability, flesh wounds of the upper extremities and minor flesh wounds of the 4ead, neck, trunk and lower extremities. Compound fractures of the upper extremity are included, as patients with such injuries frequently are able to sit or stand after debridement of the wound and immobilization of the part in plaster of Paris. 1829
1830
JOHN it. GIBBON, jR., Cl.AR~ C. llOnG~
ORGANIZATION
It would be meaningless to discuss the treatment of war injuries without at least a very brief mention of the facilities for applying the treatment proposed. Warfare in the past five years has reverted again to one of movement, as opposed to the more or less fixed trench warfare of 1914-1918. The development of the airplane has eliminated safe areas, twenty or thirty miles back of the fighting line. In modern total war, high explosive bombs can wreck hospitals well to the rear of the fighting area. The war of movement and of the airplane, consequently, has resulted in inevitable and necessary changes in the handling of wounded soldiers. The Surgical Team. of the Spanish War.-In the Spanish Civil War, 1937 to 1939, the medical organization of the Loyalists for the care of the wounded underwent considerable modification during the course of the war. The basis of the Spanish Republican medical organization was a "surgical team," which was self-sufficient and equipped with its own means of transportationY The "team" consisted of fourteen people; two surgeons and two anesthetists and the appropriate number of nurses, orderlies, etc. Transportation was provided by an "autochir," a large truck which carried the operating room equipment, autoclave, generator for electric current, and other accessories. In addition, there was an ambulance for the transportation of the personnel. When the team was established for work the ambulance was used to evacuate the wounded. This group could go to a forward position close to the front line, and be ready to take care of wounded in a few hours. Several of these groups could be combined to form, with other personnel, general or evacuation hospitals. The division of the medical organization into such teams made for efficiency because the individuals were accustomed to working together. In a special article in the Lancet15 the advantages of this system are mentioned and the elimination of unnecessary advanced dressing stations is recommended. Evacuation of the Wounded.-Rapid evacuation of the wounded from the scene of the fighting is of the utmost importance. All unnecessary halts before reaching the place where first definitive surgical treatment is undertaken should be
THE TREATMENT OF MINOR WAR INJURIES
1831
eliminated. l4 Transportation of the wounded by airplane is probably only of value under special circumstances, i.e., where the enemy has either lost control of the air or is rapidly retreating. Such circumstances obtained during the German operations in Poland and have been described by Schmidt.26 Jollyll emphasizes that the care of the wounded should be based upon the time factor, rather than the distance from the scene of the fighting, the object always being to render adequate surgical care at the earliest possible moment. The efficiency and adaptability of these basic surgical teams provided with their own means of transportation were admirably shown under the test of war conditions in Spain. BURNS
Because of the great number of gasoline-propelled vehicles in.modern warfare, and the increasing use of incendiary bombs, it is likely that there will be an increasing incidence of burned patients. The systemic treatment of extensive burns does not lie within the province of this paper. We shall consider only the local treatment of burns of such extent that they do not produce shock. The greatest change from civilian practice has been the elimination of tannic acid in the treatment of burns of the hands and face. 16 • 25. 29 The tendency of the stiff eschar to crack over areas frequently moved, as the fingers and face, opens up avenues for infection. Furthermore the tan may interfere with the blood supply of the fingers and produce necrosis of the distal phalanges (Figs. 230 and 231). Minor Burns.-The War Wounds Committee of the Medical Research Council in England has published an outline of the treatment of minor burns,16 which is an excellent summary of current methods. It advises cleansing minor burns with soap, water and ether. Thorough cleansing and debridement are essential. The mechanical element in cleansing is important but must be done with a minimum of trauma. The skin surrounding the burned area should also be cleansed carefully, adjacent hair shaved for some distance from the margin of the burn and meticulous care taken to remove overhanging bits of devitalized tissue along the edge of the burn. Special attention
1832
JOHN H. GIBBON, JR., CLARE C. HODGE
should be given to nails as these serve as potent sources for subsequent infection.4 Following the soap and water toilet and the debridement the area is thoroughly washed with saline solution and dried. Sterile vaselinized gauze is then applied to burns of the face and hands. Tannic acid jelly or 1 per cent gentian violet jelly is used for burns on other parts of the body. When these jellies are used, no dressing is applied.
Fig. 230.-Third degree burn of hand treated with tannic acid. Terminal necrosis of the fingers can be seen. (Wakely, "The Treatment of War Burils," SUrgery, Vol. 10, p. 207, 1941.)
