IN the early stages of the First World War chest injuries were treated conservatively and little was done apart from the treatment of the external wound. The wound itself was not treated by radical excision in the same way as wounds of the trunk and buttocks, as there was not the same danger from anaerobic infection of muscle.

Chest surgery, as we now know it, had not been developed. The mortality from chest injuries was high (it still is for that matter), but infection was a common and dangerous complication. During the bloody and prolonged battle of the Somme, with its heavy and continuous casualties, the problem of sepsis in relation to penetrating wounds of the chest became an insistent one, and Cask, then working in a CCS at Heilly, came to the conclusion that an attempt should be made to treat wounds of the chest and lung by full exposure and radical excision on the same principles as that applied to other gunshot wounds. He courageously tackled the problem and developed a technique of early operation which consisted of excision of the wound of the chest wall, opening the chest, freely excising wounds of the lung, and removing foreign bodies and blood from the pleural cavity. He closed the chest by suture and aspirated afterwards. His capacity as a surgeon enabled him to get satisfactory results, especially as regards the prevention of infection, but the mortality was naturally high. Chest cases were then sent to him from the whole area—the first development of a forward chest centre. The necessity for special training of the surgeon, special anaesthetists, and equipment restricted the development, and the majority of surgeons continued to treat the chest cases conservatively.

Gask, however, continued his work and undoubtedly gave a great stimulus to chest surgery. Moynihan at the end of the war was convinced that chest surgery had a great future before it and that marked progress would be made as a result of experience in war. His vision has proved correct. It was strange perhaps that experience in the Second World War showed that early radical exploration of the chest was undesirable, and that the best results were obtained by conservative methods.

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During the First World War there was much severe and prolonged sepsis with chronic empyemata. Treatment by the instillation of the hypochlorites was undertaken with beneficial results when the Carrel-Dakin treatment was introduced. (Thoracoplasty. was required later in some of the cases.)

In the First World War the New Zealand forces had no special chest surgeon, nor did they have one during the 1939–45 War. They relied when necessary on the British centres.