War Surgery and Medicine
PRIMARY LOCAL TREATMENT
PRIMARY LOCAL TREATMENT
At the beginning of the war treatment by tanning was carried out in the Middle East and generally in Britain. The treatment first carried out in the Middle East consisted of the cleansing of the burnt surface, followed by tanning. Light anaesthesia was used for all but the slight cases. The clothing was removed, blisters were snipped, and the loose epidermis gently removed. The burnt area was then carefully cleansed with pledgets of sterile wool or gauze soaked in normal saline solution. Scrubbing and the use of strong antiseptics were avoided. The surface was then swabbed gently over with 1 per cent aqueous solution of gentian page 344 violet and allowed to dry. A 10 per cent solution of tannic acid or silver nitrate was then applied, either by spray or by wool pledgets, and the burn left uncovered to dry, a cage being used to keep off the bedclothes. Further application was seldom necessary, but gentian violet was used at the edge as required. It had been noted that severe painful constriction often occurred in the fingers and wrist, caused by the shrinking of the coagulum. A strip was therefore left untanned on the extensor or flexor aspect, being treated by gentian violet only.
In April 1941 the Burns Committee of the Medical Research Council recommended similar treatment, consisting in cleansing with soap and water and then by saline followed by tanning. Gas and oxygen anaesthesia was recommended. Sulphanilamide powder was dusted on to the dry burnt area before the coagulant was applied. The coagulants used were silver nitrate 10 per cent, tannic acid 10 per cent, silver nitrate 10 per cent and tannic acid 5 per cent alternatively, and triple dye (gentian violet, brilliant green, acriflavine). Sulphanilamide powder was dusted in any cracks. No coagulant, however, was used on the face, hands, wrists, or feet, and circumferential tanning was avoided. The bad results seen in cases treated by tanning of the hands, face, and flexor areas were causing surgeons to question the universal application of tanning. Plastic and orthopaedic surgeons in Britain were agreed that tanning was harmful for hands, feet, or limbs, and in the Middle East it was abolished early and vaseline gauze used instead. The late results of tanning of other areas were also unsatisfactory, and sepsis was found to be prevalent under the adherent sloughs, which were very slow to separate. This is illustrated by the following comment made early in the war: ‘An assistant was actually removing, under an anaesthetic, an extensive coagulum from both legs of a burnt patient. Most of it was floating on a bath of foul smelling pus.’
Anxiety was felt at this time at the high mortality, up to 40 per cent, reported in several series of burns casualties. Early in 1942 tanning was being replaced in the MEF by the sulphanilamide and tulle gras, or vaseline gauze, treatment. In the 2 NZEF this was hastened first by the contact of our medical officers with McIndoe in England in 1940 and then with Major Rank of the Australian Forces in the Middle East.
In March 1942 Major Brownlee, our senior plastic surgeon, came to the Middle East after a period of training in England and strongly advised against tanning and advocated the sulphanilamide treatment. By April tanning had been condemned in the MEF, page 345 and supplies of vaseline gauze and tulle gras were being prepared at the Base for supply to the field units, including the RMOs.
In July 1942 an experiment carried out at 62 General Hospital, Tobruk, was reported wherein one limb of a patient had been treated by tanning and the other corresponding limb by sulphanilamide and tulle gras dressing. One hundred cases were so treated, and it was demonstrated that the tanned cases were not nearly as satisfactory as the others. This was the end of tanning in the MEF.
Necrosis of the liver was first brought to notice in America in 1940 when a case dying of burns treated with tannic acid was found at post-mortem to have acute necrosis of the liver. The association was confirmed later. In the meantime necrosis of the liver and congestion of the kidney and nephritis had been noted and ascribed to toxaemia and absorption from the damaged tissues. A heavy death rate was also noted, though most of this was due to the early and severe shock. Later investigations into, and experiments in, the treatment of burns by tannic acid showed that liver necrosis had been reported in a considerable number of burned patients treated with tannic acid. Non-fatal cases frequently showed marked disturbance of liver function in the acute phase of the burn. The liver lesion was readily reproduced experimentally. The case against tannic acid was proved.
