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Chapter II

Contents

CHAPTER II

General Considerations of Thoracic Wounds

Frank B. Berry, M.D.

CLASSIFICATION OF CHEST WOUNDS

Wounds of the thorax are divided basically into two groups, (1) non-penetrating wounds of the chest wall, and (2) intrathoracic wounds, which may be either penetrating or perforating. In a penetrating intrathoracic wound, the wounding agent has penetrated into the pleura, and there is no wound of exit. In a perforating wound, the missile has completely traversed a segment of the pleural cavity.

Statistics prepared by the Medical Statistics Division, Office of The Surgeon General, Department of the Army, bear out the clinical impression that penetrating wounds of the chest were several times more frequent in World War II than perforating wounds (table 2).

It was generally agreed by those with experience in the reparative phase of management of thoracic wounds that the perforating type of injury was less likely to be associated with complications than the penetrating type:

1. In the perforating type of wound, there were no retained foreign bodies to invite infection, and the likelihood of immediate threatening symptoms because of gravely disturbed physiology was far less.

2. There was less tissue destruction in bullet wounds, which accounted for a much higher proportion of perforating wounds than did shell fragments.

CHARACTERISTICS OF CHEST WOUNDS

Even chest surgeons with a wide experience in civilian practice had had little or no experience with the type of chest wounds encountered in World War II unless they had also served in World War I, and the number in this category was very small.

The chest injuries with which medical officers had dealt in their pre-Army experience were most often stab wounds or low-velocity bullet wounds of the closed, penetrating type, in which extensive tissue damage, serious cardiovascular disturbances, and infectious sequelae, while they might occur, were not the rule except for the neglected hemothorax, with the resulting fibrothorax. In the 1,187 chest injuries reported by Boland (1) from the Emory University Division, Grady Hospital, Atlanta, Ga., in 1936, empyema and other serious infections occurred in less than 2 percent of all cases. In the 553 cases reported by Elkin (2) from the Emory University Division, Grady Hospital, for the


52-53

Table 2.-Number of admissions for battle injuries and wounds of the thorax and thoracoabdominal region in the U.S. Army, by anatomic site and nature of injury, 19441


54

same year, the rate of infection was 1.4 percent. The same proportion of infections occurred in the 2,091 chest injuries collected by DeBakey (3) from Charity Hospital of Louisiana at New Orleans for the 5-year period ending in 1936, and hemothorax was a factor in only 13.8 percent of the cases.

In combat-incurred wounds of the chest in World War II, this situation was reversed. Tissue and structural damage was extensive and serious because the majority of injuries were caused by shell fragments. Hemothorax occurred in 75 percent or more of all cases. Finally, although infectious complications were far less frequent than in World War I, they were still more frequent than in civilian practice.

WOUNDING AGENTS

Incidence-The tendency to employ wounding agents with greater destructive ability in successive wars is evident from the figures. In the American Civil War, approximately 9 of every 10 wounds were caused by low-velocity bullets and only 1 by high explosive shell fragments (4). In later wars, this ratio was reversed. In World War I, approximately 7 of every 10 wounds were caused by high explosive shells (5). In World War II, the ratio was about eight wounds caused by shell fragments to every two caused by bullets. The implications as to the increased severity and destructiveness of the resulting wounds are clear.

The same situation occurred in chest wounds as in other wounds. In the Civil War, only 12.5 percent of all wounds of the thorax were caused by high explosives. In 1944, the year in which the majority of U.S. Army wounds were sustained, only 5,502 of the 25,064 admissions1 for chest wounds were reportedly caused by bullets from rifles, machineguns, and other similar weapons (table 3). A like proportion was maintained for the entire war (table 4).

Case fatality rates.-There was a striking difference in both World Wars in the case fatality rates of bullet wounds and wounds resulting from high explosive shells. In World War I, among 20,662 wounds in U.S. troops caused by rifle and pistol bullets and involving all areas of the body, the case fatality rate was 4.7 percent, compared to a rate of 7.2 percent in 52,106 wounds caused by shell fragments. The respective case fatality rates in wounds of the chest were 31.9 percent and 46.6 percent (5, 6).

Similar differences in the case fatality rate were evident in World War II, as is shown in tables 5 and 6. In 1944, for instance, 663 of the 2,010 deaths occurred in 5,502 wounds caused by bullets, while 1,120 occurred in the 16,841 wounds produced by exploding shells, tables 3 and 5.

1The Medical Statistics Division, Office of The Surgeon General, Department of the Army, defines wound admissions as instances in which a wound was reported as the primary cause for the patient's being hospitalized for medical treatment or otherwise treated in an excused-from-duty status. In the tables used in this chapter and prepared by this Division, such variables as the causative agent, the nature of the traumatism, and its anatomic location pertain to the admission diagnosis.


