Medical Science Publication No. 4, Volume 1
PROBLEMS OF WOUND TREATMENT DURING THE
EARLY PHASES OF THE KOREAN WAR*
COLONEL JOSEPH P.RUSSELL, MC
The sudden outbreak of war in Korea created an unpredictable and immediateneed for field medical units. To meet this emergency it was necessary to"gut" every military hospital in Japan of all but a few of itsmedical personnel. Understaffed, skeletonized, field medical units werethen rapidly formed and dispatched to Korea. Obstetricians, internists,pediatricians, general practitioners, orthopedists and surgeons alike foundthemselves at once responsible for the care of overwhelming numbers ofseriously wounded battle casualties.
Despite the lack of unit training, shortage of medical personnel, andlack of comprehensive experience in war surgery, these units magnificentlyperformed an almost impossible task. Their contribution is reflected inthe lowest overall death rate in military hospitals ever recorded in anywar.
This success was primarily due to the unified efforts of the Army, Navyand Air Force working jointly as an effective medical team, and to theselfless performance of each individual concerned. A highly coordinatedmedical supply system, operating through an unmolested base of operationsin Japan, provided a profusion of modern equipment and supplies of excellentquality, including plenty of whole blood and a wide range of antibiotics.The development of helicopter evacuation, employment of MASH units in closesupport of combat, use of hospital ships as nearby floating hospitals,the wide use of air evacuation and development of specialized teams andtreatment centers, all contributed to the overall lowered mortality. Aneffective preventive medicine program was responsible for the suppressionof malaria and absence of epidemics, while the development of the armoredvest and improved footgear further reduced the death and casualty rate.
While the general picture of medical accomplishment during the Koreanwar was one of steady improvement and advance, the histories of World WarsI and II and observations made during the Korean conflict reveal instanceswhere all of us could have profited from know-
*Presented 22 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.
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ing more about, and applying the lessons learned, in previous wars.
In any national emergency many a capable surgeon, with ample experiencein civilian surgery, will be confronted with treating multitudes of seriouslywounded patients and may find himself uncertain and confused with new problemsnot ordinarily met in his practice. The current management of war casualtieshas been evolved throughout the years based on the wisdom, trials, errorsand accumulated experience of hundreds of surgeons in preceding wars. Onlyby knowing and applying the broad policies and guiding principles establishedby those who preceded him can one avoid the repetition of serious and sometimesfatal errors.
In an effort continuously to improve the standards of war surgery, eachmedical officer must become familiar with the basic concepts, so that thepriceless lessons of other wars need not have to be "rediscovered"in World War III. These principles refer not only to forward medical careand wound management, but to the time and methods of evacuation, the timingand place of operation and other problems of good medical service throughoutthe chain of evacuation.
Throughout the first year of the war it was evident that, when the initialmanagement of the wounded had been guided by established principles, mostof the patients presented no problem when they reached a rear area hospitaland pursued an uncomplicated course. On the other hand, many of the serioussurgical problems encountered at Tokyo Army Hospital resulted from lackof experience in war surgery, delay in, omission or inadequate applicationof, some principle at initial surgery.
In the early days of the war, patients often arrived at Tokyo Army Hospitalwithin 3 to 10 days after wounding. Because of the limited number of bedsand the unstable tactical situation in Korea, rapid evacuation of patientsfrom forward hospitals became an absolute necessity and could not be deferred.The result was that the medical officer who performed the initial surgeryhad no way of following the subsequent course of his patient to determinethe final outcome of his treatment. Since no complications had become manifestby the time the patient was evacuated, the surgeon might logically assumethat his management of the case had been proper, and unknowingly developa false impression which led to repetition of the same improper procedurein subsequent patients.
Rather than to be content with the fine record established in the Koreanwar it may be of value to cite examples wherein we did poorly, and howwe may eliminate the same problem in another war.
Débridements were often incompletely done through inadequateincisions with the result that, during the early months of the war, theincidence of wound infections was extremely high. The faulty use
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of Vaseline gauze did more harm than good. Some wounds were found tightlycorked with a yard or more of Vaseline gauze which completely preventeddrainage of the wound. These patients were febrile and quite toxic andon removal of the gauze plug it was common for a half pint or more of foulpus to gush and bubble from the depths of the wound. Besides damming thepus in the wound, the gauze packing had served as a splint which held thewalls of the wound widely separated converting the wound into a cylinderwith indurated, fixed walls which would not readily collapse. To avoidthis condition thorough initial débridement should be done usingbold linear incisions that will allow exposure of the entire wound tractfor removal of foreign bodies and devitalized tissue. Good exposure willresult by applying the old generalization that "the wound should betwice as long as it is deep." A few layers of gauze should be laidinto the wound to keep the wound edges apart and allow the wound to collapse.Under no circumstances should the wound be plugged and propped open withgauze packing. Counter-incisions should be made if needed to provide dependentdrainage.