The early application of sulphanilamide powder to gunshot wounds in the forward areas proved successful in combating sepsis. It was only to be expected that the same treatment would be applied to the burnt areas of the skin when tanning proved unsuitable. As tanning was very harmful when applied to the face, hands, wrists, feet, and flexor areas, sulphanilamide was used for burns of these areas. The treatment was successful, and as tanning was given up later for the treatment of burns of the other parts of the body, sulphanilamide took its place.
The same preliminary cleansing under anaesthetic was carried out with soap and water and saline solution. Blisters were emptied and the raised epidermis removed except in the hands and fingers, the feet and toes, and the ears where the skin was preserved. The sulphanilamide was frosted on the surface by a blower. A vaseline gauze or tulle gras dressing was applied, covered by several layers of dry gauze and cotton wool. Plaster-of-paris splints were often used for the limbs. In extensive burns it was soon learned that there was a danger of absorption of sulphanilamide and the amount dusted on was limited to 10 grammes. Serious symptoms, including delirium and coma, had been observed. Instead of the powder page 346 spray, sulphanilamide was mixed with the vaseline or used as an emulsion so as to obviate excessive absorption. Formulae for emulsions were:
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|Sod. Hydroxide (20 p.c. W/V)||2.1|
Full aseptic precautions were taken in dressing the burns as the likelihood of infection was realised. The dressing was normally left unchanged for fourteen days unless it became soaked.
At re-dressing local sulphanilamide was again applied, but in carefully restricted dosage. The occurrence of sensitisation to sulphonamides following local application had been observed in our hospitals in Egypt, and any large dosage or repeated dosage was deprecated. The value of the treatment was emphasized, however, when it was demonstrated that streptococcal infection was very successfully dealt with by this method. When sulphanilamide was applied locally precautions were taken to see that none was given by the mouth. On the other hand, the sulphonamides were often given by mouth and not locally. Sulphadiazine was given orally in an initial dose of 4.0 grammes, followed by 0.5 gramme four-hourly until kidney function became normal, when the dose was increased to 1 gramme.
The treatment was carried out till the burn was healed or grafted or else, as in our Force, saline bath treatment was substituted at the base hospital.
Penicillin was substituted for the sulphonamide treatment in 1944 as soon as adequate supplies were available. It was first used locally in a sulphathiazole base and reapplied at subsequent dressings. The extent of the burnt area often called for relatively large quantities of penicillin, and its instability and limited period of action rendered it unsatisfactory for repeated local application. As soon as supplies permitted, therefore, it was given parenterally and sulphanilamide or simple protective dressings utilised locally. Parenterally, dosage could be accurately controlled and the results were very satisfactory. The penicillin treatment was continued till early skin grafting could be carried out.
The treatment finally adopted was very much simplified and consisted essentially in covering the burnt area with an atraumatic page 347 dressing after the application of penicillin sulphathiazole, the giving of parenteral penicillin, and early skin grafting. Anaesthesia was abolished, as was any definitive cleansing of the wound.
This treatment was a very old-established one, especially for an infected wound. It was utilised by McIndoe, plastic surgeon in charge of Air Force casualties in England, right from the beginning of the war. He developed a bath unit by means of which a controlled supply of saline solution could be supplied at regulated temperature to baths in which the whole patient could be immersed at regular intervals, generally for an hour daily. This involved a rather elaborate engineering mechanism which required skilled attention. The dressings were allowed to float off in the bath and fresh dressings were applied under aseptic precautions afterwards. When sulphanilamide was introduced as a local application for wounds it was also used for the dressing of the burns. Major Rank, an Australian medical officer, introduced the treatment into the MEF, using an improvised bath unit, and, impressed by his results, 2 NZEF purchased an elaborate bath unit in England and set it up at its hospital at Helwan in 1942. Captain Manchester, who had been trained in England, was in charge of the unit. Baths of 2 per cent warm saline were given for two hours daily. The treatment after bathing was: (a) if the burnt area was fairly clean, spraying of a thin film of sulphanilamide powder while still wet, then covering with tulle gras and saline pack, this being kept wet from a douche can during the day and bandaged firmly with a crepe bandage during the night. (b) If unhealthy, treating without sulphanilamide by eusol instead of saline, and otherwise as under (a) till fairly clean, when sulphanilamide and saline packs were used.
