War Surgery and Medicine
The operating theatre technique depended to a great extent on the supplies available and on the possibility of washing and sterilising under the prevailing conditions. The elaborate arrangements of a civil hospital were naturally impossible in a tent in the desert. It was impracticable to use large numbers of sterile gowns and guards, and generally impossible to wash them properly. This led to the minimal use of linen gowns and guards for operation. At times, when conditions rendered it possible, sterilised gowns, guards, and dressings were sent up to the forward areas from the base hospitals in Egypt. However, for the abdominal cases gowns and guards were used whenever possible, but sparingly. Caps and masks were used, and care taken that the masks were impervious. Ordinary soap and water allowed satisfactory cleansing of the page 241 hands, and methylated spirits gave some added safety. Gloves were used generally for all cases, and always for abdominal cases.
Sutures and ligatures were freely available, but catgut was sparingly used. Cotton and linen thread were utilised instead. Ordinary cotton was found quite suitable for ligatures and caused less trouble than catgut. Catgut was utilised for deep stitches in the abdominal wall where sepsis might ensue. Linen thread was used for sutures both for the intestine and for the skin.
Instruments and Appliances
Abdominal sets of instruments were often prepared in readiness for instant use. The instruments generally available were ample, but a good pedicle clamp, simple flexible abdominal retractors, and a strong rib spreader were useful additions. An efficient suction apparatus was considered essential, as was electric lighting. Independent electric lighting sets for FSUs were eagerly sought after, and the Italians had an excellent model. An angle-poise lamp was found of use in abdominal cases.
Skin Preparation: Soap and water was mainly relied upon for pre-operative cleansing of the operation area and shaving was carried out as required. Antiseptics (such as iodine, dettol, mercurichrome), however, were commonly applied afterwards.
Catheterisation was regularly performed before operation.
Morphia had normally already been given to these patients, and further dosage was administered as required with or without atropine.
The type of anaesthetic used depended a good deal on the anaesthetist. Our teams generally used pentothal for induction followed by ether. When the Macintosh's apparatus became available it proved of great value in the forward areas in the desert. Later much use was made by experienced anaesthetists of anaesthesia machines and sometimes of cyclopropane. Intratracheal anaesthesia was also used, especially for thoraco-abdominal cases.
Wounds elsewhere in the body complicated the operative procedure. The determination of the sequence of operative attack called for experience and judgment in the surgeon. The patients were as a rule very ill, and only urgently necessary procedures in regard to other than abdominal injuries were normally carried page 242 out. Any urgent wound treatment that necessitated other than a recumbent position was done first so as not to move the patient after laparotomy. If bleeding was taking place from a limb injury it was attended to first. A traumatic amputation was also dealt with so as to facilitate the rapid resuscitation of the patient. Other injuries which could be dealt with readily in the recumbent position were left until after laparotomy, so that should the patient collapse they could be left alone. It was often of great value to have two surgeons working at the same time on different lesions in order to cut down the operating time. The association of head injuries created a difficulty, but if the patient could not be safely evacuated to a head unit for combined operation, then abdominal operation was carried out and the head wound dealt with as deemed necessary at the time, and according to the experience of the surgeon in head surgery.
The Abdominal Incision
Careful excision of the gunshot wound was carried out so as to ensure an aseptic healing following suture. Exploration of the abdomen was carried out either through the enlarged original gunshot wound or through a separate incision. The original wound was utilised frequently at the beginning of the war, especially for approach to the flanks. It was then realised that healing of these wounds was often unsatisfactory and other more normal exploratory incisions were used. There was no standardisation of these incisions, surgeons often using the one they were accustomed to in civil practice. Some used a paramedian, some a rectus split, and others a mid-line incision for a general approach, and transverse or oblique incisions in the flanks, sometimes extending forwards to the mid-line. The original wound was still used occasionally for injuries localised to one flank The wound of entry was sometimes preferred when the damage to the abdominal wall was extensive and a wide excision of it seemed the easiest method of approach. Considerable difficulty was often experienced in closing such incisions.
One of our surgeons used the following incisions in a series of abdominal cases: mid-line, 18; paramedian, 66; transverse, 21; oblique, 9; thoracic or thoraco-abdominal, 10.
