i FCRV&RD SURGERY OF THE - SEVERELY WOUNDED VOLUME I A History of the Activities of the 2nd Auxiliary Surgical Group 1942 - 1945 il HEADQUARTERS 2ND AUXILIARY SURGICAL GROUP APO 512, US Army 27 August 1945 Letter of Transmission SUBJECT; Forward Surgery of the Severely Wounded (A History of the Activities of the 2nd Auxiliary Surgical Group) TO: The Surgeon General Ariry Service Forces Washington, D.C. Submitted herewith is the History of the Activities of the 2nd Auxiliary Surgical Group entitled, "Forward Surgery of the Severely Wounded", / £kMS5 H. FORSEE //Colonel, MG Ls Commanding 1st Ind. HEADQUARTERS MTOUSA, OFFICE OF THE SURGEON, APO 512, 18 October 1945. TO; The Surgeon General, U.S. Army, Washington 25, D.C. 2 Incls. Incl 1 - Vol I Incl 2 - Vol II iii I K MEMORIAM Killed In Action: I.Iajor John 3, Adams, i.!C, AUS 2nd Lt LaVeme Farquhar, AIIC Technician Fifth Grade Theron McCombs Died In The Service: Technician Fifth Grade Swaldt F. Hasenv/inkel iv EDITORIAL BOARD Major Luther H. Wolff, MG, AUS, Chairman Major Reeve H. Betts, MG, AUS Major Paul G. Samson, MG, AUS Major Robert H. Wylie, MG, AUS Major Samuel B. Childs, MG, AUS Captain Wooster P. Biddings, MG, AUS V PREFACE In the history of modern warfare it is doubtful if a group of Amer- ican surgeons have ever had such a vast experience in the surgical care of severely wounded casualties as have members of the 2nd Auxiliary Sur- gical Group. This experience was gained in two active Theaters of Oper- ations, the North African, later to become the Mediterranean Theater, and the European Theater of Operations. The period covered is from 1 Kay 1942 to 27 August 1945. The campaigns in which this organization has participated are: the Tunisian, Sicilian, Naples-Foggia, Rome-Arno, North Apennines, Po Valley, Southern France, Rhineland and Central Europe. Ad- vanced elements of the unit were engaged in the French Morocco-Algeria Campaign. It has participated in the initial landings of five major am- phibious operations in NATOUSA. Such an extensive experience cannot be accurately depicted solely/ by the tabulation of statistical data refer- able to the casualties from these campaigns who were treated by members of this Group. A comprehensive appraisal of the nature and severity of the injuries as well as the principles and procedures that have been evolved in their management has been made by members of this Group and is presented in this report. These casualties were those which, in the vast majority of instances, required immediate care and could not be safely transported beyond the rear boundary of the division without surgery. They have been designated as nontransportables. Churchill’s description of those casualties places them in two categories: First, those reouir- ing the correction of profound physiological disturbances which immedi- ately endanger life; secondly, those requiring the arrest or prevention of the complications of infection that, if allowed to develop or progress may endanger life or lead to grave disability. The initial surgical man- agement of battle casualties suffering from the above types of wounds constituted the principal function of this organization. An indication of the surgical experience of this Group in the for- ward surgery of the severely wounded is evidenced by the following data: 2629 casualties suffering from intra-abdominal wounds, 903 from thoraco- abdominal, I364 from intrathoracic, 915 from traumatic amputations, 2416 from severe compound fractures of long bones, and 574 from serious head wounds were among the casualties who received their initial surgery by members of the Group*. These data do not include approximately 2000 pa- tients suffering ftom intrathoracic injuries and approximately 1000 pa- tients with maxillofacial injuries who received their reparative surgery from members of this Group at specialty centers in base hospitals. In- all, approximately 22,000 casualties, have received operative surgery by members of this Group. On each of the patients, a carefully recorded case record has been made at the time of operation and retained at the * The great majority of these casualties were treated in first priority surgical hospitals (a platoon of a Field Hospital) located adjacent to division clearing stations. vi Preface, contd Group Headquarters, It is believed that no similar number of case re- cords of battle casualties suffering from the types of wounds described above is available in the annals of American surgery. Foresight and constant diligence have been responsible for recording this large amount of data. Throughout the entire existence of this organization, the teams have functioned in other medical installations, and any success they have achieved has been due in a very appreciable degree to the splendid cooperation rendered by these installations. Surgical and shock teams of this unit have been employed in 53 different American hospitals and medical installations, IS different British hospitals and medical instal- lations, and in two Italian hospitals while overseas. During the period in which the unit was in the United States, it was stationed at Lawson General Hospital. To the staffs of each of those installations as well as the staffs of the medical sections of base sections, Corps, Armies and Theaters in which the Group has' functioned, deep appreciation is acknow- ledged, Naturally, many individuals have greatly aided in making it pos- sible for this unit to carry out its mission properly. Their number is so large that adequate credit cannot be recorded here. Trie history of this organization would not be complete without recording grateful appre- ciation to the following individuals: Colonel Edward D. Churchill, LiG, Consulting Burgeon, NATOUSA and MTOUSA. Colonel Churchill's great vision, understanding and surgical knowledge have been the inspiration guiding the surgical pursuits of this organization in its overseas experience. Colonel Frank. B, Berry, MG, Surgical Consultant, Seventh Army (form- erly Chief, Surgical Service, 9th Evacuation Hospital). Colonel Deny has been a close friend of this organization since the early days of the Tunisian Campaign. His direction of the surgical efforts in the Seventh Army was a beacon light in the experience of this Group. Major General Morrison G. Stayer, Theater Surgeon, NATOUSA and MTO- USA, was the force which carried through many measures that enabled this organization to accomplish its mission. Brigadier General Joseph I. Martin, Surgeon, Fifth Army, was tire- less in his efforts to make available all facilities needed to permit this Group to bring to the severely wounded soldier its surgical talents. To the following members of his staff, grateful acknowledgement is ac- corded: Colonel Clement F. St John, MG, Operations Officer; Colonel Howard S. Snyder, MG, Surgical Consultant; Colonel Charles 0. Bruce, MG, Executive Officer, Lt Col Marcel H. Mial, SnC, Supply Officer; and Major Helen E. Wharton, ANG, Director of Nurses. Colonel Myron P, Rudolph, MG, Surgeon, Seventh Arny, was the wise counsellor end friend of this unit in the days in North Africa and for that portion of the Group which functioned with the Seventh Army in France vii Preface, coutd and Germany. To the following members of his staff, grateful acknow- ledgement is accorded; Colonel Albert -H, Robinson, MG, Executive Officer, Colonel Joseph Rich, MG, Operations Officer: Lt Col A. J. Guenther, MAG, Supply Officer; and Major Edith P, Frew, ANG, Director of Worses. Colonel Richard T. Amest, MC, Surgeon, II Corps, during the Tunisian and Sicilian Campaigns, Colonel Arnost lent irnir.oa.sura.ble assistance to the surgical teams of this Group which participated, in these campaigns. The experience gained, in these early campaigns did ranch in formulatin'* the policy for the future employment of this Group, Brigadier General Fred W. Rankin, Chief Consultant in Surgery, Of- fice of the Surgeon General* US Array, Washington, D.G. General Rankin early recognized the importance of the proper selection of personnel for this Group. His accurate and detailed knowledge of the personnel posses- sing the surgical training and ability required for the surgeons of this Group resulted in the meticulous selection of its original personnel. If the raise ion of the Group has been accomplished in a measure commensurate with what he envisioned in the selection of its professional staff, great pride may be rightly felt by the members of the Group. General Mark W. Clark, Commanding General, 15th Army Group. During the period 9 September 194-3 to 15 December 194-A, this organization was privileged to serve under the direction of General Clark, then Command- ing General, Fifth Army. Lieutenant General.Alexander M. Fateh, Commanding General, Seventh Army. The smooth functioning of this organization with the Seventh Army in .France and Germany was greatly enhanced by the earnest desire and in- terest of General Fateh to provide the best possible surgical care to the wounded soldiers. Lieutenant General Lucian K. Truscott, Jr., Commanding General, Fifth Army, Throughout the field e:cperience of this organization, General Truscott has been the commander most closely allied with its efforts. As Gomanding General, 3rd Division in Sicily end the early battles on the Italian mainland, later as Commanding General, VI Corps, throughout most of the battle at Ansio, the campaigns of Southern France and part of the Rhineland, and finally as Commanding General, Fifth Array, General Trus- cott has been the sincere friend of this organization. viii TABLE OF CONTENTS VOLUME I Pages I. PROFESSIONAL SERVICES 1. GENERAL CONSIDERATIONS 1 The Employment and Function of Teams of the 2nd Auxiliary Surgical Group 2-6 Preoperative Diagnosis and Triage,. 7 -22 Resuscitation and Preoperative Care of the S everely Wounded 23 -49 The Operating Room and the Operation,, 50 -53 General Considerations of Anesthesia in War Casualties*..... , 54 -64 Postoperative Care of the Seriously Wounded,.,,,, 65 -83 2. WOUNDS OF THE ABDOMEN: AN ANALYSIS OF 3154 CASES. 84 -87 Part I; General Subjects Relevant to All Abdominal Wounds...... 88-120 Part II; Detailed Discussion of Subjects Pertinent To All Abdominal Wounds* 121-209 Part III; Specific Viscus Injuries* 210-408 VOLUME II 3, THORACIC WOUNDS 410 Part I: In the Forward Hospitals* 411-536 Part IIs In the Base Hospitals*.......,,......... 537-564 4* THCRACO-ABDOMINAL WOUNDS 566-591 5, AMPUTATIONS., 593-619 6, COMPOUND FRACTURES 621-654 7, CRANIAL INJURIES 656-682 8, MAXILLO-FACIAL INJURIES 683-714 Part I: In the Forward Hospitals, 683-705 Part II: In the Base Hospitals,,.,,,,,,,,,,,,,,,, 706-714 9, VASCULAR INJURIES 715-746 ♦Derailed tables of contents will be found immediately preceding each of these sections. ix Table of Contents, contd Pages 10. ANAEROBIC INFECTIONS 746-757 11. POST-TRAUMATIC RENAL FAILURE 758-772 12. DEATHS IN FORTiARD HOSPITALS 773-813 II. ADMINISTRATION 814-844 III. OPERATIONAL ACTIVITIES 855-900 IV. ROSTER OF PERSONNEL 901-915 V. AMDS AND DECORATIONS 916-922 VI. LIST-OF PUBLICATIONS AND REPORTS 923-931 ERRATA 1. There is no page 418. 3. There are no pages 845 - 854 (incl.). X I. PROFESSIONAL SERVICE SECTION zl C 0 N T a I 3 II T 0 R S The compilation of the data presented in the professional service section of this report has been accomplished through the assistance of the great majority of the medical officers of the Group under the di- rection of the editorial board. The final preparation of these data and the arrangement of the specific subjects in this report has been the re- sponsibility of the officers listed below: 1. GSKERAL subjects '•The Employment and function of Teams of the 2nd Auxiliary Surgical Group" Pages 2 to 6 Colonel James H. Forsee, MG, ACS "Preoperative Diagnosis and Triage" Pages 7 to 22 Captain Beverly T, Towery, MG, AUS "Resuscitation and Preoperative Care of the Severely " Pages 23 to 49 Captain Beverly T. Towery, MC, AUS "The Operating Room and the Operation" Pages 50 to 53 Captain Wooster P. Biddings, MC, AUS "General Considerations of Anesthesia in War Casualties" Pages 54 to 64 Major George S. Donaghy, MC, AUS Captain Werner F, A. Hoeflich, MC, AUS Captain Charles W. Westerfield, MC, AUS "Postoperative Care of the Seriously Woundedj Prevention and Treatment of Complications" Pages 65 to 83 Major Gordon F. Madding, MC, AUS Captain Knowles B. Lawrence, MG, AUS Major Paul C, MC, AUS "Anaerobic Infections" Pages 746 to 757 Major Robert H. Wylie, MC, AUS "Posttraumatic Renal Ihilure" Pages 758 to 772 Captain Beverly T, Towery, MC, AUS Contributors, contd "Deaths in Forward Hospitals" Pages 773 to 313 Captain Glen H. Guinness, MG, AUS 2. ABDOMINAL SURGERY "Wounds of the Abdomen - An Analysis of 3154 Gases" Pages 84 to 87 Major Luther H. Wolff, MG, AUS Captain Wooster P, Giddings, MG, AUS Part I: "Presentation of General Data" Pages QQ to 120 Major Luther H. Wolff, MG, AUS Major Samuel B. Childs, MG, AUS Captain Wooster P, Giddings, MG, AUS Part II: Detailed Discussion of General Subjects "The Problems of Shock Therapy in Abdominal Wounds" Pages 122 to * 131 Captain Beverly T. Towery, MG, AUS Captain John D. Welch, MG, AUS "Time Lag in Abdominal Injuries" Pages 132 to 146 Captain Clarence R. Brott, MG, AUS Major Samuel B, Childs, MG, AUS "Incidence of Associated Injuries and Their Effect on Mortality in Abdominal Cases" Pages 147 to 161 Major Leigh K, Haynes, MG, AUS Major floyd D. Taylor, MG, AUS "Traumatic Eviscerations" Pages 162 to 168 Major Samuel B. Childs, MG, AUS "Anesthesia in 3154- Abdominal and Thoraco-abdominal Battle Casualties" Pages 169 to 186 Major George E. Donaghy, MG, AUS Captain Ernest V, Doud, MG, AUS Captain Werner F. A. Hoeflich, MG, AUS Captain Charles D. Westerfield, MG, AUS Contributors, contd "Laparotomy Incisions, Closures and Dehiscence” Pages 18? to 196 Major Hugh F. Swingle, MG, ADS Captain Dominic S. Goridie, MG, ADS ’’Penicillin and Sulfonamide Therapy in Abdominal Cases” Pages 197 to 202 Captain Ja.mes C. Drye, MG, AUS ’’Postoperative Complications in Abdominal Cases” Pages 203 to 209 Captain James C. Drye, MG, AUS Part III: Specific Viscus Injuries ”Wounds of the Stomach” Pages 211 to 229 Major Luther H* Wolff, MG, AUS ”Duodenal Injuries” Pages 230 to 237 Captain William H. Cave, MC, ADS ”War Injuries of the Small Intestine” Pages 238 to 269 Captain Wooster P. Giddings, MG, AUS Captain John R. McDaniel, MG, AUS ”Wounds of the Colon and Rectum” Pages 270 to 306 Major Frank F, Ghunn, MC, AUS Major Richard V, Hauver, MC, AUS "War Wounds of the Liver” Pages 307 to 326 Major Gordon F. Madding, MC, AUS Captain Knowles 3. Lawrence, MG, ADS Captain Paul A, Kennedy, MC, AUS ”Injuries of the Spleen” Pages 327 to 345 Major Leon H. Poole, MG, AUS “Injuries of the Pancreas” Pages 346 to 355 Major Leon H. Poole, MG, AUS "A Study of 4-27 Wounds to the Kidney in 3154- Abdominal and Thoraco-abdominal War Injuries” Pages 356 to 372 Captain Walter L, Byers, MC, AUS Contributors, contd ’’Pertinent Data in 27 Wounds to Ureter Among 3154- Abdominal Gases” Pages 373 to 377 Captain Walter L. Byers, MG, AUS ’’Wounds of the Urinary Bladder, An Analysis of 155 Gases” Pages 378 to 382 Major Leon M. Michels, MG, AUS ’’Wounds of the Urethra" Pages 383 to 384 Major Leon M. Michels, MG, AUS ”Abdominal Vascular Injuries" Pages 385 to 395 Major Hugh F. Swingle, MG, AUS Captain Dominic S, Gondie, MG, AUS "Re trope ritoneal Heraatoma " Pages 396 to 400 Major Hugh ?. Swingle, MG, AUS Captain George T. Flynn, MG, AUS "Abdominal Injuries of Special Types" Pages 401 to 403 Major Gordon F. Madding, MG, AUS Captain Knowles B, Lawrence, MG, AUS 3. THORACIC INJURIES Part Is In the Forward Hospitals "The Initial Surgery of 2267 Penetrating and Perforating Injuries of the Thorax including 903 Thoraco-abdominal" Wounds" Pages 411 to 536 Major P^eeve H, Betts, MG, AUS Major Paul. C, Sanson, MG, AUS Major Lyman A. Brewer III, MG, AUS Major Lawrence M. Shefts, MG, AUS Assistance in the compliation of this report was rendered by the followings Major Frederick W. Bowers, MG, AUS Major Robert H. Wylie, MG, AUS Captain William M. Lees, MG, AUS Caotain Werner F. A. Hoeflich, MG, AUS Captain Charles A. Schiff, MG, AUS Captain Donald B, Williams, MG, AUS Captain William F. Rose, MG, AUS Contributors, contd Fart II: In Base Hospitals ’’Thoracic Wounds, Reparative -Surgery" Page 537 to 584 Major Paul G. Samson, MG, AUS Major Thomas H. Burford, MG, AUG Major Lyman A. Brewer III, MG, AU-3 U, THORACO-ABDOMINAL INJURIES "The Thoraco-abdominal Casualty" Page 5SS to 59i Major Robert II. Uylie, MG, AUG Major Henry L. Hoffman, MG, AU3 Captain Donald D, Williams, MG, AUS Captain Aaron Himmelstein, MC, AUS 5. AMP UT AT 101 IS "Amputations" Pare 593 to 619 Captain Paul Milligan, MC, AUS Captain Fredrick D, Wilson, MG, AUS Captain Thomas F, Ahearn, MG, AU3 Captain Raymond V, Rukke, MG, AUS Captain John M. Gosslee, MG, AUG 6. COMPOUND FTLIGTUICS "Compound Fractures " Page 621 to 654 Major Richard V. Hauver, MC, AUS Captain Freeman F. Brorm, Jr., MC, AUS Captain William H. Kastle, MG, AUS Captain Harry L, Pulton, MG, AUS Captain Julius A, Gurvey, M;, AUS 7. CRANIAL INJURIES "The Initial Surgical Management of Severe Head Wounds" Page 656 to 682 Major Charles E. Bowman, MC, AUS Major Milton Tinsley, MG, AUS Captain Herbert L. Moore, MG, AUS Captain Raymond V. Rukke, LIC, AUS Captain William V. Ran Riper, MG, AUS Captain Irving W. Kaplan, MG, AUS Contributors, contd 8. MAXILLOFACIAL INJURIES Fart I; In the Forward Hospitals "Facial Fractures" Pages 683 to 705 Major John K. Nattinger, MG, AUS Captain Hubert Nall, DC, AUS Fart II) In the Base Hospitals "Base Section Maxillofacial Care" Pages 70S to 714 Major Henry B. Clark, MG, AUS 9. VASCULAR INJURIES "Arterial Injuries in War Wounds" Pages 715 to 745 Major Lawrence M. Shefts, MG, AUS Captain John R. McDaniel, MG, AUS Captain Knowles B, Lawrence, MG, AUS Captain Ross E. Hobler, MG, AUS INDEX OF FIGURES Fig. 1: Panorama of Field Hospital (left foreground)and Division Clearing Station (right foreground) 4 Fig. 2 &3: Laboratory and X-ray Facilities in a Field Hosp- ital IS Fig. 4: Patient in Shock Ward of a Field Hospital 39 Fig. 5: Tent Operating Room of a Field Hospital 53 Fig, 6 & 7: Postoperative ?7ards of Field Hospitals 78 Fig, 8: Historical Analysis of Casualty Rates 96 Fig. 9: Mortality, Winter and Summer, 1944 - 1945 97 Fig. 10: Mortality Rate by Months 98 Fig, 11; Arms and Services Distribution of Abdominal Casual- ties 99 Fig. 12; Incidence of Wounds Caused by Various Wounding Agents 101 Fig. 13; Effect of Position on Visceral Wounding 102 Fig, 14; Distribution of Wounds of Entry 106 Fig, 15; "Multiplicity Factor" in 2918 Abdominal Wounds 110 Fig, 16; "Multiplicity Factor" as Applied to Various Viscera 111 Fig, 17: Chronologic Distribution of 717 Deaths Occurring in 2895 Cases 114 Fig, 18; Mortality in Relation to Day of Death and "Multi- plicity Factor" 115 Fig. 19; Principal Causes of Deaths and the Day Deaths Occurred 117 Fig. 20; The Relation of Blood Pressure to Replacement Therapy in 957 Abdominal Cases 125 PAGE Index of Figures, (contd) PAGE Fig. 21: Mortality - Initial Blood Pressure Relationship 126 Fig, 22: Day of Death in Relation to Admission Blood Pressure 127 Fig. 23; Number of cases Living and Dead for Each Two Hour Period (Time Lag) 133 Fig. 24: Death Rate Increase Plotted Against Time Lag, Show- ing Number of Abdominal Organs Involved 134 Fig. 25: Comparative Mortality Rates Among Abdominal Cases With and Without Associated Injuries 153 Fig. 26: Comparative Mortality Rates Among Abdominal Cases With and Without Associated Injuries 153 Fig, 27: Incidence of Severe and Non-severe Associated Injur- ies Among Serious and Less Serious Abdominal Injur- ies 155 Fig, 28: "Multiplicity Factor" in Relation to Mortality in 298 Cases of Traumatic Evisceration, 1944 - 1945 164 Fig. 29: Mortality in Relation to Time Lag in 203 Cases of Traumatic Evisceration of One or More Abdominal Organs (Omentum Excluded), 1944 - 1945 166 Fig. 30r Mortality in Relation to Time Lag in 37 Cases in which Small Bowel Alone was Injured and Eviscerated, (1944 - 1945). 167 Fig, 31; Incidence of Complicating Injuries to Other Viscera in Stomach Wounds 217 Fig, 32: "Multiplicity Factor" in Wounds of the Stomach 218 Fig. 33: Appearance of Ulcer-like Lesion from Penetrating Wound of Stomach 221 Fig. 34: Duodenal Injuries - Site of Wound Entry in 118 Cases 231 Fig. 35: Frequency of Complicating Injury to Other Viscera (Small Bowel Wounds) 239 Fig. 36: Mortality - Time Lag Relationship (Small Bowel Wounds) 253 xix Index of Figures, (contd) PAGE Fig. 37: Mortality - Time Lag Relationship (Small Bowel Wounds 254 Fig. 38: Postoperative Survival Time (Small Bowel Wounds) 256 Fig. 39: Mortality - Time Lag Relationship (1222 Colon and Rectum Cases, 1944 - 1945) 274 Fig, 40: "Multiplicity Factor" in Colon and Rectal Injuries (1155 Cases, 1944 - 1945) * 277 Fig. 41: "Multiplicity Factor" in Relation to Time Lag. Effect on Mortality in 1155 Colon and Rectal Cases, 1944 - 1945. 278 Fig. 42; Types of Colostomy 284 Fig. 43: Types of He ©-Colostomy 285 Fig, 44: Types of lieo-Colostoray and Colostomy 286 Fig, 45: Table XII Operations and Mortality Rate (Colon) 287 Fig. 46: Percentage Regional Involvement, Colon and Rectum Cases 288 Fig, 47: Multiple Organ Involvement. Effect on Mortality Rate of liver Wounds 308 Fig, 48: Mortality Rate of liver Wounds plus Other Visceral Wounds 309 Fig. 49: Principle Causes of Death - 193 Cases (liver Wounds) 313 Fig, 50; Relation of Degree of Shock to Mortality in Splenic Injuries 329 Fig. 51: "Multiplicity Factor" in Splenic Wounds 335 Fig, 52: Anterior Relations of the Kidney 357 Fig. 53: Posterior Relations of the Kidney 358 Fig. 54: Incidence of Involvement of Other Organs in 414 Wounds of the Kidney 359 XX Index of Figures, (contd) PAGE Fig. 55: Incidence of Involvement of Other Organs in 27 Wounds of the Ureter 374 Fig. 56: Apparent bizarre Course of an Intrathoracic Missile 421 Fig. 57: Extremes of Diaphragmatic Excursion 422 Fig. 58: Missile Paths in Various Types of Diaphragmatic Wounds 423 Fig. 59: Anterior Thoracotomy with Claviculo-steraal Flap 443 Fig. 60A : Wound Suitable for Latissimus Dor si Flap 449 Fig. 60S & C: Latissimus Loop Flap for Small Wound 450 Fig. 600, E, F: Debridement Costectomy of Large Wound Intercostal Lattice-work Closure 451 Fig. 61A: Low Para-vertebral ?/ound 452 Fig. 61B: Plug Flap of Erector Spinae Muscle for Para- vertebral Wound 453 Fig. 62A, B: Wound with Sternal Defect 454 Fig. 62C: Sternal Defect Covered by pectoral Flap 455 Fig. 63A, B: Lower Anterior Thoracic Wound 456 Fig. 63C: Pedicled Flap of Pectoral Muscle for Closure of Lower Anterior Thoracic Wound 457 Fig. 64: Split Muscle Flap Permitting Imbrication 456 Fig. 65A, B, C: Sucking Wound. Rib Fragments in lacerated Lung 460 Fig. 65D: Rib Fragments Removed from Lung 461 Fig. 66: Diffuse Contusion of Right Ventricle 466 Fig. 67: Contused Left Ventricle with Mural Thrombus 467 Fig, 68: Shell Fragment Embolic to Right Ventricle 468 Fig. 69: Manual Retraction for Wounds of Posterior Surface of the Heart 474 XXI Index of Figures, (contd) PAGE Fig. 70: Method of Placement of Sutures for Ventricular laceration 475 Fig. 71: Free Muscle Graft and Imbricated Pericardial Closure 476 Fig. 72: Pericardial Flap in Closure of Cardiac Laceration 477 Fig. 73: Closure of Penetrating Wounds of the Auricle 478 Fig. 74: Postoperative Drainage of Chest Using Two Inter- costal Tubes 481 Fig. 75: Roentgenogram of Clotted Uninfected Hemothorax 541 Fig. 76: Roentgenogram One Month Later 541 Fig. 77: Cross Section of Chest With Organizing Hemothorax 542 Fig, 78: Roentgenogram Showing Pneumopyothorax 550 Fig. 79: Roentgenogram Two Weeks After Total Pulmonary Decortication 550 Fig. 80: Roentgenogram: Impending Chronic Empyema 551 Fig. 81: Roentgenogram Two Weeks After Total Pulmonary Decortication 552 Fig. 82: Complications of Retained Intrathoracic Foreign Bo, During the SO months fighting experience of the Fifth Army, 35 battle casualties per 1000 ad- mitted to hospitals suffered from intra-abdominal wounds. The mortality rate of 3154- patients with in tra-abdominal wounds treated during 1944. and 1945 by members of this Group was 24$• Those data become even more sig- nificant when it is appreciated that the increased rate of admission of such casualties is in the group of the most severely wounded. If only the less severe abdominal wounds are considered, which probably would be more nearly comparable to the World War I series, the mortality rate closely approximates 13% (page 110). A similar marked improvement in the management of thoracic wounds has been achieved. In World War I, the fre- quency of admissions to hospitals was 10.5 per 1000 with a mortality rate of 4-7.6<3fj, In. the Fifth Army, the frequency was lvo per 1000, and the mor- tality rate among 1364 patients suffering from intrapleural injuries, treated by members of this Group, was 9.89$. Figures arc not available from World War I relative to thoraco-abdominal wounds, but a mortality rate of 27.35 among 903 casualties suffering from such injuries treated by members of this Group is a worthy achievement. The careful recording of_ data relative to the surgical management rendered casualties by members of this Group has enabled a detailed study of the problems of forward surgery. These records have been made by the surgeons of the Group while working under the extremely hazardous condi- tions of enemy observation, shelling and bombing, often during inclement weather while living in tents, and during periods of rapid movements and prolonged and sustained periods of intense surgical activity. The re-' cords have been meticulously preserved and have become the source material 6 Tiie Employment and Function of Teams of the 2nd Auxiliary Surgical Group (contd) for the factual data recorded in this report. It is urgently hoped that they will be maintained for future reference and study cordinated with follow-up data. The professional service section of this report represents the com- bined surgical experience of the Group. The compilation of the data con- tained in the report has been accomplished through the efforts of the great majority of the medical officers of the organization and has been in progress at varying periods during the past two years. In fact, plans were formulated for recording the combined surgical experience of the Group even before it participated in an active Theater of Operations, The final effort to compile these data was accomplished after the end of the war in Europe, At that time certain members of the Group were not available to assist in this work as some were employed with functioning teams and some had returned to the United States. All other medical of- ficers of the Group participated in the final compilation of this report. Major Luther H, Wolff, MC, was in charge of the final preparation of the professional service section of this report. For the past eight months the major portion of his time has been devoted to this work. His able direction of this large undertaking is reflected in the excellence of the professional service section. In July 194-5, a board of officers was de- signated as an editorial board for the preparation of the professional service section of this report. Captain Maurice J. Walsh, MC, ably as- sisted the board in preparation of the report. Captain Paul A, Kennedy, MG, assisted by Pfc Walter Meigs, Jr,, was responsible for the prepara- tion of the charts and graphs contained in this report. REIERENGES 1, Churchill, Edward D,: The Surgical Management of the Wounded in the Mediterranean Theater at the Time of the Fall of Rome. Annals of Surgerv, 120:26c. September 1944. 2, Love, Albert G.s War Casualties — Their Relation to Medical Service and Replacements, Army Medical Bulletin, 21:124-. 3, Data obtained from the Office of the Surgeon, Fifth Army, (US), 7 PREOFERATIVfi DIAGNOSIS AND TRIAGE 8 PREOPERATIVE DIAGNOSIS AND TRIAGE Preoperative diagnosis in VJar Surgery is simply the study of injury and its effects upon the wounded man. If the injury is severe, grave physiological disturbances often result which threaten life and successful resuscitation cannot be accomplished without an evaluation of the responsible factors. If fulminating infection is beginning but escapes detection, life may .be lost as the result of incomplete diagnosis and the consequent delay in operative care. Likewise, intelligent surgical care is impossible without an accurate knowledge of the extent and nature of the injury as well as the structures which are involved. In evaluating the condition of the severely wounded it is first necessary to attend to those disturbances which constitute an immediate threat to life or jeopardize the ability of the patient to withstand operation. Of greatest importance in this respect is traumatic or wound shock; its evaluation and management become the immediate problem which takes precedence over other diagnostic measures. THE DIAGNOSIS OF SHOCK: THE EVALUATION OF THE DEGREE OF SHOCK A reduction in circulating blood volume and concomitant decrease in peripheral blood flow are believed to be the most early disturbances in the syndrome of shock (l), It is important to realize that the recog- nition of shock depends upon the clinical manifestations of these circu- latory disturbances. The determination that the shock does not exist is ordinarily not difficult. It appears that individuals vary considerably in their response to trauma and that the degree of shock is not always strictly parallel to the blood volume loss, particularly when this loss has not been severe (2), This fact must always be remembered in any discussion relative to the degree of shock. It has become customary to speak of shock in which the blood pressure is normal as ''incipient shock". This is a useful concept for two reasons: first, it indicates that the fundamental disturbance of shock may exist without a fall in the blood pressure; secondly, it implies the progressive nature of the peripheral circulatory failure which follows trauma. The recognition of incipient shock depends largely upon evidences of decreased peripheral blood flow (pallor and coldness of the skin and extremities; collapse or constriction of the superficial veins; and tachycardia with a pulse of poor volume). The degree of these changes may vary considerably from patient to patient but is of extreme importance in indicating that a reduction of the circulating blood volume has occurred, regardless of the level of the blood pressure. 9 Preoperative Diagnosis and Triage. (The Diagnosis of Shock: The Evaluation of the Degree of Shock , contd). Blalock (3) has repeatedly called attention to the fact that the blood pressure is a poor index of the degree of shock and that a considerable reduction in blood volume and blood flow often occurs prior to a fall in blood pressure. Studies in this Theater (2) have shown thst a blood loss of of the expected blood volume may occur in battle casualties without an appreciable reduction in the blood pressure, Richards (l) cites evidence for a strong selective vasoconstrictor activity in shock which curtails markedly the blood flows to organs not immediately necessary for survival, He also states, "Spontaneous and abrupt failure of this selective vasoconstriction may precipitate fatal collapse", These findings support the conclusion that a fall in blood pressure indicates a reduction in the circulating blood volume for which vasoconstriction cannot fully compensate or that a failure of the vasoconstrictor mechanism has occurred. In previously healthy soldiers intense vasoconstriction usually persists until death occurs and little clinical evidence exists that vasoconstriction fails in the sense that arteriolar dilation supervenes, however, the marble- like mottled cyanosis which is occasionally seen in moribund patients may constitute evidence for arteriolar dilatation in such cases. In the recognition of the more severe degrees of shock, a falling blood pressure will always remain as one of the cardinal signs of pro- gressing circulatory failure, Experience with the severely wounded indicates that this fall in blood pressure is almost always associated with increasing vasoconstriction and progressive reduction in the peri- pheral blood flow. Hence, the clinical correlation of the state of the peripheral circulation with the level of the blood pressure constitutes an important means of evaluating the severity of shock. The skin may be excessively cold and pale; the pulse may be barely perceptible or tend to disappear with inspiration and the rate very rapid; often there is evidence of marked constriction of the superficial veins. As the mani- festations of stagnant anoxia become apparent the skin exhibits the ashen-grey cyanosis so characteristic of profound shock, and cerebral anoxia often results in restlessness, apathy, or stupor. True coma is relatively rare except in the moribund patient. In the most severe examples of shock the blood pressure in the brachial artery may be unmeasurable, even inpalpable - and death is immediately threatened. Sweating may be observed in severe shock but it also occurs when shock is minimal or absent and has proved to be of little aid in evaluating the degree of shock. In the \ise of the blood pressure level as an indication of the degree of shock it is important to determine, if possible, the trend of the blood pressure; obviously a rapidly falling blood pressure is indicative of more severe shock than a blood pressure which has become stabilized. There has been a tendency to underestimate the importance of the blood pressure in evaluating the degree of shock. In this respect 10 Preoperative Diagnosis and Triage. (The Diagnosis of Shocks The Evaluation of the Degree of Shock, contd). the following facts are of interest: In a series of 957 cases with intra-abdominal injury the degree of shock was based upon the level of the admission systolic blood pressure. The average amount of plasma and blood which was required to accomplish resuscitation was determined for each of the four groups. It was found that the average amount of replacement therapy varied inversely with the systolic blood pressure, being greatest for the group with the lowest blood pressure. (See uThe Problem of Shock Therapy in Abdominal Wounds11, Table I and Figure 20 pages 12U-25 )• It is important to remember tha the adequacy of resus- citation therapy was determined upon the basis of the clinical response in addition to the rise in the blood pressure level at the time such replacement was being carried out. Hence, it appears that in a relatively large series of cases the blood loss (as indicated approximately by the amount of replacement therapy required) is related to and within limits predictable by the admission blood pressure level. In brief, reliance in diagnosis should never be based solely upon the blood pressure nor should the importance of a low blood pressure be overlooked. The changes and character of the pulse in patients who exhibit shock deserve some comment. The fullness of the pulse wave at the wrist should be noted carefully; its character is of importance and is of more diag- nostic value than the rate, since the latter may vary over a wide range. Severe shock may occasionally be present in a patient with a relatively slow pulse and the true reduction in the peripheral blood flow is more accurately indicated by the "thready" pulse# The trend of the rate and character of the pulse is of more diagnostic importance than an isolated determination, F0r this reason it is important to record the pulse rate, as well as the blood pressure, at the time the patient is admitted to the hospital so that these factors may be re-evaluated from time to time. The appearance of the patient may be modified by virtue of the fact that he has received a relatively large volume of plasma prior to admission to the hospital. Pallor may be present out of proportion to other evidences of reduced peripheral blood flow; not.infrequently a peculiar waxy yellow tint is noticeable. It has been noted also that the diastolic pressure may be unusually low in patients who have received large amounts of plasma. The diastolic pressure often rises more slowly than the systolic in response to blood transfusion. In a few such cases physical signs of aortic regurgitation were sought but were found to be lacking and the changes in the diastolic pressure may depend upon the lowered blood viscosity and anemia which follow liberal plasma therapy. APPRAISAL OF THE TYPE AND EXTENT OF INJURY Shock and resuscitation cannot be carried out intelligently with- out a prompt appraisal of the number, location, and extent of the injuries. Ordinarily, as stated above, the presence of or degree of shock is 11 Preoperative Diagnosis and Triage. (Appraisal of the Type and Extent of Injury, contd). determined immediately and before attention is directed to the wound jDer sjj. However, physical examination must not be delayed and unless the patient is in severe shock this is best made as soon as possible. In cases in extreme shock the need for immediate resuscitation is urgent and complete examination must await improvement in the patient’s condition. Even in these cases, however, examination must not be delayed unnecessarily - bleeding from an inaccessible wound may explain a poor response to transfusion therapy. In accomplishing an adequate examination it is necessary to examine all aspects of the body. The patient’s clothing is cut apart and gently removed. At this time the clothing and litter are inspected for the presence of blood and if possible the patient is moved to a clean, properly dressed litter. This can be accomplished by lifting the recumbent patient carefully and sliding the fresh litter beneath him. In the event that it is impractical to move the patient (spinal cord injuries) it may be necessary to place a clean, dry blanket beneath the patient to prevent further loss of body heat. Throughout all of these procedures the patient is constantly kept covered with a blanket to prevent chilling. It is desirable, if possible, to make the physical examination complete before beginning intravenous therapy since this may hamper examination at a later time. The posterior aspect of the trunk and the gluteal region must always be carefully inspected; wounds in these locations are frequently overlooked. Palpation along the expected path of the missile may frequently result in detection of the missile (partic- ularly a bullet) lying beneath the skin on the side of the body opposite the wound of entry. Also, it is very desirable to establish whether or not a perforating wound exists. Location of the missile by palpation or the definite establishment of the existence of a perforating wound may greatly simplify x-ray examination or render such examination un- necessary, This is particularly true in abdominal injuries and may result in considerable curtailment of the preoperative delay, especially during rush periods. Not infrequently the roentgen examination is repeated because no foreign body appears on the films, only for sub- sequent examination to reveal the wound of exit. The detailed examination of the patient logically starts by focusing attention upon the wound itself* All wounds and the bandages covering them should be closely inspected for evidence of continuing hemorrhage* Failure to discover external hemorrhage may affect signifi- cantly the subsequent course of the patient. In appraising the probable extent of the injury it is best to visualize as nearly as possible the track of the missile and a statement by the patient as to his position at the time of wounding may be of great help in this respect* Certain Preoperative Diagnosis and Triage. (Appraisal of the Type and Extent of Injury, contd), general types of injury will be discussed,, 'founds of the Abdomen. In the selection and care of first priority casualties it is important to determine whether injury to a hollow viscus has resulted in soiling the peritoneum. In the usual case the location of the wound and unmistakable signs of established peritoneal irritation leave no doubt that laparotomy is required. However, the occasional case presents sufficient difficulty in diagnosis that an exploratory laparotomy may be indicated. In evaluating such cases the absence of audible peristalsis, the presence of blood in the urine, gastric contents ot rectum are valuable aids. If soiling is localized to the retroperitoneal tissues or lesser peritoneal sac audible peristalsis may be misleading. Blood in the peri- toneal cavity may result in sufficient evidences of peritoneal irritation so that laparotomy is necessary to rule out hollow viscus damage; usually however, abdominal rigidity and pain are less marked than when bowel con- tents are present within the peritoneum. Severe retroperitoneal injury alone may simulate peritonitis but in our experience such cases are in- frequent. It must be remembered that previous morphine medication may alter the signs and symptoms of peritonitis. Rectal examination may be of great diagnostic aid, particularly in wounds of the buttocks or upper thighs; too often this examination is neglected. Rigid reliance should not be placed upon the absence of blood in the gastric contents, since wounds of the stomach may be present without grossly demonstrable blood. Similarly, the absence of blood in the urine does not exclude renal or urinary tract injury. bounds of the Thorax. In examination of a patient with thoracic injury attention should first be directed toward the general effects of respiratory exribarrassment* Cyanosis should be searched for constantly since it is an important in- dication of well advanced anoxia. In patients who have suffered from severe hemorrhage the degree of cyanosis may be relatively slight even though oxygenation of the blood is seriously reduced. In many of the more critically wounded it may be difficult to determine whether shock or cardio-pulmonary dysfunction is responsible for the cyanosis. Since severe hemorrhage usually precedes severe shock, marked cyanosis is usually not attributable to shock alone but to the added factor of reduced pulmonary ventilation. The character and rate of respirations should be evaluated; if severe dyspnea is observed its cause should be sought immediately. The influence of previously administered morphine upon respiration must 13 Preoperative Diagnosis and Triage. (Appraisal of the Type and Extent of Injury, contd). not be overlooked. Examination of 'founds of the chest should be thorough butnot often repeated; further Contamination of the pleura may occur and air enter the chest through a sucking wound. If possible it is desirable for the shock officer and surgeon to examine the wound together and thereafter the newly dressed wound need not be disturbed. At the time of examination the following facts are established: the size of the wound and the extent of damage to the chest wall; the loss of blood from the wound; the probable direction of the missile; the presence of bowel contamination in thoraco-abdominal wounds; and last but not least, the determination as to whether or not communication exists between the pleural cavity and the exterior, A sucking wound may be simulated by tangential wounds of the thoracic wall in regions where subcutaneous tissue and muscle are of considerable thickness, (e.g,, in the axillary and scapular regions). Usually the true state of affairs nay be established by observing the wound while the patient coughs. Hemopneumothorax is present to some degree in practically all wounds of the chest in which the normal pleura is lacerated. The volume of blood and air which accumulates within the pleural cavity varies considerably; consequently there is wide variation in the clinical picture and one of the chief problems of the preoperative period is the diagnosis and management of hemopneumothorax. Simple observation, percussion and auscultation will provide important in- formation and should not be neglected. The signs vary depending upon the predominance of blood or air in the pleural cavity but not in- frequently the condition of the patient or the presence of other wounds restrict® the usefulness of physical diagnosis. Mild degrees of subcutaneous emphysema are Common, particularly if marked adhesive pleuritis and/or bronchopleural fistula are present. Pressure pneumo- thorax, though relatively uncommon, is usually not difficult to recognize. Characteristically, dyspnea and cyanosis are severe; the trachea and cardiac impulse are shifted toward the opposite side; often the patient gives e history of increasing dyspnea prior to admission. Except for evidences of mediastinal shift a similar picture may be seen in large pneumothora.ces. In both instances collapse of the lung may be incomplete in areas in which there has been considerable trauma to the pulmonary parenchyma, One should be cognizant of this fact as well as search carefully for evidence of intrapleural adhesions in the interpretation of roentgenograms of the chest in such cases. Aside from its therapeutic value, thoracenthesis is capable of supplying helpful diagnostic information, particularly when other measures prove to be inconclusive. By this means the amount of blood 14 Preoperative Diagnosis and Triage. (Appraisal of the Type and Extent of injury, contd). and air In the chest way be determined within fairly close limits. The Continued removal of air indicates the presence of a significant broncho-pleural fistula and the need for establishing continuous decompression of the pleural cavity. Once this has been instituted (by means of a needle or preferably a catheter in the second anterior intercostal space) the amount of air lost through the water seal affords a means of evaluating the size of the broncho-pleural fistula. Thora- centesis is also helpful in that the removal of blood and air may simplify the Interpretation of subsequent roentgen films. Furthermore, in rare instances gross and microscopic examination of the aspirated fluid may definitely establish the presence of severe bacterial con- tamination in patients that have been wounded for many hours. the pulmonary parenchyma is injured varying degrees of hemorrhage may occur depending upon the nature and extent of the trauma and the type and caliber of the vessels involved* Injury to a hilar vessel is of grave significance; certainly the majority of patients with such injuries become exsanguinated or are asphyxiated by massive intrabronchial hemorrhage before reaching a forward hospital* Sven moderate degrees of hemorrhage into the bronchi are important because of the likelihood that atelectasis of a considerable portion of the lung will result* In the presence of hemopneumothorax typical signs of atelect- asis may be absent or greatly modified* Evidence of a shift of the mediastinum toward the affected side is important but it is probable that a considerable degree of atelectasis may exist without producing a shift in the trachea or cardiac impulse. If signs of decreased pulmonary ventilation persist after thoracentesis one should suspect the presence of atelectasis. Severe degrees of atelectasis may be encountered follow- ing maxillo-facial wounds or cervical wounds with injury to the respiratory passages. Similarly bronchial obstruction and atelectasis may occur in the unconscious patient following the aspiration of vomitus. It is important if possible to establish the presence of mediastinal involvement in all thoracic injuries. This is best accomplished by visual- izing the path of the missile with the aid of x-ray studies. Isolated injury of the esophagus is uncommon and substernal pain upon swallowing may be the only indication of esophageal injury. Evidence of cardiac injury may be deduced from the type of pain, cardiac irregularity or widening of the pericardial shadow by x-ray. Often an accurate diagnosis of a wound of the heart is difficult to establish and ths greatest aid is to be derived from the projected course of the missile, (See section dealing with Cardiac Wounds, page 463 ),. Mediastinal emphysema has not proven to be of great importance in the experience of thoracic surgeons of this Group; concomitant laceration of the mediastinal pleura may prevent the accumulation of a large volume of air just as the majority of pericardi 15 Preoperative Diagnosis and Triage. (Appraisal of the Type and Extent of Injury, contd). lacerations prevent the development of cardiac tamponade. If a major bronchus is lacerated near the hilus of the lung one may suspect a rapid accumulation of air within the pleural cavity and pressure pneumo- thorax may follow within a relatively short time. Thoraco-Abdominal 7Jounds, All wounds of the chest below the seventh interspace posteriorly and the fourth rib anteriorly should be considered as potential thoraco- abdominal wounds. H0wever, perforation of the diaphragm may occur from missiles which enter via the gluteal or shoulder region but in the average case the wound of entrance lies in the lower half of the chest. Very uncommonly the diaphragm is perforated from below* It is of utmost importance to establish the presence of intra- abdominal injury in all thoracic cases and such a diagnosis may be rendered difficult by virtue of pain arising in the lower thoracic wall. The usual diagnostic measures are employed as discussed above. In such cases adequate roentgen studies are invaluable in arriving at a correct diagnosis. Re-examination of the patient following intercostal nerve block may be helpful since abdominal rigidity due to peritonitis remains unchanged whereas pain and voluntary muscle spasm due to thoracic wall injury may be considerably reduced* However, too much emphasis upon the effect of nerve block may lead to erronous conclusions. The presence of pain referred to the shoulder is important evidence of injury to the diaphragm; such pain is very infrequent in simple thoracic wounds, but it may be absent even though injury to the diaphragm is found subsequently at operation. If, after careful study, it cannot be established definitely that intra-abdominal injury does not exist, operative exploration is indicated. Vfounds of the Spinal Cord In wounds of the trunk or cervical region the examiner should always be cognizant of the possibility of spinal cord injury. Unless one is sufficiently aware of this possibility it may easily be overlooked in the pre-occupation with other more obvious injury. Often simple inspection of the patient will indicate the probable diagnosis; priapism, unusually full superficial veins of the lower extremities or loss of abdominal respiratory motion are signs of importance. Absence of deep tendon reflexes and loss of sensation and motor activity below the level of injury serve to establish the diagnosis. The level and completeness of the lesion should be determined prior to operation. Also, the patient should be questioned as to the rapidity with which paralysis ensued after injury; in the vast majority of cases loss of function will be immediate bub in rare cases delayed paralysis may indicate that coiipression 16 Preoperative Diagnosis and Triage, (Appraisal of the Type and Extent of Injury, contdj. of the cord has occurred subsequent to the initial injury. Maxillo-Facial Wounds. All but the slightest maxillo-facial injuries are commonly associated with considerable oral or nasopharyngeal hemorrhage and aspiration of blood must be prevented, particularly in the stuporous or comatose patient. All such patients should be evacuated in the prone position with the face slightly lower than the trunk. In both maxillo-facial and cervical wounds severe tracheal obstructions may occur with alarming rapidity and the need for immediate tracheotomy must be evaluated promptly, particularly in injuries of the hypopharynx or larynx. The source and degree of hemorrhage deserve careful attention. Wounds of the Extremities^ Major vascular injuries are common in extensive wounds of the extremities and the examination should determine initially the presence or absence of a tourniquet and whether or not active bleeding is in progress. Likewise, one must determine the state of the circulation of the extremity. The character of the peripheral pulse in the injured limbs should be compared with that of the normal .extremity; cyanosis, edema, induration and the response of the skin circulation to localized momentary pressure are points -worthy of notice. The examination should establish the fact that adequate splinting of fractures- has been accomplished and that no constricting bandages encircle the extremity. Nerve injury should be assessed as completely as possible during the preoperative examination, particularly in w0unds which involve the upper extremity. This is equally true in wounds of the pelvic or shoulder girdle which may result in nerve or nerve plexus injuries* Granial Injuries* 'found shock is not often a major problem in those patients with cerebral injuries who live bo reach the forward hospitals. The immediate threat to life is determined not by failure of peripheral circulation but by the extent of brain damage. Often it is well to keep such patients under observation in the Field Hospital for a short time to establish definitely the fact that no rapid increase in intracranial pressure is occurring. However, evacuation of the patient to the care of a neurosurgeon (Evacuation Hospital) must not be delayed unnecessarily. In our ex- perience signs of an appreciable increase in intracranial pressure are not common. In the stuporous or comatose patient aspiration of voraitus may occur with grave embarrassment of pulmonary function. Likewise, severe cerebral injury may occasionally produce pulmonary vasomotor changes which result in pulmonary edema indistinguishable from that caused by blast injury of the lungs. 17 Preoperative Diagnosis and Triage. (Appraisal of the Type and Extent of Injury, contd). In the examination of cranial wounds great care must be exercised to prevent further contamination. Time rarely permits exhaustive neuro- surgical examination prior to evacuation of the patient from the Field Hospital; however, when important localizing signs are observed these should be noted upon the patient’s record. In ocular injuries the visual defect should be evaluated as well as possible. The presence of blood in the anterior chamber should be noted because of the indication for the prompt use of mydriatics in such cases to prevent the formation of synechiae. Again, evacuation of the patient for expert ophthalmological care should be accomplished without delay unless other injury requires prompt initial surgery. Blast Injury. The organs which are :aDst commonly injured as the result of concussion from a nearly explosion are the lungs and hollow viscera. The brain is not believed to suffer damage from the blast wave (4) but traumatic concussion may result if the patient is thrown forcibly against a stationary object. Examples of solitary blast injury are infrequent - usually the soldier sustains shell fragment wounds at the same time. Patients suffering from pulmonary blast injury may experience moderate dyspnea and tachypnea may be present. Scattered moist rales may be heard throughout the chest and small amounts of serosanguinous fluid may be expectorated. Cyanosis may be present, usually it is not marked but is often not completely relieved by the inhalation of 90-100/6 oxygen. It is important to remember that pulmonary fat embolism (following fractures and, less frequently, extensive trauma of adipose tissue) may be indistinguishable from pulmonary blast injury. Lacerations of the bowel may result from blast injury or exten- sive necrosis of the bowel wall may occur, (See Case No.8 page U8 ’•Resuscitation and Preoperative Care of the Severely hounded") • In the patient who has received previous morphine medication and in whom no abdominal wound is present intra-abdominal blast injury may easily be overlooked. In patients suffering from partial or complete traumatic ampu- tation of the foot due to mine explosion one nay rarely observe ex- pensive edema of the entire leg. This appears to be due to vascular damage caused by direct concussion of the limb and not by the effect of the blast since the opposite leg may escape injury completely. Figure 2 Figure 9 Figure* 2 and 3 Laboratory and X-ray Faoilltiaa in Field Hospital 19 Preoperative Diagnosis and Triage, THE USE CF ROENTGENOGRAPHY B1 DIAGNOSIS .Conclusive diagnostic studies may be impossible without adequate bi-directional roentgenograms, Roentgen examination should be accom- plished as soon after admission as possible, although often, some degree of replacement therapy will be required first. However, if the patient shows little or no evidence of shock films are easiest to obtain prior to the initiation of replacement therapy. In patients whorequire vigorous shock therapy roentgenography is usually postponed until immediately prior to operation. In attempting to localize foreign bodies it is the duty of the shock officer to see that adequate antero-posterior and lateral films are made. Films should include a considerable view above and below the wound of entry; in wounds of the mid-trunk it often saves time to first localize the foreign body by means of antero-posterior films of the chest and abdomen (including upper gluteal region); the lateral exposure may then be taken over the location of the fragments. Adequate lateral films of the upper thigh and gluteal regions may be difficult in the presence of a leg splint and it may be necessary to tilt the tube and lift the gluteal region above the litter bar by providing a support- ing platform from below. Placing the patient on a clean litter will greatly reduce the incidence of artifacts due to foreign material in the blankets or on the litter. Occasionally bullets or shell fragments may fall free in the chest or peritoneal cavity and appear in unexpected positions, A foreign body may overlie the heart in an antero-posterior film and not be seen in the lateral; when this occurs one should suspect a foreign body in the heart or pericardium, cardiac motion preventing its visualization in lateral films. In frontal films heavy penetration frequently aids in visualizing cardiac foreign bodies. Diagnosis in the wounded man is ordinarily much more direct and less detailed than in civilian practice and much less emphasis is placed upon the patient's history. However, questioning the patient relative to a few simple facts may afford considerable help. Initially, it is often well to direct one's attention to the chief complaint of the patient and determine the location and severity of the pain which he may experience, A few questions have already been mentioned in connection with the various types of wounds. Additional facts may be established such* as: corroboration of data which appear on the patient's field medical tag; the exposure to cold; the presence and amount of hemoptysis after injury; the severity, of hemorrhage; the occurrence and severity of vomiting; the time of the last meal prior to injury; the presence of previous upper respiratory 20 Freoperative Diagnosis and Triage. (The Use of Roentgenography in Diagnosis, contd). infection, etc# The medical tag snould be carefully checked to determine the amount of morphine the patient has received and the time it was given, as well as the amount of plasms which has been administered# TRIAGE Triage is eamply the process of coordinating the time and place of the patients1 initial surgical care with the severity of the injury. 3y virtue of its location near the combat area, the Field Hospital Unit is in the most nearly ideal situation to care for the severely wound- ed - the "non-transportable" casualties whose life would be endangered by further evacuation to the rear. Consequently the Field Hospital receives from the Divisional Clearing Station those patients which fall into one or more of the following categories: (l) those In which injury has resulted in severe physiological disturbances which constitute an immediate threat to life; (2) patients in which overwhelming infection will soon jeopardize life. Specifically, the following types of wounds require initial surgery or resuscitation in the forward area: patients suffering from shock due to severe or progressing hemorrhage; patients with respiratory distress due to open wounds of the chest or maxillo- facial wounds with obstruction of the respiratory passages; wounds of the abdomen; compound fractures of long bones; traumatic amputations; major injury to the vessels of an extremity or extensive trauma to soft tissue which may be followed by anaerobic myositis (gas gangrene) and rarely, cranial injuries with increasing intracranial pressure. In order that the limited personnel of a Field Hospital may deal exclusively with the care of such casualties it becomes mandatory that patients with lesser wounds not be sent to such installations but be evacuated from the Clearing Station directly to the rear. Occasionally it may be impossible to determine the extent of the patient's injury in the Clearing Station and it becomes necessary to refer such casual- ties to the Field Hospital for roentgen examination and more detailed diagnostic study to determine "whether or not the injury is of such a nature as to warrant initial surgical care in the divisional area. The establishment of the presence of intra-abdominal injury is usually the information needed but this practice may be carried to extreme lengths particularly when Clearing Station personnel are unfamiliar with war wounds and the task of the Field Hospital, The facilities of such a hospital may be greatly overburdened should the Clearing Station personnel regard the Field Hospital roentgen unit as a screening unit for a large number of patients whose wounds are relatively mild. 21 Preoperative Diagnosis and Triage. (Triage, contd). Nevertheless, it is often possible to establish the fact that a casualty^is evacuable after a brief observation in the shock ward, thus allowing surgical teams to concentrate upon the true priority casualties. Likewise, stabilization of the patient may be attained which will allow his prompt evacuation if the threat of severs in- fection does not exist. This is particularly true of single thoracic injuries. continually been able to evacuate before operation as high as 50% of all uncomplicated thoracic cases by the use of thoracentesis, intercostal nerve block and transfusion therapy, all of which can be accomplished in a relatively short time, and often replacement therapy is not required. Such preoperative triage, therapy and prompt evacuation are particularly important during rush periods when the number of very severely wounded casualties may cause prolonged preoperative delay for casualties with less severe injury. Obviously criteria for evacuation from the preoperative ward of a Field Hospital depend somewhat upon the inflow of casualties, the proximity of the Evacuation H0spital, etc. During relatively quiet periods patients may be operated upon in the most forward hospital who would often be evacuated to the rear during busy'periods. Among those patients whose injury requires prompt surgery the principles of triage or selection for priority of operation still holds. In general, those patients with the most severe wounds deserve priority for surgical care; this is particularly true in wounds of the abdomen and those in which continuing hemorrhage is present which cannot be controlled by ordinary first aid measures, (See Case page ij? ). The following example illustrates this point: assume that two patients have responded well to shock therapy; one suffers from a simple thoracic wound, the other from a thoraco-abdominal wound, - - obviously the thoraco- abdominal wound should receive priority for operation if, as often happens, operating facilities will only accomodate one patient at any given time. In establishing the relative individual priority among several patients awaiting surgery it is necessary to utilize one’s diagnostic acumen to the utmost and from, time to time the clinical improvement (or more exactly, lack of improvement) must be evaluated in relation to all clinical data at hand. Nothing so greatly taxes the smooth functioning of a shock ward as the simultaneous admission of six or eight severely wounded patients to a hospital whose operating facilities will accomodate only two to three patients at a time. Expert judgment is required to evaluate promptly the severity and type of injury .in each case so that replacement therapy as well as the timing of operation may be accurately adapted to the needs of the patient. In such instances the close diagnostic collaboration of the surgeon and the shock officer may be of inestimable value in determining the status of the patient as well as his therapeutic needs. During such rush periods nothing will supplant * ”Reouscitation and Freoperative Care of the Severely hounded11, Freoperative Diagnosis and Triage (Triage, contd) 22 a prompt and thorough physical examination, the discover?/ of an obvious perforating wound of the abdomen will allow operation to be started with- out further delay. Attention may then be focused upon patients with more obscure injuries, shock treatment administered and diagnositic studies carried out so that as soon as one operation is completed another patient will be ready for surgery. Every attempt should be made to maintain continuity of care. Pre- ferably the surgeon should acquaint himself with the problems presented by the particular patient upon whom, operation is to be performed. He should receive the fullest possible aid from the officer in charge of preopera- tive care. It is well for the surgeon and the shock officer to review to- gether the roentograms and other laboratory studies pertaining to the pa- tient. SUMMARY Diagnostic problems encountered in the preoperative care of severely wounded men may be simple or exceedingly complex. Through study of the injured man an attempt is made to evaluate the effects of injury upon nor- mal physiological mechanisms as well as to alloy; intelligent planning of operation through close attention to the wound itself and the structures which have been injured. In military surgery the largo number of casualties makes it neces- sary to classify patients according to the severity of their wounds and to afford initial surgical care as the severity or injur?; indicates. Hot only are triage and selection of cases applicable throughout all echelons of medical installations but also within individual forward hospitals priority for surgical care is based upon the severity of the injury and the immediate or delayed consequences thereof. Should such selection of patients be poorly managed much of the advantage of the hospital's forward location may be lost. The preoperative ward should be run in such a way that a. steady flow of patients to surgery is assured without unnecessary delay between operations. Continuity of professional care must be obtained by free liaison betvreen the surgeon and the officer in charge of resusci- tation and preoperative care. BIBLIOGRAPHY 1, Richards, D. W, Jr.,: The Circulation in Traumatic Shock in Man, Harvey Lectures, 39s217 - 253, 194-3-1914. 2. Board for the Study of the Severely Wounded. MTOIJSA, 1941-1915 (personal communication), 3. Blalock, A., The Principles of Surgical Care, St. Louis, C. V. Mosby, 1910, 1, Gnurchill, E. D,: Military Surgery, section for Textbook of Sur- geiy (Christopher), in press. 23 RESUSCITATION AND PREOPERATIVE CARE OF THE SEVERELY WOUNDED 24 RESUSCITATION AND PREOPERATIVE CARE OF THE SEVERELY WOWED The problems of preoperative diagnosis have'been discussed in a ore' vious section* dealing with the local end general effects of severe in- jury upon the wounded man. It is well at this point to deal briefly wit! wound shock in the light of present concepts as to its pathogenesis. Fa tore which are important in the production of wound shoe1: will bo dis- cussed and finally, the resuscitation of the critically Injured man and his preparation for initial surgery will be outlined. THE PATHOGENESIS OF WOUND SHOCK The intelligent management of traumatic shock in the war wounded de- mands that emphasis be placed upon certain well-established facts of prac- tical importance. Theoretical or highly controversial ideas must ofen be [ disregarded in the face of the exigencies of war and it is not pertinent to discuss here the many theories related to the pathogenesis of the peri- pheral circulatory failure which follows injury. It is generally agreed that the single most important factor in the production of traumatic shock is the loss of whole blood or plasma from the vascular bed in the trauma- [ tized area. The acceptance of this fact is based upon the outstanding experimental work of Blalock and associates (l) end Parsons and Phemister (2). More recent work has confirmed the validity of these impressions in man. Richards, in summarizing this work, offers convincing proof that the underlying disturbances in shock are a failure of return of blood to the heart with diminished blood flow and tissue anoxia (3). Detailed studies of wounded men have been carried out in the Medi- terranean Theater of Operations (4). A close correlation was found be- tween the blood loss and the degree of shock which follows injury; the important factor in the production of shock is the character of the wound I end especially its relation to hemorrhage. The success of plasma and blood replacement in the therapy of shock during the present war affords further conclusive evidence that r reduct- I ion in the circulating blood volume is of,fundamental importance in the production of wound shock. Likewise, it has been shown (see "The Problem of Shock Therapy in Abdominal Wounds", Table I and figure 20 , page 125) that the volume of blood and plasma required in resuscitation increases directly as the severity of shock increases. Those findings and those cited above offer strong support to the contention that the most import- ant factor in the reduction of blood volume and the production of shock is the loss of fluid from the site of injury. It must always be remembered that the loss of fluid from the vascular! bed is rarely a simple process. In- battle casualties the loss of whole blood from the site of trauma is of outstanding importance and is usually I * "Preoperative Diagnosis and Triage" (page 7 ) Res us citation, and Preoperative Care- of the Severely Wounded (The Patho- genesis of Wound Chock, contd) the predominant initiating factor in such injuries. However, particularly in wounds of the abdomen, large amounts of fluid may be lost through ex- udation and. transcl nation from serosal stir faces. Likewise, the loss of plasr.ia or plasma components about the periphery of a wound or in ti e ■•.•/all of the bowel due to mechanical >r chemical irritation constitutes an ad- ditional source of fluid loss. Also, considerable fluid may be lest by vomiting, or paralytic ileus.may interfere with the reabsorption fluid, from the large bowel in the presence of diffuse peritoneal contamination• In attempting to evaluate any causative factor in shock it is imperative that associated fluid loss bo critically assessed (5). Those and other factors will be discussed subsequently in more detail. As the effective circulating blood volume is reduced through blood or plasma loss, certain physiological responses are called into play which more or less determine the clinical appearance of the wounded man. Chief among these processes is the action of a strong vasoconstrictor mechanism which serves to divert blood from the skin and muscles and certain organ systems to the central circulation (3). Thus the arterial blood pressure is maintained for some time in the face of blood, loss but at the czpersc of the peripheral circulation, end the skin becomes pale and cold, super- ficial veins are constricted and weakness may be severe. Evidence of poor cardiac filling end decreased stroke volume may be found in the rapid, thready radial pulse. As the effective circulating blood volume is fur- ther reduced the blood pressure falls in spite of intensive vasoconstric- tor activity, and the central circulation is decreased. Several Investigators have insisted that henoconcentration is an es- sential and fundamental factor in traumatic shock (6), Our observations in wound shock do not support this contention for the following reasons: l) The vast majority of battle casualties who exhibit unmistakable signs of shock show normal or low hematocrit levels. This experience is in ac- cord with the findings of Lalich (?) and the Board for the Study of the Severely Wounded (A). 2) In the most severe degrees of shock the lowest hematocrit levels (for example 15-20 volumes percent) are often observed due to spontaneous hemodilution and the previous administration of plasna. 3) Finally, the shock that may be present or prove fatal in the immediate postoperative period is consistently associated with a low rather than a high hematocrit in spite of the liberal transfusion of whole blood. It must be remembered that the level of the hematocrit which is ob- served after injury is the resultant of the action of several factors. Following hemorrhage it remains within normal limits until hemodilution occurs; as extracellular fluid enters the blood stream the hematocrit falls. The predominant importance of hemorrhage in the pathogenesis of wound shock is indicated by the factors which were mentioned above. Me believe that an elevation of the hematocrit (as seen in burns, crushing 26 Resuscitation and Prooperative Care of the Severely Wounded (The Patho- genesis of Wound Shock, contd) or contusion injury and in the presence of diffuse peritoneal contamina- tion) is simply an indication that a greater amount of plasma than of v.iiole blood has been lost into the traumatized area. In the literature dealing with traumatic shock reference is often made to "irreversible shock"; a condition characterized by a generalized increase in capillary permeability which renders replacement therapy in- effectual, inasmuch as such fluid is rapidly lost from the vascular bed. This "negative response to transfusion" is construed to constitute evi- dence for generalized capilary damage which occurs after shock lias existed for some time. The work of Stead (8) casts serious doubt that an increase in capillary permeability occurs distant to the area of trauma except as an agonal change. Wore and more evidence is being accumulated that injury to various organs is the deciding factor as to whether or not resuscita- tion from severe and prolonged shod: can be accomplished (4-}(9)(10). A priori it would be supposed that cerebral function would suffer the most severe damage as a result of the anoxia of shock. However, experience has shown that the cerebral circulation tends to be maintained at a fairly satisfactory level until the end. In young healthy adults moderate cloud- ing of the sensoriura, mild disorientation and amnesia may be observed fairly frequently in severe shock. Coma and signs of focal brain damage are rare except in the moribund patient and even in these patients it may be possible to exclude other causative factors (fat embolism, traumatic concussion, etc.), Lauson and associates (10) have shown that a marked reduction in re- nal blood flow occurs in shock, and the;/ present evidence that prolonged shock ms.y result in renal failure. Similar evidence has been derived from the study of posttraumatic renal insufficiency in this Theater (4.). These findings strongly suggest that shock may produce renal ischemia of such severity that irreversible renal damage may result if shock is of sufficient duration. Some evidence exists that severe shock may result in cardiac damage in rare instances, Burnett, Bland and Beecher (ll) found electricardiographic abnormalities in five out of 30 cases studied within a short time after injury; Post-mortem evidence of cardiac fail- ure may be found in patients who have exhibited severe degrees of shockj however, such findings may depend upon renal failure and hydremia rather than upon damage to the heart per se. Kihlsteadt and Page (12) have re- ported evidences of disturbances in cardiac function in terminal hemorr- hagic shock in dogs. The foregoing discussion does not imply that a single causative fac- tor suffices to explain all aspects of the pathogenesis of traumatic shock nor that the problem of shock is completely understood. Our knowledge is far from complete in many resnects, e.g.: The mechanisms by which severe infections bring about peripheral circulatory failure; the local vascular 27 Resuscitation end Preoperative Care of the Severely Wounded (The Patho- genesis of Wound Shock, contd) responses to diffuse peritoneal contamination; the importance of fat em- bolism in the production of shock and early death'; the cellular metabolic changes wnlch result irom prolonged snook. However, in preoccupation with unknown factors the practical application of accepted concepts must not be neglected. EVALUATION OF THE CAUSATIVE FACTORS IN WOUND SHOCK We believe the following to be the most important causes of the shock which occurs in battle casualties: 1. Hemorrhage from the traumatized area. 2. The loss of plasma or plasma components in the traumatized or contaminated area. a. Exudation or transudation from inflamed serous surfaces under the influences of mechanical and chemical trauma and beginning in- fection, b. The loss of fluid into the tissues adjacent to the area of greatest trauma or due to the action of chemical irritants. 3. Additional factors related to certain types of injur;/'. a. Cardiopulmonary dysfunction associated with wounds of the thorax. b. Loss of vasomotor reflexes associated with lesions of the spinal cord. c. Fat embolism resulting from trauma of bone or adipose tis- sue, 4. Blast injury of lungs and abdominal viscera. 5. Overwhelming infection. Hemorrhage from the Traumatized Area In severely wounded battle casualties, hemorrhage is by far the most important factor in initiating the circulatory disturbances which charac- terize shock. Furthermore, when severe shock is observed, it may be as- sumed that a relatively large volume of blood has been lost, Blalock (13) has shovm that hemorrhage is capable of producing shock in dogs which is closely related to the shock produced by other means. This does not imply that other factors may not be involved, but hemorrhage per se, if severe, vd.ll produce all the clinical and physiological manifestations of severe traumatic shock. 28 Resuscitation and Preoperative Care of the Severely Wounded (Evaluation of the Causative Factors in Wound Shock, contd) The rate at which blood is lost is important in determining the clin- ical manifestations of hemorrhage. Blood loss msy be so rapid that an immediate reduction in the circulating blood volume occurs and shock (aside from syncope) is manifest promptly. If on the other hand hemorrhage is loss rapid, the circulation nay remain at a relatively normal level for some time and manifestions of shock fail to appear until a decrease in the circulating blood volume occurs. The severity of the hemorrhage bears an important relation to the evacuation of battle casualties; severe hemorr- hage that occurs rapidly will greatly shorten the time during shich suc- cessful shod: therapy may be accomplished. If prompt evacuation cannot bo effected death may occur before such, patients reach the Field Hospital, Conversely, if severe or profound shock is present within one to two hours after injury it may be, assumed that severe hemorrhage has occurred as a result of the injury. Blood loss has been determined in various types of wounds (l). The following wounds are in order of increasing blood loss: abdominal wounds, extremity wounds without fractures, traumatic amputation; thoracic wounds, and extremity wounds with major compound fractures. The Loss of Plasma or Plasma Components in the Traumatized Area a. Exudation and transudation from inflamed serous surfaces under the influences of mechanical and chemical trauma and beginning in- fection. Tile local loss of fluid into a contaminated peritoneal cavity comprises an important means whereby fluid is lost from the blood stream with a consequent reduction in the circulating blood volume. When con-* lamination is widespread and the contaminating agent highly irritating, this loss may be excessive. The extremely high mortality which has been observed in association with contamination of a pleural cavity by stomach or bowel contents offers hurther evidence of the importance of contamina- tion and infection in the production of shock. Such patients often die within a short time after operation v/ith clinical evidence of shock in spite of the fact that replacement therapy brought about a satisfactory response during the preoperctive period. Likewise, the role of diffuse peritoneal contamination in increasing the severity of shock in the pre- sence of evisceration of bowel has proven to be of interest. VJhen simple evisceration exists without peritoneal contamination, shock is often sur- prisingly mild in degree and the response to therapy is much more prompt and sustained then when there is coexisting diffuse peritoneal contamina- tion. See cases numbers 1, 2 and 3. It is evident that the degree and extent of injury, which includes peritoneal contamination, is of more im- portance in determining the degree of shock than is the simple mechanical existence of eviseration. (See section on "Traumatic Evisceration", page 162 .) 29 Resuscitation -and Preoperative Care of the Severely Wounded (Evaluation of the Causative Rictors in Wound Shock, contd) Changes which occur in the splanchnic capillary bed due to ir- ritation appear to be of some importance in reducing the effective cir- culating blood volume in those cases with severe peritoneal contamination. Mann (14.) pointed out that mechanical trauma to the bowel is associated with an increased capacity of the splanchnic vascular bed and observations at operation in cases with diffuse peritoneal contamination indicate that a considerable volume of blood may be pooled in dilrted and engorged ven- ules and capillaries. Furthermore, this factor may be increased dArina operation through the necessary handling of the bowel which, attends sur- gery. b. The loss of fluid into the tissues adjacent to the area of greatest trauma,or duo to the action of chemical irritants. The swelling adjacent to a wound is partially due to the pre- sence of serous fluid which has leaked -from vessels which have been dam- aged but have not been torn asunder. Similar loss occurs into the wall of the bowel under the influence of the irritation of peritoneal contam- ination or bacterial growth. In war wounds extensive laceration and mang- ling of tho bowel may occur and serous fluid (as well as blood) loss into such tissues may be considerable, Strangulation of the blood supply has proved to be a very uncommon cause of segmental edema and necrosis of the bowe11 wall even In cases with evisceration. In paralytic ileus which follows peritoneal contamination or in- fection, the failure of tho small bowel secretions to reach the colon pre- vents the normal reabsorption of water from the bowel. Actually, moderate dehydration may exist whether vomiting has or has not occurred. 2rora the foregoing discussion it may be seen that changes v/hich occur within the contaminated peritoneal cavity following injury favor the loss of plasma or fluid from the blood stream. Thus, if preceding or con- comitant hemorrhage is slight, these factors may load to hemoconcentration• In battle casualties the tendency towards heraodilution secondary to hemorr- hage must always be remembered; only an elevated hematocrit will be of aid in evaluating the presence of, or the degree of plasma loss. A similar tendency for the hematocrit to be elevated is observed in burns, crush injuries and severe contusive injury. In massive soft tissue infections (anaerobic nyositis or cellulitis) the hemoconcentrating effects of tras- udation and exudation are often offset by previous hemorrhage. Additional Factors Related to Certain Ames of Injury Aside from hemorrhage and the loss of blood components from the site of injury, other factors may be on considerable importance in maintaining shock or increasing the severity thereof. The presence of multiple wounds may invoke deleterious action of several factors upon the state of the wounded man; the degree of shock being influenced by the summation of these factors. 30 Resuscitation and Preoperative Care of the Severely Wounded (Evaluation of the Causative Factors in Wound Shock, contd) a. Cardiopulmonary dysfunction associated with Wounds of the thorax. The insult imposed upon the circulation by open wounds of the chest, hemopneumothorax and pressure pneumothorax; may greatly increase the degree of peripheral circulatory failure. If severe, these factors may be of primary importance in the production of shock due to the loss of normal cardiorespiratory function of the thoracac cage which results in decreased cardiac filling and decreased blood flow. Hemorrhage is frequently severe in thoracic injuries; in combination with the factors just mentioned it may be responsible for profound shock. When hemopneu- mothorax, atelectasis and pulmonary injury interferewith adequate oxygen exchange severe degrees of anoxia may result; if severe shock also exists the effects constitute an immediate threat to life. The effect of pleu- ral contamination has been mentioned. Occasionally severe anoxia may be associated with an elevated blood pressure even though unmistakable signs of shock are present. b. Loss of vasomotor reflexes associated with lesions of the spinal cord. Some interesting observations have been made upon patients with traumatic lesions of the spinal cord. These patients have been observed to exhibit hypotension which is not analogous to that seen in shock. How ever, lack of understanding of the circulatory dynamics in such cases nay lead to mistakes in therapy — particularly excessive delay of operation and overtransfusion. The level of the blood pressure is usually only moderately or slightly depressed. In general, the higher the lesion of the spinal cord the lower the blood pressure level; if considerable hem- orrhage has also occurred the blood pressure may be very low. One of the outstanding characteristics of the blood pressure is the difficulty with which it can be restored to a level which approaches normal. Fullness of the peripheral veins, particularly of the lower extremities may be strik- ing. It appears that these disturbances in circulatory dynamics which ar< observed in such patients are due to the loss of reflex vasomotor activ- ity below the level of the lesion as well as to the decrease in venous re- turn due to muscle paralysis. In high spinal cord lesions the efferent limb (thoracolumbar sympathetic outflow) of the carotid sinus and aortic body vasomotor reflexes become inactive due to interruption of the reflex at the level of the lesion (15). The response to hemorrhage in these cases is similar to that which is seen in the experimental animal follow- ing sympathectomy (16). c. 5ht embolism due to trauma of bone or adipose tissue. The importance of fat embolism in the pathogenesis of shock is poorer understood. Studies of tissues after death indicate that fat em- boli are frequently observed in the pulmonary vessels following severe 31 Resuscitation and Preoperative Care of the Severely Wounded (Evaluation of the Causative factors in Wound Shock, contd) trauma. The relation of bone trauma to fat embolism is well recognized, but injury to soft tissues may result in fat embolism (17). In a series of 51 autopsies performed by a member of this Group in the Field Hospi- tals, the microscopic reports have been reviewed. In 31 cases in which sections of lung were examined there were 17 cases (5/., 87) of pulmonary fat embolism. In five cases (16$) the embolism was described as "severe" by the pathologist; in five additional cases, as "moderate". It is of interest that severe embolization was noted as soon as seven hours after injury; the longest survival in a patient with moderately severe fat em- bolism was approximately 130 hours. It is noteworthy that respiratory difficulties neve common, that in the patients who died a short time af- ter injury there were indications of central depression of respirations and that pulmonary edema and congestion were more outstanding in these patients who lived upwards to 130 hours. It is not implied that fat em- bolism was the sole cause of death in these cases. Thus, pulmonary fat embolism appears to be common in battle casualties. It seems, however, that the pulmonary circulation prevents fat from reaching the systemic arteriolar bed except in the instances of severe embolization. In these cases it appears that fat emboli were in- strumental in producing shock and death. (See Case 9.) 'The clinical recognition of fat embolism has been difficult, Methods for demonstrating neutral fat in the urine and sputum were not available and the usefulness of these methods in the diagnosis of fat em- bolism is not known. In a patient who responds slowly to shock therapy or exhibits a sudden fall in blood pressure (perhaps with evidences of central nervous system involvement) the tentative diagnosis of fat embo- lism may be made when other factors fail to explain the observed clinical picture. In the absence of blast injury, persistent cyanosis which is not relieved by 100% oxygen therapy may be indicative of pulmonary fat embolism; scattered fine or medium moist rales may be due to pulmonary fat embolism but are often of little differential value. Patients with severe fractures are particularly liable to exhibit a fall in blood pres- sure following movement of the fractured extremity; fat embolism may of- fer a partial explanation of this fact, although the changes may be so prompt as to suggest a neurogenic or syncopal feature. Blast In.iurv to Lungs and Abdominal Viscera Involvement of the lungs has proven to be more common than the in- volvement of other organs in our experience, -but cases have been seen in which the major damage due to blast has involved the abdominal organs, (Case No. 8) Clinically, it may be impossible to differentiate the ef- fects of pulmonary blast injury from those of severe pulmonary fat embo- lism. Associated blast injury may render successful- shock therapy dif- ficult but the pathological physiology of shock in blast injury is not 32 Resuscitation and Preoperative Care of the Severely Wounded (Evaluation of the Causative Pb.ctors in Wound Shock, contd) completely understood. In many instances the predominant injury appears to involve the smaller blood vessels in the traumatized area, though lacerations of the bowel may be produced. Overwhelming Infection The most severe infections which occur as the result of wounds are anaerobic myositis (gas gangrene), anaerobic cellulitis and diffuse peri- tonitis , In the severe lacerating and destructive wounds of modern warfare anaerobic infection may occur relatively early and progress rapidly in ischemic and devitalized muscle. Evidences of peripheral circulatory failure form a common part of the clinical picture in such cases and are attributed to the exotoxins which are produced by the invading organism. However, the exact influence which these toxins exert upon the cardio- vascular system is not completely understood. Discussion now appears to be centered upon the cuestion as to whether or not the heart or the peri- pheral vascular bed is primarily involved. Whatever the exact cause proves to be, experience has shown that the peripheral circulatory failure so in- duced responds poorly to replacement therapy. The control of shock in such cases depends upon early and adequate surgery — not upon transfusion alone. The loss of fluid (exudate or transudate) into the contaminated peri- toneal cavity has been discussed; further aspects of the relation of shock to peritoneal soiling and peritonitis will be discussed in the section, "The Problem of Shock Therapy in Abdominal Wounds", page 122 , THE MANAGEMENT 0? SHOCK IN FORWARD AREAS Hie Use of Blood and Blood Substitutes Preoperative replacement therapy attempts to restore circulatory dynamics to a level which will permit the successful accomplishment of initial surger; without such preparation, the scope of forward surgery would be greatly limited. The disturbances in circulatory dynamics which characterize wound shock have been discussed. At the present time the most important fac- tor in the initiation of these disturbances is believed to be the loss of blood or plasma from the vascular system at the site of injury. The rationale for the present transfusion therapy of shock is based upon this concept. The aim of shock therapy is to restore the circulating blood volume by returning to the blood stream those constituents which have been lost as the result of injury. It is furthermore important to institute replacement therapy as soon as possible after injury so as to minimize the deleterious effects which severe shock imposes upon the wounded. 33 Resuscitation and Preoperative Care of the Severely Wounded (The Manage- ment of Shock in Forward Areas) The prevention of severe shock by early replacement therapy is much more likely to be successful than is the treatment of shock in its severe or late stages (13). Therefore, forward medical installations are in the ideal situation to provide treatment for shock at the time when the great- est benefit will be derived therefrom. To carry out such therapy adequate1 iy it becomes necessary to provide large ouantities of citrated blood and plasma for use in the forward hospitals. The recognition of the importance of early and complete replacement therapy in shock has resulted in two important advances in military sur- gery, namely: (l) The provision of adequate quantities of lyophilized plasma to all medical echelons, particularly those in the immediate combat zone. (2) The establishment of blood banks and facilities for distribu- ting large quantities of citrated blood to forward hospitals. Without such help, the adequate therapy for shock in the severely wounded would have been virtually impossible. The surgery of major trauma under field conditions is, at best, an exacting problem; in the patient suffering from shock, initial surgery is greatly handicapped. The object of adequate shock therapy is to mini- mize as much as possible the restrictions which severe traumatic shock, impose upon the surgeon. Of overwhelming importance in attaining this end is the transfusion of reconstituted plasma and whole blood; all other therapeutic measures are of secondary importance. Once a clinical appraisal of the patient has been accomplished it is possible to decide within approximate limits the degree of shock which exists end plan replacement therapy accordingly. Study of Table I*indi- cates the approximate amount of replacement therapy that vdll be neces- sary to treat various degrees of shock. These figures are more or less empirical and based only upon individual clinical judgment — not upon accurate measurement of the degree of oligemia. The procedure in treatment of moderate and mild degrees of shock us- ually follows a rather uniform pattern. The patient is admitted; his blood pressure and pulse are recorded and a brief survey of the degree of shock is made. If there is no evidence of injury to the spinal cord and shock is not severe, the patient's clothing is removed while minimiz- ing his exposure to cold. If possible, it is preferable to move the pa- tient to another litter which has been properly dressed with clean, dry blankets. The patient remains in the recumbent position and Is gently lifted while the new litter is placed beneath him. Having made the pa- tient as comfortable as possible, the number and location of the wounds are noted and a physical examination performed in an attempt to decide the probable extent of the trauma. Once this has been accomplished, a large (18 gauge) needle is inserted in an arm vein and a sample of blood obtained for cross-matching; the administration of plasma is started im- mediately through this needle and is continued until matched blood is * See page 12U • Resuscitation and Preoperative Care of the .Severely Wounded (The Manage- ment of Shock in Tbrward Areas) ready. During the infusion of plasma, wounds are checked for bleeding; the urine is examined and a Levin tube is passed. The presence or ab- sence of blood in the gastric contents is noted on the shock record. Oc- clusion of sucking wounds of the chest with vaseline and gauze dressings must be done if it has not been done previously. If the degree of shock is mild or moderate, sufficient improvement in the clinical condition will roentgenographic studies to be carried out and the patient should be ready for surgery within 60 to 90 minutes, having received approximately 500 c.c, of plasma and 500 to 1000 c.c. of citrated blood. The administra- tion of blood is continued as operation is begun and additional matched blood is held in reserve for use during surgery. Even in these cases of mild or moderate shock, the average patient will receive an additional 1000 c.c, during operation. Only by this means may preoperative therapy be supplemented and the unavoidable blood loss during surgery be corrected The routine Infusion of plasma and cross-matching for transfusion offers several advantages in the care of patients even with no manifest shock or mild shock in forward hospitals for the following reasons j 1. The most effective means of shock therapy are utilized promptly to prevent the development of shock or, more importantly, to prevent the progression of mild into severe shock. 2. It constitutes a means of compensating therapeutically for the difficulty in accurately estimating the interplay to oligemia and peri- pheral vasoconstrictor activity. Thus, sudden collapse is largely pre- vented in this group of patients. 3. Early replacement therapy, by further stabilizing the circula- tion, increases the ability of the patient to withstand blood loss and anesthesia during operation. A. The prompt institution of shock therapy allows greater flexi- bility in selecting from the preoperative ]?ard those patients who are ready for surgery. This is of extreme importance during rush periods and allows the surgical teams to proceed with the task at hand so as to curtail the preoperative delay for all patients. We are aware of the fact that many patients who exhibit only mild or moderately severe shock may improve considerably without the benefit of replacement therapy, simply when allowed to remain quiet. It is our preference, however, to provide some replacement therapy at first; if conditions are such that operation will be delayed, transfusion may be discontinued when it is judged to be sufficient. Often, under these conditions, the needle in the vein is kept open by the slov; administra- tion of,saline or glucose and saline solutions. Whereas the treatment of mild or moderate degrees of shock is usu- ally not difficult, the successful treatment of severe or profound shock 35 Resuscitation and Preoperative Care of the Severely Wounded (The Manage- ment 'of Shock in Forward Areas, contd) is often extremely so. All evidence indicates that the oligemia may be extreme when the blood pressure has fallen to excessively low levels; after a loss of 50$ of the normal blood volume the average systolic blood pressure will usu- ally be below 50 ram. (A). The patient in severe or profound shock will usually have an admission systolic blood pressure of 70 mm, or below, though occasionally it nay be higher. Such patients reouire prompt and vigorous replacement therapy to provide a circulating blood volume which will prevent irreparable damage to body tissues and death. Furthermore, patients in severe shock frequently receive relatively large quantities of plasma prior to reaching the field hospital with a conseouent further depression of the hematocrit, h/hen the dilution effect of large volumes of plasma is added to the physiological response to hemorrhage, the hom- acrit value has been observed to fall as low as 20 to 22 volumes percent. Herein lies the chief limiting factor in the use of plasma in the severely wounded, and whole blood is the agent of choice in the treatment of severe posthemorrhagic shock. If anemia is severe the effects of anemic anoxia nay be appreciable even though the blood volume and cardiac output are not decreased. Study the effects of hemorrhage in the wounded has shown that hemoglobin loss is consistently greater than blood volume loss; the greatest deficiency is not in the plasma constituents but in hemoglobin (a) ♦ If the patient exhibits severe shock on admission, a rapid search is made for continuing hemorrhage and blood (low-titer*, Group 0) is started immediately (except in such an emergency all blood is cross- matched prior to its administration). A rapid flow must be maintained so that the patient will receive 500 c.c, of blood within the first 15 to 20 minutes (as much as 1000 c.c. of blood have been given in 15 min- utes without deleterious effect). In the cases with most profound shock, it is advisable to start a second transfusion in the opposite arm or a saphenous vein using matched blood as soon as it becomes available. Cannulisation of a vein should be performed without delay if constric- tion and collapse of the vessels precludes successful venipuncture. In- closing an arm in a warm moist towel has proved to be of great assistance in accomplishing venipuncture even in severe shock. Our experience indicates that patients survive only a very short time once the systolic pressure falls below A0 to 50 mm. of mercury. In other words, a stabilization of the circulation at such a low level rarely occurs; the pressure continues to fall until death results or spontan- eous improvement occurs through cessation of bleeding and hemodolution. * Iso-agglutinin titer 1:6A or below. 36 Resuscitation and Preoperative Care of the Severely Wounded (The Llanage ment of Shock in /forward Areas, contd) V/hen excessively lov: blood pressures are observed the failure of the vaso- constrictor mechanism to compensate for reduced blood volume is often the result of severe or progressing hemorrhage snd the preceding period of in- tense vasoconstriction and shock tends to be of shorter duration than when blood loss has been slower. Consequently, v/hen shock is of relatively short duration the response tc vigorous transfusion may be prompt in spite of the fact that the blood pressure has reached an excessively lov/ level. Conversely, death may rapidly supervene in the absence of therapy. Rich- ard, s (3) mentions the importance of transfusion in restoring the adequacy of the vasoconstrictor mechanism — a rise in blood pressure may occur which is out of proportion to the volume of blood which is given initially Inspection of Table I ("The Problems of Shock Therapy in Abdominal Wounds”, page 122) indicates that a patient in profound or severe shock will receive between 2000 and 2500 c.c, of blood or blood substitutes prior to surgery. Likewise, he will receive two to three times as much whole blood as plasma. We do not believe this represents overtreatraent; the severe blood loss in battle casualties has been cited previously. Through preoperative replacement therapy an attempt is made to pre- pare the patient adequately for operation; ordinarily this means that the circulatory dynamics should be restored as nearly as possible to normal. Often this cannot be accomplished through replacement therapy alone and within practical limits, sufficient therapy is provided to allow the pa- tient to successfully withstand operation. The decision that a patient is adequately prepared for operation is a difficult one to make since it is impossible to evaluate clinically the interplay of such factors as oli- gemia and the vasoconstrictor mechanism. In this respect, clinical judg- ment is by far the best guide; one must not be led astray by normal blood pressure levels in the presence of tachycardia, thready pulse and clinical evidence of vasoconstriction. The intensity of vasoconstriction during the response to replacement therapy is not completely understood — usu- ally a rising blood pressure is associated with a fairly prompt increase in the peripheral blood flow; less frequently evidence of considerable re- duction in blood flow to the periphery persists oven when the blood pres- sure approaches normal levels. T!rom the practical standpoint, one must assume that the circulating blood volume has been adequately restored when evidences of peripheral vasoconstriction cease to exist and the blood pressure has approached nor- mal levels. To accomplish this, blood and plasma are given in the amounts required (within certain time limitations to be discussed later). In re- spect to replacement therapy such a patient is deemed to be ready for surgery. It must be remembered that the patient who has partially recov- ered from shock is apt to be in a changing and delicate circulatory bal- ance, and seemingly minor factors such as loss of body heat, further hem- orrhage, anesthesia, etc,, may result in a sudden fall in blood pressure. 37 Resuscitation and Preoperative Care of the Severely Wounded (The Manage- ment of Shock in Forward. Areas, contd) Therefore, it is wise, if in doubt as to the adequacy of therany, to err in the direction of liberal replacement to provide additional stabiliza- tion of the circulation. Two factors (aside from agonal, shod:) interfere greatly with the ef- fectiveness of transfusion therapy in the management of shock. These factors are continuing hemorrhage and beginning virulent infection. Practically all severely wounded patients continue to lose blood in varying amounts during the preoperative period. This is of greatest im- portance when the blood loss (not controlled by simple first aid measures) proceeds at a rate sufficient to render transfusion therapy ineffectual. Such blood loss nay be from a single large vessel or, more commonly, from many smaller vessels which have been lacerated. The control of the overwhelming infection remains as one of the great- est problems with which military surgeons are confronted. Those infec- tions which have proved to be of greatest importance in immediately threat- ening life ares massive infection of the peritoneal and pleural cavitiesj anaerobic myositis and anaerobic cellulitis. Clinical experience indicates that the peripheral circulatory failure which is seen in the presence of severe infection is very often difficult to treat successfully hy means of replacement therapy. It is believed that a poor response to vigorous shock therapy (2000 to 2500 c.c. of plasma and blood given within one to two hours) is strong- ly indicative that significant hemorrhage is continuing or that fulminat- ing infection is beginning. Unfortunately, these two condition often co- exist. Since neither threat to life is amenable to replacement therapy alone, early surgery is indicated and every attempt is made, through in- telligent therapy and triage, to limit the preoperative delay to two to three hours. All such patients constitute difficult problems during sur- gery and means must be available to supply relatively large quantities of blood during operation. In this respect an interesting trend has been noted as surgeons have become more familiar with the problems of war sur- gery. Llany careful observers feel that the preoperative delay should be curtailed as much as possible (with concomitant vigorous replacement ther- apy) in abdominal wounds and believe that successful resuscitation can be carried out during surgery. This practice has several advantages, chief of which are earlier control of contamination and infection, and a reduc- tion in the total amount of blood lost. However, it may not be possible to give sufficient plasma and blood within a short time (20 to 30 minutes) to prevent fatal collapse upon the induction of anesthesia, particularly when massive hemorrhage has occurred. 38 Resuscitation and Preoperative Care of the Severely Wounded (The Manage- ment of Shock in Forward Areas, contd) In summarizing our views on the therapy of severe wound shoe, we be- lieve that the capabilities of properly designed replacement therapy will be exhausted within two to three hours and that in no case should opera- tion be wilfully delayed beyond this period. Therapeutic Problems Peculiar to Certain Types of Wounds Thoracic Wounds. In the control of associated chest wounds it is manda- tory that cardiopulmonary physiology be returned as nearly as possible to normal. Fortunately, direct and successful moans are available to ac- complish this. They are: occlusion of sucking wound; the aspiration of blood and air from the pleural spaces; intercostal nerve block (procaine); endotracheal aspiration and the administration of oxygen. (See "Resusci- tation in Thoracic Casualties", page U25) If the wound is not thoraco- abdominal in type, autotransfusion has been routinely employed when thor- acentesis results in the removal of a significant quantity of blood. The problem of shock therapy in the average thoracic wound has not proved to be difficult when such measures, are utilized. In the management of chest wounds the volume of transfusion therapy is held to an effective minimum to prevent excessive bleeding into damaged pulmonary tissues or the de- velopment of pulmonary edema. Having been aware of these possible compli- cations we have observed clinical pulmonary edema very infrequently during the preoperative period even in patients with apparent pulmonary blast injury. Most chest injuries require that the patient be placed on his side during operation and cannulization of a saphenous vein is helpful in insuring continuity of transfusion therapy during operation; the position of the patient may render transfusion unsatisfactory by the antecubital veins. Extremity Wounds with Fractures. The relatively high incidence of pul- monary fat embolism in patients with severe trauma to bones has been noted In addition to insuring adequate replacement therapy and reducing the blood loss by first aid measures, it appears that means of controlling fat embolization should be employed if possible. At the present time it appears that the only adjunct to surgery which may prove worthwhile is the application of an effective turniquet during the time that debridement and manipulation of injured extremities are being carried out. Wounds of the Sninal Cord. In the presence of lesions of the spinal cord it should be remembered that a sustained rise of blood pressure may be difficult to attain even with the use of excessive quantities of blood and such a patient may be exposed to the dangers of massive group 0 blood transfusions unnecessarily. In general, the care of the patients with high spinal cord lesions is discouraging. 39 Figure Us A Patient In the Shook Ward of a Field Hospital Resuscitation and Preoperative Care of the Severely 'wounded (The manage- ment of Shock in Forward Areas, Gontd) I.Iaxillofacial Wounds. The chief therapeutic problem in such wounds is the maintenance of an adequate airway. Suction equipment for clearing the oropharynx should be available at all times. Emergency tracheotomy may be required and means should always be at hand to accomplish this without delay. The Use of means Other Tnan Replacement Theranv in the Management of Shock There are several important adjuncts to transfusion therapy in the treatment of shock. These ares placing the patient on a ,clean, dry, properly dressed litter to curtail loss of heat from the body; the con- trol of pain by adjustment of splints and the judicious use of morphine; contolling blood loss as much as possible by pressure dressings and the application of effective tourniquets when necessary; gastric drainage by Levin tube; and last but not least, the avoidance of excessive moving or manipulation to insure as complete rest as possible. A patient always responds better if he is made comfortable. Oxygen therapy (BLB mask or nasopharyngeal catheter) is useful in thoracic injuries as stated above, and is of great value in overcoming the anoxic anoxia of morphinism. Beecher (19) has emphasized the delayed absorption of subcutaneous morphine in severe shock and the intravenous • I route is employed in administering morphine (1/8 to 1/6 grain) to all such patients. Great care, however, should be used in giving any morphine in the presence of profound shock because the full absorption of previous doses may result in depression of respiration only after resuscitation has been in progress for quite some time. It has been the policjr to ad- minister oxygen in all cases of profound shock, and it is our impression that it is of value if used early and in high concentration. Often the ashen-grey cyanosis of profound shock will clear considerably with the administration of oxygen -- in other coses, clinical evidence of improve- ment may not follow oxygen therapy. The external application of heat has been studiously avoided, par- ticularly in the presence of the more severe degrees of shock. The loss of vasoconstriction and the increase of blood flow which follows the warm- ing of an extremity can only result in a decrease in the volume of blood which is available to maintain the central circulation (3)(18). Further- more, considerable evidence exists that tissues survive anoxia longer when the temperature is reduced and the skin and muscles are less sensitive to oxygen lack than the brain and other organs. However, chilling and loss of body heat must be avoided since it is poorly tolerated by the patient in shock. At the present time it is generally agreed that elevation of the feet (”shock position”) is a valuable adjunct in the treatment of shock. A Resuscitation and Prooperative Caro of the ' everely wounded (The Llanage- ment of Shock in Forward Areas, contd) rather prompt rise in blood pressure and clinical improvement follows elevation of the foot of the litter in cases with mild shock. Richards (3) reports a similar finding and reports the significant observation that the pressure in the right auricle does not rise -when the patient is placed in the shock position. He believes that the improvement is due to increased efficiency of the central circulation supplying the brain. we believe elevation of the feet has its greatest usefulness An im- provin';- the circulation under conditions in which the venous system con- tains a relatively large quantity of blood; namely, (l) those cases ’with traumatic myelitis and (2) during the administration of general anes- thesia. Several instances have come to our attention which substantiate the usefulness of the shock position in these conditions and we feel that it deserves emphasis as an adjunct to transfusion therapy in the control of shock during anesthesia, VJhen the patient remains upon an unsupported litter during operation the head and upper thorax often lie considerably above the level of the remainder of the body due to the presence of arm boards and sagging of the litter. Elevation of the feet under such con- ditions has often resulted in a rise in the patient's blood pressure. In the treatment of profound shock the shock position is routinely employed as an adjunct to rapid transfusion therapy. In these cases it nay accomplish relatively little (3) and is never employed alone. The determination as to whether or not replacement therapy has been adequate is difficult because of the many factors which are involved. A sudden fall in blood pressure with the induction of ‘anesthesia is of prac tical importance in indicating that replacement therapy has been incom- plete; death in the immediate postoperative period without sustained re- covery from shock affords conclusive evidence that replacement and surgi- cal therapy have failed to halt the inexorable effects of a lethal wound. Inadequate or unsuccessful shock therapy usually depends upon one or more of the following factors? 1. Failure to recognize and to treat adequately incipient shod 2. Failure to analyze critically the clinical response to therapy with consequent inadequate replacement. 3. Transfusion at an ineffectual rate, particularly in relation to a failure tq control external bleeding by effective first aid measures A. Poor triage and excessive delay or surgery in patients who re- spond poorly to replacement therapy because of progressive internal hem- orrhage and beginning severe infection. Resuscitation and Preoperative Care of the Severely Woundea (The Manage- ment of Shock in Forward Areas, contd) 5. Excessive delay in evacuation or in the institution of adequate therapy. Irreparable cellular damage due to the combined effects of pro- longed and severe shock and beginning infection. In evaluating the cause of death in the severely wounded a great many factors appear to be concerned. During the postoperative period, shock is a very frequent manifestation of impending death in such patients but it may be impossible to determine whether shock is the actual cause of death or simply indicative of a widespread disintegration of metabolic functions. For further discussion of irreparable renal damage which oc- curs foil.owing severe shock, see "Posttraumatic Renal Failure”, page 758 Likewise, the section MThe Problems of Shock Therapy in Abdominal Wounds”, page 122, deals with the relation of the severity of shock to mortality rate. It must always be remembered that early and adequate surgery is in itself a most important and final means of controlling shock by effect- ively stopping blood loss and limiting the ravages of infection through careful debridement and closure of wounds of the gastro-intestinal tract. It is obvious that preoperative care and surgery are mutually interdepend- ent — neither alone is sufficient and the two must be combined and cor- related to the highest degree if the severely -wounded patient is to sur- vive. SUMMARY 1, The pathogenesis of wound shock is discussed briefly in rela- tion to the present concepts of the fundamental circulatory disturbances which follow injury. 2. Factors which have been observed to play a role in the causa- tion of shock in wounded men are discussed. 3. A detailed account is given of the management of shock in the severely wounded. A. Failures in shock therapy are considered briefly. CONCLUSIONS Battle casualties have received blood and blood substitutes on a large scale in order to restore the circulating blood vihlume and thus minimize the incidence and severity of shock during the accomplishment of initial surgery. The blood loss in such patients is apt to be con- siderable; often it may be extreme and in such instances vigorous re- placement therapy is required. Through the use of blood and blood Resuscitation and Preoperative Care of the Severely Wounded (The Manage- ment of Shock in Forward Areas, contd) substitutes, the scope of initial surgery has been widened to include many patients who have been resuscitated from severe or even profound shock. The surgical care of the less critically wounded, has by like means, been greatly facilitated. Beginning fulminating infection and continuing hemorrhage have proven to be the most important factors in limiting the effectiveness of trans- fusion therapy. These factors, acting singly or together, are fre'quently responsible for prolonged or severe shock which proves fatal in spite of liberal replacement therapy. BIBLIOGRAPHY (l) Blalock, A.s Experimental Shock: The Cause of Low Blood Pressure Produced by Muscle Injury, Arch, Surgery, 20; 959-996, 1930. (2) Parsons, E,, and Phemister, D, B,; Hemorrhage and ’’Shock” in Traumatized Limbs, Surg., Gynec. & Obstet,, 51: 196-207, 1930 (3) Richards, D. V/. Jr,,: The Circulation in Traumatic Shock in Man, Harvery Lectures 39 : 217-253, 1943-1944. (4.) The Board for the Study of the Severely Wounded, MTO 1944--194-5, Data in preparation. (5) Phemister, D, 3,: The Mechanism and Management of Surgical Shock, Jour. Am. Med. Assoc,, 127: 1109-1112, 28 April 1945. (6) Moon, 5T, H,: Shock and Related Capillary Phenomena, New York, Oxford University Press, 1938. (7) Lalich, Joseph L.: Hematocrit and Plasma Protein Findings in Battle Casualties Treated in a Field Hospital. Report submitted to The Sur- geon, MT0USA, July 1944. (8) Stead, E. A. Jr., and 7/arren, J. V.: Archives of Surg, 50:1, Jan, 1945. (9) Symposium on Shock: I Statement of Subcomittee on Shock, Division of Medical Sciences, Nation Research Council, The Med Bull of NAT0USA 1; 6. pg 2. (June 1944). (10) Lauson, H. H,, Bradley, S. E., and Goumand, A.: The Renal Circula- tion in Shock. Jour. Clinical Investigation, 23: page 400, May 1944. hh '• ;esus citation and Preoperative Gare of the Severely V/ounded (Bibliography contd) (11) Burnett, B. H., Bland, E, 7., and Beecher, H. K,t Jour, Clin. Invest. ■September 19$5 (in press). (12) Ilohlstaedt, K, G,, and Page, I, H.s Terminal Hemorrhagic Shock, Surgery, 16: $30-$65, September 19$$. (13) Blalock, A.: The Principles of Surgical Care. St Louis, C. V. Mosby, 19$0, (]$.) Bonn, F. G.: Surgery, Gynec fc Obstet, 21s $30, 1915, cited by (8) Above, (15) Best, G, H., and Taylor, N. B,: The Physiological Basis of Medical Practice, Baltimore, Jilliams and Wilkins, Third Edition, 19$3« (16) Freeman, If., Shaffer, S. A., Schecter, A. E., and Holling, H. E, J.* Tlie Effect of Total Sympathectomy on the Occurrence of Shock from Hemorrhage, Jour. Clin. Invest, 17: 359, 1938, (l?) Personal communication, Captain Joseph G. Rothenberg, 1st Mob. Med, Lab, (IS) Duncan, G. V/., and Blalock, A.: Archives Surgery, $5: 183, 19$2, (19) Beecher, H, K,: Personal communication. APPENDIX ILLUSTRATIVE CASE RECORDS Case I -umber 1 WIA by shell fragments; arrived in the Field Hospital one hour after injury. Blood pressure O/O. Evisceration of 90$ of the snail bowel through a large defect in the right lower abdominal wall. Large amount of blood oozed from the abdominal wound. Patient was given 1250 c.c. of plasma and 2000 c.c of blood, but practically no res onse was observed. One and one-half hours after admission the patient was taken to surgery; B/P. O/O. Bleeding was in progress from the mesenteric vessels and the inferior epigastric artery. There was massive contamination of the peri- toneal cavity due to multiple lacerations of the bowel. Patient expired on the operating table. Resuscitation and Preoperative Care of the Severely Wounded (Appendix, contd) Comment: This case indicates the overwhelming degree of trauma which had produced evisceration and the severe contamination of the peri- toneal cavity. These facts plus the progressive hemorrhage were respons- ible for the severe shock which did not respond to liberal replacement therapy. The patient had a blood pressure -’hlch was too low to measure for more than one and one-half hours; the implications of this fact in relation to resuscitation therapy require no comment. Case Humber 2 P.0,IT, Patient admitted with evisceration of small bowel, B.P. O/O. The tine of injury was not known. Perforating wound of the abdomen. Re- mained in shock ward for five hours during which tine he received only 250 c.c. of plasma, 10CC c.c. of blood and 1000 c.c of 5% glucose in sal- ine solution. At the beginning of surgery the blood pressure was 80/60. At operation there was severe contamination of the peritoneal cavity secondary to transection of the jejunum, and perforation of the splenic flexure of the colon. Bubbles of gas were noted in the "anterior abdom- inal wall”. The patient expired on the operating table. Comments This case illustrated two important points. First, the transfusion therapy was given at an ineffectual rate. 1250 c.c. of blood or blood substitutes is not sufficient therapy in the presence of profound shock, particularly when it is spread over a period of five hours. This amount of therapy should have been given in a period of 60 to 80 minutes or loss. Second, the preoperative delay was excessive in a patient who responded poorly to replacement therapy due to the presence of eviscera- tion and massive-peritoneal contamination in addition to probable anaer- obic infection of the abdominal wall. Case Humber 3 Penetrating wound of the abdomen with evisceration of small bowel. Patient was seen two hours after injury at which time the blood pressure was 120/80; shock was mild in degree. During two and one-half hours in the shock ward the patient received 250 c.c. of plasma and 500 c.c, of blood. Prior to operation the blood pressure was 146/70. At operation no peritoneal contamination was present, nor was there excessive bleeding. During surgery the patient was given an additional 500 c.c of blood. Pa- tient did well and was evacuated from the Field Hospital. Comment: This case illustrates the fact that evisceration of bowel had existed for two hours without the development of an appreciable de- gree of shock. Obviously the extent of injury was much less than in the Resuscitation and preoperative Care of the Severely Wounded (Appendix, contd) first two cases. The good prognosis in the absence of peritoneal con- tamination is fairly characteristic of this group of cases in contrast to those in which peritoneal contamination exists. The lack of serious hemorrhage is likewise of extreme importance. Case Number 4. Patient wounded in action at 1600 hours by shell fragment which penetrated the right hip. On arrival at the Field Hospital the blood pressure was 4-0/0, The patient was given 250 c.c. ob plasma and 1000 c.c. of blood. Surgery was started at 2000 hours; blood pressure 30/0, At operation the following diagnoses were made: fracture, compound, comminuted of the acetabulum, right, with severe destruction of the right ischium; multiple perforations of the small bowel and transection of the ileum; avulsion of the superior gluteal vessels, right ureter and sciatic nerve; perforation of the rectosigmoid colon. In addition, severe retroperitoneal anaerobic infection with gas formation was noted. The patient expired nine hours after operation. Case Number 5 WIA at 074-5 hours by shell fragments. On admission to the hospital the blood pressure was o/o and the patient was in profound shock. In spite of the administration of 250 c.c, of plasma and 1500 c.c, of blood the blood pressure remained at O/O, The patient was apprehensive and restless and there was severe abdominal pain; crepitus was present in the abdominal wall about the wound of entrance and about the missile which lay in the subcutaneous tissue, and the presumptive diagnosis of anaer- obic infection of the abdominal wall was made. At operation, started sir-: and one-fourth hours after injury, there were found multiple perfor- ations and transection of the ascending and transverse colon with tearing of the transverse mesocolon, multiple perforations of the jejunum, and avulsion of the lower third of the left kidney. The abdominal cavity was filled with foul-smelling dark fluid which contained bubbles of gas. The patient expired on the operating table at 14-30 hours. Comment: Both of these cases demonstrate the poor response to shock therapy in the presence of oven-helming infection as well as the rapidity with which anaerobic infection may become manifest in the presence of massive fecal contamination of the peritoneal cavity and retroperitoneal tissues. Resuscitation and Preoperative Care of the Severely Rounded (Appendix, contd) Case Number 6 P.O.W, Penetrating wound of the abdomen via the right buttock. Admission B.P, O/O. During four hours of shock therapy the patient re- ceived 2500 c.c, of blood but the blood pressure was never measurable. At operation AO00 c.c, of blood were present in the peritoneal cavity and active bleeding was in progress from the ri?Tht internal iliac vein and artery. The patient expired on the operating table. Comments The inability to attain effective transfusion therapy in the face of such progressing hemorrhage is obvious. Case Number-7 Received shell fragment wounds of the left lateral chest at the level of the tenth rib at 1215 hours, 9 October 194A* Admitted at 1900 hours in profound shock with blotchy, grey cyanosis of the legs. Prior to operation received 1000 c.c. of blood with poor response. At 2130 hours the B.P. was 80/60, pulse 100, and operation was advised. Upon moving the patient to X-ray the blood pressure fell considerably. At operation (2155-2330 hours) a badly torn spleen was prompter removed and 2000 c.c. of blood v/ere noted in the peritoneal cavity. On opening the lesser peritoneal sac the lacerated splenic artery was found to be act- ively bleeding. During the control of hemorrhage the blood pressure fell to 0/0 and 1500 c.c, of blood and 1250 c.c, of plasma were given during the remainder of the operation with a steady improvement in the condition of the patient; at the end of operation B.P. 92/50, P. 100, During the operation two perforations of the stomach were closed, the diaphragm was repaired and the sucking wound of the chest closed. The immediate post- operative period was stormy but the oatient was sent to the rear in good condition and was ultimately evacuated to the Z. of I, Comment: Another example of the need for early surgery in the pre- sence of continuing internal hemorrhage. Replacement therapy could never have been completely successful in the control of shock until hemorrhage had been stopped. Case Number 8 Injured by mine explosion at 1620 hours, 6 November 19A4* During evacuation the patient received 1750 c.c. of plasma, l/2 grain of mor- phine tartrate, and one c.c. of ephedrine^sulfate. Arrived at the Field Hospital at 2300 hours at which time the B.P, was 152/30, P. 128. In spite of the level of the blood pressure the patient exhibited signs of severe shock with cold skin and a rapid pulse of poor quality. There Resuscitation and Preoperative Care of the Severely Wounded (Appendix, contd) v;ere multiple penetrating wounds of the right thigh, left upper chest, right forearm and left hand. A constricting circular bandage was pre- sent about the right thigh and the right leg was cyanotic and cold. A transfusion of 500 c.c. of blood was given and operation begun. The lacerated right femoral vein was ligated and multiple wounds were de- brio ed . Those of the left chest were found to bo superficial. During operation the blood pressure fell to 50-60/0 and 1500 c.c. of blood were given. At the end of the operation the B.P, was 90-95 mm, systolic. Following operation the condition of the patient was fairly good in spite of the fact that he showed a persistent tachycardia (P. 150) and B.P, 80/60. On the day following operation the patient was given a transfus- ion of 1000 c.c. of citrated blood without reaction. Patient expired approximately 24- hours after operation. Autonsy findin~s; Gross; Fracture of the fifth rib in the left anterior axillary line; moderately severe contusion of the peripheral portion of the upper lobe of the lung. Congestion and edema of the lungs, particularly in the dependent portions; the bronchi and trachea contained a considerable quantity of frothy serous fluid. There was no evidence of contusion of the abdominal wall or penetration of a missile into the peri- toneal cavity. Throughout the extent of the small bowel there were num- erous subserosal ecchymoses which become progressively more numerous as the ternianl ileum was examined. In the terminal portion (35-AO cm.) of the ileum there were extensive subserosal hemorrhage and edema, end the wall of the bowell appeared to be undergoing necrosis, being dark in col- or, considerably distended, and covered by thin strands of fibrinopuru- leiit exudate. However, no perforations were present. The lumen of the bowel contained a large quantity of hemorrhagic, necrotic mucosal slough. The circulation through the smaller vessels appeared to have been severely compromised but there was no evidence of thrombosis of the larger mesen- teric vessels. microscopic examination confirmed the presence of necrosis of the bowel wall but there was no evidence of local thrombosis of the smaller vessels though all were engorged with blood. Sections of the lung showed hyperemia of the alveolar septa, scattered intra-alveolar hemorrhage with patchy atelectasis, end emphysema. A small number of fat emboli were seen in the capillaries of the alveolar septa. Comment; This case illustrates the damage which blast injury may produce in air containing viscera. The high admission blood pressure is of interest in relation to the previous administration of a large ouantity of plasma and ephedrine. In spite of the level of the blood pressure, the watient exhibited well marked evidence of shock from the clinical standpoint. Resuscitation and Preoperative Care of the Severely wounded (Appendix, contd) Case Humber 9 Incurred shell fragment wounds of left chest and right thigh at 1400 hours, 30 March. Arrived at the Field Hospital at 1820 hours after having received 1250 c.c. of plasma. Blood pressure at this time 98/AD; slight cyanosis was observed and respirations were labored. Multiple rib fractures noted along missile tract from shoulder region to exit wound at level of the 10th rib. Thoracentesis, left, resulted in removal of 1500 c.c. of blood and a small amount of air. Prior to operation the patient received 500 c.c. of plasma and 1700 c.c. of citratedblood. At 2135 hours, blood pressure 130/70 mm. Operation; (.Anesthesia started 2135; ended 2330). Debridement and closure of chest defect (4- x 8 cm). Junctures of second to fifth and tenth and eleventh ribs and extreme damage to subcutaneous tissues v/ere noted. Extensive gutter wound at left upper and lower lobes, interior and posterior catheter-water seal drainage of left pleura was provided and the left chest firmly strapped with adhesive. Debridement of exten- sive perforating wound of right thigh and buttocks, (no fracture present). Blood pressure at end of operation was 130/70 ram. Postoperative Course: At 0530 hours, 31 March, the blood pressure had fallen to 90/aD ran.; pulse 120, of good quality. Respirations shal- low, Breath sounds were diminished or absent over the left chest but were normal on the right. Rales were not noted. Anterior drain func- tioning properly. Progressive slowing of respirations and death occurred at 0635 hours, in spite of continuous oxygen therapy. Postmortem Findings: Gross; Extreme traumatic infarction of post- erior aspect of both lobes of the left lung. Severe congestion and edema of involved portions of left lung and the whole of the right lung. Re- mainder of gross examination was essentially negative. Microscopic; Pulmonary, myocardial and renal fat embolism, severe. Comment; This case illustrates an unusual degree of fat embolism. The source of the fat appears to have been the fractured ribs and trau- matized adipose tissue of the left chest wall. The man was wounded in a tank, and blast injury may have been partljr responsible for the severe embolism. Cerebral fat embolism was no doubt present but the brain was not examined. THE OPERATING ROOM AND THE OPERATION 51 THE OPERATING ROOM AND THE OPERATION The Field Hospital operating rooms have usually been in tents, although building have been utilised on occasion. Either single or double (side-to-side) ward tents were used. Each had its advantages and its disadvantages. The double tent was more spacious and conven- ient and generally the more suitable. However collections of snow or rain on the roof with resultant leakage were drawbacks to this type of tent in the winter months. The single tent was more stable in high winds and less inclined to leak, but here the operating quarters wore cramped and the erection of cubicles for surgery was not possible. In summer, a tent hospital in a field soon became extremely dusty, and passing vehicles on unpaved roads even 100 yards away raised dust clouds which billowed across the area and into the operating tent. Personnel walking through the surgical theater raised more dust from the ground. Water for sprinkling was seldom available, and when it was, evaporation was usually so rapid as to nullify the effort. It has been impossible to control completely flies and insects. Fitted wire screens and doors could not be carried because of limited motor transport. The tents were screened with cheesecloth and dis- carded mosquito netting. The benefit from these measures was only partial, and was largely offset by the constant passage of personnel into and from the tent, and by the wind. To those trained in the aseptic ritual of the modem surgical amphitheater, conditions in tent operating rooms were at first sight appalling. Temperatures varied from near freezing in winter to al- most intolerable heat in summer. The floor was often either thick mud or the powdery dust of desiccated, richly manured earth. Flies were a plague in summer and in winter the roof often leaked onto the sterile field. The meager space about the operating table was always crowded. The passage of personnel on necessary errands taking them through the operating tent has been nearly continual in times of heavy casualties. One would expect in these conditions epidemics of wound sepsis, anaerobic infection, and cross-infection, and would think it impossible that streptococcal and other wound infections should not be prevalent. Yet in our experience wound infections other than those directly attributable to contamination from a soiled peritoneal cavity have been unusual. Clinical streptococcal infections have been of great rarity. There has been no Instance of apparent contamination from case to case. Mo east of so-called ■surgical scarlet" or "wound erysipelas" has bean encountered. Anaerobic infections have been observed primarily in winter, when they were attributed to mod carried in by missiles; 52 The Operating Room and the Operation, cent *d. clostridial seeding of wounds by contaminated dust in the summer months does not appear to have occurred* Si spite of the crudeness of facilities, the surgeons of this organization have always observed at the operating table the rigid procedures of aseptic technique* Wide, painstaking skin preparation with soap and water and thorough shaving have been done. Ample sterile drapes have been used except in situations where the linen supply was critical* Supervision of the operating room conduct of enlisted personnel has been strict* Masks and caps have been provided for all passing through the operating room and their use has been required* Instruments, gloves, and when possible, gowns have been changed whenever indicated by contamination, either accidental or by a soiled wound. We believe that it is of the utmost importance for the forward surgeon never to compromise his observance of the aseptic technique regardless of working conditions. We feel that observance of operat- ing room surgical discipline more than any other factor has mads pos- sible the low incidence of exogenous wound infections which we have observed* The sulfonamides and penicillin have doubtless aided in the prevention of sepsis, but we believe their role to have been secondary in importance to the surgeons* observation of the rules of the operating theater* TIME ELEMENT Since approximately 50$ of all eases had associated wounds. It will be appreciated that the need for surgery other than that to the abdomen has been great* Debridement of multiple extremity wounds can be difficult and time-consuming. Some feel that additional operating time so spent may be hazardous to the patient, but we believe that this is rare indeed. The usual practice has been to perform all in- dicated surgery at the original operation, except in a very few cases where it appeared definitely unwise to continue debridements to com- pletion. In the usual case, the danger to the patient of incomplete- ly treated peripheral wounds was as great as that of an additional 30 or 45 minutes on the operating table* The vast majority of battle casualties have been found to tolerate well operations of great extent and duration* Secondary operations in the early postoperative period are undesirable in the abdominal ease, and such procedures are necess- ary if the original operation has not been complete* The need for rapid, straightforward, purposeful surgery, and for reduction to a minimum of time lost between cases must be emphasized* The saving of time is of far greater importance to the patient await- The Operating Room and the Operation (Tine Element, cont'd). ing hie turn for surgery than it is to the case on the operating table* In tines of great activity and heavy casualties, the patients may be delayed several hours in the preoperative ward because all surgeons are occupied* It is for the man who is awaiting surgery, and whose time lag is inevitably increasing, that the surgeon must use time with maximum efficiency* figure 5* Ibnt Operating Boon of a field Hospital* GENERAL CONSIDERATIONS OF ANESTHESIA IN WAR CASUALTIES GENERAL CONSIDERATIONS OF ANESTHESIA IN WAR CASUALTIES INTRODUCTION An Auxiliary Surgical Group is composed of officers, nurses and enlisted men, the latter being trained surgical technicians. The per- sonnel is divided into teams, each of which is composed of a surgeon, assistant surgeon, anesthetist, nurse and two enlisted men. Since each team is to function independently, it is supposed to have its own trans- portation and its own surgical equipment. The anesthetist, for example, carries an anesthesia kit containing drugs, syringes, needles, Yankauer masks, endotracheal set, and blood pressure apparatus. In addition, he possesses a machine to administer closed anesthesia under positive pres- sure. An important part of the treatment of battle casualties is practi- cal and efficient anesthesia, and it should be administered by persons especially trained in this specialty. Naturally, there are wounds in- volving every organ of the body, singly or in combination with other injuries, and therefore the anesthesia may vary in type or in method. Also, there is greater choice of agents in the less seriously wounded soldier, and in the more rearward hospitals, inasmuch as these patients have a more stable circulatory balance. Anesthetists are associated with teams specially Qualified in var- ious branches of surgery. These include not only general surgery, but also orthopedics, neurosurgery, thoracic surgery and maxillofacial sur- gery. The locus operand! of an Auxiliary Surgical team is ideally in a forward hospital unit, preferably a Field Hospital platoon, where the earliest definitive treatment may be offered to the patients. Naturally this entails considerable disadvantages, not only in the working condi- tions, but also in the manner of living. For that reason, the personnel of an Auxiliary Surgical Group shouldtecf a younger age group as a whole than that found in the usual hospital. Coincidentally, their general physical condition is superior to that of other medical personnel who do not suffer the rigorous life in the field to which members of the Aux- iliary Surgical Group are exposed. Pbr the most part, the anesthetists in the Group are particularly well qualified, some being certified specialists, and others having ex- perience in anesthesia either by virtue of special aruy training or private civilian practice. It is true that a few officers were appointed arbitrarily as anesthetists, and functioned as such, though their formal training in anesthesia was meager. No one can deny that they performed very creditably, and the more so as time went on. There were, likewise, General Considerations of Anesthesia in War Casualties (introduction contd several nurse anesthetists in the Group, most of whom had had some train- ing in anesthesia prior to their induction into the Army Nurse Corps, and were particularly familiar with inhalation anesthesia. Most of the sur- geons who used these nurse anesthetists were entirely satisfied, although in occasional instances this arrangement added a natural burden to the surgeon, already concerned and occupied with the surgical aspects of the case. It would be desirable if a method of training anesthetists, male and female, could be evolved for the type of cases encountered in for- ward installations, with stress on endotracheal anesthesia and recogni- tion and treatment of shock. The -Group, during its work in the Mediterranean Theater, took part in every amphibious operation, and consequently worked in every conceiv- able medical installation from Clearing Stations to General Hospitals, both American and British. Until the Held Hospitals were set up and functioning, the teams worked in Evacuation Hospitals and Station Hospi- tals for the most part. Working in Clearing Stations and medical bat- talions was never satisfactory, due to the obvious lack of facilities, equipment and personnel. It developed that the Field Hospital platoon was an admirable vehicle for the surgical teams, supplying the personnel and equipment which by necessity were not part of the Auxiliary Surgical Group. As a consequence, the preponderance of nontransportable cases in the Fifth and Seventh Armies during 19AA-A5 were qperated upon in the Field Hospitals by the 2nd Auxiliary Surgical Group and attached teams. Many of the difficulties and disadvantages of working in the for- ward areas have been eliminated as a result of experience. For example, the teams making the amphibious invasions of Anzio (Italy) and Southern France, were attached to Field Hospital platoons, which in turn brought ashore the teams1 equipment allowing for speedy functioning. At Salerno, on the other hand, a few months previously, the teams, some of which were assigned to Clearing Stations, did not have their equipment on the boats with them. This all important materiel was not disembarked until ‘D plus '2, Other factors militating.against the best treatment of the patient, although later rectified in most instances, included lack of adequate tent flooring, poor heating arrangements for the tents in winter, insuf- ficient blood for transfusions, absence of gas machines and other sup- plies, and too close proximity to our artillery for the patients’ comfort. let, in spite of the relatively minor discomforts, the privilege of working in such a medical installation far outweighed these temporary disadvantages. Here, as far as the anesthetist was concerned, each case offered problems seldom, if ever, encountered in civilian work, Further, the importance of good anesthesia was never more fully appreciated or necessary than in these severely wounded cases at the Field Hospital. This is the place where the anesthetistte skill, judgment and intelligence are constantly on display in the show case of combat zone surgery. From 57 General Considerations of Anesthesia in War Casualties (Introduction contd) this type of anesthesia a rich and satisfying experience nav bo obtained by the conscientious anesthetist. The manner in which the men of this Group met the challenge of these difficult cases supports the plea for more men trained in the practice of modern anesthesia. R0L3 OF THU AIwSTHSTIST The integrity of each team rests on the interdependence of its mem- bers, and particularly the relationship between surgeon and anesthetist. The anesthetist should be able, by virtue of his general medical back- ground and appreciation of surgical conditions, to relieve the surgeon of a certain amount of responsibility. This is especially true In his preoperative evaluation of the patient, assistance in the shock ward, knowledge of shock therapy, and performance of postoperative procedures on the ward. In civilian or peace-time army anesthesia, the anesthetist is sel- dom concerned with the same responsibilities as in combat casualties. At a Field Hospital on the other hand, in addition to giving the anes- thetic, he must learn to perform procedures with which he may not have been familiar up to that time. Ills previous training, his adaptability to this type of work, and his ingenuity are truly tested under these trying circumstances. Occasionally, as must be expected among any large group of medical officers, there was,someone who failed to adapt himself harmoniously to the position of being the anesthetist on a surgical team. This is not particularly strange inasmuch as these individuals perhaps had had some formal training in other fields of medicine, or expected to receive such training while working in the army. Since this was not practicable in this organization in all instances, and since there was an already ex- istent dearth of anesthetists, these men were summarily designated as such. Llost of those who were not at their ease in this position we re later assigned, to more suitable duties in this or another unit. The re- mainder were able to adjust themselves quite satisfactorily to the v/ork in anesthesia. It has been stated that the reason for the assignation of the inex- perienced personnel to anesthesia was due to the difficulty of obtaining more adequately trained men. 3very effort should be directed toward ob- taining as many as possible of the best qualified anesthetists for the work in the forward hospitals. Certainly if the Field Hospital is to care for priority surgical cases, as was its function here, then the pa- tients should enjoy the ministrations of priority anesthetists. 58 General Considerations of Anesthesia in War Casualties (contd) DUTIES OF THE ANESTHETIST In addition to his usual facility in administering the various agents, the anesthetist in the Held Hospital must perform other spec- ial tasks in and out of the operating room for the care of the patient. Especially will his presence be'appreciated in the preoperative shock ward, where he may profitably serve as a consultant or actually carry out some of the supportive therapy. Not always are the shock wards over-staffed, and particularly is this true during the busier periods. Another indisputable fact is that not all shock wards function at the same level of efficiency, and it is then that the anesthetist can mat- erially assist in the patients’ preparation and evaluation. The lat- ter, we believe, to be of the greatest importance to the patients’ wel- fare, A proper estimation of the condition of the wounded soldier to withstand surgery entails many factors, such as his nutrition, the sea- son and degree of exposure, location and severity of the wound, possible blast injury, blood loss, replacement therapy en route, blood pressure and pulse with notation of their behavior since admission, premedication and contemplated surgery, to name the more important considerations. The picture the patient presents at this stage will depend upon the im- portance attached to these factors in the individual case by the exper- ienced or inexperienced anesthetist. This subject will be further dis- cussed under the section on general care of the patient. The anesthetist is also in a position to assist in the preoperative care of the patient by his knowledge of local anesthesia. Therapeutic nerve blocking is a special feature in the treatment of certain wounds. Intercostal, paravertebral, and epidural blocxs have an important place in the therapy of chest wounds. It would be of particular benefit to the anesthetist to be acquainted with these and other common orocedures employing local anesthesia, not only for his war work but also for the practice of anesthesia in general. Premedication, with special reference to the use of morphine, also concerns the anesthetist and his preoperative evaluation of the patient, but will be taken up below under the heading of ’’Premedication’1 (page 61 ). Preparing the patient for surgery (shaving, washing, etc.) should be done as much as possible prior to the beginning of induction. This may be of extreme importance in reducing the total anesthesia time in badly wounded patients. During the operation, the anesthetist should be in complete command of the patient’s condition. With closed endotracheal anesthesia using the CO2 absorption method, he is able to maintain control of the tions. He supervises the fluid therapy for the support of the blood 59 General Considerations of Anesthesia in War Casualties (Duties of the Anesthetist, contd) pressure and directs general antishock measures. In case of any unto- ward condition developing he so advises the surgeon, who then can modify or perhaps even stop his operating. At all times he must keep the airway patent. Postoperatively he should be able to bronchoscope the patient if necessary, and this will be advisable in many instances, especially in thoracic wounds. A general appraisal of the patient's condition at the conclusion of the operation is of distinct value in determining the im- mediate postoperative therapy. The responsibility of the anesthetist to the patient does not cease with the completion of the operation. In the immediate postoperative period he is concerned with the maintenance of a patent airway, anti- shock therapy, and general supportive measures while the patient is emerging from his anesthetic state. In most instances this cannot be personally supervised by the anesthetist himself, but must be handled according to his directions. Training the ward personnel in such pro- cedures as tracheal aspiration with a soft rubber catheter is of ines- timable value, particularly in cases with blast conditions or whenever there is an unusual amount of raucous or blood in the bronchial tree. After the patient has recovered consciousness there are other fea- tures of his treatment which may be considered within the domain of the anesthetist. Of special importance is his ability to perform lumbar sympathetic blocks for vascular injuries in the extremities. Again, he may be called upon to perform diagnostic spinal puncture. In cases with painful incisions, it may be necessary to do intercostal, paraver- tebral-intercostal, or epidural blocks in order that the patient may cough efficiently, and thus increase his pulmonary seration. Occasion- ally, it is necessary for the anesthetist to bronchoscope a patient un- der local anesthesia for congestive or atelectatic conditions involving the lungs. Prom the foregoing, it is obvious that the anesthetist should ac- company the surgeons on their ward rounds in order to assist in the di- agnosis or treatment of the postoperative patient. In this way, the anesthetist will not only broaden his perspective on anesthesia, but will assist in increasing the efficiency of his surgical team. APPARATUS In the early phases of the Mediterranean campaign, shortages of anesthesia equipment and other supplies were very definite hindrances to the administration of proper anesthesia and proper supportive treat- ment of the patient while under anesthesia. The basic items of anes- thesia were supplied* agents, airways, Yankauer masks, laryngoscopes, 60 General Considerations of Anesthesia in War Casualties (Apparatus, contd) endotracheal tubes, syringes and needles, sphygmomanometer and stetho- scope. With these agents and equipment pentothal could be given intra- venously, ether administered by open drop, and spinal, local and regional procedures carried out. Apparatus for closed-positive pressure-oxygen anesthesia was avail- able in Evacuation and General Hospitals. Work done forward of these installations was without benefit of this method. Some efforts were made toward improvising equipmentcf this nature but none were successful enough to be widely adopted. Oxygen could be secured, but reducing valves were practically nonexistent. Reducing valves used in oxy-acet- ylene welding were sometimes obtained from engineer units when they could be spared. Plasma was plentifully supplied but blood supply was the concern of the individuals caring for the patient. Personnel of the unit where patients were being cared for, or other nearby units, were used as donors. Technicians and equipment for cross-matching blood were more often than not unavailable. Blood was given frequently without testing for compatibility or with no more than a gross test for agglu- tination, Illustrative of supply shortages that occurred was the ex- perience of teams in a landing with a Clearing Station. The shortages listed are only those noted by the anesthetists as hindering their work: 1. No laboratory technician to procure and choose suitable donors. 2. No microscope, test tubes or glass slides. 3. No eouipment, sterile or unsterile, for taking or administer- ing blood, other than needles, syringes and sterile plasma tubing, 4. No Levin tubes or stomach tubes to empty stomachs. 5. No intravenous preparations of saline or glucose, 6. No means of giving a closed anesthetic. 7. No facilities for oxygen therapy. Early in the Italian campaign, equipment and supplies became more plentiful. Platoons of Field Hospitals were each allotted one anes- thetic machine. This was inadequate, however, as freouently two or three severe injuries were being operated upon at the same time. Major thor- acotomies and thoraco-abdominal cases had priority on the single machine. In Evacuation Hospitals blood banks were set up. In Field Hospitals blood banks were not feasible at the time because the platoons were not authorized refrigeration. However, vacuum bottles with citrate became available, which was of great importance to the satisfactory and rapid collection of blood. Shock teams came into wide use and relieved the personnel of the surgical teams of the responsibility of having to draw blood at frequent intervals as needed by the individual patients. Oxy- gen equipment was available in limited quantities at this time. By im- provising multiple oxygen outlets and connecting sections of plasma tubing together, oxygen could be piped to several patients from a single tank. 61 General Considerations in Anesthesia in War Casulaties (Apparatus, contd) In March 1944, issue was started of the Beecher portable anesthetic machine (WD Item No, 9N01600) to platoons of 51eld Hospitals and shortly afterwards to many of the surgical teams. Thus each platoon had suffic- ient equipment for several closed anesthetics to be given simultaneously. By this time, the blood bank was functioning adequately. After this time supplies were never a serious problem except in oc- casional instances where teams were required to work in clearing stations or medical battalions or in the first day or two of an amphibious land- ing. Three types of anesthetic machines were in general usej Heidbrink, McKesson and Beecher portable model. The portable Heidbrink and McKesson machines are familiar to all anesthetists. The Beecher model was de- signed particularly for military use in the Pacific Theater to provide a compact light weight machine with which a closed positive-pressure ether anesthesia could be given using oxygen for a tank, or outside air provided by foot bellows, GO2 absorption was to and fro in type. In- duction could not be carried out with the machine. This was accomplished using ether or ethyl chloride open drop, or pentothal. Obviously an ap- paratus this size and weight could hardly have the full performance of the larger machines, yet many anesthetists reported satisfactory results using it in all types of cases. PREMEDICATION Premedication was, in most cases, simply the administration of 1/100 or 1/150 gr. of atropine. This was true for the reason that by the time the patient had reached a hospital installation he had ordin- arily received an adequate or more than adequate dosage of morphine. Dosage totals of Ig- gr. of morphine were repeatedly noted, given over periods of time no longer than four to six hours. Some factors which favored overdosage are as follows: (l) Poor absorption of the drug due to impared circulation and/or exposure to cold with chilling of the body surface; the patient had no effect from the morphine already received and more was given along the chain of evacuation because the patient com- plained of pain, (2) The standard army morphine preparation for combat use is the gr. syrette of morphine tartrate, which amount, if not too large for an initial dose, is certainly too large for additional doses. (3) Ihilure of morphine administration to be recorded on Emergency Med- ical Tags with subsequent needless repetition of dosage. (4) Inadequate education of those entrusted with morphine administration concerning the hazards of delayed absorption of accumulated doses. Shortly after admission to a warm shock tent and improvement of circulation by restorative therapy, this hidden morphine came to light in the form of varying degrees of morphinism. In abdominal wounds with 62 General Considerations of Anesthesia in War Casualties (Premedication, contd) mounting infection and cases of continuing hemorrhage, anesthesia and surgery could not be delayed for the reason of morphine depression. Aided or controlled respiration with a closed system was used to carry these patients through anesthesia. The difficulty of morphine over- dosage be corrected to a great extent by: (l) reducing the amount of morphine in a syrette from s’ to gr; (2) limiting'doses for each pa- tient to two syrettes, over a period of six to eight hours, with reason- able exceptions or under the direct supervision of a medical officer; (3)' urging that records be kept as accurately as possible (the diffi- culty of this under combat conditions is recognized); (4) administration of all morphine intra-muscularly, rather than subcutaneously by company aid men, at battalion aid stations, collecting stations, and clearing stations. The intramuscular route is not as sure as the intravenous route, but the latter method poses obvious technical difficulties which make its general use forward of hospital installations not feasible. Additional morphine administered by us to these patients was done so only after examining the patient for signs of morphinism, checking the Emergency Medical Tag for time and amount of morphine given, and where accuracy was doubtful, the patient was questioned. The course of events both preadmission and postadmission also affected this decision. Suffice it to say that additional morphine was given meagerly and cau- tiously, and not at all if there were any doubts as to its need. Intra- venous (into infusion tubing) was the logical and most commonly used route, in consideration of the unstable circulatory balance of these patients. This was given in combination with the atropine 10 to 1$ minutes before anesthesia was expected to begin. Scopolamine was not in general use because of its central depressant action. COMPLICATIONS Generally speaking, the complications arising out of wartime anes- thesia are the same as those met in civilian practice, due allowance being made for the incidence factor in the soldier age group. On the other hand, it must be kept in mind that the wounded patient often re- quires much more extensive surgery than the civilian patient, as well as suffering varying degrees of exposure,*infeotion and shock, all con- tributing to anesthetic complications. Moreover, the anesthesia is administered by personnel of variable training and experience. By the proper selection of cases and agents, and careful attention to dosage, the incidence of anesthetic complica- tions can be appreciably lowered. It is probably a truism that the in- cidence of complications is in inverse ratio.i to the experience and knowledge of the anesthetist, and this is specially applicable in war anesthesia. 63 General Considerations of Anesthesia in War Casualties (Complications, contd) A full discussion of this topic is covered .in any of the standard textbooks on the Subject of anesthesia. The complications arising out of 315A anesthetics in abdominal and thoraco-abdominal battle casualties is taken up under the section on (pp 182 t Anesthesia in 315A Abdom- inal and Thoraco-abdominal Battle Casualties), BLAST INJURIES Any discussion of blast injuries must be qualified by stating that the statistical data recorded is quite incomplete as to the actual num- ber of cases that had associated, blast injury. The following discussion is based chiefly on the combined clinical impressions of our Group, Very few cases come to the operating table with the definite diagnosis of blast or as a predetermined major complication to wounds due to high explosive fragments. The usual cause of blast injury is the detonation of a large charge of explosive in close proximity to the body, or as a result of direct trauma. This problem has been fully discussed by Martin and Schwab (Anesthesiology, March 19A5). They considered both air blast and hy- draulic abdominal concussion. (See section on Thoracic Injuries, page Ull .) The treatment of these cases is quite difficult. The use of fluids is always a perplexing problem. The very slow administration of whole blood or plasma is the only variation in treatment from the usual care of casualties. Frequently the fluids must be stopped due to increase in pulmonary exudation. Oxygen per nasal catheter or B.L.B, mask, i.e., in high concentrations, is necessary because of the poor respiratory ex- change and also in the treatment of the pulmonary edema. Morphine is used as indicated for pain and apprehension. Slight Fowler’s position for comfort and efficient pulmonary ventilation is important. The anesthetic management of severe blast cases is more difficult than that of other casualties, in that induction with inhalation anes- thesia may be inrpared due to reduced alveolar exchange. Great care is exercised to carry the patient in as light a plane of anesthesia as is possible and to institute prompt treatment of any complications as they occur* A few severe cases developed marked pulmonary edema shortly after induction. Almost constant tracheal suction was necessary and smooth anesthesia was very difficult to maintain. Occasionally, it was difficult to provide satisfactory oxygenation for the patient. Under these circumstances it was the same type of treatment given any other case that became nwetn. Postoperative bronchoscopy, repeated tracheal aspiration and oxygen under pressure were provided as necessary. General ‘Considerations of Anesthesia in War Casualties (Blast Injuries, contd) Hot all cases of blast were as severe as described and many times the anesthetist was not aware of the blast injury until the chest was opened and the petechiae or hematoma of the lung were demonstrated by the surgeon. For these patients, the anesthesia was no different than in any other case. All those who became nwet" were not blast casual- ties, but the greater percentage of pulmonary injuries were complicated by blast. Those patients who went on to recovery were treated as de- scribed under postoperative care, with fluid balance and a clear pul- monary tree being the chief concern throughout the treatment. Simmy AID CONCLUSIONS 1, Anesthetists working in forward hospitals should be well trained, preferably of a young age group, and of good physical stamina. The advantages and disadvantages of working in combat installations are discussed. 2. Priority surgery demands the the anesthesia be administered by the best available anesthetists. 3* The duties of the anesthetist preoperatively, operatively, and postoperatively are noted. 4-. The apparatus available to the anesthetists of the 2nd Auxil- iary Surgical Group, both early and late in the war, are discussed. 5. Preraedication, with special attention to morphine, and its dangers in war use, is commented upon. Methods&r preventing the over dosage with morphine are listed. 6. Anesthetic complications in war anesthesia simulate those in civilian practice, allowance being made for the age group involved, and the severity of combat wounds. 7. Blast injuries in the war casualty are discussed from the anesthetists standpoint of treatment and management on the table. 65 POSTOPERATIVE CASE OF THE SERIOUSLY WOUNDED 66 POSTOPERATIVE CARE OF THE SERIOUSLY WOUNDED; PREVENTION AND TREATMENT OF COMPLICATIONS The necessity of constant attention to detail in the postoperative care of patients with serious war wounds cannot be overemphasized. If any appreciable reduction in the mortality and morbidity rates of this type of case is to be obtained, it must come from even greater diligence in combating shock and by the more successful prevention and treatment of the numerous complications which arise postoperatively, The nature and degree of the problem is illustrated by a tabulation of the princi- pal causes of death in several large groups of seriously wounded or in- jured patients operated upon in forward hospitals of the Mediterranean and European Theaters in 194-3, 1944- and 1945. TABLE I Causes of Death in the Seriously Wounded Causes Abdominal Wounds Thoraco-Abd Wounds Thoracic Wounds Extremity Wounds * Persistent shock 51% 52.6* 8.6* LA. 6% Intrathoracic conrolications 15% 21.0* 58. 7* 17.5% Abdominal conrolications ..... 20% 10. A* (2 cases) 1.7* 0.0% Other conrolications - -U% 11.0* 17.2* 36.5% Hot recorded - - 3% 5.0% l.A* Total cases studied 2251 903 136A 2378 Total deaths .509 2A7 135 7A Mortality acafee 21,1S 9.9* 3.1* * Includes amputations and fractures of long bones but not uncompli- cated vascular injuries. The data in this table apply only to the periods of treatment in the forward hospitals. "Persistent shock” was the most commonly recorded cause of death except for the group of thoracic injuries, and was in- cluded in the list though not a complication per se (see "Shock Syndrome" page log ). Fatal intrathoracic complications had by far their highest percentage (58,7%) in thoracic wounds. The rate for thoraco-abdominal wounds (21%) was not much higher than that for abdominal wounds (15%). 67 Postoperative Care of the Seriously Wounded; Prevention and Treatment of Complications (contd) The latter figure was boosted somewhat by a higher percentage of pulmon- ary embolism in the abdominal wounds. Most of the fatal abdominal com- plications consisted of peritonitis, either general or local. A substan- tial portion of the ’’other complications" in each wound category was re- presented by the anuric cases. This highly fatal complication is dis- cussed thoroughly in the section on "Posttraumatic Renal Failure" (pare • 758 ). Anaerobic infections formed the second most numerous group of cases under "other complications". Nonfa.tal complications, though gen- erally similar in type and relative incidence to the fatal ones, could not be tabulated as accurately. This may have been due to the fact that these patients were followed only during their stay in the forward hospi- tals and that the records were incomplete in some cases (see section on "Postoperative Complications in Abdominal Wounds", page 203 )• Details of postoperative care varied with the individual surgeons of the Group, but the underlying principles were essentially the same. They form the basis for part of the discussion in this paper. Special varia- tions in postoperative management appropriate to wounds of the nervous system, to maxillofacial wounds, compound fractures, amputations, peri- pheral vascular injuries and genito-urinary injuries are detailed in the sections on those subjects. Most of these special cases, however, can be evacuated rearward far earlier than abdominal or thoracic cases and so present shorter treatment problems and fewer complications in the forward hospitals, fluid Balance Every effort was made to keep the patient in a normal state of hydra? tion, and to this end a majority of the surgeons utilized the following general routine, fluid intake was usually maintained at 2000 to 3000 c.c, daily, unless there was a reason to increase or decrease the amrpount be- cause of complicating factors, when fluids were given parenterally, they were administered preferably by a drip mechanism which made it possible to accurately regulate the rate of flow, fluids were spaced'throughout the day and night. One or more liters of the total fluids given was nor- mal saline, either alone or mixed with glucose. If the excretory func- tion of the kidney was impaired, the administration of normal saline solu- tion usually was restricted to not more than, one liter per day. The re- mainder of the fluids consisted of five or ten percent glucose in distilled water and variable amounts of blood and plasma to meet the total fluid re- quirement, The danger of "drowning" patients suffering from anuria with too much water and saline intravenously should be emphasized. Patients who were losing excessive amounts of fluid by vaporization, vomiting, gas- tric suction, diarrhea or fistulae, received an additional amount of sa- line solution to replace this loss. A daily output of 1000 c.c. of urine with a good specific gravity was a prime objective and served also as a useful clinical rule in determining the required fluid intake. 68 Postoperative Care of the Seriously Wounded; Prevention and Treatment of Corn-plications (Eluid Balance, contd) Thoracic casualties presented a special problem in intravenous fluid administration. Clinically patients did better if kept mildly de- hydrated, Saline solutions also were given only to replace thatlost by gastric suction and by other routes. It has been observed that trauma- tized lung tissue is particularly prone to become edematous after the administration of intravenous fluid. The oral administration of fluids, although preferred, xvas contra- indicated in the abdominal cases for varying periods because of the fre- quency of wounds of the intestinal tract and complicating peritonitis or paralytic ileus. Parenteral fluids were administered by vein almost always and infrequently by the subcutaneous route. Rectal administra- tion- was rarely utilized because of the uncertainty of the amounts that would be absorbed. The sternal route did not prove sufficiently satis- factory to be used widely. ANALGESIA AND SEDATION Postoperative analgesia and sedation have been handled somewhat differently;- than in major operative cases in civilian practice. Several points in regard to', the routine use of morphine in the seriously wounded or injured beai* emphasis. As a result of shock, relatively deep and pro- longed ether anesthesia and sheer battle fatigue, the majority of the seriously wounded have required surprisingly little analgesic medication during the first 18 to 24- hours postoperatively. After this period, morphine in doses of grains 1/6 to 1/4 every three to four hours may be required for another 48 hours. After the second or third day, codeine by mouth should be substituted as much as possible. There has been a tendency to administer morphine somewhat longer than necessary, partic- ularly if the orders are written as np.r.n.n. In thoracic cases where morphine is given more for its sedative than analgesic effect, it was found wise often to prescribe this drug in smaller and less frequent doses than for the abdominal wounds to avoid depression of respirations and the cough reflex. The anoxia inherent in thoracic cases may be seriously in- creased by this depression. The same caution was found to be appropriate in maxillofacial cases. Codeine hypodermically and barbiturates usually were effective analgesics and sedatives in head injuries and avoided the respiratory depressant and "symptom-masking" action of morphine. Barbiturates have been very useful to complement the action of mor- phine, During the later postoperative periods they have been effective alone as hypnotics and to allay apprehension particularly when forward hospital areas were subjected to enemy artillery and air attack. OXYGEN ADMINISTRATION Anoxia of varying degree was a frequent finding in the seriously wounded. It was particularly notable in thoracic wounds as an expression 69 Postoperative Gc.re of the Seriously hounded; Prevention and Treatment of Complications (Oxygen Administration, contd) of altered respirator;/- function, but was encountered also in "a.tientc v/itn serious abdominal v/ounds. Curtailment of respirrtions by pain and the mechanical compression of the lun'-s by abdominal distension \iere import- ant causes of pulmonary anoxia in such cases. Prolonged shock in any seriously wounded case caused circulatory anoxia and in turn was increased by it. In these patients, particularly, morphine given to allay pain and restlessness tended to increase the an- oxia by depressing the respirations. Dyspnoea or tachycardia are positive indications for administration of oxygen. One should not wait for devel- opment of cyanosis which is a late manifestation. (keygen administered by nasal catheter or mask was utilized almost routinely by many of our surgeons to combat this anoxia. Through a soft #10 or #12 French catheter, six to eight liters of oxygen ner minute could be administered to the patient for several when indicated, multiple small, perforations in the catheter near its tip and an efficient humidi- fying bottle inserted in the oxygen line will greatly enhance the patients tolerance of the treatment. The catheter should be cleaned at least once daily and changed tp the other nostril, flasks of the BL3 type were avail- able when higher concentrations of oxygen were desired or the nasal cath- eter was tolerated poorly. The success of this oxygen treatment was made ouickly annarent in many patients by improvement in their shock, relief of dyspnoea and al- layment of restlessness. We feel that less immediate and less obvious benefits, such as improved resistence of tissues to infection and improved oxygenation of extremities with locally impared circulation also resulted from continued oxygen therapy. In general, oxygen, whether used prophy- lactically or for specific indications, proved a valuable aid to treat- ment in the forward hospitals. BLOOD COUNT AND HEMOGLOBIN Despite administration of large quantities of whole blood in the treatment of shock and acute anemia due to initial blood loss, some anemia was apparent not infrequently during the postoperative courses. At times this became aggravated by sepsis or secondary hemorrhage. Using the he- matocrit red blood count and hemoglobin determinations as guides, addi- tional blood transfusions were given as indicated. The importance of a normal hemoglobin level in relation to tissue oxygenation is well known. Little benefit could be derived from the administration of iron by mouth during the relatively short forward hospital treatment periods. Postoperative Care of the Seriously Hounded; Prevention and Treatment of Complications (contd) NUTRITION AND PROTEIN BALANCE The majority of battle casualties appeared in a good state of nutri- tion and were maintained so by administration of blood, plasma, and diet as tolerated postoperatively. Only in the cases with protracted compli- cations did gross nutritional deficiency develop and present problems in treatment. The reduction in plasma proteins in the injured patient was rarely severe and the body reserves were able to maintain a normal plasma protein volume in most cases. In rare instances of more severe protein loss, however, certain such as pulmonary edema and infec- tion and wound disruption seemed favored. It was found helpful to obtain protein determinations* on the blood serum in such cases and to treat vigorously as indicated. The available means of preventing such protein deficiency states in forward hospitals was limited to the use of whole blood, blood plasma and amino acid preparations. The latter were administered to a fewpat- ients and were discontinued after a fatality attributed to the prepara- tion in use. It was rarely possible to obtain any form of specialized high protein liquid.diet for these patients in the forward hospitals and nearly complete reliance was made upon the above-mentioned intravenous preparations, VITA-MEN LEVEL MAINTENANCE The parenteral use of vitamins was largely limited to vitamins B and G, The known beneficial effect of vitamin B in regeneration of red blood cells and in maintenance of intestinal tone and the importance of Vitamin C in wound healing and increasing resistence to infection seemed to justify their use. furthermore, buccal signs of early vitamin B and C deficiency have been observed in a significant number of wounded and otherwise normal soldiers overseas. Some surgeons prescribed prepara- tions of these two vitamin complexes routinely while others reserved their use for patients whose postoperative courses became complicated and pro- tracted. In a few instances of severe liver damage or biliary fistula, vitamin K concentrates were administered in the forward hospitals. Mul- tivitamin preparations were given to nearly all patients as soon as oral intake was pennitted. * The so-called "copper sulfate series" was performed in the labora- tories of most of the forward hospitals and provided the surgeon with highly useful figures on the hematocrit, hemoglobin and blood specific gravity in addition to the plasm proteins. 71 Postoperative Care of the Seriously Wounded; Prevention and Treatment of Complications (contd) s POSTOPERATIVE CARS IN THORACIC WOUNDS Rational postoperative care of the wounded thorax is based on an understanding of intrathoracic traumatic pathology and its correction. In many instances of purely thoracic wounds it has been difficult to sep- arate postoperative "complications" from the states arising as a natural evolution of the pathological process. The three main objectives of postoperative care in thoracic cases are: Attainment of prompt and complete pulmonary re-expansion; mainten- ance of a patent air way; and relief of pain. Early pulmonary re-expansion is of primary importance in the pre- vention of empyema and the restoration of normal intrathouacic physiology. This view was foreshadowed following World War I by Yates-*- who stated "resistence of serous activities (i.e. serosal surfaces) is commensurate with their ability to maintain their mesothelial surfaces in approxima- tion". All air and fluid should be removed from the pleural cavity as rapidly as possible. There are no indications for air-replacement, «hen drainage has been employed the tubes should be "milked" at least once or twice daily to maintain patency. They should be removed promptly when they have ceased to function, Major adjustments and irrigations of drain- age tubes increase the dangers of infection and should be avoided. If there are residual fluid collections, thoracentesis should be done. When the chest has not been drained, thoracentesis should be continued daily, as long as 100 c.c. or more of fluid or air is obtained. Frequent roentgen- ograms are necessary in determining the status of the lung. Increased bronchopulmonary secretions and blood resulting from trauma to the lung are of common occurrence postoperatively and must be considered part of the original pathology. Purulent bronchial secretions at this time nearly always signify a pre-existing bronchitis. The presence of ex- cessive fluid in the bronchi is evidenced by rattling respirations, fre- ouent ineffectual cough, dyspnea, and often cyanosis. These excretions must be evacuated. In every case, ward attendants should periodically support the c?aest end urge the patient to cough. Hyperventilation and frequent turning are aids, When the patient cannot raise sputum, intra- tracheal catheter aspiration is indicated (2). The resulting expulsive effort will force srjiall plugs of material out into the larger bronchi where they can be removed by suction. The aspiration may be performed every few hours without ill effect. Eronchoscopic aspiration, which can be performed on the ward under topical anesthesia, should be used if catheter aspiration has not been effective. The control of postoperative pain has an intimate bearing on the patient’s comfort and on his ability to cough and raise sputum. Regard- less of how much bronchial fluid is present, the soldier will not cough 72 Postoperative Care of the Seriously Wounded; Prevention and Treatment of Complications (Postoperative Care in Thoracic Wounds, contd) effectively if he has a painful thorax. I.Iuch of the pain may have been controlled by crushing or injecting the intercostal nerves at the time of operation. Residual pain can be controlled oostoperatively by means of intercostal nerve block, using It procain (3), an easy ward procedure. Usually the effects of a single block will last at least 2/+ hours or longer but the injections may be repeated as often as necessary. In general, morphine is contraindicated for the relief of thoracic pain because of its depressant, effect on respirations. Adhesive strapping has been al- most completely discarded as inefficient and unphysiological. Postoperative chemotherapy in. thoracic casualties has followed the general trend. Since June 1944, when penicillin became readily availab- le, the routine local and systemic use of sulfa drugs has ceased. In major intrathoracic wounds, penicillin in doses of from 20,000 to 25,000 units lias been given intramuscularly every three hours for approximately 10 days following operation. In the majority of thoracotomies, 25,000 units in 25 c.c, of water have been injected into the pleural cavity at the tine of closure. Particularly following the debridement of large sucking wounds (traumatic thoracotomy), in the uresence of especially heavy contamination or actual infection, we have not hesitated to place from five to 10 grams of crystalline sulfanilamide into the pleural cav- ity and wound in addition to penicillin. Twenty-five thousand units of penicillin may be injected at the time of periodic thoracentesis, par- ticularly if the wounds in general are contaminated or infected. POiTOPURAT IVi) IHTRATHQRAGIC COMPLICATIONS Postoperative pulmonary, or, more properly, intrathoracic complica- tions are important and frequent causes of morbidity and mortality in the war surgery of any region of the body (see Table I), As stated above, in thoracic casualties the postoperative intrathoracic complications often may be indistinguishable from the original pathology, vihen such compli- cations do arise however, their treatment is exactly the same whether they occur in an already injured lung, or in a normal lung following operation for other wounds. In the following paragraphs all complications will be discussed without regard to whether or not a thoracic injury was present. Pulmonary Complications: Atelectasis. Lobar or total pulmonary atelectasis was a rare complica- tion. Patchy or lobular atelectasis probably occurred with great fre- quency but often it was difficult if not impossible to distinguish it roentgenolqgically from an area of pulmonary contusion. Occasionally when dyspnea was out of proportion to the size of the roentgen shadow in the lung, atelectasis could be suspected. Of whatever degree, atelecta- sis in our experience always has been caused by excessive fluid accumu- lation completely obstructing a bronchus. These excretions were mainly 73 Postoperative Care of the Seriously 'Wounded; Prevention and Treatment of Complications (Postoperative Intrathoracic Complications, contd) from an injured lung, a pre-existing bronchitis, or the result of pro- longed ether anesthesia. The prevention of atelectasis rests on the var- ious me as area which ’fill keep the air-way clean and dry as outlined above. The treatment of a well-defined atelectasis consists of greater efforts in aiding the patient to expell fluid from his bronchial tree, and in the early and repeated use of bronchoscopy if other means fail. Aspiration of Vomitus. This is a serious complication and demands spec- ial attention. It can be orevented to a large orient if the stomach is emptied routinely in the shock tent and the tube left in place during operation. Stomach contents are very irritating to the respiratory tract and their presence excites a rapid and severe emulative chemical bronchi- tis and bronchiolitis. Immediate bronchial obstruction may develop, es- pecially if food material has been aspirated. When aspiration of vomitus occurs before the patient has completely reacted from anesthetic (the usual time, he mill not co-operate and no time should be wasted in at- tempts at getting him to cough voluntarily. We believe immediate bron- choscopy to be the safest and most efficient procedure. Frier to bron- choscopy, atropine, grains 1/100 should be injected intravenously if none has been given within an hour. This minimizes the dangers of sudden car- diac arrest from a hyperactive vago-vagal ref3.es. Bronchoscopy allows for visualisation and facilitates the removal of particulate matter. VJhen bronchoscopy cannot be done, thorough tracheo-bronchial catheter aspira- tion should be carried out at once. If fatal asphyxia does not occur, a fulminating pneumonitis frequently follows failure to remove aspirated vomitus, Pneumonitis. The infectious pulmonary complications have been diagnosed as bronchopneumonia, lobar pneumonia, pulmonary consolidation, etc. The diagnosis has been based on the development of toxicity, increased fever, pulmonary signs of consolidation, and autopsy findings in fatal cases. It is of interest that in comparing patients with thoraco-abdominal and intrathoracic wounds, the percentage of infectious complications was prac- tically equal in the two groups. In nearly all instances the pneumonitis developed on the basis of stagnation of excessive bronchial fluid, atel- ectasis, and a secondary infection. In the winter months especially, pre- existing purulent bronchitic was an important source of the infection. In a few Instances, lobar consolidation appeared as the primary pathology, without a previous diagnosis of atelectasis. Sulphadiazine was the drug of choice, and often, when a pneumonia developed under penicillin therapy, it responded promptly to sulfa administration. In many cases the stagna- tion of bronchial secretions persisted end both catheter suction and bron- choscopy were employed if the patient could not cough effectively, even though undoubted nulmonarv infection was already -present. 