Priority and Optimum Time for Operation

Early operation in abdominal cases was carried out during the 1914–18 War and the considered opinion at that time was that the earlier the operation the better the results. This was in accord with the results obtained in civil surgery in such conditions as perforated gastric or duodenal ulcer and in acute appendicitis.

At the beginning of the Second World War this opinion was strongly held by all surgeons, and Brigadier Ogilvie advocated operation within six hours, with a maximum of two hours spent on resuscitation. During the first campaigns in Libya in 1940 the rapidity of movement in the desert prevented the proper functioning of the CCS in the performance of early operation on the abdominal cases, and a few surgical teams were attached to Field Ambulances for urgent surgery.

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In Greece the conditions during the retreat and evacuation militated against early operation. In Crete, again, orderly treatment was impossible and operation was carried out under great difficulties. Major Christie, who was attached to the Field Ambulances in Greece and Crete as a surgical team, reported that the abdominal cases were operated on as soon as possible.

During the second Libyan campaign in 1941, again, though provision had been made for the attachment of surgical teams to Field Ambulances to enable early abdominal surgery to be undertaken, and the Sims Mobile Surgical Unit had been attached to the New Zealand Division for the same purpose, the disorganisation of evacuation by the enemy armoured attack prevented the carrying out of our plans. Even at the forward operating centre which was set up by our Field Ambulances with the MSU attached, few of the abdominal cases were operated on within twenty-four hours of wounding.

Abdominal cases, however, along with cases with active haemorrhage and sucking wounds of the chest, were looked upon as first priority.

Conditions for surgery were more favourable when the Division was holding the Alamein line in 1942. Surgical teams from British CCSs, and later on from our own CCS, were attached to our MDSs and dealt with the abdominal cases as soon as rapid resuscitation by means of blood and plasma transfusions had been carried out.

The abdomens continued to be dealt with as first priority cases during the battle of Alamein and throughout the advance to Tunis. The forward position of the NZ CCS at different times, especially in Tunisia, rendered it possible for the operative treatment to be carried out almost as soon at the CCS as it could have been done at the MDS, and operation was therefore carried out at the CCS. Special arrangements were made for performing abdominal surgery in the Field Ambulances during the left hooks at Agedabia, Nofilia and Mareth, and in the final advance to Tunis.

During the Sangro battle in Italy at the end of 1943 all the abdominal cases were operated on at the MDS. The CCS was not far away at Vasto, but evacuation was very difficult, except during the latter part of the battle. It would have been possible to do the operations at the CCS at this later period, but it was still considered that the time-lag before operation was of primary importance. The conditions at Cassino early in 1944 were fortunately quite different, the CCS being sited on a good road so that cases could be rapidly evacuated to it. Operation could thus be undertaken almost as quickly as at the MDS, and the CCS dealt with the abdominal wounds. It was then found that a longer period of rest and resuscitation enabled the patients to stand the page 229 operation better and definitely improved the results. Operation within six to eight hours, as previously adopted as a standard, was held not to be of primary importance as against the giving of adequate time for full resuscitation before operation. The only exceptions to this fresh outlook were cases deemed to have continuing intra-abdominal haemorrhage or profound toxaemia from serious wounds elsewhere, such as traumatic amputations and large muscle wounds.

The average period spent in the pre-operation ward for resuscitation before operation was three and three-quarter hours, nearly double the period advised previously. There were only 11 deaths in 50 cases operated on in our CCS at that time, and cases operated on at a comparatively late period did well. Lieutenant-Colonel Button, the CO of 1 NZ Mobile CCS, stressed the fact that the men died of shock and that infection was rare at that stage, so there was not the same urgency as in the treatment of large flesh wounds. This opinion was supported by Major Lowdon, RAMC (attached for a considerable period to our CCS), who found that cases operated on between ten and twenty hours after wounding had a lower mortality than those operated on under ten hours; although elimination of some of the more serious cases had some effect on the figures, he stressed the necessity for adequate resuscitation and rest before subjection to the further trauma of operation.

