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Contents

Books and Documents

Contents

FRONTMATTER

CONTRIBUTORS

FOREWORD

PREFACE

ACKNOWLEDGMENTS

Part I

RESUSCITATION, CONTROL OF PAIN, AND ANESTHESIA

I. Resuscitation of Men Severely Wounded in Battle
The Evolution of Methods of Resuscitation in the Mediterranean Theater
General Considerations of Resuscitation
Chain of Evacuation
Preoperative (Shock) Wards
Shock: Predisposing and Precipitating Factors
Appraisal of the Wounded Man
Stabilization Versus Rapid Preparation of Battle Casualties for Surgery
Plasma
Whole Blood
Albumin
Other Fluid Replacement Therapy
Other Resuscitative Measures

II. The Control of Pain in Men Wounded in Battle
Morphine Overdosage and Poisoning
Investigation of Pain in Wounded Men
Relief of Pain
Thirst
Psychologic Preparation for Operation

III. Anesthesia for Men Wounded in Battle

Historical Note
Military Considerations of Anesthesia
Personnel
Equipment
Anesthetic Agents
Pre-Anesthetic Medication
Endotracheal Intubation and Bronchoscopy
Anesthetic Deaths

Part II

ABDOMINAL INJURIES AND THE INITIAL SURGERY OF ABDOMINAL WOUNDS

IV. Derivation of Data, Source Material, and Methods of Analysis
The 2d Auxiliary Surgical Group
Source Material
Methods of Analysis
Limitations of the Analysis
The Concept of Abdominal Surgery in World War II
Definition of Terms

V. Distribution of Injuries and Other Statistical Data
Distribution of Injuries
Case Fatality Rates

VI. Wounding Agents

VII. Timelag and the Multiplicity Factor in Abdominal Injuries
Multiplicity Factor
Limitations of the Multiplicity Factor

VIII. Associated (Extra-Abdominal) Wounds (1,089 Casualties)
Multiplicity Factor

IX. Shock Therapy (957 Casualties)
Classification of Shock
Timelag and Character of Wound
Role of Hemorrhage and Other Fluid Losses in Pathogenesis of Shock
Replacement Therapy
The Total Picture of Shock in World War II
A Clinicopathologic Study of Abdominal Wounds Associated With Shock

X. Traumatic Evisceration (312 Casualties)
Case Fatality Rate in Relation to Shock and Peritonitis
Case Fatality Rate in Relation to Multiplicity Factor and Timelag

XI. Diagnosis and Preoperative Routine
Diagnosis
Preoperative Routine

XII. Anesthesia
Status of Casualties
Agents and Methods
Preoperative Management
Management During Operation
Postoperative Complications of Anesthetic Origin
Anesthetic-Connected Deaths

XIII. Laparotomy Incisions and Closures, and Wound Dehiscences
Incisions
Closures
Wound Dehiscences

XIV. Penicillin and Sulfonamide Therapy (2,410 Casualties)
Methods of Administration
Case Fatality Rates

XV. Postoperative Complications: Prophylaxis and Therapy
Pulmonary Complications
Nonpulmonary Complications

XVI. Factors of Mortality
General Considerations
Special Factors of Mortality
Time and Cause of Death
Ultimate Causes of Death

XVII. Wounds of the Stomach (416 Casualties)
Diagnostic Considerations
Nature of the Injury
Technical Considerations
Postoperative Complications
Time and Causes of Death

XVIII. Wounds of the Duodenum (118 Casualties)
Diagnostic Considerations
Nature of the Injury
Technical Considerations
Postoperative Complications
Time and Causes of Death

XIX. Wounds of the Jejunum and Ileum (1,168 Casualties)
Nature of Injury
Diagnosis
Preoperative Routine
Treatment
Postoperative Complications
Univisceral Wounds

XX. Wounds of the Colon and Rectum (1,222 Casualties)
Nature of the Lesion
Time and the Multiplicity Factor
Shock
Treatment
Regional Injuries
Postoperative Complications
Case Fatality Rates
Causes of Death

