- Email: [email protected]
ORIGINAL ARTICLES
ORIGINAL IN - THE MIDDLE EAST * E. G. MUIR, MS LOND, FRCS
SURGERY
LIEUT.-COLONEL RAMC
THE major surgery in the Middle East is as a rule limited to three units-the surgical team or field surgical unit, the casualty clearing station, and the base hospital. The surgical team consists of a surgeon, anaesthetist and a varying number of RAMC personnel, usually drawn, as in the last war, from the base hospitals. They may be used to reinforce a CCS, or may work in the forward area with the light section of a CCS or the main dressing station of a field ambulance. A forward surgical team is likely to be of particular use in mobile and fluid warfare when the absence of a fixed line makes it necessary to keep a CCS a considerable distance behind the forward area. The equipment carried by a surgical team is designed to allow the team to function on its own for a limited period. Their theatre may be a lean-to tent fixed to the back of a lorry, or a separate theatre tent. Successive advances into Cyrenica and East Africa resulted in the capture of many Italian hospital tents, and these became popular with surgical teams, either as a theatre or as a ward ; double-sided and roofed, and well supplied with windows, they are excellent tents though a little cumbersome to carry. Lighting of the theatre may be by ’Petrolmax ’lamps or from the lorry or truck. ThePrimus ’ stove is one of the surgical unit’s most valuable instruments-as indeed it is with any unit. The mobility and small size of these field surgical units enable them to be moved nearer the scene of action than a CCS. In Eritrea and Abyssinia the CCS was occasionally as far back as 200 miles from the scene of fighting. The forward surgical unit shortens the period between the receipt of the wound-and its treatment, often considerable in the Western Desert, it provides a surgical opinion in the forward area, and its presence is appreciated by the combatant troops. The surgeon must confine his attention to the very seriously wounded, those with penetrating wounds of the abdomen, sucking wounds of the chest, severe burns, certain wounds of the head and face and serious limb injuries-in fact, the cases which might not be expected to reach the CCS alive. If he starts to treat others a sudden rush of serious casualties will swamp him. One of the difficulties of such units is that once a serious case has been operated on the patient becomes immobile for perhaps 48 hours or longer and the mobility of the unit may be impaired. As with other forward units they are exposed to ground strafing by enemy aircraft and more than once they have
been taken prisoners. The surgeon in the CCS of the last war must, I think, have had a happier time than his successor in the Middle East. The necessity to keep the CCS further back has led to some of his surgery being stolen by a field surgical unit, and on at least two occasions when casualties have been plentiful, a base hospital has taken over the duties of a CCS, as in Tobruk and later at Alexandria. For a CCS, too, periods of inactivity with few casualties and little work have been frequent in the Middle East and its situation has made this inactivity worse. Apart from those which are housed in existing buildings, most of our base hospitals have been created by the Royal Engineers, on desirable desert sites, on fine sandy soil with rail facilities, and I have never ceased to wonder at the short time in which a piece of sandy desert is transformed into a 1200 bed hospital, partly tented, partly hutted, well equipped, with a good water-supply, roads and electric light. Such a hospital experiences
perhaps its only disadvantage when
a
cold sandstorm
[JAN.
ARTICLES
2, 1943
bullet wounds are best left alone, apart possibly from the introduction of some sulphonamide powder and the application of an antiseptic dressing. For larger wounds the term excision is misleading, since the ideal to be aimed at is the removal of necrotic tissue, cleansing and the provision of really good drainage. The use of powdered sulphanilamide or sulphapyridine and a ’Vaseline ’ pack is almost universal in the Middle East for wounds of any size. The importance of immobilisation for soft tissue injuries is well recognised and many flesh wounds of the limbs are treated in plaster. Certainly all serious wounds will have begun a prophylactic course of sulphapyridine or sulphanilamide in the forward area, though by the time they arrive at the base hospital their dosage will often have been erratic. Intravenous sulphanilamide or sulphapyridine solutions are easily obtainable and the blood-transfusion service in the Middle East has deservedly won praise for its work. The usefulness of skin-grafts in the healing of wounds and burns cannot be over-emphasised. Faciomaxillary units in the Middle East are available for those an extensive or difficult graft, but pinch or Thiersch grafts for wounds of moderate size can effect a saving of weeks in healing time and can be applied in any hospital. In the preparation of the surface for grafting we have e found a sulphanilamide spray as valuable as it was economical in the treatment of other wounds. A very efficient substitute for tulle-gras was obtained by purchasing curtain net of small mesh in Port Said or Cairo. The provision of Army hospitals in South Africa has rendered it unnecessary to retain in a Middle East hospital a patient who is likely to require several months hospital treatment, and while the surgeon may sometimes regret that he cannot see the end-result of the case there is never any doubt as to the patient’s own feelings when he is told that he is to be evacuated. In Eritrea and Abyssinia the Italian hand grenade caused a high proportion of our casualties. The particular one in vogue at that time was a small red one with a light metal casing. Their size and weight made them easy to carry and the Italians and their native askaris, crouched behind the rocks on the mountains round Cheren,
requiring
flung large numbers down on our troops. The noise they made was startling, but the fragments had little penetrating power. They caused many casualties with multiple small wounds ; direct hits were more unpleasant, but few were fatal. A great number were left by the retreating Italians, and many natives, unable to overcome their curiosity, lost their fingers and their eyesight in attempts to open them. Among our casualties in Syria was a very high proportion of bullet wounds. The effect of this was most obvious in the compound fractured femurs of that campaign, for most of them, caused by bullet, had little or no sepsis and united as quickly or even quicker than a simple fracture. The Western Desert has of course produced casualties of all kinds, but compared with the fighting elsewhere land-mine injuries have been very common, such as bilateral fracture of the os calcis from the blowing up of a truck. It has also furnished a surprisingly high number of accidental burns, some of them very serious, caused by the use of petrol in sand fires, usually for making tea. Though hardly a battle casualty, the desert appears to be a bad place for the patient with piles. that they are quite well as long as Many patients say " they are not up in the blue." Once there they become constipated and their symptoms recommence. They attribute this to the diet, which can hardly be varied, to the comparative lack of water, and, for some of them. their inability to take liquid paraffin regularly.
