War Surgery and Medicine
SECOND WORLD WAR
SECOND WORLD WAR
The lessons learnt in the First World War had not been entirely forgotten between wars. There were available in 1939 well-trained neurologists and neurosurgeons in Great Britain, with their highly efficient equipment developed for the carrying out of the elaborate technique used in brain operations in civil life.
Mobile head and chest units were developed in England at the beginning of the war with special vehicles fitted up with magnificent equipment, included in which was a diathermy set and a powerful suction apparatus. These units were sent over to France with the British Expeditionary Force in 1940 and, with all the elaborate equipment, were captured by the Germans. During hostilities they did a great deal of excellent work, but found that it was impossible to restrict their activities to head injury, and that they were called upon to operate on all types of wounded as they arrived. After Dunkirk fresh efforts were made to equip other units. At that time the Second Echelon of the 2 NZEF arrived in England. The Sims Mobile Surgical Unit was organised and equipped in England just after the Dunkirk period to deal with head and chest cases as well as other war wounds in 2 NZEF, and was equipped on the same pattern, every assistance being given by Professor Cairns and Mr. Tudor Edwards.
In Egypt, meanwhile, arrangements were made for the institution of neurological units. Major Ascroft, in charge of the first unit, carried out work in the forward areas as a special Forward Surgical Unit and gained valuable experience of war surgery. He found, however, that it was impossible to limit his work to neurological surgery as few head cases were seen, and there were many other urgent wounded cases to be dealt with. Most of the head cases were being operated on elsewhere, both in the forward areas and at the Base. Ascroft therefore advised the setting up of a special centre in Cairo where all head and spine wounds could be congregated and dealt with by the Neurological Unit. As a result the unit was attached to 15 Scottish General Hospital in Cairo, and forward units were advised to send head cases there, so that the definitive surgery could be undertaken by the unit and not in the forward areas, except in the case of emergency such as for haemorrhage, increasing compression, and when injuries of other parts demanded immediate treatment.
In cases that could not reach the unit under seventy-two hours a limited operation in the forward areas was advised, consisting of excision of all devitalised tissues and foreign matter, and minimal removal of bony fragments and non-suture of the wound, which was treated with sulphanilamide powder. The head cases did not suffer page 141 severely from shock and travelled well, especially by air. The cases which were operated on at the Base within seventy-two hours, Ascroft considered, did much better than those dealt with in the forward areas.
All our New Zealand head and spine cases were transferred to 15 Scottish Hospital both from the forward areas and from the Base, and came under the charge of the unit. This arrangement, which worked admirably without friction, made it possible to provide excellent treatment for our own troops.
The treatment given at that time was outlined by Major Ascroft at a surgical conference in Cairo in February 1942. At that time the attitude adopted was very conservative, but embodied the technique of the First World War.
In first-aid treatment the steps were:
Note degree of shock, depth of coma, the nature of the head wound, and other wounds present.
Cut away the hair around the wound, dust liberally with sulphanilamide powder, apply a first-aid dressing and secure firmly with adhesive tape, and apply pressure by bandaging to control any bleeding.
Lay the patient half prone, to prevent suffocation.
Give sulphadiazine by mouth or intravenously.
On the lines of communication attention was directed to:
The recording at regular intervals of the state of consciousness.
The need to note the presence of any fresh signs.
The necessity of blood transfusion in moderate amount.
The urgency of evacuation to the Base, if possible by air.
The necessity to take measures to combat dehydration, if necessary by saline drips.
At the Base the same advice as given to units on the L of C still held good, but more complete examinations were possible and X-rays had to be taken. Also,
Any eye condition had to be evaluated in conjunction with an eye specialist and any nasal condition, such as cerebro-spinal rhinorrhoea, with a nose and throat specialist.
Any other wound, and these were common, had not to be overlooked.
Blood Transfusion: Though shock was not severe, blood loss was common and transfusion was required, and up to 2 to 4 pints could be safely given, operation itself causing much additional blood loss.
Lumbar Puncture: Major Ascroft held that the value of this was limited before operation, but that after operation it was of the highest diagnostic, therapeutic, and prognostic value. In the page 142 early stages, if cerebral compression was suspected, a pressure of more than 250mm. usually meant that immediate operation was required.
