War Surgery and Medicine
It was stated by Major Stead, RAMC, in his Italian survey that abdominal operations represented 4·6 per cent of all opefations performed on battle casualties in the forward units, but that half the deaths occurred in the abdominal group.
The results obtained in the treatment of abdominal injuries during the war were undoubtedly satisfactory in comparison with those achieved in previous wars. It was most important, however, to realise the pitfalls of statistics. The results quoted were nearly always the percentage of recovery in cases operated on. It was obvious that this depended on the operation rejection rate and also on the number of cases reaching the operation centre. If operation was carried out at the Field Ambulance, cases were dealt with which would possibly not have survived to reach the CCS. The cases dying before operation or not operated on were not generally included in the figures. The follow-up of cases evacuated from the forward areas was always difficult, and it was probable that some deaths were missed at that stage. It was also necessary to cover a long period and a large number of cases as freak results were sometimes obtained in a small series. There were several surveys made during the war, and results are set out in the following table:
|Period||Reported by||Number of Cases||Percentage Mortality||Remarks|
|End 1941||Surg Conf MEF||25||60|
|Late 1942||Giblin, AAMC||90||58||Before exteriorisation.|
|Late 1942||Giblin, AAMC||90||38||After exteriorisation.page 265|
|1942–43||Harrison, NZMC||36||36||No rejected cases.|
|Mid 1943||Ogilvie, RAMC||628||39.2|
|1942–43||NZ cases in Ogilvie series||96||29|
|Late 1943||Lowdon, RAMC||64||44|
|Early 1944||Button, NZMC||50||22|
|1944–45||Stead, RAMC||78||60||Laparotomy,79percent; thorac-otomy, 35 percent.|
Major A. W. Douglas, NZMC, who was a forward surgeon with the Field Surgical Unit, has reported a series of 125 abdominal cases operated on from February 1943 to August 1944 in North Africa and Italy. The after-history was assiduously followed up except in a few prisoner-of-war, South African, and Canadian casualties. Every case operated on has been included, and every death, no matter what the cause, one case dying from a head injury. Three or four of the cases were laparotomies without intra-peritoneal injuries and one of these cases died. From the records it was not possible to separate abdomino-thoracic from purely abdominal injuries. There were more injuries of the large than the small intestine, and also a lower mortality in the colon cases. Douglas remarks,' The better figures for North Africa are probably partly the luck of the game and partly due to passing on good risks to the CCS when working with the MDS in Italy'. The mortality in the series is 36 per cent, which is the same as the mortality in the survey of New Zealand abdominal casualties in Italy.
|Number of cases||28||97||125|
|Mortality (per cent)||25 per cent||39 per cent||36 per cent|
A complete survey of abdominal injuries in 2 NZEF in Italy was carried out at the end of the war. There was a total of 364 abdominal casualties, of which 73 (20 per cent) were thoraco-abdominal—44 of the 73 were included in a survey of chest cases page 266 with available details less complete. Altogether there were 183 recoveries (50·3 per cent). There were 281 operations performed with 177 recoveries (63 per cent).
In the abdominal cases there were 227 operations with 146 recoveries (64·3 per cent). In the thoraco-abdominal cases there were 54 operations with 31 recoveries (57·4 per cent).
Of the total of the two groups 59 died without operation before reaching the CCS, including 34 casualties brought in dead to medical units. Only 11 cases reaching the CCS alive died without operation (3·6 per cent), and seven of the cases were not admitted to our own CCS. A further 10 cases were not operated on at the CCS but recovered.
Results in the Main Group
There were 317 cases with a death rate of 50 per cent, covering cases brought in dead to field units and cases dying in the field units but not operated on. Of patients admitted alive to a CCS 96·3 per cent were operated on, and of those admitted alive to any unit, including the ADS, 89·6 per cent were operated on. The mortality in cases operated on was 39 per cent, which included all deaths at the Base. The marked fluctuation in results in small series is shown by a mortality of 15 per cent in one month and 41 per cent in another.
