War Surgery and Medicine
The only battle casualties that are worthy of special comment are those due to the effects of blast on the ear. These cases fell into two main groups—the sudden injury and the gradual one.
Sudden injury due to blast was a very common one. It was far more common than generally realised, as a man with a painful wound from a near-bursting missile often failed to notice his aural symptoms until much later, or, if they healed, failed ever to be aware of them. When Major Elliott was in command of an ADS at the Battle of Alamein he made a survey of ear injuries. In this battle the vast majority of wounds were due to mines, mortar and aerial bombs, and to shells. All these weapons produce a blast effect not present with small-arms fire. Of all cases passing through the ADS at least 30 per cent showed some clinical lesion of the eardrum. These ranged from gross perforation through page 453 contusion and flame-shaped haemorrhage, down to minimal hyperaemia with deafness and tinnitus. Many of the men did not complain of aural symptoms until questioned.
In the early days of the war perforations of the eardrum with the usual haemorrhage due to blast were treated by the instillation of spirit drops, or even by syringeing out the blood clot. They nearly all became infected and became cases of suppurative otitis media, often chronic, and resulted in permanent damage to the ear and down-grading. Later in the war the standard treatment, laid down by definite orders, was that no local treatment should be employed apart from a plug of sterile dry cottonwool in the ear. Sulphonamides were often given by mouth. A prophylactic course of sulphonamide was given for blast rupture, and a full therapeutic course for all infected cases. Cases so treated usually healed without infection. After healing of the drumhead, hearing often returned, but a fair percentage had permanent impairment of hearing, usually of the high tone type. Troublesome tinnitus was a frequent sequel and was very difficult to relieve, still being seen often in war pensioners.
In a survey of 1000 battle casualties admitted to 2 NZ General Hospital in 1944–45, Major F. B. Korkis found that 3.1 per cent had deafness attributable to blast. Half of these cases were found to have had a rupture of the drum. Deafness was generally of mixed middle and inner ear types, 83 per cent having some nerve deafness which showed little or no recovery. Infection in some degree had occurred in half the cases with rupture of the drum. Acute mastoiditis was uncommon, but the sub-acute type was relatively common and was treated by drainage when it persisted for more than five weeks. The smaller lesions of the drum healed spontaneously in the absence of infection.
Blast injury of gradual onset is an occupational disease of gunners, mortar crews, and the like. The incidence varies according to the weapon, the high-velocity gun such as the anti-tank gun and guns fitted with muzzle breaks being the worst offenders. Gunners of long service often began to get troublesome tinnitus and developed a high tone nerve deafness. These disabilities were found to be permanent and are frequent causes of pensions claims. During the Second World War much attention was given to the problem, but it was never satisfactorily solved. The use of verbal orders precluded the wearing of efficient ear protectors, and, in Middle East conditions, certain types of ear plugs caused a high incidence of otitis externa. A vaselined wool plug was held to be reasonably effective. This is a subject requiring more research both by medical and artillery officers.page 454
Other Wounds: Wounds of the temporal bone, the larynx, and the facial bones were dealt with in consultation with the general and the plastic surgeons.
Neurosis Aspect: There was a danger of establishing a neurosis complex through the interpretation of minor nasopharangeal symptoms as a chronic disability. Major Elliott believed that most of the troops who went through the North African desert campaign or a summer of fighting in hot and dusty Italy had nasal symptoms and headaches to a greater or lesser degree. The threshold at which a man reported sick depended on the stamina and will to fight of the individual.
In Italy in May 1944 Captain Simpson said: ‘An increasing number of soldiers are becoming “sinus conscious” and every headache is attributed to sinusitis—in some cases to an obsessive degree. It is a more fixed idea where a previous attack has been labelled sinusitis. These obsessions may be infectious unless the RMOs narrow down the diagnosis of sinusitis to the true cases, and discourage loose talk on the subject.’