MEDICAL DEPARTMENT

UNITED STATES ARMY

IN WORLD WAR II

MEDICAL DEPARTMENT, UNITED STATES ARMY

SURGERY IN WORLD WAR II

Volume II

GENERAL SURGERY

Editor in Chief

Colonel John Boyd Coates, Jr., MC

Editorfor General Surgery

Michael E. DeBakey, M. D.

Associate Editors

W. Philip Giddings, M. D.

Elizabeth M. McFetridge, M. A.

OFFICE OF THE SURGEON GENERAL

DEPARTMENT OF THE ARMY

WASHINGTON, D. C., 1955
SURGERY IN WORLD WAR II

Prepared under the direction of

Major General S. B. Hays

The Surgeon General, United States Army

Historical Unit, Army Medical Service

Colonel John Boyd Coates, Jr., MC, Director

Major I. H. Ahlfeld, MSC, Executive Officer

Captain J. K. Arima, MSC, Special Projects Officer Donald O. Wagner, Ph. D., Chief, Historians Branch

Willa B. Dial, Chief, Editorial Branch

Josephine P. Kyle, Chief, Archives and Research Branch

Hazel G. Hine, Chief, Administrative Branch

Rita Nelson, Publications Editor

Advisory Editorial Board

Michael E. DeBakey, M. D., Chairman

Frank B. Berry, M. D. John B. Flick, M. D.

Brian Blades, M. D. Frank Glenn, M. D.

J. Barrett Brown, M. D. M. Elliott Randolph, M. D.

Sterling Bunnell, M. D. Isidor S. Ravdin, M. D.

Norton Canfield, M. D. Alfred R. Shands, Jr., M.

B. Noland Carter, M. D. Howard E. Snyder, M. D.

Edward D. Churchill, M. D. R. Glen Spurling, M. D.

Mather Cleveland, M. D. Barnes Woodhall, M. D.

Daniel C. Elkin, M. D. Robert M. Zollinger, M. D.

Colonel Joseph R. Shaeffer, MC (ex officio)

Colonel John Boyd Coates, Jr., MC (ex officio)
GENERAL SURGERY

Volume II

VII

Contributors

Henry K. Beecher, M. D.

Dorr professor of research in anesthesia and anesthetist in chief, Harvard Medical

School and Massachusetts General Hospital, Boston, Mass. Formerly lieutenant

colonel, MC, AUS.

Clarence R. Brott, M. D.

President, Nebraska Academy of General Practice. Formerly major, MC, AUS.

Walter L. Byers, M. D.

Formerly major, MC, AUS.

W. Herschel Cave, M. D.

Formerly captain, MC, AUS.

Samuel B. Childs, M. D.

Assistant clinical professor of surgery, University of Colorado School of Medicine,

Denver, Colo. Formerly lieutenant colonel, MC, AUS.

C. Frank Chunn, M. D.

Formerly lieutenant colonel, MC, AUS.

Dominic S. Condie, M. D.

Visiting surgeon, Charity Hospital; senior visiting surgeon, Hotel Dieu; and police

surgeon, New Orleans, La. Formerly major, MC, AUS. George E. Donaghy, M. D.

Director of the department of anesthesia, Faulkner Hospital, Jamaica Plain, Mass.

Formerly lieutenant colonel, MC, 26th Infantry Division, Massachusetts National

Guard.

Ernest A. Doud, M. D.

Lieutenant colonel, MC, USAR, and anesthesiologist, San Diego, Calif.

James C. Drye, M. D.

Associate professor of surgery, School of Medicine, University of Louisville, Louisville,

Ky. Formerly major, MC, AUS.

W. Philip Giddings, M. D.

Assistant professor of surgery, Albany Medical College, Albany, N. Y.; surgeon, Putnam

Memorial Hospital, Bennington, Yt. Formerly major, MC, AUS. Richard V. Hauver, M. D.

Assistant chief of surgery, Washington County Hospital, Hagerstown, Md. Formerly

lieutenant colonel, MC, AUS. Leigh K. Haynes, M. D.

Formerly major, MC, AUS.

Werner F. Hoeflich, M. D.

Formerly major, MC, USAR. Paul A. Kennedy, M. D.

Assistant clinical professor of surgery, University of Buffalo School of Medicine, Buffalo,

N. Y. Formerly major, MC, AUS.

Knowles B. Lawrence, M. D.

Instructor in surgery, Boston University School of Medicine, Boston, Mass. Formerly

captain, MC, AUS.

Gordon F. Madding, M. D.

Assistant clinical professor of surgery, Stanford University School of Medicine, San

Francisco, Calif. Formerly lieutenant colonel, MC, AUS.
VIII GENERAL SURGERY

John R. McDaniel, M. D.

Surgeon, Thompson-Brumm-Knepper Clinic, St. Joseph, Mo. Formerly major, MC,

AUS. Leon M. Michels, M. D.

Associate chief, department of surgery, Mount Zion Hospital, San Francisco, Calif.

Formerly lieutenant colonel, MC, AUS. David Henry Poer, M. D.

Formerly colonel, MC, AUS. H. Leon Poole, M. D.

Formerly lieutenant colonel, MC, AUS. Hugh F. Swingle, M. D.

Surgeon, Swingle Hospital, Johnson City, Tenn. Formerly major, MC, AUS.

Floyd D. Taylor, M. D.

Major, MC, USAR, and chief of surgical department, Hendrick Memorial Hospital,

Abilene, Tex.

Beverly T. Towery, M. D.

Associate professor of medicine, Vanderbilt University School of Medicine, Nashville,

Tenn. Formerly Markle Scholar in medical sciences, Vanderbilt University School of

Medicine, and major, MC, AUS.

John D. Welch, M. D.

Clinical associate, University of Oregon Medical School, Eugene, Oreg. Formerly

major, MC, AUS.

Charles W. Westerfield, M. D.

Formerly captain, MC, AUS. Luther H. Wolff, M. D.

Lieutenant colonel (retired), MC, USAR. Surgical consultant, United States Army

Hospital, Fort Benning, Ga.
Foreword

This volume on general surgery is set apart from other volumes of the

history of the Medical Department of the United States Army in World War

II by number of special considerations.

This is story not only of surgery performed in forward Army medical

units, but of extremely urgent surgery; all abdominal injuries constituted

emergencies, and all casualties with abdominal injuries were nontransportable.

This volume is also the record of the performance of an auxiliary surgical group,

and as such is typical of the outstanding work done in all theaters of operations

by the medical oflicers assigned to similar units, as well as by medical officers

organically assigned to frontline hospitals in which surgical teams from auxiliary

surgical groups were employed.

The 3,154 abdominal injuries upon which this story is chiefly based were

all the result of the violence of war, and all but about hundred were combat

incurred. This is perhaps not the largest series of combat injuries of the

abdomen ever to be recorded, but it is undoubtedly the largest series to be

analyzed in such detail. This series, furthermore, has the great advantage,

which most recorded series do not possess, that the analysis of cases was planned

in advance. There are some statistical inadequacies, it is true. They were

inevitable in the circumstances in which the data were collected. These

inadequacies, however, in no way alter the clinical conclusions which were

arrived at by the experienced surgeons who made the analysis and which,

incidentally, were merely the confirmation of the clinical impressions which

had already become evident. The data were analyzed overseas, immediately

after they were collected. They were reanalyzed later, in the more normal

environment of the United States, when more sober second thoughts were

possible. The analysis is entirely objective. Errors of technique and mistakes

of judgment are related as frankly as are surgical triumphs.

At the beginning of World War I, the policy of management of combatincurred abdominal injuries was one of so-called surgical abstention. As the

war progressed, the undesirability of such policy became more and more

evident, and surgical intervention began to be practiced, but for variety of

reasons, including lack of organization, operation was still not the general

rule when the war ended. In World War 11, as the result of both the previous

military experience and the intervening civilian experience, the official policy

was to operate, as promptly as possible, on all casualties with abdominal

injuries in whom the mere act of operation would not be fatal. Only small

number of patients (considerably loss than percent) fell into this category.

The policy of prompt surgical intervention in abdominal injuries was made

practical and possible because of another concept that was new in World War

II, the practice of preoperative resuscitation, which is also described in this

volume. Many of the fatalities in World War occurred because the patients
GENERAL SURGERY

were never in condition to be operated on. In World War II, small number

died while resuscitation was being attempted, but at least the attempt had

been made to bring them to status in which surgery could be tolerated.

The liberal use of whole blood was the central feature of resuscitation, but, as

Doctor Beecher points out in his account of the program, every detail was

important, from the placing of blankets underneath the patient, as well as

over him, to the deliberate care with which his position was changed on the

operating table. The program of resuscitation, combined with competent

anesthesia, permitted surgery of great magnitude on patients whose initial

condition was such that in an earlier day they could only have been left to die.

Three extremely important departures from previous medicomilitary

practices require specific mention. The first is the management of wounds

of the rectum and large bowel by colostomy, with or without exteriorization

of the damaged segment. Although colostomy had been an established procedure in civilian surgical practice before World War I, it was used only in

desperate cases in that war and was never routine, even when surgical intervention in abdominal injuries had become fairly general. United States Army

medical officers used colostomy in the fighting in North Africa in 1942 and 1943

without knowledge of the previous British experience with it. The results

were so good that its use became official Medical Department policy in October

1943. The performance of colostomy saved thousands of lives immediately

after wounding, and the excellence of the final results is described in the last

chapter of this volume, which deals with the repair of colostomy in Zone of

Interior hospitals.

Wounds of the liver were never treated surgically in World War I, even after

the policy of surgical intervention for abdominal injuries had been introduced.

Their management in World War IIrepresents process of evolution, since the

military surgeons who encountered them had no decisive principles to guide

them other than the general policy that surgical intervention in abdominal

injuries is in the best interests of all patients who survive to reach forward

hospitals. Drainage of Morison’s pouch, which eventually became established

practice, resulted in considerable salvage of life, as well as in considerable

reduction in both primary and postoperative complications in injuries of the

liver.

The transdiaphragmatic approach to thoracoabdominal wounds, of which

there were 839 in this series, represents new practice in military surgery.

The cardiorespiratory risks associated with this technique were reduced to

minimum by the ready availability of competent anesthetists and suitable

anesthetic equipment. The ease of intimate surgical exploration of the left

upper quadrant, in properly selected cases, by way of this incision is evident in the good results achieved in injuries of the spleen, in which, in contrast to

World War practice, splenectomy was the accepted method of management in World War II.

The 333 negative explorations in this series are, in some respects, the most

important group of all. One of the outstanding observations in this analysis
FOREWORD XI

was that in not single instance did missile pass harmlessly across the general

peritoneal cavity in major diameter. The prompt exploration of every case

in which there was any suspicion of penetration of the peritoneal cavity was

therefore standard practice and was entirely justified, in view of the minimal

mortality associated with exploration and the risks involved in nonsurgical

management of penetrating abdominal wounds. These 333 negative explorations may, in sense, be described as unnecessary emergencies, but they well

illustrate the surgical philosophy which directed the management of abdominal

injuries in World War II.

should be derelict if brought this foreword to close without specific

recognition of the technical competence, sound professional judgment, and

surgical courage of the members of the 2d Auxiliary Surgical Group who handled

these cases, and without paying tribute also to the indispensable assistance

they, like all other military surgeons, received from the anesthetists and the

resuscitation teams whose part in the management of abdominal injuries is

described in this volume.

S. B. Hays,

Major General

The Surgeon General.

Preface

Prevailing United States Army doctrines in 1942 held that combat force

could best be supported by activating methods and procedures generally known

at the outbreak of war. Exception was made for new developments which were

expected to emerge from an intense scientific effort in this country, specifically that fostered by the Office of Scientific Research and Development, with the

advice of the National Research Council. Otherwise, combat in the field was

pictured as calling for the replacement of personnel and supplies and reasonable modicum of skill in the adaptation of standardized procedures to specialized

situations as they were encountered. It was not generally understood that

experience in the field could point the way toward immediate and radical changes

of methods and equipment and that quick footwork in making these changes

spelled survival. To be sound, changes of this type required as much factual

evidence as could be assembled.

As consequence, no provision was made for the collection and analysis of

surgical evidence so that corrective measures might be devised by those on the

spot when confronted with unexpected happenings. The idea of sending out

skilled observers to identify new problems and solve them then and there was

not entertained. In fact, such an idea smacked of the academic and was

dismissed by the stern reminder that medicine was on the march to help fight

war—not to indulge in research.

Interestingly enough, it was the combat components that pointed the way

by the utilization of the services of experts to observe and report on the performance of machines of war. Many were the “bugs’’ that remained in new

tanks, planes, and missiles, and these defects were constantly being ironed out.

Precise and scientific measurement of novel developments by the enemy

required alert and expert intelligence. One recalls the encounter with magnetic

mines that threatened shipping in the North Atlantic. Combat commanders

and their conventional military staffs cannot be expected to solve such problems

unaided and, in fact, may not even be able to define them in terms that can

lead to solution elsewhere. The same may be said of wound surgeon

confronted by case of anuria in forward hospital.

Beginning in the North African campaign and continuing through Sicily,

Italy, and southern France, the surgeons of the theater were hard pressed by

the need for surgical evidence to guide their daily work. Some of the first

compilations of the records of patients who had disappeared into the evacuation

stream were made as followup studies by members of the 2d Auxiliary Surgical

Group. This was partly because the surgical teams had periods of inactivity

that could be devoted to such pursuits and partly because of the wise insistence
XIV GENERAL SURGERY

of their commanding officer, Col. James H. Forsee, MC, on maintaining

duplicated and full clinical records. It could have been so easy to let down

standards and be too busy to keep records adequate for analysis.

The theater from which the greater part of this volume has originated

was also fortunate in the assignment of affiliated hospital units from leading

teaching hospitals with chiefs of surgery who insisted on the maintenance of

high standards. professor of surgery from Oslo, after weeks in the forward

area of the Fifth United States Army in Italy, said: “You are holding to the

standards of university clinic surgery under fire and in tents with mud floors.”

Finally, the small group of peripatetic officers who were identified as

consultants were not deployed with the mission of commissars or gauleiters.

They were searching for surgical evidence by direct observation and discussion.

The achievement of consultant was aptly described by Sir Patrick Berkeley

Moynihan, following World War I:

“I have gathered posie of other men’s flowers and nothing but the thread

that binds them is mine own.”

Of course, the Mediterranean Theater of Operations provided favorable

environment for such undertakings. It was an experimental laboratory not

only for surgery but also for medicine as whole; for ordnance; for equipment;

and, as many are reluctant to recall, even for rations. It was vital that wound

surgery be carried on within framework of inquiry, for this theater was

the proving ground for the greater task that was to come.

Edward D. Churchill, M. D.

John Homans Professor of Surgery,

Harvard Medical School, and

ChieJ 0/ the General Surgical Services,

Massachusetts General Hospital.
XV

Acknowledgments

Without the contribution of the authors of

this book, made with no material reward and at

the sacrifice of time and expenditure of energy which

professional men can ill afford, there would not have

been this history of surgery in World War II, and

the many valuable lessons learned in the surgical

care of battle casualties would not have been recorded.

The counsel and assistance of the Advisory

Editorial Board in many matters is equally and

gratefully recognized. Members of this board,

individually and collectively, have given generously

of their knowledge and experience in consultative

and advisory capacity.

Much credit is due Miss Elizabeth M. McFetridge, associate editor, for her skill and untiring

labor in consolidating, organizing, rewriting, and perfecting the manuscripts for this book.

Grateful acknowledgment is given to the following personnel of the Medical Statistics Division,

Office of The Surgeon General, for their review of

statistical data in part II of this volume: Mr. E. L.

Hamilton, chief; Mr. A. J. McDowell, assistant

chief; Mr. M. C. Rossoff, assistant chief, Statistical

Analysis Branch; and staff members.

All illustrations were prepared for publication

by Mr. R. Pierce Thompson, under the direction

of Mr. Herman Van Cott, chief, Medical Illustration

Service, Armed Forces Institute of Pathology.

Contents

FOREWORD IX

PREFACE XIII

ACKNOWLEDGMENTS-- XV

Part

RESUSCITATION, CONTROL OF PAIN,

AND ANESTHESIA

Chapter Page

Resuscitation of Men Severely Wounded in Battle

The Evolution of Methods of Resuscitation in the Mediterranean

Theater

General Considerations of Resuscitation

Chain ofEvacuation Preoperative (Shock) Wards 10

Shock: Predisposing and Precipitating Factors 12

Appraisal of the Wounded Man 13

Stabilization Versus Rapid Preparation of Battle Casualties for Surgery 18

Plasma 21

Whole Blood 24

Albumin 29

Other Fluid Replacement Therapy 31

Other Resuscitative Measures 32

II The Control of Pain in Men Wounded in Battle 41

Morphine Overdosage and Poisoning 41

Investigation of Pain in Wounded Men 43

Relief of Pain 46

Thirst 49

Psychologic Preparation for Operation 49

III Anesthesia for Men Wounded in Battle 53

Historical Note 53

Military Considerations of Anesthesia 56

Personnel 57

Equipment 59

Anesthetic Agents 65

Pre-Anesthetic Medication 75

Endotracheal Intubation and Bronchoscopy 77

Anesthetic Deaths 78

378327°—56
XVIII CONTENTS

Part II

ABDOMINAL INJURIES AND THE INITIAL SURGERY

OF ABDOMINAL WOUNDS

Chapter Page

IV Derivation of Data, Source Material, and Methods of Analysis 81

The 2d Auxiliary Surgical Group 81

Source Material 82

Methods of Analysis 83

Limitations of the Analysis 85

The Concept of Abdominal Surgery in World War II 87

Definition of Terms 87

Distribution of Injuries and Other Statistical Data 89

Distribution of Injuries 89

Case Fatality Rates 94

VI Wounding Agents 97

VII Timelag and the Multiplicity Factor in Abdominal Injuries 103

Multiplicity Factor 107

Limitations of the Multiplicity Factor 111

VIII Associated (Extra-Abdominal) Wounds (1,089 Casualties) 113

Multiplicity Factor 114

IX Shock Therapy (957 Casualties) 119

Classification of Shock 121

Timelag and Character of Wound 122

Role of Hemorrhage and Other Fluid Losses in Pathogenesis of Shock- 122

Replacement Therapy 124

The Total Picture of Shock in World War II 129

Clinicopathologic Study of Abdominal Wounds Associated With

Shock 130

Traumatic Evisceration (312 Casualties) 173

Case Fatality Rate in Relation to Shock and Peritonitis 174

Case Fatality Rate in Relation to Multiplicity Factor and Timelag 174

XI Diagnosis and Preoperative Routine 177

Diagnosis 177

Preoperative Routine 178

XII Anesthesia 181

Status of Casualties 181

Agents and Methods 182

Preoperative Management 185

Management During Operation 186

Postoperative Complications of Anesthetic Origin 188

Anesthetic-Connected Deaths 188

XIII Laparotomy Incisions and Closures, and Wound Dehiscences 191

Incisions 191

Closures 192

Wound Dehiscences 193

XIV Penicillin and Sulfonamide Therapy (2,410 Casualties) 197

Methods ofAdministration 197

Case Fatality Rates 198

XV Postoperative Complications: Prophylaxis and Therapy 203

Pulmonary Complications 204

Nonpulmonary Complications 208
CONTENTS XIX

Chapter Page

XVI Factors of Mortality 213

General Considerations 215

Special Factors of Mortality 217

Time and Cause of Death 219

Ultimate Causes of Death 220

XVII Wounds of the Stomach (416 Casualties) 223

Diagnostic Considerations 224

Nature of the Injury 226

Timelag and the Multiplicity Factor 227

Associated Injuries 229

Technical Considerations 229 Postoperative Complications 231

Case Fatality Rate 231

XVIII Wounds of the Duodenum (118 Casualties) 235

Diagnostic Considerations 236

Nature of the Injury 236

Technical Considerations 237

Postoperative Complications 237

Time and Causes of Death 238

XIX Wounds of the Jejunum and Ileum (1,168 Casualties) 241

Nature of Injury 241

Diagnosis 245

Preoperative Routine 245

Treatment 245

Postoperative Complications 249

Univisceral Wounds 251

XX Wounds of the Colon and Rectum (1,222 Casualties) 255

Nature of the Lesion 256

Timelag and the Multiplicity Factor 256

Shock 259

Treatment 261

Regional Injuries 264

Postoperative Complications 270

Case Fatality Rates 270

Causes of Death 271

XXI Wounds of the Liver and of the Extrahepatic Biliary Tract (829 Casualties). 275

Nature of Injury 275

Evolution of Methods of Management 276

Treatment 278

Postoperative Complications 280

Case Fatality Rates and Factors of Mortality 282

Wounds of the Extrahepatic Biliary Tract 283

XXII Wounds of the Pancreas (62 Casualties) 285

Nature of Injury 286

Multiple and Associated Injuries 286

Clinical Findings 286

Treatment 287

Postoperative Complications 288

Case Fatality Rates and Factors of Mortality 288
XX CONTENTS

Chapter Page

XXIII Wounds of the Spleen (341 Casualties) 291

Nature of Injury 291

Clinical Considerations 293

Treatment 294

Postoperative Complications 297

Case Fatality Rates 297

XXIV Wounds of the Kidney (427 Casualties) 301

Anatomic Considerations 302

Nature of the Injury 302 Clinical Considerations 303

Diagnosis 304

Treatment 305

Postoperative Management 306

Postoperative Complications 306

Factors of Mortality 307

XXV Wounds of the Ureter (27 Casualties) 309

Diagnosis 309 Treatment 310

Factors of Mortality 310

XXVI Wounds of the Urinary Bladder (155 Casualties) 313

Nature of the Injury 313

Clinical Considerations 313

Treatment 314

Postoperative Complications 315

Factors of Mortality 315

XXVII Wounds of the Great Vessels of the Abdomen (75 Casualties) 317

Injuries to the Major Veins 317

Injuries to the Major Arteries 320

Postoperative Vascular Insufficiency 321

Factors of Mortality 322

XXVIII Retroperitoneal Hematoma (207 Casualties) 325

Clinical Considerations 325

Treatment 326

Factors of Mortality 326

XXIX Special Types of Abdominal Injury 329

Visceral Injuries Without Penetration of the Peritoneal Layer of the

Abdominal Wall 329

Visceral Injuries Caused by Blunt Trauma and Blast 331

Penetrating (Perforating) Wounds of the Abdominal Wall Without

Visceral Injuries 331

Part III

COLOSTOMY

XXX The Management of Colostomies 337

Historical Note 337

Colostomy in Overseas Hospitals 338

Colostomy in Zone of Interior Hospitals 341

Comment 362

Summary 370

Index 373
CONTENTS XXI

Tables

Number Page

Relationship of degree of shock and average blood loss in 67 patients with all

types of wounds 16

Analysis of pain sensation in 215 freshly wounded patients with major injuries. 45 Provision of anesthetic personnel in sample evacuation, general, and station

hospitals in Mediterranean theater 59 Sample distribution of surgical procedures in Mediterranean (North African)

campaigns (1943-44) 70 Distribution of injuries and deaths in 3,154 abdominal injuries by hospital installation 89

Regional distribution of wounds and deaths in 3,154 abdominal injuries 91

Distribution of univisceral and multivisceral wounds in 3,154 abdominal injuries. 92

Comparative percentages of univisceral and multivisceral injuries in various

recorded series of abdominal wounds 93

Timelag, multiplicity factor, and case fatality rates in 2,926 abdominal injuries. 106

10 Multiplicity factor and case fatality rates in wounds of various viscera 109

11 Multiplicity factor and case fatalityrates in various recorded series of abdominal

injuries 111

12 Associated wounds in 2,315 abdominal injuries, with case fatality rates 113

13 Distribution according to type of 1,403 individual associated wounds in 1,089

casualties with abdominal injuries 113

14 Distribution of 659 major fractures (pelvis, femur, and humerus) in 1,403 associated injuries 114

15 Case fatality rates in 527 abdominal injuries complicated by associated injury. 115

16 Case fatality rates in 299 abdominal injuries complicated by associated injuries. 115

17 Case fatality rates in 142 abdominal injuries complicated by associated injuries. 116

18 Replacement therapy in relation to degree of shock in 957 traumatic gastrointestinal perforations 121

19 Distribution of wounds and deaths in 312 traumatic eviscerations 173

20 Primary cause of death and time of death in 94 traumatic eviscerations 175

21 Combined influence of evisceration and multiplicity factor on case fatality rates

in 3,129 abdominal injuries 175

22 Timelag and case fatality rates in 203 traumatic eviscerations 176

23 Anesthetic agents used in 3,154 abdominal injuries 182

24 Techniques of anesthesia in 3,154 abdominal injuries 183

25 Abdominal incisions and wound dehiscences in 2,258 abdominal injuries 191

26 Wound dehiscences in relation to techniques of closure in 2,258 abdominal injuries 192

27 Wound dehiscences in relation to techniques of retention suturing in 2,121

abdominal injuries 194

28 Comparative case fatality rates from peritonitis in 2,410 abdominal injuries 198

29 Antibacterial therapy and case fatality rates in 1,526 abdominal injuries 199

30 Antibacterial therapy and case fatality rates in 2,410 abdominal injuries 200

31 Pulmonary complications in 3,090 abdominal injuries 206

32 Multiplicity factor and infectious thoracopulmonary complications in 2,831

abdominal injuries 206

33 Primary causes of death according to time of death in 737 abdominal injuries 214

34 Injuries and deaths according to age in 3,154 abdominal injuries 216

35 Seasonal distribution of cases and deaths in 2,332 abdominal injuries 216

36 Case fatality rates according to viscus wounded in 3,154 abdominal injuries 218

37 Case fatality rates of visceral wounds in various recorded series of abdominal

injuries 218
XXII CONTENTS

Number Page

38 Essential data in 416 gastric wounds 223

39 Comparative distribution of gastric wounds in various recorded series of abdominal injuries 224

40 Case fatality rates in relation to type of injury in 416 gastric wounds 226

41 Multiplicity factor and case fatality rates in 416 gastric wounds 227

42 Case fatality rates in gastric wounds complicated by other visceral wounds 228

43 Surgical approaches in 412 gastric wounds 229

44 Primary cause of death in relation to time of death in 169 gastric wounds 232

45 Essential data in 118 duodenal wounds 235

46 Site and type of injury in 112 duodenal wounds 237

47 Primary cause of death and time of death in 67 duodenal injuries 238

48 Degree of shock and case fatality rates in 114 duodenal wounds 239

49 Multiplicity factor and case fatality rates in 118 duodenal wounds 240

50 Essential data in 1,168 jejuno-ileal wounds 241

51 Frequency of various types of injury in 1,168 jejuno-ileal wounds 242

52 Comparative results of anastomotic and suturerepair in 1,117 jejuno-ileal wounds. 246

53 Comparative case fatality rates of resection with various techniques of anastomosis in 428 jejuno-ilealwounds 247

54 Causes of death in 31 primarily fatal jejuno-ilealwmunds 253

55 Essential data in 1,222wounds of colon and rectum 255

56 Case fatality rates in 191 thoracoabdominal injuries involving the colon 256

57 Timelag and case fatality rates in 1,222wounds of colon and rectum 257

58 Timelag, multiplicity factor, and case fatality rates in 1,155 injuries of colon and

rectum 258

59 Degree of shock, timelag, and case fatality rates in 1,140 injuries of colon and

rectum 260

60 Blood and plasma replacement in wounds of colon and rectum 260

61 Location of injury, type of operation, and case fatality rates in 1,222 wounds of

colon and rectum 261

62 Technique and case fatalityrates in 273 wounds of ascending colon 266

63 Technique and case fatalityrates in 414 wounds of transverse colon 266

64 Technique and case fatality rates in 119 wounds of descending colon 267

65 Technique and case fatality rates in 154 wounds of sigmoid colon 267

66 Technique and case fatality rates in 116 wounds of extraperitonealrectum 268

67 Technique and case fatality rates in 32 wounds of ascending and transverse colon. 268

68 Technique and case fatality rates in wounds of ascending and descendingcolon. 269

69 Technique and case fatality rates in 48 wounds of transverse and descending

colon 269

70 Technique and case fatality rates in 39 combined wounds of colon and rectum 269

71 Site of injury and case fatality rates in 328 univisceral wounds of colon and rectum 271

72 Primary causes of death in 397 injuries of colon and rectum 272

73 Essential data in 829 hepatic wounds 275

74 Surgical approaches in 432 hepatic wounds 279

75 Percentage distribution of operations in 695 hepatic wounds 279

76 Essential data in 62 pancreatic wounds 285

77 Multiplicity factor and case fatality rates in 62 pancreatic wounds 286

78 Influence of specific additional organs wounded on case fatality rates in 61 multivisceral pancreatic wounds 287

79 Essential data in 341 splenic wounds 292

80 Degree of shock, types of wound, and case fatalityrates in 319 splenic wounds 294

81 Methods of treatment in 340 splenic wounds 295

82 Surgical approaches in 337 splenic wounds 296
CONTENTS XXIII

Number Page

83 Primary cause of death and time of death in 67 fatalities following splenectomy 298

84 Essential data in 427 renal wounds 301

85 Comparative distribution of renal wounds in various recorded series of abdominal

injuries 302

86 Essential data in 155 wounds of urinary bladder 313

87 Influence of wounds of intestinal tract on case fatality rates in 155 wounds of

urinary bladder 316

88 Primary cause of death and time of death in 42 wounds of urinary bladder 316

89 Essential data in 75 wounds of major abdominal vessels 317

90 Type of injury and case fatality rates in 75 wounds of major abdominal vessels 318

91 Essential data in 33 vena caval injuries 318

92 Essential data in 13 injuries of major abdominal arteries 320

93 Essential data in combined injuries of major abdominal arteries and veins 320

94 Degree of shock and case fatality rates in 69 wounds of major abdominal vessels 323

95 Multiplicity factor and case fatality rates in 67 wounds of major abdominal

vessels 324

96 Essential data in 12 injuries of intraperitoneal viscera without penetration of

peritoneal layer of abdominal wall 330

97 Essential data in 14 intra-abdominal injuries caused by blunt trauma and external blast 332

98 Closure of colostomy and associated operations in 464 battle-incurred wounds

of large bowel 358

Illustrations

Early care of wounded man in forward hospital. Removal of all clothing 14

Administration of plasma to wounded man 23

Elevation of foot of litter of wounded man 27

Sedation (barbiturate) and administration of morphine 33

Spiritual care of wounded man 34

Emptying of stomach of wounded man 37

Administration of artificial respiration to wounded man 38

Transportable anesthetic apparatus 60

Transportable anesthetic apparatus 61

10 Administration of ether in simplified closed system 62

11 Administration of ether with oxygen in simplified closed system 64

12 Administration of Pentothal Sodium anesthesia 75

13 Administration of Pentothal Sodium anesthesia with oxygen 76

14 Summary sheet for collection of data on abdominal injuries 84

15 Distribution in relation to intensity of combat of 3,154 abdominal injuries 90

16 Proportional distribution, by branch of service, of 2,137 abdominal injuries 91

17 Distribution of causative missiles in 3,052 abdominal injuries 97

18 Anatomic distribution of wounds of entry in 2,586 abdominal injuries 98

19 Possible effect of position on track of missiles and resulting visceral injuries 100

20 Influence of timelag in 2,863 abdominal injuries 104

21 Multiplicity factor and case fatality rates in 3,129 abdominal injuries 108

22 Multiplicity factor and case fatality rates in various combinations of abdominal

wounds 108

23 Multiplicity factor and associated injuries in 3,154 abdominal injuries 116

24 Multiplicity factor and gravity of associated injuries in 3,154 abdominal injuries- 117

25 Average replacement therapy in relation to degree of shock in 957 gastrointestinal perforations 125
XXIV CONTENTS

Number Page

26 Resuscitation tent in field hospital in Italy, winter, 1944-45 205

27 Wounds of entry in 118 duodenal injuries 237

28 Types of colostomy 263

29 Types of colostomy 264

30 Types of colostomy 265

31 Exteriorization of damaged sigmoid 341

32 Right-sided colostomy 345

33 Fecal fistula into extraperitonealrectosigmoid 346

34 Double stoma in transverse colon, with complete division of bowel 347

35 Resection for injuries of descending colon 348

36 Lumbar colostomy 349

37 Excessive protrusion of transverse colon and mucosal eventration with incomplete division of bowel 350

38 Sigmoid colostomy 351

39 Revision of sigmoid colostomy 354

40 Left inguinal colostomy 355

41 Resection for injuries of descending colon 363

42 Proximal colostomy in descending colon for wounds of rectosigmoid 366

43 Proximal colostomy in transverse colon for wounds of rectosigmoid 367

44 Exteriorization of damaged sigmoid colon 368

45 Right-sided colostomy 369
Part

RESUSCITATION, CONTROL OF

PAIN, AND ANESTHESIA

CHAPTER

Resuscitation of Men Severely Wounded in Battle

Henry K. Beecher M. D.

THE EVOLUTION OF METHODS OF RESUSCITATION IN THE

MEDITERRANEAN THEATER

The fighting in the Mediterranean (North African) Theater of Operations

in World War II began in November 1942 and ended early in May 1945. As

whole, the campaigns carried out during this time were among the longest

fighting conducted by any American army since the Civil War. From the

medical standpoint, and entirely aside from any military considerations, the

duration of combat provided the inestimable advantage of time for the evolution of sound medical practices, for the correction of errors, and for the development

of expeditious medicomilitary methods.

The two case histories which follow illustrate excellently how, over this period, earlier, erroneous concepts of therapy gave way to advanced, sounder

concepts:

Case 1.—On 21 March 1943, during the fighting in Tunisia, an infantryman sustained

compound fracture of the left humerus and laceration of the left side of the chest from

shell fragment. He was tagged at regimental aid station at 1100 hours. First aid consisted

of the intramuscular injection of 30 mg. (gr. )£) of morphine and the application of sulfanilamide-powdered dressings and Thomas arm splint. At the division clearing station, the man was given cc. of tetanus toxoid and 500 cc. (2 units) of blood plasma. His general

condition was not described on the medical tag.

During the afternoon of the same day, the patient was evacuated to field-type hospital.

At 1715 hours, his blood pressure was recorded as 110/70 and his pulse rate as 120. Examination revealed absent breath sounds and hyperresonance on the left side of the chest, with

abdominal rigidity and tenderness. At 1745 hours, he was given second transfusion of

500 cc. (2 units) of blood plasma. Roentgenologic examination of the left arm revealed

fracture of the lower third of the humerus, with lateral bowing. Fluoroscopic examination

of the chest and upper abdomen showed increased density in the left hemithorax; the mediastinum was pushed over to the right, apparentlyby fluid. large foreign body was observed

in the region of the stomach. As there was no evidence of sucking in the chest wound, it

was closed by suture. The diagnosis at this time was combined thoracoabdominal wound,

with rupture of viscus and probable hemorrhage.

The blood pressure at the time the fluoroscopic examination was conducted was satisfactory, and the pulse was of fair quality. Immediate operation was therefore undertaken,

after transfusion of 500 cc. of whole blood. As soon as the abdomen was opened, through

long left rectus incision, there was gush of blood and air. Respiratory difficulty was

apparent immediately. The patient’s condition improved after 4-cm. laceration of the

•Except as otherwise noted, part is based upon the personal experience of the author as consultant in resuscitation

and anesthesia, North African-Mediterranean Theater of Operations, and upon reports submitted to him.
GENERAL SURGERY

dome of the abdomen had been closed. 10-cm. laceration of the stomach, near the greater

curvature, was also closed. It had been caused by shell fragment by by cm. The only

other intraperitoneal injury was small laceration of the spleen, which was not bleeding. The

incision in the abdominal wall was closed after 12 gm. of sulfanilamide powder had been

dusted into the peritoneal cavity.

Shortly after the operation had been concluded, sucking became apparent in the chest

wound at the site of entrance of the missile, where simple suture closure had been done.

Closed drainage was established at once, and the wound was packed tightly with vaseline

gauze. The patient became deeply cyanotic, in spite of these measures, and died 21 March

at 2315 hours, little over 12 hours after injury.

Case 2.—On 21 April 1945, during the fighting in the Po Valley, 26-year-old infantryman received compound fractures of the left femur and both ankles, penetrating wound of

the chest with hemothorax, and multiple lacerations of the legs and face from shell fragments.

In the collecting station, to which he was brought at 1315 hours, 15 minutes after injury, he

was given 15 mg. (gr. %) of morphine and 1,500 cc. (6 units) of blood plasma. Dressings

were applied to his various wmunds, and his legs were supported by splints. He was then

evacuated to clearing station, where he was given another 250 cc. (1 unit) of blood plasma

and 20,000 units of penicillin intramuscularly. Because of his exceptionally poor appearance,

he was also given transfusion of 1,000 cc. of whole blood, which was obtained from the

adjacent field hospital. His blood pressure was then 90/60. When the patient was received in the field hospital at 2100 hours, his blood pressure was

not measurable. His face was pale, but the skin was warm. The extremities were cool, and

the veins were collapsed. He was classified as in severe shock. Laboratory studies showed

the hemoglobin to be 9.8 gm. percent; the hematocrit 29; and the blood volume 5,010 cc., or

19 percent below his normal calculated blood volume. When the values were corrected for

fluids which had been administered, it was found that, since wounding, he had lost 76 percent

of his normal blood volume and 55 percent of his normal hemoglobin.

In the hours which followed his admission to the field hospital, the patient was given

500 cc. (2 units) of plasma, 2,000 cc. of whole blood, and 25,000 units of penicillin intramuscularly. At the end of this period, his blood pressure had risen from to 110/65, and his

pulse was 138 and of good volume.

Operation was performed at 0330 hours 22 April, 14)4 hours after wounding, under

endotracheal nitrous oxide-ether anesthesia. It lasted 2)4 hours. It consisted of guillotine

amputation of the lower third of the left leg, together with debridement of the wounds of the

extremity and chest wall. Twenty-five thousand units of penicillin were placed in the right

pleural cavity, after 1,000 cc. of blood had been aspirated from it. Nasal oxygen was instituted as soon as the operation was ended. Blood was also used liberally in the postoperative

period.

The patient made rapid, uncomplicated recovery.

Comment.—The first of these patients, who was clearly desperately

wounded, was resuscitated by units of plasma and 500 cc. of whole blood.

Although the blood pressure was finally recorded as normal, the pulse, which

continued rapid and of only fair quality, provided evidence that resuscitation

had been inadequate. It was not possible to determine from the record the

gravity of the pneumothorax that seems to have caused this man’s death, or to

determine whether bilateral pneumothorax was overlooked, but the failure to

tolerate accidents during and soon after operation was entirely characteristic of

the seriously wounded, bled-out casualty who, in the first months of fighting in

the North African theater, was resuscitated by plasma but did not receive

adequate blood replacement.

The second patient, who was also desperately wounded, was resuscitated by
RESUSCITATION

2,250 cc. of blood plasma (9 units) and 3,000 cc. of whole blood. In addition, blood was used liberally during the postoperative period to overcome acute

anemia and promote wound healing. Penicillin, which had not been available when the first of these soldiers was treated, was also used freely. The tremendous measured blood loss in the second case emphasizes how dangerous it

would have been to attempt to prepare this man for operation by plasma alone.

The use of oxygen should also be noted.

As both of these histories indicate, the major problem of resuscitation of

badly wounded men in World War II had to do with the management of shock.

Shock is disability of the circulatory system that parallels, and is caused by,

loss of effective blood volume and hemoglobin. The major problem in all

combat areas was how best to overcome these losses, or, more correctly, how to

overcome them sufficiently to enable the patient to tolerate transportation to

the hospital nearest the frontline where surgical facilities were available and

where he could be prepared to withstand the surgery required by his special

injury. For all practical purposes, then, an account of the resuscitation of

wounded men in combat area is principally matter of blood-volume replacement. The history of resuscitation in the Mediterranean theater is epitomized

in the innovations made in blood-volume replacement therapy and in their

consequences.

The incidence of shock varied according to the echelon at which the patient

was seen. One study showed that about 2.5 percent of 2,853 wounded men

were in need of special resuscitative measures on their arrival at an evacuation

hospital in Italy, because surgical shock was established or impending. Two

thousand two hundred and ninety-six of these men were injured on the Anzio

beachhead, where, for tactical reasons, the evacuation hospital performed the

functions ordinarily performed by field hospital. Additional data supplied

by the 2d Auxiliary Surgical Group and extended by material from the Office

of the Surgeon, Mediterranean Theater of Operations, United States Army,

showed about percent of another group of wounded men to be in need of

special resuscitative measures on their arrival at field hospital. The incidence of shock on the level of the field hospital may therefore be assumed to

have been from to 2.5 percent.

GENERAL CONSIDERATIONS OF RESUSCITATION

The interval from the time the soldier was wounded until he had been

restored to sufficiently good condition for his wound to be repaired was the most

critical period he could undergo. In untreated patients, the balance during

this interval was swung toward life or toward death by the operation of natural

forces. The direction and extent of the swing could be influenced, in most

cases, by the character and the timing of the treatment given the wounded man.

As has already been intimated, the first concern of those who had the care

Beecher, H.; and Burnett, C.: Field Experience in the Use of Blood and Blood Substitutes (Plasma, Albumin)

in Seriously Wounded Men. M. Bull. North African Theater of Operations 2-7, July 1944.
GENERAL SURGERY

of freshly wounded man during this period was to do what was necessary to

enable him to withstand transportation to hospital. Their next concern was

to prepare him to withstand the stress of emergency surgery. Everything

else, even the question of his ultimate survival, was secondary to these immediate considerations.

The consequences of all wounds were cumulative. Pain often made rest

impossible. Exhaustion was increased by emotional factors. Dehydration,

which often was present before wounding, was increased by unusual fluid losses

in sweat and vomitus, as well as by continuing hemorrhage and loss of plasma,

with consequent reduction of hemoglobin and blood volume. If treatment

was delayed, infection developed. These and other undesirable consequences

were set in operation by the initial wound, and they continued unabated in the

seriously wounded man until they were checked by surgery or interrupted by

death. Resuscitative measures halted these effects temporarily, but such

measures were merely palliative. Real relief from the grave consequences of

the wound inflicted by enemy action could be accomplished only by surgery.

After the wounded man had been received in forward hospital, it is true that

preparation for surgery was the immediate goal of resuscitation; but it was

not an end in itself. In the broad general sense (p. 18) surgery was itself an

essential phase of resuscitation.

These were not academic considerations. Any other concept of surgery

would have led to an unfortunate separation between the activities of shock

teams and surgical teams. The care of the wounded man had to be continuous, and his supervision had to be uninterrupted. Neither activity could be separated into compartments. The recognition of the essential unity of resuscitation and operation, though it was somewhat late in coming, was an important

surgical advance in World War II.

That the operation itself should be an integral part of the resuscitative

procedure was perfectly logical concept. When internal hemorrhage persisted, for instance, there could be no resuscitation without surgery, and it was

wasteful of both time and blood to attempt to raise the patient’s blood pressure

to normal before operation. The blood or plasma which was administered merely leaked into the traumatized regions and was wasted, while at the same

time the patient was submitted to the hazard of an unnecessary number of

transfusions. Surgery, with control of the hemorrhage, was the simplest and

most effective way of accomplishing full resuscitation in such case. Similarly, when extensive fecal contamination of the peritoneal cavity had occurred, or

when leakage into or possible absorption from large areas of devitalized tissue

was taking place, the shock and toxic manifestations which ensued could be terminated only by control of the causative factors at the source.

The best method of management in all such cases was to resort to surgery

as soon as the patient had been brought to the desired stage of resuscitation (p. 18) and to continue resuscitative measures during the operation. This

was the cardinal principle which, by process of evolution, was finally worked

out for the management of battle casualties during World War II. It does
RESUSCITATION

not seem to have been emphasized or practiced to any considerable degree

during World War I.

Differences in medical organization, evacuation policies, technical and

human resources, and even the denotations and connotations of medical terminology differed so greatly in World War and World War II that comparisons

are, in general, neither useful nor valid. The following comparative data are, however, presented because the organization and mission of the 127th Field

Hospital, which served in France in 1918, seem reasonably comparable to the

organization and mission of the 33d Field Hospital, which served in the Mediterranean theater in 1943:

Over 7-day period in 1918, the 127th Field Hospital admitted 256

wounded casualties, 41 of whom died before operation and 34 after operation.

The total case fatality rate was thus 29.3 percent and the surgical case fatality

rate 15.8 percent. Over 30-day period in 1943, the 33d Field Hospital admitted 297 wounded men, all of whom underwent operation, with 56 deaths. The total case fatality rate, which was entirely surgical, was thus 18.9 percent.

These figures, while perhaps not precisely comparable from statistical point of view, illustrate very clearly the difference in concepts of management

of severely wounded men in World War and World War II. The significant

point of the comparison is that, in 1918, 41 of 256 wounded soldiers (16 percent)

died without operation, probably because they were never regarded as fit

subjects for surgery, while in 1943, every one of 297 freshly wounded men was

resuscitated and given his chance of survival through surgical intervention.

The key to the difference is, of course, the emphasis placed upon preoperative

resuscitation in World War II and the lesser emphasis placed upon this phase

of medical care in World War I.

The problems of resuscitative therapy in World War II were greatly simplified once there was general acceptance of the concept that the cause of

the deterioration of the status of seriously wounded man was reduction

in the circulating blood volume because of loss of blood. Still further simplification occurred when the additional concept won general acceptance that,

except for processes leading to dehydration, fluid loss from the circulation could

be explained by loss at the site of injury alone. When profound anoxia was

present, there was also some loss because of the general increase in capillary

permeability associated with this condition.

The studies upon which these concepts were based showed in useful

and practical way the almost quantitative relationship between the blood loss

after wounding and the degree of shock. This relationship had long been

recognized, but it had lacked substantial proof up to this time. The proof

was needed to outride the storms which arise again and again from suggestions

The Medical Department of the United States Army in the World War. Washington; U. S. Government Printing

Office, 1927, vol. XI, pt. I, pp. 109-110.

Annual Report, Medical Section, North African Theater of Operations, U. S. Army, 1943.

Medical Department, United States Army, Surgery in World War II. The Physiologic Effects of Wounds. Washington; U. S. Government Printing Office, 1952.
GENERAL SURGERY

that the cause of shock is mysterious and is to be explained by toxins or by the

breakdown of some vague but vital force.

This emphasis on the relationship between blood loss and shock, which

was one of the outstanding features of the management of the battle-incurred

injuries in World War II, did not in any way decrease the interest of medical

officers in the problems of shock which remained to be solved. It also did not

lead to any miderestimation of the complexity of the mechanisms involved in

the production of shock. It did, however, simplify the application of effective therapy, the chief component of which, as all the experience showed, was

the prompt administration of blood in the quantities in which the individual

wounded man required it.

All the available evidence pointed to blood loss, with the corresponding

reduction of the circulating blood volume, as the explanation of the poor general

condition of seriously wounded men when they were first seen in forward

hospitals. All the evidence also pointed to the correction of these losses by

replacement of the lost blood as the only method of improving the condition

of these injured men and rendering them fit for surgery. The treatment of

the local wound and the relief of pain and of mental distress were important,

but not in comparison with the replacement of the lost blood. Furthermore,

the more rapidly the losses could be corrected up to the point at which the

deterioration of the man’s condition could be checked, the better for him. These facts were demonstrated in every preoperative ward and every operating

room from the beginning of the fighting in North Africa to the end of the fighting in Germany.

The stress of surgery for battle injuries.—The chief reason for the resuscitation of the freshly wounded soldier was to correct his impaired status.

An additional reason was to prepare him for the strain to be imposed upon

him by the operative procedure necessary to repair his injuries. How severe

that strain was likely to be is suggested by the following data concerning the

duration of typical operations, for the most part performed on the Anzio

beachhead. The single large hospital area on the beachhead was near, and

often in the midst of, the area of active combat. Many of the wounded were

injured in the actual hospital area, and others on the adjacent road, which

came to be known as Purple Heart Highway.

The duration (exclusive of the time occupied in the induction of anesthesia)

of 130 typical major operations, chiefly performed in this hospital area, was as

follows:

For 20 craniotomies in which the dura was opened, 109±11 minutes.

For 10 laminectomies, 122 ±7 minutes.

For 20 thoracotomies, 148 ±14 minutes.

For 20 laparotomies, 117±12 minutes.

For 20 vascular operations on the extremities involving ligation of the

large vessels, 62±5 minutes.

For 20 operations for compound fractures of the femur, including the

application of the spica, 83 minutes.
RESUSCITATION

For 20 guillotine amputations of the femur, 69 ±7 minutes.

These data are for consecutive, unselected cases. The operations were

done by number of different surgeons, all of whom were able and experienced.

In spite of that fact, only wounds of the extremities could be handled surgically

in approximately an hour. Operations on the head, chest, or abdomen without

exception required about hours or more. These operating times were typical

of the experience in all forward areas. They do not differ materially from the

operating times for similar operations in civil life. The strain of surgery of

such magnitude, carried out over such long periods of time, could not have

been withstood if the patients had not been adequately prepared in the shock

tent to tolerate prolonged surgical stress.

At the beginning of World War II, it was the general impression that

major surgical procedures in time of war seldom occupy more than an hour.

Possibly this impression arose from the experience in World War I, in which

operations on the extremities constituted much higher proportion of the

total operations than they did in World War II. As the figures cited show,

this was not the experience in World War II, and these data symbolize the

revolution in surgical thinking and progress which occurred between the world

wars.

CHAIN OF EVACUATION

Since the status of wounded man was influenced by the methods employed

to remove him from the battlefield and transport him to field hospital where

he could be treated, brief outline of the chain of evacuation is necessary in

discussion of resuscitation.

Resuscitation began at the battalion aid station, which was ordinarily

located about 500 yards behind the line of combat, and which was reached,

depending upon the wounded man’s condition, by foot or by litter carry. Here,

as well as in the collecting and clearing stations farther to the rear, the main

objective of treatment was to make the wounded man transportable and to

refrain from any procedure which would make him nontransportable. Therapy

was therefore limited to such simple but essential measures as the control of

hemorrhage; the application of splints and bandages, and of tourniquets

if they were necessary (p. 35); the closure of sucking chest wounds; and the

administration of plasma and morphine according to the indications of the

special case.

Collecting stations, which were located about mile beyond the battalion

aid stations, were reached on foot, by litter carry, or by ambulance. As in

aid stations, treatment was limited to what was absolutely essential. At

times nothing more than inspection was required.

The division clearing station, which could care for approximately 100-150

patients at one time, was usually about miles behind the collecting station.

It was reached by ambulance. Here the patient’s status was carefully apThe Medical Department of the United States Army in the World War. Washington: U. S. GovernmentPrinting

Office, 1927, vol. XI, pt. I, p. 5.

378327°—56
10 GENERAL SURGERY

praised, and it was decided whether he could withstand the additional journey

of several miles to the evacuation hospital, where necessary surgery could be

performed, or should be taken at once to the field hospital for emergency

surgery. The field hospital, which consisted of three platoons, with capacity

of 100 beds per platoon, was located adjacent to the division clearing station.

It was staffed and equipped for major emergency surgery, and, equally important, for the care of patients for maximum of 12 days after operation.

The patient’s condition chiefly determined whether he should be removed

to field hospital for immediate surgery or transported farther to the rear for

surgery later, but many other factors influenced the decision at the clearing

station. It was necessary to take into considerationwhether the road connecting

the clearing station with the evacuation hospital was long or short, good or

bad, and easy or difficult to traverse during blackout. Conditions in the field

hospital were also consideration. This type of installation was invaluable

when the nature of the injury or the status of the soldier contraindicated

additional transportation, or when, for any reason, the time factor was important. The staff was usually competent, especially when teams from an

auxiliary surgical group were assigned to supplement the regular staff. On the

other hand, this type of hospital was frankly set up to handle emergency

surgery. Because the medical staff was small, resuscitation was sometimes

less rapid than in an evacuation hospital. Equipment was relatively limited,

and the environment for postoperative care had some undesirable features.

The field hospital was always far forward—near, or sometimes in front of,

heavy artillery positions. Incessant cannonading made it difficult for the

patient to get the rest he needed after operation, and limitations of personnel

sometimes made postoperative care difficult, particularly during periods of

heavy military action.

The patient operated on in field hospital was eventually moved to the

rear. Whenever possible, he was returned to duty directly from an army

hospital. If this was not practical, he was moved, as soon as his condition

permitted, from the evacuation hospital to station or general hospital.

These were fixed installations, equipped and staffed for the performance of

reparative operations designed to hasten healing, prevent irreparable damage

or deformity, and expedite the wounded man’s return to military duty. Resuscitation was seldom an essential phase of treatment in these fixed hospitals.

PREOPERATIYE (SHOCK) WARDS

In the course of World War II, numerous arrangements were tried out for

the efficient management of wounded men to be prepared for surgery in forward

installations. Some plans were unsatisfactory in their conception. Others were

cumbersome and impractical. Experience eventually showed that, while

details varied materially from one installation to another, some arrangement

such as the following was the most generally satisfactory:

1. Shock wards or tents were set up, and all casualties in shock were
RESUSCITATION 11

admitted to them, whether or not it was thought that they would require

surgery.

2. Each shock ward was in charge of single medical officer, who remained

in the position for matter of weeks, at least. Quick rotation of personnel

merely promoted inefficiency.

In field hospital the officer in charge of the shock ward was preferably

chosen from the internists or junior surgeons on the staff. This was not

position for an inexperienced man, but the prolonged assignment of an experienced surgeon was also not wise; it inevitably led to discontent on his part and,

eventually, to poor care of casualties. An assistant shock officer was trained

to cover half of the 24-hour period, and at least nurse or aidman, or

preferably both, were on duty at all times to assist the officer in charge. Twelvehour periods of duty were not too taxing, even during times of action,

but longer assignments invariably led, within or days, to inadequate performance during rush periods.

In the evacuation hospital, single medical officer was in charge of the

shock ward, but an assistant was on duty with him at all times. The situation

in this type of hospital differed from that in field hospital. In field hospital,

all patients admitted were in need ofresuscitation, but their number was limited.

In an evacuation hospital, the incidence of shock was much lower, but the

number of patients admitted during heavy drives made it necessary for two

officers to be on duty continuously. Two additional officers were required to

relieve these officers for half of the 24-hour period. At least aidmen and

nurses were on duty at all times during rush periods. One of the officers on

duty in the shock ward directed the flow of patients through it to the operating

room, separating the patients who were in poor condition and in need ofresuscitation from the others. The other officer directed resuscitative measures.

It is difficult to overestimate the importance of the function of the officer

in charge of the shock ward. Toward the end of the war, some of the most

experienced surgeons overseas took over the duty of its supervision.

3. The shock ward, when properly set up and administered, was good

deal more than valve to regulate the flow of patients into the operating

room, though this was common and serious misconception of its function.

Individual evaluation was necessary in every case. It was never possible to

set up, on mechanical basis, relation between the optimum time for surgery and the number of casualties awaiting treatment, although such relationship was inherent in the metered-flow point of view which there was

sometimes temptation to adopt.

4. The preoperative ward functioned satisfactorily only when the chief

of the surgical service made frequent visits to it. It was part of his function,

in collaboration with the shock officer, to set up priorities of operating time.

As soon as possible, all patients awaiting surgery were assigned to specific surgical teams, and thereafter, as far as possible, the surgeon into whose charge

the patient had been committed shared in all decisions concerning him, including decisions involving preparation for operation.
12 GENERAL SURGERY

The plan just outlined insured continuity of attention for the wounded man,

which was an integral part of good surgical care. Any system would have

been fundamentally had which allowed one group—the personnel of the shock

ward—to carry patient so far and no farther, after which his care was assumed by an entirely new group- the surgical team—whose personnel were

completely unfamiliar with the man’s previous status and therapy.

SHOCK: PREDISPOSING AND PRECIPITATING FACTORS

The treatment given wounded men in battalion aid stations, collecting

companies, and clearing stations was generally good and often lifesaving. On

the other hand, erroneous and inadequate therapy sometimes accounted for

the poor condition of the patients when they arrived at forward hospitals.

Among the common faults were overmedication, chiefly in the form of an excessive use of morphine (p. 41); the administration of too much plasma, or,

less often, of too little plasma (p. 22); failure to recognize and close an open

pneumothorax, or its inadequate closure; inadequate measures to control serious hemorrhage; transportation of wounded men with head injuries and

injuries of the pharynx in the dorsal instead of the prone position and failure

to protect casualties properly during transportation. Under the last heading

are included wide variety of errors and omissions, ranging from careless

splinting of broken bones to inadequate use of blankets, especially failure to

place blankets under, as well as over, the patients in cold weather.

The pathologic processes set in motion when wounding occurred were

basically responsible for the poor condition in which many wounded men arrived at forward hospitals. External circumstances, however, increased the

number of those in precarious condition and in many instances precipitated,

as well as aggravated, shock. The most important of these circumstances

were exposure, incorrect treatment in forward areas, and delay in evacuation.

Exposure.—North Africa, Sicily, and Italy provided wide variety of

geographic and climatic conditions, including desert heat and mountain cold,

high and low altitudes, and dry terrain and marshy land. It was over this

terrain, some of which is among the most difficult in the world, that fighting

was conducted by means of amphibious landings, isolated beachheads, rapid

advances, and prolonged holding operations. Exposure under these conditions

of combat was inevitable. Sometimes it led to heat exhaustion and sometimes

to cold injury. It was usually associated with inadequate intake of food and

fluid, and often with lack of rest.

Timelag.—The effect of delay on the wounded man’s condition and the favorable influence of brief lapse of time from wounding until operation were

naturally appreciated from the beginning of the fighting in North Africa in

November 1942. It was not, however, until the Italian phase of the war that it came to be generally realized that too much time was being lost before surgery, and that patients were being handled far too much, because of strict

adherence to the formula of delays for inspection purposes along the line of
RESUSCITATION 13

evacuation. These delays were defeating the efforts of the medical personnel,

which were directed toward single aim, that of presenting to the surgeon

patient who was as favorable as possible an operative risk.

As the plan of evacuation was set up, the patient was removed from the

ambulance or inspected on the litter at each stop. Almost inevitably, the

medical personnel attached to the special installation felt it incumbent on them

to do something to him. This was to be expected. Because of shortages of

experienced physicians, division clearing and collecting stations were necessarily manned by young men whose judgment had not yet been formed by

experience, and who, in their eagerness to do their full duty, did not always

distinguish between what was essential and what was superfluous. The timelag was materially lengthened by these practices. When the men were critically injured, that fact was usually apparent. Additional inspections were

not necessary to establish it. It was to the patients’ best interest that the}"

be handled as little as possible and be taken at once to the nearest hospital in

which essential surgery could be carried out.

Possibly some patients with extremity wounds would have profited from

being held at forward installations for an hour or two, but to teach corpsmen

and inexperienced young doctors to identify those who would be helped by

delay was simply not possible. The selection of the wrong patients for delay

could be disastrous. Medical officers who did frontline work repeatedly stated

that they had never seen patient lose his life because he was evacuated too

promptly, but all could recall instances in which lives had been lost because

evacuation was too slow. This was sometimes unavoidable, but sometimes it

was attributable to the cumbersome and time-consuming routine which had

to be followed.

While reduction in the timelag from wounding to surgery was not the only

factor in the reduction of morbidity and mortality, it was an important consideration. It influenced the salvage of extremities. It lessened deformity.

It shortened convalescence. Sometimes it altered the outcome. The solution

of the problem would have been the elimination of one or more stops along the

line of evacuation, and it was repeatedly suggested that the system in use,

which did not permit such bypassing, should be critically reviewed and modified

in the light of experience. This did not happen. The system instituted at

the beginning of the war remained essentially unaltered to the end.

In addition to the lowering of the patient’s reserves by the delays on the

battlefield and along the evacuation chain, rough handling was sometimes

unavoidable in difficult litter transportation down mountain trails and in

prolonged ambulance hauls over rough roads. These additional stresses,

whether they were avoidable or unavoidable, could precipitate shock or increase it if it already existed.

APPRAISAL OF THE WOUNDED MAN

Although certain routine of resuscitation was carried out in all shock

wards, resuscitative measures were always applied on the basis of individual
14 GENERAL SURGERY

needs, after careful estimate (1) of the extent to which the casualty had

suffered from his wounds and (2) of the therapy needed to enable him to tolerate

immediate surgery in field hospital or to withstand transportation to hospital farther to the rear. Once he had reached the field or evacuation hospital,

his reaction to the rigors of his journey, as well as his response to the resuscitative measures employed, furnished essential information concerning the additional treatment required to fit him to tolerate whatever surgery might be

necessary. The first step was to rescue him from the state of shock in which

organic damage could occur as the result of inadequate circulation. The

next decision concerned the institution and timing of additional measures of

resuscitation and of the operation itself—the operation, as already emphasized,

being considered to be one phase of the resuscitative regimen.

The man’s clothing (fig. 1) was removed completely before examination

was undertaken or any resuscitative measures were instituted. Flagrant

errors could follow failure to observe .this’ elejpentary precaution. Its necessity

can be shown by single illustration. soldier accidently discharged his

own rifle, wounding..himself in the htjttock^, The bullet reached its destinaFigure 1.—Routine of early care of wounded man in forward hospital.

Removal of all clothing.
RESUSCITATION 15

tion only after it had passed between his scalp and the inside of his helmet and

then reversed its direction.

After the man’s clothing had been removed, the litter was checked to make

certain that blankets had been placed underneath him as well as over him. He

was then completely examined, and plan of management was drawn up.

Basically, all patients were placed in two categories:

1. The patient with slight wound, in good condition, was operated on

as soon as there was space for him in the operating room, with due regard to

the needs of those who were more seriously wounded.

2. The patient in poor condition was sent to the ward or tent set aside

for men in shock and was given over to the charge of the shock team.

Patients in the first category required little of no special preparation for

operation. For severely wounded patients in the second category, the preparation which they received for operation might make the difference between

survival and death.

Classification of shock.—For practical purposes, the seriously wounded

man was placed in of possible categories (table 1), depending upon the presence or absence of shock, and, if it were present, upon its degree. All of the

following statements refer to the average patient:

1. The patient not in shock had normal blood pressure and normal pulse.

The temperature and color of the skin were normal. The pressure test, which

showed prompt return of color to the skin, indicated the integrity of the circulation. The patient might be thirsty, but his thirst was not abnormal. His

mental state was clear, and he was capable of feeling depressed.

2. The patient in slight shock had blood pressure about 20 mm. Hg below

the normal level. The quality of the pulse was normal. The skin was cool.

Its color was pale. The response to the blanching test was somewhat delayed.

Thirst was not abnormal. The mental state was clear, but the patient was distressed.

3. The patient in moderate shock had 20-mm. to 40-mm. Hg depression

of blood pressure. The pulse volume was diminished. The skin was cool and

pale. The response to the blanching test was unmistakably slow. The patient

complained of thirst. His mental state was clear, but he was likely to be apathetic unless he was stimulated.

4. The patient in severe shock had greatly depressed blood pressure,

ranging from 40 mm. Hg below normal to an unrecordable level. The pulse was

weak or imperceptible. The response to the blanching test was greatly delayed.

The patient might complain bitterly of thirst, but otherwise he was apathetic

and comatose and seemed to suffer very little distress.

While all of the observations listed furnished useful diagnostic information,

the most important considerations in the appraisal of the status of freshly

wounded man were the trend of the pulse rate and the trend of the blood pressure. The trends were great deal more significant than the levels at any given

time. rising pulse and falling blood pressure nearly always indicated trouble
16 GENERAL SURGERY

Table 1.—Relationship of degree of shock and average blood loss in 67 patients with all types

of wounds

to come, especially if, in association withthese phenomena, the skin of the patient

who had been in comfortably warm room felt cool to the touch.

It was essential that resuscitation teams understand the practical implications of shock as dynamic and not static state. The whole wartime experience proved that patients in shock did not remain in the same condition for

any length of time. Their condition improved, or it deteriorated. This is why

trends were sounder guides to therapy than absolutes. When the systolic blood

pressure showed constant upward tendency and had reached level of 80 mm.

Hg, the pulse rate usually showed constant downward tendency, and the skin

was usually warm and of good color. The patient was ready for surgery when

these things occurred and could be operated on with safety long before the blood

volume or blood pressure had been restored to absolute normal.

It was seldom difficult to recognize in the preoperative tent the casualty

who was in poor condition. He seldom furnished any problem of identification.

He usually carried obvious hallmarks of his status. The real problem was to

identify the casualty whose condition, while still not critical, was deteriorating,

and to identify him early enough to check the adverse forces at work in him.

His prompt recognition was of benefit to him and also of benefit to his wounded

associates. It meant economy of care, of materials, and of nursing and medical

Degree of shock

Clinical observations

Average

blood loss (corrected

values in

round numbers, in per- centage of normal)

Blood pressure (approximate) Pulse

quality

Skin

temperature Skin color

Skin circu- lation (response to pressure,

blanching)

Thirst Mental state Bloodvolume

Hemoglobin

PercentPercent

None--. Normal Normal Normal. Normal Normal Normal. Clear and

distressed.

14 20

Slight Decreased 20

percent or

less.

do Cool Pale. Definite

slowing.

-_-do do 21 30

Moderate. Decreased 20

to 40

percent.

Definite

decrease

in volume.

-_-do ...do. __.do Definite. Clear and

some apathy unless

stimulated.

34 46

Severe Decreased 40

percent to

nonrccordable.

Weak to

imperceptible.

Cold.... Ashen to

cyanotic

(mottling).

Very

sluggish.

Severe.. Apathetic to

comatose;

little distress except thirst.

46 56

Source: Medical Department, United States Army, Surgery in World War II. The Physiologic Effects of Wounds.

Washington: U. S. GovernmentPrinting Office, 1952, pp. 28, 56.
RESUSCITATION 17

effort. Because these tilings were expended only where they were needed, more

rapid preparation of all wounded men for surgery was possible. This was

indispensable if intolerable congestion in the preoperative ward was to he

avoided. In the end, it meant the salvage of more lives. Experience repeatedly

proved that it was far simpler from every standpoint to prevent serious deterioration in the condition of wounded man than to rescue him from shock, once

he had slipped into it.

The selection of patients who required close observation was made on

clinical evidence: Their arms and legs were cool or cold. Their skin was pale.

When it was blanched by pressure, the return of color was considerably delayed.

The pulse was of rather small volume. The blood pressure might or might not be below normal levels. When it was below normal, resuscitative care was

urgently needed.

Additional useful diagnostic points were the appearance of the wound; its character and extent; the evidence of considerable blood loss, whether

internal or external; the evidence supplied by blood-soaked clothing; history

of exposure or exhaustion; and history of delay in evacuation. Thirst was

likely to be intense in the patient in critical condition; frequently it caused much

suffering.

Except for those with head wounds, severely wounded men who were not

in shock were usually clear mentally and often could give surprisingly accurate

accounts of the events of wounding. Later, there was likely to be considerable

amnesia for the early periods. In sample of 201 badly wounded men who were

not in shock when they arrived at field hospital on the Anzio beachhead, 200

were in possession of their faculties.

In World War I, the absolute pulse rate, sweating, nausea, and vomiting

were regarded as valuable signs and symptoms in the composite picture of shock. In World War II, they were not so regarded. Instead, they were

thought to be related to the character of the wound or to psychologic factors, or to be reactions to the administration of morphine. The actual pulse rate

could be influenced by too many factors to be of great value in itself in the

estimate of shock, but its quality and its upward or downward trend were both

most important. The degree of thirst and the patient’s mental status, to

neither of which much attention was paid in World War (or is paid in civilian

practice), were found to be extremely useful in the evaluation of the degree of

shock in World War II. One of the principles of resuscitation established in World War If was that

if operation could not be undertaken immediately, as it frequently could not be

when the flow of casualties was heavy and selection of cases had to be practiced,

it was not necessary to achieve improvement beyond rising blood pressure of

at least 80 mm. Hg and warm skin of good color. It was essential, however,

not to permit regression, though it was best to withhold further resuscitative

measures if the need for them was not evident. The patient who was merely

kept in the satisfactory status described was unlikely to lose as much hemo-
18 GENERAL SURGERY

globin if bleeding recurred as he would lose if plasma were given to raise the

blood pressure higher than was necessary during the waiting period.

Laboratory data.—Laboratory data which could be secured in the field

during the first hours after wounding were limited and were likely to be misleading. Estimates of the hemoglobin, hematocrit, and plasma-protein values

showed little change immediately after wounding, when blood dilution had not

yet taken place, though the information was of great usefulness in evaluating

the needs of the wounded man during the postoperative period. Determination

of the blood-volume level would have been of real assistance immediately after

wounding, but the methods available for making this determination in World

War II were too time consuming to justify their routine use in frontline

hospital. For these reasons, the simple clinical symptoms and signs described

were used almost exclusively to gage the condition of the patient and the quantity of blood necessary to satisfy his individual need. If rightly interpreted,

they proved entirely adequate for the purpose.

STABILIZATION VERSUS RAPID PREPARATION OF BATTLE

CASUALTIES FOR SURGERY

Early in November 1943, at about the time the Volturno River was crossed

and the fighting below Venafro was heavy, new point of view began to appear

in the shock wards of the Fifth United States Army. In effect, it was that too

much urgency was being exercised in the preparation of the wounded for surgery.

At first, it was an entirely negative concept. After or months, and especially

during the prolonged fighting before Cassino in the early months of 1944, it came

to be expressed more positively that the wounded fared better when surgery

was delayed for what was vaguely termed equilibration or stabilization. Exactly

what was supposed to be accomplished by this period of delay was never clearty

defined. The patient was merely supposed to be better for it.

There was, of course, some logic in this point of view. There was no doubt

that seriously wounded man who had suffered period of exposure, who had

been bounced in speeding ambulance over rough roads for several hours, who

had had little rest, and who sometimes was in great pain because of the effect of

the trauma of transportation on his original wound frequently was the better

after period of rest. He was likely to arrive with rapid, weak pulse and low

blood pressure. After he had rested for 10 or 15 minutes, even if he had no other

treatment, he usually looked better, his pulse improved in quality, and his

blood pressure rose. These gains, however, were usually achieved in about

15 minutes.

The point of view of those who favored immediate operation and who

opposed delay after the patient had been brought out of shock and after the

downward trend of the blood pressure and the upward trend of the pulse had

been reversed could be stated about as follows;

wound sets in action several continuing processes. There is loss of blood.

See footnote 4, p. 7.
RESUSCITATION 19

There is loss of plasma from serous surfaces and into traumatized tissues. Contamination leads to infection, and infection is progressive. All of these processes

drain the resources of the seriously wounded man. They must be combated,

and he must be supported, by the use of blood and plasma. It is general

principle that in any given case the smallest amount of blood and plasma should

be used that is compatible with the patient’s well-being. If surgery is delayed,

larger quantities of these agents must be used to maintain him on an even keel

than would be necessary if operation were performed earlier. This is undesirable from many standpoints, including the practical consideration that in

World ar II both blood and plasma were often in limited supply in the early

part of the war.

On the basis of this reasoning, the advocates of early surgery contended

that delay to achieve stabilization of the patient was without merit. They also

based their reasoning on the analogy of perforated peptic idcer in civilian practice. In that catastrophe, peritoneal contamination occurs, and the mortality

rises sharply with the passage of time. Experience had shown that with the

grosser contamination encountered in battle-incurred wounds, rise in the case

fatality rate when surgery was delayed could also reasonably be expected.

deliberate test was undertaken in order to establish the proposition that

as prompt surgery as possible was best for the patient and that delay for the

sake of so-called stabilization did him no good and was often actually harmful.

The management of 2,853 wounded men who were injured at Cassino and on

the Anzio beachhead was conducted on the principle of operating as soon as

resuscitation had been accomplished. In every instance, the patient was taken

to the operating room as soon as the systolic blood pressure had reached 80 mm.

Hg and was tending upward, the pulse rate was consistently falling and the

quality of the pulse was improving, and the skin was warm and of good color.

If additional blood was considered necessary, it was given in the course of the

operation.

Comparison of the Anzio-Cassino experience in 1944 with experiences in

field and evacuation hospitals below Venafro and Mignano on the Cassino front

in November and December of 1943 established the soundness of speedy resuscitation and prompt operation. In 1943, resuscitation of the seriously wounded

to the point of operability often required to hours after the patients had

reached the hospital. In 1944, even patients who were extremely bad risks when

they were first seen were prepared for operation and submitted to surgery on an

average of hours and 20 minutes after wounding. The readier availability of

whole blood in 1944 naturally had much to do with the reduction in the timelag

as compared with 1943, but the change in the concept of the optimum time for

operation played the major role in the improvement.

When the experience in the hospitals employed at Anzio and Cassino was

compared with the theaterwide experience, other significant differences became

apparent: In the Anzio and Cassino hospitals, each patient received an average

of unit of plasma, against an average of units for the theater as whole, and

See footnote 1, p. 5.
20 GENERAL SURGERY

an average of 1,537 cc. of blood, against an average of 2,610 cc. for the theater as

whole. Transfusions averaged per patient in the Anzio and Cassino hospitals,

against per patient for the theater as whole. In other words, proper timing

ofresuscitation and surgery, in addition to cutting the time occupied by resuscitation in half, greatly reduced the amount of plasma and whole blood required

forresuscitation. These are not trifling considerations. In spite of the generous

provision of whole blood in the later part of World War II, it was always necessary to use it economically, and it will probably be necessary to use it even more

economically in all future wars. The key to its economical use, without hardship to the wounded man, lies in the correct timing ofresuscitation and surgery.

When the test of speedy resuscitation and prompt operation was undertaken in 1944, the concept was viewed with skepticism, and there was considerable discussion and disagreement before the conditions of the test were

set up. The results, however, were so good from every standpoint that the

concept of stabilization was gradually discarded and the concept of operation

at the earliest possible moment came to be accepted as satisfactory working principle. The time interval between wounding and operation was, on

the whole, materially reduced by its adoption, but until the end of the war

many medical officers felt that sufficient progress along these lines had not

yet been accomplished.

The concept of prompt operation required an understanding of what

could be achieved by resuscitative measures and what was impossible. The

aim was not the restoration of the shocked patient to normal status before

surgery was undertaken. That goal was unattainable. Those responsible for

resuscitation had to face the realities of the situation and to decide what was

desirable, what was possible, and wbat was impossible in the shocked patient.

One thing that was impossible was the repair, in matter of hours, of the

organic damage produced by even fairly brief periods of low blood pressure.

Many days would have been required for this in some cases. This amount

of time could not be granted, nor was it necessary to take it in man who

was organically sound before he was wounded. All that was necessary was

to make him safe for surgery. This was not always possible in patients with

continuing internal bleeding or wide contamination of the peritoneal cavity.

When resuscitative pleasures failed, in such cases, to produce their desired

effects, the surgeon was faced with the necessity of undertaking operation in

patient in poor condition. This was bold and critical decision, but many

lives were saved in World War II because it was made affirmatively.

An important reason for not delaying surgery after the seriously wounded

man had been brought out of shock was the readiness with which he could

slip back into it. For reasons not altogether clear, seriously wounded man

or man depleted by loss of blood could often be resuscitated to the point at

which ho was regarded as fit to tolerate the additional strain of surgery. If, however, operation were delayed and he were allowed to slip back into shock,

second resuscitation was always difficult, was often not as adequate as the

first, and was sometimes not possible at all. All military surgeons, no matter
RESUSCITATION 21

what their original point of view, eventually realized the importance of operating as soon as the patient had been brought to optimum status within

minimum period of time.

PLASMA

The difficulties experienced in resuscitation in the early fighting in Tunisia

in World War II were in large part directly attributable to the completely

mistaken concept, with which most surgeons entered the war, of the limits of

usefulness of human blood plasma. These matters are discussed in detail

elsewhere in this history, but no account of resuscitation in theSecond World

War would be complete without brief account of that concept and how it

was finally overturned.

The first recorded suggestion that plasma be used as substitute for

blood was made during World War by Capt. Gordon R. Ward in letter

to the editor of the British Medical Journal in 1918:

There is abundant clinical and experimental evidence that it is not the corpuscles that

are wanted, but the ideal fluid for keeping blood pressure at proper level. man

apparently dying from haemorrhage is not dying from lack of haemoglobin but from

draining away of fluid, resulting in devitalization and low blood pressure.

These remarks were followed by the eminently sensible suggestion that

trial of plasma should be undertaken and should be controlled by comparable

trial of transfusions of whole blood (and gum acacia). Plasma, however, did

not become available in World War I, and Ward’s suggestion seems never

to have been carried out. Presumably, it stemmed from the belief that the

methods of blood transfusion then available, with the hazards they involved,

offered such great obstacles to the widespread use of blood in the resuscitation

of battle casualties that the risks were not justified by the possible results.

The numerous studies made on plasma in the years between World War

and World War II are not pertinent to this brief account. The wartime

enthusiasm for this agent began in 1939, when Tatum, Elliott, and Nesset 10

recommended it as “an ideal substitute for whole blood in emergency treatment

of shock and hemorrhage from war wounds.” Their recommendation was

echoed by numerous other observers in the subsequent months. The result,

as DeBakey and Carter 11 commented, was that sound clinical judgments were

pushed aside and the misconception became widespread that plasma was

complete and effective substitute for whole blood in the management of shock

in the seriously wounded. This misconception, they continued, became so

firmly entrenched in the minds of both administrative and professional personnel that it handicapped the organization and development of more effective

measures for the management of shock.

With increasing experience in the management of shock in the fighting in

See footnote 4,p. 7. Ward, G.: Transfusion of Plasma (correspondence). Brit. M. J. 1: 301, March 1918.

10 Tatum, W. L.; Elliott, J.; and Nesset, N.: Techniquefor the Preparation of Substitute forWhole Blood Adaptable for Use During War Conditions. .Mil. Surgeon 85: 481-489, December 1939.

11 DeBakey, M. E.; and Carter, B. N.: Current Considerations of War Surgery. Ann. Surg. 121:545-563, May 1945.
22 GENERAL SURGERY

North Africa, it became increasingly evident that plasma was by no means the

physiologic substitute for whole blood which it had originally been believed to

be. It was useful for bringing the wounded man out of shock and maintaining

his blood volume during the period of transportation and immediately after

his admission to the hospital, before blood transfusion could be started,

but its effects were transient. Moreover, it created completely false sense of

security, particularly if the surgeon in charge was of limited experience in

combat surgery. Superficially, the patient to whom plasma had been administered might seem fully prepared for surgery. Actually, he was ill prepared.

Often he could not tolerate movement, let alone anesthesia and otherprocedures

which were part of the preparation for surgery. Their mere institution often

caused him to fall back into shock. If operation were proceeded with under

the circumstances, the result could be disastrous. In short, the early experience

with plasma made it clear that whole blood was the only therapeutic agent

which would prepare seriously wounded men for the surgery essential for the

saving of life and limb.

The course of events might have been expected. Since plasma contains

no hemoglobin, there was never any logical reason for believing that it would

be satisfactory substitute for blood in wounded man who had lost great

deal of blood, as most seriously wounded men had. The use of plasma in these

circumstances could be actually dangerous. The patient in poor condition

because of blood loss, with low blood volume and possibly low hematocrit,

could be placed in jeopardy if his blood (and effective vascular) volume was

increased by plasma while his hemoglobin remained deficient. The blood

volume might have been restored, but the meager quantity of hemoglobin

available in the blood stream would have been correspondingly diluted and,

within brief time, would be further decreased because of the leakage permitted

by restoration of the blood pressure. Many times in the early part of the

Tunisian campaign, before the deficiencies of plasma for resuscitation were

fully realized, small additional loss of hemoglobin from renewed bleeding or in

the course of operation was sufficiently critical to be disastrous. The patient’s

specious appearance of well-being promptly disappeared, and it became evident

that, though he was apparently well prepared, he was completely unfitted to

withstand the stress of anesthesia and surgery.

Although the misconceptions and errors that attended the early use of

plasma in World War II are now widely recognized, they should not be permitted to obscure the remarkable value of this substance as lifesaving agent.

All through the war, it superbly fulfilled the role of supporting life until transportation could be accomplished to an installation at which whole-blood transfusion was feasible, as was not usually the case in battalion aid stations or

division collecting or clearing stations near the frontline (fig. 2). By temporarily sustaining seriously falling blood pressure and increasing cardiac

output, it kept the patient alive long enough for more effective measures to be

taken. When this concept of the possibilities and limitations of plasma

became general and the stopgap character of plasma therapy was realized,
RESUSCITATION 23

Figure 2.—Sicilian women and children watch from doorway as blood plasma is administered to an American infantryman wounded by shrapnel in 1943. (U. S. Army

photograph.)

the concept of resuscitation was correspondingly altered, and whole blood came

to occupy its proper place as an agent of primary importance in the preparation

of seriously wounded men for surgery.

It was not always easy to determine in forward installation how much

plasma seriously wounded man needed and could safely be given. The

initial dose, as rule, was 500 cc. (2 units), and it was seldom necessary to give

more than 1,000 cc. (4 units) during the or hours which usually elapsed

before his admission to the field hospital. The objective was to give only

enough plasma to raise the systolic blood pressure to about 80 mm. Hg and to

keep the skin warm and the color good. The casualty did not suffer further

deterioration when the blood pressure was at this level, nor did he sustain the

needless and harmful loss of hemoglobin which might occur as consequence

of bleeding when the pressure was elevated more than was necessary to keep

him out of shock. After he had reached field or evacuation hospital, preparation for operation, as general rule, required about additional unit of plasma

to units of whole blood.

Burns.—Although plasma, in time, ceased to occupy the dominant place it
24 GENERAL SURGERY

originally occupied in the preparation of wounded men for surgery, all through

the war it formed part of the definitive therapy of burns. It compensated,

indeed, for the chief deficit in that injury, since plasma is the fraction of the

blood which is lost. Various rules were made for the quantities to be used,

but the most common and most useful was that units of plasma should be

given in the first 24 hours of injury for each 10 percent of body surface burned,

and that this regimen should be continued until hemoconcentration had been

corrected. When laboratory examinations could be made, the rule was to give

100 cc. of plasma for each point the hematocrit was above the normal level of

45. If plasma-protein values were low, the quantity of plasma calculated to

be necessary was increased by 25 percent for every gram below the 6-gm.

percent level. Economies were effected in the treatment of burns, if the required quantity of plasma could be administered over the whole 24-hour period

rather than in the space of few hours, since, if more plasma than was needed

was given at any one time, it was probably lost from the circulation.

In the management of burns, it had to be remembered that secondary

shock might occur after the initial injury. This meant that anemia might be

secondary development in these cases and might require treatment with

transfusions of whole blood.

WHOLE BLOOD

The shifting emphasis in the use of plasma and whole blood is evident in

certain statistics from the Mediterranean Theater of Operations for 1943-45:

During the campaign in Tunisia, between February and 31 March 1943,

972 casualties from the II Corps (34.3 percent of all wounded men requiring

plasma) received an average of 320 units per thousand wounded.

Between 21 January and 28 February 1943, 101 of 431 seriously wounded

II Corps casualties received plasma, the total quantity not being stated, and

31 also received blood transfusions.

In March 1943, 561 patients were given 97 transfusions in preparation for

741 operations in field hospital.

In March 1943, at the 9th Evacuation Hospital, during the Tunisian campaign, 1,146 casualties were given 17 blood transfusions, 1:67.4 In April,

1,588 casualties received 54 transfusions, 1:29.4. In May, 397 casualties

received 27 transfusions, 1:14.7.

During the first hundred days of the Italian campaign, which began

September 1943, the ratio of transfusions to battle casualties was 1:4.5. In

January 1944, the ratio in all Fifth United States Army hospitals was 1:2.4.

In March, month after blood bank had been established in the base area,

the ratio was 1:1.9.

Between September 1944 and May 1945, 122 casualties in Fifth United

States Army forward hospitals received, before operation, an average of 3.8

units of plasma per man, and 10received, during operation, an average of 1.68

units per man. One hundred and twenty-seven patients received on the
RESUSCITATION 25

average, before operation, 1,450 cc. of whole blood, and ninety-five received, during operation, an average of 1,160 cc. of whole blood. In other words, these patients, in contrast to those treated in Tunisia in 1943, received from the time of wounding to the end of operation an average of transfusions of whole blood and an average of to units ofplasma per man.

The use of blood and plasma varied, of course, among hospitals and casualties. During the first hundred days of the Italian campaign, the field hospitals of the Fifth United States Army, which cared for only one-thirteenth of the

total number of battle casualties, used one-third of the available blood. Disproportionately large amounts were also required by individual severely

wounded men. The establishment of the base blood bank early in 1944 made

it possible, when necessary, to give as much as several liters of blood over

brief period of time to single severely wounded man.

Blood was available in large quantities before the theater blood transfusion

unit began to function. It was secured from local blood banks, from emergency donors, and on loan from the British. There was no comparison, however, between the convenience and safety of transfusion from the base blood

bank and from these sources. These arc not matters which can be easily

shown in statistics or graphs.

Indications for blood replacement.—It has already been pointed out (p. 17)

that the most helpful guides to the need for blood replacement were secured by

simple clinical observation. To reiterate, they included the presence of bloodsoaked clothing; the location and extent of the wound; the timolag since wounding; the rate and quality of the pulse, with particular emphasis on the trend; the

level of the blood pressure, with particular emphasis on the trend; the state of

the peripheral circulation, as indicated by the temperature of the skin and the

speed of the response to blanching by pressure; the color of the mucous membranes; and the complaint (or lack of complaint) of thirst.

The paradoxical situation that the blood pressure might sometimes be

normal when the patient was seriously depleted of blood led some physiologists

remote from the battlefront to disparage the level of the blood pressure, even

when it was low, as useful sign in determining the need for blood. This was

not safe attitude, though, as has been pointed out, the upward or downward

direction of the blood pressure, coupled with the quality of the pulse and its

upward or downward swing, was far more useful than reliance upon arbitrary

levels of pressure or pulse rate.

Quantitative blood replacement.—Studies made on the Anzio beachhead 12

may be taken as typical of the amounts of plasma and blood needed to prepare

seriously wounded casualties for surgery. In this area, the most seriously

wounded patients arrived at hospital installations about 4K hours after wounding, The average ambulance haul was about 10 miles, over good roads. The

comparatively short timelag justified deliberate appraisal of the patients, it

being scarcely likely that an additional delay of few minutes, added to the

12 See footnote 1, p. 5.

378327°—56
26 GENERAL SURGERY

delay already experienced, would do them any serious harm. On the other

hand, it had to be remembered that these men could not tolerate any extended

delay, since the wounds themselves, the necessary handling, and the ambulance

ride immediately preceding their entry into the hospital had probably reduced

their reserves to their lowest point.

About quarter of these most seriously wounded men studied in the Anzio

beachhead hospital entered with no measurable blood pressure. From the time

they were received in the hospital until definitive surgery was undertaken, an

average of unit of plasma (or albumin) and an average of 870 cc. of whole

blood were given to each man in preparation for operation. During operation,

about two-thirds of the patients received an additional 500 cc. of blood each,

and about one-third received an additional 1,000 cc. of blood each. The

quantities of blood administered by no means replaced the quantities lost; yet

these men were apparently well prepared for surgery. None of them died in

the course of operation. During the period of the investigation, the case

fatality rate in the hospital involved was 1.48 percent, which was extremely low

for surgery at this echelon. Finally, the surgeons who operated on these

patients were unanimous in their opinion that preparation for operation was

satisfactory.

All of the patients were prepared on the principles already outlined.

They were considered fit for surgery when the systolic blood pressure was 80

mm. Hg and tending upward, when the pulse volume was good and the rate

was tending downward, and when the skin was warm and the color good.

When these criteria had been met, operation was undertaken without further

delay. If additional blood was indicated, it was given in the course of the

procedure. The medical officers responsible for the preparation of these

patients considered that transfusion should be given on these principles for two

fundamental reasons:

1. Transfusion is potentially hazardous procedure, which should not be

employed any more often than is absolutely necessary.

2. Economy in the use of whole blood was obligatory, because it was often

in short or potentially short supply, particularly during periods of heavy action.

Certain other observers who did not share this point of view prepared

patients in serious condition with quantities of blood which averaged 1,000 cc.

more per man than these most seriously wounded men received at the Anzio

hospital. The results of excessive administration were equally as good as, but

no better than, the results accomplished in patients who had received smaller

quantities of blood.

Technique of administration.—Except in serious emergencies, all blood

given to wounded men was grouped and crossmatched with their own blood.

Although this was not always easy under combat conditions, it was seldom

impossible. The precautions obviously were necessary. Unless the greatest

care was taken in the use of blood, accidents could nullify its value and place

the patient in grave danger. Possibly, in the future, fuller information concerning low-titer blood may reduce the necessity for grouping and cross-
RESUSCITATION 27

matching in the field, but, at the close of World War II, these precautions were

still essential for the safe transfusion of whole blood.

After 1,000 to 1,500 cc. of non-type-specific blood had been given to

bled-out casualty, new sample of his blood was obtained for crossmatching.

This precaution was repeated after the administration of every additional liter.

The speed with which blood was administered depended entirely upon

how critical was the status of the man to whom it was being given, though certain general principles were also followed. If the patient’s condition was

considered to be desperate (that is, if the systolic blood pressure was below

60 mm. Hg), he was placed at once in the head-down position, with the foot

of the litter elevated about 12 inches (fig. 3). unit of plasma or albumin

was administered while transfusion of low-titer (iso-agglutinin titer of 64

or less) blood was prepared. Blood was always obtained at the first venipuncture for grouping and crossmatching in subsequent transfusions; but in

desperate cases time was not taken at the first transfusion for these precautions

and they were sometimes omitted at the second also.

The first blood was often forced in rapidly by the use of bulb from

blood-pressure apparatus attached to the air inlet of the blood flask. OcFigure 3.—Routine of early care of wounded man in forward hospital. Elevation of foot

of litter.
28 GENERAL SURGERY

casionally, second transfusion was also given by this technique. It was not

desirable method, for in careless hands it could, and did, cause fatalities from

air embolism. As soon as the blood pressure had begun to rise, the speed of

introduction of the blood was reduced, though the rate was promptly increased

if signs of improvement were not maintained.

In critically injured patients, to be certain that the blood would flow in

promptly, cannulas were introduced under direct vision after the vein had been

cut down on. In emergencies, two or more transfusions were run in simultaneously through different veins.

Subsequent transfusions were given more slowly. When the systolic

blood pressure had risen to 80 mm. Hg, the administration of 500 cc. over

30-minute to 60-minute period was usually adequate. The same rate was

adequate when the transfusion was given for prophylactic purposes, to guard

against fall of blood pressure which was probable or possible, but which

had not yet occurred.

Reactions.—The transfusion of blood is always complicated procedure

filled with opportunities for human error. These opportunities, naturally,

were greater in warfare than in civilian practice. As transfusions increased in

number and the volume of blood used also increased, additional strains were

placed on laboratory facilities and on personnel who dealt out the blood and

checked it against the blood of the recipient.

The rapid use of large quantities of non-type-specific blood also opened

the way to serious reactions, although their number, exclusive of those which

followed the use of clearly mismatched blood, was on the whole remarkably

low. Experiences in hundreds of hospitals with many thousands of transfusions showed that, with the proper precautions, the incidence of transfusion

reactions need not exceed percent. Reactions chiefly took the form of

transient malaise, chills, fever, and urticaria. All of them could usually be

traced to faulty preparation of the apparatus used. The chief errors were

inadequate cleaning of equipment and delay of more than hours in sterilization after cleaning. Fatal reactions were almost entirely attributable to

urinary depression and uremia, apparently associated with renal damage

arising from the deposition of free hemoglobin in the kidneys.

Blood transfusions in fixed hospitals.—Blood transfusions fulfilled the

greatest need and had their greatest usefulness in forward (field and evacuation)

hospitals, but they also had wide field of usefulness in station and general

hospitals, where reparative surgery was done. Many operations in these

installations were major undertakings. An operation on compound fracture,

for instance, might require inspection of the fracture site, removal of bone

fragments, and internal fixation of the fracture. Often fractures were multiple, as were the procedures undertaken to correct them. These and other

operations were therefore often attended by considerable blood loss, with

resulting depression of the hemoglobin and hematocrit.

Experience in civilian surgery before World War II had demonstrated

the importance of liberal blood transfusions in preparing the patient with
RESUSCITATION 29

chronic sepsis for operation. In station and general hospitals, transfusions

on this indication were fully as important as they were in civilian practice.

Finally, in spite of the liberal use of whole blood in the army area, many

of the wounded, after undergoing initial wound surgery, arrived at general

hospitals with profound reductions in hemoglobin and hematocrit values.

In time, under the influence of an adequate diet supplemented by iron therapy,

this type of anemia would undoubtedly have undergone spontaneous correction. Time, however, was lacking. There were number of reasons in

every case for getting ahead with the surgical program as promptly as possible,

in addition to the general reason that the bed space was likely to be needed

shortly for another wounded man. The sooner secondary surgery was done,

the less likely was infection to occur or become established. The timelag

between initial and reparative surgery was very important period in wound

management, sometimes equal in importance to the period between injury

and initial surgery. Early closure of gaping wound was imperative, if for

no other reason than to prevent bacterial seeding of the raw surface during

repeated dressings. It was also important to repair large defects by suture

before fibroplasia stiffened the tissues and made approximation impossible

without dead spaces.

For these various reasons, an extensive program of blood transfusion

was developed in fixed hospitals. As result, patients with low hemoglobin

and hematocrit values were able to withstand secondary surgery promptly,

while full advantage was taken of any favorable effect that the correction

of anemia might have on the process of wound healing.

ALBUMIN

Albumin, like plasma, has the property of elevating low blood pressure.

This fraction of the blood exerts greater osmotic pressure than any of the

other plasma proteins; 80 percent of the colloid osmotic pressure of normal

plasma is accounted for by the albumin fraction. These and other observations had been made in the laboratory, and clinical trials had been conducted

with albumin, before the United States entered World War II; and they

were continued in Zone of Interior hospitals during the early months of American participation.

On the surface, it appeared that albumin would be an ideal agent for

military use. As it was put up, it was ready for immediate administration,

no reconstitution being necessary. Its small bulk and ready availability made

it particularly attractive, in view of the limitations of space and weight which

military necessities imposed on the transportation of supplies. It was remarkably stable. It could be administered in third to half of the time required

for the administration of plasma. Finally, its administration was free from the

risk of such sequelae as hepatitis and other infections. These various advantages suggested that albumin would be particularly useful in forward

installations in combat zone.
30 GENERAL SURGERY

Certain disadvantages, however, had to be weighed against these advantages. Albumin is expensive in terms of the quantities of blood needed to

prepare it. It was known, before the outbreak of the war, that its effects were

likely to be transient. Since the albumin molecule is smaller than the molecule

of the globulins, albumin presumably leaks out of the blood stream more

rapidly. The antibodies naturally present in plasma are, of course, lost as

albumin is separated out of plasma, and it was not known positively during

World War II whether this loss was important. Finally, the use of undiluted

albumin was dangerous in dehydrated patients.

For an adequate evaluation of its effectiveness, albumin should have been

compared with plasma in controlled study of its influence on the cardiac

output and blood volume. This apparently had not been done in the various

studies carried out in civilian hospitals before World War II, and the combat

zone was not the place to pursue such an investigation. When, however,

this agent first became available in Italy, in 1944, it was investigated in the

first 200 patients in whom it was used, with the following results;

Blood-pressure determinations were made at 10-minute intervals in 61

men who had each received 25 gm. (1 unit) of albumin, and these values were

compared with similar determinations in 89 patients who had each received

unit of plasma. The spread of the initial blood pressures, which were all

below 80 mm. Hg, was comparable in both groups, as were the age, the nature

of the wounds, the state of hydration, and the general condition of the patients.

All observations could not be secured in all cases, but the available results were

as follows:

In 19 cases treated with plasma, in which the average initial blood pressure

was 49/21, the average pressure after unit of plasma had been given was

88/52 in 15 cases. In 16 cases, the average minimum time required to achieve

the maximum blood pressure was 19 minutes, while in cases the average

minimum time for the fall of blood pressure to begin was 29 minutes. In 40

cases treated with albumin, in which the average initial blood pressure was

47/22, the average pressure after unit of albumin had been given was 83/53. In 34 cases, the average minimum time required to achieve the maximum blood

pressure was 22 minutes, while in 19 cases the average minimum time for the

fall of blood pressure to begin was 33 minutes. Comparative studies in other

groups of cases in which the initial blood-pressure levels were higher gave

results of substantially the same order as these.

These data were supplemented by observations of the general condition,

skin temperature, and rate and quality of the pulse in the treated patients.

All these observations, like the data on the blood pressure, had to be secured

under the crude conditions of combat zone, but clinically they added up to

the conclusion that there was no demonstrable difference in the effects produced

by the administration of unit of albumin and unit of plasma, although

theoretically albumin was much more powerful agent.

Plasma also had certain clinical advantages over albumin. The water

in which it was administered was an asset in wounded man with tendency
RESUSCITATION 31

toward dehydration. Concentrated albumin, on the other hand, depends for

its effects on the withdrawal of fluid from the tissues into the blood stream;

it therefore produces tissue dehydration. In well-hydrated patient this was

not serious consideration. In dehydrated patient it was, and in such

cases albumin was administered in physiologic salt solution, usually in the

amount of units to the liter.

No severe untoward effects were observed from the use of albumin in the

200 patients studied. In cases, mild, transient urticaria was attributed to

its use, and transient moist rales were observed in another patient with

thoracic injury. Albumin was always used with caution in patients with

thoracic injuries, because of the possible risks of sudden increase in blood

volume.

The limited clinical trials carried out with albumin in the Mediterranean

Theater of Operations led to the conclusion that its chief advantages were its

small bulk and ready availability. These properties suggested that it might

be useful in battalion aid stations and other posts difficult of access in combat

area, as well as in submarines and ambulance planes and for airborne troops.

In other words, its usefulness seemed limited to places in which space and

weight were at premium. Whether it will be used for these purposes in

future war will depend upon the general principles by which military medical

supplies are selected.

OTHER FLUID REPLACEMENT THERAPY

Numerous discussions of fluid-replacement therapy during World War II

began with the injunction to give fluids by mouth if the wounded man would

tolerate them. Instructions exactly to the contrary would have been more

nearly in line with good medicomilitary practice. Fluids by mouth were

usually definitely contraindicated before operation, especially if, as was almost

always true, anesthesia was to be induced and operation performed within

matter of hours. An additional reason for withholding fluids during this

period, aside from the fact that the man might have gastric or intestinal

perforation, was the fact that after wounding the gastric emptying time was

always much longer than normal. Not infrequently, one observed the regurgitation of fluids and food which had been ingested as long as 10 hours earlier.

There were still other reasons for the restriction of oral fluids. They

often precipitated vomiting, especially in patients who were already nauseated

from the administration of morphine. Under these conditions, the net result

of the ingestion of fluids by mouth was often loss rather than gain.

Furthermore, it became increasingly clear as the war progressed that one

of the commonest preventable accidents on all surgical services was aspiration

of gastric contents into the lungs. Sometimes the accident was the result of

vomiting during anesthesia; very often it was the result of quiet aspiration, by

the deeply anesthetized patient, of gastric contents forced into the pharynx as

the result of surgical manipulations in the upper abdomen. However it
32 GENERAL SURGERY

occurred, this was always serious accident, and it could be fatal, especially if

it was not realized that it had happened and if no steps were taken to correct it.

As general rule, dehydration was not special problem in recently

wounded men in the Mediterranean theater, at least when the plan was followed

of operating on them as promptly as possible after resuscitation had been

accomplished. If man complained of thirst, allowing him to rinse his mouth

with water or suck moist sponge would keep him more comfortable. These

simple expedients kept the lips and mouth moist but introduced no fluid into

the gastrointestinal tract. In the occasional case in which dehydration was

sufficiently marked to require prompt correction, fluids were administered by

the parenteral route, chiefly the intravenous route, in the form of physiologic

salt solutions and dextrose solutions.

During periods of heavy action, when scores and even hundreds of wounded

men were sometimes awaiting surgery in single hospital, the maintenance of

an adequate fluid intake might become difficult problem because of the delay

in treatment. Patients without gastrointestinal injuries were sometimes given

fluids by mouth, with due regard to the time they were scheduled for operation.

Others were given subcutaneous injections of physiologic salt solution or intravenous infusions of 5-percent dextrose in similar solution. In no circumstances was more than single liter offluid given at single infusion or injection,

and the quantity administered was just sufficient to prevent dehydration.

At one period during the fighting on the Anzio beachhead, more than 300

patients were awaiting operation at the same time in one of the several hospitals

in the area. Almost the same situation prevailed in other hospitals. It would

have been difficult task to keep all of these patients properly hydrated and

otherwise cared for until their turns came for surgery. The situation was

relieved, and the necessity of fluid replacement eliminated, by shuttle of

evacuation planes to the large hospital base at Naples, 40 minutes away by air,

where there were facilities and personnel for prompt operation on all the

patients.

The use of physiologic salt solution and dextrose solution was limited to

the correction of dehydration. As blood substitutes, these solutions were

not effective, and they could be dangerous. The elevation in blood volume

and blood pressure which they accomplished was so transient as to be of little

value, because the fluid promptly leaked out of the blood stream. If they

were used in head injuries in large enough amounts to have significant effect

on the blood pressure, intracranial pressure might be seriously increased.

Finally, their use in patients suffering from pulmonary injuries or in patients

whose hearts were already subjected to stress might precipitate pulmonary

edema or increase it if it were already present.

OTHER RESUSCITATIYE MEASURES

Relief of pain.—The control of pain under field conditions is discussed

at length elsewhere in this volume (p. 46), but since it is part of resuscitation

general principles should bo restated here.
RESUSCITATION 33

Figure 4. Routine of early care of wounded man in forward hospital. Control of mental

and physical distress by sedation (barbiturate) and administration of morphine.

Severe pain in badly wounded men was found to be much less common

than it had previously been believed to be (p. 44). Excitement, fear, hysteria,

and the restlessness caused by hemorrhage did not require morphine. They

were best treated by small doses of barbiturate (fig. 4), such as Sodium Amytal

(sodium isoamylethylbarbiturate, p. 49). Many men reacted better to

cigarette and friendly reassurance than to narcotic drug.

Although the principle was not always followed in practice, the only

proper use of morphine was for the relief of severe pain. The ideal was to

employ the smallest dose which would be effective. Large dosages caused

nausea and vomiting and induced sweating, which led to undesirable losses

of fluid. Most dangerous of all the effects of morphine was depression of the

respiratory centers, which resulted in anoxia and was followed by an increase

in shock. It was not possible to standardize dosages, but only occasionally,

if at all, was dose as large as 30 mg. (gr. %) necessary or indicated. dose

of this size was never repeated for at least hours.

When small doses of morphine failed to relieve pain, the explanation was
34 GENERAL SURGERY

often poor absorption of the drug. The peripheral circulation of wounded

men with low blood pressure, particularly in cold weather, was often so sluggish

as to delay the absorption of any drug which had been administered subcutaneously or intramuscularly. When relief of pain was urgent, the intravenous

route was therefore the route of choice. Almost immediate relief could be

secured by the intravenous injection, over period of minute, of 10 mg.

(gr. %) of morphine, or of 15 mg, (gr. %) diluted in not more than 1.0 cc. of

sterile water.

Proper preparation of the freshly wounded patient for initial wound

surgery required not only that his pain be relieved but also that his psychologic

and emotional problems be regarded as real and treated with sympathetic

consideration (fig. 5). Understanding of these problems might, at the moment,

seem less important than prompt surgical action, but disregard of them could

leave psychologic and emotional scars which would be as harmful later in

life as the results of poor surgery.

Management of the local wound.—The local wound in the preoperative

period required little more than the control of hemorrhage and the application

of splints. Control of hemorrhage was accomplished, in the order of preferFigure —Routine of early care of wounded man in forward hospital. Spiritual care.
RESUSCITATION 35

ence, by ligation of the bleeding vessel, insertion of pressure pack, and the

application of tourniquet.

tourniquet was necessarily employed when traumatic amputation had

occurred or when limb was badly mangled and was attached to the body

by little more than shreds of tissue. It was applied just below the site of

election for amputation and was not removed until the extremity had been

severed.

When tourniquet was applied to limb in which there was possibility

of salvage, control of hemorrhage was frequently lifesaving, but the risk of

ischemia and serious nerve damage was always present. When tourniquet

was applied under these circumstances, it was always placed as low on the

limb as possible, and it was not loosened or removed except by medical

officer and not then until blood was already running into vein. The risks of

ignoring this precaution were first pointed out in the Mediterranean Theater

of Operations, where it was shown that man could lose his life from the

additional blood loss which occurred when the tourniquet was loosened or

removed casually. If, however, the man’s condition was good, his blood pressure normal, the previous blood loss slight, and medical officer available,

then the tourniquet could be removed at half-hour intervals in an attempt to

avoid additional tissue damage. Cooling of the extremity distal to the tourniquet was desirable, particularly when the environment was hot.

Temporary splinting of wounded extremity prevented further damage

and loss of blood and prevented or relieved pain. badly applied splint could,

in itself, cause pain and do damage. frequent error early in the Tunisian

campaign was to apply the Thomas splint withoutremoving the shoe. Swelling

invariably occurred distal to the wound and caused great pain, which was

entirely unnecessary. The difficulty was overcome whenit became the practice

to unlace and slit the shoe if it was left on the foot in the application of

Thomas splint.

Position.—The quickest way of improving the wounded man’s general

condition on his arrival at the forward hospital was to elevate the foot of the

litter about 12 inches (fig. 3) and permit him to rest in this position, with the

head and upper part of the body lower than the rest of the body. In almost

all cases which wore not frankly hopeless, improvement was observed, with

return of perceptible blood pressure, when this position was instituted, even

before fluid replacement had been started. All badly wounded patients were

therefore placed in the Trendelenburg position upon their arrival at the forward

hospital, unless contraindications existed.

Pulmonary edema was one such contraindication. The head-down position

was also used both tentatively and cautiously in patients with chest wounds,

in whom it might produce respiratory difficulties, and in patients with head

wounds. If, however, these casualties were in frank shock or had systolic blood

pressures below 80 mm. Hg, the Trendelenburg position was employed under

close observation and was maintained unless obvious signs of distress, labored

respiration, or cyanosis required its abandonment. When once the systolic
36 GENERAL SURGERY

blood pressure had risen to 80 mm. Hg, the head of the litter was gradually

elevated; often as long as 20 to 30 minutes were spent in bringing the patient

back to the recumbent position.

Conservation of body heat.—The wounded man frequently arrived at

medical facility cold and thoroughly chilled. Additional exposure to cold would

naturally have affected him undesirably, but rapid warming was equally

undesirable. Additional fluid loss through perspiration, increased metabolic

needs, and dilatation of the protective vascular constriction were all possible

and dangerous consequences of rapid, careless warming. The problem was to

conserve the man’s own body heat, not to increase it by artificial means.

Gradual warming was best accomplished by placing the patient in bed in

tent or ward at normal room temperature, with blankets under him as well

as over him, while blood replacement was accomplished. Experience showed

that this was an effective means of warming freshly wounded men. During

the fighting before Cassino, although the ground was frozen hard and the

nearby mountains were covered with snow, no other method had to be resorted

to in any of the casualties observed by the surgeons in the mobile hospitals

supporting the Fifth United States Army. Similar observations were made

on theAnzio beachhead. Only occasionally, in fact, was artificial heat necessary.

In May 1944, when the weather had become warm, one casualty with rectal

temperature of 84° F. was brought into an army hospital at Anzio. His temperature remained at this level for many hours in spite of the application of hotwater bottles to various parts of the body, and did not reach normal level

for more than 24 hours. This man had suffered blast injury, with intracranial

damage which was thought to have involved the hypothalamic area.

Emptying of the stomach.—Correct preoperative preparation included

emptying of the stomach before anesthesia, to avoid the risk of aspiration of

gastric contents (p. 31). This measure was desirable in all wounded men and

urgently necessary if food or fluid had been taken after wounding or as recently

as hours or less prior to wounding. An additional reason for employing it was

the observation that in some cases gastric dilatation might be great enough to

interfere with the circulation. The mechanism of the circulatory improvement

which was frequently observed after the stomach had been emptied was not

clear, but there was no doubt of its occurrence. Possibly the greatly distended

stomach interfered with proper fdling of the heart. Another theory was that

the vagal reflexes were involved. Aspiration was occasionally necessary to empty the stomach (fig. 6), but

as rule it was better to induce vomiting. The largest size gastric tube that

would slip down easily was introduced and was manipulated judiciously as it

went down. Gastric lavage was seldom necessary and was always contraindicated if the location or manifestations of thoracic or abdominal wounds suggested that perforation of the esophagus or stomach might have occurred. Oxygen administration.—Oxygen inhalations (fig. 7) were used freely for

resuscitation during World War II, for the logical reason that they produced

definite signs of clinical improvement in the form of lowered pulse rate and
RESUSCITATION 37

Figure 6.—Routine of early care of wounded man in forward hospital. Emptying of

stomach.

better coloration of the blood. Whether they were of lifesaving value in the

management of severely wounded men was not established.

In the discussions of the use of oxygen, much was made of the fact that

cyanosis will not appear as long as hemoglobin concentration is maintained

at about third of normal. Such low levels were not common in freshly
38 GENERAL SURGERY

Figure 7.—Routine of early care of wounded man in forward hospital. Artificialrespiration

with oxygen.

wounded men. In study of 37 severely wounded men filtered out from 2,853

casualties 13 who, for the most part, had sustained their wounds on the Anzio

beachhead, the average hemoglobin level was still 12.3 gm. percent at the end

of hours after wounding, because sufficient time had not yet elapsed for

complete blood dilution. The hematocrit varied. It was in the twenties in

of these cases, in the thirties in 16, and between 40 and 44 in 8. In the

remaining case in which it was determined, it was 50.

Cyanosis was more important and more readily detectable sign of

anoxia and oxygen deficiency than low hemoglobin levels. It was frequently

overlooked, however, because of hasty examination under poor light in the

preoperative tent. When it was present, an increase in the oxygen tension of

the inspired air was undoubtedly desirable, though to what degree this objective was achieved in the field by the use of oxygen was open to considerable

question. When oxygen was employed on any indication except respiratory

obstruction or respiratory depression, it was used with the fidl realization that

the patient’s chief needs were an increase in the volume of the circulating blood

and in the total quantity of circulating hemoglobin in the blood.