PENETRATING WOUNDS OF THE ABDOMEN January or a hot sandstorm or khamsin To me one of the greatest disappointments of war and as far out the as will Nothing sand, keep is practical dressings are left untouched and operationssurgery has been the lack of success with penetrating The published records of these postponed. To such hospitals the sick and wounded from wounds of the abdomen. wounds in the last war had led me to hope that a survivalthe desert arrive by ambulance train, and in spite of a = of 40-50% might be obtained. and indeed, descripjourney of perhaps over 200 miles they ,haveusuallyrate tions of casualties in the Spanish War and more recently arrived in good condition.
rages in in May.
"
"
GENERAL TREATMENT OF WOUNDS
I have not yet felt justified in practising excision and primary suture of any wound. Clean through-and-through a discussion at the Medical Nov. 23. 1942.
* Introducing 6227
Society of London
on
’ in civilian casualties at home show results of that order. From my own limited experience and surgical gossip with colleagues I do not think that the operative survival]fate for penetrating abdominal wounds in the Middle East would be more than 20-30% and probably less. Of my own 17 cases only 5 survived, approximately
A
2 30 %. Perhaps the best picture I can give of the mortality of these cases is the fact that during one year at a base hospital of 1200 beds only 7 postoperative cases of pene0 trating wounds of the abdomen were admitted. Most of these cases are treated by the field surgical unit ; only occasionally does the CCS receive them, and the base hospital only under exceptional circumstances. The earliest abdomen on which I operated was 6i hours from the receipt of the wound ; a young officer with a penetrating wound of the ascending colon, destruction of one testicle and a compound fracture of the tibia. The average time which elapsed before operation was about 14 hours. Lieut.-Colonel Ian Aird, one of my colleagues working in the Western Desert, in 18 cases of abdominal wounds, had only one admitted within 12 hours of wounding and only 7 within 24, hours. In East Africa the delay was largely due to the mountainous and difficult terrain, necessitating a long carry by the stretcher bearers, occasionally up to 7 hours. In the Western Desert it is partly due to the immobility of transport at night and the scattered nature of the fighting. Peritonitis wa& present on arrival in about three-quarters of my cases. Heat was an unpleasant factor in East Africa. A
shade temperature of 105°-110° F. was common near Cheren. Ether boiled when the cork was removed from the bottle ; gas was not then available and chloroform became a necessary anaesthetic. It is not to be recommended for the shocked abdominal patient in whom the surgeon wants relaxation. PENETRATING WOUNDS OF THE CHEST AND SKULL
centres for the reception and treatment of chest wounds exist in the Middle East. Their treatment in the forward area, however, devolves on the general Some of the sucking wounds are closed by the surgeon. first medical officerwho is able to insert one or two throughand-through sutures. If left alone, the value of this form of closure is doubtful, since wounds closed in this necessarily shipshod manner are apt to break down badly when infected ; there is something to be said in favour of a temporary pack and delaying any closure of the wound until it can be performed under proper surgical surroundings. In general the tendency of surgeons in the forward area has been to deal conservatively with chest cases and to do little more than close a sucking wound. The after-treatment has been repeated aspiration, with or without air replacement, blood-transfusions according to the patient’s haemoglobin level, and sulphapyridine. Most cases seem to have done well on these conservative lines. Even when there is a retained foreign body of some size in the chest no early attempt has as a rule been made in the forward area to remove it. Surgeons feel that to attempt to remove a foreign body by an early thoracotomy in such a setting would be to court disaster. The majority of penetrating wounds of the skull are admitted to a special centre. The initial treatment will be done elsewhere and useful instructions have been issued to all surgeons emphasising the important points in the examination and.closure of such wounds.
