U.S. Army Medical Department, Office of Medical History
Skip Navigation, go to content

HISTORY OF THE OFFICE OF MEDICAL HISTORY

AMEDD BIOGRAPHIES

AMEDD CORPS HISTORY

BOOKS AND DOCUMENTS

HISTORICAL ART WORK & IMAGES

MEDICAL MEMOIRS

AMEDD MEDAL OF HONOR RECIPIENTS External Link, Opens in New Window

ORGANIZATIONAL HISTORIES

THE SURGEONS GENERAL

ANNUAL REPORTS OF THE SURGEON GENERAL

AMEDD UNIT PATCHES AND LINEAGE

THE AMEDD HISTORIAN NEWSLETTER

Chapter V

Contents

CHAPTER V

Study on Wound Ballistics-Bougainville Campaign

Ashley W. Oughterson, M.D., Harry C. Hull, M.D., Francis A. Sutherland, M.D., and Daniel J. Greiner, M.D.

The purpose of the wound ballistics study1 conducted on Bougainville was to obtain information on the relative effectiveness of different weapons as casualty-producing agents. To obtain this information, a study was made of all battle casualties (living and dead) which had occurred in the U.S. Army Ground Forces on Bougainville Island from 15 February to 21 April 1944.

Though it was possible to obtain information on all casualties, living or dead, for the entire period from 15 February to 21 April, post mortem examinations were limited to the interval from 22 March to 21 April. The number of autopsies was further curtailed because the bodies of some of those killed in action were not obtained before decomposition was far advanced. It was also hoped to study the effect of U.S. Army weapons on the enemy dead. The character of the fighting resulting in multiple wounds by rifle, machinegun, grenade, mortar, and artillery fire made it almost impossible, however, to determine what weapon was responsible for death. Furthermore, because of delay in obtaining the Japanese dead, the state of deterioration frequently precluded post mortem examination. Also, during this period, it often required all the available personnel to perform post mortem examinations on U.S. Army killed-in-action casualties.

Since the effect of weapons may be observed on the living as well as the dead, a clinical appraisal especially with regard to end results was needed. Furthermore, the relative effect of weapons may be greatly influenced by the quality of medical care. For this reason, the ballistics team after completing the study in the forward area followed the patients through the hospitals of the rear echelon.

The battle casualties studied may be divided into two large groups: The killed in action and the wounded in action.

1In accordance with instructions from The Surgeon General, 21 January 1944, a team was organized for the purpose of conducting a study on wound ballistics. This team included Col. Ashley W. Oughterson, MC, Surgeon; Lt. Col. Harry C. Hull, MC, Surgeon; Maj. Francis A. Sutherland, MC, Surgeon; Maj. Daniel J. Greiner, MC, Pathologist; Sgt. Reed N. Fitch, T4g. Charles J. Berzenyi, and T5g. Charles R. Restife. The team was organized to participate in the contemplated New Ireland operation and was ordered to Guadalcanal for training and organization. The New Ireland operation was cancelled, and the team was then ordered on detached service with the XIV Corps on Bougainville and reported there on 22 March 1944.


282

Killed in action.-Those killed in action prior to 23 March were recorded in the graves registration files. While some of these records were excellent, many were inadequate. Information on the circumstances attending death, such as type of missile, distance from burst, terrain, time, and type of protection, was supplemented by personal interviews with the medical officers and aidmen or with comrades who, during the action, had seen the soldier killed or had seen him before he expired. This information is better obtained by personal interview than by questionnaire because the circumstances attending death are so varied. In order to obtain reasonably accurate data, evaluation of the situation by trained and interested personnel is necessary at the time of interview. Subsequent to 23 March 1944, all the dead were brought to the 21st Evacuation Hospital which was located near the cemetery. Here, excellent facilities and assistance for post mortem examinations were available. This work was carried on by the pathologist who was assisted by a clerk and a photographer. When the number of autopsies exceeded 10 or 12 per day, additional assistance was provided by the surgeons. A few additional post mortem examinations were obtained on those wounded in action who died later in hospitals of the rear echelon. A card index was kept on all wounded, and this was checked for death against the records of the hospitals in the rear echelon.2This check was made at a later date, and for the majority of patients, a period of 1 to 4 months had elapsed since they were wounded; hence, there is reason to believe that all or nearly all of the dead are recorded in this study.

Wounded in action.-The wounded in action fell into three groups: (1) The more seriously wounded who were evacuated from Bougainville, (2) the relatively minor wounds treated in the clearing stations or hospitals and returned to duty in 1 to 3 weeks, and (3) the very minor wounds and abrasions returned to immediate duty from the battalion aid and collecting stations. This latter group was not studied. The second group, of minor wounds treated and returned to duty from the clearing stations and hospitals, were studied in detail, as were those evacuated from the island. Factors relating to ballistics in the wounded in action were obtained by questionnaire and by personal interview. The personal interview was undoubtedly superior, but since these troops were still in battle it was sometimes impossible to obtain an interview with an eyewitness. When emergency medical tags and hospital records were checked with eyewitness accounts, many discrepancies were found as to the weapon, the distance, what the soldier was doing, and the exact circumstances surrounding his injury. Allied officers and enlisted men were questioned regarding effectiveness of enemy weapons and tactics, as well as their own. Questions were also asked regarding the construction of pillboxes and the use of camouflage with reference to their effectiveness as a means of protection.

2Throughout this chapter, hospitals in the rear echelon refer to those on Guadalcanal, Espíritu Santo, and New Caledonia.-J. C. B.+


283

FACTORS PECULIAR TO THE BOUGAINVILLE CAMPAIGN

Geography

Bougainville Island is in the northernmost part of the Solomon Islands group, lying between latitudes 50°28' S. and 5°51' S. It is approximately 130 miles long with an average width of 30 miles. It is a tropical island of volcanic origin with a backbone of rugged mountain ranges. Behind the Empress Augusta Bay sector, the Crown Prince Range rises to a height of 6,560 feet with an active volcano, Mount Bagana. The Empress Augusta Bay and Torokina Point sectors present a low sandy shoreline with heavy surf. The south shore of this island has very little coral, and behind the shoreline a sandy alluvial plain rises gently to the foothills of the Crown Prince Range, about 4,000 yards inland. Near the shore are some lagoons and in the region of the Torokina River extensive swamps. The subsoil of the plain is black volcanic sand providing good drainage. The rainfall which is fairly uniform throughout the year averages approximately 11 inches per month. The typical heavy tropical showers wash and erode the hillsides and make constant road maintenance a necessity.

The Empress Augusta Bay beachhead was virgin jungle except for a small coconut plantation on Torokina Point. The elaborate system of roads shown in the situation map (fig. 159) had all been built since the initial landing during the first week of November 1943. At the time of the enemy attack on 8 March 1944, this system of roads was nearly completed except for a section of the perimeter road connecting the Americal and 37th Division sectors. The perimeter at its greatest depth was carried along the high ridges of the foothills, and this extremely rugged terrain presented a major problem in evacuation where roads were not present or were under fire. This road system alone played an important role in saving the lives of many casualties which might otherwise have been lost. However, the problem of evacuation of wounded within the perimeter was simple when compared to the difficulties encountered in evacuating men wounded on patrol. Patrols constantly covered this rugged terrain beyond the perimeter for distances of 1,000 to 8,000 yards. Even a 1,000-yard carry over these ridges and draws was exhausting to both the litter bearers and the patient.

Medical Installations and Routes of Evacuation

The medical installations and routes of evacuation (fig. 153) were better developed on Bougainville at the time of the attack than for any other island campaign in the South Pacific. This was due to the fact that the beachhead had been developed steadily over a period of 4 months before the Battle of the Perimeter began.


284

FIGURE 153.-One of the routes of evacuation between the clearing station of the Americal Division and the 21st Evacuation Hospital.

Two-way all-weather roads made all parts of the perimeter easily accessible with one exception. This one sector lay near the boundary line between the Americal and 37th Divisions, where the perimeter road had not been completed (fig. 154). Furthermore, the roads were kept open throughout the battle except on Hill 700. The one-way all-weather road over very rugged terrain leading to the latter Hill was for a time under enemy fire, and as a result a difficult litter carry of 1,200 yards was necessary during the attack. Later at this point, and at others where sporadic fire was encountered, half-tracks were used for evacuation, and patients were then transferred to jeep ambulances and taken to the hospital. The greatest distance from the front-line to a clearing station was found on the Americal sector at the mouth of the Torokina River which was approximately 10, 000 yards over a good road. Figure 155 is an illustration of the type of road which existed outside of the perimeter area.

Owing to this excellent system of good roads, the majority of patients arrived at the hospitals within 3 hours, and frequently within an hour. A sample of 142 patients showed that 87 percent were on the operating table within 3 hours. Patrol missions presented the most difficult problems of evacuation. Small patrols, frequently no larger than a platoon, were so numerous that it was impractical to send a medical officer with each one. Larger combat patrols were usually accompanied by a medical officer. On only one occasion, however, was a patrol large enough to warrant the use of a portable surgical hospital. As a consequence, some patients who were wounded on patrol did not reach the hospital until after 24 to 48 hours had elapsed. However, every effort was


285

FIGURE 154.-Perimeter road near junction of Americal and 37th Divisions. A good route of evacuation over difficult terrain built by the 117th Engineer Combat Battalion.

FIGURE 155.-Roadway along the Laruma River, outside the perimeter.


286

made to reduce delay to the minimum and to provide surgery at the earliest possible moment.

The medical installations available for the Bougainville campaign were more than adequate. The clearing stations of both the Americal and 37th Divisions had been augmented with additional surgical equipment before the hospitals were established on the beachhead. The 31st Portable Surgical Hospital had been assigned to the Americal Division and the 33d Portable Surgical Hospital, to the 37th Division. Owing to the fact that more adequate medical facilities became available later, the portable surgical hospitals were not necessary, although they were both utilized. The 52d Field Hospital was utilized for the care of service troops and functioned chiefly as a station hospital for the island. The 21st Evacuation Hospital (figs. 156 and 157), an affiliated unit from the University of Oklahoma, Norman, Okla., had an exceptionally well qualified staff, including the various specialists. The construction of this hospital was completed on 8 March 1944; however, the hospital had functioned for a limited number of patients since 15 February. The normal capacity of the 21st Evacuation Hospital was 750 beds with facilities available for an additional 250 beds (fig. 158). Casualties from all combat troops were cared for at this hospital. Since the 21st Evacuation Hospital was situated only 4,000 yards from the frontlines at the nearest point of attack (forward of some artillery batteries), the majority of the seriously wounded patients were sent directly to the hospital to avoid delay at the clearing stations.

FIGURE 156.-Ward area of the 21st Evacuation Hospital on Bougainville.


287

FIGURE 157.-Underground operating room of the 21st Evacuation Hospital on Bougainville. There was a similar operating room above-ground providing space for eight tables.

FIGURE 158.-Interior of underground ward, 21st Evacuation Hospital on Bougainville. Space was provided for 120 litter patients. This would have been inadequate if shelling had been heavy.


288

All patients from the island were evacuated through the 21st Evacuation Hospital. Nearly all patients evacuated to the rear were sent by air transport to Guadalcanal and were cared for there in one of three 500-bed station hospitals. Patients requiring a long period of convalescence were evacuated from Bougainville by ship or air transport to Espíritu Santo and to New Caledonia.

Allied and Japanese Forces

Allied forces on Bougainville were concentrated in the Empress Augusta Bay beachhead. The perimeter line of defense had been extended previously in three phases until, by the time of the Japanese attack on 8 March 1944, it enclosed about 20 square miles and was approximately 22,000 yards in length. The total strength within this perimeter as of 31 March 1944 was 60,583. Included were 11,220 Navy and Marine personnel and civilians. The few casualties from these groups were due mostly to shelling and bombing and are not included in this study. The casualties included in this study were derived, therefore, from a total strength of 49,363. Of this number, 40,404 were U.S. Army Ground Force combat troops of which 27,831 constituted the 37th and Americal Divisions. The remainder of the ground force combat troops were attached to the XIV Corps and the 25th Regimental Combat Team. Allied forces other than U.S. troops, chiefly Royal New Zealand Air Force and Fijian Infantry, numbered 3,424. It should be noted that, of these forces, the number actually involved in combat was comparatively few. This number could not be ascertained except for certain specific engagements. The perimeter line of defense was divided between the 37th and Americal Divisions although other forces were used in the line at various times. The Fijian troops, among whom there were a considerable number of casualties, were used chiefly on patrol missions.

Immediately before the attack, the effective strength of the Japanese Army and Navy forces on Bougainville numbered about 27,000. Of these, about 18,000 were believed to be Army combat troops. The remaining strength consisted of Army and Navy antiaircraft, base, service, and labor troops. No surface ships had been observed in the Bougainville area since mid-November 1943 and whatever supplies were brought in were carried by submarine or barge. With the exception of small arms ammunition, there was evidence that the enemy was short of basic supplies. Although elements of the 17th Division (one battalion each from the 81st and 53d Infantry Regiments) were identified in the Torokina area, the brunt of the attack was borne by the Japanese 6th Division. The backbone of the enemy's strength was the 13th, 23d, and 45th Infantry Regiments (fig. 159). These units were supported by the 6th Field Artillery Regiment (2d Battalion) elements of the 4th Heavy (Medium) Artillery Regiment, as well as miscellaneous mortar, artillery, engineer, and road construction units. The 1st Battalion, 13th Infantry (minus one company), was to be the division reserve. The total strength of these units actually in combat in the Battle of the Perimeter was believed to be only slightly more than 10,000.


289

FIGURE 159.-Situation map. Disposition of principal enemy units, 29 February 1944.

The enemy forces faced great difficulties of transportation in the maneuvering of various units, especially heavy artillery, into positions favorable for attack. This had to be accomplished over the most rugged type of terrain at great expenditure of manpower. Finally, they attacked with almost no air support.

Description of the Weapons Commonly Employed by the Japanese3

In the period under study, Japanese weapons accounted for 1,569 casualties, including killed and wounded. Table 57 is a breakdown of the type of Japanese weapons responsible for 1,569 Allied casualties.

Estimates based upon captured weapons indicate that the ratio of 6.5 mm. (caliber .256) to the 7.7 mm. (caliber .303) rifle was approximately 4 to 1.

3A complete description of Japanese ordnance is contained in chapter I, pp. 4-35.


290

TABLE 57.-Japanese weapons responsible for 1,569 Allied casualties

Type of weapon

Allied casualties

Number

Percent

Mortar

659

42.0

Rifle

393

25.1

Grenade

205

13.1

Machinegun

151

9.6

Artillery

151

9.6

Miscellaneous

10

.6

Total

1,569

100.0


Furthermore, of the smaller caliber (6.5 mm.) weapon, roughly 90 percent were "long," 7 percent "short," and 3 percent "medium" types.

The almost complete absence of muzzle flash in the Model 38 (1905) is a characteristic commented upon favorably by U.S. soldiers. Since the latest Japanese rifle, Model 99, did not possess this feature, it was apparently considered unimportant by the enemy.

Most commonly employed by the enemy at Bougainville, in a ratio of approximately 4 to 1, were the Model 96 (1936) 6.5 mm. light and the Model 92 (1932) 7.7 mm. heavy machineguns. Extremely rare was Model 11 (1922) 6.5 mm. light machinegun ("Nambu Keiki") among the 200 captured machineguns. Closely resembling the British Bren light caliber .303 model, the Model 96 (1936) 6.5 mm. light machinegun was considered an excellent weapon by American officers.

Wounds ascribed to the mortar at Bougainville in many instances were actually produced by the grenade discharger. Mistakenly called the knee mortar, this weapon, because of its accuracy and efficiency, had earned the respect of the American combat troops and was more feared than any other Japanese weapon. If the "knee mortar" was grouped with the other types of captured mortars, it was found to constitute approximately 90 percent of the total. Among the conventional mortar types, the ratio of the 81 mm. to the 90 mm. was about 3 to 2. A total of 96 mortars were captured, only one of which was the 90 mm. Model 97 (1937).

Because it could he thrown by hand, fired from a grenade discharger, or used as a rifle grenade, Model 91 (1931) hand grenade, "Kyuichi Shiki Shuryudau," was a useful, versatile, and frequently employed weapon. Model 97 (1937) hand grenade was similar to Model 91 except that it had no propelling charge and could not be fired from a grenade discharger. It was carried by all Japanese frontline troops but was said to have poor fragmentation, the fragments being small and of short range. The effective range from the burst was estimated at 5 yards and the danger zone, 30 yards.

In the plan to neutralize and seize the three Torokina airfields, the artil-


291

lery support was the most extensive yet employed by the enemy in the South Pacific. The Japanese were able to transport a considerable number of heavy weapons through dense jungle and over exceedingly rough terrain to positions overlooking the U.S. perimeter. Assuming all units at full strength, an order of battle indicates that the maximum number of weapons available to them was 136. Actual observation suggested the presence of approximately 40 or 50 pieces.

With the exception of the 10 and 15 cm. pieces, all weapons were of pack type and were undoubtedly carried by hand. Possibly the 150 mm. howitzers may have been dismantled also, as some of these were reported on Mount Bagana. These weapons were brought by water to Koaris and thence by road to the vicinity of Hills 500 and 501. Limited use of horses was reported on the Kahili-Empress Augusta Bay track. Apparently there was no serious shortage of ammunition by Japanese standards, fire having continued intermittently from some positions for 3 weeks. Considerable quantities of ammunition were generally found with the captured weapons.

Principal targets were the airstrips, supply and command post areas, road junctions, and the tank areas. Massing of fire was not utilized and gunfire seemed independent. The heaviest concentration occurred in the early morning and evening hours. On 23 March, in less than 2 hours, 70 rounds fell on the Piva airfields. After the first 2 days of attack, during which some parked planes were destroyed, rarely in a single day did more than five or six shells fall on these same airfields. Difficulties inherent in jungle warfare precluded the use of artillery in close support of attacking Japanese infantry. For this purpose, the Japanese relied principally upon 90 mm. mortar fire.

The Japanese employed at least thirty-five 75 mm. guns, Model 41(1908) and Model 94 (1934), the former predominating. These pieces were situated north and northeast of the perimeter. Four 150 mm. howitzers were located on the northeast and east and two 105 mm. howitzers on the east near Hill 501. Mortar fire received was principally from the north and northwest sections. The greatest concentration of fire in any one day was 200 rounds. In contrast to the experience during the weeks after the landing in November, the proportion of "duds" was remarkably low. Observers were able to identify by type of burst or by duds about 1,300 rounds received. Of these, 885 were 75 mm. shells and 130 were 150 mm. shells. Many types of artillery weapons were captured. The five most commonly encountered models will be described briefly.

Model 94 (1934) 37 mm. gun was designated "Kyuyon Shiki Sanjunana Miri Ho," and commonly called Sanjunana Miri Ho. It could be used both as an AT (antitank) and antipersonnel weapon, employing AP (armor-piercing), HE (high explosive), and shrapnel ammunition. This gun had a long, slender barrel measuring 66.5 inches in length. The effective range was 2,500 yards and the maximum range 5,000 yards. The total weight of the weapon in action was 714 pounds. The effective burst of the HE shell was said to be 10 yards with a zone of danger extending about 75 yards. Fragmentation tests


292

revealed that the 560 grams of metal in the shell broke into 490 fragments. Only 143 of these fragments were classified as lethal (average weight of lethal fragment being 3.1 grams).

The Model 92 (1932) 70 mm. howitzer (Battalion Gun), "Kyuni Shiki Hoheiho" was a horse-drawn infantry support howitzer. It weighed 468 pounds and could be handled by a 10-man section. It had an effective range of 1,500 yards and a maximum range of 3,000 yards. The estimated effective range of burst was 20 yards, and the area of danger was 200 to 300 yards.

Issued for use as an infantry regimental gun, the Model 41 (1908) 75 mm. mountain (infantry) gun was originally used as a field artillery pack gun. The effective range of this weapon was 2,100 yards, and it fired both HE and AP shells. With the long, pointed shell, its maximum range was 7,675 yards and with the ordinary shell, 6,575 yards. The total weight was 1,200 pounds. Its muzzle velocity was listed as 1,200 f.p.s. (feet per second). The shell had a probable effective burst of 20 yards with a danger zone of 300 feet.

The Model 96 (1936) 150 mm. mobile field howitzer has a range of 13,200 yards. The effective range of the shellburst was said to be 50 yards with an area of danger of 500 yards. The effect produced was that of blast and fragmentation.

The Model 98 (1938) 20 mm. AA/AT (antiaircraft, antitank) machine cannon was an all-purpose weapon. It was gas operated and semiautomatic or full automatic. The ammunition for this weapon was HE, tracer, and AP and was fed by a 20-round box magazine. This weapon was very maneuverable, weighing without wheels 836 pounds. The rate of fire was 120 rounds per minute. The muzzle velocity was 2,720 f.p.s. and the maximum ranges, horizontal 5,450 and vertical 12,000 feet.

A list of Japanese rifles, machineguns, mortars, grenades, and artillery weapons captured on Bougainville follows.

Nomenclature

Nomenclature

Model 38 (1905) 6.5 mm. Rifle (Long)1

Model 97 (1937) Grenade1

Model 38 (1905) 6.5 mm. Rifle (Short)

Model 91 (1931) Grenade1

Model 97 (1937) 6.5 mm. Snipers Rifle

Model 23 (1923) Boobytrap Grenade1

Model 38 (1905) 6.5 mm. Rifle (Medium)

Model 94 (1934) 37 mm. Gun

Model 44 (1911) 6.5 mm. Cavalry Carbine

Model 1 (1934) 47 mm. Gun

Model 99 (1939) 7.7 mm. Rifle1

Model 92 (1932) 70 mm. Howitzer (Battalion Gun)1

Model 11 (1922) 6.5 mm. Light Machinegun ("Nambu")

Model 41 (1908) 75 mm. Mountain (Infantry) Gun (or Regimental Gun)1

Model 96 (1936) 6.5 mm. Light Machinegun

Model 94 (1934) 75 mm. Mountain Gun

Model 99 (1939) 7.7 mm. Light Machinegun

Model 91 (1931) 105 mm. Light Field Howitzer

Model 92 (1932) 7.7 mm. Heavy Machinegun1

Model 96 (1936) 150 mm. Mobile Field Howitzer1

Model 97 (1937) 82 mm. Mortar1

Model 97 (1937) 20 mm. AT Rifle

Model 94 (1934) 90 mm. Mortar1

Model 98 (1938) 20 mm. AA/AT Machine Cannon

Model 97 (1937) 90 mm. Mortar

Model 89 (1929) 50 mm. Grenade Discharger ("knee mortar")


1Models most frequently employed.

293

BOUGAINVILLE CAMPAIGN DURING SURVEY PERIOD (15 FEB.-21 APR. 1944)

The Allied beachhead was established during the first week of November 1943. The period before the Battle of the Perimeter was characterized by consolidation of the defenses of the airfields which were being used for attacking enemy installations in the Bismarck Archipelago and on Bougainville. By 15 February, the airstrips were completed and the perimeter established with the 37th Division on the left flank and the Americal Division on the right flank. From 15 February to 8 March, the perimeter defense was strengthened, and an extensive system of roads was further developed within the perimeter. During this period, patrols made contact with enemy forces moving into position north and east of the perimeter. Some artillery installations were discovered, and strong enemy positions were noted on Hills 1000, 1111, and 600 east of the Torokina River mouth (fig. 159). However, during this period, contact with the enemy was limited to patrol skirmishes and an occasional bombing raid at night.

The Battle of the Perimeter extended from 8 March to 24 March. The Japanese had laid plans for this offensive sometime around the turn of the year. Allied intelligence obtained information that the enemy attack was to be launched on 8 or 9 March, thereby permitting ample preparation for defense of the perimeter.

Enemy plan.-The three infantry regiments were to leave their respective lines of departure following an artillery barrage. This barrage was to commence at 0430 Y-day from the main strength of the 6th Artillery Regiment (fig. 159) located near Blue Ridge (mountain guns) and the medium field artillery (10 and 15 cm. field pieces) deployed near Hill 500. It appears that the 45th Infantry was to constitute the main thrust and was to strike Allied lines near the point where the Piva-Numa-Numa Road enters the perimeter (129th Infantry sector). Simultaneously, the 23d Infantry was to launch its attack from approximately 1,000 yards northeast of Hill 700 with the 3d Battalion on the left and the 2d Battalion on the right and the 1st Battalion in reserve. By the end of Y-day, the 3d Battalion was to have captured Hill 700 and the 2d Battalion was to have occupied Cannon Hill. These heights overlooked the Piva airstrip, and the main strength of the 23d Infantry was to have attacked the strip from the east while the 45th attacked from the west. The 13th Infantry was to attack Hill 260 and then join with elements of the 23d Infantry to proceed in the general direction of the airstrip.

The enemy's Torokina operation began on 8 March with preliminary artillery fire directed mostly on the Piva airstrips. Blue Force counterfire against hostile positions located in the general areas of Hills 1111 and 501 began immediately. The main Japanese drives began under the cover of darkness during the night of 8 March and the morning of 9 March at the three points on the perimeter. In the east sector patrol, contacts and fire fights took place in the vicinity of Hill 260. To the north on Hill 700, the Japanese


294

infiltrated through Allied lines and occupied the northwest slope of the hill. Blue Force counterattack reduced the Japanese positions, and the perimeter was reestablished. In the northwest sector, several fire fights occurred. The Japanese had occupied strong points on Hill 260 and severe fighting resulted in retaking these points, but by 11 March two Blue Force companies occupied Hill 260 with the exception of strong points on the southeast slope. Another attack on the northern sector was repulsed. Meanwhile, preparations for an enemy drive from the northwest continued. On 12 March, three major attacks from the northwest near the Numa-Numa Trail placed the Japanese within the U.S. perimeter. American tank-infantry teams reestablished the lines next day. The same Blue Forces on Hill 700 received and repelled the third attack on that position. On 15 March, another attempt was made by the Japanese to break through the sector held by the 129th Infantry. Tank-infantry counterattack again restored the perimeter. The next strike by the enemy was again from the northwest near the Piva-Numa-Numa Trail on 17 March. Although a 75-yard penetration was made for the third time, tanks and infantry drove the enemy back. For a week, the Japanese remained relatively quiet, regrouping their forces opposite the northwest sector of the perimeter. Smaller holding forces which were dug in were contacted on the other sectors. On 24 March, after a feeble attempt at laying an artillery barrage, the Japanese struck toward the Piva airstrips once more, penetrated the 129th Infantry lines, and again were driven back, losing 300 men and a field gun. On each occasion when penetration was made, the enemy succeeded in occupying pillboxes within the U.S. perimeter only to be dislodged with heavy losses.

The Japanese did not again attack in force after the repulse on 24 March and began a general withdrawal. Hill 260, however, was not evacuated by the enemy until 28 March. From 28 March to 22 April when this study was completed, contact with the enemy was limited to a few fire fights, patrol skirmishes, and occasional shelling of the airstrips. There were 5,522 Japanese dead counted between 8 March and 22 April. This, however, did not include all areas subjected to U.S. artillery fire.

Battle of the Perimeter

Operations on Hill 2604

The original garrison on Hill 260, a reinforced platoon from Company C, was attacked by a Japanese force of undetermined size at dawn on 10 March. The enemy generally occupied the area south of the outpost tree (fig. 160), and, from this date until the termination of the battle, the Japanese tried to increase their garrison and improve their positions on that side of the hill in order to secure observation for an all-out attack on the main line of resistance.

4Report, Lt. Col. Wm. J. Mahoney, Executive Officer, Headquarters, 182d Infantry, Americal Division.


295

FIGURE 160.-Focal point of entire Hill 260 battle. Banyan tree used as an Americal Division artillery spotting post. In the 20-day fight for the hill, 541 Japanese were killed.

The terrain was that of an elongated hill with moderately steep sides covered by rain jungle. The outpost tree (fig. 160), around which the heaviest fighting occurred, was one of a common variety of trees on Bougainville, the roots of which plus excavation make a very strong defensive position (fig. 161).

After the initial attack, the Japanese held the south end of Hill 260. They greatly increased the force which had made the original attack because they beat back the Allied attempt to storm the northwest, southwest, and southeast ridges of the hill during the period 11-17 March. Apparently, their main route of supply and evacuation was down the steep east side of the hill, then north clinging to the east side of the west bank bluff overlooking the Torokina River. This route was well concealed and in defilade and difficult to reach by fire. After the initial engagement, reinforcements were sent to secure the north side of Hill 260. The establishing of a perimeter there and the continual pressure on the Japanese positions completely neutralized the effect of the offensive action taken by the Japanese. The possession of Hill


296

FIGURE 161.-Banyan trees are common in the jungle on Bougainville and offer excellent protection. The outpost tree on Hill 260 was of this variety.

260 by the enemy would have jeopardized a considerable portion of the Allied main line of resistance.

From the outset, the problem on Hill 260 was one of ejecting the Japanese from the south end of the hill. Their positions were well dug in (fig. 162), and the various American assaults to take the hill were turned back with heavy casualties. Artillery and mortars were useful in blasting Japanese positions in the general area, but because of the proximity of American troops, prepared fires could not be used on the Japanese positions just outside the U.S. perimeter. Artillery was effective on the exposed southwest slope, and after a week's fighting the Japanese were pretty well removed from that area (fig. 163). But those in defilade on the southeast slope dug in and countered every American move. Various means were used to force the Japanese from their dugouts during the closing 10 days of the battle. It was obvious at that time that the Japanese garrison was considerably reduced in numbers although there was no corresponding lessening of firepower. Flamethrowers and gasoline ignited with thermite grenades reduced a few pillboxes (fig. 164). As late as the morning of 28 March, Japanese were seen near pillboxes on the southeast slope. On the morning of 28 March, three patrols were sent around the base of the hill to fire on the Japanese. When there was no fire, the Allied patrols investigated and found that the Japanese had evacuated. At 1246, 28 March, Hill 260 was secured. On the morning of 30 March, the 2d Battalion, 182d Infantry, was replaced on the hill by 1st Battalion, 24th Infantry.


297

FIGURE 162.-Jungle growth on Hill 260, showing protection afforded by trees.

FIGURE 163.-Hill 260 being shelled by Americal Division artillery fire, on 19 March. The firing continued for several hours at the end of which time it was believed that all enemy resistance had been neutralized. Note partial destruction of jungle growth.


298

FIGURE 164.-Enemy pillbox on Hill 260. The dense jungle growth has been entirely cleared away by artillery fire.

American forces engaged.-Companies B, E, F, G, and H plus one platoon of Company K, 182d Infantry, and Company G, 164th Infantry, actively took part in the action on the hill. All other companies in the regiment were in general support plus A and B Companies, 57th Engineer Combat Battalion; 246th and 247th Field Artillery Battalions; 82d Chemical Battalion-total, 1,350 men.

Japanese forces engaged.-Elements of the 13th and 23rd Infantry Regiments, both part of the 6th Division, were identified as taking part in the battle for Hill 260. It was estimated that 1,400 Japanese were involved in this action.

Table 58 lists the casualties sustained by the 1,350 U.S. troops engaged on Hill 260.

In comparison to the other two main thrusts by the enemy on the perimeter, there was more offensive action by U.S. troops on Hill 260. The enemy in the initial attack had captured and had managed to defend the outpost tree which was the focal point on the hill. Furthermore, the character of the terrain lent itself readily to defense and prevented the effective use of tanks.

The heaviest casualties were in the 182d Infantry with 800 troops involved (table 59).

Estimates of Japanese killed and wounded were difficult to make because of their practice of carrying away and burying their own dead. A total of 212 Japanese bodies were found by U.S. troops on Hill 260, and the Americal Division G-2 (intelligence) listed 541 Japanese as the total killed. The ratio of Japanese to U.S. troops killed was 7.6 to 1. In addition, many wounded


299

were seen going to the rear, and it is believed an entire battalion plus a number of supporting troops were virtually wiped out. The heaviest fighting occurred during the period 10-14 March and, as indicated later by prisoner-of-war reports, this engagement broke up the initial attack of the entire Japanese 13th Infantry Regiment on the Bougainville perimeter.

TABLE 58.-Distribution of 713 casualties among 1,350 U.S. Army troops engaged on Hill 260, by category

Category

Number of casualties

Percent of-

Officers

Enlisted men

Total

Total casualties

Total troops engaged

Killed-in-action

8

63

71

9.9

5.2

Wounded:

Seriously

9

204

213

29.9

15.8

Slightly

37

370

407

57.1

30.2

Missing-in-action

4

18

22

3.1

1.6

Total

58

655

713

100.0

52.8


TABLE 59.-Distribution of 426 casualties among 800 men of the 182d Infantry engaged on Hill 260, by category

Category

U.S. casualties

Total troops engaged

Number

Percent

Percent

Killed-in-action

63

14.8

7.9

Wounded:

Seriously

106

24.9

13.2

Slightly

256

60.1

32.0

Self-inflicted

1

.2

.1

Total

426

100.0

53.2


Operations on Hill 7005

The terrain here was mountainous but mostly second growth (fig. 165) rather than virgin jungle. The sides of the ridges were very steep (fig. 166) and at one point of the assault were almost precipitous. The action by U.S. troops was largely defensive but did involve the recapture of certain positions into which the Japanese had infiltrated. A one-way road leading along behind Allied lines for a time was under enemy fire (fig. 167), necessitating a difficult carry (fig. 168) for the litter bearers of more than a thousand yards.

5Report, After Action Operations, 37th Infantry Division, pt. II, G-3 Operations Narrative, 8 Nov. 1943-30 Apr. 1944.


300

FIGURE 165.-Partially cleared jungle growth on Hill 700. Through this draw, the Japanese made their approach to the hill.

FIGURE 166.-Precipitous hillside off the perimeter road. Grenades were rolled down this bank causing many casualties.


301

FIGURE 167.-Wounded being transferred from halftrack to jeep. Halftrack was used because road was under fire.

FIGURE 168.-Wounded soldier being helped down the side of Hill 700 by two medical aidmen.


