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Chapter 5

Contents

CHAPTER V

Distribution of Injuries and Other Statistical Data

Luther H. Wolff, M. D., Samuel B. Childs, M. D., and W. Philip Giddings, M. D.

DISTRIBUTION OF INJURIES

The statistical material used in this study is heavily weighted by a preponderance of first-priority casualties. About 90 percent of the 3,154 casualties were operated on in field 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

Type of installation

Number of cases

Percent of total

Deaths

Case fatality rate

Field hospital

2,851

90.4

693

24.3

Evacuation hospital

232

7.4

35

15.1

Casualty clearing station (British)

58

1.8

26

44.8

Clearing station

10

.3

1

10.0

Not stated

3

.1

1

33.3

Total

3,154

100.0

756

24.0


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.


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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.

FIGURE 15.-Text


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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

Type of wound

Year

Cases

Deaths

Case fatality rate

Abdominal

1944

1,744

406

23.3

Thoracoabdominal

1944

639

180

28.2

Abdominal

1945

571

130

22.8

Thoracoabdominal

1945

200

40

20.0

Total abdominal wounds

1944-45

2,315

536

23.2

Total thoracoabdominal wounds

1944-45

839

220

26.2

Total

---

3,154

756

24.0


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Analysis of these 3,154 abdominal injuries from the standpoint of the particular viscera involved (tables 7 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 a 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. A 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. A striking example

TABLE 7.-Distribution of univisceral and multivisceral wounds in 3,154 abdominal injuries 1

Organ injured

Univisceral

Multivisceral

Total

Number

Each organ

Number

Each organ

Number2

All patients

 

 


Percent

 

Percent

 

Percent

Stomach

42

10.1

374

89.9

416

13.19

Duodenum

2

1.7

116

98.3

118

3.74

Jejuno-ileum

353

30.2

815

69.8

1,168

37.03

Colon only

251

23.6

816

76.4

1,067

33.83

Rectum only

64

55.2

52

44.8

116

3.68

Colon and rectum

13

33.4

26

66.6

39

1.24

Liver3

339

40.9

490

59.1

829

26.28

Gallbladder and bile ducts

0

0

53

100.0

53

1.68

Pancreas

1

1.6

61

98.4

62

1.97

Spleen

100

29.3

241

70.7

341

10.81

Kidney

56

13.1

371

86.9

427

13.54

Ureter

1

3.7

26

96.3

27

.86

Urinary bladder

21

13.5

134

86.5

155

4.91

Great vessels

8

10.7

67

89.3

75

2.38


1The term "univisceral" refers to an abdominal wound in which a single viscus has been injured. It carries no implication concerning the number of injuries any single organ has sustained. The term "multivisceral" refers to a wound in which more than 1 viscus has been injured, again without any implications concerning the number of injuries each single organ has sustained.
2The 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.
3Calculations for injuries of the liver are made throughout part II of this volume on a total of 3,066 abdominal injuries, instead of on 3,154, the base figure for all other calculations. When the 88 histories which represent the difference between the two totals became available, the medical officers who had done the work on wounds of the liver had already been transferred from the command, and it was thought wiser not to change their tabulations.


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TABLE 8.-Comparative percentages of univisceral and multivisceral injuries in various recorded series of abdominal wounds1


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of such a 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 a 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 multivisceral-univisceral ratio. The higher incidence of involvement of the various viscera in this series also makes it reasonable 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.1

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 1 percent.

1NOTE.-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, where many of these casualties occurred, he not only placed hospitals as far forward as tactically feasible but also demanded and obtained early and efficient medical evacuation under most difficult combat conditions.-J. B. C., Jr.


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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 337 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, a 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, 2 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.

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