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Problems of Wound Treatment During the Early Phases of the Korean War

Medical Science Publication No. 4, Volume 1



The sudden outbreak of war in Korea created an unpredictable and immediate need for field medical units. To meet this emergency it was necessary to "gut" every military hospital in Japan of all but a few of its medical personnel. Understaffed, skeletonized, field medical units were then rapidly formed and dispatched to Korea. Obstetricians, internists, pediatricians, general practitioners, orthopedists and surgeons alike found themselves at once responsible for the care of overwhelming numbers of seriously wounded battle casualties.

Despite the lack of unit training, shortage of medical personnel, and lack of comprehensive experience in war surgery, these units magnificently performed an almost impossible task. Their contribution is reflected in the lowest overall death rate in military hospitals ever recorded in any war.

This success was primarily due to the unified efforts of the Army, Navy and Air Force working jointly as an effective medical team, and to the selfless performance of each individual concerned. A highly coordinated medical supply system, operating through an unmolested base of operations in Japan, provided a profusion of modern equipment and supplies of excellent quality, including plenty of whole blood and a wide range of antibiotics. The development of helicopter evacuation, employment of MASH units in close support of combat, use of hospital ships as nearby floating hospitals, the wide use of air evacuation and development of specialized teams and treatment centers, all contributed to the overall lowered mortality. An effective preventive medicine program was responsible for the suppression of malaria and absence of epidemics, while the development of the armored vest and improved footgear further reduced the death and casualty rate.

While the general picture of medical accomplishment during the Korean war was one of steady improvement and advance, the histories of World Wars I and II and observations made during the Korean conflict reveal instances where 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.


ing more about, and applying the lessons learned, in previous wars.

In any national emergency many a capable surgeon, with ample experience in civilian surgery, will be confronted with treating multitudes of seriously wounded patients and may find himself uncertain and confused with new problems not ordinarily met in his practice. The current management of war casualties has been evolved throughout the years based on the wisdom, trials, errors and accumulated experience of hundreds of surgeons in preceding wars. Only by knowing and applying the broad policies and guiding principles established by those who preceded him can one avoid the repetition of serious and sometimes fatal errors.

In an effort continuously to improve the standards of war surgery, each medical officer must become familiar with the basic concepts, so that the priceless lessons of other wars need not have to be "rediscovered" in World War III. These principles refer not only to forward medical care and wound management, but to the time and methods of evacuation, the timing and place of operation and other problems of good medical service throughout the chain of evacuation.

Throughout the first year of the war it was evident that, when the initial management of the wounded had been guided by established principles, most of the patients presented no problem when they reached a rear area hospital and pursued an uncomplicated course. On the other hand, many of the serious surgical problems encountered at Tokyo Army Hospital resulted from lack of experience in war surgery, delay in, omission or inadequate application of, some principle at initial surgery.

In the early days of the war, patients often arrived at Tokyo Army Hospital within 3 to 10 days after wounding. Because of the limited number of beds and the unstable tactical situation in Korea, rapid evacuation of patients from forward hospitals became an absolute necessity and could not be deferred. The result was that the medical officer who performed the initial surgery had no way of following the subsequent course of his patient to determine the final outcome of his treatment. Since no complications had become manifest by the time the patient was evacuated, the surgeon might logically assume that his management of the case had been proper, and unknowingly develop a false impression which led to repetition of the same improper procedure in subsequent patients.

Rather than to be content with the fine record established in the Korean war it may be of value to cite examples wherein we did poorly, and how we may eliminate the same problem in another war.