302

On the morning of 8 March, the Japanese attack began with some artillery and spasmodic small arms fire which continued throughout the day. During the night of 9 March, boobytraps warned of attack followed by hostile fire from mortars and rifles. At dawn, it was found that at least one company of Japanese had occupied the north slope and crest of Hill 700 and had penetrated the Allied line to a depth of 75 yards over a 100-yard front. During the day, a counterattack by the 1st and 2d Battalions of the 145th Infantry regained several pillboxes on the south slope of the hill. One tank was used with fair success along the road which was under fire. On 10 March, the enemy retained possession of the crest of the hill in spite of continued ground action. Efforts to reach the Japanese positions on Hill 700 by engineer "polecharges," bangalore torpedoes, and bazookas were without avail and resulted in numerous casualties due to the excellent Japanese field of fire.

At 1700 hours on 10 March, a determined attack was made by U.S. forces who, in spite of intense enemy light and heavy mortar and artillery fire (fig. 169), succeeded in driving the enemy from the crest of Hill 700. Japanese concentrations coming up to reinforce this area were subjected to heavy bombing and artillery fire which was very effective. On 11 March at daylight, the enemy made a general assault on Cannon Hill held by the 3d Battalion of

FIGURE 169.-Japanese 75 mm. gun emplacement on Blue Ridge that was used by the enemy in their attack on Hill 700. Interior view; note the large window.


303

the 145th Infantry. The attack was repulsed with the exception of one pillbox gained by the enemy on Hill 700 (fig. 170). Japanese losses were reported as enormous with the enemy assault wave attacking over piles of their own dead. On 12 March after severe fighting, U.S. forces succeeded in driving the enemy from Hill 700. A total of 399 Japanese dead were counted within the wire on the crest and on the forward slope of the hill. On the night of 13 March, the enemy again attacked in the draw west of Hill 700. Searchlights were used successfully to reflect light from the overhanging clouds, and the attack was repulsed. After this date, only intermittent contact was made with the enemy in this area.

FIGURE 170.-Enemy dead killed while defending their position in a pillbox on Hill 700.

During the engagement on Hill 700, there were approximately 2,600 U.S. troops involved. Table 60 summarizes the various types of casualties among the 519 total casualties.

A total of 2,219 (719 counted, 1,500 estimated) Japanese were killed in action during the engagement of Hill 700. For this encounter, the ratio of U.S. dead (KIA plus DOW) to Japanese dead was 1 to 36.

The large number of enemy dead estimated rather than counted was due to the enemy custom of burying several bodies in one grave and also to the large number killed by U.S. bombing and artillery fire behind the lines, making it impossible to obtain an immediate count.


304

TABLE 60.-Distribution of 519 casualties among 2,600 U.S. troops engaged on Hill 700, by category

Category

Casualties

Total troops engaged

Number

Percent

Percent

Killed-in-action

45

8.7

1.7

Wounded-treated-died

16

3.1

.6

Total

61

11.8

2.3

Wounded living:

 

Returned to duty

215

41.4

8.4

Hospitalized

243

46.8

9.3

Total

458

88.2

17.7

Grand total

519

100.0

20.0


Operations on 129th Infantry sector6

The terrain here was fairly flat (fig. 171) covered with second growth and provided fair ground for tank maneuvers. The action here was characterized by temporary withdrawals of U.S. troops from forward positions under the pressure of Japanese attacks followed by highly effective tank supported counterattacks (fig. 172).

On 6 March, there were numerous patrol contacts and clashes with superior Japanese forces advancing along the Laruma River, and Allied outposts were forced back. The main attack by the Japanese 45th Infantry was launched on the morning of 12 March and succeeded in penetrating Allied wire and in occupying several pillboxes, some of which were retaken by counterattack. Again, in the early morning of 13 March, the enemy succeeded in taking six more pillboxes, and counterattacks supported by tanks resulted in retaking all but two pillboxes (fig. 173). The Japanese were attacking very strong positions in relatively open terrain, and their losses were heavy, estimated at 350-500 dead on this day, compared with 2 killed and 10 wounded in the 129th Infantry sector. The next day, 14 March, was a relatively quiet day during which Allied wire was repaired under cover of the tanks. On 15 March at 0400 hours, the Japanese again attacked and, after heavy fighting, penetrated to a depth of 100 yards over a 1,000-yard front. A tank-supported counterattack failed to dislodge the enemy who had now brought in at least one 77 mm. field gun. A second counterattack, supported by tanks and by a heavy concentration of artillery, reestablished the Allied line. Spasmodic fire occurred

6See footnote 5, p. 299.


305

FIGURE 171.-A cleared field of fire in front of the 129th Infantry sector.

FIGURE 172.-Light tank of the 754th Tank Battalion. This tank was in action against the Japanese at Company G, 129th Infantry, 37th Division perimeter. The cleared area in front of perimeter greatly facilitated the use of tanks.


306

FIGURE 173.-Soldiers of Company F, 129th Infantry, 37th Division, crawling up to barbed wire. Japanese were just in front of and to left of the wire and occupied the American pillboxes to the left and to the right (not shown in picture). American troops were surrounded until tanks were called upon to knock out the enemy.

on 16 March, but on 17 March at 0400 hours the enemy again attacked, breaching Allied wire to a depth of 75 yards where the attacks stopped and the enemy dug in. Prisoners' statements indicated that Allied artillery had taken a huge toll in the support and reserve units. Allied artillery continued a heavy harassing fire (fig. 174), and except for sporadic fire fights the sector was relatively quiet until 24 March when shortly after midnight the Japanese began to infiltrate. By daylight, the enemy had penetrated 300 yards (fig. 175). During the day, there was heavy hole-to-hole fighting and tank-supported counterattacks (fig. 176) which regained control of the high ground. During the latter fighting, the Japanese losses were large (fig. 177), 310 dead were counted within Allied wire compared to U.S. losses of 16 killed and 42 wounded. The artillery placed an extremely heavy concentration in front of Allied lines (fig. 178) following which only sporadic attempts to penetrate Allied wire occurred.

Table 61 gives a breakdown of the 450 casualties that were sustained by the 1,850 U.S. troops engaged on the 129th Infantry sector.

Approximately 4,300 Japanese troops were engaged on the 129th sector up to 16-17 March when an additional 600 men were brought into the area. The actual count of enemy dead was 2,373. The ratio of U.S. dead (KIA plus DOW) to Japanese dead was 1 to 30.


307

FIGURE 174.-An area devastated by U.S. artillery shell fire.

FIGURE 175.-Scene at area command post during action of Japanese infiltration of 2d Battalion, 129th Infantry, 37th Division. Reinforcing troops of Company A are in prone positions as an enemy machinegun opens fire. Tanks in background were called upon to knock out enemy positions. Burning jeep is the result of a Japanese grenade.


308

FIGURE 176.-Scene of a General Sherman medium tank and infantrymen attacking Japanese positions along the perimeter of 129th Infantry, 37th Division.

FIGURE 177.-Japanese killed on the perimeter of Company F, 129th Infantry, 37th Division. The enemy dead were hit by so many missiles it was impossible to determine cause of death.


309

FIGURE 178.-Japanese foxholes under bank of draw in 129th Infantry sector. Note how jungle was cleared by artillery fire.

TABLE 61.-Distribution of 450 casualties among 1,850 U.S. troops engaged on 129th Infantry sector, by category

Category

Casualties

Total troops engaged

Number

Percent

Percent

Killed in action

64

14.2

3.5

Wounded-treated-died

14

3.1

.7

Total

78

17.3

4.2

Wounded living:

Returned to duty

160

35.6

8.6

Hospitalized

212

47.1

11.5

Total

372

82.7

20.1

Grand total

450

100.0

24.3


Comment on Relatively Large Number of Japanese Casualties

Since one of the purposes of this study was to make observations on the relative lethal effects of weapons, the great disproportion between enemy and U.S. casualties deserves some comment. It is estimated that the enemy had 8,527 killed in action out of 10,000 troops involved in combat, as contrasted


310

to 210 killed (180 KIA plus 30 DOW) out of 5,800 U.S. troops involved. This is a ratio of 23.9 Japanese for each 1 of U.S. forces killed.

The approximate time for the Japanese attack was known, as well as the most likely points of attack. Consequently, the enemy attacked against extremely well prepared positions. United States supplies of ammunition were abundant and easily accessible to the front by an excellent system of roads. The concentration of firepower, especially artillery and mortar, was intensive. United States artillery concentration on Japanese reinforcements moving over restricted jungle tracks was particularly effective. United States forces had complete control of the air making it easy to observe, as well as to bomb, enemy troop concentrations. The limited supply of enemy artillery and ammunition had to be transported under great difficulties over the most rugged terrain. Furthermore, as in other campaigns in the South Pacific, enemy artillery was never used in concentration as judged by U.S. standards. Whenever the Japanese broke through Allied lines, which they did repeatedly, they never appeared to have sufficient reserves to follow up the advantage. There is evidence that the concentration of U.S. artillery fire on Japanese reinforcements prevented the accumulation of any effective body of troops.

On Hill 260, the ratio of Japanese dead to U.S. dead was 8 to 1. This was the most favorable ratio for the Japanese in any of the three sectors. The enemy had taken the hill very early and acquired the advantage of the terrain. Consequently, the action of U.S. troops was mostly offensive under the disadvantage of retaking a hill in which the enemy occupied well dug-in positions. The terrain prevented the use of tanks, and the proximity of the lines limited the use of U.S. artillery.

On Hill 700, the ratio of Japanese dead to U.S. dead was 36.3 to 1. While it was necessary here, also, to retake the crest of the hill, the major part of U.S. action was defensive in well-prepared positions. The enemy approach to this sector was limited because of the terrain, making artillery concentrations on their reinforcements highly effective and accounting for the greater number of enemy dead. On reaching the vicinity of U.S. lines, the enemy attacked up steep slopes in great concentration.

On the 129th sector, the ratio of Japanese dead to U.S. dead was 30 to 1. Here the approach for the enemy via the Numa-Numa Trail was easier, and the terrain permitted attack on a wider front. The terrain was also favorable to the use of tanks, and these were highly effective in retaking positions lost after the enemy had exhausted the force of their initial impact and their reserves had been disrupted by U.S. artillery. On this sector, also, the enemy attacked in great concentration on a narrow front against strongly prepared positions. Against these concentrated attacks, the use of canister-type ammunition was highly effective.

Control of the air, the use of tanks, and superior firepower in defensive positions, in addition to the greater and more effective concentrations of artillery fire, were the chief factors accounting for the large number of the enemy dead.


311

DISPOSITION OF BATTLE CASUALTIES AND ANATOMIC DISTRIBUTION OF WOUNDS

In this chapter, the term "battle casualty" is used to designate only those combatants who were killed or wounded by weapons. All deaths or injuries produced by other agents, such as falling trees, motor vehicle accidents, or others of a similar nature have been excluded. The total number of casualties includes all those wounded both by Allied and enemy weapons. Wounds caused by Japanese weapons and those resulting from U.S. weapons have been separated and are discussed under separate sections. It was impossible to ascertain which of the self-inflicted wounds were due to the soldiers' willful misconduct and which were accidental. These wounds are included and discussed in the section on U.S. weapons. It is known that 12.3 percent of the total casualties were produced by U.S. weapons. The actual percentage, however, may be slightly greater, for it is known that the enemy did use some U.S. captured weapons, particularly rifles and grenades.

There were 2,335 battle casualties. Of these, 547 (23.4 percent) were lightly wounded and were returned to duty immediately from the battalion aid or collecting stations. These 547 casualties are included in the initial total for the sake of completeness, for it was assumed that reports of casualty studies in other armies are based on computations which also include this group of minor wounds. However, in the remainder of the study, these patients have been excluded, because of the insignificant disability entailed by their injuries. Therefore, this study was based primarily on 1,788 casualties who were killed in action or who sustained wounds which necessitated hospital treatment. The term "hospital" includes two augmented clearing stations. The majority of patients returned to duty in the first echelon7 were treated in these clearing stations. With few exceptions, all patients who were returned to duty in the first echelon left the hospital within 30 days. Those patients in a hospital of the rear echelon, who were not evacuated to the United States, were usually returned to duty within 120 days.

Since no exact definition for the term "killed in action"8 has been established, an arbitrary standard was selected. In this study, KIA (killed in action) includes only those killed instantly, those found dead, and those who were mortally wounded and died shortly thereafter. Reports from division surgeons invariably contained a greater number of KIA than are found in this study. Explanation for this discrepancy is apparent and lies in the fact that the battalion surgeon frequently included, among the KIA's, patients who were initially seen alive but who were known to have died later. In this particular campaign, because of the close proximity of hospitals to the front, a large number

7In this chapter, "first echelon" is defined as the beachhead perimeter on Bougainville Island.-J. C. B.
8The usual definition is: Wounds directly due or attributable to enemy action which result in death before the casualty is admitted to a medical installation or receives treatment from a medical officer.-J. C. B.


312

of casualties are included under WIA (wounded in action),9who perforce, under less favorable circumstances, would have been classified as killed in action.

Table 62 gives a breakdown of the Bougainville casualties during the survey period and the general disposition of the WIA. It may be seen that the 395 dead (320 KIA and 75 DOW) constitute 16.9 percent of the total casualties. Thus, there was approximately one battle death (KIA plus DOW) among every six casualties (WIA, including DOW, plus KIA). Nearly 70 percent of all casualties were returned to duty within the theater and, of the 1,940 living wounded, 1,622 (83.6 percent) were returned to duty. However, 547 of these were returned to duty from a first aid post and did not require hospitalization. These soldiers had very minor wounds and were not lost to battle. Since the incapacitating effect of weapons on this group was negligible, they were eliminated from the remainder of this study, leaving 1,788 casualties who were killed or whose wounds were of such severe degree that they were lost to the battle. Using this criterion, there was approximately one battle death (KIA plus DOW) among every four and a half casualties (WIA, including DOW, plus KIA). The WIA (including DOW)/KIA ratio was 4.6:1. Those who died and those who were evacuated to the United States were classed as "lost to service" and comprised 30.5 percent of the total casualties.

A study of both the living and the dead is essential in order to gain an accurate and complete picture of the anatomic distribution of wounds produced

TABLE 62.-Distribution of 2,335 Allied casualties in Bougainville campaign, from 15 February to 21 April 1944, inclusive, by category

Category

Casualties

Number

Percent

Killed-in-action

320

13.7

Wounded-treated-died

75

3.2

Total

395

16.9

Wounded, living:

Evacuated to United States

318

13.6

Returned to duty from-

Aid station

547

23.4

First echelon hospital

700

30.0

Rear echelon hospital

375

16.1

Total

1,940

83.1

Grand total

2,335

100.0

9The usual definition is: Wounds directly due or attributable to enemy action which necessitate admission of the casualty to a medical installation and treatment by a medical officer. This generally includes those who are wounded treated, and died later (died-of-wounds (DOW)) or preferably wounded-treated-died (WTD).-J. C. B.


313

by various weapons. Although many wound studies have been made on the living, few records are available which analyze the effect of weapons on both the dead and living. In this investigation, data concerning all those who were killed in action as well as those who were wounded in action and died later have been collected and combined with the records of the living wounded.

Information regarding the circumstances of wounding in the living is relatively easy to obtain. Frequently, the facts may be elicited by an interview with the person wounded. However, the information will be still more accurate if checked with an eyewitness. To secure accurate details concerning the dead, however, is much more difficult. Post mortem examinations should be done, of course, whenever possible. Autopsies, however, were limited by the fact that all bodies could not be recovered and also by the fact that some were decomposed when recovered. Unfortunately, rapid deterioration occurs in the tropical climate of Bougainville, and for sanitary reasons the dead must be buried as soon as possible. The dead, when recovered, frequently exhibit wounds other than those which produced death. Wounds inflicted after death were especially common in areas subjected to concentrated artillery or mortar fire. Furthermore, it was often difficult and frequently impossible to identify the lethal weapon from the appearance of the wound or the missiles recovered at autopsy. In many instances, discrepancies were found when the emergency medical tag, hospital record, and post mortem findings were compared. It became apparent, therefore, that the true sequence of events leading to death could be secured only by careful personal questioning of witnesses who saw the soldier killed or who knew personally of the circumstances surrounding his death. By adhering to this method of investigation, a relatively high degree of accuracy was achieved, not only in the records of the dead but also of the living.

All casualties were classified under anatomic regions according to the location of the wound. In many instances, a major wound was accompanied by one or more minor wounds. In this event, the anatomic location of the major wound alone determined the classification. Furthermore, if a single wound among others was responsible for death or disability, the anatomic location of that wound determined the classification. In the classification of the casualties, it became necessary to add to the conventional division by anatomic regions, an additional group which was designated "Multiple Wounds." The term "multiple wounds" is used for those casualties sustaining two or more wounds, either one of which might have been responsible for the soldier's death or for rendering him unfit for action. It was difficult or impossible to classify accurately all casualties who received more than one wound. In many instances, the dead were struck by other missiles after death, under which circumstances it was not possible to decide which of several wounds produced death. In other instances, decomposition of the body made examination unsatisfactory. For these and other reasons, some patients were placed in the multiple wound classification, who probably should have been included properly with those grouped under single anatomic regions. Because of the diffi-


314

culty in analysis of the "multiple wounded," every effort was made to keep to a minimum the number so classified. Nevertheless, the "multiple wounded" constituted 18.6 percent of the casualties (table 64).

It is desirable in a study of this kind, if possible, to evaluate the influence of various factors on the anatomic distribution of wounds. Particular consideration should be given to the type of action (defensive or offensive), available cover or protection, armor, terrain, and type of weapon and projectile employed. Furthermore, if a true representation of the distribution of wounds is to be established, the data should be derived from a study of the dead as well as the living.

In table 63, the anatomic distribution of wounds in the living and dead in Bougainville is compared with similar wound distributions in the living in two past wars and in World War II. It will be observed that head wounds were more frequent at Bougainville than elsewhere. Perhaps this was due to the relatively close range of rifle fire in jungle warfare. Another discrepancy is observed by comparing the percentage of wounds of the head, chest, and upper extremities in the living. For example, wounds of these regions on Bougainville attained a total of 60.5 percent, whereas the Russians in World War II reported a total of only 48.5 percent.

TABLE 63.-Comparison of wounds in living wounded of two past wars and World War II with casualties of Bougainville campaign, 15 February to 21 April 1944, inclusive, by anatomic location

Anatomic location

Living wounded

Bougainville campaign

Dead1

Civil war

World War I

World War II

Living wounded1

U.S. Army

British Army

U.S. Army

Russian Army

Head, face, neck

9.1

11.4

16.8

16.1

9.1

20.7

49.0

Chest

11.7

3.6

7.8

9.8

11.4

12.4

29.6

Abdomen

6.0

3.4

4.7

5.6

6.2

5.7

16.3

Upper extremities

36.6

36.2

30.4

28.2

28.0

27.4

.3

Lower extremities

36.6

45.4

40.3

40.3

45.3

33.8

4.8

Total

100.0

100.0

100.0

100.0

100.0

100.0

100.0


1Multiple wounds excluded.
Source: Monthly Progress Report, Army Service Forces, War Department, April 1944, Section 7: Health.

With the exception of head wounds, the anatomic distribution of wounds in jungle warfare does not appear to differ greatly from the distribution of wounds reported for other types of warfare. In the absence of available data on other types of warfare, it is difficult to derive an adequate explanation for this high frequency of head wounds. The mortar followed closely by the rifle was the most frequent cause of wounds of the head. Since rifles are used frequently, and at close range, in jungle warfare, it is suggested that the greater


315

number and accuracy of bullets might account for the high incidence of head wounds. However, no proof can be offered for this hypothesis. The factor of exposure appears to offer no better explanation, since the head is apparently exposed to the same degree in jungle as in other types of warfare. The predominance of lower extremity wounds is accounted for by the high incidence of mortar hits.

Table 64 shows the anatomic distribution (regional frequency) of wounds in the 1,788 Bougainville battle casualties.

TABLE 64.-Distribution of wounds in 1,788 battle casualties, by anatomic location (regional frequency)1

Anatomic location

Total casualties

Dead

Living

Number

Percent

Number

Percent2

Number

Percent2

Head

384

21.5

144

37.5

240

62.5

Thorax

231

12.9

87

37.7

144

62.3

Abdomen

114

6.4

48

42.1

66

57.9

Extremities:

 

Upper

320

17.9

1

.3

319

99.7

Lower

407

22.7

14

3.5

393

96.5

Multiple

332

18.6

101

30.4

231

69.6

Total

1,788

100.0

395

22.1

1,393

77.9


1Any casualty with major wounds in more than one anatomic region is cataloged under "Multiple." Therefore total number of wounds is same as total number of casualties.
2Percent for dichotomy, dead versus living, by each anatomic location and for total dead versus living.

The anatomic distribution of wounds in the dead (table 65) is in striking contrast to the distribution of wounds in the living (table 66). The low incidence of extremity wounds among the dead is a rough index of the effectiveness of modern surgery, when dealing with wounds which do not involve a vital organ. Multiple wounds hold second place among the dead. Bullets (rifle and machinegun), mostly at close range, caused 58.2 percent of all deaths (table 77), while high explosives (artillery, mortar, grenade, and mine) caused 38.8 percent. A consideration of those who were wounded in action and died later (table 65) indicates that the major problem is encountered in wounds of the abdomen and thorax. These two regions accounted for 65.3 percent of all those who were wounded in action and died later.

An index of the degree of the residual disability may be obtained by a consideration of the number of patients returned to duty or evacuated to the United States (table 66). It should be noted that while the total number of patients in the anatomic divisions varies considerably, the percentage of patients returned to duty in each anatomic region remains remarkably constant.


316

TABLE 65.-Distribution of wounds in 395 dead, by anatomic location

Anatomic location

Total casualties

Killed in action

Died of wounds

Number

Percent

Number

Percent1

Percent2

Number

Percent1

Percent2

Head

144

36.5

134

41.9

93.1

10

13.3

6.9

Thorax

87

22.0

66

20.6

75.9

21

28.0

24.1

Abdomen

48

12.2

20

6.2

41.7

28

37.3

58.3

Extremities:

 

Upper

1

.2

1

.3

100.0

---

---

---

Lower

14

3.5

6

1.9

42.9

8

10.7

57.1

Multiple

101

25.6

93

29.1

92.1

8

10.7

7.9

Total

395

100.0

320

100.0

81.0

75

100.0

19.0


1Percent killed in action or died of wounds by each anatomic location of total killed in action or died of wounds, respectively.
2Percent of dichotomy, killed in action versus died of wounds, by each anatomic location and for total killed in action versus died of wounds.

TABLE 66.- Distribution of wounds in 1,393 living wounded, by anatomic location

Anatomic location

Total casualties

Returned to duty

Evacuated to United States

Number

Percent

Number

Percent1

Number

Percent1

Head

240

17.2

199

82.9

41

17.1

Thorax

144

10.3

110

76.4

34

23.6

Abdomen

66

4.8

42

63.6

24

36.4

Extremities:

Upper

319

22.9

243

76.2

76

23.8

Lower

393

28.2

308

78.4

85

21.6

Multiple

231

16.6

173

74.9

58

25.1

Total

1,393

100.0

1,075

77.2

318

22.8


1Percent for dichotomy, returned to duty versus evacuated to United States, by each anatomic location and for total returned to duty versus evacuated to United States.

Table 67 lists the regional frequency of wounds and the disposition of the living wounded in the 1,788 casualties.

Head wounds alone were responsible for 384 or 21.5 percent of all battle casualties. Of the 134 KIA in this group, death resulted from brain injury in 125 and from wounds of the face and neck in 9. In the 10 patients who were wounded in action and died later, 9 sustained brain injuries and 1 a transection of the cervical spinal cord. A more detailed description of these 10 patients will be found in another section under "Treatment of the Wounded." Of the surviving 240 patients, 157 (65.4 percent) were returned to duty in the first echelon.


317

TABLE 67.- Distribution of 1,788 battle casualties, by disposition and anatomic location of wounds (regional frequency)

Anatomic location

Regional frequency

Total casualties

Dead

Living wounded

Total

Killed in action

Wounded in action (DOW)

Total

Returned to
duty from
first echelon1

Returned to
duty from
rear echelon2

Evacuated to
United States

Number

Percent

Number

Percent

Number

Percent

Number

Percent

Number

Percent

Number

Percent

Number

Percent

Number

Percent

Percent

Head

21.5

384

100.0

144

37.5

134

34.9

10

2.6

240

62.5

157

40.9

42

10.9

41

10.7

Thorax

12.9

231

100.0

87

37.7

66

28.6

21

9.1

144

62.3

63

27.3

47

20.3

34

14.7

Abdomen

6.4

114

100.0

48

42.1

20

17.5

28

24.6

66

57.9

19

16.7

23

20.2

24

21.0

Extremities:

Upper

17.9

320

100.0

1

.3

1

.3

---

---

319

99.7

175

54.7

68

21.2

76

23.8

Lower

22.7

407

100.0

14

3.5

6

1.5

8

2.0

393

96.5

195

47.9

113

27.7

85

20.9

Multiple

18.6

332

100.0

101

30.4

93

28.0

8

2.4

231

69.6

91

27.4

82

24.7

58

17.5

Total

100.0

1,788

100.0

395

22.1

320

17.9

75

4.2

1,393

77.9

700

39.1

375

21.0

318

17.8


1Defined as the beachhead perimeter on Bougainville Island.
2From hospitals on Guadalcanal, Espíritu Santo, and New Caledonia.


318 

In table 68, the head wounds previously summarized (in table 67) are combined with those head wounds which are described later under "Multiple Wounds," making a total of 505. It is evident by comparison of the two tables that the ratio of the dead to those evacuated to the United States, and to those returned to duty, remains relatively unchanged. The inclusion of multiple wounds with those classified under single anatomic regions may lead to duplication and confusion. For this reason, multiple wounds have not been included in any tables except those devoted to the analysis of head wounds.

TABLE 68.-Distribution of 505 casualties with head wounds (including multiple wounds), by category

Category

Casualties

Number

Percent

Killed-in-action

165

32.7

Died of wounds

12

2.4

Total

177

35.1

Wounded, living:

Evacuated to United States

62

12.3

Returned to duty from-

First echelon1  

196

38.8

Rear echelon2  

70

13.8

Total

328

64.9

Grand total

505

100.0


1Defined as the beachhead perimeter on Bougainville Island.
2From hospitals on Guadalcanal, Espíritu Santo, and New Caledonia.

Thoracic wounds accounted for 12.9 percent of all battle casualties. Of the dead, 66 were killed in action. Of the 21 who were wounded in action and died later, 15 died during or following operation. Perforating wounds of the thorax were present in all those who were killed or died later. Of 63 patients returned to duty in the first echelon, only 3 had wounds which penetrated the pleural cavity; all others had wounds of the chest wall only. In the group of 47 patients returned to duty from the rear echelon, 33 sustained chest wall wounds only. Among the remaining 14 with lesions involving the lung or pleura, 6 underwent lung operation. Of 34 patients who were evacuated to the United States, 24 had injuries of the lung; 19 of this latter group were treated by surgical operation and 5 by conservative measures. The remaining 10 patients had wounds of the chest wall which did not communicate with the pleural cavity.


319

A total of 114 patients sustained abdominal wounds. The abdomen was struck less frequently than any other anatomic region, and these wounded constituted the smallest number (6.4 percent) of all casualties. In 10 patients, wounds involving both the abdomen and thorax with perforation of the diaphragm were present. Twenty patients were killed in action, one of whom sustained a transection of the spinal cord. A relatively greater number (28, 24.6 percent) of patients were wounded in action and died later in this group than any other. Of these 28 patients, only 3 died without operation. In most instances, death resulted either from shock and hemorrhage or from peritonitis. The entire group of 19 patients returned to duty in the first echelon had wounds of the abdominal wall only. Of 23 patients returned to duty from the rear echelon, 13 had abdominal wall wounds; 1 had a combined thoracoabdominal wound; and the remainder had visceral lesions distributed as follows: Liver, 4; colon, 2; spleen, kidney, and bladder, 1 each. Fewer patients wounded in the abdomen (36.9 percent) were able to return to duty, than were those wounded in any other region. Of the 24 patients evacuated to the United States, 18 had injuries of the abdominal viscera, 5 had abdominal wall wounds, and 1 a transection of the cauda equina. The visceral lesions among these patients were distributed as follows: Small intestine, 6; small intestine and colon, 4; colon, 3; spleen and diaphragm, 2; stomach and liver, colon and diaphragm, and bladder, 1 each.

Wounds of the upper extremity alone constituted 17.9 percent of all battle casualties, yet wounds of this region carry a death risk of only 0.3 percent. No patients died who received treatment. The number of patients returned to duty in the first echelon is greater among those receiving upper extremity wounds than among those wounded in any other region. Of these 175 patients, 4 had fractures of the hand and 2, incomplete fractures of the arm. In the 68 patients returned to duty from the rear echelon, there were 12 fractures as follows: 6 of the bones of the hand and 2 each of the scapula, humerus, and forearm. In the 76 patients evacuated to the United States, there were 58 compound fractures and 5 amputations. The fractures were distributed as follows: Humerus, 23; bones of the forearm, 19; bones of the hand, 12; and scapula, 4. The percentage of patients evacuated to the United States was higher in upper extremity wounds than in wounds of any other anatomic region.

Wounds of the lower extremity were the most numerous of all battle wounds (22.7 percent) and accounted for next to the lowest mortality of any region (1.5 percent KIA). There were six casualties classed as killed in action, although with one exception all were alive when first seen. These soldiers either could not be reached or else died before adequate medical aid could be given. There were eight patients who were wounded in action and died later. Seven of these died in the first echelon and one in the second echelon. Of the seven deaths in the first echelon, two resulted from gas gangrene and five from shock and hemorrhage. Two deaths in the latter group might have been avoided by the use of a tourniquet. From the first echelon, 195 patients were


320

returned to duty. With the exception of one patient who had a chip fracture of the tibia, all of these patients had soft-tissue wounds only. From the rear echelon, 113 patients were returned to duty, 8 of whom had fractures of the bones of the leg and 4 of the bones of the foot. In 85 patients evacuated to the United States, there were 58 compound fractures distributed as follows: Bones of the leg, 31; femur, 18; and bones of the foot, 9. In addition, there were 10 amputations of the thigh or leg.

The risk of death in wounds of the extremities is low. In 727 casualties with wounds of the upper and lower extremities, there were 15 deaths (2.0 percent). On the other hand, wounds of the extremities constituted half of all patients evacuated to the United States. The majority of patients with wounds of the extremities, who were lost to the service by evacuation, had fractures as shown in table 69. Fractures among upper extremity wounds are more common (29.5 percent) than among the lower extremity lesions (18.3 percent). The greater relative volume of soft tissue to bone in the lower extremity may explain the lower incidence of fracture. On the other hand, the explanation may lie in the fact that the percentage of high-velocity missile

TABLE 69.-Disposition of 319 casualties with wounds of upper extremities and 393 casualties with wounds of lower extremities

Disposition

Total living wounded

Fractures

Nonfractures

Number

Percent

Number

Percent1

Number

Percent1

Upper extremity wound

Returned to duty from-

First echelon2

175

54.9

6

3.4

169

96.6

Rear echelon3

68

21.3

20

29.4

48

70.6

Evacuated to United States

76

23.8

68

89.5

8

10.5

Total

319

100.0

94

29.5

225

70.5

Lower extremity wound

Returned to duty from-

First echelon2

195

49.6

1

0.5

194

99.5

Rear echelon3

113

28.8

13

11.5

100

88.5

Evacuated to United States

85

21.6

58

68.2

27

31.8

Total

393

100.0

72

18.3

321

81.7


1Percent for dichotomy, fractures versus nonfractures, under each disposition category and for total fractures versus nonfractures by upper and lower extremity wounds.
2Defined as the beachhead perimeter on Bougainville Island.
3From hospitals on Guadalcanal, Espíritu Santo, and New Caledonia.


321

wounds are slightly greater in the upper than in the lower extremity. Bullets produced 36.9 percent of all wounds of the upper extremity and 27.9 percent of the wounds of the lower extremity. Patients who returned to duty in the first and second echelons usually had fractures of small bones, chip and perforating fractures, and other fractures with minimal bone damage. It should be noted that 89.5 percent of the patients with wounds of the upper extremity and 68.2 percent of those with wounds of the lower extremity were evacuated to the United States because of fractures. The cause of fractures is discussed further in a later section devoted to the relative effect of weapons.

Wounds were classed as multiple only if two or more wounds of different regions could have caused death or disability. Such wounds caused 18.6 percent of all battle casualties. As in wounds of the head when death occurred, it was usually instantaneous. On the other hand, a relatively high percentage of patients with multiple wounds were returned to duty. In a group of 91 patients returned to duty from the first echelon, there were 203 soft-tissue wounds distributed as follows: Upper extremity, 73; lower extremity, 61; thoracic wall, 22; face and neck, 20; scalp, 14; abdominal wall, 8; and eye, 5. Present also were chip fractures of the clavicle, finger, and leg. From the rear echelon, 82 patients were returned to duty with 186 soft-tissue wounds distributed as follows: Upper extremity, 62; lower extremity, 61; thoracic wall, 24; face and neck, 17; scalp, 10; abdominal wall, 8; abdominal perforations, 2 (spleen and rectum); eye, 1; and lung perforation, 1. There were 8 chip fractures, 6 of the upper and 2 of the lower extremity, and also 2 perforating fractures of the pelvis; in addition, there were 2 finger amputations. There was a total of 151 soft-tissue wounds and fractures in 58 patients who were evacuated to the United States. The 38 fractures were distributed as follows: Upper extremity, 20; lower extremity, 16; and jaw, 2. The following soft-tissue wounds were present: Upper extremity, 36; lower extremity, 34; thoracic wall, 16; face and neck, 12; eye, 5; amputations, 5; scalp, 3; brain, 1; and abdominal wall, 1. Among these patients with multiple wounds, fractures were the chief cause for evacuation to the United States.

