War Surgery and Medicine
SECOND WORLD WAR
SECOND WORLD WAR
First Aid: Treatment carried out in the field and in the Advanced Dressing Stations almost always consisted in the prevention of bleeding by the application of a firm pad and bandage. Crepe bandages were of special value for this purpose and shell dressings made an efficient pad. Except in very rare cases this treatment proved quite effective. If a large bleeder was seen in the wound an artery forceps was applied to control the haemorrhage temporarily.
Use of the Tourniquet: During the war the use of the tourniquet fell into disfavour. It was found that it was rarely necessary and that its use for any length of time gravely threatened the viability of the limb. The only type of case for which it was recommended was the traumatic amputation, where its application at the lowest possible site prevented further bleeding and allowed of amputation above the level of the tourniquet. It had some value also as a temporary measure at operation till the bleeding vessel was secured.
Operative Treatment at the Forward Operating Centre: All large wounds were operated on as the essential part of wound treatment, and in the course of the surgical toilet any injury to a main vessel was dealt with by ligature above and below with division of the vessel, and, at first, also of the accompanying vein. In smaller wounds operation was performed when there was marked swelling, tenseness, or bruising, especially if in a muscular area, and in these cases vascular injury was not uncommon. When there was little swelling small penetrating or perforating wounds were generally left alone. In cases of active bleeding ligation of the vessel was obviously required. It was only in the latter period of the war that arterial repair by primary suture and temporary repair by the use of plastic tubes was carried out, and then only in a few cases.
The results of primary ligation of the main vessels in the limbs, especially those in the lower limbs, were very serious. A large proportion, in the case of the popliteal artery the very great majority, have ended in amputation. Makins' figures certainly were no guide with regard to the results of primary ligature. The Consultant Surgeon 2 NZEF stated at the surgical conference in Cairo in February 1942 that he had seen only one successful case at that time following primary ligation of the popliteal, and only one other case of the survival of the limb was vouched for among all the surgeons present. The results in the femoral cases were better, and in the arm cases better still and better than in Makins' figures.page 327
With regard to the results of popliteal ligation, in our own New Zealand force, where this condition was probably observed more closely than anywhere else because of the interest displayed in it by our forward surgeons and our consultant surgeon from the beginning of the war, very few successful cases were recorded.
Thus in April 1944 it was noted that no case of ligation of the popliteal vessels escaped subsequent amputation in spite of lumbar sympathetic injections in some cases.
In May 1044 a case in a British CCS had been seen with the leg still viable after division of the fascia of the calf.
In June 1944 the Consultant Surgeon 2 NZEF was pleased to report the survival of two legs following ligation of the popliteal vessels, both having had fasciotomy performed.
Again, Lieutenant-Colonel Mason Brown in his paper read at the Rome conference in February 1945, when the fascial split was the fashion, stated that he had seen only four cases of injury to the popliteal operated on immediately after wounding. In one, ligation was carried out and the limb survived, but was crippled by severe ischaemic changes. In another, primary suture had been carried out and thrombosis of the artery had taken place, but the limb survived.
In another, gangrene of a large area of the heel had taken place and there was ischaemia of the muscle. All these three cases had had the fascia split and had had resuture of the wound later. Finally, there was a further case which Mason Brown described as the only really satisfactory result of popliteal ligation that he had seen. He asked,' Why do so few popliteal ligations find their way to the Vascular Centre? Is it because the results are so good or is it because they have already lost their limbs?' These results from the only vascular centre in Italy, where all cases were sent with vascular lesions or after ligature of main vessels, surely bear out entirely the results reported in Cairo in 1942.
Brigadier Stammers reported at the Rome conference in 1945 that he had had reports from forward surgeons of ligation of the main lower limb arteries. There was no certainty of follow-up of these cases and it was possible that some limbs were lost after evacuation. Figures obtained in this way are generally over-optimistic. His figures were 26 amputations in 36 cases of ligation of the popliteal and 21 amputations in 31 cases of ligation of the femoral artery. He described it as a dismal picture, but if the figures were complete it is likely they would be much worse than those quoted by Stammers, not taking into account the severe ischaemic changes often present in the limbs that do survive.