An occasional case was seen early in the war in which débridementand primary suture had been performed. Some of these wounds healed withoutcomplication but the majority of patients developed wound sepsis with furtherloss of tissue and delayed wound healing. Although it may at times be tempting,primary closure should be avoided and employed only in certain instances,such as craniocerebral, maxillofacial and certain abdominal, thoracic andhand wounds.
Pressure sores over the dorsum of the foot and impaired circulationof an extremity were occasionally seen as a result of a tight cast whichhad not been split prior to evacuation. An extensive slough of the skinon the dorsum of the foot, due to traction applied to the bare foot, wasseen in one case. To avoid these complications, all casts must be splitcompletely through to the skin prior to evacuation. The shoe should notbe removed when applying a temporary traction hitch to the foot.
The wisdom of open amputation was again demonstrated. Two badly infectedpus-filled amputation stumps were due to a definitive type of closed amputation;both required further surgery with additional sacrifice of stump length.The open circular type of amputation has been found to be the safest forwar surgery and should be used exclusively. The amputation should be performedat the lowest possible level, without regard for the final utility of thestump. The use of this type of amputation demands that skin traction willbe continuously applied until the stump is healed or the patient evacuated.Failure to maintain skin traction results in retraction and fixation of
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the soft tissue with protrusion of the bone and necessitates reamputationwith sacrifice of addition stump length.
Transverse abdominal incisions were found to be bad in war surgery.While this incision may at first appear attractive because it can be developedto provide a wide range of exposure, it was followed by a high percentageof huge ventral hernias with extensive loss of abdominal wall. Some ofthese hernias were so large that satisfactory repair was unlikely. Anotherserious disadvantage of the transverse incision was evident when a tornsegment of colon had to be exteriorized through one end of the operativeincision because no other area was available laterally. Exteriorizationof the colon through the operative incision is undesirable as it almostassures a badly infected exploratory wound. The vertical paramedian incisionis preferable as it provides good exposure, is least liable to complications,and allows the colon to be exteriorized through a short laterally placed,separate incision rather than through the operative wound.
Because of fecal contamination in war wounds of the abdomen, varyingdegrees of infection of the exploratory incision were common, ranging fromminor redness and induration in the usual case to frank suppuration, woundabscess, extensive fasciitis and slough in the rare instance. To minimizethe effects of wound contamination and to prevent extensive loss of abdominalwall, the peritoneum and posterior sheath should be closed and the remainderof the wound loosely approximated with heavy through-and-through, wirestay sutures. The larger the wire, the better: 0.028 or larger wire gavethe best results. As swelling of the wound occurs, the wires should beloosened to prevent strangulation of the tissues. Small-caliber wire wasfound to be entirely unsuitable as it quickly cut through the tissues,loosened and acted only as a foreign body. It is probably a wise precautionto drain all except the completely clean intra-abdominal wounds, not forpresent infection but to prevent future trouble. As a result of underlyinginfection the abdominal wall gains tensile strength more slowly than normal.It was found that wire stay sutures should ordinarily remain in place 15to 20 days. Early removal of the wires, even in wounds that appeared strong,was followed by evisceration sufficiently often to warrant the adoptionof this view.
Bile peritonitis developed in several patients with liver wounds, inwhom the abdominal wall had been tightly closed with no provision for biledrainage. There is extensive seepage of bile following a liver wound andthe abdomen should be routinely drained through a laterally placed stabwound to allow escape of bile and minimize peritonitis.
Extensive intra-abdominal abscesses, peritonitis and fecal fistulaeresulted from the breakdown of colon wounds which had been repaired
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and dropped back into the abdomen. While a wound may occasionally healwithout complications the majority of patients will develop abscesses,fistulae, peritonitis and die unless the injured segment of colon is exteriorizedby subsequent surgery. Injured segments of colon must be exteriorized orfunctionally excluded by a proximal diverting colostomy. All but the extremelower portion of the colon can be mobilized and brought to the surface.Wounds involving the lower sigmoid or rectum should be repaired and defunctioningcolostomy performed proximally. In exteriorizing an injured segment ofcolon the bowel should be brought out through a laterally placed muscle-splittingincision and not through the primary operative incision. The colon mustbe mobilized sufficiently to allow it to lie in the wound without tension,otherwise the exteriorized segment will retract into the abdomen with infectionof the wound and formation of intra-abdominal abscesses.