Operation: As regards the actual technique of the operation certain points were stressed:
Bone should be conserved wherever possible, and large fragments of bone not completely separated should be levered into satisfactory position and left in situ. Bone should be removed only sufficiently to expose the dural arid brain wounds to allow of cleansing of the brain tracks.
All metallic fragments embedded in bone should be removed if accessible.
The dura should not be opened, if intact, unless there was definite danger to life from subdural clot.
All missile wounds should be drained, the drains to be left in for four to seven days.
All dural wounds should be left open, as 12 per cent developed brain abscess later.
In late cases:
Loose pieces of bone should be lifted out, all debris washed away, and the wound then stitched up and drained by a stab drain. Sulphanilamide powder was dusted and sprayed on the open wound after cleansing.
For septic wounds sulphanilamide and glycerine was often used.
Generally the treatment of late cases consisted in the treatment of infection by:
The danger of spreading infection by removing large pieces of bone and opening the dura was stressed and delay advised in operating on cerebral abscess.
In suitable cases the removal of the abscess as a whole was recommended.
As regards post-operative treatment, particular points were:
An efficient and adequate staff, consisting of at least six trained nurses, twelve medical orderlies, and eight fit patients for a ward of 50 beds. These were all needed to give the constant attention necessary to prevent bedsores and to deal with such conditions as incontinence.page 143
The necessity of plenty of fluids owing to the frequency of dehydration. Fluids had to be forced and given intravenously if necessary. Feeding was often necessary by means of the nasal tube.
Sedatives: Intravenous paraldehyde in doses of 3 ccms. was advised, the injection being given very slowly. Sleep could then be maintained by adding to the intravenous drip small doses of paraldehyde.
Patients were to be got up and interested as soon as possible, and occupational therapy utilised to the full.
There was no doubt that the work done by Major Ascroft and at other units in the Middle East laid the groundwork on which was built the excellent neurosurgical work performed in the British Army during the war. The results achieved by Ascroft's unit at that time were much better than those obtained in the First World War. There were 15 per cent of deaths in 292 penetrating wounds, and only two deaths in 224 non-penetrating cases. There was an overall death rate of 10.8 per cent from infection, as against 36.5 per cent in Cushing's cases.
2 NZEF Experience, Libya, November – December 1941
As far as the 2 NZEF was concerned, there was little in the way of head surgery till the second Libyan campaign. In this campaign the New Zealand Mobile Surgical Unit, staffed with competent surgeons and very liberally equipped, was available and was sited alongside the open Field Ambulance. From the gift of Sir Arthur Sims there had been developed a completely mobile and self-contained surgical unit and a special establishment had been authorised by Middle East command. In particular, a special van had been built to carry the equipment, lighting outfit, steriliser, suction apparatus, and special water tanks. It had equipment and staff to hold and nurse patients. Originally it was intended to restrict the work of this unit to special types of cases including head wounds, but, as had been found in France and also by Ascroft earlier in the MEF, when a rush of serious casualties took place it was impossible to restrict such a unit to special cases. The unit was, however, enabled to operate on all the serious head cases, and this was of special value as evacuation of the cases was rendered impossible by the capture of the unit by the enemy. Our head cases from the Libyan campaign were admitted to Ascroft's unit in Cairo when they reached Egypt and transferred to 1 NZ General Hospital at Helwan for disposal.
Battle of Alamein
The technique by this time had become standardised as recommended by Ascroft. Head cases were not treated as cases of first emergency, and the great majority were evacuated, mostly by air, to the head centre in Cairo, without any operation having been performed in the forward areas. The cases travelled well. From the point of view of the prevention of infection, the Consultant Surgeon 2 NZEF considered that operation on the larger lacerated wounds would be better carried out at the CCS and that X-rays and suction should be provided there.
Advance to Tunis
After the period at Alamein New Zealand surgeons did not carry out the surgical treatment of head wounds except in cases of emergency or in association with wounds of other parts. However, attached to 1 NZ Mobile CCS during a great part of the desert campaign from Alamein to Tunis was a Mobile Neurological Unit under Major Eden, RAMC. This unit was formed to carry out neurosurgery in the forward areas based on a forward CCS, and it was our privilege and pleasure to have the unit associated with our CCS, which was often the foremost CCS in the advance. Our CCS mothered the unit, sorted out and resuscitated the patients, and nursed them following operation. Our own casualties were thus ensured early and skilled treatment as regards head and spine wounds and our CCS personnel learnt how to deal adequately with these difficult cases. First-class work was done by Major Eden and his team, and we felt his death in Italy very acutely.
