War Surgery and Medicine
EXPERIENCE OF NEW ZEALAND MEDICAL CORPS DURING THE DIFFERENT CAMPAIGNS
EXPERIENCE OF NEW ZEALAND MEDICAL CORPS DURING THE DIFFERENT CAMPAIGNS
First Libyan Campaign
Our Division was not involved in this campaign, but our Medical Corps had the privilege of treating a considerable number of Australian and other casualties in the Helwan hospital. The wound treatment carried out was the surgical ébridement of the wound, followed by the closed plaster treatment. It was noted that there was little serious infection and that the smaller perforating and penetrating wounds generally healed satisfactorily.
The majority of the larger wounds also showed little serious infection, though the treatment was prolonged and necessitated much changing of plaster splints. Pyocyaneus infection was common and many of the wounds sluggish in healing in consequence. The smell of the stained plasters was objectionable and was aggravated by the heat of Egypt.
Comparatively little wound treatment was carried out by our units in Greece, except simple primary treatment in the forward areas by the RMOs and the Field Ambulances. Some surgical treatment was possible, however, at the Thermopylae line, where the closed plaster technique was used and sulphonamides given orally to serious cases.
In Crete more surgical work was done by our Field Ambulances and by our surgical team attached to British units, though the conditions and some lack of supplies made adequate treatment extremely difficult. Infection was marked in many cases and drainage was much utilised. Nearly all seriously wounded men became prisoners of war and were later evacuated to Greece by the Germans. One case of tetanus occurred in our force and the patient died at Athens, and gas gangrene was also seen.
Second Libyan Campaign
In this campaign our Division experienced serious casualties. The majority of the wounded were captured by the enemy while they were in the main dressing stations and were not relieved for page 29 ten days. During this time they suffered from serious lack of water and also from restricted rations.
Wound treatment had to be undertaken often at the ADS when out of contact with the MDS. Excision of wounds, drainage of infected wounds, and removal of obvious foreign bodies was carried out at one ADS in addition to the control of bleeding, the amputation of shattered limbs, and the suture of sucking chests. Acriflavine was used for the primary dressing. It was noted that the majority of deaths were associated with severe loss of blood. The main wound treatment was undertaken by our Field Ambulance MDSs, and also by the very well equipped and staffed Sims Mobile Surgical Unit. All types of cases were operated on by this unit, including abdomens, chests, and heads, but lack of water during the period of captivity rendered sterilisation difficult and the provision of sterile gowns and towels wellnigh impossible. Still more serious was the severe lack of drinking water and fluid for transfusion, which made it impossible to counteract the marked dehydration present in all cases, and particularly in the abdominal cases. Major Furkert, OC Mobile Surgical Unit, reported that ' By this time the water and food situation was desperate and patients began to die rapidly from dehydration.'
Furkert wrote a very clear account of the conditions of the wounded in this campaign and their treatment. He stated that hardly any of the casualties reached the unit within twenty-four hours of injury and many wounds were over three days old. The absence of highly pathogenic bacteria minimised the seriousness of this delay and few fulminating infections were seen, though severe infection was noted in many cases. There were serious deficiencies in supplies of all kinds—particularly ether, morphia, and plaster-of-paris. The shortage of water was desperate, and no patient was washed in any way for eleven days. Wound treatment consisted of excision with gauze lightly packed in the wound and plaster splints.
Observation of cases at the Base in Egypt showed that sulphanilamide powder was almost a universal wound treatment and that gauze dressings were used. Plaster was extensively used in the treatment of severe wounds, and fractures of the leg and forearm were universally treated in enclosed plasters. The fractured femurs were treated in Thomas splints, and cases from Tobruk were in the Tobruk splint, a combination of plaster and Thomas splint. Fractured humerus cases were mostly treated by posterior slab splints and simple slings, sometimes by Kramer wire splints and at times in abduction plasters. Severe sepsis was present in many wounds, and secondary haemorrhage and amputations were relatively common in the base hospitals. Gas gangrene, page 30 however, was infrequent. The conditions of the campaign had prevented adequate wound treatment and especially early and rapid evacuation. Sepsis had in consequence been marked in contrast to that seen in the first Libyan campaign, and this stressed the importance of early and adequate forward surgery. No gas gangrene was seen in our New Zealand base hospitals. The gangrene seen was in every case due to damage of the main vessels of the limb.
