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New Zealand Medical Services in Middle East and Italy

REVIEW OF FORWARD SURGERY AT THE END OF THE NORTH AFRICAN CAMPAIGNS

REVIEW OF FORWARD SURGERY AT THE END OF THE NORTH AFRICAN CAMPAIGNS

The priority of operation followed at that time was:

A.

Abdomens, bleeders, sucking chests.

B.

Amputations, fractures with swelling or bleeding, joint injuries, large flesh wounds, especially with swollen limbs and situated in the buttock, thigh, or calf.

C.

Heads, eyes, jaws, spines.

The abdomens were treated as first priority and so were dealt with frequently at the MDS of the field ambulances.

The Work of a Forward Operating Centre

The medical units responsible for this work were the MDSs of the field ambulances and the CCS. By the time of the Tunisian campaign the work had become highly organised and the staffs of the units fully trained in the different aspects of the work, so that large numbers of patients could be handled swiftly and efficiently. At the reception tent the cases were sorted and particulars taken, kits attended to, exchange of stretchers and blankets arranged with the ambulances, and the patient sent on to the pre-operation tent, to the wards, or to the evacuation tent. This work was greatly facilitated by prior sorting and information supplied by the ADS or MDS.

The pre-operation ward carried out all resuscitatory and other preliminary treatment, including washing the patients, the provision of clean clothing, and the checking and control of personal belongings. The patients were examined and decision made as to the urgency of operation and the resuscitation required. An FTU carried out the blood and plasma transfusions and a senior surgeon attended to the diagnosis, conferring with the transfusion officer concerning priority. At the CCS an X-ray plant was available, the types of cases normally X-rayed being:

(a)

Doubtful abdominal injuries.

(b)

Head and spinal cases.

(c)

Injuries involving joints, especially the knee.

(d)

Doubtful fractures.

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Resuscitatory measures at that time were:

1.

Blood, the main and generally the sole measure of importance. Generally two or three pints were given.

2.

Plasma was given to counter haemo-concentration in severe burn cases and also to supplement blood.

3.

Warm fluids given, such as tea, cocoa, etc.

4.

Morphia, when pain or restlessness was present.

5.

Warmth: excessive warmth had been found to be deleterious. Simple warming by blankets in a warmed tent was carried out.

Types of cases selected for early operation:

1.

Abdominals: The diagnosis depended on: (a) the site of the wound and probable course of the missile; (b) local signs of abdominal injury such as rigidity of the abdominal wall, lack of audible peristalsis, abdominal distension, dullness in the flanks or pelvis; (c) general signs—shock and distress, signs of internal bleeding (pallor and rapid thin pulse). X-ray was used in doubtful cases, especially when diaphragmatic and retro-peritoneal injuries were present. Bleeding was found to be responsible for the early and serious symptoms, and sometimes prevented full resuscitation and demanded urgent operation for its control. Peritonitis was a late development.

2.

Chest cases: The only cases which demanded operation were those with large chest wounds, open sucking wounds, and occasionally with bleeding from an intercostal artery. Only a pint of blood was generally given to chest cases.

3.

Head cases: All injuries involving the scalp, skull, or brain were operated on if the general condition was satisfactory. The severely shocked and sterterous cases were left till signs of recovery were present and operation was felt to be justified.

4.

Fractures of the long bones: The extent of the wounds of the soft parts determined the necessity and extent of the operative treatment, and vascular injury was of special importance. Splinting in any case was required and X-rays, if time allowed, were of value in certain cases, especially if any joint involvement was suspected.

5.

Vascular injuries: Injuries to large vessels as shown by a history of serious bleeding, a pale and shocked patient, dressings soaked in blood, limb swollen and tense, loss of pulsation in terminal vessels, demanded urgent operation to prevent further bleeding and also secondary haemorrhage later.

6.

Joint injuries: Although operation was often unnecessary, splinting was essential.

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7.

Foot injuries: These were very common, largely due to mines, and amputation was often required.

8.

Facio-maxillary injuries: As a rule these did not require urgent surgery, but eye injuries might demand enucleation or removal of foreign bodies by the electro-magnet and dental splinting might be required for fractures of the jaw.

9.

Spine: Might require a suprapubic drainage.

10.

Large flesh wounds: especially of the buttock, thigh and calf, owing to their liability to anaerobic infection and vascular injury.