13 See footnote 1, p. 5.
RESUSCITATION 39

Oxygen was most conveniently administered by nasal tube, after it had

been humidified by being bubbled through water column. The technique

made it possible to service or patients from single oxygen tank. small

catheter (12 to 14, French), well lubricated, was inserted into the nasal pharynx

until the patient was observed to swallow bolus of air. The tube was then

withdrawn for half an inch and was firmly anchored to the cheek with adhesive

tape. The correct distance of insertion was ordinarily about half an inch less

than the distance between the ala nasi on one side and the lobe of the ear on

the same side.

gas flow of to liters per minute of 100-percent oxygen was usually

well tolerated. If signs of oxygen deficit were not promptly relieved, higher

concentration in the alveoli could be achieved through closed system (fig. 7)

with carbon dioxide absorption. The Beecher anesthesia machine proved

satisfactory for this purpose.

in high concentrations was not given continuously for more than

12 hours at time. If, as occasionally happened, it was required beyond this

time, the periods of administration in high concentrations were alternated with

12-hourperiods during which the concentration was reduced to 50 to 60 percent.

Care had to be taken to avoid gastric dilatation, particularly in unconscious

patients.

Drugs.—Vasoconstrictor and stimulating drugs were of little or no value

in the management of freshly wounded men and were almost never used.

When they were employed, it was always in small dosages.

378327 °—56 41

CHAPTER II

The Control of Pain in Men Wounded

in Battle

Henry K. Beecher M. D.

MORPHINE OYERDOSAGE AND POISONING

Early in November 1943, curious phenomenon was repeatedly observed

in the operating tents of forward hospital installations in Italy. Wounded

men who were brought into the receiving wards in shock and thoroughly chilled

all presented essentially the same appearance and clinical picture on their

arrival. Some of them, after they had been warmed and had been treated by

standard shock therapy, responded to it in the usual manner. Others, however, after receiving exactly the same kind of treatment, presented profound

respiratory depression associated with pinpoint pupils, although neither of

these signs had been present before resuscitation. These men, though they had not had morphine since they entered the hospital, were clearly suffering

from morphine poisoning. In fact, in the absence of head injuries, and under

the circumstances of combat, it was impossible to attribute their condition to

any other cause. Alcoholism, chloral hydrate, and the barbiturates, all of

which can produce similar picture, could be excluded, for obvious reasons.

This phenomenon had been observed in patients who were burned in the

Cocoanut Grove disaster in November 1942. It had also been recorded in

the civilian medical literature before it was observed in the Mediterranean

Theater of Operations in the fall of 1943.

How frequently the syndrome of morphine poisoning occurred it is not

possible to say. Often it was too severe to be overlooked. Occasionally it

was fatal. On the other hand, it probably went unrecognized in many instances, because the manifestations were slight or subclinical. When it was

serious, it might be misunderstood, but it could not be ignored. In the first

10 days of November 1943, morphine poisoning was recognized in several

hospitals. On 11 November, it was discussed at the regular weekly medical

meeting of the Fifth United States Army medical officers. Subsequently it

was observed and commented on in all the hospitals in the theater.

consideration of the circumstances of wounding and resuscitation

offered an entirely reasonable explanation of what had happened to these

wounded men. Early in November 1943, it was cold in the valley of the

Volturno, where the fighting was taking place. It rained frequently, and

The fire in the Cocoanut Grove, Boston, Mass., night club, occurred on the evening of 28 November 1942. As

result of the disaster, 491persons lost theirlives. The author of part of this volume was on the staff of the Massachusetts

General Hospital, which received 114 of the fire victims within period of hours.
42 GENERAL SURGERY

snow fell low on the mountainsides. If man was not wet and chilled before

he was wounded, he promptly became wet and chilled after he fell, even if

he was picked up shortly after injury. Often he was subjected to further

exposure in the course of difficult litter carry to the receiving hospital. The

result was impairment of the circulation in the skin and subcutaneous tissues.

Sometimes the impairment was slight, but sometimes it amounted to almost

complete cessation of the local circulation.

Under these conditions, it was not likely that the morphine administered as first-aid measure on the battlefield would be absorbed. That it

was not absorbed was proved by the fact that, in many instances, the injection of 30 mg. (gr. }Q, the amount put up in Army-issue syrettes, brought no

relief of pain. second, and often third, injection in the same amount

would therefore be given over period of hours, each time with no perceptible

effect. These wounded men were often described as “resistant” to morphine.

When they were in good general condition and not in serious shock, an active

peripheral circulation was promptly restored as they warmed up in the hospital, even if no other measure of resuscitation was employed. The restoration of the circulation caused the rapid, simultaneous absorption of all unabsorbed deposits of morphine, sometimes many hours after the injections

had been made. If shock was present, and resuscitative measures in addition to warming were employed, the restoration of the peripheral circulation

often led to dangerously rapid absorption. Either course of events was likely

to be followed by morphine poisoning.

It soon became evident that although morphine poisoning was an increased

risk in cold weather, it was equally likely to develop, regardless of weather, in

the presence of surgical shock, hemorrhage, or any other condition leading to,

or associated with, reduction in the peripheral circulation. It often became

evident during anesthesia, in cases in which it was necessary to undertake

operation before full resuscitation from shock had been accomplished. The

chain of events was as follows: Ether stimulated the respiration. Peripheral

vasodilatation then occurred. Morphine, which might have been injected as

long as or 10 hours earlier, was rapidly absorbed. When pinpoint pupils

and profound respiratory depression developed before the surgical stage of

anesthesia had been reached, induction was greatly prolonged, sometimes taking

an hour or more.

Clinical manifestations.—Pinpoint pupils and slow respiration were the

first manifestations of morphine poisoning. Respiratory depression led to

anoxia, which was followed, in turn, by circulatory depression. These were

the most serious consequences of overdoses of morphine, but less severe manifestations were frequent, and even small doses sometimes produced reactions

which complicated treatment. single injection of morphine might cause

anorexia, nausea, and vomiting, which limited the intake of food and fluids by

The possibility and dangers of morphine poisoning’s developing inbattle casualties,particularly under coldweather

conditions, had been recognized and emphasized in the curricula for officer and noncommissioned-officerstudents at the

Medical Field Service School, Carlisle Barracks, Pa., in the years preceding World War II.
CONTROL OF PAIN 43

mouth and increased the fluid loss in vomitus and sweat. The use of morphine even for brief periods was sometimes followed by severe constipation.

Management.—The realization that morphine intoxication might have

rather abrupt onset, sometimes many hours after the last injection, was essential in the diagnosis of morphine poisoning. Unless that fact was constantly

borne in mind, treatment was likely to be delayed.

The first step in therapy was the application of tourniquet proximal to

the site of injection, to delay absorption. It was loosened at regular intervals.

Body heat was conserved. Then the attention was devoted to the chief aim

of therapy, which was to prevent anoxia. This was best accomplished by

the administration of oxygen, supplemented by artificial respiration, if necessary. Oxygen was preferably given by means of closed anesthesia apparatus,

with carbon dioxide absorption, accomplished by intermittent pressure on the

breathing bag. Atropine in doses of mg. (gr. %o) by vein, combined with

ephedrine in doses of 30 mg. (gr. also by vein, was sometimes useful, the

latter as central stinmlant and as support against falling blood pressure.

Hypertonic glucose solution was used intravenously for its diuretic effect, to

hasten the excretion of morphine by the kidneys.

If coma developed, gastric tube was inserted at once to eliminate the risk

of aspiration of gastric contents. Pulmonary complications were guarded

against by frequent changes of position. Supportive treatment was continued

until it was apparent that the excess of morphine administered had been largely

destroyed in the body.

INVESTIGATION OF PAIN IN WOUNDED MEN

The numerous instances of morphine overdosage and poisoning observed

in Italy in November 1943, and in the succeeding weeks, suggested that the

routine administration of morphine to wounded men, particularly in large doses,

was not safe procedure. The question also arose whether all wounded men

experienced enough pain to warrant the risk attached to the use of this drug,

especially in large doses.

To settle this question, study was made of 225 patients who had sustained

major wounds during the prolonged action on the Anzio beachhead and the

Venafro and Cassino fronts and, in few instances, in southern France. The

selection was as consecutive as the criteria permitted, the objective being to

select patients with major injuries in certain categories who were clear mentally

and who were not in shock when they were questioned. Ten of the two hundred

and twenty-five men included in the original collection had to be dropped because they were unconscious or not clear mentally. few others who had been

in shock when they arrived at the hospital were not questioned until their

status had improved. Included in the 215 patients were 50 with compound

fractures of the long bones, 50 with extensive wounds of the peripheral soft

tissues, 50 with penetrating wounds of the thorax, 50 with penetrating wounds of

the abdomen, and 15 with penetrating head injuries. In most instances, the
44 GENERAL SURGERY

wounds which formed the basis of selection (table 2) represented only the chief

wounds. Most of the patients had multiple injuries.

The incidence of pain in the several categories ofinjuries was arrived at by

asking the patients, shortly after their arrival at forward hospitals, several

pertinent questions. These questions had been carefully framed, and great

care was taken to see that each patient understood their meaning.

The first question was, “As you lie there, are you having any pain?” To it,

69 of the 215 patients (32.1 percent) replied that they felt no pain at all. The

146 patients who had complained of pain were then asked, “Is it slight pain,

moderate pain, or bad (severe) pain?” In reply to this question, 55 (25.6 percent of the original 215) complained of slight pain, 40 (18.6 percent) of moderate

pain, and 51 (23.7 percent) of severe pain.

These replies were not in accord with the long-accepted generalization

that all extensive wounds are associated with severe pain and that the more

extensive the wound, the worse is the pain. If it is possible to speak of such

subjective experience as pain in exact terms, it might be said that the generalization held in only about quarter of all cases and failed partly or

entirely in the other three quarters.

Patients who admitted to pain of any degree were next asked if they wished

something to relieve it. The use of the term “morphine” was deliberately

avoided. Experience had already shown that it was an unfortunate word to use

in front of wounded men, who were likely to form the impression that if their

condition was serious enough for them to need morphine they must, indeed, be

quite badly off. close parallelism naturally existed between the number of

wounded men who complained of severe pain (51 patients, or 23.7 percent of

the 215 in the scries) and the number desiring medication for relief (58 patients,

or 27.0 percent of the total number). In all, 157 of the 215 patients (73.0 percent) desired no medication, and 164 patients (76.3 percent) had no pain or

slight to moderate pain. The results of this study seemed to show clearly that

the routine injection of morphine was not necessary in forward hospitals.

In great many of these patients, the striking absence of severe pain, and of

any pain, could not be explained either by the amount of morphine received or

the time at which it was given (table 2). Of the 51 who complained of severe

pain, had had no morphine since they were wounded. The other 46 had had

an average total dose of 30.5 mg. and had received an average of 24.5 mg. in the

most recent injection. Of the 157 who wished no medication when they were

questioned, 32 had had no morphine at all. The other 125 had received an

average total dose of 27.3 mg. The elapsed time since the last dose was essentially the same in both groups. It was therefore not possible to explain the

degree of pain, or its presence or absence, on the basis of the amount of morphine

given and the time at which it had been injected.

Only of the 15 patients with penetrating wounds of the head complained

of severe pain, in contrast to of the 50 patients with wounds of the thorax,

12 of the 50 with extensive compound fractures of the long bones, and 24 of

the 50 with penetrating wounds of the abdomen. Although there was little
CONTROL OF PAIN 45

Table

2.

—Analysis

of

pain

sensation

in

215

freshly

wounded

patients

with

major

injuries

Type

of

wound

Num- ber

of

cases

Age

Elapsed time

sincewounding

Average total

dose of

mor- phine

Average last

dose

Time since

last dose

Degree

of

pain

experienced

Further relief

by

therapydesired

Essential data

in

patients

with

severe pain

Essential data

in

patients

who

desired

no

additional medication

Years

Hours

Mg.

Mg.

Hours

119

none

12

patients.

Total

mor38

patients.

Total

morCompound fracture

of

long

bones.

50

24.

8±0.

12.

5±1.

27.

Oil.

22.6

7.

OiO.

112

slight 17

moderate[l2

severe

11

phine

33.6

mg.

Last

dose

24.8

mg.

5.7

hours

ago.

phine

28.1

mg.

Last

dose

7.4

hours

ago.

19

none 15

slight moderate [8

severe

[7

patients.

Total

mor30

patients.

Total

morExtensive

peripheral

soft50

24,

5±1.

11.

3±1.

27.0i2.

19.5

7.

2i0.

phine

33.0

mg.

Last

phine

27.5

mg.

Last

tissue

wounds.

dose

22.8

mg.

hours

ago.

dose

6.5

hours

ago.

15

none J18

slight 111

moderate |6

severe

[5

patients.

Total

mor30

patients.

Total

morPenetrating wounds

of

50

24.

5±0.

9.

8±1.

25.

Oil.

21.2

6.

5i0.

10

phine

23.9

mg.

Last

phine

26.1

mg.

Last

thorax.

dose

19.0

mg.

hours

ago.

dose

6.4

hours

ago.

17

none slight moderate 14 124

severe

[21

patients.

Total

mor21

patients.

Total

morPenetrating wounds

of

50

22.

7±0.

7.

2±0.

29.

0i2.

25.0

4.8i0.

27

phine

29.4

mg.

Last

phine

30.1

mg.

Last

abdomen.

dose

26.0

mg.

hours

ago.

dose

5.1

hours

ago.

none slight |0

moderate [l

severe

fl

patient.

Total

morPenetrating wounds

of

cerebrum.

15

25.1±1.4

7.

9±1.

19.

8i4.

19.8

6.

2il.

phine

30.0

mg.

(last

dose)

14

hours

ago.

Standard errors of

the

mean

are

shown.

All

doses

of

morphine

are

averages.

Patients who

receivedno

morphine

are

omitted

from

the

appropriate

calculations.

All

doses

of

morphine are

averages.
46 GENERAL SURGERY

difference in the amount of morphine received by the two groups of patients,

there were four times as many complaints of severe pain in the group with

abdominal injuries as in the group with thoracic injuries. Perhaps the explanation is the spill of blood and intestinal contents into the peritoneal cavity,

as well as the role of infection. Bo this as it may, these data supported the

idea that, in forward areas, it was not necessary to give morphine routinely

and that it would be wiser to administer it according to the needs of the individual patient.

RELIEF OF PAIN

Routine for administration of morphine.—It became apparent early in the

Tunisian campaign that the 30-mg. (gr. %) amounts of morphine put up in

Army-issue syrettes were toolarge for many patients, even when only single injections were used. Some observers attributed the difficulties which arose from

overdosage of morphine and morphine poisoning to the fact that medical aidmen, for the first time in United States Army history, were being permitted to

administer the drug. This was not the general opinion. It was repeatedly

observed that medical officers were much more likely to be at fault in the overgenerous use of morphine than were medical aidmen.

Throughout the war, there was tendency in all theaters to overtreat

wounded men with morphine in an endeavor to relieve pain. The situation

in Italy began to improve when the Chief Surgeon, North African Theater of

Operations, in December 1943, established the rule that morphine usually

was not to be administered in more than gr. (half syrette) single dose.

In addition, vigorous educational program was begun, and this endeavor,

together with an increasing appreciation of the disastrous possibilities of

delayed morphine poisoning, led to sharp decline in the excessive use of the

drug. It was about this time that the study just described was begun on the

Anzio beachhead, and it promptly became clear that severe pain is much less

common than was generally supposed in severely wounded men and that if

morphine is used at all, it is not necessary to use it in large doses.

Eventually the following routine for the administration of morphine

became fairly well standardized:

1. As general rule, the amount injected in single dose did not exceed

15 mg. (gr. Yi). In patients to be transported by air, in whom respiratory

depression was particularly undesirable, the amount was reduced to or 10

mg. (gr. /8 or %). Maximum analgesic effects could be secured with these

dosages, and the undesirable side effects caused by larger doses were seldom

apparent.

2. Subcutaneous or intramuscular injection was employed when gradual,

prolonged effect was sought, but this route was avoided when the peripheral

circulation was slowed by exposure, hemorrhage, shock, and other causes.

Intravenous injection was then better choice. It was also better choice

Circular Letter No. 50, Headquarters,North African Theater of Operations, United States Army, Office of the Surgeon,30 Dec. 1943, subject: Morphine.
CONTROL OF PAIN 47

when the immediate relief of pain was desired or when delayed absorption

might prove harmful, as in impending shock. When or 10 mg. (gr. or %)

were given by this route, the full effect was achieved within few minutes, and there was no possibility of delayed absorption. If the desired results

were not obtained by the first injection, second could be given, without

risk, within 15 or 20 minutes. As practical matter, it was almost never

possible to administer morphine intravenously to wounded man on the battlefield. Every circumstance conspired to make the continued use of peripheral

injections necessary—the extra time which would be required for venous

puncture, the urgent need for haste in the face of enemy action, the large

numbers of casualties requiring treatment when combat was intense, the

frequently collapsed state of the wounded man’s veins, the poor physical

facilities, and the inexperience of the nonprofessional personnel who gave the

treatment. It was therefore the rule to give the injection on the battlefield

intramuscularly (not subcutaneously) and to follow it by massage. The injection was made low enough on the extremity to permit the placing of tourniquet above it to slow down the absorption rate if signs of morphine poisoning

should develop. The site of the injection, the time it was given, and the size

of the dose were recorded on the wounded man’s emergency medical tag.

3. Morphine was not administered in the field to patient who would be

required to walk back to the battalion aid station, nor was it administered at

the aid station to man who would be evacuated to the rear at once as walking

wounded. Its use under these circumstances was extremely dangerous. The

man might become confused, lie down along the evacuation route, go to sleep,

and suffer serious exposure or other untoward consequences. Another reason

for withholding morphine from walking wounded was the accumulated evidence

that nausea following its use was apt to be much more severe in ambulatory

patients than in patients at rest in the recumbent position.

4. It was constantly emphasized to both medical officers and corpsmen

that the only justifiableuse for morphine was the relief of severe pain. Codeine

or aspirin was to be used for mild degrees of pain.

5. In the absence of respiratory depression, morphine could be given in

small doses to patients with head or chest wounds.

6. The routine use of morphine was avoided, unless it was required for

pain, in the pre-anesthetic medication of seriously wounded patients, in whom

anesthesia was usually easy to induce (p. 76).

7. The contraindications for the use of morphine were repeatedly emphasized. It was not to be employed for sedative effect in nervous, manic, or

hysterical patients. It was not to be used to allay fear, to promote sleep, or to

control restlessness associated with hemorrhage. It was to be used in these

circumstances only if pain was present. Otherwise, phenobarbital or pentobarbital sodium or paraldehyde, all of which were available, met the needs of

the patient better than morphine. When pain was present in these conditions,

the combination of small doses of morphine and barbiturate often accomplished better results than large doses of either agent alone.
48 GENERAL SURGERY

Morphine was absolutely contraindicated in patients in shock unless, as

was highly unusual, severe pain was also present. The respiratory depression

and the increased fluid loss in vomitus and sweat made its use in shock particularly undesirable. Morphine was used with great caution, if at all, in

minor degrees of anoxia, such as were present in circulatory impairment. It

was not used when the respiration was impaired by pneumothorax, hemothorax, or pleural effusion. It was not used when there was mechanical

obstruction of the airway or when central depression existed. It was recognized as dangerous in hypothyroid patients or in those with low metabolism

from other causes. Finally, it was used with great caution, if at all, in patients

with liver disease, such as infectious hepatitis, since it is largely destroyed in

the liver.

Relief of pain by other means.—Throughout the war, it was necessary to

emphasize repeatedly to medical officers and corpsmen that morphine is not

the only means of relieving pain. Regional nerve block, for instance, was

sometimes useful, particularly in wounds of the chest. Either intercostal or

paravertebral block controlled the pain of these injuries quickly and even

dramatically, and, at the same time, by making it possible for the patient to

breathe normally, this measure helped to restore pulmonary ventilation to

normal.

Adequate support of the wound was another simple method of relieving

pain. Swelling of the lower leg and foot usually occurred rapidly after fractures of the long bones of the extremity and was often extremely painful if the

limb was left unsupported. Adequate immobilization of the wounded part

whenever skeletal injury was known or suspected to exist not only relieved

pain but also prevented further local damage and militated against shock.

Needless suffering could often be eliminated, without drugs, simply by unlacing

and slitting the shoe in fractures of bones of the extremities.

The effectiveness of barbiturate administration, without morphine, is

shown in the following case history:

Case report. —A husky 19-year-old soldier was brought into forward hospital on the

Anzio beachhead hours after injury by mortar shell. He had wound near the vertebral

column, which looked as if it had been made with meat cleaver, through all the ribs from the

5th through the 12th. He was cyanotic and had lost great deal of blood. The hemoglobin

was 9.5 gm. percent, and the blood was not yet completely diluted. The patient was obsessed

with the idea that he was lying on his rifle. He complained bitterly of pain and struggled

constantly to get off the litter; three attendants were required to hold him on it. He appeared

to be wild from pain, and his wound supported the idea, though examination in any adequate

sense was impossible.

The patient had had no morphine for at least hours, but it was decided, instead of

giving him more, to give him 150 mg. (gr. 2}i) of Sodium Amytal by vein. Almost immediately after it was administered, he quieted down and went to sleep. His color improved

strikingly, probably, at least in part, because the nasal oxygen tube, which he had repeatedly

pulled out, could now be kept in place. His systolic blood pressure also rose from 60 to 80 mm.

Hg. Before the barbiturate was given, all who saw him agreed that his condition was rapidly

deteriorating. He began to improve as soon as he received it. The dose given could not

possibly have controlled pain, and it seemed reasonable to assume that his manic state was

not due to pain.
CONTROL OF PAIN 49

The patient could be roused, but he did not move of his own volition until he was taken

to the operating room an hour later. In the meantime, full examination had revealed that

eight ribs had been cut in two. He had also sustained an open pneumothorax, lacerations of

the lower lobe of the lung from the fractured costal end, and laceration of the diaphragm.

Catheterization, which had previously been impossible, revealed grossly bloody urine, which

was found at operation to be due to wound of the kidney.

Sodium Amytal was given to this patient, and to others treated in the

same period, not from choice but because it was the only barbiturate then

available. Pentobarbital sodium would have been used if it had been at hand.

The small dosage of barbiturate employed in this case should be emphasized.

Depleted, bled-out men, in shock, appeared extraordinarily sensitive to these

agents, and the usual rule was that single dose of 60 mg. (gr. 1) was the

maximum amount permitted at any single injection.

THIRST

Three factors were usually of major importance in the suffering experienced

by wounded men; namely, actual pain, mental distress, and thirst. Pain and

mental distress were commonly encountered in men in good general condition, who were not in shock. In well-established traumatic shock, such suffering as

was experienced was usually not from wounds or from anxiety, but from thirst.

This was borne out by the men who were investigated from the standpoint of

pain. They were not in shock, and they did not complain to any extent of thirst,

of which men in shock usually complained bitterly.

It was not possible, of course, to alleviate thirst by oral administration of

fluids in patients soon to be anesthetized. Its correction required restoration

of the depleted blood volume, which could best be achieved by intravenous

fluid therapy. While the fluid balance was thus being restored, the patient’s

lips were moistened frequently, and he was permitted to rinse out his mouth.

In view of the amount of suffering which can be caused by thirst, it isremarkable

that so little attention has been paid to it and to measures for relieving it.

PSYCHOLOGIC PREPARATION FOR OPERATION

consideration of certain psychic and emotional factors may throw some

light upon the relatively small incidence of severe pain after wounding, as

evident in the investigation conducted in the Mediterranean theater. The

psychologic preparation for operation was quite as important as the physical

preparation, and it is unfortunate that under the stress of combat conditions

less attention was paid to it than it should have received.

Most wounded soldiers were young, and their reactions were correspondingly immature. The natural emotional instability of youth had been exaggerated by the harrowing experiences they had undergone. They had suddenly

been released by their wounds from an exceedingly dangerous environment

filled with fatigue, discomfort, fear, anxiety, and real danger of death.

The wide experiences of Chaplain (Maj.) M. I. English and Maj. Douglas Kelling, MC, were drawn upon for this

section.
50 GENERAL SURGERY

Many men in the confusion of the first hours after wounding became euphoric.

Euphoria was probably more often an early postoperative manifestation, but

it was by no means unusual to observe it in the preoperative ward. It was

probably based on the overwhelmingrealization that, no matter what happened

in the future, the war was suddenly over for this particular wounded man.

His wound, in effect, had furnished him with ticket to the safety of the

hospital. With that thought, he overcompensated and became euphoric, with

the further result that this emotionalrelease blocked the pain which he might

otherwise have felt. If there are other, more valid, explanations for the absence

of pain in the study conducted in Italy, they did not become apparent.

The early euphoric reaction was often followed by profound depression.

Psychiatrists repeatedly commented on this sequence, which was particularly

notable in men who required amputation.

Before wounding, as has just been mentioned, the soldier had lived under

circumstances of anxiety and emotional stress. He had been grieved by the

wounding and death of friends. He was naturally fearful for his own safety.

These emotions were likely to be exaggerated by the sights and sounds of prolonged combat, coupled with the physical discomforts of exposure to bad

weather, inadequate food and fluid intake, loss of sleep, and exhaustion, as well

as pain. Then, in addition to these considerations, the wounded man suddenly

had to face the consequences of his own wound: If his arm was injured, would

he lose it? If there was blood about the genitals, would he become impotent?

This was possibility about which there was always great anxiety. Would he

lose his sight? Would he be disfigured? Would the chest wound or the abdominal wound he had sustained kill him?

This inner turmoil was manifested in various ways. Sometimes the man

lay quietly, seemingly asleep, until casual question brought out, in rush of

words, the indications of great mental stress. Other men showed their turmoil

by restlessness or, occasionally, by manic behavior. Patients who were described as writhing in pain and who had been given large doses of morphine were

sometimes found to be suffering from restlessness caused by cerebral anoxia, or

from excitement caused by fear and apprehension, which could be overcome by sedation with barbiturates. Morphine was never indicated in these

circumstances.

Psychiatrists were always in too short supply and were too much occupied

with other matters to participate very often in the preparation of the wounded

man for surgery. Psychologic preparation for operation therefore had to be the

concern of other members of the medical staff and the chaplain. Medical officers carried heavy responsibilities, and in their involvement in them, they were

sometimes inclined to disregard mental and emotional considerations in the

wounded men under their care. It is unlikely that any deaths occurred as

result, but only the future will reveal what effect disregard of these considera- tions will have on these men’s later lives. In any preoperative ward, thoughtful discussion of their condition with wounded men showed how important these
CONTROL OF PAIN 51

considerations were and how much needless suffering was caused when they

were ignored.

The surgeon’s first approach to the wounded patient was the most important. Ideally, he represented the trusted family physician. He was cheerful but never casual. His confidence in his own ability, which could further bo

built up by the chaplain, was transferred to the patient.

Consultations were always avoided in the patient’s presence; they were

likely to make him think he was worse off than he really was. His questions

were answered carefully. Hope was held out in all correctible lesions. If the

lesion was not correctible, the man was told frankly that he might have to lose

an arm or leg. He was assured that everything possible would be done to save

the limb, and it was stressed that many men who had undergone similar experiences had been able to live normal, useful lives afterward. Whenever possible,

the patient who needed an amputation was told of it before operation; failure to

do so was likely to lead to lack of confidence in his future care.

Certain uncorrectible lesions, such as great facial disfigurement, loss of the

genitalia, and paraplegia, were difficult to discuss. If the outcome could not be

foretold, it was usually best to assure the man that everything possible would

be done for him. The proper psychologic management of patients in this group

presented fruitful field for study, which was not gone into during World War II.

Neglect of these emotional problems also had military implications. The

patient’s permanent outlook on his Army duties might be powerfully and

lastingly influenced by it. The casual, lighthearted statement by medical

officer that the patient, now that he was wounded, could go home, could do untold damage if it later proved untrue. It might be impossible, in fact, to reestablish in the healed patient the qualities of good combat soldier. If

patient’s condition was called exhaustion in his hearing, good response to

treatment was likely to be obtained. If it was called shellshock, he was likely

to be incurable. The early hours after wounding were thus important for establishing in the patient point of view that would facilitate his early return

to duty.

The chaplain.—The commanding officer or the medical officer directly in

charge of wounded man was often inclined to appraise the value of the chaplain in terms of his own need, or lack of need, for religious support, rather than

in terms of what the man himself might want. fair minority of seriously

wounded men were not at ease mentally until they had received spiritual attention. They suffered without it. It was an error for the medical officer to take

the position that there was nothing the chaplain could do for wounded man

that good physician could not accomplish. It was frequently observed, in

fact, that the physician who assumed that he was good at handling such matters

was actually very bad at them.

The enlisted man, in the combat zone, at least, was often more religious

than might be expected. Even if he had grown away from his religion through

carelessness, he, like the man who had continued to follow his religion, had

confidence in the help the chaplain could give him, and he wanted it in this
52 GENERAL SURGERY

crisis. Medical officers presented different problem. Members of this group

sometimes actively rejected religion for intellectual reasons, or felt superior

to it on grounds of logic, or were merely indifferent. The best medical officers,

however, were the ones who recognized in an able chaplain an intelligence equal

to their own and who acted on the assumption that he had something to offer

the wounded man, even if they could not put into words just what it was.

The chaplain who cared properly for the wounded needed great deal of

understanding and sympathy. He had to grasp the fact that the soldier had

been torn from his familiar life and thrown into strange milieu, where old

standards of conduct were ignored or were deliberately escaped. Animal

spirits might have led him into adventures that his early training and standards

had taught him were wrong. Then he was wounded and suddenly faced with

the possibility of death. He was frightened and spiritually confused, and the

chaplain who could deal with his feelings of guilt and who could help him to

acquire serenity was heartily welcomed.

It was essential, ol course, that the chaplain be brought into the case

matter of factly. It was serious error to project religious care abruptly upon

the wounded man, no matter what his beliefs. Invariably this mode of

approach convinced him of the gravity of his wound, whether or not that was

true. On the other hand, the presence of the chaplain was essential to wounded

men whose religious faiths embodied ritual of departure. To men of these

beliefs, the administration of the Last Sacraments was not alarming. Experienced chaplains and experienced psychiatrists alike insisted that it was sometimes desirable to tell wounded man that he was going to die. Even medical

officers who did not share his religious beliefs often saw anguished hope give

place to tranquillity when once the wounded man knew that for him the end

was not far away.
53

CHAPTER III

Anesthesia for Men Wounded in Battle

Henry K. Beecher M. D.

The selection of an anesthetic agent, the technique of administration

employed, and the competence of administration of the anesthetic are matters

of the greatest importance in the peacetime practice of surgery. They are

doubly important in the surgery of combat-incurred injuries. The relationship between anesthesia aud shock is particularly close in operations performed upon seriously wounded men, not only because of the frequent occurrence of shock after wounding but also because, if it is not already present,

anesthesia can be, and often is, precipitating factor in its development. It

is entirely possible for an unwisely selected or incompetently given anesthetic

to precipitate such profound shock in wounded man whose status was previously not unsatisfactory that compensated circulatory system is transformed into state of decompensation. All of the mechanisms of this process,

although not yet fully clarified, were sufficiently well understood when the

United States entered World War II for the considerations which determined

the acceptability or unsuitability of available anesthetic agents to be clearly

comprehended and to be translated into appropriate action by all anesthetists

who cared for wounded men.

HISTORICAL NOTE

It is indicative of the lack of emphasis placed upon anesthesia in World

War that the section dealing with it in the official history was written by

surgeon, Col. George W. Crile, MC. The specialty was not represented in

The Surgeon General’s Office, and consultants in anesthesia were not appointed

for service either overseas or in the United States. Few of the points of view

presented in the summary which follows could be substantiated at the beginning of World War II, but the material is presented because of its historical

interest.

Nitrous oxide-oxygen anesthesia. —In the first year of the First World

War, according to the official history, the paramount value of nitrous oxideoxygen anesthesia was clearly demonstrated by American anesthetists attached

to the Western Reserve University unit, which worked at the American Ambulance at Neuilly, France, Satisfactory anesthesia could be obtained with

this agent in operations on seriously wounded men, whatever their degree of

exhaustion. When the unit returned to America, one of the nurse-anesthetists

Crile, George W.: Anesthesia. In The Medical Department of the United StatesArmy in the World War. Washington: U. S. Government Printing Office, 1927, vol. XI, pt. 1, pp. 166-184.
54 GENERAL SURGERY

remained in France, at the special request of French and English medical

officers, to give instruction in the technique of nitrous oxide administration.

The early enthusiasm for nitrous oxide-oxygen anesthesia continued for

considerable period. Conclusions adopted by the Inter-Allied Surgical Conference at its second session, in Paris, in 1917, reaffirmed the confidence felt in

it by the delegates present, who represented England, Belgium, France, Italy,

Japan, Portugal, and Serbia. It was the consensus of the conference that this

form of anesthesia (combined with local anesthesia) was the method of choice

in traumatic shock, in amputations, and in gas gangrene. Ether was the

second choice. Local anesthesia was preferred for cerebral injuries. Chloroform was regarded as dangerous, and spinal anesthesia was reported as giving

varying results.

When Base Hospital No. (the Lakeside unit), which was the first basehospital unit of the United States Army to be called into service after the

United States entered the war, left for France, it was equipped with what was

assumed to be an adequate supply of nitrous oxide and with sufficient apparatus

for its administration. During the summer of 1917, surgeons of the unit had

opportunities at British base hospital in Rouen and at British casualty clearing

stations in Flanders to test the comparative advantages of nitrous oxide, ether, and spinal anesthesia. English and French medical officers became interested

in securing adequate supplies of nitrous oxide, and it was soon evident that what

the Lakeside unit had brought over would not be sufficient for its own needs.

The English supply was totally inadequate. The difficulty was solved by the

appropriation by the American National Red Cross of funds for the construction of plant for the production of nitrous oxide. Various delays ensued, and

it was not until the early summer of 1918 that the plant was in operation in

France and was manufacturing the gas at the rate of 125,000 gallons every

hours.

It was generally acknowledged that nitrous anesthesia gave

less satisfactory muscular relaxation than either ether or chloroform, that it

required expensive and cumbersome apparatus for its transportation and administration, that it cost more than other anesthetics, that it was technically the

most difficult to administer of all the anesthetics then available, and that it

was dangerous in inexpert hands. These disadvantages, however, were thought

to be outweighed by its advantages, including the following: It was quick in

action and pleasant to take; recovery was immediate, without nausea; food

could be taken soon after recovery; transportation was possible soon after

recovery; less nursing care was required; such complications as bronchitis, pneumonia, and nephritis did not follow it; and, finally, nitrous oxide was

thought to be strongly protective against the shock of surgery. It was particularly favored for short operations but was regarded as equally suitable for long

Surgery at the Base. Compilation of Responses by Base-Hospital Staffs to Questionnaire Sent Out by Research

Committee. QuestionnairePrepared by Brig, Gen. J. M. T. Finney and Col. G. W. Crile. Compilation of Responses

Made by Maj. T. W. Burnett. War Med. 2: 1281-1350, February-Mareh 1919.
ANESTHESIA 55

ones. If it did not bring about sufficient muscular relaxation in abdominal

operations, it could be supplemented by regional anesthesia.

Ether and chloroform.—In the chapter on anesthesia in The Medical

Department of the United States Army in the World War, ether and chloroform

are discussed under the same general heading. Both were thought to contribute

actively to shock and exhaustion. Both, if given for any length of time, were

thought to cause cytologic changes in the cells of the brain, the liver, and the

adrenal glands identical with those resulting from other causes of exhaustion.

Patients who did well under ether anesthesia were said to do poorly later. It

was believed that ether tended to cause bronchopneumonia, especially in abdominal surgery performed in the winter; to be unsuitable in infections because

it diminished, and even temporarily abolished, phagocytosis; to be unsuitable

in shock because of its tendency to cause fall in blood pressure; and to be

responsible for rather large diminution in the reserve alkalinity of the blood.

Spinal anesthesia. —The tendency of spinal anesthesia to produce fall in

blood pressure was recognized in World WarI, the decrease being most notable

in patients whose blood was greatly diluted and whose hemoglobin was low. On

the other hand, this was stated to be the type of patient most in need of protective nerve block. The practice was to attempt to overcome the fall in blood

pressure by preliminary blood transfusion. The disadvantage of psychic

shock, arising from the sights and sounds of the operating room and the patient’s

awareness of what was happening, was recognized, but it was pointed out that

these difficulties could be overcome by the administration of morphine or, better,

by very light nitrous oxide-oxygen anesthesia or partial ether anesthesia.

Spinal anesthesia was believed to be of special value when lesions in the

air passages rendered inhalation anesthesia inadvisable or when the prone

position was necessary because of the nature of the wounds. It was granted

that it was time consuming to administer, and its use in rush periods was

therefore not thought to be justified, on the ground that it would work hardship to other patients awaiting operation, who might be subjected to the risk

that anaerobic contamination could become gas gangrene. The statement

that one of the advantages of spinal anesthesia is that it does not require

trained anesthetist to give it has curious sound to modern ears.

Regional and local anesthesia.—Regional and local anesthesia were

regarded as of great value in many of the exigencies of war surgery in World

War I, especially in rush periods at the front, when it might not be practical

to give nitrous oxide-oxygen anesthesia because of the apparatus required, and

when prolonged periods of induction and recovery would not be feasible. Even

when inhalation anesthesia was available, local anesthesia was regarded as

preferable for the excision of damaged soft tissues, the removal of debris, the

probing of soft tissues for retained missiles, the amputation of fingers, the

repair of scalp wounds, and intracranial operations. The chief disadvantage

It should be emphasized again that the data on nitrous oxide anesthesia are presented for their historical interest

only. Neither clinical nor experimental evidence warranted the high favor accorded to this form of anesthesia.

See footnote 1, p. 53.
56 GENERAL SURGERY

of local anesthesia was thought to be the possibility that it might decrease the

resistance to infection of tissues which were already contaminated.

Pre-anesthetic medication in World War was limited to morphine.

MILITARY CONSIDERATIONS OF ANESTHESIA

When the United States entered World War II, anesthetists had at their

disposal wide range of agents and techniques. number of these had been

introduced since World War I, including ethylene, ethyl chloride, Pentothal

Sodium (thiopental sodium) by the intravenous route, and endotracheal

anesthesia. Equipment had been greatly improved. In particular, modern,

efficient machines for gas anesthesia had been made possible by the development of the carbon dioxide absorption technique. This technique, although

it had been described in 1915, had not come into common use until the decade

preceding World War II. It permits measured amounts of anesthetic gases

and oxygen to be delivered to the patient, ether being added to the mixture in

small quantities until the desired plane of anesthesia is reached. As the gases

are expired, they pass through canister containing chemical absorbent, by

means of which expired carbon dioxide is removed. The gases then pass into

rebreathing bag, and the patient, on inspiration, receives warm mixture of

anesthetic gases and oxygen or of vapor and oxygen.

The closed method of administering gas-oxygen and ether anesthesia has

number of advantages. It greatly reduces the fire hazard, since all gases

used are contained in closed circuit. It also reduces the cost of anesthesia,

since the closed circuit conserves whatever agents are used. In addition, this

technique permits the maintenance of intermittent positive pressure anesthesia

and also permits the anesthetist to control the patient’s respiration at will. It

is not too much to say that without this, and other, advances in anesthesia,

the surgical progress accomplished in World War II would not have been

possible.

The wide range of anesthetic agents and techniques available at the outbreak of World War II did not, of course, mean that all of them could be

employed according to peacetime practices. In addition to the fact that

medicomilitary efficiency could be achieved only by the establishment of

standardized methods, there were several other reasons why anesthetic agents,

at least in forward zones, were chiefly limited in World War II to ether, Pento- thal Sodium, and procaine hydrochloride:

1. 'The use of cumbersome equipment was undesirable because of the

disproportionate amount of scarce shipping space which it occupied in transit

to destinations overseas.

2. The use of such equipment was also impractical. Many times during

the course of the war, hospital installations in forward areas, even 400-bed

evacuation hospitals, had to evacuate their patients; tear down their equipment;

move forward, often many miles, often over difficult, congested roads, and

sometimes under fire; set up again and be ready to receive patients within 24
ANESTHESIA 57

hours after the first notification of the move. When such moves had to be

accomplished, as well as under other military circumstances, it was almost

impossible to protect delicate, complicated apparatus from injury. Gas

machines are delicately adjusted, and when they were handled roughly they

were likely, in short time, to leak and to lose their serviceability.

3. The problem oflogistics played further part in the choice of anesthestic

agents in forward areas. Interruption of supply channels and constantly

changing supply routes soon convinced even anesthetists who had strong

preferences for certain agents to the exclusion of others that they must content

themselves with fewer agents, preferably those which, when necessary, could

be transported by hand and which could be administered, when necessary, by

improvised techniques and equipment.

4. The shortages of trained personnel for the administration of anesthetics

made it necessary, from the standpoint of safety, to limit the agents employed

to those which could be given, without undue risk to the patient, by physicians

and nurses of limited experience in this field.

PERSONNEL

The outbreak of World War II found the whole United States with far

fewer trained anesthetists than were needed for the practice of the specialty in

peacetime. The Army Medical Corps, which represented cross section of

American medical personnel and practice, naturally reflected this shortage.

Furthermore, because of the previous Army policy in regard to training medical

officers as anesthetists, it was not until March 1939 that 6-month course of

instruction was begun at the Mayo Clinic by the first medical officer to he

designated for formal training in anesthesia since World War I. When he

completed his course, he was replaced by another officer, and this limited policy

was still in effect at the time of Pearl Harbor. While these officers were being

trained, nurses continued, as previous!} to give inhalation anesthetics in the

various Army hospitals in the United States. Spinal, local, and regional

anesthetics were given by the surgeon himself or by some other medical officer

designated for this purpose.

The Army shortage of trained personnel in anesthesia was seriously reflected

in the North African Theater of Operations, where the first prolonged fighting

against the western Axis powers took place. Of the 77 physicians in the theater

designated as specialists in anesthesia, only 10 percent had been certified by the

American Board ofAnesthesiology. Fifteen percent of the so-called specialists

in anesthesia had been trained in courses which lasted from to months,

and 20 percent had had no training at all except what they had obtained incidentally, during surgical residencies and rotating internships.

The small number of physicians available for assignment to anesthesia in

the Mediterranean (North African) Theater of Operations was compensated

for by number of substitutions and shortcuts:

1. Although shortages in personnel seldom seriously slowed down the care

378327°—56
58 GENERAL SURGERY

of casualties, the possibility was always constant and uncomfortable threat.

When the situations arose, dentists, as had been arranged previously, helped

out voluntarily.

2. good many medical officers who had had little, if any, special preparation in anesthesia were also pressed into service.

3. Aidmen, under close supervision, sometimes gave anesthetics in times

of stress in forward areas. This was not desirable expedient. These men,

because of their earnest application to their duties, often rendered good service,

but, in general, this was not satisfactory plan.

4. Continuous training of nurses was practiced. Four general hospitals

were employed for this purpose in the Mediterranean theater. They were

more suitable for supervised training in anesthesia than were forward hospitals.

Theoretically, the course of training was months. Actually, how long the

student remained depended upon how long she could be spared from her unit.

Often this was only months, and sometimes it was only month.

5. Schools of anesthesia were supplemented by individual training given

in the various units in the theater. In number of instances, the unusual

abilities possessed by anesthetists in affiliated units working at the rear were

utilized in the training of anesthetists to be sent to forward areas.

Surveys made in certain evacuation, station, and general hospitals in the

Mediterranean theater in September 1944 showed that the relationship between

personnel administering anesthesia and the surgical load varied widely (table 3).

The assignments, for obvious reasons, were made according to the function of

the hospital. Evacuation hospitals naturally required the greatest concentration of personnel in the forward areas. Field hospitals, in which newly

wounded nontransportable men were cared for, and which had 100-bed

capacity per platoon, were usually staffed by four auxiliary surgical teams.

Each of these teams included an anesthetist, who was usually physician, and

the setup was such that two operating tables could be kept in continuous use

day and night. Occasionally, when the load was particularly heavy, three or

four operating tables could be used at the same time in single platoon, but

this arrangement could not be maintained for very long.

As working principle, it was found best to assign the ablest anesthetists

to the combat zone. Here there were the greatest demands on native intelligence, judgment, resourcefulness, and technical ability. In practice, this

principle could not always be applied, because physicians in units associated

with affiliated schools and hospitals could not readily be detached from them.

It was undoubtedly true that surgery undertaken in station and general hospitals in rear areas required at least as much judgment, skill, and training on

the part of the anesthetists as were required in forward areas, but itwas equally

true that the circumstances under which surgery was done in forward areas

put particularly heavy tax upon these qualities and qualifications.
ANESTHESIA 59

Table 3.—Provision of anesthetic personnel in sample evacuation, general, and station

hospitals in Mediterranean theater (September 1944

EQUIPMENT

The portable Heidbrink and McKesson anesthetic machines issued by the

Army were of the standard type used in all civilian hospitals. The Beecher

Capac- ity

listed

Anesthetic personnel

Hospital Occupancy Daily oper- ations Physicians Nurses Auxiliary

surgical

group

Aidman

in field

Remarks

EVACUATION HOSPITALS

750 800 28 to 100 tables day, night.

400 600 25 to 120 tables day and night.

on second call.

750 50 to 100 tables day and night. physician and

nurse-anesthetists care for 50-case

days; auxiliary surgical-group anesthetists assist on 100-case days.

Auxiliary surgical-group anesthetists

assist on 138-case days.

internists and auxiliary surgicalgroup anesthetists assist on 125-case

days.

to tables day and night. dentist

and internists assist on 120-case days.

400 550 60 to 138

400 500 50 to 125

750 400 80 to 120

GENERAL HOSPITALS

1,600

1.500

1,600

1.500

1.500

900 10 anesthesia utilitymen help with apparatus; they do not give anesthetics.

1,700 50

26

1,000

950

10 or internists help, as needed.

13

STATION HOSPITALS

250 348 physician on part-time anesthesia duty.

Surgeons give all spinals.

Part-time physician-anesthetist also has

ward.

600 250

500

500

400

surgeons cover anesthesia on part-time

basis.

500 389 6. Medical officers rotate on anesthetic

250 490 15

duty.

500 625 4.5 surgeons cover anesthesia on part-time

basis.

At time of survey.
60 GENERAL SURGERY

machine was designed especially for military use. As early as 1941, the Subcommittee on Thoracic Surgery of the Committee on Surgery of the National

Research Council, with vivid recollection of the high death rate which followed wounds of the thorax in World War I, had attacked this problem from

various aspects, with the idea of developing methods of making early transpleural intervention practical. Patients with wounds of the thorax frequently do not tolerate delay in transportation to distant hospitals. At the

same time, successful forward surgery could not usually be done in the absence

of positive pressure in the airway. The problem, from the standpoint of

anesthesia, was therefore twofold: (1) To devise simple anesthesia apparatus

which would be light, compact, and easily carried by hand; and (2) to construct

it in such manner that positive pressure could be developed with it, without dependence on tanks of oxygen, the provision of which, it was then thought,

would be impractical in forward areas of active combat.

The machine designed to meet these requirements (figs. 8, 9, and 10)

consisted of the following parts: foot bellows, with air intake well above the

floor; an air reservoir bag; an air-reducing valve and reducing valve arrangement which permitted the use of compressed oxygen when it was available;

Figure 8.—Transportable anesthetic apparatus for administration of ether in simplified

closed system with and without oxygen.

Beecher, H. K.: An Easily Transportable Apparatus for Anesthesia With or Without Compressed Oxygen. Especially Designed for Positive Pressure Anesthesia in Thoracic Surgery Under Military Conditions. War Med. 2: 602-608, July 1942.
ANESTHESIA 61

Figure 9.—Transportable anesthetic apparatus in carrying case and set up

safety blowoff valve; an ether-vaporizing bottle with string wick, to promote rapid volatilization of ether; face mask; and breathing bag with

to-and-fro soda-lime filter (Waters’ type for the removal of excreted carbon

dioxide). At the distal end of the soda-lime canister was an adjustable vent,

which was chiefly used when room air was employed. An intake tube feet

long, which could be attached to the operating table, maintained the air intake

of the foot bellows at considerable distance above the floor so that no floor
62 GENERAL SURGERY

Figure 10.—Administration of ether in simplified closed system in evacuation hospital in

Italy, 1944.

dust was taken up. The parts of the machine made of rubber were preferably made of conductive rubber. The machine permitted the maintenance

of positive pressure in the airway when this was necessary, but at the same time

could be so adjusted as to allow the gradual escape of air from which part of

the oxygen had been extracted during respiration.
ANPJSTIIESIA 63

Several changes were made in the original model after it was tested in actual use. It was found that the foot bellows could be dispensed with because

oxygen was available in forward as well as rear areas. It was also found

advantageous to add dropper of the oil-cup type, to enrich the ether atmosphere. Finally, the machine was further simplified by elimination of the flow

meter, which was not really necessary for the air or oxygen used in maintenance. If the breathing bag was kept adequately fdled and if care was taken to see

that the patient’s blood was always of good color, nothing else was needed

beyond the respiratory excursions adequate to remove carbon dioxide.

This machine was carried, by hand when necessary, in compact container

measuring 10 by 10 by 19 inches (fig. 9). The container was large enough

to contain additional supplies, including laryngoscope (Eversole) with the

battery in the handle, and extra light bulbs for it; rubber intratracheal

tubes (Magill, #29 and #32); an aspiration bulb and catheter (Flagg) for clearing

out the bronchi; small packet of the agent used for induction, usually Pentothal Sodium; and cans of ether (1 pound each). When the container was

fully loaded, the total weight was 25 pounds. The machine itself was so small

that it occupied little space in crowded operating tent, and it was so simple

and durable that there were few parts to get out of order and few opportunities

for leakage. An additional advantage was that itrequired only small amounts

of critical materials for its manufacture.

Anesthesia could be induced with this apparatus by the so-called straight

ether method at least as conveniently as by the open cone method. Civilian

experience had shown that induction with nitrous oxide was satisfactory in

transpleural surgery, but nitrous oxide was seldom available at the fieldhospital level. Pentothal Sodium was sometimes used for induction in ether

anesthesia, but this agent was not safe, even for this limited purpose, in

seriously wounded men (p. 72).

Although one of the reasons the Beecher machine had been devised was

to make thoracic surgery feasible without the use of compressed oxygen,

this did not mean, of course, that oxygen was not used when it was available

(fig. If). As matter of fact, and contrary to expectations before the war,

oxygen was supplied at most forward installations. If the amounts available

were limited, it coidd be added in small quantities to the room air in the system

during the period the pleura was open. If, for instance, the pleura was open

for 30 minutes, the addition of 9.5 liters (2.5 gallons) of compressed oxygen

aided greatly in maintaining ideal operating conditions. Compressed oxygen

was thus conserved, and little was made to go as far as possible. When

compressed oxygen was not available, constant flow of room air was maintained through the apparatus. When the system was constantly flushed in

this manner, it was not necessary to use the soda-lime carbon dioxide absorbent.

Although the Beecher machine was devised specifically for use in thoracic

surgery, experience in the combat zone proved its usefulness for any other

type of operation in which inhalation anesthesia was employed. It could

also be used for the administration of ox} gen and for artificial respiration.
64 GENERAL SURGERY

Figure 11.—Administration of ether with oxygen in simplified closed system in

evacuation hospital in Italy, 1944.
ANESTHESIA 65

ANESTHETIC AGENTS

The pattern of anesthesia had been clearly established by September

1944 in the North African (Mediterranean) Theater of Operations, where there

had been active and often intensive combat since November 1942. Ether

had emerged as the agent of choice for operation on seriously wounded soldiers,

and its corresponding merits in men who were better risks had also become

evident. Local anesthesia had been shown to be inadequate for major procedures and was not well tolerated by apprehensive, badly wounded men, who frequently had multiple wounds and who sometimes were in great pain.

Intravenous anesthesia with Pentothal Sodium had its first valid trials in

military surgery during the fighting in North Africa. After proper regimen

for its use had been established and limitations and contraindications had

been determined, it was found to be admirably suited for the needs of war

surgery.

In the following sections, the advantages and disadvantages of the various

anesthetics and techniques available at the outbreak of World War II are

briefly discussed from the standpoint of their use in combat zones. In station

and general hospitals, there were no special problems of anesthesia because

conditions in them approximated those in civilian hospitals.

Spinal Anesthesia

When spinal anesthesia was first introduced, its tendency to cause fall

in blood pressure was so significant and so serious that its use was almost discontinued. Then it was found that vasoconstrictor drugs could control this

effect, though the most potent vasoconstrictors could not maintain levels of

safety in patients who had suffered severe trauma and had lost large amounts

of blood.

Spinal anesthesia was additionally undesirable for another reason. When

it is used, the vasomotor fibers are the first to be paralyzed and the last to

recover. The area over which this effect occurs is larger than the area over

which the pain response is eliminated, since to interrupt vasomotor control

requires lower concentration of whatever agent may be employed than is

required to interrupt pain sensation. Spinal anesthesia therefore breaks down

an important body defense against shock by the interruption of vasomotor

control, which is one of its integral effects. In spite of these well-known disadvantages, many surgeons contended in

the first years of the war that spinal anesthesia was desirable in military

surgery. Many American surgeons argued for its employment, in spite of the

data concerning its risks and inefficiency which came in from areas of combat

early in the war, on the ground that errors of administration could account for

the unsatisfactory results.

Studies reported from the Massachusetts General Hospital in 1943

Beecher, H. K.: The Choice of Anesthesia for Seriously Wounded Patients. J. A. M. A. 121 899-903, 20 Mar. 1943.
66 GENERAL SURGERY

effectively answered these arguments. These studies were carried out in two

series of patients with perforated peptic ulcers. The patients, chiefly men, of

an average age of 44 years, were seen within 30 minutes to 40 hours of the

accident, and all were submitted to the same well-standardized reparative

operation. One group was operated on under spinal and the other under ether

anesthesia. Whether the administration was by widely experienced anesthetists or by beginners, fall in blood pressure was observed twice as frequently

when spinal anesthesia was used.

Spinal anesthesia had limited use early in the fighting in the North

African theater, but its popularity decreased as it came to be appreciated that

there were few indications for its employment in forward areas. One reason

for limiting its use in these areas was the difficulty of preserving sterility of

equipment in the field. more potent argument was the poor tolerance of

freshly wounded men for it, as indicated by the tendency of the blood pressure

to fall when it was used. The condition of the circulation, always precarious

in freshly wounded man, deteriorated rapidly when it was employed, and

eventually few surgeons or anesthetists, whatever their practices and preferences

might have been in civilian life, recommended its use in forward areas, even in

lightly wounded men. It always had, of course, considerable and proper use

in hospitals to the rear.

survey of 12 hospitals in September 1943 showed that, since November

1942, spinal anesthesia had been used in almost 20 percent of the operations in

forward hospitals. second survey, in August 1944, showed that in the intervening period it had been used in only percent of operations in forward

hospitals. Further analysis showed that this proportion was composed largely

of emergency appendectomies and other operations not related to warfare.

The sharp decrease in its use indicated, as already noted, both realization of

and an acceptance of the fact that spinal anesthesia is usually poor choice

in badly wounded men and may, indeed, be major error.

Local (Regional) Anesthesia

Local anesthesia must always be considered when noninflammable

anesthetic is required or when surgery must be carried out on traumatized and

exsanguinated patients for whom it would be adequate. The English experience

early in the war, however, showed that the moderate discomfort and psychologic trauma associated with its use made this type of anesthesia poorly tolerated by seriously wounded men who were aware of their condition and surroundings. In their hands, as later in American hands, it was sometimes useful

for minor surgical procedures on phlegmatic or apathetic subjects, but appraisal of the patient’s possible tolerance for occasional discomfort and other

inconvenience was an essential preliminary to the decision to employ it.

The technique of local anesthesia is not difficult for surgeons who use it

regularly and have had special experience with it. In other hands, there is

considerable proportion of partial successes and actual failures. These difficulties made local anesthesia time consuming and furnished another sound
ANESTHESIA 67

reason for its limited use under combat conditions in the Mediterranean

Theater of Operations in World War II. Finally, the soundest reason for the

limitation of its use was the multiplicity of wounds usually present in each

case. In these circumstances, it was not practical method.

Harmful circulatory effects can occur from the use of too large amounts of

local anesthetic agents or from their too rapid absorption. These undesirable effects can he minimized by two precautions:

1. The addition of epinephrine hydrochloride (1:200,000 in the optimum

final dilution). This practice prolongs the anesthetic effect perhaps fivefold and

at the same time reduces the quantity of procaine hydrochloride needed. Vasoconstricting agents should not he used, however, in operations about the genitals

or on the fingers, toes, ears, or nose, because of the danger of sloughs. They

should not be employed when cyclopropane, chloroform, ethyl chloride, or

Avertin (tribromoethanol solution) are to be used, because of the danger of ventricular fibrillation. Finally, they should be employed with great care, if at all,

in patients with organic circulatory impairment.

2. Careful attention to dosage. Toxicity from the absorption of local

anesthetic agents increases in geometric progression as the dosage is increased.

Thus it is usually safe to give an able-bodied man 150 cc. of 1-percent procaine

solution over period of an hour but dangerous to give him 75 cc. of 2-percent

solution over the same period. Not more than 35 cc. of the 2-percent solution

can be used with safety in the space of an hour.

Within the limitations and with the precautions specified, local and

regional block, chiefly with procaine hydrochloride, proved useful in certain

neurosurgical and maxillofacial operations, as well as in minor surgical procedures. It also had other uses. In the form of intercostal and paravertebral

block, procaine hydrochloride was useful in controlling pain in the traumatized

chest wall, with consequent improvement of the respiratory function, and in

improving the blood supply to an extremity. Peritoneal block under direct

vision after the abdomen was opened often improved relaxation of the abdominal

wall to such degree that only light general anesthesia was necessary.

When topical anesthesia was indicated, it was accomplished with Pontocaine (tetracaine hydrochloride) or cocaine.

Chloroform

From the theoretical standpoint, chloroform has number of advantages.

It can be administered smoothly with minimum of equipment. Its potency is

so great that only low concentrations are needed in inspired air, and adequate

oxygenation can be obtained from the atmosphere of the operating room. It

produces excellent muscular relaxation. It is easily transportable, and it does

not burn or explode.

These advantages are outweighed by number of disadvantages and

dangers. The ventricular fibrillation, central hepatic necrosis, and destruction

of the convoluted tubules of the kidneys which chloroform is capable of producing can cause death or serious and permanent disability. Its effect on the
68 GENERAL SURGERY

circulation is profoundly depressing. It slows the heart rate, weakens the

strength of the cardiac contractions, reduces the cardiac output, and depresses

the blood pressure. It also causes acidemia. Hepatic damage produced by

chloroform can be minimized by its administration with high concentrations of

oxygen in inspired air and by diet high in protein and carbohydrate; but these

precautions are not always possible under conditions of combat, and they do not

alter the possible effects of chloroform on the circulation.

Chloroform had been practically discredited in civilian practice for many

years before World War II, and its effects on the circulation are such that there

would seem to be even less reason for using it in men wounded in battle and

already suffering from circulatory impairment than in nontraumatic civilian

practice. It was therefore almost never used in the Mediterranean theater.

With the other agents available, it was difficult to find legitimate use for it,

except when Pentothal Sodium, nitrous oxide, or local anesthetic agent was not

adequate and it was imperative to use noninflammable agent.

The suggestion was made that chloroform be provided in small ampules for

administration by nonmedical personnel to wounded soldiers who had become

manic in burning tanks and who might be more easily removed through the

narrow escape hatch if they could be controlled. So far as is known, chloroform

was not used for this purpose in any theater of operations.

Nitrous Oxide, Ethylene, and Cyclopropane

Nitrous oxide, ethylene, and cyclopropane all have the initial disadvantages, from the military standpoint, that they require steel cylinders for their

storage and that they must be used with compressed oxygen.

Nitrous oxide and ethylene have undesirable metabolic effects if they are

administered without adequate oxygenation, which is generally impossible

requirement if full surgical level of anesthesia is necessary. This is particularly true when nitrous oxide is used, since the high partial pressurerequired

leaves little room for oxygen. The same is true, though to lesser degree,

when ethylene is used. Satisfactory muscular relaxation cannot be produced

with either of these agents within the limits of safety.

Cyclopropane has deleterious effects on the heart and has apparently

caused death from ventricular fibrillation in considerable number of cases.

Aside from this effect, it seems to be better tolerated, from the circulatory

standpoint, by animals in shock or in impending shock than any of the other

anesthetic agents, with the possible exception of ethylene. Whether this is

true of human subjects in shock is not yet known.

Neither cyclopropane nor ethylene was issued to medical officers in the

Mediterranean theater. When nitrous oxide was available, it was occasionally

used for minor surgical procedures, such as painful changes of dressings. It

was also occasionally used to supplement other forms of anesthesia, such as

Pentothal Sodium (with 50-percent oxygen), or for induction in ether anesthesia. It was useful for all of these purposes, but it was by no means indis-
ANESTHESIA 69

pensable. Nor did it rank in efficiency with ether, Pentothal Sodium, or

procaine hydrochloride.

Vinyl Ether

Vinyl ether acts rapidly and is readily transportable. In spite of these

advantages, it was not used extensively in any theater in World War II because

its advantages were outweighed by its disadvantages. It is difficult to use

satisfactorily without closed rebreathing apparatus. It has tendency to

cause laryngeal spasm, profuse salivation, muscular twitchings, and even

convulsions and liver damage. It is chemically unstable, and it is possible

that the results just listed may be caused by that property.

Ether

Ether is undoubtedly the most useful anesthetic agent for general purposes

and under nearly all circumstances, including military circumstances. Its

great potency permits an adequate supply of oxygen, even if only room air is

available. Its straight induction in seriously wounded men is remarkably

easy and is apparently not unpleasant for the patient, whether the open-drop

method is used, or, as is preferable, it is given by the closed method, with oxygen (fig. 11). Ether produces excellent muscular relaxation. It is well

established that even an impaired circulatory system tolerates prolonged ether

anesthesia well. man in shock, in fact, seems to tolerate ether far better than

an animal in shock.

Ether has, on the other hand, some undesirable properties. It is irritating

to the mucous membranes of the respiratory tract—though it has never been

adequately demonstrated that this characteristic increases the incidence of

respiratory complications or the number of deathsfrom them, while considerable evidence suggests that the irritation which it causes is of no clinical importance.

Ether also causes considerable disturbance of metabolism, the blood sugar

frequently being elevated from 100 to 200 percent.

In World War II, ether was the anesthetic of choice in the seriously

wounded, whether the gravity of their injuries depended upon widespread

tissue destruction, penetration of body cavities, or severe hemorrhage from

wounds which in themselves might not otherwise have been of great consequence, Since it was the anesthetic best tolerated by men in shock, it

seemed reasonable to use it also in men who were less badly off. In the first

months of fighting in North Africa, it was not used as widely as it should have

been, at least in forward hospitals. The increase in its use in the second

year of fighting may be unimportant statistically, but clinically it is of great

significance, since it occurred chiefly in the field hospitals, where the surgically

important group of patients was treated. These were the men with wounds

of the abdomen and thorax and compound fractures of the femur.

An intelligent appraisal ofanesthesia practices is not possible without some

knowledge of the type of surgery performed. The mere tabulation of data

(table 4) does not tell the full story. The true picture is better obtained from an
70 GENERAL SURGERY

analysis of the experience of auxiliary surgical groups, which had wide experience in forward surgery, particularly in the surgery of nontransportable

patients in field hospitals. In such an analysis, surgery of the abdomen and

chest assumes greater importance than the tabulated data indicate. Of

15,925 wounded men treated by the 2d Auxiliary Surgical Group, for instance,

during the North African, Sicilian, and part of the Italian fighting, 1,628 (10.2

percent) had abdominal injuries, 1,502 (9.4 percent) had thoracic injuries with

pleural involvement, and 508 (3.2 percent) had thoracoabdominal injuries.

Since the 1,628 abdominal injuries included number of cases in which exploration was negative, the thoracic injuries may be said to have been approximately

as frequent as abdominal injuries in the experience of this group, while the combined total of thoracic and thoracoabdominal injuries exceeded the number of

abdominal injuries. The responsibility of the anesthetist in surgery of such

magnitude is too evident to need elaboration.

Table 4.—Sample distribution of surgical procedures in the Mediterranean (North African)

campaigns (1943-44)

The Barbiturates

Civilian experience up to World War II showed that when the barbiturates

(Evipal Sodium (hexobarbital soluble) and Pentothal Sodium) were used for

major as well as minor surgery, the death rate, depending upon the quality of

the clinic, was likely to be from to 10 times higher than for ether anesthesia.

At the Massachusetts General Hospital, where these agents are chiefly used

for procedures on able-bodied adults which last less than an hour, 8,000 consecutive anesthesias were administered with barbiturates with no deaths.

Early in the series, however, number of lessons were learned: That bad-risk

patients tolerate these drugs poorly, except when they are used in small amounts

as supplements to other forms of anesthesia; that, even in these circumstances, fall in blood pressure may occur during spinal anesthesia; and that patients

with circulatory impairment tolerate full barbiturate anesthesia particularly

poorly.

See footnote 6, p. 65.

Site of major surgery

Area Number of

operations Extrem- Abdo- Chest

Central Ear, Miscellaneous

ities men nervous

system

nose,

throat Major Minor

Forward (field and evacuation) hospitals 9, 199

Percent

28.

Percent

7.

Percent

3.

Percent

1.

Percent

0.

Percent

3.

Percent

56.

Rear (station and general)

hospitals 11, 261 13. 6. 1. 2. 4. 71.
ANESTHESIA 71

Adequate studies have shown that intravenous anesthesia with barbiturates

is associated with two other outstanding hazards:

1. It causes progressive loss, whichfinally becomes complete, of the sensitivity of the respiratory center to its normal chief stimulus, carbon dioxide,

the content of which in the blood may rise to depressant levels during anesthesia with barbiturates.

2. When the normal respiratory drive becomes impaired or disappears

completely, supplementary mechanism is necessary to keep it going.

shift is therefore made from the normal driving action of carbon dioxide on

the respiratory center to the action of anoxia on the chemoreceptors, chiefly

the aortic and carotid bodies.

Pentothal Sodium was provided in the North African Theater of Operations from the time of the first landings in November 1942. Its ready availability; the simplicity and compactness of the equipment for its administration; the ease and smoothness of induction, even by inexperienced physicians; and

the apparent infrequency of undesirable after effects—all made it popular

anesthetic drug under combat conditions. These advantages tended to outweigh other important considerations; That Pentothal Sodium is powerful

tool, that overdosage is not easy to overcome, that the lethal dose varies within

wide range from one patient to another, and that this form of anesthesia is

definitely contraindicated in certain types of injury and under certain circumstances.

The results of the casual acceptance of the advantages of Pentothal Sodium

without regard for its dangers and disadvantages, were apparent in the first

survey of anesthesia made in the theater, in September 1943. Sample data

secured from 12 hospitals showed that this agent had been used in 2,672 operations and that in of the fatalities which followed (1:450), death could be

attributed only to anesthetic causes. Further investigation at other hospitals

produced similar data. Results throughout the theater, in fact, were so bad

that it was seriously proposed that this form of anesthesia be abandoned em

tirely, particularly since the experience in North Africa paralleled the experience

reported from Pearl Harbor.

detailed analysis of the fatalities caused by Pentothal Sodium anesthesia

in 1942-43 cast somewhat more hopeful light upon the situation. Two errors

were outstanding, but both ere readily correctible. The first was the use of

this method of anesthesia by completely inexperienced medical officers, many

of whom seemed to have the impression that all that was necessary was for the

drug to be injected into vein. The second error was the frequent use of this

method in conditions in which it was actually contraindicated and in which it

should never have been employed. The impression derived from the analysis

was that if these errors could be corrected and the conditions of its administration controlled, Pentothal Sodium might prove to be, in practice, the ideal

anesthetic for certain types of injuries of warfare, just as it had always been in

theory.

The decision to continue the use of Pentothal Sodium as an anesthetic
72 GENERAL SURGERY

agent in the Mediterranean theater proved sound. survey conducted in

10 hospitals in the theater in September 1944, year after the first survey,

showed that only deaths could be attributed to its effects in 11,136 operations

(1:5,550). In other words, during the period covered by the second survey,

Pentothal Sodium, although it had been used in about times as many cases as

during the first period, was responsible for only third as many deaths. The

figures indicate the magnitude of the improvement which had been achieved in

the course of the year.

It should be emphasized again that this improvement occurred over

period in which the use of Pentothal Sodium had increased considerably. In

September 1943, this agent had been used in over 2,500 (53 percent) of the

operations performed in the forward hospitals surveyed and in 1,462 (28 percent) of the operations performed in the station and general hospitals surveyed.

In September 1944, these proportions had risen, respectively, to 63 percent

(6,721 operations) and 48 percent (4,415 operations). large part of the increase could be explained by the widespread adoption of the practice of secondary wound suture, procedure for which this of anesthesia approaches

the ideal.

By this time, the indications and contraindications for Pentothal Sodium

anesthesia had been standardized. It was regarded as the optimum anesthesia

not only for delayed primary wound closure but also for any other procedure

which could be performed within 30 to 45 minutes. If the duration of the

operation was unexpectedly increased, it was the practice to shift to ether.

Pentothal Sodium had wide use in evacuation hospitals but was seldom used

in field hospitals, in which ether was the anesthetic of choice. Long experience

in the Mediterranean theater led to the almost universal view that Pentothal

anesthesia should never be used in the seriously wounded patient, whether he

was in good general condition or not. In the early days, many fatalities apparently due to Pentothal anesthesia occurred, and this contraindication became

clear. It was useful for the induction of ether anesthesia in men in good condition but was contraindicated for this purpose in poor-risk patients. It was also

contraindicated in the following circumstances unless there was some overriding

reason for its use:

1. When shock was present or impending.

2. When the intake or distribution of oxygen was impaired or in any way

jeopardized.

3. When an overdose of morphine had been given (p. 41).

4. When severe hemorrhage had occurred, or when the patient had sustained penetrating wounds of the thorax or abdomen or compound fracture

of the femur. Ether was the anesthetic of choice for all such cases.

5. When inflammation was present in the region of the carotid body and

carotid sinus. Inflammation in this area apparently causes sensitization of the

reflexes in it, and this phenomenon may explain the sudden deaths which sometimes occur under Pentothal Sodium anesthesia in wounds of the neck. Pentothal Sodium and other barbiturates are not highly effective in depressing these
ANESTHESIA 73

reflexes, and it was best to avoid possible trouble by resorting to another

anesthetic. On the other hand, when compound fractures of the face made the

administration of an inhalation anesthetic impractical, Pentothal Sodium, in

spite of its risks, might be the best choice for incision of cervical abscess or

some similar lesion. When it was employed in such cases, number of precautions were taken; The patient was heavily atropinized before operation. If the carotid sinus was found to be irritable, the operation was not begun until at

least 10 minutes had elapsed since the administration of Pentothal Sodium.

Pressure on the carotids was carefully avoided, and, whenever it was feasible, they were blocked with local anesthetic.

6. When gas gangrene was present. The contraindication to Pentothal

Sodium in this condition was based on the fact that the toxins elaborated

produce such severe circulatory damage that the patient is, for all practical

purposes, in shock. It is true that the skin temperature of the extremities

rises under Pentothal Sodium anesthesia, but the elevation does not necessarily

imply better cellular oxygen supply. The elevation may be attributable to

the effect of the anesthetic on the arteriovenous anastomoses. Investigations

have shown that the lymph flow is greatly reduced by barbiturate anesthesia,

in comparison with local or ether anesthesia, and this observation might be

construed as evidence that the oxygen supply of the tissues is impaired by it.

Such an effect should be avoided in clostridial myositis, in which oxygenation

is already deficient.

7. When the operative position or procedure seemed likely to interfere

with the airway or make artificial respiration difficult. If, for any reason, Pentothal Sodium had to be used in these circumstances, all the precautions

surrounding its use were sedulously observed. This form of anesthesia was

avoided, if it was at all possible, in operations which had to be carried out in

the face-down position and in operations for maxillofacial injuries involving

the airway. If local anesthesia was inadequate, as it frequently was, these

patients were best managed by ether anesthesia with endotracheal intubation.

8. When intracranial procedures were necessary. skillful—or

fortunate—anesthetist might sometimes employ Pentothal Sodium anesthesia

without an accident, but, for number of reasons, the risk was not regarded as

justified. Intracranial operations were usually of long duration. In series

of 20 typical craniotomies performed in combat zone in Italy, the average

operating time was 109 11 minutes, exclusive of the time for induction of

anesthesia. Another reason for avoiding Pentothal Sodium anesthesia in

intracranial surgery was the heavy blood loss, which was often liter or more

by actual measurement. The respiratory depression and anoxia which may

occur unexpectedly with this form of anesthesia introduced an entirely unjustifiable risk. Anoxia produces immediate swelling of the brain, which can

make an intracranial procedure difficult or impossible. Finally, the hiccoughing, laryngeal spasm, and straining occasionally encountered during this

form of anesthesia, or during recovery from it, were, as always, highly undesir378327°—56
74 GENERAL SURGERY

able in intracranial surgery. In most cases, therefore, Pentothal Sodium was

avoided, and inhalation anesthesia with ether or local anesthesia with procaine

hydrochloride was employed.

9. When severe burns had been sustained. Burned patients, for reasons

which were never clarified, were found to tolerate Pentothal Sodium anesthesia

poorly. Perhaps the explanation was the great reduction of the circulating

blood volume which is characteristic of burns. Whatever the reason, the

circulatory impairment from this cause is comparable to the effects of hemorrhage, in which Pentothal Sodium is always contraindicated.

Technique.—When the use of Pentothal Sodium had become standardized

in the Mediterranean theater, it was employed according to the following

technique:

1. It was used in 2.5-percent solution.

2. Atropine was used routinely for preliminary medication to minimize

vagal reflexes. The dose (0.6 mg., gr. Moo) was preferably administered

subcutaneously about an hour before induction. second injection of half the

original amount was given intravenously just before the anesthetic was started.

When the flow of casualties was heavy, this routine was not always practical,

and the total dosage (0.6 mg., gr. Moo) was given intravenously about 10

minutes before operation. When laryngeal spasm occurred during anesthesia,

atropine was again given intravenously, in the same dosage, and without delay,

no matter how shortly after the previous injection the emergency occurred.

3. While there was general agreement concerning the usefulness of atropine

as preoperative drug in Pentothal Sodium anesthesia, there was considerably

less agreement in principle or practice about the preoperative use of morphine.

For one thing, as pointed out elsewhere (p. 42), the reduction in the total

quantity of Pentothal Sodium accomplished by the use of morphine had to be

weighed against the possible dangers of overmorphinism in the injured man.

For another, it was not altogether clear whether morphine heightened the

activity of the laryngeal reflex, which was occasionally troublesome in Pentothal anesthesia. Nor was it altogether clear what part was played by morphine

in the long depressions which sometimes followed the use of Pentothal Sodium.

For these reasons, the administration of morphine was strictly individualized, and it was given before operation or withheld according to the needs of the

special patient.

4. The injection was made by an anesthetist or physician who had been

trained in the technique (fig. 12). The patient was under constant observation,

and the pulse rate, respiration, and blood pressure were recorded at frequent

intervals. It was the neglect of such precautions, which are traditional with

other agents, that accounted for the poor record of Pentothal Sodium when it

was first used in the Mediterranean theater.

5. As safety precaution, and always in long operations, oxygen was

administered with Pentothal Sodium (fig. 13).
ANESTHESIA 75

Figuke 12.—Administration of Pentothal Sodium anesthesia by nurse in evacuation

hospital in Italy, 1944.

PRE-ANESTHETIC MEDICATION

Early in the North African fighting, it was found that men who had been

seriously wounded in battle needed little pre-anesthetic medication and were

better off without it (p. 43). This early experience was repeated, often under

extremely adverse circumstances, at Cassino, on the Anzio beachhead, in

the Po Valley, and all through the campaigns in northern Italy and southern

France.

Atropine before ether anesthesia was usually given to cut down the flow

of mucus and minimize the vagal reflexes. The latter objective was particularly important in certain types of operations, including operations on the

thorax; within the abdomen, especially the upper abdomen; and on the neck

when inflammation was present in the region of the carotids (p. 72). The dose

(0.6 mg., gr. Koo) could be repeated within an hour if necessary. Atropine

was also useful, as already mentioned, when intravenous anesthesia with Pentothal Sodium was employed, to counteract the laryngeal spasm which occasion-
76 GENERAL SURGERY

Figure 13. Administration of Pentothal Sodium anesthesia with oxygen by medical officer

in evacuation hospital in Italy, 1944.

ally occurred when this agent was used (p. 74). When spasm became troublesome, second injection was usually employed and was given intravenously.

Morphine was given with great caution or was withheld entirely. As

pointed out elsewhere (p. 42), the peripheral circulation was always poor in
ANESTHESIA 77

chilled and shocked wounded men, and the morphine usually given as first- aid measure might not have been absorbed from the subcutaneous deposit.

When resuscitation had been effected, and later when vasodilatation occurred in response to ether anesthesia, poisoning was always possibility if the injec- tion of morphine was repeated and the double dosage was taken up into the

blood.

Morphine was given when local anesthesia was employed if pain or considerable discomfort was present or seemed likely to ensue. In addition, Pentothal Sodium was given by mouth in divided doses of 90 to 180 mg. (gr. 1)4 to 3) about 45 minutes before operation. Morphine was also used when it

was thought that pain was severe enough to interfere with the induction of

anesthesia. It was given intravenously or 10 minutes before operation,

always in small doses. This method of administration was routine during periods of heavy action.

ENDOTRACHEAL INTUBATION AND BRONCHOSCOPY

Endotracheal intubation was employed routinely in all intracranial, maxillofacial, and abdominal operations performed under general anesthesia.

It was also used routinely in all thoracic operations in which the pleura was

involved. Finally, it was employed routinely in any operation likely to exceed

an hour in duration. Otherwise, it was used, as general rule, only when the

operative position was such that maintenance of satisfactory airway was

difficult. Endotracheal intubation had far wider application on the level of

the field hospital than on the level of other hospitals.

The preparation of seriously wounded patients for surgery always included

check on the availability of bronchoscope, but the instrument was not

employed routinely, even in open thoracic operations. If the airway could be

kept clear by frequent aspiration through catheter in the trachea, the simpler

procedure was preferable, and bronchoscopy was resorted to only when this

could not be done.

Some surgeons and anesthetists advocated the routine use of the bronchoscope at the end of all major operations. This practice was considered undesirable by the majority of medical officers in both groups for two reasons:

1. If the bronchoscope was introduced at this time, it was necessary either

to maintain general anesthesia at deep level for longer time than was otherwise required, or the anesthesia had to be deepened for this purpose. Neither

practice was desirable at the end of trying operation, when the patient’s

condition might be poor.

2. If ether anesthesia was not maintained or deepened, topical anesthesia

had to be employed for bronchoscopy. Under these circumstances, if the

patient vomited during his reaction from general anesthesia, it was almost impossible to prevent the aspiration of vomitus through the locally anesthetized

airway.
78 GENERAL SURGERY

ANESTHETIC DEATHS

There is not always full agreement in civilian practice on what constitutes

an anesthetic death. In the Army, the decision could be more arbitrary. It

was the usual practice to classify in this category any death which occurred

without adequate explanation in the condition of the patient or in the operation

performed and which followed pattern characteristic of death under the particular agent employed.

The two surveys of anesthesia made in the Mediterranean Theater of

Operations in September 1943 and September 1944 showed total of 12 deaths

attributable to anesthesia in 27,564 administrations ofanesthetic agents. There

was considerable difference in the distribution of the fatal cases. There were

deaths in the anesthesias reported from the hospitals included in the 1943

survey, roughly 1:1,000, against deaths in the 19,914 anesthesias reported

from 10 hospitals in the 1944 survey, roughly 1:5,000. Clearly, as methods

became standardized and experience increased, anesthesia became increasingly

safer for the seriously wounded man.
Part II

ABDOMINAL INJURIES AND THE

INITIAL SURGERY OF

ABDOMINAL WOUNDS

W. Philip Giddings M. D., Editor

81

CHAPTER IV

Derivation of Data, Source Material, and

Methods of Analysis

W. Philip Giddings, M. D.

The data presented in the following pages, which concern only forward

surgery of abdominal injuries, are derived from the report to The Surgeon

General, United States Army, dated 27 August 1945, which describes the

activities of the 2d Auxiliary Surgical Group in the Mediterranean (North

African) Theater of Operations and in the European Theater of Operations

during World War II. In numerous instances, these data are characterized

by the omissions and discrepancies inevitably associated with the collection

of medical data under combat conditions. It is therefore important that the

manner in which they were collected and compiled should be clearly understood.

THE 2D AUXILIARY SURGICAL GROUP

The 2d Auxiliary Surgical Group functioned under Table of Organization

8-571, which authorized 121 medical officers, 11 dental officers, 70 members of

the Army Nurse Corps, and 176 enlisted men. The enlisted men were, for the

most part, surgical technicians who had been graduated from training schools

operated by the Army Medical Department. The personnel of the group was

broken down into surgical teams, 28 of which were assigned to general surgery

and the remainder to the various surgical specialties. As rule, each team

consisted of members; namely, surgeon, an assistant surgeon, an anesthetist, an operating-room nurse, and enlisted technicians.

Except for small permanent headquarters, the group maintained no

formal installation of its own. Instead, the surgical teams functioned on

detached service with various other organizations. After the Sicilian campaign, in 1943, the 2d was the only auxiliary surgical group assigned in the

North African Theater of Operations. During 1944 and 1945, its surgical

teams were employed by the Theater Chief Surgeon chiefly to furnish surgical

care in field hospitals and to augment the staffs of evacuation hospitals as

special needs arose. Individual teams were sometimes attached to British

mobile casualty clearing stations, installations which in setup and function

resembled United States Army field hospitals. ...

Teams from the 2d Auxiliary Surgical Group also participated in all major

amphibious operations of the Mediterranean campaigns, including the initial

landings at Anzio-Nettuno and in southern France. On these missions, they

Forward Surgery of the Severely Wounded. History of the 2d Auxiliary Surgical Group, 1942-45, vols. and II.
82 GENERAL SURGERY

functioned with field and evacuation hospitals, division clearing companies,

and, during early phases of the operations, with special troops (Rangers). In

August 1944, about half of the personnel of the group was attached to the

Seventh United States Army for the invasion of southern France. These

teams remained with the Seventh Army until the end of the war, passing with

it across France and Germany and into Austria. On this mission, they were

divorced from the remainder of the group for almost year.

Most of the work reported in the following chapters was done in the

platoons of the field hospitals customarily situated in close proximity to division

clearing stations during periods of combat. These hospitals, which were small,

mobile surgical units, were placed well forward, and their staffs were augmented

with competent surgical teams on detached service from the auxiliary surgical

group. Nontransportable casualties, after being selected by triage in the

nearby clearing stations, were sent directly to these hospitals for resuscitation

and urgent surgery. All patients with abdominal injuries were classified as

non transportable.

Some installation such as the field hospital was essential for the prompt

treatment of abdominal wounds. It was also essential for psychologic and

humanitarian reasons. The morale of combat troops was strikingly improved

by the knowledge that if they were wounded, all facilities for their care were

ready at hand and that, as far as possible, their priority for treatment would

be proportionate to the severity of their injuries. The morale-raising effect of

this knowledge was repeatedly commented upon both by combat officers and

by enlisted men, even those who had not become casualties.

Field hospital platoons, because of their geographic position within the

division area, were often uncomfortably close to legitimate military targets.

They almost always worked forward of Allied heavy artillery and always

worked within range of enemy artillery. At the Anzio beachhead, they were

many times subject to shellfire and to aerial-bombing attacks. Frequent

changes of location were necessary for tactical reasons, and, on occasion, undesirably early evacuation of patients was necessary to protect them from

enemy action. These facts go far to explain deficiencies and discrepancies in

the data to be presented.

SOURCE MATERIAL

The source material of this report is 3,154 patients with abdominal injuries

treated by the surgeons of the 2d Auxiliary Surgical Group in forward surgical

installations during 1944 and until the conclusion of the fighting in Italy and

elsewhere on the European Continent in May 1945. This material does not

include (1) casualties operated on by surgeons on temporary duty with the

group nor (2) 371 casualties with abdominal injuries treated in 1943, during the Tunisian and Sicilian campaigns and during the first months of the fighting

Unless specifically noted to the contrary, theterms “patient,” “casualty,” “case,” “wound,” and “Injury”refer to single cases or patients. Multiple injuries were numerous in this series of cases, but the analysis is always made on the

basis of single eases or patients unless otherwise specified.
DERIVATION OF DATA 83

in Italy. These cases are the subject of previous reports and are mentioned in these chapters only occasionally, for comparative purposes.

All 3,154 abdominal injuries were the result of the violence of warfare,

3,052 being caused by combat missiles. Approximately 90 percent of the

casualties sustained their injuries in actual combat. Wounded civilians, soldiers

of other Allied armies, and prisoners of war made up about 15 percent of

the series.

The series includes, in addition to injuries of intraperitioneal organs and

of extraperitoneal abdominal viscera, 839 thoracoabdominal wounds, 26

injuries of intraperitoneal viscera in which the abdominal wall was not penetrated (pp. 329,331), and 333 injuries in which exploration of the peritoneal

cavity revealed no intraperitoneal injury (p. 95).

METHODS OF ANALYSIS

This analysis was planned late in 1943, and the compilation of data was

begun January 1944. Mimeographed forms (fig. 14), prepared with special

attention to brevity and completeness and entirely separate from standard

army forms (field medical record), were supplied to the various surgical teams,

with instructions to keep separate clinical record for each patient treated.

The accumulated completed case histories were sent periodically to the 2d

Auxiliary Surgical Group Headquarters, where they were indexed and filed.

Compilation of data for the final report was begun in December 1944, but for obvious reasons not great deal could be done until after the German

surrender, in May of the following year. Intensive work was started in Juno

1945, when most of the teams were recalled from the field, the teams detached

to the Seventh United States Army returned, and the entire group was reunited

at Riva, Italy. For the next few months, all personnel who could be spared

from other duties cooperated in the preparation of the report to The Surgeon

General, of which the section on abdominal injuries represents about third.

The entire report required the review of, and tabulation of data from, approximately 22,000 case histories.

The various sections of the report were prepared by individual medical

officers, who worked under the direction of an editorial board composed of six

officers. Nurses and enlisted personnel assisted in clerical capacities, and the

final report prepared overseas represented the combined efforts of at least 200

persons. The last work on it was done during the period of redeployment, when

clerks and typists, as well as medical personnel, were constantly being transferred out of the unit. Upon the termination of the operational activities of

the 2d Auxiliary Surgical Group in the summer of 1945, small number of

officers and enlisted men, who had formally expressed the desire to remain in

Riva until the report was finished, completed the work in August 1945.

Report on the Surgeryof Abdominal Wounds (unpublished data), submittedto the commandingofficer, 2dAuxiliary

Surgical Group, 14 April 1944.

See footnote 1, p. 81.
84 GENERAL SURGERY

Surgeon: Date OP. Hour Hosp

Team: NAME; ASN;

AGE ORG: INJURY: Date Hour Type Agent:

Sites of Injury Time Lag How transported:

PRIOR TREATMENT Sulpha

Place Time IV Fluids po loc. Sedative Prior Op.

PRESENT STATUS; Dehydrated Nutrition Disease

Conscious Bleeding Shock

Phy ic al

Pertinent lab.

PREOPERATIVE TREATMENT:

OPERATION:_

Wound excision :PROCEDURE

Debridement

Chemotherapy

Pack

Dra ins

Type closure

P.O. DIAGNOSIS

ANESTHESIA RECORD

PRE-OP MED BP: PULSE RESP RISK 12 Duration _Technic Anesthetist;

REMARKS

Figure 14.—Summary sheet used by surgeons of the 2d Auxiliary Surgical Group for collection of data on abdominal injuries. Details of operation and the progress notes were entered on reverse of sheet. The abbreviation “Sulpha po loc.” refers to the postoperative local use of sulfonamides.

In its present form, the material on abdominal injuries represents complete revision made in theUnited States. The originalworksheets were reviewed,

all the data were subjected to recount and careful review, and revised data

were thus secured for number of sections, including those on timelag and the

multiplicity factor. The entire manuscript was then rewritten, many sections
DERIVATION OF DATA 85

several times, to incorporate these revisions and to give the authors the opportunity to introduce whatever second thoughts had occurred to them in more

normal environment than that in which the original manuscripts were prepared.

LIMITATIONS OF THE ANALYSIS

The source material used in this report was naturally affected in respect

to both completeness and accuracy by certain uncontrollable military circumstances. In an occasional case, the special record form had not been filled out

and had to be discarded. Some records were lost or destroyed, as the result of

enemy action or for other reasons. Information secured from the patient himself, or even from his emergency medical tag, was sometimes open to question.

There was often doubt as to the precise hour of wounding; whether the sulfonamide pills in the medical kit had been taken as soon as the wound was

sustained, if at all; how much morphine had been given, and when it was

given; and how much plasma had been given prior to the patient’s admission

to the field hospital. These and other details were sometimes recorded incompletely on the battlefield and in transit, or, occasionally, were not recorded at

all, and the patients themselves could recall them only hazily. In the field

hospitals, forced evacuation of casualties and the frequent shifting of surgical

teams militated against the maintenance of complete case histories. Finally,

during times of stress, when the load of casualties was heavy and continuous,

recorded data had to be limited to little more than brief statements concerning

the nature of the wounds and the surgical procedures.

Most patients with abdominal wounds stayed in forward hospitals only

briefly. Although the range of forward hospitalization per patient in days

was from to 30, the usual period of hospitalization was from to 14 days.

This fact, combined with the unavoidable deficiencies of records kept under

field conditions, explains the statistical inadequacy of the section on postoperative complications (p. 203). Progress notes were, understandably, often

sacrificed to the press of other duties or to the imperative need of overworked

surgeons for some rest.

One point which should be emphasized at this time and which will be

discussed again later (p. 94) is that the 756 deaths known to have occurred in

these 3,154 abdominal injuries are only the fatalities recorded in the forward

hospitals in which the initial surgery in these cases was performed. The other

(presumed) fatalities were lost to the records for variety of reasons. Some

patients were evacuated as consequence of enemy action. When, for example,

field hospital was shelled out of action on the Anzio beachhead, some patients

who had only recently been operated on were moved to other hospitals, and,

in spite of efforts to trace them, their ultimate fate was not discovered. Some

of them very probably died. In other instances, the followup records were
86 GENERAL SURGERY

incomplete, usually because the surgical teams were moved and the patients

were left in other hands early in their postoperative course. Some of these

patients unquestionably died. Finally, what happened to most of the patients

after they left the field hospitals in which they were operated on also is not

known by the writers of this report, though there is no doubt that the great

majority of all fatalities from abdominal wounds occurred in these forward

hospitals.

In addition to the errors and discrepancies inherent in the collection of

medical data under combat conditions, one other possible source of statistical

error must be mentioned, namely, the intrinsic human error which invariably

and inevitably enters when large number of different persons interpret the

same data. This error was enhanced by the fact that because of the special

circumstances in which this report was compiled, consistent editorial policy

could not be developed in advance of the analysis of the data. The policy,

in fact, evolved with the project. Since all questions which might involve

conflicts of views between individual authors could not be foreseen, data

derived by different authors from the same source material were not always

presented in the same manner. There was, for instance, no predetermined

policy about whether or not to classify nonperforating trauma to the walls of

hollow viscera under visceral injuries. Some authors therefore included it in

these injuries, while others excluded it. In the section on injuries to the

jcjuno-ileum, this type of injury is included as visceral wound. In the

chapter on wounds of the colon, it is not thus included. In certain other

chapters, it is not always clear which of these policies has been followed.

Again, the authors of the section on wounds of the colon, when they encountered

the case history of single perforation of the colon and severe contusion of

the ileum, listed the case as an instance of univisceral wound of the colon.

The authors of the section on wounds of the jejuno-ileum classified the same

case as multivisceral wound of the ileum complicated by wound of the

colon (p. 241). Variations in critical standards thus led to certain numerical

discrepancies which could not be reconciled after the original work had been

completed and the group had separated.

The statistical material in this report cannot now be supplemented or

altered, and such errors as it contains must stand. Nevertheless, when the

report was completed, it was the unanimous opinion of the surgeons of the 2d

Auxiliary Surgical Group that the presentation was substantially correct. For

one thing, the series is of such magnitude that, in the main, positive and negative errors probably have canceled each other out. For another, the conclusions to which the data point represent the consensus of the surgeons of the

group, partly as determined by informal polls and partly as derived from the

uniformity of practice reflected in the case records. Finally, there was general

agreement that the trends reflected by the statistical data are entirely consistent with wartime clinical experiences.
DERIVATION OF DATA 87

THE CONCEPT OF ABDOMINAL SURGERY IN WORLD WAR II

The concept of management of abdominal wounds underwent radical

reversal in the years before World War II. Between the Boer War (the

South African War of 1899-1902) and the outbreak of World War in

1914, the policy was one of strict nonintervention. The wisdom of this policy

began to be questioned by many surgeons as World War progressed, and by

the end of hostilities there was rather general agreement that most abdominal

injuries should be treated surgically, though lack of organization had prevented as wide an implementation of this principle as was desired. During

the Spanish Civil War (1936-39), when competent surgeons were available and

facilities and organization were adequate, prompt intervention was the rule,

and the number of cases in which the wounds were regarded as too severe to

permit surgery were relatively few.

The fundamental objective in the management of abdominal injuries

in World War II was as prompt surgical intervention as possible in all casualties

to whom the mere act of operation would not be fatal. Surgery was almost

never withheld on the grounds of the severity of the wounds; the precise

figures are not available, but it is certain that considerably less than percent

of the casualties with abdominal injuries who came under the care of surgeons

of the 2d Auxiliary Surgical Group were regarded as too severely wounded to

withstand operation. No matter what the man’s condition might be when

he was first seen, vigorous resuscitative measures were at once instituted, in

the expectation that surgery would be done. small proportion of these

casualties failed to respond and died during the attempt at resuscitation, but

they were the exceptions. In all other cases, the goal of giving every man with

an abdominal wound the benefit of surgery could be met.

DEFINITION OF TERMS

In the past, the terms “uncomplicated” and “complicated” have frequently

given rise to misunderstanding and confusion when they were applied to

wounds. In this analysis, they have been replaced by the terms “univisceral”

and “multivisceral,” which are used in the following special senses:

1. The term “univisceral” refers to an abdominal wound in which single

viscus has been injured. It carries no implications concerning the number

of injuries any single organ has sustained. Simultaneous perforations of the

cecum and sigmoid colon, for instance, are classified as univisceral wound

of the colon.

2. The term “multivisceral” refers to wound in which more than one

viscus has been injured, again without any implications concerning the number

Bailey, Hamilton: Surgery of Modern Warfare. Baltimore: the Williamsand Wilkins Co., 1944, vol. II, pp. 867-869.

Jolly, Douglas W.: Field Surgery in Total War. New York: Paul B. Hoeber, Inc., 1941, p. 166.
88 GENERAL SURGERY

of injuries each single organ has sustained. Coincidental injury to the colon

and the ileum, for instance, is regarded as multivisceral wound of either the

colon or the ileum.

3. The term “associated wound” refers to wound of part of the body

other than the abdomen.
378327°—56 89

CHAPTER

Distribution of Injuries and Other

Statistical Data

Luther H. Wolff, M. DSamuel B. Childs M. D., and W. Philip Biddings M. D.

DISTRIBUTION OF INJURIES

The statistical material used in this study is heavily weighted by preponderance of first-priority casualties. About 90 percent of the 3,154 casualties

were operated on infield hospital platoons (table 5), and most of the remainder

(7.4 percent) were operated on in evacuation hospitals. The case fatality rate

for each type of installation clearly reflects the severity of the injuries treated

in it.

Table 5.—Distribution of injuries and deaths in 3,154 abdominal injuries, by hospital

installation

As might be expected, the actual numbers of abdominal wounds observed

in the various campaigns varied directly with the fury of the fighting, each

offensive and each lull being mirrored in the number of casualties treated

(fig. 15). The exact relationship of abdominal to other injuries is not known,

but it is reasonable to assume that the curve for them closely paralleled the

curve for all casualties.

Since the infantry, as always, bore the brunt of the fighting, it naturally

received the majority of injuries, 69.6 percent (fig. 16). When only American

troops are considered, this proportion rises to 82 percent.

Involvement of viscera.—Almost three-quarters of these injuries involved

only abdominal viscera (table 6). The remaining 839 wounds were thoracoabdominal.

Type of installation Number

of cases

Percent of

total Deaths Case fatality rate

Field hospital 2, 851 90. 693 24.

Evacuation hospital __ 232 7. 35 15.

Casualty clearing station (British) __

58 1. 26 44.

Clearing station 10 10.

Not stated 33.

Total 3, 154 100. 756 24.
90 GENERAL SURGERY

■Battles before Cassino,

RCt.Porch.ia, SanVittore

Rapido River Crossing Anzio beachihead established

German counterattack-Anzao.

Allied attack.-An.210

Injuries

Fatalities

Assault on Grastav Line Anz-io

breakout,Breach o£ HitlerLine

Breach of Valmontone -Vclletri Lins,.

{Rattles before Arno Payer,

Vblterra,Laiatico

Arno reached.

Invasion o£ Southern Prance

Resistance on Rhone at Montelimar

Assault of Gothic Line-.

Attach on Vosges MtS,

Heavy m. Vosges and. Apennines.

Saverne (tap breakthrough.

Battle for Bitche,

CcerinarL counterattack, across Rhine at Gcambsheim,

■Colmar Pocket mop-upBattle for Saarbrcxecken and Porbach.

Limited offensive., Mt. Belvedere taken

SaarValley offensive be^un. general oriensive, beventti

and Fifth Armies,Bavaria and North Apennines.

Figure 15. (See opposite page for legend.)
DISTRIBUTION OF INJURIES 91

Figure 16.—Proportional distribution, according to branch of service, of 2,137 recorded abdominal injuries.

Table 6.—Regional distribution of wounds and deaths in 3,154 abdominal injuries

Figure 15.—Shown in the graph on the facing page is the distribution in relation to

intensity of combat of the 3,154 abdominal injuries which are the source material of part II

of this volume. These 3,154 injuries (casualties), including 756 fatalities, were sustained

in the 1944-45 campaigns in Italy, southern France, and Germany.

Type of wound Year Cases Deaths Case fatalityrate

Abdominal 1944 1, 744 406 23.

Thoracoabdominal 1944 639 180 28.

Abdominal 1945 571 130 22.

Thoracoabdominal 1945 200 40 20.

Total abdominal wounds 1944-45 2, 315 536 23.

Total thoracoabdominal wounds __1944-45 839 220 26.

Total- 3, 154 756 24.
92 GENERAL SURGERY

Analysis of these 3,154 abdominal injuries from the standpoint of the

particular viscera involved (tables and 8) suggests that the frequency of

wounding of an abdominal organ was almost directly proportional to its size.

The frequency of univisceral wounds of any given organ was apparently proportional to the extent of its area of contact with the abdominal wall. In other

words, in modern warfare the frequency of wounding of any given abdominal

organ seems directly proportional to the space which it occupies. The soundness of this conclusion is evident from consideration of the agents of wounding

in this series (p. 97). About 70 percent of the wounds were produced by fragmentation missiles. The remaining injuries, while they were caused by

bullets, were chiefly produced by roughly aimed automatic weapons. sniper’s

bullet, no matter how accurate the sighting might be, was not fired with selective intention toward any single abdominal organ. The fact that patients

with certain types of injuries were not seen alive is the explanation of variations

from the rule that the frequency of wounding of any given abdominal organ

was directly proportional to the space which it occupies. striking example

Table 7.—Distribution of univisceral and multivisceral wounds in 3,154 abdominal injuries

Univisceral Multivisceral Total

Organ injured

NumberEach

organ

NumberEach

organ Number Allpatients

Stomach 42

Percent

10. 374

Percent

89. 416

Percent

13. 19

Duodenum __

1. 116 98. 118 3. 74

Jejuno-ileum 353 30. 815 69. 1, 168 37. 03

Colon only 251 23. 816 76. 1, 067 33. 83

Rectum only 64 55. 52 44. 116 3. 68

Colon and rectum 13 33. 26 66. 39 1. 24

Liver 339 40. 490 59. 829 26. 28

Gallbladder and bile ducts 53 100. 53 1. 68

Pancreas 1. 61 98. 62 1. 97

Spleen 100 29. 241 70. 341 10. 81

Kidney 56 13. 371 86. 427 13. 54

Ureter 3. 26 96. 27 86

Urinarv bladder 21 13. 134 £6. 155 4. 91

Great vessels 10. 67 89. 75 2. 38

The term “univisceral” refers to an abdominal wound in which single viscus has been injured. It carries no Implication concerning the number of injuries any single organ has sustained. The term “multivisceral” refers to wound in

which more than viscus has been Injured, again without any implications concerning the numberof injuries each single

organ has sustained.

The figures in this column considerably exceed the total number of cases because in multivisceral wounds the same

patient appears in more than one category. For the same reason, the percentage distribution of wounds in the various

viscera exceeds 100 percent.

Calculations for injuries ofthe liver are madethroughout part IIof this volume on totalof 3,066 abdominal injuries,

insteadof on 3,154, the base figure for all other calculations. Whenthe 88 histories which represent the difference between

the two totals became available, the medicalofficers who haddone the work on wounds of the liverhad already been transferred from the command, and it was thought wiser not to change their tabulations.
DISTRIBUTION OF INJURIES 93

Table 8.—Comparative percentages of univisceral and multivisceral injuries in various recorded

series of abdominal wounds

Series Organ injured Total Univisceral Multivisceral

World War I:

American

Percent

7.0

Percent

66.

Percent

33.3 British, 8.5 68.3 31. Spanish Civil War ..

8.4

48.3 51.7

World War II:

British 4.6 2d Auxiliary Surgical Group ..

13.2 10.1 89.9

World War I:

22 British. 37.6 70.3 29.7 Spanish Civil War 31.5

56.8 43.

World War II:

British 32.9 2d Auxiliary Surgical Group 37.0 30.2 69.8

World War I:

22.0

60.0 40.0

21.4 (•)

65.6 34.

World War II:

25.5

33.8 23.6 76.4

World War I:

13.3 75. 25.0

16.8 90.8 9.

15.9

85. 14.3

World War II:

14.2

26.3 40.9 59.1

World War I:

1.4 33.3 66.

5. 59.3 40.7

4.6

75.0 25.0

World War II:

4.9

10.8 29.3 70.7

World War I:

6.3 50.0 50.0

7.6

70.0 30.0

8.0

World War II;

4.0

13.5 13.1 86.9

The American percentages for World War arc derived from The Medical Department of the United States Army

in the World War. (Washington: U. S. Government Printing Office, 1927. See vol. XI, pt. 1, pp. 65, 446-465). The

British percentages for World War are from War Surgery of the Abdomen, by Cuthbert Wallace (London: J. A.

Churchill, 1918). The percentages for the Spanish Civil War are based on series of 238 cases recorded by Douglas W.

Jolly (see p. 169 of Field Surgery in Total War, New York: Paul B. Hoeber, Inc., 1941). The British percentages for

World War II are derived from two series reported by W. H. Ogilvie in Abdominal Wounds in the Western Desert (see

Surgery, Gynecology and Obstetrics, 78: 225-238, March 1944).

Not stated.

Western Desert combined series (628 cases).

Western Desert second series only (247 cases).

Estimated
94 GENERAL SURGERY

of such variation is the comparative incidence of wounds of the vena cava

and of the abdominal aorta (pp. 318, 322). Thirty-three of the former were

observed, but none of the latter, presumably because wounds of the abdominal

aorta were almost immediately fatal.

When the distribution of abdominal visceral injuries in this series is

compared with the distribution in other reported series (table 8), two important

differences are at once apparent:

1. In general, the frequency of wounding of all organs was higher in this

series than in most other series.

2. The rate of univisceral to multivisceral wounds was strikingly reversed

in comparison with earlier experiences. The assumption seems warranted

that in this series much higher proportion of severely wounded men (that is,

men with multiple visceral wounds) reached forward hospitals, and were operated on, than was the case in other reported series. No other explanation

seems reasonable for the overall increase in frequency of wounding of all

organs, or, more particularly, for the marked change in the multivisceralunivisceral ratio. The higher incidence of involvement of the various viscera

in this series also makes itreasonable to assume that while the figures probably

are still too low, they more closely approximate the true frequency of wounding

of each organ than do those previously reported.

That so many more of the seriously wounded casualties were seen at

forward hospitals in World War II than in previous wars is difficult to explain,

except on the basis of the efficient performance of medical echelons working

forward of these hospitals and responsible for the evacuation of the wounded

from the frontlines.

CASE FATALITY RATES

In 1944, surgeons of the 2d Auxiliary Surgical Group treated 2,383 abdominal injuries in forward hospitals supporting the Fifth and Seventh United

States Armies, with 586 recorded deaths (24.6 percent). In 1945, they treated

771 similar injuries, with 170 recorded deaths, 22.0 percent. The case fatality

rate for the whole series of 3,154 injuries was thus 24.0 percent (table 6).

Two things must be emphasized in this connection:

1. These 756 deaths, as already pointed out, include only those known to

have occurred in the forward hospitals in which initial surgery was performed.

The postoperative stay in these hospitals seldom exceeded 14 days and was

frequently briefer. Additional deaths undoubtedly occurred in installations

farther to the rear, though since no followup of the patients was possible, the

exact number is not known. Informal inquiries indicated that fatalities in these

hospitals did not exceed percent.

Note.—Col. (later Maj. Gen.) Joseph I. Martin, MC, surgeon, Fifth U. S. Army, for many years had taught the

principles of medical evacuation in forward areas of combat at the Medical Field Service School, Carlisle Barracks, Pa.

During combat in Italy, wheremany of these casualties occurred, he not only placed hospitals as far forward as tactically

feasiblebut also demanded andobtained early and efficient medical evacuation under most difficult combatconditions.

J. B. C„ Jr.
DISTRIBUTION OF INJURIES 95

2. It is highly probable that more than 756 deaths occurred in forward

installations. The records of 256 patients contained no note at all concerning

their postoperative progress, and in 81 other cases progress notes ceased after

the third postoperative day. These data were lacking chiefly because of forced

movement of surgical teams or early evacuation of patients under difficult

tactical circumstances. In the completely recorded cases, the case fatality rate after the third day was 4.6 percent. If it is assumed that the rates in the 837

incompletely recorded cases just mentioned were the same as in the completely

reported cases, there would have been 65 additional deaths. The total number

of fatalities would thus be raised to 821 and the gross case fatality rate to

26.0 percent.

The case fatality rates require explanation from still another standpoint.

Included in the series are 333 cases, 10.6 percent of the total, in which no visceral injury was found. In 41 of these cases, the indication for exploration was

penetration of the peritoneal cavity by the missile. In the other 292 cases, the

indication was suspected penetration of the cavity. In 59 of these explorations,

retroperitoneal hematoma was found. In the remaining cases, the exploration

was entirely negative.

There were 24 deaths, 7.2 percent, in these 333 negative explorations, of

them in the category of penetration of the peritoneal cavity without visceral

injury. These deaths were, for the most part, the result of associated wounds

(p. 117). When the 333 cases in which there was no visceral injury are deducted

from the total number of cases, there remain 2,821 cases, 732 of which (25.9

percent) were fatal.

In assessing the relative distribution and lethality of wounds of solid and

hollow viscera, the analysis, for obvious reasons, must be limited to univisceral

injuries. In 496 univisceral injuries of solid viscera, there were 55 deaths (11.1

percent). In 734 similar injuries of hollow viscera, there were 128 deaths

(17.4 percent), the case fatality rate thus being 56.7 percent higher than for

injuries of solid viscera.

97

CHAPTER VI

ounding Agents

Luther H. Wolff, M. D., Samuel B. Childs, M. D., and

W. Philip Biddings, M. D.

Of the 3,154 abdominal injuries which make up this series, 3,052, or 96.8

percent of the total, were caused by missiles of war (fig. 17). High-explosive

fragments of various types caused 2,123 of these 3,052 wounds (69.6 percent),

1,844 of this group being caused by artillery-shell fragments. The remaining

929 wounds were caused by missiles discharged from small arms. Probably

many of the wounds listed in the records as caused by shell fragments were

actually the result of mortar fire. The case fatality rate for bullet wounds was

24.7 percent and for high-explosive fragments 23.1 percent.

Wounds of entry and exit.—The experience in this large series of injuries

made it clear that the effects of given type of missile are by no means uniform.

It was generally true, for instance, that the wound of entry was smaller than

the wound of exit, but cases were observed in which the wound of exit was the

smaller. The wound of exit was always the smaller when slender fragment

which presented its greatest diameter at the site of entry made its exit along

path parallel to its long axis.

In the 2,586 abdominal injuries in which data concerning the site of entry

and of exit of the wounding agent were accurately recorded (fig. 18), the missiles

entered anteriorly in 1,228 cases (47.5 percent), posteriorly in 730 (28.2 percent),

and laterally in 617 (23.9 percent). Three hundred and forty-one wounds of

entry (13.2 percent) were in the buttocks or the region of the hips, and 11 (0.4

percent) were in the perineum.

The wounds were distributed almost equally between the right and left

sides of the body. Excluding the 151 wounds in the midline and the 11 inNumber of injuries

Fra^naentation

5mall arms

Figure 17.—Distribution of causative missiles in 3,052 abdominal injuries.
98 GENERAL SURGERY

Figure 18.—.-Anatomic distribution of wounds of entry in 2,586 recorded abdominal injuries.
WOUNDING AGENTS 99

stances in which the wound of entry was through the perineum, there were 1,209 wounds on the right side and 1,215 wounds on the left side.