Button's observations radically altered our outlook and the abdomens were placed lower on the priority list, and thereafter were normally dealt with at the CCS; but they were still considered by us to demand urgent operation at this level as soon as satisfactory resuscitation was assured. There was danger, however, in considering that the time lapse was no longer of paramount importance, especially if the decision as to the priority of the case was not made by an experienced surgeon with full knowledge of war injuries, and especially in those cases difficult to resuscitate. Figures for our New Zealand cases in Italy show that cases operated on in the first twelve hours still had a much lower mortality.

Table Showing Relation of Time of Operation After the Receipt of the Wound to the Death Rate

Time of Operation	Total	Dead	Percentage Mortality
Under twelve hours	79	39	49.3
Over twelve hours	26	18	79.2
On third day	4	2	50.0

In a small group of 36 cases operated on by Major Harrison at the CCS level from July 1942 to May 1943 in North Africa the mortality rate showed the effect of shock and haemorrhage in that the cases operated on in the first six hours carried the heaviest mortality page 230 (44 per cent), while those operated on from six to twelve hours after wounding had a mortality of 31 per cent, and those over twelve hours 28 per cent. (Major Stead's survey of British cases in Italy gave a mortality of 32 per cent for those operated on under six hours, 46 per cent between six and twelve hours, and 46 per cent between twelve and eighteen hours.)

It was considered by forward surgeons that abdominal cases should be evacuated normally straight back without stop from the ADS to the forward operating unit responsible for abdominal surgery so as to save time and movement. In-ambulance drips would provide any resuscitation required during the journey.

Place of Operation

It has already been pointed out that the peculiar condition of the early desert warfare rendered it impossible to utilise the CCS for first priority cases, including the abdomens. Surgical teams, later given an adequate establishment as Field Surgical Units, were therefore attached to the MDSs of the Field Ambulances to deal with these cases. They laboured under considerable difficulties. The Field Ambulance's normal function was to collect and evacuate casualties and to remain mobile ready to move off at any moment. Its function was not to operate on and nurse serious cases, and it was not equipped or staffed for this purpose. The surgical teams brought the staff and equipment necessary for the operative treatment, but not for the nursing and other care of the patients after operation. The presence of serious casualties hamstrung the Field Ambulances to some extent during phases of active movement if the evacuation of the cases was held to be inadvisable or was otherwise impossible. The nursing of the serious cases threw a great responsibility on the personnel of the ambulances, comparatively untrained for this work. In the early periods it was the custom to attach a single surgical team to a Field Ambulance, partly because there were few teams available, but also because of the desire of medical units and even senior combatant officers to have teams rigidly attached to their own separate forces. This frequently led to the single team having more cases to deal with than it was possible to operate on within a reasonable time, and the team carried on till it was exhausted, and the optimum time of operating on abdominal cases could not always be observed. This condition was improved by the attachment of more than one team, as was arranged in our MDS in the pre-Alamein period. It was also met to some extent in our own Field Ambulances by the attachment to each Field Ambulance of at least one surgeon capable of performing major surgery, so that the Field Ambulance itself could, and page 231 normally did, set up and staff an operating unit of its own. The nursing still remained a difficulty, though the Field Ambulance orderlies did their best and quickly learned the essentials of nursing.

The difficulties under which abdominal surgery was undertaken at the Field Ambulances during the earlier campaigns is illustrated by the following observation by one of our forward surgeons:

The treatment of abdominal injuries was undertaken under these circumstances as it was felt that the cases would otherwise surely have died. We had to depend on comparatively untrained orderlies for postoperative nursing; we had no beds, and only an odd bottle of saline or glucose. The blood transfusion service was not then functioning, and we had to depend on what blood we could collect locally. I used to start the morning of each day by taking blood from donors from the nearby Divisional Headquarters, usually half a dozen at a time, and the blood had to be used the same day as we had no refrigeration or cold storage. We had no autoclave, and our sterilisers were constructed from petrol tins.