Special
COMPOUND FRACTURES
With few exceptions compound fractures have been treated by wound toilette, removal of dead or devitalised vaseline pack and plaster. doubt as to the great value of this treatment regards the patient’s future and the immediate problem of transportation. The faults of this treatment have arisen from technical errors-a tight plaster, excision of too much skin, failure to remove devitalised muscle, particles of clothing or other foreign matter from the wound, and the excessive removal of bone
tissue,
There is both as
a
sulphonamide
no
fragments. Compound fractures of the humerus have as a rule been treated by plaster with the arm to the side unless the type of fracture indicated an abduction plaster. Compound fractures of the femur remain one of the most serious casualties. Most of these arrive at a base hospital in a Thomas splint with extension strapping, a wound toilette having been already carried outand a sulphonamide vaseline pack inserted. Whether a compound femur should be treated by a plaster spica remains a matter of debate. My own preference, were I ever to
suffer from such an unpleasant injury, would be a really wide excision of the wound so that the bone ends could be seen at the bottom of the sloping sides, ensuring good drainage, a sulphonamide vaseline pack, a Kirschner’s wire through the tibial crest with weight extension, and a plaster spica from waist to toes, cut open over the knee. After two to three weeks I should prefer to be treated on a Thomas splint. I believe that plaster and packing for the first two to three weeks effectively seals off the fracture from the tissue planes and greatly reduces the ’likelihood of gravitation abscesses. Excision of the wound is unnecessary in the case of compound fractured femur with a small entry and exit wound of a bullet and no sign of infection ; where there is a small apparently uninfected entry wound and a larger exit wound, only the larger wound should be excised, AMPUTATIONS
The sites of election for a lower limb amputation are almost standard but when such an amputation should be performed is more debatable. This question does not arise in civil life since a street accident is admitted to hospital with little delay. In warfare a wound of the lower limb, which by its severity requires amputation, is often 24 hours old before surgery is available. It is infected and any amputation performed in its proximity stands a considerable risk of becoming infected also. If amputation is carried out at the site of election and gross infection ensues, further amputation will subsequently be necessary and the patient has then lost the most favoured site. Up to what period after the receipt of a wound it would be safe to choose the site of election must depend on the surgeon and the wound, but in doubtful cases a guillotine amputation at the site of injury would probably be the safest course. A true guillotine amputation at the site of election can only be justified if there is no other alternative. These amputations are seldom done ; in most of the amputations performed in the forward area flaps of some kind have been fashioned, held together with one or two
sutures, perhaps
over a sulphonamide-vaseline pack occasionally stitched back. Secondary suture has in many cases produced an excellent stump. Of amputations admitted to a base hospital I have seldom seen an amputation stump of the lower limb heal completely by first intention, and when an attempt has been made in the forward area to obtain this by the insertion of or
many sutures the results have often been disastrous.
The inference to be drawn is that if a wounded limb is more than 12-24 hours old, the site of amputation must be regarded as a potentially and perhaps heavily infected area. Amputation through the knee-joint may be a lifesaving measure, but posterior retraction, with perhaps a visible popliteal artery and vein in the infected granulations, is unpleasant and should be avoided if possible.
requiring amputation
BURNS
The treatment of burns was one of the subjects discussed at a surgical conference held in Cairo in the early part of 1941. It was noteworthy for the varied opinions expressed. Tanning methods have produced some excellent results but many failures and when these methods fail it would have been far better for them never to have been tried. They are as a rule unsuitable in the forward area unless optimum facilities are present and adequate time for careful cleansing. The use of tannicacid jelly as a first-aid dressing is now generally depreciated. Treatment by moist dressings is difficult wheree long lines of evacuation are present and some form of sulphonamide vaseline dressing has much to commend it. In my experience, most of the severe and extensive burns received at a base hospital, 2-4 days old, have required treatment afresh. Cleansing under an anoesthetic, a sulphonamide spray, and bandaging with six-inch rolls of vaseline gauze is the treatment I havepreferred. The patient is’given a course of sulphanilamide by mouth and a plasma drip till the haemoglobin is reduced to 100%. The highest I have seen was 140%, a finding which was confirmed by the pathologist who pointed out that it was actually higher but that this was the highest level he could record. The patient, a South African with second degree burns of more than a third of his
3
body surface, made a surprising recovery. If pyrexia subsides, and the dressings do not become soaked in pus, they are left till they drop off. When secondary infection is present, the dressings are soaked off in a The warm saline bath every 48 hours and reapplied. greater part of these burns is usually second degree but whole skin destruction often only becomes apparent when sloughing appears. For these areas sulphaniland moist dressings are excellent amide powder, tulle-gras as a preparation for skin-grafting, but for the earlier and more extensive dressings the wide vaseline gauze roll has the great merit of speed in application. Glycerin and sulphanilamide dressings, and the use of plaster for
limb burns have their adherents. Some of the more recent methods of treatment recommended in this country have not been available for the Middle East or have been unsuitable. TETANUS AND GAS GANGRENE
Of the surgeons in the Middle East, many are at that in professional life when, but for the war, they would have been about to start a surgical registrarship. Instead they now learn their surgery and gain their experience in a different school. This experience is valuable for all but princfpally for the specialist in certain subjects. For the general surgeon it cannot take the place of what he has missed.
stage
CROSS-DESENSITISATION IN ALLERGIC DISEASES KATE
MAUNSELL, M D KIEL, L R C P E (From King’s College Hospital and Horton Emergency Hospital) THIS paper deals with desensitisation to that class of " "
allergens, called " idiotoxins by Freeman or atopens" in America, which cause bronchial asthma, eczema, conjunctivitis and rhinitis. The allergic properties can be exerted by biologically different groups-food proteins, pollen and other constituents of plants, animal feather, hair and wool, and all sorts of dust. Bacteria and moulds can also act as idiotoxins, apart from their immunological properties. The routine method of attempting a general " specific desensitisation is the injection of those allergens to which the patient shows a special sensitiveness. If only one positive test is found, then that particular allergen alone
.