55

Table 3.-Number of admissions1 for battle injuries and wounds of the thorax in the U.S. Army in 1944, by causative agent and theater2

[Preliminary data based on tabulations of individual medical records]

Causative agent

Outside continental United States3

Europe

Mediterranean

China-Burma-
India

Southwest Pacific

Central and South Pacific

Number

Number

Number

Number

Number

Number

Bomb and bomb fragments

544

315

110

2

107

10

Shell, shell fragments, and flak

16,841

12,494

3,515

61

493

274

Bullet, machinegun, rifle, etc.

5,502

3,914

681

58

584

262

Landmine, boobytrap

518

329

163

2

13

11

Grenade and grenade fragments

478

261

91

9

69

48

Explosion of ammunition, weapons, etc.

107

59

30

---

10

8

War gases, screening smoke, incendiaries

23

17

1

1

1

3

Firearms, mechanism or effects of discharge of

47

41

4

---

2

---

Aircraft, excluding aircraft weapons

155

100

21

6

21

7

Parachute jump

60

42

11

2

5

---

Boat sinking and accident

49

33

7

---

4

3

Tank, tractor, caisson

40

32

7

---

1

---

Motor vehicle, passenger and cargo

64

54

9

---

---

1

Vehicle, other and unspecified

16

12

4

---

---

---

Cutting or piercing instruments

31

18

---

1

10

2

Fire, hot liquid, or objects

9

5

2

---

1

1

Fall or jump, twisting, turning, lifting, slipping, etc.

220

131

66

1

17

5

Other and unspecified

360

240

61

2

40

17

Total

25,064

18,097

4,783

145

1,378

652


1 Excludes cases carded for record only.
2There were no records of admissions for injuries or wounds of the thorax during 1944 in the Middle East, North America, or Latin America.
3Includes 9 admissions aboard transports.

Characteristics of bullet and shell-fragment wounds-The different characteristics of the two types of wounds offer some explanation of the different mortality rates. Bullet wounds have the following general characteristics:

1. They are likely to be sharply localized penetrating wounds or simple through-and-through wounds, with a small puncture point of entry and a somewhat larger exit. This is especially true of wounds produced by bullets from small-caliber arms. When the wound is simply penetrating, the bullet obviously has lost most of its velocity. For example, there is the penetrating wound caused by a bullet in the suprasternal notch, in which the bullet had penetrated only the skin, without any damage to the deeper structures.

2. In bullet wounds, tissue contamination and structural damage are likely to be limited and localized. The amount of the damage depends entirely upon the velocity already expended by the bullet. If the bullet is still truly


56

Table 4.-Number of admissions1 for battle injuries and wounds of the thorax2 in the U.S. Army, by causative agent and year, 1942-453

[Preliminary data based on tabulations of individual medical records]

Causative agent

1942-45

1942

1943

1944

1945

Number

Number

Number

Number

Number

Bomb and bomb fragments

873

37

114

544

178

Shell, shell fragments, and flak

27,591

111

1,645

16,841

8,994

Bullet, machinegun, rifle, etc.

10,608

140

545

5,502

4,421

Landmine, boobytrap

1,037

1

123

518

395

Grenade and grenade fragments

987

3

33

478

473

Explosion of ammunition, weapons, etc.

262

5

78

107

72

War gases, screening smoke, incendiaries

39

---

---

23

16

Firearms, mechanism or effects of discharge of

115

1

7

47

60

Aircraft, excluding aircraft weapons

252

3

37

155

57

Parachute jump

102

1

18

60

23

Boat sinking and accident

75

2

17

49

7

Tank, tractor, caisson

78

2

7

40

29

Motor vehicle, passenger and cargo

115

---

13

64

38

Vehicle, other and unspecified

31

---

2

16

13

Cutting or piercing instruments

81

1

11

31

38

Fire, hot liquid, or objects

17

---

1

9

7

Fall or jump, twisting, turning, lifting, slipping, etc.

480

---

31

220

229

Other and unspecified

683

21

109

360

193

Total

43,426

328

2,791

25,064

15,243


1 Excludes cases carded for record only.
2Excludes thoracoabdominal region.
3Includes admissions in December 1941. Excludes cases wounded or injured in action in the Philippine Islands in 1941 and 1942.

in the high-velocity range, it causes the usual explosive damage to the tissues along its path. Because of the differences between tissue and muscle and bone, this damage, of course, varies, and is less for lung tissue. This is well described in the volume on wound ballistics (7).

3. The track of a bullet is long and narrow and is marked by coagulation and searing of the tissues through which the missile passes, together with more or less distant tissue damage depending upon velocity.

4. Cardiorespiratory disturbances occur less frequently in bullet wounds than in the larger wounds so commonly caused by shell fragments. Because of the perforating character of the wound, the wounds of entrance and exit tend to be relatively sealed, so that, barring extensive hemorrhage within the chest, or damage to a larger bronchus with the resulting rapid accumulation of hemothorax or tension pneumothorax, there is less physiologic disturbance.