The most significant discrepancy in the distribution of the wounds of entry

is the much larger number of anterior than posterior wounds. For this there

are two possible explanations, aside from the obvious reason that the casualties

were part of an advancing army:

1. The greater thickness of the musculature of the back, combined with

the presence of the bony spine, tended to afford more protection against injury

than did the anterior abdominal wall.

2. Soldiers carrying field packs on their backs had some additional protection from them, especially against low-velocity missiles.

On the other hand, certain number of posterior wounds are to be expected.

Combat soldiers, while advancing, are often pinned to the ground, and many

times lie prone, thus exposing posterior portions of the body and making them

readily accessible to exploding agents of war.

Tracks of missiles.—Clinical observations suggest that the possibility of

tracks of missiles not following straight line has been greatly overemphasized

in the past. In practically every instance in this series, the course of the

missile within the body was straight line. Bizarre or circuitous tracks were

extremely uncommon. seemingly erratic course could almost invariably be

explained by an accurate reconstruction of the position of the soldier when he

was struck (fig. 19). Changes of posture caused significant displacement of

viscera and altered their customary relationships.

In no instance in the series did missile traverse major diameter of the

abdomen without causing visceral injury.

Effects of missiles.—Clinically, effects of the missiles were of extraordinary

variability, the results apparently being related to the size of the fragment,

which was usually roughly proportional to the caliber of the shell; its shape;

and the distance of the soldier from the site of the explosion. This distance

served as rough index of the velocity of the missile. Explosive, concussive

effects were more frequently observed in casualties injured at close range than

in those at distance from the shell burst. Jagged, lacerated, irregular wounds

were, in general, more frequently caused by shell fragments than by missiles

from small arms, but there were many exceptions to this generalization. In

some instances, large fragments or multiple smaller fragments produced by

shell burst close at hand destroyed large parts of the abdominal parietes or even

carried away the entire flank; casualties with injuries of this kind seldom survived to reach the hospital.

Wounds caused by mortar fragments, especially at close range, were often

characterized by the presence of multiple small fragments which were slight in

mass but which had entered the body at high velocity. These fragments

apparently deceleratedrapidly on impact; though they penetrated theabdomen,

One interesting case of this kind is personally known to the editor in chief. The surgical consultant, Office of the

Surgeon, Headquarters, Third U. S. Army,was wounded by sniper in France. The bullet struck the left anteriorchest

of thisofficer, fractured rib, followed the ribpath laterallyand posteriorly, and lodgedbeneath the left scapula.
100 GENERAL SURGERY

Effect o£ Position.

Figure 19.—Possible effect of position on track of missiles and resulting visceral injuries.

they seldom caused perforating (through-and-through) wounds. Roentgenologic examination of casualties who were literally peppered with tiny holes

showed the penetration of the skin by hundreds of small fragments. Tissue

destruction of an almost unbelievable extent was sometimes found below the

cutaneous wounds, because each fragment had imparted all of itskinetic energy

to the tissue through which it had passed. It was impossible in such cases

even to localize all the fragments accurately, let alone to remove them.

Wounds caused by rifle fire were usually single. Wounds from German

machineguns or machine pistols were usually multiple, because these weapons

fired at very rapid rate. The destructive effect of small-arms missiles on the

tissue was often similar to the effect of high-explosive fragments. When

bullets struck perpendicularly, they often caused small, clean perforations.

When their impact was tangential, they produced large lacerations and even

concussive rupture of viscera. Their effects, which were frequently multiple,

depended upon velocity as well as upon angle of impact, as the following case

history shows:

Case history.—A German prisoner of war was wounded at range of about 20 yards

by caliber .30 bullet from an American carbine, when the missile was in the initial phase
WOUNDING AGENTS 101

of high velocity. The wound of entry was in the left midaxilla, and the wound of exit was

through the symphysis pubis on the same side. The missile caused 5-mm. perforation of

the diaphragm, with only slight contusion, and gutter wound of the lateral margin of the

left kidney. Its concussive effect was such, however, that the entire kidney was split

wide open to the uretero-pelvic junction. Two small through-and-through perforations of

the jejunum resulted from the perpendicular impact of the bullet, while in other portions

of the bowel its tangential impact produced mangled perforations and lacerations. The

bullet also passed through the bladder, leaving large, explosive wound of entry and

small, clean wound of exit.

In wounds caused by armor-piercing bullets of small caliber, the jacket,

which was usually shed by the projectile, sometimes acted as secondary

missile. The trauma produced by the steel core was similar to that caused by

bullet with an ordinary lead core, but the jacket, because of its ragged

contour, was often mistaken roentgenologically for shell fragment. Bullets

which ricocheted were usually distorted, and the jacket was usually partially

separated at the base. The tearing effect of such missiles was often extremely

destructive.

Mine fragments, nearly all from the German “S-mine” or “Bouncing

Betty,” caused small number of abdominal wounds. The characteristic

missiles from these mines were steel balls (shrapnel) and small, machine-cut

steel cylinders. Their effects were essentially the same as those of shell

fragments.

Dirt, stones, occasionally bits of impedimenta carried in the pocket, pieces

of identification tags, and bone fragments were encountered as secondary

missiles. Of these, bone fragments were the most destructive. In large

number of the 238 cases in this series in which fractures of the pelvis occurred in

association with abdominal wounds, the forcible irruption of spicules of bone

into the peritoneal cavity caused perforations of both the large and the small

intestine, particularly the cecum. similar effect was observed when missiles

entered the peritoneal cavity through the spine.

Ruptures of the intraperitoneal viscera were occasionally associated with

injuries in which the peritoneum was not penetrated. Injuries of this kind

were apparently caused by missiles of extremely high velocity and great concussive power (p. 331).

The extent of tissue destruction caused by the various missiles used in

World War II, particularly by artillery-shell fragments, at times almost passed

belief. Intestines were often found shredded into ribbons, and solid viscera

often seemed to have exploded, with completely detached pieces of liver,

spleen, or kidney being observed free in the peritoneal cavity. The destructiveness of the missiles employed in World War II is impossible to overemphasize.

Nothing seen in civilian surgery even remotely approaches the extent of the

trauma associated with the wounds encountered in this war.

103

CHAPTER VII

Timelag and the Multiplicity Factor in

Abdominal Injuries

Luther H. Wolff M. /)., W. Philip Giddings M. D.,

Samuel B. Childs, M. Dand Clarence R. Brott M. D.

At the beginning ofWorld War II, as in previous wars, it was universally

accepted concept that the length of the timelag (the interval from wounding

until the institution of therapy) had an important influence on the case fatality

rate in abdominal wounds. On the surface, this is perfectly reasonable point

of view. Hemorrhage, peritoneal contamination, and disturbances of cardiorespiratory and gastrointestinal physiology combine to produce state of shock

following wounding. The longer these conditions are permitted to continue

uncorrected, the more severe does the shock become, the more serious is the

deterioration of the wounded man’s status, and, presumably, the graver is the

prognosis.

It was with full acceptance of this concept that the analysis was undertaken of the 2,926 abdominal injuries in this series in which data concerning

the timelag were available. The average interval from wounding to operation

was found to be almost 10.5 hours, the two components being, respectively,

6.5 hours for the period from injury to hospitalization and 3.9 hours for the

period from hospitalization to operation. The chief obstacle to earlier hospitalization lay in the obvious difficulties in evacuating casualties from the battlefield. The delay in the hospital was more apparent than real; it was explained

by the time consumed in necessary preoperative resuscitation, particularly of

poor-risk patients. further explanation, in times of stress, was the overburdening of available surgical facilities, which resulted in an inevitable prolongation of the timelag.

All through the war, every possible effort was directed toward shortening

the timelag, in line with the belief that the earlier operation could be performed,

the better would be the results, and vice versa. As the result of these efforts,

and as the experience of military personnel increased and evacuation facilities

were improved, substantial reduction in the average timelag was achieved.

In 1944, it was 11.4 hours (6.9 hours between wounding and hospitalization

and 4.5 hours between hospitalization and operation). In 1945, it was reduced

to 9.5 hours (6.1 hours between wounding and hospitalization and 3.4 hours

between hospitalization and operation).

In view of these facts, it was therefore disconcerting, when this analysis

was conducted after the war, to find that the figures furnished little support

for the concept that the length of the timelag had an important influence on the

case fatality rates. When they were calculated in 2-hour periods (fig. 20), no
104 GENERAL SURGERY

Number

of

Injuries Survival

Fatality

hoars)

Figure 20. —Influence of timelag (wounding to operation) in 2,863 recorded abdominal injuries. Sixty-three cases in which the timelag was greater than 36 hours are not

included, because the number would have been too small in each category over 36 hours

to be of significance.

consistent change in them was observed with the passage of time. Obviously

it was necessary to seek an explanation for the paradox that an increase in the

timelag did not greatly increase the case fatality rate, while shortening of

the interval did not greatly improve it.

When the abdominal wounds in the series were evaluated in terms of their

severity, the apparent paradox was promptly resolved. An analysis from this

point of view showed that wounds of the same viscus differed from casualty to

casualty in respect to their extent, the degree of associated hemorrhage, the

amount of peritoneal contamination, and the specific effect of the wound upon
TIMELAG AND THE MULTIPLICITY FACTOR 105

the individual. On the other hand, in spite of their evident importance, these

considerations could not be reduced to statistical form. From these standpoints, each case was an entity in an exclusive category. As practical solution of the problem, therefore, these abdominal injuries

were classified from the standpoint of severity in terms of the number of visceral

injuries each individual casualty had sustained. When this had been done, it

immediately became clear that whether or not patients who had sustained the

greatest number of visceral injuries (and who, presumably, were the most

severely wounded) were to live or die did indeed depend in large measure upon

the time elapsed between wounding and the institution of surgical care. The

most severely wounded patients, in terms of multiplicity of injuries, survived

only if they were operated on promptly, and the case fatality rate increased

progressively from category to category as the timelag increased (table 9).

It was 100 percent in the categories in which the largest number of wounds

was associated with the longest timelag. There were no survivals among the

casualties who suffered visceral injuries each, although of the were

operated on within 16 hours of wounding, and there were only survivals

among the 22 patients with visceral injuries each, although 20 of the 22 were

also operated on within 16 hours of wounding. It is true that in some of the

categories the numbers of cases were so small as to be without statistical significance, but in general the figures corroborated the clinical impression that

the least severely wounded man could tolerate certain prolongation of the

timelag, while the most severely wounded men could not. Some wounds were

potentially lethal, regardless of the brevity of the timelag, while others were

not necessarily lethal originally but tended to become so as the timelag

increased.

The truth of the assumption that the case fatality rate increases as the

timelag lengthens was generally acceptable for the individual patient, though at

the extremes of time there were balancing factors which effectively precluded its

demonstration. Many of the fatalities in the first hours after injury occurred in

mortally wounded men, who were given priority of treatment in what proved

vain attempt to save their lives. These deaths elevated the case fatality rates

for the early hours. At the other extreme of time, patients who survived after

18 to 24 hours without operation might well have lived without treatment; no

one would contend that all abdominal wounds are fatal without surgery.

Examination of the multiplicity indexes (table 9) confirms these generalizations. They are, respectively, 1.64, 1.59, 1.45, 1.41, and 1.13. By these criteria,

the most severely wounded patients obviously were operated on in the first

8-hour interval, and the least severely wounded were operated on after 24

hours. The figures thus afford statistical confirmation of recognized clinical

observation; namely, the case fatality rate in casualties operated on early was

elevated by the inclusion in this category of relatively large number of the

most critically wounded casualties, while the rate among those coming to

surgery late was kept below expected levels by the inclusion of similar proportion of the less seriously wounded.

378327°—56
106 GENERAL SURGERY

Table

9.

—Influence

of

combined

timelag

and

multiplicity

factor

on

case fatality

rates

in

2,926

abdominal injuries

Timelag

(wounding to

operation,

in

hours)

through

through

16

17

through

24

25

through

36

37

to

90

Organs

injured

Case

Case

Case

Case

Case

Cases

Deaths

fatality

Cases

Deaths

fatality

Cases

Deaths

fataltiy

Cases

Deaths

fatality

Cases

Deaths

fatality

rate

rate

rate

rate

rate

None---

98

5.1

116

7.8

34

8.8

20

15.0

11

18.2

One

496

50

10.

519

77

14.8

146

24

16.6

72

19

26.4

36

12

33.3

Two.

402

97

24.1

391

112

28.6

103

32

31.

37

11

29.7

13

61.5

Three

132

56

42.4

144

67

46.5

24

12

50.0

14

50.0

33.3

41

22

53.

38

25

65.8

85.

50.0

13

12

92.3

85.

100.

100.0

100.

100.

100.

Total

1,185

245

20.7

1,217

298

24.5

314

78

24.8

147

43

29.3

63

23

36.5

Multiplicity

index

1.64

1.59

1.45

1.41

1.13
TIMELAG AND THE MULTIPLICITY FACTOR 107

MULTIPLICITY FACTOR

Since the importance of the multiplicity of visceral injuries was an entirely

new concept in military surgery, new nomenclature had to be devised for it.

The terms “multiplicity factor” and “multiplicity index” were accordingly introduced. Multiplicity factor was employed to designate the number of abdom- inal organs injured in any given patient, as determined at operation or autopsy.

Multiplicity index was employed to indicate the aggregate severity of the individual cases in given series of abdominal wounds. It was obtained by

dividing the total number of organs injured in the series by the number of cases

which made up the series.

In the interests of clarity, certain explanations are necessary in regard to

this nomenclature. Multiplicity factor does not imply selectivity of viscera.

Combinations are limited entirely to numerical incidence. Only the number of

organs injured matters. Nor does the term carry any implications concerning

the total number of wounds sustained in given case, since multiple wounds of

the same viscus are counted as single wound. Thus, wounds of the cecum, transverse colon, and sigmoid colon in the same patient would be counted as

single wound of the large bowel, and wounds of the jejunum and ileum would be

counted as single wound of the small bowel.

In this analysis, wounds of the major abdominal blood vessels (as distinguished from wounds of the visceral blood supply) are not regarded as visceral

injuries. It is evident, however, that the multiplicity factor is just as valid in

them as it is in other abdominal injuries (p. 323), the only difference being that

the case fatality rates for vascular injuries begin at much higher level.

It should be emphasized again that the concept of the multiplicity factor

was postwar development. It was evolved only when it became evident that

the timelag, upon which the major emphasis had been placed in the past,

apparently did not play the role in the case fatality rate in abdominal

injuries which it was formerly supposed to play. When the multiplicity

factor was adopted as yardstick in the analysis, much that had been contradictory and confusing when the timelag alone was used as point of reference

was immediately clarified. It now became clear that, when only the timelag was

analyzed, dissimilar cases were being compared with each other and that the

analysis of this type of trauma would be valid only when the cases were

separated into comparable and exclusive categories.

When the injuries in which sufficient data for this purpose were available

were categorized according to the multiplicity factor (tables and 10, figs. 21

and 22), the timelag fell into the proper perspective, the case fatality rate was

found to ascend in almost arithmetical progression with each additional viscus

injured, and the increase was almost as constant for each special organ as it

was for the entire series.
108 GENERAL SURGERY

Organs injured.

Figure 21.—Influence of multiplicity factor on case fatality

rates in 3,129 recorded abdominal injuries.

Kidney Liver Stomach

Organs injured.

Figure 22.—Influence of multiplicity factor on case fatality

rates in various combinations of abdominal wounds.
TIMELAG AND THE MULTIPLICITY FACTOR 109

Table 10.—Influence of multiplicity factor on case fatality rates in wounds of various viscera

The multiplicity factor also proved valuable aid in the appraisal of

abdominal injuries from number of other points of view:

1. Associated injuries.—An analysis of the 1,089 cases in which abdominal

wounds were associated with extra-abdominal wounds (p. 114) revealed that

moderately severe extra-abdominal injuries were often associated with abdominal wounds of high multiplicity and that the reverse was also true, severe

extra-abdominal injuries usually being associated with abdominal injuries of

low multiplicity. The statistics suggested that when severe extra-abdominal

injuries were associated with abdominal injuries of high multiplicity, the

wounded men seldom survived to reach the hospital.

2. Shock. —Virtually every one of the deaths which occurred in this series

within the first 24 hours after operation was attributable to shock, which

developed as the result of hemorrhage, peritoneal contamination, or tissue

destruction. As might have been expected, definite association was found to

exist between the multiplicityfactor and these deaths. In the756 fatalities in the

whole series, 35 percent of the deaths in univisceral wounds occurred within 24

Organs injured Cases Deaths Case fatal- ity rate

Stomach:

Alone 42 12 28.

With other viscus 174 47 27.

With other viscera __ 112 44 39

With other viscera 50 29 58

With other viscera 23 23 100.

Total 401 155 38.

Liver:

Alone ______ 339 33 9.

With other viscus 238 63 26.

With other viscera 151 60 39.

With other viscera 62 35 56.

With (and more) other viscera 39 33 84.

Total .__ 829 224 27.

Kidney:

Alone. 56 16.

With other viscus 172 41 23.

With other viscera 105 38 36.

With other viscera. ... ... 47 30 63.

With other viscera __ __ 24 19 79.

Total 404 137 33.

There are omitted from this category IS cases in which wounds of the stomach and one or more other viscera were complicated by wounds of the great vessels.
110 GENERAL SURGERY

hours of operation, as did 36 percent of the deaths in which organs were injured, 40 percent of the deaths in which organs were injured, and 51 percent

of the deaths in which or more organs were injured.

3. Pulmonary complications. —The incidence of postoperative pulmonary

complications (p. 204) rose from 6.5 percent in univisceral injuries to 13.0 percent when or more viscera were injured. This observation is of clinical rather

than statistical significance. The more severely wounded patients were more

apt to develop stagnation of the tracheobronchial secretions and therefore

presented higher incidence of atelectasis and bronchopneumonia.

4. Variations in case fatality rates.—One of the perplexing features of this

analysis before the concept of the multiplicity factor was evolved was the

differences between the case fatality rates of surgeons of equal ability and

experience. Another was the differences between the rates of more forward

(field) hospitals and evacuation hospitals. These differences had been realized

in the course of the war. They could not reasonably be explained on the basis

of superior or inferior surgical performance, or merely as matters of chance.

It was the general impression that less severely wounded patients were treated

at evacuation hospitals, but proof of the impression was lacking until this series

was analyzed on the basis of the multiplicity factor. When the severity of the

wounds was taken into consideration, differences in the case fatality rates of

hospitals in different echelons (table 5, p. 89) could easily be explained. high

rate was to be expected in field hospitals, because the most severely wounded

patients were treated in them.

single comparison will make this point clear. The case fatality rate for

232 casualties treated by surgeons of the 2d Auxiliary Surgical Group in evacuation hospitals was 15.1 percent, while the rate for surgeons of the same group

for 2,851 casualties treated in field hospitals was 24.3 percent. Differences in

the multiplicity indexes explain the differences in the case fatality rates. The

index for the casualties treated in evacuation hospitals was 1.10, while for

casualties treated in field hospitals it was 1.70. Likewise, differences in the

multiplicity indexes explain differences in the case fatality rates of surgical

teams of similar ability and experience.

Application of the multiplicity index to certain recorded series of abdominal

injuries permitted comparison of them by uniform standard of evaluation

(table 11). An examination of the Welch and Tuhy series, the Ogilvie

(Western Desert) series, and the material of the 2d Auxiliary Surgical Group

Welch, C. S.; and Tuhy, J. E.: Combined Injuries of the Thorax and Abdomen. Ann. Surg. 122: 358-374, September 1945.

Ogilvie, W. H.; Abdominal Wounds in the Western Desert. Surg., Gynec. Obst. 78: 225-238, March 1944.

Multiplicity Case fatality Team index rate

1. 42 21

1. 58 23

1. 63 25

1. 71 25

__ 1. 73 27

1. 80 28
TIMELAG AND THE MULTIPLICITY FACTOR 111

shows the correlation which might be expected between the Welch and Tuhy

figures and those of the 2d Auxiliary Surgical Group. In the British material,

on the other hand, although the multiplicity index was lower than in either of

the other series, the case fatality rate was higher. The discrepancy can

probably be explained by two factors: (1) That conditions of evacuation and

hospitalization were frequently extremely unfavorable in the fighting in the Western Desert, and (2) that penicillin was not available when these cases

were treated as it was for the patients in the other (later) series.

Table 11.—Influence of multiplicity factor on case fatality rates in various recorded series of abdominal injuries

LIMITATIONS OF THE MULTIPLICITY FACTOR

In this series of abdominal injuries, the application of the multiplicity

factor clarified much that had originally been confusing and actually inexplicable. On the other hand, while it proved to be of valuable statistical type

for series analysis, it was found to have certain weaknesses and limitations,

because ofrelative dispersion, when it was applied to individual cases. Another

reason was that it was entirely possible for wound of single viscus to be so

grave that the intra-abdominal damage was as serious as it was in another case

in which three or even more organs were wounded. Thus the multiplicity

factor was found to be not completely reliable in wounds of the stomach (table

10, fig. 22). In injuries of this organ, the case fatality rate for univisceral

wounds was slightly higher than for gastric wounds complicated by wound

of one other viscus. The explanation is the inherent gravity of all wounds of

Organs Injured

Welch and Tuhy series British World War II

series

2d Auxiliary Surgical

Group series

Cases

Case

fatality

rate

Cases

Case

fatality

rate

Cases

Case

fatality

rate

None

44

17

20.

11.

29.

33.

42

164

31

23.

31.

48.

71.

292

1, 348

1, 014

350

96

23

7.

14.

28.

46.

61.

91.

100.

One

Two

Three

Four

Five

Six

Total 70 17. 244 33. 3, 129 24.

Multiplicity index 1.30 1.02 1.58

Western Desert (second series, 244 cases; deaths on the operating table are excluded from the figures).

In this category are included ail injuries of or more organs.
112 GENERAL SURGERY

the stomach, which were likely to be associated with acute precipitous chemical

peritonitis (p. 231). For this reason, the case fatality rate in univisceral gastric

wounds was unusually high as compared with the rates for univisceral wounds

of other organs.

On the surface, it might seem that the multiplicity factor should be useful

in prognosis, making it possible to predict the outcome for the individual

casualty with reasonable degree of accuracy. In general (fig. 21), the case

fatality rate increased about 15 percent as each additional viscus was injured,

and, generally speaking, the number of viscera injured was more significant

than the particular organ involved. These generalizations, however, do not

hold for the individual case, in which the multiplicity factor must be used

with great caution. For one thing, in case in which only one or two viscera

are injured, an unusually prolonged timelag might make the prognosis more

serious than the multiplicity factor alone would indicate. For another, the

presence of serious associated extra-abdominal injuries, the development of

anaerobic and other infections, unforeseen complications such as intestinal

obstruction and wound dehiscence, and other considerations of the same sort

might completely vitiate the multiplicity factor in the individual case.

Notwithstanding the variations and limitations of the multiplicity factor

in its application to individual cases, when it was applied to this particular

series—in which many variables existed—it supplied an accurate and useful

yardstick for many different purposes and resolved at once the apparent

paradox which had existed when the case fatality rates were calculated only

in reference to the timelag.
113

CHAPTER VIII

Associated (Extra-Abdominal) Wounds

(1,089 Casualties)

Leigh K. Haynes M. D., and Floyd D. Taylor M. D.

In addition to the 839 thoracoabdominal wounds in this series of 3,154

abdominal injuries, associated (extra-abdominal) wounds of significant severity occurred in 1,089 cases (47.0 percent). Two hundred and sixty-two of these

were fatal (table 12).

Table 12.—Percent of casualties with and without associated wounds in 2,315 abdominal

injuries, with case fatality rates

The associated wounds in these 1,089 casualties numbered 1,551, but data

suitable for analysis were available for only 1,403 (table 13). Fractures were

the most frequent type of associated injury, and the bony pelvis was the most

frequent site of fracture (table 14).

Table 13.—Distribution according to type of 1,403 individual associated wounds in 1,089

casualties with abdominal injuries

Abdominal wounds Cases Frequency Deaths Case fatalityrate

Without associated wounds 1, 226

1, 089

Percent

53.

47.

272

262

22.

With associated wounds 24.

Total 2, 315 100. 534 23.

All thoracoabdominalwounds in the series are excluded from these calculations.

Type of wound Number of

wounds Proportion

Fracture (compound) 659

Percent

47.

Soft tissue- 531 37.

Thoracic 101 7.

Spinal cord 40 2.

Maxillofacial and neck_ 20 1.

Major vascular 18 1.

Major amputation- 18 1.

Peripheral nerve_ 10

Brain __

Total 1, 403 100.
114 GENERAL SURGERY

Table 14.—Distribution of major fractures (pelvis, femur, and humerus in 1,403 associated

injuries including 659 fractures

MULTIPLICITY FACTOR

The importance which had been attributed to the multiplicity factor in the

general evaluation of the severity of abdominal injuries (p. 105) suggested an

analysis of associated injuries from this point of view (tables 15 to 17 inclusive).

The results were entirely dissimilar. There was no progressive rise in the case

fatality rates (such as practically always had been observed with increases in

the multiplicity factor in abdominal injuries) as the number of associated

injuries increased. This might perhaps have been expected, in view of the

different severity of abdominal wounds and associated wounds. The strikingly

high case fatality rate of 39.4 percent in casualties with associated wounds

(table 17) could not be explained. Severe associated wounds were unusual in

the group of patients with four or more associated injuries, multiplicity rather

than severity apparently being the dominant factor in this category. In the

121 cases which make up this group, multiplicity was so extreme that tabulation

was not attempted. There were, however, only 27 deaths, 22.3 percent, approximately the same as for the entire series of 1,089 casualties with associated

wounds.

Although detailed analysis did not bear out the clinical impression that

the presence of severe extra-abdominal wounds materially increased the case

fatality rate in abdominal wounds, comparison of the injuries categorized

according to the visceral multiplicity factor (fig. 23) indicated that the rate

in each category was definitely increased when the factor of associated wounds

was superimposed. Case fatality rates computed on this basis are almost

parallel.

Proportion of—

Fracture Cases

1,403associated

injuries 659 fractures

Pelvis 238

Percent

17.

Percent

36.

Femur only 57 4. 8.

Femur and other major bone 33 2. 5.

Humerus only 31 2. 4.

Humerus and other major bone 21 1. 3.

Total 380 27. 57.

See table 13.
ASSOCIATED (EXTRA-ABDOMINAL) WOUNDS 115

Table 15.—Case fatality rates in 527 abdominal injuries complicated by associated injury

Table 16.—Case fatality rates in 299 abdominal injuries complicated by associated injuries

When associated wounds were classified, on the basis of all available data,

according to whether they were moderate or severe (a difficult and admittedly

arbitrary classification), two facts became evident (fig. 24);

1. The frequenc} of associated injuries of great severity was highest

among patients with abdominal wounds of least severity (that is, of low multiplicity).

2. The frequency of associated injuries ofleast severity was highest among

patients with abdominal wounds of greatest severity (that is, of high multiplicity).

Type of associated injury Cases Deaths Case fatality rate

Fracture 236 40 16.

20.

33

Soft tissue 182 37 Thoracic 42 14

Spinal cord 28 14 50 Maxillofacial and neck Major vascular

13 23.

40

Major amputation 33

Peripheral nerve

Brain. 33.

Total 527 115 21.

Type of associated injuries Cases Deaths

Case

fatality

rate

Two fractures.- 92 21 22.

Fracture and soft tissue 72 13 18.

Fracture and thoracic 19 26.

Fracture and major vascular 20.

Fracture and spinal cord__ 40.

Fracture and amputation

Two soft tissue- 37 21.

Soft tissue and thoracic 14 14.

Soft tissue and spinal cord 16.

Soft tissue and major vascular 12.

Other combinations- 35 10 28.

Total 299 64 21.
116 GENERAL SURGERY

Table 17. Case fatality rates in lj2 abdominal injuries complicated by associated injuries

With associated injuries

No associated injury

Figure 23.—Influence of multiplicity factor and presence of associated injuries in 3,154

abdominal injuries.

Type of associated injuries Cases Deaths

Case

fatality

rate

Three fractures 10 10.

Fracture and two soft tissue 54 13 24.

Fracture, soft tissue, and thoracic 87.

Fracture, soft tissue, and spinal cord .. ...

Fracture, soft tissue, and peripheral nerve- .. 25.

Fracture, soft tissue, and maxillofacial 33.

Fracture, thoracic, and maxillofacial 50.

Two fractures and thoracic 14 64.

Three soft tissue 15 60.

Two soft tissue and amputation 33.

Other combinations 26 12 46.

Total 142 56 39.
ASSOCIATED (EXTRA-ABDOMINAL) WOUNDS 117

These two facts explain why associated wounds in series of abdominal

injuries such as this exerted an apparently minor influence on the overall case

fatality rate. The casualties who sustained simultaneously severe abdominal

wounds and severe extra-abdominal wounds seldom reached the surgeon alive.

Those who survived had severe abdominal wounds associated with mild

extra-abdominal wounds or vice versa.

The case fatality rate for casualties with abdominal injuries and associated

wounds but without visceral injuries was 7.2 percent (fig. 23), which was lower

than for any other category of patients with extra-abdominal injuries. On the

other hand, in 19 of the 22 fatal cases in this group, the associated extraabdominal injuries were severe. The rate among casualties witli abdominal

injuries but without visceral injuries or associated injuries was 3.8 percent.

There seems no doubt that in these combined injuries the fatalities were

chiefly reflection of the severity of the extra-abdominal wounds rather than

of the risk of exploratory laparotomy in the absence of visceral damage (p. 95).

Severe associated, injuries

Moderately severe

associated injuries

Organs injured. or more

Figure 24.—Influence of multiplicity factor and gravity of associated injuries in 3,154

abdominal injuries.

119

CHAPTER IX

Shock Therapy (957 Casualties)

Beverly T. Towery M. D., and John D. Welch M. D.

From the standpoint of the therapy of traumatic shock, soldiers with

major wounds of the abdomen presented more serious problems than any other group of casualties. There were number of reasons:

1. Hemorrhage was frequently massive.

2. Contamination of the peritoneal cavity and retroperitoneal tissues

carried the threat of fulminating infection.

3. Concomitant transdiaphragmatic injury of the thorax frequently

caused serious disturbances of cardiopulmonary function.

4. These same injuries rendered the pleura liable to contamination by

gastrointestinal contents or bile.

5. Multiple visceral and vascular injuries, which were common, often

created surgical problems of great technical difficulty, with the result that the

duration of anesthesia and operation was necessarily prolonged and further

blood losses were likely to occur.

The problem of traumatic shock is considered in detail elsewhere in these

volumes. Resuscitation therapy, however, played such an important role in

the management of casualties with abdominal injuries that it must be discussed

in some detail here. Furthermore, the important causes of shock deserve

careful consideration in relation to therapy and therapeutic failure in these

injuries.

The background of this discussion is series of 957 casualties selected for

this purpose from the whole series of 3,154 casualties with abdominal wounds

who were treated by surgeons of the 2d Auxiliary Surgical Group during 1944

and 1945. Selection was on two grounds; (1) That all the injuries included

perforations of hollow viscera and therefore carried the threat of fulminating

peritonitis, and (2) that in all cases data relative to shock therapy were complete. The figures for replacement therapy, as well as the case fatality rates,

must be interpreted with the reservation that the selected series perhaps contains an undue proportion of poor-risk cases, the explanation being that the

data were more likely to be complete in such cases than in cases in which the

surgical risk was better.

The term “shock” throughout this discussion should be understood as synonymous with the term “traumatic

shock.” An attempt to distinguish between traumatic and hemorrhagic shock would serve no useful purpose.

Medical Department, United States Army, Surgery in World War II. The PhysiologicEffects of Wounds. Washington: U. S. Government Printing Office, 1952.
120 GENERAL SURGERY

The initial care of casualties in World War II fell into three phases: (1)

Prooperative resuscitation or the therapy of traumatic shock, (2) definitive

surgery, and (3) postoperative care. Care could not be considered optimal

unless these three phases were closely integrated to insure complete continuity

of effort. The immediate aim of shock therapy was to restore the circulatory

dynamics to sufficient state of competence to permit successful operation.

If fatal outcome from the deleterious effects of shock, continuing peritoneal

contamination, and the establishment of widespread virulent infection was to

be prevented, it was essential that both resuscitation therapy and surgery be

accomplished with as little delay as possible. Moreover, replacement therapy

frequently had to be continued during operation and throughout the first days

after operation.

The medical officer responsible for triage and shock therapy played

unique role in the care of battle casualties. His chief asset was the ability to

judge the gravity of the situation. His initial examination established the

status of the patient with respect to the extent of injury and the severity of

shock and permitted tentative decisions as to appropriate replacement therapy

and the response to be anticipated from it. Thereafter he carefully followed

the patient’s progress during transfusion therapy so as to recognize promptly

any failure of response or actual deterioration. Sound judgment was especially

needed in reaching decision as to the optimal time to operate upon patient

with continuing intra-abdominal hemorrhage. Often the shock officer had to

decide who, among number of wounded men, was in most urgent need of

immediate surgery, as well as whose chance of survival would be least compromised by delay.

Intelligent triage during the period of resuscitation was difficult to achieve

because it depended upon awareness, experience, and judgment which were

not easily acquired. Nevertheless, skill in this, as in surgical technique, was

an extremely important factor in the successful treatment of the seriously

wounded.

The objective of treatment was thus continuity of therapeutic endeavor

which afforded optimum coordination of replacement and surgical therapy and

which recognized the fundamental importance of operation in the resuscitation of the severely wounded. The operation was of special importance in

resuscitation when, because of continuing intra-abdominal hemorrhage or early

fulminating infection, transfusion therapy alone had failed to bring about sustained improvement. Obviously, more than blood replacement was required

to correct these conditions. The only hope for successful outcome—and

frequently the hope was slight—lay in supplementing massive transfusion

therapy by prompt and skilled surgery. The care of these casualties thus constituted challenge to all those responsible for all phases of their management

in forward hospitals.
SHOCK THERAPY 121

CLASSIFICATION OF SHOCK

The classification of shock into categories for statistical purposes is never

entirely satisfactory, since the objectivity of different observers naturally varies

considerably and their interpretations vary accordingly. For purposes of comparison and reference, however, four degrees of shock (table 18) were recognized

in the 957 instances of traumatic perforation of the gastrointestinal tract upon

which this discussion is based: (1) No shock, or incipient shock, in which the

lower level of the systolic blood pressure was 101 mm. Hg; (2) moderate shock,

in which the systolic blood pressure was 71 to 100 mm. Hg; (3) severe shock, in which the systolic blood pressure was 41 to 70 mm. Hg; and (4) profound or preterminal shock, in which the systolic blood pressure ranged downward

from 40 mm. Hg to 0. More than half of the 957 patients in this series (table

18) exhibited degrees of shock ranging from moderate through preterminal,

and more than quarter exhibited severe or profound shock.

Table 18.—Administration of replacement therapy in relation to degree of shock in 957 traumatic perforations of the gastrointestinal tract

The chief shortcoming of classification based on the level of the blood

pressure lies in the fact that the blood pressure was often maintained at relatively normal levels for considerable period of time following injury. As

result, the soldier’s condition might seem better than it really was (cases

through 4). Oligemia and reduction of the peripheral blood flow in the patients

classified as not in shock or in incipient shock were likely to be disproportionately greater than the level of the systolic pressure would indicate. This was

not true, however, of the other categories. All the experience in forward hospitals indicated that when once the blood pressure had fallen below normal levels,

certain therapeutic and prognostic implications were inherent in the initial

reading.

For the protocols on these cases and the other cases referred toin this chapter, see Clinicopathologic Study of AbdominalWounds, at theend of the chapter.

378327°—56 10

Replacement therapy (average)

Degree of shock Cases Proportion Deaths Casefatality

rate

Timelag

(average)

Preoperative During operation Total

Plasma Blood Plasma Blood Plasma Blood

None or incipient (101 to

120 mm Ha) 446

Percent

46.6 81 18.2

Hours

10.4

cc.

492

CC.

619

CC.

178

CC.

962

CC.

670

CC.

1,581

Moderate (71 to 100 mm.

Ha) 250 26.1 95 38.0 11.6 602 873 261 1,063 863 1,936

Severe (41 to 70 mm. Hg). 121 12.7 61 50.4 10.7 687 1,271 311 1,278 998 2.549 Profound (0 to 40 mm.

Hg). 140 14.6 93 66.4 10.8 713 1,745 311 1,617 1,024 3,362

Total 957 100.0 330 34.5 10.7
122 GENERAL SURGERY

TIMELAG AND CHARACTER OF WOUND

The average timelag between wounding and operation in these 957 casualties with traumatic perforations of the gastrointestinal tract varied from 10.4

to 11.6 hours (table 18). Aside from the fact that it was slightly less in patients

with no shock and with incipient shock than in those in other categories, there

was no correlation between timelag and the severity of shock as indicated by

the level of the blood pressure. Obviously, in wounds of equal severity, the

total amount of blood lost and the severity of shock would increase with the

passage of time (case 4). patient admitted 10 hours after injury, for example,

might exhibit signs of severe shock, whereas if he had been admitted hours

after injury, only moderately severe shock might have been observed.

The correlation between the degree of shock and the severity of the wound

is borne out by an analysis of the cases in this series. Not only did the patients

in the deepest shock consistently exhibit more severe injuries than those whose

blood pressure approached normal, but multiple visceral injuries were also more

common in the categories of severe shock (cases through 8). The high case

fatality rate in patients with combined gluteal and abdominal wounds was

almost certainly related to the frequency in such injuries of massive hemorrhage

from the iliac and femoral vessels (cases 1. 5, 6, and 9). Lacerations of the

spleen and major vascular injuries furnished other illustrations of the relation

of vascular injuries to the degree of shock. Of the 140 patients with gastrointestinal perforations in the category of profound or preterminal shock, 43

(30.7 percent) had associated injuries of this sort, as did 21 of the 121 patients

(17.4 percent) in the category of severe shock. In contrast, this type of injury

was present in only 39 of the 250 patients (15.6 percent) in moderate shock, and in only 37 of the 446 patients (8.3 percent) in incipient shock or not in shock.

ROLE OF HEMORRHAGE AND OTHER FLUID LOSSES IN

PATHOGENESIS OF SHOCK

Massive hemorrhage was frequently present in injuries of the abdomen,

as the result of disruption of major vessel or laceration of the spleen or the

liver. Even in the absence of such major injuries, widespread damage of smaller

vessels could account for considerable blood loss. Blood loss was undoubtedly

the most important factor in the production of traumatic shock in patients

with abdominal injuries. It was also chiefly responsible for the depression of

the hematocrit frequently observed in battle casualties. On the other hand,

it had to be remembered, in the appraisal of severe shock, that the administration of plasma also tended to reduce the hematocrit and the oxygen-carrying

capacity of given volume of blood. If an excessive amount of plasma had

been given after hemorrhage, the total volume of the circulating blood might

be only moderately reduced; yet marked anemia might be present, with

hematocrit reading of onty 15 to 18 percent. This observation, incidentally,

furnishes additional proof of the superiority of whole blood over reconstituted

plasma in the resuscitation of battle casualties (p. 22).
SHOCK THERAPY 123

In addition to hemorrhage, the loss of plasma or of plasma components

into the traumatized or contaminated area of the abdomen contributed materially to the production of shock. This loss occurred as the result of transu- dation or exudation of fluid from inflamed peritoneal surfaces and into visceral

tissues under the influence of mechanical and chemical trauma and beginning

infection. While the precise importance of fluid loss from this source has been disputed, certain observations made by the surgeons of the 2d Auxiliary Surgical Group caused them to be inclined to regard it as significant. An extremely

high case fatality rate was observed when the pleura was widely contaminated

by gastric or intestinal contents, and the shock present in this type of case was

apt to be especially severe (cases and 10). Similarly, diffuse peritoneal

contamination consistently increased the severity of the circulatory collapse

associated with evisceration of the intestines (case 11). When, on the other

hand, evisceration occurred without appreciable peritoneal soiling, shock

was often surprisingly mild, and the response to replacement therapy was

more favorable than in the presence of diffuse contamination of the peritoneum.

Changes in the splanchnic capillary bed produced by irritation and infection also appeared to be of some importance inreducing the effective circulating

blood volume, though there was no agreement concerning the quantitative

influence exerted by these alterations. Mann had noted in 1915 that mechanical trauma to the bowel was associated with an increased capacity of the

splanchnic vascular bed. Similar observations were made by the surgeons of

the 2d Auxiliary Surgical Group who found that, in patients with perforations

of the gastrointestinal tract, considerable volume of blood was likely to be

pooled in dilated and engorged venules and capillaries and that the accumulation was increased when the bowel was manipulated at operation.

Another source of fluid loss was dehydration, which existed in some degree

in all patients with gastrointestinal perforations, whether or not vomiting

had occurred. Because of paralytic ileus, which was natural consequence of

peritoneal contamination or infection, small-bowel contents did not reach the

colon, and the normal reabsorption of water did not occur.

Although the loss of plasma or its components into the contaminated

peritoneal cavity resulted in rise in the hematocrit of the circulating blood,

hemorrhage, which was an almost universal sequela of penetrating wounds of

the abdomen, ultimately had the opposite effect. The hemodilution which

follows hemorrhage would seem to account for the fact that even in severe

shock associated with widespread soiling of the peritoneum, hemoconcentration was seldom observed and was, in itself, factor of negligible significance

in the pathogenesis of shock in battle injuries.

Furthermore, patient who showed clinical evidence of severe shock

might occasionally present no significant decrease in the hematocrit level, and

there was frequently little apparent correlation between the hematocrit reading

and the severity of peripheral circulatory failure. On the other hand, conMann, F. C.: Shock and Haemorrhage: An Experimental Study. Surg., Oynec. Obst. 21: 430-441, October 1915.
124 GENERAL SURGERY

siderable hemodilution was often found in association with severe shock.

These low hematocrit levels, as already mentioned, were usually observed in

cases in which the initial blood loss had been severe and in which large amounts

of plasma had been used to prevent death within short time after injury.

The subsequent management of these patients was always difficult, fact that

was not always readily apparent at the time of the initial examination.

The maintenance of normal or slightly elevated hematocrit level in

patient with penetrating wound of the abdomen did furnish some evidence

that the effects of peritoneal contamination had equaled or exceeded the

effects of hemorrhage. So many factors, however, influenced the hematocrit

in wounds of the abdomen that its usefulness as means of quantitative

assessment of the loss of blood or of plasma components from the circulation

was quite limited.

REPLACEMENT THERAPY

Aside from any theoretic considerations, increasing experience led the

surgeons of the 2d Auxiliary Surgical Group to emphasize the important role

of local loss of fluid, particularly blood, in the initiation of the traumatic

shock which followed penetrating wounds of the abdomen. Undeniable support for their position was furnished by the proved efficacy of plasma and

whole-blood replacement in the resuscitation of these severely wounded men.

Replacement therapy was frequently begun in the battalion aid station

with the administration of reconstituted plasma. Whenever severe shock

was apparent soon after injury, plasma was usually given, occasionally in

excessive amounts. Plasma received under these circumstances is included in

the calculation of the average figures for replacement therapy in this series

(fig. 25; table 18).

The total amounts of blood and plasma used for resuscitation were proportionate to the severity of the shock exhibited by the casualties. Furthermore, the volume required in each category of shock agreed fairly well with

the estimate of blood loss made by the Board for the Study of the Severely

Wounded. These facts lend support to the contention that the level of the

blood pressure is, in spite of its shortcomings, an important criterion in the

evaluation of the degree of shock and the extent of blood loss in severely

wounded casualties.

Although application of average data to individual casualties would

naturally be expected to reveal discrepancies, nevertheless the values calculated as average for this relatively large series may be taken as general guide

to the requirements which had to be met in preoperative resuscitation. Patients suffering from severe shock often had to be given extremely large quantities of plasma and blood. The administration of 5,000 to 6,000 cc. was not

unusual. Uncontrollable hemorrhage during operation also called for the

Medical Department, United States Army, Surgery in World War II. The Physiologic Effects of Wounds. Washington: U. S. Government Printing Office, 1952, pp. 21-74.
SHOCK THERAPY 125

Plasma

Blood

Decree o£ .shock.

Figure 25.—Average replacement therapy (whole blood and plasma) in relation to

degree of shock in 957 abdominal injuries with perforation of gastrointestinal tract.

use of very large amounts of fluid. One patient in this series, for example,

received total of 8,250 cc. (1,750 cc. of plasma, 6,500 cc. of whole blood),

chiefly because intra-abdominal bleeding could not be effectively controlled

during the early phase of the operation.

Adequate replacement therapy was not available in World War I, and

surgeons quickly recognized the futility of attempting operation in the presence of severe traumatic shock. Had the same lack of replacement therapy

prevailed in World War II, the severity of shock would have precluded operation in many of the 261 patients in this series whose systolic blood pressures

were 70 mm. Hg or less (table 18). Operation was attempted in the field hospital in every instance, however, after adequate replacement therapy, and

107 (41 percent) survived to be evacuated to the rear, after the usual period of

convalescence.

Accurate data are not available concerning deaths before operation in

patients in severe shock after perforation of the gastrointestinal tract. Presumably the number was small. During 4-month period in 1944-45,

single shock team lost only patients (2.1 percent) of the 285 it was attempting to prepare for operation.

During World War I, Maj. J. W. Vaughan, MC, consulting surgeon, 32d

Division, recorded that of 256 patients sent from the triage to an operating

station for seriously wmunded, 41 died in spite of attempts to combat shock
126 GENERAL SURGERY

by various methods, leaving only 215 who received operative treatment.

In marked contrast, under similar circumstances in field hospital platoon in

1943, there were no preoperative deaths among 297 consecutive patients admitted for surgery.

The saving oflife in World War II among casualties in severe and profound

shock was largely attributable to liberal, and frequently massive, transfusions.

In numerous instances operation would have been impossible without such

therapy. The improvement which followed prompt and intensive replacement

therapy was often striking, particularly among patients who had suffered

very severe shock of relatively short duration. Improvement was not observed uniformly in this category, it is true, but it occurred with sufficient

frequency to emphasize the therapeutic potentialities of liberal replacement

therapy in the resuscitation of severely wounded men.

Failures of Replacement Therapy

The fact that significant or sustained improvement did not invariably

occur after replacement therapy suggested that, in spite of the importance of

the fluid loss in the pathogenesis of shock and the unique role of replacement

therapy in its management, other factors, which were probably not completely

amenable to this type of therapy, had to be taken into account.

One of the most important of these additional factors was massive peritoneal contamination, with early fulminating peritonitis, the deleterious

effects of which were often augmented by severe hemorrhage, prolonged

timelag, or both.

The case fatality rate in the various categories of shock in this series

was directly related to the degree of shock (table 18). The steadily ascending

rate emphasized the increasing gravity of the prognosis as the degree of shock

increased. About three-quarters of the deaths in the 3,154 cases in the total

series occurred by the end of the second postoperative day. Casualties who

died within this period often pursued relentlessly downhill course characterized by persistent or recurrent shock. It was soon learned that failure of the

patient to manifest sustained benefit from adequate resuscitative measures,

particularly when replacement therapy had been liberal and intensive, was

clear evidence that the prognosis was grave (cases 8, 9, and 12).

The course of such patient was characteristic. When he was received

at the field hospital he was in shock, which often was severe. The blood

pressure was extremely low. The pulse was rapid and of poor volume. The

extremities were cold. The skin was pale, and if the degree of shock was

profound there was often more orless purple-red mottling or cyanosis. Venous

filling was apt to be poor, even after tourniquet had been applied. The rectal

temperature was seldom above 100° F. and was frequently subnormal. The

patient was aware of his extreme weakness, complained little if at all, and wanted

The Medical Department of the United States Armyin the World War. Washington: U. S. Government Printing

Office, 1927, vol. XI, pt. 1, pp. 109-110.
SHOCK THERAPY 127

to be left undisturbed. The sensorium was likely to be clouded, but in the

absence of acute morphinism true coma was not common except as terminal

manifestation. Appraisal of the history often suggested that the timelag,

although perhaps not intolerable in itself, had become intolerable because of

the extent and character of the wound. Considerable transient improvement

might be attained by liberal transfusion therapy, but the clinical response was

likely to be incomplete or poorly sustained, and increasingly severe shock often

supervened after operation. In fact, one of the most constant characteristics

in this type of case was the tendency to recurrent shock.

The terminal decline as rule occurred shortly after operation, but in

many instances it was sufficiently delayed for widespread bacterial growth to

occur. Death was usually attributable to shock or to shock and peritonitis,

but the peritonitis, it must be emphasized, differed from the type of purulent

peritonitis familiar in civilian practice (p. 198). It was characterized by massive contamination of the peritoneum and by the gross pathologic changes

observed during the early stages of bacterial growth. In addition, the circulatory and metabolic changes associated with severe traumatic shock, as well as

the overwhelming nature of the peritoneal infection, appeared to be capable of

inhibiting to an appreciable degree the local leukocytic response. Autopsy

revealed edema and discoloration of the intestine, opacity and dullness of the

serosal surfaces, moderate amount of turbid, serosanguineous exudate, and

relatively little fibrin (cases 7, 8, 10, and 11). purulent exudate of significant

amount was not usually seen, probably because of the brief duration of the

inflammatory process.

The peritoneal reaction which was the result of early massive soiling thus

differed materially from the usual bacterial peritonitis of to days’ duration.

Early in the war, the deleterious local effects of such soiling were not always

appreciated because the surgeon’s judgment was based on knowledge limited

to the classical variety of peritonitis.

Preexisting traumatic shock was undoubtedly the explanation of the

promptness and frequency with which death occurred after wounding in this

type of peritonitis. When massive peritoneal contamination was further complicated by continuing intra-abdominal hemorrhage, successful resuscitation

and surgery were often impossible.

In some cases, in spite of massive transfusion therapy, careful surgery,

chemotherapy, oxygen therapy and all other available measures, the fatal

outcome was merely delayed for day or two. Its apparent inevitability, in

spite of what seemed to be adequate replacement therapy, introduced the

question of the possible role of toxic factors in the production of so-called

irreversible shock. The toxic theory is particularly interesting because of the

massive peritoneal contamination and the associated circulatory failure present

in many of these severely wounded men. The analogy to anaerobic myositis

was suggestive, especially because in few instances pure cultures of Clostridium

welchii were obtained from the peritoneal cavity. Similar infections of the

pleural cavity were occasionally observed (case 13). These isolated observa-
128 GENERAL SURGERY

tions, however, cannot be construed as valid evidence that the same factors were

responsible for severe shock in the presence of peritoneal contamination. The

role of toxicity cannot be denied on the basis of the evidence at hand, but

toxic factor, other than infection per se, remains to be isolated and established.

It should be realized that the exigencies of warfare often precluded the

accumulation of data which would fully explain the apparent failures ofreplacement therapy in the management of shock. In the absence of these data,

unwarranted conclusions were frequently drawn relative to the effect of what

were termed toxic factors. When comparatively complete clinical and post

mortem data were critically analyzed, these conclusions usually could not be

substantiated. The protocols found at the end of this chapter (cases to 4,

inclusive; 9; 10; 14; and 15) disclose various findings which, regardless of their

relationship to shock, limited the chance of survival of the seriously wounded.

The investigations of the Board for the Study of the Severely Wounded

afforded no evidence of the existence of toxic agents and led the investigators

to suggest that the term ‘‘irreversible shock” should be abandoned because of

its implications in this respect.

Excessive prolongation of the period of peripheral circulatory failure was

apparently the most important reason for failure ofliberal replacement therapy

to accomplish resuscitation in some cases. The importance of the duration

of shock cannot be arrived at by simple analysis of statistical data (table 18).

There was no significant correlation, as already pointed out, between the

severity of shock and the duration of injury before operation. Moreover, it

was frequently impossible to determine the exact duration of the observed state

of shock from the field medical record.

It was readily apparent, however, that the more severe the peripheral

circulatory failure, the more rapidly did state of profound or so-called irreversible shock ensue. relatively short period of delay in resuscitation might prove

fatal to patient in severe shock, although it could easily be tolerated by

patient in moderate shock. Traumatic shock, satisfactorily alleviated by the

prompt transfusion of 1,500 to 2,000 cc. of whole blood, could constitute irreversible shock in the absence of such therapy. It is rather general custom to label

shock as irreversible when the therapy at hand has proved to be unsuccessful,

but this is vague characterization defined by therapeutic trial, not by

exact knowledge of the fundamental pathologic physiology.

All the World War II experience indicated that peripheral circulatory

failure is followed, within variable period of time (the variation depending

upon its severity), by alterations in general cellular metabolism which cannot

be corrected by transfusion therapy alone. These changes were thought to

depend upon the interruption of the supply of oxygen and other nutrients to

large groups of cells, as, for example, those of the liver and kidney, rather than

upon changes in the capillary endothelium. Shock therapy was effective only

See footnote 5, p. 124.
SHOCK THERAPY 129

insofar as it restored adequate circulatory dynamics and alleviated tissue anoxia. Changes in cellular metabolism could thus be prevented or arrested,

but they could not be completely reversed. In this respect, replacement

therapy was always prophylactic.

If the metabolic changes associated with severe shock were thoroughly

understood, the knowledge might serve to resolve the enigma of so-called

irreversible shock without invoking factors other than fluid loss in its pathogenesis. Unfortunately, no simple methods were available duringWorld WarII

nor are they available now—by which the clinician could determine accurately

the onset of irreversible cellular changes during the course of traumatic shock.

The only solution of the problem was, therefore, to treat existing circulatory

failure as promptly and as vigorously as possible.

THE TOTAL PICTURE OF SHOCK IN WORLD WAR II

The experience of the 2d Auxiliary Surgical Group with casualties in shock

and in need of resuscitation following abdominal wounds apparently paralleled

the total war experience. Local fluid loss undoubtedly was the most important

factor in the initiation of traumatic shock. The most efficacious means of

resuscitation was prompt and adequate replacement therapy, in which whole

blood was the most important component. The nature of battle wounds

of the abdomen demanded that prompt and expert surgery constitute

an integral part of resuscitative therapy, in order to arrest hemorrhage

and peritoneal contamination with the least possible delay. Many factors, not

all of which were completely understood, augmented and perpetuated shock.

One, which was extremely important, was massive contamination of body cavities. The circulatory disturbances of severe shock promptly led to bodily

changes which could not be completely reversed by replacement therapy.

Delay in initiating such therapy, as well as improper utilization of available

measures, whether as the result of military exigencies or for other reasons, resulted in failures of resuscitation.

Many abdominal injuries were lethal, at least in relation to methods of

resuscitation and surgery then at hand. They remained, at the end of the war,

as challenge for the future. It is in the resuscitation of gravely wounded men

that the therapy of traumatic shock will meet its most severe test. Advances

will depend upon more fundamental knowledge concerning the relationship

of massive peritoneal contamination to traumatic shock and death, as well as

upon more thorough understanding of the cellular derangements produced

by severe shock. The failures in replacement therapy which occurred in World

War II point to the need for further study of the problem but must not be interpreted to permit the neglect of available measures of resuscitation in the

management of severely wounded men with abdominal injuries.
130 GENERAL SURGERY

CLINICOPATHOLOGIC STUDY OF ABDOMINAL WOUNDS

ASSOCIATED WITH SHOCK

Introductory Note

In March 1944, the author of this study (Maj. Beverly T. Towery) had

the good fortune to assume the direction of Shock Team No. 6, 2d Auxiliary

Surgical Group, which was then engaged in the resuscitation of nontransportable

casualties in the field hospitals of the Fifth United States Army, Mediterranean

Theater of Operations. As explained elsewhere, the evacuation of gravely

wounded casualties was always specifically interrupted in forward medical

echelon for the treatment of shock, followed by surgical intervention, after

which the patient was retained in the field hospital for period of convalescence.

At this time, almost no post mortem examinations were being carried out

upon the fatal cases in this group of patients, although the high incidence of

severe shock and the resulting deaths among these “casualties of immediate

urgency” provided remarkable opportunity for the study of the clinical as

well as of the morphologic characteristics of wound shock. The tissues and

clinical protocols which the microscopists received were often too inadequate to

permit an intelligent interpretation of the findings. Conversely, reports of

microscopic diagnoses usually failed to find their way back to the prosectors.

With the enthusiastic encouragement of the late Lt. Col. Tracy B. Mallory,

MC, systematic program was set up for the clinical and post mortem study

of patients who died in field hospitals, as follows:

1. The author, with only one or two exceptions, performed the post

mortem examinations.

2. He was responsible for providing the microscopist with record of the

gross anatomic findings.

3. With this report, he also included provisional diagnoses and brief

summary of the case, based upon the autopsy findings and the clinical data

available at the time of the post mortem examination.

4. The microscopists provided histologic descriptions of the tissues, added

microscopic diagnoses, and frequently wrote brief comments upon their observations.

5. The original observations made by the prosector were retained in the

protocols, and the provisional diagnoses were not amended to conform to the

subsequent reports of microscopic findings. Such inconsistencies as might

have arisen were discussed and rectified in the final summarizing statements

attached to the end of each protocol.

During the 13-month period in which this program was continued, it was

possible to accumulate relatively complete clinical and post mortem data upon

47 men who had been wounded under varying circumstances of terrain, climate,

and tactical situation in Italy, France, and Germany. Thirty of these casualties (64 percent) had sustained wounds of the abdomen. The 15 protocols

which follow have been selected from this group of cases, in an attempt to define
SHOCK THERAPY 131

clearly the magnitude of the problem of shock among patients with abdominal

injuries. It is believed that these records constitute representative source

material.

The author was personally responsible for part or all of the resuscitation in

most of the cases in the total series. As collator, however, he has drawn freely

upon the clinical observations of numerous colleagues in respect to replacement

therapy, anesthesia, surgical management, and postoperative care.

This study clearly showed that hemorrhage and peritoneal contamination

were the most important determinants of the outcome of intra-abdominal

trauma. Regardless of the ultimate detrimental effects of peritoneal contamination, the early onset of severe shock was almost invariably due to brisk

hemorrhage. Widespread peritonitis unquestionably increased the likelihood

of fatal outcome, though, aside from the attendant local loss of fluid, the

mechanism of the deleterious effects of this complication remained unexplained

in this study. morphologic evaluation of these phenomena proved to be

difficult undertaking and one which, on theoretical grounds, was not particularly rewarding. From practical standpoint, however, the demonstration of

microscopic lesion, such as diffuse pulmonary fat embolism, sometimes provided crucial data in fatality which otherwise might have remained obscure.

Resuscitation by means of vigorous replacement therapy removed, at

least in part, the immediate risks of shock but seemed to accentuate certain

microscopic changes contingent upon partial or complete recovery from it.

Hemoglobinuric nephropathy was perhaps the most striking of these lesions,

and the importance of post traumatic renal failure will be readily apparent on

perusal of these records. It is ironical that the development of this particular

lesion seemed to depend upon measure of success in resuscitation.

One of the major aims of this study was to obtain evidence concerning the

fundamental pathogenesis of irreversible shock. The results were illuminating.

In effect, it was evident that careful post mortem examination very often

revealed findings which provided some other logical explanation for the fatality.

Among these findings were unrecognized perforations of the gastrointestinal

tract, the autotransfusion of contaminated blood, unsuspected infection, pulmonary edema, and cerebral emboli. On the basis of the experience obtained

in this investigation, one would thereforebe inclined to minimize the importance

of shock which does not have reasonable explanation in terms of hemorrhage,

exudation, and infection.

Protocols

Case

CLINICAL DATA

This patient received bullet wound of the left hip on June 1944, at

1000 hours. When he reached field hospital at about 1600 hours, after having

The author gratefully acknowledges the generous assistance in this study of the various pathologists whose microscopic studies (sometimes identified by initials) appear in the protocols. Heis particularly indebted to the late Lt. Col.

TracyB. Mallory, MC, and to 1st Lt. Leslie S. Jollifle, MC, and Capt. Joseph Q. Rothenberg, MO. First Lt. Kathryn

T. Driscoll, ANC, provided invaluable clerical assistance.
132 GENERAL SURGERY

received 250 cc. of plasma, his blood pressure was 110/60 mm. Hg. He did not

appear to be in shock, but examination of the abdomen revealed generalized

rigidity. He was given 500 cc. of plasma and 500 cc. of blood before operation,

and his condition seemed relatively good. His blood belonged to group A. At operation, much blood was found in the peritoneal cavity. The

missile had perforated the abdomen by way of the left buttock. When exploration was attempted, profuse hemorrhage occurred from the left iliac vessels, and the aorta and inferior vena cava were temporarily ligated with tape.

After great deal of difficulty, it was possible to ligate the left external iliac

vein, and the internal iliac vein and artery.

The patient’s condition was extremely poor during this procedure, and

he was given 4,500 cc. of group blood in an attempt to replace the blood loss.

Extensive exploration of the abdomen was not carried out, but there was no

evidence of perforation of the intestine or of peritonitis. At the end of the

procedure, which lasted approximately hours, the blood pressure was 100/40 mm. Hg; it had risen considerably after bleeding had been controlled.

The right leg became moderately cyanotic after operation, and, on both

the first and second postoperative days, right lumbar sympathetic blocks were

performed with procaine. Some improvement was noted. On the second

postoperative day, the temperature was 98.6° F., the pulse was 100, and the

respiration was 24. When the patient was catheterized, only 60 cc. of darkbrown urine was obtained, although the fluid intake had been adequate. Its

specific gravity was 1.025. The patient became somewhat confused and died

at 2000 hours June 1944, 58 hours after wounding.

AUTOPSY

Autopsy was performed June 1944, 12 hours after death (Cori, Italy).

Gross observations.—The delay in performing the autopsy, without benefit of refrigeration, had produced marked changes in the body. The pericardial cavity contained 30 cc. of pink serous fluid, and 120 cc. of similar

hemolyzed blood-stained fluid was present in each of the pleural cavities. The

peritoneal cavity was not remarkable, except for generalized pink (hemoglobin)

staining of the serous surfaces.

The lungs showed bilateral and symmetrical edema and deep purple-red

discoloration, with considerable reduction in crepitus. No bronchial obstruction was present nor were any emboli present in the carefully dissected branches

of the pulmonary artery.

Two perforations were observed in the retroperitoneal portion of the

ascending colon. They were caused by passage of the bullet through this

viscus about cm. distal to the ileocecal valve. There was also extensive

retroperitoneal hemorrhage in this region, with rather scanty fibrinopurulent

exudate.

The kidneys were swollen and moderately increased in size. The cut surface bulged above the edge of the capsule. The cortex was rather pale, but
SHOCK THERAPY 133

its pallor was modified by hemoglobin staining of all the tissues. Hydroureter

and renal-vascular occlusion were not present.

The finer detail of the pelvic vessels was greatly obscured by extensive

suffusion of tissues by markedly hemolyzed blood.

Sections of muscle taken from the upper thigh on the left were not grossly

remarkable except for moderate pallor.

Gross anatomic diagnosis.—(1) Penetrating gunshot wound of left buttock, with two perforations of retroperitoneal portion of ascending colon and

early retroperitoneal abscess; lacerations of left common iliac vein, external

iliac vein, and internal iliac artery and vein, all secondarily ligated; and (2)

severe, exsanguinating hemorrhage, secondary to these lacerations.

Comment.—Death may be ascribed to shock, secondary to severe and

prolonged hemorrhage. Since death occurred on the second postoperative day,

the perforations of the colon may have had relatively little to do with the

fatality. These perforations, however, served to contaminate the wound

track with anaerobic organisms, and clinical manifestations would probably

have supervened shortly, had the patient survived. How important this

contamination was in causing death must remain conjectural. The oliguria

present before death suggested renal lesion, but in all probability the inadequate renal blood flow (hypotension) during the postoperative period was

alone responsible for the decreased urinary output.

Microscopic observations.—Histologic examination of the kidney showed

the lower nephron segments to be extensively plugged with pigmented casts.

In the cortex, some tubules contained masses of intensely blue-staining granules

and spherules suggesting calcareous material. These masses were not found

in the pyramid. There were many bacilli in the interstitial tissues, and

fixation was too poor to judge epithelial degeneration.

Examination of the bowel showed much of the mucosa to be necrotic.

All layers of the wall were infiltrated with leukocytes, and the serous surface

was covered by thick fibrinopurulent membrane.

Comment.—The severe lower nephron nephrosis of the hemoglobinuric

type is suggestive of transfusion reaction. The story of the administration

of 4,500 cc. of group blood to group recipient within period of few

hours is interesting and may have been the responsible factor. The clostridial

infection was evidently only agonal and cannot be held responsible for the

fatality. There was no massive necrosis of voluntary muscle which could have

produced myohemoglobinuria. The calcareous masses in some of the tubules

are assumed to represent past history; they could be remnants of previous

sulfonamide reaction. (T. B. M.)

SUMMARY

Death probably was due to combination of factors in this case: (1) Severe

shock during prolonged operation; (2) perforation of the colon with contamination of the retroperitoneal tissues; and (3) renal failure, with consequent
134 GENERAL SURGERY

pulmonary edema. Of these factors, the first seems to be ofgreatest importance,

since death occurred within relatively short time after operation. Uremia

per se was probably not of primary importance in causing death; under the

conditions at hand it is extremely difficult to assess the importance of infection

in this case.

Case

CLINICAL DATA

This patient received shell-fragment wounds of the left thigh and right

costal margin 19 March 1945 at 0230 hours. tourniquet was applied to the

left leg at 0300 hours. When the patient reached field hospital at 0630 hours,

after having received 500 cc. of plasma, the blood pressure was 110/70 mm. Hg,

and the pulse was 80. Before operation, he was given 600 cc. of plasma and

500 cc. of whole blood. His blood belonged to group AB.

Anesthesia was begun at 1105 hours 19 March. Laparotomy revealed

laceration of the right lobe of the liver and severe destruction of 10-cm.

portion of the transverse colon. spur colostomy was made through the

right upper quadrant, and drains from the hepatic laceration were brought out

through the wound at the right costal margin. The operation required 3K hours, and during it the patient received 2,000 cc. of whole blood.

In addition to his abdominal wound, this patient had fracture of the

lower third of the left femur, with severe comminution and posterior angulation

of the distal fragment.

The day after operation, the patient was semistuporous. The blood pressure was 84/50 mm. Hg and the pulse 140. He received 500 cc. of plasma.

Medium rales were heard in both lungs. Moderate cyanosis was relieved by

the administration of oxygen. There was profuse drainage of bile-stained

fluid from the drains at the right costal margin. During the first 12 hours after

operation, the patient excreted 275 cc. of urine. His respirations were quite

shallow, and he coughed only occasionally and ineffectually. He died at 1630

hours on the second postoperative day, 62 hours after wounding.

AUTOPSY

Autopsy was performed hours after death (St. Avoid, France).

Gross observations.—The abdomen was moderately distended, in spite of

the presence of several drains. The peritoneal cavity contained about 300 cc.

of blood-tinged, purulent fluid, which was present chiefly above and posterior

to the colostomy spur; moderate amount of yellow-gray purulent exudate

was also found in this area. There was considerable dilatation of the stomach

and of the upper bowel down to the point at which the small bowel was partially obstructed as itlay posteriorly and lateral to the proximal segment of the

colostomy. Distal to this point, the bowel was not distended, though the loops
SHOCK THERAPY 135

were lightly bound together by fibrinopuriilent exudate. There was no leakage

into the peritoneal cavity from the colostomy, the transverse spur of which appeared to be under slight tension.

The right auricle was considerably distended by blood. The tricuspid

valve appeared slightly dilated. There were petechial hemorrhages over the

surface of the posterior aspect of the heart, particularly along the coronary

sulcus. On section, the myocardium appeared paler than normal.

There were severe partial atelectasis of both lungs; the aeration of all lobes

except the left upper lobe was moderately to markedly decreased. There was

well-established nodular consolidation of the entire right lower lobe, the hilar

portion of the right middle lobe, and the posterior portion of the right upper

lobe. Near the hilus of the right lower lobe there appeared to be beginning

abscess formation.

The spleen was of usual size and was covered by thin layer of fibrinopurulent exudate. On section, it was purple red and moderately firm, but the

pulp scraped away readily.

There was small laceration of the lateral margin of the right lobe of the

liver, but no appreciable collection of bile was present within the peritoneal

cavity. In the dome of theright lobe was large, irregular area of yellow mottling. There was no evidence of suppuration in the tissue adjacent to the

laceration.

The kidneys were somewhat smaller than normal, and the capsular surfaces were smooth and pale pink, with small irregular patterns of vascular

congestion. The cut surface was not remarkable. The adrenals were normal.

Gross anatomic diagnosis.—(1) Perforating shell-fragment wound of

abdomen, via upperright flank, with exit just to right of umbilicus, with moderately severe laceration ofright lobe ofliver, and severe perforation and laceration of right transverse colon, with spur colostomy; (2) acute, moderately

severe, fibrinopuriilent peritonitis, secondary to perforation of transverse

colon; (3) severe pulmonary atelectasis, involving all lobes, with early acute

bronchopneumonia of right lung and left upper lobe, and possible abscess of

right lower lobe; dilatation of right auricle and subepicardial petechial hemorrhages probably due to atelectasis and asphyxia (possibly terminal); (4) perforating shell-fragment wound of left lower thigh, with complete, compound,

comminuted fracture of lower third of left femur and laceration of capsule of

left knee joint and of suprapatellar bursa; and (5) lacerating shell-fragment

wound of left chest wall near 12th rib.

Comment.—The immediate cause of death in this case appears to have been

atelectasis and bronchopneumonia. The post mortem findings suggest that

these complications began soon after operation. The semistuporous state and

the diffuse peritonitis and distention of the stomach and upper small bowel

were probably responsible for the poor respiratory exchange and ineffectual

cough. In the presence of severe bone trauma, stupor and pulmonary rales

suggest the possibility of fat embolism.
136 GENERAL SURGERY

Microscopic observations.—In the alveoli of the lungs were large amounts

of eosinophilic coagulum and varying degrees of polymorphonuclear infiltration

into the coagulum. second section revealed dissolution of the alveolar walls

with extreme infiltration and accumulations of polymorphonuclear leukocytes.

In the central portions of these accumulations were bacterial groups and necrotic

debris. Some alveolar walls which were still present appeared necrotic. Thrombi

were seen in the vessels in these areas. On the pleural surface was thin,

fibrinoid material with enmeshed polymorphonuclear leukocytes. Large

amounts of eosinophilic coagulum were seen in alveoli along with polymorphonuclear leukocytes.

In the section studied from the liver, small vacuoles were seen throughout

the parenchyma. About the central vein, which was slightly dilated, slight

sinusoidal congestion was observed.

The sinusoids of the spleen were dilated and congested.

The tubular cytoplasm of the kidney was granular. Many of the nuclei

were indistinct or absent. The glomeruli were not remarkable.

Vacuolation of cortical cells was most noticeable in the zona glomerulosa

of the adrenal glands.

Microscopic diagnosis.—(1) Lobular pneumonia with abscess formation,

(2) moderate fibrinopurulent pleuritis, (3) severe acute purulent peritonitis,

(4) edema of small intestine, and (5) traumatic necrosis of liver.

SUMMARY

This case is an instance of severe abdominal injury. After relatively

short delay, the patient reached the field hospital in surprisingly good condition.

In spite of the many favorable circumstances, however, he died of plumonary

atelectasis and bronchopneumonia on the second postoperative day. Peritonitis was probably also contributory factor in the fatality. It is unfortunate

that microscopic studies of the lung were not sufficient to exclude pulmonary

fat embolism.

Case

CLINICAL DATA

This patient received bullet wound of the left abdomen 18 April 1945 at

1800 hours. When he was admitted to field hospital at 2215 hours, his blood

pressure was 130/80 mm. Hg. He received 500 cc. of group (his blood group)

blood before operation. His condition during the preoperative period was

relatively good.

As the peritoneal cavity was being opened, the blood pressure fell abruptly

to 0/0 mm. Hg. The systolic pressure rose to 90 mm. Hg when 1,500cc. of whole

blood were given rapidly. As abdominal exploration was continued, large quantity of blood was found in the peritoneal cavity. There was severe

laceration of the proximal jejunum; small segment wasresected and an end-to-
SHOCK THERAPY 137

end anastomosis was performed. lacerated segment of the colon was exteriorized through stab wound in the left upper abdomen. Operation was completed 19 April at 0220 hours.

Immediately after operation, the systolic blood pressure was 170 mm. Ilg,

which was attributed to mild transfusion reaction during the operation. The

blood pressure then progressively declined; it was 100/66 mm. Hg at 0830 hours

19 April and only 22/0 mm. Hg at 1200 hours. At this time, the patient appeared moribund. He had vomited large quantities of blood, and itwas thought

that the fall in blood pressure was caused by bleeding in the upper gastrointestinal tract.

In an attempt to control this bleeding, second operation was undertaken

at 1400 hours 19 April. At this operation, no blood was found in the peritoneal

cavity. The original jejunal anastomosis was examined through an opening

made in the bowel just distal to it. At this time, although he had had 3,000 cc.

of blood just before the operationand during its course, the patient was in severe

shock. No point of bleeding could be found along the line of resection. The

anastomosis was, nevertheless, reenforced by an additional row of through-andthrough sutures, and the jejunotomy was closed. gastrotomy was then

performed, and large volume of clotted blood was removed from the stomach.

There was no evidence of gastric bleeding from the mucosal surface, which was

examined as completely as possible through the incision.

After the second operation, the blood pressure was 80/0 mm. Hg. By 1830

hours, it had fallen to 20/0 mm. Hg, and it did not again exceed this level. The

patient expired in profound shock at 2220 hours 19 April 1945, 28 hours after

wounding.

During his brief hospitalization, this patient received 5,500 cc. of whole

blood, all group and all carefully crossmatched with his blood.

AUTOPSY

Autopsy was performed 13 hours after death (Poxdorf, Germany).

Gross observations.—The body was not remarkable except for considerable

dependent lividity.

The lungs showed only post mortem hypostasis.

The abdominal cavity was not remarkable except for the thin, opaque,

fibrinous exudate which covered several loops of small bowel. This portion of

the bowel was not distended, and there was no appreciable collection of purulent

exudate.

The spleen was moderately enlarged and rather soft and appeared somewhat less congested than is usual after massive transfusion therapy.

The gastrotomy, jejunotomy, and jejunal anastomosis cm. distal to the

ligament of Treitz were all snugly sutured, and there was no evidence of leakage

of bowel contents. When the gastrointestinal tract was opened, about 300 cc.

of old blood were found in the stomach, and small amount of similar blood

was also found in the loop of jejunum at the site of anastomosis. The duo378327°—56 11
138 GENERAL SURGERY

denum, which was free of blood, was deeply bile stained. In an attempt to

locate possible source of bleeding, the mesenteric vessels leading to the

jejunojejunostomy were cannulated and infused with water, but no vascular

leak was disclosed. Since no blood was present distal to the jejimostomy, the

upper gastrointestinal tract was examined minutely. No source of hemorrhage

was present. small, shallow excoriation of the distal esophagus and another

in the first portion of the duodenum showed no evidence of tissue reaction, and

no vessels were exposed. No varices were present in the lower esophagus.

The kidneys were somewhat smaller than usual but were not remarkable

on section. The left kidney and adrenal were partly surrounded by the blood

in the retroperitoneal area.

Gross anatomic diagnosis. (1) Penetrating bullet wound of abdomen

with severe laceration of proximal jejunum, secondary resection and jejunostomy, jejunotomy; perforation of transverse colon, colostomy; and (2) exsanguinating postoperative hemorrhage from upper jejunum secondary to lacerating wound of jejunum, with the operations described.

Comment.—A very careful examination of the upper gastrointestinal tract

failed to reveal any source of hemorrhage. The most likely sequence of events,

therefore, is that thepatient bled extensively from the initial jejunojej unostomy.

It may be that no bleeding was found at the second operation because of the

very low blood pressure at the time. The failure of response to transfusion

therapy before and during the second operation is probably related to the

considerable time during which the blood pressure remained at very low level.

From the evidence obtained at autopsy, the second row of sutures about the

jejunum was apparently successful in preventing further hemorrhage, but fatal

hemorrhage had already occurred.

The histologic picture of the kidneys will be of interest in this case, in view

of the massive therapy with type-specific blood. During the 10 hours the

patient was on the ward between operations, there was no recorded output of

urine. During most of this time, the blood pressure was below the level necessary for renal filtration.

Microscopic observations.—The sections from the lungs showed confluent

patches of bronchopneumonia. The exudate was hemorrhagic in few foci

but chiefly showed polymorphonuclear leukocytes. In another section, scattered, small areas of atelectasis were seen. Two small vessels were thrombosed.

The alveolar septa were hyperemic.

Sections from the liver showed the centers of the lobules to be congested.

The liver cells in these regions contained granular brown pigment (lipochrome).

The pulp of the spleen was moderately congested. The malpighian bodies

were large and conspicuous, with active secondary follicles, in some of which

much free and phagocytized nuclear debris was present.

The only change noted in section from the gastroesophageal junction was

autolysis of the gastric mucosa.

The epithelium lining some of the collecting tubules and Henle’s loops in
SHOCK THERAPY 139

the kidney showed degeneration and desquamation. With this exception,

both glomeruli and tubules appeared normal.

Comment.—The degenerative changes in the kidney in this case were not

pronounced and may be entirely post mortem changes. One would be more

inclined, however, to attribute them to the prolonged, severe shock which this

patient sustained.

The fact that this patient received 5,500 cc. of blood without histologic

evidence of incompatibility is tribute to those responsible for the transfusions.

In similar cases, the experience has been quite the contrary, especially when

group blood has been given to group patient, (J. G. R.)

SUMMARY

In this case, postoperative hemorrhage from jejunal anastomosis was responsible for prolonged, severe shock and eventual death. Microscopic examination of the kidneys failed to reveal the presence of pigment nephropathy,

which might have been expected because of its frequency under similar circumstances. The following factors may offer partial explanation for the absence of such lesion; (1) The use of group-specific blood instead of the customary low-titer group blood in the resuscitation of group patient, and (2)

the failure of the blood pressure to reach the glomerular filtration pressure

throughout the prolonged period of shock. Presumably, pigment casts do not

appear unless some degree of glomerular filtration is resumed or is maintained

after the initial insult.

Case

CLINICAL DATA

This patient received an accidental bullet wound on May 1945, at 0945

hours. The wound of entrance was located at theright costal margin in the midclavicular line, and the wound of exit was just lateral to the inferior tip of the

left scapula. When he was received in clearing station immediately after injury,

the blood pressure was 120/60mm. Hg, and the pulse 130. He was given 125 cc.

ofplasma, and the 5th to 12th intercostal nerves on the right side were blocked

with procaine. The patient was then moved forward with the field hospital

which was in convoy at the time. Upon his arrival at the new installation, the

blood pressure was 90/50 mm. Hg, and the pulse was 140.

right thoracentesis was not productive, but 635 cc. of blood were removed

from the left chest. The patient complained of extreme pain in the abdomen,

right chest, and both shoulders. The response to the administration of 750 cc.

of plasma and 635 cc. of blood by autotransfusion was poor.

Epidural block with procaine was performed, with good results, but severe

bilateral pains in the shoulders persisted. When the patient was turned on his

side before this procedure, there was transitory fall in the blood pressure, but

the block was accomplished without difficulty. Just before operation, the blood

pressure was 84/50 mm. Hg. The patient’s blood belonged to group B.
140 GENERAL SURGERY

Gas-oxygen-ether endotracheal anesthesia was begun at 1815 hours. The

wound of exit was debrided, and thoracotomy was performed through the left

ninth intracostal space, with resection of fragment of the ninth rib. Splenectomy and suture of laceration of the greater curvature of the stomach were

carried out through transdiaphragmatic incision. Laparotomy was then performed, with closure of perforation in the upper portion of the lesser curvature

of the stomach. The missile track had traversed the left lobe of the liver.

Just before thoracotomy, when the patient was turned on his right side,

there was marked fall of blood pressure. Within short time, he was given

1,500 cc. of whole blood and 250 cc. of plasma. The agglutinin titers of theblood

which he received at this time were not known; no blood with known agglutinin

titer was available.

On May, the day after wounding, the patient’s condition was poor,

because of atelectasis of the left lung. After tracheal aspiration, there was an

increased density of breath sounds on the left side and lessening of cyanosis.

The abdomen was flat. There was considerable drainage of bile. Approximately 600 cc. of bloody fluid drained from the left chest. The hematocrit was

37 and the hemoglobin 13 gm. percent; the plasma protein was 5.8 gm. percent.

The systolic blood pressure was 85-90 mm. Hg. Intravenous fluids consisted

of 500 cc. of plasma and 500 cc. of blood. The urine output since operation was

700 cc. The serum showed no evidence of hemolysis.

On May, the patient was somewhat improved after tracheal aspiration,

withremoval of dark, blood-tinged mucus. Aeration of the left chest was better,

but beginning pneumonitis was suspected. The temperature was 101°-102° F.

by rectum. The urinary output was 200 cc.; albumin plus was present. The

blood pressure was 100/60. The patient was irrational and required sedation,

for which paraldehyde was used. He perspired profusely, and venous distention was pronounced. All fluids were discontinued.

On May, the left chest was clearing. Bronchial breath sounds were

heard over the right base. Oxygen was administered by mask.

At 1300 hours, the patient was moved to the X-ray table. Here he rapidly

became cyanotic, in spite of continued oxygen administration, and failed to

respond after endotracheal suction. The superficial veins were greatly distended. He died May 1945 at 1400 hours, about 76 hours after wounding.

AUTOPSY

Autopsy was performed hour and 15 minutes after death (Adelstetten,

Germany).

Gross observations.—There was considerable evidence of dehydration.

The veins of the arms and neck were quite distended. In addition to the healing

surgical incisions, the wound of entry lay just inferior to the right costal

margin, and the wound of exit was at the level of the ninth rib just lateral to

the tip of the left scapula.

The peritoneal cavity contained small amount of clotted blood. The

surfaces were smooth and glistening and there was no general fibrinopurulent
SHOCK THERAPY 141

exudate. Along the drainage tracks to the posteroinferior aspect of the liver

and the anterior portion of the stomach was moderate deposit of yellow,

fibrinopurulent exudate. There was no fluid or bile in the subhepatic space.

The diaphragm was at the level of the fifth rib bilaterally.

The right chest contained about 75 cc. of clotted blood. moderate

amount of air escaped from the left chest when the cavity was opened and

pressure was applied to the sternum. The chest on this side contained 400 cc.

of bloody, turbid fluid, which was enmeshed in fibrinous strands and which

compressed the lung more or less uniformly. Anteriorly, fibrinopurulentlined pocket was present, with capacity of approximately 250 cc.; it appeared

to have contained air. The left diaphragm was sutured without leakage.

The pericardial cavity contained about 40 cc. of clear, straw-colored fluid.

The heart appeared considerably distended, especially on the right. The right

auricle was distended by blood, which brought the trabeculae into sharp relief.

The tricuspid valve measured 13.0 cm. in circumference. There were scattered

subepicardial petechiae, chiefly over the posterior cardiac aspect along the

coronary sulcus.

The left lung was moderately reduced in size and air content. The surface

was covered by shaggy, yellow-pink, fibrinopurulent exudate in which were

embedded foreign particles with the appearance of food. Both lungs were

greatly congested and edematous, particularly in the dependent portions.

Edema was more severe on the right, and the right lung was somewhat heavier

than the left. Both, however, were considerably increased in weight. Section

of the right lung revealed it to be practically airless. Dark, serosanguineous

fluid oozed freely from the cut surface. The right lower lobe contained no areas

of consolidation, but small areas of early consolidation were present in the

subpleural portion of the right upper lobe. There was no consolidation of the

left lung, but all bronchi contained copious, blood-tinged, serous fluid streaked

with purulent exudate. No demonstrable isolated bronchial obstruction existed;

rather, obstruction was generalized. There was moderately severe contusion of,

and hemorrhage into, the parenchyma of the inferior portion of the left lower

lobe.

The liver was not generally remarkable. The missile had entered the left

lobe at the falciform ligament anteriorly and had emerged near the lesser

curvature of the stomach. There was the usual degree of infarct necrosis along

the missile track. There was no gross evidence of suppuration.

There were two sutured perforations of the fundus of the stomach; no leakage was noted along either suture line.

The kidneys, which were similar in appearance, were both considerably

swollen, particularly in the anteroposterior diameter. The smooth cortical

surface was pale yellow gray and faintly mottled. On section, the bulging

cortex appeared pale and opaque. The pyramidal striations were moderately

increased. The renal pelves and vessels were negative.

Gross anatomic diagnosis.—(1) Bullet wound of left thoracoabdominal

area, with moderately severe perforating wound of left lobe of liver; severe
142 GENERAL SURGERY

perforating wound of stomach with acute fibrinopurulent peritonitis localized

to subhepatic region; laceration of spleen, splenectomy; healing perforation of

left posterolateral diaphragm; severe contusion of lower lobe of left lung;

complete compound fracture of left ninth rib; (2) severe left fibrinopurulent

pleuritis, secondary to perforating wound of stomach and perforation of left

diaphragm; (3) moderate partial left pneumothorax secondary to contusion of

lower lobe of left lung and complete compound fracture of left ninth rib;

(4) possible hemoglobinuric nephropathy or shock kidney, as manifested by

severe bilateral pulmonary congestion and edema; acute congestive heart

failure, predominantly right sided; clinical oliguria; and (5) acute purulent

early bronchopneumonia of upper lobe ofright lung.

Comment.—No group blood in which the agglutinin titer had been

determined was available for this patient. The only blood which could be

used did not fall into the category of low-titer blood. Under such circumstances, autotransfusion would ordinarily have been particularly desirable, but

in this case, because of the injury of the stomach with soiling of the left pleura,

it was incorrect.

This patient appeared to have been extremely sensitive to changes in

position. On two separate occasions, the blood pressure fell sharply when he

was turned on his side. Before thoracotomy, the blood pressure remained at

excessively low levels for period of about 80 minutes, in spite of liberal transfusion therapy. During such periods, the renal blood flow must be markedly

reduced, and it is suggested that this was crucial factor in the production

of pigment nephropathy in this case.

The delay before operation was unusually long. Part of it was caused by

the fact that the field hospital was in process of moving when the patient

reached the clearing station. During the delay, his condition deteriorated

considerably, and liberal replacement therapy was necessary before operation.

Unfortunately, however, operation was not urged at the earliest possible

moment because of the mistaken belief that there had been no perforation of

hollow viscus. Obviously, the optimum time of operation would have been

when the patient first reached the clearing station, only short time after

injury.

Microscopic observations.—In one section of the lungs, the tissue was

packed with red blood cells. Several vessels contained thrombi. In another

section, the congestion was almost as severe, and the bronchiolar walls contained purulent exudate. In third section, which was free from congestion,

the alveolar walls showed patchy approximation and stretching. There was

fibrinopurulent exudate on the pleura.

Rare round cells were found beneath the epicardium. No myocardial

changes were noted.

In one section of the liver was largo zone of infarct necrosis, bordered

by region of inflammatory exudate, beyond which was normal-appearing

liver tissue. The peritoneal surface showed thick, purulent exudate. Both

in the infarcted area and in the exudate were masses of bacteria.
SHOCK THERAPY 143

Sections from the kidneys showed amorphous material and lightly staining

spherical bodies in capsular spaces and proximal convoluted tubules, which

were moderately dilated. Brown, granular casts were present in the distal

tubules and loops of Henle. Nuclear pyknosis and cell shrinkage were noted

in relation to these casts. There was moderate swelling of the capsular and

convoluted tubidar epithelium. few cysts filled with pink-staining coagulum

were present.

One zone of cortical necrosis was noted in the adrenal glands. Otherwise,

there was decrease in the usual vacuolar appearance of the cortical cells.

Adjacent fat tissue showed regions in which cells had lost their vacuolated

structure.

Microscopic diagnosis.—(1) Focal necrosis of the adrenal gland; and (2)

moderately severe, early hemoglobinuric nephrosis.

Comment.—The microscopic findings are in general agreement with the

gross findings. Although the kidney lesion was classified as hemoglobinuric

nephrosis, death appears to be related to trauma, peritoneal infection, and

pulmonary circulatory obstruction rather than to uremia.

SUMMARY

This patient affords an example of severe thoracoabdominal wound in

which the military exigency afforded an opportunity to observe the steady

deterioration which can be caused in wounded man’s condition by the delay

in operation. Resuscitation and operation were made much more difficult in

this case by the passage of relatively short period of time. Failure to realize

that wound of the stomach was present was partly responsible for the delay

and was also responsible for the use of autotransfusion in the presence of

contamination of the pleura by gastric contents.

Microscopic examination confirmed the presence of pigment nephropathy,

which accounts for the oliguria and gross anatomic changes in the kidneys.

Pulmonary edema and mild congestive heart failure were again noted as

terminal manifestation of the renal failure which follows severe traumatic

shock.

Case

CLINICAL DATA

This patient received bullet wound of the left buttock June 1944, at

0300 hours. He was given 15 mg. of morphine tartrate at 0305 hours and was

brought to the collecting station at 0600 hours. Here his wound wasre-dressed,

in preparation for evacuation to the rear. The record indicates that he seemed

in relatively good condition, but at 0630 hours, while he was urinating, he

lapsed into deep shock and stopped breathing. After the use of artificial

respiration and the administration of 1,750 cc. of plasma, supplemented by two

large doses of caffeine sodium benzoate, breathing was resumed. At this time

(0815 hours), it was noted that the left pupil was dilated and that there was
144 GENERAL SURGERY

weakness of the face on the left side, with equivocal aphasia. At 0900 hours,

improvement was continuing, and at 0930 hours the patient was sent to the

rear. He reached the clearing station at 1000 hours and was taken at once to

the field hospital. At 1005 hours, his blood pressure could not be obtained by

auscultation or palpation. In spite of plasma transfusion and oxygen inhalations, he continued poorly oriented. Death occurred at 1200 hours. The left

pupil was notably larger than the right.

This patient had received total of 500 cc. of plasma in the field hospital.

He expired just as whole blood was obtained. His blood pressure was not

obtainable at any time after he reached the field hospital.

AUTOPSY

Autopsy was performed hours after death (Cori, Italy).

Gross observations.—Externally the body was not remarkable except

for extreme pallor.

The brain was negative, except that the cerebral vessels were exceedingly

pale. There was no gross area of infarction. The lungs were negative, except

for some patchy atelectasis.

The peritoneal cavity contained an enormous quantity of blood, estimated

at 4,000 to 5,000 cc. The source was the left hypogastric artery, which was

transected at the point at which it crosses the brim of the pelvis. There was

large hematoma in the areolar tissue of the retroperitoneal space and along

the course of the missile, which was through the medial aspect of the ramus of

the ischium. second fragment of the bullet lay free in the left upper quadrant

of the abdomen. The mesentery of the sigmoid colon and loop of the mesentery of the small bowel were perforated, and there were two perforations of the

jejunum. It was impossible to judge the amount of fecal contamination of the

peritoneum with any accuracy because of the large amount of blood present

in the peritoneal cavity. Contamination, however, was not thought to be

great.

Gross anatomic diagnosis.—Bullet wound of abdomen, entering by way

of left buttock, with laceration of left hypogastric artery and exsanguinating

intraperitoneal hemorrhage; two perforations of jejunum; compound comminuted fracture of ramus of left ischium.

Comment.—There is no reasonable doubt in this case that death was

caused by massive intraperitoneal hemorrhage. The cerebral changes were due

to the severe degree of cerebral anoxia. It is regrettable that whole blood was

not available at the time this man reached the field hospital, although its

liberal use might not have changed the outcome in the face of longstanding and

profound shock.

Microscopic observations.—Examination of sections from the lung showed

extensive alveolar atelectasis with overdistention of the respiratory bronchioles.

This finding is consistent with story of prolonged artificial respiration.
SHOCK THERAPY 145

few fat droplets were found in small arteries and arterioles, but the number was

not sufficient to make them of functional significance.

The choroid plexus appeared edematous. The kidney and brain were

negative.

SUMMARY

This case illustrates several important points in connection with shock

among battle casualties.

1. It may be exceedingly difficult to detect the fact that severe circulatory

collapse is about to occur, particularly when hemorrhage is in progress.

2. Once the blood volume has reached critical level, relatively minor

happening, in this instance the act of sitting up to urinate, may be followed

immediately by the onset of profound shock.

3. It is almost impossible to treat shock caused by severe and progressive

hemorrhage with plasma alone.

4. Laparotomy to control hemorrhage offers the only hope of success in

such case as this, and yet, as in this case, it may be impossible to prepare the

patient adequately for operation in the face of severe bleeding.

Case

CLINICAL DATA

This patient, who was 22 years of age, received shell-fragment wound of

the left buttock October 1944, at 2230 hours. After delay of unknown duration, he was brought to field hospital in profound shock. Even after he

had received 250 cc. of plasma and 2,500 cc. of group blood (it is believed that

his blood belonged to group AB), the blood pressure was only 98/60 mm. Hg

and the pulse was 130, but operation was begun without further delay because

intra-abdominal hemorrhage was suspected. The patient received 50,000 units

of penicillin intramuscularly, but no sulfonamides were given in the field

hospital.

Exploration of the abdomen revealed multiple perforations of the small

and large bowel. In the peritoneal cavity, there was an estimated 1,000 to

1,500 cc. of blood which was found to have come from the region of the bladder

on the left side posteriorly. The retroperitoneal space was opened, and, after

considerable difficulty, the bleeding was brought under control by the ligation

of two branches of the left internal iliac vein. The perforations of the small

bowel were sutured, and sigmoid colostomy was performed through the left

lower quadrant of the abdomen. The gluteal wound was dcbrided.

The patient was in critical state throughout the operation. In spite of

the administration of 4,000 cc. of group blood and 750 cc. of plasma, his blood

pressure was often as low as 40/0 mm. Hg, and at the end of the operation,

which took hours, the blood pressure was only 90/48 mm. Hg.

On the first postoperative day, the blood pressure was 100/50 mm. Hg,

The urine was deep red brown and contained to red blood cells per high-power

field.
146 GENERAL SURGERY

The second day after operation, the blood pressure was 120/70mm.Hg. The

patient was moderately dyspneic. Examination of the abdomen revealed no

evidence of peritonitis. Catheterization produced only 10 cc. of urine. Isotonic glucose solution and 500 cc. of 2-percent solution of sodium bicarbonate

were given intravenously.

On the third postoperative day, dyspnea was severe. The patient was

drowsy, and his speech was slurred. The blood pressure was 180/100 mm. Hg.

Moist rales were first noted throughout both lungs about 2% hours before death.

Dyspnea rapidly worsened, and death occurred at 1830 hours October 1944, 44 hours after wounding. The total output of urine from the beginning of

operation until death was about 210 cc.

AUTOPSY

Autopsy was performed 12 hours after death (Elayes, France).

Gross observations.—The peritoneal cavity contained 200 cc. of bloody

fluid. There was no exudate other than the generalized matting of loops of

small bowel by fibrin. In the pelvis was small amount of clotted blood. The

lungs were indurated and edematous. Only the kidneys were saved for microscopic study. They were somewhat swollen and appeared to be congested.

Small subcapsular hemorrhages were scattered over both renal surfaces, but on

section it was found that they did not extend into the cortex. The cut surfaces

of the kidneys were rather pale.

Gross anatomic diagnosis.—(1) Perforating shell-fragment wound of

abdomen with multiple perforations of ileum, multiple perforations of sigmoid

colon, and multiple lacerations of branches of left internal iliac vein; and (2)

pigment nephropathy, hemoglobinuric type, possibly due to massive transfusion

of group blood, with severe pulmonary congestion and edema, manifest clinically by severe oliguria, moderate arterial hypertension, and severe pulmonary

edema.

Comment.—Although the blood group of this patient is not positively

known, it is believed that his blood belonged to group AB. If this be true, his

AB cells were susceptible to agglutination and hemolysis by the anti-A and antiiso-agglutinins found in the plasma of group blood. The difficulty of providing enough group-specific blood is apparent, as are the shortcomings of universal donor blood under such circumstances.

Microscopic observations.—Examination of the kidney tissue revealed

that very large number of collecting tubules, and smaller number of distal

convoluted tubules, were plugged with pigmented casts. There was slight dilatation of the proximal nephrons. The interstitial tissues were slightly edematous. In some areas, proliferation of the tubular epithelium was evident, the casts being encapsulated within the tubules. Here and there, small granulomas had formed in the interstitial tissues. There were scattered foci of

lymphocytic infiltration.

Microscopic diagnosis.—Severe hemoglobinuric nephropathy.
SHOCK THERAPY 147

SUMMARY

This case provides another example of posttranmatic renal failure, with the

microscopic finding of pigment nephropathy. Although definite proof is not

available, it is believed that the transfusion of large volume of group blood

contributed to the production of the renal lesion. Perhaps, in the presence of

severe shock, the kidney is particularly liable to injury by relatively small

amount of hemoglobin in the plasma. moderately severe degree of hypertension was observed before death; its possible relationship to the pathologic

physiology of renal failure is of considerable interest.

Case

CLINICAL DATA

This patient, German prisoner of war with bullet wound of the abdomen,

was first seen March 1945 at 1430 hours. The precise time of wounding was

unknown but was probably several hours earlier. He reached field hospital

at 1715 hours, after having received 750 cc. of plasma. At this time, he was in

profound shock, and his blood pressure could not be obtained. He was stuporous and at times semidelirious, and his appearance was striking because of

peculiar cherry-red flush of the face and extremities and red mottling of the

skin of the trunk. He was moderately dehydrated. The response to 1,500 cc.

of plasma and 1,500 cc. of blood was poor; the blood pressure rose only to 78/40 mm. Hg, and no clinical improvement was evident. His blood group was O.

Operation was begun March at 2210 hours. Laparotomy revealed

extensive contamination of the peritoneal cavity by 2,000 cc. of bloody fecal

material. There were multiple perforations of the jejunum, and the transverse

colon was found almost completely torn away from its attachments except for

narrow band of tissue along the mesenteric border. It was necessary to resect

about 15 cm. of the small bowel; three perforations in the jejunum were sutured,

and colostomy was performed. The patient received 1,000 cc. of whole blood

during the operation.

At the conclusion of the operation, the blood pressure was at very low

level, and there was never any significant rise. Often it was unobtainable.

The patient was stuporous, and death occurred 11 hours after operation.

AUTOPSY

Autopsy was performed hours after deatli (St. Avoid, France).

Gross observations.—-The mottled, pink-gray discoloration of the skin

of the trunk noted before operation was still present.

The peritoneum showed the effects of severe contamination. small

amount of seropurulent fluid was present. The serosal surfaces of the bowel

were opaque, dark and congested, and patches of fibrinopurulent exudate

were present.

The heart was rather soft. The right side was distended by blood.
148 GENERAL SURGERY

The pleural cavities were not remarkable, except for an old fibrous pleuritis

at both bases.

Both lungs showed considerable hypostatic congestion and partial atelectasis of the dependent and inferior portions.

There was moderately large laceration of the left lobe of the liver.

The spleen was about three times the usual size and was dark purple red.

The consistency was firm. The pulp, which was uniformly dark purple, did

not scrape away easily.

The gastrointestinal tract showed the sutured lacerations and anastomoses

of the small bowel already described.

The kidneys were of the same size, but the right kidney appeared somewhat

more congested and purple than the left. The cortical surfaces of both kidneys

showed focal punctate hemorrhagic areas, more marked on the right side.

On section, these hemorrhagic areas were seen to extend varying distances into

the cortex in the form of small, blood-suffused columns. On section, the

parenchyma bulged above the cut edge of the capsule. few petechiae were

present in the mucosa of the renal pelvis.

The cortex of the left adrenal gland exhibited several radial hemorrhagic

areas in which there was possibly destruction or necrosis of the tissue. The

medullary area was negative.

Gross anatomic diagnosis.—(1) Perforating gunshot wound of abdomen,

with severe laceration and avulsion of transverse colon; multiple perforations

of small bowel; moderately severe laceration of left lobe of liver; (2) severe

generalized peritonitis, secondary to injuries of transverse colon and small

bowel; (3) extensive hemorrhagic focal necrosis of kidneys and possibly of left

adrenal, causes unknown; (4) moderately severe splenomegaly, possibly secondary to massive transfusion therapy and peritonitis; and (5) hypostatic pulmonary congestion and edema, with bilateral partial atelectasis.

Comment.—The exact lapse of time between wounding and operation in

this case was unknown but seems to have been at least 16 to 18 hours. The

patient was moribund on admission, as the result of shock and extreme peritoneal contamination.

The case illustrates the difficulty which occasionally was encountered in the management of patients with overwhelming contamination of the peritoneum. Once contamination of this degree has occurred, effective therapy

is difficult even though the patient is seen relatively soon after wounding.

The peculiar gray-pink mottling of the skin suggests considerable degree

of capillary damage. The pathogenesis of the hemorrhagic columns in the

renal cortex is obscure, but is possibly related to the severity of the shock and

infection.

Microscopic observations.—There were few atelectatic patches in the

lungs. The alveolar septa were hyperemic. The bronchial walls were infiltrated with lymphocytes. One small artery was thrombosed. Another section showed scattered small areas of hemorrhage into the peribronchial alveoli.
SHOCK THERAPY 149

The centers of the lobules of the liver were congested. The portal triads

were infiltrated with moderate numbers of lymphocytes.

The malpighian corpuscles had active germinal centers; many contained

foci of degeneration, with nuclear debris. The pulp and sinuses were engorged

with blood.

moderate number of distal convoluted and collecting tubules in the

kidneys contained pigmented casts. Protein precipitate was seen in many of

the convoluted tubules. Some of the tubules contained hyalin casts. Neither inflammatory reaction nor edema was present in the interstitial tissues.

small number of basophilic structures, probably sulfonamide crystals, were

seen. Vascular congestion was pronounced.

There was pronounced congestion of both the inner zone of the cortex

and of the medulla. Small foci of lymphocytes were seen in the medulla.

The serosal layer of the intestine was thickened and edematous. It was

infiltrated with lymphocytes, histiocytes, and pol3 morphonuclear leukocytes.

The mucosa was covered with blood, serum, and epithelial debris.

Microscopic diagnosis.—(1) Hemoglobinuric nephropathy, moderately

severe; and (2) focal necroses in spleen.

Comment.—In the absence of other factors which produce pigmented casts

in the renal tubules, the renal lesion in this case must be attributed to the

blood transfusions which the patient received. His blood group was O, and

he received 1,500 cc. of bank blood. If the blood typings were correct,

the crossmatches negative, and the blood free of hemolysis before transfusion,

there is no evident explanation for the nephropathy. (J. G. R.)

SUMMARY

This patient sustained an extremely severe wound of the abdomen with

widespread peritoneal contamination, and his status on arrival at field

hospital reflected the relatively long lapse of time since the injury. He died

within short time, in spite of replacement therapy and prompt surgical care.

Failure to survive such wound seems to depend upon (1) the severity of the

hemorrhage and (2) the deleterious effects of massive peritoneal contamination. It seems likely that appropriate bacteriologic studies would have

revealed significant findings in this instance.

Case

CLINICAL DATA

This patient received perforating bullet wound of the abdomen 30

March 1945, at 1740 hours. When he reached field hospital at 1945 hours,

he was in profound shock, with blood pressure of 42/20 mm. Hg and pulse

of 128. His response to 500 cc. of plasma and 1,500 cc. of whole blood was

not good. At 0030 hours 31 March, his blood pressure was only 80/60. His

blood group was O.
150 GENERAL SURGERY

Laparotomy was performed about 4% hours after the patient was received

at the field hospital. The peritoneal cavity was full of blood, and there were

perforations of the stomach and proximal ileum, as well as laceration of the

left lobe of the liver. Severe bleeding was in progress from the gastrohepatic

ligament; it was stopped as promptly as possible. The perforations in the

intestine were then sutured, and large defect in the transverse mesocolon

was repaired. The spleen and the left kidney, both of which were badly

lacerated, were removed. The wounds of entrance and exit were debrided.

Throughout the operation, the patient’s condition was critical in spite of the

administration of 250 cc. of plasma and 2,750 cc. of whole blood.

He failed to improve after operation and died at 0005 hours April 1945,

about 24 hours after operation and 28 hours after injury.

AUTOPSY

Autopsy was performed 15 hours after death (Grossostheim, Germany).

Gross observations.—There was considerable post mortem lividity of

the neck and face. The abdomen was moderately distended.

The loft chest contained 600 cc. and the right chest 200 cc. of blood-tinged

fluid. The peritoneal cavity contained about 800 cc. of cloudy, blood-tinged

fluid. The loops of small bowel were loosely bound together by strands of

fibrinopurulent exudate, particularly in the vicinity of the sutured perforations of the ileum. No free purulent exudate was present in the peritoneal

cavity. The adipose tissue of the colon and omentum exhibited numerous

focal areas 0.5 to 1.5 cm. in diameter, of chalky, gray-white discoloration, particularly in the upper abdomen.

The heart was not remarkable except for the presence of subepicardial

ecchymosis posteriorly along the coronary sulcus and over the wall of the left

auricle.

The lungs were both markedly increased in weight and showed hypostatic

congestion and atelectasis. The tracheobronchial tree was filled with tenacious, blood-tinged mucoid exudate which was occasionally flecked by

purulent material. Some of the smaller bronchi contained similar material.

There was no evidence of established pneumonic consolidation.

The left lobe of the liver, which was the site of an extensive laceration,

as well as portion of the right lobe, was pale, yellow gray, and of abnormally

soft consistency.

The body of the pancreas was partially torn away from its attachments,

and there had been considerable autolysis of the contiguous tissues. The

portion of pancreas adjacent to the bullet track was pale, reddish gray, and

extremely soft in consistency. Surrounding this area were evidences of old

hemorrhage. No purulent exudate, however, was present in the pancreatic

area.

The gastrointestinal tract showed only healing sutured perforations.

Gross anatomic diagnosis. (1) Perforating gunshot wound of left abdo-
SHOCK THERAPY 151

men, with severe laceration of left lobe of liver, possible necrosis of most of

left lobe and of portion of right lobe; two healing perforations of proximal

ileum; laceration or contusion of body of pancreas with autolysis of pancreatic

tissue and acute fat necrosis throughout peritoneal cavity; severe laceration of spleen, surgical removal; severe laceration of left kidney, surgical removal;

(2) severe bilateral pulmonary atelectasis, secondary to bronchial obstruction

by mucus; (3) subepicardial hemorrhage, probably due to asphyxia, secondary

to pulmonary atelectasis; (4) acute fibrinopurulent peritonitis, secondary to

perforating wounds of intestine and liver; and (5) moderately severe bilateral

pleural effusion.

Comment.—Aside from the severe trauma to several organs, the insult

of extreme pulmonary atelectasis appears to be immediately responsible for

the death, which seemed inevitable from the time of wounding.

Microscopic observations.—Numerous hemorrhages were present in the

fat tissue around the adrenal gland. Several small hemorrhages were also

seen in the medullary portion. portion of the cortex stained very faint

pink resembling an area of infarction. The sinusoids were congested.

Numerous hemorrhagic areas were seen in two slides of the lung tissue.

Areas of atelectasis were present. Cells of the heart-failure type were present

in all areas. In third slide, the tissue was for the most part normal, but in

one area were alveoli filled with protein-rich fluid in which were many

erythrocytes.

Granules of brown pigment were seen in the muscle bundles of the heart.

Some hemorrhage was visible in the fat of the pericardium.

Extensive areas of hemorrhage and necrosis of liver substance were observed along one side of the first slide examined. In the immediate vicinity

of the traumatized area were considerable accumulations of polymorphonuclear leukocytes and lymphocytes. In some areas were evidences of small

abscess formation. Numerous lymphocytes were seen in nearly all the periportal areas. In second slide, extensive areas of tissue destruction were

present. The liver cells were dark-staining cords without nuclei.

SUMMARY

The findings in this case are characteristic of the massive abdominal

injuries which are by no means rare among severely wounded men. Wounds

of this kind produce profound shock by destruction of tissue, hemorrhage, and

massive peritoneal contamination. Death almost always occurs with little

delay in spite of liberal replacement therapy and prompt surgical care. If

the patient does survive the immediate postoperative period, the renal damage of the period of profound shock may prove fatal within few days.

The microscopic observations in this case suggest that there was widespread necrosis of liver tissue which was not restricted to the missile track.

Since the kidneys were not examined microscopically, the question of renal

lesion cannot be settled.
152 GENERAL SURGERY

Case CLINICAL DATA

This patient received perforating bullet wound of the right buttock 30

March 1945, at 1700 hours. When he was received at the field hospital at 1945

hours, he appeared moribund; neither pulse nor blood pressure could be obtained. In the space of an hour, he was given 250 cc. of plasma and 2,500 cc.

of group blood, but the response was poor. Laparotomy was undertaken in

the belief that hemorrhage was continuing. Just before operation, the blood

pressure was 50/30 mm. Hg. The patient’s blood belonged to group O.

Exploration of the wound track from the right gluteal fold to the right

iliac fossa revealed (1) complete laceration of the right external iliac artery

and vein, (2) complete laceration of the right gluteal artery and vein, (3) division of the right femoral nerve, and (4) perforation of the terminal ileum. All

the injured vessels were ligated, and the ileal perforation was closed. During

the operation, an extensive expanding retroperitoneal hematoma was noted.

At the end of the operation, the blood pressure was 70/40 mm. Hg; 2,500 cc. of

group whole blood had been given while it was in progress.

The patient’s condition continued critical after operation. On the first

postoperative day, the hemoglobin was 55 percent of normal; the red blood

cells numbered 3,290,000 per cubic millimeter. On the second day, the volume

of urine was 225 cc. On the third day, no urine was excreted. The right leg

was gangrenous, with line of demarcation just below the knee. On the fourth

day, no urine was excreted. The blood pressure was 160/80 mm. Hg. Venesection was carried out for the relief of pulmonary edema, but dyspnea continued.

The patient died April 1945, at 1635 hours, about 96 hours after wounding.

AUTOPSY

Autopsy was performed hour and 25 minutes after death (Grossostheim,

Germany).

Gross observations.—The sclerae were slightly icteric. There was considerable brawny edema of the whole of the right leg, with an effusion into the

knee joint and beginning dry gangrene below the knee.

The pericardial and pleural cavities contained small amounts of strawcolored fluid. There was large bilateral retroperitoneal hematoma, which

was larger on the right. Blood had disseminated upward as high as the perirenal tissue bilaterally and downward to fill the areolar tissue about the bladder.