Débridements were often incompletely done through inadequate incisions with the result that, during the early months of the war, the incidence of wound infections was extremely high. The faulty use


of Vaseline gauze did more harm than good. Some wounds were found tightly corked with a yard or more of Vaseline gauze which completely prevented drainage of the wound. These patients were febrile and quite toxic and on removal of the gauze plug it was common for a half pint or more of foul pus to gush and bubble from the depths of the wound. Besides damming the pus in the wound, the gauze packing had served as a splint which held the walls of the wound widely separated converting the wound into a cylinder with indurated, fixed walls which would not readily collapse. To avoid this condition thorough initial débridement should be done using bold linear incisions that will allow exposure of the entire wound tract for removal of foreign bodies and devitalized tissue. Good exposure will result by applying the old generalization that "the wound should be twice as long as it is deep." A few layers of gauze should be laid into 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 with gauze packing. Counter-incisions should be made if needed to provide dependent drainage.

An occasional case was seen early in the war in which débridement and primary suture had been performed. Some of these wounds healed without complication but the majority of patients developed wound sepsis with further loss 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 and hand wounds.

Pressure sores over the dorsum of the foot and impaired circulation of an extremity were occasionally seen as a result of a tight cast which had not been split prior to evacuation. An extensive slough of the skin on the dorsum of the foot, due to traction applied to the bare foot, was seen in one case. To avoid these complications, all casts must be split completely through to the skin prior to evacuation. The shoe should not be removed when applying a temporary traction hitch to the foot.

The wisdom of open amputation was again demonstrated. Two badly infected pus-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 for war surgery and should be used exclusively. The amputation should be performed at the lowest possible level, without regard for the final utility of the stump. The use of this type of amputation demands that skin traction will be continuously applied until the stump is healed or the patient evacuated. Failure to maintain skin traction results in retraction and fixation of


the soft tissue with protrusion of the bone and necessitates reamputation with 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 developed to provide a wide range of exposure, it was followed by a high percentage of huge ventral hernias with extensive loss of abdominal wall. Some of these hernias were so large that satisfactory repair was unlikely. Another serious disadvantage of the transverse incision was evident when a torn segment of colon had to be exteriorized through one end of the operative incision because no other area was available laterally. Exteriorization of the colon through the operative incision is undesirable as it almost assures a badly infected exploratory wound. The vertical paramedian incision is 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, varying degrees of infection of the exploratory incision were common, ranging from minor redness and induration in the usual case to frank suppuration, wound abscess, extensive fasciitis and slough in the rare instance. To minimize the effects of wound contamination and to prevent extensive loss of abdominal wall, the peritoneum and posterior sheath should be closed and the remainder of the wound loosely approximated with heavy through-and-through, wire stay sutures. The larger the wire, the better: 0.028 or larger wire gave the best results. As swelling of the wound occurs, the wires should be loosened to prevent strangulation of the tissues. Small-caliber wire was found to be entirely unsuitable as it quickly cut through the tissues, loosened and acted only as a foreign body. It is probably a wise precaution to drain all except the completely clean intra-abdominal wounds, not for present infection but to prevent future trouble. As a result of underlying infection the abdominal wall gains tensile strength more slowly than normal. It was found that wire stay sutures should ordinarily remain in place 15 to 20 days. Early removal of the wires, even in wounds that appeared strong, was followed by evisceration sufficiently often to warrant the adoption of this view.

Bile peritonitis developed in several patients with liver wounds, in whom the abdominal wall had been tightly closed with no provision for bile drainage. There is extensive seepage of bile following a liver wound and the abdomen should be routinely drained through a laterally placed stab wound to allow escape of bile and minimize peritonitis.

Extensive intra-abdominal abscesses, peritonitis and fecal fistulae resulted from the breakdown of colon wounds which had been repaired


and dropped back into the abdomen. While a wound may occasionally heal without complications the majority of patients will develop abscesses, fistulae, peritonitis and die unless the injured segment of colon is exteriorized by subsequent surgery. Injured segments of colon must be exteriorized or functionally excluded by a proximal diverting colostomy. All but the extreme lower portion of the colon can be mobilized and brought to the surface. Wounds involving the lower sigmoid or rectum should be repaired and defunctioning colostomy performed proximally. In exteriorizing an injured segment of colon the bowel should be brought out through a laterally placed muscle-splitting incision and not through the primary operative incision. The colon must be mobilized sufficiently to allow it to lie in the wound without tension, otherwise the exteriorized segment will retract into the abdomen with infection of the wound and formation of intra-abdominal abscesses.