The anatomic distribution of wounds may vary according to the type of weapon causing the wound, the degree of exposure of different parts of the body, the protection afforded by various means, and the direction of fire. If the body were unprotected in an atmosphere of flying missiles of equal distribution, wounding should occur in direct proportion to the exposed surface area. However, such a theoretical condition never exists. On the contrary, missiles usually move in one direction at a given time. The projected area of the body if completely exposed, therefore, offers a better measure for the study of the probable hits. The mean projected body area10 is obtained from projection in three positions, standing, kneeling, and lying. The hits with all weapons are compared with the mean projected body area (table 70). The head is the only region in which the percentage of wounds appreciably ex-

10Burns, B. D., and Zuckerman, S.: The Wounding Power of Small Bomb and Shell Fragments. R. C. No. 350 of the Research and Experiments Department of the Ministry of Home Security.


322

ceeded the percentage of the projected area for that region. The percentage of hits in the abdominal area is considerably less than the percentage of its projected area. The question may be raised why wounds of the head so far exceed the projected head area. Was this due to good marksmanship or exposure? Obviously, the head must be exposed for marksmanship to be effective. Since wounds caused by rifle bullets and mortar shell fragments were found in significant numbers and the circumstances were known with reasonable accuracy, they may be compared. The directed fire of the rifle and the undirected hits with mortar fragments were found to approximate closely the total hits by all weapons. This is evidence that exposure is one of the chief factors in accounting for the high incidence of head wounds. Nevertheless, the number of wounds caused by rifle fire does exceed the number caused by mortar fragments in the head, upper extremity, and thorax. This may be interpreted as evidence that marksmanship does play a small but important part in the high incidence of head wounds. This observation is further substantiated by the fact that the lower extremity presents the reverse of these findings.

TABLE 70.-Mean projected body area and wound distribution (excluding multiple wounds)

Anatomic location

Mean projected body area

Total hits for all weapons1

Total hits for rifle

Total hits for mortar

Number

Percent

Number

Percent

Number

Percent

Percent

Head

12.0

384

26.4

119

29.1

127

23.7

Thorax

16.0

231

15.9

66

16.2

79

14.7

Abdomen

11.0

114

7.8

30

7.3

39

7.3

Extremities:

Upper

22.0

320

22.0

99

24.2

119

22.2

Lower

39.0

407

27.9

95

23.2

172

32.1

Total

100.0

1,456

100.0

409

100.0

536

100.0


1Includes all other weapons in addition to rifle and mortar which are shown specifically.

THE DIFFERENT WEAPONS CAUSING BATTLE CASUALTIES

It is obvious that the number of battle casualties produced by various weapons will depend upon the type of warfare, the number of weapons employed, and the training and tactics of the opposing forces. Thus, the measure of effectiveness of a given weapon must, of necessity, vary according to the circumstances under which it is used. The effectiveness of a weapon depends not only upon the total number of casualties it produces but also upon the ratio of the killed to wounded and upon the severity of the wound. In a certain local situation, the most effective weapon might be one which temporarily disabled the greatest number of the enemy and hence allowed the capture of a particular


323

objective or the winning of a single battle. If the effectiveness of a weapon is to be measured by this latter criterion, it would be necessary to set up an arbitrary definition of "temporary disability." In this event, a solution of the problem would be found in classifying the wounded on the basis of "ability to continue combat if life depended upon it."

The ratio of the killed to wounded is subject to various interpretations and must be clarified. As previously stated, the term "killed in action" in this study indicates those killed instantly and those who were mortally wounded and died within a relatively short time. Because of the proximity of medical installations on Bougainville, many mortally wounded patients lived to reach the hospital and were classified among those who were wounded in action and died later. Doubtless, under other less propitious circumstances, many of these casualties would have been classified with those who were killed in action. The term "dead" refers to the total number of those killed in action and those who were wounded-treated-died-later.

Since the severity of a wound is an abstract quality, open to individual interpretation and judgment and hence to consequent error, it was necessary to establish another criterion by which to judge the degree of disability sustained. The ultimate disposition of the patient seemed to offer a more reasonable basis for this estimation. All wounded, therefore, were separated into three groups depending upon whether the nature of the wound allowed the patient to be returned to duty from the first or from the rear echelon or whether it necessitated his evacuation to the United States. It is recognized that this is an arbitrary standard and open to the criticism that it is also an index of medical care; nevertheless, it is a factual and objective measure of the relative effect of weapons in the living wounded.

A fairly comprehensive description of the common types of Japanese weapons used on Bougainville has already been presented (pp. 289-292). From wound examination alone, it was never possible to distinguish the caliber of rifle or machinegun bullets nor the size of explosive shells. It was frequently impossible to judge with any accuracy whether the wound had been produced by a bullet or grenade shell or bomb fragment. Aerial bombing by the enemy did not occur during the Battle of the Perimeter. Miscellaneous weapons producing wounds were the bomb (U.S. aerial bombs), 13; pistol, 13; bangalore torpedo, 9; powder explosion, 5; bayonet, 2; bazooka, 1; and parachute flare, 1.

The Relative Lethal Effect of Weapons

The phrase "relative lethal effect" of a weapon refers to the percentage of deaths among the total number of casualties (dead and wounded) caused by that particular weapon. As previously stated, the ratio of the number of deaths to the number of casualties produced by any given weapon depends upon such variable factors as the type of action (offensive or defensive), number of weapons employed, terrain, exposure, and available protection. These factors


324

determine primarily the necessary degree of exposure of the soldier and consequently the number of hits, other factors being equal. The type and number of the particular weapon employed is then of prime importance in determining the relative lethal effect. For example, a small number of machineguns may produce few casualties but a "high lethal effect,"11 whereas a great many casualties may result from heavy mortar fire yet the lethal effect will remain relatively low.12

A comparison of the incidence of casualties caused by different weapons (table 71) shows that the mortar wounded more men (38.8 percent) than any other weapon. This was the weapon most feared by Allied troops. However, the relative lethal effect of the mortar is low (11.8 percent), rating next to the grenade which has the lowest (6.2 percent) relative lethal effect. There were 1,741 casualties caused by HE shells, grenades, landmines, and bullets and 47 casualties produced by miscellaneous weapons. High explosive shells, grenades, and mines caused wounds in 1,145 men (64.1 percent), but only 153 deaths (38.7 percent) occurred in this group. In contrast, bullets hit a total of 596 men (33.3 percent), but they accounted for 230 deaths (58.3 percent of total hit). The rifle was responsible for wounds in 445 casualties with a lethal effect of 32.1 percent. The machinegun, while causing fewer casualties (151), had the highest lethal effect of 57.6 percent. The very low lethal effect of the grenade (6.2 percent) is a characteristic probably peculiar to the Japanese hand grenade. Of the 34 landmine casualties, 33 were produced by U.S. mines. The 47 casualties (2.6 percent) listed under miscellaneous weapons were caused by pistols, bangalore torpedoes, bazookas, flares, powder explosions, and bayonet wounds.

Table 72 is a breakdown of the various causative agents according to the anatomic distribution (regional frequency) of wounds in the 1,788 casualties.

TABLE 71.-Distribution of 1,788 battle casualties, by relative lethal effect of causative agent

Causative agent

Total casualties

Dead

Living

Number

Percent

Number

Percent1

Number

Percent1

Rifle

445

24.9

143

32.1

302

67.9

Machinegun

151

8.4

87

57.6

64

42.4

Artillery

194

10.9

44

22.7

150

77.3

Mortar

693

38.8

82

11.8

611

88.2

Grenade

224

12.5

14

6.2

210

98.3

Mines

34

1.9

13

38.2

21

61.8

Miscellaneous

47

2.6

12

25.5

35

74.5

Total

1,788

100.0

395

22.1

1,393

77.9


1Percent for dichotomy, dead versus living, by each causative agent and for total dead versus living.

11High mortality-low morbidity.-J.C.B.
12High morbidity-low mortality.-J.C.B.


325-326

There were 384 casualties (21.4 percent of the total number) due to wounds of the head alone. Moreover, wounds of the head (144) accounted for 37.5 percent of all dead. Excluding the 5 wounded by miscellaneous weapons, 208 head casualties (54.2 percent) were produced by high explosives (fragments) and 171 (44.5 percent) by bullets. However, high explosives accounted for

TABLE 72.-Relative lethal effect of weapons, by anatomic location of wounds and for multiple wounds

Causative agent

Total casualties

Dead

Living

Number

Percent

Number

Percent1

Number

Percent1

Head wounds

Rifle

119

31.0

65

54.6

54

45.4

Machinegun

52

13.5

40

76.9

12

23.1

Artillery

46

12.0

15

32.6

31

67.4

Mortar

127

33.1

20

15.7

107

84.3

Grenade

32

8.3

1

3.1

31

96.9

Mine

3

.8

3

100.0

---

---

Miscellaneous

5

1.3

---

---

5

100.0

Total

384

100.0

144

37.5

240

62.5

Thoracic wounds

Rifle

66

28.6

34

51.5

32

48.5

Machinegun

25

10.8

18

72.0

7

28.0

Artillery

29

12.5

16

55.2

13

44.8

Mortar

79

34.2

14

17.7

65

82.3

Grenade

24

10.4

3

12.5

21

87.5

Mine

3

1.3

1

33.3

2

66.7

Miscellaneous

5

2.2

1

20.0

4

80.0

Total

231

100.0

87

37.6

144

62.3

Abdominal wounds

Rifle

30

26.3

14

46.7

16

53.3

Machinegun

17

14.9

13

76.5

4

23.5

Artillery

8

7.0

3

37.5

5

62.5

Mortar

39

34.2

12

30.8

27

69.2

Grenade

14

12.3

3

21.4

11

78.6

Mine

---

---

---

---

---

---

Miscellaneous

6

5.3

3

50.0

3

50.0

Total

114

100.0

48

42.1

66

57.9

Upper extremity wounds

Rifle

99

30.9

---

---

99

100.0

Machinegun

21

6.6

---

---

21

100.0

Artillery

36

11.3

---

---

36

100.0

Mortar

119

37.2

1

.8

118

99.2

Grenade

33

10.3

---

---

33

100.0

Mine

1

.3

---

---

1

100.0

Miscellaneous

11

3.4

---

---

11

100.0

Total

320

100.0

1

.3

319

99.7

Lower extremity wounds

Rifle

95

23.3

6

6.3

89

93.7

Machinegun

17

4.2

1

5.9

16

94.1

Artillery

52

12.8

1

1.9

51

98.1

Mortar

172

42.3

5

2.9

167

97.1

Grenade

59

14.5

1

1.7

58

98.3

Mine

5

1.2

---

---

5

100.0

Miscellaneous

7

1.7

---

---

7

100.0

Total

407

100.0

24

3.4

393

96.6

Multiple wounds

Rifle

36

10.9

24

66.7

12

33.3

Machinegun

19

5.7

15

78.9

4

21.1

Artillery

23

6.9

9

39.1

14

60.9

Mortar

157

47.3

30

19.1

127

80.9

Grenade

62

18.7

6

9.7

56

90.3

Mine

22

6.6

9

40.9

13

59.1

Miscellaneous

13

3.9

8

61.5

5

38.5

Total

332

100.0

101

30.4

231

69.6


1Percent for dichotomy, dead versus living, by each causative agent and for total dead versus living by anatomic location of wounds and for multiple wounds.

only 27.1 percent of the dead, whereas bullets were responsible for 72.9 percent. Thus, while high explosives caused more casualties, the lethal effect produced was relatively low. This may be explained by the average lower velocity of shell fragments and the relative greater protection afforded against them by


327

the helmet and skull. This is further substantiated by the fact that in 92.3 percent of the deaths due to head wounds, the skull had been penetrated.

Wounds of the thorax accounted for 12.9 percent of all casualties and for 22.0 percent of all deaths. Excluding 5 wounded by miscellaneous weapons, high explosives (fragments) produced 135 casualties (60 percent) and bullets 91 (40 percent). However, again contrasting relative lethal effects, bullets accounted for 59.7 percent of the deaths and high explosives for 40.3 percent. In thoracic wounds, the contrast between the lethal effect of wounds due to high explosives and bullets is not so pronounced as in wounds of the head. Possibly, this is due to the fact that the thoracic cage offers less protection to the vital organs than does the skull and helmet. This hypothesis seems to be substantiated further by the fact that while the lethal effect of both mortar and artillery fragments is increased in the thorax, the lethal effect of the grenade is increased fourfold. Bullet wounds were limited to the chest wall in only 18 instances, while high explosives caused 85 wounds which did not penetrate the thoracic cavity. The relatively lower velocity of some of the HE shell fragments would appear to account for its frequent failure to penetrate the thorax.

Casualties occasioned by wounds of the abdomen had the lowest incidence and accounted for only 6.4 percent of the total wounded and 12.1 percent of the dead. Whereas, high explosives (fragments) caused 56.2 percent of the casualties due to abdominal wounds, bullets accounted for 62.5 percent of the deaths from these wounds. This ratio may represent a distorted picture when compared to findings in other theaters, since it is based on such a small number (8) of wounds of the abdomen caused by artillery shells. However, the mortar and the grenade show almost twice the relative lethal effect in wounds of the abdomen as they do in wounds of the thorax. This is further evidence that the bony structures of the body wall may offer considerable effective protection against these low-velocity fragments. High explosive fragments caused 30 of the 53 wounds perforating the abdominal cavity, which would appear to indicate a relatively high index of penetration. Nevertheless, the relative protection afforded by the abdominal wall to low-velocity fragments should also be mentioned. Of 38 wounds limited to the abdominal wall, 30 were caused by HE fragments.

Wounds of the upper extremity accounted for 17.9 percent of all casualties and for only 0.3 percent of the dead. High explosive fragments caused 59.1 percent of these wounds. More than half of all wounds caused by high explosives were due to mortar shells. The relative effectiveness of bullets and HE fragments may be judged from the severity of the wound as indicated by the disposition of the patients shown in table 73.

The one death among the upper extremity casualties was caused by a mortar shell. Since the lethal effect of wounds of the upper extremity was negligible, it deserves no discussion.

Wounds of the lower extremity accounted for the highest number of casualties (22.7 percent). However, lower extremity wounds were responsible for only 3.5 percent of all deaths. High explosives caused 70.8 percent of lower


328

extremity casualties; of these, mortar shells alone were responsible for more than half. Bullets, however, caused 7 of the 14 deaths. The severity of wounds caused by bullets and high explosives may be judged by the disposition of casualties as shown in table 74.

TABLE 73.-Disposition of 123 and 196 casualties with upper extremity wounds, by relative effectiveness of bullets and HE fragments, respectively

Disposition

Casualties wounded by-

Bullets

HE fragments

Number

Percent

Number

Percent

Returned to duty from-

First echelon1

44

35.7

131

66.8

Rear echelon2

33

26.8

35

17.8

Evacuated to United States

46

32.7

30

15.4

Total

123

100.0

196

100.0


1Defined as the beachhead perimeter on Bougainville Island.
2From hospitals on Guadalcanal, Espíritu Santo, and New Caledonia.

TABLE 74.-Disposition of 110 and 283 casualties with lower extremity wounds, by relative effectiveness of bullets and HE fragments, respectively

Disposition

Casualties wounded by-

Bullets

HE fragments

Number

Percent

Number

Percent

Returned to duty from-

First echelon1

44

40.0

151

53.4

Rear echelon2

30

27.3

83

29.3

Evacuated to United States

36

32.7

49

17.3

Total

110

100.0

283

100.0


1Defined as the beachhead perimeter on Bougainville Island.
2From hospitals on Guadalcanal, Espíritu Santo, and New Caledonia.

Wounds of the extremities constituted the largest group of battle casualties in this survey and accounted for 40.6 percent of all wounds. These wounds, however, accounted for the smallest number of dead (3.8 percent). Since relatively few deaths resulted from wounds of this region, the effectiveness of weapons on the extremities must be judged by the duration of the soldiers' incapacity and by the number of casualties lost to the service by evacuation to the rear echelon and to the United States. In view of the fact that fractures were the chief cause of evacuation to the United States, the


329

relative effect of weapons on the extremities was also judged by the number of fractures they caused. The rifle caused the greatest number of fractures in both the upper and lower extremities (table 75). In the upper extremity, the rifle led not only in the number but also in the percentage chance of fracture. In general, the chance of fracture appeared to parallel the velocity of the missile. Bullets caused only 37.5 percent of upper extremity and 26.3 percent of lower extremity wounds, whereas these missiles caused 66 percent of upper extremity and 60 percent of lower extremity fractures.

TABLE 75.-Relative effect of weapons causing wounds of upper and lower extremities, among the living wounded

Causative agent

Total wounds

Fracture

Nonfracture

Number

Percent

Number

Percent1

Number

Percent1

Upper extremity

Rifle

99

31.0

55

55.5

44

44.5

Machinegun

21

6.6

7

33.3

14

66.7

Artillery

36

11.3

6

16.7

30

83.3

Mortar

118

37.0

18

15.3

100

84.7

Grenade

33

10.3

4

12.2

29

87.8

Miscellaneous

12

3.8

4

33.3

8

66.7

Total

319

100.0

94

29.5

225

70.5

Lower extremity

Rifle

89

22.6

28

31.5

61

68.5

Machinegun

16

4.1

9

56.2

7

43.8

Artillery

51

13.0

9

17.6

42

82.4

Mortar

167

42.5

15

8.9

152

91.1

Grenade

58

14.7

4

6.9

54

93.1

Mine

5

1.3

5

100.0

---

---

Miscellaneous

7

1.8

2

28.6

5

71.4

Total

393

100.0

72

18.3

321

81.7


1Percent for dichotomy, fracture versus nonfracture, by each causative agent and for total fracture versus nonfracture, by upper and lower extremity wounds.

Casualties due to multiple wounds rated third in incidence and constituted 18.6 percent of the total number. High explosives caused 79.5 percent of these wounds and 53.5 percent of the resultant deaths; however, the machinegun and rifle showed the highest relative lethal effect. The severity of multiple wounds caused by bullets and high explosives as judged by the disposition of casualties is shown in table 76.


330

TABLE 76.-Disposition of 16 and 215 casualties with multiple wounds, by relative effectiveness of bullets and HE fragments, respectively

Disposition

Casualties wounded by-

Bullets

HE fragments

Number

Percent

Number

Percent

Returned to duty from-

First echelon1

2

12.5

89

41.4

Rear echelon2

8

50.8

74

34.4

Evacuated to United States

6

37.5

52

24.2

Total

16

100.0

215

100.0


1Defined as the beachhead perimeter on Bougainville Island.
2From hospitals on Guadalcanal, Espíritu Santo, and New Caledonia.

The Dead

Table 77 shows the distribution of the dead according to the causative weapon. There were 395 dead of whom 230 or 58.2 percent were killed by bullets. Of these 395 dead, 75 (19 percent) were wounded in action, treated, and died later. Of these 75 patients, 50 died within 24 hours; of these 50, 40 were classed as mortally wounded. Had medical facilities been further removed from the frontline or had transportation problems been more difficult, a large number of those who were wounded and died later would, no doubt, have been classed as KIA. Bullet wounds tended to produce more immediate fatalities than did wounds produced by mortar and artillery shells. Among those who were wounded and died later, wounds were produced by the mortar in 28.0 percent, by artillery in 27.3 percent, and by the rifle in 14.7 percent.

TABLE 77.-Distribution of 395 fatal casualties, by relative effect of causative agent

Causative agent

Total dead

Killed in action

Died of wounds

Number

Percent

Number

Percent1

Number

Percent1

Rifle

143

36.2

122

85.3

21

14.7

Machinegun

87

22.0

72

82.8

15

17.2

Artillery

44

11.1

32

72.7

12

27.3

Mortar

82

20.8

59

72.0

23

28.0

Grenade

14

3.6

11

78.6

3

21.4

Mine

13

3.3

12

92.3

1

7.7

Miscellaneous

12

3.0

12

100.0

---

---

Total

395

100.0

320

81.0

75

19.0


1Percent for dichotomy, killed in action versus died of wounds, by causative agent and for total killed in action versus died of wounds.


331

Effectiveness of Weapons

To measure the effectiveness of a weapon by the number of casualties it produces may lead to erroneous conclusions. To reiterate, the number of casualties depends on such factors as the necessary exposure of the soldier, the concentration of troops, the number of weapons employed, and the effect of the missile. It is seldom that all these varying conditions of battle can be duplicated. On the other hand, the percentage chance of death and the length of disability when hit by a given weapon should remain relatively constant and, therefore, should offer a fairly accurate index of the effectiveness of various missiles.

The percentage chance of death when hit by various weapons is shown in table 78. Casualties receiving two or more wounds, either one of which might have produced death, are not included in this table, but are discussed under "Multiple Wounds." Nevertheless, many of these casualties did have more than one wound. The order of these weapons suggests that the chance of being killed is a function of the velocity of the missile. The risk of death when hit by a machinegun in the head, chest, or abdomen is approximately equal. The contrast in death risk between the machinegun (54.5 percent) and the rifle (29.1 percent) is not entirely due to multiplicity of hits, since multiple hits were found not infrequently with rifle fire. On the average, machinegun fire originated at a closer range than rifle fire, 61 percent of the hits being from less than 50 yards. The chance of death when hit by a grenade (4.9 percent) is approximately half that when hit by the mortar (9.7 percent). The risk of death when hit in the abdomen by mortar or grenade is relatively greater than when hit in the head or thorax. This suggests that the helmet and skull (fig. 179) as well as the ribs may offer considerable protection against many of these relatively low-velocity fragments.

The relative effect of weapons may be judged by the percentage chance of a light wound or of a severe wound (tables 79 and 80). These tables are based on living wounded only. A light wound was defined as one which allowed return to duty in the first echelon and a severe wound as one which necessitated evacuation to the United States. There appears to be considerable difference in the severity of a wound according to the anatomic region hit, as well as to the weapon causing it. In general, high explosives (fragments) tend toward light wounds while small arms (bullets) tend toward more severe wounds.

The relative effectiveness of weapons may also be evaluated by a consideration of the total dead plus the total evacuated to the United States. Together, these may be considered as "lost to the service" (table 81), although some who were returned to the United States may serve in future campaigns. It should be noted by this criterion that wounds of the extremities and abdomen assume a far greater relative importance than when death alone is utilized as an index of weapon effectiveness.


332

TABLE 78.-Relative effect of weapons: Probability of hits resulting in death, by anatomic location of wounds (excluding multiple wounds)

Weapon1

Total areas

Head

Thorax

Abdomen

Extremities

Hits

Deaths

Hits resulting in death

Hits

Deaths

Hits resulting in death

Hits

Deaths

Hits resulting in death

Hits

Deaths

Hits resulting in death

Hits

Deaths

Hits resulting in death

Number

Number

Percent

Number

Number

Percent

Number

Number

Percent

Number

Number

Percent

Number

Number

Percent

Rifle

409

119

29.1

119

65

54.6

66

34

51.5

30

14

46.7

194

6

3.1

Machinegun

132

72

54.5

52

40

76.9

25

18

72.0

17

13

76.5

38

1

2.6

Artillery

171

35

20.5

46

15

32.6

29

16

55.2

8

3

37.5

88

1

1.1

Mortar

536

52

9.7

127

20

15.7

79

14

17.7

39

12

30.8

291

6

2.1

Grenade

162

8

4.9

32

1

3.1

24

3

12.5

14

3

21.4

92

1

1.1


1Excluding mines and miscellaneous agents.


333

FIGURE 179.-Roentgenogram of skull showing artillery shell fragment lodged in sinus cavity. A soldier, standing in the company area, was hit by a Japanese 75 mm. artillery shell which exploded at a distance of 100 yards. A fragment of the shell penetrated the outer wall of the maxillary sinus and lodged in the sinus cavity. This is a good example of the relative protection afforded by bony structures to low-velocity fragments, even of large size. A. X-ray of skull. B. Recovered fragment.

Table 82 shows the number of patients returned to duty from the first echelon (Bougainville). Table 83 shows the total number of casualties dead and evacuated to the rear echelon and to the United States. These were lost to the Bougainville campaign. Note that the percentage effectiveness of each weapon suggests a possible correlation with the average velocity of hits.

Conditions of battle may be such that the effectiveness of a weapon can best be measured by whether the wounded soldier was able to continue fighting. Hence, the number of casualties per se is not a sufficient criterion since many of the wounded may continue to fight and hold off the enemy, at least temporarily. It is, therefore, desirable to know the number who are put out of action immediately and the number who could continue combat for a period of hours, if life depended on it. A questionnaire to determine whether an individual did or did not continue combat was found to be misleading, since conditions of battle were frequently such as to permit the soldier to seek immediate treatment. This he usually did when possible, since he had been so instructed by Medical Corps personnel. However, there were numerous instances of soldiers who were severely wounded and yet who continued to hold their position in the line until relieved. (For example: Two soldiers were holding a pillbox at night under Japanese attack. Eventually, each had a hand blown off, but with two hands between them, they cared for their wounds, manned their guns, and held off the attack until relieved at daybreak.)


334

TABLE 79.-Relative effect of weapons: Probability of causing light wounds1

Weapon


Total

Head

Thorax

Abdomen

Extremities

Sur-
vived


Re-
turned to duty

Per
cent

Sur-
vived

Re-
turned to duty

Per
cent

Sur-
vived

Re-
turned to duty

Per
cent

Sur-
vived

Re-
turned to duty

Per
cent

Sur-
vived

Re-
turned to duty

Per
cent

Rifle

290

110

37.9

54

32

59.3

32

7

21.9

16

3

18.8

188

68

36.2

Machinegun

60

22

36.7

12

4

33.3

7

3

42.9

4

0

0

37

15

40.5

Artillery

136

80

58.8

31

25

80.6

13

3

23.1

5

3

60.0

87

49

56.3

Mortar

484

272

56.2

107

70

65.4

65

32

49.2

27

8

29.6

285

162

56.8

Grenade

154

104

67.5

31

21

67.7

21

16

76.2

11

3

27.3

91

64

70.3


1Based on percent of living wounded (survived less multiple wounded) returned to duty from first echelon (defined as the beachhead perimeter on Bougainville Island).

TABLE 80.-Relative effect of weapons: Probability of causing serious nonfatal wounds1

Causative agent


Total

Head

Thorax

Abdomen

Extremities

Sur-
vived


Evacu-
ated to United States

Per
cent

Sur-
vived

Evacu-
ated to United States

Per
cent

Sur-
vived

Evacu-
ated to United States

Per
cent

Sur-
vived

Evacu-
ated to United States

Per
cent

Sur-
vived

Evacu-
ated to United States

Per
cent

Rifle

290

93

32.1

54

10

18.5

32

13

40.6

16

4

25.0

188

66

35.1

Machinegun

60

28

46.7

12

4

33.3

7

3

42.9

4

4

100.0

37

17

45.9

Artillery

136

23

16.9

31

3

9.7

13

2

15.4

5

2

40.0

87

16

18.4

Mortar

484

83

17.1

107

16

15.0

65

11

16.9

27

9

33.3

285

47

16.5

Grenade

154

26

16.9

31

8

25.8

21

3

14.3

11

4

36.4

91

11

12.1


1Based on percent of living wounded (survived less multiple wounded) evacuated to the United States.


335

TABLE 81.-Relative effect of weapons: Lost to service in the theater 1

Causative agent

Total

Head

Thorax

Abdomen

Extremities

Hit

Dead plus evacu-
ated to United States

Per
cent

Hit

Dead plus evacu-
ated to United States

Per
cent

Hit

Dead plus evacu-
ated to United States

Per
cent

Hit

Dead plus evacu-
ated to United States

Per
cent

Hit

Dead plus evacu-
ated to United States

Per
cent

Rifle

409

212

51.8

119

75

63.0

66

47

71.2

30

18

60.0

194

72

37.1

Machinegun

132

100

75.8

52

44

84.6

25

21

84.0

17

17

100.0

38

18

47.4

Artillery

171

58

33.9

46

18

39.1

29

18

62.1

8

5

62.5

88

17

19.3

Mortar

536

135

25.2

127

36

28.3

79

25

31.6

39

21

53.8

291

53

18.2

Grenade

162

34

21.0

32

9

28.1

24

6

25.0

14

7

50.0

92

12

13.0


1Percent of hits (dead plus survived, excluding multiple wounded) resulting in death or evacuation to the United States.


336

TABLE 82.-Relative effect of weapons: Casualties returned to duty from first echelon1

Weapon

Total casualties

Casualties returned to duty

Number

Percent of total

Number

Rifle

445

112

25.2

Machinegun

151

22

14.6

Artillery

194

84

43.3

Mortar

693

325

46.9

Grenade

224

133

59.4


1Defined as the beachhead perimeter on Bougainville Island.

TABLE 83.-Relative effect of weapons: Casualties lost to Bougainville campaign (dead or evacuated to rear echelon1or to United States)

Weapon

Total casualties

Casualties lost to Bougainville campaign

Number

Percent of total

Number

Rifle

445

333

74.8

Machinegun

151

129

85.4

Artillery

194

110

56.7

Mortar

693

368

53.1

Grenade

224

91

40.6


1To hospitals on Guadalcanal, Espíritu Santo, and New Caledonia.

An arbitrary criterion based on the seriousness of the wound seemed justified in order to determine whether a soldier will be able to continue in battle for a number of hours, if his life were at stake. For this purpose, an arbitrary schedule was derived, and the following wounded were classed as "Lost to Combat":

1. Wounds of the head and central nervous system producing unconsciousness or paralysis.

2. Wounds of intrathoracic structures producing hemorrhage and shock.

3. Wounds of intraperitoneal structures producing hemorrhage and shock.

4. Wounds of the extremities producing fractures of long bones, severance of major blood vessels, or major traumatic amputations.

5. Extensive wounds of soft tissue producing shock.

The wounded were classified according to the criteria listed and added to the dead to determine the total lost to combat (table 84). This table again suggests that the percentage effectiveness of the weapon is a function of the average velocity of the missiles.

Callender and others have shown that the wounding power of a missile is in proportion to the cube of the velocity, the mass and other factors being equal. In this report, the percentage effectiveness of weapons as judged by


337

the chance of death, and the severity of the wound, appears to be in accord with the observation that the wounding power of a missile is chiefly a function of velocity. When hits occur, the weapons in order of effectiveness are (1) machinegun, (2) rifle, (3) artillery, (4) mortar, and (5) grenade.

TABLE 84.-Relative effect of weapons: Casualties lost to combat

Weapon

Total casualties

Casualties lost to combat

Number

Percent 

Number

Rifle

445

233

52.4

Machinegun

151

114

75.5

Artillery

194

59

30.4

Mortar

693

170

24.5

Grenade

224

42

18.8


The Relative Effect of Weapons on the Disposition of Patients

An evaluation of the effectiveness of each weapon may be obtained by considering both the number killed and the severity of the wound as determined by the disposition of the patient.

There were 700 casualties returned to duty from the first echelon (defined as the beachhead perimeter on Bougainville Island). These patients spent an average of 12.7 days in the hospital (table 85). However, if the requirement had existed, the majority of these men would have been available for emergency combat duty in a shorter time. Nevertheless, the problem of the lightly wounded, treated in the first echelon, is of considerable importance, both because of days lost to the service and because these casualties occupy beds which might be needed for the more seriously wounded. Wounds caused by HE shell fragments constituted the major problem in the first echelon. Wounds of the extremities and multiple wounds comprised a majority of these lesions (table 86).

The rear echelon included hospitals on Guadalcanal, Espíritu Santo, and New Caledonia; the evacuation distances ranged from 400 to 1,500 miles from Bougainville. Consequently, patients evacuated to hospitals in the rear were lost to the service insofar as the Battle of the Perimeter was concerned. Subsequently, some of these patients were returned to duty from the rear echelon and performed service in combat units, hence were not lost to the South Pacific theater. The severity of the wounds in these casualties usually justified their removal to a rear echelon for convalescence. Only a very few were evacuated because of the need for additional vacant hospital beds on Bougainville. Hence, transfer to the rear echelon may be taken as a fair measure of the severity of a soldier's wound from the standpoint of his ability to undergo combat. The wounded were usually returned to duty from the


338

TABLE 85.-Days lost by 700 casualties returned to duty from first echelon1 hospitals, by causative agent

Causative agent

Casualties

Average number of days in hospital

Number

Percent

Rifle

112

16.0

14.2

Machinegun

22

3.1

16.6

Artillery

84

12.0

12.0

Mortar

325

46.5

12.0

Grenade

133

19.0

12.2

Mines and miscellaneous

24

3.4

18.0

Total

700

100.0

12.7


1Defined as the beachhead perimeter on Bougainville Island.

TABLE 86.-Days lost by 700 casualties returned to duty from first echelon1 hospitals, by anatomic location

Anatomic location

Casualties

Average number of days in hospital

Number

Percent

Head

157

22.4

9.0

Thorax

63

9.0

11.2

Abdomen

19

2.7

18.4

Extremities:

Upper

175

25.0

11.7

Lower

195

27.9

14.9

Multiple

91

13.0

15.8

Total

700

100.0

12.7


1Defined as the beachhead perimeter on Bougainville Island.

rear echelon or were evacuated to the United States within 120 days. However, the average elapsed time before return to duty was considerably less than this.

Though many patients evacuated to the United States were returned to duty eventually, they must be considered as lost to the service for a long period.

Table 87 presents the anatomic distribution of the hits by the various causative agents, and table 88 lists the general disposition of the nonfatal casualties.