The right external iliac artery and vein and the right gluteal artery and vein

had been ligated.

The heart was pale. Subepicardial petechial hemorrhages were distributed

over the surface. The right ventricle was unusually soft. The tricuspid valve

measured 13.5 cm., the mitral valve 10.3 cm., and the aortic valve 5.8 cm.

The coronary vessels were normal.

Both lungs were partially atelectatic. The cut surface was very wet and

exuded large quantity of serosanguineous fluid. The bronchi were filled with

edema fluid.
SHOCK THERAPY 153

The liver was apparently slightly increased in size, but on section the

parenchyma was not remarkable.

The spleen was moderately increased in size. The consistency was somewhat softer than normal and the malpighian bodies were prominent.

The gastrointestinal tract was negative, apart from healing laceration of

the ileum.

The kidneys, both of which presented the same appearance, were somewhat smaller than usual. The surfaces were smooth and were deep purple red,

with peculiar, finely mottled, nutmeg appearance. On section, the cortex was

somewhat pale in comparison to the color of the renal surface. The peripheral

portions of the pyramids as seen on section were dark, due to the presence of

fine, closely placed, red-brown striae. The renal vessels were negative.

Gross anatomic diagnosis.—(1) Perforating bullet wound of abdomen via

right buttock, with laceration of right external iliac artery and vein, laceration

of right gluteal artery and vein, division ofright femoral nerve, healing perforation of terminal ileum, and incomplete fracture of right ilium; (2) severe retroperitoneal hemorrhage, secondary to laceration of iliac vessels; (3) edema and

dry gangrene of lower right leg, secondary to ligation of iliac and gluteal vessels;

(4) pigment nephropathy possibly due to shock and ischemia of right leg, as

evidenced clinically by oliguria, slight hypertension, and pulmonary edema; (5) pulmonary congestion, bilateral, severe, with partial atelectasis, possibly

due to uremic pneumonitis and left heart failure secondary to pigment nephropathy; (6) multiple petechial subepicardial hemorrhage; and (7) icterus, slight.

Comment.—This case epitomizes the outcome in many patients who have

suffered severe shock for long periods of time. In such instances, the ultimate

decline is manifest chiefly as cardiorenal decompensation with increasing pulmonary edema, particularly when relatively large quantities of fluid are given.

Ischemic muscle necrosis, massive transfusion therapy, and the extensive retroperitoneal hematoma present in this case may have contributed to the pigment

which will almost certainly be found in the renal tubules on microscopic examination. Whatever may bo the source of the pigment, it would appear that

in this case the severe degree of shock was the most important factor in the development of the renal lesion.

The blood which this patient received was fresh; it was drawn in the field

hospital just before it was administered. All flasks were inspected for hemolysis, and none was apparent. lioutine crossmatchings showed no incompatibility, and the group of all the blood used was carefully checked just before

transfusion.

Microscopic observations.— few small areas in the pulmonary alveoli

contained fibrin and few polymorphonuclear and mononuclear cells. The

interlobular septa were edematous. On frozen section large number of fat

emboli were observed in the alveolar capillaries and arterioles.

The portal triads were infiltrated with moderate numbers of lymphocytes

and eosinophiles.

378327—5G 12
154 GENERAL SURGERY

The pulp of the spleen was moderately congested. There were increased

numbers of eosinophiles in the malpighian bodies.

very large number of the distal convoluted and collecting tubules in the

kidney sections were plugged with pigmented casts. Sulfonamide crystals

were seen here and there in the tubules. few small foci of lymphocytes were

found in the interstitial tissues. Epithelial proliferation had occurred about

some of the casts in the pyramid. No fat emboli were seen on frozen section.

Sections of the pancreas showed cystic dilatation of small number of

acini, which contained pink-staining material.

Microscopic diagnosis.— (1) Severe pulmonary fat embolism; and (2) severe

pigment nephropathy, hemoglobinuric type.

SUMMARY

Because of his severe vascular injury and the resulting hemorrhage, this

patient remained in shock for prolonged interval. In spite of the fact that

resuscitation and operation were accomplished with fair degree of success,

postoperative oliguria occurred, and death followed, from pulmonary edema,

on the fourth day after operation. Microscopic examination confirmed the

presence of pigment nephropathy and revealed, in addition, high degree of

pulmonary fat embolism. It is suggested that the fat embolism may have been

the more important factor in the pulmonary edema which occurred on the

fourth day after operation. It seems unlikely, however, that this patient could

have survived the renal lesion.

The amount of trauma to the bone appears to have been relatively mild

in this case, and it may be that injury of gluteal adipose tissue contributed to the pulmonary embolism.

Case 10

CLINICAL DATA

This patient received perforating shell-fragment wound of the thorax

and abdomen 14 December 1944, at 1020 hours. When he reached field hospital at 1245 hours, the blood pressure was 80/34. Hg, the pulse was 140, and he

was in moderately severe shock. He complained of shortness of breath and of

right-sided chest pain. The wound of entry was at the left lateral costal margin and the wound of exit in the fourth interspace in the right anterior axillary

line. Right thoracentesis produced 960 cc. of blood. The right 4th to 12th

intercostal nerves were infiltrated with procaine, and pain in the chest lessened.

At 1525 hours, after the administration of 500 cc. of plasma and 1,000 cc. of

whole blood, the blood pressure was 122/64 mm. Hg. catheterized specimen

of urine showed occasional erythrocytes.

Thoracotomy was begun at 1600 hours, under endotracheal gas-oxygenether anesthesia. The thorax was opened in the right fifth interspace, and frag- ments of the fifth costal cartilage were removed. Five hundred cubic centimeters of blood were aspirated from the right pleural cavity. small laceration
SHOCK THERAPY 155

of the lower lobe of the right lung was closed with mattress suture. After

6-cm. laceration of the right diaphragm had been sutured, the thoracotomy

incision was closed. The sucking wound of the anterior right chest was debrided and closed.

Laparotomy revealed much blood in the peritoneal cavity. The source

appeared to be the severely lacerated and comminuted left lobe of the liver.

There was an extremely severe laceration of the left transverse colon, which

involved about three-fourths of its circumference for distance of cm. This

portion of the large bowel was exteriorized through left subcostal incision.

No perforations were evident in the remainder of the gastrointestinal tract,

and at this time there was no evidence of an acute inflammatory process within

the peritoneal cavity. The spleen and kidneys were not injured. During the

course of the operation, the patient’s condition remained poor, although he

received 1,500 cc. of whole blood, 750 cc. of plasma, and an autotransfusion of

the 960 cc. of whole blood which had been aspirated from the right chest before

operation. The operation required hours.

Immediately after operation, the blood pressure was 40/0 mm. Hg, the

pulse 104, and the respiration 24. The respirations were described as gurgling.

The patient reacted from anesthesia at 0100 hours 15 December 1944, but

respirations ceased at 0625 hours, about 20 hours after wounding.

AUTOPSY

Autopsy was performed hours after death (Meisenthal, France).

Gross observations.—The peritoneal cavity contained 300 cc. of foulsmelling, bloody fluid. There was an extensive laceration of the left lobe of

the liver. The omentum, which was dirty and hemorrhagic, was displaced

about the colostomy. Gentle pressure upon the stomach caused leakage of

gas and gastric contents through small aperture in the midportion of the

omentum just inferior to its attachment to the greater gastric curvature. The

loops of small bowel, particularly those in the lower portion of the peritoneal

cavity, exhibited evidences of marked peritoneal contamination. The serosa

was injected, bright red, and more opaque than normal. No fibrinopurulent

exudate was recognized.

Theright pleural cavity contained 300 cc. of blood, but there was relatively

little fibrinous exudate. There was defect in the fifth costal cartilage and

fracture of the sixth costal cartilage on the right.

The heart was somewhat dilated. The myocardium was softer than usual

in consistency.

The appearance of both lungs was the same. They were considerably

increased in weight and exhibited generalized atelectasis and loss of resiliency.

The laceration of the right lower lobe had been closed, and contusion of the

pulmonary parenchyma was not marked. On section, much blood and serous

fluid dripped from the cut surfaces. The main bronchi and their smaller

branches were occluded by tenacious, mucosanguineous exudate which appeared to be responsible for the observed atelectasis. There was no evidence
156 GENERAL SURGERY

of bronchopneumonia, but some of the smaller bronchi contained moderate

amounts of mucopurulent exudate.

The spleen was small and soft but not otherwise remarkable.

The liver was of normal size. There was marked destruction of the left

lobe, but no evidence of suppuration, and little autolysis was observed along

the track of the missile. No exudate was present, nor was there discernible

zone of leukocytic infiltration. Thrombosis of the hepatic veins was noted only

in the immediate vicinity of the laceration and was not striking. On section,

the right lobe of the liver was not remarkable.

The stomach was greatly distended by partially digested food. There

was small (8-mm.) unsutured perforation in the greater curvature 10 cm.

proximal to the pylorus. The contamination of the lesser peritoneal sac was

minimal, and gastric contents appeared to have been extruded into the main

peritoneal cavity through small perforation in the omentum. small (3-mm.)

perforation of the ileum was located about 90 cm. from the ileocecal valve.

The kidneys were not enlarged, but the smooth cortical surfaces were pale,

and on section the cortex showed faintly hemorrhagic markings through the

pale yellow-gray substance. The renal pyramids were faintly striated by redbrown markings and had peculiar pale-pink coloration.

Gross anatomic diagnosis.—(1) Thoracoabdominal shell-fragment wound,

with entrance at left costal margin and exit via right chest at level of fifth

costal cartilage, with small perforation of greater curvature of stomach; small

perforation of terminal ileum; severe laceration of transverse colon, loop

colostomy; severe laceration and comminution of left lobe of liver; sutured

perforation of right leaf of diaphragm; moderately severe laceration of lower

lobe ofright lung, closed; multiple compound fractures ofright fifth and sixth

costal cartilages and left sixth and seventh costal cartilages; (2) severe bilateral

bronchial obstruction with pulmonary atelectasis; (3) acute generalized peritonitis, secondary to perforating wounds of stomach, terminal ileum, and transverse colon; (4) moderate right hemothorax, secondary to thoracoabdominal

wound; and (5) congestion and edema of lungs, probably secondary to

bronchial obstruction and at electasis.

Comment.—The severe laceration of the liver and the extreme peritoneal

contamination were ominous findings at operation. It is remarkable, however,

that there was so little evidence of peritonitis at this time. severe fibrinopurulent peritonitis was present at autopsy. The difference was perhaps due

simply to the passage of time, though it must be remembered that unclosed perforations of the stomach and ileum had permitted additional contamination

of the peritoneal cavity.

The large amount of bloodstained mucoid exudate present in the bronchi

at autopsy was remarkable. It did not seem reasonable to try to account

for it simply on the basis of the contusion of the right lung. The severe

atelectasis appears to have been immediately responsible for death, and its

development may have been favored by the fact that after operation the

patient received two injections (each of 0.008 gm.) of morphine sulfate.
SHOCK THERAPY 157

The use of autotransfusion under the circumstances of this case constituted an error of judgment. In the presence of large wound of the colon,

the blood could scarcely have escaped contamination, and its use undoubtedly

contributed to the fatality.

Microscopic observations.—The lung tissue showed large areas of atelectasis. The alveolar septa were hyperemic. Many pigmented macrophages

were seen within the alveoli.

One section of the liver was essentially normal. The other showed extensive traumatic infarction.

Examination of the spleen showed the rnalpighian bodies to be numerous

and large and the pulp slightly congested.

few cystic tubules in the kidney were lined with flattened epithelium

containing pigmented material. The epithelial cells in some of the collecting

tubules contained granules of golden-brown pigment. single focus oflymphocytes was seen in the interstitial tissues.

One of the interlobular septa seen in the section from the pancreas was

infiltrated with polymorphonuclear leukocytes and few histiocytes.

section of voluntary muscle showed hemorrhage and polymorphonuclear leukocyte infiltration into the tissues between the muscle bundles.

small amount of purulent exudate covered small area in the serosa

of the jejunum. In the spaces between the valvulae conniventes were desquamated and necrotic epithelial cells. The mucosa was infiltrated with moderate number of lymphocytes and few eosinophiles.

Section from the stomach showed hemorrhage into the submucosa and

many mononuclear cells containing formalin-pigment (formaldehyde pigment)

precipitate. In one small area was collection of polymorphonuclear

leukocytes.

SUMMARY

This is an example of very severe thoracoabdominal wound in which death

occurred within relatively short time after injury. Extreme destruction of

the liver and widespread peritonitis appear to have been the most important

factors in the fatality. The patient’s critical state and the widespread visceral

damage explain why two small perforations of the gastrointestinal tract were

missed at operation. Other important lethal factors were undoubtedly the

continuing peritoneal contamination, the autotransfusion of contaminated

blood, and the rather liberal administration of morphine.

Case 11

CLINICAL DATA

This patient received shell-fragment wound of the abdomen 17 October

1944 about 1130 hours. When he reached field hospital at 1350 hours,

his blood pressure was 128/70 mm. Hg, and his condition appeared surprisingly

good. The foreign body had entered the abdominal cavity through the right
158 GENERAL SURGERY

upper quadrant and had made its exit through large defect in the left upper

quadrant, with the evisceration of 14 to 16 cm. of the transverse colon, several

loops of small bowel, and most of the omentum. Two hundred and fifty

cubic centimeters of plasma were administered rapidly, and transfusion of

group whole blood was begun. During roentgenologic examination, after

he had received about 300 cc. ofblood, the patient had chill. The transfusion

was stopped immediately, and second flask of blood was substituted for the

first. On the operating table, shortly after the chill, the blood pressure was

90/60 mm. Hg, and operation was deferred until it reached 124/70 mm. Hg.

This delay amounted to about hours.

Laparotomy revealed small amount of blood and some bile in the peritoneal cavity. There was large laceration of the liver, perforation of the

second portion of the duodenum, perforation of the midjejunum, and multiple

perforations of the transverse colon. The duodenal perforation was sutured,

and posterior gastroenterostomy performed. The jejunal perforation was

sutured. segment of the colon was exteriorized. It was noted that during

operation bleeding tended to be excessive and hemostasis was difficult. Before

the abdomen was closed, 50,000 units of penicillin were placed in the peritoneal

cavity.

The patient’s condition was so critical after operation that he was immediately given 1,000 cc. of blood. The blood pressure had fallen to 90/60, and

shortly afterward it fell to 80/50 mm. Hg. The day after operation, the exteriorized colon was opened; its appearance was not remarkable. Coarse rales

appeared in the chest, and considerable quantities of purulent material were

aspirated from the trachea. Death occurred 19 October 1944, about 48 hours

after operation.

During this period of survival after injury, this patient received total of

3,000 cc. of plasma and 3,500 cc. of blood. Before the first plasma transfusion

was started, sample of blood was taken. The group was O, and all the blood

which he received was compatible by routine crossmatching.

AUTOPSY

Autopsy was performed hours after death (Luneville, France).

Gross observations.—The right pleural cavity contained 200 cc. of serous

fluid. The peritoneal cavity contained 300 cc. of thin, purulent exudate.

generalized fihrinopurulent peritonitis was present. There apparently had

been no appreciable hemorrhage from the liver after operation, and the serous

surfaces were not bilestained. Neither the sutured lesions of the intestine nor

the gastroenterostomy was remarkable. The colostomy was also not remarkable. There was large defect of the anterior peritoneum medial to the

colostomy in the left upper quadrant, and there appeared to be an early infection in the properitoneal tissues of the upper abdomen.

The heart was negative except for slight atherosclerosis of the coronary

arteries.
SHOCK THERAPY 159

There was considerable atelectasis of all lobes of the lungs, particularly

in the lower and posterior portions. The right upper lobe, in addition, was

firm and had slightly nodular consistency. On section, there was early

peribronchial consolidation. The bronchi contained moderate amount of

mucopurulent, blood-tinged exudate.

The spleen was three times normal size. It was soft, and on section the

pulp was easily scraped away. The secondary follicles ere prominent.

small laceration of the right lobe of the liver was not remarkable.

Although local congestion and focal hepatic vein thromboses were noted

adjacent to the missile track, the hepatic defect was partly filled by plasma

clot.

The kidneys were moderately swollen and congested. On section, the

cortex was slightly pale.

Gross anatomic diagnosis. (1) Perforating shell-fragment wound of

upper abdomen, with evisceration of transverse colon, small bowel, and

omentum; multiple perforations of transverse colon; perforation of jejunum;

perforation of second portion of duodenum; moderately severe laceration of

liver; (2) generalized severe fibrinopurulent peritonitis; (3) generalized severe

congestion, edema, and atelectasis of lungs; (4) early acute bronchopneumonia

of right upper lobe; (5) acute splenomegaly, secondary to peritonitis and possibly to multiple transfusions; and (6) moderately severe passive congestion

of kidneys.

Comment.—Death in this case appears to have been caused by severe

visceral trauma and the effects of massive contamination of the peritoneal

cavity. The chill which occurred during transfusion was attributed either to

chilling of the patient or to the presence of pyrogens in the transfusion equipment. It was not thought to be due to incompatibility of the blood. The

appearance of the urine, however, suggested that hemoglobin-derived pigment

might have been present. Plasma was given in an unusually large volume

during operation, in an effort to limit the amount of blood needed, and thus

to lessen the danger of transfusion reaction.

Microscopic observations.—The heart was negative, except for slight

atherosclerotic changes in the coronary arteries.

The pulmonary tissue showed an extensive bronchopneumonia, confluent

in places. The bronchial and alveolar exudate in some lobules was composed

of polymorphonuclear leukocytes. In some areas, many red blood cells were

mixed with the leukocytes. In one section in which the alveoli contained

protein-rich edema fluid, few hyalin membranes were seen in the respiratory

bronchioles.

Sections from the liver showed large areas of hemorrhage and traumatic

infarction. One section showed moderate degree of vacuolation of the liver

cells in all parts of the lobule.

Groups of fat cells were seen in some of the malpighian bodies of the

spleen. Considerable nuclear debris was enmeshed in fibrinous exudate

which covered the capsxde.
160 GENERAL SURGERY

Sections from the kidneys showed that moderate number of collecting

tubules and small number of distal convoluted tubules contained pigmented

casts. Some of the proximal nephrons were dilated. There was no epithelial

proliferation, interstitial edema, or inflammatory reaction.

Microscopic diagnosis.—Moderately severe hemoglobinuric nephropathy.

Comment.—This case represents another instance of hemoglobinuric

nephropathy in patient supposedly belonging to blood groupO. In the experience of the 6713th Blood Transfusion Unit at Naples, which covered many

thousands of donors, listings of the blood type on the identification tag were

found to be incorrect in about 10 percent of the soldiers, and one wonders

whether that happened in this case. Unless hemolyzed blood is injected,

there would seem no reason for transfusion reaction in group recipient

when blood is given. In crossmatching, there is one possible source of error

in reading the result if the possibility is not borne in mind. Agglutination

hemolysis may occur, and crossmatching may be reported by an unwary

observer as compatible. (J. G. R.)

SUMMARY

This patient had very severe abdominal wound, with massive evisceration of abdominal viscera, and death occurred within relatively short time

after injury. The blood pressure remained at low level during operation and

most of the postoperative period. It is thought that the most important

lethal factors were (1) severe abdominal injury with evisceration and consequent peritonitis, (2) prolonged anesthesia and operation, and (3) bronchopneumonia and pulmonary edema.

Uremia per se probably was not important in producing death so soon

after operation, and the importance of the renal lesion as lethal factor is

minimized by at least two facts, namely, the moderate renal changes present

and the fact that the patient excreted 300 cc. of urine during period of 48

hours in which the blood pressure ranged from 90/60 mm. Hg downward.

It was customary in World War II to disregard the blood group listed on

the identification tag, for the reasons already stated. This patient was regrouped in the field hospital, and his blood type was found to be O. He did,

however, receive blood which had been drawn to days earlier, and small

amounts of free hemoglobin may have been present in the 3,500 cc. of blood

which he received.

Case 12

CLINICAL DATA

This patient received shell-fragment wound of the right hip and sacral region October 1944, at about 0800 hours. He was brought into the field

hospital at 1700 hours with rapid, weak pulse and blood pressure of 70/50 mm. Hg. He had received 500 cc. of plasma. Before operation he received
SHOCK THERAPY 161

another 500 cc. of plasma and 2,500 cc. of group (his blood group) blood, but the blood pressure never rose above 90/60 mm. Hg. Through error, he

did not receive penicillin before operation.

Operation was unavoidably delayed until approximately 24 hours after

injury. Exploration revealed an extensive perforating wound of the right

buttock with widespread destruction of the gluteal muscles and fractures of

the right wing of the ilium and the right side of the sacrum. The missile

track was filled with semiliquid, necrotic muscle, which was pale pinkish gray.

The necrosis evident along the walls of the missile track seemed to extend for

considerable distance into the muscles of the lumbar region and posterior

upper thigh. So extensive was the process that complete excision of damaged

muscles was impossible. At operation, sections were taken from the right

gluteus medius at the base of the wound and were fixed for microscopic study.

At no time during operation were gas bubbles or crepitus noted in the muscle

or in the subcutaneous tissue adjacent to the wound.

Laparotomy revealed two small perforations of the terminal ileum, but

the site of entry of the foreign body could not be identified. The right colon

was intact. Small spicules of bone had been driven into the soft tissue, and

these fragments may have been responsible for the injury to the small bowel.

Sigmoid colostomy was performed. No perforations were found on careful

examination of the intraperitoneal portion of the rectum. Before the abdomen

was closed, 10 gm. of sulfanilamide crystals were placed in the abdominal

cavity. The wound of the hip was widely debrided, and fasciotomy was

performed along the right lateral gluteal fold. Zinc peroxide, which was

sprinkled liberally throughout the gluteal wound, could not be activated

because no reliable source of heat was available. Operation was completed

at about 1200 hours 10 October. During its course, the patient received

1.000 cc. of blood.

Immediately after operation, the patient was given 2.5 gm. of sulfadiazine sodium by vein. On the third day, it was found that the penicillin

which had been ordered intramuscularly in dosages of 25,000 units every

hours was being given subcutaneously. As soon as the error was discovered,

100.000 units were given intravenously.

For the first day or two after operation, the patient looked remarkably

well. There was little systemic evidence of severe infection, the pulse remained

within the normal range, and the maximum temperature elevation was 99.6°

F. On the second postoperative day, the blood pressure was 126/90 mm. Hg.

The patient appeared slightly drowsy and was oliguric. An attempt was made

to render the urine alkaline by placing gm. of sodium bicarbonate in the

stomach every hours. An intravenous infusion of 1,000 cc. of 1.25 percent

sodium bicarbonate solution also was given daily. Although the total daily

fluid intake averaged 3,000 cc., the greatest single volume of urine was about

100 cc., and the total output from operation to death, which occurred on the

sixth day after wounding, was about 400 cc. The urine was dark amber

brown and contained many granular casts and many erythrocytes. few
162 GENERAL SURGERY

sulfadiazine crystals were noted soon after operation. The hemoglobin by the

copper sulfate method was 12.7 gm. percent and the plasma protein 5.1 gm.

percent.

The patient received an average of 250 cc. of plasma daily, and during

the immediate postoperative period he also received 750 cc. of carefully crossmatched O-typc blood.

On 13 October, the blood pressure was 178/120 mm. Hg, but it declined

from this level and during the last days of life was in the range 140/80 to

160/85 mm. Hg. On 13 October, the leukocyte count was 6,000 per cubic

millimeter, with moderate increase in stab forms. There was also moderate

pitting edema, and the temperature reached 100.2° F. On the night of the

fifth postoperative day, moist rales were noted throughout the chest, and intratracheal aspiration was performed. The patient died the following morning,

15 October 1944, at 0800 hours, approximately 144 hours after injury.

AUTOPSY

Autopsy was performed an hour after death (Luneville, France).

Gross observations.—Externally the body showed moderate pitting edema

over the back and sacrum. There was no icterus.

The peritoneal, pleural, and pericardial cavities were negative.

The right side of the heart was greatly distended by blood; the tricuspid

valve measured 15 cm. There was considerable degree of atherosclerosis of

the coronary arteries, most marked in the right circumflex artery.

There was complete atelectasis of all lobes of the lungs except the right

upper lobe. There was loss of crepitus, and the involved lobes were rubbery

in consistency. Consolidation was thought to be present but was difficult to

detect because of the marked degree of atelectasis. On section, the lung was

purple and beefy red. There was only moderate increase in the amount of

serous fluid which oozed from the cut surface. The bronchi contained large

quantity of hemorrhagic purulent exudate.

The spleen was twice normal size and moderately firm. On section, it

did not seem remarkable, but the purple-red pulp scraped away somewhat

more easily than would have been expected from the firmness of its consistency.

The liver was moderately enlarged. On section it was not remarkable

except for the presence of scattered pinpoint areas of hemorrhage.

The gastrointestinal tract showed the operative changes already mentioned.

Both kidneys were considerably swollen, particularly in the anteroposterior

diameter. Their size was estimated at 1% times normal. The subcapsular

surface was uniformly homogeneous, yellow gray, and of an opaque, slightly

granular appearance. On section, the parenchyma bulged above the edge of

the capsule. The cortex appeared somewhat thickened and was of the same

yellow gray as the surface. The pyramids were gray brown; near their bases

the tissue had an opaque granularity like that of the cortex. The tips of the

pyramids were congested and the mucosa was hemorrhagic, as was the mucosa

of the renal pelves generally. The renal arteries showed early atherosclerosis.
SHOCK THERAPY 163

Examination of the adrenals showed liquefaction and destruction entirely

out of proportion to the brief time which had elapsed since death. There was

no evidence of medullary hemorrhage.

There was moderate edema of the bladder mucosa.

In the lumbosacral area was an extensive phagedenic wound track extending

from the right posterolateral rib margin downward and across the midline to

the left gluteal region. There was considerable undermining of the subcutaneous tissue, with involvement of the adjacent muscle and connective tissue

about the periphery of the track. The odor was foul. The exudate was

watery and grayish green, except that in many places it was slightly pink, the

color suggesting the presence of blood or muscle pigment. The exposed sacrum

and the wing of the ilium formed the floor of the wound. There was no evidence

that the peritoneal cavity had been invaded.

At operation, an attempt had been made to provide drainage for the wound

by making incisions along the right gluteal fold and in the posterior right flank.

The edges of these incisions had the appearance of those of the original wound.

Infection had extended upward to the level of the 12th rib along the lumbar

muscles and downward into the posterior muscles of the upper thigh. Grossly

there was no apparent predilection for muscle tissue, and adipose and connective

tissue were extensively involved. In the midst of the wound, however, palepink, edematous, and necrotic muscle fibers were present.

Gross anatomic diagnosis.—(1) Perforating shell-fragment wound of right

lumbosacral and gluteal regions, with extensive destruction of soft tissue, and

compound, comminuted, incomplete fracture of right ilium; compound, comminuted, incomplete fracture of right posterior aspect of sacrum; two healing

perforations of terminal ileum; (2) extensive phagedenic infection of wound

of gluteal region, with necrosis of muscle and connective tissue, bacterial cause

unidentified; (3) nephrosis, possibly hemoglobinuric in type, with pulmonary

congestion and edema, moderately severe, manifest clinically by oliguria, uremia, and arterial hypertension, moderately severe; (4) purulent bronchitis, bilateral,

severe, with complete atelectasis of left lung, right lower and middle lobes, due

to bronchial obstruction by exudate; (5) extensive bilateral necrosis of adrenal

medulla, possibly due to overwhelming infection; and (6) moderate, generalized

atherosclerosis.

Comment.—The clinical and gross post mortem findings in this case are

typical ofpigment nephrosis. In view of the widespread destruction of skeletal

muscle, myoglobin rather than hemoglobin may have been the offending pigment. Whatever the pigment, the kidney always appears to be particularly

vulnerable to it during periods of severe shock.

This type of infection is of considerable interest. Bubbles of gas were

never observed, but the invasive and destructive properties of the infecting

organisms were evidently very great. mixed infection which includes microaerophilic streptococci deserves consideration. The delay in effective penicillin

therapy may or may not be important. The delay of 24 hours in operation

certainly was.
164 GENERAL SURGERY

Microscopic observations.—Sections of the lungs showed small patches of

atelectasis. Several lobules were filled with exudate composed largely of red

blood cells, stringy protein deposits, and small numbers of polymorphonuclear

leukocytes and mononuclear cells. The character of the alveolar exudate varied

in different lobules. In some it was chiefly composed of erythrocytes. In

others, the red blood cells were mixed with granular, pink-staining protein

precipitate. In still others, there was an admixture of these elements with

mononuclear cells. few small bronchi contained polymorphonuclear leukocytic exudate. Slight edema of the interlobular septa and blood were observed

in scattered alveoli, but nothing else of note was seen. On frozen section, fat

emboli, in moderate numbers, were present in capillaries in the alveolar septa.

The liver cords in the centers of the lobules were atrophic. The cells contained fat vacuoles and granular brown pigment. few foci composed of

histiocytes were seen. The portal triads were infiltrated with moderate numbers of lymphocytes.

The splenic pulp was moderately congested. There was large amount

of formalin-pigment (formaldehyde pigment) precipitate.

largo number of distal convoluted and collecting tubules in the kidneys

were plugged with pigmented casts. The proximal nephrons were slightly

dilated. Some tubules contained epithelial debris mixed with pigment. There

was moderate degree of epithelial proliferation, most evident in the medulla, with the formation of few granulomas in the interstitial tissues. Only very

slight inflammatory reaction, consisting of lymphocytes, was seen. small

number of sulfonamide crystals were identified in the tubules.

The appearance of the voluntary muscle varied in different sections, and

even in different parts of the same section. Many muscle fibers were swollen.

Some took an orange stain. Others had lost striations and nuclei. In places,

the interstitial tissues were edematous. There was large amount of polymorphonuclear leukocytic infiltration in the interstitial tissues in some areas and

small amount in others. In still others, there was an absence of inflammatory

reaction. few vessels were thrombosed.

Sections examined after straining by the MacCallum-Goodpasture technique showed large numbers of organisms, usually mixed. There were present

large, fat, gram-positive bacilli, some of which were comma shaped. No spores

were seen. The other prominent organism was gram-positive coccus. Some

of these cocci were small, some large.

Microscopic diagnosis.—Moderate pulmonary fat embolism.

Comment.—Histologically the voluntary muscle lesion in this case appears

to be combination of clostridial and suppurative myositis. Without cultural proof, an exact diagnosis is not possible. One can guess, however, that the germpositive rods were Clostridium sordellii and that the cocci were streptococci. The renal lesion is typical of hemoglobinuric nephropathy. The very

destructive muscle lesion might conceivably have liberated myoglobin, but

whether this would be absorbed and then excreted through the kidney, as in the crush syndrome, it is not possible to say. In addition, clostridial organ-
SHOCK THERAPY 165

isms are hemolytic, and, if hemolysis were sufficiently severe, this process, too,

might produce hemoglobinemia and hemoglobinuria. In recipient belonging

to group and receiving only group blood, there would seem no reason for

transfusion reaction, unless hemolyzed blood had been injected. This fact

would tend to favor relationship between the myositis and the nephropathy.

SUMMARY

This case provides another example of posttraumatic renal failure and

pigment nephrosis. The type of wound infection encountered here, however,

was not common, and the myositis per se may have been important in the

development of the renal lesion. In attempting to assess the role of this infection in the pathogenesis of the nephrosis, otherfactors should not be overlooked,

including prolonged and severe shock due to trauma and hemorrhage, massive

transfusion therapy, and sulfonamide administration. Probably the single

most important lethal factor was the prolonged period of shock, and it may well

be in this regard that the myositis exerted its deleterious effect upon the kidney.

Case 13

CLINICAL DATA

This patient suffered shell-fragment wound of the right costovertebral

region 18 May 1944 at 1300 hours. After delay of 38 hours, during which he

received 1,000 cc. of plasma and several injections of morphine, he arrived at

field hospital 20 May at 0300 hours. The delay in evacuation was duo to an

offensive breakthrough; combat units outstripped supporting medical units.

At this time, the patient’s condition was critical. The blood pressure was

88/52 mm. Hg, the pulse 98, and the respiration 26. He was dehydrated,

febrile, and semistuporous. In hours after he reached the field hospital,

he received 1,400 cc. of plasma and 1,000 cc. of group whole blood; 10,000

units of polyvalent gas-bacillus antitoxin; and 100,000 units of penicillin by

vein and 100,000 units by instillation into the right pleural cavity, from which

1,000 cc. of bloody, foul-smelling fluid had been aspirated. These measures

produced little improvement; at 0600 hours the blood pressure was 108/30. At operation, laceration of the diaphragm was closed. The chest was

also closed after catheter had been inserted in the right pleural cavity.

Laparotomy revealed laceration of the right kidney. The kidney was not

removed, and drainage was provided for the perirenal, subdiaphragmatic, and

subhepatic regions on the right. The patient was apparently in fairly good

condition throughout the procedure but died suddenly as operation was being

concluded.

AUTOPSY

The autopsy was performed hour after death (Minturno, Italy).

Gross observations.—The skin and sclerae were definitely icteric. The

abdomen was moderately distended and tympanitic. No bubbles of gas were
166 GENERAL SURGERY

noted in the tissues at the site of entrance of the missile, which was beneath the

12th rib in the right costovertebral region. The shell fragment had passed

forward through the reflection of the diaphragm and then through the dome of

the liver, coming to lie beneath the skin in the right midclavicular line at the

level of the sixth intercostal space.

The right pleural cavity was remarkable in that the right lung was almost

completely collapsed and the entire cavity was lined with thick, fibrinous

exudate. This cavity contained about 200 cc. of bloody fluid. The stomach was

greatly dilated; it extended downward to point cm. below the umbilicus.

It was so distended with gas that it appeared tense and drumlike. The hepatic

flexure of the colon was plastered to the anterior surface of the right kidney by

fibrinous exudate. There was moderate bile staining of the lesser peritoneal sac

and of the retroperitoneal tissues of the right renal region.

There was practically total collapse of the right lung, which was bound

down by the exudate just described. This exudate covered all exposed surfaces,

and in the thicker portions, which lay posteriorly, there were many bubbles of

gas. The amount of gas present was out of proportion to the degree of subcutaneous emphysema present, and it was thought that the gas represented the

product of bacterial growth in the exudate. This lung contained practically

no air, and on section it was found to be almost completely consolidated, the

collapsed tissue being suffused with hemorrhagic fluid. There was almost

complete atelectasis of the left lower lobe and moderately severe patchy

atelectasis of the left upper lobe, in which peripheral emphysematous blebs

were observed. The bronchi contained moderate amounts of serous bloody

fluid, but there was no evidence of obstruction of major bronchus.

missile had passed through the dome of the right lobe of the liver.

Incision through Glisson’s capsule at point of hemorrhagic discoloration

released bloody fluid containing bubbles of gas. On section, the wound track

measured to cm. in diameter. The walls were made up of pale-yellow,

opaque, necrotic liver parenchyma, which contained small, irregular bubbles of

gas and had the appearance of fermented culture media. Bubbles of gas were

expelled from the blood vessels of the liver.

Except for the extreme gastric dilatation already described, and thinning

of the wall by pressure of retained air and gas, the stomach was notremarkable.

The passing missile had caused severe contusion of the central portion

of the right kidney, and on section spherical hemorrhagic area was seen,

which was to cm. in diameter. Overlying this area was considerable capsular reaction, but the cortex of the kidney did not appear to be directly lacerated by the missile.

The spleen was moderately swollen and somewhat softer than normal.

The capsule overlying the relatively normal portion of the kidney stripped

away with some difficulty and slight tearing of the underlying parenchyma

The renal pelvis on the right was bile stained to degree not noted on the left.

Gross anatomic diagnosis. (1) Shell-fragment wound of right thoracoabdominal region, with right hemopneumothorax and extreme atelectasis of
SHOCK THERAPY 167

right lung; empyema of right pleural cavity, possibly caused by clostridia;

laceration of right lobe of liver with extensive necrosis due to anaerobic infection; and (2) severe atelectasis of left lower lobe and partial atelectasis of left

upper lobe, secondary to right pneumothorax and gastric dilatation; severe

acute dilatation of stomach; severe contusion of right kidney, and moderately

severe contusion of hepatic flexure of colon; sutured laceration of right diaphragm.

Comment.—When this patient was received in the field hospital, he was

suffering from overwhelming infection and severe respiratory embarrassment.

Gastric dilatation and atelectasis of the left lung may have accounted for his

sudden death on the operating table. roentgenogram taken before operation showed large gas bubble in the region of the stomach.

Microscopic observations.—The heart veins were dilated and engorged

with blood.

Two sections of the lungs showed massive collapse with patent bronchi.

Many dust cells were present. The pleural surfaces were covered with

fibrinopurulent exudate which showed no evidence of organization. Exudate

stained with the MacCallum-Goodpasture stain showed many gram-positive

spore-bearing bacilli morphologically consistent with clostridia.

One section of the liver showed extensive traumatic necrosis. second

showed central congestion, acidophilia, and slight vacuolation.

The splenic pulp was very cellular.

One section of kidney tissue showed only moderate diffuse dilatation of

all portions of the nephrons. second showed massive hemorrhagic traumatic

necrosis. Many of the collecting tubules were plugged with casts; some were

hyaline, some consisted solely of red blood cells, and others showed all grades

of transition.

The pleural surface of the pericardium was covered with fibrinopurulent

exudate. The pericardial surface was normal.

Comment.—This is the first case to come to autopsy in the Naples laboratory with what appears to be clostridial infection of the pleural cavity.

(T.'b. M.)

SUMMARY

Even if this patient had survived operation, it is doubtful that he could

have tolerated such overwhelming infection. His response to replacement

therapy before operation was slow and incomplete and was in itself indicative

of the profound circulatory changes which characterize clinical gas-bacillus

infection.

Case 14

CLINICAL DATA

This patient received bullet wound of the mid-upper abdomen 17 April

1945, at 1800 hours. He reached field hospital 18 April, at 0130 hours,

without replacement therapy during evacuation. The blood pressure at this
168 GENERAL SURGERY

time was 80/60 mm. Hg and the pulse 120. Improvement was prompt after

the administration of 500 cc. of plasma and 500 cc. of whole blood, and the

blood pressure before operation was 128/80 mm. Hg. The patient’s blood

belonged to group O.

Laparotomy through left paramedian incision revealed the omentum

to be badly lacerated and torn. The proximal jejunum, which was transected,

was repaired by end-to-end anastomosis. The splenic flexure of the colon,

which was badly lacerated, was resected and the loops were brought out in the

left abdomen as colostomy. The posterior wound of exit in the loft flank

was debrided. Exploration showed that the loft kidney was lacerated, but it

was not removed. The perirenal space was drained, and drains were brought

out through the inferior portion of the abdominal incision. The patient’s

condition was satisfactory during operation, in the course of which he received

an additional 500 cc. of blood.

His condition the day of operation continued fairly good. He voided 600

cc. of urine. The following day, 19 April, his status worsened rapidly; he became

stuporous and was unable to void. The following laboratory values were reported: Hematocrit, 51; hemoglobin, 17.2 gm. percent; and plasma protein,

6.5 gm. percent.

On 21 April, the patient’s condition was fair, though drainage of smallbowel contents was noted through the posterior wound in the left flank, and it

was thought that the jejunal anastomosis might have broken down.

On 22 April, the patient was very ill, and there was evidence of severe

peritonitis. He died on this day at 1000 hours, approximately 112 hours after

injury.

AUTOPSY

Autopsy was performed hours after death (Poxdorf, Germany).

Gross observations.—Externally the body showed dehydration and

moderate weight loss. The abdomen was quite distended. Foul-smelling,

watery fluid oozed from the wound in the left flank.

considerable quantity of gas escaped when the abdominal cavity was

opened. The cavity contained about 2,000 cc. of foul, blood-tinged fluid in large pocket which extended from the left upper abdomen across the midline to the right para-umbilical region. The walls of this pocket were made up of

fibrinopurulent exudate, and the serosa of the adjacent bowel was opaque and

dark in color. Fluid present in the pelvic portion of the peritoneum contained small particles of undigested food. Strands of purulent exudate were scattered

throughout the peritoneal cavity. The diaphragm was elevated to the level of

the third rib bilaterally; both leaves were intact.

There was much old blood in the left perirenal tissues.

The left cardiac ventricle showed moderately severe concentric hypertrophy.

The lungs revealed only slight congestion and atelectasis of the inferior

portions of the lower lobes.
SHOCK THERAPY 169

The spleen was somewhat softer than normal.

In the posterior wall of the stomach were two unclosed perforations. The

larger, which measured cm. in diameter, lay near the attachment of the gastrocolic omentum in the midportion of the greater curvature. The second, which measured cm. in diameter, overlay the tip of the pancreas. The

stomach was empty and contained no blood, but apparently considerable bleeding had taken place into the peritoneal cavity from the gastric perforations. The jejunojejunostomy was not remarkable.

There was small area of trauma at the extreme tip of the tail of the pancreas. Two small foci of fat necrosis were present in the interlobular adipose

tissue of the pancreas. There was no gross evidence that pancreatic juices had

entered the peritoneal cavity to any appreciable extent.

On the anterolateral aspect of the lower pole of the left kidney was 3-cm.

stellate laceration.

Gross anatomic diagnosis. (1) Perforating bullet wound of abdomen,

with transection of proximal jejunum, healing jejunostomy; severe laceration of transverse colon, colostomy; two large perforations of posterior wall of stomach; moderately severe laceration of left kidney, with retroperitoneal hemorrhage; minimal laceration of tail of pancreas; (2) severe, acute, generalized

peritonitis, secondary to unclosed perforations of stomach; and (3) gastric

fistula via wound of exit in posterior left flank, secondary to unclosed gastric

perforations.

Comment.—The technical error of omission in this case emphasizes the

necessity for thorough exploration of the abdomen in any combat-incurred

wound. Unfortunately, the lesser peritoneal sac was not explored at operation.

Microscopic observations.—On the pleural surface of the lung, an exudate

of polymorphonuclear leukocytes, blood, and fibrinoid material was noted. The

alveolar walls were approximated, and blood or slight amount of eosinophilic

coagulum was present in some alveoli. The vessels were engorged. Alveolar

hemorrhage was most apparent subpleurally. second section showed approximation of the alveolar walls with foci of intra-alveolar fibrinoid material and

clumps of polymorphonuclear leukocytes; these changes were moderately extensive in certain areas. Several small bronchioles showed ulceration of the

epithelium with blood and polymorphonuclear leukocytes in the lumens.

Other bronchioles were partly filled by accumulations of polymorphonuclear

leukocytes.

fibrinoid material with intermingled polymorphonuclear leukocytes was

present on the capsular surface of the spleen. The sinusoids were large and

filled with blood.

There was vacuolation of the liver cells, chiefly about the central vein of

the lobule. The veins appeared to be slightly dilated.

Hemorrhage had occurred into the interlobular fat of the pancreas, and

there was focal collection of fibrinoid material with enmeshed leukocytes.

378327°—56 13
170 GENERAL SURGERY

On the serosal surface of the stomach was an extensive fibrinoid exudate

with scattered polymorphonuclear leukocytes. At the attachment adjacent

to the serosa, the exudate showed early organization, as evidenced by fibroblastic and capillary proliferation.

The tubules of the kidney showed degeneration to the point of necrosis,

with granularity of the cytoplasm and loss of nuclear detail. The glomeruli

were small. Another section showed irregular necrosis and hemorrhage into

the parenchyma. About the periphery of these areas were moderate accumulations of polymorphonuclear leukocytes.

Microscopic diagnosis. (1) Moderatelobular pneumonia; (2) fibrinopurulent pleuritis; (3) severe traumatic renal necrosis and hemorrhage; (4) slight

fatty metamorphosis of liver; (5) moderate interlobular pancreatic hemorrhage;

and (6) pulmonary atelectasis.

Comment.—The microscopic findings were in essential agreement with the

gross diagnosis. The peritonitis was well illustrated by the exudate seen on the

capsidar surface of the spleen and the serosal surfaces of the stomach and pancreas. (E. N. B.)

SUMMARY

This case is an example of one of the numerous pitfalls which can occur as

the result of failure to carefully explore all abdominal wounds. In spite of the

severity of the abdominal wound, the patient tolerated operation surprisingly

well. Failure to close two perforations of the stomach, however, led to death

on the fourth postoperative day.

Case 15

CLINICAL DATA

This patient sustained shell-fragment wound of the right lumbar region

June 1944, at 1510 hours. He reached field hospital at 1800 hours, after

having received 1,000 cc. of plasma. The blood pressure at this time was 86/44 mm. Tig and the pulse 120. Remarkable improvement occurred after the administration of 1,000 cc. of plasma and 500 cc. of whole blood. Just before

operation, the blood pressure was 120/88 mm. Hg, and there was no excessive

bleeding from the large wound.

At operation, the wound of the right lumbar region was found to be perforating and very large. The missile had entered the abdomen just to the right of

the third lumbar vertebra and had caused extensive destruction of the body of

this vertebra and of the cauda equina. There was massive defect in the lumbar

muscles on the right, with extreme damage to the cecum, which required resection. An ileotransverse colostomy was performed. The wound was debrided

and drained, and large pack was placed in the retroperitoneal muscle defect.

During operation, in spite of continued transfusion of whole blood, the patient’s

condition became critical. He did notrally after operation and died June 1944.
SHOCK THERAPY 171

AUTOPSY

Autopsy was performed hours after death (Cori, Italy),

Gross observations.—There was no apparent invasive infection of the large

lumbar wound, which measured 6.0 by 8.0 cm. and which made gaping defect

in the right paravertebral region. The floor of this defect was formed by the

posterior portion of the parietal peritoneum. large retroperitoneal hematoma

was present.

The pericardial and pleural cavities were not remarkable. There was no

increased fluid in the peritoneal cavity, although the loops of small bowel were

loosely bound together by strands of fibrinopurulent exudate.

The heart showed minimal coronary atherosclerosis, with some increased

thickness of the left ventricular myocardium.

The lungs showed only moderate congestion and edema of both lower lobes.

The liver, spleen, and adrenal glands were essentially negative. The gastrointestinal tract showed only recent healing ileotransverse colostomy.

The kidneys were normal, and the intact right ureter bridged the lumbar

defect. There was moderate hydroureter and slight hydronephrotic dilatation

of the right renal pelvis. The orifice of the ureter was partly occluded by two

blood clots at the level of the wound (third lumbar vertebra). No blood was

present in the renal pelvis. The bladder showed somewhat increased trabcculations of the mucosal surface.

Examination of the vertebral column showed extensive destruction of the

third lumbar vertebra, with contusion of the filaments of the cauda equina.

Gross anatomic diagnosis. (1) Severe shell-fragment wound of right posterior abdomen, with multiple lacerations and perforations of cecum and

ascending colon, secondary resection of cecum and ileotransverse colostomy;

compound comminuted fracture of body and transverse and spinous processes

of third lumbar vertebra, with severe retroperitoneal hemorrhage; moderately

severe contusion of right ureter, with moderate hemorrhage into ureter and

slight secondary hydronephrosis; (2) severe, acute, purulent, generalized, early

peritonitis, secondary to wounds of cecum and ascending colon; and (3) severe,

multiple contusions and lacerations of cauda equina, secondary to fracture of

third lumbar vertebra.

Comment.—The massive trauma, blood loss, and severe peritoneal contamination made the outlook in this case very poor from the first. It is surprising that the patient responded as well as he did to 1,000 cc. of plasma and

only 500 cc. of blood. In retrospect, it seems probable that he received too

much plasma, and, more important, too little blood before operation.

Microscopic observations.—The lungs showed diffuse partial atelectasis

and marked congestion. few fat droplets were present in the arterial tree,

chiefly in the arterioles.

The kidney showed focus of interstitial and intratubular hemorrhage consistent with traumatic lesion. Scattered through the cortex were spaces

lined with very flat epithelium or swollen endothelium which contained orange-
172 GENERAL SURGERY

staining material. No pigment precipitates were found in any part of the

tissues which could be recognized definitely as nephron. The nature of the

lesion was not apparent, but it was not regarded as important to clinicopathologic correlation.

Microscopic diagnosis.—Minimal pulmonary fat embolism. (T. B. M.)

SUMMARY

It is remarkable, in retrospect, that this patient lived as long as he did,

because of (1) extreme tissue destruction and consequent loss of blood, (2) the

difficulty of controlling blood loss during operation, and (3) the overwhelming

contamination of the peritoneal cavity. Early postoperative deaths were not

uncommonly seen in severely wounded patients after such long and tedious

operation as this patient underwent.
173

CHAPTER

Traumatic Evisceration (312 Casualties)

Samuel B. Childs M. D.

In the 3,154 instances of abdominal injury observed by the 2d Auxiliary

Surgical Group during 1944 and 1945, there were 312 traumatic eviscerations (table 19), 126 of which (40.4 percent) were fatal. Evisceration, for the purposes of this discussion, is defined as the protrusion of an abdominal viscus

outside of the peritoneal cavity through missile track which has interrupted

the continuity of all layers of the abdominal wall.

Table 19.—Distribution of wounds and deaths in 312 traumatic eviscerations in 3,154

abdominal injuries

In this series, the frequency of evisceration of particular organ apparently

varied in relation to (1) its own mobility and volume and (2) the site and size

of the missile track. The omentum alone, the small bowel alone, the colon

alone, and the small bowel and colon in combination were involved in 86.9

percent of the total number of eviscerations. In injuries (4 involving the

small bowel and the small bowel and colon), the protruding abdominal

viscus had not been injured. The organ extruded was not recorded in cases.

Exclusive of 25 cases in which the site of extrusion was not recorded and

of 86 in which only the omentum was involved, the evisceration occurred in

the upper abdomen 75 times, in thelower abdomen 68 times, in the left flank

28 times, the right flank 13 times, the left chest 10 times, the right chest times,

the right side of the back twice, and the left sacral region and the left buttock

Organs injured Cases Proportion Deaths Case fatality rate

Omentum only .. 86

Percent

27. 57 32 37.

Stomach 2. 88 33.

Stomach, small bowel, and colon 1. 60 40.

Stomach and colon 64 100.

Stomach and spleen 32

Small bowel 123 39. 43 43 34.

Small bowel and colon 24 7. 69 14 58.

Small bowel and liver 32

Colon._ 38 12. 19 21 55.

Colon and liver 96 100.

Colon and spleen 32

Liver 2. 24 42.

Spleen 96

Not recorded 2. 88 33.

Total. 312 100. 00 126 40.
174 GENERAL SURGERY

in case each. If the wound of entry in perforating wounds was sufficiently

large, evisceration sometimes occurred through it. More often it occurred

through the wound of exit. Sometimes wide-open track was found between

the wounds of entry and exit.

The wounding agent, which was recorded in 299 cases, was shell fragment in 171 cases, small-arms bullet in 97, and mortar, bomb, grenade, or

mine fragment in the remaining 31 cases.

CASE FATALITY RATE IN RELATION TO SHOCK AND

PERITONITIS

In 86 cases, 32 of which (37.2 percent) were fatal, only the omentum

protruded from the abdomen. The 24 deaths which occurred in this group

by the end of the second postoperative day were all attributed to shock. Two

deaths in this group (6.3 percent of the total number) which occurred on the

ninth postoperative day were attributed to peritonitis; perforations of the

stomach and the colon were also present in both. Four patients in this group

died of other causes, and in two instances (also 6.3 percent of the total number)

the cause of death was not recorded. The proportion of the 32 deaths attributed to peritonitis (6.3 percent), corrected for the no-record cases to 6.7

percent, did not exceed the case fatality rate for peritonitis (12.3 percent) in

the whole group of 3,154 cases (p. 208). The data suggest that evisceration

of the omentum alone introduced no additional factor of contamination and

was significant only in relation to the severity of the abdominal wound.

In the 226 cases in which an abdominal organ other than the omentum

was extruded, there were 94 deaths (41.6 percent). All but of the 61 deaths

which occurred by the end of the second postoperative day were caused by

shock (table 20). The 10 deaths caused by peritonitis accounted for 10.6

percent of the 94 fatalities, corrected for no-record cases to 11.6 percent. This rate approximated the case fatality rate for peritonitis (12.3 percent) in

the whole group of 3,154 cases.

The single fatality in the cases in which there was no injury to the

extruded viscus (in all instances intestine) occurred on the fourth postoperative

day and was caused by massive pulmonary embolism. Whether evisceration

occurred in this group of casualties at the time of wounding or subsequently

was not known. It seems significant, however, that, whatever the duration

might be, none of these patients exhibited signs of clinical shock either when

they arrived at the field hospital or during their later postoperative course.

CASE FATALITY RATE IN RELATION TO MULTIPLICITY

FACTOR AND TIMELAG

An analysis of the 298 cases in which sufficient data were available for

this purpose (1) indicated that the multiplicity factor played the same significant role in the case fatality rate for traumatic eviscerations as for other

groups of injuries (table 21), and (2) further supported the concept that this
TRAUMATIC EVISCERATION 175

Table 20 .—-Primary cause of death and time of death in 94 traumatic eviscerations

factor is satisfactory index of the severity of battle-incurred abdominal

injuries.

The influence of the timelag is by no means as clear cut as is the influence

of the multiplicity factor (table 22). Variations in the case fatality rate suggest that other factors played part. Two are immediately apparent:

1. large proportion of severely wounded men seen after short timelag

had wounds whose lethality was not altered by surgery.

2. Men who were more lightly wounded (relatively or absolutely) died

after longer timelag and in smaller numbers. Probably not all of the casualties with traumatic eviscerations woidd have died within 10-day period if

they had not been operated on, and certainly surgery could not alter the

essentially lethal nature of the wounds sustained by many of the severely

injured casualties.

Table 21.—Combined influence of evisceration and multiplicity factor on case fatality rates in

3,129 abdominal injuries

Cause Deaths Proportion

Postoperative day

2d 3d 4th 5th 6th 7th 8th 9th After

9th Not recorded

Shock .. ..

59

10

Percent 62.8

10.6

5.3

4.2

1.1

1.1

1.1

1.1

8.5

59

Peritonitis ..

I...

Anuria.

Pulmonary embolism

Pneumonitis...

Empyema

Thrombosis, inferiormesenteric vein.

It

Total 94 100.0 61

The 32 fatal cases in which only the omentum was extruded are excluded from this table.

Organs injured

Without evisceration With evisceration

Cases Deaths

Case

fatality

rate

Cases Deaths

Case

fatality

rate

None. 287 21 7. 20.

One. 1, 253 177 14. 95 24 25.

Two 913 247 27. 101 38 37.

Three _. _. 279 119 42. 71 43 60.

Four 81 48 59. 15 11 73.

Five ._ 16 16 100. 71.

Six. 100. 100.

Total.. 2, 831 630 22. 298 126 42.
176 GENERAL SURGERY

Table 22.-—Influence of timelag on case fatality rates in 203 traumatic eviscerations

In 41 of the 123 instances in which evisceration of the small bowel occurred, only the bowel was extruded, and there were no complicating multivisceral injuries. The bowel itself was injured in all 41 cases, but the absence

of the compounding effect of injuries to other structures makes it possible to

consider in this group the effects of evisceration per se on the case fatality rate

for abdominal injury.

There were deaths, 19.5 percent, among these 41 patients. Four died

within the first two postoperative days, in shock, with peritoneal contamination by small-bowel contents perhaps playing some part in the fatality. Two

died of peritonitis, on the 8th and 22d days, respectively, after operation.

Another died of pneumonia on the 5th day, and the remaining patient died

on the same day, of an unstated cause. The timelag in all of these cases was

short, the average being 5% hours, which shows that it was not necessary to

keep the patients in the shock ward for long time before operation. It also

implies priority of evacuation and surgery. In spite of these favorable factors, the case fatality rate in these 41 cases (19.5 percent) was higher than the

rate of 13.1 percent for the 314 univisceral injuries of the small bowel in

which evisceration did not occur.

This discrepancy suggests that traumatic evisceration is, in itself, serious

type of injury. This is well demonstrated by comparison of the case fatality

rates in casualties who did and who did not sustain it. In the first five multiplicity categories (0 to organs wounded), the average increase in rates from

category to category when evisceration had occurred was approximately 13

percent (table 21). The trend was reversed when five organs were injured, but

the figures are not large enough to be of statistical significance. Apparently

evisceration affected the prognosis adversely to approximately the same degree

as did the involvement of each additional organ in the multiplicity factor scale

(table 21).

The occurrence of traumatic evisceration was also, in general, an indication

of the severity of the wound. It was observed in only 1.7 percent of patients

having no visceral injury but in out of with viscera damaged (table 21).

Timelag Cases Deaths

Case

fatality

rate

to hours 77 29 37.

to 12 hours __94 42 44.

12 to 18 hours 16 31.

18 to 24 hours 33.

Over 24 hours 10 40.

otal 203 82 40.
177

CHAPTER XI

Diagnosis and Preoperative Routine

W. Philip Giddings M. D., and Luther H. JVoIfj\ M. D.

DIAGNOSIS

The preoperative diagnosis of visceral injuries in battle casualties was

necessarily inexact. It was based chiefly on probabilities. It required careful

consideration of (1) the site of the wound of entry, (2) the site of the wound of

exit, (3) the direction from which the soldier believed ho was struck, (4) his

posture at the time of wounding, and (5) the position of the retained foreign

body as demonstrated by roentgenologic or fluoroscopic examination.

Diagnosis was particularly difficult in multiple wounds of the abdominal

wall, since any one, or several, of the fragments which had caused the visible

injuries might have penetrated the peritoneal cavity. Exploration for diagnostic purposes was frequently necessary in injuries of this kind. It was also

the established routine in any patient in whom the possibility of peritoneal or

extraperitoneal visceral injury could not be positively excluded by any other

method. In almost every instance of abdominal injury, final and complete

diagnosis was possible only after direct visualization of the peritoneal cavity at

laparotomy.

It was always important to determine whether hollow viscus had been

injured, with resultant soiling of the peritoneum, because patients with this

type of injury were given priority of treatment. As rule, the location of the

wound combined with unmistakable signs of established peritoneal irritation

left no doubt that spillage had occurred, though in the occasional case diagnosis

was not so simple. In the evaluation of doubtful cases, the absence of audible

peristalsis was useful diagnostic aid. On the other hand, peristalsis might be

present if soiling were localized to the retroperitoneal space or to the lesser

peritoneal cavity. Similarly, blood in the peritoneal cavity might give rise to

peritoneal irritation, and blood in the urine, gastric contents, or feces was

always important diagnostically; but its mere absence in these specimens did

not necessarily exclude wounds of the urinary tract or of the stomach (pp. 255, 304). Rectal examination was an essential part of the diagnostic routine, and

it was particularly important in wounds of the buttocks and upper thighs.

Retroperitoneal injury, uncomplicated by other injuries, occasionally simulated

peritonitis.

It was essential to remember, in the evaluation of symptoms and signs in

casualties with abdominal wounds, that the clinical picture could be materially

altered by the administration of morphine before the examination.

Thoracoabdominal wounds.—Experience showed that it was of the utmost

importance to establish the presence or absence of an associated abdominal
178 GENERAL SURGERY

injury in every thoracic wound (table 6). Wounds of the chest below the seventh interspace posteriorly and below the fourth rib anteriorly were regarded as

possible thoracoabdominal wounds. The potentialities, however, were not

limited to these areas. Perforation of the diaphragm was possibility in any

of the wounds caused by missiles which had entered anywhere from the gluteal

region to the shoulder, though in most injuries of this kind the woundof entrance

was in the lower half of the thorax. Among the 903 thoracoabdominal injuries

treated in the period 1943-45 by the 2d Auxiliary Surgical Group, there were

66 (7.3 percent) in which the diaphragm was perforated from below.

Pain in the lower thorax was one of the reasons why the diagnosis of

abdominal injuries which were associated with thoracic injuries was often

difficult. It was sometimes helpful to reexamine the patient after intercostal

nerve block; abdominal rigidity caused by peritonitis persisted after the block,

whilepain and muscle spasm arising from thoracic injury might be considerably

reduced. If, however, too great reliance were placed upon these observations,

the conclusions might be erroneous. Pain referred to the shoulder was found to

be important evidence of injury to the diaphragm. Though pain was not

always present in such cases, it was extremely infrequent in injuries limited to

the thorax.

Roentgenologic studies, though often inadequate for practical reasons,

were an invaluable aid in suspected thoracoabdominal injuries. Often, however, in spite of the information thus provided, abdominal exploration was

regarded as mandatory. It was usually carried out through thoracotomy

incision.

PREOPERATIYE ROUTINE

The preoperative care of the casualty with an abdominal wound included

the following measures: Placing the patient on clean litter; removal of all his

clothing; maintenance of body heat by blankets placed under as well as over

him; securing rapid clinical history; making of rapid but complete physical

examination; blood typing and crossmatching; catheterization, if the patient

could not void voluntarily, and urinalysis; passage of Levin tube, with gastric

aspiration; and roentgenologic examination. As soon as possible, even before

these studies were completed, measures of resuscitation were instituted and

penicillin sodium (20,000 to 25,000 units) was administered by the intramuscular or intravenous route. Blood was always administered according to

the indications of the special case (p. 124). Hematocrit and hemoglobin values

were carefully checked.

Patients with thoracoabdominal injuries presented special problems in

preoperative preparation because blood and mucus were likely to accumulate in

the pharynx and throat. If they were conscious, they coidd frequently raise the

accumulation by voluntary coughing. If coughing was painful, it could be

facilitated by intercostal nerve block by the anesthetist. All unconscious

patients, as well as some who were conscious, required tracheobronchial suction

for the removal of secretions and improvement of the respiratory exchange.
DIAGNOSIS AND PREOPERATIVE ROUTINE 179

The usual method was to pass through the nose long #16 catheter, with hole

in the side near the proximal end and several holes in the distal end, and to suck

out the material through it. If one application of the tube was not sufficient to

clear the airway, it was reintroduced. Preoperative thoracentesis was also employed to improve the respiratory exchange in cases of pneumothorax or

hemopneumo thorax.

The measures described were usually carried out by the shock officer,

assisted by the anesthetist (p. 120) and other personnel working under his direction. It was, however, the ultimate duty of the surgeon to assure himself that

all the steps of the preoperative routine had been properly carried out. Ideally,

the shock officer and the surgeon cared for the patient jointly; but if casualties

were heavy, the surgeon was almost always occupied elsewhere, and the ideal

was therefore not achieved. Nevertheless, regardless of circumstances, it was

the surgeon’s responsibility before operation to review the history, physical

findings, laboratory data, and roentgenograms, and it was also his responsibility, preferably in consultation with the shock officer, to determine the

optimum time for operation in every case.

181

CHAPTER XII

Anesthesia

George E. Donaghy M. D., Ernest A. Bond M. D.,

Wemer F. Hoeflich, M. D., and Charles W. Weslerjield, M. D.

For the most part, anesthesia in the 3,154 abdominal injuries treated the

teams of the 2d Auxiliary Surgical Group during 1944 and 1945 was administered by physicians. Many of the 45 anesthetists attached to the group had

received formal training. Others had had limited training and experience, but

some had had neither training nor experience. Ideally, because soldiers with

abdominal injuries may present incredible difficulties in anesthetic management, anesthetists who care for them should possess good general medical

background, an understanding of the principles of management of the physiologic disturbances following abdominal and thoracoabdominal wounds, and

proficiency in the diagnosis and treatment of shock and in the recognition and

care of complications. For obvious reasons, this ideal was frequently not

achieved.

STATUS OF CASUALTIES

Detailed information concerning the status of casualties on their arrival

at the field hospital after triage at the division clearing station is set forth

elsewhere (p. 124), but certain of these facts should be reiterated here; they

furnish the background for the discussion of anesthesia in abdominal injuries

in wartime.

The majority (approximately 90 percent) of the casualties with abdominal

wounds treated in the field hospitals by surgeons of the 2d Auxiliary Surgical

Group were nontransportable; that is, they required immediate operation.

The timelag from wounding until hospitalization ranged from between 15

and 30 minutes to between 30 and 40 hours. Exclusive of the cases in which

the abdominal wall was penetrated without visceral injury, the injuries varied

from small wound of single viscus to penetrating and perforating wounds

of several organs. More than quarter of the patients (26.6 percent) had

thoracoabdominal injuries. All types of associated (extra-abdominal) injuries

were present in all conceivable sites. The physical status of many of the

casualties was only fair or actually poor. Some degree of shock was present

in most cases; frequently it was extremely severe. In representative sample

of 957 cases, 14.6 percent of the patients had systolic blood-pressure readings

from to 40 mm. Hg, 12.7 percent from 41 to 70 mm. Hg, 26.1 percent from

71 to 100 mm. Hg, and 46.6 percent from 101 to 120 mm. Hg. Often there

had been periods, sometimes long periods, of fatigue, exposure, and dietary

limitations before the injuries had occurred.
182 GENERAL SURGERY

Pulmonary blast injuries deserve special mention. The small number in

this series suggests that only the most severe were put on record and that the

majority, because they were minimal, were either not recognized or not entered

on the charts. The gravity of this particular problem naturally varied with

the degree of injury. Casualties who had sustained severe bilateral injuries

furnished the anesthetists with many special problems. It was real achievement to anesthetize patient with this type of injury without losing him on

the table from pulmonary edema. No form of anesthesia, least of all ether, was

well tolerated, and it was always difficult to maintain an adequate airway

during operation and afterward.

AGENTS AND METHODS

Although wide variety of anesthetic agents was available in the Mediterranean theater, anesthesia, for practical reasons, was accomplished in more

than 90 percent of all cases with ether (table 23). The agents supplied included,

in addition to ether, chloroform, ethyl chloride, nitrous oxide, Pentothal, procaine, Pontocaine, cocaine, and oxygen. Methods employed included the

open-drop method; the closed-circle flow absorption method, with Heidbrink

and McKesson machines; the closed to-and-fro absorption method, with the

Beecher model machine; intravenous injection; intratracheal injection; local,

regional, and field block; and topical application.

Table 23.—Distribution of anesthetic agents in 3,154 abdominal injuries

Anesthetic agents

1944 1945 Total

Cases Proportion Cases Proportion Cases Proportion

Nitrous oxide-oxvgen-ether 1, 306

Percent

54. 81 642

Percent

83. 1, 948

Percent

61. 77

Ether 752 31. 56 48 6. 800 25. 37

Ethyl chloride-ether 224 9. 40 57 7. 281 8. 91

Pentothal-ether 49 2. 06 50 1. 59

Chloroform-ether 04 03

Nitrous oxide-oxy gen-etherPentothal 04 03

Ether-procaine. 13 09

Procaine (local) 21 19

Procaine (spinal) 08 06

Procaine-Pentothal (spinal) 04 03

Nitrous oxide-oxvgen 04 03

Pentothal 04 03

Oxygen 04 03 Not stated 36 1. 51 22 2. 68 1. 84

Total 2, 383 100. 00 771 100. 3, 154 100. 00

Patient diedfrom aspiration of gastric contents following vomiting during inductionofanesthesia.

Simple debridement of thoracoabdominalwound of entrance. Patient unconscious and moribund.
ANESTHESIA 183

Routine Agents and Method

The 2d Auxiliary Surgical Group found soon after it had become operational that the most satisfactory anesthesia for severely wounded battle casualties was secured by (1) induction by nitrous oxide-oxygen and (2) maintenance

by ether-oxygen in closed carbon dioxide absorption system. This method

was adopted and came into general use because of its ready availability, its

simplicity of administration, its satisfactory tolerance by patients, and its

wide margin of safety. The possible toxic effects of ether on the heart, liver,

and kidneys were fully realized, but simplicity of administration and the wide

margin of safety were considerations of greater importance in view of the fact

that, as already mentioned, the anesthetics were administered by some 45

anesthetists of widely varying training, experience, capabilities, and judgment.

Although ether, combined with and following induction with

nitrous oxide, was the most popular anesthetic agent in this series, its use by

the open-drop method was considerably less extensive than might have been

expected (table 24). This method was used in 12.5 percent of all cases treated

in 1944, when anesthesia machines were in limited supply, but in only 2.7

percent of the operations in 1945, when equipment had become widely available.

Closed anesthesia had many desirable features for military surgery, including conservation of body heat and moisture, the maintenance of high oxygen

content and the control of carbon dioxide content in the blood, ease of attaining

and maintaining desired levels of anesthesia, and control of respiration and

maintenance of positive pressure when these special conditions had to be met.

The necessity for an anesthesia in which these objectives could be accomplished

was naturally magnified in casualties in critical condition. There was therefore

an increasing use of the closed technique as the war progressed (table 24).

The endotracheal technique also had an extensive and increasing use,

which in most cases was essential rather than preferential. By it, patent

airway was provided and maintained, no matter what the position of the patient.

Table 24. —Distribution of techniques of administration of anesthesia in

3,154 abdominal injuries

Method

1944 1945 Total

Cases Proportion Cases Proportion Cases Proportion

Inhalation: Percent Percent Percent

Closed 2, 028 85. 727 94. 2, 755 87.

Open 298 12. 21 2. 319 10.

Semiopen

Others 14 15

Not stated 36 1. 22 2. 58 1.

Total 2, 383 100. 771 100. 3, 154 100.
184 GENERAL SURGERY

The anesthetist, as result, had sufficient freedom of action to aspirate blood

and accumulated secretions easily via the tube and to supervise or administer

transfusions when they were required. The endotracheal technique facilitated

the control of respiration by positive pressure and assisted in the attainment

of desired levels of anesthesia, while the increased smoothness of respiration

achieved with tube in situ simplified the task of the surgeon working in the

abdominal cavity. The endotracheal technique was employed in 1944 in 89.8

percent of the 2,108 cases in which definite statement was made on the matter.

The fact that in 1945 it was employed in every one of the 749 cases in which

technique was recorded is an indication of the increased appreciation by the

surgeons of the group of its numerous advantages.

Other Agents and Methods

Chloroform.—Why chloroform was used for induction in one case in this

series is not clear. The dangers of this agent were so well known to both the

surgeons and the anesthetists of the group that there was no temptation to

employ it to anesthetize casualties with such injuries as these men had sustained.

Pentothal. —In 1944, Pentothal was used 49 times as an induction agent

preceding ether anesthesia and once as an adjunct to spinal analgesia (table 23).

In this same year, it was used in one instance as the sole anesthetic agent, for

simple debridement of thoracoabdominal wound of entrance. In 1945, it

was used only once, as the induction agent.

The extremely limited use of Pentothal by the surgeons of the 2d Auxiliary

Surgical Group has significant implications. This anesthetic agent was reported

to have been used extensively elsewhere, in some areas in 95 percent of all cases,

and it may be that the discrepancy between this usage and the usage of the

group can be explained by the type of cases handled, the problem of supply,

the echelon at which surgery was done, or combination of these factors. In

the opinion of the group surgeons, all the well-recognized contraindications to

Pentothal were present in most of the abdominal injuries which came under

their observation. large proportion of the patients were in shock. Hemorrhage before hospitalization was often serious, and further loss of blood could

be expected during operation. Anoxia of varying degrees resulted from

hemorrhage and shock, and the accumulation of secretions in the tracheobronchial tree, hemothorax and pneumothorax, painful respiration, and other

derangements of cardiorespiratory physiology furnished other problems. The

surgery required was frequently formidable and time consuming. Muscular

relaxation was essential during operation, particularly while exploration and

closure were being carried out. Endotracheal intubation, which was almost

universally employed, was difficult to accomplish under Pentothal anesthesia,

because of irritability of the larynx and poor relaxation of the muscles of the

jaw. The status of the patient thus militated against the use of Pentothal,

while the criteria of desirable anesthesia for this type of injury were difficult or

impossible to attain when it was used. Finally, serious reactions often occurred
ANESTHESIA 185

when the tube was inserted, and second reaction was likely to occur when the

catheter was moved as the patient was shifted on the operating table or when

his head was turned.

Nitrous oxide.—Nitrous oxide, although it was used routinely as an induction agent, was never used as the sole anesthetic agent (table 23). It was

always employed with oxygen concentrations of at least 20 percent, and many

anesthetists preferred concentrations of 30 percent or more. Concentrations

of 60 to 75 percent were frequently used, and no difficulties were experienced in

the brief periods in which they were necessary. Such concentrations, however,

are not compatible with satisfactory level of anesthesia, and nitrous oxide

would therefore have been impractical as the primary anesthetic for patients

who, like these, were in shock, who had serious and often multiple wounds, who

required prolonged major surgical procedures, and who had to be provided with

the highest possible concentrations of oxygen to compensate for the loss of

their own oxygen-carrying powers.

Ethyl chloride.—Ethyl chloride was used as an induction agent in large

number of cases (table 23) and was satisfactory for this purpose when it was

administered cautiously. It was not ordinarily used in patients who presented

poor risks, and it was never used as the sole anesthetic agent.

Spinal analgesia.—Spinal analgesia was not regarded as suitable for frontline military surgery for number of reasons, including the following; The

length, as well as the variability, of the time necessary for surgery; the unstable

cardiovascular balance of casualties in shock, who had sustained large blood

losses; the frequency of associated wounds in areas which cannot be affected

by this anesthetic method; and the undesirability of full consciousness in an

apprehensive casualty not long removed from the battlefield. Spinal analgesia

was used only times in the 3,154 cases (table 23). In each instance, the

patient was in excellent condition and there was no doubt that intra-abdominal

injury was minimal.

Procaine. —Procaine was occasionally used to secure regional or field block

analgesia (table 23), each time in combination with light inhalation anesthetic.

In retrospect, the combined method seems to have excellent potentialities in

military surgery, and it isregrettable that itwas not given more adequate test.

Cocaine.—Cocaine was used according to the ordinary indications for

bronchoscopy on conscious patients and, occasionally, to facilitate difficult

intubation.

PREOPERATIYE MANAGEMENT

When field-hospital platoon was well organized and fully staffed, patients

with abdominal and thoracoabdominal injuries were placed in charge of

experienced shock teams as soon as they were received from the clearing station. These ideal circumstances did not always exist. In the absence of

shock team, or when the flow of casualties was extremely heavy, both anesthetists and surgeons worked in the resuscitation ward. It was therefore

378327°—56 14
186 GENERAL SURGERY

necessary, as already intimated, for the anesthetist to be familiar with shock

therapy because emergencies might arise during which the full responsibility

for resuscitation would fall upon him.

It was always desirable for the anesthetist to make preliminary study of

the patient before he received him in the operatingroom, but during rush periods

such contacts were not always possible. The anesthetist, however, always

determined the pre-anesthetic medication to be administered in the particular

case. As rule, atropine gr. }{ was given, in combination with morphine if

that drug was indicated (p. 76). Before operation, morphine was usually given

by the intravenous route.

MANAGEMENT DURING OPERATION

The patient was kept in the shock ward until the anesthetic equipment was

in order and the instruments were set up for operation. Resuscitation therapy

was interrupted as briefly as possible during his transfer to the operatingroom.

If oxygen, for instance, was being administered, it was discontinued only during

the actual interval of transportation by the litter carriers.

Induction was seldom difficult. Many of the wounded had gone without

sleep for long periods and were completely exhausted, and those who were in

shock, or who had been in shock, were, as usual, easy to anesthetize. Severe

excitement stages seldom occurred, in contrast to their relative frequency in

civilian practice. This was surprising. It had been expected, if only because

of the sounds ofAllied and enemy artillery and the unavoidable noise and bustle

in busy surgical tent, that excitement would have been frequent and violent.

Anesthesia was maintained in the lightest possible plane compatible with

the surgery required in given case. Men in the condition of these casualties

could not usually tolerate deep planes of anesthesia for more than brief periods

of time.

Two of the anesthetists in the group were authorized to employ preparation of curare, on trial basis, as supplementary anesthetic agent, to facilitate

intraperitoneal manipulations during periods of light anesthesia. Included in

the 26 casualties in whom the method was used were 10 with thoracoabdominal

wounds and 13 who had recently been in shock. All received nitrous oxideoxygen-ether anesthesia by the closed endotracheal technique and were given

curare in various dosages and at various times during the operation.

The immediate results of this method were excellent in all cases in which

it was tested; there were no postoperative complications and no deaths which

could possibly be attributed to the use of curare. Abdominal relaxation was

entirely satisfactory in every instance, and ether anesthesia could be maintained

in the lower part of the first plane, which was thought to be more desirable than

the deeper levels ordinarily necessary in military surgery within the abdomen.

Both anesthetists who conducted the trials with curare stressed the importance

of employing the endotracheal technique when it was used.

Doud, E. A.; and Shortz, G.: The Use of Curare for Abdominal Surgery in Seriously Injured Patients. Anesthesi- ology 7: 522-525, September 1946.
ANESTHESIA 187

The foot of the litter was frequently raised before anesthesia was induced,

and many operations were performed with the patient in the Trendelenburg

position. All anesthetists commented on the fall in blood pressure which occurred when the position was changed. The drop was most notable when

patients were changed from the supine to the prone position, or vice versa,

but alterations also occurred when they were turned on the side. This phenomenon was interpreted as direct evidence of the instability of the vasomotor

system in severely wounded, anesthetized patients. Experience soon showed

that unnecessary movement of the patient on the operating table must be

avoided, and that when changes of position were necessary, they must be accomplished slowly and gently, so that the decrease in tension would be minimized as far as possible. Ephedrine (gr. %) was occasionally administered

few minutes before the position was to be changed, in an attempt to produce

general vasoconstriction and increased cardiac output and thus to sustain the

blood-pressure level.

clear airway was maintained at all times. Attention to this point was

particularly necessary during the winter, when many of the wounded came to

operation with bronchitis and had large accumulations of thick mucoid material.

Attention has already been called to the increase in the number of patients

handled under endotracheal anesthesia as the anesthetists gained proficiency

in this method.

In other respects, the management of patients during operation was also

continuation of resuscitative measures. Pain was abolished by anesthesia.

Reestablishment of normal metabolism was aided by the administration of

oxygen in high concentrations. Restoration and maintenance of the blood

volume were accomplished by transfusions. Solutions of dextrose and saline

were used only to combat dehydration. When there had been decrease in the

adequate circulating blood volume, citrated blood in the necessary amounts

was administered. Very large amounts (up to 6,500 cc.) were used in patients

who had sustained injuries to the major blood vessels. Stimulating drugs were

seldom administered.

It is well recognized in civilian practice that the longer the duration of an

operation, and therefore of anesthesia, the more likely the patient is to leave the

operating table in poor condition and to present postoperative complications.

The observation was equally valid in military surgery, but little could be done

to alter the unfavorable circumstances. In dealing with seriously wounded

men, especially when their wounds were multiple, there were few short cuts

available to the surgeon by which the operating time could be reduced. The

anesthetist did all in his power to maintain viable patient, by the use of

oxygen, Coramine (nikethamide), ephedrine, Adrenalin (epinephrine hydrochloride), transfusions (sometimes into every extremity), sternal transfusion,

and artificial respiration, according to the indications. All that the surgeon

could do was to work as quickly as he could in the light of the needs of the

patient.
188 GENERAL SURGERY

Differences in techniques and in individual speed among the various

surgeons of the group, as well as differences in injuries among the casualties,

resulted in wide variations in operating time. The average time was between

2% and hours, but the range was between 45 minutes and hours. The

duration of anesthesia was always 10 to 15 minutes longer than the duration

of the surgical procedure.

POSTOPERATIVE COMPLICATIONS OF ANESTHETIC ORIGIN

The postoperative care of the patient was the joint responsibility of the

anesthetist and the surgeon, with the anesthetist, as rule, concerned primarily

with the prevention of shock and pulmonary complications. In times of stress,

however, he was obliged to take over the entire responsibility for postoperative

care, including nasogastric suction, the maintenance of an adequate fluid

balance, thoracentesis for the removal of fluid and air, to facilitate the pulmonary exchange, and the administration of drugs. The essentials of the postoperative regimen are discussed elsewhere.

Postoperative pulmonary complications which occurred within the first 48

hours after operation were classified as of anesthetic origin. Atelectasis

(table 31, p. 206) was most frequent. In most instances, the condition was

transitory and cleared uneventfully. No deaths occurred from this cause alone

within the specified 48-hour period. The atelectasis found at autopsy and not

recognized ante mortem in 12 fatalities which occurred within this period was

regarded as an incidental rather than causative factor; all the patients had

serious injuries and other serious postoperative complications.

Prophylaxis against atelectasis included the measures already listed; that

is, voluntary coughing, frequent changes of position, measures to relieve pain,

and the administration of oxygen. Atropine was also frequently administered,

though not if the patient presented any signs of increased pulmonary transudation.

Lobar pneumonia and bronchopneumonia were infrequent complications

(p. 206). They might have been expected to occur more often following prolonged anesthesia and operation, especially since, as already noted, the patients

had often been fighting in intolerable weather; had suffered long periods of

exposure before, and sometimes after, wounding; and often had preexisting

upper respiratory infections or tracheobronchitis. Undoubtedly, the prophylactic measures employed routinely after operation and the routine use of

penicillin and the sulfonamides prevented serious consequences, even in these

cases.

ANESTHETIC-CONNECTED DEATHS

The majority of the 86 deaths which occurred on the operating table

(11.4 percent of the total number of fatalities) were caused by shock, hemorrhage, or fulminating infection. Nine, however, were attributable to anesthetic causes. In some of these fatalities, the position had been changed just
ANESTHESIA 189

before death occurred. In four instances, the patients vomited and aspirated

gastric contents. Two similar fatalities, incidentally, occurred on the wards

shortly after operation; the patients had not completely reacted, and the

fatalities must be charged to inadequate supervision. The same accident

occurred in four other cases in which the patients survived.

Two deaths occurred at the conclusion of the operation, during bronchoscopy, presumably from vagovagal reflex. These cases represented 0.4

percent of the 436 recorded bronchoscopies. The vagovagal reflex is foreseeable catastrophe, and in each of these cases it had been guarded against by

the usual measures, namely, intravenous atropinization just before bronchoscopy

was undertaken; light anesthesia; and rapid, careful instrumentation, so that

mechanical stimulation of the cough reflex would aid in clearing the air passages.

In spite of these precautions, vagovagal reflex ensued and proved fatal.

CHAPTER XIII

Laparotomy Incisions and Closures, and

onnd Dehiscences

Hugh F. Suingle M. D., and Dominic S. Condie, M. I).

In the 3,154 abdominal injuries treated by teams of the 2d Auxiliary

Surgical Group, 2,258 records were sufficiently complete to permit an analysis

of the technique of incision and closure, as well as an analysis of the 36 wound

dehiscenses which occurred in these cases within the period of postoperative

observation at forward hospitals (a usual range of to 14 days).

INCISIONS

Of the abdominal incisions in these 2,258 cases, 2,072 (91.8 percent) were

vertical, and the remainder were transverse (table 25). The great preponderance of vertical incisions reflects the consensus of the surgeons of the group

Table 25.—Distribution of abdominal incisions and wound dehiscences in

2,258 abdominal injuries

Incision Cases Proportion Dehiscence Frequency

Vertical: Percent Number Percent

High midline 150 7. 2.

Low midline 268 12.

High rectus. 1, 176 56. 25 2.

Low rectus .. 140 6. 2.

High paramedian 303 14. 1.

Low paramedian ____35 1.

Total 2, 072 100. 34

Transverse:

Subcostal 54 29. 1.

Gridiron 46 24.

Loin 26 14.

Anterior 60 32. 1.

Total 186 100.

Grand total 2, 258 36 1.

All midrectus, midline, and paramedian incisions are arbitrarily grouped with the appropriate high incisions.

This was an upper abdominal incision used to connect wounds of entry and exit.
192 GENERAL SURGERY

that transverse incisions were of very limited value in war wounds of the

abdomen. There were two principal reasons for this opinion:

1. Vertical incisions permitted the extensions which were often necessary

to secure satisfactory access to injuries not diagnosed before the abdomen

was open.

2. Vertical incisions left the lateral and medial portions of the abdominal

wall free for separate incisions for colostomies. Exteriorization of the colon

was necessary in great many of these cases and was best accomplished through

another incision rather than through the surgical incision.

CLOSURES

Forty different methods of closure were used in the 2,258 laparotomy

wounds on which this chapter is based, the different techniques representing

the individual choices of the various surgeons. In general, these methods fell

into four large groups (table 26), with closure of the wound in layers by means

of catgut sutures supplemented by retention sutures comprising more than

two-thirds of the cases. Mass closure, which was utilized in only 252 cases,

was usually accomplished by means of heavy braided silk, steel wire, or doubled

silkworm gut.

In some of the cases classified as layer closures, the peritoneum was closed

with running suture of catgut, and the other layers were approximated with

retention sutures which incorporated skin, fascia, and muscle, or merely skin

and fascia. In some cases, interrupted sutures of silk or chromic catgut were

used in the anterior fascial layer, while the other layers were approximated with

through-and-through sutures. In some cases, the peritoneum was closed by

the usual running catgut suture, while nonabsorbable sutures were used in the

anterior fascial layer and retention sutures were placed by some one of the

usual techniques. When retention sutures were omitted, interrupted cotton

or silk sutures were used for all layers, including the peritoneal layer.

Table 26.—Distribution of wound dehiscences in relation to techniques of closure in

2,258 abdominal injuries

Method Cases Proportion Dehiscence Frequency

Layer closure: Percent Number Percent

Catgut, retention sutures,

Interrupted silk or cotton sutures in anterior

1, 536 68. 22 1.

fascia 333 14. 2.

No retention sutures 137 6.

Mass closure, through-and-through sutures only 252 11. 2.

Total 2, 258 100. 36 1.

The majority ofpatients in this category were submitted to exploration with negative findingsor had onlyminimal

lesions. For purposes of comparison, this group should therefore be excluded.
LAPAROTOMY INCISIONS AND CLOSURES 193

One variation in the technique of closure was the use of small gauze or

rubber drain, placed just beneath the anterior fascia and usually removed about

the third day after operation. Gauze or rubber drains were frequently placed

in the subcutaneous tissue, to maintain separation of the skin edges for or

days. Drainage of the incision was frequently carried out in contaminated

wounds. Sometimes the skin was left open; sometimes it was partially closed; and, in selected cases in which hollow viscera had not been perforated,

both subcutaneous and subfascial drainage were omitted, and it was sutured

primarily.

In spite of the wide variety of techniques of closure which they employed,

it was the general feeling of the surgeons in the group that there was no satisfactory substitute for accurate approximation of the various layers of the

abdominal wall, combined with some method of retention suturing that would

actually maintain wound closure. Mass closure, although it had real place

in the management of patients in precarious condition, invariably meant the

sacrifice of accurate layer approximation in the interest of saving time. As

rule, therefore, it was resorted to only when the condition of the patient on the

operating table was so serious that prolongation of the procedure seemed

likely to deny him his best chance for recovery. Under these circumstances, mass closure was thought to be entirely justified and definitely indicated.

WOUND DEHISCENCES

The 36 wound dehiscences observed in the 2,258 abdominal injuries on

which this analysis is based (1.6 percent) all occurred in forward hospitals in

1944 and 1945. If all the casualties could have been traced through the hospitals to which they were evacuated, the incidence might have been considerably

higher, as the following figures indicate: Of 250 patients who lived more than

days (out of 346 casualties with abdominal and thoracoabdominal injuries

operated on by surgeons of the group in 1943), 30 sustained wound dehiscences

after they were evacuated to general hospitals.

An analysis of these 36 cases reveals the following data:

The accidents happened from to 19 days after operation, the average

lapse of time being about days. Exploration of the abdomen had been negative in only one instance; all the other patients had sustained some sort of

intra-abdominal injury. The small bowel was injured 21 times, the colon 17,

the liver 9, the stomach 7, the kidney 4, the spleen twice, and the urinary bladder

twice (the figures are overlapping). The diaphragm was injured in cases, and

retroperitoneal hematomas were present in cases. The order of frequency of

visceral injuries thus coincided with the order of frequency in the entire series

of 3,154 cases (table 7, p. 92), which suggests that wounds to specific viscera

cannot be regarded as predisposing to wound disruption.

Report on the Surgery of Abdominal Wounds (unpublished data), submitted to the commandingofficer, 2dAuxiliary

Surgical Group, 14 April 1944.
194 GENERAL SURGERY

The precise cause of the accident was not evident in any of these 36 cases,

but the following conditions (multiple in instance) probably contributed to the

disruptions: Distention, in 10 cases; wound sepsis, in cases; excessive coughing,

in cases; vomiting, spontaneous fistula of the small bowel, delirium, and clostridial myositis which required removal of the entire rectus muscle, in cases

each; severe nutritional deficiency in cases; and spontaneous gastric fistula

and the use of the laparotomy incision for the colostomy, in case each.

All the principal methods of closure failed at least once in these 36 cases

(table 26), and most of them failed in several. Layer closure with nonabsorbable sutures of silk or cotton in the anterior fascia showed no superiority over

closure with catgut sutures. In fact, on the basis of the available figures

(table 26), the frequency was somewhat greater when nonabsorbable sutures

were used. The incidence of disruption, as might have been expected, was

higher for mass closure than for either of the two principal methods of layer

closure.

Retention sutures were used in the primary closure in 35 of the 36 cases.

In the single case in which they were omitted, running suture of plain catgut

was used in the peritoneal layer, the anterior fascia was closed with interrupted

sutures of chromic catgut, and Penrose drain was placed in the subfascial

space.

The figures concerning dehiscence in relation to the method of employing

retention sutures are of interest though of no statistical value (table 27). When

they were placed through the skin and the fascia (either as loop or figureof-eight), there were wound disruptions in each 100 cases. When they in- cluded the skin, the fascia, and the muscle, there were 2.1 disruptions in each

100 cases. When mass closure was employed, there were 2.4 disruptions in

each 100 cases. When, however, layer closure (closure of one or more layers,

with the skin usually left widely open) was combined with through-andthrough retention suturing, with all layers of the abdominal wall, including

the peritoneum, incorporated in the retention sutures, there was only disruption in each 480 cases (0.2 percent).

Table 27.—Distribution of wound dehiscences in relation to techniques of retention suturing in

2,121 abdominal injuries

Method Cases Proportion Dehiscence Frequency

Through skin and fascia 813

Percent

38.

Number

16

Percent

2. Through skin, fascia, and muscle 576 27. 12 2.

Through all layers of abdominal wall:

With layer closure 480 22.

With mass closure _______ 252 11. 2.

Total __ 2, 121 100. 35 1.

In ease of wound separation not included in this table, retention sutures werenot used.
LAPAROTOMY INCISIONS AND CLOSURES 195

Catgut was used for the layer closure in the majority of cases in which

this combined technique was employed. The through-and-through retention

sutures were inserted in one of two ways; They were either pulled up and tied

fairly snugly in the midline, or they were tied laterally over rubber tubes

placed on each side of the incision. In only one instance in this series did

possible mechanical intestinal obstruction result from the employment of this

technique. The obstructive signs in this case disappeared when the throughand-through sutures were released on the fifth postoperative day, and recovery

thereafter was smooth. The use of pulley sutures, either for mass closure or as method of retention suturing to supplement layer closure, produced almost uniformly poor

results in this series. Reports from general hospitals mentioned number of

cases in which strangulation of the tissues was followed by massive sloughs

and which usually required secondary wound closure.

Management

In of these 36 instances of wound dehiscence, the wound was taped

and no surgery was done. In 28 cases, secondary suture was carried out.

Silk through-and-through sutures were used in 16 cases, wire through-andthrough sutures in 11 cases, and silk figure-of-eight sutures in case. The

remaining patient died on the operating table before surgery could be started.

Two patients, one of whom had been treated conservatively and the other

by secondary suture, later presented small intestinal fistulas.

Causes of Death

There were deaths in these 36 cases, of which were apparently caused

by the wound dehiscence itself. One patient, as already noted, died on the

operating table, partly from shock and partly from the anesthetic. In one case,

fatal peritonitis followed retraction of colostomy (which had been exteriorized

in the laparotomy wound) into the peritoneal cavity. In one case, peritonitis

resulted from two leaking areas in the small bowel caused by trauma from the

through-and-through wire sutures used in the secondary closure. In one case,

death occurred hours after secondary suture; aspiration of vomitus during

anesthesia was followed by fatal pulmonary and bronchial edema. In the

remaining case, which was treated conservatively, death was the result of

acute mechanical intestinal obstruction.

Prophylaxis

The large number of wound dehiscences reported in 1943, to which reference has already been made, provoked serious consideration among the surgeons

of the 2d Auxiliary Surgical Group. The whole subject of wound closure was

studied, and special attention was given to measures which might prevent

future accidents. Analysis of the cases reported in 1943 revealed certain

See footnote 1, p. 193.
196 GENERAL SURGERY

practices which could be considered as possibly causative. Thus it was not

uncommon in the early experience in the North African theater to omit retention sutures in laparotomy wounds, even though the incisions were usually

closed in layers. It was also not uncommon to exteriorize damaged segment

of colon in the laparotomy incision rather than in separate small incision.

Finally, it was rather common practice to evacuate patients with abdominal

wounds prematurely (that is, before the optimal interval of 10 to 14 days),

even though evacuation necessitated long ambulance hauls over terrain that

was often rough. The policy of eliminating all of these practices unquestionably played part in reducing the incidence of wound dehiscence in 1944 and

1945.

No policy, however, and no technique could entirely prevent wound

dehiscence, to which there existed natural tendency in penetrating and perforating injuries of the abdomen. For this there were number of reasons:

1. Massive soiling of the peritoneal cavity, as the result of perforation of

hollow viscera, produced peritonitis, either chemical or bacterial, in large

proportion of cases and also resulted in heavy contamination of the laparotomy

incision. Clinical sepsis, with its deleterious effects on sound wound healing,,

not infrequently followed.

2. Prolonged nasogastric suction was essential in these injuries at time

when nutritional reserves were likely to be critically low.

3. The rather high incidence of pulmonary complications, especially during

the winter months, and the resulting severe and protracted cough often added

considerably to the strain on the abdominal incision.

4. The tactical situation was sometimes such that patients with abdominal

injuries had to be evacuated soon after operation, in spite of the undesirability

of the practice. The combined effect of these various uncontrollable factors

explains why even in 1944 and 1945, when conscientious efforts were made to

prevent it, the incidence of wound dehiscence was far higher among military

casualties with abdominal injuries than it would be in series of nontraumatic

abdominal operations in civilian life.

The measures employed to prevent wound disruption were multiple and, if they were to be effective, had to be instituted as soon as the incision was

made. The trauma of both incision and closure was kept to minimum.

Gross soiling and contamination of the incision were avoided in every possible

way. The Halstedian principles of tissue handling were sedulously employed

to prevent wound reaction, the absence of which favored uncomplicated wound

healing. Certain physiologic and chemical principles were also borne in mind:

The erythrocyte count was kept at million per cubic millimeter, or higher,

and the hemoglobin level was kept above 12 gm. percent. Plasma was given

in amounts of 250 cc. once or twice daily as long as Wangensteen decompression

was required. Vitamin was given parenterally over the same period and was

given orally as soon as feeding by mouth could be resumed. The patient was

evacuated with the retention sutures still in situ, and, during transit, additional

abdominal support was provided by binder, preferably of the scultetus type.
197

CHAPTER XIV

Penicillin and Sulfonamide Therapy

(2,410 Casualties)

James C. I)rye, M. D.

Prior to May 1944, patients with abdominal injuries were treated with some

one of the sulfonamide drugs, usually parenterally. At that time, penicillin

was introduced, and thereafter it became part of the routine of treatment.

The basis for this analysis is formed by 2,410 patients who received

sulfonamide drug, penicillin, or both agents. The series is selective in that it

excludes men who presented no intraperitoneal injury at operation, patients

who died on the operating table, and patients whose records were deficient in data concerning antibacterial therapy. Since the analysis was not undertaken

until the end of hostilities, no control series exists. For that matter, there would

have been small justification for withholding these presumably beneficial agents

from any wounded man in order to provide such controls.

METHODS OF ADMINISTRATION

Until penicillin became available, sulfadiazine sodium was given by the

intravenous route, usually in amounts of 2.5 gm. at 12-hour intervals. The

first dose was customarily given in the shock ward, as part of the routine of

resuscitation. After penicillin had become available in sufficient quantities to

be supplied in the division clearing stations, the first intramuscular injection

was given at that echelon. Doses in the field hospitals ranged from 5,000 to

25,000 units at 3-hour intervals.

Although crystalline sulfanilamide was available for intraperitoneal use

throughout the war, it was not used regularly by this route in the Mediterranean Theater of Operations, and the same was true of penicillin after it became

available. Some surgeons used either agent, or both, with fair regularity, and

most surgeons used one or the other in selected cases; the decision was always

individual. There was notable tendency to use the intraperitoneal route

whenever wounds were severe or contamination was extensive. Crystalline

sulfanilamide was used in doses of to 10 gm. and penicillin in doses of 50,000

units.

The postoperative use of both agents also varied with the practices of individual surgeons. Some used one or the other routinely; some only when

complications developed. Some preferred to employ both at the same time.

Sometimes one was discontinued in favor of the other. Dosages varied widely.
198 GENERAL SURGERY

CASE FATALITY RATES

Because of the variations in the use of the sulfonamides and penicillin,

as well as the variations in methods of administration and dosages, precise

statistical analysis of the cases in which they were employed was not possible.

The most practical means of determining their relative efficacy was to analyze

the case fatality rates in peritonitis.

The case fatality rate from all causes in the 2,410 cases in which one or the

other, or both, of these agents was used was 23.2 percent (560 deaths). There

were 422 deaths (24.4 percent) in the 1,732 cases treated in 1944 and 138

(20.4 percent) in the 678 cases treated in 1945. These rates closely parallel

the case fatality rates for the whole series.

One hundred and thirty-seven of the 560 deaths were caused by peritonitis

(table 28). These deaths cannot be properly discussed until they are broken

down into two categories. As is pointed out elsewhere (p. 127), two types of

fatalities from peritonitis were observed in abdominal injuries in World War II.

In the first, so-called contamination type, there was massive peritoneal soiling,

the casualties were in shock and did not respond to the usual measures of

resuscitation, and death occurred within the first 48 hours after operation.

In the second type of fatality, the patients presented the classical type of suppurative peritonitis. The clinical manifestations were those usually observed,

including fever, vomiting, abdominal tenderness, distention, and ileus. Death

from this variety of peritonitis commonly occurred between the 4th and 11th

postoperative days. In this analysis, no deaths were attributed to the classical

form of peritonitis if they occurred within the first days after operation.

Table 28.—Comparative case fatality rates from massive peritoneal contamination (shock)

and bacterial peritonitis in 2,jl0 abdominal injuries

In some cases in which peritonitis developed, the peritoneal infection was,

at the most, contributory cause of death, and antibacterial agents could not

have been expected to influence the final outcome. This group included the

patients who were moribund on admission to the hospital, those who died

from such accidents as aspiration of vomitus, those with serious intercurrent

Year Cases

Massive peritoneal

contamination Bacterial peritonitis

Deaths Case fatality rate Deaths Case fatality rate

1944 1, 732 58 3. 32 1.

1945 ___ 678 37 5. 10 1.

Total 2, 410 95 3. 42 1.
PENICILLIN AND SULFONAMIDE THERAPY 199

disease, and those with serious or fatal noninfectious extra-abdominal injuries.

No death in this group of cases was attributed to peritonitis in this analysis.

On the basis of these criteria of selection, the case fatality rate for the

classical type of peritonitis was found to be 1.7 percent, against 3.9 percent for

the contamination type (table 28).

In an unplanned investigation such as this, in which there is no control

series and complete statistical data are lacking, it would not be permissible to

draw anything beyond tentative conclusions concerning the possible benefits

of chemotherapeutic and antibiotic agents in abdominal injuries (tables 29 and

30). It would also not be permissible to attempt precise comparisons between

the effects of the sulfonamides and penicillin, chiefly because the advent of

penicillin coincided closely with two other events which greatly improved the

management, and therefore improved the prognosis, of battle-incurred abdominal injuries in the Mediterranean Theater of Operations. The first of these

events was the establishment of theater blood bank in Naples. The second

Table 29.—Influence of antibacterial therapy on comparative case fatality rates in 1,526 abdominal injuries

Deaths Case fatality rate

Therapy Cases

Total

From

peritonea] contamination

From

bacterial

peritonitis

Total

From

peritoneal contamination

From

bacterial

peritonitis

1944:

Parenteral sulfadiazine

alone or with intraperitoneal sulfanilamide 361 117 12 18 32. 3. 5.

Parenteral penicillin alone

or with intraperitoneal

penicillin 727 158 18 21. 2.

1945:

Parenteral sulfadiazine

alone or with intraperitoneal sulfanilamide

Parenteral penicillin alone

or with intraperitoneal

penicillin 438 97 10 22. 2.

Totals, 1944-45:

Parenteral sulfadiazine

alone or with intraperitoneal sulfanilamide 361 117 12 18 32. 3. 5.

Parenteral penicillin alone

or with intraperitoneal

penicillin 1, 165 255 28 21. 2.
200 GENERAL SURGERY

Table 30.—Influence of route of administration of antibacterial therapy on comparative case

fatality rates in 3,410 abdominal injuries

was the wide distribution, among the surgical teams, of portable machines for

anesthesia, which thereafter was much more efficient. The decrease in the case

fatality rates for abdominal injuries after the spring of 1944 therefore cannot

be attributed solely to the advent of penicillin but must be regarded, at least

in part, as reflection of these other benefits. Finally, there must be taken

into account the increasing experience of the surgical teams.

In addition to these major considerations, climatic and tactical factors

must be taken into account in the comparison of the relative effects of the

sulfonamides and penicillin in abdominal injuries. The sulfonamide-treated

cases were all observed in 1944, most of them in the first months of the year.

This particular period covered the fighting before Cassino and on the Anzio

beachhead. Conditions of weather and terrain and facilities for evacuation were

notoriously unfavorable during both campaigns. As rule, severe exposure

was commonplace, and the evacuation timelag was frequently prolonged. The

case fatality rate, which was markedly elevated at this time, was undoubtedly

influenced by both factors. The corollary of this reasoning is that the improvement which occurred later in 1944 and continued into 1945 cannot fairly be

attributed only to the greater efficiency of penicillin, and the figures (table 29)

must be interpreted in the light of these facts.

When penicillin was substituted for the sulfonamide drugs (table 29),

there was very slight reduction in the case fatality rate in peritoneal conDeaths Case fatality rate

Routes of administration Cases

Total

From

peritoneal contamination

From

bacterial

peritonitis

Total

From

peritoneal contamination

From

bacterial

peritonitis

1944:

Parenteral route only 635 131 20. 0. 0.

Parenteral and intraperitoneal routes 1, 097 291 49 27 26. 4. 2.

1945;

Parenteral route only 341 55 16. 2.

Parenteral and intraperitoneal routes 337 83 29 24. 8. 2.

Totals, 1944-45:

Parenteral route only 976 186 12 19. 1.

Parenteral and intraperitoneal routes 1, 434 374 78 35 26. 5. 2.

Penicillin or sulfadiazine.

Intraperitoneal sulfanilamide with parenteral sulfadiazine or penicillin, or intraperitonealand parenteral penicillin.
PENICILLIN AND SULFONAMIDE THERAPY 201

lamination but very considerable reduction in the rate in bacterial peritonitis.

The change in therapy, as already noted, occurred in May 1944. The case

fatality rate for all abdominal injuries fell from 32.8 percent in the first quarter

of 1944 to 22.4 percent for the April-December period (p. 216). This decrease

was disproportionately less than the decline in the case fatality rate observed in

peritonitis alone. It was the opinion of the surgeons of the 2d Auxiliary Surgical

Group that the decline in deaths from peritonitis was too marked and too

abrupt to be explained only by improvement in weather and combat conditions,

even in combination with increasing experience in the management of abdominal injuries. They therefore concluded, at least tentatively, that penicillin

was more efficacious than the sulfonamides in the prevention and treatment of

peritonitis secondary to war wounds of the abdomen.

The case fatality rates calculated according to route of use might seem to

suggest, on casual inspection, that deaths were more numerous when the combined parenteral-intraperitoneal method was employed than when the parenteral route alone was used (table 30). The conclusion would be completely

unjustified. Analysis of the individual cases which make up the series shows

that antibacterial agents were usually used by the intraperitoneal route only

when wounds were extensive and contamination was serious. The higher case

fatality rate therefore merely reflects the fact that these agents were used intraperitoneally only in the most severely wounded patients. Whether the rate

would have been even higher if this route had not been employed it is, of course,

not possible to say.

378327°—56 15

203

CHAPTER XV

Postoperative Complications: Prophylaxis

and Therapy

James C. Diye, M. D., and W. Philip Giddings M. D.

The records of the 2d Auxiliary Surgical Group are not complete in respect

to postoperative complications and are particularly fragmentary in respect to

less severe and nonfatal types. For these deficiencies, there are two explanations. The first is, as already pointed out, that the circumstances of war did

not permit the keeping of clinical records which were complete and accurate in

all details. The second is that many postoperative processes which in civilian

practice would be regarded as complications were so frequent in battle wounds

that they came to be regarded as almost implicit in certain injuries and after

certain operations. Such complications were seldom made matter of record.

That is why, in this series, it is impossible to make any accurate determination

of mild incisional sepsis, ileus of brief duration, pulmonary complications of

minor severity, and similar processes.

Early in the war, it was found that premature evacuation of casualties

with abdominal injuries increased the incidence of wound dehiscence, ileus,

peritonitis, and other major postoperative complications. The trauma and

discomfort of ambulance transport over rough roads, as well as the loss of

continuity of treatment in critical stage of convalescence, made these results

almost inevitable. It therefore became the policy that, whenever the tactical

situation permitted, patients with abdominal wounds should not be evacuated

earlier than the eighth day after operation (p. 85). In practice, evacuation

was delayed for 14 days in great many cases, and, if the injuries were unusually severe, it was sometimes delayed for as long as 30 days. The tactical

situation frequently prevented complete adherence to this policy, but the majority of the patients in this series were nevertheless held in forward hospitals

from to 14 days. It was the emphatic opinion of the surgeons of the group

that this policy, quite as much as any other consideration, produced the low

morbidity and case fatality rates generally observed in casualties with abdominal injuries in World War II.

Only 3,090 of the 3,154 records used in this analysis were sufficiently

complete to permit an analysis of the presence or absence of postoperative

complications. All of the complications discussed are also discussed under

special headings in other sections of this report. In spite of the inevitable

repetition, however, it was thought worthwhile to bring them together at this

point and comment upon them briefly.
204 GENERAL SURGERY

PULMONARY COMPLICATIONS

In spite of the known frequency of postoperative pulmonary complications, their recorded occurrence is less accurate than that of other complications in this series (table 31). In addition to the general reasons already

listed, still other reasons can be advanced to explain this situation: An accurate diagnosis of pulmonary conditions was likely to be difficult under field conditions. Even though an adequate physical examination was sometimes impossible, the diagnosis usually had to be based entirely on physical findings.

Postoperative roentgenograms of the chest were seldom made. When they

were, they were usually unsatisfactory because of the limited technical facilities in forward hospitals. In many other instances, examination was precluded by the precarious state of the patient or by the presence of heavy

plaster casts.

Sputum examinations were seldom made, because bacteriologic facilities

were not easily available. For these various reasons, the statistics tabulated

are admittedly deficient. They are, however, in accord with mature, clinical

impressions, and the trends which they indicate can be accepted as accurate.

Pulmonary complications were frequent after operation in patients with

abdominal injuries, as might have been expected, because conditions in the

theater favored the development of such complications. large proportion

of the casualties occurred during the period of the year which is cold and wet

in Italy (p. 216). Troops fought in mud and were almost constantly exposed

to heavy rainfall or snow from October through March. As result, more

casualties were received with established respiratory infections during this

period than during the summer months, the common cold following the same

seasonal trend in Italy as it does in the temperate zones of the United States.

Furthermore, many patients passed the critical hours immediately before and

after operation in damp tents (fig. 26), in environmental temperatures of 60°

or 50° F., or lower. All of these circumstances combined to cause high

incidence of infectious pulmonary complications, particularly during the

winter months.

The recorded case fatality rate, almost 40 percent (table 31), is further

proof that only the most severe pulmonary complications were listed. It was

the general impression that their severity, as well as their frequency, was

greater during the winter than during the summer, and the case fatality rates

for the two periods lent support to this opinion. Available figures, however

(table 31), suggest that the presence of associated chest wounds did not appreciably affect either the frequency or the case fatality rate of the usual infectious

pulmonary complications which occurred in abdominal casualties.

There seems no doubt that most of the infectious complications were

atelectatic in character and that they arose on the basis of bronchitis or some

other respiratory infection already present at the time of operation. In

other words, they were those which might be expected to develop in patient
POSTOPERATIVE COMPLICATIONS 205

Figure 26.—Conditions of surgery in field hospital in Italy in winter of 1944-45.

Resuscitation tent.

population of combat troops carrying heavy prewounding load of endemic

respiratory infections.

The only two instances of lung abscess, both of which were fatal, were

not associated with thoracic injuries. Empyema, on the other hand, was associated with chest injuries in 25 of the 29 recorded cases, 11 of which were fatal.

All fatalities which occurred in the instances of bile empyema were associated with thoracoabdominal wounds.

The fact that hydropneumothorax was recorded only 91 times in the 3,090

abdominal injuries suggests that note was taken of only the more serious cases,

in which repeated thoracenteses were necessary. The incidence was undoubtedly much higher. In most instances, to aspirations of the pleural cavity

were sufficient.

The actual incidence of both pulmonary edema and the so-called traumatic

wet lung is known to be considerably greater than the recorded figures indicate

(table 31). Pulmonary edema was readily precipitated in severely wounded

patients, especially in those in shock, if intravenous fluids were given in too

great quantities or too rapidly.

As was pointed out in the discussion of the multiplicity factor, the incidence

of postoperative pulmonary complications tended to rise with the increase in

the number of viscera injured, the observation being, however, of clinical rather

than statistical significance (table 32). The explanation was simple; the more
206 GENERAL SURGERY

Table 31.—Distribution of recorded pulmonary complications in 3,090 abdominal injuries

Table 32.—Influence of multiplicity factor on development of infectious thoracopulmonary

complications in 2,831 abdominal injuries

severely wounded patients were the ones most likely to present stagnation of

the tracheobronchial secretions, and atelectasis and pneumonia were therefore

more likely to develop in them.