Small bowel fistulae were more prone to develop at the site of a repaired perforation than through an anastomosis. This is probably due to a wider zone of tissue destruction about the perforation than is evident at the time of repair. Patients with small bowel fistulae were frequently severely dehydrated and appeared moribund on admission. Procrastination beyond the time necessary to restore fluid and improve electrolyte balance is not justified. Regardless of the degree of infection present in the abdomen and abdominal wound these patients should be operated upon as early as possible to close the intestinal fistula. The patient may appear too critically ill to withstand abdominal exploration and one may be tempted to delay operation for several days in the hope that the patient's condition will improve; however, this is usually futile wishful thinking; delay in operation to close the fistula will result in gradual decline of the patient and his death.

Round worms were the cause of intestinal fistulae in several instances. The ascaris is an inquisitive worm, constantly probing about, and will work itself through a freshly sutured perforation or anastomosis. This complication was seen in six patients and ascarids were found lying free in the abdominal cavity. Since certain United Nations troops were found to harbor ascaris routinely, such a patient with a small bowel fistula was treated to rid him of round worms before any attempt was made to close the fistula. In two cases in which preoperative vermifuge was omitted, round worms again worked themselves through the anastomosis and out through the abdominal incision.

Duodenal wounds which had been repaired at the initial surgery frequently broke down with the development of duodenal fistula. This is a grave complication and the course of these patients is rapidly


downhill because of loss of bile, fluids, electrolytes and digestion of the skin. If the patient is to survive, provisions must be made for the maintenance of his nutrition and replacement of fluids and electrolytes. Nine patients who had duodenal fistulae secondary to the breakdown of the duodenal wound were operated upon and the duodenum closed and jejunostomy performed for feeding. Wounds involving the posterior aspect of the duodenum buttressed against the posterior abdominal wall were found to heal better than wounds located on the anterior free surface of the duodenum.

Closure of duodenal fistulae at a second operation was not usually successful and the duodenal fistula frequently recurred after 3 to 5 days. Sump drainage was employed in these cases and all bile and duodenal contents were collected and returned to the intestinal tract through the jejunostomy. The use of a Levin tube in the stomach and duodenum is of value in preventing pressure on the repaired duodenum and may assist in preventing breakdown of the repair. Two patients with right kidney injury requiring nephrectomy were found to have, in addition, wounds involving the posterior aspect of the duodenum. In wounds about the right kidney the duodenum should be routinely explored for injury. Patients with duodenal injuries must be considered absolutely nontransportable until the outcome of the repair is determined.

Biliary fistulae developed in a few patients in whom a perforating wound of the gallbladder had been repaired at the initial surgery with no provision for drainage of the gallbladder. Perforating wounds of the gallbladder are preferably managed by cholecystectomy and if for some reason this procedure is not possible, a cholecystostomy should be performed following the repair of the perforating wounds.

Wounds of the spleen should not be repaired. Two patients developed delayed hemorrhage from lacerated spleens which had been repaired and required subsequent splenectomy. The pulpy consistency of the spleen is such that repair of this friable organ is an unsatisfactory procedure. Suturing of the splenic tissue has been compared to "suturing a wet paper bag full of raspberry jam." Wounds of the spleen require splenectomy.

Intestinal obstruction occasionally developed as a result of herniation of a knuckle of intestine into the wound of entry or exit in the abdominal wall. This problem can be prevented by closing the wound of entry or exit at the initial surgery or if utilized for a drain site, the size of the opening should be reduced to prevent herniation of the bowel.

Spreading retroperitoneal clostridial cellulitis was present in a few cases with perforating wounds of the rectum. To prevent this serious complication a proximal defunctioning colostomy must be performed


and the perirectal space widely drained from below at the initial surgery. Rectal injuries almost never occurred alone and were usually associated with 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 high mortality because of the severity of the injury and infection. Every effort must be made at the initial surgery to prevent further fecal contamination and to provide open free drainage of the areolar tissue about the rectum.

