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REPORT TO A MEETING OF THE HAWAII COUNTY MEDICAL SOCIETY
I feel rather diffident in having occasioned this meeting; however, I have had certain opportunities, and it has appealed to me that, if I could pass along any benefits or knowledge that I had acquired, it was my duty to do so, particularly as Society affairs in part accounted for my being in Honolulu. We may think they won't hit here again. That attitude might be unfortunate, so I thought it better be now and not next month.
If I am unable to tell you anything today that will be of benefit it will not be from lack of opportunity, but rather inability to observe and deduce from my observations.
I will take up my connection with events while in Honolulu in a rather chronological manner. On the Sunday morning of the 7th of December there was a meeting at 9:00 o'clock at the Mabel Smyth Memorial Building to hear a lecture by Dr. Moorhead, that had been postponed from the previous day. Just before the lecture, while gathered outside the lecture room, Dr. Hodgins arrived from Pearl Harbor, very excited, telling of hearing bombing and seeing a cruiser lying on her side and burning at Pearl Harbor. His information was received in rather a disbelieving way, so much so that he proceeded himself to believe that what he was seeing was anti-aircraft practice, and we went in and sat down at the lecture. However, there seemed to be an uncertainty in the air from that time. Dr. Moorhead began his lecture by mentioning that he had served in France in the last war and that if the opportunity came he wanted to do his bit again in any capacity which he could. After a few minutes one or two individuals were called from the lecture, and then an announcement was made through the loud speaker that surgical teams and medical help were wanted at Tripler. We then, of course, realized that something was happening. I got in the car with Dr. Hodgins and we started toward Tripler, which is on the old road out of Honolulu toward Pearl Harbor. Traffic going out was already dense, consisting of the greater part of men from the various posts who were trying to return to duty.
After some delay owing to traffic, we reached the hospital and went up to the operating floor. Certain surgical teams, which had previously been arranged for under the civilian defense committee of the Medical Society, were arriving and ready to work. Dr. Moorhead and myself, having no previous connections, teamed up together and. were assigned to a table. Already the wounded were covering the floors of the halls and available space leading to the theatre.
My observations from now on will be largely the product of my association with Dr. Moorhead over the next two days, and it is on this authority of that association that I am talking today. When I mentioned to him that I expected to quote my experiences and hoped that I would not misinterpret his opinions, he was good enough to say that he was quite willing to take a chance on that.
I cannot possibly recall to you all the cases. I will just mention a few cases, which will bring out all the points that I want to make as I go along from here.
The first patient that came to us had a traumatic amputation of the hip. One leg had been shot off right through the hip joint leaving a stump of the femur about three or four inches long. This was this man's only wound. In this case about two inches of the femoral artery was lying exposed on the tissues just like a finger, and filled with clot. It seems hard to understand why he had not died from hemorrhage. However, there was a firm clot in this exposed portion of the artery.
Right here I want to say in partial explanation that the type of surgery that was being done was the mass surgery of a tremendous emergency.
The first procedure in this, and in all cases, was to wash about the wound with soap and water, and then flush the wound itself with sterile water or salt solution, then ligation of the large vessels, debriding of devitalized tissues and skin, merely tacking the remaining flap to the wound with no attempt at covering. A note was given to the anesthetist of what had been done, and the patient was returned to the ward with an order for an immediate transfusion.
I want you to note that there was a history of what was done made at the end of this case, as well as in all subsequent cases.
The next case was a compound fracture of the tibia and fibula with a large portion of the calf torn away. And here is a point I want to make. On quickly sizing up this injury Dr. Moorhead said, "Amputation." There may have been a query in my expression, because it looked to me like a case which, under individual conditions, we might have treated conservatively. However, he quickly said that with the amount of destruction of the tissue, the condition of the bones, the splintering of the fragments, coupled with the fact that these cases when they go out from these emergencies are not under your observation, and that amputation in such a case was a life-saving procedure. Later he brought out the fact that an artificial leg in this type of case is of much more use than a mutilated and painful leg.
Now, there were a large number of amputations performed those days. While a man with the experience of traumatic surgery of Dr. Moorhead could make a quicker decision, it seems to me that an amputation for us should require a getting together for a moment of time, even though very brief, before coming to the decision to amputate, except in very clear cut cases.
This amputation was a chop, or guillotine amputation performed below the knee through the bones, not through the joint, even though higher amputation may be later required.