Conditions improved considerably just before Alamein when some beds were provided in the Field Ambulances and nursing orderlies were attached from the CCS. Field transfusion units were also attached at the same period and remained thereafter a regular attachment to our active MDS. X-rays were not available at the MDS, and this lack assumed some importance in the diagnosis of obscure cases. Generally it was possible to give reasonably efficient treatment to the abdominal cases at the MDS when conditions demanded that operation should be carried out at that level. Even when surgical teams were attached to the Field Ambulances it was difficult for them to cope with all the abdominal casualties. When the teams became exhausted during a rush of casualties they were forced to send on some of the abdominal cases to the CCS for operation there. It was, however, the considered opinion of consultants and forward surgeons alike that abdominal operations were better dealt with at the CCS. The energy, initiative, and enterprise displayed in carrying out, at times, very successful abdominal surgery in the Field Ambulances was often misplaced and not in the real interests of the patients. It was done because the delay of a couple of hours was thought to be really serious and to override other considerations. The CCS possessed certain distinct advantages, and when it was decided that, within reasonable limits, the time-lag was not of supreme importance there was no longer any necessity for operation at the MDS. The CCS was in every respect better equipped. It was normally better staffed both as regards surgeons and especially as regards nursing sisters and orderlies. It had more elaborate equipment of all kinds, including beds and bedding, and an X-ray was available.

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Sterilisation of theatre supplies was possible. Above all, however, the CCS provided rest and quiet, freedom from anxiety, and extra comfort. As a forward surgeon stated,' One has often seen the terror of the patient, anchored to his bed with intravenous apparatus and gastric suction, when the vicinity is being shelled'. Finally, and most important, the CCS had the ability to hold and nurse the abdominal cases till complete stabilisation had taken place, a period normally of about a fortnight. The best position of a CCS was as far forward as the provision of the above conditions and the presence of nursing sisters allowed.

Staffing for Abdominal Operations

This was satisfactorily arranged, as far as the surgical operation was concerned, by the attachment of well-trained young abdominal surgeons to Field Surgical Units in the forward areas, either attached to the Field Ambulances or to the CCS. The surgeons were chosen with prior experience of abdominal surgery, with an adequate background of sound training in a first-grade hospital, and also with some experience of war surgery. The middle thirties was the most suitable age, and courage, initiative, resource and stamina were essential. As already pointed out, there were weaknesses in the attachment of lone teams, and at no time in rush periods was there ever sufficient surgical potential to deal quickly with all the cases.

Well qualified and experienced anaesthetists were in short supply in the forward areas, and stress was laid by all surgeons on the value and necessity of having the very best anaesthetists and the best available apparatus for the benefit of these very serious cases.

Nursing sisters proved of the utmost value both as theatre sisters and in the nursing of cases after operation. Orderlies became very efficient in the pre-operation ward and in the theatre.

Diagnosis

The diagnosis of an injury to the abdomen was generally obvious, but at times was very difficult, and the services of a surgeon of wide experience were invaluable. It was of considerable importance to make sure that abdominal operation was really necessary, as a serious mortality attended negative exploration. As Major Rob, RAMC, pointed out in 1945, a full clinical examination was essential, and the abdomen should never be opened until a sound diagnosis had been made. This epitomised what was our New Zealand approach to the problem. It was also of importance to determine beforehand the possible extent of the intra-abdominal injury and so be able to restrict the extent of the exploration, especially in seriously ill patients.

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Normally the diagnosis of abdominal injury would be made in the forward divisional areas, and the case sent back clearly labelled as an abdominal casualty.

The diagnosis depended on:

(a)	The site of the injury and probable course of the missile.
(b)	Local signs of intra-abdominal injury, such as rigidity of the abdominal wall, lack of audible peristalsis, abdominal distension, dullness in flanks or the pelvis.
(c)	General symptoms of abdominal injury: shock and appearance of distress, signs of internal bleeding (pallor and rapid, thin pulse).
(a)	Site of Injury: The wound of entry was at times far removed from the abdominal cavity. Buttock wounds were notorious for their abdominal complications, which might include intra-peritoneal lesions of the rectum or bladder, or injury to the urethra, and even thigh wounds were associated with abdominal injury. Fortunately a perforating wound of the abdominal wall or the loin very commonly traversed only the superficial structures, the missile being often deflected from a straight course.
(b)	Local Signs: Abdominal rigidity in the left upper abdomen was often present in diaphragmatic and also in retro-peritoneal injuries, but the absence of intra-abdominal injury was generally recognised by the rigidity being less marked and more localised, and by the lack of other signs of peritoneal involvement. Lack of Audible Peristalsis: This sign was of great importance, especially in injuries in the region of the liver. This was stressed at the Rome Surgical Conference, 1945, by Major Rob, who considered auscultation essential in diagnosis, the absence of peristaltic sounds being conclusive of intestinal injury. By this means he had excluded from laparotomy 51 cases, including practically all the liver and kidney injuries, out of a total of 162 cases showing definite abdominal symptoms and signs. Captain Douglas, NZMC, however, considered that peristalsis might sometimes be present in cases with small lateral colon and intra-peritoneal rectal wounds. Retro-abdominal Haematomata: Large accumulations of blood in the loin and pelvis were common, and it was at times difficult to decide whether penetration of the abdominal cavity and possible injury to a hollow viscus had occurred. One case operated on at our CCS during the battle of Mareth had a large retro-peritoneal haema-toma, and a moderately large foreign body lay directly behind the peritoneum. X-ray Examination: This proved of very great value in doubtful cases by showing whether a foreign body had probably traversed or was lying in the general abdominal cavity. For instance, if an page 234 entry wound was in the left flank and the missile was shown by X-ray to be well to the left of the mid-line, there would be no need to explore the right colon and pelvis, and handling and retraction would be saved. Operation was often negatived by localising the foreign body in the region of the diaphragm or in the retro-peritoneal tissues. In both of these positions marked abdominal signs were often present.
(c)	General Symptoms: Shock and haemorrhage were the pre-operative problems. The general symptoms relating to abdominal injury were at first almost entirely due to the extent of the intra-abdominal bleeding, provided there was no gross trauma elsewhere in the body. When there had been little bleeding the abdominal signs were often very slight, and injury, especially to the small intestine, was easily overlooked. There might be progressive deterioration due to continued serious haemorrhage which prevented satisfactory resuscitation by blood transfusion and which constituted a definite indication for immediate operation.

A casualty was noted at the MDS to be in quite good condition some hours after wounding, but when he arrived at the CCS he was pulseless and gravely ill. He was given blood, but his condition did not improve very much, and a very experienced transfusion officer doubted his ability to stand any operation. The surgeon, however, diagnosed mesenteric haemorrhage and counselled immediate operation with continuous blood transfusion. A large, freely-bleeding mesenteric vessel was found with minor injury to the small intestine. The patient made a rapid recovery.

Vomiting was unusual, especially in the early stages. Lack of bowel movement was naturally not of much moment under battle conditions. Approaching the twenty-four hour period there was present a general deterioration, which became accelerated as the time after wounding increased and the toxaemia due to peritoneal infection became manifest. The signs of peritonitis from faecal contamination were seen only in the late, generally hopeless, cases. Peritonitis was rather a post-operative than a pre-operative problem.

The following case illustrates difficulty in diagnosis:

Soldier wounded in left buttock on 23 October 1942 at opening of battle of Alamein. Wound dressed at ADS, and re-dressed at ⅔ Australian CCS. The MO on ambulance train noticed' abdominal distension, vomiting and rigidjty'. Patient admitted 2 NZ General Hospital on 26 October with a history of vomiting for two days. He was still vomiting with a distended abdomen especially in caecal area; there was no audible peristalsis but the abdomen was not rigid. X-rays showed a perforation of the wing of the ilium and a large foreign body apparently in the abdominal cavity. Intravenous drip and gastric suction was started, and after some hours audible peristalsis was noted and wind was passed. Later the bowels acted and stools became frequent. The local abdominal signs appeared satisfactory, but patient's general condition deteriorated steadily and he suddenly collapsed and died on the eighth day. On the page 235 day before his death he had a white count of 21,000. Post-mortem disclosed localised purulent peritonitis with pus between coils of small intestine, apparently originating in region of the descending colon. The FB was not found. There were small pyaemic abscesses in the lung.