57

Table 5.-Number of deaths1 among admissions in 1944 for battle injuries and wounds of the thorax in the U.S. Army, by causative agent and theater of admission2

Causative agent

Outside continental United States3

Europe

Mediterranean

China-Burma-
India

Southwest Pacific

Central and South Pacific

Number

Number

Number

Number

Number

Number

Bomb and bomb fragments

40

21

14

---

5

--

Shell, shell fragments, and flak

1,120

840

231

2

32

15

Bullet, machinegun, rifle, etc.

663

457

61

7

92

45

Landmine, boobytrap

41

26

12

---

3

---

Grenade and grenade fragments

10

4

4

---

1

1

Explosion of ammunition, weapons, etc.

3

1

1

---

1

---

Firearms, mechanism or effects of discharge of

1

1

---

---

---

---

Aircraft, excluding aircraft weapons

6

3

1

1

1

---

Tank, tractor, caisson

3

2

---

---

1

---

Vehicle, other and unspecified

2

---

2

---

---

---

Cutting or piercing instruments

2

1

---

---

1

---

Other and unspecified

119

95

13

---

7

4

Total

2,010

1,451

339

10

144

65


1Consists of all admissions which ended in death, not necessarily due to the injury or wound causing admission or necessarily occurring during the year of admission.
2There were no records of admissions for injuries or wounds of the thorax during 1944 in the Middle East, North America, or Latin America.
3Includes 1 death among admissions aboard transports.

Bullet wounds have also certain unfavorable characteristics:

1. Bullets that strike the thoracic cage tangentially or emerge from the chest in an erratic course sometimes produce larger defects in the chest wall than normally expected.

2. Bullets can cause considerable contusion of the structures through which they pass, or, in the case of a high velocity, very superficial wound of the chest wall, which is almost of a searing nature, they might indeed cause a complete reflex temporary dysfunction of the hemithorax, with resulting atelectasis of the underlying lung. The writer personally has seen two such instances.

3. Bullets often traverse greater distances than shell fragments, and their tendency to involve more than one body cavity is conspicuous.

Fragments of high explosive shells, bombs, and mines have the following characteristics:

1. They are likely to produce great destruction of tissue because of their irregular shape, frequently large size, and high spin.

2. When a shell fragment is the causative missile, the wound in the chest wall is likely to be larger, open injuries more frequent, and multiple injuries also more frequent than when a bullet is the wounding agent.


58

Table 6.-Number of admissions and case fatality ratios for battle injuries and wounds of the thorax1 in the U.S. Army, by causative agent, 1942-45M

[Preliminary data based on tabulations of individual medical records]

Causative agent

Admissions2

Admissions resulting in death3

Case fatality ratio

Number

Number

Percent

Bomb and bomb fragments

873

67

7.7

Shell, shell fragments, and flak

27,591

1,880

6.8

Bullet, machinegun, rifle, etc.

10,608

1,316

12.4

Landmine, boobytrap

1,037

100

9.6

Grenade and grenade fragments

987

26

2.6

Explosion of ammunition, weapons, etc.

262

7

2.7

War gases, screening smoke, incendiaries

39

---

---

Firearms, mechanism or effects of discharge of

115

1

.9

Aircraft, excluding aircraft weapons

252

10

4.0

Parachute jump

102

---

---

Boat sinking and accident

75

---

---

Tank, tractor, caisson

78

3

3.8

Motor vehicle, passenger and cargo

115

1

.9

Vehicle, other and unspecified

31

2

6.5

Cutting or piercing instruments

81

4

4.9

Fire, hot liquid, or objects

17

---

---

Fall or jump, twisting, turning, lifting, slipping, etc.

480

1

.2

Other and unspecified

683

195

28.6

Total

43,426

3,613

8.3


1 Excludes thoracoabdominal region.
2Excludes cases carded for record only. Includes admissions in December 1941. Excludes cases wounded or injured in action in the Philippine Islands in 1941 and 1942.
3Consists of all admissions which ended in death, not necessarily due to the injury or wound causing admission or necessarily occurring during the year of admission.

3. As a consequence, hemorrhage, shock, and cardiorespiratory disturbances are more frequent and severe because of the sharply deranged cardiorespiratory physiology.

4. Shell fragments carry into the tissues with them fragments of bone, bits of clothing, and other foreign contaminants. Because of the resulting contamination, the incidence of infection is therefore higher than in wounds caused by bullets.

5. High explosive shell fragments are retained much oftener than bullets. Nicholson's and Scadding's (8) figures are typical. In an analysis of 291 penetrating wounds of the chest treated in British forward installations in the Middle East, they found retained foreign bodies in 91 percent of such wounds but in only 32 percent of the wounds caused by bullets.

6. For these various reasons, open operative intervention is necessary more often in shell-fragment wounds than in bullet wounds. The wounds are frequently difficult to manage, and both morbidity and mortality rates are somewhat higher.