Suprapubic tubes were occasionally placed too low in the bladder lying against the pubis and produced the painful complication of osteitis pubis. This can be avoided by bringing the suprapubic tube out of the dome of the bladder and away from the pubis. Perivesical infection secondary to perforating wounds of the bladder is a common complication. Repair of the bladder wall and drainage of the space of Retzius should be routine to minimize the effects of perivesical contamination.

The breakthrough of malaria was cause for concern during the early days of the war until the condition was recognized. After wounding, suppressive therapy was occasionally omitted and frequently these patients developed high temperatures, without chills, a few days after arriving at rear area hospitals. These high temperatures were initially thought to be due to some hidden complication or wound infection; however, blood examinations revealed the true cause of the fever and treatment with chloroquine promptly controlled the symptoms. Latent malaria is prone to break through following severe injury.

Circular adhesive tape around the penis to anchor an indwelling urethral catheter produced marked edema with threatening gangrene of the penis in two cases. Indwelling urethral catheters should be anchored in urethra with longitudinal adhesive and never anchored by encircling tape.

Clotted hemothorax requiring decortication developed in a high percentage of patients when the hemothorax had been treated by intercostal tube drainage rather than by multiple needle aspirations. Multiple tappings of the chest are a time-consuming procedure and frequently these patients require two to three aspirations each 24 hours for the first few days. The pressure of work in the forward hospitals occasionally was such that multiple daily aspirations could not be done and closed intercostal tube drainage was employed as a substitute with an underwater seal. While this procedure may 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 of water upside down on his abdomen with the water churning back and forth into the pleural cavity with each respiration. Oc-


casionally the tubes were so placed in the chest that they did not provide dependent 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 into the wound to control bleeding. These patients all had an underlying arterial injury and required further surgery to control the injured vessel before they could be evacuated. No patient who has had a severe secondary hemorrhage should be considered safe for evacuation until the injured vessel has been inspected and repaired or ligated. Packing the wound with gauze or hemostatic agents 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 blood from an infected wound is a sure indication that there is an underlying vascular injury, and is the warning that a furious secondary hemorrhage is soon to occur. These patients should be considered nontransportable until the vascular lesion has been controlled.

The high incidence of secondary hemorrhage during the early months of the war constituted a serious problem in rear area hospitals. These hemorrhages almost always originated in grossly infected wounds with unknown underlying vascular injury. When the hemorrhage developed within a plaster cast a few patients almost bled to death before the cast could be removed and a tourniquet applied.

When the major artery in an extremity has been ligated, fasciotomy is often necessary to prevent further restriction of blood supply due to postoperative swelling. Intense swelling of the soft tissues within the confining fascial planes may completely compress the remaining blood vessels of the limb with resultant gangrene. In such cases incision of the fascia will relieve the constricting pressure, allow the compressed vessels to dilate, and reestablish the blood supply. Sympathectomy, on the other hand, will accomplish little or nothing since the interference with blood flow is not due to spasm of the vessel but to external compression. Three patients were admitted with cold swollen forearms and hands with early gangrene of the fingers, following ligation of the brachial artery. In each case cervical sympathectomy had been done without benefit. Incision of the confining fascial envelope from above the elbow to the hand was followed by immediate return of circulation in two of these cases. Fasciotomy should be done without hesitation and before gangrene develops when postoperative swelling threatens the blood supply of an extremity.

Clostridial cellulitis and myositis, as seen at Tokyo Army Hospital, usually developed in a poorly débrided wound in which damage to a major artery was present. Extensive incision and drainage and ex-


cision of necrotic tissue followed by the use of an oxidizing agent such as hydrogen peroxide or zinc perioxide combined with large doses of antibiotics gave uniformly good results with clostridial cellulitis. Therapeutic gas antitoxin appeared to be of little value. Amputation was performed only in those cases in which the extremity was obviously gangrenous. The incidence of clostridial infection can be reduced by thorough initial débridement.