There seemed to be less trouble following the central abdominal incision, and more herniation following rectus split and transverse rectus incisions. (All incisions were sutured with, at times, temporary drainage in the original wounds.) Separate incisions were generally made for colostomy or abdominal or retro-peritoneal drainage.page 243
The Exploration of the Abdomen
Every forward surgeon recognised the need to carry out a thorough and orderly examination of the abdominal contents. The probability of injury to any organ or viscus was evaluated from the position of the wounds and the probable course of the missile, but, especially in the case of the mobile small intestine, it was difficult to be certain that no injury had taken place. The surgeons worked on an orderly plan. First came suction and mopping up of blood, which was generally present in some degree, and, in about half the cases, to a marked degree. Large abdominal cloths were used and gentle tilting of the body often allowed blood to run out. Then at the earliest moment any actual bleeding vessel was caught up with forceps and tied off with fine thread. The mesentery or omentum was the common site of serious continued bleeding. The small intestine was then examined loop by loop from one end to the other, generally starting at the caecum, forceps being applied to each lesion as it was found, and repair carried out at the end of the examination of the small bowel. Multiplicity of wounds in the small intestine was so common that examination of the whole of the small bowel was essential except in exceptional circumstances. Then the stomach and the large bowel were examined, and finally the liver, spleen, kidney, and bladder, as indicated by the wound and the other injuries.
In examining the colon, freeing of the fixed colon was often necessary when the bowel was injured or when injury to the retro-peritoneal aspect was considered possible, the liberation of the bowel facilitating both the examination and the treatment, generally by exteriorisation, of any lesion present. One of our forward surgeons stated that the fixed colon should almost always be mobilised as suture would be difficult unless this were done, and there was, in any case, usually a through-and-through wound of the colon. Another of our surgeons stated:' In wounds of the fixed colon the damaged section should ideally be mobilised and exteriorised. But, if any great difficulty arises in doing this, a local repair plus free drainage and a proximal colostomy should be done. Better a live patient with a proximal colostomy and a faecal fistula than a dead one with exteriorised damaged bowel'. Unfortunately, the efficiency of this method was offset by the extra shock produced, especially in the severe cases. Major Estcourt, RAMC, who reported in 1945 a series of operations on wounds of the colon with the low mortality of 36·5 per cent, stressed the severity of the extensive mobilisation necessary to exteriorise the fixed portion of the colon, and described it as a shocking procedure which the war abdomens would not stand. page 244 The stomach could be adequately examined by an approach through the gastro-colic omentum.
Treatment of Bleeding in the Mesentery
Sometimes severe and continued bleeding was encountered from a mesenteric vessel, and bleeding into the mesentery itself made treatment difficult. Brigadier Ogilvie, RAMC, pointed out the danger to the circulation of the bowel of using sutures in this situation. He strongly advised the picking up of the bleeding vessels by small forceps and ligature by fine thread, including the minimum of tissue. His advice was followed by us.
Treatment of Wounds of the Small Intestine
The holes in the small intestine marked by the forceps were then dealt with in turn, generally by a single layer of stitches. The stitches were either continuous or single according to the nature of the lesion, and were of fine thread and sometimes of catgut. Resection was employed only when the mesenteric blood supply was interfered with or when portion of the intestine was hopelessly damaged, it being recognised that resection was followed by a high mortality. Simple end-to-end suture was employed in resection cases, generally using only one row of stitches.
Illustrative Case of Multiple Injuries, including Resection of Small Intestine: Soldier wounded by shrapnel in sacral region 20 April 1943. Laparotomy ten hours after wounding disclosed, (a) six ragged tears of lower ileum for which eight inches of gut were resected with end-to-end anastomosis; (b) small hole at pelvi-rectal junction of colon, which was oversewn and inguinal colostomy performed; (c) perforation of intra-peritoneal wall of bladder, which was closed and a suprapubic cystostomy established.
A drain was placed to the pelvis. The foreign body was not found. Patient was given six pints of blood altogether. He was evacuated on 12th day, and eventually reached 3 NZ General Hospital at Tripoli on 16th day. Just over a month later the suprapubic incision had healed, and the colostomy was working well, and he was evacuated to Egypt.
