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Missile injuries in Aden, 1964–7
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MISSILE INJURIES IN ADEN, 1964-7 Wing Commander R. F. BROWN and Wing Commander J. H. BINNS Royal Air Force Medical Branch
An account is given of the missile injuries suffered by British servicemen, their wives and children in Aden between May, 1964 and November, 1967. Records of 776 individuals are reviewed. One hundred and twenty-one died : of these, 99 were killed in action and 22 died of their wounds in hospital. One hundred and thirty-six casualties with major wounds are assessed, and the lasting value of delayed primary suture described in some detail, since its value in civilian accident surgery is overlooked. The advent of the helicopter has made possible the rapid evacuation of the wounded to fixed base hospitals by-passing field surgical units. Nothing is new save that which has been forgotten IN April, 1964, armed tribesmen were in revolt in the mountainous Radfan area 60 miles north of Aden. An area virtually without roads, the movement and supply of British forces was by air. In December, 1964, incidents began to occur in the town, mainly grenade or pistol attacks on servicemen and their dependents, which continued until the final departure of British Forces in November, 1967. Aden was the main base for British troops in the South Arabian Federation and approximately 10,000 men and their families lived and worked in the area. In the town there were two Royal Air Force hospitals in which all service casualties were treated. This paper will show that warfare has presented the surgeon with similar problems throughout the past 60 years, but that, as surgical techniques improve, so the requirements for ancillary services increase and the greater is the need to treat casualties in fully equipped base hospitals. ANALYSIS OF RECORDS We have records of 776 individuals who sustained missile injuries in the period under review. One hundred and twenty-one died, either killed in action or subsequently of their wounds; this was 15.6 per cent of the total. This compares with a 23 per cent mortality in those sustaining missile injuries (i.e., ' h i t ' ) in World War II (Beebe and de Bakey, 1952). During similar disorders in Cyprus in 1955-7, 704 Britons sustained missile injuries and 135 died, a 19.2 per
cent mortality (Watts, 1960). In Vietnam from October, 1965, to June, 1967, nearly 6000 died and 40,000 were wounded. With small casualty figures, the local conditions determine the type of injury and the figures may not be truly comparable. For example, in Aden there were a number of revolver shots at point-blank range, fatal instantaneously. The proportion of missile injuries from the accidental discharge of a serviceman's own or a comrade's weapon was small: 51 incidents, 6'6 per cent of the whole. In the jungles of Malaya the proportion was very much higher: 37.5 per cent of casualties were not due to ' enemy action ' (Clyne, 1954). Table I shows a breakdown of casualties according to the missile (causative agent) involved, showing the numbers wounded and the percentage who died in each case. (In the records available, it is not always possible to know what hit a man dying rapidly and this was often loosely recorded as ' gunshot wound '* on the field surgical card.) We have records of 111 servicemen killed by enemy action in Aden, and 4 who lost their lives from the accidental discharge of a weapon. We *' Gunshot wound' in World War I indicated an injury arising from any weapon using explosives, as opposed to those wielded by men to cut, stab, or gas; in World War II the term described injuries from small arms (pistol, rifle, or machine gun) which fired solid bullets, rather than from shells, which exploded. We have used this accepted definition.
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have also included the deaths of 6 service dependents and civilians. These deaths are further broken down in Table H to those killed in action and those who died of wounds. In the first case death occurred before they reached an aid station for preliminary treatment of their wounds, or before aid could reach them. Autopsy Records There have been few records of autopsies on those dying in battle. In our series, records of full post-mortem examinations are available for
deaths in the following 6 groups (Beebe and de Bakey, 1 9 5 2 ) : Group 1 : Those killed instantly In this group there are 54 deaths and there is no record of the patient having survived any length of time. There were 2 Royal Marines, 49 Army personnel, and 3 Royal Air Force. Only 3 were considered to have been accidental of self-inflicted. The agent causing death was a gunshot wound in 43 cases, a grenade in 4, the explosion of a shell in 5, and of a landmine in 2.
Table L--CASUALTIES IN ADEN, 1964--7 No. OF
MISSILE
No. OF
INJURED
NO. OF DEATHS
PERCENTAGE OF DEATHS
ACCIDENTS
224
68
30"4
37
51
8
15'7
10
394 57
19 6
4"8 10'5
4 0
50
20
40"0
0
776
121
15"6
Bullet, (rifle, pistol, or machine gun) Shell (high explosive, mortar, cannon, rocket) Grenades (and booby traps) Mine explosions Unclassified (' G.S.W. ')* Total
51
I *See footnote p. 293.
Table//'.--CAUSES OF DEATH: KILLED IN ACTION AND DIED OF WOUNDS KILLED IN ACTION
DIED OF WOUNDS
Bullet (G.S.W.) Shell Bomb Blast Unclassified
58 6 10 5 20
10 2 9 0
68 8 19 6 20
Total
99
22
121
MISSILE
1
TOTAL
63 deaths, together with a brief pathologist's report on a further 9. We have attempted to determine, as precisely as possible, the time interval between the individual being hit and his subsequent death, and also the cause of death. In view of the brief interval between the injury and death, it is obvious that the geographical circumstances of the campaign and the number of medical auxiliaries deployed, will determine how many of those injured are evacuated to an aid post or hospital. We have classified our
The cause of death, determined by postmortem in 29 cases, showed that catastrophic mediastinal haemorrhage from heart and great vessels had occurred in 12 cases, intracranial injury with gross destruction of brain tissue in 12 cases, and in 2 cases transection of the spinal cord in the neck or upper thoracic region. In 3 deaths, haemorrhage occurred in large vessels other than the mediastinum (the inferior vena cava, the common iliacs, or abdominal aorta). It is considered that in these individuals no medical care, however organized, could have saved their lives. Group 2 : Those who survived temporarily but died without Medical Aid In this group there are 38 deaths recorded: 1 Royal Navy, 2 Royal Marines, 34 Army, and 1 Royal Air Force. Thirty-two were reported as due to bullets, 2 to grenades, 3 to mines, and 1 to a shell exploding. One death was not due to enemy action. It is instructive to consider the cause of death in relation to the time interval elapsing in the 9 cases where this is known. In 1 Army death, the
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individual survived 1 hour following transection of the femoral artery. He was alone at the time up-country. Individuals survived a few moments following haemorrhage from iliac vessels (2), renal vessels (1), thoracic outlet (1), or mediastinal vessels (2), and multiple injuries to abdomen and chest causing haemorrhage from a mine explosion. One officer died 2 hours after injury from haemorrhage from his lung in an ambush when he was struck by a single bullet. He was far from Aden and unable to obtain assistance, although able to drive. It will be clear therefore that the majority recorded as surviving a few moments, to all intents and purposes died instantaneously. There was insufficient time to organize medical care to save their lives.
Group 3 : Died but received First Aid Treatment, in the Field, only In this group 7 deaths are recorded. All deaths were due to enemy action, 2 in Royal Marines, 5 in Army personnel. Three were due to bullets and 4 to grenades. Two of these deaths followed minutes after injury from major haemorrhage from the iliac vessels and from injury to the heart. The circumstances of their deaths, in Aden itself, permitted the ineffectual deployment of first aid. In 5 other cases, injuries were multiple. One patient was injured in the chest, abdomen, and leg and survived 20 minutes; another with injuries to lung and face, but with the main vessels intact, survived 4 hours up-country. A patient with torn gastric vessels and multiple pulmonary lacerations survived 2 hours in Aden, one with lacerations of the legs and spleen survived 1½ hours up-country, and finally a patient with a compound fracture of the tibia and haemorrhage from the femoral artery survived 2 hours in Radfan. It is apparent that these patients may not have received mortal wounds and might have been saved, had they survived to be admitted to a surgical unit. It is in the light of these failures that the organization of medical care should be judged and the efficiency of first aid. Essential measures for the preservation of life should be taught to all service personnel, and probably to their families also in a theatre where they may be equally at risk. In practice, there are only a few conditions where the knowledge of the principles of first aid can help an individual with a potentially lethal wound, but in these cases these measures may well save a life and cannot depend upon the presence of medical auxiliaries.
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a. Staunch catastrophic haemorrhage by firm direct pressure maintained directly over the wound with a pad and bandage, or field dressing. (A tourniquet may help but only whilst the dressing is being adjusted.) b. Maintain an airway free of blood, mucus, and vomit by clearing the air passages and turning the patient to allow fluid and secretions to escape naturally. Avoid injury to the spinal cord while moving a patient with a suspected spinal injury. c. Close a sucking chest wound with a pad to prevent collapse of the lung. Successful primary aid will certainly give an opportunity for medical personnel to start measures for the resuscitation and the comfort of the patient. In Aden medical orderlies and medical officers in the field were encouraged to set up intravenous transfusions for the seriously injured as soon as they were seen. Plasma was usually given, and no problems with storage were encountered. Blood was not given outside the hospitals, in view of the difficulties in storage and in ensuring accurate cross-matching, and the delays that might result. Fractures were temporarily splinted, either by tying the legstogether or with Kramer wire. Most casualties were given intravenous or deep intramuscular morphine and those from upcountry an initial injection of 1 million units of crystalline penicillin and a booster dose of anti-tetanus toxoid. It is by no means certain that antibiotics in this dosage are effective in preventing or delaying the onset of wound infection. In this campaign, and also in Vietnam, evacuation for early optimal surgical treatment was so satisfactory that controlled assessment is not possible. If casualties occurred in overwhelming numbers or evacuation for surgical care was delayed then some means of protecting the patient from the onset of wound infection would prove invaluable. So far we have dealt with deaths classified as ' killed in action ', 99 in all. The number depended upon the proximity of hospital services. In the incidents in the city, obviously more ' fatally w o u n d e d ' individuals were brought to hospital and died during subsequent attempts at resuscitation. This makes comparison with campaigns elsewhere misleading.