Severe Burns.-More extensive burns are similarly cleansed and then dusted with sulfanilamide powder. Except in burns of the face, hands, wrists, or feet, some coagulant is then applied. Those commonly used are ( 1) 10 per cent silver nitrate, (2) 10 per cent tannic acid, (3) 10 per cent silver nitrate and 5 per cent tannic acid, used alternately, (4) "triple dye" (gentian violet, 1 :400, brilliant green, 1 :400, and neutral
THE TREATMENT OF MINOR WAR INJURIES
1833
acriflavine, 1: 1000, equal parts of each). The coagulants are best applied with a gauze mop. Great care should be exercised if circumferential tanning is used, for fear of interfering with the blood supply. On those parts where coagulants cannot be used the burns are cleansed, dusted with sulfanilamide powder
Fig. 231.-Skiagram of hand depicted ill Fig. 230, showing necrosis of the terminal phalanges. (Wakely, "The Treatment of War Burns," Surgery, Vol. 10, p. 207, 1941.)
and covered with tulle gras, which is in turn covered with six or eight layers of gauze soaked in salt solution. Tulle gras consists of squares of curtain net (mesh 2 mm.) impregnated with soft paraffin, 96 gm., and balsam of Peru, 2 gm., and then autoclaved. When treating extensive burned ·areas with sulfanilamide powder, the total amount used should not exceed 20
1834
JOHN H. GIBBON, JR., CLARE C. HODGE
or 30 gm., in order not to produce excessive concentrations of the drug in the blood. 9 Morphine should always be used liberally in severely burned patients, and antitetanic serum administered prophylactically. If infection occurs beneath the tan, the tan must be soaked off with salt solution and treatment continued by saline baths and dressings. The recent development by Bunyan2 of waterproof envelopes which entirely enclose a limb and which are filled at intervals with electrolytic sodium hypochlorite for irrigation, may be of value in the later treatment of some burns after evacuation of the patient from the front line area. The method is better adapted for use in hospitals 7 than in advanced stations for the treatment of wounded. FLESH WOUNDS
The operative treatment of flesh wounds remains the same as in the first World War, with the addition of the use of chemotherapy. We shall only consider here flesh wounds of the upper extremity and nonpenetrating wounds of the head and trunk. Debridement.-With the exception of small through-andthrough bullet wounds which require no special care, the treatment is debridement, which ideally consists of surgical excision of the entire wound. 24 The possibility of employing this procedure under wartime conditions, with extensive, lacerated, contused and disrupted wounds, does not always exist. The ideal, however, should be approached as nearly as possible under the existing circumstances. Most gunshot wounds received in warfare are badly lacerated and contused. After proper anesthetization the wound is covered up to its edges with a plain gauze pack and the surrounding skin carefully shaved and thoroughly cleansed with soap and water and some fat solvent. The skin then, if desired, may be painted with an antiseptic up to the wound margins. The skin edges are then excised. Skin should not be unnecessarily sacrificed; frequently l,4 inch is all that needs to be removed around the margin of the wound. Often the injury is more extensive than that of the skin wound itself, in which case adequate exposure must be obtained by further skin incision. This should be made in the longitud-
THE TREATMENT OF MINOR WAR INJURIES
1835
inal axis of the limb. All dirty and contaminated tissue and devitalized muscle must then be excised, preferably en masse. In wounds of the face the excellent blood supply permits a limited debridement, and mechanical cleansing should take the place of radical excisionY Important nerves and blood vessels must be preserved whenever possible. Primary nerve or tendon suture should not be attempted under war conditions. 5 Secondary repair of these structures can be un~ertaken a,t a later date with far greater likelihood of success, especially if infection has been avoided during the primary treatment. Successful nerve suture may be performed up to two years after the original injury.l Foreign bodies are located and removed, preferably by digital exploration. Eloesser5 has pointed out that the use of x-ray in advanced stations is impracticable. Hoffman8 agrees with this and states that it has been used in less than 5 per cent of cases. Packing and Immobilization.-After excision of all dead and damaged tissue and removal of all foreign bodies,· the wound should be thoroughly irrigated with normal saline, packed open, and the extremity immobilized in the position of function by the use of plaster. The only possible exceptions to this rule of avoiding primary suture are minor wounds of the head, hand, foot and wrist.1> Minor wounds of the scalp may be sutured per primam provided a very thorough debridement has been performed. Otherwise such wounds are best left undisturbed until definite treatment can be given. 18 The packing used in the wounds may consist of plain gauze, vaselinized gauze, or gauze smeared with some form of antiseptic paste, such as "Zisp." This is made up of equal parts of zinc peroxide, iodoform and sulfanilamide powder, with enough paraffin in to make a thin paste.8 The use of gauze saturated with cod liver oil has also been favorably mentioned. 23 ANESTHESIA
