War Surgery and Medicine
SUMMARY OF DEVELOPMENTS IN SECOND WORLD WAR
SUMMARY OF DEVELOPMENTS IN SECOND WORLD WAR
From the beginning of the war simple techniques of suture were used for injuries of the small intestine, and end-to-end anastomosis was carried out for irreparable damage. Suturing of serious liver wounds was attempted at times, but was not often found to be satisfactory, and packing was generally resorted to when bleeding was still continuing. Bladder wounds were sutured and suprapubic drainage instituted, while kidney wounds were treated conservatively.
Early in the war Brigadier Ogilvie, RAMC, made a strong plea for the exteriorisation of the colon in all large bowel injuries, and his advice was followed. A proximal colostomy, combined when necessary with free perineal drainage, was used for wounds of the rectum. Though opinions varied at first as to the necessity for drainage of the abdomen, almost unanimous agreement was reached that drainage should be used in colonic wounds, in retro-peritoneal wounds, and for any peritoneal collection.
The ample provision of blood and plasma in the forward areas and of trained and energetic transfusion officers resulted in resuscitation being developed to a high degree. Post-operative treatment was developed early, and by gastric suction, intravenous saline, and glucose administration ileus was practically eliminated and fluid balance ensured. Major Giblin, AAMC, operating in the forward areas in the pre-Alamein and Alamein periods, at first did not employ gastric suction and found ileus common. Then he used Ryle's tube, and later much larger tubing combined with a Solivac apparatus, and got no ileus.
Some changes in treatment took place as experience was enlarged. In mid-1942 sulphadiazine was introduced into the peritoneum at the end of the operation with, it was believed, beneficial results. Evacuation of abdominal cases from the forward areas after operation was always a difficulty, and experience showed that these cases should be held where they were operated on until all possible danger was over, thus placing full responsibility on the forward surgeon. In Italy at the latter stage of the war the treatment of wounds of the colon began to be reviewed, and many surgeons treated the right colon and first part of the transverse colon in a similar way to the small intestine, though usually instituting drainage, especially in the retro-peritoneal areas. Suturing of small wounds in the caecum and ascending colon became common, and early secondary closure of caecal wounds was practised.
In massive injuries an ileo-transverse colon anastomosis was utilised with excision of the damaged colon. Even in injuries to the splenic flexure in an occasional suitable case, suture was performed with or without a proximal colostomy.page 226
In the left colon, however, and in nearly all severe colon injuries elsewhere, exteriorisation remained the routine procedure. There arose a disinclination to carry out the radical freeing of the fixed colon which at one time was done almost by routine. It was learned that the large majority of liver wounds needed no operative treatment and that bleeding soon stopped—massive wounds generally meant an early death. There was another marked change in that, following operation, Fowler's position was abandoned in favour of the ordinary horizontal position, with great benefit in cases of shock and increased comfort and ease of nursing.
The early and regular administration of parenteral penicillin was held to have made an appreciable difference in the incidence of peritoneal infection.
Gastric suction continued to be used, but water was given by the mouth immediately after the operation, and, if circumstances permitted, nourishing fluid was given after forty-eight hours.
The administration of the different types of intravenous fluids was regulated according to the loss of chlorides by gastric suction, and plasma was given regularly to make up protein loss. Blood was also found to be necessary in the majority of cases at about the seventh day, when a critical phase often developed. The lower bowel often required attention by means of enemata and even at times by the manual removal of constipated faeces.
Thoraco-abdominal cases, which had an evil reputation before the war, still carried a high mortality, but as time went on surgeons learnt that approach through the chest was satisfactory in the majority of cases and that it carried a much lower mortality.
There were many changes, and there came a realisation that the optimum time for operation was not at the earliest moment that the patient could be put on the operation table, but immediately after optimum recovery from the primary shock had taken place. Some delay was beneficial, but long delay was still fatal.
Operation shock was realised to be a very serious condition which demanded measures of resuscitation, in a similar manner to the pre-operative routine.
Although loss of blood was generally very much less than that suffered in limb wounds, yet in the majority of cases a moderate loss was present, and in some cases, such as injury to mesenteric vessels, dangerous continuing bleeding occurred. Diagnosis of this condition was of the utmost importance, as was the diagnosis excluding intestinal injury. The presence of audible peristalsis generally determined the absence of injury to the intestine and therefore saved laparotomy, which had been proved to have in itself a serious mortality. The X-ray was also used to determine whether there was abdominal injury.page 227
An experienced surgeon proved of great value in the early diagnosis of these cases and in the settling of operation priorities. Accurate diagnosis before operation was considered an unfair responsibility to be placed on the transfusion officer.
It was agreed finally that the best place to do abdominal surgery was at the CCS level, where stability was possible, where conditions were satisfactory and relatively comfortable, where nursing sisters were available, and, particularly, where cases could be held till all danger was over.
The analysis of the results obtained in Italy in the 2 NZEF showed that half the men wounded in the abdomen, apart from those buried on the battlefield, died. It also showed that of those who were operated on (which meant practically all those, actually over 96 per cent, reaching the CCS), 64 per cent lived. Other forces had similar results, as was shown in the figures produced at the end of the war.
It is a much brighter picture than that of the First World War, and of course incomparably better than the results of the South African War. Some further improvement may be possible, but not very much, as it has been clearly shown that the majority of the cases die in the first twenty-four hours from the severity of the trauma. Operation will save few of these. The standard of resuscitation was at a high level throughout the war, so there seems little chance of any radical improvement in that regard. Our best chance seems to be prevention, and the utilisation of body armour must be seriously considered in any future war.
From this general summary of abdominal surgery during the war we turn to special problems which will be dealt with in more detail.