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Preface

Contents

Preface

On 3 September 1944, the Commanding General, North African Theater of Operations, appointed a Medical Board to Study the Treatment of the Severely Wounded, his action following by only two days a recommendation by the Surgeon of that theater that such a board be appointed. Appendix A includes the Surgeon's communication and the order appointing the Board, together with data concerning its organization and operation.

Each of the authors of this volume was a member of the Board as formally established. Before that time several of us had been interested individually in various aspects of the physiologic and pathologic changes in the severely wounded, and the chapters of this volume include our observations both as members of the Board and as individual investigators. The background against which the study was undertaken is described fully in the Introduction.

At the time this study began, our attention was focused in considerable part on anuria in the wounded. This interest continued, but it early became apparent that to limit ourselves to the study of anuria was undesirable and actually impossible. Thus at the end of the work we have found, almost inevitably, that what we have is a kind of physiologic atlas of the severely wounded. In producing it we have followed the trend that medicine as a whole has taken: Probably there are few new things to be learned in studies of gross morphology, but certainly much remains to be found in the domain of function. So too it may be with the wounds of battle. They have already been accurately described in terms of structural loss, but there are great deficiencies in our knowledge of the effects of wounds on the function of organs. If this study has contributed in a useful way toward filling these gaps, our effort will have been justified.

The several chapters of this volume have been written by the member or members of the Board responsible for those particular phases of the investigation. The aim has been to present factual observations, with a minimum of essential supplementary remarks to orient the reader. We have, there-

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fore, in most instances deliberately avoided detailed discussion of the data. Many of the findings were provocative to us, and we hope they will be to others; in any event the mass of data accumulated in this battlefront study provides a basis for contemplation and further work. From these data the reader who may differ with our views can construct his own and perhaps more accurate interpretations and conclusions.

For those who have not had a similar experience, it may be difficult to judge which things caused trouble during the course of the work and which were not important. Of real importance were the winds that blew some tents down, split others, upset stoves, knocked bottles off shelves, and stirred up endless clouds of dust that swirled around our hilltop at Monghidoro and invaded the laboratory. The rain and mud were unpleasant but not of real consequence until the dampness began to interfere with the spectrophotometer. When we were up in the Apennines, water froze and the cold at night caused solutions to alter and saturated solutions to crystallize out. Troublesome as these things were, they were overcome either by waiting until the environmental conditions had improved, or by the ingenuity of our technicians.

Supplies and equipment needed for our studies were for the most part delivered promptly and in adequate quantity but occasionally delays in arrival of items influenced the progress of our observations. In only two instances was absence of supplies of material consequence. We never succeeded in obtaining equipment to make desired oxygen determinations, and materials for renal clearance studies arrived so late that only a few cases could be studied.

Although the spectacular "artificial moonlight" produced by great floodlights reflected from clouds lighted up the out-of-doors at night and was much used in the months of the Northern Apennines Campaign, we never escaped from the necessity of working in blacked-out tents, and in poorly lighted tents it was easy to overlook cyanosis or icterus.

The major consideration at all times was that our studies must not delay or otherwise interfere with the treatment of the wounded soldier. The necessity of not interfering with the therapy due the wounded man was important. The patient's good came first; it was trying but necessary sometimes to let observations go, knowing that an unfortunate shortcoming would be present in the case under study. During periods of heavy action, when the cases best suited for study were coming in, the man covering the shock tent needed all the maneuvering skill of a combat pilot to keep out of the way of those

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responsible for the care of the wounded man. At times he failed, all of us failed, to get the observations needed for completeness.

Sometimes a patient would be accessible to us for only a few hours and then would be evacuated to the rear, never to be seen again. Most of the patients were followed into the postoperative period, but some were evacuated at, for our purposes, their most enlightening stage, or sometimes, because of the tactical situation, we were obliged to move forward or back and leave them.

We realize that those accustomed to working in the atmosphere of leisure and with the laboratory facilities of peacetime can find much to criticize here. We had to get what we could when we could, and record it "on the go." Our observations are published as recorded at the time and without later attempt to identify and compare individual cases in all the various aspects of the study. It will be readily appreciated that identical data could not be obtained on all cases. We present the results without apology. Moreover, we believe that what we were able to do indicates the soundness of our attempt to study the wounded in the line of combat where they fell.

Finally, we are bound to acknowledge the extraordinary spirit of the newly wounded, those with whom we dealt. They did all they could to help us in this work.

                        HENRY K. BEECHER, M.D.
                        (Formerly Consultant in Resuscitation and Anesthesia, North African-Mediterranean Theater of Operations)

Boston, Massachusetts
23 February 1952

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