The equipment of Eden's unit consisted of a captured Italian bus, solid, well-made and roomy, which had been converted into an operating theatre. There were sinks and cupboards, and, although somewhat cramped, it proved quite satisfactory for the special type of work. It was clean and sand-proof, and, of course, could shift off at a moment's notice. Extra space was provided by erecting a small tent alongside to hold patients awaiting operation, to shelter cases waiting return to the wards, to hold extra supplies, and to shelter the staff in between operations. Eden had a good anaesthetist, a capable sister, and orderlies.
After Tripoli had been passed the unit was split up into two sections, the forward section remaining with the NZ CCS whilst the rear section was attached to a British base hospital in Tripoli. This arrangement functioned perfectly. The cases dealt with by Major Eden were staged at Tripoli and afterwards sent by air to Cairo. If Eden was swamped with cases he sent some on to Tripoli to be operated on, and air evacuation was available from there, if necessary, to take the cases to Cairo in another twelve hours.page 145
Major Eden had all the special equipment required to deal with any case, including diathermy, good suction, and blood transfusion. His results showed a very definite improvement on the results obtained in Cairo, where there was a greater time-lag. Infection especially was largely prevented, and his figures compared more than favourably with Base figures as they necessarily included the serious cases which would not ordinarily have survived to reach a base area. (If the Base were back far enough the death rate could be reduced to zero, as no patients but those destined to survive in any case would reach there.)
In 102 brain wounds only 13 became infected, 5 developed meningitis and 1 an abscess. (In Major Ascroft's cases 25 per cent developed abscess.) Primary healing occurred in 85 per cent of all cases, and in 71 per cent of the penetrating wounds of the brain. There was no mortality in scalp wounds; 1.45 per cent in fracture cases, and 23.6 per cent in brain wounds.
Major Eden pointed out the importance of the association of other injuries, especially associated injuries of the eye. In 325 cases 90 had other wounds, and 19 of these had eye wounds. Our observations at that time were that' the early segregation of these cases under a neurosurgical unit in the forward operating centres has led to most excellent results during the last Tunisian campaign.'
Eden's results proved conclusively that, provided skilled staff, efficient equipment, and adequate nursing and other attention were available, operation in the forward areas produced better results than similar treatment at the Base, and this established the set-up for the rest of the war in the British Army.
Eden's cases were selected by his team from those cases set aside by the CCS surgeon in the pre-operation tent. As complete a neurological examination as possible was carried out. Eden considered that lumbar puncture had very little value in the early stages of treatment. All cases in deep coma, especially if breathing was stertorous, were set aside and their condition watched in the pre-operation tent. Very seldom did any of these revive sufficiently to warrant operation.
Eden's table shows the mortality related to state of consciousness:
All other cases were put on the operation list and dealt with in order of priority, the penetrating cases being dealt with first. In the meantime resuscitation was being carried out by means of page 146 fluid and blood transfusion. Shaving of the head was performed by competent orderlies whenever possible, but generally this had to be left till the patient was anaesthetised on the table. X-ray films were taken from two angles and developed ready for inspection before operation. Local anaesthesia was generally administered after omnopon and scopolamine had been given, but pentothal and some general anaesthetic was given on occasion. The wound was excised with great care down to the bone. Loose bone fragments were removed and the bone edges nibbled sufficiently to expose the dura and brain wound. The brain track was cleansed of debris, including in-driven bone fragments and accessible metallic fragments, by a combination of syringing and suction. Sulpha-diazine powder was dusted on the wound, which was sutured in two layers with thread. The skin was undercut and fresh incisions made if necessary to bring the wound together without tension. A rubber stab drain was inserted for twenty-four to forty-eight hours. A plaster cap was applied to hold the dressings in place. Sulpha-diazine was then given in doses of 3 grammes four-hourly for forty-eight hours and then three times a day. When intravenous administration was required a dose of 5 grammes was given twice daily. Paraldehyde and luminal were given as sedatives, and in comatose patients the stomach tube was utilised for feeding purposes. Normal evacuation to rear units was carried out in two or three days.