Small bowel fistulae were more prone to develop at the site of a repairedperforation than through an anastomosis. This is probably due to a widerzone of tissue destruction about the perforation than is evident at thetime of repair. Patients with small bowel fistulae were frequently severelydehydrated and appeared moribund on admission. Procrastination beyond thetime necessary to restore fluid and improve electrolyte balance is notjustified. Regardless of the degree of infection present in the abdomenand abdominal wound these patients should be operated upon as early aspossible to close the intestinal fistula. The patient may appear too criticallyill to withstand abdominal exploration and one may be tempted to delayoperation for several days in the hope that the patient's condition willimprove; however, this is usually futile wishful thinking; delay in operationto close the fistula will result in gradual decline of the patient andhis death.
Round worms were the cause of intestinal fistulae in several instances.The ascaris is an inquisitive worm, constantly probing about, and willwork itself through a freshly sutured perforation or anastomosis. Thiscomplication was seen in six patients and ascarids were found lying freein the abdominal cavity. Since certain United Nations troops were foundto harbor ascaris routinely, such a patient with a small bowel fistulawas treated to rid him of round worms before any attempt was made to closethe fistula. In two cases in which preoperative vermifuge was omitted,round worms again worked themselves through the anastomosis and out throughthe abdominal incision.
Duodenal wounds which had been repaired at the initial surgery frequentlybroke down with the development of duodenal fistula. This is a grave complicationand the course of these patients is rapidly
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downhill because of loss of bile, fluids, electrolytes and digestionof the skin. If the patient is to survive, provisions must be made forthe maintenance of his nutrition and replacement of fluids and electrolytes.Nine patients who had duodenal fistulae secondary to the breakdown of theduodenal wound were operated upon and the duodenum closed and jejunostomyperformed for feeding. Wounds involving the posterior aspect of the duodenumbuttressed against the posterior abdominal wall were found to heal betterthan wounds located on the anterior free surface of the duodenum.
Closure of duodenal fistulae at a second operation was not usually successfuland the duodenal fistula frequently recurred after 3 to 5 days. Sump drainagewas employed in these cases and all bile and duodenal contents were collectedand returned to the intestinal tract through the jejunostomy. The use ofa Levin tube in the stomach and duodenum is of value in preventing pressureon the repaired duodenum and may assist in preventing breakdown of therepair. Two patients with right kidney injury requiring nephrectomy werefound to have, in addition, wounds involving the posterior aspect of theduodenum. In wounds about the right kidney the duodenum should be routinelyexplored for injury. Patients with duodenal injuries must be consideredabsolutely nontransportable until the outcome of the repair is determined.
Biliary fistulae developed in a few patients in whom a perforating woundof the gallbladder had been repaired at the initial surgery with no provisionfor drainage of the gallbladder. Perforating wounds of the gallbladderare preferably managed by cholecystectomy and if for some reason this procedureis not possible, a cholecystostomy should be performed following the repairof the perforating wounds.
Wounds of the spleen should not be repaired. Two patients developeddelayed hemorrhage from lacerated spleens which had been repaired and requiredsubsequent splenectomy. The pulpy consistency of the spleen is such thatrepair of this friable organ is an unsatisfactory procedure. Suturing ofthe splenic tissue has been compared to "suturing a wet paper bagfull of raspberry jam." Wounds of the spleen require splenectomy.
Intestinal obstruction occasionally developed as a result of herniationof a knuckle of intestine into the wound of entry or exit in the abdominalwall. This problem can be prevented by closing the wound of entry or exitat the initial surgery or if utilized for a drain site, the size of theopening should be reduced to prevent herniation of the bowel.
Spreading retroperitoneal clostridial cellulitis was present in a fewcases with perforating wounds of the rectum. To prevent this serious complicationa proximal defunctioning colostomy must be performed
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and the perirectal space widely drained from below at the initial surgery.Rectal injuries almost never occurred alone and were usually associatedwith fractures of the pelvis, hip, wounds of the bladder and small intestine.Rectal injuries are among the most serious of war wounds and carry a highmortality because of the severity of the injury and infection. Every effortmust be made at the initial surgery to prevent further fecal contaminationand to provide open free drainage of the areolar tissue about the rectum.