74 Postoperative Caro of the Seriously Wounded; Prevention end Treatment of Complications (Postoperative Intrathoracic Complications, contd) Pulmonary Edema. This occurred in patients both with thoracic and non- thoracic wounds, but it was impossible to distinguish the causative fac- tor in man;/ instances. In some cases with severe pulmonary contusion an early edema developed. As Drinker and hav pointed out, pulmonary transudates (i.e. edema fluid) are caused also by dyspnea and by anoxia. In other cases the edema probably was due to the too rapid administration of large volumes of intravenous fluids. A small percentage of these pa- tients manifested signs of right heart failure (hyperpnea, distended neck veins and falling systolic and pulse pressures). Prompt venesection of from 500 to 750 c.c. was necessary when right heart failure was obvious. In the fracture group, some of the cases of pulmonary edema undoubtedly were secondary to pulmonary fat embolism. Delayed edemas, developing from five to 10 days after injury, usually were associated with anuria. Since pulmonary edema frequently was secondary to other pathology, specific treatment was in the main unsatisfactory, and often failed en- tirely. Efforts always were made to increase tissue oxygenation. Atro- pine sulphate, grain 1/100, given intravenously apparently benefitted a few cases. When frothy pulmonary secretions were excessive, tracheo- bronchial catheter suction was used repeatedly. At times, a small cath- eter was left indwelling in the trachea and oxygen administered between aspirations. In a fev cases, oxygen given under positive pressure through a mask was of distinct benefit. Pulmonary Embolism. This frequent complication was often fatal. In some cases the diagnosis could be made clinically; in many, however, embolism was an autopsy finding. As in civilian experience, the majority of the emboli, fatal and nonfatal, arose in the deep veins of the lower extremities. In a partial review of cases of phlebothrombosis found in the seriously wounded pa- tients listed in Table I, Gumness-5 noted eleven cases of fatal embolism with origin of the emboli in the deep veins of the lower extremities. None of these had been treated surgically for the jhlebothrombosis. In six other cases, femoral veins were ligated after evacuations of thrombi. Pulmonary embolism occurred in only one of these six cases and was not fatal. Of special interest was the fact that, of the 17 total cases of phlebothrombosis listed by him, the patients had sustained direct wounds of the involved lower extremity in all but three. Infection appeared to be a factor in some of these cases. In a few instances of severe wounds of the lung, pulmonary vessel thrombosis was described, but no case of retrograde embolism to the contralateral normal lung was recognized. No consideratiqn need be given to the operative treatment of embo- lism in the group of patients under discussion. The treatment frequently described for similar cases in civilian practice can be applied under war conditions, but it has not been used in its entirety. Briefly, this con- sists of upright position in bed, oxygen administration, and the intra- venous injection of atropine, grains 1/75 and papaverine hydrochloride. 75 Postoperative Care of the Seriously Wounded; Prevention and Treatment of Complications (Postoperative Intrathoracic Complications, contd) grains l/2, three or four times a day. Prophylaxis is greatly preferable. It is only fair to say that many factors in forward hospitals have com- bined to cause some neglect of prophylactic measures. The patient’s pos- ition should be changed frequently, both from side to side and tfith head both raised and lowered. He should not be left in Jbwler's position in- definitely as this will tend to cause some obstruction to the return flow of blood from the extremitiesi Whenever possible, simple muscular exer- cise of the foot, leg and thigh should be carried out several times a day. The lower extremities should be examined routinely but carefully in these seriously wounded patients for evidence of phlebothrombosis and thrombophlebitis of the deep veins. If such becomes evident, whether or not nonfatal pulmonary embolism has occurred, we feel that the femoral or iliac veins should be ligated promptly above the thrombus. The clot may be evacuated if it seems appropriate. Such treatment of the vein ap- pears to be the only relatively certain method of preventing subsequent embolism in these cases. Heparin and Dicoumarin were not available in the forward hosnitals Pulmonary Fat Embolism. The rate of occurrence of this complication can- not be stated with accuracy but it is believed to be relatively high. Clinical diagnosis is almost impossible in the presence of intrathoracic wounds. In fatal cases, microscopic evidence of fat is necessary if there is concomitant pulmonary injury. Given a patient with a major fracture and a previously normal chest, however, pulmonary fat embolism may be di- agnosed clinically with some accuracy. Within a few hours to several days after injury there may develop thoracic discomfort, a rapid pulse, dysp- nea, cyanosis and scattered fine rales, especially at the bases. The pa- tient may die rapidly from asphyxia. Supervening amnesia, muscular twitch' ings, mental confusion, and even coma are characteristic of cerebral in- volvement, Ihere is no specific treatment. Oxygen should be administ- ered in liberal amounts and the patient kept quiet. Prophylaxis is of great importance and starts on the battlefield. Secure immobilization and gentle handling of fractured bones are essential. After admission to the hospital, the limb should be moved as little as possible and roentgen examination done with splints in place. Even on the operating table, manipulations which displace the bone should be kept to the minimum. Pulmonary Abscess. All types of pulmonary abscess are uncommon in for- ward hospitals. Distinction must be made between the abscess developing from aspiration (the usual civilian type) and the traumatic abscess, us- ually due to the passage of a missile through, or lodgement in, the lung. In the latter category there is evidence to suggest that in some cases at least, pulmonary vascular thrombosis from trauma is an important pre- disposing factor. Many of the "traumatic" abscesses surround a residual 76 Postoperative Care of the Seriously wounded; Prevention and Treatment of Complications (Postoperative Intrathoracic Complications, contd) foreign body. Treatment is aimed at securing adequate bronchial drainage and re-expanding the lung immediately if it is collapsed. Unless there is marked toxicity or recurring hemorrhages, or unless the abscess rup- tures into the pleural cavity end the prostration is profound, no surgery should be attempted in forward hospitals either to drain the abscess or to remove the offending foreign body. Patients sboiild receive priority evacuation to a base section thoracic center. There.is a third type of abscess which is encountered with great rarity and ha’s an identical civ- ilian counterpart. This type is associated with blood stream infection, is embolic in nature and usually multiple. Little can be done and the prognosis is extremely poor. Bronchopleural -Fistula. This almost never occurs except in patients with intrathoracic wounds. Usually it is due to a blow-out of previously dam- aged pulmonary tissue and results in pneumothoraj:. The majority will not produce intrapleural Infection in forward hospitals, unless the fistula itself develops on the basis of an infected missile track. The lung should be immediately re-expanded. If this cannot be accomplished readily by thoracentesis, a small catheter should be inserted in an upper anterior intercostal space and attached to a water-trap bottle. The fistula might be large enough to produce a pressure pneumothorax and an unexpansible lung, but we have not seen this complication. Operation might be neces- sary under these circumstances for closure of the fistula. Intrapleural Complicationsj Clotted Hemothorax. Blood appears to clot in the pleural cavity with great frequency but this seldom prevents at least partial aspiration in forward hospitals. Rarely (less than 5'0 a hemothorax may become com- pletely unaspiratable very soon after injury. This is no indication for emergency surgery. The fact of the clotting should be noted prominently on the chart and the patient evacuated to the base as soon as possible. Posttraumatic Infection Including Infected Hemothorax and Ilomothoracic Empyema. A few patients (less than 5;j) will develop early intrapleural infection in forward hospitals. Bach case must be treated on its merits, Where the Infection ,is not fulminating and develops in a large hemothorax, priority evacuation should be given to a base thoracic center. In an early, toxic empyema, due for example to the rupture of a pulmonary ab- scess into the pleural cavit:/, or the presence of a large bronchial fis- tula, drainage must bo undertaken in a forward hospital. Air-tight rib resection drainage with a water trap is preferable unless the patient is too ill to under go,even this minor procedure. In such cases, closed in- tercostal drainage on the ward nay be used as an interim procedure. When rib resection has been done, the drainage may be made open in a short tine and the patient safely transported with a tube in his chest, Except under the most unusual circumstances relatively early thoracotomy (five 77 Postoperative Care of the Seriously Wounded; Prevention and Treatment of Complications (Postoperative Intrathoracic Complications, contd) to 3.0 days) for decortication of the Imp, because of massive infected hemothorax or empyema, is not justified in forward hospitals. Subohrenic Abscess. This rarely develops in patients before they are evacuated, VShen it occurs, however, drainage should be undertaken ac- cording to recognized principles. Every effort must be made not to vio- late the pleural cavity. POSTOPERATIVE CARE OF ABDOMINAL GASES The usual patient with wounds of the abdominal viscera will require postoperatively the continued treatment for "shock" when present, the proper maintenance of his fluid balance and nutrition and blood hemoglobin and sufficient morphine or other drugs to keep him comfortable as outr lined above. He may be benefitted greatly by oxygen administration. It is especially important also, to encourage his moving about in bed and the exercise of his legs beginning at the earliest possible moment. He should be urged to do deep breathing from time to time and to cough fre- quently if there are excessive pulmonary secretions. The use of naso- gastric suction, probably the most important single feature of postoper- ative management in abdominal cases, is described below. Good nursing care, of course, occupies its usual important place in the treatment of these very sick patients. For the prevention and treatment of the various complications, spec- ial measures are ‘In order. Abdominal Complications Ileus. Ileus was present to some degree in all wounds involving the peri- toneal cavity and reflexly in some other wounds. Usually, it was of the functional or adynamic type. Several factors contributed to ‘this ileus: Peritoneal contamination and subsequent peritonitis, trauma to the bowel at the time of injury and surgery, presence of retroperitoneal hematomas, and in some cases a peristaltic depressant action of morphine. The most effective method of preventing or treating this ileus was by the early and continuous use of gastro-duodenal suction (Wangensteen), A Levin tube was passed into the stomach of virtually all seriously wounded patients in the shock ward before anesthesia and proved to be an additional aid in the preparation of these patients for surgery by pre- venting and relieving gastric dilation. Aspiration of gastro contents, a serious complication in our early experience, was thus largely avoided. Suction was maintained during surgery and for several days thereafter in most abdominal cases. Distention usually could be prevented if ade- quate suction was maintained. 78 Figures 6 * 7 - The post operative ward of Field Hospitals 79 Postoperative Care of the Seriously Wounded; Prevention and Treatment of Complications (Postoperative Care of iibdominal Cases, contd) Patxents were allowed to drink small amounts of water during the postoperative period while the tube was in place. The average abdominal battle' casualty required suction for three to six days postoperatively. Mien the patient began to pass gas freely by rectum or otherwise mani- fested a return of active peristalsis, the tube could usually be removed with impunity. However, it was found best to clamp it for a number of hours before removal, to be certain that the patient would do satisfac- torily without it. After the tube had been removed, the patient was al- lowed to increase his fluid intake orally as tolerated, and parenteral fluid administration was reduced or omitted. When gastroduodenal suction does not relieve the distension, additional aid may be derived from the use of the Miller-Abbott tube, Cne must be careful not to persist in the use of such conservative measures when strangulation obstructions or closed loop obstructions are suspected. In such cases early surgical intervention is mandatory. Peristalsis-stimulating drugs had little value in the treatment of ileus in our* series. The use of high concentrations of nasal oxygen in a few cases was not followed by striking results. Intestinal Obstructions. There were at least 22 cases of postoperative obstructions involving the small intestine. Only five of these cases were re-operated. Conservative measures are appropriate in the early stages of this complication, unless strangulation obstruction or closed loop obstruction is suspected, as stated above. Peritonitis. The treatment of peritonitis included those measures pre- viously outlined for care of ileus plus the lose of penicillin and sulfo- namide agents in adequate dosage. Sequent blood transfusions and lib- eral amounts of intravenous plasma were also helpful. Some degree of peritonitis v/as present in every abdominal and thoraco-abdominal case and was the principal cause of death in approximately 12% of the fatal group. Localised abscesses in the peritoneal cavity were drained as soon as di- agnosed. Penicillin was administered to nearly all abdominal cases postoper- atively after May 194-4-. The usual intramuscular dose was 25,000 units every three hours, maintained for from five to 10 days or more, depending on the clinical course. In many instances sulfadiazine, parenterally or by mouth, v/as given also, particularly if there had been fecal contamina- tion of the tissues. A review of this experience has led to the impres- sion that.penicillin was a more valuable adjunct than sulfadiazine in the control of peritoneal infection in these cases ("Penicillin and Sulfona- mide Therapy in Abdominal Wounds", page 197), The intraperitoneal appli- cation of the sulfonamides and penicillin however, seemed to have no ef- fect on the actual mortality rates of wounds of the colon and rectum. (See section on this subject, page 298.) 80 Postoperative Care of the Seriously Wounded; Prevention and Treatment of Complications (Postoperative Care of Abdominal Gases, contd) Intestinal Pistalas. There were one gastric, two duodenal, twelve small intestinal, eight large intestinal fistulas recorded as complications during the forward hospital periods. Frequent changes of dressings, pro- tection of the skin by ointments and other medicaments and, rarely, suc- tion were available as local treatments in the forward hospitals. Glu- cose and saline solutions and protein were reouired in unusually large amounts parenterally as outlined above to combat loss of these elements in fistula- cases. They were evacuated rearward as soon as possible. Wound Disruption and Infection. Wound disruption occurred 36 times in abdominal cases. (See page 187.) When the general condition of the pa- tient permits, an immediate secondary closure by suture should be made. Rarely, in critically ill patients, adhesive taping may be used to ap- proximate the wound edges. The former practice is preferable for it re- duces the chances of adherence of intestinal loops in the incision and the possible subsequent development of intestinal obstructions. Apprec- iable operative wound infection without actual disruption was seen less frequently. It responded well to reopening of the incision as necessary and to hot, wet or antiseptic dressings. Secondary Hemorrhage. This complication was seen infrequently, but, when it occurred, presented a serious problem. Six secondary hemorrhages were recorded in cases with gastric lesions, and three of these proved fatal. In one instance, a secondary hemorrhage occurred from a jejunal anastomo- sis, This patient did not survive the re-operation. Two secondary hem- orrhages were seen in cases with extraperitoneal perforation of the rec- tum. The buttock and rectal wounds were infected and the superior gluteal artery bled severely on the 10th and 12th postoperative days respectively, in these cases. In one case a severe secondary hemorrhage occurred from a wound in the hilura of the liver. This was satisfactorily controlled by laying open the missile tract to the liver and suture-ligating the bleed- ing artery. There were no recorded cases of secondary hemorrhage follow- ing injuries to the kidney. In general, secondary hemorrhages were best treated by prompt operative exposure and hemostasis. Packing for bleeding in wounds of most of the organs was unsatisfactory. Anaerobic Infections. Anaerobic infections were recorded as either the principal or contributory cause of death in 24- patients with trunk or extremit}/- wounds. The regions involved v»ere: The extremities or buttock in 16 cases; the abdominal wall or retroperitoneal tiss\ies in six cases; the chest wall in two cases. Nearly all of these patients were given vigorous penicillin end serum therapy in addition to appropriate surgical handling. This subject is discussed in detail in the section on "Anaer- obic Infections" (page 746), Other Complications. Urinary tract infection was seen rarely. This was probably due to the freouency with which penicillin and the sulfonamides were administered in treatment of the patients1 primary pathology. Sup- rapubic cystotomy usually was performed for cases in which urinary re- tention was associated with spinal cord injuries. 81 Postoperative Care of the Seriously Wounded; Prevention and Treatment of Complications (Postoperative Care of Abdominal Gases, contd) Bed sores following cord injuries were difficult to prevent. The main effort was toward elimination of pressure points, Freouent turning of the patient, protection of the heels and buttocks by gauze rings and air cushions, plus constant attention to beeping the skin dry in these areas were the means most readily available in forward hospitals. DRAINS AND THEIR REMOVAL Drainage of the general peritoneal cavity was rarely attempted. When inserted, these drains were removed usually on the fourth to tenth postoperative day. Drains used in the surgical care of liver wounds, usu- ally were loosened beginning on the fourth postoperative day and were out completely by the tenth o° twelfth postoperative day. However, the pre- sence of biliary drainage is the most important criteria, and no liver drain should be removed until this drainage has ceased. Similar indica- tions for removal apply to drains use-’ for kidney and pancreatic wounds as well as those placed in the snace of Retains, CARE 0? THE C0L0ST0MI Approximately 1200 colostomies were performed in the group of 3154 abdominal cases, from the point of vie- of obtaining solid healing of the bowel to the abdominal wall and of reducing the possibility of in- fection, it would have been desirable to leave colostomies closed for several days. This did not seem safe, however, in the majority of ex- teriorized wounds of the colon and early opening was usually practiced. Even in the proximal divorsional colostomies made for wounds of the colon and rectum, peristalsis often returned in less than 4S hours, renuiring opening of the colostomies at that time, .In the loop type colostomy, the bowel should be opened along its longitudinal axis and with its greater part of the opening proximal to the supporting glass rod or rubber tube. The care of the colostomy in these cases presents few additional problems to those encountered in civilian practice. It is very important to keep the stoma separated from the main laparotomy incision and this can be accomplished by covering the former with adhesive tape and oiled silk an- chored to the skin with liquid adhesive. In all cases, the abdomen should be cleaned immediately after the colostomy has functioned. This is par- ticularly necessary where a thoracobrachial or hip-splca cast has been applied for associated extremity pathology. There is considerable psy- chological value to the patient, also, in good colostomy care. LOCATION 0? FORWARD HOSPITALS Effect on Patient The surgeons of this Group have been impressed by the importance of the tactical disposition of the forward hospitals (usually single, platoons 82 Postoperative Care of the Seriously Wounded; Prevention and Treatment of Complications (Location of Pbrward Hospitals, contd) of Jleld Hospitals) in relation to the medical progress of the patients postoperatively. If the hospital was located near an artillery emplace- ment or an important supply junction which drew enemy shell fire or air attack, the patients were highly apprehensive and restless. Under such conditions, badly needed rest was impossible and progress was retarded correspondingly. Though proximity of these hospital units to the combat area is important in permitting rapid evacuation and early definitive surgery, our experience has shown that the patient’s recover:’' is en- hanced by placing the unit a little farther to the rear or in a quieter area whenever possible. THE 5DRWARD HOSPITAL TREATMENT PERIOD '.The matter of how long these first priority surgical cases should be held in the forward hospitals after operation Avas of great importance and had to be learned by experience. It was found that transportation of these patients could be carried out with the least untoward effects during certain periods of their postoperative courses. Except when the tactical situation forced the surgeon's hand the following periods of treatment and observation in the forward hospitals were found generally advisable; 1, Abdominal cases -- eight to ten days 2, Chest cases with thoracotomy — seven to nine days 3, Sbctremity wounds with circiolatory deficiency — held until via- bility of limb was determined and livelihood of fulminating gas gangrene minimized — four to five days A, Major compound fractures in the absence of peripheral circula- tory deficiency — two to three days 5. Head and maxillofacial injuries — transportable as soon as shock was overcome and patient’s condition generally stabilized with as- sured air way. These time intervals represented the minimal ones desirable and were subject to considerable modification by the condition of the individual patient. SUMMARY 1, The nature and degree of the problem involved in postoperative care of the seriously wounded and the handling of complications has been illustrated by a tabulation of principal causes of death in a large series of wounds and injuries involving the trunk and extremities (Table I, this paper)• 83 Postoperative Care of the Seriously Wounded; Prevention and Treatment of Complications (Summary, contd) 2. Next to persistent shock, which was not a true complication, intrathoracic complications constituted the largest group of principal causes of death. The importance of trauma to the lungs and other chest struc- tures in the development of pulmonary atelectasis is emphasized. The further relationship of atelectasis to the so-called "infectious pulmon- ary complications", is stressed also. 3. Abdominal complications, notably peritonitis, occupied import- ant roles in the postoperative courses of abdominal wound cases, and virtually none in purely thoracic or extremity wounds. A, The routines of postoperative care of the seriously wounded as practiced by teams of the 2nd Auxiliary Surgical Group, are presented with special emphasis on measures toward prevention and treatment of the various complications encountered. 5. Since the postoperative care of patients with wounds of the central nervous and genito-urinary systems, and with maxillofacial and extremity wounds is described in detail in other sections (pages 621 & 593 ), it has been omitted from this discussion. REFERENCES (l) The Medical Department of the United States Army in the World War, Vol XI, Part I, page 36S, Government Printing Office, Washington, 1924. (2) Samson, Paul G,, Brewer, Lyman A. Ill, and Burbank, Benjamin: Tracheobronchial Catheter Aspiration; Indications and Technique, Bull. US Army Med, Dept., in press. (3) Samson, Paul C,, and Fltzpatric, Leo J.j Intercostal Nerve Block; Its Role in the Management of Thoracic Casualties, Gal, and West Med. 62: 254 (May) 1945. (4) Drinker, ,C. K,, and Warren, M. F,s The Genesis and Resolution of Pulmonary Transudates and Exudates, J.A.M.A. 122: 269 (May 29) 1943 (5) Gumness, Glen H, "The Management of Phlebothrorabosis in War Wounds to be published. WOUNDS OF THE ABDOMEN: AM ANALYSIS OF 3lSk CASES 85 WOUNDS OP THE ABDOMEN - AN ANALYSIS OF 5154 CASES INTRODUCTION The concepts regarding the proper treatment of casualties having abdominal wounds have undergone a remarkable and radical change during the past 20 years. Bailey1 has pointed out this change in concepts. During the period from the Boer War (1899-1901) until 1915. the accepted principle followed in war wounds of the abdomen was one of strict surgi- cal nonintervention. Thereafter the policy of noninterference began to be questioned in the minds of many men. and by the end of World War I. it was more or less generally agreed that most abdominal injuries should be treated by operation, although lack of organisation prevented this course from being followed as widely as was desired. It is of interest to note that as late as the Spanish Civil War (1936-1938). even though the need for surgical intervention in abdominal wounds was generally ac- cepted. 50% of patients having such wounds were denied the benefits of surgery (Matas)**. This appalling situation apparently resulted either from lack of personnel and equipment to handle these severely wounded individuals, or else the casualties were adjudged to have wounds of such severity as to preclude operation. The concept of the treatment of the abdominal casualty, as it exists and is practiced today, is one which denies surgery to no case on the grounds of severity of wounds. Exact figures sure not available, but it is certain that far less than 1% of cases in this series were deemed too severely wounded to be denied the benefits of surgery. Re- suscitation measures were invariably and vigorously begun in all patients, no matter what tbs condition on admission, with the anticipation that surgery was to be done. A small percent of total cases failed to res- pond and died during the resuscitation period, but the ultimate goal in every ease was the benefits of surgery. This non-selection of oases inevitably led to an increase in mortality rate, especially in regard to deaths during the induction of anesthesia, and during surgery. However, in none of the 756 deaths re- corded was it felt that surgery was responsible for the death, and in almost every case it was certain that death would have followed in- evitably had operation not been undertaken. A gratifyingly large number of very severely wounded patients survived their wounds because of surgery, death being the only alternative had surgery been denied them. The need for a small mobile surgical unit, placed well forward, and having highly trained and well qualified personnel for the early treat- ment of abdominal wounds is unquestioned, bat only from a humanitarian motive, bub also because of the effect on morale. Troops in the line 86 Wounds of the Abdomen-An analysis of 3154 Cases. (Introdution, contd) have known that there hare always been near at hand facilities for their care should they be wounded, and that their priority for treatment would be proportionate to the severity of their wounds* The effect on troop morale of this knowledge has been large, and has frequently been com* nentod upon by both soldiers and officers of the line, whether wounded or not* Many patients with abdominal wounds, although acutely and critical- ly ill for the first few days, ultimately make a complete recovery, without, we believe, crippling or disabling sequelae* Of the 3532 patients with abdominal wounds treated by this Surgical Group, it is probable that most were saved from certain death, and it is expected that most of these will have no physical abnormalities other than some soars* The exact proportion of abdominal wounds to wounds of other regions of the body is not known, hut it is believed that patients with abdom- inal wounds make up a very high proportion of the critically wounded seen in hospitals* The salvaging of these cases materially reduces the mortality rate of any Army, SCOPE OP SURVEY This report is based solely upon 3154 eases of abdominal Injury treated by the surgeons of this organisation in forward surgical in- stallations* These oases include all casualties so treated in which trauma was sustained incident to the violence of warfare* Wounded civilians. Allied soldiers, and prisoners of war are included and to- gether comprise slightly more than 15% of the entire series* Cases operated upon by surgeons on temporary duty with this command have been excluded. Statistics and statements regarding deaths and complications apply only to those observed in the hospitals of original treatment* Ho follow-up data are included* The source material for this study has been the individual case records prepared by the surgeons for the files of the Group* Due to uncontrollable factors resulting from military stress, the data in all records are not complete, and for this reason, certain apparent statls tioal discrepancies will he noted* Opinions expressed in the section on Abdominal Surgery represent the consensus of the sturgeons of the Group, based either on informal polls or on obvious uniformity of practice as reflected in the case records* Information is included which is not of purely medioal import* This information embraces data and statistics of interest from the his torloal and military points of view* 87 Wounds of the Abdomen-An Analysis of 3154 Cases. (Scope of Survey, contd) The majority of the cases reported, 2851 or 90.4$ were operated upon in Field Hospital Platoons. Two hundred thirty two or 7.4$, received their initial surgery in Evacuation Hospitals. The remaining 2$ were treated either in Clearing Stations or Allied Hospitals, or did not have the type of installation recorded. The numbers of oases treated in the various types of hospitals are tabulated in Table I, together with the mortality rate for each instal- lation, The lower mortality in Evacuation Hospitals as compared with Field Hospitals probably reflects the less severe injuries received in Evacuation Hospitals# TABLE I Distribution and Mortality Rates By Hospitals 3154 Abdominal Cases, 1944-45 Type Hospital No. of Cases Percent No. of Of All Cases Deaths Mortality Percent Field Hospital 2851 90.4$ 693 24.3$ Evacuation Hospital 232 7.4$ 35 15.1$ Casualty Clearing Station (British) 58 1.8$ 26 44.8$ Clearing Station 10 0.3$ 1 10.0$ Not Known 3 0.1$ 1 33.3$ Total 3154 100.0$ 756 23.9$ Part I of this section deals with general subjects relevant to all abdominal casualties. Statistical data for the series as a whole are presented here and analyzed. Observations regarding missiles, the anatomical sites of entrance of abdominal wounds, and data not purely medical in nature are made here. In Part II will be found more detailed presentation of specific subjects pertinent to the care of all abdominal wounds, e.g., the pro- blems of shock, incisions, time lag, anesthesia, etc. Part presents detailed analyses of frequency, mortality, and methods of management of injuries to the individual viscera# WOUNDS 0? THE ABDOMEN Part I General Subjects Relevant to All Abdominal Wounds Page (1) 'lypes of Cases 89 (2) Incidence of Abdominal Wounds in General . . 89 (3) Gross Statistics 90 (4-) Wounding Agents 100 (5) Entry and licit Wounds 105 (6) Time Lag (Summary) 107 (7) Preoperative Care and Diagnosis (Summary) . 107 (8) "Shock Syndrome" 108 (9) Associated Extra-abdominal Injuries (Summary) 109 (10) The "Multiplicity Factor" 109 (11) Discrepancies and Corrective Factors .... 112 (12) Deaths 112 89 Abdominal Injuries, Part 1. Presentation of Data. TYPES OF CASES The 2nd Auxiliary Surgical Group has operated upon 3532 patients for abdominal injury. All patients having, or suspected of having abdominal visceral Injury are Included in the report. Hence, thoraoo-abdominal wounds, extraperitoneal injuries to abdominal viscera (e.g., eztraperltoneal rectal wounds), negative exploration, intraperitoneal visceral injury without penetration of a missile, and peritoneal penetration without visceral injury are all submitted and analysed, since no clear out differentiation exists between these groups of cases. The number of eases in relation to year and campaigns is given in Table II. TABLE II Abdominal Cases Treated: Tears and Canpalgns Year Campaigns Total Cases 1943 Tunisian, Sicilian and first four months of the Italian Cas$>aign 378 1944 Fifth and Seventh Armies 2383 1945 Fifth and Seventh Armies 771 Total Cases 3532 Previous detailed reports have been submitted by members of this Group on the Tunisian Campaign and on the 1943 abdominal oases. Conseq- uently, these oases have not been included in the present report, and are not alluded to in subsequent statistics and opinions except for the sake of comparisons • Therefore, statistics are based on the 1944- 1945 case reports, the number being 3154. INCIDENCE OF ABDOMINAL WOUNDS IN GENERAL No figures are available to show the absolute incidence of abdominal wdunding, nor are data available to us for comparative incidence of abdominal wounds in relation to wounds of other parts of the body. All of the statistical material gathered in this study is heavy weighted by a preponderance of first priority casualties. However, it is estimated that 5Q/£ of patients admitted to Field Hospitals have abdominal wounds. 90 Abdominal Injuries, Part I. Presentation of General Data, GROSS STATISTICS - PRESENT STUDY Total Cases by Years, All statistics quoted hereafter are based on the study of the 1944 and 1945 records. TABLE III Total Number of Abdominal Cases Including Thoraco-Abdominal Wounds By Years and Mortality Year Cases Li Ted Died Mortality Rate* 1944 2383 1797 586 24.6# 1945 771 601 170 22.0# Totals 3154 2398 756 24.0# Incidence of Thoraco-Abdominal and Abdominal Wounds. The following table shows the relative incidence of abdominal and thoraco-abdominal wounds in all abdominal wounds with mortality for each* TABLE IV Year Type of Case Cases Died Mortality Rate 1944 Abdominal 1744 406 23.3# 1945 Abdominal 571 130 22.4# 1944 Thor aco-abdominal 659 180 28.2$ 1945 Thoraoo-abdominal 200 40 20.0# Total Abdominal Injuries 2315 534 23.1# Total Thoraoo-Abdominal Injuries 839 222 25.3# ♦This mortality figure is based on known deaths occurring in the forward hospitals in which the initial surgery was done* For corrective factors see Page 118. ♦♦Slight discrepancies will be noted in relation to the section on thorac0-abdominal injuries* See Page 112. 91 Abdominal Injuries, (contd) Hsg&‘tiT6 Explorations • Included in the abdominal cases are a number of negative explora- tions. Fifty-nine of these negative explorations were in the presence of retroperitoneal hematoma. The remainder was performed because of doubt regarding the penetration of missiles. TABLE V Negative Explorations Percentage Percent Year Cases of Total Cases Deaths Mortality 1944 153 6.4* 8 5.2* 1946 42 5.4* 2 4.7* Total 195 6.2* 10 5.1* In addition to the negative explorations, there was a group of 41 cases which had penetration of the peritoneal cavity without visceral damage, with two deaths. Therefore, there was 2918 patients with vis- ceral injury, having a mortality rate of 26.5#. Incidence of Vlsous Woundlni A summary of the incidence of wounding of various organs is listed below (Tables VI. VII, & VIII). TABLE VI Incidence of Wounding of Abdominal Organs - 3154 Cases Organ lo. Cases Incidence in 3154 oases Stomach 416 .... 1S.2* Duodenum 118 3.795 Jejunum - Ileum 1168 37.095 Colon and intraperitoneal rectum 1106 36.0# Rectum (extraperitoneal) 156 4.995 Lifer 829 26.795 Gall Bladder and Bile duot 63 ~ Spleen 541 o . 00 Kidney 42* 1SU95 Ureter zi 0.8% Urinary bladder 165 Pancreas 62 £3 Major abdominal vascular injury 76 -4# 92 Abdominal Injuries* (Incidence of Vlscus Wounding* contd) TABLE 71I Incidence of Uncomplicated Wounding in Relation to Total Wounding of the Various Abdominal Viscera* Organ No oases Incidence Stomach 42 10.1% fiuodemuB 2 TM J ejunum-Ileum 363 30.2^ Colon and intraperitoneal rectum 251 22. 7% Rectum (extraperitoneal) 64 Liver 339 40.8% Gall bladder and bile ducts 0 .0% Spleen 100 29.3% Kidney ~ 56 • to H Ureter 1 3.7% Urinary bladder 21 13.6% Pancreas 1 1.6% liajor abdominal vascular injury 8 10.7% TABLE VIII Incidence of Complicated Injury in Relation to Total bounding in The Various Abdominal Viscera Organ No. Cases Incidence Stomach 374 89.9% feuodenua ll6 ~ 98.4% Jejunum-Ileum 815 69.3% (Solon and intraperitoneal rectum 856 77.3% fiectum (extraperitoneal) 91 Mtot 490 59.2% (Sail 'bladder and bile ducts 53 100.0% Spleen 241 70.6% Kidney 371 86.9% Ureter 2d 96.3% tfrinary bladder 34 ■“ 86.5% Pancreas 81 “ Uajor abdominal vascular injiur 89.3% ♦Throughout the abdominal section* for the sake of uniformity, the term "Uncomplicated" alludes to injury to a single abdominal tIsous* whereas "Complicated" refers to the wounding of two or more wisoera* 93 Abdominal Injuries. (Incidence of Visous Wounding, oontd) TABLE VIII Incidence of Complicated Injury in Relation to Total Wounding in the Various Abdominal Viscera Organ No Cases Incidence Stomach 374 89.9% !)uo2eaua 116 98.4% Jej unum-11sum 815 69.8% Colon and intraperitoneal rectum 855 77.3% Rectum (extraperitoneal) 91 58.7% Liver 490 59.2% Gall bladder and bile ducts 53 ” 100.0% ' Spleen 241 70.6% Kidney 5f 1 ' 86.9% Ureter 26 96,3% Urinary bladder 34 86.5% Pancreas 61 98,4% Major abdominal vascular injury 6t ” 89,3% It is readily apparent from a study of the above tables that the frequency of wounding of an abdominal organ is almost directly propor- tional to the site of that organ. Likewise, it is obvious that the in- cidence of uncomplicated wounds of any given organ is proportional to the area of that organ in contact with the abdominal wall. An aphorism of modern warfare might well be stated: The incidence of wounding of any given abdominal organ is directly proportional to the space that organ occupies. The truth of this statement is apparent when one con- siders that of all abdominal wounds in this series were produced by unaimed fragmentation missiles, while the remaining Z\% Incurred from bullets wore for a goodly part from roughly aimed automatic wea- pons. Even the most finely sighted sniper’s bullet was not fired with selective Intention toward a single abdominal visous. It follows, therefore, that any variation in igcldenoe from the maxim stated above probably indicates that patients with certain lesions are not being seen alive. A striking example of this variation, as pointed out in the abdominal vascular injury discussion (Page 394-) is seen in the compari- son of Incidence of wounds of bhe aorta and vena cava. Thirty-seven vena caval lesions were seen; no abdominal aortio lesions were seen. The cooperative tables of incidence given below indicate an impor- tant point. It will be noted, in general, that frequency of wounding of all organs is considerably higher, and that the proportion of uncom- plicated to coaplioated wounds has been remarkably changed in this series as compared to those formerly reported. Abdominal Injuries, (contd) TABLE IX Comparative Statistics of Incidence of Abdominal Visceral Injury- Source Percent of Total Cases Percent Percent of of Uncomplicated Complicated Cases Cases Stomach: World War I (USA)3 7.0% 66.6% 33.3% Wallace 4 8,5% 68.3% 31.7% Ogilivie5 5.8% 43.0% 57.0% Jolly 6 8,5% Not given Not given Present series 13.2# 10.1% 89.9%" Small Intestine: World War I (DBA) 22*0# Not given Not given Wallace 37.3% 70.5% 29.7% 6gilivie 34,8% 73 ,0% 27.0% Jolly 31.5% Mot given Not given Present series 57,0% 30.2% 69.8% Colon: World War I (USA) 22,0% Not given Not given Wallace Mot given 60.0% 40.0% bgilivie 34.4% 72.5% “27.6% Jolly n-M Not given Not given Present series 55,0% 22.7% 77.3% Liver: World War I (USA) 13.5% 75.0% 25.2% Wallace l4.8% 90.8% 9,7% Ogillrie il.3% 85.$ 14.4% Jolly 1<>.9% Mot given Mot given Present series 26.7% 40,8% 59.2% Spleen: World War I (USA) 1,0% Not given Not given Wallace 5,e%* 59.5% 40.7% Cgilivie t,$% 1$,o% zV,d%~ Jolly 4,5% Mot given N0t given Present series 10.8% 29,4% to.$ Kidney: World War I (USA) 6.5% 50*0% 50.0% Wallace 7,6% Mot given Not given C^ilivie 5 #3^ 7070% 30.0% Jolly Mot given Not given Present series 13.4% SJ}9% *5,6% - Estimate* Abdominal Injuries, (contd) Other organa follow much the same pattern as the above It is clearly evident from the comparative figures that in these campaigns a much higher proportion of the severely wounded (men with multiple visceral wounds) were being seen and operated upon at the forward hospitals. No other explanation is possible to account not only for the overall increase in incidence, but also more particularly for the marked change in the complicated-uncomplicated ratio. It is believed that the figures presented in this report much more closely approximate the true incidence of wounding of the various organs than do those previously reported. Even these figures are actually below the absolute incidence. That so many more of the seriously wounded were seen at the first hospitals is difficult to explain. Certainly all credit belongs to the medical personnel and the evacuation system in echelons forward of the hospitals for bringing about this remarkable accomplishment. Incidence of VTounding In Relation to Type of Organ Injured Table X indicates the incidence and mortality of wounds to solid viscera (either singly or in combination), to hollow viscera (either singly or in combination), or to various combinations of solid and hollow viscera. TABLE X Type of Organ Involved Cases Deaths Percent Mortality Solid viscera only 668 94 Hollow viscera only 1512 m 23,t % Both solid and hollow viscera 672 269 40.02 Caution must be used in accepting the mortality data given above without considering the effect of the ’'multiplicity factor” discussed on Page 109 • A more accurate mortality rate is shown by comparing single viscus injuries. For-single hollow viscera the mortality rate was 17,4$; for single solid viscus the rate was 11,1$, The combination solid and hollow visceral mortality rate reflects the effect of multi- plicity of injuries, rather than any inherent danger in such combinations. Plmirc 8 97 Abdominal Injuries, (contd) Analysis of 1944 snd 1945 Campaigns. Monthly and Seasonal Variations in Abdominal V/punds and Mortality. It is apparent from Figure that the number of abdominal wounds varied directly with the fury of the fighting, each offensive and lull being mirrored by the number of casualties treated. It is quite likely that the curve of abdominal casualties clocely parallels the incidence of casualties in general. The incidence and mortality rates are plotted in actual numbers in Figure 8 and hence do not show the parallel courses of the two curves that would be apparent if' they were plotted on arithmo-logmarithmic paper. It has long been observed from a clinical point of view that patients arrive at Field Hospitals in a more severe state of shock during the cold, wet months of winter than do similar cases in the summer months. Moreover, infections and pulmonary complications, as shown in the postoperative statistics on Page 20? are 30% higher In winter than in summer. Chronic bronchitis and tracheitis seem almost universally present among the front line infantrymen during winter fighting, and it is not surprising that pulmonary complications follow, with an increased mortality rate. These situations are corroborated by the statistical evidence submitted in Figure 9. MORTALITY RATIS HR 1000, WINTER AND SUMMER Figure 9 - Mortality - VJinter and Summer - 1944 and 1945. 98 Abdominal Injuries, (contd) The mortality rate ran higher for the "winter months" (October through March) than for the "summer months" (April through September), Casualties for August were the lowest of any mon'ch (see Figure ]_o )* but due to the fact that they occurred almost entirely during the Southern France landings, with the inevitable confusion and delay in establishment of hospital facilities, the mortality rate showed a sharp rise (Figure 10 )» Figure 10 - Mortality by months, 1944-1945. Table XI shows the incidence and mortality rates by quarters of the year. 99 Abdominal Injuries, (contd) TABLE XI Month Cases Deaths Percent Mortality January through March 430 141 32.8% April through June 470 91 19,4% July through September 503 103 20.5% October through December 929 232 25,0% Relation of Branch of Service to Incidence of Abdominal Wounds. As would be expected, the infantry bore the brunt of the fighting, and consequently the preponderance of casualties occurred in this Arm, (81# of all abdominal casualties among American troops.) All other arms and services had comparatively few wounds of the abdomen. Figure 11 is self-explanatory* ARMS AND SERVICE. DISTRIBUTION OF CASUALTIES IN 2137 ABDOMINAL CASE.5 Figure 11"“"*- Arms and Services Distribution of Abdominal Casualties* 100 Abdominal Injuries, (contd) ±fi®L Table HI below shows the effect of age on mortality. TABLE HI Incidence of Age Groups and Mortality, 3154 Cases Total Percent Age Group Cases Deaths Mortality e - 20 707 164 23.2$ 21-25 987 202 20.4# 0 to 1 to CM 591 139 23.6$ 31 - 35 250 60 24.0$ 36-40 78 21 26.9$ 40 plus 42 18 42.8* No record of ages 499 152 30.5$ There is a slight, almost insignificant, increase in mortality rate with increasing age in the military group. The rise on either end of the age groups indicates the influence of civilians, - children who were wounded withstood their injuries and surgery poorly, as did the aged. The "no record" group consisted largely of civilians and POITs of whom age was not determined because of linguistic difficulties. The somewhat higher mortality rate is reflected in this group. WOUNDING AGENTS There were 3052 patients in this series whose injuries were due to missiles of war; these oases represent 96.8# of all abdominal cases herein reported. High explosive fragments of all types caused 2123, (69.6#) of these wounds, and small arms missiles caused 929, (50.4#). A detailed analysis of the frequencies of wounds caused by the various types of high explosive fragments and bullets is given in Figure In this large series of casualties it has become apparent that the effects of a given type of missile are by no means invariable. It has been generally true that the wound of entry was smaller than the wound of exit. However, a slender fragment #iioh presents its greatest dia- meter at the site of entry and makes its exit on a path parallel to its long axis can obviously cause an exception to this statement. Cases have been seen in which the exit wound was the smaller of the two. 101 Abdominal Injuries, (contd. INCIDENCE OF WOUNDS CLASSIFIED AS TO WOUNDING AGENT. BATE PER 1000 Figure 12 - Incidence of Wound Caused by Various Wounding Agents• Contrary to earlier opinions, we believe from our observations that the course of a missile within the body is a straight line in practically every instance. Bizarre or circuitous tracts have been of extreme rarity. The seemingly erratic course of missiles in some eases has almost invariably been explained by accurate consideration of the position of the soldier when struck. (See Figure 13 drawn Ikon a case in this scries). 102 Abdominal Injuries, (oontd) Figure 13 - Effect of Position on Visceral Wounding. It must be remembered that changes of posture cause significant displacement of viscera from their usual anatomic sites and relation- ships. Wo believe that the possibility of other than straight-line tracts has heretofore been greatly over-emphasized. In this series there is no instance of a missile having traversed a major diameter of the abdomen without causing visceral injury. Artillery shell fragments caused 1844 or 58.5% of the casualties in this series of 3154 oases, (it is probable that many wounds listed in the records as due to shell fragments were actually caused by mortar fire.) 103 Abdominal Injuries, (contd) Clinically, the effect of these missiles has been of extraordinary variability. This variability appeared to depend, upon the size of the fragment (usually roughly proportional to the caliber of the shell), its shape, and the distance of the soldier from the explosion. The latter has served as a rough index of the velocity of the missile. Explosive, ooncussive effects upon tissues have been more frequently seen among casualties injured at close range than among those who were at a distance from the shell burst. In general, jagged, lacerated, irregular wounds have been caused more frequently by shell fragments than by small arms missiles, but frequent exceptions have been encoun- tered, Very large fragments or multiple smaller ones emanating from a very near burst have literally removed larger parts of the abdominal parietes, and cases have been observed with the entire flank carried away. Such patients rarely survive even to reach the hospital. Wounds caused by mortar fragments, especially at short range, are often characterized by a multiplicity of very small fragments, which are of slight mass but higfr velocity. They apparently decelerate rapidly on impact and penetrate but do not often perforate the body. Patients have been seen literally peppered with tiny holes, with hundreds of small fragments visualized roentgenographically. Each fragment has imparted all of its kinetic energy to the tissues through which it passed, and beneath the cutaneous wounds has been found tissue destruc- tion of almost unbelievable extent. It has been impossible accurately to localize or remove all fragments. The diangosis of abdominal injury has been difficult in the presence of multiple such wounds of the abd- ominal wall, any number of which may have entered the peritoneal cavity, Laparotooy for exploration and diagnosis has often been indicated. Rifle bullet wounds have usually been single. Wounds from Gorman machine guns or machine pistols have frequently been multiple because of the very rapid rates of fire of these weapons. The mortality rate of bullet wounds has been 24.7$, slightly greater than that from high explosive fragments, which was 23.1$. In our eixperience, the destructive effect upon tissues of small arms missiles has been quite similar to that of high explosive fragments. Striking perpendicularly, bullets often caused clean, small perfofations; tangential impact gave rise to large lacerations, and concussive rupture of viscera has been observed. The multiple effects of a bullet were well illustrated in a particular case: A German prisoner of war had been wounded at about 20 yards range by a 0.30 calibre American carbine bullet. The missile was in the initial phase of high velocity. The wound of entry was in the left mid- axilla, and of exit, through the left pubis. There was a 5 mm. perfora- tion of the diaphragm with very little contusion. The missile caused a gutter wound of the lateral margin of the left kidney, but the con- oussive effect was such that the entire organ was split widely open to the uretero-pelvic junction. Small, through-and-through perforations of the jejunum were present in two places (perpendicular impact), but Abdominal Injuries, (oontd) there were extensive mangled perforations and lacerations in the other parts of the bowel (tangential impact). The wound of entry into the bladder was large and explosive in appearance, while that of exit was small and clean. Prom the foregoing description, it will be seen that the effects of bullets are nmltiple, and depend upon velocity as well as upon the angle of impact. Wounds caused by armor-piercing small caliber bullets have been characterised by the fact that the jacket was usually shed by the pro- jectile and might act as a secondary missile of irregular shape. The steel core caused trauma similar to that from an ordinary lead-core bullet* The jacket has been easily mistaken for a shell fragment in the roentgen film because of its jagged contour* Ricocheted bullets usually were distorted, and frequently the jacket was partially separa- ted at the base. The tearing effect of such missiles upon tissues has been obvious* Mine fragments have caused a small number of abdominal wounds. Nearly all such injuries have been due to the German "S-Mine" (Bouncing £etty")* The characteristic missiles from these mines have been steel balls (shrapnel) or small, machine-out steel cylinders* Their effects have been essentially similar to those of shell fragments. Secondary missiles have consisted of dirt, stones, bone,fragments, and rarely bits of the impedimenta present in the soldiers' pockets or of his identification tags. The most important are the bone fragments. In 238 oases in this series, fractures of the pelTls were noted in association with abdominal wounds. In oases in which a missile entered the abdomen through the bony pelvis, there was frequently forcible ir- ruption of spicules of bone into the peritoneal cavity. These bony splinters have been observed to cause perforations of both the large and small intestine, notably the cecum. The same effect has been ob- served in wounds from missiles entering through the spine. There have been rare instances of rupture of intraperltoneal viscera associated with wounds which did not penetrate the peritoneum. Such injuries have been caused apparently by missiles of very high velocity and great concussive power* It most finally be stated that the extent of tissue destruction caused by missiles of war, particularly artillery shell fragments, has at times almost surpassed belief* Intestine has often been shredded to ribbons, and solid viscera have on occasion seemsd to have exploded* Completely detached pieces of liver, spleen, or kidney have been obser- ved free in the peritoneal cavity* We have been nothing In civilian surgery which remotely approaches the extent of trauma associated with war wounds* 105 Abdominal Injuries* (oontd) ENTRY AND BUT WOUNDS There have been 2066 penetrating aid 656 perforating wounds in this series (data available in 2722 oases). The frequency and morta- lities of these types of wounds are represented in Table XIII* TABLE XIII Inoidenoe and Mortality, Penetrating and Perforating Abdominal Wounds, 1944 - 1945* (2722 cases data available) Number Number Percent Type of Wound of Cases of Deaths Mortality Penetrating 2066 329 15.9% Perforating 656 165 23.6% Total 2722 484 17.8% The anatomical distribution of wounds of entrance into the abdomen is graphically depicted in Figure 14. In 2586 oases in which data were accurately recorded as to the site of wounds, 1228 (47.5#) missiles entered anteriorly, 730 (28.2#) entered posteriorly, and 617 (23,8#) entered from a lateral aspect of the body. Eleven missiles (0.4#) entered through the perineum. The < wounds were nearly identically distributed between the right and left sides of the body. Excluding wounds of the midline, there were 1209 on the right end 1215 on the left. There were 341 or 13# of all wounds in which the entry wound was in the buttocks or region of the hips. 106 Abdominal Injuries, (oontd) DISTRIBUTION Of WOUNDS OF ENTRANCE INTO THE ABDOMEN 2586 CASES Figure 14- - Distribution of Wounds of Entry. The most significant discrepancy in th® foregoing figures is in the greater incidence of anterior than of posterior wounds. This may possibly be explained by the greater thickness of the musculature of the back and by the presence of the bony spine* both of which would tend to afford more protection than would the anterior abdominal wall. Soldiers with field packs on their backs would also receive added protection* specially against low velocity missiles from behind, Another obvious ' ation is that our soldiers were advancing. 107 Abdominal Injuries, (oontd) TIME LAG The significance of the interval of time between wounding and surgery is discussed in seme detail (Page 132 ). Because the average time lag between wounding and surgery was relatively short, and in an appreciable numer of cases was less than six hours, many critically wounded oases were admitted who could not have been treated at all, because of impending death, had the first priority surgical hospital been further removed from the lines of battle. The high ratio of these severely wounded who died altered the character of the curve which re- presented mortality rate plotted against time. The average time lag of all oases plotted against mortality rate yielded a curve with a very gradual slope, but it must be emphatically stated that the duration of the interval between wounding and surgery was of vital significance, and average canes cannot be considered. The several distinct types of casualty must be considered separately. Reference is again made to the section devoted to "Time Lag". (Page 132 J PREOPERATIVE CARE AND DIAGNOSIS The preoperatlve care of the casualty with an abdominal wound has consisted of the following routine: removal of all clothing; placement of the patient upon a clean litter; rapid but complete physi- cal examination and clinical history, blood typing and cross matching; immediate institution of necessary res its citation therapy; intramuscular or Intravenous administration of penicillin sodium (20,000 - 25,000 units); catheterization if the patient could not void, urinalysis; placement of a Levin tube in the stomach and gastric aspiration, and finally, roentgen examination. The foregoing measures have been carried out in the main by the shock officer and personnel under his charge. However, it has been the ultimate responsibility of the surgeon who is to operate on a given case to assure himself that all indicated steps in the preopera- tive care have been performed. Ideally, the surgeon and shock officer jointly oared for the patient, but this has frequently not been possible when the surgeon was operating at the time other oases were received. It is obvious that the history and physical examination, and review of laboratory findings and roentgen films have demanded the personal at- tention of the surgeon. The surgeon haw also decreed the optimum time for operation, although often with the assistance of the shook officer* Detailed consideration of the techniques and procedures of resus- citation therapy will be found in the report "Preoperative Preparation" (Page 23 )« The problems of preoperative diagnosis are dealt With in detail in the discussion of injuries to the various viscera (Part III), Abdominal Injuries, (contd) Suffice it to say here that in the average case, diagnosis of wounds of abdominal viscera is inexact, and has been based largely on probability after careful consideration of the site of the entry wound, the site of the exit wound (or of the retained foreign body on the roentgen films or fluoroscopy), the direction from which the soldier believed he was struck, and the posture of the soldier at the moment of wounding. In all cases, the final complete diagnosis oould only be made by direct visualization at operation. PREOPERATIVE CARE AND COMPLICATION Postoperative care and complications are considered in detail in the section on the postoperative care (Page 65 ) and in Part II of the abdominal section (Page 203 ). Further disoussion is found in Part III of the abdominal section for each specific visous. 'SHOCK SYNDROME" An outstanding finding in this study has boon that approximately 51% of all deaths occurred within the first 72 hours postoperatively. Battle casualties with abdominal wounds who die in this period fall into a well-defined group of oases. They are nearly always admitted to the hospital in severe shook and respond poorly to resuscitative therapy and to surgery, Pr«opa*atively or postoperatively the blood pressures may be brought to normal levels by nassive and rapid transfusions but they cannot be maintained. Severe peritoneal contamination is frequent- ly noted in the records and is clinically believed to mater- ially to the patients* severe illness and poor response to treatment. We have chosen to designate the symptom-complex described here as the "Shock Syndrome", This term is applied only in abdominal cases in which the clinical picture is as here presented and in which there is a fatal termination. Before and after operation these patients present the appearances of severe shock. The blood pressure as has been mentioned tends to be low and oan be only temporarily sustained by heroic measures. The pulse is weak and rapid. Pulse deficit has been observed. The sensorium may be clouded. The color of the skin it pale, usually with oyanosis or mottling. The temperature is sometimes subnormal and rarely above 100° F. Massive transfusions, careful surgery, constant oxygen inhalation! therapy, chemotherapy and all other measures fail appreciably to alter the picture and early deaths ensues. The causes of death commonly cited in these oases are "shook", "irreversible shook", "shook and hemorrhage" or "shock and peritonitis", (By "peritonitis" is usually assart an over- whelming peritoneal contamination.) 109 Abdominal Injuries* (Shock Syndrome, oontd) It appears that if any significant reduction in the mortality of abdominal wounds below that reported in this series is to be attained, it must come from an increased salvage rate in this group of cases* It is our opinion that relative to the ability of present day surgery to save lives, these casualties represent lethal wounds. The life-saving value of free replacement therapy with whole blood in unquestioned* Nevertheless in patients presenting this shook syndrome it appears to be of no avail* The physiology of severe traumatic shock, particularly in the presence of massive peritoneal insult, must be further understood before these lives can be saved. ASSOCIATED EXTRA-ABDOMINAL INJURIES Associated extra-abdominal injuries would be expected to have a pronounced effect upon the mortality of abdominal wounds. This subject is separately considered in Part II. It has been found that contrary to expectations, the mortality rates for patients with and without associated wounds have been nearly the same. Further analysis however has disclosed that there is a constant increase in mortality rates of about 3.8$ in the presence of associated injuries, if these rates are plotted against individual groups of cases according to the"multiplicity factor”(i.e., single, double, triple organ injuries, etc.). These data are presented in Figure 26 , Page 154 (report on Associated Injuries in Abdominal Wounds, Part II). It is apparent that the effect of associated injuries in exclusive categories of cases is definite, but that in gross statistics for the series as a whole it is masked by other factors. THE "MULTIPLICITY FACTOR" The "multiplicity factor" refers to the number of abdominal organs Injured in a given case, as determined at operation. No selectivity of organs is necessarily implied, and combination is limited to numerical incidence alone. The necessity for d etermining the extent of injury in abdominal wounds early became apparent in this study. The statistical data that were gathered were often meaningless unless comparable oases could be evaluated. This was particularly true in regard to the time lag and associated injuries, as well as in comparisons of wounds of the given viscus itself. The most valuable and consistent yardstick for measuring the extent of damage in the abdomen proved to be the number of viscera involved in any given abdominal wound. This "yardstick" we have designated as the "multiplicity factor". As shown in Figure 15* (Mortality rates in percent). 110 Abdominal Injuries. (The "multiplicity Factor”, contd) Figure 15 - "Multiplicity Factor" in 2913 Abdominal Wounds. The mortality rate ascends with each additional organ injured in almost arithmetical progression. Not only does this hold true for abdominal wounds as a whole, but constantly for each particular viscus also. Abdominal Injuries, oontd. Figure 16 - "Multiplicity Factor" as Applied to Various Viscera. Variations occurred in a fev organs, such as the stomach, pancreas, and in vascular Injuries, and in these instances a plausible explanation was apparent for the variation. It is realized that severe hemorrhage, extensive damage to a single visous, prolonged time lag, and associated injuries of extra- abdominal structures produce discrepancies which effect the "multiplicity factor" when applied to the individual case, but for group analysis it has proved to be a consistent and valuable index for the assessment of injuries in abdominal wounds. 112 Abdominal Injuries (contd) DISCREPANCIES AND CORRECTIVE FACTORS The principal numerical discrepancy which arises in subsequent re- cord data is due to the inevitable variation which must occur when dif- ferent individuals assess records from different points of view. At times the compilation of data was completed for some studies before all the case records were made available. In many instances, the records were incom- plete as to particulars sought, and the numerical incidence of cases used was less than the total number of cases in a category. Discrepancies a- rising in regard to the number of thoraco-abdominal cases recorded in the abdominal section, and. the particular section on troraco-abdorainal injur- ies, are attributable to the fact that the latter study included cases done in 1943 as well as 1944; and 1945, and the definition of thoraco-ab- dominal cases was more rigid. Prom a purely statistical point of view, when cases were omitted from a category because insufficient data were not available for the de- tails sought, variation within a range must be allowed for. This range, applicable to any percentage figure stated, varies wit]), reference to the number of cases with data not recorded, within the limits of most favor- able, most unfavorable connotation. When cases are subdivided into similar groups for purposes of com- parison, the usual reservation applies to categories numerically insig- nificant. DEATHS Gross Statistics. A total of 756 deaths are known to have occurred among the 3154 cases in the forward hospitals in which tho initial surgery was performed. This gives on over-all mortality rate of 2U%. As shown in Table IV, page 70 , there was a gradual decrease in mor- tality rate with increased experience in treating abdominal casualties, the mortality rate of thoraco-abdominal wounds showing the greatest de- cline, This decline is, we believe, largely the result of better handling of the' thoraco-abdorainal wounds through the influence of the thoracic surgeons of the Group. Table XIV, shows the mortality rate for each organ involved. 113 Abdominal Injuries. (Deaths, oontd) The mortality rates seem much higher than the general overall mortality rate because of the duplication of recorded deaths resulting when multiple organs were injured. TABLE XIV Mortality in the Various Viscera Injured (Complicated and Uncomplicated Cases) Visous Cases Deaths Mortality Colon (excluding rectum only wounds) 1106 406 57% Jejunum and Ileum 1168 345 50% Liyor 829 224 27% Stomachs 416 169 W Kidney 427 149 56% Spleen 341 85 21% Rectum 155 47 50% Bladder 155 46 50% Duodenum 118 66 _ - - 68* Pancreas 62 36 68% Gall Bladder 53 16 so< .. .... Ureter 27 11 11% The mortality rate of uncomplicated and complicated injuries of each vlscus is given in Table XV: TABLE XV Mortality of Uncomplicated and Complicated Wounding of Abdominal Viscera Uncomplicated Cases Complicated Cases* Visous Cases Deaths Mortality Cases Deaths Mortality Colon (excluding rectum) 251 57 . 855 387 40.8# Jejunum and Ileum 363 49 1*5 815 296 36.3# Liver 339 35 ...i$...... 490 191 38.2# Stomach 42 12 374 127 _ «•§ . Kidney 56 9 i§ 371 140 37.7# Spleen 100 12 1*5 241 73 30. 3# Reotum 64 9 1*5 91 38 41.7# Bladder 21 0 P* 134 46 **.*% duodenum 2 1 502 116 65 56.9# ♦The mortality rate in complicated cases is apparently high due to the additive effect of the same death being listed tinder two or more organs* Abdominal Injuries« (Deaths, Table XV, contd) Table XV, contd. Visoua Uncomplicated Cases Cases deaths Mortality Complicated Cases* Cases deaths Mortality Pancreas 1 1 100# 61 35 55,7% Gall Bladder 0 0 0% 55 16 30.0% Ureter 1 0 0% ~26 11 42.3* *The mortality rate in complicated cases is apparently high due to the additive effect of the same death being listed under two or more organs. Day of Death. Figure 17 below, shows the number of deaths occurring on each postoperative day. Forty-eight percent (363) of all deaths occurred on the day of operation. Of these, four died during the induction of anesthesia, and 83 died during surgery or within 10 minutes thereafter. Figure 17- Chronological Distribution of 717 Deaths Occurring in 2895 Cases. Abdominal Injuries, (Deaths, contd) The remaining 109 died within 24 hours of the operation. As shown in Figure 19 these deaths, with few exceptions, occurred with the picture of the "shook syndrome"• TABLE XVI Principal Causes of Death Cause of Death "Shock" Number 472 Percent of Total Deaths 62.4$ Pulmonary 97 12.8$ Peritonitis 91 12.0$ Anuria 55 Anaerobic Infection 12 i-sji Miscellaneous 30 No record 19 27m To-ta.1 756 99.9$ MORTALITY IN RELATION TO JAY Of JfATH AND MULTIPLICITY FACTOR IN 7J6 ABDOMINAL CASES /m - ms Figure 18 - Mortality in Relation to Day of Death and "Multiplicity Factor", 116 Abdominal Injuries (Deaths, contd) The multiplicity factor in relation to the day of death is seen in Figure 18 , Since practically all deaths occurring on the day of op- eration died of shock, it is seen that a higher proportion of patients have this syndomre when a high multiplicity factor is present. Causes of Death. Sixty-two percent of patients died in shock within 72 hours of op- eration, For brevity and clarity, all cases dying with the picture of shock are classified under this heading. Included are 64. cases in which the principal cause of death was acute hemorrhage, cases with shock from severe peritoneal contamination and clinical peritonitis, patients with cardiorespiratory embarrassment, cardiovascular injuries, severe brain injuries, vago-vagal refles, blast injury to the lung, and other relat- ively rare and shock-producing phenomena. In approximately 51$ of all deaths, no particular shock-producing factor could be singled out as being the principal cause of death. In- stead the death seemed to be produced by the interaction of conditions of hemorrhage, peritoneal contamination and tissue destruction, pro- ductive of the '‘shock syndrome” described in Pages 108 - 109 of this sec- tion. Other principal causes of death occurring in a significant number of cases were pulmonary complications, anuria, and peritonitis. These three most significant causes of death, together with the ”shock” deaths are graphically illustrated in Figure 19 in relation to the day of death. It will be noted in Figure 19 that most deaths from pulmonary com- plications occurred from the second through the seventh postoperative day. These pulmonary complications consisted mainly of pneumonitis, atelec- tasis, empyema, pulmonary embolism and some balst injury to the lungs, and produced almost 13$ of all deaths. They are fully discussed in the report on "Postoperative Complications", pages 205 - 209 and also in the section on "Deaths", page 773 Anuria, if it occurred, was not recognized during World War I as a clinical entity. Deaths from this complication amounted to approximately 5$ of total deaths. It is discussed in detail in the report "Posttrau- matic Renal Failure", page 758 • Abdominal Injuries (Deaths, contd) Figure 19 - Principal Causes of Deaths and the Day Deaths Occurred Peritonitis, as designated here, does not include the early type associated with the '’shock syndrome”, but refers to the generally re- cognized clinical type familiar in civilian life. It accounted for 12% of the deaths, death occiirring mostly between the second and tenth post' operative days. Anaerobic infections produced- death in 1,5% of all fatal cases. These include anaerobic infections of wounds involving the abdomen or retroperitoneum, as well as extremity anaerobic infections. 118 Abdominal Injuries* (Deaths, contd) Approximately 4$ of deaths are accounted for by a miscellaneous group of cases, including overlooked visceral lesions, abscesses of the abdomen, dehiscences, intestinal obstructions, and others. The reader is referred to the section on "Deaths in the Forward Hospitals", Pages 773 to 813 for a detailed analysis. Corrective Factors in Mortality The mortality rates as given are admittedly lower than the true figures. It must always be remembered that only deaths occurring in the hospital in which the surgery was initially done are included. No attempt has been made to obtain follow-up data, and no estimates of deaths rates in subsequent installations are available to us. Moreover, in 256 cases, no record of progress was made after the initial surgery. In 81 cases, no record of subsequent course was avail- able after the third postoperative day. These data were lacking mostly because of movements of teams, or because of very early forced evacua- tion of patients. By a simple proportion of known deaths occurring in a known number of cases, a corrective factor can be made for the cases with no progress notes. Assuming that the proportion holds true, it ie estimated that 67 additional deaths occurred in the initial surgical installations. This figure raises the gross mortality rate to 26,1$, which figure we believe to be fairly accurate for the deaths occurring in this seriet* All mortality figures are therefore probably about 2$ lower than the true figures for the initial surgical installations. Discussion of Deaths, The mortality rate in a series is a composite expression of the interaction in each individual case of all factors which have led to death. By selecting exclusive categories of injuries, we have been able to demonstrate the nature of the major contributing factors. The fol- lowing facts are pertinent: 1, The original severity of the visceral wound, whether to one organ or to several, is the principal determinant in its lethality. This fact cannot be graphically expressed. 2. The most reliable index of wound severity which is susceptible to statistical study is the multiplicity factor: The more organs in- jured, the high&r the case fatality rate. Multiplicity factor affords a convenient classification of eases into exclusive categories according to severity. Abdominal Injuries, (Deaths, contd) 3. Prolonged time lag has an adverse influence on prognosis, and the more severe the wound, the greater is the danger from increased time lag. 4, Sixty-two percent of all deaths have occurred within 72 hours of admission to the hospital, and these deaths have almost universally been ascribed to shock. 5, The more severe the shock on admission, the graver the prog nosis. In assaying mortality, two main factors only need be considered, if we except for the moment the less frequent causes of death. First is the original severity of the wound. Our best method of analyzing this is in terms of multiplicity, which is admittedly only an approxi- mation, The second is time lag. The correlating factor between these two is the degree of shock, which is to be regarded as a manifestation of the effects of a wound of given severity affecting the patient for a given length of time. Death ascribed to shock is the extreme manifesta- tion of the combined effects of the two factors. The following facts have been derived from this study: (a) That there are two categories of cases which show universally high mortality rates. These are oases having high multiplicity factor, and oases ad- mitted to the hospital in severe shock, (b) That oases having high multiplicity have as a group the greatest frequency of severe shock, (c) That oases with high multiplicity are not seen with long time lag. This confirms the logical expectation that the most severely wounded either reach the hospital early or not at all. Consideration of the facts presented above leads to a conclusion which is quite in agreement with clinical observations. This conclusion is that the majority of deaths (actually about 62$) in forward surgical hospitals occurred among casualties in which theeffeots of very severe wounds and of time lag combined to produce a stats that could not be corrected. In short, the combined effects of the wound and the time lag are lethal, regardless of all efforts to defeat them. Pulmonary complications, peritonitis, and renal failure (anuria, "hemoglobinuria nephropathy") have together caused 5($ of all deaths. These causes have been shown also to be related at least in part to the severity of the wound and to time lag. The frequency of pulmonary complications has risen in direct pro- portion to increase in multiplicity of organ injuries. Peritonitis has been observed most frequently as a cause of death among patients having unusually prolonged time lag. This would be 120 Abdominal Injuries (Deaths, contd) expected. The longer peritoneal contamination exists, the greater is the likelihood of development of a virulent peritonitis. Anuria has usually occurred in patients with initial severe shock, in whom resuscitation has been difficult and who have required massive replacement therapy. These cases seemed closely related to the 62% who died early of the severity of their wounds. The 5% dying in anuria re- present similar cases in which early fatality has barely been verted, but in which fatal physiologic changes were apparently already estab- lished. The remaining 5% of deaths were caused by many miscellaneous fac- tors, including associated wounds, anaerobic infections, and anesthetic and surgical complications. These causes of death cannot be said to have ha.d more than a slight effect upon the mortality rate of the series. BIBLIOGRAPHY 1, Bailey, Hamilton! Surgery of Modem Warfare, Vol I, E, & S, Liv- ingstone, Edenburg. 2. Matas, Rudolph: Abdominal Gunshot Wounds, Annals of Surgery, 3:815 (May) 1945. 3. The Medical Department of the US Army in the World War. Govern- ment Printing Office, Washington, 1924. 4-. Wallace, Sir Cuthbert: ‘War Surgery of the Abdomen. London, 191B, 5. Ogilvie, H. H.j Surgery, Gynecology and Obstetrics, 78:225 (Peb) 1944. 6. Jolly, Doughlas H.: Field Surgery in Total War. P. B, Koeber Inc,, New York, 194-1. 121 ZOUNDS 0.1? THE ABD0I5SH Part II Detailed Discussion of Subjects Pertinent to All Abdominal .Zounds (l) Shock Therapy in Abdominal bounds 122 Pa^e (2) Time Lag (3) associated .ictra-abdominal Injuries .... 1/7 U) Tr aunatic Evisceration 1O2 (5) .anesthesia in Abdominal Sounds 169 (6) Incisions, Closures and Dehiscences .... 187 (7) Effect of Sulfonamides and Penicillin , . . 197 (B) Postoperative Complications 203 THE PROBLEM OF SHOCK THERAPY IN ABDOMINAL VJDUNDS INTRODUCTION The success of military surgery often depends upon adequate control of shock before and during operation, particularly in forward installations where care is provided for the severely wounded. Of the severely wounded, those with major wounds of the abdomen constitute the greatest problem in the treatment of shock, for the following reasons: 1, Aside from injury to hollow viscera, vascular injury is often extreme either due to isolated laceration of the spleen, liver, or a major vessel, Sven more commonly, excessive blood loss arises due to multiple injuries and the laceration of numerous small vessels. 2, The contamination of the peritoneal cavity and/or adjacent retroperitoneal tissue greatly complicates the problem of simple replace- ment therapy since it imposes the certain threat of overwhelming infection. Intelligent management of this- exigency demands that surgical care be instituted with as little delay as possible. Cases with evisceration require prompt surgery for the relief of evisceration and control of peritoneal contamination* 3, The frequent concomitant transdiaphragmatic injury of the thorax is important from the standpoint of cardiopulmonary embarrassment as well as rendering the pleura liable to contamination by bile or bowel contents. 4* The multiple vascular and visceral injuries which are so common in these cases often present surgical problems of great technical difficulty. The duration of anesthesia and operation as well as the blood loss during operation may be extreme. Intelligent shock therapy plus well-conceived surgery and post- operative care attempts to restore circulatory dynamics to as nearly a normal level as possible. Those in charge of shock therapy as well as the surgeon must always realize the limitations or replacement therapy in patients with continuing hemorrhage or early fulminating infection. In such cases, life may be saved in no other way than by prompt and skilled surgery. The care of these casualties constitutes the greatest challenge to all personnel who work in forward hospitals. DATA AND REMARKS During the years 1944 and 1945, 3154 abdominal operations were performed by teams of the 2nd Auxiliary Surgical Group, From this group, 123 The Problem of Shock Therapy in Abdominal Wounds. (Data and Remarks, contd). 957 cases were taken in ■which there was perforation of a hollow viscus and in which the data relative to shock therapy were complete. This afforded a means of evaluating shock therapy in which the problem of peritonitis exists. In reviewing the records of all cases it was noted that shock data were aore apt to be complete in the poor-risk cases, consequently a relatively high proportion of these cases appears in our series. For this reason our figures on mortality and amount of replace- ment therapy are somewhat more applicable to the poor-risk than to the average patient* The classification of shock into statistical categories is diffi- cult since the objectivity and interpretations of different observers may vary considerably. However, for purposes of comparison and refer- ence, the following criteria have been used in the tabulation of the data under discussion. "Degree” of Shock Systolic Blood Pressure Incipient or no shock 101 - 120 plus Moderate 71 - 100 Severe £ 1 -<3 O Profound or pre-terminal 0 1 S This classification is employed with the full realization of its shortcomings, chief of which is the fact that the fall in blood pressure does not occur early, and the severity of shock and oligemia are apt to be greater in the first group than the blood pressure indicates, "Preoperative Diagnosis and Triage” page 7 )• However, experience with a large group of severely wounded indicates tnat once the blood pressure has°falien below normal levels, certain therapeutic and prognostic impli- cations may be deduced from the admission blood pressure readings. The average time interval is expressed in number of hours from time of injury to initiation of surgery. Among the four groups the average time intervals varied from 10*4 to 11.6 hours (see Table I) and it is evident that these figures are not indicative of the importance of the time factor as related to the degree of shock. Obviously, in wounds of equal severity, the total amount of blood loss and the severity of shock will tend to in- crease with the passage of time. 124 Summary of Replacement Therapy Admission Systolic Blood Pressure (mm. Mercury) No. Cases Incidence Rate Average : Replacement Therapy** • Mortality Rate Time Interval* Preoperative During Surgery No. Died Plasma : Blood Plasma Blood Plasma : Blood 0 1 5 140 14.6* 10.8 713 1745 311 1617 1024 3362 66.4* 41-70 121 12.7? 10,7 687 1271 311 1278 998 2549 61 50.4* 71 - 100 250 26.1* 11.6 602 873 261 1063 863 2036 9? 38.0* g i M 8 446 46 .6* 10.4 492 619 178 962 670 1581 81 18.1* * TOTAL * * • 957 : 100* 10.7 330- 35.4? * Time, in hours, from injury to*pperation, **Blood and plasma, in cubic centimeters, per patient# 957 ABDOMINAL GASES WITH PERITONEAL CONTAMINATION SECONDARY TO PERFORATION OF GASTR0-INT3STINTRACT TABLE I The Problem of Shock Therapy in Abdominal Wounds, (Data and Remarks, contM}* Figure 20 - The Relation of Blood Pressure to Replacement Therapy. 126 The Problem of Shock Therapy in Abdominal Vfounds. (Data and Remarks, contd). Figure 21- Mortality - Initial Blood Pressure Relationship. 127 The Problem of Shock Therapy in Abdominal bounds, (Data and Remarks contd)* Figure 22 - Day of Death in Relation to Admission Blood Pressure.* 1944 128 The Problem of Shock Therapy in Abdominal Wounds, (Data and Remarks, contd). Replacement therapy of the wqr wounded is often actually started in the Battalion Aid Station with the initial unit of reconstituted plasma. There- fore, the figures concerning the quantity of plasma given preoperatively indicate the amount of plasma given prior to admission to the hospital as well as that given in the shock ward. The figures concerning blood and plasma used in replacement therapy are expressed as an average per case in each group, "Total11 replacement therapy refers to that amount of blood and plasma which the patient received prior to or during operation. The mortality rate is expressed separately, in percent, for each group* The vast majority of the deaths occurred in the Field Hospital and it is realized that the death rate would be higher if it were possible to follow each patient through the period of hospitalization in the base section. Table I and Figure 21 show clearly the correlation be- tween the degree of shock and the mortality rate and emphasize the poor prognosis in those cases with severe shock. Figure 22 relates the degree of shock to the time of death and indicates the high incidence of death in the immediate postoperative period. Further analysis of Table I shows that over 50% of all patients in this series exhibited moderate, severe, or profound shock. The relative amounts of replacement therapy required to accomplish resus- citation increase in almost direct proportion to the degree of shock as shown graphically in Figure 20 • As discussed in "The Resuscitation and Preoperative Care of the Severely Wounded" (page 23), this indicates the importance of blood pressure in evaluating the degree of blood loss. How- ever, it must be remembered that the values represent averages for a relatively large number of patients; application of these data to a single patient may lead to error but they represent a general guide to therapy. Furthermore, the volume of replacement therapy which has been found necessary is of the same order of magnitude as the blood loss in various degrees of shock. The patients in the lowest blood pressure group consistently ex- hibited more severe injury than those patients whose blood pressure app- roached nonaal i,e,, multiple visceral injuries were more common in the severe shock groups. Similarly, .the incidence of lacerations of the spleen or major vessels was almost four times as common in the 0-40 mm, group as in the 101-120 mu, group. The incidence of these injuries was as follows* 129 The problem of Therapy in Abdominal Wounds, (Data and Remarks contdj, * Admission Systolic Blood Pressure (am. of Mercury) Spleen or Major Vascular Iniurv- No. Cases No. Cases 1 Incidence 0 - 40 ..140. 43 31 % 41 70 121 25 21% 71 - 100 250 39 ~ ws 101 - 120 7T ...446 2L 8% These data further emphasize the importance of hemorrhage in the production of severe shock. THE ROLE OF INFECTION IN PRODUCING SHOCK AND DEATH IN PATIENTS WITH ABDOMINAL INJURIES The various aspects of fluid loss and changes in the splanchnic vascular bed which follow severe peritoneal contamination h:ve been discussed* and this will not be repeated here. Certainly, fluid loss by seepage from irritated peritoneal surfaces is important in reducing the effective circulating blood volume, though the tendency to hemo- concentration is usually masked by hemorrhage in battle casualties. Also a large volume of relatively static blood may be contained within the dilated splanchnic vascular bed. We believe that these factors suffice in the majority of instances to explain the wound shock which is seen within 6-10 hours after injury. We do not believe, however, that such is a full explanation of the shock which precedes death during the period 24-4# hours after injury. In the latter period shock due to the relatively simple process of blood end plasma loss becomes a more complex phenomenon which depends upon the summation of the deleterious effects of hemorrhage, contamination and beginning infection. In the final analysis an evaluation of the role of peritonitis in the production of shock becomes, essentially a study as to the mechanism of death in peritonitis. Any discussion of either problem is likely to accomplish little because of the paucity of real information concerning the underlying pathological physiology. Too often death from peritonitis is ascribed simply to ntoxemia" or the statement is made that 11 too much contamination was present for the peritoneum to overcome it1*. What factors * "Resuscitation and Preoperative Care of the Severely Wounded", (page 23 )« 130 The Problem of Shock Therapy in Abdominal Wounds, (The Role of Infection in Producing Shock and Death in Patients With Abdominal Injuries, contd). are responsible for death in such cases; why did the patient fail to overcome the effects of contamination? These and many more questions must be answered before our understanding of such problems advances beyond the elementary stage. Certainly, the extant of peritoneal contamination in war wounds is much greater than that ordinarily encountered in civilian surgery. Likewise, the average time (10,7 hours) from injury to operation is considerable and of sufficient duration that the peritonitis of fecal contamination is being supplemented by the peritonitis of bacterial growth. That fatal infection often becomes established is not remark- able in view of previous experiences with the effect of preoperative delay upon the mortality of ruptured duodenal ulcers. The remarkable fact is the predominance of death within 24-48 hours following operation (see Figure 22 ), Autopsy examination of such patients characteristically shows only moderate dullness and opacity of the peritoneal surfaces; a moderate amount of slightly cloudy serosanguinous exudate and a few strands of fibrinous exudate. Insufficient time (or perhaps shock due to fluid loss) has not allowed the production of a frankly purulent exudate. Or, perhaps, the local leukocytic response is inhibited by the overwhelming nature of the infection similar to that seen in rapidly invasive streptococcal or clostridial infections. The lethal implications of a generalized purulent peritonitis (as seen four to five days after peritoneal contamination) £re apparent; it is believed that the peritonitis just described may be of equal significance at an earlier period, partic- ularly in a patient whose recovery from wound shock is incomplete or in progress. Practically no data are available concerning the bacteriology of the peritonitis which follows severe contamination. Judging from previous experience, little would have been added to our knowledge by such study* However, rare cases of gas infection of the peritoneal cavity have been observed by members of this Group, In one case a pure culture of Cl. welchi was obtained from the peritoneum, (See section on Clostridial Infections, page746), * Obviously much remains to be learned concerning the mechanism of shock in the pathogenesis of infection; the importance of the presence of certain types of organisms (e,g,, the Clostridia) or of several symbiotic organisms, etc,, are problems for the future. Perhaps the foregoing preoccupation with the unsolved problems of peritoneal contamination is unwarranted. Certainly, it comprises one of the most difficult problems which have confronted military surgeons during the present war. Experience has shown that severe peritoneal contamination demands prompt surgical care even though, in association 131 The Problem of Shock Therapy in Abdominal V/ounds. (The Hole of Infection in Producing Shock and Death in Patients With Abdominal Injuries, contd). with severe blood loss, it may make resuscitation difficult. In no instance is greater coordination of replacement and surgical therapy required, and preoperative delay must be curtailed as much as possible. SUilMAHY AND CONCLUSIONS 1, From a series of 3154 cases with abdominal injury, shock therapy was analyzed in 957 cases with peritoneal contamination due to perforation of the gastro-intestinal tract. 2, These patients were categorically divided into four groups depending upon their admission blood pressures; the amount of replacement therapy and mortality rates were determined for each group. 3, In this series of abdominal injuries, the necessity for control of shock before and during operation is evident. To accomplish this, blood and plasma were given in quantities which shovfed a progressive increase as the degree of shock increased. 4, The degree of shock as manifest in the admission blood pressure level, was found to bear a direct relation to mortality which was highest in those cases with excessively low blood pressures. Both factors, i,e,, degree of shock and mortality rate, tend to parallel the extent and duration of injury. 5, With increasing degrees of shock there was a progressive rise in the incidence of laceration of a major vessel or of the spleen. 6, The role of infection in the production of shock and death has been discussed briefly. The urgent need for prompt surgery in the control of peritoneal contamination has been stressed. 132 TIME LAG IN ABDOMINAL INJURIES That the passage of time has a profound effect upon the wounded soldier is universally accepted. Hemorrhage, peritoneal contamination, and disturbances of physiology are rendered more serious, the longer they remain uncorreoted, An index of the severity of these threats to life may be reflected in the wounded men by the degree of shock. Severe shock may be compatible with life for a short time; it is incompatible with life for long. A review of 3154 traumatic abdominal and thoraoo-abdominal oases in reference to time lag is submitted for study. Whenever pertinent data were not available, the fact was indicated in the tables by the reduced number of cases considered, or indicated as not having been recorded. TIME LAG FROM INJURY TO SURGERY The average time lag from injury to surgery was 10.1 hours in a series of 2978 eases. Factors which influenced the length of the time interval included terrain, climate, evacuation distance, the tactical situation and the physical capacity of the hospital. The wounded ware often recovered from remote and inaccessible positions under eneay fire* Unusual circumstances such as invasions and paratroop landings may have increased the time lag to several days. The average mortality rate for this series of cases was found to be 22$. (Table I, Appendix). TIME LAG FROM INJURY TO ADMISSION TO HOSPITAL The average time lag from injury to admission into the hospital was 6.2 hours for a series of 1107 abdominal oases. (Table II, Appendix), It was a seeming paradox that the farther forward surgical treatment ms initiated, the higher was the overall mortality rate. The reduction of the initial time lag by forward movement of the surgical hospital brought more of the gravely wounded to the operating table. The death irate for the total number of casualties treated, the ref ore, rose, because in some of the severely wounded the wound was lethal, and the outcome was not affected ty treatment. However the mortality rate fell by the ini- tiation of early surgery in those whose wounds were not inevitably fatal, but which would have become so with the passage of time. TIME LAG FROM HOSPITAL ADMISSION TO SURGERY The duration of the time Interval between admission into the hospital and the commencement of surgery, was the joint decision of the surgeon and the shock officer, provided the available operating room space was 133 Time Lag in Abdominal Wounds. (Time Lag from Hospital Admission to Surgery.) not overtaxed by previous oases. The factors udiich influenced this decision are discussed elsewhere. (Prooperative Diagnosis and Triage, Page 7 ). The average time lag from hospital admission to surgery was 3.9 hours in 1157 oases. (Table HI* Appendix). Cases operated upon two hours after admission had a mortality rate of 16,1, four hours, a rate of 20.5$, six hours, 33.6$ and at 16 hours, 46.4$, The more seriously wounded received the longer shock treatment in many instances, but the futility of delaying surgery beyond an irreducible minimum in those cases suffering from continuing hemorrhage, peritoneal contamination, and significantly altered physiology, may be commented upon. In Figure 23 plotted on an arithmo-logarithmic scale, the mode of the oases is shown. In Figure 24the mortality rate of all cases is shown by the heavy line, plotted against eight hour time intervals. The significance of the duration of the interval between wounding and surgery as indicated by the heavy line is masked by several factors. The significance of time lag becomes more apparent when the average is separated into its several components discussed below and shown in Table I and Figure Figufe 23 - Number of Cases Living and Dead for Each Two Hour Period. 134 Time Lag in Abdominal Injuries, Figure 24 - Death Rate Increase Plotted Against Time Lag Showing Number of Abdominal Organs Involved, 135 Time Lag in Abdominal Wounds. TABLE I Time Lag in Relation to Multiplicity Factor Ho. Abdominal 0 ■ - 8 8 - 16 16 - 24 24 plus Organs Total Mort, Total Mort, Total Mort. Total Mort, Injured, Cases Rate Cases Rate Cases Rate Cases Rate 1 557 6.8$ 617 10.6$ 142 19.0$ 100 25,0$ 2 442 23.2$ 339 28.3$ 91 26.3$ 45 40.0$ S 162 41.5$ 125 46.4$ 22 59.0$ 15 46.6$ 4 44 52.2$ 32 65.6$ 7 85.7$ 0 5 18 83.3$ 5 100$ 0 0 6 4 100$ 0 0 0 Roughly there are three gradations of the severity of wounded, which differed in their mortality response in respect to time-lag: I) The most a ere rely wounded in which there was a high mortality rate. In the fatalities in this group, the immediate or impending lethal nature of the wound was not affected by surgery, and the ease died within the first two postoperative days. Cases with six abdominal organs appeared only within the first eight hours after wounding; eases with five organs within the first 16 hours; and oases with four organs within the first 24 hours. That the mcst severely wounded died within the first two days is shown in the section on the "Multiplicity Factor". 2) the second category is that in which the wound itself was potentially lethal, ohiefly in reference to the duration of elapsed time. Many of this group were salvaged by early surgery. An example of this group appears in the seotlon on wounda of the small bowel. (Figure 234)* 5) the third category is small - those lightly wounded, who it might be inferred by the long duration of their time lag, might well have survived without surgery at all. The ratio of cases in these three categories determined the properties of the curve shown. TABLE II 1944 1945 Total Time - Injury to Surgery 11.5 Hr*• t.f Hr*. Injury to Admission 6.9 Hr*. 5.5 Hr*. Admission to Surgery 4.5 Xrs. 5.4 Hr*. Comparison of Time Lag, 1944 and 1946 136 Time Lag in Abdominal Wounds. This comparison doubtless reflected the effects of several factors, which included increased experience, better facilities of transport, type of terrain, and in many instances the desire of the surgeon to com- mence operation earlier on abdominal injuries. DISCUSSIOH The mortality rate of any tinsel acted group of abdominal cases at any selected time interval from wounding to surgery is approximately constant. This is clearly indicated by the parallelism of the two curves in the arithmo-logmaf ithmio scale of Figure 23 and also by the very gradual rise of the heavy line (average mortality, all cases) in Figure 24. Clinical experience indicates definitely that increasing time lag is high- ly detrimental to the individual cane. Thus a paradoxical situation exists between the overall mortality - time lag relationship and clinical experience. Obviously, a masking effect on the significance of time lag occurs when considering overall averages. A study of Figure 24 and Table I demonstrates where this masking effect takes place. It is clearly shown that time lag is of marked sig- nificance if the severity of the wound is taken into consideration. ("Multiplicity Factor" taken as an index of severity of the wound). It becomes at once apparent that no matter how soon an individual with a high multiplicity range is operated upon, the mortality rate is very high, and the rate increases rapidly with additional hours of time-lag. In fact, if these severely wounded patients are not operated upon early, very few oases will remain alive. This is the group of oases that raises the general overall mortality rate in the short time lag periods (under eight hours). On the other hand, it is seen that oases with a low "multiplicity factor" have an extremely low mortality rate if operation is carried out early, but with additional hours of delay, a gradual but significant rise in mortality rate is produced. This is the group of oases that raises the mortality rate in the relatively long time lag bracket (over 16 hours). In effect, therefore, a patient with a low "multiplicity factor" and a long time lag is likely to be in as serious condition as a patient with a higher multiplicity factor and a short time lag. Thus, a balancing effect takes place between the various multiplicity categories in relation to time lag, so that average overall mortality rates are essentially the same for each selected time interval. In other words, the masking effect noted above takes place unless exclusive cate- gories of the severity of the wounding are taken into account. It must be borne in mind that mortality rates in relation to time 137 Time Lag in Abdominal Injuries. lag are at best only a rough approximation of the actual picture. No calculation can be accurate unless the absolute number of deaths and the time lag from wounding to death in patients dying before reaching the hospitalare known. If these could be determined, and the severity of the wound estimated, the influence of time lag on mortality would be accurately pictured. SUMMARY AM) CONCLUSIONS 1. The interval of time between the wounding and the surgical man- agement of a casualty is of vital significance. 2. Graphs showing the relation of time lag to mortality rate are presented and discussed. 3. Overall averages of mortality rates in relation to time lage are of little significance. 4. The adverse effect of increasing time lag upon mortality is demonstrated tjy correlating time lag in relation to severity of wounding. 138 APPENDIX TABLE I Total Time Lag - Injury to Surgery - 1944 and 1945 Time - Hour* Lived Died Mortality Rate 0-2 8 4 33,3* 2-4 123 29 18.2# 4-6 399 108 19.1* 6-8 470 119 17.7* 8-10 373 119 19.6* 10 - 12 269 80 20.4* 12 - 14 167 64 25,0* 14 - 16 131 43 22.8 16 - 18 81 50 22.4* 18-20 61 23 31.5* 20 - 22 49 17 23.4* CM 1 CM CM 48 7 16,6* 24 - 26 21 15 69.1* 26 - 28 25 8 22.5* 28-30 11 3 23.0* 30 - 32 19 7 27.4* 52 - 34 15 6 28.5* 34-56 10 3 25.0* TOTAL 2303 675 22.6* (average) Average time lag from injury to surgery for the above eases (2978) was 10.1 hours. Under 36 hours. 2303. Thirty six hours and over was 45 and 25. Under 36 hours 2303 673 22.6^ 36 hours and over 45 26 33.3$ , Total, all oases 2548 700 22.9# (average) Average time lag from injury to surgery for all oases including ose over the 36 hours was 10.5 hours. (3048 oases). *?ES SOT INCLUDED: (For discussion purposes) * available - 119. 139 Appendix* (oontd.) TABLE II Injury to Admission 1944 - 1945 Hours Lived Dead Mortality Rate 0-2 54 17 21.4$ 2-4 262 86 22.9$ 4-6 239 66 19.3$ 6-8 120 26 16,9$ 8-10 61 19 21.5$ 10 - 12 31 14 26,6$ 12 - 14 19 11 49.9$ 14 - 16 15 6 33,3$ 16 - 18 16 2 13.3$ 18 - 20 9 1 10.1$ 20 - 22 7 3 37.5$ 22 - 24 7 2 25.0$ 24 - 26 4 1 20,0$ 26 - 28 2 1 33.3$ 28-30 4 3 45.0$ 30-32 3 3 50.0$ 32-34 2 0 00.0$ 34-35 1 1 50.0$ TOTAL 846 261 (»▼.) Average "time lag11 for the above oases (llO?) was 6.2 hours. Under 36 hours - 846 261 25,5$ 36 hours and orer - 0 7 100>0ff Total All Cases 846 268 24.0£ Average "time lag" from Injury to admission for all oases (1114) including those over 36 hours was 6.5 hours. VOTE: The above table is based on 1114 oases only. Either "time of injury” or "admission to hospital" time was looking on all the others making it inpossible to determine the time lag. 140 Appendix* (contd) TABLE III Time Lag - Admission to Surgery 1944 - 1946 Hour a LiTod Dead Mortality Rate 0-2 156 30 2-4 405 105 20.5# 4-6 174 88 53 • 6-8 85 55 29.1# 8-10 32 16 33.3# 10 - 12 17 6 27.5# 12 » 14 7 1 14.2# 14 - 16 5 4 46.4# 16 - 18 2 0 00.0# 18 - 20 1 0 00.0# 20 - 22 0 0 00.0# 22 - 24 1 0 00.0# 24-26 0 2 100.o# CO CM » co CM 0 0 oo.o# 28-30 0 0 00 .0# 30-32 0 0 00 .0# ss 1 CM to 0 0 00.0# 54 - 36 0 0 00.0# TOTAL 883 274 23.6# (av.) The average "time lag" from admission into the hospital until surgery for the above oases (1157) was 3.9 hours. Under 36 hours - 883 274 23,6^ 36 hours and over - 0 1 100>0^ Total All Cases - 883 275 25# Average The average "tine lag" from admission to surgery remained the same when the one over 36 hours was added, namely 3.9 hours. HOTEx The above tabulisation was made from a series of 1158 eases, the remainder of the abdominal series lacking sufficient data to determine accurate time lag. 141 Appendix* confcd. TABLE IV Total Time Lag - Injury to Surgery 1944 Hours LiTod Dead Mortality Rata 0-2 2 4 66,6# 2-4 75 19 20.2# 4-6 278 79 22.1# 6-8 337 99 22.4# 8-10 ■288 92 24.2# 10 -* 12 221 65 22.8# 12 - 14 125 39 23,7# 14 - 16 107 37 25.7^ 16 - 18 71 28 28.2# 18-20 50 23 31.5# 20-22 41 15 26.8# 22 - 24 38 7 16.5^ 24 - 26 21 13 38.2# 26 - 28 21 7 25.0^ 28-30 10 5 25.0# 30-32 14 5 26,5# 32-54 15 6 28.5^ 54 - 56 9 3 25.0# TOTAL 1723 544 23,5# (av.) Average "time lag* from injury to surgery for all oases including those over 36 hours, mas 11.4 hours. Average "Time,,lag,f from injury to surgery for the above eases (2088) was 11*3 hours. Under 36 hours - 1723 644 25*5$ 36 hours and over - 36 18 33.3$ Total All Cases - 1759 562 24*2$ (»▼•) Cases not included (for discussion purposes) No record available - 119. 142 Appendix* (contd) TABLE 7 Time Lag Injury to Admission - 1944 Hours 0- 2 Lived 34 Dead 13 Mortality Bate 27*7# 2-4 173 64 26.8# 4-6 151 53 25,9# 6-8 80 19 19.2* 8-10 39 15 27.7% 10 - 12 18 12 40.0% 12 - 14 18 9 S3.3% 14 - 16 12 6 S3.3% 16 - 18 IS 2 13.3% 18-20 9 1 10.0% 20-22 e 3 37.5% 22 - 24 6 2 25.0# 24 - 26 4 1 20.0# 26 - 28 2 1 33.3% 28 - 30 3 2 40.0% 30 - 32 3 3 60.0# 32-34 2 0 00.0# £4-36 1 1 50.0# Under 36 hours 573 208 23.6# (av.) 36 hours and over 0 2 100.0# Total All Cases 573 210 23.7# Average "time lag" for all oases (783) from injury to admission to hospital mas 6.9 hours. NOTE: The above table is based on only 783 oases* all other cases of the abdominal series lacked sufficient data to determine "time lag". 143 Appendix. (Contd) TABLE VI Time Lag - Admission to Surgery - 1944 Hours Lived Dead Percent Mortality 0-2 66 20 23,2% 2-4 269 78 22.4% 4-6 132 61 SI,6% 6-8 66 31 53.0% 8-10 27 13 32 .S% 10 - 12 12 3 20.0% 12 - 14 6 0 00.0% 14 - 16 4 3 42.8# 16 - 18 1 0 00.0% 18 - 20 1 0 00.0% 20 - 22 0 0 00.0% 22 - 24 1 0 00,0% 24 - 26 0 2 100.0% 26 - 28 28-30 30 - 32 32-34 * 34-36 TOTAL 585 211 (»T) The average "time lag" for the above cases (769) eas 4,5 hours. Under 36 hours - 585 211 26,5?£ 36 hours and over - 0 1 100,($ Total all Cases 585 212 (av.) The average "time lag" after including the one ease over 36 hours, remained 4.5 hours. BOTE: The above tabulation was made from a series of 797 canes; the remainder of the cases of the abdominal series had insufficient data to accurately determine the time lag. Appendix# (oontd)* TABLE VII Injury to Surgery - Total Time Lag 1945 Hours Lived Dead Mortality Rate 0-2 6 0 00.0% 2-4 51 10 16.3?$ 4-6 121 29 16.1?$ 6-8 133 20 13.0?$ 8-10 85 27 15.1?$ 10 - 12 68 15 18.0?$ 12 - 14 42 15 26.3?$ 14 - 16 24 6 20.0?$ 16 - 18 10 2 16.6?$ 18 - 20 11 0 00.0?$ 20 - 22 8 2 20.0?$ 22 - 24 1 0 00.0?$ 24 - 26 0 2 100.0?$ 26 - 28 4 1 20.0?$ 28-30 1 0 00.0?$ 30 - 32 5 2 28.5?$ 32-34 0 0 00.0?$ 34 - 36 1 0 00.0?$ TOTAL 580 131 18,4# Average "time lag" from injury to surgery for the above cases (711) was 8.9 hours. Under 36 hours - 580 131 18*4$ 36 hours and over - 9 7 43.7% Total All Cases 589 158 18.8^ Average "time lag" from injury to surgery for all oases including those over 36 hours was 9.7 hours. Cases not included (for discussion purposes) No record available - 43. 145 Appendix, (eontd) TABLE VIII Time Lag - Injury to Admission - 1945 Hours Lived Dead Mortality Rate 0-2 20 4 15.1% 2-4 89 21 19.0% 4-6 88 13 12.8% 6-8 40 7 14.7% 8-10 22 4 15.3$ 10 - 12 13 2 13.3% 12 - 14 1 2 66.6% 14 - 16 3 0 00.0% 16 - 18 3 0 00.0% 18 - 20 0 0 00.0% 20-22 2 0 00.0% 22 - 24 1 0 00.0% 24 - 26 0 0 00.0% 26 - 28 0 0 00.0% 28-30 1 1 50.0% 30 - 32 0 0 00.0$ 32 - 34 0 0 00.0% 34 - 36 0* 0 00.0% TOTAL 273 63 1SJ}% Average "time lag" for all oases from injury to admission for the above oases (326) was 5.6 hours. Under 36 hours - 273 53 16,0$ 36 hours and over - 0 5 100.0$ Total All Cases - 273 58 17.5$ Average “time lag" for all cases (33l) including those over 36 hours was 6.1 hours. NOTE: The above table is based on only 331 cases, all other oases of the abdominal series lacked sufficient data to determine title lag> 146 Appendix, (oontd. TABLE IX Time Lag - Admission to Surgery - 1946 Hours Lived Dead Mortality Rate 2-4 88 10 10.2% 4-6 136 27 16. 5# 6-8 42 14 25.0% 6-8 19 4 17.3# 8-10 5 3 35.0# 10 - 12 5 3 36.0# 12 - 14 1 1 50.0# 14 - 16 1 1 50.0# 16 - 18 1 0 00.0# 18-20 20 - 2 2 22 - 24 24 - 26 26 - 28 28-30 30-32 32-54 34-36 TOTAL 298 63 17.4# (ar.) The average "time lag from admission to surgery for the above oases (36l) was 5.4 hours. 36 hours and over - none. NOTE: The above tabulation was made from a total of 361 oases; many oases not inoluded because time of admission into the hospital was not mentioned, thus making it impossible to compute time lag* INCIDENCE OF ASSOCIATED INJURIES AND THEIR EFFECT ON MORTALITY IN ABDOMINAL GASES During the year of 1944 and early months of 1945, the surgical teams of this Group operated on 3154 patients with abdominal injuries. Of this total, there were 839 thoraco-abdominal wounds and 1089 cases which presented various major extra-abdominal associated injuries other than the thoraco-abdominal type. It is the latter group that is reported in this paper,* Ihe records of the 1089 cases have been reviewed and an- alyzed in an attempt to determine the incidence of various type of asso- ciated injuries and their effect upon the general mortality. Surgical shock and time lag as accompanying and potential influ- ences on mortality will be considered briefly. It is probably well to point out before presenting the detailed analysis of the cases, that the general overall mortality rates were found to be closely similar in three large groups of cases, viz: A, All abdominal cases - 23.1$ (2315 cases), (Exclusive of thor- aco- abdominal injuries) B, Abdominal cases with associated injuries - 24.1$ (1089 cases), C, Abdominal cases without associated injuries - 22.1$ (1226 cases). This near agreement of figures is remarkable and at a glance, likely to be surprising. Nevertheless, it constitutes one of our findings and we believe it represents a significant truth. Our interpretation of this finding may be stated as follows: Of associated injuries it is likely that many of the more severe and rapidly fatal ones are screened from surgery by an early death, leaving the less severe ones to reach the hos- pital and to influence the mortality. Also, there seems to be a tendency towards coupling severe abdominal injuries with less severe associated injuries and vice versa. Working together, such factors as these would obviously tend to balance the general mortality rates for the two groups designated "B" and "C" above. CLASSIFICATION OF INJURIES Occurring concomitantly with abdominal injuries, there are innumer- able types of associated wounds. In view of their frequent multiplicity and complexity, a thorough-going classification would almost call for individual consideration of cases. * The cases which presented thoraco-abdominal injuries were excluded from this study and are analyzed in a separate section of this report. Incidence of Associated Injuries and their Effect on Mortality in Abdominal Cases (Calssification of Injuries, contd) In this study we have excluded the obviously minor injuries of all regions, Ue have endeavored to consider only the major associated in- juries, i.e,, those of sufficient severity and magnitude to influence the prognosis during surgery and the early postoperative period. In an attempt to appropriately classify the cases and injuries we have been led to the belief that no single basis for analysis will serve for all purposes. Desiring to establish the incidence of the various associated injuries, we adopted for this purpose a dual classification. Its nature is self-evident in the tables. Tables I-A and I-B show the incidence of associated injuries as to their anatomic types, and tables I, II, and III (Appendix), show their Incidence as to their multipli- city. The number of deaths and mortality rates for specific types and groups are also shown in the tables. Probably the most significant information depicted in Tables I, II, and III (Appendix), is that of frequency. The mortality figures are in- teresting, but it is to be remembered that the deaths in many cases were probably not due to the associated injury per se, but to one or more of several factors in play. The bulk of evidence produced in this study has indicated that the one quality of associated injuries that is most significantly related to their effect on mortality is the "severity"* and not their type nor their degree of multiplicity. For this reason, in our analysis of the fatal cases we were prompted to utilize a third classification of the associated injuries, viz,, that based on the "severity", all cases being classed "moderate" or "severe". The findings relative to this analysis are shown in the graphic figures 25 , 26 and 2? • INCIDENCE OF ASSOCIATED INJURIES Excluding the thoraco-abdominal wounds, there were 2315 abdominal cases operated on. Of these, 1089 or A7$** presented associated in- juries. * It has been shorn in other studies that with reference to abdominal injuries, the "multiplicity of organs involved" is the paramount feature influencing mortality. (See pagel09 .) ** If thoracic injury in thoraco-abdominal cases had been considered as an associated injury, the incidence would have been 61.1$, Incidence of Associated Injuries and Their Effect on Mortality in Abdominal Cases (Incidence of Associated Injuries, contd) Definition and Incidence of Anatomic Typesj All major associated injuries were "broken down" into nine funda- mental typest 1. Soft tissue — (All except those coincident to other types* ) 2. Fractures — (All fractures of major long bones and bones of the pelvis) 3. Chest injuries — (All those involving the pleura and requir- ing surgery exclusive of thoraco-abdominal wounds) A. Spinal cord injuries — (All injuries to the spinal cord and cauda equina) 5. Brain injuries — (All types) 6. Maxillofacial and/or neck injuries — (Major) 7. Major vessel injuries — (All extra-abdominal) 8. Peripheral nerve injuries 9. Injuries necessitating major amputations There were 1551 injuries encountered among 1089 cases. Of the 1551, 1403** were analyzed as to incidence and are shown in Table I-A. TABLE I-A Frequency of Occurrence of 1403 Associated Injuries According to Anatomic Types Type of Injury No. of Injuries Encountered Percent of Total Injuries Fractures . 659 47.0*) ) Soft tissue 531 37.8*) 91.9* Chest 101 7.1*) . Sninal cord 40 2.9%) \ Maxillofacial and/or neck 20 1.4*) Maior vessel 18 1.2%) r 7.8% Perinheral nerve 10 0.7%) f —— Wound necessitating major amoutation 18 1.2%) Braiji 6 0.4*) Total MQ1 99.2% * Fractures, nerve injuries, and injuries necessitating amputations all present coincident soft tissue injuries. Such soft tissue injuries were not counted separately. ** Number of injuries in which data in the records were adequate for this study. Incidence of Associated Injuries and Their Effect on Mortality in Abdominal Cases (Incidence of Associated Injuries, contd) TABLE I-B Incidence of Fractures of Ttemur, Humerus and Pelvis Bone Involved Ho. Gases No. Deaths Pferaur alone 57 u Femur and one other manor bone 33 10 Humerus alone 10 Humerus and one other manor bone 21 g Pelvic bones 238 22 Total 380 2Q GENERAL INCIDENCE OF ASSOCIATED INJURIES TABLE II Grouping and Incidence of Associated Injuries According to Their Multiplicity Percent of Group No. Cases Mortality Total Cases Gases presenting one associated injury 527 20,7$ ) 75.8$ Gases presenting two associated injuries 299 . 21.3$ ) Cases presenting three associated in juries 39.0$ ) Cases presenting four or more associated in.iuries m.. ) 2's.n ) 24.2$ A more detailed analysis of the cases comprising the above cate- gories is shown in Tables I, II and III (Appendix). It will be noted from Table II that in all except one group of cases (those presenting three associated injuries), the group mortality rates were relatively close to and slightly less than that for all abdominal cases. Since in the classification neither the severity of associated injury nor the nature of the abdominal injury is taken into considera- tion, the mortality rates for groups one, two and four* are within thd limits of what we would expect. The mortality rate of 39$ for group three, however, warrants further consideration and analysis. Even though the cases comprising group three probably presented more severe injuries than did those of any other group, it is unlikely that the associated injuries accounted for the uniquely high mortality rate. We were led to this belief when we re-analyzed, on the basis of other factors, 25 fatal and 25 nonfatal cases of group three. The findings relative to the 50 cases re-analyzed are shown in Tables IV and V (Appendix). It is to be noted that among the fatal cases such factors as prolonged time * Cases comprising group four were not the most severe injuries. Mul- tiplicity rather than severity was the dominant feature among them. Incidence of Associated Injuries and Their Effect on Mortality in Abdominal Cases (General Incidence of Associated Injuries, contd) lag, severe degrees of shock and multiplicity of visceral injuries were much in evidence, whereas among the nonfatal cases they were con- spicuously low or present in less grave combinations. Shock and Time Lag The number of patients who were in each of the various degrees of shock are presented in tabular form (Table III). No effort has been made to analyze the specific causes of shock. (See section of this report on "Shock", pageloS.) We have regarded shock for the purposes of this report as a clinical manifestation of the combined effects of the severity of the patient’s injuries and the length of time lag. It will be seen from Table III that nearly 60$ of the cases in this series were in either "moderate" or "severe" shock. In arriving at our classifica- tion, all available data in the records were utilized (e.g,, the sur- geon’s estimate of the degree of shock, the recorded blood pressure readings, etc.). TABLE III Degree of Shock, 1089 Abdominal Cases Having Major Associated Injuries Grade of Shock No shock or susoected shock No. Gases _ . l&L Percent of Total Cases 16.856 Wild shock 270 24.8$ Moderate shock 292 26,8$ Severe shock 343 31.5* 1089 99.9% Time lag appears to bear no uniform relationship to the general mortality. In the great majority of cases time lags fall within rather narrow limits* (six to 12 hours). In our group, the largest number of deaths occurred in patients with time lags of six to 10 hours. (See Table IV.) MORTALITY Among the 1089 cases, there were 262 deaths. An accurate appraisal of these deaths as to cause is difficult on survey of the records. Be- cause of the usual complexity of the injuries, we cannot rightfully con- demn one injury and exonerate another. It is likely that in most instances * See section of this report on "Time Lag" (Page 132), Incidence of Associated Injuries and Their Effect on Mortality in Abdominal Cases (Mortality, contd) the deaths resulted from an unpredictable interplay of several factors, each known to be capable of influencing the mortality. In attempting to evaluate any one of these factors, exclusion of the others would be desirable but this is rarely, if ever, completely possible. TABLE IV Length of Time Lag, Wounding to Surgery, 262 Fatal Abdominal Cases Having Major Associated Injuries Time Lag (Injury to Surgery) No. Cases Frequency among Total Deaths 0 to 5 houpp 3A 13.0% 6 to 10 hours 110 42.0% ..... 11 to 15 hours 53 20.2% I.Iore than 15 hours U1 17.9% Not recorded 18 6.9? Total 2& 100.0% The question of what effect associated injuries have on the mor- tality rate in abdominal cases has proved to be an intriguing subject for study. Our method of attack on the problem was to analyze the mor- tality in three rather large groups of cases. These groups were; 1, All abdominal cases (both with and without associated injur- ies — 315A cases). 2, Abdominal cases without associated injuries (1226 cases). 3, Abdominal cases with associated injuries (1089 cases). Each of these groups was analyzed with respect to multiplicity of abdominal visceral injuries, and the third group the severity of the associated injury is taken into consideration. The results of this analysis are represented in condensed form in Figures 25 , 26 and 27 *, On examining Figure 25 it will be seen that the overall mortality rate in abdominal cases starts at 5% and as- cends uniformly to 65%**. The rates in this group, when represented as a curve, serve as a fair average for comparison. (See curve "a” in * Tables VI and VII (Appendix) show the numerical basis for the graphs. ** Figures taken from the section on Abdominal Injuries. 153 Incidence of Associated Injuries and Their Effect on Mortality in Abdominal Oases (Mortality, contd) COMPARATIVE MORTALITY RATES FOR THREE GROUPS OE ABDOMIMAE CASES SHOWING EFFECT OF MULTIPLE VISCERAL INJURIES WITH AND WITHOUT ASSOCIATED INJURIES - ALL ABDOMINAL CASES (SIS*) - ABDOMINAL CASES WITH ASSOCIATED WJUDIES (10891 8 ABDOMINAL CASE5 WITHOUT ASSOCIATED INJUSIES (1/42) —A— Figure 25> - Comparative Mortality Rates Among Abdominal Cases With and Without Associated Injuries. Figure 2£ ). The effect of the presence or absence of associated in- juries on mortality is apparent in the corresponding curves for the other two groups (See curves "b” and ncw, Figure 2$ ). It is seen that they are roughly parallel and separated by an average difference of only and that they follow quite closely the ’’overall" curve throughout. The incidence and distribution of ’’moderate’1 and ’’severe’’ associ- ated injuries are plotted against multiplicity of visceral injury in fatal cases. (See Figure 27 ) The contours of the two curves, when correlated with the multiplicity of visceral injury serve two signifi- cant purposes, viz: Incidence of Associated Injuries and Their Effect on Mortality in Abdominal Cases (Mortality, contd) COMPARATIVE MORTALITY RATES FOR 3 GROUPS OF CASES WITH RESPECT TO MOJIPLICITV OF VISCERAL INJURIES. ANDTME FRLOENCY OF'MODE RATE AND SEVERE AS- $«IArtO injuries among the fatal cases with ASSOCIATED INJURIES IkOTOUTY RATE FDR ALL ABDOMINAL CASES I MORTALITY RATE FOR A«0 OKEi WITHOUT ASSOOATED INXRES 1 KeRTAUTY RATE fOC AfiO CASE! WITH ASAXWCD «JL*B 1 FREQUENCY OF SEVERE ASSOCIATED IMJUfitS IN FATAL CASES IrREQUtNCV Of MOOCWTC amciateo njures n fatal cases X MORTALITY Figure 26 “ Comparative Mortality Rates Among Abdominal Cases With and Without Associated Injuries 1, They indicate the type (or severity) of associated injuries that reach the surgeon and thev type of abdominal injuiy with which they are most frequently associated. 2. They tend to explain why in those cases reaching the surgeon associated injuries do not elevate the mortality rate more. In essence, the salient triplications are these: Patients sustaining both severe abdominal and severe associ- ated injuries evidently do not live to reach the surgeon. Associated injuries in general., regardless of the multiplicity of the visceral Incidence of Associated Injuries and Their Effect on Mortality in Abdominal Cases (Mortality, contd) FREQUENCY OF MODERATE AND SEVERE ASSOCIATED INJURIES AMONG FATAL ABDOMINAL CASES SHOWING EFFECT OF MULTIPLE VISCERAL INJURIES — NUMBED or VI5CERA INJURED SEVtK ASSOCIATED IHUUHES MODERATE ASSOCIATED INJURIES ELgure 2? - Incidence of Severe and Nonsevere Associated Injuries Among Serious and Less Serious Abdominal Injuries. injury, tend to increase the mortality rate by about 3.8$ over that of cases without associated injuries. This increase is contributed to by associated injuries of all degrees of severity, but relatively mild as- sociated injuries are predominant with the more multiple abdominal in- juries, and severe associated injuries predominate with the less multi- ple abdominal injuries. Of all factors influencing mortality, that of multiplicity of visceral injury seems to be paramount and most constant increasing mortality rate by approximately 15$ with each additional vis- cua injured. lf>6 Incidence of Associated Injuries and Their Hiffect on I.ortality in Abdominal Cases (Mortality, contd) In the section of this report devoted to the small bowel, a group of cases with uncomplicated small bo\7el injuries were analyzed. The in- cidence of severe associated injuries was found to be 55$ in 49 fatal cases and 24$ in 304 survival cases. From this doubly high incidence in the fatal cases one might suspect asociated injuries of influencing the mortality rate more than is indicated in this.study. It is notewor- thy however, that the time lags in the fatal cases were found suspic- iously long, with an average double that in the survival cases. SUMMARY 1. The records of 1089 cases, receiving abdominal operations and presenting extra-abdominal associated injuries, were reviewed and the results of the study are presented. 2. The incidence of associated injuries was studied and the fol- lowing information is shown in accompanying tables and graphs: a. Incidence among the grand total of abdominal cases (3154-). b. Incidence (anatomic) among the total number of associated injuries (14.03). c. Incidence, on the basis of multiplicity of associated in- juries. 3. Mortality among cases with associated injuries was compared to that in cases without associated injuries. The elevating effect of as- sociated injuries on the general mortality rate was determined and is illustrated graphically. 4-. The probable factors accounting for this effect are discussed. OBSERVATIONS 1, Associated injuries were present in 4-7$ of cases receiving abdominal operations, if thoraco-abdominal injuries are excluded, and in 61,1$ if they are included as associated injuries. 2, There were 1551 associated injuries in 1089 abdominal cases. In 14-03 of 1551 associated injuries, records were satisfactory, and the following anatomic type incidence was found* Fractures 4.7.0$ Soft tissue 37.8$ Chest 7.1$ . 91.9$ All others (6 types) , , , 7,8$ 157 Incidence of Associated Injuries and Their Effect on Mortality in Abdominal Cases (Observation, contd) 3. The general mortality in the group with associated injuries is found to approximate closely that for the group without such injuries 4. When, hov/ever, the cases are classified according to multipli- city of visceral injury, the group of cases having associated injuries was found to have a mortality rate approximately 3.8$ higher than that for the group without. 5. Associated injuries were classified according to severity as ’’moderate" and "severe". The severe ones were found to be predominantly coupled with the abdominal injuries of low multiplicity and the moderate ones with abdominal injuries of high multiplicity.. 6. Mortality in the group of cases with associated injuries as well as in that without was found to increase appreciably with each ad- ditional visceral injury. CONCLUSIONS 1. The case incidence of associated injuries among abdominal bat- tle casualties was of the order of 50$ (when thoraco-abdominal injuries are excluded), 2. Of the major associated injuries encountered, fractures, soft tissue wounds, and chest wounds constituted the majority (in our series 91.9$). Six other types, viz., spinal cord, maxillofacial and/or neck, peripheral nerve, major vessels, brain injuries, and injuries necessi- tating amputations made up the minority of 8 - 10$. 3. Fractures proved to be the most common of all major associated injuries and of the fractures, those of pelvic bones were encountered most frequently. 4. Major associated injuries influence the abdominal mortality rate, increasing it by approximately 3.8$. This Influence appears to be fairly constant regardless of the multiplicity of visceral injury. 5. Its constancy and relatively small magnitude are probably ex- plainable by the following reasoning: Pfew patients reach the surgeon with both the more serious abdominal and associated injuries. With the more serious abdominal injuries are found the less serious associated injuries; and conversely, the more serious associated injuries are found in the presence of less severe abdominal wounds. Incidence of Associated Injuries and Their Effect on Mortality in Abdomina Gases (contd) APPENDIX TABLE I Incidence and Mortality in Cases with One Associated Injury Soft tissue No. Gases 182 Deaths 37 Mortality 20.31 Juncture 236 40 17.01 Chest 42 U 33.31 Spinal cord 28 . 14. 50.01 Brain . 6 2 33.31 Maxillofacial / Neck 13 .. 3 23.01 Manor vessel 5 2 ... 40.01._ Peripheral nerve 6 0 o4ol Injuries necessitating amputations 9 3 33.31 Totals 522 _Ji5 20.7% TABLE II Incidence and Mortality in Cases with Two Associated Injuries, No. Cases Deaths Mortality Fracture and soft tissue 72 13 18.0$ Double fracture 92 21 22.8$ Double soft tissue 37 8 21.6$ Soft tissue and chest U 2 U.2$ Fracture and chest 19 5 26.3$ Fracture , and major vessel 5 1 20.0$ . Fracture and soinal cord 5 2 A0.0$ Soft tissue and soinal cord 6 1 16.6$ Soft tissue and vessel 8 1 12.5$ Fracture and amputation 6 0 “0.0$ Other combinations (rare) 35 IQ 28.8$ T7-. 1.806 Clearing Station 2 0.086 4 0.536 6 0.166 Medical Battalion L 0.166 0 .... A _Jk_ 0.12S6 Not recorded L 0.166 0 *06—. 4 0.1256 Total 2383 771 3154 As may be seen from the above table most of the cases were treated in the Field Hospital, while the Evacuation Hospitals occupy second place. 170 Anesthesia in 3154- Abdominal and Thoraco-Abdominal Battle Casualties. AGE FACTOR The age groups dealt with in this series, as would be expected in any report of military surgery, fall in the lower brackets. There, were some cases above AO and below IS years of age. These were civi- lians for the most part. The following table gives a breakdown of this factor. TABLE II Age 0-20 No. of Cases 707 21 - 25 987 26 - 30 591 . 31-35 250 36 - 4-0 78 41/ 42 No record of age 499. Total 3154 TYPE OF PATIENT Types of cases considered are limited to, (1) Abdominal, (2) Thoraco-abdorainal. These casualties were screened from the run of the mill cases at the Divisional Clearing Stations and transfered with minimum delay to the adjoining Field Hospital Platoon, where facilities and personnel for immediate definitive cere were avail- able, These cases offered a challenge to all those responsible for their care. Each one presented a problem. Time elapsed from time of injury to time of admission varied from 15-30 minutes to 30-4-0 hours according to distance from the front, tactical situa- tion, terrain, condition of roads, weather, and efficiency of the Divisional medical organization. Extent of injury varied from a single penetration or perforation of a single viscus to damage to many organs. Thoraco-abdomlnal wounds were common. All types and conceivable combinations of associated injuries were encountered in conjunction with the two main types of casualties under con- sideration. All degrees of shock were seen and some degree of shock or an incipient shock state was more commonly present than absent. Some sort of resuscitation therapy was deemed necessary for the majority of patients. The following table gives blood pressures on admission to the hospital of 91A abdominal cases, representative of this series, with the percentage total of each group: 171 Anesthesia in 315A Abdominal and Thoraco-Abdominal Battle Casualties. TABLE III Representative Blood Pressure Readings Blood Pressure (Systolic) Percentage of Total t o U.6 LX - 70 12.7 71 - 100 26.1 101 - 120 L 6.6 Further complicating factors of these cases were fatigue, exposure and improper diet over considerable periods of time. This section can- not itempt to give more than this brief picture of the type of patients handled. Detailed information may be had by consulting other sections of this report*. The following table gives incidence and percentage of the total of the two types of cases: TABLE IV Type No. Percent of Total .Abdominal 2315 73.39 Thoraco-abdominal . . 839 26.61 . Total 315 A Types of Cases AGENTS AND METHODS The choice of agents and methods used was limited by what was available. Agents and eouipment were available for administration of: 1. Chloroform, ethyl chloride, and ether by open drop. 2. Nitrous oxide and oxygen by closed, circle flow, absorption method. 3. Nitrous oxide, oxygen, and ether by closed, circle flow, ab- sorption method with Heidbrink and McKesson machines. A« Ether and oxygen by closed, to and fro, absorption method with the Beecher model machine. 5• Pentothal by vein. 6. Procaine and pontocaine by intrathecal injection. 7. Procain for local, regional, or field block. 8. Cocain for topical application. *See section on "Preoperative Care of the Patient", page 23 . 172 Anesthesia in 3154 Abdominal and Thoraco-Abdominal Battle Casualties. (Agents and Methods cont’d). Chloroform ms used as an induction agent in one case. No reason for choice of this agent was given on the record of this case. The dangers of this agent have been too well known for a long time in the experience of surgeons and anesthetists to warrant consideration as an anesthetic for use in patients of the type discussed here. Pentothal was not suited to this work. All the generally accepted contraindications to its use were present in these casualties. The surgery was formidable in nature and time consuming. Average time of operation me two and one—half to three hours. Hemorrhage before ad- mission was the rule and further blood loss could be expected during the major surgery to come. Incidence and degree of shock has already been mentioned. Varying degrees of anoxia were common because of hemorrhage and shock, accumulated secretions in the tracheo-bronchial tree, hemothorax and pneumothorax, painful respiration, and variolas other derangements of cardiorespiratory physiology. Muscular re- laxation was necessary, particularly during the periods of explora- tion and closure in abdominal cases. Pentothal could not provide this in safe dosage. Tracheal intubation was considered essential. Intubation is not as easily accomplished under pentothal as some other agents because of the poor relaxation of the muscles of the jaw and irritability of the larynx. Intubation under pentothal is followed by severe "reaction" to the tube and this recurs on movement of the catheter as when the patient is shifted on the table or when the patient's heed is turned, Pentothal was used 49 times in 2383 cases (2,05$) in 1944 as an induction agent followed by open drop ether or ether-oxygen in a closed system. In 1945 it was not used at all in 771 cases. We are aware of some few who think pentothal desirable for the severely wounded. We are not in accord with this view. We are also aware of reports which state that pentothal comprised as high as 95$ of total anesthesia in forward surgery. This high figure may be due to the types of cases handled, problems of supply, or location where work was done. Unsuitable as this agent may be for non-transportable or first priority esses its value in the lightly wounded and properly selected moderately wounded cases, which two groups add up to the bulk of casualties, make it possibly the greatest single advance in war anesthesia. Spinal anesthesia was also unsuitable for this type of work because of length and variability of time required for completion of cases, unstable cardiovascular balance in the patients due to factors, already mentioned, frequency of associated wounds in areas 173 Anesthesia in 3154 Abdominal and Thoraco-Abdominal Battle Casualties. (Agents and Methods cont'd. not anesthetized by this method, and the undersirability of the conscious state in an apprehensive patient just removed from the battle- field. This method was used only two times in a total of 3154 cases. Both of these cases were in excellent condition pre-operatively and readily recognizable as having minimal intra-abdominal injury. Nitrous oxide (with oxygen) was not used as the sole anesthetic agent in any of these cases. Because of the long durstion of anesthe- tics, the necessity for relaxation, the severity of the wounds and the high incidence of shock, we thought that these patients deserved the highest concentration of oxygen we could provide to compensate as much as possible for their decreased oxygen carrying powers. Nitrous oxide was of great value as an induction agent. Concentrations of 60 - 55 percent nitrous oxide were used. No trouble was encountered in the brief length of time required for induction. Some were hesitant to use nitrous oxide for induction at first but its use gradually became genei'al. It was used in this way in 83.25% of cases in 1945 as compared to 54.8C% in 1944. Ethyl chloride was used extensively as an induc- tion agent. It performed this function satisfactorily when cautiously administered. However, it was not used ordinarily in the cases of veiy poor risk. Procaine was used for regional or field block anesthesia in only five cases. It is regreted that this procedure in combination with a light general anesthetic was not giveh an adequate trial in the man- agement of these cases. In retrospect, this procedure appears to have great potentialities. Cocaine was used in the usual manner in bronchoscopies on conscious patients. Occasionally it was vised to facilitate a difficult intubation. Open drop ether did not occupy as prominent a place as might be expected. The use of ether in this manner decreased from 12.5% of the cases in 1944 to 2.72% of cases in 1945. The figure for 1944 would have been much lower had gas machines been more plentifully supplied at that time. The most satisfactory anesthetic for severely wounded battle casual- ties in our experience was an induction by means of nitrous oxide-oxygen with maintenance by ether-oxygen in a closed,carbon dioxide absorption system. We do pot think this Indicates that the millenium has been re- ached in anesthesia for these types of war injuries. Toxic effects of ether on the heart, liver, and kidneys are realized. This choice of anesthesia was prompted and became predeminently in use because of avail- ability, satisfactoiy tolerance by the patients, simplicity of adminis- tration, and its wide margin of safety. The last two assume great 174 Anesthesia in 3154 Abdominal and Thoraco-Abcominal Battle Casualties. (Agents and Methods cont’d). importance in view of the fact that this work was done by approximately 45 anesthetists of variable training, experience, capabilities, and judgement. The need f or making use of the advantages of closed anesthesia was magnified in cases of precarious nature. Conservation of body heat and moisture, high oxygen content, control of carbon dioxide content, ease of attaining and maintaining desired levels of anes- thesia, control of respiration where necessary, and positive pres- sure were more than mere desirable features. Employment of intratracheal technic was considered essential. Assurance of a patent airway was obtained, no matter the position, giving the anesthetist sufficient freedom of action to attend to the multiple infusions of blood. Aspiration of blood and accumulated secretions from the trachea was easily accomplished via the intra- tracheal tube. Controlled and aided respiration by positive pres- sure was facilitated. Desired levels of anesthesia could easily and quickly be reached. Increased smoothness of respiration was of value to the surgeon, particularly in abdominal surgery. A striking increase in the use of intratracheal anesthesia was noted. In 1944- intubation was employed in 88.45/6 of cases whereas, in 1945 it was employed in 10Q6 of-recorded cases of ab- dominal and thoraco-abdominal procedures. Certain trends may be noted by comparing figures for 1944 and 1945 in the following tables. 1944 1945 * Total * G. O.E. 1306 54.80 642 83.27 1948 61.76 Ether 752 31.55 48 ‘ 6.22 800 25.36 C^Cl-Ether 224 9.40 57 7.40 281 8.90 Pentbthal—Ether 49 2.05 V 1 0.12' 50 1.58 Ether—Proc aine 3 0.12 0 .0 3 0.10 CHC13-Ether 1 0.04 0 .0 1 0.03 G.O.E.—Pentothal 1 0.04 0 .0 1 0.03 G. 0. + 1 0.04 0 .0 1 0.03 Oxygen ++ 1 0.04 0 .0 1 0.03 Procaine (Local) 5 ’ 0.20 1 0.12 6 0.19 Spinal 2 0.08 0 .0 2 ' 0.06 Spinal-Pentothal 1 0.04 0 .0 1 0.03 Pentothal +++ 1 0.04 0 .0 1 0.03 Not Recorded 36 1.51 22 2.85 58 1.83 Total 2383 ■ - - - 771 3154 + Vomited during induction, espirated gastric contents, and died. ++ Patient moribund and unconscious. +++ Simple debridemant of wound of entrance in a right—sided thoraco—abdominal case. TABLE V AGENTS USED 176 Anesthesia in 315U Abdominal and Thoraco-Abdominal Battle Casualties. (Agents and Methods cont’d.) TABLE VI No. cases No. cases Percent- Total No. Total in Year Percentage in year age of cases per Percent- Method 1944 of use 1945 . . use Method asre of use Closed 2023 85 .10 727 94.29 2m _ . 87.24 Ooen 298 12.50 21 2.72 319 10.11 Semi-open 7 0.28 0 .0 7 0.22 Others 14 0£6 1 0.12 15 0.47 Not Recorded 36 1.51 22 2.85 58 ... 1.84 Total 2383 771 3154 METHOD TABLE VII INTUBATION 1944 Percent Percent Total Percent Endotracheal 2108 88,46 749 97.14 2957 . 90.57 _ N on-end otrach eal 239 10.83 0 .0 _ 239. 7.59 Not recorded 26 1.51 22 2.85 53 1.84 Total 2383 771 3154 PREOPERATIVE MANAGEMENT In the well organized and fully staffed Field Hospital Platoon, the'abdominal end thoraco-abdominal casualties were placed in the -capable hands of a shock team immediately after arriving from the clear- ing station. The details of preoperative management are fully discussed in another portion of this study entitled "The Problem of Shock Therapy in Abdominal lounds", pages 169 to 186, The anesthetist did not have the opportunity to study his patient during a "push" until the restora- tive therapy had readied him for surgery. At this time, the need for preanesthetic medication was determined and the necessary drugs were administered (intravenously, in the majority of cases). This consisted of atropine gr. 1/100 in most instances together with morphine when, and in dosage as was deemed necessary. This is more fully discussed in the remarks on premedication (page6l "General Considerations of Anesthesia in War Casualties"). 177 Anesthesia in 3154- Abdominal and Thoraco-Abdominal Battle Casualties. (Preoperative Management cont1d). These circumstances were not always encountered, In the absence of a shock team or when the flow of casualties was extremely heavy, the surgeons and the anesthetists performed the resuscitation. Be- cause of the possibility that the responsibility of preoperative man- agement may be his, and because of his interest in administering anesthesia to a patient in the best possible condition, the anesthe- tist should be familiar with shock therapy. Some of the thoraco-abdominal patients were unable to clean their respiratory passages of blood and mucus and required tracheo-bronchial suction in order to improve the respiratory exchange. This was done by blindly passing a long no. 16 catheter (with a hole in its side near the proximal end and several holes in the distal end) nasally and sucking out the foreign material. One application of the suction tube was sometimes sufficient, but this procedure was repeated when there was a reaccumulation of fluid. Respiratory physiology was fur- ther enhanced by preoperative thoracentesis when it was disturbed by pneumothorax or hemopneumothorax. Coughing was facilitated and pain controlled in selected cases by intercostal nerve blocks. Unilateral blocks were used for chest pain and bilateral blocks for abdominal pain. Some anesthetists requested the patients to cough and clear the tracheo-bronchial tree and pharynx voluntarily before beginning the anesthesia. This was an important step because they might have been lying quietly in a depressed state for many hours. OPERATIVE MANAGEMENT The management of these battle casualties during anesthesia and surgery consisted of, in the main, a continuation of the resuscitation. Pain was abolished by the anesthesia, repair of the damaged organs was accomplished by the surgery, restoration of the blood circulation volume was continued by means of the infusions and the re-establishment of a more normal metabolism was aided by the administration of a high con- centration of oxygen. The anesthetist did not transfer the patient to the operating tent until his equipment and the surgical instruments were ready for use. Thus, there was no interruption of therapy. For example, oxygen administration 'Was discontinued only while the patient was transported by the litter bearers. As a rule the inductions were not difficult. Many of the wounded had gone for long periods without sleep and were exhausted. Patients 178 Anesthesia in 3154 Abdominal and Thoraco-Abdominal Battle Casualties* (Operative Management, cont’d), in shock or who recently have been in shock are generally easy to anesthetize. An attempt was made by a number of the anesthetists always to use 30%' or more oxygen and the others did not use less than 20% oxygen for the nitrous oxide-oxygen inductions. The severe excitement stage was a most unusual occurrence in contrast to its relative frequency in this group in civilian practice. We expected more violent excitement stages because of the noise in a busy surgical tent and the disturbance created by our own and enemy artillery. As a precaution, someone supported the extremity receiving infusions to make certain that the needle was not dislodged by sudden involuntary movements. Anesthesia was maintained in the lightest planes compatible with the surgery being done. These patients could not tolerate deep planes of anesthesia for more than brief periods of time. To facilitate intra- peritoneal interference in light periods of anesthesia, curare extract was used in 26 patients for abdominal relaxation with excellent results. One anesthetist of this Group was authorized to use this drug for clinical trial*. A clear airway was always assured. The majority of the abdominal and all the thoraco-abdominal cases were done with the endotracheal technic. It was noted that when all the anesthetists had gained pro- ficiency in the last stages of the European War, all the abdominal cases were also anesthetized with the endotracheal technic. The tracheo- bronchial toilet was an important part of the anesthesia because many of the winter campaign casualties had bronchitis and thick mucoid material was frequently found. Most of the endoscopies were done on the thoraco-abdominal cases, Citrated blood in amounts necessary to maintain an adequate circulating blood volume was administered throughout each operation. The largest amounts used (6,500 c,c.) were in patients with injuries to large vessels. The average quantities of blood and plasma ad- ministered to each type of case are recorded in Table I in the section on shock (page 122 to 131 )• Dextrose and saline solutions were used less frequently and only for combatting dehydration. Stimulating drugs were not used as a general rule in the average case. Specific therapy with penicillin or the sulfonamides was instituted during the operation by the anesthetist at the surgeon’s request. *The Use of Curare for Abdominal Surgery ih Severely Wounded Battle Casualties, Doud, B, A, and Shortz, G, K,* In press. 179 Anesthesia in 3154- Abdominal and Thoraco-abdominal Battle Casualties (Operative Management, contd) c The fall in blood pressure occasioned by changing the position of these patients was noted by all the anesthetists. The greatest declines occurred after turning them from the supine to the prone positions or vice versa. Changes also occurred when they were turned onto the side. This phenomenon is direct evidence of the instability of the vasomotor systems of the severely wounded, anesthetized patients. Great care must be used to turn them slowly and gently to minimize this decrease in ten- sion, Unnecessary turning of the patient should be avoided. The foot end of the litter was often raised before the induction of anesthesis to avoid interrupting the surgery by waiting until im- pending shock necessitated the change in position. There is no ques- tion that this position was helpful in combating .shock. POSTOPERATIVE CARS The postoperative care of the patient is the joint responsibility of the anesthetist and the surgeon. Usually the anesthetist is con- cerned only with the prevention of shock and pulmonary complications. However, in times of stress the anesthetist may be forced to take over full postoperative care of some patients. Shock is one of the most difficult conditions that the anesthetist has to prevent and treat. It usually occurs in those patients with very severe wounds or in those who have been in prolonged shock and have only partially recovered, or in those cases that go into shock during surgery. Oxygen should be used postoperatively in all the cases just mentioned. Every effort must be made to prevent anoxia. The anoxia can be very in- sidious and progress to a fatal end if unchecked.. Anoxia, when it once begins, develops a vicious cycle that becomes progressively worse. It behooves the anesthetist to see to it that everything is done to insure sufficient respiratory exchange and adequate oxygenation. The proper position in which to place these patients often presents serious difficulty. In cases with thoraco-abdorainal injuries, it is not always practical to use Trendelenberg position because this increases respiratory difficulty. Therefore, these patients should be kept as near horizontal as they will comfortably tolerate. These who do not pre- sent a shock picture may well be placed in Pbwler's position, in which their respiratory exchange is more efficient. Nerve block for relief of pain is often indicated. In thoracic cases some teams anesthetized the intercostal nerves while they were 180 Anesthesia in 315-4 Abdominal and Thoraco-abdominal Battle Casualties (Operative Management, contd) exposed during the operation, or did a block before the patient was re- moved from surgery. When the patient begins to experience pain again, a block should be done and repeated when necessary. If the patient was allowed fluids by mouth, nembutal in ijr gr. doses was given when multi- ple blocks were indicated. If nembutal could not be administered, pento- thol was available in the event that the patient developed a procaine reaction. This should be kept in mind especially if more than one ounce of 1% procaine is to be used. The intercostal or paravertebral technic was used in most phases, but in the latter part of the war epidural blocks were used in some cases. These were instances where bilateral, blocks would ordinarily be indicated for the upper abdomen. The fact that only one puncture is necessary is strongly in its favor over multi- ple punctures for there is always a chance of missing one nerve and los- ing much of the effect from the block. Once the technic is mastered, it is well worth while in selected cases. The careful use of morphine for the relief of pain without depress- ing respiration is very essential. Less narcotic is required if blocks are used and repeated as indicated. The use of small doses of morphine sulfate intravenously during the early postoperative period is probably the safest and best method to get accurate evaluation of its effective- ness. Atropine has little use unless the patient has a tendency to pro- duce large amounts of mucoid secretions. The use of ephddrin sulfate, or other pressor drugs, intravenously and subcutaneously in repeated doses was not effective in maintaining the blood pressure of these shocked patients. The use of fluids, chiefly blood and plasma, was very important. Ihe patients who were in shock usually had received large amounts of fluid preoperatively and during the operation, so that it was difficult to decide how much to give and which colloid solution was indicated, iVequent hematocrit estimations were used to determine the relative pro- portions of plasma to whole blood to be given. The fluid intake and output was another check which, after the first ?U hours, was used as a guide in treatment. In both thoracic and abdominal cases there are factors present which predispose the patient to both atelectasis and pneumonia. The chief interest of the anesthetist is to prevent these complications, and if they do occur, to institute early treatment. The normal depth of respiration and an effective cough must be maintained to insure a clear tracheobronchial tree. Relief of pain with adequate support to the injured site and operative incision are necessary. Pain relief has been discussed. Support may be accomplished Anesthesia :a 3154- Abdominal and Thoraco-Abdominal Battle Casualties (Postoperative Care, contd) by dressings, but if they restrict respiratory excursion, they should be avoided. Firm manual pressure to the site is the best aid in assisting the patients in their efforts to cough. Soon they learn to support them- selves, especially if they have abdominal wounds. Frequent coughing and changing of position are important. In a few patients with multiple wounds it is difficult to change their positions; particularly if they are in large bulky casts. A few patients refuse to cough or cannot cough adequately. In this group of cases, tracheal aspiration is necessary. Aspiration using a soft rubber catheter passed through the nose into the trachea is a relat- ively simple procedure. Usually no anesthetic is necessary. Introduc- tion of the catheter into the trachea often causes severe paroxysms of coughing. Many times this alone is sufficient to clear any obstructions present. Suction through the catheter removes the obstructing material that has been loosened by the coughing. Those patients who are "wet”, and are unable to clear effectively the tracheobronchial tree may necessitate repeated tracheal aspirations. If this is necessary, the catheter may be left in the trachea and oxygen administered intratracheally between aspirations. On a few occasions those patients who are persistently nwetn have been benefitted by oxygen under slight pressure (3-6 cm. water) over a period of time. A closed system of oxygen is used with a GO2 absorber. At first the patient re- sists but soon he finds it much easier to breath and tolerates the sys- tem quite well. Some degree of relief has been noted in almost all cases. It may be necessary to continue this treatment 24 hours or longer depend- ing on the case. Most patients who are benefitted by this treatment soon appreciate its value and request it when the mask is removed during the "rest" periods. Most patients need only one tracheal aspiration to convince them of the importance of coughing. A few are not benefitted by it and the ob- struction may persist. These cases require bronchoscopy. Usually the surgeon performs the bronchoscopy under topical anesthesia, although in many cases, this has been done by the anesthetist. The procedures discussed thus far have been chiefly carried out by the anesthetist after discussion with the surgeon. Occasions have arisen when for one reason or another, the anesthetist was called upon to do more of the postoperative procedure. Only tho£e concerned with cardiorespiratory physiology will be mentioned. Thoracentesis is neces- sary for the removal of fluid and/or air to allow for greater pulmonary exchange. Nasogastric suction is important for the relief and prevention of abdominal distention. The maintenance of an adequate fluid balance, and medication whenrit is indicated to treat complication, are both adr juncts in the treatment of these casualties. 182 Anesthesia in 3154- Abdominal and Thoraco-Abdominal Battle Casualties (con'fc COMPLICATIONS An attempt has been made to determine the complications resulting from or associated with the anesthesia in this group of abdominal and thoraccf.abdoninal cases. This has not been too successful for the fol- lowing reasons: In the first place the records failed to state the complications in all cases. Secondly, many records listed the compli- cations incompletely. Thirdly, progress notes were missing in many in- stances. Again, some of the cases developed postoperative pulmonary condition which in our opinion, after studying the records, were not re- lated to anesthesia. For that reason, an arbitrary time period of A8 hours was taken, after which pulmonary conditions were not regarded as pertinent to anesthesia. Many of the cases resulting in death to the patient were found at autopsy to have a terminal "bronchopneumonia”. Unless death resulted within AS hours postoperatively, this condition was not recorded in our table. In many reports there was a striking variation in the surgeon's diagnosis of the condition. As far as possible these were examined and allotted to what we believed to be the proper heading. TABLE VIII PostoperativejAGomplications Related to Anesthesia Atelectasis (recovery) 57 Atelectasis (with other fatal complications) 12 Lobar pneumonia (recovery) 12 Lobar pneumonia (cause of death) 8 Lobar pneumonia (with other fatal complications) 3 Broncho pneumonia (recovery) 21 Broncho pneumonia (cause of death) 2 Broncho pneumonia (with other fatal complications) 19 Blast injury to (recoveryi 1 Blast injury to lunss (cause death) 5 Blast injur'/- to lunes (with other fatal complications) 5 . _ Aspiration eras trie contents (death on table) L Aspiration gastric contents (death on ward) 2 Aspiration rastric contents (uneventful) L Pulmonary edema (recovery T~ 3 Pulmonary edema (fatal) * 1 . Death on table during bronphgscopy 2 * Died four hours postoperatively after a secondary operation under pentothal during which he vomited and aspirated gastric contents. 183 Anesthesia in 3154- Abdominal and Thoraco-Abdominal battle Casualties (Complications, contd) As can be seen, the largest group of recorded complications comprises the condition of atelectasis, host of these were temporary and cleared uneventfully. There were no deaths from this state, per se, within the stated time limit, although there were 12 showing this condition at’ aut- opsy. In view of the severe wounds and other serious postoperative con- ditions in these cases, atelectasis was thought to be merely an accom- panying, and not causative, factor in their deaths. We believe that prophylaxis against atelectasis is important. This can be carried out in the operative as well as postoperative period by means of artificial respiration, administration of morphine for the re- lief of pain, and bronchoscopy. Atropine administered preoperatively, is effective in checking the cause of atelectasis. However, if the pa- tient already presents signs of increased pulmonary transudation, atro- pine is probably best avoided. Having the patient voluntarily cough on the ward, administration of oxygen and turning him frequently, will also militate against this condition. The Infectious states of lobar and broncho pneumonia fortunately have not been as common as might be expected with soldiers fighting in intolerable weather, and suffering long periods of exposure both before and after wounding. Many patients arrive at the hospital with an al- ready existent upper respiratory infection or tracheobronchitis. Fol- lowing a .prolonged anesthesia and operation, pneumonia would not have been a surprising event prior to the routine administration of penicil- lin and sulfa drugs, and the close observance of prophylactic postoper- ative measures. Blast injuries to the lungs are discussed under "General Considera- tions of Anesthesia in War Casualties" (page 63 ). One thing is certain from the few cases recorded as such, and that is that many were unrecog- nized or at least no notation made of them. Perhaps this was due to the fact that the degree of blast varied and that the minor cases gave minimal trouble. Severe bilateral pulmonary blast should offer no pro- blem in diagnosis, but the problem is anesthetizing such a case without losing the patient on the table from pulmonary edema. These patients do not tolerate anesthesia well, particularly ether, and every effort must be made to maintain adequate respiratory exchange, not only during the operation but postoperatively. One of the most important preoperative therapeutic measures is that of emptying the patient's stomach. This has a dual purpose: l) prevent- ing gastric dilatation, 2) removing the possibility of vomiting under anesthesia. In spite of this widely held view there were 10 recorded 18U Anesthesia in 3154 Abdominal and Thoraco-Abdominal Battle Casualties (Complications, contd) cases which vomited under anesthesia and aspirated gastric contents, with six of these being fatal accidents. Two of these occurred postoperative- ly on the ward before the patients had completely reacted, and must be ascribed to inadequate supervision. Of the four cases noted of pulmonary edema, one was fatal, and re- sulted from vomiting and aspiration following pentothal sodium for a secondary operation. Finally, there were two cases of death dating bronchoscopy at the conclusion of the operation. This is 0,4$ of the 436 recorded bron- choscopies (known to be very incomplete) as determined in the survey by the thoracic surgeons. Both cases were attributed to the vago-vagal reflex syndrome, which must be guarded against as a forseeable catast- rophe. This is best accomplished by intravenous atropinization of the patient just prior to the procedure, and by rapid careful bronchoscopy. Light anesthesia at this stage is preferable since the nechanical stim- ulation of the cough reflex assists in clearing the air passages. DEATHS ON THE OPERATING TABLE In any large group of seriously wounded battle casualties, there are some who are so badly off that they die shortly after admission to the Field Hospital. These we have come to designate as "fatally wounded". It is small wonder, therefore, that many die on the operating table dur- ing their siirgery in spite of the most heroic measures to preserve their lives. In the series of cases under consideration, 68 such deaths oc- curred. This is 2.15$ of the total series„ Of these, four resulted from vomiting and aspirating gastric contents, while two expired during bron- choscopy. The chief cause of death in these cases is shock, while infection and acute hemorrhage are important factors. Sudden change of position, during the course of a long operative procedure on a patient in poor condition, has resulted in death on the operating table. In theory this is said to be due to sudden diminution of circulatory volume by "inter- nal bleeding" into muscles and widely dilated capillary beds. It has been suggested that in addition to extreme care in turning these patients ephedrine gr. 3/4 be given a few minutes previously in an attempt to produce a general vasoconstriction and increased cardiac output, thus sustaining the blood pressure. Every means of resuscitation known to the anesthetist must be em- ployed in the effort to keep these patients alive. Oxygen, artifici 1 * Anesthesia in 3154- Abdominal and Thoraco-Abdominal Battle Casualties (Deaths on the Operating Table, contd) respiration, coramine, ephedrine, adrenalin, infusion of blood in every extremity and sternal infusion if possible, should be attempted. All too often, unfortunately, nothing seems to help very much, and in spite of every effort the patient succumbs to the gravity of his wounds. DURATION OF ANESTHESIA It is well recognized that the longer the operating time, and con- sequently anesthesia time, the more apt the patient is to leave the table in poor condition, and also, the more he is subject to postoperative com- plications, However, in dealing with these badly wounded men, especially those with multiple wounds, there are very few "short cuts" in the surg- ery which car lessen the operating time. The best that can be done under these circumstances is for the surgeon to work quickly yet carefully, while the anesthetist does everything to maintain a viable patient. Be- cause of the personal equation involved, no two surgeons work alike or at the same speed, nor are the wounds of any two patients exactly similar in extent or number. For that reason the length of operating time on these abdominal*and thoraco-abdominal cases is bound to vary between wide extremes. Indeed the extremes have been found to extend from 4-5 minutes to six hours, depending upon the severity of the wounds and their multiplicity. The average operating time for these patients was deter- mined to be between 2 1/2 to three hours, while the length of anesthesia time was approximately 10 to 15 minutes longer. SUMMARY AND CONCLUSIONS 1. The anesthesia employed in 3154- cases of abdominal and thoraco- abdominal combat casualties is reviewed. Most of these were done in Field Hospitals during the years 194-4--4-5. See Table I. 2* Trained anesthetists should be used in these forward instal- lations. I 3. The age groups of these patients are noted in Table II, 4-. The agents and methods available throughout the period are discussed. endotracheally by the closed GOp absorbtion technique is judged to be the method most frequently used, and least injurious to the patient. Tables supporting thes$ views are included, 5. Preoperative management is considered with reference to medi- cation, antishock therapy, emptying the stomach, local blocks, and clearing the respiratory passages. 186 Anesthesia in 3154- Abdominal and Thoraco-Abdominal Battle Casualties (Summary and Conclusions, contd) 6. During the operative phase, the lightest plane of anesthesia compatible with the contemplated surgery was employed. Curare was used in 26 patients for additional relaxation with good results. Shock treat- ment was continued throughout the operation as needed, 7. Postoperative bronchoscopy was valuable in many cases, 8. In the postoperative period the anesthetist is concerned with pervehtion and treatment of complications, and continuation of shock therapy. 9. Complications as recorded in this series are noted in Table VII. 10. Deaths on operating table from shock, vomiting, and bronchos- copy are noted. 11. The average duration of anesthesia was between 2 3/4. and 3 1/4, hours. 187 LAPAROTOMY INCISIONS, CLOSURES, DEHISCENCES In the 3154. abdominal and thoraco-abdominal cases operated upon in 1944 and 1945, 2258 cases with laparotony wounds had records sufficiently complete to allow an analysis of the type of incision and the type of closure in each instance. Inasmuch as the majority of these cases were held in the Field Hospital only for a period of seven to 14 days, it is obvious that this study would take on greater significance if a detailed follow-up could be undertaken after the cases had been evacuated, and especially, after they had reached the General Hospitals in this Theater. Probably more wound dehiscences occur after ten days than before. Any such follow-up would not relate to the incidence of incisional hernia, which, to be accurate, would require a follow-up over a period of months and years. INCISIONS A tabulation of the types of laparotony incisions in this series of 2258 cases has been made. They were broadly grouped into two main classification, vertical and transverse incisions. It was found that 92$ of all incisions were vertical and that only 8$ were transverse in type. The former group was subdivided into raidline, rectus splitting and paramedian muscle-retracting incisions. The group of transverse in- cisions was subdivided into subcostal, gridiron, loin and transverse an- terior incisions. Midrectus, mid-midline and midparamedian incisions were arbitrarily grouped with the high rectus, high midline and high paramedian incisions as the case might be. TABLE I Incidence of Vertical Incisions (2072 Cases - 92$ of Total) Not Cases Total Vertical Incisions High midline incisions 150 7% Low midline incisions 268 13% High rectus incisipns 1176 56% Low rectus incisions 1AD 7% High naramedian incisions 303 15% Low oaramedian incisions 23 2%. It is not the purpose of this paper to debate the relative merits of each of these incisions. Each has its proper place in civilian ab- dominal surgery. However, we feel that the most suitable laparotomy 188 Laparotomy (Incisions, contd) TABLE H Incidence of Transverse Incisions (186 Cases or 8% of Total) Total Transverse No. Cases Incisions Subcostal 5U 29% Gridiron Lh 25% Loin 26 ... u% Transverse snterior 60 2221 incision for handling war injuries of the abdomen is the vertical in- cision. This is true for two reasons: First, it permits upward or downward extension of the wound to allow a satisfactory approach to in- juries which had not been anticipated pre-operatively. Secondly, it is undesirable to exteriorize an injured segment of colon in the explora- tory wound, and by the use of a vertical incision, the lateral and med- ial portions of the abdominal wall are left free for the exteriorization of the colon in separate stab wounds. As to the type of vertical incision to be used, it makes little difference whether a midline, a rectus splitting or a rectus retracting is employed so long as it is of sufficient length to permit good expos- ure. We will show subsequently, however, that the dehiscence rate per 100 cases is lower for high paramedian incisions than for high rectus or high midline incisions. CLOSURES In the surgical closure of 2258 laparotomy wounds by 34- surgical teams, a total of 4L different methods were utilized. These represented the preference of the surgeon in each instance. In general, these var- iations as to type of closure have fallen in to four large groups with many deviations in each group. These groups are: 1, Layer closure of the wound using catgut throughout, plus retention sutures (68$). 2. Layer closure using interrupted sutures of cotton or silk in the anter- ior fascia, plus retention sutures (15$). 3. Layer closure but no re- tention sutures (6$). 4-. Mass closures with through and through su- tures of heavy braided silk, steel wire or doubled silkworm gut (11$), All layer closures (2006) had retention sutures of some type except for 137 cases, or 6,8$ (of the total number of layer closures). In some instances, the only part of a layer closure consisted in a running cat- gut suture in the peritoneum, reliance for the approximation of other layers being placed upon retention sutures incorporating skin, fascia and muscle, or just skin and fascia only. In other instances, through Laparotomy (Closures, contd) and through sutures incorporating all layers of the abdominal wall were used in conjunction with interrputed sutures of silk or chromic catgut in the anterior fascia only. In a few cases, interrupted cotton or silk was used in all layers including the peritoneum, without any retention sutures whatever. Also, nonabsorbable suture was used in the anterior fascia in combination with the usual running catgut suture in the peri- toneum together with any one of the three methods of placing retention sutures. Mass closures alone were used employing only retention sutures of heavy braided silk, doubled silkworm gut, or steel wire. Other variations in the layer closures consisted in placing a small ponrose drain, superficial to the peritoneum and deep to the anterior fascia. In most instances the skin was left open; in others It was par- tially closed; and in veiy selected cases, without hollow viscus perfor- ation, it was closed tightly without either a subcutaneous or a subfas- cial drain. The many possible combinations of these variations resulted in the J+0 different methods of laparotomy wound closure. TABLE III Incidence of the Pbur Principal Methods Of Laparotomy Wound Closure Method No. Cases Percent of Total Cases Layer closure throughout, using catgut ■plus retention sutures 1536 . 68 % Layer closure using interrupted silk or cotton in anterior fascist 333 15% Layer closure but n6 retention sutures 137 6% Mass closure, through and through sutures only _2S2 11% TABLE IV Incidence of Laparotomy Wound Closures on the Basis Of the Method of Retention Suturing Used Method Percent of No, Cases Total Cases Retention sutures through skin and fascia 813 38% Retention sutures through skin, fascia an$ mijscle 576 27% Retention sutures through all layers of abdominal wall with layer closure A-30 23% Retention sutures through all layers of abdominal wall, no layer closure 252 . . 12% 190 Laparotomy (Closures, contd) The surgeons of this Group feel that there is probably no satis- factory substitute for the accurate suturing of laparotomy wounds in layers, together with the employment of some method of retention sut- uring that will actually retain the wound. Mass closure, though rapid and having a definite place in the surgical management of the more se- verely wounded, is a definite sacrifice of accurate wound closure for the sake of speed. We believe that the latter should be resorted to only when the condition of the patient on the operating table is such that prolongation of the operation is likely to deny the patient his best chance for recovery. Under such circumstances, this method is not only justified but indicated. DEHISCENCES Thirty-six abdominal wound dehiscences, out of this group of 2258 cases, occurred in first priority hospitals, an incidence of 1.6$. This figure is accurate for first priority hospitals only. He have studied these 36 dehiscences from the standpoint of types of incisions and clos- ures used; the frequency of involvement of intra-abdominal viscera at the time of original surgery; the recorded factors felt to contribute to or provoke the dehiscence; and the type of treatment instituted once the dehiscence was recognized clinically. TABLE V Incisions Used in 36 Wounds which Dehisced High rectus incisions Cases with Dehiscence 25 Total No. of Cases 1176 Percent 2.1256 Low rectus incisions 3 UP 2.1L% High midline incisions 3 150 2,00% High oaramedial incisions 3 303 0,99% Left unuer transverse 1 60 1,66% Transverse upper abdominal connecting wounds of entrv and exit 1 Thirty of the 36 wound dehiscences were closed in layers and some method of retention suturing was used in all the layer closures except one. This particular case had a running suture of plain catgut in the peritoneal layer, interrupted chromic catgut in the anterior fascia, a subfascial penrose drain, but no retention sutures. 191 Laparotomy (Closures, contd) TABLE VI Primary Closures Used in 36 Cases With Subsequent Dehiscence Cases With Dehiscence Total No. of Cases Percent Layer closure throughout with catgut olus retention sutures 22 1536 1.43*_ Layer closure with interrupted cotton or Silk in anterior fascia, plus retention sutures 7 333 2.1* Layer closure (catgut), no retention sutures * 1 137 ,13% Mass closure with through and through retention sutures only 6 252 3t4*... * 4.7 of these cases were McBumey incisions for appendectomy and the remainder were negative explorations or had minimal pathology to warrant a closure of this type. Pbr purposes of comparison, this group should be excluded. TABLE VII Tabulation of 36 Dehiscences in Relation to Method of Retention Suturing Used (In one case with dehiscence, no retention sutures were used) Cases with Dehiscence Retention sutures through skin and fascia 16 Total No. of Cases 813 Peraeift .1.9656 Retention sutures through skin and fascia and muscle 12 576 2.1$ Retention sutures through all layers associated with a layer closure 1 480 0.2$ Retention sutures through all layers - Mass closure - no layers 6 2sa„, ZA2L 192 Laparotomy (Closures, contd) Incidence of Iniurv to Abdominal Viscera at Original Surgery,.3ui 36 Gases of Subsequent Laparotomy Wound Dehiscence Ho. Gases Small bowel 21 Colon ...» - 17 Liver 9 Stomach Kidney 4 Diaphragm Spleen 2 Urinary bladder 2 Retroperitoneal hematoma * K Causitive and Provocative Photons in 36 Instances of Laparotomy Wound Dehiscence * Ho. Gases Distention 10 Wound sepsis 7 Cough (excessive) U Vomiting 3 Small bowel fistula, spontaneous 3 Gastric fistula, spontaneous 1 Colostomy in laparotomy wound 1 Irrationality 3 Nutritional deficiency, severe 2 Removal entire rectus nuscle (clostridial nyositis) 3 Method of Treatment in 36 Dehiscences No. Cases Re suture of wound 28 Closed with T & T silk 16 Closed with T & T wire 11 Closed with figure of 8 silk ... 1 Taping of wound 7 No treatment (patient died) 1 These 36 dehiscences occurred from one to 19 days postoperatively. The average time postoperatively was approximately eight days. All cases had abdominal pathology at the time of surgery except for one negative exploration. 193 Laparotomy (Closures, contd) Death occurred in seven out of these 36 cases. In five instances the cause of death seemed to be the result of the- dehiscence, 1. Death from retraction of colostomy into peritoneal cavity with fatal peritonitis (colostomy exteriorized in laparotomy wound) 1 2. Death attributable to peritonitis resulting from two leaking areas in small bowel produced by trauma against through and through wire sutures at the time of dehiscence 1 3. Death from "shock and anesthesia" on operating table at time of resuture for a complete wound dehiscence ... 1 4. Death due to aspiration of voraitus with subsequent (four hours) development of excessive pulmonary and bronchial fluid — accident occurred at time of resuture 1 5. Death from acute mechanical intestinal obstruction secondary to partial wound dehiscence treated by taping only 1 Two additional cases developed small bowel fistulae following de- hiscence. One dehiscence had been treated by resuture while the other was handled by taping only. COMMENT The surgeons of this Group have always been interested in the sub- ject of laparotomy wound dehiscence for several reasons: First, because the surgical management of abdominal and thoraco-abdominal cases in for- ward hospitals has been our especial concern. Secondly, because of the high incidence of laparotomy wound dehiscence among the early cases, those operated upon in 1942 and 1943* Thirdly, because it was logical to expect that dehiscence would occur with considerably greater frequency in war injuries of the abdomen than in an equal number of nontraumatic abdominal cases. And fourthly, because of our desire to employ active measures to lessen the frequency of this complication. In a series of.346 abdominal and thoraco-abdominal cases operated upon by this Group in 1943, Jarvis reported 30 laparotomy wound dehis- cences in the 250 cases that lived over one week, an incidence of 12$, These cases were traced through the General Hospitals in this Theater, His report alone provoked serious thought on the subject of dehiscence and toward measures which could be utilized to prevent it. 19U Laparotomy (Comment, contd) The high rate of occurence among the early cases was attributable to several factors. It was not uncommon in the early overseas experience to find laparotoiler wounds closed in layers but without retention sutures. The use of retention sutures soon became a requirement prescribed in di- rectives from the Theater Surgeon. It was not uncommon to find a damaged segment of intestine exteriorized in the laparotomy wound rather than in a separate small incision. Likewise, this practice was soon stopped. Premature evacuation of patients before the optimal time (which is usual- ly 10 to l/f days), necessitating long ambulance rides and often over rough terrain, eventuated in directives against this. These corrective measures have helped greatly with lessening the incidence of dehiscence among war-incurred abdominal injuries. When the above measures have been taken into consideration, theye still exists a great tendency for wound dehiscence to occur in penetrat- ing and perforating wounds of the abdomen. The massive soiling of the peritoneal cavity from hollow viscus perforation produces peritonitis, either chemical or bacterial, in a high percentage of instances. This usually results also in heavy contamination of the laparotomy wound. Clinical sepsis, with its deleterious effect on sound wound healing, is not infrequently the result. The adynamic ileus which is occasioned by peritonitis of the degree present in most of these cases necessitates prolonged nasogastric suction at a time when reserves may be critical. This may result in hypoprotcinemia, or in other nutritional deficiency states, especially Vitamin C deficiency. The incidence of postopera- tive pulmonary complications is not low, especially during the ?/lnter months, and a severe and protracted cough adds considerable strain to the wound. When we add to these factors the occasional necessity for pre- mature evacuation of patients because of tactical reasons, we can readily understand why more laparotony wound dehiscences occur in these cases than in a series of comparable size of nontraumatic conditions of the abdomen. That we have not altogether succeeded in preventing dehiscence of laparotomy wounds is attested by the fact that 36 instances occurred in 194-4- and 194-5, out of a series of 2258 cases in forward hospitals alone, an incidence of 1,6%, This, of course, represents only a fraction of the total, because undoubtedly other dehiscences occurred among these patients after we had evacuated them. It is unfortunate that we do not have the complete story in regard to this group of cases because from it we would be in position to accurately estimate the true incidence of oc- currence as well as the relative value of the different methods of clos- ure. On the basis of the 36 dehiscences which occurred while the cases were still under our observation, we can say that all of the 195 Laparotomy (Comment, contd) principal methods of closure have failed once, and usually several times. Layer closures with nonabsorbable sutures of silk or cotton in the an- terior fascia have shown no superiority over catgut closures. In fact, on the basis of the figures which we have, the dehiscence rate is 1,4-3 per 100 cases with layer closures using catgut throughout, whereas the rate is 2,1 per 100 cases where cotton or silk is used in the anterior fascia. Mass closures carried a rate of 2.4- per 100 cases, higher than either of the two principal methods of layer closure. The dehiscence rate in relation to the method of retention suturing resulted in some interesting figures. When the retention sutures were placed through skin and fascia (either as a loop or figure of eight) the dehiscence rate was 1.96 per 100 cases; when they incorporated skin, fascia and muscle, the rate was 2.1 per 100 cases; when mass closure with through and through retention sutures was done, incorporating all layers of the abdominal wall, and without any part of a layer closure, the rate was 2.4- per 100 cases; when a layer closure (closure of one or more lay- ers, skin usually being left entirely open) is Combined with through and through retention sutures incorporating all layers of the abdominal wall, including peritoneum, the rate was only 0.2 percent. Actually, 4-80 cases were closed in this manner and in only one laparotony wound did dehiscence occur. Catgut was used for the layer closure in the majority of these cases. The through and through retention sutures were handled in one of two ways. They were pulled up and tied fairly snugly in the midline, or else tied laterally over rubber tubes, one tube being placed on either side of the incision. In either method, they were pulled up and tied after the layer closure was completed. We have recorded only one case in which a mechanical intestinal obstruction was thought to have been due to retention sutures of this type. The etiology of obstruction in this case was not proved. The obstructive signs disappeared with the release of the through and through sutures on the fifth postoperative day and no obstruction or small bowel fistulation occurred subseouently. One hundred cases closed in this manner by three surgeons of the Group (and included within the total of 480 cases) had a follow-up study through the General Hospitals in this Theater, No instance of complete wound dehiscence occurred in this group of 100 cases. One case had a partial separation of the superficial layers of the wound (though the peritoneal layer remained intact) and required resuturing. A second case was reported from the General Hospital some five weeks after the original surgery to have a large incisional hernia. The use of "pulley11 sutures, either in mass closure of the wound or as a method of retention suturing to supplement layer closure, has resulted’ in almost uniformly bad results. A number of these cases have been reported from the General Hospitals to have developed large sloughs in the ?