This is a very interesting case showing: (a) the danger of overlooking abdominal injury in buttock wounds in a rush of casualties; (b) the value of recording signs and symptoms as shown by the accurate diagnosis of abdominal injury on the hospital train; (c) the deterioration in abdominal cases following early evacuation; (d) that information given by X-ray in obscure cases is often of great value; (e) the difficulty in diagnosing late cases of peritonitis when positive local signs such as rigidity are often absent and general signs of toxaemia predominate, and when loose bowel movement is often seen; (f) the danger and severity of infection arising from wounds of the large intestine; (g) the unusual frequency of vomiting, possibly associated with the constant movement due to the non-recognition of abdominal injury.

Special Diagnostic Measures

1.	X-ray has already been mentioned. Experienced surgeons were emphatic on the value of X-rays in difficult cases.
2.	Auscultation has also been discussed and its value stressed.
3.	Catheterisation was a routine procedure both for the diagnosis of urological injury and for the comfort of the patient.
4.	Suprapubic incision. Brigadier Donald, RAMC, during the Alamein battle carried out, and advised, a limited suprapubic laparo-tomy to determine whether blood was present in the pelvis, as this was almost a constant sign of intra-abdominal injury warranting laparotomy. In seriously ill cases particularly, the limitation of the exploration was of considerable value.
5.	If there was any doubt as to whether a missile had penetrated the peritoneum the wound was debrided and enlarged to make certain, and, if necessary, a fresh exploratory incision was made to deal with the intra-abdominal injuries.
6.	Percussion was of special value in determining the presence of fluid in the flanks or in the pelvis as well as the loss of liver dullness from intestinal gases.
7.	Rectal examination. This was carried out in all suspected rectal and pelvis injuries. Proctoscopic examination was sometimes added.

Resuscitation

As in other casualties the administration of blood, plasma, and serum was invaluable in the resuscitation of abdominal patients. Other measures such as rest, quiet, comfort, and reasonable warmth were also of great value, and it was learnt as the war went on that page 236 some time must be allowed for recuperation from the wound trauma before operation should be undertaken. The centra-indications of fluid by the mouth increased the difficulties of resuscitating the abdominal cases which suffered, like all seriously wounded men, from dehydration. This rendered the administration of intravenous fluid particularly valuable.

There was considerable difference of opinion as to the importance of blood loss in abdominal injuries. Lieutenant-Colonel Grant, RAMC, considered that, whereas in serious limb injuries a blood loss of 50 per cent was common, the blood loss in abdominal cases was much less serious. This was corroborated by the Canadian research unit, which found that the average blood loss in the abdominal cases was 25 per cent against a 50 per cent loss in other serious cases. Forward surgeons, however, were agreed that serious blood loss was common and that the abdominal cavity was often full of blood, and our results show that the mortality in the cases with marked blood in the abdomen was very high. Most experienced forward surgeons strongly stressed this, and Major S. Wilson, NZMC, drew particular attention to the cases associated with severe bleeding and the necessity for urgent operation and the bad prognosis of these cases. Many of the patients who died on the table or during the first few hours after operation were those in whom severe bleeding had taken place. Forward surgeons expressed the opinion that marked loss of blood was much more serious in the abdominal case than it was in a limb injury. There was no doubt, however, of the value of blood transfusion in these cases. Lieutenant-Colonel Grant recommended the giving of plasma in the field units and blood immediately before operation. Patients differed considerably in their ability to withstand loss of blood, and some cases were found to have efficient circulation after a loss of a third of their blood volume. There was common agreement that loss of circulatory fluid was the main factor in the production of shock, and fluid replacement by blood and plasma was found to relieve cardiovascular collapse satisfactorily in practically every case. If a case failed to respond to resuscitation by blood, it usually meant either continued internal haemorrhage or else irreversible shock, the result of gross irrecoverable injury.