Suprapubic tubes were occasionally placed too low in the bladder lyingagainst the pubis and produced the painful complication of osteitis pubis.This can be avoided by bringing the suprapubic tube out of the dome ofthe bladder and away from the pubis. Perivesical infection secondary toperforating wounds of the bladder is a common complication. Repair of thebladder wall and drainage of the space of Retzius should be routine tominimize the effects of perivesical contamination.
The breakthrough of malaria was cause for concern during the early daysof the war until the condition was recognized. After wounding, suppressivetherapy was occasionally omitted and frequently these patients developedhigh temperatures, without chills, a few days after arriving at rear areahospitals. These high temperatures were initially thought to be due tosome hidden complication or wound infection; however, blood examinationsrevealed the true cause of the fever and treatment with chloroquine promptlycontrolled the symptoms. Latent malaria is prone to break through followingsevere injury.
Circular adhesive tape around the penis to anchor an indwelling urethralcatheter produced marked edema with threatening gangrene of the penis intwo cases. Indwelling urethral catheters should be anchored in urethrawith longitudinal adhesive and never anchored by encircling tape.
Clotted hemothorax requiring decortication developed in a high percentageof patients when the hemothorax had been treated by intercostal tube drainagerather than by multiple needle aspirations. Multiple tappings of the chestare a time-consuming procedure and frequently these patients require twoto three aspirations each 24 hours for the first few days. The pressureof work in the forward hospitals occasionally was such that multiple dailyaspirations could not be done and closed intercostal tube drainage wasemployed as a substitute with an underwater seal. While this proceduremay possibly be acceptable when the patient is to remain in one hospital,it was found to be an unsatisfactory method when the patient required evacuation.Frequently the patient would arrive on his litter holding the bottle ofwater upside down on his abdomen with the water churning back and forthinto the pleural cavity with each respiration. Oc-
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casionally the tubes were so placed in the chest that they did not providedependent drainage and acted merely as a foreign body.
An occasional patient, who had suffered a severe secondary hemorrhage,was received for evacuation to the Z. I. with gauze packing stuffed intothe wound to control bleeding. These patients all had an underlying arterialinjury and required further surgery to control the injured vessel beforethey could be evacuated. No patient who has had a severe secondary hemorrhageshould be considered safe for evacuation until the injured vessel has beeninspected and repaired or ligated. Packing the wound with gauze or hemostaticagents may temporarily control the hemorrhage but bleeding will recur.Impending hemorrhage can often be forecast by the appearance of the wound.The intermittent discharge of clots or small amounts of bright red bloodfrom an infected wound is a sure indication that there is an underlyingvascular injury, and is the warning that a furious secondary hemorrhageis soon to occur. These patients should be considered nontransportableuntil the vascular lesion has been controlled.
The high incidence of secondary hemorrhage during the early months ofthe war constituted a serious problem in rear area hospitals. These hemorrhagesalmost always originated in grossly infected wounds with unknown underlyingvascular injury. When the hemorrhage developed within a plaster cast afew patients almost bled to death before the cast could be removed anda tourniquet applied.
When the major artery in an extremity has been ligated, fasciotomy isoften necessary to prevent further restriction of blood supply due to postoperativeswelling. Intense swelling of the soft tissues within the confining fascialplanes may completely compress the remaining blood vessels of the limbwith resultant gangrene. In such cases incision of the fascia will relievethe constricting pressure, allow the compressed vessels to dilate, andreestablish the blood supply. Sympathectomy, on the other hand, will accomplishlittle or nothing since the interference with blood flow is not due tospasm of the vessel but to external compression. Three patients were admittedwith cold swollen forearms and hands with early gangrene of the fingers,following ligation of the brachial artery. In each case cervical sympathectomyhad been done without benefit. Incision of the confining fascial envelopefrom above the elbow to the hand was followed by immediate return of circulationin two of these cases. Fasciotomy should be done without hesitation andbefore gangrene develops when postoperative swelling threatens the bloodsupply of an extremity.
Clostridial cellulitis and myositis, as seen at Tokyo Army Hospital,usually developed in a poorly débrided wound in which damage toa major artery was present. Extensive incision and drainage and ex-
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cision of necrotic tissue followed by the use of an oxidizing agentsuch as hydrogen peroxide or zinc perioxide combined with large doses ofantibiotics gave uniformly good results with clostridial cellulitis. Therapeuticgas antitoxin appeared to be of little value. Amputation was performedonly in those cases in which the extremity was obviously gangrenous. Theincidence of clostridial infection can be reduced by thorough initial débridement.