/ound from strangulation and several cases have required secondary suture. 196 Laparotomy (Comment, contd) The measures to be employed in the prevention of wound dehiscence must necessarily be multiple and they must begin when the incision is made. The trauma necessary to make and close an incision must be kept at a minimum. Gross soiling and contamination of the wound must be pre- vented if at all possible. The Halstedian principles of tissue handling were all designed to lesson wound reaction which in turn favors the un- complicated healing of wounds. Jhilure to observe these principles con- tributes just ns effectively tov/ard the production of dehiscence as does the failure to have a good closure to safeguard against it. Though we have placed great faith in a good mechanical closure of the v;ound, we have not underestimated the importance of certain physi- ological and chemical factors in sound wound healing. The erythrocyte count should be kept at, or above, four million, and the hemoglobin above 12 grams percent. Plasma 250 c.c. once or twice daily should be given as long as Wangensteen decompression is required. Vitamin C should be supplied parenterally in dosage of 200 mgm. daily until nourishment can can be taken by mouth and thereafter, 50 mgm. t.i.d. given orally. It is also well at the time of evacuation to leave the retention sutures in place and to provide additional abdominal support while in transit with a binder preferably of the Scultetus type. 197 PENICILLIN AND SULFONAMIDE THERAPY IN ABDOMINAL WOUNDS Of the 3154 cases of abdominal ■wounds treated during 1944 and 1945, the records in 2410 instances were considered adequate for the purposes of this study. Cases which have been excluded are those in which exploration of the abdomen was negative, those that died on the operating table, and those in which the records were incomplete with reference to data on sulfonamide and penicillin therapy. In the total mortality of this group are all the cases in which death occurred from whatever cause during the period from the time of leaving the operating table to evacuation, a period usually of 10 days. Included also amongst these fatalities are those with multiple wounds. In this group of 2410 cases, all received either penicillin or sulfonamide by some route. Previous to May 1944, sulfadiazine was used, and was given intravenously at 12 hour intervals in doses of two and one-half grams. After the beginning of May 1944 all patients routinely received 5,000 to 25,000 units of penicillin intramuscularly every three hours. The intraperitoneal administration of sulfanilamide, or penicillin, or both, depended on the judgment of the surgeon, TTIhen they were used in the peritoneal cavity, sulfanilamide in crystal form was given in doses of five to 10 grams and penicillin in doses of 50,000 units. No surgeon routinely gave either drug intraperitoneally. A few surgeons used either or both with fair consistency; most used them in selected cases, the most severely wounded; a few used them only occasionally by this route. In the treatment of postoperative complications due to severe infection, there was more variation in the parenteral use of these drugs, Surgeons tended to switch drugs, to use both simultaneously, or to increase the dosage of penicillin, Data pertinent to the use of the drugs in these particular cases in the postoperative period are not available. In selected cases, such as those with potential or actual gas infections in associated wounds, or those with severe peritoneal soiling, the dose of parenteral penicillin was increased, or both penicillin and sulfadiazine were given simultaneously. Data suitable for statistical analysis con- cerning this are not available. In all these patients there was some degree of peritoneal contamination ranging from only a minimal amount from the missile with associated body dirt and shreds of clothing, to the massive peritoneal soiling from a rent in the bowel. This in turn resulted in various degrees of peritoneal reaction or peritonitis. In all these patients who came to autopsy some degree of peritonitis could be demonstrated. This obviously does not mean that they all died because of peritonitis. In such a series of patients in which multiple wounds are common it is difficult to determine at death exactly what 198 Penicillin and Sulfonamide Therapy in Abdominal Wounds. killed the patient. In many instances death cannot be attributed to one particular wound. Since one of the purposes of this study was an attest to compare the efficacy of sulfonamide and penicillin, and also various routes of administration, the criteria for attributing a death to peritonitis were strict. One would not expect these drugs to have an influence on the mortality of peritonitis in cases in which there was serious or fatal aon-infectious associated pathology, or in cases who were moribund on admission and who did not live long enough for the drug to have any effect. For these reasons deaths were not attributed to peritonitis if they occurred in the first three days, Even those cases with severe peritonitis which died la the ward from aspiration or other accident, and those which had other serious disease, such as Bacillus coli empyema, were not counted as deaths from peritonitis. It is because of this strict exclusion that the mortality from peritonitis here is somewhat less than reported elsewhere in this work. Peritonitis occurred in two rather well defined groups. The first group was composed of patients with massive peritoneal soiling, typically arising from leakage of the right colon. These patients were in profound shock which was very resistant to any therapy and they usually died with- in 24 to 4# hours, remaining in a state of shook the entire time. The second group ran the more common course of peritonitis as one usually conceives it. These patients developed distention, abdominal tenderness and either vomited or put out large quantities of fluid through the Levin tube. When death occurred it happened between the fourth and 11th post- operative days. Strangely enough these cases were relatively rare, accounting for only 42 deaths in 2410 cases, a mortality rate of !•?£• This represents of deaths in the series studied. Except in this small "peritonitis" group, the peritoneum as seen at autopsy in cases in which death occurred from other causes usually presented a dull, only faintly pinkish grey appearance and contained perhaps 100 c.c, of dark sanguinous, odorless fluid. Adhesions were usually limited to the operative site. Active progressive peritonitis was not often seen. TABLE I Gross Mortality in Casas Reviewed Abdominal Cases In 1944 1732 Deaths 422 or 24«4# Abdominal Cases in 1945 67 8 Dea^a .... 138 or 20.4* TOTALS l- 5ft? 23*3 199 Penicillin and Sulfonamide Therapy in Abdominal Wounds, TABLE II Mortality Due to Peritonitis and to Overwhelming Peritoneal Contamination With Shock Abdominal Cases in 1944 Deaths Due to Peritonitis Deaths Due to Overwhelming Peritoneal Contamination With Shock 1732 32 or 1,82 $8 or 3.43 Abdominal Cases in 194$ Deaths Due to Peritonitis Deaths Due to Overwhelming Peritoneal Contamination With Shock 678 10 or 1.5* 37 or 5.5* TOTALS 2410 42 or 1.7* J!iL or S& DISCUSSION Unfortunately there are no adequate data concerning the incidence or morbidity of complications. Even in the matter of mortality it is difficult to make a comparison of the effectiveness of one drug as opposed to the other, or of the effectiveness of different routes of administration in this series. This is because the conditions differed under which the two drugs were given and because, as a rule, the intra- peritoneal route was used in more serious cases. This is more fully explained elsewhere in this paper. Further, there is no other series of cases in which no drug was used which can serve as a control to demonstrate the effect of either drug. Only in war surgery would one find a series of similar injuries occurring in a similar group of young healthy males. There are few injuries in civilian life which are comparable to those from high velocity shell, bomb fragments or from anti-personnel mines. In other series of war injuries such as those of World War I or of the Spanish War in which sulphonamides and penicillin were not available, other factors which influence mortality, such as unlimited supply of blood and plasma, naso-gastric siphonage, and widespread use of carbon dioxide absorbtion anesthesia were likewise not available. i t t Total Caaaa i t Wit* Abdominal i t Wounda t J L i Total Oaatha In t Patlanta With Abdominal t Wounda t I Dataia from Parltonltia in Abdominal Wounda Oaatho from Onnbolmlng Faritonaal Contamination With Shook l t t 1944 J i *945 « Total i 1944 1 1949 i Xptal TW I 1945 ' Total t'U '4? « Totalt Wo. » % « ?9, i f i Wo. * % t J»*>_ I. 9 i la l % ilo. i % >»a. ' TTW. I 2 i la. J » Pannieral aulfadiaxino and parenteral aulfadiaslna plan intraparitonaal •uiranilaside i : t t t 361 0 : t t s i t t I t 361 < i i < i i i i i 117 '32.4* 0 : i t t t i i 0 t i i t i • t i t 117 »32.4« t > i i 18 t i t i i 5.0i 0 I t i i i i i • t i t t i 0 i IB i9.0 t t i i i I i t 12 i 3.3i 0 i t i t i i t t i 0 i 12 t t t i 3.3 ParaaUral penicillin and panntaral panlolllin plna Intraparitonaal panlolllin i t i « 7*7 436 § t i i t i i t i 19* '21.7* 77 I 1 t t t I t t *16.6* i t t t I t i t 255 *22.0' t 1 I 1 2 ' • t t i 0.3« 4 l t * I l r i t t t I t t0.9 ' 6 '0.9 i t t i t i t i 18 t 2.6t 10 i t i t I t I t l I i 2.3' J» t i t t i « 2.4 J I J L ! L t ' I i 1 I -J ! J! 1 L- —J 1 I t t Total Caaaa t Abdoaln*! t Wowiido i t i t Total Daatha la t I Pationta With Abdoailnal t l Wounda t » i i Daatha fro* Parltonltia i Daatha fros Orarwhalmlng in | Parltonaal ContaoioatAon Abdominal Hounds i With Shook i t t t i 1944 t 1945 l Total » 1944 i 1945 « Total < 1944 « 1945 « Total i'44 1 *45 i Total < Vo. t X ilo. I X I No. 1 X 1 No. «. X I Jo. < X 0.8i 2 i 0.4i 7 < 0.7< 4 < 0.4t 8 t i i l I » i i t t t * 8.4‘ 78 * 5.5 i t i t i • i 2.3< 12 i 1.2 tit 1. Satrwporitoaoal awlfaallaadda with aulfadiamlna or paaloillln, or iniraparltonaal pul* 1111b with parwntaral pwnlallllB. *. Uthwr ywwiUnl pwalwlllln *r nlftfUiiM. Cewparlaen of the Mortality in Two Groupa of Patlanta, Ono of Wfaloh Hoooivod Sulfonamide* and tho Othor Penicillin Cooparlaoa of tho Mortality In Two Group a of Patlanta, Ono of ’'tolah RwaalraA Druga Intraparitonaally and Farontarally and tha othor Only Parantarally TAHLo XU TABU XT 200 201 Penicillin and Sulfonamide Therapy in Abdominal Wounds, (Discussion, contd). In Table III there is a statistical comparison of results in two groups of patients. One group received penicillin parenterally, or parenterally and intraperitoneaHy, The other group received sulfa- diazine parenterally, or sulfadiazine parenterally and sulfanilamide intraperitoneaHy. The mortality rate in the penicillin group is much lower than the sulfonamide group which were all treated in the early months of 1944* Some reduction of the mortality in the cases done in the latter part of 1944 and 1945 would be expected. The medical personnel were more experienced in handling battle casualties, blood banks were in use, and blood more freely available for transfusion in the latter cases. Further, it was the general impression that the patients arrived at the hospital in poorer condition during the early part of 1944# This was due to an unusual tactical situation and to the terrain, both of which evacuation from the front to the hospitals, and to the bitterly cold, wet weather. However, the most marked difference in the mortality was in the "peritonitis" group. Here, the mortality in the penicillin series is only 10% as great as that of the aulphonanide series, while in the "total mortality" and in the "overwhelming peritoneal contamination and Siock" groups the penicillin mortality is roughly 60# aa great as the sulfonamide group mortality. We believe that this may be a significant difference. It must be emphasized that these figures pertain to the result of drugs as used in these instances described, and not to the results of an ideal method of use. It is fully appreciated that giving sulfadiazine in two and one-half gr. doses at 12 hour intervals is not the best method of administering this drug. With large numbers of patients and limited personnel it was the only feasible method. The practical difficulties encountered in giving sulfonamide is a factor in favor of penicillin. While the former would require the full time service of at least one medical officer, the latter can be entrusted to an enlisted technician who simply goes around to Inject all patients every three hours. It is also felt that intravenous sulfonamide nay contribute to the oliguria and anuria in the severely shocked patients among whom this iw a fairly common occurrence. 202 Penicillin and Sulfonamide Therapy in Abdominal Wounds. (Discussion, contd). In examining the statistics of the two groups, one of which received only parenteral therapy and the other both parenteral and intraperitoneal therapy, it is seen that the mortality of the latter is much higher (Table IV), This is readily explained by the fact that the more severely wounded patients more often received both parenteral and intraperitoneal therapy. Because of the large number of variables, such as evacuation time, exposure to weather, various combinations of wounds, etc, it is impossible to pick out two groups of similar cases, one of which received intraperitoneal therapy, and one which did not, with enough cases in each to make a significant comparison. SUMMARY AND CONCLUSIONS What part penicillin and sulfonamides played in the low mortality due to peritonitis Is difficult to determine. We believe they certain- ly played some beneficial part. However, it is impossible to separate statistically the effects of these drugs from the effects of good surgery and anesthesia, availability and use of large volumes of blood and plasma, and adequate ward care with careful attention to continuous gastric siphonage. 203 POSTOPERATIVE COMPLICATIONS IN ABDOMINAL CASES The records of 3090 patients with abdominal wounds were reviewed to determine the incidence and nature of the postoperative complications. In Table I there is a simple list of the postoperative complications as they were recorded excluding the thoracic ones. The latter are taken up in detail in Table II. TABLE I Recorded Postoperative Complications Other Than Pulmonary Dehiscence of abdominal incision 36 Infection of abdominal incision 32 Urinary suppression 36 Fistula from gastro-jntestinal tract 23 Small bowel 12 "Fiscal" 8 Duodenal 2 Gastric 1 Gas infections (Tot$l) 21 Abdominal 1 Retroperitoneal 5 Othey Subphrenic 15 Pelvic abcess 9 Intestinal obstruction 21 Thrombophlebitis and phlebothrorabosis 5 Secondary hemorrhage 8 Intercostal artery l Fbmoral artery. l Gastric hemorrhage 6 Urinary fistula 6 Flat embolism L Acute gastric dilation 3 Vesicorectal fistula 1 Parotitis, acute noncont^geous 1 Orchitis, acute nonspecific 1 Fhcephalomalacia due to ligation of common corotid artery 1 Meningitis, secondary to spinal cord in.iurv 1 Cerebral infarct 1 Anephvlactic shock (due to "Amigen") 1 Cachexia due to ileostomy 1 Air embolism 1 Postoperative Complications in AbdominalCases (contd) We wish to emphasize that the true incidence of complications is much larger than recorded here. Many processes commonly regarded as complications occurred so frequently that they came to be regarded as normal occurrences and not as complications since no effort was made to make special note of them on the records. This was often true, for ex- ample, of mild atelectasis, mild or moderately severe infections of the operative incision, mild degrees of peritonitis, end hydropneumonthorax in the cases with associated intrathoracic wounds. However, it is be- lieved that this study shows the comparative frequencies of many of the various complications. SHOCK Although found to be the most frequent principal cause of death, ’’shock” was not classified here as a true complication. It has been discussed as a separate entity in other papers (see pages 108to 109) found to account for 62$ of the total deaths. INFECTIONS AND DEHISCENCE OF ABDOMINAL WOUNDS The vast majority of the abdominal incisions had some degrees of infection, as the majority of the abdominal cases were contaminated. However, most of these infections were not clinically significant and they were recorded in only 32 instances. There were 36 instances of dehiscence of the abdominal wound. The high prevalence of respiratory infections and infections of the wound were contributing causes. In the winter time when fresh vegetables were not available, avitamihesis probably played some part. The subjects of wound dehiscence and infections are covered com- pletely in another report (page I87). PERITONITIS All patients ?dth an abdominal wound had some degree of periton- itis. It ranged in degree of severity from that which would be regarded as a peritonitis only from an academic view to the severe, overwhelming type which caused death within a few hours. It is impossible to draw a line where clinical peritonitis begins, hence no figures are given for the antemortem incidence of peritonitis. It did, however, account for 12% of the total deaths. For further information, see the papers ’’Postoperative Care of the Seriously Wounded” (page 203) and ”Penicillin and Sulfonamides in Abdom- inal Wounds” (page 197), Postoperative Complications in Abdominal Cases (contd) URINARY SUPPRESSION This highly lethal complication was unforseen. This is fully dis- cussed elsewhere (see page ), SUBPHRENIC AND PELVIC A3CESS Subphrenic abcess was recorded in 1$ instances and pelvic abcess in nine. The standard methods of management, i.e,, early diagnosis fol- lowed by surgical incision and drainage, were employed in these cases. Inasmuch as our patients were usually evacuated within 10 days, the true incidence was undoubtedly much higher. OTHER COMPLICATIONS Urinary infections were manifest only as a laboratory finding. Clinically they did not occur. The various other complications listed occurred so rarely as to require no comment. Some are covered in the discussion of other sections. PULMONARY COMPLICATIONS Table II is a list of the intrathoracic complications as they were recorded. The cases listed under *hydropneumothorax11 include cases in which small amounts of blood, fluid and air were present singly or in combinations. This figure is obviously incorredt as practically all of the 965 abdominal cases with associated intrathoracic wounds had some blood, fluid, and air present postoperatively. As to the various infectious pulmonary complications shown in Table II, although they are broken dowfi into various categories, it is the general consensus of opinion that the vast majority of them represent cases of unrelieved atelectasis followed by infections. Pulmonary infarction was recorded in 22 cases. On the average they occurred on the seventh postoperative day; the earliest occurred on the day of operation and the latest on the 22nd day; only 3 occurred after the 12th day. This is somewhat earlier than usually reported. It is suggested that in this series the origin of some of the emboli may have been in traumatized intra-abdominal veins. It is interesting to note that the incidence of pulmonary infarction is somewhat higher in cases who did not have an associated chest wound. 206 Postoperative Complications in Abdominal Cases (Pulmonary Compileoions contd) Infarction occurred in 0.8$ of cases without an intrathoracic wound and in 0.52$ of the abdominal cases with an associated intrathoracic wound. Of the 22 cases 21 died. 7fe are certain that nonfatal pulmonary- emboli and infarcts of the lung occurred more than once. The difficulty of making an accurate diagnosis of mild or even moderate degrees of pul- monary infarction in patients who have other serious diseases of the ab- domen, chest or both should be obvious. TABLE II Recorded Intrathoracic Complications in 3090 Abdominal Cases. Srnpyem^ 965 Abd Cases Assoc Thoracic With Wounds 2125 Abd Cases Without Assoc Intrathoracic Wd Lived 16 Died 9 Total 25 Lived 2 Died 2 Total A Hydrothorax . 77 9 86 . 5 0 5 Bronchopleural fistula 13 .. 5 18 0 0 0 Pulmonary embolism 0 ... 5 5 1 16 -23 . Atelectasis 12 11 . .. 23 . 32 5 37 Bronchopneumonia 6 6 12 20 19 39 . . Lobarpneumonia 0 2 2 0 5 5 ’’Consolidation” 2 A 6 A A 8 ”Wet lun^” 1 3 A 5 A 9 ’•Pulmonary edema” 2 A 6 5 11 16 Bronchitis 1 1 2 0 1 1 Bile empyema 2 A 6 1 0 1 Aspiration of vomitus 0 1 1 2 5 7 Blast 1 1 _ 2 1 3 A Lung Abscess 0 0 0 0 2 2 Other 0 1 1 6 0 6 Totals 122. 66 122_ ba 27— 161 Total recorded complications 199 ♦ 161 s 360 Total deaths 66+ 77 = U3 Table III shows the effect of weather'on the incidence of, and mor- tality occurring in selected pulmonary complications. It is to be noted that there was about a 40$ increase in the incidence of these infections and that they were a little more fatal in the cold months than in the warm months. 207 Postoperative Complications in Abdominal Cases (Pulmonary Complications contd) TABLE III Effect of Weather on Pulmonary Complications * Occurring in Abdominal Gases Cold Months Warm Months Total cases 1828 1262 No. nulnonarv comolicrtions . 112 55 .. Incidence rate 6,1% Deaths 56 22 . Mortality rate 5S L0% * Includes Bronchopneumonia, Lobarpneumonia, "Consolidation", "V/et lung” and Pulmonary edema of Table II. Table IV is an analysis of abdominal cases for the purpose of de- termining the effect of associated thoracic wounds on the incidence and mortality of infectious pulmonary complications (empyema excluded). Contrary to the expected result, it is seen that the incidence and mortality rate of pulmonary infection is about the same whether ‘an in- trathoracic wound is present or not TABLE IV Effect of an Associated Intrathoracic Wound on Pulmonary Infections* Occurring in Abdominal Cases Total cases Wound of Abdomen Only Wound of Abdomen and Chest 2125 965 No. nulmonary infections 55 22 Incidence rate 2,6% 2.2% Deaths 31 13 Mortality rate * Includes Bronchopneumonia, Lobarpneumonia, "Consolidation", Bronchitis and Lung abscess of Table II. In considering empyema alone it is found to occur 1A times as often in cases with an associated intrathoracic wound (see Table II), being recorded 25 times in the 965 cases with- an associated chest wound and only four times in 2125 of the abdominal cases without an associated chest wound. 208 Postoperative Complications in Abdominal Cases (Pulmonary’- Complications contd) Table V shows the effects of weather on associated intrathoracic wounds on the incidence of, and mortality in pulmonary infections oc- curring in abdominal cases. It is seen that the mortality rate for the pulmonary infections is definitely highest in cold months in patients with an associated intrathoracic wound. The figures in the incidence rates are not very enlightening, hhile it is evident.that for the simple abdominal cases there is a marked increase in the cold months it is not so for abdominal cases complicated with an intrathoracic wound. As previously shorn in Table IV, it can be seen here again that an intrathoracic wound does not seen to increase the Incidence or the mortality rate of pulmonary infection. TABLE V Effect of ’.leather and Presence of Associated Intrathoracic Wound on Selected Pulmonaiy Complications* in Abdominal Cases Abdomen Only Abdomen and Chest Cold Warm Cold Warm Months Months Months Months Total cases 12A3 882 585 380 No. rmlmonarv infections 79 35 33 20 Incidence rate 6.33 A.03 5.63 5.33 Mortality r^te 45.5* 3 A.3S 60.63 50.03 * Includes Bronchpneumonia, Lobarpneumonia, "Consolidation", "Wet Itmg" and "Pulmonary edema" of Table II, Table VI shows the effects of the number of intra-abdominal organs injured; with increasing number of organs involved the incidence of pulmonary infection increased. TABLE VI Effect of the "Multiplicity Factor” on Incidence of Pulmonary Complications No, Organs involved 1 2 3 1 5 No. Cases (total) 1116 897 322 83 13 No, cases developing in- fectious pulmonary .contolip^tions .87 55 10 11 3 Incidence rate 6.13 6,11_ 12.73 --13..3? 23. 209 Postoperative Complications in Abdonina Cases (Pulmonary Complications contd) In Table VII the infectious intrathoracic complications are ana- lyzed for the effect of time lag. As demonstrated in the study on "Time Lag” (page 132 to ll*6), it is again evident that if one groups unselected dissimilar cases for analysis of the effect of time lag, that the other factors neutralize the effect to such an extent that the effect of time lag is hidden. It is most emphatically against ail clinical experience to hold in a given case that an increase in the time lag does not adversely effect the natient. TABLE VII Effect of Time Lag on Incidence of Selected Pulmonary Compli- cations* and on the Mortality Rate in These Cases Time Lag 0-6 hrs 7-12 hrs 13 or more hrs Total number of abdominal cases 695 1509 886 No. developing pulmonary complications 55 75 55 Incidence pate 7,9% . . A.3% 6,3# Deaths ... 2A 3L 25 Mortality rate AMI _ —41*211 * Includes Bronchopneumonia, Lobarpneumonie, "Consolidation”, "Wet lung" and "Pulmonary edema" of Table II. CONCLUSIONS 1. The complications recorded in 3090 cases reviewed are tabulated and discussed. 2. The number of cases with complications in almost all instances are much too low and are not to be taken as the actual frequency of the various complications, 3. Weather during the ”cold months” and multiplicity of abdominal organs injured increased the incidence of intrathoracic complications, 4-. The intrathoracic wound does not increase the incidence or mor- tality of infectious pulmonary complications. 5. The effect of time cannot be demonstrated in studying groups of unselected dissimilar cases even if the groups are large. WOUNDS OF THE ABDOMEN Part III Specific Viscus Injuries Page (1) Sto mach 211 (2) Duodenum 230 (3) Jejunum and Ileum 238 (/f) Colon and Rectum 270 (5) Liver and Extrahepatic Biliary Tract .... 307 (6) Spleen 327 (?) Pancreas 346 (8) Kidney 356 (9) Ureter 373 (10) Bladder 378 (11) Urethra 383 (12) Abdominal Vascular Injuries 385 (13) Retroperitoneal Hematomas 396 (L+) Wounds of Special Types 4-01 211 WOUNDS OF THE STOMACH (An Analysis of 416 Cases) Wounds of the stomach are one of the deadliest of abdominal le- sions produced in modern warfare, being exceeded in mortality only by wounds of the pancreas and duodenum. A study of the 416 wounds of the stomach treated during 1944 and 1945 indicates (l) that wounds of the stomach occur more frequently in war injuries than was formerly sup- posed, (2) that wounds of the stomach are complicated by injury to other abdominal viscera in 90$ of the cases, and (3) that the mortality rate in stomach wounds is significantly higher than wounds of the colon, small intestine, liver, spleen, or genito-urinary tract. Various other data of interest in relation to incidence, diagnosis, shock, treatment, complications, and deaths in wounds of the stomach have been collected and analyzed. The resultant data and conclusions are presented. GROSS STATISTICAL DATA Incidence The stomach was involved in 416 instances among 3154 abdominal and thoraco-abdominal wounds, an incidence of 13.2$. Table I gives the gross incidence and mortality figures in stomach wounds. TABLE I Incidence and Mortality GROSS I TOTAL ♦UNCOMPLICATED CASES ♦COMPLICATED CASES No. Cases Inci- Mort- dence ality in 3154 Rate, Cases Gross No. Cases Inci- dence of 416 Cases Mort- ality No. Cases Inci- dence of 416 Cases Mort- ality 416 13.2% 40.7$ 42 10. l£ 28.5$ 224 89.9% _42.0l_ * In this study, the terra "uncomplicatedn indicates that the stomach was the only abdominal viscus involved, while "complicated" indicates other abdmoninal visceral involvement. The term "associated injury" refers to extra-abdominal injury. The figures 13.2$ for gross incidence of stomach wounds in abdom- inal cases, and'89.9$ for incidence of complicated injuries to the sto- mach are in marked variance with other sources of statistical informa- tion, Table II compares the incidence data reported from several sources. 212 Wounds of the Stomach (Gross Statistical Data contd) TABLE II Comparative Incidence of Stomach Wounds Source Total Abdominal Cases Reported No. of Stomach Wounds Inci- dence No. of Complica- ted Sto- mach Wds Incidence of Compli- cated Sto- mach Wds World War I (l) not given ILL 7.0* - A8 _ 33.3* Wallace (2) 965 82 8.5* 26 31.7* Ogilvie (Lybian Campaigns)(3) 381 22 . 5,8* 11 50.0* Jolly (Spanish Civil War (Republican))(4.) 238 20 8.3* not given not given Present Series . 315A A16 13.2* m 89.9* Relative Incidence of Wounding of Stomach in Thoraco-Abdominal Wounds and Abdominal Wounds Of 416 stomach wounds, 196 (47$) were produced by missiles tra- versing the diaphragm. There were 85 deaths among the 196 cases, the mortality rate in this group being 43.4$. The remaining 220 cases (53$) were wounded by projectiles entering or traversing the abdominal cavity only. Eighty-four deaths occurred in this group, a mortality rate of 38,2$. It is to be noted that the difference in mortality rate of the two groups is 5.2$. A number of records stated that a "violent chemi- cal pleuritis" was seen in patients with stomach wounds in whom a lac- eration of the diaphragm existed. This may partially account for the difference in mortality noted above. TIME LAG It is a well established fact that for the individual case, time lag is of the utmost importance. Without the consideration of time lag in relation toother factors, such as multiplicity of injuries, amount of peritoneal contamination, and associtated injuries, time lag statis- tics are of little significance or value. (See "Time Lag", pages 132 through147.) In this series, the wounds of the stomach were of such a relatively small number as compared with intestine, and uncomplicated stomach wounds so few, that extensive breakdown into the several fac- tors was not of statistical significance. The time lag in relation to mortality rate is given in Table I (appendix), and shows nothing of statistical value. SHOCK IN STOMACH WOUNDS The correlation of the severity of shock in stomach wounds to mor- tality is shown in Table III. 213 Wounds of the Stomach (Shock in Stomach Wounds contd) TABLE III , Relation of Shock to Mortality - hounds of the Stomach - IP A Cases* Degree of Shock on Admission Gases Deaths Mortality- Rate No Shock or Incipient Shock 66 A 6% Mild Shock 103 ... 19 18% Moderate Shock 106 ... 50 1.7,1% Severe Shock ia„ 98 76.0% * Data not available on 12 cases for estimate of shock. Shock esti- mates based on blood pressure, clinical degree of shock, preoperative resuscitation therapy, and anesthesia records. It is to be noted that an unusually high proportion of patients fall into the moderate and severe shock grouns, end this can probably be explained, at least in part, by the spillage of acid gastric con- tents into the general peritoneal cavity. The phenomenon of shock fol- lowing the acute perforation of a peptic ulcer is a familiar clinical entity. There seems to be little doubt that when the acid gastric con- tents are dumped into the peritoneal cavity, an almost immediate chemi- cal peritonitis ensues, quickly productive of a shock-like state. Later a superimposed bacterial peritonitis occurs. The anatomical location of the stomach, overlying the celiac axis area, the aorta, and the inferior vena cava and portal veins leads to a situation in which wounds are likely to be attended by considerable heme» orrhage. Actually, however, of the patients seen at surgery, hemorrhage has not appeared to be more striking than hemorrhage from many other organs. The part hemorrhage plays in the production of shock in stomach wounds cannot be determined, but in the average case, hemorrhage often seems to be of secondary importance to peritoneal contamination. Confirmatory evidence of the severity of shock in stomach wounds is indicated by the fact that death occurred on the operating table in 22, or l3/o of all patients dying with stomach wounds. One hundred and fifteen, or of the deaths occurred between the start of surgery and the end of the second postoperative day. Almost invariably, the re- corded causes of death were "shock" or "shock and peritonitis". CLINICAL DIAGNOSIS: SIGNS AND SYMPTOMS OF STOMACH WOUNDS There are only two signs in preoperative diagnosis which point con- clusively to a stomach wound: One, the emission of undigested food from a wound; the other, the observation of a perforation or laceration in a prolapsed stomach. Other signs and symptoms are merely indicative. 214 Wounds of the Stomach (Clinical Diagnosis; Signs and Symptoms of Sto- mach Wounds, contd) The literature has repeatedly and repetitiously called attention to vomiting as a cardinal sign of stomach injury. In this series of cases, vomiting has been no more frequently associated with stomach wounds than any other abdominal injury, and is not, we believe, a re- liable symptom. The presence of vomiting was noted only Seven times in four cases of which it was bloody. A survey of the opinions and ob- servations of the surgeons and resuscitation officers of this Group disclosed that no one was of the opinion that vomiting was an outstand- ing or significant feature. Blood in the vomitus or in the aspirated, gastric contents is a very suggestive sign, and one of the most reliable, it being recorded in 4.1 cases. The fact that swallowed blood from wounds of the head, neck, or lungs may give the same findings and lead to erroneous conclusions must be kept in mind. If these confusing factors can be ruled out, how- ever, the sign is a valuable clue. The absence of blood in gastric contents, on the other hand, does not mean that the stomach is uninjured. Clear stomach contents were noted eight times in this series. It is the opinion of this Group (an opinion carried out in prac- tice) that no hesitation whatsoever need be felt over passing a Levin tube preoperatively in wounds of the stomach. On the contrary, every effort should be made to insert the tube not only as a dignostic mea- sure, but also from a therapeutic standpoint. The accumulation of gas and fluid in a perforated stomach will only lead to increased leakage and more severe peritoneal contamination, and relief of this condition far outweighs any possible "contamination" introduced by the tube. Gastric dilatation and distention from fluid and gas is a common occur- rence in abdominal wounds, and also may and does occur in stomach wounds. The leakage of gas from the damaged stomach may be a valuable diag- nostic sign, inasmuch as there may be produced a variety of interesting and at times comfusing clinical pictures, For example, subcutaneous emphysema of all degrees may be produced in the abdominal and chest wall; gas may actually bubble, from the abdominal wound on expiration. In the event that the wound is of the thoraco-abdominal type, gas from the stomach may escape through the lacerated diaphragm into the pleural cavity, producing pneumothorax. A gas bubble lying free in the peri- toneal cavity may be discovered on roentgenographic examination (noted six times in this series). At other times the surgeon, on opening the peritoneum, may be greeted by a somewhat disconcerting gush of air. These gas signs are often confusing since it may be difficult to deter- mine whether the intra-abdominal gas is coming from the chest through a perforated diaphragm, or from the stomach. Only a careful explora- tion will determine the source of this free gas. Furthermore, a diag- nostic problem may present itself in regard to anaerobic infections. It is often quite difficult to determine whether the crepitus and tissue discoloration are the results of an early anaerobic infection, or the results of the gas and acid leakage from a perforated stomach. 215 ?founds of the Stomach (Clinical Diagnosis; Signs and Symptoms of Sto- mach Wounds, contd) « The preoperative diagnosis of stomach wounds depends primarily on the visualization of the course of the missile, and applying accurate anatomical knowledge of the location of the organ. The entrance and exit wound in perforating injuries, and the entrance wound and locali- zation of the missile by two-plane roentgenography will permit this visualization in the great majority of cases. The anatomical type of the stomach (HJW shaped, steer horn, etc.,) and the body position at time of wounding are complicating factors. The following case illus- trates the influence of position* A Prisoner of War was admitted to a Field Hospital with an entrance wound of the left hip just above the head of the femur, and an exit wound of the right hip through the wing of the ilium, A low midline exploratory incision was made, which dis- closed multiple perforation of the small bowel and sigmoid colon. In addition, at a distance of four inches above the upper end of the in- cision, a badly lacerated stomach was found.* Undoubtedly, this man had been crouched over as only being under fire can make a man crouch, forcing his stomach into the lower abdomen. PATHOLOGY OF STOMACH WOUNDS Stomach wounds seen in warfare vary greatly. The wound may be a simple tangential laceration of the stomach wall without penetration into the lumen (16 euch cases recorded in this series). The wound may be a trivial perforation, or it may be a laceration up to 20 cm in length. Finally, complete transection of the stomach mav be produced by the violence of the trauma (five cases in this series). In general, a fair proportion of the wounds are made by small missiles which per- forate one or both walls of the stomach in a perpendicular plane or at an obtuse angle. These perforations may result in little or no peri- toneal contamination from gastric leakage, inasmuch as the gastric mu- cosa being redundant, tends to act as a valve. On the other hand, mis- siles entering the stomach wall at an acute angle may produce extensive lacerations regardless of the size of the projectile. It is safe to assume (confirmed by clinical observations) that a fair number of the simple, small perforations of the stomach result in little peritoneal contamination, and conseouently less severe shock and mortality. On the other hand, perforating wounds may leak profusely. Lacerating wounds inevitably lead to severe peritoneal contamination. The re- sultant effect on mortality is demonstrated* TABLE IV Perforating and Lacerating Wounds of the Stomach Tyne of Lesipn No. Cases Deaths Mortality Rate Perforating 258 91 35$ Lacerating 117 1L 6(S 216 Wounds of the Stomach (Pathology of Stomach Wounds, contd) It is recognized that larger missiles tend to produce lacerating wounds, and in general, more lethal wounds. This undoubtedly explains in part the difference in mortality. UNCOMPLICATED STOMACH WOUNDS Wounds of the stomach alone, without complicating wounds of other abdominal organs, occurred in 4-2 instances of the 416 cases, or an in- cidence of 10.1$, This incidence is remarkably lower than any previ- ously reported (Table II shows the converse). Uncomplicated stomach wounds carried a surprisingly high mortality rate (28,5$) and it Wbuld seem that this is one of the organs in which the multiplicity factor does not follow the general rule, i.e., the greater the number of organs injured, the higher the mortality rate (see Figure 32 and Table II appendix). Each cf the 12 cases ending fatally was analyzed to see if some clue could be obtained as to why uncomplicated stomach wounds carried such a high mortality in this ser- ies, It was found that seven of the deaths occurred either on the day of operation or within the first two postoperative days, the cause of death falling in that group of cases classified as dying from ’’shock” and ’’shock and peritonitis”. Two cases died the fourth and eighth postoperative days, respectively, of peritonitis, one died on the I/.th postoperative day of secondary gastric hemorrhage, and one died on the 15th postoperative day of a gastric fistula and peritonitis. One case had no data regarding the cause of death. Mortality figures based on 4-2 cases are subject to considerable statistical error, but one is im- pressed by the large number of deaths occurring in the "shock" group of cases. COMPLICATED STOMACH WOUNDS Tliis group of eases constitutes 90$ of the stomach wounds. Table V shows the incidence and mortality rates of stomach wounds in which a single additional viscus complicates the stomach wound. TABLE V Stomach Wounds Complicated by Wounds of One Other Viscus Stomach and Duodenum No. Cases 2 No. Deaths 0 Mortality Rate 0.0% Stomach and Je.iunum 16 L 25.0% Stomach and Ileum 7 0 0.0% Stomach and Colon PA 11 Z.5.8% Stomach and Liver _ 67 20 30.0% Stomach and Solean L2 8 19.0% Stomach and Pancreas 6 1 17.0% Stomach and Kidney 10 Stomach and Major Vascular Iniurv 2 2 100.0% 217 Wounds of the Stomach (Complicated Stomach Wounds, contd) The incidence of wounding of various viscera, and the mortality in complicated stomach wounds, without regard to number of viscera injured, is given in figure 31 and Table III (appendix). The liver, as would be expected, was involved the greatest number of times, the spleen ■ colon being injured next most frequently, while the jejunum and kid.’ were wounded in a significant number of cases. Concomitant injury the colon, in general, produced the highest mortality rate. Major ve cular injuries complicating stomach wounds were almost universally fat INCIDENCE OF COMPLICATING WOUND} 4/6 STOMACM INJUCIE} /944 ' 19U5 figure 31 - Incidence of Complicating Injuries to Other Viscera in Stomach Wounds Combinations of organ injury varied widely, and treatment was suc- cessful in certain combinations not previously recorded, fbr example, states that no combination of wounds involving the stomach, small intestine and colon had been reported as surviving at the time his book was written. In the present group of cases, 24- instances of such wound- ing were reported, thirteen of which survived. Eleven of these cases 218 Wounds of the Stomach (Complicated Stomach Wounds, contd) had, in addition, a liver wound. Table IV (appendix) shows the vari- ous combinations of organ injury encountered when the combination oc- curred five or more times. THE "MULTIPLICITY FACTOR" The ’Multiplicity factor” (see discussion of "Multiplicity Factor", page 112 ) has been found to be a more reliable index of prognosis than any other factor in abdominal wounds, but in wounds of the stomach this factor showed some inconsistency (Figure 32 text and Table II appendix) There is undoubtedly some margin of error of a statistical nature in the figure 28.5$ mortality for wounds of the stomach alone, since the uncom- plicated stomach group of J+ 2 cases is not large enough to be conclusive. However, in spite of possible error, the mortality of stomach wounds alone seems to be of some significance. MULTIPLICITY FACTOR IN WOUNDS OF THE STOMACH IN,339 CASES /9AA' l9*+5 Figure 32 -"Iftultiplicity Photoi** in Wounds of the Stomach 219 Wounds of the Stomach (contd) OPERATIVE TECHNIQUE Surgical Approach A transdiaphragmat ic surgical approach to wounds of the fundus and body of the stomach greatly facilitates the repair of lesions in these areas. The surgeons of the Group used this type of approach in 60% of the 196 thoraco-abdominal wounds, and it became tlife incision of choice in selected cases. The transdiaphragmatic approach to stomach wounds in those cases having no diaphragm perforation was avoided; only in one such instance v;as it used. Details of incisions and surgical approaches- are given in Table V, appendix. The importance of thoroughly examining the posterior wall of the stomach by incising the gastrocolic omentum cannot be stressed too strongly, and it was universally dons by the sur- geons of this Group. Both the anterior and posterior surfaces of the fundus are accessible transdiaphragmatically without the incision of peritoneal folds. Procedures Used in Stomach Wounds Simple suture of stomach lacerations and perforations was performed in 409 cases, even though the laceration was very extensive, five cases showed complete transection of the stomach, and necessitated resection. Of these, two had end-to-end anastomosis, one dying; of the remaining three, some type of gastrojejunostomy (Polya or Hoftneister) was done, all dying. There were two patients in whom perforations are known to have been overlooked. In one, a gastropleural fistula developed and death ensued. In the other, the overlooked perforations had closed spontaneously with- out apparent leakage. They \vere discovered in a patient dying of embolism and did not contribute to the fatality. No particular type of suture or suture materials were used in the cases of this series, these matters being individualized through the pre- ference of the surgeon. Purse string suture of the stomach, we believe, is to be avoided; the reasons are discussed below. Suture in Relation to Postoperative Hemorrhage There is one highly important technical point which has emerged from this study. Postoperative gastric hemorrhage of severe proportions oc- curred in six instances, end constituted the largest group of postoper- ative hemorrhage encountered in the entire abdominal series. In three of these cases, death ensued; two patients survived with conservative management; one recovered uneventfully after a secondary operation to control the hemorrhage. In all cases, the stomach wounds were simple perforations which were closed, in effect, with reinforced purse string sutures. This type of suture leads to a set of circumstances which are ideal for the subsequent development of postoperative hemorrhage, and the writer has seen this clearly demonstrated in two instances, A 220 Wounds of the Stomach, Operative Technique (Suture in Relation to Post- operative Hemorrhage, contd) purse-string sture of the stomach rarely, if ever, picks up the mucosa of the stomach. Subsequently, the edges of the mucosa slough, become endurated and retract, thereby exposing the blood vessels which tra- verse the submucosa, and producing a condition paralleling the patho- logical rdcture of on acute ulcer (Figure 33 ). Erosion of the pre- viously scaled underlying vessels is likely to occur and hemorrhage follows. The case cited below is illustrative* A soldier was admitted to a Field Hospital because of multiple shell fragment wounds, including a left thoraco-abdominal wound. His general condition was excellent. Left thoracotomy was performed and a transdiaphragmatic repair of a single perforation of the upper portion of the body of the stomach carried out. Convalescence was exceptional- ly smooth until the fifth postoperative day, at which time an unex- plained rise in pulse rate was noted. Eight hours later it became ob- vious from signs and symptoms that the patient was hemorrhaging, though the location of the bleeding was not readily ascertainable. The naso- gastric tube produced only a small amount of reddish brown fluid. Transfusions were given, but the response was only temporary. Conse- quently, after seven hours of observation, laparotomy was done. A distended stomach was found; it was completely filled with a clot es- timated to contain 1500 c.c, of blood. This clot formed a perfect cast of the stomach, Gastrotomy was carried out, and after removal of the clot, the site of perforation previously sutured was inspected from the mucosal side. The surgeon's recorded discription is adequate: "A white indurated area is seen from which the mucosa is retracted. From the edges, in two places, are seen continuous but small streams of blood, one venous and the other arterial. This ulcer-like area, then, is the cause of all bleeding". The entire ulcer-like area was excised and closed. Uneventful recovery followed. It is believed, on the basis oT these and similar reports on other cases, that every effort must be made to approximate the gastric mucosa by suture in all stomach wounds. Small perforations must be enlarged by transverse incision in order to adequately expose and accurately su- ture the mucosal layer. The conclusion that purse-string suture of stomach wounds in general is to be avoided is .justified. 221 Wounds of the Stomach (contd) FIG. 1 Plgure 33 - Appearance of Ulcer-like Lesion from Penetrating Wound of the Stomach POSTOPERATIVE COMPLICATIONS OF STOMACH WOUNDS Practically every stomach case that died within the first two post- operative days had the familiar picture designated under the generic term "shock". All these patients had varying degrees of peritonitis, extensive tissue damage, blood loss, disturbed pulmonary physiology, or the various combinations of these factors. Although strictly speaking, these were in fact postoperative complications, the picture that this group of cases presented was excluded from this discussion of postoper- ative complications. It is seen from Table VI (appendix) that pulmonary complications were by far the commonest. Pneumonia, empyema, and atelec- tasis accounted for approximately one-half of the serious complications. 222 Wounds of the Stomach (Postoperative Complications of Stomach Wounds, contd) Laparotomy, dehiscence, postoperative gastric hemorrhage, and periton- itis were next in order of frequency, while other complications seldom occurred. Peritonitis recorded as such was the usual clinical type of peri- tonitis, and resulted in a high mortality rate (five out of six cases died). ASSOCIATED INJURIES Severe extra-abdominal injuries occurring in patients simultane- ously vdth a stomach wound were present in approximately one fourth of the patients. The chest injuries of thoraco-abdominal stomach wounds are, strictly speaking, associated injuries, but their discussion is not included here although the presence of such a lesion apparently pro- duced a 5% increase in mortality in the thoraco-abdominal group. The evaluation of each associated injury and its influence on mor- bidity and mortality is almost impossible to arrive at unless one ana- lyzes each case individually. Therefore, the associated injuries are simply tabulated in Table VII (appendix) no effort being made to assess their importance in individual cases. There were 4-3 major fractures, 4.1 major soft tissue injuries, nine major amputations, nine spinal cord lesions, four heart, and four brain wounds. The overall mortality of patients with associated injuries was not significantly different from that of patients with stomach and abdominal injuries alone, although the fallacy of this figure applied to the individual case is obvious. ANALYSIS OF DEATHS One hundred and sixty-nine deaths occurred in the forward hospital in the A-16 patients with stomach wounds. Twenty-two, or 13$ of deaths took place on the operating table, a somewhat higher proportion than the 10$ occurring when no stomach wound existed. Seventy percent of the deaths occurred by the end of the second postoperative day, the cause of death almost invariably being ascribed to "shock", ’'shock and peritonitis”, "shock and hemorrhage", or "overwhelming contamination". Anuria was recorded as the cause of death in 10 cases. In deaths oc- curring after the second postoperative day, peritonitis played a sig- nificant role in approximately 50$. Details of causes and day of death are recorded in Table VIII (appendix). DISCUSSION Three points of importance have emerged from this study of A16 wounds involving the stomach. They are* 223 Wounds of the Stomach (Discussion, contd) 1, Incidence The incidence of stomach wounds is nearly twice as great as any previously reported incidence, and the number of complicated stomach wounds is nine times as great as uncomplicated stomach wounds. These figures merely confirm what can be deduced on a logical basis. As has been pointed out in a previous portion of this paper (pages 93 to 95 ) the incidence of wounding of any organ is almost directly proportional to the space it occupies. It follows, therefore, that the stomach, be- ing a relatively large organ, should have a fairly high incidence of wounding, and that the incidence given is merely the incidence, not of wounding, but of patients seen at the hospital. We believe that our figure more nearly approaches the true incidence than lower figures, although the actual figure is undoubtedly higher yet. Similarly, the incidence of uncomplicated stomach wounds theoretically, should be quite low, inasmuch as the liver, spleen, colon, and kidneys almost completely invest the stomach. Our statistics confirm this. Here again, it would seem that the proportion of uncomplicated to complicated stomach wounds more nearly approaches the true incidence than other previously reported proportions. 2. Mortality The data collected in this study point ouite strongly to the fact that stomach wounds per se are one of the more serious types of wounds encountered in warfare. Some of the wounds are comparatively trivial matters, but on the other hand, the leakage of the acid gastric contents into the general peritoneal cavity when it does occur is a most shocking matter. (Our data confirm this. Patients with stomach wounds, in general, not only exhibited a more severe degree of shock, but the mortality in this group of cases was significantly higher than in a comparable group of cases without stomach wounds. Moreover, the mortality rate of patients with lacerating wounds of the stomach was almost double that of patients having perforating wounds, it being rea- sonable to assume that all patients with lacerating wounds had periton- eal flooding v/ith acid stomach contents, while only an indeterminate proportion of patients with perforating wounds had severe peritoneal contamination. Yet another confirmatory bit of evidence Is shown in the high rate of death in uncomplicated stomach wounds. In general, the multiplicity factor shows consistency if one takes into account that the initial mortality of stomach wound alone is high. The relative vascularity of the stomach and its environs played a part in the lethality of stomach wounds, but we believe that this is of secondary importance, basing our belief on the collected clinical ob- servations of the surgeons in this Group, who noticed nothing particu- larly bloody about stomach wounds. 224 Wounds of the Stomach (Discussion, contd) 3. Postoperative Gastric Hemorrhage Evidence is submitted to show that the incidence of postop- erative secondary hemorrhage in stomach wounds is higher than secondary hemorrhage from any other viscus in first priority surgical patients. The cause of this phenomenon is discussed, and the conclusion drawn that purse-string suture of stomach perforations should not be done. Rather, the mucosa of the stomach should be exposed and accurately su- tured . SUMMARY AND CONCLUSIONS 1. An analysis of 416 wounds of the stomach has been made. The incidence of stomach wounds in 3154 abdominal injuries was 13.2$, of which only 10.1$ were wounds of the stomach alone. In 47$ of the cases the wounding missile traversed the pleural cavity; in 53$ of the cases the wound was confined to the abdominal cavity alone, 2. There were I69 deaths in the forward surgical installations, a mortality rate of 40•7$ among the 416 cases. Uncomplicated stomach wounds (42 cases) had a mortality rate of 28.5$. 3. Statistical and clinical data are presented on shock, patho- logy, operative technique, associated injuries, postoperative compli- cations, and mortality; these various subjects are discussed. The cause and prevention of postoperative secondary hemorrhage from the stomach was presented. 4. Evidence was submitted to show that stomach wounds -per se are one of the more serious of abdominal wounds occurring in warfare. REFERENCES 1. Medical Department of the United States Array in World War, Gov- ernment Printing Office, Washington, D.C., 1927. Vol XI, part i, pages 65 and 4-67. 2. Wallace, Sir Cuthbert. "War Surgery of the Abdomen”, London 19IS (Quoted by Bailey, H,, "Surgery of Modern Warfare”, E & S Livingstone, Edinburg, 1942. Vol I, page 412.) 3. Ogilvie, W. H. "Abdominal Wounds in the Western Desert", Surg, Gyn, and Obst, Vol 78, No. 3, March 1944, pages 225-238. 4. Jolly, Douglas W, "Field Surgery in Total War", Paul B. Hoeber, Inc,, New York, 1941* Page 169 5. Bailey, H. "Surgery of Modem Warfare", E & S Livingstone, Edin- burg, 1942. Vol i, page 6 225 Wounds of the Stomach (contd) APPENDIX OF STATISTICAL TABLES TABLE I Time Lag and Mortality Hours Las Ho. Gases Deaths Mortality Rate 0-6 121 LI A03 6 - 12 179 67 37% 12 - 18 65.. _ 30 c? 1 CO rH 20 6 ... . 303 . . 24 17 7 412 TABLE II Multiplicity Factor in Stomach Wounds Stomach wounded alorje No. Cases L2 Deaths 12 Mortalitv 28,5$ Stomach wounded and one other wounded viscus 173 . m 27.73 Stomach wounded and two other wounded viscera, 111 LL 39.6$ Stomach wounded and three other wounded viscera 50 29 58.0$ Stomach wounded and four or more wounded viscei^ 23 23 100.0$ Stomach wounded and major vascular and other viscera 15 14— 94.3% 226 Wounds of the Stomach (Appendix of Statistical Tables, contd) TABLE III Frequency of Injury of Other Abdominal Viscera (in 4-16 Gases of Stomach Wounds) and the Mortality* No. Cases Incidence Deaths I.brtalitv Duodenum 28 7t 18 6 A%._. Jeriunum 87 21 % 32 37% Ileum 23 51 . .. 12 . . . 52% . . Colon 122 291 68 56% .._ Liver 177 L2% .... 82 . L6% Spleen 109 26 % L2 39% _ . Pancreas 3.8 91 21 .. . 55% Kidney 67 U% L7 . _ 70% Ureter 3 It 2. 66% Bladder 2 ... . It 1 50% Ma.ior Vascular Lesion IS... Lt 3A-_ 9 Lt * Multiple Organs Involved TABLE IV Wounds of the Stomach combinations of Organs Occurring in More than 5 Instances Stomach Cases LZ Deaths 12 Stomach and Je.iunum 16 ___ L Stomach. Jertunura. and Liver 9 3 Stomach. Je.iunum and Kidney 6 2 Stomach. Spleen. and Kidney 6 2 Stomach. Je.iunum. and Coloi} 13 L Stomach. Je.iunum. Colon, and Liver 11 5 Stomach pn4 Ileum 7 0 Stomach Colon 24. 11 Stomach. Colon, and Liver 18 9 Stomach. Colon, and Spleen 6 2 Stomach. Colon, and Kidnev 5 5 Stomach. Colon. Liver, and Spleen 5 2 Stomach a,nd Livep 67 20 _ Stomach. Liver, and Spleen 17 5 Stomach. Liver, and .Pancreas 5 1 Stomach and Spleen A2 8 227 Wounds of the Stomach (Appendix of Statistical Tables, contd) TABLE V Surgical Incisions and Approaches Laparotomies 29 3 Thoracotomies 95. Thoracolaparotomies 6 Combined Laparotomy and Thoracotomy 18 Not Recorded L Total A16 Percent Thoracotomies 33% TABLE VI frequency of Postoperative Complications in 4-16 Stomach Wounds* Complication No. Gases Pneumonia 12 Empyema 11 Dehj.pceppe 8 Ateleclepis 6 Postonerative Hemorrhage 6 Peritpnitis 5 Gastric Fistula 2 Intestinal Obstruction 5 Malaria 2 Anaerobic Infectiop 1 Heart Disease 1 Absqepses Subnhrenic 2 Pelyip 3 Retroperitoneal 2 InpjLsional 6 Intra-abdominal 2 * Data confined to cases in which diagnosis made clinically before evacuation or death, and does not include post-mortem diagnoses. 228 Wounds of the Stomach (Appendix of Statistical Tables, contd) TABLE VII Associated Injuries - Al6 Stomach Wounds Maior Junctures Ilia 1 or Anoutations .-2-. Soinal Gord Injuries 9 Heart Injuries L Brain Injuries L Ma.ior Soft Tissue Injuries LI TABLE VIII Causes and Time of Death, 169 Stomach Gases No, Deaths Hate Deaths on Operating Table zz 13% Shock 13 Shock and Peritonitis 1 Shock and Hemorrhage 5 Shock and Gas Gangrene 1 Shock and Atelectasis 1 Heart Lesion 1 Deaths and Causes 'through 2nd Postoperative Day Shock A3 . Shock and Peritonitis 28 Peritonitis (Overwhelming) 9 Shock and Anaerobic Infection . 2 Shock and Atelectasis 3 Shock and Hemorrhage A Pulmonary Embolism 1 Pneumonia and Peritonitis 2 Intestinal Fistula and Peritonitis 1 Died from start of operation through 2nd postoperative d^y Vi1? 70% Deaths and Causes after 2nd Postoperative Dav % 30% Pneumonia 6 Pneumothorax and Pleurisy 3 Pneumonia. Empyema or Pleurisy and Peritonitis 12 Peritonitis and Shock (all 3rd P.0. Day) 8 Peritonitis 6 Anuria 10 Hemorrhage. Secondary 3 Intestinal or Gastric Fistula 2 Brain Injury 1 Uhkgioyfa _J 229 Wounds of the Stomach (Appendix ot Statistical Tables, contd) TABLE IX Mortality in 416 Stomach Wounds in Relation to Type of Viscera Injured Stomach and Solid Viscera Ko. Gases 168 Deaths L7 Mortality 27,9% Stomach and Hollow Viscera 69 21 30.5/V Stomach and Both Solid and Hollow * 118 71 60,2$ * The high mortality rate in this of the ”multiplicity factor”. group obviously reflects the effect 230 DUODENAL INJURIES Injuries to the duodenum occur infrequently, and it is a distinct rarity that tl\e duodenum alone is damaged. In World War I, there were 10 instances of duodenal injury comprising 6£ of all small bowel in- volvement. The mortality for these 10 cases was 8CJ6 . The statement is made in the general surgical section of the "Medical History of World War I", that multiple lesions are usually encountered in duodenal in- jury, the average expected is four to six. Jarvis, in his analysis of the abdominal wounds handled by this Group in 1943, reports nine cases of duodenal injury with seven deaths. In two cases, the duodenal lesion was missed at operation and in one of these the missed perforation was the cause of death. These nine cases were marked by the multiplicity of organs involved. In three of the seven deaths reported, the pancreas was involved, in one the vena cava, and in another the superior mesenteric artery. For the year 1944 and the active part of 1945, there have been 118 instances of duodenal injury encountered by this Group, and these 118 cases are the basis of this study. Three thousand one hundred and fif- ty-four abdominal operations were performed in this period, and duoden- al injury was present in 3.7M, of the cases Table I). Of the 1286 instances of small bowel injury, the duodenum comprises 9*2$ of the cases. TABLE I GROSS TOTALS UNCOMPLICATED CASES COMPLICATED CASES Inci- Mort- No, dence ality Cases in 3354- Rate Cases (gross) No. Cases Inci- dence of Cases Mort- ality No. Cases Inci- dence Mort- ality 118 3.7# 55 .Sit 2 1A-- 0 116 9S.& 56.9* Incidence and Mortality MORTALITY Mortality in this series is computed upon the basis of cases known to have died in the installation in which the initial surgery was done. In the 118 cases, 66 deaths occurred within the first 10 days, a mortal ity rate of 55 . There are three instances in which death probably occurred within the first ten days, but the records are incomplete. The site of the wound of entry is fairly consistent in duodenal injury. The missile entered the right side of the trunk, either front or back, in 98 or 83& of the 118 cases. Twenty per cent of all wounds were perforating in type. As will be shown later in the discussion of 231 Duodenal Injuries (Mortality contd) complicating injuries, there is a wound pattern in which duodenal in- jury may be reasonably expected and sought for. Figure 3i* illustrates the approximate area of penetration of the missile in the duodenal in juries of this series and the frequency in actual numbers. DUODENAL INJURIES SITE OF WOUND ENTRV IN 118 CASES Figure 3U - Duodenal Injuries - Site of Wound Entry in 118 cases* There was one case of duodenal injury without penetration. The patient had a large gutter wound across the epigastrium with omentum herniated through the wound. No wound of exit was present and a for- eign body could not be demonstrated by X-ray. It was felt by the op- erator that the stellate lacerations of the liver and second portion of the duodenum were due to blast. SHOCK RECORD The shock record upon admission to the hospital is constant in that the patients who subseouently died were in the main in a more se- vere state of shock than those that recovered. The classification of shock is taken from the records just as recorded. Duodenal Injuries (Shock Record contd) TABLE II Degree of Shock Decree of Shock Lived Died None U 6 Mild 12 3 Moderate 12 g_ Severe 10 4-9 In four instances, the degree of shock was not recorded. Of the nine cases of vena cava laceration, one was not in shock, four in only moderate shock, and four in severe shock. CAUSE OF DEATH Shock and hemorrhage was the recorded cause of death in thirty- nine or 59*5$ of the deaths. Forty-seven or 71$ of-the deaths occurred in the first three postoperative days. Two of the deaths resulting from peritonitis were due to injuries overlooks;! at operation, one a laceration of the common duct, the other a perforation of the third portion of the duodenum. TABLE III Day of Death and Cause Day of Death At First 24 hrs 3 to Cause of Death .Operation 24 hrs to 72 hrs 10 days Totals Shock and hemorrhage 5 25 8 1 39 Pneumonia 2 7 9 Anuria 2 ~T~ r Transfusion reaction 2 T Pulmonary embolism 1 r Peritonitis 3 3 No record 2 2 r COMPLICATING INJURIES Multiple complicating lesions are usual in duodenal injuries. There were only two cases of damage to the duodenum alone in this ser- ies of 118, an incidence of 1.6$, and both survived. 233 Duodenal Injuries (Compliceting Injuries contd) In Table IV are shown the complicating lesions in addition to the duodenal injury in actual numbers. These figures are misleading in that in many instances there are multiple lesions to one organ which are re- corded. in the table as one; it does not take into account the vascular injuries, and further, the severity of the damage to one organ cannot be shown. TABLE IV Frecuency of Complicating Injuries No. of organs injured in addition to duodenum Lived Died Mortality 1 12 15 55 M 2 25 20 AAM ? 7 U 66 L 5 15 75 .06 5 1 1 _JO.O£ ? Not included in Table IV were the two cases of duodenal injury alone, and one of duodenum complicated by a portal vein laceration. It is seen that with three complicating injuries, the mortality is dou- bled and with four it is tripled. The one case recorded as living with five complicating lesions probably died as he was left moribund on the fourth postoperative day with a holding company. In Table V is shown the greater number of organ resections re- curred in these patients who subsequently died. TABLE. V Organ resections Operation Lived Died Splenectomy 1 U Cholecystectomy 2 6 Nephrectomy 9 12 Right Colectomy 2 7 Resection oR small bowel u 9 Ga st ro 1 e,i most omy 0 k. Vascular injuries are not an infrequent complicating wound in in- juries to the duodenum. In this series of 118, there were nine, or 1M instances of vena cava laceration with eight deaths. There were two cases of ■portal vein laceration, two of the pancreaticoduodenal artery, and one each of the hepatic and right spermatic artery. All of these cases died. Duodenal Injuries Injuries contd) In Table VI are listed the organs most frequently complicating duodenal injury, and the percentage frequency of their involvement. It may be seen from this chart, that there is a fairly constant wound pattern when the duodenum is injured. If, for example, there is a wound of the right upper quadrant that, -has involved the right kidney, liver, and right colon, an injury to the duodenum is quite likely. TABLE VI Incidence of Complicating Injuries to Other Viscera No. of times injured Liver 69 Colon 50. & Right Kidney 37 31.3K Small Bowel 36 . ... 30.5£ Stomach 21 i6. n Gall Bladder 17 U-fa Pancreas ... . 9 1M Vena Cava 9 7.« Portal Vein 2 l.« The pancreas was involved in 7.6$ of the cases in this series. Of the nine capes with pancreatic involvement, eight died. There was only one case in which the pancreatic head was damaged to the extent of severing the duct. The gall bladder was injured 17 times in this series, an incidence of 14-./$. ASSOCIATED INJURIES There were 15 of the 118 cases of duodenal involvement with an associated chest injury. This varied in severity from a simple per- foration of the diaphragn to severe laceration or contusion of the lung. Of the 15 cases with associated chest damage, 11 died. It is not within the scope of this paper to discuss shock, but it is shown that vascular inj uries with concomitant hemorrhage played an important role in influencing mortality, and chest injuries with disturbance of cardiorespiratory physiology may have contributed to fatalities. DUODENAL DAMAGE Severe damage to the duodenum per se is not frequent. In only four instances was the damage severe enough to require a short-cir- cuiting procedure. Of the four gastrojejunostomies done, all died. Duodenal Injuries (Duodenal Damage contd) In only one instance was the ampulla of Vater damaged, and there was only one of common duct injury. In no case ?;as it necessary to per- form a common duct short-circuit. Table VII lists the site and type of injuries to the duodenum. TABLE VII Site and Type of Duodenal Injury Site Transection Perforation Laceration First oortion 7 12 8 Second oortion 7 34 14 Third oortion 1 6 8 Junction of first and second 2 4 Junction of second and third 1 2 . 2 Duodeno- .1 e.1 unal .iunction . 4 Totals 30, 56 26 In six cases, the type and location were not recorded. COMPLICATIONS OF DUODENAL REPAIR In most instances, lacerations and perforations of the duodenum were repaired as any small, bowel laceration and technique varied but little among the individual surgeons. Transections of the duodenum were repaired by end to end anastomosis with running atraumatic chro- mic suture in most instances reinforced with black silk or cotton. In almost every case, the site of the repair was drained and universally when complicating pancreatic or liver wounds occurred. In most in- stances, the peritoneum was closed over the wound. In three cases where gastrojejunostony was done, the duodenum was badly damaged and the proximal end was inverted, but none of these lived long enough to develop any possible complications. There are two known duodenal fistulae that developed in the first priority hospital. Both of these were transections of the duodenum with an end to end anastomosis. Both developed on the sixth postoper- ative day. There is an additional case that probably developed a du- odenal fistula. The record was not complete, but it had been noted on the sixth postoperative day that a clear irritating discharge was draining through the operative wound, and it Y/as the opinion of the observer that a duodenal fistula had developed. This case was a sim- ple laceration of the second portion of the duodenum, repaired by one row of running atraumatic chromic catgut reinforced with black silk sutures. 236 Duodenal Injuries (Complications of Duodenal Repair contd) There was one case that probably had a duodenal blow-out, but the necropsy was not done. It was the opinion of the officer who saw him at death, that the duodenal suture had not held. The patient had had a through and through perforation of the upper pole of the right kidney that v/as drained, and a through and through perforation of the second portion of the duodenum that had been closed with two layers of running atraumatic chromic suture. On the seventh postoperative day, he became markedly distended, and developed severe epigastric pain and expired in eight hours following the onset of these symptoms. DIAGNOSIS OF DUODENAL INJURY The preoperative diagnosis of a duodenal injury- has no essential differences from that of any intra-abdominal injury. At operation, it was the practice of surgeons of this Group to always reflect the right colon and duodenum where there was any suspicion of a duodenal injury. The increasing consciousness of this possibility is shown in that of nine cases of duodenal injury handled by this Group in 19A3> there were two perforations of the duodenum overlooked. In the one hundred and eighteen cases in this series done in 19A4-45, there is only one case of an overlooked duodenal injury. Too much stress cannot be placed upon the advisability of thorough exploration of the duodenum in cases where there is any possibility that the missile perforated the retroperiton- eal space behind the right colon, and this can only be done by reflect- ing the right colon. DISCUSSION It is seen that 98,4$ of duodenal injuries have complicating les- ions. The most frequent organs involved in order were liver, colon, and right kidney. In 83$ of the cases, the missile entered either right lumbar area or right abdomen. With these facts in mind it may be rea- sonably deduced that a missile entering the ri£ht side, front or back, and injuring the liver, colon, and right kidney, has a very strong prob- ability of also injuring the duodenum. It is again emphasized that it was the practice of surgeons in this Group to routinely reflect the right colon and examine the duodenum thoroughly in any case possessing the wounds as described above and also in any case presenting the probabil- ity of a duodenal injury. Incidence of injury to particular portions of the duodenum was out of proportion to the mass of duodenum and its protection by bony struc- tures such as the vertebrae. In 4,6.6$ of this series, the second por- tion was injured, the first in 22.8$, and the third in 12.7$. In many of the cases of injury to the first portion of the duodenum, there was a continuous lesion with the pylorus and similarly in the third portion a continuous lesion of the jejmura. It is surmised that many injuries to the first portion of the duodenum do not survive to reach operation because of its close relationship with the vena cava, hematic artery, and portal vein end again similarly with the third portion of the duo- 237 Duodenal Injuries (Discussion contd) denum with its close relationship with the aorta, vena cava, and mes- enteric vessels. Twenty instances of duodenal transection were encountered in this series. The usual repair was by end to end anastomosis with a double layer of chromic catgut reinforced with interrupted black silk. Six of these transections lived through the sixth postoperative day and two of the six developed a duodenal fistula on the sixth day. The freouency of this complication can only be indicated by this small series but it aids to emphasize the necessity of drainage to a repaired duodenal in- jury. SUMMARY AND CONCLUSIONS 1. Injuries to the duodenum are Infrequent in abdominal wounds, and very rarely is the duodenum alone involved. 2. In abdominal wounds with duodenal injury, the mortality was 55.9$ in 11B cases. 3. In this series, the site of the entry wound was in the right trunk in 83$ of the cases, A. Severe shock was usually present preoperatively in this series. 5. Multiple complicating injuries are usual in duodenal injur;/-. Vascular injuries are not infrequent. 6. It was found that 12.7$ of the 118 cases had an associated chest injury. \ 7. In only four cases of this series was the damage severe enough to require a short-circuiting procedure. There was only one case of in- jury of the Ampulla of Vater, and in no instance was a common duct short circuit required. 8. There were 20 transactions of the duodenum in this series with the development of fistula in two. However, most transections died within the first three days. Six transections of the duodenum lived through the sixth postoperative day. Of these, two developed fistula. There is a strong indication of a high incidence of fistula development in the transected duodenum, 9. It is the practice of the surgeons in this Group to routinely reflect the right colon in injuries where there is any reason to suspect a perforation of the duodenum. 238 WAR INJURIES (F THE SMALL INTESTINE The small intestine is frequently injured in wounds of the abdomen. Among 3532 patients with abdominal and thoraco-abdcminal injury there were 1287 or 3&*U% who suffered injury to the small bowel, A minor fraction of the total cases, comprising those treated in 1942 and 1943» has been previously reported, by Lowry and Lowry1, and Jarvis*. Except for the computation of incidence and gross mortality rates, these cases are not included in this report (Tables X and II,Appendix)* From 1 January 1944 until the cessation of hostilities in Europe, there were 3154 cases with abdominal injuries treated by surgeons of this organization (Table I). TABLE I Gross Incidence and Mortality Rates, 1168 Small Intestine Injuries* (Exclusive of Duodenum) 1944-1945 GROSS TOTALS UNCOMPLICATED CASES COMPLICATED CASES Incidence Morta- No« in 3154 lity Cases Cases Rate No, Incid- Morta- Casee ence lltv No, Inc id- Morta- Gasec ence lity *» U6S 37** 29.5 % _253 3P-2? 13.9* 815 69.8* 36.3* ♦Incidence of small bowel wounds including duodenum in A.E.F, World War I, was 22*,3 ♦•Mortality of small bowel wounds. World War I, 80*.* was between 70* and Small Intestinal injury was present in 1168 {37%) of these cases, and this group forms the basis of the present study* All cases are Included which were treated by members of the Group, A number of patients in this series died during surgery and several others expired during the induction of anesthesia** Inclusion is made of those hav- ing injury to the bowel wall without penetration of the lumen* Ho exclusion has been made of civilian wounded, nor on the basis of age; however, civilians and persons in the extreme age groups form only a small fraction of the total cases. Six cases of non-penetrating trauma to the abdomen are included; all were due to vehicle accidents and sustained rupture of the small intestine* One patient is included who stated that he was violently impaled on a small tree stump by the blast from an exploding shell, and who sustained a severe transfixing thoraco-abdoainal wound* With ♦A total of 28 deaths on the operating table occurred in this series. 239 War Injuries of the Small Intestine the exception of these seven cases, all wounds were caused by high explosive fragments or small arms missiles« There were no bayonet nor stab wounds* In analyzing uncomplicated small intestinal wounds, we have re- garded the bowel in the light of its anatomical subdivisions into jejunum and ileum. This distinction proved impractical in the study of complicated cases, and in this group the intestine has been regard- ed for statistical purposes as a single organ. The duodenum is not included in this survey. In thisstudy, the term "complicating wound" is reserved for wounds to other abdominal organs or major vascular trunks, and "associated wound" denotes extra-abdominal pathology. (Figure 35 ) CHART NO I INCIDENCE Of INVOLVEMENT Of OTHER ABDOMINAL VISCERA IN 8/4 CA6E5 HAVING SMALL BOWEL WOUNDS AND ASSOCIATED IN ERA-ABDOMINAL TRAUMA (im-ws) Frequency of Complicating Injury to Other Viscera Figure 35 War Injuries of the Small Intestine THE INCIDENCE AND MORTALITY CF SMALL. INTESTINAL WAR INJURIES As previously stated, 37% of all abdominal cases treated in 1944 and 1945 had small Intestinal wounds. Of these, 345 or 29*5$ died, (Table I), The great majority of these deaths appears to have been due to complicating injuries. Among 815 complicated cases there were 296 deaths, a mortality of 36,3$, On the other hand, there were 353 cases in the uncomplicated group with 49 deaths and a mortality of 23,9%, These calculations have been made without regard for assoc- iated wounds to the thorax, head and neck, or extremities. These figures are in agreement with the observation that the fatality of abdominal wounds is usually proportional to the number of viscera involved. THE NATURE CF WOUNDS TO THE SHALL INTESTINE It will require no imagination by one acquainted with the engines of modern warfare to realize that the varieties of trauma they produce are all-inclusive. Lesions seen in the small intestine varied from pinpoint perforations and small contusions to extreme maceration and destruction of the greater part of the bowel. For convenience of con- sideration, types of trauma are grouped in three main classifications: injury to the wall only, perforating injury, and injury to the mesen- tery, There have been wide extremes of severity in each of these groups, and in the usual case two or more of them were seen in combination. Traumatic evisceration and the state of the peritoneum cure separately considered in this section. Trauma To The Wall Of The Bowel, Trauma to the wall of the bowel includes contusions and serosal or sero-arascular lacerations which do not perforate the mucosa* These hare been the least frequently seen types of injury (Table III, Appendix)* Contusions of the bowel wall were seldom more than 2 cm* in diameter, and varied in appearance from a slight eechymosls to a circumscribed area of gangrene* A contusion of the bowel wall implies by its very nature that the missile which caused it had reached the end of its flight and was traveling at low velocity* Inpact against the intestine was sufficient to stop it, and such missiles have not infrequently been found free in the peritoneal cavity* Lacerations of the outer layers of the intestinal wall are caused by tangential impact and carry no implications as to the velocity of the missile* Such trauma has usually been seen in association with perforation into the lumen in other portions of the bowel* Lacerations theoretically may be of any length, but they have been rarely seen of more than 2 cm* without perforation, and some were the merest breaks War Injuries of the Small Intestine (Trauma to the Wall of the Bowel, coat'd)* in the serosa* There were usually evidences of contusion about the margin of these wounds, and such laceration-contusions were considered potential sites of future perforation* Perforating Trauma of the Bowel. By far the commonest injury to the small intestine was in the form of perforation into the lumen. Reference to Table III, (Appendix) Trill show that perforations were present in nearly every case, and that multiplicity was the rule, with an average of approximately four perforations per case. The individual lesions varied from the tiniest of holes to gashes extending for six inches or more. Small holes were usually caused by the very small fragments into which thin-walled projectiles (e.g, mortar bombs, certain anti-personnel aerial bombs) burst on explosion. Occasionally small perforations were apparently- caused by in-driven fragments of bone, particularly in cases in which the missile had entered the abdomen through the ilium. Shell fragments (and mortar fragments at close range) and bullets usually caused largo perforations, though rifle bullet wounds have been seen in which the missile had caused remarkably small holes. In general, it has been apparent that the size and shape of the rent in the bowel were deter- mined by the corresponding characteristics of the missile, and by its velocity and direction of flight, Through-and through perforations and complete transection of the intestine were both frequent. In most perforations of any size, the findings were usually simi- lar, The tissues at the edges were contused and ecchymotic, the mar- gins were jagged, and the mucosa pouted from the wound, bleeding from the wall of the intestine was at times free, and sizeable quanti- ties of blood have been seen in the peritoneal cavity when the bowel wall was the only source of hemorrhage. Small holes were on occasion nearly completely sealed off by the pouting mucosa and gave rise to a minimum of soiling. In such instances, bluish discoloration of the bowel from intra-luminal bleeding was sometimes present. Less commonly, blood and intestinal contents were extensively spilled from a small perfora- tion (Case 1, Appendix), Combined injuries to the bowel were usually found in close proxim- ity, and the damage was commonly confined to a segment one or two feet in length or less. However in instances where the missile had traversed major diameters of the abdomen, one occasionally found scattered perfor- ations along the intestine at wide intervals. Rarely, isolated perfor- ations were found at a considerable distance from the major trauma. It was always necessary to examine the entire length of the bowel for injury. War Injuries of the Snail Intestine Injuries to the Meaente: The mesentery was traumatized both at a distance from the bowel and at the attachment. The injuries varied from small hematomata or peritoneal lacerations to rents across the mesentery to its very root. In transactions of the bowel and in perforations involving the mesen- teric border, some amount of damage to the adjacent mesentery was near- ly always present. This damage usually did nob complicate the necess- ary repair or resection of the bowel. Active bleeding was seen, but frequently it had ceased. Perforations of the mesentery other than those adjacent to injur- ies of the bowel were frequent. These were usually staple througb-and- through holes, sometimes with associated hematoma. In the majority there was no indication that a vessel of great consequence had been involved. The incidence of mesenteric damage of such extent as to necessitate intestinal resection was remarkably low. In this series there were only 30 cases in which resection was indicated by vascular impairment from mesenteric trauma, conditions are present in mesen- teric injuries which should be expected to produce vascular thrombosis* Most important art the effects of energy transmitted to tissues, and the natural tendency to clot formation in a lacerated blood vessel* Observations have borne out the impression that thrombosis should occur in the traumatized mesentery. Thrombi were commonly found protruding from the ends of severed vessels, even those of considerable size* The throofeotic process however, was restricted to the immediate area of damage, bo case of extensive mesenteric thrombosis in the usual clinical sense of the term has been encountered in which the pathology seemed primarily to be due to mesenteric trauma.* The State of the Peritoneum in Small Intestinal Wounds. The frequent presence of hemoperitooeum in small bowel wounds was consistent with the vascularity of the organ* Mesenteric bleeding *0oe patient with a perforating wound of the upper thorax had severe abdominal symptoms. At laparotomy mesenteric thrombosis was found with gangrene of two feet of ileum, which was resected. Death occurred on the third posoperative day, and at autopsy a spicule of rib was found lodged in the wall of the ascending aorta, projecting into the lumen* A clot was attached to the tip of the bone fragment, and eatoolus from this point was apparently the origin of the mesenteric occlusion* The patient's death was attributed to cerebral embolus from the same source. In another case, mesenteric thrombosis was found at autopsy in a man with a violent peritonitis. War Injuries of the Small Intestine (The State of the peritoneum in Snail Intestinal Wounds, uont'd) also was on occasion massive, and cases have been seen with 2000 c,c, or more of blood in the peritoneal cavity. At, the other extreme were occasional cases where bleeding had been minimal. Contamination of the peritoneal cavity to some extent with small bowel content was the rule, although there were instances where no gross soiling was apparent. Usually the amount of contamination was consistent with the number and size of the perforations. The reaction of the peritoneum was fairly constant, visible peritoneal reaction was unusual in cases coming to operation within six hours, violent, exuda- tive peritonitis when it appeared was usually seen in patients with relatively long time lag (12 hours or more). In cases surviving over 24 hours without operation there was usually early walling off with loops of bowel adherent about the perforations. Exceptions were observ- ed however, and severe generalized peritonitis was at times seen in late cases (Case 1, Appendix), and conversely localization appeared early in some instances. Peritonitis was noted as being present at the time of operation in only 50 of 353 uncomplicated intestinal wounds. This figure is undoubtedly low, and this may be attributed to the necess- ary brevity of some records written under field conditions. Evisceration of the Small Intestine, Evisceration of the small intestine was recorded in 153 of all abdominal wounds, an incidence of approximately In 126 eviscera- tions there was trauma to the bowel or its mesentery which required operative repair. In the remaining cases the evisceration was inci- dental and demanded no treatment other than reduction. Reduction of a non-traumatized loop of Intestine has sometimes been attempted in the shock ward while the patient was being prepared for surgery. As a rule however, the usual procedure has been to protect the bowel with warm, moist gauze until the time of operation. In only one case was strangulation of an eviscerated loop sufficient to demand resection, (For details of the influence of evisceration on mortality, see section on “Traumatic Evisceration", page 162)* THE MANAGEMENT OF WOUNDS OF THE SMALL INTESTINE There have been no criteria upon which to include or exclude pre- operative ly the poasiliLity of intestinal injury, and the preoperative diagnosis has been based on probability, Indriven fragments of bone and the concusslve effect of missiles passing extraperitoneally have both been observed to cause intestinal perforation or rupture. It has never been safe to assume that the bowel was uninjured, and the final diagnostic criterion has been direct observation at operation whenever signs and symptoms have indicated intra-abdominal pathology. War Injuries of the Small Intestine (The Management of Wounds of the Small Intestine). The preoperative management of small intestinal wounds has differed in no respect from that of all abdominal wounds. The routine estab- lished for all such cases has included placement of a Levin tube in the stomach. The surgeons of this organization have followed no rigid dicta re- garding the techniques of handling of small bowel wounds, for none have been set down. The principles adhered to were similar and usually agreed upon. Most important of these principles were gentle handling, use of fine suture materials, speed, and maximum protection possible of the bowel from exposure. Approximately one third of the surgeons felt that it was expedient to eviscerate the intestine through the operative incision and examine it outside the abdomen, rapidly replacing it as one went along its length. The complete examination of the bowel and its mesentery, as well as of other viscera, was facilitated by this procedure, and it was felt by those who advocated it that it was not appreciably shocking to the patient if speedily performed. This procedure was only used in cases with extensive damage, in which the pathology was obscured by marked spillage. Hemorrhage and frequently injury to other viscera took precedence over the operative repair of small bowel lesions. It has usually proven wise to begin the latter procedure by evaluating the entire damage to the bowel. Procedures were planned so as to provide the most rapid and safe repair. The Repair of Trauma to the Wall of the Bowel, Contusions and lacerations of the wall of the bowel were repaired and re-enforced by peritonealizing suture, either linear or purse string. The types of suture and material employed have been matters of Individual taste. The Repair of Perforating Trauma of the Bowel. A wide variety of choice was available in the methods of manage- ment of perforations. Lesions of practically every conceivable size and shape have been dealt with. The principle followed has been to perform the most expedient and conservative procedure compatible with secure repair and adequate preservation of the lumen. Very small per- forations were usually purse-stringed, larger ones sutured transverse- ly. Trimming of the traumatized edges of holes was always conserva- tive and by no means always done. It has sometimes been convenient to convert two perforations into one, particularly if they lay close to- gether in the same vertical plane, and suture the ensuing defect. Less time was required than for two suture lines, and less kinking of the bowel resulted. War Injuries of the Small Intestine (The Repair of Perforating Trauma of the Bowel, cont*d). Transactions were anastomosed with or without resection of short adjacent segments depending on the condition of the bowel* Among 361 transactions specifically mentioned, there were 86 transections in 54 eases In which direct anastomosis was done. A large number of the total were resected along with severely mangled loops. Resection was obviously mandatory in many cases having hopelessly macerated segments of bowel. It was also required for bowel which had been avalsed from its mesentery. The management of multiple, adjacent perforations with normal tissue between them presented more of a prob- lem. Some surgeons performed individual sutures under these conditions, and others resected the entire segment if it was not of great length. These resections were based on the conviction that multiple suture lines close together would compromise the lumen and lead to kinking with obst nation. Among 1117 cases having perforations into the lumen, repair by suture only was performed in 635 patients or 56.8%* Resection and anastomosis were performed in 428 or 38*3%, and anastomosis without resection in 54 cases or 4«d£« (Excluded from these figures are all cases in which resection of the terminal ileum and ileo-colostcoy were the sole treatment.) The mortality for all anastomotic repairs was 37*3%, and for suture repairs it was 23*3%* In Table II, text, and Table 17, Appendix, are presented a detail- ed analysis of anastomotic vs. suture repairs, with respect to frequency and mortality in the complicated and uncomplicated groups. The ratios of mortality between anastomotic and suture repairs in the complicated and uncomplicated groups are nearly identical, and are in close proportion to the incidence of thetwo groups in the series as a whole. The frequency of the two procedures is seen also to be roughly the same for each group, with anastomosis recorded six per cent more frequently among complicated than among uncomplicated cases. Resection and anastomosis according to frequency of types of anas- tomosis and mortality are shown in Table III. It is seen that the mortality for all resections in this group of cases has been 33*9%* The total number of resections done in these patients was AS9* with double resections being performed in 35 instances, and triple resec- tions in three. (Table V, Appendix), (Case 2, Appendix). Type of Case end Total Number ANASTOMOSIS* SUTURE ONLY Anast. Total Anast. Frequency Percent Lived Died Mort- ality Percent Suture Only Total Suture Frequency Percent Lived Died Mortality Percent 769 Complicated Cases 347 45 .1% 192 155 hU.% 422 5U.% 296 126 29.9% 348 Uncomplicated Cases 135 38. 8% 110 25 18.5% 213 61.2% 191 22 10.3% TOTALS 1117 Cases** 4-82 43.# 302 180 37.3% 635 56.8% 487 148 23.3% *Includes anastomosis of transactions, without resection. in 54- cases. **Excluded are cases having non—perforating trauma to the colostomy was the only treatment. bowel, and those in which ileo- Frequency and Mortality of Anastomotic and Suture Repairs, 1117 Complicated and Uncomplicated Small Intestinal Injuries. 1944'- 1945 War Injuries of the Small Intestine Repair of Perforating Trauma of the Bowel, cont'd). TABLE II War Injuries of the Small Intestine (The Repair of Perforating Trauma of the Bowel, cont»d). TABUS in Intestinal Resections With Anastomosis, Frequency and Mortality 1944- 1945 Type of Anastomosis Resections: Mo. Cases frequency Per Cent Deaths Mortality Per Cent End-to-End 377 120 3Z*o$ Side-to-Side 34 7.9* 16 47.0* * Not Stated TJ 5,0^ 9 53.0* TOTALS 428 loo.o* ..W. 33.9? Data were recorded as to the length of the resected segments in 394 instances. The extremes were two inches and 12 feet, and there were four cases in which segments of over eight feet were removed (Case 3, Appendix), The lengths of resections are given in tabular form in Table IV. There were 122 instances of segments greater than one foot in length being resected. In this group there were 43 deaths with a mortality of This figure is in close agreement with the rate of 33*9% for all resections. TAB IE IV Intestinal Resection and Anastomosis, Lengths of Resected Segments (394 Cases) 1944-1945 Length of Segment, Inches Number of Cases Average Length, Inches 2" - 12“ 272 6“ $verT3" 132 51p> TOTAL m 33-" The foregoing figures support the belief that resection carries a higher mortality than does closure by suture only. In this series, the rate was higher by approximately k3% (33*9% as compared with 23.3$). The same has been true of anastomosis without resection* The difference in mortality rates cannot be explained by disproportionate distribution *This figure la misleading. Sido-toalde anastomosis was usually employed in massive resections, and the high mortality rate is a reflection of the severity of trauma in these cases* War Injuries of the Small Intestine (The Repair of Perforating Trauma of the Bowel, cont'd), of the procedures between complicated and uncomplicated cases, for such disproportion has not occurred to a significant degree. Furthermore, the mortality of anastomosis has been relatively greater among uncom- plicated than among complicated cases when it is compared with the corresponding rates for repair by suture only (Table II, Text, and Table IV, Appendix), It must be remembered that the principal indication for resection has been extensive trauma, and it has usually been performed for the removal of bowel which was shredded beyond hope of repair. The higher mortality is probably as much a reflection of the severity of the in- juries as of dangers inherent in the procedure (Case 5> Appendix), Many operative techniques have been employed in performances of intestinal repairs. The majority of surgeons have preferred an open, two-layer, end-to-end anastomosis. Closed methods have been used in cases having minimal soiling, and a few surgeons employed routinely a closed, two-layer, all silk technique, Side-to-side anastomosis has been reserved usually for the lower ileum, or for instances where there was a marked discrepancy in the size of the lumina to be anastomosed after extensive resections. Two surgeons report success with a single- layer anastomosis, and two have employed triple layers. Running or interrupted intestinal catgut, and interrupted fine silk or cotton have all been extensively used. All surgeons have usually employed the same types of sutures and material for the repair of perforations that they have used for anastomosis. We have found only one instance in which enterostomy was used for' the primary treatment of small bowel perforation* This was a case in which a email hole at the ileo-cecal junction was treated by perfom- ance of a tube ilco-cecostony, and the procedure was apparently dictat- ed by the peculiar anatomical site of the injury. It may be stated that the surgeons of this organization have found no place for enter- ostomy in the initial treatment of small intestinal injuries, (Trauma to the right colon and ileum was usually managed by some type of ileo- colostoray, often after resection of a part of the terminal ileum. Detailed consideration of these procedures will be found in the section of this report dealing with colon injuries (Page 2?0 ), The Management of Mesenteric Damage, Simple through-and-through perforations of the mesentery have been sutured so as to reperitonealize the raw surfaces. In the presence of large hematomata or continuing bleeding, mesenteric dissection has obviously been indicated. The hematoma was evacuated, and the hemorr- hage controlled. The mesentery was then closed by suture. As mention- War Injuries of the Small Intestine (The Management of Mesenteric Damage, cont'd). ed earlier, in only 30 instances was intestinal resection indicated by mesenteric vascular trauma. In these patients, the usual criteria of viability of the bowel have been observed and resection performed in accordance with recognized surgical principles (Case 3, Appendix), The Management of the contaminated Peritoneal Cavity, The majority of surgeons have felt that drainage of the peritoneal cavity was to be condemned. Two of the group have routinely placed drains to the peritoneal space however in the presence of contamination, whether from the small bowel or other sources, A few of the surgeons were of the opinion that lavage of the severe- ly contaminated peritoneal cavity prior to closure of the abdomen might be of value in the removal of gross material which could not be evacuated by other means. This procedure cannot be evaluated as to its efficacy or possible dangers, for it has been used infrequently. The employment of intraperitoneal chemotherapeutic agents is con- sidered in detail in the section on chemotherapy (page 197 ). In general, the practice of employing available drugs (sulfanilamide crystals, penicillin sodium) in this manner has been a matter of choice with the individual surgeon. One or other of the drugs or a combina- tion of the two was employed in 59% of the cases in this series; this figure is undoubtedly low because of omission of the pertinent data in some records. No opinion as to the efficacy of the procedure in small intestinal injuries can be adduced, (Table VI, Appendix), Postoperative Care Following Small Bowel Injury, Ileus, distention, and vomiting were apparently almost universal phenomena among abdominal cases in the last war5, These dangerous conditions have been practically eliminated in our experience by the use of nasogastric decompression. Patients with abdominal wounds have had Levin tubes placed in their stomachs prior to surgery, and promptly on admission to the postoperative ward, three-bottle siphonage suction has been applied to the tubes. The custom of the surgeons has been to leave these tubes in place for from three to eight days postoperatively. There has been a strong difference of opinion as to the length of time for which decompression was necessary, but the majority seem to have favored a period of from three to six days. In all cases, the usual clinical criteria of return' of intestinal function (audible peristalsis, pas; je of flatus, etc,) have been employed as guides. Other routines of postoperative care of the small bowel injury 2^0 War Injuries of the Small Intestine (Postoperative uare Following Small Bowel Injury, cont'd). differed in no important respect from those employed in all abdominal cases. The patients were usually kept in Fowler’s position until peritonitis had definitely subsided. Energetic attention was given to the maintenance of fluid and electrolyte balances, and of blood levels and nutrition. Diets were cautiously advanced after removal of the Levin tube in accordance with the patient’s ability to tolerate food. GOMPLICATIOIB FOLLOWING SMALL INTESTINAL WOUNDS The incidence of postoperative conplications directly related to the small barrel among these patients has been extraordinarily low, but is probably not representative of the true course of a large number of cases of this type. Complications have undoubtedly developed in a significant proportion of these men after they have passed from our care. Intestinal Obstruction. Among the 1168 patients having small bowel injury, there were 20 (1,7%) who developed mechanical obstructive symptoms while in the hospital of their primary surgery. Eleven of these cases had resection and anastomosis, four had anastomosis without resection, and five had repair by suture only. (There was one double resection, and two cases having resection also had simple anastomosis of transections; in ten of fifteen cases in which anastomosis was done, suture repair was also necessary for other perforations). Peritonitis had been noted at oper- ation in two instances, and gross contamination in six; 10 of the cases had severe complicating wounds. The time of appearance of obstructive symptoms was recorded in 17 instances, and ranged from the third to the 32nd postoperative day. The average time was between the ninth and tenth days. If two cases are omitted in which symptoms became apparent on the 32nd day, the average time is lowered to between the sixth and seventh days. This coincides fairly closely with the time at which Levin tube decompression has been discontinured, when one would ordinarily expect early obstruc- tion first to manifest itself* Seven patients (31$) of the 20 died. The method of dealing with the obstruction was mentioned in only one of the fatal cases*. In this instance a Miller-Abbott tube, although it did not pass the pylorus, successfully decompressed the intestine (this man died of severe * It is safe to assume that the other patients were treated conserva- tively, Had surgery been performed, the fact would almost certainly have been recorded. 251 War Injuries of the Small Intestine (intestinal Obstruction, cont'd), atypical pneumonia and hepatitis of unknown etiology). In six of the fatal cases, autopsy data are available as to the causes of obstruction. These causes were:- Adhesions...........••••••••••••• 3 Cases Kinked Anastomosis,,..,.,,.,,,.,, 1 Case Edema at Anastomosis....«•••••«•• 1 case Peritonitis; leaking Anastomosis. 1 case In the remaining case autopsy was not done, but the patient deve- loped a small intestinal fistula which was attributed to leakage of an anastomosis. Among the 13 surviving patients, 10 were treated conservatively, with re-establishment of naso-gastric decompression being the princi- pal therapeutic measure. In all Instances the symptoms were relieved. Data are not available as to the length of time required for relief. The remaining three patients were operated upon after failure of con- servative therapy. In one case obstruction was found due to adhesions, in another to adhesions and multiple abscesses, and in the third to volvulus of the ileum. It should be noted that the Miller-Abbott tube, though readily avail- able, has only been occasionally used. It is the consensus of opinion of the surgeons that in the majority of cases of the type with which we have been dealing, adequate decompression has been attained by a tube in the stomach, and there appeared to be little indication far a tube which lies in the intestine. This has been fortunate, for in the in- stances when the Miller-Abbott tube has been used, it has been found that under field conditions it has been difficult to get it past the pylorus. Intestinal leakage and Fistula. There were 12 cases (1,0£) in which small bowel leakage occurred postoperatively, and in nine of these fistulas developed. (Not includ- ed is the case of a German Prisoner of War who was admitted to the hospital three days after wounding with an established small bowel fis- tula and intraperltooeal abscess. Case 4, (Appendix)), In the eight cases where the time of development of tbs complication is given, it occurred between the sixth and 26th postoperative days. The average time at which leakage was first observed was on the 13th postoperative day. Six of the 12 patients had severe complicating wounds of other hollow viscera. In three patients the leak was proved at autopay to have occurred War Injuries of the Small Intestine (Intestinal Leakage and Fistula, cont*d)« at suture lines, and in two cases it was assumed to have had a similar origin* In one instance, two perforations of the terminal ileum were attributed to erosion by wire through-and-through sutures which had been used to repair a dehiscence on the ninth postoperative day. The patient died of peritonitis on the 22nd day, and the perforations were found at autopsy. Data as to the origin of leakage in the remaining cases are not given* Secondary operation for closure of fistula was not done in the forward hospitals* It was believed that patients with this complica- tion were best evacuated immediately to a general hospital where facil- ities for prolonged care were available, and this policy was followed* Small bowel leakage proved as always a serious matter, and five of the 12 patients died* Two of the nine cases having external fistulas died, and leakage without the establishment of fistula was fatal in all three cases in which it occurred. In four of the five fatalities, death was attributed to peritonitis; In the fifth, the cause was not stated* ASSOCIATED INJURIES Among the 1168 cases with small intestinal injury, 252 had what may be classed as major associated wounds, and in 202 minor associated wotaads were present. An additional 143 patients had penetrating or perforating wounds of the thorax; 94 of these were thorace-abdominal wounds (82 of all small bowel injuries), and 49 were associated chest wounds. In stannary, it is seen that 597 or almost exactly half of all eases associated wounds were present. In 395 cases (major peripheral plus thoracic wounds) or one third of all, the associated wounds were of a major nature. UNCOMPLICATED SMALL BOWEL WOUNDS There were 353 uncomplicatedwounda of the email intestine, an Inci- dence of 11*22 of the entire series of 3154 abdominal injuries* These cases represented 302 of all small bowel injuries* Two non-battle injuries of the small intestine are included. The remaining 351 patients were all wounded by high explosive fragments or bullets* There were 49 deaths, the mortality rate being 13*92* The ileum was injured more frequently than the jejunum, the ratio being roughly three to two* Both portions of the bowel were injured simultaneously only one fourth as frequently as was the ileum alone* Mortality rates for wounds of the jejunum and ileum separately were approximately the same (10*22 and 12*82 respectively)* Among injuries 253 War Injuries of the Small Intestine (Uncomplicated Small Bowel Wounds, cont'd). involving both ileum and jejunum, the mortality rose sharply to 29$, This is attributable to the fact that many such injuries represent very extensive trauma to a large segment of the mid-bowel. It is largely among this group that the most massive resections have been performed. The incidence and mortality by anatomical portions of the bowel are summarized in Table VII (Appendix), CHART 2 MORTALITY'' TIME LAG BEIATIONSHIP IN 3 39 UNCOMPLICATED SMALL BOWEL WOUNDS - /9/t5 UVED WtD MORTALITY IN PERCENT Figure 36 - Mortality-Time Lag Relationship It has been found that the average time lag among patients dying with uncomplicated small bowel injuries was just twice that among those who survived, (Table V, Figures 36 and 37 )• The impression War Injuries of the Small Intestine (Uncomplicated Small Bowel Wounds, cont’d). is inescapable that if patients with this type of injury can be oper- ated on within eight hours of wovnding, their chances of recovery are enhanced. CHART 3. MORTALITV-TIME LAG RELATIONSHIP IN 335 UNCOMPLICATED SMALL BOWEL WOUNDS WITH TIME-LAG OF V8 HOURS OE LESS 9 HOUR INTERVALS 1999-/9*95 Figure 37 - Mortality-Time lag Relationship TABLE Y Average Time Interval, Wounding to Operation, Small Intestinal Wounds 1944 - 1945 • —wsnsr, Wounding to Operation Hours All Snail Bowel Cases 1057 Cases* hours Unc c*npli’ca£ecr 339 cases 10,9 hours Uncomplicated. Survived 293 Cases 9,5 hours Uncomplicated. Died 46 Cases 10,1 hours** dumber of cases for which data are available, **If two cases of unusual delay, 72 and 90 hours respectively are onltted, this figure becomes 16,3 hours. War Injuries of the Small Intestine (Uncomplicated Small Bowel Wounds, cont'd). It appears that a disproportionate number of severe associated in- juries has contributed to the mortality. Such woxavis were more than twice as frequent among the fatal cases as among those which survived, A major associated wound is considered as included in the following complete compound fractures of long bones, traumatic amputations other than of digits, penetrating wounds of the thorax other than thoraco- abdominal, severe cranial injury, severe maxillo-facial injury, and soft tissue wounds which were very extensive or productive of severe hemorrhage. Such wounds were recorded in 72 or 24$ of the 301* patients who survived in the uncomplicated group. In contrast, major associated wounds were observed in 27 or 55$ of the 49 fatal uncomplicated cases. The recorded incidence of peritonitis observed at the time of operation is probably low, due to omission of information in some records. Nevertheless it is of interest that among the uncomplicated cases vfaich died, peritonitis was specifically mentioned in the surgeon's operative notes as being present in 41$ of cases, as contrasted with wily 10$ among the patients who lived. Deaths occurring among battle casualties within the first 46 hours postoperatively, unless due to a surgical or anesthetic catas- trophe, are practically always indicative of wounds of extreme or even mortal severity. Such cases commonly are not responsive to surgical or resuscitative measures however heroic, and the usually cited causes of death are "shock", "shock and hemorrhage", or "shock and periton- itis" (Case 5, Appendix). With these observations in mind, it has been found that of the 49 fatal cases under consideration 15 or 31$ sur- vived operation by less than 24 hours, and another ten cases or 20$ died between 24 and 46 hours. These figures imply that a significant proportion of deaths occurred among patients with wounds of more than average severity as compared with the uncomplicated group as a whole. The postoperative survival times for the fatal cases are represented graphically in Figure 38 • The average survival time for all these eases was 3*6 days, < 256 War Injuries of the Small Intestine (Uncomplicated Small Bowel Wounds, cont'd). SURVIVAL TIME POSTOPERATIVE , 49 DEATHS, UNCOMPLICATfO SMALL INTESTINE WOUNDS /m - 1945 Figure 38 - Postoperative Survival Time Among Fatal Cases, There were three cases among the 49 fatalities in which death may justifiably be attributed primarily to associated injuries. One was a death cm the operating table from cardiac tamponade, one a death five hours postoperatively fro® pulmonary blast injury, and one death was attributed to hemolytic streptococcal bacteremia and pyemia from infec- tion in a massive wound of the thigh. Necropsy was done in all three cases. In addition to the cases mentioned above, there were 15 in which death was apparently due to the combined effects of intestinal and 257 War Injuries of the Small Intestine (Uncomplicated Small Bowel Wounds, cont *d). associated wounds, both of which were serere. Case 6 (Appendix) is cited as an example of this group. If we exclude from discussion the IS cases in which death was attributable in whole or in large part to associated wounds, a more accurate impression may be gained as to the causes of death among patients in whom the small bowel injury was the primarily fatal factor. There were 31 such cases in thisgroup, and pertinent data regard- ing these patients are summarized in Table VUI (Appendix), "Shock" and/or "peritonitis" were listed as causes of death in 15 patients who survived operation for periods of time varying from five minutes to two days. These cases fall into a well-defined group of casualties seen in forward hospitals, who come to the hospital in severe shock which seems in part to be secondary to massive peritoneal contamination. The time lag is usually long and associated hemorrhage is frequent. Death occurs in the early postoperative period. Forty-eight per cent of the 31 deaths under consideration fall into this group, "peritonitis" is listed as the primary cause of death in eight cases who survived operation for periods varying between three and 22 days. In these patients an established, uncontrollable infection within the peritoneal cavity, without the element of traumatic shock, was the primary cause of death. One death was attributed to intestinal obstruction. The remain- ing seven patients (excepting one in which cause of death was not given) died of complications not peculiarly related to wounds of the small intestine (pulmonary embolism, anuria, etc.). Summarizing the data on Table VIII (Appendix) it is seen that approximately one half of the cases died in the immediate postopera- tive period of overwhelming wounds and contamination, one fourth died of peritonitis, and the remaining fourth died of unpredictable comp- lications, including one patient with intestinal obstruction. The outstanding factors contributing to mortality among cases dying with wthaH bowel injuries as the primary cause of death appear to be shock in association with severe peritoneal contamination, prolonged time lag, and peritonitis. Interaction among these factors has been observ- ed clinically and they have appeared to be mutually complementary. It is not possible completely to divorce one from the others for statistical analysis. War Injuries of the Small Intestine, SUMMARY AND CONCLUSIONS A review has been made of small intestinal injuries occurring in a series of 3154 abdominal and thoraco-abdominal wounds. The cases studied were all treated in forward surgical installations by surgical teams of the 2nd Auxiliary Surgical Group. Six cases of non-penetrating trauma to the abdomen were Included; all other wounds but one were caused by missiles* Small bowel injury was present in of all cases. Uncomplicated small bowel wounds numbered 353 and comprised 11,2$ of the entire series. The gross mortality rate for all small Intestinal wounds was 30%, The mortality in the uncomplicated group was 13,9$. A section is included on the nature of the trauma to the intestine and its mesentery as it has been observed, and another section is devoted to the techniques of management employed by the surgeons of this Auxiliary Surgical Group, The majority of perforations were re- paired by suture. The mortality among all cases having repair by suture only was Resection and anastomosis were performed in 428 cases. The mortality in this group was with 145 deaths. Double resections were performed 35 times, and triple resections three times. Enterostomy was not employed as a method of primary treatment of small intestinal wounds. Postoperative distention, ileus, and vomiting have not been fre- quent, The elimination of these conditions is attributed to the routine use of naso-gastric suction for decompression of the gastro- intestinal tract. The Levin tube has been found most satisfactory for this purpose. Twenty cases of intestinal obstruction and 12 cases of intestinal leakage following small bowel surgery have been observed. The combined incidence of these complications was 2,7# of all eases, Th j average tine of manifestation of obstruction was between the sixth and seventh postoperative days, and of leakage, on the 13th day. Major associated wounds were present in one third of all cases. Eight per cent of all small intestinal injuries occurred in thoraco- abdominal wounds. Among 353 uncomplicated wounds, the ileum was injured more fre- quently than the jejunum in a ratio of approximately three to two. 259 War Injuries of the Small Intestine (Summary and Conclusions, cont'd). Ileal wounds were only slightly more lethal than were those of the jejunum. The average time lag from wounding to operation in uncomplicated cases was 10,9 hours. Among those cases which survived it was 9.5 hours, and among fatal cases it was 19.1 hours. Major associated trauma was observed over twice as frequently among fatal uncomplicated cases as among those which lived, and con- tributed materially as a cause of death in approximately one third of all fatal cases in the uncomplicated group. Among the remaining two thirds, 48£ survived operation by less than 72 hours. Prolonged time lag was a prominent factor, and peritonitis was the most frequent cause of death in patients dying primarily of small bowel injuries who sur- vived operation by more than two days. REFERENCES 1. Report on the Surgery of Abdominal Wounds; unpublished data sub- mitted to the Commanding Officer, 2nd Auxiliary Surgical Group (13 August 1943). 2. Report on the Surgery of Abdominal Wounds; unpublished data sub- mitted to the Commanding Officer, 2nd Auxiliary Surgical Group (14 April 1944). 3. The Medical Department of the United States Arny in the World War, Vol, Hm Surgery, Part 1, Page 458. (Washington; Government Printing Office,, 1927), 4. ibid. Page 460, 5. ibid. Page 455. 260 War Injuries of the Small Intestine. APPENDIX List Of Tables Page I. Incidence of wounds to the small intestine in all abdominal wounds (including thorac0-abdominal and non-penetrating injuries) 1942-45* .... 261 II. Gross mortality rates, all cases having small intestinal injury. 1942-45.................... 261 III. Incidence of types of injury to the small intestine. 1944-45.. ••••.•• ••...•••••• ••••• 262 17. Distribution of anastomotic and suture repairs, 1117 complicated and uncomplicated small intestinal injuries. 1944-45 262 V. Multiple resections, mortality, 1944-45. 263 VI. Small intestinal wounds, 1944-45. Frequency of use of intraperltoneal chemotherapeutic agents......... 263 VII. Uncomplicated small intestinal injuries, 1944-45* Incidence and mortality of injuries to the jejunum and ileum.............. •••••••••• 264 VIII. Causes of death in 31 cases having small intestinal injury the primarily fatal wound, 1944-45.......... 265 Cases Referred to In the Text Case Number 1... 26? Case Number 2 26? Case Number 3 268 Case Number 4. 268 Case Number 5«... 269 Case Number 6.... 269 261 War Injuries of the Small Intestine (Appendix, cont’d). TABLE I Incidence of Wounds to the Small Intestine in all Abdominal Wounds (Including Thoraco-Abdominal and won-penetrating Injuries) 1942 - 1945 1942-43 1944 1945 Total Percent of All Abdominal Abdominal Wounds 378 2383. 771 3532 100.0* Small bowel Involved 129 849 319 1297 33.9? .... Small Bowel Cnly 22_ 259 94 ■ ,itk- UsE TAB IE II Gross Mortality Rates, All Cases Having small Intestinal Injury 1942 - 1945 Jear Cases, Small Bowl Injury Deaths Mortality Percent 1942-1943 129 47 36-^ 1944 Bk9 252 ... 29.T% “T%5 93 ...... 29 .2% TOTAL 1297 392 2°12* 262 War Injuries of the Small Intestine (Appendix, cont »d). TAB IE III Incidence of Types of Injury to the Small Intestine, (Combinations of Different Types are Included) 1944 - 1945 Type of Trauma Number of Cases Number of Injuries Average Frequency per case Injury to Wall Only 27 31 1 Severe Mesenteric Injury* 30 30 i fransection 213 ill “T~ Perforation** Id© 45© *Roquiring resection* **An arbitrary figure of 5 has been used whore "multiple" are recorded* The true figure is probably higher* perforations TAB IE IV Distribution of Anastomotic and Suture Repairs, 111? Complicated and Uncomplicated Small Intestinal Injuries, 1944*45* (Compare with Table II in Text) Total Cases Complicated Cases Number Percent Unc Duplicated Cases Number Percent Total Series in? 63.8$ 348 31.2* Anastomosis m ... 72.0$ 135 28,0% Suture Only 422 66.5% hEk 263 War Injuries of the Small Intestine (Appendix, cont*d). TABLE V Multiple Resections, Mortality (All multiple resections had end-to- end Anastomosis) 1944-45 Number Resections Per Case 2 3 Survived 22 1 Died 13 2 Total 35 3 Mortality m TAB IE VI Small Intestinal Wounds, 1944-1945* Frequency of Use of Intraperi- toneal Chemotherapeutic Agents. (Sulfanilamide crystals. Penicillin, or Both). Total Series Uncomplicated Uncomplicated 1168 cases 304 Survived 49 Died Number Percent Number Percent Number Percent Drugs Used 684 59% 212 70% 31 63* JEJUNUM ILEUM BOTH TOTAL Cases Deaths Cases Deaths Cases Deaths Cases Deaths Mortality 1944 96 10 135 15 28 8 259 33 12.% 1944 1945 32 3 to $ 17 5 94 16 17.0$ 1945 T'TAL 128 13 180 23 45 13 353 49 13.9$ TOTAL MOETALITY JEJUNUM ILEUM BOTH TOTAL 10.% 12.8$ 29.C$ 13.9$ •(piq.uoD ‘xfpuaddv) atrcq-secpui jo aafjnCul Uncomplicated Small Intestinal Injuries, ly44-45 . Incidence and Mortality of Injuries to the Jejunum and Ileum TABLE VII 265 Time Lag Hours Auto- psy Survival Post-op. Site of Injury Cause of Death 1. 4 Yes 8 days Ileum Generalized and localized purulent peritonitis; leaking anastomosis 2. 8 Yes 36 hours Jejunum & Ileum Peritonitis; shock ?. 90 No U days Jejunum Generalized peritonitis fclinical') u. 19 Yes 2 days Ileum Generalized peritonitis, severe. Pulmonary edema, severe. 17 Yes 2 hours Jejunum Shock; peritonitis. (Clinical) 6. 12 No 24 hours Jejunum & Ileum Shock (clinical) 7. Yes 5 days Ileum Peritonitis, suppurative, generalized, severe; # mesenteric thrombosis lower l/3 ileum. 8. 23?~ Yes 8 days Jejunum Acute fibrinopurulent peritonitis, severe, lAnuria, uremia..clinical) (Case 1, Appendix) 9. 20 No 2‘days Jejunum & Ileum Shock (clinical) 10. .36 No 36 hours Jejunum Shock; severe mesenteric hemorrhage (clinical) 11. 27 Yes 9 hours Ileum Generalized fibrinopurulent peritonitis present at operation. 12. U Yes- 22 days Jejunum & Ileum Two perforations ileum due to wire sutures. Generalized and localized peritonitis. !?• 6 No 3 days Ileum Peritonitis (clinical) H. 36 No 5 hours Ileum Shock; peritonitis (clinical) 22 No 5 rain. Jejunum & Ileum Shock; peritonitis (clinical) (Case 5. Appendix) War Injuries of the Small Intestine cont'd). Causes of Death in 31 Cases Having Small Intestinal Injury the Primarily Fatal Wound 1944 - 1945 TABLE VIII 266 Time Lag Hours Auto- psy Survival Post-op Site of Injury Cause of Death 16. 15 No 11 days Ileum Peritonitis (clinical) 17. 7 Yes 10 days Ileum Massive Pulmonary embolism 18. 7 No 5 hours Jejunum & Ileum Shock (clinical) 19. 16 Yes 5 days Jej mum & Ileum Oliguria, anuria, uremia 20. 4 Yes 1 day Ileum Cardio-respiratory death unexplained clinically or at autopsy. 21. 13 No 24 hours Jejunum Shock; peritonitis (clinical) 22. 48 No 8% hours Ileum Shock; peritonitis (clinical) 23. 10 Yes 5 days Ileum Intestinal obstruction; kinked anastomosis 24. 11% Yes 24 hours Jejunum & Ileum Generalized peritonitis 25. 37 No 14 hours Jejunum & Ileum Shock; peritonitis (clinical) 26. 6% Yes 3 days Jejunum Diffuse purulent tracheobronchitis 27. 7 Yes 12 days Jejunum & Ileum Generalized peritonitis; bronchopneumonia 28. ? No 5 days Jejunum & Ileum Not stated 29. 10 Yes 24 hours Jejunum & Ileum Generalized peritonitis (Shock, clinical) 30. Yes 10 min Ileum Aspiration of Vomitus 31. 4 Yes 13 days Jejunum Hepatitis; atypical pneumonia; intestinal obstruction. War Injuries of the Small Intestine {Appendix, Table VIII cont'd) 267 War Injuries of the Snail Intestine (Appendix, cont»d) Cases Referred to in Text, 1* A 29 year old American infantryman, mounded by a machine gun bullet which entered the left lamer abdomen, fractured the iHnm, and fractured the greater trochanter of the femur at the mound of exit* The patient arrived in the Field Hospital 20 hours after injury, in severe shock* He mas given one unit of plasma and five pints of blood preoperatively* He mas mentally disoriented on admission (anoxia)* At operation 24 hours after wounding, the surgeon noted, "This patient had the most extensive spillage of Intestinal contents I have ever seen* Peritonitis is generalized and fulminating"* There mas only one small perforation found, in the jejunum* This mas repaired by Butin's* Post operatively the patient remained toxic, developed oliguria which progressed to anuria, and he died on the eighth postoperative day* At necropsy, an acute, flbrinopurulent, generalized peritonitis mas found, with subphrenic abscess on the right side as well* (Case Ho* 8 in Table YHt Appendix - same case)* 2* A 42 year old American artilleryman, mounded by a shell frag- ment which penetrated the abdomen through the left lower quadrant • He arrived in the Field Hospital in good condition, and mas given 500 c.c of blood* Roentgen examination disclosed a metallic foreign body in the right lower quadrant* Operation mas performed eight hours after injury* "Multiple perforations of very large size" mere found in the small bowel, nece- ssitating resection of three separate loops of intestine* At each resection, and end-to-end anastomosis mas performed* One resection mas in the jejunum, one in the upper ileum, and one in the lower ileum* The large shell fragment was removed from the mall of the ileum* The postoperative course mas uneventful* He mas evacuated in good condition, taking liquid diet, on the eighth postoperative day* War Injuries of the Small Intestine (Appendix, Cases Referred to in Text, cont'd). 3# An American medical corpsman sustained a severe penetrating gunshot wound of the left abdomen. He arrived at the Field Hospital about two hours after Injury, He was in severe shock, and the blood pressure and pulse were not obtainable. After 2500 c,c, of blood had been rapidly administered, the pulse was perceptible, but could not be counted, and the blood pressure was 52/40 mm, Hg, The patient presented a large defect in the abdominal wall, with extensive evis- ceration of small intestine. Operation was performed three hours after injury. The root of the mesentery was found to be avulsed, with severe and persistent bleeding. There were multiple transect ions and lacerations of the ileum and jejunum. The missile had perforated the left mesocolon, and lay in the lumbar musculature. Ten feet of small intestine were resected because of vascular impairment; side-to-side anastomosis was done. Several perforations of the jejunum were sutured. Follow- ing control of the hemorrhage the patient's condition gradually im- proved, and at the end of the operation the blood pressure was 104/60 mm. Hg, One transfusion of 500 c,c. was given during the oper- ation. The postoperative course was good. The Levin tube was re- moved on the sixth day, and the patient had spontaneous bowel move- ment, He was evacuated on the 13th postoperative day in good condition, (He reported by letter one month later that he was doing well, and ready for evacuation to the Zone of the Interior), 4, A German Prisoner of War, wounded by a shell fragment which penetrated the right lower quadrant of the abdomen. He was admitted to the Field Hospital three days after injury, dehydrated but other- wise in good condition. There was tenderness in the right lower abdo- men, and a thin, watery discharge exuded from the wound. At operation, the wound was lengthened so as to make a modified gridiron incision, A large abscess cavity was entered, which lay anter- ior to the cecum. Within the abscess cavity was a perforated loop of ileum, A tube ileostomy was done through the perforation. Postoperatively the patient did fairly well, but in the ileos- tomy discharges were noted undigested food particles, and the note was made that the perforation had probably been higher than originally thought. It was suggested that an effort at closure of the Intestinal perforation might have been preferable to ileostomy. The patient was evacuated on the tenth postoperative day. 269 War Injuries of the Small Intestine (Appendix, oases Referred to in Text, cont »d). 5. An 18 year old German Prisoner of War was admitted to the Field Hospital approximately 20 hours after sustaining a penetrating shell fragment wound of the abdomen, he was in severe shock, which did not respond satisfactorily to vigorous resuscitation therapy. Operation was performed 2k hours after injury. Marked contam- ination with small bowel content and a plastic peritonitis were noted. The bowel was of poor color. Three segmental resections of small bowel were done, removing a total of about three feet of badly damaged intestine. End-to-end anastomoses were done, the highest of them about four Inches below the ligament of Treltz. Several perforations were repaired by suture. In spite of continued infusions of blood during operation, the patient’s condition became progressively worse on the table, and he died about five minutes after the completion of surgery. Prolonged shock was stated as the cause of death. (Case 15, Table VUI, Appendix* same case). 6, An American infantryman sustained a severe shell fragment wound of the right buttock. He was brought to the Field Hospital in severe shock about 20 hours after wounding. Three thousand c.c of blood were given for resuscitation, and operation was commenced about 2k hours after the tine of injury. Two small perforations of the ileum were found, and there was an early fibrinous peritonitis. There was a very severe wound of the buttock, with an assoc- iated phagedenic infection involving the entire gluteal muscle group, and the lumbar and posterior thigh muscles. The patient became oli- guric and uremic, and died on the fifth day after a rapidly downhill course. The extensive infection proved impossible to control. At autopsy the peritoneal cavity was found clean. The infection and necrosis in the buttock and thigh were severe. The buttock wound and associated sepsis were stated as the chief causes of death. 270 WOUNDS OF THE COLON AND RECTUM Tha total number of patients with intra-abdominal wounds operated on by surgeons of this Group from 1943 through May 1945 was 3532. Of this series 1358 were patients with wounds of the colon and rectum or both, or 38.4$ of all patients with wounds of the abdomen* TABLE I Incidence of Colon and Rectum Cases Total Abdominal Cases 3532 Total Colon and Rectum Cases 1358 Percent Colon and Rectum Cases 38.4^ Of these 1353 patients with colon or rectum wounded and undergoing laparotomy, 867 lived and 491 died, a mortality rate of 36.17$. TABLE II Mortality Rate Total Colon and Rectum Cases 1558 Deaths 491 Percent Mortality 36.17^ During "ttie year 1943 (from April through December 31) 136 laparoto- mies were done on that number of patients for colon and rectum wounds. Seventy-eight of these patients lived and 58 died. The mortality rate was 42.6$. This series of 136 eases during 1943 has been previously reported by this Group and will not be included in this report of colon and rectum oases for the years 1944 and 1945. (See Table III). TABLE III Year Number Patients Deaths Percent 1945 156 58 42.$ 1944 917 334 36.4$ 1945 305 99 32.4$ TOTAL 1558 491 56.1$ Colon and Rectum Cases Pros 1 January 1944 through 8 Hay 1945 there were 1222 patients with sounds of the colon or reotun or both, who underwent laparotoay. 271 Wounds of the Colon and Rectum. This series has not been previously reported and the following report of statistics will refer only to this group unless otherwise stated. For the survey ««a 1S*LS 6T ee T ' 9 9 9 6 1 e ••a.AW,^ %rez U 9TT I 52 28 , tree e 2 9 9C 2C 28 PT"^T« terse 021 X X e 89 j Z.9 *«TP'»3«*a <9*8C vn ii9 X 2 C 9 i T | 991 252 <8*0C I “ 2»2 C 1 _ ’ i * Cl iX 62 X 6C I i2 59T »on>w*>n * i a I 0 •<*0 9» PMO«T 4MQ P®°l ««*0 ®w P*»T •9*n •w«n ®ll •3TO^J°2 V«M **) V CTTCJO •VOJ \mh °*n I«"*S •T9n<>a V»W| irwwr 9»«XO0 °«ti V*«»g ggggT85~«>H °9) 9*<»T<>0 * «»T»3 T»uot» -a«ATQ •■nuI) OPBUTIOliS iBD 1CBT4UTT Figure 45 - Operations and Mortality Rates The transverse colon alone was involved in 34$ of all oases reported, nert in order of frequency of wounds were; ascending colon, 22$; sig- moid 13$; descending oolon 10$; rectum (extraperitcneal) 9$; transverse and descending oolon 4$; colon and rectum 3$; ascending and transverse oolon 2*7$; and ascending and descending oolon 0.7$, (See Figure A6). The appendix was either perforated or transected in 12 patients (l$ of total). All of these patients had other and more important ab- dominal wounds; all were treated by appendectomy* 288 Wounds of the Colon and Rectum, (Surgical Management of the Colon and Rectum) PERCENT REGIONAL INVOLVEMENT COLON AND RECTUM CASES Figure 46 - Percent Regional Involvement Colon and Rectum Cases Wounds of the ascending colon presented a particularly difficult problem when it was necessary to resect the entire right colon and terminal ileum. Early in the war the most popular procedure was the resection and double barrel ileo-eolostoay. This operation was not satisfactory and carried a mortality rate of 64*7/$. Later on, resec- tion and ileo-colostoiqy anastomosis and either double mucus fistulae or single mucus fistula was advocated and was done with some improvement in the mortality rate. However, this mortality rate remained high at 51.7$. Two patients with resection of a portion of the ascending colon had the proximal and distal ends exteriorized separately and both patients died. 289 Wounds of the Colon and Rectum. (Surgical Management of the Colon and Rectum, contd) Of interest are the figures that 15 patients had a primary repair of the right colon without colostomy and with only one death. Of course, this indicates nothing beoause these were the less seriously wounded by far and cannot be considered in any way as being comparable to those patients who required resection of the entire right colon or even those with single large wounds. In 10$ of all patients with wovnds of the ascending colon a tangential colostoiy was done with no deaths. This procedure was done only when the perforation of the bowel was small and on the antimesenteric border of the bowel. The bowel was either repaired and no fecal fistula established at time of operation or the bowel was not repaired and a fecal fistula was present. This group of wounds of the ascending colon was included in colostomy” type operation of the ascending colon. (See Table XIII) TABLE XIII Ascending Colon Type Operation Loop Colostoey Number Lived Died 145 113 32 Percent Mortality 22.0# Spur Colostony 27 17 10 37.0# Tube Colostomy 39 29 10 25.6# Closure Perforation Proximal Colostomy 1 1 0 - Resection and Ileo-colostocy Anastomosis 29 14 15 61.7# Resection and Double Barrel ileo-colostonyl7 6 11 64.7% Closure Perforation Ho Colostomy 13 12 1 7*6% Resection Limbs Exteriorized Separately 2 0 2 100.0% Ho Operation 6 2 4 66.6% Laparotomy done Lesion Missed 5 1 2 66.6% TOTAL 282 195 87 20.6% The transverse colon was involved in 34$ of all colon and reotal wounds of this series. This was by far the most frequent segment involved (See Table V). There were 417 patients with wounds of the transverse colon, with 161 deaths or a mortality rate of 38.6$. Here again there were six patients who had a primary repair of the perforation and no colostony. There were no deaths in this group of six oases and all of these wounds were comparatively minor. (See Table XIV). 290 Wounds of the Colon and Rectum* (Surgical Management of the Colon and rectum, contd) TABLE XIV Transverse Colon Type Operation Humber Lived Died Percent Mortality Loop Colostomy 252 172 80 31.7# Spur Colostoiqy 146 74 72 49.3# Tube Colostosqy 4 2 2 50.0 Closure Perforation and Proximal Colostomy 1 1 0 0 Resection and Double Barrel Heo-col ostony 2 1 1 50.0# Closure Ho Colostomy 6 6 0 0 Resection - Limbs Exteriorized Separately 3 0 3 100.0# No Operation 2 0 2* 100.0# Laparotomy done Lesion Missed 1 0 1 100.0# TOOLS 417 256 161 38.6# *Died on Operating Table. Wounds of the descending colon presented no unusual problems as compared to mounds of the ascending and lower sigmoid segments. All lesions were dealt with by simple loop exteriorization, or a spur colostoiqy, or closure of perforation and proximal oolostony* One patient was treated by repair of the perforation and return of ih.e bowel to the peritoneal cavity. The mortality rate was 4$ above that for the ascending colon. (See Table XV). 291 Wounds of the Colon and Rectum (Surgical Management of the Colon and Rectum* oontd) TABLE XT Descending Colon Typo Operation Loop ooloatoB^r Number 67 Li-rad 48 Died 19 Percent Mortality 28.3 Spur Colostony 48 27 21 43.7$ Closure Perforation and Proximal Colostomy 3 2 1 33.3 Closure No Colostony 1 1 0 0 Laparotomy done Lesion Missed 1 0 1 100.0$ TOTAL 120 78 42 35.0$ The sijpaoid colon presented two problems not present in the colon proximal to the sigmoid. When a perforation of the lower sigmoid was encountered it was quite often impossible to exteriorize the wounded segment due to insufficient distal bowel. In these oases the perfora- tion was repaired and a proximal diversional oolostony was formed (eithar a loop or spur oolostony)• The second problem which was only enoounte* d in four cases was a perforation at the rectosigmoid junction just at the reflection of the peritoneum on the pelvic floor. In these cases the perforation was repaired, a proximal diversional colostomy was done with fasoia-propria drainage of the rectum posteriorly, (See Table XVI), TABLE XVI Sigmoid Colon Type of Operation Number Lived Died Percent Mortality Loop Colostony 82 61 21 25,6% Spur Colostony 32 18 14 40.6% Closure Perforation Proximal Colostomy 34 23 11 52,5% Fasoia Propria' Coinage-Closure Proximal Colostomy 4 3 1 22.2% Resection-Limbs Exteriorized Separately 2 0 2 100,0% No Operation 3 0 3* 100,0% TOTAL 157 105 52 33,1% ♦Died on Operating Table* 292 Wounds of the Colon and Rectum. (Surgical Management of the Colon and Rectum, oontd) The extraperitoneal rectum was perforated in 116 patients of whom 89 lived and 27 died. In Table XVII, there are eight patients listed as having had only a proximal colostomy (sigmoidostony), to divert the fecal stream from the rectum. Nothing was done locally to the rectum. The mortality rate for these eight patients was 62,8$, One patient had the rectal perforation sutured and no proximal colostomy. This patient died. The remaining patients had proximal diversional colostomy, fascia- propria drainage of the rectum and either closure or no closure of the rectal perforation. The mortality rates were ZA% and 1$£ respectively* The so-called "fascia propria drainage" is defined as adequate ex- posure and drainage of the extraperitoneal rectum either by removing tie coocyx and freeing the fascia-propria from the rectum or by dissecting the fascia-propria from the rectum and obtaining adequate rectal exposure through an incision just lateral to the coccyx. This type of operation with a proximal diversional colostomy* (either a loop or spur) was done in the great majority of patients with perforations of the rectum* TABLE XVII Rectum (Extraperitoneal) Type of Operation Number Lived Died Percent Mortality Diversional Colostooqy (only) 8 S 5 62.59$ Fascia-Propria Drainage and Proximal Colostomy 82 67 16 18.39$ Pascia-Propria Drainage-Closure Perforation and Proximal Colostomy 25 19 6 24.09$ Closure* No oolostony 1 0 1 100.09$ TOTAL 116 89 27 25.2$ The mortality rate was noted to increase sharply when two different segments of large bowel were involved. One hundred thirty patients had wounds of either two different segments of colon or oolon and rectum. The mortality rate was 49.2$. Tables I7III, XIX, XX and XU show the various oombinAtion with multiple large bowel segment involvement with the individual mortality rates. 293 Wounds of the Colon and Rectum. (Surgical Management of the Colon and Rectum, contd) In these groups of patients with multiple segments wounds of the colon or colon and rectum, 43 patients nad two different colostomies estab- lished at the site of the colon wounds. Of the 43 patients with two colostomies, 17 died, a mortality rate of 39.5$, TABLE XVIII Ascending and Transverse Colon Type Operation Humber Lived Died Percent Mortality Loop Colostomy 3 3 0 0 Spur Colostoi^ 9 3 6 66.6ff Closure Distal Perforation Loop Extsriorisation of Proximal Perforation 6 3 3 50.C)ff Resection Heo-Colostony Anastomosis 6 2 4 66.6ff Closure, Ho Colostomy 2 1 !♦ 50 .Off Resection Double Ileo-colostony 6 2 4 66.6ff No Operation (died on table) 1 0 1 100.Off TOTAL 33 14 19 57.5ff ♦Died of pulmonary embolus TABLE XIX Ascending and Descending Colon Type Operation Number Lived Died Percent Mortality Doable Loop Colostony 1 0 1 100.0# One spar cue loop Col os tony 1 0 1 100.0# One Tube and One loop Colostomy 1 1 0 0.0# Closure of Distal Perforation Loop Exteriorization of Proximal Perforation 6 2 4 66.6# TOTAL 9 5 6 66.6# 294 Wounds of the Colon and Rectum. (Surgical Management of the Colon and Rectum, oontd) TABLE XX Transverse and Descending Colon Type Operation Number Lived Died Percent Mortality Doulle Loop Colostony 9 6 3 35,5% One Spur and One Loop Colostony 29 18 11 38.0% Closure Distal Perforation and Exteriorization of Proxi- mal Perforation 9 5 4 44.4% Proximal Tube Colostony and Distal Loop Colostomy 1 1 0 100.0% No Operations 1 0 1 100.0% TOTAL 49 30 19 38.7% TABLE XXI Colon and Rectum Type Operation Diversional Colostony (only) Number 2 Lived 1 Died 1 Percent Mortality 50.0# Resection Double Barrel ileo- oolostony and loop sigmoidostony 1 0 1 100.0# Fasoia-Propria drainage and Proximal colostomy 19 10 9 47.3# Fascia Propria drainage- closure Perforation and Proxi- mal Colostomy 17 8 9 53.0# TOTAL 39 19 20 51.2# INTRAPERITOHEAL CHEMOTHERAPY (940 Colon and Rectum Cases) There is a striking uniformity in the mortality rate regardless of the intraperltoneal chemotherapy. One is prone to interpret this 295 Wounds of the Colon and Rectum. (Intraperitoneal Chemotherapy oontd) as meaning that the chemotherapeutic agents are ineffectual, when used locally. Before any deduction is made, it is necessary to explain that prior to June 1944 it was routine to give intravenous sulfadiazine postoperatively; after this date, penicillin was given intramuscular Ijr at three hours intervals from admission onward. Some surgeons continued the intra- venous sulfadiazine in conjunction with penicillin. There is a possibi- lity too, that some svrgeons, who used no agent in the abdomen on slightly contaminated cases, did use some on their bad cases. It seems safe to say that intraperitoneal chemptherapeutic agents made no de- monstrable improvement in the results. TABLE XXII Intraperitoneal Chemotherapy (940 Colon and Rectum Cases) Number Patients Deaths Percent Mortality Sulfanilamide 522 177 33.9# Penicillin 134 46 34,3# Sulfanilamide and Penicillin 141 49 54.7# No Drug 143 47 32.9# TOTAL 940 319 ‘ 33.9# POSTOPERATIVE COMPLICATIONS (1222 Colon and Rectum Cases) From, records available it is often impossible to make an accurate appraisal of complications which arose poatoperatively. Often there was no note after operation except that of the general condition on discharge or a note about a fatality when it occurred. No doubt many more of the important complications are listed than minor ones. Also, it can be assumed that there were many more oases of non-fatal atelec- tasis and lobular pneumonia than are noted below. Likewise there must have been additional wound infections, minor hemorrhages and even tem- porary partial obstructions from edema in the areas of intestinal anastomosis • 296 Wounds of the Colon and Rectum, (Postoperative Complications, contd) Without additional comment herewith are listed those complications, fatal and non fatal which were noted, each with the number of occurrences: Peritonitis 50 Pneumonia* ....... 46 Anuria* • ....... 45* Wound Infection* • . • • 30 Atelectasis 28 Wound Dehiscence* * * . 12 Intestinal Obstruction • 11 Anaerobic Infection. . • 11 Fecal Fistula 8 Empyema. ........ 7 Secondary Hemorrhage . • 6 Subphrenio Abscess. • • 6 Pelvic Abscess 6 Pulmonary Edema. • • • • 5 Cerebral Embolus. • • • 1 Fat Emboli 1? CAUSE OF DEA.TH (1358 Colon and Rectum Cases) In considering the cause of death in these patients suffering from war wounds it is important to remember thatit is difficult in many Instances to name one (Primary) cause of death. Many patients have multiple wounds. Some have severe head and extremity wounds and a large percentage have associated chest or thoraco-abdominal wounds. To Illustrate the seriousness of the latter complication, 20% of the deaths in colon cases occurred in thoraco-abdominal wounds. A majority of the fatal cases had post-mortem examination, complete or incomplete, to establish a cause of death. In the others the clinical examination and course, the operative findings and the attending surgeon's opinion were carefully examined and if possible a cause of death listed. In forty cases no oause is known. These are not considered in figuring proportions. (See Table VI, Appendix), Shock Forty-four percent were attributed to this cause. These were patients, mostly severely wounded and almost invariably in severe shock on admission, who may or may not have responded fully to adequate pre- operative shock therapy. They were operated upon, but never responded or reacted to even the most heroic postoperative treatment and died. ♦The discrepancy between this figure and that used for oases of anuria in all abdominal oases is probably due to the shorter elapsed time used in this series. 297 Wounds of the Colon and Rectum* (Causes of Death* contd) usually within 24 hours but occasionally after 36 hours* Whether death was due to shook entirely, the so-called "irreversible” shook, or to a combination of shock and the effects of an overwhelming peritoneal con- tamination is debatable. Certainly, most of these patients died before a fatal type of bacterial peritonitis could be identified. Just as cer- tainly, there was present in most of these oases sufficient irritative peritoneal contamination in the form of feces, small intestinal contents, bile, blood, or urine to cause a "shook" reaction* Also, the actual loss of blood in these patients was of tremendous importance, along with the other factors, in the causation of this severe and fatal type of shock* Until more is known about the disturbed physiology and how to con- trol and correct it, this phenomenon will continue to be one of the major factors in the mortality rate* This type of death was especially prone to occur after operations for extensive wounds involving the right colon, cecum, and lower ileum where the bowel contents are liquid and notably irritative* Constant changes were made in the suggested means of handling these patients because of the high mortality* It seems that the remedy does not lie so much in finding a better operation but in being better able to cope with and alleviate the marked disturbance in physiology* Intra-Abdominal• Intra-abdominal causes of death represented 26$ (119 cases) of the total and, except for hemorrhage (7 cases), were directly or indirectly due to infection within the abdomen. Hemorrhage» Unquestionably in some of the deaths attributed to shock, hemorrhage played an important part. Postoperatively though, hemorrhage was re- latively unimportant as a primary cause of death* Peritonitis. Ninety, or 20$ of deaths had a degree of generalized peritonitis which made it the apparent cause of death* Fatal peritonitis was most frequent in right colon lesions (24$ of deaths) and decreased as the lesion was store distal (15$ of deaths in sigaoid lesions)* It is difficult to suggest how improvement in this rate could be made* No doubt a number of oases died because of an associated lesion which when combined with peritonitis, was overwhelming* Some, it can be imagined. 298 Wounds of the Colon and Rectum, (Causes of Death , oontd) might hare carried orer their infection had they had the more indivi- dualized treatment which is possible in periods of lessoned activity. Peritonitis is a cause of death less to be feared than formerly and one which possibly can be further eliminated by full use of all the means at our command. From facts at hand, there is no proof that any intraperitoneal chemotherapy influences the mortality rate (See Chemotherapy, Page We are unable to add, except by inference, that it fails to aid in the control and treatment of peritoneal infection. Penicillin has been used routinely since June 1944 and some surgeons hare continued to use intravenous sulfadiazine in addition to the penicillin in all colon and rectum injuries. Retroperitoneal cellulitis. Retroperitoneal cellulitis has been responsible for seven deaths. Two were extraperitonsal rectal oases and the others were lesions dis- tributed about equally over the entire colon, ascending to sigmoid. Local abscess. There were few deaths from this cause reported - only five. The obvious reason is that deaths from subphrenio and other abscess, when they occur, are late and usually in hospitals to the rear. Of the five deaths from abscess, one was in an ascending and four were in transverse colon wounds. Abdominal "gas" infection. Apparently no fatal intraperitoneal anaerobic infection has bean recognized sinoe the routine us© of penicillin. Five deaths from this cause were reported in this series prior to February 1944, Intestinal obstruction. There were five deaths from obstruction. All had complicated small bowel lesions which later were the sites of obstruction. In at least two, the obstruction followed a breaking down of small gut anastomosis. Like abscesses, this is a complication occurring late and deaths take place in other hospitals. Anuria,* Forty-fire patients or 10% of the total died in anuria. In these the kidney lesion was the primary cause of death. No death was attri- ♦The discrepancy between this figure and that used for cases of anuria in all abdominal oases is probably due to the shorter elapsed time used in this series. 299 Wounds of the Colon and Rectum, (Causes of Death, contd) buted to this cause unless at least three days had elapsed between injury and death. This arbitrary time limit was based upon the genera- lly accepted concept that three days is the minimum time in which fatal renal dysfunction from this cause can occur. Some men set a longer minimum time. Intrathoracic. Intrathoracic causes of death made up 14$ (63 cases) of the total deaths with known causes. In view of the fact that in 95 deaths (20$) there was thoracic involvement through the diaphragm and in still others there was associated chest injury without perforation of the diaphragm this percentage does not loom large. Chest injury. In 11 oases, including four blast Injuries, the chest wound was the primary cause of death. Pulmonary embolus. Pulmonary embolus caused 16 or 3.5$ of deaths. Pneumonia, Pneumonia was responsible for anly 20, or of deaths. This low figure is no doubt made possible by the routine chemotherapy of all wounded patients in addition to the skill of the anesthetists. Certainly, endotracheal anesthesia and tracheobronchial aspirations during and after anesthesia hare played an important part in preventing and re- lieving atelectasis and thus, subsequent pneumonia. Atelectasis caused five and pulmonary edema 10 deaths. There was one death ffom empyema. The remainder of deaths were classified MISCELLANEOUS but most important were six due to associated head injury and seven due to soft tissue anaerobio infection. Some of the latter were in buttock wounds in direct communication with rectal and colon wounds but most were in concomitant extremity wounds. Summarizing, one finds that of all known deaths in this large series of oases, only one in four was due to intraperitoneal infection; two of the four were due to shook or anuria, the immediate effects of trauma; and bhe fourth was due to complications and, to a lesser degree, to associated injuries, (Data summarized in Table VI, Appendix.) 300 Wounds of the Colon and Rectum. SUMMARY AMD CONCLUSIONS 1. In a consecutive series of 3532 abdominally wounded patients operated upon by the 2nd Auxiliary Surgical Group, 38.4$ had open or gangrenous wounds of the large intestine, including the rectum. The recorded mortality rate was 36.2$ in the hospitals of operation. 2. The average time lag from wounding until surgery was begun was 10.9 hours. We believe that preoperative time lag in colon injuries definitely effects the mortality rate adversely. In rectal wounds with no colon involvement there was not the same adverse effect. 3. There was a definite and almost regular increase in the morta- lity rate proportional to the number of additional abdominal organs in- jured. This ’’multiplicity factor” seems to be more important than the nature of the particular organs involved, in determining prognosis. 4. The degree of "shock” on admission was of utmost importance. Sixty-nine percent of the severely shocked patients died; twenty-nine percent of patients admitted in moderate shock died and only 10$ of patients in slight or no shock died. The degree of shock closely paral- lels the "multiplicity factor" of injured-abdominal organs, i.e., the greater the number of abdominal organs involved the greater will be the degree of shock, 5. Colon injuries with an associated thoraoo-abdominal wound had a 50$ mortality and represented 20$ of all deaths. 6. The preoperativa resuscitation of colon cases in particular should be early and vigorous and should be continued throughout surgery. The average amount of blood received per patient preoperatively was 1840 c.c, 7. Fundamentally the basic principles of colon surgery in war wounds are three: l) Exteriorization of wounded portions of bowel, when- ever feasible to avoid intraperitoneal leakage; 2) Complete diversion of the fecal stream away from distal wounds of the colon and rectum by proximal colostony, and 3) Incomplete diversion of the fecal stream for gaseous decompression and possible future complete diversion, by colos- tony. 8. Simple loop colostomy has been most frequently used. The spur type has been reserved in most cases for resections, transections and large mesenteric border wounds of the colon, 9. Mary small antimesenterio perforations of the colon, particular- ly on the right side may be closed and the closed site exteriorized 301 Wounds of the Colon and Rectum, (Summary & Conclusions, contd) tangentially, thus maintaining bowel continuity, without ever forming a fistula. Others may be handled as a tube colostomy, 10. Severe right colon wounds requiring resection are probably best treated by ileo-transverse colic anastomosis with exterioriza- tion of the proximal end of the transverse colon or the variation of this operation in which the distal end of the ileum is also exteriorized through a separate incision. Some surgeons of the Group feel that a spur ileo-oolostomy is preferable. 11. Posterior drainage of the peri-rectal space is mandatory in all extraperitoneal rectal wounds in addition to a diversional colostomy. 12. All parts of the colon can be exteriorized except the lower sigmoid and all retroperitoneal portions must be reflected for thorough examination if a wound is suspected, 13. All contaminated retroperitoneal spaces should be adequately drained but it is not necessary to drain the peritoneal cavity in most instances. 14. There is no evidence that intraperitoneal chemotherapy is an effective adjunct to the systemic use of penicillin and sulfadiazine in colon injuries. 16. More than half of the deaths were due to "shock" and anuria ("Shock" and Anuria It seems reasonable to assume that until more is known about the physiology of shock and more adequate methods of prevention and treatment are employed, the high mortality rate can- not be lowered, 16, Intra-abdominal infection caused 25% of all deaths. The frequency of fatal peritonitis was greatest in right colon lesions and decreased as the lesions were more distal. 302 APPENDIX TABLE I Time Interval - Wounding to Operation (1222 Colon & Rectum Cases) 0 - No. Pts, 6 Died 6 - No Pts. 12 Died 12 - w~ Pts. 18 Died 18 - 1*0 Pts. 24 Died 24 - Pts, 48 48 : tfo Died Pts Plus Died Ascending 93 25 114 43 33 6 17 3 17 7 8 5 Transverse 119 39 212 87 49 22 19 8 15 6 3 0 Descending 29 6 62 19 17 10 5 3 7 4 Sigmoid 40 10 69 27 29 11 7 1 11 3 1 0 Rectum (extra peritoneal) 15 5 57 12 23 7 11 1 10 2 Rectum and colon 7 4 21 11 6 3 4 1 1 1 Ascending ft Descending 3 2 3 1 1 1 1 1 1 1 Ascending ft Transverse 14 7 13 8 5 3 1 1 Tranaverse ft Descending 16 7 24 7 5 2 1 1 3 2 9 TOTAL 336 105 575 215 168 65 66 20 65 25 12 3 PERCENT 31.3# 37.4# 38. .7# 30.3# 38 .5# 25.0# 303 Wounds of the Colon and Rectum. (Appendix oontd) TABLE II Complicating Abdominal Injury (1222 Colon and Rectum Cases) Number of Patients Deaths Percent Mortality Colon alone 251 67 23.0# Colon and Hollow Viscera 480 176 37,($ Colon and Solid Viscera 159 55 35,0# Colon, Hollow and Solid Viscera 177 98 55.0# Colon and Rectum 13 6 46.0# Rectum alone 64 9 14.0# Rectum and Hollow Viscera 72 29 40.0# Rectum and Solid Viscera 2 0 o.o,« Rectum, Hollow and Solid Viscera 4 3 75.0# TOTAL 1222 435 35.4# 304 Wounds of the Colon and Rectum, (Appendix, contd) TABLE III Colon or Rectum Alone Patients Deaths Mortality 0-6 Hr s' 6-12 Hrs 12 - 18 Hrs 18 - 24 Hrs Over 24 Hra Total 71 9 12.6$ 120 26 21.6$ 38 6 15.8$ 25 4 16.0$ 38 12 31.7$ 292 57 19.5$ Colon and Patients 159 242 79 25 28 533 One Deaths 45 79 32 6 10 172 Organ Mortality 22.0$ 32.06$ 40.5$ 24.0$ 35.7$ 32.3$ Colon and Patients 67 110 34 14 8 233 Two Deaths 31 53 17 6 5 112 Organs Mortality 46.2$ 48.1$ 52.3$ 42.8$ 62.6$ 48.0$ Colon and Patients 25 31 7 5 2 70 Three Deaths 14 12 6 4 1 37 Organs Mortality 56,0$ 38.7$ 85.7$ 80.0$ 50.0$ 52.9$ Colon and Patients 7 13 1 1 22 Four Deaths 6 10 1 1 18 Organs Mortality 85.7$ 76.9$ 100.0$ 100.0$ 81.8$ Colon and Patients 1 4 5 Five Deaths 1 4 5 Organs Mortality 100.0$ 100.0$ 100.0$ T OTA 1*3 Patients 330 520 159 69 77 1155 Deaths 106 184 62 20 29 401 Mortality 32.1$ 35.4$ 39.0$ 29.0$ 37.7$ 34.7$ Tim© Lag and Multiplicity of Organs Involved (1155 Colon & Rectum Cases) 305 Wounds of the Colon and Rectum* (Appendix contd) TABLE IV Shock in Relation to Time Interval Wounding to Admission (1140 Colon and Rectum Cases) 0 - 6 Hrs 6 - 12 Hrs 12 - 18 Hrs 18 - 24 Hrs Over 24 Hrs Pts Died Pts Died Pts Died Pts Died Pts Died None or Slight 217 24 11# 101 7 7% 24 1 4# 20 3 15# 21 3 14# Moderate 199 58 29^ 103 24 23# 32 16 47# 11 1 9# 14 7 50# Severe 225 163 68# 125 84 67# 24 20 81# 12 9 75# 12 8 66# TOTAL 641 235 329 115 80 36 43 13 47 18 TABLE V Related Thoraco-Abdominal Injury (1358 Colon and Rectum Cases) Number of Patients Deaths Percent Mortality Ascending Colon 13 9 70$ Hepatic Flexure 22 15 68$ Transverse Colon 76 33 43$ Splenic Flexure 57 30 53$ Descending Colon 23 8 35 TOTAL 191 95 50 306 Wounds of the Colon and Rectum. (Appendix, contd) TABLE VI Primary Cause of Death (1358 Colon and Rectum Cases) Percentage of Number Deaths From Deaths Known Causes 1. "Shock" 200 4A% 2. Intra-abdominal• ......... a. Hemorrhage. ......... 7 • • • • 1.5% b. Intestinal Obstruction. • • . 5 • • • • 1.0% c. Peritonitis generalized. . . 90 • • • • 20.0% d. Abscess 5 • • • • 1.0% e. "Gas" infection peritoneal) • 5 • • • • 1.0% f. Retroperitoneal cellulitis. • 7 • • • • 1.5% 3. Anuria* 45 4, Intrathoracic. a. Pneumonia. 20 • • • 4.4% b. Pulmonary Embolus 16 • • • • 3.5% c. Pulmonary Edema 10 • . • • 2.2% d. Atelectasis. . 6 • • • • 1.0% e. Empyema. •••.••••••• 1 • • • • 0.2% f. Blast Injury. •• ...... 4 • • • • 0.8% g. Severe Chest Injury Primary cause of Death. •••.•• 7 • • - • 1.8% 5. Cranial a. Head Injury Primary Cause of Death. . 6 • • • « 1.3% b. Fat Embolism. • 1 • • • • 0.2% c. Cerebral Malaria. ...... 1 • • • • 0.2% 6. Miscellaneous • . 3.8% a. Anaerobic Infection. ... • 7 • • • • 1.5% b. Injury Extremity, Primary. • 1 • • • • 0.2% c. No record except primary cause not intra-abdominal. • • • . 8 • • • • 1.8% Total Deaths From Known Causes. . . . 451 7. Insufficient Information. • • . • 40 TOTAL DEATHS 491 ♦The discrepancy between this figure and that used . for cases of anuria in all abdominal cases is probably due to the shorter elapsed time used in this series. 307 MR WOUNDS OF THE LIVHl The present war has offered an opportunity for the critical appraisal of the surgical treatment of liver wounds* In discussions based on World War I experience, hemorrhage from liver wounds usually is considered as the chief cause of fatalities and complications (l, 2 and 4). Our observations, however, point to the complications of bile leakage and hepatic parenchymal damage as of greater significance* Our mode of surgical care has been altered accordingly* The increase in coincidental injury to other abdominal viscera found in these later studies should tend to raise the morbidity and death rates. Surgical management has improved to such a degree in the present war, however, that a significant overall reduction in mortality has res tilted (See Table I, Appendix)* The data presented are based on a series of 829 patients with wounds of the liver and biliary tract, taken from a group of 3154 abdominal and thoraoo-abdominal cases. Three thousand sixty-six records were available for our analysis at the time it was made. The data necessarily are limited to the forward hospitals in which the initial surgery was performed. Sufficient information pertaining to the outcome of these patients in hoapitals to the rear is not avail- able for analysis at this time* Some of the clinical records were incomplete in various details. Certain charts and tables have been based, therefore, on less than the total cases studied. INCIDENCE The following table presents the overall incidence and mortality for wounds of the liver in our series, 1944 and 1945: TABLE I Wounds of Liver and Biliary Tract - Incidence and Mortality 1944 1945^ Combined 1944-45 Total Cases (Abdominal and Thoraco-Abdomlnal Wounds) 2583 771 3154 Cases Utilized" 2296 iil 30d6 Total Cases - Wounds of Liver 5TS TffST S25 Incidence Rate 28.1% 21.3% 26,75S Total Cases-Wounds of Gall Bladder or bile ducts (liver involved in all cases) 40 13 53 Percentage, Wounds of Gall Bladder l.t% 1.7$ 1.7% Fatal Cases, total 193 SI 224 Mortality Rate, Total 29,8$ 16.9% 27.0% ♦Covers period 1 January to 8 May 1945 inclusive# 308 War Wounds of the Liver, (Incidence oontd) Abdominal wounds comprised 46.2/$, and thoraco-abd orcinal wounds 53.8/$ of all wounds involving the liver (See Table Till, Appendix). It is interesting to oompare the incidence of liver wounds in this series with available statistics for World War I (Table I, Appendix). Restricted to liver involvement in abdominal wounds only the World War I incidences of 13.3% and 16.8% respectively are seen to agree fairly closely with our incidence of 17.1%. MORBIDITY AND MORTALITY The overall mortality rate for wounds of the liver in our series was 27,0$ as contrasted to a mortality rate of in World War I, The number of viscera involved in association with the liver wound represented the most important single factor in prognosis, As shown in Table II,(Appendix) mortality was directly proportional to the number of other viscera wounded. Uncomplicated wounds of the liver had a mortality rate of 9«7/£, The mortality rate when the liver and one other organ were injured was 26,6/6, But the mortality rate rose to 84,6/S when the liver and four or more other viscera were wounded, (See Figure 47)* TABU a. MULTIPLE ORGAN INVOLVEMENT — EFFECT ON MORTALITY RATE OF LIVER WOUNDS Wf - TOTAL CASES 329 Figure 47Multiple Organ involvement. Effect on Mortality Rate of Liver Wounds. 309 War Wounds of the Liver (Morbidity and Mortality oontd) From Table III* (Appendix)* it will be seen also that when the liver was injured in association with the colon only* the mortality rate was the greatest for ary single organ-liver combination (32,3%), The seoond most serious combination was that in which the liver and the stomach-duodenum were involved* (31«3/£)« These relationships are graphically represented in Figure 48) MORJALITK OF LIVER WOUNDS PLUS OTHER VISCERAL WOUNDS Figure 48- Mortality of Liver Wounds Plus Other Visceral Wounds. The location of the wound is important because of the proximity to other organs* Wounds about the hilum of the liver occasionally involved the extra-hepatic bilary ducts* retroperitoneal duodenum* pancreas * stomaoh* oolon* or vena oava. These complicated wounds carried a high mortality rate. During the year 1944, 558 records defined the location of liver wounds with sufficient accuracy for use in this s tudy: 310 War Wounds of the Liver. (Morbidity and contd) TABLE II Anatomical Site of Liver Wounds in 658 Cases Loba of Liver Involved Humber of Cases Percentage Right lob© 446 83.6^ Left lobe It 13.1* Both lobes 19 zM The extent and location of the liver wound are of importance* However, a small penetrating wound may be followed by more serious complications such as bile leakage or hemorrhage than one in which a larger mass of liver tissue is involved. The majority of oases. 76%, fell into Grade 1 or II on a basis of I. II. or III Grades of severity. They were most often described as a lacerating, penetrating or per- forating wound, small or moderate in degree. Twenty four percent of the group were described as "severe wounds" (Grade III) and on some occasions required resections of a part of a lobe, even the entire left lobe. Bleeding from the liver had ceased at the time of exploration in 91.1% of the oases. In the remainder it was rarely described as severe. In no case of this series was death ascribed to bleeding from the liver during the postoperative period in the forward hospitals. It was impossible to evaluate the amount of bile in the peritoneal cavity. Usually some bile leakage had occurred, but the presence of much Intestinal content plus exudate and blood made even a rough estimate unsatisfactory. There are certain associated factors which may have influenced the morbidity and mortality in this group although difficult to prove statistically. The wounding agent, time lag from injury to strgery. the availability of adequate shook treatment and the use of sulfona- mides and penicillin all played varying roles. It is known also that the mortality in this group of oases was higher in winter months when the incidence of pulmonary infection was high* OPERATIVE INC ISIONS Location of operative incisions In these oases is given in Table V, and was as follows* Abdominal (47.2%); Thoracio (36.3%); both (12.5%)• The incision frequently varied with the amount of visceral injury in ary given case and in particular whether thoracic or abdominal viscera or both, were involved. An Increase in the trans- diaphragmatic approach is apparent in the 1945 group. With increased experience the surgeons found the results to be better when this approach could be utilized. "Thoraco-laparotony" was performed in seven cases. If. in this incision, the thoracic wound is extended down over the anterior chest wall into the abdomen, cutting the 311 War Wounds of the Liver, (Operative Incisions oontd) chonctalaroh in its course* complications may follow, Suoh wounds become infected easily and tend to break down* resulting in difficult treatment problems. If the abdominal pathology encountered in a thoracoabdominal wound o&nnot be handled adequately through the initial thoraco approach* we believe a separate laparotomy incision should be used rather than cutting across the costal arch. SURGICAL TREATMENT A tabulation was made of the various types of surgical treatment of the liver wound itself (Table III), Nearly 58$of all cases tabulated (695) were treated by placement of drains only, 28.1$ by packing* by suture of the wound plus drainage* and 7,8$ without local treatment. Of more significance* however* is the change in these modes of treatment with increased surgical experience. The use of drains alone rose from in 1944 to in 1946* with a corresponding reduction in use of the liver pack from 34,$ to 9,6*, There was also a sharp decrease in the number of liver wounds left without any treatment in 1945* though the total number of suoh oases was small* TABLE III Types of Surgical Treatment 1944 1945 Combined 1944-1945 Total oases tabulated 528 167 695 Type of ’Treatmentt Drain (s) 48.6# 87.4# 57.8# Paok 34.1% o? 28.2% Suture (and drain) 6.5% 1.8# (3 oases) 5.^T“ Suture and paok “ 0.95# (5 oases) .0# ' • Musole graft 0.15# (l case) ” Vo# ** So treatment 9.8# 1.21# (2 oases) 1,8# Comment: The trend in treatment away from packs to simple external drainage in 1945 is well illustrated here. It parallels an improvement in mortality rate for that year, (See Table I* Text). 312 War Wounds of the Liver* CAUSES OF DEATH Table 7 (Appendix)# enumerates the principal causes of death# Autopsies were performed on a majority of the oases whioh died in the forward hospitals# and# in most instances# by the operating surgeon# "Shook” was listed as the ohief cause of death in (115 cases)# This diangosis represented a state of persistent circulatory collapse and none of the oases so listed sarrived beyond the second postoperative day# Blood loss appeared to be only one of several fhotors contribu- ting to the shook# A multiplicity of factors including disturbances of oardio-respiratory physiology, overwhelming contamination of the peritoneal and pleural oavities, tissue destruction and widespread retroperitoneal cellulitis all played significant roles# Pulmonary complications represented the second most important group of causes of death# There were S3 such oases# of the total group of fatalities# Trauma to the diaphragm in over half of all liver wounds# trauma to the lung# bile oontamination of pleural oavities and prolonged other anesthesia provided ample background for pulmonary complications# Some degree of peritonitis existed in all the fatal oases# When listed as a oause of death# it implied either a widespread or marked local process (such as subphrenio abscess)* Oliguria and renal failure represented the ohief oause of death in 19 oases It is interesting to speculate on the possible relationship of liver damage to renal failure though we could not eliminate "transfusion" or "shook kidney" as the baalo pathology in most of these oases# A miscellaneous group of causes of death: gas gangrene; head injury; paralysis following wound of spinal oord; and others# totalled 10#7£# (24 oases)# Causes of death for the year of 1944 only# sure portrayed graphic ally in Figure • complications* 313 War Wounds of the Liver, (Causes of Death oontd) W0UND5 OF THE LIVER PRINCIPLE CAUSES Of DEATH - M3 CASES Figure 49" Principal Causes of Death - 19S Cases Extra-Abdominal Wounds. Extra-Abdominal Wounds. Coincidental wounds outside of the abdominal cavity undoubtedly exerted on effect on morbidity and mortality in this series* These included frequent injury to the lung, occasional trauma to the heart* and* in every thoraoo-abdominal case* wounds of the diaphragm and thorax* Several instances of* spinal cord wounds contributed to mortality also* The significance of peripheral wounds sueh as com- pound fractures of long bones* traumatio amputations or head womds could not bo evaluated separately* Wounds of the Gall Bladder and Bile Ducts. Fifty-three wounds of the gall bladder and bile dusts (51 gall War Wounds of the Liver. (Causes of Death contd) bladders. 2 common ducts) were Included In this series and represented 6,3$ of total liver and biliary system or 1,7$ of all abdominal and thoraco-abdominal wounds. In every case, the gall bladder or bile duct wound was complicated by a wound of the liver. Because of this circumstance and the frequent occurrence of wounds of other abdominal viscera in these cases, it was Impossible to evaluate their signifi- cance in the morbidity and mortality rates. In general, however, the mortality for cases exhibiting wounds of the gall bladder and bile ducts has been 30$. corresponding closely to the overall mortality rate of 27,0$ in liver wounds. The degred of damage to the gall bladder varied greatly. In one case the fundus was partly avulsed from its bed with- out direct damage to the gall bladder wall. Simple suture sufficed to repair this damage. In 5 instances small wounds of the fundus were closed with purse string sutures. The balance of 47 oases ms about equally divided into severely lacerated gall bladders requiring choleoy- s tec tony and less severe wounds treated by tube oholeoysteotosy. One of the two common duct oases sustained a wound of the duct near the ampulla of Vater, This was overlooked at operation and undoubtedly contributed to the death in this case. In the other case the common duot was perforated in the hepatico-duodenal ligament. Simple suture without drainage was followed by recovery. DISCUSSION The large number of liver wounds encountered in this war and the frequency of complications following soma methods of treatment have directed our attention to a more oritioal appraisal of the important problems. In the past, the ohief concern in the treatment of liver wounds has been the control of hemorrhage. It is our belief, based upon this large series of oases, and our own personal experiences, in both forward and base hospitals that bleeding is not the most im- portant feature. In only 9$ of this large group of oases was aotlve bleeding present at the time of exploration. In 91$ of the oases, therefore, spontaneous hemostasis had occurred by the time of opera- tion, The ohief sources of bleeding in any liver wound are from the hepatic artery, whioh enters the porta of the liver, divides into its branches, and from the portal vein whioh similarly enters at the liver porta and imnediately branches into small ramifications. Unless a hilar injury is sustained or a missile penetrates deep into the liver, serious bleeding should be rare. The larger branches of the portal vein extend nearer the surface than do those of the arterial system, but the pressure in the venous system is low (8-10 am Hg,). and bleed- ing from these vessels oan be controlled readily as described later in this discussion. In this series of liver cases, only one instance of serious postoperative bleeding was recorded and this is reported in detail. 315 War Wounds of the Liver, CASE REPORT An American soldier was wounded by high explosive shell fragments, 29 January 1945, with injury to the right ooeto-phrenio sulcus and the hilar region of the liver* Under gas anesthesia the wound was debrided and enlarged and a shell fragment, and bits of clothing were removed from the liver wounds* Penrose drains were placed and brought out through a separate drainage inoision. There was oopiofas drainage of old blood and bile for 36 hours after operation* The general course was uneventful however, until the eighth postoperative day, when a severe hemorrhage occurred through the drainage incision* This ceased spontaneously* On the ninth postoperative day a second se- vere hemorrhage occurred and a gauze pack was inserted deeply into the liver wound through the enlarged drainage inoision* There was no sign of infection in the liver substance or adjacent structures at this time* A third hemorrhage ensued. After replacement of the pack by a fresh one this bleeding stopped* The patient developed chills end fever (pack still in place) on the 16th postoperative day* The texq>erature spiked to 105*8 F on the 17th postoperative day, and another severe hemorrhage about the pack occurred* Under pento- thal anesthesia,the external wound was reopened and the wound in the liver exposed by incision with the actual cautery to a depth of seven cm* There was found a large artery which had been partly severed by the original injury* This vessel was clamped and ligated, and the liver wound was drained with Penrose drains* On the 18th postoperative day severe abdominal distents ion develop- ed* On the 22nd postoperative day, bile drainage became very profuse and on the 32nd postoperative day, a liver abscess was drained* A pelvic abscess was drained the 41st postoperative day and a sub- hepatio abscess was drained the 51st postoperative day* The patient was making a satisfactory convalescence on the 75th postoperative day* Analysis of the Case by The Operating Surgeon, "I. The original thorecofcony was justified by the apparent location of the wound trad; and the olinloal signs of intra-abdominal injury* 2* The foreign bodies were removed from the liver readily, and the increased oozing of dark blood which followed seemed insufficient to require any special hemostatic measures* 3* The hemorrhages on the eighth and ninth postoperative days were massive and obviously arterial* This may have been due to re-opening 316 War Wounds of the Liver. (Case Report oontd) of the partially severed artery as the surrounding clot retracted. Perhaps the insertion of the first pack on the morning of the ninth day ms justified as an attempt at control by conservative means. In retrospect, I think it would have been wiser however not to have packed the wound when hemorrhage reoccurred, but to have explored the bleeding area directly at that time. The known location of the wound in the hilum and the degree of hemorrhage, requiring a large pack to stop it, even temporarily, probably were adequate indications for ro-operation. 4, There was no local or systemic evidence of infection at the time the packs were first inserted (nine days after wounding). Seven days later, however, established infection was evidenced by chills and fever up to 105,8° F. I feel certain that the packs were instrumental in causing this infection by damming back drainage. Later difficulties (secondary venous bleeding, liver abscess, subhepatic and pelvic abscess) apparently were complications of this infection. Those com- plications might have been avoided had the source of bleeding been approached immediately in preference to the attempt of conservative control by packing," It is our opinion that the establishment of adequate external drainage of both bile and tissue products from the traumatised region is the most important feature in the surgical care of liver wounds. Any method that will satisfactorily accomplish this should be followed by good results. The dry pack, the treatment agent most frequently re- corded in the literature, will not function satisfactorily as a drain. Advocacy of the liver pack wa s based on the assumption that bleeding from the liver was the chief factor which determined the prognosis. In view of our recent experience, we know that this is not the case. It is true that in a small number of cases (9%), the liver was bleeding at the time the abdomen was explored. Some have recommended suture alone or in association with a muscle stamp for its control. As shown in Table III, above, relatively few liver wounds were sutured by surgeons of this Group and apparently without regret, for the practice was nearly abandoned in 1945, It has been our observation, as well as that of some others, that the bleeding which occurs following suture of the liver may exceed that which existed prior to such treatment. In one interes- ting case active oosing from a large superficial wound of the right lobe of the liver was observed at the time of operation. Dry gauae was packed against the bleeding area until the remainder of the abdominal pathology was oared for. Before closing the abdomen, the pack was re- moved and it was found that all the bleeding had ceased. Such use of the pack will occasionally be found worthwhile. The number of complications of liver wounds seen in Field Hospitals is small when compared with those in hospitals further to the rear. A report (5) from a chest center at a General Hospital offers a better indication of the frequency of these complications. In a series of 98 wounds of the liver which had received their primary operative treat- ment at forward hospitals, Burford found that 25$ presented complications. 317 War Wound* of the Liver. (Discussion oontd) These were complications resulting from inadequate drainage and included fourteen cases of subphrenio abscess* five eases of bile em- pyema* and six oases of intra-hepatio abscesses* A gauze pack does not function as an adequate drain* The pack* whether used alone or in conjunction with drains tends to aot as a tampon and may cause one or more complications* such as subphrenio* sub-hepatic or pelvic bile collections and abscesses* The diaphragm was perforated* of course* in all the thoraco- abdominal wounds (55*8% of all wounds in our series)* The bile and exuded fluids* prevented from draining externally by the liver paok have on occasions* forced their way through the sutured diaphragmatic wound* This has been followed by a bile empyema or bilary thoracic fistula* This complication was seen in different oases regardless of the iype of closure of the diaphragm. In one instance* the lung was aherent to the suture line of the diaphragm* and the bile eroded through into a bronchus creating a very serious problem* Occasionally the bile not only eroded the sutured diaphragm* but* after reaching the pleural oavity* also caused a breakdown of the thoraootoay incision* Sub-phrerio pleurooutaneous-fistulas resulted* Intra-hepatio necrosis* abscess* hepatitis* and bile peritonitis have all been observed in cases treated with gauze paoks. A less important but significant feature is the pain associated with the removal of a large liver pack* It occasionally necessitated the use of an anesthetic* thus adding to the postoperative problem* Secondary hemorrhage following the removal of a pack may occur. An autopsy on a patient who sustained a fatal secondary hemorrhage following the removal of a liver paok on the 18th postoperative day at a general Hospital was observed by one of the surgeons of this group* Vascularization had occurred in the liver bed as a reaction to the pack* The granulation tissue which had invaded the meshee of the gauze bled profusely when the paok was removed* The patient became exsanguinated before surgioal intervention could be undertaken* In an effort to obviate the above* early removal of the paok has been practiced in some cases with resultant premature closure of the external drainage wound* Attempts at replacement of the gauze paok by a Penrose drain have been unsuccessful. It is impossible to place the drains adequately except under direct vision at the time the abdomen is opened* Because primary bleeding from the liver is rarely serious and because the complications following the use of gauze paoks have been so numerous* we believe their use should be discontinued* Adequate control of bleeding* when it occurs, almost always can be obtained by the use of a teoporary gauze pack during operation or by insertion of the wiok end of the Penrose oigarette drain loosely to aot as a olot supporting 318 War Wounds of the Liver. (Discussion contd) surface* In addition to the control of the bleeding this trill provide adequate drainage. A penrose or a Penrose cigarette drain should be placed over the liver dome to the involved area. If large or separate wounds are present two drains are led to this space* A Penrose drain is placed laterally to the postero-inferior margin of the liver obvia- ting a collection in this region. The sub-hepatic space is drained also* All drains are delivered through a dependent drainage incision* usually placed sub-oostally, in the anterior or mid-axillary line. This drainage incision must be at least one and one-half Inches in length and cleanly incised through all layers of the abdominal wall. A large skin incision and a small opening in the deep layers is inadequate. If all layers are not widely opened* the drains will be strangulated and the drainage function will be defeated. Liver drains should not be brought to the exterior through the laparotomy or thoracotomy incision* since this leads to a higher incidence of wound infections and disrup- tions, A debrided wound tract coinciding with the usual subcostal drainage incision location may be satisfactory. The proper removal of the drains holds as important a place in the treatment of the liver wounds as does their initial placing. The shortening must be gradual beginning usually on the 4th or 5th post- operative day. The drains are out completely, preferably by the 10th to 12th postoperative day* though complete removal should be deferred until drainage has virtually ceased. Frequently such a staged removal of Penrose cigarette drains becomes difficult due to the adherence of the gauze wick to the liver bed. Because the free outer ends will stretch before the inner ends are moved* the sudden "give" following traction or twisting of the drains may withdraw the drains too far; fluid collections are thus likely to become pocketed in the liver region. To obviate such a possibility we use drains in which the ten- dency to stretch has been eliminated. This is done by simply threading surgical tape through the Penrose tubing and anchoring the tubing to it* at intervals of three to four inches* by means of silk suture. Thus* when one withdraws the free outer end of the drain an inch* the inner and is withdrawn a like distance. It is important that the primary method of treatment of the liver wound afford adequate external drainage. If the liver wound is not adequately drained and becomes Infected* a draining sinus may result which will take mazy weeks to close. One rarely encounters a liver wound which is too small to require drainage. It is true that some oases will not drain bile postoperatively but we know of no criteria by which such oases can be selected preoperatively or at operation. The size of the missile is not the all important factor. A small foreign body which outs a main bile passage may be followed by a greater drainage of bile than a superficial liver wound of greater proportions. For this reason* ws feel that all liver wounds should be explored and adequate external drainage established. 