Results in the Main Group

There were 317 cases with a death rate of 50 per cent, covering cases brought in dead to field units and cases dying in the field units but not operated on. Of patients admitted alive to a CCS 96·3 per cent were operated on, and of those admitted alive to any unit, including the ADS, 89·6 per cent were operated on. The mortality in cases operated on was 39 per cent, which included all deaths at the Base. The marked fluctuation in results in small series is shown by a mortality of 15 per cent in one month and 41 per cent in another.

The percentage of deaths in all cases recorded at different stages and the gradings of those surviving is shown in the following chart:

A = dead (BID); B1 = died in field ambulance (no operation); B2 = died in casualty clearing station (no operation); C = died in twenty-four hours; D = died in forty-eight hours; E = died later in forward areas; F = died at Base; G = alive, graded A–D; H = alive, graded E (evacuated to NZ).

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There were in all 28 casualties brought in dead to medical units. Of the 20 deaths in field units of wounded who had had no operation performed, one occurred at the RAP, nine at an ADS, and ten at MDSs.

A = died in twenty-four hours; B = died in forty-eight hours; C = died later in forward areas; D = died at Base; E = alive, graded A–D; F = alive, graded E.

Nearly half of the post-operative deaths (46 out of 102) occurred in the first twenty-four hours, with a further 7 deaths in the next twenty-four hours. These deaths, it will be agreed, were due to the severity of the trauma, first from the wound and then from the operation. Of the 33 deaths which occurred later in the forward areas, anuria was the most common cause, accounting for one-third. Chest complications, peritonitis, and obstruction accounted for 11 deaths. Infection in some form was responsible for half the deaths.

At the Base all the 16 deaths were due to some form of infection. There were no deaths at Base during the last eight months of the period. This might be attributed to the early parenteral administration of penicillin and to the holding of serious cases longer in the forward areas. The surviving patients generally remained in hospital in Italy for some months pending evacuation by hospital ship to New Zealand. The only patients requiring further treatment in New Zealand were a few who still had an open colostomy. Only 8 surviving patients were not subjected to an abdominal exploration, either direct or through the chest, the majority having liver injuries with retained foreign bodies

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[In Major Stead's review the causes of death were given as:

(a)	Within twenty-four hours (55 per cent)—shock and haemorrhage.
(b)	From two to ten days (33 per cent)—renal insufficiency then lung conditions and peritonitis,
(c)	Later (12 per cent)—commonest condition was peritonitis, and all deaths were due to some type of sepsis.

Ileus was reported to be rare.]

The time after operation when death occurred is shown in Chart III.

The association of other injuries was of great importance. It was reported by one surgeon' that no recovery of an abdominal wound had been seen in the presence of a fracture of the femur or a traumatic amputation. Cases of survival are, however, reported in our series. Multiple abdominal injuries also were associated with a high mortality. Severe general injuries included in the series were 9 fractured femurs, 9 amputations, 7 severe head injuries, and 9 severe spinal injuries. At least 9 of this list died without operation.

Thirty of the cases remained in a very bad condition at every stage, and possibly all these cases could have been left without operation and this would have improved the operative mortality considerably; but, as already mentioned, our routine was to operate on every case fit to be put on the table, and occasionally our faith was justified, but the figures naturally were not improved. The deletion of these 30 cases from operation would have improved the operative mortality from 39 per cent to 311·4 per cent. It was noted that 28 patients at no time showed the least signs of recovery following operation, 5 dying on the table and 2 as soon as they reached the ward. It might be inferred that operative trauma was page 269 responsible for the failure in these cases. This was disproved, however, by an evaluation of the severity of the original trauma in the cases that died, checked in the great majority of the cases by postmortem examination. It was ascertained from the case records in which the data were available that the original injury sustained in the cases that died was hopeless in 23 cases, very severe in 21, severe in 23, and there are only 2 other cases. What this does signify is that the large majority of these cases are inevitable deaths, and that in these very severe cases operation must entail the minimal trauma. This is of special significance when one considers such procedures as the freeing of the fixed colon and the type of operation to be undertaken in the late cases. A third of the deaths were associated with severe injuries to other parts of the body.

The average time lapse before operation was worked out in regard to the ultimate results. When death occurred within twenty-four hours of operation this time interval was 6·4 hours, and when death occurred later in the forward areas it was 7·25 hours. Of those who recovered but were invalided to New Zealand, the interval was 6·0 hours, while with those who recovered but did not require invaliding the period was 6·5 hours. It would appear that the average time it took to evacuate abdominal injuries to the operating centre during the Italian campaign was six and a half hours. The interval between the receipt of the wound and the actual surgical operation was 10·4 hours, both in the group of cases that died and in the group that recovered.