War Surgery and Medicine
PROBLEMS AT THE BASE HOSPITALS
PROBLEMS AT THE BASE HOSPITALS
In a survey of battle casualties at an advanced base hospital (2 NZ General Hospital) in Italy abdominal cases totalled 2·7 per cent of all casualties admitted, the same proportion as major amputations and just more than chest wounds. The abdominal cases, however, accounted for 10 out of a total of 16 deaths in the hospital among battle casualties.
As already stated, the main complications arising in the abdominal cases at the Base were due to infection in one form or another.
Secondary haemorrhage sometimes occurred, mainly associated tvith colostomy wounds. Rarely was it seen in the abdomen, but cases of bleeding from the mesentery were recorded. In one case, at the CCS, fatal haemorrhage took place from a repaired wound of the jejunum. The bleeding came from a very small raw area in the invaginated suture line close to, but not at, the mesenteric border, and seemed to be the result of a small false aneurysm. The patient's condition following other extensive abdominal injuries did not allow of exploration, and blood transfusion did not save him.
In all there were seven recorded cases of secondary haemorrhage, with five deaths, all of which, except the jejunal case, were associated with marked sepsis.
Intestinal obstruction: This was usually a sequel of peritonitis. One case, however, was noted with the development of a volvulus following haemoperitoneum without visceral injury. This pointed to the necessity of evacuating blood from the abdomen during operation. A case was reported of obstruction due to herniation of the small bowel lateral to a left iliac colostomy. There were 9 cases in 2 NZEF in Italy, with 6 deaths. Two of the deaths followed resection of the small intestine.
Case Illustrating Late Obstruction at the Base Soldier wounded 23 October 1942, Battle of Alamein. Operated on at MDS six hours later. Three small holes in descending colon and a large hole in transverse colon found. Splenic flexure mobilised and transverse colon sutured to pelvic colon, and the whole splenic flexure brought out as a colostomy. Drain to pelvis; 10 grammes sulphadiazine introduced; 5 pints of blood during operation. Eight days later passed through 1 NZ CCS, and twenty-six days after wounding admitted to 2 NZ General Hospital with a history of having had a secondary haemorrhage on the tenth day, for which he was given 3 pints of blood. When admitted to 2 NZ General Hospital he was very pale and ill, but the abdominal wound and drain wound had healed; the colostomy was healthy, but there was a pocket of pus lateral to the colostomy. Eleven days after admission to 2 NZ General Hospital he was operated on for acute obstruction, and a loop of small intestine was found to have prolapsed through a foramen formed page 261 by the lower limb of the colostomy and the lateral abdominal wall. This was reduced, but his condition did not allow of closure of the foramen. Patient recovered, and later the pus pocket was opened up and a bullet removed from the region of the spine.
Burst Wound: This was always associated with infection, both of the wound and of the peritoneum. It carried a high mortality- 8 deaths in 11 noted cases and 6 of a series of 16 deaths at our base hospitals. Retention of cases in the forward areas and penicillin given parenterally from the beginning appreciably lowered its incidence. Half of the deaths at Base had serious infection of the abdominal wound, associated with peritoneal and generalised infection.
Wound Sepsis: This was found to be much more common if the gunshot wound was utilised for abdominal exploration or for the exteriorisation of the colon. Lieutenant-Colonel J. M. Clarke, NZMC, reported that half the incisions which involved the original wound had severe sepsis afterwards. Abdominal wall abscesses were serious and were often silent. Lieutenant-Colonel L. A. Bennett, NZMC, reported that no case which had a colostomy brought through a separate incision, or in which the retro-peritoneal tissue had been well drained, developed an abscess.
Incisional Hernia: This was relatively frequent and was referred to by many observers. Transverse rectus incisions were found by Colonel Brebner, South African Consultant, to be especially prone to hernia, but so also were rectus split incisions and to some extent also paramedian incisions. The mid-line incision seemed to give less trouble and was utilised much more towards the end of the war.
Peritonitis: This was the commonest cause of death in the base hospitals, as shown in Major Stead's figures, in Lieutenant-Colonel Clarke's report, and in Colonel Stout's review.
In Italy peritonitis accounted for 14 deaths in the 2 NZEF, 9 of them at the Base. It was recorded in Lieutenant-Colonel Clarke's report that all 3 cases of resection of the small bowel died of peritonitis in the base hospital. It was also recorded that out of 11 cases of peritonitis 7 died, and in no case had a drain been used at the original operation. Only eight of 57 cases had been drained. This was a very significant observation and was in keeping with Ogilvie's opinion as to the advisability of drainage.
Recorded Case: Patient with ten holes in small intestine, foreign body removed from the pelvis. Developed haematoma of the wound which became septic and burst. A faecal fistula developed, followed by localised peritoneal abscesses. Death took place on the twentieth day, the patient having been evacuated at a comparatively early stage from the CCS. At the post-mortem gangrenous peritonitis was found.page 262
Gangrene of the Bowel: Two deaths occurred from gangrene following vascular damage. In one case the last six inches of the ileum and two-thirds of the ascending colon were affected, and in the other a portion of the stomach.