319 War Wounda of the Liver« SUMMARY OF FINDINGS 1. A large series of mounds of the liver representing the collective operative experience of the 2nd Auxiliary Surgical Group, for the period 1 January 1944 to 8 May 1945* has beens tudied. 2. In a grand total of 3154 abdominal and thoraoo-abdominal wound oases (3066 records available for this study), 829* or 26.7$ manifested wounds of the liver. The derived data apply only to the period of stay in the forward hospitals where the operation was performed. These liver wounds were found divided almost equally into the abdominal thoraco- abdominal wound categories. 3. Overall mortality rate for wounds of the liver in this series was 27.0$ (Table I). Coincidental wounding of other abdominal viscera was found to be a highly important factor in prognosis. The mortality rate for wounds of the liver in absence of other abdominal visceral injury was only 9.7$ in contrast to a rate of 84.6$ when four or more other abdominal viscera had been wounded also (Table II* Appendix). 4. This study and our personal experience indicate that continued bleeding from liver wounds following operation has not been a potent cause of morbidity and mortality. Bile leakage and liver parenchymal damage appear to have been factors of greater importance. 5. The traditional "pack" for liver wounds has been unnecessary in most oases. Its use has led to serious oompliofcions• 6. Operative exploration of all liver wounds with establishment of adequate external drainage is advocated as the most satisfactory mode of treatment. REFERENCES 1, Office of the Surgeon General Medioal Department of the United States Aray in the World War. Government Printing Office* Washington* DC* 1927* Vol XI* Page 462-463. 2* Bailey* Hamilton: Surgery of Modern Warfare. 2nd Edition Vol 1, Page 414-415, Edinburgh, 1942. 3. Wallace* Sir Cuthbeft: War Surgery of the Abdomen. London, 1913. - quoted in Bailey, (2). 4. Hational Research Counoil: Abdominal and Genito-Urln&zy In- juries. Military Surgical Manuals* III* Page 90-94. W.B. Salidders Co., Pa«* 1942. 5. Burford* Thomas H.t The Bulleting of the DS Aray UD* 98C70-72, June 1945. 320 APPENDIX DATA OH WOUNDS OP LIVER Operated Casas 1944 - 1945 2ND AUXILIARY SURGICAL GROUP TABLE OF CONTENTS I. Wounds of Liver; Comparative Statistics from Two Wars. II. Multiple Organ Involvement. III. Effect of Injury to Certain Other Abdominal Organs on Mortality of Liver Hounds• IV. Locations of Operative V. Principal Causes of Death. VI. Abdominal and Thoracoabdominal Wounds Involving Liver| Comparative Incidence and Mortality. 321 Appendix* TABLE I Wounds of the Liver Comparative Statistics from Two Wars (Restricted to Abdominal Wounds Only) World War I World War II Surg. General Reports (l) Wallace British (3) 2nd Aux Surg Gp 1944 1945 Comb ined 1944 1945 1) Percentage of Abdominal Wounds With Liver Involved 13.3$ 16*8$ 18.5$ 12.6$ 17.1$ 2) Operative Mortality of Liver Wounds 66.2$ 34.0$ 15.1$ 27.9$ Comment: Although the incidence of liver involvement in abdominal wounds for two wars was quite similar, there has been a sharp drop in operative mortality rates in World War II, This comparison is only approximate since the World War I figures may not include some liver wound oases treated without operation, A farther error is introdnoted by the fact that no follow up data are available for World War II mortality rates. 322 TABLE II Multiple Organ Involvement Effect on Mortality Rate of Liver Wounds Combined 1944 1945 1944-1945 Total Liver Wound Cases. 646 183 829 Mortality Rates: I • Overall Mortality 29.8# 16.9% 27,0% 2 Liver (uncomplicated)* 9.8% 9.5% 9.7% ' 2 Liver plus other abdominal organs (combined) 42.7% 23.0% 38.5% a) Liver plus 1 other organ 5 . O) e\j 1 15.2% 26.5% b) Liver plus 2 other organs 43.9% ' 25.7% 59.7% o) Liver plus 3 other organs 60.0% 33.3% ' “ 54.8% d) Liver plus 4 or more otLer organs 90.9% 50.0% 34,6% ♦"Uncomplicated liver wounds" refers to liver wounds uncomplicated by wounds of other abdominal viscera. Coincidental wounds of other por- tions of the bo«fy may be present in such cases. 323 Appendix. TABLE III Effect of Injury bo Certain Other Abdominal Organs On Mortality of Liver Wounds 1944 - 1946 lams of Viscera Mp. of Deaths Deaths Mortality l) Liver Only 339 53 9.7# 2) Liver Plus Stomach-duodenum 84 20 31.3# 5) Liver Pitas Jejunum-ileum 15 2 13.3# 4) Liver Plus Colon 34 11 32.3# 5) Liver Plus Kidney 77 20 26.9# 324 Appendix. TABLE IV Location of Operative Incisions 432 Cases Studied 1944 No. Pet. No. 1945 Pot. Combined 1944 - 1945 No. Pet. Abdominal 172 53.6$ 42 39.3$ 214 47.2$ Thoracic 107 32.6$ 50 46.7$ 157 36.3$ Abdominal and Thoracic 40 12.0$ 14 13.1$ 54 12.5$ "Tho rac o-Laparot aay”* 6 1.9$ 1 0.9$ 7 1.6$ ♦Extension of thoracotomy inoislon across costal arch usually. and into abdomen Comment: Note the Increase In use of the thoracic approach in 1946. 325 Appendix. TABLE 7 Principal Causes of Death Total Deaths - 224 Mortality Rate - 27,0$ 1944 1945 Combined 1944 - 1946 1) Shook 61.8# 48.4# 51.4# 2) Pulmonary Complications 17.7# 12.9# 17.0* «) Peritonitis 12.9# 9.7# 12.5# 4) Renal Failure 8.5# 9.7# 8.6# «L Other Causes 9.3# 19.5# 10.7# Comment: Persistent shock was responsible for approocimately half the deaths despite rigorous anti-shock treatment com- bined with early operation and a minimum of transporta- tion of the case. 326 Appendix* Table VI Incidence Mortality 1944 NO, Pot* 1946 No. Pot. Combined No. Pot, 1944 No. Pot. 1945 No. Pot. Combined No. Pot, Abdominal Wounds 311 48.2# 72 39.5# 383 46.2# 106 54.0# 11 15.1# 117 50.6# Thorao©-Abdominal Wounds 335 51.8# 111 60.7# 446 53.8# 87 25.9# 20 16,2# 107 23.9# Abdominal and Thoraoo-Abdomiml Wounds Involving Liver Comparative Incidence and Mortality TABLE VI Appendix* 327 INJURIES OF THE SPLEEN A review of injuries of the spleen in this series reveals experiences contrasting sharply with those previously reported. An analysis of the 3154 abdominal and thoraco-abdominal injuries managed by th© members of this Auxiliary Surgical Group demonstrates a marked divergence from the very limited reports and opinions concerning battle injuries to this viscus. These differences appear in th© incidence of involvement, the operative approaches employed, the operative findings, the frequency of complicating lesions, the treatment, and the mortality rate. The following table of injuries to th© spleen shows the total number, the number of uncomplicated and complicated oases, and the incidence and mortality of each. TABLE I Number, Incidence and Mortality of Splenic Injuries GROSS TOTALS UNCOMPLICATED CASES COMPLICATE) CASES Inci- Mort. Inoi- Inoi- No. of dence in Rate No. of dence in Mort. No of dense Mort. Cases 3154 eases (gross) Cases 341 oases Rate Cases of oases Rate 341 10.8# 24.9# 100 29.3# 12# 241 70.6# 30.3# In this discussion th© term "complicated” will be reserved to indicate injury to intra-abdominal viscera other than the spleen, whereas "associa- ted” will be used to indicate the presence of concomitant extra-abdominal injuries* INCIDENCE The spleen was involved in a surprisingly large number of in- stances in the total abdominal and thoraco-abdominal wounds included in this report. Among the total 3154 oases, injury to this organ occurred 341 times, an incidence of 10.8#. Reports of wounds incurred by the American Expeditionary Forces in World War I included only 49 in- stances of injury of the spleen. No record of its incidence of injury in the Spanish Civil War is available, but Joily* states that uneom- 328 Injuries of the Spleen. (Incidence, contd) plicated wounds of the spleen are very rare. An estimated incidence of 5.6$ was reported by Bailey3 and only 54 oases were included. reported splenic injuries in three instances of 90 abdominal wounds operated upon in the Alamein Campaign, In the two periods cover- ed by Ogilvie’s3 report on abdominal wounds in the Western Desert in 1942, splenic injury occurred in 29 instances giving an incidence of 4,6$, Jarvis® reported splenic injury occurring 22 times in 346 unsel- ected abdominal wounds that were managed by the members of this Group, giving an incidence of 6,5$ (These oases are not included in this report). The predominant number of the splenic injuries in this series ocox» rred in thoraoo-abdominal injuries. Two hundred fifty-three, or 74,1$ occurred in these as compared to 88, or 25,9$, in abdominal injuries, (See Appendix, Table II), The left diaphragm as reported in the section on "Thoraco-abdominal Wounds” (Pages 566 and59l) was involved in 468 instances in all the thoraoo-abdominal injuries. Thus the spleen was injured in 64$ of the instances that the left diaphragm was involved. CAUSATIVE AGENTS Agents causing injury to the spleen were of the same type and essen- tially the same frequency as those encountered in abdominal injuries in general, (See Appendix, Table III), Blast was recorded as the cause on three occasions. Pour instances of splenic injury wore non-battle in origin. Two of these were incurred in accidental Calls, one in a vehicu- lar accident, and one in a penetrating wound by the metal loop of a cartridge belt. TYPES OF INJURY TO THE SPLEEN The spleen showed all degrees of damage from a small fissure to complete fragmentation of the body, A few instances of penetration of the organ were noted. Severe lacerations, penetrations, or perforations produced essentially the same gross pathology as fractures of the organ, that is, irregular rents in the capsule radiating from the tract of the causative agent. Injury to the splenic pedicle alone occurred eight times and suboapsular hamatoma three. Dividing the injuries into slight, moderate, and severe; 61$ were in the last mentioned classification; 29$ in Idle moderate, and only 9$ in the slight, (See Appendix, Table IV), Active hemorrhage from the injured spleen was encountered at the beginning of abdominal exploration only in rare instances. When it was encountered, it was always from a severely damaged body of the organ or an injury to the pedicle. Active bleeding usually recurred during the handling of the organ at splenectomy. In oases other than those in whi8 A Study of 427 Wounds to the Kidney in 3154 Abdominal and Thoraco- Abdominal War Injuries (Specific Anatomy from the Surgical Viewpoint, Cent*d). POSTERIOR. RELATIONS OF THE KJDNE.V Figure 53 - Posterior Relations of the Kidney The peri-renal adipose tissue may cushion the blow to the kidney from the missile, for it was noted in certain instances, that exten- sive fragmentation of the liver or spleen was accompanied by perfora- tion or segmental destruction of the kidney. 3# A Study of 427 Wounds to the Kidney in 3154 Abdominal and Thoraco- Abdomlnal War Injuries (Specific Anatongr from the Surgical Viewpoint, font'd). INCIDENCE OF INVOLVEMENT OF OTHER ORGANS IN 414 WOUNDS OF KIDNEY Figure 54. - Incidence of Involvement of Other Organs in 414 Wounds of Kidney* additional cases of renal wounding were reported after the chart had been made. The complicating organs Involved make no practi- cal alteration in the chart. 360 A Study of 427 Wouade to the Kidney in 3154- Abdominal and Thoraco- Abdominal War Injuries (Specific Anatomy from the Surgical Viewpoint, Cont*d). Anomalies The possibility of performing nephrectony upon a patient with agenesis of the opposite side was not disregarded despite the fact that cystoscopy or urography were not feasible in forward areas. Every effort was made to distinguish renal shadow by roentgen examin- ation on the uninjured side prior to surgery. Examination of the necropsy records does not reveal any instance of agenesis, fused or horseshoe kidney. Gross Pathology of Renal Wounds Renal wounds may be divided for convenience of discussion into two classes: 1. Those involving the hilum of the kidney, 2. Those involving the parenchyma. Probably most of the wounded who had incurred injury to the major blood vessels of the abdomen, including the renal artery and vein, did not survive to reach surgery. These were sixteen cases in which the renal vessels had been lacerated or severed. Nine died, six were evacuated in good condition within 10 days following surgery. One had no record of disposition. Nephrectomy was performed in each instance. The known mortality was 6Q£. Four patients died within 20 hours following surgery from continued severe shock, one lived 72 hours in severe shock, while another died on the fifth day postopera- tive from peritonitis. In two instances damage to the inferior vena cava complicated the wound to the hilar vessels. One of these involved complete transection of the cava and the patient died during the operation The second required nephrectomy, but involved laceration to the vena cava which could not be sutured. The vena cava was ligated and the patient survived with apparently normal urinary volume. He was evacuated on the ninth day following surgery. There was but one wound to the pelvis recorded in which the vessels were not damaged. Repair of the small laceration was done with one interrupted suture followed by uneventful recovery. Parenchymal wounds varied from neatly drilled holes to complete maceration. There did not appear to be any relation between the type of missile and the character of the wound. The size of the missile and its velocity were, however, directly responsible for the degree of des- truction. There was practically always a certain amount of hematoma 361 A Study of 427 Wound* to the Kidney In 3154 Abdominal and Thoraco- Abdominal War Injuries (Gross Pathology of Renal Wounds, Cont’d), in the perirenal area, but active bleeding from the renal wound at time of surgery was not constant* Tbs wound was usually covered with an irregular clot which was rather firmly adherent to the wound edges* An attempt to dislodge the clot usually resulted in renewed bleeding from the wound surface* Even in the event of destruction of large sections of one or the other of the poles there was bub little active bleeding found at surgery* Although there was frequently communication through the wound into the pelvis of the kidney, attempts to identify urine in the wound or about the kidney met with little success* Cortical hemorrhage frequently separated the tunica fibrosa to considerable extent* This resulted in varying degrees of disturbance of the anatomical relation of the capsule to the cortex* During mobilisation, the finger of the operator often perforated the distended capsule and actually a subcapsular dissection was done* CLINICAL PICTURE Hematuria and location of the wound were the primary indications of damage to renal structures* The presence of gross or microscopic blood in voided or catheterized urine specimens was the greatest single finding in the diagnosis of renal trauma* The uncomplicated renal wound was most often caused by a missile traveling at low velocity* In this case, the fragment was found in the kidney or adjacent to it* At other times, the angle of penetra- tion was such that the kidney alone was wounded* Wounding of the renal parenchyma alone did not always elicit particularly severe general re- action, and shock was commonly absent or of mild nature* The complicated wound presented a such more extensive and varied problem* The signs of wounding to the complicating structures often overshadowed the renal trauma* It was this group of patients that was most commonly seen in forward surgical installations, and comprised the greatest share of kidney injuries* Size of entrance or exit wound is no indication of the extent of wounding to the kidney* It was sometimes possible by careful inspection to detect dispar- ity between the flanks in kidney wounds, but this was almost entirely dependent upon the amount of tissue destruction and hematoma* Bleed- ing from wounds of the flank and loin were in no manner conclusive of 362 A Study of 427 Wounds to the Kidney in 3154 Abdominal and Thoraco- Abdominal War Injuries (Clinical Picture, Cont‘d), hilar damage for the renal parenchyma can bleed vigorously, and intra< peritoneal blood can also escape from a flank wound. We know of no case of worn ding to the kidney in which pain was referred in the classic manner along the course of the ureter to the groin or scrotum. Commonly, pain was referred to the abdomen. DIAGNOSIS Catheterization was almost routinely necessary to recover urine specimens. The bladder must be completely drained in order to rule out hematuria. It was not unusual to note the first portion to be clear, but the last to become grossly colored. This was especially true of patients with a long time interval since wounding. Close inspection of wounds was especially pertinent to the deter- mination of structures involved. Considerable helpful information can be gained if the patient can describe his position at the time of wounding, or the direction from which the missile came. This was especially true in penetrating wounds. There was usually tenderness and guarding of the muscles of the flank to palpation to the extent that deep palpation was difficult. Diagnostic acumen was sorely tried in the complicated wound because of the predominance of intra-abdominal objective signs and symptoms, frequently, the degree of shock was so severe that until resuscita- tion therapy had progressed sufficiently, physical findings by palpa- tion were totally unreliable. In addition, hemoperitoneum or peri- toneal contamination from a perforated hollow viscus caused such muscular guarding of the abdomen that examination was only possible with great care and urging of cooperation from the patient, Cn a veryftw occasions, retroperitoneal hematoma was palpable through the flank and abdomen, Thoraco-abdominal wounds coaqsrised 162 of 427 wounds, or 43,6$ of all the wounds involving the kidney, (Appendix, Table IV), The usual area of penetration was posteriorly and poster©later- ally from the chest into thedjdomen, and frequently involved the costophrenic angle. On the left side of the abdomen, when there was wounding to the thorax associated, the spleen and kidney were both involved 56 times (69,1$). Without thoracic involvement, the spleen and kidney were associated 25 times (30,9$), 363 A Study of 427 Wounds to the Kidney in 3154 Abdominal and Thoraco- Abdorainal 7.'ar Injuries RADIOGRAPH! In forward surgical units, roentgenology was limited to flat plate exposures of film, and fluoroscopy. Stereoscopy and similar refinements were not available, A common error encountered was the limitation of exposure to the abdomen when the wound was in that area. A mild hemothorax was at times missed in physical examination that would have been detected if the lower chest had been included in the projection, or if separate chest film had been made. Retrograde pyelography was not done, cystoscopy is attended with some degree of shock, and this in addition to shock already existent, was felt to further jeopardize the life of the patient. Intravenous urography was not practised. Resuscitation therapy was well standardized in forward areas and differed in wounds to the kidney, in no manner from that for any other wound. OPERATIVE TREATMENT The conservative treatment of renal trauma was carried into oper- ative procedure. Every attempt was made to avoid if at all possible. Damage to the penal vessels, extensive destruction of the parenchyma or widespread fracturing with destruction of the blood supply to segments required nephrectooy. There were 120 nephrectomies performed (Appendix, Table IV) of which there were 16 for reason of wounding to the renal artery and vein. The remainder were done because of extensive parenchymal des- truction, One of the three kidney wounds overlooked died because of continued bleeding from laceration to the renal vein. Seventeen nephrectomies (Appendix Table V) were done in 56 uncomp- licated cases with a mortality of four (23,5$). The complicated renal wounds required nephrectomy 103 times. Death occurred 49 times (44,1$). Shock was the most commonly recorded cause of death. Of the four deaths in uncomplicated renal injury, there was one death from anuria, one died of shock 20 minutes postoperative}y, a third case died on the seventh postoperative day of an anaphylactic shock following 100 cc of Alsever’s solution intravenously. The fourth case died on the fourth postoperative day of ascending nyeli- tis from an associated cord injury. 36h A Study of 427 Wounds to the Kidney in 3154 Abdominal and Thoraco- Abdominal War Injuries (Operative Treatment, cont’d). Hemorrhage from the renal parenchyma -was not always found at time of operation. When it did occur, however, moist packs to the kidney frequently controlled the bleeding. Resection and repair was done on seven kidneys with one death attributed to peritonitis. The procedure was not popular among the surgeons of the Group, and the autopsy finding in the one case may be significant as to the reason resection or suture was not considered favorably. Notation was made that "During the three day interval be- tween surgery and death, the sutures had become buried in the swollen renal parenchyma, while the areas included were dark, and engorged with blood on cut section". Drainage was considered a routine procedure in every operation where wounding occurred. Two hundred eighty-five of the 427 cases were treated by drainage alone. There were but eight instances in which there was no drainage established. The abdominal transperitoneal approach (Appendix, Table VI) was the most commonly employed Incision (60,6%) because of the necessity fbr exposure of the abdominal viscera. The possibility of retro- peritoneal contamination was admitted, but all too frequently this had already come about as a result of the wound, A combination of abdominal and loin incision was not used, chiefly because of the time clement involved. Wounding to the thorax and kidney occurred in 347 instances or of 427 renal wounds, (Appendix Table VII), An analysis of the figures shows that where the wound of the thorax was below the eighth interspace, thoracotony was done in 64 Instances and trans-diaphragmatic entrance made into the abdomen and retro-peritoneal area. We believe this approach to the kidney is convenient and where indicated, is attended by good results. Separate thoracic and abdominal incisions were used in 40 cases, abdominal incision alone in 39, and flank incision three times. One case died of chock after surgery of an overlooked laceration to the left renal vein. Flank or loin incision (12*4£) was the preferable approach in wounding that was limited to the upper quadrant. Exposure was excell- ent, the incision was capable of extension antro-medially for cell- otomy and procedures necessary to the abdominal viscera. A Study of 427 Wounds to the Kidnev in 3154 Abdominal and Thoraco- Abdontinal War Injuries (Operative Treatment, cent ‘d). The flank incision healed by primary intention in practically every instance. However, it is the most favorable area for exterior- ization of the colon. This is the main objection to the incision. 36f> Suture Materiel The routine supply of suture material was quite adequate in all instances with the exception of that suitable for segmental resections and repair of fractures of the parenchyma. The inclusion of ribbon suture in the supply to forward areas would have been an incentive to an even greater conservative attitude and fewer nephrectomies. Drainage Materiel Soft rubber materiel of the Penrose type, with or without wick, afforded adequate drainage and was easily removable. Incisions for drainage iiebrided missile tracts in the flank or loin were employed as drain- age areas for renal wounds* The fact that they were to be used as such in no manner precluded thorough debridement. Some criticism can be directed at the Inadequacy of some stab wounds* Muscular relaxation during anesthesia was deceptive. It was obvious that muscle and fascia had to be widely divided to insure patency after muscle tonus had returned. We believe there is little danger of herniation. Packing Packing of the kidney and renal area with gauze was used in but three instances. There was active renal parenchymal bleeding in but one case. The opinion of surgeons of the Group is that gauze packing, as it is used to control bleeding, could preferably be avoided as far as sur- gery of war wounds is concerned* Because firm pressure is necessary to accomplish hemostasis the gauze is usually packed firmly from renal fascia to the skin level. The immediate consequence is lack of drain- age to an area already potentially, if not actually, infected. The adherent and irritating nature of the materiel may cause bleeding upon its removal. 366 A Study of 427 Wounds to the Kidney in 3154 Abdominal and Thoraco- Abdominal War Injuries. COMPLICATIONS The common complications of renal trauma ares 1* Sepsis 2. Secondary hemorrhage 3* Urinary fistula Sepsis was most commonly associated with perforation of the retro- peritoneal colon. Thorough wound debridement with removal of tissue debris, clothing, free blood, and metallic foreign bodies was necess- ary, in addition to adequate drainage for the control of infection. There were no recorded instances of secondary hemorrhage in the series* The formation of urinary fistula occurred following parenchymal wounding that involved the pelvis. Pocketing of urine due to inadequate drainage was not common, but when it did occur, there was febrile re- action and the general condition failed to improve until adequate drain- age was established. It was not uncommon to note urine on dressings following drainage for renal wounding, but it generally ceased spon- taneously after two to three days. Nephrostomy was not done in any case in the series. POSTOPERATIVE CARE Dressings covering a considerable wound in the flank through which drainage of the renal fossa has been established, generally require several changes of dressings dally. A convenient method was to cover the wound with a few sterile folded gauze sponges reinforcsd by one or two abdominal pads* The dressing was held in place by a large bath towel encircling the abdomen and secured anteriorly with safety pins* Excoriation of the skin by adhesive tape was therefore avoided and the dressings are more easily changed* Drainage material was left in place as long as there was any significant soiling of the dressings, which was usually seven to 10 days. Adequate fluid intake was necessary, and ranged from 2000 to 3000 c*c* daily by mouth or infusion* 367 A Study of 427 Wounds to the Kidney in 3154 Abdominal and Thoraco- Abdominal War Injuries* MORTALITY There were 155 deaths among 427 incidents of wounding involving the kidney, a mortality of 36,3$* Of the 56 wounds to the kidney alone, there were nine deaths (16,7$), The mortality increased in direct proportion to the multiplicity of complicating organs wounded at the same time (Appendix, Table VIII), The incidence of multiple wounding decreased after wounding to the kidney plus one other organ, which constituted the greatest single group. One hundred and twenty (81$) of the deaths from wounds involving the kidney occurred within 72 hours following surgery (Appendix, Table EC), The greater part of these patients had suffered mortal wounds. Their response to shock therapy and surgery was very minimal. Twelve patients died on the operating table. In addition to severe primary and secondary shock, there were other contributory factors such as pulmonary edema (1), far advanced generalized peritonitis (2), anuria (2), ascending nyelitis (1), There were 28 deaths (18.6%) occurring after the second post- operative day. The severity of wounds, shock from hemorrhage, peri- toneal contamination, and pulmonary association are the particular reasons for early deaths. 1, A study was made of 427 wounds to the kicbiey found among 3154 abdominal and thoraco-abdominal wounds. 2, There were 56 wounds involving the kidney alone of which nine died, a mortality of 16$, 3, Three hundred and seventy-one (86,8$) of the renal wounds were complicated by wounds to other organs, Che hundred and sixty-two of these wounds involved the thorax, 4, Renal vascular injuries accounted for sixteen wounds. Nine of these cases died, 5, The principle of treatment was conservatism and drainage wherever possible, 6, The use of gauze packing to the kidney was not favored, 7, Nephrectomy was performed 120 times, or in 28,1$ of all the wounds. The mortality was 44*1$* SUMMARY 368 A Study of 42? Wounds to the Kidney in 3154 Abdominal and Thoraco- Abdominal War Injuries (Summary, cont*d), S, An abdominal incision was employed 255 times (60,6$), thoracic approach ID? (25*2$), and flank or loin incision 52 (12,1$), There was no record of the incision in seven cases, 9, Thoracotomy was the most frequently used incision in dealing with renal wounds involving the thorax. The mortality was lower (23,4$) than with any of the other incisions employed, ID, There were 155 deaths (36,3$) in 42? wounds. Eighty-one per cent (120) of the deaths occurred before the end of the second post- operative day. 369 A Study of 427 Wounds to the Kidney in 3154 Abdominal and Thoraco- AbdominaJL War Injuries. APPENDIX TAB IE I Incidence of Renal Involvement in 3154 Cases GROSS TOTALS UNCOMPLICATED CASES COMPLICATED CASES Incidence No. in 3154 gases gases Morta- lity Rate NO* gases Inc id- Uorta- ence lity MO. oases Incid- ence Morta- lity 427 13.4? 56 33.1* 9 86.8* 146 TABLE II Comparative Incidence of Previous Studies Authority Total Abdominal Wounds Total Renal Wounds Per cent Young* 23 ?5 !2? 5.4 ... Wallace* % 73 M Joll^ 2?8 ""l9 8t8 Present Series 3M— TABLE III Incidence of Types of Missiles Wounding the Kidney in 427 Cases Fragmentation* Gunshot Wounds Others and Not recorded il5 2$~ 66.5* ♦Includes aerial bombs, artillery and mortar shells, grenades of all types, and land mines. 370 A Study of 427 Wounds to the Kidney in 3154 Abdominal and Thoraco- Abdominal War Injuries (Appendix, cont'd). TAB IE IV Surgical Procedures in Treatment . of 427 Renal Wounds Surgical Procedure Drained Onljjr Number 12^ Per cent 4-f Nephreclony ip No Treatment" l.i Resection or Suture T" Packed 3 Overlooked 3 .8 Capsulotoiqy 1 .2 TOTAL 421 loo.o" TABLE V Nephrectonjy in 427 Cases GROSS TOTALS UNCOMPLICATED CASES COMPLICATED CASES Incidence Morta- Morta- Morta- No. in 427 lity No. Incid- lity No. Incid- lity Q§as& Saasa. Rate Cases enco . gate,,. Cwm ansa— Rate 427 120 IA.U 56 17 23,5* 371 103 TABLE VI Anatomic Distribution of Incisions in 427 Wounds involving the Kidney ♦Abdominal Thoracic Flank No record Kidney ■—25r~ “W" ~5r 7 Kidney and Ureter i 1 Per cent of Total &0.6 25.2 1.6 ♦ Includes midline muscle splitting or retracting and anterior subcostal. 371 A Study of 427 Wounds to the Kidney in 3154 Abdominal and Thoraco- Abdominal War Injuries (Appendix, cont»d). TABLE VII Incidence of Thoraco-Abdominal Wounds Involving the Kidney and Incisions Employed Thora- Total cotomv Thoraco and Abdominal flbdnminal Flank Overlooked Number U7 . 64 40 39 3 1 Mortality “St" . 35 20. - -10 _ . X 1 Per Cent Mortality 23 .U 50.0 76.9 33.3 100. TABLE VIII Relative Increase in Mortality With Additional Complicating Wounds to Other Organs Number Involved Times Involved Kidney Only 56 _£JL 172 ~nr 105 JL-. 47 24 Number of Deaths 9 __ 41 _ 38 30 19 Per Cent Mortality 16.0 23.6 36.1 63.8 79.1 Eight cases involving five and six organs complicating were deleted because their number was too small to be significant. Four cases also deleted because of unreliable recording. TABLE H 371 Complicated Renal Wounds Relative Frequency of Death within 72 hours of Operation M*. of Deaths Percent of all Deaths Death Within 72 Hours Postoperative^ 120 81.6 Death After 72 Hours Postoperatiyely _ _2£ 18 .i TOTAL M3L 100.0 372 A Study of 427 Wounds to the Kidney In 3354 Abdominal and Thoraco- Abdominal War Injuries (Appendix, cont»d)• • BIBLIOGRAPHT 1, The Medical Department of the United States Amy in the World War, Vol, XI, Part 1, pp 4-70-476, Washington, Government Print- ing Office. 1927, 2, Jolly, D.W.: Field Surgery in Total War. pp 21S-223, New York. Paul B, Hoeber, 1941, 3, Young (quoted by Jolly^), 4* Wallace (quoted by Jblly^), 5. Bailey, Hamilton: Surgery of Modern Warfare. Vol. I., Chapter TLT7, pp 437-442. Edinburgh. E & S Livingstone, 6. Braasch, W.F.: Preliminary Survey of the Diagnosis of War In- juries of the Genitourinary Tract In General. In Military Surgical Manuals III: Abdominal and Genito-urinary Injuries, pp 135-148. Phila. W.B. Saunders Co. 1942. 7. Scholl, A.J«s Injuries of the Kidney and Ureter, ibid. pp 149-172, 373 PERTINENT DATA IN 27 WOUNDS TO THE URETER AMONG 3154 ABDOMINAL CASES Four 7/ounds to the ureter were reported in the records of the Office of theSurgeon General following World War I. The present study of 3154 wounds involving the abdomen revealed 27 incidents of ureteral trauma* TABLE I Incidence of Ureteral Involvement in 3154 Abdominal Wounds GROSS TOTAL COMPLICATED CASES UNCOMPLICATED CASES Incidence Percent Percent Total in 3154 Morta- Inci- Morta- Inci- Morta- Cases Cases Hty dence Deaths lity dence Deaths lity 27 0.836 40.7* 26 11 42.3* • H* i - i I O ■ O With one exception every wound to the ureter was complicated by wounding to other abdominal structures. The single uncomplicated wound was from a fragment which caused a small laceration of the upper ureter without any other injury. 374 Pertinent Data in 27 Wounds to the Ureter Among 3154 Abdominal Cases, INCIDENCE OF INVOLVEMENT OF OTHEB ORGANS IN 27 WOUNDS OF URETER figure 55 - Incidence of Involvement of Other Organa In 27 Wounds of Ureter TAB IE II Frequency of Wounds to Other Organs Complicating Injuries to the Ureter Organs Complicailng Incidence Small Intestine.• Large Intestine jfirtflfip, 6 1,1 VAT , . , . . . . •**».*****... ......... a. . . 6 ftl dn*»y. TVnorfafjiim . , . . 4 Major Abdominal Blood Vessels Stomach . * . 375 pertinent Data in 27 Wounds to the Ureter Among 3154 Abdominal Cases. Of the complicating injuries involving the ureter, that to the small intestine was the most common, this.organ being involved 21 times* (Figure 55). The large intestine was wounded 18 tines* Wounding to these two represented more than one half of the cduplicating wounds* The incidence of involvement of other abdominal structures dropped markedly. Injuries to major blood vessels of the abdomen occurred in four instances with ureteral wounds* There were two deaths among the four* One died 48 hours after surgery from multiple pulmonary and coronary eaboli from the inferior mesenteric vein* The other died on the seventh postoperative day of generalised peritonitis* The ureteral repair had not broken down* None of these injuries involved a vessel larger than the internal iliac vein* There were no anomolies of the ureter found at operation or post- mortem* The diagnosis of ureteral involvement in abdominal wounds is not easily made preoperatively. There was record of but three Instances of hematuria where the bladder or kidney were not involved* The diagnosis was made in practically every instance through exploration of the wound* We have not been able to diagnose ureteral wound by the detection of the presence of urine on dressings or in the wound* cystoscopy and intravenous urography were not used* TABUS m Operative Procedures Employed In 27 Ureteral Wounds Operative Treatment vesicle Transplant Number 1 Nephrectomy 5 Telescoping Anastomosis 4 ligation Both Ends of Ureter 3 Suture of Laceration 2 End-to-En'd Ureieroanastomosis 2 Brained Orly 2 Overlooked 2 Cutaneous Ureterostomy T"“ TOTAL 2Z Operative treatment of these eases was extremely varied, Reim- plaaatatlon into the bladder was done six tines. One of the six separated on the third postoperative day and was successfully re-oper- ated upon. In five instances, nephrectomy sas done because of severe renal injury. Telescoping uretereasastooosis efts performed on four 376 Pertinent Data in 27 Wounds to the Ureter Among 3154 Abdominal Cases* occasions. Three were successful* End-to-end ureter©anastomosis was done without ureteral catheterization or nephrostomy in two instances* Both patients died of shock within 48 hoursfrom mortal wounds* Two lacerations were successfully sutured* Cutaneous ureterostomy was done on one occasion* Destruction of a considerable segment did not permit repair and the condition of the patient did not warrant extension of operating time to perform nephrostomy* Two instances of drainage to suspected ureteral damage were found* One of these was in a ease where the ureteral laceration was not dis- covered until necropsy* There were two recorded Instances of overlooked ureteral damage* Both cases failed to survive* The lacerations were cited as contrib- utory causes to death* It was an accepted practice among surgeons of this Group to expos# the ureter whenever the missile had passed along its course* Ligation, of the ureter in transecting wounds with destruction over same distance was done on three occasions* In but one case was there complicating renal damage* The mortality rate among 27 ureteralwounds was 40*7$* How much the two overlooked incidents contributed toward the death of the patients was not clearly stated* However, we can presume they played an extensive contributing if not a principal role* Nephrostomy or ureterosigmoidostocy was not done la any of the wounds of this series* Ureteral catheters were not included in supply to for- ward surgical installations • Had they been supplied they might have stimulated more extensive surgery to the ureter with better results* Black silk was the suture of choice in all uretsro-anastomoses, while chromic catgut was used in the -vesicle re-implantations« Eight of the deaths (72*750 occurred within 72 hours of wounding from shock* SUWIART 1* A study was made of 27 instances of ureteral sounds among 3154 abdominal oases* 2* The small and large intestine constituted mors than 50% of the complicating wounds* 3* There was but one instance of uncomplicated ureteral wound* 4* Reimplantation into the bladder, telescoping anastomosis, and 377 Pertinent Data in 27 Wounds to the Ureter Among 3154 Abdominal Cases (Sunnary, cont'd) suture of lacerations were performed six, four, and two times, respect* truly. 5, There were 11 deaths among the 27 cases with a mortality rate of 4'0.?£« REFERENCES !• A Study of 427 Wounds to the Kidney in 3154 Abdominal and Thorac©-abdominal War Injuries, (page 356of this Report), 378 WOUNDS 0? THE URINARY BLADDER An Analysis of 155 Gases, In the period 1 January 194/- to 8 May 1945, the surgical teams of the 2nd Auxiliary Surgical Group, functioning in Italy, France, and Germany, operated on 3154 wounded individuals having abdominal pathol- ogy. One hundred fifty-five of these had bladder lesions. There were 19 additional cases with bladder lesions operated on in the period 8 November 194? to 31 December 1943, but these are not included in this report because insufficient data are available on these early cases of the African and Sicilian Campaigns. These 155 cases were operated on by approximately 39 different teams. The diagnosis of a bladder lesion is not difficult. The path of the missile, as determined from an alignment of the wounds of entrance and exit, or from the wound of entrance and the location of the foreign body as seen on the X-ray film, indicates whether the bladder may have been involved. Fractures of the bony pelvis merit investigation, and in the occasional case, pressure or blast will damage the bladder. In this series of cases the most frequent sites of entry of the missile were through the buttocks (56 times) and anterior abdominal wall (56 times). Other sites of entry were through the thigh, hip, perineum, back and flank. Approximately one third of the cases had wounds of exit, the missile having left the body. The missile was retained in the other two-thirds. There is nothing characteristic in the abdominal physical findings. Tenderness, rigidity and peristalsis depend to a large mea- sure on the complicating intra-abdominal lesions and the amount of in- tra-abdominal or retroperitoneal hemorrhage. The presence of a urinary fistula indicates damage to some portion of the genito-urinary tract as does hematuria. Clear, normal urine does not eliminate bladder damage. Rive of these 155 cases with lesions of the bladder had no blood in the urine. Six cases had a urinary fistula before operation. Filling the bladder with some solution prior to surgery for diagnositic purposes is not recommended. More contaminated material may be forced into the peri- toneal cavity, but more important, extravasation of infected fluid may occur retro- and infraperitoneally. Most of these cases had other ab- dominal lesions reouiring laparotomy, so it was thought preferable to v/ait until the abdomen was opened before instilling saline through a urethral catheter. This procedure was not' employed by all surgeons. In these 155 cases, the correct diagnosis was made preoperatively or at surgery 149 times. Six cases were overlooted: Two of these died the first postoperative day and the bladder wounds were found at autopsy. Three of the six developed urinary fistula (thigh, abdominal wound, and rectal) and were later subjected to cystostomy with satisfactory results. In the sixth overlooked case, bladder injury was suspected, but could not be demonstrated at operation. An indwelling catheter was left in the bladder for six days postoperatively. Following removal of the catheter, a small foreign body was passed by urethra. Recovery was un- eventful. 379 Wounds of the Urinary Bladder (contd) In considering mortality in bladder wounds, it is necessary to realize the high incidence of complicating intestinal pathology. One hundred and thirty-four of the 155 cases (88$) had bowel lesions.in ad- dition to the bladder damage. In these cases, the gastro-intestinal tract injuries merited and received primary consideration. Even in some which did not involve the bowel, hemorrhage from the pelvic blood vessel was of more serious import than the bladder injury, and certainly pre- sented a greater'technical problem. All deaths which occurred in cases with bladder damage were complicated by intestinal injury. The mortal- ity rate in cases having bladder leions deoends mainly on how much bowel damage co-exists, (Table I and Table II) There were no deaths in cases with uncomplicated bladder wounds. This seems to indicate that uncom- plicated bladder lacerations which are operated on promptly are not life-threatening, but it is significant that a multiplicity lesions increases mortality. The mortality rate for 353 cases with only small bowel lesions operated upon by this Auxiliary Surgical Group was 14$. If the bladder was involved along with small bowel (40 cases) the mor- tality rate was 22$. Similarly the percentage mortality for 251 cases with only colon lesions was 23$. For colon and bladder lesions co- existing it was 43$. TABLE I Percentage Mortality in Wounds of the Bladder With and Without Complicating Bowel Lesions Total cases with bladder lesions No. Cases 155 Deaths 46 Mortality 30$ Bladder lesions with complicating bowel lesions 134* 46 34$ Bladder lesions without complicating bowel lesions, 21 0 0% * 55 of these 134 Involved rectum TABLE II Percentage Mortality in Wounds of the Bladder with Complicating Bowel Lesions Location of Bowel Wound No. Cases Deaths Mortality Bxtraperitoneal Rectum only 6 1 17% Intraperitoneal Rectum only 17 3 18^ Small Bowel only 40 9 22% Colon only (excludes rectum) 2 9 43% Both Large and Small Bowel ”55" 2A ' u&i 380 Wounds of the Urinary Bladder (contd) The shock-mortality relationship followed the usual pattern. The greater the degree of shock on admission to the hospital, the higher was the mortality rate (mortality rate: no shock; 25'4 moderate shock and 63% severe shock). Thirty-five cases were wounded by gunshot with a mortality of 34%• Seventy-one cases were wounded by shell fragment with a mortality of 32%. There were three cases of bladder injury classified as due to blunt trauma, with no deaths. In 46 cases the agent causing injury was not recorded. One hundred and thirty-seven of the 155 cases had an intrapcriton- eal laceration of the bladder. Nine cases had only an extraperitoneal laceration and none of these died. Nine cases had a severe contusion without a laceration. These last nine all had serious other intra-ab- dominal lesions and three of them died. Surgical procedures carried out for bladder wounds varied very lit- tle, One hundred and ten cases had suprapubic cystostomy with repair of the laceration; 13 cases had suprapubic cystostomy without repair; six cases had repair without any other procedure; three cases had an indwelling urethral catheter placed; six cases were overlooked; seven cases died on the operating table. There are no data available con- cerning the type of.surgery done on 10 cases. Repair of the lacera- tion with suprapubic cystostomy was the procedure of choice. The abdo- men was opened to explore and repair what other intraperitoneal injury was present |nd the intraperitoneal bladder was thus easily inspected and repaired. After closing the peritoneum and in doing the suprapubic cystostomy, the extraperitoneal portion of the bladder was inspected and repaired. The space of Retains was routinely drained. In this ser- ies, sulfonamides were occasionally used in the abdomen or wound and in the later cases, penicillin was at times used intra-abdominally. Post- operativcly, all patients received sulfonamides orally or intravenously, penicillin' intramuscularly, or both. Three of the nine natients with severe bladder contusions were treated by suprapubic cystostomy (one died) and six received no bladder treatment (two died). The 109 living cases were followed for from one to 20 days, de- pending on the tactical situation. Only 25 cases were followed less that five days. There were 17 postoperative complications (Table III) but there was no infection of the paravesicular tissue in any case that lived. There was one retroperitoneal cellulitis in a case that died. The.46 deaths are analyzed in Table IV. All deaths occurred in cases which had complicating bowel lesions. Early deaths were largely due to shock. Chest complications, urinary suppression, and peritonitis were important as principal causes of death after the third postoper- ative day. There were three deaths due to gas gangrene of extensive as- sociated wounds. 381 Wounds of the Urinary Bladder (contd) TABLE III Postoperative Complications, 109 Surviving Cases with Bladder Lesions (17 Complications) Atelectasis Secondary Hemorrhage , , . . 1 Pneumonia Pyelitis , . . 1 Cardiac Failure .... . . . 1 Epididymitis . 1 Fever, unspecified . . . . . 1 Infected Laparotomy Wounds 3 Fecal Fistula (one later eviscerated) Urinarv Fistula .... . . . 1 Subphrenic Abscess .... Abscess, unspecified . . . . 1 , 1 TABLE IV Analysis of Deaths by Day and Causes Day of Death C a uses Total Un- known Mi sc* Shock Peri- Chest tonitis Comp- lica- tions An- uria Em- bolism Operation 1 U 9 1 1 16 1st Postoperative 2 1 3 2nd " 1 4 3 2 1 11 3rd " 1 1 1 1 1 5 4.th " 1 1 1 2 1 6 5th « 1 1 6th-8th " 1 1 1 1 L Totals 4 7 _15 7 __5 4 L Ub * Miscellaneous deaths: 3 gas gangrene; 2 anesthesia (not definite); 1 heart lesion; 1 retroperitoneal cellulitis. SUP.il/IARY Data are presented on 155 cases of bladder lesions incurred as war wounds. The physical findings, shock-mortality relationship and wound- ing agents are presented. The significance of hematuria is discussed but cases are listed in which bladder lesions occurred without any blood being present in the urine The high incidence of complicating intestinal pathology is shown All deaths occurred in cases which had bowlel lesions in addition to the bladder wound. None of the patients with bladder lesion uncomplicated 382 Wounds of the Urinary Bladder (contd) by a bowel lesion died, indicating that bladder lesions, promptly oper- ated up, are not necessarily life-threatening. It is shown that the mortality rate for small and large bowel lesions is considerably raised by having a complicating bladder injury, indicating the grave signifi- cance of a multiplicity of lesions. The threatment of choice has been the establishment of bladder drainage by a suprapubic cystostomy with repair of the laceration. The space of Retzius was routinely drained end sulfonamide and/or penicillin were used both locally and systemic- ally. Only one case developed postoperative paravesicular infection. The complications and principal causes of death which are presented, are more related to the complicating bowel lesions than to the urinary track. 383 WOUNDS OF THE URETHRA In the period B November 1942 to B May 1945 there were 43 urethral lacerations operated oc by the teams of the 2nd Auxiliary Surgical Group, Most of these 43 had other serious lesions or they would not have been oared for by this Group* In 10 of these 43, the bladder Kss also perforated* It is not difficult to diagnose a lacerated urethra* Wounds of the penis, scrotum or perineum are to be especially suspected of having co-existent urethral tears* Bleeding from the penis or blood in the first portion of the urine are frequent finding 9* The inability of the wounded to urinate associated with difficulty In passing a urethral catheter indicates a urethral lesion* Siaultaneous rectal palpation and the passage of a urethral catheter may give valuable diagnostic information* In the 43 recorded cases of urethral wounds, there were eiz deaths* All these six had serious other complicating wounds as follows 1« lacerated rectum, tucking thoracic wounds* 2* Bilateral sucking thoracic wounds* 3, lacerations, email and large bowel* 4* Hemorrhage left common Iliac artery and rein. 5« Laceration email and large bowel* 6. Extensive multiple soft tissue wounds. Primary treatment of urethral wounds has been satisfactorily accomplished by the establishment of bladder drainage through a supra- pubic eystostooy* The placement of an indwelling urethral catheter oan usually be accomplished when the bladder is opened, by simultan- eous manipulation from above and below* If this can bo accomplished at the primary operation, any necessary secondary procedures are mads easier* Suture of the urethra was seldom done (five times), the em- ployment of a catheter splint usually being considered satisfactory* Thirty-five of the 43 cases were treated by suprapubic eystostooy and in IS of these, an indwelling urethral catheter was also placed* The other eight eases were treated only by an indwelling catheter* SWART Relatively few urethral wounds were treated by teams of the 2nd Ancillary Surgical Group, for unless they had ether sedcus lesions they did not come to units at which this group functioned. The six deaths in the 43 treated cases can all be attributed to other serious lesions* Diagnosis of urethral tears is not difficult and depends on -.wound location, bleeding from tbs penis, and the ease with which a 384 Wounds of the Urethra (Stannary, cont'd). urethral catheter can be passed. Treatment is best accomplished by a suprapubic cystostony and the passage of an indwelling urethral cath- eter to act as a splint during healing* It has occasionally been deemed necessary to suture the urethra (five cases only of these 43)• 385 ABDuLINAL VASCULAR INJURIES In the 3l5h abdominal and thoraco-abdominal cases operated upon by the 2nd. Auxiliary Surgical G’oup in the years IdiiU and 19U5? 75 cases were encountered in Field Hospitals in which one or more great vessels of the abdomen were injured. This report is based on a statis- tical analysis and appraisal of these 75 cases, There are instances of other intra-abdominal vascular injuries such as severance of a colic artery, a splenic artery, or a renal pedicle, which have been purposely omitted from this report. These visceral vascular lesions have been delegated to the sections dealing with injury to those abdominal organs. Only injuries to the great vessels have been con- sidered. Table I Incidence of Vascular Injuries of the Abdomen Total No. of cases lived Lied Mortality I. Vein Injury (Single Vein) 38 11 27 715 II. Combination Two or more Veins 8 1 7 67.53 III. Combination Vein and Vis- ceral Vascular Lesion 7 0 7 1003 TV. Arterial Injuries 13 5 8 62.03 V. Combination Artery and Vein 9 3 6 66.6,3 Total Great Vessel Injuries = 75 lived 20 = 273 Tied 55 - 733 The inferior vena cava, common, internal, and external iliac veins, and portal vein comprise the vein injuries. The common, internal, and external iliac arteries make up the group of arterial injuries, while these same vessels with their corresponding veins make up the combination artery and vein injuries. No instances of injury to the abdominal aorta survived to have sur- gery in the field Hospital. 386 Abdominal Vascular Injuries (contd) TABLE II Relation of Clinical Shock at the time of Admission to Field Hospital to mortality 4 / Shock No. Cases . 39 Lived 6 Died 33 Percent Mortality 85$ 3 / Shock 8 2 6 75* " 2 / Shock ~lT~ 6 10 62.5$ 1 / Shock 2 1 1 50^ No Shock 4 2 2 50$ . Not Recorded 6 4 2 33.3* Inasmuch as the blood pressure and pulse on admission to the Field Hospital were not recorded in many of these cases, we have related the mortality to the degree of clinical shock. The latter was often a more accurate index to the degree of shock than the blood pressure alone. It represents the surgeon’s impression of the severity of shock taking into account these factors; (l) general appearance of the patient (2) blood pressure (3) rate and quality of the pulse. Very severe shock (usually with no blood pressure or pulse obtainable) was classified as 4/j moderate' ly severe shock was 3/; moderate shock as mild shock as l/, A perusal of the above table (Table II) indicates that the mortality is directly parallel to the severity of shock on admission. TABLE III Causes of Death in 5$ Cases No. Cases Percent Hemorrhage and Shock 21._ 492 Anurj„a 12 22^ Pulmonary Embolism 4 Pneumonia 3 1&% Pulmonary Edema 3 Peritonitis 2 Gas Infection (Extremities) 2 11% Retroperitoneal Suppuration 1 Cause Unrecorded 1 Relation of Time-Lag to Mortality The time-lag as we have considered it is the time elapsing from the time of injury until the time of surgery. We arbitrarily divided it into six hour periods. The majority of patients received surgical treatment within 12 hours of injury, N0 significant data otherwise were obtained by this study. 3S7 Abdominal Vascular Injuries (contd) Multiplicity Factor in Mortality Table 17-shows a computation of the mortality rate without any abdominal viscus being injured, and also in conjunction with injury to one, two, three, four and five organs. The mortality rate is higher where no abdominal viscera are involved than where one organ is injured. Otter than for this one discrepancy, there is a gradual rise in mortality rate with the increase in number of ab- dominal organs injured. In a comparison of the multiplicity factor* for abdominal cases in general with these 75 abdominal cases having an injury to one or more great vessels, it can be seen that the greatest factor in the consistently high mortality rate of the latter group is the injury to the great vessel itself. 388 Abdominal Vascular Injuries cont'd. Table IV Multiplicity Factor in Mortality (75 Cases) in Wounds of the Great Vessels of the Abdomen Total Lived Died Mortality * Total Mortality * Total Cases No organ 8 3 . 5 62.5/6 9.1* 10.6* One organ 22 10 12 54.5* 21.8* 29.3* Two organs 21 4_ 17 81* 30.9* 28.0* Three organs 13 2 11 84.6* 20* 17.3* Four organs 1 0 1 10085 1.8* 1.3* Five organs 2 0 2 100? 3.6* 2.6* No record 8 1 7 87.5* 12.7* 10.6* Total 75 20 55 . . 73* . 100* . All Table V Table Showing Comparison of Multiplicity Factor for Abdominal Cases in General and 75 Abdominal Cases with Great Vessel Injury. All Abdominal Cases Mortality % Abdominal Cases with Great Vessel In.iury Mortality t One orean 12£ 5A.5% Two oreans 26.6?. BU Three oreans .. m BLM Four oreans 60.6j£ 10Q? Five oreans S3.36 100? Group I. Injuries of the Great Veins of the Abdomen. Injury to a single great vein of the abdomen occurred in 38 cases. For statistical study, we have divided these great vein injuries into two groups: (1) inferior venae cavae alone, and (2) veins other than in- ferior venae cavae. 389 Abdominal Vascular Injuries cont'd. Table VI Surgical Management of Great Vein Injuries A. Inferior Venae Cavae Alone; 22 Cases Furglcal Management No. of Cases Lived £ied Vein ligation 12 .3 . . 9 Vein suture 6 2 U Vein clamped tangentially 1 0 1 Vein uncontrolled 3 0 3 Total 22 5 17 Total Cases Died - 17 - TH> Total Cases Lived - 5 - 2% B. Great Veins Other Than Venae Cavae. - 16 Cases No. of Surgical Cases Management Lived Died Common-lilac 6 Ligation .5, Packed 1 2 K Internal lilac 5 Ligation 2 1 1 Fxternal lilac 5 Ligation 5 3 2 Portal vein 2 Uncontrolled 1 Packed 1 0 2 Total Cases Died - 10 - 62.5% Total Cases Lived - 6 - 37.5% 390 Abdominal Vascular Injuries cont'd. Table VII Group II. Combination of Injuries to Two or More Great Veins - Eight Cases Inferior Vena Gnva Involved five times - one case lived - four cases died Surgical No. of Cases Management Lived Died Inferior Vena cava Common iliac vein 3 Ligated 1 Sutured 1 Uncontrol- led - 1 0 1 0 1 0 1 Inferior vena cava Portal vein Hepatic artery 1 Uncontrol- led - 1 0 1 Inferior vena cava Both common iliac veins Right internal iliac vein 1 Ligation 0 1 Left common iliac vein Left internal iliac vein 1 Ligation 0 1 Right common iliac vein Right internal iliac vein 1 Ligation 0 1 Right external iliac vein Right internal iliac vein 1 Ligation 0 1 Total - 8 Cases Total Lived - 1 - Total Died - 7 - 87^ Table VIII Group III. Combination Great Vein Injury and Visceral Vascular Lesion Total No. of Cases - 7. All 7 Cases died. Mortality - 100$ 3 Cases - Inferior vena cava and right renal pedicle: 1 case - Inferior vena cava sutured and right nephrectomy. 1 case - Inferior vena cava ligated and right nephrectomy 1 case - Inferior vena cava uncontrolled and right renal pedicle uncontrolled. 391 Abdominal Vascular Injuries Table VIII cont’d. 1 Casp - Inferior vena cava plus right gastric artery and vein; inferior vena cava, uncontrolled; gastric artery and vein ligated. 1 Case - Inferior vena cava (spontaneous thrombosis) and hepatic artery ligated. 1 Case - Inferior vena cava (ligated) plus superior messentric artery sutured. 1 Case - Portal vein and hepatic artery (packed). Table IX luminary of All Vena Cava Injuries A. No. of Inferior e Women) vena cava alone (single vascular injury of cases 22 Inferior vena cava plus other great vein injuries 3 Inferior vena cava plus visceral vascular injuries 6 Total vena cava injuries - 33-Lived 6 (13$) - Died 27 - (82£). B. Surgical Management of 33 Inferior Vena Cava Injuries No. of Cases Lived £led Ligation 16 3 13 Future 8 3 _5 Tangential Clamping 1 0 i Spontaneous Thrombosis 1 0 i Uncontrolled 7 0 7 Surgical management of the six cases that survived to be evacuated from the Field Hospital; Vessel Sutured - 3 cases - below renal veins Vessel Ligated - 3 cases - below renal veins In two cases, one of which eventually died of massive pulmonary embolism, swelling of the lower extremities was noted. In the latter case the inferior vena cava had been sutured, - not ligated. 392 Abdominal Vascular Injuries, Table IX cont’d. In two cases distention of the veins of the lower extremities was noted, following ligation of the vena cava in one and suture in another. In the latter esse, spontaneous thrombosis probably occurred subsequent- ly at the site of injury and repair. No case in which the inferior vena cava was ligated or sutured above the renal vessels survived. There were eight of these cases, six of which were handled by ligation, one by suture, and one by tangential clamping. Table X Group IV. Arterial Injuries (alone') - 13 Cases A. Tabulation of 13 Arterial Injuries in Relation to Mortality No. of Cases Lived ided External iliac artery 6 2 _A Internal iliac artery 3 1 o < Common iliac artery 2 2 Total arterial injuries alone - 13 Lived - 5 cases - 386 Died - 8 cases - 626 B. Surgical Management of Arterial Injuries No. of Vessel Vessel cases Liaation Lived Died Suture Lived pied External iliac artery 6 5 1 4 1 1 0 Internal iliac artery 3 ... 3 1 2 0 0 0 Common iliac artery , k.. 2 0 2 2 2 0 Total 13 10 2 B 3 3 0 C. Summary of Surgical Management in Relation to Mortality. No. of Cases Lived £ied Arterial injuries lifted 10 2 8 Arterial injuries sutured 2 0 In two cases with injury to the external ilisc artery which re- quired ligation, the external iliac vein was electively ligated. One of these cases developed vascular insufficiency of the corresponding lower extremity, necessitating amputation, while one did not. 393 Abdominal Vascular Injuries, Table X ccnt'd. Vascular insufficiency of the lower extremities occurred in three out of these 13 cases, in all instances following vessel ligation. (I) External iliac artery injury and vein ligated) Leg demarcating at mid-calf when patient died on 3rd P.0, day of anuria and overlooked retroperi- toneal injury of the cecum. External iliac artery injury artery only ligated) Amputation necessary left mid-thigh on 7th P.0, day because of gangrene due to arterial insuf- ficiency plus gas gangrne of the extremity. (3) Common iliac artery injury t,artery end vein ligated) Amputation subsequently necessary in thigh on corresponding side. Patient eventually died of gas infection in this stump. Groiip V. Combination Artery and Vein Injuries - 9 cases. The-combined injury of a great artery and a great vein occurred in nine cases and in all instances involved corresponding iliac vessels in the pelvis. Table XI A. Tabulation of Nine Combined Artery and Vein Injuries in Relation to Mortality. External iliac artery and vein No. of Cases 2 Lived 1 Died 1 Internal iliac artery and vein 6 2 4 Common iliac artery and vein 1 0 1 Lived - 3 cases - 33 •% Died - 6 cases - 66. In nine combined artery and vein^injuries, eight cases had vessel ligation while' one case was handled‘by clamping only. 394 Aboominal Vascular Injuries, Table XI cont'd. B. Surgical Management of Combined Artery and Vein Lesions No. of Vessel Vessel Cases Li gation Lived Died Clamped Lived Died External iliac artery and vein 2 2 1 1 Internal iliac artery and vein 6 5 2 3 10 1 Common iliac artery and vein 1 1 0 1 Total Vessels clamped - 1 Died - 1 Total Vessels ligated - 8 Died - 5 Lived - 3 Vascular insufficiency of the corresponding lower extremity occurred in two of these nine cases with combined artery end vein injury. (1) Injury to left external and internal iliac veins and left in- ternal iliac artery. (All vessels ligated). Left leg mottled and cold 12 hours postoperatively. Patient died 4-0 hours postoperatively in shock from severe periton- itis before amputation of extremity was necessary. (2) Injury to the left common iliac artery and vein (both vessels ligated). Developed gangrene of left lower extremity and required ampu- tation of left thigh on 4th P.0, day. COMENT It has been pointed out that the frequency of injury to any abdom- inal viscus is directly proportional to the space occupied by that viscus, Page 93 • Reasoning along these lines, it is obvious that injury to the corresponding great arteries and veins should occur with approximately the same frecuency inasmuch as these vessels approximate each other in size. A review of our 75 cases with injury to one or more great vessels of the abdomen shows that 53 cases (776) involved one or more veins, whereas 22 cases {2%) were arterial injuries alone, or associated with injury to the corresponding vein. This is not a dis- parity in incidence of injury between arteries and veins, but, rather, a disparity in lethality between the two. Fewer arterial injuries sur- vived to have surgical treatment in the Field Hospital. This is further borne out by the fact that 33 Vena Cava lesions were treated while no lesions of the abdominal aorta survived to have surgery. The overall mortality for all arterial injuries was 646 as compared to an overall 395 Abdominal Vascular Injuries, Comment coni'd. rate of 1% for the veins. Even cases with severe injury to the great veins managed to reach the hospital alive apparently because a point was reached in the process of bleeding whereby the intra-abdominal tension rose suf- ficiently high end the venous pressure dropped sufficiently low to prevent complete exsanguination and death. This must have occurred with much less frecuency in arterial injuries and fewer of these patients were received. The lower mortality rate for arterial lesions that actually received sur- gical treatment must be attributable to the unusual circumstances that allowed these patients to reach the Hospital alive in the first place. These injuries were probably minimal, the blood loss less before surgery, and the bleeding controlled with greater rapidity after the abdomen was opened. The overall mortality for injury to the great vessels in this series whether, artery or vein, or combination thereof, is 1% . It carries the highest mortality rate in war incurred injuries of the abdomen. No pro- blem so challenges the technical skill of the surgeon as the ability to control severe hemorrhage in the abdomen with sufficient rapidity to allow the patient a chance to recover. 396 RETROPERITONEAL HEMATOMA. Retroperitoneal hematoma is defined as any extravasation of blood, whether circumscribed or diffuse, into the retroperitoneal areolar tissues. In 3154 abdominal and thoraoo-abdominal oases operated upon in 1944 and 1945, retroperitoneal hematoma was frequently encountered. We are unable to give the exact incidence with which it occurred because of the relative infrequency with which the surgeon recorded it. Any missile which penetrated or perforated the retroperitoneal space almost invariably produced a hematoma of some degree. Not all oases resulted from direct penetration because sene of the recorded instances resulted from blunt Injury to the abdomen. The majority of these cases were well-handled surgically but some few errors ooourred which will be pointed out. Many required no particular treatment and were of little or no pathological significance. The adoption of an attitude that most of them oould be handled in this manner led to the oversight of existing lesions whioh resulted in the loss of life. At the outset, it my be stated with certainty that olinical re- cognition of the existence of a retroperitoneal hematoma cannot be made prior to surgical exploration. It oan be stated with equal assurance that olinloal differentiation between the existence of a retroperitoned hematoma and a visceral injury cannot be made prior to surgery. The sigis and symptoms of each my bs identical, and frequently both lesions are present in the same patient. In this connection, it is of interest to note that a retroperitoneal hematoma alone was the only pathology in 59 cases whioh had otherwise negative abdominal exploration. All 59 of these oases presented the signs of an acute abdomen with tenderness, spasm and often rigidity. There were four deaths subsequently from those 59 explorations, a mortality rate of 6.8$. The cause of death in these four oases was as follows: (1) Pulmonary embolism - 1 case* (2) Asphyxia from aspiration (anesthetic death* died on table) - 1 ease* (S) Pneumonia* both lower lobes - 1 case* (4) Retroperitoneal oellulitis and thrombosis left renal rein - 1 ease* In addition to presenting the signs of an aoute surgical abdomen, 16 of these 59 oases presented clinical shook of seme degree on admission* 397 Retroperitoneal Hematoma• TABLE I Showing Clinical Shock on Admission in Relation to Mortality in 59 Cases of Retroperitoneal Hematoma With Otherwise Negative Abdominal Explorations Clinical Shock Lived Pled 4 Plus - 1 Case 1 0 3 Plus - 2 Cases 1 1 2 Plus - 6 Cases 5 1 1 Plus - 7 cases 7 0 None - 25 Cases 24 1 Not Recorded - 16 Cases 17 1 TOTAL - 59 Cases 55 4 In general, it has appeared that this group of oases presented less shock than is usually encountered in a group of similar sise with intra- peritoneal injury to a single solid or hollow viscus* We have been unable to.verify the existence of the retroperitoneal syndrome described by JollyW following his experiences in the Spanish Civil War. This syndrome, as he described it, consisted of a state of shook with generalized pallor and sweating; a rapid thready pulse often becoming imperceptible; the complete absence of abdominal tenderness and spasm (in fact, no abdominal signs); and, in some oases, a semi- erection of the penis, which, when it occurred, was of grave prognostic significance and, once it had appeared, usually persisted until the death of the patient* The underlying pathology was said to be a retro- peritoneal infiltration of blood about the ooeliao plexus. In the 3154 abdominal and thoraco-abdominal cases operated upon by surgeons of this §l*oup, we have not encountered a syndrome resembling this. As we have pointed out, the signs and symptoms of retroperitoneal pathology and hematomas have been indistinguishable at times from those resulting from perforation of a hollow viscus. The presence of priapism, in our experience, has visually been associated with injury to the spinal cord; in the Infrequent instances in which it has been associated with retroperitoneal hematoma, it has not implied a grave prognosis* The presence of retroperitoneal hematoma is recorded in only 207 cases from our entire series. This does not begin to represent the 398 Retroperitoneal Hematoma, true incidence of occurrence, but rather, the incidence only with which the surgeons made it of record. As proof of this, we know that there were 427 kidney injuries in all of which there were retroperitoneal hematomas of varying degree. Likewise, we had 75 instances of injury to one or more great vessels of the abdomen, all of which traverse the retroperitoneal space. Undoubtedly, all of these cases had retroperi- toneal hematomas, but accurate written record of such was made in only 33 oases. These two groups alone total roughly 500 oases. When we add to this the number of duodenal, colon, ureteral and bladder injuries which do not overlap with each other or with the aforementioned kidney and vascular injuries, we can be assured that the 207 recorded cases represent only a fraction of the total and that retroperitoneal hema- tomas are among the most frequently encountered lesions in abdominal explorations for war-incurred injuries• In 11 of our 207 recorded cases diagnosis only of retroperitoneal hematoma was made and no treatment, presumably, was necessary. An additional 63 oases were so diagnosed and the majority of these were drained only; some few had evacuation of clots plus drainage; while an occasional case required packing to control bleeding that was not readily controlled otherwise. Thirty-three out of 76 oases with injury to one or more great vessels of the abdomen were diagnosed as having retroperitoneal hematomas. The treatment in these cases consisted of retroperitoneal exploration, evacuation of the blood, and control of the bleeding vessel in one of three ways: by ligation, suture of the vessel, or clamping. TABLE II Mortality in 207 Cases in Relation to the Method of Treatment of the Retroperitoneal Hematoma. Group Died I 111 Cases retroperitoneal hematoma, no treatment 19 II 63 cases retroperitoneal hematoma, drained, packed, or clot evacuated and drained; or ligation of other than great vessels 22 III 33 oases retroperitoneal hematoma associated with great vessel injury of abdomen 22 In Group I, the 19 deaths which occurred were apparently unrelated to the retroperitoneal hematomas and attributable to the associated intra-peritoneal pathology. In Group II, 22 deaths occurred, in half of which (ll oases) the cause of death was directly referable to the pathology in the retro- 399 Retroperitoneal Hematoma* peritoneal space: 5 oases - died of shock and hemorrhage as a direct result of severe retroperitoneal bleeding not originating from great vessels. 3 cases - died subsequently from anuria following severe shock from retroperitoneal bleeding. 2 oases - died of retroperitoneal oellulitis. 1 oase - died of retroperitoneal oellulitis and pulmonary embolism* « In Group III, the 22 deaths which occurred were directly related to the causes of death in general for injuries to the great vessels of the abdomen* (See discussion on abdominal vasoular injuries. Page 385 The real significance of a retroperitoneal hematoma, other than for the clinical signs which are indistinguishable from those of viaous perforation lies in the fact that it may obscure injury to vital retro- peritoneal structures. We have recorded two instances of overlooked duodenal perforation with two deaths;two overlooked ureteral injuries with one death; four overlooked retroperitoneal colon injuries with three deaths; and six overlooked bladder injuries with two deaths. As we have stated previously, many small and insignificant retrooeritoneal hematomas do not require exploration or drainage. Excessively large hematomas, or those that give evidence of continued bleeding must be explored and the bleeding vessel controlled. It is easy under these oireurnstanoes which necessitate control of severe hemorrhage, and in the presence of a larger hematoma, to overlook a co-existing lesion such as a retroperitoneal colon perforation. One suoh case was reported. We strongly large the necessity for careful exploreticm of the surround- ing structures after a large hematoma has been evacuated and the he- morrhage brought under control. Likewise, we urge the exploration of the retroperitoneal space in the presence of a hematoma of any size if the anatomical location is suoh as to suggest possible injury to the ureter, posterior aspect of the colon, duodenum, or bladder. We advocate satisfactory extraperitoneal drainage for retroperitoneal hematomas associated with injury to any portion of the urinary tract (kidney, ureter, or bladder), in injuries to the pancreas, or in any lesion of the colon which has resulted in heavy contamination rotroperitoneally. This should be made, if necessary, through a freshly made drainage incision in the flank or posteriorly assuming that a debrided wound of entry or exit does not exist that can be utilized for this purpose* In large hematomas with vascular injuries, we believe that the evacua- tion of the clot when possible and ligation of the bleeding vessels is usually sufficient. Any opening in the posterior peritoneum, whether made by the missile or operating surgeon, should be carefully ra- 400 Retroperitoneal Hematoma. peritonealized to eliminate communication between the peritoneal carity and the retroperitoneal spaoe. REFERENCES I* Jolly, Douglas W.: Field Surgery in Total War, Page 176. Paul B, Hoeber Ino,, New York, 1941, hoi PART- II ABDOMINAL INJURIES OF SPECIAL TYPES Injuries of Abdominal Viscera Without Penetration of Peritoneum Associated with Open Wounds Due to Blunt Trauma and External Blast Wounds Penetrating the Peritoneal Cavity Without Visceral Injury 402 INJURIES OF ABDOMINAL VISCERA WITHOUT PENETRATION OF PERITONEUM Associated with Open Wounds Thirty-one hundred and fifty four (31f>U) patients with abdominal and thoraco-abdominal wounds and injuries were operated upon in for- ward hospitals by teams of this Group during the period 1 January 19Ui to 8 May 19h$» Only 12 cases of open wounds were recorded in which significant injury to intra-peritoneal viscera occurred without pene- tration of the peritoneum by the wounding missile* Nine of the wounds involved the abdomal wall; one involved the chest wall and diaphragm, one the left chest wall and adjacent abdominal wall and one the chest wall only. The wounding agent was listed as high explosive shell frag- ment in eight cases; it was not recorded in the other four. The one fatal case sustained a severe penetrating wound of the left chest. The missile lacerated the pleural surface of the left dome of the diaph- ragm, apparently denting it against the stomach wall to produce a sub- serosal hematoma there. Damage to the lung was extensive and the patient died postoperatively of shock and pulmonaryedema. The intra- abdominal injury played no significant part in the death. The wounds perforated the extra-peritoneal abdominal wall in 10 of the 12 cases. The velocities of projectiles producing this type of wound must be greater than those causing penetrating wounds of these tissues. We believe the apparent explosive effect in the abdominal wall wounds is due to this additional Imparted energy, which may be in turn transmitted to intra-abdominal structures. In nine cases of the group, gas and liquid containing viscera were injured. This tyoe of viscus may be particularly prone to In- jury from such indirect trauma due to the transmission of the force by the contents. The splitting open of the cecum and ascending colon along its anterior longitudinal band in case #3 is offered as an ex- ample. It is a fallacy to assume that no abdominal viscus is involved because the peritoneum has not been found penetrated after laying open the abdominal wall wound. On exploration of the abdominal cavity, in several such cases included in this study a severe injury was seen involving one or more viscera. When there is clinical evidence of intraperitoneal involvement, an exploratory laparotomy is mandatory. h03 Case No. Wound A pent Wound Type Wound Location Organs Involved Nature of _ Organ Injury Surgical Treatment Comment I. No record Penetrating LLQ of abdomen Desc. colon Incomplete laceration Laparotomy and suture None 2. No record Perf orat ing Right flank Liver Laceration minor Laparotomy drainage None 3. Shell fragment Perf orating RUQ Cecum and asc. colon Split open along ant. surface Laparotomy and bowel ex- teriorized Also had Compd free, of f emur 4. Shell fragment Perf orating RUQ Liver Stellate tear right lobe Laparotomy end drainage None 5. Shell fragment Perforating Left abdomen Spleen Severely lacerated Laparotomy and splen- ectomy None 6. Shell fragment Perforating Left abdomen Ileum Contusion Ls par ot omy None 7. Shell fragment Penetrating Right flank Ascend. colon Small perf. anterior Laparotomy and suture None 8. No record Perforating left cheat Stomach Hematoma of wall Thoracotomy and abdominal exploration thru diaphra- Lied shock and pulmon- ary edema. Extensive lung in.i. 9. Shell f ragment Perforating Right abdomen Cecum Contusion Laparotomy None A brief tabulation of this series of cases follows;- Injuries Of Abdominal Viscera Without Penetration Of Peritoneum, (Associated with Open Wounds (Cont»d). UoU Injuries Of Abdominal Viscera Without Penetration Of Peritoneum. (Associated with Open Wounds Cont'd). Case No. Wound Agent Wound Type Wound Location Organs Involved Nature of Organ Injury Surgical Treatment Comment 10. Shell fragment Perforating Right abdomen Ascend. colon perf. and con- tused areas. Lap. and ex- terioriza- tion nfbowel 4 None 11. No record Perf orating Post-lateral chest, left Splenic flex- ure of colon and jejunum * Perf. colon and contus- ions of jejunum Lap. and ex- terioriza- tion of colon None 12. Shell fragment Perforating Left chest and left abd- ominal wall 1. liver left lobe. 2. Transverse colon. 3. Jejunum 1. Lacerated 2. Lacerated 3. Lacerated 1. Trained 2. Exterior- ized. 3. Sutured Unevent- ful course UoS Injuries Of Abdominal Viscera Without Penetration Of Peritoneum Due to Blunt Trauma and External Blast Perforation or rupture of an intra-abdominal vis crus is a potential danger in any "blunt" or "blast" injury of the abdomen. This type of injury in the absence of peritoneal penetration was found in lU in- stances out of 315U abdominal and thoraco-abdominal cases studied, an incidence of O.Uli#. A group of injuries to the bladder, urdthra, and other unogenital structures associated with fractures of the pelvis was not included. They have been covered in a separate study, (see page 378), Although the number of cases here presented is small, the lesions were such that in a majority of the cases death would have occurred in the absence of operative treatment. The viscera most fre- quently involved either alone or in combinations were: the small in- testine, spleen, colon, kidney and mesentery. Most of these injuries resulted from vehicle accidents (9 of the total lii cases). There were three cases in which the "blast" from the nearby explosion of an artillery shell was sufficient to seriously injure intra-abdominal viscera. The patient's history and physical findings were the most helpful elements in deciding the pre-operative diagnosis. In no case was there a skin wound, but, on occasions, a subcutaneous hemorrhage indicated the area of greatest trauma. There was usually tenderness, and in 13 cases an absence of peristalsis suggested a "surgical abdomen". Al- though, in no case was a definitive pre-operative diagnosis made, the signs were such that exploratory laparotomy was performed in all ex- cept one of the cases* Case no, Hi, Table I, represents the one in which the abdominal pathology was not suspected Initially, and the surgical treatment was limited to that of the chest wall wound. At autopsy the abdominal lesions described were noted. The mortality rate in this group of injuries was l5% (two deaths). This rate is considerably lower than those found in the literature in which mortality rates of hh% and 55£ respectively are given for similar types of injuries. We feel that the early and vigorous shock therapy administered to our cases, when indicated, plus early surgical Intervention were two factors contributing to this low figure. A tabulated record of the entire group of cases follows* REFERENCES 1. Kelly, E. C.j Non-penetrating abdominal trauma. Hi : 163. Surgery, 19U3. 2. Ficarra, B. J.: Traumatic perforations of the Small In- testine due to non-penetrating abdominal injuries. 15 : U65. Surgery, 19kh» U06 Cape . Wound . Agent . . . Type of Injury . Location of Injury Viscera Involved Pathology Treatment (Surgical) Postoperative Course 1. Jeep accident Cent lie ion Left flank Ileum, de- scending colon Transected lacerated Resection exter- iorization Uneventful 2. Jeep accident Contusion Abdominal wall Ileum 2 lacera- tions Sutured Uneventful 3. Jeep accident Contusion Left upper quadrant Spleen torn pedicle splenectomy pneumonia {recovered) u. Jeep accident Contusion Left flank Kidney 1. mesentery 2. Pedicle torn 1 Torn 2. .1. Nephrectomy 2. Sutured Uneventful 5. Shell explosion blast, con- tusion - Abdominal wall Spleen Fractured Splenectomy Wound dehiscence 7 PC day. 2° clos. recovered. 6. Half track Crushing Abdominal wall Descend- ing colon Serosal tears Sutured Uneventful 7. Command car Crushing Abdominal wall Jejunum Transection Sutured Uneventful 8. Jeep Contusion right groin Ileum Laceration Sutured Uneventful 9. Wagon Crushing Abdominal Wall Ileum Laceration Sutured Uneventful 10. Auto Blunt Injury Abdomen 1. Jejunum 2. Mesent- ery 3. trans- verse colon. 1. transected 2,. Tom 3. serosal tears - 1. res.ection 2. Sutured 3. sutured died 13 PC day peritonitis pneumonia Injuries of Abdominal Viscera Due to Blunt Trauma and External Blast 407 Cape No. Wound Agent Type of Injury Location of Injury Viscera Involved Pathology Treatment (Surgical) Postoperative Course 11. Shell explosion Blast Abdomen Spleen Fractured Splenectomy Uheventful 12. Fall 12 feet Blunt Injury Left flank 1. spleen left 2. Kidney 1. fractured 2. pedicle torn 1. splenectomy 2. nephrectomy Uneventful v 13. Bailey Bridge injury Blunt injury Left hypo- chondrium Tinea coli Descending divided colon and re- tracted Sutured and exteriorized Uneventful u. Shell explosion Perf. wd of chest wall blast in- jury to abdomen Left ch- est left abdomen left arm Lung Stomach Small bowel Colon Hematoma and pneumonitis (blast) Sub- serosal hemo- rrhage Mucosal tears Mucosal hemo- rrhages Chest wall de- bridement No surgery of abd- omen . Patho- logy found at autopsy. Died 17th P.0, day of acute circ. collapse and in- testinal abst. Sec. to the blast injuries. Injuries of Abdominal Viscera Due to Blunt Trauma and External Blast ccnt'd. 408 Abdominal Injuries Of Special Types Wounds Penetrating Peritoneal Cavity Without Visceral Injury. A comprehensive review of thoraco-abdominal and abdominal wound cases operated upon in forward hospitals by surgeons of this Group dis- closed a series of patients in whom no significant damage to intra- peritoneal viscera was sustained desoite penetration of the peritoneal cavity by a missile. Onlv Ul such cases were found, representing 1,3% of the total group of 3l5u cases reviewed for the 19Uli-u£ period. We did not include in this list 3 cases of omental injury. In one of these, a segment of omentum had herniated through a perforation in the diaphragm, becoming gangrenous, and was resected. The other two patients sustained only rents in the omentum which were sutured. The post-operative course was uneventful. Wounds of the mesenteries have been covered in separate studies, (See "Abdominal Vascular Injuries" and "War Wounds of the Snail Intestine", pages 238 and 385 ). The Ul cases represented 2k thoraco-abdominal and 17 abdominal wounds,figures which differ considerably from the relative proportions of such wounds in the entire series (thoraco-abdominal wounds 26,6^). The right diaphragm was wounded 13 times, the left ll times. The wounding agent was listed as high explosive shell fragment in 33 cases (80$6) and gunshot in eight (20%), Twenty-nine (70%) of the external wounds were penetrating in type. Eleven were perforat- ing. An analysis of the locations and nature of the wounds involving the peritoneum proved interesting. In the group of 2h diaphragmatic wounds the missile had entered from the thoracic side 23 times. The diaphragm had sustained a double perforation in seven cases with the missile either lodging in the lung or passing out through the chest wall* In eleven cases the perforation was single; two of these were produced by sharp rib fragments. The missile had lodged in the dia- phragm in the remaining five cases r>reducing only a small opening in the peritoneum. A study of the group of 17 abdominal wounds revealed no case in which the missile had passed freely across or through the general peritoneal cavity in a major diameter. The peritoneal wounds in these cases were caused by missiles which had either perforated across small angles, lacerated the peritoneum in burrowing through extraperitoneal tissues, or had so exhausted their momentum asito fall harmlessly into the peritoneal cavity. Variable degrees of hemoperitoneum were found in most of the Ul cases,, the source being extra-peritoneal. It was this blood, sometimes over a liter in amount, which produced the clinical symptoms and signs of intra-abdominal patnology in these cases. Surgical approaches to the abdominal explorations done in each case conformed fairly closely to the type of wound. All the abdominal wound cases were explored through laparotomy incisions. In the 2h thoraco-abdominal wounds 20 explorations were done through the ohest 409 Abdominal Injuries Of Special Types. (Wounds Penetrating Peritoneal Cavity Without Visceral Injury cont’d). and diaphragm onlyj two through laparotomy only, and two through both incisions. The wound of the diaphragm was sutured in every case. Only two deaths occurred in the entire series. One patient who had sustained an evisceration of one and one-half feet of ileum through an abdominal wall wound died unexpectedly three days after operation, of a massive pulmonary embolism. The source of the embolus was not stated. The other oatient had sustained a severe retro-peritoneal wound with severance of the left common iliac vessels. He died 10 days after operation from pneumonia, peritonitis, and retro-peri- toneal cellulitis. We feel that one observation of special interest was made during this study, i.e., no instance was found in which the missile had passed across the general abdominal cavity. Since the total group studied represents a very large series (315U cases) in which the policy has been to explore all cases presenting evidence or suspicion of peri- toneal penetration, it would seem that instances of missiles passing through the abdomen without causing harm, must be rare indeed. Clinical recovery may ensue in such cases without operation, because certain wounds of the gastro-intestinal tract tend to seal themselves. The risks involved in non-operative handling of such cases, however, are not Justified in view of excellent present day surgical facilities in forward hospitals. i FORWARD SURGERY OF THE SEVERELY WOUNDED VOLUME II A History of the Activities of the 2nd Auxiliary Surgical Oroup 1942 - 1945 II TABLE OF CONTENTS VOLUME II Pages 3. THORACIC WOUNDS 410 Part Is In the Forward Hospitals*.........,,,,,.,,,,. 411-536 Part II: In the Base Hospitals*,,,,,.,,.,,,,.,,,,.,,,, 537-564 4. THQRAC0-ABDOMIHAL WOUNDS 566-591 5. AMPUTATIONS 593-619 6. COMPOUND FRACTURES 621-654 7. CRANIAL INJURIES 656-682 8. MAXILLO-FACIAL INJURIES 683-714 Part It In the Forward Hospitals 683-705 Part II: In the Base Hospitals,, •••„•••••••• 706-714 9. VASCULAR INJURIES 715-745 10, ANAEROBIC INFECTIONS 746-757 11, POST-TRAUMATIC RENAL FAILURE 758-772 12, DEATHS IN FORWARD HOSPITALS 773-813 II. ADMINISTRATION 814-844 III. OPERATIONAL ACTIVITIES 855-900 IV. ROSTER OF PERSONNEL 901-915 V. AWARDS AND DECORATIONS 916-922 VI. LIST OF PUBLICATIONS AMD REPORTS 923-931 ♦Detailed tables of contents will be found immediately preceding each of ttyese sections. 410 THORACIC WOUNDS All THORACIC HOUHDS Part I The Initial Surgery of 2267 Penetrating and Perforating Injuries of the Thorax Including 903 Thoraco-abdominal founds Pane (1) Transporta'o ility of Thoracic Casualties . . , 4.13 (2) Material 4-14 (3) Diagnosis 4.15 (4.) Preoperative Preparation 4.25 (5) Anesthesia 435 (6) Basic Operative Considerations 437 (7) Penetrating or Perforating Wounds Hot Demanding Thoracotomy 438 (8) Indications for Thoracotomy ....... ,c . 440 (9) Incision Thoracotory 441 (1C) Thoracotory for Thoraco-abdominal Injury . . 443 (11) Traumatic Thoracotomies . 447 (12) Intrathoracic Procedure 459 (13) Heart and Pericardium 463 (14) Closure of Thoracotomies * 479 (15) Tracheobronchial Aspiration on the Operating Table 482 (16) Postoperative Treatment 483 (17) mortality 484 (18) Comment 489 (19) Summary and Conclusions 4-91 (20) Statistical Appendix 497 412 THE- INITIAL SURGERY OF 2267 PENETRATING AND PERFORATING INJURIES OF THE, THORAX INCLUDING 903 THORAC0-ABDOMINAL WOUNDS A Summary of Cases Treated by the 2nd Auxiliary Surgical Group from November 1942 to May 1945• In war wounds of the chest treated during the North African and European Campaigns of World War II there has been a great re- duction in mortality rates as compared with those of the last World War. Though it is now recognized that the treatment of war wounds of the abdomen has been revolutionized during World War II in reality a similar advance has been made in the treatment of wounds of the chest. Both have been achieved by the same means, namely, the application of the physiological approach to those injuries and the use of principles previously developed and applied in civi- lian life during the period between the wars. The principles of treatment of thoracic war wounds have not been radical departures from previously conceived principles and methods. The advances are due to the greater appreciation and application of the physiology of the cardio-respiratory system together with skill- ful anesthetists and adequate anesthestic apparatus. Even though civilian experience in trauma of the thorax was meager up to the onset of the present war, the great developments in non-trauniatic surgery formed a solid base on which the concepts of treatment, outlined in this report, were built. The report here presented is a summary of the work done by the surgical teams of the 2nd Auxiliary Surgical Group during the camp- aigns in Tunisia, Sicily, Italy, Southern France, the Rhineland and Central Europe. The work of 27 general surgical teams and five thoracic surgical teams is presented. All cases with penetrating or perforating wounds of the pleural cavity are included. Injuries to the thoracic cage without pleural penetration are not included even though we realize that many cause intrapleural damage without pleural penetration. This report is concerned only with the INITIAL surgery of the wounded, the term "initial” being used in the sense in which it was set forth by the Theater Surgical Consultant . All cases were operated upon either in Field Hospitals or in forward Evacuation Hospitals and in each instance comprised the first surgical treat- ment afforded the casualty except for such preliminary measures as may have been applied in the Battalion Aid Station or in the Clear- ing Station. A small group, during the early phase in Tunisia and during first day or two of some of the five amphibious landings, were operated upon in Clearing Stations. 413 The Initial Surgery of The Thorax And Thoraco-Abdominal Wounds, A detailed description3 of the use of Field Hospitals as first priority surgical installations in the forward area and the employ- ment therein of auxiliary surgical teams will be found in the section on Operations, page 34-7, y TRANSPORTABILITY OF THORACIC CASUALTIES The Field Hospital platoon has equipment and personnel (even with Auxiliary Surgical Group teams) for handling only a limited number of first-priority surgical patients. Whenever the patient load gets over 50 first priority cases it is impossible for the small staff of nurses and enlisted men to care adequately for all the patients. It is therefore advisable that the number of patients operated on in the Field Hospitals be kept to a minimum. It is not feasible for these reasons to attempt to operate on all chest casualties at this most forward surgi- cal installation. The emphasis in the Field Hospital should be on abdominal, thoraco-abdominal and severe extremity injuries where time lag is a more important factor. Also, it is well recognized that these first- priority patients do not withstand the necessary time and discomforts incident to further evacuation. In contrast, thoracic injuries that are not in shock or have been restored to cardiorespiratory balance withstand evacuation very well indeed , If it were possible to treat all cas- ualties of any degree or any region at this early stage it would be commen- dable, but this is not practical and the load of caring for the large majority of cases must be borne by the Evacuation Hospitals, It is these hospitals that should treat all but the most severe thoracic casualties. The main function of the Field Hospital insofar as the majority of chest lesions is concerned is to act as a triage center to which the medical officers of the clearing Station can send any case about which they are in doubt either as to his transportability or the presence of a thoraco-abdom- inal lesion. The latter is not always an easy decision to make. If there is reasonable suspicion that such may exist, especially if on the left side, he should be held in the Field Hospital for surgical exploration. In the early campaigns it was not always appreciated by many how well thoracic cases could be transported if care was taken to assure their being in the best possible state before being evacuated. Such evacuation has now become a standard practice and has relieved the load on the Field Hospitals. Shefts^- working in an Evacuation Hospital studied this problem on patients evacuated to him. In his series of 113 cases there was not one death that could in any way be attributed to the*patients1 evacuation. Over 50% of the pure thoracic cases admitted to the Field Hospital during the later campaigns were evacuated to the Evacuation Hospitals. 414 The Initial Surgery of the Thorax end Thoraco-Abdomina.1 Wounds. (Transportability of Thoracic Casualties cont'd). without surgery being done. Frequently simple measures such as thora- centesis or intercostal nerve block were employed in the preoperative tentto effect cardiorespiratory stabilization so that they became transportable cases. Thus, ceses treated in Field Hospitals ('when used as first-priority surgical installations) were composed of abdom- inal, and thoraco-abdominal injuries, traumatic amputations, severe vascular injuries or thoracic cases that could not be brought into cardiorespiratory balance by other than surgical therapy. Most thora- cic cases without exceptionally large chest wall defects or thoraco- abdominal injuries, can be stabilized and safely evacuated. MATERIAL During the period covered by this report surgical teams of the 2nd Auxiliary Surgical Group operated on approximately 22,000 cases. Included in this group are 2,629 abdominal injuries, 903 thoraco- abdominal lesions and 1,364- penetrating or perforating injuries of the pleural cavity. Of the 1,364- thoracic injuries, 135 ended fatally in the hospi- tals in which they were operated. This is a mortality rate of 9.8%. If all save U;S. troops are eliminated, the mortality for American soldiers is 9.23$. The chest was the major wound in 1,112 of these patients while 137 has associated wounds that were of greater severity than their thoracic lesions. The mortality for the 1,112 was 6.2% and the mortality for the 137 was 33-59$» Two hundred and forty-seven of the 903 thoraco-abdominal lesions ended fatally, a mortality rate of 27.35$ . * In order to have a basis of comparison of the early ana late campaigns, the cases have been divided arbitrarily into two groups using 1 May 194$- as the dividing line. By this time, the principles of management of thoracic war wounds had become much more widely disseminated and a somewhat better defined policy had been laid down. The effects of this wider knowledge should therefore become evident. Also, this date coincides quite closely with the period at which adequate amounts of blood became available through the blood bank. Penicillin which previously had been reserved for 415 The Initial Surgery of the Thorax and Thoraco-Abdominal Wounds. (Ms t er ial c ont ’ d). special types of cases was made available for all, and it can be assumed that such therapy was used in practically all major thoracic injuries after that date. Cases treated by the thoracic surgical teams have likewise been summarized separately from the general surgical teams to determine if there was any difference between the two groups and if there has been corresponding improvement in the two series. It is fully realized that so many imponderables enter into any study of cases based on records filled out by medical officers under field conditions that the statistical analysis thereof may be most misleading. Although the records of this group of patients are quite good, comparatively, the date are by no means sufficiently complete to warrant derivation of conclusions on the basis of the figures alone. It is our intention therefore, not to rely solely on the figures. The discussion and conclusions are presented as the combined opinions of the Group, that have been developed on the basis of a two and one-half years’ personal experience. Even though follow-up studies are available on a sizeable percentage of the cases, it is not complete to a degree compatible with accuracy and, there- fore, this study is limited to the condition of the patients at the time of discharge from the hospital where first treated. Mortality figures as well as the incidence of complications during this phase are reasonably complete and, therefore, of statistical significance. Tables have been compiled from those case records which have in- cluded the necessary data. They may be found in the statistical appendix. DIAGNOSIS Rational therapy can be based only on accurate diagnosis. This is true in thoracic wounds to a greater degree than for certain other regions of the body. In many, such as the abdomeh, it‘ is known that if there is presumptive evidence of peritoneal penetration a laparotomy is mandatory. One may also explore a severe wound of an extremity before deciding whether or not an amputation should, be done. Such procedures are not applicable in thoracic injuries as it is im- portant that Intra-thoracic manipulations be avoided in the forward areas except for specific indications. The type of operative treat- ment (.that is, either debridement or thoracotomy) depends upon the surgeon’s examination and decision as to the probable damage. Two auestions are nosed by every thoracic casualty seen in the Field Hospital. The first are whether or not the injury is such' that the 416 The Initial Surgery of the Thorax end Thoraco-Abdominal Wounds. -D i agn o s i s c ont * d. patient should be operated on in the Field Hospital or evacuated? The second is what type of operation should be performed? In the forward Evacuation Hospital only the second problem has to be con- sidered. There are three main points of interest to the examiner of a thoracic ca.sua.lty; First, the course of the missile and the probable damage done by it directly; secondly, an estimation of the "blast" effect produced by the missile; thirdly, the detection of signs of completely or partially obstructed airway. The general appearance of the patient should be the first thing to which the examiner dir- ects his attention. Even though it may be unscientific, there are certain patients that just "don't look good". It is one of the most important observations that one c£:n make. In war surgery it is to be relied upon to a greater extent than the blood pressure, pulse or other recordable findings. This first over-all appraisal should take in any associated wounds, the patient's general condition, and. various other factors that do not admit an accurate description. The expression on the soldier's face, his color, type and character of respirations, the "look in his eyes", and whether or not he is alert are all factors that the experienced examiner takes in at first glance. After this first survey is made one is ready to proceed with a more orderly and complete examination. HISTORY: The term history has a connotation that is not applicable in war surgery. There are many things, however, about which more information should be obtained than will be found on the Emergency Medical Tag. As is true of civilian practice, it is wise to ask the patient what is bothering him the most. War wounds are freq- uently multiple and often the chest may not be the patient's main complaint even though it is his most serious wound. If attention is first directed to the patient's chief complaint he is more apt to feel that the surgeon is really interested in helping him and thus confidence is established. Specific things that should be asked about include the following; Pain, its type, location and relationship to resoirstion; difficulty in breathing and whether or not the difficulty is increasing or decreasing; has he coughed up blood and if so how much; has he felt nauseated or has he vomited; when did he eat last and what is the relationship of this to the time of wounding undigested food remains in the stomach many hours under the stress and strain of combat conditions); was he unconcious and if so for how long; has he noted any sucking of the wound; does the time he was injured agree with that noted on the record; what type of missile does he believe struck him and if it 417 The Initial Surgery of the Thorax and Thoraco-Abdominal Wounds. (History cont'd.) was an explosive shell how far from him was it when it exploded; and what position was he in when hit. All these questions can be asked in b few moments and will often yield a surprising amount of addi- tional information. Pain of some degree is the rule in thoracic wounds although it frequently will have been dulled by morphine before the patient reached the Field Hospital. As the pain is from the chest wall it’s presence or absence has no bearing on the question of pleural pene- tration. As it is accompanied by splinting of the hemithorax it favors hypo-ventilation and should be relieved, (as discussed below when of such severity as to produce diminished respiratory excurs- ions. The patient's greatest hazard in the pre-operative period is anoxia and all necessary measures should be taken to combat it. Difficulty in breathing may either be due to actual "shortness of breath" or the more common complaint of being "unable to take a good breath". The latter is due to the associated pain and can be relieved by injecting the intercostal nerves. "Shortness of breath" implies deficient oxygenation of the blood which in the absence of severe blood loss, is usually attributable to decreased functioning pulmonary parenchyma.. Many factors contribute to this, the most prominent of which are hemothorax, pneumothorax and hemorrhagic infiltrations of the lung. If a history of increasing dyspnea is obtained it suggests increasing pressure on the lung by blood or air and its removal, without delay, is,,indicated. Hemoptysis of some degree is expected in almost all cases of penetrating lesions of the thorax. It is likewise common in severe thoracic wall lesions or blast injuries in which the lung is con- tused. It is a warning sign that damage has been done. The amount of blood coughed up varies with the particular lesion but has some bearing on its severity. Those with large amounts are more apt to have some postoperative difficulties unless care is taken to maintain an open airway. When the patient is unable to raise the material by himself he must be assisted, otherwise the air exchange is hindered and oxygenation of the blood in the pulmonary capillaries is inhibited. Nausea and vomiting are not commonly seen in the casualty with only a thoracic wound. If present, they suggest a possible thoraco- abdominal lesion. 419 The Initial Purgery of the Thorax and Thoracoabdominal 'Pounds. (History cont’d.) A short period of unconciousness is not infreauent when injury has been caused by a high-explosive shell. Longer periods, especially if preceded by conciousness, are apt to be due to cerebral anoxia and are therefore of utmost importance, both in regard to the severity of the wound and from a prognostic standpoint. Unconciousness of more than momentary duration means that there is either cerebral concussion, severe blood loss, or cerebral damage from prolonged anoxia. Maniacal manifestations, frequently a sign of severe anoxia, may likewise be present and this oxygen want must be combatted vigorously. A history of "sucking” or exchange of air through the wound is presumptive evidence that the missile has penetrated the pleura. Rarely, such a noise may be noted in extensive soft tissue lesions without pleural involvement especially if there are multiple rib fractures giving -a flaccid chest wall. The absence of sucking has no bearing on the course of the missile nor the damage it may have produced. The position the patient was in when injured, the type of missile and how close to him it exploded, if an explosive shell, are all of great significance when arriving at a final decision as to the pro- bable intra-thoracic lesion. Only by knowing .these factors can one visualize the probable injury. It is absolutely imperative that the surgeon plot the course of the missile to his best ability in order to aonraise most accurately the damage to the thoracic organs and tissues involved. Pr:YPICAL; Hemopneumothorax is the most common physical finding in thoracic casualties. Any penetrating or perforating wound of more than slight severity must result in at least a small amount of blood or air entering the pleural cavity. Small amounts are of little significance, but when either blood or air restricts and prevents complete lung expansion, and thus adequate oxygenation, they become symptomatic and means of correction are indicated. A discussion of the physical signs of hemo- or pneumothorax is not necessary. It should be emphasized however, that the signs may be most misleading as to the size of the pleural collection and that the severity of the symptoms may be little related to the amounts of fluid or air detected on physical examination. Certain things are always to be looked for. Most important is the general appearance of the patient including his color. If cyanosis of any degree is detected it is a warning sign that vigorous measures are indicated to re-adjust the 420 The Initial Surgery of the Thorax: and Thoraco-Abdominal Wounds. (Physical c on.t * c .). cardiorespiratory mechanism to a more nearly normal state. If other signs of cerebral anoxia are oresent such as unconciousness or maniacal manifestations, the urgency for adeauate therapy is greater. Fvery ef- fort should be nut forth to prevent, combat, or alleviate decreased oxygenation. It is to be remembered that cyanosis is a sign of com- paratively advanced anoxia and measures to decrease anoxia such as thoracentesis and the administration of oxygen are better instituted before the appearance of cyanosis. In cases with severe blood loss, cyanosis may not be detectable due to the lowered hemoglobin content of the blood. The type and character of respirations are of particular import- ance. Those patients with badly contused lungs either from a dire'ct injury or blast often exhibit the signs of "wet lung" as discussed below. The rapid, rattling respirations with frequent, ineffectual coughs indicate that difficulty is being encountered in maintaining a clear air-way. Certain gross physical findings seem to be of more importance in the examination of thoracic war casualties than are the more refined methods applicable in other situations. For example, check- ing the position of the trachea in the suprasternal notch or the a.oex impulse of the heart will give as much or more evidence of a clinically significant hemopneumothorax than very careful, time- consuming percussion and auscultation. The latter methods are not to be disregarded but a busy, noisy, preoperative ward is often times a difficult place in which to carry out a meticulous examin- ation. Minor deviations from normal are not of particular signifi- cance and it is the patient as a whole and his gross abnormalities upon which attention should be focused. After the examiner has talked with the patient and secured as much of the information as possible that was discussed above, and has made a ouick general survey of the patient and noted any accomp- anying wounds of clinical importance, he is ready to examine the wound or wounds of the thorax. A decision as to the type of sur- gical therapy that will be indicated is based largely on the damage assumed to be done from the information so far obtained plus lining up the wound of entrance and present location of the foreign body as- found on roentgenography, or projecting the course of the missile between tie wounds entrance and exit in the case of perforating wounds. Multiple inspections of the wounds by various personnel are to be avoided, as they only lead to added risk of infection and, in the case of sucking wounds, further admission of air into the pleural cavity. Wounds that are adeouately dressed before admission to the Field Hospital need not to be disturbed until they can be 421 The Initial furgery of the Thorax end Thoraco-Abdominal Wounds. (Physical cont'd.) seen'by both the shock officer and the surgeon et the same time. The entire thorax, back, lumbar area and abdomen must be examined in every case otherwise a small wound of entrance may be overlooked to the later consternation of the surgeon. Fortunately, most foreign objects travel in a straight line from entrance to exit, or entrance to lodgement. The voluminous literature on the erratic course of missiles within the body have tended to over- emphasize the exceptional case that takes a bizarre course due to striking a rib or other bony structure. The explanation of most pecu- liar foreign body tracks is found by questioning the patient regarding the position he was in when injured. ’Wien the patient with a foreign body within the thorax that shows no wound of entrance other than the one over the deltoid tubercle of the arm tells the examiner that he was lying on the ground with his arm extended along side of his head, the course of the missile is no longer mysterious. Figure 56 - Illustration of the apparent bizarre course of an intrathoracic missile, in a patient whose only wound is in the upper part of the arm. 422 The Initial Surgery of the Thorax and Thoraco-Abdominal Wounds. (Physical cont’d). As is discussed below, the most freouent single indication for surgical treatment of the thoracic casualty in the forward area is a thoraco-abdominal- injury either proved or suspected. All thoracic wounds should be inspected with this injury in mine.. Again, the roost reliable information is obtained by projecting the course of the missile. Those foreign bodies that enter the chest and can be demonstrated to lie clearly within the abdomen by roentgenographic examination or those entering the abdomen and lying clearly in the thorax nose no particular diagnostic problem. Those that either perforate the chest in an area. There the diaphragm might be in- volved or which penetrate the thorax and lodge in the vicinity of the diaphragm give the greatest diagnostic difficulty. Cue to the motion of the diaphragm, wounds of the entire lower half of the thorax may nenetrate this division between the thorax and abdomen. As can be seen in the accompanying drawings (Figure 57), any lesion below the seventh interspace posteriorly or below the fourth rib anteriorly rosy injure the diaphragm if the patient is in the ex- piratory phase of respiration at the time. Figure 57 - See text. 423 The Initial Surgery of the Thorax anc Thoraco-Abdcminal bounds (Physical cont'd). Likewise, the pleural reflection extends down to the attachments cf the diaphragm to the ribs and costal arch so that any lesion at the level of the 12th rib or above posteriorly or involving the costal arch or shove anteriorly is a potential thoraco-abdominal lesion. PLATE. B DEMONSTRATION OE VARIOUS TYPES OE DIAPHRAGMATIC WOUNDS FROM PENETRATING OR PEREERAT1NG MISSIES Figure 58 - See text. 424 The Initie.1 Surgery of the Thorax and Thoracc-Abdominal Wounds. (physical c ont’d). Physical signs of abdominal involvement in the thoracc-abdominal injuries are helpful but not completely reliable. Many thoracic wounds give pain and spasm of the upper abdomen and many abdominal injuries nay exhibit a paucity of physical signs, especially if the spleen or liver are the only abdominal organs injured. In those in- stances of ueritoneal contamination from perforation of a viscus, intercostal nerve block of the lower thoracic nerves may be expected to relieve the spasm but not to affect the deep tenderness. Similarly, peristalsis is usually absent in the presence of intestinal perfora- tion. None of these signs is pathognomonic and it is, therefore, necessary that where reasonable doubt exists as to abdominal involve- ment exploration should be done. Injuries to the mediastinal structures are the second greatest diagnostic problem. Inasmuch as lesions of the heart and pericardium oresent a somewhat soecial situation they will be discussed later. Large hilar blood, vessels, trachea or major bronchi,and the esophagus must be considered. Lesions of all these structures are not frequently encountered. Fere again the projected course of the missile is the most reliable indication of suspected damage. Signs of continuing intrapleural hemorrhage are to be expected when a la,'rge blood vessel has been injured, but this need not be so. Injury to the trachea or major bronchi causes rapid accumulation of air in the pleural cavity and it will be found frequently under increased pressure. In fact, whenever air continues to leak into the pleural cavity it nay be assumed that a bronchus or branch bronchus is involved. Associated with this, may be noted varying degrees of mediastinal emphysema which, in combined experience has never been noted to be under sufficient pressure to obstruct the venous return to the heart end become symptomatic. It is our opinion that most of the symptoms commonly ascribed in the literature to mediastinal emphysema have been due to unrecognized, accompanying pressure pneumothoraces. There are no pathognomic signs of esophageal injury other than a demonstration of a break in continuity by the.swallowing of a radio- ops cue material. Diagnosis is usually made on the suspected course of the foreign body. In some instances of esophageal injury pain has been noted in the region of the posterior thorax or radiating down to the lumbar area:. Sub sternal pain on swallowing also has been de- scribed, This is probably a result of an inflammatory reaction in the posterior mediastinum, the most freouent cause of which is leak- age -From the esophagus. If lipiodal is available (it usually is not), the swallowing of one or two cc. with fluoroscopic or roentgenographic examination will give invaluable information. It is to be remembered that widening of the mediastinal silhouette is not necessarily due 425 The Initial Surgery of the Thorax and Thoraco-Abdominal Wounds. (Physical c ont1d). to esophageal, perforation. This same finding is often due to blood from injury to the vessels at the base of the neck. In many instances where these vessels may be involved, it is wise to explore the neck lesion first as the exact point of involvement may not be determin- able preoperatively. Also, certain of these vessels are better appro- ached from the neck than trans-thoracically. ROENTQZNQGRAPHIC EXAMINATION: Rational, intelligent, surgical therapy of thoracic and thoraco-abdominal injuries is not possible without roentgen studies. Every effort should be made to secure the best possible exposures in order to obtain all the information possible. Films should be taken with the patient in the erect position, with the exception of the severely shocked thoraco-abdominal patients, as such films permit much more accurate appraisal of the extent of the process and the organs involved. Projections in at least two planes are necessary. In the occasional instance that demonstrates the foreign body at a considerable distance from what was suspected from examination of the patient, especially if the missile is demon- strated to lie low in the thorax, the possibility of its being free in the pleural cavity is justified. This can sometimes be proved by another film taken with the patient lying down showing a marked shift of the missile. In those cases showing no foreign body roentgenographically and no wound of exit on examination, one should remember the other poss- ible explanations. The foreign body may have been a large missile of low velocity striking the chest, causing a wound, then falling back to the outside, or, it may be lodged in the abdomen or neck. So frequently are such cases encountered that some hospitals routin- ely take both abdominal and thoracic views in any case with injury to either region. Although this wastes a few films it eliminates taking patients back for further plates with attendant discomfort to the patient and loss of time. After the roentgen examination has been completed a review of the case in the lightof all the information, including the course of the foreign body as revealed by fractured ribs, will often clarify the doubtful case. PREOPERATIVE PREPARATION The preoperative preparation of the thoracic casualty is not just the administration of the proper amounts of blood and plasma to restore the circulating blood volume to a normal or near normal level. The most important single factor is the correction of 426 The Initial Surgery of the Thorax and Thoraco-Abdominal Wounds, (Preoperative Preparation, cont'd). cardiorespiratory imbalance and it is the duty of the shock officer to correct these abnormalities, insofar as possible, before the patient is operated on. The fact that should always be upper- most in the mind of the shock officer is that the aim of the surgical treatment of these casualties is primarily a mechanical readjustment to permit normal respiration, and secondarily, to prevent infection. In abdominal injuries the time interval from wounding to, surgery is of prime importance but is of only secondary concern in treating thoracic injuries. The thoracic case frequently dies of mechanical difficulties and attending cardiorespiratory imbalance, but only rarely does he die from infection, while the reverse is true of ab- dominal casualties. As far as time alone is concerned, it is im- portant only to shorten the interval to the minimum where diminished blood-oxygen supply may produce cerebral damage. Oncenormal oxygen- ation of the tissues is established, the time interval from that point to surgery is of much less importance. Hemopneuraothorax, blood loss, pain and an obstructed air-way are the most important shock-producing factors in patients with thoracic wounds, (if a thoraco-abdorainal lesion is present, periton- eal and pleural contamination must be added). Varying degree's of one may be present without the other, but the severe injury prac- tically always presents all in combination. The bony thorax imposes very definite limitations on the size of the thoracic cavity. Thus, any space-occupying medium can seriously disrupt the normal function of the heart and lungs, Pneumothorax and hemothorax, both being space-occupying, produce almost identical results. By impeding cardiac return and pulmonary expansion they not only tend to reduce the volume of circulating blood but decrease the degree of oxygen saturation. The response is an increased cardiac and respiratory rate, both almost invariably present in any severe thoracic casualty. The concomitant damage to the thoracic cage produces pain, and to minimize this component, motion is restricted. One therefore finds that these patients present a rapid pulse and rapid but shallow re- spirations. Deficient tissue oxygenation alone from an obstructed airway, pulmonary compression or contusion, or from a cardiac wound will produce the clinical picture of shock with low or unrecordable blood pressure, and rapid, feeble pulse. The inexperienced are apt to institute rapid blood replacement which may be fatal to an already unbalanced cardiorespiratory system. Intravenous therapy should be withheld in the thoracic casualty until it has been de- termined that he is suffering from-blood loss. The first and pri- mary effort except in those cases with obvious blood loss to the outside should ibe to ascertain the amount of blood and air that 427 The Initial Surgery of the Thorax and Thorac©-Abdominal Wounds. Preoperative Preparation contfd.) Ls In the pleural cavity and to remove it. By aspirating blood or air, or both, from the pleural cavity more will be dene toward re- lieving shock than by starting a blood transfusion. THORACENTESIS; Much has been written about the use of aspiration of blood and replacement with air in the treatment of hemothorax. It has now been well established that such air replacement is not only unnecessary but is to be avoided. Likewise the fear of as- pirating blood from the pleura during the early phase has been dispelled. There is no proof that the relief of intrapleural pres- sure and resultant lung expansion will start the bleeding anew from the injured pulmonary parenchyma. Even if it did, the shock ward is the proper place to determine this fact as the surgical manage- ment may differ widely if the surgeon knows beforehand that he is dealing with a potential injury to a large blood vessel. Bleeding from the pulmonary parenchyma will stop of its own accord in the vast majority of oases, and the relatively small pressure differ- ential that may exist in the pleural space due to a pneumothorax is not efficacious in checking a hemorrhage from one of the sys- tematic vessels. Many more errors are made by not aspirating the chest, than by aspirating it, with the remote possibility of re- starting a previously stopped hemorrhage. There has also been much discussion regarding the amount of blood that should be removed at any one time. No rule can be laid down but it is rarely necessary to stop because of the amount of blood per se. Certainly 1200 cc. to 1500 cc. can be removed with impunity. Should the patient experience discomfort or a feeling of pressure it is wise to stop and repeat the aspiration later if necessary. It is advisable to have blood either available or per- haps already running in the vein during the thoracentesis if the amount involved is found to be musually large. In the absence of a thorac©-abdominal injury larger hemothoraces, if less than 2A hours old, should be aspirated directly into a sterile Baxter donor bottle in order to save the blood for auto-transfusion. Air in the pleural cavity poses much the same problem as blood. It should be removed preoperatively for several reasons. First, to Increase aeration of the pulmonary parenchyma. Second, to ascertain the presence or absence of a pressure pneumothorax. Third, to determine the presence and approximate size of any broncho- pleural fistulas- Fourth, to obtain apposition of the lung and thoracic wall and thereby decrease the risk of empyema. Although a pressure pneumothorax is a real, life-endangering condition it is not found frequently. Iu this group of eases it was recorded as 428 The Initial Surgery of the Thorax and Thoraco-Abdominal Wounds. (Thoracentesis conVd.) being present in only 11 cases (O.SJ?). Furthermore, it is doubtful if all the reported cases were true pressure pneumothoraces because, such presupposes an injury that produces a valve-like mechanism which permits an easy ingress but difficult egress of air from the pleural cavity. This is not often found. Air is occasionally found under more than normal or even above the atmospheric pressure, bub such may be due to compression of air by intrapleural bleeding or, most frequently, to the irregular, splinting-type respiration, the result of thoracic wall pain. If thoracentesis reveals air under pressure that does not recede to normal levels, it is wise to assume that a pressure pneumothorax is present and provide a safety-valve by in- troducing a needle or catheter in the pleural space and attaching it to a water seal. The average thoracic casualty will be most comfortable when lying on his back with his head and thorax slightly elevated. In this posi- tion the diaphragms function more efficiently. Thoracic casualties in marked shock, with a systolic blood pressure of 90 mm. Hg. or less, and those that are in coma should have their heads slightly lower than the remainder of their bodies. When there are no signs of anoxia and the patient is conscious, he should be either flat or with his head elevated, whichever is more comfortable and provides the easier respirations. Some have hesitated to carry out thoracentesis frequently enough because they did not wish to disturb the patient by making him change position. This is not necessary as it is possible to remove almost all the fluid from the chest by introducing the needle low in the axilla. The place of preference for aspirating a pneumothorax is the 2nd anterior interspace. Thus, it is seldom necessary to dis- turb the patient in the least to carry out a chest aspiration. The needles used should be 17 or 18 gauge with short beveled, rather blunt points to prevent damaging the lung. The amount of blood and/or air removed from the chest is a very useful guide to the surgeon in planning the way in which he will repair the injury and help to re- establish normal cardiorespiratory function. The medical officer caring for the casualties preoperatively is a vital link in successfully treating such patients. There has been too great an inclination in the past to delegate such duties to just anyone who did not have any other pressing duties at the time. This was a costly lesson to learn as it takes wise judgement to treat in- telligently the thoracic casualty preoperatively. Whenever possible, such officers should be well-grounded in the basic physiological fmet ions of the heart and lungs. As a rule, a well-trained inter- nist is a better shock officer than a poorly trained surgeon. 429 The Initial Surgery of the Thorax and Thoraco-Abdominal Wounds, kSLIEF CF PAlb ; It has already been mentioned above that pain is an almost constant accompaniment of any injury to the chest. The painful stimuli originate in the thoracic wall and not in the lung itself. This is the key to proper therapy. It is far better to interrupt these painful stimuli near their origin rather than at- tempting to mask the symptoms by the use of depressant drugs. The painful impulses can be easily blocked near their origin by a procaine injection of the intercostal nerves supplying that area. This is another procedure that comes within the province of the officer in charge of the preoperativp preparation of the patient. Intercostal nerve block is a simple, efficacious procedure that can be accom- plished in five or ten minutes end will produce lasting effects far superior to morphine or other depressant drugs. If the painful segment of the thoracic wall is blocked, including two nerves above and two below the site of the injury, lasting effect is the rule rather than the exception. The use of intercostal nerve block has been discussed by many authors * and the technic has been amply described ?• These nerves can be anesthetized at any point central to the lesion. Some find it more convenient to do the injection at the angles of the ribs when the lesion is located anteriorly. Others prefer to do a paravertebral intercostal injection routinely. For the comparatively rare case involving the paravertebral thoracic wall, an injection of the sympathetic trunk above that location will also effectively block most of the pain-carrying fibers. Some confusion has arisen in the recent literature in this regard and it should be emphasized that it is not necessary to block the sympathetic chain In the usual case nor is there any evidence that a sympathetic block produces any result other than that obtained by the simpler inter- costal injection. It is probable that any sympathetic block also anesthetizes the contiguous intercostal nerve roots. The technic of paravertebral intercostal nerve block need not be set forth here but suffice it to say that it is a simple procedure technically and without appreciable risk to the patient. There .is seldom any indication for further administration of morphine to the thoracic casualty in the forward zone. One dose of morphine is usually administered by the company-aid man on reaching the casualty. As the standard army morphine syrette contains one- half grain, this is the usual dose. Although this dose is not harm- ful to many patients, it may be if they are already in severe shock and suffering from relative anoxia. From the thoracic standpoint, at least, It would be far better if the standard syrette contained only one-fourth grain as this dose has practically the same pain- abolishing power as the larger dose and yet is not as, depressant. It is not unusual for some patients to be given two or three doses 430 The Initial Surgery of the Thorax and Thoraco-Abdominal hounds. (Relief of Pain, contd). before they reach the Field Hospital,, This is often due to the rush of casualties and* insufficient time for the medical officer in the Battalion or Clearing Station to appraise the patient’s symptoms and determine whether or not his complaints are due to pain or other causes* Cerebral anoxia is very frequently accompanied by restless- ness that at times may be maniacal. It is not difficult to inter- pret such actions as writhing from pain and thus another syrette of morphine is given. The patient in whom this is most serious is the one who is already in rather marked shock with a lowered blood pressure and poor peripheral circulation. Under such conditions much of the drug may not be absorbed by the blood stream and thus the symptoms are unrelieved, leading to another dose of the drug. By such methods two or three one-quarter or one-half grain dosws of morphine may be given without the patient receiving much benefit. When,however, such a casualty reaches the Field Hospital and his circulating blood volume is restored to normal, all this accumulated morphine in the subcutaneous tissues is picked up by the improving circulation and he gets the effects of a huge dose at once with the signs and the symptoms of morphine intoxication. Four percent of our patients received over one-half grain while 0»5% had one grain or more during period. This problem has been discussed by Beecher In discussing morphine administration in the forward area men- tion should be made of a small group of cases that have been observed by many but for which, at present, there seems to be no definitely proven explanation. There is an occasional thoracic casualty brought into the forward medical installations that presents the typical picture of an overdose of morphine. That is, they have pin-point pupils, a slow respiratory rate and are difficult to arouse. Their records, however, do not record mare than one dose of morphine as a rule or perhaps two one-quarter grain doses. Thus, it does not seem that their symptoms were due to the morphine alone. Of course, it is well recognized that the medical record is not always accurate and when these cases were first seen it was attributed by many of us to morphine poisoning and we assumed that the total dosage of morphine as recorded was inaccurate. It is possible that such may still be the cause occasionally, but we believe that such cases are seen too frequently to be attributable to this mistake. Although we have no definite proof of this theory it is our clinical impression that it is another manifestation of relative anoxia. Such patients al- most invariably are severely wounded, have suffered from exposure and vjithout oxygen administration show cyanosis. They appear to be more common during the cold winter months when the patient may have 431 The Initial Surgery of the Thorax and Thoraco-Abdominal Wounds. (Relief of Pain cont*d.) lain out in the cold and wet for several hours, then during the per- iods of more moderate weather. If morphine is administered, the intravenous route is preferable as the effects are much more pre- dictable thereby. REPLACEMEMENT THERAPY; The amount of blood and/or plasma that should be given to a thoracic casualty depends mainly upon the amount of blood lost into the pleural cavity, into the lung or to the out- side. It is not necessarily dependent upon the degree of shock as measured by the level of the blood pressure as cardiorespiratory imbalance may be more at fault than actual blood loss. Any thoracic casualty will have lost some blood from the circulating blood volume and replacement therapy is a necessary adjunct in restoring the patient to a stable condition. The important thing is not to in- stitute rigorous replacement therapy using large amounts of blood or plasma unless it has first been determined that blood loss is playing a major role, and until measures toward correcting the mechanicalafcnormalties that are embarrassing the heart and lungs have been at least started. Rapid infusions of intravenous fluids when the heart is already overburdened by a large hemothorax or pneumothorax may so overload the heart as to produce a fatal issue. Likewise, the speed with which blood or plasma is given is import- ant and it need never be given rapidly unless it has been deter- mined that there is continued bleeding from a large vessel or that there has been marked blood loss previously. Obviously, the only reliable guide to the amount of blood or plasma that should be used is the clinical condition of the patient. The level of the blood pressure is to be used only as a guide to the aaoizit of blood or plasma to be given. It ie rarely indicated to use plasma in the preoperative preparation of the thoracic casualty ex- cept in those instances where some delay may be encountered in secur- ing and giving blood. Plasma may be needed and have to be given to sustain the patient before admission to the Field Hospital but It should not be needed otherwise in the preoperative preparation. In this regard, it is to be remembered that the time factor is of lesser importance compared with the abdominal wound, or traumatic amputation where gas gangrene may threaten. It is better to proceed slowly with restoration therapy rather than to crowd the deranged oardio-vasoular mechanism. In thoraco-abdominal injuries one has to balance the above fac- tors against the risk of increased time lag, a factor of much impor- tance in any abdominal injury. 432 The Initial Surgery of the Thorax and Thoracoabdominal Wounds, Replacement Therapy contrd. It is necessary to operate on the majority of chest casualties either chi the side or to turn them on the operating table to expose various -rounds. Thus, much time will be saved and difficulties minimized if the infusion given in the preoperative ward is started in one of the veins of the leg. This can usually be accomplished at the ankle without the insertion of a cannula but such should be done if a needle cannot be inserted. Should a cannula be used, the saphenous vein, six inches above the internal malleolus, is the point of preference. A needle in an arm vein so frequently becomes dis- lodged or the vein obstructed due to the position or turning of the patient on the table that the precaution of starting it in the ankle is very worth while. It not only saves the anesthetist the bother of trying to re-start the intravenous fluids during the operation when the needle becomes dislodged or occluded but provides the pat- ient with added protection as one never knows beforehand when it will become necessary to administer blood rapidly during the opera- tion. Patients with multiple extremity wounds needing prolonged intravenous therapy may not present available avenues of adminis- tration. In such instances, use should be made of other routes such as sternal puncture, external jugular veins, and the corpus cavernosum of the penis. Except for the few patients with continued bleeding from large vessels, it should be possible to restore the thoracic casualty to a comparatively normal balance before proceeding with surgery. In this regard, it is to be remembered that anoxia and excessive CO2 nay result in an elevated blood pressure. Thus, a patient that is admitted with a high normal or elevated blood pressure may at first show a fall with the institution of proper shock therapy. Such readings will not mislead the loan experienced in preoperative care but the elevated pressure on admission may give the inexper- ienced a false sense of security. There is no one reliable guide to the degree of shook in such patients and the clinical impression of the experienced medical officer is a much better guide than any body function that can be measured and recorded nuaerically. OXYGEN THERAPY; The greatest hazard to the soldier with a thoracic wound is insufficient oxygenation of the tissues. Thus, any means of increasing the amount of oxygen transported by the blood is in- dicated. It is a safe rule always to start oxygen on these patients as soon as they are admitted and to continue it until a more de- tailed appraisal of the patient can be made. Although a mask may be more efficient, it usually has been found that the use of an intra-nasal catheter with oxygen flowing at the rate of at least six to seven liters per minute is the mere practical means of 433 The initial Surgery of the Thorax and Thoraco- Abdominal Wounds. (Oxygen Therapy contfd). administration. The role of oxygen therapy in the treatment of shock in general has been much debated but there would seem to be no logical argument against its routine use in thoracic casualties . WIT LONG: The pulmonary parenchyma reacts to trauma in much the same way as any other body tissue. That is, either trauma to the thoracic wall or a penetrating or perforating lesion of the lung produces a certain amount of laceration and contusion resulting in extravasation of body fluids into the pulmonary tissues. The amount of such reaction is dependent upon the size and velocity of the missile, and whether or not it strikes any portion of the bony cage, besides many other less important factors. Also the size of the damaged intrapulmonary vessels has a bearing on the amount of extravasated blood. Blast lungs are an example of the amount of pulmonary damage that may result from such a contusing effect even though there is no pleural penetration or even evidence of thoracic cage involvement. There must necessarily to a certain amount of this "blast" effect in any penetrating or perforating lesion quite apart from the damage done by the passage of the foreign body itself. Thus, any thoracic injury, except those of the smallest magnitude, results in some degree of pulmonary con- tusion. Since the vessel walls are thin and in close approximation to the air sacs, some fluid or blood itself, if the damage is severe enough, must escape into the airway. The pathological findings in pulmonary blast from a pressure wave and in pulmonary contusion from a penetrating or perforating wound are essentially the same. That is, both result in interstitial and intra-elveolar extravasation of blood with edema and rupture of the alveolar walls. The natural reaction to pain of injury is splinting. Thus, the corresponding hemithorax moves less than the unaffected side with a resultant decrease in the movement of air back and forth in the bronchi. This decreased tidal respiration is probably of more importance than previously recognized as it lessens the amount of material that might be disposed of by evaporation. It has been noted repeatedly that the findings of "wet lung" are much more common in the cold, wet winter months when many of the casualties have a productive, purulent bronchitis before being wounded. Some of the severely wounded present an extreme type of "wet lung". Anoxia, tracheal obstruction and increased respiratory effort (all. of which may be present in the severely wounded) have been shown by Drinker and Warren to produce pulmonary transudates and exudates. This fluid forms so rapidly and in such amounts that it may be difficult 434 The Initial Surgery of the Thorax and Thoreco-Abdominal Wounds. {Wet Lung contfd.) to keep the airway clean even with a tracheal catheter or by bronchos- copy. Because this condition resembles pulmonary edema seen in other conditions, positive pressure oxygen therapy as used by Baracb was employed. In some instances the reduction in rate of formation of this fluid was dramatic. This subject has been discussed by Brewer et al The above mentioned factors are all operative in the production of more than the normal amount of materiel in the respiratory passages. Such accumulation of material in the smaller bronchi, the limitation of motion due to pain, the tendency to suppress the desire to cough because of pain, together with the suppression of the cough reflex by morphine, mil Inhibit proper oxygenation of the blood. The re- sultant diminished oxygenation is a potent factor in the production and prolongation of shock. Breaking this cycle is an Important step in shock therapy. The problem can be attacked in two ways. One is by relief of pain by intercostal block as mentioned above. This may, in some cases, be all that is necessary. With the relief of pain the patient is no longer hesitant about coughing and by this means removes material from the air passages. Often however, the block alone is insufficient as the patient may be exhausted, or uncooperative for other reasons so as not to cough effectively. In such instances it becomes necessary to remove the blood and excessive tracheo-bronchial material by mechanical means. The simplest method of so doing is the introduction of a catheter into the trachea and major bronchi and aspirating with a suction machine. Such a catheter can easily be introduced through the nose in the Banner originally described by Haight and modified by Samson, Brewer and Burbank •• In all but the nearly moribund the presence of the cathe- ter in the trachea produces a very powerful desire to cough which can- not be ignored willfully by the patient. He Is thus forced to cough even though he may try to prevent it. It is this combination of in- duced coughing together with the mechanical removal of the material through suction on the catheter that clears the airway. The results of such therapy are often dramatic and will change the cyanotic, coma- tose patient with a very wet, rattling type of respiration to an alert patient with good color in a matter of a few minutes. One such as- piration may improve the patient sufficiently soiiat he will cooperate and cough effectively thereafter. If not, the aspiration must be re- peated. in those Instances where the patient is comatose or unres- ponsive, even after aspiration, it is often convenient to leave the intratracheal catheter in place using it for aspiration of fluid mater- ial when necessary wtd for administration of oxygen in the interval between. (Caution is to be exercised to assure the correct position 435 The Initial Surgery of the Thorax and Thoraco-Abdominal Wounds. (Wet Lung cont’d.) of the catheter. Inadvertent introduction into the esophagus can produce gastric dilation of serious proportions). Such a catheter is surprisingly well tolerated for a period of hours by the comatose patient. A detailed discussion of this problem of "wet lung" will be found in the literature by Samson. Burford, Brewer and Burbank U, 17, 18. GASTRIC Many patients even without abdominal injury show marked degrees of gastric dilatation sufficient to cause respiratory embarassment. It is especially true of thoracic cases. This finding has recently been discussed by Beech and Wolff 1 . A Levin tube should be inserted into the stomach during the preoperative period to relieve any dilatation of the stomach and to help prevent vomiting during the induction of anesthesia. In thoraco-abdominal injuries drainage of the stomach preoperatively is mandatory. ANESTHESIA The anesthetist is probably the most important member of the opera- tive team caring for thoracic casualties during surgery. As has been pointed out elsewhere 20 well-qualified anesthetist can support an inexperienced surgeon better than a brillant surgeon can maintain an inexpert anesthetist". Whenever possible, the anesthetist should be a physician as he has far greater responsibilities than just keeping the patient in the proper plane of anesthesia. He should be able to manage the shock therapy during the operative period and must main- tain a clear airway at all times. Ideally he should also be qualified to carry out bronchoscopic aspiration. There is a place for local anesthesia in the treatment of thoracic wounds but it is quite limited in the forward zone. Not only do these patients usually have a sufficiently severe wound to require general anesthesia but it is the rule rather than the exception to have asso- ciated injuries requiring operation so that local anesthesia becomes impractical. Paravertebral nerve block plus local infiltration is sufficient, as far as pain relief is concerned, to carry out practi- cally any thoracic procedure. But the necessity of positive pressure to Inflate the Itngs and the need for anesthesia for other accompanying wounds has resulted in a very small Incidence of local anesthesia for thoracic injuries in the forward area. On the average 14.& of the •anesthesias used in this Group before May 1944 and 7•% after 1 May 1944 were procaine. The higher incidence in the first period was due to the treatment of a greater number of the less severely wounded thoracic eases in Field Hospitals instead of sending them to the Evacuation Hospitals as was the policy later on. 436 The Initial Surgery of the Thorax and Thoraco-Abdominal Wounds. (Anesthesia cont*d.) The same can be said of pentothal anesthesia. It can be need in the less severe cases and in any where the pleural defect is snail or the pleural cavity is not to be exposed. The uncertainty of determining precisely before operation just what will be fotaid at operation has limited very markedly the application of this anesthetic agent. It is a sage rule to always use endotracheal anesthesia in any instance where it is contemplated either to expose the pleural defect or do anything more than a simple debridement of the thoracic wall. A study of our figures reveals that endotracheal anesthesia was used in 48 of the cases prior to May 1944. During the one year period from May 1944 to May 1945 the percentage of endotracheal anesthesia was found*to be 80.• This again reflects the change in evacuation policy as well as the realization by the surgical teams that it is better to err on the side of too extensive preparation rather than to start an operation under pentothal or procaine, only to find that it is desired to carry out a more extensive procedure, necess- itating a change of anesthestic agents. Anesthetizing a severely wounded thoracic casualty is a far cry from the routine anesthesia given in civilian practice. These men have not been as well prepared «s is the rule in civilian life. They have had recent damage to their respiratory systems and often have considerable oozing of blood into the respiratory passages. Besides these factors, their shock may not have been completely corrected, and treatment of it must be continued during the period of the opera- tion. All these factors impose an added burden on the anesthetist as he must handle them all, while keeping the patient in the proper plane of anesthesia. Maintenance of a clear airway is of prime im- portance. The problem of wet lung has been briefly discussed above and there can be no doubt but that the soldier with a chest wound is apt to have a marked amount of material composed of blood and mucus In his respiratory passages. If this material is allowed to accumulate it prevents ingress of air and interferes with oxygenation of the blood, which presents a real hazard to the patient. It is a prime duty of the anesthetist to keep the material out of the air passages and to provide optlmun conditions for oxygenation. A fur- ther threat of this excessive material in the bronchi and trachea is the possibility of its being disseminated to the opposite lung as it is usually necessary to operate these patients lying on their better side. This provides the best possible condition for the drain- age of blood and mucus from the injured lung to the uninjured side with resultant atelectasis. Periodic aspiration of the trachea and bronchi with a long, small caliber catheter Introduced through the endotracheal tube is usually sufficient to cope with this hazard. It nay be necessary, because of demonstrated Inadequate exchange. 437 The Initial Surgery of the Thorax and Thoracoabdominal Wounds. cont’d.) to perform a bronchoscopy during operation. Though this is rarely indicated the anesthetist should be able to carry out the procedure when necessary. Likewise, the cleansing of the air passages at the completion of the operation is his responsibility and bronchoscopy is often indicated. It is advantageous to have the lung expanded periodically during the operation by the anesthetist in order to facilitate re-expansion at the termination of the operation. Such expansion should likewise be done during the operation at any time when there is any indication that the patient may not be well oxygenated. It can be readily appreciated in view of the foregoing that the anesthetist carries a large part of the responsibility in treating these severely wounded men. The more competent the anesthetist the less the burden on the surgeon. With a well-qualified anesthetist at the head of the table the surgeon can give his undivided attention to the operative procedure itself. BASIC OPERATIVE CONSIDERATIONS As stated previously in most wounds of the thorax, without abdom- inal involvement, cardiorespiratory physiology will be restored in part or entirely,by resuscitative means. Major surgery is necessary in a small number to restore cardiorespiratory balance but in the great majority, including t home ©-abdominal injuries, it is employed to prevent infection. It is only to the degree that the surgeon is able by surgical Mans to restore the patient to a normal cardio- respiratory balance that he will obtain dramatic improvement in the condition of the patient with an uncomplicated thoracic injury. It is not to be implied that thoracic patients do not die of infection, but it is not the usual cause of early postoperative deaths. These early deaths are due to disturbed physiology while the deaths from infection are practically all limited to the late phase from weeks to months later. Thus the surgeon*s primary interest at operation is the restoration of a functioning lung which is fully expanded against an Intact or restored thoracic wall. Prevention of infection is important but only secondary. Respiration is dependent upon lung expansion and an intact thoracic cage, and it is toward the attain- ment of these two objectives that the surgeon’s attention is directed. The above factors plus those of peritoneal contamination are of importance in the thoracoabdominal eases. Here, resuscitation cannot be complete without surgical repair of the intraperitoneal 438 The Initial Surgery of the Thorax and Thoraco-Abd ominal Wounds. (Basic Operative Considerations cont’d), damage. Operative interference is indicated as soon as cardiorespiratory stability will permit. It is not necessary that the surgeon be too concerned with what may be the later complications, in the case with only thoracic involve- ment. His prime concern is the saving of life and other less pressing factors may be relegated to the thoracic center in the base. With some regard however, for what may be the late complications the for- ward surgeon can go a long way in relieving the load on the base center and lessening the morbidity. That is, a foreign body in the lung should be removed if the surgeon has the lung exposed for some other reason, yet an intra-pulmonary foreign body is seldom an indication for a thora- cotony in the forward area. On the other hand it is known that large hemothoraces which are allowed to clot and are not removed often result in a marked reduction in pulmonary function due to a fibrin deposit that encases the lung. When this is of sufficient degree it may have to be evacuated at the base. If the surgeon who carries out the ini- tial surgery removes this blood there will be no further pulmonary crippling necessitating a second operation. Thus, it can be under- stood that the surgeon doing the initial surgery is to be primarily concerned with saving the patient’s life yet, by exercising judgement and taking advantage of the opportunities presented, he may be able to prevent increased morbidity, including that due to infection, and secondary operative procedures. PENETRATING uR PERFORATING WOUNDS NOT DEMANDING THORACOTOMY A recent MTuUSA directive clearly states what conditions in themselves are not indications for early thoracotony in the forward areas, either ty extension of the wound or by separate incision: "(a) Foreign bodies, i.e., metallic fragments, or rib fragments in the lung, or small fragments that may be in the pleural space, (b) Hemothorax (evacuation of blood, from the pleural cavity by suction at the time of chest wall debridement is not considered a thoracotomy)• (c) Lacerated or contused lung unless there is definite evidence of continuing hemorrhage". The surgeon doing forward thoracic surgery must always remember that his main objective is the preservation of life and that he is not to concern himself primarily with anything else, It has been conclusively shown *2, 24., over-zealous surgical interference in the early phase results in an increased morbidity and number of complications. It is further suggested by the figures presented in the statistical appendix attached hereto that the mortality is the lowest when the forward surgeon confines his major Intrathoracic operations to the definite indications 439 The Initial Surgery of the Thorax and Thoraco-Abdominal Wounds, tPenetrating or Perforating Wounds Not Demanding Thoracotomy contM). presented below. It should be emphasized that the performance of an unwarranted thoracotomy puts an added burden on an already damaged cardiorespiratory system. By so doing, the forward surgeon unwittingly may be administering the coup de grace. For the purpose of discussion it is necessary to divide these penetrating and perforating wounds into two groups, the small and the large, as the surgical treatment of them differs. The larger ones, by which we mean any that produce a pleural defect six cm. or more or which destroys three or more ribs and intervening structures are termed traumatic thoracotomies. The latter term is employed because when the wound is debrided one is presented with a pleural defect of such extent that any necessary intrathoracic procedure may be carried out. THE OPERATION THEREBY BECOMES A THORACOTOMY, BECAUSE OF THE SIZE OF THE DEFECT CAUSED BY THE MISSILEi The surgical treatment of the first group, the small penetrating or perforating lesions, resolves itself into treatment of the wound, removal of blood and/or air from the pleural space, re-expansion of the lung and securing an air-tight closure. This group {pleural de- fect after debridement of less than six cm.) does not present any great difficulty in thoracic wall closure. Most often it is not possible to close the pleura itself, but we feel it is unnecessary mless easily accomplished. This means however, that there is an opening between the thoracic wall structures and the pleural cavity. Thus, any infection occurring in the soft tissues of the thoracic wall can easily extend into the pleura producing an empyema. For that reason we advocate a radical debridement of the missile track down to the intercostal structures. These need not be resected ex- cept in instances of marked damage, since by so doing the defect is enlarged. Wound excision of the thoracic wall would be a more app- ropiate name for our method of treatment. In this group of smaller lesions, closure of the thoracic wall structures is not difficult, and one should feel free to excise as widely as necessary. Whether or not a catheter is inserted into the pleural cavity for pleural lavage with normal saline depends upon the amount of blood and clots present. In many instances it is possible to so remove not only the liquid blood but clots as well. Thus, one of the main objectives of early therapy - rapid expansion of the lung - may be advanced by this procedure. Diligent aspiration of the chest with a needle is just as effective in the removal of fluid blood and has been used in the majority of cases in this report. 440 The Initial Surgery of the Thorax and Thoraco-Abdominal Wounds. (Penetrating or Perforating Wounds Not Demanding Thoracotomy cont’d). It is advisable to leave the skin open as it can be closed a few days later at the base and there is little delay in securing complete wound healing. Primary suture could be carried out safely in many of the cases but the complications in the occasional case more than offset the gain that would be obtained. Following the operative procedure it is our practice to carry out an intercostal nerve block going at least two nerves above and two below the site of injury in order to insure a painless wound that allows the patient deep res- piratory movements and coughing without pain. Such prophylaxis pre- vents many postoperative complications that might otherwise ensue. INDICATIONS FOR THORACOTOMT The indications for thoracotomy in the forward area have been the subject of much discussion. Out of the early confusion a rather clearly defined policy has evolved that has proven its worth. We believe that thoracotomies in the forward area should be done for the following in- dications? 1. Possible thoraco-abdominal injuries; 2, Large chest wall defects (traumatic thoracotomies);* 3. Miscellaneous indications, (a) suspected injury to the heart that might be amenable to repair, (b) severe continuing intrapleural hemorrhage of whatever source, (c) possible esophageal damage, (d) large branchial fistulae from injury to the trachea or a major bronchus, (e) removal of excessively large intrapleural or intrapulmonary foreign bodies (such foreign bodies will in most instances have produced a traumatic thoracotomy in traversing the thoracic wall). Although the numerical list of indications for thoracotomy in the miscellaneous group is large, the actual incidence of such being the Indication for operation is small. Much emphasis has been placed on continued intrapleural hemorrhage as an indication for' thoracotomy. No one can argue that such a condition is not an in- dication for thoracotomy, but it has been the universal experience of those doing forward surgery that this is a. rare rather than a common condition. It has infrequently been necessary to do a thora- cotomy for continuing hemorrhage. (Table VIII). Also it is obvious from the records of our Group that some surgeons have operated for supposed continued hemorrhage without adequate evidence that the hemorrhage was continuing. It is difficult to generalize on how much bleeding constitutes life-endangering hemorrhage. Bleeding of such severity from the pulmonary parenchyma is exceedingly rare. That which does occur is mostlv-from one of the systematic vessels car from the heart itself. We have found the following criteria to be the most reliable guides to serious continued hemorrhages 441 The Initial Surgery of the Thorax and Thoraco-Abdominal Wounds. (Indications for thoracotomy cont’d.) (1) A blood pressure which falls to rise with apparent adequate blood transfusions in amounts as high as 2500 cc., or having risen to relatively normal levels, falls again; (2) Re-accumulation of 1500 cc. to 2000 cc. of blood in the pleural cavity within 2U hours of the initial aspiration of a similar, large amount; (3) Persist- ing severe anemia in spite of blood replacement, as determinated by serial hematocrit readings. INCISION FOR TH0RAC0T0MI There has been considerable discussion regarding the classifica- tion of thoracotomies as to whether they "were "through the wound", "through a separate incision", or "limited thoracotomies". This has been done in an attempt to differentiate between the comparatively major and comparatively minor intrathoracic procedures that are carried out. There is considerable doubt if such a distinction accomplished this purpose. There is not necessarily any correla- tion between the location of the incision and the extent of the needed repair work. It is similar to classifying abdominal opera- tions into small laparotomies and large laparotomies. It is our opinion that too much stress has been placed on the question of incision, i.e., whether through the wound or through a separate in- cision. To us, THE PARAMOUNT QUESTION TO BE ANSWERED IS WHETHER OR NOT THERE IS AN INDICATION FOR A THORACOTOMY. Once that has been decided in the affirmative, selection of the site of incision is simple. If there is a wound so placed on the thoracic wall that it involves the area chosen for thoracotomy then the operation should be carried out through an extension of this original wound. We are strongly opposed however, to using the wound unless it is placed in the area of election. The incision should he selected with one consideration in mind and that is gaining maximum exposure of the desired area. In other words, the location of the thoracic wall wound Itself has no bearing on the indication for a thoracotomy. Such a wound should not be enlarged into a thoracotomy any more readily then the surgeon would proceed with a thoracotomy through a separate incision for the same lesion. We are again in agreement with the Theater policy of advising a posterior approach for practically all thoracotomies. It not only permits the best exposure to most of the chest but such a wound is much more readily closed, and' is not subject to as many complications as an incision in the relatively thin anterior thoracic wall. Prac- tically the only exceptions to this rule are the traumatic thoraco- tomies and the occasional cardiac wound in which an anterior approach 442 The Initial Surgery of the Thorax and Thoraco—Abdominal Wounds. (Incision for Thoracotomy contM.) may be preferred. In carrying out an anterior thoracotomy, an inter- costal incision is definately better than resecting a rib because the former permits a much more satisfactory type of wound closure. Re- section of an anterior rib often leaves a soft thoracic wall. In dealing with thoraco-abdominal wounds or when such are sus- pected, consideration should be given to the projected course of the missile in selecting the site of incision. Too often attempts are made to deal with these lesions through incisions too low chi the thoracic cage. This is especially true if the missile has gine through the 11th or 12th ribs. Resecting one of these ribs does not give ade- quate exposure for exploration. As a general rule, it is best to use the ninth or tenth rib (or corresponding interspace) for lesions in- volving the posterior segment of the diaphragm and either the ninth or eight rib for lesions of the mid-or anterior diaphragmatic portions. Some surgeons have employed a combined incision for certain thoraco- abdominal injuries. That is, extention through the chondral margin on to the abdominal wall. It is our opinion that such an incision is to be avoided because of the resultant Instability of the thoracic cage and the increased morbidity should wound infection in the costal cartilages ensue. It may also be stated that wide exposure is to be commended. If the surgeon has reason to inspect the interior of the thorax he has reason to explore it completely. The wound of the anterior, superior chest presents a unique problem in exposure if it is necessary to expose the large vessels in the superior mediastinum and base of the neck. The mediastinal portion alone can be quite well managed intrathoracically, but so often the exact point of injury is undertermined preoperatively that it is necessary to have exposure of both the cervical and mediastinal portions of the vessels. In such instances a curving anterior in- cision exposing the base of the neck, clavicle, and lateral half of the sternum on one side has been the most satisfactory, k section of the manubrium with the sternoclavicular joint can be reflected outward by previously dividing the clavicle. In this manner all the major vascular structures can be exposed and if the pleura has not already been damaged the operation can be done ertrapleurally. When available, a Gigli saw makes %he sternal and clavicular sections easier to accomplish, (Figure 59), 443 The Initial Surgery of the Thorax and T h oraco-Abdominal Wounds. (Incision for Thoracotomy cont’d.) Figure 59 - (Modified from Harken), See text THORACOTOMY FOR THORACO-ABDOMIML INJURY DEFINITION: There has been some confusion due to inadequate definition. A thoraco-abdoadnal injury signifies that the missile has entered or traversed both the pleural and peritoneal spaces. This necessitates perforation of the diaphragm. Ill injuries that involve the chest and abdomen by the same missile are true thoracoabdominal injuries. If separate foreign bodies have entered each of the cavities they are not true thoraco-abdoainal lesions as the diaphragm has not been injured. As surgical procedures may differ from those employed in thorac©-abdom- inal injuries, cases with separate injury to the thorax and abdomen are better termed combined thoracic and abdominal. injuries. 444 The Initial Surgery of the Thorax and Thoraco-abdominal Wounds. for Thoraco-abdominal Injury cont'd.) POSSIBLF THORACO-ABDOMIMAL INJURY: It is of paramount importance to explore every thoraco-abdominal injury just as much as a laparotomy is indicated in every suspected abdominal penetration. The various factors that influence the selection of the proper approach - that is whether through the chest or through the abdomen - will be con- sidered in detail below. Inasmuch as all but 66 of the 903 thoraco- abdominal wounds treated by our Group showed the path of the missile to be from thorax to abdomen, it is readily apparent that most of the questionable cases will show thoracic involvement without peri- toneal inj toy in those cases that prove to be non-thoraco-abdominal lesions. Therefore, it is wise to explore the chest first in any doubtful case. That such a policy has been followed in our Group is indicated by the figures in Table VIII. It was found that 122 thoracotomies were done for suspected diaphragmatic penetration but none found at operation. The importance of this group is more readily appreciated by noting that it comprised 2% of all thoraco- tomies done in the forward area even when the positive thorac©-ab- dominal lesions are excluded. In all these cases it was obvious clinically that the abdominal damage would have to be confined to the vicinity of the diaphragm and could be handled transdiaphragma- tically. This figure for negative exploration may appear high to the inexperienced, in comparison with the number of negative abdom- inal laparotomies that have been done for suspected abdominal injury. The discrepancy is attributable to two factors. The first is the difficulty of ascertaining by clinical means whether or not an organ in the upper abdomen has been injured such as the liver or spleen, and which may be associated with a paucity of the usual abdominal signs or symptoms. The-second is the fact that lesions of the lower thorax often produce abnormal signs in the upper abdomen. The lethality of untreated abdominal injuries is such that exploration must be carried out in each instance where there is any doubt. The only cases that permit any other course are those in which small foreign bodies can be demonstrated to lie Within the right lobe of the liver. If such missiles are but two mm, or three mm. in dia- meter the chance of their producing sufficient damage to warrant exploration is remote. Any foreign body larger than three mm. should be considered of sufficient siae to demand exact knowledge of the damage it may have produced. AFJffiffAQLl:. hard and fast rule can be laid down as to the operative approach for all oases . The question is whether it shall be through the chest or through the abdomen or both. The choice is dependent on three factors. First, whether the abdominal damage can be repaired 445 The Initial Surgery of the Thorax and Thoraco-Abdominal Wounds. (Approach cont’d.) more easily from above or below; second, whether more extensive damage is expected in the chest or in the abdomen; third, the personal choice of the surgeon which is dependent on his training and experience. Thora- cic surgeons tend to do more cases from above while abdominal surgeons take the opposite stand and prefer to do as many as possible through the abdomen. What are the advantages of each approach? The transthoracic method will be presented first. There are eight factors that need to be men- tioned, 1. If there is much thoracic as well as abdominal damage, the thoracic part cannot be done from below. 2, Certain upper abdominal lesions are more easily handled through the diaphragm. This applies to the spleen, splenic flexure of the colon, upper portion of the stom- ach (especially if the posterior surface is involved), the dome of the liver, and both kidneys. 3. Diaphragmatic repair is best accomplished transthoracically. This is true of both the right and left sides. Small lesions of either side may be closed adequately through the abdo- men. But, those over the liver dome and large defects such as result from the tearing of the diaphragm from the costal margin, especially posteriorly, must, in most instances, be repaired from above. 4, It permits exteriorization of the transverse or splenic flexure of the colon through a subcostal gridiron incision at a greater distance from the operative incision than is possible if a laparotomy has been done. Wound infection is thereby reduced to a minimum. 5. Postoperative pain is less severe from a thoracotomy than from a laparotomy. During thoracotomy the two accompanying intercostal nerves are easily exposed and crushed with a hemostat. Having less pain the patient will aerate the lings more adequately - and raise bronchial secretions more com- pletely than if he is experiencing discomfort from an abdominal incision, 6. If marked pleural contamination is present due to a lacerated stom- ach or colon, copious pleural lavage with normal saline solution will decrease the severity of the pleural infection. Such a procedure is possible only through the chest. 7. The patient may be carried in a light plane of anesthesia during a transdiaphragmatic laparotomy as abdominal relaxation is not necessary. 8. Although it may not be apparent preoperatively, considerable damage to the intrathoracic organs may be present. This will not be determined and its repair, therefore, not accomplished if the exposure is an abdominal one. The factors favoring an abdominal approach are two. 1. It is indicated to repair lesions of the lower ileum, cecum, ascending, lower decending, sigmoid and hepatic flexure of the colon. Many of these structures cannot adequately be exposed transdlaphragmatioally. 446 The Initial Surgery of the Thorax and Thoraco-Abdominal Wounds. (Approach cont’d). In such instances, laparotomy is mandatory. 2. Should the thoracic disturbance be minimal and operative therapy not indicated, (such as a small hemothorax or minor perforation of the lung) an abdominal ex- ploration prevents entering another serous cavity, provided that the diaphragmatic repair can be done from below. It is apparent, therefore, that certain lesions are best done from above and certain others from below. Inasmuch as most of the abdominal damage will be found in the upper abdomen it is advisable to do all questionable cases from above. Also, if it appears that there has been appreciable damage in the thorax the lesion is best approached through the chest. Should such exploration reveal abdom- inal lesions that cannot be exposed adequately one should have no hesitancy in doing both a thoracotomy and a laparotomy. If the thoracic physiology is restored by the thoracotomy the patient is in better condition to withstand a laparotomy. Finally, one must take account of the experience and qualifications of the individual surgeon. We do not submit that the performance of a thoracotomy is a difficult procedure nor that the postoperative management of patients subjected to intrathoracic operations is difficult. The general surgeon however, whose experience in modern thoracic surgery has been limited, does not fully appreciate the importance of securing air-tight closure and stability of the thoracic cage, complete and rapid re-expansion of the injured lung, and the maintenance of a clear tracheo-bronchial pass- age during the postoperative period. If the surgeon is not conversant with these objectives and the means of securing them it is safer for him to utilize the abdominal approach. .OPERATIVE TREATMENT; The abdominal phase of the repair of thoraco- abdominal lesions does not differ from that of the plain abdominal injury, and as the thoracic phase will be presented below it is not necessary to discuss these factors in any detail at this time. There are two points of particular significance in relation to thoraco-abdom- inal lesions that we wish to emphasize. The diaphragm can be repaired by many different methods. Inasmuch as there have been reports of bile empyemata * on the right side end diaphragmatic hernia on the left, it is necessary to repair the diaphragmatic defect as securely as possible. In our hands, a two layer closure has been found the most satisfactory. This may either be by imbrication of two cm. of the diaphragm or by simple approxima- tion re-cnforced by a second layer of inverting mattress sutures. All sutures are of cotton or silk and all are placed interruptedly. This type of repair is seldom possible through an abdominal approach. In general we have felt that there are few Indications for crushing the phrenic nerve. 447 The Initial Surgery of the Thorax and Thoraco-Abdominal Wounds. (Operative treatment cont’d.) Any hepatic lesion that warranto exploration should be drained by some means. Packing is rarely indicated and the standard Penrose drain is the usual one employed. The drain or pack is brought out subcostally in such a manner as to provide dependent drainage. This means that the incision should be placed as far laterally a,s possible in order tc avoid collections in the gutter, or, the liver laceration can be drained by the shortest route to the outside with an added drain in the right gutter. The drainage incision should be at least four cm, in length thru all layers of the abdomen wall and not a simple stab wound Certain innocent appearing liver perforations may have damaged the larger bile radicals and such cases may subsequently drain large amounts of bile. This may cause bile peritonitis or a disruption of the dia- phragmatic suture line if adequate drainage is not employed. The amount of drainage that escapes through the drain is variable, depend- ing upon the amount of damage. Likewise, the period during which drain- age may continue is unpredictable. One should err on the side of leav- ing the drains in place too long rather than to remove them too early. This problem should seldom confront the forward surgeon as in most instances it is best to leave the drains in place until the patient is evacuated to the base, also section on Hepatic Wounds, page 307) TRAUMATIC THORACOTOMIES Traumatic thoracotomies have been arbitrarily defined as any lesion of the thoracic wall that when debrided leaves a pleural defect six cm. or greater in one diameter or destruction of three or more ribs and all intervening structures. use of the term is compar- able to the term traumatic amputation. If, as a result of trauma, an extremity is completely amputated or so badly damaged that an adequate debridement results in an amputation, the term traumatic amputation is used). Such extensive damage to the thoracic wall, in practically every instance, results in some damage to the underlying lung as pul— monary lacerations or retained fragments. Thus, some intrathoracic manipulation may be indicated inasmuch as the exposure has already been obtained by debridement of the wound. They must be classified as thoracotomies, therefore, even though the intrathoraeic damage in itself is not an Indication for thoracotomy during the early treatment. These large chest wall defects have not been given as much recognition as they deserve and are not even mentioned in most articles or directives. The size of the pleural defect is admittedly an arbitrary figure. In some instances smaller pleural defects permit the removal of a foreign body or the suture of a lung laceration. The important dis- tinction to be kept in mind is that the size of the pleural defect following debridement is such as to permit any indicated intrapleural 448 Initial Surgery of the 'thorax and Thoraco-abdominal Wounds (Traumatic Thoracotomies, tcontd) nari'i mila tions. BUT SUCH I1ITRAPLSURAL LBSlONi ARE NOT Id IN- DICATIONS FOR THORACOTOMIES IN THE FORWARD AREA. THE INTRAPLEURAL PART OF THE OPERATION IS ENTIRELY SECONDARY. This 'toup of cases is the second of the two main indications for thoracotomy in the early treatment of thoracic war wounds. These wounds are most often caused by a fragment of high explosive shell. In some in- stances a bullet striking the thoracic cage tangentially or emerging from the chest in an erratic manner produces a disproportionately large thoracic wall defect. The size of the foreign body is not necessarily propor- tional to the size of the defect. The velocity of the missile and whether or not a rib is encountered seem to be of more importance. A traumatic thoracotomy is performed through the wound of exit if it is a perforating wound or through the defect in a tangential wound. Since it is desirable, and in many of the large thoracic wall defects im- perative, that the wounds be closed, including the skin, we have felt that they should be debrided even more radically than those that are to be left open. As much of the ribs and intercostal structures as possible should be preserved to prevent paradoxial motion of the chest postoperatively. We, therefore, removed only the loose fragments of bone, and tissues that were devitalized. Rib fractures that have not penetrated the pleura are left strictly alone. The rough, sharp edges of rib stumps are smoothed up with the rib shears. The inner or outer table alone of the fractured rib may be displaced. In such cases the remaining half is left in place as a half rib gives.more support than no rib. All damaged intercostal bundles are ligated anteriorly end posteriorly when observed to be bleed- ing at the time. When easily accessible the nerve is crushed but not in- cluded in the suture ligatures. To prevent postoperative pains and to encourage full respiratory excursion, the nerve accompanying the rib a- bove the lesion is crushed, A paravertebral intercostal block of all nerves on the injured side that were not visualized and crushed at oper- ation is advisable. Some ingenuity is often necessary to effect an adequate closure of the chest wall. Intercostal structures are used where possible (Figurd 60A-F). In some instances catgut pericostal sutures have been used to approximate separated ribs end reduce the size of the costal defect. Low on the thoracic cage near the spine, we have frequently had to swing a flap of the paraspinalis muscle to close the defect (Figure 61AB), Ant- eriorly the pectoral muscles (Figures 62 and 63 ) and recti are all that are available. If possible, these are used, if not, one has to rely on the subcutaneous fascia and skin. Rarely, one may have to resort to us- ing the diaphragm to effect a closure of certain strategically placed de- fects on the lower thoracic cage. Generalizations cannot be made regard- ing the closure of these large defects as each case has to be individual- ised, The amount of available muscle for use is of great importance. 449 Initial Surgery of the Thorax and Thoraco-abdominal ..bunds (Taumatic Thoracotomies, contd) Figure 60A. - See Text Every advantage of that obtainable must be utilized by such procedures as splitting it to make two layers (RLgure 64 ), imbricating it with the existi?ig intercostal bundles, etc. Relaxing incisions at a distance from the wounds are often of help and extensive dissection and freeing up of the subcutaneous tissues is a necessitjr. All tension on suture lines is to be avoided to the greatest extent possible. The dressing of traumatic thoracotomies should be apolied with care. It -would give maximum support to the thoracic cage by use of "Ace" band- age or a liberal amount of wide adhesive passing to or beyond the midline Initial Surgery of the Thorax and Thoraco-abdominal Sounds (Traumatic Thoracotomies, contd) Figure 60B,C- See Text. (Latissimus loop flap). both anteriorly and posteriorly. The skin is first painted with tincture of benzoin or "Ace Adherent" to secure good traction and to prevent skin blisters that often form when adhesive is applied tightly without this precaution. Such a supportive dressing minimizes the paradoxical motion of the chest, keeps the muscles and thoracic cage in approximation and, by restricing motion and therefore pain, aids the patient in expectora- ting material from the tracheobronchial tree. 451 Initial SuiY/nry of the Thorax and Thoraco-abdoninal Wornds (Traumatic iioracetowics, oontd) H.gures 60 D,U and F - r:o Initial or? the Thora:c end Thoraco-abdornina.1 Wounds (Traumatic Th or ac otonics, contd ) 51-ure 61 A *■ 6ee Text. Initial Surgeiy of the Thorax and Thoraco-abdominal wounds (Traumatic Thoracotomies, contd) ** Figure 61 B - See Text* 454 Initial Surgery of the 'Thorax and Thoraco-abdominal wounds (Traumatic Thoracotomies, contd) Figure 62 A,B- See Text* 455 Initial Surgery of the Thorax and Thoraco-abdorainal Wounds (Traumatic Thoracotomies, contd) Figure 62 C - See Text, 456 Initial Surgery of the Thorax and Thoraco-abdominal Wounds (Traumatic Thoracotomies, contd) Figure 63 A,B- See Text. Initial Surgery of the Thorax and Tboraco-abdominal Wounds (Traumatic Thoracotomies, contd) Figure 63 C - See Text* Initial Surgery of the Thorar: and Thoraco-abdominal Sounds (Traumatic Thoracotomies, contd) Figure 64 - See Text. 459 Initial Surgery of the Thor a:-: and Thoraco-abdominal bounds (contd) IiratATHOlACIC PHOCSDIPJiS Intrathoracic manipulations indicated in the thoracotomies done in the forward area aro few in the majority of cases, Foreign bodies that are readily available are best removed to prevent a secondary operation at a later date. If the thoracotomy was undertaken for some indication other than removal of the foreign body this procedure is relegated to a minor position. At this early stage, the lung is always the site of contusion and induration due to intrapulnonary hemorrhage and edema which make foreign body localization by palpation a more difficult procedure than at a later date when the acute reaction has subsided and been ab- sorbed. Therefore, it is unwise to prolong the operation unduly or sub- ject the lung to more trauma by searching too diligently for a small for- eign body. Bone fragments are more often found in the lung than are metallic foreign bodies (Figure 65D ). Again, judgment is necessary in regard to their removal. Certainly, those that are easily found should not be left in place. As bone fragments usually are not seen on the preoper- ative X-ray, only those either seen or felt at operation will be recog- nized. Therefore, prolonged search is unlikely, such as might be under- taken for metallic missiles. It seems to us that those spicules of bone that are found partially in the lung and partially in the pleural space are the ones most apt to give rise to later complications. Fortunately they are also the most easily found and, removed. Lacerations of the pulmonary parenchyma (Figure 65A-0 will be en- countered in practically all thoracotomies as any perforating lesion of the lung must necessarily cause some sort of a wound. This may vary from a small puncture wound to a very extensive laceration. It has been a source of amazement to all those doing forward thoracic surgery to ob- serve the tremendous recuperative power of the lung. At first, all had the belief on seeing these badly contused, lacerated, hemorrhagic, boggy lobes that probably they should be resected. Yet, in practically every instance it has not been done because of the patient's poor general con- dition or other associated major wounds. Bucb cases have been closed with trepidation and with the expectation of all sorts of postoperative complications from the damaged lobe. In our experience, however, they have almost universally cleared in a comparatively short time and when one views the postoperative roentgenogram two to three weeks later it is almost unbelievable to see the apparently normal lung fields. The re- cords of our Group show only ‘a single instance of a resection of a lobe being carried out in the early treatment. That patient died during the operation. Pneumonectomy was not attempted in any instance. It is in- teresting to compare our experience and the results obtained, with the opinion of those who were dealing with similar cases in World War I (29). 