The buttock wound was always suspect of associated intra-abdominal, rectal, or lower urinary tract injury.

Splinting of Fractures:

1.

Humerus: The most satisfactory splint for transport was the adduction plaster with a cap plaster over the shoulders, slabs well moulded round the upper arm, liberal padding in the axilla between the arm and the chest, the whole bandaged to the chest by circular plaster bandage, the forearm being included in both the slabs and the circular bandage, leaving the hand free.

2.

Forearm and wrist: Plaster slabs were used with circular turns but without restricting movement of the metacarpo-phalangeal joints.

3.

Femur and knee joints: The New Zealand Tobruk method was the normal application of the Thomas splint—slightly bent at the knee with elastoplast extension, and flannel slings. Then a posterior plaster slab was applied outside the slings from the buttock to three inches above the ankle. Padding was then put between the limb and the splint and in front of the limb, a roll of coarse wool being used. A circular plaster bandage was applied from the groin to just above the ankle, the foot being suspended in the foot-piece by strapping. Extension just to steady the limb was applied. The spare space usually present at the outer part of the ring was filled by padding or a moulded plaster pad. Extension to correct shortening was contra-indicated by the danger of the ring riding over the tuber ischii and the formation of pressure sores during transit.

4.

Tibia, fibula, and feet: Plaster splints were applied from the upper thigh to beyond the toes, but allowing of toe movement. All plasters were well padded and were also cut up before evacuation to prevent interference with circulation.

Operative Technique

Two tables were used in the theatre. Improvised methods of concentration of electric light were used and standard lights were sometimes available. Arm boards were essential for the giving of page 456 blood and also pentothal injection. Suction apparatus, generally improvised, was also always used. Plain soap and water was used for skin cleansing and shaving was freely resorted to. Iodine was the usual skin application. The surgeons wore macintosh overalls, caps, and face masks. Gloves were generally worn but not always changed for each operation. Macintosh and rubber guards were commonly used, but for abdominals the full surgical technique with linen guards was used. There was great wear and tear on surgical instruments due to the constant boiling. Fine thread was generally used for ligatures.

As regards wound treatment, the removal of skin had been reduced to the minimum and only definitely damaged and devitalised tissue was removed. All avascular and badly traumatised muscle, however, was carefully excised as a precaution against anaerobic infection. Only definitely loose fragments of bone were ever removed. Free and, if possible, dependent drainage was provided in all large wounds associated with much muscle or bone damage. Relief of tension was of the greatest importance and incision, both longitudinal and sometimes transverse, of the fascia was regularly carried out. Foreign bodies, especially clothing, were removed if readily accessible. If deep muscular gangrene was present whole muscle groups were removed, and if the whole limb was gangrenous amputation was carried out. Ligature of the vein in addition to that of the artery was being given up in the treatment of injuries of the main vessels. Injured nerves were dealt with only by approximating the severed nerve ends. The surgeon regularly wrote up notes after the operation, both in the operation book and on the field medical card.

Treatment of Different Injuries

Joints: No operative treatment was carried out in small perforating and penetrating wounds. Large wounds were excised, large accessible foreign bodies were removed, and the patella, if seriously damaged, was completely excised. The synovial membrane was sutured but not the skin.

Heads: Careful excision of the wound down to the bone was performed. Loose bone was removed and the skull nibbled away to expose the dura and brain wound. A combination of syringing and suction removed the pulped brain and accessible bone fragments or foreign bodies. Sulphadiazine was applied to the wound and also given intravenously following operation. The wound was sutured in two layers with thread and a small stab drain inserted for a few days. A plaster cap was used to keep the dressings in place. Diathermy was used to control bleeding.

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Eyes: Corneal spattering was very common, as were penetrating wounds by small foreign bodies. The removal of these by the electromagnet was very difficult, many fragments being non-magnetic.

Jaws: Fractures were dealt with by dentists skilled in the application of inter-dental splints, or extra-dental splints, and pins were used in combination with a head plaster.

Chests: Large and also sucking wounds were dealt with by excision. A vaseline gauze pack kept in place by sutures was used to close the sucking chest. Ligature of bleeding intercostal arteries was sometimes necessary. Aspiration was carried out when respiratory distress was present.