In mobile warfare dependence should be placed upon the simplest and most easily transportable anesthetic agents.17 Ether and chloroform both fulfill these requirements, while anesthetic gases which must be transported in heavy cylinders
183'6
JOHN H. GIBBON, JR., CLARE C. HODGE
should not be relied upon. For extensive wounds requiring prolonged operation, general inhalation anesthesia will probably be necessary. Brachial plexus block in injuries to the upper extremity has been found by Eloesser 5 to be useful. Ten to 30 cc. of 1 per cent novocain containing 2 minims of 1: 1000 solution of epinephrine hydrochloride to the ounce, is injected in and about the plexus by passing the injecting needle posteriorly 2 cm. above the middle of the clavicle. For other minor injuries pentothal sodium intravenously has been found satisfactory. Six to 8 cc. of a 5 per cent solution is injected intravenously for induction. A total of 16 to 18 cc. is necessary for a satisfactory anesthesia. 25 The use of 2.5 per cent solution of the drug is probably safer than the stronger solution. CONTROL OF HEMORRHAGE
First aid control of hemorrhage should always be attempted by direct pressure over the wound combined with elevation. Only in the rare cases where this is inadequate should a tourniquet be used. If a tourniquet is applied, it should be released every twenty minutes. Should the hemorrhage recur, it can then be reapplied. Where the patient has reached facilities for direct treatment of the wound the hem or rh age will of course be controlled by direct ligation of the bleeding vessels. Under unusual circumstances it may occasionally be necessary to control hemorrhage by packing the wound. If this is done tightly there is a great danger of subsequent infection, particularly as under these circumstances debridement has probably not been adequate. If tight packing is used, it should be removed at the earliest possible moment. It is also dangerous to apply tight circumferential bandages over a wound in a limb for hemostasis. Such a bandage will later produce severe pain and great edema in the distal portion of the limb. 19 LOCAL AND ORAL CHEMOTHERAPY
The report of Jensen and coworkers1o in 1939 on the local implantation of sulfanilamide in compound fractures was a great stimulus to the local use of sulfanilamide in many situations, particularly, in traumatic wounds and compound fractures. The local use of the drug does not eliminate the neces-
THE TREATMENT OF MINOR WAR INJURIES
1837
sity for very adequate and thorough debridement, but it probably is a useful adjunct to such a procedure. The drug is absorbed into the general circulation and eliminated; consequently, it is advisable to supplement the local use with administration by mouth. An initial dose of 4 gm. should be taken orally as soon after the injury as possible. This should ' be followed by 1 gm. every four hours, for one week. In cases without evidence of infection the dosage may be diminished after two or three days. Where infection occurs larger doses will be required. Not more than 15 gm. should be placed in the wound. Five to 10 gm. are usually sufficient. Other sulfonamides may prove to be more efficient and less toxic, but their general use will have to await further study. Chemotherapeutic agents are undoubtedly most efficient when used prophylactically and in the early stages of infection. S Sulfanilamide powder in the amount of 5 to 10 gm. can be sprinkled on a wound when the first aid dressing is applied, and the initial dose taken by mouth at the same time. When the wound is debrided, sulfanilamide powder can again be placed in the wound and the administration by mouth continued. Such use of sulfanilamide was found to be of considerable value in diminishing the incidence of streptococcal infection during the evacuation from Dunkirk20 and in the fighting in Libya. 19 Ross and Hulbert25 do not routinely employ sulfanilamide either locally or generally. However, 50 per cent of their wounded were aviators in which cases the contamination seen in wounds of the infantry soldier from soil and dirt must have been largely absent. COMPOUND FRACTURES OF THE UPPER EXTREMITY
Closed Plaster Dressings.-Probably the greatest change which has occurred in the treatment of war wounds has been the use of closed plaster dressings for compound fractures. Following the publication of Orr's book on this subject in 1929,21 the closed plaster method was slowly adopted in the United States in the treatment of osteomyelitis. The remarkable results which could be attained by this method in the treatment of compound fractures were not generally appreciated
1838
JOHN H. GIBBON, JR., CLARE C. HODGE
Fig. 232.-Wound of upper third of humerus, produced by aerial bomb and not treated for twenty-four hours. Extensive debridement was performed before application of plaster. (Trueta, "Treatment of War Wounds and Fractures." Courtesy of Hamish Hamilton Medical Books, London, England.)