This case illustrates the sound technique utilised by the forward surgeons at that period.
Treatment of Wounds of the Colon
It was in treatment of wounds of the colon that the greatest interest was shown during the war. This was a natural sequence to the advancement in operative procedures in civil surgery, and especially the recognition of the dangers of infection following operations on the colon. This had led to the adoption of conservative types of operation such as the Paul-Mikulicz in preference page 245 to direct excision and suture. Devine had used a proximal colos-tomy to divert the intestinal contents and so render subsequent excision of the colon much safer. The repair of the thin and fat-laden wall of the colon was difficult and the danger of leakage and infection ever present. In gunshot wounds there was extra bruising and devitalisation of the bowel. Ogilvie early in the war made a vehement appeal for the exteriorisation of the colon, saying that' no surgeon might repair and suture a colon injury and return it to the abdominal cavity.' This appeal had a marked effect on surgeons in the MEF and they adopted the method, thus bringing about a marked lowering in the mortality of these cases as compared with the First World War. Great improvement in his results was reported by Major Giblin, AAMC, who first utilised suture and later adopted exteriorisation. Major S. L. Wilson, NZMC, carried out exteriorisation from the beginning, and this was the regular routine of all our later forward surgeons. Wilson stated that' the decompression produced by the combined use of colostomy and gastric suction in large bowel injuries produces as completely as possible the ideal of complete physiological rest of the whole intestinal tract and contaminated cavity'. The colon was at times brought out through the original wound, but this was found unsatisfactory and a small separate incision was then always used for the colostomy, no suturing being required. A double-barrelled colostomy was made if at all possible, and a definite spur was formed. Serious bruising of the colon without actual perforation was also dealt with by exteriorisation as subsequent sloughing and perforation was not uncommon. A proximal colostomy was opened at the original operation, but exteriorised damaged bowel was not generally opened until twenty-four to forty-eight hours later. Exteriorisation remained throughout the war as the standard form of treatment for colonic injuries, and especially for lesions of the left side of the colon.
As time went on, however, and difficult cases arose, many surgeons were not satisfied with the rigid rule, and in the case of the wounds of the right colon began to suggest that closure might be both justified and beneficial. Many considered the right colon should be treated like the small intestine, except in major injuries. Suture began to be tried in the lesser cases, and marsupialisation combined with tube or Paul tube drainage in all but the severest cases. The copious and irritating discharge of fluid contents from the caecum caused much trouble, infected the parietes, and many cases died. A case was observed at the battle of Mareth of a severe injury to the caecum in which a large mass of caecum and ascending colon was exteriorised with the ileo-caecal valve protruding in the wound. Marked loss of fluid occurred, page 246 with irritation of the skin and infection of the wound extending into the loin. Partial closure was attempted a few days later, but without success. The case made a deep impression on all who saw the distressful condition present. Radical excision of the right colon as for the treatment of cancer of the bowel was often undertaken, but this was a severe operation and the cases needing such treatment often could not stand it. Short-circuiting of the terminal ileum into the transverse colon was often used with success, but the damaged colon had still to be dealt with. When suture was adopted drainage of the abdomen, and also of the retro-peritoneal tissues if involved, was deemed essential by most surgeons. Suture was also undertaken by some surgeons in the lesser lesions of other parts of the colon, being more cautious with choice of cases on the left side. It is recorded that cases of tearing of the walls of the transverse colon without injury to the mucous membrane healed successfully after suture of the external coats. Proximal colostomy associated with suture was performed by some, especially in the splenic flexure cases, and as a routine in the lower pelvic colon and rectal cases. When exteriorisation was carried out, as in the majority of cases, and in all the severe cases, sufficient bowel was brought out to allow of the formation of a satisfactory spur. Care was taken to approximate the limbs, so that the mesenteric attachment would not be afterwards caught in the clamps when the spur was crushed. When drainage was instituted in wounds of the caecum early closure was carried out, generally on the fourth day, to prevent the continued discharge of fluid and the soiling of the wound as the Paul's tube became loosened.