Neurosurgical injuries presented a serious problem in the early months of the war because of lack of skilled neurosurgeons. This problem was resolved by organization of neurosurgical teams which were assigned to forward hospitals in Korea, making available skilled neurosurgical treatment in a matter of a few hours. The prevention of pressure sores in paraplegic patients in the early phases of the war constituted a major nursing problem. Stryker frames were obtained which greatly facilitated the care of these patients and eliminated the pressure sore problem. Turning frames were subsequently used in air evacuation of paraplegic patients from Japan to the United States allowing continuous care en route.

Renal insufficiency, with varying degrees of a uremic state presented a problem in many of the more seriously wounded patients. The incidence of this disorder did not vary appreciably throughout the war.

Serum hepatitis was frequently seen in patients who had received large numbers of blood or plasma transfusions. The use of plasma was discontinued because of the high incidence of hepatitis following its administration.

Frostbite cases were seen in large numbers during the first winter of the war and constituted a serious problem. Frozen extremities will frequently appear 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 revealing an intact, viable part. Amputation of frozen parts can be delayed indefinitely unless the part becomes moist and infected, producing generalized symptoms. Frostbites should be gently cleansed and exposed to the air. No dressings should be applied. In cases where Vaseline gauze dressing had been applied to frozen parts, infected moist gangrene developed, necessitating amputation in some cases.

A strong tendency was noted in the rear area hospitals to use split-thickness skin graft to cover defects which could be closed primarily by mobilization of the skin or by rotating flap. Because of the retraction of the skin, skin defects often appear much larger than they actually are. Since the quality of split-thickness skin graft is very


inferior to normal skin covering, grafts should be reserved for those cases which cannot be closed otherwise.

A number of small arteriovenous fistulae in the extremities were overlooked in the early months of the war. Almost without exception these small A-V fistulae developed in patients who had sustained hundreds of small, minor, penetrating wounds of an extremity. The A-V fistulae usually became evident in 4 to 6 weeks after injury and frequently after the patient had been restored to duty. Any patient who has sustained multiple small penetrating wounds of the extremity should be carefully checked approximately 1 month after injury for evidence of A-V fistulae.

Other problems of the early phase of the war were related to scanty records, language barrier and evacuation of patients. Scanty records often failed to provide a clear concept of the extent of the injury and treatment. The early lack of interpreters and language difficulties with many of the United Nations soldiers created a problem in communication and deprived the patient and the doctor of the advantages of a thorough history. The assignment of interpreters overcame this problem for rear area hospitals. Too early evacuation of some of the more seriously injured patients and other problems of evacuation were solved as the war became more stabilized and medical personnel better indoctrinated.

Several approaches were employed in a continuing effort to improve the standard of medical care and to reduce complications to a minimum. Photographs were made showing typical complications which resulted from violation or omission of some principle at the initial surgery. These photographs were hand-carried by the surgical consultant on his regular visits to Korea and discussed at each medical installation to emphasize the principle involved and to dispel any faulty preformed ideas of wound management. The "followup" card was widely used to enable each doctor to follow the course of his patient to determine the final outcome of the case. An intensive l-day indoctrination program for newly arrived doctors was conducted at Tokyo Army Hospital, designed to acquaint the new officer with the medical situation in the Far East Command. The principles involved in the care of battle casualties were reviewed and typical patients were demonstrated to further emphasize the soundness of each principle. When possible, the policy of orienting newly assigned doctors in rear area hospitals for a few weeks before assigning them to forward units was profitable and assisted in the standardization of medical care. It is felt that an atlas of war surgery depicting typical wounds and their management would be of great value in the library of each hospital, especially during the early phases of a war, and would visually emphasize guiding principles more clearly than the written word alone.


The impressive reduction of mortality in the Korean war is evidence of the high quality of medical care provided. It is hoped that even higher standards of military medical practice will result from the continuous striving to improve.