Group 4: Deaths occurring ill Hospital, where Attempts at Resuscitation had already begun There are 9 deaths in this group, 2 in Army personnel, 2 in R.A.F., 2 Service dependents, 2 civilians, and 1 American sailor. All were involved in incidents in the city limits. Five
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suffered grenade injuries, 3 bullet wounds, and 1 a blast from a mine. Five deaths occurred, in spite of immediate transfusion, following haemorrhage from large vessels in the chest or root of the neck, 1-3 hours after injury. In 2 there were also multiple injuries elsewhere. Three cases died from intracranial injuries; these were not operated upon, but were intubated and artificially respired. The last case involved 2 bullet wounds, one across the root of the neck and the second dividing the trachea at the level of the bifurcation. The patient suffered extensive surgical emphysema and died after 1 hour 40 minutes. Such cases are the test of the skill, training, and organization of the surgical teams. It is a measure of their availability and their experience of traumatic surgery in war and in accident services at home. All medical officers, specialist or nonspecialist, in a hospital accepting major trauma, must be familiar with the techniques of immediate resuscitation, maintaining airways, and artificial respiration. One or more transfusions of plasma or dextran and subsequently of matched whole blood, must be set up and given under pressure, if necessary, as soon as possible. As in civil surgery the numbers of units of blood used for trauma increases in every succeeding campaign. The area for the reception of casualties must be large enough to receive the numbers anticipated and to provide a clear area around each individual for examination and manipulations. It must have running water for cleansing the patients (who are often filthy) and easy access to laboratory for blood examination, to an X-ray unit, and to the operating theatre. Documentation must be fast and accurate and facilities must be provided elsewhere for information to be passed to higher command, and to the patients' units for transmission to their next-of-kin. In our present age also, members of the press require access to details of those injured. It should not be necessary to emphasize that those not directly involved in the care of the injured are kept away from casualty reception areas. This does not appear to have presented a problem to previous military surgeons. The purpose of resuscitation is to save life and to prepare the patient for necessary surgery; responsibility for this rests with the surgeon in charge of the cases and the operating theatre. Continuity of surgical care is essential since only thus can the sorting of casualties be carried out, and the priority for surgery assessed. In any one incident the numbers of serious cases requiring urgent surgery was relatively small, and remained
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manageable, with one or two surgical teams available. In the last sixty years, there has been a considerable decrease in the delay in submitting patients to surgery after admission to hospital (Whelan, Burkhalter, and Gomez, 1968). In World War II an average delay of 4-5 hours was usual. In Korea it was considered advisable not to spend more than 3 hours on resuscitation. In Aden, and also Vietnam, this period was shortened to 1~}-2 hours, after which prompt surgery was advised for all but the obviously mortally wounded. The commonest cause for the failure of response was continued uncontrolled haemorrhage. In our series no deaths are recorded of cases submitted to surgery to stop bleeding. Other causes of failure of response include massive peritoneal contamination, particularly from wounds of the lower bowel or large eviscerations, blast injuries of the lungs or brain, and indeed any severe wound where the bloodvolume cannot be maintained.
Group 5: Patients operated upon after Admission to Hospital but who did not survive Initial Surgery There are 7 deaths within 24 hours in this group. Six were Army personnel, 1 a civilian. Four were injured by bullets, 3 by grenades. Two died from persisting shock 4 hours after surgery for multiple injuries to the limbs and perforation of the bowel. Five patients died from gross cranial injuries after decompression and in spite of tracheostomy, artificial respiration, and transfusion. The extent of the brain damage was confirmed post mortem Like Group 4, Group 5 swells the numbers who apparently died of their wounds in hospital and who in previous campaigns might have been recorded as killed in action, before reaching medical establishments.
Group 6: Patients who died of their Wounds having survived Initial Surgery There are only 6 patients in this category. One Royal Marine, 4 Army, and 1 Royal Air Force. The causes of death here are quite different from those recorded previously. In those dying 2-4 weeks after injury, septicaemia was found in all, complicating renal failure in one and secondary haemorrhage in another. All had suffered extensive multiple wounds, with injury to the buttocks and bowel (1), to the abdomen (2), and to chest and abdomen (1). Two cases died of their wounds many months later after returning to the United Kingdom. One patient died of
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delayed renal failure, 2 years after sustaining a bullet wound traversing both kidneys and treated conservatively, the other from traumatic transection of the cervical cord (Table III). Thus 22 patients in Groups 4-6 died of their wounds in hospital, 13 following operation. Even if we include the deaths in hospital consequent upon efficient evacuation of casualties, the mortality rate is still low (2.6 per cent of those struck by missiles). This compares with 2.5 per cent in Vietnam, 2 per cent in Korea, and 4 per cent in World War II. Deaths in hospital occurring in the first 24 hours (16) comprised 73 per cent. In Vietnam it is 62-3 per cent (Whelan and others, 1968). In Cyprus the mortality for cases alive on admission and fit for surgery was 3 per cent (Watts, 1960), and Malaya 3.7 per cent (Clyne, 1954).
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all intracranial, intrathoracic and intra-abdominal (intraperitoneal) wounds, together with gross soft-tissue injuries, with or without fractures, causing shock. One hundred and thirty-six such patients are recorded. Intermediate injuries were those which required surgery less urgently than the major wounds. They included missile wounds tracking through muscles or involving bones and joints, and those causing injury to vessels or nerves where the vitality of the whole limb was not imperilled and shock was not an immediate risk. In addition we included faciomaxillary, eye, and neck wounds where vital structures were not involved. There were 143 in this group. Minor wounds were not a danger to life at any time and did not involve structures below the deep fascia. They included many cases of peppering
Table IlL--CAuSES OF DEATH FOLLOWING SUCCESSFUL INITIAL SURGERY
PATIENT
1. R.M.
INJURIES
Multiple injuries to
2. Army 3. R.A.F.
4. Army 5. Army
6. Army
abdomen and legs Perforation of both kidneys Perforation of small bowel, stomach, and liver Injuries to abdomen, buttocks, and legs Thoracoabdominal wound and gastropleural fistula Wound of neck and paraplegia
Wound Surgery The total number of patients who were submitted to surgery for their wounds was 668, of whom 13 died (1.9 per cent). We have attempted to classify these according to the severity of their injuries. Unfortunately no standard criteria for assessment exists, a lack felt by previous authors in this field. The obviously severe and the trivial can be distinguished but a variable mid-zone of intermediate severity exists. In general we have classified as severe, wounds which required prompt surgery. This included
CAUSE OF DEATH
PERIOD FOLLOWING INJURY
Septicaemia and renal failure
28 days
Renal failure
2 years
Biliary peritonitis and secondary haemorrhage Septicaemia
3 days
21 days
Haemorrhage
31 days
Septicaemia
Not known
with grenade fragments and superficial bullet wounds. There were a large number of patients in this group and, although they provided few surgical problems, their wounds required excision and suturing (either at once or later) and encouragement to return to their duties or homes retaining their morale. They totalled 396 patients.
Major Wounds The distribution amongst the services and according to the weapons involved is given in Tables I V and V.
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The main principles of treatment of war wounds were clearly defined during World War II and are recorded in the Surgical Histories of that war (Churchill, 1952; Cope, 1953) and are the basis of the advice given in both the Field Surgery Pocket Book (1962) and the NATO Handbook (1958). It is not our purpose to repeat all the precepts within those manuals bul rather to re-emphasize some of the points which we consider important today and Io discuss certain changing concepts and possible advances.