59

VELOCITY OF MISSILES

A careful distinction must be made between high-velocity and low-velocity missiles. The fragments of a shell containing high explosives have an extremely high velocity immediately following the explosion, but this initial velocity is subject to a very rapid decay and so, as a rule, when the missiles strike, they have lost much of their original speed and are well within the low-velocity range. The modern bullet in its effective trajectory range is almost always a high-velocity agent. Two bullets from an automatic weapon that strike the chest in close proximity to each other, for example, are likely to produce much greater damage than the sum of the two injuries if the hits are farther apart.

While the disruptive effect of high-velocity missiles on tissues is far greater than that of low-velocity missiles, it is also proportional (1) to the density of the tissues affected and (2) to whether secondary missiles consisting of bone fragments are developed. Structures of lesser density sustain appreciably less damage than structures of higher density. In this respect, the lung, which is the least dense of all body structures and which, in its totally expanded state, is of little greater density than the atmosphere, is unique. High-velocity missiles that traverse the pulmonary tissue therefore often cause surprisingly little pulmonary damage. The high immediate lethality of high-velocity wounds of the chest is apparently directly related to the percentage chance of damage to vital structures, particularly the heart and great vessels. If the high-velocity missile does not inflict a mortal wound, then it often traverses the chest with considerably less damage to the thoracic contents than is caused by a low-velocity shell fragment.

The type of missile and its inherent velocity are thus the chief determinants of the type of thoracic wound produced. Other determinants include the size and course of the missile (p. 55), the distance of the casualty from its point of origin, and his position when he was wounded (p. 230).

VULNERABILITY OF THE CHEST TO WOUNDING

Definition of chest wounds.-It is regrettable that up to this time there has been no agreement as to exactly what portion of the body constitutes the chest. Without a generally accepted definition, there has naturally been disagreement in the statistics for chest wounds.

Beebe and DeBakey (9) quoted Churchill's demarcation of the surface areas of the body, in which he defines the chest as follows:

* * * On the surface * * * the simplest line is one that approximately follows the lower limits of the pleural cavities. In front, this line passes from the lower end of the sternum obliquely downward along the costal margin to the 8th intercostal space. A horizontal line carried around the body to meet the corresponding point on the other side will pass approximately over the midpoint of the 11th rib and the spine of the first lumbar vertebra. The chest region as described includes the entire circumference of the trunk and is not interrupted posteriorly by a "back" or a "spine".


60

Earlier wars-It is unfortunate that this, or some other, anatomic specification has never come into general use. On the other hand, however the chest may be defined and delimited, it presents a large target area, and it is therefore logical to expect that it would sustain a correspondingly large number of battle wounds. Since it houses vital structures of the first order, it might also be logically expected that these wounds would be followed by a large number of deaths.

In addition to the size of the target which the various areas of the body present, their exposure varies with the special types and circumstances of combat, as well as with the relative degree of protection afforded by the position of the body, the clothing worn, the terrain, the availability of foxholes and trenches, and similar considerations. Any or all of these factors may account for the differences between the actual and expected distribution of body injury.

Modern offensive weapons have a much greater wounding potential, with correspondingly greater lethality, than older weapons. In spite of this, the incidence of combat-incurred injuries of the chest has remained substantially the same in successive wars of the past 100 years (p. 5). It seems reasonable to assume, therefore, that the most important single factor controlling the incidence of chest wounds is, as in all other wounds, the factor of body area exposed. The exhaustive study of wound ballistics made by Col. Ashley W. Oughterson, MC, in the Southwest Pacific Area (10) makes this clear. He and his associates could not accept the aiming of missiles as an explanation of the location of hits.

INCIDENCE AND CASE FATALITY RATES

Hoche's (11) extensive studies of 11,000,000 war wounds in English, French, American, and German casualties in World War I showed that 6 percent were wounds of the chest. Only wounds of the limbs, head, face, and neck exceeded wounds of the chest in frequency. The total case fatality rate was 8 percent. The rate for wounds of the chest was 56 percent, this being second only to the case fatality rate of 68 percent in abdominal wounds. In a special study of 12,350 fatalities, Hoche found that wounds of the chest seemed to be the primary cause for 20 percent of all deaths, in comparison with 11.8 percent for wounds of the abdomen and pelvis, 47 percent for wounds of the head, and 9.9 percent for wounds of the limbs.

Official figures for the U.S. Army in World War I show 174,296 admissions for all battle injuries exclusive of gas injuries (5). Of these wounds, 4,595 (2.6 percent) involved the chest. The case fatality rate for all wounds was 7.73 percent and for chest wounds 24.05 percent.

Attention has been called elsewhere (p. 7) to the incredibly low incidence of both British and U.S. chest injuries recorded in World War I and to the possible explanation, that some wounds of the thorax in the U.S. records are hidden in wounds of the back or the shoulder area, which are listed separately.