When the burnt area was healthy, as shown by rapidly ingrowing skin edges with fresh-looking granulations, and the absence of streptococci on bacteriological examination, the wound could be at once skin grafted (for which the firm bandaging had created an ideal smooth surface), or sutured, with almost certain success. The streptococcus had been proved to be the cause of delayed healing and the destruction of the growing skin edge. The other organisms were of no special significance. It normally took a week's preparation after any sloughs present were removed.
Full aseptic technique was enforced and the bath was cleaned with 1:20 lysol after each patient. Infection of the bath itself had proved a difficult problem. The Bath Unit at 1 NZ General page 348 Hospital, Helwan, was very efficient and proved invaluable not only for the cases of burns, but also for the treatment of large gunshot wounds.
In Italy an improvised bath unit was set up at 2 NZ General Hospital at Caserta in 1944. Two baths were used without any elaborate equipment. A field cooker was used to heat the water. Barrels held the solution of 20 per cent brine and chlorinated water used for the baths. The unit was kept very busy and dealt with as many as twenty cases at a time, and two sisters were fully occupied. Good results were obtained in spite of the imperfect surroundings. Parenteral penicillin, when it became available, was given to control infection.
Treatment of Burns of the Hands
The hand and wrist as well as the face and feet presented special problems in the treatment of burns. It was realised very soon that tanning was unsuitable for these cases.
The Burns Committee of the Medical Research Council in April 1941 recommended dusting with sulphanilamide and then applying a tulle gras dressing covered with gauze wrung out in warm normal saline, the gauze to be kept moist and changed every three to four hours, and the complete dressing changed daily. Saline baths for half an hour or more daily were advised. Stress was laid on asepsis.
A conference of plastic and orthopaedic surgeons in August 1941 recommended atraumatic dressings, saline baths, and early skin grafting. They called attention to the constriction and oedema often present, affecting the interossei and lumbricals, with the danger of the development of claw hand. They considered immobility in this condition could produce a frozen hand, that early mobility was essential, and that the hand should be kept in the optimum position for future function.
In the Middle East tanning was discarded very soon. Sulphanilamide with vaseline gauze and tulle gras dressings were then used in the forward areas, and at Helwan the bath treatment was carried out for New Zealand cases as a preparation for early skin grafting. Care was taken that all skin was preserved on the hands, the blisters being emptied but the epidermis left.
The marked oedematous swelling then began to cause anxiety, as it was realised that this led to coagulation in the tissues and excessive formation of fibrous tissue, with marked delay in the return of function. This was combated by enclosing the arm in a plaster splint or else applying firm bandaging over the dressings. The hand was also kept elevated. Experiments showed that this prevention of swelling enabled healing to occur more rapidly.page 349
The firm bandaging of the hand to prevent swelling interfered with early movement, and two schools arose in consequence. One school favoured treatment by immobilisation in the optimum position of slight dorsiflexion at the wrist, 60 per cent flexion at the metacarpo-phalangeal joints, and 45 per cent at the inter-phalangeal joints with the thumbs in opposition; firm bandaging and plaster utilised with elevation of the hand; fixation of the hand for three to four weeks. The Americans belonged to this school. The other school encouraged early and repeated active movement in the burnt hand (as advocated by McIndoe). Some modified this and encouraged movement after the first period of acute reaction, lasting ten to twelve days.
The method used in the forward areas by our New Zealand units, in common with the British, was the application of penicillin and vaseline gauze dressings, and at our base hospitals we favoured pressure dressings for the first ten to fourteen days, followed by saline baths. In severe cases plaster splinting in the optimum position was carried out, but movements were carried out as soon as possible.
The Bunyan Stannard bags were also thought very suitable for hands, weak Dakin's solution being used for irrigation twice daily.
Skin grafting at the earliest possible moment was deemed the most important part of the treatment, making possible the resumption of functional activity and rehabilitation.