Table/K--DISTRIBUTION
OF MAJOR WOUNDS AMONGST THE SERVICES
STATUS
R.N. Army R.A.F. Families Civilian Total
MAJOR WOUNDS
DEATHS
13 96 9 2 16
1 12 3 2 4
136
22
Soft-tissue Wounds These are by far the commonest of all wounds. By the end of the 1914-18 War the principle of wound excision and secondary suture at 8-12 days was accepted by most military surgeons. Topical antiseptics were used (e.g., CarrelDakin's solution of sodium hypochlorite) and the wound was sutured when considered to be relatively bacteria-free. If suturing was not feasible it was allowed to heal by granulation with inevitable scarring and deformity. In World War II, after initially using methods of 25 years before, delayed primary suture became the rule. The previously excised wounds were closed at 4-6 days and healing was obtained without wound infection, more quickly, and with minimal scarring and deformity. In Aden, the first few cases of missile injury were treated by secondary suture and took 6--8 weeks to heal. Packs were removed in the wards, eusol soaks were instituted to prepare the wound for suture, and the wound edges were trimmed before suturing them. The results were thoroughly unsatisfactory. Subsequently missile wounds were correctly managed and few became infected. The important points stressed to surgeons treating these wounds were : - a. Adequate d6bridement, involving both the excision of non-viable tissue (liberally in the case
of muscle but only limited excision of skin edges and bone fragments) and the wide incision of fascia longitudinally to decompress the injured limb. The majority of missiles were travelling at relatively low velocities and few cases of massive necrosis of muscle were seen (French and Callender, 1962; Thoresby, 1966) but the wound infections that occurred were due to failure to resect injured muscle sufficiently widely. b. No attempt was made to close these wounds. A single layer of tulle gras was laid on the raw
Table V.--CAUSAT1ON OF MAJOR WOUNDS
MISSILE
Bullet Shell Grenade Mine Total
MAJOR WOUNDS
DEATHS
56 10 46 24
13 0 8 1
136
22
surface of the wounds and covered by loose gauze to absorb exudate, and surrounded by plenty of cotton-wool and cr~pe or cling bandage. The limb was elevated and immobilized in plaster-of-Paris if the wound was large, to rest the part. The use of gauze packs with petroleum jelly was highly unsatisfactory, as they acted as plugs preventing the escape of exudate and resulting in further deep infection. c. The next inspection of the wound occurred in theatre 4--5 days later, although earlier if pyrexia, bleeding, swelling, or odour suggested closed sepsis. In the latter case further d6bridement was carried out and suturing postponed. d. If the wound was clean, it was washed over with aqueous Hibitane (chlorhexidine), loose tissue was trimmed away, and a single-layer repair, leaving no dead space, was carried out without further excision of the wound edge. If the tension was unacceptable then a free graft of split skin was laid on the clean granulations and a pressure dressing applied. The majority of such wounds were healed in 21 days without infection. The problems arose when the wounds were extensive and multiple; adequate excision was time-consuming and if major intraperitoneal injury was also present, the limb wounds may not have received the attention they required in an attempt to complete the operation in a reasonable time. In such cases two surgical teams working
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simultaneously were almost essential when the trained manpower was available. Wide excision of multiple soft-tissue wounds is mutilating, but necessary, and to retain pressure dressings in place on such areas as the groin, buttocks, and axillae is not easy. Once they slip or exudate seeps through, then infection can enter from without. Other measures were taken to enable the patient to heal without infection. A normal haemoglobin level was maintained, transfusing more blood during the healing phase if the blood picture suggested that the initial blood-loss was underestimated and not replaced. A high protein diet was provided and routine antibiotics given, either 1 million units of crystalline penicillin followed by 500,000 units 6-hourly or tetracycline 1 g. and 0.5 g. 6-hourly for 5-10 days, in the case of limb wounds. These doses are considerably smaller than those advocated by American surgeons in Vietnam. Local antibiotics on the raw surfaces were occasionally used but their efficacy was difficult to assess; certainly antibiotics failed to overcome inadequacies in wound excision and drainage. There is still no place today for neglecting this aspect of wound care. In many cases of less severe wounds our surgeons were tempted to close the wounds primarily. In general this was successful provided the wounds were superficial (i.e., confined to the subcutaneous tissues) and caused by low-velocity missiles releasing little energy (e.g., grenade fragments with short tracks before coming to rest). In the Aden climate clothes were light and laundered, and seldom embedded in superficial wounds. The wounds were thus clean and treatment was carried out within 8 hours. Other wounds which were closed primarily included scalp and clean-cut facial wounds. The former included cranial wounds where it was essential to cover the dura or skull defects with viable scalp. Penetrating chest wounds were closed in the depths to seal the pleural cavity. Wounds of the hands and feet gave some difficulty. In the case of simple hand wounds primary skin cover was achieved, but for some more c o m p l e x ' u n t i d y ' hand wounds delayed cover by free skin-grafting at 5-7 days healed the hand more rapidly with minimal infection. If the grafts subsequently contracted or caused deformity, then secondary flap cover was considered. Through-and-through bullet wounds of the feet invariably became infected and often contained dirt and foreign material (fragments of socks or boots). Such wounds failed to heal
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if they were sutured and they were left open with free drainage after excision, to heal by granulation. In the cases where amputation was considered necessary at the primary operation, usually of extremities grossly injured with mutiple fractures and disruption of joints and soft tissues and division of main artery, or nerve, or both, this was performed as distally as possible, perhaps through the fracture site. No attempt should be made to close the flaps; if this is done infection is inevitable and occurred in our earlier cases. Amputation at the site of election was performed later, in Aden or the United Kingdom after evacuation, when the wounds were free from risk of infection. Vascular Injuries In the early months injuries to vessels were treated by ligation and relying on the development of a collateral circulation to maintain the vitality of the limb. In cases where there were other injuries, particularly causing oedema, gangrene resulted and amputation was performed. Secondary haemorrhage in the presence of infection is most likely to occur at 10-14 days and limbs with arterial injury should not be moved until the overlying skin is healed. One of our cases required emergency amputation at a hospital en route for the United Kingdom by air, at 9 days. Some attempts to repair lacerations of arteries and veins were successful but no arteries were reconstituted by venous grafts. This current trend in the surgery of trauma has improved the results of vascular injury in accident surgery and many limbs can be saved in war also. Head Injuries The results of primary care of head injury were satisfactory. Adequate oxygenation by tracheostomy was advised for the unconscious cases. The entry and exit wounds were excised and brain tissue aspirated by gentle suction and irrigation, but deep exploration was not carried out. If possible the dura was closed but otherwise the scalp was sutured over the defect. We treated 20 patients shot through the vault: 8 died, all within 24 hours. The remaining 12 recovered consciousness and are all able to live useful independent lives. Three patients with spinal transection were treated by primary wound excision, without any attempt at bone fixation, and were evacuated by air to the United Kingdom to the National Spinal Injuries Centre at Stoke Mandeville.
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Chest Wounds In our series there were 17 penetrating chest wounds, and 4 patients died shortly after admission to hospital from uncontrollable major haemorrhage, without undergoing surgery. The majority of cases (9) were treated conservatively by thoracentesis of blood and air to expand the lungs and restore a normal cardiopulmonary physiology as rapidly as possible. F r o m 3 to 5 aspirations were required to empty the pleural cavity of blood and exudate. Underwater seal drainage was used for the cases with pneumothorax. Open thoracotomy was carried out for persisting haemorrhage and for the removal of large metallic foreign bodies in 4 cases, without mortality. One required a later decortication in the United Kingdom. Abdominothoracic Wounds There were 4 abdominothoracic wounds and of these 1 died a month after injury. In general, conservative treatment of the chest was combined with abdominal laparotomy. The patient who died had been shot through the left arm and lower chest and sustained a ruptured spleen, perforated colon and stomach, laceration of the diaphragm, and some intrapleural bleeding. The abdomen was opened and the stomach repaired, the spleen removed, and a colostomy performed. The diaphragm was repaired and the chest drained but not opened. The patient subsequently died from haemorrhage, having earlier developed a gastropleural fistula. A second patient was struck by a single bullet which traversed the left elbow and left loin. Three ribs were fractured and a haemothorax was present. At wound excision, omentum was found in the pleural cavity and laparotomy revealed a ruptured spleen and left kidney, perforation of the splenic flexure of the colon, and a lacerated diaphragm. The spleen and left kidney were removed, colostomy performed and the diaphragm sutured, and the pleural cavity drained. The patient made a good recovery. Abdominal Wounds Twenty-nine cases of intraperitoneal abdominal injury were recorded with 5 deaths, 2 of them within 24 hours from persisting wound shock. Both had extensive injuries and were severely shocked on admission. The policy should be one o f ' look and see ' rather than ' wait and see '. If the missile track could conceivably have entered the abdominal cavity, exploration, in standard hospital conditions, will do no harm and may save life. Wounds of the buttocks,
Injury April 1970