In number of wounds produced, the rifle was exceeded only by the mortar and was responsible for 24.9 percent of all battle casualties. However, the rifle ranked first as a lethal agent, accounting for 36.2 percent of all dead. Moreover, it was second in percentage relative lethal effect (32.1 percent), being exceeded only by the machinegun (57.6 percent). The rifle produced


339-340

wounding in 53.7 percent of all casualties lost to the service by death and evacuation to the United States. The rifle caused more head wounds than any other weapon and was second only to the machinegun in relative lethal effect in head wounds. It ranked third in relative lethal effect in thoracic wounds,

TABLE 87.-Anatomic distribution (regional frequency) of wounds, by causative agents

Anatomic location

Total casualties

Dead

Living

Number

Percent

Number

Percent1

Number

Percent1

Rifle

Head

119

26.7

65

54.6

54

45.4

Thorax

66

14.8

34

51.5

32

48.5

Abdomen

30

6.7

14

46.7

16

53.3

Extremities:

Upper

99

22.3

---

---

99

100.0

Lower

95

21.4

6

6.3

89

93.7

Multiple

36

8.1

24

66.7

12

33.3

Total

445

100.0

143

32.1

302

67.9

Machinegun

Head

52

34.4

40

76.9

12

23.1

Thorax

25

16.5

18

72.0

7

28.0

Abdomen

17

11.3

13

76.5

4

23.5

Extremities:

Upper

21

13.9

---

---

21

100.0

Lower

17

11.3

1

5.9

16

94.1

Multiple

19

12.6

15

78.9

4

21.1

Total

151

100.0

87

57.6

64

42.4

Mortar

Head

127

18.3

20

15.7

107

84.3

Thorax

79

11.4

14

17.7

65

82.3

Abdomen

39

5.6

12

30.8

27

69.2

Extremities:

Upper

119

17.2

1

.8

118

99.2

Lower

172

24.8

5

2.9

167

97.1

Multiple

157

22.7

30

19.1

127

80.9

Total

693

100.0

82

11.8

611

88.2

Artillery

Head

46

23.7

15

32.6

31

67.4

Thorax

29

14.9

16

55.2

13

44.8

Abdomen

8

4.1

3

37.5

5

62.5

Extremities:

Upper

36

18.6

---

---

36

100.0

Lower

52

26.8

1

1.9

51

98.1

Multiple

23

11.9

9

39.1

14

60.9

Total

194

100.0

44

22.7

150

77.3

Grenade

Head

32

14.3

1

3.1

31

96.9

Thorax

24

10.7

3

12.5

21

87.5

Abdomen

14

6.3

3

21.4

11

78.6

Extremities:

Upper

33

14.7

---

---

33

100.0

Lower

59

26.3

1

1.7

58

98.3

Multiple

62

27.7

6

9.7

56

90.3

Total

224

100.0

14

6.3

210

93.7


1Percent for dichotomy, dead versus survived, by each anatomic location and for total dead versus survived by each causative agent.

being exceeded by the machinegun and artillery shell, and second in abdominal wounds. While the rifle was second to the mortar in causing wounds of both the upper and lower extremities, it produced more fractures than any other weapon (fig. 180).

The machinegun caused fewer casualties than any other weapon, 8.4 percent. However, its percentage relative lethal effect was the highest of all weapons, 57.6 percent. It was not possible to separate the casualties produced by the 6.5 mm. weapon from those produced by the 7.7 mm. machinegun. The percentage lost to the service by death and evacuation to the United States was also the highest of any weapon, 78.1 percent. Measured by the number of patients lost to the service, machinegun wounds were the most severe among those produced by any weapon. This high degree of effectiveness of the machinegun bullet may be explained partially by close range fire in this campaign and also by the multiplicity of wounds. The percentage relative


341

FIGURE 180.-Roentgenogram of compound comminuted fracture of the humerus caused by a Japanese .25 caliber rifle bullet fired from a distance of 75 yards. This is a typical example of the explosive effect of the .25 caliber rifle bullet when it strikes bone or a solid organ. Many of these bullets caused similar damage to the arm and then passed through the chest.

TABLE 88.-Disposition of 1,337 nonfatal casualties, by causative agent

Causative agent

Total survived

Returned to duty

Evacuated to United States

Total

From first echelon1

From rear echelon2

Number

Percent3

Number

Percent3

Number

Percent4

Number

Percent4

Number

Percent3

Rifle

302

67.9

206

46.3

112

54.4

94

45.6

96

21.6

Machinegun

64

42.4

33

21.9

22

66.7

11

33.3

31

20.5

Mortar

611

88.2

495

71.5

325

65.7

170

34.3

116

88.2

Artillery

150

77.3

123

63.4

84

68.3

39

31.7

27

13.9

Grenade

210

93.7

173

77.2

133

76.9

30

23.1

37

16.5

Total

1,337

78.4

1,030

60.4

676

65.6

354

34.4

307

18.0


1Defined as the beachhead perimeter on Bougainville Island.
2From hospitals on Guadalcanal, Espíritu Santo, and New Caledonia.
3Percent of total casualties inflicted by causative agent.
4Percent for dichotomy, first echelon, versus rear echelon of those returned to duty (= 100 percent).


342

FIGURE 181.-Roentgenogram of thoracic cavity of soldier who was prone on the ground when a mortar shell of unknown size exploded 1-yard distant. This soldier was also wounded in the arm, thigh, and both ankles. An open operation was performed, and the numerous lacerations in the lung, caused by the small fragments, were sutured and the intercostal vessels ligated. The soldier made a good recovery.

lethal effect was uniformly high for all regions of the body with the exception of the extremities.

The mortar caused more wounds than any other weapon and accounted for 38.8 percent of all battle casualties. However, its relative lethal effect was only 11.8 percent (fig. 181). The only weapon having a lower lethal effect was the grenade. Furthermore, 71.5 percent of the living wounded were returned to duty, a higher percentage than for any other weapon except the grenade. The dead and evacuated to the United States (lost to the service) totaled 28.5 percent. The highest relative lethal effect (30.8 percent) was observed in wounds of the abdomen, whereas the greatest number of deaths occurred in multiple regional involvement.

The use of artillery by the enemy in this campaign was relatively limited. Wounds caused by artillery shells, however, accounted for 10.9 percent of the casualties and were fourth in frequency. Artillery ranked fourth in cause of death (11.1 percent) and fifth in percentage lethal effect, 22.7 percent. Among casualties evacuated to the United States, artillery produced the lowest number of wounds, 13.9 percent. However, the percentage of those lost to the service by death and evacuation to the United States was 36.6 percent. While wounds


343

FIGURE 182.-Roentgenogram of thoracic cavity of soldier who was prone in a foxhole when a Japanese hand grenade exploded at a distance of not more than 1 foot from the chest wall. This X-ray shows the characteristic small fragments of the hand grenade. Most of the fragments were stopped by the chest wall, but some of them penetrated the pleura. The fragmentation of the Japanese hand grenade is irregular but usually very small.

of the extremities were frequent, only one death occurred. This death was produced by a lower extremity wound. Lethal wounds in order of frequency by regions were the thorax, head, multiple, abdomen, and lower extremity.

The grenade ranked third in wound production and accounted for 12.5 percent of all battle casualties (table 71). However, its relative lethal effect was the lowest of all weapons, 6.2 percent. Furthermore, the majority of the wounds were of a minor nature (fig. 182). The grenade was first among all weapons as gaged by the percentage of wounded returned to duty, 77.2 percent, and three-fourths of these patients were returned to duty from the first echelon. The grenade was responsible for the lowest number of casualties (22.8 percent) among those who were lost to the service by death and evacuation to the United States. Of all wounds produced by the grenade, 68.7 percent were classified as extremity wounds and multiple wounds.

Weapon Evaluation by Multiplicity of Wounds

The question has been frequently asked: Do missiles causing multiple wounds result in more serious casualties because of the number of wounds per se? The data available do not answer this question satisfactorily. Multiple


344

wounds were analyzed according to the number of different anatomic regions involved rather than by the total number of wounds. Thus, a patient with 10 wounds of the leg and 5 of the hand was classified under multiple wounds in two anatomic regions; that is, as an upper and a lower extremity casualty without regard to the number of lesions present.

Table 89 relates the casualties with multiple wounds to the number of anatomic regions involved and the severity of the wounds. The disposition of the patient was used to determine the severity of the wounds. The number of the multiple wounded casualties discharged in each echelon is tabulated by weapon. The corresponding number of anatomic regions hit is also recorded by weapon. Thus, there were 53 patients, with mortar wounds in 117 different anatomic regions, returned to duty in the first echelon. Therefore, among the patients returned to duty in this echelon, there were mortar wounds in 2.21 of the various anatomic regions per patient (table 90). The ratio of anatomic regions wounded per patient is slightly higher for each weapon among the casualties evacuated to the United States. However, the difference is so slight as to suggest that multiplicity of wounds alone is not a factor of great importance. The relatively low mortality of 3.3 percent for all patients with multiple wounds seen alive suggests that the multiple wounds per se add little to the risk. It is likely that the actual severity of the wound is the more important factor in determining death and disability. It would be desirable, however, to have data which include a count of the actual number of wounds by anatomic region in both the living and the dead.

TABLE 89.-Disposition of patients with multiple wounds as related to number of anatomic regions hit and to severity of wounds, by causative agent

Causative agent

Patients

Anatomic regions hit in patients-

Returned to duty from first echelon1

Returned to duty from rear echelon2

Evacuated to United States

Total

Returned to duty from first echelon1

Returned to duty from rear echelon2

Evacuated to United States

Total

Number

Number

Number

Number

Number

Number

Number

Number

Mortar

53

41

33

127

117

99

85

301

Grenade

29

16

11

56

70

40

29

139

Landmine

2

7

5

14

4

20

16

40

Artillery shell

4

6

3

13

9

12

8

29

Rifle

2

7

3

12

4

17

7

28

Machinegun

---

1

3

4

---

3

8

11

Total

90

78

58

226

204

191

153

548


1Defined as the beachhead perimeter on Bougainville Island.
2From hospitals on Guadalcanal, Espíritu Santo, and New Caledonia.


345

TABLE 90.-Ratio of number of anatomic regions hit per patient evacuated in each echelon, by causative agent

Causative agent

Returned to duty from-

Evacuated to United States

Total

First echelon1

Rear echelon2

Mortar

2.21

2.41

2.58

2.37

Grenade

2.41

2.50

2.64

2.48

Landmine

2.00

2.86

3.20

2.86

Artillery shell

2.25

2.00

2.67

2.23

Rifle

2.00

2.43

2.33

2.33

Machinegun

---

3.00

2.67

2.75

Total

2.27

2.45

2.64

2.44


1Defined as the beachhead on Bougainville Island.
2From hospitals on Guadalcanal, Espíritu Santo, and New Caledonia.

Relative Lethal Effect of U.S. Weapons and Japanese Weapons

It had been the intention of the survey team to study the effect of U.S. weapons on the enemy dead. Unfortunately, this plan was found impracticable because of difficulty in obtaining the enemy dead before decomposition had occurred and also because of the paucity of team personnel. Certain local conditions prevailed which circumvented accuracy in such a study. In the first place, because of the character of the fighting and the extensive use, by Allied forces, of artillery and mortar fire, the enemy dead were frequently struck by many different missiles before the bodies could be recovered. Furthermore, it was impossible to obtain any detailed information regarding the circumstances surrounding death.

It was possible, however, to investigate the effect of U.S. weapons on a limited number of American soldiers who were wounded (table 91). There were 219 casualties (12.3 percent of the total) due to U.S. weapons in the hands of American troops. Though the Japanese used some U.S. weapons, particularly rifles and grenades, as a rule it was impossible to know when this occurred. Among Allied forces, there were 63 deaths (16.0 percent of the total dead) produced by U.S. weapons.

There were 52 casualties caused by the rifle, 16 of whom died (table 92); 19 were wounded by the accidental discharge of a rifle by a fellow soldier. Mistaken identity resulted in 13 deaths and the wounding of 6 others. Of these deaths, 8 were occasioned by the soldier seeking to relieve himself at the toilet during the night. Self-inflicted wounds, accidental or intentional, were responsible for 10 casualties, 3 of whom died. Mortar and artillery fire accounted for 54 of the wounded and 22 of the dead. Among these, 13 were killed and 40 wounded by mortar and artillery "shorts." Among the 16 casualties who were


346

wounded on patrol by U.S. artillery, 8 died. The accidental tripping of landmines and boobytraps produced 14 deaths in a total of 40 wounded. Hand grenades, other than those used in boobytraps, were responsible for 8 deaths and 4 wounded. Miscellaneous weapons including bangalore torpedoes, bombs, pistols, knives, and powder explosions accounted for 38 casualties; 7 of these casualties died.

TABLE 91.-Distribution of 219 U.S. casualties produced by U.S. weapons, by category

Category

Casualties

Number

Percent

Dead:

Killed in action

48

22.0

DOW (died of wounds)

15

6.8

Total

63

28.8

Wounded, living:

Evacuated to United States

25

11.4

Returned to duty from-

First echelon1

85

38.8

Rear echelon2

46

21.0

Total

156

71.2

Grand total

219

100.0


1Defined as the beachhead perimeter on Bougainville Island.
2From hospitals on Guadalcanal, Espíritu Santo, and New Caledonia.

TABLE 92.-Relative lethal effect of U.S. weapons on 219 U.S. casualties

Weapon

Total casualties

Dead

Living wounded

Number

Percent

Number

Percent1

Number

Percent1

Rifle

52

23.7

16

30.8

36

69.2

Machinegun

1

.5

1

100.0

---

---

Mortar

34

15.5

5

14.7

29

85.3

Artillery

42

19.2

17

40.5

25

59.5

Grenade

19

8.7

5

26.3

14

73.7

Mine

33

15.1

12

36.4

21

63.6

Miscellaneous

38

17.3

7

18.4

31

81.6


Total

219

100.0

63

28.8

156

71.2


1Percent for dichotomy, dead versus living, by each causative agent and for total dead versus living.


347

Though the number of casualties just cited was too small to allow adequate comparison between the effect of Japanese and U.S. weapons, it was the only available data and has been utilized (tables 92 and 93). It is evident that the relative lethal effects of the Japanese mortar and rifle are essentially similar to the lethal effects of these same U.S. weapons. However, the relative lethal effect of U.S. artillery is 40.5 percent, while that of the Japanese artillery is only 17.8 percent. A possible explanation for this discrepancy may lie in the proportion of different weapons employed by the opposing forces. The predominant Japanese artillery piece was the 75 mm. gun, whereas most of U.S. artillery weapons were 105 mm. or larger caliber. In relative lethal effects, a sharp contrast is observed between the U.S. grenade, 26.3 percent, and the Japanese grenade, 4.4 percent (fig. 183). This finding is in accord with the generally observed ineffectiveness of the Japanese grenade.

TABLE 93.-Relative lethal effect of Japanese weapons on 1,569 U.S. casualties

Weapon

Total casualties

Dead

Living wounded

Number

Percent

Number

Percent1

Number

Percent1

Rifle

393

25.0

127

32.3

266

67.7

Machinegun

150

9.6

86

57.3

64

42.7

Mortar

659

42.0

77

11.7

582

88.3

Artillery

152

9.6

27

17.8

125

82.2

Grenade

205

13.0

9

4.4

196

95.6

Mine

1

.1

1

100.0

---

---

Miscellaneous

9

.6

5

55.6

4

44.4

Total

1,569

100.0

332

21.2

1,237

78.8


1Percent for dichotomy, dead versus living, by each causative agent and for total dead versus living.

TREATMENT OF THE WOUNDED

A detailed clinical study would be out of place in a report on wound ballistics. On the other hand, a résumé of end results in the treatment of the wounded is essential to the proper evaluation of the effect of weapons. This is well illustrated by the results obtained in the treatment of compound fractures of the femur early in World War I, when the mortality at first was 50 percent. Such a mortality would materially change the evaluation of the effect of weapons causing wounds in the lower extremities.

The purpose of this section on the treatment of the wounded is to indicate the quality of the treatment, good or bad; to account for all of those wounded in action and who died later; to record the amount of disability as indicated by the disposition of the patients; and to give a very brief classification of the


348

FIGURE 183.-Roentgenograms of lower and upper extremities. A. Lower extremity wound caused by a U.S. hand grenade thrown by a Japanese. The grenade exploded 3 yards from the leg. The typical large fragment is shown. B. Fracture of the ulna and the usual small fragments characteristic of the Japanese hand grenade. The soldier was lying in a foxhole, and the grenade exploded almost in contact with the arm. Under these circumstances, there may be considerable brisance effect on the soft tissues.

types of wounds encountered in the various anatomic regions. A recording of the circumstances on how each wound was acquired and even a brief description of the wound would make this section far too lengthy. On the other hand, such descriptions are helpful in giving the reader an appreciation of the type of warfare encountered. For this reason, a brief description is given of the circumstances associated with the wounding of each patient who was wounded in action and died later.

Wounds of the Head and Neck

There were 250 patients13 with wounds of the head and neck alone who were seen alive (table 67); 10 of this number (4 percent) died. These 10 patients were considered as mortally wounded, and 7 died without operation (Cases 1 to 7). Three patients died following operation, making an operative mortality for all head and neck wounds of 1.2 percent (Cases 8, 9, and 10).

Of these 250 patients, 198 had wounds of the scalp, face, and neck. There were 55 patients who had injuries of the eye, 19 of whom (35.5 percent) were

13There were 90 patients listed under multiple wounds who also had wounds of the head and neck. However, these wounds did not constitute major problems of the head and neck, and, in order to avoid duplication, such patients were considered only under multiple wounds.


349

returned to the United States because of permanent visual impairment. The most serious wounds encountered in the group of face and neck injuries were 4 perforations of the trachea, 9 compound fractures of the mandible, and 4 of the maxilla. The majority of face and neck wounds were not serious, and 86.6 percent of the patients who received such wounds were returned to duty within 4 months. There were 52 patients who sustained brain injury; 27 of these had concussion, and 3 were evacuated to the United States.

Of the remaining 25 patients who had brain injury, 9 were mortally wounded. Nineteen of these patients underwent operation and three died, making a mortality of 15.7 percent. All three of these patients may be considered as having been mortally wounded (Cases 8, 9, and 10). Among the 19 cases having operation, the dura was open and the brain lacerated in 14, and in 5 there were depressed fractures without opening of the dura.

CASE REPORTS: WOUNDED-TREATED-DIED-LATER

Head and neck wounds

Case 1.-A Fijian soldier, while on patrol, was wounded by a fragment of a U.S. 90 mm. shell which exploded at a 20-yard distance, at 1700 hours on 30 March 1944. At the 21st Evacuation Hospital, he was found to have a penetrating wound of the skull through the right frontal bone with extensive laceration of the brain and severe intracranial hemorrhage. He died shortly after arrival, at 2000 hours on 30 March 1944, of respiratory failure and extensive brain damage. (See autopsy protocol Case 3, p. 381.)

Case 2.-A Fijian soldier, while on patrol, was struck by a U.S. 90 mm. shell fragment 25 yards from the burst at 1700 hours on 30 March 1944. He received a penetrating wound of the head in the right temporal region and was taken directly to the 21st Evacuation Hospital. The patient was moribund and died at 1855 hours on 30 March 1944. (See autopsy protocol Case 12, p. 386.)

Case 3.-A soldier of the 145th Infantry, 37th Division, was struck in the head by a Japanese machinegun bullet fired from a distance of 30 yards at 1250 hours on 9 March 1944. He was given first aid, including plasma, but never regained consciousness and died in the battalion aid station 2 hours later.

Case 4.-A Fijian soldier was mistaken for the enemy and shot in the head and abdomen by a U.S. .30 caliber rifle at a distance of 15 yards. He was wounded at 1810 hours on 23 March 1944 and taken directly to the 21st Evacuation Hospital. Examination disclosed a severe gutter wound of the right side of the head with extensive brain damage and a wound of the abdomen. He was given 1 unit of plasma but, being moribund, died at 2055 hours on 23 March 1944. (See autopsy protocol Case 22, p. 390.)

Case 5.-A soldier of the 182d Infantry, while withdrawing from enemy fire, was hit in the back of the neck by a .25 caliber Japanese bullet fired by a sniper from a distance of 35 yards. He was wounded at 0600 hours on 15 March 1944, kept in the battalion aid station about 2 hours, and then taken to the 21st Evacuation Hospital. He was paralyzed and in shock and no operation was done. His death was associated with hyperthermia and occurred at 1300 hours on 15 March 1944. The clinical impression was transection of the cervical cord at the level of cervical fifth vertebra., but post mortem revealed that the cord had not been penetrated. (See autopsy protocol Case 21, p. 388.) (NOTE.-This was the only instance of trauma to the spinal cord in which the dura was intact.)

Case 6.-A soldier of the 145th Infantry, 37th Division, was struck by fragments of a mortar shell which exploded in a tree 15 feet overhead. He sustained multiple wounds of the head and shoulder and a partial avulsion of the leg. A tourniquet was applied to the leg,


350

plasma was given, and the patient was removed from the lines within an hour. He died on the way to the hospital. Death was thought to have been due to head injury.

Case 7.-A soldier of the 129th Infantry, 37th Division, was wounded by a .25 caliber bullet fired by a Japanese sniper from a distance of 75 yards. The bullet passed through the helmet producing a severe gutter wound of the right parieto-occipital region. The injury occurred at 1430 hours on 24 March 1944. The patient received aid promptly and was given 9 units of plasma before arriving at the 21st Evacuation Hospital. He was mortally wounded, however, and died at 1920 hours on 24 March 1944 without operation. (See autopsy protocol Case 25, p. 391.)

Case 8.-A soldier of the 145th Infantry, 37th Division, was struck by a Japanese machinegun bullet fired from a distance of 30 yards on Hill 700. Because the road was under enemy fire, a 1,000-yard litter carry was necessary over very rough terrain. He was given plasma at the aid station but arrived at the hospital in a semiconscious condition. He had a gutter wound of the left frontotemporal region and a severe laceration of the brain. The wound was debrided and shock treatment instituted, but the patient died 24 hours later. Death was due to extensive brain damage.

Case 9.-A soldier of the 129th Infantry, 37th Division, was struck by a fragment of a Japanese mortar shell (90 mm.) which burst 20 feet distant at 0630 hours on 17 March 1944. He was removed to the aid station at 0830 hours and thence to the 21st Evacuation Hospital. He had a gutter wound of the right temporal region which measured 4 X 2 inches and a deep laceration of the brain measuring 2 X 2 X 2 inches. Though the patient appeared to be mortally wounded, a sanguine attempt was made to control hemorrhage. In spite of supportive treatment, the patient died at 2000 hours on 17 March 1944 with hyperthermia. (See autopsy protocol Case 26, p. 391.)

Case 10.-A soldier of the 145th Infantry, 37th Division, was struck by a fragment of a Japanese mortar shell which burst 3 yards distant at 1800 hours on 10 March 1944. He was evacuated promptly to the 21st Evacuation Hospital and found to have a severe wound penetrating the right eye and base of the skull with intracranial hemorrhage. In spite of supportive treatment, he died at 2400 hours on 10 March 1944. (See autopsy protocol Case 23, p. 390.)

Wounds of the Thorax

A discussion of wounds of the thorax is complicated by the fact that frequently the causative missiles pass through the diaphragm causing wounds of abdominal organs which in turn may be responsible for the death of the patient. For this reason, wounds involving both the thorax and abdomen are discussed in a separate section. Multiple wounds present a special problem, since they include many wounds of the thorax, and they also are discussed in a separate section. Included under multiple wounds were 62 wounds of the thoracic wall alone and 3 wounds perforating the lung. None of these patients died, and the three perforating wounds were treated conservatively.

Excluding the groups previously mentioned, there were 156 patients with wounds of the thorax who were seen alive. Thirteen of these patients died, giving a mortality of 8.3 percent; the operative mortality for the entire group, however, was much lower since seven of these patients died of shock and hemorrhage without operation (Cases 1 through 7).

Wounds of the thorax may be divided into two general groups, those involving the chest wall only and those perforating the thoracic cage. There were 102 patients (65.4 percent) who had wounds limited to the thoracic


351

wall. None of these patients died. The majority of these had penetrating wounds caused by small fragments from HE shells. Only 10 of these patients (9.8 percent) were evacuated to the United States and the remainder returned to duty.

There were 54 patients with perforating or lacerating wounds of the lung who were seen alive. All 13 deaths occurred in this group, making a mortality of 24.1 percent. Eighteen of these patients were known to have had sucking wounds. There were 29 open operations on the chest with 6 deaths, an operative mortality of 20.7 percent (Cases 8 through 13). Eighteen patients with penetrating or perforating wounds were treated conservatively with debridement only. There were no deaths in this group. The total operative mortality for perforating or lacerating wounds of the lung was 12.7 percent; 47 patients underwent operation and 6 died.

CASE REPORTS: WOUNDED-TREATED-DIED-LATER

Thoracic wounds

Case 1.-A soldier of the 246th Field Artillery Battalion, Americal Division, was riding in the back of an uncovered truck when a Japanese 105 mm. shell exploded at a distance of 5 yards to the rear, at 0730 hours on 8 March 1944. He was struck by a shell fragment which caused a large wound of the posterior aspect of the left side of the chest. He was taken immediately to a battalion aid station, a dressing applied, and plasma given. He did not recover from shock, however, and died at 1120 hours on 8 March 1944.

Case 2.-A soldier of the 148th Infantry, 37th Division, was lying prone on the ground when a mortar shell exploded at a distance of 2 feet at 0800 hours on 12 March 1944. On arrival at the 21st Evacuation Hospital 50 minutes later, he was moribund with multiple wounds of the left side of the jaw, upper right arm, and profuse hemorrhage from a large perforating wound which extended through the right shoulder into the chest cavity. He was mortally wounded and died without treatment at the hospital at 0910 hours on 12 March 1944.

Case 3.-A soldier of the 182d Infantry, Americal Division, was manning a machinegun in a foxhole on Hill 260. This soldier slipped out to look for the enemy position and was struck by a fragment of a Japanese mortar shell which burst at a distance of 40 yards. He received multiple severe wounds of the left side of the chest and of the left arm and did not regain consciousness. While in the battalion aid station, he died from hemorrhage at 1300 hours on 11 March 1944.

Case 4.-A soldier of the 182d Infantry, Americal Division, was advancing in an upright position in a skirmish line on Hill 260 when he was struck by Japanese .25 caliber machinegun bullets at 1430 hours on 10 March 1944. He received multiple wounds of the chest and arm, was given first aid which included plasma, but died at the collecting company at 1530 hours on 10 March 1944.

Case 5.-A soldier of the 145th Infantry, 37th Division, was standing in a covered foxhole by a machinegun when he was hit by a Japanese mortar fragment at a distance of 5 yards from the burst. The shell fragment penetrated the soldier's left shoulder and entered the chest. He received immediate first aid, including plasma, at the aid station. The wounding occurred at 0545 on 12 March 1944, and the patient died in the aid station of pulmonary hemorrhage 3 hours later.

Case 6.-A soldier of the 129th Infantry, 37th Division, was advancing behind a tank when he was wounded by a Japanese .25 caliber machinegun bullet fired from a distance of 25 yards at 1245 hours on 24 March 1944: The bullet entered the chest and transected the


352

spinal cord. His death at the 21st Evacuation Hospital 24 hours later was accompanied by shock and hyperthermia. (See autopsy protocol Case 52, p. 398.)

Case 7.-A soldier of the 132d Infantry, Americal Division, was wounded by a shell fragment from a U.S. artillery "short" at 0815 hours on 7 April 1944. The distance from the burst was unknown. A large sucking wound of the left side of the chest and multiple penetrating wounds of the left thigh were evident. He died in the clearing station at 1145 hours on 7 April 1944, as a result of severe hemorrhage from the chest wound.

Case 8.-A Fijian soldier was crouching on patrol when he was struck by a .25 caliber Japanese sniper bullet fired from a distance of 30 yards. An extensive wound of the lower part of the left side of the chest was accompanied by profuse hemorrhage. On arrival at the 21st Evacuation Hospital, it was evident that fatal exsanguination was imminent; accordingly, an immediate but futile attempt was made to relieve intrathoracic pressure and to control hemorrhage. During operation, the patient was given 1,500 cc. of whole blood and 6 units of plasma, but he died on the operating table. (See autopsy protocol Case 56, p. 400.)

Case 9.-A soldier of the 182d Infantry, Americal Division, was lying prone on Hill 260 operating a machinegun when he was hit by a .25 caliber Japanese machinegun bullet fired from a distance of 50 yards at 1200 hours on 12 March 1944. He sustained a sucking wound of the lower part of the right side of the chest accompanied by multiple fractured ribs posteriorly and disruption of the rib cartilages anteriorly. At the 31st Portable Surgical Hospital, 2,000 cc. of plasma and 1,200 cc. of whole blood were administered and the skin rapidly closed over the sucking wound. After transfer to the 21st Evacuation Hospital, the patient continued to have severe respiratory difficulty because of the crushing chest wound. An attempt was made to reconstruct the posterior thoracic cage by wiring the fourth, fifth, sixth, seventh, and eighth ribs to their paravertebral stumps. At operation, the lung was stated to have the appearance of "blast injury"14 (consolidation). There were several rents in the lung but no bleeding. On 14 March 1944, it was apparent that the patient had pneumonia, his temperature had risen to 106° F., and his respiratory rate to 50. Accordingly, 100,000 units of penicillin were given. The paradoxical breathing due to the disrupted anterior cartilages became worse, and the patient died of respiratory failure at 2300 hours on 14 March 1944.

Case 10.-A soldier of the 129th Infantry, 37th Division, was prone on the crest of a ridge behind a tank attack when he was hit by a .25 caliber Japanese rifle bullet fired from a distance of 100 yards. He received a severe wound of the posterior aspect of the left side of the thorax, at 1100 hours on 24 March 1944, and was removed at once to the 21st Evacuation Hospital. At operation, the lacerated lung was repaired and the wound closed tightly. On the following day, because of the development of pneumonia, penicillin therapy was instituted, using 25,000 units every 4 hours. A severe right pneumothorax was aspirated. On 26 March, the patient's temperature was 105° F. and his condition poor. Slight improvement occurred, but on 28 March the patient suddenly cried out, ceased breathing, and died at 0730 hours. The radial pulse was perceptible for a brief interval after respiration ceased. A diagnosis of pulmonary embolism was made. (See autopsy protocol Case 50, p. 398.)

Case 11.-An airman of the Thirteenth Army Air Force accidentally shot himself with a .30 caliber carbine at 1300 on 4 April 1944. The bullet perforated the left side of the chest. He was taken immediately to the 52d Field Hospital and given 3 units of plasma. At operation 2 hours later, the patient died on the table. The cause of death was not entirely clear, although a large intrapleural hemorrhage may have been sufficient to account for the fatal termination. A contusion of the heart muscle was found at post mortem. (See autopsy protocol Case 53, p 399.)

14This type of pulmonary hemorrhage is seen with the large temporary cavity produced by the passage of high-velocity missiles. The term "blast injury" is used rather frequently throughout the case reports, and in most instances, especially where it is associated with small arms wounds, the pulmonary damage is related to the temporary cavity effect. Small patchy areas of pulmonary hemorrhage are related to blood aspiration.-J. C. B.


353

Case 12.-A soldier of the 129th Infantry, 37th Division, was standing by his foxhole when he was struck by a fragment of a 4.2-inch U.S. mortar shell which fell short and burst at a distance of 7 feet. At the 33d Portable Surgical Hospital, a sucking wound of the right side of the chest was sutured. Since this hospital had no thoracic surgeon, the patient was transferred to the 21st Evacuation Hospital. En route, severe bleeding occurred because of dehiscence of the recently sutured thoracic wound. While 1,500 cc. of blood and 10 units of plasma were being administered, a second operation was done. A rib fragment was removed from the lung and active bleeding of the intercostal arteries controlled. The wound was closed tightly with through-and-through sutures. At the termination of the operation, the blood pressure was 80/50. A penicillin solution containing 17,500 units was left in the pleural cavity. The patient did not recover consciousness and died at 1500 hours on 30 March 1944. Autopsy showed acute dilatation of the heart, hemorrhage in the right lung and right hemothorax. (NOTE.-Interhospital transfer of this patient was obviously inadvisable.)

Case 13.-A soldier of the 182d Infantry, Americal Division, was moving up a hill when he was struck by a .25 caliber Japanese bullet fired from a distance of 30 yards at 1130 hours on 20 March 1944. The bullet fractured the posterior portion of the ninth rib, perforated the upper lobe of the right lung, and made its exit in the right supraclavicular fossa. Sucking wounds were present on the posterior and anterior aspects of the chest, with free bleeding from the posterior wound. At the 31st Portable Surgical Hospital, plasma was given, and the sucking wounds were debrided and closed. The lung appeared consolidated from intrapulmonary hemorrhage. The patient died of shock and hemorrhage shortly after operation.

Wounds of Thorax and Abdomen

The anatomic divisions of thorax and abdomen are satisfactory for a consideration of wounds of entrance. From a clinical standpoint, however, those wounds which are caused by missiles which pass from one cavity into the other present special problems of sufficient importance to warrant placing them in a separate category.

There were 24 patients with wounds in which the missile penetrated both the thoracic and abdominal cavities. More than half of these wounds were caused by bullets entering the chest. The various missiles entered through the thorax in 17 cases; through the abdomen, in 4; and through both the abdomen and chest, in 3. Bullets caused 16 of these wounds; mortar fragments, 5; and artillery shell fragments, 3.

The mortality of these wounds is higher than for wounds of the thorax or abdomen alone. Of the 24 cases, 18 died, resulting in a mortality of 75.0 percent. Three of these patients died of hemorrhage and shock without operation. Twenty-one patients underwent operation; of these, 15 died, giving an operative mortality of 71.4 percent. Brief case histories are given for all patients who were wounded in action and died later.

The high operative mortality requires some further explanation. If medical installations had not been so easily available, some of these patients probably would have been classed as killed in action. Shock from hemorrhage was usually severe, and occasionally, when bleeding continued, it was necessary to attempt "heroic surgery" (Case 5) in an effort to control it. Bleeding into both the thorax and abdomen resulting from explosive wounds


354

of the liver, spleen, and kidney frequently contributed to the shock. On the whole, anesthesia appeared to have been well done but occasionally left something to be desired. More whole blood would have been beneficial in some instances, since blood loss was frequently great and could be replaced by plasma only within limits. Hemorrhage and shock were the chief causes of death as seen in Cases 5, 6, 8, 10, 11, 14, 16, 17, and 18. Case 15 was moved immediately after operation. This may have contributed to the shock. Case 4 illustrates the sequelae which may be encountered from the temporary cavity effect due to high-velocity bullets. Case 12 died with uremia associated with a high sulfathiazole blood level. (This patient also had an explosive wound of one kidney.) Extensive liver damage appeared to account for one death (Case 7). Two patients who were evacuated to the rear echelon died; one from sepsis and empyema (Case 9) and the other from secondary hemorrhage (Case 13). The strain of evacuation may have contributed to death in these cases.