Prophylaxis and therapy.—The prophylaxis and therapy of pulmonary

complications were both based on few fundamental principles. The most

efficient prophylaxis consisted of expertly administered anesthesia, with parComplication

With thoracoabdominal

or associated chest

wounds (965)

Without thoracoabdominal or associated

chest wounds (2,125)

Total

Cases Deaths Cases Deaths Cases Deaths

Hydropneumothorax __ 86 91

Atelectasis 23 11 37 60 16

Bronchopneumonia __ __ 12 39 19 51 25

Empyema 25 29 11

Pulmonary embolism 17 16 22 21

Pulmonary edema 16 11 22 15

Bronchopleural fistula 18 18

“Consolidation” 14

Wet lung 13

Aspiration of vomitus

Lobar pneumonia

Bile empyema

Blast

Bronchitis __

Lung abscess

Other

otal 199 66 161 77 360 143

Associated wounds include nonpenetrating trauma to the chest wall.

Item

Number of organs involved

Total cases

One Two Three Four Five

Cases 1, 348 1, 014 350 96 23 2, 831

Complication 87 55 40 11 196

Incidence (percent) __ __ 6. 5. 11. 11. 13. 7.
POSTOPERATIVE COMPLICATIONS 207

ticular attention to careful tracheobronchial toilet at the close of the operation.

Catheter aspiration or aspiration bronchoscopy was part of the established

routine in patients with thoracoabdominal injuries and associated chest wounds

and was frequently carried out in patients with other types of injuries, just

before they were taken off the operating table. Dressings were applied so as

not to restrict the respiratory excursion.

After operation, the first essential was to maintain clear tracheobronchial

tree. For this, frequent changes of position and frequent coughing were essential. In patients with multiple wounds, particularly those in large, bulky

casts, changes of position were not always easy to accomplish. Firm manual

pressure was of great aid to patients endeavoring to cough, and many learned

to support their own incisions.

If the patients refused to cough or could not cough satisfactorily, tracheobronchial suction was again resorted to. If it was not effective, bronchoscopy

was employed without delay. Oxygen therapy was employed according to the

indications. All of these measures, which were standard practice, approximate

the usual methods of prevention of postoperative complications in civilian

practices.

Patients with wet lungs, who required repeated tracheal aspirations to

clear the airways effectively, were usually treated with tracheal catheter in

situ. It was aspirated at regular intervals, and oxygen was usually administered in the interim, sometimes under slight pressure.

Morphine was administered in as small doses and as infrequently as

possible, to prevent depression of the respiration. The amount necessary could

frequently be reduced by the use of nerve blocks for the relief of pain. Some

surgeons of the group made it practice to block the intercostal nerves from

within, while they were exposed in thoracoabdominal wounds, or to perform

nerve block before the patient was removed from the operating table.

Pulmonary edema could usually be prevented by care in the administration of intravenous fluids. Hypodermoclysis was occasionally resorted to

instead of infusion, but the method was not looked upon with favor because

of the possibility of introducing anaerobic organisms. In few instances in

which pulmonary edema appeared soon after operation, venesection was done, with apparent benefit. Preparations of digitalis by the parenteral route also

seemed of benefit. These measures were resorted to on empirical grounds.

Atropine was used according to the indications.

Although penicillin and sulfadiazine were given routinely as part of the prevention and treatment of pulmonary complications, pneumonias still developed

in patients who were adequately treated by these agents. It was thought,

although this was merely clinical impression, that patients with pneumonic

processes who did not respond to chemotherapy and antibiotic therapy, or

who died under proper treatment, might have the so-called atypical variety of

pneumonia.
208 GENERAL SURGERY

NONPULMONARY COMPLICATIONS

Shock.—Shock was the most important of all postoperative complications

(p. 119). Its correct incidence is undoubtedly greater than the figures suggest.

The role it played in the case fatality rate in these 3,090 cases is shown by the fact that 64 percent (472) of all the deaths (737) were attributable to it. It was

the most frequent cause of death in the first 48 hours after operation, and it

was almost invariably fatal in the small number of patients in whom it persisted

after this time.

The essentials of management were blood replacement, oxygen by nasal

catheter or the Boothby mask, and careful analgesic medication administered

with due care to prevent further depression. These measures were instituted

as soon as the patient was seen and were continued after operation as long as

necessary. When morphine was indicated, the dose was kept small, and it

was preferably administered by the intravenous route.

Peritonitis.—Peritonitis of some degree existed priori in all patients

with perforations of hollow viscera. Its frequency can be estimated from the

fact that injuries of this type were present in more than half of all cases in the

series. The true ante mortem incidence of invasive bacterial peritonitis is

not known. It existed in all degrees of virulence, sometimes in so mild form

that the diagnosis was merely academic and sometimes, at the other extreme,

in such overwhelming contamination and infection that the patient died within

few hours. The great majority of patients who presented the usual clinical picture of ileus, abdominal tenderness, and fever recovered uneventfully, but

91 (12.3 percent) of all the deaths were due to this cause. The most effective

measures in both prevention and therapy were decompression of the gastrointestinal tract and routine parenteral administration of sulfadiazine and

penicillin.

Abdominal distention.—Abdominal distention, whether as manifestation

of peritonitis or from other causes, was uncommon in this series, undoubtedly

as the direct result of the routine practice of postoperative decompression of the gastrointestinal tract. Two- or three-bottle siphonage suction was used,

by the Wangensteen method; discarded 1-liter flasks originally used for intravenous solutions were excellent for this purpose. The tube was usually left

in place from to days. It was essential to leave it in situ until there was

definite evidence of return of intestinal tonus and motility; most instances of

distention followed its premature removal. This simple method of preventing and controlling abdominal distention and subsequent ileus was chiefly responsible for the low incidence of complication which, with its sequelae, had plagued military surgeons in earlier wars.

Intestinal obstruction.—Mechanical intestinal obstruction was recorded in

21 cases, in all but instance in patients with wounds of the small intestine

(p. 250). The figure is probably correct; the condition is too serious complication to be overlooked. Operation was performed in only patients, all of

whom survived; there were deaths in the remaining 18 cases. Although
POSTOPERATIVE COMPLICATIONS 209

operation seems to have been withheld in some of the fatal cases because the

patients were in precarious condition, review of the records suggests that

some of these lives might have been saved by more aggressive policy of

surgical intervention.

Incisional sepsis.—Minor degrees of incisional sepsis, which were seldom

recorded, were not uncommon. Major sepsis was infrequent, the 32 recorded

cases representing approximately percent of the whole series.

The best method of preventing wound infection was found to be the

routine drainage of subcutaneous tissues. It became the established practice

to accomplish this by the following technique: thin strip of fine-mesh gauze

or small bandage was laid longitudinally in the incision, before the skin was

closed, so as to keep the cutaneous margins and subcutaneous fat separated.

The skin sutures were then tied loosely across it. The gauze was left in place

until the second or third day. It was the clinical impression that drainage of

subcutaneous fat, which was particularly vulnerable to infection, materially

expedited healing by first intention.

Because the incisions used for abdominal wounds were almost always potentially infected, it was necessary to change the dressings and inspect the

wounds more frequently than is customary in civilian practice. Surgical

drainage was instituted promptly whenever suppuration developed.

Wound dehiscence.—The incidence of wound dehiscence was higher in

this series than in civilian practice, for reasons outlined elsewhere (p. 196).

Prompt resuture was the treatment of choice.

Gastrointestinal fistula.—The 23 instances of gastrointestinal fistula recorded in this series represent relatively small incidence in view of the large

number of perforations of hollow viscera. It is likely that additional fistulas

were observed after the patients were evacuated, since this is frequently

somewhat delayed development.

Gastrointestinal fistulas, while they did not represent immediate emergencies, were considered an indication for priority of evacuation to fixed hospitals, where more adequate therapeutic facilities were available than in field

and evacuation hospitals. The basis of treatment was to provide the patient

with maximum nutritional support and to employ gastrointestinal decompression whenever this measure was indicated.

Intraperitoneal abscess.—The 15 subhepatic or subphrenic abscesses and

the pelvic abscesses recorded in this series represent an incidence of slightly

less than percent. This is not excessive, in view of the type of wounds

treated and the fact that this is another complication which probably presented

itself in number of other cases after evacuation. The treatment was surgical

drainage.

Anaerobic infections.—Clostridial infections of the abdomen were encountered after operation only eight times. Death occurred in every instance.

In five cases, the retroperitoneal space was infected. In the other three cases,

the process involved the abdominal wall, and en bloc excision of the entire

rectus abdominis muscle on one side was followed by wound dehiscence.
210 GENERAL SURGERY

Treatment always included massive doses of polyvalent anti-gas-gangrene sera,

in addition to penicillin and sulfadiazine in large doses.

Secondary hemorrhage.—Only eight instances of secondary hemorrhage

were recorded. There is no doubt that moderate bleeding, such as might

occur after removal of pack from the liver, took place in many other cases

but was not recorded. In of the cases, the bleeding was from remote

vessels, in instance an intercostal artery and in instance the femoral artery.

In the other cases, the hemorrhage was from sutured gastric wounds (p. 230).

These six cases comprise the only recorded instances of gastrointestinal

bleeding, which is probably to be explained by the fact that, although very

large number of gastrointestinal repairs were carried out, the operations were

chiefly on the small intestine, in which suture lines are less likely to bleed

than suture lines in the colon. The policy of exteriorization of wounds of the

colon thus not only protected the patient against necrosis and leakage but

apparently reduced the risk of postoperative hemorrhage as well.

Thromboembolism.—The 22 instances of proved or suspected pulmonary

embolism, 21 of which were fatal, must be considered as merely an approximation, since autopsies were not performed in at least 40 percent of all deaths.

Nonfatal emboli undoubtedly occurred, but they were either not diagnosed

or not recorded. Nonfatal thrombophlebitis and phlebothrombosis were

recorded only five times but were probably much more frequent.

In the majority of cases in which emboli were shown to have originated

in the veins of the leg, there had also been wounds in the involved extremities.

In one instance, the autopsy showed the source of the embolus to be the right

external and common iliac veins. This particular patient had sustained

wound of the pelvis, with perforation of the bladder and extensive extraperitoneal trauma, and the surgeon, because of the evidence of severe damage

near the great vessels in the right side of the pelvis, debated at operation the

propriety of prophylactic interruption of the right common iliac vein, even

though it had not been directly traumatized. Unfortunately, he did not act

affirmatively on his premonition of trouble, and the man lost his life.

Prophylactic or therapeutic interruption of the femoral veins was employed

only occasionally in this series of abdominal injuries. This prophylactic

procedure should probably have been employed more frequently, in view of

the apparent tendency for an embolism to arise in wounded extremity,

especially when an associated abdominal wound increased the hazard. This

was particularly true when, as was usually the case, the limb had to be immobilized in plaster of paris, which not only compounded the risk of thromboembolism but also precluded frequent examinations for the detection of postoperative phlebothrombosis. The case history just related also indicates the

importance of giving serious consideration to ligation of the great veins of the

pelvis when trauma to adjacent tissues has occurred.

Since the anticoagulant drugs (heparin, Dicumarol (bishydroxycoumarin,

U. S. P.)) were not available in field hospitals, no comment can be made on

their efficacy in the treatment of thromboembolism. It can be said, however,
POSTOPERATIVE COMPLICATIONS 211

that in many abdominal injuries their employment would be both difficult and dangerous. They would certainly be contraindicated in wounds of the

liver or in associated wounds of the soft tissues, lung, or head, because of the risk of hemorrhage. Even in future wars, it is doubtful that heparin could be

made available in adequate quantities and equally doubtful that adequate

facilities could be provided for the use of Dicumarol under field conditions.

For these reasons, if needless fatalities from pulmonary embolism are to be

prevented, it would seem that the military surgeon of the future must be well

versed in the indications for, and techniques of, prophylactic interruption

of the femoral veins.

Anuria.—Anuria (posttraumatic renal failure, lower nephron nephrosis,

pigment nephropathy) was recorded in 36 cases in this series, 35 of which were

fatal. Very little was known about this complication early in the war, and

there is no doubt that the diagnosis was overlooked at that time. With

increasing experience, however, surgeons became aware of its frequency and

its dangers and were even able to predict that it might develop in certain

cases.

There were four major warning signs of impending renal failure:

1. While it was insidious in onset and usually could not be diagnosed

positively until the third or fourth postoperative day, it was particularly likely

to occur in the most severely wounded men, particularly when shock had been

profound and of long duration. Earlier than the third day, renal failure

could not be distinguished from the physiologic oliguria which accompanied

shock and which might persist for 48 hours after operation.

2. Renal failure was possibility whenever diuresis did not occur at the

end of this time and the patient, if he was out of shock, continued to be oliguric.

It was thus ofprime importance to measure the daily volume of urine accurately.

Once shock had been controlled and the blood pressure was tending to normal

level, 24-hour output of urine of less than 700 cc. was an ominous sign.

3. Hypertension was the next warning sign. With developing renal

failure, there was usually slow increase in the blood pressure, which sometimes

climbed to 180/120 mm. Hg.

4. Azotemia was another sign of impending trouble. It was not uncommon immediately after operation, when the nonprotein nitrogen level of the

blood might reach 80 mg. percent. Usually, however, the value returned to

normal on or about the second postoperative day, when diuresis occurred.

Persistent or increasing azotemia after this time usually meant impending

anuria. The nonprotein nitrogen of the blood was readily determined under

field conditions by the copper sulfate method.

The treatment of renal failure was chiefly under the direction of the Board

for the Study of the Severely Wounded, as research project, and extensive

details are contained in the report of that group. Results were disheartening.

While management was not standardized, the general plan was to restrict

Medical Department, United States Army, Surgery in World War II. The Physiologic Effects of Wounds. Washington: U. S. Government Printing Office, 1952.
212 GENERAL SURGERY

fluid allowances to 1,000 cc. or less for the 24-hour period, this being the

minimumrequired to compensate for insensible fluid losses. Salt was withheld

entirely. The purpose of these restrictions was to prevent the pulmonary

edema which was common in these cases. The urinary output was accurately

measured by means of an indwelling catheter. Diuretics, including ethanol

(5 percent) by vein, were tried but proved of little help. Alkalinization of the

urine with salts of lactic acid was also tried but was later abandoned as useless

and dangerous; renal block prevented the desired effect, and serious alkalosis

resulted. Peritoneal lavage was equally ineffective.

Miscellaneous complications. —Other complications, most of which were

fatal, were recorded only occasionally. According to the clinical charts,

urinary fistula occurred times; fat embolism, times; acute gastric dilatation, times; and vesicorectal fistula, acute noncontagious parotitis, acute nonspecific orchitis, encephalomalacia following ligation of the common carotid

artery, meningitis secondary to spinal cord injury, cerebral infarct, anaphylactic shock following the use of intravenous protein hydrolysate, cachexia

associated with ileostomy, and air embolism, in case each.
213

CHAPTER XVI

Factors of Mortality

W. Philip Giddings M. D., and Luther H. Wolff M. D.

The most dreaded complication of abdominal wounds inWorld War was

sepsis, which usually took the form of peritonitis. Sepsis and hemorrhage were

apparently the major causes of postoperative deaths in that conflict. Shock

was not prominent cause. When it is recalled, however, that in World War

patients were frequently selected for surgery according to their chances of

survival, and that forward hospitals maintained so-called moribund wards for

the care and comfort of the hopelessly wounded, this is easily understood.

In this series of abdominal injuries sustained in World War II, postoperative sepsis caused only 91 deaths, 12.3 percent of the total number (table

33), and postoperative hemorrhage was not at all common. Shock, on the

other hand, was predominant cause of death, being responsible for 64.0

percent of all the fatalities. This is an index of the penalty paid, in terms of

surgical mortality, for adherence to the policy of offering to every casualty the

possible benefits of operation.

The lack of selection of patients for surgery (p. 87) inevitably led to

certain increase in the number of surgical deaths, especially during the induction

of anesthesia and in the course of operation. In almost none of the 756 recorded

fatalities, however, was it thought that surgery in itself had been responsible for

the fatal outcome. On the contrary, in practically every fatal case the feeling

was that death would surely have occurred if operation had not been undertaken. Moreover, gratifyingly large number of even the most critically

wounded men survived their injuries because they were operated on; they

would certainly have died if surgery had been denied them. Many of them,

although they were gravely ill for the first few days after operation, had, so far as

is known, no disabling or crippling sequelae. Of the 3,154 casualties with

abdominal wounds operated on by the 2d Auxiliary Surgical Group during 1944

and 1945, very large number were saved from certain death by surgery, and

most of them were left with no significant physical abnormalities.

It is important to emphasize again that the 756 deaths known to have

occurred in this series are only those which occurred in forward hospitals, in

which urgent initial surgery was performed and in which the usual postoperative

stay was to 14 days, with range of to 30 days. Additional deaths undoubtedly occurred in installations farther to the rear, though the exact number

is not known, followup of these patients having proved impractical (p. 85).

The MedicalDepartment of the United States Army in the World War. Washington; U. S. Government Printing

Office, 1927, vol. XI, pt. 1, p. 451.
214 GENERAL SURGERY

Table

33.-

—Distribution

of

'primary

causes of

death

according to

time

of

death

in

737

abdominal

injuries

On operatingtable

Postoperative day

Propor- tion

of

fatal

cases

Cause

Day

of

operation 1st

2d

3d

4th

5th

6th

7th

8th

9th

10th

11th

12thand later

Total

83

268

118

472

Percent 64.0

Thoracopulmonary

(all).

20

15

14

10

97

13.

20

13

10

10

91 35

12.3

12

1.6

30

4.1

86

277

132

51

45

35

32

20

19

12

11

737

100.0

11.7

49.3

67.2

74.

80.2

84.9

89.3

92.0

94.6

96.2

97.3

98.2

98.5

100.0

Nineteen

cases

in

which

the

data

on

these

points

were

incomplete

are

excluded

from

this

table.
FACTORS OF MORTALITY 215

It is thought that an additional percent (approximate) of the patients in the

entire series of 3,154 cases died in forward hospitals but were unreported, and

it should therefore be borne in mind that the rates cited throughout this report

are actually somewhat lower than the true rates.

Although factors of mortality are discussed under various other headings

throughout this report, it seems profitable to comment upon them again under

general heading.

GENERAL CONSIDERATIONS

Type of wound.—The gross case fatality rate for the 2,315 cases in this

series in which the injuries were confined to the abdomen was 23.2 percent, and for the 839 thoracoabdominal injuries, 26.2 percent (table 6, p. 91). There was

some improvement in the rates in both categories as the war progressed, more

notably in thoracoabdominal injuries, as the result of the teaching and example

of the thoracic surgical teams. In this type of wound, the case fatality rate fell

from 28.2 percent in 1944 to 20.0 percent in 1945. The general improvement in the whole series can be explained on several valid grounds; (1) The increasing

experience of the surgeons who cared for the casualties, (2) the advent of

penicillin, and (3) the establishment of theater blood bank.

Site of hospitals.—The discrepancy (table 5, p. 89) between the case

fatality rate in field hospitals (24.3 percent) and in evacuation hospitals (15.1

percent) is readily explained by the fact that the farther forward military

hospital was located the greater was the number of severely wounded who

survived to reach it and the more serious was their surgical risk. The significance of the multiplicity factor in this connection has been discussed elsewhere

(p. 110). Among the men who died in field hospitals were many who were

mortally wounded but who were operated on because of the theater policy,

which was based on the conviction that surgery offered the best chance of

survival to all casualties with abdominal wounds.

Age.—In the military-age group (roughly 20 to 40 years), there was

slight but steady rise in the case fatality rate as age increased, ranging from

20.5 percent in the first 5-year group to 26.9 percent in the last (table 34).

Deaths before and after the military age period occurred, for the most part,

in civilians, and the higher rates are to be explained by the unfavorable reaction

of young children and aging persons both to injury and to subsequent surgery.

Civilians were often brought to treatment late, and their physical state was

generally poorer than that of American troops. The large group of patients

whose age was not recorded and large proportion of whom died consisted

chiefly of civilians and prisoners of war, and the lack of data is explained by

linguistic difficulties.

Shock.—The case fatality rate of these abdominal injuries was in proportion to the state of shock in which the patients were admitted (p. 121). It was

18.2 percent among patients not in shock or in minimal shock and 66.4 percent

among those in profound shock (table 18, p. 121).
216 GENERAL SURGERY

Tablb 34.—Distribution of injuries and deaths according to age in 3,154 abdominal injuries

Season.—It was repeated clinical observation that casualties received

at field hospitals during the cold, wet winter months were likely to be in

more severe state of shock than men with comparable wounds during the summer months. Their poorer status was undoubtedly caused, at least in part,

by exposure and by difficulties (and consequent slowing) of transportation.

In addition, infectious pulmonary complications were almost third more

frequent in the winter, when chronic bronchitis and tracheitis seemed almost

universal among frontline infantrymen (p. 204).

These circumstances were reflected in the difference in the case fatality

rates for the winter months (October through March) and the summer months,

which were, respectively, 27.4 and 19.9 percent (table 35). The casualties for

August 1944 were lower in actual numbers than for any other month (fig. 15,

p. 90), but the case fatality rate showed rise. The explanation is that most

of the injuries were incurred during the landings in southern France, when

some delay in the establishment and operation of hospital facilities was inTable 35.—Seasonal distribution of cases and deaths in 2,332 abdominal injuries (1944)

Age (years) Cases Deaths Case fatality rate

through 20 707 164 23.

21 through 25 987 202 20.

26 through 30 591 139 23.

31 through 35 250 60 24.

36 through 40 78 21 26.

Over 40 42 18 42.

Not stated 499 152 30.

otal 3, 154 756 24.

Months Cases Deaths Case fatality rate

January-March 430 141 32.

April-June 470 91 19.

July-September 503 103 20.

October-December 929 232 25.

Total 2, 332 567 24.
FACTORS OF MORTALITY 217

evitable. sharper peak in the case fatality rate during February 1944 can

be explained by similar difficulties in the early phase of the operation on the

Anzio beachhead.

SPECIAL FACTORS OF MORTALITY

It has already been noted that when these 3,154 abdominal injuries were

studied as whole and the case fatality rate was plotted against the time

interval from wounding to operation (timelag), the inimical effect of delay was

surprisingly slight (fig. 20, p. 104). This was contrary to expectations and was

not in accord with clinical observations.

The explanation was found in the multiplicity factor (p. 105). An analysis

of cases from the standpoint of the number of organs injured revealed an

almost arithmetical increase, of approximately 15 percent, in the case fatality

rate with each additional viscus injured (fig. 21, p. 108). The rate rose from

7.5 percent when there was no visceral damage and 14.9 percent when only

single viscus was injured to 100 percent when organs were injured.

When the cases were analyzed in exclusive categories from the joint

standpoint of the multiplicity factor and the timelag (table 9, p. 106), it became

apparent that the prognosis was gravely affected by prolonged timelag. In

univisceral injuries, the case fatality rate was 10.1 percent for the first hours,

14.8 percent for the second, and 16.6 percent for the third. At the end of

36 hours, the rate was 26.4 percent. The cases in other categories of multiplicity followed essentially similar patterns of increase.

Superficially, the case fatality rate did not seem to be materially affected

by the presence of coincidental extra-abdominal wounds. Here again, however,

different conclusion resulted when the multiplicity factor was taken into

account. When the analysis was made from this standpoint, there was an

average increase of approximately 3.9 percent in each category in the presence

of associated wounds (fig. 23, p. 116).

Multiplicity of injuries was also found to influence the case fatality rate

when the calculations were made on the type of organ injured (p. 95) and the

particular organ injured (table 36). Rates for special organs are discussed in

detail under the appropriate headings, but it should be emphasized here that

the most reliable conclusions concerning the lethality of wounds of individual

organs are obviously drawn from data relating to univisceral wounds. The

type of organ injured definitely influenced the case fatality rate, univisceral

injuries of hollow viscera being more lethal (17.4 percent) than those of solid

viscera (11.1 percent).

It is unfortunate that figures are not available to permit detailed comparisons, on the basis of the number of viscera injured, of the abdominal injuries

treated by the 2d Auxiliary Surgical Group and other recorded series. Such

comparisons as are possible are presented in table 37.

378327°—56 16
218 GENERAL SURGERY

Table 36.—Case fatality rates according to viscus wounded in 3,154 abdominal injuries

Table 37.—Case fatality rates of visceral wounds in various recorded series of abdominal injuries

Organ injured

Univiseeral wounds Multivisceral wounds Total

Cases Deaths

Case

fatality

rate

Cases Deaths

Case

fatality

rate

Cases Deaths

Case

fatality

rate

Stomach 42 12 28. 374 157 42. 416 169 40.

Duodenum 116 67 57. 118 67 56.

Jejuno-ileum 353 49 13. 815 296 36. 1, 168 345 29.

Colon only 251 57 22. 816 329 40. 1, 067 386 36.

Rectum only 64 14. 52 18 34. 116 27 23.

Colon and rectum 13 46. 26 14 53. 39 20 51.

Liver 339 33 9. 490 191 39. 829 224 27.

Gallbladder 0) 53 16 30. 53 16 30.

Pancreas 100. 61 34 55. 62 35 56.

Spleen. 100 12 12. 241 73 30. 341 85 24.

Kidney 56 16. 371 146 39. 427 155 36.

Ureter.. 26 11 42. 27 11 40.

Bladder 21 134 46 34. 155 46 29.

Great vessels 62. 67 50 74. 75 55 73.

Total 1, 238 187 15. 1, 916 569 29. 3, 154 756 24.

Case fatality rate not applicable.

Organ injured Series Cases Deaths Case

fatality

rate

Stomach

[World War I, American

World War II:

144 99 69

British _, 29 14 48

2d Auxiliary Surgical Group 416 169 41

Duodenum

[World War I, American

World War II;

10 80

British

2d Auxiliary Surgical Group 118 67 57

Jejuno-ileum

[World War I, American

World War II:

272 205 75

British 206 99 48

2d Auxiliary Surgical Group 1,168 345 30

Colon,,

[World War I, American

World War II:

222 171 77

British __

160 86 64

2d Auxiliary Surgical Group 1,106 406 37

The rates listed are not strictly comparable, since the statistics for the 2d Auxiliary Surgical Group cover only forward hospitals. The American figures for World War are from The Medical Department of the United States Army

in the World War (Washington: U. S. Government Printing Office, 1927, see vol. XI, pt. 1, p. 65) The British figures

are from the Western Desert combined series (628 cases) reported by W. H. Ogilvie in Abdominal Wounds in the Western

Desert (see Surg., Gynec. Obst. 78: 225-238, March 1944).
FACTORS OF MORTALITY 219

Table 37.-—Case fatality rates of visceral wounds in various recorded series of abdominal injuries —Continued

TIME AND CAUSE OF DEATH

Three hundred and sixty-three of the 737 deaths in this series (49.3 percent) in which these data were available for analysis occurred on the day of

operation (table 33). Eighty-six patients died on the operating table, four of

them during the induction of anesthesia and the remainder during the procedure

or within 10 minutes of its conclusion. The remaining 227 casualties in this

group died within 24 hours after operation. Almost three-quarters of all the

deaths occurred within 72 hours of operation. Thereafter, the number decreased with each succeeding day. The preponderance of fatalities during

operation and within the immediate postoperative period is clear index of the

severity of the wounds.

The majority of deaths which occurred within 72 hours of operation were

ascribed to shock, which accounted for 472 (64.0 percent) of the 737 deaths

available for analysis from this standpoint. Included in this group of fatalities

are 64 deaths in which the principal cause of shock was acute hemorrhage, as

well as smaller numbers caused by shock attributable to severe peritoneal conOrgan injured Series Cases Deaths Case

fatality

rate

Eectum ..

World War I, American

World War II:

102 48 47

British __ 47 17 36

2d Auxiliary Surgical Group 155 47 30

Liver

fWorld War I, American

World War II:

258 173 67

British 78 32 41

2d Auxiliary Surgical Group 829 224 27

Gallbladder

fWorld War I, American 11 64

British 20

2d Auxiliary Surgical Group 53 16 30

Pancreas

fWorld War I, American

World War II;

100

2d Auxiliary Surgical Group 62 35 57

Spleen

fWorld War I, American

World War II:

51 34 67

British 32 16 50

2d Auxiliary Surgical Group 341 85 25

Kidney. ...

fWorld War I, American

World War II:

129 75 58

British 30 15 50

I, 2d Auxiliary Surgical Group. 427 155 36

Ureter.

fWorld War I, American..

World War II:

50

2d Auxiliary Surgical Group 27 11 41

Bladder

fWorld War I, American _.

[World War II:

125 67 54

British 24 10 42

2d Auxiliary Surgical Group. 155 46 30
220 GENERAL SURGERY

tamination, cardiorespiratory embarrassment, cardiovascular injuries, severe

cerebral injuries, blast injuries to the lungs, and other less common shock-producing injuries. In slightly more than half of these deaths, no single shockproducing factor could be identified. The fatality seemed to be caused by the

interaction of hemorrhage, peritoneal contamination, and tissue destruction.

Thoracopulmonary complications, which were the cause of 13.2 percent

of all deaths, consisted chiefly of pneumonitis, atelectasis, empyema, and

pulmonary embolism. Their frequency was found to be related, at least in

part, to the severity of the wound and the timelag, but their incidence rose in

relation to the increasing multiplicity of visceral injuries (table 32, p. 206).

Peritonitis, which was responsible for 12.3 percent of all deaths, was most

frequent in patients with an unusually prolonged timelag. This is what might

be expected because the longer peritoneal contamination exists, the greater is

the likelihood that virulent peritonitis will develop. It should be emphasized again that the peritonitis responsible in this series for death after the

third postoperative day was the type of bacterial process ordinarily seen in

civilian practice, not the type caused by overwhelming contamination associated with shock and responsible for death soon after operation.

Anuria (lower nephron nephrosis, hemoglobinuric nephropathy), which

was responsible for 4.8 percent of the deaths, does not seem to have been recognized as clinical entity in World War I. It usually occurred in patients who

were in severe shock when they were first seen, in whom resuscitation had

been difficult, and who had required massive replacement therapy (p. 131).

These fatalities seemed closely related to the fatalities which occurred earlier

from shock. The patients escaped death, but at this time the physiologic

changes which ultimately proved fatal were apparently established.

Miscellaneous causes of death, which accounted for 4.1 percent of the

total number, included associated wounds and surgical and anesthetic complications. As individual causes of death, they cannot be said to have had more

than slight influence on the case fatality rate for the series as whole.

ULTIMATE CAUSES OF DEATH

The case fatality rate in any series of injuries is composite expression of

the interaction of all the lethal factors in each individual case. By the classification of the 3,154 injuries of the abdomen treated by the 2d Auxiliary Surgical

Group into exclusive categories, it has been possible to demonstrate that the

most important factors in this series were apparently as follows:

1. The original severity of the wound, as it affected one organ or several.

Though this was the most significant determinant of lethality in every case, it

cannot be expressed graphically.

2. The number of organs injured. In the statistical analysis of this

material, the clinical impression was immediately confirmed that the greater

the number of organs injured, the higher was the case fatality rate. This

factor is susceptible of statistical analysis.
FACTORS OF MORTALITY 221

3. The timelag, or the period from wounding to surgery. This factor, while it is susceptible to statistical analysis, is reliable only when it is related to

the severity of the wound, expressed in terms of the number of viscera injured.

The more severe the wound, the greater was the danger from prolongation of

the timelag and the graver was the prognosis.

4. The state of shock on admission. Almost three-quarters of all deaths

in this series occurred within 72 hours after the patients were admitted to the

hospital, and almost all of the fatalities in this group were attributable to

shock. The more severe the state of shock, the graver was the prognosis.

In analyzing the factors of mortality in this series of abdominal injuries,

it was immediately apparent, when the less frequent causes of death were

excluded, that the most important lethal influence was the original severity of

the wound. Since it was not possible to reduce severity to statistical terms,

the most practical way to express it was in terms of the number of viscera

injured; that is, the multiplicity factor, which is granted to be only an approximation. The second most important lethal factor was the timelag. The

correlating factor between the multiplicity factor and the timelag was the

degree of shock, which can be roughly defined as the manifestation of the effects

of wound of given severity affecting casualty for given length of time.

Death caused by shock was the extreme manifestation of the combined effects

of the multiplicity factor and the timelag.

The highest case fatality rates in this series occurred in two groups of

patients: (1) Those who presented high multiplicity factor, with injuries of

four or more viscera, and (2) those admitted in severe shock. Actually, the

two groups were usually one and the same because the greatest frequency of

severe shock was observed in patients with the highest multiplicity factors.

Patients with wounds of this kind were seldom seen after prolonged timelag,

for the reason that, if they did not reach the hospital promptly, they died

before they could be brought to it.

consideration of these facts leads to conclusion quite in accord with

clinical observations and also supported by the fact that approximately threequarters of the deaths in forward surgical hospitals occurred within relatively

short period (72 hours) after operation. This conclusion is that the combined

effects of severe wound and of prolonged timelag were likely to be lethal,

regardless of the best resuscitative and surgical efforts.

223

CHAPTER XVII

Wounds of the Stomach (416 Casualties)

Luther H. WoljJ M.

An analysis of the 416 wounds of the stomach (table 38) which occurred in the 3,154 abdominal injuries treated by the 2d Auxiliary Surgical Group

during 1944 and 1945 makes three points clear:

1. Wounds of this organ were considerably more frequent than they had

heretofore appeared to be.

2. They were complicated by injuries to other viscera in out of every

10 cases.

3. The case fatality rate in gastric injuries (40.6 percent) was significantly higher than it was in injuries of the colon, small intestine, liver, spleen,

or genitourinary tract (q. v.).

Table 38.—Essential data in 416 wounds of stomach

One hundred and ninety-six of these gastric injuries (47.1 percent) were

produced by missiles which traversed the diaphragm. There were 85 deaths

in these thoracoabdominal injuries (43.4 percent). In the remaining 220 cases,

the projectiles entered or traversed only the abdominal cavity. There were

84 deaths in this group (38.2 percent).

In addition to the unexpectedly high frequency of injuries of the stomach

in relation to total injuries in this series, the ratio of univisceral to multivisceral

wounds is at marked variance with data reported in other series of abdominal

wounds (table 39). The frequency was nearly twice as great as that previously reported. Actually, this is what might be expected. As has been pointed

out (p. 92), the incidence of wounding of any organ is almost directly proportional to the space which it occupies. It follows, therefore, since the stomach

Frequency

Type of wound Cases In 3.154

abdominal

injuries

In 410

gastric

injuries

Deaths Case fatality rate

Univisceral_ 42

Percent

1.

Percent

10. 12 28.

Multivisceral 374 11. 89. 157 42.

Total 416 13. 100. 169 40.
224 GENERAL SURGERY

is relatively large organ, that it would be injured fairly frequently. Furthermore, the frequency of wounding was probably even higher than is indicated

by these figures, which take no account of casualties who died before reaching

field hospital.

Table 39.—Comparative distribution of wounds of stomach in various recorded series

of abdominal injuries

The marked predominance of multivisceral over univisceral wounds is also

what might be expected. Univisceral wounds are naturally infrequent in an

organ almost completely invested by the liver, spleen, colon, and kidneys. It

is believed that the figures for this series more nearly approach both the true

frequency of wounds of the stomach and the true ratio of univisceral and multivisceral gastric injuries than any statistics previously reported, if only because

in World War II more casualties survived to undergo surgery than in any

previous war.

DIAGNOSTIC CONSIDERATIONS

Experience showed that only two signs could be regarded as conclusive

in the preoperative diagnosis of wound of the stomach. One was the emission

of undigested food from an abdominal wound. The other was the actual

observation of perforation or laceration in an eviscerated stomach. In the

absence of these two signs, the diagnosis was only presumptive.

According to the literature, vomiting is cardinal sign of wound of the

stomach. An analysis of these 416 gastric wounds does not support this

observation. Vomiting was no more frequent in wounds of the stomach than

Wounds of stomach Multiviseeral wounds

of stomach

Source Total series

Cases Frequency

(total series) Cases

Frequency

(wounds of

stomach)

World War I: Percent Percent

American 144 7. 48 33.

British 965 82 8. 26 31.

Spanish Civil War

World War II:

238 20 8.

British 628 29 4. 15 51.

2d Auxiliary Surgical Group 3, 154 416 13. 374 89.

The American World War figures are from the Medical Department of the United StatesArmy in the World War

(Washington: U. S. GovernmentPrinting Office, 1927, vol. XI, pt. 1, pp. 65, 457, 458). The British World War figures

were reported by Cuthbert Wallace in War Surgery of the Abdomen (London: J. A. Churchill, 1918) The Spanish

Civil War series was reported by Douglas W. Jolly in Field Surgery in Total War (New York: Paul B. Hoeber, Inc.,

1941). The British World War II figures were reported by W. H. Ogilvie in Abdominal Wounds in the Western Desert

(Surg., Gynec. Obst., March 1944).

Not stated.

Western Desert combined series.
WOUNDS OF THE STOMACH 225

in wounds of other abdominal viscera. It was actually recorded only times

in the 416 cases, and inquiry of resuscitation officers and of surgeons in the

group revealed that none of them considered it an outstanding or reliable

sign of gastric injury.

Blood in the vomitus or in the aspirated gastric contents was, however, regarded as both suggestive and reliable. It was noted altogether in 41 wounds

of the stomach (4 times in vomitus), and constituted valuable clue to the

nature of the injury when blood swallowed in wounds of the head, neck, or

lungs could be ruled out. The absence of blood was not recorded consistently,

being mentioned only eight times. The negative observation, even when itwas

recorded, was obviously of no diagnostic value.

The preoperative passage of Levin tube, in the opinion of the surgeons of

the group, not only did no harm in suspected wounds of the stomach but was,

on the contrary, useful diagnostic and therapeutic measure. The risk of

introducing possible contamination to the injured site was far outweighed by

the relief of the accumulations of gas and fluid which were common in gastric

and other abdominal injuries and whose persistence led to increased leakage of

gastric contents and more serious peritoneal contamination.

Leakage of gas from the damaged stomach was sometimes valuable

diagnostic sign, though it could also produce variety of confusing but interesting clinical pictures. Thus subcutaneous emphysema of varying degrees was at

times observed in the abdominal and chest walls, and in some instances gas

actually bubbled from the abdominal wound. If the gastric wound were thoracoabdominal, gas from the stomach might escape into the pleural cavity through

the lacerated diaphragm and produce pneumothorax.

Pneumoperitoneum was matter of record in only six of the roentgenograms taken in wounds of the stomach. This is deceptively low figure, since

90 percent ofall casualties with abdominal wounds had preoperative roentgenographic examinations. The circumstances, however, were not conducive to

precise roentgenography. All the examinations were made with portable

apparatus. Practically always, as concession to pain and shock, the patients

were not moved from the supine position. Lateral views were impractical and

were seldom attempted. Finally, conditions for both development and interpretation of the films were difficult. Under the circumstances, there is no

doubt that gas bubble lying free in the peritoneal cavity was sometimes

overlooked.

In some cases, as soon as the peritoneum was opened, the surgeon was

greeted by rather disconcerting gush of air. It was often difficult to determine whether it originated in the stomach or from the chest, through perforation of the diaphragm, and careful exploration was necessary to determine

its origin. The presence of gas in the abdomen also introduced still another

diagnostic problem—the possibility of an anaerobic infection. Crepitus and

discoloration of tissues might be the result of gas and leakage of acid secretions

from perforation of the stomach, but it might also be explained by an early

infection of this kind.
226 GENERAL SURGERY

The preoperative diagnosis of wound of the stomach depended chiefly on

visualization of the course of the missile and the application ofaccurate anatomic

knowledge concerning the location of the organ. In the great majority of these

wounds, the location of the wounds of entry and exit—if the injury was perforating—and the location of the wound of entrance, combined with localization

of the missile by two-plane roentgenography—if the injury was penetrating—-

permitted an accurate preoperative diagnosis.

Variations in the shape of the stomach and the position of the soldier at the

time of wounding (p. 100) naturally complicated the diagnosis, as the following

case history indicates:

Case 1. prisoner of war was seen in field hospital with wound of entrance in the

left hip just above the head of the femur and wound of exit in the right hip through the

wing of the ilium. low midline exploratory incision disclosed multiple perforations of the

small bowel and sigmoid colon. It also, rather unexpectedly, disclosed severe laceration of

the stomach some inches above the upper end of the midline incision. Reconstruction of

the injury suggested that the stomach was in the lower abdomen at the time of wounding,

the man undoubtedly being crouched over in the position combat soldier automatically

assumes when he is under fire.

NATURE OF THE INJURY

Wounds of the stomach varied widely in type (table 40). In 16 cases, the

wound was simple tangential laceration of the stomach wall, without penetration into the lumen. At the other extreme were cases in which the violence

of the trauma resulted in complete transection of the organ. In the remaining

cases, the wound varied from trivial perforation to laceration 20 cm. long.

fair proportion of the wounds were caused by small missiles, which

perforated one or both walls of the stomach in nearly perpendicular plane.

Perforations of this kind often caused little or no peritoneal contamination from

gastric leakage, since the redundant gastric mucosa tended to act as valve and

seal off the injury. Shock was not usually severe. fairly large number of

such injuries accounted for the relatively low case fatality rate in perforating

wounds of the stomach (table 40). In contrast, missiles which entered the wall

of the stomach at an acute angle were likely, regardless of their size, to produce

Table 40.—Case fatality rates in relation to type of injury in Jjl6 wounds of stomach

Type of injury Cases Deaths Case fatality

rate

Perforating 258 91 35.

Lacerating __ 117 71 60.

Not stated __ 41 17.

Total 416 169 40.

Includes complete transactions.
WOUNDS OF THE STOMACH 227

extensive lacerations. Leakage was profuse, peritoneal contamination was

severe, and the case fatality rate was correspondingly higher (table 40). Larger

missiles tended to produce lacerating wounds, which were potentially more

lethal, and part of the difference in the case fatality rates of perforating and

lacerating wounds can be explained on this basis.

TIMELAG AND THE MULTIPLICITY FACTOR

As has already been mentioned (p. 217), the timelag was of the utmost

importance in individual wounds of the viscera. In the whole series of 416

injuries, however, it did not seem of serious significance unless the analysis also

took into account such other considerations as the multiplicity of visceral

injuries, the number and character of associated injuries, and the degree of

peritoneal contamination.

Univisceral wounds of the stomach (table 41) were so few (42, 10.1 percent)

that their analysis from the standpoint of the timelag would be of no statistical

importance. This is, also as already noted, considerably lower frequency than

is reported in any other comparable series. The case fatality rate, 28.6 percent,

was surprisingly high. Although the multiplicity factor (p. Ill) was found to be

more reliable prognostic index in abdominal injuries than any other factor,

the general rule that the greater the number of organs injured, the higher the

case fatality rate (fig. 21, p. 108) did not hold in wounds of the stomach in the

first two multiplicity categories (table 41). It is true that in category of only

42 univisceral wounds, statistical error is likely. On the other hand, an analysis

of the 12 deaths in these 42 injuries seems to provide clue to the lethality of

type of wound which in other structures was attended with proportionately

lower case fatality rate. This analysis showed that of the 12 deaths in univisceral gastric injuries occurred either on the day of operation or within the

first days after operation, and that the cause was recorded in every instance

as shock or shock and peritonitis. In two other cases, death occurred from

peritonitis, one on the fourth and one on the eighth postoperative day. Another

death was caused by peritonitis and gastric fistula on the 15th postoperative

Table 41.—Influence of multiplicity factor on case fatality rates in 416 wounds of stomach

Organs injured Cases Deaths Case fatality

rate

Stomach only_ 42 12 28.

Stomach and viscus 174 47 27.

Stomach and viscera 112 44 39.

Stomach and viscera 50 29 58.

Stomach and viscera 23 23 100.

Stomach, other viscera, and great vessels 15 14 93.

Total 416 169 40.
228 GENERAL SURGERY

day. One of the two remaining deaths was caused by secondary hemorrhage

from the stomach, on the 14th postoperative day. In the other case, no

cause of death was stated. These are small figures and of no statistical significance, but clinician cannot fail to be impressed by the causes and time of death

and by the number attributed to shock.

In multivisceral injuries (table 42), the liver, as might be expected, was

most frequently involved, with the colon and the spleen next in order. Concomitant injury to the colon produced the highest case fatality rate except for

concomitant injuries to the great vessels. The latter were almost universally fatal (table 41).

One extremely significant fact in the analysis of these multivisceral

wounds was the discovery that treatment had been successful in certain combinations of wounds which up to this time had been uniformly fatal. Bailey,

for instance, stated in 1942 that in the past no combination of wounds involving the stomach, small intestine, and colon had ever been successfully treated.

In the 24 injuries of this kind in this series, in 11 of which the liver was also

injured, there were 15 survivals.

Table 42.—Case fatality rates in wounds of stomach complicated by wounds of other viscera

Bailey, Hamilton: Surgery of Modem Warfare. Edinburgh: E. S. Livingstone, i, 1941-42.

Organs injured Cases Deaths Case fatality

rate

Stomach only 42 12 28.

Stomach and liver 67 20 29.

Stomach and spleen 42 19.

Stomach and colon 24 11 45.

Stomach, colon, and liver 18 50.

Stomach, liver, and spleen 17 29.

Stomach and jejunum 16 25.

Stomach, jejunum, and colon 13 30.

Stomach, jejunum, colon, and liver_ 11 45.

Stomach and kidney 10 30.

Stomach, jejunum, and liver 33.

Stomach and ileum

Stomach, colon, and spleen 33.

Stomach, jejunum, and kidney 33.

Stomach, spleen, and kidney. 33.

Stomach and pancreas 16.

Stomach, colon, and kidney 100.

Stomach, colon, liver, and spleen 40.

Stomach, liver, and pancreas __ ... 20.

This table does notinclude combinations of visceral wounds which occurred less than times each. It also does not include injuries of the stomach and duodenum in which both patients survived and injuries of the stomach and great

vessels in which both patients died.
WOUNDS OF THE STOMACH 229

ASSOCIATED INJURIES

About quarter of the 416 casualties with wounds of the stomach also

had severe extra-abdominal injuries. Forty-three presented major fractures,

forty-one major soft-tissue injuries, nine major amputations, nine injuries of

the spinal cord, four injuries of the brain, and four injuries of the heart. The

chest injuries present in thoracoabdominal wounds were, strictly speaking,

separate associated lesions, and their presence apparently produced 5-

percent increase in the case fatality rate in this group. An evaluation of the

effect of the associated injury and its influence on morbidity and case fatality

rates would require case-by-case analysis. Generally speaking, the rate

among patients with associated injuries did not differ significantly from that

of patients without them, though the fallacy of the application of such generalization to the individual case is obvious.

TECHNICAL CONSIDERATIONS

The transdiaphragmatic approach to wounds of the fundus and body of the

stomach (table 43) greatly facilitated the repair of injuries in these areas, both

the anterior and posterior surfaces of the fundus being accessible through the

incision without opening of the peritoneal folds. It is, therefore, not surprising

that this incision was used in 119 (60 percent) of the 196 thoracoabdominal

injuries. Eventually, it became the incision of choice in selected cases, though

it was used in only one instance in which there was not perforation of the

diaphragm. In that type of injury, vertical incision in the upper abdomen was

preferred.

The gastrocolic omentum was incised routinely at operation, to permit

examination of the posterior gastric wall. Whether operation was done from

above or from below the diaphragm, this was most important step of the

procedure in patients known or suspected to have sustained gastric injuries.

Table 43.—Distribution of surgical approaches in 412 wounds of stomach

Approach Cases Percentage

Laparotomy 293 71.

ransdiaphragmatic:

Thoracotomy.

Combined laparotomy and thoracotomy

Thoracolaparotomy __ __

Total

Grand total __

95

18

23.

4.

1.

119 28.

412 100.

Information is lacking on this point In four cases.

By this technique, the thoracicincision is extended across the costal arch onto the abdominal wall.
230 GENERAL SURGERY

Simple suture, which was used in 409 of the 416 injuries of the stomach,

was regarded as the procedure ofchoice, even in extensive lacerations. Resect ion

was required in the five cases in which transection of the stomach was complete.

The Polya or Hofmeister technique was used in three cases, all of which were

fatal, and end-to-end anastomosis in the other two, one of which was fatal.

Perforations of the stomach were overlooked at operation in the two remaining cases in the series. One of the patients died of gastropleural fistula;

the other died of embolism. At autopsy, the overlooked perforations were

discovered; they had closed spontaneously, without apparent leakage, and had

not contributed to the fatal outcome.

The type of suture closure, as well as the kind of suture material, varied

with the preference of the individual surgeon. Except that purse-string suture

proved unsatisfactory, as will be pointed out shortly, variations in technique

seemed to make no difference in the outcome of the case.

In six cases, all simple perforations, severe postoperative hemorrhage

occurred from the stomach. This was the largest number of postoperative

hemorrhages encountered in the entire series of 3,154 abdominal injuries.

Three patients died. Two survived under conservative management, and the

other recovered uneventfully after secondary operation to control bleeding.

It is significant that in all six instances of postoperative bleeding, closure

had been by reenforced purse-string suture. This method can produce circumstances ideal for the development of hemorrhage. Since the suture seldom,

if ever, includes the gastric mucosa, the mucosal edges retract. As result,

the blood vessels which traverse the submucosa are exposed, and the resulting

pathologic picture simulates that of acute peptic ulceration. Erosion of the

previously sealed underlying vessels, and subsequent hemorrhage, are therefore

possibilities whenever this method is used. The following case history illustrates this fact:

Case 2.—A soldier with multiple wounds from shell fragments, including left thoraco- abdominal wound, was admitted to field hospital in excellent general condition. Transdiaphragmatie rephir of single perforation of the upper portion of the stomach was carried

out by means of purse-string suture through left thoracotomy incision. The operation

was performed without complications, and convalescence was smooth until the fifth postoperative day, when evidences of internal bleeding were observed. When laparotomy was

resorted to, after hours of conservative therapy, the stomach was found to be completely

occupied by clot estimated to contain 1,500 cc. of blood. After the clot had been removed,

the site of perforation and suture was inspected from the mucosal side. The surgeon’s

notes adequately explained the hemorrhage: “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.” Excision of the affected area and closure of the wound were followed by an

uneventful recovery.

This report and others like it led to certain technical changes:

1. Every effort was made to approximate the gastric mucosa by suture in all wounds of the stomach.
WOUNDS OF THE STOMACH 231

2. Small perforations were enlarged transversely so that the mucosal layer

could be exposed and accurately sutured.

3. Purse-string suture was no longer employed in wounds of the stomach.

POSTOPERATIVE COMPLICATIONS

As already noted, practically every patient who died within the first 48

hours after operation as the result of wound of the stomach presented the

clinical picture designated under the generic term “shock.” All had sustained

extensive tissue damage, massive blood loss, disturbed pulmonary physiology,

peritoneal contamination of varying degrees, or combinations of these conditions. Persistent shock resulting from these conditions is, strictly speaking,

postoperative complication, but it is not classified as such in this discussion

because of the time of its occurrence. Actually, it was part of the original

pathologic process.

Of the complications which occurred later than 48 hours after operation,

by far the commonest were pulmonary. In fact, pneumonia (12 cases),

empyema (11 cases), and atelectasis (6 cases) accounted for approximately 40

percent of the serious complications seen after this time. Peritonitis was

observed in cases, of which were fatal. In all instances, it was of the

usual clinical (bacterial) type.

CASE FATALITY RATE

The data analyzed in this section bear out the initial statement that

wounds of the stomach, whether univisceral or multivisceral, are among the

most serious injuries encountered in warfare (table 44). Some perforations

were comparatively trivial, but the leakage of acid gastric contents into the

general peritoneal cavity was always serious and was likely to be associated

with high degree of shock. In general, patients with wounds of the stomach

exhibited much more severe degree of shock than those with other abdominal

wounds. In 22 cases (13 percent of the fatalities) death occurred on the

operating table; death occurred in the course of operation in only 11 percent

of all other fatalities in the total series of abdominal injuries. The 115 fatalities (68 percent of the total deaths from wounds of the stomach) which occurred

by the end of the second postoperative day were chiefly attributable to shock

alone or in association with peritonitis and, to lesser degree, other complications, or to overwhelming peritoneal contamination.

In 12 of the 416 casualties with wounds of the stomach, the records contributed nothing concerning the presence or absence of shock. In 66 other

cases, the patients were either in no shock at all or in incipient shock. One

hundred and three of the remaining patients were in mild shock, one hundred

and six in moderate shock, and one hundred and twenty-nine in severe shock.

The unusually high proportion of casualties in moderate and severe shock can

be explained, at least in part, by the spillage of acid gastric contents into the
GENERAL SURGERY

general peritoneal cavity. There seems no doubt that whenever spillage of

such contents occurred, an immediate chemical peritonitis ensued, which

quickly produced either shock or shocklike state and which was entirely

different from the bacterial peritonitis observed in later stages of the injury

in patients who survived.

Table 44.—Primary cause of death in relation to time of death in 169 wounds of stomach

Another possible explanation of shock in wounds of the stomach originates

in anatomic considerations, that the stomach overlies highly vascularized

.area in which are located the celiac axis, the aorta, the inferior vena cava, and

Time and cause of death Cases

On operating table:

Shock 13

Shock and hemorrhage

Shock and atelectasis

Shock and gas gangrene

Shock and peritonitis (contamination)

Cardiac

Total 22

Through second postoperative day:

Shock__ 43

Shock and peritonitis (contamination) 28

Shock and hemorrhage __

Shock and atelectasis

Shock and anaerobic infection

Peritonitis (massive contamination)

Peritonitis (massive contamination) and pneumonia

Peritonitis (massive contamination) and intestinal fistula

Pulmonary embolism

Total 93

After second postoperative day:

Peritonitis (bacterial) __ __ __

Peritonitis (bacterial) and shock (all third dav)

Peritonitis (bacterial) and pneumonia, empyema, or pleurisv ___ 12

Anuria 10

Pneumonia

Hemorrhage, secondary

Pneumothorax and pleurisy _____ ___

Intestinal or gastric fistula

Brain injury

Not stated

Total 54
WOUNDS OF THE STOMACH 233

the portal vein, and that massive hemorrhage is therefore frequently associated.

Although this is theoretically sound reasoning, hemorrhage in gastric wounds

did not appear to be more severe than in numerous other visceral wounds in

this series. The part which it played in the production of shock was often

difficult to evaluate, it is true, but in the usual wound of the stomach it seemed

to be secondary in importance to peritoneal contamination.

After the second postoperative day, peritonitis and pulmonary complications were the most important causes of death (table 44). The case fatality

rate among casualties with lacerating wounds was almost double that among

those with perforating wounds (table 40), the explanation probably being that

all patients with lacerating wounds suffered massive peritoneal flooding with

acid stomach contents, which presumably happened in much smaller proportion of those with perforating wounds. The high case fatality rate among

patients with univisceral wounds of the stomach (table 41) is further proof

of this hypothesis. Although the relative vascularity of the stomach and the

adjacent structures theoretically should play part in the lethality of gastric

wounds, the collective clinical observations of the 2d Auxiliary Surgical Group

did not support this point of view.

378327°—56——17

235

CHAPTER XYIII

Wounds of the Duodenum (118 Casualties)

W. Herschel Cave M. D.

The figures from World War indicate that wounds of the small intestine

are among the most lethal encountered in warfare. Wallace, who reported

363 cases in 985 abdominal injuries in British soldiers, recorded case fatality

rate of 65.9 percent for uncomplicated (univisceral) injuries and of 74.1 percent for complicated (multivisceral) injuries. The case fatality rate for

American troops was between 70 and 80 percent. That modern surgical

measures and efficient adjunct therapy have greatly improved the chances of

survival in this group of casualties is evident from the figures reported for

World War II.

Wounds of the duodenum are infrequent. They accounted for only

percent of all injuries of the small bowel recorded among American soldiers in

World War I, and there were only 16 (4.4 percent) in Wallace’s series of 363

small-bowel injuries. The 118 wounds of the duodenum observed by the 2d

Auxiliary Surgical Group in 1944-45 (table 45) represent only 3.7 percent of

the 3,154 abdominal injuries treated by the group during that period.

Table 45.—Essential data in 118 wounds of duodenum

Wounds of the duodenum are almost never univisceral. In this series,

other organs were injured in 116 of the 118 cases (table 45), while all duodenal

injuries observed in 1943 were multivisceral and were, like the 1944-45 cases,

characterized by the variability of the organs involved.

Wallace, Cuthbert; War Surgery of the Abdomen. London: J. A. Churchill, 1918.

The Medical Department of the United States Army in the World War. Washington; U. S. Government Printing

Office, 1927, vol. XI, pt. 1, pp. 65, 459-460.

Ibid.

See footnote 1.

Frequency

Type of wound Cases In 3,154 abdominal

injuries

In 118 duodenal

injuries

Deaths Case

fatality rate

Univisceral

Multivisceral 116

Percent

0.

3.

Percent

1.

98. 67 57.

Total 118 3. 100. 67 56.
236 GENERAL SURGERY

DIAGNOSTIC CONSIDERATIONS

The preoperative diagnosis of injuries of the duodenum was made principally on the basis of probability. As experience with the pattern of the

injury increased, it could readily be deduced that missile entering the right

side of the abdomen or the right lumbarregion was likely to injure not only the

liver, the colon, and the right kidney, but also the duodenum. It therefore

became routine, when the abdomen was opened for an injury in these regions,

to reflect the right colon and examine the duodenum thoroughly. The

results of increasing consciousness of the possibility of injury of the duodenum

are seen in the fact that while perforations of the duodenum were overlooked

in the duodenal injuries treated by the 2d Auxiliary Surgical Group in 1943,

only was overlooked in the 118 cases treated in 1944-45. Other visceral

injuries in this series of duodenal injuries included 69 of the liver, 59 of the

colon, and 37 of the right kidney.

NATURE OF THE INJURY

The site of the wound of entry was fairly constant in these injuries of the

duodenum (fig. 27) and suggested the diagnostic pattern which has just been

described. In 96 instances, 81.4 percent, the missile entered the right side of

the trunk from the front or the back.

In the 112 wounds in which the details were stated (table 46), the second

portion of the duodenum was injured in 49.1 percent, the first portion in 24.1

percent, and the third in 13.4 percent. In the remaining cases, more than one

portion was injured. In many injuries of the first portion, the lesion was continuous with wound of the pylorus, and several injuries of the third portion,

similarly, were continuous with wounds of the jejunum. The predominance

of injuries of the second portion of the duodenum suggests that many casualties

with injuries of the first portion did not survive to reach the hospital because of

simultaneous fatal injuries of such close-lying structures as the vena cava, the

hepatic artery, and the portal vein. Similar reasoning can be applied to explain

the small number of injuries of the third portion; there is close anatomic

relationship between the duodenum and the aorta, the vena cava, and the

mesenteric vessels.

Although the majority of the duodenal wounds were perforating or lacerating (table 46), there were 20 instances of transection in the series. In one

instance, the injury was attributed to indirect violence. The patient presented

large gutter wound across the epigastrium, through which omentum had

herniated. No wound of exit was found, nor was foreign body demonstrable

by roentgenology. The stellate lacerations of the liver and the second portion

of the duodenum discovered at laparotomy were assumed by the surgeon to

have been caused by concussion.
WOUNDS OF THE DUODENUM 237

Figure 27.—Sites of wounds of entry in 118 injuries of duodenum.

Table 46.—Site and type of injury in 112 wounds of duodenum

TECHNICAL CONSIDERATIONS

Lacerations and perforations of the duodenum were usually repaired by

standard, fairly uniform technique. Transections were repaired by end-to-end

anastomosis with running sutures of atraumatic chromic catgut, usually reenforced with silk or cotton sutures. The peritoneum, as rule, was closed over

the wound. The site of repair was drained in almost every case, and drainage

was mandatory if the pancreas or the liver was also wounded. In the four

cases in which gastrojejunostomy was necessary (all of which were promptly

fatal), the damage to the duodenum was extensive and beyond repair.

POSTOPERATIVE COMPLICATIONS

Two fistulas of the duodenum are known to have developed in the field

hospitals in which these 118 duodenal injuries were treated. Both occurred

on the sixth postoperative day, and both in cases in which transections of the

Site of injury Perforation

LacerationTransection Total

First portion 12 27

Second portion __ 34 14 55

Third portion 15

Junction of first and second portions

Junction of second and third portions

Duodenojejunal junction

Total 56 36 20 112
238 GENERAL SURGERY

duodenum had been repaired by end-to-end anastomosis with chromic catgut

reenforced by silk. The figures are too small to be significant, but it may be

that there is tendency for fistulas to develop after transection of the duodenum.

Drainage following repair, therefore, seems indicated in all injuries of this type.

In another instance, it was assumed that fistula developed. The injury

was simple laceration of the second portion of the duodenum, which had

been repaired by single running suture of atraumatic chromic catgut reenforced with interrupted silk sutures. The clear, irritating discharge which

began to issue from the wound on the sixth day was regarded as duodenal in

origin.

TIME AND CAUSES OF DEATH

Sixty-seven of the one hundred and eighteen patients with duodenal

injuries (56.8 percent) are known to have died in forward hospitals within the

first 10 days after operation. In two additional cases, it is believed that death

also occurred within this period, though the records are too incomplete to permit positive statement. These figures are to be compared with the World

War American Army figures, which show fatalities in the 10 recorded

instances of duodenal injury. In 47 of the 67 fatalities (table 47), death

occurred within the first days after operation.

Table 47.—Primary cause of death and time of death in 67 injuries of duodenum

Shock and hemorrhage were recorded as the cause of 39 of the fatalities,

58.2 percent (table 47). The patients who did not survive were, on the whole, in more severe state of shock when they were hospitalized than were those

who survived (table 48). Two of the three deaths attributed to peritonitis

occurred in cases in which visceral injuries had been overlooked at operation;

See footnote 2, p. 235.

Time of death

Cause of death On operating

table

First 24

hours

24 to 72

hours

4th to 10th

days, in- clusive

Total

Shock and hemorrhage 25 39

Pneumonia

Anuria

Transfusion reaction

Pulmonary embolism

Peritonitis

No record.

Total 25 17 20 67
WOUNDS OF THE DUODENUM 239

one was laceration of the common bile duct and the other perforation of the

third portion of the duodenum.

Of the 20 patients who sustained transections of the duodenum, 14 died

within the first days after operation. The other six are known to have

survived beyond this period. In one instance, in which autopsy was not

performed, it was thought that the duodenal suture had given way. The

patient had sustained through-and-through perforation of the upper pole of

the right kidney, which had been drained, and through-and-through perforation of the second portion of the duodenum, which had been closed with two

layers of running sutures of atraumatic chromic catgut. He became greatly

distended on the seventh postoperative day and complained of severe epigastric

pain; death occurred hours later.

Table 48.—Influence of degree of shock on case fatality rates in 114 wounds of duodenum

Multivisceral wounds, as already noted, were the rule in duodenal injuries

(table 49), being present in all but two instances in this series. Both patients

with univisceral injuries survived. The factor of multiplicity greatly increased

the lethality of wounds of the duodenum. The major surgery required in

multivisceral wounds played an important part in the increase in the case

fatality rates. The rate was 57.0 percent in the 21 cases in which nephrectomy

was done, 75.0 percent in the cases of cholecystectomy, 70.0 percent in the

13 small-bowel resections, 77.7 percent in the cases of colectomy, and 80.0

percent in the cases of splenectomy.

Wounds of the large blood vessels played particularly important part in

the high case fatality rate of duodenal injuries. Of the patients who had

lacerations of the vena cava, died; the only survivor was not in shock when

he was first seen. Death also occurred in the injuries of the portal vein, the

injuries to the pancreaticoduodenal artery, and the injuries of the hepatic

and the right spermatic artery (1 each).

Pancreatic injuries were also highly fatal; death occurred in of the

cases, though in only instance was the head of the pancreas so badly damaged

that the duct was severed.

Degree of shock Cases Deaths

Case

fatality

rate

None _____

20 30.

Mild 15 20.

Moderate 20 40.

Severe 59 50 84.

Total ____ __ _______ 114 67 58.
240 GENERAL SURGERY

Table 49.—Influence of multiplicity factor on case fatality rates in 118 wounds of duodenum

One fatality in this category was univisceral wound, complicated by wound of the portal vein, which was pr;

marily responsible for the fatal outcome.

In 15 of the 118 duodenal injuries, an associated chest injury was present,

varying in severity from simple perforation of the diaphragm to severe

lacerations or contusions of the lung. Eleven of these fifteen patients died.

Organs wounded Cases Deaths

Case

fatality

rate

Duodenum only

Duodenum and viscus 28 16 57.

Duodenum and viscera._ __

45 20 44.

Duodenum and viscera 21 14 66.

Duodenum and viscera 20 15 75.

Duodenum and viscera 100.
241

CHAPTER XIX

Wounds of the Jejunum and Ileum

(1,168 Casualties)

W. Philip Giddings M. Dand John R. McDaniel M. D.

Between January 1944 and May 1945, the surgeons of the 2d Auxiliary

Surgical Group treated 1,168 casualties with injuries of the jejunum and ileum,

of whom 345 (29.5 percent) died (table 50). These 1,168 injuries represent 37.0

percent of the 3,154 abdominal injuries observed over the period of time stated.

Table 50.—Essential data in 1,168 wounds of jejunum and ileum

NATURE OF INJURY

Included in these injuries of the jejunum and ileum are six in which the

abdominal wall was not penetrated. All were incurred in vehicular accidents

and all resulted in rupture of the small bowel. Another patient, who sustained

severe transfixing thoracoabdominal wound, was injured when he was impaled

on the stump of small tree by the blast of an exploding shell. With these

seven exceptions, all the wounds in the series were caused by high-explosive

fragments or missiles from small arms. There were no bayonet or stab wounds.

The lesions varied from pinpoint perforations and small contusions to

extreme maceration and destruction of the greater portion of both ileum and

jejunum. For convenience of discussion, the injuries have been classified under

four headings: (1) Injury to the intestinal wall, (2) injury to the mesentery,

(3) perforating injury, and (4) transections (table 51). Wide extremes of

severity were noted in each group, and as rule or even lesions were seen in

combination.

Frequency

Case

fatality

rate

Type of wound Cases In 3,154

abdominal

injuries

In 1,168

jejuno-ileal

injuries

Deaths

Univisceral

Multivisceral ____

353

815

Percent

11.

25.

Percent

30.

69.

49

296

13.

36.

Total 1, 168 37. 100. 345 29.
242 GENERAL SURGERY

Table 51.—Frequency of various types of injury in 1,168 wounds of jejuno-ileum

Severe enough to require resection.

The arbitrary figure of was used when perforations were recorded as “multiple,” without statement of the precise

number. Whenever the precise numberwas recorded, it was used.

Injury to the intestinal wall.—Trauma to the intestinal wall included contusions and lacerations of the serosal or seromuscular coats which did not perforate the mucosa. This type of injury was not frequent (table 51). Contusions, which were seldom more than cm. in diameter, varied from areas of

slight ecchymosis to circumscribed areas of gangrene. contusion of the bowel

wall implied, by its very nature, that the missile which had caused ithad reached

the end of its flight and was traveling at such low velocity that its impact

against the intestine was sufficient to stop it. In this type of injury, the missile

either was embedded in the wall of the bowel orlay free in the peritoneal cavity.

Lacerations of the intestinal wall were caused by tangential impact, and

no inferences are, therefore, permissible concerning the velocity of the causative

missile. They usually occurred in association with perforations of the lumen in

other portions of the bowel. Theoretically, laceration might be of any

length. Practically, in the absence of perforation, it was seldom more than

cm. long. Some lacerations were merely breaks in the serosa. Usually there

were evidences of contusionabout the margins of laceration, and the lacerationcontusion type of injury was considered potential site for future perforation.

Injury to the mesentery.—Injuries of the mesentery occurred both at the

mesenteric attachment and at considerable distance from the bowel. They

varied from small hematomas or peritoneal lacerations to rents which extended

across the mesentery to its root. Some damage to the adjacent mesentery

nearly always occurred in transections of the bowel and in perforations involving

the mesenteric border. Bleeding had usually ceased when the casualty was

first seen, but in some instances bleeding was still active.

Perforations of the mesentery other than those adjacent to injuries of the

bowel were frequent. They were usually simple through-and-through holes.

Hematomas were sometimes present also, but in the majority of cases there was

no indication that vessel of major consequence was involved. The incidence of mesenteric damage sufficiently extensive to necessitate intestinal resection

was remarkably low; in all 1,168 injuries of the jejunum and ileum there were

only 30 cases in which resection was required because of vascular impairment

Injury Cases Injuries

Average

frequency

per case

Injury to intestinal wall. ____ 27 31

Injury to mesentery __

30 30

Perforation __ 1.083 4, 589

Transection. __213 361
WOUNDS OF THE JEJUNUM AND ILEUM 243

from mesenteric injury. The circumstances of this type of injury, including the

effects of energy transmitted to the tissues and the natural tendency to clot

formation in lacerated blood vessel, would be expected to produce thrombosis.

Thrombi were commonly found protruding from the ends of severed vessels in the

mesentery, even when the vessels were of considerable size, but the thrombotic

process was invariably restricted to the immediate area of damage. There was

no instance in the series of extensive mesenteric thrombosis (in the usual clinical

sense of the term) in which the pathologic process could be regarded as caused

primarily by trauma to the mesentery.

Perforating trauma of the intestine.—By far the commonest type of injury

to the small intestine was perforation into the lumen. This occurred in 1,083 of the 1,168 injuries, and multiplicity was the rule, the average number of

perforations per case being four (table 51).

Small perforations occasionally seemed to have been caused by indriven

fragments of bone, especially when the missile had entered the abdomenthrough

the ilium. Generally speaking, the size and shape of the rent in the bowel were

determined by the corresponding characteristics of the missile, as well as by its

velocity and the direction of its flight. Through-and-through perforations and

complete transections were both frequent.

Under some conditions of injury, isolated perforations might be found at

considerable distance from the major trauma, though as rule multiple injuries

were in close proximity to each other, and damage was ordinarily confined to

segment or feet in length, or even less. These phenomena were explained by

the fact that in the usual case, intestinal damage was caused by single missile,

the effect of which was confined to its line of flight. Scattered perforations were

caused by missiles which traversed major diameters of the abdomen; by separate

missiles with different wounds of entry; or by multiple fragments which, though

they entered through common wound, pursued divergent courses within the

abdomen.

Individual lesions varied from tiny holes to gashes inches or more in

length. When the perforations were of any size, the findings were similar.

The tissues about the edges were contused and ecchymotic. The margins

were jagged. Mucosa usually pouted from the wound. Bleeding from the

intestinal wall was sometimes free, and considerable amounts of blood were

seen in the peritoneal cavity when the bowel wall was the only apparent source

of hemorrhage. Small perforations were sometimes almost completely sealed

off by pouting mucosa, so that there was minimum of soiling of the cavity.

In such cases, there was bluish discoloration of the bowel, from intraluminal

bleeding. Less commonly, blood and intestinal contents were extensively

spilled from small perforations, as in the following case:

Case I. —A 29-year-old infantryman was wounded by machinegun bullet which entered

the left lower abdomen. The ilium was fractured at the wound of entrance and the greater

trochanter of the left femur was fractured at the wound of exit. When the patient was

This case appears in table 54 as case 18.
244 GENERAL SURGERY

admitted to field hospital 20 hours later, he was in severe shock and was anoxic and disoriented.

Operation was performed 23.5 hours after wounding, after the administration of unit

of plasma and pints of blood. Although the injury was limited to single small perforation

of the jejunum, which was readily repaired by suture, generalized, fulminating peritonitis

was already present, and the surgeon noted on the operating sheet that the spillage of intestinal contents was the most extensive he had ever seen.

After operation, the patient remained extremely toxic. Oliguria developed and progressed to anuria. Death occurred on the eighth postoperative day. Post mortem examination revealed an acute, fibrinopurulent generalized peritonitis, with right-sided subphrenic abscess.

Transection.—Transections of the intestine, which were fairly common

(table 51), represented the extreme form of perforations of the jejunum and

ileum. The most characteristic feature of these injuries was that they were

nearly always accompanied by extensive spillage.

State of the peritoneum.—The small bowel is well vascularized, and the

frequency of hemoperitoneum in injuries of the jejunum and ileum was consistent with that fact. In some instances, 2,000 cc. of blood, or more, were in

the peritoneal cavity, usually as the result of massive bleeding from the mesentery. At the other extreme, bleeding was occasionally minimal.

The peritoneal cavity was usually contaminated to some degree with

contents of the small bowel, though in an occasional case no gross soiling was

apparent. The degree of contamination was usually compatible with the size

and number of the perforations. The peritoneal reaction was fairly constant

in relation to the time at which surgery was undertaken. When operation

was performed within hours of injury, there was usually no visible reaction.

Violent exudative peritonitis was the rule only in patients seen after relatively

long timelag (12 hours or more). In casualties who survived longer than 24

hours without operation, early walling off of the perforation with loops of

adherent bowel was likely to have occurred. These findings, of course, were not

invariable. Severe generalized peritonitis was sometimes seen in patients

treated early, and localization was also occasionally seen in early cases. Definitive peritonitis was recorded at operation in only 50 of the 353 univisceral

wounds of the jejuno-ileum, figure which is undoubtedly too low.

Evisceration. —Evisceration of the jejunum and ileum occurred in 153

instances in the whole series of 3,154 abdominal injuries. Trauma to the

involved bowel or its mesentery required repair in 126 cases. In the remaining

cases, evisceration was incidental and required no treatment other than reduction. In only one instance was resection necessary because of strangulation

of the eviscerated loop.

Associated injuries.—Two hundred and fifty-two of the 1,168 casualties

with injuries of the jejunum and ileum had major associated peripheral wounds, and 202 had minor associated wounds. Another 143 casualties had penetrating

or perforating wounds of the thorax, of which 94 (8.0 percent of all injuries of

the jejuno-ileum) were thoracoabdominal. About half (597) of all the casual-
WOUNDS OF THE JEJUNUM AND ILEUM 245

ties with injuries of this portion of the small bowel thus had associated wounds, about two-thirds of which (395) were of major character.

DIAGNOSIS

The preoperative diagnosis of wounds of the jejunum and ileum was made

chiefly on probabilities. There were no criteria hy which their existence could

bo established or excluded before operation. Indriven fragments of bone and

the concussive effect of missiles passing extraperitonoally were known to cause

perforation or rupture, and whenever these circumstances were present it was

not regarded as safe to assume that the bowel had not been injured. Diagnosis,

therefore, was usually established or, occasionally, disproved by exploration of

every case in which the circumstances of wounding and the clinical signs and

symptoms indicated possible intra-abdominal injury.

PREOPERATIVE ROUTINE

The preoperative management of wounds of the small intestine differed

in no respect from the preoperative management of other abdominal injuries.

An essential part of the routine was the introduction of Levin tube into the

stomach, followed by aspiration of the gastric contents.

TREATMENT

Certain general principles were universally followed in the management

of wounds of the jejunum and ileum. These included nontraumatic handling of all tissues, maximum protection of the bowel from exposure, the

use of fine suture material, and as rapid operation as was consistent with

thorough exploration and necessary repair procedures. In many instances,

the control of hemorrhage and operations on other viscera took precedence

over the repair of the small-bowel lesions. Time was always saved by preliminary evaluation of the total damage. About third of the surgeons in the

group thought it expedient, in the investigation of possible damage to the small

bowel, to bring it out through the surgical incision and examine it outside of

the abdomen. Complete examination of the jejuno-ileum and its mesentery

was facilitated by this technique, and those who practiced it felt that, if it were

carried out gently and expeditiously, it was not shocking to the patient. Its

use was limited to cases in which the damage was obviously extensive and the

lesions were obscured by some degree of spillage.

Contusions and lacerations of the intestinal wall were repaired and reenforced by peritonealizing linear or purse-string suture, of whatever material

the individual surgeon might prefer. With this exception, the type of repair

was related to the type of injury.

Simple through-and-through perforations of the mesentery were sutured,

to reperitonealize the raw surfaces, but dissection was carried out in the presence

of large hematomas or continuing bleeding. After the hematoma had been
246 GENERAL SURGERY

evacuated and hemorrhage controlled, the mesentery was closed by suture.

As already mentioned, intestinal resection because of mesenteric vascular

damage was required in only 30 cases in the series. In these patients, the usual

criteria of viability of the bowel were observed, and resection was performed in

accordance with recognized surgical principles.

wide variety of techniques was used in the repair of perforating lesions

of the bowel. The basic principle of management was to select the most

conservative procedure compatible with secure repair and preservation of an

adequate lumen. Very small perforations were usually closed by purse-string

suture. Larger perforations were sutured transversely. Debridement of the

traumatized edges was frequently omitted. If it was regarded as necessary,

it was as conservative as possible. It was sometimes found convenient to

convert two perforations into single lesion, particularly if they were located

close together in the same vertical plane. The single defect which resulted

could be sutured in less time than was required to suture two separate perforations, and in the end there was less kinking of the bowel.

Resection and anastomosis.—The indications for resection (tables 52 and

53) were usually clear cut. It was clearly mandatory when segments of the

bowel were hopelessly macerated. It was also required when the bowel had

been avulsed from its mesentery. Multiple adjacent perforations separated

by areas of intact bowel always presented problems. Under these circumstances, some surgeons repaired each perforation separately. Others, if the

involved segment was not too long, resected it in toto, fearing that multiple

suture lines so close together might compromise the lumen and lead to intestinal

obstruction from kinking.

Table 52.-—Comparative results of anastomotic and suture repair in

1,117 wounds of jejuno-ileum

Omitted from this table are nonperforating injuries andall injuries in which ileocolostomywas the only treatment In 54 cases, anastomosis was performed withoutresection.

Various techniques of anastomosis were employed (table 53). The majority

of surgeons preferred an open, two-layer, end-to-end method whenever it was

practical. Closed methods were used when soiling was minimal. few surgeons

routinely employed the closed silk technique. Side-to-side anastomosis was

usually reserved for injuries of the lower ileum or for cases in which, after extensive resection, there was marked discrepancy in the size of the lumens to be

Total series Anastomosis Suture

Type of injury

Cases Deaths Case

fatality

rate Cases Frequency Deaths Case

fatality

rate Cases Frequency Deaths Case

fatality

rate

Univisceral 348 47 13.5 135

Percent

38.8 25 18.5 213

Percent

61.2 22 10.3 Multivisceral... 769 281 36.5 347 45.1 155 44.7 422 54.9 126 29.9

Total 1,117 328 29.4 482 43.2 180 37.3 635 56.8 148 23.3
WOUNDS OF THE JEJUNUM AND ILEUM 247

Table 53.—Comparative case fatality rates of resection with various techniques of anastomosis

in 4®8 injuries of the jejuno-ileum

anastomosed. Two surgeons reported successful results with single-layer type

of anastomosis. Two others preferred triple layers. Running or interrupted

sutures of catgut and interrupted sutures of fine silk or cotton were widely used.

As generalrule, the same type of suture and the same suture material employed

for anastomosis were also used for the repair of perforations.

Four hundred and twenty-eight patients were subjected to 466 resections,

which included 35 double resections with 13 deaths (37.1 percent) and triple

resections with deaths. The case fatality rate of 47.1 percent (table 53) for

the 34 side-to-side anastomoses is reflection of the severity of the trauma in

the cases in which it was used, rather than an index of the risk of this technique.

It was unusually employed only in massive resections.

In the 394 cases in which data on this point were available, the length of

the resected segments ranged from inches to 12 feet. In 272 cases, the length

was between and 12 inches. In the other 122 cases, it averaged 34 inches. In

cases, segments more than feet in length were resected. The case fatality

rate in the 122 cases in which the resected segments measured 12 inches and

more in length as 35.2 percent (43 deaths), which is in close agreement with the

case fatality rate of 33.9 percent for all resections (table 53).

The case fatality rate of resection in injuries of the jejuno-ileum (33.9 percent) was higher than the rate of repair by suture (23.3 percent). The rate for

anastomosis without resection (54 cases, 35 deaths, 64.8 percent) was very

considerably higher. The ratio of the case fatality rate of repair by anastomosis

to repair by suture was 1.79 in univisceral cases (18.5 and 10.3 percent respectively) and 1.50 in multivisceral cases (44.7 and 29.9 percent, respectively). In

other words, anastomotic repair carried higher case fatality rate than suture

repair in both groups of cases, and of approximately the same order in each.

The multiplicity factor furnishes no explanation of these figures, since the case

fatality rate of anastomosis was higher in univisceral cases.

The results in this series therefore confirm the general impression that

anastomotic repair of the small bowel is more hazardous than repair by suture,

regardless of the circumstances under which it is employed. On the other hand,

the principal indicationfor intestinal resection in this series was always extensive

Technique of anastomosis Cases Frequency Deaths Case fatality rate

End-to-end 377

Percent

88. 120 31.

47.

52.

Side-to-side 34 7. 16 Not recorded __ 17 4.

Total ______ __ 428 100. 145 33.
248 GENERAL SURGERY

trauma. The procedure was usually undertaken only when the bowel was in

shreds and beyond hope of conservative repair. The higher case fatality rate

for this procedure is therefore probably as much reflection of the severity of

the injury as of the relative risks of suture repair and intestinal resection.

The following case histories are presented as typical:

Case 2.—A medical corpsman was brought into field hospital about hours after he

had sustained severe penetrating gunshot wound of the left abdomen, with an extensive

evisceration of small intestine through large defect in the abdominal wall. He was in

severe shock, and neither blood pressure nor pulse could be obtained. After 2,500 cc. of

blood had been administered as rapidly as possible, the blood pressure rose to 52/40 mm.

Hg and the pulse became perceptible, though it still could not be counted.

Laparotomy was performed hours after wounding. The root of the mesentery was

found avulsed, this injury being the source of massive, persistent bleeding. The missile had

perforated the left mesocolon and lay in the lumbar musculature. There were multiple

lacerations and transections of the ileum and jejunum, and because of vascular impairment

it was necessary to resect 10 feet of small intestine. Several perforations of the jejunum

were also sutured. The patient’s condition began to improve as soon as hemorrhage had been

controlled, and by the end of the operation the blood pressure was 104/60 mm. Hg. transfusion of 500 cc. of whole blood was given on the operating table.

Recovery was uneventful. The Levin tube was removed on the sixth day, and on the

same day the patient has spontaneous bowel movement. He was evacuated in good

condition on the 13th postoperative day. month later, it was learned that his improvement

had continued and that he was about to be evacuated to the Zone of Interior.

Case 3. —An 18-year-old German prisoner of war was admitted to field hospital about

20 hours after he had sustained penetrating wound of the abdomen from shell fragment.

He was in severe shock that did not respond to vigorous resuscitation therapy. Operation

was undertaken about 24 hours after wounding. The peritoneal cavity was extensively

contaminated with small-bowel content and was the site of plastic peritonitis. The color

of the bowel was unhealthy, and it was seriously mangled in three separate areas. total

of feet was resected in three segmental procedures, and several other perforations were

repaired by suture. End-to-end anastomoses were performed, the highest about inches

below the ligament of Treitz.

The man’s condition became progressively worse during operation, in spite of continuous

transfusions of whole blood, and death occurred about minutes after the abdomen had been

closed.

Case 4.—A 42-year-old artilleryman, wounded by shell fragment which penetrated

the abdomen through the left lower quadrant, arrived at field hospital in good condition.

He was immediately given 500 cc. of blood. Roentgenologic examination disclosed metallic

foreign body in the right lower quadrant of the abdomen. Operation, performed hours

after wounding, revealed “multiple perforations of very large size” in the small bowel.

Resection of three separate intestinal loops, with end-to-end anastomosis, was performed in

the jejunum and in the upper and the lower ileum. The large shell fragment visualized in

the roentgenogram was removed from the wall of the ileum.

The postoperative course was entirely uneventful. The patient was in good condition

and was taking liquids by mouth when he was evacuated on the eighth postoperative day.

Enterostomy. —Enterostomy was employed only twice in the initial management of these 1,168 injuries of the jejunum and ileum. In the first instance, small perforation at the ileocecal junction was managed by tube ileocecostomy, the procedure being selected because of the peculiar anatomic site of the injury. The history of the second patient follows:

This case appears in table 54 as case 9.
WOUNDS OF THE JEJUNUM AND ILEUM 249

Case 5. German prisoner of war was admitted to field hospital days after he

had been wounded by shell fragment which had penetrated the right lower quadrant of

the abdomen. His condition, except for dehydration, appeared good. There was tenderness

in the right lower quadrant of the abdomen, and thin, watery discharge exuded from the

wound in this area.

At operation, the wound was converted, by lengthening it, into modified gridiron

incision. large abscess cavity anterior to the cecum contained perforated loop of ileum,

and tube ileostomy was performed through the perforation. Convalescence was fairly

smooth, but undigested food particles were observed in the discharge from the ileostomy.

note was made that the perforation was probably higher in the intestine than it had seemed

to be at operation and that an attempt at closure might have been preferable to enterostomy.

The patient was evacuated on the 10th postoperative day. This case represents of the instances of fistula formation in the series (p. 251).

Management of the contaminated peritoneal cavity.—Two surgeons in

the group routinely placed drains to the peritoneal space in the presence of

contamination, whether from the small bowel or from other sources. The

remainder were opposed to drainage of the cavity. very few surgeons believed

that lavage of severely contaminated peritoneal cavity prior to closure of

the abdomen aided in the removal of gross material which could not bo evacuated by other means, but this method was used too infrequently to permit an

evaluation of either its efficacy or its possible risks.

According to the records, sulfanilamide crystals or penicillin sodium were

used intraperitoneally, alone or in combination, in 59 percent of the injuries

of the jejunum and ileum. The actual figure is thought to be higher. Whether

or not they were used in this manner rested with the individual surgeon. No

opinion was arrived at concerning the efficacy of intraperitoneal chemotherapy

and antibiotic therapy in injuries of the small intestine.

POSTOPERATIVE COMPLICATIONS

The recorded complications of injuries of the jejunum and ileum during

the time the patients were under observation in forward hospitals were extraordinarily few. It is unlikely that serious complications were not recorded.

On the other hand, the figures are perhaps not really representative, since

complications undoubtedly developed in many cases after evacuation.

Ileus, distention, and vomiting apparent!} were almost universal among

patients with abdominal injuries in World War I. In World War II, the

routine use of nasogastric decompression practically eliminated these dangerous

postoperative complications. Patients with injuries of the jejunum and ileum

were intubated with the Levin tube prior to surgery, and three-bottle siphonage

suction was instituted as soon as they reached the postoperative ward. The

tube was left in place for from to days after operation. Considerable

differences of opinion existed as to how long decompression was required after

operation, but most surgeons favored period of to days. Removal of the

tube was determined by the standard clinical criterion; namely, return of

intestinal function as manifested by audible peristalsis, the passage of flatus

378327°—56 18
250 GENERAL SURGERY

and similar phenomena. After the tube had been removed, oral nutrition was

cautiously increased in accordance with the patient’s ability to tolerate food.

The Miller-Abbott tube, although it was always readily available, was

only occasionally used in the management of jejuno-ileal injuries. It was the

consensus of the surgeons of the group that there were few indications for

intubation of the intestine since in most instances adequate decompression

could be obtained by the Levin tube. This was fortunate, for in the few cases

in which the Miller-Abbott tube was used it was difficult, under field conditions, to get it past the pylorus.

Routine postoperative care prevented the development of most other complications. Careful attention was given to the maintenance of the fluid

and electrolyte balance, to the hematocrit level, and to nutrition. Patients

were usually kept in Fowler’s position until peritonitis had definitely subsided.

Intestinal obstruction.—Of the 1,168 patients with injuries of the jejunum

and ileum, 20 (1.7 percent) presented symptoms of mechanical intestinal

obstruction while they were still in forward hospitals. Ten had sustained

severe multivisceral wounds; peritonitis had been present at operation in two

cases; and gross contamination of the cavity had been recorded in six others.

Five of the twenty patients had undergone suture repair, four anastomosis

without resection, and eleven resection and anastomosis. One patient had

had double resection, and two others had had resections as well as simple

anastomoses of transections. In 10 of the 15 cases in which anastomosis was

performed, suture repair was also necessary for other injuries.

Obstructive symptoms, in the 17 cases in which these data were recorded,

appeared between the 3d and the 32d day after operation. If the cases are

omitted in which symptoms became apparent on the 32d day, the average

time of appearance of symptoms is lowered to between the 6th and 7th days.

Seven of the twenty patients died (35.0 percent). In the six instances in

which necropsy was carried out, the cause of the obstruction was found to be

adhesions in three cases, and kinking of the anastomosis, edema at the anastomosis, and leakage from the anastomosis with subsequent peritonitis in one

case each. In the single fatality in which autopsy was not performed, death

followed development of small intestinal fistula which was attributed to

leakage at an anastomosis.

The method of management of the obstruction was mentioned in only

of the fatal cases. In this instance, although the Miller-Abbott tube did not

pass the pylorus, decompression of the obstructed bowel was successful, and

death was caused by severe atjqucal pneumonia and hepatitis of unknown

etiology. It seems safe to assume that conservative measures were also employed in the otherfatal cases; had operation been performed, it would certainly

have been recorded.

Ten of the thirteen patients who survived were treated conservatively,

reinstitution of nasogastric decompression being the principal therapeutic

measure. Data are not available concerning the length of time it was required.
WOUNDS OF THE JEJUNUM AND ILEUM 251

The other (three) patients were operated on when conservative therapy proved

unsuccessful. In one case, obstruction was the result of adhesions, in one of

adhesions complicated by multiple abscesses, and in one of adhesions compli- cated by volvulus of the ileum.

Intestinal leakage and fistula formation.—Leakage from the small bowel

occurred in 12 cases after operation and was followed in instances by fistula

formation. In of the 12 cases, there were severe wounds of other hollow

viscera. In the cases in which these data were recorded, the complication

developed between the 6th and the 26th postoperative days, the average time

being 13 days.

As always, leakage from the small bowel proved serious matter. It was

fatal in all cases in which fistula formation did not occur, and in other cases

in which fistulas developed. In of the fatalities, death was attributed to

peritonitis; the cause was not stated in the fifth case. In each of the three

autopsied cases, leakage was found to have occurred at suture line, and it

seems reasonable to assume that the same accident happened in the two other

fatal cases. In of the autopsied cases, perforations of the terminal ileum

resulted from erosion of the intestine by the through-and-through wire sutures

used to repair wound disruption on the 9th postoperative day; the patient

died of peritonitis on the 22d day. Data are not available concerning the origin

of the leakage in the two other autopsied cases.

Secondary surgery for closure of fistulas was not performed in forward

hospitals. The patients were evacuated as promptly as possible to general

hospitals, where facilities for prolonged special care were available.

UNIVISCERAL WOUNDS

The 353 imivisceral injuries in this series (table 50) include, as already

mentioned (p. 241), nonbattle injuries. The other 351 casualties were all

wounded by high-explosive fragments or by bullets. The ileum was injured

more frequently (180 cases) than the jejunum (128 cases), the ratio being roughly

2. Both portions of the bowel were injured simultaneously 45 times, which

is only about quarter as frequently as the ileum was wounded alone.

The case fatality rate for the 353 univisceral injuries (table 50) was 13.9

percent. The rate for wounds of the jejunum alone (13 deaths) and of the

ileum alone (23 deaths) was approximately the same, 10.2 and 12.8 percent,

respectively. The case fatality rate rose sharply to 28.9 percent (13 deaths)

when both portions of the bowel were involved. The increase is readily explained by the fact that many of the injuries represented extensive trauma to

large segment of the midbowel and required massive resection.

The average timelag from injury to operation in the recorded fatal cases

of univisceral injury of the jejuno-ileum was twice that in the recorded nonfatal

Attention Is called elsewhere (p. 249) to the additional case of fistula formation observed in German prisoner of war,

who had an established fistula of the small bowel and an intraperitonealabscess when he was admitted to field hospital

days after wounding.
252 GENERAL SURGERY

cases, being 9.5 hours in 293 nonfatal cases and 19.1 hours in 46 fatal cases.

If cases in which the timelag was unusually prolonged (72 hours and 90 hours,

respectively) are omitted, the figure for the fatal cases is reduced to 16.3 hours.

The timelag for all 339 (recorded) univisceral injuries was 10.9 hours, which is

essentially the same as the lag (10.6 hours) for the 1,057 cases in the whole

series of jejuno-ileal injuries in which these data are available. If all patients

with this type ofinjury could have been operated on within hours of wounding,

their chances of recovery would probably have been greatly enhanced.

disproportionately large number of severe associated injuries apparently

contributed to the case fatality rate of univisceral wounds of the jejunum and

ileum. Associated injuries were more than twice as frequent among the fatal

as among the nonfatal cases. They were recorded in 72 (23.7 percent) of the

304 patients with univisceral injuries who survived and in 27 (55.1 percent) of

the 49 patients who died. They included serious compound fractures of the

long bones, traumatic amputations of extremities, penetrating wounds of the

thorax other than thoracoabdominal wounds, severe cranial injuries, severe

maxillofacial injuries, and soft-tissue wounds which either were extensive or

were associated with severe hemorrhage.

At least of the 49 fatalities in univisceral wounds of the jejunum and

ileum can be justifiably attributed to these associated injuries. One man with

wound of the heart died on the operating table from cardiac tamponade.

Another, who had also sustained blast injury of the lungs, died hours after

operation. The third died from hemolytic streptococcic bacteriemia and

pyemia following infection of massive wound of the thigh. In all three cases,

the diagnosis was established at autopsy.

In 15 other cases, death apparently was the result of the combined effects

of intestinal and associated wounds, both of which were severe, as the following

representative case history indicates;

Case 6.—An infantry man was brought into field hospital in severe shock 20 hours

after he had sustained an extensive shell-fragment wound of the right buttock. Operation

was performed hours later, after he had received 3,000 cc. of blood. Two small perforations

of the ileum were sutured at laparotomy, which revealed an extensive early fibrinous

peritonitis.

It proved impossible to control the extensive phagedenic infection which developed in

the wound of the buttock and which ultimately involved the entire gluteal muscle group

and the lumbar and posterior thigh muscles also. The patient became oliguric and uremic

and died on the fifth day after operation, his course having been continuous!} downhill.

At autopsy, the peritoneal cavity was found clean and free of infection, and infection and

necrosis in the thigh and buttock were reported to be the chief causes of death.

If the 18 cases in which death was attributable wholly or in part to associated wounds are excluded from this discussion and if only the 31 fatalities in which the intestinal injury played the major role (table 54) are considered, more accurate impression can be obtained of the causes of death in cases in

which injury of the jejunum and ileum was the primarily fatal factor. Shock

or peritonitis was listed as the chief cause in 15 patients who survived operation
WOUNDS OF THE JEJUNUM AND ILEUM 253

for periods of time varying from minutes to 48 hours. These cases fell into

the well-defined group of casualties, seen in forward hospitals, who were

admitted to the field hospitals in the severe shock which seemed, in part at

least, to be secondary to massive peritoneal contamination (p. 127). The

timelag was usually long, associated hemorrhage was frequent, and death

occurred promptly.

Peritonitis was listed as the primary cause of death in patients who

survived operation for periods varying from to 22 days. Peritoneal infection

could not be controlled in these cases, but the element of persisting shock,

which was present in the patients who died promptly after operation, was no

part of the picture.

Table 54.—Causes of death in 31 primarily fatal injuries of jejuno-ileum

Case Timelag Site of injury Postoperative survival Cause of death

11

Hours8.0 Jejuno-ileum 36 hours Peritonitis; shock.

Generalized peritonitis, severe; pulmonary edema,

severe.

Shock; peritonitis.

19.0

17.0

12.0 Jejuno-ileum

20.0 do days Do.

38.0 Jejunum 36 horns. Shock; severe mesenteric hemorrhage.

Generalized fibrinopurulent peritonitis (present at

operation).

Shock; peritonitis.

Do.

27.0 Ileum.

36.0 do hours

22.0

10 do

11 13.0 Shock; peritonitis.

12 48.0 Do. Ileum. _.

6.5 hours.

13 11.5 Generalizedperitonitis.

Shock; peritonitis.

Generalizedperitonitis; shock.

Generalizedperitonitis.

Suppurative, generalized peritonitis, severe; mesenteric

thrombosis lower third ileum.

Acute fibrinopurulentperitonitis, severe; anuria; uremia.

Generalizedand localizedperitonitis; perforations ileum

caused by wire sutures.

Peritonitis.

14 37.0 do

15 10.0 do 24 hours

16 90.0

17 14.5 Ileum.

18 23.5

19 14.0

20 6.0 Ileum. days ...

21 15.0 do 11 days ... Do.

22 7.0 Jejuno-ileum.. 12 days Generalized peritonitis; bronchopneumonia.

Generalizedand localized purulent peritonitis; leakage at

anastomosis.

Intestinal obstruction; kinked anastomosis.

Massive pulmonary embolism.

Oliguria; anuria; uremia.

Diffuse purulent tracheobronchitis.

Hepatitis; atypical pneumonia; intestinal obstruction.

Aspiration of vomltus.

Cardiorespiratory death, unexplained clinically or at

autopsy.

Not recorded.

23 4.0 Ileum. days

24 10.0 do __ ___

25 7.0 do 10 days.

26 16.0

27

28

6.5

6.5

Jejunum

do

days

13 days ...

29

30

31

5.5

4.0

Ileum.__ ... __

do

Jejuno-ileum

10 minutes.._

day

days.

Autopsy.
254 GENERAL SURGERY

The incidence of peritonitis recorded at operation is not considered reliable

because many of the operative notes were incomplete. It is of interest, however, that it was specifically mentioned as being present in 41 percent of the

patients who died, as contrasted with only 10 percent of those who survived.

One death was attributed to intestinal obstruction. In one case, no cause

of death was stated. In the six remaining cases, the fatalities were attributed

to causes not inherently related to wounds of the small intestine, such as

pulmonary embolism and anuria.

In the fatal univisceral wounds, therefore, about half of the patients

died in the immediate postoperative period of shock and overwhelming peritoneal contamination. About quarter died later of peritonitis. The remainder, except for the patient who died of intestinal obstruction, died of

unpredictable and unrelated complications. The outstanding causes of death

in patients who died primarily of univisceral injuries to the jejunum and ileum

were shock, severe peritoneal contamination, prolonged timelag, and peritonitis. Interaction among these factors was often observed clinically. Apparently they were mutually complementary, and they cannot be completely

divorced from each other for the purpose of statistical analysis.
255

CHAPTER XX

ounds of the Colon and Rectum

(1,222 Casualties)

C. Frank Chunn M. D., and Richard V. Hamer, M. D.

In the 3,154 casualties with abdominal wounds treated by surgical teams

of the 2d Auxiliary Surgical Group between January 1944 and May 1945, there were 1,222 with wounds of the colon, rectum, or both. These injuries

are in addition to the 136 similar injuries treated between April and December

1943. The case fatality rate in the 1943 series was 42.6 percent (58 deaths),

as compared with 35.4 percent (433 deaths) in the cases managed in 1944 and

1945. The essential data in the 1944-45 cases are set forth in table 55.

Table 55.—Essential data in 1,222 wounds of colon and rectum

As in all other groups in this series, the 1,005 patients with wounds of

the colon and rectum for whom these data were available were chiefly (63.0

percent) in the age range 20 to 40 years. The case fatality rate was essentially

the same for this age group (33.8 percent) as for the group from infancy to

20 years (32.4 percent), although the latter group includes civilian children

who had rate somewhat above the average. The 22 casualties over 40 years

of age, 10 of whom died, were chiefly civilians.

Frequency

Case

fatality

rate

Type of wound Cases In 3,154 abdominal

injuries

In 1,222colonrectum

injuries

Deaths

Colon only _____

1, 067

Percent

33.

Percent

87. 386 36.

Univisceral 251 7. 20. 57 22.

Multivisceral 816 25. 66. 329 40.

Rectum only 116 3. 9. 27 23.

Univisceral 64 2. 5. 14.

Multivisceral 52 1. 4. 18 34.

Colon and rectum 39 1. 23 3. 20 51.

Univisceral 13 41 1. 46.

Multivisceral 26 82 2. 14 53.

Total.. 1, 222 38. 100. 433 35.

Univisceral 328 10. 41 26. 72 21.

Multivisceral 894 28. 32 73. 361 40.
256 GENERAL SURGERY

NATURE OF THE LESION

Wounds of the colon were caused by the same agents, which were implicated with approximately the same frequency, as all other abdominal wounds

(p. 92). The series does not include serous and seromuscular lacerations without perforation into the lumen. There were only few of these injuries, and

they resulted chiefly in minor bruises or subserosal hematomas. The series is

made up entirely of perforations, transections, and other severe injuries to the

large bowel, including injuries which resulted in interruption of the blood supply.

The perforations, as in injuries of other portions of the bowel, ranged from

small holes without leakage to injuries which completely destroyed large segments of the bowel and were associated with massive fecal spillage.

Contamination of the retroperitoneal space from perforation of the

extraperitoneal colon was common and always presented formidable complication, particularly in extensive wounds of the right colon. Fecal matter was

spread widely and forcibly through severely damaged muscle and areolar

tissue. Adequate debridement often required extensive excision of the lumbar

and iliopsoas muscles, and satisfactory surgery was often performed with

difficulty because of extensive hematoma formation and the close proximity of

important anatomic structures, notably the ureter and the great vessels of

the pelvis. Identification of retroperitoneal structures and the control of

hemorrhage were frequently time consuming and of great technical difficulty.

Of the 1,358 wounds of the colon treated in the 1943-45 period, 191 were

thoracoabdominal (table 56).

Table 56.—Case fatality rates in 191 thoracoabdominal injuries involving the colon

TIMELAG AND THE MULTIPLICITY FACTOR

The average lapsed time from wounding to operation in the 1,222 wounds

of the colon and rectum in this series was 10.9 hours, the interval being essentially the same for both fatal and nonfatal cases. It is to be compared with

It will be noted that in this chapter there are apparently no cases in which data concerning timelag are lacking.

There are two explanations: (1) The authors of the chapter made special effort to check all nonreeord cases with the

operating surgeons and were often able tosecure approximate time intervals from them. (2) When they couldnot secure

these data, as well as in cases in which investigation of the missing data was not possible, they adopted the plan of using

for their calculations the average timelag of all cases treated by the teams which handled these cases.

Site of intestinal injury Cases Deaths Case fatality rate

Ascending colon 13 69.

Hepatic flexure 22 15 68.

Transverse colon 76 33 43.

Splenic flexure

Descending colon

57

23

30 52.

34.

Total 191 95 49.

These injuries occurred in the 1,358 wounds of the large bowel treated in 1943-45.
WOUNDS OF THE COLON AND RECTUM 257

the average time interval of 10 hours recorded for all 3,154 cases in the total

series, as well as with the interval of 11.3 hours reported for all abdominal

injuries in 1943. The average time spent in resuscitation in the hospital before operation was undertaken was hours, which makes the interval from wounding to hospitalization between and hours. In more than quarter of all

cases (27.5 percent), operation was begun within hours of injury, and in almost three-quarters of the cases (74.5 percent) it was begun within 12 hours.

tendency toward an increase in the case fatality rate in wounds of the

colon (table 57) was apparent through the 18-hour period. It ceased after

this interval. In later categories, the figures available for analysis were too

small to permit conclusions.

The case fatality rates in relation to the timelag between wounding and

operation must be interpreted in the light of two considerations:

1, While in general the patient’s chances were improved the shorter the

interval between wounding and surgery, account must also be taken of the

influence of the multiplicity factor (table 58).

2. The case fatality rate in patients operated on within 12 hours of wounding (320 of 911 patients, table 57) was kept to 35.1 percent, in spite of the fact

that this group included the casualties who were critically and often mortally

wounded and who often reached the hospital alive only because of rapidity of

evacuation.

Table 57.—Influence of timelag on case fatality rates in 1,222 wounds of colon and rectum

Injuries of the colon were accompanied by injuries of or more other

viscera (table 58) in approximately out of every cases (74.7 percent). Injuries of the rectum were accompanied by injuries of other viscera in more

than half of all cases (58.7 percent). In both portions of the large bowel,

wounds of additional viscera caused an increase in the case fatality rate, the

increase being directly proportional to the number of viscera affected. Injuries of both solid and hollow viscera caused an increase in the case fatality

rate in about the same proportion. In the 552 wounds of the colon in which

hollow viscera were also injured, there were 205 deaths (37.1 percent); and in

Timelag

All cases Colon only Rectum only Colon and rectum

Cases Deaths

Case

fatality

rate Cases Deaths Case

fatality

rate Cases Deaths Case

fatality

rate Cases Deaths Case

fatality

rate

to hours 336 105 31.3 314 96 30.6 15 33.3 57.1

To 12hours 575 215 37.4 497 192 38.6 57 12 21.1 21 11 52.4

To 18 hours 168 65 38.7 139 55 39.6 23 30.4 50.0

To24 hours 66 20 30.3 51 18 35.3 11 9.1 25.0

To48 hours 65 25 38.5 54 22 40.7 10 20.0 100.0

48 hours or more 12 25.0 12 25.0

Total 1,222 433 35.4 1,067 386 36.2 116 27 23.3 39 20 51.3
258 GENERAL SURGERY

Table

58.

—Influence

of

combined

timelag

and

multiplicity

factor

on

case fatality

rates

in

1,155

injuries

of

colon

and

rectum

to

hours

To

12

hours

To

18

hours

To

24

hours

Over

24

hours

Total

Injury

Cases

Deaths

Case fatalityrate

Cases

Deaths

Case fatalityrate

Cases

Deaths

Case fatalityrate

Cases

Deaths

Case fatalityrate

Cases

Deaths

Case fatalityrate

Oases

Deaths

Case fatalityrate

Colon or

rectum

only

71

12.7

120

26

21.7

38

15.8

25

16.0

38

12

31.6

292

57

19.5

Colon

and

viscus

159

45

28.3

242

79

32.6

79

32

40.5

25

24.0

28

10

35.7

533

172

32.3

Colon

and

viscera

67

31

46.3

110

53

48.2

34

17

50.0

14

42.9

62.5

233

112

48.1

Colon

and

viscera

25

14

56.0

31

12

38.7

85.7

80.0

50.0

70

37

52.9

85.7

13

10

76.9

100.0

100.0

22

18

81.8

100.0

100.0

1CO.O

Total

330

100

32.1

520

184

35.4

159

62

39.0

69

20

29.0

77

29

37.7

1,155

401

34.7

2.22

2.21

2.08

1.99

1.70
WOUNDS OF THE COLON AND RECTUM 259

the 161 wounds in which solid viscera were also injured, there were 55 deaths

(34.2 percent).

In addition to the complicating visceral injuries just discussed, damage

to major blood vessel of the abdomen was complication in 25 cases, 23 of

which terminated fatally. In cases, of which were fatal, the vascular

injury was the only complicating wound.

In the 1,155 cases in which adequate data on the multiplicity factor were

available for the tabulation (table 58), there was definite and almost arithmetical increase in the case fatality rate from 19.5 percent in univisceral injuries (22.7 percent in wounds of the colon, 14.1 percent in wounds of the

rectum) to 100 percent when additional organs were injured. The outcome

in every injury of the colon apparently depended more upon the number of

additional organs injured than upon precisely which organs were involved.

It should be noted that while the case fatality rate rose progressively for

each additional organ injured, there was no consistent increase in the rate for

the various time intervals after injury. The timelag, naturally, is not unimportant. In view of the danger of infection of the peritoneum in wounds of

the large bowel, timelag was probably more important in such wounds than

in any other type of abdominal wound. When the figures are interpreted in

the light of these various considerations, they strongly suggest that reduction

of the timelag in patients with wounds of the large bowel enhanced their

chances of survival. On the other hand, the bad effects of delay in surgery,

the chief of which was the development of peritonitis, were overshadowed by

the increased influence of multiple visceral injury, the chief of which was

probably shock.

SHOCK

On the basis of clinical appearance, blood pressure, amounts of blood and

plasma used in resuscitation, response to measures of resuscitation, and similar

criteria, it was possible to classify 1,140 patients according to the degree of

shock present when they were admitted to the field hospital (table 59). Approximately third of this number was in each of the three categories; namely,

no shock or slight shock, moderate shock, and severe shock. The case fatality

rate increased proportionately with the increase in the degree of shock, though

when the cases were classified according to the timelag no pronounced differences were observed (table 59) except in the 12- to 18-hour period. On the

other hand, it seems reasonable to surmise that, as time passed without treatment, patients who at first were in minor degrees of shock entered more serious

states and so fell into different categories. The degree of shock, as would

have been expected, was also related to the number of organs injured.

Resuscitation therapy.—In the immediate resuscitation and preparation

for operation of patients with wounds of the colon, the greatest reliance was

placed upon blood, which was used immediately, liberally, and always in

larger amounts than plasma (table 60). The quantities of plasma, however,
260 GENERAL SURGERY

were probably larger than the tabulated data suggest, because under field

conditions the full amounts used were not always recorded.

Table 59.—Influence of degree of shock and timelag on case fatality rates in 1,140 injuries

of colon and rectum

Table 60.—Blood and plasma replacement in wounds of colon and rectum

It was the policy in the earlier cases in this series to delay operation until

the systolic blood pressure was over 100 mm. Hg. As experience increased, this policy was replaced by regimen in which operation was performed earlier in the period of resuscitation and active shock therapy was continued throughout the operative procedure. The timelag before operation was thus shortened in numerous cases in which full resuscitation before operation was notably hard to achieve, particularly in severe injuries of the right colon, evisceration, and active abdominal hemorrhage. Casualties witli wounds of the colon

associated with extensive fecal soiling showed marked resistance to resuscitation therapy.

Timelag

Degree of shock

Total

None to slight Moderate Severe

Case Case Case Case Cases Deaths fatality Cases Deaths fatality Cases Deaths fatality Cases Deaths fatality

rate rate rate rate

to hours 217 24 11.1 199 58 29.1 225 153 68.0 641 235 36.7

to 12 hours 101 7.0 103 24 23.3 125 84 67.2 329 115 35.0

12 to 18 hours 24 4.2 32 15 47.0 24 20 83.3 80 36 45.0

18 to 24 hours 20 15.0 11 9.1 12 75.0 43 13 30.2

Over 24 hours... 21 14.3 14 60.0 12 66. 47 18 38.3

Total 383 38 9.9 359 105 29.2 398 274 68.8 1,140 417 36.6

Data on these points are lacking in 82 cases.