460 Initial burrery ox the Thorax and Thoraco—abdominal Viounds (Intrathoracic Procedures, contd) Figure 65 - A, Location of ’found. B, Exposure of contused and lacerated lung with retained rib fragments* G. Appearance of laceration following removal of bone fragments and detritus. It a parentis was their belief that ail such hemorrhagic infiltrations or ’’.uplGrJ.zation", as they called it, had to be resected to prevent a fated issue. The great recuperative power of the lung is due in part, re believe, to the manner in which it derives its blood supply. As all the major vessels branch out radially from the hilus it is necessary to divi e them near their origin in order to do irreparable damage to the lung parenchyma. Undoubtedly sue]-) lesions occur, but with damage to the large hilar vessels the patient usually succumbs end does not even reach the field Hospital. It is also of interest to carry the speculation a bit farther. It has been found by engineers that the best protection for wiring in airplanes is to simply fasten the wires loosely along the side of the plane. Thus, missiles are able to pass through the group of wires without doing much damage. When the same wires were placed in a conduit, a single bullet striking the conduit would completely divide nil the wires. The same phenomenon is probably active in the lung. The blood vessels are surrounded by a fragile, elastic medium and hence they can easily be displaced in any direction by the foreign body. 3y being so displaced they usually escape severe damage. 461 Initial Surgery of the Thorax and Thoraco-abdominal bounds (intraxnoracic Procedures, contd) Figure 65 - D, Bone fragments. Those lung lacerations that are oozing actively when observed, or those fiat present narked air leaks are best repaired with a row of in- terrupted sutures. There is some discussion as to whether other lung lacerations should be so treated or’ left alone. Some feel that it is better to close most -of them trustin'1 to internal drainage through the bronchi to care for any collection of material within the lung. Others believe that the smaller ones should be left alone, feeling that the pleura is better able to cope with any discharge than is the bronchial tre. It is the practice of most of us to test all the lung lacerations at the time of operation by use of 10 cm. to 15 cm. of rater positive pressure v.dtfc the heralthorax sufficiently full of normal saline solution 462 Initial Surgery of the Thorax and Thoraco-abdominal bounds (Intrathoracic Pro cod '.are s, c ontd) completely to cover the lunf-. Those lacerations that are so demonstrated to Ieoh air or have been noted to be oozing blood are renaired. Others may be left alone. If the chest is to be drained, a snail air leak is unimportant; if the chest is to be closed without drainage, any question- able laceration is best repaired. It is the experience of most of us that a single layer of interrupted nonabsorbable sutures is the most sat- isfactory. The denser, hemorrhagic layers will not hold the sutures, therefore the visceral only is closed. 'founds of the trachea and major bronchi producing large air leaks are uncommon but one must be on the lookout for then. Their presence is most commonly susneeted by projecting the course of the missile, and in- ability to connletely re-exnand the lung in spite of repeated aspirations or the use of a catheter with under-water seal. If the latter method is used it will be noted that bubbles of air are excelled during quiet ex- piration. Although our combined experience with lesions of the trachea and major bronchi is not large (four cases) the above findings have been present in all. when there are just grounds for suspecting such an in- jury, a thoracotomy.is warranted, generally a high posterior approach gives the most adequate exposure, lepair is best affected by a simple closure with interrupted sutures. Conceivable severe damage to a bron- chus may 'warrant resection of the lobe or the lung but we are not aware of any such lesion being treated in the forward area. As was to be expected from civilian practice, esophagal lesions are particularly dangerous. Their detection is frequently difficult. If there is reasonable evidence of such from the course of the missile, or perhaps some blood on passing a Levin tube or occasionally a history of pain on swallowing or a widened mediastinal shadow by X-ray, exploration is advisable, (It is to be remembered, however, that hemorrhage may also give a widened mediastinal shadow. Although such cases will be explored in most instances, all the possibilities must be considered). Injuries to the esophagus are not common and in oaor series the results even with operation were poor. V/e have records of only six cases of injury to the intrathoracic portion of the esophagus. In three of these cases the le- sion was not diagnosed until post mortem. Two of the others ended fat- ally and in the third the surgeon removed the missile from the wall of the esophagus and it is his opinion that the lumen of the esophagus was not entered. We, therefore, have no certain recovery from a proven in- trathoracic esophageal penetration. The very high mortality justifies exploring any suspected lesion, We believe that the best method of management is to expose these le- sions, suture them with interrupted sutures, then if possible close the mediastinal pleura over the injiored area and provide extrapleural drain- age paravertebrally. If the extrapleural pathway is dissected out to the angle of the ribs from inside the chest, track can be easily exposed through a short incision with rib resection and the drains inserted after 463 Initial Surgery of the Thorax and Thoraco-abdominal Wounds (Intrathoracic Procedures, contd) the thorax has been closed. There is one case in which this procedure was carried out but which ended fatally due to other lesions. He lived for five days without evidence of leakage fron the repair or involvement of the pleura. Unfortuantely, in this instance, no post mortem examin- ation was carried cut. Our experience is not large enough to arrant making definite state- ments nor are we prepared to state what is the best method of handling esophageal injuries postoperativoly. It is our opinion that gastrostom- ies need not bo done in the forward area for nutritional purposes. A Levin tube should be used either down to the site of repair for decom- pression as advocated by in esophageal, resections, or passed on into the stomach if the surgeon believes that to bo preferable, HEART AND PERICARDIUM Among the total of 2?67 cases with thoracic wounds, there were 75 instances of cardiac or uericardial involvement. This is an incidence of 3*3m. Ho individual tear, took care of more than ten cases. One of the 75 cases was a self-inflicted stab wound; the remainder were battle- incurred. There were 4-3 cases in the pure. thoracic group and 12 cases in the thoraco-abdominal group. Of the 75 cases, IS were examples, of pure pericardial injury, and 57 patients had lesions of the heart it- self, The soldiers were wounded by shell fragments in 53 instances, by small arms fire in 21, and by a knife (self-inflicted) in one. Among the pericardial cases, two wounds were caused directly by rib fragments, and at least one case of extensive contusion of the myocardium was caused, by rib fragments acting as secondary missiles. Diagnosis It obviously has been difficult to diagnose cardiac wounds and in- juries in forward hospitals. Electrocardiograms have never been avail- able and roentgenograms have been limited to frontal and lateral films, I'loroscopy should have been used more freouently. The data suggesting a cardiac wound as found on the case records has been supplemented by in- terviewing the individual surgeons. In more than 50% of the cases, the actual cardiac wound was undiagnosed prior to commencing surgery. The thorax was opened in the majority of these because of suspected thoraco- abdominal involvement, or for the debridement of large sucking wounds. In seven cases, .continued hemorrhage of unknown origin (or merely sus- pected cardiac origin), either during resuscitation or at the beginning of surgery, prompted exploration. In three cases the presence of a for- eign body in the mediastinum was an indication. In 15 cases (including two deaths in the shock ward)the cardiac wound was first discovered at autopsy. 464 Initial Surgery of the Thorax and Thoraco-abdominal ’.bunds (Intrathoracic Procedures, contd) The suspicion of a cardiac wound must be predicated first, on recog- nizing the possibility that such a lesion exists and then, on consider- ing the diagnostic criteria listed in Table XXIII. It is seldom that one finding alone will clinch the diagnosis, frequently the diagnosis may be suspected by thorough physical ex- amination (Table XXIII) and accurate localization of external wounds. Plotting of the missile track often can be made with considerable accur- acy when this examination is combined with roentgen studies showing the location of foreign bodies and the position of fractured ribs, further proof can be gained.when the foreign body is in the region of the heart and its outlines are roentgenographically recorded as fuzzy or double- contourca. In localizing missiles within the cardiac shadow, heavy pen- etration must be used, either by means of "bone technique" or the Potter- Bucky diaphragm. Often a missile will be completely overlooked in a thoracic film of usual exposure. Plouroscopy should be used more fre- quently to study the motion of the missile and whether or not it is in- cluded within the cardiac shadow in all projections. The cardiac out- line may be altered, and. has been described as "water-bottle", fuzzy or enlarged. In two cases where the outline was blurred or fuzzy, operation disclosed hemorrhage into the pericardial membrane and the areolar tis- sues of the lower mediastinum. Symptoms of anoxia may be present iq some patients with cardiac wounds. Before attributing these symptoms to a cardiac lesion, great care must be exercised in ruling out other causes of oxygen want such as hemorrhage, hemothorax or pres since pneumothorax and extensive peri- toneal contamination. In the absence of severe extern:,! wounds, peri- toneal contamination, etc., and following the application of resuscita- tive measures, therq remain cases in which dyspnea, cyanosis, or mental confusion persist which are out of all proportion to the visable thoracic damage. Such evidence then indicates a cardiac lesion as the basis for continuing anoxia. Direct evidence of cardiac dvs.function may be encountered. (Table XXIII) It is certain that more frequent cardiac examinations would lead to an Increase in these findings. Thus, three medical officers made all eight observations of arrhythmias. As with anoxic symptoms, the observ- ation of a continued rapid pulse must be uredicated on ruling- out other causes of tachycardia in the patient, before it can be assumed that the tachycardia is on an intrinsic cardiac basis. A soft systolic apical murmur is an exceptional finding (3-1). The one example of paradoxical pulse was noted in a patient with severe myocardial contusion, who died in the shock ward, friction rubs were heard preoperatively on onlj: two patients. In both, however, the friction rub was heard 2U hours after injury and operation was greatly delayed (three and five days, respec- tively), Since a friction rub or splash was noted in eight additional cases postoperatively, it is evident that a certain time interval is nec- essary for this sign to appear. 465 Initial Surgery of the Thorax and Thoraco-abdominal Wounds (Intrathoracio Procedures, contd) In comcarison to the frequency with which it is noted in civilian cardiac wounds, tamponade has been an infrequent finding in this series. In war wounds, the missiles usually are larger and most often there is a pericardial laceration which allows drainage into the pleural cavity. The condition must always be looked for because of its lethal potential- ities. Death occurred trice due to unrecognized tamponade, although in one case, with a severe thoraco-abdominal injury, it was susnected. In this instance, exploratory puncture was not successful because all the blood in the pericardium had clotted. It should be remembered that in acute traur.u tic tamponade the blood often comes from wounds involving a cardiac chamber, but it may also come from a severed coronary artery branch, from the myocardium itself, or from a vessel in the pericardium. In the three cases the diagnosis was based, on the findings of distended neck veins, muffled heart sounds and a "water bottle" appearance to the cardiac shadow. Here again, fluoroscopy can be used more frequently in depicting a decrease or absence of pulsation. Lowered pulse pressures •were not noted, Hemopericardium of from 50 c.c. to 150 c.c, was noted in five cases at operation. In none had there been clinical evidence of increased pressure. Pathology The cardiac lesions as seen at surgery or autopsy have been classi- fied as follows: Contusion, pure laceration, laceration with contusion, penetrating and perforating wounds of the chambers, and embolus to the heart. Gases in which foreign bodies were found in the myocardium or chambers v:ere placed in the various pathological categories depending up- on the type of myocardial injury produced, without respect to whether or not the foreign body was still present. In general, the signs and. symp- toms exhibited, the indications for surgery, and the cause of death dif- fered in the various pathological categories, (See Tables XXIV, XXV^ Insofar as operative therapy is concerned, contusive lesions are non- surgical. Pathologically they are very similar to the contusions de- scribed by Beck32, and others, occurring as the result of blunt trauma to the chest, "steering wheel" injuries and the like. In most instances of battle casualties, however, the pathogenesis is probably different in that the contusive force is propagated by the passage, of a small high velocity .missile in the immediate vicinitjr of the heart. In some instances in this series, the ribs or sternum (RLgure 66 ) apparently acted as secondary missiles, causing blunt injury directly. The question of localized "blast" effect from the passage of the missile cannot be an- swered. Certainly, none of the contusions in this series was due to a generalized "blast" effect, i.e,, a pressure wave in the atmosphere, While theoretically possible for serious cardiac injury to result from blast, it has not been observed by us, although always considered when performing autopsies on patients dying from blast injury. 466 Initial Surgery of the Thorax and Thoraco-abdominal Wounds (Intrathoracic Procedures, contd) Figure 66 - Fatal case in which contusion was caused by bullet exerting indirect force through sternum. The pathology of contusive lesions consists of scattered or con- fluent petechial hemorrhages involving the myocardium over varying areas of one or two chambers (figure 66 ). There may be superficial abrasions of the enicardium and the subepicardiel vessels may be engorged and throm- bosed. The myocardial hemorrhage often extends through to ohe endocard- ium and the muscles itself may show gross evidence of degenerative change or actual necrosis. In fatal cases where there has been involvement of the entire thickness of the myocardium, mural thrombi are frequently found attached to the endocardium (Figure 67). With extensive lesions scat- tered along the acute or obtuse margin of the heart, it is not uncommon to see hemorrhage extending into the myocardium of both ventricles and a portion of the interventricular septum. In the group of contusions there was a death rate of 31,5% due to the heart lesion itself. Of the 16 cases of myocardial contusion, nine had an intact pericardium. 467 Initial Surgery of the Thorax and Thoraco-abdominal Wounds (Intrathoracic Procedures, contd) Figure 67 - Fatal case in which contusion mural thrombus formation followed wounding of myocardium by rib fragments acting as secondary missiles. The pericardium was intact in this case. The other lesions may be classified as "potentially surgical" lesions. In the pure laceration category are placed all cases with incised or cleanly lacerated wounds of the myocardium, in which there was no gross evidence of myocardial contusion or necrosis. Two cases with foreign bodies in the myocardium are included here, since the nyocardial wound itself fitted this classification pathologically. The less serious impli- cations of wounds of this type is mirrored by the single death due ‘to the heart in ten cases of pure lacerated wounds. Vflienlacerated wounds are associated with extensive contusion, whether or not a foreign body is present, the lesion is a serious one. In this category there was a L$% death rate due to the heart. In wounds penetrating to the chambers of the heart, hemorrhage is the most frequent complication and the most important cause of death. The hemorrhage may be exsanguinating or cause tamponade. The death rate Initial Surgery- of the Thorax and Thoraco-abdominal Wounds (Intrathoracic Procedures, contd) in this pathological category was 50%. There were five cases of perforat- ing (through and through) wounds of the chambers in this series. Two oc- curred in the left ventricle and both survived following suture. One of these cases has been renorted in detail elsewhere (35). In three cases of perforation of the right auricle there were two deaths. Ho case of perforation of the interauric alar or interventricular septum has survived to reach a forward hospital. Gases of embolism to and from the heart form a small but interesting group. There were four examples in this series. In two, the missile came to rest in the right ventricle by way of the inferior venaca.va. In one, the situation was recognized and the U5 caliber bullet successfully removed (35). In the other case, the shell fragment "disappeared” after having entered the body through the right flank. Thoracic roentgenograms revelaed a questionable missile just above the diaphragm. The films were Figure 68 - See Text, page 469* 469 Initial Surgery of the Thorax end Thoraco-abdominal Wounds (Intrathoracic Procedures, contd) repeated later using ordinary technique and the foreign body was not vis- ualised, Over a period of ten days the patient had attacks characterized by decreased blood pressure, high fever, mental confusion, pallor, rapid pulse and Mshockyw appearance. In retrospect these attacks could well have been due to myocardial ischemia. At autopsy, after sudden death, the right ventricle was found to be greatly dilated and the myocardium overlying the foreign body in the right ventricle was hemorrhagic and. ne- crotic, (Figure 68 ) Had the condition been removal of the shell fragment probably would have been life-saving. As an embolus from the heart, the foreign body nay ente" the pulmonary circulation, become retrograde in the systemic venous circulation or enter the systemic ar- terial vessels. One case in this series entered the rr-ht auricle, drome into the inferior vena cave and eventually was recovered from, the left common iliac vein (36). In the fourth case, a bullet entered the left ventricle and came to rest in the right flank region, resurably the might iliac artery. The patient had. no symptoms of obstruction. Operative findings and Treatment Analysis of the records (Table XXVI) shows that a surprising number of wounds of the myocardium (10 out of 16) were not repaired. There seemed to be no immediate ill effect resulting from lack of repair, Further, of the cases of laceration seen at autopsy, only, none of the deaths were be- lieved to be due to lack of repair. The cases were listed as completely repaired if the edges of the laceration had been completely approximated with sutures. The two cases of partial repair vrere those in which com- plete approximation could not be obtained, and pericardium was used to help bridge the defect. Note was made of the use of free muscle grafts in only two cases. The use of the pericardium was frequently described, either sutured over the wound or sutured to the edges of a poorly approx- imated would, V«hen the pericardium was sutured over a wound it was drained posteriorly. In 13 cases of wounds involving the cardiac chambers, complete clos- ure was obtained successfully in 10 cases. One wound was not bleeding at the time of operation and was not sutured. In two cases of auricular wounds, closure was attempted and failed and the patients died of uncon- trollable hemorrhage. In both, attempts were made to plug the defect in the auricular wall with the finger. In 21 cases, the foreign body was described as in the heart or peri' cardium as indicated below* Jfete of Foreign Bodies Pericardium Pericardial ’Myocardium Completely sac in chamber Wo. of cases 4 3 (2 probable) 10 4 Removed 4 1 3 1 Not removed 2 (both probable) 7 3 ifound at autopsy (5) (3) 470 Initial Jurgery of the Thorax and Thoraco-abdominal bounds (Intrathoracic Procedures, contd) These figures show a low percentage of removal. The majority not removed were small fragments, 0.5 cm, or less. In several, the condition of the patient did not warrant farther search. The foreign bodies marked “probableM were not definitely located, but from X-ray evidence and op- erative findings, their presence in the pericardial sac seemed likely. Of the eight foreign bodies found at autopsy, the missile was directly responsible for one death (embolus to the heart) and. possibly for a sec- ond death. Pericardium. There were If cases of pure pericardial injury. Three deaths occurred in this group, all more than 4-0 hours following operation and none due to the pericardial lesion. Of the 18 cases, there were 14 lac- erated wounds and four with foreign bodies present, two nctalic and. two rib fragments. Of all the rounds in which the pericardium was opened it was sutured tightly in five cases; he remainder were drained into the pleural cavity. In,two of the five cases (one, a pure pericardial in- jury, and one a myocardial wound) there was massive troublesome pericard- ial effusion postoporatively. This was not noted in the cases which were drained. Time and Place for Cardiac Turnery. linen confronted by a patient with a suspected cardiac wound, decision should be made if possible as to the type of pathology present in the heart end as to the presence or absence of a foreign body in the heart or pericardium. Two distinct ouestions must be answered. Can the cardiac lesion itself be corrected by surgery, and should f is surgery be performed in a forward hospital or at the base? That is the effect of the cas’diac status on the patient's ability to ’with- stand needed surgery for other wounds? In contrast again to civilian cardiac injuries, the heart in all war casualties is but one of several orrans injured and both the diagnosis and the decision as to time of op- eration are complicated by the presence of these multiple injuries. V.'ith those factors in mind it is gratifying rather than otherwise that nearly 50:1 of the cardiac wounds were recognized prior to operation. The problem rv. y be approached bp considering each pathological clas-. sification of the heart more or less separately, V/hen a cardiac contusion is suspected, decision may be difficult as to when to operate on concom- itant wounds. As stated above, the contusion per se, is not a "surgical” lesion. The fact that six ouf of the 11 deaths in the contusion group were due to the heart shows that these patients probably arc not good operative risks. The diagnosis of a cardiac contusion should not be ex- tremely difficult since it has been noted in the present series that the majority of signs and symptoms indicative of oxygen want, and of cardiac dysfunction (persistent tachycardia, arrhythmia, etc.) were found in pa- tients who had significant contusions of the myocardium. These signs, and the gross and microscopic appearance o* the myocardium have much in common with the picture of myocardial infarction following coronary oc- clusion, and we have felt that these Patients might well be handled as 471 Initial Surgery of the Thorax and Thoraco-abdominal Wounds (Intrathoracic Procedures, contd) if they had an acute coronary occlusion. If this analogy is carried further, then the first 2/+ to IB hours is an extremely dangerous period for surgical intervention in that during this time the danger of death from an irritable myocardium and lethal arrhythmias may be enhanced by any anesthetic or onerative manipulation. In many causes, however, at- tention must be given to other serious wounds, especially those with thoraco-abdominal involvement where undue delay in surgery often is dis- astrous, The best that can be done under these circumstances is to pre- pare the patient as thoroughly as possible consistent with the major surgical lesion. The mortality rate in such cases inevitably will be high. There remains a group of cases with pure thoracic wounds in which early surgery (within six to 12 hours) usually is not mandatory, and in which delay because of a cardiac contusion may be practicable. Viewed from this standpoint the cases of contusion were carefully analyzed. There were three, all with a fatal outcome, in which it was ■'‘elt further delay in surgery probably would have been beneficial. Two were pure thoracic wounds and one was a high rhoraco-abdominal wound in which it was obvious that only the liver was involvea. The time between wound- ing and surgery was.5, U and 17 hours respectively. In each instance, signs of cardiac dysfunction were prominent. During the resuscitation period the patients remained in poor general condition with rapid pulse, semistupor, and dyspnea out of proportion to the visible intrathoracic damage, in spite of an increase of the blood presumes to 95 or above. In each instance death occurred either on the operating table or shortly after the surgery was completed. We have also reviewed a fourth case, not included in this series, in which there was a pure thoracic wound, a six-hour lag, and sudden death on the operating table. At autopsy, this patient showed extensive contusion of the right ventricle and thrombosis of the anterior descending branch of the left coronary artery. While any of these four cases might well have died even if surgery had not been performed, the added burden of the anesthetic and an operative procedure cannot be ignored. In contrast to the relatively early surgeiy in these four cases, two cases may be cited in \vhich surgery was considerably de- layed (three and five days after wounding). Both were in shock on ad- mission to the hospital and cardiac contusions were diagnosed. In one, the pulse remained over 120 beats per minute for AO hours. In the sec- ond case, there were intermittent periods of cardiac arrythmia for four days, associated with wet lung, pulmonary edema and jaundice. In both cases there was recovery from surgery. It was our strong feeling that operation performed in either‘case at 12 hours or less could well have ended disastrously. To summarize our beliefs, when a cardiac contusion has been diag- nosed and indications for early operation, such as continuing hemorrhage or thoraco-abdominal involvement are not present, surgery probably should be postponed for a minimum of at least 2A to A8 hours to give every op- portunity for the reduction of nyocardial irritability. Initial Surgery of the Thorax and Thoraco-abdominal Wounds (Intrathoracic Procedures, contd) 472 As to the'feasibility of operating in forward hospitals for the ex- press purpose of suturing cardiac lacerations, no final conclusions can be drawn. With pure lacerations there are few if any symptoms of cardiac dysfunction and damage to the heart cm only be suspected from the course of the missile or from a possible tamponade. Ten of the 16 lacerations exposed in this series were not repaired and of the remaining six, two wore partially repaired. In no case was it felt that there was any im- mediate disability, nor were the deaths due to lack of repair. If a lac- eration is to be sutured, it is better accomplished at a forward hospital It is probable that no efficient repair can be performed in a base sec- tion hospital five to 10 days after injur;/. Retraction of edges of the myocardial defect, with induration from fibroblastic tissue proliferation probably combine to defeat a good approximation. Penetrations or perforations of the cardiac chambers, particularly of the auricles, are often manifest by continuing hemorrhage and early surgery is mandatory. If foreign bodies are found or it is suspected that the:' are in the chambers, an attempt should be made to remove them at the same time, but it should bo remembered that the main indication for the operation is the control of hemorrhage, and long continued search or extensive blind manipulations within the chambers is not justified. If the missile is not found almost immediately, the defect should be su- tured and further consideration given to removal of the intracardiac frag- ments at a base hospital. If the bleeding causes tamponade rather than exsanguinating hemor- rhage, treatment may be more individualized. Should the tamponade de- velop rapidly, it is probably better to operate at once, particularly if it is kr.Qwn that the missile causing the wound was large. If however, the tamponade develops slowly, one or two aspirations may suffice, with- out surgery, as has been suggested by Blalock and Elkin. IVhen foreign bodies are suspected of being in the pericardium or myo- cardium it is probable that their removal should be postponed until the patient can be evacuated to a base section center, unless there are early and continued episodes of cardiac dysfunction, or bleeding. The dearth of diagnostic facilities and the lack of time for unhurried Study in for- ward installations often make accurate localization difficult. Two other factors enter into the considered opinion for a delay in the removal of cardiac foreign bodies. In the present series, nine of the 13 missiles believed to be in the pericardial sac or myocardium were not removed. In only one was it believed that death was possibly due to the presence of th.e foreign body itself. In addition, in a base section center has now operated on AO patients with removal of the foreign body from the pericardium or myocardium without a death. metallic foreign bodies acting as emboli through the venous system to the right auricle or ventricle non are becoming recognized more 473 Initial Surgery of the Thorax and Thoraco-abdominal Wounds (intrathoracic Procedures, contd) frequently (35). In the past, their removal has been the subject of much discussion (31) (3&). While some have remained asymptomatic for a long period of time, others have caused death from embolism, focus of infec- tion or myocardial damage. In the majority, it is probable that early removal in a base section center is the wiser policy. Harken has now re- nfov'ed a number of those v7ithout a death. On the other hand, recognition that the presence of the foreign body in the chamber is causing cardiac disability or emboli should be an indication for early removal in a for- ward hospital. Comment on dxnosure and Operative Techniques. When a cardiac wound in need of surgical repair is suspected, adequate exposure through an elec- tive approach is mandatory. The tragedy of inadeouate e'rposure is il- lustrated by a case of exsanguination from a wound of the right auricle which was unsuspected, 'and the operative incision was a low posterior thoracotomy for a thoraco-abdominal wound. The hemorrhage could not be controlled with the exposure given. For most purposes an anterior approach is more suitable. An inter- costal incision always should be employed unless the corresponding rib is badly fractured. The-third or fourth intercostal space offers the best exposure for the auricles and the fifth or sixth for the ventricles. This approach should be transpleural, He feel strongly that no time should be wasted by attempting an extrapleural exposure of the heart. Such operations take longer and the exposure, particularly for poster- iorly placed lesions, is not as satisfactory. We feel too that drainage should be provided into the pleural cavity. In addition, intrapleural damage and a hemothorax are almost always present, which would make ex- trapleural exposures even more difficult. Ten c.c. of 5% procaine usually has been injected into the pericar- dial sac for several minutes before exposing the heart, following the sug- gestion of Beck. This materially cuts dorm the incidence of ectopic beats v/hile the heart is being handled. Several maneuvers have been employed in manipulating the heart. For anterior lesions, the "palming’1 method (.31) or the Sauerbruch grip have advantages. By the former means, the third, fourth and fifth fingers are passed -behind the heart, the index finger is passed in front and the thumb is free to apply hemostasis. This gives ex- cellent control both of the heart and of the bleeding area. In exposing the diaphragmatic surface, some prefer the apical sut’ire. The authors, however, feel that the hand of the assistnat makes a much better retrac- tor (Figure 69 )% The apex of the heart can be rotated at least 90 de- grees forward and the cardiac movement is considerably dampened by using the hand. By spreading the fingers a slotted type of retractor can be simulated which will expose any portion of the wall. 474 Initial 'Surgery of the Thorax and Thoraco-abdominal Wounds (intrathoracic Procedures, contd) Figure 69 - See Text* Tie owe much of our knowledge of the actual suturing technioue to the well-known writings of Beck, Elkin, Bigger and others. The general di- rectives which they have promulgated form the background for most cardiac manipulations. Our chief concern here, is the emphasis on certain tech- niques which are particularly valuable in dealing with large wounds. Suture materal should be of braided 0 and 00 silk, preferably waxed or oiled. A snal3.-eyed or atraumatic round needle should be used. Inter- rupted suture technique always should be employed end the sutures placed close to the edge of the wound, tied during systole if possible, and without tension. Necrosis of the wound edges, particularly in ’wounds in- volving the chambers, may lead to secondary "atal hemorrhage. The sutures should not be passed throughh the endocardium as this increases the possi- bility of thrombus formation (Figure 70 ), In the repair of auricular wounds, however, this may be impossible to avoid. As discussed above, many of the lacerations in this series were not sutured and it is certain that some should be left alone since attempts at suture may lead to fur- ther difficulties. Such wounds include the superficial, npnbloeaing T 475 Initial SurrerT' of the Thorax and Thoraco-nbdoninal '.'ovncls (ir.trathoracic Procedures, contd) Figure 70 - Illustrating the placement of sutures, avoiding the endocardium. laceration of one or two millimeters in depth, particularly if they in- volve the left ventricle; round or oval lacerations, especially* in the region of the apex; laceration near a major coronary vessel, the repair of which might cause thrombosis of the vessel. In genera1., laceration of the right ventricle are easier to suture than those of the left and since the wall of the right ventricle is thinner, it should be repaired more often. The justification for repair lies in the fact that the scar from a sutured laceration is stronger and the wall is thicker than if no repair is performed. Complete suture, or repair of some type is manda- tory if the bottom of the laceration feels thin or if there is any bulg- ing. Without adequate suture, later aneurysm of the myocardium nay de- velop and cases*of this kind have been resorted by Loison (quoted by Lillienthal-'51). Some lacerations, because of loss of substance or sur- rounding contusion and necrosis of the muscle, are difficult if not impos- sible to suture completely. Considerable ingenuity must then be exer- cised, particularly when the laceration has opened a chamber. Free muscle grafts are useful in this connection and should be employed much more fre- quently. They can be laid in the defect and'held in place by fine sutures. 476 Initial Surgery of the Thorax and Thoraco-Abdominal Wounds (Intrathoracic Procedures, contd) This not only helps to fill the defect but is instrumental in stopping hemorrhage or myocardial ooze, ' As a further reinforcing mechanism, the pericardium always should be sutured over the a~ea of repair, after first draining the pericardium into the pleural cavity posteriorly through a cruciate incision. The edges of the pericardium may be approximated or imbricated. Sutures may be taken into the epicardium and superficial myo- cardium at the edge of the myocardial defect. The pericardium combines very nicely with a free muscle graft in giving a solid repair (Figure 71 and JZ )• Figure 71 - Use of free muscle graft; imbrication of pericardium over wound. Wounds penetrating the chambers of the heart should be sutured even though not bleeding and plugged by clot when exposed. Secondary hemor- rhage is frequently a complicating factor if this is not done. Large wounds of the auricle deserve special mention. Even three centimeter ?rc>unds of the auricles may not exsanguinate, because the lung collapsed against the wound, or clot has formed. The maneuver of covering the de- fect with the finger as employed in wounds of the ventricle cannot be 477 Initial Surgery of the Thorax and Thoraco-abdoroina1 Wounds '(Intra thoracic Procedures, contd) Figure 72 - Use of flap of pericardium as an extra layer, when bleeding is not completely controlled by myocardial suture. used when the auricular chamber has been penetrated, because of the thin- ness of the wall. If sutures cannot be placed at once, each edge of the laceration should be grasped with fine forceps, which can then either be approximated, or ligated temporarily until sutures can be prouerly placed (Figure 73,1 ).' If the wound is at the edge of the auricle, it can be completely occluded with rubber-shod forceps (Figure 73,2 ), Perforating (through and through) wounds of the chambers can be repaired successfully if both wounds are on the surface. Ho method of exposure has yet been discovered to repair a wound on the posteromesial surface of the right auricle. There were two cases of this type in the series and both died of exsanguination. 478 Initial-Surgery of the Thorax and Thoraco-abdorninal s/ounds (Intrathoracic Procedures, contd) Figure 73 - See Text, page 477 When small branches of the coronary arteries are bleeding, meticu- lous ligature or suture of the individual branch is necessary. If fine clips are available, they may be used as Bede has suggested. Postoperative Findings. In the patients that lived, certain findings re- lative to the heart,were recorded. Seven patients developed friction rubs postoperatively and some were audible up to three weeks. Massive pericardial effusion developed in two patients in whom the pericardium was not drained at the time of operation. These were both relieved by pericardiocentesis and there were no seouelae, Two patients suffered significant myocardial accidents, probably myocardial infarctions. One of these was following the single stab wound in the series. The other '-atient developed a typical coronary occlusion 2U hours postoperatively 479 Initial Surgery of the Thorax and Thoraco-abdominal hounds (Intrathoracic Procedures, contd) with transient auricular fibrillation, precordial pain and circulatory collapse. He had extra systoles before operation, and at operation it was necessary to ligate a small bleeding terminal branch of the anterior des- cending artery. In addition, the nationt had a superficial, clean lacer- ation at the apex which was not repaired. One patient developed a hemi- plegia after operation, at which a laceration of the left ventricle was described. One may speculate s to whether or not mural thrombi did de- velop in the left ventricle. CLOSURE OF THORACOTOJ.il3S Pleural Lavage After completing the intrathoracic repair it ir advisable to remove all blood, blood clots and detritus from the pleural space, .dost of this material is easily removed with the suction tip but there is always a certain amount of blood and clot that escapes detection and removal by this method alone. It is our opinion that the remainder is best removed by copious flushing of the pleural cavity with normal saline solution at body temperature. This is less traumatizing than the use of gauze sponges even though they be soaked in saline beforehand. Rubbing the delicate pleural surfaces is certain to produce some damage and this adds to the amount of pleural exudate in the postoperative period, as well as pre- disposing to the formation of pleural adhesions when the lunr and thor- acic wall cone into apposition. Some are of the opinion that normal saline should not be used as they feel that the remaining blood in the pleura is not irritating. There is much evidence, however, that blood in the pleura is an irritant. According to Yates29, "Delrey and . 'iddleton showed that blood is so ir- ritating to joint and chest serosa as to produce a serofibrinous seros- itis", He also adds, ''Irritation of serosa (pleural) provokes a very rapid serous effusion which occurs promptly with hemothorax and. soon ex- ceeds the amount of blood originally present." These quotations from the Liedical History of V.’orld Viar I are of much interest as they indicate that they were approaching the problem of hemothorax in the correct manner. On the other hand, it is somewhat difficult to explain the statement made therein that, "bashing out the pleural cavity is a temptation to bo re- sisted as the subsequent healing is poor". ,ie have not found this to be true and it is our practice to flush out thoroughly the hemithorax with 1500 c.c. to 2500 c.c. saline at the completion of any thoracotomy. The amount of fluid so used is not of importance. The important thing is to continue the flushing until the return is clear, indicating that all the blood has been washed off the pleural lining.. Although this practice has resulted in considerable discussion it seems a very logical procedure and one that most of us used routinely in civilian practice. It is not a now procedure as has been supposed by some. It is our opin- ion that this cleansing of the pleura reduces the amount of postoperative effusion thus making for a smoother convalescence. 480 Initial Surgery of the Thorax and Thoraco-abdominal bounds (Closure of Thoracotomies, contd) If the chest is to be closed without drainage, great care should be exercised in securing complete lung expansion at the time of closure. Apposition of the lung and thoracic cage is of paramount importance, be have found that it is most easily obtained in the following manners As the nleural closure is started, the anesthetist gently increases the intrabronchial pressure to plus 5 cm. to 10 cm, of water. A 22? cath- eter with at least two holes in the tip is inserted into the chest through the pleural sutures and so placed as to lie in the uppermost portion of the chest. 'The suction machine is then attached to the catheter which has an air vent, previously made, near its proximal end. This prevents too much suction which might damage the lung but does provide encourage- ment toward expansion. The pleural closure is then completed. When the pleural repair is finished, the intrabronchial pressure is ;iincreased by the anesthetist to 15 cm. to 20 cm, of water. At the same time, the surgeon carefully increases the suction on the catheter with his finger, A suture is placed ground the catheter by the assistant, the catheter is slowly withdrawn and the suture tied to prevent any ingress of air through the small defect. If the chest is going to be drained with under-water drains, such extensive precautions to obtain complete, prompt pulmonary expansion as enumerated above are not necessary, since any residual air or fluid will be expelled through the drains. It is wise, however, to expand the lung at least once just before closure to be sure the limp is expansible. The question of chest drainage following thoracic operations is one that is best decided by the individual surgeon as it will depend on many factors such as the physical location of the hospital, the ademiacy of the nurs- ing care, the lesions that were present in the individual case and fin- ally on the surgeon’s personal experience. If drainage is not employed it is necessary to observe the patient closely and to re- move any collection of fluid or air by thoracentesis, dome will not have to be aspirated at all, i lilc others may need daily aspirations for a few days. Mien tubes are employed, it has been found that a second small cath- eter (preferably mushroom in type) placed in an upper anterior inter- costal space and used as an air vent, will lead to more certain, rapid, re-expansion. The lower tube should not be placed more posteriorly than the posterior axillary line, nor more dependently than the ninth Inter- costal space. Use of the eighth or seventh space is practicable. Abso- lute dependency, so necessary in the drainage of empyema, is not essent- ial in these cases. The lower tube should not be a catheter but Standard Issue red rubber tubing, 1/7+ inch I.'D. by l/l6 inch wall (Catalogue No. 3B7S000), The end should be beveled and three or four holes cut in the Initial Surgery of the Thorax and Thoraco-abdominal Wounds (Closure of Tlioracotonics, contd) 481 distal two to two and one-half inches. The skin should be dr arm sharply upwards and a small stab incision made at right angles through the selected intercostal space. Then the beveled end and 2 1/2 inches of the tube are pulled into the pleural cavity and the skin released, the intrapleural portion of the tube will tend to angle slightly upward, (Such passage of the fube also prevents ingress of air when the tube is removed.) The tube should then be pushed into contact with the parietal nleura and the tip of the bevel tacked with a fine suture so that the infrathoracic portion of the tube lies flat and without kinicing along the parietal pleura. In those instances where it is inconvenient to so uture the tip of the catheter, it can be held in place by looping a suture over it and tiein- it over a small bolster outside the skin. It is also wise when inserting the an- terior catheter to place one skin suture which can be tied dorm at the time the tube is removed, thus preventing any ingress of air. In those instances in v/hich penicillin is left within the chest, the posterior drain is clamped off for six to eight hours. (Figure 74 ). Figure 74 - See Text, 482 Initial Surgery of the Thorax and Thoracoabdominal Wounds (contd) TPAGHEOBRONCIIIAL ASPIRATION ON THE OPERATING TABLE It is our opinion that a very thorough aspiration of the trachea and major bronchi at the completion of the operation is a most important step in the surgical care of thoracic war wounds. All such patients have more or less blood or mucus in the air passages. The alert anesthetist per- iodically removes this during operation by inserting a small catheter through the endotracheal tube. At the completion of the operation, this is done with extreme? care. The catheter is left in place as the endotra- cheal tube is withdrawal to remove as much as possible of any material ■fchat may have been missed previously or has gathered around the endotra- cheal tube. It must be recognized, however, that at best catheter aspir- ation through the tube is a blind procedure and no natter how much one turns the head or goes through other manipulations it is impossible to be certain that both main stem bronchi as well as the trachea have been aspirated. Anyone who has done lipiodal instillations of the bronchial tree with a catheter in the trachea end under floroscopic control, has experienced the difficulties sometimes encountered in passing a catheter into the left main bronchus. Also, catheter aspiration does not permit visual inspection of the air way to be certain that all such material has been removed. In instances where the patient has had more than a slight amount of such material during oneration or has shown considerable ’’blast effect” of the lungs on the preoponative film, most of us have carried out a. orxachoscopic aspiration as soon as the endotracheal tube was re- moved. he are aware that some are of the opinion'that bronchoscopy is rarely indicated in.this immediate postoperative period (9), but those of us who have had considerable experience in doing the actual surgery in the forward areas are strongly convinced that it is a most useful and very freouontly indicated procedure. The objections raised by are for the most part based, we feel, on misconceptions. The majority of us .are of the opinion that it is not possible to clean completely the air wav with a catheter. We have repeatedly bronchoscopcd patients im- mediate!" after a very earnest attempt to do a careful aspiration with a catheter and. have been amazed to find the amount of material that had been missed and often evidence showing that the left main bronchus had not been aspirated at all. Furthermore, if the anesthetist is alert, he can gauge the depth of the anaesthesia so that the.anesthesia need neither be prolonged now deepened to permit bronchoscopy. All that is needed is that the jaws be kept separated and this must necessarily be done until the endotracheal tube is removed. It takes only two to three minutes from that point to the completion of the bronchoscopic aspiration so it does not seem warranted to classify this as either unduly prolonging or deepening the anesthesia. In actual practice, it is often possible for the anesthetist to do the bronchoscopy as the surgeon is finishing up, since there often are other wounds that have to be debrided and the bronchoscopy can be done concomitantly. It should also be pointed out that the patient should be in a light plane of anesthesia for this aspir- ation, as it is desirable that he cough from the stimulation of the as- pirating tube. This will loosen material in the smaller bronchi and bring it v/ithin reach of the aspirator. If the patient does not cought during the procedure, he is too deeply anesthetized. 483 Initial Surgery of the Thorax and ‘Thoraco-abdominal Wounds (Tracheobron- chial Aspiration on the Operating Table, contd) Another objection that has been raised to postoperative bronchos- copy is the slight risk to which the patients are subjected. It cannot be said that any procedure on the human body is without risk no matter what the operation. There have been two instances in this series where the patient died during bronchoscopy from what was apparently a nvago- vagal1* reflex. We have not known this to occur when the patient had been given a therapeutic dose o:~ atropin" within an hour. Inasmuch as atro- pine does theoretically protect against such accidents, it is advisable to administer atropine grains 1/100 intravenously 10 or 15 minutes before bronchoscopy, even though a preoperative dose of atropine has been given. It is our considered opinion that the slight risk engendered by postop- erative bronchoscopic aspiration is more than offset '07/ the benefits ob- tained. An extremely rare death from bronchoscopy is a dramatic arm* long remembered incident, while the common postoperative death from pulmonary complications is so frequent as to be disregarded. Although we are aware of the fact that the records are not accurate as to the number of times bronchoscopy was used immediately postoperrtively, we do have records of its use in 436 cases but know that it was used in many more cases but not recorded. These were all thoracic, abdominal or thoraco-abdominr.l lesions In this group there were two fatalities attributed to the bronchoscopy. Tliis latter figure has been checked by a personal canvass of all! the sur- geons and anesthetists and we have been unable to find any other instance; Thus, it can be stated that the risk is approximately 0,4m or loss, which seems perfectly justifiable in view of the high incidence of postoperat:. •. complications. POSTOPERATIVE TREAT;,ENT The success of the operation, the degree of functional level i . the patient returns and the number and extent of complications with whi the base section must contend, is dependent on the efficacy of the imm- iate postoperative treatment. The three prime objectives of‘the pod. p erative care are: Attainment of Gariy, complete lung expansion; main- tenance of a clear air way and thus the prevention of pulmonary compli- cations; and relief of pain in order that the Patient will m:intaiu mum respiratory excursions and be able to cough effectively. The deaf of management together with prevention and treatment of postoperative pulmonary complication is fully described in the section on posteperat care (page 65 ). Details of the treatment of abdominal postoperative c plications in the thoraco-abdorainal injuries are not presented here as they differ in no vra.7 from that of the usual abdominal lesion. In gene- it may be said that the postoperative course of the thoracolaparotomy w.1 transdiaphragmatic repair is much smoother than the usual laparotomy, d.. to the decreased discomfort in the postoperative period and the lessen!* of abdominal distension. Severe wound infection or dehiscence of a 'h- acotomy is so uncommon as to be a rarity. 484 Initial Surgery of the Thorax aril Thoraco-abdominal Wounds (contd) MORTALITY In discussing the mortality in this group of 2267 thoracic and thor- aco—abdominal cases, one must remember that the actual period of obser- vation for all cases in this report is limited to the period of’time that the patients were treated in the forward hospital. Thus, only matters pertaining to the initial treatment can be presented. Since preservation of life is the main objective of the forward surgeon, factors bearing on the mortality of this type of casualty are of prime im ortance. A series of tables has been prepared which considers the various factors influenc- ing the mortality rate. Of the 1364 cases with penetrating or perforat- ing wounds of the chest 135 died, a mortality of The 903 thoraco- abdominal ’.rounds showed a mortality rate of 27.355 or 9MH fatalities. The more salient points that have a bearing on the management of the thoracic and thorace-abdominal wounds will be briefly discussed. Thoracic Injuries In assessing the value of any mortality figures, the severity of the wound is a most important item. This is an intangible factor varying v.dth the judgment of the individual surgeon. The great majority of cases in this group were treated in Held Hospitals or in Evacuation Hospitals. These cases were for the most part "nontransportable" cases and as such represent the most severe type of thoracic wound reaching the forward hos- pital. As might be expected, the mortality was higher for those having a thoracotomy as compared with those having only a sim le debridement of the thoracic wall (Table XIV), The mortality figure was 6.90$ in the 76S cases where debridement was done, as contrasted to 12.4-1$ in the 435 cases of thoracotomy. Thus, the mortality for thoracotomy was almost twice that for simple debridement. A study of Table VIII shows the indi- cations for thoracotomy in these cases. Traumatic thoracotomy was second only to thoraco-abdominal lesions as an indication for thoracotomy. In the traumatic thoracotomy group the thoracic wall and pulmonary damage was severe and the resultant derangement of the- cardiorespiratory physi- ology so great that it is logical that this type of wound should have a high mortality. If we add this group to those thoracotomies done for questionable abdominal or mediastinal penetration, they comprise 70$ of all thoracotomies. Thus in 70$ of those with only intrathoracic injuries in which thoracotomy was performed there was an ’’absolute" indication for the performance of this operation. In 75 cases (17$) no indication for thoracotomy was noted on the record. It is only pure speculation to attempt to say how many of these cases did not have, what in the light of the experience of this Surgical Group, is considered as a "bona fide reason" for performing a thoracotomy. It is known to ell of us that, in the early days,, not a few needless thoracotomies were done. In view of the almost double mortality of thoracotomy over debridement it behooves the forward surgeon to think twice before performing such an operation in a forward hospital. 485 Initial Surgery of the Thorax and Thoraco-abdorninal Wounds (Mortality, contd) A study of the factors causing fatalities in the thoracic cases be- fore May 1944, and after May 1944, is of interest. This date has been arbitrarily chosen for several reasons. By this time the policy for hand- ling these injuries in the forward area had been crystalized in this Sur- gical Group. Furthermore, the employment of the surgical teams had grav- itated from the Evacuation to the Field Hospitals. The Field Hospitals were usually employed (as far as the surgical teams in this Group were concerned) for the reatment on nontransportable cases. Also, by this time, the policy of evacuating thoracic cases from the Field Hospital to the Evacuation Hospital had been changed considerably. It had been shown that those cases in which the cardiorespiratory physiology had been sta- bilized could be safely transported to the Evacuation Hospital. Thus, only those thoracic cases which were not readily stabilized were kept in the Field Hospital. The late group were, accordingly, a much more severely wounded group than those treated before May 1944-. Thus, one would expect m Increase in the mortality rate in the post-May 1944 group. Actually, the reverse is true. Of the 400 cases treated in the pre-May 1944 group 45 died, a mortality of ll*.27$. In the post-May 1944 group of 849 cases 71 died, a mortality of 8.3%, Thus, in spite of the fact that a more se- vere type of case was treated there was an improvement in the mortality rate of 2,9%, The factors involved in this improvement ares 1. A more physiological approach to the preoperative management; 2. A more com- plete understanding and a wider appreciation of the limited indications for early thoracotomy; 3. Improved postoperative care; 4. Adequate amounts of blood through the blood bank; 5. Better anesthesia, as the result of the widened experience of our anesthetists and more adequate anesthetic equipment (47); 6. Universal availability of penicillin for the seriously wounded. It is unfortunate that there is no numerical or quantitative standard that we can apply to the more severe type of case treated in the post-May 1944 group. Suffice it to say, that this mor- tality of 8.36$ represents the death rate for the severest type of chest wound reaching the most forward hospital (Table XII). The causes of death in the 116 cases that died in this series are tabulated according to frequency and day of death in Table XXI, There were nine cases that died on the operating table before the operation could be finished. Slightly over half (54*3$) of the fatalities occurred by the end of the second postoperative day and 91.3$ of these that died did so on or before the seventh day following operation. Since there are 41 different causes of death they will, be correlated in groups to simplify the discussion (Table XXII). The largest and, from the clinical standpoint, most important group as they are amenable to treatment, are those that died of pathological conditions related to varying degrees of obstruction of the tracheobron- chial tree. This group consists of 28 cases or 24.1$ of the total deaths. 486 Initial Surgery of the Thorax and Thoraco-abdominal Wounds (Mortality, contd) Seven of these were diagnosed as pulmonary edema occurring on the first to fourth postoperative days. The pathogenesis of pulmonary edema in persons with thoracic trauma, and the role of obstruction of the air way and the resultant anoxia so produced, has been previously discussed in this report. These cases represent a most difficult clinical problem in which the pulmonary damage is usually severe. It is not known whether positive pressure oxygen therapy, found by the authors to be beneficial in treating this type of pulmonary edema, was or was not employed as a therapeutic measure for cases in this group. We have seen, from what has ..been discussed above, that a patient not too severely wounded may recover ‘from shock without complete relief of the tracheobronchial obstruction, or that there may be r recurrence of the obstructive process in the pul- monary tree. The latter sets the stage for the development of atelec- tasis and pneumonia. These complications arise in a manner similar to postoperative pulmonary complications in civilian life. The same eti- ological factors are present in both instances; An abnormal amount of fluid substances in the bronchial tree and conditions preventing the ex- pulsion of this obstructing material. In the group of severe chest wounds it is not surprising that in 15 instances the cause of death was listed as "pneumonia" and in four cases "atelectasis". One other case died of tracheal obstruction due to mucus and in still another case the cause of death ’was listed simply as "wet lung" on the fifth postoperative day. Two'cases, not included in the lb, died due to aspiration of vomitus on the operating table. In the case of pneumonia the added factors of the exposure on the battlefield, pre-existing upper respiratory infection, the virulence of the organism and the resistence of the host are import- ant factors. Infection flourishes in those parts of the lung with poor bronchial drainage. Therefore, the measures outlined earlier in this paper to improve tracheobronchial drainage are important not only during the resuscitation period to combat anoxia but also to prevent later ate- lectasis and, along with chemotherapy, to treat lobular and lobar pneu- monia. "Shock" was the next largest numerical group with 10 cases (8,6$). Eight of the 1C patients died on the operative day. The other two died, one each, on the day after and the second dair following surgery. "Post- traumatic renal failure" was the next most iimortant cause of death with nine cases (7,7$). This subject along with shock is considered in another section of this rewort (see page 759). It is important to remember, how- ever, that this complication is a significant cause of death in severe thoracic wounds. The deaths due to heart injury are included in the sep- arate section on heart lesions. Blast injury, six in all (3 pulmonary, 2 cerebral and 1 mediastinal) was the next most common cause of a fatal issue. Intrapleural hemorrhage was the cause of death in six instances. This represents 5.2$ of all the deaths but only 0.4-8$ of the 1249 cases 487 Initial Surgery of the Thorax and Thoraco-abdominal Wounds (Mortality, contd) with thoracic wounds in this series. In three cases, laceration of the aorta was present; in one a laceration of the vena cava; and in the other two the cause of death was stated simply as "intrapleural hemorrhage", of which one was probably from a laceration of the internal mammary ves- sels. This small number of deaths from intrapleural hemorrhage is a most important point when one considers how much intrapleural bleeding is stressed in the medical literature as a cause of death. These figures point out that death from intrapleural hemorrhage is not as common as we were led to believe. Therefore, great circumspection must be exercised before a thoracotomy is dons solely for the cause. The criteria laid down earlier in this report for continued intrapleural hemorrhage should be considered carefully as they have proven of practical value in hand- ling this large group of thoracic wounds. Mediastinal infection was listed as the cause of death in three in- stances in two of which lacerations of the esophagus had been overlooked. Empyema was the cause of death in only one case in the forward hospitals, an incidence of Deaths due to pressure pneumothorax and severe laceration of the lung were recorded in only two instances. This indi- cates that considerable attention was paid to the mechanical aspects of stabilizing the cardiorespiratory physiology by the prompt employment of the measures previously described. Cerebral complications, other than anoxia, were present in two cases (one abscess and one embolus). In eight cases the causes of death were extrathoracic. Cardiac Injuries There were 30 deaths in the series of 75 cases. Three of the deaths occurred among the 18 cases of pericardial wounds and none was due to the pericardial involvement. Twenty-seven deaths occured among the 57 pa- tients with myocardial lesions; of these 20 (35/0 were due directly to the heart. The other seven were due to shock, severe thoraco-abdominal wounds, bronchopneumonia, esophageal wounds and anuria. As would be expected, none of the contusions could have been helped by surgery. Hie largest group, again expected, which could have been benefitted by surgery, were those in which the chambers were penetrated. There were seven cases in which it is probable that successful repair of the defect would have saved the lives of those concerned. One Perforat- ing wound had been repaired successfully but died of acute myocardial in- sufficiency, There was extensive contusion of the myocardium in this case. The foreign body embolus to the heart has been described previous- ly. Had the condition been recognized even a few days before death, re- moval of the fragment probably would have been life-saving. reported a similar but less marked, area of contusion overlying an embolic foreign body to the right ventricle which was removed at operation. Re- ferring to Table XXX, this is the case in which removal would have saved 488 Initial Surgery of the Thorax and Thoraco-abdominal Vvounds (llortality, contd) life. The one case that might possibly have benefitted from surgery was also concerned with a foreign body. In this instance the missile was ly- ing in a lacerated, contused wound of the right ventricle between the ventricle and sternum. The patient died suddenly and it is possible that removal of the foreign body might have reduced ectonic stimuli. Three cases of laceration and contusion would probably not have benefitted from surgery as the myocardial damage appeared to have been lethal and there was no conceivable repair that would have changed the fatal outcome. In two, for example, the lacerations and contusion had involved the anterior descending branch of the coronary artery and the vessel was thrombosed for at least half it's length. Thoraco-abdoninal Injuries For a comprehensive discussion of all statistics relating to the 903 cases of thoraco-abdominal injury, see section of "The Thoraco- abdominal Casualty" (page 566 ), and Tables XXXI through XLIII of the following appendix. 489 Initial Surgery in Thorax and Thoraco-abdominal Wounds (contd) COMMENT The group of cases here reported is large enough (226?) and treated over a sufficiently long period of time (two and one-half years) and over a variety of terrain (Tunisia, Sicily, Italy, Southern France and Ger- many) to have balanced a few of the variables and eliminated certain fac- tors present in a smaller series in less diversified geographical loca- tions, The cases here reported were all operated on in the forward hos- pitals where they could be held only long enough to become safely trans- portable, T./o, therefore, do not have sufficient later studies to be able to express any opinions except as they apply to the initial surgery of thoracic and thoraco-abdominal lesions, ue do not believe that the a- vailable records are sufficiently adequate on which to base a statistical study. Vie do believe, however, that the combined opinions of those who have treated these esses are of significance. Hie following comments are made on the basis of our personal, experience in treating these cases. It has been to the delight of all that the Army medical Department has been able to provide even the most forward surgical hospital with excellent equipment. The surgical instruments, roentgenographic and anesthetic apparatus approaches very closely that found in the better surgical clinics in civilian practice and has been found by us to be very adequate for tho surgical treatment of traumatic lesions of the thorax and abdomen, h'ith this equipment at hand end well trained and qualified personnel, there is no need for any slipshod or "foxhole” surgical pro- cedures, even in the first-priority surgical hosnital set up in conjunc- tion with the divisional Clearing Station. For tho most part the fundamentals of thoracic war surgery are those of civilian thoracic surgical practice. There have been a few concep- tions held over from the First World Mar that have been unsubstantiated by the experience in the present war. One of the most outstanding is the treatment of hemothorax. From the literature even of recent date (ll), (39), (1), one would assume that hemothoraces during the early phase are best left alone (34-), (40), unless of sufficient size to produce dyspnoea or else they should be aspirated and some of the fluid replaced with air. It has now been substantiated that there is no appreciable risk of start- ing up fresh bleeding by the aspiration of a hemothorax. The sooner and more completely the pleural space is evacuated, the smoother the course and the less likelihood of subsequent complications arising. It is now well established that there is no indication for the use of air replace- ment to check pulmonary hemorrhage as the severe hemorrhages are usually from a systemic.vessel end the slightly increased intrapleural pressure is ineffective in stopping bleeding from one of these vessels. In fact, there are two definite contraindications to the use of air replacement in the early treatment of hemothorax. First is the inability to control the amount of pulmonary collapse for a sufficiently long period of time. 490 Initial Surgery in Thorax and Thoraco-abdominal hounds (Comment, contd) in many instances, because of the rapid evacuation O' the patient. This has resulted in many patients arriving at the base with a collapsed lung The second is that should empyema develop it is almost always total in extent thus making the problem of treatment much more complicated. One of the more important concepts to come out of this war from a thoracic standpoint is the relative infrequency of indicated intrathor- acic procedures. With the exception of the rare injuries to the media- stinal structures (heart, great vessels, trachea and major bronchi) there are very few indications for intrathoracic manipulations except as incidental maneuvers in spite of recent publications to the contrary (4-1). The great majority of surgical procedures within the chest are done because it is necessary to expose or enter the pleural cavity for some other reason such as an operation for a thoraco-abdominal injury or a traumatic thoracotomy. All have been surprised by the tremendous recuperative power of the lung. It was thought toward, the end of World War I (29) and to a lesser extent recently (4-2) that in many cases with a large contusion or laceration of the lung, pulmonary resection was in- dicated, Our experience has been that the great majority of these le- sions have been observed to resorb spontaneously and heal within a few v/eeks, Although there are at least theoretical indications for major resections we have found no fatal case in this series that we believe might have survived if a total lobectony or pneumonectomy had been done. The one case that had a lobe resected died on the operating table. Although it has been the practice in this Theater to debride all wounds (4-3)? one still finds references in the recent literature (l), (4/-), to the advisability of not debriding chest vrounds that are old or definitely infected. The reasons given have to do with the breaking down of the natural walls of resistance that have been set up and the fear of spreading the infection. We have not found this to be true and have treated old or infected wounds in exactly the same manner as the fresh ones. In fact, it is often necessary to do so in thoracic wounds and even carry out some type of plastic repair in order to effect an air-tight closure of a large thoracic wall defect. We believe that the most dramatic improvement in any group of war wounds compared with the last war has been in the thoraco-abdominal group. The startling reduction in mortality from 60$ to 70$ (46) has been reduced to approximately that for straight abdomens (20$ to 25$). Such results were made possible largely by the advances in thoracic and abdominal surgery in the period between the wars. It was possible for the surgeon to enter this war with a well grounded understanding of the physiology of the cardiorespiratory system. This knowledge together with skillful anesthesia by a well trained anesthetist using modern anesthetic apparatus allowed the surgeon to work unhurriedly and safely through the open thorax for as long as was necessary to accomplish his purpose. Experience in the transdiaphragmatic resections of the lower 491 Initial Surgery in Thorax and Thoraco-abdominal Wounds (Comment, contd) esophagus and upper portion of stomach pointed the way to transdia- phragmatic thoraco-abdominal repair. This transthoracic approach plus the realization by the surgeon of the necessity of correcting thoracic physiology first in those cases in which a laparotomy had to be done has resulted in a very acceptable mortality rate for this severely wounded group. It would seem to be amiss if some mention was not made in this re- port of the employment of thoracic surgical teams on the basis of the experience gained in their use in this Theater. During war ideal condi- tions usually are not obtainable. There will never be enough well quali- fied thoracic surgeons to have a sufficient number in every medical in- stallation. In order to use these that are available most efficiently, they should be able to devote their full time to the care of thoracic casualties. This was not possible for most of us during the period of this report. By thq use of a first priority surgical hospital it is pos- sible to concentrate the severely wounded in these installations with the least possible delay as outlined previously. Although it is possible to evacuate the majority of the thoracic cases to an Evacuation Hospital directly from the Clearing Station or after resuscitative procedures have been done at the Held Hospital (average of 57$ in one nine-month it is still necessary to retain some severe thoracic casualties and those with thoraco-abdominal lesions. During periods of heavy activity, it is not possible for one thoracic team to care for all thoracic and thoraco- abdominal cases in a platoon of a Held Hospital. It is suggested that should the necessity arise in the future it would be wise to place with each platoon one senior thoracic surgeon who would have two teams under his direction. In this way the one thoracic surgeon would be able to supervise the care of all serious thoracic and thoraco-abdominal casual- ties. The load of thoracic cases will fall on the Evacuation Hospital from a numerical standpoint and there will be also a certain proportion of those who are severely wounded. In an Evacuation Hospital it is im- portant for a well trained thoracic surgeon to be a member of the staff. VJhile he cannot operate on all the cases himself he should have super- visory control and be able to establish the principles upon which all thoracic cases are treated. An integral part of the plan should be a thoracic surgical center in the base section set as close up to the Evac- uation Hospitals as possible. It has been well established that the con- centration of thoracic cases in a minimum of institutions where their care can be under the supervision of a thoracic surgeon is of utmost im- portance . SUMARY AND CONCLUSIONS 1. Two thousand two hundred sixty-seven thoracic wounds, includ- ing 903 thoraco-abdominal injuries are presented whose initial surgery in the forward areas during the campaigns in Tunisia, Sicily, Italy, Southern Prance, Rhineland and Central Europe, was carried out by the surgical teams of the 2nd Auxiliary Surgical Group. Pbr penetrating or 492 Initial Surgery in Thorax and Thors.co-abdominal ;ounds (Summary and Conclusions, contd) perforating wounds of the thorax without penetration of the diaphragm the mortality was 9.89/0. The thoraco-abdominal lesions showed a mor- tality of 27.35%, 2. Restoration of cardiorespiratory balance is the most import- ant factor in the resuscitation of the thoracic casualty, then in car- diorespiratory balance, many cases with thoracic injuries (except thor- aco-abdominal lesions) can be safely evacuated to an Evacuation Eospi- • tal for surgery, thus relieving the load on the forward,* first-priority surgical hospital. Thoracentesis (without air replacement), intercostal nerve block or tracheobronchial catheter aspiration all may be indicated in addition to replacement therapy by blood in restoring the thoracic casualty to an improved physiological state. The time interval from in- jury to operation is not as important as the time from injury to stabil- ization and the concomitant banishment of anoxia. 3. The aim of the forward surgeon doing initial surgery on thoracic patients is the saving of life first, and the prevention and control of infection second. 4-. We believe the following to be the indications for thoracotomy in the forward area} 1. Possible thoraco-abdominal injuries; 2. Large chest wall defects (traumatic thoracotomies); 3. miscellaneous indica- tions, (a) suspected injury to the heart that might be amenable to re- pair, (b) continuing severe intrapleural hemorrhage, (c) possible eso- phageal damage, (d) bronchial fistulae from injury to the trachea or a major bronchus, (e) removal of excessively large intrapleural or intrapulraonary foreign bodies (such foreign bodies will in most instances have produced a traumatic thoracotomy in transversing the thoracic wall). Thoracotony in the forward area for other than these definite indications is strongly condemned. 5. Thoraco-abdominal injuries (proven or suspected) is the most frequent indication for thoracotomy in the early treatment. Ibr those demanding laparotomy, the cardiorespiratory system should be stabilized first even if this necessitates a thoracotony (prior to the laparotomy) The advantages of each approach have been presented. In this series of cases the transdiaphragmatic approach has been employed more freouently than laparotomy alone. 6. Large chest wall defects (pleural opening of 6 cm. or greater following debridement-) frequently must be treated in the forward hospi- tals as they often cannot be completely resuscitated and brought into cardiorespiratory balance without surgical repair of the wound. Such cases have been termed "traumatic thoracotomies” as debridement of the wound gives adequate exposure for any indicated intrathoracic procedure. 493 Ini.tial Surgery in Thorax and Thoraco-abdoninal wounds (Summary and Conclusions, contd) 7. Endotracheal anesthesia by a skillful (preferably physician) anesthetist using modern anesthesia apparatus is of utmost importance. Major intrathoracic or transthoracic procedures are better avoided in the absence of such. 8, Early, complete pulmonary expansion is the prereouisite of an uncomplicated postoperative convalescence, and is the best insurance against the development of subsequent empyema and clotted hemothorax. 9. Maintenance of a clear airway by whatever means that are nec- essary is essential during the preoperative, operative and postoperative periods. Tracheobronchial aspiration with a catheter or by bronchoscopy is strongly advocated whenever the patient is unable to accomplish this by coughing. 10, Suggestions are presented for the efficient and effective use of thoracic surgical teams in treating thoracic casualties in the for- ward area. BIBLIOGRAPHY 1. Bailey, Hamilton, Surgery of Modern Warfare, Williams and Wilkins Company, Baltimore, 194-1. 2. Churchill, Edward, The Surgical Management of the Wounded in the Mediterranean Theater at the Time of the Pb.ll of Rome, Ann. Surg., 120:268, (Sept) 1944. 3. Forsee, James H,, The Use and Control of Thoracic Surgical Teams of an Auxiliary Surgical Group, Journal of Thoracic Surgery, In press. 4-. Shefts, Lawrence M,, Doud, Ernest A., Sandzen, Sigurd G., Rose, William F,, and Michels, Leon Ivl., Observations on the Evacuability of Patients with Thoracic and Tboraco-abdominal Wounds. Unpublished report. 5. Samson, Paul C., and Burford, Thomas H., The Management of War Wounds of the Thorax in an Overseas Theater, Clinics. 3:1561 (April) 1945. 6. Betts, Reeve H., and Lees, William M., Thoracic War Surgery in the Forward Area, J. Thor. Surg. In press. 7. Samson, Paul G., and Pltzpatric, Leo J., Intercostal lierve Block: Its Role in the Management of Thoracic Casualties, Calif, and West- ern Med., 62:254- (May) 194-5. 494 Initial Surgery In Thorax end Thoraco-abdominal Wounds (Bibliography, contd) 8. Beecher, Henry K., Delayed Morphine Poisoning in Battle Casualties, I'M-; 1193 (April 22) 191 A. 9. Beecher, Henry K., Anesthesia for Men Wounded in Battle; Med Bull. Mediterranean Theater of Operations, 3!113, (April) 1915 10,. Beecher, Henry K., Preparation of Battle Casualties for Surgeiy, Ann, Surg., 121:769, (June) 1915, 11. Alexander, John, Thoracic Injuries, Amer Jour Surg, 67:360, (Feb) 1915. 12. Drinker, 0. K., and Warren, M. F., The Genesis and Resolution of Pulrnonary Transudates and Head ate s, J.A.M.A,, 122:269, (May 29) 1913* 13. Earach, A. L., Martin, J., and Eckman, M,, Positive Pressure Res- piration and Its Application to the Treatment of Acute Pulmonary Edema, Ann. Int, Med., 12:751 (December) 1938. 11, Brener, Lyman A. Ill, Burbank, Benjamin, Sanson Paul C,, and Schiff, Charles, Wet Lung in War Casualties, To be published. 15. Haight, Cameron, Intratracheal Suction in the Management of Post- operative Pulmonary Complications, Ann. Surg., 107:218, (Feb) 1938. 16, Sanson, Paul G., Brewer, Lyman A, III, Burbank, Benjamin, Tracheo- bronchial Catheter Aspiration: Indications and Technic, Med. Bull, US Army, In press, 17, Burford, Thomas H., and Burbank, Benjamin, Traumatic Wet Lung: Observations on Certain Physiological Fundamentals of Thoracic Trauma, J. Thor. Surg., In press. 18, Samson, Paul C,, and Brewer, Lyman A, III, Principles of Improving Inadequate Tracheobronchial Drainage Following Trauma to the Chest J, Thor. Surg, In press, 19. Beech, Robert D., end Wolff, Luther H,, Gastric Dilatation in War Injuries, Med. Bull, Med. Theater of Operations, 3:186, (June) 194-5. 20, Betts, Reeve H,, Thoraco-abdominal Injuries: A Report on Twenty- nine Operated Cases, Ann. Surg., to be published. 21. Circular Letter No. 4-6, Office of the Surgeon, N1T0USA, 29 Aug 44, 22. Samson, Paul C,, Burford, Thomas H,, Brewer, Lyman A, III, and Bur- bank, Benjamin, The Management of War Wounds of the Chest in a Base Section, J, Thor. Surg, In press. 495 Initial Surgery in Thorax and Thoraco-abdominal Wounds (Bibliography, contd) 23. Eurford, Thorns H., Personal communication. 24. Tuttle, Win. M,, Langston, H. T., and Crowley, Robert T,, The Treat- ment of Intrathoracic Woundsi An Abstract, Med. Bull, MT0U3A, 2:142, (December 1944. - 25. Snyder, Howard E,, The Management of Intrathoracic and Thoraco- abdominal Wounds in the Combat Zone, Ann. Surg. In press, 26. Samson, Paul C,, Burbank, Benjamin, and Brewer, Lyman A, III, and Burford, Thomas H., Immediate Care of the Wounded Thorax, J.A.M.A. In press. 27. Jarvis, Fred J., Report on the Surgery of Abdominal Wounds, (April) 1944. To be published. 28. Madding, Gordeon , War Wounds of the Liver, To be published. 29. The Medical Department of the United States Army in The World War, Vol XI, Government Printing Office, 'Washington, (1927.) 30. Sweet, Richard H,, Transthoracic Resection of the Esophagus and Sto- mach for Carcinoma, Ann. Surg., 121:272 (March) 1945. 31. Lilienthal, Howard, Thoracic Surgery, Vol I, IY. D, Saunders Go., Philadelphia, 1926. 32. Beck, C. S., Contusions of the Heart, J.A.M.A., 104:109 (Jan 12) 1935. 33. Elkin, Daniel C,, Wounds of the Heart, Ann, Surg,, 120:817, (Dec) 1944. 34* Elkin, Daniel C,, and Cooper, Prederocl W, Jr., Thoracic Injuries, Review of Gases. Surg, Gyn & Obstet, 77:271, (Sept) 1943. 35. Samson, Paul G,, Two Unusual Cases of War Wounds of the Heart, Surgery. To be published. 36. Robertson, Robert W., A Case of Penetrating 'Wound of the Right Aur- icle with Retrograde Embolism of the Foreign Body to the Left Common Iliac Vein. To be published. 37, Harken, Dwight, Personal Communication. 38, Tuffer, Plaies Anclennes: Corps S’trangers du coeur, V° Gongres de la Soc int. de Ghir. 1921, page 46. Initial Surgery in Thorax and Thoraco-abdominal Wounds (Bibliography, contd) 39. McGrath, E. J., Wounds of the Chest, J.A.M.A. ,■ 12A:ASS, (Feb 19) 19AA. AO. Holman, Emile, Experiences with Chest Vfounds from the Pacific Combat Area, Ann. Surg., 119:1, (Jan) 194/-. 4.1, West, John P., Chest Wounds in Battle Casualties, Ann. Surg., 121:83: (June) 19A5. A2, Daniel, R, A, Jr., Bullet Wounds of the Lungs, Surgery, 15:7//. (May) 1944. A3. Churchill, E, D., Military Surgery, to be published in Christopher’s Textbook of Surgery, AA. Potts, Willis J,, Battle Casualties in a South Pacific Evacuation Hospital, Ann, Surg., 120:886 (Dec) 19AA. A5. Shefts, Lawrence M., Doud, Ernest A., The Management of Thoracic and Thoraco-abdominal Wounds in the Forward Areas in the Sicilian and Italian Campaigns. To be published. A6. Jolly, Douglas W., Field Surgery in Total War, Paul B, Hoeber, Inc., New York, 19A1. A7. Bowers, Frederick W., Endotracheal Anesthesia in the Combat Zone, Anesthesiology, to be published. THORACIC AND THOEACO-ABDCMINAL WOUNDS STATISTICAL APPENDIX 498 STATISTICAL APPENDIX. Introduction* This statistical appendix has been compiled to assemble in tabular form all the available information from the records of the cases herein reported,, The figures mentioned in the body Of the report are the ones that we feel to be significant and reliable. We do not believe that many of the remainder are of statistical significance. They are ail in- cluded in this appendix for the sake of completeness and are merely be- ing presented as figures with no attempt at interpretation. Whenever the figures have not supported the opinion of the surgeons doing the cases* we have disregarded the figures. We feel that the records, from which the figures were derived, are surprisingly complete when one considers the conditions under which they were originally prepared. It was necessary for each team to pre- pare from four to seven forms or records on each case. Each record necessarily contained much duplicated information. All these records had tc be prepared in longhand with no secretarial or stenographic help. Also, ail postmorten examinations had to be done by the team members and the report written in longhand. During rush periods when the teams were working long hours under very adverse circumstances, one could not expect much zeal in the preparation of duplicate records for some fu- ture study. The most amazing thing is that the records were prepared at til 1 o The experience of this Surgical Group in treating priority thoracic and thor&co-abdominal wounds in the forward area has been very exten- sive and tne authors sincerely wish that the data presented was commen- surate with this extensive practice. We do believe, however, that the compilation cf this large series of war wounds involving the thorax, in- complete as it may be, is somewhat unique and we are not aware of any similar study having been presented. It seems wise, therefore, to pre- sent ail thtJ data obtainable from the records as it is impossible to know at tnis date what may be of future importance. It should be noted that civilians and prisoners of war have been eliminated from the tables dealing with thoracic injuries, except for the one table showing the overall experience of the Group. All other figures refer to American soldiers only. It was not feasible to so separate this group in the thoraco-abdominal series. The figures in the latter group include all cases done by the various teams. Percentages appear in many tables based on a comparatively few cases. These figures are included for completeness, but cannot be con- sidered accurate. 499 Page Table I - Summary of all cases................ PENETRATING AND PERFORATING CHEST WOUNDS Table II - Type of Chest Wound... Table III - Preoperative Treatment* Table IV - Preoperative Thoracic Procedures Table V - Anesthetic Agents Table VI - Incidence of anesthetic agents Table VII - Chest Wail Debridement and Associated or Wounds Table VIII - Types of Thoracotomy and Indications........ Table IX - Associated Major Wounds Table X - Intra-thoracic Operative Findings,.......... Table XI - Operative Technical Procedures.... Table XII - Gross Mortality Table... Table XIII - Operative Mortality A (G.S, & T.S.) Table XIV - Operative Mortality B (Prior and Post 1 May 1944) Table XV - Component Mortality Table XVT - Overall Deaths Table XVII - Deaths in Thoracotomies Table XVIII - Deaths in Associated Major Wounds.,.. Table XIX - Post Mortem Findings Table XX - Overlooked Thoracic Injuries Found at Post Mortem* •••••••••••••••••••••• Table XXI - Causes of Death Table XXII - Grouped Causes of Death,• HEART AND PERICARDIUM Table XXIII - Signs and Symptoms of Cardiac Lesions*...••• Table XXIV - Type of Cardiac Wound.• Table XXV - Deaths in Cardiac Lesions*•••.* * Table XXVI - Incidence of Repair of Heart Lesions........ Table XXVII - Foreign Body Removal....•*.................. Table XXVIII- Total Deaths. •••• Table XXIX - Time of Occurrence of Death Due to Heart..., Table XXX - Cardiac Fatalities With Reference to Sur- gical Correction THORACO-ABDOMINAL WOUNDS Table XXXI - Wound Location.. ••••••••••••• Table XXXII - Causative Agent, Table XXXIII- Time Lag Table XXXIV - - State of Shock on Admission..•••••...••••••• Table XXXV - Organs Involved. Table XXXVI - Mortality (With Reference to G.S, & T.S, Teams)••••••••••••••••••••••••••.•••••••• TABLE OF CONTENTS OF STATISTICAL APPENDIX Table XXVI Table of Contents of Statistical Appendix (Thpraco-Abdojainal Wounds, contd). Page Table XXXVII - Mortality With Different Operative App- roaches • Table XXXVIII - Mortality With Reference to Combination of Organs Table XXXIX - Mortality V/ith Reference to the Side In- volved Table XL - Mortality in Mediastinal Injuries, Table XLI - Technical Procedures Table XLII - Causes of Death Table XLIII - Grouped Causes of Death 501 Statistical Appendix. TABLE I Summary of Total Cases Chest Thoracoabdominal Total Cases 1364 903 2267 Deaths 155 247 3C7 Percent Mortality 9 • 89/o 27,35/'» 17.07$ Summary of ail cases, penetrating and perforating chest and thoraco-abdominal, treated by *tnis Group, ana cne mortality rates for eaca group* TABLES OF THE PENETRATING aMD ChEST sKOUMDS TABLL II Type of Chest Wound Prior 1 May 1944 Post 1 May 1944 Total G.3.* T.S.* G.3.* T.3.* Total Cf.S, Cases 243 157 623 226 1249 Chest Main Wound 233 147 529 203 1112 Percent 95.33/0 " 93.57% 84.91/ 89.32% 89.02/ R 96 85 301 117 602 oiae involved 134 67 296 101 603 Bilateral 2 5 20 8 35 Percent of R 39.50/ 54.14/o 48.31/ 51.77/“ 48.19/ total cases L 55 .14>'o 42,57/ 47.51% 44.39/ 48.27/ Bilateral 0.82% 3.18/ 3.21/0 3. 57% 2.38/ Type Wound Pen 170 105 310 134 719 Perf 62 49 284 83 478 Lac 4 3 26 8 41 Percent of Pen 69.96/0 66.88/ 49.76/ “ 59.29/ 57.56/o Perf 25.51/0 31.21/ 45.58/ “ 36.99% 38.27% total cases Lac 1,55% 1.91/ 4.17/ 3.57% 3.28% 3, F, 183 119 . 389 139 830 Agent G.S.W. 49 35 207 80 371 Stab 2 2 Records the wounding agent, side of chest involved, and type of wound in American battle casualties. ♦G,3,-General Surgical Teams, *T,3,-Thoracic Surgical Teams. 502 Statistical Appendix, cont’d. TABLE III Preoperative Treatment Prior 1 May 1944 Post 1 iviay 1944 Total U.S, Cases 400 849 1249 None 149 314 453 Mild 67 162 2*9 Shock Moderate 83 ISO 273 Severe 44 110 154 Not recorded 57 71 128 Cases 172 633 805 Blood Total cc given 179900 753850 933750 Av cc per case 1046 1189 1150 Largest Amt given 3600 7500 7500 Cases 196 569 765 Plasma Total cc given 138200 351200 489400 Av cc per case 705 617 640 Largest Amt given 2500 2750 2750 Cases 29 42 71 Autotrans- Total cc given 23400 23950 52350 fusion Av cc per case 807 689 737 Largest Amt given 2700 2000 2700 Morphine Over grain 56 98 154 1 grain and over 9 8 17 Average time lag in hours 15.7 14.0 14.5 This table shows the preoperative (shock) treatment in American battle casualties. It included all treatment recorded on the Emer- gency Medical Tag, plus tne resuscitative measures in the form of blood and/or plasma used in the hospital of initial surgery from time of ad- mission to the end of operation, Onty those records where a definite amount of tne material was indicated, were used in this tabulation. more cases than is apparent from this table, received such therapy but as no definite record was made of the amount, tney were not included. 503 Statistical Appendix, cont’d. TABLE IV Preoperative Thoracic Procedures Prior 1 May 1944 Post 1 May 1944 Total U. S, Cases 400 849 1249 Intercostal block 8 69 77 Thoracentesis 52 209 261 Thoracentesis via intercostal catheter 1 9 10 Treated pressure-pneumothorax 1 10 11 Trm'hnni Catheter 4 25 29 ii 8tCu6£ll iiSpIravlOu n r Bronchoscope 0 8 8 Lists additional preoperative resuscitative measures. TABLE V Anesthetic Agents Prior 1 May 1944 Post 1 May 1944 Total G.S.* T.3.* G,3,* T.3.* Ether 86 53 96 72 307 Pentothal 30 34 15 29 108 Gas-oxygen-ether • 73 39 455 106 673 Gas-oxygen 1 1 Agent Novocain 37 19 44 21 121 GOE-pentothal 1 1 Ether-pentothal 2 2 Novocain- pentothal 1 1 Sp inai-pr ocaine 1 1 Brachial Block 1 1 TOTAL 228 149 611 228 1216 Ty?6, Endotracheal 92 91 520 159 862 Open 43 6 6 1 56 Mask 20 2 9 2 33 TOTAL 155 99 535 162 951 Indicates the various anesthetic agents used and tne met lod of administration. ♦G.S,-General Surgical Teams. *T,3,-Thoracic Surgical Teams, 504 Statistical Appendix, cont’d. TABLE VI Incidence of Anestnetic Agents Prior ■ 1 May 1944 Post 1 May i9a4 Total Total anesthetics recorded 377 839 1216 Cases 139 168 307 Ether Percent 36.87/0 20.02% 25,25% Cases 112 561 673 G.O.E, Percent 29.71# 66,86/o 56,17% Cases 56 65 121 Novocain Percent 14,85% 7.74/o 9.9 5/o Cases 64 44 108 ?entothal Percent 16,98/0 ' 8,3 9% 8.88/0 Cases 2 0 2 Agent Ether Pentothal Percent 0.53% 0,00% 0.16% Cases 1 o" 1 G.O.E, Pentothal Percent 0.28% ' 0.00% 0.09% Cases 1 0 1 Novocain Pentothal Percent 0.28% O.OO/o 0.0 9/o Cases 0 1 1 Gas-oxygen Percent 0.00% d, i2/o 0.09% Gases 1 •0 1 Brachial Block Percent 0.2 8/o 0 . 00% 0.0 9/o Cases 1 0 1 Spinal Procaine Percent 0,2 3/o O.OO/o 0. 09% Cases 183 679 852 Type Endotracneal Percent 48.54% 80. 93/o 70.88% inhal- Cases 49 7 56 at ion Open Percent 12.99% 0.83/o 6C/0 Cases 22 11 33 Mask Percent 5.63/0 1.31/’ 2,71% Indicates the various anesthetic agents used, the method of the administration of those agents, and the relative percentages of the total number of anesthetics given. 505 Statistical Appendix. TABLE VII Chest Wall Debridement and Associated Major Wounds Prior 1 May 1944 G.S ,♦ T.St* Post 1 May 1944 Total G.S .♦ T .St* Total oases 243 167 623 226 1249 Debridements chest wall only 160 74 385 149 768 Percent of total cases that are debridements 65.84$ 47.13$ 61.79$ 65.93$ 61.49$ Deaths 17 2 24 10 53 Mortality 10.63# 2.70$ 6.23$ 6.71$ 6.90$ Abdomen 10 29 6 45 Severe compound fract 9 4 19 8 40 Transverse myelitis 5 2 11 5 23 Negative abdominal ex- ploration 6 1 2 9 Severe soft tissue wound 4 5 W 12 ASSOC- Amputation 1 1 2 4 IATED Lacerated kidney 1 1 2 MAJOR Brachial plexus 2 1 1 4 Trench foot 1 1 2 WOUNDS Tracheal (cervical) 2 2 Major vessel 4 2 6 Peripheral nerve 3 3 Oerebral blast 4 4 Contralateral thoraco- abdominal 4 4 Perforated pharynx 1 1 Severe pulmonary blast 3 2 5 Compound fracture cervical spine 1 1 Compound fracture skull 1 1 Total associated major injuries in debridements 36 10 92 30 168 Percent of debridements that had associated major injuries 22*50$ 20»13% 21«86^ Shows the number of cases where chest wall debridement only was done. Associated major injuries are tabulated. ♦G.S. - General Surgical Team. **T.S.-Thoracic Surgical Teams. 506 Statistical Appendix, contdl TABLE VIII Types of Thoraootoay and Indications Prior Post 1 May 1944 G.S.* T.S?* 1 May 1944 G.S# T.Sf* Total Total U.S. cases 243 157 623 226 1249 Thoracotomies 67 72 224 72 435 - Percentage Thoracotomies 27.57# cn • 00 ft 35.95# 31.86# 34.83# Deaths 11 10 27 6 54 Mortality 16.42# 13.88# 12.06# 8.33# 12.41# Thoraootoiqy Through Wound 55 61 194 68 368 Separate incision 12 11 30 14 67 Type Rib resection 57 58 188 62 365 Intercostal 3 9 20 9 41 Traumatic 15 34 77 30 156 ? thoraco-abdom- Inal 16 12 65 29 122 ?Bleeding 7 12 11 6 36 Recorded In- Injury to mediaa tinum and/or heart 2 1 16 1 20 dications Foreign body 1 7*** 3 0 11 for the Lung laceration 1 0 2 0 3 thoracotomies Bone fragments 0 2 1 0 3 Bronchial fistula 0 1 2 0 3 w. ? esophagus 0 0 1 2 3 ? hilar vessel 0 0 1 0 1 Pressure pneumo- thorax 0 0 1 0 1 Unexpended lung 0 0 1 0 1 Indication not recorded 27 0 44 4 75 Reveals the statistical data available for those cases where a thoracotomy was performed* *G.S, - General Surgical Team* **T.S. - Thoracic Surgical Team* ♦♦♦7 . Three removed* 507 Statistical Appendix, oontd. TABLE II Associated Major Wounds Prior 1 May 1944 Post 1 May 1944 Total Total U.S, Cases G,S ,♦ 243 T.S.** 157 6*Sf 623 T.S.** 226 1249 Chest alone, or associated with minor wounds 201 141 514 193 1049 Total Associated major wounds 42 16 109 33 200 Abdomen 13 2 41 7 63 Severe compound frao. 9 4 25 4 42 Transverse myelitis 10 5 14 10 59 Amputation 1 0 3 3 7 Severe soft tissue 5 0 7 3 15 ASSOC Brachial plexus 1 2 1 1 5 iAijfiu Peripheral nerves 0 0 3 0 3 MAJOR Major vessels 0 0 3 1 4 wraruns Lacerated kidney 0 0 1 0 1 Negative abdomifaal exploration 2 0 0 0 2 Severe retroperitoneal hematoma 1 0 0 0 1 Penetrating eyes 0 1 0 0 1 Trachea 0 1 2 1 4 Trench Foot 0 1 0 1 2 Gas infection 0 0 1 0 1 Contralateral thoraco- abdominal 0 0 4 0 4 Perforated pharynx 0 0 I 0 1 Cerebral blast 0 0 2 0 2 Compound fracture cervical spine 0 0 1 0 1 Fractured skull 0 0 0 1 1 Pulmonary blast 0 0 0 1 1 Deaths in Associated Major wounds ***12 1 25 8 46 Mortality 28.57$ 6.2C$ 22.94$ 24,24$ 23*00$ Indicates the detailed analyses of the associated Major wounds. la this group, we have included spinal eord lesiohs area though the chest ♦G.S. - General Surgical Teams. **T.S, Thoracic Surgical Teaas* **♦12 - One before operation coapleted* 508 Statistical Appendix. Table IX, contd. wound was the major wound, for it is our opinion that the cord injury, anatomic or physiologic, is the major lesion. TABLE I Intrathoraoic Operative Findings Bleeding intercostal vessels Prior 1 May 1944 31 Post 1 May 1944 22 Total 65 Bleeding internal mammary vessels 4 8 12 Pericardium and/or heart injured 7 2§ 35 Injured esophagus 0 3 3 Demonstrates the incidence of intrapleural bleeding noted at operation. TABLE XI Operative Technical Procedures Pleural Lavage Prior 1 May 1944 39 Post 1 May 1944 134 Total 173 Pleural Drainage 97 229 526 Tmchrml annlra. Catheter 36 52 88 1 rGLCudnX -LXT» “ tion Bronchosc opy 57 212 269 Shows the incidence of the various technical procedures instituted at close of the operation. These are the recorded instances only, and represents only a fraction of the actual number of times these procedures were employed. By 1 May 1944, trache©-bronchial toilet was an accepted routine in every endotracheal anesthetic, and thus was not recorded in all instances. 509 Statistical Appendix. TABLE XII Gross Mortality Rato Total Cases Prior 1 May 1944 408 Post 1 May 1944 956 Total 1364 Civilians and P .O.W.’s 8 107 115 Total American casualties 400 849 1249 Civilian and POW 2 17 19 Deaths U.S. 45 71 116 Total 47 88 135 Civilian and POT 25$ 15.89$ 16.82$ Mortality U.S. . 11.25$ "8.36$' ' ~ 9.21$ ~ Total 11.52$ 9.20$ ~ 9.89$ Chest the main Cases 380 732 1112 wound* (U.S* cases) Deaths 32 38 70 Mortality ~ 8.42$ “ 5,19$ 6729$ Chest not the Cases 20 117 137 main wound* Deaths 13 33 46 (U.S, cases) Mortality 65.00$ 28.20$ 33,58$ Summary of mortality for all groups of oases, divided into two periods, prior 1 May 1944 and post 1 May 1944, and including all cases seen during the entire period this group was active. 510 Statistical Appendix, contd. TABLE XIII Operative Mortality-A & General Surgical Team Thoracic Surgical Team Total Total Cases 952 412 1364 Civilians and P.O.W.*s 86 29 115 Total U.S. Casualties 866 385 1249 Deaths Civilian & POW 17 2 19 u.s. 87 29 116 Mortality Civilian & POW 19.88$ 6.69$ 16.52$ U.S. 10.05% 7.57$ 9.21$' Cases 545 223 768 Debridements Deaths 41 12 53 Mortality 7,52$ 5.38$ 6.90$ Cases 291 144 435 Thoracotomies Deaths 38 16 54 Mortality 13.06$ 11.11$ 12.41$ Associated Cases 151 49 200 major wounds Deaths 37* 9 46 Mortality 24.50$ 18.37 jfo 23.00$ Autopsy Yes 54 24 78*» No. 33 3 38 Demonstrates the results and mortality rate for all cases during the entire period this group was active, but separated as to General Surgical teams and Thoracib Surgical teams. There were 27 General Surgical teams and four Thoracic Surgical teams. *37 - One before operation completed, **78 - (67.7#) 511 Statistical Appendix* (contd) TABLE XIV Operative Mortality - B Prior 1 May 1944 Post 1 May 1944 Total Cases 234 534 768 Debridements Deaths 19 34 53 Mortality 8 *12$ 6.35$ 6,90$ Cases 139 296 435 Thoracotomies D eat hs 21 33 54 Mortality 15.11,# 11.15# 12.41$“ Associated Cases 58 142 200 major wounds Deaths 13* 33 46 Mortality 22.41$ 23.24$ 23,00$ Similar to Table XIII, but cases divided into the two time periods. Calculated for U.S. Casualties only. *13 - One preoperative. TABLE XV Component Mortality Prior Post 1 May 1944 G.S.* T.S** 1 May 1944 G.S. T.S. Total Total cases 248 160 704 252 1364 Civilians and P.O.W.'s 6 3 81 26 115 Total U.S, > Cases 243 157 623 226 1249 All 33 14 71 17 135 Deaths U.S. 32 13 55 16 116 Civilians & POW's 1 1 16 1 19 All 13,30$ 8.75$ 10.09$ 6.74$ 9.89$ Mortality U.S. 13.17$ 8.28$ 8.82$ 7,08$ 9.21$ Civilians & POW's ~20.00$ 33.33$ 19.75$ 3.85$ 16.52$ Classifies the cases as to type of case, operated by General Surgical Team (G.S.) or Thoracic Surgical Team (T.S.) plus the additional break down in Prior and Post 1 May 1944, *G,S. - General Surgical Team, **T,S,-Thoracic Surgical Team, 512 Statistical Appendix, (contd) TABLE XVI Overall Deaths Prior 1 May 1944 G.S.* T.S.** Post 1 May 1944 G.S. T.S. Total Total U.S, Cases 243 157 623 226 1249 Total U.S. Deaths 32 13 55 16 116 Mortality 13.17# 8.28# 0,82# 7.08# 9.21# Chest Main Wound 21 11 30 8 70 Percent 65.62# 84.61# 54.54# 50.00# 60.34# Associated Major Wounds 12*** 1 25 8 46 Percent 34,38# 15.39# 46.46# 50.00# 39.66# Deaths Following Thoracotony 11 10 27 6 54 Percent 34.37# 76.91# 46.55# 35.29# 46.54# Preoperative Deaths (includes thosewhere operation not com- pleted. 3 1 4 1 9 Percent 9.37# 7.69# 7.27# 5.88# 7,76# Post Traumatic Uranic Syndrome 0 0 6 3 9 Percent 0 0 10.34# 17.65# 12.00# Incidence of Post Traumatic Uremia 0 0 0.96# 1.33# 1.06#**** Table of overall deaths showing breakdown into major groups. *G,S. - General Surgical Team. ♦*T.S. - Thoracic Surgical Team. ♦**12- One before operation completed. ♦♦**1.06# - This figure is calculated on basis of Post 1 May 1944 only* since no cases were recognized as such in the Prior 1 May 1944 group* 513 Statistical Appendix, (contd) TABLE XVII Deaths in Thoracotomies . Prior 1 May 1944 G.St T.St* Post 1 May 1944 G.S. T.S. Total Total U.S. Cases 243 157 623 226 1249 Deaths following thoracotony 11 10 27 6 54 Traumatic 5 4 8 1 18 ?T horac o-abd ominal 4 1 6 2 13 Indications recorded for thoracotomies in those that ?Bleeding 4 1 1 6 ?Heart lesion 1 1 2 ?Esophageal lesion 1 1 2 Lacerated lung 1 1 died. Major vessel injury 1 1 Bronchial fistula 1 1 Bone fragments 1 1 tfot recorded 2 6 8 ♦G.S, - General Surgical Team, ♦♦T.S, - Thoracic Surgical Team. 514 Statistical Appendix, (oontd) TABLE XVIII Deaths in Associated Major Wounds Prior Breakdown of Deaths in 1 May 1944 Associated Major Wounds G,S«* T.S,** Post 1 May 1944 G.S. T.S. Total Total U«Sf Cases 243 157 628 226 1249 Deaths in associated major wounds 12 1 25 8 46 Abdomen 6 15 3 22 Transverse %elitis 2 1 5 4 12 Amputation 2 1 5 Severe Fracture Compound comminuted 2 1 3 Negative Abdominal exploration 1*** 1 Severe soft tissue injury 1 1 Major vessel injury 1 1 ITaoerate& kidney not involving peritoneum or diaphragm 1 1 Thoraco-abdominal on contralateral side 1 1 Overlooked esophageal injury 1 1 *GS - General Surgical Team. **TS - Thoracic Surgical Team. ♦♦♦I - Retroperitoneal hematoma. 515 Statistical Appendix, (oontd) TABLE XII Postmortem Findings Prior 1 May 1944 Postmortem findings as recorded G.S«* T.S.** Post 1 May 1944 G.S. T.S. Total Gas infection 2 1 1 4 Aspirated vomitus 1 ' 1 Pulmonary embolus 2 1 3 Pressure pneumothorax 1 1 Massive mediastinal hemorrhage 1 1 Empyema and brain abscess 1 1 Massive intrapulmonary hemorrhage 1 1 Massive pulmonary collapse 1 1 Cerebral emboli 1 1 Multiple cerebral thrombosis and encephalomalacia 1 1 Thrombosis pulmonary artery 1 1 Severe pulmonary blast 1 1 Cardiac failure (heart had been sutured) 1 1 Vago-vagal reflex 1 1 Cerebral blast 1 1 dardiao standstill during operative and postoperative decerebrate rigidity syndrome* 1 1 *G.S. - General Surgical Team. **T,S. - Thoracic Surgical Team, TABLE XX Overlooked Thoracic Injuries Found at Postmortem Prior 1 May 1944 Overlooked Injuries G.S.* T.S.** Post 1 May 1944 G.S. T,S, Total Esophagus 1 1 2 ffeart 1 3 1 5 Perforated aorta 2 1 3 Trachea 1 1 trachea and esophagus 1 1 Vena cava ~T~~~ Heart with massive pulmonary collapse 1 l G,S** - General Surgical Team. T.S«** - Thoracic Surgical Team, 516 TABLE XXI Causes of Death Before Op Op Cause Comp Dav Postoperative Day * Per- cent 1 2 _3 A-5 6 7 8 9 10 12 12 Tot Pneumonia 2 1 1 1 2 1 1 2 2 1412*1 Shock 1 7 1 1 10 8.6 Post-traumatic uremia 2 2 1 2 9 7.7 Pulmonary edema 1 1 2 2 7 6t0 Atelectasis 2 1 4 2.4 Pulmonary embolus 2 1 1 4 2*4 Gas Ganarene (p Thoracic wall) 1 1 1 2 2.6 Cerebral anoxia 2 1 2 2.6 Lacerated aorta 1 2 2 2.6 Overlooked cardiac injury 1 2 2 2.6 Pulmonary blast 2 1 2 2.6 Mediastinitis (overlooked in.iurr to esopharrus) 1 1 z 1.7 Cardiac fibrillation 2 2 1.7 Cerebral blast 1 1 2 1.7 Massive intrapulmonary hemorrhage 1 1 2 1.7 Aspirated vomitus (anes.) 1 1 2 1.7 Massive intrapleural hemorrhage 1 1 2 1.7 Cardiac injury 1 1 2 1,7 Severe luna laceration 1 1 0.9 Cerebral malaria 1 1 0.9 Vaso-vafral refles 1 1 0.9 Mediastinal hemorrhage 1 1 0,9 Cerebral embolus 1 1 0.9 Peritonitis 1 1 0.9 Pulmonarr artery thrombosis 1 1 0.9 Overlooked injury to esopharus and trachea 1 1 0.9 "Wet” lunp; 1 1 0.9 Brain abscess 1 1 0.9 Empyema, 1 1 0.9 Cardiac tamponade 1 1 0.9 Severe whosuborns burns 1 1 0.9 Extensive wounds 1 1 0.9 Lacerated vena cava 1 1 0.9 Mediastinal bls,st 1 1 0.9 Atelectasis and cardiac injuiy 1 1 0.9 Asphyxiation (trachial obstruction) 1 1 0.9 Pneumonia and anaerobic infection 1 1 0,9 Riaht heart failure 1 1 0,9 Massive emphysema 1 1 0.9 Pressure pneumothorax 1 1 0.9 Spleno-hepatomesralv and jaundice 1 , 1 0.9 Not recorded 2 2 2 1 2 3 2 1 16 11.8 Totals , 9 26 19 9 11 11 11 3 7 3 2 3 1 1 116 Pe**cent 7.8 22.A 364 7.7 9.5 9.5 9.5 26 60 26 L7 0.9 0.9 100 £ * No deaths recorded on 11th postoperative day. Statistical Appendix. (Table XXI, contd) Lists the recorded causes of death and the incidence of deaths with relation to cause and postoperative day. TABLE XXII Grouped Causes of Death Cause Cases Percentage of Deaths Total Deaths 116 1 00# Pneumonia 15 12*93# Related to Xracheo- Pulmonary edema 7 6.03# bronchial Atelectasis 4 3.45% obstruction Asphyxiation 1 0.86 "Wet Lung" 1 0.86# Total related to tracheo -bronchial obstruction ?8 24.14# Shook 10 8.62# Post-traumatic uremia 9 7,?6% Extra thoracic 8 6.89%. Cardiac (including one tamponade 9 7.76* Blast 6 Intrapleural hemorrhage 6 5.17% Cerebral Anoxic 3 2.58# Complications Ron-anoxic 2 1.72# Pulmonary embolus 4 3.45# Mediastinitia 3 2.58% Bronchial fistula 2 Empyema 1 0.36# Miscellaneous 9 Y.Y6# Not recorded 16 13.79% HEART AND PERICARDIUM 519 Statistical Appendix, (contd) TABLE XII11 Signs and Symptoms of Cardiac Lesions Suspicion from course of missile 22 X-ray evidences Foreign body in region of heart (four labeled fuzzy or double-contoured) 8 Alteration, size and shape of cardiac shadow 5 Foreign body suspected in region of heart, not proved 2 Symptoms due to anoxia: Dyspnea 6 Necessity for continuing oxygen 6 Mental confusion or semi-stupor 5 Cyanosis 3 Signs suggestive of cardiac dysfunction; Persisting tachycardia (120 or above) 8 Arrhythmia (transient fibrillation lj extra systoles 6j) 7 Bradyeardia (below 65) 2 Apical systolic murmur 2 friction rub, precordial 2 Paradoxical pulse 1 Nausea and vomiting 1 Cardiac tamponade (recognized clinically 3) (suspected l) 5 This table is a compilation of the number of times that each sign or symptom was noted in proven cardiac cases. In a few oases the findings were noted on the records but were not appreciated until after the cardiac lesion had been discovered at operation or autopsy. 520 Statistical Appendix* (contd) TABLE XXIV Type of Cardiac Wound Anatomical Portion Involved Contu- sion Pure Lacer- ation Lacer- ation & Contu- sion Perfor- ated Chamber Embolus to Heart Total Left 7 7 5 7 0 26 Ventricle Right 5 2 2 3 2 14 Both 3 0 2 0 0 5 Auricle Left 0 0 0 2 0 2 Right 1 1 0 7 0 9 Right auricle and ventricle 0 0 1 0 0 1 Total Lesions 16 10 10 19 2 57 Total 11 1 5 9 1 27 Deaths Due to heart 6 1 4 8 1 20 Total 68.7$ 10.0$ 50.0$ 46.8$ ‘ 50.0$ ' 47.4$ Mortality Rate Due to heart 37.8$ 10.0$ 40.0$ 42.1$ 50.0$ 35.1$ Lists the types of lesiohs occurring in the various anatomical portions of the heart. Mortality rates are calculated for deaths oonsid ered due to the heart directly. 522 Statistical Appendix, contd. TABLE XXV Deaths in Cardiac Lesions Lesion Ventricle Left Right Both Auricle Left Right Right Auricle and Ventricle Total Total 4 4 2 0 1 0 11 Con- Due to Heart 3 2 1 0 0 0 6 tusion Type of death due to heart (0,0,3$ (0, x) (x) (S)._ Percent of death due to heart 75$ $0% 50% 0 0 0 68.7$ Total 1 0 0 0 0 0 1 Due to heart 1 0 0 0 0 0 1 Pure Lacera- Type of Death due to heart (0) (1) tion Percent of death due to heart 100$ 0 0 0 0 0 100$ Lacera- tion and Con- Total 2 1 2 0 0 0 5 Due to Heart 1 1 2 0 0 0 4 Type of death due to heart (c) (c) ( 0,0) (4) tusion Percent of death due to heart 50% 100$ 100$ 0 0 0 80$ Total 2 1 0 1 5 0 9 Perfora- Due to Heart 2 1 0 1 4 0 8 ted Chamber Type of death(0, due to heart h) (t) (c) (b,h, b,t) (8) Percent of delath due to heart 100$ 100% 0 100% 80% 0 88.8$ Total 0 1 0 0 0 0 1 Embolus to Due to Heart 0 1 0 0 0 0 1 Type of Death due to heart (0) (1) Heart Percent of death due to heart 0 100$ 0 0 0 0 100$ Ehis table portrays the inoidenoe of deaths attributable to the heart with reference to the type of lesion and part of heart involved. In addi- tion they are classified as to the type of deaths; vi*:- Statistical Appendix, contd. (c) death due directly to ngrocardial lesion. Usually sudden death from infarction or fatal arrhythmia, . 11 (h) death due to exsanguination from the heart, . . 4 (t) death due directly to tamponade. 2 (x) heart lesion is an essential contributory causes of death 3 Figures or letters in parenthesis also refer to deaths duo to the heart. 524 Statistical Appendix, contd. TABLE XXVI Incidence of Repair of Heart Lesions Ventricle Auricle Right auricle Lesions ) seen and at autopsy only: Laceration Left 1 Ri^it 1 Both 2 Left 0 Right 0 ventricle 0 Total 4 Perforation 1 1 0 1 3 0 6~ Lesions seen at Laceration 11 3 0 0 1 1 16 opera- Perforation 6 2 0 1 4 0 13 tion: TOTAL 19 7 2 2 8 1 39 Cases Visualized at Operation Complete Laceration 1 2 0 0 0 1 4 repair of: Perforation 6 1 0 1 2 0 10 Partial Laceration 2 0 0 0 0 0 2 repair of: Perforation 0 0 0 0 0 0 0 No Laceration 8 1 0 0 1 0 10 repair: Perforation 0 1 0 0 0 0 1 Repair Laceration 0 0 0 0 0 0 0 attempted pgr^oratlon but failed 0 0 0 0 2 0 2 In this table lacerated wounds with and without contusions are grouped together as laceration. All wounds communicating with the heart chambers are grouped together under perforation. Lesions seen at operation are broken down into types of repair performed. 525 Statistical Appendix* oontd* TABLE XXVII Foreign Bbdy Removal Pericardium Pericardial Sac Ityocardium Completely in Chamber No. of oases 4 5 (2 probable) 10 4 Removed 4 1 5 1 Not Removed 2 (both probable) 7 3 Found at amtopsy 5 3 TABLE XXVIII Total Deaths Pure Thoraco- Time of Death Thoracic Abdominal Total Preoperatively Deaths 1 1 2 Due to heart h 0 2 Before surgery comple- ted or immediately postoperative Deaths 5 5 10 Due to heart o p c c.o.h.t 8 1-5 hours Deaths v ,3 4 Postoperative Due to heart 0 o,x 3 6-12 hours Deaths 0 2 2 Postoperative Due to heart 0 0 0 13 - 24 hours Deaths 5 1 . 6 Postoperative Due to heart o,h,x o 4 25 - 48 hours Deaths 0 1 X Postoperative Due to heart 0 X 1 Over 48 hours Deaths 1 1 2 Postoperative Due to heart c e 2 Total Heart Cases 35 22 57 Deaths Total 13 14 27 Due to heart 10 10 20 Mortality Overall 37.14# 63.63# 47.37# Duo to heart ' 28.67# 45.45# 35.09# “ 526 Statistical Appendix, contd, (Table XXVIII, contd) Deaths among patients with cardiac lesions. Segregation into pure thoracic and thoraoo-abdominal wound categories with reference to tiifte of occurrence. Deaths due directly to the heart are listed with reference to type of death as well. See Table XXV for explanation of symbols, c, h,t, and x. TABLE XXIX Time of Occurrence of Deaths Due to Heart Lesion Pre During Surgery or immed- iately postop. 1-5 Hr s 6-12 Hrs 13-24 Hrs 25-48 Hrs Over 48 Hrs Total Contusion c c X c,x X 6 Pur© Lacerati on 1 Laceration and Contusion c c,c c 4 Perforated Chamber h o,h,h, t ,t h c 8 Embolus to Heart c 1 Total 2 8 3 - 4 1 2 20 Lists deaths due to heart with reference to time cardiac lesion, and type of death. See Table XXV for explanation of symbols c,h,t, and x. 527 Statistical Appendix, contd. TABLE XXX Cardiac Fatalities With Reference to Surgical Correction Heart Lesion No. Cases Would have been benefited by surgery Possibly Benefited Could rot have beneficed from surgery Contusion 6 6 Pure Laceration 1 1 Laceration and Penetrating 4 1 (o) 3 Perforating Chamber 8 7(c,h,h,h,h,t,t,) 1 Embolus to Heart 1 1 (c) TOTAL 20 8 1 11 See Table XXV for explanation of symbols c,h,t. TABLES OF THORACO-ABDOMINAL WOUNDS 529 TABLE XXXI Wound Location Wound Entrance Dianhraam Involved No. Cases Right chest Riaht _4Q5_ Eidit chest Left 6 Right chest Bilateral 7 Right abdomen Riaht 18 Rirrht abdomen Left 12 Left chest Left AO 3 Left chest Riaht 3 Left chest Bilateral . 13 Left abdomen Left 27 Left abdomen Right Illustrates the various combinations of wounds as to entrace of missile and diaphragm involved. TABLE XXXII Causative Agent Causitive Anent No«. Gases PVagmont ( Artillery 590 (_ Mine 3A . (. Bomb 6 ( Grenade L Total fragment _ 63 L Gun shot wound 2A5 Not recorded 2A Illustrates type of agent causing the wounds in this series of cases. 530 TASLE XXXIII Time Lag o8.S0r> *tho *t Time nart in Hours Fatal Cases Survived Total Mortality 0-6 61 157 221 28.961 6 - 12 96 301 100 21.009 12 - IB 39 83 ... 122 31.989 18 - 2 1 20 31 51 37.019 21— 30 9 11 -23. 39.13,9 30. t. 8 26 31 93.53:9. Hot recorded 11 38 19 22.459 Total 217 656 . -,.901 1 M 01- Totals -2Q_ . 11. o « o u TABLE XLI Technical Procedures Total Cases 903 Bronchoscopy, preooerative 4- 2 Bronchoscopy, at close of operation 110 Pleural- drainage 226 Lists recorded cases of Bronchoscopy and Intercostal, closed, pleural drainage. TAELS XLII Causes of Death Op Postoperative Da’ A* Cause Dav 1 _2_ 1. L 3 6 7 8 9 10 11 U 15 Tot c/ Shock 40 59 18 4 1 122 49,4 Post-traumatic uremia 8 5 4 4 1 1 23 Peritonitis 6 z 4 1 p 1 1 1 1 1 0.1 Pneumonia 2 7 3 1 z 2 17 6,9 Pulmonary embolus 1 z z 1 1 i 1 1 10 4.0 Atelectasis 3 1 1 z 7 2,8 Empyema 1 1 2 1 3 2.0 Peritonitis and pleuritis z z 4 lt6 Hemorrhage _4 4 1.6 Cardiac Tamponade 1 z ? 1.2 Blast z 1 3 1.2 Overlooked intest, perforation z 2 0.8 Pressure Pneumo- thorax z 2 0,8 Gas gangrene 1 1 2 0,8 Disruption of . diaphragm 1 1 2 0,8 Mismatched blood 4 1 0,4 Mediastinitis 1 1 0,4 Fat embolism 1 1 0.4 'Liver” death 1 1 o,4 Morphinism 1 1 0.4 Bronchoscopy 1 0,4 Meningitis 1 1 0.4 Liver abscess 1 1 0.4 No record 13 3,3 Totals 49 76 29 28 12 9 7 7 6 3 3 2 2 1 2A7 100 Percent 39.8 w 11,7. H3 19 3.7 ZB. a8 2.412 12 08 04 100 * No deaths recorded on 12th or 13th postoperative days 536 table xliii Grouped Causes of Death Cause No. Cases Percent of Deaths Total deaths 217 100$ Shock 122 451*32$ Intra- (pneumonia 17 6,85 Thoracic (Atelectasis . . 7 2.83% Causes (Pulmonary embolus 10 A.05$ (Errroyema 5 . . 2.02$ (Miscellaneous 13 5.26$ Total Intrathoracic causes .52 21.05$ Abdominal (Peritonitis 20 8.09$ (Liver 2 0.81$ (Hemorrhage L 1.62$ (Overlooked intestinal oer.forations 2 0.81$ (Peritonitis and Pleuritis 2 0.81$ Total abdominal causes 30 12.15$ Posttraumatic uremia 23 9.31$ Miscellaneous 7 2.83$ Not recorded 13 Tlais table groups the causes of death listed in Table XLII under the main headings as indicated. 537 THCEACIC WOUNDS Part II REPARATIVE THORACIC SURGERY IN BASE SECTION HOSPITALS Page (1) The Management of Wounds of the Thoracic Wall,,,,,,„ 539 (2) Hemothorax*....,.,.,,,,...., 54-0 (3) The Pathology of Organizing Hemothorax ,,» 54-2 (4) The Rationale and Technique of Total Pulmonary Decortication. ••••••.... 54-3 (5) Fosttraumatic Empyema,,..,,,,,,..,,..,,,,,...,,,,,,, 547 (6) Intrathoracic Foreign Bodies 553 (7) Pulmonary Contusion, Hemotoma, and Blast Injury,,,, 560 (8) Bronchial Fistula.,,,.,,. 362 (9) Thoracoabdominal Wounds 562 (10) Summary and Conclusions•••••• 538 REPARATIVE THORACIC SURGERY IN EASE SECTION HOSPITALS One of the moat significant advances in military surgery has been the development of a program of early reparative surgery in the base section hospitals of an overseas Theater* This has been based on the concept of the continuity of surgical care from the most forward areas to the Zone of Interior, even though the wounded soldier passed through many installations and was oared for by many medical officers. The establishment of centers in base section hospitals for the study and treatment of specialized surgical problems has had a far- reaching effect on increasing the number of soldiers returned to active duty in the Theater and on minimizing the crippling sequelae of infection. Nowhere has the value of such a program been more apparent than in the treatment of thoracic casualties. The success of the earliest Thoracic Center established in North Africa has led to their uniform employment in the Mediterranean Theater and to their adoption, with slight modifications, in the European Theater of operation „ The value of a base section Thoracic Center is three- fold, First, the concentration of thoracic casualties under trained personnel provides better facilities for observation and care. Secondly, there is the centralized opportunity for evaluating the efficency of prior treatment. Thirdly, the optimum time for initiating reparative procedures often arrives before the patient can be evacuated safely to the Zone of the Interior, During the past two and one-half years, three thoracic surgeons of the 2nd Auxiliary Surgical Group have had the privilodge of supervising eight major thoracic services in base section hospitals* Of these, four of the services have been offi- cially designated as Thoracic Centers, During this period approxi- mately 2200 cases of thoracic wounds and injuries were cared for, of which 1669 had intrathoracic pathology. The reparative phase of intrathoracic wound management involves the application of principles designed to prevent or minimize in- fection at its inception, and to assure the rapid restoration of normal function. Every effort is made to accomplish this end within the shortest period of time consistent with sound surgical practice. This phase may be considered to have begun as soon as the initial surgery has been completed, and the patient stabilized to the point where he is safely transportable. In the main this phase is the function of General Hospitals in the base, A large experience has indicated that the great majority of patients *ith intrathoracic 539 Reparative Thoracic Surgery In Base Section Hospitals (cont’d) wounds may be safely transported within one week from the time of injury, regardless of whether or not major initial surgery has been done. This permits the institution of necessary reparative procedures at a time consistent with maximum benefit* Thus, it has been possible to do a greater part of the reparative surgery at a time early enough for recovery from these procedures to occur within the period of conval- escence from the original wound. The increased utilization of air evacuation and the advancement of General Hospitals in close support of Army hare been measures designed to widen the scope, and increase the effectiveness of reparative surgery* Progress made in this important phase of intrathoracic wound management has been no less significant than that achieved in the initial phase* The main problems treated in these centers have been: The proper definitive management of hemothorax, including its complications of clotting, organization and infection; a rational surgical therapy for posttramatic emphyema; the establishment of sound indications for early pulmonary decortication; the precise localization of intra- thoracic foreign bodies and a critical evaluation as to the advisa- bility of their removal. Problems of importance but less frequently encountered have been: Complications of thoraces-abdominal wounds; osteomyelitis of scapula and ribs, and of chondritis? cardiac wounds and cardiac or pericardial foreign bodies* THE MANAGEMENT OF WOUNDS OF THE THORACIC WALL One of the earliest problems encountered in the Thoracic Center in North Africa was the proper handling of wounds of the thoracic wall* It soon became apparent that all ihese wounds should be closed, if possible, before reparative intrathoracic procedures were undertaken* In a group of 144 closures (originally by total wound excision and pri- mary closure) it was found feasible to shorten greatly the time in- terval between wounding and closure. This was reduced from an average of 21 days to nine The criterion for closure was on the basis of gross appearance. Bacteriological studies were not done. The local application of sulfa drugs did not appear to alter healing* A theater-wide extension of this program was undertaken on all wounds with the result that secondary closure became an essential part of reparative surgery. With the advent of penoillin and a more efficient initial debridement the closures of most wounds have been accomplished in less than five days from the time of wounding* When closed at this time usually suture approximation was all that was necessary* Chronic parietal sinuses due to costal or chondral infection have been encountered infrequently. These have been opened widely 540 Repatative Thoracic Surgery In Base Section Hospitals (The Management of Wounds of the Thoracic Wall, cont'd.). and the offending material removed. Under penicillin protection, secondary closure usually has been possible r5.thin. f5vfc to seven days, Osteonyelitis of the scapula has been seen at least 10 times, more frequently during earlier experience when some initial debridements of the scapula were not sufficiently radical. All have responded well to free incision and removal of sequestra. HEMOTHORAX Hemothorax was present in approximately 75$ of all patients with intrathoracic wounds at the time of their arrival at the base. An additional 11$ with a prior hemothorax had a dry pleural cavity when admitted to the base section hospitals. The treatment was a con- tinuation of that commenced in forward hospitals; conscientious daily aspirations, without air replacement, until no more fluid could he obtained. The blood was found to be clotted in approximately 10$ of a series of 752 although this did not necessarily prevent further aspiration. Needles up to No, 15 gauge were employed and a "currant jelly-like” material successfully removed on many occasions. Clotted hemothorax, howdver, complicated the picture. Approximately 40$ developed empyema. The possible relationship of low grade intraplural infection to clotting is not known at present. Of those not developing infection (60$ of all clotted hemothoraces), approxi- mately 16$ had primary indications for decortication; 22$ were de- corticated during removal of foreign bodies and 62$ cleared spon- taneously, When compared to our 1943 there was a signi- ficant and pleasing reduction in the percentage of patients requiring decortication for uninfected clotted hemothorax (about one fourth as many). This we believe was due not so much to narrower indications for the operation in 1944 and 1945, as to better treatment of these cases in the forward areas: Prompt and vigorous thoracentesis; early pul- monary re-expansion; and a great reduction in the number of early thoracotomies performed for the evacuation of a hemothorax (see Section on the Initial Surgery of Intrathoracic Wounds, page 412), CASE REP CRT Noa 1 ~ The Resolution of a Clotted Hemothorax Not Requiring Decortication An American soldier sustained a perforating gun shot wound of the right thorax on 14 June 1944, The missile lacerated the right lung and a right hemopheumothorax developed. Wounds debrided and a sucking wound (wound of exit) was closed, 800 cc, of blood were withdrawn from the right chest and a "flapper-valve* type of intercostal tube inserted. This drained poorly and was removed forty-eight hours after wounding. 541 Reparative Thoracic Surgery In Base Section Hospitals (Hemothorax contfd) Figure 75 . - Roentgenogram showing clotted uninfected hemothorax two weeks after injury. X-ray revealed moderate hemothorax right* Repeated aspirations yielded only a few cc of serum and clot fragment* Diagnosis made of clotted hemothorax* Due to moderate size and lack of evidence of infection within the clot it was allowed to clear spontaneously. Clearing was almost complete within six weeks of the time of injury* (Figure 76) * Figure 76 • - Roontenogram one month later. No surgery and nosepira tions. Clearing of chest aimost complete. Patient returned to duty 17 August ‘*''*4* 542 Reparative Thoracic Surgery In Base Section Hospitals, cont’d. THE PATHOLOGY OF ORGANIZING HEMOTHORAX The process of clotting will frequently lead to organization although the factors responsible for clotting and organization are not entirely clear* The presence or absence of intrapleural air has no apparent bearing on the clotting mechanism* Transient bacterial contamination is a possible factor, at least in some cases. For proper understanding of organizing hemothorax certain fundamentals in its pathogenesis must be considered. These relate particularly to early decortication as a rational therapeutic measure. There is no "thickening" of either the visceral or parietal pleural layers as it is often described roentgenographically. The current practice of referring to such peripheral obscuration by the term "thickened pleura" is a misnomer and should be discontinued. Within two or three days following injury there is deposited a thin layer of clotted blood and fibrin which is continous over both visceral and parietal pleural surfaces, A closed sac or envelope is thus formed, the "inner" surface of which is toward the hemothorax and the "outer" surface, loosely adherent to the pleura (Figure 77 ), Figure 77 , - Cross-sectional diagram showing compression of left lung, loculation of hemothorax, and location of fibroblastic "peel". Within seven days there is microscopic evidence of fibroblastic and angioblastio proliferation in this layer. The process is first visible extending into the walls of the envelope from the pleural surfaces. The "peel" or "rind" or "fibroblastic membrane" then in* creases in thickness through the progressive invasion, by fibroblasts. 543 Reparative Thoracic Surgery In Base Section Hospitals (The Pathology Of Organizing Hemothorax, cont’d). of the clotted blood and fibrin which become freshly attached to the inner surface of the envelope. Within four weeks, adult fibrous tissue can be seen forming the outer portion of the peel and the fibers and nuclei have arranged themselves roughly parallel to the outer surface. Most of the capillaries, however, extend at right angles to this surface and have obviously penetrated from the pleurae* The advancing inner border of active organization remains composed of young cellular tissue, and even single wandering fibroblasts can be seen. Within six or seven weeks small arterioles with smooth muscle fibers in the walls can be demonstrated at or near the outer surface of the peel* The membrane may reach a thickness of 1 cm, over the visceral pleura* For some reason as yet unexplained, the peel over the parietal pleura is always thicker, more adherent and more vascular, than that on the visceral pleura. When fully developed the peel is an entirely inelastic, fibrous membrane, which, by its firm adherence, keeps the lung compressed and immobilized* Eventually there is complete fibrous tissue, and vascular union with the pleura, which then loses its identity as a limiting membrane* It has been an important observation that the development of infection and empyema in a hemothorax has not changed the process of organization to any appreciable degree, although there is some evidence that the production of fibrous tissue proceeds at a faster rate, and that there is a firmer union between the peel and the underlying pleura, after infection has supervened* Miscroscopically, the only evidence of inflammation is found on the inner surface of the peel where fibrin or blood clot in the process of organization shows infiltration by varying numbers of polymorphonuclear leucocytes* THE RATIONALE AND TECHNIQUE OF TOTAL PULMONARY DECORTICATION The operation of decortication was first proposed in 1893, At that time pointed out the necessity for removing the fibrous investment on the pleura in chronic suppurative disease if pulmonary expansion was to be obtained, almost simultaneously and quite independently recognized the same principle. Despite the un- questioned validity of this concept, the procedure never enjoyed wide usage. This was due to several factors. The first of these was the inadequacy of anethesia at that time. Blood transfusions were not available to these early surgeons. The lack of bacteriostatic agents such as the sulfonamides and penincillin made surgery extremely haz- ardous when it was performed in the face of fresh suppuration. After many months of chronic infection such a degree of cellular intimacy existed between the pleura and the investing layer of organized exudate that attempts at decortication were more often failures than not. Reparative Thoracic Surgery In Base Section Hospitals (The Rationale and Technique of Total Pulmonary Decortication, cont*d). The surprisingly large number of patients with organizing hemo- thorax who have been seen so far in this war, has given us the oppor- tunity to "rediscover" and re-apply the valuable concept of decorti- cation with pulmonary mobilization* The early realization of its possi- bilities led one of us (Burford) to perform the first decortication in North African theater in May 1943* Detailed studies of the pathogenesis of hemo-organizatioa have been most fruitful in clarifying the therapeutic approach to the problems of organizing hemothorax and its infectious complications* The indications for decortication have been varied. Its employment in selected cases of infected hemothorax and posttraumatic empyema has been of great value. Decortication with complete visceral pleurolysis has now been performed on more than 120 patients. In approximately Z0% the presence of an organizing hemothorax with partial pulmonary compres- sion was a complicating factor in patients whose thoracotorry in the base hospital was primarily far the removal of an intrapulmonary foreign body. In uninfected organizing hemothorax, decortication has an important place in treating a relatively small percentage of patients. The general indications for operation are as follows: Patients in whom there is at least a 50% compression of the lung, especially if the apex is in whom aspiration has been unsuccessful and in whom there 3ms been no appreciable pulmonary expansion at the end of four to six weeks following injury. In these individuals decortication will result in immediate pulmonary re-expansion and prevent -Hie development of a possible fibro- thorax and chronic pulmonary invalidism. At least, the patient will be saved a prolonged convalescence of many months and tte Imzards of supervening infection. An important consideration is the proper selection of the time for operation. From a purely technical point of view, decortation is best performed from 3 to 5 weeks following injury. If performed less than two weeks after injury the peel is thin and friable; the operation is tedious because the poorly defined membrane must be removed piece-meal or meticulously wiped from tho pleural surface* When performed too late (probably after 10 to 14 weeks) the fibrous union between peel and pleura is often so firm that a proper cleavage plane cannot be established. The visceral pleura is frequently torn and the lung does not expand readily because of fibrous ingrowths along the septa. The operation of decortication entails open thoracotomy. Clot evacuation alone is not a sufficient procedure. Concomitant lesions in tlce thoracic parietes, lung or mediastinum are handled as may be indicated. Important technical considerations are: 1, Meticulous establishment of the proper cleavage plane between peel and visceral pleura; 2, Careful blunt dissection of the peel either digitally or by a guaze "dissector"; 3, Complete freeing of the lung where it is directly adherent to tlie thoracic wall, to the mediastinum, or along the fissural margins, so that complete circumferential ex- pansion can be obtained, 4, Decortication and mobilization of the 545 Reparative Thoracic Surgery In Base Section Hospitals (The Rationale and Technique of Total Pulmonary Decortication, cont’d). elevated, fixed diaphragm, with particular attention to re-developing the oostophrenic sulcus5* Deliberate intermittant expansion of the lung under increasing positve pressure, with careful stroking of atelectatic areas; attempts at immediate complete pulmonary re- expansion are ill advised. On removal of the constricting peel there is exposed a grossly normal, thin, translucent, expansible pleura, A considerable amount of oozing occurs, readily explained, when one remembers that numerous capillaries are torn, and left with gaping ends which open on the pleural surface. The bleeding is immediately controlled by expanding the lung With slight postive pressure. Reference is again made to the greater thickness and vascularity of that portion of die peel which is adherent to the parietal pleura. Removal of this membrane has not resulted in any significant increase in thoracic wall mobility. The bleeding has been relatively severe and, of course, not controlled by pulmonary re-expansion. From our experience, we would condemn the routine removal of this peel as un- necessarily increasing the hazards of the operation, without appre- ciably adding to the benefits. It is necessary however, to assure a perfectly smooth margin to the entire circumference of reflection. Tags and cuffs of tissue encourage pocketing, and creation of dead space. The chest wall is inspected and palpated for protrusions and these removed and smoothed up if present. The effort is made "throughout the entire procedure to achieve total pulmonary expansion, and the com- plete obliteration of pleural dead-space. The operation that fails to do this has no chance of succeeding. It should be emphasized at this point that cross-hatching of the fibrino-fibrous membrane with piece-meal removal is very rarely necessary and has never been advocated in this theater. There not infrequently remain islands of thin, tough membrane, after the re- moval of what may be called the primary ’’peel". These must be re- moved whenever they interfere with complete expansion of the lung. If a metallic foreign body is present in the lung, or if indriven rib fragments are found to exist removal is carried out at this stage9 and the lung sutured with fine silk, nylon, or cotton* Should an in- trapulmonary abscess of favorable size be encountered resection should be done and the lung closed* Closure of the esophagus in cases of esophageal lacerations, and1 excision of a transdiaphragmatic fistula with closure are done whenever present. Provision for the maintenance of pulmonary expansion is made by the insertion of two, frequently three and occasionally four, inter- costal tubes at critical sites. These sites are selected upon a basis of dead-space obliteration and include always the 8th interspace in the posterior-axillary lino, and the 2nd interspace in the mid-calvi- cular line. In infected oases it has been found wise to place a third 546 Reparative Thoracic Surgery In Base Section Hospitals (The Rationale and Technique of Total Pulmonary Decortabation, cont'd). tube in the 5th or 6th interspace in the mid-clavicular line. Rarely it has been advisable to place a fourth tube in the 7th interspace in the mid axillary line. All are connected to "water-seal" bottles. Soft rubber tubing with an internal diameter of 10 mm, has proven satisfactory for this purpose with the exception of the upper (2nd interspace) tube. Here a number 12 or 14 pezzar catheter, with the tip cut so that only a flange remains, is employed. These tubes are not to be regarded as foreign bodies so long as they function to promote obliteration of dead space and pulmonary expan- sion, The moment that they cease functioning they must be removed. Usually it is possible to remove the anterior tubes within 48 hours. The posterior tube may continue to drain serum for four to seven days. In cases which have had a previous rib-resection it frequently happens that the site of preliminary drainage will correspond with the site of election for the posterior tube. Anticipating this, it has seemed advisable when possible to remove the thoracostomy tube three or four days prior to the contemplated decortication in order that shrinkage of the track will occur. At the time of decortication this site is utilized, the edges freshened and closed tightly about the tube. At the completion of the operation the intercostal nerves are blocked with one percent procaine. The nerve of the interspace of approach, as well as two above, and two below are all that require injection. The pleural cavity is copiously lavaged with sterile physiological saline solution and aspirated completely dry. All clots and loose tissue are removed and the lung brought to full expansion and tested again for air-leaks. The chest wall is then closed, using sutures of interrupted silk throughout, Pericostal sutures are not used. After completion of the closure 25,000 - 50,000 units of penincillin in 100 to 200 cc, of physiological saline are instilled into the pleural cavity through the tubes, allocating roughly equal amounts to each tube. All tubes are clamped, and the dressing applied. Immediately on arrival in the ward the tubes are connected to "water-seal” bottles, but only the anterior ones are undamped. The posterior tube or tubes are left clamped for 4-6 hours to permit local penincillin effect. Before leaving the table attention is given to the air-way. In the event moisture is audible after painstaking tracheal catheter aspirations, or if pulmonary re-expansion was difficult or delayed, bronchoscopy is done. Blood is given during operation, the amount required depending upon the magnitude of the procedure. The amount necessary has varied from 1500 to 4000 cc. THE INFECTIOUS COMPLICATIONS OF HEMOTHORAX As described above the more serious implications of clotted 547 Reparative Thoracic Surgery In Base Section Hospitals (The Infectious Complications of Hemothorax, cont'd). hemothorax are mirrored in the 40% empyema rate as contrasted with an 11% empyema rate in cases of liquid hemothorax,®* Proof of the infection in a hemothorax was based on the finding of organisms in the grossly sanguinous fluid aspirated from patients who showed clinical signs of toxicity. Frequently, however, smears and cultures did not become positive for many days. In these cases infection was presumed if the patient remained toxic, continued to run fever or showed any increase in the amount of pleural fluid which could not be explained on the basis of further bleeding, A wide variety of organisms have been implicated but the frequency which anaerobic streptococci and staphylococci were encountered has been somewhat surprising. Non gas-forming colorstridial organisms *have caused infections in a significant number of patients. They have not behaved differently from other bacteria. Clotting and organiza- tion have been present in nearly all cases where infection has super- vened. The proper handling of these patients has presented many diffi- culties, It has always been possible to treat them conservatively aspirate until "thick" pus was present, then drain the empyema. This has been the usual procedure in patients with small infected hemothoraces, When there is a large infected hemothorax, however, with more than a 25% compression of the lung, such a policy will frequently result in extensive, relatively stationary empyema cavities, A large percentage join that deplorable group of patients with chronic empyema who, after months and even years of suppuration, are relieved by exodus or are "cured" by multi-staged, deforming, obliterative operations. In a number of patients with infected hemothorax where the lung was significantly collapsed, we have employed formal thoraco- tony with evacuation of all exudate, complete decortication of the visceral pleural peel, immediate pulmonary re-expansion and layered closure of the incision, Follwoing discovery of the intrapleural infection, these operations were undertaken as soon as it was possible to render the patient a satisfactory operative risk. In the great majority of patients so treated, no subsequent empyema developed and there was primary union of the thoracic incision. In the remainder a small, residual, basal emnyema was found easy to control. In the early cases, crystaline sulfamilamide was placed in the pleural cavity. More recently, greater protection against residual infection has been gained by the use of local and systemic penicillin, . POSTTRAUMATIC EMPYEMA Despite the advances in the prewar years in the use of chemoth- erapeutic agents, particularly the sulfonamides, in the prevention and control of the ordinary pyogenic infections, and despite their appli- cation, empyema following intrathoracic wounds still occurred in a high Reparative Thoracic Surgery In Base Section Hospitals (Posttraumatic Smpye ma, c ont’d)• percentage (22,6 percent) of the cases, in the first Thoracic Center experience• Among the efforts made to decrease this incidence, ad- vances were made in pre-operative therapy and in initial surgical therapy, in that definite indications were established for the per- formance of initial thoracotomy, and of debridement of the thoracic •'.vail alone. Also the effectiveness cf initial surgical therapy ms enhanced by the Increasing operative skill of the fqrward surgeons* The advent of penicillin represented an improvement over the sulfona- mides in the attempt to minimize the effects of any residual contami- nation* A rational plan for the management of metallic foreign bodies was involved. And of all the factors involved, that of the persistence of dead space was not the least in importance. Its early obliteration was obtained in a steadily increasing number of cases, as the prompt treatment of hemothorax, and of pneumothorax with or v/ithout a broncho- pleural fistula, was pursued with increasing vigor. - As a result, during the war it is gratifying to observe that the incidence of empyema fell progressively from its initial 22,6 percent to one of 7 percent in the final phase of the War in the Spring of 1945 2, As pointed out previously, this most significant reduction in the incidence of empyema was not the result of advance in any single phase of treatment, but rather the combination of all, A total of 213 empyemas has been drained by thoracic surgeons of this G 'oup* The mechanism of development of post traumatic empyemas varies considerably* They are caused by a rather wide variety or organisms, both aerobic and anaerobic. The infection may be introduced through the thoracic wall, as a contamination from the abdomen when the dia- phragm has been perforated, or from the lung through a bronchopleural fistula. Nearly all post traumatic empyemas develop in a pre-existing hemothorax. Because of its characteristic behavior, this type of empyema has been designated as "hemothoracic empyema”. There is no sharp differentiation between infected hemothorax and hemothoracic em- pyema, The infection has been classified as an empyema as soon as gross pus or purulent exudate was evident in aspirated material. The source of the contamination and the type of organism may vary but neither are important considerations. In effect, hemothoracic empyema develops in a olosed homotoma of the intrapleural space, since the limiting walls of the infected cavity are not the pleural surfaces themselves but are composed of a thickened membrane or peel of organi- zing fibrin which covers and protects the pleurae. This factor probably accounts for many of the differences from post pneumonic empyema that such an infection exhibits. In a developing hemothoracic empyeim, purulent exudate may not bee seen for many days; nthick” pus may not forr for several weeks. There is a greater tendency for the empyeim. to pocket, thus increasing the necessity for multiple drainage procedures. Total empyemas are most frequent and in these, pulmonary re—expansion is indefinitely prolonged. Even in patients with extensive hemo- thoracic empyemas of many weeks’ duration, no periosteal reaction of the ribs has been seen and the ribs have not become triangular. 549 Reparative Thoracic Surgery In Base Section Hospitals (Posttraumatic Empyema, cont’d). In the treatment of established hemothoracic empyema, the principle of adequate dependent drainage with rib resection has been mandatory. There is no place for intercostal drainage except in the rare instance when a patient may be too ill for rib resection. In all instances there is a tremendous amount of partially degenerated clot, fibrin and exudate which will promptly clog an intercostal catheter. The general practice of waiting for thick pus to develop must be modified if the patient is to be saved from days or weeks of toxic absorption. There seems to be no urgent reason for using a water-seal bottle to make the drainage air-tight unless the empyema has developed with unusual rapidity. In hemothoracic empyema, mediastinal immobility depends on the amount of organization which has occurred in the pre-existing hemothorax and is, therefore, roughly proportional to the length of time since injury. There is no relationship between mediastinal fixation and either the dura- tion of the infection or the thickness of the purulent exudate. As stated above, total pulmonary decortication was early recognized as a vital operation in treating total subacute or impending chronic empyemas. Until March 1944, these were all secondary decortications, that is, performed following some type of drainage operation. In March under penicillin protection, the first primary decortication (without preliminary drainage) was performed (Samson) and since that time primary decortications have been performed in an increasing number of cases. The principles have been described in detail elsewhere To date members of this organization have performed approximately 64 decorti- cations for empyema, with no deaths due directly to the operation. In approximately 75$ of the cases, the lung has re-expanded without the formation of a residual empyema. In most of the cases in which residual empyema occurred there had been persisting pulmonary pathology neces- sitating correction at the time of decortication. This included ob- literation of bronchial fistulae, wedge resections because of multiple fistulae, and resections or curettage for posttraumatic abscesses. Of further interest is the comparison between results of primary and secondary decortations. In the latter, the percentage of residual empyema has been greater than in the former. At least throe factors were responsible. First, the patients requiring preliminary drainage were sicker as a group. Secondly, when intrathoracic wounds presumably were more severe and the ensuing infection more toxic. Thirdly, the internal between wounding and operation was greater in secondary decor- tications due both to the original poor condition of the patients and to the added time necessary for recovery from the preliminary drainage operation. CASE REPORT Posttraumatic Bmpyema Qured By Early Pulmonary Decortication Without Preliminary Drainage, An American soldier was wounded in action 4 June 1944, Suffered 550 Reparative Thoracic Surgery In Base Section Hospitals (Posttraumatio Empyema, cont’d). severe penetrating shell fragment wound of the right thorax with laceration of the right lung, right hemopneumothorax, and retained intrapulrronary foreign body. Thoracotomy was performed on the day of injury at a forward evacuation hospital and the foreign body re- moved from the lung and the laceration of the lung sutured. Following an immediate uneventful postoperative period the patient developed a clotted hemothorax of the right chest and began running a daily temperature elevation of 101? - 102° F, In the base hospital pus was eventually recovered from the hemothorax•from which staphylococcus aureus grew (Figure 78 .) t x,_,ure 78. - Roentgenogram showing right sided pneumopyothorax <*r-- & 50 percent compression of the lung. Thoracotomy with decortication was done approximately four weeks after injury without premilinary drainage, and a primacy cure obtained (Figure 79} 1^ure 79 , - Roentgenogram two weeks after total eulironary decortication. Complete pulmonary re-expansion and primary cure. 551 Reparative Thoracic Surgery In Base Section Hospitals, cont’d. CASS R3P0RT. Cure Of Impending Chronic Empye;na By Decortication, An American soldier was wounded in action 31 May 1944 when stnuck in the right chest by a shell fragment. Sustained a sucking wound laceration of the right lung and a hemopneunothorax of the right pleural caviry, "Forward*1 thoracotomy performed with removal of shell fragment from lung, suture of lung and evacuation of blood from right pleural cavity, Whexi admitted to the center eleven days later a massive empyema had developed. Patient was judged to be too ill to do a decortication upon without preliminary drainage. Hence a re- opening of the thoracotomy incision was done and the empyema adequately drained through the bed of the rib that had been resected at the time of the initial thoracotomy. The infection was adequately drained, the lung did not satisfactorily re-expand and the cavity reached a static state (Figure 80), Figure 80* - Four weeks after adequate rib resection drainage and weeks after wounding. No tendency for lung to re-oxpand. Impending chronic empyema. Reparative Thoracic Surgery In Base Section Hospitals, cont’d. An impending chronic empyema was recognized as threatening and a decortication was done six weeks after adepuate drainage had been established. The lung was freed of its fibrino-fibrious membrane without difficulty and promptly re-expanded at the time of opera- tion. Complete primary cure obtained (Figure 81 ), Figure 81 • - Roentgen film two weeks after total pulmonary decortication. Lung completely re-expanded. No residual erapyem. 553 Reparative Thoracic Surgery In Base Section Hospitals, cont’d. INTRATHORACIC FCRSIGH BODIES As indicated elsewhere experience has increasingly tended to establish the base hospital as the site for the removal of re- tained metallic intrathoracic foreign bodies when removal seems indicated. Information accruing in thoracic centers has supported this principle. The establishment of a s ound policy in regard to intrathoracic foreign bodies depended initially upon proceeding according to principles evolved without satisfactory precedent until experience could either justify or intelligently modify that policy 8,. Review of cases of intrathoracic wounds when seen in the base, revealed that approximately 25 percent had metallic foreign bodies retained in either the lung or pleura* Of these, approximately four percent were in the pleural cavity. The problem of the retained foreign body is one of major importance. With the establishment of the first Thoracic Center in the Theater a policy was decided upon of removing all retained intrathor- acic metallic foreign bodies of 0,8 cm, or above, as measured on roentgen films. This size was considered to be consistent with ease of palpation at operation. Later a re-evaluation of experience occasioned an elevation of the size limit so that the policy was changed to re- commend the removal only of those of 1,5 cm, or above in one diameter. This latter figure has proven increasingly sound and added experience demonstrated no reason to alter the size limit of 1,5 cm* Since the great majority of cases were under observation from one week to two months after wounding, and many as long as 90 days, an opportunity was offered to determine what happens to retained intra- thorac ic missiles during the first 60-90 days. In a consecutive series of 291 retained intrathoracic foreign bodies (exclusive of heart and pericerdium), it was found that a significant number of these patients developed complications 9 Figure 82, In the intrapulmonary and mediastinal group there was an empyema rate of 12 percent and abscess, hemoptysis and recurrent fistulae associated with the foreign bodies accounted for an additional 11 percent of complications. The empyema rate in retained intrapleural foreign bodies was 38 percent. All complications believed due to retained intrathoracic foreign bodies occurred in 25 percent of the group; or in 15 percent if empyema associated with intrapulmonary foreign body was excluded. 554 Reparative Thoracic Surgery In Base Section Hospitals, cont’d. (MOTIONS Q[ INMMIC m\CH BODY TOTAL NUMBER OF INTRflTHOCPCIC P.Bc 291 NUMBER Of INTRAPULMONARY AND MEDIASTINAL f.B 252 (EXCLUSIVE OP HEART AND PERICARDIUM) LUNG ABSCESS A DELAYEDOR RECURRENT HEMOPTYSIS A SECONDARY INTRAPLEURAL HEMORRHAGE PROM LUNG 1 LATE OR RECURRENT BRONCHOPLEURAL PISTULAE 10 MEDIASTINAL ABSCESS WITH MEDIASTINAL P. B 2 EMPYEMA WITH INTRAPULMONARY F. B JO TOTAL COMPLICATIONS ASSOCIATED WITH INTRAPULMONARY AND MEDIASTINAL P. B 60-23% NUMBER OP INTRAPLEURAL F. B. 39 EMPYEMA WITH INTRAPLEURAL F. B. I5'38% TOTAL COMPLICATIONS OF INTRAPULMONARY, MEDIASTINAL AND INTRAPLEURAL F. B. 15-25% IP EMPYEMA OP INTRAPULMONARY F B. CROUP IS EXCLUDED -15-15% Figure 82 • - See Text. 555 Reparative Thoracic Surgery In Base Section Hospitals, coat’d* In view of the considerable discussion that has occurred pertain- ing to the relative incidence of empyema in intrapleural and intra- pulmonary metallic foreign bcdioi;, these figures are enlightening. In the intrapleural group empyema occurred in 38 percent, while in the intrapulmonary group the incidence of empyema was 12 percent 2, This latter figure is strikingly close to the over-all incidence for empyema in the same period, (Figure 83 ), Pi gure 83 • Numerical-incidence of empyema in cases of intra- pulmonary ard intrapleural foreign bodies (291 cases). This corroborates the generally held opinion that' intrapleural foreign bodies are more likely to cause trouble than intrapulmonary missiles. It should be pointed out that the incidence of intra- pleural foreign bodies is not high enough (3,7 percent) even with their higher complication incidence (38 percent) to significantly "weight” the series as a whole. Tha majority (74 percent) of these complications developed during the second and third weeks following injury. The earliest complication exclusive of the empyema group, was a lung abscess which was proved to be present at one week after injury. Only four complications developed prior to ten days, and none of these was in the intrapleural group. These figures are of the utmost importance since they give valid factual correction to the many prevalent misconceptions concerning the innocuous ness of retained intra thoracic missiles. Though repre- senting only one series, the occurrence of 15 percent significant complications during the first 90 days must be accepted as evidence that the retained missile is, on the contrary, a very significant 556 Separative Thoracic Surgery In Base Section Hospitals, cont’d. source of danger to the thoracic casualty and must be considered as such in the modern reparative management of these injuries. That so few complications developed before ten days justifies the policy of awaiting arrival in the base before removal is carried out. No correlation was apparent in this study between size, con- figuration or locations of missiles and a predilication for engen- dering complications, except in one regard, 'vlissiles located in the periphery of the lung gave rise to a higher incidence of difficulty than did those located in the hilum. This is strikingly at variance with the view popularly held that the missile lying in close proximity to vasular or bronchial structures in the hilum is the one more likely to occasion trouble. On the other hand, foreign bodies near the hilum which do give rise to complications are much more difficult t , remove. Ideally, thoracotomy for the removal of intrathoracic foreign bodies should be performed between the 5th and 14th days following injury. In most instances this gives adequate time for the secondary closure of wounds of the thoracic wall and for adequate pulmonary re- cuperation, botI> factors of the utmost importance in lowering the risk of operation. The elimination of granulating wounds from the thoracic wall prior to thorootomy greatly reduces the hazard of infection. Pulmonary recuperation (recovery from the "traumatic wet lung" syndrome) entails ro-aeration of alveoli, absorption of inter- stitial fluid, re-establishment of complete tracheobronchial patency, and at least partial disposal of any extravasted intrapulmonary blood. The influence of these factors on mortality should be obvious. Tech- nically, it is far easiew to palpate metallic fragments in crepitant aerated pulmonary tissue than in a boggy indurated parenchyma. Furthermore, the lung is better able to sustain lobotomy if there has been some recovery from the initial injnrty* After three to four weeks, thoracotony is somewhat more difficult. With the increased fibrosis present around intrapulmonary foreign bodies at that time repair and closure of the parenchymal incision is more uncertain. Extensive intrapleural adhesions of relatively firm fibrous tissue may increase the difficulty of palpating adequately the lung and separation of these adhesions is not always easy. The greater incidence of complications after the second week will increase the hazard of operation. In general, a posterior intercostal thoracotony is employed, usually without resecting or sectioning ribs. The lung is freed and decorticated if necessary so that bi-digital palpation can be effected. With the lung collapsed, sharp incision is mde over the foreign body where it is nearest the surface. The wound is closed • with fine interrupted black silk in two layers, the pleural cavity thoroughly lavaged, the lung expanded and thorax visually drained with two water-seal tubes. 557 Reparative Thoracic Surgery In Base Section Hospitals, cont'd. When the foreign body is in the hilar region, it is exposed by careful blunt dissection. Associated abscesses are either curretted out, or a wedge resection performed if tho leiion is peripheral. There is no fces itation in removing intrapulmonary foreign bodies at the time of deportation for massive empyema* In a consecutive series of 102 thoracotomies for foreign bodies 9 there were no deaths and no permanent disability. Significant com- plications occurred 10 times, or nine percent, (Figure 84), COMPLICATIONS of thoracotomy FOR FOREIGN BODY WOUND INFECTIONS 3 SUBJACENT EXTENSION TO PLEURAL CAVITY WITH SMALL EMPYEMA...3 EMPYEMA (BASAL) UNASSOCIATED VWTH WOUND INFECTION I TOTAL POST-OPERATIVE EMPYEMAS A CLOTTED HEMOTHORAX I THROMBOPHLEBITIS I POST-OPERATIVE ATELECTASIS I SECONDARY HEMORRHAGE I BRONCHOPLEURAL FISTULAE .2 TOTAL NUMBER OF COMPLICATIONS 10 PERCENT 9.+% PERMANENT DISABILITY 0 MORTALITY 0 Figure 84• - Number of complications arising in 102 Thoracotomies for the removal of the Intrathoracic Foreign Bodies* Reparative Thoracic Surgery In Base Section Hospitals, contTd, The graphic comparison with complications arising as the result of retained foreign bodies is shown. (Figure 85). Figure 85, - Comparison of complication rates with and without thoracotomy 5a retained foreign bodies. 559 Reparative Thoracic Surgery In Base Section Hospitals, coat’d. Foreign bodies of 1,5 cm, or more were removed routinely from the mediastinum. Indications for the removal of foreign bodies from the heart and pericardium were conservative. In general these were not disturbed unless the patients had symptoms of cardiac or percardial dysfunction. Precise pre-operative localization of intrathoracic foreign bodies is of course essential to their successful removal. Prin- ciples important in accurate localization have been stressed by Burbank et al 10, Those include roentgen films in two or more planes, fluoroscopy, "spot’* films under fluoroscopic guidance and the utilization of air in either the pleural or peritoneal cavities or both. Complicated methods such as the parallax and the use of electric locators have had no place in localization. The most troublesome problems have arisen when the foreign body was either in the region of the diaphragm or in the periphery of the chest, Pneumope'-itoneum has been helpful in localizing the former group, while a small artificial pneumothorax has occasionally been necessary to determine whether a peripherally located missile was just within the parietal pleura or whether it lay entirely extrapleurally. GASS REPCRT, Intrapulmonary Metallic Foreign Body With Removal By Thoracotomy. An American nurse sustained a penetrating wound of the right thorax on 29 March 1944 when struck by’a bomb fragment. Patient sustained a sucking wound of the right chest and a right sided hemopneumothorax. The bomb fragment lodged in the right upper lobe. The wound of entry was debrided and the sucking wound closed. Thoracentesis was done. Secondary closure of debrided wound done five days after wounding. Roentgen and fluoroscopic localization revealed fragment of 1,5 cm, greatest: diameter to be lying in upper lobe of right lung, (Figure 8S)a Figure 86 . Preoperative roentgen film showing metallic foreign bodies in right upper lobe. 560 Reparative Thoracic Surgery In Base Section Hospitals, cont'd. Thoracotomy -without costal section or resection was done four weeks after injury and the fragment removed. The patient made an uneventful recovery and was discharged to the Zone of the Interior for re-assignment, (Figure 87), Figure 87 • Roentgenogram two weeks after removal of shell fragment. Immediate, complete pulmonary re-expansion. PULMONARY CONTUSION, H3M0T0MA AND BLAST INJURY Practically every intrathoracic wound results in some degree of injury to the lung. This is made manifest clinically by hemoptysis, and roentgenographically by areas of obseuration of greater or less extent. In the vast majority, the lesions are regressing by the time the patient arrives 'at a base section hospital and no treatment is necessary except to insure adequate tracheobronchial drainage. In contusidn,, there is extravastion of blood into the interstitial tissue and alveoli with rupture of some of the walls of the latter, A true hemotoma or nblood tumor” is caused by complete breakdown of a portion of lung and a localized collection of blood, Roentgeno- graphically the shadows are round or oval and often there are fluid levels indicating a bronchial connection. At times, contusions and true hemotomas cannot be differentiated clinically. Often the patient continues to expectorate blood for many days. Nearly all of these regress rapidly without specific treatment. CASE REPORT. Regression Of Hematoma (Or Contusion) Of Lung. An American soldier was wounded in action, 24 May 1944 when a large shell fragment penetrated the left chest. Sustained laceration of left lung and a left homopneumothorax. Wound debrided, sucking wound closed and shell fragment removed from left chest wall. Repeated thoracentesis• 561 Reparative Thoracic Surgery In Base Section Hospitals (Pulmonary Contusion, Hemotoma And Blast Injury cont’d). Roentgenograms showed large intrapulmonary hemotoma of left lung (Figure 88), Figure 88 * Roentgenogram six days after wounding showing large hemotoma of left lung. This regressed favorably and had almost entirely disappeared within six weeks of iniury (Figure 89 )• Figure 89 . Film taicen six weeks later, process almost entirely cleared except for residurun at periphery in upper pulmonary field. Notes A proper understanding of intrapulmonary hemotomas is highly important to those charged with the management of thoracic wounds. 562 Reparative Thoaraic Surgery In Base Section Hospitals (Pulmonary Contusion, Heraotoma And Blast Injury cont'd). Their behavior is almost universally benign and infection practically never supervenes in them if a foreign body is not present. They clear rapidly, usually within four to six weeks after injury. They frequently show central excavation by x-ray and have been mistaken for abscesses of tho lung, particularly when the patient happened to present a concomitant fever. No permanent damage to the lung has been observed, even in the massive hemotomas. In rare instances hemotomas may become complicated by infections or may rapture into the pleural cavity. Surgery then may bo undertaken as indicated. Pure blast injury of the lungs has never caused any complications in patients who have lived long enough to be admitted to a base section hospital. BRONCHIAL FISTULA Persistent or recurring bronchial fistulae were noted in approxi- mately six percent of all intrathoracic wounds. Occasionally these were associated with intrapleural or intrapulmonary infection. Under these circumstances the fistula usually was treated concomitantly with the infection, by closure or resection. In some, a localized empyema was drained and the fistula allowed to close spontaneously. In the vast majority there was no associated infection. The treatment in these cases was conservative and aimed at rapid re-expansion of t ie lung. Ordinarily this was obtained by the insertion of a small water-seal catheter in an unper anterior intercostal space. Occasion- ally repeated aspirations sufficed to re-expand the lung, although the fistulae often recurred several times. THCRAC O-ABD OMINAL WOUNDS In these cases most o? the complications at the base which directly affected the chest were associated with liver wounds. Repairs of the diaphragm, particularly on the left, remained solid and no case of diaphragmatic hernia or eventration was seen. Approximately 25$ of a series of liver wounds developed subphrenic abscess, bile empyema or hepatic abscess The main faults of forward therapy were: Lack of drainage of exposed liver wounds; failure to make the drainage incisions large enough and to place them far enough laterally; and too early removal of drains. Review of the records showed that there was a significant reduction in these complications toward the end of the war. This was due entirely to an increased understanding of the prob- lems involved and to the expert care rendered by surgeons in the forward areas (See Section on Wounds of the Liver, Page 307), 563 Reparative Thoracic Surgery In Base Section Hospitals, (Summary and Conclusions)• SUMHARY AND CONCLUSIONS 1, A survey has beer, made of 1,659 patients with intrathoracic wounds whose reparative treatment has been carried out by thoracic surgeons of the Second Auxiliary Group, This work has been done over a period of two and. nne-half years on eight separate Thoracic Surgrcm Services, located in North Africa* Italy and France, 2, Charged with the direction of the first Thoracic Canter to be established in an overseas theater in this war, thoracic surgeons of this Group were instrumental in establishing the indications for, and elaborating the operative techniques of, many procedures which have become standard in traumatic thoracic surgery. 3, Chief among these have been: a, Tnsistance on immediate repeated thoracentesis, mainten- ance of an adequate tnacheobronchial air-way and rapid re-expansion of fcho lung as the sine quR non of early intrathoracic therapy. b. The rational treatment of organizing hemothorax, infected hemothorax and hemothoracic empyema, based on pathological studies of intrapleural hemo-organization. c« The re-ostablishment of the operation of pulmonary- decortication together with several important technical modifications, and the application of this operation in the early treatment of selected cases of massive organizing hemothorax, infected hemothorax and extensive hemothoracic empyema. d. Recognition of the essential points of distinction be- tween postpneuraonic and posttraumatic (including hemothoracic) empyema, e« The development of indications, and of localization and surgical techniques, for the removal of intrathorcic foreign bodies. 4, Brief discussion of the topics listed above has been nado. 5, The mortality for patients in base section centers, whose main wounds have been thoracic, has ieen less than two percent. 564 Reparative Thoracic Surgery In Base Section Hospitals, cont'd. REFERENCES OR BIBLIOGRAPHY 1, Samson, Paul C,, Burrford, Thomas H, and Burbank, Benjamin, Final Report on the Thoracic Surgery Center in North Africa, Un- published data. 2. Bur ford, Thomas H,: Review of One Thousand Thoracic Cases, Bull, U.S. Army Med. Dept, No 89: 70 (June) 1945. 3, Fowler, George R.: A Case of Thoracoplasty for the Removal of a large Cicatricial Fibrous Growth from the Interior of the Chest, the Result of an Old Empeyraa, Medical Record 44; 838 (Dec, 30) 1893, 4, Delorme, M,E,s Nouveau Traitenent des Empyeraes Chroniques, Gaz, D * hop s 67:94 (Jan 25) 1894. 5, Parker, Edward F, and Burtford, Thomas H,; The Management of Posttraumatic Empyema, to be published. 6, Burford, Thomas H,, Parker, Edward F, and Samson, Paul C,: Early Pulmonary Decortication in the Treatment of Posttraumatic Empyema, Annuals of Surgery, 122:163 (August) 1945. 7, Samson, Paul C, and Burford, Thomas H,: The Management of War Wounds of the Thorax in an Overseas Theater, Clinics, 3:1561 (April) 1945. 8, Samson, Paul C,, Burford, Thomas H,, Brewer, Lyman A, III and Burbank, Benjamin: The Management of War Wounds of the Che st in a Base Center, Journal of Thoracic Surgery, In Press, 9, Burford, Thomas H, and Parker, Edward F,; Intrathoracic Foreign Bodies, to be published. 10, Burbank, Benjamin, Burford, Thomas H,, Samson, Paul C,, and Mesdnow, Sidney: Experience in the Localization of Thoracic Foreign Bodies, Jounal of Thoracic Surgery, In Press, 565 thohaoo-abdclonal wounds 566 THE THORACO-ABDOMINAL CASUALTY The scope of this report is a discussion of the tnoraco-abdominal casualty in tne forward hospital, with a presentation of the available data from 903 case records of the kind Auxiliary Group daring 1943, 1944 and 1945. No attempt has been made to interpolate for the lack of complete records. Where tnere are a number of instances in which there are no records, it is so stated. The thoraco-abdominal wound is defined in this report as a wound produced by a missile perforating tne diaphragm with entrance into the pleural ana peritoneal cavities. Casualties in which the pleural cavity and peritoneum have been entered by separate missiles without injury to tne diaphragm have been excluded. However, a wound of the so-called "bare area" of the liver, incurred by a fragment entering through the chest and diaphragm has been considered a true tnoraco-abdominal wound. A comparison of the incidence of the tnoraoo-abdominal wound witn respect to ail abdominal wounds is of interest. During the period cover- ed by this report, 3532 operations on abdominal wounds of all types were performed. The thoraco-abdominal wound comprised 25*5fo of this group of abdominal casos* The great majority of casualties presented are infantrymen of the U.G, Army and of the Wehrmacht, with a scattered number of Allied British and French soldiers, and a few civilians. The age factor, tnen, is of little significance, because of necessity these men were in tne young healthy adult male group. TABLE I Age Distribution of Casualties Up to 20 21 - 25 26 - 30 31-40 Over 40 No Hecord 190 297 176 95 4 141 Artillery and mortar fire was responsible for 590 of the thoraco- abdominal wounds and rifle, machine gun, and pistol fire accounted for 245. The few remaining wounds were caused by bomb, mine, and grenade fragments. The pattern of entry of the fragments or bullets in thoraco-abdom- inal wounds shows that 837 of the missiles entered the abdomen through the tnorax, against 66 which peretrated the chest through the abdomen. The entrance wound in the chest was equally distributed on the right and the left sides. Four hundred and eighteen missiles entered through the right, and 419 through the left chest. In the 20 cases which had 567 The Thoraco-abdominal Casualty, cont’d. side-to-side perforations of both diaphragms, tn© wound of entry was on the right seven times and on Che left id times. The tuoraco-abdominal wound then, is caused by missiles entering tnrough the chest in the greatest proportion of cases, and tneir distribution is equal as to the right and left. For the sake of maintaining continuity in presentation of data, and in discussion of points of practice, the report is divided into the precperative, tne operative and the postoperative phases. THE PREOPERATIVE PERIOD The preoperative phase of the course and treatment of the casualty with a tnoraco-abdominal mound embraces the time period from wounding to operation. It is the period of so-called "time lag". This interval is concerned with the evacuation of the casualty from the battlefield to the hospital, the treatment of snock, and the examination and diagnosis. Time' lag for all patients, and for patients who died, is presented as the number of cases in each six hour interval up to 30 hours, and for these that came to operation at any time after 30 hours. The percentage mortality shows a progressive increase after the first l‘d hours, and drops again for those operated on after 30 hours. The greater mortality in the period up to six hours is a reflection of tno fact that the near- er to the front the Field Hospital is set up, tne higher the expected mortality, because with a snort evacuation distance from the line, more of the desperately wounded patients will arrive in the hospital before dying. For example, all the patients in this series with wounds of the vena cava and portal vein are found in this period. The eight casual- ties that came to operation after 30 hours sustained wounds involving the liver in two cases, the spleen in three instances, the kidney once, and two cases had penetration of the peritoneal cavity without damage to a viscus. The Thoraco-abdominal Casualty (The Preoperative Period, cont’d). Figure 90 - Mortality - Time Lag* Relationship in 903 Thoraco-Abdominal cases. TABLE II TB'iE LAG - From Wounding to Operation in 903 Thoraco-abdominal Cases and in 247 Fatal Cases Time Lag All Cases 0-6 6-12 12-18 18 - 24 24 - 30 Over 30 No Hecon 221 400 122 54 23 34 49 Tim© Lar Fatal Cases 64 96 39 20 9 8 11 28.9?£ 24.0% 31.9^ 57% 39,1^ 23* 6% 569 The Thoraco-abdominal Casualty (The Preoperative Period, cont'd). When these casualties were received in the first priority surgical hospital from the division clearing station, measures to combat shock and maintain respiratory equilibrium had already been instituted in the form of occlusive dressings to sucking wounds of the cnest, injection of morphine, and infusion of plasma. On arrival at the hospital, 455 casualties with thoraco-abdominal wounds had received an average of 525 cc. of plasma each. One hundred and forty-four patients had not re- ceived plasma before admission and the information was missing on this point in 324 instances. When first seen at the hospital on admission, the degree of clinical shock was recorded by the surgeon as "none", "mm”, "moderate", or "severe", or its equivalent, 'With an increase in the severity of clin- ical shock on admission, there was a corresponding rise in the percent- age of fatalities. There was a 5,5% mortality in these casualties reach- ing the hospital without clinical evidence of snock, whereas 59,6% of all cases that arrived in severe clinical shock, died subsequently. TABLE III Degree of Shock in All Thoraco-Abdominal Patients and in Fatal Cases SHOCK IN ALL CASES None Mild Moderate Severe No Record 145 75 174 275 233 SHOCK IN FATAL CASES 8 10 31 164 34 5.5^ 13.056 17.5^ 59.656 In the shock tent of the hospital, replacement therapy was continu- ed as indicated by the degree of shock and estimated blood loss. The usual practice in those cases requiring replacement treatment was to start an infusion of plasma immediately while waiting for blood to be cross-matched. Thereafter, therapy was continued with blood transfusion. Four hundred and eight patients received an average of 500 cc. of plasma. Two hundred and fifty two casualties did not receive plasma and in 353 instances there were no records of it. Similarly, 619 patients receiv- ed an average of 1100 cc, of blood in the shoo* tent, while 60 casualties did not get any. Records were lacking on transfusion in glucose in saline during the courasof the operative procedure as a supplement to plasma and blood. During 116 operations, no replacementms deemed necessary. One hundred and thirty records do not treat with this point. Before dealing with the operative approach and procedure in these thoraco-abdominal wounds a discussion of the pathology encountered will be presented. As stated above, the wound of entrance in the thoraco-abdominal casualty was in the thoracic cage 837 times, as against 66 instances in which the abdomen was the site of entry. In most instances, the injury to the chest wil was associated with fractured ribs. The fractured ribs roughly corresponded to the zone of the diaphragm. In only three in- stances, of the ribs reported as fractured, was the site above the 6th rib posteriorly or the 4th rib anteriorly. The small size of the target, and the lethal effect of a missile entering the chest to a cephalad direction probably contributed to the pauscity of cases with entry wounds in the upper chest. Likewise, in most instances the described wound of tne lung was in either lower lobe, with some cases of injury to the middle lobe on the right, and the lingula of the upper lobe on the left. The pathology in tne lung at those sites was described as "contused”, “containing hematoma or as "perforated" or "lacerated". Because of the path of the missile through the lower part of the chest in the diaphragmatic zone, the peri- pheral portions of the lower lobes, and less frequently of the middle lobe and lingulm of the left upper lobe, were injured. In some cases with perforation of tne costo-phrenic sulcus there was minimal or no lung injury. The injury to the diaphragm falls roughly into three categories, the single or double small perforating wounds, the large lacerated wounds, and tne avulsion of the diaphragm from its chest wall attachment. Similar to the chest wail, the rignt and left diaphragms were wounded about equally. The right diaphragm was perforated in 436 cases and there were 448 wounds of the left. Both diaphragms were wounded in iiO instances. At the time of operation, evisceration of abdominal contents through the diaphragm was recorded to have occurred in 57 cases. In 17 573 The Thoraoo-abdominal Casualty (Operative Period, cont’d). instances omentum alone protruded into -cue pleural cavity, but in 40 cases abdominal viscera were found in the chest. TABLE IV Frequency of Perforation of Right and Left Diaphragm with Mortality Total Cases Number Deaths Percent mortality Total Hignt Diaphragm 435 103 23.6% Total Left Diaphragm 448 136 50.8% Total Both Diaphragms 20 8 40.0% 903 247 TABLE V Evisceration of Abdominal Concents Through the Diaphragm Presenting at Operation Total Number of Cases* 57 Number with Evisceration of Omentum Only. 17 Number Cases Fatal Cases Percent Mortality Evisceration of Abdominal Viscera Through Diaphragm 40 15 37.5 % Through Right Diaphragm 5 2 o » o Through Left Diaphragm 35 13 37.1;^ The mediastinum was injured in 30 instances. The heart itself was wounded 14 times and the pericardium alone in 13 cases. The esophagus was injured once, and the posterior mediastinum twice. The Thoraco-abdominai Casualty (Operative Period, cont’d). TAbLE VI Injuries of the Mediastinum in 903 Thoraco-Abdominai Wounds Type of Injury Total Survived Died Ventricular Myocardium and Pericardium 21 8 13 Auricle and Pericardium 1 0 1 Pericardium Only ** 10 7 3 Esophagus 1 0 1 Posterior Mediastinum 2 1 1 Total 35 16 IS In regard to the pathology in the peritoneal cavity a consideration of tne right and left diaphragm with tneir different underlying anatomical relationship, bears discussion. Wounds of the right diaphragm were as- sociated in 407 out of 436 times with a wound of the liver. The liver, then was the organ w.iicn took tne impact of the missiles entering through the rignt diaphragm. After the liver, the following organs in order of frequency wexe wounded: the right kidney, the colon, the stomacn, the small bowel, tne duodenum, and the gall bladder. On the left side: the spleen, stomach, and colon were wounded most frequently, and received the impact of most missiles coming through the left diaphragm. In 448 wounds of the left diaphragm, tne spleen was injured 272 times, the stomach 167, and the colon in 145 instances. The liver and left kidney were wounded an equal number of times, followed by the small intestine and pancreas, in order of frequency. A comprehensive list of the fre- quency of organs and combinations of organs wounaed is presented from the records (Tables III and IV, Appendix). The anatomical relationships below the diaphragm have a direct bearing upon the operative approach and procedure on the right and left side, A tabulation of the types of approaches, that were used in 903 cases is presented from tne records. 