61

With these exceptions, the incidence of chest wounds in all recorded wars has been close to 8 percent.

World War II-Official figures for U.S. Army casualties in World War II show that in a total of 599,788 battle wounds and injuries (table 7), 20,810 were fatal (table 8). Of the total wounds and injuries, 43,426 (7.24 percent) were wounds of the chest (table 9), of which 3,613 (8.3 percent) were fatal (table 10). These figures cover all casualties who survived to be hospitalized but do not cover those who died on the battlefield or in battalion aid stations or collecting or clearing stations. Not all of the 3,613 fatalities were necessarily due to wounds of the chest, but every casualty who died had such a wound.

Statistics for the Tunisian campaign in 1942-43 are not satisfactory, but as far as can be estimated from them, not more than 6 or 7 percent of the casualties who reached forward evacuation hospitals, corps clearing stations (in which surgery was then done), and the single surgical hospital operating in the area had wounds of the chest. In contrast, of approximately 50,000 casualties treated in Fifth U.S. Army hospitals in 1944, about 9 percent of the 46,000 hospitalized in evacuation hospitals had wounds of the chest (12). The remaining 4,000 casualties, practically all of them seriously wounded and nontransportable, were treated in field hospitals; 25 percent had thoracic wounds.

As these figures indicate, there was a remarkable increase during the course of the war in the number of casualties who survived to reach a hospital. One undoubted reason for the improvement, as well as for the improvement in case fatality rates, was the development and utilization of field hospitals, staffed with auxiliary surgical group teams, close to the frontline (p. 92).

It was naturally to be expected that the farther forward casualties with thoracic wounds were treated, and the larger the number of seriously wounded casualties treated, the higher would be the case fatality rates. In 4,320 chest injuries, for instance, in Seventh U.S. Army hospitals, the total case fatality rate was 5.4 percent, but it was 8.7 percent in field hospitals as compared with 3.3 percent in evacuation hospitals.

In an analysis of 22,246 admissions to Fifth U.S. Army hospitals between 1 August 1944 and 31 May 1945, Lt. Col. (later Col.) Howard E. Snyder, MC, Consultant in Surgery, Fifth U.S. Army, and Capt. (later Maj.) James W. Culbertson, MC (13), found that intrathoracic and thoracoabdominal wounds accounted for 6.29 percent of all admissions and 28.2 percent of all deaths over this special period. In an analysis of 1,450 deaths in Fifth U.S. Army hospitals, including 39 cases in which the casualties were dead on arrival, these same observers found that 212 of the deaths were the result of thoracoabdominal wounds and 138 the result of intrathoracic wounds. The combined proportion of deaths (24.1 percent) was exceeded only by the deaths in intra-abdominal wounds (28.1 percent, 408 fatalities).

In spite of the increase in the lethal potential of modern weapons of war, there was an encouraging reduction in the case fatality rate for chest wounds as


62

Table 7.-Number of admissions1 for battle injuries and wounds in the U.S. Army, by nature of traumatism and theater of admission, 1942-452

[Preliminary data based on tabulations of individual medical records]

Nature of traumatism

Outside continental3 United States

Europe

Mediter-
ranean

Middle East

China-
Burma-
India

South-
west Pacific

Central and South Pacific

North America

Latin America

Number

Number

Number

Number

Number

Number

Number

Number

Number

All battle injuries and wounds

599,788

393,992

107,326

315

2,616

59,651

33,605

1,512

36

Fractures:

Simple

16,194

9,765

3,681

38

129

1,527

932

65

2

Compound

114,568

79,259

18,206

45

451

10,350

5,944

271

5

Comminuted

100,023

70,605

15,124

33

322

8,715

4,971

223

4

Other

14,545

8,654

3,082

12

129

1,635

973

48

1

Total fractures

130,762

89,024

21,887

83

580

11,877

6,876

336

7

Traumatic amputations, avulsions, etc.

12,900

8,744

2,278

4

38

1,160

661

10

---

Wounds, penetrating

194,538

128,099

37,802

101

747

17,691

9,657

338

13

Wounds, perforating

64,933

43,249

9,612

11

317

7,751

3,707

264

5

Wounds, lacerated

57,522

37,133

10,187

26

286

6,390

3,350

102

5

Wounds, abraded or contused

28,098

17,594

6,686

17

126

2,361

1,217

26

---

Wounds, unqualified

19,024

6,599

3,759

31

129

3,995

4,363

94

2

Crushing

208

99

55

2

5

30

17

---

---

Burns

5,906

3,197

943

7

59

1,070

570

1

1

Other traumatisms

85,897

60,254

14,117

33

329

7,326

3,187

341

3


1Excludes cases carded for record only.
2Includes 439 admissions in December 1941 in the Pacific. Excludes 1,231 cases wounded or injured in action (TAGO source) in the Philippine Islands in 1941 and 1942.
3
Includes 735 admissions aboard transports.


