|Surgical lessons of war|
|Saturday, 01 January 2011|
Jon Clasper reviews the impact military surgery has had on modern day wound treatment
Military deployments in Iraq and Afghanistan have again seen service medical personnel gain considerable experience in the management of severely injured casualties. Improvements in personal protection, enhanced prehospital care and rapid aero-evacuation to medical facilities capable of providing optimised resuscitation and damage control surgery have resulted in an unprecedented increase in survival from battlefield injuries from 69.7% in World War II to 88.6% most recently in Iraq.
"Throughout the ages, the progress of general surgery has been intimately related to that of military surgery" – Trueta
One of the most significant advances in recent conflicts has been the development of a trauma system, with co-ordinated advances from the point of wounding, through medical evacuation, to the hospital management of the casualty. In 2008, a report by the Healthcare Commission described the military trauma system as "exemplary".
Specific advances have been described elsewhere, but include the control of catastrophic haemorrhage before airway management, new techniques of external haemorrhage control, intra-osseous access and fluid administration, helicopter evacuation via a Medical Emergency Response Team, the concept of Damage Control Resuscitation and a consultant delivered service. Many of these advances are now being adopted in civilian practice.
However, this is not the first time that medical care in conflict has lead to advances in civilian practice. Indeed, the majority of large conflicts have resulted in medical advances – it has been said that warfare has played an important part in the development of wound management.
The first written description of the treatment of battle wounds is attributed to the Iliad, with Hippocrates the first person to document treatment of open fractures. He believed in the "healing power of nature", and the basis for his treatment was antisepsis and the reduction and splintage of fractures. Turpentine and tar were used as dressings and the limb was splinted with wax, starch or clay-impregnated bandages. The Hippocratic methods of decontaminating the wound and immobilising the fracture site are still used today in the management of open fractures. Decontaminating the wound can be considered in terms of antisepsis, wound debridement and antibiotics.
Until the First World War the surgical treatment of wounds was not considered particularly important. One of the major advances of the nineteenth century had been the development of better topical antiseptics. In 1867, Lister published the results of using carbolic acid packs in open fractures and believed that wound infections were due to decomposition of tissue caused by floating particles in the air. Lister advocated dressing the wound with something capable of sterilising it.
Debridement had been practiced (usually in war), but this was the equivalent of fasciotomy, allowing for swelling and access to bleeding vessels, rather than the excision of non-viable tissue, in the sense that the term is used today. Much of this is understandable as injuries were low-energy, (missiles were low-velocity), resulting in little damage outside of the wound tract, and there was a risk of iatrogenic damage. As well as active bleeding, wounds associated with a fracture would be explored, but many of these were treated by amputation anyway.
At the start of the First World War the Listerian philosophy of "leaving the healing of wounds to nature" was universally accepted, and endorsed by Watson Cheyne, then the President of The Royal College of Surgeons of England. The role of surgery for the open wound was merely to "see that the antiseptic has free access to every part of the wound". It was not felt that every wound required surgery, especially if the wound track had been laid open by the missile. Some soldiers, wounded during trench warfare, had antiseptic paste applied as the only treatment for penetrating missile wounds.
Unsurprisingly, during the first months of the war there was a high infection rate and, as a result, a high mortality rate from open fractures – blamed on the surgeons rather than the surgical technique itself. Gradually, the importance of adequate debridement was realised, and that the heavily manured fields of Flanders and the high energy wounds of the trenches were not the same as the conditions in previous conflicts.
In some cases, the surgery was too radical, aiming for an en-bloc excision of the wound and normal surrounding tissue. By the end of the war, the technique of a careful but thorough debridement, removing foreign material, dead and contaminated tissue, and leaving healthy tissue was recommended. However, antiseptic was not abandoned, but combined with debridement of the wound.
During the First World War, research did continue to find the antiseptic of choice. Dakin, a chemist from America, investigated the properties of a number of chemicals and felt the best agent to use was sodium hypochlorite; this had a potent antiseptic action, but was non-irritant to the tissues. Carrel, a surgeon working in a military hospital in France, recommended the use of hypochlorite continuously for three to five days, infused through rubber tubes that were placed in all areas of the wound. This method and its application were described in detail in the British Medical Journal. It became known as the Carrel-Dakin method, and was used for the treatment of missile wounds during the First World War.
In Europe, Trueta (1897-1977) described a different method of treatment, which he used in the Spanish Civil War. Dissatisfied with the use of antisepsis and frequent wound inspections, he began to treat wounds by debridement, packing with dry sterile gauze, and encasing the limb in plaster. Trueta made no attempt to monitor the wound, which was allowed to heal by secondary intention beneath the plaster.
With the acceptance of debridement in civilian practice, as well as war, the need for an antiseptic to sterilise the wound became less, and surgeons were prepared to close wounds early. Some were closed at the time of initial operation, but the majority were managed by delayed primary closure. Delayed primary closure was itself a military practice developed due to of the risk of wound complications during casualty evacuation. Wounds were debrided at a forward surgical centre, and then delayed primary closure was carried out at a base hospital when the casualty could be observed more closely.
Delayed suture of wounds at an interval of two to four days was recommended for the treatment of gunshot wounds during the First World War. One of the advantages of the technique was the ability to determine the microbiology of the wound prior to suturing. Fraser stressed the high complication rate of suturing wounds contaminated by haemolytic Streptococci. It is interesting to note that this concept is still recommended today.
As Santayana says: "Those who cannot remember the past are condemned to repeat it."