Subphrenic abscess, which led to three deaths, caused great difficulty both in diagnosis and treatment. Adequate drainage was established posteriorly and from below by an approach through the bed of, or below, the last rib.
Recorded Case: Operation in twelve hours, extensive blood in the abdomen associated with injury to the liver, no drainage. Developed subphrenic abscess and empyema for which drainage was instituted. Patient died suddenly, probably from cardiac failure associated with the toxaemia. Lack of primary drainage is noted.
Retro-peritoneal abscess: Infection in this region was relatively common, but was generally warded off by free drainage of retro-peritoneal injuries.
Abscess Elsewhere: These were not common but demanded careful handling. Abscesses were opened when the location and access were both quite definite and nothing but simple opening and drainage instituted. Searching and dissection for obscure abscesses in the abdomen was an unsatisfactory and dangerous procedure. Constant alertness had, however, to be exercised in elucidating the explanation of continued illness and pyrexia in all wounded patients, especially with lesion of the abdomen or chest. Ten cases were recorded with four deaths, all associated with very severe injuries.
Recorded Case: Moderate bleeding in the peritoneal cavity; small intestine injury and one large tear in the extra-peritoneal portion of the rectum, which was sutured and drainage instituted through the buttock wound. Abscess of the abdominal wound developed on the tenth day. The patient was evacuated on the eleventh day. He also had a fracture of the femur. Sepsis developed in the buttock wound and in the femur, and he developed a cerebellar abscess, meningitis and broncho-pneumonia. The femur wound was responsible for his evacuation from the CCS on the tenth day so that definitive treatment could be carried out at the base hospital, which was quite close and easily reached over a good road. Even if he had been retained at the CCS recovery could hardly have been hoped for. Patient died in hospital.
Kidney Infection: Serious infection sometimes developed in a damaged kidney, especially when there was an associated wound of the colon. The kidney infection produced rapid deterioration of the patient's condition, often rendering secondary nephrectomy impossible, and it was associated with a high mortality. Primary nephrectomy was therefore generally carried out when there was injury of both kidney and colon.
A man was wounded in the right loin with involvement of the hepatic flexure and the right kidney. Colostomy was performed and the kidney drained. Six weeks later he died from pyelo-nephritis. Primary nephrectomy would have saved him.page 263
Colon Injuries at a Base Hospital
In a series of 39 cases of injury to the colon treated at 3 NZ General Hospital in Italy there were 2 deaths, a mortality of 5 per cent. One of the deaths was an associated injury of the colon and kidney without nephrectomy, and the other a severe injury to the right colon with prolapse of the ileo-caecal valve and an intermuscular abscess.
Anaemia: Secondary anaemia was common in abdominal cases and was frequently associated with sepsis. A marked deterioration often set in about the seventh day, and extra blood and plasma transfusion at that period proved very valuable. At a later period, especially in the infected cases, extra blood was again required. Fresh blood, carefully cross-typed, was necessary at that stage, as severe reactions were not uncommon.
Nutritional Deficiencies: These were quite common following abdominal injuries, no doubt due to the semi-starvation and also to the toxaemia present. Improvement followed the early administration of light nourishment during the latter part of the war. Blood and plasma infusion were also of assistance, as well as a high protein diet and vitamin products. A great deal of importance was placed on these matters at the end of the war. The rapid healing of the wounds was also held to be dependent on proper general nutrition.
Chest Complications: These were relatively uncommon. Nine deaths were recorded. Apart from the obvious septic conditions, lung complications were of little importance, and some cases of oedema of the lung were probably due to anuria. Three cases of pneumonia were recorded.
Repair of Colostomy: In the first half of the war little attempt was made to close the colostomy wounds overseas, and the patients were evacuated to New Zealand to have the repair carried out there.
In the latter part of the war, however, every effort was made to repair the colostomy in Italy before evacuation to New Zealand. This was carried out by pressure clamp on the spur, by operative repair, or by a combination of the two. The repair was carried out in the colon cases as soon as definite stability had been reached. Rectal cases needed a much longer interval to enable the perineal wound to heal. In caecal injuries with drainage by Paul's tube repair was carried out by purse-string suture on the day the tube came out.
Disposal of Cases at the Base Hospitals
The large majority of the abdominal cases were evacuated to New Zealand as no longer fit for active service, and only two out of 57 men at one base hospital were returned to full duty. Our page 264 opinion was that it was in general undesirable to retain such men in the forces. Even if they made a satisfactory recovery, a long period of convalescence was desirable, and this was better carried out in New Zealand.
(As reported from the Pensions Department in New Zealand)
It has been ascertained that abdominal injuries generally cause no permanent disability and that comparatively few pensions have been granted for them. There have been very few reports also of serious complications.