Few
,
of tetanus have occurred in the Middle East, which is in keeping with the experience of surgeons who served there during the last war. I cannot say what part tetanus toxoid has played in this low incidence. I have only had one case-the only occasion on which I have been guilty of associating with an unqualified cases
practitioner.
_
An Arab of the Arab Legion was wounded by bombing during the Syrian fighting. He was admitted to hospital three days later with a large lacerated wound of the thigh and a compound fractured femur. After the usual treatment of the wound he was put up in a plaster spica. On the 12th day he developed tetanus but recovered after a stormy passage. At one time it was feared that he might lose his leg, and his
father asked that he should be allowed to call in an Arab boneI replied that I should be very pleased to consult with him and a few days later he arrived at the hospital accompanied by all the near-and most of the remote-relatives of the patient. He was an imposing figure, 80 years of age, a huge mountain of a man with a large hooked nose and wrinkled brown face. He was a shepherd from Bethlehem Fields who from the age of 6 had been interested in fractures and had gradually acquired a reputation and a practice among his people. We examined the case together and then, with the aid of an interpreter, discussed the treatment. He told me that the Arab believes that a broken bone will heal in the same number of days as the patient’s age and requires splinting and rest for this period. Thus the bone of a man of 40 will take 40 days to unite. The rule broke down in the case of infants and in the presence of an open wound. In his practice, he made it a rule never to treat a fracture with an open wound but to wait till the wound had healed before taking over the I explained that I was not in the happy position of case. being able to choose my cases and we parted amicably. The patient kept his leg and eventually obtained union. True gas gangrene has been uncommon, and though I know of several cases I have only operated on one, an Abyssinian patriot in the army of Ras Sayoum, who sustained a compound fractured femur and on whom I setter.
-
performed
an
amputation. MORTALITY
-
The surgical mortality will necessarily be high in the forward area and low at the base. The deaths which occurred in the surgical division of a 1200 bed base hospital in the Middle East during twelve months were :Appendicitis and its complications ........ 2
Tonsillectomy Pulmonary embolus
.............
............ Cellulitis of face multiple burns and bronchitis Compound fractured femur Fractured spine and ribs.......... Fractured skull Shell wound of leg ; compound fracture tibia and fibula ; gangrene ; anuria after blood-transfusion in hospital .. Shell wound ; compound fractured humerus ; admitted with anuria after blood-transfusion in forward area .. Shell wound ; compound fractured femur ; duodenal ileus on 48th day .... Shell wound ; compound fractured femur ; secondary ........
........
............
haemorrhage Of this totalof in battle.
............
14, only the last 4
were
in
men
1 2 1 1 1 1 I 1 I
1 1
wounded
-
is used for desensitisation. In the common case where several positive reactions are found the opinion of allergists varies as to the course that should be adopted. Freeman (1933), and Freeman and Hughes (1938) have shown that a patient successfully desensitised with any But the one pollen ceases to react to any of the others. question whether the injection of a single allergen in multisensitive patients can, as a rule, also protect against allergens of another group has not been settled. This investigation therefore is designed to examine the specificity of the anti-allergic mechanism. For this purpose a method of local desensitisation of the skin has been studied. This technique has been applied in order to obtain evidence whether in multisensitive patients one allergen can desensitise the skin so that it will no longer react to" the others. This is termed " crossdesensitisation as opposed to the " direct desensitisation " in which the same allergen is used for desensitising and retesting. MATERIAL AND METHODS
The investigations were carried out on patients with bronchial asthma, eczema or hay-fever, most of whom were under the care of Dr. J. L. Livingstone. Other cases were volunteers from the medical staff. Those submitted to local cross-desensitisation showed multiple sensitiveness. All patients received the usual general treatment for their disorder, including breathing exercises, (Livingstone and Gillespie 1935) and elimination of focal sepsis, but no specific treatment was employed throughout the period of local desensitisation. The desensitising injections were carried out with two allergic extracts, A and B-e.g., pollen and fish or feather and flour (see tables I and 11). Extract A was injected into a localised area on one side of the back, B into a symmetrical part. The intracutaneous method has been used for tests and for local desensitisation. Instead of injecting 0-01 c.cm., as is usually done in routine intradermal testing, I used 0 05 c.cm. which can be measured more accurately. The local desensitisation was effected by injecting the allergic extracts in increasing doses. The additional units were given merely by using more concentrated extracts, not by increasing the quantity injected. The reason for this was that repeated inoculations produced some tissue damage which was more obvious when quantities larger than 0-05 c.cm. were injected. Therefore 0-05 c.cm. of extracts of varying
concentration were used throughout the experiments. The doses were so graded that the concentrations increased at a rate of 25% with each successive injection. Where with any particular concentration the reaction appeared to be rather intense the subsequent injection The inoculations were was of the same concentration. given when possible on successive days, otherwise on alternate days. By this means the dose has been
SURGERY
LIEUT.-COLONEL RAMC
