War Surgery and Medicine
Clinical Experience in Egypt
Clinical Experience in Egypt
The ENT disabilities in the Middle East that called for treatment fell into two categories—those dating from pre-enlistment and cases arising on service. Pre-enlistment disabilities that had been missed at medical examination, or which recurred under the climatic and service conditions of Egypt, included the chronic perforations of the eardrum in which otorrhoea persisted or recurred, re-infected radical mastoid cavities, nasal polypi, and chronic sinusitis. It was felt that most of these should have been eliminated at the original boarding or else in camp before going overseas. Many of these cases were sent back on the first available ship. But page 449 the greatest problem in Middle East conditions was otitis externa, a very large number of men reporting sick with this annoying complaint. Acute and chronic rhinitis, often associated with sinusitis, was common, as was acute and recurrent tonsillitis. Factors contributing to these conditions were the hot, dusty climate, the primitive sanitation of the native race, and the large amount of swimming by the troops in overcrowded inland swimming pools. The mucosa of the upper respiratory tract was also rendered vulnerable by the extremely dry and hot atmosphere, with its drying effect on the normal secretions of the mucosa.
Men with a history of chronic nasal allergy did badly in Egypt, and this was borne out by the aggravation of asthmatic symptoms in the same climate. Swimming was blamed for a good deal of ear and nose trouble, and at various times orders were given banning high diving or underwater swimming. It would appear that the irritation of the water treated by substances intended to sterilise it caused at least as much trouble as water that was merely dirty and infected. Major Elliott considered that dust, dirt, sweat, and the drying air were the chief causes of the incidence of ear, nose, and throat diseases.
Otitis externa: As the condition is at first a trivial one, apart from acute furunculosis of the meatus, these men were usually treated first at their RAP, and reached the ENT specialist only when otitis was chronic and well-established. The first essential for successful treatment was found to be adequate and thorough daily toilets of the meatus done by a trained man with proper apparatus and adequate illumination. The lack of success with various antiseptics was illustrated by the number of these used. Elliott found that the best results were obtained by thorough frequent cleansing and the daily application of gauze wicks lightly packed into the full depth of the meatus. In the more acute cases he found that aluminium acetate on these wicks was helpful, and during healing some antiseptic such as acriflavine in spirit. Various antiseptic drops or ointments were used later to prevent recurrence. Others used lotio calamine if there was much weeping, and calamine cream if dry. For severe cases argyrol 10 per cent or protargol 5 per cent was painted on the meatus, or introduced on a wick of ribbon gauze and left on for twenty-four hours. Bathing was strictly forbidden. The recurrence rate was high. During the summers in Italy the conditions were as bad as, if not worse than, those in North Africa.
Otitis media was a very common complaint. Acute cases were admitted to hospital, if possible, and treated on the usual lines of sulphonamides by mouth, paracentesis where necessary, and page 450 careful ear toilets. Carbolic acid in glycerine was generally used in acute cases, followed later by boracic powder or spirit. Local sulphonamide treatment proved unsatisfactory. The results were very good as the cases were under the daily supervision of the specialist and the authorities wisely allowed certain nursing sisters to remain for lengthy periods attached to the ENT wards, and they thus became highly skilled at local treatments of the ear. Simple mastoid operations were done if urgently required, or if necessary to render a man safe for transport in a hospital ship.
Cases of chronic suppurative otitis media did badly if treated as out-patients at the RAP. The perfunctory administration of ear drops by an orderly on top of a pool of pus in the meatus was worse than useless. Many cases of suppurative otitis media were due to blast wounds in action.
Otorrhoea: All cases of chronic otorrhoea were admitted to hospital for intensive and skilled treatment, if beds were available. Under these conditions many healed. If the perforation persisted the man was boarded and usually returned to New Zealand, unless he had some special skill which could be utilised under good living conditions.
The radical mastoid operation was not done except for complications of an urgent nature, as these men were still unfit after operation to serve in the Middle East.
Nasal Sinusitis: A fairly large number of cases of chronic sinusitis which had not been eliminated by medical boards in New Zealand had to be down-graded or invalided. A much larger group were those who arrived as fit men and later acquired acute or chronic nasal infection. Treatment at the RAP by the dropping of a few minims of ephedrine solution up the nose was illusory as a cure or relief. The minor and favourable case recovered with, or in spite of, treatment. The resistant case could only be coped with by admission to hospital. Early in the war the new techniques of ephedrine replacements were not known, and treatment was inclined to be too radical. In the early years of the war Elliott tried ephedrine drops and inhalations. If these failed he did a small antrostomy purely to facilitate easy antral lavage. After the symptoms were relieved the antrostomy often closed. This routine cleared up most cases, combined as it was with the fact that the patient in hospital was living away from a dusty atmosphere. The resistant case was down-graded. Radical surgery of the antrum or frontal sinus was frowned upon, unless of lifesaving urgency.