Fig. 233.-8ame patient as in Fig. 232, seventy-five days later. Fracture had united but wound had not completely healed. Plaster was again applied. (Trueta, "Treatment of War Wounds and Fractures." Courtesy of Hamish Hamilton Medical Books, London, England.)
THE TREATMENT OF MINOR WAR INJURIES
1839
Fig. 234.--Same patient as in Figs. 232 and 233, after application of final plaster. (Trueta, "Treatment of War Wounds and Fractures." Courtesy of Hamish Hamilton Medical Books, London, England.)
Fig. 235.-End-result in case illustrated in Figs. 232 to 234. (Trueta, "Treatment of War Wounds and Fractures." Courtesy of Hamish Hamilton Medical Books, London, England.)
1840
JOHN H. GIBBON, JR., CLARE C. HODGE
until the Spanish Civil War (Figs. 232, 233, 234 and 235). The best summary of this method and its results is to be found in Trueta's book.27 The technic of the application of the plaster is excellently described by Eloesser. 5 He stresses the importance of placing plaster splints in position before applying the circular turns. Casts constructed in this manner are stronger and lighter than those made entirely by circular turns. It is also easier to split these casts longitudinally, which should always be done if patients must be evacuated shortly after the application of the plaster. The operative treatment of the wound itself is similar to that outlined above in the treatment of flesh wounds. In addition, any loose bits of bone unattached to periosteum are removed. The bones are placed in proper alignment by traction and manipulation and held in place while the primary plaster splints are applied, followed by the complete circular cast: All the wounds are packed open. Dry gauze was used in Spain but vaselinized gauze, "Zisp," cod liver oil, or gauze saturated with a sulfanilamide paste may be used. Wallis and Dillworth 30 have recently recommended gauze soaked in a 12 per cent solution of lactose for packing these wounds. Because fermentation takes precedence over putrefaction, they state that these casts do not develop a foul odor for periods up to four weeks. Streptococcal septicemia was the most common cause of death in the wounded during the war of 1914-1918. In the bacteriologic studies of the closed plaster cast during the Spanish Civil War, streptococci could be grown from the wounds at almost any stage in the healing process,22 but streptococcal septicemia was an extreme rarity. This appears to indicate the effectiveness of complete immobilization in preventing absorption from raw surfaces. 21 . 28 Immobilization of Fractures.-Abduction plaster casts for fractures of the humerus should not be used in advance stations. 5 • 6 The arm in the abducted position interferes with transportation and exposes the part to injury. Immobilization by binding the arm to the chest is useful in emergencies. When possible a cast should be applied with the arm slightly abduc-
THE TREATMENT OF MINOR WAR INJURIES
1841
ted and in slight anterior flexion. The forearm should be at right angles to the arm and directed forward. 12 Splints.-:-Except for actual litter work on the battlefield, plaster of Paris is the ideal modern splint for use in the care of the wounded. 13 Plaster weighs more than other splints, but is less bulky and easier to transport. Furthermore, plaster can be adapted' for use in any situation, whereas when other material is used a variety of splints for different purposes must be kept on hand and returned to the forward areas when they are removed from the patient. Finally, the immobilization achieved by plaster during the transportation of the wounded, cannot' be obtained by any other means. SUMMARY
1. In modern warfare a medical organization will be most efficient when it is built up of small surgical units which possess their own means of transportation and supplies. Such units can be set up quickly to take care of casualties close to the scene of action'. When many units are combined they may serve as an evacuation or general hospital, in association with other specialty units. 2. Burns of the hands and face should not be treated with tannic acid. 3. Debridement, ideally wound excision, is stilI the essential basis of treatment of gunshot wounds. 4. Primary suture should never be employed in contused, lacerated gunshot wounds. 5. Sulianilamide, locally and generally, should be employed in all patients with traumatic wounds. 6. The closed plaster of Paris dressing has been proved to be the ideal primary treatment of compound fractures and extensive flesh wounds. BIBLIOGRAPHY 1. Bristow, N. R.: Peripheral Nerve Injuries (Report of Societies). Brit. 1: 373, 1941. 2. Bvnyan, J.: Envelope Method of Treating Burns. Proc. Roy. Soc. 34: 65, 1940. 3. Buttle, C. A. H.: Chemotherapy of Infected Wounds. Lancet, 1: 890, 4. Cohen, S. M.: Treatment of Burns; Tannic Acid versus Saline. Brit. 2: 754, 1940.