XXI. Wounds of the Liver and of the Extrahepatic Biliary Tract (829 Casualties)
Nature of Injury
Evolution of Methods of Management
Treatment
Postoperative Complications
Case Fatality Rates and Factors of Mortality
Wounds of the Extrahepatic Biliary Tract

XXII. Wounds of the Pancreas (62 Casualties)
Nature of Injury
Multiple and Associated Injuries
Clinical Findings
Treatment
Postoperative Complications
Case Fatality Rates and Factors of Mortality

XXIII. Wounds of the Spleen (341 Casualties)
Nature of Injury
Clinical Considerations
Treatment
Postoperative Complications
Case Fatality Rates

XXIV. Wounds of the Kidney (427 Casualties)
Anatomic Considerations
Nature of the Injury
Clinical Considerations
Diagnosis
Treatment
Postoperative Management
Postoperative Complications
Factors of Mortality

XXV. Wounds of the Ureter (27 Casualties)
Diagnosis
Treatment
Factors of Mortality

XXVI. Wounds of the Urinary Bladder (155 Casualties)
Nature of the Injury
Clinical Considerations
Treatment
Postoperative Complications
Factors of Mortality

XXVII. Wounds of the Great Vessels of the Abdomen (75 Casualties)
Injuries to the Major Veins
Injuries to the Major Arteries
Postoperative Vascular Insufficiency
Factors of Mortality

XXVIII. Retroperitoneal Hematoma (207 Casualties)
Clinical Considerations
Treatment
Factors of Mortality

XXIX. Special Types of Abdominal Injury
Visceral Injuries Without Penetration of the Peritoneal Layer of the Abdominal Wall
Visceral Injuries Caused by Blunt Trauma and Blast
Penetrating (Perforating) Wounds of the Abdominal Wall Without Visceral Injuries

Part III

COLOSTOMY

XXX. The Management of Colostomies
Historical Note
Colostomy in Overseas Hospitals
Colostomy in Zone of Interior Hospitals
Comment
Summary

