War Surgery and Medicine
POST-OPERATIVE PROGRESS IN THE FORWARD AREAS
POST-OPERATIVE PROGRESS IN THE FORWARD AREAS
This was influenced markedly, as one would expect, by the general conditions of the campaign and also by the conditions under which the surgical treatment, resuscitation, and nursing could be carried out. Thus, in the first Libyan campaign lack of mobility of the CCS militated against prompt treatment of abdominal casualties. In Greece and Crete battle conditions made it very difficult to provide page 256 efficient treatment. Both Lieutenant-Colonel Debenham, RAMC, and Major Christie, NZMC, reported that the abdominal cases in Crete did badly and generally ended fatally if the bowel was perforated, and all rectal cases died. In the desert campaigns evacuation over the rough terrain had serious effects on abdominal cases, as did early evacuation by air. In Sicily the continuous and exhausting fighting led to a marked increase in mortality. In Italy at the Sangro battle there were severe weather conditions as well as difficulties of evacuation. During the worst period at Castelfrentano 9 cases died out of 12 abdominal operations. Later in Italy the conditions improved, and with our marked air predominance medical treatment was largely unhampered, giving the abdominal cases a better chance of survival.
It was realised from the beginning of the war that the majority of the deaths occurred soon after wounding or soon after operation, generally within the first forty-eight hours. It was also realised that gross trauma and serious haemorrhage were the main causes of these deaths, and that infection with peritonitis was a secondary or later danger. There were certain lesions with a bad prognosis, and the common association of serious injury elsewhere in the body added markedly to the mortality. Multiple abdominal lesions were naturally more fatal. Large bowel lesions, especially rectal injuries, were more serious than lesions of the small intestine, but resection of the small intestine had a high mortality. Duodenal lesions were generally fatal, as were massive injuries of the liver. Thoraco-abdominal injuries involving a hollowr viscus also had a high mortality. Deaths from ileus were largely prevented by the adoption of continuous gastric suction and intravenous fluid administration, and the giving of blood and plasma, both following operation and about a week later, did much to improve the chances of survival. The use of the sulphonamides and penicillin also contributed, but probably to a much lesser degree.
The commonest cause of death from the second to the tenth day in the forward areas was anuria. Lung complications also occurred. These could be prevented by adopting the normal lying position following operation, and also by the prevention and removal of bronchial mucus and the encouragement of deep breathing and, if necessary, coughing. Peritonitis was noted generally in the late cases.
Anuria developed in the seriously shocked cases which responded slowly to resuscitation.
Eight of the twelve deaths from anuria in our New Zealand series in Italy took place between the fourth and seventh days following operation, and the last two cases were on the tenth day. Conditions noted in these cases were that four patients were page 257 extremely shocked; four had a very large quantity of blood in the abdomen; three had faeces and also a fairly large quantity of blood in the abdomen; only one case had been given an extra large transfusion of blood; two had injuries to the main blood vessels of the lower limbs; one had amputation of the thigh; two had large buttock wounds; two were injured by blast, which in itself causes a high mortality; three had multiple abdominal injuries; three had injuries to both the small and large intestines; one had injury to the pancreas, one to the duodenum, and one to the liver and gall bladder.
It is quite evident that in our cases anuria was associated with very severe injury, and anoxia of the kidney following the shunting off of the renal circulation would seem a rational explanation of the damage to the renal tubules which takes place, and which is often associated with casts and albuminuria. To prevent the onset of anuria full resuscitation, both pre- and post-operative, was essential, and the giving of intravenous fluid at the same time to attempt to keep the urinary function active seemed a logical plan. Treatment proved largely unavailing. Various methods were tried to stimulate the kidneys to function, such as 10 per cent glucose or sodium sulphate intravenously, pressor substances, renal lavage and sympathetic block, without result.
There was often noted to be a dangerous weakening about the seventh day, possibly toxaemic in origin. Later septic manifestations showed themselves, and proved the main problem, at the base hospitals.