The saline bath treatment, as introduced for burns, was adopted for the treatment of chronic infections in limb wounds, in conjunction with both local and general sulphonamides. An elaborate bath unit, the only one in the Middle East, had been installed at our Helwan hospital, where there was a plastic surgeon.
At a conference held in Cairo in February 1942 in the quiet period following the second Libyan campaign, there was agreement on the value of the surgical cleansing of the wound of all devitalised tissue and on the importance of the removal of devitalised muscle.
The necessity of adequate incision to permit both proper inspection of the wound and subsequent drainage was recognised. Small perforating wounds had in the great majority of cases healed satisfactorily without any surgical treatment.
Dressings had consisted of vaselined gauze laid loosely in the wound. The poor results of plugging wounds with gauze were commented upon. The immobilisation of limb wounds in plaster without further dressing of the wound for ten days was the normal line of treatment, but later dressings of hypochlorite and other antiseptics were being utilised in conjunction with the plaster splinting. The Pyocyaneus infection, so often an aftermath of the closed plaster treatment, proved difficult to eradicate, and acetic acid was being used in its treatment.
Pre-Alamein Battles, June-October 1942
The lessons learned from the second Libyan campaign had borne fruit. There were better facilities for surgery, and more experienced surgeons were available. The lines of evacuation for the casualties were considerably shorter. Much less sepsis was seen in the wounds, this being due, it was stated, to earlier operative treatment and more efficient local sulphonamide therapy, especially to the wound. The sulphanilamide sprinklers had been issued to all field units, and sulphonamide tablets were given regularly. Closed plaster technique was still utilised and the splinting of fractures had improved, especially with regard to fracture of the femur. Our New Zealand technique of a combination of Thomas splint page 31 and plaster bandaging, a modification of the Tobruk method, had been introduced with great success. The utilisation of a plaster table for the application of spicas and shoulder casts was discussed, as difficulty in applying such casts was being met with, especially as plaster spicas were being utilised for large buttock wounds.
The plaster spica proved unsatisfactory when long evacuation was necessary, especially over the rough surface of the desert. Pressure sores were almost inevitable under those conditions unless very careful padding was carried out. No other splintage, however, was available for the hip and buttock cases.
Alamein Battle, October-November 1942
The surgical set-up for the Alamein battle had been arranged carefully beforehand, with the result that there was a satisfactory distribution of the operative work and more efficient evacuation, which was, of course, facilitated by the close proximity of the front line to Alexandria.
The normal wound treatment had become stabilised at this time. Surgical cleansing of the wound was understood by all the operating surgeons. Sulphanilamide powder was sprinkled on the wound as a fine dust. Vaseline gauze or tulle gras dressings were applied without plugging, and the limb put up in an enclosed plaster. Sulphonamide tablets were given regularly, and dosage cards affixed to the field medical cards. Blood was available in ample quantity, even up to the RAP, and was liberally given. Field transfusion units were attached to the operating units.
An order had been issued some time prior to the battle that all plasters must be split, but the order was not always carried out, and extra work was given to our CCS in splitting the overtight plaster splints and some limbs saved by the relief of tension. Fracture cases were efficiently splinted, mostly in plaster, the femur being splinted in the standardised New Zealand method.
Tunisian Campaign, Early 1943
During this period our New Zealand medical services had exceptional facilities both to observe and perform forward surgery. Our CCS was privileged to be the most forward CCS during the whole campaign, and had attached to it British specialist personnel of excellent ability as special neurosurgical, ophthalmic, field surgical and transfusion units. Probably 50 per cent of all casualties passed through our CCS during the campaign. Our Field Ambulances were also very active, well equipped, and very well staffed, and they carried out a great deal of major forward page 32 surgery. At one stage in the campaign some casualties were first seen a considerable time after being wounded. The wounds were generally very septic, even small penetrating wounds without any serious muscle damage. This tended to show that our lack of sepsis was definitely due to the surgical treatment, and not, as happened in the first Libyan campaign, due to a real absence of primary infection. Blood-transfusion arrangements were now functioning perfectly, and two to three pints were given to the individual case when required. Wet serum was also available and was often given to supplement the whole blood.