575 The Thoraco-abdominal Casualty (Operative Period, cont'd). TABLE 711 Metnod of Operative Approach and Mortality in 903 Tnoraco-Abdominai Wounds Total Deaths Percent Mortality Thoracotomy Only witn Transdiaphragmatic Laparotomy 488 91 20.3/, Laparotomy Only 202 77 38,1/0 Thoracotomy, then Laparotomy 144 36 25.0;:. Laparotomy, then Thoracotomy 74 26 35.1;:, Thoracotomy with Transdiaphragmatic Procedure followed by laparotomy 20 7 35# 0/o Thoracolaparotomy Traversing the Chondral Arch 6 3 50,0/o Non-op©rated 3 1 33,3/i Died Before End of Operation 6 6 100. O/o Any discussion of methods of approach must be qualified at the onset by saying that no one approacn is ideal for all patients, but tn© judg- ment of the surgeon, knowing the individual patient, and his own capa- bilities, will decide the approacn to be used by him. In general, where a tnoracotomy and laparotomy were botn contemplated, one cuest procedure was performed first because the patient stood a laparotomy better after the chest wall and diaphragm had been closed and the lung re-expanded. In other words, a mo~e balanced cardio-respiratory system is an import- ant measure in combatting shock, and thoracotomy should be performed be- fore, rather than after a long abdominal procedure. The practice of stabilizing the chest operatively, by closure of the chest wall and diaphragm, and removal of blood with re-expansion of the lung, before attempting otner procedures is a principle of attacx about whicn there can be little disagreement. The question of how much surgery should, or can be done tnrough the cnest and diaphragm, and how muon through the abdomen, is open to discussion. In tnis series, 362 cases with thoraco-abdominal wounds had the entire abdominal procedure performed through the diaphragm. In tnis group, 31 different combinations of organs were operated upon. The mortality of eacn of these procedures 576 The Thorac0-abdominal Casualty (Operative Period, cont'd). with the number of cases in each category, is presented (Table V, Appendix). Of the 448 oases with thoracotomy only, 86 cases in which exploration, removal of foreign bodies, or simple retroperitoneal drainage was performed, have not been included. In further discussion of this topic a consideration of the possi- bilities of approach when the wound is on the right or on the left side will be debated. Perforating wounds of the chest on the right side, in the upper zone of the diaphragm, are more satisfactorily attacked through a thoracotomy incision, because the diaphragm is much more readily su- tured from above than from below. The presence of the liver makes ade- quate exploration and suture difficult and often impossible from below the diaphragm. Similarly, penetrating wounds of the upper zone of the diaphragm, in which the foreign body lies beneath the dome of the dia- phragm well within the liver, are more easily handled by the thoracotomy diaphragmatic route. However, on the right side, perforating or pene- trating wounds of the lower zone of the diaphragm in the region of the costo phrenic sinus, in which the tract of the missile may well have passed below the liver, should be attacked primarily by a laparotomy approach. Debridement and closure of the chest wall may be done first or secondly, depending upon the urgency of the suspected abdominal pathology and the amount of respiratory embarrassment present. The diaphragm may be closed by either route in the region of the costo phren- ic sinus except posteriorly, where closure was difficult and sometimes impossible from the abdominal cavity. Through the transdiaphragmatic approach on the right side, the field of exploration of the abdomen was limited to the superior surface of the liver, the right kidney, and the hepatic flexure of the colon. On the left side, the problem is somewhat different. The absence of the liver mass, and the relationship of the fundus and body of the stomach, spleen, splenic flexure of colon, body and tail of pancreas, and the left kidney to the inferior surface of the diaphragm not o nly makes for easy accessibility to these organs through the diaphragm, but also permits greater facility of exploration and suture of the diaphragm from below. Wounds of the left diaphragm carry with them the greater threat of contamination of the pleural cavity through the diaphragmatic wound by stomach, colon, and small bowel contents. The data collected from the records cannot be used to show the superiority of either the laparotony or the thoracotomy approach sep- arately in these cases. Depending in the individual case upon the magnitude of the abdominal and thoracic problems, the a pproach may be best by thoracotomy or by laparotomy, or by both. It may be said, however, in perforating wounds in the upper zone of the left diaphragm, or in pene- trating wounds in which the fragment .on X-ray can be demonstrated t o lie within the area of the dome of the diaphragm, that these patients may be treated with facility through the thoraootony-diaphragmtio 577 The Thoraco-abdominal Casualty (Operative Period, cont’d). approach. In these cases the expected injury was a perforation of the spleen, stomach, or kidney, ail of whicn organs are accessible to surgery througn the diaphragm. Likewise, wounds of the splenic flexure of the colon may be exteriorized in the flank tnrough this exposure. In addi- tion to these organs, it must be stated, that exposure of, and operation upon most of the transverse colon, the upper part of the descending colon and the small intestine from the ligament of Treitz to within 10 inches of the ileo-cecal junction, can be performed through the left diaphragm, depending somewhat upon the habitus of the patient, and tne length of the mesenteries. In those instances of perforation of a hollow abdominal viscus par- ticularly where there is a diaphragmatic wound of any size, a thoraco- tomy is distinctly of advantage before a laparotomy, in order to cleanse the pleural cavity of gross contamination. In fact, an important part of any thoracotomy entails removal of all foreign material and clot, with a thorough irrigation of the pleural cavity with saline solution. How- ever, in those cases in which a small perforation in tne diaphragm is present, and in which contamination is minimal, it must be considered whether it is wise to widely open the diaphragm to attack perforations of hollow organs, thus exposing the pleura and chest wall to wider con- tamination, These are some of the problems tnat are met, and which must color the judgment of any surgeon required to meet them. Further discussion of operative procedure will be limited to the problems peculiar to the thoraco-abdominal wound. Thoracotomies as per- formed on these cases were of four types: Ij a limited thoracotomy achieved by extending the missile wound, 2) a thoracotomy through rhe area of the wound, 3) thoracotomy outside the area of the wound, and 4) the thoracolaparotomy incision, in which the thoracotomy was extend- ed through the costal aroh and down through the abdominal musculature. In the first category are found those in which the chest wound to be debrided was large, and by simple extension of tnis wound adequate ex- posure and suture of the diaphragm could be carried out. In Groups 2 and 3, are the majority of cases. They comprised those in which a formal approach was performed, usually pos be ro-late rally, and either tnrough the rib bed of the ninth rib or the nintn intercostal space, A small proportion of these thoracotomies were performed laterally in the region of the sixth and seventh spaces. Approximately twice as many of these thoracotomies were performed through the intercostal space as through the bed of a rib. The exposure whicn gave the best approach to trans- diaphragmatic work was the postero-lateral one in the region of the ninth or tenth ribs. ' The transchondral thoracolaparafcony, of which there were six recorded, was used in two cases in which the chondral margin had already been destroyed by the missile. In the four cases in whicn it was employed as an elective approach one oase resulted in a fatal in- fection, breakdown, and disruption of the wound. Nothing can be said in favor of this type of approach, as an elective procedure. 578 The Thoraco-abdominal Casualty (Operative Period, cont'd). In this series of cases, records of procedures performed upon the lung incxuded 80 instances in which lung suture was done, ana two in- stances where a segment of tne rignt lower lobe was excised in a seg- mental manner. Recoras of removal of foreign bodies from tne lung were found in nine cases. The method of opening the diaphragm for exposure of abdominal vis- cera was not specifically stated in tne records, more than tnat the "wound was extended" or in case of two wounds, that they "were connected by incision". As stated above, the missile wound or wounds in the dia- phragm were utilized in the performance of a more extended opening in the diaphragm. The direction and extent of incision will depend upon the site of the suspected or known viscera wounded, and the amount of exposure necessary. The closure of the diaphragm is of utmost importance in these cases, both on the right, and on the left. Suture of tne left diaphragm is imperative to cut off tne patn of contamination and infection from the peritoneal cavity, and to prevent herniation of abdominal viscera into the pleural cavity. It is likewise mandatory to close the right dia- phragm to prevent the occurrence of bile pleuritis and empyema, and also to keep contamination and infection from invading the pleural cav- ity. Even in those instances in which a small fragment has penetrated the liver tnrough tne diaphragm, it is conservative to explore, suture the diaphragm, and drain the liver, because it is impossible to estimate in every case the size of the diaphragmatic laceration or liver injury from the size of the missile. In some instances, particularly where a rib has been fragmented in passage of a small missile, it is surprising to find the extent of diaphragmatic and liver laceration. A firm closure in the greatest proportion of tnese cases was in- sured by interrupted silk sutures. In those cases in which the dia- phragm was avulsed from the chest wall, it was secured by transplanta- tion and suture at a higher level on the onest wall, A legend of the various methods of closure employed is presented. The phrenic nerve is recorded as having been crushed in 11 instances. 579 The Thoraco-abdominal Casually (Operative Period, cont'd). TABLE VIII Technique of Suture Used in Closure of the Diaphragm Interrupted Silk - No statement of number of layers 276 Interrupted Silk - One layer 38 Interrupted Silk - Two layers 61 Interrupted Cotton 66 Combined - Chromic catgut and silk or cotton 21 Interrupted chromic catgut 64 Transplanted* (interrupted Silk 6 (Interrupted chromic catgut 3 (No record 5 No Suture 39 No Records 267 Discussion of the specific treatment of individual organs of the abdominal cavity is not the province of this report. Suffice it to say that wounds of the stomach and duodenum were sutured, wounds of tne colon were exteriorised, wounds of the small bowel treated by suture or by resection and an anastomosis, of the spleen by splenectomy, and of the liver by subcostal drainage. Wounds of the kidney were treated by nephrectomy, only when hemorrhage was persistent, or the pelvis in- volved, otherwise drainage sufficed. Treatment of the pancreas was by suture and drainage, or by drainage alone. Detailed complete information in respect to closure of the thoracic wound was not present in the records. In general, closure of the thoracic cage was accomplished by approximation of adjacent ribs or intercostal musculature, depending on whether the thoracotomy was performed through the intercostal space or the bed of a rib. In the case of thoracic wail defects, utilisation of contiguous musculature in layers was the usual method employed. Closure of the muscle layers of the cnest wall was performed with, or sometimes without closure of subcutaneous tissue and skin. As already emphasised unaer anesthesia, one of the most important parts of closure is the re-expansion of the lung by the anesthetist utilising positive pressure. In order to achieve complete exhaustion of air and fluid in the pleural space, either catheter suction just prior to closing the chest, or needle aspiration after closure was useful. Three hundred and twenty-six cases were recorded as having been drained by a closed water trap intercostal catheter or tube. Either a 580 The Thoraco-abdominal Casualty (Operative Period, cont'd). large sized fenestrated catheter, or tube of equal caliber, with enough rigidity to prevent it from collapsing, was une available material most commonly used for drainage. Tne site of drainage was usually the postero- lateral or lateral aspect of the lower cxxest through a separate intercostal stab wound. In a few instances a small catneter, in addition was placed in the second interspace anteriorly. The management of the pleural space by drainage or by reliance on aspiration is of prime importance in re-expansion of the lung, A dis- cussion of tne question of whether drainage should be required in these thoraco-abdominal wounds, leads to a consideration of tne extent of tae lung damage, the defect of tn« caest wall, the magnitude of the diaphragma- tic perforation, and tne presence of gross contamination from the wound, or particularly, through the diaphragm from a perforated abdominal viscus© Only in those cases in which the tnoracic wail defect is small, and in whicn lung and diaphragmatic injuries are minimal without gross contami- nation, may water seal intercostal drainage oe disregarded as a factor in postoperative expansion of the lung by elimination of pleural blood and air, and control of transient broncho-pieurai fistulae. The role of the intercostal catheter drainage in control of pleural infection is that by elimination of the pleural dead space, the process is limited and localized. It is pertinent to stress tnat the care of the water trap drainage in the postoperative period requires constant vigilance on the part of the surgeon, and a thorough knowledge and conscientious attention on the part of the nursing and corpsman staff of a forward hospital. THE POSTOPERATIVE PERIOD The records of the various phases of postoperative care are incom- plete in respect to the various details, so that a discussion must be given of the problems encountered. In general, the care of the patient with a thoraco-abdominal wound entails attention to details of care common to both the chest and the abdominal patient. The complications that were recorded in 656 surviving‘patients with thoraco-abdominal wounds are presented (Table VI, Appendix). The most frequent complications recorded in order of frequency were atelectasis, empyema, subphrenic abscess and pneumonia. Bronchopleural fistula was recorded four times - twice with empyema and twice with a bile empyema. Pressure pneumothorax occurred in three instances as a postoperative complication. The postoperative care of the chest is directed towards maintaining cardio-respiratory balance, promoting expansion of the lung, and removal of blood and air from the pleural cavity to allow full expansion and minimize the chances of pleural thrombus formation. When those patients are brought into the postoperative tent, some will need oxygen and add- itional blood as indicated by cyanosis or signs of peripheral circulatory 581 The Thoraco-abdominal Casualty (The Postoperative Period, cont’d). failure. As soon as the patient is conscious, he should be started on a regime of frequent turning from side to side, with insistence upon deep breathing and coughing. If the patient cannot, or will not cough, and raise the blood and mucus, intercostal nerve block and tracheal as- piration by catheter snould be instituted early and repeated as frequently as is necessary in the presence of atelectatic areas in the lungs, or detectable amounts of blood or mucus in the tracneo-bronohial tree. Often after the first tracheal aspiration the patient will cough ana raise without protest. In the event that these metnods do not avail in the presence of a pulmonary collapse, broncaoscopy should be employed. There are records of the use of bronchoscopy in 12 instances in the post- operative period. The advantage of the thoracotomy wound alone, with- out laparotomy, was distinctly appreciated in tne postoperative period. The absence of an abdominal incision made for more comfort and for better cooperation from tne patient in his important part in lung expansion. It was the general practice to continue water trap intercostal tube drainage of the cnest for two to three days. Often these tubes did not function efficiently for this period, but became sealed off after 24 hours. After removal of the tube on the second or third day, and be- fore, in cases without drainage, aspiration of blood and air was done as indicated, daily if necessary. Often a pocket of air was encounter- ed anteriorly, even in tnose patients who had a lateral or postero-latoral intercostal tuba This was evacuated by aspiration with a needle as soon as detected. Morphine in doses larger than 1/4 grain should not be given to these patients, and its use should not be on a routine basis. One sixth of a grain in many instances sufficed to control the pain in these patients. A detailed discussion of the postoperative care directed at the abdominal port of the wound will not be entered in this report, except to emphasize the importance of nasal tube stomach slphonage. All these cases particularly with hoiiow viscus injury should have a nasal tube stomach drainage for varying periods up to four days, depending upon tne re-establishment of peristalls to the surgeon's satisfaction. Use of stomacn siphonage indiscriminately beyond the period or four days may veil a bowel obstruction, and delay recognition and correction of it. An accurate knowledge of the daily Intake and output of the pat- ients is imperative. During the period In which n&so-g&stric siphonage was in use between 2000 and 3000 oo. of five percent glucose in saline was given to these patients dally. Caution should be exercised in giv- ing a total amount of parenteral fluids in excess of 3000 ec. daily be- cause of the impaired cardio-respiratory reserve which may exist, and the possibility of producing pulmonary edema. The amount of replacement in blood and plasma given in the postoperative period should be guided by hemoglobin, hematocrit, and serum protein determinations, A nomal level should be reached as soon as possible. The routine employment of vitamins B and C in the postoperative period was considered advan- tageous. 582 The Thoraoo-abdominal Casualty (The Postoperative Period, oont’d). The use or sulphonamide and penicillin therapy as employed in these cases from the time of wounding through the postoperative period was as follows* Sulphanilamide crystals were placed in the fresh wound in the battalion aid station -throughout the entire period* During 1943 and up to May of 1944 sodium sulphadiazine was given parenteraliy in the postoperative period. After May 1944 penicillin was instituted and was given intramuscularly in doses which varied between 20,000 and 25,000 units at three hour intervais starting in the shock tent and ex- tending tnrough the postoperative period. Before May 1944 three to ten grams of sulfanilamide crystals were placed in the pleural cavity be- fore closure of the chest in most cases and after May 1944 penicillin in amounts ranging from 30,000 to 50,000 units were used similarly in the majority of instances. The use of sulphonamide and penicillin in the abdominal cavity was not as uniform. In most instances their use depended upon the perforation of a hollow viscus. Before May 1944 five to ten grams of sulphanilamide crystals were left in the peri- toneal cavity and after May 1944 about one half of the cases still received sulphanilamide crysttk, and one half 50,000 units of peni- cillin intraperitoneally. Due to the lack of folxow-up in the sur- vival patient, it is impossible in this report to give any definite data referable to the relative role these drugs played in preventing infection* Before dealing more fully with mortality, it is pertinent to re- cognize that the lower mortality rate for these patients in the latter half of 1944, and the year 1945 coincides with the era of penicillin. Without proof, nevertheless, it is considered that this reduction In mortality is a reflection more likely of a greater knowledge and e:qer- ience in dealing with the problem of the thoraoo-abdominal wound as a whole, a greater appreciation of the taoracic implications and com- plications, a greater experience in facility of the individual surgeon and anesthetist in the operative treatment, and, lastly, a keener ap- preciation and attention to details of preoperative and postoperative care* The gross mortality for 903 cases with thoraco-abdominal wounds was 246 or 27,8?i, For 1943 the fatalities were 36,1%,for the first six months of 1944, 34,9%, for the last half of that year, *b%m and for 1945 20$, Those mortality figures are for deaths in the first priority sur- gical hospitals, where the usual postoperative residence was from seven to ten days. Some eases remained in this hospital only a few days, while some stayed as long as 18 days. 583 The Thoraoo-abdominai Casually (The Postoperative Period, oont’d). TABLE IX Mortality Rata - 903 Thorac©-Abdominal Wounds - First Priority Surgical Hospital Only Total 1943 Jan-Jun 1944 Jul-Dec 1944 1945 Humber Cases 903 68 243 392 200 Humber Deaths 247 25 84 98 40 Percent Mortality 27,5% 56,7% 34,9$ 25.0% 20,0$ It is Impossible in the discussion of the mortality data to dis- cover what effect the chest component of the wound had upon mortality except in the oase of the wounds injuring the mediastinum. The mor- tality when this part of the chest was wounded was 54/4, However, the most lethal part of the thoraoo-abdcminal wound was the abdominal portion. Roughly, tne type of organ and number of organs wounded below the diaphragm wore reflected in the mortality rate. Wounds involving five or more different organs were universally fatal. The mortality rate of all abdominal wounds in the first priority surgical hospitals as compared to tne thoraoo-abdominai wound is of interest. In abdominal wounds of axi types there was a mortality rate of 24.1%, in the thoraoo-abdominai wound the rate was This covers the entire period of 1943, 1944 and 1945 in tne oase records of the 2nd Auxiliary Surgical Group. The cause of death and postoperative day on which death ooourred were recorded in 234 out of 247 fatalities. Shook was given as the most frequent cause of death on the operating table, tne day of operation, and tne first postoperative day. Four cases were recorded as having died on the operating table of hemorrhage. However, in the so-oalled shoe* death, blood loss was a contributory factor, as were overwheMng contamination and infection of the peritoneal and pleural cavities and retroperitoneal space, disturbance of oardio-respiratory physiology, and massive tissue destruction. In 15 cases renal failure as express- ed in oliguria and anuria was the cause of death most commonly encount- ered from the third to the fifth day postoperative. Peritonitis and pneumonia were the next most frequent causes of fatalities respectively, (Table VII, Appendix). In nine oases, death was considered to have been due to the effect of an associated injury rather than as a result of the thoraoo-abdominai wound. The role of the associated wound in the morbidity of these pat- 584 The Thoraco-abdominal Casualty (The Postoperative Period, cont’d). ients is an important factor. Lesions of the spinal cord, produced by tne missile of the thoraco-abdominal wounds, have been considered as associated wounds. There were 95 severe, 129 moderate, and 16i mild associated wounds. The types of wounds in the severe category are stated (Table VIII, Appendix). The moderate group included fractures of long bones other than the femur, and multiple wounds of less serious nature than tnose of tne severe category. Flesh wounds and those in- volving fractures of the hand and foot are listed under mild wounds* SUMMARY 1. Available data in 903 thoraco-abdominal cases have been pre- sented from the records of tne 2nd Auxiliary Surgical Group during 1943, 19a*, ana ±y45* Thoraco-abdominal wounds comprised 25*5$ of ail abdominal wounds operated upon by the surgical teams of the Group. 2, Topics not covered by recorded data have been discussed from the point of view of practice. 3. An attempt has been made to give an accurate picture of the patient with a thoraco-abdominal wound through the period of treatment in forward hospitals. CONCLUSIONS 1. Recognition of perforating wounds of the diaphragm in chest and abdominal casualties is of prime importance. 2. The value of correction of altered cardio-respiratory physio- logy in the preoperative period, of endotracheal anesthesia during the operation, and of re-expansion of the lung at operation and postopera- tively cannot be overestimated in the treatment of these patients. 3. The importance of early operation because of the abdominal wound, and of initial control of the thoracic pathology at operation upon the thoraco-abdominal wound is shown. 4. The transdiaphragmatic procedure is a satisfactory method of approach in certain types of thoraco-abdominal wounds as demonstrat- ed by the results of 362 procedures. 5. The reduction in the mortality of thoraco-abdominal wounds from 36,7$ in 1943 to 20$ in 1945 in forward hospitals is the result of a fuller understanding of the problems of the thoraco-abdominal wound as a whole, of its thoracic implications in particular, of a wider ex- perience of the individual surgeon and anesthetist, and of a keener ap- preciation of the essentials of pasoperative care and postoperative care. The role of penicillin cannot be estimated. 585 The Thorac0-abdominal Casualty, cont'd. APPENDIX TABLE I Causative Agent Shell Fragment Gunshot Mine Fragment Bomb Fragment Grenade Frag- No Wound Wound Wound Wound ment Wound Record 590 245 34 6 4 24 TABLE II Site of Injury in 903 Thoraco-Abdominal Wounds Wound of Entry Diaphragm Involved Total Right Chest Right Diaphragm 405 Right Chest Left Diaphragm 6 Right Chest Both Diaphragms 7 Right Abdomen Right Diaphragm 18 Right Abdomen Left Diaphragm 12 Left Chest Left Diaphragm 403 Left Chest Right Diaphragm 3 Left Chest Both Diaphragms 13 Left Abdomen Left Diaphragm 27 Left Abdomen Right Diaphragm 9 Total 903 586 The Thoraco-abdominal Casualty, (Appendix, cont*d). TABLE III Total Times Each Organ Was Involved Without Reference to Combination With Other Organs Right Diaphragm Total Left Diaphragm Total Both Diaphragms Total Cases Fatal Cases Fatal Cases ' Fatal Liver 407 96 82 34 18 7 Spleen 2 1 272 17 5 2 Right Kidney 84 33 5 2 0 0 Left Kidney 0 0 82 36 0 0 Pancreas 6 4 26 11 1 1 Adrenal 1 0 2 0 0 0 Stomach 32 17 167 71 12 5 Duodenum 17 12 2 1 0 0 Jejunum 11 7 62 29 1 0 Ilium 13 4 9 1 0 0 Cecum 3 1 0 0 0 0 Ascending Colon 8 6 2 2 0 0 Hepatic Flexure 18 13 4 2 0 0 Transverse Colon 13 8 62 26 1 0 Splenic Flexure 2 1 54 26 1 1 Descending Co1cm 0 0 23 8 0 0 Call Bladder 12 9 0 0 1 1 Common Duot 2 2 0 0 0 0 Portal Vein 1 1 0 0 0 0 Ureter 0 0 1 1 0 0 Vena Cava 4 4 1 1 0 0 587 The Thoraco-abdominal Casualty, (Append!*, cont’d). TABLE IV Frequency of Wounding and Mortality of Vigoera and Combination of Viscera in 903 Thoraco-Abdominal Wounds Liver Total Cases 297 Fatal Cases 35 Percent Mortality ii.rf. Spleen 95 10 10.5$ Liver and Sidney 59 14 23.7% Spleen and Stomach 43 18 4U6% Liver and Stomach 30 11 36,6$ Peritoneal Cavity Only 26 3 11.5$ Spleen, Kidney 27 4 14.8$ Spleen and Left Colon 19 4 21.0$ Left Colon 18 6 33.3$ Spleen, Kidney and Left Colon 12 6 50.0$ Liver, Spleen and Stomach 11 3 27.2$ Spleen, Stomach and Left Colon 8 4 50.0$ Spleen, Kidney and Stomach 9 3 33.3$ Liver and Small Intestines 9 1 113 Liver, Stomach and Colon 8 5 62,6$ Liver, Kidney and Right Colon 5 4 80.0$ Liver, Small Intestine, Left Colon 6 5 83.3$ Liver, Stomacn, Biliary Tract 6 4 66.6$ Kidney 11 4 36.6$ Stomacn and !Left Colon 8 2 25.0$ Spleen and Small Intestine 9 0 0.0$ Liver and Spleen 7 3 42.8$ Stomacn, Small Intestine, Colon 8 2 25.0$ Small Intestine, Left Colon 6 3 50.0$ Liver and Right Colon 7 4 57.1$ Kidney and Stomach 4 1 25.0$ Liver and Left Colon 3 1 33.3$ Spleen, Stomach and Pancreas 3 2 66.6$ All Other Combinations (62 in all mortality of five organs or more - 100$) 115 73 63.4$ The Thoraco-abdominal Casualty, (Appendix, cont*d)« TABLE V 31 Transdiaphragmatic Procedures in Which Thoracotomy Alone was Employed Total Procedure Cases Liver Drainage 148 Fatal Cases 17 Percent Mortality Splenectomy 87 9 10.3% Splenectomy and Stomach Suture 27 12 44*4% Stomaon Suture 23 5 Colostomy (left colon flank colostomy) 12 3 25.0% Splenectomy and Colostomy 10 3 30.0% Stomach Suture and Liver Drainage 7 5 Splenectomy, Colostomy and Jejunal Repair 6 3 Right Nephrectomy and Liver Drainage 6 2 Left Nephrectomy and Splenectomy 5 0 Splenectomy, Stomacn Suture, and Liver Drainage 4 1 Splenectomy, Stomach Suture and Colostomy 3 1 Stomach Suture and Colostomy 3 3 Splenectomy and Jejunal Anastomosis 2 1 Splenectomy, Stomach and Pancreas Sutured 2 1 Splenectomy and Liver Drainage 2 0 Jejunal Repair 1 0 Left Nephrectomy, Stomach and Jejunal Repair 1 0 Stoiaach Suture, Colostomy and Liver Drainage 1 0 Left Nephrectomy, Splenectomy and Colostomy 1 0 Left Nephrectomy and Stomach Suture 1 1 Stomach Suture, Colostomy and Liver Drainage 1 0 Left Nephrectomy, Splenectomy and Stomach Suture 1 1 Stomach and Small Intestine Suture and Colostomy 1 1 Jejunal Suture, Colostomy and Liver Drainage 1 1 Stomach and Jejunal Suture 1 1 Splenectomy, Stomaoh Suture, Colostomy and Liver Drainage 1 0 Left Nephrectomy 1 0 Left Nephrectomy and Stomach Suture and Colostomy 1 1 Colostomy and Liver Drainage 1 0 Left Nephrectomy, Jejunal Suture and Colostomy 1 0 TOTAL 362 72 19,9# The Thoraco-abdominal Casualty, (Appendix, cont'd). TABLE VI Recorded Complications in 656 Thoraco-Abdominal Wounds - Survival Cases Number of Cases Atalectasis 21 Empyema 17 Empyema with Bronchopleural Fistula 2 Subphrenio Abscess 15 Pneumonia 12 Abdominal Wound Disruption 7 Abdominal Wound Disruptionwltn Evisceration 3 Bile Empyema 5 Bile Empyema with Bronchopleural Vistula 2 Chest Wound Infection and Breakdown 8 Intestinal Obstruction 5 Persistent Pleural Effusion 6 Tension Pneumothorax 3 Jaundice 3 Incomplete Expansion of Lung 2 01iguria 2 Gastric Hemorrhage 2 Chest Wall and Diaphragm Breakdown 1 Psychotic State 5 Leg Vein Thrombosis 2 Hepatic Abscess 1 Pelvic Abscess 1 Pulmonary Edema 1 Hemorrhage from Thoracotomy Wound 1 Pulmonary Embolism 1 No Complications Recorded 364 No Records 165 TOTAL 656 The Thoraco-abdaminal Casualty, (Appendix, cont’d). * M 05 M tv: M M ct pr M o 03 03 cn £ 03 ro (S» 9 Jr £r p- pr PJ” pr P* cr f a a d- t-3 O JS ►O O' O *d T) |TtJ *T) r° id hd y |XJ r0 cT o O o o c o o o O o o o o o t 9 8- Day Day Day Day o 5 Day Day Day Day 1 Day 1 Day 1 o S' 0*5 to 52 h-> tO o o to 03 05 o> -0 to H* to ro 03 to (O -o o> 20 Humber of Deaths h-> 05 o H* M to 5-5 03 cn to s Shock * Hemorrhage M C71 M i-* rf* cn "Renal Failure" Oliguria and Anuria -J ro t-* *-* 05 Atelectasis CO to M 05 •O to Pneumonia 05 ro HT, Tamponade or Injury lO o H5 t-> (-1 M M to M to o> Peritonitis tO to Missed Perforation to to Peritonitis and Pleuritis *“• O h-> M M »-• to to Pulmonary Embolus M h-> Mis-Matehed Blood 05 M to Blast H-* 5—1 Mediastinitis »-* M Fat Embolism to ro B-P Fistula (Pressure Pneumo thor ax ) M I-1 Liver Deaths tO M M Gras Infection to h-> (—* Disruption Diaphragm M Morphinism H1 M Bronchoscopy M »-* Meningitis >-* M Liver Abscess . Sight cases of double amputations of the thighs or logs end no other major injuries were admitted with a blood pressure of 0/C. Seven of these survived to be evacuated. Triple Amputations, A total of four cases had triple amputations performed, Tv.’o died while under the observation of the surgical teams. The two who survived had perceptible, blood pressures when admitted; the two who did not, died. DISiulT ICUL AT I0«3 TABLE IV The total number of disarticulations done were as follows; Tarso-Aletatsrssl No. Cases 6 Lid-Tarsal 17 Ankle 1 Knee 18 Hip ... . 2 V/rist 4 Llbow 1 Shoulder 10 TOTAL 59 most disarticulations fell into disfavor due to complaints report from the Base Hospitals, The principal difficulty encountered in the immediate postoperative care of disarticulations was the severe pain that sometimes occurred, probably due to the drying of the exposed cartilage. Certainly, it could be relieved by section of the bone end proximal to the cartilage. TREATMENT RECEIVED PRIOR TO ADMISSION TO A SURGICAL INSTALLATION Tourniquets, Most patients who were seen with major amputations showed evidence of marked blood loss on admission. Division medical personnel reduced this loss by means of pressure dressings and tourniquets, T'eb cloth tourniquets were commonly used, Sven when applied at the site of pre- 599 Amputations, (Disarticulations, contd). ference for tourniquets - as they usually were - they did not always completely control hemorrhage. The use of rubber tourniquets was limited. Cases have been admit bed in which a strong rubber tourni- quet had been'placed immediately proximal to the traumatic amputation site. This appeared to be a satisfactory measure in patients having a devitalised stump end. In only one case record was mention made of the possibility of a tourniquet being responsible for amputation at a higher level than would Vive otherwise been necessary. In this instance it was by no certain that the tourniquet was at fault* Morphine« There were 12 cases in which signs and symptoms of acute morphine intoxication /were recorded. Six of these were classed as moderate on the basis of sluggishness, semi-consciousness, moderate depression of respiration and pin point pupils. Six were classed as severe on the basis of marked respiratory depression requiring stimulants or artifi- cal respiration. No deaths were directly attributable to morphine. In nine, case records one grain was recorded as having been given prior to admission. Splints, The use of splints for complete amputations was not common. When the extremity was still attached, a splint prevented tugging by the life less portion during transportation. In some instances where the ampu- tation was complete except for strands of fascia or a tendon, these were advantageously severed in the Battalion Aid Station, Plasma, In calculating the average amount of plasma given to amputation cases before admission to a surgical installation, those patients who had other major injuries were excluded. Specifically, concomitant, intracranial, intrathoracic, intra-abdominal injuries and compound fractures of long bones were excluded. Four hundred and ninety case records of amputations were selected on this basis. The average quantity of plasuifl received by these patients was units or 635 c,c. One hundred case records of amputations without other major injuries indicated that blood was given before admission to a Field or Evacuation Hospital, These 100 cases received an average of 2,29 units, or 1,145 c.c, of blood. Amputations. SHOCK Hi AMPUTATION CASES It was recognised that blood pressure was not the sole criterion of shock nor always a reliable one. However, the evaluations of the degree of shock made by a number of different observers did not lend themselves to statistical study. Suffice it to state that all patients with major amputations exhibited some degree of shock. The degree of shock was less in cases which had the more sharply demarcated stumps. The most severe states of shock were found in those patients who sus- tained severe injuries to an extremity with interruption of the main blood supply but with some collateral circulation present, not enough to maintain viability for any length of time. As an example of the common problem of shock in amputation cases, the average patient with an amputation through the distal third of the thigh presented the following picture: His blood pressure was about 60/30. His pulse was thready and ranged around 120, His hands were definitely cold, harked pallor was evident in the face, especially in the lips and conjunctiva. The skin was dry. His saliva was viscid. He was apathetic and seldom complained of pain. His response to question- ing was slow and labored. He remembered details of what he was doing at the time of injury but was apt to be hazy about what happened after that. He went to sleep readily. Vftien aroused he invariably asked for a drink of water* Forty-one case records of patients with amputations and no other major injuries indicated that they had no obtainable blood pressure on admission. Seven of these died while under the observation of the surg- ical teams giving an observed mortality rate of 17/»* BLOOD PRESSURE AND PULSE AVERAGES Hi AMPUTATIONS Cases with no other injuries apt to influence the blood pressure and pulse were selected for these averages. The number of cases on which each average was based is placed in parenthesis. TABLE V 1# Average Blood Pressures and Pulses of All Uncomplicated Gasesi Blood Pressure Pulse Admission 81/45 ( \2hh) 115 (91L. Before Operation ■nwi SB m (3wl Low During Operation 91/52 { 296) 120 (13ZL Close of Operation - 1QA/6Q_ ■ ( :378) 117 12Q2L 601 Amputations. (Table V, contd). 2. Leg. Blood Pressure Pulse Admission 92/52 (108} 112 (42} Before operation . 119/70 115 (170 lev-’. Suriru Operation 99/57 U51> 119 Close of Operation 109/62 (icv) 114 (93) 3. Thigh. Admission 74/40 .(99) 1 120 (39) Before Operation 112/69 v 214 J 122 w Low During Operation ti/VT aio) . 124 (54J Close of Operation 99/59 C136 J 120 179) 4. Forearm, Admission 75/48 (6) 94 (D . Before Operation 120/72 C29; 102 14; Low During Operation 77/46 (6) no 3) Close of Operation 92/5.4 (9) 100 (4) 5, Arm. I Admission 72/43 (26) 109 (9) Before Operation 116/69 {72) U2 w Low During Operation 88/50 (19; n8 (9; Close of Operation 106/61 (34) 115 (l8j 6, Shoulder Disarticulation, t Admission M Before Operation 96/59 C63 140 Low During Operation - Close of Operation 94/50 (4) . 1PJ>_ (2). . 7. Knee Disarticulation, Admission — Before Operation 108/69 (8) 129 (?) . . Low During Operation 83/50 (8 130 (4) Close of Operation 9ii/i6., isi 121. M SHOCK THERAPY Shock in amputation cases usually responded well to rest, plasma and blood* %en a patient was admitted, plasma was started immediately and kept going until crocs-matchsd blood was available. In the more 602 Amputations. (Shock Therapy, contd). critical patients at least part of the fluid replacement was adninistered under pressure. At the end of an hour the blood pressure had usually begun to rise. PLASMA ADMINISTERED IN THE SHOCK WARD PREOPERATIVELT TABLE VI Units Based on No. Cases Shoulder Disarticulation 3.00 2 Arm 2.09 33 Forearm 1.90 12 Hand 0.00 1 Thigh, Proximal Third 2.52 19 Thigh, Middle Third 1.76 17 ... Thigh, Distal Third 2.23 59 Knee Disarticulation 2.66 6 Leg, Proximal Third 2.10 28 Leg, Middle Third 2.26 30 .. Leg, Distal Third 1.93 48 Portion of Foot 1.20 5 BLOOD ADMINISTERED IN THE SHOCK WARD PREOPERATIVELT TABLE VII Shoulder Disarticulation Units 1.5 Based on No. Cases 3 Arm 23S 44 . Forearm .Sb 12 Hand 4.00 1 Thigh, Proximal Third 2.&0 35 Thigh, Middle Third 2.66 24 Thigh. Distal Third 2.76 53 Knee Disarticulation 2.25 4 leg, proximal Third 1.33 43 Leg, Middle Third 1.77 Leg, Distal Third 05 Portion .of Foot & The average time a patient was kept in the shock ward of a Field Hospital was four and one-half hours. In an Evacuation Hospital it was nine hours. During this time he was given an average of 492 c.c. of plasma and 1,120 603 Amputations. (Shock Therapy, contd). c.c. of blood. The average blood pressure rose from 61/45 to 116/69 during this interval. The admission to surgery time lag of nine hours in Evacuation Hospitals, averaged from Auxiliary Surgical Group team records, re- flects the fact that the teams were used largely in times of stress by these hospitals. Even the Field Hospital time of four and one-half hours does not reflect the minimum time necessary to prepare the average amputation case for surgery. This has often been accomplished in one to two hours. The simultaneous presence of higher priority cases in the shock ward has tended to lengthen the time spent there by patients with amputations. Some cases have required the arrest of hemorrhage after admission to the shock ward. This was accomplished by means of tourniquets and pressure dressings. Recurrence of bleeding with the rise of blood pressure was rare. Few patients complained of pain. When they did, attempts were made to relieve it by adjusting the dressings and by the use of morphine. The application of external heat was felt to be of value only when the tent was so cold that the shocked patient would shiver or complain of the cold. The heat was applied by means of warmed blankets or hot water bottles. In severely shocked patients, who showed little or no response to fluid replacement, the application of a strong rubber tourniquet has sometimes been followed by a rise in blood pressure. Vftien the site of the amputation precluded the use of a tourniquet a rapid guillotine amputation was done without further delay, Some of these responded favorably and made uneventful recoveries. BEHAVIOR OF THE BLOOD PRESSURE DURING OPERATION Ordinarily, the patient was not considered to be ready for operation until the systolic blood pressure had exceeded 100 mm. and had become stabilized. Operative intervention was felt to be indicated at any time the blood pressure ceased to continue its rise or began to fall in spite of attempts at resuscitation. The alert anesthetist learned to anticipate drops in pressure and prepared for them ahead of time by having a large bore needle or cannula in one or more veins, cross-matched blood within arm’s reach and apparatus at hand for giving blood under pressure if the need arose. 604 Amputations, (Behavior of the Blood Pressure During Operation, contd). A slight drop occurred during the induction phase of anesthesia, A further drop came with the skin preparation of areas inaccesible prior to anesthesia. Where advisable, the latter drop was controlled by the application of a surgically effective tourniquet prior to the preparation. The blood pressure became stabilized, in fact would often rise, follow- ing the application of a tourniquet. ’Vhen released after amputation, there would be an immediate drop of up to 20 mm. in the systolic press- ure, These fluctuations were more pronounced in patients who had had inadequate fluid replacement. The following case illustrated fluctuations of blood pressure W. S. - American Soldier, Age - 21. Diagnosis. 1, Amputation, traumatic, incomplete, right leg, middle third. 2, Fracture, compound, comminuted, tibia, left, middle third, with three inch bony loss, 3, Fracture, compound, comminuted, fibula, left, middle third. 4, Laceration, complete, anterior tibial artery and vein, left. History. Wounded in action, shell fragments, 1400 hours, 9 January 1945. At 1445 hours he was given one-fourth grain of morphine. Sterile dressings and short basswood splints were applied to both legs. At 1615 hours he was given 500 c.c. of plasma and four grams of sulfa- diazine. Physio,^Lt The patient was in shock. Blood pressure 60/40. Marked pallor was present. He responded sluggishly to questioning. The right leg was amputated in the middle third except for a strip of skin anteriorly and a band of muscle and skin posteriorly. A wound about three inches in diameter passed from one side of the left calf to the other in the middle third. The basswood splints did not immobilize the fractures or prevent tugging by the partially amputated leg. Preoperative Treatment. Two hundred and fifty c.c. of plasma and 500 c.c, of blood were given. The pressure rose rapidly to 120/80, He was carefully taken to X-ray which was in an adjoining room. The X-ray films were slipped under the legs just as they lay. No attempt was made to got lateral views. Thence, ha was carried to surgery - a distance of less than 15 feet. He was left on the litter. N© recurrence of bleeding was noted. During 605 Amputations, (Behavior of the Blood Pressure During Operation, contd). this minimum of handling his systolic pressure had dropped to 60. Five hundred c.c, of blood were given over a period of one hour, during which time he was allowed to lie still. The blood pressure rose to 90/60. Anesthesia started. Operation* 2105 hours, 9 January 1945. Oxygen ether anesthesia was used. Another 500 c.c. bottle of blood was started. As soon as the patient was anesthetized tourniquets were applied high on both thighs and skin preparation of the legs com- pleted. This involved lifting both legs to wash and shave the posterior aspects. During the preparation the blood pressure rose to 100/60. A circular flapless guillotine amputation of the right leg in the middle third was performed. On release of the tourniquet the blood pressure fell suddenly from 100/60 to 80/60, The wound of the left leg was then debrided. Anterior tibial artery and vein ligated. Tourniquet released. The blood pressure dropped from 80/60 to 60/30. During the application of the cast to the left lower extremity and Thomas splint to the ampu- tation, the pressure fell to 40/0 although the remainder of the bottle of blood was being given under pressure. While the plaster was setting the blood pressure rose to 100/50. He was left in surgery another 30 minutes for observation, during which time the blood pressure rose to 110/60. Removal to the ward did not cause another fluctuation. Progress« Convalescence was uneventful during the period observed. He did not remember being admitted to the hospital or anything that transpired in the shock ward. He was given a total of 2,000 c.c, of blood over a period of two days, at the end of which time his red cell count was 3,860,000, hemoglobin (Sahli) 11.5 grins. He was given another 500 c.c. of blood, the dressing changed on the stump and a traction cast sub- stituted for the Thomas splint. Evacuated on the fourth postoperative day. This case has been selected to illustrate the variations in blood pressure because the fluctuations were marked. Patients with more complete fluid replacement preoperatively often showed similar changes but were lass pronounced. TIKE LAG IN AKPUTATI0N CASES These averages were calculated from cases not complicated by other major injuries. The average for all these cases in which time lags could be calculated were* 606 Amputations, (Time Lag in Amputation Gases, contd). TABLE VIII Time Lag, All Cases Hours No. of Cases Average is Based On Wounding to Admission 6.88 73 Admission to Surgery 3.63 73 Wounding to Surgery 21*22 m To gain more accurate information regarding the time lag of battle casualties, these were selected and averages calculated. Eight battle casualties were omitted because of unuaual circumstances. For instance, one paratrooper was not rescued until 5 days after wounding. The other seven cases had the following wounding to admission times: 72, 72, 72, 90, 63, 64, 67 hours. TABLE IX Time Lag, Battle Casualties Field Hospital Evacuation Hospital Hours Cases Hours Oases Hounding to Admission 5* 79 IQi 10 Admission to Surgery 4* 81 9 10 Wounding to Surgery 9-3/4 597 jfej/A 161 ANESTHETIC AGENTS The anesthesia preferred by most anesthetists was nitrous oxide, oxygen, ether. T#hen this was not available drop ether with or without ethyl chloride for induction was used. As time went on ethyl chloride fell into disfavor. Shocked patients were given oxygen throughout the operation. Spinal anesthesia was used a few times early in the war but was soon discontinued. Pentothal was sometimes used for lesser ampu- tations. It was found to be a satisfactory agent* Endotracheal anes- thesia became increasingly popular as the war progressed. Local or nerve block anesthesia was not used. OPERATION TECHNIQUE Severely shocked patients were left on the litter for operation, not already going, blood or plasma was started intravenously. Anesthesia was started. When the extremity was still attached by a few shreds of 607 Amputations, (Operation Technique, contd). fascia or skin these were severed and the extremity removed. Frequently it was impossible to shave the posterior aspect of the stump prior to anesthesia. Usually a towel was placed around the extremity for padding and a -tourniquet applied. An ordinary blood pressure apparatus was found to be satisfactory for the upper extremity provided it was fixed in place with roller bandage, pumped up to 250 mm. and both tubes lead- ing from the cuff clamped. Some surgeons preferred to work without a tourniquet. Skin preparation consisted of soap and water followed by tincture of iodine or one of the mercurial antiseptics. The site for amputation was the lowest possible level of viability regardless of the utility of the stump, VIhen there was any question as to this level, serial circular incisions were made until a debridable level was reached. The ever-present plasma box was used under the sterile drapes to prop up the extremity. The flapless guillotine amputation was the standard procedure. The technique for the performance of amputations is as follows* A circular incision is made through the skin at the lowest level compatible with viable tissue and the skin allowed to retract; the fascia is then incised at the level to which the skin has retracted. The superficial layer of muscle is then cut at the end of the fascia and permitted to retract. At its point of retraction, the deep layers of muscle are cut through to the bone. After the deep muscles have retracted, the periosteum of the bone is cleanly incised and the bone sawed through flush with the muscles. No cuff of periosteum is removed as in a closed amputation. Bone denuded of periosteum will sequestrate if in- fection is present and a ring sequestrum often results when the perio- steum has been removed. It is important also that no periosteum be elevated or torn from the bone in the stump by rough handling. The properly performed flapless guillotine stump exhibits a slightly concave open cross section of the extremity. Lacerations of the stump were not sutured but pulled together and excessive gaping prevented during the application of the stockinette. Vaseline gauze strips were laid over the stump end and fluffed gauze applied. Toward the end of the hostilities in Europe vaseline gauze was more and acre replaced by dry fine mesh gauze. The skin edge and a bit of the fluffed gauze were grasped in four to six places with towel clamps. The stump was held up by these while the skin was dried with ether and "Ace Adherent" applied. The stockinette was then placed over the operator's hand and lay in a small roll around his wrist. He grasped the towel clamps with this hand. The stockinette was then 608 Amputations. (Operation Technique, contd). easily slid over the hand, towel clamps and dressing and rolled on to the stump. This method of applying the stockinette was more rapid and less apt to stir up ooze than if no towel clamps were used. A spreader was placed inside the stockinette. When there had been considerable blast injury to the stump, copious serous drainage occurred during the first two or three days. If this were anticipated, the application of a traction cast was delayed until it had subsided, the stump meanwhile being bandaged in a Thomas splint with elastic traction attached. Figure 9A - Diagram of a Traction Cast, 609 Amputations, THE TRACTION CAST It was early recognized that effective traction applied to a lower extremity stump by means of a Thomas splint was invariably un- comfortable and if used for more than a few days would result in a pressure sore over the ischial tuberosity. Padding failed to remedy the situation. Therefore, the traction cast came into general use and has proven satisfactory. The essential function of a traction cast was to allow an elastic cord or tube to produce adequate traction on the skin of a stump yet distribute the covin ter traction over such a large portion of the patient's anatomy that pressure sores would be avoided. One method used for constructing a traction cast was as follows* The portion of the cast about the stump was the same for all amputation sites. The skin was cleansed with ether and '‘Ace Adherent" painted on with cotton swabs. Sterile stockinette was immediately rolled onto the distal 12 inches of the stump or to the nearest joint, leaving enough hanging over the edge to cover the dressing and allow the fixation of an elastic cord. All wrinkles were smoothed out. Elastic bandage was wrapped snugly but not tightly over the stockinette. If this was used the stockinette never slipped. A single layer of muslin gave the st.ump dressing a smooth gliding surface. Over this were applied two or three layers of sheet wadding. Then the entire extremity was covered with another layer of stockinette. In the case of the simple cylindrical casts, which were used for amputations distal to the elbow or knee, the stockinette was the only padding used beneath the plaster proximal to the joints, since this was the area where the counter-traction was to be distributed. The elbow was placed at 90° flexion, the knee in full but not forced extension. Generous felt doughnuts were fashioned and taped to the stockinette over bony prominences, such as the head of the fibula. Plaster was applied to within about an inch of the stump end. After several layers of plaster, a wire 1 .dder splint, greased to prevent rusting, was bent into a "U" shape and the open ends incorporated anteriorly and posteriorly into the plaster. A splint placed in this manner supported the weight of the blankets better than one placed laterally. If the amputation were above the elbow or knee a spica was applied and the stump cuff incorporated into it. Shoulder spicas were more comfortable if extended over the iliac crests to prevent the lower edge digging into the ribs. A mass of sheet wadding was placed in the axilla. During the summer, foot powder was dusted into this sheet wadding to prevent maceration of the axillary skin and keep down fungus growths. Adequate breathing space was obtained by placing a folded 610 Amputations* (Traction Cast, contd). bath towel next to the skin over the anterior chest, then removing it after the plaster was hard. The opposite shoulder of the cast WdS cut away. Hip spicas extending only to the iliac crests and liberally cut away in front were adequate and allowed maximum freedom of move- ment* The skin of the stump with its attached stockinette would pull down easily in the finished cast due to the sliding motion allowed by the saooth muslin against the sheet wadding. Pressure sores were avoided because the counter traction was distributed over large areas of soft tissue in the simple cylindrical casts, to the pelvis in general with the hip spica, and to the entire lateral aspect of the chest wall with the shoulder spica. Postoperative Care. Even after the administration of 2,000 c.c, of whole blood to a mid-thigh amputation case, for example, the patient would often have a postoperative red cell count of less than 3,400,000. It was felt that the postoperative course was smoother if such a patient were given one or two additional transfusions in the first few days after operation. Efforts at complete restoration of normal blood values were limited by the fear of transfusion complications. When necessary, secondary dressings were done. Amputations carried out through markedly traumatized tissue could be expected to pour out a profuse serous drainage for two or three days, often saturating the dressing and soiling the bedding. When this had sub- sided the patient was given a light sodium pentothal anesthesia and the dressing changed. At this time any sloughs or devitalized tissue that had become apparent since the original operation were excised. If the stump appeared clean a traction east was applied at once. If not, application of the traction cast was delayed and the patient returned to bed. The Thomas splint could not be re-applied because few patients would tolerate it with the necessary traction. Continuous hot wet packs were maintained. Traction was preferably by means of a weight and pulley. Patients were held on average of 4«4 days before evacuation. In the early part of the mar one of the sulfa drugs was routinely given by mouth. In the summer of 1944, penicillin in doses of 20,000 - 25,000 units intramuscularly every three hours starting at admission became routine in all medical installations where surgical teams operated. 611 Amputations, TABLE X Postoperative Complications in Amputation Stumps Anaerobic Myositis Mo. Gases ’ 16 Abscess 4 Aerobic Cellulitis 2 Devitalized Stump 2 Hemorrhage (Profunda Femoria) 1 TOTAL 25 TABLE XI Causes of Early Re-amputation No. Cases Anaerobic Myositis ... U — Pyogenic Sepsis 1 Devitalized Stump 1 Protrusion of Bone 1 Not Recorded 1 TOTAL 17 . .. 612 Amputations. TABLE XII Causes of Death Lot Attributable to Other Injuries No • Cases Shock 30 Anaerobic Sepsis 16 Anuria 9 Embolism 4 Fat Embolism 2 Pulmonary Edema 5 Sudden Respiratory Death 1 Cardie-Vascular Accident 1 Tetanus (German POW) 1 Unknown 1 TOTAL 70 The cases of sudden respiratory death and the cardio-vascular accident were probably caused by emboli but were not proven as such. Pneumonia was remarkable for its absence among the causes of death in a series of 1,028 major amputation cases. The observed mortality rate for major annotations was 6,81%, Deaths definitely caused by other injuries were not included in this calculation. TABLE XIII Mortality in Single Amputations Having no Other Major Injury No. No. Percent Location Cases Deaths Mortality Left 359 2 0.55% Thifth 278 15 5.39% Fprearm 36 0 Arm no 2.12% TOTAL 783 20 613 Amputations, Those cases having intra-abdominal, intrathoracic, intra- cranial injuries or compound fractures of long bones were excluded from this calculation. The 15 deaths in the thigh amputations were from, the following causes: Shock 4 Anaerobic Sepsis 3 Fat Embolism £ Emboli 1 Blast Injury 1 Pulmonary Edema 1 Anuria 1 Cardio-Vascular Accident 1 Unknown 1 TOTAL 15 One of the deaths in leg amputations was caused by shock and the other by pulmonary edema. The three deaths in arm amputations were caused by tetanus, shock and anaerobic sepsis. POSTOPERATIVE INFECTIONS IN STUMPS Early infections in amputation stumps were not common, ’/hen they did occur they were most often the result of inadequate debride- ment, errors In judgment as to the viability of tissue, severance of the blood supply to the remains of a muscle at the time of amputation or inadequate blood replacement therapy. In the amputation of a badly mangled extremity at the lowest possible level the likelihood of errors in judgment as to the viability of tissue increased as the wounding to surgery time decreased, other factors being equal. Performing amputations at any level instead of the sites of election predisposed to the accidental interruption of blood supply to a portion of a muscle group retained in the stump. Instances where this was apt to occur were: (l) an amputation Immediately distal to the knee in which* the stump of the soleus was deprived of blood supply and (2) a high thigh amputation which deprived the origins of the adductor muscles of blood. Retained non-viablc tissue in a stump invariably led to infection which cleared up when the offending tissue was removed. Prior to penicillin 13 cases out of 741 amputations developed anaerobic myositis in the stumps postoperatively, an incidence of 1,1%, Of the 13 cases reported, nine occurred in Southern Italy and Sicily, Amputations. (Postoperative Infections in Stumps, contd). After the routine administration of penicillin was instituted three cases out of a total of 617 amputations were reported, an incidence of 0.4There were only two amputations for anaerobic cellulitis re- ported, One of those was done before and one after penicillin. The fact that surgical judgment in the management of war amputations im- proved as time went on cast a cloud over the exact role played by the new drug in the prevention of anaerobic sepsis in stumps. The occurrence of abdominal distention and hiccoughs was noted several times in high thigh amputations. No cause was ascertained, it Levine tube was used for its relief. In the cases reported it sub- sided spontaneously. Figure 95 - Quarterly Incidence of Amputations for Anaerobic Sepsis, 615 Amputations. AMPUTATIONS SECONDARY TO INFECTIONS Only one amputation was performed for infection other than clostridial. One hundred and eight amputations were recorded as having been done for anaerobic infection. However, it is interesting to note that all but 11 of these had interruption of the principal blood supply to the infected part. The average time from wounding to initial operation was 28.5 hours. Sixty-seven were amputated at the first operation. Forty-seven were debrided and required later amputation. The average time interval between the two operations was 3.34 days. It was noted that anaerobic infections resulting in amputation usually had interruption of the principal blood supply to the part. The systemic administration of penicillin could hardly be expected to prevent the development of gas infection when little blood was reaching the site of injury. AMPUTATIONS SECONDARY TO VASCULAR INSUFFICIENCY A total of 152 amputations were performed because the extremity was rendered non-viable by vascular injury. Of these, 76 had small wounds only and 76 had severe wounds in addition to the vascular in- terruption. The specific arterial injuries resulting in amputations were as follows: TABLE XIV Arterial Injuries Resulting in Amputation No. Csses Popliteal 35 Femoral 20 Anterior and Posterior Tibial 9 Axillary Brachial 8 TOTAL ~W~ Of these 76 cases 46 were amputated at the first operation, the extremity being obviously already dead. 616 Amputations, (Amputations Secondary to Vascular Insufficiency, contd). The remaining 30 cases came to operation too early for the appearance of rigor mortis or having a little collateral circulation present. The policy in these was to delay amputation and attempt to restore circulation by removal of thrombij suture of arterial lacer- ations, sympathetic blocks, sympathectomy, fasciotomy and transfusions. It has been repeatedly observed that an extremity which was slowly dying from inadequate blood supply was a potent source of danger, With or without the oneet of clinically demonstrable anaerobic in- fection the patient sometimes began to exhibit symptoms of a profound toxemia. He became listless, or even irrational. The pulse rate would go up to 120/160 and the temperature to 102° - 104°. These symptoms could be relieved at once by amputation. Dissection of the extremity would demonstrate thrombosed vessels, muscles with minimal changes in color and consistency, and often nothing else. The discovery of gas or a pyogenic infection would afford obvious cause for the toxemia,. The onset of anaerobic sepsis in these extremities was common. It occurred even in extremities with no other injury than a small one severing the blood supply. For example, one patient with ligation of the femoral artery proximal to the origin of the profunda femoris had no wounds in the distal third of the thigh, in the calf, or in the foot. Three days after injury the entire calf, including muscles and fascia were spongy with gas. These observations have served to emphasize the necessity for constant vigil in cases with extremities of questionable viability. Determination of the viability of an extremity has not always been easy. The blanching test was not accurate. If color returned to an area following pressure with one’s thumb it simply meant that blood was present in the extremity. Vihen rigor mortis has been present the extremity has invariably come to amputation even when the circulation has been restored, The safest rule for selecting the time of amputation has been to await the appearance of a definite rigor mortis. Nothing has been gained by waiting for dry gangrene in battle casualties. Too often severe sepsi has intervened necessitating amputation at a higher level than would have originally been necessary. As has been pointed out, penicillin has prove no safeguard against this tragedy. The site of amputation selected has been the lowest level at which a viable stump could be obtained. In determination of this level it was deemed necessary that all muscles left in the stump bleed when visible vessels in the muscle belly were cut, Either contractility or normalcy in color and consistency were considered essential, kuscles which appea: normal and would bleed but would not contract were considered to be temporarily paralyzed by the blast effect of the injury. They have been left in stumps and have survived. 617 Amputations. MANAGEMENT OF AMPUTATIONS IN CON JUNCTION V.TITH CTHJE V/CUNDS Patients having a colostomy and thigh amputation have presented a problem. The traction epica was unsatisfactory because of soiling from the colostomy. Resumption of the use of the Thomas splint was necessary. To avoid pressure sores over the ischial tuberosity the traction was maintained by means of a pulley and a weight hung over the end of the bed until just before evacuation when it was exchanged for an elastic cord fixed to the Thomas splint. Cases with combinations of an intrathoracic wound and an arm amputation were managed by means of a simple pulley and weight arrange- ment for traction until ready for evacuation. By this time the daily chest aspirations were no longer necessary and a shoulder spica could be applied. In chest cases particular care was exercised to make the spica roomy. No trouble from interference with respiration was en- countered. The most comfortable shoulder spicas were applied with the patient awaks and sitting up. If this was not possible the patient was laid on an ordnance-made canvas strip with ratchet arrangement for drawing it taut. A Thomas arm splint extending over the edge of the table was used when nothing else was available, the patient's head resting in the padded ring. Casts applied by the third method did not fit as well as the others but were satisfactory. PSYCHOLOGICAL CONDITIONING Prior to the operation the patient seldom inquired about use of prosthetic appliances end this problem was not discussed with the patient. He was usually too apathetic to worry over such matters. He was often in shock, had had considerable morphine or both. If a dead extremity were in place, the patient was informed of the nature of the impending operation. Often he showed little or no interest in this information. The emotionally unstable patient was especially apt to be heavily narcotized, Vfhen he was not, the information was withheld until shortly before the anesthetic so as to lessen the time available for brooding. If £ patient displayed enough interest to inquire why an amputation was necessary, the reasons were explained to him and the extremity demonstrated, to his satisfaction, to be already dead. Regardless of what had been told him preoperatively, the patient was often not aware of the nature of his injury when he recovered from the anesthetic. After being informed of his loss he might ask questions. These were answered definitely - if such was possible - and honestly. Amputations, (Psychological Conditioning, contd), High on the priority list of questions was the one as to when he would get back to the Waited States. This could be answered only by stating that everything possible would be done to speed his return. No estimate of time could be given. The story of a friend or acquaintance with an injury similar to his own was often related - how he was happily married, made a comfortable living, etc. The patient was reminded that the urge to overcome physical disability has often provided the incentive that has resulted in men getting much more out of life than the average. Magazines carrying popular articles about the present status of arti- ficial limbs were helpful, especially since the average soldier’s mental picture of an artificial limb was derived from the common peg leg. SUMMARY 1. The 1131 major amputations performed by surgical teams of the 2nd Auxiliary Surgical Group formed the basis of this report. 2, Most of the cases were done under field conditions, usually in a platoon of a Field Hospital functioning as a first priority surgical hospital. 3. Amputations caused by different agents were sufficiently different in appearance to warrant separate descriptions. Thus, the amputations caused by land mines were characterized by burning of the tissues and stripping of the soft tissues from the bone. A. Fifty-nine disarticulations were performed. Generally, they were unsatisfactory. 3. The treatment received prior to admission to a surgical in- stallation consisted of pressure dressings, tourniquets, morphine, splints, plasma, and sometimes whole blood. The web cloth tourniquets did not completely control hemorrhage. At the same time, they never caused necrosis. 6, Since shock therapy played such an important role in the early treatment, considerable space 'was given to this phase. The average admission blood pressure was 8l/45. Forty-one patients with amputations and no other major injuries were admitted with no obtainable blood pressure or pulse. All but seven of these survived to be evacuated. This was made possible by an efficient blood bank system. 619 Amputations. (Summary, contd). 7. The fluctuations of blood pressure that occurred during the early treatment were enumerated, A foreknowledge of these proved to be of great value. S, The operative technique used was the flapless guillotine amputation. Often this was little more than a debridement of the already existing traumatic amputation. Several points in the mechanics of the operation were mentioned. 9. H detailed description of the traction cast was presented, minor points in the construction of the cast varied from team to team. For the sake of clarity and brevity only one method of construction was outlined. 10. The mortality was calculated in two different ways. The over- all mortality, excluding deaths definitely caused by injuries other than the amputation, was 6*81$, For those cases having a single major ampu- tation and no intracranial, intra-abdominal, intrathoracic injury or compound fracture of a long bone, the mortality rate was 2,55%, 11. Serious postoperative infections in stumps were rare. VJhen they did occur they were almost always the result of dead or foreign material retained in the stump. In view of the fact that the surgeons became more adept in removing these causative factors as time went on, no specific evaluation could be made of the role played by chemotherapy. 12. One hundred and eight amputations were recorded as having been done for anaerobic infection. All but 11 of these had interruption of the principal blood supply to the part. 13. One hundred and fifty-two amputations were done for vascular insufficiency. It was noted that, when dealing with battle casualties, a dead or dying extremity was a potent source of danger. The optimum time for amputation was when rigor mortis became definitely demarcated. 14, The psychological aspect of the early treatment of amputation cases was discussed. It was found that many soldiers thought of an artificial limb in terms of the familiar peg leg. By maintaining their confidence, this and other unnecessary apprehensions could be corrected. COMPOUND FRACTURES 621 CQulPOUND FRACTURES The following is a report of the study of compound fractures based on the operative records of the surgical teams of the 2nd Auxiliary Surgical Group, The period covered was that between 8 November 1942 and 8 iiuay 1945, The operations, with very few exceptions were performed in first priority hospital installations. The records studied were those of the orthopedic surgical, general surgical and thoracic surgical teams. All compound fractures were reviewed except those of the ribs, sternum, scapula, patella, skull and face. It was felt that these'were adequately covered in the reports of the various specialty teams. Included in this report are soldiers and civilians whose fractures were incurred in battle or by accidental injury. A total of 5438 compound fractures were reviewed. Of these 3354 were compound fractures of the long bones and 2084 were of other bones. In this report, the term "long bones” refers to femur, httoerus, radius ulna, tibia and fibula only. It is felt that this study could best be reviewed by presenting it in statistical form and the first section was written with tnis in mind. In addition there are sections on "Surgical kanagementwand "Causes of Death", The 3354 compound fractures of long bones were incurred by 2416 in- dividuals* These fractures are reviewed in detail in this report. All other compound fractures treated by this group were tabulated but the number of individuals which they occurred in wore not recorded. It will also be noted that multiple compound fractures of tne carpus, meta- carpus, tarsus, metatarsus and phalanges were considered in each in- stance as single fractures of the part. Thus, if four metacarpals were fractured it was considered as a single fracture of the metacarpus. An uncomplicated compound fracture, in this report, is one without major blood vessel involvement and no other major associated injury. Anaerobic infection, if present on admission, was considered as causing it to be a complicated fracture, A fractured bone with an involvement of an adjacent Joint was considered as uncomplicated, the Joint injury being part of the fracture process. If amputation was performed at the initial operation the compound fracture is not- included in this series. Cases receiving secondary am- putation are included. 622 Compound Fractures, (cent* d). PART I STATISTICAL STUDY TABLE I Number of Compound Fractures Long bones 3354 Other bones 2084 TOTAL 5438 TABLE II Compound Fractures of Long Bones No* of Fractures Percent of all Comp* Fradures Percent of ail Comp, Fractures of Long Bonos Femur 701 12.9$ 20.9$ Humerus 590 10.8$ 17.6$ Tibia 779 14,3$ 23.2$ Fibula 556 10.8$ 16.5$ Radius 335 6.2$ 9.9$ Ulna 393 7.2$ 11.7$ TOTAL 3354 61.6$ 99. 8$ TABLE III Compound Fractures of Other Bones No. of Fractures Percent of all Compound Fractures Spine 284 5,2% PeIvis 385 7,1% Clavicle 65 1,2% Carpus 77 1*4% Metacarpus 267 4. 9% Phalanges (Hand) 255 4,7* Tarsus 273 5.0:i Metatarsus 292 " 5.4 /5 Phalanges (Foot) 93 l.~7^~ Patella 93 1,7% TOTAL 2084 38. Z%> 623 Compound Fractures (cont'd). FEMUR 1. All Compound Fractures Number of fractures*.. 701 Percent of ail compound fractures,. 12.9% Percent of compound fractures of long bones <£0,2% Number of patients (Femur only or primary 668 Number of deaths * 61 Percent mortality* 9,1/5 2, Uncomplicated Fractures Number of fractures 401 Percent of all compound fractures of femur, 67,4% Percent of compound fractures of long bones,*. 11,9/5 Number of patients, 401 Number of deaths 4 Percent mortality 1,0% 3, Complicated Fractures Number of fractures 300 Percent of all compound fractures of femur.,..,,,,, 42,7% Percent of all compound fractures of long bones,,,, 8,2% Number of patients (Femur only or primary fractur e) 267 Number of deaths,,...• ,., 57 Percent mortality 21.3% 4. Statistics on all Compound Fractures of Femurs a. Fracture site Number of each Upper third 183 Middle third 114 Lower third 282 Not recorded 122 b. Bilateral fractures - 14 patients, c. Fractures of femur associated with other more severe fractures - 19. d. Joint involvement. Knee in 139 fractures. Eip in 17 fractures. Compound Fractures, (Femur, cont’d). e. Associated with fractures of other long hones. Tibia.. 42 Fractures Fibula.. 11 Fractures Tibia and Fibula.••.... 38 Fractures Humerus •••.. 30 Fractures Radius and/or ulna 31 Fractures f. Associated with vascular injury*. Femoral artery (Part net stated)....... 20 Fractures Femoral vein*.••«••••.••••••••••••••••• 20 Fractures Popliteal artery 15 Fractures Popliteal vein..... 15 Fractures Profunda femoris artery ••••••••••• 11 Fractures Profunda femoris vein, 2 Fractures g. Associated with Nerve Injuries. Sciatic nerve.••••••••• •••••••• 20 Fractures Peroneal nerve ••••• •••• 11 Fractures Tibia! nerve........................... 2 Fractures h. Associated witn other Injuries. Penetrating wound of abdomen ••••..102 Fractures Penetrating wound of chest., 41 Fractures Thoraco-abdominai wound 18 Fractures Traumatic amputation 37 Fractures i. Complications**. Anaerobic infection present on admiss- ion 12 Fractures Anaerobic infection developed after ad- mission. .... •••••• 16 Fractures Gangrene due to avascularity. 6 Fractures j. Anesthetic agents used. No. of Patients Fther 338 Pentothal ••••••••••• 97 Gas-oxygen-ether 196 Pentothal-ether... 5 Spinal ••••••• 21 Local.•••... ••••••••••••• 2 No record..,,,,,,, 7 TOTAL 668 ♦Refer to Section on vascular injuries, page ?l£ to 7Uf> **Sefer to section on “Anaerobic Infection*page ylt6 to ?£? 625 Compound Fractures, (Femur, cant'd). k. Deaths. No. of Patients Shock 17 Pulmonary embolism. 9 Anaerobic infect ion.. 8 Anuria 6 Peritonitis*....,............... 2 Pulmonary edema,, 2 Pneumonia. 1 Biast-lung. 1 Aspiration asphyxia............. 1 TOTAL 61 5. Statistics on Uncomplicated Compound Fractures of Femur. a. Fracture site No. of Patients Upper third..• 100 Middlo third. 87 Lower third........ 142 Unclassified 72 TOTAL 401 b. Time Lag. No. of Patients 0-8 hours....••••••••••••••••••• 103 8-16 hours.....•••••............ 100 16-24 hour 53 Over 24 hours................... 81 Not stated. 64 TOTAL 401 c. Shock. No. of Patients Systolic blood pressure over 100mm....................... 135 Systolic blood pressure 71-100 mm 74 Systoxic blood pressure 41-70 mm.•••..••••••••«••.•«• 17 Systolic blood pressure 0-40 mm 5 Unclassified....... •••••••• 170 TOTAL 401 626 Compound Fractures, (Femur, coat’d). d. Resuscitation. No. of Patients Received treatment...,.,.,....,.,, it05 No treatment necessary,.,, 60 No treatment recorded 136 TOTAL 401 e. Anesthetic agents used. No. of Patients Ether,,,..,.,. 192 Pentothai. 100 Gas-oxygen-ether . , , 75 Pentothai-ether ......... 2 Spinal...... 28 Not recorded 4 TOTAL 401 f. Anaerobic infection. No, of Patients Developed after admission •••• 2 (Amputation not necessary; botn survived. ) g. No. of Patients Deaths*••••••••••••••••••••••••••• 4 Shock. 3 Pulmonary embolism.1 HUMERUS 1. All Compound Fractures. Number of fractures •••••••••• 590 Percent of aix compound fractures 10.8$ Percent of compound fractures of long bones.. 17.6$ Number of patients (Humerus only or primary fracture) •••••••• 545 Number of deaths 37 Percent mortality 6,8$ *See page 6U9 627 Compound Fractures. (Humerus, cont'd). 2, Uncomplicated Fractures. Number of fractures. 281 Percent of all compound fractures of humerus 47,5% Percent of compound fractures of long bones. . 8.4% Number of patients....................... 281 Number of deatns 0 Percent mortality 0 3, Complicated Fractures. Number of fractures. 309 Percent of aii compouno fractures of humerus 52.4% Percent of compound fractures of long bone 9.1% Number of patients (Humerus only or primary fracture) ••••• 264 Number of deaths ••...••. . 37 Percent mortality........ 14.0% 4, Statistics of all Compound Fractures of Humerus. a. Fracture Sj-fce No. of Each Upper third. ••••• 185 Middle third.• 83 Lower third 204 Not recorded.118 b. No. of Patients Bilateral fractures ......*•• 8 o* No. of Patients Fractures of humerus associated with other more severe fractures....... 37 d. Joint involvement. Elbow in 88 fractures. Shoulder in 51 fractures. e. Associated with fractures of other long bones, Radius 25 fractures. Ulna 31 fractures, Radius and ulna 42 fractures Femur 30 fractures. 628 Compound Fractures, (Humerus, contTd), f. Associated with vascular injury. Brachial artery. 29 Fractures. Bracnial vein 3 Fractures. Axillary artery 3 Fractures, Radial artery,,,,,,,,,, 4 Fractures. Anterior humeral circumflex artery,,,,, 3 Fractures. g. Associated with nerve injury. Radial nerve.. 73 Fractures. Ulnar nerve.. 48 Fractures. Median nerve.... 25 Fractures. Brachial plexus 3 Fractures. h. Associated with onner injuries. Penetrating wound of abdomen,,,,....,.. 66 Fractures, Penetrating wound of chest., 54 Fractures. Thoraco-abdominal wound, 25 Fractures. Traumatic amputation..................• 10 Fractures. i. Complications*. Anaerobic infection developed after admission.,................••••••••• 8 Fractures. Gangrene due to avascuiarity,.......... 7 Fractures. j. Anesthetic agent used. No. of Patients. Ether 187 Pento thal •••.•••....201 Gas-oxygen-ether 138 Pentothal-ether 7 Local. 7 Not recorded 5 TOTAL 545 ♦Refer to Section on "Anaerobic Infections", page to 7^7 629 Compound Fractures, (Humerus, cont’d). k, Deaths. No. of Patients Shock •••••••••• 16 Anuria. 3 Anaerobic infection.. 3 Peritonitis 3 Pneumonia.. 3 Pulmonary embolism 3 Brain damage ••••• 3 Blast-lung. 1 Pulmonary edema. 1 Aspiration asphyxia 1 TOTAL 37 5. Statistics on Uncomplicated Fractures of Humerus. a. Fracture site No. of Patients Upper third.... 105 Middle third 41 Lower third. 89 Unclassified • 46 TOTAL 281 b. Time lag. No. of Patients 0-8 hours ••••• 75 8-16 hours...... 97 16-24 hours. 41 Over 24 hours. ••••••••••••••••••• 42 Not stated.•••.•••••••• ••••••••• 30 TOTAL 281 c. Shock. *. 3,4 % Number of patients. 58 Number of deatns 0 Percent mortality 0 3. Complicated Combined Fractures. Numbers of combined fractures ...164 Percent of all combined compound frac- tures of radius and ulna......••.•••••• 64.2$ Number of bones fractured, .208 Percent of compound fractures of long bones. ... ... 6.2$ Number of patients (radius and uj.ua only or primary fracture).,.45 Number of deaths...... 7 Percent mortality. 15,5> Compound Fractures, (Radius and Ulna, oont’d). 4. Statistics on all Combined Compound Fractures of the Radius and Ulna, a. Bilateral fractures (radius and ulna on each side) None. b. Combined fractures of radius and ulna associated with other more severe fractures. 59 c. Joint involvement, Elbow in 30 fractures. Wrist in 7 fractures. d. Associated with vascular injury. Radial vessies.. 8 Fractures. Dinar vessels,.... 5 Fractures. e. Associated with nerve injury. Ulnar nerve •••••14 Fractures. Median nerve, .15 Fractures. Other nerves.... 5 Fractures. TIBIA 1* All Compound Fractures (Except those In combinations of tibia and fibula). Number of fractures••.....••• •••395 Percent of all compound fractures,,.. 1.2,% Percent of compound fractures of long bones ,,,,,11,4$ Number of patients (tibia only or pri- mary fracture) ,309 Number of deaths,, 10 Percent mortality,,, 3.2/£ 635 Compound Fractures, (Tibia, cont’d). 2. Uncomplicated Fractures* Number of fractures, ............ 193 Percent of all compound fractures of tibia,.. 47,7/S Percent of compound fractures of long bones.. 5.7/fc Number of patients, 195 Number of deaths 0 Percent mortality 0 3. Complicated Fractures. Number of fractures 200 Percent of all compound fractures of tibia.,, 52,Z% Percent of compound fractures of long bones,, 5,9/i Number of patients (tibia only or primary fracture) ...•• ••••• .116 Number of deaths. •••••••••••••••••••••• 10 Percent mortality 8,6% 4. Statistics on all Compound Fractures of Tibia. a. Bilateral fractures (tibia only on each side) •••.•• ••••••••.••••• 6 b. Fracture of tibia associated with other more severe fractures 78 5. Statistics on Uncomplicated Compound Fractures of the Tibia. a. Time Lag No. of Patients 0-8 hours 57 8-16 hours*. 59 16-24 hours. •••••••• •••••••• 29 Over 24 hours.. 26 Not stated.•••«.•.••.••••••••••••••••..•• 22 TOTAL 193 b. Shock No, of Patients Systolic blood pressure over 100 mm...... 92 Systolic blood pressure 71-100 mm... 4 Systolic blood pressure 41-70 mm,... 4 Systolic blood pressure 0-40 mm 0 Unclassified.93 TOTAL 193 636 Compound Fractures, Tibia, cont'd). c. Resuscitation. No. of Patients Received treatment. 46 No treatment necessary 61 No treatment recorded.... 86 TOTAL 193 d. Anesthetic agents used. No. of Patients Etner 47 Pentothal 115 Gras-oxygen-ether 12 Pentothal-ether..................... 3 Endotracheal 2 Sp inai 10 Local. 3 Not recorded. 1 TOTAL 193 e« Joint involvement. Knee in 14 patients. Ankle in 8 patients. Anaerobic infection developed after admission 1 patient g« Deaths .None FIBULA 1, All Compound Fractures (except tnose in combinations of tibia ~and fibula). Numoer' of patients. 170 Percent of all compound fractures 3.1% Percent of ail compound fractures of long bones.. 5.1% Number of patients (fubula only or pri- mary fracture) ••••••137 Number of deaths 4 Percent mortality... 2,9% 637 Compound Fractures,(Fibula, cont'd). 2, Uncc«npHeated Fractures* Number of fractures 78 Percent of all compound fractures of fibula,, 46,0% Percent of compound fractures of long bones,, 2,3% Number of patients 78 Number of deaths,....... 0 Percent mortality 0 3, Complicated Fractures. Number of fractures. 92 Percent of all compound fractures of fibula.. 54,0% Percent of compound fractures of long bones.. 2,4% Numoer of patients (fiouia only or primary fracture). ..*• ....,••••••.••• 59 Number of deaths., 4 Percent mortality 6.8% 4, Statistics on ail Compound Fractures of Fibula. a. Bilateral fractures (fibula only on each side),.. ••••...•••. 4 b. Fracture of fibula associated with other more severe fractures,.......... 29 5, Statistics on Uncomplicated Compound Fractures of the Fibula. a. Time Lag. No. of Patients 0-8 hours...•••••••••••••••••••.•••• 23 6-16 hours....••••••••••••••••••••••••••• 24 16-24 hours ••••• ••••••••• 9 Over 24 hours. •••••••••• 15 Not stated. 7 TOTAL 78 b. Shook. No. of Patients Systolic blood pressure over 100 mm 31 Systolic blood pressure 71-100 mm... 5 Systolic blood pressure 41-70 mm,... 2 Systolic blood pressure 0-40 mm 1 Unclassified.... 39 638 Compound Fractures, (Fibula, cont’d). c. Resuscitation. No. of Patients Received treatment 21 No treatment necessary*.... 24 No treatment recorded... 33 TOTAL 78 d. Anestnetio agents used. No. or Patients Ether. 17 Pentothal. 54 Gas-oxygen-ether 3 Pentnthai-ether 1 Spinal 1 Local. 2 TOTAL 78 e. Joint involvement. Knee in 1 patient. Ankle in 5 Patients. f. Anaerobic infection ••••.... None. g. Deatns.. None. TIBIA AND FIBULA 1, All Compound Fractures (Combined tibia ana fibula). Number of combined fractures. 386 Number of bones fractured........... 772 Percent of all compound fractures 14,0% Percent of compound fractures of long bones 11,5% Number of patients (Tibia and fibula only or primary fracture),., ••••••••••• 329 Number of deatns 21 Percent mortality, 6,4% 639 Compound Fractures, (Tibia and fibula, oont’d). 2, Uncomplicated Combined Fractures. Number of combined fractures.,..,, 164 Percent of ail combined compound fractures of tibia and fibuia, 40,2/o Number of bones fracturtd 503 Percent of compound fractures of long bones... 9,2$ Number or patients 154 Number of deaths 0 Percent mortality,.,, 0 3, Complicated Compound Fractures. Numoer of combined fractures.................. 232 Percent of ail combined compound fractures of tibia and fibula...... 59.3$ Number of bones fractured....................• 464 Percent of compound fractures of long bones.,, 13.6$ Number of patients (tibia and fibuia only or primary fractur'd) 175 Number of deatns, 21 Percent mortality 12.0$ 4, Statistics on ail Combined Compound Fractures of Tibia and Fibula. a. Bilateral fractures (tibia and fibula on eacn side).... 19 b. Combined fractures of tibia and fibuia assocated witn otner more severe fractur •••• 33 5, Statistics on Uncomplicated Combined Fractures of Tibia and Fibula. a. Time Lag, No. of Patients 0-8 hours57 8-16 hours... 33 16-24 hours 14 Over hours. ••••••. 21 Not stated 29 TOTAL 154 Comoound Fractures, (Tibia ana *xbuia, cont’d). b. Shock. No. ol' Patients Systolic blood pressure over 100 mn 67 Systolic blood pressure 71-100 mm,. 14 Systolic blood pressure 41-70 mm... 2 Systolic blood pressure 0-40 mm,,,, 4 Unclassii’ied. 67 TOTAL 154 c. Resusc.te.tion, No, or Patients Received treatment,,,,,,,,.,,,,,.,.,,.,, 57 No treatment necessary. 46 No treatment recorded,, 51 TOTAL 154 d. Anesthetic agents used. No. or Patients Ether • 60 Pentothal64 Gas-oxygen-ether, 18 Pentothal-ether 2 Endotracheal.... 2 Spinal 6 Local. 2 TOTAL 154 e. Joint involvement. Knee in 4 patients. Ankle in 9 patients. f. Anaerobic infection developed after admission - None, g. Deaths - None. 641 Compound Fractures, (cont'd). Bone Percentage Wo, of of ail Compound Compound Fractures Fractures Percentage of ail Compound Fractures of Long Bones Wo, of Patients Deaths Percentage of mortality Femur 701 12.9% 20,9% 668 61 9.1# Tibia 393 7,2% 11.4/0 309 10 3.2# Fibula 170 3.1# 5.1# 137 4 2.9# Combined Tibia and fibula 772 fract- ures (386 comb.) 14,0# 23,0# 329 21 6.4# Humerus 590 10,3$ 17,6# 545 37 6,8# Radius 173 3.2# * 5,2/b 142 6 4,2# Ulna 231 4,2% 6.9# 183 6 5,3# Combined radius and ulna 324 fract- ures (162 comb.) 5,8# 9.6# 103 7 00 • CO TOTAL 3354 99,7# 2416 152 6,3# All Compound Fractures of Bong Bones Table iv 6U2 Compound Fractures, (cont'd). No. of Uncomplicated Compound Fractures Percentage of ail Compound Fractures of Soecific Bones Percentage of ail Compound Fractures of Long Bones No. of Patients Deaths Percentage of Mortality 401 57.4$ 11.9$ 401 4 1.0$ T-i'K-;* 193 47.7$ 5.7$ 193 0 0$ 78 46.0$ . 2.3$ 78 0 0$ Combined "tibia. and fibula 308 fractures (154 combined) 40.2$ 18..4$ 154 0 0$ 281 47.6$ 8.4$ 281 0 0$ 78 45.1$ 2.3$ 78 0 0$ in? 48.3$ 3.1$ _____ 107 0 0$ u 0.110. • - — Combined radius and ulna 116 fractures ( 58 combined) 35.8$ S«8$ 58 0 0$ TOTAL 1562 58.9$ 1550 4 0.3$ Uncomplicated Compound Fractures of Long Bones TABLE V 61*3 Compound Fractures, (cont’d). Bone No, of Complicated Compound Fractures Percentage of all Compound Fractures of Specific Bone Percentage of ail Compound Fractures of Long Bones No. of Patients Deaths Percentage of Mortality Femur 300 42,7$ 8.2$ 267 57 21.3$ Tibia 200 52.3$ 5.9$ 116 10 8.6$ Fibula 92 54.0$ 2.4$ 59 4 6.8$ Combined tibia and fibula 464 fractures (232 combined) 59.8$ 27.2$ 175 21 12.0$ Humerus 309 52.4$ 9.1$ 264 37 14,0$ Radius 95 54.9$ 2.8$ 64 6 9.4$ Ulna 124 53.7$ 3.6$ 76 6 7.9$ Combined radius and ulna 208 fractures (104 combined) 64.2$ 12.4$ 45 7 15.5$ TOTAL 1792 71.6$ 1066 148 13,9$ Complicated Compound Fractures of Long Bones TABLti VI 6UU COMPOUND FRACTURES PART II SURGICAL MANAGEMENT OF COMPOUND FRACTURES Patients with compound fractures, the results of battle and acci- dental wounds, represent long term problems in treatment to the Army- Medical Department, Tnis is particularly true of fractures of the major long bones, Tne management of these patients is spread over all ecneions ana zones and the care of each patient is divifed among numer- ous hospitals and is carried out by many different medical officers. To obviate, in so far as possible, tne dangers inherent in sucn a sit- uation the treatment of these patients has been divided into four per- iods eacn of whicn is carefully limited in scope and purpose. These periods are: ij First-aid splinting in the field and subsequent care through the various divisional medical installations. 2) Surgical de- bridement and transportation splinting in a mobile hospital (Field or Evacuation), 3) Final correction of deformity and attainment of wound healing in a fixed hospital. 4) Reconstructive surgery in hospitals of the Zone of Interior, All but a few of the patients handled by teams of this Group wore in Evacuation or Field Hospitals. Therefore this report deals only with patients in the second phase of their treatment when tney are re- ceiving their initial surgery and being prepared for evacuation to a fixed hospital. Initial surgery and handling of tnese patients became highly stand- ardized as experience was gained, Witn a few exceptions the surgeons of this Group adhered closely to a course of procedure outlined by the Theater Surgeon, Tnis procedure was altered from time to time to in- clude new developments and the lessons learned from increased exper- iences. The fundamental surgical principles remained uncnanged, how- ever. Most patients when received at mobile hospitals were well splinted and had received plasma, as indicated. Many patients were ready for surgery without additional preoperative treatment. Others had addi- tional and more serious concomitant wounds and required special atten- tion depending upon the nature of their other wounds. Still others were in verying degrees of shock from the fracture wounds. Some of these had multiple fractures, most had severe v/ounds, and many had as- sociated vascular injury with hemorrhage. In these the shock from whatever cause had to b© treated before surgery could be started. PREOPERATIVE CARE Patients received tetanus toxoid routinely, usually before reach- ing the hospital. Upon admission and every three hours thereafter all patients received 20,000 to 25,000 units of penicillin (this latter routine was begun in June 1944), 61*5 Part II, Compound Fractures, (Preoperativ© Care, cont'd). During the first examination, splints were inspected for possible embarrassment to circulation and tourniquets were removed or loosened while keeping tne patient under close observation. In most cases the problem of tourniquets had been handled well. Resuscitation consisted of tne liberal use of plasma, whole blood and crystalloid solutions. In most instances patients were quickly stabilized, especially if the snock was primarily due to hemorrhage and this was controlled. There was one group of patients which was found to be difficult or impossible to stabilize adequately. These patients usually had severe and extensive damage to bone and soft tissue of the thigh or leg. In spite of large amounts of blood and plasma it was often impossible to obtain a pulse rate under 140 per minute or to raise the blood pressure to 100 mm, Hg, In others shock would rapidly recur if therapy were not continued vigorously. As experience was gained it was learned that in these types of cases early surgery with continued active shock treatment was imperative and that as soon as operation was completed the patient improved rapidly. Thereafter, these patients were given high priority. Hoentgen-ray examination is essential and was carried out in al- most ail cases. Whenever possible the more severely wounded patients were roentgen-rayed on their way to surgery in order to obviate addi- tional moving. Aside from visualization of xne fracture, roentgen-ray examination is necessary for the localization of opaque foreign bodies and there should always be two different views of the part in question. Fluoroscopy was used occasionally in rush periods# OPERATIVE PROCEDURES As much of the preparation of the operative area ars possible was done before the induction of anesthesia. That which required painful movement was delayed until after induction. It was customary to shave a large area of the affected part and to include the entire circumfer- ence. The skin was washed with white soap and water. The wound itself was not prepared except to remove goss dirt and foreign materials at times or to flush obviously dirty wounds with saline or water. Most surgeons used an antiseptic solution on the surrounding skin before draping. Actual surgery befcan with enlargement of the wounds by incision in the long axis of the part. Very few of the original wounds were large enough without additional incision. The incision was contin- ued through fascia and this layer was often split far up and down under intact skin. As experience increased the incisions of the wounds be- came larger. At first skin wounds were circumcised but later only de- vitalized skin was excised. All devitalized tissue, particularly mus- cle, was excised to normal areas. This was done even if it required 6k6 Part II, Compound Fractures, (Operative Procedures, cant'd). removal of an entire muscle or group of muscles, A serious attempt was made to find and remove all foreign materials. Counterincisions were used frequently for the removal of foreign bodies. Loose bone fragments were removed. Counterincisions were also used to obtain dependent drain- age in all areas where it was necessary. This latter procedure is ne- cessary in almost all thigh and calf wounds with fractures in whicn the original wounds are anteriorly placed. In femur fractures stress was placed upon postero-lateral drainage proximal to the fractures, and incisions were made through the fibrous attachments to the linea aspera of the femur. Many surgeons flushed fracture wounds with sterile water or saline to remove additonal dirt and loose tissue fragments after surgery was completed. This was not always possible. Sulphanilamide was dusted into all wounds prior to the routine use of penicillin intramuscularly. After the advent of penicillin most sur- geons continued to use local sulphanilamide but others discontinued it entirely. There were no obvious differences in the wounds treated by the two methods. At first all wounds had strips of vaseline gauze placed into xheir depths. In many cases this amounted to packing which was not desired. Later, either vaseline gauze or plain fine mesh gauze was used to sep- arate the akin and fascial edges. Immobilization was almost invariably attained by plaster splints or casts. It must be remembered that the splinting was for transportaion only. It wen not intended for anatomic reduction or fixation for a pro- longed time. It was this limitation of scope and purpose wnicn made standardization possible and the use of plaster casts routine. In add- ition to the ordinary principle in the use of plaster casts there are two which were found to be essential in war surgery. They arei l) Ade- quate padding of all casts, and, 2), splitting or bivalving of all casts througn alx layers to tne skin. Very few exceptions were made to these requirements in this series of cases. Special types of casts will be discussed below. Femur, The most popular cast for fractures of the femur was the "one and one-half" plaster spica with a low waist whicn did not encroach upon the costal cage. It extended to just above the knee on the good side. The knee on the affected side was slightly flexed and the thighs placed in only slight abduction. Greater abduction interfered witn handling during transportation. A variation of tnis method used by some surgeons was the single plaster spica extending well up onto the costal cage to obtain immobili- zation. The objections to this cast are the restricted waist motion and discomfort over the lower ribs. 6h7 Part II* Compound Fractures, (Operative Procedures, oontdj. The Tobruk cast waw used very infrequently and when used was limited almost entirely to lower third fractures of the femur and injuries to the knee joint, A few were applied when it was essential to keep the ab- domen and lower back exposed for subsequent surgery or treatment. Humerus. Here again there was a popular cast. This was the plaster Velpeau bandage which bound the arm to the trunk with the forearm flexed to a right angle and placed across the chest. Since there was no circular bandage around the arm it was unnecessary to split the oast in most in- stances, The oasts were usually comfortable and were not made heavy. It could be applied by pulling the patient out over the head of the table and supporting him on a narrow board, broom handle or Jones arm splint placed under the spine and head. This temporary appliance was removed after the plaster set. A satisfactory variation of this method but less popular in this Group was the thoraco-brachial cast (including long slab splints) with the arm forward in internal rotation and the forearm at a right angle. The Army humerus splint was vised temporarily in some cases with concomitant chest injuries and in patients too ill to place in a oast at the time of the original operation. Radius and Ulna, Fractures of the forearm were almost all treated by circular plas- ter bandage (with slab splint), with ri$it angle flexion of the elbow and with the oast extending from the proximal palmar crease to just be- low the axillary folds. The hand was usually kept midway between prona- tion and supination. Tibia end Fibula, Here a circular plaster bandage (with posterior slab spint) was used. It extended from the toes to the groin with the knee slightly flexed and foot in neutral position. The posterior slab splint was extended distally beyond the toes for support and protection. SPECIAL CONSIDERATIONS IN SURGERY Amputation.* As nearly as can be determined no amputation was done for a frac- ture alone. Amputations were done for non-viability or irreparable damage which would leave a funotionless extremity. In some oases, however, the presence of a severely comminuted fracture was the deciding factor in an otherwise questionable situation. ♦Refer to Section on "Amputations”, Page 593 to 619 6U8 Part II, Compound Fractures, (Special Consideration in Surgery, cont'd). Associated Injury to a Major Vessel.♦♦ The treatment was the same except that special attention was paid to the preservation of ail possible collateral circulation and tne casts were more heavily padded. Old Fractures. Untreated fractures of 48 hours or Longer duration received the same treatment except that in the presence of infection larger doses of penicillin and larger amounts of blood were given prior to surgery to Improve -cue general condition. Anaerobic Infection. The presence of a fracture does not fundamentally alter the treat- ment of anaerobic infection. Incision, debridement, or amputation was done as indicated by the severity of tne infection and not because of the presence of a fracture, IThen amputation was done the fracture line was often used as tne level of amputation even though the infection may have extended higher. POSTOPERATIVE CARE Penicillin was continued postoperatively in 20,000 - 25,000 unit doses every three hours, usually until evacuation. In cases of actual or suspected anaerobic infection tnis was doubled. Intravenous fluids, crystalloids, plasma, and wnoie blood were used freely and as indicat- ed to maintain as nearly as possible a normal physiologic status. Full diet was given as soon as it could be tolerated. Some surgeons gave vitamins routinely. It is essential that all casts be watched carefully and constantly. It was found that frequent adjustments, trimmings ana paddings were necessary for tne comfort of me patient. EVACUATION Early evacuation to a fixed hospital was the general policy with fracture patients. Many patients were evacuated on the day following operation and most within three or four days. Associated Chest or ab- dominal injuries, cawes with anaerobic infection and ail patients with associated major vascular injury had to be retained longer. Air evac- uation is ideal and was used for many of these patients. ♦♦Refer to Section on "Vascular Injuries", page to 7h5 ♦♦♦ Refer to Section on "Anaerobic Infections", page ?U6 to ?£? 6U9 Compound Fractures, (coat’d)* PART III MORTALITY IN PATIENTS WITH COMPOUND FRACTURES OF LONG BONES In considering mortality among patients suffering from compound fractures of long bones it immediately becomes apparent that we must divide our cases into complicated and uncorapiicated groups. The entire series of cases under consideration at present represent soldiers and occasionally civilians wnose injuries have occurred under war conditions highly favorable to multiple serious wounds of all parts of tne body simultaneously. By complicated therefore it follows chat it will be understood that the injuries in combination with a compound fracture constitute as muon if not more of a threat to survival than the frac- ture itself. These combined injuries include penetrating cnest and abdominal wounds, associated fractures of other long bones, major vas- cular injuries accompanying tne primary fracture or in association with other wounds, extensive soft tissue damage in addition to that incident to tne fracture, central nervous system trauma, maxiilo-facial trauma and traumatic amputations. Uncomplicated compound fractures constitute a very small group in this mortality series. In this series 2416 patients were found to have suffered from com- pound fractures of the long bones. Of these 1065 were complicated', and 1350 were uncomplicated, Furtner analysis reveals a total of 152 deaths occuring in this series of 2416 cases making a gross mortality rate of 6.3/o. Of these 162 deaths, 145 fell in tae complicated compound frac- ture group making a mortality rate ol 13,9$, The remaining four deaths fell in tne uncomplicated group making a mortality rate of , 3/«, Inheres tingly enough all four of the deaths in this uncomplicated group were due to compound femurs. TABLE VII Mortality Percentage No, of Patients Deaths Percent All compound fractures 2416 152 6, 3:/o Complicated compound fractures 1066 148 13,9^0 Uncomplicated compound frac- tures 1350 4 ,3> Further analysis of the mortality statistics of the compound frac- tures with associated major injuries of the body would seem helpful in understanding the extent and degree of associated injuries with the var- ious long bone fractures. For this purpose tne following table is in- cluded. 650 Part III, Compound Fractures (Mortality in Patients Witn Compound Fractures of Long Bones, cont'd). TABLE VIII Incidence of Associated Injuries in Fatal Cases of Complicated Compound Fractures of Long Bones Associated Injuries Femur 57 pts. Tibia 3± pts. Fibula 4 pts. Humerus 37 pts. Radius 13 pts. Ulna 6 pts. Abdominal 27 20 2 17 8 3 Chest 8 5 0 7 2 0 Thoraco-abdominal 3 1 1 6 3 1 Compound Fractures other large bones 25 32 0 11 7 1 Traumatic amputations 8 4 0 0 2 2 Vascular injuries (major) 10 4 2 5 3 0 Multiple soft tissue wounds 8 5 0 4 0 1 Having seen in the foregoing table the actual numerical relation of other major injuries with compound fractures of long bones, we shall proceed to a direct review of the causes of death in an effort to under- stand more clearly the part played by the fracture and the part played by tne associated injury. It is our feeling that a great number of the complicated compound fractures are so overshadowed by the associated injury in tne production of a fatal result that the fracture per se can reasonably be said to have been of relatively minor importance. In many instances death occurred, on the table during thoracic or abdominal exploration before any definitive treatment could be directed toward the fracture. Again there are a few instances where sudden death was attributed to aspiration of vomitus postoperatively or, as in one case, sensitivity to morphine injected intravenously during the postoperative period. Again too, it is unfortunate that the ascribahle cause of death is not uniformly based upon postmortem anatomical diagnosis, but on more debatable clinical grounds. Still further when autopsy reports were available the description of microscopic change was lacking, making at best a gross diagnosis the only one available. The following table lists the various causes of death occurring in all cases of fractures of the long bones* 651 Part III, Compound Fractures (Mortality in Patients With Compound Fractures of Long Bones, cont’d). TABLE IX Immediate Causes of Death, lt»£ Cases of Compound Fractures of Long Bones Cause of Death Femur Tibia Fibula Humerus Radius Ulna Total Not stated 14 2 1 1 2 20 Shock 17 15 1 16 5 1 55 Anaerobic infection 8 5 3 1 15 Peritonitis 2 3 3 1 9 Anuria 6 2 2 3 3 1 7 Pneumonia 1 1 3 1 6 Embolism 9 1 3 1 1 15 Blast injury lung 1 1 1 3 Pulmonary edema 2 2 2 6 Asphyxia, aspiration 1 1 1 3 Cerebral damage 1 1 2 Morphine sensitivity 1 1 TOTAL 61 31 4 37 13 6 * 152 In considering the foregoing table it will be noted that the first cause of death, namely, not stated or unknown, includes a rather large numoer or cases. In all of these, careful scrutiny of the records failed to give enough data even for clinical speculation as to cause of death. Shook as a cause of death covers the largest group of cases and was so ascribed when death occurred before surgery was possible, during or immediately after surgery or in the first twenty-four hour period after surgery when clinical data incidated a failure of the circulatory system to become stabilized. Where autopsy records were available in no instance in tnis group were any other causes of death forthcoming. Over- whelming anaerobic infection as a cause of deatn occurred 15 times but it must be remembered that the diagnosis is based on clinical signs rather than on bacteriological data. Peritonitis and pneumonia rank relatively low as causes of death in contrast to former times; in ail these cases the immediate postoperative period had been weathered and death super- vened several days later. Anuria as a cause of death is a relatively newly recognized entity in this particular war and it is hoped that in- tensive research being carried on at present may throw some light on this baffling problem. Pulmonary embolism as a cause of death repre- sents a fair number of cases and thus far is the first cause of death which seems in any way directly related to a compound fracture. Inter- estingly enough it occurred most frequently in femoral fractures. The embolus was in most cases of vascular origin but where autopsy material was available fat embolism in a few instances was described, presumably originating in the marrow of the fractured bone. Tnere were three cases of blast injury to the lung confirmed by postmortem examination and six 652 Part III, Compound Fractures, (Mortality in Patients Witn Compound Fractures of Long Bonos, oont'd). cases ascribed to pulmonary edema. The latter term is not too well understood and in no instance could further illumination of tne term be obtained by careful scrutiny of the records, Tne tnree cases of aspir- ation asphyxia and the case of morphinism can hardly be considered in compound fracture mortality statistics. Cerebral damage is listed in two cases and in each instance oartainly outweighs the effect of tne long bone fractures as a cause of deatn. There remain four cases of uncomplicated compound fracture of the femur in aii of whicn death can be ascribed to the fracture per se. In three of these shock is ascribed as the cause of death and in tne fourth pulmonary embolism was proved by postmortem examination and tne source of tne embolus was shown to be in the femoral vein on tne involved side. All four of these cases are presented in detail* Case 1. A prisoner of war, age 38, was tagged 1000 hours, 12 January 1344 at a Collecting Company near the Cassino front. No knowledge of the exact time of injury was indicated on the record but the patient was found in poor condition in the open. Four hours later at another Col- lecting Company a splint was applied to the rignt lower extremity and morphine was given. One and one-half hours later the patient was re- ceived at a Field Hospital where blood and plasma were started. The patient was in very poor condition, pulse and blood pressure were not obtainable. Examination at the time revealed a fracture, compound, comminuted of tne upper right femur and through and through wounds of the rignt upper thigh with marked soft tissue damage. There was no evidence of anaerobic infection. After five hours of intensive fluid replacement the blood pressure failed to rise above 58/30, Debridement and immobilization were done under ether-oxygen anesthesia. Shortly after returning to the postoperative ward the patient ceased breathing. Autopsy was done but failed to reveal any additional pathological change* Case 2, A 23 year old American officer was tagged for injury at *115 hours, 26 May 1944 at a Battalion Aid Station, one hour and fifteen minutes after sustaining severe shell fragment wounds to the left thigh. Mor- phine was given and a Thomas splint and tourniquet were applied to the left lower extremity. The patient arrived at a Field Hospital eight and three fourths hours after injury but in tne intervening hours tne tourniquet had not been released. The patient was given 500 cc. of blood and two hours after arrival at tne hospital was taken to surgery where the tourniquet was released. Fresh bleeding of the left thigh did not occur out the entire limb began to flush and the skin became pink and warm. During debridement under enuotraoneai gas-oxygen-ether 653 Part HI, Compound Fractures, (Mortality in Patients With Compound Fractures of Long Bones, cont’d). anesthesia only small branches of the femoral artery required ligation. During debridement and shortly after releasing the tourniquet, the blood pressure and pulse suddenly became unobtainable. With the aid of blood and plasma they were reestablished to fair levels at the close of the operation. The patient was returned to the postoperative ward where oxygen therapy was started. He improved rapidly but on xne morning of the second postoperative day the patient developed circulatory embarrass ment and died. Postmortem examination revealed thrombus formation ex- tending from the left femoral vein into the common iliac vein. Massive emboli were found plugging the pulmonary arteries and extending back into the right ventricle. Case 3. An Italian civilian, age 13, was injured on 6 November 1943, time not stated, by a land mine. The patient was admitted directly to a Field Hospital where a compound fracture of the right femur, middle third, severe, was found. There were in association a minor compound incomplete fracture of the sacrum and minor wounds of the right buttock and arms. The patient was not in shocx: and apparently did not receive any supportive fluids. At 1130 hours, 6 November 1S43 time lag not recorded, the patient was taken to surgery, where, under ether anes- thesia, all wounds were debrided and the rignt lower extremity was im- mobilized in a Thomas splint using skin traction. At the close of the operation the patients pulse was 140/min. and associated with rapid shallow respirations. The anesthesia note stated the patient was conscious on leaving the operating room. The patient expired four hours postcperatively apparently because of progressive shock. Postmortem examination wets not done. Case 4, An American infantryman, age 21, was injured 1 February 1945 at 0100 hours by small arms fire. The patient was tagged at 1200 hours on the same day at a Battalion Aid Station where he received two units of plasma, morphine sulphate grs. 1/4, and a Thomas splint to the right lower extremity. Admission to a Field Hospital occurred 16 hours after injury. At this time physical examination revealed a severe perforating wound of the right buttock with compound, comminuted fracture of the upper right femur. There were associated relatively minor wounds of the anterior cnest wall, right leg and foot with an incomplete compound fracture of the os calois. The abdomen and chest were normal on ex- amination and the urine was clear. Although the record of this patient does not indicate the degree of shock, he received 1500 cc. of whole blood before operation. The blood pressure at the start of the opera- tion was 118/70, pulse 110/min, Under endotracheal gas-oxygen-ether anesthesia, debridement of all wounds was effected with the patient on his left side. Gradually the blood pressure dropped to 80/50. The 6& Part III, Compound Fractures, (Mortality in Patients Witn Compound Fractures of Long Bones, cont'd), patient was then turned to tne supine position in preparation for a hip spica. Suddenly the blood pressure and pulse became unobtainable. Despite ail efforts at resuscitation the patient could not be revived and was pronounced dead a few minutes later. Autopsy failed to reveal any further anatomical causes for death. The latter was ascribed to the orignai wounds and consequent snock. 6S5 CRANIAL INJURIES 656 THE INITIAL SURGICAL MANAGEMENT CF SEVERE HEAD WOUNDS By far the majority of all cranio-cerebral wounds handled by this Group were operated upon by trained neurosurgeons with the it teams. Excluding scalp lacerations, less than of all operations done by general surgical or other specialty teams were cranio-cerebral operations. For the greater part of the period May 1943 to May 1945, three teams were adequate for the needs to be met by this Surgical Group. In the three month period, March-June 1944, four teams were active. For periods of not over a month at a time only two teams were active. This report is taken from the records submitted by those teams, working usually singly in Evacuation Hospitals. The policy of the theaters in which this Group was active was to have the initial neurosurgery done in the forward Evacuation Hospitals. Here usually there were adequate space, lighting, and linens. Electro- surgical and suction apparatus were available. The hospitals were close enough to the fighting that time lag was not markedly increased by the tine distance factor. Also, they moved less frequently than the Field Hospitals. As a check on this policy, neurosurgical teams were placed In Field Hospital platoons acting as small mobile units supporting the division medical service. The Field Hospital platoo fas set up next to the Clearing Station, Here the teams of this Auxiliary Surgical Group functioned in caring for priority and non-transportable patients. The proximity to the Clearing Station allowed for consultation in all head cases. Only non-transportable cases with head wounds were held for operation by the neurosurgical team at the Field Hospital, all others being sent back to the Evacuation Hospital, The experience of one team was as follows: Of 27 cases seen, six were held for operation; five died postoperatively. The sole survivor was transportable insofar as the cranial wound was concerned, but was held and operated on because of the severity of his associated wounds (Tinsley, Milton, 1945, sub- mitted for publication). This experience indicates that the increase in time distance factor for evacuation to the next station in this Theater would not have influenced the eventual outcome in such extreme brain injuries. The neurosurgical team usually furnished the only neurosurgeon with the Evacuation Hospital not staffed with a neurosurgeon. Although one team was sufficient with the usual flow of casualties, at times whan a heavy flow of casualties or a concentration of neurosurgical cases was expected, two teams alternating on 12 hour shifts were used. This allowed better pre and post-operative care, with earlier surgery in the individual case. During much of the period only three teams were organized so that this practice could not be done as frequently as it might have been. 657 Cranial Surgery, 2nd Aux Surg Gp, Since the team usually worked singly in the Evacuation Hospital, it was on 24 hour call. For this reason though jstost scalp wounds were seen, the team rarely cared for these cases unless there were signs of such magnitude to make one suspect intracranial complications. Almost all cases operated on had either penetrating head wounds or depressed skull fractures. Records were kept of operations on about 40 closed head injuries, treatment of which did not differ from similar cases in civil life, therefore, they will not be discussed in this report. About 100 on patients with scalp lacerations were kept, most of which consist only of a brief note at the time of operation. So follow-up is available on these cases* Our subjective impression is that a fairly wide shaving and closure which includes the galea were the main factors for success in handling these cases. Host cases were retained at the Evacuation Hospital for four to 10 days after operation. Barely was it necessary to evacuate cases earlier than the third day, and serious cases not infrequently could be kept as long as 20 days after operation. Follow-up notes after evacuation are incomplete. A single case was recognized in a published paper from a fixed General Hospital in the Zone of Interior, Other than this case the last progress reports are from within the Theaters, Knowledge of the final outcome of the surviving cases would be most desirable. Discussion here is limited mainly to what happened to patients with depressed skull fractures and penetrating head wounds operated on by the neurosurgical teams of this unit working usually’- in the Evacuation Hospitals, Admission procedures were handled by the Evacuation Hospital staff through the admitting officer, who usually sent all surgical patients to a preoperative ward. Here, any emergency shock procedures were initiated by the ward officer who notified the team immediately of any emergency case. The neurosurgical team took responsibility for any cranio-cerebral case after notification until the patient was discharged, AH other head cases were sent for examinations and the team notified. In mild to moderately severe head injuries with severe associated priority wounds, where craniotomy could safely be postponed, the associated injury was usually operated upon as' soon as therapy was completed. In such cases the craniotomy was performed as a continuation of the associated operation if the condition of the patient at the end of this operation was satisfactory. At times the craniotomy was postponed for 4& hours or more, but could usually be dona within 36 hours. All such cases were usually seen before the major associated injury was treated. Severe head injuries with severe associ- ated wounds at times could not be operated upon at all, but where clinical 658 Cranial Surgery, 2nd Aux Surg Gp, and x-ray examination could be accomplished and shock controlled, the lesion of major urgency as decided in consultation was first cared for, Almost all patients with scalp lacerations with unconsciousness were seen, and when neurological signs were present were operated upon and followed by the team. All but the mildest of associated injuries were operated upon by the general or specialty teams of the Evacuation Hospitals, When non-emergency cases were admitted after midnight the preoperative ward officer checked the patient's blood pressure and pulse, had the patient's head shaved and x-ray examination completed, and the team was notified of the admission in the morning. Some such routine is necessary with the team on 24 hour call. EBPRESSED SKULL FRACTURES Records are available on 120 depressed skull fractures of varying severity* The mildest showed local depressions a centimeter in diameter with no neurological signs. The most severe had marked depression of the inner table, up to eight centimeters in diameter, which tore the longitudinal sinus and contused the underlying brain over a fairly large area* The dividing line between this group and the penetrating head wounds depended on complete penetration of all layers of the dura. TABLE I Depressed Skull Fractures c D a e a Intra- Fron- In- Con- a © Extra Sub cere- Venous tal Dura Dura fee- vul- t s dural dural bral sinuses sinus Opened Closed tion sions h Shell s fragment SI 6 U 5 ? 22 12 5 1 h Gunshot wound 17 2 0 0 0 0 5 3 i 0 \ Bomb fragment L P 0 1 p 2 1 0 X I Mine fragment 3 0 i 0 0 0 . 1 0 i 0 0 Grenada 2 0 0 0 0 0 0 0 0 ; 0 Misc, 13 2 2 0 0 1 5 2 0 i 2 , TOTAL 120 ..la -5 —4... k 6 35 _13 4 The dura was opened in 35 cases .with abnormal neurological signs. Subdural or intracerebral heaatomata were found in 13 instances, Host of the other oases had local cerebral contusions or lacerations, which 659 Cranial Surgery, 2nd Aux Surg Gp, (Depressed Skull Fractures, contd). were usually debrided. These findings indicate that in such cases ’with focal or neurological signs the dura should be opened. In cases where the injury site was heavily contaminated, the subdural space was exposed through a nearby trephine opening. Only thus could the surgeon be sat- isfied that no operable cause for the signs had been neglected. Con- vulsions after operation occurred in at least four oases, or 3• 3,'j, all focal and all controlled by phaaobarbital, infections occurred in seven cases or of the group. Table II shows pertinent data on these seven cases* TABLE II Infections in Depressed Fractures Case Number Agent Time lag vTound Dura 456 Shell fragment. 23 hrs. Frontal Left open. clean. Comments; staph albus eventually healed* Associated injury None , 458 Shell fragment. 31 hrs. Temporal. Not opened. Cements: 5th day - Slight separation of wound edges. 12th day - .'found crusted over, 16th day - Crusts removed* Thin pus from under flap, inspissated pus in second area. Hemothorax left medial nerve* Superficial 459 Shell fragment, 32 hrs, Widely Left open. Minor pen. and damaged perf. wounds of scalp chest wall and occipital, shoulder. Comments: ill 1 damaged scalp could not be debrided without major plastic closure* 2nd day - Sloughing, 7th day - Cerebral fungus, Fungus excised later. 29th day - Not yet healed, otherwise satisfactory. 483 Shell fragment, 14 hrs, ObliqUe Closed. scalp entry with 6x3 cm. denuded fatty scalp layer occipital. Minor lacerated and pen. leg wounds. Comments: ATi denuded scalp could not be debrided without major plastic closure. Pericranium and galea closed in overlapping fashion. Then skin margin sutured to fatty layer as split thicknass graft over galeal closure. 4th day - Slight drainage, 7th day « Superficial infected area, small. Follow-up definitely infected. 660 Cranial Surgery, 2nd Aux 3urg Gp, (Table II, contd). TAELS II No. Associated injury Cases. Agent Time lag Wound Dura 487 Mine fragment. 46 hrs. Small Not Traumatic amputa- pinched out opened. tion of leg - coa- forehead. pie ted 1st. Many pen. face and nose wounds. Coawents: Wound apparently communicated with face wounds, and all subcutaneous channels were not widely opened. Frontal sinus margin was seen but not opened. , . . . , 3rd day - 3utures out; pus from lower end of me is ion and nasal wound on pressure. Follow-up - Frontal wound opened widely, developed osteonyelit hare - eventually sequestrum was excised, and wound healed. 522 Gunshot wound. 2? hrs. Right parietal Closed. None, gutter. Coacaentss 4th day - Slight drainage froa wound. 7th day - found reopened, seropurulent epidural pocket-granulation ov< dura - dural suture reiaoved epidural pack. X2th day - Evacuated* 551 Shell fragment. 18 days. Right fore- Not Frontal sinuses head wound . opened, both entered, draining pus, through frontal sinus, Coacientss Foreign body had been removed several days before admission* Osteomyelitis debrided, N0 postoperative notes or follow-up. Infection could have been avoided by wide debridement and plastic closure in Cases Nos. 459 and 463, and either by leaving the wound open or by more thorough face wound debridement in Case No. 467* Case No. 551 had an infected wound when admitted. Death occurred in eight cases in this series while under the observe tion of the operating team. Case Mb. Tims Lag Hours Admission BP/P/R Agent Examination Dura Day of Death Comment Autopsy Findings 465 16 82/70 Shell fragment. Confused, negativiatio pupils dilated, fixt. 7 cm. stellate mid line occipito-parietal lac- eration, spastic right am. Neck mod. stiff. Left open. 5th. Died with hyperthermia. Multiple diffuse brain softenings, particularly in left parietal lobe and around the left ventricle. 473 Over 13 142/76 80 Gunshot sound. Conscious, Severe hypersthesia of occi- put, neck, shoulders, 4 cm. mid line frontal lacerated wound. Not opened. 1st. Never reacted from endotracheal ether anesthesia. Death of res- piratory failure with clear airway, 1 cm. bipolar frontal softenings. Flame shaped 1 cm. long hemorr- hage in upper cervical cord in posterior column, posterior horn, central gray matier, and spino thalamie tract. 493 18 110/70 120 24 Unknown. Comatose, decerebrate, conjugate eye deviation to right. Left parietal lacerated wound neuro- logical otherwise normal. Left open. 1st. Large subdural hygroma at operation. Brain showed diffuse small and large hemorrhages in cerebrum, cerebellum, and medulla. 513 33 130/80 126 24 Shell fragment. Neurological normal. Not opened, . 1st. FCC right tibia, pen. wound right thigh, with gas infection, ampu- tated 6 hrs. after Died of gas infection 18 hrs, later, in deep shock. 524 13 - Bomb Stertorous hemoplegia Comatose, breathing, left pupils dilated and fixed. Multiple small wounds left parietal area. Left open. Day of operation. 30 o.c. subdural clot evacuated, underlying brain mushy, herniates. Was in very poor general condition in spite of 2 units of blood and 2 units of plasma. No autopsy. Deaths in Depressed Fractures TABLE III 661 Cranial Surgery, 2nd Aux Surg Gp. Case Mj- Time Lag Hours Admission BP/P/R Agent Examination Dura Day of Death Comment Autopsy Findings 525 3 days 160/80 68 22 Shell fragment. Semicomatose, pupils sluggish. 7 cm. left temporal laceration with foul smelling pus exuding. Battle1s sign on right, ecchymosis of left eye. Not opened. 2nd. Moderate extradural hematoma at operation. Slight subdural hematoma at autopsy. Marked softening of left posterior temporal and parietal lobes, with cortical contusion and laceration. 0,5 cm. post- erior dorsal meso-encephalio hemorrhage. 566 18 120/70 54 30 Shell fragment. Comatose, pupils dilated, left fixt, moves no extremities, 7 cm. mid line frontal laceration. Left open. Day of operation. Sagittal sinus found torn at operation; dura tense, dark, bulging on both sides, attempt- ed exploration for subdural encountered severe bleeding from sagittal and contribu- ting sinuses. Closure after control of hemorrhage without another exploration. Autopsy showed thin widespread subdural clotted blood. 567 8 112/60 120 24 Fall. Comatose elderly prisoner, restless moves all extremities, 5 cm. triangular dirty scalp lacerations in left oocioital region. Not opened. 3rd. Dura pulsating at operation, not opened. Never regained consciousness. Autopsy showed moderate destruction of the left occipital lobe. TABLE III Cranial Surgery, 2nd Aux Surg 3p. (Table HI, contd). 662 663 Cranial Surgery, 2nd Aux Surg Gp. (Death in Depressed Fractures, contd). Two deaths were due to associated injuries; in Case No. 473, there was an upper cervical cord hemorrhage,with neurological signs which were considered to be only a nerve root concussion. Case No. $13 died of gas gangrene of the legs. Death in the other cases was due to massive brain damage, particularly in the brain stem. SUmRI OF DEPRESSED SKULL FRACTURES 1. One hundred and twenty case records were reviewed, with seven infections and eight deaths. 2, There are four recorded cases of convulsions after operation, all Jacksonian in type, and all controlled by phenobarbital, 3* The dura was opened in 35 cases, in 19 of which it was not closed© 4, The dura should be opened in any case with neurological signs. In this series nine subdural hematomas and four intracortical hema- tomas were noted in the 35 cases where the dura was opened. In addition, mushy lacerated and contused brain, which could only have produced scar tissue, was evacuated. PENETRATING HEAD WOUNDS Records are available on 454 penetrating head wounds. These varied in magnitude from the tiniest complete dural tear resulting from a depressed skull fracture to massive penetrating and gutter wounds. There were 63 deaths in the series, 11 from infection. Fifteen infected cases, including superficial wound infections, were evacuated. There were 29 wound disruptions, from tiny cerebro-spinal fluid leaks to major dis- ruptions with cerebral hernias. 66U Cranial Surgery, 2nd Aux Surg Gp. (Penetrating Head Wounds, contd). TABLE IV Time Interval in Penetrating Head Wounds Average Time Interval 19,3 hours Tims Lag Wounding to Operation in Hours No. Cases No. Percent Deaths *«ortality Dis- rupted Infec- tion Penici- Sulfa llin Sulfa as Penici- llin Under 12 0-12 185 UN CJ 14* 8 6 33 0 Over 12 12 - 18 74 7 9% 6 5 12 21 1 Over 18 18-24 70 10 14* 4 4 & 18 1 .. Over 24 24-48 77 18 23% 7 7 10 17 0— 3 © > o 35 3 US 4 4 4 6 I Not Specified 13. 0 o% 0 0 0 0 0 TOTAL Jflt- 63 ui _22 26 68 —22 i- Time Interval Over half of the cases, 259,,were operated upon less tha 13 hours afte injury. The average time lag between injury and operation was 19 hours and 18 minutes. In arriving at this average the 43 cases operated upon after 43 hours were considered as having been operated on then. Due to the fact that teams were usually on call 24 hours a day, only the more serious cases arriving after midnight were operated upon before eight o’clock the next morning. Since it was possible to do only one case at a time, the more seriously ill case, if ready for operation, was done first unless decere- brate, (Cases decerebrate on admission are discussed under deaths). Wounding Agents. Shell fragments caused by far the largest number of head wounds, accounting for 347 cases. Small arms fire produced 77# Thirty-two shell fragments (9*2$) perforated the head, while 29 bullets (37.750 traversed the calvarium. 665 Cranial Surgery, 2nd Aux Surg Gp. (Penetrating Head Wounds, contd). TABLE V Wounding Agent in Penetrating Heed Wounds In 64 Cases no Notes Were Available as to Whether Foreign Body Was Present, Absent, or fiemoved Shell Fragment Gunshot Mine Bomb Wound Fragment Fragment Gren- ade Misc. Total Penetrating 315 48 11 6 2 11 393 Perforating 32 29 0 0 0 0 61 No foreign body 74 47 2 2 1 10 138 Foreign body retained 116 11 3 2 1 0 133 Foreign body removed 96 18 2_ 1 0 1 U9 Artillery shell fragments produced a variety of wounds. There was the small depressed fracture with small foreign body in the skull, dural tear and minimal brain damage. Large block depressions of the skull were seen, caused usually by a large slow velocity shell fragment, with small dural tear and superficial underlying brain damage. The gutter wound was frequent, with severe dural and brain damage due to vertically indriven bone chips, but no foreign body. The typical true penetrating wound showed a puncture-like wound of entrance, indriven hair and bone in single or multiple tracts, and a retained intracerebral foreign body. The per- forating head wound showed entry and exit wounds, or entry wound and extra cranial foreign body, with a brain tract containing bone chips, hair and debris, Mortar fragments usually did not perforate, and such wounds were frequently complicated by a fair amount of cerebral commotion or blast effect. Saall arms fire usually produced a gutter wound, perforating wound, or puncture-penetrating wound. With ricocheted or spent bullets one saw the depressed fracture type. Mine, bomb, and grenade wounds were usually of the puncture-pene- trating type, but more rarely produced the gutter-type wound. With these agents the patient almost invariably showed some evidence of cerebral cbmmotion due to blast. 666 Cranial Surgery, 2nd Aux Surg Gp, (Penetrating Head Wounds, contd). State of Consciousness The main criterion of seriousness in a given case was the state of consciousness, as shown in Table VI where noted. There are a number of duplications, as agitated patients were conscious, semi-conscious or comatose, and all decerebrate patients were comatose. TABLE VI State of Consciousness in Penetrating Head Wounds No. Cases No. Deaths Percent Mortality Pen. Perf. Cere- Ven. Ventric bellar Sinus Art- eries Hentf Conscious 227 10 4# 202 2? 22 2 a 2 62 Semi- conscious- ness a? 6 7* 7? 12 12 2 2 2 20 Coaatoss ?2 _ 44 71 21 18 1 ? 5 27 Agitated & 8 i53 41 12 2 0 4 0 A Debrebrate 12 92* 10 2 0 -.A- 0 8 Herniation of brain on admission was more frequent than is indicated on the table, as in cases where it must have bean present (from other in- dications in the record) it was not recorded* Neurological slnns gave further indication as to the seriousness of the wound. In the comatose patient some findings could not be determined or were not recorded. Although lesions of the anterior portion of the frontal lobes and the infaro-lataral temporal lobes produced no localizing signs, damages elsewhere produced well-known clinical patterns. Only six peripheral cranial nerve lesions were noted, four which involved the auditor nerve. Isolated speech handicaps, monoplegias, hemianopsias, either partial or complete, were produced by small lesions. Larger lesions showed trip- legias, tetraplegias, and mixed motor, sensory visual and speech losses. The most grave cases showed decerebration, dilated fixed pupils, Cheyne- Stokes respirations with hyperthermia and hypertension* 667 Cranial Surgery, 2nd Aux Burg Gp, (Penetrating Head Wounds, contd). TABLE VII Neurological Findings in Penetrating Head Wounds No. Cases No. Deaths 1. Monoplegia Leg Right k ... 1 . left 3 0 Arm Right 2 0 Left 4 1 2. Hemiplegia Right 77 10 - Left 56 8 3. Paraplegia Leg 2 1 Arm 1 0 Triplegia 8 3 Anesthesia Arm Riffht 2 . 0 Left 5 0 Leg Right 1 0 Left 2 0 Head. Right 9 0 Left u 1 Aphasia 55 ■1--.. Bye Deviation 19 5 Dilated Pupils Hemolateral \ 3 Cpntralateral 0 Bilateral 24 a Cheyne Stokes 8 3. Tetraplegia 9 9 668 Cranial Surgery (Penetrating Head Wounds, contd) X-ray.? were very valuable in determining the amount og damage. Stereoscopic film? were rarely made, but were of help in special cases, Wc were impressed by the fact that the X-ray tended to minimize the ex- tent of the nku.ll lesion. Also, repeatedly many more bone fragments wore removed at operation than one suspected from the X-ray films. Associated Injuries wore recorded in. of cases. They were con- sidered mild in 17.2$ and moderate to severe in 12.3m. TABLE '/III Associated Injuries and Shock in Penetrating ’load Wounds Shock As coci ated In .-juries None Mild Moderate to Severe Total Survived None 20 4 46 15 . . 265 . Wild 53 ... 14 11 78 Moderate to severe 22 9 17 48 Deaths Hone U 5 4 23 Mild 11 2 . L 17.. Moderate to severe U 2 . 7 23.. HI 0 1 318 78 . .£L 454 Shoe]': was recorded as present in 36.6m of cases. Mild shock was diagnosed if the systolic blood pressure was above BO but below IOC and the pulse pressure was over 30 ram. of mercury, provided that the syst- olic pressure was restored to 100 or above with one or two units of plasma. All patients vrho received plasma in amounts of not over two units before admission and no blood were considered to have mild shock, if no blood and not over two units of plasma altogether were necessary before opera- tion, A patient with a systolic blood pressure of less than BO, or a pulse pressure of less then 30, or who received blood, or a total of over two units of plasma altogether was considered to have moderate to severe shock, Mild shock as diagnosed above was recorded in 20,94 of cases, while moderate to severe shock occurred in 15.64 of patients. 669 Cranial Surgery, 2nd Aux Surg Gp, (Penetrating Head Wounds, contd). The shock associated with head injuries was due to blood loss and was comparatively mild. This form of shock was easily combatted with small amounts of plasma, blood or fluids, Severe shock as seen in patients with wounds elsewhere was rarely seen in uncomplicated cranial injuries. The shock-like condition which occurs in decerebrate states is discussed more fully under deaths. Severe head injuries exhibited signs related to embarrassment of the vital cerebral centers, with hypertension, increased pulse pressure, slow pulse, cyanosis, and rising temperature. This state was usually due to increased intracranial tension, which could be relieved, if at all, by surgery. Anesthesia varied according to the preference of the surgeon, and the preference, ability, and availability of the anesthetist. There was an overall shortage of physician anesthetists and widely trained nurse anesthetists throughout the Surgical Group from time to time. Since the neurosurgeons were accustomed to operating under local anesthesia, it was thought that they could manage better without an anesthetist than could some other teams. For this reason the number of cases done under local anesthesia alone was a bit larger than if free choice of agents were always available. In the presence of severe associated wounds or of nasopharyngeal bleeding endotracheal other was the anesthesia of choice. Agitation required some form of general anesthesia. Quiet coma with serious general condition made one prefer local. Minor associated wounds were frequently operated on under pentothal after craniotomy under local anesthesia. The objection to local, that it produces psychic trauma in the conscious patient, can be neutralized to a large extent by a barbiturate in addition to the routine morphine before operation, thus making the patient drowsy and somnolent. This of course can also be accomplished with repeated small doses of pentothal. The other objection to local anesthesia is the constant tempt- ation for the operator to minimize the amount of surgery done, with resultant incomplete debridement. The scalp is readily anesthetized with local, but large amounts were required for lengthy formidable procedures. As much as 300 c.c. of a 1$ solution was used in some cases, without apparent adverse effect, but the wisdom of such large doses might justifi- ably be questioned. 670 Cranial Surgery, 2nd Aux Surg Gp. (Penetrating Head Wounds, contd). TABLE IX Anesthesia in Penetrating Head Wounds Local Pentothsl Local and Pentothal Endo- tracheal Biaax.. Percent No. Mortality Deaths Conscious 130 11 ~M _J2 —H— 10 —conscious 39 5 ... . 10 1% 6 59 1 16 16 m - 4L. Agitation 16 11 2 6 1 16 1 ns11 8 12 i/Cvui Q v/r? Total Deaths ~ 255 19 1 m n 6*2 14, Pentothal alone was used infrequently, in 4.6* of casesExcept for very short procedures, such as debridement and drainage of an infected small penetrating wound, it is advisable to use local also, or to use ether, rous oxide, because of its anoxic factor, was used only as an induction agen before endotracheal ether, or rarely in low concentration -ioh nigh oxyg mixtures for short continuation after it was deemed unwise to give more pentothal, Ooerative procedures varied little from those in civil injuries. The scalp was shaved widely. Soap, water, and ether were used Either iodine and alcohol or mercurial antisepticwereusedforscalppp ration. All non-viable skin was debrided, even if a shift in* flaJ°^02 with or without grafts were necessary. Tripod incisions were avoided where possible, extension by curvilinear and flap incisions being preferred. Damaged pericranium was debrided liberally, and the bony defect enl rg to expose the dural margins. Dural debridement was rarely found to be necessarv. Brain tracts ware followed, usually by direct vision with plain or lighted retractors, using the suction to debride and keep the fielddry. Bone chips were almost invariably found caught in a net of blood ve 1 > which could be clipped or coagulated as they were exposed. Foreign readily exposed were removed. In some cases the electro magnet or pro were used for location of foreign bodies, but in the majority of cases remote foreign bodies not seen were not removed. Usually at this stage the brain was no longer tense, the tract tending to gape. If such were not the situation, other intracranial blood collect- ions were uuspected. Not infrequently, particularly when the entry wound was small, exploration of the subdural space on the same side yielded sufficient old blood to produce the desired relaxation. In some case , particularly those with very distant foreign bodies on the same or the 671 Cranial Surgery, 2nd Aux Surg Gp. (Penetrating Head Wounds, contd). opposite side, counter incisions exposed subdural or intracerebral hematomas* Osteoplastic craniotomies were done in 13 cases or 2,9$, Orbital roof fractures, cerebrospinal rhinorrheas, and contralateral explorations for retained foreign bodies were the only indications. Dural closures, with or without pericranial, fascia lata, or pre- served dura grafts, were a matter of individual decision. 3calp closures were usually made in two layers with interrupted fine silk. Necessity for haste in view of the condition of the patient, or because of the time factor when the operative load was heavy, occasionally resulted in interrupted through-and-through closure, but under these circumstances the galea was always included. Tension with resultant ischaemia and later slough was the main cause of wound disruptions. For this reason liberal enlarging incisions with wide undermining, counter incisions, large plastic flaps, and galeal incisions beneath the flap proved of help. Relaxing incisions had to be placed at least seven cm. from the wound to avoid ischasmia of the strip between, the galea had to be freed from the underlying pericranium between wound and incision and around both, and the relaxing incision had to be at least half as long again, Incisions so used were placed so that the major arteries were not severed. Sliding flaps about three times the size of the defect to be covered were freed, the wound closed and if the flap could not be sutured over the denuded pericranium, Thiersch grafts with vaseline gauze moulage for pressure were sutured over the resultant defect (Balkin S; Dowman, CJS.j Klemperer, W.W.; Vol. 128, Page 70 , 12 May 1945). Drains were employed by some surgeons in some cases. Intradural drains were eventually abandoned by all, Upidural packs were used by one surgeon in all frontal and ethmoid sinus and mastoid complications. Chemotherapy was not employed inside the dura by two surgeons. Others used both sulfanilamide crystals and penicillin intracerebrally. 672 Cranial Surgery, 2nd Aux Surg Gp. (Penetrating Head Wounds, contd). TABL-S 1 Closure and Chemotherapy in Penetrating Head Wounds Scalp and Scalp and dura dura closed, closed, no drain, drained. Scalp closed, dura open, no drain* Scalp closed, dura open> drained# Scalp Scalp open open, dura dura closed open. T i L No Chemotherapy Cases 103 / _Ji 0 129 1L 12 0 0 11 ? 289. 21_ Disruption ** ...J 9 0 5 22 26 1 2 0 2 0 26 -JlL Sulfa Cases 22 Ik u 12 0 ,1— -a. 1 1 Hh Disruption Deaths 1 2 5 - 8 Cases 80 k 10 \ 0 1 0 _iS. Infection 1 1 2 Deaths 5 & Sulfa 2 1 OJ H * JL Postoperative Pare. An nursing care was furnished by the Evacuation Hospital personnel under the supervision of the surgeon and assistant surgeon of the team. Overactive patients were sedated when their activities were such as to be a danger to themselves and restraints had to be employed at times for the same reason. Frequent turning and tracheal catheter aspiration helped in prevention of bronchopneumonia in the comatose patient. One surgeon kept all patients’ heads elevated. No surgeon restricted fluids. Comatose or agitated patients ware given fluids by vein or stomach tuba, patien were kept in bed. A few hospital type beds when available were of great 673 Cranial Surgery, 2nd Aux Surg Gp. (Postoperative Care, contd). help in the care of unconscious and agitated patients. Patients ideally were retained at the Evacuation Hospital for four to 10 days when the tactical situation permitted. When more rapid evac- uation was necessary every effort was made to send the patient directly to a hospital staffed with a neurosurgeon. One objection to doing neuro- surgery in the Field Hospital is the necessity for frequent moves, leaving patients behind with a holding group. There are not enough neurosurgeons to leave one behind with each small group of patients. During the postoperative period, the blood count or hematocrit was determined and blood replacement given to return the red blood count to 4,000,000 or the hematocrit to 35%* All patients were given sulfadiazine by mouth or vein before penicillin was made available (June 1944)* There- after all patients received penicillin intramuscularly. During quiet periods it was possible to do dressings as frequently as indicated, and at the desired times. During periods of heavy casualty load, dressings were done at odd hours and infrequently. Ideally, the surgeon kept each patient until all sutures were removed. Infections. There were 26 infections noted in the entire group and 11 of these cases died. The coli-aerogenes group was responsible for most deaths. The organism in survivors was usually staphylococcus or pneumococcus, though a few of the coli group also survived. Diagnosed infections also included superficial wound infections. The total incidence of infection while under observation by the teams is given in Table IV, Table X shows the relation- ship of closure and chemotherapy to infection. Table XI shows infections among survivors, and the type of wound and agent. TABLE XI Infections Among Survivors of Penetrating Head Wounds No. Cases Infections Percentage Total Cases 391 15 Penetrating 339 13 3.3* Perforating 52 ... 2 3.8* No foreign body 118 5 Foreign body retained 108 ; Q.?g Z Foreign body removed 108 6 , Fragment 290 n 3.8* Gunshot wound <2 A 6.2* 67U Cranial Surgery, 2nd Aux Surg Gp, Deaths Sixty-three patients died while under observation of the operating team, a mortality rate of 13.9*. This rate is artiflcally low, as at times patients had to be evacuated who would have died in our hands in a few days. Table VI, in spite of its duplications, shows that^thoughball of all patients were conscious, rational and quiet, only 15*9$ , occurred La tins group, and the mortality in this group was 4.4*. State of on adkssion, therefore, is of definite prognostic signi- ficance, Anesthesia deaths were so rare as not oo have been recorded in this series. This may be because the neurological status so “outweighs thf ordSar; manifestations of anaesthetic death. Table XII shows the woLSnfagLt, type of wound, and foreign body history on all deaths. TABLE XII Deaths in Penetrating Head bounds — — No. No. Cases Deaths Percentage 454 63 U&— Shell fragments Small anas Mine fragments N?t perforating Perforating No foreign body Foreign body removed 347 n 11 322 136 132 .. U9 . 3Q 12 1 J4 -9 18 25 H -jii- 9.1* 13.7*. . 18-9* 9.2» The most serious cases were those which arrived comatose and decere- brate wile o f aS logical efforts they died. Due to this result no easl ofleSlebrati* .as operated if a more favorable »e operation. op.rations 2 ..* a perforating bullet «und’from right rig^teoporal adfrfs:^ chases The left leg did not move except in the attacks* lood p 150/58] Pulse 32, Respirations 1*0-48 and Oheyne Stokes in c » en operation under endotracheal ether three hours after admission a ten y by°eight centimeter defect of the right frontal and temporal lobes was produced fer debridement. Three days later he talked, had left leg, and was having midbrain seizures. This is h f note onSthie patient. Since he was a German Prisoner of War it is probably the last we shall ever know. 6?5 Cranial Surgery, 2nd Aux Surg Gp, Hematomas, In the hematoma group death occurred in 12,1$ of cases. Parasa- gittal subdural hematoma was found ?.t autopsy in one case with a wound traversing both hemispheres, One patient who died had a large undis- covered subdural hematoma on the side of the entry wound at autopsy; thereafter, in any patient where pressure was not relieved by tract debridement the subdural space was explored homolaterally or bilaterally* Dne patient had a large contralateral subdural hematoma evacuated, and at autopsy showed a large contralateral intracerebral hematoma. The fourth patient with subdural hematoma also had damage to the basal ganglia which proved fatal* One patient with an intracerebral hematoma who died is discussed with the subdural group. The other had cerebral anaerobic infection at the time of operation. The patient with the epidural hema- toma also had fatal basal gangliar damage. TABLE XIII Hematomas in Penetrating Head Wounds Survived Died Total Extradural 11 1 12 Subdural 22 4 26 Intracortical 18 2 20 Intracranial complicating wounds were fairly common, as is shown in Table XIV, There are of course many duplications here, particularly in the air sinus and orbit groups, as these are frequently all affected in a single case. Ventricular injuries were recorded in 52 oases or of the series. The scalp was closed tightly in all cases. In 20 cases the dura was left open; one case became infected but survived, while nine died. The dura was closed in 32 cases with no infections among survivors and eight deaths. Operative treatment was not modified because of this complication. Major cerebral artery lesions occurred in 10 cases, with five deaths. In all, the arterior cerebral artery had been involved. Venous sinuses were torn in 26 cases. The sagittal sinus was com- pletely torn in 10 instances with five deaths; it was partially torn in 14 cases with two deaths. The lateral sinus was partially torn in two instances with no deaths. Bleeding from these sinuses was controlled by ligation, silver clips, muscle, fibrin foam, or a combination of 676 Cranial Surgery, 2nd Aux Sulbg Op. (Hematomas in Penetrating Head bounds, contd)• with electro-cautery. Air sinus or mastoid wounds complicated 7S cases, with 12 One mastoid wound became infected. The relatively low death and infection rate in this group was obtained because every effort was made to wall off the air cavity from the subarachnoid space. Dural repairs were accomplished wherever possible, and where this could not be done muscle stamps, pericranial stamps, or fibrin foam were used to encourage rapid sealing of the cerebrospinal fluid leak. Involvement of the basal ganglia proved to be quite lethal, with only one survivor in 16 cases. TAELS XIV Complicating Intracerebral Wounds in Penetrating Head Wounds Survived Survived No* Clean Infection Deaths Total Orbit —-— \ $7— Frontal sinus ZfcL — — r ft Ethmoid sinus f Sphenoid sinus J — f 7T —" Ventricle a oo Cerebellar JL_—.———i— Arteries f S IS Sagittal sinus ,, Partial 12 \ Complete 5 ——i — Lateral sinus 0 Partial g — Involved lobes of the brain are shown in Table XV, Some of the reco are rather incomplete, so that a case showing single lobe entry may have had other lobes involved as well. Only entry site is shown on some record and no description of the x-ray findings or exact point where the foreign body lay is available. 677 Cranial Surgery, 2nd Aux Surg Gp. TABLE XV Involved Lobes of the Brain in Penetrating Head ’founds Survived Deaths Total Wound Clean Wound Infected Frontal only Unilateral Right 41 2 8 51 Left 61 0 9 70 Bilateral 19 2 3 24 Parietal only • Unilateral Right 23 1 6 30 Left 58 2 10 70 Bilateral 3 0 0 3 Temporal only Unilateral Ri^ht 26 2 3 31 Left 25 . 1 4. _ 30 Bilateral 2 0 0 2 Occioital only Unilateral Right 23 . 1 2 26 Left . 17 . . 1 2 20 Bilateral 0 0 1 - 1 Fronto-oarietal Unilateral Right 9 1 2 12 Left 14 . _ 0 0 14- Bilateral 0 0 2 2 Three lobes a 0 0 8 Four lobes i 0 0 1 678 Cranial Surgery, 2nd Aux Surg Gp, (Table XV, contd). TABLE XV Fronto-temporal Unilateral Right Wound Glean 6 Survived Wound Infected 0 Deaths 0 Total 6 Left 2 0 0 2 Bilateral 0 0 2 2 Three lobes 3 0 2 5 • F ronto-temporo-oc cip ital Bilateral Three lobes 1 0 0 1 Fronto-parietal temporal Unilateral Right 2 0 0 2 Left 0 0 i 1 Bilateral Three lobes 1 0 0 3 Four lobes _ -I- 0 0 1 Fronto-parieto-occipital Unilateral Right 2 1 X 4____ Left 0 0 0 0 Bilateral Three lobes 2 0 - 0 2 Four lobes 0 0 1 1 Five lobes 1 0 1 2 Temooro-parieto-occipital Unilateral Three lobes k 0 0 4 Fronto-temporo-parieto-ocicipital Unilateral Right 1 0 1 2 679 Cranial Surgery, 2nd Aux Surg Gp. (Table XV, contd). TABLE XV Survived Deaths Total Wound ole an Wound Infected Fronto-occipital Bilateral 0 0 1 1 Parieto-temporal Unilateral Right 2 I 0 3 Left 6 0 1 7 Parieto-occipital Unilateral Right 2 0 0 2 Left 4_ 0 0 4 Bilateral Two lobes 1 0 0 1 Three lobes ... 1 _ p 0 1 Temporo-occipital Unilateral Hl&ht 1 0 0 1 Left 1 0 0 1 SUMMARY OF PENETRATING HEAD WOUNDS 1. Four hundred and fifty-four records of penetrating head -wounds are reviewed. There were 63 deaths, the wounds of 11 of which were infected. Fifteen cases with infected wounds survived* 2. The average time lag was 19 hours and 18 minutes. Over half of all cases were operated less than 18 hours after woundings, 3. Shell fragments caused 347 wounds, of which 32 were perforating. Small arms fire caused 77 wounds, 29 of which were perforated. 680 Cranial Surgery, 2nd Aux Surg Gp, (Summary, contd). 4» State of consciousness was of definite prognostic significance• Half of all patients were conscious, rational and quiet; only 4»4$ of these died. Twenty and four-tenths percent of the cases were comatose, and 47*8$ of these died, 5. Tetraplegias, mid-brain seizures, dilated fixed pupils, and Cheyne-Stokes respiration were grave prognostic signs, 6« Peripheral cranial nerve palsies were rare* 7# Mild associated injuries occurred in 11*2% of cases. Moderate to severe associated injuries were present in 12.8$ of cases, 8. Mild shock occurred in 20.9$ of cases, while moderate to severe shock occurred in 15.6$ of cases, 9. Shock in uncomplicated head injuries was usually mild, Moderate to severe shock was recorded in 19 of 288 cases having no associated in- juries, a frequency of 6.2$. 10. Local anesthesia alone was used in 255 cases, pentothal alone in 19 cases, local and pentothal in 114 cases and endotracheal ether in 82 cases, 11. Decompressive craniotomy was used in 441 cases. Osteoplastic craniotomy was performed in only 13 cases, 12. Henote foreign bodies were rarely removed. The electro-magnet was used infrequently, 13. Debridement was mainly directed toward removal of all organic indriven matter, devitalized brain and extravasated blood, 14. All devitalized scalp, galea, and pericranium were usually excised, 15. Procedures in scalp closures were directed toward preservation of blood supply and avoidance of tension. 16. The dura was closed in 257 cases, with 22 deaths, four infected survivors, and five wound disruptions. It was left open in 197 cases with 41 deaths, 11 infected survivors, and 24 disruptions, 17# Ninety-six cases were drained with 20 deaths and 11 infected survivors, 681 Cranial Surgery, 2nd Aux Surg Gp, (Summary, conid)* 18, Local chemotherapy was used in 16$ cases, with 47 deaths, 21 Infections, and 26 disruptions. 19, The venous sinuses were involved in 26 cases with seven deaths, 20, Major cerebral arteries were involved in 10 cases with five deaths. In all deaths the anterior cerebral artery was involved, 21, Intracranial hematomas occurred in $3 cases, with seven deaths, 22* The ventricle was open in $2 cases, with 17 deaths, 23, The basal ganglia were damaged in 16 cases with 1$ deaths. 24. The air sinuses were involved in 78 cases, with 11 deaths and one infection. CONCLUSIONS 1, The Evacuation Hospital is the place of choice for forward cranial surgery* 2* Ideally, it is advantageous to have two neurosurgical teams alternating on 12 hour shifts in the same hospital* 3* The subdural space and underlying brain should be exposed in all depressed skull fractures where abnormal neurological signs exist, and in other cases where the dura is tense and discolored and does not pulsate* 4, The state of consciousness on admission is of definite prognostic significance* 5» The concussive force of the wounding agent on the brain increases the severity of the brain damage, 6, Shock is not a problem in uncomplicated head wounds* 7* Decompressive craniotomy is the procedure of choice ir war wounds of the cranium. 8* Thorough debridement of damaged brain, extravasated blood, and all indriven organic matter is the single most important factor in pre- vention of infection* 682 Cranial Surgery, 2nd Aux Surg Gp, (Conclusions, contd). 9* Intracranial hematomas should be suspected where adequate debridement has not relieved the increased intracranial tension, 10* Head wounds complicated by air sinus involvement are not formidable# 11* The scalp should be closed in all uninfected cases regardless of time interval or amount of scalp loss* 12# Hospital type beds are invaluable in aftercare of comatose and agitated patients# 683 MAXTLLO-FACIAL INJURIES PART I IN THE FORWARD HOSPITALS 684- TREATMENT OF MAXILLO-FACIAL INJURIES IN FORWARD HOSPITALS The oases that form the basis of this study were taken from records submitted by teams of the 2nd Auxiliary Surgical Group and cover a period from June 1943 to May 1945* These casualties were incurred in Africa, Italy, and Southern France* Mutilating wounds incurred in the first World War were character- ized by their extensive loss of bony and soft tissue, delayed secondary closures, prolonged periods of convalescence and repeated esthetic operations. Success of reparative surgery is dependent upon the skill of the operator and the availability of the tissue with which to work. It is this letter factor which may bo altered favorably' by a change in the technical procedures in the forward hospital installations. For all practical considerations Maxillo-Faoial cases may be handled in Evacuation hospitals and it is only the exceptional case that cannot be adequately treated for shock and impaired airway in forward units to make rapid evacuation to the rear reasonable* By this triage the patient has advantage of all the facilities of Surg- ical and dental departments as well an their trained oral and plastic personnel. By' this fortunate combination of material and skill, the patient may expect the most p ©raising results in the field of function- al as well as esthetic results. Briefly stated, the most radical changes in procedures developed during this war are* (l) The immediate closure of all facial wounds; (2) Extreme conservation of both soft and bony tissue; (3) Immediate reduction ana immobilization of fractures; (4) Prophylastic use of the sulfonamides and penicillin* With these principles carried out to their maximum extent the patient should reach the hospital in the rear in excellent condition, infection should be insignificant, and tissue loss minimal, and as a result of primary closures much of the reconstructive surgery of the Base Hospitals will become unnecessary. PREBPERATIVE PROCEDURES Tt^Evacuation Hospital Treatment Therapy given by Battalion Aid Stations and Clearing Stations must of necessity be limited, and should go no further than the follow- ing procedures * 68* Study of 276 Gases of Facial Fractures Treated in Field, Evacuation, and ueneral Hospitals in Italy, (Preoperative Procedures, contd). Haemostasis, In spite of profuse arterial supply to the face and neck it is only the rare case that reaches the forward Aid Stations in need of haemostats or sutures. Pressure dressings will usually suffice and mitigate against further contamination of the wound which would result from extensive haemostatic procedures. Airway. Maintenance of a clear respiratory tract may be accomplished by tracheotomy, metal airway, extension of the tongue, and by postural drainage. Shock. In extensive facial injuries with involvement of bone, shock is primarily due to loss of blood. Shock as a result of hemorrhage is best controlled by the administration of whole blood. Blood pressure reading will give an adequate index as to the degree of shock and efficiency of treatment. There is little or no danger of overloading the system as might be expected in cases of thoracic or cardiac injuries, (See page Therapy. Due to mechanical respiratory difficulties in many of these cases it is wise to give morphine sparingly and in no case is it advisable to give more than l/4 grain every four hours. Prophylactic therapy may consist of tetanus toxoid and oral or intravenous sulfadiazine. The local application of sulfonamides may well be discontinued for it only incrusts the wound, its local action in the presence of blood and secretions is quite limited, and what absorption of the drug takes place is uncontrolled. The parenteral use of the sulfonamides is adequate when used in conjunction with penicillin in doses of 25,000 units every four hours. Under these circumstances it has become evident that local and general infections are well controlled. Evacuation Hospital Treatment: Shock. The time lag between administration of emergency treatment to the casualty and admission to an Evacuation Hospital may range from two to as much as 20 hours. Under these circumstances varying degrees 686 Study of 2?6 Cases of Facial Fractures Treated in Field, Evacuation, and General Hospitals in Italy, (Preoperative Procedures, contd). of secondary shock may develop and it is with this variety of shock that the Evacuation Hospital is most concerned. Treatment is limited to the administration of fluids to restore the blood volume and should be accomplished by the introduction of whole blood, plasma, and glucose- saline solution. Solutions or drugs tending to draw tissue fluids into the vascular system are not indicated. In the average maxillo-facial case immediate surgery is not im- perative and in the presence of haemostasis, clear airway, and a reason- ably comfortable patient, it is wise first to reduce shock to a minimum. Many cases will require time-consuming operative procedures under general anesthesia and therefore surgery should be attempted only under controlled conditions. Much can be accomplished at this time by detailed surgery which will in many cases eliminate multiple secondary operations. Continued shock therapy during operative procedures is frequently a requisite. It will also permit prolongation of operative time well beyond ordinary limits. The average blood administration per case was found to be only 125 c,c, per patient in addition to 100 c,c, of plasma, (i.e. - One in four patients received one unit of blood), When associ- ated injuries are deleted from this study it becomes obvious that only the occasional maxillo-facial case is in severe shock when admitted to any hospital installation. Patients in shock from blood loss however, require vigorous and prompt blood replacement. Physical Examination and X-ray. Physical examination of patients with badly comminuted wounds of the face is difficult. This is due to the discomfort experienced by the patient during examination because of impaired airway, potential second- ary bleeding and impaired oral functions. In many cases observation of the track of the missile will give all the information that is required. In the simpler forms of facial fractures the diagnosis may be made on the usual findings of deformity, pain on motion, crepitus and loss of tissue. Preoporative diagnosis is best based upon x-ray findings. In prac- tically all cases films can be taken in sufficient numbers to make an accurate diagnosis. Anterior-posterior and lateral views are generally sufficient for the mandible, maxilla and nasal bones. The Water's position will give good films in fractures of the orbit, entrum, zygoma and frontal sinuses. Anesthesia. Mascillo-f acini cases of the-severe variety may present indications for two types of anesthesia. Preoperative medication, shock therapy and 687 Study of 2?6 Gases of Facial Fractures Treated in Field, Evacuation, and General Hospitals in Italy, (Preoperative Procedures, contd), general supportive treatment can improve the patient’s condition to a point where minor procedures and intermaxillary wiring may be done under procaine. It is felt however, that general anesthesia is indicated in cases requiring manipulation, those having bleeding into the mouth or oro-nasal cavities, and those in an apprehensive condition. Few if any patients can be adequately handled by drop ether or by any other type of simple inhalation anesthetic. Only by the use of endo- tracheal tube and proper attachments can a clear operative field be obtained and the patient be properly protected against the hazards of aspiration and bleeding. The best results are obtained by passing the tracheal tube nasally since it gives the operator a completely clear oral field. If a reasonably small tube is used it need not be removed for 20 or more hours and will guarantee an adequate airway over a suffici- ent period of time to avoid, in most cases, the necessity for a tracheo- tomy , Many simple facial fractures as well as a considerable proportion of compound mandibular and maxillary fractures may well be handled under Sodium psntothal. Of the 2?6 fracture cases 94 received endo-tracheal anesthesia while 102 received Pentothal. With intravenous anesthesia there is always the threat of aspiration from oral bleeding, and the length of operating time is definitely limited. During recent months there has been a definite and increasing tendency to use pentothal for the induction, followed by endo-tracheal inhalation anesthesia. This removes the excitement stage of gas-ether inductions and eliminates the dangers of initiating new bleeding and aspiration. OPERATIVE PROCEDURE Debridement« The patient at this time enters the operative phase. He has previously been given premedicstion of morphine axid atropine, his shock has been controlled, his diagnosis adequately established and a satis- factory anesthetic level obtained, Pridary consideration now centers on cleaning and debridement of the wound. Many facial wounds contain only the foreign body or its fragments while others have a great deal of exbreneous material driven 688 Study of 276 Gases of Facial Fractures Treated in Field, Evacuation, and General Hospitals in Italy. (Operative Procedure, contd). into the wound. The nature of this material depends upon the type of surface covering and the wounding agent, Wounds may contain metal, cloth, stone, dirt, wood and other substances. Foreign matter must be scrupubusly removed either as individual fragments or by flushing the wound with large amounts of saline. Unless painstaking care is given to this feature, subsequent procedures may be rendered useless as infection from retained foreign material will usually result. Due to their tissue tolerance fine metallic particles need not be searched for. After thorough cleansing, the process of debridement may be initiated and it is here that individual opinions differ. Debridement of the bone should be limited strictly to those fragments that will come free with the gloved finger or which may be withdrawn by wiping with gauze. If this course is followed, only those fragnents having some periosteal attachment will remain. These act as potential grafts and should remain viable even though the wound communicates with the buccal cavity. Tissue debridement is far more limited in facial wounds than elsewhere. It may be stated that buccal mucosa should not be debrided at all. Muscle tags and shreds of fascia had best be excised but only in case of the complete absence of a satisfactory attachment. In practically no case may we debride the skin more than one-sixteenth of an inch. This means a mere freshening of the margins and ragged edges in order to enhance primary union. The major point of this super- conservatism is preservation of all facial tissue, A loss of more than 5 am. of skin adjacent to any facial orfice may well mean a severe facial deformity with subsequent multiple plastic procedures necessary for correction. If this type of conservation of bone and soft tissue is to be a success and accomplish its purpose, it must be followed by a meticulous primary closure. Primary Closure. After stabilization of the bony framework, which will be discussed under fracture treatment, the tissue closure should begin with the buccal mucosa. It need not be closed tightly or too accurately for it is planned to use this buccal surface f or Inbfc-oral drainage. The areas between mucosal sutures present an extensive drainage system that will do much toward controlling the postoperative edema and induration that attend most facial wounds. 689 Study of 276 Cases of Facial Fractures Treated in Field, Fv and General Hospitals in Italy. (Operative Proof iur . ;onc .),„ The accurate apposition of muscle and skin follows, Deep or buried sutures should be limited to as few as is compatible witn approximation* The skin is best closed with multiple fine interrupted silk or dermal sutures. By proper suturing, undermining of tissue, and the utilization of local flaps all wounds may be closed primarily. These maneuvers will cover all exposed bone, protact the tissue from infection and contraction, and promote early and complete primary healing. Many cases have been so badly contaminated with foreign material that it is imperative to drain the wound. This may be accomplished by utilizing the buccal surface rather than the skin. Inasmuch as the patient will be in the prone position drainage from most of the buccal «rea will be dependent. External drains are to be avoided if at all possible due to their conspicious tendency to form sinus tracts and scar bands. Stabilization of the fractures and closure of the soft tissue having been completed, it remains but to apply a dressing- Considerable import- ance is attached to this feature inasmuch as moderate continued pressure is'deemed a requirement» Immobilization of the sot. t tissue is physio- logically correct and can be adequately obtained by the use oi diagonally cut stockinette bandage. This material follows the contour of the face in an excellent manner and produces a mild constant pressure. Dressings should not be changed sooner than four or five days provided hemorrhage, acute infection, wound disruption or some other serious complication do not intexvene. Postoperative!/ the patient is started on a course of 25,000 units of penicillin every four hours for a period of three days, or longer if he is febrile. Following the cessation of panic HI in a regiuae of sulfa- diazene is instituted and carried on until the soft tissues have healod or some contraindication has arisen. Chemotherapy. Occasionally, localized cellulitis, induration and abscess formation occurred in spite of the prolonged administration of the above medicaments. This leads us to believe that their routine administration is unnecessary and probably detrimental after a fall in temperature to near normal. Nutrition, The more severe mandibular and maxlllar oases may require some fom of tube feeding for the first 43 hours, however In no case "M “ found necessary to continue this type of administration longer than the 690 Study of 2?6 Gases of Facial Fractures Treated in Field, Evacuation, and General Hospitals in Italy, (Operative Procedure, contd). above time. This was due largely to the excellence of the nursing care and the fine cooperation of the patients. Oral intake was started on the third postoperative day and in practically all cases it was suplemented by intravenous fluids, whole blood, and plasma as indicated. Evacuation, The average hospitalization period for maxillo-facial cases in Evacuation Hospitals was five days and in no case did the time exceed 10 days. Some cases required longer periods due to their associated injuries. TREATMENT OF FRACTURES Emergency Care* Adequate first aid treatment of the severe maxillo-facial casualty cannot be overstressed. Wounds of the face neck and jaws are, as a rule, so extensive in nature and involve such vital structures relative to respiration that prompt and correct first aid must be rendered if the casualty is to survive. Pain is not necessarily severe in most cases, but the sensation of extreme discomfort and impending death is always present. Many times this feeling of impending death is interpreted by the medical officer or first aid man as pain. The casualty is given massive doses of morphine with the idea of relieving him of intense pain. This can be a very dangerous procedure. Any drug which tends to relax or relieve the life struggle of the casualty to maintain an adequate airway and to keep the mouth and throat clear of blood and mucus is contraindicated, Morphine can and should be used but only in minimal doses. The patient must maintain consciousness as it is only by his own efforts that the upper respiratory passages can be kept clear. Hemorrhage must be controlled at once. Due to the size and number of vessels found in the face and neck massive hemorrhage is present in most cases. Compression type bandages or packs may be used to control the bleeding. The application of digital pressure to known points and ligation of vessels is permitted when indicated. Ejqjerience has shown that the Barton bandage as a means of first aid dressing for maxillo-facial casualties is not adequate, and in many cases has proven to be detrimental to the well-being of the patient. 691 Study of 276 Cases of Facial Fractures Treated in Field, Evacuation, and General Hospitals in Italy, (Treatment of Fractures, contd). As has been stated before, the maintenance of an adequate airway is of prime importance in all wounds of the face and jaws, A bandage which in any way burdens or makes respiration more difficult should not be used. The way in which a Barton bandage is applied with its circular tension from the chin to the occiput violates the principle of maintainance of adequate airway. The bandage has a tendency to gather the tissue within its "chin lock11 and by means of its posterior wrapping to force the tissue into the mouth and cause interference with respiration. The whole principle of the Barton bandage is wrong as a first aid dressing for these cases. A bandage must be used which will act as a cradle for the injured tissue, give it support and lift it forward, upward and away from the throat and respiratory passages. The tongue, with its tendency to drop backward into the throat in case of fracture of the hyoid and damage to the supra hyoid muecles, always presents a problem to the battalion surgeon. If the patient has no control of the tongue or if he is unconscious a suture should be passed through the tongue and tied or pinned to the clothing or bandage. Tension applied to the suture will pull the tongue forward and clear the oro-pharynx. Transportation of the casualty will present no problem if the patient is conscious since he will assume the position best suited to his needs. Generally, this position is on the side. In the unconscious patient it will be necessary to provide for dependent drainage and a clear respiratory tract which again are best obtained by the side or face down position. The former is advocated. Classification of Fractures. For this paper, war fractures have been divided into two groups, using as a basis for division the simplicity or complexity of the treat- ment involved. As all war fractures are compound and in thq majority of the cases comminuted, the accepted classification was found impractical for discussion and charting purposes. The two types of fractures used for a basic discussion hereafter are designated as uncomplicated and complicated. The uncomplicated fracture is classified as one in which a minimum amount of treatment is required to give an adequate result and in which there are few problems to deal with at the time of initial surgery. In this typej the soft tissue wound may be more severe than the fracture but all treatment is routinely simple. The complicated fracture may be stated to be more severe, to present multiple problems in immobilization, occlusion, drainage and general treatment. The time element of surgery for the complicated fracture is greatly increased over that for uncompli- cated fracture esses. 692 Study of 276 Cases of Facial Fractures Treated in Field, Evacuation, and General Hospitals In Italy, (Treatment of Fractures, contd>. Treatment of Fractures. The treatment of uncomplicated fractures is not difficult. All the basic fundamental principles of civilian practice are used and are acceptable. Intermaxillary wi*ing has proven to be more practic- able and simpler than any other means of stabilization. Stout s continu- ous loop nethod was most frequently employed. Single loop wiring may be indicated in those cases presenting an extensive loss of bone or where only one or two teeth remain in the posterior segment.^totra- maxillary elastic traction has proven successful because of its ease of application and ready removability in case of emergency. Fixed wiring may be used on a floating posterior fragment where elastic stabilization may be difficult to apply and maintain. Chin traction has frequently been used as an accessory support. The traction or chin strap is made from orthopedic elastic bandage with plasma tubing attached to an operating cap to supply the traction. It is of definite aid to the patient in that it supports the chin an tends to relax the muscle of mastication. As in civilian life, al war fractures of the simple type receive reduction whenever Possible, and stabilization by means of intermaxillary wiring, intermaxillary traction, and chin support. The treatment of compound war fractures requires all the ingenuity, ,wl1 and surgical ludemsnt of the maxillo-facial team. Each case is different and presents different problems although a few basic principles determined from experience apply in all cases. One of the first and possibly most important steps in handling a case of this nature is to make a complete and thorough evaluation of the case. This must be highly stressed for it is of prime importance. Evaluation of the case should include not only the maxillo-facial injury but the associated injuries as well. It may be operative to do nnlv a partial reduction of the fractures or the type of stabilization may have to be altered to reduce the time element. Decision as o gene or local anesthesia may be determined at this .toe. It has bead found J the majority of oases that the entering wound can be closed without ane. thesia or at least under local. Even under the best of conditions ana in the hands of a skilled operator a minimum of one-half hour is requm £ place toe Intermaxillarywiring and in case of a badly compounded fracture the time may be greatly increased. If this work can be done without anesthesia the total operating time is reduced to a minimum d the dental officer becomes available for help in the subsequent oper ti procedures which will be done under general anesthesia. 693 Study of 2?6 Cases of Facial Fractures Treated in Field, Evacuation, and General Hospitals in Italy, (Treatment of Fractures, contd). Fractures of the Middle Third of the Face. Fractures of the middle third of the face are either the result of severe blows directly upon the involved bony framework or, in the greater nunfcer of cases the result of foreign bodies entering the face at high speed. These two classes may be grouped together and sub- divided into simple and compound fractures. Simple fractures or those resulting from the mass application of pressure are frequently depressed. The objective findings indicate the procedure of treatment. Of most common occurrence are fractures of the nose with or without displacement. If the nose is without obvious deformity it is unnecessary to treat the fracture with other than routine hygiene and the use of a vaso-constrictor to the nasal mucosa to improve the airway. Fractures with deviation as a result of breaking the continuity of the nasal bones or frontal processes of the maxilla must be corrected by complete mobilization of the fragments before reduction is attempted. This can only be adequately done under general anesthesia. Fragments are freed by nasal forceps after which the nasal dorsum is forcibly elevated to permit the septum to be returned to its proper relationship. This maneuver prevents the septal deflection so often complicating nasal fractures. If the nasal fracture is properly reduced no splinting is necessary. Frequently the xranipulation produces marked nasal hemorrhage. This is easily controlled by vaseline nasal packs for a period of 24 hours. Compound nasal fractures and those resulting from penetration by missiles should receive a thorough cleansing and an extremely conservative debridement. Free fragments of bone should always be removed even at the expense of some deformity, for these fragments are generally lost as a result of absorption or low grade infection. Reduction of the remaining fragments is accomplished as in the case of simple fractures and adequate splinting is obtained by nasal packs. In severe nasal wounds it is imperative that the lining mucosa of the nasal airways be approximated by suturing. The nasal airways must be maintained and if the mucosa is severely lacerated it may be necessary to suture the fragments over a catheter. Failure to do this may result in ulceration, ultimate loss of mucosa, severe scar formation and final re- traction of the nasal tissue. These deformities and complications are extremely difficult and sometimes impossible' to correct, Atrasia of the nasal airway may readily result from Inadequate primary definitive surgery. 694 Study of 276 Cases of Facial Fractures Treated in Field, Evacuation, and General Hospitals in Italy, (Treatment of Fractures, contd). If the bony framework has been adequately mobilized and reduced and the nasal lining and superficial covering accurately closed, it is probable that no splinting will be required. Tissue loss of the dorsum of the nose, sides, and alae as well as the tip should be repaired in some form of plastic procedure. In general, losses of dorsum and lateral walls may be replaced by naso-labial flaps. This method is equally applicable for losses of the alar skin and adjacent tissue. Loss of tissue of the tip and coluella require more technical procedures for esthetic repair and hence should be closed primarily by approximating skin and mucosa in order to facilitate later surgery. If the wound is too large to permit this to be done it is best to cover the area with a Thiersch graft as a temporary procedure to prevent infection and contraction until the patient may be in a position to receive prolonget plastic surgery. Fractures of the Zygomatic Arch and Antrum. Simple fractures of the malar arch may result from frontal or latera blows and as a rule are depressed. Clinical appearance is that of a depression in the prominence of the cheek with a fullness at the level of the antrum* The fracture sites are generally at the suture lines and as such may involve the floor of the orbit. Diplopia is a characteristic j sign resulting from the lowering of the floor of the orbit or due to interference with the function of the ocular muscles. Reduction of the fracture and correction of the deformity is best accomplished by the Gilles method, An elevator is inserted through a skin incision over the temporal muscle and passed along the deep fascia beneath the muscle to extend beneath the depressed fragments. Moderate leverage will easily effect a dissolution of the impaction, and reduction may be readily effected, Vgry slight muscle pull in oals area will make splinting unnecessary if adequate reduction has been accomplished. When a crushing injury has been sustained and the floor ol the antr i and orbit have been shattered and depressed a combination of methods may be used. In these cases the zygomatic fragments can be mobilized by the Gillies method while the more medial elements are better handled by introducing a small elevator through a buccal Incision at tne level of the second bicuspid tooth. This elevator passes into the antrum and easily encounters the depressed fragments of the fracture, mild leverag of both elevators will produce a prompt reduction. Drainage through tne buccal incision for at least 24 hours is recommended. 69* Study of 276 Cases of Facial Fractures Treated in Field, Evacuation, and General Hospitals in Italy, (Treatment of Fractures, contd). Mandibular Fractures. A total of 153 mandibular fractures are included in this study and represent 57$ of the total facial fractures. Mandibular war fractures are characterized by severe comminution and tremendous loss of bony tissue. A severe shattering effect is produced by the high velocity of the missile as it strikes the bone, resulting in the mandible being broken into multiple large and small fragments. There may be a loss of bony tissue of the entire body from the midline to the angle. The soft tissue of the mouth, tongue and throat may be severely traumatized, all tending to make stabilization difficult. Under consideration here are only those cases of fracture which are the direct result of penetrating wounds and as such are not confined to the usual angle and mental areas, but may occur at any point. Treatment of these injuries may be divided into three steps: Debridement, closure, and fixation. Of primary importance is debridement which should be attempted only under endotracheal anesthesia preferably given by way of the nasal airway. The posterior pharynx is packed off so that the danger of aspiration of blood is practically negligable, After all bleeding has been controlled debridement is begun. Beginning with the skin surface the margins are trimmed followed by moderate excision of the damaged fascia and muscle and lastly control of the bony fragments is accomplished. It has been our policy to remove only those portions of bone that are completely free of any attachments. These attached fragments along with their periosteum should be studiously preserved for they will provide a regenerating bridge across the destroyed mandibular sections. Teeth in the area of impact may be either shorn off at the gingival margin or may show multiple fractures. It is characteristic of these teeth to have multiple fractures so that removal has to be done inv sections and all too frequently the alveolar plate must be excised to permit the exposure of the roots. With this in Mnd it is deemed best not to attempt extraction of teeth from small Fragments or sections of the mandible. Removal may be done after the mandible has solidified and the roots partially loosened. 3h severely shattering injuries the entire body and symphysis of one side may be so comminuted that the fragments contain only one or two teeth. Muscle and periosteal attachments are so reduced that the section exists only by virtue of soft tissue suppert. 