Cases Units Average per

patient

Blood:

Total ____ ___ __

4, 165

cc.

1, 841

1, 415

2, 590

728

Survivals 2, 043

Deaths 2, 122

Plasma:

Total 3, 220

Survivals 1, 722 610

Deaths __

1, 498 938

The figures for blood are based on 1,131 casualties and for plasma on 1,106 casualties.

unit ofblood is 500 cc. and unit of plasma is 250 cc.
WOUNDS OF THE COLON AND RECTUM 261

TREATMENT

While on first glance (table 61) it might seem that very large number

of procedures were utilized in the 1,222 wounds of the colon and rectum which

make up this series, actually there was no wide divergence of opinion among

surgeons in the 2d Auxiliary Surgical Group over how wounds of the large

bowel should be managed. There were numerous modifications of technique,

it is true, but the opinion of the various teams was probably as definite, as

concrete, and as unanimous concerning methods of management as it was

in any intra-abdominal injury. Exteriorization of the injured bowel was

fundamental principle, though several different techniques were employed to

accomplish it, and procedures other than exteriorization were resorted to only

when for any reason it was inadvisable or actually impossible to perform this

operation.

In general, all surgical procedures for wounds of the colon and rectum

involved three basic techniques:

1. Exteriorization of the wounded segment of bowel, to prevent intraperitoneal leakage at suture line. The damaged exteriorized segment could

be used as the site of colostomy on appropriate indications.

Table 61.—Influence of location of injury and type of operation on case fatality rates in 1,222

wounds of colon and rectum

Operation Ascend- ing

colon

Transverse

colon

Descending

colon

Ascending and transverse

colon

Descending and transverse

colon

Ascending and

descend- ing

colon

Sigmoid

Extraperitoneal

rectum

Colon

and

extraperitoneal

rectum

Total

Colostomy:

145

27

39

252

146

67

48 29

82

32

559

292

43

60

10

35

26

101

46

23

18

Intraperitoneal closure, proximal

colostomy

Diversional colostomy

34

Resection, ileocolic anastomosis,

29

17

Resection, double-barreled ileo19

17

Posterior drainage, proximal

82

25

Posterior drainage, closure, prox13

Resection, separate exteriorizaNo intestinal operation

Total cases

Total deaths

Case fatality rates

282 417 120 33 49 157 116 39 1,222

87

30.9

161

38.6

42 19

35.0 57.

19

38.8 66.7

52

33.1

27

23.3

20

51.3

433

35.4

In of these 18 injuries (3 involving the ascending, the transverse, and the descending colon) the wound was overlooked at laparotomy. Eleven of the remaining patients died on the operating table before the intestinal lesion was dealt

with. The other two developed,respectively, pelvic abscess and fecal fistula and underwent secondary surgery for

these complications.
262 GENERAL SURGERY

2. Diversion of the fecal stream away from wounds of the distal or lower

colon and rectum, which was accomplished by any one of several techniques of

colostomy. Colostomy was always performed for perforation of the rectum,

but adequate posterior drainage through the fascia propria was also mandatory.

3. Incomplete diversion of the fecal stream, which was temporary

measure, designed for purposes of decompression as well as to bring the bowel

to the surface, so that diversional colostomy could be performed. Either

tube or tangential enterostomy was utilized in the cecum, though this type of

opening could not be converted into diversional colostomy.

Special procedures carried out in these wounds of the colon and rectum

were as follows:

1. Loop colostomy, which was simple exteriorization of segment of

colon through an abdominal incision. The exteriorized segment was maintained by tube laid across the incision and under the segment of colon (fig.

28A).

2. Spur colostomy, which was exteriorization of segment of colon or of

the proximal and distal ends of segment of colon, through an abdominal

incision. Both limbs of the colostomy were sutured together along the antimesenteric surface for distance of to inches to form the spur (fig. 28B).

The colon was rotated so that the mesentery lay medially,

3. Tube cecostomy, which was an enterostomy with rubber tube sutured

into the lumen of the colon and brought out through small abdominal incision

(fig. 28C).

4. Intraperitoneal closure with proximal colostomy, which consisted of

repair of the perforated colon which was left in the peritoneal cavity while

loop or spur colostomy was done at convenient distance proximal to the

repair.

5. Diversional colostomy, which was spur or loop colostomy placed

proximal to perforation of the colon or rectum to divert the fecal stream.

6. Resection with ileocolic anastomosis and colostomy. This was

procedure (fig. 29A) which included (1) resection of the terminal ileum and

ascending colon; (2) closure of the terminal end of the ileum; (3) side-to-side

anastomosis of the ileum and transverse colon, the anastomosis being left in the

peritoneal cavity; and (4) exteriorization of the proximal end of the transverse

colon as mucous fistula through separate incision in the abdominal wall.

This procedure was sometimes varied by performing end-to-side ileocolostomy

with exteriorization of the proximal end of the colon (fig. 29B). Another variation of the basic technique was the performance of side-to-side anastomosis

between the ileum and transverse colon, with exteriorization of the distal end

of the ileum and the proximal end of the transverse colon through separate

incisions in the abdominal wall, to create mucous fistulas (fig. 29C).

7. Resection with double-barreled ileocolostomy, which was essentially

the same as resection with spur colostomy, the only difference being that one

of the exteriorized limbs was ileum and one was colon (fig. 30A).
WOUNDS OF THE COLON AND RECTUM 263

Figure 28.

—Types

of

colostomy.

A.

Loop

colostomy.

B.

Spur

colostomy.

C.

Tube

cecostomy
264 GENERAL SURGERY

Figure 29.—Types of colostomy. A. Resection of wounded segment, with side-to-side

ileocolic anastomosis and creation of single mucous fistula. B. Same, with end-to-side

anastomosis. C. Same with side-to-side anastomosis and creation of double mucous

fistulas.

8. Posterior drainage (drainage of the fascia propria) and proximal

colostomy, which was indicated in wounds of the rectum or of the rectum and

the sigmoid. It included (1) coccygectomy or an incision just lateral to the

coccyx; (2) freeing of the rectum from the fascia propria for drainage of the

perforated rectum, which was not repaired; and (3) creation of proximal

loop or spur colostomy through an abdominal incision. One variation of

this technique was to repair the perforated rectum and drain the perirectal

space.

9. Resection, with separate exteriorization of the limbs, which required

resection of segment of the colon with exteriorization of the proximal and

distal limbs through individual abdominal incisions rather than as doublebarreled colostomy.

10. Tangential colostomy, which was exteriorization of small area of

the antimesenteric wall of the colon through separate abdominal incision

(fig. SOB), with maintenance of the continuity of the bowel.

Whenever the retroperitoneal space had been penetrated or perforated, it

was drained through an independent incision. The peritoneal cavity itself

was drained in not more than 10 percent of the remaining cases.

REGIONAL INJURIES

The transverse colon alone was involved in the largest number of cases in

this series (417 cases, 34.2 percent), followed in the descending order of frequency by the ascending colon (282 cases, 23.1 percent), sigmoid (157 cases,

12.8 percent), descending colon (120 cases, 9.8 percent), extraperitoneal

rectum (116 cases, 9.5 percent), transverse and descending colon (49 cases,

4.0 percent), colon and rectum (39 cases, 3.2 percent), ascending and transverse
WOUNDS OF THE COLON AND RECTUM 265

colon (33 cases, 2.7 percent), and ascending and descending colon (9 cases, 0.7 percent).

The appendix was either perforated or transected in 12 instances (1.0

percent of the total number of wounds of thelarge bowel). All of these patients

had other and more important intra-abdominal wounds. All were treated by

appendectomy.

Ascending colon.—Wounds of the ascending colon (table 62) presented

particularly difficult problems when it was necessary to resect the entire

right colon and terminal ileum. Early in the war, the most favored procedure

under these circumstances was resection and double-barreled ileocolostomy,

but it carried case fatality rate of almost 65 percent and was unsatisfactory

for other reasons. It combined the most undesirable feature of small-bowel

fistula, that is, an irritant and digestive discharge, with the contaminating

discharge of colostomy. The resulting fecal contamination of irritated and

digested wound surfaces produced conditions which at times it was impossible

to control. Later, resection and ileocolic anastomosis and colostomy, with

the creation of single or double mucous fistula, accomplished some improvement in the case fatality rate, which still, however, remained high (51.7 percent). Two patients who required resection of portion of the ascending colon

were treated by separate exteriorization of the proximal and distal ends;

both died.

There were no deaths in the 27 patients treated by tangential colostomy

(included under loop colostomy, table 62). This method was employed only

when the perforation was small and was located on the antimosenteric border

of the bowel. Two techniques were used: The bowel was repaired and no

fecal fistula was established at operation, or it was not repaired and the perforation was permitted to serve as the fistula.

Figure 30.—Types of colostomy. A. Double-barreled ileocolostomy.

B, Tangential colostomy.

378327°—56 19
266 GENERAL SURGERY

Table 62.—Influence of technique on case fatality rates in 273 wounds of ascending colon

Thirteen patients with injuries of the right side of the colon were subjected

to primary repair, without colostomy, with only one death. The results are

not statistically significant, nor are they of particular significance clinically.

These patients were among the least seriously wounded and are in no wise

comparable to the casualties who required resection of the right side of the

colon. They are not even comparable to casualties with large single wounds

of the colon.

Transverse colon.—The 417 wounds of the transverse colon included

comparatively minor injuries in which primary repair of the perforation was

successfully carried out without colostomy (table 63). All these six patients

made smooth recoveries. No special comment is necessary on any of the other

cases in this group.

Table 63.—Influence of technique on case fatality rates in 414 wounds of transverse colon

Operation Cases Deaths Case fatality rate

Colostomy:

Loop 145 32 22.

Spur 27 10 37.

Tube 39 10 25.

Closure, proximal colostomy

Resection, ileocolic anastomosis and colostomy 29 15 51.

Resection, double-barreled ileocolostomy 17 11 64.

Closure only 13 7.

Resection, separate exteriorization of limbs 100.

Total 273 81 30.

Nine additional cases are omitted because no intestinal operation was performed in them: Six patients died on the

operating table, and in cases, of which were fatal, the lesion was missed.

Operation Cases Deaths

Case

fatality

rate

Colostomy:

Loop 252 80 31.

Spur 146 72 49.

Tube 50.

Closure, proximal colostomy..

Resection, double-barreled ileocolostomy 50.

Closure only__

Resection, separate exteriorization of limbs_ 100.

Total 414 158 38.

Three additional cases are omitted because no intestinal operation was performed in them. Two patients died

on the operating table, and in case, also fatal, the lesion was missed.
WOUNDS OF THE COLON AND RECTUM 267

Descending colon.—Wounds of the descending colon (table 64) presented

no special problems as compared with wounds of the ascending colon or the

lower sigmoid. All were dealt with by some form of colostomy except for

the single case managed by repair of the perforation with return of the bowel

to the peritoneal cavity.

Sigmoid colon.—Wounds of the sigmoid colon (table 65) presented two

problems not encountered in wounds of the colon proximal to the sigmoid;

1. When perforation of the lower sigmoid was present, it was often impossible to exteriorize the wounded segment because the distal bowel was not

long enough. In this type of case, the perforation was repaired and proximal

diversional colostomy of either the loop or the spur type was created.

Table 64.—Influence of technique on case fatality rates in 119 wounds of descending colon

Table 65.—Influence of technique on case fatality rates in 154 wounds of sigmoid colon

2. The second problem, which was encountered in only four cases, concerned perforations at the rectosigmoid junction, just at the reflection of the

peritoneum on the pelvic floor. In these cases, the procedure just described

Operation Cases Deaths

Case

fatality

rate

Colostomy:

Loop 67 19 28.

Spur __

48 21 43.

Closure, proximal colostomy 33.

Closure only

Total_ ____ ____ 119 41 34.

An additional (fatal) case is omitted because the lesion was missed at operation.

Operation Cases Deaths

Case

fatality

rate

Colostomy:

Loop 82 21 25.

Spur 32 14 43.

Closure, proximal colostomy 34 11 32.

Posterior drainage, closure, proximal colostomy 25.

Resection, separate exteriorization of limbs 100.

Total 154 49 31.

Three additional cases are omitted because the patients died on the operating table before the intestinal operation

could be performed.
268 GENERAL SURGERY

was followed, with the addition of fascia propria (posterior) drainage of the

rectum.

Rectum.—The majority of patients with injuries of the extraperitoneal

rectum (table 66) were treated by proximal colostomy and posterior drainage.

The perforation was closed in 25 of the 107 cases in which this technique was

used.

Multiple intestinal injuries.—The case fatality rate, as might have been

expected, increased sharply when more than one segment of the large bow el had

been wounded (tables 67 to 70, inclusive). Of the 1,222 patients in this series,

130 had injuries of two different segments of the colon or injuries of the colon

and rectum. There ere 64 deaths in this group (49.2 percent). There ere

17 deaths (39.5 percent) in the 43 cases in hich colostomies were created at

two different sites.

Table 66.-—Influence of technique on case fatality rates in 116 wounds of extraperitoneal rectum

Table 67.—Influence of technique on case fatality rates in 32 wounds of ascending and

transverse colon

Anadditional case is omitted because thepatient died on the operating table before the intestinal operation could bo

completed

Operation Cases Deaths

Case

fatality

rate

Diversional colostomy 62.

Posterior drainage, proximal colostomy 82 15 18.

Posterior drainage, closure, proximal colostomy 25 24.

Closure only 100.

Total 116 27 23.

Operation Cases Deaths

Case

fatality

rate

Colostomy:

Loop

Spur 66.

Closure distal perforation, loop exteriorization proximal

perforation ____

____

50.

Resection, ileocolic anastomosis and colostomy 66.

Resection, double-barreled ileocolostomy 66.

Closure only ____

__

50.

Total 32 18 56.
WOUNDS OF THE COLON AND RECTUM 269

Table 68.—Influence of technique on case fatality rates in wounds of ascending and

descending colon

Table 69.—Influence of technique on case fatalityrates in 48 wounds of transverse and

descending colon

Table 70.—Influence of technique on case fatality rates in 39 combined wounds of colon and rectum v.

Operation Cases Deaths

Case

fatality

rate

Colostomy:

Double loop 100.

Spur and loop 100.

Tube and loop

Closure distal perforation, loop exteriorization proximal

perforation 66.

otal 66.

Operation Cases Deaths

Case

fatality

rate

Colostomy:

Double loop 33.

Spur and loop _______ 29 11 38.

Proximal tube, distal loop ._

Closure distal perforation, exteriorization proximal perforation_ 44.

Total 48 18 37.

An additional case is omitted because the patient died on the operating table before the intestinal operation could be

completed.

Operation Cases Deaths

Case

fatality

rate

Diversional colostomy. 50.

Resection, double-barreled ileocolostomy, loop sigmoidostomy. 100.

Posterior drainage, proximal colostomy 19 47.

Posterior drainage, closure, proximal colostomy __

17 52.

Total 39 20 51.
270 GENERAL SURGERY

Up to May 1944, when penicillin first became available, sulfadiazine was

given by vein after operation in all injuries of the colon and rectum. Thereafter,

penicillin was given at 3-hour intervals from the time the patient reached the

hospital until days, or more, after operation. few surgeons continued to use

sulfadiazine intravenously in conjunction with it.

Some surgeons who used no antibacterial agent in the abdomen in mildly

contaminated cases are known to have employed this method when contamination of the peritoneal cavity was serious or massive. The case fatality rate in

wounds of the colon and rectum does not seem to have been materially affected

by the introduction of either chemotherapeutic or antibiotic agents into the

peritoneal cavity.

POSTOPERATIVE COMPLICATIONS

According to the records, important postoperative complications included

peritonitis, pneumonia, anuria, wound infection, atelectasis, evisceration, intestinal obstruction, anaerobic infection, fecal fistula, empyema, secondary

hemorrhage, subphrenic abscess and pelvic abscess, pulmonary edema, cerebral

embolism, and fat embolism. The list is necessarily presented without commept, since the records were entirely inadequate. Unquestionably, there were

more instances of nonfatal atelectasis and patchy bronchopneumonia than the

records indicate, just as there were unquestionably many more wound infections, minor hemorrhages, and temporary partial obstructions from edema in the area

of intestinal anastomoses. As for minor complications, the majority were

simply not entered on the charts.

CASE FATALITY RATES

There were 433 deaths in forward hospitals among the 1,222 patients with

perforations of, or other severe damage to, the colon, rectum, or both, case

fatality rate of 35.4 percent (table 55, p. 255). Actually, for reasons pointed out

elsewhere (p. 85), there is little doubt that the rate was somewhat higher than

these figures indicate.

The case fatality rates for injuries of the large bowel improved progressively

as the war progressed. In 1943, there were 58 deaths in 136 casualties (42.6

percent); in 1944, 334 deaths in 917 casualties (36.4 percent); and in 1945,

99 deaths in 305 casualties (32.5 percent).

Case fatality rates varied according to the location of the injury (table 71)

and according to whether the wound was limited to the large bowel or was

multivisceral. In univisceral injuries of the colon, the rate was 22.7 percent

(table 55, p. 255). In univisceral injuries of the extraperitoneal rectum, it was

14.1 percent. In multivisceral injuries, these rates were, respectively, 40.3

and 34.6 percent. When the wounds involved both the colon and the rectum, the rate for univisceral injuries was 46.2 percent and for multivisceral injuries

53.8 percent.
WOUNDS OF THE COLON AND RECTUM 271

When only univisceral injuries of the large bowel were considered (table 71),

the case fatality rate was found to vary according to the site of the wound and

the number of wounds. Casualties who had sustained injuries of the extraperitoneal rectum had the best chance of survival, the rate for these wounds

being 14.1 percent. Those with combined injuries of the colon and rectum had

the least chance, the rate for these wounds being 46.2 percent. Univisceral

wounds of the colon carried higher case fatality rate (22.7 percent) than

similar wounds of any other organ except the stomach (table 36, p. 218).

Table 71.—Influence of site of injury on case fatality rates in 328 univisceral wounds of colon and rectum

CAUSES OF DEATH

It is not possible to state the causes of death with complete accuracyin the 433 patients who died with injuries of the colon and rectum (table 72).

In many instances, injuries of other viscera, as well as associated injuries of

the head, extremities, and chest, were probably responsible, wholly or in part,

for the fatality. In 36 cases, the cause of death was not stated at all on the

records, and it was not possible to determine it from the data available. Most

of the remaining 397 patients were subjected to partial or complete necropsy,

or the records were sufficiently detailed and specific to permit primary

cause of death to be determined.

Shock.—Shock, which occurred in 185 cases, 46.6 percent of the fatalities

in which the cause of death could be determined, was the largest single primary

cause of death. The patients in this group were all gravely wounded. On

admission to the field hospital, they were almost invariably in severe shock,

which usually did not respond fully, if at all, to adequate preoperative resuscitative therapy. All were operated on, but they usually did not respond to heroic

measures employed during and after operation. Sometimes they did not react

at all after surgery. Thirteen died on the operating table. few lived as

long as 36 hours, but in most of the fatal cases those who survived the operation

died within 24 hours. In numerous instances, it was not possible to determine

Site of injury Cases Deaths

Case

fatality

rate

Right colon. __ __________ 107 20 18.

Transverse colon __ 60 14 23.

Left colon ____ ____ ___ ___ 65 17 26.

Multiple injuries of colon _. _____ __ 19 31.

Rectum 64 14.

Colon and rectum 13 46.

Total __ ________ 328 72 22.
272 GENERAL SURGERY

Table 72.—Distribution of primary causes of death in 397 injuries of colon and rectum

whether death was caused by shock alone or by combination of shock and the

effects of an overwhelming peritoneal contamination. There is no doubt that it

occurred before fatal type of infectious peritonitis was established, but there

is also no doubt that in most of these early fatal cases there was enough irritative

peritoneal contamination, from the spill of feces, small-bowel contents, and bile,

Cause Cases Proportion

Shock _____ __ ____185

Percent

46.

Intra-abdominal:

Peritonitis, generalized 87 21.

Hemorrhage. __

1.

Cellulitis (retroperitoneal) __

1.

Abscess __

1.

Anaerobic infection __

1.

Intestinal obstruction.. __ 1.

Total 112 28.

Anuria __ __ 35 8.

Intrathoracic:

Pneumonia 13 3.

Pulmonary embolus 11 2.

Pulmonary edema ___ 1.

Severe chest injury __ __ ... 1.

Atelectasis 1.

Blast injury __ 1.

Total 45 11.

Cranial:

Head injury. __

1.

Fat embolism __ 25

Total 1.

Other:

Anaerobic infection 1.

Injury of extremity __

25

Not recorded, but primary cause clearly not intra-abdominal. 2.

Total __ 13 3.

Total deaths from known causes __397 100.

Exclusive of 36 cases in which the primary cause of death was not stated.

In some of these cases hemorrhage, shock, and peritonitis perhaps played the dominantrole.
WOUNDS OF THE COLON AND RECTUM 273

blood, and urine, to cause shock reaction. The actual loss of blood, in combination with other factors, was of enormous importance in these patients in

the causation of the severe and fatal type of shock which they presented.

Death from shock was particularly likely to occur after operation for extensive wounds involving the right side of the colon, the cecum, and the lower

ileum, the reason being that in these portions of the bowel the contents are

liquid and possess notably irritating properties. The high case fatality rates

in these injuries were disturbing, and there were frequent changes in the plan

of management, with, however, no great improvement in results.

Intra-abdominal causes of death.—Intra-abdominal causes of death were

responsible for the fatalities in 112 cases, 28.2 percent of the total number (table

72). All these deaths were the direct or indirect result of infection except for

six in which hemorrhage was the primary cause. Postoperative hemorrhage

was, however, unimportant in this series as primary cause of death.

In 87 cases (21.8 percent of the total number of deaths), the peritonitis

present was sufficiently extensive to assign to it the primaryrole in the fatality.

Fatal peritonitis was most frequent in lesions of the right side of the colon, in

which it accounted for 24 percent of the fatalities, and least frequent in sigmoid

lesions, in which it was responsible for 15 percent. Peritonitis was less to be

feared in World War II than in former wars, and it is difficult to see how the

number of deaths from this cause could have been further reduced. There was

no evidence that the intraperitoneal use of chemotherapeutic and antibiotic

agents greatly influenced the case fatality rates, though there is no doubt that

the svstemic use of sulfonamide drugs, replaced or supplemented by penicillin

after the latter became generally available in May 1944, had an important role

in the control and treatment of peritoneal infections.

number of patients probably died ofperitonitis who might have survived

the infection ifit had not been present in association with another serious lesion.

Others who died from peritonitis during periods of great tactical activity would

perhaps have been saved if they could have had the individualized treatment

which this condition demands but which was practical only when fighting was

less intense.

Two of the five deaths from retroperitoneal cellulitis occurred in patients

with wounds of the extraperitoneal portion of the rectum. In the three other

cases in this group, the original lesions were distributed over the colon, from

the ascending portion to the sigmoid. Of the deaths from intraperitoneal

abscess, followed wound of the ascending colon and followed wounds of the

transverse colon. Figures relative to abscess formation must not be accepted

absolutely, since this complication was delayed development and deaths caused

by it usually occurred in second or third echelon hospitals.

All five deaths from intraperitoneal anaerobic infections occurred prior to

February 1944. Whether the availability ofpenicillin soon after this date played

any part in the improvement, it is not possible to say.

All four patients who died of intestinal obstruction also had injuries of the

small bowel, which in every instance was the site of the obstruction. In two
274 GENERAL SURGERY

known instances, the obstruction followed the breakdown of an intestinal

anastomosis. The number of deaths from intestinal obstruction must be evaluated in the light of the fact that this complication, like abscess formation, was

often late development, and fatalities caused by it were as likely to occur in

rear as in forward hospital installations.

Intrathoracic causes of death.—The 45 deaths from intrathoracic causes

accounted for 11.3 percent of the total number. The majority need no particular comment. The fact that pneumonia was responsible for only 13 deaths

can probably be attributed to two circumstances: (1) The routine use of

chemotherapeutic and antibiotic agents, and (2) the skill of the anesthetists

who worked with the surgeons on these cases. Endotracheal anesthesia and

tracheobronchial aspiration during and after operation must be assigned an

important role in the prevention and control of postoperative atelectasis and,

in turn, in the prevention of the pneumonic process which so frequently follows

this complication.

Other causes of death.—The remainder of the deaths following wounds

of the colon and rectum (table 72) were attributable to variety of causes and

for the most part need no special comment. In of the fatal anaerobic

infections, the infection was in wound of the extremity. The infection in

the two other cases was considered autogenous; it was apparently the result

of direct contamination of the wounds of the buttocks and flank from the

wound of the large bowel.
275

CHAPTER XXI

Wounds of the Liver and of the Extrahepatic

Biliary Tract (829 Casualties)

Gordon F. Madding M. /)., Knowles B. Lawrence M. D.,

and Paul A. Kennedy M. D.

The 829 wounds of the liver which are discussed in this chapter occurred

in 3,066 of the 3,154 abdominal injuries observed by the 2d Auxiliary Surgical

Group during 1944 and 1945 (table 73). Four hundred and forty-six (53.8

percent) were thoracoabdominal. The case fatality rate in this group was

24.0 percent (107), against 27.0 percent (224) for the whole group. In 51 of

the 829 wounds of the liver, the gallbladder was injured, and the extrahepatic

biliary ducts were injured in others. There were 16 deaths in these 53 cases.

Table 73.—Essential data in 829 wounds of liver

NATURE OF INJURY

The majority of these injuries occurred in the right lobe of the liver, as

might have been expected because of its greater size. In the 538 cases observed

in 1944 in which these data were accurately stated, the right lobe was involved

446 times (82.9 percent), the left lobe 73 times, and both lobes 19 times. InCalculationsfor injuries of the liverare made on total of 3,066 abdominal injuries, Instead of on3,154, the base figure

for all other calculations. When the 88 histories which represent the difference between the two totals became available, the medical officerswho had done the work on wounds of the liver had been transferred from the command, and

it was thought wisernot to change their tabulations.

Type of wound Cases

Frequency

Deaths

Case

fatality

rate In 3,066

abdominal

injuries

In 829 liver

injuries

Percent Percent

UnivisceraL ________ 339 11. 40. 33 9.

Multivisceral __ 490 16. 59. 191 39.

Total 829 27. 100. 224 27.
276 GENERAL SURGERY

volvement of adjacent viscera could usually be explained by the location of

the hepatic injury. Wounds about the hilum were seldom seen, possibly

because its protected location kept it from injury but more probably because

most such injuries were immediately fatal. Injuries in this area involved such

structures as the extrahopatic biliary ducts, the retroperitoneal portion of the

duodenum, the pancreas, the stomach, the colon, and the vena cava.

Most wounds of the liver were lacerating, penetrating, or perforating.

Penetrating wounds were usually less serious than those which involved larger

masses of tissue, though they were sometimes followed by graver complications,

such as bile leakage or hemorrhage. Twenty-four percent of all hepatic injuries

were severe, sometimes severe enough to require resection of part of lobe.

The remaining wounds were described as of slight or moderate severity.

Bleeding from the liver, which was only occasionally described as severe,

had ceased at the time of exploration in 91.1 percent of all cases. The significance of this observation will be discussed later (p. 278).

Some bile leakage had occurred in practically every case, but the presence

of blood and exudate in the peritoneal cavity, and sometimes of intestinal

content also, made an estimate of the amount of bile spill impossible.

EVOLUTION OF METHODS OF MANAGEMENT

The management of wounds of the liver by surgeons of the 2d Auxiliary

Surgical Group was matter of evolution and the result of their own clinical

observations. They had no decisive principles of therapy to guide them. Observations of military surgeons in World War were brief and frequently contradictory. Bailey advocated expectant treatment if it were possible to be

certain that the wound affected only the liver. Lee and Wallace also favored

nonintervention in most cases. The Committee on Surgery of the National

Research Council apparently felt that, in World War II, operative therapy

would be necessary more often than it had been in the past.

All of these observers recognized the possibility that spontaneous hemostasis might occur in injuries of the liver, but they placed different degrees of

reliance upon it. Bailey felt that physiologic changes incidental to anesthesia

and surgery might cause renewed bleeding. On the contrary, Wallace’s

experience that spontaneous hemostasis usually occured within to 10 hours

of wounding is in close agreement with the experience of the 2d Auxiliary

Surgical Group.

The observers cited were in general agreement about the possibility of

secondary hemorrhage from the liver, although there was some variance of

Bailey, Hamilton: Surgery of Modern Warfare. Edinburgh; E. 8. Livingstone, 1941-42. The Medical Departmentof the United StatesArmy in the World War. Washington: U. S. Government Printing

Office, 1927, vol. XI, pt. 1. Wallace, Cuthbert: War Surgery of the Abdomen. London; J. A. Churchill, 1918.

Abdominal and Genito-Urinary Injuries. Military Surgical Manuals. Prepared under the auspices of the Committee on Surgery of the Division of Medical Sciences of the National Research Council, Philadelphia and London;

W. B. Saunders Co., 1942.

See footnote 4.
WOUNDS OF THE LIVER 277

opinion about its frequency and danger. Makins stated that secondary

hemorrhage did not occur in the absence of sepsis.

Lee advised suture of the liver in preference to packing. Wallace gave

diametrically opposite advice. Bailey, 10 while admitting the theoretic superiority of suture, nevertheless concluded that packing was “infinitely better”

because of the technical difficulties attending suture of the liver. Packing,

suture, and free muscle grafts were all mentioned by the Committee on Surgery

of the National Research Council as permissible methods for the accomplishment of hemostasis and repair of hepatic wounds. 11 Comments on the use of

simple drainage and on the risk of bile peritonitis were notably lacking in

these discussions of hepatic injuries.

The greatest measure of agreement among surgeons prior to World War II

was their advocacy of expectant or conservative treatment, or no treatment

at all, for most wounds of the liver. Many of these men were surgeons who

had carried over the idea from their experience in World War I. This policy,

however, was incompatible with the surgical philosophy of World War II, in

which operative intervention was held to be in the best interests of practically

every casualty with an abdominal wound if he lived to reach forward hospital.

Since the liver was frequently wounded, both alone and in combination with

other organs, the problem of management of hepatic injuries became important

early in the war.

During the initial activities of the 2d Auxiliary Surgical Group in 1942-43

(a period not covered by these data), wounds of the liver were variously

managed by packing, suture, free muscle grafts, and expectant treatment.

Suture and muscle grafts proved impractical in the hands of most surgeons,

and expectant treatment was not thought to be reliable. During this period,

therefore, gauze packing was the most frequently used of all methods. As

time passed, however, serious complications were observed following this

technique. The removal of gauze packs in field hospitals was more than once

attended by disastrous hemorrhage. Abscesses occurred within the liver or

the perihepatic space, and necrosis of hepatic tissue occurred in areas which

had been packed. Hepatitis and biliary peritonitis were other complications.

These and other undesirable results of gauze packs were emphasized in Burford’s 12 report of hepatic injuries observed in general hospital.

Early removal of the pack was practiced in some cases in an attempt to

prevent these complications, but this plan was not successful. As soon as the

pack was removed, the external wound tended to close prematurely. Attempts

to substitute Penrose drains for packs were also unsuccessful. Adequate

Makins. Cited by Bailey. See footnote 2, p. 276.

See footnote 3, p. 276.

See footnote 4, p. 276.

10 See footnote 2, p. 276.

11 See footnote 5, p. 276. 12Review of 1,000 Thoracic Cases. Bull. U. S. Army. M. Dept. 89 70-72, June 1945,
278 GENERAL SURGERY

drainage by this means proved impossible except under direct vision, when the

abdomen was open.

By early 1944, many surgeons of the group had concluded that the use of

packs in wounds of the liver was associated with too many risks to justify their

employment if it could possibly be avoided. They had become aware of the

frequency with which spontaneous hemostasis was observed in fresh wounds,

and it seemed to them that the only justification for the use of pack was the

prevention of secondary hemorrhage. Since this was not frequent complication, trend began away from the use of gauze packs and toward simple

drainage of the subhepatic space (Morison’s pouch). At first there was some

disagreement concerning the necessity for drainage, but the presence of bile

in discharges in substantial proportion of cases when both drains and gauze

packs were used, as well as the frequent observation of bile in the peritoneal

cavity in wounds of the liver, convinced most surgeons of the necessity for

external drainage as protection against bile peritonitis.

Some surgeons continued to close the abdomen without drainage when the

injuries of the liver were limited to lacerations or penetrations which required

no special treatment. The majority, however, took the position that all

injuries required drainage, on the ground that it was impossible to predict, in

given case, whether bile leakage would or would not occur. In few patients

with thoracoabdominal wounds, troublesome bile empyema resulted from

failure to drain the subphrenic space after operation had been performed

through the right thorax. It was the consensus that this complication would

probably not have occurred in these cases if drainage had been instituted

through subcostal incision.

These clinical observations led to almost complete abandonment of

packing as method of treatment in hepatic injuries and to its almost universal

replacement by drainage of Morison’s pouch. The data recorded in this

chapter substantiate the soundness of this change of policy. The almost total

absence of postoperative hemorrhage in the cases which were drained indicates

that this risk had been overemphasized early in the war. Similarly, the

efficacy of drainage as means of preventing bile peritonitis is attested by the

absence of this complication in the cases treated by this method.

TREATMENT

The location of the incision in injuries of the liver (table 74) naturally

depended, in any given case, upon the extent of the injury or injuries, and, in

particular, upon whether the wound was abdominal or thoracoabdominal.

The popularity of the transdiaphragmatic approach increased as the war

progressed. In an occasional case, thoracolaparotomy was employed; the

incision was extended over the chest wall onto the abdomen, the costal arch

being cut or the incision passing through the 10th or 11th intercostal space.

In many wounds of the liver, there was sufficient fragmentation of the

organ to necessitate actual resection of the damaged tissue instead of debride-
WOUNDS OF THE LIVER 279

ment. Often substantial amount of tissue had to be removed. In this sort

of case, it was not unusual to find completely detached pieces of liver lying free

in the peritoneal cavity as result of the original trauma.

Table 74.—Distribution of surgical approaches in 432 wounds of liver

In sample of 695 cases observed in 1944 and 1945 in which full data

concerning treatment were available (table 75), the changing proportions of

cases treated by drainage and by packing are significant reflection of increasing

surgical experience. Though originally some wounds of the liver were regarded

as too small to require drainage, this attitude became less and less frequent as

the war progressed. In some cases in which drainage was instituted, there was

no bile in the discharge after operation, but, as already noted, it was impossible,

either preoperatively or at operation, to identify the cases in which this could

be expected to happen. The size of the missile was not the determining consideration. wound caused by small foreign body which cut main bile

channel was likely to be followed by more profuse drainage than superficial

hepatic injury of greater extent. The principle that all suspected wounds of

the liver should be explored and the additional principle that all should be

treated by adccpiate drainage were eventually established as the only sound

policy in this type of injury.

Table 75.—Percentage distribution of operations in 695 wounds of liver

Approach

1944 1945 Total

Cases Proportion Cases Proportion Cases Proportion

Percent Percent Percent

Laparotomy 172 53. 42 39. 214 49.

Thoracotomy 107 32. 50 46. 157 36.

Combined laparotomy and thoracotomy 40 12. 14 13. 54 12.

Thoracolaparotomy 1. 1.

Total 325 100. 107 100. 432 100.

In this technique, the thoracic incision was extended across the costal arch onto the abdominal wall.

Operation 1944 1945 Total

Drainage only 48. 50 87. 57.

Suture and drainage 6. 50 1. 5.

Suture and pack 95

Pack only 34. 10 9. 28.

Muscle graft 15

No treatment. 9. 80 1. 7.
280 GENERAL SURGERY

Drainage was instituted with Penrose or cigarette drains. Two were

employed if the wound was large or if there was more than one injury. The

accepted practice was to place Penrose drain lateral to the postero-inferior

margin of the liver, to prevent collections of bile or pus in this region, and to

use the same technique for drainage of the subhepatic space. To guard against

wound infections and disruptions, the drains were not brought to the exterior

through the original laparotomy or thoracolaparotomy incision. Instead, they

were delivered through dependent incision placed subcostally in the anterior

or midaxillary line and preferably at least 1.5 inches long. It was found essential to extend this incision through all layers of the abdominal wall. If they

were not widely opened, the drains were likely to become strangulated and

their whole purpose would be defeated. In the occasional case, debrided

wound track coincided with the site of the usual subcostal incision for drainage

and could be used satisfactorily for this purpose.

It was imperative to keep the drains in situ until bile drainage had ceased

completely. This was usually by the 10th or 12th day, though it was sometimes considerably later. Drains were always shortened gradually, beginning

on the 4th or 5th day. They were never removed abruptly in toto.

Although packing became less and less popular as definitive method of

treatment as the war progressed, the temporary use of dry pack was occasionally extremely helpful. Active oozing from large superficial wounds of the

liver could be controlled by this means while more urgent injuries were being

cared for. It was unusual, when the pack was removed, not to find that

bleeding had ceased and that no other measures were necessary to control it.

Relatively few wounds of the liver were sutured by surgeons of the group

in the course of the war. By 1945, most of them had abandoned the practice

completely, chiefly because it had been repeatedly observed that more serious

bleeding might follow this procedure than had existed before it.

POSTOPERATIVE COMPLICATIONS

Not very many complications of wounds of the liver were observed in

forward hospitals as compared with the number observed in hospitals farther

to the rear. report by Burford 13 from general hospital showed that 25,

chiefly resulting from inadequate drainage, had occurred in 98 wounds of the

liver. They included subphrenic abscess in 14 cases, intrahepatic abscess in

cases, and bile empyema in cases.

The complications observed in field hospitals were what might have been

expected in view of the nature of the wounds. They were chiefly presented

as bile empyema or biliary thoracic fistula. The diaphragm was obviously

perforated in all thoracoabdominal wounds, which comprised 53.8 percent of

the wounds of the liver. Bile and exuded fluids, if they could not drain externally because pack had been used or for other reasons, sometimes forced

their way through the sutured diaphragmatic wound, with the results just

13 See footnote 12, p. 277.
WOUNDS OF THE LIVER 281

stated. The technique by which the diaphragm was closed seemed to have

nothing to do with their occurrence. In one such case, the lung was adherent

to the diaphragmatic suture line, and the erosion of bronchus by bile created

an extremely serious problem. Occasionally the bile, after it had eroded the

diaphragmatic suture line and reached the pleura, caused breakdown of the

thoracotomy incision, with resulting subphrenic pleurocutaneous fistula.

Although there was no instance in forward hospital of fatal secondary

hemorrhage, surgeon of the group witnessed such an accident in general

hospital after removal of pack from the liver on the 18th postoperative day.

The single instance of serious postoperative bleeding which occurred while

these patients were under observation in forward hospitals is recorded in

detail because of the lessons implicit in the case:

Case report.—An American soldier was admitted to field hospital after being wounded

in the right costophrenic sulcus and the hilar region of the liver by high-explosive shell

fragments. The wound was extended and debrided under nitrous oxide-oxygen-ether

anesthesia, and shell fragment and several bits of clothing were removed from the liver.

There was some oozing of dark blood, but the bleeding was not thought sufficient to justify

any special hemostatic measures. Penrose drains were introduced and brought out through

separate drainage incision.

For 36 hours after operation, there was copious drainage of bile, but the postoperative

course was otherwise uneventful until the eighth postoperative day. Then severe hemorrhage occurred through the drainage incision. It ceased spontaneously, and there was no

further bleeding until the ninth day, when second severe hemorrhage occurred. Like the

preceding hemorrhage, it was massive and obviously arterial in origin. It was checked by

the insertion of gauze pack deeply into the liver wound, through the enlarged drainage

incision. third hemorrhage 36 hours later was checked by the insertion of fresh pack

after the removal of the original pack.

Chills and fever occurred on the 16th postoperative day, while the second pack was

still in situ. On the 17th day, the temperature rose to 105.8° F., and another severe hemorrhage occurred about the pack. The external wound was then opened under Pentothal

anesthesia, and the wound in the liver was exposed by excision with the actual cautery for

depth of cm. large artery was found to have been partially severed by the original

injury. It was clamped and ligated, and Penrose drains were inserted into the depth of

the wound.

Convalescence was stormy. Severe distention developed on the 18th day (counting

from the day of the first operation). On the 22d day, there was profuse biliary drainage.

On the 32d day, liver abscess was drained. On the 41st day, pelvic abscess was drained, and on the 51st day subhepatic abscess was drained. Thereafter recovery was satisfactory, and when the patient was evacuated on the 75th day, he was in good condition.

The hemorrhages in this case were probably all caused by repeated reopening of the partially severed artery as the surrounding clot retracted.

The insertion of the first pack, on the ninth day after operation, was perhaps

justified, in an attempt to control bleeding by conservative means. In retrospect, however, it clearly would have been wiser to explore the bleeding

area without delay when hemorrhage recurred; it was known that the wound

was in the hilum, and the hemorrhage was so massive that extensive packing

was necessary to check it. There was no local or systemic evidence of infection when this pack was applied. It seems certain, however, that the compli378327°—56 20
282 GENERAL SURGERY

cations which followed—infection, secondary venous bleeding, hepatic abscess,

subhepatic abscess, and pelvic abscess —all arose because pack was used and

drainage was thus impeded. Any one of these complications could readily

have been fatal, and all might have been prevented bad the secondary

hemorrhage been attacked at its source when it first occurred on the eighth

postoperative day.

CASE FATALITY RATES AND FACTORS OF MORTALITY

The case fatality rate in these 829 wounds of the liver, 27.0 percent (224

deaths), is to be compared with the rate of 66.3 percent reported for similar

wounds in American Expeditionary Forces in World War I. 14 These 829

wounds represented 27.0 percent of 3,066 abdominal injuries, in contrast to

the 13.3 percent represented by comparable wounds among American soldiers

in World War (table 8, p. 93). The British proportion of wounds of the

liver in that war was 16.8 percent (table 8).

Shock was responsible for 115 of the 224 fatalities in wounds of the liver,

51.3 percent of the total number of deaths. All deaths from this cause occurred before the end of the second postoperative day. When these patients

were first seen, they were all in serious circulatory collapse, which persisted in

spite of vigorous efforts at resuscitation. Blood loss was only one of several

contributory factors; others included disturbances of cardiorespiratory physiology, overwhelming contamination of the peritoneal and pleural cavities,

actual destruction of tissue, and widespread retroperitoneal cellulitis.

Pulmonary complications were the cause of 38 deaths, 17.0 percent of the

total number. Trauma to the diaphragm, which occurred in over half of all

wounds of the liver; trauma to the lung; contamination of the pleural cavities

by bile; and the necessary prolongation of anesthesia and operation provided

an ample background for this cause of death.

Peritonitis was primarily responsible for 28 deaths, 12.5 percent of the

total number. It was present to some degree in all fatal cases, but it was not

considered the primary cause of death unless it was widespread or took the

form of localized process, such as subphrenic abscess.

Oliguria and renal failure were the chief causes of death in 19 cases (8.5

percent). The so-called transfusion kidney and pigment nephropathy could

not be excluded as the principal lesion in these cases, but interesting possibilities obviously suggest themselves concerning the relationship between the

liver damage and the renal failure.

In the remaining 24 cases, the causes of death included such conditions

as gas gangrene, head injuries, and wounds of the spinal cord with paraplegia.

The hepatic injury in this group usually played only minorrole in the fatal

outcome.

It should be emphasized again that in no case in this series could death

during the postoperative period in forward hospital be ascribed to bleeding

14 See footnote 3, p. 276.
WOUNDS OF THE LIVER 283

from the liver. In World War I, hemorrhage was the chief source of both

morbidity and mortality in wounds of the liver, while in World War II, at

least in the cases handled by the 2d Auxiliary Surgical Group, bile leakage and

damage of the hepatic parenchyma (after shock) were the chief factors of mortality.

The source of bleeding in wounds of the liver is the hepatic artery, the

hepatic vein, or the portal vein. Unless, therefore, hilar injury has been

sustained or missile has penetrated deeply into the liver tissue, serious bleeding should not be common. The larger branches of the portal vein lie nearer

the surface than the branches of the arterial system, but the pressure in the

venous system is low (8 to 10 mm. Hg), and hemorrhage from them, as is clear

from this series of wounds of the liver, is not difficult to control.

The change in therapeutic methods reflects this change of emphasis. In

World War I, packs to control hemorrhage furnished the chief method of

treatment when active treatment was undertaken at all. In World War II,

active therapy was undertaken in all cases, and drainage eventually became

the most popular method of treatment.

The deathrate in this series undoubtedly was influenced by certain factors

such as the wounding agent (p. 97), the timelag from injury to operation (p.

103), the availability ofadequate shock therapy (p. 124), and the use of the sulfonamides and later of penicillin (p. 197). It is difficult, however, to reduce

their influence to statistical terms. The case fatality rate was higher during

the winter than the summer, probably, as in other injuries, because of the

higher winter incidence ofrespiratory infections.

The case fatality rate was directly proportional to the number of viscera

injured (table 10, fig. 22). It was 9.7 percent when only the liver was injured,

but it rose to 84.6 percent when four or more other viscera were injured

also.

Associated extra-abdominal injuries were chiefly compound fractures of

the long bones, traumatic amputations, injuries of the head and spinal cord,

and injuries of the lungs and other thoracic structures, including, occasionally,

the heart. They added greatly to the morbidity of this series and undoubtedly

contributed to the death rate, though it is impossible to evaluate their individual influence.

WOUNDS OF THE EXTRAIIEPATIC BILIARY TRACT

The degree of damage to the gallbladder varied widely in the 51 wounds

of the liver in which this organ was implicated. In one instance, the fundus was

partially avulsed from its bed; but the gallbladder wall was not damaged, and

simple suture was the only treatment necessary. In five cases, the wounds of

the fundus were small and could be closed by purse-string suture. In the

remaining cases, the damage was almost evenly divided between severe lacerations which required cholecystectomy and less severe injuries which could be

treated by cholecystostomy.
284 GENERAL SURGERY

One of the two patients with an injury of the common duct suffered

perforation of the hepaticoduodenal ligament; simple suture, without drainage,

was followed by prompt recovery. The other had wound of the duct near

the ampulla of Vater. It was overlooked at operation, and, while the patient

had other severe injuries, this error unquestionably contributed to the fatal

outcome.

Because of the presence of wounds of the liver in all wounds of the extrahepatic biliary tract, it is clearly impossible to determine the influence exerted

by the latter type of injury upon the case fatality rate. It was probably not

very important. The rate for all wounds of the liver was 27.0 percent. For

the 53 cases in which wounds of the liver were associated with injuries of the

extrahepatic biliary tract, it was 30.2 percent, which is not materially different.
285

CHAPTER XXII

Wounds of the Pancreas (62 Casualties)

IT. Leon Poole M. D.

The pancreas was wounded less frequently than any other major abdominal

organ in the 3,154 abdominal injuries treated by the 2d Auxiliary Surgical

Group in 1944-45 (table 76). The low frequency, 2.0 percent, parallels other

reported experiences. In World War I, there were only such injuries reported

by British observers in series of 965 cases (0.5 percent), and the proportion

in all abdominal injuries sustained by the American Expeditionary Forces was

even lower (0.2 percent). Jolly reported injuries of the pancreas in series

of 970 abdominal injuries observed in the Spanish Civil War.

Table 76.—Essential data in 62 wounds of pancreas

The low frequency suggests that many of the patients who sustained such

injuries did not survive to reach the hospital. The risk is not so much in the

injury of the pancreas per se as in the almost inevitable damage to surrounding

structures. This is borne out by certain facts:

1. Only of the 62 injuries in this series was univisceral.

2. Thirteen of the casualties also suffered injury to major blood vessel, in five cases the vessel being the vena cava.

3. Every patient was in shock wdien he was first seen.

4. The case fatality rate was 56.5 percent (35 deaths).

The precise danger inherent in wound confined to the pancreas cannot

be determined from this series, in which, as just mentioned, there was only one

univisceral injury. The relative surgical inaccessibility of the pancreatic

History of the Great War Based on Official Documents. Medical Services Surgery of the War. London: His

Majesty’s Stationery Office, 1922, vol. I.

The Medical Departmentof the United States Armyin the World War. Washington: U. S. GovernmentPrinting

Office, 1927, vol. XI, pt. 1. Jolly, Douglas W.: Field Surgery in Total War. New York: Paul B. Hoeber. Inc., 1941.

Frequency

Type of wound Cases In 3,154 abdominal injuries

In 62 pancreatic injuries

Deaths Case fatality rate

Univisceral

Percent

0. 03

Percent

1. 100.

Multivisceral 61 1. 93 98. 34 55.

Total __ 62 1. 97 100. 35 56.
286 GENERAL SURGERY

region is attested by the fact that in three cases the wound was diagnosed

only at autopsy.

NATURE OF INJURY

Agents causing injuries of the pancreas were of the same type, and acted

with essentially the same frequency, as in other categories of abdominal injuries.

Lacerations and perforations were the commonest type of wound. Penetrating

wounds were present in cases, and the organ was transected times. In the

52 cases in which data concerning location were recorded, the head was involved 14 times, twice with involvement of the pancreatic duct also; the tail

24 times; and the body 14 times. Peritonitis caused by spill of pancreatic

secretions was recorded in only one instance.

Thirty-two injuries, of which sixteen were fatal, were thoracoabdominal,

and thirty, of which nineteen were fatal, were confined to the abdomen.

MULTIPLE AND ASSOCIATED INJURIES

Wounds of the pancreas were associated with wounds of other viscera in

all except of the 62 cases (tables 76 to 78, inclusive). The other damaged

organs, in order of frequency of involvement, were the stomach, liver, spleen,

kidney, colon, duodenum, and jejunum and ileum. Two or more other viscera

were injured in almost three-quarters of all cases. Vascular injuries were

associated in 13 cases, in every one of which other viscera were also injured.

Associated injuries, all of which were severe, were present in 16 cases

(25.8 percent). Seven of these injuries were compound fractures or extensive

soft-tissue wounds, and two patients had spinal-cord injuries.

Table 77.-—Influence of multiplicity factor on case fatality rates in 62 wounds of pancreas

CLINICAL FINDINGS

All 62 patients with injuries of the pancreas were in shock when they were

first seen. In not single instance were clinical findings such as to arouse

suspicion that the pancreas had been injured.

Organs injured Cases Deaths

Case

fatality

rate

Pancreas only 100.

Pancreas and viscus 15 33.

Pancreas and viscera 22 11 50.

Pancreas and viscera 15 60.

Pancreas and viscera 100.

Total 62 35 56.
WOUNDS OF THE PANCREAS 287

Table 78.—Influence of specific additional organs wounded on case fatality rates in 61 multivisceral wounds of pancreas

All the men were seen too early for the effects of digestive secretions to

have become apparent upon the skin. It was not possible by clinical methods

to differentiate digestive peritonitis from peritonitis caused by fecal contamination. It was impossible to identify the pancreatic secretion in the discharge

from the wound because of the admixture of blood and gastrointestinal contents. Laboratory facilities were not available for such determinations as

the serum amylase test for pancreatitis. The sole clue to pancreatic wound, in short, was the anatomic site of the injury.

TREATMENT

transdiaphragmatic approach was used in 12 of the 32 thoracoabdominal

injuries, and some type of abdominal incision in the other 48 cases in which

this detail was recorded. Because the pancreatic wound was of secondary

importance in all but one case in the series, the approach which afforded the

greatest facility in the management of the other wounded viscera was always

chosen.

Drainage of the site of the pancreatic injury was the only treatment in 24

of the 59 cases in which the diagnosis was made ante mortem. The wound

was sutured in 17 cases, in 11 of which drainage was instituted. Packing was

employed in cases, in of which drainage was instituted. The other

cases were managed by partial pancreatectomy, in instances supplemented

by drainage. Ligation of the pancreatic duct was performed in of the

cases in which this structure was injured.

Organs Injured

Two organs only Plus additional organs Total

Cases Deaths

Case fatality

rate

Cases Deaths

Case fatality

rate

Cases Deaths

Case fatality

rate

Pancreas and stomach 25. 33 21 63. 37 22 59.

Pancreas and duodenum. C) 11 81. 11 81.

Pancreas and jejunoileum 87. 87.

Pancreas and colon 66. 14 10 71. 17 12 70.

Pancreas and liver. 40. 20 13 65. 25 15 60.

Pancreas and spleen 20 11 55. 22 11 50.

Pancreas and kidney 19 16 84. 20 16 80.

Pancreas and major vessels 0) 13 11 84. 13 11 84.

Not applicable.
288 GENERAL SURGERY

In three instances, as already mentioned, the injury was overlooked and

an ante mortem diagnosis was not made. Four patients died on the operating

table, and in the six remaining cases it was not possible to determine from the

records why no active treatment had been instituted.

POSTOPERATIVE COMPLICATIONS

Shock which was present before operation and continued afterward was

not listed as postoperative complication. When it is excluded, postoperative

complications occurred in 13 cases (21.0 percent). Anuria was present in five

cases. Digestive peritonitis was observed in two instances; in one the diagnosis

was made at operation and in the other at autopsy. Acute pancreatitis,

jaundice, gastric hemorrhage, biliary fistula from an overlooked common duct

injury, pulmonary edema, pneumonia and empyema, and femoral phlebitis

occurred in one case each. Pancreatic fistula and its complications were not

observed in forward hospitals, the patients being evacuated before these

became manifest, but the records did not mention particular difficulties from

pancreatic drainage.

CASE FATALITY RATES AND FACTORS OF MORTALITY

There wore 35 deaths in the 62 pancreatic wounds (56.5 percent). Four,

as already noted, occurred on the operating table, and an additional

15 occurred within the first 24 hours after operation. Two patients died on

the first postoperative day, three on the second, one on the third, seven between the fifth and seventh days, and three after the seventh day.

Shock, hemorrhage, or both, were the primary causes of death in 21 of

the fatalities (60.0 percent). Anuria was responsible for other deaths and

peritonitis for 3. The other six were variously caused by pancreatitis, gastric

hemorrhage, atelectasis, pulmonary edema, pneumonia, and the vagovagal

reflex following bronchoscopy.

The single patient with univisceral pancreatic injury died on the eighth

postoperative day, of pneumonia and empyema. In multivisceral injuries,

the case fatality rate increased progressively as additional organs were involved

(table 77) and reached 100 percent in the cases in which were involved in

addition to the pancreas.

The cause of death was not stated in of the patients who died on the

operating table. In the other three cases, the causes were, respectively,

pancreatitis, hemorrhage and shock, and hemorrhage from an injured medias- tinal vessel. All three patients whose pancreatic injuries were not discovered

until autopsy had other serious visceral or vascular injuries. One of these

three deaths was caused by anuria, one by peritonitis caused by an unrecognized

lesion of the duodenum, and one by bile peritonitis arising from an overlooked

injury of the common bile duct.
WOUNDS OF THE PANCREAS 289

There were 11 fatalities in the 13 cases associated with vascular injury

(84.6 percent). All five patients with injuries of the inferior vena cava died,

as did each of the patients with injuries of the duodenal and pancreatic vessels

and of the lumbar artery. One of the four patients with injuries of the splenic

pedicle survived, as did one of the two with injuries of the renal pedicle.

291

CHAPTER XXIII

Wounds of the Spleen (341 Casualties)

H. Leon Poole M. D.

The experience of the 2d Auxiliary Surgical Group with wounds of the spleen was at some variance with previous experiences with these injuries. The

frequency was greater, the proportion of multivisceral injuries was larger, and

the damage to the organ was more severe than previous records showed, but

the case fatality rate w~as lower, probably because policies of treatment, including operative approaches, were different.

Records of 3,546 abdominal wounds sustained by the American Expeditionary Forces in World War include only 49 instances of injury to the

spleen, frequency of 1.4 percent. Bailey, in 1942, reported only 54 splenic

injuries among British troops and estimated their frequency at 5.6 percent.

Jolly reported percentage of 4.6 injuries of the spleen in series of 238 cases

of abdominal injuries in the Spanish Civil War. Giblin reported splenic

injuries among 90 abdominal wounds observed during the El Alamein campaign.

Splenic injuries occurred in 32 cases, 5.1 percent of the total number, in the two

periods covered by Ogilvie’s report in 1942 on abdominal wounds in the Western Desert.

In contrast to these figures, the surgeons of the 2d Auxiliary Surgical

Group observed 341 instances of splenic injury in the 3,154 patients with abdominal injuries treated during 1944 and 1945 (10.8 percent) (table 79). This was

greater than the frequency of 6.4 percent (22 of 346 abdominal injuries) recorded

by the same surgeons in 1943.

Two hundred and fifty-three of the three hundred and forty-one wounds

(74.2 percent) were thoracoabdominal injuries. In their entire experience

from 1943 through 1945, the group surgeons treated total of 903 thoracoabdominal injuries, in which the left diaphragm was involved 468 times. There

were 277 wounds of the spleen (59.2 percent) in these 468 cases.

NATURE OF INJURY

The agents causing injury to the spleen were in general of the same type

and operated with essentially the same frequency as those responsible for other

abdominal injuries. Blast was recorded as the cause of three wounds. Of

(1) The Medical Departmentof the United StatesArmy in the WorldWar. Washington: U. S. GovernmentPrinting Office, 1927, vol. XI, pt. 1. (2) This number does not Include two cases of injury to the spleen among American

troops in Russia.

Bailey, Hamilton: Surgery of Modern Warfare. Edinburgh: E. S. Livingstone, 1941-42.

Jolly, Douglas W.: Field Surgery in Total War. New York: Paul B. Hoeber, Inc., 1941.

Giblin, T.: Abdominal Surgery in the Alamein Campaign. Australian New Zealand J. Surg. 13:37-64, July

1943.

Ogilvie, W. H.: Abdominal Wounds in the Western Desert, Surg., Gynec. Obst. 78:225-238, March 1944.
292 GENERAL SURGERY

Table 79.—Essential data in 341 injuries of spleen

the non-battle-incurred injuries in the series, were the result of accidental

falls and the result of vehicular accident.

All degrees of damage were present after wounding, ranging from small

fissures to complete fragmentation of the body of the spleen. In few instances,

the organ was penetrated. Severe lacerations, penetrations, and perforations

produced essentially the same gross lesions as splenic fracture; that is, irregular rents in the capsule radiating from the track of the causative agent.

Injury to the splenic pedicle, without injury to the body of the organ, occurred

times and subcapsular hematoma times. From the standpoint of degree,

the injuries were classified as severe in 61.3 percent of the cases, as moderate

in 29.3 percent, and as slight in only 9.4 percent.

Active hemorrhage from the injured spleen was only occasionally encountered when the abdomen was opened. In these cases, either the pedicle

was injured or the body of the organ was seriously damaged. Unless, however,

the injury was slight, there was always evidence of previous hemorrhage, and

active bleeding usually recurred during the maneuvers incidental to splenectomy. In some instances of thoracosplenic injury in which very little blood

was encountered in the peritoneal cavity, an extensive left-sided hemothorax

was present. The finding was so commonly associated with injuries of the

spleen, in fact, that their presence was suspected whenever large hemothorax

was present in association with missile wounds in the lower portion of the left

chest. This phenomenon was probably the result of negative intrapleural

pressure, which caused the blood in the upper abdomen to be sucked up through

the diaphragmatic rent.

Multivisceral and associated injuries.—One hundred of the three hundred

and forty-one wounds of the spleen (29.3 percent) were univisceral (table 79).

Eighty-two of these occurred in thoracoabdominal injuries. The proportion

Frequency

Case

fatality

rate

Type of wound Oases In3,154

abdominal

injuries

In 341 splenic

injuries

Deaths

Univisceral 100

Percent

3.

Percent

29. 12 12.

Multivisceral 241 7. 70. 73 30.

Total cases 341 10. 100. 85 24.

Thoracoabdominal. 253 8. 74. 67 26.

Abdominal 88 2. 25. 18 20.

Total cases 341 10. 100. 85 24.
WOUNDS OF THE SPLEEN 293

of univisceral injuries is lower than that reported in other wars. One-third of

the 49 splenic injuries recorded among American Expeditionary Forces in

World War were univisceral, as were 59.2 percent of the 54 cases reported

among British troops by Bailey in 1942. Jolly, while citing no exact figures,

stated that univisceral injuries were “rare” in the Spanish Civil War. Ten of

the twenty-two injuries of the spleen treated by the 2d Auxiliary Surgical

Group in 1943 were univisceral.

The 241 multivisceral injuries of the spleen in this series were chiefly

associated with wounds of the stomach (100 cases), the colon (92 cases), the left

kidney (84 cases), the small intestine (53 cases), the liver (50 cases), and the

pancreas (22 cases). The jejunum was most frequently involved in

wounds of the small intestine, the duodenum being injured only three times.

The most commonly involved portions of the colon were the splenic flexure, the

left transverse colon, and the upper portion of the descending colon. In

number of instances, two separate portions of the colon were injured.

Other structures were injured with much less frequency. The adrenal

gland was injured in three cases and the gallbladder once. Major vascular

channels, including the gastroepiploic artery, the left renal vein, the celiac axis,

and the thoracic aorta, were involved in four instances. second wounding

agent had made separate entry in each of the three cases in which the urinary

bladder, the sigmoid colon, and the rectum were also injured.

Severe associated injuries, which were themselves multiple in 20 instances,

occurred in 128 cases (34.6 percent). The most important were as follows: 53

soft-tissue injuries with 14 deaths, 36 compound fractures with 10 deaths, 13

spinal cord injuries with deaths, and amputations with death. These

injuries were often so severe that they contributed materially to the development of shock prior to surgery and to the development of complications after

operation.

CLINICAL CONSIDERATIONS

Shock was an extremely common clinical finding in injuries of the spleen

(table 80). Its absence, however, could not be taken to indicate that the spleen

was not involved in the injury. It was mentioned as not present when the

patient was first seen in 78 of 319 recorded cases (24.4 percent), in 48 of which

the injury was multivisceral. Mild shock was present in 13.5 percent of the

injuries and moderate or severe shock in 62.1 percent.

Tenderness and muscle defense in the left upper quadrant of the abdomen

were always present in splenic injury. Pain referred to the left shoulder and to

the base of the neck was observed in few cases. The frequency of extensive

left-sided hemothorax has already been commented on.

See footnote 1, p. 291.

See footnote 2, p. 291.

See footnote 3, p. 291.
294 GENERAL SURGERY

Table 80.—Influence of degree of shock and type of wound on case fatality rates in 319 injuries

of spleen

TREATMENT

The “surgical abstention” practiced in World War was never seriously

considered as method of treatment for wounds of the spleen managed in

World War II by the 2d Auxiliary Surgical Group. It was the general opinion

that splenectomy was the procedure of choice in all cases and that it was imperative in every injury of more than minimal severity. It was performed in

299 of the 341 wounds in this series (87.7 percent) (table 81), in instances

with supplemental drainage.

Three of the forty-one patients in whom splenectomy was not performed

died on the operating table, before the operation could be completed. In one

severe injury in which the splenic vein was severed, surgery was limited to ligation of the vein. In 12 cases (table 81) in which the injury was not severe,

drainage, pack, or suture was considered sufficient. In the majority of these

cases, though not in all, the lesion consisted merely of small fissure, with no

active hemorrhage and little or no evidence of previous hemorrhage. In the

remaining cases, the other visceral injuries or the associated injuries were of

such severity that they took precedence over the splenic injury, or it was

thought that the addition of splenectomy to the procedures already accomplished woidd be beyond the limits of the patient’s tolerance.

Suture of the spleen, which was carried out in seven cases, proved an inadequate and unsatisfactory measure for the control of active hemorrhage, the

prevention of subsequent hemorrhage, and the repair of damage to the spleen;

the risk of secondary hemorrhage, in fact, was substantial. Moreover, this

measure was as time consuming as splenectomy. The supplementary use of

muscle strip, which was employed in one case, was no more effective than simple

suture. Packing of the spleen also proved an ineffective method of management.

Modern hemostatic agents such as absorbable gelatin sponges were available in overseas theaters during World War II only in limited quantities and

Degree of shock

Univisceral wounds Multivisceral wounds Total

Cases Deaths

Case

fatality

rate

Cases Deaths

Case

fatality

rate

Cases Deaths

Case

fatality

rate

None ...30 3. 48 4. 78 3.

Mild 18 5. 25 20. 43 14.

Moderate 29 10. 66 15 22. 95 18 18.

Severe 16 43. 87 49 56. 103 56 54.

Total 93 12 12. 226 71 31. 319 83 26.

These data are missing in 22 cases.
WOUNDS OF THE SPLEEN 295

for designated purposes. If the situation had been different, the necessity for

the removal of only slightly damaged spleens might have been prevented.

Table 81. —Methods of treatment in 40 injuries of spleen

The record of patient who died on the operating table does not make clear what had been accomplished when

death occurred.

In the 29 cases in this group, the wound of the spleen, for various reasons, was not attacked. Twenty-one of the

operations were performed through thoracoabdominalincision.

Surgical approach.—The surgical approach to injuries of the spleen in this

series (table 82) differed materially from the techniques employed in previously

reported series. The most striking departure from earlier methods was the

frequent use of transdiaphragmatic incision in thoracoabdominal wounds.

This approach was used in 171 cases, 67.6 percent of the 253 thoracoabdominal

injuries and 50.1 percent of the 341 injuries which make up the total series of

wounds of the spleen. In the other 82 thoracoabdominal injuries, the abdominal approach was employed in 75 cases (29.6 percent), and both thoracic and

abdominal incisions were used in the other cases. Since thoracoabdominal

wounds furnished almost three-quarters of the wounds of the spleen, it is not

surprising to find that the transthoracic approach was used in so large proportion of the cases. Anesthesia is an important consideration in this technique,

but the ready availability of competent anesthetists, who were provided with

adequate equipment, prevented any difficulties in that respect.

The case fatality rates for the transdiaphragmatic and abdominal approaches to thoracoabdominal injuries of the spleen, 19.9 percent against 41.3

percent, are so greatly in favor of the transdiaphragmatic approach as to suggest that all the advantages lay with it. Actually, the marked disparity in the

figures should not be interpreted as furnishing true appraisal of the respective

rates by the two techniques. Rather, the lower rate for the transdiaphragmatic

Type of wound

Methods of treatment Thoracoabdominal AbdominalTotal

Splenectomy:

Cases 224 75 299

Deaths 60 13 73

Case fatality rate__ __ 26. 17. 24.

Other measures;

Cases 29 12 41

Drainage only ______

Pack

Suture

No operation on spleen 21 29

Deaths 12

Case fatality rate 24. 41. 29.
296 GENERAL SURGERY

Table 82. -—Surgical approaches in 337 wounds of spleen

approach is reflection of thefeasibility and ease of intimate surgical exploration

of the left upper abdominal quadrant by this incision in appropriate cases. In

many of the thoracoabdominal injuries involving the spleen handled by the

abdominal route, the multiplicity and location of the visceral injuries made

approach from below mandatory. number of cases showed that it was questionable wisdom to repair the diaphragm from below under these circumstances,

although some surgeons followed this plan, on the ground that in very sick

patient it might be better to proceed with celiotomy, in the hope of avoiding

two major incisions.

In spite of the advantages of transdiaphragmatic incision in the management of thoracoabdominal injuries involving the spleen, this approach was not

used when the thorax was not involved in the wound, for two reasons:

1. It was seldom possible before operation to exclude the presence of other

intraperitoneal injuries which could not be properly explored and repaired

through the diaphragm.

2. When wounds of the stomach, small intestine, or colon complicated the

splenic injury, there was always risk of contaminating an undamaged pleural

cavity during the transdiaphragmatic repair of the gastrointestinal wounds.

Although surgeons were in general agreement, as already mentioned, that

the transdiaphragmatic approach was not the best technique for injuries of the

spleen confined to the abdomen, there was no agreement as to how this type

of injury should be approached. The left rectus and left paramedian incisions

were most frequently used. Occasionally the one or the other was extended

to the left, but as rule splenectomy, as well as other operations in the left

upper quadrant and other parts of the abdomen, could be accomplished through

the original incision. The loft subcostal incision and certain transverse incisions also proved satisfactory for splenectomy, though their usefulness

Surgicalapproach

Type of injury

Total

Thoracoabdominal Abdominal only

Cases Deaths

Case

fatality

rate

Cases Deaths

Case

fatality

rate

Cases Deaths

Case

fatality

rate

Transdiaphragmatic 171 34 19. 171 34 19.

Abdominal 75 31 41. 84 18 21. 159 49 30.

Transdiaphragmatic and

abdominal 28. 28.

Total 253 67 26. 84 18 21. 337 85 25.

Thisinformation is lacking in cases.
WOUNDS OF THE SPLEEN 297

was limited by the possibility of other visceral injuries and the fact that full exploration of the peritoneal cavity was difficult or actually impossible through

any of them. An additional serious objection, in view of the many instances

in which injury to the large bowel complicated the splenic injury, was the

fact that all of these incisions utilize the space best adapted for exterioriza- tion of the colon.

POSTOPERATIVE COMPLICATIONS

Although the records of 69 patients, 20.2 percent of the total number, were incomplete, it was possible to determine indirectly, from various sources,

that large proportion of this group was evacuated without the development

of postoperative complications. Aside from peritonitis and shock, which were

present alone or in combination in many cases at operation, major complications were recorded in 21.0 percent of the 341 splenic injuries. Anuria, wound

infection, and atelectasis were the most frequent. Portal thrombosis and

secondary hemorrhage from the spleen or splenic pedicle apparently did not

occur. There was also no mention of accidental injury to the pancreas or

stomach incurred during the operative procedure. Among miscellaneous complications were malaria (3 instances); intestinal obstruction, pneumothorax,

anaerobic infection, and psychosis (2 instances each); massive gastric hemorrhage, paroxysmal tachycardia, femoral phlebitis, pelvic abscess, jaundice,

decubitus ulcer, cardiac failure, spinal meningitis, pulmonary edema, transfusion reaction, and breakdown of the diaphragmatic repair (1 instance each).

Anuria occurred only in patients who had been in severe shock before or

during operation or at both times, or who had received large amounts of blood.

Eight of the nine instances of atelectasis occurred in patients with thoracoabdominal injuries. Two of the three patients with infections of the left

subphrenic space had complicating injuries of the colon. All three instances

of pulmonary embolism were fatal. The first occurred in patient with

univisceral injury of the spleen. The second patient also had compound

fracture of the femur on one side and traumatic amputation of the leg on the

other. The third had severe complicating injuries of the stomach and liver.

CASE FATALITY RATES

The case fatality rate of 24.9 percent (85 cases) in these 341 injuries of the

spleen is considerably lower than the 66.7 percent reported by Giblin in 1943

from El Alamein, the 50 percent reported by Ogilvie 10 in his combined series

from the Western Desert in 1944, and the 67 percent reported in American

troops in World War I. 11

It is also lower than the 33.3-percent rate reported by the surgeons of the

2d Auxiliary Surgical Group in 1943. Except for the latter series and Ogilvie’s

See footnote 4, p. 291. 10 See footnote 5, p. 291.

11 See footnote (1), p. 291.

378327°—56 21
298 GENERAL SURGERY

series, it is not clear whether the figures cited do or do not include postevacuation studies.

Bailey 12 estimated that the case fatality rate in the univisceral wounds of

the spleen in his series was 40 percent. In World War I, the British rate for

univisceral injuries was 50 percent and for multivisceral injuries 60 percent. 13

In the 2d Auxiliary Surgical Group series, these respective rates were 12.0 and

30.3 percent. The rate rose progressively and rapidly as the number of complicating visceral injuries increased, reaching 61.5 percent when three or more

organs were involved in addition to the spleen. The case fatality rate of

24.4 percent following splenectomy in this series is to be compared with the

“practically 100 percent” reported for this procedure in World War I. 14

Death occurred on the operating table in 10 of 67 patients submitted to

splenectomy and occurred in the first 24 hours after operation in 23 others

(table 83). Three other patients died on the operating table before splenectomy could be performed.

Table 83.—Primary cause of death and time of death in 67 fatalities following splenectomy

In comparing the case fatality rate (table 81) for splenectomized patients

(24.4 percent) with the rate for nonsplenectomized patients (29.3 percent),

it must be borne in mind that in most of the latter group operation was omitted

because the splenic wound was not considered serious. In nine cases, however,

either severe multivisceral or severe associated injuries, orboth, contraindicated

additional surgery, or the complications which caused death could not be

attributed solely to wounds of the spleen.

Shock was the primary cause of death in 38 splenectomized patients (table

83) and in others in whom splenectomy was not performed. Peritonitis,

12 See footnote 2, p. 291. 13 History of the Great War Based on Official Documents. Medical Services Surgery of the War. London; His

Majesty’s Stationery Office, 1922, vol. I. 34 See footnote (1), p. 291.

Cause

On

operating

table

To 12

hours

12 to 24

hours

1st

day

2d

through

3d

days

4th

through

7th

days

After

7th

day

Total

Shock 13 38

Anuria. 12

Peritonitis

Pulmonary embolism

Pneumonia

Atelectasis.

Other

Total 10 14 14 11 67
WOUNDS OF THE SPLEEN 299

pneumonia, and atelectasis were responsible for one death each in the nonsplenectomized patients. In the remaining cases in this group, the cause of

death was either undetermined or unrecorded.

Additional complications in the fatal cases included the vagovagal reflex

after bronchoscopy, transfusion reaction, spinal meningitis, massive empyema,

bilateral hemothrax, gastric hemorrhage, and disruption of the diaphragmatic

repair complicated by atelectasis and by herniation of the stomach and colon

into the chest.

301

CHAPTER XXIV

ounds of the Kidney (427 Casualties)

Walter L. Byers M.D.

Wounds of the kidney occurred in 427 (13.5 percent) of the 3,154 abdominal

injuries treated by teams of the 2d Auxiliary Surgical Group during 1944 and

1945 (table 84). The official history of the American participation in World

War lists the frequency of renal injuries in that war as 6.3 percent, which is

slightly higher than the 5.4 percent reported by Young in his Practice of

Urology (table 85).

Table 84 .—Essential data in wounds of kidney

In all but 56 cases, the renal wounds were multivisceral (table 84). The

colon (211 cases), the liver (168 cases), the small intestine (105 cases), and the

stomach (67 cases) were most frequently involved. It is matter of technical

interest that 37 of the 105 wounds of the small intestine occurred in the duodenum in association with wounds of the right kidney, and that the pancreas

was wounded 20 times in association with wounds of one kidney or the other.

The ureter was damaged along with the kidney in cases and the bladder in

cases. Approximately third of all wounds of the kidney were thoracoabdominal (table 84).

The Medical Department of the United States Army in the World War. Washington: U. S. Government Printing

Office, 1927, vol. XI, pt. 1.

Young, Hugh H.; and Davis, David M.; Young’s Practice of Urology. Philadelphia: W. B. Saunders Co., 1926.

Frequency

Case

fatality

rate

Type of wound Cases In 3,154

abdominal

injuries

In 427

renal

Injuries

Deaths

Univisceral 56

Percent

1.

Percent

13. 16.

Multivisceral 371 11. 86. 146 39.

Thoracoabdominal 147 4. 34. 67 45.

Abdominal 280 8. 65. 88 31.

Total 427 13. 100. 155 36.
302 GENERAL SURGERY

Table 85. —Comparative distribution of wounds of kidney in various recorded series of abdominal injuries

Young, Hugh H.; and Davis, David M.: Young’s Practice of Urology. Philadelphia: W. B. Saunders Co., 1926.

The British figures are from War Surgery of the Abdomen, by Cuthbert Wallace (London; J. A. Churchill, 1918).

The Spanish Civil War figures were reported by Douglas W. Jolly in Field Surgery in Total War (New York: Paul

B. Hoeber, Inc., 1941).

ANATOMIC CONSIDERATIONS

The anatomy of the kidney is such that the organ possesses both advantages

and disadvantages in respect to vulnerability to battle-incurred injuries. It is

well protected within the body by adipose tissue, muscle, bone, and the visceral

structures of the abdomen and chest. It is also conceivable that perirenal

adipose tissue may cushion the blow from missile; it was noted several times

in this series that in injuries which had resulted in extensive fragmentation of

the liver or the spleen, only perforation or segmental destruction of the kidney

had occurred. On the other hand, the kidney bears such close anatomic

relationship to adjacent and nearby structures that any injury in this area was

likely to result in renal involvement, while any injury of the kidney was likely

to be accompanied by damage to other viscera from the same missile.

Examination of the autopsy records in this group of cases revealed no

instances of renal agenesis or of fused or horseshoe kidney. Cystoscopy and

urography were not feasible in forward areas, but the possibility that nephrectomy might be performed for renal injury on one side upon patient with

agenesis of the opposite kidney was constantly borne in mind, and in every case

an effort was made by roentgenologic examination to distinguish the renal

shadow on the uninjured side before operation was undertaken.

NATURE OF THE INJURY

In the 399 cases in which these data were recorded, 284 injuries (71.2

percent) were caused by fragmentation missiles, including all types of grenades,

artillery shells, land mines, boobytraps, and bombs. Small-arms fire accounted

for the remaining cases.

For convenience of discussion, wounds of the kidney may be classified

under two headings, those involving the renal hilum and those involving the

renal parenchyma.

Injuries of the hilum.—There were only 16 wounds of the hilar structures

Source Total

series

Renal

injuries Frequency

World War I, American (Young) 2, 385 129

Percent

5.

World War I, British 965 73 7.

Spanish Civil War 238 19 8.

2d Auxiliary Surgical Group 3, 154 427 13.
WOUNDS OF THE KIDNEY 303

in this series, with deaths, all of them after nephrectomy. In 15 cases, the

injury was either laceration or complete severance of the renal vessels, in

instances complicated by damage to the inferior vena cava. In one of these

cases, the inferior vena cava was completely transected and the patient died in the course of operation. In the other, repair of the laceration proved impossible, and the vein had to be ligated; the patient was evacuated in good

condition on the ninth day, with apparently normal urinary volume. In

another case, laceration of the renal vein was overlooked, and death occurred

from continued hemorrhage. In the only hilar injury in which the renal

vessels were not damaged, laceration of the pelvis was repaired with single

interrupted suture, and recovery was uneventful.

The very small number of wounds of the renal vessels observed in forward

hospitals suggests that casualties with such injuries, particularly if other major

abdominal blood vessels were also injured, did not usually survive long enough

to be submitted to surgery.

Injuries of the parenchyma.—Injuries of the renal parenchyma ranged

from neatly drilled holes to complete disintegration of the tissues. The size

of the missile and its velocity were directly responsible for the degree of destruction, but otherwise there was no apparent relationship between the type of

missile and the character of the wound. hematoma of variable size was

practically always present in the perirenal area, and the wound was usually

covered with an irregular clot which was rather firmly adherent to its edges.

Active bleeding from the renal wound was not constant finding, even in the

event of destruction of large sections of one pole or the other, but attempts at

operation to dislodge the clot from the wound usually resulted in renewed

bleeding from the wound surface. Cortical hemorrhage had frequently caused

separation of the tunica fibrosa, sometimes of considerable extent, with varying

degrees of disturbance of the anatomic relationship of the capsule to the cortex.

During mobilization of the parts, the surgeon often unwittingly perforated the

distended capsule, so that subcapsular dissection was performed.

CLINICAL CONSIDERATIONS

The chief symptoms and signs in wounds of the kidney were tenderness,

guarding of the muscles of the flank, and hematuria. retroperitoneal hematoma could occasionally be palpated through the flank and abdomen, but

muscle guarding frequently made deep palpation difficult or impossible. In

the multivisceral injuries which comprised the bulk of these renal injuries

(table 84), the predominance of intraperitoneal symptoms and signs arising

from wounds of other viscera was likely to overshadow the symptoms and signs of renal injury. Hemoperitoneum and peritoneal contamination, because of

the resulting muscle guarding, added to the difficulties of satisfactory abdominal palpation. When pain was present, it was commonly referred to the abdomen.

There was apparently no case in this series in which it was referred in the classic

manner along the course of the ureter to the groin or the scrotum.
304 GENERAL SURGERY

wound of the renal parenchyma alone did not always elicit particularly

severe general reaction, and shock might be either mild or absent. In some

cases, however, chiefly of injury to the renal vessels and of other viscera, shock

was so deep that physical findings obtained by palpation were totally unreliable

until resuscitation therapy had begun to be effective.

DIAGNOSIS

The two most important diagnostic evidences of renal damage were the

location of the wound and the presence of hematuria. The physical findings,

as already noted, were relatively slight insofar as localization to the kidney was

concerned, and were also likely to be confused by the reaction of other viscera

to injuries.

Close inspection of the wound was often useful in determining what structures were involved. It was always helpful, particularly in penetrating wounds,

if the patient could describe his position at the time of wounding or knew the

direction from which the missile had come. In univisceral wounds, the causative missile was likely to be traveling at low velocity; the fragment was therefore

likely to be found in the kidney or adjacent to it when the wound was explored.

At other times, the angle of penetration was such that only the kidney was

wounded. In thoracoabdominal wounds, the usual direction of penetration

was posteriorly and posterolaterally from the chest into the abdomen. The

costophrenic angle was frequently involved. The size of the wounds of entrance

and exit was never an index of the extent of damage to the kidney.

It was sometimes possible, by careful inspection, to detect some disparity

in the appearance of the flanks, but no difference was likely to be observed

unless there had been considerable destruction of tissue or hematoma of

considerable size was present. Bleeding from wounds of the flank and loin

did not necessarily point to hilar damage. The renal parenchyma can bleed

vigorously, and intraperitoneal blood can also escape from wound in the flank.

Although wound into the pelvis provided direct communication from

the kidney to the exterior surface of the body, attempts to identify urine in

the wound or about the kidney were seldom successful. Catheterization was

practically always necessary to recover urine specimens. The absence of blood

could not be assumed until the bladder was completely emptied. It was not

unusual for the first portion of the catheterized specimen to be clear and the

last portion to be grossly discolored with blood, especially if there had been

long timelag since wounding.

Roentgenologic examination in forward units was limited to flat films and

fluoroscopy; stereoscopy, retrograde pyelography, intravenous urography, and

similar diagnostic refinements were not practical under field conditions. Moreover, retrograde pyelography was regarded as undesirable because cystoscopy

is sometimes attended with some degree of shock. If shock from this cause had

been superimposed on shock from wounding, seriously wounded casualty

might conceivably have been placed in still further jeopardy.
WOUNDS OF THE KIDNEY 305

TREATMENT

Specific treatment was deliberately withheld in of the 427 renal injuries,

because it was not regarded as necessary. It was not instituted in other

cases, because the renal wound was overlooked. The remaining cases were

chiefly managed by nephrectomy or by drainage only.

Surgical approach.—An abdominal transperitoneal approach was employed

in 259 (61.7 percent) of the 420 injuries in which the type of incision was listed

because it was necessary in these cases to expose abdominal viscera along with

the kidney. The risk of retroperitoneal contamination inherent in this approach was fully realized, but the objection was regarded as less valid than

under other circumstances, because of the probability that contamination was

already present as the result of the original wound. combined abdominalflank incision might have been more desirable, but it was not employed, chiefly

because of the added time it would have required.

Thoracotomy was employed in 64 (43.5 percent) of the 147 wounds of the

kidney in which the thorax was wounded also. This transdiaphragmatic

approach to the abdomen and retroperitoneal area proved convenient, and

when it was employed on proper indications the results were good. In 40

cases, separate incisions were made into the thorax and into the abdomen; in

39, the approach was transabdominal; and in 3, the injury was approached

through the flank. In the remaining case, the renal injury was overlooked.

The flank or loin incision was found preferable for wounds limited to the

upper quadrants of the abdomen. This approach provided excellent exposure

and had the added advantage that the incision could be extended anteromedially for laparotomy and for necessary operations on the abdominal viscera.

It practically always healed by primary intention. This was not, however,

desirable incision when the large bowel was also injured, since it interfered

with proper exteriorization of the colon.

Procedures. —Nephrectomy was performed in 120 of the 427 renal injuries

(28.1 percent). It as employed in 16 cases because of damage to the renal

artery and vein and as used in the other cases because of extensive destruction

of the renal parenchyma. less radical procedure was chosen wdien it

as practical, but damage to the renal vessels, extensive destruction of the

renal parenchyma, and widespread fracture of the kidney with destruction of

the blood supply to the segments frequently left the surgeon with no other

choice.

Drainage was the only procedure in 285 cases (66.7 percent of the total

number). It was also carried out in association with other procedures in 134

other cases (all but of the renal injuries treated by other surgical measures).

It was conveniently accomplished by soft rubber material of the Penrose type,

wuth or without wick. If the original wound was not suitably located,

drainage as instituted through separate stab wound. Otherwise, debrided

missile tracks in the flank or loin were utilized for this purpose. Complete

debridement as the rule before drainage as instituted.
306 GENERAL SURGERY

Resection and suture, which were used in only seven cases, were not

popular in the 2d Auxiliary Surgical Group, probably for the reason brought to

light by autopsy in the single fatal case in which the method was used. The

notation read: “During the 3-day interval between surgery and death, the

sutures had become buried in the swollen renal parenchyma, while the areas

included were dark, and engorged with blood on section.

Packing was employed three times. This was another method not highly

regarded, and control of hemorrhage by other measures was preferred, for

obvious reasons. Because firm pressure is necessary to accomplish hemostasis,

the gauze had to be packed firmly from the renal fascia to the skin level, and

the immediate consequence was inhibition of drainage in an area already

potentially, if not actually, infected. Furthermore, fresh bleeding was always

possibility when the pack was removed.

Capsulotomy was employed in one case in the series. Nephrostomy was

not employed at all.

Suture material.—Ordinary types of suture material proved satisfactory

for all procedures on the kidney except segmental resections and repair of

fractures of the parenchyma. The inclusion of ribbon suture material in the

tables of equipment for forward hospitals would have been an incentive to even

further conservatism and might have made unnecessary few of the nephrectomies which were performed.

POSTOPERATIVE MANAGEMENT

Drains were left in place as long as there was significant soiling of the

dressings, which was usually to 10 days. Dressings over large wound in the

flank through which drainage of the renal fossa had been established had to be

changed several times daily. The repeated removal of adhesive tape caused

skin irritation, and the entire task proved too time consuming for busy nurses.

Another type of dressing was therefore devised. The wound was covered with

few sterile gauze sponges reenforced by one or two abdominal pads, all held

in place by large bath towel which encircled the abdomen and was secured

anteriorly with safety pins. With this method, changes of dressings could be

quickly and easily accomplished, and excoriation of the skin by adhesive tape

was entirely avoided.

An extremely important phase of the postoperative management of renal

wounds was an adequate fluid intake, ranging from 2,000 to 3,000 cc. daily by

mouth or parenterally. Otherwise, the postoperative routine did not differ

from the usual routine for abdominal wounds.

POSTOPERATIVE COMPLICATIONS

Sepsis seldom occurred in wounds of the kidney, except in association

with perforation of the retroperitoneal portion of the colon. It was guarded

against by thorough debridement of the wound, with excision of dead tissue, free blood, bits of clotlung and metallic foreign bodies, and by adequate drain-
WOUNDS OF THE KIDNEY 307

age. Secondary hemorrhage does not seem to have occurred in any case in the series.

Because urinary fistulas seldom occur in renal injuries except after wounding of the parenchyma with involvement of the renal pelvis, they were not

common in this series. Pocketing of the urine as the result of inadequate

drainage also was uncommon. When it did occur, it was accompanied by

febrile reaction, and the patient’s condition did not improve until adequate

drainage was established. Urine was often noted on the dressings, but as

rule, urinary drainage ceased spontaneously after few days. Nephrostomy,

as already noted, was not performed in any case in the series.

FACTORS OF MORTALITY

As would be expected, the case fatality rate in wounds of the kidney

depended upon whether they were univisceral or multivisceral (table 84),

The multiplicity factor proved as important from the standpoint of prognosis

as it proved in all other regional injuries (table 10, fig. 22).

Seventeen of the fifty-six univisceral injuries were treated by nephrectomy,

with four deaths. One occurred from shock 20 minutes after the operation

was concluded. The second was the result of anaphylactic shock. It occurred

on the seventh postoperative day, immediately after the intravenous infusion

of 100 cc. ofAlsever’s solution. The third patient died of anuria. The fourth

died of ascending myelitis from an associated injury of the spinal cord.

There were 49 deaths (47.6 percent) in the 103 nephrectomies performed

in the multivisceral injuries. This case fatality rate is to be compared with

the 44.2-percent rate for nephrectomy in the whole series (53 of 120 operations).

The time of death could be determined from the records in 149 of the 155

fatal cases. It occurred within the first 72 hours after operation in 120 cases

(80.5 percent). The great majority of these patients had sustained wounds

which were essentially lethal, and their deaths were attributable to shock.

309

CHAPTER XXV

Wounds of the Ureter (27 Casualties)

Walter L. Byers M.

There were only 27 wounds of the ureter (0.86 percent) in the 3,154 abdominal injuries in this series. Only ureteral injuries are listed in the records of

the American Expeditionary Forces in World War I. They constituted 0.1

percent of all abdominal and pelvic injuries.

The single univisceral injury of the ureter treated by the 2d Auxiliary

Surgical Group surgeons was caused by shell fragment which produced

small laceration of the upper portion. In the 26 multivisceral wounds, the

small intestine was involved 21 times and the large intestine 18 times. Injuries

to these two structures represented more than half of the coincidental injuries.

The bladder and liver were each involved times; the kidney times; the duodenum, extraperitoneal rectum, and great vessels of the abdomen times each; and the stomach and spleen twice each. The internal iliac vein was the

largest vessel involved in the complicating vascular injuries.

DIAGNOSIS

The preoperative diagnosis of ureteral injuries was not easy, particularly

when other structures within the abdomen were also injured, as they were in

all but one case in this series. Hematuria was not pathognomonic; it was

present in only three cases in which the bladder or kidney was not also

damaged. In no instance in the series was there detectable amount of

urine on the dressing or about the wound. The explanation, at least in part,

was shock; it was frequent in these patients, and it was usually accompanied

by oliguria or anuria. As result, there was no telltale urinary leakage to

lead to suspicion of ureteral wound.

Facilities for cystoscopy, intravenous urography, and ureteral catheterization, as noted in the previous chapter, were not available in field hospitals.

Even if they had been, most of these casualties, because of the gravity of their

injuries, would not have been suitable candidates for such diagnostic procedures. Accordingly, the usual diagnostic refinements of urologic surgery had

to be dispensed with.

As result of these various circumstances, the diagnosis of ureteral injury

was usually made only at operation, and even then was overlooked in of the

27 cases.

The Medical Department of the United States Army in the World War. Washington; U. S. GovernmentPrinting

Office, 1927, vol. XI, pt. 1.
310 GENERAL SURGERY

TREATMENT

It was the accepted practice to expose the ureter fully whenever missile

had passed anywhere along its course. Exposure was often difficult because

of the retroperitoneal hemorrhage common in such injuries. When leakage

from wounded colon was also present, technical difficulties were still greater.

These difficulties explain the fact already mentioned; namely, that the ureteral

wound was overlooked at operation in three cases. In one of the overlooked

cases, drainage was instituted because of wound in the retroperitoneal portion of the colon, but the ureteral injury was not found until autopsy.

In the 24 cases in which ureteral damage was identified at operation,

seven separate surgical techniques were employed, as follows:

Transplantation of the ureter into the bladder was performed in six cases.

This procedure could be utilized only in wounds of the distal ureter. In one

instance, the suture line separated on the third postoperative day but was

successfully repaired.

Ureteroanastomosis was performed six times. Four of the operations were

done by the telescoping technique, with one failure, as manifested by postoperative urinary drainage. The two patients treated by end-to-end anastomosis died within 48 hours of operation. Both fatalities were caused by shock

and were not attributable to the ureteral injuries.

Nephrectomy was performed five times, in each instance because of extensive renal damage. In no case was the injury to the proximal ureter of clinical

significance in comparison to the wound of the kidney.

Ligation of the ureter at both ends was carried out in three transecting

wounds, with extensive loss of substance. In one of these cases, the kidney

was also wounded.

Ureteral lacerations were successfully sutured in two cases. One case

was managed by drainage only. Cutaneous ureterostomy was done in one

case; destruction of considerable segment did not permit repair, and the condition of the patient did not warrant extension of the operating time to perform nephrostomy. The latter procedure was not employed in any of these

ureteral injuries, though in retrospect it seems that it might have been useful

in certain cases.

The small number of ureteral injuries and the various procedures used

in their management make the discussion of any special technique of no value.

FACTORS OF MORTALITY

The 11 deaths in these 27 ureteral injuries all occurred in patients with

multivisceral wounds. The deaths which occurred within 72 hours of

wounding were attributed to shock. There were fatalities in the multivisceral injuries in which the great vessels were involved. One patient died

48 hours after operation, from multiple pulmonary emboli, and the other on

the seventh postoperative day, of generalized peritonitis. The ureteral repair
WOUNDS OF THE URETER 311

did not break down in either instance. The cause of death was not clear in

one case.

In the three cases in which ureteral injuries were overlooked at operation,

the error was assigned an important contributory role, though not the primary

role, in the fatal outcome.

378327°—56 22 313

CHAPTER XXVI

Wounds of the Urinary Bladder (155 Casualties)

Leon M. Michels M.

There were 155 wounds of the urinary bladder (4.9 percent) in the 3,154

abdominal injuries in this series (table 86). One hundred and thirty-four

were multivisceral; some portion of the intestinal tract as well as the bladder

was wounded in every one of these cases.

Table 86.—Essential data in 155 wounds of urinary bladder

NATURE OF THE INJURY

The most frequent sites of entry of missiles causing wounds of the

bladder were the buttocks and the anterior abdominal wall. Each of these

sites was penetrated 56 times. Other sites of entry were the thigh, hip,

perineum, back, flank, and, in one instance, the midaxilla. The missiles were

retained in the body in about two-thirds of the cases. Thirty-five wounds

were caused by bullets, seventy-one by shell fragments, and three by blunt

trauma. In the remaining cases, the wounding agent was not recorded.

The wound was an intraperitoneal laceration of the bladder in 137 cases

an extraperitoneal laceration in cases, and severe contusion without laceration in cases.

CLINICAL CONSIDERATIONS

The physical findings in bladder injuries were not pathognomonic. Tenderness, rigidity, and the presence or absence of peristalsis depended chiefly

upon complicating intra-abdominal wounds and the amount of intra-abdominal

or retroperitoneal hemorrhage. Discharge of urine through the abdominal

wound was observed in cases, and hematuria was present in 150 cases. Both

Frequency

Case

fatality

rate

Type of wound Cases In 3,154

abdominal

injuries

In 155

bladder

injuries

Deaths

Univisceral- 21

Percent

0. 67

Percent

13.

Multivisceral 134 4. 25 86. 46 34.

Total 155 4. 91 100. 46 29.
314 GENERAL SURGERY

findings pointed to injury of some portion of the urinary tract but did not

necessarily implicate the bladder.

Diagnosis was made correctly before operation in 149 of the 155 cases.

It was based partly on inferences derived from the nature of the wound. The

path of the missile, as determined by an alinement of wounds of entrance and

exit, or by the location of the wound of entrance in relation to theroentgenologic

position of the retained foreign body (bodies), was the most important diagnostic consideration. possible injury of the bladder always had to be borne

in mind in fractures of the bony pelvis, as well as in occasional instances of

abdominal injury following pressure or blast.

Although hematuria and the existence of urinary fistula pointed to injury

of the urinary tract, their absence by no means warranted the conclusion that

it had not occurred. Filling the bladder with some solution for diagnostic

purposes was not regarded as good practice. If the organ had been punctured,

additional contaminated material was likely to escape into the peritoneal

cavity, and, more important, extravasation of fluid could occur retroperitoneally and infraperitoneally. Another contraindication to this practice was

the fact that the majority of the patients had other abdominal lesions. Since

laparotomy was required in all cases, nothing was lost, and the patient’s safety

was enhanced, by delaying instillation of saline solution through urethral

catheter until the abdomen was opened and conditions could be ascertained

and controlled. Not all surgeons employed this method even then.

There were fatalities in the bladder injuries overlooked at operation.

Both patients died on the day after operation, of other causes, and the vesical

wounds were found at autopsy. The three other patients developed urinary

fistulas, through wounds in the thigh, rectum, and abdomen. All were

subjected to cystostomy, with satisfactory results.

In one case, suspected injury to the bladder could not be demonstrated

at operation, but an indwelling catheter was nevertheless introduced. When

it was removed, on the sixth day, small foreign body was passed by the

urethra. Recovery was thereafter uneventful.

TREATMENT

Since multivisceral wounds were present in most patients with bladder

injuries, laparotomy was required, regardless of the vesical wound. It was

therefore easy to inspect the intraperitoneal portion of the bladder and carry

out such repairs as were necessary. After the peritoneum had been closed

and suprapubic cystostomy performed, the extraperitoneal portion of the

bladder was inspected, and whatever surgery might be required in that area

was carried out.

The bladder injury, as already noted, was not identified at operation in

cases. Seven patients died in the course of operation. In 10 other cases

there was no record of the type of procedure. In the remaining 132 cases,
WOUNDS OF THE URINARY BLADDER 315

repair was done in 116, in 110 of which suprapubic cystostomy was also performed, and 13 patients were submitted to suprapubic cystostomy alone. An

indwelling catheter was used in the three other cases. The space of Ketzius

was drained routinely.

Sulfonamides were occasionally implanted in the peritoneal cavity or in

the wound, and penicillin, when it became available, was occasionally used in

the same manner. After operation, all patients received sulfonamide drug

by mouth or by vein, penicillin by the intramuscular route, or both agents in

combination.

POSTOPERATIVE COMPLICATIONS

In spite of the high frequency of other intra-abdominal injuries, recorded

postoperative complications were not numerous in this series of bladder injuries. Atelectasis occurred in cases, and wound infection in 3. Evisceration

occurred later in one of the infections. Fecal fistulas developed in cases.

Other single recorded complications included pneumonia, cardiac failure, urinary fistula, secondary hemorrhage, pyelitis, epididymitis, and subphrenic

abscess. An abscess of unspecified location occurred in one case and pyrexia

of undetermined origin in another. There was no instance of infection of the

paravesical tissues in any of the surviving patients in the period (1 to 20 days)

in which they were followed in forward hospitals, and there was only one

instance of retroperitoneal cellulitis among the patients who died.

FACTORS OF MORTALITY

In analyzing the case fatality rate in these 155 wounds of the bladder, it

must be borne in mind that 134 of them were multivisceral. Furthermore,

in practically all the multiple injuries, the other wounds presented greater

technical problems and were of far more serious import than wounds of the

bladder. This was particularly true of wounds of the pelvic blood vessels

and wounds of the intestinal tract; an intestinal injury was present in every

multivisceral wound (table 87).

All 46 deaths (tables 86, 87, and 88) occurred in patients with other intraabdominal injuries, the case fatality rate rising as the number of other visceral

injuries increased. The existence of the bladder wound apparently increased

the risk associated with the other injuries. The case fatality rate for 353

univisceral injuries of the ileum and jejunum, for instance, was 13.9 percent

(table 50). In the 40 cases in which bladder injury was associated with

the intestinal injury, the rate was 22.5 percent. The case fatality rate for

251 univisceral injuries of the colon was 22.7 percent (table 55). When

bladder injury was associated with the intestinal injury, the rate rose to 42.9

percent. On the other hand, none of the 21 casualties with univisceral lesions

of the bladder died, which makes the case fatality rate 34.3 percent (46 deaths)

in the 134 multivisceral cases.
316 GENERAL SURGERY

Table 87.—Influence of wounds of intestinal tract on case fatality rates in 155 wounds of urinary bladder

The causes of death (table 88) were those usually responsible for fatalities

in abdominal injuries. The shock-mortality relationship followed the expected

pattern; namely, the greater the degree of shock when the patients were first

seen, the higher the case fatality rate. The rate was percent inpatients not in

shock, 25 percent in patients in moderate shock, and 63 percent in patients in

severe shock.

Table 88.—Primary cause of death in relation to time of death in wounds of urinary

bladder

Injuries Cases Deaths

Case

fatality

rate

Total 155 46 29.

Without intestinal injuries 21

With intestinal injuries 134 46 34.

Wounds of

extraperitoneal rectum 16.

intraperitoneal rectum 17 17.

small bowel 40 22.

colon, exclusive of rectum 21 42.

large and small bowel and rectum 50 24 48.

Day of

operation

Postoperative day

Total

cases Cause

1st 2d 3d 4th 5th th to th,

inclusive

Shock 15

Peritonitis

Respiratory

Anuria

Pulmonary embolism

Other

Total 15 10 42

Exclusive of deaths in which the causes are not known and which occurred, respectively, at operation and on the

second day, the third day, and between thesixth and eighth days after operation.

Miscellaneouscauses included gas gangrene in cases, heart lesion and retroperitoneal cellulitis in case each, and

(probably) an anesthetic cause in cases.
317

CHAPTER XXVII

\\ ounds of the Great Vessels of the Abdomen

(75 Casualties) Hugh F. Swingle M. D., and Dominic S. Condie M. D.

There were 75 wounds of one or more of the major vessels of the abdomen

included in the 3,154 abdominal injuries treated by the 2d Auxiliary Surgical

Group during 1944 and 1945 (table 89). These injuries (table 90) consisted of:

1. Injuries to the major veins, including the vena cava; the common,

internal, and external iliac veins; and the portal vein (53 cases).

2. Injuries to major arteries, including the common, internal, and external

iliac arteries (13 cases).

3. Injuries to some combination of these arteries and veins (9 cases).

Table 89.—Essential data in 75 wounds of major vessels of abdomen

Of the 75 casualties, 55 (73.3 percent) died, and no soldier with an injury

to the abdominal aorta survived long enough to undergo surgery in field

hospital.

INJURIES TO THE MAJOR VEINS

Injuries of the major veins of the abdomen (table 90) occurred alone in

45 cases, in combination with injuries of the blood supply of various viscera

in cases, and in combination with injuries of the major arteries of the abdomen

in cases.

Injuries to the blood supply of special viscera, such as the colon,spleen, and kidney,are discussed underthe heading

of the vlseus involved and are excluded from this discussion unless they complicated wounds of the major blood vessels

of the abdomen. As matter of convenience, combined injuries of the arteries and veins are discussed under the heading

of arterialinjuries. Becauseof the wide distribution of injuries and operations and the small numbers in each category,

it is necessary to describe many cases in all categories individually.

Frequency

Type of injury Cases In 3,154

abdominal

injuries

In75 vascular injuries

Deaths Case fatality rate

Vascular onlv

Percent

0. 25

Percent

10. 62.

Vascular and visceral 67 2. 13 89. 50 74.

Total 75 2. 38 100. 55 73.
318 GENERAL SURGERY

Table 90.—Influence of type of injury on case fatality rates of 75 wounds of major vessels

of abdomen

Vena caval injuries.—-The vena cava was injured 33 times (table 91),

more frequently than any other single vessel. In the 22 cases in which the

injury was univisceral, there were 17 deaths. Nine followed ligation, which

was employed in twelve of the univisceral injuries, and four followed suture, which was employed in six cases in the same category. In one fatal case, the

vena cava was clamped tangentially, as temporary measure, and in the

three other univisceral fatalities hemorrhage proved uncontrollable.

The were 10 deaths in the 11 injuries associated with injuries of other

major abdominal vessels or of the visceral blood supply.

Table 91.—Essential data in S3 injuries of vena cava

Injury Cases Deaths Case fatality rate

Veins only 45 33 73.

Single vein 38 27 71.

Two or more veins 85.

Vein and visceral blood supply 100.

Arteries only 13 61.

Artery and vein 66.

Total 75 55 73.

Type of injury and therapy Cases Deaths Case fatality rate

Vena cava:

Without other injuries 22 17 77.

With other vascular injuries 75.

With visceral and other vascular injuries 100.

Total ___ 33 27 81.

Therapy (all vena caval injuries);

Ligation 16 13 81.

Suture 62.

Tangential clamping 100.

Spontaneous thrombosis 100.

Uncontrollable hemorrhage 100.
WOUNDS OF THE GREAT VESSELS 319

Univisceral injuries of other major veins.—In the 16 univisceral vascular

injuries in which veins other than the vena cava were implicated, the distri- bution of cases, procedures, and deaths was as follows:

Six injuries of the common iliac vein were treated by ligation in five cases

and by packing in one case, with four deaths.

Five injuries of the external iliac vein were treated by ligation, with two

deaths.

Two injuries of the internal iliac vein were treated by ligation, with one

death. Another, similar injury was treated by packing and ended fatally.

In the last-mentioned case, the injury was described as involving the “pelvic”

vein, but the record left no doubt that the vessel injured was the internal

iliac vein.

Two injuries of the portal vein were both fatal. Packing was employed in one case, and in the other hemorrhage was uncontrollable by any measures.

Multiple venous injuries.—In the cases in which or more of the

major veins of the abdomen were injured (table 90), the distribution of the

cases, procedures, and (6) deaths was as follows: The inferior vena cava and the common iliac vein were involved in three

cases. One patient, treated by suture, survived. One died after venous ligation, and in the third case hemorrhage was uncontrollable.

The inferior vena cava, both common iliac veins, and the right internal

iliac vein were injured in one case. Death followed ligation.

The left common iliac vein and the left internal iliac vein were wounded

in one case, and the same veins on the right side were wounded in another.

Death followed venous ligation in both.

The right internal and external iliac veins were wounded in one case, in

which death followed ligation.

Combined injuries of the major abdominal veins and the visceral blood

supply.—All eight cases in which venous injuries were combined with injuries

of the blood supply of major abdominal viscera ended fatally (table 90):

The inferior vena cava, the hepatic artery, and the portal vein were

wounded in one case, in which death was caused by uncontrollablehemorrhage.

The inferior vena cava and the hepatic artery were injured in one case.

The artery was ligated, and the vena cava underwent spontaneous thrombosis.

The inferior vena cava and the superior mesenteric artery were injured

in one case. The vena cava was ligated and the artery sutured.

The inferior vena cava and the right gastric artery and vein were injured

in one case. The gastric artery and vein were ligated, but the patient died of

uncontrollable hemorrhage from the vena cava.

The inferior vena cava and the right renal pedicle were injured in three

cases. Nephrectomy was done in two cases, once combined with suture, and

once with ligation, of the vena cava. In the third case, hemorrhage from both

sources proved uncontrollable.

The portal vein and the hepatic artery were injured in one case, in which

packing was employed.
320 GENERAL SURGERY

INJURIES TO THE MAJOR ARTERIES

Arterial injuries.—In the 13 cases in which major arteries of the

abdomen were injured without complicating injuries of other vessels (table 92),

the distribution of cases, procedures, and deaths was as follows;

Six wounds of the external iliac artery were treated by suture in one case, with survival, and by ligation in five cases, with four deaths.

Three wounds of the internal iliac artery were treated by ligation, with

two deaths.

Four injuries of the common iliac artery were treated by suture in two cases,

with survival in both, and by ligation in two cases, with death in both. Combined arterial and venous injuries.—There were deaths in the

combined arterial and venous injuries (table 93). In one instance, clamp

was applied to the internal iliac artery and vein and left in situ because the

Table 92.—Essential data in 13 injuries of major abdominal arteries

Table 93.—Essential data in combined injuries of major arteries and veins of abdomen

Injuries and therapy Cases Deaths

Case

fatality

rate

Vessel injured:

External iliac 66.

Internal iliac 66.

Common iliac 50.

Total 13 61.

Therapy:

Ligation 10 80.

Suture_

Vessel injured and therapy Cases Deaths

Case

fatality

rate

External iliac artery and vein 50.

Internal iliac artery and vein 66.

Common iliac artery and vein 100.

Total -- 66.

Therapy:

Ligation 62.

Clamp 100.
WOUNDS OF THE GREAT VESSELS 321

patient was moribund; he died before more definitive procedure could be

accomplished. Both the vein and the artery were ligated in the other eight

cases. Three patients survived, one with wound of the external iliac artery

and vein and two with wounds of the internal, iliac artery and vein.

POSTOPERATIVE VASCULAR INSUFFICIENCY

Postoperative vascular insufficiency occurred in patients in this series

who survived injury and operation long enough to present it. The veins were

affected in cases, the arteries in 3, and both arteries and veins in 2, as follows:

Two patients with injuries of the inferior vena cava presented swelling of

the lower extremity. In one instance, the vein had been ligated. The other

patient, who later died of massive pulmonary embolism, had undergone suture

of the vein. Two other patients with similar injuries presented distention of

the veins of the lower extremities. In one instance, the vena cava had been

ligated; in the other, it had been sutured, and it was thought that thrombosis

had probably occurred subsequently at the site of injury and repair.

In one injury of the external iliac artery, gangrene followed ligation of

the artery and elective ligation of the vein. The leg was demarcating at the

midcalf when the patient died on the third day after operation of anuria combined with an overlooked retroperitoneal injury of the cecum. In another injury of the external iliac artery treated by ligation, amputation was necessary

at the left midthigh on the seventh day after operation because of gangrene

resulting from arterial insufficiency and clostridial myositis.

In one injury of the common iliac artery, the artery was ligated, and elective ligation of the vein was also done. Amputation was later necessary

through the thigh on the affected side, and the patient eventually died of

clostridial infection in the stump.

In one case in which wounds of the left external and internal iliac veins

and the left internal iliac artery were treated by ligation, the affected leg

became mottled and cold 12 hours after operation. The patient died 40

hours after operation, in shock from severe peritonitis. Amputation of the

extremity would probably have been necessary if he had lived.

In one case in which the left common iliac artery and vein were injured,

both vessels were ligated. Gangrene ensued, and amputation of the extremity

through the thigh was necessary on the fourth postoperative day.