THE major surgery in the Middle East is as a rule limited to three units-the surgical team or field surgical unit, the casualty clearing station, and the base hospital. The surgical team consists of a surgeon, anaesthetist and a varying number of RAMC personnel, usually drawn, as in the last war, from the base hospitals. They may be used to reinforce a CCS, or may work in the forward area with the light section of a CCS or the main dressing station of a field ambulance. A forward surgical team is likely to be of particular use in mobile and fluid warfare when the absence of a fixed line makes it necessary to keep a CCS a considerable distance behind the forward area. The equipment carried by a surgical team is designed to allow the team to function on its own for a limited period. Their theatre may be a lean-to tent fixed to the back of a lorry, or a separate theatre tent. Successive advances into Cyrenica and East Africa resulted in the capture of many Italian hospital tents, and these became popular with surgical teams, either as a theatre or as a ward ; double-sided and roofed, and well supplied with windows, they are excellent tents though a little cumbersome to carry. Lighting of the theatre may be by ’Petrolmax ’lamps or from the lorry or truck. ThePrimus ’ stove is one of the surgical unit’s most valuable instruments-as indeed it is with any unit. The mobility and small size of these field surgical units enable them to be moved nearer the scene of action than a CCS. In Eritrea and Abyssinia the CCS was occasionally as far back as 200 miles from the scene of fighting. The forward surgical unit shortens the period between the receipt of the wound-and its treatment, often considerable in the Western Desert, it provides a surgical opinion in the forward area, and its presence is appreciated by the combatant troops. The surgeon must confine his attention to the very seriously wounded, those with penetrating wounds of the abdomen, sucking wounds of the chest, severe burns, certain wounds of the head and face and serious limb injuries-in fact, the cases which might not be expected to reach the CCS alive. If he starts to treat others a sudden rush of serious casualties will swamp him. One of the difficulties of such units is that once a serious case has been operated on the patient becomes immobile for perhaps 48 hours or longer and the mobility of the unit may be impaired. As with other forward units they are exposed to ground strafing by enemy aircraft and more than once they have
been taken prisoners. The surgeon in the CCS of the last war must, I think, have had a happier time than his successor in the Middle East. The necessity to keep the CCS further back has led to some of his surgery being stolen by a field surgical unit, and on at least two occasions when casualties have been plentiful, a base hospital has taken over the duties of a CCS, as in Tobruk and later at Alexandria. For a CCS, too, periods of inactivity with few casualties and little work have been frequent in the Middle East and its situation has made this inactivity worse. Apart from those which are housed in existing buildings, most of our base hospitals have been created by the Royal Engineers, on desirable desert sites, on fine sandy soil with rail facilities, and I have never ceased to wonder at the short time in which a piece of sandy desert is transformed into a 1200 bed hospital, partly tented, partly hutted, well equipped, with a good water-supply, roads and electric light. Such a hospital experiences
perhaps its only disadvantage when
a
cold sandstorm
[JAN.
ARTICLES
2, 1943
bullet wounds are best left alone, apart possibly from the introduction of some sulphonamide powder and the application of an antiseptic dressing. For larger wounds the term excision is misleading, since the ideal to be aimed at is the removal of necrotic tissue, cleansing and the provision of really good drainage. The use of powdered sulphanilamide or sulphapyridine and a ’Vaseline ’ pack is almost universal in the Middle East for wounds of any size. The importance of immobilisation for soft tissue injuries is well recognised and many flesh wounds of the limbs are treated in plaster. Certainly all serious wounds will have begun a prophylactic course of sulphapyridine or sulphanilamide in the forward area, though by the time they arrive at the base hospital their dosage will often have been erratic. Intravenous sulphanilamide or sulphapyridine solutions are easily obtainable and the blood-transfusion service in the Middle East has deservedly won praise for its work. The usefulness of skin-grafts in the healing of wounds and burns cannot be over-emphasised. Faciomaxillary units in the Middle East are available for those an extensive or difficult graft, but pinch or Thiersch grafts for wounds of moderate size can effect a saving of weeks in healing time and can be applied in any hospital. In the preparation of the surface for grafting we have e found a sulphanilamide spray as valuable as it was economical in the treatment of other wounds. A very efficient substitute for tulle-gras was obtained by purchasing curtain net of small mesh in Port Said or Cairo. The provision of Army hospitals in South Africa has rendered it unnecessary to retain in a Middle East hospital a patient who is likely to require several months hospital treatment, and while the surgeon may sometimes regret that he cannot see the end-result of the case there is never any doubt as to the patient’s own feelings when he is told that he is to be evacuated. In Eritrea and Abyssinia the Italian hand grenade caused a high proportion of our casualties. The particular one in vogue at that time was a small red one with a light metal casing. Their size and weight made them easy to carry and the Italians and their native askaris, crouched behind the rocks on the mountains round Cheren,
requiring
flung large numbers down on our troops. The noise they made was startling, but the fragments had little penetrating power. They caused many casualties with multiple small wounds ; direct hits were more unpleasant, but few were fatal. A great number were left by the retreating Italians, and many natives, unable to overcome their curiosity, lost their fingers and their eyesight in attempts to open them. Among our casualties in Syria was a very high proportion of bullet wounds. The effect of this was most obvious in the compound fractured femurs of that campaign, for most of them, caused by bullet, had little or no sepsis and united as quickly or even quicker than a simple fracture. The Western Desert has of course produced casualties of all kinds, but compared with the fighting elsewhere land-mine injuries have been very common, such as bilateral fracture of the os calcis from the blowing up of a truck. It has also furnished a surprisingly high number of accidental burns, some of them very serious, caused by the use of petrol in sand fires, usually for making tea. Though hardly a battle casualty, the desert appears to be a bad place for the patient with piles. that they are quite well as long as Many patients say " they are not up in the blue." Once there they become constipated and their symptoms recommence. They attribute this to the diet, which can hardly be varied, to the comparative lack of water, and, for some of them. their inability to take liquid paraffin regularly.