Base Hospital, Cairo
Meanwhile the rear portion of Major Eden's unit was working in Tripoli dealing with all the cases that he had operated on and evacuated, as well as cases which had in rush periods been sent back for definitive operation at Tripoli. The same technique was adopted. The cases were held till deemed fit to evacuate by air to Cairo, where they were admitted to the base unit at 15 Scottish Hospital.
For seven months from the end of February to September 1943 there were attached to this hospital two of our New Zealand medical officers, Major McKenzie, a surgeon experienced in neuro-surgery, and Major Caughey, experienced in neurology. This arrangement enabled the neurological unit to be considerably strengthened and at the same time enabled our officers to gain very valuable experience of this special work.
The NZMC seldom contributed medical personnel to British units during the war, so that it is pleasing to record that the work of these two officers was very much appreciated by the RAMC. Major McKenzie, who for many months was in charge of the unit, page 147 did a considerable amount of brain surgery, including several successful cases of repair of the dura in cases of rhinorrhoea. His return to New Zealand before the Italian campaign determined our policy of referring all our neurological cases to the special RAMC units.
McKenzie noted the remarkable power of recovery in cases not dying rapidly from severe trauma. He pointed out the difficulty in diagnosis and the danger of overlooking brain injury. For this reason he advised, as did others, against giving morphia but counselled the careful recording of simple neurological observations. At the Base he carried out neurological and X-ray examinations. Spinal puncture was recommended only for later cases at the Base. Blood examination was done as soon as the case arrived at the Base, so as to have a check on the necessity of blood transfusion. Encephalograms and ventriculograms were done without hesitation to localise an abscess or the track of a missile.
In Major McKenzie's operative technique intravenous drip pentoihal was the anaesthetic used and the head was shaved under anaesthesia. A diathermy unit and sucker were regarded as essential. Excision of the wound was carried out. Wounds were closed in three layers by using a triradiate extension or a reversed S-incision. All infected wounds were left open. Minimal removal of bone was carried out and no bone flap was ever used. The dura was not sutured. As regards the brain, suction was used to clear the track and then a narrow band retractor was inserted and the bone chips picked out. The track was gently irrigated and then powdered with sulphathiazole. Bone chips were searched for, even, at the end, in the ventricle, because of the frequency of associated infection. Drainage was provided through a separate stab wound only for a special reason, such as an open ventricle, infection arid fear of haemorrhage. Special points noted were the closing of the subarachnoid space by suture, graft, or vaseline plug, removing only the adjacent mucosa of the frontal sinus. He also removed half an inch of the optic nerve in cases of eye enucleation to avoid sympathetic ophthalmia. Bleeding was feared in wounds near the sagittal or lateral sinuses or the Sylvian fissure.
Chemotherapy was utilised. First, sulphadiazine was given, 6 grammes daily, for prophylaxis, and 12 grammes for the treatment of meningitis, which cleared up unless pus was loculated or undrained. Oral administration was preferred, as intravenously it was efficient only in concentrated solution, and this rapidly led to clotting in the veins. No urinary complications were noted. In McKenzie's opinion penicillin gave no better results. A warning was sounded against sulphonamides being given intrathecally.page 148
Post-operative nursing was heavy, the patient needing constant attention, change of position and often nasal feeding. Intravenous paraldehyde proved the best sedative, and sodium luminal was very useful. Early rehabilitation was essential. All patients had a final spinal puncture and encephalographic examination to exclude latent infection.
As regards results, Major McKenzie noted that regimental medical officers had stated that only one out of three patients with head injury reached a Field Ambulance alive, and on one occasion only one in seven. Out of 116 penetrating and 10 perforating injuries, 126 in all, 14 developed meningitis, 5 abscesses, and there were 6 deaths. Of 55 patients operated on in forward areas by general surgeons, 29 required further operation. Of 113 patients operated on by the forward neurosurgical team only 15 required further operation. Only 28 cases were finally category A.
(Note: It is probable that many of the 55 patients had a deliberately planned partial operation as recommended by the neurosurgical unit, so the figures are not fully comparable.)
The scene now shifts to Italy, and the part our New Zealand Medical Corps played in the treatment of wounds of the head and spine becomes less important.
Our neurosurgeon returned to New Zealand and the neurologist became re-attached to our own Corps as a divisional medical officer of a base hospital. We relied on the Medical Corps of other forces for the treatment of our head and spine cases. Urgent cases were dealt with at our CCS, but otherwise all cases were referred to the highly efficient British neurosurgical units, the organisation of which followed on the lines developed in the desert campaigns.