AFTERWORD

Tables

1. Relationship of degree of shock and average blood loss in 67 patients with all types of wounds
2. Analysis of pain sensation in 215 freshly wounded patients with major injuries
3. Provision of anesthetic personnel in sample evacuation, general, and station hospitals in Mediterranean theater
4. Sample distribution of surgical procedures in Mediterranean (North African) campaigns (1943-44)
5. Distribution of injuries and deaths in 3,154 abdominal injuries by hospital in stallation
6. Regional distribution of wounds and deaths in 3,154 abdominal injuries
7. Distribution of univisceral and multivisceral wounds in 3,154 abdominal injuries
8. Comparative percentages of univisceral and multivisceral injuries in various recorded series of abdominal wounds
9. Timelag, multiplicity factor, and case fatality rates in 2,926 abdominal injuries
10. Multiplicity factor and case fatality rates in wounds of various viscera
11. Multiplicity factor and case fatality rates in various recorded series of abdominal injuries
12. Associated wounds in 2,315 abdominal injuries, with case fatality rates
13. Distribution according to type of 1,403 individual associated wounds in 1,089 casualties with abdominal injuries
14. Distribution of 659 major fractures (pelvis, femur, and humerus) in 1,403 associated injuries
15. Case fatality rates in 527 abdominal injuries complicated by 1 associated injury
16.Case fatality rates in 299 abdominal injuries complicated by 2 associated injuries
17.Case fatality rates in 142 abdominal injuries complicated by 3 associated injuries
18.Replacement therapy in relation to degree of shock in 957 traumatic gastrointestinal perforations
19.Distribution of wounds and deaths in 312 traumatic eviscerations
20.Primary cause of death and time of death in 94 traumatic eviscerations
21.Combined influence of evisceration and multiplicity factor on case fatality rates in 3,129 abdominal injuries
22.Timelag and case fatality rates in 203 traumatic eviscerations
23.Anesthetic agents used in 3,154 abdominal injuries
24.Techniques of anesthesia in 3,154 abdominal injuries
25.Abdominal incisions and wound dehiscences in 2,258 abdominal injuries
26.Wound dehiscences in relation to techniques of closure in 2,258 abdominal injuries
27.Wound dehiscences in relation to techniques of retention suturing in 2,121 abdominal injuries
28.Comparative case fatality rates from peritonitis in 2,410 abdominal injuries
29.Antibacterial therapy and case fatality rates in 1,526 abdominal injuries
30.Antibacterial therapy and case fatality rates in 2,410 abdominal injuries
31.Pulmonary complications in 3,090 abdominal injuries
32.Multiplicity factor and infectious thoracopulmonary complications in 2,831abdominal injuries
33.Primary causes of death according to time of death in 737 abdominal injuries
34.Injuries and deaths according to age in 3,154 abdominal injuries
35.Seasonal distribution of cases and deaths in 2,332 abdominal injuries
36.Case fatality rates according to viscus wounded in 3,154 abdominal injuries
37.Case fatality rates of visceral wounds in various recorded series of abdominal injuries
38.Essential data in 416 gastric wounds
39.Comparative distribution of gastric wounds in various recorded series of abdominal injuries
40.Case fatality rates in relation to type of injury in 416 gastric wounds
41.Multiplicity factor and case fatality rates in 416 gastric wounds
42.Case fatality rates in gastric wounds complicated by other visceral wounds
43.Surgical approaches in 412 gastric wounds
44.Primary cause of death in relation to time of death in 169 gastric wounds
45.Essential data in 118 duodenal wounds
46.Site and type of injury in 112 duodenal wounds
47.Primary cause of death and time of death in 67 duodenal injuries
48.Degree of shock and case fatality rates in 114 duodenal wounds
49.Multiplicity factor and case fatality rates in 118 duodenal wounds
50.Essential data in 1,168 jejuno-ileal wounds
51.Frequency of various types of injury in 1,168 jejuno-ileal wounds
52.Comparative results of anastomotic and suture repair in 1,117 jejuno-ileal wounds
53.Comparative case fatality rates of resection with various techniques of anastomosis in 428 jejuno-ileal wounds
54.Causes of death in 31primarily fatal jejuno-ileal wounds
55.Essential data in 1,222 wounds of colon and rectum
56.Case fatality rates in 191 thoracoabdominal injuries involving the colon
57.Timelag and case fatality rates in 1,222 wounds of colon and rectum
58.Timelag, multiplicity factor, and case fatality rates in 1,155 injuries of colon and rectum
59.Degree of shock, timelag, and case fatality rates in 1,140 injuries of colon and rectum
60.Blood and plasma replacement in wounds of colon and rectum
61.Location of injury, type of operation, and case fatality rates in 1,222 wounds of colon and rectum
62.Technique and case fatality rates in 273 wounds of ascending colon
63.Technique and case fatality rates in 414 wounds of transverse colon
64.Technique and case fatality rates in 119 wounds of descending colon
65.Technique and case fatality rates in 154 wounds of sigmoid colon
66.Technique and case fatality rates in 116 wounds of extraperitoneal rectum
67.Technique and case fatality rates in 32 wounds of ascending and transverse colon
68.Technique and case fatality rates in 9 wounds of ascending and descending colon
69.Technique and case fatality rates in 48 wounds of transverse and descending colon
70.Technique and case fatality rates in 39 combined wounds of colon and rectum
71.Site of injury and case fatality rates in 328 univisceral wounds of colon and rectum
72.Primary causes of death in 397 injuries of colon and rectum
73.Essential data in 829 hepatic wounds
74.Surgical approaches in 432 hepatic wounds
75.Percentage distribution of operations in 695 hepatic wounds
76.Essential data in 62 pancreatic wounds
77.Multiplicity factor and case fatality rates in 62 pancreatic wounds
78.Influence of specific additional organs wounded on case fatality rates in 61 multivisceral pancreatic wounds
79.Essential data in 341 splenic wounds
80.Degree of shock, types of wound, and case fatality rates in 319 splenic wounds
81.Methods of treatment in 340 splenic wounds
82.Surgical approaches in 337 splenic wounds
83.Primary cause of death and time of death in 67 fatalities following splenectomy
84.Essential data in 427 renal wounds
85.Comparative distribution of renal wounds in various recorded series of abdominal injuries
86.Essential data in 155 wounds of urinary bladder
87.Influence of wounds of intestinal tract on case fatality rates in 155 wounds of urinary bladder
88.Primary cause of death and time of death in 42 wounds of urinary bladder
89.Essential data in 75 wounds of major abdominal vessels
90.Type of injury and case fatality rates in 75 wounds of major abdominal vessels
91Essential data in 33 vena caval injuries
92.Essential data in 13 injuries of major abdominal arteries
93.Essential data in 9 combined injuries of major abdominal arteries and veins
94.Degree of shock and case fatality rates in 69 wounds of major abdominal vessels
95.Multiplicity factor and case fatality rates in 67 wounds of major abdominal vessels
96.Essential data in 12 injuries of intraperitoneal viscera without penetration of peritoneal layer of abdominal wall
97.Essential data in 14 intra-abdominal injuries caused by blunt trauma and external blast
98.Closure of colostomy and associated operations in 464 battle-incurred wounds of large bowel

