Surgical Policy

The surgical policy at the MDSs during the Sangro battles was dictated solely by the time factor for evacuation between the MDS and the CCS. From 4 MDS at Atessa the road to Vasto via Scerni and Cupello was poor and deteriorated rapidly in wet weather. The journey for ambulance cars usually took four to five hours. It became dark about 4.30 p.m. and the journey after dark became very much slower and not without hazard. Therefore, most of the surgery was done at the MDS, where conditions in the civil hospital building were good. Evacuation from forward areas was slower than occurred in the desert warfare. Wounded tended to arrive in a steady stream and not in large convoys, and there was never a large number of cases awaiting operation at one time. It was certain that few, if any, abdominal cases would have survived operation after the journey to Vasto, their condition being precarious enough on arrival at the MDS. The same consideration applied to more serious limb injuries at 4 MDS. There were two cases of gas gangrene whose onset preceded admission to the MDS—a course distinct from the usual insidious onset and benign nature of this infection occurring in the desert.

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From Castelfrentano, where 6 MDS opened on 14 December, the evacuations could be carried out along a better road down the Sangro valley and more cases were sent to 1 Mobile CCS for their initial surgery, but a large proportion of surgery was still done at the MDS. On 18 December ADMS 2 NZ Division held a conference of all unit commanders at 6 MDS at Castelfrentano, and the question of treatment and evacuation of casualties was discussed. The main discussion was on the type of case to be dealt with at the MDS and CCS. The general feeling was that everything depended on the line of evacuation from the MDS to the CCS. If this was short in time, the majority of cases, excluding chests, abdomens, and severe fractures, could be evacuated with minimal treatment at the MDS. If, however, conditions on the road were such that long delays were inevitable, considerably more surgery would have to be performed at the MDS. To meet this contingency extra surgical teams would have to be made available.

The opinion of the divisional units was not entirely supported by the British consultants, and there was a feeling that possibly too much stress was being laid on the urgency of operation and too little on the other factors determining the survival of the wounded man. The New Zealand consultant surgeon made the following comments at the time:

While the MDS was at Atessa and nursing sisters could be utilised, conditions were probably satisfactory, but later at Castelfrentano conditions deteriorated. It was rightly deemed unsuitable to employ sisters there and the surgical conditions were in no way comparable to those provided at the CCS. The distance by road between the MDS and the CCS was such that it could be covered under good conditions by ordinary car in two hours. Under such conditions one feels that the greater part of the operative work should be carried out in future at the CCS and the NZ surgical team be attached to the CCS especially for the treatment of abdominal cases.

The performance of the primary operation as early as possible is the surgical ideal, but I feel that does not mean the performance of surgery in the actual battle zone under relatively unsuitable surroundings and uncomfortable and disturbing conditions for the patients and the surgical staff. A slightly longer delay is more than worthwhile if the operations can be more efficiently done by a more rested staff and much better nursing facilities and comfort provided afterwards.

The really urgent conditions of haemorrhage, the removal of mangled limbs, and the tamponage of sucking chests must necessarily be done regardless of refinements, but the rest of the surgery should be carried out under as good conditions as possible. It would appear that under European conditions the CCS will generally be able to be moved near enough to the battle area to carry out the primary surgery. If that is impossible, then the MDS that will be constituted a forward operating centre should be placed far enough back to enable the surgery to be performed under conditions comparable with those available at the CCS and under conditions which might render it possible to employ nursing sisters.

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Elasticity of staff should be possible, to switch over personnel – medical officers, sisters and orderlies, to the place they are most needed, and that elasticity has been evident in the Division latterly.

Our main difficulty is the undoubted zeal of our medical personnel in the Division which urges them to carry more than their relative share of the treatment of the wounded men.