Infection was the common and most serious complication met with in the treatment of burns. The large areas often involved gave an excellent opportunity for the growth of pathogenic organisms and the absorption of toxic products caused serious general illness. When the tanning treatment was in use the superficial burnt area gave little trouble, but the deeper burns were commonly infected and spread was encouraged by the pocketing possible under the deep adherent sloughs, and the sloughs themselves encouraged infection. Toxaemia was generally marked from the absorption from the extensive septic areas. The treatment necessitated the complete and early removal of the sloughs with or without anaesthesia, followed by the treatment of the infected areas. Saline baths proved of great value and the application of sulphanilamide powder was shown to clear up streptococcal infection. Other antiseptics, especially Dakin's solution, were employed with success and 2 per cent acetic acid was used for pyocyaneus infection. Sulphonamides were also given by mouth. Infection became a lesser problem when the sulphonamide treatment page 350 replaced tanning, but deep sloughs had still to be dealt with and wound infection cleaned up in preparation for skin grafting. Saline baths were still used and local antiseptics and sulphonamide therapy. With the introduction of penicillin, infection became much less common and less serious, and the treatment less difficult. Parenteral penicillin generally took care of any infection present and enabled early skin grafting to be carried out. The presence of any raw area was recognised as a potential focus of infection.
Frequent changes of dressings encouraged infection, and care was taken to restrict these, especially when the sulphonamide treatment was adopted. In the final stages of the war, with sulphathiazole-penicillin applied locally and penicillin parenterally and the application of pressure dressings, especially to the hands, dressings were left alone for long periods with satisfactory results. The special value of the Bunyan bag treatment was that it did away with local dressings.
The saline bath treatment necessitated daily dressings, often of very extensive areas. The danger of infection was ever present, and this largely prevented the adoption of this form of treatment away from properly equipped hospitals.
These were utilised as the final stage in the healing of the burn and all prior treatment was a preparation for the grafting. In the Middle East the technique employed in grafting varied according to the type of case. Thiersch grafts of some thickness were preferred. They were put on the fresh raw area, or clean granulation area, on top of the thin film of sulphanilamide and a tulle gras dressing applied and bandaged on the part. If very large areas had to be grafted, pinch grafts were often used, and these were also used on small wounds, where the grafting was done as a dressing on the wounds. Pinch grafts were not as satisfactory as the split skin graft. Skin taken from other patients was found to take but subsequently did not grow, so was used solely as a temporary dressing when there was lack of skin.
In plastic work skin was always grafted on any bare area so as to prevent the development of infection.
Whole skin grafts were used in areas such as the bend of the elbow, where the deep structures were exposed and where skin mobility was essential. These grafts were made by simple lifting of a skin flap, generally from the abdomen, again grafting the raw area left by the lifted skin.
The use of the dermatome greatly facilitated the procedure and made very much more skin available. The control of infection, page 351 especially streptococcal infection, first by the sulphonamides, and later and better by penicillin, made success in grafting almost assured. The grafting on the fourth day became common and just as satisfactory as the delayed primary suture of wounds. At the end of the war in Italy Brigadier Edwards, RAMC, gave a résumé of the practice followed at that time as follows:
The raw surface is most receptive to free skin 2–4 days after the sloughs are removed, and it has become the practice to graft during this period and to inspect the graft in 4 days, and to graft again any raw areas the natural healing of which will probably be a lengthy process. In the most extensive burns, grafting may have to be performed in stages. The aim in all is to secure healing by grafting within 6 weeks of the original injury for all cases, irrespective of the extent of the burn. Such healing rates are usually achieved except in burns arriving at the centres late. Patch grafts have become the routine form of skin application, and are held in place by fixation with vaseline gauze and a pressure bandage, except in areas where pressure is not applicable. Here a gum elastic glue is used.
In the early period of the treatment of burns, cleansing and dressing in the forward areas was done under anaesthesia. It was recognised that pentothal was an unsuitable anaesthetic, but gas and oxygen was not available in the Middle East, and small doses of pentothal were often used. The cleansing of burns became steadily of less importance and anaesthesia was used less and less till it was finally abandoned.