perineum, upper thighs, and lower chest may also have involved intra-abdominal structures. All perforations in hollow viscera were sought for and closed, or the segment of injured bowel resected. Injury to the caecum was treated by a caecostomy tube inserted into the perforation: wounds of the colon were either exteriorized or closed and a more proximal double-barrelled colostomy performed. Liver wounds and bilateral injury to the kidneys were treated conservatively. Injury to the bladder was repaired and catheter drainage instituted. The main complications of intra-abdominal wounding were still paralytic ileus and sepsis. If a patient fails to maintain satisfactory improvement postoperatively, consideration should be given to the indications for a second laparotomy, lest an intra-abdominal injury has been missed. The hidden areas of the retroperitoneal surface of bowel, in abdomen and pelvis, are the most likely sites of missed perforation, and all haematomata there must be explored. A soldier with grenade injuries to the abdomen died on the third postoperative day from haemorrhage and peritonitis associated with a missed perforation in the posterior wall of the stomach in the lesser sac. The fragment had traversed small bowel and stomach and entered the liver by the porta hepatis. The wounds in bowel and two perforations in the stomach had been closed and the porta drained. The continued peritonitis was considered biliary in origin and a third stomach wound was not considered. At postmortem it appeared that there was a third stomach perforation due to a glancing injury. Repeat laparotomy should have been performed. A patient with similar injuries was noted to be severely shocked at the end of the primary operation. The abdomen was re-opened and the stomach found to be distended with blood from an injury to the posterior wall of the first part of the duodenum. The bleeding vessel was undersewn and recovery was uneventful. There were no cases of wound dehiscence. Most patients had through-and-through tension sutures as well as stitches to the skin edges. Postoperative Care and Evacuation Postoperatively all patients were retained in hospital or adjacent Unit Medical Centres in Aden until their wounds were healed and they were fit to return to duty with their units. Minimal sick leave was given since there were no convalescent centres in the area and little opportunity for prolonged relaxation. The majority of
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those with minor injuries returned to light duties under the supervision of their Medical Officer. Cases who would not be fit within 6 weeks were flown back to the United Kingdom by R.A.F. Transport Command. The determination of a patient's ability to tolerate air travel is somewhat empirical. The surgeon should be familiar with the aircraft, the route and facilities available en route, and the delays that are likely. Steady flight seldom distressed a patient, but take-off, landing, and stopovers did. Cabins were pressurized to 60(0)-8000 feet, the air was dry, and there was very limited access for the care of patients. Thus abdominal wounds should be fully healed before moving by air, with normal bowel movement. Chest injuries gave no trouble since the lungs were already expanded. Brain and head injuries and spinal injuries were nursed on Stryker turning frames and travelled well. The major error that occurred was in moving patients with gross limb wounds and associated vascular injuries too soon. This was done to improve the chances of saving a limb with impaired blood-supply by transferring to special centres for vascular surgery or hyperbaric oxygen in the United Kingdom. Cases of sudden secondary haemorrhage occurred requiring urgent operation for their control, one en route, one shortly after arrival in Britain. It is probably preferable to delay transfer of such cases of gross injury for 14 days. Most sudden changes and complications occur in patients' conditions within the first 2 weeks of wounding. Subsequently patients were admitted to service hospitals in the United Kingdom where reparative surgery was carried out, followed by rehabilitation. Some were invalided from the services, but the majority returned to their units. Feed-back of information and comment from hospitals and surgeons at home is desirable. DISCUSSION Aird (1944) has stated that ' the surgical needs of a campaign may be deduced from the recorded geography of the terrain over which it is to be fought, and the contemporary trends of battle tactics '. In Aden (and in Vietnam) with undisputed control of the air and limited communications on the ground, and with fighting in the streets of the towns adjacent to the hospitals, the immediate admission of casualties to base hospitals was logical. The helicopter has made this possible. The average time from wounding to surgery, for abdominal wounds, was 10-5 hours in World War II (Wolff, Giddings, Childs, and
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Broth, 1955), 6.3 hours in Korea (Artz, Bronwell, and Sako, 1955), and 2"8 hours today in Vietnam (Whelan and others, 1968)--the most rapid evacuation of wounded ever achieved in battle. In Aden similar times were recorded in the city, or less, but the delay for most up-country casualties remained at about 2-6 hours. Morale benefited from the knowledge that injured servicemen would be treated in modern hospitals, fully equipped with ancillary services for investigation and treatment. Such facilities can never be deployed in field surgical hospitals. Campaigns elsewhere in other conditions may prohibit the use of such tactics, and the problems of mass casualties and of thermonuclear irradiation are totally different. Our post-mortem findings in fatal missile injuries confirmed what we had expected to find as the causes of rapid death. Nevertheless this approach to the assessment of a casualty service is valuable and tests the efficacy of the care provided at different points, in the field and in hospital. There may have been no innovations in the handling of soft-tissue wounds since 1945 but the development of new and more powerful antibiotics has not eliminated the need for adequate wound excision and drainage and the advantages of delayed primary suture. We have presented our comments on soft-tissue injuryat some length since we feel that the principles required restatement, and that surgeons working in civilian accident units may have overlooked the value of delayed primary suture of the extensive contaminated wounds of their practice. The mortality of abdominal wounds has steadily fallen in the last 60 years, as a result of reducing the delay before laparotomy is undertaken, more energetic resuscitation with the increasing use of blood replacements, larger doses of antibiotics, and some advances in the care of certain wounds (e.g., of the colon and liver). Air evacuation enables the wounded serviceman to be in his home country within hours of leaving the theatre of operations. He can be referred for specialist treatment at home, he can convalesce in optimal surroundings and with his family, and if necessary can return to his unit as easily. The pattern of care and administration alters, but in many ways the solutions to the many problems of injury in war remain the same through the ages.
Acknowledgements The authors wish to record their debt to all their medical colleagues, administrative and
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clinical, in t h e t h r e e services, w h o served w i t h t h e m in A d e n , a n d w i t h o u t w h o s e c o - o p e r a t i o n this a c c o u n t w o u l d h a v e been very different. T h e a u t h o r s are grateful to A i r V i c e - M a r s h a l Sir Peter D i x o n a n d A i r V i c e - M a r s h a l G. H. Morley, S e n i o r C o n s u l t a n t s in Surgery, R o y a l A i r Force, for t h e i r e n c o u r a g e m e n t in t h e p r e p a r a t i o n o f this p a p e r a n d to t h e D i r e c t o r - G e n e r a l , A r m y Medical Services, a n d t h e D i r e c t o r - G e n e r a l o f the R o y a l A i r F o r c e Medical Services for permission to publish. REFERENCES AIR.D, I. (1944), 'Military Surgery in Geographical Perspective ', Edin. Med. J., 51, 166. AR.TZ, C. P., BR.ONWELL, A. W., and SAKO, Y. (1955), 'Experience in the Management of Abdominal and Thoraco-abdominal Injuries in Korea ', Am. J. Surg., 89, 773. BEEBE, G. W., and DE BAKEY, M. E. (1952), Battle Casualties: Incidence, Mortality and Logistic Considerations, ch. 3. Springfield, Ill. : Thomas. CHURCHILL, E. D. (1952), ' T h e Management of Wounds (Initial and Reparative Surgery)', in Symposium on Treatment of Trauma in the Armed Forces, ch. l l. Washington: Army Medical Service Graduate School, W R A M C .
Injury April 1970
CLYNE, A. J. (1954). ' Missile Wounds in Malaya ', Br. reed. J., 2, lO. COPE, Z. (ed.) (1953), ' S u r g e r y ' in History of the Second Worm War: U.K. Medical Series. London: H.M.S.O. FRENCH, R. W., and CALLENDER, G. R. (1962), ' Ballistic Characteristics of Wounding Agents', in Wound Ballistics, p. 91. Washington, D.C.: Office of the Surgeon General, Department of the Army. NATO HANDBOOK (1958), Emergency War Surgery. Washington, D.C.: U.S. Government Printing Office. THORESBY, F. P. (1966), 'Cavitation, a Review', JI R. Army med. Cps, 112, 89. WAR OFFICE (1962), A FieM Surgery Pocket Book. London: H.M.S.O. WATTS, J. C. (1960), ' M i l i t a r y Surgery: Missile Injuries in Cyprus ', Ann. R. Coll. Surg., 27, 125. WHEATLEY, P. R. (1967), 'Research on Missile Wounds: the Borneo Operation Jan. 1963-June 1965 ', JI R. Army med Cps, 113, 18. WHELAN,T. J., BUR.KHALTER.,W. E., and GOMEZ, A. (1968), ' T h e Management of War W o u n d s ' , in Advances in Surgery, vol. 3, p. 227. Chicago: Year Book Medical Publishers. WOLFF, L. H., GIDDINGS, W. P., CHILDS, S. B., and BROTH, C. R. (1955), ' Timelag and the Multiplicity Factor in Abdominal Injuries ', in Surgery in Worm War II: General Surgery, vol. 2, p. 103. Washington: Office of the Surgeon-General, Department of the Army.
Requestsfor reprints should be addressed to:--Wg. Cdr. R. F. Brown, M.A., B.M., B.Ch., F.R.C.S., R.A.F. Hospital, Ely. Cambridge.shire, England.
ABSTRACTS MANAGEMENT
OF RESPIRATION
Preventing Damage from Cuffed Tracheal Tubes Only by a strict routine of intermittent deflation can ' pressure sores ' of the trachea be prevented in long-term ventilatory problems such as head injuries or stove-in chests. Cooper and Grillo have invented a thin-walled cuff of latex that has ample dimensions to fill the trachea without itself becoming tensely distended. In experimental dogs this was found to cause no damage even when deflated only twice a day whereas the thickwalled tensely distended cuff in normal use caused much damage. The first lesson to learn, however, is that a strict routine of intermittent deflation is desirable. COOPER, J. D., and GRXLLO, H. C. (1969), ' Experimental Production and Prevention of Injury due to Cuffed Tracheal T u b e s ' , Surgery Gynec. Obstet., 129, 1235. Effects of Chest Injury Now that blood-loss is adequately treated, respiratory insufficiency is revealed as the next major cause of death. The Walter Reed Medical Center has turned its attention to this problem in a substantial number
of war casualties. Investigations included respiratory rate and volume, blood-gas analysis, intrapulmonary shunt, the dead space/tidal volume ratio, and the effects of breathing oxygen and of a respirator. MOSELEY, R. V., DOTY, D. B., and PRUITT, B. A., jun. (1969), 'Physiological Changes following Chest Injury in Combat Casualties ', Surgery Gynec. Obstet., 129, 233.
Blast Injury of the Chest Twelve cases are described which showed radiological signs in the chest 8-9 hours after the blast. The clinical picture includes chest pain, dyspnoea, and haemoptysis and may be masked in cases of immersion blast by the clinical picture of acute abdomen when severe abdominal injury is present. There is often no evidence of external injury. Two types of radiological finding are recognized : - a. Pulmonary haemorrhage which clears within 1 week. b. Pulmonary laceration often suggested by the presence of interstitial emphysema, pneumomediastinum, or haemothorax. When there is extensive damage to the lungs there may be evidence of secondary right heart failure. The authors stressed the recognition of radiological signs of pulmonary laceration in the management of these patients. HURSCH, M., and BAZINI, J. (1969), ' Blast Injury of the Chest ', Clin. Radiol., 20, 362.