From the Sangro, cases were transferred from our CCS at Vasto to the mobile neurosurgical unit attached to 5 British CCS at Vasto and from there to the 98 British General Hospital at Bari, which was sited alongside our 3 NZ General Hospital. When convalescent the cases were transferred to 3 NZ General Hospital for disposal.
During the Cassino battles our CCS at Presenzano arranged for all our head and spine cases to be admitted to an American evacuation hospital nearby, under the charge of a highly competent neurosurgeon, Major Weinberger. This arrangement worked very satisfactorily. The cases were most competently handled, and the association between our own and the American medical officers was of the happiest, and we were sorry when we were separated. page 149 From the American hospital all the cases were referred to the British neurosurgical centre under Lieutenant-Colonel Ascroft's command at Naples, and then were finally admitted to 2 NZ General Hospital at Caserta for disposal.
During the battle for Florence our cases went from our CCS at Siena to an advanced neurosurgical unit under Major Shoreston, RAMC, situated alongside Lake Trasimene. From Trasimene the cases were flown to Naples to Ascroft's unit, and so to 2 NZ General Hospital at Caserta.
During the battles for the Po valley a small hospital was established at Riccione to house all the special units, and all our cases were referred there. They then went to a base hospital on the lines of communication, where the rear part of the forward neurosurgical unit was sited, and then back to Naples again.
The development of the neurosurgical unit is shown by the efficiency of the treatment and the smoothness of administration during the Po battles.
Major Gillingham, RAMC, in charge of the forward section of the neurosurgical unit at Riccione, has put on record the conditions at that time, the technique used, and the results obtained. Contrary to expectation, no more infection was encountered in Italy, and a much bolder attitude to déAbridement was adopted. By the end of 1944 the unit was enlarged considerably, three operating teams being available, and general surgeons were attached to deal with other than head wounds. The attachment of a Field Transfusion Unit was essential. Air evacuation was so efficient that cases could readily be evacuated either to the base section of the unit or to the base unit at Naples.
Some 20 per cent of the cases had other injuries, and it was the custom for the neurosurgeon and the general surgeon to operate under the same anaesthetic, the case being transferred to the general surgeon in another theatre when the neurosurgeon had completed his operation, or vice versa as the condition demanded. The anaesthesia employed was at first local, following omnopon (gr. ⅓) and scopolamine (gr. 1/150), but later general anaesthesia was preferred, with induction by pentothal (gr. ½) followed by endotracheal gas and oxygen and ether.
Operative Technique at End of War
The surgical technique at that time consisted of the usual déAbridement of the wound, but the brain track was radically cleaned, removing all of the devitalised brain tissue. Illuminated retractors were used to ensure the cleaning of the deeper part of the track and page 150 to assist in the removal of in-driven bone fragments and foreign bodies, more attention being paid to the latter than previously. Ventricular wounds were also cleaned out gently but thoroughly.
Wounds involving the nasal sinuses and the ear were freely exposed, and if it was not possible to carry out the complete operation by approach through the wound at first only déAbridement was done, and after a few days an osteoplastic flap was turned down and the dural defect repaired, generally by fascia.
Posterior fossa cases were given adequate bony decompression. The skin was completely closed in two layers utilising the methods of plastic repair, especially the swinging flap. The dura was repaired as a rule, but the opinion was expressed that with the primary healing being obtained this was unnecessary. When the dura was intact, skull defects were often repaired by utilising the outer table along with the pericranium adjacent to the defect.
In Major Gillingham's series in northern Italy there was a mortality of 22 per cent pre-operative and 11 per cent post-operative. There was only 1 death from infection in 81 cases. Occasional headache and giddiness occurred in 19, severe headache in 9 and fits in 8 cases. Most of the cases were graded down.
Major Gillingham's conclusions were that primary healing depended on the age of the wound, complete déAbridement, especially of the brain track, closure of the scalp wound without tension, and local and general penicillin. He considered operation should be carried out within twenty-four hours and that to ensure this no staging in the forward areas should be allowed.