Illustrative Case: Patient admitted five hours after accidental wounding in lower chest by grenade. Condition very grave; BP 60/30. Three pints of blood given rapidly, but condition failed to improve and continuing bleeding diagnosed. Urine was blood stained. Abdomen opened by left upper rectus-splitting incision; massive retro-peritoneal haemorrhage found coming from a ruptured kidney with completely severed pedicle. Rapid nephrectomy performed, but patient collapsed and died before bleeding could be properly checked, dying ten minutes after the induction of anaesthesia.

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The management of resuscitation proved to be of the utmost importance. It was quickly realised that a patient could not be satisfactorily resuscitated more than once. Preliminary treatment, especially in the severe cases, was often necessary in the field units, and plasma proved of grear benefit at that stage. Continuation of the transfusion, either of plasma or blood, as an in-ambulance drip was sometimes advisable during evacuation to the operating centre. The final preparation and full resuscitation was only given in the pre-operation ward immediately preceding the abdominal operation, the timing of the operation being carefully judged by the transfusion officer in charge. The amount of blood and plasma given was on an average two pints of blood and one of serum, but there was considerable variation, some cases requiring little blood, whereas others with severe intra-abdominal haemorrhage were given large quantities. (A case is recorded in which seven pints of blood and two of serum were administered before and during operation. The abdomen was full of blood coming from severed arteries at the root of the mesentery. There were three holes in the small intestine. The patient recovered, though resuture of a ruptured wound was required later.) Sometimes only plasma was required. The rate of transfusion was of great importance. This was pointed out by Major Giblin, AAMC, who first gave blood very slowly with unsatisfactory results, and then allotted a maximum period of one and a half hours for the administration, giving serum followed by a pint of blood in ten minutes. The rapid administration of the first pint or two of blood was soon the regular practice, any further blood generally being given more slowly. As already stated, stress was laid at the beginning of the war on the performance of operation at the earliest possible moment after wounding, but experience showed that the more important factor was the obtaining of adequate resuscitation, and that a little extra time spent for that purpose paid handsomely in results.

The Indication for Laparotomy: Abdominal exploration was indicated when the diagnosis of intra-abdominal injury involving a viscus or associated with haemorrhage was made, or when the diagnosis was seriously in doubt. Expectant treatment was only justified when the opinion was strongly against any such involvement.

Operatability

Very early in the war the difficult decision was arrived at by our forward surgeons that an operation should be performed if there was any vestige of hope for the patient. It was impossible to operate on every wounded man when casualties were heavy, and the more patients operated on the more delay in the individual case.

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A surgical team could, as a rule, perform only twelve operations a day. It was a question of priority, and some rightly argued that time spent in operating on a hopeless abdominal case would have been better spent in dealing with other serious wounds in patients likely to recover and also likely to be of further use in the Army. The training and outlook of medical men, however, has always been to give a patient a chance however poor it may be, and this outlook led to our surgeons operating on practically all patients able to be brought to the operating table. Only three abdominal patients admitted to our CCS were not operated on during the Italian campaigns, and (including cases operated on in CCSs other than our own) over 96 per cent of our New Zealand cases were operated on at that level. This naturally vitiated the results as far as recovery after operation was concerned, but fortunately results were not allowed to enter into the question, each patient being dealt with as a separate problem. A tenth of our cases in Italy remained in a very serious condition at every stage and were probably hopeless from the beginning, and possibly should not have been operated on, but surprising recoveries sometimes did take place.

The prolapse of bowel was a very grave prognostic feature. Major Giblin, in reporting 90 abdominal cases at the Alamein period in which he obtained excellent results, stated that all his prolapsed bowel cases died. However, we have records of recovery in two of these cases, both necessitating resection of small intestine, at an FSU attached to a Field Ambulance in the final battles in Italy.

Illustrative Case: Operation five hours after wounding by a bazooka. Most of the small intestine prolapsed on the abdominal wall through a large deficiency in the right lower recrus muscle with considerable burning of the abdominal wall. Twelve inches of small intestine was non-viable due to damage to the base of the mesentery. Resection and end-to-end anastomosis was performed and burnt appendix also removed, as also was a piece of bomb. The defective abdominal wall could only be closed by peritoneum. The condition of the patient was critical for forty-eight hours. Peristalsis returned on fifth day. Some sloughing occurred in the abdominal wall, but patient's general condition was satisfactory. The abdomen was enclosed in a plaster cast and he was evacuated on the tenth day and recovered.