PENETRATING WOUNDS OF THE ABDOMEN January or a hot sandstorm or khamsin To me one of the greatest disappointments of war and as far out the as will Nothing sand, keep is practical dressings are left untouched and operationssurgery has been the lack of success with penetrating The published records of these postponed. To such hospitals the sick and wounded from wounds of the abdomen. wounds in the last war had led me to hope that a survivalthe desert arrive by ambulance train, and in spite of a = of 40-50% might be obtained. and indeed, descripjourney of perhaps over 200 miles they ,haveusuallyrate tions of casualties in the Spanish War and more recently arrived in good condition.
rages in in May.
"
"
GENERAL TREATMENT OF WOUNDS
I have not yet felt justified in practising excision and primary suture of any wound. Clean through-and-through a discussion at the Medical Nov. 23. 1942.
* Introducing 6227
Society of London
on
’ in civilian casualties at home show results of that order. From my own limited experience and surgical gossip with colleagues I do not think that the operative survival]fate for penetrating abdominal wounds in the Middle East would be more than 20-30% and probably less. Of my own 17 cases only 5 survived, approximately
A
2 30 %. Perhaps the best picture I can give of the mortality of these cases is the fact that during one year at a base hospital of 1200 beds only 7 postoperative cases of pene0 trating wounds of the abdomen were admitted. Most of these cases are treated by the field surgical unit ; only occasionally does the CCS receive them, and the base hospital only under exceptional circumstances. The earliest abdomen on which I operated was 6i hours from the receipt of the wound ; a young officer with a penetrating wound of the ascending colon, destruction of one testicle and a compound fracture of the tibia. The average time which elapsed before operation was about 14 hours. Lieut.-Colonel Ian Aird, one of my colleagues working in the Western Desert, in 18 cases of abdominal wounds, had only one admitted within 12 hours of wounding and only 7 within 24, hours. In East Africa the delay was largely due to the mountainous and difficult terrain, necessitating a long carry by the stretcher bearers, occasionally up to 7 hours. In the Western Desert it is partly due to the immobility of transport at night and the scattered nature of the fighting. Peritonitis wa& present on arrival in about three-quarters of my cases. Heat was an unpleasant factor in East Africa. A
shade temperature of 105°-110° F. was common near Cheren. Ether boiled when the cork was removed from the bottle ; gas was not then available and chloroform became a necessary anaesthetic. It is not to be recommended for the shocked abdominal patient in whom the surgeon wants relaxation. PENETRATING WOUNDS OF THE CHEST AND SKULL
centres for the reception and treatment of chest wounds exist in the Middle East. Their treatment in the forward area, however, devolves on the general Some of the sucking wounds are closed by the surgeon. first medical officerwho is able to insert one or two throughand-through sutures. If left alone, the value of this form of closure is doubtful, since wounds closed in this necessarily shipshod manner are apt to break down badly when infected ; there is something to be said in favour of a temporary pack and delaying any closure of the wound until it can be performed under proper surgical surroundings. In general the tendency of surgeons in the forward area has been to deal conservatively with chest cases and to do little more than close a sucking wound. The after-treatment has been repeated aspiration, with or without air replacement, blood-transfusions according to the patient’s haemoglobin level, and sulphapyridine. Most cases seem to have done well on these conservative lines. Even when there is a retained foreign body of some size in the chest no early attempt has as a rule been made in the forward area to remove it. Surgeons feel that to attempt to remove a foreign body by an early thoracotomy in such a setting would be to court disaster. The majority of penetrating wounds of the skull are admitted to a special centre. The initial treatment will be done elsewhere and useful instructions have been issued to all surgeons emphasising the important points in the examination and.closure of such wounds.