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MISSILE INJURIES IN ADEN, 1964-7 Wing Commander R. F. BROWN and Wing Commander J. H. BINNS Royal Air Force Medical Branch
An account is given of the missile injuries suffered by British servicemen, their wives and children in Aden between May, 1964 and November, 1967. Records of 776 individuals are reviewed. One hundred and twenty-one died : of these, 99 were killed in action and 22 died of their wounds in hospital. One hundred and thirty-six casualties with major wounds are assessed, and the lasting value of delayed primary suture described in some detail, since its value in civilian accident surgery is overlooked. The advent of the helicopter has made possible the rapid evacuation of the wounded to fixed base hospitals by-passing field surgical units. Nothing is new save that which has been forgotten IN April, 1964, armed tribesmen were in revolt in the mountainous Radfan area 60 miles north of Aden. An area virtually without roads, the movement and supply of British forces was by air. In December, 1964, incidents began to occur in the town, mainly grenade or pistol attacks on servicemen and their dependents, which continued until the final departure of British Forces in November, 1967. Aden was the main base for British troops in the South Arabian Federation and approximately 10,000 men and their families lived and worked in the area. In the town there were two Royal Air Force hospitals in which all service casualties were treated. This paper will show that warfare has presented the surgeon with similar problems throughout the past 60 years, but that, as surgical techniques improve, so the requirements for ancillary services increase and the greater is the need to treat casualties in fully equipped base hospitals. ANALYSIS OF RECORDS We have records of 776 individuals who sustained missile injuries in the period under review. One hundred and twenty-one died, either killed in action or subsequently of their wounds; this was 15.6 per cent of the total. This compares with a 23 per cent mortality in those sustaining missile injuries (i.e., ' h i t ' ) in World War II (Beebe and de Bakey, 1952). During similar disorders in Cyprus in 1955-7, 704 Britons sustained missile injuries and 135 died, a 19.2 per
cent mortality (Watts, 1960). In Vietnam from October, 1965, to June, 1967, nearly 6000 died and 40,000 were wounded. With small casualty figures, the local conditions determine the type of injury and the figures may not be truly comparable. For example, in Aden there were a number of revolver shots at point-blank range, fatal instantaneously. The proportion of missile injuries from the accidental discharge of a serviceman's own or a comrade's weapon was small: 51 incidents, 6'6 per cent of the whole. In the jungles of Malaya the proportion was very much higher: 37.5 per cent of casualties were not due to ' enemy action ' (Clyne, 1954). Table I shows a breakdown of casualties according to the missile (causative agent) involved, showing the numbers wounded and the percentage who died in each case. (In the records available, it is not always possible to know what hit a man dying rapidly and this was often loosely recorded as ' gunshot wound '* on the field surgical card.) We have records of 111 servicemen killed by enemy action in Aden, and 4 who lost their lives from the accidental discharge of a weapon. We *' Gunshot wound' in World War I indicated an injury arising from any weapon using explosives, as opposed to those wielded by men to cut, stab, or gas; in World War II the term described injuries from small arms (pistol, rifle, or machine gun) which fired solid bullets, rather than from shells, which exploded. We have used this accepted definition.
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have also included the deaths of 6 service dependents and civilians. These deaths are further broken down in Table H to those killed in action and those who died of wounds. In the first case death occurred before they reached an aid station for preliminary treatment of their wounds, or before aid could reach them. Autopsy Records There have been few records of autopsies on those dying in battle. In our series, records of full post-mortem examinations are available for
deaths in the following 6 groups (Beebe and de Bakey, 1 9 5 2 ) : Group 1 : Those killed instantly In this group there are 54 deaths and there is no record of the patient having survived any length of time. There were 2 Royal Marines, 49 Army personnel, and 3 Royal Air Force. Only 3 were considered to have been accidental of self-inflicted. The agent causing death was a gunshot wound in 43 cases, a grenade in 4, the explosion of a shell in 5, and of a landmine in 2.
Table L--CASUALTIES IN ADEN, 1964--7 No. OF
MISSILE
No. OF
INJURED
NO. OF DEATHS
PERCENTAGE OF DEATHS
ACCIDENTS
224
68
30"4
37
51
8
15'7
10
394 57
19 6
4"8 10'5
4 0
50
20
40"0
0
776
121
15"6
Bullet, (rifle, pistol, or machine gun) Shell (high explosive, mortar, cannon, rocket) Grenades (and booby traps) Mine explosions Unclassified (' G.S.W. ')* Total
51
I *See footnote p. 293.
Table//'.--CAUSES OF DEATH: KILLED IN ACTION AND DIED OF WOUNDS KILLED IN ACTION
DIED OF WOUNDS
Bullet (G.S.W.) Shell Bomb Blast Unclassified
58 6 10 5 20
10 2 9 0
68 8 19 6 20
Total
99
22
121
MISSILE
1
TOTAL
63 deaths, together with a brief pathologist's report on a further 9. We have attempted to determine, as precisely as possible, the time interval between the individual being hit and his subsequent death, and also the cause of death. In view of the brief interval between the injury and death, it is obvious that the geographical circumstances of the campaign and the number of medical auxiliaries deployed, will determine how many of those injured are evacuated to an aid post or hospital. We have classified our
The cause of death, determined by postmortem in 29 cases, showed that catastrophic mediastinal haemorrhage from heart and great vessels had occurred in 12 cases, intracranial injury with gross destruction of brain tissue in 12 cases, and in 2 cases transection of the spinal cord in the neck or upper thoracic region. In 3 deaths, haemorrhage occurred in large vessels other than the mediastinum (the inferior vena cava, the common iliacs, or abdominal aorta). It is considered that in these individuals no medical care, however organized, could have saved their lives. Group 2 : Those who survived temporarily but died without Medical Aid In this group there are 38 deaths recorded: 1 Royal Navy, 2 Royal Marines, 34 Army, and 1 Royal Air Force. Thirty-two were reported as due to bullets, 2 to grenades, 3 to mines, and 1 to a shell exploding. One death was not due to enemy action. It is instructive to consider the cause of death in relation to the time interval elapsing in the 9 cases where this is known. In 1 Army death, the
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individual survived 1 hour following transection of the femoral artery. He was alone at the time up-country. Individuals survived a few moments following haemorrhage from iliac vessels (2), renal vessels (1), thoracic outlet (1), or mediastinal vessels (2), and multiple injuries to abdomen and chest causing haemorrhage from a mine explosion. One officer died 2 hours after injury from haemorrhage from his lung in an ambush when he was struck by a single bullet. He was far from Aden and unable to obtain assistance, although able to drive. It will be clear therefore that the majority recorded as surviving a few moments, to all intents and purposes died instantaneously. There was insufficient time to organize medical care to save their lives.
Group 3 : Died but received First Aid Treatment, in the Field, only In this group 7 deaths are recorded. All deaths were due to enemy action, 2 in Royal Marines, 5 in Army personnel. Three were due to bullets and 4 to grenades. Two of these deaths followed minutes after injury from major haemorrhage from the iliac vessels and from injury to the heart. The circumstances of their deaths, in Aden itself, permitted the ineffectual deployment of first aid. In 5 other cases, injuries were multiple. One patient was injured in the chest, abdomen, and leg and survived 20 minutes; another with injuries to lung and face, but with the main vessels intact, survived 4 hours up-country. A patient with torn gastric vessels and multiple pulmonary lacerations survived 2 hours in Aden, one with lacerations of the legs and spleen survived 1½ hours up-country, and finally a patient with a compound fracture of the tibia and haemorrhage from the femoral artery survived 2 hours in Radfan. It is apparent that these patients may not have received mortal wounds and might have been saved, had they survived to be admitted to a surgical unit. It is in the light of these failures that the organization of medical care should be judged and the efficiency of first aid. Essential measures for the preservation of life should be taught to all service personnel, and probably to their families also in a theatre where they may be equally at risk. In practice, there are only a few conditions where the knowledge of the principles of first aid can help an individual with a potentially lethal wound, but in these cases these measures may well save a life and cannot depend upon the presence of medical auxiliaries.
295
a. Staunch catastrophic haemorrhage by firm direct pressure maintained directly over the wound with a pad and bandage, or field dressing. (A tourniquet may help but only whilst the dressing is being adjusted.) b. Maintain an airway free of blood, mucus, and vomit by clearing the air passages and turning the patient to allow fluid and secretions to escape naturally. Avoid injury to the spinal cord while moving a patient with a suspected spinal injury. c. Close a sucking chest wound with a pad to prevent collapse of the lung. Successful primary aid will certainly give an opportunity for medical personnel to start measures for the resuscitation and the comfort of the patient. In Aden medical orderlies and medical officers in the field were encouraged to set up intravenous transfusions for the seriously injured as soon as they were seen. Plasma was usually given, and no problems with storage were encountered. Blood was not given outside the hospitals, in view of the difficulties in storage and in ensuring accurate cross-matching, and the delays that might result. Fractures were temporarily splinted, either by tying the legstogether or with Kramer wire. Most casualties were given intravenous or deep intramuscular morphine and those from upcountry an initial injection of 1 million units of crystalline penicillin and a booster dose of anti-tetanus toxoid. It is by no means certain that antibiotics in this dosage are effective in preventing or delaying the onset of wound infection. In this campaign, and also in Vietnam, evacuation for early optimal surgical treatment was so satisfactory that controlled assessment is not possible. If casualties occurred in overwhelming numbers or evacuation for surgical care was delayed then some means of protecting the patient from the onset of wound infection would prove invaluable. So far we have dealt with deaths classified as ' killed in action ', 99 in all. The number depended upon the proximity of hospital services. In the incidents in the city, obviously more ' fatally w o u n d e d ' individuals were brought to hospital and died during subsequent attempts at resuscitation. This makes comparison with campaigns elsewhere misleading.