Neurosurgical injuries presented a serious problem in the early monthsof the war because of lack of skilled neurosurgeons. This problem was resolvedby organization of neurosurgical teams which were assigned to forward hospitalsin Korea, making available skilled neurosurgical treatment in a matterof a few hours. The prevention of pressure sores in paraplegic patientsin the early phases of the war constituted a major nursing problem. Strykerframes were obtained which greatly facilitated the care of these patientsand eliminated the pressure sore problem. Turning frames were subsequentlyused in air evacuation of paraplegic patients from Japan to the UnitedStates allowing continuous care en route.
Renal insufficiency, with varying degrees of a uremic state presenteda problem in many of the more seriously wounded patients. The incidenceof this disorder did not vary appreciably throughout the war.
Serum hepatitis was frequently seen in patients who had received largenumbers of blood or plasma transfusions. The use of plasma was discontinuedbecause of the high incidence of hepatitis following its administration.
Frostbite cases were seen in large numbers during the first winter ofthe war and constituted a serious problem. Frozen extremities will frequentlyappear black, shriveled and mummified with the appearance of dry grangrene;however, this appearance should not be the basis for immediate amputation.In many cases the black, shriveled skin will slip off in 3 to 4 weeks revealingan intact, viable part. Amputation of frozen parts can be delayed indefinitelyunless the part becomes moist and infected, producing generalized symptoms.Frostbites should be gently cleansed and exposed to the air. No dressingsshould be applied. In cases where Vaseline gauze dressing had been appliedto frozen parts, infected moist gangrene developed, necessitating amputationin some cases.
A strong tendency was noted in the rear area hospitals to use split-thicknessskin graft to cover defects which could be closed primarily by mobilizationof the skin or by rotating flap. Because of the retraction of the skin,skin defects often appear much larger than they actually are. Since thequality of split-thickness skin graft is very
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inferior to normal skin covering, grafts should be reserved for thosecases which cannot be closed otherwise.
A number of small arteriovenous fistulae in the extremities were overlookedin the early months of the war. Almost without exception these small A-Vfistulae developed in patients who had sustained hundreds of small, minor,penetrating wounds of an extremity. The A-V fistulae usually became evidentin 4 to 6 weeks after injury and frequently after the patient had beenrestored to duty. Any patient who has sustained multiple small penetratingwounds of the extremity should be carefully checked approximately 1 monthafter injury for evidence of A-V fistulae.
Other problems of the early phase of the war were related to scantyrecords, language barrier and evacuation of patients. Scanty records oftenfailed to provide a clear concept of the extent of the injury and treatment.The early lack of interpreters and language difficulties with many of theUnited Nations soldiers created a problem in communication and deprivedthe patient and the doctor of the advantages of a thorough history. Theassignment of interpreters overcame this problem for rear area hospitals.Too early evacuation of some of the more seriously injured patients andother problems of evacuation were solved as the war became more stabilizedand medical personnel better indoctrinated.
Several approaches were employed in a continuing effort to improve thestandard of medical care and to reduce complications to a minimum. Photographswere made showing typical complications which resulted from violation oromission of some principle at the initial surgery. These photographs werehand-carried by the surgical consultant on his regular visits to Koreaand discussed at each medical installation to emphasize the principle involvedand to dispel any faulty preformed ideas of wound management. The "followup"card was widely used to enable each doctor to follow the course of hispatient to determine the final outcome of the case. An intensive l-dayindoctrination program for newly arrived doctors was conducted at TokyoArmy Hospital, designed to acquaint the new officer with the medical situationin the Far East Command. The principles involved in the care of battlecasualties were reviewed and typical patients were demonstrated to furtheremphasize the soundness of each principle. When possible, the policy oforienting newly assigned doctors in rear area hospitals for a few weeksbefore assigning them to forward units was profitable and assisted in thestandardization of medical care. It is felt that an atlas of war surgerydepicting typical wounds and their management would be of great value inthe library of each hospital, especially during the early phases of a war,and would visually emphasize guiding principles more clearly than the writtenword alone.
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The impressive reduction of mortality in the Korean war is evidenceof the high quality of medical care provided. It is hoped that even higherstandards of military medical practice will result from the continuousstriving to improve.