Wounds of the Rectum
The serious nature of wounds of the rectum was recognised early, as was their frequent association with wounds of the buttock and pelvis. Severe infection, especially in the retro-peritoneal tissues, was usual in these injuries. Suture of any injury to the intra-peritoneal part of the rectum and the lower sigmoid was carried out and a proximal colostomy formed, through a small separate stab wound, generally in the left iliac region, no stitching in the wound being necessary or desirable. Drainage was instituted to the pelvis. In extra-peritoneal injuries a colostomy was formed and free drainage instituted in the mid-line of the perineum with removal of the coccyx to give adequate room. In Crete Major Christie reported that the rectum was usually opened in severe wounds of the sacral and coccygeal regions. These cases developed severe toxaemia, and probably also peritoneal infection, and none survived in spite of a transverse colostomy being performed on one case.page 247
In the earlier periods of the war a colostomy was sometimes performed to ensure non-soiling and better healing of large buttock wounds, and this seemed justified in seriously ill patients, though adding another risk and burden to the patient. The introduction of penicillin rendered this operation unnecessary, and many large buttock wounds were dealt with successfully either by primary or delayed primary suture, combined with local and parenteral penicillin.
Injuries of the Stomach and Duodenum
Stomach wounds lent themselves to satisfactory suture, and normally did well if not, as was common, complicated by other serious intra-abdominal injuries.
Duodenal injuries were dealt with by suture which frequently presented great difficulty. Drainage was provided as leakage was common. The mortality was high.
Illustrative Case of Stomach and Duodenal Injury: GSW wound operated on within eight hours. Entrance wound in left flank. Lower pole of the spleen was torn, splenectomy performed. Two holes in stomach sutured. A perforation of the transverse colon necessitated exteriorisation. Multiple holes in the jejunum were closed. A perforation of the peritoneal aspect of the second part of the duodenum was closed by a double layer of sutures. The patient had a smooth convalescence and was evacuated from the CCS on the fifteenth day after operation.
Injuries of the Bladder
These were dealt with by suture of the wounds of the bladder and drainage provided suprapubically and, if necessary, extra-vesically, and in the cave of Retzius. Some of our cases had to have both a colostomy and a suprapubic cystostomy performed for multiple injuries of the colon and bladder.
Injuries of the Liver
The treatment of liver injuries was the cause of some anxiety in the early period, and special needles were provided for possible suture. It was recognised that in severe lesions there was considerable bleeding and that in these cases there was a heavy mortality. Suturing, however, proved difficult and unsatisfactory, and fortunately was only very rarely necessary.
Captain A. Douglas, of 1 NZ General Hospital surgical team, stated that of 56 abdominal operations during the advance from Alamein to Tunis only one liver injury needed treatment, and in that a pack was inserted. Suturing over a muscle graft was sometimes carried out with success. Packing with gauze, protected by page 248 omentum, was resorted to in the few cases with active bleeding. The large majority of the cases had small lesions and bleeding had ceased.
A case illustrating the severity of some of the liver injuries had a thoraco-abdominal injury, and laparotomy disclosed that the peritoneum was full of blood from a damaged liver. Four mattress stitches were inserted and a foreign body removed from the dome of the liver. The patient did not pick up and died within twenty-four hours.
A large number of liver injuries were associated with penetrating wounds through the chest wall and not involving any other abdominal organ. They were treated, if necessary, in conjunction with the chest wound, by a thoracic approach. Drainage was at first instituted through the chest wound, but this was generally found to be unsatisfactory, often leading to infection of the pleura. Better results were obtained, when drainage was deemed necessary, by retro-peritoneal drainage through the loin and below the diaphragm. Operation for liver injuries alone was found to be seldom necessary as bleeding had practically always ceased before exploration and, except in the very severe fatal cases, was seldom of any consequence. Major Rob, RAMC, operated on only one of a series of 33 liver injuries.
Injuries of the Gall Bladder and Ducts
These were of more importance. Drainage was always carried out after repair of the ducts. The damaged gall bladder was either removed or drained.