696 Study of 2?6 Cases of Facial Fractures Treated in Field, Evacuation, and General Hospitals in Italy. (Treatment of Fractures, contd). In this type of case it is well to immobilise the large mandibular fragment on the good side and align the small fragments by tissue suturing only. If alignment and intermaxillary wiring is attempted these small incorporated fragments would be isolated due to retraction of oral tissue. These pieces of bone should be firmly attached to their new bed before any attempt is made to align and stabilize them. Fixation of large fragments as well as the uninvolved side may be accomplished by various types of intramaxillary wiring and occlusion maintained by intramaxillary elastic traction. The latter greatly facilitates adjustments and permits almost immediate relief in case of aspiration. Intramaxillary wiring may be used throughout the period of stabilization and treatment. In those cases of multiple wounds of the oral cavity and pharynx a cap splint may prove more valuable wnen repeated access to the mouth is necessary. The external wounds in these cases are closed as in simple lacer- ations, The buccal mucosa is only loosely approximated and if drainage is indicated it should be orally. If the buccal wound, is relatively filial 1 external drainage may be provided by a stab wound below the level of the mandible at or near the fracture site. Much has been said regarding the closure of wounds of the face that penetrate into the mouth and in the course 0f the penetration have involved salivary gland tissue. The majority opinion seems to favor the tight closure of both skin and buccal mucosa to the point where the buccal laceration is impervious to contamin- ation from mouth secretions. Some surgeons do not agree with this procedu and as a consequence have closed the skin and deep tissue of the face with the purpose of promoting primary healing of the surface tissue while the buccal surface of the wound has been loosely approximated. In those wound involving salivary tissue and others requiring drainage the procedure has been to drain from the depths of the wound into the mouth rather than through the skin surface. In no instance has there been evidence of disruption due to drainage of salivery secretions. Conversely, lacerating wounds of the parotid gland not communicating with the oral cavity invariably drain externally until such time as reduction of edema and swelling permit normal ductal drainage of the secretions. Fractures involving partial or complete loss of the symphysis present no problem other than that offered by the tongue ana the muscula- ture of the floor in the mouth. Intramaxillary wiring of the body of the mandible provides adequate immobilization and accurate occlusion. In this series only two cases were provided with splints. These . patients were admitted 10 days after injury. Both had gunshot wounds of the symphysis with minimal bone loss or displacement. In no instance ox mandibular fracture has it been found necessary to utilize the arch bar. 697 Study of 2?6 Cases of Facial Fractures Treated in Field, Evacuation, and General Hospitals in Italy, (Treatment of Fractures, contd). All simple fractures were adequately handled by intramaxillary wiring. Of the compound cases only two were splinted and in no case was open reduction found necessary or advisable. Debridement within the oral cavity should be at a minimum. No structure, tissue or fragment should be removed if there is a reasonable possibility of its retaining its vitality. The ability of the mucous membrane to retain its viability is remarkable, and, mucosa will often survive even though stripped from its bed and severely traumatized. Fragments of exposed bone if covered will in many cases retain theii blood supply and will aid greatly in future reconstructive procedures. As stated before complete reduction may not always be accomplished at the time of initial surgery, for the degree of reduction will depend upon the condition of the patient, associated injuries, etc. Stabilization must be obtained in all cases eventually. Intra- maxillary wiring, chin traction, cradle type bandage can all be used when definite Immobilization is necessary. Fractures of the MaxillaeA Compound maxillary fract-ores constitute a smaller number of the total fractures than do the compound mandibular fractures and as a rale are more easily handled. Of the 276 cases, 61 *ere compound raaxixlae which represent 22* of the total. Of the total number of compound maxilaae nine or had antral involvement. This number is sufficiently large o warrant a discussion of the methods of handling maxillary fractures com- plicated by antral involvement, A smal 1 penetrating wound into the antrum is not, for puipose- of discussion, classified as antral involvement. Only those cases presenting a loss of the bony wall are so considered. After debridement of the area is accomplished the " should^ ciosed half-inch bucoal sul -• allowed to project through the drainage point into "h8 The pack is partially removed in 24 hours and completely removed X to maintained. EigW mouth hygiene should follow. Fractures involving f e hard ™ ~s a tracheotomy for relief of this complication. 698 Study of 276 Cases of Facial Fractures Treated in Field, Evacuation, and General Hospitals in Italy, (Treatment of Fractures, contd). After an adequate airway is assured the mucosa over the fracture should be sutured and the fragments reduced by digital manipulation. These fractures are usually associated with penetrating wounds of the antra or severe fractures of the maxilla and as such are stabilized in con- junction with the adjacent fractures. In 61 cases of maxillary fracture 6% were further complicated by the involvement of the orbital bones and 6% by the zygoma. Both of these fractures should be reduced at the time of the maxillary reduction. Since surgical intervention is generally required for these fractures, even though not compounded, it has been the policy to do all reductions under general anesthesia. Reduction of the orbital fractures may be accomplished by the external use of a towel clip or intra-oral use of an elevator introduced through the buccal sulcus. Elevation and reduction of zygomatic fractures can be done by the extra-oral method of Gillies, Of the total maxillae involved, 20 cases or 36% were associated with fractures of the mandible. Reference to Table II will give the fractures most commonly associated with the maxilla. Fracture of one side of the maxilla may be reduced and stabilized by intermaxillary wiring or, if the patient is edentulous, by inserting dentures and supplying support by means of chin traction. Transverse fractures involving the entire maxilla, with the possible involvement of the antral and ethmoid sinuses is not uncommon. These cases can be best stabilized by intermaxillary wiring after manual reduction. Care must be used to restore the nasal airways to provide drainage for the involved sinuses. Impacted fractures of the maxilla were not encountered hence plicated apparatus for their reduction was not required; this type of case would best be handled in a General Hospital, Statistical Review. * A review of over 2,000 records of injuries of the head and neck revealed 276 cases to have suffered bony injury, and of these, 176 were known to be the result of missile trauma. Of the 276 cases, 61 were the result of civilian type accidents or agents and in 37 cases the agent were unknown. From statistics caapHed at an Evacuation Hospital from 12 April 1944 until 2 April 1945, it was found that l*% of the 6943 battle casualti 699 Study of 276 Gases of Facial Fractures Treated in Field, Evacuation, and General Hospitals in Italy. (Treatmsnt of Fractures, contd). passing through the hospital had injuries of the head and neck. Of the 4$, 104 cases or 1*756 had bony injury and can be classified as true maxillo-facial cases. This finding closely follows the Theater finding of 2*2$* The 1*7/6 would be increased if inclusion were made of those cases presenting extensive soft tissue injury without bony involvement* It is of note that true severe maxillo-facial cases comprise only a small part of the total battle injuries* A further finding is the extreme rarity of cases presenting excessive loss of facial tissue. In fact, it may be postulated that only the rare case presents an appreciable tissue loss. Of the 276 listed cases of facial fractures 151 or 54$ were the result of shell fragments. Ten cases were the result of mines and 17 were due to small arms* Non-battle facial fractures comprise some 36$ of the total. This proportion has been consistent throughout the Theater* High velocity missiles have the characteristic of a small point of entry, marked explosive type of damage to the soft tissue, extreme comminution of bone, and a proportionally large portal of exit. Bone is shattered at marked distances from the point of contact and fragments are widely dispersed into the surrounding tissue. Shell fragments differ from small arm missiles only in that their bulk may increase their range of tissue damage, and their motion and size produce a greater amount of trauma at their points of entry and exit. Table I. This table indicates the predominance of definitive treatment in the Evacuation and General Hospitals. Intermax ill ary wiring has been done in 1&% of the cases encountered in the Field Hospitals as against 60% in the Evacuation Hospitals and 67$ in the General Hospitals* Tracheotomies are listed as 29$ in field units and 9,5$ in Base Hospitals, which indicates two possible considerations. One, that those cases triaged to Field Hospitals are more severe and two, that definitive surgery in Evacuation and General Hospitals will often eliminate the necessity for tracheotomy* Table II* If facial fractures are grouped as to severity it is found that approximately one-third are severe, one-third moderate, and the remaining third mild. If the grouping is limited to battle casualties only, the 700 Study of 276 Cases of Facial Fractures Treated in Field, Evacuation, and General Hospitals in Italy. (Treatment of Fractures, contd), percentage of severe cases is increased 55% due to the compounding of the fracture. It is of interest to note that only 35 were not associated with other injuries. Of the 35 cases 30 were civilian type injuries. Ci trie associated soft tissue injuries the face was involved in 198 case ' this involvement being limited to forehead, cheeks and chin. Inv- lv -.i .--nr of the lips, nose, tongue and eyes were next in frequency and occurred r the order given, I.r ;r s ; tS compound fractures of the mandible the tongue was involve times* TABLS I Definitive Treatment of Fractures of Mandible and Maxilla Relative to Hospitals Treat-aex;. Field Hospital Percent No. of 65 Cases Gases Treated Evacuation Hospital Percent No. of 112 Cases Gases Treated General Hospital Percent No. of 29 Gases Cases Treated In ; ermaxiliary Wiring 12 18.% 70 . 60.% 20 67.% Primary Closure 35 53.% 85 ... 73.2 9 30.1 Oressines 29 Uk.i 22 19.* 2 6.6% Preoperative Fluid Therapy 21 32.% 25 .... 21.% 1 2.8% Emergenc y listens ion Support 5 .1% 1 .1% Tracheotomy 19 29.% 11 9.5% 3 io.3^ Acrylic Splint 1 .17% 1 2,8% Simple Reduction o .9% 11 9.5% 6 20.6% Chin Traction 1 .1% ? 10,3% _ No Record of Treatment _ Jt 6.% 6 5.2% 1 1.8* Total Gases Total Cases Total Cases Seen by Seen by Seen by Field Hospital Evacuation Hospital General and Station Hospitals - 65 112 29 701 Study of 276 Gases of Facial Fractures Treated in Field, Evacuation, and General Hospitals in Italy. TABLE II Severity of Fractures Mandible Maxilla Mandible & Maxilla Others Severe 67 26 16 —44 ..., Moderate 49 16 2 Slight O 18 1 3,0..-.- - Complicating and Associated Injuries Associated Injuries: Extremities 98 Chest 28 Abdcpmen 14 7th Nerve Laceration 1 Brain . U Neck 44 Complicating Injuries: Tongue 27 Lips M Face 198 Septum I N9se n Eves 10 TABLE III Missile Type Total Percent of 276 Cases Shell Mine 151 10 - TTvZ Bullet Civilian Type 17 __ Car Bisffl Fall & 3iL 1 8.3% - .36? oTT Plaae — Ustoaa— l -JI 13*7% 702 Study of 276 Cases of Facial Fractures Treated in Field, Evacuation, and General Hospitals in Italy, TABLE IV Relation of Fracture to Agent Mine SheJLl G.S.W Trauma Car Unknown Total s. Mandible 0 _ 3 0 7 8 2 20 C.C. Mandible 3 97 14 .. 5 3 16 138 S. Maxilla 0 5 0 1 3 _ 1 10 C.C* Maxilla 2 36 5 1 1 6 51 Antra 5 21 3 2 0 6 37 Nasal 2 .19 1 18 13 10 63 Frontal 1 7 1 3 0 . .. 4 16 Zy/soma 1 15 2 9 8 3 38 Condyle 0 2 0 1 3 2 8 Hyoid 0 4 0 0 0 0 . 4 Coronoid 0 2 0 1 0 0 3 TOTAL Individual Fractures 388 Tables III and! IV, High explosive shell fragments accounted for 5K% of all fractures and B5% of all casualties in this series. Small arms fire accounted for but 9% and mines 5% of all fracture cases. It is to be noted that 35% of all facial fractures are the result of civilian type accidents and as such must be classed as pptentially avoidable accidents. Tables V, VI, and VII, These tables indicate the relative frequency of the various fractures and their associated fractures. Due to their size and prominence the mandible and maxilla lead in frequency, and the combination of the two fractures occurs approximately five times more often than any other. 703 Study of 276 cases of Facial Fractures Treated in Field, Evacuation, and General Hospitals in Italy, TABLE V Multiplicity of Fractures Involving Mandible No. Cases Percent of Total Mandibles Percent of Total Facial Fractures. S* Mandible 1? 8.2* .. 3.3? C.C. Mandible 102 64.0% 26.0% S. Mandible - Zygoma 4 .. 2.5?. 0.1ff C.C. Mandible - Condyle 1 o.ffl 0.2% C.C. Mandible - 0.0. Maxilla 20 12.0% 5.4% C.C. Mandible - C.C. Maxilla Antral - Frontal - Nasal . 4. . 2.5% 1.03% C.C. Mandible - Antral 1 3.8* 1.5% C.C. Mandible - Orbital - Zygoma 1 0.63% 0.2% C.C. Mandible-Hyoid 2 1.5% 0.4%. C.C. Mandible - Zygoma 2.5? 1.03% TOTAL Mandibles Involved 157 TOTAL Fracture Cases 388 TABIS VI No. Cases Percent Total of Cases Percent Total of Fractures Sf Maxilla 2 3.6% 1^4— C.C. Maxilla 8 lk.0% 2.06% C.C. Maxilla - C.C. Mandible 20 36.0$ 5.15? C.C, Maxilla - C.C. Mandible Frontal - Nasal U 7.2% 1.03% S. Maxilla - Antral - Nasal 1 Xg S- Maxilla — Nasal 5 - i— 1.2% S, Maxilla — Zveoma 2 3.6% 0.51^ C.C* Maxilla - Nasal 5 9.0% l.» U 7.2% —— C.C. Maxilla - Antral L— 7.2* 1.03$ TOTAL Maxillae Involved 55 TOTAL Fracture Cases 3&L.— — ——— 70U Study of 2?6 Oases of Facial Fractures Treated in Field, Evacuation, and leneral Hospitals in Italy, TABLE VII Multiplicity of Fractures - Mixed No. Cases Percent of Mixed Cases Percent of Total Fracture Gases Nasal 37 43.03 . 9.53 Nasal - Antral 3 3 .33 \8l Nasal - Frontal 2 .. 2±2% . M Nasal - Zygoma 2 2.23 Antral - Frontal 3 3 Antra], 7 7.73 1.83 Antral - Zygoma 2 .... 2.23 .53 Frontal - Zy^pma 1 TZ3 .253 .. Frontal 6 iM 1.53 Zygoma ....... 19 . 21.03 4.83 C(jnc\y3,e 4 4.43 1.033 Cgrgniji^ 1 1.13 .253 Hyoid 2 2o23 .53 TOTAL Destruction 1 . 1.13 • 253 TOTAL Mixed Facial Cases 90 TOTAL Fracture Gases m Maxillo-Facial Deaths Figures taken from a survey of 1165 deaths recorded in forward hospital installations show a 0,6% mortality rate for maxi.llo-facial cases. Of the eight cases recorded six were due to maxillo-facial injury and two had minor associated injuries. Of the six aaxillo-facial cases one death was the result of encephalomalacia following ligation of the common carotid artery, three died from shock and two from associated brain injuries. SUMMARY 1, A study was made of 276 patients with fractures of the facial bones. 2, The use of sulfonamides, penicillin, and blood replacement therapy permits primary closure of the soft tissue wound with a reduction in infection and deformity, 3* While the degree of shock was minimal in most cases (an average of only 125 c.c. of blood plus 100 c.c, of plasma being required), severe 705> Study of 276 Gases of Facial Fractures Treated in Field, Evacuation, and General Hospitals in Italy, (Summary, contd). blood loss occasionally required repeated transfusions 4, Interdental ■wiring with intermaxillary elastic tractxon is applicable to nearly all of these cases, fulfills nearly all require- ments of fixation, and may well constitute the definitive as well as the primary treatment* 5, Of the 276 cases, 178 were due to missile trauma, 6, Statistical tables are presented, covering etiology, methods of treatment, severity, complications, type and distribution of the injuries. MAXELLO-FACIAL INJURIES PART n IN THE BASE HOSPITALS 707 BASE SECTION MAXILLO-FACIAL CARS INTRODUCTION The mental image suggested by the term “gunshot -wound of the face and jaws” invariably induces an emotion of sympathy, pity, or out and out revulsion, itfhile numbering few in the total of war casualties, they demand and deserve every conceivable effort in the matter of medical care. This implies skills and facilities over and above the level of “proper” or “ordinary” care, providing it is con~ sistent with the best interests of the Military Service to provide them. An opportunity was afforded for one team from the 2nd Auxiliary Surgical Group to serve in a Maxillo-Facial Center at the 52nd Station Hospital in Naples, Italy, for months, from May 1944 to April 1945, or all but two months of the period of activity of the center. This project was unique in that the paucity of such injuries had not seemed to warrant a full scale effort, complete with triage arrangements, prior to the period of April 1944, Hence, it was felt by the Theater Surgeon that it would be preferable to set limited goals well within reach of attainment rather than to prejudice the chances for success by setting out on too ambitious a program, Experience has shown this to have been a wise decision. The goals toward which effort was spent were as follows lo To return the man to duty in the Theater, 2, To prevent deformity, 3, To gather all possible facts and data regarding this type of casualty. Significantly omitted is the effort to correct deformity where it was evident the man could not be returned to duty in 90 or 120 days in this Theater. The prognosis as to this factor was often extremely difficult at the time of admission, for tissues heal differently in each patient. However, after a few weeks* hospitalization it was usually possible to classify each case nicely so that reconstructive efforts might be limited to those which would return to duty, and the others prepared for return to the United States for further treatment. STATISTICAL STUDY Seven hundred ninety patients were registered on the Maxillo-Facial Service during the 11 months it was operative. The records of these 708 Base Section Maxillo-Facial Care. (Statistical Study, contd). patients were studied in three groups, some of which were overlapping, but it seemed the best composite picture of the statistical data could be presented in that way. This study was made by three individuals, one to each groups Lt. Col* Langdon Parsons, Major H, B. Clark, Jr,, and Major Walter Bird, The findings and conclusions are possibly somewhat colored by the feelings of the man surveying each group, but by and large the opinions met with unanimous agreement. CASES WITH FACIAL SOFT TISSUE WOUNDS ONLY Two hundred thirty-five soft part wounds without facial fracture were studied. The mean average time from injury to arrival at the Center was four days. The mean average time from injury to first definitive treatment was eight hours. Seventy-eight percent of the entire 235 returned to duty in this Theater, Sixty-five percent of the 235 or 155 were primarily sutured. Of these, 66% were sutured in the first 12 hours. Seventy-nine percent of the patients primarily sutured returned to duty. Eighty percent in this group were classified as moderate or severe, while only 50% of those debrided with or without suture appeared in this category. The multiplicity of wounds other than to the face prolonged the hospitalization and decreased the number returning to duty appreciably. Excluding associated wounds to other structures only 3% returned to the Zone of Interior. CONCLUSIONS Primary suture of the face may well be employed as a standard procedure without fear of sepsis. The possibilities of a scar deformity will be reduced to a minimum. This is important for the individual, for the Army, and for the national exchequer, Where the wound involves the 709 Base Section Maxlllo-Facial Care. (Conclusions, contd). face alone and is not complicated by associated damage to other struct ures the man may well be returned to duty within the Theater. Without increasing the risk to the patient, primary suture will in a facial wound of equal severity return a higher percentage of men to duty, with a better cosmetic result, in a shorter period of time, than any other of the popular surgical procedures. It is suggested that it be adopted as a standard approach to this type of wound. GASES V.1TH SOFT TISSUE BOUNDS OVER FACIAL FRACTURES Primary suture over compound wounds of the facial bones was successfully accomplished in 182 cases among 270 missile wounds, or 10%. Eighty percent of the primarily sutured cases were classified as severe, as against 6h% for those debrided only. Three percent of the original primary sutures subsequently broke down. Osteomyelitis was present in 3% of those primarily sutured as against 5.5% for the entire group. Two cases developed non-union of fracture. Seventy percent of the 182 cases were sutured after six hours and U0% after 12 hoursi Sepsis of all degrees among the group of 270 was present in Twelve percent were regarded as severe, with profuse purulent discharge. The end result was influenced by the sepsis in only 2%. The difficulties of suture over compound fractures in the region of continual contamination are obvious, but the possibility of improving tremendously the patient’s status makes the effort worthwhile. These closures should invariably be drained for 48 hours. CONCLUSIONS A noteworthy observation at this Center was the fact that virtually none of the hideous, wide-open facial wounds of World War I fame were seen. The basic reason for this lies in the primary closure of the wound 710 Base Section Maxillo-Facial Care. (Conclusions, contd). following a meticulous debridement. Preferably this should be* accomplished within the first 12 hours. Yet 40$ were done after that time without in- creasing the amount of sepsis. The important factor is the meticulous debridement, not the time interval. After seeing all varieties of primary closure as well as a large number where debridement alone has been performed, we are convinced that disfigurement and deformity can be prevented to a large extent by this procedure. In brief, it would be ideal to care for both soft tissue damage and bony displacement at the same time and within a few hours of wounding. Yet 't.iis is not always possible, VftiHe we agree that early reduction and fixation of the facial fracture is highly desirable it is our feeling that if only a certain amount of time and energy are available for any given case, the first attention should be directed toward the soft part damage. This point will be further discussed in the sections on treatment of the fracture. CASES WITH FRACTURE OF THE MAXILLA One hundred fifty cases with fracture of the maxilla, with or with- out other facial fracture, were studied. Among the various combinations of injuries, 25$ had fracture of the maxilla alone, 22$ had fracture of maxilla and mandible, and 14$ had fracture of maxilla and malar bones. Eighty-five percent battle casualties and 15$ civilian type injuries are noted. Civilian type injuries are less severe - twice as many men return to duty. The extent of comminution in this group is severe, being rated as ••severe” in 45$ and ''moderate” in 25$, Bone loss and displacement are less frequent than in the lower facial area, (A possible explanation for this finding is that when such wounds occur in the upper face the injury is quite likely to prove fatal and do not reach the hospital). The extent of compounding has a direct bearing on disposition, i.e., a case compounded both through skin and oral mucosa is less likely to return to duty than one compounded through either surface singly. 731 Base Section Maxillo-Facial Care. (Gases With Fractures of the Maxilla, contd}• Observations on patients received from forward hospitals showed that proper care had been carried out in nearly all instances. However, 45$ of the cases in this group requiring interdental wiring had not had it done prior to admission to this Center, The time delay apparently did not jeopardize their chance for a prompt recovery. Thirty-eight percent of this group returned to duty in this Theater, One and three tenths percent of this group died after admission at the Center, CONCLUSIONS The general impression is gathered as far as returning a man to duty with an upper facial fracture is concerned, that the ultimate dis- position is determined from the moment he is hit on the field of battle. This is chiefly so because of the high incidence of crippling associated injuries. Further, salvage is possible by early attention to the soft part injury even at the expense of some delay in meticulous reduction of the fracture. Some doubtful cases would be returned to duty with a more elastic evacuation policy. CASES WITH FRACTURE OF MALAR BONE ALONE AND NASAL BONES ALONE Small groups of 21 solitary malar fractures and 16 solitary nasal fractures were studied. All other injuries to these bones were grouped in the series above. Prompt reduction of the displacement is imperative if deformity is to be avoided. After 14 days it may be assumed the fracture wall be fixed, so that refracturing measures will be required. These fractures must be diligently sought for in all UPP®** *-acial injuries with edema, for the swelling may well remain for the 14 day period. CASES WITH FRACTURE OF THE MANDIBLE ALONE Of 219 fractures of the mandible alone, 73$ were missile type of injuries and 26$ were of the so-called civilian type. Two cases of non-union were present among 58 civilian type injuries. 712 Base Section Maxillo-Facial Care. (Gases With Fracture of the Mandible Alone, ccntd), Sighty-five percent of the civilian type injuries returned to duty as against 40$ for the missile type injuries. In the entire group 70$ were unilateral fractures - 66$ in the body of the mandible. Comminution was present in every missile type injury and in 70$ of the entire group. Seventy percent of comminution had more than two cm, 'of mandible involved. Bone loss was present in 30$ of cases, Eighty percent of compounding occurred through the skin or skin and mucous membrane. Seventy percent of the entire group »»’ere compounded to a severe degree. Interdental witing and intermaxillary elastics were the most popular methods of treatment. Less than 20$ required any basic alteration. Trismus has more relation to extent of comminution and compounding than to duration of fixation. The upriding fragment and displacement at the symphysis together with bone and soft tissue loss present the greatest problems. Displacement of the condyle is rarely troublesome. Thirty-five cases of tooth in-line-of-fracture without other mechanism of compounding were available. Delayed union was noted in one and soft part sepsis requiring drainage in three. CONCLUSIONS The relative importance of the soft part wound in relation to the treatment of the fractured mandible is well demonstrated by the differenc< in the number of patients returning to duty following the so-called civil, type of injury, as compared to the missile, or battle types of injury. The civilian type of injury returned to dutytwice as frequently as the missile type. Though the degree of compounding is greater in the missile type, the main difference lies in the extent of the soft part damage. 713 Ease Section Maxillo-Facial Care. (Conclusions, contd). The method of treating these cases by interdental wiring with intermaxillary elastics or wire for the usual type of case has demon- strated its efficiency to a marked degree and certainly may be regarded as the treatment of choice for the Army patient. It can be applied at the first treatment and in many instances respresents the sole definitive treatment. The feet that less than 20* required any basic alteration is ample proof of this fact. There still remain the basic problems of the disintegrated symphysis with bone and soft tissue loss, the upriding proximal fragment, the missing teeth, and the edentulous patient. It is in this group that arch bars, acrylic or silver cast splints are most useful. The other problems of trismus, tooth-in-^ine-of-fracture, the displaced condylar head, and the collapsed lateral segment proved to be far less common in occurrence than would have been expected. From the point of view of salvage in this group perhaps a more optimistic attitude toward early operative interference with bone re- placement might well be considered. There will always be the case where soft part and bone loss is so extensive that closure of the soft parts at the expense of the fracture may be questionable. It is nevertheless a debatable point, for certainly a soft tissue bed fibrosed by prolonged sepsis is not a proper field for reconstructive surgery. Assuming that there are cases which should have fixation of the fracture to the neglect of the soft part wound, it still holds from this experience that these cases are so infrequently encount- ered that they should not be permitted to sabotage the entire program of early soft part closure as the primary consideration. RETAINED FOREIGN BODIES On the subject of foreign bodies, in connection with gunshot wounds of the face and Jaws, it was concluded that they may be retained with a minimum of symptoms. Special indications for removal from strategic areas must be based on surgical judgment. In forward areas they should usually not be removed unless readily available during the course of the debridement• DISEASE CONDITIONS OF M1ILLO-FACIAL AREA During the course of its operation 52 patients entered the Center with various disease entities. The most frequent diagnosis was cellu- litis, with 22 cases. Others were, in the order of frequency: mandibular 7lU Base Section Maxillo-Facial Care. (Disease Conditions of Maxillo-Facial Area, contd). joint disorder, maxillary sinusitis, osteomyelitis of mandible, tumor, and sebaceous cyst. Of this group, liB were returned to duty and four sent to the Zone of Interior, EYE INJURIES Ninety-eight eye cases were studied as a separate group, of which 58 were not recorded in the list of 790 maxillo-facial cases* Perforating vfounds or rupture of the globe resulted in enucleation in Intra-ocular hemorrhage occurred in 16 cases, invariably associated with severe reduction in vision or blindness. Figures on intra-ocular foreign bodies were unsatisfactory as many eyes, which doubtless contained metal, had been removed at forward in- stallations. Mine fragments ranked high among etiological agents forqye injuries. DISPOSITION Overall disposition of the 790 patients was as follows: To Duty To Z. of I. Battle Casualties 349 Civilian Type 183 23 TOTALS 532 or 67% 258 or 33$ 715 9. VASCULAR INJURIES' 716 ARTERIAL INJURIES IN WAR WOUNDS SECTION A - SUMMARIZING TABLES OF DATA ON ARTERIAL INJURIES Table I; Distribution of Injuries of Major Arteries Table IIA: Secondary Amputations Table IIB; Total Limb Loss Table III; Relation of Associated Fractures Table IV: Effect of Time lag Table V: Mortality in Injuries to Arteries SECTION B - DETAILED DATA ON ARTERIAL INJURIES Table VIA; Axillary Artery - Types of Lesions Table vEB: Axillary Artery - Associated Fractures Table VIC: Axillary Artery - Treatment Table VID; Axillary Artery - Mortality Table VILA; Brachial Artery - Types of Lesions Table vIIB; Brachial Artery - Associated Fractures Table VIIC; Brachial Artery - Mortality Table vIID; Brachial Artery - Treatment Table VIII; Radial and Ulnar Arteries Table IXA: Femoral Arteries - Types of Lesions Table IXB: Femoral Arteries - Associated Fractures Table IXC; Femoral Arteries - Mortality Table IXD; Common Femoral Artery - Treatment Table 3XE: Deep and Superficial Femoral Artery - Treatment Table IXF; Superficial Femoral Artery - Treatment Table XA; Poplitial Artery - Types of Lesions Table XB; Poplitial Artery - Associated Fractures Table XC: Poplitial Artery - Mortality Table XD; Pop].itial Artery - Treatment Table XIA: Tibial Arteries - Types of Lesions Table XIB; Tibial Arteries - Associated Fractures Table XIC: Tibial Arteries - Mortality Table XID; Anterior Tibial Artery - Treatment Table XIE: Posterior Tibial Artery - Treatment Table XIF; Anterior and Posterior Tibial Arteries - Treatment Table XII; Subclavian Artery - Treatment Table XIII: Common Iliac Artery - Treatment Table XIV; External Iliac Artery - Treatment Table XVA; Sympathetic Interruption - Lower Extremity Table XVB; Sympathetic Interruption - Upper Extremity SECTION C - DETAILED CASE CHARTS Table XVI; Carotid Artery- Table XVII: Acute Aneurysms and Arterio-Venous Fistulas 717 ARTERIAL INJURIES IN WAR WOUNDS Many major vascular injuries were .found in seriously wounded pa- tients treated in the high priority hospitals of the Mediterranean and European Theaters during the war just ended, , Injuries of certain major arteries operated upon by surgeons of the 2nd Auxiliary Surgical Group in these hospitals form the basis for this report. Four hundred sixty-three injuries to major arteries in which an at- tempt Hacl been made tcypreserve the involved limb were tabulated. These occurred in 4-58 patients. Since our chief interest lay in the relation- ship of arterial injury to viability of limbs, the vessels studied were the major arteries of the extremities and. the branches of the aorta which supply them. Injuries to other major arteries, either visceral or pari- etal, within the trunk, for example the hypogastries, were not tabulated because they bore no direct relationship to limb survival. Separate tabulations were made of a group of IS 2 “primary amputa- tions" in 180 patients (in addition to and separate from the 4-63 arter- ial injuries referred to above). For purposes of this study, we listed only those primary amputations in which the surgeon had noted that the lack of blood supply was the chief, or one of the most, important rea- sons for doing the amputation primarily. These "primary amputations" are included in this presentation because their number, added to the 4-63 arterial injuries in which the limb was preserved initially, will represent a fairly complete estimation of the total arterial injuries. The injuries to the carotid arteries (17 injuries in 17 patients) and a single instance of injury to the innominate artery have been tab- ulated separately from the arteries concerned with the blood supply of the extremities. Acute arteriovenous fistulae (5) and acute aneurysms (?) encountered in the forward hospitals also have received separate listing-. These vessel wounds have been recorded primarily under the particular artery involved and this additional listing is merely for purposes of separate analysis. In general, the surgeons of this Group followed a radical policy toward arterial injuries whether diagnosed preoperative.lv or at the time of wound debridement. This policy was careful surgical investigation of any wound when it was felt that either the blood supply to the extremity was jeopardized, or the local findings of hemorrhage made surgery impera- tive. Several factors limited both the scope and the accuracy of this study: (l) Evacuation of patients. Patients with'doubtful circulation in an extremity were held in forward hospitals until a favorable result was as,cured or amputation performed. The tactical situation, however,. Arterial Injuries in War Wounds (contd) occasionally required the premature evacuation of some such cases or even the entire hospital. Deleterious effects- on life and limb of some pa- tients may have resulted. (b) Records. Some of the clinical records uere incomplete particularly in respect to the fate of the limb or of the pa- tient while still in the forward hospital after operation. Because of these deficiencies a few cases could not be tabulated at all, and in cer- tain of our tables other cases had to be marked as "undetermined11, (c) Follow-up. Progress notes after evacuation have been obtained on on_y a small portion of these patients. The data presented in this study, therefore, are in the main only those recorded during the periods of treat- ment and observation in the forward hospitals. The material for this study is presented in three sections. Lection A consists of tables summarizing the distribution of injuries, percentage of limb loss, relation of time leg and fractures to limb loss, and mor- tality statistics. Section E contains detailed data on certain indivi- dual arteries, including the effects of various types of lesions on limb loss and detailed tables on treatment. Section G consists of detailed case charts on carotid artery injuries, acute aneurysms and acute arter- iovenous f i s tuJ.a.e, In many of the charts it will be noted that percentages for limb loss and mortality for certain arterial injuries are at variance with the Group’s experience and common sense. This is due to two factors. First, percentages for the above factors in a small group of injuries result in greatly disproportionate statistics. The fallacy of percentages of small numbers is readily apparent (Note amputation rate for the anterior tibia artery) and needs no further comment. Second, altnougn deaths and ampu- tations usually were recorded by the surgeon we did not consider all the other patients and limbs as having survived. Only those having postoper- ative notes, or at least a note relative to evacuation, were considered as having survived. Section "A” TABLE I Distribution of 4-80* injuries oi Major Arteries Brnchial 99 Axillarv 25 Superficial and Prvnl i t.anT Radial 20 deem femoral 6 Simerf'l cial femoral 67 Common Carotid** 17 Subclavian 4 Posterior tibial Common femoral 14 Radial and ulnar 4 Ant/evi or tibial 16 Ulnar l? Common iliac 4 Anterior and posterior tibial External iliac 12 Innominate i J0_ * Included above with the artery involved are 4 acute arteriovenous xis- tulae and 2 acute aneurysms. Not -included in the above total is one case of an arteriovenous fistula' between an external carotid and an internal jugular vein. One case of injury to both the internal and the external carotid art- eries is listed and charted as a common carotid artery. 719 Arterial Injuries in War Wounds (Section "A", contd) The order of frequency of arterial injuries also may be considered from the standpoint of true numbers of injuries to closely associated arteries. Thus, instead of the brachial artery frith 99 injuries being first, the tibials (anterior, posterior and the combination of anterior end posterior) with- 123 injuries would be first in order. The corrected order would then be: first, tibials, 123; second, brachials, 99; third, feraorals, 87; and fourth, popliteals, 72. Table II A presents the percentage of limb loss for each artery. This represents the group for which secondary amputation was necessary following the initial operation on the vessel,. The percentages of total amputations are actually higher then would be expected from mere liga- tion of a main artery. It -would be anticipated that in a fair number of cases the branches of the main artery would act as collateral circula- tion. However, in war wounds with large excavating defects and exten- sive muscle damage of the extremities many arterial branches are injured and the blood supply is further jeopardized. Furthermore, clostridial myositis also interferes with the patency of the small blood vessels. Thus the degree of soft tissue destruction is a factor of great import- ance in eventual limb viability. This introduces an element which does not lend itself to statistical evaluation. In lieu of this, Tablo III lists the effects of compounded fracture on limb loss. Compounded frac- tures were usually noted in the surgeon’s case reports and are used here as an index of the severity of the wound. This table shows fairly con- sistently the higher rate of limb the arterial injury is as- sociated with a compounded fracture. The purpose of Table II B is an attempt to arrive.at a more accur- ate estimation of total arterial injury by including "primary amputations" (amputation done at time of initial operation). Thus, for example, the limb loss of 68.4$ for the popliteal artery (Table II A) is increased to 83,9«i (Table II B). Those figures ere again of importance only for the arteries more frequently injured. 720 Arterial Injuries in War Wounds (Limb loss)(Section "A", contd) TABLE II A Limb Loss in Arterial Injuries with limb Preserved at Initial Operation Vessel Subclavian Tfo.of Limbs* ~T— Secondary Anputations Number Percent —I W.o ' Axillary- 6 3l»o Brachial 111 TO Radial & ulnar , 3 1 53o “ Sadial lu ’ 1 7.0 Ulnar lo 1 10.(5 ’ Common iliac .3 1 33.3 . Skternal iliac ll h 36.11 Common femoral 12 7 58.3. Superficial & deep femoral h ... 3 75.0 Superficial femoral 52 ii6.2 Popliteal IT 39 60.li .Anterior & posterior tibial 28 10 .35.7- .Anterior tibial 52“ 10 81.8 Posterior tibial h5 “T~ 0.9 TOTAL 35>9 I3I1 _37.3 _ * In -which fate of limb • i 10 •H Arterial Injuries in Vfer "bounds (Limb loss, contd) (Section "A", contd) TABLE II B Total limb Loss* Injuries Injuries Requiring Requiring No. of Primary Secondary Total Vessel Injuries Amputation .Amputation Aaputations Subclavian k 0 1 1 Percent of Amputations " TZ.S Axillary 5 5 II 1+5. B Brachial 95 20 “HT" 3i+ Radial & ulnar 9 6 1 7 7.B Radial Ik 0 1 1 7.1 Ulnar 16 6 1 ' 1 16.0 " Common iliac h 1 1 T~ 56.0 External iliac 12 ~T~ “IT" 5 i+1.7 Common femoral 11+ 2 7 “ 6I+.3 . Superficial & deep femoral 11+ 10 3 13 92.8 Superficial femoral 73 21 21+ 1+? 61.6 Popliteal H2 55 39 9U cc . \o .Anterior & posterior tibial 78 50 10 60 16.9 Anterior tibial 25 Id 21 bh.6 Posterior tibial 53 it “12" 22.6 "TOTAL 182 ” l3l+ 315 * 3h which fate of limb is known. 722 Arterial Injuries on War Wbunds (Associated fractures, contd) (Section "A11, contd) TABLE III Relation of Associated Fractures to limb Loss in 3f>5> Arterial Injuries Ibial Ifcact or Vessel Injuries Anpul Rations Vessel limbs No Fract Number Percent Number Percent Subclavian h Fr. 0 0.0 6 0.0 No Fr. h 100.0 1 2^.6 Axillary 19 Fr. 7 ■36.5 ■■■■ 3 HOT" No Fr. 12 s.2 -- 5 Brachial 75 Pr. 30 ... ho.o 9 3?.o No Fr. $ 60.0 5 11.1 Radial & 3 Fr. 0 6.0 0 670 " ulnar No ft*. ) loo. 6 1 35*3 Radial lh Fr. 9 6iu3 1 ll.l No P*r. 5 0 0.0 Ulnar 10 Fr. 5 0 0.6 No Fr. 5 50I0 l 2o.o Common 3 fr. 0 6.0 0 6.6 iliac No Fr. ~T~ 16o,o 1 33.3 Ebcternal " ii Fr. O' 6.6 6 0.0 iliac No fr. n loo.o k fr Common Fr. 3 25.0:: 2 66.6 femoral No Fr. 9 75.0 _ $ ss.s Superficial 52 Fr. 13 25.6 9 69.3 femoral No~W.— 39 15 3«.U tfeep & super- ii Fr. 2 50.0 2 I6O.6 ficial femoral No Fr. ~T~ 50.0 1 56.6“ Popliteal 57 Fr. __3l 5h.li 23 7U.1 No Fr. 56 U5.6 16 61.6 Anterior & 2b fr. 20 71. U 6 36.6 posterior tibial No Fr. b 2b.6 6 Anterior 21 Fr. 15 ?l.ii 2 13*3 tibial No Fr. 6 28.6 0 0.0 Posterior U2 Fr. 17 ii0.5 3 U.7..... tibial No Fr. 25 59.5 1 4.6 TOTE 355 . TOTAL fr.~ 152 1*2.8 66 39*5 No Fr, 263 TT? 60 723 Arterial Injuries in War TiVbunds (Time lag) (Section "A”, contd) TABLE 17 Effect of Time Lag from to Initial Surgery on limb Loss in 300 Arterial Injuries Time lag (hours) 0-6 T* L** % i T > - 12 “T * 12 - T L • 18 —% 18 - T L • 2k 21; plus Subclavian 4 1 25.0 Axillary U 3 2 2 22.2 1 2 brachial Hi U 2o,6 2? U ll.U ? 1 HT S1 ITT 1 Radial & ulnar 1 2 1 50.0 ftadial 3 8 1 tinar 1 u Common iliac 1 1 1 100.0 Ibcternal iliac k 3 75.0 5 1 20.0 Common femoral 1 U 2 50.0 U 2 5o.o 11 100,0 1 1 100.0 Superficial femoral 10 U Uo.o 17 9 52,9 8 2 25.0 2 2 66.6 ii 2 5o.o tteep and superficial femoral h ,3 75..P Popliteal 9 60.0 27 lb oo.6 7 5 tt-it 2 1 50.0 5 5 100.0 Anterior and posterior tibia! $ 3 60.0 11 5 U5.5 u i 25.0 1 1 100.0 2 Anterior tibial i 7 1 Hi. 3 ii 2 Posterior tibial 8 1 12.5 1? 2 10.5 _5_ i 20.0 3 2 “TOTAL 71 28 39.3 _1S3. ub 3l.4 U3 12 167 ~wr TTST !3S * JAunber of arteries injured ** Number of limbs lost Patients who died from the following causes were placed in the category of deaths due to vessel injury: Hemorrhage from the injured artery and the resultant shock, clostridial myositis which appeared after the initial vessel surgery, And pulmon- ary emboli arising from the wound area which involved the injured vessel. Deaths due to pneumonia, atelectasis or emboli not arising in the wound area involving the injured artery were classified as deaths due to general causes. The over-all mortality for the 4111 patients was 13.3%. This rate, when broken down, revealed,a mortality of 8.7$ for arterial injuries uncomplicated by other major wounds, and a rate of 18.7$ for those having other major complicating wounds. Mortality rates for each artery with and without major complicating wounds are indicated-in the above table. In section B the tables which are repeated for mortality rates for the individual arteries list the exact causes of death when such information was available. Vessel Injured Alone Vessel Injury Complicated by Major Wound _• t : *„ Deaths Deaths t 2 No. Cases • Due to j Vessel • Injury :Due to {General {Causes •Total* {Deaths {Percentage : of :Deaths No. Cases Due to Vessel In jury Due to General Causes Due to * CompL “Total Wnnnds {Deaths Percentage of Deaths {Total {Cases.. { Total j Deaths Percentage of Deaths Subclavian 2 : ! 0 : 0 : 0 x s , 2 0 1 2 0 ; 1 2 ,4 2 2 i 25.0? 12 : 2 : 0 . { 2 : 16 M 10 1 1 0 ; 2 20,0? : 22 t 4 18.2? Brachial 46 : 2 : 1 : 3 : 6.5? 31 0 6 5 : 11 35.5? { 77 : 14 18,2? : Radial and Ulnar 3 : s 0 : 0 : 0 : Of 1 0 0 1 : 1 100.0? 2 4 2 1 25.0? Radial 15 ; 0 : 1 : 1 ? 5 0 0 0 { 0 056 : 20 ; 1 Ulnar 8 : 1 : 0 : 1 : 12,5? 4 0 0 0 S 0 0? : 12 : i 8.3JA Common Iliac 1 s 0 { 0 s 0 : 0? 4 0 1 1 { 2 50,0?~ : 5 : 2 40,6? External Hiao 1 : 0 : 0 : 0 * o? 11 3 1 1 ; 5 45.4? : 12 • 5 Cnmmnn Femoral 8 : 1 { 2 ; 3 i. 37.5? 4 1 0 0 .• 1 25.0? : 12 . 4 353 Superficial Femoral 46 » 3 s 1 : 4 1 8.7? 13 3 2 0 s ? 37.7? 5? 9 15.3? Superficial and Deep Femoral 4 t ! 2 2 2 0 : 2 : 50.0? 1 0 0 2 0 : 0 • 0? 2 5 • 2 40.0? Popliteal 38 ! 0 : 1 : 1 1 2 18 1 0 2 ! 3 16.6? 2 56 2 4 7.1? Anterior and Posterior Tibial 5 2 2 * 1 2 2 : 0 2 * 1 - X s 20.0? 25 2 2 0 1 2 s - 12.0% t 3° 2 2 2 4 13.3? Anterior Tibial 17 t j i { s 0 s 1 2 t .5.9%. 19 i x 0 Q X Q { 0 0% 36 2 I 1 27.7? Posterior Tibial 23 t j 0 2 1 1 i 1_ X A 4.3? 34 : J 0 : t 0 t o • 0 ! 0? 2 i 57 2 2 1 1.7? TOTALS 232— to.c>*.7?} : 7(3.00 ; 20 J 8*7.? L182_ :9(4.9?):13C7.2?):12(6.g>: J4 18,7? 5 411 54 13*1? (Mortality) Mortality in Injuries to Arteries in All Patients TABLE V Arterial Injuries in War Wounds. (Section "A", contd) Arterial Injuries in War Wounds (Axillary arteries, contd)(Section 3) Section nDw TABLE VI A Relation of Type of Lesion to Limb Loss in 19 Injuries of the Axillary Artery Lesion * Number of Limbs Fingers Amputations Above Elbow Total Percent Transection 7 2 .... 1 3 h2.9 Laceration 9 0 3 , 3 33.3 Spasm 2 0 0 0 0.0 Compression 1 0 0 0 0.0 TOTAL 19 2 U 6 31.6 * Three cases of Thrombosis are limb was not recorded* not included because the fate of the TAB IE VI B Relation of Fracture to Liirib Loss in 19 Injuries of the Axillary Artery Number of Limbs Fingers Amputations Above Elbow Total Percent No Fracture 12 1 2 3 25.0 Compounded Comminuted Fracture _2 1 ■ .2 2_ 42.8 TOTAL 19 2 k L— 31.6 726 Arterial Injuries in War Wounds (Axillary arteries, contd) (Section ”3", contd) TAB IE VI C Results of Various Types of Treatment of 13 Injuries of the Axillary Artery as Measured by Idnb Loss Lesion Transection Procedure Ligation Mo. of Lirrbs 8 Amputations Above Fingers Elbow 1 3__ Total . . 4 and Laceration Ligation & stellate ganglion block 6 1 1 2 Suture & stellate ganglion block 1 0 0 0 Spasm Perivascular stripping and injection & ganglion block 1 0 0 0 Perivascular stripping & in.iection 1 0 0 0 Compression Evacuation of hematoma & perivascular stripping 1 0 0 0 TOTAL 18 2 k 6 TABIE VI D Mortality in 22 Cases with Injury of the Axillary Artery Number Causes of Death -Total Percen-Un- of Cases Vessel Injury Other Deaths tage known Without Major Complicating Wounds 12 2 * 0 2 16.6 2 With Major Com- plicating wounds 10 1 1 2 20.0 2 TOTAL 22 3 1 U 18.2 h * One of these cases died of Clostridial • 727 Arterial Injuries in War Wounds (Brachial arteries, contd) (Section MB", contd) TABLE VEL A Relation of Type of Lesion to Lint) Loss in 71 Injuries of the Brachial Artery •^Amputations above Elbow Type of Lesion Nunber of Linfcs Nunber Percent Transection 42 9 21.4 Laceration 17 1 .. 5.9 Thrombosis L_ 4 so.o Sp^sm 7 0 0.0 TOTAL 71 19.6 * All amputations occurred above elbow. TAB IE VII B Relation of Fracture to Limb Loss in 75 Injuries of the Brachial Artery Nuntoer of Limbs ♦Amputations above Elbow Nunber Percent No Fracture 45 5 11.1 Compounded Communited Fracture 30 9 30.0 TOTAL 75 34 18.8 ♦ All amputations occurred above elbow. Arterial Injuries in War (Brachial arteries, contd) (Section ,r3n, contd) TABLE VII C Mortality in 77 Cases -with Injury of the Brachial Artery Number Causes of Deaths Ibtal Perc- link- of Cases Vessel Injury Other Deaths entage norm M.thout Major Com- plicating Iflbunds U6 2* 1** 3 6.5 16 With Major Com- plicating Vbunds 31 0 11-jh** 11 35-5 . 5 TOTAL 77 5 15“ lh ioTz 51 * Doth deaths due to clostridial myositis. ** Che death due to pulmonary embolus. *-** 5 deaths due to shock, 2 due to head injuries, 1 to pulmonary embolus, 1 to bilateral thoracic wounds, 1 to respiratory paralysis from spinal cord injury, and 1 to blast injury to brain and lungs. TABLE VII D Results of Various IJ/pes of Treatment of 71 Injuries of the Brachial Artery as Measured by limb Loss Lesion Lacerations Procedure Ligation "1E7ST- Limbs Anput- ations * “T~ _ and Ligation & stellate ganglion block 19 5 Transactions Ligation & perivascular stripoing 1 0 Suture & stellate ganglion block 1 0 Suture, stellate ganglion block & perivascular stripping 1 0 thrombosis lb treatment b h Spasm No treatment ~~T~ o Stellate ganglion block i 0 “ Perivascular stripping h 0 Total 71 iU * All amputations done above elbow 729 Arterial Injuries in War Vfounds (Hadial and ulnar) (Section "B”, contd) TABLE VTTI Number of limbs Anputations Number Percent Number Deaths Percent Cause Radial 11* I 71.1* 1 7l.il- ' Pulmonary embolism from femoral vein tilnar 16 1 16.6 " 1 16.6 Clostridial myositis in arm Radial and ulnar 1 1 33.3 1 33.3 Clostridial myositis in lee wound Radial and Ulnar Arterial Injuries 730 Arterial Injuries in War Wounds. (Femoral Arteries) (Section r,I3M, contd) TABLE DC A Relation of Type of Lesion to Limb Loss in 68 Injuries of the Common Femoral, Superficial Femoral, and Deep and Superficial Femoral Arteries, Lesion Vessel No. of Limbs Toes Foot Amputations Leg - Below Above US/3 Knee Knee Total Per- cent Trans action C* 2 1 1 50.0 s' 22 1 2 7 10 46.4 D£> 2 2 2 100.0 Laceration C 6 4 4 66.6 S 26 2 2 4 3 1 12 ■~437T DS 2 1 1 50.0 Thrombosis C 1 ? s 3 2 2 66.6 Contusions s 1 0 Spasm c 2 !*♦ 1 50.0 Compression c 1 1 1 100.0 TOTAL 68 3 5 4 3 19 34 50.0 * C - Common Femoral alone S - Superficial Femoral alone DS - Deep and Superficial Femoral combined *♦ Combination of spasm of common femoral and laceration of the deep femoral. The latter required ligation. Death followed amputation for clostridial nyositis. 731 Arterial Injuries in War Wounds. (Femoral Arteries, contd) (Section !iB", contd) TABLE IX B Relation of Fracture to Limb Loss in S8 Injuries of the Common Femoral, Superficial Femoral, and Deep and Superficial Femoral Arteries, 1 Vessel No. of Limbs T oes Foot Leg Itfs Amputations - Below Above Knee Knee Total Per- cent No Frao- C* 9 5 5 55.5 t vires S 39 3 4 3 1 4 15 33.4 DS 2 2 2 100,0 Compounded C 3 1 1 2 66.6 comminuted S 12 1 2 5 T~ 66.5 fracture DS 2 1 1 50.0 Simple fracture S 1 1 1 100.0 TOTAL 68 3 5 4 3 19 34 50.0 * C - Common Femoral alone S - Superficial Femoral alone DS - Deep and Superficial Femoral combined Arterial Injuries in War Wounds, (Femoral Arteries, oontd) (Section H3M, contd) TABLE IX C Mortality in 76 Cases with Injury to the Common Femoral, Superficial Femoral and Superficial and Deep Femoral Arteries. No. of Causes of Death No. of Peh- Vessel Case Vessel Injury Other Deaths centage Unknown Without major C® 8 lrt 2 3 37.5 8 complicating S 46 s f # " i 4 8.7 1 wounds DS 4 ZJ * ! 2 50.0 With major C 4 : 1 25.0 1 complicating S 13 ftTf ~ 5 37.7 wounds DS 1 0 TOTAL 75 10 5 15 19.7 TO 0 C - Common Amoral alone S - Superficial Femoral alone DS - Deep & Superficial Femoral combined n - Died of clostridial myositis if - Died of pulmonary emboli from the associated • f! ~ Died of shook * - Died of hemorrhage vein ' 733 Arterial Injuries in War Wounds. (Common Femoral Artery) (Section :,B”, contd) TABLE IX D Results of Various Types of Treatment of 12 Injuries to the Common Femoral Artery as Measured by Limb Loss Amputations Lesion No. of Procedure Limbs Above Foot Knee Total Lacerations and Ligation 5 3 3 Transeotion Ligation tc lumbar sympathetic block 1 1 1 Ligation, surgical symp, & fasoiotouy 1 1 1 Suture & lumbar symp, block 1 Thrombosis Arteriotomy & lumbar sympathetic block 1 Spasm No treatment 1 1* 1 Periarterial injec- tion 1 Compression Perivascular strip- ping & lumbar symp. block 1 1 1 TOTALS 12 1 6 7 * Combination of spasm of common femoral artery with ligation of deep femoral artery. the TABLE IX E Results of Various Types of Treatment of 4 Injuries to Both the Deep and Superficial Femoral Arteries. Lesion Procedure No. of Limbs *Amputa- tions Laceration and Ligation Sc lumbar symp. block 1 1 Transection Ligation & surg. lumbar symp. 1 1 Suture 1 Suture, perivascular stripping Sc lumbar symp. block 1 1 TOTALS 4 3 * All amputations occurred above the knee* Arterial Injuries in War Wounds. (Superficial Femoral Artery) (Section "3", contd) TABLE DC P Results of Various Types of Treatment of 50 Injuries to The Superficial Femoral Artery as Ueasured by Limb Loss Lesion Procedure Ho. of Limbs Toes Amputations Leg Below Above Foot Jl/Z Knee Knee Total Lacerations Ligation 13 2 1 2> 1 3 9 and Tran- sect ions Ligation & lum- bar sympathetic block 20 1 1 1 2 5 Ligation A surg. lumbar sympath- ectomy 4 1 1 1 1 4 Ligation, surg. lumbar, symp., A fasoi©tony 1 Ligation, lumbar symp. block A fasototomy 2 1 1 2 Ligation A refridg- eratlon 1 Suture 1 Suture A lumbar symp. block 1 Suture, A surg. lumbar symp, A poriTO.se. strip. 1 1 1 Suture, lumbar symp.block, peri- vascular stripp- ing, A fasoiotony 1 Suture, lumbar symp. block, A perivaso. strip. 1 Ho treatment “T“ 1 1 Thrombosis Surgical Lumbar symp. 1 1 1 Ho treatment 1 1 1 Spasm tfo treatment T“ TOTAL 50 3 4 4 3 10 24 Arterial Injuries in War Wounds (Popiteal arteries, contd) (Section ’•B”, contd) TAB IE X A Relation of types of Injury to Limb Loss in 57 Injuries of the Popliteal Artery Lesion Severed Number of Limbs 23 Toes 0 Foot 3 Amputations Leg-E/3 Above Knee 2 Ik Total 19 Percent 82.6 LAcerated 18 1 1 0 8 10 55.5 Thrombosed ... 7 0 2 0 3 5 71.4 Compressed .. . 3 0 0 0 0 0 00.0 Spasm . _ . .. 6 00 0 0 5 5 . 83.3 TOTAL £2 1 6 2 30 . 39. 68.4 TAB IE X B Relation of Fracture to Limb Loss in 57 Injuries of the Popliteal Artery No Fracture Number of Limbs 26 Toes 1 Foot — Amputations UfAi/3 Ab< 1 svc Knee 8 Total 16 Percent 61.6 Fracture 31 0 0 1 22 23 74.1 TOTAL n 1 6 2 30 39 68,4 TAB IE X C Mortality in 56 Cases with Injury of the Popliteal Artery Nunber of Cases Causes of Death Total Vessel Injury Other Deaths Percen- tages Unknown Without Major Complicating Wounds 38 . 0 1 i 2.6 - U . With Major Complicating Wounds 18 1 * 2 16.6 2 TOTAL 36 1 7.1 16 ♦ Clostridial Myositis Arterial Injuries in War Wounds (Popiteal arteries, contd) (Section "B”, contd) TABLE X D Results of Various Types of Treatment of 57 Injuries of the Popiteal Artery as Measured by Linfc Loss Lesion Laceration Number Procedure of Limbs No treatment 1 Toes 0 Amputations Leg- Foot M/3 0 1** Above Knee 0 Total 1 and Ligation 10 0 0 1 7 8 Transection Ligation & lunbar symp. block 18* 0 2 1 7 10 Ligation with surg. lumbar symp. 4 0 0 0 3 3 Ligation & fasciotomy 1 0 0 0 i i Ligation & stripping 1 0 0 0 i i Ligation, fasciotomy & lumbar symp, block 2 1 0 0 i 2 Ligation, fasciotomy & surg. lumbar symp. 2 0 0 0 2 2 Suture & lumbar symp.‘block 2 0 1 0 0 1 Suture., fasciotomy & lumbar symp, block 1 0 1 0 0 1 Suture, stripping & lumbar symp. block 1 0 0 0 0 0 Thrombosis No treatment 2 0 1 0 1 2 Arteriotony & lumbar symp. block 1 0 0 0 0 0 Lumbar symp. block 2 0 1 0 1 2 Compression Fasciotomy 1 0 0 0 0 0 Spasm Lumbar symp, block 2 0 0 0 2 2 Stripping & lunfoar symp. block ? 0 0 0 2 2 Stripping & periarterial injection 1 0 0 0 0 0 Periarterial injection & lumbar symp, block 1 0 0 0 1 1 • Stripping, periarterial injection & lunbar block 1 0 0 0 0 0 TOTAL 1 6 3 29 ?? * One of these is a thronbosis which was symp.block. ligated and treated with a ** Lesion of vessel discovered at secondary amputation. 737 Arterial Injuries in lifer bounds (Tibial arteries, contd) (Section contd) TABLE XI A Relation of Type of Lesion to limb Loss in 91 Injuries of the Tibial Arteriea Number imputations Lesion Vessel of limbs Number Percent Laceration Anterior tibial 50 ~~T~- "TEE or Pnstarinr tibial LI 7-3 Transection Anterior & Posterior tibial 2k io la.7 Thrombosis Posterior tibial 1 1 ioo. 0“ Anterior & Posterior tibial 2 T“ <076 Spasm Anterior tibial 1 0 o.O" Anterior & Posterior tibial 1 1 166.0 Compression Anterior & Posterior tibial 1 0 0.0 rom ~~w~ 18' i9.f TABLE XI B Relation of Fracture to limb loss in 91 Injuries of the Ubial Arteries Number Amputations Vessel of limbs Number Percent No Anterior tibial 5 5“ _ 0.0 Fracture Posterior tibial 25 1 h.o Anterior & Posterior tibial 8'" 6 75.0 Compounded interior tibial 15 2 13.31 Comminuted Posterior tibial T7“ 3 Fracture Anterior & Posterior tibial 20 6 30.0 TOTAL 19.b Arterial Injuries in Liar Lbunds (Tibial arteries, contd) (Section "E”, contd) TABLE XI C Tortslity in 121 Cases -with Injury of the Tibial Arteries Member Causes of Death Total Vessel of Cases Vessel Injury Other Deaths Perc- entage Without A* 17 I 5.5 Major compli- ~~T~ 23 0 1 i >3_ eating wounds p 5 1 0 1 20.6 Wth" i ~~T9 CT" 0 0 0.0 Major compli- p 3h 0 0 ' 6 S7T5 cat in/? wounds A&P §5 0 3 3 . “1575 TOTAL “155 5“ h 6 u.«? * A - .Anterior tibial P - Posterior tibial Me.P - Anterior & Posterior tibial TABLE XI D Results of Various TVpes of Treatment of 19 Injuries to Anterior Tibial Arteries as Measured by limb Loss Lesion IVansection Procedure Ligation Number of Limbs — Number of Amputations and laceration ligation & lumbar symp. block 6 2# Spasm Easciotomy & lumbar symp. block 1 0 total 22" __T * Che patient had the anterior and peroneal arteries ligated. the posterior tibial and the # Each mark indicates presence of clostridial myositis. 739 Arterial Injuries in War ’founds (Tibial arteries, contd) (Section "i1*, contd) TABLE XI E Results of Various types of Treatment of hh Injuries to Posterior Tibial Arteries as Measured by limb loss lesion Transection Procedure ligation Number of limbs Number of Anputations and laceration ligation & lumbar symp. block 9 . 3# . ligation fc fasciotomy 2 0 ligation, fasciotomy & lumbar symp. block 1 0 TOTAL uu li # Each mark indicates presence of clostridial myositis. TABLE XI F Results of Various 'types of Treatment of Injuries to both the Anterior & Posterior Tibial Arteries as Measured by limb Loss Lesion ifransection Procedure Ligation fiumber of limbs 53 . Number of Anputations W'" and lacerations ligation & lumbar symp. block 3 m ligation & surgical lumbar sympathectomy 3 20 ligation & fasciotomy 2 i«* # ligation, fasciotomy & lumbar symp. block 1 i Compression Evacuation of hematoma 2 0 ' fasciotomy 1 5 TOTH 27 ll ** Che patient had the anterior and the peroneal arteries ligated. posterior tibial and # Each mark indicates presence of clostridial myositis. 740 Arterial Injuries in Infer Tfounds (Treatment) (Section l!B”, contd) TABLE HI Results of Various of Treatment of b Injuries of the Subclavian Artery as Measured by limb Loss tesion Procedure Kb. of limbs No* of Anpntations transection Ligation 5 r and laceration Ligation •with stellate ganglion block 2 i TOOT Ji i TABLE HII Results of Various 'fypes of Treatment of 3 Injuries of the Common Hiac Artery as Measured by limb Loss lesion Procedure Ife. of limb's" No. of Amputations Transection ligation "1" — r and laceration Suture 2 0 “ 'TOTAL'" 2 i TABLE HV Results of Various t?pes of Treatment of 10 Injuries of the External Iliac Artery as Measured by limb Loss Lesion Procedure No. of limbs Kb. of Aiputations Transection ligation 3 . 5 and laceration ligation & lumbar symp. block 1 0 ligation & surgical lumbar symp. 1 0 Sutured 2 “T“ Sutured & lumbar symp, block 1 0 Sutured & lumbar surgical symp. 1 i 3paszn lumbar symp. block 5 TOTAL lo li ' 741 Arterial Injuries in VJar bounds (Section WBM, contd) In considering the lesion and treatment tables it is readily appar- ent that thrombosis of an artery not ligated is followed by a high rate of limb loss. It is obvious that the theater policy of ligating and ex- cising the thrombosed segment is well founded; Treatment by interruption of the regional or local sympathetics.alone does not appear efficacious, Arteriotony in a few instances was successful in saving the limb. How- ever, such cases should be carefully selected so that arteries which are badly contused or the vessel wall anoxic over an extended time interval are’excluded. Spasm of arteries is not an innocous lesion for about one-fourth lost limbs. The groups treated by a variety of types of sympathetic in- terruption and the group receiving no treatment are too small to evalu- ate the treatment. Arteries compressed by hematomas respond well to local decompression operations. This is commonly noted in compression of the tibial arteries. The- results of treatment of injuries of the popliteal artery are poor. The group in which the wounds of the vessel were repaired by su- ture resulted in the least limb loss. However, th:is comprised but a small pant of the total injuries. It appears that any one or a combina- tion of methods which aims at immediate restoration of the continuity and patency of the artery should be consistently tried. Airberial Injuries in War Wounds (Section M3H, contd) TABLE XV A Effects of Sympathetic Interruption on Limb Loss - Lower Extremity Libation onl v Ligation Lumbar Sympathetic with block Ligation with Lumbar Sura. Syrao. Amputations Total Amputations Total , Amoutations Limbs Ho. 4 Limbs Ho. % Limbs . No. % External il ie c ro AO.O 2. . 0 0.0 2 i _52.o Fcnorals* 18 12 66,6 22 7 31.8 2_ 8 88.8 pord teals 10 8 .80,0 17 10 58.8.... 6 .5 83.1, 33 22 66,6 LI 17 L2.*L— ._JJZ IL 32.A * Common .tenoral artery Superficial artery Superficial end deep femoral artery TABLE XV B Effects of f. sympathetic Interruption on Linb Loss - Upper Bztrernity Libation only Ligation with Stellate Block Total Aranutations Limbs No. /o Total Amoutations Limbs No. % Subclavian . . 2 0 0.0 2 1 ?oto ibcillarv 9 L LL*L ■ 9 2 22.2 Brachial 3 .6 5 13.9 19 5. 26.3. Totals LI 9 12*1 30 8 26,6 heview of the detailed treatment charts reveals such a variety of methods, end combinations of methods, with too few arterial injuries be- ing treated in a like manner to make possible the drawing of many con- clusions. However, by examining various arteries treated similarly in respect to sympathetic interruption it becomes evident that ligation with lumbar sympathetic procaine block is superior to simple ligation in treat- ment of injuries of the external iliac, popliteal and femoral arteries. Examination of the tables shows that limb loss following ligation with lumbar surgical synpathetectomy is approximately double the limb loss fol- lowing ligation with lumbar sympathetic procaine block. The answer to this paradox probably lies in selection of patients. However, there is too little information on the preoperative condition, of the limb to eval- uate the specific cases for which surgical sympathectomy was done. Operative procedure Recoveries Deaths Time Age lag Shock Preoperative examination Associated injuries and degree of vessel in.iurv Vessel Other Cerebral signs Day evac Comment and Day follow-uo P.O. Cause 19 24* Wo Conscious. Rt ■Homei*s syndrome, paralysis of rt diaphragm. No hemiplegia. Transected rt phrenic and recur- rent laryngeal n. Contused symp chain. Rt C. C.* severed Ligation of artery Elective lig, of int. jugular v. None None 7 Also had hemi- paralysis of vocal cords 8' Mod Conscious. No hemiplegia Contusion of 5th and 6th Cervical nerves. Lt C. G. lacer- ated at bifurca- tion Lig, of C. C,, None ext. & int, carotid and vertebral arteries left- Rt hemi- 7 plegia. Lt facial paralysis 29 8i-‘ No Conscious. No hemiplegia lit C. C, lacer- ated near aorta & connected by fis- tula to int. jugu- lar vein. Quadruple liga- tion None None 6 Left-sided headache P.O. 2' No Conscious, No hemiplegia Sucking thoracic wound Rt C. C. lacer- ated near origin Lig. rt C. C. Closure sucking of wd. Hemiplegia im- 2 mediately p.o. Encepha- lomalacia 25 Sev Perforation of trachea C. C. severed Ligation of C. C, Trache- otomy None 3 No hemiplegia 18 days p.o. ISF- No Conscious. No hemiplegia Rt G. C. lacer- ated Ligation rt C. C. Trache- otomy Lt hemi- plegia Lethargy 4 Hemiplegia and lethargy improv- ing at time of evacuation. 21 15 days Conscious. No hemiplegia Pen. wds. of face Rt C. C. lacer- ated Ligation rt C. C. Trache- otomy None Original opera- tion was trache- otomy. C.C. lig. for hemorrhage on 18th p.o. day. 19 36' Conscious. No hemiplegia F. c. c. maxilla and mandible. Lt C. C. lacer- ated Ligation It C. C. None None 8' Unconscious F. c. c. thyroid cartilage. Pen. wds arm & shoulder Lt C, C. lacer- ated at bifurca- tion Lig. of C. C., ext. if: int. caro- tid arteries None 10 Uncepha- lomalacia Sev Conscious. Quad- riplegic. c-vrt facial pa^y Contused superior & modiam cords of brachial plexus & phrenic n. Lt C. C, throm- bosed & It.int. jugular vein lacerated Lig. of It int. jugular vein Autopsy showed 4 thrombosed It C. C. artery Er.cepha- loraalacia 19 6-1-' C. C. perforated Lig. of G. C. & removal of damaged segment 13 24 9tV! No hemiplegia Fen. wd. of thorax Lt C, C. lacer- ated near origin Lig. of G. C. Had heimplegia 2 P.O. lin.ccma- lomalacia 24 3fr' Sev Conscious, Ho hemiplegia Perf. of cervical esophagus. Con- tusion It phrenic nerve Rt G. G. lacer- ated near ox’igin. Rt int. jugular v. Lt vortebr.il a. transected. Trache- otomy Died before op- eration of hem- orrhage from It vertebral a. into pleu-al cavity. * C . C. - Common Carotid Artery Injuries of the Carotid Arteries TABLE XVI Arterial Injuries in War Wounds (contd) Section "C" Operative procedure Recoveries .Deaths . Time klS. l££_ ! Preoperative Associated !ty-pe and degree Vessel other Cerebral Day Comment and signs evc.c follow-up Day . P..Dt Clause Conscious, j'o hominlecTa Per., wt. of thimh Lt 0. 0, lacerated Lig, of 0. G.* Debride- nDr-t bomicomatose 5 "Cerebral dcath" ::o r.uto-cv „ —£7"* To Lt hemiplegia P.t G. C. lacerated just before bifur- cation, Int. jug- ular v. severed. ’’Blakemore cuff" Trache- anastonosis using otory saphenous v. Int. ‘jugular v. ligated. Scnicoratose p.o, Partial recovery from hemiplegic1 by 4th -.o. day. 19 lice- a lone.? ac ia 1C 24' ITo Pen. yjiIs of knee, thora- cic wall .and face. Lt G. C, intiraa bulged through lac- eration in muscu- lar! s. Lt subclav- ian v, lacerated at junction with int. i uvular v. Inversion of aneu- None 2 rysn and suture of muscularis. Lig- ation of veins No interrup- tion of blood flow at any time. 3gv No hemiplegia Contusion It cervical sympathetica Lt int. carotid a. thrombosed ft It ext. carotid a. severed. Lt ext. carotid a. Trache- ligated, otomy 9 Jnecu' aloualacia. thrombosis o* int. carotid a. extend- ing into cerebral vessels. Innominate a. laceration 2 cm. 2 cm. from aorta. Ligation of in- nominate fertery. 3 Inc eph n"1.01 ae. la c ia.. Pcrf. of cervical trachea and cso- . nha.gusj. * C. C. - Common Carotid Artery Table XVI includes 17 natients with common carotid artery injuries and one patient with artery. In 13 o'' the patients the common carotids were lacerated, transected or perforated, were ligated and one was treated by nonsuture anastomosis (Blakemore cuff). In two of the pa. thrombosed, end no surgery was done on either vessel. One injury was an acute aneurysm wMch One acute arteriovenous fistula was treated by quadruple digation. injury to the innominate Twelve of these arteries tients the arteries were was inverted and sutured. Bight of the 17 patients with common carotid artery Injury died (4.7.1;*). Seven died of encephalomalacia hemorrhage into the pleural cavity from a lacerated vertebral artery on the opposite side from the lacerated otid did not survive to reach surger-% Information relative to the preoperative condition was present in six patients dying of encephalomalacia. - Only two of the six had a preoperative hemiplegia. The seventh patient scious and the nuestion of paralysis was not determined. . One with common car- of the seven was uncon- Data concerning preoperativo hemiplegia were available on only six of the nine surviving patients. None of t had a hemiplegia before surgery. There were two postoperative hemiplegias. Neither of these two natients had a plcgia before operation. ;hese six hemi- Artorir.l Injurio- In .J&r . founds, Section "G" (Table XVI, contd) Tine Inf? Lesion Treatment Associated oper- ative findings Complicating wounds and. treatment Results 24' Xntima bulged out through lacerated mpscularis of loft C.C.* artery. Inversion of intima and suture of nus- cularis. None Penetrating wound of riaht knee. Arthrotomy. Evac. 2nd p.o. day. Carotid puJ.se present. 141 30" Us tula between rt external carotid artery & internal .iup'ulnr vein. Ligation of artery and vein. Compounded, com- minuted fracture of rt humorous, None Evac. 3rd p.o, clay. No cerebral signs or symp- toms , S' 30" ■Ustula between It G.G. artery and internal jugular vein. Quadruple ligation None None Evac. 5th p.o. day. No cerebral signs. Lt sided headache (?). 8* 30" Fistula between upper portion of It brachial art- erv and vein. hone No operation for fistula. Penetrating wound of abdomen. Resec- tion of small in- testine . Died 1st p.o, day of shock end atelectasis. 41 45" XIstula between mid portion of It brachial artery and vein. Quadruple ligation and peri-arterial stripping. None Hone Kvac. 1st p.o. day. brachial and radial puJ.se present. 7* 10" ‘fistula bo two on rt popliteal art- ery and vein just above bifurcation Ligation during debridement fol- lowed by primary ar.ro ut at ion, Lxtonsive loss of calf muscles. None Nvac, 8th p.o. day. Uneventful, recovcry. 8 days Pseudo-aneurysm of right popliteal arte w. Primary amputation for ischemic gan- grene . None None Evac. 4th p.o. day. Condition good. * G.G. - Common Carotid Artery Acute Aneurysms and Arteriovenous .Fistulas TABLE XVII Arterial Injuries in Jar Sounds, Section ,,G*1 (contd) 10. ANAEROBIC INFECTIONS ANAEROBIC INFECTIONS A comprehensive report of this important subject in battle casual- ties cannot be prepared from the amount of data pertaining to this sub- ject found in the records. However, one of this Auxiliary Surgical Group, Ife-jor Floyd H. Jergesen, was associated with Lt. Col, P. H. Simeone in the study and report of anaerobic infection in the Fifth Army between the 9th of September 1943 and the 29th of February 1944. The material of this report has been extracted and utilized freely in an attempt to give a picture of this infection in the forward hospitals. Data from the re- cords of the 2nd Auxiliary Surgical Group are presented in respect to incidence in amputations and in association with wounds of the abdomen and chest. Anaerobic infections have been the most serious infections encoun- tered in the forward hospitals. Tetanus infection has virtually been absent. Only one case in an American soldier oould be recalled from the records of this Group during 1943, 1944 and 1945. Three clinical types of anaerobic infection have been encountered, namely clostridial nyo- sitis, anerobic cellulitis and anerobic streptococcal nyositis. The first two were met most often, while the last rarely occurred. Clostridial nyositis is used synonymously with gas gangrene and de- notes the basic pathology of an acute Invasive infection of the viable muscle by pathogenic Clostridia. This infection is fulminating and fatal unless treatment is instituted early and energetically. As found in the study of Fifth Army, casualties with this infection, three-fourths devel- oped in the lower extremity, one-eighth in the upper extremity and one- eighth in the trunk. Prom the clinical point of view, the above-mentioned report to the Fifth Army gives a description of the Welch and Oedematiens types. The discussion of the two types is given below: •Welch Type of Clostridial Myositis "The average length of time from wounding until the diagnosis is apparent in the Welch type is approximately two days. The onset nay be as early as six hours and practically all oases will occur within>10 days after wounding. "Fain Is the most frequent and most striking symptom. It may start as a dull aching pain or it may be of suoh severity as to simulate a major vascular crisis. The pain may be relieved by morphine or splitting a plas- ter casing. Sometimes it becomes progressively more severe until the overwhelming toxemia shrouds it. This symptom is of sufficient value that we have encouraged surgeons not to leave routine orders for morphine af- ter 24 hours. As a general rule* a patient that requires a strong opiate for relief of pain in an extremity 24 hours after operation deserves the attention of his surgeon. Anaerobic Infection (contd) "Increase in the pulse rate is also of importance. The pulse rate of a patient with only extremity wounds and no appreciable secondary anemia should be voider 100 at the end of the second postoperative day, A sustained pulse rate of approximately 120 or a rising pulse rate is a valuable sign of local trouble but by itself, it is not diagnostic. "An elevation of temperature up to 102° to 103° is frequently found and is a characteristic of the Welch type of clostridial myositis. Oc- casionally, the temperature will rise rather precipitously from approxi- mately normal to 104° at idle onset. "The mental symptoms accompanying the Welch type of clostridial myo- sitis are striking. The ‘patient is alert, apprehensive and acutely aware of his surroundings. This apprehension may be extreme. The patient con- stantly quizzes the surgeon concerning his progress. At times, person- ality changes have been noted. A patient who has been cooperative and appreciative will suddenly become hypercritical of the nurses or ward at- tendants’ efforts. We have seen patients throw urinals on the floor, ex- pectorate at nurses and curse the surgeons. As the toxemia disappears, the same patients would apologize, being acutely aware of their previous mental reactions. They remain mentally clear and answer questions rapidly and relevantly. We have repeatedly seen patients remain aware of thei surroundings until a few minutes before death. "As the toxemia increases, the blood pressure gradually falls until the patient is in a state of shock. The rapidity of the fall of the blood pressure depends upon the severity of the infection. Along with the fall in blood pressure, the extremities become cold and the finger tips become cyanotic. "Local examination of the wound is of paramount importance in making an early diagnosis. This can only be carried out satisfactorily with all the dressings removed, adequate light and exposure. It is generally necessary to take the patient to a room where aseptic technique can be carried out and anesthesia administered if necessary. The ordinary ward tent frequently does not provide an ideal place for such examinations. Careful examination of the wounds with adequate retraction will give in- valuable information. It should be pointed out here that we do not ad- vise or encourage malicious disturbance of wounds by frequent dressings. Our enthusiasm to give the patient the benefit of an early diagnosis can be a two-edged sword. However, the judicious examination of wounds has made it possible to diagnose these infections before the patient is mori- bund and in some instances to salvage extremities by local resections that a.few hours later would require amputation, "Two of the most fallacious and least reliable local signs are odor and crepitation. For instance, a wound infected by the Clostridium per- fringens with a minimal number of secondary invaders has practically no Anaerobic Infections (oontd) odor. The foul, putrefactive odor generally associated with clostridial myositis for the most part is due to relatively nonpathogenic organisms, frequently the proteolytic Clostridia. Subcutaneous crepitus is generally not an early finding. Frequently it does not appear at all. Gas in the muscle tissue is of some diagnostic value in this type of infection. It is only contributory and not pathognomonic. Gas in the connective tissue and along the fascial planes is a manifestation of the gas under pressure following the route of least resistance. Not infrequently gas will.be found around the femoral vessels and sciatic nerve in the thigh, having dissected proximally from an infection in the calf. The extend of the gas in the fascial planes is not a manifestation of the extent of the clos- tridial infection. Gas in the muscle tissue and especially in muscle tis- sue that probably was not traumatised by the original injury is an import- ant sign. An X-ray film of the involved area when gas formation has taken place will show a pennate distribution along the muscle fibers. The swelling of the extremity in this type of clostridial myositis is due for the most part to the gas in the soft tissues and to a lesser degree to a minor edema of the subcutaneous tissues. "Early, the skin shows no discoloration but later, it may become cyan- otic. If the soft tissues have been appreciably distended by gas, then the skin may be pale and marble-like in appearance due to the local an- emia. "The most valuable local sign is the appearance of the muscle tissue. Sometimes this cannot be adequately determined without exploration of the wound under general anesthesia with adequate retraction or oven explora- tory incisions. Early, the muscle exposed on the surface may be dark reddish-brown but after this has been removed or the muscle tissue exam- ined some distance from the surface, the characteristic color changes will be noted. The muscle early is pale pink, later it becomes pinkish gray and then bluish-gray. The normal firm resiliency gives way to a softness that simulates the feel of a ball of cotton. Occasionally t he muscle is pasty or mucoid in consistency. These alterations are probably due to the presence of associated proteolytic Clostridia. A transverse section of the muscle bundles will show thdt the normal architecture has been destroyed in varying degrees, depending upon the progress of the in- fection. A transverse section of normal muscle tissue will show the in- dividual bundles standing out quite clearly. Muscle involved by the Welch type of clostridial myositis loses this appearance and presents an almost homogeneous mass. The muscle is relatively dry. Very little fluid can be expressed. Contractility is last early. Pinching or cutting the muscle fibers fail to elicit a response. Bleeding from the smaller ves- sels is absent. Nevertheless, bleeding from larger vessels may persist until relatively late in the progress of the infection. This infection spreads rapidly and in a few hours, the infected muscles, from origin to insertion, will be hopelessly involved. 750 Anaerobic Infections (contd) "Oedematiens Type of Clostridial Myositis "The average length of time from wounding until the clinical appear* anoe of the Oedematiens type of infection is approximately five days, be- ing somewhat longer than the Welch type of infection. A sharp Increase in this type of infection has been noted during this campaign among those wounded in the region of major rivers. As a rule the onset is more in- sidious. Local pain is not an outstanding symptom. It is noted in some- what less than half the oases and is not severe, being dull in character. A sensation of increased weight in the extremity may be one of the earli- est complaints. This has been noted even in amputation stumps. "The pulse rate as a rule is not as rapid at the onset as in the Weloh type. Frequently it will fluctuate between 100 and 110 per minute but may increase to 130 to 140 late in the disease. "If secondary bacterial invaders are minimal, the temperature is low, generally below 100°. However, with an associated aerobic or anaer- obic Infection there may be an elevation to 102° or 103°. It has been noted that following 48 hours of energetic treatment, the temperature will often rise from normal to 102 to 103 degrees. "The mental symptoms accompanying the Oedematiens type of infection are almost the opposite of those of the Weloh type. Very early, the pa- tient shows no mental changes but as the toxemia progresses, he becomes less interested in his surroundings, gradually becoming listless, apath- etic and somnolent. During this phase he will answer questions correctly but slowly. This bradyphrenia in a patient who has been previously alert is a very important sign. The answers to questions are deliberate and brief without an attempt to qualify or clarify the answer. As the toxemia progresses, the patient beoomes stuporous. The seasorium becomes dulled to a point that the removal of dressings that ordinarily would be quite painful, causes little or no discomfort. This may be one of the reasons why local pain in the wound is not a characteristic early symptom. Oc- casionally, we have seen patients become maniacal after the stage of stupor. This acute mania lasts only a few hours, to be followed by an ante- mortal coma and then death. "The blood pressure remains remarkably well sustained, in fact a slight increase in the systolic pressure has occasionally been noted. The blood pressure does not fall until relatively late in the progress of the disease. In one case the blood pressure remained within normal limits until five minutes before death. In spite of the unaltered blood pres- sure, the extremities become pale. "Looal examination of the wound in the very early stages may be very misleading unless it is carried out carefully and with utmost considera- tion of minor changes. Early, the extent of the involvement of muscle may be only in a small part of the wound. However, with good light and adequately exposed, the changes can be seen. 751 Amorobio Infections (contd) "The most important and striking of the local findings is serous exudate. Swelling of the affected part can bo explained entirely on edema. Early in the disease, there is little if any gas in the tissues. Gas formation in this type of infection is a late manifestation. The skin early shows no changes, later it turns bronze and very late becomes bluish- purple with bleb formation. The extent of subcutaneous edema can some- times be outlined in treated oases by the bronze discoloration of the skin a week or so after the diagnosis has been made. The amount of subcutane- ous edema varies considerably with the progress and the stage of the in- fection. Very early, it may involve the subcutaneous tissue in one sec- tor of the wound. Late, it has been seen to extend from a thigh wound up over the anterior abdominal wall, buttocks, chest and reach the scapular region. The outpouring of fluid into the tissues has been so marked in some cases as to oause hemoooncontration. The edema, of the muscle early may be limited only to a small area. As it progresses, the muscle becomes more swollen and bulges from the wound, the skin edges become everted and porky in consistency. The dressings become saturated, as do the plaster splints and bod covers. The consistency of the muscle tissue early is slightly firmer than normal, and just before gas formation starts, it be- comes almost cartilagenous in firmness. Early the color is paler than normal, being pink and having a waxen appearance. This persists until very late when the muscle turns deep red, reddish-brown, purple and then black. It is during this stage of rapid color changes that gas formation takes place* During the stage that the muscle is pink and waxen, the wound generally has a gelatinous membrane over its surface. This gelatin- ous membrane is probably the fibrin of the normal blood clot from which the rod cells and hemoglobin have been washed hy the outpouring of serous fluid. Frequently, bright scarlet, stellate fleks of altered hemoglobin can be seen in this gelatinous membrane. The involved muscle loses its contractility early but uninvolved adjacent areas may continue to contract. The muscle retains its blood supply until relatively late, even being hy- peremio. When one of the involved tufts of muscle is out, there is a profuse oozing of blood and serous exudate. Late in the disease, just before the color changes and gas formation, the blood supply is destroyed. Sections of such areas will grossly show thromboses of the smaller ves- sels, Even in fatal cases, it is surprising to see how little muscle tissue has been involved. At autopsy it has been repeatedly noted that muscle eight to 10 cm, from the wound is grossly normal. "Laboratory findings are not of great value in making a diagnosis. Smears of the wound are of value only in differentiation from anaerobic streptococcal The most striking laboratory finding is the blood count. There is almost always a secondary anemia of varying de- gree. In a few oases, the blood sugar has been found to be lowered. Plasma proteins are generally decreased. The hematocrit may be elevated during the phase of exudation in the Oedematiens type. 752 Anaerobic Infections (contd) infections are rarely pure. They are almost always associated with other organisms, many times giving bizzare and confusing clinical pictures according to the associated organisms. Subsequent aerobic and anaerobic saprophytic infections in these wounds are the rule. These secondary infections many times are quite difficult to treat. The subse- quent anaerobic saprophytic infections follow the clinical course of anaerobic cellulitis for the most part,” The diagnosis then was based on clinical observation of the patient and his wounds. The use of smears of the wound was of little significance in arriving at a diagnosis. It was sometimes necessary to make explora- tory incisions into the muscle to determine the diagnosis. In the prophylactic treatment, the most important factor was the early and complete debridement of wounds. The gas antitoxin, as given, and sulfonamide did not seem to be a determining factor in the prevention of infection. The role of penicillin cannot bo discussed due to lack of evidence at the present. The early use of transfusions of blood in over- coming anemia should not be neglected. In the curative treatment of clostridial nyositis antitoxin was ef- fective in controlling the toxemia of the disease. An initial dose of 10 vials and subsequent doses of five vials every eight hours was the us- ual schedule employed. The role of sulfonamides seems to be the control of secondary invaders rather than of the clostridial infection. Again transfusion of blood was extremely important because of the rapidly de- veloping anemia in this infection. Penicillin as used in these oases was administered with an initial dose of 100,000 units Intravenously and 20,000 to 25,000 units every three hours by the intramuscular route there- after. It is felt that penicillin is a valuable adjunct to surgery In the treatment of clostridial myositis. In the experience of the Fifth Army report the place of operative treatment in the cure of this infection was as follows: "The most important phase of treatment is operative. The anesthesia of choice in these oases is ether and oxygen. As a rule, anemic and toxic patients have not reacted well under pentothal anesthesia. Spinal anes- thesia with the concomitant peripheral vascular dilation, may increase absorption from soft tissues laden with toxins. "Adequate supportive treatment in the form of blood, plasma and dex- trose solution during the operation nay be the decisive factor in making it possible to prolong the procedure until all infected tissue has been removed* "Occasionally, it has been possible to salvage a patient’s life by the application of a very tight tourniquet. Sometimes, a diagnosis is not made until the patient is profoundly toxic. In such condition, ary 753 Anaerobic Infections (contd) major operative intervention would not be wise. A physiological amputa- tion by means of a very tight tourniquet, above the infected area if pos- sible, may reduce absorption until energetic supportive measures resusci- tate the patient to a point that a surgical amputation can be performed above the tourniquet. The period between physiological and anatomical amputation has been as long as 24 hours with survival of the patient, "As far as extremities are concerned, the question immediately arises whether local excision or amputation should be done. Before penicillin was available, 11 cases had local excisions and- all of those patients died. Furthermore, practically all cases that were amputated through in- fected muscle tissue subsequently died. With the availability of peni- cillin, it has been feasible to do a greater number of local resections. Moreover, a high percentage, of cases that have been amputated through infected muscle tissue have also survived with the concomitant adminis- tration of penicillin. "As far as the Oedematiens type of infection is concerned, frequently a diagnosis can be made sufficiently early so that no muscle tissue need be removed primarily. Sometimes it is quite difficult in this typo of in- fection to decide during the phase of toxemia how much diseased muscle will subsequently survive. If the diagnosis has been made early and the major arteries are uninjured, we have elected in a number of instances to Insure adequate drainage and await demarcation. It has been gratifying to see muscle tissue recover that was originally thought to be beyond salvation. However, in sharp comparison with the Oedematiens type of in- fection, the Welch type of infection has always irreparably destroyed some muscle tissue. It is of paramount importance to thoroughly remove this diseased muscle. As a general rule, the decision whether to attempt local resection or to amputate will be made by the extent of the infection. The exposure of major arteries and nerves to sepsis and trauma without adequate soft tissue protection should not be done. When amputation is necessary, it should be done through normal muscle tissue if possible." The most conmon type of anaerobic infection encountered was the anaer- obic cellulitis. This was seen as an acute infection of devitalized soft tissue. It was invasive, but spread for the most part in connective tis- sue and is synonymous with "gas abscess". This infection was encountered where there was severe tissue trauma, interference with blood supply, and inadequate or lack of wound debridement. One of these factors was gener- ally present in the case with anaerobic cellulitis. These were seen most commonly in the extremity or buttocks. This infection, as described in the report to the Fifth Amy, was as follows: "The length of time from wounding until the diagnosis is apparent is approximately three to five days. General symptoms accompanying the in- fection as a rule are not dramatic. Frequently, the infection is discov- ered during a routine dressing or while attempting to explain minor ele- vations of the temperature or pulse. Pain has been rather uncommon. When present it has not been severe. Anaerobic Infections (oontd) "Fever, when present, has been moderate as a rule but on occasion during the spread of an infection or when larger areas are involved, daily- fluctuations between 101° and 103° have been noted. "The pulse rate is generally elevated but roughly follows the temper- ature curve. No changes in the mental status of the patient has been noted, "Examination of the wound is the most important diagnostic method. Odor is invariably present. It is generally foul and putrefactive. Gas is present in varying amount. It is not uncommon to elicit subcutaneous crepitus 20 cm, away from the wound. The gas is present for the most part in the fascia planes and spreads along the fascial planes. The extent of the infection cannot be judged by the extent of subcutaneous crepitus. When gas is present in muscle tissue it does not extend further than the muscle that has been devitalized by the initiating trauma. Edema of the fascia may be present but it is not impressive. "Examination of the depths of the wound reveals thick grayish-white pus in varying quantities along with shreds of devitalized soft tissues. The wound not infrequently is lined with a shaggy-grayish-white, diphther- itic membrane. When this membrane is cut away, normal, healthy, bleeding, contractile muscle is quickly encountered. To be sure, where such an in- fection has gone untreated for days, the adjacent muscle tissue may be somewhat edematous. However, the edema of the muscle tissue is not ex- tensive, Its limitation can be somewhat anticipated by the extent of fascial involvement. As an example, if the fascail sheath of the rectus femoris is involved for a distance of 6 cm, from a lacerated wound of the mid thigh that has been untreated for a period of five days, it would not be unreasonable to expect some edema of the corresponding underlying mus- cle. Careful examination of the fascial planes will show purulent exudate preceded by edema. Ahead of this serous exudate, it is not uncommon to find some gas. Discoloration of the skin has not been noted except as a manifestation of subcutaneous hemorrhage from the original trauma. Red- ness of the skin and local tenderness has been noted at times when con- comitant pyogenic invaders are present." The smear of wound organisms was of no value in arriving at the diag- nosis, which was made entirely on clinical observations. The prognosis in this type of infection is good. Prophylactic treatment is surgical and dependent upon early excision of devitalized tissue and incision of fascial planes for drainage. Likewise the curative treatment of this infection is based upon the surgical removal of devitalized tissue and wide drainage. Cases that came to amputation with this infection did so more because of factors such as interruption of the blood supply to the part or extensive original tissue damage rather than because of the infection alone. Penicillin was felt to be a valuable adjunct to surgery in the control of infection. Antitoxin and sulfonamides were used also, without decisive results. 755 Anaerobic Infections (contd) The rarest type of anaerobic infection encountered was anaerobic streptococcal myositis. It was an invasive infection of muscle and con- nective tissue. A description of a few cases seen in the report to the Fifth Army was as follows: "The onset in one case was two days after injury and the other was five days. Both patients had a moderately elevated temperature and pulse rate. Both complained of pain in the wound which was not marked and was described as "soreness”. "Examination of the wounds showed edema of the subcutaneous fascia, intramuscular fascia and muscle. The muscle involvement seemed to be focal rather than diffuse. Early, circumscribed areas of firm pale mus- cle were noted, these later become whitish-gray, then began to liquify, coalesce and form a small amount of gas. The muscle tissue adjacent to these foci appeared grossly normal in every respect except for some edema. There was a foul odor from the wound. In one sector of the wounds, the skin and subcutaneous tissue had become gangrenous. Elsewhere in both wounds, the skin showed a slight erythema. "The local process stubbornly progressed in both instances and was controlled only by rather energetic measures. Local resection of the involved muscle tissue did not stop the progress although it was repeated twice in one instance and three times in another. "Penicillin parenterally, sulfonamides orally and Zinc Peroxide lo- cally, slowly arrested both infections. In one instance, penicillin was discontinued before all infected tissue was removed and reactivation of the local process started immediately. After the progress of the infec- tion has been controlled, the local use of continuous warm wet dressings has aided drainage and hastened the separation of necrotic tissue." In addition to the discussion of anaerobic infection taken from the report to the Fifth Arc*/, the incidence of the infection as encountered in the records of the 2nd Auxiliary Surgical Group are presented. There were 108 amputations performed for anaerobic infection out of a total of 1357 amputations — a rate of 7,9/£. In all of these amputa- tions, except in 11 instances, there was some interference with blood sup- ply to the part in addition to the anaerobic infection. In the postopera- tive complications of the cases that had initial amputation for cause other than infection, clostridial myositis occurred in IS instances and anaerobic cellulitis was present twice. In this entire group in which 108 amputa- tions were performed for anaerobic infection, 16 deaths occurred from an- aerobic sepsis. In abdominal and thoraco-abdominal cases done by this Group in the forward hospitals there were 21 anaerobic infections recorded. Of these there was one case involving the abdominal wall and five the retroperi- toneal space. All six of these patients died. In the remaining 15 in- 756 Anaerobic Infections (contd) stances the anaerobic infection involved the buttocks or extremity and six of these had fatal outcome. Intraperi,toneal Clostridial Infections Although not included in the 1944-45 statistical survey, at least five cases of fulminating intraperitoneal clostridial infection were seen during the latter part of 1943 by members of this Group. These cases presented a striking clinical and pathological picture that was not dif- ficult to recognize once it was seen. All five patients were admitted to the hospital within twenty hours of wounding, the earliest within four and one-half hours. Uniformly, they showed certain clinical signs and symptoms. These were: (l) shock to an extreme degree, with no response to intensive resuscitation therapy, (2) severe abdominal pain the conscious patient, unrelieved by morphine, (3) mental symptoms, ranging from acute apprehension and agitation to pro- found coma, the latter resembling idle coma seen in some severe head injur- ies, (4) subcutaneous and intramuscular emphysema which was progressive, (5) tympanitic abdomen, with shifting dullness, (6) free gas in the peri- toneal cavity on roentgen examination, and gas bubbles in the abdominal wall, (7) an odor of the wounds suggestive of clostridial infection. Four of the five oases were operated upon, the fifth died before sur- gery could be undertaken. In the four surgical cases, the following was noted; A large amount of foul-smelling free gas escaped on opening the peritoneum. The abdomen contained quantities of very black, thin fluid. There was no evidence of peritoneal defense, no fibrin formation, and no localization. In this there was a marked difference from the peritoneal status exhibited by the oases of "overwhelming contamination", for in this latter type of case there was always present some fibrin deposits. The color of the intestine, particularly of the portions in contact with the peritoneal fluid, was purplish black, and appeared quite gangrenous, yet without the fibrinous coating usually seen on other types of gangrene. The whole picture resembled that of a massive acute mesenteric thrombosis more than anything else. There was little swelling of the intestinal wall. On section of vessels in the mesentery and of the intestinal wall itself, thrombi were seen to fill each vessel, particularly the veins, and bleeding did not occur except from the larger branches of the mesen- teric artery. Gas was seen retroperitoneally and between the leaves of the mesentery if the missile had traversed these areas, otherwise it was not. In all cases the colon was perforated or lacerated. Two of the four patients died before surgery could be completed. The other two lived for 6 l/2 and 10 hours after operation respectively, and in spite of continuous infusions at no time developed a systolic pres1 sure of above 80. Death, with preterminal coma, resulted. 757 Anaerobic Infections (intraperitoneal Clostridial Infections, oontd) All patients had post-mortem examination. The one patient who died before surgery was admitted to the hospital in deep coma and shortly died. Post-mortem revealed no evidence of head or brain injury. In no case was findings other than described above encountered at autopsy. One case showed a pure culture of cl. welohii from the peritoneal fluid. Labora- tory reports were not received on other smears and cultures taken. In the group of thoracic cases treated in forward hospitals, there were two cases recorded who had anaerobic infection of the chest wall. Both of these patients died. Infections of the pleural cavity have been encountered of the foul anaerobic type in which the predominating organism was clostridial. One of these oases showed gas bubbles throughout an intrapleural thrombus on roentzen ray examination. The toxicity and course of these patients did not differ from foul empyemas caused by other organisms. SUMMARY AND CONCLUSIONS 1. The report to the Fifth Army of Simeone and Jergesen has been extracted in order to give a picture of anaerobic infection. The value of this work in the clarification of the subject, and in directing the treatment of anaerobic infection in the forward hospitals is empha- sized. 2, A summary of the incidence of anaerobic infections, as encountered in forward hospitals by the surgeons of the 2nd Auxiliary Surgical Group, is presented as seen in the main first priority casual- ties, i.e, amputations, abdominal and thoraco-abdominal, and thoracic cases. POST-TRAUMATIC RENAL FAILURE 759 POST -TRAUMATIC RENAL FAILURE It has been recognized for a considerable period of time that trau- matio shock is associated with a scant urine output. The cause of oli- guria is believed to be the reduction in the glomerular filtration pres- sure which occurs when the systemic blood pressure falls. As long as the filtration pressure remains low, oliguria persists and azotemia ("pre- renal") results. It is ordinarily believed that adequate restoration of the blood pressure will result in the resumption of urine excretion and that damage of the renal parenchyma, if present at all, is not appreci- able. In the presence of hypotension it becomes extremely difficult to evaluate the functional capacity of the kidneys per se, and in the pre- sence of shock the decreased renal function is commonly attributed to the inadequacy of the circulation. The extent to which the renal circu- lation is decreased in shock has been studied in man. Lauson et al1 have shown that traumatic shock is associated with a marked reduction in renal blood flow which cannot be explained upon the basis of the fall in blood pressure alone and they believe that renal vasoconstriction is responsible for the disproportionate renal ischemia. By means of this vasoconstriction blood is shunted from the kidneys to the central circu- lation (lungs, heart, and brain). They also cite evidence to indicate that the renal ischemia may be so marked in severe or prolonged shook that irreparable kidney damage results and that kidney failure persists after restoration of the circulation to a normal level. In the severe- ly wounded, death often occurs within 24 to 48 hours after operation, and during this period of survival shock of varying severity and dura- tion is commonly observed. In most instances a decreased or absent urine output may be completely explained upon the basis of shock and decreased renal blood flow. However, it is no longer possible to assume that damage of the renal parenchyma has not occurred even though evi- dences of pre-renal oliguria predominate in these cases, (loc. cit.). Observations upon severely wounded men have tended to confirm the earlier Impressions of Lauson and his associates and it has been found that certain patients may survive the immediate postoperative period only to die subsequently of renal failure. Furthermore, this renal failure cannot be satisfactorily explained by the usual concepts of pre-renal oliguria and azotemia since the blood pressure la normal or definitely elevated. Autopsy studies first called attention to the fact that pigment nephropathy and renal failure were not uncommonly observed in the severely wounded who required large volumes of blood in their resuscitation. Lately more extensive studies have been carried on in this theater by The Board for the Study of the Severely Wounded, (A detailed report of the findings of this group is now in the process of preparation. Through the kind permission of the members of the Board we have been able to peruse much of this data. We gratefully acknowledge the help of Lt Col E.K. Beecher, Consultant in Anesthesiology and Resuscitation. Without the interest of Col E.U. Churchill, Surgical Consultant, Med. Theater of Operations a study of this material would not have been possible.) 760 Post-Traumatic Renal Failure (contd) It is difficult to determine accurately the incidence of renal failure among all patients. Many instances of transitory oliguria are not recorded, particularly when the patient survives injury and opera- tion without a complicated postoperative course. An attempt has been made to determine the incidence of oliguria or anuria in the group of 957 cases of intra-abdominal injury previously studied ("The Problem of Shock Therapy in Abdominal Wounds,” see page 122). The incidence of oliguria or anuria among the patients who died in the Field Hospitals is shown in the following table. No patient who died sooner than 48 hours after operation is included in this analysis since the effects of existing shock serve to explain the decreased urine output in the major- ity of these patients. TABLE I ADMISSION SYSTOLIC BLOOD PRESSURE 0®u Hg) Total No. Patients No. of Patients Who Died No. Patients Showing Olig- uria or Anuria Before Death COMBINED INCIDENCE OF ANURIA AND OLIGURIA In fatal In all cases oases 0-40 140 93 10 10.8# 7,1# 41-70 121 61 3 4.9# 2.5# 71-100 250 95 6 6.3# 2.4# 101-120 446 81 5 6.2# 1.1# TOTAL 957 330 24 7.3# 2.5# The most significant finding in this analysis is the increase in the incidence of oliguria and anuria as the degree of shock increased; a definitely higher incidence of renal failure is seen among the patients in the 0-40 mm. group than in the other three groups. 2 Recent studies in this Theater have shown that the level of the non- protein nitrogen rises following injury and that initial levels are higher when shook is severe than when shook is absent or mild. Should diminished urine volume persist after operation there is a progressive rise in the non-protein nitrogen until death or diuresis occurs. Furthermore, when the non-protein nitrogen reaches 65 mgms per cent or above, 70$ of such patients die. In postmortem studies of patients with renal failure a distinct pathological entity has been observed. In brief, the microscopic find- ings are characterized by the precipitation of pigmented casts in the renal collecting tubules. Secondary intranephric hydronephtosis. 761 Post-Traumatic Renal Failure (contd) degeneration and regeneration of tubular epithelium, and interstitial inflammatory changes may bo noted at various stages depending upon the duration of the lesion before death occurred. This lesion is indis- tinguishable from that which follows the transfusion of incompatible blood and early in our experience the term "hemoglobinuria nephropathy" was used to designate the microscopic changes. Now it appears that "pig- ment nephropathy" is more exact sincg considerable evidence exists that the pigment is not always hemoglobin (however the abbreviation "H. ne- phropathy" has been retained in Chart I). Other terms applied to this lesion are "shock kidney" and "lower nephron nephrosis". Since renal failure has been observed to be followed by the demon- stration of pigment nephropathy at autopsy a clinicopathological analysis of -patients dying with this lesion is of interest, (see Figure 96)., Complete autopsy studies have been made upon 51 severely wounded men who died in the Field Hospitals. At the present time reports of the mi- croscopic study of the kidneys are available in 33 of these cases*. This small series has been analyzed from the standpoint of renal pathology and 16 cases (48,4$) were found to have the microscopic diagnosis of pig- ment nephropathy. In two cases the changes were slight or only moderate- ly severe; in 14 oases (42.4$) there was severe or very severe involve- ment. That these patients were severely wounded is evidenced by the fact that, in 14 oases (excluding from the total one case of burn and another case with only slight renal changes) the average admission blood pres- sure was 77/46, The average total** replacement therapy was 1200 cc. of plasma and 3260 oc. of citrated blood (15 cases, burn excluded). Two patients each received 6500 oc. of blood before and during surgery. Further evidence of the severity of shock and injury is afforded by the fact that eight of these 14 patients (57$) had received plasma (an aver- age of 500co. per patient) prior to reaching the Field Hospital, Early in this study it was felt that the transfusion of a large volume of blood (Group 0) which contains anti-A and anti-B agglutinins was the most important factor in the production of pigment nephropathy. It was thought that such changes would occur only in patients whose erythrocytes were susceptible to agglutination and hemolysis by these antibodies, i.e. Group A, B and AB. However, the incidences of patients belonging to the four blood groups are roughly the same in this small series as in the general population. Hence massive universal donor transfusions do not explain all cases in which typical renal lesion are found. * A olinicopathologic correlation such as this pre-supposes the inclusion of microscopic study of autopsy material. For such reports, we are deeply indebted to Lt Col Tracy B. Mallory and Gapt Leslie S, Jolliffe of the 15th Medical General Laboratory and Capt Joseph G, Rothenberg of the 1st Mobile Medical Laboratory. They have also given freely of their time in numerous personal communications. ♦* The total plasm and total blood given from the time of injury to end of operation. 8 Hi I1! 11 II i] W Hii ill H||I 4! Hji iJl Hi •ii) kn j 1 2 ! 1 1 ! 1 « 3 1 1 1 i 1 (! i| !t 3! • l i s I 1 ! i ( 1 • 2 1 } ) 1 j ilh i | ii s i i h ll ii 1 IS h Sh il ti t SI 1 =| « M i fit! m. { 4 5-i - hli |ll ■’ll i |i !| II . * if m |i l|' A A 11 ii* 1 , II in 1 II Ipi E j : S? 2 si ’ li III I Is th ii «il -S s:* 58 ,= s !* Ills Sj 8 1 8-88 sf M Ii i*l» e ? ]i : : Is i ’ 2:8 1 fin a siSil| Sill 3* II |i l p • i , Ii « 8 - SZ2 rfn i ?8 8 -4 ijlSli !il! s,lSS : • ss 1il iii'js in i . 3 • • % Its fiiij i ; SHl| ! Ii ?i) h.s * si M H - * • J*sr.i ns|*i !}jh1 i3|,Ii |3|l H Jail ji iiU \ t j • 155! t - .5*«* **5 * i jiiii s* 1 t Hiss ll 1 >sf *jl 111 5,w* j.r : c. 5.4 i! ii ii \] ri[i fl {S28; ii M 15!! «.-rt «•* . . H'-l i : i *i Jijfil I I ui II llfi Si ilii s# |ii3 t-nt» d). Table V gives a rough idea of the type c* in these priority oases. These figures ww obtains . .. Jy those cases dying primarily of shock. TIME INTERVAL Because of the lack of data on many charts, the only accurate information was obtained for the period from the time of injury to that of operation. Thirty-six percent of the cases in this series had a time lag of over 12 hoars. The following complications were noted either on entry or at operation in this latter group cf patients# TABLE VI Complications Associated With Prolonged Time Lag Time Interval 12-24 hours Severe Shock 55* Estab- lished peri- tonitis 18% Anaerobic Infection 8* . General- ized Wound Infec- tion 3* _ Mening- itis 1% Nt Apparent ucitplica- tiuns 28% 24 - 36 hours 30* 25* 1D% 4% 0 36 end over M 18% 52? 3L m. . Theoretically, most abdominal injuries have peritonitis b .t jsily those cases with a notation of marked peritoneal reaction (exudate and fibrin formation) were counted for the above figure. It is interesting to note that the various infections (except wr tonitis) show a steady increase in frequency with the interval as would be expected. The drop in the percentages of thcas cases with the longer time interval entering the hospitals with ssve. shock and peritonitis is probably due to the fact that the very serious ly wounded die in the field within 12 to hours wien treatment vt available. The same argument may be true for thosw patients anc ao not have one of these complication? on entry. (See last colum of above table). 780 Deaths in Forward Hospitals. • ANESTHESIA Most cases were graded prior to surgery as to their risk, risk 4 being the most serious cases. Fifty-three per cent were risk 4, 29.4$ rick 3, 16$ risk 2, and one and onetenths percent risk 1, Practically all cases were seen preoperatively by the anesthetist and the anesthesia was decided upon in consultation with the surgeon. Pre-medication consisted mainly of atropine sulfate, usually given intra-venously, as the patients had already received large doses of morphine in the forward area. In 28 cases there was actually some element of morphine intoxication which contributed a distinct hazard to the course of the case, some patients arriving at the hospital in coma and with markedly depressed respirations, in one case 6-8 respfc« ations per minute, nineteen cases died in the shock tent and 12 cases died during the induction of the anesthesia. In 1040 cases the following types of anesthesia were used: TABLE VH Type of Anesthesia Used in 1040 Fatal Priority uases Anesthesia Ether & Nitrous- Oxide Oxygen (Endo- tracheal) Thoraco- Abdominal 194 • Thoracic 66 Abdom- inal 38? Extrem- 3*z 95 Head & Spine 6 Neck 6 Total 752 Ether Closed System 2 11 3 16 Pentothal Sodium 8 1 13 14 3* Ether Open Drop 16 7 100 59 2 1 1*5 Local 3 i 32 5 4? Spinal i 1 2 Chloroform i 1 Ethyl Chloride i 1 Deaths in Forward Hospitals (Anesthesia, cont'd). The duration of the operations in 802 cases were as follows; TABIE VIII Duration of Operation Minutes 0-60 60 - 120 ' 12 0 - 1&) and over 14.9$ 35*8$ 30.3^ 19% In IS (1.6$) cases, the deaths were directly attributed to anes- thetic complications. Four deaths occurred during the induction of the anesthesia, seven during the operation, and seven postoperatively. The anesthetic agents used in these fatal cases were gas-coygen-ether endotracheal seven, pentothal five, ether open-drop four, ethyl chloride one, and in one case the agent was not stated. In twelve cases, the death was due to the aspiration of vomitus, two during induction of the anesthesia and five each during and after operation. In one case, the vomiting was precipitated by the surgeon trying to introduce a Levin tube with the patient still under anesthesia. In another case the endotracheal tube was undoubtedly in the esophagus for when positive pressure was applied, the stomach was seen to en- large and before any corrective measures could be applied, the patient vomited profusely and died an asphyxial death. An autopsy of the abdomen revealed an air and fluid filled stomach of tremendous pro- portions , The agents used in these cases were gas-oocygen-ether five, ether open-drop four, pentothal two, and unknown one. In one case the patient died during a pentothal anesthesia, but the record was Incomplete and no explanation of the death was noted. The following brief case reports are of the five remaining cases of deaths due to anesthetic complications, uase 3, This 20 year old soldier had wounds of both lower legs and thighs. He received morphine tartrate gr, 1/4 but no atropine preoperatively and was operated on 39 hours after injury under pento- thal sodium anesthesia. His general condition was good on entry and during the 70 minute operation (B,P, 130/78, Pulse 88, respirations 18 preoperatively). Thirty minutes after operation he was found dead. Autopsy revealed much mucus in the tracheo-bronchial tree with plug- ging of the bronchi. Case 4, This 22 year old soldier had wounds of the abdominal wall and a compound fracture of the femur. He had received morphine Deaths in Forward Hospitals (Anesthesia, cont'd). tartrate gr. 3/4 and two units of plasma before entry and was in clinical shock on entry* B.P* 160/68, pulse 152, respirations 24* He was given one unit of blood and atropine sulfate gr* 3/200, and then operated upon under gas-oxygen-ether endotracheal anesthesia 60 hours after his injury. The abdomen was found to be negative and upon closure of the peritoneum he suddenly stopped breathing. Bronchoscopy revealed copious amounts of thick yellow mucus which could not be removed quickly enough to prevent his death. Autopsy revealed the bronchial tree and lungs to be filled with this thick yellow secretion. Case 5, This soldier entered the hospital in severe shock with a right thoraco-abdominal injury, he responded well to shock therapy and continued to do well during the 100 minute operation under ether endotracheal anesthesia. Four hours after operation, he was found in marked respiratory difficulty due to obstruction of his airway by his tongue. This was immediately corrected, but he died almost at the same time. Case 6, This patient arrived in moderate shock after having received nine units of plasma and morphine tartrate gr, 1/2 in the forward medical installations. Be had pounds of his right arm and abdomen, wine hours after injury and after he had received two units of blood and two of plasma, the anesthesia was started (B.F, 110/60, pulse 160, respirations 20) using ethyl chloride for induction. When he reached the first plane of the third stage of anesthesia his res- pirations became irregular and stopped in spite of oxygen, coramlne and epinephrine. The opinion was that he died of ventricular fibrilla- tion. Case 7# This 23 year old soldier had one small wound in the left popliteal space with a lacerated popliteal artery and vein, he was admitted 11 hours after injury in severe shock and with markedly depressed respirations. In the 90 minutes prior to entry this patient had received four units of plasma. Morphine tartrate gr. 1 1/2, He was treated for two to three hours and responded well from his shock oad over-morphinization, Five minutes after starting the pentoth&l anesthesia his pulse becamt markedly Irregular and he expired in apitc of supportive measures. The opinion was that he died of ventricular fibrillation. All anesthetic complications are not included. There were several eases of postoperative atelectasis and pneumonia but the records were not couplets enough for accurate analysis, acst cf the complications listed above occurred in the early phases of the wav. Most of the cases during the early period received open drop ether anesthesia without preliminary gastric aspiration, and Deaths in Forward Hospitals (Anesthesia, cont’d). bronchoscopy was seldom done. During the latter part of the war gas- tric aspiration was done on all cases, the patient entering the oper- ating tent with the stomach tube in place, and endotracheal anesthesia was almost routinely used. Furthermore, bronchoscopies were done when indicated. WOUNDING AGENTS The causative agent in many of these cases was not stated and in many cases where it was stated, the specific type of missile was not noted, most cases being simply high explosive fragments. However for 1093 cases the following missiles were given: TAB IE U Type of Missile High Explosives Shell Fragments (unclassified) "W Oases 74% 692 ti Mortar fragments 32 M Mines 40 n Bombs 31 ti Booby traps 3 11 Hand grenades 10 « Rifle grenades 1 n Small arms 254 Cases 23.2% Gunshot (unclassified) 218 H Machine gun 32 it Machine pistols 4 it Missiles other than above 30 Cases 2.7% Knife 2 it Burns 8 it Rocks 1 n Tree stump 1 it Blast 1 M Accidents 17 11 TYPES OF CASES AND NUMBER OF INJURIES In order to better study these cases as to their cause of death, they were divided into nine different groups according to the type of their major injury. In the majority of cases the group in which the 784 Deaths in Forward Hospitals (Types of Cases and Number of Injuries, cont’d). case belonged was self evident. In some however, there was a question as to the group in which the case properly belonged. Where the case had two or more different types of injury an opinion was made on the evidence in the case record as to which injury seemed to be the most serious at the time of operation, and the case was placed with the corresponding group. Roughly, of these fatal cases had one or more complicating injuries aside from that of the group in which the case was placed. The following table shows the grouping of the cases in this series of 1165 deaths. One case of this series had no wound but suffered from a severe blast injury, particularly to his brain and lungs, as proven by autopsy. TAB IE I Type of Major Injury in 1165 Fatal Priority Cases No. Dying No, Dying No. Dying no. Dying No. in Shock During Indue- During After Type of Injury Cases Ward tion of Anes, Operation Operation Thoraco- Abdominal 238 5 0 24 209 _ Thoracic 1 1 11 85 Abdominal 534 T~ “T 483 Extremity 191 4 5 & 179 Head 52” 2 0 1 5? Spin© 8 0 0 0 8 Neck ~i*r 1 0 1 16 Maxillo-facial 7 0 0 1 5 Bilims 8 0 “IT" 0 ir~ Blast Injury 1 0 "1T“ 0 i TOTAL 11&5 12 —w 1049 ti.W a.on (7.3*) Nineteen cases in this series died in the shock tent before they could be prepared for surgery. This figure in no way indicates the total nunber of cases dying in Field Hospitals before surgery. During the major portion of the time the shock teams were made tip from Field Hospital personnel and their records are not included in this series. Only those records on cases which were treated by members of the Auxiliary Surgical Group were available. Twelve cases died during the induction of the anesthesia and 85 cases during operation. These records cover all cases in these latter categories as all of these cases were cared for by this group. 785 Deaths in Forward Hospitals (Types of Cases and Number of Injuries, cont 'd). That these cases were of the priority group is further attested by the following table on the number of serious major injuries requiring operative intervention: TABLE XI Number of Major Percentage of Injuries per Patient All Fatal Cases 1 21.3? 2 29.3% 3 26.2^ 4 501 ... 5 6 or more 3*5? Frequency of Major Injuries An attempt was made to determine the principal and one main con- tributing cause for death in each case. In sooecasee this was easily done, but in many cases, the problem of determining the causes of death was a difficult and unsatisfactory one. The records were often incomplete, giving no cause for death or only a contributing cause for death without the principal cause. Some records gave causes for death that did not seem to be related with the general course of the case as stated in the progress notes, or were not supported by autopsy findings. Examples are cases dying of pulmonary edema only or of renal failure within 24 to 48 hours of their operation. Seven hundred and seven (60,7/6) of the cases in this series were autopsied. Only those cases dying cm the operating table where the surgeon continued his exploration and those cases actually autopsied were included in this figure. Cases dying immediately after operation or later were not included unless a formal autopsy was done. Although 60.7% of the cases had some type of an autopsy, hardly any were complete, the autopsy being an exploration of the abdomen alone, chest alone, or a combination of both, in the majority of cases. Also very few autopsy records included microscopic reports. In only \0% of the cases recorded as dying of gas gangrene was there a conformation by smear or culture* Eighty percent of the cases dying of pulmonary embolism were however, recorded as having been found at autopsy. For all the other cases the recorded clinical opinion was the only diagnosis available. 786 Deaths in Forward Hospitals (Types of Cases and Number of Injuries, cont *d). In many cases, the principal cause for death was easily found but because of the multiplicity of serious injuries the main contrib- uting cause of death could not be determined. There were also a few cases with more than one serious injury which did not have any appar- ent principal cause for death other than their wounds, i'or these two groups of patients the contributing and principal causes for death, respectively, were listed as "injuries". All cases in which either the principal or contributing cause, or both, could not be determined, were placed in the "unknown" category, (See Tables), THORACOABDOMINAL INJURIES In tnia series of 1165 cases, 238 (20,4$) were primarily thoraco- abdominal injuries. Five of these cases died in the shock ward short- ly after their admission. Of the other cases, 131 (56,2%) were single thoraco-abdominal wounds and 96 (41,2$) were associated with other injuries. There were six cases which had bilateral thoraco-abdominal wounds without other complicating injuries. In 123 cases (52,8$) the thoraco-abdcminal wound was on the left and in 104 (44.6$) on the right. It is interesting to note that of 44 cases of small bowel injury, the duodenum was involved in 14 cases. Of 19 cases of small bowel injury in right thoraco-abdominal cases, the duodenum was injured in 11 cases (58$). However, of the six injuries to the inferior vena cava, five of them occurred in left thoraco-abdominal cases. The number of other visceral injuries follows roughly as would be expect- ed from the side of injury. The number of injuries to the lungs is probably not correct as they were not always recorded, however in many cases the missile passed very low in the pleural cavity and did not injure the lung. An abdominal approach was used in 39$ of the recorded cases either alone or with a chest debridement or a thoracotony incision. Of these abdominal approaches, 41 were in right, 50 in left and one in bilateral thoraco-abdominal cases• In 127 cases living longer than 24 hours there were 76 recorded complications which did not immediately cause death but which mater- ially hindered the progress of the case. Deaths in Forward Hospitals (Thoraco-Abdominal Injuries, cont’d). TABLE XII postoperative Complications in Thoraco-Abdominal Cases Pulmonary edema ,,, Pneumonia...................... Number of Cases Atelectasis. . Jaundice Anaerobic infection,............................... Subohrenic abscess, Pressure pneumothorax, , Cardiac failure Gastric ulcer, Malaria, , .. Duodenal fistula. Extensive hematoma and/or hemorrhage of the lung.., Of the four cases of anaerobic infection, three occurred in left uncomplicated thoraco-abdominal wounds. In one case, the cardiac failure was in a patient with rheumatic heart disease (old). The duodenal fistula occurred in a case where the perforation was over- looked at the time of the operation. On entry to the hospital 51$ of these cases were in severe shock and in 42$ of the cases it was the principal cause for death. Almost half (46$) of these fatal cases died within 24 hours of their opera- tion (106 cases) or in the shock ward (five cases). It is interest- ing to note that of the six bilateral thoraco-abdoninal cases, only two entered the hospital in severe clinical shock, three cases how- ever died of shock due respectively to hemorrhage, severe contamina- tion, and trauma and contamination. Of the other three cases one each died of pulmonary embolus on the sixth day, cardiac failure on the second day, and atelectasis on the day of operation. Of the cases dying of peritonitis, nine were associated with overlooked visceral perforations of the gastro-intestinal or genito-urinary tract. Of the cases dying principally of shock it was found that 48$ of the cases were with single thoraco-abdominal wounds while 34$ were with thoraco-abdominal wounds with an associated injury. One case died during bronchoscopy immediately postoperatively. This death was thought to be due to the vago-vagal reflex causing an 788 Deaths in Forward Hospitals (Thoraco-Abdominal Injuries, cont’d). acute cardiac standstill* Twenty-nine cases died before their immediate treatment could be carried out, five In the shock ward and 24 at some stage of the opera- tion, The following table shows the causes for death as given for these early fatal cases. TAB IE XIII Causes of Early Death in 29 Thoraco-Abdominal Cases Shock In Shock Ward During Operation 13 Hemorrhage 2 4 Injuries 0 1 Unknown 3 0 Ventricular fibrillation 0 2 Atelectasis 0 1 Aspiration of vomitus 0 1 Cardiac Tamponade 0 1 Vago-vagal syndrome during bronchoscopy 0 1 Infection, wound, general 0 0 Peritonitis 0 0 ABDOMINAL INJURIES The largest single group of patients entering the forward Field Hospitals as priority patients are those with abdominal injuries. For this reason and also because usually the abdominal injuries are of a more serious nature the deaths associated with this injury roughly equal those from all other groups. In this series they make up i+6% of all deaths in the forward hospitals. Of 534 abdominal cases twelve cases died before any surgery could be done, 281 had abdominal injuries only and 253 cases had associated injuries as follows; TABLE XIV Associated Wounds in Abdominal Cases Extremity Wounds No. Cases —m~~ Thoracic or chest wall wounds 2d Head wounds 11 Neurological wounds 11 Vascular wounds (other than abdominal) UU Skeletal wounds (other than extremity) 14 Neck wounds 5 789 Deaths in Forward Hospitals (Abdominal Injuries, cont'd). Of 411 cases recorded, 270 (65.7$) entered the hospital in severe shock and 65 (15.8$) in moderate shock. In 484 cases where the pri- mary cause for death was noted, 45$ were due to shock. Fifty-one cases (9.5$) were in such poor condilon that they died before a great deal could be done for them. In this latter group, 44 cases (86$) died primarily of shock. The following table lists the principal causes of death for these cases as given on the case records: TABLE XV Causes for Early death in 51 Abdominal Cases Shock from Hemorrhage In Shock Ward U During Induc- tion of Anesthesia 2 During QBSX&ASSi 11 Shock from trauma and/or contamination 1 2 24 Anaerobic infection 2 Anesthetic complication, aspiration of vomitus 1 Anesthetic complication ventricular fibrillation 1 Unknown 1 1 Injuries 1 The percentage of deaths due to peritonitis (14$) is high but it is due in part to the fact that in 17 cases perforations in the gastro- intestinal or genito-urinary tract were overlooked at operation. Cor- recting for this brings the rate to 10,6$, It was further noted that 16.5$ of the cases in this series had a full blown, established peri- tonitis at the time of operation. THORACIC INJURIES There were 98 cases (8,4$) that were primarily chest injuries. Two cases died before surgery, one in the shock ward and one during the induction of the anesthesia. The causes of the death were not stated. Of the remaining cases, 58 were injuries to the chest only and 38 were chest injuries associated with other injuries. In six cases the chest injury was bilateral, two of which also had associated extrem- ity wounds. 790 Deaths in Forward Hospitals (Thoracic Injuries, cont »d). Of these 98 cases only 52 lived longer than 24 hour: after oper« tion and among these cases there were 31 postoperative complications recorded. TAB1E XVI Postoperative Complications in Thoracic Cases Atelectasis No. of Cases “IT" Pnevroonia 7 Pulmonary e'dema lo Br one ho-iie ural fistula 3 _ Empyema 2 Malaria 1 Pulmonary edema, pneumonia and atelectasis complicated both thoracic and thoraco-abdominal cases with about the same frequency according to these figures. TABLE XVII Comparison of Thoracic Complications in Thoracic and Thoraco-abdominal Cases, Thorac ©-Abdominal Thoracic Cases Cases Pulmonary edema 16* m . . Pneumonia m Atelectasis 152 Fifty-seven percent of these cases entered the hospital in severe shock and 30% died of shock primarily within 24 hours of their opera- tion* Five of the six cases of pulmonary embolus occurred in cases without associated injuries and in five cases the right chest was the side injured. In thoraco-abdominal cases however, this does not hold, the incidence of pulmonary embolus being fairly evenly distributed to all types of cases. Eleven cases died during the operation* The following table lists the principal causes of death for these cases. 791 Deaths in Forward Hospitals (Thoracic Injuries, cont’d). TAB IE XVIII Causes of Early Death in 11 Thoracic Cases Shock due to trauma Number of Cases .... h Shock due to hemorrhage 1 Anesthetic complication aspiration of vomitus 2 Aieleciasis, massive 1 Ventricular fibrillation 1 Cardiac tamponade 1 Blast injury to the lungs 1 EXTREMITY INJURIES Sixteen percent (191) of these fatal cases were in patients that primarily had extremity injuries, A little over half of these cases (55«5£) had wounds involving the extremity only. The majority of associated wounds were minor in nature but in five cases there were associated abdominal injuries. In three cases an intra-abdominal wound was not suspected and perforations of the bladder, duodenum, and ileum were overlooked. In the fourth case there was a breakdown and leaking from a sigmoid suture line and in the fifth case there was a spontaneous perforation of the ileum in a small infarcted area of the bowel due to a severe blast injury. In four of these cases peritonitis was either a principal or contributing cause for death. Thirty-four cases suffered one wound only and 33 cases {17%) had only soft tissue wounds. In 149 cases there were 156 major fractures, 51 traumatic amputations and 41 major vascular injuries. Two cases had three traumatic amputations (both lower legs and one arm). There was no case reported in which parts of all extremities were amputated traumatically. Sixty-two per cent {62%) of these cases had one major injury and 36$ had two (traumatic amputations and/or fractures). 792 Deaths in Forward Hospitals (Extremity Injuries, cont'd). TABLE XIX Type of */ajor Injuries in Extremity Cases Fractures Femur' No. Cases 47 Traumatic Amputations Upper leg No. Cases Vascular Injuries Common iliac A&V No. Cases 1 Tibia & fibula 40 Lower leg 30 Femoral A&V 19 Foot and ankle 12 Foot 6 Popliteal A&V 7 Humerus 23 Upper arm 5 Axillary A&V 6 Radius & Ulna 7 Lower arm 2 Brachial A&V 8 Pelvis 18 Hand 0 Scapula 5 On entry, 58 % of these cases were in severe shock and 21% in moderate shock, and in 39% of the cases shock was the principal cause of death. An anaerobic infection accounted for 19% of the principal causes for death. Nine cases died before reaching surgery, four in the shock ward and five during the induction of the anesthesia. Eight morecases died on the operating table at some stage of their operation. The follow- ing table lists the principal causes for death in these 1? cases: TABLE XX Principal Causes of EarUy Death in Nine Extremity Cases Cause of Death In Shock Ward During Induc- tion of Anes* During Operation Shock from trauma 1 1 5 Shock from hemorrhage 1 1 Unknown 3 1 1 Pulmonary embolus 1 Ventricular fibrillation (?) T (Case 7, Page ) _ Pentothal death (unexplained) 1 HEAD AND SPINE INJURIES Roughly 5$ (62 cases) of these fatal cases were primarily injuries of the head. Forty-five cases had head injuries alone and 1? were com- plicated by associated injuries. Although these cases were considered 793 Deaths in Forward Hospitals (Head and Spine Injuries, cont'd). as priority cases they were not considered non-transportable unless the injury was extremely severe. It was found that these cases stood transportation better before their operation than after, so practic- ally all cases were treated in the Evacuation Hospitals, Two cases reached the hospital in a moribund condition and died of very exten- sive cerebral damage in the shock ward shortly after arrival. Twenty-two percent of these cases entered the hospital in severe shock while 71$ had either none or very mild clinical shock. There was no case that died primarily of clinical shock. The majority of these cased (76,6$) died of extensive cerebral lacerations, mostly within the first 24 hours, only two patients living for five days. Either meningitis or infection of the head wound was the cause for death in 12.7$of the cases, the patients dying on the fourth to the 15th day. Oily two cases died of causes not related to their head injury, one from a pulmonary embolus and the other from an anaerobic infection in the extremity wound. Although there were 43 fractures of the spine y/ith spinal cord trauma there were only eight cases (0,7$) in which it was the primary injury. Of these, three were in the cervical area (C6, C7j C6, C7; and Tl), three in the dorsal area (D6,D7; D8,D9j and DIO) and two in the lunibar area (Ll and LI and 12)• Two of these cases had minor extremity wounds, (DIO and H), Twocf the three cervical cases (C6 and C7) died a respiratory death within the first 24 hours and one case (D8) died of a severe blast injury to his lungs and abdomen. One case (DIO) died on the day of his admission from shock, and one case (Ll) on the thii;d day from an anaerobic infection in the extrem- ity wound. The other three cases lived from five to six days, but their causes of death were not stated. All of the remaining 35 cases of spine and spinal cord injuries were in cases that had major injuries elsewhere and were classed with the other groups as follows; TAB IE XXI Number of Cases With Cord Trauma Complicating the Major Injury Thorac o-abdominal 12 Thoracic 5 Abdominal 15 Extremity 2 Neck 1 794 Deaths in Forward Hospitals (Head and Spine Injuries, cont'd). Thirty percent (30$) of these cases died on the day of their ad- mission, five from traumatic shock, two from hemorrhagic shock and one each from a pressure pneumothorax, a massive atelectasis, and respira- tory failure. In seven cases (22$) the deaths were based on this injury, four from meningitis and three from respiratory failure; and the spinal cord injury was a strong contributing factor in 10 other cases dying primarily of shock. The remaining 18 cases died from causes not particularly related to the spinal injury. The following table is of the causes of death in the 35 complicating spinal lesions. TABIE XXII Principal Causes of Death in 35 Cases with complicating Spinal Injuries Principal Cause of Death Thoraco- Abdominal Thor- acic Abdom- inal Extre- mity Neck Location of Spinal Injury Shock 2 2 6 12,LI; C8&9, D5; Dn,3, D12, LL&2. L12&3? Unknown . 3 2 Meningitis 1 2 1 Dll, LL&2,IA; DIO Anuria 3 1 L2.L2&3.D7iU Respiratory- failure 1 1 1 C4. C5-7, C7 . Atelectasis 1 1 Atelectasis with pneumonia 1 DIO Pulmonary- embolus 1 1 D? Peritonitis 1 13 Pressure pneumothorax 1 D6 Massive emphysema 1 D7 Pneumonia 1 TT“ 795 Deaths in Forward Hospitals. NECK INJURIES In seven cases the neck was the only region involved md in U other neck cases there were minor associated wounds, making a total of 18 neck cases (1.5$) in this series. One case died of hemorrhage in the shock ward but the source of the hemorrhage was not stated. Forty-six per cent of these cases entered the hospital in severe shock but only one other case died of shock from hemorrhage, this latter case dying on the operating table while attempts were being made to control a lacerated common carotid artery and internal Jugular vein. Tracheotomies were necessary in UU% of the cases. It is interesting to note that eight cases, five with lacerated common carotid arteries, one with a lacerated internal carotid artery and two with thrombosis of the internal carotid artery, all developed a hemiplegia and died one to seven days postoperatively, with the exception of one case who lived for 19 days. The deaths In these eases were all ascribed to an encephlomalacia corresponding to the side injured, five of which were proved by autopsy. In all but one case the arteiy was ligated. In the one case, a common carotid laceration, a vein transplant was used with excellent results (temporal pulp) on the injured side which was not present preoperatively) but the patient continued to have hemiplegia and died of an encephlomalacia on the 19th day. One other case died of a secondary hemorrhage and asphyxia on the sixth postoperative day but the autopsy did not reveal the source of the hemorrhage except that it arose in the deep tissues of the neck and filled the tracheo-bronchial tree through a large perfor- ation of the trachea. MAXILLD-FACIAl INJURIES Seven cases (0.6$) were primarily maxillo-facial cases and In only two cases were there associated injuries, both of them minor. Besides having severe lacerations of the face and Jaw, the following injuries were noted: TABIE XXIII Injuries in Maxillo-Facial Cases Compound fracture of maxilla 4 Compound fracture of nose 3 Compound fracture of mandible 4 Compound fracture of hard palate 1 Basal* skull fracture 1 Lacerated internal carotid artery “1 Lacerated tongue —3 796 Deaths in Forward Hospitals (Maxill©-Facial Injuries, cont d) In two cases the trauma was severe enough to cause extensive cerebral damage without actual penetration of the skull. These cases died of a lacerated brain with a sub-dural hematoma and a severe contusion of the brain with sub-archnoid hemorrhage. Five of these cases died within the first 2U hours of their operation, the other two both lived 7 days. One of these latter cases died of meningitis due to an extension of the wound infection through the cribriform plate, and the other of an encephlomalacia, resulting from a thrombosis of the internal carotid artery due to a severe wound infection and liga- tion of the external carotid artery near its bifurcation from the common carotid. BURN INJURIES There were, in this series, eight cases (0.%) that had extensive burns that Involved large areas of the body (.50-9550 and were not associated with other injuries. Four of these cases died within the first 2A hours of severe shock and, in three cases, a severe pulmonary edema due to burns of the tracheo-bronchial tree, one case died on the second day with a severe pulmonary edema, the cause of which was not stated. Two patients lived six days and died of acute glomerulo- nephritis and pulmonary embolus with a lung abscess respectively. In one case, the cause of death was not stated. CARDIO-V A.3CULAR INJURIES Major cardio-vascular injuries always exert a serious influence upon a case. Excluding those cases with trauma to the small vessels where collateral circulation is usually always good, there were in this series 176 cases (35$) having major cardio-vascular injuries. 797 Deaths in Forward Hospitals (Gardio-Vascular Injuries, cont’d). TABLE XXIV Cardio-Vascular Injuries Reported in 1165 Fatal Priority Cases Vessel Injured (lacerated or perforated) No, of Times Injured Heart 12 Superior vena cava 1 Inferior vena cava 24 Pulmonary artery and vein 1 Right pulmonary vein 1 Aorta 7 Innominate Artery 1 Common Carotid artery Common and external carotid artery 1 External carotid artery 2 Internal carotid artery 1 Jugular vein 8 Superior mesenteric artery and vein 1 Coelie axis 1 Portal vein 2 Portal vein and hepatic artery 1 Portal vein, hepatic artery, and inferior vena cava 1 Splenic Artery and vein or Artery Alone 3 Vein Alone Renal 4 1 Subclavian 1 Axillary 5 4 prachial 10 1 Common iliac 5 4 Internal iliac 6 1 External iliac 2 2 Common iliac and femoral 1 Femoral 15 17 PopliteaT 7 2 Stomach vessels 1 Unknown source of hemorrhage 11 In addition to the above there was a notation of a vessel being in spasm or being occluded by a thrombus in seven other cases, all of which had a bearing on the outcome of the case. 798 Deaths in Forward Hospitals (Cardio-Vascular Injuries, cont’d). Injuries to the cardio-vascular system accounted principally for 71 deaths (6.1$ of all cases), or 40.3$ of those cases with vascular injuries. Of these, ten were directly due to heart injuries. Follow- ing is the type of heart injury and the principal cause of death in each case: TABLE XXV Heart Injuries and Principal Causes of Death Heart Lesion Principal Cause of Death Perforated right auricle Shock from hemorrhage Perforated left auricle Cardiac tamponade perforated right A-V .1 unction Shock from hemorrhage Perforated right ventricle Cardiac tamponade Perforated right ventricle cardiac failure (? tamponade) Lacerated myocardium Cardiac failure Lacerated myocardium with thrombosis of coronary artery Shock from hemorrhage Lacerated left ventricle Shock (cause not stated) Contusion base of heart With many petechie Ventricular fibrillation Contusion left coronary artery and myocardium Myocardial infarction All of these cases died within the first 24 hours of their admission. Two other cases had heart lesions, perforation of the right auricle and a laceration of the myocardium respectively. In the former case the cause of death was not recorded and in the latter the patient died of an atelectasis postoperatively. The perforation of the right ventricle in the patient dying of cardiac tamponade was overlooked at the time of operation as only a simple debridement of the wound was done. In 61 cases, death was due directly to hemorrhage from a major vessel or severe vascular injury and in 15 more cases the vascular trauma directly contributed to the fatal outcome of the cases. Of these latter cases, injuries to the carotid arteries resulted in cer- ebral degeneration and death in nine cases. Spasm and/or thrombosis of the major vessels to an extremity In five cases caused a vascular gangrene to part of the extremity, necessitating a second operation in four cases, and contributed to the establishment of a gas gangrene in the fifth case. In one case, trauma in the region of the superior mesenteric vessels resulted in a thrombosis which led to a vascular Deaths in Forward Hospitals (Cardio-vascular Injuries* cont’d). gangrene of the bowel supplied by these vessels. Fourteen other ras — died of hemorrhage but the source was not definitely stated* In this series 56 cases died principally of an anaerobic infection (clinical anaerobic myositis). Four of these cases (7$) had major vascular injuries alone and seven (12$) had vascular injuries associated with compound fractures which were probably very strong contributing factors to the fatal outcome of the case. In nine cases, pulmonary embolism was found to be directly related to the vascular injury, the embolus arising from the vein injured, but in many cases the source of the embolus was not stated. ANAEROBIC INFECTION Fifty-eight cases (5$) in this series were reported as dying principally of gas gangrene. This diagnosis however was supported in only 10$ of the cases by smear or culture, the diagnosis being made in most cases by t,he appearance of the patient and of the wound and on the course of the case. Of these cases, 28 wer€ associated with compound fractures, four with major vascular injuries, seven with compound fractures and vascular injuries both, and 19 cases had soft tissue wounds only. The time interval between wounding and operation was prolonged in these cases, 57$ entering the hospital 12 hours or longer after their injury, the shortest time interval being four hours and the longest six days. Seventeen cases (30$) were noted to have had the infection on entry or at the primary operation, the earliest seven hours after injury and the latest six days after injury. TABLE XXVI Gas Gangrene - 58 Cases - Average Time Interval - Injury to Operation Not Present on Entry Present on Entry With compound fracture lii. hours 26 hours* With fracture and vascular injury 13 hours none With soft tissue injury only 10 hours 1*7 hours** With vascular Injury 6 hours 11 hours •#Not including two cases with interval of three and four days each, **Not including one case with interval of six days. 800 Deaths in Forward Hospitals. RENAL FAILURE In this series there were 83 cases listed as having had renal failure; in 54 cases it was given as the principal cause of death and in 14 as the contributing cause. The diagnosis was made primarily on a clinical basis in most cases, nearly aH of which had oliguria or complete anuria for a period of several days. Of these cases, six were associated with severe febrile transfusion reactions, in two of which there was a precipitation of hemoglobin in the kidney tubules microscopically. Three cases had hemorrhagic kidneys, apparently from trauma, two had a thrombosis of one renal vein, two had nephrotic kidneys, one had infarcts of both kidneys (cause not stated) and one had renal degeneration which was not explained in the record. In the remaining 68 cases, 16 at autopsy had enlarged, pale edematous kidneys and 12 had microscopic diagnosis of hemoglobinuric nephropathy. These cases were all seriously wounded and as a group received 6,3 units of whole blood per patient before and during operation, the lowest being one unit (500 c.c.) of blood and the highest 15 units (7500 c.c.) of blood. The average time interval (injury to operation) for these cases was 11,2 hours and 73% were noted to be in severe shock. The majority of cases died on the fourth to the seventh day (average 4,7 days). Three cases were listed as having anuria on the first postoperative day but died from other causes, and one case lived for 15 days. In one of these former cases the W.P.N, was 99, The following table shows how these cases were related to the different types of injury: TABLE XXVII Incidence and Distribution of Renal Failure in 1165 Fatal Priority Cases Frequency As Cause Distribution of Renal of of Renal Type of Case Failure Death Failure Thoraco-abdominal w. 3lT3? Thoracic 3.5* ... 2.h% tM, Abdominal 8.5% 5>j 49.4% Extremity 8% 15 Vki The above figures excluded all cases dying in the shock ward, during induction of the anesthesia, or during the operation. Twenty-nine (34$) of these cases had direct injury to the kidney. In 14 cases the liver and kidney both were injured and in four the spleen and kidney were injured. Following is a list of organ injuries 801 Deaths in Forward Hospitals (Renal Failure, cont'd). in these renal failure cases in 66 abdominal and thoraco-abdoninal cases. TABIE XXVIII Organs Injured in Cases of Renal Failure Stomach .... - P Spleen 12 Small bowel 32 Pancreas 1 Large bowel 30 Vena cava 1 Kidney 29 Common iliac vein 2 Liver “IS Common iliac artery 1 Gall bladder 3 U rinary bladder . 5 OVERLOOKED INJURIES AND POSSIBLE ERRORS IN JUDGMENT In this series of cases there were in all, 47 injuries to the various organs which were overlooked at operation in 43 cases, or their presence was not suspected but was found in all cases at autopsy. This probably does not include all overlooked injuries as only 60$ of these cases were autopsied. Cases dying before the operation could be consisted were not counted. 802 Deaths in Forward Hospitals (Overlooked Injuries and Possible Errors in Judgment, cont*d), ♦ TABLE jOCIX Injuries Not Suspected or Missed at Operation .... Type of Cases Ors-tan Injured Heart Abdom- inal “T— Thoraco- Abdominal Thoracic T Extre- mity Neck Superior Vena Cava 1 Trachea 1 Bronchus 1 Esophagus i 1 Si ome n “T" 2 1 Small bowel (including duodenum) 4 4 3 large bowel 6 3 kiclney 2 Bladder- 3 1 Ureter 2 Renal artery *. nd kidney 1 Renal vein 1 Abdomen 1 liver 2 Pancreas 1 TOTAL 20 16 4 5 2 The case listed above as an overlooked abdomen was done as a thoracic case, the perforation in the diaphragm not being found at operation. This patient lived six days during which time he developed a violent peritonitis and distention. The abdominal organs injured were not stated. In addition to the above there were 19 other cases that displayed technical accidents or possible errors in judgment, most of which might nave played a part in the fatal outcome. 803 Deaths in Forward Hospitals (Overlooked Injuries and Possible Errors in Judgment, cont'd). TABLE XXX Technical Errors Breakdown of suture lines ...7 Small bowel perforations 3 (1,4$ of total) Large bowel perforations 1 (2,3$ of total) Small bowel anastomosis... 3 (1.9$ of total) Retraction of colostomies,. ..,.5 (1.3$ of total) No colostomies in perforated colons ...3 Ileostomies (? necessary), ...,2 uolostony distal to perforated colon in case of situs inversus .........I Descending colon exteriorized and transverse colon sutured ...1 These figures include only those cases where the complications developed in the forward hospital and not those which may have devel- oped after evacuation. In the two cases with ileostomies, one was done because of a 1,5 cm. laceration of the cecum and the other be- cause of persistent vomiting not controllable with a Levin tube. Both cases suffered from severe dehydration and severe skin reaction postoperatively which in the latter case, lead to a severe abdominal wall infection and dehiscence of the wound. The following table shows the procedures done in 760 abdominal and thorac©-abdominal cases. In many cases the procedure was not stated. Deaths in Forward Hospitals (Overlooked Injuries and Possible Errors in Judgment, cont’d). TABLE XXXI Procedures Done in 760,, Fatal Priority Cases Stomach 160 Injuries Sutured 150 Gastro-jejunostomy with resection*.,. 5 Gastro-jejunostomy without resection. 1 Small Bowel 400 Sutured* 214 End-to-end anastomosis...... 154 Side-to-side anastomosis,,., 32 Large Bowel, 520 Colostomies. 386 Sutured 44 End-to-end anastomosis.• 1 Side-to-side anastomosis 1 Resections 77 Ileo-transverse colostomies spur 19 Ileo-transverse colostomies with proximal colostomy 9 Spleen ••••• 96 Sutured,.,,,,., 1 Splenectomies 83 Liver 250 Sutured 15 Packed 88 Drained 81 No treatment.. 15 Gall Bladder. 22 Cholecystectomy, 16 Cholecystostony 6 Kidney, 146 Drained, 60 Nephrectomies ••• 60 Pancreas 30 Sutured, ,,, 3 Drained,,,,, 17 Deaths in Forward Hospitals (cont’d). MEDICAL DISEASES AND ANATOMICAL ABNORMALITIES There were, in 707 autopsied cases, 23 (3.4$) in which there were found co-existing medical diseases or anatomical abnormalities. TABLE XXXII Medical Diseases and Anatomical Abnormalities Found in 707 Autopsied Cases Rheumatic heart disease (old),,,, 3 Cirrhosis of the liver 1 Jaundice (without liver injury},, 6 Gastric ulcer 1 Regional ileitis (gross),,,.,,,,, 1 Acute glomerulonephritis,,,,,! Cerebral malaria.,, 2 Brain tumor (? type),,, 1 Malaria.,,.. 2 Horseshoe kidney,,,, 1 Tuberculosis with cavitation 1 Old infarction, left Sarcoidosis of the lung (micro,). 1 ventricle (Age 35),,..,, 1 Situs inversus, complete,,,, 1 The above table shows the type of lesions found in these cases. Most of these lesions exerted a direct influence on the fatal outcome of each case. PRINCIPAL AND CONTRIBUTING CAUSES OF DEATH The tables following are composite tables on all of these cases. In the majority of cases the principal cause of death is acceptable, in some cases however the true principal cause of death was not noted, a rather vague term being used (e.g, cardiac damage) without explana- tion, These cases were listed as recorded. Other cases were listed under headings which were not strictly principal causes of death, but which seemed to explain the fatal outcome of the case better (e.g. Cases dying from hemorrhage were listed that way rather than under shock. Bile peritonitis was listed as a cause of death because all these patients followed the same general course, gradually going down hill and dying in shock or cardiac failure). All cases listed under hemorrhage had severe active bleeding. All cases under bile periton- itis had large amount of bile in their abdominal cavities which was being constantly added to and not being drained out along the drains and packs. Cases dying before surgery was actually started are not included in these tables but are included under the different types of injuries already discussed. Deaths in Forward Hospitals (Principal and Contributing Causes of Death, cont»d). TABLE XXXIII Number of Major Visceral Injuries in 1165 Fatal Battle Casualties Heart Type of Case Thoraco- Abdominal Thoracic Abdom- inal Head & Neck Extre- mity Total 8 ... J 15 Ltngs 74 w 160 Trachea 3 6 9 Esophagus 1 6 7 Aorta 3 1 3 7 Pulmonary vein 2 3 Stomach 78 a 1 160 Small bowel 45 352 3 400 bowel 76 444 520 Liver 116 55 250 Gall bladder 4 18 22 Common bile duct 1 1 2 Spleen 63 33 9$ Kidney 57 8? 146 Ureter 17 1? Bladder 4? i 50 Pancreas 12 18 30 Vena cava 6 18 24 Common iliac artery 3 3 1 Portal vein 2 3 5 Hepatic artery 1 2 3 Splenic artery 2 2 Mesenteric artery 1 1 Coeliac axis 1 1 Renal artery 2 2 Transected cord 11 9 16 3 4 Lacerated brain 1 52 4 65 Inter, Mam. artery 6 6 C.carotid artery “T“ T 7 Int, carotid artery 1 1 Ext, carotid artery 2 2 Int. jugular vein 8 “1“ Subclavian artery 1 T" Innominate artery 1 1 807 Deaths in Forward Hospitals (Principal and Contributing causes of Death, cont'd). TAB IE XXXIV Principal and Contributing Causes for Death in 522 Abdominal Cases Pulmonary Pneumonia Primary 19 Contributing 11 Pulmonary embolism 15 2 Pulmonary edema 0 25 Blast injury ii 6 AEeTeciasis 3 5 Pressure pneumothorax 0 4 Massive empyema 0 1 Cardiac Myocardial damage 1 0 Myocardial failure 18 5 Coronary thrombosis 1 0 Cardiac tamponade 1 0 Acute dilatation 0 1 Myocarditis 1 0 Coronary emboli 1 0 Rheumatic heart disease 0 1 Infections Anaerobic infection 19 8 Generalized infection 13 14 Meningitis 1 0 Hepatitis 0 5 Tetanus T" 0 Liver abscess i 0 Cerebral malaria i 0 Reactions Transfusion 4 0 Alsever’s solution 2 0 Gas gangrene sera ”5” 2 808 Deaths in Forward Hospitals (principal and Contributing Causes of Death, cont »d), TABLE XXXIV (cont »d) Abdominal Peritonitis Primary 68 Contributing 67 Bile peritonitis ? 3 Intestinal obstruction 9 0 liver failure 3 0 Mesenteric thrombosis 2 1 Gangrene of small bowel J?cause) 1 0 Gangrene of large bowel [?cause) 0 1 Adrenal insufficiency 1 0 Cirrhosis of liver 0 1 Overlooked visceral in.lury 0 14 Breakdown of suture 0 7 Retraction of colostomies 0 2 Perforating bowel by wire suture 0 1 Head Lacerated brain 7 2 Cerebral edema 0 1 Contusion of brain 1 1 Enceo'ha lomalacia 0 1 Other Shock 187 63 Injuries 25 156 Unknown 45 95 Hemorrhage 31 6 Anuria 15 .... 9 Anesthetic complications 3 0 Fat embolism 1 0 Diarrhea (? type) 1 0 Delirium tremens 0 1 809 Deaths in Forward Hospitals. SUMMARY A statistical report of 1166 fatal cases in forward hospitals in the combat zone of the North African, Mediterranean, and Eunopean Theaters is presented. The cases reported include only those that were classed as priority or non-transportable cases an' who weise treated by the 2nd Atociliary Surgical Group throughout this war. The cases were further limited to those ending fatally in the forward hospitals while still under the care of the Group. The first part of the report deals with preoperative treatment, shock, time intervals, anesthesia, wounding agents and autopsy rate in a general way for all the cases in this series. The cases are then broken down into nine different groups according to tho type of their major injury and each group is presented separately and some of the problems, complications and causes of death are discussed. Statistics on cardio-vascular injuries, anaerobic infections and renal failures are then presented. Finally, overlooked injuries, possible errors in Judgement, associated medical diseases and anatomical abnorm- alities found in the autopsied cases are tabulated. Charts are in- clined showing the incidence of the majority of visceral injuries and of the primary and secondary causes of death in all of these cases. ►3 o O o > w * cf C+* H* ) H ® > ►i *4 P H p P C_J, p CO > > ► c+ p H* > » 00 > • H H>(& O 8 o cf » O B « f *• c o H- o p* 1 1 p P-« fo > H- H* » > MO H« g4 TS P H» M P' p <+ P wcj B W fcH wa g Win C_J. f o «+ H* > K »cP m M O p X iO •i o P^ p cf hb H ef < <+hd H «+• p ® * > ♦ ® • • ® • ® ® • (D «.+• » pi •i P* hJ ro » ) H-»Q. > » ry P' > , ' £ E OV > *-• -» *4 Shock cf H O', ro -** cr ro *4 r4 ro o M4*V» V JDk H* ®' P ffi w • > 4>* u» w *0 Ui 4k •4 r>o-q —* O' Anaerobic infection O P a «>’ P O v-4 00 > ** 4k » ) w Pulmonary embolism ® P> , >1^ , , ) Anuria ® u» W u< Ml *4 ’ -t vjn o o* ; ! ) i Blast H) ® U ro o U» *4U *4 » *0 ' p. , HI u> ro *4 Ui ro ro «4 <4 ro ro Unknown ® o> 1 i i , > , > P Hj ) CO ) > row 1 , ' Generalized rf ' {S' o. «*.«» » 1 k > t4 «4 4k «-4 infection • P CO o cn ) > ro *4 dbl N3 Hemorrhage CD' •Jr , , ) , , » s / 6C> 9 . u» cr\ w m | ro • oi ro ro > OO > » cn > ro > 4k *-» 4k > ~0 ■ Injuries r—1 O 4k ro 4 •4 kJ Anesthesia ) ro > IV) . *♦ ro , ) 1 Lacerated o ►v •4 1 » ‘ ) > , brain ) ro > > > > ) Air H) o , > ) •4 , ) ) » *4 embolism h’* Oto> —* l\J > *4 Ml > ' Pneumonia ro ro •4 ' > , Peritonitis ®> H 8 > o fv> ) » *4 > ) *4 Adynamic »4 ) ) «■% ) ) «* > ! *4 > » ) } Atelectasis Pat H« 1 o ■A ) ’ | * ) * Ml embolism » ) > ) - Transfusion o wM » , ) > ) Ml ) i reaction o o 9* > 1 i > > ) Anapaylaxis P I , > ) gas serum £• to ®. o ■ —* , O w* > > rr* • > •4 > ■* ' i ) Ul ‘ ) VJ1 > > Pulmonary edema o > ) ' > ) Hepatitis H» » ® > o > 4* t > > i ro ro CaJTdio-resp* failure P «+ P* • Principal and Contributing Causes of Death, in 162 Extremity Cases TABLE ZXXVT cf t-3 Hi 33 t-3 4 O o H- S3- H- cf cf cf o o' P P p p S3" © 4 P hi M t-1 o' o' M ■ Jr> (YJ H O f3 H- 4 S3" 51 p- p4 (D (D cf H H- H- O hi (D H- o H* c |3 X 4 H- O -S3 0'< P 3 O 4 P cf s cf B Pi*+ ® cf 4 c_i. I hi f n S3 H- P- S3" p- S3- 4 K S3" ® - P s& ® cf S3 S3 S3 p H- 4 o' *< 4 H- O' p o H- —,■ P p H P H & cf H cf * U»Co cn -4 ro vn o cn cf H- i £ H -P- fO Lo ro CJI -H 01^0 O' O -H Unknown H, U> JO «*A cr 4UI — cn a Anuria (ft H H > Peritonitis P 4 CT> . ) lo cn ro ro co cn -4 -4 ra CH H cn ■ •■A •4 r • Co -4 ro *4 •—A to ro Hemorrhage P M i 4 p U» O H -A -a ) ro a. to —A UDU» f* -A -J^ JO CO [Co Injuries H- u> uo •»A /. -4 fO JO _4 (V) to Pneumonia u> CO > *A ro ro —A ••4 -4 Co Atelectasis P to —3 Co —A «taJk •-A —A «_* Pulmonary embolism o tr Anesthetic to ►5 o CJ1 complications . Extensive o •■A aa \ cerebral damage Anaerobic ? o ( - •4 Co infection Blast CJ to u> •A • > -jJ •A ■ 1 k —a! injury uo V «-A -4 ro Ventricular fibrillation CJI uj ) •4 ro cn Generalized infection Hj » i H* s o to 1 > > -4 ) •a Empyema Pressure 4 -A JO ) > ro pneumothorax l( O »■ *A Fat embolism T—A > «*A Lung hematoma o «“"A *4 > Transfusion react. . B ro ro > > to Pulmonary $ O o ’ ro ro -3 edema » Lo •—A | ,) - ro Bile peritonitis » Morphine ro o 1 ’ » -A I ■ «-A intoxication o , > Retroperitoneal ro o >■4 infection 4 ro > • ro Myocardial O 1 f ailure H > Intestinal *-* o ' | •-A obstruction ro o o-k Malaria o ■ f4 «-4 Meningitis II o o t3 u» .4 > ’ »4 r* •4 Cardiac damage \ Principal and Contributing Causes for in 233 Thoraco-Abdominal Cases TABLE XXXV Principal and Contributing Causes of Death in Head, IJaxillo—Facial, Neck, Burn and Spine Cases Type of Injury Extensive lacerated brain Meningitis Unknown Anaerobic infection Contusion of brain Internal , hydrocephalus Pulmonary embolism Wound infection of heed at M U .at H K i •S| 2 CD •no PP Mpq Hemorrhage Thrombosis internal carotid artery Anuria Blast injury to lung Shock Contusion of. . spinal cord (C4) !>» P 0 ■p ajH a) ai Kediastinitis Burn injury Cardiac failure Facial. infection •d rl O P H3J.C C0 h «J S 0 s poj 0 p O Td CSJ i 0* a vxprrx;% 1 0 H S m 0) CO fl ® 008 O r -H to £> •H Qj Ol®P 3-Hp t»D ® pP< P n 0® 3 ®*4p H il'ead alone — 4 r 45 cases 1 8 Head with extremity 8 4 1 1 1 1 1 injury - 17 2 1 H Maxillo-facial - 1 1 i 1 1 - .... . ... - . - 1 7 cases v 1 2 2 1 t Heck — 3 _T~ 1 1 - .... 17 eases 2 10 2 1 1 1 Burns — 2 -4 1 8 cases 1 2 4 1 Spine - 5 1 1 i .2 8 cases 8 Total Principal 47 9 11 2 2 1 } 1 1 9 3 0 0 1 5 0 1 0 1 0 10 0 1 0 Total Contributing 4 0 42 0 0 0 0 0 42 0 02100 r 0 1 2 0 1 0 14 0 1 Figures in squares are number of cases. Upper figure = Primary cause of death. Lower figure = Contributing cause ! Of death . • TABLE E3CVII pi . P =3 1-3 sc ftS’ S' (0 o hI 13- M > H H- H- H o c+ H P* P CJ* so pi M * cf 4 = ) H o P j P o H- 13 Ob S' (0 H i 3 cf H M- > ® I O *< Cl o a Cl- P o, 3 4 -j, h- 3 13 & $ cf *d g, co a o ! 0 H- c_j. O 4 H* o' H* H cf g H, H* H * *< M td w W W H- S' H - JH H W fri H Cfta «+ cf cf cf cf H* e+ c+ H- cf cf P P* ♦ »> r f H ♦ • H 0 f H <0 P P 5 (0 cf cf OB * f II & IP H » • £ op k£) H H rooj IPUi IP H -H Shock Unknown p 4 M P so c+ W 4 03 IP H CP -P IP H H HH CP H HIP V u» b H ipfp Hemorrhage Si? H IP H H Oj Pneumonia p ® mI ' cf H* cf , ; ' Pulmonarz Is o C* H ( • H embolisn o p SI M fp PI H H H IP HH Blast injurz o PI > H , H H fP IP U»H Atelectasis ® « H ’ , IP Cerebral from o H, O H ■H ’ H ’ J HH shock o Us ’ * IP Ventricular P- o H H eibrillation P SO rf » o UP W 4 Anesthesia P* P, • » s er> 9 o re- - ! H H Anuria * o . rp Pressure PJ* Cl neuothorax ►p ® 4 Hj H- H M . . H HH (Jeneraliaed infection O ip H ; > H Cardiac failure -X) H H H IP IP IP edema Hi O W H H IP H H IO ■ Peritonitis Mediastinitis H o » H Jaundice Cebebral M a y . . H* malaria TABLE XXXVIII Principal and Contributing Causes of Death in 96 Thoracic Cases II ADMINISTRATION 815 II ADMINISTRATION 1. General. The administration of this organization has been closely allied with its professional services. In fact, no distinct demarcation was permitted and all administrative matters were directed toward making available to theprofessional services the adjuncts required for the successful operational activities of the surgical and allied teams. 2. Organization. a. Origin of the Unit. The End Auxiliary Surgical Group was constituted as an in- active unit of the Regular Army, 1 October 1933 pursuant to Letter, by AG 302.2 (8/16/33) dated 13 August 1933. was activated at Lawson General Hospital, Atlanta, Georgia, 10 April 1942 in compliance with General Order No. 33, Headquarters Third Army, San Antonio, Texas, dated 1 April 1942, It was the first Auxiliary Surgical Group ever activated and organized in the Army of the United States, The original cadre of six enlisted men was transferred from the Detachment Medical Department, Lawson General Hospital, Atlanta, Georgia, On 1 May 1942, Colonel James H, Forsee, MC, (then Major) was assigned as the unit's commander by the War Department, He proceeded from Walter Reed General Hospital, Washing- ton, D.C, and joined the unit on 9 May 1942, b. Table of organization and Tables of Equipment. The unit began functioning under T/0 8-512, dated 1 November 1940 and changed to revised T/0 8-571, dated 13 July 1942, The Group has functioned continuously under the basic organizational setup of the latter T/0 and the T/E 8-571 which has been found satisfactory. The flexibility of this organizational arrangement has proven to be of the greatest practical importance, and the functional operational changes which have been followed throughout the overseas experience of the Group, have been found feasible and practical under this T/0 and T/E, No ex- perience has been had in the operation of the Professional Service Unit prescribed by T/0 and T/E 8-500, dated 18 January 1945. c. Functional Organizational Changes. The functional organizational changes found feasible in the experience of this Group are: (l) Orthopedic Surgical Teams, These teams have been organized on the same basis as other surgical teams and composed of the following personnel: One orthopedic surgeon, one assistant surgeon, one anesthetist, one surgical operating room nurse, and two surgical tech- nicians. 816 II Administration (Organization, oont'd). (2) Gas Teams* Fortunately, there has been no need for such teams and the personnel have been utilized on other teams* (3) Miscellaneous Teams* These teams have functioned as shock teams, (4) Two medical administrative officers have been members of this organization since September 1942, and their services have been of great value in the administrative organization. An additional MAC officer could be utilized to good advantage. Also one master sergeant as chief clerk is needed in the Group Headquarters, d. Departmental Organization, Other departments have been organized as diagramatically represented below. The simplicity of this organization is obvious and enables the most efficient operation of the Group, GROUP HEADQUARTERS iDETACH-i i HE NT HQ) PERSONNEL SECTION PROFESSION- AL SERVICES NURSINGi SECTION) ■ MESS; POSTAL ; SECTION; TRANSPOR- TATION SUPPLYj GENERAL ; SURGICAL; TEAMS ; ORTHOPEDIC SURGICAL TEAMS THORACIC SURGICAL TEAMS NEURO SURGICAL: TEAMS MAXILLO ;FACIAL SURG- ICAL TEAMS ; DENTAL i PROSTHETIC i TEAMS i SHOCK; TEAMS; 3* Function of the Group* a. Primary, The primary function of this Auxiliary Surgical Group has been to augment hospitals or other medical installations located prin- cipally in the forward area with surgical and allied specialty teams for the surgical care of severely wounded battle casualties. Three phases of this function may be described* II Administration (Function of the Group, cont'd). First; In all amphibious operations conducted by the North African or Mediterranean Theater of Operations and even before the Theater was established, surgical teams of this Group have participated in the initial or "D” day landings. Five such amphibious operations have been accomplished. The most feasible method of achieving the op- erational requirements of surgical teams of this Auxiliary Surgical Group in these landings has been to have them accompany first priority surgical hospitals (platoons of Field Hospitals) in the initial land- ings. (See also Section IV, Operation Activities). Second; The responsibility for the surgical management of priority surgical casualties (non-transportable wounded) treated in the first priority surgical hospitals. It has been in this type of installation that the surgical and shock teams have carried out most of their work. Third; The augmenting of the surgical staffs of Evacuation Hospitals with surgical teams of all types, in particular, ortnopedio and neurosurgical teams. In our experience, every Evacuation Hospital actively engaged in the Fifth and Seventh Armies required additional surgical teams to supplement its own staff during periods of heavy fighting. b. Secondary, The supplementing of base hospitals with certain highly qualified surgical specialists to conduct or participate in the repara- tive phase of the surgical management of specialized surgical problems, especially thoracic and maxillo-facial plastic surgery. In addition and during quiet periods at the front, many of the surgeons of the Group had the opportunity to study problems of surgical management as encountered in the base hospitals. This function per- mitted an excellent opportunity for the surgeon working in the forward area to become familiar with the later care of battle casualties, 4, Employment of the Group, a. General. This unit has been assigned to the Theater in which it fun- ctioned and its employment has been controlled by the Theater Surgeon, This employment has been principally with an Army and to a much lesser degree in the base sections. The assignment as a Theater unit has per- mitted the ready availability of certain personnel, especially qualified in the surgical specialties to function for extended periods in base installations. 818 II Administration (Employment of the Group, cont'd). b, Employment in Base Sections* The experience gained during approximately six months of 1945 in which the Group was attached to various base sections demon- strated these facts: First, base hospitals seldom need augmentation of their surgical staffs, except occasionally by especially qualified specialists in certain fields of surgery* Second, the function of surgical teams of an Auxiliary Surgical Group cannot be adequately accomplished at the base hospital level. c, Employment in an Army. (1) Experiences in the employment of the Group at this level and attached to an Army have been as follows (See also Section IV Operation Activities): II Corps, functioning as a separate Corps, lb November 1942 to 13 May 1943 (Tunis! an campaign)* Seventh Army, 10 July 1943 to 17 August 1943 (Sicilian camapign)* Seventh Army, 15 July 1944 to 14 June 1945 (Southern France, Rhineland and Central Europe campaigns). Fifth Army, 9 September 1943 to 20 August 1945 all the campaigns in Italy)* This experience has indicated that the most efficient use of an Auxiliary Surgical Group is obtained when it is attached to and func- tions with an Army, A type Army of seven or more infantry divisions actively engaged requkes the services of an Auxiliary Surgical Group as organized under T/0 8-571 dated 13 July 1942, (2) Standard Operating Procedure, The following standard Operating Procedure of this Auxiliary Surgical Group functioning with an Army has proven efficient. Standard Operating Procedure For the Use and Control of the 2nd Auxiliary Surgical Group. (a) General, An Auxiliary Surgical Group is composed of gen- eral surgical, orthopedic, neurosurgical, thoracic, maxillo-facial, shock. 819 II Administration (Employment of the Group, oont'd). and dental prosthetic teams. The activities of the Group are controlled by the Group Headquarters. The function of the Group is to supplement the surgical service of hospitals. Primarily, the teams will function in Army hospitals and installations, but may be used in hospitals within the base section. (b) Personnel* 1. The surgical teams consist of si* persons as follows* Surgeon (Officer in Charge of Team), assistant surgeon, anes- thetist, operating room nurse, and two surgical technicians. 2, The shock team is normally composed of one officer, one nurse, and two technicians. (o) Equipment* The teams are equpped with all essential surgical instruments and a portable anesthesia and suction apparatus. Tentage for quarters is a part of their organic equipment. They are not self sustaining and are dependent, upon the installation in which they are employed for messing and housekeeping facilities, (d) Transportation* Teams routinely have their own transportation. The number of vehicles is limited and when teams are employed in Evac- uation Hospitals they will seldom have their own transportation. Trans- portation furnished is primarily for the movement and supply of teams and only in emergencies will it be used for other purposes. (e) Installations in which employed* 1_, Employment in Evacuation Hospitals* In these Installations, the teams will function under the supervisions of the Chief of the Surgical Service. 2, Employment in Field Hospitals* In these in- stallations, the surgeon designated by Group Headquarters will be charged with the responsibility to the hospital commander for the sur- gical service of that hospital. (f) Administration* The Group Headquarters is responsible for the administration of the Group.. Personnel records will be maintained in that office.» 820 II Administration (Employment of the Group, Gontd) (g) Coordination: All matters pertaining to the professional ser- vice and the employment of these teams in Army installations will be co- ordinated through the Army Surgeon. (h) Requests for Teams: Requests for teams to be placed on temporary duty with a hospital or installation will be made by the hospital commander or unit dental surgeon through the office of the Army Surgeon. This of- fice will advise Group Headquarters of the need for teams at various hos- pitals. Reouests for teams should, if possible, be anticipated several hours in advance to facilitate their movement, (i) Release of Teams: All hospital commanders are enjoined to cooper- ate in the maximum utilization of Auxiliary Surgical Group teams. To this end, the personnel will be released from hospitals and returned to their Group Headquarters as soon as their mission has been accomplished in order that they may be readily available for assignment elsewhere, 5. Employment of the Different Types of Teams, a. General Surgical: This team has been the type which, as anticipated, has been in the greatest demand. Its need has been greatest in Field Hospitals, functioning as first priority surgical hospitals. At this level, the tri- age of patients is based upon the urgency of the wound. Segregation on the basis of surgical penalization is not feasible. Thus, the team functioning at this installation must be professionally equipped to care for any wound that renders the patient unsuitable for further transporta- tion to the rear without surgery. This demands surgeons whose qualifica- tions enable them to care for serious trauma, in any part of the body. The general surgeon is best equipped to meet these requirements. It has been the good fortune of this Group to have a sufficient number of quali- fied specialists to permit their emnloynent in these priority surgical installations. Their contributions in the care of specialized surgical problems have been of inestimable value and will be discussed under the employment of the surgical specialty teams. The general surgeon treating the wounds due to modern warfare has become the surgical specialist of trauma. Experience has demonstrated that four to six general surgical teams are necessary for the proper functioning of a busily engaged first priority surgical hospital. The teams have been charged with entire re- sponsibility for surgical care of patients in these hospitals. 821 II Administration (Employment of the Different of Teams, contd) b. Orthopedic Surgical Teams* This team finds its greatest usefulness in Array installa- tion in the Evacuation Hospital. At this level in the chain of evacua- tion there is a permissible segregation of patients within the hospital into surgical specialty categories which enables the orthopedic surgeons to devote their time to the care of extremity injuries. No hospitals, designated as specialty centers, have been established within the Arny zone. However, the qualified orthopedic surgeons of this Group have made outstanding contribution to the management of extremity injuries in the first priority surgical hospitals. Through their expertness in the use of plaster of Paris bandages, they have taught many of the general sur- geons important features in the use and application of this valuable dressing. By their accurate knowledge of the detailed anatony of the ex- tremities, they have demonstrated essential refinements in operative tech- niques, which have encouraged a better understanding of the management of severe extremity injuries. Finally, by employment in first priority sur- gical hospitals, the orthopedic surgeons have been brought into the clos- est contact with the problems related to the early surgical management of severe trauma of the extremities which has, of recent years, become more and more a part of this surgical specialty. Experience gained from the employment of orthopedic surgical teams in priority surgical hospitals has demonstrated that during busy periods, the services of a qualified orthopedist are not capable of being used to the greatest advantage. This results from the fact that the highly trained orthopedic surgeon is seldom a qualified general surgeon and is unable to take his regular turn, or shift, on the operative schedule for the care of all admissions to the hospital. Thus, it has become more and more evident that the greatest utilization of the highly trained end qualified orthopedic surgeon, who is not also a qualified general surgeon, requires that he be placed in installations where reparative and reconstructive surgery are being ac- complished. This is in fixed hosnitals, either overseas or in the Zone of Interior. To this end, the qualified orthopedic surgeons have gradu- ally been transferred from this Group to numbered General Hospital where their capabilities in the management of the more strictly orthopedic pro- blems could be utilized to a greater degree. This should not be meant to imply that qualified orthopedic surgeons should not be included in the organization of an Auxiliary Surgical Group but rather that, in the case of this unit, the need for the highly trained orthopedic surgeon h$.s be- come less as the general surgeons have become more experienced in the man- agement of wounds of the extremities. c. Thoracic Surgical Teams* In general, qualified thoracic surgeons have had consider- able training in general surgery and are capable of doing abdominal and extremity surgery as well as thoracic surgery. Thus, thoracic surgical teams of this Group have been extensively employed in Evacuation and -Field Hospitals. Also, appreciable use has been made of the thoracic surgeons 822 II Administration (Employment of the Different Types of Teams,- contd) in this Group in base hospitals designated as thoracic surgical centers. The employment of thoracic surgeons in priority surgical hospitals has been especially profitable in contributing to and emphasizing the follow- ing essential principles in the early management of severe wounds of the thorax: The early removal by thoracentesis of blood and air, within 2% hours, in injuries causing a hemothorax. The employment of Intercostal nerve block to relieve thor- acic pain and aid in the expectoration of secretions from the tracheo- bronchial structures. The use of catheter suction for the removal of tracheo- bronchial secretions. Erequent bronchoscopic aspiration of tracheobronchial blood and mucus, in the preoperative, operative and postoperative management of intrathoracic and intra-abdominal injuries. The great importance of the endotracheal method of admin- istering the anesthetic agent in intrathoracic and intra-abdominal in- juries. The focusing of attention in intrapleural injuries to the rapid and complete re-expansion of the lung and early restoration of the functional integrity of the respiratory system. The function of the priority surgical hospital in deter- mining the transportability of casualties suffering from thoracic injuries, The dissemination of information regarding thoracic physi- ology and its application in the management of war wounds of the thorax. Experience has indicated that a very appreciable percentage (ap- proximately 50/0 of the casualties suffering from intrapleural injuries alone are transportable, or may be made transportable, by the employment of measures enumerated above. Under this plan, the need for the thoracic surgical team increases in the Evacuation Hospital as more thoracic injur- ies will be treated in these installations. Two thoracic surgical teams working on 12 hour operating schedules have been able to efficiently care for a large volume of thoracic wounded and organize excellent surgical sections in the hospital during periods of great activity at the front. The excellent opportunities afforded several of the thoracic surgeons of the Group to work in base hospitals has greatly enhanced the knowledge and experience of these surgeons and contributed appreciably to the high standards of surgical care which the patients suffering from thoracic wounds have received. The listing of their contributions in this II Administration (Employment of the Different Types of Teams, contd) field of surgery requires a recapitulation of the advances in the renara- tive phase of the surgical management of war wounds of the thorax. The problems relative to the removal of intrathoracic metallic foreign bodies have occupied an important place in this work." "The radical management of massive organizing hemothorax by thoracotomy, evacuation of the clots and decortication' of the lung has proven its effectiveness in returning soldiers to duty and appears to have diminished the incidence of empyema. The sane procedure applied to established posttraumatic empyema with penicillin therapy as an adjunct, is followed by immediate healina with a fully expanded lung" (Churchill). The thoracic surgeons of this Group initiated this method of management in KAT0U3A, d. Neurosurgical Teams: The employment of neurosurgical teams in the first priority surgical hospitals has been practiced sufficiently to conclusively confirm the view that casualties suffering brain injuries transport well and preferably should receive their initial surgery in Evacuation Hospitals, Two neurosurgical teams working 12-hour operating shifts in a busily en- gaged Evacuation Hospital are ideal. In general, however, one neurosurgi- cal team has, during such periods, been required to carry the entire load. In addition to the employment of these teams in Evacuation Hospitals, there have been occasional opportunities for their use in base hospitals. Here again the advantages gained from observing the late results of the surgical management carried out in forward installations have been of great value to the surgeons of this Group. e. Maxillofacial Plastic Surgical Teams; Experience in the employment of these teams has included their functioning in Field, Evacuation and General Hospitals. Their use in Field Hospitals as strictly specialty teams has proven untenable. The Evacuation Hospital is the feasible installation in which these teams should be employed and one team has been sufficient to meet the require- ments of such a hospital. When the regular staff of the hospital has had a maxillofacial surgeon, it has not been necessary to augment that hospii- tal. The greatest utilization of these teams has been in General Hospi- tals or hospitals designated as centers for the care of maxillofacial in- juries, Experience has indicated that the need for this type of surgical team in this Auxiliary Surgical Group has been limited and never more than two teams have functioned as such at any one time. On the basis of this experience it is believed that' qualified maxillofacial surgeons could be better utilized in other types of medical units -and maxillofacial plastic teams deleted from the organization of an Auxiliary Surgical Group. f. Shock Teams: The employment of these teams has been almost exclusively in the first priority surgical hospitals and it is impossible to over- II Administration (Employment of the Different lypes of Teams, contd) estimate their value in the proper care of the nontransportable casualties. The need for officers interested and qualified to head shock teams has always exceeded the number available. It is desired to emphasize that the professional qualifications for the officer in charge of the shock team are exacting. Experience has indicated that, in general, the compet- ent young internist becomes a better shock officer thana young surgeon. 'The services of a qualified shock officer are invaluable to the success- ful surgical management of the severely injured battle casualties and the opportunities afforded for his observations in the manifestations of clinical shock are indeed great. The function of the officer in charge of a shock team has been clearly defined and practiced by this organization. His function is to carry out shock therapy measures under the direction of the surgeon who will undertake the operative surgery. The operating surgeon is charged with the entire responsibility for the proper surgical care of that pa- tent and the patient is not served up to him as an individual whom the shock officer has decided is ready for surgery. This function has in no v/ay interferred with the initiative of the shock officer but on the con- trary has permitted the closest coordination with the surgeon and stimu- lated both to investigate and analyze the clinical data available rela- tive to the recognition and management of shock, g. Dental Prosthetic Teams: The demand for dental prosthetic teams has constantly ex- ceeded the number available. These teams composed of one dental officer and three enlisted men have been employed in almost all types of instal- lations and under varied conditions. Prior to Hay 194/-, they had func- tioned frequently in conjunction with the base section dental laborator- ies and in dental clinics set up in the Corps and Army areas. In each of these installations they functioned efficiently and rendered very val- uable service to the troops. In May 194A, mobile dental laboratories (trucks) were placed in operation for these teams. All subsequent func- tion of these teams has included the use of the mobile dental laboratory. The mobility of the laboratory has enabled a freedom of movement which has permitted teams to be employed especially in areas and with units in the Army v/hich otherwise would be required to send their patients an ap- preciable distance, even requiring hospitalization, for dental prosthetic work. The method which has been found most efficient is for the unit dental surgeon to request through the Army Surgeon a dental prosthetic team to be on temporary duty v/ith the designated unit. The team with its own transportation and tentage for quarters functions with that unit un- till it completes the dental prosthetic work required. It is the respon- sibility of the unit dental surgeon to have the patients report at the specified time for treatment and that the proper dental preparation of the patient's mouth has been carried out prior to reporting for dental prosthetic work. On completion of its work the team is available for duty with another unit. This flexibility of employment has permitted the 825 II Administration (iilmployment of the Different Types of Teams, contd) greatest utilization of these teams affording their services to units located in areas where they often encountered considerable difficulty in obtaining needed dental prosthetic work. By the above method of employ- ing these teams, the amount of time lost from duty, especially among com- bat troops, has been minimized. The expex-ience of this Auxiliary Burgical Group has been such as to encounter lit.tie demand for oral surgeons.’ Therefore, the dental officers of this Group have been engaged principally in dental prosthetic work and general dentistry, 7. Functions of Group Headquarters. a. General: The activities of this Auxiliary Surgical Group have been directed by the Group Headquarters. These activities have been coordin- ated to effect a uniformity of control which has established the identity of the Group and has integrated its functions not only in the commands under which it has served, but also in the installations in which person- nel of the Group have been employed. The problems of the professional services have guided the administrative functions and this guidance has been found to enhance surgical care during military operations. These facts are evident from a study of the professional service section of this report. The accomplishments of any organization are a reflection of its leadership, and the function of the Group Headquarters has been to accept the responsibility of proper leadership in all phases of the activities of the Group. -The physical location of the Grouo Headquarters has been sn important consideration as it must be situated in, close prox- imity to the area in which the teams of the Group are employed. This per- mits close liaison with the Army Surgeon, particularly with his surgical- consultant end operations officer. Likewise, personal contact with the teams, the commanding officers and chiefs of the surgical services of the hospitals or medical installations in which the elements of the Group are employed is more easily maintained. The Group Headquarters ’establishes housing, either tents or buildings, messing and general housekeeping fac- ilities for the Group. These requirements vary greatly depending upon the activity at the front and the demand for teams in forward installa- tions, In extremely busy periods of heavy fighting the personnel on duty at Group Headquarters is veiy minimal, while during quiet periods at the front the major portion or entire command may be assembled at Group Head- quarters. Thus) the reoulrements for the above facilities are constantly changing and planning must always allow for maximum demands. The depart- mental activities maintained at Group Headquarters are: professional ser- vice, personnel section, nursing section, transportation, supply, medical detachment, mess and postal section. 826 II Adnini s tr at ion (Function of Group Headquarters, contd) Early in the overseas experience of this organization it be- came evident that the Group Headquarters, or a detachment of Group Head- quarters should be readily available to any sizeable detachment of teams regardless- of the area in which they were employed. The feasibility of this plan was exceedingly well demonstrated during the campaigns of South- ern Stance, the Rhineland, and Central Europe when a large detachment of teams from this Group was employed in these areas. A detachment of Group Headquarters functioned with these teams during these campaigns. The professional service section of Group Headquarters has been a most important department of this organization. Early in the training period of this unit an extensive study was made from the available liter- ature dealing with the management of war wounds. The analysis of this literature clearly demonstrated the paucity of factual data referable to this subject. This lead to an appreciation of the need for carefully re- cording all data which the surgical experience of members of this Group might encounter. To simplify the recording of these data, a standardized individual case record form was prepared prior to embarking for overseas (see page 8^1), This form permitted an adeouate record which if care- fully completed would make available the essential technical data regard- ing each patient treated by members of this Group during the period in which the patient remained under their care. In addition, a form for a brief follow-up note.was standardized. This form was attached to the pa- tients1 medical records and a fair percentage of follow-up studies were forwarded to this organization from hospitals in which the patient re- ceived further treatment. Each surgeon in charge of a team was responsi- ble for completing the individual case record. These case records were retained at the Group Headquarters. In addition, all surgeons were en- couraged to keep careful case records for their own personal files on all patients treated. The Group Headquarters became the repository for the records of the professional activities of the members of the Group, Erora these data many important studies have been made which had an immediate bearing on the surgical management of the wounded. Constant diligence was maintained in encouraging the surgeons, anesthetists and officers in charge of shock teams to analyze these data and submit reports of their findings. Each officer in charge of a team was required to submit per* iodic reports of this team’s activities and these reports were made avail- able to all members of the Group and to the Theater Surgeon. Erom this beginning there has been gradually built up a series of approximately 22,000 individual case records dealing principally-with first priority surgical injuries. This* series of case records is believed to be unpara- lleled in the annals of American surgery. It is upon the factual data contained in these records, combined with the personal experience of the members of this Group that the professional service section of this re- port is based. 827 II Administration (Functions of Group Headquarters, contd) b. Personnel Administrative Section: The personnel section of Group Headquarters has been charged vdth the management of personnel administrative matters. The problems of placement or assignment of personnel have not been delegated to this de- partment. Early in the overseas experience of this Group, the feasibility of handling all personnel administrative matters, records, etc., at Gfoup Headquarters was clearly demonstrated. Luring the early campaigns in which elements of this Group participated oersonnel records accompanied members of the teams. It was found that due to the frequent moves of the teams and the temporary nature of their attachment to other organizations that the personnel records were often not kept current or accurate and not in- frequently the records were lost. Enlisted men were occasionally not paid for several months. The correction of the deficiencies in the records entailed considerable time and difficulty as well as unnecessary delay as corrective measures must await the teams* return to Group Headquarters, Following this experience, the service records, preparation of payrolls and the pay of all personnel, handling of allotments, individual qualifi- cation cards, 66-1, 201 files and all other personnel administrative mat- ters have been functions of the personnel section of Group Headquarters, The administrative matters relative to the issuance of orders for team movements, changes in team assignments, the- typing and mimeo- graphing of many scientific papers on professional subjects have been carried out by members of this section. The personnel available for as- signment to this very busy department has been insufficient and this has restilted in unusually long hours of work for its assigned members. There is a definite need for a master sergeant at Group Headquarters to have supervision of this section. The work of this section becomes readily evident when it is noted that the officer strength of this organization (196) is equivalent to that of two infantry regiments. The following data are pertinent, A total of $129,919.00, requiring 1272 separate vouchers .was transmitted to the United States through the personnel office since the Personal Transfer Account system was inaugurated (May 19A3). During the months of October, November and December 19AA, 640 officers* pay vouchers were prepared amounting to payments of $209,009.33, and enlisted payrolls of cash payments in the ammount of$22,893.16 were prepared and paid,, To obtain the signatures on payrolls and officers* vouchers and to accom- plish payments often required a 500-mile trip over a period of two to four days to contact all members of the Group. c. Nursing Section: The requirements for nurses assigned to this Group have been exacting. The need for maintaining the specialized nursing service 828 II Administration (Nursing Section, contd) of the organization at the highest possible level of competency is a pre- requisite to its successful operation. The nurse personnel have been carefully selected on the basis of their professional qualifications. The nurse must have detailed knowledge of her duties whether as a surgical operating room nurse, on a shock team, or as an anesthetist. In addition, she must possess the temperament and adaptability required for the cheer- ful, efficient performance of long and difficult surgical procedures per- formed in forward hospitals which are often subjected to enemy attack. Excellent health is essential, as ‘living conditions are seldom ideal and duty is often very strenuous. Throughout the experience of the organiza- tion the nursing personnel have met these requirements in a highly com- mendable manner. The principal chief nurse is stationed at Group Headquarters. The personnel records for the nurses are maintained in her office. She is responsible for the supervision of the nursing functions of the teams and maintains close personal contact with the teams in all installations in which they function. Nursing activities are coordinated with the chief nurse of these installations and with the Army Director of Nurses. The assistant chief nurse has functioned as a surgical nurse, assistant to the principal chief nurse, and as the chief nurse in the large detach- ment of teams which functioned in the campaigns of Southern France, the Rhineland, and Central Europe, d. Transportation: The major defect in the T/E 8-571 has been in the inadequate allowance of transportation. This deficiency has been overcome by an ad- ditional authorization, in excess of T/E by the Theater Commander. This authorization has been as follows and has been found to be barely adequate for meeting the minimum requirements for this Group. One truck, and a one ton trailer plus a weapons carrier for two surgical teams is ideal. Truck, 3/4 ton, 4x4 W/C ea. 10 Truck, 2 1/2 ton, 6x6, cargo ..... ea. 15 Trailer, 2 wheel, 1 ton ....... ea. 10 Trailer, water, 250 gallon ea. 3 Truck, 1/4 ton 4x4 ea. 2 The essential piece of transportation is the two and one-half ton truck. This vehicle has the durability and capacity to travel over extremely poor roads carrying personnel and equipment which, in our ex- perience, could not have been accomplished as well by any other vehicle. This truck plus a one-ton trailer is the minimum required to move two surgical teams. The three-quarter ton 4x4 weapons carrier is an excel- lent personnel carrier but in no sense has it been found to be a replace- ment for the two and one-half ton truck. The "peep” is an economical means of transportation most useful in maintaining contact with teams func- tioning in various hospitals. Water trailers have been needed to trans- port potable water. In no situation in which this Group has functioned was potable water available from local native sources. 829 II Administration (Transportation, contd) The transportation section operates at Grouo Headouarters and is responsible for the dispatching of transportation, its maintenance, and coordinating the vehicular requirements of actively engaged teams. In order to minimize the transportation requirements a small pool of ve- hicles are held in reserve at Group Headquarters and a minimal number of vehicles are allotted to functioning teams. This permits independent movement by the teams. During periods of rapid advances and when many teams are moving it is necessary to make use of a shuttle system and all transportation facilities are severely taxed. The following data, estimated only, are of value in envision- ing the work of the transportation section; (1) Total number vehicles -which the Group has operated — 58. (2) Number of miles vehicles have traveled — °00,000. (This is equivalent in distance to thirty-six times around the world.) (3) Gallons of gasoline consumed — 95,000. (A) Number of accidents in 29 months of operation -- 16, From these data it is evident that a number of drivers and several automotive mechanics are required. This problem has been met by employing enlisted personnel not actively engaged on teams in the maintenance and driving of these vehicles. Continual emphasis has been placed on the training of mechanics and on the careful driving of ve- hicles, During the period in which the organization was functioning in two different Theaters of Operations, the transportation available to the Group was often hard pressed in the movement of teams and at times had to be supplemented. f. Supply: General. It has been the experience of this Auxiliary Surgi- cal Group that supply problems have varied and have evolved from condi- tions peculiar to the type of command to which the Group was attached and the locations in which the teams were employed. During the first six months of overseas operation the Group Headquarters was attached to base sections. All supply procedure had to be carried on with base depots, Movement from one base section to another necessitated complete renewal of the authorizations for the equipment held in excess of T/S that was necessary for the efficient operation of the Group. For the pest 22 months, this Group has been functioning with an Army. With this employ- ment problems of supply have been considerably simplified and with minor revisions an adaptable unit supply system was maintained with relative ease. II Administration (Supply, coAtd) The supply procedures for the entire organization were coordin- ated through the Unit Supply Section located at Group Headquarters. 3ur- - gical teans functioning on temporary duty at other medical installations were dependent upon Group Headquarters for their supplies and ecuipment and v/ere required to draw all equipage from the Unit Supply, In this man- ner an accurate check could be kept on all equipment and proper account- ability maintained. Experience taught that by maintaining unit supply in standard boxing and crating it could be moved and set up quickly and ef- ficiently, This procedure also simplified the estimation of cubages and weights on occasions when equipment has had to be moved by rail or ship. Tentage. This organization has been chartered in tents through- out the greater portion of its overseas experience. The T/E 8-571 does not authorize any tentage. The following allowances for tentage have been met by authroization by the Theater Commander end have been adequate: Tent, pyramidal (complete with pins and poles) . . . ea. 80 Tent, storage (complete with pins and poles) .... ea. 8 Tent, wall large (complete with pins and poles) . . ea, 6 Tarpaulin, 12 x 17 ea. 5 Medical Department Equipment. Toe following additional items of Medical Department equipment have been authorized by the Theater Commander and have been found desirable to retain as essential to the Medical. Department Equip- ment list I.TD item 9720300j Auxiliary Surgical Group: CLASS 3 ITEMS 3054500 Bronchoscope, 8 ram x 40 cm, adult ea. 24 34-02300 Ophthalmoscope, eledtric ea. 4 344-1200 Retractor, flexible, abdominal set 28 3535000 Spreader, rib ea. 24- 3493200 Shears, rib, Bethune, 13 l/2 inch -ea. 24 3548500 Tube, aspirating, 50 cm ea. 24 3550800 Tube, aspirating open and warning stop at 4-0 cm ea. 24 3558000 Tube, aspirating, trachea, size 5 ea. 24 3621500 Batteiybox ea. 24 3670300 Electrosurgical unit portable ea, 4 3774700 Stop-cock, one way ea. 28 3775008 Suction Aparatus, portable electric * .... ea. 32 (* An improvised suction machine was devised by a member of the Group and used during the early campaign? in NAT0USA. Brewer, Lyman A. Ill, Portable Handdriven Suction Machine. Bull. Med. Dept, US Army No. 75S-19 (April 1944.) II Administration (Supply, contd) CLASS 7 ITENS 7099400 Table, orthopedic, portable ea. 6 7751000 Chest, tool, small ea. 1 77S9000 Cylinder, valve adapter, high pressure ... ea. 42 7531505 Machine, Office, duplicating, handooerated ea. 1 CLASS 0 ITEMS 9350000 Anesthesia, apparatus, portable ea. 42 9753500 Chest, field plain ea. 60 9950000 Sterilizer, dressing & utensil, horizontal ea. 1' Comment is warranted at t is point to emphasise the need for a durable container approximately twice the size of the chest, field, plain (item 9753500) for the transporting and filing of personnel records office supplies, etc., for all field medical units. Due to the diversity of requirements and ideas among even the same types of units, it seems desirable not to attempt an elaborate interior design for this chest, but rather that emphasis be placed on their durability. This would eliminate a significant problem in removing the need for the construction of many boxes which are often short lived. This was a major problem, especially in North Africa and Italy, as the lumber supply was extremely limited, g. Detachment, Medical Departments The functions of the detachment. Medical Department have been varied. The Detachment Commander has, in general, been charged with the additional duties of supply and transportation officer. These acti- vities have been coordinated in his office. The high percentage of ef- ficiently qualified technicians with the small number of basics among the enlisted men has required that many of the routine duties necessary in the maintenance of a military organization have been performed by these technicians when they were not actively engaged on functioning teams. h. Mess: The Ration. During much of the first year overseas, the ration furnished consisted largely of nCn rations. During the first months in Morocco, it was possible to supplement the T,Cn diet with fresh eggs pro- cured locally and later in Tunisia some fresh vegetables and melons were available. The prevalence of intestinal-borne diseases reduced the pur- chase of such supplements to a minimum. The Group was fortunate in hav- ing well trained cooks but the repeated issue of Vienna sausage, spam,• chili-con-came, dehydrated potatoes, beets, carrots and powdered eggs severely taxed their ingenuity in the preparation of appetizing foods. 832 II Administration (Mess, contd) Rations in Italy improved and an almost daily issue of fresh neat, occasional issue of fresh eggs and butter, and fresh'fruits and vegetables in season, provided excellent fare. In Southern France !,Btt rations were available early in the campaign, and the gratitude and friendliness of the French people produced many gifts in the form of fresh eggs, potatoes, vegetables, poultry and cheese. However, upon en- tering Germany, due to the added burden of feeding hundreds of thousands of displaced persons and released prisoners of war, the basic ration was cut 10;'j, In addition, no outside purchases were permitted. This cut was noticeable in the ness kit of the individual soldier. Mess Sanitation. The standard methods as prescribed in the basic field manuals have been used for the control of flies, washing of mess kits and utensils and safeguarding perishables and other food. Garbage was occas- ionally buried but for the most part was picked up by the local populace who were more than anxious to get it. Some difficulty was encountered in keeping the wash water for mess kits at a high enough temperature with the standard burner unit. Pbr a while this was taken care of by the use of an improvised gasoline heaterj gasoline was piped underneath the G.I. cans containing the wash water where it was ignited, and the aosuing heat vaporized the gasoline as it left the pipe making a very hot flame that kept the water at the boiling point. This method was dangerous and had to be carefully supervised. It was abandoned upon the issue of the new immersion type water heater which has proven ideal. During the two and one-half years of overseas duty no diarrheas or food poisonings were im- puted to the unit mess. Civilian Mess Attendants. Following the cessation of hostilities, civilian per- sonnel were emplojred as mess attendants and kitchen police. This released enlisted personnel to take part in the educational and recreational pro- grams as prescribed by redeployment directives. Military Personnel. The unit mess has been staffed with the same enlisted personnel throughout; the turnover has been slight. They were selected by their qualifications and desire for that type of work and consequently have done a superior job. On occasions, medical officers and nurses who were not actively engaged with the professional duties on surgical teams have acted as Mess Officers. Their periods of employment were usually necessarily brief as they would have to leave the position when their teams were called out. This was disadvantageous to the efficiency of the mess, A Mess Officer, preferably of the Medical Administrative Corps, 833 II Administration,(Mess, contd) who acts as Mess Officer in addition to his other duties, is reouired to afford the command the best opportunities, through its ness, for good health arid a high morale, i. Unit Postal Section: In the case of troops overseas, mail is possibly their one link with life as they formerly knew it. Hence, the reasonably prompt receipt and dispatch of communication between troops and the home' front becomes all inportnat. Because of the nature of this organization and the wide de- ployment of its oersonnel subject to frequent and oftentimes unexpected changes, the prompt delivery of mail presented an unusual problem. Early in the North African Campaign, it was noted that the time required for the delivery of mail from Group Headquarters through exist- ing Array Postal Units was too great — sometimes running into weeks. Throughout the Italian, Southern Prance and Germany Campaigns, this con- dition was corrected by expediting the dispatch of incoming nail from Group Headquarters to the medical installation in which the surgical teams were employed, Much of the mail received at the Unit Post Office for per- sonnel on temporary duty elsewhere was delivered by individuals from Group Headquarters whose duties involved direct contact with the functioning teams, 'They might be replacement personnel for forward teams, messengers, and in many instances, the Commanding Officer or his representative. Mail was freauently collected also by members of teams in the field who returned temporarily to Group Headquarters on other business. This greatly expe- dited the delivery of mail and was a factor of great morale value to the members of surgical teams. Outgoing mail was well taken care of by the established Army pos'tal facilities which maintained postal service for the installation to which our teams were temporarily attached. Mail for personnel on detached service in far removed areas or those hospitalized was in most cases delivered through Amy postal chan- nels, The proportionately large number of officer personnel and the pre- sence of many well trained enlisted technicians in the assigned strength of this organization seemed to influence the volume of mail, both incom- ing and outgoing which numbered many times the volume to be expected from a unit with a similar number of members. The absence of lost mail, the absolute minimum amount of delayed delivery mail and the high morale of the organization are all testimony to the efficiency of the unit mail system. In addition, the characteristic functions of a post office were carried out. These included parcel post facilities, postage, ex- peditionary force senders* composition messages and money orders. The unit post office acted as a message center between Group Headquarters and detached personnel. II Administration (Unit Postal Section, contd) From time to time the unit post office has been confronted with the problem of providing postal .service for many additional attached per- sonnel su.cn as surgical teams from other Auxiliary Surgical Groups during the campaign in Southern France and Germany, The system of handling mail was readily adaptable to existing and varied conditions and as a result, mail service continued to function smoothly throughout the entire period that this Group has been overseas. The return of attached personnel to their units brought the problems of promptly forwarding mail to the cor- rect stations of the personnel involved. A complete set of locator cards kept by the unit post office proved to be of immense value in accurately carrying on this service. I i 8, Trainings a. General. Constant diligence has been exercised throughout the his- tory of this organization in the training of its personnel. A policy has been maintained of having, as nearly as possible, two individuals trained for the performance of each essential job, b. Training of Assistant Surgeons. It is of particular interest to note that during the over-, seas experience of this organization, 16 officers who originally served as assistant surgeons, or entered the Group as assistants, have in the past year made creditable records as heads of surgical teams. It is be- lieved fundamental to the requirement of having well qualified surgeons in charge of surgical teams of an Auxiliary Surgical Group, that emphasis be placed on the selection of junior surgeons capable of being trained within 12 to It:‘months to have charge of their own surgical teams. For- tunately for this organization, a veiy appreciable number of the assist- ant surgeons assigned were sufficiently well trained prior to their en- tering the military service to permit them to take over the duties of the operating surgeon as soon as a was available. It seems inevit- able, under the disrupted plan of pre?;ar medical education and postgrad- uate training, that the number of officers with professional qualifica- tions similar to those originally assigned to this Group as heads of sur- gical teams would not be available for such assignment if World War II had continued, c. Training of Anesthetists. The training of medical officers in anesthesiology has been of particular importance to this organization. There has never been an adequate number of qualified physician anesthetists to staff all of the surgical teams of the Group. Fortunately, the demands for the engagement 835 II Administration (Training, contd) of all of the teams progressed slowly end reasonable opportunity has been afforded to train other officers in anesthesio 1 o77. Also, we have been fortunate in having several especially well Qualified nurse anesthetists who have rendered yeoman service as anesthetists of surgical teams. How- ever, the demand for replacements of qualified anesthetists is ever pre- sent, and here again there is difficulty in securing competently trained physician or nurse anesthetists. To meet these demands training in this field has been continuous and several assistant surgeons have been rotated in their duties to receive training in anesthesiology whenever conditions permitted. This is a field of medicine which is destined to become in- creasingly important during the postwar period. It has been a universal comment of the operating surgeons of this Group that their work in the surgical care of the most seriously wounded could not have been accomplished had it not been for the excellence of the work of the anesthetists. Like- wise, all of these surgeons will demand the best of anesthesia in their own practices, d. Training of Array Nurse Corps Members. The training of nurses in operative surgery has not pre- sented any major problem to this organization. There has* however, been a steadily increasing need for replacements.for the experienced surgical nurses. Throughout the history of this unit it has been the policy to alternate nurses in their assignments to surgical teams, and during relat- ively ouiet periods, to assign the less experienced nurse to the function- ing surgical teams. This permitted the training of several nurses, who have later been able to take over this work during the periods of great activity. It has at times been suggested that enlisted men might be trained to replace surgical nurses in the forward area. The experience of this organization has been such as to definitely disfavor this suggestion. The period of training required in the nurses1 education cannot be rapidly duplicated by short courses of training of enlisted men. However, if such a change should be required, particular attention should be focused on selecting men with high scores as determined by the Army General Glassi- fication Test, Graduate male nurses should, when possible, be selected. A minimum of six months didactic and practical training in surgical oper- ating room methods should be reouired in the training of these men, e. Training of Enlisted Men. The basic and advanced training in military subjects which the enlisted men of this Group underwent in the United States has proven to be of real practical value. Likewise, the teaching and training which they received in the Enlisted Men's Technicians School can be said without II Administration (Training, contd) reservation to have been excellent, doubtless, this preparation made it much easier for them to participate rapidly in the practical application of their duties as surgical and medical technicians. There is, however, one point worthy of emphasis, and that is that one learns very rapidly certain requirements of seeking cover, observing blackout rules, and avoiding traffic violations in forward areas when exposed to the immed- iate hazards of enemy action. Further, the repetition of completed train- ing programs, schedules, etc,, soon loses its significance after many months of actual field experience, and should be held to the very minimal rcouiroment. This does net imply any deviation in the rules of military discipline and courtesy, "or they must be constantly emphasized and prac- ticed. 9. Personnels a. General, The problems of personnel management are, in general, di- rectly proportional to the percentage of the personnel performing duties in which they are interested, desire to perform and are qualified to per- form, The officer personnel of the Group was carefully selected on the basis of their professional qualifications. This selection has been con- tinued during its overseas experience and personnel placement problems have been minimal. Certain problems in personnel management do arise and have been handled as individual matters with all efforts being directed toward placing the individual in the position for which he is best quali- fied. In the early part of August 194-2, the Commanding Officer of the Group was ordered to the Surgeon General's Office, Washington, D.C., to confer with the Surgical Division of the Professional Service Section for the purpose of selecting the medical officers to be assigned to the Group, The professional qualifications of all medical officers suitable for such an assignment were studied. The officers possessing the required quali- fications were made available, except officers on duty with the Air Ibrce, those assigned to affiliated hospital units unless they constituted an overstrength, and those officers already overseas. Brigadier General Pred W. T.ankin, Director, Surgical Division, Surgeon General's Officer, di- rected the assignment of the medical officer personnel. An analysis of the officers selected to head the surgical teams at the time of departure for overseas service reveals the following information: The average age of the team heads was 34- years j each averaged four years of postgraduate surgical training, three years of private practice and slightly more than a year of active military duty. Thus, the standards of surgical training among these officers was high- b. Promotion, The promotion of medical officers from the grade of captain to major should, it is believed, be based on considerations other than II Administration (Personnel, contd) T/0 vacancies alone. It is suggested that an additional basis for pro- motion to this rank be considered including the length of military ser- vice and professional qualifications, c. Rotation. Thepclicy of rotating a small percentage of personnel to the United States for reassignment is considered very desirable and has been practiced to the fullest extent possible by this organization. Likewise, these comments are appropriate concerning the policy of tempor- ary duty in the United States for 30 days and the return of the indivi- dual to his organization overseas. The defects in the practical applica- tion of these procedures have, in our experience, been the-following: First, the quotas have been entirely inadequate. In particular has the officer personnel been unduly restricted in this respect. This organisation has a larger number of officers than enlisted men, and spec- ial consideration is warranted in allotting quotas for officer personnel in an Auxiliary Surgical Group. Second, the period which elapses before a replacement for the personnel rotated is received has been prolonged. For example, two of- ficers left the Group on rotation in October 194-3, and their replacements reported for duty March 1944? a lapse of five months. A similar situation exists relative to replacements for enlisted men, 'The requirement of not permitting the filling of the position vacancy created by rotation requires someone else to perform the duties of the personnel rotated without the possibility of promotion. This tends to lessen one's interest in doing a good Job and has deleterious effect on morale. The recuirement for elig- ibility for promotion requires the actual occupation and performance of the position for periods often of less duration that that which usually results from doing the Job while awaiting, the arrival of a rotation re- placement. 10, Health: The health of the conunand is paramount in maintaining its ef- ficiency and morale. During the period which this organization has been overseas every effort has been made to provide the officers, nurses and enlisted men with the most adequate medical facilities that could be main- tained under field conditions. Constant attention has been paid to the problems of preventive medicine, malarial control, mess hygiene, sanita- tion, and venereal disease control. The low incidence of communicable di- seases, . venereal disease, and thosemaladies caused by insect vectors has attested to the effectiveness of this program. A unit dispensary was con- tinually in operation at the Group Headquarters. 838 II'- Administration (Health, contd) During the period 9 March 194-3, to 31 July 194-5, 133? patients were treated in the unit .dispensary. These patients received 3057 indi- vidual treatments. During the same time, immunizations were administered in the following numbers to members of the command: Tyohoid - 755, Small- pox - 4-3?, 'Typhus - 870, Tetanus - 34-9, a total of 2406 immunizations that were provided. Medical service was often extended to neighboring units who did not possess facilities.of their own. These included patients from other American units, united Kingdom troops, Indian troops and South Afri- can troops. The personnel of this command had 44-28 hospital days during this period (Table I,), The most frequent cause for hospitalization was gastro-enteritis with recurrent malaria the next most common. Thirty- three of the personnel were treated or hospitalized for wounds received as the result of enemy action. Of those, 3-1 were returned to duty and two were transferred to the Zone of Interior. Throe individuals were killed in action and one died of accidental causes. The greatest inci- dence of illness during the 30-month period was during the months of March and April 194-4-, with a corresponding increase- in March 1945. Respiratory diseases and gastro-intestinal disorders were the most prevalent diseases in these periods. The health of the command was the best during the month •of September 1944, with a total of 6,06)3 of the mean strength of the unit hospitalized, (figure 97) During the period 15 August 1944, to 15 Juno 194-5, the Group was separated into two functional units. In the Detach- ment that was employed in Prance raid Germany and the portion that remained in Italy during that time, the most prevalent causes of illness in each case were gastro-enteritis and recurrent malaria. During the 30-month period that the entire Group has functioned overseas, there have been 44 individuals returned to the Zone of Interior for further hospitalization. This group of patients consisted of 20 of- ficers, 12 nurses and 12 enlisted men. Of these, nine were individuals who had arrived in North Africa on "I)’1 Day, B November 1942, or shorter thereafter. The most frequent causes for return to the Zone of Interior were neuropsychiatric disorders and gestation, there being sir: each of such patients. Next in frequency'were cardiovascular diseases of which there were five cases. The strenuous effort that was placed on the education of the troops in the control of venereal disease is reflected in the low vener- eal disease rate of nine cases or .01045 cases per thousand per annum for the entire 30-month period that this unit has been overseas. Of the total number of cases, there were one case of primary syphilis, five cases of gonorrhea and three cases of chancroid that occurred. The program for the control of venereal disease consisted of the employment of visual aids, training films said frequent informal discussions held during formations of the Medical Detachment. It has been the policy to always have avail- able at any hour of the day or night a trained noncommissioned officer in attendance at the unit Pro Station, These attendants were thoroughly 839 II.' Mministration (Health, contd) schooled in matters relating to venereal disease control. Pall advantage was talcen of organized athletics, recreation and other elements of the Special Service and Information-Education programs offered by Army and the Theater Commands. It was felt that because many off-duty hours of the enlisted men were occupied by these diversions, they definitely aided in influencing the low venereal disease rate of the unit. TABLE I incidence of Illness Requiring Hospitalization Hospital Officers Enlisted Men Nurses Ie,ar -Month Tot Days Number Days Number • Days Number Days 1943 March 54 .. 5 22 ... . 5 19 2 13 April 109 14 57 12 28 6 24 May 96 10 32 12 52 5. . 12 . June 232 10 . 90 9 136 1 6 July 212 11 61 12 121 2 30 August 78 2 15 . 17 53 1 10 September 81 3 IS 10 63 0 0 October 72 3 23 _5 23 . 1 26 November 103 6 33 5 .... 5.4 1 16 December 124 5 40 8 70 1 34 1944 January 190 8 108 4 52 .2 .... 30 February 260 16 103 . 16 130 6 27 March 308 14 163 16 112 4 ._ 33 April 339.. . . 12. 167 12 115 . 7 52 May 130 6 33 6 30 2 17 . June 90 . 3 42 5 J6 1 12 July 235 6 94 6 102 4 39 August . 164 .. 6 35 9 92 7 37 September 88 2 35_ -2. 35 . 2 18 October 111 6 43 4 . . 45. _ 3_ 21— November 225 9 104 7 65 _ 3 ... 56 December 103 4 48 3 48 . 1 7 1945 January 156 7 .. 39 6 33 5 84 February 21? 8 109 6 71 4 32.... March 239 3 33 10 169 . . 2. April 97 4 56 8 29 2 . 12 May 169 -1 8 10 85 8 76 June 93 3 24 5' 21 3 48 July 58 4. 25 6 24 2 2 Totals 4428 ■ ■■ASL jaS- 236 1913 88 800 II Administration (U< cZ - contd) MM MCI Df KKSONNFL HOSPITALIZED IN nmm to mean strength figure 97 - Incidence of Personnel Hospitalized in Proportion to I/iean Strength, 841 II Administration (contd) 11, Illustrations of Professional Service Norms: a. Individual Case Record. 2ND AUXILIARY SURGICAL GROUP APO 512, U.S..Array Surgeon: Date OP. Hour Hosp Team: NAME: ASN:_ AGE QRG: . INJURY: Date Hour ' Type Agents Sites of Injury Time Lag How transported: PRIOR TREATMENT Sulpha Place Time IV Fluids no lee. Sedative Prior Oo. PRESENT STATUS: Dehydrated Nutrition Disease Conscious Bleeding Shock Physical Pertinent lab, PREOPERATIVE TREATMENT: ~ OPERATION; Wound excision : PROCEDURE Debridement : Chemotherapy : Pack : Drains : hme closure • P.0. DIAGNOSIS ~ " ANESTHESIA RECORD PRE-OP MED 3P: PULSE RESP RISK 1 2 3 4- Duration Technic Anesthetist: REMARKS II Administration (Illustrations of Professional Service Forms, contd) b. Follow-up Card, Headquarters Hospital APO , US Amy Official Business Commanding Officer 2nd Auxiliary Surgical Group APO 512, US Army Figure - Follow-up card placed in Record Jacket, LTD Form 52d of patients evacuated to the rear after treatment by surgical team. Patients (Name) (ABU) (Org) (Team & No .7 TGs Surgical Service, Base Hospital, CZ. We .shall appreciate your cooperation in supplying the date asked for below at the time of final disposition of this patient in your hospital. 1. Complications: 2. Secondary Operations. Date; 3. Disposition; If ZI, date: b. If RTD, date and class of Duty; c. If died, date, primary cause, Post-mortem; A. Remarks* Kindly fill in, staple, and drop in the mail. (Signed) ~ (Hosp.) Figure - Reverse side of Follow-up Card tnat was filled out by base section surgeons and returned to the Group Headquarters to be filed with the operative case record of the patient. 843 II Adrrdnistration (contd) SUMMARY The administrative requirements for the efficient functioning" of an Auxiliary Surgical Group' are manifold and exacting. Ac the profes- sional qualifications for the medical officers are high an equally high standard of administration is mandatory if the Group is to render its maximum service. These matters of administration must extend into the details of military discipline, moss management, supply service, trans- portation and motor maintenance, personnel administration, supervised re- creation facilities, as well as the fundamentals of other matters of mil- itary administration applicable to all military organizations. All personnel engaged in administration .functions should be cogni- zant and wholeheartedly devoted to the fundamental f riction for which the Group is intended. It is the duty of such perse ns] to make every effort to see that administrative requirements are fully not and in such a manner as to minimize any delays and difficulties which might divert attention from the organization’s basic function. The varied and often wide dispercement of the personnel of the Group entails increased atten- tion to the details of administration. Military discipline must be con- stantly inculcated in the minds and actions of all of its personnel. Much of the reputation and a great deal of the impression of the effic- iency of an Auxiliary Surgical Group is obtained by the discipline dis- played by its members. The fact that their employment is in installa- tions in which they are not regularly assigned members of the staff, de- mands an alertness and display of even more exacting discipline than that of the intrinsic members of the unit in which they are functioning. A headquarters mess capable of accommodating fifty or four hundred persons on short notice requires ingenuity, adaptability, and minimal tempera- mental tendencies of moss personnel to warrant complimentary expressions for its members, A supply service which prides itself in readily fur- nishing the great variety of items from flashlights, to nurses’ clothing, to anesthesia apparatus, and secures repairs of surgical instruments, cannot be idle if it anticipates these needs. The pay of personnel often employed in a dozen different and widely scattered areas, the regular and rapid distribution of mail, the maintenance of more than five times the amount of transportation originally allotted for the Group furnishes em- ployment for enlisted personnel not actively engaged in team functions. The special requirements of furnishing proper recreational activities and the best possible living quarters under field conditions reouire constant diligence end ingenuity. Thus, the functions of Group Headquarters re- quire a high degree of efficiency from all its personnel. The Headquar- ters must be located in close proximity to the teams and the installations in which they function. To meet these requirements a marked degree of flexibility in the organization is necessary so that it operates with such a smoothness that the varied duties performed are manifested only to those engaged in its operation. The Commanding Officer must maintain close and cordial relationship with the Commanding Officers and Chiefs II!. Administration (Summary, Oontd) of the- Surgical Service in which the teams of the Group s.rr employed. His contact with the Array Surgeon and his staff especially the Array Sur- gical Consultant must be close enouph to permit him to have knowledge of anticipated operational activities. The planning of higher headquarters which nay require the employment of surgical teams recmires that close liaison be maintained with the Theater Surgeon’s office, especially with the Theater Consulting Surgeon ”as recommendations regarding placement of teams, replacement of personnel, as well as surgical technics and pro- cedures reouire close coordination with planning, movements of hospitals, and other items of theater policy.” Inasmuch as these duties require that much time be spent in keeping close personal contact with his teams, the hospitals in which they function, and higher headquarters, it is man- datory that the Group Headquarters must be organized to function effic- iently during his absence. III. OPERATIONAL ACTIVITIES TUNISIA ALGERIA MOROCCO vir;urc r-T 857 IIL OPERATIONAL ACTIVITIES, 1* General. Throughout the overseas history of this organization the Group has been very much a part of the operational activities of the Department in NATOUSA and MTOUSA, and to a lesser degree in ETOUSA -while functioning with the Seventh Army in France and Germany. These activi- ties have been evidenced not only in the amphibious operations of NATOUSA and MTOUSA, but also specifically with the Fifth and Seventh Armies. In general, the phases of the operational activities of this Auxiliary Surgical Group functioning with an Army will be discussed unde, the headings of the various campaigns in which this organization has par- ticipated. In addition, note will be made of specialized types of mil- itary operations requiring the services of elements of this Auxiliary Surgical Group. Before describing these details of the operational act- ivities of this Group a brief discussion of the factors which have gover- ned these activities while functioning with an Army will be presented. These factors concern themselves principally with the organization of the medical service of a field force relative to the surgical management of battle casualties in an Army. 2. Triage of Casualties at Division Clearing Station. The function of the division medical service includes the evac- uation of casualties from its area. The division clearing station is the hub of the installations through which the casualties are evacuated. Repeated experiences of surgical teams functioning in division clearing stations have confirmed the inadvisability of using a clearing station for a surgical hospital. The single exception has been the employment of surgical teams from this Group in division medical installations dur- ing the early phases of amphibious operations when the facilities of a Field or Evacuation Hospital were not available. Even in amphibious operations, surgical teams are much better able to perform their func- tion when attached to Field or Evacuation Hospitals which land during the first 24 hours. Our experience has repeatedly demonstrated that ap- proximately eight percent of the casualties reaching the clearing sta- tion must receive surgery at this point in the chain of evacuation if they are to be afforded the best cnance to recover. Certain facilities are essential for the care of such patients and the farthest point for- ward at which initial surgery can be well done is where these essentials can be assured. They includes (Circular Letter Mo. 18. Office of the Surgeon. NATOUSA. dated 14 June 1943) (1) An experienced surgeon, anesthetist, and operating room personnel. (2) Simple, but adequate operating room equipment. (3) Adequate lighting end water supply. (4) Good, but not necessarily female nursing. (5) Proper facilities to retain more seriously wounded patients 10 to 14 days. 858 Oper»tional Activities (Triage of Casualties at Division Clearing Sta- tions, cont'd). These facilities have been made available in NATOUSA and MTOUSA, and in the Seventh Army by utilizing platoons of a Field Hospital as small mobile surgical hospitals set up immediately adjacent to the div- ision clearing station. Thus, the division medical service has immedia- tely available a hospital to care for the casualties from its area who cannot be transported further to the rear without surgery. A division clearing station becomes, as Churchill has described, "The focal point of triage based on surgical urgency of the wound". The casualties ar- riving at this station are sorted into two principal categories; those mho cannot be safely transported farther to the rear without surgery (non-transportable), and tnose that may be safely transported further to the rear, i.e., to Evacuation Hospitals for initial surgery. This sort- ing is an important function of the division medical service* 3. First Priority Surgical Hospitals. (Platoons of a Field Hospital). This small mobile surgical hospital was developed as an out- growth of the experience of employing surgical teams of this Auxiliary Surgical Group in clearing stations. As noted above, the clearing sta- tions are not suitable nor intended to perform the function of a first priority surgical hospital. In the Sicilian campaign, the platoons of two Field Hospitals (10th and 11th) were employed as priority surgical hospitals in which the Auxiliary Surgical Group teams were charged witn the surgical management of the battle casualties. This short campaign demonstrated the feasibility of such a plan which was fully developed during the early campaigns in Italy. It is of first importance that these installations be able to move quickly in their organic transpor- tation and be able to accept patients within two hours after arrival at their new site. To meet these requirements, the Field Hospitals functioning in such a capacity have had to be revamped. Additional transportation for each platoon was a prerequisite. The bed capacity for each platoon was decreased from 100 to a patient capacity of ap- proximately 50. The surgical management of the casualties is a respon- sibility of the Auxiliary Surgical Group teams functioning in the hos- pital. The physical setup of these first priority surgical hospitals when quartered in tents has been developed through extended experience and has become largely standardised. It is so erected in ward tents that the receiving ward, shook ward, operating room, postoperative ward. X-ray and laboratory form a cross. The receiving ana shook ward is situated at the main entrance, the postoperarative ward occupies the tent which is a prolongation of the shock tent, while the X-ray and lab- oratory occupy a tent opposite to the operating room. A pyramidal tent forms the central point in the cross. 859 Operational Activities (First Priority Surgical HoapxtaJLS, (Pl*.i.oon« of a Field Hospital), coat'd). Receiving & Shook Postoperative Operating Soon X-Say * Laboratory This compact arrangement enables more efficient care of the pat' ionts, conserved the personnel requirement for the hospital, improves facilities for heating, eliminates the necessity for transporting pat- ients from one tent to another in inclement weather, and enables an eff- icient blackout. When these hospitals are set up in buildings, the problem is one of adapting the physical characteristics of the building to the fun- ctional needs of the hospital. Sometimes this is easy, at other times, tentage is more efficient than buildings. 860 Op. r,„ :■ /• tivities (First Priority Surgical Hospitals, (platoons of a Field Hospital. contfd). Figure 99* A Field Hospital Platoon# Italy* The postoperative nursing care is a function of the nursing personnel regularly assigned to the hospital. The regularly assigned medical and medical administrative staff are fully occupied with the administrative operation of the hospital. One exception is that the medical officers, other than the commanding officer, have been acti- vely engaged in aiding the shock officers of Auxiliary Surgical Group shock teams and the surgeons in the management of shock. The first priority surgical hospital is located at the rear of the division boundary, and is often set up in physical conjunction with the division clearing station. In general, three actively engaged div- isions require six platoons (2 Field Hospitals) of priority surgical hospitals to provide adequate surgical care for non-transportable battle casualties. During periods of rapid tactical advances, these platoons "leap frog" one another in keeping up with the advancing front. The platoon left behind becomes a "holding unit”, charged with the respon- sibility of the postoperative surgical care of the patients. This Operational Activities (First Priority Surgical Hospitals, (Platoons of a Field Hospital), cont'd). holding period varies, but usually lasts about 10 days. One surgical team usually remains with tne holding unit. Not infrequently, major sur- gical procedures are required during tnis period, and always there many problems arising in the postoperative care which tax the surgical judgment of the most able surgeons, As soon as all of the patients are evacuated, the holding unit becomes the platoon ready for an assignment forward, and again is set up adjacent to the division clearing station. To state that no defects in the scheme of operation of a prior- ity surgical hospital have been experienced would be inaccurate. The fundamental principle for which it was conceived in the surgical manage- ment of non-transportable battle casualties is sound, and any defects are not involved in this basic principle. The defects are concerned with the living conditions wnioh have often, been experienced in these hospitals. These conditions must at times, especially during periods of rapid move- ments, be meager for comfort. However, under more stable situations, the living conditions can be made very pleasant. The messing facilities have in general been found to be poor in these hospitals. These factors have a great influence and properly so, on the morale of the surgical teams functioning in these installations, wnich in turn may indirectly effect the care of the patients. These defects are readily correctable as has been repeatedly demonstrated when tactful, energetic, wise platoon com- manders are placed in charge of such platoons. The position of a platoon commander of a Field Hospital is a very important one, and the proper selection of the officer for tnis job requires great car© for, and ap- preciation of his duties. The solution to this problem lies basically in the selection of proper medical officer for the position of platoon commander and not in attempting to make a new or different hospital to serve the purpose of treating first priority surgical battle casualties under the conditions which this Auxiliary Surgical Group has experienced in Europe* 4, Role of Auxiliary Surgical Group Teams in First Priority Sur- gical Hospitals, It is in this small forward mobile surgical hospital that teams of this Auxiliary Surgical Group have been extensively employed. They have been charged with the entire responsibility for the surgical care of the wounded treated in these hospitals. A senior surgeon from among the team personnel has been designated as the officer in charge of the professional work and responsible to the commanding officer of the hos- pital for its proper execution* During the last phases of the Italian campaigns, this plan was somewhat altered. One surgeon from a surgical beam was relieved from his team duties and designated as chief of the surgical service in each active platoon. He functioned as a coordinator of the teams activities and was especially valuable, at this time, as several teams from base hospitals functioned for the first time in these priority surgical hospitals, Iflhether or not this arrangement is desir- able under different conditions is, at present questionable* 862 Operational Activities (Hole of Auxiliary Surgical Group Teams in First Priority Surgical Hospitals, oont'd). In general, a busily engaged platoon required four to six gen- erax surgical teams and one shock team. A thoracic surgical team cap- able of doing general surgery should, if available, be included as one of the teams functioning in a platoon. These hospitals are simply but ade- quately equipped to furnish all the essential for good surgery. Whole blood is supplied through the facilities of a blood bank operated in a base section. Folding cots provide adequate beds and improvised head rests are used as indicated. The surgical teams furnish their own in- struments and each team has a complete set of surgical instruments. To visualize a tent operating room in these hospitals, one sees a long, often double ward tent, with usually three operating tables. These tables are generally hand made wooden ones, or litters across iron or wooden "saw-horses”. Sheets strung from a wooden frame form the partitions be- tween the operating pavilions. On the opposite side of the tent is the sterilizing equipment which is in almost constant operation. The traffic through the operating room is often heavy and the activity is continuous until all the casualties requiring surgery have received treatment. The comment of the Consulting Surgeon, MTOUSA, Colonel Edward D, Churchill, (Annals of Surgery, Vol. IkO, September 1944 p. 271) is appropriate for describing the work of the Auxiliary Surgical Group in these first priority surgical hospitals. "Surgeons assigned the responsibility of caring for the wounded in a first priority surgical hospital must be highly trained and exper- ienced as their tasks are the most exacting of military surgery. The Auxiliary Surgical Group has been found ideal as a source for this per- sonnel. The experience of the individual surgeon is augmented it the base during periods of an inactive front. Unity and uniformity in this portion of forward surgical personnel has produced a high level of com- petence as well as economy in the deployment of specialized surgical skill and taient. If the achievements in this theater are ever Judged noteworthy, they are attributable to the fact that expert rather than inexperienced surgeons are doing the work. All other measures are ancillary items”. 5. Role of Auxiliary Surgical Group Teams in Evacuation Hospitals, From the division clearing stations, the transportable casual- ties are transported to the Evacuation Hospitals. These installations care for the great bulk of the casualties, approximately 90%, and the a- mount of surgery performed is great. The type of surgery differs con- siderably from that performed in the platoons of Field hospitals as the number of abdominal wounds and severe thoracic wounds form a small per- centage of the total number of casualties treated. The percentage of patients suffering from soft tissue injuries, fractures, less severe thoracic, and head injuries constitute cue great bulk of casualties. During busy periods these installations require surgical teams to sup- plement their staff. In fact, our experience has been that all hospitals 863 Operational Activities (Role of Auxiliary Surgical Group Teams in Evacuation Hospital, cont’d). doing surgery in an Army require surgical teams from an Auxiliary Surgical Group when the fighting activity is great. It is in the Evacuation Hos- pitals that the specialty surgical teams find their greatest usefulness in an Amy. The need for general surgical teams in these installations has been definite, but in general, less urgent than for the specialty teams, 6, Operational Activities During The Campaigns In Which This Organ- isation Participated, a. General, During the earlier campaigns in NATOUSA, the surgical teams participating in the campaigns functioned at great distance from the Group Headquarters* In fact, during the Algeria-French Morocco part of the Tunisia campaign, the Group Headquarters had not arrived in the Theater, and could not exercise control over the activities of these teams nor render them assistance. The Group Headquarters and the major portion of the organisation arrived in NATOUSA 9 March 1943. Earlier detachments had arrived on 8 November 1942 and 19 November 1942, No formulated plans had been established for the proper functioning of an Auxiliary Surgical Group in this Theater prior to the arrival of the Group Headquarters in NATOUSA, The many problems encountered in the successful performance of its mission required proper employment of highly trained surgeons, unusual tact, foresight, common sense, and en- ergetic effort. As a result there was gradually evolved a method for the use and control of an Auxiliary Surgical Group which has proven highly successful and is detailed in this report, b, Algeria-French Morocco Campaign (8 November to 11 November 1942), The preparations made for the utilization of surgical teams of an Auxiliary Surgical Group in the Algeria-French Morocco campaign were, from the experience of this group, entirely inadequate. In fact, there appears to have been little detailed planning in this respect ex- cent that surgeons would participate early in the landing phase of the campaign. The 2nd Auxiliary Surgical Group was in the process of being formed at Lawson General Hospita, Atlanta, Georgia, in the early part of September 1942, A total of ten medical officer* three dental officers, two medical administrative corps officers and 66 enlisted men constitut- ed the personnel of the unit -at that time. None of the enlisted personnel was a qualified surgical technician, (l) First Detachment of Teams Ordered Overseas, Orders were received 15 September 1942 for two general surgical teams, one orthopedic surgical, and one shock team, (a total of 864 Operational Activities (Operational Activities During The Campalgnn In Which This Organization Participated, cont*d). eight medical officers, four nurses, and six enlisted men) to report tv the New York Port of Embarkation, New York, by 16 September 1942 It is evident from the above strength report that nurses were not present* Sufficient qualified madic&l officer personnel and enlisted men required to constitute these teams had not been assigned to the Group* These de- mands were partially met by assigning to the teams the qualified officers who were present, and obtaining orders from the War Department for quali- fied officers available in the Nedioal Department Replacement Fool at Lawson General Hospital to be assigned to the Group for duty with these teams* Still the requirements could not be met and one officer and four nurses were ordered from other stations to join these teams at the New York Port of Embarkation* Thus, the personnel which finally comprised these teams had, in several Instances never seen the other members of their team until they embarked from the New York Port of Embarkation* In fact, the detachment was never assembled as a whole until it landed in Ireland. The enlisted men were new recruits having been in the Army only eight weeks when they departed for overseas duty to perform a high- ly technical job* This is indicative of the state of planning and con- fusion of the early days of the war, for it is hardly conceivable that such a hurridly constituted detachment of teams oould be expected to work immediately either as a well coordinated group, or as individual teams* These teams left New York 25 September 1942 and arrived in Northern Ire- land early in October 1942* They remained there approximately three weeks. The nurses were replaced by six additional enlisted men, tnree of whom were well qualified surgical technicians. The detachment of teams was attached to the Eastern Task Force to function with tbs 39th Combat Team for the forthcoming invasion of North Africa* They departed from Ireland 24 October 1342* The nurses of this detachment never re- joined the 2nd Auxiliary' Surgical Group* The activities of this detachment of teams, which will be de- tailed presently, and those of a second detachment of teams which ar- rived in North Africa on 18 November 1942, portray some of the difficul- ties encountered during the early campaigns. However, the early exper- iences of these teams in the surgical management of severely wounded battle casualties were of greatest value in later formulating an effi- cient organisation for the operational activities of this group in the subsequent campaigns. Their experiences proved that the Group Headquart- ers or a detachment of the headquarters should be made available to any sizable detachment of teams which might be required to function at an inaccessible distance from tne remainder of the group* They likewise emphasized the need for a proper installation in which major surgery could be well dene in areas forward of the Evacuation Hospital* These factors have been overcome In subsequent similar campaigns by having the Group Headquarters or a detachment of the group headquarters located in close proximity to the teams* The development of the present small mobile first priority surgical hospital was in a large measure an out- growth of the early experiences of the surgical teams of this group* 865 Operational Activities (Operational Activities During The Campaigns In tfhicn This Organisation Participated, cont'd). The extract of the report which follows is from Major Paul L« Dent, M,C, (then Captain) operating surgeon of a general surgical team of this organisation which became the first surgical team of an Auxiliary- Surgical Group of the United States Army to ever function in an active Theater of Operations* "On November 8, 1942, the 39th Task Force, part of the 9th Division anchored off Charley Red Beach near Surkouf, tnirteen miles east of Algiers about It00 A*M* The Navy Medical personnel set up an aid station on the beach after the beachhead was secured* The plan was to evacuate casualties to the shxps until it was thought safe to land a clearing station. This plan was never carried out because the sea was too rough to land equipment* At 1:00 P.M*, 8 November 1942, the ship received a radio call to send medical personnel a- shore. Captain Dent and Captain Mansfield were asked to go ashore and determine what medical equipment was needed. We landed about 4t00 P.M., but were never able to contact the ship again, due to roughness of the water. No more landing barges were dispatched. Captain Mansfield and myself assisted the Naval personnel in the Aid Station Sunday evening and night 8 November 1942. The only supplies available were dressings and morphine. We could not evac- uate casualties to tne ship and had no instructions from the ?ask Force Surgeon as to the disposition of them on land by the morning of 9 November 1942. We evacuated some twenty odd patients to the dispensary of the Air Field, Maison Blanche fifteen miles southeast of Algiers, by truck and French ambulances. We were no better off here in the way of equipment, but eld have a building, and Captain Mansfield and myself had to do the cooking, feeding and complete care of the patients* Not having received any instructions, we loaded the casualties in French ambulances and Captain Dent rode with them through the lines to the French Army Hospital in Algiers* After explaining our situation, the French Cammadant was very sympathetic and promised to care for our casualties until our own medical instailatiais could be landed and set up* We evacuated to the French until Wednesday night, 11 November, averaging about twenty to thirty casualties a day, mostly from the heavy bombings of the air field where we were located.......” "Our ships docked at Algiers on the evening of 11 November, and we set up in a school building in Maison Carree, with Captain fancy's Clearing Station. Our two general surgical, and one orthopedic and one shock team did our first surgery here, on 12 November 1942"* As noted in this report there were no installations available which furnished the hospital facij&ies needed for the proper functioning of surgical teams of an Auxiliary Surgical Group* Also, a period of three days elapsed after the landing before the teams did any major surgery. Operational Activities (Operational Activities During The Campaigns In Which This Organization Participated, cont’d.) Qualified surgeons and surgical instruments are entirely in- adequate unless proper facilities are made available to care for the patients before and after surgery. The Algeria-French Morocco campaign terminated 11 November 1942, The experiences of this detachment of sur- gical teams continued through the Tunisian campaign, (2) Second Detachment of Teams to go Overseas* On 6 October 1942 an alert order was received at Group Headquarters, Lawson General Hospital, Atlanta, Georgia, for eight general surgical, three orthopedic and three shock teams to arrive at the New York Port of Embarkation 10 October 1942, As it later developed, these teams were the reserve to be employed in the Algeria-French Morocco cam- paign if needed. Fortunately, the campaign was very short and their ser- vices were not needed in that campaign, A presentation of their opera- tional activities from the time they left the Group Headquarters until the entire organisation arrived in NATOHSA will be outlined. By the time the alert order arrived at Group Headquarters, the T/0 medical officer strength of the unit had been almost filled. Un- fortunately, there had been no opportunity for any unit training for the officers. There were no nurses present and no qualified surgical technicians. Thus, to comply with this order it required that surgical technicians be selected from functioning hospitals. This was accomplish- ed by ordering forty-two qualified and experienced surgical technicians from various hospitals of the Fourth Service Command to join this unit for duty with the alerted surgical teams. Nurses did not accompany this detachment of surgical teams and each team had an additional enlisted man in lieu of an operating room surgical nurse. This detachment, with- out an administrative headquarters, departed from Group Headquarters, Atlanta, Georgia, 8 October 1942 for Camp Kilmer, N©w Jersey# On arrival at Camp Kilmer, they were attached to the 8th Evac- uation Hospital, On 2 November, they sailed with the 8th Evacuation Hospital aboard the "Santa Elena", This vessel joined the convoy of the Western Task Force enroute to Casablanca, French Morocco, The vessel became part of tne D-5 Convoy, On 11 November 1942, the news of the capitulation of the French forces in North Africa was joyfully received. The harbor at Casablanca had been damaged and for the following seven days, the ships in the convoy cruised off the coast of Northwest Africa. The ship carrying the teams and the 8th Evacuation Hospital docked at Casablanca 19 November 1942, The casualties from the campaign had been light and the surgical teams were not needed# For the following four months the major portion of tnis detachment remained witn the 8th Evac- uation Hospital at Casablanca, The nospital functioned, but was not particularly busy and did not need the assistance of the surgical teams. These four months were very trying days for most of the detacnment. They had no administrative headquarters and their only professional work in Casablanca consisted in operating a venereal disease section of the 8th Evacuation Hospital, 867 Operational Activities (Operational Activities During The Campaigns In Which This Organisation Participated, oont’d). c, Tunisian Campaign (17 Novemoer 1942 - 13 May 1943)* The Txuiigiaxi campaign was a long, bitterly fought series of battles in which American forces were very limited in experience and num- bers, During these early days, many of the problems which must be met in the successful operation of teams of an Auxiliary Surgical Group be- came apparent, Tne mass of details, plans, and decisions necessary to insure the efficient functioning of such an organization, was bought forcibly to the attention of this organization during tne period of tnis campaign, Near the beginning of the Tunisian campaign there were ten gen- eral surgical, four ortnopedic surgical, and four shock teams of this Group in North Africa. Early in January 1943, three general surgical, one orthopedic and two shock teams were functioning witn the II Corps (U.S,), the headquarters of which was at that time in Constantine, Algeria, The Allied troops had advanced into Tunisia on lb November 1942, after securing Morocco and Algeria, They drove east for Tunis and Bizerte but were halted less than 50 miles from these two big ports and forced to witndr aw into Algeria. One surgical and one shook team of this unit were with the forward elements of a British Casualty Clearing Station when the Allies penetrated into Tunisia, Further extracts from the report of Major Paul L, Dent referred to above are quoted, and indicate the nature of tne operational activi- ties of the surgical teams during tnis period. His team partioipaxed throughout the Tunisian campaign: "January 10th, 1943, we proceeded to Ei-Guerrah to report to th© U.S, Army Hospital located there. On arrival at El-Guerrah, no American medical installation was found. Inquiry revealed that there was one at Telergma. We proceeded there and were told that their orders to set up in Sl-Guerrah had been cancelled two days ago and that they were waiting for new orders. We proceeded to Tebessa and bivouacked in Tebessa Heights five miles past the town. We perform- ed two major operations at tnis place”. "January 21st 1943, we were ordered to proceed to Sbeitla where we sot up with the 16th Clearing Platoon, fhe majority of the medical personnel were* uncooperative and seemed to think that va were depriv- ing them of their Just dues. We managed to iron out the difficulties without too much trouble. Worx here was sporadic and consisted mostly of road accidents and casualties from strafing and bombings, Wa were working under very difficult conditions here. The wind blew sand and dust through the tents constantly, the lighting system gave out usually in tne middle of operations, which had to be finished with Operational Activities (Operational Activities During The Campaigns In Which This Organization Participated, cont*d). flashlights or lanterns. Our trouble with the heating units for sterilizers and autoclaving was ever present11. "January 31st, 1943, we were attached to tne 16th Medics and direct- ed to go to Gafsa where we would receive further orders. After driving ail nignt we arrived in Gafea at 5s 10 A.M, We were ordered to remain in the outskirts of Gafsa until the situation clarified itself. We tried to sfeep but between the wind, sand and air raids, this was impossible. In the late afternoon, orders came for us to move up with the 47th Medics who were supporting the First Armored Division and part of tne 168tn Infantry attempting to taJse the town of Sened, The platoons of the I6tn Medics and our group contacted the 47th Medics and set up with them about four miles behind the fighting lino. We began work immediately, getting about nine hours sleep la four days". ,rWe received orders to retreat at 7|15 P.M. February 4th, as our troops were being pushed back. We were five hours traveling eignteen miles as tne roads were crowed with tanks, guns, etc., falling back. We were pulled bacic to Tebessa Heights to the loth Medical Battalion Headquarters and bivouacked for ten days while the II Corps reorgan- ized." "February 14th, 1943, we moved to the French Barracks at Ferriana and were attached to the 1st platoon, Caspany "D" of the 51st Med- ical Battalion. The personnel of the company were very cooperative and helpful. We began work at 7:30 A.M, February 15th 1943. After completing three cases we were informed that we were three miles in front of our own lines. Headquarters got through to us with an order to fail bacK to the top of the mountain, tnirteen miles west of Thelepta, and bivouac. We were here until 6:30 A.M, February 17th when we received orders to fail back miles further to Bou Cheleka. Here we set up two ward tents, one for admission and snook and one for surgery. We operated on occasional cases, but not enough to keep busy. The only unit in front of us was the 1st Hanger Battalion of 60 enlisted men and three officers"# "February 20th, 1943, we were ordered to move back eight miles fur- ther. February 25th 1943 w© moved ten miles east of La Meskiana to bivouac. While resting here, equipment was cleaned ana washed, vehicles repaired and everything readied. He really appreciated the pyramidal tent and stoves that Major Dent procured in Oran. Thor® was almost constant rain and snow"# "On March 15th, 1943, after 19 days of inactivity, we were ordered to move to a location a few miles west of Bau Chopeta. March I8tn 1943 at 7:30 A.M. we moved to the vicinity of Gafsa on the road to El Guettar, but nad to go back almost to Ferriana because the raod from Moul&res to G&fsa hed not been cleared of mines. Heavy rains Operational Activities (Operational Activities During fh« C Which This Organization Participated, contM), welled the roads with water and several of the vehicles becam* bogged down ana had to have assistance. We arrived in Gafsa ac 5:00 P.M, Marcn I8ta 1943. Orders were that we go to Gafsa end if the liaison officer did not contact ua there to continue on to an olive grove two miles west of El Guettar, Enrovte we were stopped by a Colonel who inquired where we were going and what unit we were. Oa being informed, he laughed ana raid that we 'must be a damn tough bunch of medics'. On being asked if we "poke German and receiving a negative reply he informed us that we had better return to Gafsa because tne olive grove for whicn we were headed was at tue moment inhabited by Germans ana that he was organizing & patrol at dusk to rout them, he returned to Gafsa and bivouacked in a building across from the railroad station. While at Gafsa we were bombed frequently. On two nights the raids were practically continuous, many antipersonnel bombs being scattered over the area. Little damage was done excluding tne window panes. Colonel Porsee, Commanding Officer, End Auxiliary Surgical Group arrived in Gafsa during our stay there and informed ua of the arrival of the entire Group in the Theater, We were anxious for news of the group and happy that hur headquarters would take over the control of our team. "April 11th 1943, we moved to Ferriana. We convinced Ordnance that a C & R was more appropriate for us than a truck, so we affected a trade. Now we have a two and one-half ton truck and a C & R, April 14th, 1943, we left Ferriana and moved to the vicinity of Sauk-El- Kemis by way of Tebessa, L© Kouf and Le Kef and Eouok-El-Arba. We arrived at our bivouac area ten miles north of 3ouk-El-Kemis at 5:30 PM. While here, we paid a visit to the 1st G.C.S, to look up old acquaintances”, "We moved twice between April 15th and 21st, On the latter date the 15th Evacuation Hospital set up adjacent to our bivouac site. This was the first hospital of this type which we had seen. We moved over and started to work doing mostly minor injuries, some of which had been in the hospital for thirty-six hours and were frankly in- fected. We worked here April 24th and 25th, doing approximately 26 cases. No work on 26th and 27th, "May 8th, 1945, orders attached the 1st Platoon of Company "D" of the 51st Medical Battalion and our surgical and shock teams to the 9th Division Medics and we were ordered to bivouac on the Djebel Afoid-Dedjeome-Bizerte roAd about 15 miles west of Ferryviile, Bizerte and Tunis fell to us on May 8th, 1943 at 3:30 and 4:20 P.M., approximately. No method nor facilities were available to care for the thousands of Axis prisoners, many of whom were injured and sick. The 1st Platoon of the 51st Medical Battalion, with our surgical and shock team was ordered on May 10th, to set up in the barbed wire prison stockade four miles west of Mateur, There was no work to be done there, as all injured prisoners were evacuated to tne 9th Evacuation Hospital for oare". 870 Operational Activities (Operational Activities During The Campaigns In Which This Organisation Participated, cont'd). "May 12th, 1943, we received orders to rejoin the 51st Medical Battalion located two miles west of Mateur and go into bovouac. We refined here until 16 May 1943 when orders were receired de- taching us from II Corps and ordering us to return to our own headquarters, location unknown* Information received from Colonel Churchill of AFHQ, Algiers, was that the Group Headquarters was in the Oran area, but we did not know the exact location. Location was unveiled to us by the Mediterranean Base Section Surgeon in Oran. We r eported to Colonel For see at 2nd Auxiliary Surgical Group Headquarters on Goat Hill, one mile north of Assi Aaeur at 6*20 P.11M 20 May 1943". The problems of a strictly professional nature encountered dur- ing these early days were great when compared with the high standard of the facilities available to the surgical teams of this Group during the later campaigns in Italy, France, and Germany. These excerpts from re- ports of Captain William Weiss (anesthetist) and Captain William Mansfield (assistant surgeon) members of Major Dent's surgical team are of special interests "Anesthesia was ether or sodium pentothal. No gases were avail- able". "Postoperative care was lacking. There were no trained personnel, no facilities for Intravenous fluids, no food for patients ex- cept "C" rations, no facilities for transfusion of #iole blood, except the blood received from military donors, and there was no way of checking such blood for the presence of malaria or syphilis. Patients were evacuated as rapidly as possible, the majority in six to eight hours postoperatively, some after they had reacted from the anesthesia and some while still under anesthesia. The latter seemed best suited for abdominal cases". Among the 175 patients treated by Major Dent's team (records on an additional 125 cases treated during the period of November and December were lost by enemy action) the location of the injuries among the casualties treated were aa follows. The types of injuries treated are in marked contrast to those treated by surgical teams of this Group functioning in first priority hospitals in Italy, France and Germany* Head 29 Neck. •••.•••• 5 Thorax* Chest Wall Only 14 Suoklag •••••• 8 Nibs....... ••••••• 4 871 Operational Activities (Operational Activities During The Campaigns In Which This Organisation Participated, cont'd). Abdomen: Abdominal Wall Only*•••••••••••••• 7 Intra-abdominal,.,,,,., 17 Soft Tissue,., 103 Fractures, compound excluding fingers and toe at Upper Extremity..,. ,,,, 13 Lower Extremity.. 30 External Genitalia 5 The following excerpt from the report of another general sur- gical team which functioned with II Corps for four months in the Tunisian campaign emphasises several points presented in the foregoing report, (Extract from report of Major Robert 0, Garlinghouse), "One hundred and nineteen days were spent in the combat zone. Of these the number of days in which the team was actively engaged was 71, The team trailed 2462 miles in 24 moves. We slept in pup tents from the middle of January to the 20th of March, The lack of organic transportation for each team was keenly felt dur- ing the entire period of activity of this team. The lack of a Group or detachment Headquarters in close prdximity to the teams functioning in the forward area was a great handicap. The full and earnest cooperation of II Corps Surgeon and his staff was enjoyed by all the surgical teams working in the forward area, and this fortunate situation stood us in good stead throughout the long months of the winter campaign"• The following extract from the annual report of the Consulting Surgeon, NATOUSA, 1943 (Colonel E, D, Churchill) relative to the Aux- iliary Surgical Groups is as follows* "It is impossible to overestimate the contribution to surgical standards in the Theater made by members of the Auxiliary Surgical Groups, The distinguished history of these organizations will be recorded independently, but certain observations from the per- spective of the Theater as a whole deserve special comment. It is one thing to describe the organization of the Group, its mission in general terms, and quite another to visualize the actual work of a single team. At the time of the Initial landing and later during the early phases of the Tunisian campaign, the members of the Detachment of the 2nd Auxiliary Surgical Group were scattered here and there living the life of gypsies. There were no pre- cedents that established their mission, no plans that defined the policies for forward surgery, and no adequate facilities for per- forming surgery in the combat area. These highly trained surgeons were transferred from one unit to another without explanation or designation of their function, bivouacked in pup-tents throughout months of cold and rainy weather and begged for transportation 872 Operational Activities (Operational Activities During The Campaigns In Which This Organisation Participated, oont’d). necessary to carry out urgent orders. Their surgical skill saved many lives but in addition, they nursed and at times prepared food for their patients, out firewood to keep them warm, rode with them as attendants in ambulances, laundered and resterilized essen- tial surgical linen, improvised surgical working not only under trying conditions but frequently exposed to enemy bomb- ing and strafing as well as the hazards of an inadequately defended and shifting defense line”, (l) Departure of Group Headquarters and the Main Body of Teams for Overseas, On the 21st of February 1942, the main body of the 2nd Auxiliary Surgical Group moved from Lawson General Hospital Atlanta, Georgia, to Camp Kilmer, New Jersey to embark for overseas duty. About one week before, approximately 20 qualified surgeons had been trans- ferred from this group to tne 1st and 4th Auxiliary Surgical Groups to form the nucleus of those two organizations which had recently been activated. It was a very pleasant privilege to have several of these former members of the Group to again function under the control of this organization from December 1944 to May 1945 in France and Germany while they were members of the 1st Auxiliary Surgical Group, All of the mem- bers of the Army Nurse Corps assigned to the Group, except four, who were with the Group at Lawson General Hospital, Atlanta, Georgia had been ordered to Camp Kilmer, New Jersey, to await the arrival of the organization at this embarkation point. On the 27th of February 1943, the Group boarded the H,M,T, 11 Andes” and sailed unescorted from the New York Port of Embarkation the following afternoon. The strengtn of this Group was as follows: 93 Officers, 66 Nurses, and 139 enlisted men. The voyage was uneventful and the Group disembarked at Casablanca, French Morocco, the 9th of March 1943, The personnel were temporarily quartered in local hotels, school buildings, and tents. On 20 March the Group Headquarters was established in tentage about one and one-half miles from Rabat, French Morocco, On the arrival of the main body of the organization, the two previously arrived detachments reverted to the control of the parent Group• The location of tnese detachments at this time was as follows: One general surgical team at Safi, French Morocco, One general surgical team, one orthopedic surgical teem at the 96th General Hospital (British), Algiers, One general surgical team at the 31st General Hospital (British), (ftwd Athmenia, Algeria. Three general surgical teams, II Corps (Tunisia), One orthopedic surgical team, II Corps (Tunisia), Two ebook teams, II Corps (Tunisia), four general surgical teams, two orthopedic surgical teams, two •hock teams, 8th Evacuation Hospital, Casablanca, French Morocco, Operational Activities (Operational Activities During The Campaigns In Which This Organization Participated oont'd). During the first weex in April, the Commanding Officer reported to the Theater Surgeon in Algiers and arrangements were made to visit all elements of the Group in NkTOUSA, The Commanding Officer accompani- ed Colonel Edward D, Ghurcnili, Theater Consultant Surgeon in inspecting all forward installations in which the teams were functioning. Upon the information obtained on this tour, mucn of the planning for the fu- ture employment of this Group was based. In April, arrangements were made for several of the teams.to immediately begin functioning in the British General Hospitals in Algiers and Tunisia, In April, nine surgical teams were placed on tem- porary duty with the 94th, 95th and 99th British General Hospitals in Algiers and witn the 5th, 67tn and 100th British General Hospitals in Bone and Philiipeville, Tunisia, The experience gained from the em- ployment of surgical teams in these British Hospitals was very valuable. It was the first opportunity ror tne members of these teams to parti- cipate in the surgical management of battle casualties. The extended prior experience of the British surgeons in these hospitals was pre- sented to the memoers of the surgical teams of this Group in a most in- teresting and pleasing manner. All of our work with the British has been characterized by pleasant associations. Also, one general sur- gical team and one shock team operated a provisional station hospital at Port Lyautey, French Morocco, Three dental prosthetic teams began functioning in the Mediterrean Base Section Dental Clinic at Oran, Algeria. Following the close of the campaign in Tunisia, lb May 1943, all of the teams reassembled at the Group Headquarters in Oran, Algeria. (2) Comment, The Tunisian campaign served to provide the initial indications of certain requirements for the successful operation for this Group, Basically, the following recommendations were made and a- greed upon. First, that sufficient transportation be added to enable adequate mobility of the teams. Second, that sufficient tentage be alioted for housing purposes. Third, that Group Headquarters be es- tablished in close proximity to the teams functioning in the forward areas. Fourth, tn&t a clearing station is not a suitable installation for the surgical care of seriously wounded battle casualties. In Juno 1943, Brigadier General Joseph I, Martin (then colonel) Surgeon, Fifth Arcy, visited Group Headquarters and tentative plans for the employment .of the Group with the Pifth Army were discussed. He assured everyone that there was plenty of surgical activity in store for the Group. d. Sicilian Campaign, (9 July 1943 - 17 August 1943), Early in June, seven surgical teams, (six general and one orthopedic) were requested from this organization for the forthcoming missions of II Corps in the campaign for Sicily. These teams were oar fully selected. Although detailed information was- not available at to 874 Operational Activities (Operational Activities During The Campaigns In Which This Organisation Participated, oont'd). the nature of the forthcoming operation, the plan as related to the sur- gical teams of this Group was briefly as foiiow&: An amphibious operation was contemplated. The general scneme for the care of battle casualties on the beaches and afterwards involved the employment of the surgical teams of tnis Group in Field and Evacuation Hospitals and for a brief period in division clearing stations. Casualties encountered during the initial assault waves were to be evacuated directly to ships and cared for by Navy personnel. As soon as possible, probably on "DH day, a clearing station would set up on the beach with surgical teams attached to oare for ths seriously wounded casualties who could not be safely transported to the ships located offshore. The surgical teams would move to and function in Field Hospitals as soon as these installations could be brought ashore, probably "D” day plus two. Evacuation Hos- pitals were to be set up on MD” day plus four. On 16 June 1943, this detachment of teams reported to the Head- quarters, 1st Division (infantry) near Oran and the following day moved to an assembly area at Staoueii, on the outskirts of Algiers. Five of the teams were attached to the 11th Field Hospital and two teams to a provisional Clearing, Collecting Company, 51st Medical Battalion, The latter unit was to function as a small surgical hospital on the beach. The detachment of teams started on 26 June 1943 from Algiers by L.3,T, to another staging area at La Goulette, near Carthage, Tunisia, arriv- ing at tnis site 30 June 1945, Prior to embarking for the actual inva- sion operation the officers of the surgical teams were assigned to dif- ferent ships in the convoy to act as snip surgeon during the trip. On 6 July all personnel boarded their assigned ships and embarked for the forthcoming invasion* rtH" hour was at 0245, 10 July 1943, and the firing of the Navy cruisers, flares and searchlights on the shore and enemy firing could be seen from the ships off shore* Between 0800 and 1400 hours on “D" day the surgical teams had disembarked and were ashore. The following ex- tract is quoted from the report of Major Henry T, Ballantine Jr*, sur- geon in charge of one of the general surgical teams participating in tnis operation which functioned initially in a provisional cloaring- ooileoting company* "At hours, 10 July 1943, after a rough crossing, our ship lay off the beach, rolling in a moderate sea* At 0930 hours ww moved in toward the beach and unloading began. Air activity was moderate, but tnere was no enemy ground opposition at the time on the beacn itself. At 1330 hours our personnel debarked to find that we had been landed in the 45th Division area and that eight and one-half miles, approximately, lay between us and our station site. The latter was reached about 1730 hours, progress being slow due to tne difficulty of walking through sand, ana the fact that the beach ana the landing craft thereon were subject to re- peated strafing. We reached our station site without casualty. 875 Operational Activities (Operational Activities During The Campaigns In "Which This Organization Participated, cont’d). and were at this time about 3/4 mile from the water. The only- equipment available was that contained in the 2j| ton truck, which included the chests belonging to the surgical team. The next morn- ing, the transportation began to roll in, but due to the possi- bility of a tank break-through by the Germans three miles away, it was felt advisable to delay setting up station until this threat had been removed. At about dusk the tents began to go up pat- ients began to arrive. Some had by-passed the clearing station entirely and received their first primary treatment here. By 2000 hours, tne station was jammed and every effort was made to send any transportable patient to the ships. This team operated on five non-transportable cases in the following 24 hours and supervised the evacuation of about 100 wounded men. Surgical routine was in- terrupted by the presence of German planes over the beaches, and the efforts of German artillery to re&on a gasoline dump in our rear," "It was manifestly impossible to obtain blood in sufficient quanti- ties at tnis time, and facilities for cross-matching or storage of blood were lacking. Also absent was any form of positive pressure anesthesia and there were no X-ray facilities whatever. Postopera- tive care was not as good as one could wish, due to the l&cx of trained personnel. The advantage of holding acutely ill postopera- tive patients was doubtful under this arrangement. It was quite apparent that a platoon of a Field Hospital was urgently needed if any surgery was to be done in the clearing station area, since such a platoon was equipped more fully for preoperative, operative and postoperative oare. It should be emphasized that this need in no way reflects upon the personnel of the clearing station, but is in- tended to reemphasise a fact now well known, namely, tnat a clearing station eannot be readily equipped for definitive surgical care of patients. Furthermore, i,t should be noted that this principle ap- plies just as readily on the beachhead as elsewhere and that a pla- toon of a Field Hospital should be able to accompany a clearing station on an amphibious operation. Under the circumstance a, how- ever, the degree of cooperation and service rcndcxed the surgical teams by the clearing station to which they were attached was mag- nificent," "By 13 duly the 11th Field Hospital had set up in Gela, Sicily, and had taken over the function of a priority surgical hospital". This campaign which lasted 38 days was characterized by rapid advances and fortunately fbwr casualties than anticipated. It was dur- ing this campaign that the plan of utilizing platoons of Field Hospitals aa first priority surgical hospitals functioning in conjunction with division clearing stations was formulated and put into action. The following extract from a report of Major Henry L, Hoffman, MC, surgeon in charge of a team participating in this early phase of the development of first priority surgical hospitals indicates the potential value of this plan* Operational Activities (Operational Activities During The Campaigns In Which This Organization Participated,, cont'd). nfhe greater port of our tine in the field has been spent with pla- toons of the Field Hospital and I feel this is tine ideal place for use of the surgical teams. Here the team functions as a unit; they supervise the shock therapy, do the surgery and postoperative care, Ihe platoon has X-ray facilities which are of considerable value. The employment of nurses on the wani is of tremendous help to the patient as well as the team* A very Important provision was the formation of a holding unit to keep patients until they wore ready for evacuation. One team remained with the holding unit while the hospital and remainder of the teams moved onM, On 11 August, seven nurses departed from Group Headquarters, near Bizerte, to join their respective teams functioning in Sicily, These nurses accompanied their teaais to Italy, landing at Paestum on ''I)” day plus six. One surgical, one shook, and one maxillo-facial surgical team functioned aboard the Hospital Ship Carrier "Lennister" (British,* in earing for casualties transported from Sicily to North Africa during July and August 1943, Although the surgical experiences of teams participating in this campaign were not as extensive as in later campaigns, several very valuable lessons were learned which emphasized these points. First, that whole blood was needed in large amounts for the early treatment of severely mounded battle casualties. Second, that the employment of Field Hospital platoons as first priority surgical hospitals set up at the rear of the division and devoted exclusively to the care of non- trausportable casualties was feasible. Third, that the need of organic trcusportation for surgical teams was urgent. Although recommendations for a detachment of the Group Head- quarters bad been made and tentative plans for the entire group to move to Sicily had been contemplated, the short duration of the campaign pre- vented its accomplishment. Again the lack of tae availability of the Group Headquarters in the immediate vicinity of this campaign was keenly felt by the teams in Sicily, • In preparation for the Sicilian campaign, the Group Headquarters and all teams which had not departed earlier for the campaign moved from Oran, Algeria, to an area near Bizerte, Tunisia, This move placed the Group in an accessible location, should they be required in Sicily. It also placed tnem in the vicinity whore they were most needed for the care of casualties returned from the Sicilian campaign, A plan for the em- ployment oi the Group in the hospitals of the Mateur, Tunis, Bizerte area was formulated which was put into execution on 10 July 1943 and proved very successful, A unique situation presented itself in July, August, end Sept- ember for the employment of the teams located in the above area. The 877 Operational Activities (Operational Activities During The Campaigns In Which This Organization Participated, cont'd). Sicilian campaign began 10 July 1944 and the ports of Bizerte and Tunis wore the debarkation points for casualties from that campaign. Two 750 bed Evacuation Hospitals wore functioning in tnis area and one General Hospital was soon put into operation. Thirty surgical and allied spec- ialty teams from this Group were placed on temporary duty at eight diff- erent Station Hospitals in the Bizerte-Tunis-Mateur area. Certain of these hospitals augmented by the general and specialty surgical teams of this Group were designated as centers to care for particular types of injuries such as chest, head and spine, severe extremity injuries,.burns, and maxillo-facial. The utilisation of surgical teams at this time and in the manner described provided expert surgical treatment for the cas- ualties and afforded an excellent opportunity for the surgeons to gain experience and evaluate the surgical management of battle casualties in rearward hospitals. This situation did not again present Itself in the experience of this organization as almost all of the employment was to be in the forward areas* e« Campaigns in Italy, Southern France, and Germany. (1) General, This organization participated in all campaigns in Italy and baaed upon its work with the Fifth Army evolved the methods which are considered best for the Use and Control of an Auxiliary Sur- gical Group functioning in a field Army. (2) Naples-Foggia Campaign, (9 September 1943 - 21 January 1944). Preparation for the employment of surgical teems of this organization to function with the Fifth Army in the campaigns in Italy began about the middle of August 1943. Two detachments consisting of five general surgical two orthopedic, and two shook teams were alerted for the forthcoming amphibious operations to be undertaken by the Fifth Army. The first detachment of teams left Group Headquarters, Bizerte, 26 August 1943. They traveled by train and Joined the VI Corps in Oran, Algeria, 30 August 1945. The second detachment departed from Group Headquarters 2 September 1945 and arrived in Oran 6 September 1943 about the same time the seven surgical teams in Sicily were relieved from the Seventh Army and attached to the Fifth Army. The first detachment of teams was placed aboard three different ships, tha "John Stanton", "Orantes", and "Marnix", together with their equipment and set tail in the "D" day convoy for the forth- coming invasion* The nurse members of the teams had accompanied the de- tachment to Oran but were detained there and Joined their respective 878 Operational Activities (Operational Activities During The Campaigns In Which This Organisation Participated, cont’d). teams on HDn day plus 12* This detachment of teams landed on "D" day, 9 September 1943 at Paestum, Italy. During the first several days of tnis battle, which was doubtless the most difficult beachhead assault in which surgical teams of this Group have participated, they worked tirelessly and efficiently in performing expert surgery under the most difficult conditions of war. The following brief extract from the re- port of Major Frank W. Hall, MG, surgeon in charge of one of the sur- gical teams, describes the initial landing, "We sailed from Oran harbor with the invasion forces for the land- ing at Salerno Beach, Italy on 9 September 1943. Our boat stood approximately ten miles off shore at dawn and shortly after noon on "D" day we waded ashore from our L.C.I, without any previous in- structions or prearranged plan." "The first few hours ashore were spent digging and diving in fox- holes in an attempt to preserve life and limb from enemy artillery shelling, dive bombing and strafing. Around 1600 hours we noticed a hospital ward tent marked with the Red Cross being pitched approx- imately 300 yards inland from Red Beach. This was the place for us, since the Red Cross might offer us some feeling of security. On ar- rival we found this to be the 602nd Clearing Station, 162nd Medical Battalion, commanded by Captain Walter Lillehi. We immediately at- tached ourselves to this unit, proceeded to dig another foxhole, set up an operating tent and await the arrival of casualties. The first night and the following day were spent in setting up the hospital and operating section. Battle casualties during this period were evac- uated directly to the ships standing off shore. During the afternoon of the second day (MDM plus one) the operating section preparations were complete. General Surgical Team No. 11 along with General Sur- gical Team Nos. 7 and 15 and Orthopedic Team No. 6 of the End Aux- iliary Surgical Group started doing what is believed to be the first operative surgery to be performed by American Surgeons of the United States Army, on the continent of Europe in World War II, Two of the four teams and much of the time all teams operated continuously for five days and nights. During this time our teams of the 2nd Auxil- iary Surgical Group had couplets charge of the operating section which included not only the surgery, but the triage, pre and post- operative treatment, sterilising of all supplies, repairing the gaso- line burners for sterilizers and autoclaves, the laundry, and much of the time the litter bearing. The 95th Evacuation Hospital landed on "Dn day. Two surgical teams of this detachment functioned with this hospital which was in operation by "Dn day plus three. The following extract from the report of Major Luther H, Wolff, MG, surgeon in charge of one of the surgical teams lists the diagnosis of the cases treated by his team during the first 96 hours after the initial landing at Paestum, Italy. 879 Operational Activities (Operational Activities During The Campaigns In Which This Organisation Participated, oont'd)* "10 September 1949 - (1) Thoraco-abdominal wound, involving chest, lung, dia- phragm, spleen, jejunum, and colon. Shook profound. Strictly non-transportable• (2) Strangulated hernia, inguinal. Twenty-four hour duration, 11 September 1945 - (l) Wound, severe, involving buttocks, rectum ana recto- sigmoid, Ion-transportable• 12 September 1943 - (1) Wound, severe, right flank, (a) Wound,moderate, right buttocks, (b) Wounds, minor, right forearm and arm, (2) Wound, moderate, penetrating right buttocks and thigh, (3) Wound, moderate, penetrating, intrathoraoic, (4) Wound, moderate, penetrating, left thigh, (5) Wound, perforation, right arm, .(a) Wound, penetrating, right cheek, (b) Wound, penetrating, right chest wall". On "D" day plua aiz, the detachment of seven teams widen had functioned in Sicily including nurses, landed at Paestum with the 93rd Evacuation Hospital, The nurses from this group and the 93rd Evacuation Hospital were among the first American nurses to arrive in Italy, Two surgeons from the Group were attached to the 94th Evacuation Hospital which also landed on the above date, Qkx "D" day plus 12, 2i September 1943, the second detachment of nine teams that had departed ft cm Bizerte landed at Paestum, Italy. The nurse members of the teams which were now functioning in Italy joined their respective teams during the period 15 to 21 September 1943, line nurses were aboard the British Hospital Ship "Newfoundland" off the shore of Salerno, Italy, on "D" day plus four awaiting to disembark and join their teams when the ship was bombed by the enemy and the vessel had to be abandoned. No American nurses were killed but five British nurses were lost. The nine nurses returned to Group Headquarters, Bizerte and again set sail for Italy and joined their respective teams 21 September 1945, 880 Operational Activities (Operational Activities During The Campaigns In Which This Organization Participated, oont'd). On 1 October 1943 the disposition of the Group was as follows: Twenty-three surgical and shock teams were functioning with Fifth Amy in Italy* The remainder of the Group was in the vicinity of Biserte, Tunisia* On 1 October 1943 the surgical teams with the Fifth Army were employed in the following installations south of the Voitumo divers 8th and 14th British Casualty Clearing Stations; 15th* 16th, 94th, 95th Evacuation Hospitals, also the 120th Medical Battalion and the 3rd Medical Battalion Clearing.Staticm* The crossing of the river had been accomplished and by 31 October the Army hospitals had moved north of the %turno* The 33rd Field Hospital was now functioning as a first priority surgical hos- pital and 14 general surgical teams and shock teams began functioning in this installation* The Group Headquarters and the remainder of the teams arrived in Italy from North Africa 22 November 1943* Several teams which had been functioning since the early landings were relieved and replaced by recently arrived teams. The presence of the Group Head- quarters was a boon to all* The entire unit was now together and func- tioning with a field Army on a mission for which it was originally de- signed* The control of all teams was taken over then by the Group Head- quarters which relieved the Army Surgeon of that responsibility. All administrative matters, the movement of the teams, changes in the com- position of the teams, housing and messing facilities for the Group be- came functions of the Group Headquarters. Likewise, needed vehicles were now available. The distribution of mail and the pay of all per- sonnel was by the Headquarters* Reports of the experiences of the teams were obtained and based upon the information contained in these reports recommendations were made which later became accepted as general policy for the use and control of an Auxiliary Surgical Group functioning with a field Army* Also certain surgical practices in forward hospitals were altered to conform with the experiences and recommendations of the sur- geons on these teams* From 17 November to 15 January 1944, three phases of tne winter line campaign occurred. Beginning on 17 November the first phase had secured the southern shoulders of the gap in tne main enemy defenses in the Liri Valley, The southern shoulder of the gap was formed by the Mount Camino hill mass and the northern shoulders by the Mount Summacro hill mass and the mountains north and northeast of Cassino* In between lay the Mignano Gap* By 16 December 1944, the secend phase had been partially completed with the caputre of Mount Summacro on the northern shoulder* Phase three of tne winter line campaign focused attention on the mass of mountain barriers which stood in the way of an assault on the town of Cassino and the Gustav Line which hinged on Cassino* The extreme difficulty encountered in an offensive against this terrain and the strength of the enemy defenses is indicated by the fact that during the entire winter line campaign the total area penetrated was a nine mile wide belt of mountains. Thus, it is evident that there was little need for movement of hospital* Throughout this period and until the 881 Operational Activities (Operational Activities During The Campaigns In Which This Organization Participated, conc’d). groat May offensive was launched, tne severe winter of cold, mud, rain and constant seemingly hopeless effort to advance characterized tne hec- tic days along this front in Italy during the winter of 1943-1944. Only one first class road was available. Highway No. 6 and most of cue hos- pitals were situated along tnis road during tne winter line campaign. Throughout the above period ail tne surgical and allied. teams of this group functioned in Army installations. These included the ilth and o3rd Field Hospitals and occasionally tne 10th Field Hospital, as well as the 16th, 38th, 94th, and 95th Evacuation Hospitals. One thor- acic surgical team was employed in the 52nd Station Hospital and one thoracic surgeon in the 3u0th General Hospital in Naples. (2) Home-Arno Campaign (21 January 1944 - 15 August 1944). (a) Stalemate at Cassino. During this period all surgical and allied teams not employed at the Anzio-Nettuno Beachhead functioned at the Cassino Front in the lOtn and iltn Field Hospitals and at various times in the 38th, 56th, 94th, and 95tn Evacuation Hospitads. There were also spec- ialty teams employed from time to time in Base Hospitals designated as surgical centers for the care of thoracic eases. (b) The Anzio-Nettuno Beachhead (23 January 1944 - 4 June 1944)* The Group Headquarters, located In Mareianlse, proved to be in an ideal location in view of the bilateral operational activity of the Fifth Army. The prolonged duration of tne Anzio opera- tion plus tne stalemate at Cassino and the adverse conditions under which these military operations wore carried out resulted in the most hazardous and difficult winter which this organization experienced. Two officers and one enlisted man were killed in action and 19 Purple Hearts were awarded to members of this Group functioning in the Anzio Beachhead operation. ”The medical plan for the Anzio Operation derived its character from the nature of tne overall tactical plan. The beachhead it- self was designed to serve either as a magnet or as a dagger point- ed at the rear of the German force in tne Liri Valley. As a magnet, it oouid draw strength away from the Gustav Line and contribute to the success of an assault on that line by tne main body of the Fifth Army. As a dagger, it could force the Germans to retire from the whole of the Liri Yaiiey in order to husband the limited forces believed to bo available to the German command-forces which would face the danger of bsiag cut in two if they oiung to their Liri Vailey positions’1* Fifth Army Medical History, 1944)* These plans did not, however, result in a quick junction of the Fifth 882 Operational Activities (Operational Activities During The Campaigns In Which This Organisation Participated, coat’d). Army forces and a long bitter struggle ensued during the winter. Four months were to elapse on tfae arin Firth Army front as well as the Anslo Beachhead before the limited successes of phase three of the winter line campaign could be exploited to their full potentialities* Ten surgical and two shock teams were alerted about 10 January 1944 for movement with the 33rd Field Hospital which was to be under the control of VI Corps for the forthcoming operation. Four days before the initial landing was scheduled two of these surgical teams were attached to the 1st Hanger Battalion to support this latter organisation in its early landings* No hospital facilities were to accompany these teams but the plans were for the two teams to rejoin the 33rd Field Hospital as soon as it was in operation. The feasibility of utilising surgical teams in this manner is doubtful, and to partiaxiy overcome tne mown, defects additional quantities of sterile surgical supplies and operat- ing room equipment was included for these two teams* Oh "D" day, 22 January 1944 and HDH day plus one. ten surgical and two snook teams, less nurse members of the teams, landed on the Ansio-Nettuno Beachhead and began functioning in the 33rd Field Hospital and 95th Evacuation Hospital. The two teams accompanying the Hangers were the first surgical teams to land and function on tne Ansio Beach- head • On “D" day plus six the nurses joined their respective teams on the beachhead* On 10 February. 2nd Lt La Verne Farquhar. ANC, of this organisation was killed by enemy action when the enemy shelled tne o3rd Field Hospital* On 2i January 1944. four surgical teams were placed on T/D with four British Hospital Ship carriers to evacuate and treat casualties en- countered during the early hours and(hys of the beachhead landings* On the night of 24 January these ships were bombed by enemy planes* One of the three snips was sunk resulting in the death of one officer and one enlisted man of this organisation* The following account was given by one of the nurses of this organisation who survived this deliberate act- ion by tne enemy: HI was on the British Hospital Carrier "St* David"* It arr- ived off tne coast of Port Ansie. Italy, about 1000 hours on 29 Janu- ary 1944. approximately £ mile off snore* Patients started arriving at about 1100 via motor boats which had been launched from emu* ship and L*C*I*'s coning alongside* Our team, consisting of Major John £* Adams. MC*. Lt Hindman. ANC. Cpl, McCombs and myself began oper- ating and by 0430. 24 January 1944 there were 78 patients on board who had received necessary surgery* We had moved out of the harbor for the night and came back that morning arriving at approximately the same distance from snore around the same time (1000)* No pat- ients were taken aboard that day as it was too rough to send our own boats out and none were brought aboard per L*C.I*f8* Shortly after lunch the air raids began and continued throughout the entire after- 883 Operational Activities (Operational Activities During The Campaigns In TThion This Organization Participated, cont'd). noon* I was on dec*. most of tne time and war ships were firing on all sides of us* At about 1730, we started out to sea for tne nignt. W© were told that there was a convoy coming in that was being raided, but we passed quit© near it with our iignts out, without being harm- ed, After we were four miles out the snips* lights were turned on. At about 1900, I went to my cabin and found Hindman there asleep. At 2000 we were about 20 miles off shore with all -one snips* lights on* 1 was suddenly awakened by a terrific explosion. Almost simul- taneously ail lights went out. Miss Hindman and I grabbed our 'life belts and ran to the upper deck where we saw Major Adams supervising the evacuation of patients. We said that we were going up to cue next decK where the life boats were. As I started up the stairway I saw Major Adams going to the back of the ward to get some more of his patients who were still there* If he had come with us then he would have had time to get into the life boat because we immediateiy jumped into a life boat whicn s 1msbody started lowering. After it was lowered about a foot it started turning over. I heard someone say *The ship is sinking, jump*. 1 jumped into the water calling to Miss Hindman to follow me, but I couldn't see her. When I came up I oouid just see the last end of the snip going down. I tried to swim away from tne snip so tnat I would not be puiied down by the suction. In a few minutes someone near called, 'Here's a raft', and 1 reached out and caught it. Gradually more people started hanging on until there were about 12 of us including one patient who was pulled onto the raft. We had two flashlights among us and took turns waving them as our arms became tired. We were hoping that some- one in one of our lifeboats would see the light. After being in the water for about an hour we saw the lights of the British Hospital Carrier "Leinster” and tne "St. Andrew". We kept waving tne iignts and calling until a life boat from tne Britisn Hospital Carrier "Leinster" came to us. The boat stayed out for sometime after w© got aboard picking up otner survivors. When we arrived at the snip, we were told to olimb aboard the rope ladder as the sea was too rough to bring the boat up. Everyone climbed up except the patients, who were pulled up in the boat in spite of the difficulties. 1 was taken to tne resuscitation ward". Throughout the hazardous days of the Anzlo Beachhead operations the enemy almost daily shelled and bombed tne area occupied by tne hos- pitals supporting the ground troops. Beginning in emriy April tne teams functioning on the beachhead were rotated with those working on the Cassino front and practically ail members of the group served at Anzio during the period of that battle. The experience of this organization in amphibious operations warrants special comments and the following excerpts of a report from Major Charles F, Chunn, operating surgeon on a surgical team wnicn par- ticipated in the entire Anzio operation, indicates tne marked Improvement in the facilities furnished surgical teams of this Group for the care of 884 Operational Activities (Operational Activities During The Campaigns In Whicn This Organisation Participated, coat'd). their patients ©specially when compared with the early reports of the activities of teams in tno Tunisian Campaign* "Cb. 20 January 1944 we hoarded an L.S.T, and on the following day moved out of the harbor to join a large convoy. At about 0400 hours on 22 January 1944 we had reached our destination off Ansio-Mettuno, Italy. At 0330 hours our group was given orders to land on Red Beach* As we were climbing into the small landing craft a mine swoeper just next to us was seen to blow up. Evidently it had struck a mine and sank in about five minutes, life pushed off in our landing craft to pick up survivors but other small boats reached the scene beforo we did and did tne job. Our craft was then turned toward Red Beach. At this time German air raids over the beach wore occurring at fre- quent intervals. From tho time we left the landing craft* waded ashore and crossed the beaoh we were bombed once with two near misses and strafed three times. As a result of these raids I received my first patients, casualties from an L.C.I. lying next to our craft, that had taken a direct bomb hit. Several soldiers and sailors were killed, one died a few minutes after I saw him. A soldier with a severe head wound and one with an abdominal wound were dressed by a naval medical officer. Our hospital platoon had not yet landed so these patients were evacuated to an L.S.T. At tnis time our medical equipment consisted or bandages and a a mail box of morphine •" "The L.S.T. carrying tho Field Hospital equipment end supplies had been damaged during an air raid and was unable to unload until late afternoon. By dark the hospital platoon was set up enough to re- ceive patients in the shook tent. This tent was filled almost im- mediately with wounded. We started operating and continued at the operating table for the next c4 hours. Cta 25 January more surgical teams were landed and our three teams were relieved for rest but not for sleep. Sleep was impossible due to the frequent air raids on the beach and the heavy artillery 1000 yards from us. The hospital platoon had been set up 1000 yards from the water." "During the first days on the beaonhead, supplies were limited and our equipment was pressed to the utmost. The water point had been hit by artillery fire and there was barely enough water for the operating tent and to drink. Surgical drapes, towels and gowns were soon exhausted. Food consisted of cold "C" rations and water. How- ever, one of our most valuable items was present in adequate quantity due to the foresight of the captain of our shock team (Captain Lalioh). The shock team hrough with them 5C pints of blood (British). Most of this was used within the first 36 hours but that was time enough for more to arrive from the British blood bank"* "On 29 January am interesting and very pathetic thing occurred. A young Italian father carried his little three year old daughter into the hospital. The father was in tears and the little girl was very slok* She had been shot 24 hours before, through the left thigh and 885 Operational Activities (Operational Activities During The Campaigns In Which This Organisation Participated, oont’d). buttock, right, perforating the rectum. The father told the story that his daughter had been shot by Germans and that his wife had been carried away by the Germans. I did a sigmoid colostomy and resected the coccyx for drainage. The wounds were debrided. Alberta made an uneventful recovery and was evacuated to Naples 1 March 1944," "On 31 January the hospital platoon moved about a mile inland and con- tinued receiving patients. We were set up in a field next to the 56th, 93rd and 9bth Evacuation Hospitals. On the afternoon of 7 Feb- ruary 1944, the 95th Evacuation Hospital was bombed by a German plane causing approximately 30 deaths and 80 wounded of tne hospital per- sonnel and patients. The 33rd Field Hospital which was adjacent to the 95th Evacuation Hospital received tne severely wounded." "A move of four miles toward the front was made by the platoon on 16 February 1944. We operated at the location until 29 February at which tine the hospital area was heavily shelled by German artillery. An emergency evacuation of patients was carried out and tne platoon evacuated the following day. We set up tne hospital in the area we had left two weeks previously". All hospital installations functioning on the Ancio Beachhead required surgical teams to care for battle casualties. These installa- tions included! 33rd Field Hospital, 11th, 15th, 38th, 56th, 93rd, 94th and 95th Evacuation Hospitals. In this battle ail hospitals were group- ed in one area and the usual policy of delegating the first priority surgical eases to field hospitals was not feasible. All hospitals shar- ed in the care of all types of battle Injuries. One surgical team of the group which accompanied the Rangers was detailed to function with the 2nd British Casualty Station set up about three miles from Ancio, Throughout the following four and one-half months this team had a most interesting and profitable tour with the British. A total of 10809 battle casualties were treated in the medical installations on the beachhead. A fair snare of these casualties re- ceived tneir treatment from members of the 2nd Auxiliary Surgical Group. Ho other military operation in which this unit has participated will be remembered longer than the heotio days spent on the Ancio Beacnhead. (o) The Advance on Rome (ll May 1944 » 4 June 1944). Qa 11 May the great offensive on Rome was launched and the breakthrough from the Ancio Beachhead with the junction of the forces from the main Fifth Army effected on 25 May 1944. In prepara- tion for this major offensive the S, forces which comprised the II Corps moved to a sector of the front which had been occupied by the British X Corps. This new sector for U. S. troops was a narrow strip of territory running 13 miles inland from the sea to the Mount Camino hill mass. The Franco Expeditionary Corps was placed on the rignt of 886 Operational Activities (Operational Activities During The Campaigns In Which This Organization Participated, cont’d). the II Corps* In conformity witn, this shift of combat forces medical installations were shifted to the new sect ore being located along the only main road. Highway No. 7, The advance on Home was characterised by rapid movements of surgical teams in all Field and Evacuation Hospitals. The organic team transportation greatly facilitated the team movements. These movements were accomplished by pooling the transportation and dis- patching it from Group Headquarters plus alloting a minimum number of vehicles to each group of teams employed in hospitals several miles from the Group Headquarters. Group Headquarters moved from Marcianise to Carano, Italy 28 May and on to Antic on 4 June 1944. Headquarters was established in Rome, 11 June 1944, six days after the city fell to Allied troops. Following the junction of the forces on the Cassino front with those at Anzio it became a common experience for surgical teams to report to a platoon of a Field Hospital and find that the site selected for the hospital c4 hours earlier was now many miles behind the front. During this phase of rapid advance there were fortunately few casualties, and frequent and long moves of the hospitals, particu- larly the first priority surgical hospital, were necessary to give ade- quate support to the combat forces. Throughout the advance on Rome, surgical and shock teams from the Group were employed continuously in the 10th, 11th, and 33rd Field Hospitals end in the 8th, 15th, 38th, 56th, 93rd, 94th, and 95tn Evac- uation Hospitals. (d) Pursuit North of Rome (5 June 1944 - 8 September 1944) The battle of pursuit North of Roue covered a distance of 150 miles and continued a period of about six weeks. High- way No. 1 was the principal axis of advance for the U, S, troops. It is the coastal road and runs northward to Civitavecchia, Grosseto, Piombino, Ceoina, Leghorn and Pisa. During this battle of pursuit the elements of this Group moved rapidly. During the 19 day period in which the Group Headquarters was situated in Rome there was sufficient lull in the activity at the front to permit many teams to be reassemb- led at the Group Headquarters. This offered an excellent opportunity *or sight seeing trips in Rome and a much needed rest. Team equipment was carefully checked and needed articles furnished. Vehidas were re- pair ed. Several changes in team assignment were made and preparation made to move northward. The respite was short and durng this period surgical teams functioned constantly in the first priority surgical hospitals although tne number required was less than during the periods of heavy fighting* 887 Operation*! Activities (Operation*! Activities During The Campaigns In Which This Organisation Participated, cont'd). The disposition of the elements of the Group as of 30 June 1944 was as follows s { Four general surgical teams. Gbe shook team 11th Field Hospital. Four general surgical teams. Okie thoracic team. Okie shook team 33rd Field Hospital. 2- Two general surgical teams 15th Evacuation Hospital. Two neurosurgical teams. Two orthopedic teams.••••••••••.••• 94th Evacuation Hospital. One dental prosthetic team. 3rd Infantry Division Headquarters. One dental prosthetic team......... 16th Evacuation Hospital. One maxillo-facial team.••••••••••• 52nd Station Hospital. Cbe neurosurgical team. One maxilio-faeial team...... 38th Evacuation Hospital. One neurosurgical team........ 56th Evacuation Hospital. 7 One thoracic surge on. 300th General Hospital. I' Eighteen general surgical teams. One dental prosthetic team. Three shock teams. P Three thoracic teams. Two orthopedic teams.•••••••••••.•• Group Headquarters. Cto. 1 July 1944 Group Headquarters was established in tentage in the vicinity of Follonioa, Italy on Route Ho. 1. Several teams were recalled frcoi the Evacuation and Field Hospitals. Early in July pre- parations were made for twenty-eight surgical, shock, and dental pros- thetic teams to be attached"to the Seventh Army for forthcoming opera- tions. . ( ** 8 May 44 Asst Gen Surgeon 9 May 44 m 27 Aug 45 BROWN, FREEMAN P. JR. Capt Anesthetist 7 Mar 43 ft* 10 Aug 45 BROWNELL, PAUL G. Capt OC Shock Team 28 Sep 42 •ft 16 Feb 43 BURBANK, BENJAMIN Major OC Splint Team 24 Jun 42 •ft 18 Aug 42 OC Miso Team 19 Aug 42 - 13 Jul 44 OC Shock Team 14 Jul 44 - 10 Jun 45 BURFORD, THOMAS H. Major Thoracic Surgeon 14 Sep 42 20 Aug 45 BURICH, FRED T. Capt Asst Gen Surgeon 26 Aug 44 - 14 Aug 45 BYERS, WALTER L. Capt Asst Gen Surgeon 5 Oot 42 •* 30 Nov 44 Asst Neuro Surgeon 1 Deo 44 - 31 Mar 45 General Surgeon 1 Apr 45 - 27 Aug 45 CALAWAY, GEORGE A. Major Oral dental Surgeon 22 Sep 42 m 10 Feb 43 on MF Team 13 Jul 44 •ft 15 Aug 44 CALDWELL, GENE D, Major Orthopedic Surgeon 28 Sep 42 •ft 2 Aug 44 CANT LON, EDWIN L. Major General Surgeon 14 Apr 44 •• 4 May 45 4 Jul 45 • 23 Aug 45 GAVE, WILLIAM H. Capt Asst Gen Surgeon 22 Hot 44 - 14 Aug 45 903 ROSTER OF ASSIGNED PERSONNEL 2ND AUXILIARY SURGICAL GROUP CONT«D NAME RANK DUTY DATES CHANDLER. JOHN H. Major Asst Thor Surgeon 5 Oct 42 •ft 19 Feb 43 CHI IDS. SAMUEL B0 Major Asst Gen Surgeon 1 Nov 44 1 Feb 46 1 General Surgeon 2 Feb 45 • 27 Aug 45 CHUNK, CHARLES F. Major General Surgeon 28 Sep 42 •ft 27 Aug 45 CLARK, HENRY B. JR* Major Maxillo Facial Surg 5 Oct 42 m 27 Aug 45 CLARK, ORVILLE R* Major General Surgeon 24 Sep 42 •• ’ 23 Mar 44 CONDIE, DOMINIC S* Capt Asst Gen Surgeon 1 Feb 45 •ft 20 Jul 45 CRANDELL, WALTER B. Gapt Asst Gen Surgeon 11 May 44 - 26 Jan 45 CROSBY, WILLIAM D. Capt Asst Gen Surgeon 13 Sep 44 - 16 Jul 45 CUNNINGHAM, RALPH T* Capt OC Shook Team 6 Oct 42 •ft 7 Mar 43 Asst Gen Surgeon 7 Mar 43 - 11 Jul 44 General Surgeon 11 Jul 44 •ft 12 Oot 44 DEMPSEY, THOMAS F* Major Asst Gen Surgeon 10 Oct 42 •ft 13 Feb 43 DENT, PAUL L, Major General Surgeon 6 Jul. 14 Feb 44 DONAGHY, GEORGE B, Major Anesthetist 5 Oct 42 - 27 Aug DOUD, ERNEST A. Capt Anesthetist 11 Nov 42 - 27 Aug 45 DOUGHERTY, DANIEL V, Capt OC Shock Team 2 Deo 42 ft* 12 Mar 43 DOWMAN, CHARLES E. Major Neurosurgeon 16 Sep 42 - 27 Aug 45 DOZIER, ROBERT L. JR* Capt Asst Gen Surgeon 5 Feb 45 - 27 Aug 45 DRYE, JAMBS C* Capt Anesthetist 9 Mar 44 - 27 Aug 45 DUGGAN, JOHN F, Capt Asst Gen Surgeon 27 Mar 45 - 20 Jul 45 EASLEY, CHARLES E. JR* Capt Asst Gen Surgeon 28 Dec 43 - 21 Feb 45 General Surgeon 22 Feb 45 •ft 29 Mar 45 EDWARDS, WILLIAM C, Capt Orthopedic Surgeon 5 Oct 42 - 2 Feb 45 EMUI, ANTHONY J, Capt OC Shock Team 10 Oct 42 - 7 Mar 43 Asst Gen Surgeon 7 Mar 43 - 27 Aug 45 ERVING, HENRY W, Capt Asst Neurosurgeon 31 Mar 45 m 20 Jul 45 EWING, WILLIAM M* Major Orthopedic Surgeon 22 Sep 42 ft* 11 Mar 44 FINEGOLD, JOSEPH Capt Asst Gen Surgeon 7 Mar 43 • 10 Apr 45 General Surgeon 10 Apr 45 «• 13 Jun 45 FIRESTEIN, BEN Z. Gapt Anesthetist 28 Sep 42 •• 27 Aug 45 FISCHER, IRVING C. Capt Asst Gen Surgeon 19 Apr 45 •• 14 Jun 45 FISHWICK, DWIGHT B* Major General Surgeon 8 Dec 43 - 21 May 45 FITZPATRICK, LEO J* Major Anesthetist 24 Jun 42 22 Oot 44 FLOOD, CLYDE £* Capt Asst Gen Surgeon 7 Mar 43 - 5 Apr 44 FLYNN, GEORGE T* Capt Asst G©n.Surgeon 2 Mar 44 - 27 Aug 45 FORSEE, JAMES H. Colonel Commanding Officer 2 May 42 •ft 27 Aug 45 FRANK, NORRIS H, Major Anesthetist 28 Sep 42 - 27 Aug 45 FULTON, HARRY L* Capt Asst Gen Surgeon 19 Apr 45 - 27 Aug 45 GARDNER, LYTT I* 1 Lt OC Shook Team 4 Apr 45 19 Jun 45 GARLINGHOU3E, ROBERT O* Major General Surgeon 28 Sep 42 « 19 Sep 43 GAY, ELLERY 0. Major Maxillo Surgeon 24 Sep 42 •ft 27 Aug 45 GIDDINGS, WOOSTER P. Capt Asst Gen Surgeon 16 Sep 42 •ft 7 Oct 44 General Surgeon 7 Oct 44 - 27 Aug 45 GOSS USE, JOHN M* Capt Asst Gen Surgeon 9 Feb 45 14 Jul 45 GRANTHAM, EVERETT G* Capt Neurosurgeon 22 Sep 42 - 16 Feb 43 GREENE, WARREN W. Capt Anesthetist 8 May 44 ~ 13 Jul 44 Asst Gen Surgeon 13 Jul 44 «• 25 Nov 44 Anesthetist 25 Nov 44 •• 28 Jun 45 ROSTER OF ASSIGNED PERSONNEL 2ND AUXILIARY SURGICAL GROUP CONI'D SAME RANK DUTY DATES GREENFIEID, JACK Capt Asst Thor Surgeon 7 Mar 43 „ 28 Jun 43 Asst Gen Surgeon 28 Jun 43 m 2 Mar 44 GREENSPON, SAMUEL E. Capt Anesthetist 13 Nov 44 m 14 Jun 45 GUMMESS, GLEN H, Capt Asst Gen Surgeon 7 Mar 43 - 4 Apr 45 General Surgeon 4 Apr 46 - 27 Aung 45 GURVBY, JULIUS A, Capt Anesthetist 7 Mar 43 m 11 Jul 44 Asst Gen Surgeon 11 Jul 44 - 27 Aug 45 HALL, FRANK W. Major General Surgeon 2 Oct 42 - 27 Aug 45 HAMILTON, ALFRED T. Major Asst Gen Surgeon 5 Oct 42 - 11 Feb 43 HAMILTON, THOMAS P. Major Asst Thor Surgeon 24 Sep 42 - 13 Feb 43 HARALSON, ROBERT H. JR, Capt Anesthetist 14 Apr 44 m 14 Aug 45 HART, WILLIAM W, Capt Anesthetist 28 Sep 42 m 26 Jun 45 HAUVER, RICHARD V. Major General Surgeon 24 Sep 42 - 27 Aug 45 HAYNES, LEIGH K, Major Maxillo Facial Surg 10 Oct 42 - 16 Sep 44 Asst Gen Surgeon 16 Sep 44 Ml 16 Mar 45 General Surgeon 16 Mar 45 «M 31 Mar 45 HEAD, HOMER Capt OC Shock Team 28 Sep 42 - 2 Apr 43 Asst Ortho Surgeon 2 Apr 43 m 12 Oct 43 HEANEY, HARRY G. Capt Asst Gen Surgeon 14 Nov 44 - 29 Mar 45 Asst Ortho Surgeon 29 Mar 45 - 21 Apr 45 HERSTEIN, DAVID C. Capt Anesthetist 7 Mar 43 - 23 Feb 44 HICKS, DAVID Y. JR, Capt Asst Gen Surgeon 24 Sep 42 - 13 Feb 43 HIMMELSTEIN, AARON Capt Asst Thor Surgeon 26 Dec 42 m 7 Jul 43 OC Shook Team 8 Jul 43 m 2 Aug 43 Asst Gen Surgeon 3 Aug 43 m 7 Jun 45 HOBLBR, ROSS E, Capt Asst Gen Surgeon 21 Sep 44 m 19 Aug 45 HOEFFDING, WALDEMAR Capt OC Gas Team 30 Nov 42 - 1 Oot 43 Anesthetist 1 Oot 43 •• 22 Apr 44 HOEFLICH, WERNER F. A. Capt Anesthetist 2 Oct 42 m 27 Aug 45 HOFFMAN, HENRY L, Major General Surgeon 22 Sep 42 - 27 Aug 45 HOFRICHTER, FRANK C, Capt Asst Ortho Surgeon 7 Mar 43 m 6 Jan 44 Asst Gen Surgeon 6 Jan 44 m 4 Dec 44 * Asst Ortho Surgeon 4 Dec 44 m 29 Mar 45 Asst Gen Surgeon 29 Mar 45 m 27 Jun 45 HOPKINS, GEORGE S. Major General Surgeon 28 Sep 42 m 27 Aug 45 HURT, LAWRENCE E, Major General Surgeon 22 Sep 42 - 8 Feb 45 HUTCHINS, PAUL F. Capt Anesthetist 4 Sep 42 m 13 Jul 44 Asst Ortho Surgeon 13 Jul 44 - 8 Oct 44 Asst Gen Surgeon 8 Oct 44 - 11 Jan 45 HYFER, HARRY J, Capt Anesthetist 4 Jul 44 - 19 Jul 45 I OVINE, VINCENT M. Major General Surgeon 9 Apr 44 - 21 May 45 IRONS, HARRY S, 'JR, 1 Lt JACOBSON, MURRAY B. Capt Anesthetist 10 Oct 42 - 12 Feb 44 JARVIS, FRED J. Major General Surgeon 22 Sep 42 - 26 Mar 45 JEANS, VIRGIL E, Major Asst Gen Surgeon 10 Oot 42 - 11 Feb 43 JERGESEN, FLOYD H, Major Orthopedic Surgeon 14 Sep 42 - 27 Jan 45 JONES, FLOYD H. 1 Lt Asst Neurosurgeon 10 Oct 42 • 2 Feb 43 KAPLAN, IRWIN Capt Anesthetist 2 Mar 44 m 14 Aug 45 KARLIN, SAMUEL Capt Asst Gen Surgeon 12 Feb 43 • 16 Feb 43 KASMAN, LOUIS P, Capt Asst Gen Surgeon 11 Nov 42 m 13 Feb 43 905 ROSTER OF AS SI BRED PERSONNEL 2ND AUXILIARY SURGICAL GROUP CONT‘D NAME RANK DUTY DATES KASTL, WILLIAM H. Capt Asst Gen Surgeon 5 Oct 42 10 Jul 43 Asst Ortho Surgeon 10 Jul 43 m 23 Jan 44 Asst Neurosurgeon 23 Jan 44 m 4 Jul 44 Asst Gen Surgeon 4 Jul 44 - 14 Aug 45 KATZ, SIDNEY Capt Never joined KAY, RAYMOND M. Capt OC Shook Team 5 Oct 42 * 15 Oct 42 KENNEDY, FRANCIS J* Capt Anesthetist 2 Aug 43 «* 11 Jul 44 KENNEDY, PAUL A. Capt Asst Gen Surgeon 22 Sep 42 - 1 Nov 44 General Surgeon 1 Nov 44 - 27 Aug 45 KING, RICHARD Capt Asst Thor Surgeon 5 Oot 42 •* 20 Feb 43 KLEMPERER, WOLFGANG W. Capt Asst Neurosurgeon 7 Mar 43 m 1 Feb 44 Neurosurgeon 1 Feb 44 m 27 Aug 45 KNOTTS, FRANK L. Capt Asst Thor Surgeon 7 Mar 43 m 13 Jul 44 Asst Gen Surgeon 13 Jul 44 m 28 Oot 44 KOCOUR, JAMES L. Capt Asst Gen Surgeon 7 Mar 43 - 9 Feb 44 KREIDER, JAMBS A* Major Dental Prosthetist 14 Sep 42 m 27 Aug 46 LA CORE, IVAN A* Capt Asst Gen Surgeon 14 Sep 42 m 11 May 44 LADD, GRAHAM A. 1 Lt Anesthetist 10 Oot 42 m 16 Feb 43 LALICH, JOSEPH J. Capt OC Shook Team 18 Oot 43 m 28 Mar 45 LATOFF, THOMAS J. Capt Asst Gen Surgeon 7 Mar 43 m 20 Feb 45 LAWRENCE, JOSEPH Capt Anesthetist 7 Mar 43 m 27 Aug 45 LAWRENCE, KNOWLES B* Capt Asst Gen Surgeon 10 Apr 45 m 27 Aug 45 LEAK, GLBNN H. Capt Asst Gen Surgeon 11 Mar 44 m 27 Apr 44 LEES, WILLIAM M* Capt Asst Neurosurgeon 24 Sep 42 - 28 Jun 43 Asst Thor Surgeon 28 Jun 43 m 27 Aug 45 LEGG, EUGENE P, Capt Asst Gen Surgeon 5 Oot 42 m 26 Oot 42 LEMMSR, JOHN A. JR* Capt Asst Gen Surgeon 7 Mar 43 m 28 Jun 43 OC Shook Team 28 Jun 43 - 2 Mar 44 LEVINS, HAROLD P. Major Dental Prosthetist 14 Sep 42 - 27 Aug 45 LCWRY, FORREST £• Major Asst Gen Surgeon 22 Sep 42 - 28 Jun 43 General Surgeon 28 Jun 43 m 27 Aug 45 LOWRY, KENNETH F* Major General Surgeon 22 Sep 42 m 1 Nov 44 LYNCH, CORNELIUS G, JR* Capt Anesthetist 2 Oot 43 - 27 Aug 45 MAC MILLAN, HUGH A. JR* Capt Asst Gen Surgeon 2 Mar 44 - 31 Mar 45 General Surgeon 31 Mar 45 m 7 Jun 45 MADDING, GORDON F. Major General Surgeon 22 Sep 42 m 27 Aug 45 MANSFIELD, WILLIAM K. Major Asst Gen Surgeon 18 Aug 42 m 28 Jun 43 General Surgeon 28 Jun 43 m 5 Apr 44 MAPLB,JOHN L* Capt Anesthetist IS Sep 44 m 27 Aug 45 MASON, JAMES M* m Major General Surgeon 5 Oot 42 m 27 Aug 45 MASSENGILL, FRANK C. Capt Asst Gen Surgeon 7 Mar 43 m 2 Apr 43 OC Shook Team 2 Apr 43 m 2 Aug 43 Asst Thor Surgeon 2 Aug 43 m 15 Jan 44 Asst Ortho Surgeon 16 Jan 44 m 15 Jul 44 Asst Gen Surgeon 16 Jul 44 m 18 Jan 45 MC DANIEL, JBHN R* Capt Asst Ortho Surgeon 11 Apr 44 ~ 13 Jul 44 Asst Gen Surgeon 14 Jul 44 - 27 Aug 45 MC CLINTIC, MOSES H. Capt Asst Gen Surgeon 17 Sep 42 m 16 Feb 43 906 ROSTER OP ASSIGNED PERSONNEL 2ND AUXILIARY SURGICAL GROUP CONT'D RANK DUTY DATES MICHELS, LEON M, Major Asst Gen Surgeon 28 Sep 42 17 Mar 44 General Surgeon 18 Mar 44 « 27 Aug 45 MILLIGAN, PAUL R. Capt Asst Gen Surgeon 28 Sep 42 m 12 Jan 43 Asst Ortho Surgeon 12 Jan 43 - 1 Jun 43 Asst Gen Surgeon 1 Jun 43 m 13 Sep 44 Orthopedic Surgeon 13 Sep 44 - 27 Aug 45 MI IRANI, JACQUES H. Capt Asst Gen Surgeon 5 Oct 42 m 7 Mar 43 General Surgeon 7 Mar 43 m 10 Oot 43 MOORE, HERBERT L, Capt Asst Gen Surgeon 5 Oct 42 m 7 Mar 43 Asst Neurosurgeon 7 Mar 45 m 9 Mar 45 Asst Gen Surgeon 9 Mar 45 m 27 Aug 45 MORRIS, JOHN P. Capt Anesthetist 7 Mar 43 • 20 Apr 44 MUSMAN, SAMUEL Capt Anesthetist 7 Mar 43 m 19 Feb 44 MUNSLOW. RALPH A. Major Neurosurgeon 28 Sep 42 m 3 Aug 44 NALL, HUBERT H, Capt Oral Dental Surgeon 28 Aug 42 m 17 Apr 44 Oral Dental Surgeon 19 May 45 m 27 Aug 45 NATTINGER, JOHN K, Major Mazlllo~Faolal Surg 26 Deo 42 m 27 Aug 45 NEIS ON, WILLIAM A. JR, Capt Adjutant 9 May 42 *» 27 Aug 45 NORQUIST, DONALD M. Capt Orthopedic Surgeon 10 Oot 42 6* 18 Feb 43 OSHER, SEYMOUR L, Capt Anesthetist 28 Sep 42 m 16 Aug 45 PARK, BARTON E, Major General Surgeon 28 Sep 42 m 23 Jun 43 PARK, CHARLES L, Major General Surgeon 13 Jui 42 m 15 Aug 42 PLATT, EDWARD Y, Capt Anesthetist 10 Apr 44 m 27 Aug 45 POOLE, HAROLD U Major General Surgeon 24 Sep 42 m 27 Aug 45 PRBISS, AARON 1 Lt ROBERTSON, ROBERT W, Major Asst Gen Sturgeon 2 Oot 42 m 5 Apr 43 General Surgeon 5 Apr 43 m 27 Aug 45 ROBINETT, JAMES B, JR, Major Anesthetist 22 Jul 44 m 10 Sep 44 ROBINSON, EDWARD B. JR. Major Anesthetist 10 Oot 42 m 27 Aug 45 ROSE, EDWARD E, Major Oral Surg MF Teaa 1 Aug 42 m 22 Not 44 Dental Prosthetist 22 Nov 44 m 27 Aug 45 ROSE, WILLIAM F. Capt Asst Thor Surgeon 13 Mar 44 MS 16 Mar 44 Asst Gen Sturgeon 16 Mar 44 - 27 Mar 45 General Surgeon 27 Mar 45 • 12 Jul 45 RUBNITZ, WILLARD Capt Asst Gen Surgeon 18 Oot 43 . 31 Jul 45 RUKKB,. RAYMOND Y. Capt Asst Gen Surgeon 29 Apr 45 ■m 12 Jul 45 RUSSELL, ALEXANDER F. Major General Surgeon 28 Sep 42 - 22 Feb 44 SAFER, JACOB B, Capt Asst Neurosurgeon 7 Mar 43 m 27 Sep 43 SAMSON, PAUL C. Major Thoraoio Surgeon 28 Sep 42 M 27 Aug 45 SANDERS, RICHARD Capt Anesthetist 26 Sep 42 m 16 Feb 43 SAUNDERS, GEORGE R, 1 Lt SCHIFF, CHARLES A, Capi Asst Ortho Surgeon 7 Mar 43 m 31 Deo 43 Asst Thor Surgeon 1 Jan 44 X* 17 Aug 45 SCHNEIDERMAN,BENJAMIN I, Capt Anesthetist 7 Mar 43 m 27 Aug 45 SCHUS3HEIM, JOSEPH Capt OC. Shook Teaa 7 Mar 43 m 7 Jul 43 Asst Gen Surgeon 7 Jul 43 m 10 Jan 44 OC Shook Teaa 10 Jan 44 m 11 Mar 44 SEHLINGER, GEORGE A, Capt Anesthetist 22 Sep 42 m 16 Oot 44 SELLER, WILLIAM C, Capt Asst Gen Sturgeon 5 Oot 42 m 13 Feb 43 SELDIN, STEWARD D, Major Oral Dental Surgeon 1 Aug 42 m Aug 45 907 ROSTER OF ASSIGNED PERSONNEL 2ND AUXILIARY SURGICAL GROUP COUTH- NAME RANK DUTY DATES SHEETS , LAWRENCE M. Major Thoraoic Surgeon 28 Aug 42 • 27 Aug 45 SHEPARD, WARREN B. JR. Capt Asst Gen Surgeon 6 Apr 44 m 16 Nov 44 SHERIDAN, WILLIAM J. Lt Col Executive Officer 18 Aug 42 - 20 May 44 SHORBE, HOWARD B. Major Orthopedic Surgeon 10 Oct 42 - 5 Sep 44 SHORTZ, GERALD Capt Anesthetist 28 Sep 42 - 27 Aug 45 SHURE, ABRAHAM L. Capt Orthopedic Surgeon 14 Sep 42 - 10 Mar 44 SIEGAL, HENRY A. Capt Asst Neurosurgeon 5 Oct 44 m 4 Nov 44 Asst Gen Surgeon 4 Nov 44 • 27 Dec 44 Asst Neurosurgeon 28 Dec 44 m 18 Mar 45 Asst Gen Surgeon 18 Mar 45 - 27 Aug 45 SUTLER, WERNER G. Major Oral Dental Surgeon 5 Oct 42 m 18 Jul 45 SMITH, CODE A, I Lt Detachment CO 29 Aug 42 m 27 Aug 45 Supply Officer Transportation Off SNEIDERMAN, ROBERT Capt Anesthetist 7 Mar 43 m 7 Jun 45 STANDEE, LEONARD Major Asst Gen Surgeon 22 Sep 42 • 13 Feb 43 STAUGH, OMAR A. Capt Asst Gen Surgeon 31 Mar 45 m 1 Aug 45 STEPHENSON, GEORGE W. Major General Surgeon 4 Nov 44 - 27 Aug 45 STERNBERG, JACOB C. Major Orthopedic Surgeon 14 Sep 42 mt 2 Oct 42 STILL, RICHARD M. Major General Surgeon 8 Jul 42 - 13 Feb 43 STRAIT, JOHN M* Capt Anesthetist 17 Feb 45 m 14 Jun 45 SULLIVAN, JAMES M. Lt Col General Surgeon 28 Sep 42 m 30 Jun 44 CO Detachment 20 Aug 44 - 13 Jun 45 Executive Officer 14 Jun 45 - 27 Aug 45 SULLIVAN, ROBERT F. Major Oral Dental Surgeon 28 Aug 42 m 16 Jun 44 SWINDLER, CHARLES M. Capt OC Shock Team 5 Mar 44 - 13 Jul 44 Asst Ortho Surgeon 15 Jul 44 - 10 Jan 45 Asst Gen Surgeon 10 Jan 45 - 14 Jul 45 SWINGLE, HUGH F. Major Asst Gen Surgeon 5 Oct 42 «4 7 Mar 43 General Surgeon 7 Mar 43 • 27 Aug 45 3YD0RIAK, WALTER L. Capt General Surgeon 14 Sep 42 m 4 May 43 OC Shook Team 4 May 43 m 2 Mar 44 Asst Gen Surgeon 2 Mar 44 • 20 Mar 44 TAYLOR, FLOYD D. Major Asst Gen Surgeon 24 Sep 42 - 11 Jan 44 General Surgeon 11 Jan 44 m 27 Aug 45 THOMAS, JAMES J* Capt Asst Gen Surgeon 22 Sep 42 m 2 Oct 42 Anesthetist 2 Oct 42 m 27 Aug 45 TINSLEY, MILTON Major Neurosurgeon 28 Sep 42 m 27 Aug 45 TOBEY, ALBRO Capt Asst Gen Surgeon 10 Apr 45 m 21 Jun 45 TQUERY, BEVERLY T. Capt OC Shock Team 51 Mar 44 m 27 Aug 45 VAN RIPER, WILLIAM D. Capt Asst Gen Surgeon 16 Mar 45 - 3 Aug 45 WALKER, OSCAR T. JR. Major Dental Prosthetist 14 Sep 42 m 27 Aug 45 WALSH, MAURICE J. Capt Asst Gen Surgeon 7 Mar 43 m 25 Aug 44 Asst Executive Off 25 Aug 44 m 27 Aug 45 WARD, FRANCIS C, Capt Asst Gen Surgeon 24 Sep 42 m 13 Feb 43 WEISS, LEO Capt Anesthetist 27 Apr 44 m 24 Jun 45 WEISS, WILLIAM A« Capt Anesthetist 18 Sep 42 • 20 Mar 44 WELCH, JOHN D. Capt OC Shoek Team 5 Mar 44 m 7 Jul 45 WESTERFIELD, CHARLES W. Capt Anesthetist 5 Oct 42 • 27 Aug 45 908 ROSTER OF ASSIGNED PERSONNEL 2ND AUXILIARY SURGICAL GROUP CONT'D NAME RANK DUTY DATES WESTON, CHARLES L. Capt OC Gas Teem 30 Nov 42 27 Feb 44 Asst Gen Surgeon 27 Feb 44 - 15 Nov 44 WILLIAMS, DONALD Bo Capt Asst Thoracic Surg 16 Mar 44 - 1 Nov 44 Thoracic Surgeon 1 Nov 44 - 16 Jul 45 WILSON, FREDRICK D. Capt Asst Gen Surgeon 10 Oct 42 - 8 Oct 44 Asst Ortho Surgeon 8 Oct 44 - 4 Dec 44 Asst Gen Surgeon 4 Dec 44 - 9 Mar 45 Asst Neurosurgeon 9 Mar 45 - 27 Aug 45 WOLFF, LUTHER Ho Major General Surgeon 5 Oct 42 - 27 Aug 45 WYLIE, ROBERT H. Major General Surgeon 16 Sep 44 - 27 Aug 45 ZURLO, DOMINICK A,' Capt Anesthetist 7 Mar 43 - 4 May 43 Asst Gen Surgeon 4 May 43 - 19 Apr 45 ■ , General Surgeon 19 Apr 45 m 27 Aug 45 ALLINSON, CELIA 1 Lt Nurse Op Room 24 Feb 43 m 1 Apr 45 BARNES, WILMA L. 1 Lt Nurse Op Room 25 Feb 43 - 8 Jul 45 BECKER, IRENE C, 2 Lt Nurse Anesthetist 22 Feb 43 - 16 Nov 44 BERRET, ANNA B, 1 Lt Nurse Anesthetist 22 Feb 43 - 6 Jul 45 BOSS, RUTH E. 2 Lt Nurse Op Room 22 Feb 43 m 30 Oct 43 BRIX, ANNE K, 1 Lt Nurse Anesthetist 22 Feb 43 - 6 Jul 45 BROOKS, VIOLETTA A. 1 Lt Nurse Op Room 23 Feb 43 - 7 May 45 CAMPBELL, MARY A. 1 Lt Asst Chief Nurse 15 Jan 43 m 6 Jul 45 Nurse Op Room CAMPO, AMANDA R. 2 Lt Nurse Op Room 23 Feb 43 ~ 31 Mar 44 CARLISLE, FLORENCE M. 1 Lt Nurse Op Room 22 Feb 43 - 6 Jul 45 COLLINS, ESTHER R, 1 Lt Nurse Op Room 22 Feb 43 - G Jul 45 COM OR, DORIS M, 2 Lt Nurse Genl Duty 22 Feb 43 - 7 Jul 44 CONWAY, VALERA I, 2 Lt Nurse Op Room 22 Feb 43 - 1 Dec 43 COOPER, AUDENE H. 1 Lt Nurse Genl Duty 22 Feb 43 - 9 Jul 45 CCK, DESSIE M. 1 Lt Nurse Anesthetist 24 Feb 43 - 6 Jul 45 DAVIS, A. LAWRASON 1 Lt Nurse Op Room 25 Feb 43 - 11 Aug 45 DAVIS, OPAL Go 1 Lt Nurse Op Room 22 Feb 43 1 Feb 45 DICKSON, GROVA-HELLE 1 Lt Nurse Op Room 22 Feb 43 - 1 Jan 45 DONAHOE, RHODA E. 1 Lt Nurse Op Room 23 Feb 43 - 6 Jul 45 DRISCOLL, KATHRYN T, 1 Lt Nurse Genl Duty 27 Feb 44 m 6 Jul 45 ELBERTSON, GLADYS H. 1 Lt Nurse Op Room 17 Mar 45 - 6 Jul 45 ELLIOTT, CATHERINE V, 1 Lt Nurse Op Room 2 Dec 43 m 9 Jul 46 ESCHENBEHG, CHRISTINA M, 1 Lt Nurse Op Room 17 Feb 44 - 6 Jul 45 ELSIK, BLANCHE A, 2 Lt Nurse Op Room 22 Feb 43 - 12 Mar 44 FARQUHAR, LA VERNE 2 Lt Nurse Op Room 23 Feb 43 - 10 Feb 44 FIRST, HELEN M, 2 Lt Nurse Op Room 12 Oct 44 - 20 Oct 44 FISCHER, DOROTHY E. 1 Lt Nurse Op Room 23 Feb 43 6 Jul 45 FLEMING, MILDRED N. 1 Lt Nurse Genl Duty 22 Feb 43 - 6 Jul 45 GREGG, ETHEL M, 1 Lt Nurse Op Room 24 Feb 43 - 6 Jul 46 GRINNELL, NORMA E, 2 Lt Nurse Genl Duty 8 Jan 45 - 21 Apr 45 HARRELL, ISABEL G. 1 Lt Nurse Op Room 24 Feb 43 - 6 Jul 45 HINDMAN, LAURA R. 1 Lt Nurse Op Room 22 Feb 43 «• 2 Mar 45 HINSHAW, ESTHER A. 1 Lt Nurse Anesthetist 21 Deo 42 - 6 Jul 45 909 ROSTER OF ASSIGNED PERSONNEL 2ND AUXILIARY SURGICAL GROUP CONT'D NAME RANK DUTY DATES HUCKNALL, DORTHA M. 1 Lt Chief Nurse 16 Jul 42 m 11 Mar 44 HUFF, M* MARGUERITE 1 Lt Nurse Op Room 22 Feb 43 m 6 Jul 45 JOHNSON, CHARLOTTE B, 1 Lt Nurse Op Room 22 Feb 44 m 10 Oct 44 JOHNSTON, DENUM 2 Lt Nurse Anesthetist 22 Feb 43 m 24 Nov 44 KIEREPKA, AGNES E. 1 Lt Nurse Op Room 21 Feb 43 m 6 Jul 45 KIRK, EVELIN A* 1 Lt Nurse Op Room 3 May 45 m 4 Jul 45 KRESS, JOSEPHINE A« 2 Lt Nurse Op Room 18 Sep 42 - 18 Oct 42 LANG, HELEN L* 1 Lt Nurse Op Room 22 Feb 43 - 6 Jul 45 LEGAKO, IRENE £. 1 Lt Nurse Op Room 22 Fob 43 • 6 Jul 45 LENZ, MARI C, 2 Lt Nurse Op Room 22 Feb 43 • 12 Mar 44 LINDSEY, ODESSA M, 1 Lt Nurse Genl Duty 22 Feb 43 - 6 Jul 45 LOCKEMAN, FRANCES M« 1 Lt Nurse Op Room 22 Feb 43 m 1 Feb 45 LOMBARDO, MARY £• 1 Lt Nurse Anesthetist 23 Feb 43 m 6 Jul 45 MACOMBER, LOUISE F, 1 Lt Nurse Op Room 26 Jan 45- 27 Jun 45 MARCOUX, SHIRLEY R, 1 Lt Nurse Op Room 22 Feb 43 m 4 Jul 44 MATLOCK, MARY A. 1 Lt Nurse Anesthetist 22 Feb 45 m 6 Jul 45 MAYSARROS, ANN 1 Lt Nurse Anesthetist 25 Jun 44 - 6 Jul 45 MC DONALD, ANNA K« 1 Lt Nurse Op Room 22 Feb 43 • 17 Mar 45 MELLA, MARGUERITE R, 1 Lt Nurse Op Room 22 Feb 45 • 16 Feb 44 MIERNICKE, FRANCES A, 1 Lt Nurse Op Room 22 Feb 43 • 6 Jul 45 MITCHELL, JOSEPHINE C. 2 Lt Nurse Op Room 18 Sep 42 m 18 Oct 42 MOSHER, FRANCES L* 1 Lt Nurse Op Room 22 Feb 43 m 9 Jul 45 MUHS, ELEANOR J« 1 Lt Nurse Op Room 22 Feb 43 m 15 Jan 45 NEUBERT, GEORGIA E, I Lt Nurse Genl Duty 22 Feb 43 m 6 Jul 45 NICHOLS, ELSIE M#> 1 Lt Nurse Genl Duty 22 Feb 43 m 12 Mar 44 0*BRIEN, MARY L* 2 Lt Nurse Op Room 22 Feb 43 m 10 Deo 44 0* SHAUGHNESSY, MARIE J. 1 Lt Nurse Anesthetist 22 Feb 43 m 13 Jul 45 PARRISH, JOSEPHINE C. 1 Lt Nurse Op Room 24 Jun 44 m 6 Jul 45 PIETRZYK, WANDA C, 1 Lt Nurse Op Room 25 Feb 43 m 6 Jul 45 PIZZOLATTO, LENA C, 1 Lt Nurse Op Room 23 Feb 43 m 6 Jul 45 PONKO, RUTH 2 Lt Nurse Op Room 25 Feb 45 m 26 Oot 44 PRATHER, EDITH W. 1 Lt Nurse Op Room 22 Feb 43 m 6 Jul 45 PRICE, IDA G. Capt Chief Nurse 25 Feb 44 m 16 Aug 45 RANDOLPH, MARY W. 1 Lt Nurse Op Room 23 Feb 43 m 9 Feb 45 RHEAUME, JULI ANNE M. 1 Lt Nurse Op Room 22 Feb 43 m 6 Jul 45 RICKERT, HELEN B0 1 Lt Nurse Op Room 22 Feb 43 m 6 Jul 45 ROGERS, HILDA E, 1 Lt Nurse Anesthetist 22 Feb 43 m 6 Jul 45 RODRIGUEZ, JOSEFINA M. 1 Lt Nurse Op Room 22 Feb 43 m 6 Jul 45 RODMAN, CATHRINE M. 2 Lt Nurse Op Room 24 Feb 43 m 12 Feb 44 RYAN, MARGARET U» 1 Lt Nurse Op Room 24 Feb 44 m 3 Jul 45 SHEARER, MARY V, 1 Lt Nurse Op Room 22 Feb 43 m 25 Feb 45 SHOCKCOR, MARGARET B. 1 Lt Nurse Anesthetist 31 Mar 45 m 6 Jul 45 SMITH, ANNA M* 2 Lt Nurse Genl Duty 25 Feb 43 m 8 Feb 46 SMITH, MARIE J, 1 Lt Norse Anesthetist 20 Apr 45 m 6 Jul 45 SOBECK, RUTH C. 1 Lt Nurse Genl Duty 22 Feb 45 m 6 Jul 46 STURNIOLO, BERNARDINE N« 1 Lt Nurse Op Room 26 Feb 44 m 5 Jul 46 STRATTON, LINA J» 1 Lt Nurse Op Boom 22 Feb 43 m 6 Jul 45 SWAB, MARY E. 1 Lt Nurse Op Boom 25 Feb 43 m 6 Jul 46 THOMAS, MARTHA G. 1 Lt Nurse Genl Duty 22 Feb 43 m 9 Jul 45 TUFFLEY, EDNA £• 1 Lt Nurse Op Room 28 Jan 45 • 8 Jul 45 910 ROSTER OF ASSIGNED PERSONNEL 2ND AUXILIARY SURGICAL GROUP CONT’D NAME RANK DUTY DATES URBAN, STACIA 2 Lt Nurse Op Room 18 Sep 42 m 18 Oct 42 USNIK, MART A* 1 Lt Nurse Op Room 25 Feb 43 m 9 Jul 45 VILLALBA, LOLA 1 Lt Nurse Op Room 28 Jan 45 m 9 Jul 45 VERAZIN, BETTY F* 1 Lt Nurse Op Room 22 Feb 43 m 9 Jul 45 WATKINS, JANE E. 2 Lt Nurse Op Room 18 Sep 42 m 18 Oct 42 WHIMPEY, GENEVIEVE L. 1 Lt Nurse Op Room 7 Feb 45 am 3 Jul 45 Adkins, McCoy P» T/4 Utility Repairman 8 May 44 m 27 Aug 45 Aldridge, Elias V« Pvt Basic 13 Feb 43 - 5 Jul 45 Anderson, Herman J* T/5 Driver 8 Jan 43 m 27 Aug 45 Antico, Joseph 1/6 Surgical Teohnivian 21 Jan 45 m 9 Aug 45 Arnold, Omar W9 T/4 Surgical Technician 3 Oct 42 ~ 4 Jan 44, Section Leader 4 Jan 44 m 6 Jan 45 Ashburn, James W« 1/4 Clerk Typist 4 Feb 43 m 27 Aug 45 Austin, Willard R» t/b Carpenter General 13 Feb 43 m 4 Jul 45 Bailey, Donald A, Pfc Dental Technician 12 Jan 45 m 11 Apr 45 Surgical Technician 11 Apr 45 m 27 Aug 45 Ballard, Waynewright A, T/4 Mechanic Automotive 25 Sep 42 « 27 Aug 45 Barnett, Edgar E, Pvt Surgical Technician 6 Oct 42 m 12 Jun 44 Barthold, Ottomar J« 1/4 Clerk Typist 28 Jul 42 m 21 Aug 43 Bartlett, Edgar W* T/4 Surgical Technician 28 Jul 42 m 27 Aug 45 Basinski, Eugene R» 1/6 Med* Lab, Techn 14 Jan 45 am 27 Aug 45 Batongelo, John A* T/4 Clerk Typist 18 Aug 44 - 27 Aug 45 Berry, Clifford W» T/5 Surgical Technician 4 Feb 43 - 28 Apr 45 Berube, Armand L, 1/4 Dental Technician 29 Sep 42 - 27 Aug 45 Bieber, Mathias J« T/5 Surgical Technician 15 Aug 42 - 27 Aug 45 Cook Thomas H, Pfc Surgical Technician 13 Feb 43 15 Jun 44 Bowerman, Ben E0 1/4 Clerk Typist 15 Jul 42 - 13 Feb 43 Bracoia, Amedeo T/5 Surgical Technician 10 Jan 45 - 9 Aug 45 Brady, Joseph T# Pvt Surgical Technician 1 Mar 44 - 27 Aug 45 Brickman, Samuel P« Pfc Surgical Technician 5 Nov 42 - 13 Feb 43 Broda, John E« T/4 Surgical Technician 15 Aug 42 «» 27 Aug 45 Burbridge, lynn L« Pfc Surgical Technician 6 Oct 42 •• 27 Aug 45 Budzynski, Casimer T, Pvt Medical Technician 28 Jul 42 Ml 14 Oct 44 Burghardt, Robert L« T/5 Surgical Technician 8 Jan 43 m 27 Aug 45 Driver Burns, Francis J« T/5 Dental Technician 28 Jul 45 — 27 Aug 45 Buse, Jessie L« Pfc Surgical Technician 3 Oct 42 m 27 Aug 45 Cady, Clayton Pi T/4 Surgical Technician 16 Apr 43 (* 10 Feb 44 Capalbo, Louis D, 1/5 Surgical Technician 26 Jul 42 27 Aug 45 Carty, John F# r/5 Surgical Technician 28 Jul 42 Ml 22 Mar 45 Chiara, Thomas Jo Pvt Surgical Technician 1 Mar 44 - 25 Jul 44 Clark, George W. t/b Surgical Technician 2 Oct 42 - 27 Aug 45 Cohen, Abe Pvt Basic 4 Feb 43 » 23 Dec 43 Collins, Cecil C* T/4 Surgical Technician 6 Oct 42 - 14 Jun 45 Collins, Robert U« T/4 Clerk Typist 31 Oct 44 •• 27 Aug 45 Cornell, Warren I« Pvt Basic 4 Feb 43 mm 17 Feb 43 911 ROSTER OF ASSIGNED PERSONNEL 2ND AUXILIARY SURGICAL GROUP COST'D SAME RAM DUTY DATES Curia, Clifford J, Pfc Surgical Technician 23 Oct 42 m 13 May 43 Cusumano, Philip S/3gt Supply Sergeant 10 Apr 42 m 27 Aug 45 Daltoo* Leonard J« Pfc Surgical Technician 29 Mar 45 - 9 Aug 45 Davidson, Arthur H, T/4 Surgical Technician 5 Jan 45 m 9 Aug 45 Davidson, Charles C* Pfc Driver 15 Aug 42 m 27 Aug 45 Davis, Gilbert I, T/5 Surgical Technician 11 Sep 42 - 11 Jan 43 Delorey, George A* Pfc Surgical Technician 2 Oct 42 - 9 Jul 45 Dettore, William E, Pfc Surgical Technician 3 Oct 42 • 6 Nov 43 Dixon, Thomas L, tA Surgical Technician 3 Oct 42 m 27 Aug 45 Dobbelaar, Ransom H, T/3 Surgical Technician 14 Oct 42 m 12 Apr 44 Douglass, Wayne B, t/s Surgical Technician 6 Oot 42 - 9 Aug 45 Dreiss, Frederick A, 1st Sgt Medical Technician 28 Jul 42 m 1 May 43 Section Leader 1 May 43 - 10 Aug 45 1st Sergeant 10 Aug 45 - 27 Aug 45 Dunlap, Loyd L, 1/5 Surgical Technician 3 Oct 42 - 19 Jul 44 Edmunds, Sidney Ca T/5 Surgical Technician 2 Oot 42 m 21 May 45 Edwards, William 0, T/4 Surgical Technician 15 Aug 42 m 9 Aug 45 Egnaozewski, Julian Jr, T/4 Surgical Technician 28 Jul 42 m 22 Jan 44 Section Leader 22 Jan 44 - 27 Aug 45 Ellingson, Orlando J, Pfc Basic 6 Oot 42 • 13 Feb 43 Ellis, Jimmy M, Pfc Surgical Technician 3 Oot 42 • 28 Feb 45 Emott, Edward M, T/5 Surgical Technician 2 Oct 42 •• 4 Sep 44 Esposito, Gennarao 0, Pfc Dental Technician 31 Oct 44 m 9 Aug 46 Feil, David P, T/6 Medical Technician 6 Oot 42 m 27 Aug 45 Feingold, Samuel T/6 Surgical Technician 4 Feb 43 m 27 Aug 45 Fisher, George B, T/S Surgical Technician 19 Jun 44 m 27 Aug 45 Franks1, Sidney T/6 Surgical Technician 11 Sep 42 m 27 Aug 45 Frankehberg,Frederick F, T/5 Dental Technician 8 Jan 43 m 9 Aug 45 Frederick, Arthur H, Pfc Dental Technician 31 Oct 44 m 27 Aug 45 Freedman, George I, Pfc Surgical Technician 31 Oct 44 m 9 Aug 45 Frick, Henry T/6 Surgical Technician 19 Jim 43 m 27 Aug 45 Friedland, Ira M, lA Medical Technician 26 Jun 42 m 27 Aug 45 Gallo, Octavio A« TA Dental Technician 11 Sep 42 • 27 Aug 45 Gardiner, Frank R, T/6 Dental Technician 31 Oot 44 m 9 Aug 45 Garvey, Verniee L, lA Dental Technician 8 Jan 43 m 27 Aug 45 Gaughran, Bernard T/4 Dental Technician 28 Jul 42 m 27 Aug 45 George, James R, Pvt Basic 13 Feb 43 m 23 Deo 43 Gillum, Harold A, T/4 Utility Repairman 6 Oct 42 - 27 Aug 45 Glioksman, Martin Pfc Med, Lab Techn 14 Jam 45 • 10 Aug 45 Goodwin, Lester M, T/4 Surgical Technician 28 Jul 42 m 9 Aug 45 Gore, Glenwood W, Pfc Basic 9 Feb 43 . 10 Jul 45 Greer, Wilbur C, tA Surgical Technician 3 Oot 42 m 9 Jul 45 Gregory, Robert R, T/5 Clerk General 28 Jul 42 m 27 Aug 45 Grosse, Stanley Pvt Basic 11 Sep 42 m 12 Nov 42 Gueriskie, Joseph J« Pvt Basic 28 Jul 42 m 21 Apr 43 Gunderson, Ervin V, T/5 Surgical Technician 6 Oot 42 m 26 Aug 45 Qutzman, Walter C, Pvt Basic 6 Oct 42 m 11 Peb 43 Hadl, Richard J, T/5 Surgical Technician 28 Jul 42 m 27 Aug 46 912 ROSTEH OF ASSIGNED PERSONNEL 2ND AUXILIARY SURGICAL GROUP CONT'D WAME RANK DUTY DATES Halpin, Francis W, T/6 Surgical Technician 21 Aug 44 «• 9 Aug 45 Handley, Joe 1, 1/6 Dental Technician 8 Jan 43 • 9 Aug 45 Hannah, Walter W, T/5 Surgical Technician 5 Oct 42 m 5 Jul 45 Harmon, Charles W, Pvt Basic 6 Oct 42 m 19 Jan 43 Hasenwinkel, Ewaldt F, T/g Surgical Technician 6 Oct 42 m 3 Aug 44 Haun, Carl E» Pfc Medical Technician 28 Jul 42 m 5 Jul 45 Higuchi, Paul H, Pvt Basic 4 Nov 42 m 11 Aug 43 Hinriohs, Holland C, tA Clerk Typist 6 Oct 42 m 27 Aug 45 Hosier, William F0 tA Surgical Technician 28 Jul 42 m 10 May 44 Holtsohlag, Walter E, T/5 Driver 6 Oct 42 m 27 Aug 45 Holtz, Otto A« T/6 Mail Clerk 15 Jul 42 «• 27 Aug 45 Honeycutt, Walter T, T/6 Surgical Technician 3 Oct 42 e* 1 May 45 Honigman, Benjamin T/4 Pharmacist 11 Sep 42 m 27 Aug 45 Horine, Floyd M, Pfo Surgical Technician 29 Mar 45 • 9 Aug 45 Hornstein, Pius T/4 Surgical Technician 6 Oct 42 » 27 Aug 45 House, Richard C* Pfc Basic 6 Oct 42 m 27 lug 45 Hudzik, Walter J, T/6 Basic 6 Oct 42 m 27 Aug 45 Iverson, Glennie J, T/6 Surgical Technician 6 Oct 42 m 27 Aug 45 Jabklewloz, Frank J, T/5 Surgical Technician 6 Oct 42 m 12 May 45 Jackson, John 7, Pvt Surgical Technician 6 Oct 42 m 14 Feb 44 Johnsmeyer, Earl W, tA Clerk Typist 18 Aug 44 m 23 Nov 44 Johnson, Robert £, 1/6 Surgical Technician 2 Oct 42 m 4 Sep 44 Johnson, Wallace R, T/5 Supply Clerk 8 Jan 43 m 11 May 44 Surgical Technician 11 May 44 m 27 Aug 45 Karathanasis, Zafiris J, T/6 Surgical Technician 28 Jul 42 • 9 Aug 45 Kargol, Joseph 1/5 Medical Technician 6 Oct 42 m 27 Aug 45 Kempner, Frank S, T/5 Surgical Technician 3 Oct 42 m 5 Jul 45 Kennedy, Jerome Pvt Basic 13 Feb 43 m 19 Jun 43 King, Robert W, T/5 Surgical Technician 4 Feb 43 m 27 Aug 45 Kiwimagi, Floyd Pvt Basic 11 Sep 42 m 13 Feb 43 Knight, William B« Jr, T/6 Surgical Technician 9 Feb 43 m 27 Aug 45 Koch, William P, S/Sgt Chief Clerk 28 Jul 42 m 27 Aug 45 Koshland, Milton P, Jr, T/5 Surgical Technician 28 Jul 42 m 12 Apr 44 Kramer, David M, Pfo Basic 28 Jul 42 - 11 Jan 43 Krieger, Norman H, tA Mall Clerk 28 Jul 42 • 27 Aug 45 Krum, Clifford 0, T/4 Transportation NCO 15 Aug 42 m 7 Jan 44 Surgical Techniclan 8 Jan 44 - 14 Jul 44 LaGrande, Joseph S, Pvt Basic 15 Apr 42 m 13 Feb 43 Lamb, Ellis G, Sgt Surgical Technician 3 Oct 42 m 14 Jun 45 Larson, Kenneth L» T/5 Surgical Technician 5 Jan 45 m 9 Aug 45 LeBeau, Benjamin A, Pfo Basic 10 Oct 42 m 13 Feb 43 Lefkowitz, Ben tA Surgical Technician 4 Feb 43 • 12 May 46 Leiderman, Nathaniel H, T/5 Surgical Technician 28 Jul 42 m 12 Jun 44 LeSaux, Henri A, Pvt Cook 28 Jul 42 m 23 Dee 43 Leslie, Simeon B, T/5 Surgical Technician 6 Oct 42 m 27 Aug 45 Levine, Herbert T/4 Surgical Technician 28 Jul 42 m 29 Mar 44 Levitt, Samuel T/6 Stirgical Technician 28 Jul 42 • 13 Feb 43 Llnamen, John S, T/6 I-ray Technician 31 Oct 44 m 9 Aug 45 913 ROSTER OF ASSIGNED PERSONNEL 2ND AUXILIARY SURGICAL GROUP CONT’D NAME RANK DUTY DATES Lingerfelt, Benjamin L, T/4 Surgical Technician 3 Oct 42 m 2 Jul 45 Looney, Frank M, tA Surgical Technician 6 Oct 42 27 Aug 45 Lotz, Ted B, T/6 Surgical Technician 2 Oct 42 - 5 Jul 45 Ludewig, Benjamin C* T/4 Mechanic Automotive 6 Oct 42 - 27 Aug 45 Mack, William Pvt Dental Technician 31 Oct 44 m 9 Aug 45 Mahnken, Henry Jr* Sgt Section Leader 28 Jul 42 m 12 Jul 44 . Surgical Technician 13 Jul 44 m 27 Aug 45 Malniok, Morris 1/5 Surgical Technician 14 Oct 42 m 20 Mar 44 Martin, Harry R, Jr* T/4 Surgical Technician 3 Oct 42 m 22 Aug 43 Martin, John P* T/4 Surgical Technician 6 Oct 42 m 27 Aug 45 MoAneney, John Pfc Surgical Technician 28 Jul 42 m 27 Aug 45 McCarthy, Peter R* */* Surgical Technician 28 Jul 42 m 27 Aug 45 Me Clung, Herman R* 1/5 Surgical Technician 8 Jan 43 m 27 Aug 45 McCombs, Theron G* T/6 Surgical Technician 6 Oct 42 m 31 Jan 44 McDonald, Joseph F* Pfc Basic 28 Jul 42 m 27 Aug 45 McElwain, John H* Jr* Pfo Basic 13 Feb 43 m 5 Jul 45 McGuokin, Walter J* T/6 Cook 28 Jul 42 m 27 Aug 45 McGuire, William H* T/6 Surgical Technician 28 Jul 42 m 27 Aug 45 McKean, Don D* T/6 Surgical Technician 8 Jan 43 m 9 Aug 45 McLaughlin, Vern B* T/4 Surgical Technician 3 Oct 42 m 9 Aug 45 Meigs, Walter Jr, Pfc Surgical Technician 28 Jul 42 m 27 Aug 45 Meisinger, Alfred D* T/6 Cook 6 Oct 42 m 29 Dec 43 Mikula, Frank T/5 Surgical Technician 5 Nov 42 m 27 Aug 45 Miller, Charles Pvt Basic 28 Jul 42 m 26 Feb 43 Murphy, Patrick F, T/6 Surgical Technician 3 Oct 42 m 5 Jul 45 Myers, Doyle C, T/5 Surgical Technician 5 Jan 45 « 9 Aug 45 Neidhart, Edward A* tA Surgical Technician 6 Oct 42 m 27 Aug 45 Nemmert, Paul A* T/4 Surgical Technician 28 Jul 42 m 27 Aug 45 Netterville, Edward A* Pvt Basic 15 Aug 42 m 15 Feb 43 Nietzer, George A* T/5 Surgical Technician 28 Jul 42 m 21 Aug 43 Nintemann, William E» Pfo Basic 6 Oct 42 - 29 Deo 43 Norris, Emmett Pvt Surgical Technician 6 Oct 42 m 27 Jan 45 Oakes, Kenneth T* T/5 Dental Technician 4 Feb 43 m 27 Aug 45 Oatman, Harry L* Pvt Surgical Technician 28 Jul 42 m 15 Oct 43 Odermann, Alfred A* T/4 Surgical Technician 6 Oct 42 m 22 Aug 45 Oleson, Edward T/5 Surgical Technician 6 Oct 42 - 2 Jul 45 Olivarez, Avelino D* Cpl Surgical Technician 31 Oct 44 «• 9 Aug 45 Ordway, Durman A* tA Driver 6 Oct 42 m 27 Aug 45 Overturf, Qrval £* 1/6 Surgical Technician 6 Oct 42 m 19 Apr 44 Facelli, Louis J* T/5 Surgical Technician 11 Sep 42 - 27 Aug 45 Palumbo, Salvatore L« T/6 Surgical Technician 11 Aug 42 - 27 Aug 45 Pantlcn, Albert W, Jr* T/5 Surgical Technician 26 Jul 42 m 21 Apr 44 Parieella, Rosario J* tA Cook 26 Jul 42 m 27 Aug 45 Payne, Raymond J* T/4 Surgioal Technician 6 Oct 42 m 27 Aug 45 Peaney, Alfred J* Pvt Basic 11 Sep 42 m 13 Doc 43 Petagno, Anthony T/6 Surgical Technician 28 Jul 42 m 15 Feb 43 Peyer, Albert W* T/4 Clerk Typist 6 Oct 42 m 27 Aug 45 Pinto, John Jr* T/5 Surgical Technician 17 Jun 44 - 9 Aug 45 ROSTER OF ASSIGNED PERSONNEL 2ND AUXILIARY SURGICAL GROUP GONT'D NAME RANK DUTY DATES Popowsky, Nathan Pfc Surgical Technician 11 Sep 42 27 Aug 45 Postanowicz, Joseph J, I/* Dental Technician 15 Aug 42 - 27 Aug 45 Potocki, Allix lA Surgical Technician 3 Oct 42 - 6 Apr 44 Privitera, Dominick 1/5 Surgical Technician 11 Sep 42 ee 27 Aug 45 Radovich, Edward J, t/< Surgical Technician 6 Oct 42 mm 27 Aug 45 Ramirez, Jose tA Surgical Technician 3 Oct 42 m 5 Jul 46 Randolph, Paul tA Surgical Technician 2 Oct 42 m 14 Jun 46 Re Her, Henry J* T/4 Dental Technician 6 Oct 42 m 27 Aug 45 Rendle, William G. Pvt Basic 11 Sep 42 m 20 Dec 42 Richardson, Robert 0, Pvt Cook 10 Apr 42 ee 13 Feb 43 Richelson, Joseph Pfc Surgical Technician 1 Mar 44 m 27 Aug 45 Ricci, John C, r/4 Surgical Technician 4 Feb 43 m 11 May 44 Supply Clerk 12 May 44 m 1 Jul 45 Ricketts, Lyle R, T/6 Dental Technician 7 Jan 45 m 10 Aug 44 Riley, Alfred E« T/4 Surgical Technician 1 Oct 42 m 6 Oot 44 Riley, William G, T/6 Dental Technician 11 Sep 42 m 27 Aug 45 Roberts, John F, S/Sgt Surgical Technician 14 Oct 42 m 4 Sep 43 Romano, George L* tA Medical Technician 28 Jul 42 m 21 Aug 43 Romano, Quindo G* T/5 Surgical Technician 6 Oot 42 m 9 Aug 46 Rood, Carl 0, Pvt Basic 6 Oct 42 «e 19 Jan 43 Roper, Hubert L« Pvt Utility Repairman 13 Feb 43 23 Deo 43 Rothwell, Kelley T/5 Clerk Typist 6 Jan 43 m 27 Aug 45 Ruth, Raymond C, Pfc Cook 6 Oot 42 ee 27 Aug 45 Rutka, Frank J* 1/6 Surgical Technician 10 Jan 45 m 27 Aug 45 Ryan, William H, T/4 Surgical Technician 3 Oot 42 - 2 May 44 Rymarski, Boleslaw J, T/5 Surgical Technician 11 Sep 42 m 27 Aug 45 Salzberg, Hugh W# TA Clerk 8 Jun 44 mm 15 Apr 45 Sanders, Edward P# T/6 Cook 15 Jul 42 mm 27 Aug 45 Soarpitti, Alfred J« tA Supply Clerk 9 Jan 45 m 9 Aug 45 Schettley, Adam J* T/6 Supply Clerk 15 Jul 42 m 27 Aug 45 Schneeweiss, Edward £, tA Surgical Technician 11 Sep 42 mm 2 Jul 46 Schweda, Edwin F# T/5 Medical Technician 6 Oot 42 m 26 Aug 44 Mail Clerk 27 Aug 44 m 27 Aug 45 Scott, Donald R# T/4 Surgical Technician 17 Feb 45 m 1 Nov 44 Mechanic Automotive 2 Nov 44 m 27 Aug 45 Scott, Vernon A* T/6 Surgical Technician 6 Oot 42 m 27 Aug 46 Seale, Franklin D, T/S Surgical Technician 30 Sep 42 m 12 May 45 Semivan, John tA Surgical Technician 3 Oct 42 m 12 May 45 Sheridan, Julian R« T/5 Dental Technician 6 Oot 42 m 27 Aug 45 Sidote, Anthony L* Pvt Basie 10 Jan 45 m 27 Aug 45 Simmons, Otha H* T/6 Surgical Technician 6 Oot 42 m 27 Aug 45 Sims, Leroy T/5 Surgical Technician 26 Feb 45 m 27 Aug 45 Skalioky, Wencil Pfc Basic 15 Jul 42 m 27 Aug 46 Slavik, Paul A« Surgical Technician 2 Oot 42 m 9 Jul 45 Small, George L* Pvt Basic lOaApr 42 m 30 Jul 42 Smith, Alvin 0, Pvt Basic 15 Jul 42 m 15 Feb 43 Smith, Franklin 5« 1st Sgt 1st Sergeant 15 Jul 42 m 9 Aug 45 915 ROSTER OF ASSIGNED PERSONNEL 2ND AUXILIARY SURGICAL GROUP CONT'D NAME Smith, Richard C, RANK Pvt DUTY X-ray Technician 28 DATES Jul 42 - 13 Feb 43 Sorrell, Alton P# Pvt Basic 11 Aug 42 m 13 Feb 43 Sperbeck, Lewis C, T/5 Driver 15 Aug 42 m 27 Aug 45 Spicker, Adolph F, T/5 Surgical Technician 14 Oct 42 m 21 Apr 44 Spurgiasz, Stanley Pvt Cook 28 Jul 42 m. 9 Nov 44 Staley, James H, T/4 Cook 10 Apr 42 «• 12 May 45 Stratos, Gus T/S Baker 28 Jul 42 m 27 Aug 45 Stoner, Bertram t/4 Surgical Technician 11 Sep 42 m 27 Aug 45 Styles, Ben F, Jr, Pfc Surgical Technician 2 Oct 42 m 1 Mar 45 Sutyak, Frank J, T/5 Surgical Technician 6 Oct 42 m 27 Aug 46 Swann, James C, Pvt Basic 11 Sep 42 m 13 Feb 43 Swlrep, Henry P, Pvt Surgical Technician 5 Jan 45 m 27 Aug 45 Teal, Guy E, Jr, T/4 Surgical Technician 3 Oct 42 m 9 Aug 45 Tignanelli, Ernest L, T/4 Surgical Technician 3 Oct 42 m 9 Jul 45 Todd, Glenn L, iA Surgical Technician 6 Oct 42 e* 28 Sep 43 Trautner, Adalbert J, T/4 Surgical Technician 6 Oct 42 - 27 Aug 45 Tsinzo, Harry Pfc Surgical Technician 10 Jan 45 m 27 Aug 45 Vaughan, Percy E, Pfc Surgical Technician 11 Sep 42 ** 13 Feb 43 Vikingstad, Fred T/5 Surgical Technician 30 Sep 42 - 13 Feb 43 Voss, Charles J, T/4 Surgical Technician 3 Oct 42 - 27 Aug 45. Wagner, Charles J* Pvt Basic 28 Jul 42 • 29 Sep 42 Wallace, James E, T/5 Surgical Technician 6 Oct 42 mi 8 Feb 45 Walker, Jack £« s/sgt Mess Sergeant 10 Apr 42 - 14 Jun 45 Walker, Robert J, Sgt Surgical Technician 16 Aug 44 • 27 Aug 45 Weaver, Eugene lA Surgical Technician 5 Oct 42 •• 9 Aug 45 Weaver, William J, T/6 Surgical Technician 28 Sep 42 Ml 9 Aug 45 Weiinsky, Henry G0 1/6 Surgical Technician 28 Jul 42 Ml 21 Apr 44 Welborn, Keith V, T/6 Surgical Technician 30 Sep 42 m 27 Aug 45 Welling, Henry T/6 Cook 4 Feb 43 m 27 Aug 45 White, Francis J, T/6 Clerk Typist 18 Aug 44 m 7 Jul 45 Wilhelsy, Fred J, 1/6 Surgical Technician 11 Sep 42 m 27 Aug 45 Williams, John H, 1/4 Surgical Technician 2 Oct 42 m 9 Aug 45 Williams, Michael T, T/4 Surgical Technician 11 Sep 42 m 27 Aug 45 Wilson, James £, 1st Sgt 1st Sergeant 10 Apr 42 - 26 Sep 42 Wilson, Max A, T/5 Surgical Technician 18 Oct 42 - 20 Mar 44 Windsor, Thomas T/6 Surgical Technician 14 Oct 42 - 20 May 43 Wojciechowski, Joseph F0 T/5 Surgical Technician 17 Jun 44 - 9 Aug 45 Wornson, Ralph G, T/5 Dental Technician 6 Oct 42 m 27 Aug 45 Yardley, Edwin L, Pfc Basic 6 Oct 42 - 27 Aug 45 Zelmer, Edward E, Pfo Basic 6 Oct 42 «• 27 Aug 45 Zirkle, George E, T/4 Cook 8 Jan 43 - 27 Aug 45 AWARDS and DECORATIONS B-A-T-T-L-E H-O-N-O-R-S TUNISIAN CAMPAIGN NORTH APENNINES CAMPAIGN SICILIAN CAMPAIGN PO VALLEY CAMPAIGN NAPIES FOGGIA CAMPAIGN SOUTHERN FRANCE CAMPAIGN RCUE ARNO CAMPAIGN RHINELAND CAMPAIGN CENTRAL EUROPEAN CAMPAIGN 918 CITATION MERITORIOUS SERVICE UNIT PIAQUE THE 2D AUXILIARY SURGICAL GROUP is awarded the Meritor- ious Service Unit plaque for superior performance of duty in the accomplishment of exceptionally difficult tasks from 1 September to 31 October 1944, in Italy, Operating within enemy artillery range and under severe weather conditions, this unit"displayed steadfast devotion to duty in the sur- gical management of the seriously wounded, greatly increasing the expectancy of survival by performing major surgery close to the field of battle. The unparalleled degree of technical skill and tireless energy of the personnel of the 2d Auxiliary Surgical Group resulted in the saving of countless lives of American and Allied Soldiers, The noteworthy accomplishments of this organization reflect credit on the Medical Corps of the United States Amy. Published in Section VI, General Order No. 39, Hq Fifth Army, on 9 April 1945* 919 DISTINGUISHED-SERVICE CROSS JOHN E« ADAMS, (0345350), Major, Medical Corps, United States Arny. For extraordinary heroism in action, cm 24 January 1944# Major ADAMS was aboard a hospital carrier which was bombed by enemy- planes twenty miles off shore. After other personnel had left for the upper decks he voluntarily returned to the resuscitation ward to evacuate seriously wounded patients who were unable to escape. The ship rapidly sank, and as a result of his selfless concern for the welfare of his patients. Major ADAMS is missing in action. His profound courage in the face of certain death reflects the heroic traditions of the Medical Corps of the United States Army, altered military service from lynchburg, Virginia. Next of kin: Mrs. Helene M. Adams (Wife), Hallock, Minnesota. published in Section I, General Order No. 52, Hq Fifth Army, on 28 March 1944. LEGIOK OF MERIT MEDAL 1st Lt. Wilma L. Barnes Major Harold L. Poole Major Reeve H. Betts Major Edward B. Robinson, Jr. Major Thomas H. Burford Major Paul C. Samson 1st Lt, Mary A. Campbell Lt, Col. James M. Sullivan Colonel James K. Forsee Major Luther II. Wolff Major Richard V. Eauver Sgt. Ellis G. Lamb Lt, Col. Kenneth F. Lowry Tec 4 Frank N. Looney Major James H. Mason III 1st Sgt. Franklin R. Smith SILVER STAR MEDAL Captain Joseph F. Barrett Captain William II, Cave Major Charles F. Chunn Captain William F, Rose BRONZE STAR MEDAL Captain Albert G. Abriel Captain Wooster P. Giddings Captain Trogler F. Adkins 1st Lt. Ethel M. Gregg Captain Thomas F. Ahearn Captain Glen H. Gummess 1st Lt. Anna B. Berret Captain Julius A. Gurvey Major Howard C. Bos Major Frank Kail Major Lyman Brewer Captain Robert H. Haralson, Jr. Captain Clarence R. Brott 1st Lt. Laura R. Hindman Major Frederick W. Bowers 1st Lt. Esther A. Hinshaw Captain Freeman F. Brown Captain Werner p. a. Hoeflicli Captain Walter L. Byers Major Henry L. Hoffman 1st Lt, Mary A. Campbell Captain Frank C. Kcfrichter Major Edwin L. Cantlon Major George S. Hopkins 1st Lt. Florence M. Carlisle Major Lawrence E. Hurt Major Samuel B. Childs Major Fred J. Jarvis Major Henry B-. Clark, Jr. Captain Irwin Kaplan 1st Lt. Bessie M, Cox Captain Wolfgang W. Klemperer 1st Lt, Opal G, Davis 1st Lt, Mary E. Lombtirdo Major Paul L. Dent 1st Lt. Irene E. Legako 1st Lt. Grova-Nelle Dickson Captain William M, Lees Major George E. Donaghy 1st Lt. Odessa M. Lindsey 1st Lt, Rhoda E. Donahoe Major Forrest E. Lowry Captain Emeet A. Doud Captain Hugh A. MacMillan, Jr. 1st Lt. Katherine Driscoll Major Gordon F. Madding Captain James- C. Drye Major James M. Mason III 1st Lt.. Catherine V, Elliott 1st Lt. Mary A. Matlock 1st Lt. Christina M, Eschenberg Captain John R. McDaniel 1st Lt. Dorothy E, Fischer Major Leon M. Michels Captain Clyde E. Flood 1st Lt. Frances A, Miernicke Major Morris H. Frank Captain Herbert L. Moore 921 BRONZE STAR MEDAL (CONT’D) Captain William A. Nelson, Jr. Tec 4 Edgar W. Bartlett 1st Lt. Elsie M. Nichols Tec 4 John H. Broda Captain Seymour L, Oscher Tec 5 Sidney C. Edmunds 1st Lt. Lena 0. Pizzolatto Tec 4 William 0. Edwards Captain Ida G. Price Tec 4 Thomas L. Dixon 1st Lt, Mary W, Randolph Tec 4 Julian Egnaczewski, Jr. 1st Lt, Julianne M. Rheaume Tec 5 George B. Fisher 1st Lt. Helen B. Rickert Tec 4 Lester M. Goodwin Major Robert W. Robertson Tec 4 Holland C. Hinrichs 1st Lt. Josefina M. Rodriguez Tec 4 Pius Homstein Major Edward E. Rose Tec 5 Ben Lefkowitz Captain Charles A. Schiff Tec 4 Benjamin L. Lingerfelt Captain Benjamin I. Schneiderman Tec 5 Ted B. Lotz Major Lawrence M. Shefts Tec 4 John P. Martin Major Howard 3. Shorbe Tec 5 Zafiris J, Karathanasis Captain Gerald Shortz Tec 4 Peter R. McCarthy Major Werner G, Sittler Tec 4 Venn E. McLaughlin 1st Lt. Anna M. Smith Tec 4 Alfred A. Odermann 1st Lt. Code A. Smith Tec 5 Salvatore L, Palumbo Captain Robert Sneiderman Tec 4 Raymond J. Payne 1st Lt. Lina J, Stratton Tec 4 Paul Randolph 1st Lt. Ruth C. Sobeck Tec 5 Quindo G. Romano Captain Charles M, Swindler Tec 4 Edward E. Schneeweiss Major Floyd D. Taylor Tec 4 Donald R. Scott Major Milton Tinsley Tec 3 Franklin D. Seale 1st Lt, Mary A, Usnik Tec 4 Paul A. Slavik Captain Maurice J, Walsh Tec 4 Guy E. Teal, Jr, Captain John D. Welch Tec 4 Adalbert J. Trautner Captain Charles W, Westerfield Tec 4 Charles J. Voss Captain Donald B. Williams Tec 4 Eugene Weaver Major Robert H. Wylie Tec 5 Keith V. Welborn Captain Dominick A, Zurlo Tec 4 Guy E. Teal, Jr. Tec 4 Waynewright A. Ballard Tec 4 Ernest L. Tignanelli PURPLE HEART MEDAL Major John E. Adams Major Ellery C. Gay Captain Trogler ?. Adlans Captain Glen H. Guinness Major Howard G. Bos Captain Julius A. Gurvey Major Bergot II, Blocksom Captain William M, Hart Captain Clarence E, Brott 1st Lt. Laura R, Hindman Major George A. Galaway Major George S. Hopkins Major Charles F. Chunn Captain John L. Maple 1st Lt. Bessie M. Cox 1st Lt. Elsie M. Nichols Captain Anthony J. Ernmi Major Edward B. Robinson, Jr. 2nd Lt. LaVerne Farquhar Major Howard B. Shorbe Captain Joseph Finegold 1st Lt. Ruth C. Sobeck Captain Ben Z. Firestein Captain Charles M. Swindler PURPLE HEART MEDAL (CONT’D) Captain James J. Thomas Tec 4 William 0. Edwards Major Milton Tinsley Tec 5 Frederick F. Frankenberg Mej or Robert F. Sullivan Tec 5 Zafiris J. Karthanasis Tec 5 Mathias J. Eiaber Tec R Theron G, McCombs Tec 5 Robert L. Eurghardt Tec 4 William H. Ryan Tec 4 Clayton F. Cady Tec 4 John Semivan Tec 5 Sidney J. Edmunds Pvt. Stanle;/ Spurgiasz HONORARY ORDER OF BRITISH EMPIRE MEDAL Major Robert W, Robertson MEDALnA DE GUERRA. (BRAZILIAN MEDAL) Captain Arkie 3. Bowyer COMMENDATION FROM FIFTH ARMY COMMANDER Major Frederick W. Bowers Pvt. Edgar E. Barnett Major Gene D. Caldwell Tec 4 Edgar \'J. Bartlett 1st Lt. Esther R, Collins Tec 5 Louis D, Capalbo 1st Lt. Bessie M. Cox S/Sgt. Philip Cusuraano 1st Lt. Opal G. Davis 1st Sgt. Frederick A. Dreiss Major Morris H. Frank Tec 4 Bernard Gaughran Major Ellery C. Gay Tec 5 Sidney C. Edmunds Captain Glen H. Gumness Tec 4 Benjamin Honigman Captain William M. Lees S/Sgt, William P. Koch 1st Lt, Irene C. Legako Tec 4 Frank M. Looney Captain Frank C. Massengill Tec 4 Paul A. Kemmert 1st Lt. Ruth Ponko Tec 4 Raymond J. Payne Major Edward B. Robinson, Jr. Tec 4 Edward E. Schneeweiss 1st Lt, Betty F. Verazin Tec 4 John Semivan Tec A James W. Ashbum Tec A Guy E, Teal, Jr. 923 VI - PUBLICATIONS AND REPORTS PUBLICATIONS ORIGINAL ARTICLES BY MEMBERS OF THE 2ND AUXILIARY SURGICAL GROUP SHOCK AND GENERAL SUBJECTS "PORTABLE HAND-DRIVEN SUCTION MACHINES" Lyman A, Brewer III, Major, MC-AUS Bulletin U,S, Army Medical Department, No, 75, April, 1944, "SHOCK AND HEMORRHAGE" James M, Sullivan, Major, MC-AUS Medical Bulletin, NATOUSA, Vol, 1, No, 6, June, 1944, "GASTRIC DILATION IN.WAR INJURIES" Robert D, Beech, Captain, MC -AUS Luther H, Wolff, Major, MC-AUS Medical Bulletin, MTOUSA, Vol, 3, No, 6, June, 1945, "RESUSCITATION OF SEVERELY WOUNDED CASUALTIES" Joseph J, Lalioh, Captain, MC-AUS James M, Mason III, Major, MC-AUS Surgery (In press), "CARE OF THE NON-TRANSPORT ABLE CASUALTY" Gordon F, Madding, Major, MC-AUS Paul A, Kennedy, Captain, MC-AUS William A, Weiss, Captain, MC-AUS Surgery, Gynecology and Obstetrics (in press), "SHOCK IN FORWARD AREAS" James M, Sullivan, Major, MC-AUS Wisconsin Medical Journal (in press). ANESTHESIA "ANESTHESIA IN THE COMBAT ZONE" Gerald Shorts* Captain, MC-AUS Bulletin U*S. Army Medical Department, No, 79, August, 1944, "THE MANAGEMENT OF THE FIRST PRIORITY SURGICAL CASUALTY FROM THE ANESTHETIC VIEWPOINT" Gerald Shorts, Captain, MC-AUS Journal Indiana State Medical Association, Vol, 38, February, 1945, "ENDOTRACHEAL ANESTHESIA IN THE COMBAT ZONE" Frederick W, Bowers, Major, MC-AUS Journal of Anesthesiology (in press)* 925 "THE USE OP CURARE FOR ABDOMINAL SURGERY IN SERIOUSLY WOUNDED BATTLE CASUALTIES" Ernest A* Doud, Captain, MC-AUS Gerald Shorts, Captain, MC-AUS Journal of Anesthesiology (submitted for publication)* GENERAL SURGERY "FORWARD SURGERY VIEWED FROM THE BASE" Wooster P* Giddings, Captain, MC-AUS Medioal Bulletin, NATOUSA, Vol. 2, No* 4, October, 1944. "TOURNIQUET PROBLEMS IN WAR INJURIES" Luther H. Wolff, Major, MC-AUS Trogler P* Adkins, Captain, MC-AUS Medical Bulletin, MTOUSA, Vol, 3, No* 6, June, 1945* Bulletin U.S. Army Medioal Department, No* 87, April, 1945, "BATTLE INJURIES OF THE COLON AND RECTUM" Lawrence E, Hurt, Major, MC-AUS Medical Bulletin, MTOUSA, Vol, 3, February, 1945 (abstract) Bulletin U,S. Army Medical Department (in press)* "EXPERIENCE WITH LUMBAR SYMPATHETIC GANGLIOHECTOMY FOR WOUNDS OF MAJOR BLOOD VESSELS OF THE LOWER EXTREMITY" James M, Mason III, Major, MC-AUS Wooster P, Giddings, Captain, MC-AUS Surgery, Gynecology and Obstetrics, Vol, 81, August, 1945* "THE SURGICAL MANAGEMENT OF COLON AND RECTAL INJURIES IN THE FORWARD AREAS" Lawrence E, Hurt, Major, MC-AUS Annals of Surgery (in press), "PHEOPERATIVE DIAGNOSIS OF THE RECENTLY WOUNDED ABDOMEN" Leon M* Michels, Major, MC-AUS Journal, American Medioal Association (in press), " A STUDY OF CASE RECORDS OF 96 INSTANCES OF WOUNDS OF THE UROGENITAL SYSTEM" Walter L* Byers, Captain, MC-AUS Surgery, Gynecology and Obstetrics (in press)* "EXPERIENCE IN THE MANAGEMENT OP THE ABDOMINAL WOUNDS OF WARFARE" Fred J* Jarvis, Major, MC-AUS Edward V* Platt, Captain, MC-AUS Surgery, Gynecology and Obstetrics (submitted for publication)* "COLON SURGERY IN THE FORWARD BATTLE AREA" James M* Mason III, Major, MC-AUS Surgery (submitted for publication )* 926 "THE THERAPEUTIC USE OF SPINAL ANESTHESIA IN PARALYTIC ILEUS - A CASE REPORT" Gordon F, 14aelding. Major, MC-AUS To be published* THORACIC SURGERY "NERVE BLOCK IN THE TREATMENT OF THORACIC INJURIES" Leo J, Fitzpatrick, Major, MC-AUS Arthur J, Adams, Captain, MG-AUS Benjamin Burbank, Major, MG-AUS Medical Bulletin, NATOUSA, Vol. 2, September, 1944# "THE MANAGEMENT OF WAR WOUNDS OF THE THORAX IN AN OVERSEAS THEATER" Paul C, Samson, Major, MC-AUS Thomas H, Burford, Major, MC-AUS Clinics, Vol. 3, April, 1945. "INTERCOSTAL NERVE BLOCK - ITS ROLE IN THE MANAGEMENT OF THORACIC CASUALTIES" Paul C, Samson, Major, MC-AUS Leo J. Fitzpatrick, Major, MC-AUS California and Y»estern Medicine, Vol. 62, May, 1945* "REYEN OF ONE THOUSAND THORACIC CASES" Thomas H, Burford, Major, MC-AUS Bulletin U,S, Army Medical Department, No. 89, June, 1945* "THE USE AND CONTROL OF THORACIC SURGICAL TEAMS OF AN AUXILIARY SURGICAL GROUP" James H, Forsee, Colonel, MC-AUS Journal of Thoracic Surgery (in press). "THE MANAGEMENT OF WAR WOUNDS OF THE CHEST .IN A BASE CENTER - THE ROLE OF EARLY PULMONARY DECORTICATION" Paul C, Samson, Major, MC-AUS Thomas H* Burford, Major, MC-AUS Lyman A, Brewer III, Major, MG-AUS Benjamin Burbank, Major, MC-AUS Journal of Thoracic Surgery (in press). "TRAUMATIC WET LUNG - OBSERVATIONS ON CERTAIN PHYSIOLOGICAL FUNDAMENTALS OF THORACIC TRAUMA" Thomas H, Burford, Major, MG—AUS Benjamin Burbank, Major, MC—AUS Journal of Thoracic Surgery (in press). "PRINCIPLES OF IMPROVING INADEQUATE TRACHEOBRONCHIAL DRAINAGE FOLLOWING TRAUMA TO THE CHEST" Pa.ul C, Samson, Major, MC—AUS Lyman A, Brewer III, Major. MC-AUS Journal of Thoracic Surgery (in press). 927 "THE* WET LUNG* IN WAN CASUALTIES" Lyman A* Brewer III, Major, MC-AUS Benjamin Burbank, Major, ?iC-AUS Paul C, Samson, Major, MC-AUS Charles A, Schiff, Captain, MC-AuS Annals of Surgery (in press), "EXPERIENCES IN THE LOCALIZATION OF THORACIC FOREIGN BODIES" Benjamin Burbank, Major, MC-AUS Thomas H, Burford. Major, MC-AUS Paul C, Samson, Major, MC-AUS Sidney Mesirow, Lt Colonel, MC-AUS "RECOVERY FROM HEMOLYTIC STAPHYLOCOCCUS AUREUS BACTEREMIA ATTRIBUTED TO PENICILLIN THERAPY" Thomas H* Burford, Major, MC-AUS Paul C, Samson, Major, MC-AUS Lyman A* Brewer III, Major, MC-AUS Benjamin Burbank* Major, MC-AUS Journal of Thoracic Surgery (in press), "MILITARY THORACIC SURGERY IN THE FORWARD AREA" Reeve H* Betts, Major, MC-AUS William M, Lees, Captain, MC-AUS Journal of Thoracic Surgery (in press)* "THE MANAGEMENT OF THORACIC-ABDOMINAL WOUNDS IN FORWARD AREAS IN THE SICILIAN AND ITALIAN CAMPAIGNS" Lawrence M, Shefts, Major, MC-AUS Ernest A, Doud, Captain, MC-AUS Journal of Thoracic Surgery (in press), "THORACO-ABDOMINAL INJURIES - A REPORT OF 29 OPERATED CASES" Reeve H, Betts, Major, MC-AUS Annals of Surgery (in press), "EARLY PULMONARY DECORTICATION IN THE TREATMENT OF POST TRAUMATIC EMPYEMA" Thomas H« Burford, Major, MC-AUS Edward F, Parker, Major, MC-AUS Paul C, Sersaon, Major, MC-AUS Annals of Surgery - Vol, 122f No, 2, (August) 1945 o "IMMEDIATE CARE OF THE WOUNDED THORAX" Paul C* Samson, Major, MC-AUS Benjamin Burbank, Major, MC-AUS Lyman A* Brewer 111, Major, MC-AUS Thomas H* Burford, Major, MC-AUS Journal, American Medical Association (in press)* "THE MANAGEMENT OF INTRATHORACIC FOREIGN BODIES" Thomas H, Burford, Major, MC-AUS Edward P* Barker, Major, MC-AUS To oo published. 928 "TRACHEOBRONCHIAL CATHETER ASPIRATION - INDICATIONS AND TECHNIQUE" Paul C* Samson, Major, MC-AUS Lyman A* Brewer III, Major, MC-AUS Benjamin Burbank, Major, MC-AUS Bulletin U.S# Army Medical Department (in press), "TWO UNUSUAL CASES OF WAR WOUNDS OP THE HEART" Paul C, Samson, Major, MC-AUS Surgery (submitted for publication), NEUROSURGERY "STATISTICAL REPORT ON SPINAL CORD INJURIES" Wolfgang W, Klemperer, Captain, MC-AUS Medical Nulletin, NATOUSA, Vol, 1, March, 1944* "SCALP DEFECTS IN CRANIOCEREBRAL INJURIES" S, G» Balkin, Major, MC-AUS Charles E, Dowman, Major, MC-AUS Wolfgang W, Klemperer, Captain, MC-AUS Journal, American Medical Association, Vol, 128, May, 1945, "PENETRATING WOUNDS OF THE HEAD" Milton Tinsley, Major, MC-AUS MAXILLOFACIAL SURGERY "STUDY OF 150 CASES OF FRACTURE OF THE UPPER JAW IN AN OVERSEAS MAXILLOFACIAL CENTER" Henry B, Clark, Major, MC-AUS Journal of Oral Surgery (in press), "SKIN DRESSINGS - IN THE TREATMENT OF DEBRIDED WOUNDS" Ellery C, Gay, Major, MC-AUS American Journal of Surgery (submitted for publication)* "INJURIES INVOLVING THE ACCESSORY NASAL SINUSES" Ellery C, Gay, Major, MC-AUS Werner G, Sittler, Major, 'r/C-AUS Surgery, Gynecology and Obstetric? (submitted for publication), NURSING SEPTIC” "UP FRONT IN ITALY" Martha G, Thomas, 1st 1ANC-AUS Re *1 itsred Nurse, Vol, 7, March 1C4 '■* "NURSING PROBLEMS ON A TRAUMATIC THORACIC SERVICE IN A THEATER OF OPERATIONS" Monette Lindsey, 1st It*, VNC-AUS eric an Journal of Nursing, Vo3 , * v>Tember, 1944, "THE DUTIES OF A NURSE ON A THORACIC SURGICAL TEAM OF AN AUXILIARY SURGICAL GROUP" Violetta A* Brooks, 1st Lt«, ANC-AUS American Journal of Nursing, (in press)* 930 REPORTS SUBMITTED TO THEATER OR ARMY SURGEON BY MEMBERS OF THE 2ND AUXILIARY SURGICAL GROUP '♦REPORT OF EXPERIENCES OF A DETACHMENT OF THE 2ND AUXILIARY SURGICAL GROUP DURING THE LANDINGS IN ALGERIA AND DURING THE TUNISIAN CAMPAIGN" Paul A. Dent, Major, MC-AUS To The Surgeon, NATOUSA, 15 May 1943* "PRELIMINARY REPORT OF ORTHOPEDIC DISABILITIES IN PATIENTS AT THE 2ND CONVAIESCENT HOSPITAL" Howard B. Shorbe, Major, MC-AUS To The Surgeon, NATOUSA, 31 May 1943. "PRELIMINARY REPORT OF SURVEY OF DISABILITIES AMENABLE TO PLASTIC SURGICAL PROCEDURES IN PATIENTS AT THE 2ND CON- VALESCENT HOSPITAL" Ellery C. Gay, Major, MC-AUS To The Surgeon, NATOUSA, 31 May 1943. "REPORT OF THORACIC SURGICAL SERVICE AT THE 21ST GENERAL HOSPITAL (NORTH AFRICA)" Thomas H. Burford. Major, MC-AUS "FORWARD SURGERY" Kenneth F. Lowry, Major, MC-AUS Forrest E. Lowry, Major, MC-AUS To The Surgeon, NATOUSA, 13 August 1943. "FINAL REPORT ON THE THORACIC SURGICAL CENTER AT THE 53RD STATION HOSPITAL AND THE 24TH GENERAL HOSPITAL" Paul C. Samson, Major, MC-AUS Thomas H. Burford, Major, MC-AUS Benjamin Burbank, Major, MC-AUS To The Surgeon, NATOUSA, 12 April 1944. "REPORT ON THE SURGERY OF ABDOMINAL WOUNDS" Fred J. Jarvis, Major, MC-AUS To The Surgeon, NATOUSA, 14 April 1944, "INTRAPLEURAL OR INTRATHORACIC WOUNDS" Leon M. Michels, Captain, MC-AUS To The Surgeon, NATOUSA, 29 April 1944. "TRANSFUSION THERAPY IN THE BATTLE CASUALTY EXHIBITING EVIDENCE OF CIRCULATORY FAILURE" Joseph J. Dalioh, Captain, MC-AUS To The Surgeon, NATOUSA, 20 June 1944. "REPORT ON ORAL SURGERY" Robert F. Sullivan, Major, DC-AUS To The Dental Surgeon, NATOUSA, 3 July 1944 931 ttftEPCHT ON THE EVACUABTLITY OF PATIENTS WITH THORACIC AND THORACO-ABDOMiNAL WOUNDS” Lawrence M» Shefte, Major, MC-AUS To The Surgeon, NATOUSA, 21 October 1944# "REPORT ON HEMATOCRIT AND PLASMA. PROTEIN FINDINGS IN BATTIE CASUALTIES TREATED IN A FORWARD HOSPITAL" Joseph J# Lalich, Captain, MC-AUS To The Surgeon, MTOUSA, 12 November 1944# "AIR EVACUATION OF PATIENTS" Wolfgang W# Klemperer, Captain, MC-AUS To The Surgeon, Seventh Army, 22 November 1944# "SURVEY OF CLOSTRIDIAL MYOSITIS" Luther H# Wolff, Major, MC-AUS To The Surgeon, Fifth Army, 12 December 1944# "NEUROSURGICAL EXPERIENCES IN A FIELD HOSPITAL DURING THE INVASION OF SOUTHERN FRANCE" Wolfgang W# Klemperer, Captain, MC-AUS To The Surgeon, Seventh Army, 15 December 1944# "NEUROSURGICAL DATA" Wolfgang W# Klemperer, Captain, MC-AUS To The Surgeon, Seventh Army, 16 January 1945# "NEUROSURGICAL DATA" Charles E# Dowman, Major, MC-AUS To The Surgeon, Seventh Army, 20 January 1945# " A REPORT OF 544 THORACO-ABDOMINAL BATTLE CASUALTIES" Henry L# Hoffman, Major, MC-AUS Aaron Himmelstein, Captain, MC-AUS To The Surgeon, MTOUSA, 20 February 1945# "REPORT OF THORACIC SERVICE AT NINTH EVACUATION HOSPITAL" Paul C# Samson, Major, MC-AUS To The Surgeon, Seventh Aray, 9 March 1945# "REPORT OF 338 BATTLE CASUALTIES TREATED ON THE THORACIC SURGICAL SERVICE OF THE 21ST GENERAL HOSPITAL (FRANCE)" Lyman A# Brewer III, Major, MC-AUS To The Surgeons, ETOUSA and MTOUSA, 27 August 1945# "ANAEROBIC DEFECTIONS" Floyd H, Jergesen, Lajor, LG-AUS To The Surgeon, Fifth Army, 23 February 1944*