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Chapter 4

Contents

Part II

ABDOMINAL INJURIES AND THE INITIAL SURGERY OF ABDOMINAL WOUNDS

W. Philip Giddings, M. D., Editor


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.1 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 a rule, each team consisted of 6 members; namely, a surgeon, an assistant surgeon, an anesthetist, an operating-room nurse, and 2 enlisted technicians.

Except for a 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

1 Forward Surgery of the Severely Wounded. A History of the 2d Auxiliary Surgical Group, 1942-45, vols. I and II.


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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 a 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 nontransportable.

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 1945.2 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 4 months of the fighting

2Unless specifically noted to the contrary, the terms "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 cases or patients unless otherwise specified.


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in Italy. These cases are the subject of previous reports3 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 1 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 a 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 a great deal could be done until after the German surrender, in May of the following year. Intensive work was started in June 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,4 of which the section on abdominal injuries represents about a 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, a 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.

3Report on the Surgery of Abdominal Wounds (unpublished data), submitted to the commanding officer, 2d Auxiliary Surgical Group, 14 April 1944.
4See footnote 1, p. 81.


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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 a complete revision made in the United States. The original worksheets were reviewed, all the data were subjected to recount and careful review, and revised data were thus secured for a number of sections, including those on timelag and the multiplicity factor. The entire manuscript was then rewritten, many sections


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several times, to incorporate these revisions and to give the authors the opportunity to introduce whatever second thoughts had occurred to them in a 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 1 to 30, the usual period of hospitalization was from 8 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 a variety of reasons. Some patients were evacuated as a consequence of enemy action. When, for example, a 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


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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 a 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, a 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 jejuno-ileum, this type of injury is included as a 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 a single perforation of the colon and a severe contusion of the ileum, listed the case as an instance of a univisceral wound of the colon. The authors of the section on wounds of the jejuno-ileum classified the same case as a multivisceral wound of the ileum complicated by a 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.


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THE CONCEPT OF ABDOMINAL SURGERY IN WORLD WAR II

The concept of management of abdominal wounds underwent a radical reversal in the years before World War II.5 Between the Boer War (the South African War of 1899-1902) and the outbreak of World War I in 1914, the policy was one of strict nonintervention. The wisdom of this policy began to be questioned by many surgeons as World War I 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,6 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 1 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. A 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 a 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 a univisceral wound of the colon.

2. The term "multivisceral" refers to a wound in which more than one viscus has been injured, again without any implications concerning the number

5Bailey, Hamilton: Surgery of Modern Warfare. Baltimore: the Williams and Wilkins Co., 1944, vol. II, pp. 867-869.
6Jolly, Douglas W.: Field Surgery in Total War. New York: Paul B. Hoeber, Inc., 1941, p. 166.


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of injuries each single organ has sustained. Coincidental injury to the colon and the ileum, for instance, is regarded as a multivisceral wound of either the colon or the ileum.

3. The term "associated wound" refers to a wound of a part of the body other than the abdomen.

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