Brigadier Stammers later gave 80 per cent as the amputation rate in popliteal lesions in Italy, which corresponded to 2 NZEF experience after the introduction of fascial incision in the calf.page 328
It is of interest to note that of 92,030 battle casualties in Third US Army in Europe vascular injuries totalled only 837, or 0–9 per cent. The results in the injured vessels treated by simple ligation were reported by the Army's surgical consultant to be as follows:
|Artery||Number||Viable||Gangrene||Per Cent Developing Gangrene|
|Brachial (above profunda)||69||32||37||55|
|Brachial (below profunda)||141||108||33||23|
|Radial and ulnar||8||5||3||37|
|Femoral (above profunda)||74||12||62||84|
|Femoral (below profunda)||62||27||35||56|
|Ant. and post, tibial||26||6||20||76|
(From INter-Allied Conferences on War Medicine, p. 169)
Measures used to Prevent the Onset of Gangrene -following Ligation of a Mam Vessel
Restoration of Blood Volume: Resuscitation by blood transfusion was the regular routine in cases associated with marked bleeding, and this sometimes led to recrudescence of bleeding from main vessels. Following ligation, the maximum circulation in the limb through the collaterals was obtained by ensuring full blood volume and satisfactory blood pressure by the provision of adequate quantities of blood as quickly as possible.
Ligation of the Vein: At the beginning of the war ligation of the accompanying vein was carried out following Makins' recommendation. Several cases developed marked swelling of the limb, and it was thought the ligation of the vein might be responsible for this. It was thought that the interference of the venous return had led to thrombosis. As a consequence many surgeons gave up ligating the vein and found no difference in the results, so it became a common routine not to tie the vein as there seemed no clear reason for doing so.page 329
Posture of the Limb: At first it was thought advisable to elevate the limb as would naturally take place, especially in a Thomas splint. Then it was considered that the limb should be dependent to preserve as much blood in it as possible. Finally, this was thought not to be of much moment and the limb was kept at the same level as the body.
Temperature of the Limb: The temperature of the limb, however, was held to be an important factor in treatment. The metabolism in the limb was lowered by cooling the limb so that less blood circulation would be required. At one time it was thought that the temperature should be lowered considerably, but it was held that this would do harm. The limb was therefore simply cooled by leaving it outside the bedclothes.
Sympathetic Interruption: A natural line of treatment seemed to be to attack the sympathetic system and so produce vasodilatation. This could be done by sympathectomy by dividing the lumbar nerves and removing the ganglia, or by injecting local anaesthetics around the ganglia. The operative approach was quite impracticable in these severely shocked cases. The injection, on the other hand, was possible and was carried out for some time by forward surgeons of our own force and others. Unfortunately this was found quite unsatisfactory and afforded no relief, although sympathectomy, performed as a preliminary to operative treatment on aneurysms developing later, met with definite success in the hands of Lieutenant-Colonel A. M. Boyd in Cairo.
Reflex Vasodilatation: By heating the other limb (arm for leg, and vice versa) to a temperature of 45 degrees C. whilst keeping the affected limb at 15 degrees C., dilatation of the superficial and periarticular circulation will occur in the damaged limb. This was similar to the effect produced by sympathectomy and was utilised by Sir Henry Learmonth and others. In the serious cases, however, involving the primary ligation of the main vessels in the lower limb, the results were not satisfactory.
It had been observed by forward surgeons that in cases which did badly there was generally a swelling of the leg, especially in the calf, which became tense and brawny, and the calf muscles when examined were swollen and congested. Incision of the calf in the early stages relieved the congestion and the colour improved.
The Consultant Surgeon 2 NZEF suggested that the incision of the deep fascia down the centre of the calf might be of use if carried out at the time of ligation of the vessel before the calf page 330 had become tense. Similar suggestions had been made at the same time in America. In the light of 2 NZEF experience of the almost universally bad results after ligation of the popliteal artery, the procedure seemed well worth carrying out. This was first done in Italy at Cassino, in an RAMC unit at our suggestion, with satisfactory results. Further good results were obtained in our own 2 NZEF cases, and the procedure was adopted by most forward surgeons in Italy, and also later in the North-West European fronts. Doubt was expressed by some as to its efficacy, but it was agreed by all that if any tension did exist it should be done. This was surely an admission that it should be carried out in any case as it could only be of real value if done at the time of ligature, and could not be expected to be of any use later when swelling had arisen. In any case, it could do no harm because the incision could be sutured later with ease if there was no swelling.
Surgeons with experience of these cases were only too anxious to adopt any procedure which had proved of some success, as no other satisfactory alternative was available.
Whatever may eventually be thought of the procedure, it certainly saved some limbs in the Second World War, and under similar conditions in the future where the main vessel has to be tied, in the light of present experience, it should be carried out as a routine. This applies especially to the calf, but, to a lesser degree, the front of the leg and forearm should also at times be subjected to the same procedure.
An illustrative case is recorded as an appendix to this article.