Review at End of North African Campaign
It was noted at this period that there was very little sepsis in our New Zealand cases at the base hospitals, and only a very few septic fracture cases, and little or no sepsis in the knee-joint cases. The head, chest, and abdominal cases had done very well, and secondary haemorrhage and late amputation had been very uncommon, a sure sign of absence of infection. Skin grafting was being commonly carried out, and very large flesh wounds complicating infected compound fractures were successfully grafted, with great improvement in the general condition of the patient, as well as more rapid return of local function.
The wound treatment at that time consisted of cleansing the skin of the limb with plain soap and water, and with shaving, not only for cleanliness, but preparatory to the application of elastoplast for extension. Iodine was then applied to the skin. The removal of skin had been restricted to the minimum, only definitely damaged devascularised edges being excised. The same applied to all the wounded area. Muscular excision was carefully carried out so that all avascular and badly traumatised muscle was removed. Only definitely loose fragments of bone were ever removed. Free, and if possible dependent, drainage was provided in all large wounds associated with much muscle or bone damage.
Generally the nerves were not dealt with, but were closely inspected to ascertain whether they were damaged or not, and clear notes written for the information of surgeons at the Base. Sometimes divided ends were sutured to facilitate operative repair later.
The treatment of wounds of the joints was conservative, it having been found that small perforating and penetrating wounds of the joints did not cause trouble if adequate splintage was applied. For large wounds the practice was adequate excision and, if possible, removal of large foreign bodies, and again adequate splinting by means of plaster.page 33
Wounds of the head were treated by careful excision and primary suture with stab drainage. Foreign bodies and bone fragments were carefully removed by suction and sulphonamide drugs administered locally and parenterally. Plaster caps were applied to ensure that the dressings remained in place, and diagrams of the wound and essential particulars were written on the plaster. Small chest wounds were left alone. Large ones were surgically cleaned and, if sucking was present, a vaseline gauze pack was sutured in position as a tamponage. Abdominal wounds were carefully cleansed and sutured and sulphadiazine was introduced into the abdomen at the end of the operation.
At our base hospitals very little infection was seen, and secondary haemorrhage rarely met with. The wound healing was improving steadily, though no routine secondary suture was being undertaken. The fractures were doing well, and large numbers of abdominal cases survived. There was distinct advance in every way, and war surgery had reached a uniformly high standard.
Chronically infected fracture cases were, however, still to be seen in the larger British hospitals where the serious cases were congregated. A ward full of infected fractures of the femur seen on one occasion showed that the problem of the control of infection had been in no way solved.
Advances in Treatment in Italy
Delayed primary suture became the routine treatment of all cases deemed suitable for suturing, whether simple wounds or those complicated by fracture-not always with perfect success, but never with any disastrous infection supervening. At times penicillin was not available at the base hospital, and in its absence suture was still carried out with success.
The wounds were arriving at 2 NZ General Hospital at Caserta early in 1944 in such excellent condition that suture was done in practically all cases on arrival, and there were very few patients with unhealed wounds sent on to 3 NZ General Hospital at Bari, except the fractured femurs purposely sent there without treatment at Caserta.
Fractures of the upper extremity were also routinely sutured at our hospital at Caserta; the leg fractures, causing difficulty because of the tension of the wound, were only occasionally sutured.
The most difficult wounds were those involving the hip joint, where sepsis was difficult to combat without the ability to give large doses of intramuscular penicillin.
In May 1944 a clinical meeting was held behind the Cassino front at 1 British CCS and forward surgery discussed. The progress in wound treatment was illustrated by the treatment of a page 34 case of severe trauma of the scapula, and scapular muscles, with anaerobic infection, which cleared up well after the primary operation, with the aid of parenteral penicillin, and delayed primary suture was carried out with success. The necessity to perform early amputation in the case of shattered limbs was being appreciated more and more, and recommendations were made for this to be done as a first priority, along with the control of severe bleeding. In mangled limbs, if amputation could not be immediately carried out, the application of a tourniquet just above the damaged area prevented further bleeding and the often serious deterioration seen in these cases, possibly due to toxic absorption. The dramatic improvement often produced in a patient's condition immediately a mangled limb was removed was vouched for by many experienced surgeons. This was in some ways comparable to the improvement in gas gangrene cases brought about by the efficient removal of the affected muscle groups. The amputation in these cases had to be done through healthy tissue above the devitalised area, as it was in the amputations through the injured area that our worst septic cases had arisen.