Injury to the Spleen
These injuries were not associated with the severe bleeding present in the crush injuries seen in civil life. In many cases the damage to the spleen was slight and little bleeding had taken place, and in some cases suture of a small tear was carried out and the spleen left without any treatment. In the majority of the cases, however, splenectomy was performed, often through a thoracic approach, which was easier and was associated with a lower mortality. In none of our cases was bleeding from the spleen the main cause of death. One of our surgeons reported 17 injuries of the spleen, of which 13 cases were treated by splenectomy. In the other four cases there were perforations or portions split off a pole or edge. In no case was the decision to leave the spleen regretted.page 249
Injury to the Kidney
This was often recognised in the course of exploration of an abdominal or loin wound or by the presence of haematuria as disclosed by catheterisation. In rare cases very profuse bleeding took place from a damaged renal vessel, but in the majority of cases the damage was not severe. Exploration was generally carried out through the loin, though the anterior-abdominal approach was utilised at times when there were other injuries present. Nephrec-tomy was performed when there was serious damage to the kidney. One surgeon carried out nephrectomy in 7 of 13 cases actually explored for kidney injury.
In lesser injuries the kidney was repaired and drainage instituted. When, however, there was an associated injury of the adjoining colon, nephrectomy was carried out. Experience had shown that there was a very real risk of serious infection of the kidney arising from the colon, and there were several deaths from this cause. Just as in civil practice, a conservative attitude was adopted for all the less severe injuries.
Injuries to the retro-peritoneal tissues were comparatively common, and marked bleeding was frequently present. Cases of fatal haemorrhage from main vessels were reported, and marked bruising of the perirenal areas was common, sometimes associated with some damage to the colon or kidney. Infection was very prone to arise in the bruised tissues, and free drainage was found to be essential.
Use of Sulphonamides
The introduction of 10 grammes of sulphadiazine in 10 per cent gelatine suspension into the abdomen at the completion of the operation was carried out by forward surgeons in the pre-Alamein period, and at first more was injected through a tube after twenty-four hours. This was done in an attempt to prevent peritoneal infection, and the generally satisfactory progress made by the abdominal cases at that time seemed to point to some benefit from this treatment. There was no evidence of any serious deleterious effect, though, on the other hand, no positive evidence of any marked benefit. In two cases that Major T. Harrison, NZMC, re-operated on, he found sulphonamide caked between the leaves of the mesentery, apparently in its original quantity.
It continued to be used by some surgeons throughout the war. Parenteral sulphadiazine was also given, some surgeons giving a three days' course intravenously.page 250
This was given locally to the wound and into the abdomen when it became available in Italy and largely replaced the sulphonamides. When supplies allowed, it was given parenterally for several days after wounding. It was believed that penicillin greatly reduced chest complications, and it certainly led to a marked reduction in abdominal sepsis, no case dying of infection at the New Zealand base hospitals during the last eight months of the war.
This was a question on which surgeons differed greatly both in civil practice and, not unnaturally, in military practice. Drainage of the abdomen had been proved to be efficient only for a very limited period unless there was a definite collection or abscess cavity to drain. Thus in civil practice many surgeons did not drain the abdomen except when an abscess cavity was present. In war injuries there came into play special factors, particularly the presence of bruised and damaged tissues.
Ogilvie early in the war recommended drainage for twenty-four hours in doubtful cases, and up to ten days in septic cases. Our forward surgeons had no fixed routine, but were inclined to use drainage only in the presence of definite contamination and to rely on the peritoneum to deal with infection in the ordinary case. One of our surgeons drained in one half (59) of the cases recorded by him. In certain conditions, however, drainage was insisted upon. These included soiling from large bowel injuries, large liver wounds, especially if involving the bile passages, pancreatic and duodenal injuries, rectal injuries, and injuries involving the retro-peritoneal regions.
The definition of a thoraco-abdominal wound is not easy. Almost every liver wound, for instance, is a thoraco-abdominal wound, but very many of these were never explored and were not enumerated as thoraco-abdominal injuries. Many upper left abdominal wounds with injuries in the region of the tenth or eleventh ribs were not classified as thoraco-abdominal wounds though the pleural cavity may have been penetrated.
Thoraco-abdominal injuries were relatively common with the foreign body traversing the thorax then penetrating the diaphragm to injure liver, kidney, spleen, mesentery, or hollow viscus. Herni-atipn of abdominal contents into the thorax sometimes occurred.