Right here I will bring in the use of the sulfonamide powders, sulfanilamide and sulfathiazole. In our first case, after debriding we packed and dusted the wound and filled its interstices with sufanilamide powder. The same was done in each case. There was, perhaps, not an actual scarcity of this medication, but it was difficult to keep it at hand, and it came to the point where you were conserving it from each case and hiding it in a corner near your table. And here I want to say that there was a very great waste of these drugs. Perhaps in the excitement of the first day it was unavoidable, but the waste carried over not only to the next day, but in subsequent days in dressings in the wards. In the attempt to shake these powders from pound bottles or from long test tubes you almost had to be wasteful. In this connection I believe that the sulfa powders should be provided in wide-mouthed bottles in various sizes so that you could pick out the one suitable to do the work that has to be done. The bottles should be wide-mouthed so that a dressing forceps handle or a tongue blade could be passed through and the powder taken out and put where it is supposed to go--to pack among the muscles, into the fascial tissues and into all the broken spaces in the tissues. This cannot be done with a shaker, but to get the powder into all the interstices of the wound it has to be carried there. I think some such solution would save three-fourths of the supply, and be more efficient.
The next case I am going to mention was a compound fracture of the femur, above the knee, in which the projectile had traversed the thigh transversely and was not in the tissues. The circulation was efficient in this case and the decision was to preserve this leg. The treatment then consisted of excising the wound of entry and the wound of exit completely, and then debriding all the devitalized tissues down to the bone. This was done in a very thorough manner, not sacrificing any tissues that were vital, but removing all tissues that were dark and which did not bleed when cut into. The Thomas splint was applied and a Kirschner wire was put through the malleolus for extension. After thorough treatment with the sulfa powder dressings were applied. In future cases instead of saying sulfanilamide or sulfathiazole I will just say "sulfa powder," because the word will be used often.
The next case I will tell you about was a gunshot wound of the abdomen. The bullet had entered the abdomen just above the anterior superior spine on the left, and there was no wound of exit. X-ray showed a projectile on the right side under the liver. The surgical treatment was as follows: The wound of entrance was excised and debrided. An incision was then made in the midline above the umbilicus. There was massive hemorrhage in the abdomen. After swabbing out the blood, the first examinations were made on the right up under the liver in the location of the foreign body in the X-ray. The bullet was found free in the peritoneal cavity. There was no evidence of hemorrhage from the liver or stomach, or transverse colon. Then, backing down toward the wound of entrance, we began to find perforations in the jejunum and ileum. In one section of the jejunum in a distance of about fifteen inches there were seven perforations. I will mention the size of the bullet removed. In appearance it was the size of a 30-30 bullet with cartridge. It came to a very sharp point, and it was not mutilated. It was said to be from a large size, I forget the calibre, machine gun such as are mounted on airplanes. The perforations were some through the mesenteric portion and some through the free bowel, and had gone through the bowel leaving wounds of entrance and exit. The remarkable thing was the way these wounds had closed down and contracted to a mere pinpoint. These perforations were closed by a double line of silk sutures Lemberting them in. These sutures were placed in the long axis of the bowel so as to minimize the encroachment on the lumen. Altogether about twenty-one perforations were found in this case and closed in the same manner. The whole bowel was looked over from ligament of Treitz to the ileo-cecal region. Sulfa powder was then dusted extensively within the peritoneal cavity and the incision closed. A vaseline strip was placed in the wound of entrance down to the peritoneal cavity.
I may say right here that on Monday morning when we were starting to work after a few hours off, Dr. Moorhead said, "Now let's review a bit. What did we do yesterday that, if we had to do over again, we would do differently?" One or two things were mentioned, such as the treatment of shock, etc., and then I said, "Well now, wouldn't we resect that loop of intestine that had so many perforations in it, instead of suturing the individual perforations"? His answer was "No," that a resection adds tremendously to the shock and the future risk of these cases. I can see the point, although I think that in civilian practice with an injury of this kind that you had completely under your control for follow-up with Wangensteen, observation of any symptoms which might develop, such as ileus, resection would be good surgery, but in the circumstances under which we were working it was inadvisable. This brings out, too, the necessity for coordination between surgery and follow-up.