Flap amputation was the rule, and delayed primary suture was generally quite satisfactory. At the primary amputation only sufficient stitches to prevent retraction were allowable, and any packing had not to be tight. Badly injured feet generally required amputation, but with early penicillin treatment, and the prevention of sepsis, more were now saved. It was then noted that the results of wound treatment were so much better that the level of amputation could be reconsidered. Amputation, especially in the lower leg, could with benefit be performed at a level which would render re-amputation unnecessary.
Knee joints even with retained foreign bodies were doing well with intrasynovial penicillin and adequate splintage. Infected cases still required drainage occasionally and, unfortunately, amputations were still at times necessary.
During the advance to Florence an adjustment of the treatment of the wounded was made by the alteration of priorities. Ordinary wounds, either with or without fracture, were dealt with at the MDS, and the heavier cases, including the abdominal and chest cases, if fit to travel, were sent back to the CCS. (The head, jaw, and eye cases were sent still further back to a British CCS, to which special centres were attached.) The alteration in attitude was brought about by the realisation that, in the case of the abdominals, recovery from shock was essential before operation was carried out, and that urgent operation was unnecessary, and indeed undesirable. The concentration on the flesh wounds at the page 35 MDS at an early stage ensured the wounds being in a satisfactory condition for the performance of delayed primary suture when the cases reached the General Hospital.page break
As reported at the Rome conference, the majority of the fracture cases had been sutured with success, but about 20 per cent were thought to be unsuitable for suture. The plating of compound fractures had not, on the whole, been satisfactory, and a more conservative view was being adopted in this regard by the surgeons who had carried out experiments in this form of treatment.
The Consultant Surgeon 2 NZEF had for some time counselled against the removal of bone in fracture cases, especially large pieces, and in the humerus where non-union was so prone to occur. This view was supported at the conference by one of the younger surgeons, and this support established this line of treatment in our units. The utilisation of bone chips in the repair of bony defects of the jaw, and of the skull, seemed to make the removal of clean bone from a clean wound an absurdity, and as the very large majority of our fracture cases were progressing well on a straightforward course of primary wound treatment, followed by delayed primary suture, we considered no bone, loose or not, should be removed, and we had no cause to regret our changed procedure.
At the time of the Po battle the working MDS carried out some of the minor surgery, while the CCS did the abdomens and chests and the major urgent surgery. No. 1 NZ General Hospital in Northern Italy did some primary surgery and the bulk of the delayed primary suture of the wounds. No. 3 NZ General Hospital in Southern Italy dealt with some primary surgery and some delayed primary suture of wounds, and a large proportion of the heavier cases had been sent direct by air from the CCS for base hospital treatment. The marked improvement in the surgical technique in the treatment of war wounds had enabled this to be done.
In April 1945 the Consultant Surgeon 2 NZEF wrote:
We can comment that the treatment of war casualties at the end of the European war has reached a very high level of efficiency, both in the saving of life, and particularly in the freedom from sepsis, and in the rapid repair of wounds. To this progress, the NZ Medical Corps has contributed its share and has rapidly adopted any progressive developments in treatment. Our young medical officers in the forward areas have especially distinguished themselves by their painstaking and skilled work.
A table reproduced at the end of this chapter shows the types of wounds which led to invaliding from base hospitals to New Zealand, and compares the figures for 1 NZEF in France with those for 2 NZEF.page 36
The forward surgery for 3 NZ Division in the Pacific was carried out by field surgical units attached to Field Ambulances and by the Field Ambulances themselves, but it was limited as there were few casualties in the division in the island assaults from October 1943 to February 1944. Lieutenant-Colonel S. L. Wilson, a forward surgeon with 2 NZ Division, was transferred to the Pacific, and wrote a short directive on war surgery which was circulated to all medical officers.
The wound treatment consisted of surgical cleansing, light packing and dressing with vaseline gauze or tulle gras, while plaster splints were used for fractures and large wounds following the Trueta technique. Primary operation was often much delayed by the difficulties of evacuation from the jungle. Sulphonamides were used both locally and by mouth. Penicillin was only available in small quantity at the end of the campaign. Infection was not marked, but some anaerobic infection with gas gangrene was seen. Secondary suture was carried out at the CCS in some cases. There were no special difficulties encountered in wound healing.