The percentage of deaths in all cases recorded at different stages and the gradings of those surviving is shown in the following chart:
A = dead (BID); B1 = died in field ambulance (no operation); B2 = died in casualty clearing station (no operation); C = died in twenty-four hours; D = died in forty-eight hours; E = died later in forward areas; F = died at Base; G = alive, graded A–D; H = alive, graded E (evacuated to NZ).page 267
There were in all 28 casualties brought in dead to medical units. Of the 20 deaths in field units of wounded who had had no operation performed, one occurred at the RAP, nine at an ADS, and ten at MDSs.
A = died in twenty-four hours; B = died in forty-eight hours; C = died later in forward areas; D = died at Base; E = alive, graded A–D; F = alive, graded E.
Nearly half of the post-operative deaths (46 out of 102) occurred in the first twenty-four hours, with a further 7 deaths in the next twenty-four hours. These deaths, it will be agreed, were due to the severity of the trauma, first from the wound and then from the operation. Of the 33 deaths which occurred later in the forward areas, anuria was the most common cause, accounting for one-third. Chest complications, peritonitis, and obstruction accounted for 11 deaths. Infection in some form was responsible for half the deaths.
At the Base all the 16 deaths were due to some form of infection. There were no deaths at Base during the last eight months of the period. This might be attributed to the early parenteral administration of penicillin and to the holding of serious cases longer in the forward areas. The surviving patients generally remained in hospital in Italy for some months pending evacuation by hospital ship to New Zealand. The only patients requiring further treatment in New Zealand were a few who still had an open colostomy. Only 8 surviving patients were not subjected to an abdominal exploration, either direct or through the chest, the majority having liver injuries with retained foreign bodiespage 268
[In Major Stead's review the causes of death were given as:
Within twenty-four hours (55 per cent)—shock and haemorrhage.
From two to ten days (33 per cent)—renal insufficiency then lung conditions and peritonitis,
Later (12 per cent)—commonest condition was peritonitis, and all deaths were due to some type of sepsis.
Ileus was reported to be rare.]
The time after operation when death occurred is shown in Chart III.
The association of other injuries was of great importance. It was reported by one surgeon' that no recovery of an abdominal wound had been seen in the presence of a fracture of the femur or a traumatic amputation. Cases of survival are, however, reported in our series. Multiple abdominal injuries also were associated with a high mortality. Severe general injuries included in the series were 9 fractured femurs, 9 amputations, 7 severe head injuries, and 9 severe spinal injuries. At least 9 of this list died without operation.
Thirty of the cases remained in a very bad condition at every stage, and possibly all these cases could have been left without operation and this would have improved the operative mortality considerably; but, as already mentioned, our routine was to operate on every case fit to be put on the table, and occasionally our faith was justified, but the figures naturally were not improved. The deletion of these 30 cases from operation would have improved the operative mortality from 39 per cent to 311·4 per cent. It was noted that 28 patients at no time showed the least signs of recovery following operation, 5 dying on the table and 2 as soon as they reached the ward. It might be inferred that operative trauma was page 269 responsible for the failure in these cases. This was disproved, however, by an evaluation of the severity of the original trauma in the cases that died, checked in the great majority of the cases by postmortem examination. It was ascertained from the case records in which the data were available that the original injury sustained in the cases that died was hopeless in 23 cases, very severe in 21, severe in 23, and there are only 2 other cases. What this does signify is that the large majority of these cases are inevitable deaths, and that in these very severe cases operation must entail the minimal trauma. This is of special significance when one considers such procedures as the freeing of the fixed colon and the type of operation to be undertaken in the late cases. A third of the deaths were associated with severe injuries to other parts of the body.
The average time lapse before operation was worked out in regard to the ultimate results. When death occurred within twenty-four hours of operation this time interval was 6·4 hours, and when death occurred later in the forward areas it was 7·25 hours. Of those who recovered but were invalided to New Zealand, the interval was 6·0 hours, while with those who recovered but did not require invaliding the period was 6·5 hours. It would appear that the average time it took to evacuate abdominal injuries to the operating centre during the Italian campaign was six and a half hours. The interval between the receipt of the wound and the actual surgical operation was 10·4 hours, both in the group of cases that died and in the group that recovered.