It has already been stressed that severe shock was the most important problem in the management of burns. This was generally most marked in the first forty-eight hours, but often persisted for much longer. It was soon learnt that the patient's condition seriously deteriorated if he was shifted during this period. At first it was thought advisable to evacuate the cases as rapidly as possible to the base hospitals so that their treatment could be more efficiently carried out, but as the treatment became simplified there was not the same reason to shift them, and they were held in the forward areas till full recovery from shock had taken place. It was necessary, however, to evacuate them so as to be able to carry out the reparative treatment, especially early skin grafting, at the base hospital or at the special plastic units sited there. It was also necessary, especially in the period of tanning treatment, to evacuate before infection arose, as the condition of the patients also deteriorated with shifting page 352 when they were suffering from the toxaemia associated with infection. Evacuation by air was very satisfactory for these cases.
General Treatment of the Patient
In the early stages the essential treatment consisted in the administration of large quantities of blood plasma to make up for the very considerable loss of plasma into the tissues around the burnt area, and to a lesser extent from the surface of the burn.
In addition to the loss of plasma there was considerable destruction of body tissue, and also general disturbance associated with the severe damage to such a sensitive tissue as the skin. This caused a great deal of metabolic disturbance to the body and contributed to the severe shock invariably present in the serious cases. The treatment given, after the stage of shock had passed, was aimed at assisting the body to recover from the metabolic upset and to regenerate the damaged tissues. A well-marked anaemia generally followed the primary haemo-concentration and whole blood transfusion was required, generally at the tenth day and repeated at intervals later, according to the condition of the patient. Further plasma was also given to supply extra protein. A rich protein diet with vitamin and fruit juices was given. The patients had to be encouraged to take ample quantities as often their appetites were found to be very poor. Iron tonics were also given.
Convalescence and Rehabilitation
The seriously burnt patient was markedly debilitated and special steps were taken to hasten his convalescence. Physiotherapy was of importance in many cases, especially where burns involved the arms and hands, and exercises were instituted at the earliest possible moment. Occupational therapy was a valuable help to many of these patients who had a long struggle back to normal function. The psychological help given at all stages was of particular importance to those who were mutilated and seriously handicapped.
Mustard Gas Burns
No. 3 NZ General Hospital had some experience of the effects produced by mustard gas when casualties were admitted following an air raid on Bari harbour on 2 December 1943. The patients had been immersed in the sea, were cold and wet, and were suffering from severe degrees of shock, and in some cases from very severe injuries. Almost all were covered with a thick deposit of fuel oil. Lieutenant-Colonel L. A. Bennett described their condition as follows:
At the end of 12 hours a number of patients began to complain of pain in the eyes and blistering about the face and the neck. The signs in these page 353 cases were different from those diagnosed as ‘flash’ burns in that there was no singeing of eyebrows or hair. Rapid degeneration of the general condition occurred in a number of cases and coincidentally extensive areas of blistering appeared on covered parts of the body, notably axillary, perineal, and scrotal regions. These were diagnosed ‘chemical’ burns. On the 4 December information was received that the water and oil in which they had been immersed was contaminated with a dilute concentration of mustard gas. Thereupon those cases (42 in number) showing blistering and a severe degree of conjunctivitis were transferred to one ward. In all there were 14 deaths, 2 in the first few hours, and the remainder over the following 10 days.
Post mortem examinations were carried out on 10 cases. Certain findings were similar in all cases and in one group there were additional abnormal pathological appearances. Briefly described these were:
Group A (5 cases):
Very extensive loss of superficial skin over face, hands, arms, buttocks, lateral wall of chest and scrotal regions.
Brownish pigmentation of remaining skin.
Marked chemosis of conjunctivae.
Intense congestion and oedema of larynx, severe degree of tracheitis (in two cases showing minute areas of actual ulceration). Similar congestion of upper end of oesophagus with pallor of the remainder of the oesophagus beyond the cricoid cartilage.
Group B (5 cases):
Similar findings as (i) to (iv) above.
Signs of ‘Blast’ injury to lungs in all cases—also in one case in heart and kidneys. These signs were subserous haemorrhages plus other characteristic areas of haemorrhage deeper in the organs concerned.
Owing to transfer of most of these patients to other hospitals, their subsequent history is incomplete. Three patients, however, remained till 23 Dec., and they, as well as two still under treatment at 2 Jan. 1944, show no after effects of conjunctivitis and are healing satisfactorily without scar formation of ‘burnt’ areas.
