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Chapter 16

Contents

CHAPTER XVI

Factors of Mortality

W. Philip Giddings, M. D., and Luther H. Wolff, M. D.

The most dreaded complication of abdominal wounds in World War I 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 a prominent cause. When it is recalled, however, that in World War I patients were frequently selected for surgery according to their chances of survival, and that forward hospitals maintained so-called moribund wards1 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 a 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 a 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, a 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, a 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 8 to 14 days, with a range of 1 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).

1The Medical Department of the United States Army in the World War. Washington: U.S. Government Printing Office, 1927, vol. XI, pt. 1, p. 451.


214

TABLE 33.-Distribution of primary causes of death according to time of death in 737 abdominal injuries1

Cause


On operating table

Day of operation


Postoperative day

Total

Proportion of fatal cases

1st

2d

3d

4th

5th

6th

7th

8th

9th

10th

11th


12th and later

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Percent

Shock

83

268

118

3

---

---

---

---

---

---

---

---

---

---

472

64.0

Thoracopulmonary (all)

3

4

5

20

15

14

10

7

8

5

3

---

---

3

97

13.2

Peritonitis

---

---

6

20

13

10

10

6

7

5

4

4

1

5

91

12.3

Anuria

---

---

---

4

9

5

9

2

2

2

1

---

1

---

35

4.8

Anaerobic infection

---

1

1

2

3

1

1

2

---

---

---

1

---

---

12

1.6

Other

---

4

2

2

5

5

2

3

2

---

---

2

---

3

30

4.1


Total

86

277

132

51

45

35

32

20

19

12

8

7

2

11

737

100.0

Proportion (culmulative)

11.7

49.3

67.2

74.1

80.2

84.9

89.3

92.0

91.6

96.2

97.3

98.2

98.5

100.0

 

 


1Nineteen cases in which the data on these points were incomplete are excluded from this table.


215

It is thought that an additional 2 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 a 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 a 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 a 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 a 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 a 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

TABLE 34.-Distribution of injuries and deaths according to age in 3,154 abdominal injuries

Age (years)

Cases

Deaths

Case fatality rate

0 through 20

707

164

23.2

21 through 25

987

202

20.5

26 through 30

591

139

23.5

31 through 35

250

60

24.0

36 through 40

78

21

26.9

Over 40

42

18

42.9

Not stated

499

152

30.5


Total

3,154

756

24.0


Season-It was a repeated clinical observation that casualties received at field hospitals during the cold, wet winter months were likely to be in a 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 a 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 a 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 in

TABLE 35.-Seasonal distribution of cases and deaths in 2,332 abdominal injuries (1944)

Months

Cases

Deaths

Case fatality rate

January-March

430

141

32.8

April-June

470

91

19.4

July-September

503

103

20. 5

October-December

929

232

25.0


Total

2,332

567

24.3

 


217

evitable. A 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 a 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 a single viscus was injured to 100 percent when 6 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 a prolonged timelag. In univisceral injuries, the case fatality rate was 10.1 percent for the first 8 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, a 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.


218

TABLE 36.-Case fatality rates according to viscus wounded in 3,154 abdominal injuries

Organ injured

Univisceral wounds

Multivisceral wounds

Total

Cases

Deaths

Case 
fatality 
rate

Cases

Deaths

Case 
fatality 
rate

Cases

Deaths

Case 
fatality 
rate

Stomach

42

12

28.6

374

157

42.0

416

169

40.6

Duodenum

2

0

0

116

67

57.8

118

67

56.8

Jejuno-ileum

353

49

13.9

815

296

36.3

1,168

345

29.5

Colon only

251

57

22.7

816

329

40.3

1,067

386

36.2

Rectum only

64

9

14.1

52

18

34.6

116

27

23.3

Colon and rectum

13

6

46.2

26

14

53.8

39

20

51.3

Liver

339

33

9.7

490

191

39.0

829

224

27.0

Gallbladder

0

0

(1)

53

16

30.2

53

16

30.2

Pancreas

1

1

100.0

61

34

55.7

62

35

56.5

Spleen

100

12

12.0

241

73

30.3

341

85

24.9

Kidney

56

9

16.1

371

146

39.4

427

155

36.3

Ureter

1

0

0

26

11

42.3

27

11

40.7

Bladder

21

0

0

134

46

34.3

155

46

29.7

Great vessels

8

5

62.5

67

50

74.6

75

55

73.3


Total

1,238

187

15.1

1,916

569

29.7

3,154

756

24.0


1Case fatality rate not applicable.

 


219

TABLE 37.-Case fatality rates of visceral wounds in various recorded series of abdominal injuries1

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 a 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 con-


220

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 shock-producing 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 a 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 a 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 a slight influence on the case fatality rate for the series as a whole.

ULTIMATE CAUSES OF DEATH

The case fatality rate in any series of injuries is a 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.


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 a 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 a wound of given severity affecting a casualty for a 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 a 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 a prolonged timelag, for the reason that, if they did not reach the hospital promptly, they died before they could be brought to it.

A consideration of these facts leads to a 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 a relatively short period (72 hours) after operation. This conclusion is that the combined effects of a severe wound and of a prolonged timelag were likely to be lethal, regardless of the best resuscitative and surgical efforts.

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