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Foreword

Contents

Foreword

This volume on general surgery is set apart from other volumes of the history of the Medical Department of the United States Army in World War II by a number of special considerations.

This is a story not only of surgery performed in forward Army medical units, but of extremely urgent surgery; all abdominal injuries constituted emergencies, and all casualties with abdominal injuries were nontransportable. This volume is also the record of the performance of an auxiliary surgical group, and as such is typical of the outstanding work done in all theaters of operations by the medical officers assigned to similar units, as well as by medical officers organically assigned to frontline hospitals in which surgical teams from auxiliary surgical groups were employed.

The 3,154 abdominal injuries upon which this story is chiefly based were all the result of the violence of war, and all but about a hundred were combat incurred. This is perhaps not the largest series of combat injuries of the abdomen ever to be recorded, but it is undoubtedly the largest series to be analyzed in such detail. This series, furthermore, has the great advantage, which most recorded series do not possess, that the analysis of cases was planned in advance. There are some statistical inadequacies, it is true. They were inevitable in the circumstances in which the data were collected. These inadequacies, however, in no way alter the clinical conclusions which were arrived at by the experienced surgeons who made the analysis and which, incidentally, were merely the confirmation of the clinical impressions which had already become evident. The data were analyzed overseas, immediately after they were collected. They were reanalyzed later, in the more normal environment of the United States, when more sober second thoughts were possible. The analysis is entirely objective. Errors of technique and mistakes of judgment are related as frankly as are surgical triumphs.

At the beginning of World War I, the policy of management of combat-incurred abdominal injuries was one of so-called surgical abstention. As the war progressed, the undesirability of such a policy became more and more evident, and surgical intervention began to be practiced, but for a variety of reasons, including lack of organization, operation was still not the general rule when the war ended. In World War II, as the result of both the previous military experience and the intervening civilian experience, the official policy was to operate, as promptly as possible, on all casualties with abdominal injuries in whom the mere act of operation would not be fatal. Only a small number of patients (considerably less than 1 percent) fell into this category. 

The policy of prompt surgical intervention in abdominal injuries was made practical and possible because of another concept that was new in World War II, the practice of preoperative resuscitation, which is also described in this volume. Many of the fatalities in World War I occurred because the patients


were never in condition to be operated on. In World War II, a small number died while resuscitation was being attempted, but at least the attempt had been made to bring them to a status in which surgery could be tolerated. The liberal use of whole blood was the central feature of resuscitation, but, as Doctor Beecher points out in his account of the program, every detail was important, from the placing of blankets underneath the patient, as well as over him, to the deliberate care with which his position was changed on the operating table. The program of resuscitation, combined with competent anesthesia, permitted surgery of great magnitude on patients whose initial condition was such that in an earlier day they could only have been left to die.

Three extremely important departures from previous medicomilitary practices require specific mention. The first is the management of wounds of the rectum and large bowel by colostomy, with or without exteriorization of the damaged segment. Although colostomy had been an established procedure in civilian surgical practice before World War I, it was used only in desperate cases in that war and was never routine, even when surgical intervention in abdominal injuries had become fairly general. United States Army medical officers used colostomy in the fighting in North Africa in 1942 and 1943 without knowledge of the previous British experience with it. The results were so good that its use became official Medical Department policy in October 1943. The performance of colostomy saved thousands of lives immediately after wounding, and the excellence of the final results is described in the last chapter of this volume, which deals with the repair of colostomy in Zone of Interior hospitals.

Wounds of the liver were never treated surgically in World War I, even after the policy of surgical intervention for abdominal injuries had been introduced. Their management in World War II represents a process of evolution, since the military surgeons who encountered them had no decisive principles to guide them other than the general policy that surgical intervention in abdominal injuries is in the best interests of all patients who survive to reach forward hospitals. Drainage of Morison's pouch, which eventually became established practice, resulted in a considerable salvage of life, as well as in a considerable reduction in both primary and postoperative complications in injuries of the liver.

The transdiaphragmatic approach to thoracoabdominal wounds, of which there were 839 in this series, represents a new practice in military surgery. The cardiorespiratory risks associated with this technique were reduced to a minimum by the ready availability of competent anesthetists and suitable anesthetic equipment. The ease of intimate surgical exploration of the left upper quadrant, in properly selected cases, by way of this incision is evident in the good results achieved in injuries of the spleen, in which, in contrast to World War I practice, splenectomy was the accepted method of management in World War II.

The 333 negative explorations in this series are, in some respects, the most important group of all. One of the outstanding observations in this analysis


was that in not a single instance did a missile pass harmlessly across the general peritoneal cavity in a major diameter. The prompt exploration of every case in which there was any suspicion of penetration of the peritoneal cavity was therefore standard practice and was entirely justified, in view of the minimal mortality associated with exploration and the risks involved in nonsurgical management of penetrating abdominal wounds. These 333 negative explorations may, in a sense, be described as unnecessary emergencies, but they well illustrate the surgical philosophy which directed the management of abdominal injuries in World War II.

I should be derelict if I brought this foreword to a close without specific recognition of the technical competence, sound professional judgment, and surgical courage of the members of the 2d Auxiliary Surgical Group who handled these cases, and without paying tribute also to the indispensable assistance they, like all other military surgeons, received from the anesthetists and the resuscitation teams whose part in the management of abdominal injuries is described in this volume.

S. B. HAYS,
Major General,
The Surgeon General.

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