CASE REPORTS: WOUNDED-TREATED-DIED-LATER

Thoracic and abdominal wounds

Case 1.-A soldier of the 132d Infantry, Americal Division, was running between foxholes on Hill 260 when he was shot by a .25 caliber rifle at 40 yards. The bullet entered the thorax at the level of the left seventh rib in the anterior axillary line. He was wounded at 1530 hours on 14 March 1944. Within 15 minutes after receiving first aid, he was taken to the aid station and from there transferred directly to the 31st Portable Surgical Hospital. The wound was extensive as the bullet had passed tangentially from the thorax into the abdomen and had lacerated the left lung, perforated the diaphragm, and had produced a massive hemothorax. The spleen was shattered, gastrosplenic artery and renal vein divided, and entire descending colon avulsed. Because he was mortally wounded, the patient was given supportive treatment only. He died at 0515 hours on 15 March 1944.

Case 2.-A soldier of the 145th Infantry, 37th Division, was souvenir hunting when he was hit by a .25 caliber Japanese rifle bullet fired from a distance of 70 yards. He was in severe shock when first seen at 1420 hours on 12 March 1944. At the aid station, he was given 3 units of plasma and then transferred to the clearing station. The bullet had entered the posterior aspect of the left side of the chest and had produced a large wound of exit in the left upper quadrant of the abdomen from which omentum protruded. He did not respond to therapy and died in the shock tent at 1700 hours on 12 March 1944.

Case 3.-A soldier of the 82d Chemical Battalion, supporting the 37th Division, was standing in a pit beside his mortar when a Japanese 81 mm. mortar shell exploded 4 yards distant at 1930 hours on 8 March 1944. He was taken directly to the 21st Evacuation Hospital and on arrival was found to be in profound shock from multiple wounds of the thorax and abdomen and both lower extremities. A severe compound fracture of the left femur was present. He did not respond to shock therapy and died without operation at 0530 hours on 9 March 1944. Death resulted from hemorrhage, shock, and respiratory failure. Cursory post mortem examination revealed multiple penetrating wounds of the left side of the chest and abdomen involving the large bowel.

Case 4.-A soldier of the 129th Infantry, 37th Division, was prone on the ground in front of the tanks when he was shot by a .30 caliber Japanese machinegun at a 35-yard distance. He was struck by two bullets in the back, at 0830 hours, and taken directly to the 21st Evacuation Hospital. He had an obvious left hemothorax, a sucking wound of the chest, and questionable abdominal involvement. After preliminary shock treatment,


355

the explosive wound of the chest was debrided and closed. The abdomen was then opened, but no lesion was found. He responded well to operation but developed increasing respiratory difficulty requiring frequent aspiration and died at 0645 hours on 28 March 1944. (See autopsy protocol Case 54, p. 399.)

Case 5.-A soldier of the 145th Infantry, 37th Division, was among a group of men preparing to climb into a truck when four shells struck within a radius of 15 yards at 0730 hours on 18 March 1944. This man received first aid immediately and arrived at the 21st Evacuation Hospital within an hour. He had a large sucking wound of the posterior aspect of the chest with a laceration of the lower lobe of the left lung, perforation of the diaphragm, and laceration of the spleen and cardia of the stomach. He received 2,000 cc. of blood and 8 units of plasma within 6 hours but neither regained conciousness nor recovered from shock. Thoracotomy was necessitated because of continued intrathoracic bleeding which produced a shift of the mediastinum. At operation, 3,000 cc. of blood were removed from the pleural cavity and lacerations in the lung and dome of the diaphragm were repaired. In spite of continuous shock therapy, recovery was not sufficient to allow repair of the abdominal defects. He died at 0545 hours on 19 March 1944. (See autopsy protocol Case 74, p. 406.)

Case 6.-A soldier of the 24th Infantry, 93d Division, was prone on the ground on a combat patrol when he was shot by a .30 caliber Japanese machinegun from a distance of 30 yards. He received multiple wounds. At 1000 hours on 19 April 1944, he was given first aid and arrived at the 52d Field Hospital at 1400 hours. In order to combat severe shock, he was given 1,000 cc. blood and 1,250 cc. of plasma. Because of suspected lung hemorrhage, thoracotomy was performed. A bone fragment was removed from the lung and the pleura and diaphragm were sutured. He did not respond to shock therapy and died at 2125 hours on 19 April 1944. (See autopsy protocol Case 73, p. 406, for description of multiple wounds.)

Case 7.-A soldier of the 145th Infantry, 37th Division, was climbing a hill when he was hit by a .25 caliber Japanese sniper bullet fired from a distance of 30 yards. He was wounded at 1745 hours on 11 March 1944, given first aid, and taken directly to the 21st Evacuation Hospital. After adequate shock therapy, thoracotomy was performed. The lower lobe of the right lung was lacerated and showed consolidation, the eighth and ninth ribs were shattered, and in addition a rent in the diaphragm and a severe explosive wound of the liver were discovered. The lung was sutured, the diaphragm transplanted, and the liver packed. Death occurred at 1600 hours on 15 March 1944, prior to which time recovery had seemed satisfactory. Post mortem examination showed no cause of death other than extensive liver damage.

Case 8.-A soldier of the 57th Engineer Combat Battalion, Americal Division, was accidentally shot by a .30 caliber M1 rifle, at 1300 hours on 22 February 1944, at a 1-foot distance. After receiving immediate first aid and plasma, he was taken to the 52d Field Hospital. A large sucking wound of the right side of the chest was present. Because of continued hemorrhage, plasma and 1,000 cc. of blood were administered during operation. Thoracotomy revealed a perforation of the diaphragm and explosive wound of the liver and large hemothorax. An attempt was made to control bleeding from the liver by packing it with muscle. The patient died of shock and hemorrhage, a half hour after the conclusion of the operation, at 1615 hours on 22 February 1944.

Case 9.-A soldier of the 145th Infantry, 37th Division, was kneeling, when he was shot by a .25 caliber Japanese rifle at 15 yards, on 16 March 1944. A sucking wound of the lower portion of the right side of the chest resulted. After blood and plasma transfusions, the thorax was explored at the 21st Evacuation Hospital. It was found that the bullet had perforated the lower lobe of the left lung, guttered a large wound in the diaphragm, and transected the spinal cord at the level of the 12th dorsal vertebra. A right lower lobectomy was done and the diaphragm repaired. He was evacuated to the rear echelon in good condition on the eighth postoperative day. Later, he developed empyema and, in spite of


356

adequate drainage and penicillin therapy, died on 25 April 1944. (See autopsy protocol Case 55, p. 400.)

Case 10.-A Fijian soldier was mistaken for the enemy and shot by a .30 caliber machinegun at a 30-yard distance. He was wounded at 1500 hours on 1 April 1944 and was evacuated immediately to the 21st Evacuation Hospital. After shock treatment, thoracotomy was done because of suspected hemorrhage. At operation, a right lower lobectomy was performed and an extensive wound in the liver packed. He did not recover from this operation and died at 2030 hours on 1 April 1944. (See autopsy protocol Case 72, p. 406.)

Case 11.-A soldier of the 37th Reconnaissance Troop, 37th Division, was on a combat patrol which was ambushed. He was shot by a .25 caliber Japanese rifle at a 25-yard distance at 1815 hours on 4 March 1944. He received first aid treatment but did not arrive at the hospital until 0800 hours on 5 March 1944. The bullet entered the abdomen through the left flank and made its exit through the anterior aspect of the right side of the chest wall. After shock therapy, perforations of the small and large bowel were sutured. The patient did not recover from shock and died at 1615 hours on 5 March 1944. (See autopsy protocol Case 71, p. 406.)

Case 12.-A soldier of the 132d Infantry, Americal Division, while on combat patrol, was shot by a Japanese rifle as he entered an enemy pillbox at 1700 hours on 29 March 1944. After a long carry, he arrived at the 121st Clearing Station at 2000 hours on 30 March 1944. The bullet had entered the chest in the sixth interspace in the posterior axillary line and had perforated the diaphragm, large bowel, and kidney. At operation, a laceration of the diaphragm was repaired, the large bowel perforation sutured, a transverse colostomy performed, and sulfonamide therapy instituted. On the third day, the urinary output having decreased to 200 cc., a diagnosis of uremia was made. The sulfonamide level was then 24. After transfer to the 21st Evacuation Hospital, he died at 0600 hours on 4 April 1944. (See autopsy protocol Case 68, p. 404.)

Case 13.-A soldier of the 129th Infantry, 37th Division, was shot through the arm and chest by a .25 caliber Japanese rifle bullet on 13 March 1944. After receiving plasma, he was taken directly to the 21st Evacuation Hospital. The bullet had fractured the left humerus, penetrated the chest, perforated the diaphragm, and produced a hemothorax. The wound was debrided and the pleura closed. The patient was evacuated by air on 15 March 1944. He died on 21 March 1944 of secondary hemorrhage. (See autopsy protocol Case 69, p. 405.)

Case 14.-A soldier of the 182d Infantry, Americal Division, was in a foxhole on Hill 260 when he was hit by a .25 caliber Japanese machinegun bullet fired from a distance of 40 yards. He was wounded at 1200 hours on 11 March 1944. At the 31st Portable Surgical Hospital, it was found that the bullet had entered the left side of the chest in the seventh interspace posterior axillary line and had coursed downward and forward into the abdomen. A sucking wound of the chest was closed and the abdomen opened. The bullet had perforated the diaphragm, stomach, and liver, and had shattered the spleen. The various perforations were closed and the spleen removed. The patient did not rally and died at 0700 on 12 March 1944. Autopsy revealed that a perforation of the jejunum had been overlooked at operation. Death was attributed to peritonitis although shock was also a factor.

Case 15.-A soldier of the 182d Infantry was advancing with a combat patrol when he was shot by a machinegun at close range on 8 March 1944. He continued to command for 20 minutes but was then evacuated to the 31st Portable Surgical Hospital. The bullet had entered just medial to the anterior axillary line in the 5th interspace and made exit near the 12th rib posterior. In its course, it had perforated the lung, diaphragm, stomach, and spleen. At operation, the diaphragm and stomach were repaired. The patient was transferred to the 21st Evacuation Hospital on 9 March 1944 and died the following day at 1845 hours. (NOTE .-The transfer of this patient on the first day after operation was inadvisable.)

Case 16.-A soldier of the 145th Infantry, 37th Division, was struck by a fragment of a Japanese knee mortar shell on Hill 700. He was approximately 25 yards from the burst.


357

Having received plasma and immediate first aid dressings, he was taken to the 21st Evacuation Hospital. Because of multiple perforating wounds of the chest and abdomen, laparotomy was done. Extensive laceration of the liver and several perforations of the jejunum and duodenum were repaired. He died of shock and hemorrhage on the day of operation at 2240 hours on 11 March 1944.

Case 17.-A soldier of the 920th Air Base Security Battalion was riding on a truck when a Japanese artillery shell exploded 5 feet behind his vehicle at 0600 hours on 24 March 1944. He was taken directly to the 52d Field Hospital and treated for shock. There were two wounds; one traversed the fourth and fifth ribs in the midaxillary line, perforated the lower lobe of the left lung, and entered the posterior mediastinum. The second fragment entered the left ilial region and perforated the sigmoid colon. Massive hemothorax was present. At operation the perforation of the lung was sutured, and the sigmoid colon was exteriorized. The patient was given 4,000 cc. of plasma and 1,000 cc. of whole blood. He did not respond, however, and died 8 hours after the operation. (See autopsy protocol Case 57, p. 400.)

Case 18.-A Fijian soldier was crawling on a combat patrol when a Japanese mortar shell exploded at a distance of 20 yards on 29 March 1944. On arrival at the 21st Evacuation Hospital, he received treatment for shock. Perforating wounds involved the lung, diaphragm, colon, spleen, pancreas, and left kidney; the patient also had a fracture of the left humerus. The spleen was removed, the colon exteriorized, and the diaphragm repaired. He died at 2215 hours on 30 March 1944. (See autopsy protocol Case 70, p. 405.)

Wounds of the Abdomen

This anatomic division is used to designate not only the abdominal cavity and contents but also the various structures surrounding it, including the muscles of the abdominal wall, the vertebral column, and the ilia. Wounds involving both the thorax and abdomen are considered in a separate section.

There were 86 patients who had wounds of the abdomen; in 49 the wounds were limited to the abdominal wall and in 37 they penetrated the abdominal cavity. The majority of wounds limited to the abdominal wall were caused by HE missiles, chiefly mortar fragments. There were 5 deaths among the 49 patients who received wounds of the abdominal wall; only Cases 1 and 2 died before operation. One death followed a negative abdominal exploration (Case 18).

Penetration of the abdominal cavity was found in 37 patients. There were 12 deaths among 36 patients undergoing operation making a total operative mortality of 33.3 percent. However, it must be borne in mind that this high operative mortality is accounted for in part by many mortally wounded patients who died of shock and upon whom operation was undertaken with little hope of success (Cases 5, 7, 10, 11, 12, 13, and 14). One patient died of shock before operation (Case 3), two died of peritonitis (Cases 6 and 8), and one of unexplained uremia (Case 17). No deaths occurred because of failure to explore the abdomen, but in two patients (Cases 4 and 9) death resulted from visceral perforations which were overlooked at operation. The very early evacuation of patients from the portable surgical hospitals undoubtedly contributed to shock and was the factor which may have precipitated death in a few instances (Cases 4, 5, 7, and 17). It is also known that patients do not


358

tolerate air transportation well soon after abdominal operations, and this type of evacuation may have contributed to the death of one patient (Case 18).

The large bowel was perforated in 15 patients among whom there were 5 deaths, making an operative mortality of 33.3 percent (see Cases 4, 5, 6, 7, 8). Among these 15 patients, the colon alone was perforated in 5, the colon and spleen in 1, and the colon and small intestine in 9. Four of the five deaths occurred in this latter group. The small intestine alone was perforated in 6 patients, the liver in 4, the stomach in 1, and the bladder in 1. All these patients recovered. In addition, three patients recovered who had wounds perforating the abdominal cavity in which the injury was limited to the peritoneum and mesenteric vessels.

CASE REPORTS: WOUNDED-TREATED-DIED-LATER

Abdominal wounds

Case 1.-A soldier of the 145th Infantry, 37th Division, having returned from patrol, was preparing to get into a truck when four Japanese artillery shells landed within a radius of 15 yards. He was wounded at 1930 hours on 18 March 1944 and taken directly to the 21st Evacuation Hospital. Multiple wounds were present which included spinal cord injury and an extensive avulsion of the tissues of the lumbar region exposing the vertebras, spinal canal, and both kidneys. The patient was treated for shock but died without operation at 1300 hours on 19 March 1944.

Case 2.-A soldier of the 145th Infantry, 37th Division, while crawling in attack on Hill 700, was hit by a Japanese machinegun bullet fired from a distance of 30 yards. He was wounded at 0700 hours on 10 March 1944 and arrived at the 21st Evacuation Hospital at 1500 hours on the same day. Extensive compound fractures involving the sacrum, fourth and fifth lumbar vertebras, and the ilium were found. There was apparently no intra-abdominal injury, but the patient failed to recover from profound shock and died at 2330 hours on 11 March 1944.

Case 3.-A soldier of the 132d Infantry, Americal Division, returning from patrol, was shot with a .25 caliber Japanese machinegun at 1600 hours on 6 April 1944. He received first aid and remained in the command post overnight. After receiving plasma, he was evacuated to the clearing station. Multiple wounds involving the lower part of the thorax, abdomen, and sacrum were found. There was no response to shock therapy and death occurred on 8 April 1944. Post mortem examination showed peritonitis, resulting from multiple perforations of the colon and terminal ileum, destruction of fifth lumbar to second sacral vertebras, and retroperitoneal hemorrhage.

Case 4.-A soldier of the 132d Infantry, Americal Division, while walking along a trail on Hill 260, was wounded by a 90 mm. Japanese mortar shellburst 25 yards distant at 1530 hours on 13 March 1944. After immediate first aid treatment, he was taken to the 31st Portable Surgical Hospital. Multiple wounds were present involving the right knee, thigh, right side of the chest, and abdomen. A shell fragment entered the abdomen through the left flank, passed transversely, and perforated the large and small bowel. At operation, the ileum, colon, and mesocolon were repaired. On 15 March 1944, the patient was transferred to the 21st Evacuation Hospital. After the administration of 1,000 cc. of blood and 4 units of plasma, a transverse colostomy was done under local anesthesia because of severe abdominal distention. The patient died at 1115 hours on 16 March 1944. Post mortem examination revealed peritonitis resulting from the two perforations of the jejunum which had been overlooked at operation. (See autopsy protocol Case 83, p. 408.) (NOTE.-Interhospital transfer was inadvisable in this case.)


359

Case 5.-A soldier of the 37th Division was running along a road carrying a box of ammunition when he was struck by a .25 caliber bullet fired by a Japanese tree sniper from a distance of 75 yards. He was wounded in the abdomen at 0739 hours on 10 March 1944 and transported immediately to the 33d Portable Surgical Hospital. In preparation for laparotomy, he was given 4 units of plasma. At operation, resection of 18 inches of lower ileum with a side-to-side anastomosis was done, and a transverse laceration of the sigmoid colon was sutured. On 11 March, he was transferred to the 21st Evacuation Hospital and died there of shock at 0700 hours on 12 March 1944. (NOTE.-It was inadvisable to have transferred this patient before recovery.)

Case 6.-A soldier of the 82d Chemical Battalion, 37th Division, was standing in the gunpit of a mortar battery when he was struck by fragments of an 81 mm. Japanese mortar shell which burst at a distance of 10 yards. Following wounding at 1930 hours on 8 March 1944, he was removed immediately to the 21st Evacuation Hospital. Severe wounds of the left flank and abdomen involving the sigmoid colon and retroperitoneal tissues were found at operation. The sigmoid colon was exteriorized, but the patient died of peritonitis at 1700 hours on 13 March 1944.

Case 7.-A soldier of the 25th Infantry, 93d Division, was returning from a patrol when he was wounded by a grenade which exploded in his right hand at 1700 hours on 9 April 1944. At the 31st Portable Surgical Hospital, five penetrating wounds of the right side of the abdomen and a compound fracture of the right hand were discovered. Because of the presence of shock, he received 8 units of plasma, 1,000 cc. of blood, and 4,000 cc. of glucose solution. The wounds were debrided and 8 inches of jejunum were resected and 8 perforations of the jejunum were sutured. Perforations of the descending colon, sigmoid colon, and cecum were also repaired and a transverse colostomy done. The patient was transferred to the 21st Evacuation Hospital on 10 April 1944 and died at 2355 hours on 11 April 1944. (See autopsy protocol Case 85, p. 409.) (NOTE.-It was inadvisable to have transferred this patient on the first postoperative day.)

Case 8.-A soldier of the 129th Infantry, 37th Division, while operating a machinegun, was hit by a .25 caliber Japanese sniper bullet, distance unknown, at 1130 hours on 13 March 1944. He received first aid within 20 minutes, was evacuated from the line within 1 hour, and arrived at the 21st Evacuation Hospital shortly thereafter. After appropriate measures to combat shock, laparotomy was done. The bullet, coursing upward after entering the abdomen on the left side, had produced two perforations of the descending colon, severed the right middle colic artery, perforated the jejunum in three places, and then made its exit through the right rectus muscle. The visceral perforations were closed, and after resection of 4 inches of jejunum a catheter was placed in the bowel for decompression. After a few days, severe abdominal distention developed, and it became obvious that the enterostomy was unsatisfactory. The patient died at 1400 hours on 20 March 1944. At autopsy, it was found that the catheter had slipped out of the bowel, probably because the bowel had not been sutured to the abdominal wall. Bile peritonitis produced by leakage was stated to have caused death.

Case 9.-A soldier of the 82d Chemical Battalion, while walking along a column of vehicles which were moving into new positions, was shot without challenge with a U.S. M1 rifle at a distance of 10 feet. He immediately received first aid dressings and plasma and 2 hours later was taken to the 21st Evacuation Hospital. A severe wound of the abdomen was present, and the sigmoid colon was perforated in three places. A bladder wound which was overlooked at the first operation was discovered on the following day. A suprapubic cystotomy was done at once, and at the same operation the left external iliac artery was ligated because of a contused area which had weakened its wall. The patient did not rally, appeared to be in shock, and died at 0344 hours on 16 March 1944.

Case 10.-A soldier of the 145th Infantry, 37th Division, was carrying ammunition to a gun position when a Japanese knee mortar shell burst 10 yards away. He was wounded in the lumbar region at 1330 hours on 10 March 1944 and immediately transported to the 21st Evacuation Hospital. The shell fragment had passed through the left kidney, spleen,


360

transverse colon, and jejunum. The operation consisted of splenectomy, exteriorization of the transverse colon lesion, and resection of a 3-inch segment of jejunum. Because of the patient's poor condition, nephrectomy was not done. He did not recover completely from shock and died on 14 March 1944.

Case 11.-A soldier of the 82d Chemical Battalion, while standing in a gunpit of a mortar battery, was hit by a fragment of a 77 mm. Japanese mortar shell which burst at a 5-yard distance. He received his wounds at 1930 hours on 8 March 1944 and was taken immediately to the 21st Evacuation Hospital. Following treatment for shock, laparotomy was done. One shell fragment passing laterally had perforated the transverse colon in three places, lacerated the right lobe of the liver, and made an exit wound 4 inches in diameter in the lateral abdominal wall. Present also were a compound fracture of the left ulna and a large wound of the right ankle. There were other smaller wounds of the legs, thighs, buttocks, back, and face. At operation, the wounds were debrided, the perforations of the transverse colon sutured, and the defect in the liver repaired. The patient did not recover from shock and died on the following day at 2330 hours on 9 March 1944.

Case 12.-A soldier of the 132d Infantry, Americal Division, while advancing on Hill 260, was struck by a fragment of a 90 mm. Japanese mortar shell, distance unknown. He was wounded at 0900 hours on 13 March 1944, given immediate first aid, and then transported directly to the 21st Evacuation Hospital. The left arm was avulsed, an extensive wound of the right leg was present, and the great vessels of this extremity were severed. There were multiple wounds of the abdomen, and the ileum was perforated. Because of severe shock, only the perforations of the ileum were sutured at the initial operation. On the following day, because of an extension of gangrene of the leg, amputation was done. The patient died at 2112 hours on 15 March 1944. Post mortem examination showed no leakage from the repaired bowel. In this case, death was attributed to traumatic shock despite the fact that there had been adequate blood replacement. (The surgeon expressed the opinion that the operation should have been postponed and the limb packed in ice.)

Case 13.-A soldier of the 24th Infantry, 37th Division, while on patrol, was struck by a Japanese .25 caliber bullet fired from a distance of 25 yards. While being moved, he was shot again by the same rifleman. This second wound resulted in evisceration. He was wounded at 1030 hours on 16 March 1944 and taken directly to the 21st Evacuation Hospital. There he received 1,000 cc. of blood and 3 units of plasma. The first bullet entered 2 inches below the right costal margin, passed downward along the rectus muscle into the flank, then through the wing of the ileum, and made its exit in the right buttock. The bullet causing the evisceration entered 2 inches below the left costal margin, traveled downward destroying the rectus muscle, perforated the jejunum and ileum, and passed under the inguinal ligament into the thigh. Moderate shock was present. At operation, the eviscerated intestine was enclosed in a pack while the rents in the jejunum and ileum were resected. Profound shock developed from which the patient did not recover, and he died at 1515 hours on 16 March 1944.

Case 14.-A soldier of the 135th Field Artillery Battalion, 37th Division, accompanied a party burying the Japanese dead in front of the 129th Infantry perimeter. He wandered away and was shot by a Japanese .25 caliber rifle at 1545 hours on 27 March 1944. He was taken immediately to the hospital. The bullet entering the lumbar region had shattered the 12th rib, driving bone fragments into the kidney, and had then passed through the right lobe of the liver, causing an extensive laceration. Following appropriate shock therapy, the abdomen was explored and the liver packed. Because of the poor condition of the patient, only the loose fragments of kidney were removed. He did not recover from shock and died at 1830 hours on 27 March 1944. (See autopsy protocol Case 81, p. 407.)

Case 15.-A soldier of the 140th Field Artillery Battalion, 37th Division, while on patrol looking for the enemy who had infiltrated the lines, was shot by a .25 Japanese rifle at a 10-yard distance. He was wounded at 1605 hours on 14 March 1944, received immediate first aid, and arrived at the hospital within an hour. A wound was present in the left axilla, and the axillary vein was severed. The major lesions consisted of compound fractures


361

of the femur and ileum with an extensive wound penetrating the right hip joint. Severe shock was present. The axillary vein was ligated. Because of the presence of abdominal symptoms, laparotomy was done but no lesion found. During this operation, the urinary bladder was explored and closed. Because of the poor condition of the patient, only a simple debridement of the hip wound was done. The patient showed a severe toxic reaction, developed gas gangrene of the hip, and died on the second postoperative day at 1450 hours on 16 March 1944. (See autopsy protocol Case 103, p. 415.)

Case 16.-A soldier of the 145th Infantry, 37th Division, while attacking on Hill 700, was shot by a Japanese machinegun at 30 yards. He was wounded at 1630 hours on 9 March 1944 and taken immediately to the battalion aid station. After he had received 3 units of plasma, he was evacuated by halftrack because the road was under fire. At the hospital, in order to combat severe shock, he was given 12 units of plasma and 500 cc. of blood. The bullet had entered the right iliac crest and passing downward had shattered the entire right wing of the pelvis. Exploration of the abdomen through a McBurney incision was negative. The hip wound was debrided and packed. He failed to recover from shock and died at 2300 hours on 10 March 1944.

Case 17.-A soldier of the 129th Infantry, 37th Division, was standing by a foxhole when a 4.2-inch U.S. mortar shell fell short and burst 7 feet away, on 27 March 1944. He received treatment for shock at the 33d Portable Surgical Hospital. One shell fragment produced a large wound over the region of the right iliac crest; it also fractured the fifth lumbar vertebra and shattered the lower pole of the right kidney. Another fragment caused a wound of the right shoulder and arm. Shock therapy was continued while the wounds were debrided. The development of severe abdominal distention necessitated ileostomy. On 31 March, he was transferred to the 21st Evacuation Hospital and died there on 1 April 1944 with unexplained uremia. (See autopsy protocol Case 84, p. 409.)

Case 18.-A soldier of the 182d Infantry, Americal Division, was standing in the open when a Japanese hand grenade burst 3 feet away. He was wounded at 1345 hours on 13 March 1944. After arrival at the 31st Portable Surgical Hospital, examination disclosed many wounds over the left side of the trunk and extremities. Following transfer to the clearing station, abdominal exploration was done with negative results. He was evacuated by air on 18 March 1944. On arrival at the 137th Station Hospital on Guadalcanal on the same day, evisceration was discovered. A secondary wound closure was done, but the patient developed peritonitis and died on 25 March 1944. (See autopsy protocol Case 82, p. 408.) (NOTE.-Air evacuation might have caused evisceration, although planes transporting casualties usually fly at low altitudes.)

Wounds of the Extremities

Wounds of the extremities are of great importance because of their frequency. Wounds of the upper and lower extremities together (excluding multiple wounds) accounted for 40.6 percent of all casualties. As a surgical problem, these wounds were of major significance since they comprised more than half of all the living wounded.

Of 320 patients with wounds of the upper extremities, one was killed in action. This patient had a traumatic amputation. There was not a single death in the 319 treated wounds of the upper extremities. Gas gangrene infection did not occur. In this group, there were 119 compound fractures of which 44 were in the humerus, 33 in the bones of the forearm, and 42 in the bones of the hand. There were 10 amputations, 2 through the humerus because of extensive destruction of tissue and impairment of blood supply, 1 traumatic amputation of the hand, and 7 of the fingers.


362

There were 401 patients with wounds of the lower extremity (not including multiple wounds), 8 of whom died; 1 of unexplained cause (Case 1); 2 of shock and hemorrhage (Cases 2 and 3); 1 of uremia associated with a probable "crush syndrome nephrosis" (Case 4); 2 not seen by a medical officer, of shock and hemorrhage following traumatic amputations of the feet (Cases 5 and 6); and 2 of gas gangrene (Cases 7 and 8). Therefore, the total mortality for the wounded who were seen alive was 2 percent.

There were 90 compound fractures of the lower extremities distributed as follows: Femur, 23; bones of the leg, 51; and bones of the feet, 16. All fractures were treated with plaster. There were no deaths due directly to compound fracture (Case 4). There were 18 amputations of the lower extremity of which 7 were "traumatic" and 11 elective. Of the 7 traumatic amputations, 3 died (Cases 3, 5, and 6). Of the 11 elective amputations, 8 were done because of extensive tissue destruction and blood vessel injury. The one death in this group occurred in the rear echelon (Case 4). The remaining three amputations were necessary because of gas gangrene infection, although in two of these patients impending circulatory gangrene was also present. One of this group died (Case 8). All amputations were of the guillotine type.

CASE REPORTS: WOUNDED-TREATED-DIED-LATER

Extremity wounds

Case 1.-A soldier of the 132d Infantry, 37th Division, was lying prone in open jungle when he was struck by a .25 caliber Japanese machinegun bullet fired from a distance of 30 yards at 1800 hours on 2 April 1944. He was taken immediately to the battalion aid station and found to have a severe perforating wound of the right knee joint. While receiving first aid treatment, he became hysterical and died suddenly at 1900 hours on 2 April 1944. While some hemorrhage had occurred, he had not lost enough blood to cause severe shock. Death was unexplained.

Case 2.-A soldier of the 132d Infantry, 37th Division, leaving the trail to the observation post to try a "short cut," tripped the wire of a U.S. land mine which exploded a few feet away. He was wounded at 0715 hours on 22 March 1944. Plasma and morphine were administered by a medical officer within 10 minutes, and the patient was immediately evacuated. At the clearing station, examination disclosed an extensive wound of the dorsal aspect of the left thigh. Because of severe hemorrhage from the larger vessels, three blood transfusions were given. Following debridement of the wound and ligation of the profunda artery, the patient did not recover from shock and died at 1500 hours on 22 March 1944.

Case 3.-A soldier of the 129th Infantry, 37th Division, was firing a machinegun when a Japanese knee mortar shell burst between his legs. He was wounded at 1000 hours on 12 March 1944 and taken immediately to the 33d Portable Surgical Hospital. A traumatic amputation at the upper third of the right femur was completed by guillotine amputation under Sodium Pentothal (thiopental sodium) anesthesia, and several small wounds of the posterior aspect of the left leg were dressed. Following operation, during which he received 4 units of plasma, the patient was transferred immediately to the 21st Evacuation Hospital. On arrival there, the systolic blood pressure could not be obtained. While awaiting blood transfusion, he was given 1 unit of plasma but died before this could be completed at 1450 hours on 12 March 1944. Cause of death was shock and hemorrhage. (NOTE.-This patient should not have been transferred to another hospital.)


363

Case 4.-A soldier of the 129th Infantry, 37th Division, was lying prone in the open when he was struck by a fragment of a Japanese knee mortar shell which burst nearby. He was wounded on 15 March 1944 and taken to the 21st Evacuation Hospital. He had a severe wound of the right leg involving the vessels and nerves and a compound fracture of the tibia. This wound was debrided. The next day because of destruction of the blood supply a guillotine amputation was done 2 inches proximal to the knee joint. He was evacuated to a station hospital in the rear echelon on 19 March 1944. On 23 March, he developed anuria and died with uremia at 0845 on 25 March 1944. Post mortem examination revealed nephrosis which was thought to have been due to "crush syndrome." (See autopsy protocol Case 93, p. 411.)

Case 5.-A soldier of the 132d Infantry, 37th Division, while on a combat patrol lying in an open foxhole, sustained a direct hit by a Japanese knee mortar shell. He was wounded at 1800 hours on 4 April 1944, was taken to the command post, given 2 units of plasma and morphine, and kept there overnight. He had a traumatic amputation of the right foot. On the following day, an attempt was made to transport this soldier to the hospital, but he died en route while crossing a river at 1300 hours on 5 April 1944. The wound was not bleeding when inspected before the journey, hence a tourniquet was not applied. However, during the long carry, bleeding occurred and death was apparently due to shock from hemorrhage. This might have been prevented by the use of a tourniquet. (See autopsy protocol Case 91, p. 410.)

Case 6.-A soldier of the 182d Infantry, Americal Division, was digging a foxhole on Hill 260 when he was struck in the ankle by a ricochetting .25 caliber Japanese bullet fired from an unknown distance. He was wounded at 1800 hours on 11 March 1944 and received immediate first aid. "There was practically no bleeding when bandaged. It was dark. We put him on a litter and started down the hill." The patient complained of feeling cold, and when the bottom of the hill was reached he was found dead. Profuse hemorrhage had occurred. The rough journey down the hill in the absence of a tourniquet had apparently dislodged a blood clot, thus initiating a fatal hemorrhage.

Case 7.-A soldier of the 182d Infantry, Americal Division, was patrolling on Hill 260 a short distance beyond the perimeter when he tripped the wire of a U.S. grenade boobytrap at 1200 hours on 28 March 1944. He threw himself on the ground but was struck in the left buttock by a fragment at a distance of 3 yards from the burst. He was evacuated immediately to the clearing station and found to have a penetrating wound of the buttocks extending upwards 7 inches into the soft tissues of the lumbar region. The point of entrance was 1 inch in diameter. Through a 3-inch incision, the fragment was removed and the wound closed without drainage. The wound of entrance was debrided but not sutured. The track was not debrided, but the wound was irrigated and dusted with sulfanilamide powder. After transfer to the 21st Evacuation Hospital on 3 April 1944, a diagnosis of gas gangrene was made. Despite the administration of 20,000 units of gas gangrene antitoxin and 1,000 cc. of blood, death occurred 4 hours later as a result of the very virulent Clostridium welchii infection.