63

Table 8.-Number of U.S. Army personnel who died of battle injuries and wounds1 during 1942-45,2 by nature of traumatism and theater of admission

[Preliminary data based on tabulations of individual medical records]

Underlying cause of death

Outside continental United States3

Europe

Mediter-
ranean

Middle East

China-
Burma-
India

South-
west Pacific

Central and South Pacific

North America

Number

Number

Number

Number

Number

Number

Number

Number

All injuries

20,810

12,521

3,733

11

127

2,936

1,431

30

Fractures:

Simple

359

140

118

---

5

59

32

2

Compound

3,313

2,229

549

2

16

334

174

6

Comminuted

2,290

1,605

352

1

7

221

99

4

Other

1,023

624

197

1

9

113

75

2

Total fractures

3,672

2,369

667

2

21

393

206

8

Traumatic amputations, avulsions, etc.

1,763

1,302

198

1

2

158

101

1

Wounds, penetrating

6,499

4,142

1,385

4

31

632

291

9

Wounds, perforating

3,565

1,997

630

1

23

667

239

5

Wounds, lacerated

1,641

1,033

271

---

7

240

90

---

Wounds, abraded or contused

69

49

14

---

1

4

1

---

Wounds, unqualified

1,828

484

382

2

23

574

356

4

Crushing

109

41

38

---

5

16

9

---

Burns

263

106

51

1

9

65

27

1

Other traumatisms

1,401

998

97

---

5

187

111

2


1 Among cases who reached a medical treatment facility. Excludes those who died in enemy prisons.
2Includes 22 deaths in December 1941 among admissions in Central and South Pacific. Excludes 120 who died of wounds (TAGO source) in the Philippine Islands in 1941 and 1942.
3Includes 21 deaths among admissions aboard transports.

World War II progressed. Figures from the Office of The Surgeon General published in 1944 indicated that approximately 8 percent of casualties with chest wounds were dying as a result of their wounds. The Fifth U.S. Army surgeon's annual report for 1944 showed considerably better results (12). During 1944, the case fatality rate for Fifth U.S. Army field hospitals, in which the most severely wounded were treated, was 12.6 percent, but the rate in evacuation hospitals was 4.8 percent and for all Army hospitals 6.7 percent.

An analysis of the 2,267 intrathoracic wounds (including 903 thoracoabdominal wounds) treated by the thoracic surgical teams and other teams of the 2d Auxiliary Surgical Group (14) showed the effects of experience in what might be termed a learning curve. For the entire period in which this group was active, the operative case fatality rates (on U.S. casualties) for the periods prior to 1 May 1944 and after 1 May 1944 are as follows: trained thoracic surgeons 8.28 percent and 7.08 percent, respectively; against 13.17 percent and 8.82 percent for general surgeons, respectively.


64

Table 9.-Number of admissions1 for battle injuries and wounds of the thorax and thoracoabdominal region in the U.S. Army, by anatomic site and year, 1942-452

[Preliminary data based on tabulations of individual medical records]

Anatomic site

1942-45

1942

1943

1944

1945

Number

Number

Number

Number

Number

Thorax:

Thorax, generally

18,918

255

2,160

10,221

6,282

Thoracic wall, generally

6,872

9

49

4,538

2,276

Posterior thoracic wall

5,257

---

---

2,931

2,326

Axilla

1,956

8

126

1,152

670

Ribs

3,082

28

305

1,852

897

Heart:

Heart, generally

33

---

1

15

17

Auricle, left

7

---

---

6

1

Auricle, right

13

---

---

11

2

Ventricle, left

22

---

---

13

9

Ventricle, right

33

---

---

20

13

Pericardium

59

1

1

32

25

Myocardium

10

---

---

6

4

Heart, other

5

---

---

2

3

Total heart

3(182)

3(1)

3(2)

3(105)

3(74)

Lungs

5,075

3

50

3,068

1,954

Trachea

131

---

3

67

61

Bronchi

4

---

---

3

1

Mediastinum

69

---

3

37

29

Pleura

235

---

2

144

89

Thoracic duct

---

---

---

---

---

Esophagus

30

---

1

16

13

Diaphragm

105

---

4

48

53

Thorax, other

1,510

24

86

882

518

Total

43,426

328

2,791

25,064

15,243

Thoracoabdominal region

3,233

---

---

1,752

1,481


1Excludes cases carded for record only.
2
Includes admissions in December 1941. Excludes cases wounded or injured in action in the Philippine Islands in 1941 and 1942.
3Figures in parentheses are subtotals.

In the opinion of the surgeons who worked in the Mediterranean theater, the improvement in the case fatality rate and in the general results in thoracic wounds could be attributed in large part to the establishment of uniform and consistent policies of management for these wounds after March 1944 (p. 199).