Group 4: Deaths occurring ill Hospital, where Attempts at Resuscitation had already begun There are 9 deaths in this group, 2 in Army personnel, 2 in R.A.F., 2 Service dependents, 2 civilians, and 1 American sailor. All were involved in incidents in the city limits. Five
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suffered grenade injuries, 3 bullet wounds, and 1 a blast from a mine. Five deaths occurred, in spite of immediate transfusion, following haemorrhage from large vessels in the chest or root of the neck, 1-3 hours after injury. In 2 there were also multiple injuries elsewhere. Three cases died from intracranial injuries; these were not operated upon, but were intubated and artificially respired. The last case involved 2 bullet wounds, one across the root of the neck and the second dividing the trachea at the level of the bifurcation. The patient suffered extensive surgical emphysema and died after 1 hour 40 minutes. Such cases are the test of the skill, training, and organization of the surgical teams. It is a measure of their availability and their experience of traumatic surgery in war and in accident services at home. All medical officers, specialist or nonspecialist, in a hospital accepting major trauma, must be familiar with the techniques of immediate resuscitation, maintaining airways, and artificial respiration. One or more transfusions of plasma or dextran and subsequently of matched whole blood, must be set up and given under pressure, if necessary, as soon as possible. As in civil surgery the numbers of units of blood used for trauma increases in every succeeding campaign. The area for the reception of casualties must be large enough to receive the numbers anticipated and to provide a clear area around each individual for examination and manipulations. It must have running water for cleansing the patients (who are often filthy) and easy access to laboratory for blood examination, to an X-ray unit, and to the operating theatre. Documentation must be fast and accurate and facilities must be provided elsewhere for information to be passed to higher command, and to the patients' units for transmission to their next-of-kin. In our present age also, members of the press require access to details of those injured. It should not be necessary to emphasize that those not directly involved in the care of the injured are kept away from casualty reception areas. This does not appear to have presented a problem to previous military surgeons. The purpose of resuscitation is to save life and to prepare the patient for necessary surgery; responsibility for this rests with the surgeon in charge of the cases and the operating theatre. Continuity of surgical care is essential since only thus can the sorting of casualties be carried out, and the priority for surgery assessed. In any one incident the numbers of serious cases requiring urgent surgery was relatively small, and remained
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manageable, with one or two surgical teams available. In the last sixty years, there has been a considerable decrease in the delay in submitting patients to surgery after admission to hospital (Whelan, Burkhalter, and Gomez, 1968). In World War II an average delay of 4-5 hours was usual. In Korea it was considered advisable not to spend more than 3 hours on resuscitation. In Aden, and also Vietnam, this period was shortened to 1~}-2 hours, after which prompt surgery was advised for all but the obviously mortally wounded. The commonest cause for the failure of response was continued uncontrolled haemorrhage. In our series no deaths are recorded of cases submitted to surgery to stop bleeding. Other causes of failure of response include massive peritoneal contamination, particularly from wounds of the lower bowel or large eviscerations, blast injuries of the lungs or brain, and indeed any severe wound where the bloodvolume cannot be maintained.
Group 5: Patients operated upon after Admission to Hospital but who did not survive Initial Surgery There are 7 deaths within 24 hours in this group. Six were Army personnel, 1 a civilian. Four were injured by bullets, 3 by grenades. Two died from persisting shock 4 hours after surgery for multiple injuries to the limbs and perforation of the bowel. Five patients died from gross cranial injuries after decompression and in spite of tracheostomy, artificial respiration, and transfusion. The extent of the brain damage was confirmed post mortem Like Group 4, Group 5 swells the numbers who apparently died of their wounds in hospital and who in previous campaigns might have been recorded as killed in action, before reaching medical establishments.
Group 6: Patients who died of their Wounds having survived Initial Surgery There are only 6 patients in this category. One Royal Marine, 4 Army, and 1 Royal Air Force. The causes of death here are quite different from those recorded previously. In those dying 2-4 weeks after injury, septicaemia was found in all, complicating renal failure in one and secondary haemorrhage in another. All had suffered extensive multiple wounds, with injury to the buttocks and bowel (1), to the abdomen (2), and to chest and abdomen (1). Two cases died of their wounds many months later after returning to the United Kingdom. One patient died of
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delayed renal failure, 2 years after sustaining a bullet wound traversing both kidneys and treated conservatively, the other from traumatic transection of the cervical cord (Table III). Thus 22 patients in Groups 4-6 died of their wounds in hospital, 13 following operation. Even if we include the deaths in hospital consequent upon efficient evacuation of casualties, the mortality rate is still low (2.6 per cent of those struck by missiles). This compares with 2.5 per cent in Vietnam, 2 per cent in Korea, and 4 per cent in World War II. Deaths in hospital occurring in the first 24 hours (16) comprised 73 per cent. In Vietnam it is 62-3 per cent (Whelan and others, 1968). In Cyprus the mortality for cases alive on admission and fit for surgery was 3 per cent (Watts, 1960), and Malaya 3.7 per cent (Clyne, 1954).
297
all intracranial, intrathoracic and intra-abdominal (intraperitoneal) wounds, together with gross soft-tissue injuries, with or without fractures, causing shock. One hundred and thirty-six such patients are recorded. Intermediate injuries were those which required surgery less urgently than the major wounds. They included missile wounds tracking through muscles or involving bones and joints, and those causing injury to vessels or nerves where the vitality of the whole limb was not imperilled and shock was not an immediate risk. In addition we included faciomaxillary, eye, and neck wounds where vital structures were not involved. There were 143 in this group. Minor wounds were not a danger to life at any time and did not involve structures below the deep fascia. They included many cases of peppering
Table IlL--CAuSES OF DEATH FOLLOWING SUCCESSFUL INITIAL SURGERY
PATIENT
1. R.M.
INJURIES
Multiple injuries to
2. Army 3. R.A.F.
4. Army 5. Army
6. Army
abdomen and legs Perforation of both kidneys Perforation of small bowel, stomach, and liver Injuries to abdomen, buttocks, and legs Thoracoabdominal wound and gastropleural fistula Wound of neck and paraplegia
Wound Surgery The total number of patients who were submitted to surgery for their wounds was 668, of whom 13 died (1.9 per cent). We have attempted to classify these according to the severity of their injuries. Unfortunately no standard criteria for assessment exists, a lack felt by previous authors in this field. The obviously severe and the trivial can be distinguished but a variable mid-zone of intermediate severity exists. In general we have classified as severe, wounds which required prompt surgery. This included
CAUSE OF DEATH
PERIOD FOLLOWING INJURY
Septicaemia and renal failure
28 days
Renal failure
2 years
Biliary peritonitis and secondary haemorrhage Septicaemia
3 days
21 days
Haemorrhage
31 days
Septicaemia
Not known
with grenade fragments and superficial bullet wounds. There were a large number of patients in this group and, although they provided few surgical problems, their wounds required excision and suturing (either at once or later) and encouragement to return to their duties or homes retaining their morale. They totalled 396 patients.
Major Wounds The distribution amongst the services and according to the weapons involved is given in Tables I V and V.
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The main principles of treatment of war wounds were clearly defined during World War II and are recorded in the Surgical Histories of that war (Churchill, 1952; Cope, 1953) and are the basis of the advice given in both the Field Surgery Pocket Book (1962) and the NATO Handbook (1958). It is not our purpose to repeat all the precepts within those manuals bul rather to re-emphasize some of the points which we consider important today and Io discuss certain changing concepts and possible advances.