Case 8.-A soldier of the 37th Division was near Hill 700 prone behind a tree when a Japanese knee mortar shell burst within a few feet. He was wounded at 0430 hours on 11 March 1944 and taken immediately to the battalion aid station. After receiving plasma, he was transferred directly to the 21st Evacuation Hospital. He had multiple severe wounds of both legs, thighs, buttocks, scrotum, and back. Following the administration of an additional 3 units of plasma and 1,000 cc. of blood, wound debridement was done under ether anesthesia. On 13 March 1944, he developed signs of gas gangrene of the right leg and was given 60,000 units of gas gangrene antitoxin. On 14 March, a guillotine amputation of the lower third of the thigh was done, following which the patient became rapidly more toxic and died at 1415 hours on 15 March 1944.


364

Multiple Wounds

Only those patients who had two or more wounds in different anatomic regions either one of which might have produced death or disability are included in the classification "Multiple Wounds." When a single wound was considered responsible for the disability, even though several additional minor wounds were present, that patient was classified according to the anatomic location of the major wound. Many factors are involved when multiple wounds occur simultaneously in different parts of the body. For this reason, endeavor was made to limit to a minimum the number of casualties included under the division designated "Multiple Wounds." Nevertheless, despite this effort, there were 239 patients seen alive who were so classified.

In this group of 239 patients who received multiple wounds, there were 8 deaths, making a mortality of 3.3 percent. With one exception (Case 3), those who died underwent surgical operation. These operations were usually sanguine procedures, and in most instances death resulted from shock and hemorrhage (Cases 1, 2, 4, 5, 6, and 7). In one patient (Case 8), death was caused by gas gangrene infection.

In these 239 patients, 569 anatomic regions were hit with wounds distributed as follows: Upper extremity, 202 (35.5 percent); lower extremity, 181 (32.0 percent); head, 92 (16.1 percent); thorax, 69 (12.2 percent); and abdomen 25 (4.4 percent). The number of wounds was actually in excess of these figures because several wounds frequently occurred in one anatomic region. There were 2.8 anatomic regions wounded per patient or well in excess of 3 wounds per patient, since many minor wounds from small fragments were not even tabulated.

CASE REPORTS: WOUNDED-TREATED-DIED-LATER

Multiple wounds

Case 1.-A soldier of the Americal Division was struck by a fragment of a shell which burst near him in the messhall at 0730 hours on 11 March 1944. He reached the operating room of the clearing station within 15 minutes and, although shock did not appear to be severe, was given 2 units of plasma. He had sustained a large perforating wound of the left leg, a compound fracture of the bones of the left foot, a wound of the left forearm, a severed temporal artery, and many small penetrating wounds. Following wound debridement, shock supervened, and, despite the administration of 1,500 cc. of blood and 2 units of plasma, the patient died at 1450 hours on 11 March 1944. Death was attributed to irreversible shock, although brain injury may have been a factor since bleeding from the ears was present.

Case 2.-A soldier of the 246th Field Artillery was riding in the back of a truck when a Japanese 105 mm. shell burst 5 yards to the rear at 0730 hours on 8 March 1944. Because hemorrhage was profuse, a tourniquet was immediately applied to the leg and plasma administered. At the nearby 36th Naval Hospital, the patient was treated for shock in association with a severe wound of the left thigh and right forearm and an extensive wound of the back accompanied by compound fractures of the third and fourth lumbar vertebras. The wounds were cleaned, but the patient did not recover from shock and died at 0120 hours on 9 March 1944.


365

Case 3.-A soldier of the 131st Engineer Combat Battalion, leaving his foxhole to rescue a friend, was struck by fragments of a Japanese 90 mm. mortar shell which burst 6 feet away at 0500 hours on 24 March 1944. He was taken directly to the hospital. It was apparent that the patient was mortally wounded, a blood pressure reading could not be obtained, and profound shock was present. A severe wound involving the brain was found in the temporal region and a penetrating abdominal wound in the region of the right flank. He died without operation at 0830 hours on 24 March 1944. At post mortem, extensive lacerations of the liver and kidney were discovered. (See autopsy protocol Case 99, p. 413.)

Case 4.-A soldier of the 132d Infantry, Americal Division, was investigating a mine field when an M3 antipersonnel mine exploded within a few feet at 0830 hours on 27 March 1944. He received immediate first aid including 3 units of plasma, following which he was removed to the clearing station. A traumatic amputation of the left foot and extensive lacerated wounds of both buttocks and the right forearm were found. Operation under ether anesthesia was started at 1000 hours and completed at 1115 hours. During the operation, 500 cc. of blood and 1 unit of plasma were given, but at the conclusion of the procedure the blood pressure was only 90/60. While recovering from ether, the patient struggled violently and died suddenly at 1455 hours on 27 March 1944. (See autopsy protocol Case 104, p. 415.)

Case 5.-A soldier of the 148th Infantry, 37th Division, was running across a jungle trail when a U.S. 81 mm. mortar shell fell short and burst "right between his legs." He was wounded at 0945 hours on 1 April 1944 and was taken directly to the 33d Portable Surgical Hospital. A traumatic amputation of the right foot, an incomplete traumatic amputation of the left leg, and lacerated wounds of the right elbow and hand were evident. After the administration of 2,000 cc. of blood and 1 unit of plasma, the traumatic amputation of the left leg was completed at operation. The patient died on the operating table at 1500 hours on 1 April 1944. (See autopsy protocol Case 94, p. 411.)

Case 6.-A soldier of the 182d Infantry, Americal Division, was in a slit trench covering a bazooka man when a Japanese knee mortar shell burst in the trench at 0830 hours on 11 March 1944. Both legs were blown off below the knees as well as the left arm and a portion of the right buttock. He received 2 units of plasma, remained rational, and reached the 31st Portable Surgical Hospital with comparatively little bleeding. At operation, the partial amputation of the arm was completed, and the other wounds were debrided. He died at 1300 hours on 11 March 1944 of shock and hemorrhage.

Case 7.-A soldier of the 182d Infantry, Americal Division, while in a foxhole on Hill 260, was wounded by a Japanese knee mortar shell which burst in the foxhole. The aidmen had difficulty in reaching him, and 5 hours elapsed before he could be removed. At the 31st Portable Surgical Hospital, shock was apparent and resulted from compound fractures of the right femur and leg and severe wounds of the right arm, chest, and pelvis. After a plasma transfusion, a Steinmann pin was inserted in the distal end of the femur and the lower leg amputated. The patient did not survive the operation, however, and died at 1350 hours on 13 March 1944. Autopsy showed multiple perforating wounds of the right thigh and a compound fracture of the femur. The right lower leg had been amputated at the junction of the upper and middle thirds, and a compound fracture of the bones of the left foot and deep lacerations of the scrotum, chest wall and medial aspect of the thigh were present. The abdominal and thoracic cavities were negative. Death was attributed to shock and hemorrhage.

Case 8.-A soldier of the 117th Engineer Combat Battalion, 37th Division, while driving a vehicle along a jungle trail, was struck by fragments of a Japanese mortar shell which burst in a tree at a distance of 25 feet. He was wounded at 1030 hours on 9 March 1944 and taken at once to the 21st Evacuation Hospital. Severe multiple wounds of the right thigh and buttocks involving the perineum and scrotum were discovered. The sciatic nerve had been transected. After appropriate shock therapy, the wounds were debrided, and the patient was given a prophylactic injection of 5,000 units of gas gangrene antitoxin. Immediately after a diagnosis of gas gangrene had been established, multiple incisions were


366

made in affected areas in the right groin and thigh. The patient expired at 2045 hours on 10 March 1944, approximately 30 minutes after the termination of the operation. Death was ascribed to gas gangrene infection.

Comment on Treatment of the Wounded

Perhaps never in the history of jungle warfare were professional talent and medical facilities so excellent and routes of evacuation so favorable as in the Bougainville campaign. Hence, the care of the wounded did achieve a very high standard. That this was accomplished is evidenced by the foregoing description of the treatment of all those who were wounded in action and died later.

The first aid treatment was prompt and efficient. Great credit should be given to the aidmen who fearlessly exposed themselves, and high approbation should be accorded to the many who were killed in order that their comrades might live. Plasma was given promptly and in large quantities. Hemorrhage was efficiently controlled in all patients, with only two exceptions. Both of these patients bled to death from traumatic amputations of the foot. Bleeding had ceased while the patient was at rest but began anew during transportation (fig. 184). These patients might have been saved by the use of a tourniquet. Considerable criticism was heard because sucking wounds of the chest were not tightly sealed by the adequate use of adhesive. However, no patient was known to have died for this reason.

The division medical services were adequately staffed to care for the type of surgery they were expected to do. Most of the major surgery was done

FIGURE 184.-Litter carry. Long and difficult litter carries contributed to some deaths.


367

FIGURE 185.-A screened operating room in a clearing station. Note excellent sterile technique.

at the 21st Evacuation Hospital, because of its proximity to the front. The clearing stations and portable surgical hospitals were usually bypassed in order to save time in the case of the seriously wounded. Minor surgery was done in the clearing stations (fig. 185). One clearing station sutured approximately 50 superficial wounds and obtained primary healing in all. This was done as a trial, and no untoward results ensued as the procedure was limited strictly to superficial flesh wounds. Though two portable surgical hospitals were available, they were not necessary in the Bougainville campaign. A few patients who underwent operation at these hospitals were transferred immediately or shortly after operation before recovering from shock. This factor may have contributed to a fatal termination in some instances. Rapid evacuation of patients (fig. 186) to the hospitals was possible, because of excellent roads and the short distance from perimeter to hospital. More than 80 percent of all patients reached the hospital within 3 hours.

The 21st Evacuation Hospital was staffed with well-qualified specialists, and no patient here failed to achieve adequate specialized care. The value of a neurosurgeon at the front is frequently a disputed point. In island warfare, unless a competent surgeon is assigned locally, the patient may have to be evacuated for a distance of hundreds of miles. Hence, the various specialists should be available, if possible, on the island where combat occurs. Especially is the thoracic surgeon of great value at the front, if the lives of patients needing his services are to be saved. The chief deficiency in the ranks


368

FIGURE 186.-Jeep ambulance. The jeep ambulance carrying three litters was well adapted for use over jungle trails.

of the specialists is the lack of adequately qualified anesthetists. One such anesthetist was available at the 21st Evacuation Hospital, but, when faced with the problem of anesthetizing eight patients simultaneously, his problem was insurmountable. As is the case so frequently, it was impossible to determine which deaths to attribute to improper anesthesia. Good anesthesia is of first importance in dealing with wounds which require major surgical procedures in the presence of impending shock.

Plasma was used in large quantities in the hospitals as well as in the forward areas. Blood transfusions were more liberally used in this campaign than in any other in the South Pacific. Over 400 transfusions were given in the 21st Evacuation Hospital, with, only three reactions. Blood loss was usually great, and very large quantities of blood were required to restore blood volume. Blood counts and hemoglobin determinations revealed these huge blood deficits, and further confirmation was frequently obtained at post mortem. All blood was donated by troops on the island and furnished from a blood bank maintained at the hospital.

Professional care of the wounded was excellent and even the unavoidable errors of judgment incident to war surgery were at a minimum. There were four patients who died of gas gangrene infections, but only one death could be attributed to an error of surgical judgment. In this instance, closure of the wound by suture was probably responsible. There were no deaths due directly to compound fractures of the extremities. Only three patients died


369

in the rear echelon. The total mortality among 2,015 treated wounded was 3.7 percent. The total mortality among 1,788 treated in hospitals was 5.1 percent. The total operative mortality was 3.5 percent.

MORBID ANATOMY

The study of morbid anatomy in battle casualties is limited by the facilities15 and the personnel available as well as the circumstances of battle. In the tropics, it is still further limited by the number of dead which must be studied before decomposition, which occurs early.

This report includes 395 dead on which 104 post mortem examinations were performed. Explanation for the relatively small number of autopsies is twofold. First, the assigned pathologist was on detached service at Bougainville for less than one-half of the period covered in this study. Second, many deaths occurred on patrol or in areas which remained under enemy fire, and the bodies were not recovered until decomposition had ensued and consequently examinations were omitted.

All autopsies were performed at Bougainville except in three instances in which death occurred in hospitals in the rear echelon. Allied dead numbered 99 of which 19 were Fijian Scouts and their New Zealand officers. Five Japanese bodies were examined to make the total of 104.

The completeness of the post mortem examinations was determined by the circumstances, such as the condition of the body, whether the cause of death was obvious, and the number of bodies awaiting autopsy (largest number was 26 on one afternoon). Every effort was made to determine the cause of death and to record the gross effects of the missile, its wounds of entrance and exit, and its effects on tissues and organs.

The wounds of entrance responsible for death are shown in figure 187. In the case of multiple wounds, whenever it was possible to decide which of two or more were responsible for death, the wound which caused instantaneous death was recorded. Missiles entering the body in the lateral plane are indicated at the extreme edge of the profile diagram.

Although the number of wounds is small, these figures may give some indication of the number of lives which might possibly be saved by protective armor. A proposed armor chest plate (9" x 8") covered a square outlined by the sternal notch above, the xiphoid process below, and the nipples laterally. Such a plate could possibly have prevented perforations of the chest cavity in

15Facilities for post mortem examination were courteously provided by the 21st Evacuation Hospital. The morgue, a screened storage tent with a concrete floor, running water, and electric lights, exceeded expectations for a combat zone. The tent was surrounded by a 6-foot canvas wall which helped to isolate it from the hospital wards. Vehicles could reach the area without driving past the ward installations. Technicians to assist with the work were detailed by the 21st Evacuation Hospital and the 52d Field Hospital. A stenographer and photographer recorded all significant wounds and photographed all recovered missiles, fragments, or foreign bodies. When identification of fragments was difficult, they were taken to the Ordnance Section of the XIV Corps for expert opinion. The Cemetery and Graves Registration Office was conveniently located near the hospital, and all dead as they were received at the cemetery were transferred to the morgue for examination.


370

FIGURE 187.-Entrance sites of lethal wounds in 104 autopsied casualties. A. Anterior view. B. Posterior view.

16 of these chest wounds (59 percent) illustrated in the anterior view. A central abdominal armorplate (8" x 6") could possibly have prevented 4 of the 7 fatal perforations of the peritoneal cavity.

Morbid Anatomy of Wounds by Region

The autopsied dead were classified under anatomic regions (table 94) according to the location of the wound considered responsible for death. In many instances, multiple wounds were present. For this reason, it was necessary to reserve the classification "Multiple Wounds" for those cases in which two or more wounds could have been responsible for death. There were 104 post mortem examinations; 68 of these dead were killed instantly, and 36 were wounded, treated, and died later.

Head.-In this study, 26 (25 percent) of the autopsied dead sustained fatal head wounds; 20 of these were killed instantly, and 6 were wounded and died later. Characteristic of this group was the extent and magnitude of the fragmentation of the skull found at autopsy. Extensive comminution of the vault with radiating basal fracture lines was almost invariably present in these


371

compound fractures. Indriven bone splinters were common. The accompanying severe laceration, herniation, or avulsion of the brain was obviously the cause of death in all head cases. None of the four patients on whom operation was undertaken survived longer than 48 hours. In three of these, an apparently hopeless prognosis existed from the time of injury.

TABLE 94.-Distribution of fatal wounds in 104 autopsies, by anatomic location

Anatomic location

Total dead

Killed instantly

Wounded-treated-died-later

Number

Percent

Number

Percent

Number

Percent

Head

26

25.0

20

76.9

6

23.1

Thorax

32

30.8

23

71.9

9

28.1

Thoracoabdominal

16

15.4

9

56.3

7

43.7

Abdomen

12

11.5

6

50.0

6

50.0

Lower extremity

10

9.6

4

40.0

6

60.0

Multiple wounds

8

7.7

6

75.0

2

25.0

Total

104

100.0

68

65.4

36

34.6


Torax.-There were 32 (30.8 percent) deaths from thoracic wounds, and of this number 23 died instantly and 9 died later. Almost half (46.2 percent) of all deaths resulted from a combination of thoracic and thoracoabdominal wounds. Remarkable to note was the widespread destruction produced by high-velocity bullets. Gross damage or "blast effect"16 in the opposite lung by such missiles was clearly demonstrated in six instances and later confirmed by microscopic sections. In two such cases, death was attributed to cardiac failure, and in these right ventricular dilatation was found. It was suggested that the pulmonary injury may have produced a partial obstruction of the pulmonary circulation. The rapid administration of intravenous fluids may have contributed to the cardiac dilatation.

Laceration of the lung by perforating or penetrating missiles was present in all cases. The left lung was involved in 15 cases, the right in 9, and in 8 instances bilateral lesions were present. Injury to the lung alone resulting in massive unilateral hemothorax caused death in 13 cases. It was not uncommon to find from 3 to 4 liters of blood in the pleural cavity. Of the 13 patients, 7 survived to undergo operation; the others died instantly. The size of the various external chest wall wounds bore no relation to the amount of underlying damage. Particularly striking were the small external wounds of the high-velocity bullet which were so frequently accompanied by extensive laceration

16Damage resulting from formation of temporary cavity and not related to the pulmonary hemorrhage seen in air blast injuries. The latter is due to the destructive force of the pressure wave set up by the detonation of high explosives. Any pulmonary (or visceral) damage resulting from the passage of a high-velocity missile is dependent upon the formation of a temporary cavity. Blast injuries are seen in association with aerial bombardment and detonation of high explosives, such as dynamite, bangalore torpedoes, and landmines. See also footnote 14, p. 352.-J. C. B.


372

and destruction of intrathoracic structures. The lower velocity fragments of explosive shells and bombs as a rule produced more extensive external defects. Bone fragments derived from ribs were common along the wound track. With the exception of Case 36, in which a metal button was removed, no foreign material was recovered.

In order of frequency, perforation or laceration of the intrathoracic structures occurred as follows: Heart, 8; aorta, 5; pulmonary artery, 4; and trachea and esophagus, 2. The thoracic cord was transected in 3 cases and the cervical cord in 1. Wounds of the heart and great vessels were found in approximately 50 percent of these cases. Hemorrhage was the cause of death in 85 percent of thorax wounds.

Thoracoabdominal wounds.-Multiple lesions of the abdominal and thoracic cavities in the same individual accounted for 16 (15.4 percent) deaths. Only those cases in which one missile was responsible for the combined injury are included in this group. The wound of entry was through the thoracic wall in 12 of the 16 cases. Nine were killed instantly, and the remaining seven underwent operation and died later. Four patients had thoracotomy, two laparotomy, and one had both laparotomy and thoracotomy. Five of these patients died within 24 hours from hemorrhage and shock, one after 8 days from secondary hemorrhage, and one (Case 68) after 6 days from cardiorespiratory failure.

The cause of death in 15 of the 16 cases was hemorrhage and shock, hemothorax and hemoperitoneum being frequently combined. The lung was injured in all cases, the heart perforated in one, the thoracic aorta in one, and the abdominal aorta in another. The abdominal organs injured in order of frequency were liver, spleen, hollow viscus, kidney, and pancreas.

Abdomen.-There were 12 (11.5 percent) fatal abdominal wounds. In 5 of the 6 patients who died instantly, death resulted from hemorrhage, and, in the sixth patient, it was due to shock from evisceration. Of the six patients who had laparotomy, none lived longer than 4 days following operation. In these cases, 1 death was attributed to hemorrhage, 1 to paralytic ileus and uremia (Case 84), and 4 to peritonitis.

Multiple lesions were usually present. In order of frequency, the abdominal organs injured were as follows: Jejunum, ileum, transverse colon, and rectum, 11; major vessels, 5; kidneys, 4; liver, 2; pancreas, 2; and spleen, 1. Fractures of the vertebral bodies were found in four instances. Damage to the spinal cord occurred in one case and to the cauda equina in another.

Lower extremities.-Wounds of the lower extremities were responsible for 10 (9.6 percent) deaths. Hemorrhage from the femoral artery accounted for death in four of the soldiers who died instantly. In the other casualties, both Japanese and about whom little is known, death apparently resulted from shock associated with severe compound fractures of the femur. Six patients were wounded and died later; four of this group underwent operation. Gas gangrene accounted for death in 3 (2 Japanese and 1 American) patients; hemorrhage, in 2; and uremia, in one.


373

Multiple wounds.-Under this heading are classified those cases in which two or more wounds could have been the cause of death. Of the 8 casualties so classified, 5 died instantly with wound distribution as follows: Head and abdomen, 2; head, thorax, and abdomen, 1; thorax and multiple fractures of the femur and extensive multiple wounds, 1; and head with multiple fractures of the femur and tibia and fibula, 1. In all cases, the immediate cause of death was hemorrhage, extensive brain damage, or shock, or a combination of these three.

Two of the remaining patients had undergone operative procedures. One who sustained a traumatic amputation of the leg and multiple wounds and fractures died from shock within 10 hours. The second patient died from gas gangrene after 48 hours following fracture of the femur and other extensive wounds.

Causes of death.-Table 95 lists the various causes of death as determined by post mortem examination among the 104 casualties. Hemorrhage was the most common cause (54.8 percent), and this was followed by brain and spinal cord damage (26 percent). The remaining cases died from a number of other conditions. The following general conclusions were reached as a result of the autopsy study:

1. Hemorrhage, frequently occult, was the most common cause of death.

2. Extensive brain damage was the second most common cause of death.

3. It was impossible to determine with accuracy the causative missile from the appearance of a wound.

4. The extent of the underlying structural damage bears no constant relationship to the size of the wound of entrance or exit. This fact is frequently not appreciated by the young, inexperienced battle surgeon and is of great significance in the proper care of the patient.

TABLE 95.-Cause of death in 104 casualties as determined by post mortem examination

Cause

Dead

Number

Percent

Hemorrhage

57

54.8

Brain or spinal cord damage

27

26.0

Shock not due to hemorrhage

5

4.9

Peritonitis

4

3.9

Gas gangrene

4

3.9

Cardiac failure

2

1.9

Uremia

2

1.9

Pulmonary edema

1

.9

Pulmonary embolus

1

.9

Empyema with sepsis

1

.9

Total

104

100.0


374 

5. Foreign material, except for the wounding missile, was seldom found.

6. Contralateral brain and lung damage from high-velocity missiles was a frequent finding. Temporary cavity effect on the contralateral lung may result in sequelae further impairing the pulmonary circulation.

7. High-velocity missiles striking large blood vessels or solid organs usually produced an explosive effect rather than a perforation.

Morbid Anatomy of Wounds by Weapon

Table 96 lists the types of weapons responsible for the lethal wounds in the autopsied cases.

Wounds caused by rifle.-The rifle was the weapon responsible for death in slightly less than half (42.3 percent) of the autopsied cases. Table 97 shows the anatomic distribution of wounds among those killed by rifle fire.

Head.-Head wounds produced by rifle fire were characterized without exception by extensive destruction of the brain and skull. Laceration, massive herniation, or total absence of large portions of the brain were the usual findings. Large areas of bony skull and scalp were frequently avulsed with shattering or widespread comminution of the residual portions of the skull. Ofttimes, bone fragments were driven deep into the brain tissue. Perforating skull wounds were more common than gutter wounds. Frequently, long, stellate fracture lines radiated across the base of the skull. Extensive damage was sometimes observed in one hemisphere of the brain, when the traversing missile track lay entirely in the opposite hemisphere. All these findings were interpreted as additional evidence in support of the modern hypotheses17 of wound production by high-velocity missiles.

TABLE 96.-Weapons causing wounds in 104 casualties, as determined by post mortem examination

Weapon

Total casualties

Killed instantly

Wounded-treated-died-later

Number

Percent

Number

Percent

Number

Percent

Rifle

44

42.3

31

70.5

13

29.5

Mortar

24

23.1

13

54.0

11

46.0

Machinegun

13

12.5

8

61.5

5

38.5

Grenade

7

6.7

4

57.1

3

42.9

Mine

7

6.7

5

71.4

2

28.6

Artillery

6

5.8

5

83.3

1

16.7

Miscellaneous

3

2.9

2

66.7

1

33.3

Total

104

100.0

68

65.4

36

34.6


17The observation that a high-velocity bullet produces terrific destruction of tissue at a considerable distance from its permanent wound track is well established. See chapter III, p. 144.


375

Table 97.- Anatomic distribution of wounds among 44 casualties killed by rifle fire, and weapon from country of origin

Anatomic location

Casualties

Weapon

Killed instantly

Wounded-treated-
died-later

Total

Japanese

United States

Number

Number

Number

Number

Number

Head

12

3

15

13

2

Abdomen-thorax

1

3

4

4

0

Thorax

12

5

17

15

2

Abdomen

2

1

3

3

0

Lower extremities

3

---

3

1

2

Multiple

1

1

2

2

0

Total

31

13

44

38

6


There were no features present to distinguish the wounds produced by the Japanese rifle from those produced by the U.S. rifle nor were there any dissimilar findings in the wounds of those killed instantly and those who were wounded and died later. Perforating wounds completely traversing the skull were recorded frequently by the Japanese .25 caliber bullet at varying distances from 10 feet to 150 yards.

Perforation of the U.S. helmet by enemy rifle fire was found in six instances. The maximum recorded distance at which this occurred was 100 yards. A sample of the sizes of the entrance and exit wounds, respectively, of the head produced by the Japanese rifle at various distances follows: At 150 yards, 0.6 and 1.2 cm.; at 100 yards, 2.5 and 3 cm.; at 20 yards, 0.5 and 1.2 cm.; and at 15 yards, 3.7 and 8.7 centimeters.

Thorax.-All rifle wounds of the chest were with two exceptions complete perforating wounds. In both these instances, the enemy .25 caliber bullet failed to perforate the thorax at a distance of 25 yards.

Massive intrathoracic hemorrhage was the immediate cause of death in all those killed instantly and in two patients who were wounded and died a few hours later. Transection of the spinal cord with fracture of vertebra was present in four instances. In two of these, death occurred immediately, and in both cases massive hemothorax was found. In one of the other two cases, death occurred in 24 hours associated with terminal hyperthermia and in the other after 1 month following an extensive empyema complicated by a bronchopleural fistula.

Fairly typical of the extensive thoracic damage caused by the .25 caliber Japanese rifle bullet is Case 40. This soldier was struck in the chest at moderately close range. The entrance wound was situated in the seventh posterior intercostal space, and the exit wound was over the clavicle. All ribs from fourth to eighth, inclusive, were fractured in addition to the clavicle.


376

The upper and lower lobes were severely lacerated, and a massive hemothorax was present.

Table 98 lists the sizes of known wounds of entrance and exit at various ranges.

TABLE 98.-Size of wounds of entrance and exit, caused by rifle bullet, at various ranges

Distance of range

Wound of-

Entrance

Exit

Yards

Cm.

Cm.

-1

0.6

2.5

5

.5

1.2

5

1.8

3.8

20

.5

3.7

20

3 x 1

3.8 x 2.5

25

.5

1.5 x 1

30

.6

4.3

30

.6

2.5

30

.5

2.5

35

.5


Thorax and abdomen.-The force of the .25 caliber Japanese rifle bullet when fired at moderately close range (25 yards or less) was well demonstrated by the great number of structures and organs injured when the thorax and abdomen were traversed by the same missile. Structures perforated in each of four illustrative cases are listed here: Case 67-anterior chest wall, upper lobe of left lung, left ventricle, right ventricle, lower lobe of right lung, diaphragm, liver, lateral chest wall; Case 71-abdominal wall, jejunum, ileum, transverse colon, liver, diaphragm, lower lobe of right lung, chest wall; Case 68-chest wall, lung, diaphragm, colon, spleen, kidney; Case 69-left elbow (fracture of humerus), chest wall, both lobes of left lung, diaphragm, spleen, kidney, chest wall. The latter patient lived 8 days and died of secondary hemorrhage from lung and spleen. Death in the third case occurred on the following day and resulted from cardiorespiratory failure. In the first two cases, massive hemothorax and hemoperitoneum were present at autopsy.

Abdomen.-The powerful disruptive effect of the rifle bullet on various abdominal structures can be appreciated best by enumerating its destructive effects in the individual case. Three patients were struck in the abdomen by Japanese rifle bullets at distances of 20 yards, 75 yards, and at an unknown distance. Respectively, their important injuries were: Case 77-fracture of the ilium and sacrum, perforation of the rectum, and massive hemoperitoneum; Case 78-fracture of the rib and vertebra, extensive lacerations of the liver, kidney, and transverse colon, and hemoperitoneum; and Case 81-extensive lacerations of the kidney and liver with hemoperitoneum. Common to all these cases and characteristic in the wounds of the solid organs in the kidney,


377

liver, and spleen was the widespread "shattering" and fragmentation produced by the explosive effect of the missile in its passage.

Lower extremity.-A Fijian soldier (Case 87) was struck in the groin by an enemy rifle bullet which severed the femoral artery and vein. He died within a few minutes from exsanguination. A Japanese soldier (Case 89) sustained a severe compound comminuted fracture of the middle third of the femur and died from shock several hours later despite therapy. Cursory examination of the decomposed body of another Japanese soldier (Case 90) revealed an extensive compound comminuted fracture of the femur with a very large wound of exit (16.6 x 13.9 cm.) but with intact femoral vessels. In these last two cases, death apparently resulted from severe shock without significant concomitant hemorrhage.

Multiple.-Two patients sustained multiple rifle wounds. One of these (Case 101) died instantly, the other (Case 103) died 2 days later from peritonitis and gas gangrene.

Mortars and grenade discharges.-Mortar fire accounted for death in approximately one-fourth (23.1 percent) of the autopsied cases. The anatomic distribution of wounds among those killed by this weapon is shown in table 99.

TABLE 99.-Anatomic distribution of wounds among 24 casualties killed by mortar fire, and weapon from country of origin

Anatomic region

Casualties

Weapon

Killed instantly

Wounded-treated-
died-later

Total

Japanese

United States

Head

4

2

6

3

3

Abdomen-thorax

2

2

4

4

0

Thorax

5

1

6

4

2

Abdomen

1

2

3

2

1

Lower extremity

0

4

4

2

2

Multiple

1

0

1

1

0

Total

13

11

24

16

8


It is interesting to observe that the immediate lethal effect of the low-velocity mortar fragment is appreciably less than that of the high-velocity rifle bullet. Only slightly more than half of the autopsied dead, wounded by the mortar, died instantly; whereas, over two-thirds of all autopsied cases struck by rifle bullets were killed instantly.

Head.-In cases in which perforation of the skull occurred, the size of the skull wounds and distance from the burst was known in three. At 25 yards, a fragment (3 x 1 x 0.8 cm.) of a U. S. 90 mm. shell perforated the skull and resulted in death 2 hours later from the extensive brain damage (Case 12).


378

The entrance wound in this case measured 2.5 cm. in diameter. A U.S. 90 mm. shell exploding at a distance of 20 yards produced a large gutter wound in the skull measuring 6.2 x 1.8 cm. (Case 3). Death followed in 3 hours. A small metal fragment (20 x 4 x 4 mm.) was recovered from the inner table of the skull. In the third instance (Case 26), a soldier was struck by a fragment from a Japanese 90 mm. shell at a distance of 7 yards. An entrance wound of 2.5 x 0.5 cm. was produced. This soldier expired after 12 hours from the cerebral injury.

Thorax.-A fairly characteristic feature of mortar wounds of the thorax was the extraordinary extent of the defect identified as the wound of entrance. For example, a Fijian soldier (Case 29) was killed instantly by a fragment from a U.S. 90 mm. shell which burst 20 yards away. Even from that distance, the fragment completely traversed the thorax and produced a wound of entrance 8.2 x 6.8 cm. and a wound of exit 20 x 12.5 cm. In another instance (Case 46), an entrance wound defect over the region of the scapula measuring 20 x 10 cm. was produced by a fragment of a 90 mm. Japanese mortar shell bursting at a distance of 20 yards. On the other hand, a mortar fragment in its greatest dimension measuring a little more than 1.0 cm. caused death from intrathoracic hemorrhage (Case 48). This fragment originated from an enemy 90 mm. shellburst at 10 yards. The wound of entrance in this case measured only 1.5 cm. One patient (Case 51) survived for a period of 3 days following severe chest injuries resulting from the explosion of a U.S. 4.2-inch mortar shell at a distance of 3 yards.

Abdomen.-In the abdomen, extensive laceration of multiple organs and structures was frequently observed. Death in these, if immediate, resulted from hemorrhage and shock. Two patients surviving for 3 and 5 days, respectively, after laparotomy, died of peritonitis. The first patient (Case 83) was struck in the abdomen by a fragment of an enemy 90 mm. mortar shell at a distance of 25 yards. Multiple perforations of the jejunum and colon resulted, but unfortunately the jejunal lacerations were overlooked at operation. The second patient (Case 84) was wounded by the burst of a 4.2-inch U.S. mortar shell at a distance of 3 yards. The largest external defect in this case was an entrance wound measuring 10 x 5 cm. over the region of the right iliac crest. Laceration of the right kidney and cauda equina and a large retroperitoneal hematoma were found at operation.

Lower extremity.-There were four autopsied dead who had sustained lower extremity wounds only. One of these deaths might have been prevented. In this case, a soldier's foot was blown off by the pointblank burst of an enemy shell (Case 91). Evacuation of this patient was effected at night, 24 hours later. In the process of transportation by litter, and unknown to the aidmen, delayed hemorrhage occurred and the soldier expired. In another case (Case 93), amputation was performed 1 day after injury, because of damaged blood supply to the extremity. This patient died 5 days later with uremia, the cause of which was unknown. A U.S. 81 mm. "short" exploded between the legs


379

of a soldier (Case 94) who lived thereafter for 6 hours. Traumatic amputations of both lower extremities resulted, the left thigh and right leg at the level of their upper thirds. A Japanese soldier (Case 96) died of gas gangrene 4 days after being wounded. The femoral vessels were intact but thrombosed, and the femur was not fractured. In this instance, the wound on the medial surface of the thigh measured 17 x 16.2 centimeters.

Two small external wounds resulted from the explosion of a 90 mm. Japanese mortar shell at a distance of 2 yards in a patient (Case 99) who survived only a few hours. One wound over the parietal region measuring only 1.5 cm. in diameter had resulted in extensive intracranial injury and hemorrhage. The liver and right kidney were extensively lacerated, and a massive hemoperitoneum was present. This was the only case listed under "Multiple Wounds" by mortar fire.