BATTLEFIELD DEATHS

Surveys of the causes of deaths on the battlefield are infrequent. Only two seem to have been conducted in World War I. In 1916, Sauerbruch (15) reported that of 300 soldiers who died on the battlefield, 30 percent had wounds of the chest. In a similar survey of 469 battlefield deaths, Loeffler (16)


65

Table 10.-Number of deaths1among admissions for battle injuries and wounds of the thorax and thoracoabdominal region in the U.S. Army, by anatomic site and year of admission, 1942-45

[Preliminary data based on tabulations of individual medical records]

 

Anatomic site

1942-45

1942

1943

1944

1945

Number

Number

Number

Number

Number

Thorax:

Thorax, generally

2,599

30

208

1,369

992

Thoracic wall, generally

56

---

---

40

16

Posterior thoracic wall

135

---

---

80

55

Axilla

39

---

---

27

12

Ribs

147

2

5

119

21

Heart:

Heart, generally

18

---

1

10

7

Auricle, left

1

---

---

---

1

Auricle, right

3

---

---

2

1

Ventricle, left

2

---

---

2

---

Ventricle, right

5

---

---

4

1

Pericardium

14

---

---

9

5

Myocardium

---

---

---

---

---

Heart, other

---

---

---

---

---

Total heart

2(43)

---

2(1)

2(27)

2(15)

Lungs

450

1

1

265

183

Trachea

26

---

1

15

10

Bronchi

---

---

---

---

---

Mediastinum

4

---

---

1

3

Pleura

9

---

---

6

3

Thoracic duct

---

---

---

---

---

Esophagus

6

---

---

4

2

Diaphragm

53

---

---

25

28

Thorax, other

46

---

---

32

14

Total

3,613

33

216

2,010

1,354

Thoracoabdominal region

698

---

---

436

262


1Consists of all admissions which ended in death, not necessarily due to the injury or wound causing admission or necessarily occurring during the years indicated. (The year shown is year of admission).
2Figures in parentheses are subtotals.

reported that 29 percent had chest injuries. It is recognized that all statistics obtained in this manner are inaccurate. For one thing, the tagging of the bodies is done by medical corpsmen who are not qualified to make diagnoses. For another, many bodies are so badly mutilated that even professionally trained medical officers would often have difficulty determining the cause of death.

Special study.-The only study of battlefield deaths carried out in World War II covered the examination of 1,000 bodies. It was conducted by Capt. William W. Tribby, MC (17), and his associates of the 2d Medical Laboratory in four U.S. military cemeteries in Italy, between 29 April and 6 November 1944.


66

In his introduction to Captain Tribby's report, Brig. Gen. (later Maj. Gen.) Joseph I. Martin, then Surgeon, Fifth U.S. Army, stressed the difficulties under which the investigation was conducted. On numerous occasions, it seemed that lack of time, obstinately bad weather, the need for secrecy, the hardships of working under battlefield conditions, and the constantly changing military situation would all contrive to halt the work, which was being done as an additional duty by the hard-pressed personnel of a very active field laboratory. Unless these circumstances were understood, General Martin pointed out, the "monumental scope" of the undertaking also would not be realized.

The work was done in military cemeteries for a number of reasons, including the fact that the bodies were received in them in large enough numbers to make the investigation feasible within a reasonable period of time. The study was unselective, except for the requirement that the bodies be in fit condition for positive identification of the location and extent of the wounds.

Every wound was probed, and its extent was determined as exactly as possible, but all examinations were external. The inaccuracy caused by limitation of the investigation to external examinations was fully realized, but experience with the first few bodies, in which autopsy was attempted, proved that a continuation of the attempt would have made the investigation entirely impractical. Had autopsies been possible, numerous additional wounds might well have been found, particularly in bodies in which the wounds were too small to be probed satisfactorily.

In most instances, it was not possible to determine the position of the casualty at wounding; those who actually saw the death occur were usually not present when the body was tagged. In many instances, also, it was impossible to determine the wounding agent.

Chest wounds were defined, in addition to anterior wounds of the thoracic region, as all wounds located posteriorly above the level of the first lumbar vertebra and all wounds of the axillary region and the region of the shoulder girdle unless the injury extended into, or was distal to, the head of the humerus. These criteria generally agree with the definition of wounds of the chest suggested by Churchill (p. 59).

Data elicited concerning wounds of the chest in these 1,000 cases were as follows:

Of the 312 single wounds, 84 were in the chest.

In the 171 bodies in which the wounds were multiple and were confined to portions of the body above the diaphragm, 120 wounds of the chest were found.

The data show that 572 wounds of the chest were found either singly or in various combinations of injuries both above and below the diaphragm. No other region of the body above the diaphragm was affected more often than the chest. Next in order of frequency were the lower extremities, which were wounded in 327 bodies.