Illustrations

1. Early care of wounded man in forward hospital. Removal of all clothing
2. Administration of plasma to wounded man
3. Elevation of foot of litter of wounded man
4. Sedation (barbiturate) and administration of morphine
5. Spiritual care of wounded man
6. Emptying of stomach of wounded man
7. Administration of artificial respiration to wounded man
8. Transportable anesthetic apparatus
9. Transportable anesthetic apparatus
10.Administration of ether in simplified closed system
11.Administration of ether with oxygen in simplified closed system
12.Administration of Pentothal Sodium anesthesia
13.Administration of Pentothal Sodium anesthesia with oxygen
14.Summary sheet for collection of data on abdominal injuries
15.Distribution in relation to intensity of combat of 3,154 abdominal injuries (Text)
16.Proportional distribution, by branch of service, of 2,137 abdominal injuries
17.Distribution of causative missiles in 3,052 abdominal injuries
18.Anatomic distribution of wounds of entry in 2,586 abdominal injuries
19.Possible effect of position on track of missiles and resulting visceral injuries
20. Influence of timelag in 2,863 abdominal injuries
21. Multiplicity factor and case fatality rates in 3,129 abdominal injuries
22. Multiplicity factor and case fatality rates in various combinations of abdominal wounds
23. Multiplicity factor and associated injuries in 3,154 abdominal injuries
24. Multiplicity factor and gravity of associated injuries in 3,154 abdominal injuries
25. Average replacement therapy in relation to degree of shock in 957 gastrointestinal perforations
26. Resuscitation tent in field hospital in Italy, winter, 1944-45
27. Wounds of entry in 118 duodenal injuries
28. Types of colostomy
29. Types of colostomy
30. Types of colostomy
31. Exteriorization of damaged sigmoid
32. Right-sided colostomy
33. Fecal fistula into extraperitoneal rectosigmoid
34. Double stoma in transverse colon, with complete division of bowel
35. Resection for injuries of descending colon
36. Lumbar colostomy
37. Excessive protrusion of transverse colon and mucosal eventration with incomplete division of bowel
38. Sigmoid colostomy
39. Revision of sigmoid colostomy
40. Left inguinal colostomy
41. Resection for injuries of descending colon
42. Proximal colostomy in descending colon for wounds of rectosigmoid
43. Proximal colostomy in transverse colon for wounds of rectosigmoid
44. Exteriorization of damaged sigmoid colon
45. Right-sided colostomy