Changes in Treatment: Penicillin
The main change in treatment during the latter part of the war was the use of penicillin for the control of infection. Though sulphadiazine had been of great value in head cases in particular, the new agent proved still more potent against the ordinary organisms. At first it was employed locally in a sulphanilamide base, but as more penicillin became available full parenteral dosage was administered. There followed a reduction of infection of all kinds in brain wounds from 45 per cent under sulphadiazine to 11.6 per cent under penicillin. There was a corresponding improvement in the progress of the individual case and in the healing of the wound. The necessity for drainage disappeared and a large proportion of the wounds were completely closed without drainage. Penicillin given intrathecally cured meningitis if the organism was susceptible to it. It was also of great value when given systemically in the treatment of grossly infected wounds, cellulitis, osteomyelitis, and brain fungus. Locally it was of use in the treatment of brain abscess.
The danger of the early administration of morphia became more apparent as the war progressed, and the neurosurgical units advised that minimal dosage only should be given with the sole object of the relief of pain. Forward units were advised to withhold morphia altogether in brain cases. This was done so that the signs and symptoms should not be masked and that accurate observations should be possible at intervals during the evacuation of the patient. The degree of unconsciousness and the presence of focal signs could not be ascertained if morphia in ordinary dosage had been given.
This became more and more efficient and was meticulously carried out as the units became experienced and personnel was increased. Ventriculography on the other hand was gradually discarded and only finally made use of in special circumstances.
Developments in Treatment in Final Stages of the War
The major development consisted in the much more thorough cleansing of the brain track, as Cairns notes, a certain boldness and ruthless thoroughness being required. This was rendered easier by the employment of illuminated retractors or lead lights. The track was cleansed down to firm bleeding brain tissue, an exact counterpart to the treatment for an ordinary flesh wound. Even the ventricles were dealt with in the same manner, blood clots being gently removed and the ventricles left clean.
The wound of the scalp was completely and accurately closed without drainage except in old-standing infected wounds. Sliding flaps were adopted as advised by Gillies and other plastic surgeons.
Wounds of the dura were also closed, grafts being pedicled from neighbouring tissues. Basal dural wounds were closed either at the original operation or later when exposure was obtained by turning down a bone flap.
Metallic foreign bodies were found to cause infection and bleeding, and as a result their removal was more frequently undertaken.
Fibrin foam was utilised with great success to deal with bleeding from the brain and also from the sinuses.
At the latter part of the war three different methods were utilised for the repair of bony defects of the skull.page 152
Bone Grafts: In Italy use was made of chip grafts taken from the cancellous bone of the ilium. These were introduced into the bony defect and moulded into place after the edges had been freshened. Often bone was utilised from one patient to fill defects of two patients. Bone was also obtained from the outer table of adjoining skull, which was then slid over the defect. Ribs were split and both halves used for the skull repair.
Tantalum Plates: The Americans utilised these on a large scale and reported satisfactory results, though sometimes infection occurred and the plates had to be removed.
Acrylic Plates: These were used by Major Shoreston at Trasimene on suitable cases when infection was thought to be improbable. The acrylic graft was 1–1½ mm. thick. It was boiled for ten minutes, wrapped in gauze, and then pressed on to the bone while hot and cooled by saline. It was made to overlap the edges of the defect and was sutured, through holes in the graft, to the pericranium, being tucked between it and the bone. The dura was stitched to the plate to stop bleeding.
The cases selected were those with holes of moderate size and no skin loss, with the brain intact and no, or only transitory, neurological disability. The immediate results were good, but Murray Falconer reported that the only two cases he encountered which were repaired with acrylic plates had to have the plates removed subsequently because of infection.
It would appear that autogenous bone which can become incorporated in the normal tissue is the logical method of closing bony defects, and that a foreign body of whatever kind can never be so suitable and will always be prone to produce tissue reaction and infection. Falconer reported that the bone chips introduced largely became absorbed and that compact bone seemed to be essential to a good repair in the skull. He utilised split rib grafts with success. (Professor Cairns at first thought the defects gave very little disability and only closed large defects below the hair line for psychological reasons. He operated early for that reason. Later he modified his views and repaired any defect sufficiently large to warrant the procedure.)
After-effects of Gunshot Wounds of the Head
The final evaluation of the patient from the point of view of any residue complication, and as to prognosis, was of great importance. For this a thorough neurological examination was required.