Of the 572 wounds of the chest, 422 (73.8 percent) were sufficiently grave to account, in themselves, for the fatality. Of the 2,385 wounds found in the 1,000


67

Table 11.-Number of U.S. Army personnel killed in action1during 1942-45,2 by anatomic location of wound and theater


68

Table 12.-Number of U.S. Army personnel killed in action,1 by anatomic location of wound and theater, 1944


69

bodies, 1,426 (59.8 percent) were sufficiently grave to explain why death occurred.

The diagnosis on the emergency medical tag proved erroneous in 276 of the 572 wounds of the chest (48.3 percent). This was the second smallest proportion of errors, the smallest proportion (35.7 percent) being in 154 of the 432 head injuries. These errors were, for the most part, inevitable: Accurate diagnoses could not be expected unless the body could be stripped of all clothing and examined by a medical officer.

The investigation was conceived as one further step to improve the protection of the soldier on the field of battle. It showed that in 202 of the 1,000 fatalities, the casualties could not have been saved from death by any type of body armor. Body armor, however, might well have averted a number of the 572 wounds of the chest in this series.

Official statistics-Official figures for casualties killed in action and for those who died of wounds show a total of 213,976 according to the figures of The Adjutant General's Office and 213,030 according to those of the Office of the Surgeon General. The discrepancy is slight and seems to relate to the manner of classification of the deaths.

Of the 192,220 casualties killed in action whose wounds were classified by anatomic site (table 11), 17,957 (9.3 percent) had wounds of the thorax and 319 (0.16 percent) thoracoabdominal wounds. These figures for the 1942-45 period cover all theaters. The figures for 1944, the year in which the largest number of casualties occurred, are presented in table 12.

References

1. Boland, F. K.: Chest Wounds in Military and Civil Practice. Mil. Surgeon 81(8): 175-193, September 1937.

2. Elkin, D. C.: Wounds of the Thoracic Viscera. J.A.M.A. 107(3): 181-184, 18 July 1936.

3. DeBakey, M.: The Management of Chest Wounds; Collective Review. Internat. Abstr. Surg. (Supp. to Surg. Gynec. & Obst.) 74: 203-237, March 1942.

4. Medical and Surgical History of the War of the Rebellion. Surgical History. Washington: Government Printing Office, 1870, pt. I, vol. II, pp. 466-650.

5. The Medical Department of the United States Army in the World War. Washington: Government Printing Office, 1925, vol. XV, pt. 2, pp. 1023-1024, passim.

6. The Medical Department of the United States Army in the World War. Washington: Government Printing Office, 1927, vol. XI, pt. 1, pp. 62, 68, 342-442.

7. Medical Department, United States Army. Wound Ballistics. Washington: U.S. Government Printing Office, 1962.

8. Nicholson, W. F., and Scadding, J. G.: Penetrating Wounds of the Chest; Review of 291 Cases in the Middle East. Lancet 1: 299-303, 4 Mar. 1944.

9. Beebe, Gilbert W., and DeBakey, Michael E.: Battle Casualties: Incidence, Mortality, and Logistic Considerations. Springfield: Charles C Thomas, 1952, p. 89.

10. Oughterson, Ashley W., Hull, Harry C., Sutherland, Francis A., and Greiner, Daniel J.: Study on Wound Ballistics-Bougainville Campaign. In Medical Department, United States Army. Wound Ballistics. Washington: U.S. Government Printing Office, 1962, pp. 281-436.


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11. Hoche, Otto: Wehrchirugische Behandlung Verwundeter und Verletzter. Berlin: Urban & Schwarzenberg, 1940, p. 27.

12. Annual Report, Surgeon, Fifth U.S. Army, 1944.

13. Snyder, Howard E., and Culbertson, James W.: Study of Fifth Army Hospital Battle Casualty Deaths. An Analysis of Case Reports From Field and Evacuation Hospitals on 1,450 Fatally Wounded American Soldiers. A preliminary report in three volumes. Gardone Riviera, Italy, September 1945. [Official record.]

14. Betts, R. H., Samson, P. C., Brewer, L. A. III, Shefts, L.M., and Burford, T. H.: Thoracic Wounds. Thoracoabdominal Wounds. In Forward Surgery of the Severely Wounded. A History of the Activities of the 2d Auxiliary Surgical Group, 1942-45, vol. 2, pp. 411-591. [Official record.]

15. Sauerbruch, F.: Kriegschirurgische Erfahrungen. Uebersichtsreferat mit besonderer Berücksichtigung der Thorax-und Abdominalschüsse. Cor.-Bl. f. schweiz. Aerzte, Basel 46: 1315-1328, 1916.

16. Loeffler, cited by Walker, K. M.: The Protection of the Soldier in Warfare. Proc. Roy. Soc. Med. 33: 607-614, July 1940.

17. Tribby, William W.: Examination of One Thousand American Casualties Killed in Action in Italy. Report to Surgeon, Fifth U.S. Army, 1944, 6 vols. [Official record.]

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