Table/K--DISTRIBUTION
OF MAJOR WOUNDS AMONGST THE SERVICES
STATUS
R.N. Army R.A.F. Families Civilian Total
MAJOR WOUNDS
DEATHS
13 96 9 2 16
1 12 3 2 4
136
22
Soft-tissue Wounds These are by far the commonest of all wounds. By the end of the 1914-18 War the principle of wound excision and secondary suture at 8-12 days was accepted by most military surgeons. Topical antiseptics were used (e.g., CarrelDakin's solution of sodium hypochlorite) and the wound was sutured when considered to be relatively bacteria-free. If suturing was not feasible it was allowed to heal by granulation with inevitable scarring and deformity. In World War II, after initially using methods of 25 years before, delayed primary suture became the rule. The previously excised wounds were closed at 4-6 days and healing was obtained without wound infection, more quickly, and with minimal scarring and deformity. In Aden, the first few cases of missile injury were treated by secondary suture and took 6--8 weeks to heal. Packs were removed in the wards, eusol soaks were instituted to prepare the wound for suture, and the wound edges were trimmed before suturing them. The results were thoroughly unsatisfactory. Subsequently missile wounds were correctly managed and few became infected. The important points stressed to surgeons treating these wounds were : - a. Adequate d6bridement, involving both the excision of non-viable tissue (liberally in the case
of muscle but only limited excision of skin edges and bone fragments) and the wide incision of fascia longitudinally to decompress the injured limb. The majority of missiles were travelling at relatively low velocities and few cases of massive necrosis of muscle were seen (French and Callender, 1962; Thoresby, 1966) but the wound infections that occurred were due to failure to resect injured muscle sufficiently widely. b. No attempt was made to close these wounds. A single layer of tulle gras was laid on the raw
Table V.--CAUSAT1ON OF MAJOR WOUNDS
MISSILE
Bullet Shell Grenade Mine Total
MAJOR WOUNDS
DEATHS
56 10 46 24
13 0 8 1
136
22
surface of the wounds and covered by loose gauze to absorb exudate, and surrounded by plenty of cotton-wool and cr~pe or cling bandage. The limb was elevated and immobilized in plaster-of-Paris if the wound was large, to rest the part. The use of gauze packs with petroleum jelly was highly unsatisfactory, as they acted as plugs preventing the escape of exudate and resulting in further deep infection. c. The next inspection of the wound occurred in theatre 4--5 days later, although earlier if pyrexia, bleeding, swelling, or odour suggested closed sepsis. In the latter case further d6bridement was carried out and suturing postponed. d. If the wound was clean, it was washed over with aqueous Hibitane (chlorhexidine), loose tissue was trimmed away, and a single-layer repair, leaving no dead space, was carried out without further excision of the wound edge. If the tension was unacceptable then a free graft of split skin was laid on the clean granulations and a pressure dressing applied. The majority of such wounds were healed in 21 days without infection. The problems arose when the wounds were extensive and multiple; adequate excision was time-consuming and if major intraperitoneal injury was also present, the limb wounds may not have received the attention they required in an attempt to complete the operation in a reasonable time. In such cases two surgical teams working
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simultaneously were almost essential when the trained manpower was available. Wide excision of multiple soft-tissue wounds is mutilating, but necessary, and to retain pressure dressings in place on such areas as the groin, buttocks, and axillae is not easy. Once they slip or exudate seeps through, then infection can enter from without. Other measures were taken to enable the patient to heal without infection. A normal haemoglobin level was maintained, transfusing more blood during the healing phase if the blood picture suggested that the initial blood-loss was underestimated and not replaced. A high protein diet was provided and routine antibiotics given, either 1 million units of crystalline penicillin followed by 500,000 units 6-hourly or tetracycline 1 g. and 0.5 g. 6-hourly for 5-10 days, in the case of limb wounds. These doses are considerably smaller than those advocated by American surgeons in Vietnam. Local antibiotics on the raw surfaces were occasionally used but their efficacy was difficult to assess; certainly antibiotics failed to overcome inadequacies in wound excision and drainage. There is still no place today for neglecting this aspect of wound care. In many cases of less severe wounds our surgeons were tempted to close the wounds primarily. In general this was successful provided the wounds were superficial (i.e., confined to the subcutaneous tissues) and caused by low-velocity missiles releasing little energy (e.g., grenade fragments with short tracks before coming to rest). In the Aden climate clothes were light and laundered, and seldom embedded in superficial wounds. The wounds were thus clean and treatment was carried out within 8 hours. Other wounds which were closed primarily included scalp and clean-cut facial wounds. The former included cranial wounds where it was essential to cover the dura or skull defects with viable scalp. Penetrating chest wounds were closed in the depths to seal the pleural cavity. Wounds of the hands and feet gave some difficulty. In the case of simple hand wounds primary skin cover was achieved, but for some more c o m p l e x ' u n t i d y ' hand wounds delayed cover by free skin-grafting at 5-7 days healed the hand more rapidly with minimal infection. If the grafts subsequently contracted or caused deformity, then secondary flap cover was considered. Through-and-through bullet wounds of the feet invariably became infected and often contained dirt and foreign material (fragments of socks or boots). Such wounds failed to heal
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if they were sutured and they were left open with free drainage after excision, to heal by granulation. In the cases where amputation was considered necessary at the primary operation, usually of extremities grossly injured with mutiple fractures and disruption of joints and soft tissues and division of main artery, or nerve, or both, this was performed as distally as possible, perhaps through the fracture site. No attempt should be made to close the flaps; if this is done infection is inevitable and occurred in our earlier cases. Amputation at the site of election was performed later, in Aden or the United Kingdom after evacuation, when the wounds were free from risk of infection. Vascular Injuries In the early months injuries to vessels were treated by ligation and relying on the development of a collateral circulation to maintain the vitality of the limb. In cases where there were other injuries, particularly causing oedema, gangrene resulted and amputation was performed. Secondary haemorrhage in the presence of infection is most likely to occur at 10-14 days and limbs with arterial injury should not be moved until the overlying skin is healed. One of our cases required emergency amputation at a hospital en route for the United Kingdom by air, at 9 days. Some attempts to repair lacerations of arteries and veins were successful but no arteries were reconstituted by venous grafts. This current trend in the surgery of trauma has improved the results of vascular injury in accident surgery and many limbs can be saved in war also. Head Injuries The results of primary care of head injury were satisfactory. Adequate oxygenation by tracheostomy was advised for the unconscious cases. The entry and exit wounds were excised and brain tissue aspirated by gentle suction and irrigation, but deep exploration was not carried out. If possible the dura was closed but otherwise the scalp was sutured over the defect. We treated 20 patients shot through the vault: 8 died, all within 24 hours. The remaining 12 recovered consciousness and are all able to live useful independent lives. Three patients with spinal transection were treated by primary wound excision, without any attempt at bone fixation, and were evacuated by air to the United Kingdom to the National Spinal Injuries Centre at Stoke Mandeville.
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Chest Wounds In our series there were 17 penetrating chest wounds, and 4 patients died shortly after admission to hospital from uncontrollable major haemorrhage, without undergoing surgery. The majority of cases (9) were treated conservatively by thoracentesis of blood and air to expand the lungs and restore a normal cardiopulmonary physiology as rapidly as possible. F r o m 3 to 5 aspirations were required to empty the pleural cavity of blood and exudate. Underwater seal drainage was used for the cases with pneumothorax. Open thoracotomy was carried out for persisting haemorrhage and for the removal of large metallic foreign bodies in 4 cases, without mortality. One required a later decortication in the United Kingdom. Abdominothoracic Wounds There were 4 abdominothoracic wounds and of these 1 died a month after injury. In general, conservative treatment of the chest was combined with abdominal laparotomy. The patient who died had been shot through the left arm and lower chest and sustained a ruptured spleen, perforated colon and stomach, laceration of the diaphragm, and some intrapleural bleeding. The abdomen was opened and the stomach repaired, the spleen removed, and a colostomy performed. The diaphragm was repaired and the chest drained but not opened. The patient subsequently died from haemorrhage, having earlier developed a gastropleural fistula. A second patient was struck by a single bullet which traversed the left elbow and left loin. Three ribs were fractured and a haemothorax was present. At wound excision, omentum was found in the pleural cavity and laparotomy revealed a ruptured spleen and left kidney, perforation of the splenic flexure of the colon, and a lacerated diaphragm. The spleen and left kidney were removed, colostomy performed and the diaphragm sutured, and the pleural cavity drained. The patient made a good recovery. Abdominal Wounds Twenty-nine cases of intraperitoneal abdominal injury were recorded with 5 deaths, 2 of them within 24 hours from persisting wound shock. Both had extensive injuries and were severely shocked on admission. The policy should be one o f ' look and see ' rather than ' wait and see '. If the missile track could conceivably have entered the abdominal cavity, exploration, in standard hospital conditions, will do no harm and may save life. Wounds of the buttocks,