The decision as to the optimum time to carry out the operation was determined by close observation of the patient's condition and by particular attention to the circulation as shown by his pulse and blood pressure. The vitality of patients differed considerably, and this was associated with their mental attitude and their will to live and their co-operation as patients.

The pulse was a valuable indication both in its volume and rate. A fast thready pulse was an indication of serious circulatory disturbance. Pallor also indicated blood loss. The blood pressure page 239 was of the greatest importance as it was possible to make accurate determinations not subject to individual judgment.

Lieutenant-Colonel Wilson, RAMC, who carried out research work at the time of Alamein, considered that a systolic blood pressure of 80 mm. Hg. was the minimum of operatability. A minimum of 100 mm. was aimed at by the transfusion officer before listing for operation unless special conditions, such as continued bleeding preventing full resuscitation, were present. The limits were not, however, rigidly enforced. Major Blackburn, RAMC, wrote,' generally it is courting disaster to begin operation with a systolic pressure of less than 90 mm. Hg., but it is courting death not to begin at all. At times an unexpected reward will be gained in an apparently hopeless case.' That epitomises the approach of our own forward surgeons to the problem. Normally operation was undertaken when the blood pressure was 100/80 and rising and the pulse and colour correspondingly improved. This usually took three to four hours.

The Late Case

There was considerable discussion with regard to the treatment of the late cases admitted to the operating centre more than twenty-four hours after wounding. It was held by some that the chances of survival of these cases were so poor that it would be better to leave them and operate on earlier cases or on other types of injury where definite good could be done. In spite of the logic of this approach the forward surgeon could not bring himself to discard these cases, even if the chance of success was very slight. Operation was therefore undertaken, unless the patient was obviously moribund. Normally the usual operative procedures were carried out.

It was not uncommon for evisceration of bowel, a grave prognostic feature, to be present. This was normally replaced and the abdomen closed. Sometimes the operative procedures entailed considerable manipulation and added to the already severely shocked condition of the patient. The results of treatment were very disappointing, most of our surgeons stating that they had had only a very occasional success and some had had none in the late cases. One surgeon states,' I never had any success with the very late abdomens. I think they should be rejected, especially if other abdominal cases are waiting.' Another records,' A very old abdomen in my opinion is best left alone.' Button at our CCS at Cassino recorded that none of the long-term cases (twenty, twenty-four and forty-eight hours, etc.) died in spite of advanced peritonitis. Stress was then laid on adequate resuscitation and conservative surgery.

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It appeared that there would have been better results if the cases had been treated more conservatively. This is illustrated by an actual case observed in Italy. Nearly three days had elapsed since the wound, and a loop of terminal ileum and a small part of the caecum were in the wound. The patient's general condition was surprisingly good and there was little abdominal distension. There were wounds of the extruded bowel. At operation a paramedian incision was made to explore the abdomen, and the small bowel was sutured and returned to the abdomen, both wounds sutured, and a drain left in the pelvis, where some purulent fluid was found. The patient subsequently died. The after-thought naturally arose as to whether any other treatment in such an unusual case was possible. Perhaps removal of the extruded loop with the ends left open as a double-barrelled ileostomy and partial closure to close over the portion of caecum could have been carried out rapidly with no trauma, and the peritoneum left to care for itself, with subsequent drainage of the pelvic collection, if necessary. He might have had a better chance with the simpler, though not perfect, procedure; and in bad cases a risk of leaving something undone must be taken.

The type of treatment of the late appendix could reasonably be followed in the abdominal wounds of war, and exploration restricted to the drainage of any abscess which developed. Cases have struggled to recovery in that way, and it must not be forgotten that abdominal cases did recover without operation during the South African and other previous wars. The utilisation of penicillin and the sulphonamides, gastric suction, and intravenous blood serum, and fluids give us a better chance today.