War Surgery and Medicine
SECOND WORLD WAR
SECOND WORLD WAR
The units responsible for the surgical treatment of the battle casualties in the forward areas at the beginning of the war were the Field Ambulance and the CCS. First-aid treatment was given by the stretcher-bearers and the RMO in the RAP, and this was continued in the ADS. Evacuation then took place to the MDS, which acted as a staging post, and then to the CCS, where the main surgical treatment was to be carried out.
In the Greek campaign this plan was carried out and the major forward surgical treatment was performed at the CCS level, though some operations were done in the Field Ambulances.
In Crete some surgery was carried out at the Field Ambulances, but most was done at 7 British General Hospital and at other improvised hospitals to which cases from the Field Ambulances were evacuated.
In the early desert campaigns, however, the remarkable mobility of the battle actions, with the alternating success of the opposing armies, impeded the functioning of forward medical units and made the performance of forward surgery difficult.
It was impossible to get the wounded back to the CCS within the optimum period for operation, and the immobilised CCS lost contact with the advanced formations. The CCS as a stable stationary unit was found quite unsuitable. It was too cumbersome and had no transport, so could not keep up with the constantly moving army. This led first to the utilisation of the Field Ambulances as forward operating units, and then to the conversion of some of the CCSs into mobile units equipped with their own transport. The MDSs of the Field Ambulances of 2 NZ Division were provided with extra equipment to enable them to carry out efficient surgery, and with extra personnel to strengthen them from the surgical aspect. At least one surgeon capable of performing major surgery was posted to each Field Ambulance.
To strengthen the Field Ambulances, surgical teams, as supplied to the CCS during the First World War, were chosen from the medical officers of the base hospitals best qualified by surgical experience and age to perform forward surgery. The relative lack of surgical equipment in the Field Ambulance rendered it necessary for these teams to take such equipment with them. The teams also took their own tentage for personnel and operating theatre, but otherwise lived as saphrophytes on the Field Ambulance. The usual arrangement was for one team to be attached to an Ambulance. page 44 A surgical team of a surgeon and an anaesthetist, with some surgical instruments, was seconded from 1 NZ General Hospital for duty with the Field Ambulances in Greece and Crete.
In 2 NZEF no provision had been made for a CCS, and this naturally led still more to the use of our MDS to take its place. The provision of a mobile surgical unit for our force, a generous gift of Mr (later Sir) Arthur Sims, filled the gap to some extent, and proved invaluable during the second Libyan campaign. This unit was organised and elaborately equipped in England and Egypt and had a special establishment approved in the Middle East Force. It was completely self-contained and mobile, and was equipped to deal with all types of forward surgery, including heads and chests, and it could hold and nurse its patients. It was a pity that it had to be broken up in 1942 on the formation of 1 NZ CCS, though it largely persisted as the Light Section of the CCS.
The British surgical teams from base units, having proved their great worth in the second Libyan campaign, were continued as definite army units, the FSUs, with an army establishment of personnel, equipment, and transport, though there was no rigidity as far as equipment was concerned. They were freely transferred so as always to be attached to the active MDS of a Field Ambulance or to an active CCS.
This simple unit of few personnel, minimal surgical equipment, tentage, and transport, was able to join an MDS and thereby form an efficient field operation centre for small numbers of casualties. Two or three FSUs could be joined to one MDS, and thus be able to cope satisfactorily with a rush of casualties. This arrangement enabled forward surgery to be carried out successfully under the peculiar conditions of desert warfare.
British units were attached to our Field Ambulances in the Alamein line in 1942, but New Zealand teams were sent forward later from the NZ CCS and from one of our base hospitals in September 1942. (This latter team was officially constituted 1 NZ FSU in June 1944.)
The CCSs, some of which, including the NZ CCS, had been provided with transport and so converted into mobile units, then began to assume more their original role as far as the British Army was concerned, although our Field Ambulances still continued to carry out much major surgery. In the period just before Alamein Field Surgical Units and Field Transfusion Units were functioning both with the Field Ambulances and the CCSs. A Blood Transfusion Service with its base in Cairo had been well organised to supply whole blood, plasma, serum, and transfusion fluids to the FTUs in the battle areas.page 45
At the battle of Alamein the organisation of forward surgery was very efficient. Units were well staffed and casualties were smoothly evacuated to the forward surgical centres at the Field Ambulances, and then to grouped CCSs. Air evacuation to the Base was used to some extent, but there were few ambulance planes and unprotected transport planes were subject to enemy attack. Nursing sisters had been attached to the CCSs, and beds had been made available to the Field Ambulances and FSUs to enable abdominal cases to be held and nursed after operation, as early evacuation of these cases by air had proved calamitous.
During the long advance to Tunis there were relatively few casualties till the battle of Mareth, and air evacuation was used freely on the ‘left hooks’ as we held complete dominance in the air at that period. The Field Ambulances continued to be strengthened by extra surgical staff, and CCSs were still grouped at times and forward surgery was well stabilised.
In Italy forward surgical units were housed at times in buildings because of weather conditions, but tents were still frequently used. The destruction of the railways and the deterioration of the roads sometimes made evacuation very difficult, especially from the Sangro. Under the better evacuation conditions at Cassino an important change in priorities was made. Abdominal cases had been proved to do better after a longer period of resuscitation and were referred to the CCS, while early operation had proved best for traumatic amputation cases and large muscle wounds so these were operated on in the Field Ambulances. More of the lesser wounds were also dealt with at the Field Ambulances so that delayed primary suture could be carried out at the base hospitals with a better chance of success.
Specialist units—neurosurgical, ophthalmological, and facio-maxillary—then had forward sections sited close to the CCSs, and patients could be sent direct to them from the Field Ambulances.
In the final period in Italy evacuation by air was a special feature, and some casualties even had their primary operative treatment carried out at the base hospitals. The war ended in Italy with the organisation of forward surgery in a high state of efficiency. Our only difficulty was the supply of young surgeons with adequate training, owing to the depletion caused by the return of experienced surgeons to New Zealand.