Extract from Medicos & Memories
(with permission of Authors)
Extract from MJA Surgical Experiences as a POW
By K. J. Fagan, Sydney
May I begin with a controversial statement? It is this: that the returned prisoner of war is in most cases not only a normal man, except for some temporary physical disability, but one who has had intellectual and emotional experiences which give him a decided advantage over his fellows. He has learned to appreciate the minor pleasures of life. He knows the essentials of existence. He has a high threshold to the pin pricks of ordinary life. He knows man for what he is – his courage, his cowardice, his limitless generosity, his gross selfishness, his nobility and his utter meanness. And if he tends towards cynicism at the discovery of the relation of man’s best qualities to his intragastric tension, he is robbed of all bitterness by the memory of the heights to which he has seen some men rise in spite of starvation, of illness and of every degradation which a malignant enemy could put upon them.
At the relief of Singapore in September 1945, the Press was in the vanguard. My first contact with the outside world was with one of its representatives, who curtly brushed aside all my perhaps incoherent demands for news with the request: “Come on, Major, tell me a horror story.” I did not tell him a horror story, nor do I propose to tell you a horror story: but in a talk on surgical experiences as a prisoner of war, some account of the background is necessary.
Our first surgical task after imprisonment was the care of battle casualties. In Singapore we were fortunate in that for the first few months we had an X-ray plant, plaster, anaesthetics and equipment, so that we were able to treat these casualties secundem artem. Our difficulties were malnutrition and intercurrent infections, particularly dysentery. One frequently had the experience of losing a patient from acute dysentery after months of work at a stage when his injuries were satisfactorily dealt with. A timely shipment of South African Red Cross food saved many of our battle casualties. It enabled us to feed them normally for a long enough period to restore their powers of resistance and healing.
In May 1943, I was detailed as surgeon to a party of 3,500 troops travelling north to Siam to work on a railroad. After a protracted and uncomfortable railway journey to Bampong in southern Thailand, followed by a most arduous march of 120 miles into the jungle, our men were set to work without being allowed time to recover from the journey. They worked for twelve to fifteen hours a day, making a cutting through solid rock with pics, shovels and hand drills. Their rations were grossly deficient in proteins, fats and vitamins, particularly thiamine and the B1 complex. The region was highly malarious; the native population was admitted by its own government to consist of 100% amoebiasis carriers. Very soon our men
were reduced to the status of a malarious, dysenteric, underfed and overworked slave gang. An epidemic of cholera killed 25% of the camp strength in six weeks. With this classical background an epidemic of acute phagedenic ulcer appeared three weeks after our arrival in Thailand. The spontaneous ulcers appeared first as a small vesicle surrounded by an area of redness, induration and tenderness. After twelve to twenty four hours, the vesicle burst, discharging a little sanious material and exposing a sloughing base, which spread with varying rapidity and to a varying depth. In the more severe cases there occurred progressive destruction of skin, subcutaneous tissue, deep fascia, tendon, intermuscular fascia, periosteum and bone. Muscle was relatively immune. The spread of the lesion was accompanied by intense pain and moderate toxaemia. A man with a severe, untreated ulcer presented an appalling spectacle. One saw a pale, wasted man with a flexed knee and a thin strip of intact skin down the calf or outer side of the leg, the rest of the leg being the side of a huge ulcer from which poured offensive, greyish pus; sloughing tenons and fasciae were exposed, the muscles were tunnelled and separated by gaping sinuses, the whole of the tibial shaft was sequestrated.
Conservative treatment was slow and troublesome. It was found that the best treatment was early excision of the necrotic tissue. If one could excise this before the deep fascia was penetrated, cessation of the necrosis, the appearance of healthy granulation tissue and healing, perhaps in the case of larger ulcers with the aid of skin grafts, could be confidently anticipated. Operation in these cases was followed by immediate cessation of pain. Once the deep fascial barrier was penetrated, secondary operations such as excision of necrotic tendons and sequestrectomy were often necessary. In the advanced cases, such as that described above, amputation was the only possible treatment; but the mortality rate was very high. The association of chronic diarrhoea was a particularly lethal factor. However, amputation enabled many of these unfortunate men to die in greater comfort and dignity.
The facilities available for surgery in the Thailand prison camps were not elaborate. My operating theatre, for example, was at first the open air, later a tent fly, and still later, when we returned to the plains at Kamburi, a luxurious affair of palm leaf with a mud floor, but completely fly proofed with American Red Cross mosquito netting. Sterilizing of towels, instruments and dressings was done in a four gallon “dixie” on an open fire outside the operating theatre. Under these conditions, in addition to excisions of ulcers, such operations as appendicectomy, mastoidectomy, craniotomy, “pinning” of the tibia and skin grafting were performed with a minimum of septic complications. This fact was due to the skill and devotion of the theatre orderlies, who fortunately had received their training in better circumstances and earlier in our captivity.
I should like to close with the surgical lessons that I learned as a prisoner of war. The first is that the necessary surgery can be performed in any circumstances, provided fuel and water are available, and provided one has
an operating theatre staff adequately trained and accustomed to improvisation. The second is the value of the Steinmann pin in treatment under primitive conditions of fractures of the lower limb. Its simplicity and portability make it invaluable where no plaster, strapping or bandages are available. The third is the value of chloroform as an anaesthetic agent under conditions of tenuous supply lines. It is safe in good hands, and economical. One can carry a large number of “chloroform anaesthetics” on one’s back. The final point is that male medical orderlies can be trained to the safe standards of efficiency and skill in operating theatre technique as women, and that it should not be necessary ever again to expose our women to the danger of captivity at the hands of an Asiatic enemy.
The above was read at a meeting of the New South Wales Branch of the British Medical Association on March 15, 1946.
Source: The Medical Journal of Australia June 1, 1946.
Notes collected by Lt. Col. Peter Winstanley OAM RFD
(Retired) JP (E-mail firstname.lastname@example.org
) with assistance from Don Lee