Surgery at the CCS

During the Cassino period 86 abdominal cases were operated on and there were 26 deaths—only 30 per cent of the total. Eighteen out of 26 died in the first forty-eight hours of shock. Some died later of anuria, which was in most cases a late complication of primary severe shock. None died of peritonitis. The patients who died had all been operated on within 5 ½ to 12 ½ hours of wounding.

Lieutenant-Colonel Button, commenting at the time, stated that the majority of the patients died because of hopeless multiple wounds, and that these cases showed little or no response to resuscitation and four cases out of fifty died on the operating table. None of the long-term cases (20 hours, 24 hours, 49 hours, etc.,) died in spite of advanced peritonitis. The impression was being confirmed that, although it was sound practice to operate as early as possible after wounding, the time factor of six to eight hours often used as a standard was not of primary importance. It was felt that adequate resuscitation was paramount, and that facilities for the giving of blood on the route of evacuation to the CCS were highly beneficial.

On admission to the CCS further resuscitation—-blood, warmth, and rest in a suitable environment—-was most essential. If a case failed to respond to resuscitation it usually meant either: (i) internal haemorrhage, or (ii) irreversible shock, the result of gross irrecoverable injury. Operation was undertaken when the blood pressure was 100/80 and rising and the pulse and colour correspondingly improved. This usually took three to four hours. The operation was page 546 done earlier only if there was no response to resuscitation and the clinical features pointed to internal haemorrhage.

At operation the principles followed were:

(i)	arrest of haemorrhage;
(ii)	suture of wounds of the small bowel;
(iii)	exteriorisation of wounds of the large bowel. (Resections had been few.)

Post-operative Treatment: Adequate nursing supervision was essential for the patient and for the peace of mind of the surgeon. Tribute was paid to the great value of nursing sisters. Gastric suction was installed immediately the patient returned to the ward and, together with intravenous fluids, was carried on for about four days. Experience showed that, before operation, adequate resuscitation and, after operation, proper nursing to prevent the onset of ileus were the two biggest factors that made for success in the handling of these cases. The time factor and the presence of peritonitis seemed to be of less importance. They were largely controlled by nursing and chemotherapy. A CCS was usually the first unit on the line of evacuation which was adequately equipped to give these facilities. Thus it seemed that, given adequate resuscitation en route, abdominal cases were better handled in a CCS twelve to twenty-four hours after wounding than earlier at a forward operating centre with an MDS.

Lieutenant-Colonel Button's evaluation gives a very clear idea of the problems of forward surgery and the experience gained at that time, and it gave a valuable lead for the future in the treatment of abdominal cases. The chest cases were also dealt with at the CCS and, in general, did well. They constituted 7 per cent of the battle casualties. Aspiration was carried out usually twenty-four to forty-eight hours after admission. Four out of thirty cases had become infected. Penicillin was not available in sufficient quantity to allow of its use except in a few cases, though its value was recognised at that time.

The treatment of flesh wounds was adequately carried out, as shown by the general cleanliness of the wounds noted on admission to 2 General Hospital at Caserta. Gas gangrene was infrequent, and in the three-monthly period April to June only two cases were seen at the CCS, with one death. One case survived after treatment with serum and penicillin. Fascial split of the calf was introduced as a primary measure in the treatment of cases following ligature of the popliteal artery, with some success in the saving of amputation of the limb.

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The neurosurgical cases were transferred to 16 American Evacuation Hospital sited near our CCS and treated with excellent results by Major Weinberger, a neurosurgeon attached to that unit. From there they were sent to 65 British Hospital at Naples to be under Major Ascroft's charge till fit to send to 2 General Hospital at Caserta and so rejoin our medical chain. The neurosurgeon at the American hospital commented on the number of cases with penetrating wounds of the skull from comparatively small pieces of metal, and suggested that the proportion was greater than amongst American troops who made a universal practice of wearing steel helmets. The greater proportion of head cases appeared to have been wounded when not wearing a steel helmet, and it was thought that the use of the helmet might have saved a proportion of these cases much disability.

Serious facio-maxillary cases were also sent from our CCS to 65 British General Hospital. The Medical Research Council's shock research unit was sited near our CCS, and two British laboratories were attached to the CCS. These units undoubtedly produced a healthy stimulus to scientific endeavour.