Later in the war attempts were made to carry out repair of the main vessel at the original operation. Arterial sutures on special needles were made available in case primary arterial suture should be possible.
In a few cases suture was carried out with success. In the great majority of the cases this probably will never be possible, but it is certainly the ideal form of treatment, and the use of penicillin should help. Attempts were also made to repair the vessel temporarily by means of cannulae joining the two ends of the cut vessel. Plastic tubes were used, and tubes with an internal venous lining were also used in an attempt to prevent thrombosis in the vessel. Heparin was also given for the same purpose.
Major Mustard, a young Canadian surgeon, utilised plastic tubes with some temporary success, but some disheartening results later. The procedure had not reached the stage of practical application to war injuries. The aim was to preserve circulation in the main page 331 vessel for forty-eight hours, encourage some collateral circulation, and so give the limb more chance to survive. The giving of heparin was not practicable under ordinary conditions in the forward areas. The surgical consultant of Third US Army in Europe, surveying a large series, stated that the use of heparin was a procedure coupled with considerable risk, as at least one-third of all casualties had multiple wounds and fatal haemorrhage occurred in a number of heparinised patients.
Conservative Treatment of Small Wounds
In smaller wounds surgical intervention was carried out when there was marked swelling, tenseness, or bruising, especially if in a muscular area. When there was little swelling, small penetrating or perforating wounds were generally left alone. In the desert campaigns it was found that these cases generally healed up satisfactorily with little or no sepsis. In a certain percentage of these cases hidden vascular injury was present, and this showed itself later by the development of aneurysmal swellings, either in haemato-mata or as true aneurysms, or by the development of secondary haemorrhage.
It would seem that our best chance of preserving some arterial flow through a partly damaged vessel is to treat the case expectantly in the hope that the injury to the vessel will be sealed off by clot, and circulation continue long enough to preserve the limb. If an aneurysm should develop it can be dealt with at leisure.
In cases of suspected injury to the main vessel, with small wounds not involving muscle, with little swelling, and without tension, it would seem well worth while to defer operative treatment in the hope that some circulation might continue. Naturally the case must be held in the forward operating centre and carefully watched. If any bleeding should arise externally, or tense swelling of the tissues, then operation is inevitable and, unless suture is possible, ligation must be carried out. With our present dismal outlook, however, anything that can obviate ligation with any chance of success should be done. There are not many cases of this kind and they could be easily retained in the forward unit. If surgeons skilled in vascular surgery were Available to link up with the surgical specialists at the forward 200–bedded hospital, then that would be the place for such cases.
The war taught us how dangerous it is to do primary ligation of the main limb vessels, and every effort must be made in the future to carry out any safe measure that can obviate this.
There was constant need for vigilance in the cases that had not had amputation performed, as, with the onset of gangrene, serious page 332 toxic symptoms arose and gas gangrene might ensue, quite apart from the presence of pain. Once the decision to amputate was made then no delay was permissible.
This was a very serious complication during the First World War. Following the second Libyan campaign, when conditions favoured unsatisfactory primary wound treatment and subsequent infection, secondary haemorrhage was relatively common. This led in many cases to secondary amputation, even of arms. During the surgical conference held in Cairo in February 1942 the question was discussed, especially as regards treatment.
Argument arose as to whether it was possible to ligate the bleeding vessel at the bleeding site or whether proximal ligation was preferable. The majority held strongly that ligation should always be done, or at least attempted, at the bleeding site and that proximal ligation was unsatisfactory and undesirable if it could be avoided. It was also held that amputation, especially in the arm, was a calamity which should seldom occur if close supervision was kept over the cases. There was generally a history of bleeding at the time and after the wound had been sustained. There was also generally sign of slight bleeding before the onset of gross secondary haemorrhage. There was slight oozing or else a bloodstained discharge. There might also be signs of poor circulation in the limb. If these signs were looked for, it was often possible to operate before any large bleeding had taken place. Also, with the help of blood transfusions, the patient's life should not be in danger if operative treatment was carried out promptly even when sharp haemorrhage had taken place. To have to amputate a limb, otherwise viable, for secondary haemorrhage was an admission of failure, and in the case of the arm was a disaster. There were two types of secondary haemorrhage. First, there was the bleeding from a temporarily sealed off injury to a main vessel. This occurred when the clot softened and the blood pressure rose. It generally took place on or about the tenth day and was not dependent in any way on infection. Ligation at the bleeding point was the obvious choice of treatment and this was simplified by applying a tourniquet temporarily to the limb, which allowed of a clear field, markedly shortened the time of operation, and prevented further bleeding.