Abdomens: These cases were given first priority. Diagnosis was often difficult, especially as wounds such as buttock and chest wounds were often associated with intra-abdominal injury. Catheterisation was always done before operation as a precautionary and diagnostic measure. Exploration was carried out either through the excised original gunshot wound or more normally through a separate incision. Lateral transverse incisions were sometimes used but vertical central incisions were generally employed. Exploration was not always carried out in liver or kidney injuries. Examination of the abdominal contents was carried out methodically, except when it was certain that the injury was strictly localised. The small intestine had to be particularly well looked at as multiple injuries were common. Suture of the perforations was always preferred to excision because of the lower mortality. Simple one-layer suture was carried out, even when excision had to be performed, with some extra stitching if time warranted it. Suture of the colon was done only, and that infrequently, in very small lesions of the caecum and right colon. In all other cases the injured gut was exteriorised and a colostomy with a spur formed. In lower sigmoid and rectal injuries a left side colostomy was made. Colostomy had been carried out in cases of severe buttock wounds to ensure cleanliness of the wound, but it had been realised that it was too heavy a price to pay and the practice had been discontinued, except when the rectum itself was involved. Liver wounds were found to require little treatment. Only very rarely was packing or suturing required to stop bleeding. Minor kidney injuries required no treatment. In severe cases exploration followed by nephrectomy or drainage was carried out. Association with a colon injury made nephrectomy advisable. Bladder injuries were sutured and suprapubic drainage was instituted, as it was for spinal cord injuries and urethral damage.

Wound Treatment: Primary skin suture was carried out for scrotal and penile injuries and also for wounds of the head and abdomen. In all other wounds there was no primary suture, and tulle gras or page 458 vaseline gauze dressings were applied following wound toilet. The ordinary wounds were dusted with sulphanilamide and then a vaseline gauze dressing applied. Sulphanilamide by mouth was then given regularly for six days, charts being utilised to ensure proper dosage.

Burns: Serious cases were treated with serum, morphia, and rest. Cleansing and dressing of the burns was left till resuscitation had taken place, and often only part of the burnt area was treated at a time and then only gently cleansed with saline dabs. Sulphanilamide powder or ointment was used, followed by tulle gras dressing. Tanning had been completely given up. The need of whole blood transfusion after the first few days was recognised, the haemoglobin often by that time having been reduced to 60 per cent or less.

Post-Operative Care

Beds were provided in the field ambulances at the time of Alamein, enabling serious cases to be nursed adequately in the field units. Copious fluids were given, if possible by the mouth. The abdominal cases were nursed in Fowler's position and chest cases also sat up as soon as possible. Close attention was given to the skin and also to seeing that plasters were not constricting the limbs. Sedatives such as paraldehyde were given to head cases.

Chests: If respiratory distress was marked, tapping was performed with air displacement in the first twenty-four hours. In First Army early, frequent, and thorough evacuation of the haemothorax was done with good results.

Abdomens: Treatment was stabilised in: (a) applying continuous gastric suction by means of a blood-taking set inverted and filled with water, so acting as a suction apparatus; (b) giving continuous intravenous fluid, glucose, and glucose saline, about 8–10 pints a day; (c) using Fowler's position; (d) holding the patient in the unit where operation had been performed for a period of ten to fourteen days before evacuation; (e) nursing on beds; (f) giving of fluid by the mouth in small quantities; (g) continuing suction for about four days and then shutting it off gradually. (Suction was not required for so long in large bowel cases.)

General Cases: Further resuscitation, especially transfusion of blood, was often required.

Evacuation of Cases from the Forward Operating Centres

Patients were normally evacuated at the earliest possible moment as soon as they were fully recovered from the anaesthetic. Certain types of cases, however, were held:

page 459
1.

Cases unfit to travel, whatever the lesion. These were held for further resuscitation.

2.

Abdominals: As already mentioned, these were held for ten to fourteen days.

3.

Chests: Severe cases were often quite unfit for travel and were held for several days.

4.

Burns: Severe cases were too shocked and toxaemic to travel for some days.

5.

Anaerobic infection: These cases were held for urgent treatment and to prevent change of surgeon.

6.

Haemorrhage: If any danger felt of further bleeding.

7.

Gangrene: Impending gangrene cases were held for observation.

On the other hand:

(a)

Head cases travelled very well, the only difficulty being restlessness.