The early approach, to the treatment of these cases was to use an abdominal approach and treat the chest wound by simple local page 251 excision, aspirating the chest if necessary. It was realised that these wounds carried a rather high mortality, and that a combined thoraco-abdominal approach was very severe, but fortunately hardly ever necessary. In large sucking wounds of the chest, however, it was found that lesions of the stomach and spleen could be dealt with by the chest approach and the diaphragm readily sutured, and that the cases did well. There was also the added consideration that forward surgeons developed a facility in operating on the chest that was not possessed by the ordinary civil surgeon who did not specialise in this field. The review of our New Zealand cases in Italy showed that the majority of patients with a thoraco-abdominal wound, for which a laparotomy had been performed, died, whereas in those dealt with solely through a chest approach the large majority survived. Though the series was small and there was a run of very severe cases, yet the opinions of others supported this preference for a chest approach.
By an intercostal incision or the excision of a rib free access was obtained and the wound of the diaphragm could be enlarged if necessary. Wounds of the spleen and stomach could be satisfactorily dealt with, and at times wounds of the intestine were sutured, though where the intestine was involved laparotomy was found to be preferable and generally essential. The diaphragm could be readily sutured through a chest approach. The chest was closed without drainage, penicillin instillation and tapping being relied on to prevent chest infection; a temporary intercostal sealed drain was utilised when infection was specially to be feared in the case of visceral injury.
For injuries of the right side, where the liver was normally involved, excision of the entry wound and the wound in the diaphragm was carried out with suture of the diaphragm to the parietal pleura, leaving a drain to the liver. However, there was trouble with sepsis, bile pleurisy, and empyema in these cases. This led to closure of the diaphragm and pleura and the substitution of drainage below the diaphragm from the loin in many cases.
The abdominal incisions utilised were either a mid-line or a subcostal incision. The abdominal approach was utilised when the chest injury was of minor degree requiring no operative treatment in itself, and also was necessary when a bowel lesion, apart from an easily dealt with lesion of the stomach, was present. The nature of the chest wound generally determined the approach. If a combined approach was necessary, the continuation of thoracic incision across the costal margin into the left upper quadrant of the abdomen and splitting the diaphragm proved satisfactory. In chest cases an excess of blood or saline transfusion was undesirable.page 252
Cases Illustrating Thoraco-abdominal Wounds
Exploration of the Chest only: Wound of the right side of chest; two large holes were present in the diaphragm associated with tears in the liver. Portion of the sixth rib was removed and a bleeding internal mammary artery tied. The haemothorax was sucked out, no foreign body was found, the diaphragm was sutured, a drain inserted to the liver, and the chest closed with a superficial drain. An intercostal nerve block was carried out. (There was in addition severe infected fractures of the foot.) An infected haemothorax developed, and this was first aspirated and then treated by intercostal tube drainage. A fortnight later four inches of the eighth rib was excised and stinking clot and a large foreign body removed from the lower lobe of the lung. Drainage was instituted and penicillin instilled regularly. The chest cleared well. The foot had to be amputated.
Exploration of the Chest and Abdomen: A sucking wound of the right side of the chest was excised, clot removed and the wound sutured. An upper muscle split abdominal incision disclosed a small hole in the diaphragm with wounds of the liver, of the gall bladder (for which a cholecystostomy was performed), and of the stomach which was sutured and covered with omentum. The foreign body was removed. A drain was inserted to Morrison's pouch. The patient developed some signs of nephritis but cleared up well.
Late Abdominal Operation: Wound of the right side of the chest associated with emphysema. X-ray disclosed a foreign body in the region of the 9th intercostal space on the right side of the chest. Aspiration was carried out several times. Later in the advanced base hospital he developed severe abdominal pain with collapse, and laparotomy disclosed a large collection of blood in the abdominal cavity with clot in the pelvis and also under the liver. Drainage was instituted and the abdominal condition subsided, though the patient still remained ill. He then coughed up profuse blood and bile-stained very offensive material. Pus and albumen appeared in the urine and oedema became marked. Finally he struggled to health after a desperate illness. It was thought that the lesion was probably a subdiaphragmatic haemorrhage of liver origin which burst first into the peritoneal cavity and then into a bronchus. X-ray films supported this interpretation.