New Zealand Medical Services in Middle East and Italy
Review of Surgery
Review of Surgery
The large majority of deaths was due directly to the severity of the injury and the primary shock produced thereby. This was shown in both the chest and abdominal cases, in which a large number of the wounded were brought in dead to the field ambulances, and practically all the others who died did so in the first forty-eight hours.
Undoubtedly the most valuable form of treatment was transfusion of blood, given early and sustained till operative treatment was possible. The giving of blood during transit in the ambulance had proved of great value. The early administration of glucose saline, both to combat dehydration and also to act as a preventative of anuria, was being carried out.
In mangled limbs, commonly seen after mine injuries, early application of a tourniquet just above the damaged area to prevent bleeding and toxic absorption, followed by early amputation through healthy tissue, had become the routine. The dramatic improvement following the removal of the devitalised tissue was vouched for by many experienced surgeons.
Anuria, generally the direct result of severe and prolonged shock, had caused many deaths and no treatment was of any avail.
Infection was being combated by adequate primary wound excision and the local and parenteral administration of penicillin. Gas gangrene had become more common but, except in a few fulminating cases, cleared up well with adequate surgery and penicillin.
Delayed primary suture of wounds had become the routine in simple wounds, in amputations, and in fracture cases and the results were satisfactory.
Chest cases with more thorough primary wound treatment and intrapleural penicillin had very rarely become septic.
Thoraco-abdominal cases showed a lower mortality when dealt with through the chest. A tendency to delay operation a little too long in abdominal cases had been noted, the pendulum having swung too far. In colon injuries the double loop colostomy was being carried out except in caecal injuries, where simple marsupialisation was all that was considered necessary. Rectal injuries associated with buttock wounds were common and sometimes apt to be over-looked. There had been an unusual number of abdominal wounds page 632 associated with evisceration of the bowel, and a more conservative approach was suggested in these cases which were almost invariably fatal.
Knee-joint cases did well with intra-synovial penicillin and adequate splintage.
Fascial incision following ligature of the popliteal and lower femoral arteries was successful in saving some limbs. A case of primary ligature of the lower part of the femoral artery dealt with by fascial split at that time was fully recorded by Major Owen-Johnston, and the subsequent progress for a period of years has been ascertained. Major Owen-Johnston wrote following the operation that:
If ischaemic gangrene does not develop in this case then I think that it can be accepted as a very good test of the efficacy of fasciotomy of the leg aponeurosis in preventing the onset of ischaemia where the popliteal or lower femoral artery has been tied in battle casualties.1
The importance of early and frequent hand movements in all arm injuries was fully recognised.
In burns the problem was recognised as one of shock, and adequate plasma was the essential form of treatment. Simple dressings without anaesthesia were carried out, and penicillin utilised both locally and parenterally.
1 The patient's final result as recorded in November 1948 was that he was still experiencing cramp but had no pain in his foot, the sensation of which was normal. There was still weak action of his toe flexors. The soldier had been granted a permanent pension for a 25 per cent disability (15s. a week). He was employed driving a baker's delivery van. The original association of motor and sensory nerve disability had made the outcome still more satisfactory. There had been severe muscle loss but the patient had made an excellent recovery.