Conditions in forward hospitals did not permit intensive efforts at combating postoperative vascular insufficiency in the lower extremities. Environmental temperature control was not feasible. No anticoagulant drugs were

available. The only practical prophylactic measure was control of the patient’s position, and the optimum posture was usually contraindicated by the

presence of severe intraperitoneal injuries. few sympathectomies were done

on patients with injuries of the femoral artery, but this procedure was not

employed in any intra-abdominal vascular injury.
322 GENERAL SURGERY

FACTORS OF MORTALITY

Since the frequency of injury to any abdominal viscus is directly proportional to the space which it occupies (p. 92), it would seem that injury to

corresponding major arteries and veins would occur with approximately

the same frequency because the vessels are of approximately the same

size. In this series of 75 injuries of major abdominal blood vessels, this generalization did not hold. Fifty-three injuries involved one or more veins, while

only twenty-two involved either arteries alone or arteries and veins. These

figures require interpretation. The considerable discrepancy is probably not

disparity of incidence but rather disparity in lethality. It arises from the

fact that fewer patients with arterial injuries reached field hospitals to undergo

treatment. This reasoning is supported by the fact that this series, although

it includes 33 lesions of the vena cava, includes no lesion of the abdominal

aorta, since no patient with an injury of that vessel survived to undergo surgery. Even when the damage to the veins was severe, many patients were

brought to the hospital alive, apparently because point was reached in the

hemorrhagic process at which the intra-abdominal tension was sufficiently high,

and the venous pressure had become sufficiently low, to prevent complete

exsanguination and death. This physiologic process apparently occurred much less often in arterial injuries, with the result that fewer patients in this

category were received in forward hospitals.

The case fatality rate for all arterial injuries was 63.6 percent (14 of 22

cases), as compared to rate of 75.8 percent (47 of 62 cases) for all injuries of

the veins. The lower case fatality rate in arterial injuries must be attributed

to unusual circumstances which permitted the patients to reach field hospitals alive. No precise data are available, but it seems reasonable to assume that in these cases the injuries were slight to minimal, the blood loss before operation

was not excessive, and bleeding could be controlled promptly after the abdomen

was opened.

Only of the 33 patients with injuries of the vena cava (table 91) survived

long enough after operation to be evacuated from the field hospital. Three had been treated by suture and three by ligation, the procedure in each instance

being performed below the renal veins. No patient survived when the injury

was above the renal vessels.

The case fatality rate in injuries of the great vessels apparently rested on

much the same basis as injuries of other viscera. Half of the deaths in the 54

fatalities in which the cause of death could be determined resulted from shock

and hemorrhage. Twelve were attributed to anuria, four to pulmonary embolism, three each to pneumonia and to pulmonary edema, two each to peritonitis and to clostridial myositis, and one to retroperitoneal suppuration.
WOUNDS OF THE GREAT VESSELS 323

One factor of great importance in the outcome was the stage of shock. In

very severe shock, the blood pressure and pulse were not usually obtainable,

and in several other cases the blood pressure and pulse were not recorded when

the patient was first seen in the field hospital. The classification into degrees

of shock was therefore made on the clinical findings. The case fatality rate

(table 94) was directly proportional to the degree of shock on the patients’

admission. The numbers of cases in some categories are too small to be significant statistically, but the results are in full accord with clinical impressions

degrees

Table 94.—Influence of degree of shock on case fatality rates in 69 wounds of major vessels of abdomen

The case fatality rate in these 75 vascular injuries also depended upon

number of other considerations, including the presence or absence of associated

visceral injuries and the number of viscera involved (table 95). There is one

discrepancy—that the rate was higher when no abdominal viscera were involved

than when one organ was injured. With this exception, there was gradual

rise in the rate as the number of abdominal organs injured increased. When

the multiplicity factor for all abdominal injuries (p. 107) is studied in relation

to the multiplicity factor in these 75 cases, it becomes clear that the injury to

the great vessels was the most important cause of the consistently high case

fatality rate in this group of cases.

Injuries to the great vessels of the abdomen carried the highest case fatality

rate of any category of injuries in this series of 3,154 abdominal wounds. No

problem so challenged the technical skill of the surgeon as the control of severe

intra-abdominal hemorrhage with sufficient rapidity to give the patient chance of survival.

Degree of shock Cases Deaths Case fatality rate

None 50.

Mild 50.

Moderate 16 10 62.

Severe 75.

Verv severe 39 33 84.

Total 69 52 75.

In cases, of which were fatal, the degree of shock was not recorded.
324 GENERAL SURGERY

Table 95.—Influence of multiplicity factor on case fatality rates in 67 wounds of major vessels of abdomen

Organs injured Cases Deaths Case fatalityrate

Major vessels only 62.

Major vessels and viscus 22 12 54.

Major vessels and viscera 21 17 81.

Major vessels and viscera 13 11 84.

Major vessels and viscera 100.

Major vessels and viscera 100.

Total 67 48 71.

In cases, of which were fatal, no data are available concerning the number of viscera Injured.
325

CHAPTER XXVIII

Retroperitoneal Hematoma (207 Casualties)

Hugh F. Sivingle M. D., and Dominic S. Condie, M. D.

It is known thatretroperitoneal hematoma, in the sense of an extravasation

of blood, either circumscribed or diffuse, into the retroperitoneal tissues was

frequently encountered in the 3,154 abdominal injuries observed by the 2d

Auxiliary Surgical Group in 1944 and 1945. The exact frequency, however,

is unknown because the data were recorded in only 207 cases, in 59 of which

hematoma was the only lesion present.

There are several reasons why this number of cases of retroperitoneal

hematoma cannot be accepted as correct:

1. It can be assumed that missile which entered the retroperitoneal

space almost inevitably produced hematoma of some sort.

2. Blunt, nonpenetrating injuries frequently had the same effect.

3. The 207 recorded cases are far fewer than the 427 renal wounds in this

series of abdominal injuries.

4. retroperitoneal hematoma was specifically mentioned in only 33 of

the 75 wounds of the major abdominal blood vessels, though it is inconceivable

that it was not present in every such injury. As matter of fact, after only

brief experience, the surgeons of the 2d Auxiliary Surgical Group came to

regard the presence of hematoma as likely in any wound of the retroperitoneal

space and usually did not record it unless it was the only lesion present or it

was of significant severity. In other words, whatever the actual statistics may

indicate, this was lesion of considerable frequency in this series of abdominal

wounds.

CLINICAL CONSIDERATIONS

It was usually impossible to make an accurate diagnosis of retroperitoneal

hematoma by clinical means alone. It was equally impossible, prior to operation, to differentiate between it and intra-abdominal visceral injury. The

signs and symptoms of both conditions were usually identical, and in this series

both lesions frequently occurred in the same patient.

There was no instance in this series of the so-called retroperitoneal syndrome observed by Jolly in the Spanish Civil War and explained by the

retroperitoneal infiltration of blood about the celiac plexus. This syndrome

consists of state of shock, with generalized pallor and sweating; rapid,

thready pulse, often becoming imperceptible; complete absence of any symptoms or signs referable to the abdomen; and semierection of the penis. The

Jolly, Douglas W.: Field Surgery in Total War. New York; Paul B. Hoeber, Inc., 1941.
326 GENERAL SURGERY

latter sign was not constantly present in Jolly’s cases, but when it appeared

it was of grave prognostic import and usually persisted until death. In this

series of cases, on the contrary, the signs and sjunptoms of retroperitoneal

hematoma were seldom distinguishable from those associated with perforation

of hollow viscus. Priapism was usually associated with injury to the spinal

cord. In the occasional case in which it was present with retroperitoneal

hematoma, the prognosis was not grave.

TREATMENT

Many of the retroperitoneal extravasations of blood observed in this series

bad little or no pathologic significance and required no special treatment. On

the other band, the feeling that most of them could be regarded as of no importance led, in the occasional case, to the overlooking of serious injury and

even to fatality.

From the standpoint of treatment, the 207 completely recorded retroperitoneal hematomas in this series can be divided into three groups:

One hundred and eleven patients, of whom nineteen died, had no specific

treatment related to the hematoma, presumably because it was thought to be

too insignificant to warrant any.

Sixty-three patients, of whom twenty-two died, for the most part were

treated by drainage, with or without evacuation of the clot. Packing was

occasionally employed, or, when it was possible, bleeding vessel was ligated.

Thirty-three patients, of whom twenty-two died, had associated injuries

of the great vessels of the abdomen. Treatment in these cases consisted of

evacuation of the blood clot and control of the bleeding vessel by ligation,

suture, or clamping.

The most important implication of retroperitoneal hematoma, aside from

the fact that the clinical signs could not be distinguished from signs of visceral

perforation, was that it might obscure injury to the vital retroperitoneal structures. That happened number of times in this series. Lesions overlooked

included duodenal perforation, ureteral injuries, retroperitoneal injuries

of the colon, and injuries of the bladder. There were only survivals in these

12 cases, in the injuries of the colon and in the injuries of the bladder.

It is easy to understand how these errors occurred. While small hematomas

required no treatment, large hematomas, and those in which there was evidence

of continued bleeding, urgently required exploration and control of the bleeding

vessels. Under these conditions, it was difficult to identify coexisting lesion,

such as perforation of the colon on its retroperitoneal aspect.

FACTORS OF MORTALITY

There were deaths (6.8 percent) among the 59 patients who had no injuries other than the retroperitoneal hematoma. The case fatality rate is of

the same order as the rate (4.9 percent) in abdominal injuries without visceral

wounds.
RETROPERITONEAL HEMATOMA 327

The 19 fatalities in the 111 cases in which there was no specific treatment

of the retroperitoneal hematoma were all attributable to concurrent visceral

injuries. Similarly, the 22 deaths which occurred in the 33 hematomas associated with injuries of the great vessels were directly related to the vascular

injuries. In both groups, the fatalities were not related to the retroperitoneal

bleeding.

Of the 22 deaths which occurred in the 63 retroperitoneal hematomas

treated directly, 11 were attributable to the retroperitoneal lesion itself. Five

patients died of shock and hemorrhage as result of severe retroperitoneal

bleeding, and three died of anuria following shock of the same origin. The

three other patients died of retroperitoneal cellulitis, in one instance associated

with pulmonary embolism.

The low case fatality rate in the group of cases in which there was no lesion

other than the retroperitoneal hematoma is apparently related to the relatively

low incidence of shock. In 18 of the 59 cases, of them fatality, there was no

record on this point. Twenty-five of the remaining 41 patients, of whom

died, were stated not to be in shock. Sixteen presented some degree of shock.

There were no deaths in the patients in mild shock, death in the in moderate

shock, and in the in severe shock. In general, therefore, there was less

shock, and less fatal shock, in this group than was usually encountered in

group of similar size with injury limited to single viscus.

As their experience with retroperitoneal hematoma increased, the surgeons

of the 2d Auxiliary Surgical Group formulated routine plan of management

for this condition:

1. After the evacuation of large hematoma in the retroperitoneal space

and control of the bleeding responsible for it, the surrounding structures were

carefully explored. They were similarly explored in the presence of any hematoma, regardless of its size, if its anatomic location was such as to suggest possible injury to the ureter, the bladder, the duodenum, or the posterior aspect of

the colon.

2. Adequate extraperitoneal drainage was provided for retroperitoneal

hematomas associated with injury to any portion of the urinary tract, the colon,

or the pancreas. If debrided missile wound of entry or exit was not suitable

for this purpose, drainage was instituted through surgical incision in the flank

or through posterior incision.

3. Evacuation of the clot and ligation of the bleeding vessel or vessels were

usually all that was necessary in large hematomas caused by vascular injuries.

4. Any opening in the posterior peritoneum, whether made by the missile

or created during the operative procedure, was carefully retroperitonealized,

to eliminate communication between the peritoneal cavity and the retroperitoneal space.

378327°—56 23 329

CHAPTER XXIX

Special Types of Abdominal Injury

Gordon F. Madding M. Dand Knowles B. Lawrence M. D.

VISCERAL INJURIES WITHOUT PENETRATION OF THE

PERITONEAL LAYER OF THE ABDOMINAL WALL

In 12 of the 3,154 abdominal injuries observed by the 2d Auxiliary Surgical

Group during 1944 and 1945, injuries of abdominal viscera occurred without

penetration of the abdominal wall by the wounding missile (table 96).

In 10 of the 12 cases the missile, while it caused through-and-through

wound of the abdominal parietes, did not injure the peritoneum. In the

other cases, the foreign body was retained within the abdominal wall. The

velocities of the missiles causing the through-and-through wounds were apparently greater than those of the missiles retained within the abdominal wall. It may be assumed that the additional imparted energy produced an explosive

effect in the abdominal wall, and that this effect was imparted, in turn, to the

intra-abdominal structures.

The fact that viscera containing gas and liquid (that is, hollow viscera)

were injured in of the 12 cases suggests that this type of viscus may be

peculiarly prone to injury from indirect trauma because of the transmission of

the force of the missile by the visceral contents. The fact that in one case

(table 96, case 3) the cecum and ascending colon were split open along the

anterior longitudinal band seems to support this theory.

In the single fatal case in this group (table 96, case 8) the patient sustained

severe wound of the left chest. The missile lacerated the pleural surface of

the left dome of the diaphragm, with apparent indentation of the stomach wall

and production of subserosal hematoma in that area. Pulmonary damage

was extensive, and the intra-abdominal injury seems to have played no significant part in the fatality, which was the result of shock and pulmonary edema.

The experience of the group surgeons with injuries of the abdominal wall

which did not involve the peritoneal layer clearly indicates that it would have

been an error to assume that there was no intra-abdominal visceral injury

merely because the missile did not enter the peritoneal cavity. Whenever

there was clinical evidence of intraperitoneal involvement, exploration was

regarded as mandatory. The visceral injuries thus found in this series are

proof of the wisdom of that policy.
330 GENERAL SURGERY

Table

96.

—Essential

data

in

12

injuries

of

intraperitoneal

viscera

without

penetration

of

peritoneal

layer

of

abdominal wall

Case

Wounding

agent

Type

of

wound

Location of

wound

Organ

injured

Lesion

Treatment

Comment

Not

recorded

Penetrating

Left

lower

quadrant...Right

flank

Incomplete

laceration

__ __do

Perforating

Liver._

Shell

fragment

Right

upper

quadrant. Cecum

and

ascending

colon.

compound

fracture

of

femur.

do

Stellate

tear,

right

lobe

.do

Penetrating

Small

anterior

perforation.

Not

recorded

Thoracotomy;

transdiaphragmatlc abdominal

exploration.

pulmonary

edema,

from

extensive

Shell

fragment..

do

__

Right

abdomen

Cecum

lung

injury.

10

___ _do___

....do

tuslons.

11

Splenic

flexure

of

colon;

jejunum.

Perforation, colon;

contusions,

jejunum.

Exteriorization of

colon..

chest.

12

Shell

fragment

Drainage

of

liver;

exteriorization of

colon;

suture

of

jejunum.

dominal

wall.

verse colon,

jejunum.

Penetrating: Missile retained in

abdominal

wall;

peritoneum

intact.

Perforating;

Through-and-through

wound

of

abdominal parietes;

peritoneum

intact.
SPECIAL TYPES OF ABDOMINAL INJURY 331

VISCERAL INJURIES CAUSED BY BLUNT TRAUMA

AND BLAST

Perforation or rupture of an intra-abdominal viscus, which is always

possibility in any instance of blunt trauma or blast, occurred in 14 of the 3,154

abdominal injuries in this series (0.44 percent) in the absence of peritoneal

penetration (table 97). These cases are exclusive of injuries to the bladder,

urethra, and other urogenital structures associated with fractures of the pelvis.

The small intestine, the spleen, the colon, the mesentery, and the kidney were

most frequently injured, alone or in combination.

Nine of the fourteen injuries resulted from vehicular accidents and three

from blast from nearby explosion of an artillery shell. Occasionally

subcutaneous hemorrhage indicated the area of greatest trauma, but in none of

these injuries was there skin wound. The diagnosis of possible intraabdominal injury was made in 13 of the 14 cases by the history of injury and

the physical findings. Tenderness was usually present, and peristalsis was

constantly absent. In the remaining case (table 97, case 14) an extensive

thoracic injury overshadowed the abdominal injury, which was not suspected

until autopsy.

The case fatality rate in this group (2 deaths in 14 cases) is considerably

lower than the rates of 44 and 55 percent reported in the literature for this type

of injury. The good results are attributable to early and vigorous therapy for

shock, followed by prompt surgical intervention. The series may be small,

but in the majority of cases the lesions were such that death would undoubtedly

have occurred in the absence of surgical intervention.

PENETRATING (PERFORATING) WOUNDS OF THE

ABDOMINAL WALL WITHOUT VISCERAL INJURIES

The peritoneal cavity was penetrated in 41 of the 3,154 abdominal wounds

in this series (1.3 percent) without significant damage to any of the intraperitoneal viscera. The wounds were perforating in 11 of the 40 recorded cases

and penetrating in the other 29. The wounding agent was listed as highexplosive shell fragment in 33 cases and as gunshot in the other 8.

In 24 of the 41 cases, the wounds were thoracoabdominal. This proportion

(58.5 percent) differs materially from the 26.2 percent of thoracoabdominal

wounds in the entire series of 3,154 abdominal injuries, though the figures are

too small to be of real significance. The right diaphragm was wounded 13

times and the left 11 times. In 23 of the 24 cases in this group, the missile

entered the peritoneal cavity from the thorax. In cases, there was double

perforation of the diaphragm, the missile either lodging in the lung or passing

out through the chest wall. In of the 11 single perforating wounds, the

injury was produced by sharp rib fragments. In the other cases in which

Threesimilar cases in which only the omentum was injured are not included these 41 cases. In of the 3, small

rents in the omentum wererepairedby suture. In the third case, segment of omentum had herniated through perforation in the diaphragm and become gangrenous. Resection was followedby an uneventful recovery.
332 GENERAL SURGERY

Table

97.

—Essential

data

in

intra-abdominal

injuries

caused

by

blunt

trauma and

external

blast

Case

Wounding

agent

Type

of

injury

Location of

wound

Organ

injured

Lesion

Treatment

Postoperative course

Ileum,

descending

coTransection

ileum,

lacIon.

eration

colon.

riorization colon.

Ileum.

Lacerations

Do.

Spleen.......

Pedicle torn.....

Kidney,

mesentery

Tear

splenic

pedicle,

Nephrectomy, suture

Uneventful.

tear

mesentery.

mesentery.

Blast,

contusion...

Spleen...

Fracture

Wound dehiscence

seventh

postoperative

day,

secondary

closure.

Serosal

tears

Command car.

Transection

Do. Do.

.do

Do.

10

Transection jejunum,

Death

13th

postoperatransverse

colon.

tear

mesentery,

tear

ture

mesentery,

cotive

day,

peritonitis,

serosa colon.

Ion.

pneumonia.

11

Shell

explosion

Fracture.. ...

12

Fall

12

feet

Spleen,

left

kidney

Fracture

spleen,

tear

Do.

renal

pedicle.

tomy.

13

Bailey

bridge

Injury.

do

Left

hy

pochondrium..

Descending

colon....

Division

and

retraction

Suture,

exteriorization.

Do.

taenia

coli.

14

Shell

explosion.

Perforating wound

Left

chest,

left

abdoLung,

stomach,

small

Blast

injury

lung,

subDebridement chest

Death17th

postoperative

chest

wall,

blast

men,

left

arm.

bowel,

colon.

serosal

gastric

hemwall.

day

from

acute

eircuinjury

abdoorrhage,

tears

and

latory

collapse

and

inmen.

hemorrhage

intestitestinal

obstruction.

nal

mucosa.

Abdominal

lesions

not

diagnosed

until

autopsy.
SPECIAL TYPES OF ABDOMINAL INJURY 333

the missile entered the abdomen from the thorax, it lodged in the diaphragm

and caused only small opening in the peritoneum.

In none of the 17 abdominal wounds had the missile passed freely across

or through the general peritoneal cavity in major diameter. In every instance,

the peritoneal wound had been caused by missiles which had either perforated

the cavity across small angles, lacerated the peritoneum in burrowing through

extraperitoneal tissues, or so exhausted their momentum as to fall harmlessly

into the peritoneal cavity,

Hemoperitoneum in varying degrees, all from extraperitoneal sources, was

present in most of the 41 cases. It was this blood, sometimes more than

liter, which produced the clinical symptoms and signs of an intraperitoneal

lesion.

The surgical approach in each instance was determined by the type of

wound. In 20 of the 24 thoracoabdominal wounds, exploration was carried

out through the chest and diaphragm. In two other cases, it was carried out

through separate incisions in the chest and abdomen. The remaining operations were performed through abdominal incisions. The wound of the diaphragm was sutured in all thoracoabdominal wounds.

There were deaths in the 41 cases. One patient, who had sustained an

evisceration of 18 inches of ileum through wound of the abdominal wall, died

unexpectedly, days after operation, of massive pulmonary embolism, the

origin of which was not stated. In the other fatal case, severe retroperitoneal

injury with severance of the left common iliac vessels, death occurred 10 days

after operation, from peritonitis, retroperitoneal cellulitis, and pneumonia.

The most important observation made in this group of cases is that in not

single instance did missile pass harmlessly across the general peritoneal

cavity in major diameter. Since the whole series represents very large

number of cases (3,154) and since the policy was to explore every injury in which there was evidence of or suspicion of peritoneal penetration, it would

seem that perforating wounds of the peritoneal cavity in which there is no

injury of the intraperitoneal structures must be extremely uncommon. It is

true that because of the tendency of certain wounds of the gastrointestinal

tract to seal over, clinical recovery may occasionally ensue in such cases, without surgery and therefore without diagnosis, but because of the excellent surgical

service and facilities provided in forward hospitals in World War II, the risks

involved in the nonsurgical management of this type of wound would not have

been justified.

Part III

COLOSTOMY

337

CHAPTER XXX

The Management of Colostomies

David Henry Poer M. D.

HISTORICAL NOTE

Although colostomy was well-established procedure in civilian surgical

practice at the beginning of World War I, military surgeons of all armies were

slow to employ it. The chief reason was that during the early months of this

war, as in all previous wars, nonintervention was the general rule in abdominal

injuries. This was partly because of the poor results which had attended

previous efforts at intervention and partly because the majority of surgeons

did not regard major surgery as practical near the front. Since abdominal

surgery, to have any hope of success, had to be performed within reasonably

short time after injury, this pessimistic point of view automatically excluded

the surgical management of these injuries.

Many surgeons, even in 1914, did not accept these premises, and as the

war progressed the concept became more and more general that recovery

could be expected in abdominal injuries if operation was performed. As mobile

hospital facilities, equipped and staffed for surgery, were set up near the front,

the practice of prompt surgery for these injuries became increasingly frequent,

and in 1917 and 1918 operation became the general rule in both the British and

the American Armies.

Colostomy, however, was never adopted as routine technique in wounds

of the large bowel. Instead, it was usually reserved for the most seriously

wounded patients, with extensive wounds of the colon. These casualties

formed distinctly unfavorable group, and the high case fatality rate which

attended the use of colostomy was no more than might have been expected.

Wallace, who wrote the section on abdominal injuries for the official British

medical history of World War I, did not mention colostomy as method of

dealing with wounds of the cecum. He considered suture preferable whenever

it was feasible in wounds of the transverse and vertical colons, and he also

stressed the importance of drainage. Colostomy, he indicated, was an undesirable alternative, which was most likely to be necessary in injuries of the splenic

flexure. Its widest application, in his opinion, was in left-sided wounds of the

(1) History of the Great War Based on Official Documents. Medical Services Surgery of the War. London; His

Majesty’s Stationery Office, 1922, vol. I, pp. 476-579. (2) The Medical Department of the United States Army in the

World War. Washington: U. S. Government Printing Office, 1927, vol. XI, pt. 1, pp. 443-490.

Wallace, C. S.: Wounds of the Abdominal Viscera. In History of the Great War Based on Official Documents.

See footnote (1).
338 GENERAL SURGERY

loin, in which sepsis tends to develop late, and in rectal injuries. Colostomy

was employed only 53 times in the 155 injuries of the large bowel upon which

Wallace based his discussion. It was, however, widely used in base hospitals

in the management of fecal fistulas which developed after failure of suture repair.

The results which Wallace cited explain why colostomy was not popular

procedure among British surgeons in World War I. The case fatality rate in

wounds of the colon, he pointed out, was higher when it was employed; 73.5

percent as compared with just over 50 percent in cases managed by suture.

These figures, Wallace added, must not be taken to indicate that colostomy is

necessarily dangerous procedure. They merely indicated that fatal sepsis was

likely to occur when colostomy was employed, because infection was already

present when the operation was performed.

Lee, who wrote the section on abdominal injuries in the official United

States medical history of World War I, set down the following general principles

for the management of wounds of the colon:

1. Suture should be performed whenever it is possible, in order to secure

satisfactory closure.

2. Colostomy should always be employed in preference to resection.

3. Colostomy is preferable in all injuries with large, ragged openings,

particularly injuries of the cecum, descending colon, and sigmoid.

4. Drainage should be usedroutinely in proved or suspected retroperitoneal

injuries. It should always be used when there is any doubtof the integrity of

the suture fine.

5. Colostomy may be required in extensive lacerations of the lower rectum

and in rect al injuries deep in the pelvis, in which suture is not possible. According to Lee, the results of suture repair were better than those of colostomy, in

which the case fatality rate was 70 percent.

Jolly’s extensive personal experienceas field surgeon in the Spanish Civil

War included 970 abdominal injuries. In his book on field surgery in total war

he described invaginating suture and resection as alternative methods of treatment in wounds of the colon. He emphasized the importance of drainage but

did not mention colostomy.

COLOSTOMY IN OVERSEAS HOSPITALS

The attitude of surgeons toward colostomy in World War II is an interesting contrast to the opinion held of it early in World War and in the Spanish

Civil War, which ended only about years before the United States entered

World War II. Its lifesaving properties were recognized almost at once, and,

together with exteriorization of the damaged segment of bowel, it became the routine method of management for injuries of the large bowel. This policy,

Lee, Burton, J.: Wounds of the Abdomen. In the Medical Department of the United States Armyin the World

War. See footnote (2), p. 337. Jolly, Douglas W.: Field Surgery In Total War. New York: Paul B. Hoeber, Inc., 1941. Ibid.
MANAGEMENT OF COLOSTOMIES 339

which saved many thousands of lives, can fairly be regarded as one of the most

important advances ever made in the treatment of battle-incurred injuries of

the colon.

Colostomy, with and without exteriorization of the damaged bowel, was

first used by British surgeons during the air bombardment of London in 1940

and 1941, at the repeated suggestion of Ogilvie.

The new policy was apparently dictated by two considerations. The

first was the success of this method of management of intestinal tumors in

civilian practice. The affected segment of bowel was brought outside the

abdomen at the first operation and resected later at second-stage operation.

The second consideration was the prohibitively high case fatality rate associated with immediate repair of injuries of the colon and replacement of the

bowel into the abdominal cavity. As Ogilvie remarked later, in report of the

British experience with abdominal injuries in the Western Desert, it would bo

rash to claim that any of the patients who died after colostomy could have

In personal communication to the author of this chapter, dated 24 May 1955, Sir Heneage Ogllvie pointed out that

much of this teaching was informal. Hehad first publiclyadvocated theuse of colostomy for wounds of the large bowelat

lecture given at the Postgraduate Hospital in Hammersmith, England, late in 1939. This lecture was one of seriesprepared for the emergency and dealing with the surgical treatment of wounds of warfare. How to manage wounds of the

colon was vigorously discussed by the numerous surgeons present, and at this meeting, as well as at later meetings, certain amount of opposition to the policy of colostomy was expressed.

lecture given by Sir Heneage in Kenya, when he was consulting surgeon to the East African Force which was conductingthe attack on Abyssiniafrom the south, wasreproduced in the June 1941 issue of the East African Medical Journal.

Thesubstance of the recommendations concerning the management ofwounds of the colon was as follows:

“Holes in thefree portions of the colon maybe closed bya purse-string suture if the bowel wallround them isperfectly

healthy, but in most cases local repair is unsafe and resection is wise. free mobilisation is often required before the

resected ends can be brought together without tension. Nearly all writers on military surgery advise end-to-end suture

after resection, with or without eaecostomy, but this advice isunsound in the lightof modern teaching and practice, and

the high mortality in colon wounds in all published statistics suggests that it is not good treatment. After mobilisation

sufficient to allow the colon above and below the injury tobe approximated without tension, the Injured segment should

beremoved and the cutendsabove and below it, closed with crushing clamps, should be broughtto the surface at one end

of the incision or wound. The clamps are removed after 24 hours, and the continuity of the bowel is restored later by

crushing the spur between the openings.

“There has been marked tendency in recent years to look on the large intestine with Increasing respect or even fear.

Its walls are thin, their blood-supply is poor, and the peritoneal coat is interruptedby broad mesentery and distorted by

fatblisters, thecontents are highly infectiveandmechanically traumatic, its luminal pressure alters with explosive suddenness. No suturescan be placedaccurately in its wall, and what are thought tobe lembertsoften pass through all coats and

carry infection. All surgeons have experienced trouble with leakage and sepsisat the suture line afterresection and many

feel today that no stitch should ever be put through colon that is not both emptyand sterile. colostomy or resected

loop should not be stitchedto the skin, but theskin openingshouldbe madeto fit the colostomy; asegment of bowel should

not be excised and the ends suturedunless the contents have been diverted above by an excluding colostomy for at least

weeks. Devine has shown the way to success in cancer of the colon by his operation of exclusion and Lahey has made

resection of the colon for ulcerative colitis and of the rectum for cancer safe by stage operations in which the bowel is

brought to the surface. In war injuries, the way tosafety is the same, foreaecostomy provides onlypartial relief of tension

at the injured site and proximal colostomy is no better unless itis done some weeks before.”

The sameadvice was repeated in variousmemorandums circulated in the British East African Force in 1941 and in the

British MiddleEast Force in 1942and 1943, as well as in field manual published for the use of British troops during the

invasion of the Continent in June 1944. Meantime, Ogilvie had published his comprehensive report Abdominal Wounds

in the Western Desert (March 1944, see footnote 7).

The personal communication from Sir Heneage Ogilvie from which the information in this footnote has been taken

concludes with the following paragraph:

“Under the influence of these antiseptics [the effective intestinal antiseptics which were later developed], with improved surgical conditions and with the development of skilled surgery in the forward units, the policy was somewhat

modified in that closureof smallperforationsin the proximal colon was countenanced if the surgeonwas manof considerable experience and if the case could beretained for the first 10days for observation. However, as far as know, up to the

end of the war it was considered that exteriorisation ofall colon wounds was the safest policy and the one to berecommended to all surgeons undertaking the abdominal surgery of warfare for the first time.”

Ogilvie, W. H.; Abdominal Wounds in the Western Desert. Surg., Gynec. Obst. 78: 225-238, March 1944.
340 GENERAL SURGERY

been saved by suture alone, but there was no doubt that certain of the deaths

which occurred after suture of the injured bowel could have been avoided by

colostomy. In his opinion, the exteriorization of the damaged colon was one of

seven decisive points in the management of abdominal injuries. By this time

(1943) the British experience had been sufficiently large for him to be able to

analyze the conditions which made closure of colostomy stoma difficult and

to suggest improved techniques.

The American experience.—Colostomy was extensively employed in

injuries of the colon during the North African campaign in 1942-43, at first, it

would seem, without knowledge of the earlier British experience. Circular

Letter No. 20, 22 June 1943, Office of the Surgeon, North African Theater of

Operations, consisted chiefly of comments from hospitals of the Communications Zone, North African Theater of Operations, United States Army, on the

management of battle casualties inforward areas during the fighting in Tunisia.

One of the criticisms had to do with failure to perform immediate colostomy in

retroperitoneal injuries of the rectum.

Colostomy became official practice for injuries of the large bowel when

Circular Letter No. 178, dated 23 October 1943, was issued from the Office of

The Surgeon General of the Army. The instructions were that

in large bowel injuries, the damaged segment will be exteriorized by drawing it

out through separate incision, preferably in the flank. In order to facilitate subsequent

closure the two limbs of the loop should be approximated by suture for distance of about

inches and then returned to the abdomen, leaving the apex exteriorized with short length

of rubber tubing or other suitable material beneath it. If the segment cannot be mobilized,

the injury should be repaired and proximal colostomy done.

Thereafter in World War II, surgery of the colon in the UnitedStates Army

was based on three general principles: (1) Exteriorization of the wounded portions of the bowel (fig. 31), to avoid intraperitoneal contamination; (2) complete

diversion of the fecal stream away from distal wounds of the colon and rectum; and (3) colostomy to effect incomplete diversion of the fecal stream for purposes

of gaseous decompression as well as possible future complete diversion.

Soldiers with wounds of the colon were for the most part treated in field

hospitals, located near division clearing stations. They were brought to them

and were prepared for surgery by resuscitative measures within remarkably

short time. Figures of the 2d Auxiliary Surgical Group (p. 256) show that the

average timelag between wounding and operation in 1,222 wounds of the colon

and rectum was 10.9 hours. The speed with which treatment was instituted in

itself saved many lives. Strict adherence to the policy of exteriorization of the

bowel and colostomy shortened the time necessary to care for wounds of the

colon and saved additional lives by making earlier treatment possible for other

wounded men.

During the early American participation in the war, revision of the colostomy stoma was undertaken, when it was indicated, in fixed hospitals overseas, after which the casualties were returned to the Zone of Interior for reconstructive surgery and closure of the opening in the bowel. As experience
MANAGEMENT OF COLOSTOMIES 341

Figure 31. —Loop of damaged sigmoid exteriorized through separate inguinal incision 12

days after wounding. When the edema now present subsides, satisfactorily

functioning colostomy will remain until it is closed.

increased and additional trained surgeons were sent overseas, closure of the

colostomy was frequently effected in numbered general hospitals in the communications zone. This was common British practice. Ogilvie related

that men who had been wounded in the abdomen at El Alamein marched with

the British Eighth Army into Tunis. Similarly, many United States soldiers

who had sustained wounds of the colon and had been treated by colostomy

were able to return to active military duty in the theaters in which they had

been wounded.

For many reasons, however, it was more expedient to close most colostomies in general hospitals in the Zone of Interior, and the greater part of the

data upon which this chapter is based concern that experience.

COLOSTOMY IN ZONE OF INTERIOR HOSPITALS

Basic Data

During the winter of 1945-46, questionnaires dealing with various aspects

of colostomy were sent to all general hospitals in the United States. Although
342 GENERAL SURGERY

many hospitals had been closed by this time and their records had been forwarded to general collection center, the replies received furnished information on 2,378 soldiers with wounds of the colon who had been treated by colostomy in forward hospitals overseas. As might have been expected, since

large majority of these patients had already undergone disposition proceedings,

numerous details were missing on many of the records.

For convenience, and because of the deficits in the data just mentioned,

these 2,378 cases are discussed in the following groupings:

1. Two thousand one hundred and two cases in which closure had been

done in Zone of Interior hospitals and on which information had been secured

when the final analysis of cases was begun.

2. Four hundred and sixty-four cases included in the two thousand one

hundred and two cases just mentioned and reported from ten general hospitals

in the Fifth and Sixth Service Commands and from McCloskey General Hospital in the Eighth Service Command (series A). These data were unusually

complete and, for that reason, are frequently discussed separately.

3. One hundred and eighty cases in which the colostomy had been closed

in eight overseas hospitals (series B).

4. Ninety-six cases from Rhodes General Hospital in the Second Service

Command (series C). These data were received after the rest of the material

had been analyzed but are discussed separately at appropriate places.

Techniques of Colostomy

As might be expected, when so many surgeons had operated on so many

patients and under such widely different circumstances, the 2,378 colostomies

which make up this composite series represented every known technique. In

approximately 300 cases, no details were stated. Loop colostomy with

single opening was performed in 40 percent of the remaining cases, the PaulMikulicz colostomy with spur in 30 percent, the Devine technique or some

modification thereof and mucous fistulas with single or multiple openings in

10 percent each, and the tube or tangential colostomy and the loop colostomy

with double openings in percent each. The colostomy was located on the

left side in 50 percent of the stated cases, in the transverse colon in 30 percent,

and on the right side in 17 percent. The remaining operations were in the

sacral region.

The location of the wound and of the colostomy was not stated in large

proportion of the records. In series A, the wound was on the left side in about

third of the 416 stated cases, and the colostomy was on this side in about 58

percent of the 338 stated cases.
MANAGEMENT OF COLOSTOMIES 343

Preclosure Problems in Zone of Interior Hospitals

The eventual medical policy in the management of wounds of the colon

was, as already stated, to close the stoma in almost all instances in Zone of

Interior hospitals. Closure, however, involved considerably more than the

actual operative act. It required very careful preoperative preparation, the

routine of which was based upon the problems presented in the special case.

Among these problems the following were the most important:

Location of wound

Right colon: Cases

Cecum _______

44

Ascending colon __ 35

Hepatic flexure 13

Transverse colon __ ____ __

92

92

72

Left colon:

Splenic flexure 20

Descending colon 42

Sigmoid 78

Rectum

140

140

112

Total _______ 416

Location of colostomy

Right colon: Cases Ileum _____

(21)

Cecum 27

Ascending colon 26

Hepatic flexure 12

Transverse colon __

65

65

75

Left colon:

Splenic flexure 13

Descending colon _____ 24

Sigmoid .. 158

Sacral ___

195

195

Total __ 338

Not included in figures for the right colon. As isnoted in the text, the ileum is not desirable location for enterostomy in wounds of the colon, but it was used in some instances because of errors in judgmentand in others because of

technical errors at operation.
344 GENERAL SURGERY

Associated wounds.—Well over half of the patients received in Zone of

Interior hospitals with unclosed colostomies had other major injuries, which

in many instances were multiple (see following tabulation of associated visceral

injuries in 179 patients in series A). Wounds of the small intestine were particularly frequent; series A, in which they made up considerably over half of

all associated wounds, is typical. Fractures of the long bones represented as

much as 40 percent of associated injuries in many hospitals. few patients

in each hospital were paraplegic.

The majority of the associated injuries were well on the to healing

when the patients reached the United States, but the associated injuries sometimes required attention more urgently than did the colostomy. If fractures, for instance, had to be treated by balanced suspension skeletal traction, closure

of the colostomy stoma was not feasible immediately; it was desirable that the

patient be ambulatory before abdominal surgery was undertaken. Nerve

suture and plastic surgery, on the other hand, were usually postponed until

after the colostomy had been closed.

Organic disease was not usual in young, sturdy soldiers, but three

patients at McCloskey General Hospital had pulmonary tuberculosis. There

were also occasional instances of this and other diseases at other hospitals.

Nutritional status.—Almost all of the patients who arrived in the Zone of

Interior with unclosed colostomies had lost weight (fig. 32). At one typical

hospital, the weight loss ranged from 10 to 80 pounds and averaged 36 pounds.

In numerous instances, the patients were at least partly responsible for their

own poor nutritional status. They deliberately restricted their food intake

in order to decrease the number of daily dressings required. Hypoproteinemia

was found in about 10 percent of the serum-protein determinations, but otherOrgan Cases

Esophagus _____

____

Stomach 31

Small intestine:

Duodenum

Jejunum 80

Ileum 126

Not stated 29

241

241

Appendix.., __ __

Gallbladder

Liver 32

Spleen 16

Diaphragm. 17

Urinarv tract _____ 64

Spinal cord

Total 420
MANAGEMENT OF COLOSTOMIES 345

Figure 32. —Right-sided colostomy. The cecum and ascending colon were resected at the

first operation after wounding, and the ends were implanted into the incisions. After

resection, the ends were brought out, and an ileostomy and colostomy were created.

Note the extreme emaciation which accompanies right-sided colostomy. This patient

also had fecal fistula in the buttocks. After long period of careful preparation, intestinal continuity was restored by ileotransverse colostomy. Full recovery followed.

wise there was little evidence of serious alteration in the basic constituents of the

blood except in patients with wounds on the right side, complicated by drainage from the small intestine.

Complications related to the colostomy.—The series statistics may be

taken as typical of the collected series in respect to complications related to the

colostomy. In 275 of the 464 cases, herniation of various degrees had occurred;

in some instances the bowel actually protruded through itself (that is, through

the colostomy stoma). Fecal fistulas were present in 70 patients, wound

infection of some degree in 38, obstruction of some degree in 34, fistulas into

the buttocks in 31, osteomyelitis in 25, wound dehiscence in 10, and peritonitis

in 7. Complications of wounding unrelated to the colostomy included urinary

fistula in cases, empyema in 2, thrombophlebitis in 2, and fistula of the

biliary tract in 1.

378327° 50- 24
346 GENERAL SURGERY

Figure 33.—Fecal fistula into extraperitoneal segment of rectosigmoid through rifle wound

of buttocks; probe indicates depth of fistula. double-barreled loop colostomy created in the descending colon immediately after injury required revision and complete separation of the stoma to prevent continued contamination of the fistula. Spontaneous

healing of the fistula followed. The colostomy was later closed by direct anastomosis

within the peritoneal cavity.

In small number of cases, the colostomy was not functioning satisfactorily when the patients were received in Zone of Interior hospitals, and

prompt revision or relocation was required. colostomy placed posteriorly in the sacral region, for instance, was relocated anteriorly, in the descending or

sigmoid colon. When there was persistent contamination of the buttocks or

persistent perineal fistula (fig. 33), secondary colostomy was necessary to

accomplish defunctionalization of the lower rectal segment. The secondary

opening was preferably placed proximally in the transverse colon (fig. 34),

site which many surgeons preferred for primary colostomy in injuries of the

pelvic colon.

Colostomies performed by surgeons working under the stress of field conditions were sometimes not performed with the care and precision possible in

civilian hospitals. Holder and Lewison, who had large experience in the

closure of colostomy overseas, listed the conditions which made reconstructive

surgery difficult as follows:

1. The colostomy had been placed so near the costal margins or the iliac

crest that osteomyelitis was an almost inevitable complication (fig. 35).

Holder, H. G.; and Lewison, E. F,; Management of Colostomies Performed for War Injuries. Ann. Surg. 126: 253-261, September 1947.
MANAGEMENT OF COLOSTOMIES 347

2. The colostomy had been placed too close to coexisting cystostomy.

3. The colostomy had been created through the exploratory incision, without adequate mobilization of the bowel. This error, which was most often

evident in colostomies of the transverse colon, was likely to be followed by

retraction of the stoma, infection of the abdominal wall, intraperitoneal infection, sinus formation, and wound dehiscence. Wound infection, in fact, was

almost inevitable because of the practice in military surgery of removing the

clamps from the bowel immediately. This was necessary precaution, for, in

the rush of work, they could easily be overlooked, and obstruction could occur

as residt; but when it was carried out in colostomy created through the

exploratory incision, feces promptly spilled over the fresh wound.

4. The colostomy was created through the wound of entry or exit (fig. 36).

This technique was almost invariably followed by infection, which frequently

went on to spreading cellulitis.

5. The spur in Mikulicz colostomy was sometimes too short because the

loops had been insufficiently mobilized. As result, the bowel retracted, and

the loops became rotated or partially obstructed.

6. Edema or necrosis sometimes complicated loop colostomies because glass

rods or heavy rubber tubing had been used to support an inadequately mobilized

Figure 34.—Double stoma in transverse colon, with complete division of bowel. The

mucous membranes, however, are still in contact, and the distal segment of the colon

remains contaminated. Note the extensive abdominal incisions, the result of multiple

surgery.
348 GENERAL SURGERY

Figure 35.—Extensive injuries of descending colon, for which resection was necessary at

first operation after wounding. Implantation of proximal end into wound of entrance

in flank; distal end has been brought out through inguinal incision. The splenic flexure

was liberated by intra-abdominal manipulationto permit primary anastomotic closure.
MANAGEMENT OF COLOSTOMIES 349

Figure 36.—Lumbar colostomy following exteriorization of cecum and ascending colon in

wound of flank. The lumbar region is not location of choice for colostomy, but in this

instance function was satisfactory. Closure was effected at an extensive intra-abdominal operation, by ileotransverse colostomy.

loop. If the incision through which the bowel had been brought out was too

short, constriction of the bowel, with partial dysfunction of the colostomy, was

likely result.

7. The openings in loop colostomies were sometimes unnecessarily large

(fig. 37). Often they had been created in the transverse axis of the bowel

rather than the longitudinal axis.

8. Complete diversion of the fecal stream had sometimes not been accomplished (fig. 38). This was essential in wounds of the rectum and extensive

wounds of the rectosigmoid, with associated injury to the bladder, urethra, and bony pelvis.
350 GENERAL SURGERY

Figure 37.—Excessive protrusion of transverse colon and eventration of mucous membrane

with incomplete division of bowel. The opening in the abdominal wall is also unnecessarily large. This patient sustained an injury of the perineum, with loss of urinary

control. After reduction of the internal herniation of the mucosa, the colostomy was

closed by primary anastomosis without too much difficulty.

9. Drainage of the retroperitoneal and pelvic spaces had been omitted in

some cases and was not adequate in others. Drainage through the track

created by the missile was almost never adequate.

In addition to the technical errors just listed, other errors were observed.

The use of sutures which were too tight and the inclusion of the mesenteric

artery in the suture of the spur could cause tension, torsion, and constriction

of the bowel, with resulting impairment of the circulation. Thrombosis was

also possible complication. Hernia might develop when too large segment

of the bowel was used for the colostomy. Partial obstruction could follow too

tight closure. Eventration of the ileocecal area was possibility in wounds

of the cecum.
MANAGEMENT OF COLOSTOMIES 351

Infection.—Infection always introduced serious preoperative difficulties.

It could arise, as just observed, in dysfunction of the colostomy. It could also

originate in number of other ways. Sometimes abscesses in the chest or the

abdomen failed to resolve completely. Infection frequently occurred along

persistent fistulous tracts, particularly when osteomyelitis was complication

or foreign body had not been removed. Fistulas which had healed spontaneously or which had been closed in overseas hospitals sometimes broke

down and became infected because the fecal stream had been incompletely

diverted and the tract had become contaminated. In cases of persistent

infection, the cause had to be sought for and eliminated and adequate drainage

established. This often required an extensive surgical procedure (pp. 352, 353).

Fecal fistulas.—Fecal fistulas were always troublesome and were sometimes

the cause of serious preoperative difficulties. This was particularly true of

fistulas of the small bowel and fistulas in the sacral region. Urinary fistulas

could also be very troublesome.

Figure 38. —Sigmoid colostomy (incomplete division of bowel), with eversion of mucous

membrane, performed to sidetrack fecal current from fecal fistula in buttocks.
352 GENERAL SURGERY

In some instances, because of surgical error, the artificial anus had been

constructed in the terminal ileum or the ileum had been used to form the

colostomy in combination with the large bowel. The spur might consist of

colon and ileum, or single or double mucous fistula might be created following end-to-end or side-to-side anastomosis between the ileum and the colon.

Fistulas of the jejunum or the duodenum were usually the result of the original

injury or of surgical attempts to repair it.

Fistulas of the small bowel produced irritation or actual digestion of the

skin. Sometimes the process was extensive. All methods used to protect the

contaminated areas were likely to be unsatisfactory. Moreover, because of

continuous drainage and the loss of essential elements from the gastrointestinal

tract, patients with fistulas were often gravely emaciated. Immediate closure

of the fistula was therefore indicated.

Small, uncomplicated fistulas could be eliminated by inversion of the

intestine into the lumen. In some complicated cases, shunting or sidetracking procedure had to be employed, with anastomosis of the ileum to the descending or transverse colon proximal to the fistula, by either the side-to-side

or the end-to-end technique. Later, the colostomy could be closed by some

one of the methods shortly to be described, or, if it was indicated, resection of

the intervening ileum and colon could be carried out. Improvement following

closure of fistula in the small bowel was usually prompt and was often dramatic.

Patients with fistulas in the sacral region usually arrived in the Zone of

Interior in poor condition, as the result of chronic sepsis. In perhaps half of

all wounds of the rectum, the bony structure of the pelvis had been damaged

also, and osteomyelitis was frequent complication. As rule, it was extensive,

involving the sacrum, the coccyx, the wings of the ilium, or the upper portion

of the femur. The joint cavities were also often involved in the infection.

The fistula was persistently contaminated because the distal segment of the

intestine had not been completely defunctionated, and the fecal drainage

enhanced the bone infection. Finally, foreign bodies, which in this location

are difficult to localize accurately and which were therefore often left in situ,

frequently served as foci of infection. The complete removal of all foreign

bodies, while extremely important at the first operation, was by no means as

simple as it may sound. Pieces of clothing and gauze and bits of equipment

which were not radiopaque were extremely difficult to visualize and identify.

If all extraneous material as not removed, persistence of infection in fistulous

tracts was inevitable. The vicious circle thus set up was extremely difficult

to interrupt.

If foreign body as not present or if osteomyelitis not complication,

fistula in the sacral region occasionally healed spontaneously, even when

there as persistent contamination of the distal segment of bowel. More

frequently, prolonged treatment was necessary. It included daily irrigations

of the fistula wdth physiologic salt solution or some other solution, the admin-
MANAGEMENT OF COLOSTOMIES 353

istration of sulfonamide, and measures directed toward improvement of the

general condition. These measures, although they were occasionally successful,

were not desirable definitive treatment for fecal fistula. For one thing, it

was impossible to determine in which cases they would succeed. For another, even an apparently successful result of expectant treatment was not always

permanent. The fistula was likely to reopen, the mucous membrane of the

bowel tended to evert into the fistulous tract,and other undesirable consequences

could ensue.

Experience soon showed that even short and direct fistulous tract which

traversed bone would not heal until three conditions had been fulfilled; (1) The

fecal stream had to be completely diverted; (2) all dead bone, including the

coccyx and parts of the sacrum, had to be removed; and (3) all scar tissue which

prevented obliteration of dead spaces also had to be removed. Paradoxically,

healing of long, tortuous fistulous tracts which traversed bone sometimes

occurred when only expectant measures were used, but the course of treatment

was long and tedious and the results were so uncertain that surgery was always

the preferred method.

The first step in the treatment of fecal fistula was diversion of the fecal

stream, either by revision of the colostomy or by creation of secondary colostomy placed proximally in the transverse colon. Revision was best accomplished by some modification of the Devine technique (fig. 39), in which the

openings would be separated by bridge of skin. The next steps were removal

of any foreign bodies in the region of the fistula and adequate unroofing of the

entire tract from its external opening down to the rectum. Unroofing was often

difficultand hazardous because of the extensive thickening and resulting rigidity

of the rectal wall and the adjacent tissues. Incisions into the peritoneum lateral

to the rectosigmoid helped to free the rectum. Eversion of the rectal mucosa

into the fistula, which had usually occurred, was corrected by excision of the involved mucosa or by inverting it into the rectal lumen. The final step of the

operation was excision of scar tissue and of the coccyx and parts of the sacrum, together withremoval of all foreign material such as metal, bits of clothing or equipment, and surgical gauze, which was sometimes still present since it

had been applied as first-aid measure.

The extensive surgery required for the repair of sacral fistulas, in addition

to the tissue lost because of the ravages of infection, usually caused serious

losses of soft tissue. Plastic repair was therefore frequently necessary. The

preferred technique was to perform staged operation, swinging muscle flaps

across the debrided tract and then using full-thickness skin grafts.

Fistulous communications between the intestine and urinary tract were

fairly frequent and had to be dealt with by various measures before closure

of the colostomy could be attempted. They were sometimes kept open by

obstruction caused by urinary calculi or by adhesions. The proctoscopic

and cystoscopic studies which were essential had to be carried out with great

care because of the induration and scar tissue present in both rectum and
354 GENERAL SURGERY

Figure 39.—Revision of sigmoid colostomy by modified Devine technique to provide complete diversion of fecal stream from fistula in buttocks. The colostomy was closed by

direct anastomosis within the abdominal cavity.

bladder. Barium enemas and the injection of the fistula with radiopaque

substances were useful in determining the limits of extension of the lesions.

If the ostium was not too large, conservative therapy was usually given

trial in urinary fistulas, in an attempt to promote healing at the point of origin.

If urinary calculi or adhesions were responsible for failure of healing, conservative measures were useless, and surgery was indicated. If the fistula communicated with the rectum in the lower segment or near the anus, plastic procedure

(the Stone operation) was almost always required. The patients in this group

were transferred to Walter Reed General Hospital for the necessary surgery.

In addition to the more usual types of fistulas, bizarre types were not

uncommon. They included fistulas extending through the vertebral column,

through the diaphragm and chest, into the acetabulum, and into the urethra.

The latter type was easily diagnosed by the passage of gas through the penis.
MANAGEMENT OF COLOSTOMIES 355

Figure 40.—Left inguinal colostomy with incomplete division of bowel following exteriorization of wounded descending colon. This frequently used type of colostomy functioned

satisfactorily and was easily closed by direct anastomosis. Application of spur-crushing

clamps was hazardous because interposition of loops of small intestine occasionally

occurred.

Preoperative Regimen

The time interval between reception of the patient in Zone of Interior

hospital and closure of the colostomy varied widely, sometimes because of the

patient’s own status and sometimes, particularly during periods of intense

activity, because of crowded hospital conditions. The categoric statement can

be made, however, that in no instance was any harm caused by the delay.

In fact, one of the strongest points in favor of handling wounds of the colon by

exteriorization and colostomy was the ability of patients thus treated to travel

long distances without harm and to wait indefinitely for closure of the stoma

without deterioration of their status.
356 GENERAL SURGERY

The relatively few patients who were received in Zone of Interior hospitals

without associated injuries, free from infection, and with colostomies which were

functioning satisfactorily were prepared for operation at once and were operated

on as soon as possible. These patients were the exceptions. The great majority

presented preoperative problems of one sort or another (p. 343) and required

more extensive preparatory regimen in addition to special measures suitable

to their individual difficulties.

As soon as patients were received in Zone of Interior hospitals, they were

taught to take care of their own dressings. Those who were able to be ambulatory were required to be. Associated injuries were treated as necessary.

Whenever it was practical, arrangements for furloughs were made. The

psychologic stimulus of return to their homes and families amply compensated

for any delay in closure of the colostomy.

Operation was not undertaken in any case until the colostomy was functioning satisfactorily (fig. 40) and certain other criteria had been met:

1. The nutritional status must be restored to level at which surgery

would not be attended with any undue risk. completely normal status was

desirable but was not regarded as essential.

2. The healing of associated injuries must have advanced to stage at

which ambulation was possible.

3. Fecal fistulas must have been healed for at least to 12 weeks.

4. The skin about the colostomy must be in optimum condition.

Special measures.—The first essential of the general preoperative regimen

was attention to the colostomy. Many patients, after trips from overseas which

sometimes occupied considerable time, were received with large amounts of

inspissated fecal material in the distal loop. These accumulations were

removed by irrigations of distilled water, physiologic salt solution, or solutions

containing acriflavine, potassium permanganate, or penicillin. After the distal

loop had been completely cleaned out by these means, irrigations were carried

out three to five times weekly, with two objectives, to restore the tone of the loop and to increase the size of the opening, which had often become much

smaller in the weeks or months since the colostomy had been created.

The second essential of preoperative preparation was the protection of the

skin from fecal discharges. This was particularly important if irritation was

already present. The best results were accomplished with dressings of kaolin

or aluminum paste.

The third essential of the general regimen was restoration of the nutritional status to level approaching normal. The caloric content of the diet was

maintained between 3,500 and 5,000 calories daily. There was special emphasis

on the protein component, which ranged between 125 and 175 gm. daily.

Transfusions of plasma and whole blood were given as indicated. Supplementary vitamins, iron, and liver extract were also given as necessary.

Immediate preoperative preparation.—Special preparations for surgery

were begun several days in advance of operation. The routine varied in details
MANAGEMENT OF COLOSTOMIES 357

from hospital to hospital but was always based upon the following general policies:

1. Routine laboratory tests were conducted, and operation was postponed

if the chlorides, protein, and vitamin-C levels of the blood were not approximately normal. The prothrombin time was determined the day before operation, and closure of the colostomy was deferred if it was not satisfactory.

Roentgenograms of the abdomen were made to demonstrate possible retained

foreign bodies, and barium-enema studies were made to exclude possible intestinal obstruction.

2. sulfonamide drug (usually Sulfasuxidine (succinylsulfathiazole),

phthalylsulfathiazole, or sulfaguanidine) was given for days before operation

in doses of gin. six times daily. If local irritation was evident on the skin during the course of treatment, kaolin or aluminum paste was applied.

3. Vitamin was usually given the day before, and the day of, operation.

Paregoric was ordered just before the patient was taken to the operating room.

4. The ample diet previously provided was discontinued days before

operation and was replaced by low-residue diet, which was, however, equally

high in protein content. Only clear fluids were permitted during the 24 hours

immediately before operation.

5. Irrigation of both loops of bowel was continued up to the day of operation. On the morning of operation, irrigations of sterile physiologic salt

solution were continued until they returned perfectly clear.

Anesthesia

Practically all methods of anesthesia were used to close the colostomies in

this series, but fractional instillation of an anesthetic drug into the spinal canal

was perhaps the most favored technique. Pentothal Sodium was sometimes

used for induction but was never used for the entire procedure. Local anesthetic agents were avoided, because of the risk of spreading infection.

Technical Considerations

Official directives did not specify any standard procedure for the closure

of colostomy. This left the surgeons at the various general hospitals free

to develop their own methods, under the general supervision of consultants.

Since 106 surgeons are known to have closed the 2,198 colostomies managed in

the general hospitals in the United States, the range of detailed techniques

was correspondingly wide, although only few basic techniques were employed.

During the early months of American participation in the war, the tendency was to employ extraperitoneal methods of closure. Later, intraperitoneal

techniques became increasingly popular, for two reasons:

1. In spite of careful efforts to avoid opening the peritoneal cavity, it was

frequently entered during extraperitoneal operations.
358 GENERAL SURGERY

2. It was found that undesirable consequences did not follow deliberate

or accidental invasion of the peritoneal cavity during the closure of colostomy.

In the 1,813 cases in which the technique employed in closing colostomies

in the Zone of Interior hospitals was stated, the intraperitoneal approach was

used 1,055 times (58.2 percent) and the extraperitoneal approach 758 times.

At Rhodes General Hospital (series C), all 96 patients were treated by the

intraperitoneal technique. In the 437 cases in which this information was

available in series A, the intraperitoneal approach was used 186 times and the

extraperitoneal 251 times.

Information concerning the precise technique of closure was available in

only 1,331 of the 2,198 operations performed in Zone of Interior hospitals.

End-to-end anastomosis was employed in 642 cases (48.2 percent). The

Pauchet type of anastomosis was employed in 22 cases, all at the same hospital,

and other measures, including spur crushing followed by closure, were employed

in the remaining 667 cases. At Rhodes General Hospital, simple closure was

performed in 60 cases, end-to-end anastomosis in 42, and ileocolostomy in 6.

There were 12 multiple operations in this series. The procedures used in the special group of hospitals which make up series are presented in the following

table.

Table 98. Techniques of closure of colostomy and associated operations in 464 battle-incurred

wounds of large bowel (series A)

Information concerning the technique of closure employed in the 180 cases

(series B) in which closure was accomplished overseas was available in only

76 cases. Some method of anastomosis was used in cases, and spur crushing

and closure were employed in the other 71.

Extraperitoneal operations.—Simple closure of the colostomy was employed

in approximately 60 percent of the cases in which the approach was extraperitoneal. This was an entirely adequate operation when the stoma was small.

In such cases, the technique used at the original operation had been tube or

tangential colostomy or loop colostomy without division of the posterior wall

of the colon. The preferred suture material was catgut of small size. The

Procedure Cases Procedure Cases

Simple closure- 119 Ileocolostomy ______ 11

End-to-end anastomosis 316 Anal reconstruction 10

End-to-side anastomosis Closure distal loop

Side-to-side anastomosis. Crushing of spur 167

Pauchet anastomosis 22 Reconstruction of spur

Resection. 11 Coccygectomv. ___

10

This information is not available in 17 cases.
MANAGEMENT OF COLOSTOMIES 359

suture line was inverted at least once. If spur crushing had been necessary,

closure of the anterior wall of the colon was the final step of the operation.

End-to-end anastomosis was used in about 30 percent of the cases managed

by extraperitoneal operation. Side-to-side or end-to-side anastomosis was

employed in theother 10percent. These techniques all proved satisfactory in the

cases—which were not too numerous—in which it was possible to mobilize the

loops of bowel adequately outside of the abdomen, and they had the great

advantage of eliminating all risk of postoperative intestinal obstruction at the

suture line.

Intraperitoneal operations.—When intraperitoneal closure of colostomy

was contemplated, no attempt was ever made to crush an existing spur. Instead, the limbs were dissected free, and sufficient space was thus provided for

any type of anastomosis. When the peritoneal cavity was to be entered, special

efforts were also made to free the area of adhesions. These dense adhesions,

which often bound the bowel intimately to the anterior abdominal wall, many

times had to be treated by sharp dissection. The objective of these maneuvers

was to leave the repaired intestine entirely free in its normal location.

Simple closure of the anterior wall of the bowel was satisfactory technique

if the posterior wall of the colon remained intact. If it was not intact, end-toend anastomosis was the preferred technique, though number of surgeons had

good results with side-to-side and end-to-side anastomoses. The Pauchet

technique produced excellent results in the single hospital in which it was used.

In this technique, longitudinal slits are made in the proximal and distal loops

after they have been fixed with posterior suture, and side-to-side anastomosis, as in Finney pyloroplasty, is used to reconstruct the bowel. The

large stoma thus created at the line of anastomosis serves as safeguard

against possible future obstruction at this point.

Ileotransverse colostomy was used in small number of cases in which

damage to the right half of the colon and the small intestine had been followed

by infection and massive destruction of soft tissues and in which sidetracking

of the fecal current had been necessary. The operation was performed by

joining the ileum, above the injury, to the transverse or descending colon.

Closure of the original colostomy by end-to-end anastomosis was then possible.

Leakage of irritating material seldom occurred, and failure was unusual. In

most cases, because of the multiple openings, resection of some portion of the

intestine was necessary. Usually the portion resected was in the ascending,

transverse, or descending colon. If extensive damage had made two or more

colostomies necessary, it was frequently simpler, when closure was undertaken,

to resect the middle segment of the intestine and restore intestinal continuity

by an end-to-end anastomosis.

Adjunct procedures.—Herniations in the fascia (p. 345) varied from

slight weakening of the tissues, which permitted insignificant protrusions

of the peritoneal contents, to extensive openings which required plastic

repair. Unless there was some good reason for terminating the operation after
360 GENERAL SURGERY

closure has been accomplished, the repair was performed at the same time the

stoma was closed. Catgut, silk, or cotton was used for sutures, depending

upon the preference of the individual surgeon. The results of these operations

were generally good.

Drainage was seldom necessary when the stoma was closed, and instances

were on record in which it was clearly harmful. The risk of placing drains

between layers of fascia was typified by the slough which occurred in two cases

in hospital in which this technique was popular.

In few hospitals, it was the custom to close the wound through the

fascial layer at the first operation and complete the closure or days later.

Postoperative Regimen

Although practices varied from hospital to hospital, the postoperative

regimen after closure of colostomy was deliberately kept as simple as possible.

In some hospitals, nothing was given by mouth for from 24 to 48 hours. In

others, fluids were given promptly and soft food shortly afterward.

The fluid balance and nutritional status were maintained by the parenteral

administration of dextrose solution, physiologic salt solution, casein hydrolysate,

plasma, and whole blood, according to the necessities of the individual case.

Constant intestinal decompression by the Wangensteen technique or by

means of the Miller-Abbott tube was instituted in all cases in which distention

was considered possibility. These methods were most frequently employed

after operations on the right half of the colon.

The sulfonamide which had been before operation was continued

for to days afterward. When penicillin became available, it was used by

the intramuscular route in all cases in which infection seemed possibility.

The dose was 100,000 units every hours. Toward the end of the war, when

streptomycin became available, it was used with apparently good results in

gram-negative infections.

When vitamin had been used before operation, it was usually continued

for days or more after operation.

Anal dilatation was carried out daily for days after operation.

Early ambulation was not practiced uniformly, but there were no untoward

results in any of the hospitals in which it was permitted.

Before the patient was discharged, all the laboratory determinations which

had been carried out before operation were repeated. Roentgenologic studies

were also carried out, to establish the patency of the anastomosis and as final

check against overlooked foreign bodies.

Postoperative Complications

The discussion of postoperative complications is confined to the 464 cases

(series A) from the group of hospitals which supplied especially full details on
MANAGEMENT OF COLOSTOMIES 361

the questionnaires from which the data on closure of colostomy were secured.

They are typical of the complications which occurred in all hospitals.

In these 464 operations, leakage occurred at the site of closure in 70 cases

(about 15 percent). It was usually insignificant, and healing occurred promptly

under conservative management. In 23 cases, however, secondary closure was

necessary, and, in few instances, multiple operations were necessary before

the intestinal wall was securely closed. One patient required seven operations.

Local infection occurred in 39 cases (8.4 percent). It varied from slight

exudation to extensive abscess formation, and in few cases was associated

with wound dehiscence. Clostridial myositis occurred in case, and in

others the infection was apparently the result of amebic infection.

Hemorrhage occurred in six cases. It was usually manifested by local

bleeding. In one case, the formation of large hematoma was followed by

abscess formation. In two instances, bleeding occurred in patients who had

received Sulfasuxidine. Although the bleeding was controlled without

difficulty in all six cases in which it occurred, the potential seriousness of this

complication was obvious.

Paralytic ileus occurred only twice, but in one instance it was associated

with massive distention; secondary surgery was eventually required. The

negligible incidence of ileus in this series as well as in the larger total series can

be attributed to the prophylactic institution of constant intestinal decompression in so many cases.

Intestinal obstruction of some degree was apparent clinically in about 10

percent of all cases. It was usually slight and transient and subsided spontaneously; in such cases, the cause was assumed to be edema at the anastomosis

or the suture line. Adhesions were usually responsible for mechanical intestinal

obstruction, though in small number of cases it occurred because so much of

the bowel wall had been infolded that an actual diaphragm had been created

across the intestinal lumen. Although the 10-percent incidence of postoperative intestinal obstruction was undesirably high, only of the 11 deaths which

occurred in Zone of Interior hospitals after closure of colostomy could be

attributed to it. Advocates of the open abdominal approach contended that

the risk of obstruction was less when this technique was used.

Peritonitis occurred in cases, 1.8 percent of the total number in series A.

In or instances, the infection was mild and localized. In the other cases,

peritoneal involvement was generalized, and five deaths were attributed to it.

In of the surviving patients, abscess formation subsequently occurred, in

the pelvis and the subphrenic space, respectively, and surgical drainage was

necessary.

There was only one instance of thrombophlebitis. The infrequent

occurrence of this complication was attributed by many surgeons to the emphasis placed upon movement about the bed immediately after operation, as

well as to the practice, in many hospitals, of early ambulation.

378327°—56 25
362 GENERAL SURGERY

Fatalities

Eleven deaths are known to have followed closure of the colostomy stoma

in the 2,198 cases cared for in Zone of Interior hospitals (0.5 percent). They

were about equally distributed between the intraperitoneal and extraperitoneal

techniques. Five, as just noted, were caused by peritonitis and three by

intestinal obstruction. Liver failure, mesenteric vascular occlusion with gangrene of the howel, and inanition accounted for the three remaining deaths.

Two other deaths occurred before operation, in patients who were being

prepared for surgery. In each instance, the cause was an intractably poor

nutritional status and the resulting inanition. The cause of the single death

which occurred in the 180 colostomies closed in overseas hospitals is not known.

The 12 deaths which followed surgery in these 2,378 closures thus represented case fatality rate of 0.5 percent.

COMMENT

study of the 2,378 patients who underwent closure of colostomy in this

composite series indicates that, from the standpoint of the initial phase of

management overseas, casualties with wounds of the colon fared better in

World War II than in any previous war for which records are available. They

were removed from the battlefield with remarkable speed. They were prepared for operation with efficient resuscitative measures and without loss of

time. Finally, the routine practice of colostomy in wounds of the colon

saved innumerable lives which would undoubtedly have been lost in any previous war. The principle of exteriorization of the damaged colon was so

firmly established in World War II that no further controversy can possibly

arise concerning its use in any case in which the bowel can be sufficiently

mobilized to permit it. It is simple procedure, which can be carried out

safely and promptly by surgeons of limited experience. It entirely obviates

the need for difficult surgical decisions and for extensive resections and anastomoses in patients whose status is poor and who must be operated on under

field conditions. Certain aspects of the operation deserving special comment

are given in succeeding paragraphs.

Diversion of the fecal stream.—One of the items on the questionnaire

circulated in general hospitals of the Zone of Interior concerned the possibility

of accomplishing total diversion of the fecal stream with an ordinary colostomy. There was not complete agreement in the 19 replies received. Four

surgeons did not think that it could be accomplished with tube or tangential

colostomy. Four thought that it could not be, or probably could not be,

accomplished with loop colostonrv, one thought that it could be, and one

other thought that it probably could be. Four thought that it could be

accomplished by spur colostomy or probably could be, and one thought that

it could not be. The four remaining surgeons thought that total diversion of

the fecal stream could be accomplished with Devine colostomy. The infer-
MANAGEMENT OF COLOSTOMIES 363

ence, therefore, is that only by the use of the Devine technique (fig. 39, p.354)

or some other special technique (fig. 41) in which there is actual separation of

the stoma could one be absolutely certain of complete diversion of the fecal

stream. Some surgeons regarded the creation of second colostomy of the

spur type, proximal to the sigmoid colostomy, as the better method of preventing contamination of the distal segment. The transverse colon was the

preferred location for the second colostomy.

Figure 41.—Extensive damage to descending colon, with complete severance of gut,

requiring resection at first operation after wounding. The end of the colon was implanted into the abdominal incision, creating satisfactory colostomy. Closure by

primary anastomosis after reopening abdominal cavity.
364 GENERAL SURGERY

There was also some difference of opinion concerning the absolute necessity for diversion of the fecal stream in the event that fistula existed distal

to the colostomy, particularly in the sacral region or the buttocks. The

majority of the 62 surgeons who replied to this question considered it absolutely essential, or advisable, or desirable. The others did not consider it

necessary. There was general agreement that short, direct fistulous tract

would not heal if fecal contamination continued, particularly if the tract

traversed bone which was the site of an osteomyelitis. There was also general

agreement that even if long, tortuous tracts healed under conservative management, sometimes without complete diversion of the fecal current, expectant

treatment was not justified. The healing process could be expected to cover

many months, and healing was unlikely until dead bone and foreign bodies

had been removed. The consensus was that under these circumstances there

were three courses of action: (1) Complete decontamination of the fistulous

tract by revision of the colostomy into modified Devine colostomy; (2) creation of proximal colostomy in the transverse colon; or (3) closure and inversion of the fistula into the rectum, with complete unroofing of the tract, excision of everted rectal mucosa, and removal of all foreign bodies and of the

coccyx or part of the sacrum.

Technical considerations. —The trend, as the war progressed, to substitute

intraperitoneal for extraperitoneal techniques of closure has already been mentioned. The untoward results which sometimes followed crushing of the spur

had much to do with the change in practice. In civilian surgery, the management of the spur presents no problem, for the surgeon who creates the colostomy

crushes it himself. In military practice, the surgeon who constructs the colostomy almost never crushes the spur. The hundreds of patients admitted to

general hospitals in the Zone ofInterior with unclosed colostomies were operated

on by surgeons who, however experienced they might be, had no knowledge

of the initial surgery in any case beyond what was contained on the field

medical record. These data were often entirely inadequate. Even when the

records were reasonably complete, the conditions were not at all the same as

if the surgeon who was to crush the spur had been responsible for the creation

of the colostomy or had at least observed its creation. Furthermore, the

unavoidable haste with which many operations were necessarily performed in

forward hospitals, combined with thelimited experience of some of the operating

surgeons, militated against the construction of an ideal spur, when it was known that simple loop colostomy would suffice.

In addition to these fundamental considerations, unfortunate experiences

in dealing with poorly constructed spurs played large part in the substitution

of the intraperitoneal for the extraperitoneal technique. The application of

clamp or an enterotome often produced severe pain, nausea, and vomiting.

Peritonitis sometimes followed the accidental crushing of large mesenteric

vessels. Other complications included infection, fistula formation into the

ileum or jejunum, paralytic ileus, intestinal obstruction, and prolonged edema
MANAGEMENT OF COLOSTOMIES 365

and cyanosis of the intestinal mucosa. In two instances in this series, benign

neoplasms occurred at the site of the spur.

Most serious of all, rotation of the loops had taken place in nearly

hundred cases in the total series, and the existing relationships could not be

determined before the enterotome was applied. As result of this combined

experience, more and more surgeons abandoned attempts to crush the spur

and resorted, instead, to intraperitoneal closure of the colostomy.

The data available in this analysis do not supply adequate statistical proof

concerning the relative frequency of postoperative complications after extraperitoneal versus intraperitoneal colostomy closure. The clinical impression

was, however, that complications were fewer when the intraperitoneal technique was used. There was considerable logic in this point of view:

1. The peritoneal surfaces had been vaccinated before operation, because

the colostomy had practically always existed for months before closure was

attempted.

2. All the patients were young and free from organic disease. As rule,

they were in excellent condition except for the colostomy and its complications.

3. Chemotherapy and antibiotic therapy probably played some part in

the good residts, by preventing invasive infection. Streptomycin was regarded

as particularly usefid in this respect.

4. With the intraperitoneal technique, the restoration of the howel more

nearly approached normal because the anastomosis could be performed more

accurately and all adhesions could be obliterated. At the conclusion of the

operation, therefore, the repaired bowel lay free in its normal location, and

postoperative intestinal obstruction was less likely to occur.

The experience in this series showed that injuries to the right side of the

colon presented special problems, particularly if the small intestine had also

been damaged. It was not felt, however, that the use of the small bowel with

the colon to create spur colostomy offered any solution of the problem.

Wounds in this area were best dealt with by resection of the damaged cecum

or ascending colon, with direct end-to-end anastomosis between the ileum and

colon. After this had been done, single-barreled external mucous fistula was

created in the proximal colon.

Injuries of the rectum also furnished special problems. Sacral or perineal

colostomy, employed in less than percent of the cases in this total series,

was used chiefly when severe damage to the rectum was associated with partial

or total destruction of the anal sphincter. Even as temporary expedient,

however, this was not regarded as good surgery. The nursing care in such

cases was extremely difficult, irritation of the skin was almost unavoidable,

and the patients themselves objected to this type of colostomy for number

of reasons, including purely esthetic reasons.

The best plan in injuries to the fixed portions of the rectum and colon was

immediate repair of the anal sphincter, combined with posterior drainage and

followed by proximal colostomy, preferably in the transverse or descending
366 GENERAL SURGERY

colon (fig. 42). Loop openings were separated, to avoid continued contamination of the distal loop. This precaution was particularly important if the pelvis

or the sacrum had been injured or if there had been extensive damage to the

rectum or bladder below the peritoneal attachment (fig. 43).

Figure 42.—Proximal colostomy in descending colon for wounds of sigmoid and rectum.

After the damaged colon had been resected, the terminal loop was closed and an open

proximal loop was used to form the colostomy (insert).

When patient was received with sacral colostomy and with damage

to the anal sphincter which had not been repaired or the repair of which had

been unsuccessful, secondary colostomy was created at once, in the sigmoid

or transverse colon, before plastic surgery on the anus was undertaken. Even if this colostomy had to become permanent, because of failure of repair of the

anus, it was possible to close the sacral opening, and the unfortunate casualty

was left in much better condition than he had been in after the first operation.

consideration of the errors observed in the colostomies in this series leads

to the conclusion, fortified by the entire experience of World War II, that, in

injuries of the colon, the damaged loop should always be brought out through

stab wound placed laterally to the main incision and that it should be fixed in

this location by sutures which do not pass through the bowel wall (fig. 44).
MANAGEMENT OF COLOSTOMIES 367

Figure 43.—Proximal colostomy in transverse colon for retroperitoneal wounds of sigmoid

and rectum. The shell fragment also traversed sacral vertebra and the bladder.

Insert shows final double-barreled colostomy.

Satisfactory support can be provided by glass tube of the kind in which catgut is sterilized or by some similar blunt object placed beneath the mesenteric

border. Rubber tubing can also be used. Spur formation is not essential. In

fact, observations in Zone of Interior hospitals, and attempts to crush spurs in

which the relationship to surrounding structures had changed, suggested that

any technique which required creation of spur might be actually undesirable.

The revisions and relocations of the original colostomies performed in this

series would have been entirely unnecessary if the general principles set forth

in this chapter had been followed in the creation of the original opening. Furthermore, some, at least, of the problems encountered at every hospital, such

as retraction of the loops of bowel, undue protrusion of the bowel through exces-
368 GENERAL SURGERY

Figure 44.—Exteriorization of damaged sigmoid colon. No attempt has been made to

create spur. Insert shows resulting eversion of mucous membrane.

sively large fascial openings, intestinal obstruction caused by adhesions, continued contamination of distal fistulous tract, and retained foreign bodies,

would have presented no difficulties if these principles had been followed.

Chemotherapy and antibiotic therapy.—Although the colon is one of the

most heavily contaminated structures in the body, there was considerable divergence of opinion as to the necessity for, and the value of, supplemental

chemotherapy and antibiotic therapy in closure of colostomies. One or the

other of these methods, and sometimes both, were used in most cases in this total

series, but about third of the surgeons who performed the operations were not

convinced of the value of any of these agents, about 10 percent considered them

of no value, and few regarded them as harmful.

Most of the surgeons who used these drugs thought that their chief value,

at least as far as the then newly developed preparations Sulfathalidine (phthalylsulfathiazole) and Sulfasuxidine were concerned, was to insure clean intestinal

surface at the time of operation. They questioned their antibacterial effect

and were inclined to attribute the striking absence of infection in these cases to

the fact that sufficient time had elapsed since the first operation to permit some

degree of autovaccination of the peritoneal surfaces. In spite of these doubts

of the value of the routine use of these agents, it was the general practice to

administer Sulfasuxidine and Sulfathalidine orally for several days before operation to all patients who had had peritonitis or intra-abdominal abscesses, as

well as to those who were likely to require extensive resection of the colon.
MANAGEMENT OF COLOSTOMIES 369

When penicillin and streptomycin became available, they were used on the same

indications.

Almost all of the available sulfonamides except sulfanilamide were used in this series, but Sulfasuxidine and sulfaguanidine were the most popular.

Sulfatbalidine was not available at all hospitals. All routes of administration

were employed, including the local application of the powdered drug, which was

used at operation in about 10 percent of all cases. Stool examinations made in

the cases in which chemotherapy was used showed that, while there was not

complete destruction of all micro-organisms, the colonies were always greatly

reduced in number.

Irritation of the skin about the colostomy was an annoying consequence

of sulfonamide therapy (fig. 45). It could usually be controlled by the use of

Figure 45.—Right-sided colostomy. Cecum and ascending colon exteriorized at time of

injury. Note irritation of skin around colostomy, which was common in right-sided

colostomies.
370 GENERAL SURGERY

aluminum or kaolin paste. Secondary hemorrhage, another possible complication, was always potentially serious. Its prevention required careful prothrombin studies before operation and the administration of vitamin in the

immediate preoperative and postoperative period.

Penicillin was used extensively after it became available in the Zone of

Interior in the spring of 1944. It was thought to be of great value in the

prevention of infections caused by gram-positive organisms. Streptomycin

did not become available until later and then only in hospitals designated for

special studies. It was regarded as of great value in the prevention and treatment of gram-negative infections.

SUMMARY

The most important lesson to be derived from the large number of colostomies upon which this chapter is based is that the closure of the stoma created

in the management of battle-incurred injury of the colon is safe and relatively

simple procedure. In this series, almost every possible unfavorable circumstance was present from the moment of wounding. Initial treatment was

carried out in forward hospital, under field conditions. Even in fixed hospitals, treatment was conducted under the stress and strain of military conditions.

The wounds were frequently of great gravity. Other wounds were frequently

associated. In spite of these facts, the case fatality rate for closure of the

colostomy was fractional, complications were relatively few, and practically

every patient who survived was returned to normal activities and, from the

standpoint of his intestinal injury, was in excellent condition on discharge.

In World War II, improvements in the technique of intestinal surgery,

the intelligent use of replacement therapy and of chemotherapy and antibiotic

therapy, and increasing experience on the part of responsible surgeons made it

possible to close colostomies withinrelatively short periods after their creation.

The wartime experience suggests that in future wars it may be possible to

accomplish closure in all but the most complicated cases in overseas hospitals,

without evacuating the patients to Zone ofInterior hospitals. From military

standpoint, this would be most important advance, for it would permit

soldiers with wounds of the colon to return to full duty after relatively brief

periods of disability and convalescence.
371

MEDICAL DEPARTMENT, UNITED STATES ARMY

The volumes comprising the history of the Medical Department of the

United States Army in World War II are divided into two series: (1) The

administrative and operational series, which constitutes part of the general

series of the history of the United States Army in World War II, prepared by

The Surgeon General and published under the direction of the Chief of Military

History; and (2) the professional, or clinical and technical, series, prepared by

and published under the direction of The Surgeon General. This is one of the

volumes published in the latter series.

373

INDEX*

Abdomen:

anesthesia for operations on, 77

case fatality rates intraumatic evisceration in wounds of,

173-

wounds of, 85-86, 94-95, 114

according to hospital level, 110

according to type of missile, 97

causes of death in wounds of, 71, 72, 131,

174- 188-189, 195, 213, 219-221,

227-228, 238-240,250-254, 271-274,

282-283, 288-289, 307, 310, 315,

318-324, 326-327, 333

in World War I, 213

classification of wounds of, 86

compound fractures associated with

wounds of, 113-114

contamination of pleura in wounds of,

119

diagnosis of wounds of, 177-178

effect of severity of wounds of, on case

fatality rates, 104-105

effect of timelag on wounds of, 103-105

ether anesthesia in operations on, 55, 69,

77

followup of casualties with wounds of, 94

frequency of wounds of, according to

viscera involved, 89-94

management of wounds of, in—-

field hospitals, 82

World War I, 7, 87, 125-126

nitrous oxide anesthesia for operations

on, 55

nomenclature of wounds of, 87-88

nonpenetrating wounds of, 101

nonsurgical case fatality rate in wounds

of, 7, 87, 125-126

pain in wounds of, 43, 44, 45

Pentothal Sodium anesthesia in wounds

of, 72

prognosis of wounds of, 103, 131, 217

ratio of wounds of, to other wounds, 89

roentgenologic examination in wounds

of, 100

Abdomen—Continued

statistics of wounds of, 70, 81-333

use of atropine before operations on, 75

wounds of, 36, 50, 81-333

associated with shock, 130-172

great vessels of, 317-324, 325, 326, 327

See also injuries of special viscera and

other special subjects.

Abdominal aorta, wounds of, 94, 322

Abdominal surgery:

concept of, 87, 213

in World War I, 213

Abdominal wall:

clostridial infection of, 209

emphysema of, 225

nonpenetrating injuries of, 83

wounds of, 177, 181, 331-333

Abscess formation

after closure of colostomy, 361

after colostomy, 351, 368

in wounds of

bladder, 315

colon and rectum, 270, 274

liver, 277

neck, 73

Absorption—-

from devitalized tissue, as factor in

shock,

of local anesthetics, 67

of morphine, 34, 42, 47, 76-77

Acidemia after chloroform anesthesia, 68

Acriflavine irrigations of colostomy, 356

Acute pancreatitis, 288

Adelstetten, 140

Adjunct therapy in morphine poisoning, 43

Adjunct therapy. See also Blood, Plasma,

and other special measures.

Administration of morphine by medical

aidmen, 46

Adrenal glands;

effect of anesthesia on, 55

wounds of, associated with wounds of

spleen, 293

Adrenalin, 187

’Unlessspecified otherwise, all items in this Index concern abdominal surgery. With the exception of items referring

to closure of colostomy, all items referring to abdominal surgery concern the work of the 2d Auxiliary Surgical Group.
374 GENERAL SURGERY

Advances in anesthesia between World Wars, 56

Advantages of—•

albumin, 29, 31

carbon dioxide absorption technique, 183

chloroform anesthesia, 67

closed technique of inhalation anesthesia,

56, 183

colostomy, 362

endotracheal anesthesia, 183-184

ether anesthesia, 65, 69, 183

flank incision in wounds of kidney, 305

intraperitoneal closure of colostomy, 365

nitrous oxide anesthesia, 54

Pentothal Sodium anesthesia, 71

transdiaphragmatic incision in wounds of

spleen, 296

vertical incisions, 192

vinyl ether anesthesia, 69

Affiliated units, training of anesthetists in,

58

Age:

of patients with colostomies, 365

of wounded soldiers, 49

relation of case fatality rates to, 215

Age range in wounds of colon, 49

Agenesis of kidneys, 302

Agents of wounding. See Special types of

missiles.

Agglutination hemolysis, 160

Air embolism, 28, 212

Air evacuation from Anzio beachhead, 32

Airborne troops, use of albumin for, 31

Airway, maintenance of, 187

in blast injuries, 182

Albumin, 27, 29-31

Alcoholism, 41

Alkaline reserve of blood, 55

Alkalosis, 212

Alsever’s solution, 307

Altitude as factor in shock, 12

Ambulance evacuation to clearing station,

Ambulation

after closure of colostomy, 360, 361

as requirement for closure of colostomy,

356

Amebic infection after closure of colostomy,

361

American Ambulance, 53

American Board of Anesthesiology, 57

American Red Cross, 54

Amnesia in shock, 17

Amphibious landings, 12

Ampulla of Vater, wound of, 284

Amputation (s), 35

anesthesia for, in World War I, 54

associated with wounds of

jejuno-ileum, 252

liver, 283

emotional reaction to, 50

in wounds of

iliac vessels, 321

spleen, 293

of fingers, 55

of leg,

Anaerobic contamination, 55, 112

caused by hypodermoclysis, 207

in wounds of stomach, 225

Anaerobic infections. See Clostridial infections.

Anal sphincter, repair of, 365-366

Anaphylactic shock, 212, 307

Anastomosis in wounds of

colon and rectum, 266

jejuno-ileum, 246-249, 250

Anatomic distribution of wounds of

colon and rectum, 264-265

duodenum, 236

pancreas, 286

liver, 275-276

Anatomic relation of—-

colon and rectum to other viscera, 256

kidneys to other viscera, 302

liver to other viscera, 276

Anatomy of stomach, 232-233

Anemia

after initial surgery, 29

in burns, 24

Anesthesia, 53-78, 181-189

administration of

atropine before, 75

morphine before, 47

advances in, between World Wars, 56

as factor in shock, 53

aspiration of gastric contents during, 31

consultants in, in World War I, 53

control of respiration during, 56

duration of, 188

effect of, on circulatory system, 53

emptying of stomach before, 36

for closure of colostomy, 357

in burns, 74

in fixed hospitals, 65

in forward hospitals, 56-57, 60

in World War I, 53-56

in wounds of spleen, 295

induction of, with Beecher anesthesia

machine, 63
INDEX 375

Anesthesia—Continued

influence of logistics on selection of,

56-57

manifestations of morphine poisoning

during, 42

medication during, 65

military considerations of, 56-57

restriction of fluid intake before, 31

techniques of, 53, 182-185

toleration of, after plasma replacement,

22

training in, 57, 58

See also Special agents and techniques.

Anesthetic agents, 65-74, 182-185

Anesthetic apparatus, 54, 56, 59-63

Anesthetic deaths, 78, 188-189, 195

Anesthetic personnel, 57-58, 181

Anesthetists:

dentists as, 58

in field hospitals, 58

in 2d Auxiliary Surgical Group, 81

in World War I, 53, 55

nurses as, 53, 57

qualifications of, 58, 181

responsibilities of, 185-186, 188, 274

shortages of, 57

Anoxia, 50, 129

after administration of morphine, 33

as contraindication to use of—-

morphine, 48

Pentothal Sodium, 184

cyanosis as criterion of, 38

effect of, on chemoreceptors, 71

in intracranial operations, 73

in morphine poisoning, 42, 43

in shock, 48

Anterior wounds of abdomen, 99

Antibiotics. See Penicillin, Streptomycin.

Antibodies, absence of, in albumin, 30

Anticoagulant therapy, 321

Anuria, 211-212, 220

in retroperitoneal hematoma, 327

in wounds of

colon and rectum, 270

great vessels, 322

jejuno-ileum, 254

kidney, 307

pancreas, 288

spleen, 297

ureter, 309

See also Lower nephron nephrosis.

Anus, dilatation of, after closure of colostomy, 360

Anzio beachhead, 5, 8, 17, 19, 25, 32, 36,

43, 46, 75, 81, 82, 85, 200, 217

Anzio-Nettuno, 81

Aorta, anatomic relation of, to

duodenum, 236

stomach, 232

Aortic bodies, 71

Apathy in shock, 15

Apparatus for anesthesia, 54, 55-56, 59-63

Appendectomy, 66, 265

Appendix, wounds of, 265

Application of

bandages in battalion aid station,

splints after wounding, 9, 34, 35

tourniquet in—-

battalion aid station, morphine poisoning, 43, 47

resuscitation, 35

Armor-piercing missiles, 101

Army Medical Department training

schools, 81

Army Nurse Corps, 81

Arteries of abdomen, wounds of, 317-324

Artificial respiration, 73, 187

in morphine poisoning, 43

with Beecher anesthesia machine, 63

Artillery shell fragments, wounds caused

by, 97, 302

Ascending colon:

perforating wounds of, 133, 171

rupture of, by indirect trauma, 329

wounds of, 264, 265-266, 337

Aspiration of

gastric contents—•

as cause of death, 195

in morphine poisoning, 43

stomach before operation, 36, 178, 245

trachea, 77

vomitus, 31, 77, 198

Assignments of

anesthetists, 58

personnel, 2d Auxiliary Surgical Group,

81-82

Associated wounds, 113-117,181,185,199,211 case fatality rates in, 95, 113

complicating closure of colostomy, 344

definition of, 88

effect of, on case fatality rates, 217

frequency of, 113-114

in wounds of

colon, 370

colon and rectum, 271-274

duodenum, 240

jejuno-ileum, 244-245, 252

liver, 283

spleen, 293, 297, 298

stomach, 227, 229
376 GENERAL SURGERY

Associated wounds—Continued

influence of, on multiplicity factor, 109,

112

of chest, 207

operation of multiplicity factor in, 114—117

Atelectasis, 110, 133, 136, 151, 156, 167,

188, 204-205, 206, 220

in wounds of

bladder, 315

colon and rectum, 270, 274

pancreas, 288

spleen, 297, 299

stomach, 231

Atherocsclerosis, 163

Atropine:

administration of:

before bronchoscopy, 189

before Pentothal Sodium anesthesia,

73, 74

in morphine poisoning, 43

in pulmonary edema, 207

postoperative use of, 188

preoperative use of, 75, 186

Atypical pneumonia, 207

Austria, 82

Autogenous clostridial infection, 274

Autolytic pancreatitis, 151

Autotransfusion with contaminated blood,

131, 142, 143, 157

Autovaccination of peritoneal surfaces, 365,

368

Auxiliary surgical group(s), 10, 70

2d:

assignment of personnel of, 81-82

headquarters of, 81

history of, 81-82, 83

record of work of, 81-333

study of shock by,

Auxiliary surgical teams, 58

Average timelag, 103

Avulsion of

gallbladder, 283

jejuno-ileum from mesentery, 246

Axilla, wounds of, 313

Azotemia, 211

Back, wounds of, 313

Bailey, Hamilton, 228,276,277,291,293,298 Balanced suspension skeletal traction, 344

Barbiturates, 41, 48, 50, 70-74

preoperative administration of, 33

use of, for relief of mental distress after

wounding, 47

See also Pentothal Sodium and other

special agents.

Barium enema, 354, 357

Base Hospital No. —54

Battalion aid stations, 9, 12, 17, 22, 31, 124

Bed capacity of

clearing stations,

field hospitals, 10, 58

Bed space, urgency of need for, in fixed

hospitals, 29

Beecher anesthesia machine, 39, 59-63, 182

Belgium, 54

Bile empyema, 205, 278, 280. 282

Bile peritonitis in wounds of liver, 277, 278, 282, 288

Bile spill in wounds of colon and rectum,

272

Biliary fistula

associated with colostomy, 345

in wounds of pancreas, 288

Biliary thoracic fistula, 280

Bladder, wounds of, 210, 313-316, 327, 349

associated with wounds of

kidney, 301

spleen, 293

ureter, 309

case fatality rate in, 313, 314, 315

dehiscence in, 193

errors in management of, 314

multivisceral, 313, 314, 315

univisceral, 313, 315

Blanching test. See Pressure test.

Blast injury, 36, 314, 331

as factor in shock, 220

maintenance of airway in, 182

of lungs, 252

of spleen, 291

Blindness, 50

Blood;

alkaline reserve of, 55

coloration of, after use of oxygen, 37 crossmatching of, 26, 27

economical use of, 20, 26

excessive administration of, 26

in feces, 72, 177

in gastric contents, 177

in vomitus, 225

quantitative replacement of, 19-20, 24-26

rate of administration of, 27-28

shortages of supply of, 19

Blood bank, establishment of, in Naples,

24, 199, 215

Blood chlorides, determination of, 357

Blood dilution in shock, 18, 22, 38, 55, 123

Blood grouping, 26, 27
INDEX 377

Blood loss:

after release of tourniquets, 35

after wounding, 18

as contraindication to Pentothal Sodium

anesthesia, 184

as factor in shock, 6, 17, 20, 21, 25, 103,

104, 109, 119, 120, 122-124, 131, 219

effect of, in peritoneal contamination,

127

effect of, on peripheral circulation, 46

in compound fractures, 28

in intracranial operations, 73

in wounds of

bladder, 313

colon and rectum, 259-260, 273

jejuno-ileum, 242, 243, 244, 252, 253

kidneys, 303

liver, 276, 280, 282-283

pancreas, 288

spleen, 292, 294

stomach, 231, 233

ureter, 310

inefficiency of constrictor drugs after, 65

local anesthesia after, 66

measurement of,

quantitative relation of, to shock, 7-8

Blood-plasma ratio in replacement therapy,

19-20, 24-25, 26

Blood pressure:

depression of, in morphine poisoning, 43

effect of

albumin and plasma on, 30

anesthesia on, 55, 65, 66, 68, 74

barbiturates on, 70

change of position on, 142, 145, 185,

187, 188-189

transportation on, 18

elevation of, in Trendelenburg position,

35

level of—-

as criterion of rate of transfusion, 28

as criterion of readiness for operation,

19

in morphine poisoning, 43

in shock, 4, 15-17, 25, 26, 75, 78-79,

121, 126

maintenance of, by plasma replacement,

21, 23

trend of, in shock, 15-16, 18, 26

unnecessary elevation of, in resuscitation,

23

See also Hypotension, Shock. Blood pressure (volume). See Shock.

Blood replacement, 5, 18, 19, 20-21, 22-23,

24-29, 49, 54, 124-129

after plasma replacement, 22

as chief component of resuscitation,

as factor in lower nephron nephrosis, 220

as prophylaxis against wound dehiscence,

196

before closure of colostomy, 356

ease fatality rates in, 28

concept of, 22-23

during operation, 19, 26, 187

hepatitis after, 29

in chronic sepsis, 29

in compound fractures, 28

in field hospitals, 24-25

in forward hospitals, 28

in postoperative shock, 208

in preoperative preparation, 22-23

in thoracoabdominal wounds, 178

in World War I, 21, 55

in wounds of colon and rectum, 259-260

in wounds of spleen, 297

indications for, 25

infection after, 29

possibilities of error in, 28

principles of, 19, 26

timing of,

See also Transfusion.

Blood spill into peritoneal cavity, 46

Blood stream, leakage of

albumin from, 30

dextrose solution from, 32

physiologic salt solution from, 32

Blood sugar, effect of ether anesthesia on,

69

Blood supply of

colon and rectum, 256

duodenum, 286

extremities after wounding, 67 kidney, 303-304, 305

small bowel, 244

Blood transfusion:

error in, 28

position of patient during, 27

reactions to, 26, 28, 29, 159, 297, 299, 307

Blood Transfusion Unit, 6713th—160

Blood type, incorrect listing of, 160

Blood type “O,” 26, 27, 28

Blood vessels;

ligation of, in resuscitation,

of abdomen, anatomic relation of, to

colon and rectum, 256

stomach, 232

378327°—56 26
378 GENERAL SURGERY

Blood vessels—Continued

wounds of, 107, 119, 122, 317-324

associated with wounds of—-

bladder, 315

colon and rectum, 259

pancreas, 285, 286, 289

spleen, 293

stomach, 228

ureter, 309-310

case fatality rates in, 107, 228, 239

frequency of, 94

Blood volume:

effect of

albumin and plasma on, 30

change in splanchnic capillary bed on,

123

dehydration on,

maintenance of, by plasma replacement,

22, 122

risk of sudden increase in, 31

status of, in—-

burns, 74

shock, 5, 6, 7-8, 18, 38

See also Shock.

Blunt trauma:

as cause of visceral injuries, 331

in wounds of bladder, 313

Board for the Study of the Severely

Wounded, 124, 128, 211

Body heat, conservation of

during resuscitation, 36, 178

in morphine poisoning, 43

Boer war, 87

Bombs as cause of

traumatic evisceration, 174

wounds of kidneys, 302

Bone fragments as secondary missiles,

101, 243, 245

Boobytraps, 302

Bouncing Betty, 101

Brain, wounds of, 229

Brain cells, effect of anesthesia on, 55

Branch of service, frequency of wounds according to, 89

British, procurement of blood from, 25

British experience with

colostomy, 339, 340

in World War I, 337-338 local anesthesia,

wounds of

liver in World War I, 282

pancreas in World War I, 285

small intestine in World War I, 235

spleen, 291, 298

British mobile casualty clearing stations,

54, 81

Bronchial edema, 195

Bronchitis, 54, 163, 187, 204, 216

Bronchoscopy, 77, 185, 207

deaths during, 189

vagovagal reflex during, 288

Bronchus, bile erosion of, 281

Burford, T. M., 277, 280

Burns:

management of, 23-24, 74

morphine poisoning in, 41

Buttocks:

fistulas into, 345, 364

traumatic evisceration through, 173

wounds of, 14, 97, 133, 144

Cachexia, 212

Cannula technique of transfusion, 28

Capillary damage in shock, 148

Capillary endothelium, effect of circulatory

failure on, 128

Capillary permeability, association of, with

anoxia,

Capsulotomy in wounds of kidney, 306

Carbohydrate-high diet in prevention of

hepatic damage, 68

Carbon dioxide, effect of, on respiratory

center, 71

Carbon dioxide absorption technique, 56,

63, 183

Cardiac output:

effect of albumin and plasma on, 30

in shock, 22

Cardiac tamponade, 252

Cardiorespiratory disturbances as factor in

shock, 103, 119, 184, 220, 282

Cardiovascular disease, 67

Cardiovascular instability in shock, 185

Carotid bodies, 71, 72, 75

Carter, B. Noland, 21

Case fatality rates:

according to hospital level, 89, 95, 110, 215

according to incision in wounds of spleen,

295

according to type of missile, 97

before operation, 7, 87, 93, 125-126

effect of evacuation on, 203

effect of exposure on, 216

effect of reduction of timelag on, 103-104

in anesthesia with barbiturates, 70

in civilians, 215

in clostridial infections, 209

in closure of colostomy, 361, 362
INDEX 379

Case fatality rates—Continued

in colostomy in World War I, 338

in combined thoracic and gastrointestinal

wounds, 123

in field hospitals,

in forward hospitals, 89, 94-95, 215

in gastric resection, 230

in intestinal obstruction, 208, 209, 250

in lower nephron nephrosis, 211

in negative explorations, 95

in penetrating wounds without visceral

injuries, 333

in Pentothal Sodium anesthesia, 71, 72

in peritonitis, 19, 198-201

with traumatic evisceration, 174

in prisoners of war, 215

in pulmonary complications, 204-206

in resection of—-

colon, 265

jejuno-ileum, 247, 250, 251-254

in retroperitoneal hematoma, 326-327

in shock, 5, 215

in thoracoabdominal wounds, 215, 223

in thromboembolism, 210

in traumatic evisceration, 173-176

in visceral injuries—-

caused by blunt trauma, 331

without penetration of abdominal wall,

329

in wounds of

abdomen, 85, 94-95, 114-117

in relation to time of death, 105

bladder, 313, 314, 315

chest, 240

in World War I, 60

colon, 228, 370

in World War I, 338

colon and rectum, 255, 257, 259, 268,

270-274

duodenum, 235, 237, 238-240

extrahepatic biliary tract, 283-284

great vessels of abdomen, 94, 107, 228,

239, 289, 317-324

hollow viscera, 95

jejuno-ileum, 241, 250, 251-254

kidney, 301-303, 307

liver, 275, 281, 282-283

pancreas, 285, 288-289

rectum, 271

small intestine, 235

solid viscera, 95

spleen, 228, 291, 293, 295, 297-299

stomach, 223, 226, 227, 228, 229, 230,

231-233

Case fatality rates—Continued

influence of

multiplicity and timelag on, 112, 217

timelag on, 103-105

of associated wounds, 95, 113

on Anzio beachhead, 26

relation of, to

age, 215

type of wound, 215

seasonal influence on, 216

variations in, 110-111

with penicillin therapy, 198-201

with sulfonamide therapy, 198-201

without intraperitoneal viscereal injury,

117, 333

See also Deaths, Statistics.

Case history;

correct practices of resuscitation,

depressed body temperature, 36

effectiveness of barbiturates after wounding, 38-39

enterostomy in wounds of jejuno-ileum,

249

errors in resuscitation, 3-4

resection of jejuno-ileum, 248

secondary hemorrhage in wounds of—-

liver, 281

stomach, 230

special effects of missiles, 100-101

thromboembolism, 210

wounds of

jejuno-ileum, 243-244, 252

stomach, 226

Cassino, 18, 19, 36, 43, 75, 200

Casualties, relation of, to intensity of fighting, 89

Casualty clearing stations, 54, 81

Catheterization of bladder, 178, 304, 309,

314

Cauda equina, 171

Causes of anesthetic deaths, 71, 72, 188-189

Causes of death, 131, 213, 219-221

in closure of colostomy, 361, 362

in penetrating wounds of abdominal wall

without visceral injuries, 333

in tetroperitoneal hematoma, 326-327

in traumatic evisceration, 174-176

in World War I, 213

in wound dehiscence, 195

in wounds of

bladder, 315

colon and rectum, 271-274

duodenum, 238-240

great vessels of abdomen, 318-324
380 GENERAL SURGERY

Causes of death—Continued in wounds of—continued

jejuno-ileum, 250-254

kidney, 307

liver, 282-283

pancreas, 288-289

stomach, 227-228

ureter, 310

Cecostomy in wounds of colon and rectum,

262

Cecum:

resection of, 365

rupture of, by indirect trauma, 329

wounds of, 87, 101, 107, 337, 350

perforating, 87, 101, 171

retroperitoneal, 321

Celiac axis, 232, 293

Celiac plexus, 325, 326

Cellular metabolism, effect of circulatory

failure on, 128-129

Central depression, 48

Central hepatic necrosis, 67

Cerebral anoxia, 50, 144

Cerebral edema, 73, 131

Cerebral embolism, 131, 270

Cerebral infarction, 212

Chain of evacuation, 9-10

suggested modification of, 13

Changes in splanchnic capillary bed, effect

of, on blood volume, 123

Changes of position:

after operation, 207

effect of, on blood pressure, 142, 145, 185, 187

in morphine poisoning, 43. 142

toleration of, after plasma replacement,

22

Chaplain, 51-52

Character of wound as factor in shock, 17,

25, 52

Chemical peritonitis, 112, 177, 196, 198,

200-201, 232

Chemoreceptors, 71

Chemotherapy:

inclosure of colostomy, 365, 368-370

routes of administration of, 201

See also Special agents.

Chest:

operations on, 21, 26, 27, 60, 63

anesthesia for, 77

use of atropine before, 75

pain in, 178

traumatic evisceration through, 173

wounds of, 31, 35, 36, 50, 135, 178, 207,

252, 329, 331

Chest—Continued

wounds of—continued

administration of morphine in, 47

as contraindication to Pentothal Sodium anesthesia, 72

associated with wounds of

duodenum, 240

jejuno-ileum, 244

liver, 283

case fatality rate in, in World War I,

60

effect of, on pulmonary complications,

204

ether anesthesia in, 69

management of, in battalion aid stations,

pain in, 43, 44, 45, 48

statistics of, 70

Chest wall:

control of pain in, 67

emphysema of, 225

Chief of surgical service, responsibilities of,

on shock wards, 11

Chilling, effect of, in morphine poisoning,

34, 41-42

Chills in transfusion reactions, 28

Chloroform anesthesia, 54, 55, 67-68, 182,

184

Cholecystectomy, 239, 282

Cholecystostomy, 283

Chloral hydrate, 41

Circular letters:

No. 20, Off. of the Surg., NATOUSA,

22 Jim 43, 340

No. 50, Off. of the Surg., NATOUSA,

30 Dec 43, 46

No. 178, Off. of the Surgeon General,

23 Oct. 43, 340

Circulation:

damage to, in clostridial myositis, 73

depression of, in morphine poisoning, 42

effect of anesthesia on, 53, 67, 68, 69

effect of chilling on, 42

effect of dilatation of stomach on, 36

See also Shock.

Circulatory failure, effects of, 128-129

Circulatory impairment as factor in morphine poisoning, 42

Civilian medical literature, morphine poisoning in, 41

Civilian practice:

early surgery for perforation of peptic

ulcer in, 19

preoperative preparation in, 28-29

transpleural surgery in, 60
INDEX 381

Civilian practice—Continued

use of chloroform anesthesia in, 68

use of colostomy in, before World War

II, 337

wound dehiscence in, 196

wounds of colon and rectum in, 255

Civilians, case fatality rates in, 215

Classification of—•

anesthetic deaths, 78

patients for surgery, 15

shock, 15-18, 121, 215, 231, 259, 293, 323

wounds of

abdominal viscera, 86

jejuno-ileum, 241

kidney, 302-303

liver, 276

spleen, 292

Climatic conditions as factor in shock, 12,

130

Clinical course in fatal shock, 126-127

Clinical determination of need for blood

replacement, 25

Clinical experience, consistency of, with

statistics, 86

Clinical manifestations of morphine poisoning, 41, 42-43

Clinical picture in—-

peritonitis, 198

retroperitoneal hematoma, 325-326

visceral injuries caused by blunt trauma,

331

wounds of

bladder, 313-314

kidney, 303-304

pancreas, 286

spleen, 293

Closed technique of inhalation anesthesia,

56, 69, 182

Clostridial infection (s), 209-210

case fatality rates in, 209

in wounds of—•

colon and rectum, 270, 273, 274

spleen, 297

of pleural cavity, 127

Clostridial myositis, 127, 164, 194, 282

after closure of colostomy, 361

as contraindication to Pentothal Sodium

anesthesia, 73

in World War I, 54, 55

in wounds of iliac vessels, 321, 322

Clostridium sordelli, 164

Clostridium welchii, 127

Closure of—•

colostomy, 341-370

case fatality rates in, 361, 362

Closure of—Continued colostomy—continued

in overseas hospitals, 341, 358, 370

in Zone of Interior hospitals, 341-370 postoperative complications after, 361,

362

preoperative preparation for, 343-357

techniques of, 358-360

laparotomy wounds, 191-196

sucking wounds of chest, 9, 12

wounds of stomach, 230

Closure of wounds. See Wound dehiscence,

special techniques of closure.

Clothing, removal of, in evaluation of

casualty in shock, 14-15, 178

Cocaine, 67, 182, 185

Coccygectomy, 264, 364

Cocoanut Grove disaster, 41

Codeine, 47

Cold, effect of, on peripheral circulation, 76

Cold injury, 12

Colectomy in wounds of duodenum, 239

Collapse of veins after wounding, 47

Collecting stations, 9, 12, 22

Colloid osmotic pressure of plasma, 29

Colon:

anatomic relation of, to liver, 276

exteriorization of, 192, 210, 261-264,

296, 305, 338-340

herniation of, into chest, 299

resection of, 368

traumatic evisceration of, 173

wounds of, 86, 223, 224, 228, 236, 255-

274, 327, 331

associated with wounds of

bladder, 315

duodenum, 236

great vessels, 259

kidney, 306

pancreas, 286

spleen, 293, 296, 297

stomach, 228

ureter, 310

case fatality rates in, 228

dehiscence in, 193

multivisceral, 88

perforating, 101, 174, 262

suture repair of, 340

univisceral, 86, 87

See also Colon and rectum, Descending

colon.

Colon (and rectum), wounds of, 255-274

blood loss in, 259-260, 273

causes of death in, 271-274

failure of resuscitation in, 260, 271, 274
382 GENERAL SURGERY

Colon (and rectum), wounds of—Con.

hematoma formation in, 256

management of, 261-264

multiplicity factor in, 256-259

multivisceral, 270-271

penicillin in, 270

perforating, 256, 265, 267

sulfonamide therapy in, 270

timelag in, 256-259

transecting, 256

univisceral, 270-271

Coloration of

blood after use of oxygen, 37

mucous membranes in shock, 25

skin in shock, 15-17, 19, 126

Colostomy, 138, 194

closure of:

antibiotic therapy in, 368-370

chemotherapy in, 368-370

complications of, 345-350

dysfunction of, 346

errors in performance of, 346-350, 364, 366-367

evolution of use of, 338-341

in descending colon, 366

in overseas hospitals, 338-341

in sacral region, 342, 346

in Spanish Civil War, 338

in transverse colon, 342, 346, 363, 364,

365, 366

in World War I, 337-338

incision for, 192

management of, before closure, 343-357

osteomyelitis associated with, 345, 346, 351, 352, 364

relocation of, 367

revision of, 340, 346, 367

techniques of, 261-264, 340, 342-343

through stab wound, 366

See also Closure of colostomy, special

types of colostomy.

Coma in—-

morphine poisoning, 43

shock, 15, 127

Combat: conditions of, in Volturno Valley, 41

duration of, in Mediterranean theater,

effect of character of, in shock, 12

Committee on Surgery, National Research Council, 276, 277

Common bile duct, lacerating wounds of,

239, 288

Common carotid artery, ligation of, 212 Complications—-

of colostomy, 345, 350

Complications—Continued

of morphine poisoning, 43

of nitrous oxide anesthesia, 54

of packing of wounds of liver, 277

of sulfonamide therapy, 369-370

See also Postoperative complications.