(b)

Chest cases, if no distress in breathing, travelled comfortably.

(c)

Spine cases also were satisfactory.

(d)

All fractures, if adequately splinted, were no trouble.

The Type of Wounds

Wounds were caused by different missiles, varying greatly at times. Throughout the campaign there was always a considerable number of mine wounds irrespective of any actual fighting. These wounds were caused either by the metallic mine exploding on the ground or by the new wooden Schu mine, which exploded about four feet above the ground and discharged numbers of shrapnel balls, causing severe multiple injuries. The damage to the feet by the ordinary metallic mines continued to be frequent and severe. In active fighting shell and mortar wounds became more common, and in certain phases bullet wounds produced the majority of the casualties. At one field surgical unit behind Mareth the casualties due to gunshot wounds were 23 per cent; to shell wounds 46 per cent; to mines 27 per cent; and to bombs 2 per cent.

Infection in Wounds

This was not very prevalent during the campaign, due undoubtedly to the early and efficient surgery. There was some increase when Tunisia was entered. An indication of the value of surgical treatment was given when considerable sepsis was found to be present in large numbers of slight wounds sustained by Italian prisoners of war admitted to our medical units some days after wounding.

Some increase in gas infection was noted in Tunisia, many infections being of the anaerobic cellulitis type. Few serious cases of gas page 460 gangrene were seen apart from injury to the main vessels. About 60 per cent of forty-four cases reported by Major J. D. MacLennan, RAMC, had serious vascular damage. Infection by an anaerobic streptococcus was noted in eight cases, of which five died.

Sulphonamides

Routine local application by dusting from improvised pepper pots was carried out in all forward units. Tablets were given by the mouth for six days following wounding, and special cards were fixed to the field medical card by which the dosage given was checked.

Amputation

The bad results that followed an attempt in the early days to carry out site-of-election amputations had led to the conservation of the maximum length of limb. Flaps were fashioned and small dressings of vaseline gauze held in place over the stump by two or three stitches. The badly damaged tissue in the traumatic amputations was thoroughly excised to prevent serious sepsis, which had been noticed so frequently in these cases. A great number of amputations of the feet were carried out as a result of mine injuries.

Summary

In surgery, many important advances had been made in the year since the pre-Alamein battles, and surgeons had achieved a high degree of efficiency in the conditions peculiar to war. The low death rate among wounded who reached a medical unit was adequate testimony to this.

Admissions to Field Ambulances, 1943
Jan Feb Mar Apr May Total
Sick BC Sick BC Sick BC Sick BC Sick BC Sick BC
4 Fd Amb
NZ 15 21 409 6 155 352 309 566 74 15 962 960
Others 17 87 40 1 46 177 101 312 10 7 214 584
PW 10 131 38 179
5 Fd Amb
NZ 127 33 16 189 83 115 420 69 52 516 588
Others 73 71 1 42 51 72 3 17 119 211
PW 15 27 42
6 Fd Amb
NZ 130 30 32 249 26 50 39 17 227 346
Others 247 212 20 172 9 30 5 5 281 419
PW 4 79 3 18 1 3 102
—— —— —— —— —— —— —— —— —— —— —— ——
609 468 466 7 484 1309 563 1533 200 114 2322 3431
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The New Zealand Division's casualties in Tunisia, March–May 1943, were:

Sick 1008
Battle casualties 1804
Admissions, etc., 1 NZ CCS
Location Period Sick BC Total RTU Deaths Amputations
Sirte 4–12 Jan 331 154 485 26 4 4
Tamet 14–31 Jan 468 287 755 100 14 1
Tamet 1–8 Feb 60 12 72 89 1
Zuara 11–26 Feb 305 142 447 75 1
Medenine 27–28 Feb 54 51 105
Medenine 1–30 Mar 561 975 1536 122 19 16
Teboulbou 31 Mar 17 40 57 2
Teboulbou 1–8 Apr 37 523 560 16 7
El Djem 13–30 Apr 666 1037 1703 92 10 4
Sidi Bou Ali 1–23 May 870 755 1625 41 13 12
—— —— —— —— —— ——
3369 3976 7345 547 77 45
—— —— —— —— —— ——
New Zealand Casualties, Tunisia, 20 March–13 May 1943
Killed in Action 304
Died of Wounds 64
Wounded 1221
Prisoners of War 31