Machinegun.-The only distinguishing feature between rifle and machinegun wounds is that the latter are more often multiple. In all other respects, wounds produced by rifle and machinegun bullets of like caliber and muzzle velocity are identical. There were 26 separate wounds in these 13 dead. Grouped anatomically, the wounds responsible for death were divided as follows: Head, 2; thorax, 4; thorax-abdomen, 5; and abdomen, 2. Eleven were killed by enemy weapons and two by U.S. weapons. Eight of the thirteen autopsied were killed instantly; with one exception, the remaining wounded died within a few hours. Two of the dead were struck by .25 caliber bullets at distances of 150 yards, this being the maximum range recorded. In one of these (Case 27), a perforation of the thorax resulted, the entrance wound of which measured 2 cm. and the exit wound 3 x 1.5 cm. In the other (Case 5), a larger gutter wound of the skull was found, measuring 6.5 x 2.5 centimeters.

Grenades.-The grenade produced death in seven (6.1 percent) of the autopsied cases. Four of these deaths resulted from the U.S. grenade and three from the Japanese. The anatomic distribution of fatal wounds among the autopsied dead was: Abdomen and thorax, 2; thorax, 1; abdomen, 2; lower extremity, 1; and multiple, 1. With one exception, all patients wounded by grenades had multiple wounds. This soldier (Case 92) while on guard tripped the wire of a U.S. grenade boobytrap and was struck in the buttock by a single fragment. He died 6 days later from gas gangrene. A U.S. grenade exploded in the hand of an American soldier (Case 85) returning from patrol. Multiple abdominal organs and intestinal loops were perforated. Despite laparotomy and supportive treatment, this patient died on the following day. Multiple wounds and massive intrathoracic hemorrhage were found in two soldiers whose deaths resulted from pointblank bursts of U.S. grenades. In one instance (Case 98), a soldier returning to his own foxhole was mistaken for the enemy, and in the other (Case 64) an unexplained explosion occurred in the pocket of a soldier returning from patrol. Three deaths resulted from pointblank explosions of Japanese hand grenades, and in all instances multiple wounding was present. The cause of death was intrathoracic hemorrhage in


380

the two cases in which death was instantaneous. In the other case, the patient died after 12 days from generalized suppurative peritonitis due to evisceration following laparotomy. The grenade fragments did not perforate the abdominal cavity. No conclusions can be drawn from these dead as to different effects of the Japanese and U.S. grenades.

Artillery.-Of the six autopsied dead resulting from artillery fire, four were killed instantly by U.S. weapons. Two of these dead (Cases 9 and 16) sustained severe head wounds from 75 mm. shellbursts at distances of 5 and 12 yards, respectively. In the other two cases, death resulted from extensive thoracic wounds, produced in one (Case 34) by a U.S. 37 mm. shellburst at 3 yards and in the other (Case 42) by a U.S. shell of unknown caliber at a distance of 5 yards. One patient (Case 13) was killed instantly and another (Case 57) lived for only a few hours following the explosion of a Japanese shell (probably 150 mm.) at distances of less than 2 yards.

Landmines.-That the U.S. landmine is a most deadly weapon is convincingly demonstrated by the autopsy findings in seven cases. Each of these dead had multiple wounds, and all except two were killed instantly. One of the two who survived the initial blast was a Japanese soldier (Case 95). His death later in an American hospital was due to gas gangrene. The other was an American soldier (Case 104) who lived a little more than 6 hours and died from shock. The post mortem findings in this instance well illustrate the multiplicity of wounds found. The soldier sustained a traumatic amputation of the foot and 13 penetrating wounds. Present also were compound comminuted fractures of the patella, internal malleolus of the tibia, sacrum, and ulna.

Other examples of the extreme degree of trauma caused by these landmines as seen are the cases of five soldiers who were killed instantly. A striking illustration is that of a soldier (Case 102) in whom avulsion of the right and left frontal lobes and part of the right parietal lobe occurred with destruction of the orbit, frontal bone, and an area of skull measuring 10 x 6 cm. In addition, compound fractures of the tibia (bilateral), fibula, femur, ulna, and mandible were present. Altogether, there were 18 widely distributed perforating and penetrating wounds. One other case will suffice to illustrate the lethal effect of this weapon. Post mortem examination showed seven penetrating and perforating wounds (Case 100). A fragment passed through the skull, fracturing the maxilla, zygoma, and temporal bones, and then made its exit through the frontotemporal region. In its course, the missile destroyed the right frontal lobe. Another fragment entered the abdomen, severed or perforated the pylorus, duodenum, jejunum, and small intestine mesentery, and finally lodged in the bifurcation of the aorta. The peritoneal cavity was filled with blood, the brachial plexus was severed, and there were numerous other wounds of the thoracic and abdominal walls and thigh.

In all these instances, it is assumed that the victim either stepped directly on the mine or was injured at close range by having tripped a mine wire.


381

AUTOPSY PROTOCOLS

Case 1.-A soldier of the 164th Infantry, while walking through thick jungle toward Allied lines returning from patrol, was mistaken for the enemy and shot through the head with an M1 rifle at a distance of 30 yards by a fellow soldier. He was wearing a helmet when struck and this was perforated in the front and back. He was killed instantly at 1700 hours on 1 April 1944.

Examination revealed a perforating wound of the skull. The bullet produced a wound of entrance (3 cm. in diameter) through the left orbit and a wound of exit (2.5 cm. in diameter) at the junction of the parietal and occipital bones. Comminution of the cranial vault with diffuse disruption of the brain was present (fig. 188).

FIGURE 188.-Widespread destruction of cranial vault and brain (scalp retracted).

Case 2.-A Fijian soldier, while on patrol, was standing behind a tree when he was struck by a .25 caliber Japanese bullet fired from a distance of 20 yards. He was killed instantly on 31 March 1944.

Examination revealed a perforating wound of the head. The entrance wound (0.5 cm. in diameter) was situated over the lateral border of the right supraorbital ridge and the exit wound (1.2 cm. in diameter) over the occipital bone. Stellate fractures of the frontal and occipital bones radiated from both perforations. The frontal and parietal lobes of the brain were perforated, and the cerebellum was grooved.

Case 3.-A Fijian soldier, while on patrol, was standing digging a foxhole when he was struck by a fragment from a U.S. 90 mm. shell. The shell exploded on the ground at a 20-yard distance. He was wounded at 1700 hours on 30 March 1944 and died 3 hours later in the hospital. Death was attributed to severe brain damage.

Examination revealed a gutter wound (6.2 x 1.8 cm.) in the right frontal region. A stellate fracture involved the vault of the skull (fig. 189). The fragment coursed obliquely


382

FIGURE 189.-Extensive fracture of skull at site of entrance wound.

through the right cerebral hemisphere to the posterior aspect of the left parietal lobe. A metallic fragment (20 x 4 x 4 mm.) was recovered at this point and was found to be partially imbedded in the inner table of the skull.

Case 4.-A soldier of the 129th Infantry, crouching behind a tree stump, stood to throw a hand grenade and was struck in the head by a .25 caliber Japanese bullet fired from a distance of 10 feet; he was wearing a helmet which was perforated on the left side. He was killed instantly at 0930 hours on 24 March 1944.

Cursory examination18 revealed a perforating wound of the left side of the skull. The entrance wound involved the left orbit. The exit wound was found over the left parieto-occipital region. Brain tissue exuded from both openings. The cranial vault was severely comminuted and the left cerebral hemisphere destroyed.

Case 5.-A Fijian soldier, while on patrol, peered over a ridge and was struck in the head by a .25 caliber Japanese machinegun bullet fired from a distance of 150 yards. He was killed instantly at 1000 hours on 26 March 1944. After death from the head wound, he was struck again in the chest by a fragment from an artillery shell.

Examination revealed a gutter wound (6.5 x 2.5 cm.) in the center of the forehead with a portion of the frontal bone blown away. Fracture lines radiated through the temporal, parietal, and occipital bones. Both frontals and the right temporal lobes were lacerated. A bullet was recovered from the right temporal fossa. The chest was penetrated by a shell fragment entering through a wound (10 x 5.6 cm.) in the left seventh and eighth intercostal spaces in the anterior axillary line. In its course, the fragment fractured the 8th, 9th, 10th, and 11th ribs, lacerated the lower lobe of the left lung, the upper and lower lobes of the right lung, fractured and perforated the bodies of the seventh and eighth dorsal vertebras,

18On this afternoon, 26 bodies were received, and, since time did not permit a complete examination of all cases, some of these in which the cause of death was obvious received only cursory examinations.


383

FIGURE 190.-Missile fragment of (left) .25 caliber Japanese machinegun and of (right) artillery shell recovered from head and chest wounds.

transected the spinal cord, and fractured the third, fourth, fifth, and sixth ribs at the costovertebral junctions. The fragment was lodged in the subcutaneous tissue of the right posterior chest wall.

Figure 190 shows the two recovered missiles.

Case 6.-A soldier of the 117th Engineer Combat Battalion, while lying in an open foxhole in a cleared area of the jungle, was struck by fragments of a Japanese mortar shell. The shell exploded on the ground at a distance of 1 yard. He was killed instantly at 2015 hours on 24 March 1944.

Examination revealed a penetrating wound of the head. The entrance wound (2.5 cm. in diameter) perforated the left occipital bone. There was severe comminution of the cranial vault, and several fracture lines continued inferiorly through the base of the skull traversing the foramen ovale and cribiform plate. The left occipital and temporal lobes were severely lacerated, and small indriven bone fragments were removed from these lobes. Two metal fragments were recovered from the depth of an irregular laceration of the left cerebellar hemisphere. The fragments measured 15 x 5 x 1 mm. and 15 x 10 x 2 mm. Figure 191 shows the extensive skull fractures and the recovered fragments.

Case 7.-A soldier of the 129th Infantry was lying behind a tree root and was struck by a Japanese .25 caliber bullet fired from a distance of 10 yards. He was killed instantly at 1000 hours on 24 March 1944.

Cursory examination revealed a perforating wound of the skull. The entry wound traversed the right orbit, and the exit wound was found over the parieto-occipital region. The cranial vault was extensively fractured, and marked destruction of the right cerebral hemisphere was evident.

Case 8.-A soldier of the 129th Infantry, 37th Division, was standing on his bunk in an open tent in battalion headquarters firing at the enemy, when he was struck by a .25 caliber Japanese bullet fired from a distance of 25 yards. He was killed instantly at 0630 hours on 24 March 1944.


384

FIGURE 191.-Extensive fracture of skull. A. Site of entrance wound. B. Mortar shell fragments recovered from wound.

Examination revealed a gutter wound (5 x 2˝ cm.) of the left parietal region. Brain tissue exuded through the perforation in his helmet. Lacerated brain tissue, portions of the frontal and parietal lobes, was herniated through the wound. Marked subgaleal hemorrhage was present. The cranial vault was comminuted by stellate fractures. Both hemispheres of the brain were extensively lacerated. A mushroomed .25 caliber bullet was found in the right anterior fossa (fig. 192).

Case 9.-A soldier of the 164th Infantry, while on patrol in cleared jungle lying in an open foxhole, was struck by a fragment of U.S. 75 mm. shell which fell short. The shell exploded on the ground at a distance of 5 yards. He was killed instantly at 1600 hours 26 March 1944.

Examination revealed an extensive gutter wound traversing the left side of the skull. The occipital, parietal, and temporal bones were almost entirely destroyed. Only fragmentary portions of the left cerebral hemisphere remained.

Case 10.-A Fijian soldier, peering over the edge of an open foxhole to fire at the enemy, was struck by a .25 caliber Japanese bullet fired from a distance of 15 yards. He was killed instantly at 1400 hours on 1 April 1944. The body was not recovered immediately and received other wounds from shell fragments after death.

Examination revealed a perforating wound of the head and multiple wounds of the extremities. The head wound of entry (3.7 cm. in diameter) was located at the inner canthus of the left eye and the exit wound (8.7 cm. in diameter) at the vertex of the skull. The skull was comminuted, and there was almost complete destruction of the left half of the brain. Present, in addition, were a perforating wound of the right elbow associated with compound comminuted fracture of the radius, a perforating wound of the soft parts of the right calf, and an extensive gutter wound of the left hand.


385

FIGURE 192.-Deformed .25 caliber bullet recovered from right anterior fossa.

Case 11.-A soldier of the 129th Infantry was crouching and moving forward in a skirmish line when he was struck by a Japanese .25 caliber bullet fired from a distance of 20 yards. He was killed instantly at 1300 hours on 24 March 1944.

Cursory examination revealed an extensive gutter wound 15 x 10 cm. involving the left temporal, occipital, and parietal regions. Large portions of these bones and underlying brain were absent. Extensive comminution of the remaining cranial vault was present. Figure 193 shows the destructive effect of the missile.

FIGURE 193.-Head wound.


386

Case 12.-A Fijian soldier, while on patrol, was standing digging a foxhole when he was struck by a fragment of a U.S. 90 mm. shell. The shell exploded on the ground 25 yards distant. He was wounded at 1700 hours on 30 March 1944 and died 2 hours later. Death was caused by extensive brain damage.

The wound of entry (2.1 cm. in diameter) in the head was located 2 cm. above the right tragus. Brain tissue exuded from this wound. The fragment perforated the temporal bone producing stellate fractures of the temporal and frontal bones. The wound track traversed the right temporal, frontal, and left frontal lobes. A fragment (3 x 1 x 0.8 cm.) was found in the left frontal lobe. Examination revealed additional wounds; traumatic amputation of the left thumb, extensive laceration of the dorsum of the left hand and wrist, and perforating wounds of the soft tissue of the anterior right and left midthighs.

Figure 194 shows a metal probe inserted into the wound of entry in the head and also the extensive hand wound.

FIGURE 194.-Entrance wound in head (with metal probe inserted) and wounds of left upper extremity.

Case 13.-A soldier of the 182d Infantry, while in a covered pillbox on top of a hill, was struck by fragments from a 150 mm. Japanese shell which exploded on the ground 1 yard from the hole. He was killed instantly at 1400 hours on 26 March 1944.

Examination revealed a gutter wound (15 x 5.5 cm.) of the left side of the neck with extensive soft-tissue damage and transection of the external jugular vein. Another gutter wound (10 x 3.7 cm.) extended obliquely across the fifth and sixth cervical vertebras. The vertebras were shattered. At autopsy, the dura was opened and the cervical cord was exposed and found intact. No foreign bodies were found.

Case 14.-A soldier of the 129th Infantry was found dead in the 129th sector on 24 March 1944. He was struck in the left arm and leg by a Japanese .25 caliber bullet. In addition, a head wound was believed to have been caused by a fragment from a Japanese mortar shell.


387

FIGURE 195.-Head wound.

Cursory examination revealed perforating wounds of the soft parts of the left thigh and arm. A severe penetrating wound through the left orbit was present as illustrated in figure 195. Marked comminution of the cranial vault was found with brain tissue exuding from the head wound.

Case 15.-A soldier of the 132d Infantry was on patrol duty and had bivouaced in the open for the night. During the middle of the night, he stood up to void and was shot by an apprehensive fellow soldier with an M1 rifle at a distance of 10 yards. He was killed instantly at 2550 hours on 21 April 1944.

Examination revealed a perforating wound of the neck. The entrance wound (1.2 cm. in diameter) penetrated the left submental triangle, and the exit wound (12.5 x 7.5 cm.) occupied the posterior cervical region from the third to the sixth vertebras. The fourth and fifth vertebras were shattered; the cord was exposed and was partially severed at the same level.

Case 16.-A soldier of the 164th Infantry, while on patrol in the jungle, was lying on a slope under a tree when he was struck by a fragment of a U.S. 75 mm. shell which fell short. The shell exploded in a tree 12 yards above the soldier. He was killed instantly at 1600 hours on 26 March 1944.

Examination revealed a penetrating wound of the left occipital region 3.7 cm. in diameter. Brain tissue exuded through this wound. The fragment pierced the left occipital bone, left occipital lobe, and left cerebellar hemisphere. A shell fragment was found on the inferior surface of the cerebellum. A linear fracture line extended across the left occipital, parietal, and temporal bones.

The recovered fragment measured 6 x 5 x 4 mm. (fig. 196).

Case 17.-A soldier of the 129th Infantry, while walking up a jungle trail, was struck by a Japanese .25 caliber bullet fired from a distance of 100 yards. He was killed instantly at 1320 hours on 24 March 1944.


388

FIGURE 196.-U.S. 75 mm. shell fragment recovered from brain wound.

Examination revealed a perforating wound of the head. The wound of entrance (2.5 cm. in diameter) traversed the right infraorbital ridge; the exit wound (3 cm. in diameter) was located in the left parieto-occipital region. When the body was received, the helmet had not been removed and brain tissue was extruded over its surface.

Case 18.-A U.S. soldier was standing in a cleared area digging a foxhole when he was struck in the head by a .25 caliber bullet. The shot was fired by a Japanese sniper at a distance of over 150 yards. The soldier was killed instantly at 1500 hours on 26 March 1944.

Examination revealed a perforating wound of the head. The entrance wound (0.6 cm. in diameter) was posterior to the left mastoid process, and the exit wound (1.2 cm. in diameter) was at the outer canthus of the right eye. The bullet coursed in a superior and anterior direction and perforated the atlas; it then crossed the foramen magnum and severed the brain stem at the lower level of the pons. The track continued through the base of the skull, right ethmoid, and right orbit to the point of exit. Figure 197 shows a catheter in the wound track.

Case 19.-A U.S. soldier, while on duty as a sniper in the jungle, peered over a protecting log and was struck in the head by a .25 caliber bullet. The shot was fired by a Japanese sniper from an unknown distance. The soldier was killed instantly on 24 March 1944.

Cursory examination revealed a penetrating wound of the skull, with the wound of entrance in the left orbit. A compound comminuted fracture of the skull with marked brain destruction was present. The large number of dead received on this day prevented a more complete examination.

Figure 198 shows the extent of the wound of entrance.

Case 20.-A soldier of the 129th Infantry was sitting on a log holding a flamethrower when he was struck in the head by a .25 caliber Japanese bullet fired from a distance of 75 yards. His perforated helmet was found lying on the ground. He was killed instantly at 1130 hours on 27 March 1944.

Examination revealed a gutter wound 17.5 x 4 cm. involving the right temporal and frontal regions (fig. 199). There were deep lacerations of the frontal, parietal, and temporal lobes. Disorganized brain tissue filled the wound. Extensive comminution of the cranial vault was found.

Case 21.-A soldier of the 182d Infantry, while crouched, withdrawing from enemy fire, was struck in the back of the neck by a .25 caliber Japanese bullet fired by a sniper from a


389

FIGURE 197.-Perforating head wound with catheter in wound track.

FIGURE 198.-Entrance wound in head.


390

FIGURE 199.-Large defect in skull at site of entrance wound.

distance of 35 yards. He was wounded at 0600 hours on 15 March 1944. His death, about 8 hours later, was accompanied by a terminal hyperthermia.

Examination revealed a perforating wound of the posterior cervical region. The entrance wound (0.5 cm. in diameter) was located to the right of the spinous process of the fifth cervical vertebra and the exit wound (5 cm. in diameter) over the vertebral border of the left scapula. A fracture of the transverse process and lamina of the fifth cervical was discovered. The dura and the cord were intact, but the cord was bulbous and hemorrhagic for a distance of 2 cm. Because of the patient's profound shock, no operative interference was attempted.

Case 22.-A Fijian soldier, while walking toward his own lines returning from patrol, was mistaken for the enemy and shot. He was struck in the right side of the head and abdomen by .30 caliber bullets fired from a Lee-Enfield rifle at a distance of 15 yards. He was wounded at 1810 hours on 23 March 1944 and died at 2055 hours. The soldier died on the operating table, while an attempt was being made to stop bleeding from the brain.

Post mortem examination revealed a gutter wound of the right side of the head extending from the inner canthus of the right eye to the occipital bone. The diffusely lacerated right cerebral hemisphere was herniated through the wound. Bone fragments had been driven into the brain, and extensive hemorrhage was present. The abdominal cavity was filled with blood from severe lacerations of the right kidney and the liver.

Case 23.-A soldier of the 145th Infantry, while standing on the crest of a hill in the open observing mortar fire, was struck by a fragment of a Japanese mortar shell. The shell burst on a pillbox 3 yards distant from the soldier. After injury, the patient walked to the bottom of the hill; he was then placed in an ambulance and taken directly to the 21st Evacuation Hospital. He was wounded at 1800 hours on 10 March 1944. Craniotomy was performed, but the patient died 6 hours later. Death was attributed to severe intracranial hemorrhage.


391

Examination at autopsy revealed a penetrating wound of the right orbit with destruction of the globe. Craniotomy incision was present. A stellate fracture of the right frontal bone with laceration of the frontal lobe and marked intracranial hemorrhage was found.

Case 24.-A soldier of the 182d Infantry, while walking through the jungle on patrol, was struck by a Japanese machinegun bullet. He was wounded at 1800 hours on 30 April 1944 and arrived at the hospital 3 hours later. A gutter wound of the left frontoparietal region was debrided and closure of the wound attempted. His death at 1210 hours on 2 May 1944 was accompanied by terminal hyperthermia.

Examination revealed a gutter wound 8.7 x 5 cm. in the left frontoparietal region through which an infected fungus protruded. Closure of the wound at the time of operation had not been complete. Portions of the frontal and parietal bones were absent. Bone edges had been rongeured. From the bone margins, stellate fracture lines radiated over the cranial vault. The remnants of the frontal and parietal lobes were grossly infected.

Case 25.-A soldier of the 129th Infantry was standing in an open foxhole when he was struck by a .25 caliber Japanese bullet fired by a sniper from a distance of 75 yards. His helmet was perforated. He was wounded in action at 1430 hours on 24 March 1944 and died 5 hours later, despite shock therapy.

Examination revealed a gutter wound (15 x 7˝ cm.) occupying the right parieto-occipital region. Portions of these bones as well as the underlying cerebral hemisphere were absent. A small metal fragment was recovered from the remaining brain tissue and was identified as part of the jacket of a .25 caliber Japanese bullet. The right lateral ventricle was filled with blood. Petechial hemorrhages were present in the left half of the brain. Stellate fracture lines coursed through the bones of the vault.

Case 26.-A soldier of the 129th Infantry was standing in a covered pillbox when a Japanese 90 mm. artillery shell exploded on the ground 7 yards distant destroying one corner of the box. A fragment of the shell struck the soldier, penetrating his skull. He was wounded at 0630 hours on 17 March 1944. Supportive treatment was given and debridement performed. Terminal hyperthermia was present at death, about 12 hours later.

Post mortem examination limited to the head revealed compound linear fractures of the right parietal and temporal bones. Present also were large extra and subdural hemorrhages. A laceration 2.5 x 0.5 cm. with a surrounding area of contusion was present in the right temporal lobe. Destruction of the preoptic area was noted.

Case 27.-A Fijian soldier was behind a tree directing his platoon on patrol when he was struck by a .25 caliber Japanese machinegun bullet fired from a distance of 150 yards. He was killed instantly at 1200 hours on 25 March 1944.

The wound of entrance (2 cm. in diameter) was found over the right fifth intercostal space in the postaxillary line and the exit wound (3 x 1.5 cm.) at the right sternoclavicular articulation. The bullet fractured the fourth, fifth, and sixth ribs, lacerated the middle and upper lobes of the right lung, and fractured the first rib, clavicle, and sternum at its exit. A right hemothorax (2,500 cc.) was present.

Case 28.-A soldier of the 129th Infantry, while running in open terrain toward his foxhole, was struck by a .25 caliber Japanese machinegun bullet fired from a distance of 30 yards. He was killed instantly at 0500 hours on 24 March 1944.

The entrance wound (1.0 cm. in diameter) was located on the right side of the suprasternal notch. The wound of exit was found in the fifth left intercostal space at the costosternal junction. In its course, the bullet fractured the sternum and first rib, severed the aortic arch and trachea, grooved the esophagus, and perforated the lower lobe of the left lung. Massive bilateral hemothorax and mediastinal emphysema were present.

Case 29.-A Fijian soldier, while on patrol standing and digging a hole, was struck in the chest by a fragment of a 90 mm. U.S. shell which burst on the ground 20 yards away. He was killed instantly at 1700 hours on 30 March 1944.

The wound of entry (8.2 x 6.8 cm.) in the posterior aspect of the left side of the chest extended from the level of the third to the seventh rib. The wound of exit (20 x 12.5 cm.) (fig. 200) destroyed the anterior aspect of the chest wall above the nipple. In its course, the


392

FIGURE 200.-Chest wound of exit.

fragment fractured the left scapula, destroyed all but a small portion of the left lung, and lacerated or severed the heart, thoracic aorta, and inferior vena cava.

Case 30.-A soldier of the 129th Infantry was creeping up on a Japanese pillbox when he was struck by a .25 caliber Japanese rifle bullet fired from a distance of 20 yards. He was killed instantly at 1000 hours.

Examination revealed the wound of entry (3 x 1 cm.) in the fourth right intercostal space in the midaxillary line and the wound of exit (3.8 x 2.5 cm.) in the third left intercostal space in the anterior axillary line. In its course, the bullet fractured the fourth rib and lacerated the left auricle ventricle. There was marked extravasation of blood in both lungs and a massive bilateral hemothorax.

Case 31.-A U.S. soldier, while walking through the jungle on patrol, was struck by a .25 caliber Japanese bullet fired from a distance of 30 yards. He was killed instantly at 1145 hours on 8 April 1944.

Examination revealed the wound of entry (0.6 cm. in diameter) in the anterior left second intercostal space in the midclavicular line and the wound of exit (2.5 cm. in diameter) in the posterior right fifth intercostal space in the posterior axillary line. In its course, the bullet perforated the upper lobe of the left lung, pericardium, pulmonary artery, the upper lobe of the right lung, and fractured the right fifth rib in its exit. Hemothorax (left, 400 cc.; right, 1,500 cc.) and hemopericardium were present.

Case 32.-A soldier of the 117th Engineer Combat Battalion, while walking and covering the evacuation of a casualty, was struck by a .25 caliber Japanese bullet fired from a distance of 35 yards. He was killed instantly at 1300 hours on 24 March 1944.

Examination revealed a perforating wound of the chest. The wound of entry (0.5 cm. in diameter) was located in the anterior axillary line in the fourth left intercostal space and the wound of exit in the seventh intercostal space in the right midaxillary line. In its course, the bullet grooved the anterior medial border of the lower lobe of the left lung, pierced the


393

pericardial sac, right ventricle, and middle and lower lobes of the right lung. Bilateral hemothorax (2,500 cc.) and hemopericardium were present.

Case 33.-A soldier of the 129th Infantry, while walking beyond the perimeter, stepped on a U.S. landmine and was killed instantly at 1015 hours on 12 April 1944.

Examination revealed seven penetrating and perforating wounds. A chest wound was responsible for instantaneous death. One fragment entered the left side of the chest through the second rib in the midclavicular line and made its exit through the right sixth intercostal space in the midaxillary line. In its course, the fragment fractured the second rib, lacerated the upper lobe of the left lung, avulsed the anterior wall of the ascending aorta, perforated the middle lobe of the right lung, lacerated the lower lobe of the right lung, and fractured the sixth and seventh ribs at its exit. There were 2,000 cc. of blood in each pleural cavity. A compound comminuted fracture of the mandible was present. In addition, wounds of the right forearm and arm, left frontal region, and left thigh were found.

Case 34.-A soldier of the 182d Infantry was in an open foxhole with his "buddy," when he was struck by fragments of a U.S. 37 mm. shell which burst on the ground 3 yards distant. The other occupant was not injured. This soldier was killed instantly at 0710 hours on 24 March 1944.

Examination revealed a perforating wound of the chest. The entrance wound (7.5 x 4 cm.) was in the right third intercostal space at the costosternal junction and the exit wound (6.5 x 4 cm.) in the left fourth intercostal space in the midaxillary line. The fragment severed the left intercostal and the internal mammary arteries. The lower lobe of the left lung and the middle lobe of the right lung were contused, and massive hemopericardium and left hemothorax were present. The right ventricle and auricle were lacerated, but the pericardial sac was intact.

Case 35.-A U.S. soldier was standing in a covered pillbox when he was struck by a fragment of a Japanese mortar shell which came through the peepslit. The shell burst on the ground at a 25-yard distance. He was killed instantly at 2000 hours on 23 March 1944.

Examination revealed a penetrating wound of entry (2.5 cm. in diameter) in the right side of the chest in the second intercostal space, anterior axillary line. The fragment (fig. 201) in its course fractured the second rib, perforated the upper lobe of the right lung, partially severed the thoracic aorta, perforated the lower lobe, fractured the eighth rib, and lodged in the subcutaneous tissues over the ninth rib in the right midscapular line. Massive hemothorax was present.

Case 36.-A soldier of the 129th Infantry was killed in action in the 129th sector at 2140 hours on 25 March 1944. He was struck by fragments from a Japanese mortar shell. Other circumstances are not known.

Examination revealed a large entrance wound (12.5 x 10 cm.) on the left extending from the nipple to the midaxillary line and from the level of the third to the sixth rib (fig. 202). The fragments shattered the fifth and sixth ribs creating an opening (4 cm. in diameter) into

FIGURE 201.-Mortar shell fragment recovered from chest wounds.


394

FIGURE 202.-Chest wound. A. Wound of entrance. B. Recovered mortar shell fragments.

the left side of the pleural cavity. Bone fragments were driven into the lower lobe of the left lung producing an irregular laceration. A small metal fragment penetrated the left dome of the diaphragm, and a button from the soldier's jacket was found in the omentum. A lacerated wound (3.2 x 3 cm.) was found in the left ventricle. The seventh and ninth ribs posteriorly were fractured, and in the subcutaneous tissue in this region five metal fragments were found. Massive left hemothorax was present.

Case 37.-A soldier of the 148th Infantry, on 1 April 1944, having been struck in the arm by a Japanese .25 caliber bullet fired from a distance of 7 yards, walked back toward the first aid station. En route he was mistaken for the enemy and was struck in the chest with a .30 caliber bullet fired from a U.S. M1 rifle from a distance of 30 yards. He was killed instantly.

Examination revealed a perforating wound of the right side of the thorax and a wound of the right shoulder. The entrance wound in the chest (0.5 cm. in diameter) was located in the first intercostal space in the midclavicular line and the exit wound (2.5 cm. in diameter) at the level of the 12th rib in the midscapular line. The bullet perforated the upper and lower lobes of the right lung and fractured the 10th and 11th ribs. Massive hemothorax was present. The penetrating wound of the left shoulder (0.5 cm. in diameter) involved only the left deltoid muscle. No foreign body was found.

Case 38.-A Fijian soldier, while on patrol, was kneeling behind a rotten log when struck by a .25 caliber Japanese bullet fired from a distance of 5 yards. He was killed instantly at 1545 hours on 31 March 1944.

The entrance wound (0.5 cm. in diameter) was found over the sternum at the junction of the manubrium with the body and the exit wound (1.2 cm. in diameter) in the left eighth intercostal space in the anterior axillary line. In its course, the bullet fractured the sternum,


395

FIGURE 203.-Japanese hand grenade fragments recovered from chest wound.

perforated the aorta, pulmonary artery and lower lobe of the left lung, and fractured the eighth rib in making its exit. Massive bilateral hemothorax was present.

Case 39.-A soldier of the 129th Infantry, while attacking a Japanese pillbox, was killed instantly by the pointblank explosion of a Japanese hand grenade at 0800 hours on 24 March 1944.

Examination revealed multiple penetrating wounds of the chest, head, face, and abdomen. One fragment, entering the thorax through the third right intercostal space in the nipple line, had lacerated and lodged in the upper lobe of the right lung. A massive hemothorax was present. The 12th dorsal vertebra and the mandible and temporal bones were fractured.

The recovered fragments are shown in figure 203.

Case 40.-A soldier of the 164th Infantry, while walking through the jungle on patrol, was struck by .25 caliber Japanese bullets fired from a distance of 5 yards. He was killed instantly at 1130 hours on 29 March 1944.

Examination of the chest revealed an entrance wound (1.8 cm. in diameter) in the posterior aspect of the left side of the chest in the seventh intercostal space and an exit wound (3.8 cm. in diameter) in the left midclavicle. In its course, the bullet had fractured the fourth, fifth, sixth, seventh, and eighth ribs in the axillary line, severely lacerated both lobes, and fractured the clavicle at its exit. Massive left hemothorax was present. Another bullet had penetrated the soft tissues of the left thigh, making its entrance through the lateral side of the upper third. It was found in the vastus medialis. A third bullet perforated the left foot through the first metatarsophalangeal joint.

Figure 204 shows the bullet recovered from the thigh.

Case 41.-A U.S. soldier, while kneeling in the open administering first aid to a casualty, was struck by a .25 caliber bullet fired by a sniper from a distance of 35 yards. He was killed instantly at 1300 hours on 24 March 1944.

Examination revealed a perforating wound of the left side of the chest. The entrance wound (0.5 cm. in diameter) lay over the third rib anteriorly 4 cm. from the midline and the exit wound (1.5 x 1 cm.) over the angle of the left scapula. In its course, the missile fractured the third rib and lacerated the hilum of the left lung severing a large branch of the pulmonary artery and a secondary bronchus. The upper lobe of the left lung was severely lacerated. Hemothorax (1,500 cc.) was present on the left. Blood exuded from the mouth.

Case 42.-A soldier of the 129th Infantry, while squatting in a shallow hole on patrol, was struck by a fragment of a U.S. artillery shell which burst on the ground 5 yards distant. He was killed instantly at 1230 hours on 29 March 1944.


396

FIGURE 204.-Japanese .25 caliber bullet recovered from thigh. Note deformity of tip of bullet.

Examination revealed a penetrating wound of the right side of the chest. The wound of entrance (3.7 cm. in diameter) was situated in the third right intercostal space in the midaxillary line. The fragment fractured the fourth rib, perforated the middle lobe of the right lung, the right auricle, the right ventricle, and lodged in the lower lobe of the left lung. Hemopericardium and massive right hemothorax were present.