M.
J.,
Med., 1940. M. J.,
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. JOHN H. GIBBON, JR., CLARE C. HODGE
5. Eloesser, L.: Treatment of Compound Fractures in War: Report of Prac. tical Experience in Spanish Civil War. J.A.M.A., 115: 1848, 1940. 6. Ernst, M.: Preparation of Wounded for Transportation from Front Line Hospitals. Miinchen. Med. Wchnschr., 87: 1377, 1940. 7. Hannay, J. W.: Treatment of Burns by Envelope Irrigation. Brit. M. J.,
2: 46, 1941. 8. Hoffman, S. J.: Treatment of Air Raid Casualties. Brit. M. J., 1: 785, 1941.
9. Hooker, D. H. and Lam, C. R.: Absorption of Sulfanilamide from Burned Surfaces. Surgery, 9: 534, 1941. 10. Jensen, N. K., Johnsrud, L. W. and Nelson, M. C.: Local Implantation of Sulfanilamide in· Compound Fractures; Preliminary Report. Surgery, 6: 1, 1939. 11. Jolly, D. W.: Field Surgery in Total War. Paul B. Hoeber, Inc., New York,
1941. 12. Key, J. A. and Conwell, H. E.: Fractures, Dislocations and Sprains. St. Louis, C. V. Mosby Co., 1934. 13. Lancet, Editorial: Surgical Lessons of Heavy Fighting, 1: 1052, 1940. 14. Lancet, Editorial: Evacuation of Army Casualties, 1: 573, 1941. 15. Lancet, Special Article: Medical Organization in the R.AM.C. and Spanish Republican Army, 1: 579, 1941. 16. Lancet, Special Article: Treatment of Burns, 1: 425, 1941. 17. Macintosh, R. R. and Pratt, F. B.: Anesthesia in War Time. Brit. M. J. 2: 1077, 1939. 18. McKissock, W. and Brownscombe, B.: Apparently Trivial Head Injuries. Lancet, 1: 593, 1941. 19. Mitchell, G. A. G., Logie, N. S. and Handley, R. S.: Casualties from the
Western Desert and Libya Arriving at a Base Hospital. Lancet, 1:
713, 1941. 20. Ogilvie, W. H.: Treatment of the Infected Wounds. Lancet, 1: 608, 1940. - - - :Surgery of Infected Wounds. Lancet, 1: 975, 1940. 21. Orr, H. W.: Osteomyelitis and Compound Fractures. St. Louis, C. V. Mosby· Co., 1929. 22. Orr-Ewing, J., Scott, J. C. and Gardner, A. D.: The Bacteriological In23. 24. 25. 26. 27. 28. 29. 30.
vestigation of Wounds Treated by the Closed Plaster Method. Brit. M. J., 1: 877, 1941. . Palser, J. E. R.: Closed Plaster Technique for Infected Fracture and War Wounds (letter to the Editor). Brit. M. J., 2: 764, 1940. Reid, M. R. and Carter, B. N.: The Treatment of Fresh Traumatic Wounds. Ann. Surg., 114: 4, 1940. Ross, J. A. and Hulbert, K. J.: Treatment of 100 War Wounds and Burns. Brit. M. J., 1: 6, 8, 1941. Schmidt, F.: Transportation of the Wounded by. Plane. MU. Surgeon, 87: 136, 1940. Trueta, J.: Treatment of War Wounds and Fractures. New York, Paul B. Hoeber, Inc., 1940. Trueta, J. and Barnes, J. M.: The Rationale of Complete Immobilization in Treatment of Infected Wounds. Brit. M. J., 2: 46, 1940. Wakeley, C. P. G.: The Treatment of War Burns. Surgery, 10: 207, 1941. Wallis, A. D. and Dillworth, M. J.: Lactose for Prevention of Odor in the Closed Cast Treatment of Compound Fractures. Brit. M. J., 1: 750, 1941.