A survey of 59 cases referred for investigation of sinuses in February 1944 was made by Captain Simpson at 3 General Hospital, page 451 Bari. Twenty-one were sent from the forward units with a diagnosis of sinusitis, and the other cases arose among the in-patients and out-patients of the hospital. Simpson pointed out that the diagnosis was difficult except in obvious cases with mucopus pouring like lava into the middle meatus. Symptoms of pain and nasal discharge, combined with signs such as fever, tenderness over one or other sinus, or mucopus in the nose, led to a diagnosis of sinusitis, especially by RMOs. If these signs and symptoms were bilateral, the conditions might well be a common head cold more severe than the average. If the signs and symptoms were unilateral, the condition was much more likely to be sinusitis. A symptom of great significance was the occurrence of bouts of pain, relieved by discharge from the nose. The discharge in true sinusitis varied in consistency but was always yellow. Maxillary sinusitis had been found to be the most common, true frontal sinusitis being a rarity. Cases of severe persistent headache should be evacuated ‘Headache NYD’ to be fully investigated at the hospital, and not diagnosed as sinusitis lest soldiers become ‘sinus conscious’. At the hospital X-ray was a help in diagnosis, but the final decision depended on diagnostic puncture, by which the contents of the maxillary antrum could be inspected and also a judgment formed as to the thickness of the mucosa and the presence or absence of polyposis. The finding of thick yellow mucopus in sufficient quantity (at least 1 c.c.) justified positive diagnosis and operative interference. A small quantity of grey mucopus or flakes was inadequate evidence. Gross polyposis, even in the absence of pus, generally required operation. Of the 59 cases, 49 were clinically negative, and in these X-ray was positive in 29; diagnostic puncture done on 23 of the 29 cases was positive in 9. An analysis indicated that the most certain diagnoses could be made in those cases where clinical and X-ray findings were both positive, but unless X-rays were taken and diagnostic puncture performed in selected cases from those clinically negative, then a large number of positive cases would be overlooked.
Nasal Polypi and Chronic Allergic Rhinitis: Nasal polypi were in Elliott's opinion a definite bar to a man serving out of a temperate climate, and at that, outside a base organisation. A history of nasal polypi should result in a recruit being graded for home service only. In the Middle East polypi recurred in a matter of weeks after removal. The polypi were removed with a simple snare and the soldier regraded. Chronic allergic rhinitis, if a very definite cause cannot be found for the allergy, should preclude a man serving out of a temperate climate.
Deflected Nasal Septum: Many men who are quite fit for any vigorous exercise in a temperate climate, and who are rightly page 452 passed as fit for active service, find difficulties in a hot, dusty theatre of war. Many of these men have nasal obstruction due to either a congenital or acquired deflection of the nasal septum. In Egypt it was found that the hot climate increased the respiratory rate. The soldier, burdened with his equipment and weapons, marched often in a cloud of dust raised by his comrades ahead. The mouth breather was sadly handicapped, and was either forced to fall out of the line of march or ended the day severely fatigued. Many of these cases were referred to the ENT specialist and were found to have nasal obstruction due to a deviated nasal septum. The SMR operation was carried out in a large number of cases with excellent results. Under normal conditions SMR operations were not advised, and the AIF actually prohibited the operation later in the war.
The Tonsil Problem: The question of tonsillectomy on the soldier serving overseas is a very vexed one. In 2 NZEF the principle was adopted that, if a man was otherwise fit and was disabled on several occasions by acute tonsillitis with fever, then tonsillectomy was justified in the hope that the man would then be fit for normal duties. In camp conditions a soldier should remain at least twelve days in a general hospital and then another ten days either in a convalescent depot, or excused duty, before resuming training.
Operations Overseas: In general, routine ENT operations, as all other similar operative procedures elsewhere in the body, were not performed overseas. Operation was restricted to those cases of urgency and to those which would normally lead to the increased efficiency and lengthened service of the soldier, without too long hospitalisation.