Special
COMPOUND FRACTURES
With few exceptions compound fractures have been treated by wound toilette, removal of dead or devitalised vaseline pack and plaster. doubt as to the great value of this treatment regards the patient’s future and the immediate problem of transportation. The faults of this treatment have arisen from technical errors-a tight plaster, excision of too much skin, failure to remove devitalised muscle, particles of clothing or other foreign matter from the wound, and the excessive removal of bone
tissue,
There is both as
a
sulphonamide
no
fragments. Compound fractures of the humerus have as a rule been treated by plaster with the arm to the side unless the type of fracture indicated an abduction plaster. Compound fractures of the femur remain one of the most serious casualties. Most of these arrive at a base hospital in a Thomas splint with extension strapping, a wound toilette having been already carried outand a sulphonamide vaseline pack inserted. Whether a compound femur should be treated by a plaster spica remains a matter of debate. My own preference, were I ever to
suffer from such an unpleasant injury, would be a really wide excision of the wound so that the bone ends could be seen at the bottom of the sloping sides, ensuring good drainage, a sulphonamide vaseline pack, a Kirschner’s wire through the tibial crest with weight extension, and a plaster spica from waist to toes, cut open over the knee. After two to three weeks I should prefer to be treated on a Thomas splint. I believe that plaster and packing for the first two to three weeks effectively seals off the fracture from the tissue planes and greatly reduces the ’likelihood of gravitation abscesses. Excision of the wound is unnecessary in the case of compound fractured femur with a small entry and exit wound of a bullet and no sign of infection ; where there is a small apparently uninfected entry wound and a larger exit wound, only the larger wound should be excised, AMPUTATIONS
The sites of election for a lower limb amputation are almost standard but when such an amputation should be performed is more debatable. This question does not arise in civil life since a street accident is admitted to hospital with little delay. In warfare a wound of the lower limb, which by its severity requires amputation, is often 24 hours old before surgery is available. It is infected and any amputation performed in its proximity stands a considerable risk of becoming infected also. If amputation is carried out at the site of election and gross infection ensues, further amputation will subsequently be necessary and the patient has then lost the most favoured site. Up to what period after the receipt of a wound it would be safe to choose the site of election must depend on the surgeon and the wound, but in doubtful cases a guillotine amputation at the site of injury would probably be the safest course. A true guillotine amputation at the site of election can only be justified if there is no other alternative. These amputations are seldom done ; in most of the amputations performed in the forward area flaps of some kind have been fashioned, held together with one or two
sutures, perhaps
over a sulphonamide-vaseline pack occasionally stitched back. Secondary suture has in many cases produced an excellent stump. Of amputations admitted to a base hospital I have seldom seen an amputation stump of the lower limb heal completely by first intention, and when an attempt has been made in the forward area to obtain this by the insertion of or
many sutures the results have often been disastrous.
The inference to be drawn is that if a wounded limb is more than 12-24 hours old, the site of amputation must be regarded as a potentially and perhaps heavily infected area. Amputation through the knee-joint may be a lifesaving measure, but posterior retraction, with perhaps a visible popliteal artery and vein in the infected granulations, is unpleasant and should be avoided if possible.
requiring amputation
BURNS
The treatment of burns was one of the subjects discussed at a surgical conference held in Cairo in the early part of 1941. It was noteworthy for the varied opinions expressed. Tanning methods have produced some excellent results but many failures and when these methods fail it would have been far better for them never to have been tried. They are as a rule unsuitable in the forward area unless optimum facilities are present and adequate time for careful cleansing. The use of tannicacid jelly as a first-aid dressing is now generally depreciated. Treatment by moist dressings is difficult wheree long lines of evacuation are present and some form of sulphonamide vaseline dressing has much to commend it. In my experience, most of the severe and extensive burns received at a base hospital, 2-4 days old, have required treatment afresh. Cleansing under an anoesthetic, a sulphonamide spray, and bandaging with six-inch rolls of vaseline gauze is the treatment I havepreferred. The patient is’given a course of sulphanilamide by mouth and a plasma drip till the haemoglobin is reduced to 100%. The highest I have seen was 140%, a finding which was confirmed by the pathologist who pointed out that it was actually higher but that this was the highest level he could record. The patient, a South African with second degree burns of more than a third of his
3
body surface, made a surprising recovery. If pyrexia subsides, and the dressings do not become soaked in pus, they are left till they drop off. When secondary infection is present, the dressings are soaked off in a The warm saline bath every 48 hours and reapplied. greater part of these burns is usually second degree but whole skin destruction often only becomes apparent when sloughing appears. For these areas sulphaniland moist dressings are excellent amide powder, tulle-gras as a preparation for skin-grafting, but for the earlier and more extensive dressings the wide vaseline gauze roll has the great merit of speed in application. Glycerin and sulphanilamide dressings, and the use of plaster for
limb burns have their adherents. Some of the more recent methods of treatment recommended in this country have not been available for the Middle East or have been unsuitable. TETANUS AND GAS GANGRENE
Of the surgeons in the Middle East, many are at that in professional life when, but for the war, they would have been about to start a surgical registrarship. Instead they now learn their surgery and gain their experience in a different school. This experience is valuable for all but princfpally for the specialist in certain subjects. For the general surgeon it cannot take the place of what he has missed.
stage
CROSS-DESENSITISATION IN ALLERGIC DISEASES KATE
MAUNSELL, M D KIEL, L R C P E (From King’s College Hospital and Horton Emergency Hospital) THIS paper deals with desensitisation to that class of " "
allergens, called " idiotoxins by Freeman or atopens" in America, which cause bronchial asthma, eczema, conjunctivitis and rhinitis. The allergic properties can be exerted by biologically different groups-food proteins, pollen and other constituents of plants, animal feather, hair and wool, and all sorts of dust. Bacteria and moulds can also act as idiotoxins, apart from their immunological properties. The routine method of attempting a general " specific desensitisation is the injection of those allergens to which the patient shows a special sensitiveness. If only one positive test is found, then that particular allergen alone
.