Next I want to bring up a chest injury. This man had a large wound in the chest around the axillary line about the region of the 4th or 5th rib on the right, and the projectile had traveled downward and may have been in the mediastinum, the lung, or in the diaphragm, somewhere in the lower part of the thoracic cacity. This was the type of wound described as "sucking," that is, air was passing in and out with each respiration, and with all the possibilities of disturbances of the mediastinum that take place under this condition. The treatment was as follows: The wound of entrance was debrided, at the same time maintaining a plug within the wound to prevent sucking. Then a tube 1 inch in diameter and long enough to reach to the floor was placed in the wound. It was fixed there by a succession of strips of adhesive tape around the tube in an elliptical way, one on top of the other, increasing in size until the wound was entirely shut off from the outside. The end of the tube was placed in a large bottle containing sterile fluid to cover the end. No attempt was made to explore the chest or to look for a foreign body, the object being to allow the lung to expand and prevent mediastinal shift. In these cases in massive hemorrhage within the pleural cavity, after closing the wound aspiration once, or repeatedly, may be necessary. I think that possibly something of added value in these cases would be, after having proceeded as above, to make a heavy suspension of the sulfa powder and inject it into the pleural cavity with a large needle through the tube. I believe that it might be of marked value in minimizing subsequent infection.
Another case I wish to speak of for special points was a wound in the sacral region. The projectile, a large shell fragment, had crashed in and amputated the lower end of the sacrum, as in a Kraske operation, and was imbedded in the tissue in front of it. This case was reached late in the first day. There was a history of his not having voided. A catheter was passed into the bladder and only a very small amount of urine was obtained, but there was no blood. The wound of entry was excised and opened up, the foreign body was located and removed, the wound was debrided and fragments of the sacrum were also removed. The question then arose whether the wound had penetrated sufficiently to injure the rectum and soil the peritoneal cavity anterior to it. It seemed to me unlikely, and I think that I would have done no more. However, Dr. Moorhead called for a new set of instruments, and opened this man suprapubically. Nothing was found within the peritoneal cavity. The peritoneum and the cul-de-sac about the rectum was ecchymotic. I mention that I might not have made this exploratory because possibly some of you might have taken the same attitude, and it is mentioned to stress the attitude of Dr. Moorhead in insisting on visualizing the peritoneal cavity in this case.
The next subject I am going to touch on is foreign bodies in the tissues, which were mostly shell fragments of various sizes. The procedure, of course, depended on the location and the tissues involved. If there were a large projectile in the tissues and the X-ray showed it, the procedure was to follow the wound down to the projectile, debriding all devitalized tissues down to it, and on reaching it the bed of the projectile was debrided. Unless the resulting wound was very shallow, particularly if the foreign body were nearer the surface elsewhere than at the entering site, a counter opening was made. The tract was well treated with sulfa powder, and then a vaseline strip was passed through it. This was not in any sense a pack, it would lie very loosely in the wound. In the first cases there was a little difficulty encountered in pushing the sulfa powder out as you pushed the vaseline strip in. So the method was devised of treating the vaseline strip on the surface with the sulfa powder so that it would carry it through with it.
No sutures were used to close the wounds. I may say that was an absolute rule. Occasionally sutures were placed and a bow knot tied in them for subsequent tightening, but this was the exception rather than the rule.
I saw no burn cases at Tripler. The cases were practically all Army men from Hickam Field and vicinity. However, I understand that there were many burn cases at Pearl Harbor and they were taken to the Naval Hospital there.
Just from observations of the many abrasions aid wounds, I formed an opinion as to the treatment of burns. It has no authority and little experience behind it. I believe that the procedure as far as the local condition is concerned would consist of thorough cleansing with soap and water, debriding of obviously devitalized tissues, drying, and the use of the sulfa powder thoroughly applied, over this a dressing of one thickness of vaseline gauze reinforced with plain gauze. This is based on seeing how quickly these wounds and abrasions treated thus became dry and ceased to secrete, with the prevention of infection.
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To summarize: we have been discussing war surgery, and in these days civilians are almost equally involved. Your case today may be pushed along for the casualty of tomorrow, so you have no assurance of opportunity to follow up with advice or correct any omissions of today; therefore, complete and correct first treatment means saving of life and limb, and will greatly shorten the average hospitalization and disability.
To again briefly list the means:
(1) Treatment of general condition-shock, hemorrhage, et cetera.
(2) Investigation of wounds in all their possible extensions.
(3) Complete debriding.
(4) The efficient use of sulfa drugs, locally and by mouth.
(5) No suturing for closure.
(6) Vaseline gauze to keep wounds open, not for packs.
(7) Records to go definitely attached to the patient.
I can't close without mentioning the men who were "taking it." Most of them were lads in their twenties. Their attitude may be summed up in the words self-control and cooperation . They showed it in the quiet way they took an anesthetic, yes, and in the quiet way they came out of anesthetic. It greatly lightened the work, and without doubt improved their chances. They were admirable.
Dec. 20, 1941. S. R. BROWN, M.D.
Medicine in Hawaii: The World War II Experience
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