The second type of bleeding was associated with erosion of the vessel wall and was generally due to infection, though sometimes a mechanical cause such as the pressure of a fracture was responsible. It was in these cases that ligation at the site was often difficult, but nevertheless this was desirable, and half measures such as packing page 333 should not be tolerated. It was in these cases also that amputation had sometimes been called for, the view having been taken that there might be danger to life from the combination of bleeding and sepsis, and that the saving of a doubtful limb might not be worth the risk. This situation was not an uncommon one, and a heavy responsibility rested on the surgeon. It was obvious that in the case of the arm a much bigger risk could be taken than in the case of the lower limb. In the first place the arm was so much more valuable and was irreplaceable, but an artificial leg could replace in some degree a normal limb.
Again, infection in the arm was much less serious and the risk of gas gangrene, particularly, was much less.
The risk of secondary haemorrhage must be realised when wounds of the main vessels were deliberately treated expectantly so as to save primary ligature, with its serious threat of gangrene. Such cases must of necessity be retained in the forward operating area for observation and not be evacuated till full stability had been reached. The majority of cases of secondary haemorrhage would, however, arise at the Base as they were due to unsuspected damage to main vessels, which would only be recognised when bleeding started about the tenth day. If this were realised by all surgeons in base hospitals, prompt and satisfactory treatment would be available.
Proximal ligation had the disadvantages of:
The cutting off of collateral circulation in the limb.
The possibility of recurrence of bleeding at the original site of the haemorrhage.
The risk of sepsis at the site of proximal ligation.
Injuries to main vessels which had not been dealt with at the time of wounding by ligature, or possibly suture, gave rise later to the formation of aneurysms of different types, depending on the degree of original damage to the artery or to the vein. The development of an aneurysm in an arterial haematoma has been discussed under secondary haemorrhage, and because of this complication these cases were generally operated on early and urgently. If haemorrhage did not occur, then an arterial aneurysm might develop and steadily increase in size. There might be an injury of both artery and vein and a junction formed between them either directly or by means of an intermediate channel formed in a haematoma. In the case of an arterial aneurysm there was a pulsatile swelling which gave on auscultation a systolic murmur, whereas in the case of an arterio-venous aneurysm the pulsatile page 334 swelling gave a murmur which was continuous. In the arterio-venous cases there was seldom any dilatation or pulsation in the veins.
The symptoms produced by these aneurysms depended on the size of the aneurysm, and on whether it was near to, or distant from, the heart. When there was a well-marked aneurysm near the heart, serious cardiac disturbances might arise. The majority of the distant aneurysms gave rise to little in the way of symptoms, but might demand treatment because of a steady increase in size. There might be special symptoms caused by local pressure such as that produced by the involvement of nerves in the aneurysmal area.
The treatment of these cases demanded sound judgment and much skill. As already stated the arterial haematomata would generally demand early treatment because of haemorrhage or, maybe, because of rapid increase in size. On the other hand the arterio-venous type could usually be dealt with conservatively, or with delayed operation.
The treatment could be summarised as follows:
Leave alone if no symptoms, not increasing in size, and not affecting the heart.
Operate if symptoms are troublesome and increasing, but allow ample time for collateral circulation to be established.
Operate if signs, or probability, of marked cardiac disturbance.
Operate if any signs of urgent symptoms developing.
If operation had been decided on, the question arose as to when this should be done. Realising the danger to the limb of ligature of the main vessels, it was generally agreed that reasonable time should be given for full collateral circulation to become established, and, if in any doubt, the operation should be postponed. A period of several months was necessary so as to be certain of proper circulation in the limb.
Lieutenant-Colonel Mason Brown advised that:
Operation should never be carried out until the collateral circulation was safely established.
Repair was easiest between the sixth week and the sixth month.
If repair was not contemplated, the operation (ligation or excision) must await the maximum development of the collateral circulation.
If operation was carried out the aim should be the preservation of the main arterial circulation, if at all possible. This meant the page 335 repair of any arterial defect by suture in preference to the ligation of the vessels. This repair could be undertaken through the false aneurysm formed by the haematoma, or through the vein in the case of the arterio-venous type. The actual arterial wall must be sutured, and not the false lining of the sac. In some arterio-venous cases ligation of the communicating link might be possible, but very rarely. In many cases quadruple ligation of both artery and veins was the only practicable course.
The following six operative procedures were utilised:
Arterial aneurysm: Suture of the true vessel wall after opening the false sac.
Arterio-venous aneurysm: Suture of the arterial defect after exposure through the vein.