Few
,
of tetanus have occurred in the Middle East, which is in keeping with the experience of surgeons who served there during the last war. I cannot say what part tetanus toxoid has played in this low incidence. I have only had one case-the only occasion on which I have been guilty of associating with an unqualified cases
practitioner.
_
An Arab of the Arab Legion was wounded by bombing during the Syrian fighting. He was admitted to hospital three days later with a large lacerated wound of the thigh and a compound fractured femur. After the usual treatment of the wound he was put up in a plaster spica. On the 12th day he developed tetanus but recovered after a stormy passage. At one time it was feared that he might lose his leg, and his
father asked that he should be allowed to call in an Arab boneI replied that I should be very pleased to consult with him and a few days later he arrived at the hospital accompanied by all the near-and most of the remote-relatives of the patient. He was an imposing figure, 80 years of age, a huge mountain of a man with a large hooked nose and wrinkled brown face. He was a shepherd from Bethlehem Fields who from the age of 6 had been interested in fractures and had gradually acquired a reputation and a practice among his people. We examined the case together and then, with the aid of an interpreter, discussed the treatment. He told me that the Arab believes that a broken bone will heal in the same number of days as the patient’s age and requires splinting and rest for this period. Thus the bone of a man of 40 will take 40 days to unite. The rule broke down in the case of infants and in the presence of an open wound. In his practice, he made it a rule never to treat a fracture with an open wound but to wait till the wound had healed before taking over the I explained that I was not in the happy position of case. being able to choose my cases and we parted amicably. The patient kept his leg and eventually obtained union. True gas gangrene has been uncommon, and though I know of several cases I have only operated on one, an Abyssinian patriot in the army of Ras Sayoum, who sustained a compound fractured femur and on whom I setter.
-
performed
an
amputation. MORTALITY
-
The surgical mortality will necessarily be high in the forward area and low at the base. The deaths which occurred in the surgical division of a 1200 bed base hospital in the Middle East during twelve months were :Appendicitis and its complications ........ 2
Tonsillectomy Pulmonary embolus
.............
............ Cellulitis of face multiple burns and bronchitis Compound fractured femur Fractured spine and ribs.......... Fractured skull Shell wound of leg ; compound fracture tibia and fibula ; gangrene ; anuria after blood-transfusion in hospital .. Shell wound ; compound fractured humerus ; admitted with anuria after blood-transfusion in forward area .. Shell wound ; compound fractured femur ; duodenal ileus on 48th day .... Shell wound ; compound fractured femur ; secondary ........
........
............
haemorrhage Of this totalof in battle.
............
14, only the last 4
were
in
men
1 2 1 1 1 1 I 1 I
1 1
wounded
-
is used for desensitisation. In the common case where several positive reactions are found the opinion of allergists varies as to the course that should be adopted. Freeman (1933), and Freeman and Hughes (1938) have shown that a patient successfully desensitised with any But the one pollen ceases to react to any of the others. question whether the injection of a single allergen in multisensitive patients can, as a rule, also protect against allergens of another group has not been settled. This investigation therefore is designed to examine the specificity of the anti-allergic mechanism. For this purpose a method of local desensitisation of the skin has been studied. This technique has been applied in order to obtain evidence whether in multisensitive patients one allergen can desensitise the skin so that it will no longer react to" the others. This is termed " crossdesensitisation as opposed to the " direct desensitisation " in which the same allergen is used for desensitising and retesting. MATERIAL AND METHODS
The investigations were carried out on patients with bronchial asthma, eczema or hay-fever, most of whom were under the care of Dr. J. L. Livingstone. Other cases were volunteers from the medical staff. Those submitted to local cross-desensitisation showed multiple sensitiveness. All patients received the usual general treatment for their disorder, including breathing exercises, (Livingstone and Gillespie 1935) and elimination of focal sepsis, but no specific treatment was employed throughout the period of local desensitisation. The desensitising injections were carried out with two allergic extracts, A and B-e.g., pollen and fish or feather and flour (see tables I and 11). Extract A was injected into a localised area on one side of the back, B into a symmetrical part. The intracutaneous method has been used for tests and for local desensitisation. Instead of injecting 0-01 c.cm., as is usually done in routine intradermal testing, I used 0 05 c.cm. which can be measured more accurately. The local desensitisation was effected by injecting the allergic extracts in increasing doses. The additional units were given merely by using more concentrated extracts, not by increasing the quantity injected. The reason for this was that repeated inoculations produced some tissue damage which was more obvious when quantities larger than 0-05 c.cm. were injected. Therefore 0-05 c.cm. of extracts of varying
concentration were used throughout the experiments. The doses were so graded that the concentrations increased at a rate of 25% with each successive injection. Where with any particular concentration the reaction appeared to be rather intense the subsequent injection The inoculations were was of the same concentration. given when possible on successive days, otherwise on alternate days. By this means the dose has been