Compound fractures:

associated with abdominal wounds, 48,

113-114

associated with wounds of

pancreas, 286

spleen, 293

stomach, 229

blood replacement in, 28

internal fixation of, 28

of face, 73

of femur, 8, 69, 72, 297

of ilium, 243

of long bones, 10, 12, 43, 44, 283

associated with

colostomy, 344

wounds of jejuno-ileum, 252

of pelvis, 101, 113, 314

associated with colostomy, 349, 352

operation for, 28

prevention of shock in, 48

Compressed oxygen, use of, in gas anesthesia, 68

Concentrations of oxygen, 39, 185

Concept of

abdominal surgery, 87, 213, 277

in World War I, 337

blood replacement, 22-23

influence of timelag on case fatality

rates, 103-105

multiplicity factor, 105-111

operation as component of resuscitation, 6-7, 18-21, 29

pain after wounding, 44

plasma replacement, errors in, 21-23

rapid preoperative preparation, 18-21

resuscitation in World War I, shock, 7-8, 16

Concussive wounds, 100

Conservation of body heat, 36, 178

in morphine poisoning, 43

Conservation of manpower by closure of

colostomy overseas, 370

Conservative management of—-

fecal fistulas, 353, 364

intestinal obstruction in wounds of

jejuno-ileum, 250-251

urinary fistulas, 354

wounds of liver, 277

in World War I, 276
INDEX 383

Constant intestinal decompression, 196,

208, 209, 360, 361

Constipation after administration of morphine, 43

Consultants in anesthesia in World War I,

53

Consultations, avoidance of, before patient,

51

Contaminated blood, autotransfusion of,

131, 143, 157

Contamination:

infection after, 19

of pleural cavity in wounds of liver, 282

of retroperitoneal space, 177, 256

Contraindications to

anticoagulant drugs, 211

nitrous oxide anesthesia, 185

Pentothal Sodium anesthesia, 65, 71,

72-74, 184-185

routine postoperative bronchoscopy, 77

spinal anesthesia, 185

transdiaphragmatic incision in wounds of

spleen, 296

Trendelenburg position during resuscitation, 35

use of morphine, 33, 47-48, 102-103

Control of

hemorrhage

as component of resuscitation,

in forward installations, 9, 12

in -wounds of great vessels, 318-324

manic personnel in tanks, 68

pain, 41-52, 67

respiration during anesthesia. 56

Contusions of

bladder, 313

ileum, 86

jejuno-ileum, 241, 242

lung, 142, 240

Convoluted tubules of kidneys, damage to,

67

Convulsions, 69

Cooling of extremities during application of

tourniquet, 35

Copper sulfate determination of nonprotein

nitrogen of blood, 211

Coramine, 187

Cori, 132, 144, 171

Corps, 11-24

Cortical hemorrhage in wounds of kidneys,

303

Costophrenic angle, involvement of, in

wounds of kidneys, 304

Craniotomy, duration of, 8, 9, 73

Crepitation in wounds of stomach, 225

Chile, Col. George W., 53

Criteria

for blood replacement, 196

for classification of shock, 121

for closure of colostomy, 356

for surgery in field hospital, 10

of readiness for operation, 19, 26

of shock, 17

in World War I, 17

Crossmatching of blood, 26, 27

Crush syndrome, 164

Crushing injuries of jejuno-ileum, 241

Cumulative effects of wounds,

Curare, 186

Cutaneous ureterostomy, 310

Cyanosis

as criterion of anoxia, 37-38

in shock, 126

Cyclopropane anesthesia, 67, 68-69

Cystoscopy, 302, 304, 309, 314

in urinary fistulas, 353

Data. See Statistics. Dead spaces, obliteration of, by wound

closure, 29

Death, attitude to, 50, 52, 54

Death rate

effect of evacuation on, 200

effect of terrain on, 200

effect of timelag on, 103-112, 200

Deaths:

after preoperative preparation by plasma, 22

after release of tourniquet, 35

before admission to hospital, 99, 109

caused by errors in transfusion techniques, 28

caused by improper use of tourniquets, 35

caused by prolongation of timelag, 13

during bronchoscopy, 189

during resuscitation, 7, 125

from anesthesia, 78, 188-189

from aspiration of gastric contents, 31,

189

from chloroform anesthesia, 67

from fulminating infection, 188

from hemorrhage, 188, 317-324

from morphine poisoning, 41

from Pentothal Sodium anesthesia, 71-72

from postoperative pulmonary complications, 69

from shock, 15, 188

in forward hospitals, 85-86, 213-215, 221

in relation to time of occurrence, 95, 105,

174, 188-189
384 GENERAL SURGERY

Deaths—Continued

on operating table, 167, 195, 219, 231, 252, 271

in wounds of

bladder, 314

kidneys, 303

pancreas, 288

spleen, 294, 297

See also Case fatality rates, Statistics,

Causes of death.

DeBakey, M. E., 21

Debridement

in retroperitoneal hematoma, 327

in wounds of

kidney, 305, 306

liver, 278-279, 280

of muscles in wounds of colon and rectum, 256

Decubitus ulcers, 297

Deficiencies of records in forward hospitals,

85, 203

Definition of

multiplicity factor, 107

multiplicity index, 107

shock,

Deformity, prevention of, 13

Dehiscence of diaphragmatic repair, 193,

297, 299

Dehiscence. See also Wound dehiscence.

Dehydration:

in shock, 6, 7, 31, 32, 123

risk of albumin therapy in, 31

Delay in operation after resuscitation, 17-

18, 20

Delayed primary wound closure:

after closure of colostomy, 360

Pentothal Sodium anesthesia for, 53, 54,

72

Delirium as cause of wound dehiscence, 194

Dental officers, 2d Auxiliary Surgical

Group, 81

Dentists as anesthetists, 58

Depression—-

following euphoria after wounding, 50

of circulation in morphine poisoning, 42

of respiration

by morphine, 47, 207

in intracranial surgery, 73

in shock, 48

of respiratory centers, 33

Descending colon:

colostomy in, 366

wounds of, 264, 265, 267, 293

Detached service, use of surgical teams on,

81

Deterioration of status of casualty—■

after plasma replacement, 23

after resuscitation, 17-18, 20

after wounding, 7, 16-17, 103, 120, 142

Devine colostomy, 342, 353, 362-363, 364

Dextrose infusions, 32, 187

Diagnosis:

administration of morphine before, 177

intercostal nerve block before, 178

Diagnosis of

lower nephron nephrosis, 211

morphine poisoning, 43

pneumothorax, 12

retroperitoneal hematoma, 325-326

shock, 15-16

thoracoabdominal wounds, 177-178

urethral fistula, 354

urinary fistula, 353-354

Diagnosis of wounds of

abdomen, 177-178

duodenum, 236

kidney, 304

jejuno-ileum, 245

pancreas, 286, 287

stomach, 224-226

ureter, 309

viscera caused by blunt trauma, 331

Diaphragm:

dehiscence in repair of, 193, 297, 299

wounds of, 331

lacerating, 225

perforating, 142, 156, 178, 225, 240,

280-281

Dicumarol, 211

Diet:

correction of anemia by, 29

correction of hypoproteinemia by, 356

Difficulties

in resuscitation, 21

of anesthesia in blast injuries, 182

of evacuation in winter, 216

of management of wounds of ureter, 310

of operation in wounds of colon and rectum, 256

of preoperative preparation in closure of

colostomy, 343-354

of roentgenologic examination under

field conditions, 225

of secondary resuscitation, 20

Digestion of skin in small-bowel fistulas,

352

Digestive peritonitis in wounds of pancreas,

287, 288

Digitalis, 207

Digits, operations on, 67
INDEX 385

Dilatation of stomach

after wounding, 36, 157

during oxygen administration, 39

Disadvantages of

albumin, 30

chloroform, 67-68

ethylene anesthesia, 68

local anesthesia, 28, 66

nitrous oxide anesthesia, 54, 68

Pentothal Sodium, 71

purse-string suture of wounds of stomach,

230

spinal anesthesia, 65-66

suture in wounds of spleen, 294

vinyl ether anesthesia, 69

Discrepancies in—-

case fatality rates in recorded series of

abdominal injuries, 110-111

protocols of abdominal wounds associated with shock, 130

statistics on abdominal injuries, 81, 94-95

Disfigurement after wounding, 50, 51

Disposition of patients in field hospitals, 10

Distention, 198, 208

Disturbances of cardiorespiratory system—-

as factor in shock, 103, 119, 184, 220, 282

as factor in wounds of stomach, 231

Diuretic drugs, 212

Diuretic effect of hypertonic glucose solution, 43

Diversion of fecal stream, 362-364

Diversional colostomy, 262, 267, 340

Division clearing stations, 9-10, 12, 22, 82, 181, 197

assignments of teams of 2d Auxiliary

Surgical Group to, 82

Dosage of

atropine before anesthesia, 74, 75

local anesthetics, 67

morphine, 33, 34, 46-47, 207

penicillin, 197

procaine hydrochloride, 67

sulfonamides, 197

Double-barreled colostomy, 264

Double-barreled ileocolostomy, 262, 265

Drainage'

in closure of colostomy, 360

in retroperitoneal hematoma, 326, 327

in wounds of

colon, 264, 337

duodenum, 237, 238

jejuno-ileum, 249

kidneys, 305

liver, 277, 278-280

pancreas, 287

Drainage—Continued

in wounds of—continued

rectum, 262, 264

spleen, 294

ureter, 310

of intraperitoneal abscesses, 209

of retroperitoneal space, 350

of space of Retzius, 315

of wound infections, 209

of wounds, 193

Driscoll, 1st Lt. Kathryn T., 131

Drugs:

pre-anesthetic use of, 75-77

use of, in resuscitation, 39

Duodenum:

anatomic relation of, to

great vessels, 236

liver, 276

fistula of, 237-238

wounds of, 235-240, 289, 327

associated with wounds of

pancreas, 286

spleen, 293

ureter, 309

case fatality rates in, 235, 237, 238-240

diagnosis of, 236

frequency of, 235

in World War I, 238

lacerating, 236, 237, 238

lethality of, 239

nature of, 236

perforating, 236, 237

shock in, 238-239

time of death in, 238-239

transecting, 236, 237, 238, 239

Duration of

anesthesia, 188

combat in Mediterranean theater, 3, 65

craniotomy, 73

drainage in wounds of

kidney, 306

liver, 280

major surgery, 8-9

nasogastric suction in wounds of jejunoileum, 249-250

operations, 8-9, 119, 187-188

for compound fractures of femur,

in World War I,

preoperative oxygen therapy, 39

Dynamics of shock, 16

Dysfunction of colostomy, 346

Ecchymosis of jejuno-ileum, 242, 243

Economy in use of

blood, 20, 26
386 GENERAL SURGERY

Economy in use of—Continued

plasma, 20

Edema:

at intestinal anastomosis, 361

of cerebrum, 73

of extremity after use of Thomas splint, 35

Editorial board, 2d Auxiliary Surgical

Group, 83

Effect of

absorption from devitalized tissues in

shock,

albumin in shock, 30

altitude in shock, 12

anesthesia on circulatory system, 53

barbiturates

during spinal anesthesia, 70

in shock, 48-49

on respiratory center, 71

blast injuries in shock, 220

blood loss in—-

peritoneal contamination, 127

shock, 17, 21, 46, 131, 219

carbon dioxide on respiratory center, 71

cardiorespiratory disturbances in shock,

119, 220

change of position on blood pressure, 142

character of combat in shock, 12

character of wound in shock, 17, 25

chilling in morphine poisoning, 41-42

chloroform anesthesia, 55, 68

circulatory failure, 128-129

climatic conditions in shock, 12, 130

continuing blood loss in shock, 6, 20, 120

cyclopropane anesthesia in shock, 68

dehydration in shock, 6,

emotional factors in shock,

ether anesthesia, 55, 66, 69

evacuation on case fatality rates, 18, 203

excessive use of intravenous fluids on

heart, 101

exhaustion in shock, 6, 12, 17, 18, 181

exposure

in morphine poisoning, 42

in shock, 12, 17, 18, 181

on peripheral circulation, 46

fluid losses in shock,

head injuries in shock, 220

hypotension, 20

local anesthesia on

circulation, 67

resistance to infection, 56

manipulation of intestine, 123

missiles, 97, 99-101

morphine, 17

nitrous oxide anesthesia, 54

Effect of—Continued

nutritional deficits in shock, 12, 181

peritoneal contamination in shock, 6, 19,

20, 131, 219

plasma replacement in shock, 22

pulmonary complications in shock, 220

severity of wounds on case fatality rates,

104-105

size of missiles on wounds, 99

spinal anesthesia, 55, 66

tactical situation

in shock, 130

on evacuation, 203

terrain in shock, 12, 13, 130

timelag—-

in pathogenesis of shock, 5, 6, 12-13,

17, 20, 25

on case fatality rates, 103-104

weather on absorption of morphine, 34

wounding,

wounds of chest on pulmonary complications, 204

Eighth Service Command, 342

El Alamein, 291, 297

Elayes, 146

Election, site of, 35

Elliott, J., 21

Emergency medical tag, 47

Emotional factors in shock, 6, 8, 47

Emotional status of wounded casualties,

33, 34, 47, 49-52

Emphysema in wounds of stomach, 225

Emptying of stomach before operation, 36

Emptying time of stomach after wounding,

31

Empyema, 205, 220

associated with colostomy, 345

in wounds of

colon and rectum, 270

pancreas, 288

spleen, 299

stomach, 231

Encephalomalacia, 212

End-to-end anastomosis in closure of colostomy, 358, 359

Endotracheal anesthesia, 56, 73, 77, 182,

183-184, 187

in Pentothal Sodium anesthesia, 184

in wounds of colon, 274

indications for, 77

technique of, with curare, 186

England, 54

Enlisted men, 2d Auxiliary Surgical Group,

81
INDEX 387

Enterostomy in wounds of jejuno-ileum,

248-249

Entry wounds, 97-99, 177

in traumatic evisceration, 174

in wounds of

bladder, 313

duodenum, 236

stomach, 226

Environmental factors in pulmonary complications, 204

Ephedrine, 43, 187

Epididymitis, 315

Epinephrine hydrochloride, 67

Equipment

for anesthesia, 59-63

of field hospitals, 10

of fixed hospitals, 10

Errors in—-

autotransfusion, 131, 143, 157

blood replacement, possibility of, 38

concept of value of plasma, 21-23

diagnosis of pneumothorax, 12

evaluation of casualties, in shock, 14

location of colostomy, 346-347

preparation of transfusion equipment, 28

resuscitation, 3-4, 12

splinting, 12, 35

statistical data, 2d Auxiliary Surgical

Group, 81-86

statistics of retroperitoneal hematoma,

325

technique of colostomy, 346-350, 366 -367

transportation of casualties, 12

use of

morphine, 12, 41-42

Pentothal Sodium, 71, 74

plasma, 12

Thomas splint, 35

Errors in management of

hemorrhage, 12

pneumothorax, 12

retroperitoneal hematoma, 326

visceral injuries caused by blunt trauma,

331

wounds of

bladder, 314

duodenum, 238-239

extrahepatic biliary tract, 284

kidneys, 303, 305

liver, 281-282

pancreas, 288

stomach, 230

Esophagus, wounds of, 36

Ethanol, 212

Ether anesthesia, 44-47, 55, 56, 65, 68,

69-70, 72, 73, 182, 183

as supplement to spinal anesthesia, 55

in blast injuries, 182

in compound fractures of femur, 69

in forward hospitals, 69

in intracranial surgery, 74

in shock, 69

in World War I, 34, 54, 55

in wounds of chest, 69

induction of, with Beecher machine, 63

manifestations of morphine poisoning

during, 42

Pentothal Sodium induction of, 72

Ethyl chloride, 56, 67, 182, 185

Ethylene anesthesia, 68-69

Euphoria after wounding, 50

European Theater of Operations, 81

Evacuation, 5, 14, 82, 94, 95, 362

after abdominal surgery, 130, 196

chain of, 9-10

modification of, 13

delay in, as factor in shock, 17

difficulties of, 103, 216

effect of, on case fatality rates, 200, 203

exposure during, 42

in Western Desert, 111

logistic considerations of, 82, 85, 196, 203

pirority of, of patients with gastrointestinal fistulas, 209

routine of inspection during, 13

toleration of, by casualties in shock,

trauma of, 6, 13, 18, 203

Evacuation hospitals, 5, 10, 14, 19-20, 23,

56, 209

assignment of teams of 2d Auxiliary

Surgical Group to, 81, 82

blood replacement in, 28

9th—24

Pentothal Sodium anesthesia in, 72

shock wards in, 11

surgical load of, 58, 110

triage in, 11

See also Forward hospitals.

Evacuation policies in World War I,

Evaluation of casualties

at clearing stations, 9-10

in shock wards, 11, 13-18

Evipal Sodium, 70-71

Evisceration

in wounds of

colon and rectum, 260, 270

jejuno-ileum, 244

of ileocecal area, 350
388 GENERAL SURGERY

Evisceration—Continued

of ileum, 333

of omentum, 236

of stomach, 224

See also Traumatic evisceration.

Evolution of

management of wounds of liver, 276-278

routine of resuscitation, 5,

surgical practices, 3-4

use of colostomy, 337-341

Excessive blood replacement, 26

Excessive use of plasma, 18

Excitement after wounding, 33

Excitement stage of anesthesia, 186

Exhaustion as factor in shock, 6, 17, 50, 55

Exit wounds, 97-99, 177

in traumatic evisceration, 174

in wounds of

duodenum, 236

stomach, 226

Exploration through thoracotomy incision,

178

Exploratory laparotomy, 177

in penetrating wounds of abdominal

wall without visceral injuries, 329, 333

in retroperitoneal hematomas, 326, 327

in wounds of—-

chest, 178

jejuno-ileum, 245

liver, 279

Explosive wounds, 101

Exposure;

as factor in shock, 12, 15, 17, 18, 46,

50, 181

during evacuation, 42

effect of, on case fatality rates, 216

risk of, in walking wounded, 47

Exteriorization of colon, 192, 210, 261-

264, 296, 305, 338-340. See also Colostomy.

Extra-abdominal wounds. See Associated

wounds.

Extrahepatic biliary ducts, wounds of, 275, 284

Extrahepatic biliary tract. See Gallbladder, Common bile duct.

Extraperitoneal closure of colostomy, 357,

358-359, 362, 364

Extraperitoneal viscera, wounds of, 83

Extremities:

operations on, in World War I,

wounds of, 8, 13, 35, 210

Extremity, improvement of blood supply

of, by intervertebral block, 67

Face;

compound fractures of, 73

disfigurement of, 51

Factors of mortality, 213-221

Failure of

resuscitation, 4, 6, 20, 126-129, 221

in wounds of colon, 260, 271, 272

secondary resuscitation, 20

Fascia propria, drainage of, 264, 268

Fat embolism, 131, 135, 136, 154, 172, 212, 270

Fear of death, 33, 50

Fecal fistulas

associated with colostomy, 345, 351-354,

356, 364

in wounds of bladder, 315

Fecal stream, diversion of, 363-364

Feces, blood in, 177

Femoral artery, secondary hemorrhage

from, 210

Femoral phlebitis in wounds of

pancreas, 288

spleen, 297

Femoral veins, ligation of, 210, 211

Femoral vessels, hemorrhage from, 122

Femur, compound fractures of, 8, 69, 72, 135, 297

Fever in—•

peritonitis, 198

transfusion reactions, 28

Fibrinopurulent peritonitis, 135, 142, 151, 156

Fibroplasia, 29

Field block, 182, 185

Field hospital(s), 9, 10, 14, 17, 23, 82, 125, 136, 209, 210

administration of penicillin in, 197

anesthesia in, 66, 69, 70, 77

assignment of personnel in, 58

assignment of teams of 2d Auxiliary

Surgical Group to, 81, 82

blood replacement in, 24-25, 28

case fatality rates in, 7, 89, 215

diagnostic facilities in, 309

disposition of patients in, 10

forced evacuation of casualties from, 85

limitations of, 10

location of, 82

management of wounds of abdomen in,

82

management of wounds of colon in, 340

mission of, 5, 82

on Anzio beachhead,

127th—7

personnel of, 82
INDEX 389

Field hospital(s)—Continued

plasma replacement in, 23

resuscitation in, 10, 82

shock wards in, 10-12

statistics of, 7, 89, 110

status of casualties in, 181-182

surgical load in, 70, 110

33d—16

timing of operation in, 19-20

wounds of liver in, 280

See also Forward hospitals.

Field medical record, 83

Field packs, protection by, against wounding, 99

Fifth Service Command, 342

Fifth U. S. Army, 18, 24-25, 36, 41, 94, 130

Fingers, amputation of, 55

Finney pyloroplasty, 359

First-aid treatment, 9, 42, 85

Fissure of spleen, 294

Fistula formation after crushing of colostomy spur, 364

Fistulas —-

into acetabulum, 354

into buttocks, 345, 364

into urethra, 354

of duodenum, 237-238, 352

of gastrointestinal tract, 209

of ileum, 364

of intestine, 195

of jejuno-ileum, 250, 251

of jejunum, 352, 364

of small intestine, 194, 265, 351

of stomach. 194, 227

of urinary tract, 212

through chest, 354

through diaphragm, 354

through vertebral column, 354

See also Special types.

Fixed hospitals, 29, 274

anesthesia in, 29, 65, 66, 72

blood replacement in, 28-29

equipment of, 10

management of wounds of colon in, 370

mission of, 10

personnel of, 10

preoperative preparation in, 28-29

resuscitation in, 10

See also General hospitals, Station

hospitals.

Flanders, 54

Flank:

traumatic evisceration through, 173

wounds of, 99, 135, 313

Flank incision in wounds of kidney, 305

Fluid balance, maintenance of, 188

after closure of colostomy, 360

during use of albumin, 31

in wounds of

jejuno-ileum, 250

kidney, 306

preoperative, 32, 49

Fluid intake:

before wounding, 50

restriction of:

in lower nephron nephrosis, 211-212

preoperative, 31, 49

Fluid losses:

after administration of morphine, 33

by rapid warming, 36

effect of, in shock, 6, 48, 129

in morphine poisoning, 43

in sweat, 6, 43, 48

in vomitus, 6, 31, 43, 48, 123

Fluid replacement therapy, 31-32

Fluoroscopy, 177, 304

Followup of casualties after evacuation,

85-86, 94, 213

Food intake before wounding, 50

Foreign bodies

as secondary missiles, 101

retained in wounds, 55, 56, 100, 352,

353, 364

Forward hospitals:

anesthesia in, 56-57, 60, 66, 69, 70, 72, 130, 274

case fatality rates in, 89, 94-95, 215

colostomy in, 370

deaths in, 85-86, 213-215, 221

deficiencies of records in, 85, 94

diagnostic facilities in, 302, 304

distribution of wounds in, 89, 215

holding periods in, 85, 94, 203

intestinal obstruction in, 250

morphine poisoning in, 41

postoperative vascular insufficiency in,

321

surgical load in, 58, 69, 70, 89, 215

wounds of great vessels in, 322

wounds of pancreas in, 288

See also Evacuation hospitals, Field

hospitals.

Fowler’s position, 250

Fracture of

kidney, 305, 306, 309

spleen, 292

Fragmentation of

kidneys, 303

liver, 278, 302

spleen, 292, 302
390 GENERAL SURGERY

France, 7, 53, 54, 130, 134, 146, 147, 155, 158, 162

Frequency of

associated injuries, 113-114

blood in gastric contents, 225

clostridial infection, 209

colostomy in World War I, 338

enterostomy in wounds of jejuno-ileum,

248

ether anesthesia, 69

evisceration in wounds of jejuno-ileum,

244

gastrointestinal fistula, 209

intestinal obstruction, 208

after closure of colostomy, 361

in wounds of jejuno-ileum, 250

intraperitoneal abscess, 209

lower nephron nephrosis, 211

nephrectomy, 305

nonpenetrating visceral injuries, 329

operations—-

in wounds of liver, 279

on extremities in World War I,

pain in—-

thoracoabdominal wounds, 178

wounded men, 33, 43-46, 49

Pentothal Sodium anesthesia, 71, 72

perforating wounds of jejuno-ileum, 243

postoperative complications in wounds

of spleen, 297

postoperative pulmonary complications,

69, 204-206, 220

postoperative sepsis, 213

resection in wounds of jejuno-ileum,

242-243, 247

retroperitoneal hematoma, 325

secondary hemorrhage, 210

shock, 5, 131

thoracoabdominal wounds, 181, 223, 291

transdiaphragmatic approach in wounds

of—-

kidney, 305

spleen, 295

stomach, 229

thromboembolism, 210

transfusion reactions, 28

traumatic evisceration, 173-174

visceral injuries caused by blunt trauma, 331

wound dehiscence, 193

wound infection, 209

Frequency of wounds

according to viscera injured, 89-94

in infantrymen, 89, 92

of bladder, 313

Frequency of wounds—Continued of colon and rectum, 255

of duodenum, 235

of great vessels of abdomen, 94, 317-324

of ileum, 251

of jejuno-ileum, 241, 251

of kidneys, 301

of liver, 274, 282

of pancreas, 285

of spleen, 291

of stomach, 223-224

of ureter, 309

Fulminating infection, 119, 188

Function of

medical officers on shock wards, 11-12

shock teams,

surgical teams, Fused kidneys, 302

Gallbladder, wounds of, 275, 283-284, 293

Gangrene, in wounds of

iliac vessels, 321

jejuno-ileum, 242

Gas bacillus infection. See Clostridial

infections.

Gastric artery, wounds of, 319

Gastric contents, blood in, 177

Gastric dilatation, 212

Gastric lavage before operation, 36

Gastroepiploic artery, wounds of, 293

Gastrointestinal disturbances as factor in

shock, 103

Gastrointestinal fistulas, 209

Gastrointestinal tract, perforating wounds

of, 131

Gastrojejunostomy, 237

Gastropleural fistulas, 230

Gelatin sponges, 294

General hospitals, 10, 342

blood replacement in, 28-29

surgical load in, 58

training in anesthesia in, 58

wounds of liver in, 277, 281

See also Fixed hospitals.

Genitalia:

loss of, 51

operations on, 67

Genitourinary tract, wounds of, 223

Genitourinary tract. See also Bladder,

Ureter.

Germany, 8, 82, 83,130,137,140,150,152,168

Giblin, T., 291, 297

Globulins, molecule of, 30

Glucose solution, use of, in morphine

poisoning, 43
INDEX 391

Gluteal region, wounds of, 122, 154, 163, 178

Gram-negative infections, control of, by

streptomycin, 370

Gram-positive infections, control of, by

penicillin, 370

Great vessels of abdomen, wounds of, 228, 317-324, 325, 326, 327

case fatality rates in, 317-324

frequency of, 317-324

multiplicity factor in, 323

Grenades, 174, 302

Groin, pain in, in wounds of kidneys, 303

Grossostheim, 150, 152

Group-specific blood, 139, 146

Guillotine amputation,

Gum acacia, 21

Head, wounds of, 17, 32, 35, 41, 73, 74, 211,

225, 229, 252, 282, 283

administration of morphine in, 47

anesthesia in, 55, 77

in World War I, 54

pain in, 43, 44

transportation of casualties with, 12

Head injuries as factor in shock, 220

Headquarters 2d Auxiliary Surgical Group,

81

Heart:

effect of

chloroform on, 68

cyclopropane on, 68

dilation of stomach on, 36

ether on, 183

excessive intravenous fluids on, 32

wounds of, 229, 252, 283

Heat, as factor in shock, 12

Heat exhaustion, 12

Heidbrink anesthesia machine, 59, 182

Hematocrit:

Depression of, at operations for fractures, 28

effect of plasma on, 122

in burns, 24

in thoracoabdominal wounds, 178

in wounds of jejuno-ileum, 250

Hematocrit deficit, cyanosis as criterion of,

37-38

Hematocrit level after—-

initial surgery, 29

wounding, 18, 22, 122-124

Hematoma: of mesentery, 242, 245-246

retroperitoneal, 95, 325-327

Hematoma formation in wounds of—•

colon and rectum, 256

Hematona formation in wounds of—Con. kidneys, 303

Hematuria, 177

in wounds of

bladder, 313-314

kidney, 303, 304

ureter, 309

Hemoconcentration, 123

in burns, 24

Hemodilution after hemorrhage, 18, 22, 38,

55, 123

Hemoglobin:

deposition of, in kidney, 28

loss of, after resuscitation, 17-18

loss of, at operations for compound fractures, 28

Hemoglobin deficit:

cyanosis as criterion of, 37-38

in shock, 5, 6, 18, 21, 22, 38, 55

Hemoglobin level

after initial surgery, 29

in thoracoabdominal wounds, 178

Hemoglobinemia, 165

Hemolytic streptococcic bacteremia, 252

Hemoperitoneum, 46

in wounds of—-

bladder, 313

jejuno-ileum, 244

kidneys, 303

without visceral injuries, 333

Hemopneumothorax, 179

Hemorrhage:

after excessive elevation of blood pressure, 23

as cause of death, 188

in World War I, 213

in wounds of pancreas, 288

as contraindication to Pentothal Sodium

anesthesia, 72, 74

control of

after wounding, 34-35

as essential factor in resuscitation,

in forward installations, 12

in wounds of

extremities, 35, 122, 317-324

great vessels, 318-324

ether anesthesia in, 69

from stomach in wounds of pancreas, 288

in morphine poisoning, 42

in retroperitoneal hematoma, 327

in wounds of—-

great vessels of abdomen, 122, 318-324

spleen, 297, 299

restlessness associated with, 33, 47

risk of, in anticoagulant therapy, 211
392 GENERAL SURGERY

Hemorrhage—Continued

See also Blood loss, Secondary hemorrhage.

Hemostasis in wounds of

great vessels of abdomen, 318, 319, 320,

321

kidney, 306

spleen, 294-295

Hemostatic agents in wounds of spleen,

294-295

Hemothorax, 48, 184

in wounds of spleen, 292, 293, 299

Heparin, 210, 211

Hepatic artery:

anatomic relation of, to duodenum, 236, 239

wounds of, 319

Hepatic blood vessels, damage to, in

wounds of liver, 283

Hepatic damage after—-

chloroform anesthesia, 67

vinyl ether anesthesia, 69

Hepaticoduodenal ligament, wounds of, 284

Hepatitis, 29, 277

as contraindication to use of morphine, 48

in wounds of jejuno-ileum, 250

Hepatorneal syndrome, 282

Herniation of

colon into chest, 299

intestine after colostomy, 345, 350, 359, 367-368

stomach into chest, 299

Hiccoughing, 73

High-caloric diet before closure of colotomy, 356

High-explosive fragments, wounds caused

by, 97, 211, 241

High-protein diet before closure of colostomy, 356

Hilum of kidney, wounds of, 302-303

Hip, wounds about, 97, 313

Histologic changes in shock, 130-131

History of—-

colostomy, 337-338

development of plasma therapy, 21

2d Auxiliary Surgical Group, 81-82, 83

Hofmeister gastric resection, 230

Holder, H. G., 346

Holding period in forward hospitals, 10, 85,

94, 213

Hollow viscera, wounds of, 177, 193, 217,

257 caused by indirect trauma, 329

lethality of, 95

Hollow viscera, wounds of—Continued

nonperforating, 86

perforating, 119-172, 196, 208, 209, 326

Horseshoe kidney, 302

Hospital level, case fatality rates according

to, 89, 110, 215

Hospital(s):

Base, No. —54

Evacuation, 9th—24

Field, 33d—16

Field, 127th—7

General:

McCloskey, 342, 344

Rhodes, 342, 358

Walter Reed, 354

in Zone of Interior, 29, 204, 341-370

on Anzio beachhead, 19

Hydronephrosis, 171

Hydropneumothorax, 205

Hypertension in lower nephron nephrosis,

147, 163, 211

Hypertonic glucose solutions, 43

Hypodermoclysis, 32, 207

Hypogastric artery, wounds of, 144

Hypoproteinemia in patients with colostomies, 344

Hypotension, 29, 138, 160

effect of, on peripheral circulation, 34

organic effects of, 20

See also Blood pressure.

Hypothalamos, blast damage to, 36

Hypothyroidism, 48

Hysteria after wounding, 33, 47

Ileocolic anastomosis, 262, 265

Ilecolostomy, 262, 358

Ileostomy, 212

Ileotransverse colostomy, 171, 359

Ileum:

contusions of, 86

evisceration of, 333

fistulas of, 364

volvulus of, 251

wounds of, 88, 107, 251-252

associated with wounds of bladder, 315

multivisceral, 86, 88

perforating, 151, 156

Ileus, 123, 198, 203, 208

after closure of colostomy, 361

in wounds of jejuno-ileum, 249

Iliac vessels, wounds of, 122, 133, 210, 309,

317, 319, 320-321, 333

Iliopsoas muscle, 256

Ilium, fractures of, 163, 243
INDEX 393

Immaturity of wounded soldiers, 49

Immobilization as factor in thromboembolism, 210

Impairment of

peripheral circulation as factor in morphine poisoning, 42, 46

respiration in morphine poisoning, 41, 42

Impotence, 50

Inanition in patients with colostomies, 362

Incidence. See Frequency.

Incipient shock, 121, 122

in wounds of stomach, 231

Incision(s), 191-193

for colostomy, 192

in penetrating wounds of abdominal wall

without visceral injuries, 333

in wounds of—-

kidney, 305

liver, 278

pancreas, 287

spleen, 295-297

stomach, 229

See also special types.

Incomplete diversion of fecal stream, 340-

349

Indications for—-

blood replacement, 78-79

bronchoscopy, 77

chloroform anesthesia, 68

colostomy, 339-340

in World War I, 338

endotracheal anesthesia, 77

local anesthesia, 66

nitrous oxide anesthesia, 68

Pentothal Sodium anesthesia, 72

preoperative use of—-

atropine, 75

morphine, 77

prompt surgery, 6-7, 14, 18-21, 22, 29,

120, 145

resection in wounds of jejuno-ileum, 246, 247-248

spinal anesthesia, 66

in World War I, 55

transdiaphragmatic approach in wounds

of

spleen, 296

stomach, 229

use of morphine, 33

Indirect trauma in wounds of

duodenum, 236

hollow viscera, 329

Individual reaction to wounding, 104

Individual requirements for morphine, 46

Induction of anesthesia, 63, 68, 69, 186

Infantry, frequency of wounding in, 89

Infection, 13, 19

after blood replacement, 29

after closure of colostomy, 361.

after colostomy, 368

after crushing of colostomy spur, 364

as cause of wound dehiscence, 194

effect of local anesthesia on resistance to,

56

ether anesthesia in, 55

of retroperitoneal space, 119

prevention of, by prompt reparative

surgery, 29

Inferior vena cava. See Vena cava.

Inflamation about carotids, 72, 75

Influence of

logistics on choice of anesthetic agents,

56-57

multiplicity factor and timelag on case

fatality rates, 105, 112

multiplicity factor on pulmonary complications, 110

timelag on case fatality rates, 103-105,

112

Inhalation anesthesia, 56, 57

Initial wound surgery:

anemia after, 29

Preparation for,

Inter-Allied Surgical Conference, 1917-54

Intercostal artery, secondary hemorrhage

from, 210

Intercostal nerve block, 48, 67, 178, 207

Internal fixation of compound fractures, 28

Interpretation of statistics, 86

Intervertebral block, 67

Intestinal obstruction, 112, 195, 208-209

after closure of colostomy, 357, 359, 361.

365

after colostomy, 345, 347

after crushing of colostomy spur, 364

as cause of death in wound dehiscence,

195

case fatality rates in, 208

in wounds of

colon and rectum, 270, 273-274

jejuno-ileum, 246, 250-251, 254

spleen, 297

Intestine:

effect of manipulation of, 123

378327° 56—27
394 GENERAL SURGERY

Intestine —Continued

wounds of:

associated with wounds of bladder,

313, 315

perforating, 31

See also Large intestine, Small intestine,

Duodenum, Ileum. Intracranial blast injury, 36

Intracranial pressure, 32

Intrahepatic abscess, 280, 282

Intramuscular administration of

morphine, 34, 46-47

penicillin, 178, 197

Intraperitoneal abscess, 209

Intraperitoneal chemotherapy, 197, 201

in wounds of

bladder, 315

colon and rectum, 273

jejuno-ileum, 249

Intraperitoneal closure of colostomy, 357,

358, 359, 361, 363, 364

Intraperitoneal hemorrhage, 144

Intraperitoneal penicillin therapy, 197

in wounds of—•

bladder, 315

colon and rectum, 273

jejuno-ileum, 249

Intravenous administration of—•

morphine, 34, 47, 77, 186, 208

penicillin, 178

Intravenous fluid therapy before operation,

32, 49

Intravenous urography, 302, 304, 309

Intubation

in diagnosis of wounds of stomach, 225

of stomach in morphine poisoning, 43

Invagination of wounds of colon, 338

Invasive infection, 365

Iron, preoperative use of, 29, 356

Irreversible shock, 127, 128, 129, 131

Irrigation of colostomy before closure, 356,

357

Irritation of skin from sulfonamide therapy,

369

Ischemia caused by application of tourniquet, 35

Ischemic muscle necrosis, 153

Ischium, compound fractures of, 144

Italy, 12, 24, 25, 36, 41, 43, 46, 54, 70, 75,

83, 130, 132, 144, 160, 165, 171, 204

Japan, 54

Jaundice, in wounds of

pancreas, 288

spleen, 297

Jejuno-ileum;

contusions of, 241, 242

fistula of, 250, 251

resection of, 246, 247-248

case history, 248

wounds of, 86, 241-254

associated injuries in, 244-245, 252

associated with wounds of pancreas,

286

case fatality rates in, 241, 250, 251-254

case history, 243-244, 252

classification of, 241

diagnosis of, 245

drainage in, 249

enterostomy in, 248-249

case history, 249

evisceration in, 244

frequency of, 241

hemoperitoneum in, 244

indications for resection in, 246, 247-248

intestinal obstruction in, 250-251, 254

lacerating, 242

management of, 245-249

multiplicity factor in, 247

nature of injury in, 241-245

perforating, 241, 242, 243-244, 245-

246, 248

peritoneal contamination in, 243, 244, 250

postoperative complications in, 249-

251

timelag in, 244, 251-252

univisceral, 241, 244, 251-254.

Jejunostomy, 138

Jejunum:

fistula of, 352, 364

resection of, 138

wounds of, 107, 293, 315

lacerating, 138

perforating, 144

Jolliffe, 1st Lt. Leslie S., 131

Jolly, Douglas W., 285, 291, 293, 325,

326, 338

Kidneys:

anatomic relations of, 302

damage to convoluted tubules of, 67

effect of blood replacement on, 28

effect of chloroform anesthesia on, 54, 67

effect of circulatory failure on, 128

fracture of, 305, 306

fragmentation of, 303

wounds of, 101, 224, 236, 301-307, 325,

331
INDEX 395

Kidneys —Continued

wounds of—continued

associated with wounds of—-

duodenum, 236

pancreas, 286

ureter, 309

dehiscence in, 193

drainage in, 305

in World War I, 301

incision in, 305

lacerating, 151, 169

lethality of, 307

management of, 305-306

errors in, 305

multivisceral, 301, 303, 307

perforating, 239

univisceral, 301, 304

Laboratory findings in—-

burns, 24

shock, 18

Laboratory studies before closure of

colostomy, 357

Lacerating wounds of—-

bladder, 313

common bile duct, 239

diaphragm, 225

duodenum, 236, 237, 238

gallbladder, 283

jejuno-ileum, 242

liver, 156, 276, 278

lungs, 240

pancreas, 286

spleen, 142, 292

stomach, 224, 226, 227, 233

ureter, 310

Lakeside Unit, 54

Laminectomy, duration of,

Land mines;

as cause of traumatic evisceration, 174

wounds of kidneys caused by, 302

Laparotomy:

duration of, 8,

in wounds of bladder, 314

negative intraperitoneal findings at, 83,

95, 331, 333

See also Exploratory laparotomy and

special operations.

Laparotomy closures, 191-196

Laparotomy incisions, 191-193

Large intestine, wounds of, associated

with wounds of ureter, 309

Laryngeal reflex, 74

Laryngeal spasm, 69, 73, 74, 75, 184

Last Sacraments, 52

Lavage of

peritoneum, 249

stomach before operation, 36

Layer closure of wounds, 192, 193, 194, 195, 196

Leakage —•

at anastomosis in wounds of jejunoileum, 251

of albumin from blood stream, 30

of gas in wounds of stomach, 225

of physiologic salt solution from blood

stream, 32

Lee, Burton J., 276, 277, 338

Lethal dose of Pentothal Sodium, 71

Lethality of wounds, 105, 129, 220

in traumatic evisceration, 175

of duodenum, 239

of hollow viscera, 95

of kidney, 307

of liver, 276

of small intestine, 235

of solid viscera, 95

of special organs, 217

of stomach, 227, 233

relation of timelag to, 127

Levin tube, 178, 225, 245

in wounds of jejuno-ileum, 249

Lewison, E. F., 346

Ligation of

blood vessels, 8, 35

in retroperitoneal hematoma, 326, 327

common carotid artery, 212

great vessels of abdomen, 210, 319, 320, 321, 322

pancreatic duct, 287 ureter, 310

vena cava, 318, 319, 321, 322

Limitations of

field hospitals, 10, 111-112

morphine, 156, 157

Pentothal Sodium, 65

plasma, 21-23, 122, 145

sulfonamide therapy in closure of colostomy, 368

Litter-carry, 9, 13, 42

Liver:

effect of chloroform anesthesia on, 55

effect of circulatory failure on, 128

effect of ether anesthesia on, 55, 183

fragmentation of, 302

necrosis of, 142, 151, 157

wounds of, 101, 135, 141, 150, 211, 223,

224, 228, 236, 237, 275-284
396 GENERAL SURGERY

Liver—Continued

wounds of—continued associated with wounds of

duodenum, 236, 237

pancreas, 286

spleen, 293, 297

stomach, 228

ureter, 309

blood loss in, 276, 280, 282-283

dehiscence in, 193

frequency of, 274, 282

in World War I, 276-277, 282, 283

lacerating, 156

lethality of, 276

lower nephron nephrosis in, 282

management of, 276-280

oliguria in, 282

secondary hemorrhage in, case history,

281

See also Hepatic.

Liver extract, use of, before closure of

colostomy, 356

Local anesthesia, 57, 65, 66-67, 68, 73, 182

administration of morphine before, 77

disadvantages of, 66

in closure of colostomy, 357

in intracranial surgery, 74

in surgery near carotid bodies, 73

in World War I, 54, 55-56

indications for, 66

Local leukocytic response, 127

Local sulfathalidine therapy, 369

Location of

battalion aid stations,

collecting stations, colostomy, 342, 346

field hospitals, 10, 82

traumatic eviscerations, 173-174

wounds, 97-99

Logistic considerations of evacuation, 82, 85

Logistics, influence of, on choice of anes- thetic agents, 56-57

London, 339

Long bones, compound fractures of, 43, 44, 252

associated with

colostomy, 344

wounds of liver, 283

Loop colostomy, 262, 267, 358, 362

Low-residue diet before closure of colostomy, 357

Low titer “O” blood, 27

Lower nephron nephrosis, 28, 131, 133, 139,

142, 143, 147, 149, 153, 154, 160, 164,

211-212, 282

Lumbar artery, wounds of, 289

Lumbar muscles, wounds of, 256

Lumbosacral region, wounds of, 163

158, 162

Lung abscess, 205

Lungs:

aspiration of gastric contents into, 31

blast injury of, 252

contusions of, 142, 156, 240

lacerating wounds of, 32, 211, 225, 240,

283, 331

Lymph flow, status of, in anesthesia, 73

Machinegun wounds, 100

Maintenance of airway, 187

Maintenance of fluid balance, 188

after closure of colostomy, 360

in wounds of

jejuno-ileum, 250

kidney, 306

Major surgery, duration of,

Makins, G. H., 277

Malaise in transfusion reactions, 28

Malaria, 297

Mallory, Lt. Col. TracyB., 131

Management:

during operation, 186-188

of burns, 23-24

of colostomy, 337-370

of fecal fistulas, 352-354, 364

in wounds of jejuno-ileum, 251

of gastrointestinal fistula, 209

of lower nephron nephrosis, 211-212

of morphine poisoning, 43

ofpenetrating wounds of abdominal wall,333

of postoperative intestinal obstruction,

208-209, 250-251

of postoperative shock, 208

of retroperitoneal hematoma, 326, 327

of secondary hemorrhage in wounds of

stomach, 230

of shock, 5, 8, 119-172

of visceral injuries caused by blunt

trauma, 331

of wound dehiscences, 195

of wound infection, 209

of wounds of

bladder, 314-315

colon and rectum, 261-264

extrahepatic biliary ducts, 284

gallbladder, 282

jejuno-ileum, 245-249

kidney, 305-306

liver, 276-280

pancreas, 287-288
INDEX 397

Management—Continued

of wounds of—continued

rectum, 365-366

small intestine associated with wounds

of colon, 365

spleen, 294-297

ureter, 310

See also Techniques, Treatment, special

types of treatment.

Mania:

as emotional reaction to wounding, 47, 50

control of, by chloroform, 68

Manipulation at operation, effect of, on

liver, 123

Mann, F. C., 123

Martin, Maj. Gen. Joseph I., 94

Mass closure of incision, 192, 193, 194

Massachusetts General Hospital, 65, 70

Maxillofacial wounds, 66, 67, 73, 77, 252

Mayo Clinic, 57

McCloskey General Hospital, 342, 344

McKesson anesthesia machine, 59, 182

Measurement of blood loss,

Mechanism of

circulatory improvement after emptying

of stomach, 36

effects of missiles, 99-101

injury in nonpenetratingvisceral injuries,

329

traumatic evisceration, 173

wounding by high-velocity missiles, 100

Medical aidmen:

administration of morphine by, 46

as anesthetists, 58

on shock wards, 11

Medical Field Service School, Carlisle

Barracks: principles of medical evacuation taught

at, 94

dangers of morphine poisoning taught at,

42

Medical organization in World War I,

Medical terminology in World War I,

Medication for pain, desire of casualties

for, 44

Meisenthal, 155

Melena, 177

Mental state in shock, 15-17

Mesenteric vessels:

anatomic relation of, to duodenum, 236

damage to, in crushing of colostomy

spur, 364

Mesentery:

hematoma of, 242, 245 -246

Mesentery—Continued

wounds of, 242-243, 331

in wounds of jejuno-ilium, 242-243 Metabolism;

effect of ether anesthesia on, 69

increase of, during rapid warming, 36

Methods of special study of abdominal

wounds associated with shock, 130-131

Mignano, 19

Military implications pf preoperative psycologic care, 51

Miller-Abbott tube, use of

after closure of colostomy, 360

in wounds of jejuno-ileum, 250

Mine fragments, 101

Minor surgery, local anesthesia for, 67

Minturno, 165

Mismatched blood, 28

Mission of

collecting stations,

division clearing stations, 9-10

field hospitals, 10, 82

fixed hospitals, 10

forward medical installations, 9-10

Mobile casualty clearing stations, 81

Modification of chain of evacuation, 13

Molecule of

albumin, 30

globulins, 30

Morale of combat troops, 82

Moribund wards in World War I, 213

Morison’s pouch. See Subhepatic space.

Morphine:

absorption of, 34, 42, 47, 76-77

dosage of 33, 34, 46-47

effects of, 17, 207

indications for use of, 33, 41-48, 77

limitations of, 156, 157

postoperative, 207, 208

nausea after, 31, 47

overdosage of, 12, 72

resistance to, 42

use of, in World War I, 55, 56

Morphine, administration of:

according to individual needs, 46

after wounding, 85

before examination, 177

by medical aidmen, 46

continued pain after, 50

contraindications to, 33

errors in, 41-42

in battalion aid stations,

in wounds of

chest, 47

head, 47
398 GENERAL SURGERY

Morphine, administration of—Continued

preoperative, 47, 74, 76-77, 186

routine for, 46-47

Morphine poisoning, 41-43, 46, 47, 77, 127

clinical picture of, 41, 42-43

in burns, 41

in hemorrhage, 42

in shock, 42

management of, 43

Mortality, factors of, 213-221

Mortar fire, 97

Mortar fragments, 99

Mortar shell as cause of traumatic evisceration, 174

Mucosa of respiratory tract, effect of ether

anesthesia on, 69

Mucous fistula, 262, 265, 342, 352, 365

Mucous membranes, color of, in shock, 25

Multiplicity factor, 84, 105-112, 220

concept of, 105-111

definition of, 107

in relation to hospital level, 215

in traumatic evisceration, 174-176

in wounds of

bladder, 315

colon and rectum, 256-259

great vessels, 323

jejuno-ileum, 247

kidney, 307

liver, 283

stomach, 227-228

influence of, in wounds of stomach, 111-

112

Mnfluence of, on ease fatality rates, 217

invalidation of, by special considerations,

112

limitations of, 111-112

operation of

according to hospital level, 110

in associated wounds, 109, 114-117

in pulmonary complications, 110

in shock, 109-110

in wounds of

blood vessels, 107

intestine, 107

relation of, to

case fatality rates in shock, 109-110

pulmonary complications, 205-206,

220

timelag, 105-112, 221

Multiplicity index, 105-107

in traumatic evisceration, 175-176

Multivisceral wounds, 217

definition of, 87, 88

of bladder, 313, 314, 315

Multivisceral wounds—Continued

of colon, 86, 88

of colon and rectum, 270-271

of great vessels of abdomen, 318, 319

of ileum, 88

of jejuno-ileum, 241, 250

of kidneys, 301, 303, 307

of pancreas, 285, 286, 288

of small intestine, 235, 236, 239

of spleen, 291, 292-293, 298

of stomach, 223-244, 227-228, 231

of ureter, 309

pulmonary complications in, 110

ratio of univisceral wounds to, 94

time of death in, 110

Muscle grafts in wounds of liver, 277

Muscle guarding in wounds of kidney, 303

Muscle spasm in wounds of chest, 178

Muscle strip, use of, in wounds of spleen,

294

Muscular relaxation inhalation anesthesia,

67, 68, 69

Myoglobinuria, 163, 164

Myohemoglobinuria, 133

Myositis, 165

Naples, 32, 160, 199

Nasogastric suction, 188

as cause of wound dehiscence, 196

in wounds of jejuno-ileum, 249-250

Nature of lesion, in wounds of

bladder, 313

colon and rectum, 256

duodenum, 236

kidney, 302-303

jejuno-ileum, 241-245

liver, 275-276

pancreas, 286

spleen, 291-292

stomach, 226-227

Nausea after administration of morphine, 31, 33,

47

after nitrous oxide anesthesia, 54

in morphine poisoning, 42

in shock, 17

Neck:

abscess of, 73

use of atropine before operations on, 75

wounds of, 72, 225

Necrosis of

adrenal glands, 163

hepatic tissue, 151, 157, 277, 282

Negative explorations, 83, 95, 331-333

case fatality rates in, 95, 333
INDEX 399

Neoplasm formation after crushing of

colostomy spur, 365

Nephrectomy in wounds of—-

kidney, 151, 239, 302, 303, 305, 306, 307,

310

renal pedicle, 319

Nephritis after nitrous oxide anesthesia, 54

Nephrostomy, 306, 307, 310

Nerve block:

in World War I, 55

relief of pain by, 48, 67

Nerve damage after use of tourniquets, 35

Nerve injuries associated with colostomy,

344

Nesset, N., 21

Neuilly, 53

Neurosurgical procedures, 67

Nitrous oxide anesthesia, 41-42, 68-69, 182, 183, 185

in World War I, 53-56

supplemental to spinal anesthesia, 55

Nomenclature of

abdominal wounds, 87-88

multiplicity factor, 107

Non-battle-incurred wounds of spleen, 292

Nonpenetrating wounds of abdominal

wall, 83, 101, 329-330

Nonperforating wounds of

hollow viscera, 86

jejuno-ileum, 242

Nonsurgical case fatality rate, 7, 87, 93,

125-126

Non-type-specific blood, 26, 27, 28

North Africa, 8, 12, 22, 70, 71, 75

Nose, operations on, 67

Nurse anesthetists, 57

in World War I, 53

Nurses:

on shock wards, 11

2d Auxiliary Surgical Group, 81

Nutritional deficiency

as cause of wound dehiscence, 194, 196

in sacral fistulas, 352

Nutritional status of patients with colostomies, 344—345, 356

“O” blood, 26, 27, 28

Objectives of

management in morphine poisoning, 43

plasma replacement, 23

resuscitation, 6, 8, 16-17, 20, 120

therapy in—-

battalion aid stations,

forward medical installations, 9-10

Office of Surgeon. See Surgeon.

Ogilvie, W. H., 110, 291, 297, 339

Oligemia, 121

Oliguria, 154, 211, 282, 309

Omentum, traumatic evisceration of, 173,

174, 236

Open-drop ether anesthesia, 69, 182

Operating table, deaths on, 167, 195, 219,

231, 252, 271, 288, 294, 297, 303, 314

Operation:

as component of resuscitation, 6-7, 8,

14, 18-21, 22, 120, 145

case fatality rates before, 125-126

classification of patients for, 15

continuation of resuscitation during, 6,

19, 26, 187

criteria of readiness for, 19

delay in, after resuscitation, 18, 20, 32, 53

duration of, 8-9, 119, 187-188

for compound fractures, 28

for noncombat conditions, 66

management during, 186-188

on blood vessels,

on chest, 26, 27, 60, 63, 75, 77

on extremities, 67

on genitalia, 67

on head, 77

on neck, 75

on nose, 67

rapid preparation for, 18-21

stabilization of casualties for, 18-21

stress of, 809

timing of, 6, 7, 10, 11, 19-20

in thoracoabdominal wounds, 179

toleration of, after plasma replacement,

22, 23

Orchitis, 212

Organic damage in shock, 14, 20

Organization of shock wards, 10-12

Organs. See Viscera.

Osmotic pressure of plasma, 29

Osteomyelitis associated with colostomy,

345, 346, 351, 352, 364

Overdosage of morphine, 12, 34, 41-43, 46,

77, 127

as contraindication to Pentothal Sodium

anesthesia, 71, 72

Overlooked laceration of renal vein, 303

Overlooked perforations of

duodenum, 238, 239, 288, 326

stomach, 142, 143, 156, 157, 169, 170, 230

Overlooked retroperitoneal wounds of

colon, 326

Overlooked visceral injuries, 238-239

caused by blunt trauma, 331
400 GENERAL SURGERY

Overlooked wounds of

bladder, 314, 326

common bile duct, 288

kidney, 305

pancreas, 88

ureter, 309, 310, 326

Overseas hospitals, closure of colostomy

in, 338-341, 342, 358, 370

Oxygen:

administration of:

during anesthesia, 68, 69, 74, 182, 185

in chest surgery, 60

in morphine poisoning, 43

in Pentothal Sodium anesthesia, 74

in positive pressure anesthesia, 60

technique of, 39, 43

postoperative use of, 188, 207, 208

supply of, to cells in clostridial myositis, 73

Oxygen deficit in circulatory failure, 128

Oxygen intake, impairment of, as contraindication to Pentothal Sodium anesthesia, 72

Oxygen therapy as component of resuscitation, 5, 63, 127, 186

Packing—-

in retroperitoneal hematoma, 326

in wounds of

iliac veins, 319

kidney, 306

liver, 277-278, 279, 280, 283

pancreas, 287

portal veins, 319

spleen, 294

Pain:

as factor in shock,

caused by use of Thomas splint, 35

control of, 8, 41-52, 77, 188

enhancement of, by trauma of evacuation, 18

euphoric blocking of, 50

frequency of, after wounding, 33, 43-46,

49

in chest, 178

in chest wall, 67

in compound fractures of long bones,

43, 44

in peritoneal contamination, 46

in thoracoabdominal wounds, 178

in wounds of

chest, 12, 43, 44, 45

head, 43, 44

kidney, 303

soft tissues, 43

spleen, 293

Pancreas:

anatomic relation of, to liver, 276

necrosis of, 151

wounds of, 151, 237, 239, 285-289, 327

associated with wounds of

duodenum, 237

kidney, 301

spleen, 293

errors in management of, 288

frequency of, 285

in World War I, 285

lacerating, 169

shock in, 285, 288

Pancreatectomy, 287

Pancreatic blood vessels, wounds of, 289

Pancreatic duct, ligation of, 287

Pancreatic fistula, 288

Pancreaticoduodenal artery, wounds of, 239

Paraldehyde, 47

Paralysis of vasomotor fibers during spinal

anesthesia, 65

Paraplegia, 51, 282, 344

Paravertebral nerve block, 48

Parenchyma of kidney, wounds of, 303,

304, 305, 306, 307

Parenteral fluid therapy:

as cause of pulmonary edema, 205

before operation, 32

in morphine poisoning, 43

postoperative limitation of, 207

Parietes, wounds of, 99

Parotitis, 212

Paroxysmal tachycardia, 297

Pathogenesis of

lower nephron nephrosis, 211, 220

shock, 6, 7-8, 12-13, 18-19, 103, 109,

122-124, 129, 131

thromboembolism, 210

wound dehiscence, 193-195, 196

Paths of missiles, 14-15, 97-101

Pauchet anastomosis in closure of colostomy, 358, 359

Paul-Mikulicz colostomy, 342, 347

Pearl Harbor, 57, 71

Pelvic abscess, 209

in wounds of liver, 282

in wounds of spleen, 297

Pelvis, compound fractures of, 101, 113,

314, 349, 352

Penetrating wounds of

abdominal wall without visceral injuries,

331-333

kidney, 304

liver, 276, 278
INDEX 401

Penetrating wounds of—Continued

pancreas, 286

spleen, 292

Penicillin, 5, 111, 163, 188, 197-201, 215

use of, in—-

clostridial myositis, 210

closure of colostomy, 356, 360, 365,

368, 369, 370

pulmonary complications, 207

thoracoabdominal wounds, 178

wounds of

bladder, 315

colon and rectum, 270, 273, 274

jejuno-ileum, 249

liver, 283

Penrose drains, 277, 280, 305

Pentobarbital Sodium, 47

Pentothal Sodium, 56, 68, 69, 70-74, 182,

184-185

contraindications to, 65, 71, 72-74, 184-

185

deaths from, 71, 72

errors in use of, 71, 74

indications for, 72

induction of ether anesthesia with, 63,

72, 357

limitations of, 65

oral use of, 77

reactions to, 184-185

Peptic ulcer, perforation of, 19, 66

Perforating wounds, 100

caused by blunt trauma, 210

traumatic evisceration through, 174

Perforating wounds of—•

bladder, 210

cecum, 87, 101, 171

colon, 101, 174, 262

colon and rectum, 256, 265, 267

diaphragm, 142, 178, 225, 240

duodenum, 236, 237

gastrointestinal tract, 131

hollow viscera, 119-172, 196, 208, 209, 326

ileum, 156, 163

intestine, 31

jejuno-ileum, 241, 242, 243-244, 245-246, 248

liver, 276 pancreas, 286

rectosigmoid junction, 267-268

rectum, 262

sigmoid, 87

small intestine, 101

spleen, 292

Perforating wounds of—Continued

stomach, 31, 36, 142, 156, 170, 174, 224,

226, 230, 231-233

transverse colon, 138

Perihepatic space, abscess formation in, 277

Perineum, wounds of, 97, 313

Peripheral circulation:

dilatation of, during anesthesia, 42

impairment of, after wounding, 25, 34,46,

76-77

in morphinepoisoning, 42

See also Circulation.

Peristalsis, 177

in visceral injuries caused by blunt

trauma, 331

in wounds of bladder, 313

Peritonealblock, 67 Peritoneal contamination, 6, 46, 104, 120,

126-127, 129, 148, 149, 151, 156, 159,

172, 174, 176, 177, 220

as cause of death, 131

as factor in shock, 6, 20, 103, 109, 119,

131, 219

case fatality rates in, 19

complicated by continuing hemorrhage,

127

in traumatic evisceration, 123

in wounds of

bladder, 314

colon and rectum, 256, 259, 270, 272-

273

kidney, 303

jejuno-ileum, 243-244, 250

liver, 276, 282

pancreas, 286

stomach, 225, 226-227, 231-233

Peritoneal lavage, 212, 249

Peritoneum, closure of, 192

Peritonitis, 135, 136, 196, 198, 200-201,

208, 220

after closure of colostomy, 361, 362

after crushing of colostomy spur, 364

as cause of death in wound dehiscence,

195

as cause of death in wounds of—-

duodenum, 238-239

jejuno-ileum, 251, 252-254

stomach, 227

ureter, 310

associated with colostomy, 345, 347, 368

case fatality rates in, 198-201

in penetrating wounds of abdominal wall

without visceral injuries, 333

in traumatic evisceration, 174
402 GENERAL SURGERY

Plasma—Continued

suggestion for use of, in World War I, 21

Plasma-blood ratio, 19-20, 24-25, 26

Plasma-protein values in—-

burns, 24

shock, 18

Plasma replacement, 4, 5, 19, 22, 23, 26, 27,

30, 122, 124-129

as prophylaxis against wound dehiscence,

196

before closure of colostomy, 356

deterioration of casualty after, 23

in burns, 23-24

Plastic surgery, 344

in closure of colostomy, 359

in sacral fistulas, 353

Pleura, involvement of, in wounds of chest,

70, 77

Pleural cavity, clostridial infection of, 127,

167

Pleural effusion, 48, 151

Pneumonia, 110, 135, 136, 142, 160, 176,

188, 206, 207, 333

after anesthesia, 55, 64

in wounds of—-

colon and rectum, 274

great vessels, 322

jejuno-ileum, 250

pancreas, 288

stomach, 231

Pneumonitis, 220

Pneumoperitoneum, 225

Pneumothrax, 4, 12, 48, 142, 179, 184, 297

in wounds of stomach, 225

Po Valley, 75

Poisoning by overdosage of morpnine,

41-43

Policies of medical management in World

War I,

Polya gastric resection, 230

Polyvalent anti-gas-gangrene serum, 210

Pontocaine, 67, 182

Portable anesthesia apparatus, 59-63, 200

Portal thrombosis, 297

Portal vein;

anatomic relation of, to duodenum, 236, 239

damage to, in wounds of liver, 283

wounds of, 283, 317, 319

Portugal, 54

Position:

at wouding, effect of, 99, 177, 304

changes of, in morphine poisoning, 43

during evacuation, 12

during resuscitation, 35-36

Peritonitis—Continued

in wounds of—-

colon and rectum, 272-273

great vessels, 322

jejuno-ileum, 244

liver, 282

pancreas, 287, 288

spleen, 297, 298

stomach, 231

relation of timelag to case fatality rates

in, 220

See also Chemical peritonitis, Peritoneal

contamination.

Permanent colostomy, 366

Personal equation in interpretation of

statistics, 86

Personnel:

assignment of, in field hospitals, 58

of field hospitals, 10, 82

of fixed hospitals, 10

of 2d Auxiliary Surgical Group, 81

of shock wards, 11-12

Phagocytosis, 55

Pharynx:

blood in, in tracheobronchialwounds, 178

forcing of gastric contents into, 31

wounds of, 12

Phenobarbital Sodium, 47

Phlebothrombosis, 210

Phthalysulfathiazole, 357

Physiologic effects of wounds, 5, 18-19

Physiologic hemostasis in wounds of great

vessels, 322

Physiologic salt solution, use of:

before operation, 32

during operation, 187

with albumin, 31

Pigment nephropathy, See Lower nephron

nephrosis.

Pinpoint pupils in morphine poisoning, 41,

42

Plasma, 21-24, 85

administration of, in battalion aid stations, 9, 124

colloid osmotic pressure of, 29

comparison of, with albumin, 30

errors in concept of, 21-23

excessive administration of, 12, 18

in wounds of colon and rectum, 259-260

limitations of, 6, 21-22, 23, 122, 145

loss of, after wounding, 6, 19, 123

as factor in shock, 123

properties of, 22

quantitative administration of, 19-20

shortages of, 19, 20
INDEX 403

Position—Continued

during transfusion, 27

effect of change of, on blood pressure,

142, 145, 185, 187, 188-189

on operating table, 73, 187 See also special positions.

Positive pressure anesthesia, 56, 60, 183,

184

Posterior drainage in wounds of colon and

rectum, 264, 268

Posterior wounds of abdomen, 99

Post mortem studies in shock, 119-172

Postoperative changes of position, 188, 207

Postoperative complications, 85, 203-212

after closure of—-

colostomy, 360-361

bladder, 315

in wounds of

colon and rectum, 270

duodenum, 237-238

jejunum, 249-251

kidney, 306-307

liver, 282

pancreas, 288

spleen, 297

stomach, 230, 231

of anesthetic origin, 188

Postoperative coughing, 188, 207 Postoperative hemorrhage in wounds of

jejunum, 139

Postoperative laboratory studies, 18

Postoperative limitation of intravenous

fluid, 207

Postoperative management, 188

after closure of colostomy, 360

in field hospitals, 10

Postoperative oxygen therapy, 207

Postoperative responsibility of anesthetists,

188

Postoperative use of morphine, 156, 157

Postoperative vascular insufficiency, 321

Potassium permanganate irrigations of colostomy, 356

Poxdorf, 137, 168

Pre-anesthetic medication, 33, 47, 74, 75-

77, 186

in World War I, 56

Pre-anesthetic use of oxygen, 36-39

Preoperative case fatality rate, 7, 87

Preoperative control of hemorrhage, 34-35

Preoperative emptying of stomach, 36

Preoperative fluid administration, principles of, 32

Preoperative induction of vomiting, 36

Preoperative preparation, 6, 18-21, 22, 23,

26, 28-29, 49-52, 178-179, 185-186

for closure of

colostomy, 343-357

fecal fistula, 352-353

in fixed hospitals, 28-29

in World War I, 56

in wounds of jejuno-ileum, 245

relief of pain in, 32-34

relief of thirst in, 32, 49

restriction of fluid intake in, 31, 49

timing of, 14

*See also Resuscitation.

Preoperative thoracentesis, 179

Preoperative wound management, 34-35

Pressure, control of hemorrhage by, 35

Pressure sores. See Decubitus idcers.

Pressure test in determination of degree of

shock, 15, 17, 25

Prevention of

deformity, 13

shock in compound fractures, 48

Priapism, 325, 326

Principles of

blood replacement, 19, 26

plasma replacement, 19

preoperative fluid administration, 32

relief of pain, 32-34, 87

resuscitation, 6, 17-18

Principles of management—-

of fecal fistulas, 353, 364

of penetrating wounds of abdominal wall

without visceral injuries, 333

of retroperitoneal hematoma, 326, 327

of visceral injuries without penetration

of abdominal wall, 329

of wounds of

colon and rectum, 261

jejuno-ileum, 245

liver, 278, 279

on shock wards, 11-12

Priorities of treatment, 82, 120, 177

Prisoners of war, case fatality rates in, 215

inclusion of, in statistics of 2d Auxiliary

Surgical Group, 83

Procaine hydrochloride, 56, 67, 69, 182, 185

Proctoscopy, 353

Prodromal signs of lower nephron nephrosis,

211

Prognosis, 103, 126, 217

in relation to timelag and multiplicity

factor, 112, 221

in retroperitoneal hematoma, 326

in traumatic evisceration, 176

in wounds of abdomen, 131
404 GENERAL SURGERY

Pulmonary edema—Continued

in wounds of

colon and rectum, 270

great vessels, 322

pancreas, 288

spleen, 297

precipitation of, by intravenous fluid

therapy, 32

Pulmonary embolism, 174, 210-211, 220,

230, 333

in retroperitoneal hematoma, 327

in wounds of

great vessels, 321, 322

jejuno-ileum, 254

ureter, 310

Pulmonary ventilation, effect of nerve

block on, 48

Pulse:

as criterion of readiness for operation, 19

during Pentothal Sodium anesthesia, 74

effect of albumin and plasma on, 30

effect of evacuation on, 18

in retroperitoneal infiltration of blood

about celiac axis, 326

in shock, 4, 15-17, 18, 25, 26, 36, 52, 126

Purple Heart Highway,

Purse-string closure of wounds of stomach, 230

Pyelitis in wounds of bladder, 315

Pyemia, 252

Pyrogenic transfusion reaction, 159

Qualifications of—-

anesthetic personnel, 57-58, 181

officer in charge of shock ward, 11

Quantitative blood replacement, 19-20,

24-26

Quantitative plasma replacement, 19-20, 23

in burns, 24

Quantitative relation between bloodless

and shock, 7-8

Rangers, 82

Rate of administration of

blood, 27-28

oxygen, 39

Ratio of

univisceral to multivisceral wounds, 94

of stomach, 223-224, 227-228

wounds of abdomen to extra-abdominal

wounds, 89

Reactions to

albumin, 31

Pentothal Sodium anesthesia, 184-185

transfusion, 26, 28, 29, 159, 297, 299, 307

Prolongation of timelag, 6, 12-13, 103

effect of, on case fatality rates, 217

relation of, to deaths from peritonitis, 220

Properties of plasma, 22

Prophylactic blood transfusion, 28

Prophylaxis against—-

atelectasis, 188

pulmonary complications, 206-207

wound dehiscence, 195-196

Protection against wounding afforded by spine, 99

from exposure—-

during evacuation, 12

of patient in shock, 15

of skin before closure of colostomy, 356, 357

Protein-high diets, 68

Protein hydrolysate, 212

Prothrombin time determinations, 357, 370

Protocols: abdominal wounds associated

with shock, 131-172

Proximal colostomy, 262, 268

Psychiatrists, 50-51

Psychic shock, 55

Psychologic considerations in—■ closure of colostomy, 356

mission of field hospitals, 82

Psychologic preparation for operation, 34, 49-52

Psychologic reactions to wounding, 17,33,34,49

Psychologic responsibilities of surgeon, 51

Psychologic trauma in local anesthesia, 66

Psychosis, complication of, in wounds of

spleen, 297

Pulmonary blast injuries, 182

Pulmonary complications, 110, 187, 188,

196, 203, 204-207

after anesthesia, 69, 188

as cause of wound dehiscence, 196

as factor in shock, 220

case fatality rates in, 204-206

frequency of, 204-206

in morphine poisoning, 43

in wounds of—•

liver, 282

stomach, 231, 233

prophylaxis against, 206-207

seasonal factors in, 188, 196, 204, 216

Pulmonary edema, 131, 134, 143, 153, 154, 160, 195, 205, 207, 212

as contraindication to Trendelenburg

position, 35

in blast injuries, 182

in visceral injuries without penetration

of abdominal wall, 329
INDEX 405

Reassurance of wmunded casualties, 33, 34

Record of

administration of morphine, 47

details of colostomy, 364

Recorded series of

abdominal ounds, 217-219

wounds of—-

small intestine, 235

stomach, 223, 227

Records, deficiencies of, in forward hospitals, 85, 94, 203

Rectal examination, 177

Rectal temperature, depression of, 36

in shock, 126

Rectosigmoid, wounds of, 267-268, 349

Rectum, wounds of, 255-274, 338, 349

associated with wounds of

bladder, 314

spleen, 293

ureter, 309

case fatality rate in, 291

colostomy in, 365-366

drainage in, 262-264

perforating, 262

retroperitoneal, 340

Recurrence of shock, 127

Reduction of timelag, 19, 103-104

Regional anesthesia, 55, 57, 66-67, 182, 185

in World War I, 55-56

Regional frequency of abdominal wounds,

89-94

Regurgitation after wounding, 31

Relation of—-

case fatality rates to hospital level, 89,

215

casualties to intensity of fighting, 89

size of viscus to wmunding, 92

viscera, alteration of, by posture, 99

Relief of

mental distress as component of resuscitation,

pain, 8, 32-34, 44, 47, 48, 77, 188

principles of, 32-34

thirst before operation, 49

Relocation of colostomy, 346, 367

Removal of clothing in evaluation of casualty in shock, 14-15, 178

Renal damage:

after chloroform anesthesia, 67

due to blood replacement, 28

Renal failure, 211-212. See also Lower

nephron nephrosis.

Renal pedicle, wounds of, 289, 293, 319

Repair of—•

anal sphincter, 365-366

Repair of—Continued

wounds of bladder, 314

Reparative surgery:

blood replacement before, 28-29

in fixed hospitals, 10

indications for prompt performance of, 29

Replacement therapy, 119, 124-129

in World War I, 125-126

in wounds of colon, 370

Resection —■

after colostomy, 339, 349, 359

in wounds of

colon, 362

in Spanish Civil War, 338

colon and rectum, 262, 264, 265

jejuno-ileum, 244, 246-248, 250, 251

liver, 278-279

of cecum, 365

of colon, 368

of stomach, 230

Respiration:

control of, during anesthesia, 56

depression of:

by morphine, 47, 207

during Pentothal Sodium anesthesia,

74

during intracranial surgery, 73

in morphine poisoning, 41, 42

in shock, 48

Respiratory center:

action of barbituates on, 71

action of morphine on, 33

Respiratory mucosa, effect of ether anesthesia on, 69

Respiratory physiology, disturbances of, in

wounds of stomach, 231

Responsibility of anesthetists, 70, 185-186

Resistance to morphine, 42

Rest, effect of, on status of casualties, 18

Restlessness

as emotional reaction to wmunding, 50

associated with hemorrhage, 47, 53

Results of

abdominal surgery in World War I, 337—

338

colostomy, 370

curare anesthesia, 186

Resuscitation, 3-39, 103, 120, 124-129, 131,

186

administration of

drugs in, 39

oxygen in, 36-39, 186

application of

splints in, 34, 35

tourniquets in, 35
406 GENERAL SURGERY

Resuscitation—Continued

blood replacement as chief component of,

4, 5,8

conservation of body heat in, 36

continuation of, during operation, 6, 120,

187, 260

control of hemorrhage in, 35

deaths during, 87

deterioration during, 20, 120, 142

efficiency of, 362

emptying of stomach in, 36

errors in, 3-4, 12, 171

evolution of, 5,

excessive use of plasma in, 18

failures of, 6, 20, 126-129, 138, 148, 149,

221

in battalion aid stations,

in field hospitals, 10, 82

in thoracoabdominal wounds, 178-179

in wounds of

colon and rectum, 257, 259-260, 271

kidney, 304

individual necessities for, 13-14

morphinepoisoning after, 41

objectives of, 6, 8, 16-17, 20, 120

operation as component of, 6-7, 8, 14, 18-21, 22. 120, 145

plasma replacement in, 4,

position of casualty during, 35-36

principles of, 6, 17-18, 87

relief of

mental distress in, pain in,

secondary shock after, 20

spiritual care as component of, 51-52

timing of, 6, 14, 20

unnecessary elevation of blood pressure

in, 23

warming of casualties during, 36, 42

See also Special measures.

Retention sutures, 192, 194-195, 196

Retraction of colostomy loops, 347, 367

Retrograde pyelography, 304

Retroperitoneal abscess, 133

Retroperitoneal cellulitis, 273, 327, 333

in wounds of bladder, 315

in wounds of liver, 282

Retroperitoneal hematoma, 95, 153, 171,

193, 325-327

in wounds of kidney, 303

Retroperitoneal hemorrhage, 169, 310, 313

Retroperitoneal infection, 119, 322

Retroperitoneal perforation of colon, 306

Retroperitoneal space:

clostridial infection of, 209

contamination of, 177, 256, 305

Retroperitoneal wounds, 177

of cecum, 321

of colon, 321

Revision of colostomy, 340, 346, 367

Rhodes General Hospital, 342, 358

Rib fragments as secondary missiles, 331

Rifle wounds, 100

Rigidity in wounds of bladder, 313

Risks of

administration of dextrose solution, 32

administration of physiologic salt solution, 32

anticoagulant drugs, 210-211

application of tourniquets, 35

chloroform anesthesia, 67-68, 184

drainage in closure of colostomy, 360

intravenous anesthesia with barbiturates,

70-71

packing in wounds of kidney, 306

Pentothal Sodium anesthesia, 184-185

repeated transfusions,

spur crushing after colostomy, 364-365

spinal anesthesia, 65

transfusion, 26

in World War I, 21

Riva, 83

Roentgenologic examination, 100. 177

after closure of colostomy, 360

before closure of colostomy, 357

in pulmonary complications, 204

in thoracoabdominal wounds, 178

in wounds of

bladder, 314

duodenum, 236

kidney, 302

stomach, 225-226

under field conditions, 225

Rotation of loops in spur colostomy, 365

Rotation of personnel on shock wards, 11-

12

Rothenbepg, Capt. Joseph G., 131

Rouen, 54

Routine of

administration of morphine, 46-47

first aid, inspection during evacuation, 13

penicillin therapy, 197

Rupture—-

caused by blunt trauma, 331

of intraperitoneal viscera, 101

of wound. See Wound dehiscence.
INDEX 407

Sacral colostomy, 342, 346, 365-366

Sacral fistulas, 351, 352-353, 364

Sacral region, traumatic evisceration

through, 173

Sacrum, compound fractures of, 163

St. Avoid, 134, 147

Salivation, 69

Scalp, wounds of, 55

Scrotum, pain in, in wounds of kidney, 303

Scultetus binder, 196

Sealing off of perforating wounds of

jejuno-ileum, 243

stomach, 227

Seasonal factors, effect of, on

death rates, 200, 201, 216, 283

pulmonary complications, 188, 196, 204

Second Service Command, 342

Secondary anemia in burns, 24

Secondary closure of colostomy, 346, 361,

363-364, 366

Secondary hemorrhage, 22, 210

after closure of colostomy, 361

after sulfonamide therapy, 370

in wounds of

bladder, 315

colon and rectum, 270, 273

kidney, 307

liver, 276-277, 278, 281, 282-283

pancreas, 288

spleen, 297

stomach, 210, 228, 230

Secondary missiles, 101

Secondary shock

after resuscitation, 20

in burns, 24

Secondary surgery in fistulas of jejunoileum, 251

Secondary wound closure, 195

Sedation by barbiturates, 50

Segmental resection in wounds of kidney,

306

Selection of—•

anesthetic agents, 53, 57

patients for surgery, 15

Sensitization of carotid reflexes, 72

Sensorium in shock, 127

Sepsis, 213

as cause of wound dehiscence, 196

blood replacement in, 29

in sacral fistulas, 352

in wounds of

colon, in World War I, 338

kidney, 306

Serbia, 54

Serum amylase test, 287

Serum protein determination before closure

of colostomy, 357

Seventh U. S. Army, 82, 83, 94

Severity of wounds, effect of, on case

fatality rates, 104-105

Shell fragments as cause of traumatic

evisceration, 174

Shell shock, 51

Shock, 16, 181, 208

administration of barbiturates in, 48-49

after anesthesia, 188

in World War I, 53, 54

apathy in, 15

as cause of death, 51, 131, 188, 208, 213, 219-220, 221

in wound dehiscence, 195

in wounds of

duodenum, 238-239

jejuno-ileum, 252-254

stomach, 227, 228, 231-233

as contraindication to

nitrous oxide anesthesia, 185

Pentothal Sodium anesthesia, 72, 184

use of morphine, 48

blood pressure in, 4, 25, 26, 126

cardiac output in, 22

cardiovascular instability in, 185

case fatality rate in,

classification of, 15-18, 121, 215

in wounds of stomach, 231

color of mucous membranes in, 25

color of skin in, 126

coma in, 15, 127

concept of, 7-8, 16

criteria of, 17

in World War I, 17

cyanosis in, 126

cyclopropane anesthesia in, 68

decrease of circulating hemoglobin in, 38

definition of, depression of respiration in, 48

deterioration of casualties in, 16-17, 103

diagnosis of, 15-16

effect of, on blood volume, 5, 8, 18, 38

effect of, on peripheral circulation, 25, 46

effectiveness of barbiturates in, 48-49

emotional factors in, 6, 12, 17

frequency of, 5, 130

hematocrit level in, 18, 22

hemodilution in, 18, 22, 38, 55

hemoglobin deficit in, 5, 18, 22, 55

in clostridial myositis, 73

in combined thoracic-gastrointestinal

wounds, 123

in retroperitoneal hematoma, 327
408 GENERAL SURGERY

Shock—Continued

in traumatic evisceration, 174

in visceral injuries caused by blunt

trauma, 331

in wounds of—-

colon and rectum, 259-260, 271-273

duodenum, 238-239

great vessels, 322, 323

kidney, 303, 304

liver, 282, 283

pancreas, 285, 288

spleen, 293, 297, 298

stomach, 225, 226

ureter, 309, 310

influence of multiplicity factor in, 109,

110

laboratory tests in, 18

management of, 5, 8, 18, 49, 119-172

morphinepoisoning in, 41-43

nausea and vomiting in, 17

operation of physiologic forces in,

organic damage in, 14, 20

outmoded theories of,

pathogenesis of, 6, 7-8, 12-13, 18-19,

103, 109, 122-124, 131

plasma-blood ratios in, 26

plasma-protein values in, 18

pressure test in, 25

prevention of, in compound fractures, 48

pulse in, 4, 25, 26, 126

rectal temperature in, 126

recurrence of, 127

relation of case fatalityrates to, 215

relation of, to lower nephron nephrosis,

211,220

sensoriumin, 127

skin temperature in, 17, 23, 25, 26, 126

statistics of, 5, 17

sweating in, 17

thirst in, 25, 49

toxic theory of, 127-128

trend of blood pressure in, 18, 25, 26

trend of pulse in, 18, 25, 26

use of albumin in, 29-31

vasomotor system in, 187

venous fillingin, 126

wounds of abdomen associated with, ISO172

Shock, effect of

anesthesia in, 54, 55, 69

anoxia in,

character of combat in, 12

climatic conditions in, 12, 130

fluid deficits in, 12, 48

nutritional deficits in, 181

Shock, effect of—Continued

plasma replacement in, 22

terrain in, 12, 13

timelag in, 5, 103

Shock, factors in:

absorption from devitalized tissue,

blast injuries, 220

blood loss, 6, 17, 20, 25, 103, 109, 119,

120, 122-124, 131, 219

cardiorespiratory disturbances, 103, 119,

220

character of wound, 17, 25

dehydration, 6, 31

delayed evacuation, 17

evacuation, 6, 14

exhaustion, 6, 17

exposure, 12, 17, 18, 181

fluid losses, 6, 12, 48

gastrointestinal disturbances, 103

head injuries, 220

loss of plasma, 123

pain,

peritoneal contamination, 6, 20, 103, 109, 119, 131, 219

pulmonary complications, 220

tactical situation, 130

terrain, 130

timelag, 12-13, 25

tissue destruction, 109

trauma of evacuation, 18

Shock Team No. 6, 2d Auxiliary Surgical

Group, 130

Shock teams, 6, 185

Shock wards, 10-12

evaluation of status of casualties in,

13-18

Shortages of

anesthetists, 57

blood, 19

experienced medical officers, 13

plasma, 19

psychiatrists, 50

Short-circuiting operations in closure of

fecal fistulas, 352

Shoulder, wounds of, 178

Shoulder pain, 178, 293

Sicily, 12, 70, 81, 82

Side-to-side anastomosis, 262, 359

Sigmoid, wounds of, 87, 107, 264, 267-268,

293

Sigmoid colostomy, 363

Sinus formation associated with colostomy,

347

Site of election for amputation, 35

Sixth Service Command, 342
INDEX 409

Size of missile, effect of, on wounds, 99

Size of viscus, relation of, to wounding, 92

Size of wounds, 97

Skin:

digestion of, in small-bowel fistulas, 352

irritation of, from sulfonamide therapy,

369

protection of, before closure of colostomy, 356

Skin grafts in closure of fecal fistulas, 353

Skin temperature in—-

clostridial myositis, 73

shock, 17, 19, 23, 25, 26, 30, 126

Small arms, wounds caused by, 97, 174, 241,

302, 313

Small intestine:

blood supply of, 244

fistulas of, 194, 265, 351

resections of, 239

traumatic evisceration of, 173, 176

wounds of, 210, 223, 228, 273-274, 331,

344

associated with wounds of

colon, 365

kidneys, 301

spleen, 293, 296

stomach, 228

ureter, 309

dehiscence in, 193

in World War I, 235

lethality of, 235

perforating, 101

S-mines, 101

Sodium Amytal, 33, 49

Soft tissues, wounds of, 211, 229, 252, 286, 293

Solid viscera, wounds of, 101, 257-259

lethality of, 95, 217

Sources of blood in Mediterranean theater,

25

Southern France, 43, 75, 81, 216

Space of Retzius, drainage of, 315

Spanish Civil War, 87, 285, 293, 325, 338

Special studies:

abdominal wounds associated with shock,

130-172

anesthetic practices, 70, 71, 72, 78

barbiturates, 70-71

blood and plasma, 24-25

comparison of albumin and plasma, 30

hemoglobin and hematocrit levels, 38

pain in wounded men, 43-46

plasma, 21

quantitative blood replacement, 25-26

Special studies—Continued

shock,

spinal anesthesia, 65-66

survey of anesthesia, 71, 72

timing of operation, 19-20

Spermatic artery, anatomic relation of, to

duodenum, 239

Spinal anesthesia, 57, 65-66, 70, 184, 185, 357

in World War I, 54, 55

Spinal cord, wounds of, 212, 229

associated with wounds of—-

liver, 282, 283

pancreas, 286

spleen, 293

stomach, 229

Spinal meningitis, 212, 297, 299

Spine:

protection by, in wounding, 99

wounds of, 101

Spiritual care of wounded men, 51-52

Splanchnic capillary bed, changes in, after

wounding, 123

Spleen:

fragmentation of, 302

wounds of, 101, 122, 223, 224, 228,

291-299, 331

associated injuries in, 293, 297, 298

associated with wounds of

pancreas, 286

stomach, 228

ureter, 309

case fatality rates in, 228

dehiscence in, 193

frequency of, 291

in World War I, 291, 292, 293, 294,

297, 298

lacerating, 142, 151

multivisceral, 291, 292-293, 298

shock in, 293, 297, 298

univisceral, 291, 293, 299

Splenectomy, 151, 239, 294-297

Splenic flexure, wounds of, 293, 337

Splenic pedicle, wounds of, 289, 292, 297

Splinting:

after wounding, 9, 12, 34, 35

errors in, 12

Spontaneous hemostasis in wounds of liver,

276, 278

Spur colostomy, 135, 262, 264, 267, 342,

352, 362, 363, 367

Spur crushing after colostomy, 358, 359,

364, 365

Sputum examination, 204

378327°—5G 28
410 GENERAL SURGERY

Stab wound, colostomy through, 366

Stability of albumin, 29

Stabilization of casualties for operation,

18-21

Stagnation of tracheobronchial secretions,

110

Station hospitals, 10, 28-29

surgical load of, 58

See also Fixed hospitals.

Statistics:

abdominal injuries, 81-333

amnesia in shock, 17

anesthetic-connected deaths, 188-189

associated wounds, 113-117

case fatality rates

according to causative missiles, 97

according to hospital level, 110

in anesthesia, 78

in clostridial infections, 274

in peritonitis, 198-201

with traumatic evisceration, 174

in shock, 126, 215

with traumatic evisceration, 174

in wound dehiscences, 193, 195

in wounds of great vessels of abdomen,

289

with prompt surgery, 19, 20

classification of shock, 121

clostridial infection, 209, 274

closure of colostomy, 341-343, 357-358, 362

curare, 186

deaths during bronchoscopy, 189

discrepancies in, 81, 94-95

duration of intracranial surgery, 73

duration of major operations, 8-9

effect of timelag on case fatality rates,

103-105

evisceration in wounds of jejuno-ileum,

244

field hospitals,

frequency of

techniques of closure, 192-193

types of anesthesia, 70, 71, 72, 182, 183, 184, 185

types of incisions, 191-192

gastrointestinal fistula, 209

interpretation of, 86

intestinal obstruction, 250-251

intraperitoneal abscess, 209

location of wounds, 97-99

lower nephron nephrosis, 211

management of wound dehiscence, 195

methods of analysis of, 81-86

1943 series, 83

Statistics—Continued

multiplicity factor and timelag in abdominal injuries, 8-10, 105-111, 112

penetrating wounds of abdominal wall

without visceral injuries, 331-333

penicillin therapy, 197, 198-201

perforations of diaphragm, 178

plasma and blood replacement, 19-20

postoperative sepsis, 213

postoperative wound infection, 209

pulmonary complications, 110, 204-206

retroperitoneal hematoma, 325-327

2d Auxiliary Surgical Group, 81-333

secondary hemorrhage, 210, 228, 230

shock, 5, 119

thoracoabdominal wounds, 83, 89, 215

thromboembolism, 210

time and causes of death, 219-221

time of death in multivisceral wounds,

110

time of death in uni visceral wounds, 109

timelag, 19, 103-105, 181, 122

timing of operation, 20-21

transdiaphragmatic incision in wounds of

spleen, 295

transfusion reactions, 28

traumatic evisceration, 173-176

wound dehiscences, 193-195

wounds of

bladder, 313-316

chest, 70

colon and rectum, 255-274

duodenum, 235-240

entry and exit, 97

extrahepatic biliary tract, 275, 283-284

great vessels of abdomen, 317-324

Jejuno-ileum, 241-254

kidney, 301-307

liver, 275-284

pancreas, 285-289

spleen, 291-299

stomach, 223-233

ureter, 309-311

See also Deaths, Case fatality rates,

Special studies.

Stereoscopy in wounds of kidney, 304

Sterilization of transfusion equipment, 28

Sternal transfusion, 187

Stimulating drugs, 39

Stimulation of respiration during ether

anesthesia, 42

Stomach:

anatomic relation of, to

great vessels, 232

liver, 276
INDEX 411

Stomach—Continued

anatomy of, 232-233

dilatation of, 36, 167

during oxygen therapy, 39

emptying time of, after wounding, 31

evisceration of, 224

fistulas of, 169, 194, 227

hemorrhage from, in wounds of spleen,

297, 299

herniation of, into chest, 299

intubation of, in morphine poisoning, 43

preoperative aspiration of, 31, 36, 178

resection of, 230

wounds of, 223-233, 293, 296, 297

associated injuries in, 227

associated with extra-abdominal injuries, 229

associated with head injuries, 229

associated with wounds of—-

colon, 228

great vessels, 228

heart, 229

liver, 228

pancreas, 286

small intestine, 228

spleen, 228, 293, 296, 297

ureter, 309

case fatality rates in, 223, 226, 227,

228, 229, 230, 231-233

case history, 226, 230

causes of death in, 227-228, 229, 230

dehiscence in, 193

diagnosis of, 224-226

frequency of, 223, 224

incision in, 229

influence of multiplicity factor in, Hill2, 227-228

lacerating, 224, 227, 233

lethality of, 227, 233

missiles causing, 226, 227

multivisceral, 223-224, 227, 228, 231

nature of, 226-227

operations for, 229-231

perforating, 31, 36, 142, 156, 170, 174, 224, 226, 230, 231-233

pneumoperitoneum in, 225

postoperative complications of, 230,

231

pulmonary complications of, 231

recorded series of, 223

roentgenologic examination in, 225

secondaryhemorrhage in, 210, 228, 230

shock in, 225, 226, 227, 228, 231-233

technique of operation in, 229-231

timelag in, 227-228

Stomach—Continued wounds of—continued

time of death in, 227- 228, 231

transecting, 227, 230

univisceral, 111, 223-224, 227-228, 231

vomiting in, 224-225

Stomach wall, lacerating wounds of, 226

Stone operation, 354

Storage of gas anesthetics, 68

Streptococcic infection, 164

Streptomycin, 360, 369, 370

Stress of operation, 8-9

Subcapsular dissection in wounds of kidney,

303

Subcapsular hematoma of spleen, 292

Subcommittee on Thoracic Surgery of Committee on Surgery, National Research

Council, 60

Subhepatic abscess, 209, 282

Subhepatic space, drainage of, in wounds

of liver, 278, 280

Submarines, use of albumin in, 31

Subphrenic abscess, 209

in wounds of

bladder, 315

colon and rectum, 270

liver, 280, 282

spleen, 297

Subphrenic pleurocutaneous fistula, 281

Subserosal hematoma, 256

Sucking wounds of chest, 9, 12

Sulfadiazine, 197

Sulfadiazine therapy in—-

clostridial myositis, 210

pulmonary complications, 207

wounds of colon and rectum, 270

Sulfaguanidine, 357, 369

Sulfasuxidine, 357, 368, 369

bleeding after use of, 361

Sulfathalidine, 368, 369

Sulfonamide pills, use of, after wounding,

85

Sulfonamide reactions, 133, 165

Sulfonamide therapy, 188, 196-201, 357,

360

in fecal fistulas, 353

in wounds of

bladder, 315

colon and rectum, 273, 274

jejuno-ileum, 249

liver, 283

Superior mesentery artery, wounds of, 319

Support of wound, relief of pain by, 48

Surgeon:

administration of anesthesia by, 57, 66
412 GENERAL SURGERY

Surgeon—Continued

preoperative examination by, 179

psychologic responsibilities of, 51

responsibility of, in thoracoabdominal

wounds, 179

Surgeon, Mediterranean (North African)

theater, 5, 46, 81, 340

Surgeon General, The, 83

report of 2dAuxiliary Surgical Group to, 81

Surgeon General’s Office in World War I, 53

Surgery, concept of, 87, 213, 277. See also

Operation.

Surgical load

as factor in prolongation of timelag, 103

at various hospital levels, 89

of hospitals:

evacuation, 58, 110

field, 110

forward, 58, 69, 215

general, 58

station, 58

Surgical practices, evolution of, 3-4

Surgical teams, function of,

Surgical technicians, 2d Auxiliary Surgical

Group, 81

Survival of casualties for surgery in forward hospitals, 94, 117, 221, 224, 236,

257, 285, 303, 322

Suture material, 192, 194-195, 306, 360

Suture repair of wounds of

colon, 340

liver, 277, 280

pancreas, 287

spleen, 294

stomach, 230

ureter, 310

vena cava, 318, 319, 321, 322

Sweat, fluid loss in, 6, 43, 48

Sweatingafter administration of morphine, 33

during rapid warming, 36

in shock, 17

Swelling in compound fractures, 48

Sympathectomy, 321

Table of organization 8-571, 2d Auxiliary

Surgical Group, 81

Tactical situation;

as factor in shock, 130

effect of:

on death rate, 200

on evacuation, 82, 85, 95, 196, 203

in wounds of colon and rectum, 273

Tangential cecostomy, 262, 342, 358, 362,

364, 365

Tanks, manic personnel in, 68

Tatum, W. L., 21

Technical considerations in closure of

colostomy, 357-358, 364

Technical errors in creation of colostomy,

352

Technique(s) of

accomplishing diversion of fecal stream,

362-363

anastomosis in wounds of jejuno-ileum,

246-247

anesthesia, 53, 54, 56, 66, 74, 182-185

application of tourniquet, 35

closure of fecal fistulas, 252-254

colostomy, 261-264, 339-340, 342-343,

358-360

drainage in wounds of liver, 280

dressing in wounds of kidneys, 306

operations on

colon, 261-264

duodenum, 237

jejuno-ileum, 245-249

stomach, 229-231

ureter, 310

oxygen administration, 39, 43

tracheobronchial suction, 179

transfusion, 26-28

transdiaphragmatic approach in wounds

of spleen, 296-297

wound closure, 192-193, 194-195

See also special techniques.

Tenderness in—-

peritonitis, 198

visceral injuries caused by blunt trauma,

331

wounds of

bladder, 313

kidney, 303

spleen, 293

Terrain:

as factor in shock, 12, 13, 130

effect of, on death rate, 200

Thigh, wounds of, 135, 313, 314

Thirst:

after wounding, 49

in shock, 15-17, 25, 49

preoperative relief of, 32, 49

Thomas splint, 35

Thoracentesis, 179, 188, 205

Thoracic aorta, wounds of, 203

Thoracic surgical teams, 215

Thoracoabdominal wounds, 83, 113, 119,

141, 143, 156, 157, 178, 179, 181, 184,

205, 207, 215

case fatality rates in, 223
INDEX 413

Thoracoabdominal wounds—Continued diagnosis of, 177-178

frequency of, 89, 223, 291

leakage of gas from, 225

resuscitation in, 178-179

statistics of, 70

with involvement of

jejuno-ileurn, 241, 244

kidneys, 301, 304

liver, 278

pancreas, 286

spleen, 291, 292, 295, 297

stomach, 223, 229

without visceral injuries, 331-333

Thoracolaparotomy, 278, 280

Thoracotomy, duration of, 8,

Thoracotomy incision, exploration through

178

Thromboembolism, 210-211

Thrombophlebitis, 210, 345, 361

Thrombosis in wounds of jejuno-ileurn, 243,

319, 321, 350

Through-and-through retention sutures,

195

Time of appearance of intestinal obstruction in wounds of jejuno-ileum, 250

Time of death, 126, 219-221

from anesthesia, 188

in multivisceral wounds, 110

in peritonitis, 198

in shock, 208

in univisceral wounds, 109-110

in traumatic evisceration, 174, 175, 176

in wounds of

bladder, 314

duodenum, 238-239

jejuno-ileum, 253

kidney, 307

pancreas, 288

stomach, 227-228, 231

Time of fistula formation in wounds of

jejuno-ileum, 251

Time of wound dehiscence, 193

Timelag, 84, 85, 103-112, 148, 149, 181

as factor in shock, 5, 12-13, 25, 103

between initial and reparative surgery,

29

effect of, in peritoneal comtamination, 19

effect of prolongation of,

in perforations of hollow viscera, 122

in traumatic evisceration, 174-176

in wounds

of colon and rectum, 256-259, 340

of jejuno-ileum, 244, 251-252, 254

of kidney, 304

Timelag—Continued

in wounds —continued

of liver, 283

of stomach, 227-228

on Anzio beachhead, 25-26

influence of, on case fatality rates, 103-

105, 200, 217

reduction of, 13, 19-21, 103-104

relation of, to—-

deaths in peritonitis, 220

lethality of wound, 127

multiplicity factor, 105-112, 221

pulmonary complications, 220

undue prolongation of, 12-13

Timing of

blood replacement,

closure of colostomy, 355-356

evacuation, 203

neurossurgery, 344

operation, 6-7, 10, 11, 19-20

in thoracoabdominal wounds, 179

in wounds of colon and rectum, 260

plastic surgery, 344

preopterative preparation, 14

resuscitation, 6, 20

Topical anesthesia, 67, 182

for bronchoscopy, 77

Tourniquets, application of:

in battalion aid station,

in morphine poisoning, 43, 47

technique of, 35

Toxic absorption from devitalized tissue,

Toxic theory of shock, 127-128

Toxicity

from absorption from devitalized tissue,

from peritoneal contamination,

in clostridial myositis, 73

of local anesthetics, 67

Tracheitis, 216

Tracheobronchial secretions, stagnation of,

110

Tracheobronchial suction, 77, 207, 274

in thoracoabdominal wounds, 178-179

Tracheobronchitis, 188

Traffic accidents as cause of visceral injuries, 241, 292, 331

Training in anesthesia, 57-58

Training schools, Army Medical Department, 81

Transabdominal incision in wounds of

kidney, 305

Transdiaphragmatic incision in—-

penetrating wounds of abdominal wall

without visceral injuries, 333
414 GENERAL SURGERY

Transdiaphragmatic incision in—Con. wounds of

kidney, 305

liver, 278

pancreas, 287-288

spleen, 295-297

stomach, 229

Transecting wounds of

colon and rectum, 256

duodenum, 236, 237, 238, 239

inferior vena cava, 303

jejuno-ileum, 242, 243, 244

pancreas, 286

stomach, 227, 230

Transfusion:

failure of, in persistent hemorrhage,

reactions to, 26, 28, 29, 159, 297, 299, 307 risks of multiple repetition of, technique of, 26-28

See also Blood replacement.

Transfusion equipment, errors in preparation of, 28

Transperitoneal incision in wounds of

kidney, 305

Transplantation of ureter, 310

Transportability of albumin, 29

Transportation of casualties, errors in, 12

Transverse colon (colostomy in), 342, 346,

347, 363, 364, 365, 366

wounds of, 107, 264, 266, 337

associated with wounds of spleen, 293 lacerating, 169

perforating, 135, 138

Trauma:

inefficiency of vasoconstricting drugs

after, 65

of evacuation, 18, 203

Traumatic amputation, 35

Traumatic evisceration, 123, 160, 173-176

Treatment:

objectives of, in forward installations, priorities of, 82, 120

See also Management, Techniques, special methods.

Trend of

blood pressure in shock, 15-16, 18, 25, 26

pulse in shock, 15-16, 18, 25, 26

Triage, 10, 11, 120, 181. See also Classification.

Tube colostomy, 262, 342, 358, 362

Tuhy, J. E., 110

Tunica fibrosa, 303

Tunisia, 21, 22, 24, 25, 35, 46, 82, 340

Types of missiles causing abdominal

wounds, 92, 97-101

Undigested food in wound, diagnostic of

gastric injury, 224

Universal donor blood, limitations of, 146

Univisceral wounds, 92, 217, 327

definition of, 87

of bladder, 313, 315

of colon, 86, 87

of colon and rectum, 270, 271

of great vessels of abdomen, 318, 319

of jejuno-ileum, 241, 244, 251-254

of kidneys, 301, 304

of pancreas, 285, 288

of small intestine, 235, 236, 239

of spleen, 291, 293, 299

of stomach, 111, 223, 224, 227-228, 231

of ureter, 309, 310-311

pulmonary complications of, 110

ratio of multivisceral wounds to, 94

time of death in, 109-110

Uremia, after transfusion, 28

Uremia. See also,Lower nephron nephrosis

Ureter:

anatomic relation of, to colon and

rectum, 256

ligation of, 310

pain in, in wounds of kidney, 303

wounds of, 309-311, 327

associated with wounds of kidney, 301

diagnosis of, 309

in World War I, 309

Ureteroanastomosis, 310

Urethra, wounds of, 349

Urinalysis, 178

Urinary calculi, 353

Urinary fistulas, 212, 307, 340, 351, 353-354

in wounds of bladder, 313, 314, 315

Urinary tract, wounds of, 327

Urticaria, 28, 31

Vagal reflexes, 36, 74, 75

Vagovagal reflex, 189, 288, 299

Variations in case fatality rates, 110-111

Vascular constriction as protecting mechanism in shock, 56

Vascular surgery, duration of,

Vasoconstricting drugs, 39, 65, 67, 187

Vasodilatation during ether anesthesia, 42, 77

Vasomotor fibers, paralysis of, in spinal

anesthesia, 65

Vasomotor system in shock, 187

Vaughan, Maj. J. W., 125

Veins: collapse of, after wounding, 47

of abdomen, wounds of, 317-324
INDEX 415

Velocity of missiles, 99, 100, 101, 124, 243,

303, 329

Vena cava: anatomic relation of, to

duodenum, 236, 239

liver, 276

stomach, 232

wounds of, 94, 317, 318-319, 321, 322

associated with wounds of

kidneys, 303

pancreas, 285, 288

Venafro, 18, 19, 43

Venous filling in shock, 126

Ventricular fibrillation, 67, 68

Vertebrae, fractures of, 171

Vertical incisions, 191-192, 229

Vesicorectal fistula, 212

Vinyl ether anesthesia, 69

Viscera:

effect of posture of casualty on wounds

of, 99

intraperitoneal rupture of, 101, 329-330

Visceral blood supply, wounds of, 318, 319

Visceral injuries—-

associated with wounds of great vessels

of abdomen, 317-324

caused by blunt trauma (blast), 331, 332

See also injuries of special organs,

Viscus, relation of size of, to wounding, 92

Vitamin determinations, 357

Vitamin therapy as prophylaxis against

wound dehiscence, 196

Vitamin therapy, 357, 360, 370

Vitamin therapy, 356

Volturno River, 18, 41

Volvulus of ileum, 251

Vomiting:

after administration of morphine, 33

as cause of wound dehiscence, 194

in morphine poisoning, 42

in peritonitis, 198

in shock, 17

in wounds of stomach, 224-225

precipitation of, by fluid intake, 31

preoperative induction of, 36

Vomitus:

aspiration of, 31, 67, 77, 198

blood in, 225

fluid losses in, 6, 31, 43, 48, 123

Walking wounded, morphine contraindicated in, 47

Wallace, Cuthbert S., 235, 276, 277,

337, 338

Walter Reed General Hospital, 354

Wangensteen, O. H., 196, 208, 209, 360, 361

War of the Rebellion, Ward, Capt. Gordon R., 21

Wanning in resuscitation, 42

Welch, C. S., 110

Western Desert, 110, 291, 297, 339

Western Reserve University Unit, 53

Wet lung, 6, 205, 207

World War I:

abdominal surgery in, 87, 213

anesthesia in, 53-56

blood replacement in, 55

case fatalityrate of wounds of chest in, 60

colostomy in, 337-338

concept of resuscitation in,

criteria of shock in, 17

duration of operations in,

lower nephron nephrosis in, 220

nerve block in, 55

policies of medical management in,

replacement therapy in, 125-126

suggestion for use of plasma in, 21

duodenum in, 238

jejuno-ileum in, 249

kidney in, 301

liver in, 276-277, 282, 283

pancreas in, 285

small intestine in, 235

spleen in, 291, 292, 293, 294, 297, 298

Wound dehiscence, 112, 191-196, 203, 209

after closure of colostomy, 345, 347, 361

in clostridial myosities, 209

in wounds of

bladder, 315

jejuno-ileum, 251

Wound infection, 203, 209

after colostomy, 345, 347

in wounds of—-

bladder, 315

colon and rectum, 270

spleen, 297

Wounding agents, 14-15, 83, 92, 97-101,

173-174, 226-227, 236, 241, 242, 243,

245, 251, 279, 283, 291, 292, 293, 302, 303, 313, 314, 329, 331-333

Wounds:

about hips, 97, 313

case fatality rates in, 85-86, 94-95, 97,

110, 103-105, 113, 114-117, 173-176

character of:

as factor in shock, 17, 25, 61

in relation of character of missiles, 99

compound fractures associated with

113-114
416 GENERAL SURGERY

Wounds—-Continued

diagnosis of, 177-178

drainage of, 193

frequency of, 89-94

lethality of, 105, 129, 175, 220

local fluid loss from, 7, 19, 123, 129

location of, 97-99

management of, in field hospitals, 82

nonsurgical case fatality rates in, 87

pain in, 43, 44, 45

preoperative management of, 34-35

prognosis of, 103, 131, 217

relation of timelag to lethality of, 127

relation of type of, to case fatality rate,

215

relief of pain by support of, 48

size of, 97

Wounds of

abdominal aorta, 94

abdominal parietes, 99, 177, 181

abdominal viscera, classification of, 86

adrenal glands, 292

appendix, 265

ascending colon, 264, 265-266, 329, 337

axilla, 313

back, 313

bladder, 193, 210, 293, 301, 309, 327,

313-316, 349

blood vessels, 94, 107, 122, 259, 285,

286, 289, 293, 309, 310, 315, 317, 319.

320, 324

buttocks, 14, 97, 133

cecum, 87, 107, 171, 329, 337, 350

chest, 31, 36, 43, 44, 45, 47, 48, 50, 69,

70, 72, 178, 204, 207, 252, 283, 329, 331

colon, 86, 88, 101, 174, 193, 223, 224,

228, 236, 255-274, 286, 293, 296, 297,

306, 310, 315, 327, 331

colon and rectum, 255-274

common bile duct, 288

descending colon, 264, 265, 267, 293

diaphragm, 142, 193, 240, 331

duodenal blood supply, 289

duodenum, 235-240, 286, 293, 309, 327

entry and exit, 97-99, 174, 177, 226, 236

esophagus, 36

estraperitoneal viscera, 83

extremities, 13, 35, 210

flanks, 99, 313

gallbladder, 275, 283-284, 293

gastric artery, 319

gastrointestinal tract, 131

genitourinary tract, 223

gluteal region, 122, 154, 178

Wounds of—Continued great vessels of abdomen, 309, 317-324,

325, 326, 327, 329, 333

head, 12, 17, 32, 35, 41, 43, 44, 47, 54,

55, 73, 74, 211, 225, 252, 282, 283

heart, 252, 283

hepatic artery, 319

hollow viscera, 95, 119-172, 177, 193,

196, 208, 209, 217, 257

ileum, 88, 107, 156, 251-252, 315

intestine, 31, 313, 315

jejuno-ileum, 86, 241-254, 286

jejunum, 107, 293, 315

kidney, 101, 193, 224, 236, 286, 301-

307, 309, 325, 331

large intestine, 309

liver, 101, 141, 193, 211, 223, 224, 228, 236, 237, 275-284, 286, 293, 297, 309

lumbar artery, 289

lungs, 32, 211, 225, 283, 331

major blood vessels, 285

mesentery, 331

neck, 72, 225

pancreas, 237, 239, 285-289, 293, 301, 327

pancreatic blood vessels, 289

perineum, 97, 313

pharynx, 12

portal vein, 317, 319

rectosigmoid, 349

rectum, 255-274, 293, 309, 314, 338, 349

365-366

renal pedicle, 289, 319

renal vessels, 303

retroperitoneal space, 177

scalp, 55

shoulder, 178

sigmoid, 87, 107, 264, 267-268, 293

small intestine, 101, 193, 222, 228, 235-

241, 273-274, 293, 296, 301, 309, 331,

344, 365

soft tissues, 43, 211, 286

solid viscera, 95, 101, 217, 257-259

special organs, lethality of, 217

spinal cord, 212, 229, 282, 283, 286, 293

spine, 101

spleen, 101, 122, 193, 223, 224, 228, 286, 291-299, 309, 331

splenic flexure, 293, 337

splenic pedicle, 289, 292, 297

stomach, 31, 36, 111-112, 142, 156, 170,

174, 193, 210, 223-233, 286, 293, 296,

297, 309

superior mesenteric artery, 319
INDEX 417

Wounds of—Continued thigh, 313, 314

transverse colon, 107, 138, 264-266, 293,

337

ureter, 301, 309-311, 327

urethra, 349

urinary tract, 327

vena cava, 94, 285, 288, 303, 317, 318-

319, 322

Wounds of—Continued visceral blood supply, 318, 319

Young, H. H., 301

Zone of Interior:

colostomy in hospitals of, 341-370

upper respiratory infections in, 204

use of albumin in hospitals of, 29

U. S. GOVERNMENT PRINTING OFFICE. 1956

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