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perineum, upper thighs, and lower chest may also have involved intra-abdominal structures. All perforations in hollow viscera were sought for and closed, or the segment of injured bowel resected. Injury to the caecum was treated by a caecostomy tube inserted into the perforation: wounds of the colon were either exteriorized or closed and a more proximal double-barrelled colostomy performed. Liver wounds and bilateral injury to the kidneys were treated conservatively. Injury to the bladder was repaired and catheter drainage instituted. The main complications of intra-abdominal wounding were still paralytic ileus and sepsis. If a patient fails to maintain satisfactory improvement postoperatively, consideration should be given to the indications for a second laparotomy, lest an intra-abdominal injury has been missed. The hidden areas of the retroperitoneal surface of bowel, in abdomen and pelvis, are the most likely sites of missed perforation, and all haematomata there must be explored. A soldier with grenade injuries to the abdomen died on the third postoperative day from haemorrhage and peritonitis associated with a missed perforation in the posterior wall of the stomach in the lesser sac. The fragment had traversed small bowel and stomach and entered the liver by the porta hepatis. The wounds in bowel and two perforations in the stomach had been closed and the porta drained. The continued peritonitis was considered biliary in origin and a third stomach wound was not considered. At postmortem it appeared that there was a third stomach perforation due to a glancing injury. Repeat laparotomy should have been performed. A patient with similar injuries was noted to be severely shocked at the end of the primary operation. The abdomen was re-opened and the stomach found to be distended with blood from an injury to the posterior wall of the first part of the duodenum. The bleeding vessel was undersewn and recovery was uneventful. There were no cases of wound dehiscence. Most patients had through-and-through tension sutures as well as stitches to the skin edges. Postoperative Care and Evacuation Postoperatively all patients were retained in hospital or adjacent Unit Medical Centres in Aden until their wounds were healed and they were fit to return to duty with their units. Minimal sick leave was given since there were no convalescent centres in the area and little opportunity for prolonged relaxation. The majority of
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those with minor injuries returned to light duties under the supervision of their Medical Officer. Cases who would not be fit within 6 weeks were flown back to the United Kingdom by R.A.F. Transport Command. The determination of a patient's ability to tolerate air travel is somewhat empirical. The surgeon should be familiar with the aircraft, the route and facilities available en route, and the delays that are likely. Steady flight seldom distressed a patient, but take-off, landing, and stopovers did. Cabins were pressurized to 60(0)-8000 feet, the air was dry, and there was very limited access for the care of patients. Thus abdominal wounds should be fully healed before moving by air, with normal bowel movement. Chest injuries gave no trouble since the lungs were already expanded. Brain and head injuries and spinal injuries were nursed on Stryker turning frames and travelled well. The major error that occurred was in moving patients with gross limb wounds and associated vascular injuries too soon. This was done to improve the chances of saving a limb with impaired blood-supply by transferring to special centres for vascular surgery or hyperbaric oxygen in the United Kingdom. Cases of sudden secondary haemorrhage occurred requiring urgent operation for their control, one en route, one shortly after arrival in Britain. It is probably preferable to delay transfer of such cases of gross injury for 14 days. Most sudden changes and complications occur in patients' conditions within the first 2 weeks of wounding. Subsequently patients were admitted to service hospitals in the United Kingdom where reparative surgery was carried out, followed by rehabilitation. Some were invalided from the services, but the majority returned to their units. Feed-back of information and comment from hospitals and surgeons at home is desirable. DISCUSSION Aird (1944) has stated that ' the surgical needs of a campaign may be deduced from the recorded geography of the terrain over which it is to be fought, and the contemporary trends of battle tactics '. In Aden (and in Vietnam) with undisputed control of the air and limited communications on the ground, and with fighting in the streets of the towns adjacent to the hospitals, the immediate admission of casualties to base hospitals was logical. The helicopter has made this possible. The average time from wounding to surgery, for abdominal wounds, was 10-5 hours in World War II (Wolff, Giddings, Childs, and
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Broth, 1955), 6.3 hours in Korea (Artz, Bronwell, and Sako, 1955), and 2"8 hours today in Vietnam (Whelan and others, 1968)--the most rapid evacuation of wounded ever achieved in battle. In Aden similar times were recorded in the city, or less, but the delay for most up-country casualties remained at about 2-6 hours. Morale benefited from the knowledge that injured servicemen would be treated in modern hospitals, fully equipped with ancillary services for investigation and treatment. Such facilities can never be deployed in field surgical hospitals. Campaigns elsewhere in other conditions may prohibit the use of such tactics, and the problems of mass casualties and of thermonuclear irradiation are totally different. Our post-mortem findings in fatal missile injuries confirmed what we had expected to find as the causes of rapid death. Nevertheless this approach to the assessment of a casualty service is valuable and tests the efficacy of the care provided at different points, in the field and in hospital. There may have been no innovations in the handling of soft-tissue wounds since 1945 but the development of new and more powerful antibiotics has not eliminated the need for adequate wound excision and drainage and the advantages of delayed primary suture. We have presented our comments on soft-tissue injuryat some length since we feel that the principles required restatement, and that surgeons working in civilian accident units may have overlooked the value of delayed primary suture of the extensive contaminated wounds of their practice. The mortality of abdominal wounds has steadily fallen in the last 60 years, as a result of reducing the delay before laparotomy is undertaken, more energetic resuscitation with the increasing use of blood replacements, larger doses of antibiotics, and some advances in the care of certain wounds (e.g., of the colon and liver). Air evacuation enables the wounded serviceman to be in his home country within hours of leaving the theatre of operations. He can be referred for specialist treatment at home, he can convalesce in optimal surroundings and with his family, and if necessary can return to his unit as easily. The pattern of care and administration alters, but in many ways the solutions to the many problems of injury in war remain the same through the ages.
Acknowledgements The authors wish to record their debt to all their medical colleagues, administrative and
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clinical, in t h e t h r e e services, w h o served w i t h t h e m in A d e n , a n d w i t h o u t w h o s e c o - o p e r a t i o n this a c c o u n t w o u l d h a v e been very different. T h e a u t h o r s are grateful to A i r V i c e - M a r s h a l Sir Peter D i x o n a n d A i r V i c e - M a r s h a l G. H. Morley, S e n i o r C o n s u l t a n t s in Surgery, R o y a l A i r Force, for t h e i r e n c o u r a g e m e n t in t h e p r e p a r a t i o n o f this p a p e r a n d to t h e D i r e c t o r - G e n e r a l , A r m y Medical Services, a n d t h e D i r e c t o r - G e n e r a l o f the R o y a l A i r F o r c e Medical Services for permission to publish. REFERENCES AIR.D, I. (1944), 'Military Surgery in Geographical Perspective ', Edin. Med. J., 51, 166. AR.TZ, C. P., BR.ONWELL, A. W., and SAKO, Y. (1955), 'Experience in the Management of Abdominal and Thoraco-abdominal Injuries in Korea ', Am. J. Surg., 89, 773. BEEBE, G. W., and DE BAKEY, M. E. (1952), Battle Casualties: Incidence, Mortality and Logistic Considerations, ch. 3. Springfield, Ill. : Thomas. CHURCHILL, E. D. (1952), ' T h e Management of Wounds (Initial and Reparative Surgery)', in Symposium on Treatment of Trauma in the Armed Forces, ch. l l. Washington: Army Medical Service Graduate School, W R A M C .
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CLYNE, A. J. (1954). ' Missile Wounds in Malaya ', Br. reed. J., 2, lO. COPE, Z. (ed.) (1953), ' S u r g e r y ' in History of the Second Worm War: U.K. Medical Series. London: H.M.S.O. FRENCH, R. W., and CALLENDER, G. R. (1962), ' Ballistic Characteristics of Wounding Agents', in Wound Ballistics, p. 91. Washington, D.C.: Office of the Surgeon General, Department of the Army. NATO HANDBOOK (1958), Emergency War Surgery. Washington, D.C.: U.S. Government Printing Office. THORESBY, F. P. (1966), 'Cavitation, a Review', JI R. Army med. Cps, 112, 89. WAR OFFICE (1962), A FieM Surgery Pocket Book. London: H.M.S.O. WATTS, J. C. (1960), ' M i l i t a r y Surgery: Missile Injuries in Cyprus ', Ann. R. Coll. Surg., 27, 125. WHEATLEY, P. R. (1967), 'Research on Missile Wounds: the Borneo Operation Jan. 1963-June 1965 ', JI R. Army med Cps, 113, 18. WHELAN,T. J., BUR.KHALTER.,W. E., and GOMEZ, A. (1968), ' T h e Management of War W o u n d s ' , in Advances in Surgery, vol. 3, p. 227. Chicago: Year Book Medical Publishers. WOLFF, L. H., GIDDINGS, W. P., CHILDS, S. B., and BROTH, C. R. (1955), ' Timelag and the Multiplicity Factor in Abdominal Injuries ', in Surgery in Worm War II: General Surgery, vol. 2, p. 103. Washington: Office of the Surgeon-General, Department of the Army.
Requestsfor reprints should be addressed to:--Wg. Cdr. R. F. Brown, M.A., B.M., B.Ch., F.R.C.S., R.A.F. Hospital, Ely. Cambridge.shire, England.
ABSTRACTS MANAGEMENT
OF RESPIRATION
Preventing Damage from Cuffed Tracheal Tubes Only by a strict routine of intermittent deflation can ' pressure sores ' of the trachea be prevented in long-term ventilatory problems such as head injuries or stove-in chests. Cooper and Grillo have invented a thin-walled cuff of latex that has ample dimensions to fill the trachea without itself becoming tensely distended. In experimental dogs this was found to cause no damage even when deflated only twice a day whereas the thickwalled tensely distended cuff in normal use caused much damage. The first lesson to learn, however, is that a strict routine of intermittent deflation is desirable. COOPER, J. D., and GRXLLO, H. C. (1969), ' Experimental Production and Prevention of Injury due to Cuffed Tracheal T u b e s ' , Surgery Gynec. Obstet., 129, 1235. Effects of Chest Injury Now that blood-loss is adequately treated, respiratory insufficiency is revealed as the next major cause of death. The Walter Reed Medical Center has turned its attention to this problem in a substantial number
of war casualties. Investigations included respiratory rate and volume, blood-gas analysis, intrapulmonary shunt, the dead space/tidal volume ratio, and the effects of breathing oxygen and of a respirator. MOSELEY, R. V., DOTY, D. B., and PRUITT, B. A., jun. (1969), 'Physiological Changes following Chest Injury in Combat Casualties ', Surgery Gynec. Obstet., 129, 233.
Blast Injury of the Chest Twelve cases are described which showed radiological signs in the chest 8-9 hours after the blast. The clinical picture includes chest pain, dyspnoea, and haemoptysis and may be masked in cases of immersion blast by the clinical picture of acute abdomen when severe abdominal injury is present. There is often no evidence of external injury. Two types of radiological finding are recognized : - a. Pulmonary haemorrhage which clears within 1 week. b. Pulmonary laceration often suggested by the presence of interstitial emphysema, pneumomediastinum, or haemothorax. When there is extensive damage to the lungs there may be evidence of secondary right heart failure. The authors stressed the recognition of radiological signs of pulmonary laceration in the management of these patients. HURSCH, M., and BAZINI, J. (1969), ' Blast Injury of the Chest ', Clin. Radiol., 20, 362.