Dr. Angus Campbell Derby (1914–2006) was only one year out of medical school (McGill '41) when he joined the Royal Canadian Army Medical Corps in 1942. In 1943, he was posted overseas, where he served as a physician in an Advance Surgical Centre (A.S.C.), treating and triaging wounded soldiers straight from the battlefield. The following is an excerpt from his self-published memoirs — Not Least in the Crusade: the Memoirs of a Military Surgeon. The memoirs recount his role as a field surgeon in WWII and the Korean war, as well as experiences as a peacetime surgeon in the Canadian Armed Forces. Below, Derby's keen interest in the history of surgical techniques and his respect for his mentors shines through his writing. — Editor's note
It was not until the turn of the 20th century, with the formation of the British and Canadian Medical Corps, that military commanders reluctantly accepted, as part of the battle plan, medical units with fixed establishments. Military surgeons quickly discovered that war wounds had dire consequences for the soldier, and the more sophisticated the weapon, the more complicated the injury. Serious wounds in most cases led to death. If the soldier did survive the initial wound, he could then look forward, all too frequently, to infection, gangrene, secondary hemorrhage, amputation, and eventually death or permanent deformity or disability. Even at the turn of the 20th century the treatment of infection and gangrene in war wounds remained an enigma.
At the outbreak of WWI, however, the answers to the mysteries of the wounds of war seemed to have been solved. Pasteur had discovered bacteria and as a result, Lister advocated antisepsis. It is little wonder then that the surgeons set out for France with high hopes and gallons of antiseptics. Furthermore, new mobile forward medical units, the field ambulance and the casualty clearing station were to ensure adequate first aid and early evacuation of casualties.
Unfortunately, this is not how it worked out. Because of overwhelming numbers of wounded, surgery was often delayed up to 48 hours. The mortality, although improved, was anything but satisfactory. Infection and gangrene remained a problem. Amputation rates were unacceptably high, and soldiers continued to die of shock. That shock was a frequent complication of severe injury was well known, but no case or treatment was found until Henderson in 1908 showed that shock was due to reduction in blood volume, and this could be treated by replacing the lost fluid. Normal saline was advocated first; however, this could only be used on a limited basis in any one patient. Then the discovery of blood typing, just before WWI, led to a unique opportunity for its use in war. Three Canadian surgeons, Robertson, Archibald and Guiou pioneered its use. Unfortunately blood had to be drawn on the spot and there were no storage facilities or any organization to supply large quantities of blood from civilian sources. At the end of this terrible war, there were 2 million battle casualties, 700 000 deaths and a hospital mortality of over 12%. The answer to the treatment of war wounds did not lie with antiseptic irrigation — the solution would have to await another conflict.
During the Spanish Civil War (1936–1939) units were introduced to collect blood from the civilian population and to store it under refrigerated conditions for use in the combat area. One of the first of these units was the Canadian Blood Transfusion Service of which Norman Bethune was a founding member. The success of the Spanish stimulated the British to organize a similar system for the second war: the centre was in Bristol. It grew to such an extent that eventually all commonwealth theatres, including the home front and the Middle East, were served. Only group O blood, the universal donor, was used. Refrigerated blood and its derivatives were flown to base transfusion units then taken in refrigerator trucks to the field transfusion units. We never ran out of blood — one day in Normandy our A.S.C. used 25 units. We also took penicillin to the continent with us, and it played a part in reducing infection. Its greatest value I believe was in cases that were already infected because of delay in evacuations for surgery.
More significant than penicillin in reducing hospital mortality was the advance made during the Spanish Civil War and reported by Professor J. Trueta of Madrid. In the first war, the medical corps optimistically had taken gallons of antiseptic to the continent, but it still hadn't solved the problem of infection and gangrene. Trueta had done forward surgery in this war, and realized that you couldn't just pour antiseptic into the wound. You had to remove the dead muscle as well. In 1940 he reported what should have been obvious — namely that missiles produce damage, not only in the direction of flight, but also at the right angles. This produces damage to muscle and adjacent tissue at the same time, carrying an abundance of bacteria on mud and dirt and on bits of dirty skin and clothing into the wound. The resulting devitalized muscle becomes an ideal medium for bacterial growth. Trueta reported that the terrible infection rate of previous wars could be prevented by early débridement of all penetrating and perforating wounds, that is, the enlargement of the wound at the entrance and exit (if one existed). All the dead and devitalized muscle and other tissue were removed until the muscle bled, indicating it was clean and viable muscle. The wounds were then left open. Pressure dressing followed, and splints applied when indicated. In approximately 7 days, if the wound were clean, it was closed.
Prior to the invasion, along with a group of doctors, I went to London to hear Trueta speak about his findings. It was all very new, and I was enthralled with his solution to the problem of infection. After the lecture, Laurie Rabson, my Chief of Surgery, said in great excitement, “Of course. That's the way we are going to do it!”
Professor Trueta's work was enthusiastically incorporated in the battle plan in the desert, Italy and Europe. The results were indeed rewarding. The answer to the infected wound and gangrene had arrived. The hospital mortality rate was reduced to 4.5% (3 times less than in WW1) with obvious reduction in morbidity. In our opinion, Trueta was a war surgeon hero.
— Excerpt from the memoir Not Least in the Crusade: the Memoirs of a Military Surgeon, 2005, Angus Campbell Derby