A small number of phosphorus burns were seen during the war. Phosphorus was present in certain shells, bombs, mortars, and incendiary bullets. Special treatment was necessary both to neutralise the effect of the phosphorus and to remove the particles from the wound.
First aid consisted in the application of water either by immersion of the wounded area in water or the application of wet dressings. Bicarbonate of soda solution in a strength of at least 5 per cent was applied as soon as it was available to neutralise the acid oxide of phosphorus. The solution was not hot, so as to guard against conversion into the carbonate which caused pain. The wound was then swabbed with 1 per cent copper sulphate solution, which helped page 354 to stop the burning and made the particles more easily recognisable. They were then removed with forceps and the wound again soaked in bicarbonate for one to two hours. Further search in the dark for particles was made and the bicarbonate soaks continued till all action ceased. Vaseline and other greasy dressings, triple dye and brilliant green were avoided. The further treatment was the same as for the ordinary burn.
Experiments carried out by the Burns Sub-Committee of the Medical Research Council showed that the risks of phosphorus poisoning from absorption were negligible.
In the 1914–18 War the treatment of burns consisted in the application of picric acid dressings to, or the spraying of ambrine wax on, the burnt area. Glucose saline and gum acacia intravenous medication was given to relieve shock.
In 1925 treatment by tannic acid was introduced in the United States with reports of a marked lowering in mortality, and great interest was taken in the new treatment. This treatment became almost universal for severe and extensive burns. There also arose a realisation of the importance of the severe shock present and gradually the biochemical changes were worked out.
At the beginning of the 1939–45 War the tanning treatment was the approved treatment in the army, and was laid down by the co-ordinating team on burns of the War Wounds Committee of the MRC in April 1941. It had been realised already, however, that this treatment was not suitable for burns of the face, hands, wrists and feet.
In the Air Force, however, McIndoe had from the beginning of the war treated the serious aeroplane burns by saline baths and non-traumatic dressings, and utilised the sulphonamides for local and general bacterio-stasis.
In the treatment of shock, morphia in large doses and warmth, fluid by the mouth, and especially intravenous plasma and blood, were recommended. For some time tanning by different techniques remained the normal method of treatment in the army, though the saline bath treatment was adopted in certain units, especially by the plastic surgeons. The slough present in the deep burns began to give rise to trouble because of the associated sepsis and the delay in healing.
The mortality in cases treated by tanning began to cause concern, and it was then found that necrosis of the liver seen in post-mortems of those cases was caused by tannic acid absorption. This, along with the appreciation of the good results obtained by sulphonamide page 355 therapy, non-traumatic dressings and saline baths, led to the discarding of tanning. Simple wound cleansing, local sulphanilamide frosting, vaseline or tulle gras dressings, and infrequent dressings became the accepted treatment and the early application of skin grafts to the deep burns was carried out. As regards shock, the enormous loss of plasma into the tissues around the burnt areas, with the consequent haemo-concentration, was more and more realised, and very large quantities of plasma were given rapidly in the first forty-eight hours.
Cleansing under anaesthesia was delayed till shock was relieved, but later anaesthesia was completely given up, and the cleansing became gentler and gentler and finally was also given up for the ordinary clean burn.
The marked oedematous swelling was also counteracted by firm pressure dressings, especially in the hand where the oedema tended to leave behind marked adhesions.
When penicillin was introduced it was applied locally in a sulphonamide base and then, as sufficient supplies became available, full parenteral dosage was given to the severe cases. Saline baths were still used in some cases, especially when the burnt area was very extensive. Skin grafting was carried out at the earliest possible moment, either as a temporary dressing or as a final treatment. It was recognised that as long as a wound was open it was an invitation to infection, and a source of toxaemia.
At the end of the war the essential elements in the treatment of patients with serious burns were the administration of blood plasma or serum, the application of pressure dressings, the parenteral and local administration of penicillin, and the early skin grafting of all deep burns. Blood transfusion, high protein diet, iron tonics, and vitamins were all needed to counter the anaemia and debilitation present in burns cases. Early rehabilitation was also of great importance physically and psychologically.