Pneumo-encephalography, as has been pointed out, was at first used in every case, but finally was seldom employed. Electro-encephalography was developed in Britain and the USA to take the place of the more dangerous and disturbing investigation.page 153
The development of mental changes fortunately proved to be uncommon. Post-traumatic syndrome, a manifestation of psycho-neurosis, however, was very prone to occur, and the prevention of neurosis became the most important problem in the rehabilitation of the patient. This was stressed by Ascroft in Cairo in his first report and by many neurosurgeons since that time. Ascroft got his patients out of bed as soon as possible and kept them moving and regularly occupied all the time till they were discharged. By this means he was able to return a large proportion to duty. He stressed the necessity for occupational therapy even for those confined to bed, and endeavoured to get the patients to assist in the ordinary work of the wards. There can be no doubt but that this was the only possible method of preventing the onset of serious psychological sequelae in these patients.
Falconer, in discussing the surgical problem in the later stages of penetrating head injuries, pointed out that many of the serious cases improved considerably and were left with little or no permanent neurological disability, and others, with special training, were able to lead useful lives. Indications for later stage operation were the need for removal of retained foreign bodies, repair of skull defects, treatment of cerebral abscess, and the excision of brain scars. Few retained foreign bodies were likely to cause epilepsy unless they were actually lodged in the cortex, or abscess unless they were already infected. Deep-seated metallic bodies were best left alone, unless they were implicated in a brain abscess, as the operative trauma tended to aggravate rather than improve the condition. When symptoms of epilepsy or abscess were present, however, and the foreign body was infected, then removal should be undertaken.
Operative repair was advised when there was a dural deficiency allowing bulging of the brain, as this was a potent epileptogenic stimulus. Split rib grafts were fixed with silk or fine wire on to a chiselled step at the rim of the defect. The necessity for careful observation of all cases following treatment of brain abscess was stressed because of the liability to recurrence at any time. Falconer advised the complete excision of the abscess whenever practicable, guarding against danger to important areas of the brain.
Epilepsy occurring in the first two years frequently cleared up, but when it arose later it generally persisted. An adequate trial of sedative treatment was essential before operation was considered. Wide excision of the scar was necessary. The results were variable, but in Penfield's series of civilian cases 25 per cent were cured and another 50 per cent improved.
Summary of Experience in Second World War
The war led to the development of efficient, well-equipped neurosurgical units operating both in the forward areas and at the Base. The general principles of wound treatment were adopted for head wounds, surgical treatment gradually became more radical, and foreign bodies were removed more frequently. Wound closure without drainage became the routine except in the presence of sepsis. At first the sulphonamides, and later penicillin, proved most valuable in the prevention and relief of sepsis.
In 1944–45 on the North-West European front the incidence of brain abscess was 3 per cent, whereas in 1941–42 in Ascroft's series it was 27 per cent, and infection in general was only 5 per cent, as against 31 per cent in Cushing's cases in the First World War. By 1945 primary healing took place in 86 per cent of the cases. There can be no doubt, however, that the improvement in surgical technique was the cardinal factor in the decrease of infection.
Recommendations for the Future
Head and spine surgery should be carried out by special neurosurgical units with personnel trained in neurology, neuro-surgery, and anaesthesia. (Two surgical teams.) These units should be equipped with the essential equipment, including suction and diathermy and lighting plant. The primary surgical treatment should be undertaken by mobile neurosurgical units sited at the CCS level, at the convergence of the forward evacuation lines, in a small forward hospital to which are also attached ophthalmic, facio-maxillary, dental and general surgical teams, as well as field transfusion and X-ray units. This primary treatment should be complete, and definitive, surgery, associated with full measures of resuscitation, skilled nursing, and bed accommodation.
There should be set up base neurosurgical units to which the patients can be evacuated, preferably by air, from the forward units. These units should be sited in hospitals associated with ophthalmic, facio-maxillary, dental, and general surgical teams. There is a grave danger of neglect of associated wounds in special units.
Rehabilitation is of the utmost importance, and patients should be got up early, have occupational therapy, be encouraged to do light hospital duties, have every incentive to be fully occupied as soon as possible, and be surrounded by optimistic personnel.
It is possible that there may be a shortage of trained neurosurgeons in a future war if casualties are heavy, and provision should be made for the training of a number of general surgeons in traumatic page 155 neurosurgery. This naturally will be of special importance as far as New Zealand is concerned, as there are only two civil neurosurgical centres at present and no reserve personnel who would be available for service overseas in any emergency.