Arterio-venous aneurysm: Suture of the artery and ligation of the vein.
Arterial aneurysm: Ligation above and below with excision of the sac, at the same time ligating any branches that were involved. The vein might be left alone or ligated.
Arterio-venous aneurysm: If there was a narrow communication between the vessels this could be ligated and divided.
Arterio-venous aneurysm: Ligation of the artery and the vein above and below (quadruple ligation).
As a pre-operative measure, Boyd suggested sympathectomy, as also did Mason Brown, utilising this if trial injection suggested a favourable response. Reflex dilatation by heat could be given after operation. Heparin could also be used after operation to prevent thrombosis.
The results obtained in experienced hands had been excellent, provided adequate time had been given for the development of satisfactory collateral circulation.
There were some cases of injury to the carotid and subclavian vessels which survived and developed aneurysmal swellings. Our attitude to these was conservative, especially in the carotid cases. One case dealt with by ligation developed hemiplegia and died. One subclavian case was operated on later in New Zealand with success. Another had to have amputation of the arm shortly after wounding, and survived.
Organisation: Special Centres
The first development of a special vascular centre in the MEF was in 1943 in Cairo, when Lieutenant-Colonel A. M. Boyd, RAMC, divisional surgical officer at 63 General Hospital, was recognised as a specialist in this branch and cases were segregated page 336 under his care. This proved of great benefit to the force generally, and his special knowledge was utilised by our New Zealand medical officers when any special problems arose. He operated successfully on many cases of aneurysm.
Later in Italy a special Field Vascular Centre was established under the charge of Lieutenant-Colonel L. L. Mason Brown, RAMC. To this centre all cases with wounds of the main vessels were sent from the forward areas. This ensured that they would be under the care of a surgeon with special experience of vascular injury. It also made possible an evaluation of the problems and the results obtained under war conditions in contradistinction to those obtained by research workers. The advice that Mason Brown was able to give at the Rome surgical conference in February 1945 was of the greatest value, and if the war had been more prolonged it would have led to definite changes in the handling of these cases in the forward areas.
There could be no doubt that special centres for vascular surgery were highly desirable, both for treatment and clinical research, and that they should be set up at the outset of any future war. There might be advanced and base sections of the unit, the advanced section being placed along with the trinity of neurosurgical, facio-maxillary and ophthalmic units, close behind the CCS.
The treatment of injuries to the main vessels complicating war wounds must always be governed by the conditions under which forward surgery is being carried out.
In the presence of a bleeding wound exploration is essential, and the bleeding has to be stopped at the time. It might be possible in the future, in many cases, to do primary suture of the vessel and then hold the case for about fourteen days in the forward operating centres. If this is not possible, it seems that ligation of the vessel is inevitable and, in any case, in the majority of these cases nothing else can be done.
In the case of the popliteal and the femoral vessels, this primary ligation results in the loss of the large majority of the limbs from gangrene. It is for this reason that every effort should be made to obviate ligation at this time. When no bleeding is taking place the treatment will depend on the site of the wound and the condition of the limb. If the wound is through a muscular area, and especially if the wound is large and involves much muscle, then exploration is normally required so as to prevent serious infection of the limb. If there is much swelling of the limb as page 337 the result of bleeding into the tissues, this also will demand exploration. If there is, however, only a small wound without any marked bleeding, and little in the way of swelling, a condition which is not uncommon in popliteal injuries, then there should be no exploration and the wound should be treated simply by pad and bandage, at the same time guarding against infection by parenteral penicillin.
This might enable circulation to be carried on to some degree through a partly injured vessel, and normally this will result in an arterial haematoma with the formation of a false aneurysm, prone to secondary haemorrhage but allowing of some development of a collateral circulation. It would seem that the only chance of saving many limbs following popliteal or femoral artery injury is either to treat the case conservatively, or else, if operated on, to do a primary suture of the vessel. The use of cannulae to join the vessel has so far proved unsatisfactory, but further research in this direction is desirable.
If ligation of the main vessel proves inevitable, then relief from possible tension in the distal part of the limb should be ensured by wide incision of the deep fascia. This is all the more necessary if there is any injury to the distal part of the limb. The fact that it still did not prevent the loss of the large majority of the limbs is certainly no argument against it. The desperate situation demands that anything holding out any chance of saving even one limb should be utilised.
The employment of vascular surgeons close to the forward areas might lead to better results in the future, but the bulk of the cases would still have to be dealt with by the forward surgeons in their general treatment of war wounds. There will always be very serious loss of life from vascular injury and also serious loss of limb.