Figure 205 shows the only fragment recovered.

Case 43.-A soldier of the 129th Infantry was killed in action in the 129th sector. He was struck by .25 caliber Japanese bullets and killed instantly at 1345 hours on 24 March 1944.

The thoracic entrance wound (0.5 cm. in diameter) was found in the sixth right intercostal space in the posterior axillary line and the exit wound in the eighth left intercostal space in the midscapular line. The bullet produced fractures of the right sixth, seventh, and eighth ribs, severe lacerations of the posterior surface of the middle and posterior lobes of the right lung, fractures of the bodies of the seventh and eighth vertebras, transection of the spinal cord, perforation of the lower lobe of the left lung, and fracture of the left eighth rib in the posterior axillary line. A flattened bullet, 1.2 x 1 x 0.2 cm., was recovered in this region. Massive bilateral hemothorax was present. A severe comminuted fracture of the middle third of the right femur had resulted from another bullet. The wound of entrance on the thigh was very small.

Case 44.-A Fijian soldier, while on patrol kneeling behind a tree and firing at the enemy, was struck by a .25 caliber Japanese bullet fired from a distance of 20 yards. He was killed instantly on 31 March 1944.

The wound of entrance (0.5 cm. in diameter) was located in the left fourth intercostal space in the parasternal line and the exit wound (3.7 cm. in diameter) in the left sixth intercostal space in the midaxillary line. The bullet produced irregular lacerations of the right and left ventricles and perforated the upper lobe of the left lung. Massive hemothorax and hemopericardium were present.

Case 45.-A soldier of the 129th Infantry stepped out of his pillbox and was struck by a .25 caliber Japanese sniper bullet from a distance of 25 yards. He fell back into the pillbox and died instantly at 0730 hours on 25 March 1944.

Examination revealed a penetrating wound of the anterior aspect of the left side of the chest wall. The entrance wound (1 cm. in diameter) was found in the fourth intercostal space at the costochondral junction. Demonstrated at autopsy were a fracture of the fourth rib and sternum, right hemothorax (3,000 cc.), perforation of the right auricle and ventricle, and a laceration of the hilus of the right lung.


397

FIGURE 205.-U.S. artillery shell fragment recovered from chest wound.

Figure 206 shows the flattened .25 caliber bullet which was found lying free in the right side of the pleural cavity.

Case 46.-A soldier of the 129th Infantry, while sitting in the cleared open jungle, was struck by fragments of a 90 mm. Japanese shell which exploded on the ground at a distance of 20 yards. He was killed instantly at 1425 hours on 25 March 1944.

Examination disclosed an entrance wound (20 x 10 cm.) over the left scapula and an exit wound (2 cm. in diameter) on the left arm 6 cm. below the acromion process (fig. 207). The head of the left humerus was shattered, and there were fractures of the third, fourth, fifth, sixth, seventh, and eighth ribs in the midaxillary line and the fifth, sixth, and seventh ribs in the anterior axillary line. The parietal pleura was torn, both lobes of the left lung were severely lacerated, and the left scapula was extensively comminuted. A hemothorax (3,500 cc.) was present.

Figure 207A shows the large wound of entrance and figure 207B the small wound of exit of one of the fragments. Several small metal fragments recovered from the scapular area are shown in figure 207C.

Case 47.-A New Zealand soldier, while walking through the jungle on patrol, was struck by a .25 caliber Japanese sniper bullet fired from a distance of 30 yards. He was killed instantly at 0930 hours on 14 March 1944.

Examination revealed a perforating wound of the neck with the entrance (0.6 cm. in diameter) situated below the tip of the left mastoid and the exit (4.3 cm. in diameter) below the right acromioclavicular articulation. In its oblique course, the bullet perforated the third cervical vertebra, severed the spinal cord, fractured the first, second, and third ribs at their costovertebral junctions, entered the pleural cavity, perforated the upper lobe of the right lung, and made its exit between the clavicle and scapula. Present on the right was a hemothorax of 2,000 centimeters.

Case 48.-A Fijian soldier, while moving forward on patrol in a crouched position, was struck by a fragment of a 90 mm. Japanese mortar shell which burst on the ground 10 yards away. He died en route to the hospital at 1000 hours on 26 March 1944.

Examination revealed a penetrating wound of the posterior aspect of the right side of the chest. The fragment entered 8 cm. from the midline at the level of the sixth dorsal vertebra through a wound 1.5 cm. in diameter. It coursed under the skin to enter the left side of the chest in the sixth intercostal space, 5 cm. from the midline. The seventh rib was fractured at this point. The posterior surface of the lower lobe of the left lung was severely lacerated. A metal fragment was recovered from the pleural cavity. A left hemothorax (2,000 cc.) was present.

Case 49.-A soldier of the 129th Infantry, while walking behind a tank, was struck twice by .25 caliber Japanese bullets fired from a distance of 40 yards. He was killed instantly at 1030 hours on 24 March 1944.


398

FIGURE 206.-Deformed Japanese rifle bullet recovered from pleural cavity.

Examination revealed two penetrating wounds of entry (4 x 2.4 cm. and 3.5 x 2 cm. in diameter); one through the right and the other through the left second costosternal junction. Post mortem examination showed compound comminuted fractures of the second ribs (right and left) and sternum, severance of the right intercostal and internal mammary arteries, bilateral hemothorax, complete transection of the aortic arch and right pulmonary artery and vein, perforation of the left auricle, laceration of the upper lobe of the right lung, incomplete division of the esophagus and trachea at the level of bifurcation, and perforation of the body of the seventh thoracic vertebra.

Case 50.-A soldier of the 129th Infantry was prone in the open behind a tank assault when he was struck by a .25 caliber Japanese bullet fired from a distance of 100 yards. He was wounded at 1100 hours on 24 March 1944. Several hours later, thoracotomy was performed at the 21st Evacuation Hospital, and a lacerated left lung was sutured. He received penicillin daily and seemed to improve. Death from pulmonary embolus occurred suddenly at 0730 hours on 28 March 1944.

Examination revealed a curved incision (22.5 cm. in length) in the posterior aspect of the left side of the chest wall extending from the fifth dorsal vertebra to the axillary line. A left fibrinous pleuritis with effusion (500 cc.) was present. A laceration of the lower lobe of the left lung had been closed by suture. The lung was congested, and a thrombus was found lodged in the pulmonary artery.

Case 51.-A soldier of the 129th Infantry, while standing in an open foxhole, received a serious wound at 1500 hours on 27 March 1944 from a fragment of a U.S. 4.2-inch mortar shell which burst on the ground 3 yards away. At the portable surgical hospital, the sucking wound of the chest was closed. The following day, the patient was transferred to the 21st Evacuation Hospital. Upon admission to the ward, dehiscence of the wound was present. A second operation was performed and bone fragments were removed from the lung and bleeding was controlled. The patient never regained consciousness and died at 1700 hours on 30 March 1944.

Autopsy revealed an oblique operative incision 17.5 cm. long, extending from the third dorsal spine to the ninth rib, in the posterior aspect of the right side of the chest. The right scapula and the seventh and eighth ribs were fractured. A right hemothorax was found, and sutures were present in the middle and lower lobes of the right lung. The lungs were emphysematous, and there was marked dilatation of the right ventricle. Death was attributed to heart failure. In this case, death may have been precipitated by the rapid administration of necessary intravenous fluids in the presence of some pulmonary obstruction.

Case 52.-A soldier of the 129th Infantry, while walking in a crouched position following a tank assault, was struck by a .25 caliber Japanese bullet fired from a distance of 25 yards. He was wounded at 1245 hours on 24 March 1944 and died 24 hours later. Death resulted from transection of the thoracic spinal cord and was associated with terminal hyperthermia.


399

FIGURE 207.-Wound of scapular area. A. Wound of entrance. B. Wound of exit. C. Metal fragments recovered from scapular area.

The wound of entrance (3 cm. in diameter) was located in the center of the left supraclavicular region. The bullet entered the chest through the first intercostal space, fractured the first and second ribs, and produced a gutter wound in the upper lobe of the left lung. The body of the second dorsal vertebra was fractured and the spinal cord severed at the same level. A massive left hemothorax was found. The bullet was not recovered.

Case 53.-An airman of the 13th Army Air Force shot himself with a .30 caliber carbine at 1300 hours on 4 April 1944. He arrived at the hospital in 10 minutes, was given three units of plasma, and underwent immediate thoracotomy. An attempt was made to suture the lacerations of the lung, but the patient died on the table from shock due to hemorrhage.

Post mortem examination revealed an entry wound 6 mm. in diameter in the anterior aspect of the left side of the chest, 10 cm. from the midline in the seventh intercostal space. The wound of exit, located posteriorly in the third intercostal space 5 cm. from the midline, was 2.5 cm. in diameter. The bullet in its course lacerated the lower lobe of the left lung. A contusion of the left ventricle and a hemothorax (1,000 cc.) were found.

Case 54.-A soldier of the 129th Infantry, while prone firing at the enemy, was hit twice by .303 caliber bullets fired from a Japanese machinegun from a distance of 35 yards.


400

He was wounded at 0830 hours on 24 March 1944 and taken to the hospital immediately. After adequate shock therapy, the chest wound was debrided and closed and laparotomy performed. The patient died at 0645 hours on 28 March 1944 of pulmonary edema.

Post mortem examination revealed two wound tracks. One bullet produced an entry wound (3.2 x 2.5 cm.) lateral to the spinous process of the first lumbar vertebra; this missile coursed superiorly and laterally, fractured the 12th rib, perforated the diaphragm, and was found lodged under the 11th rib in the midaxillary line. The other wound was perforating in type with its entrance (1.2 cm. in diameter) located 1 cm. below the right clavicle at the outer third and exit (17.9 cm. in length) located 9 cm. to the left of the 11th dorsal vertebra. In its course, this bullet produced a temporary cavity injury of the right lung, perforated the lower lobe of the left lung, and fractured the ninth rib. Edema of the lower lobe of the left lung, fibrinous pleuritis, and hemopneumothorax were present. The right lung was diffusely discolored. The abdominal examination was negative, as the bullet had traversed the retroperitoneal space.

Case 55.-A soldier of the 145th Infantry, while kneeling in the open firing at the enemy, was struck by a .25 caliber Japanese bullet fired from a distance of 15 yards. He was wounded on 16 March 1944. Thoracotomy was performed at the 21st Evacuation Hospital several hours later. The lower lobe of the right lung was removed, the diaphragm closed, and bleeding from the perforation in the body of the 12th dorsal vertebra was controlled by electrocoagulation. The spinal cord was severed at the level of 12th dorsal. The patient was evacuated from the island on the eighth postoperative day. He developed an empyema at the 31st General Hospital. Surgical drainage of the empyema was established. In spite of adequate drainage, penicillin, and supportive therapy, the patient died from the infection on 25 April 1944.

Post mortem examination revealed gross infection of the right side of the pleural cavity. The remaining upper and middle lobes were shrunken and adherent and the pleura markedly thickened. The right lower bronchus communicated with the pleural cavity. The spinal cord was transected at the level of the fracture of the 12th dorsal vertebra. The diaphragm had been repaired. Generalized intestinal distension and focal necrosis of the liver were present.

Case 56.-A Fijian soldier, while crouching and advancing on patrol, was shot through the left side of the chest by a .25 caliber Japanese bullet from a distance of 30 yards. He was wounded in the morning of 30 March 1944. Upon arrival at the 21st Evacuation Hospital, immediate thoracotomy was performed in an attempt to control pulmonary bleeding. The patient died several hours later (1420 hours on 30 March 1944) of acute cardiac dilatation and hemorrhage. The cardiac dilatation was thought to be secondary to obstruction of the pulmonary circulation (see Case 51, p. 398.)

Post mortem examination showed a wound of entry (1.2 cm. in diameter) through the second left intercostal space above the costosternal junction. The wound of exit had been closed at the time of operation. A curved anteriolateral incision from the second to sixth rib was noted. Lacerations of the upper and lower lobes had been sutured. The right heart was markedly dilated. Moderate left hemothorax was present.

Case 57.-A soldier of the 920th ABS, while stepping out of a truck, was hit by fragments of a Japanese artillery shell which burst on the ground 2 yards away. He was wounded at 0600 hours on 24 March 1944. Within an hour, he was at the 52d Field Hospital, and the wound on the left side of the chest was excised, the lung sutured, and the chest closed. In addition, a loop colostomy of the sigmoid was done because of a perforation of the colon. The patient died several hours later from massive pulmonary hemorrhage.

Examination revealed penetrating wounds of the chest and left gluteal region. The entry wound in the anterior aspect of the left side of the chest through the fifth interspace had been excised and closed. The fifth and sixth ribs were fractured. Massive hemothorax was present. A large mattress suture partially closed the laceration in the lower lobe of the left lung. The abdominal cavity had been entered by a fragment which perforated the left wing of the ilium leaving a wound of entrance 7.5 cm. in diameter. Fragments


401

FIGURE 208.-Japanese artillery shell fragments recovered from chest wall.

of bone had been dispersed extensively lacerating the gluteal muscles. As just stated, the perforation of the sigmoid colon had been treated by exteriorization through a left rectus incision.

Figure 208 shows metal fragments removed from the chest wall.

Case 58.-A soldier of the 182d Infantry, while crawling through the jungle on patrol, was struck by .25 caliber Japanese machinegun bullets. He was wounded at 2100 hours on 2 May 1944 and reached the hospital within 3 hours. Thoracotomy was decided upon because of intrathoracic bleeding. The patient died on the operating table during induction of the anesthetic at 0515 hours on 3 May 1944.

Examination revealed a perforating wound of the left side of the chest and a penetrating wound of the right axilla. One entrance wound (1.2 cm. in diameter) into the chest was situated in the left midscapular region and the exit wound (5 x 2 cm.) in the left supraclavicular fossa. In its course, the bullet fractured the scapula and the second, third, and fourth ribs. The broken ribs had severely lacerated the pleura and the upper lobe of the left lung. The bullet had not entered the pleural cavity. A massive left hemothorax was present. Another bullet penetrated the apex of the right axilla through a wound 3.7 cm. in diameter and in its course severed the radial and median nerves and fractured the upper third of the humerus. The bullet was found in the belly of the triceps muscle.

Case 59.-A soldier of the 24th Infantry, while running forward in a skirmish line, was struck by .25 caliber Japanese machinegun bullets fired from a distance of 75 yards. He was killed instantly at 1100 hours on 14 April 1944.

Examination revealed multiple wounds. A missile which produced a penetrating wound of the right side of the abdomen and traversed the right thorax was responsible for rapid death. This bullet entered the right kidney region opposite the spinous process of the second lumbar vertebra. In its course, it lacerated the lower pole of the right kidney, perforated the hepatic flexure of the colon, right lobe of the liver and diaphragm, lacerated the lower right lobe of the lung, and fractured the 8th, 9th, 10th, 11th, and 12th ribs in the posterior axillary line. Hemoperitoneum and a right hemothorax (1,000 cc.) were present. The bullet was recovered in the subcutaneous tissue. Another bullet perforating the neck entered the right side in the posterior cervical triangle and made its exit below the tip of the left mastoid process. The trachea was severed at the level of the cricoid cartilage. Another bullet struck the left side of the face (fig. 209) producing a gutter wound 12.5 x 3.7 x 0.25 cm., which destroyed the left temporomandibular joint. Present also was a perforating wound in the right infraclavicular space with fracture of the right clavicle.


402

FIGURE 209.-Gutter wound of left side of face and neck.

FIGURE 210.-Deformed .25 caliber machine-gun bullet recovered from chest wall.

Figure 210 shows the distorted bullet and a part of the jacket removed from the right side of the chest wall.

Case 60.-A soldier of the 129th Infantry, while crouching following a tank assault, was shot by a .25 caliber Japanese machinegun bullet from a distance of 25 yards. He was killed instantly at 0800 hours on 13 March 1944.

Examination showed an entrance wound (0.6 cm. in diameter) through the anterior aspect of the right side of the chest in the second intercostal space in the nipple line and an exit wound (7.5 cm. in diameter) through the left loin above the wing of the ilium. In its oblique course, the bullet perforated or severed the middle lobe of the right lung, the diaphragm, the right lobe of the liver, the pancreas at the junction of the head and body, the transverse duodenum, the jejunum, and the left colon at the sigmoid junction. Moderate hemothorax and hemoperitoneum were present.

Case 61.-A soldier of the 129th Infantry, while standing in a foxhole covered by light roofing, was killed instantly by the direct burst of a Japanese mortar shell; 4 other men were wounded. The soldier was killed at 0530 hours on 24 March 1944.

Multiple penetrating wounds of the back, chest, and abdomen were sustained. A large chest wound caused death. The wound of entrance was 9 cm. in diameter and situated in the posterior aspect of the left side of the chest 2.5 cm. from the spinous processes of T-11 and T-12. In its course, this fragment fractured the fifth and sixth ribs anteriorly and the 8th, 9th, and 10th ribs posteriorly; fragmented the lower lobe of the left lung; perforated the diaphragm; disrupted the spleen; and transected the descending colon. The bodies of the 11th and 12th dorsal vertebras were badly comminuted. Massive left hemothorax and hemoperitoneum were present.

Figure 211 shows metal fragments identified as parts of a first aid box.

Case 62.-A soldier of the 129th Infantry, while in a pillbox, was surrounded by Japanese. He was killed by fragments of a Japanese hand grenade which exploded at pointblank range; 2 other men in the pillbox were wounded. The soldier died instantly at 0800 hours on 24 March 1944.

Examination revealed multiple penetrating wounds of the chest, right thigh, right leg, and right arm. The wounds of the thorax were fatal. There were multiple, small penetrating wounds through the right posterior axillary line from the 7th to 12th rib. The largest was 1.2 cm. in diameter. Small fragments perforated the lower lobe of the right lung and diaphragm and produced a laceration (7 x 3 x 1.3 cm.) in the dome of the liver.


403

FIGURE 211.-Recovered metal fragments identified as parts of first aid box.

Massive right hemothorax and moderate hemoperitoneum were present. The remaining wounds were not extensive.

Figure 212 shows the recovered grenade fragments.

Case 63.-A Fijian soldier, while running on patrol, stepped on a U.S. landmine and was killed instantly at 1100 hours on 26 March 1944.

Examination revealed nine penetrating wounds. Three fragments entered the left side of the chest anteriorly in the first intercostal space in the nipple line and perforated or severed the upper lobe of the left lung, pulmonary artery, aortic arch, trachea, lower lobe of the right lung, diaphragm, and liver. Two metallic fragments were found in the liver. Hemothorax (left, 2,500 cc., and right, 250 cc.) was present. In addition, there were wounds of the left elbow, thigh, cheek, chin and eye, and an extensive gutter wound of the left buttock.

Case 64.-A soldier of the 21st Reconnaissance Troop was killed by a U.S. hand grenade which exploded in his pocket, while returning from patrol. He was killed instantly at 0920 hours on 25 April 1944.

Examination revealed 12 penetrating wounds, 4 of which penetrated the thorax. The fragments entered the left side of the chest in the midaxillary line at the levels of the fourth, sixth, and ninth ribs. The left fourth, fifth, and sixth ribs were fractured; the diaphragm, spleen, and pancreas were lacerated; and the stomach was perforated in two places. Massive left hemothorax and hemoperitoneum were present. One grenade fragment was recovered from the pleural cavity and two fragments from the lumen of the stomach. The remaining wounds were in the upper extremities.

Figure 213 shows the recovered fragments, the largest of which was removed from the thorax.

Case 65.-A Japanese soldier (unknown) was killed on 22 March 1944 by fragments from an HE shell.

Examination revealed an entrance wound (2 cm. in diameter) in the 11th left intercostal space. The fragments in their course lacerated the lower lobe of the left lung and diaphragm and spleen and were found in the subcutaneous tissue at the exit wound. Present also were a bilateral hemothorax and a hemoperitoneum (300 cc.).


404

FIGURE 212.-Fragments of Japanese hand grenade recovered from multiple wounds.

Case 66.-A soldier of the 21st Reconnaissance Troop, while crouching and moving forward in a skirmish line, was struck three times by .25 caliber Japanese machinegun bullets fired from a distance of 20 yards. He was killed instantly at 1600 hours on 27 March 1944.

An abdominal wound was responsible for death. The wound of entrance (0.5 cm. in diameter) was placed in the midline 7.5 cm. above the umbilicus. This bullet severed the abdominal aorta and fractured the first lumbar vertebra. Another bullet perforated the right deltoid muscle and entered the right side of the thoracic cavity through the fourth intercostal space in the anterior axillary line. The fifth, sixth, and seventh ribs were fractured, the lower lobe of the lung and the dome of the diaphragm were lacerated, the liver was perforated, and the right kidney was fragmented. There were also superficial wounds of the left hip and left forearm.

Case 67.-A soldier of the 129th Infantry was struck by a .25 caliber Japanese bullet fired by a sniper from a distance of 25 yards. His position when hit was not known. He was killed instantly at 1300 hours on 24 March 1944.

The bullet entered the left side of the thorax through a wound (0.5 cm. in diameter) in the anterior fourth intercostal space in the anterior axillary line and made its exit through a wound (2.5 x 1.5 cm.) in the right sixth intercostal space in the midaxillary line. The bullet in its course perforated the upper lobe of the left lung, left ventricle, right ventricle, lower lobe of the right lung, and the diaphragm and produced an irregular laceration in the vertex of the liver 7.5 cm. in length before making its exit. Massive bilateral hemothorax and hemoperitoneum were found.

Case 68.-A soldier of the 132d Infantry, while on patrol entering a Japanese pillbox, was struck by a .25 caliber Japanese bullet fired at close range. He was wounded at 1700 hours on 29 March 1944. Laparotomy was performed several hours later at the clearing station. At operation, the left side of the diaphragm was repaired, and a transverse colostomy was performed after suture of a perforation in the splenic flexure of the colon. The patient died at 0600 hours on 4 April 1944 with signs of cardiorespiratory failure.

Examination revealed a penetrating bullet wound of the left side of the chest entering the sixth intercostal space in the posterior axillary line. Transverse colostomy had been performed through an upper left rectus incision. The seventh, eighth, and ninth ribs were fractured, and moderate left hemothorax was present. The lower lobe of the left lung was discolored. The pericardial sac contained a small amount of blood, although it had not


405

FIGURE 213.-Fragments of U.S. hand grenade recovered from multiple wounds.

been perforated. An area of epicardial ecchymosis was found on the left ventricle.19 Present also were a laceration of the spleen and an explosive wound of the left kidney with a large hematoma. A perforation in the splenic flexure of the colon had been sutured. The repair of the diaphragm was unsuccessful.

Case 69.-A soldier of the 129th Infantry, while leading his platoon against the enemy, was struck by a .25 caliber bullet fired from a short distance. He was wounded at 0900 hours on 13 March 1944. An hour later, debridement and closure of the chest wound were done at the 21st Evacuation Hospital. He was evacuated by air on 15 March and died on 21 March 1944, at the 9th Station Hospital, of secondary hemorrhages from the left lung and spleen.

Post mortem examination revealed a perforated wound of the left elbow and a compound fracture of the humerus. The same bullet had entered the left side of the chest in the sixth intercostal space in the posterior axillary line and made its exit in the left seventh intercostal space. The thoracotomy incision was well healed. The left side of the pleural cavity contained a liter of blood. Both lobes of the left lung were lacerated, and the diaphragm, spleen, and kidney were perforated. Old and fresh blood were present in the peritoneal cavity. A retroperitoneal hematoma was well organized.

Case 70.-A Fijian soldier, while crouching in a skirmish line on patrol, was struck by fragments of a Japanese mortar shell which burst on the ground 20 yards distant. He was wounded on 29 March 1944. Splenectomy, exteriorization of the colon, closure of a chest wound, and debridement of an arm wound were performed the same day. He died at 2215 hours on 30 March 1944 of shock and hemorrhage.

Examination revealed wounds of the chest, abdomen, and left arm. A linear incision extended in the ninth left intercostal space from the nipple to the axillary line. The pleural cavity contained 3,000 cc. of blood. Fibrinous pleuritis, congestion of the lung, and dilatation of the right heart were found. The rent in the left side of the diaphragm was incompletely closed. A left rectus incision was present through which protruded the exteriorized loop of the perforated transverse colon. A small amount of free blood was present in the abdominal cavity. The spleen had been removed. The body and tail of the pancreas were lacerated. An explosive wound of the left kidney and a large retroperitoneal hematoma were found. Present also in the lower third of the left arm was the wound of a severe compound comminuted fracture of the humerus.

19This type of injury is similar in origin to the pulmonary hemorrhage seen at some distance from the permanent wound track and is a result of the formation of the temporary cavity during the passage of high-velocity missiles.-J. C. B.


406

Case 71.-A soldier of the 37th Reconnaissance Troop, while walking in a crouched position through thick jungle on patrol, was struck in the left lumbar region by a Japanese .25 caliber bullet fired from a distance of 25 yards. He was wounded at 1815 hours on 4 March 1944. Laparotomy was performed at the 21st Evacuation Hospital several hours later. Perforations in the bowel were sutured, and an attempt was made to arrest hemorrhage from a laceration in the liver. The patient died at 1615 hours on 5 March 1944 from shock and hemorrhage.

Examination revealed a wound of entry (0.5 cm. in diameter) in the left lumbar region directly below the 12th rib and an exit wound (1 cm. in diameter) through the right midaxillary line in the eighth intercostal space. In its course, the bullet perforated jejunum, ileum, transverse colon, liver, diaphragm and the lower lobe of the right lung, and fractured the right ninth rib. Moderate hemoperitoneum and hemothorax (right) were present.

Case 72.-A Fijian soldier, while standing in the jungle, was mistaken for the enemy and shot by a fellow soldier with a Bren submachinegun at a 30-yard distance. He was wounded at 1500 hours on 1 April 1944. At the 21st Evacuation Hospital, after shock therapy, right lower lobectomy was performed, and a wound in the liver was tamponaded. He died of hemorrhage at 2030 hours on 1 April 1944.

There were two perforating wounds of the right side of the chest. The wounds of entry (each 0.5 cm. in diameter) were both situated in the sixth intercostal spaces 2.5 and 3.7 cm., respectively, from the midline, and the exit wounds were in the eighth intercostal space in the midaxillary line. The ninth rib was fractured. A recent anteriolateral sixth intercostal space incision was present. The lower lobe of the right lung had been removed and the rent in the diaphragm incompletely closed. A large wound occupied the dome of the right lobe of the liver.

Case 73.-A soldier of the 24th Infantry, while lying prone in the jungle on patrol, was struck by Japanese .303 caliber machinegun bullets fired from a distance of 30 yards. At 1000 hours on 19 April, he received shock treatment followed by right thoracotomy. At operation, a bullet and a bone fragment were removed from the right lung, and the diaphragm and lung were sutured. This soldier did not recover from shock and died at 2125 hours on 19 April 1944.

Examination revealed two major wounds. One bullet produced a perforating wound of the right thigh and a compound fracture of the femur. The other bullet penetrated the left buttock and coursed superiorly to terminate in the right side of the pleural cavity. This bullet fractured the fifth lumbar vertebra, severed the cauda equina, lacerated the right kidney, and perforated the diaphragm and lower lobe of the right lung. In addition, there were superficial gutter wounds of the right and left forearms.

Case 74.-A soldier of the 145th Infantry, preparing to climb into a truck, was struck by a fragment of a Japanese mortar shell which burst on the ground 15 yards away. He was wounded at 0730 hours on 18 March 1944. After arriving at the hospital within 1 hour, continuous shock therapy was instituted. Thoracotomy was performed at 0200 on 19 March 1944 in an attempt to arrest hemorrhage.

Examination revealed a sutured wound over the posterior lower left side of the chest 10 cm. in length. A laceration in the lower lobe of the left lung had been sutured. The diaphragm, stomach, and spleen were lacerated. A moderate left hemothorax and hemoperitoneum (2,500 cc.) were present.

Case 75.-A soldier of the 25th Infantry, at 2230 hours on 2 April 1944, left his foxhole to void. On return, he was shot through the abdomen, by an apprehensive bunkmate, with a U.S. .45 caliber revolver from a distance of 2 yards. He died within an hour.

Examination revealed a penetrating wound (1.5 cm. in diameter) in the upper right quadrant of the abdomen. The peritoneal cavity was filled with blood from a perforation of the vena cava. In addition, several loops of jejenum had been perforated.

Case 76.-A soldier of the 145th Infantry, while standing in the open, was struck by fragments of a Japanese 90 mm. mortar shell which burst on the ground 2 yards distant. He was killed instantly on 18 March 1944. Apparently, a fragment had struck the abdominal


407

wall tangentially in the midline, 0.5 cm. above the symphysis. A loop of ileum was protruding. Only remnants of the urinary bladder remained. The right ilium, right pubic ramus, and sacrum were severely comminuted. The peritoneal cavity contained 2 liters of blood.

Case 77.- A Fijian soldier, while crouching on patrol, was struck in the right lumbar region by a .25 caliber Japanese bullet fired from a distance of 20 yards. He was shot at 1030 hours on 29 March 1944 and died 1 hour later in the aid station from internal hemorrhage.

Examination revealed a perforating wound of the right lumbar region. The entrance wound (0.5 cm. in diameter) was located in the right lumbar region 3 cm. above the posterior superior spine of ilium and the exit wound (0.6 cm. in diameter) on the left buttock on a level with the greater trochanter of the femur. The bullet in its course fractured the wing of the right ilium, severed the right spermatic and pudendal arteries and rectum, and fractured the sacrum. Massive hemoperitoneum was present.

Case 78.-A Medical Department soldier of the 129th Infantry, while lying prone beside his medical officer, was struck by a .25 caliber Japanese bullet fired from the rear at a distance of 75 yards. He spoke a few words, had several convulsive seizures, and died at 1100 hours on 24 March 1944.

Examination revealed a perforating wound of entrance (0.5 cm. in diameter) over the right 12th rib in the posterior axillary line and an exit wound (10 x 0.5 cm.) through the left lumbar region at the level of the fifth spinous process, 15 cm. from the midline. In its oblique course, the bullet fractured the 12th rib, mutilated the right kidney, lacerated the right lobe of the liver and mesenteric border of the midportion of the transverse colon, and fractured the body of the first lumbar vertebra. Massive hemoperitoneum was present.

Case 79.-A soldier of the 25th Infantry left his foxhole at night to defecate. While returning to his hole, he was shot by a fellow soldier with a .30 caliber U.S. machinegun from a distance of 30 yards. He was killed instantly at 1200 hours on 16 April 1944.

One wound had its entrance (0.6 cm. in diameter) over the right scapula and exit (1.2 cm. in diameter) through the left side of the neck. The bullet producing this wound fractured the third cervical vertebra and severed the spinal cord. Another bullet produced a long (32.5 cm.) gutter wound of the right side of the abdomen which resulted in evisceration (fig. 214). This missile pierced the ascending and transverse colon, the ileum, and the liver.

Case 80.-A soldier of the 129th Infantry, while running forward over open terrain, was shot by a .25 caliber Japanese machinegun from a distance of 30 yards. He was killed instantly at 0830 hours on 24 March 1944. Of the two bullet wounds, one (1 cm. in diameter) was classified as penetrating and was situated 7 cm. superior to the umbilicus in the midline; the other was a perforating wound with the entry wound (1 cm. in diameter) through the right lower quadrant and the exit wound (4 x 2 cm.) through the right transverse process of the fourth lumbar vertebra.

Examination of the abdominal cavity revealed a massive hemoperitoneum, severance of the middle colic artery, linear laceration of the midportion of the transverse colon, division of the right common iliac vein and artery, and a compound fracture of the fourth and fifth lumbar vertebras.

Case 81.-A soldier of the 135th Field Artillery, while assigned to a detail burying the Japanese dead in front of the perimeter, wandered away from the main party. He was struck by a .25 caliber bullet which was thought to have been fired by a sniper. He was wounded at 1545 hours on 27 March and arrived at the hospital within 2 hours. Laparotomy was performed, and an extensive wound of the liver was found. He died at 1830 hours on 27 March 1944 of shock from hemorrhage.

Examination revealed a penetrating wound (0.5 cm. in diameter) in the 11th right intercostal space in the anterior axillary line. A recent T-incision was present in the right upper quadrant of the abdomen. The abdominal cavity contained 2 liters of blood. An extensive laceration of the right lobe of the liver had been filled with transplanted muscle. The 12th rib was fractured. Approximately one-third of the shattered right kidney remained, and


408

FIGURE 214.-Laceration of abdominal wall and evisceration.

bone fragments were found in the remnant of this kidney. There was no wound of exit. No foreign body was recovered.

Case 82.-A soldier of the 182d Infantry, while standing in the open, was struck by multiple fragments of a Japanese hand grenade which exploded 1 yard away. He was wounded at 1345 hours on 13 March 1944. Abdominal exploration which was performed at the clearing station several hours later was reported negative. Multiple penetrating wounds of the left side of the chest wall were debrided at the same time. The patient was evacuated by air from the island on 18 March 1944. Upon arrival at a hospital in the rear echelon on the same day, evisceration was discovered. Secondary wound closure and ileostomy were done. He received penicillin and general supportive treatment but died at 0835 hours on 25 March 1944 of peritonitis. (It is suggested that air evacuation resulted in evisceration.)

Post mortem examination revealed multiple healed wounds involving the left side of the body from the axilla to the knee in a band between the anterior and posterior axillary lines. The abdomen was distended. Incomplete visceral herniation was present below the ileostomy in the partially closed incision. Advanced diffuse suppurative peritonitis was present.

Case 83.-A soldier of the 132d Infantry, while following a jungle trail, was struck by fragments of a 90 mm. Japanese mortar shell which burst on the ground at a 25 yard distance away. He was wounded at 1530 hours on 13 March 1944. Laparotomy was performed at the portable surgical hospital and a rent in the colon sutured. After transfer to the 21st Evacuation Hospital 2 days later, because of severe distension, a colostomy was done. The patient died at 1115 hours on 16 March 1944. Death was attributed to peritonitis.

The wound responsible for death had its entrance at the lower right costal margin and its exit just left of the umbilicus. Diffuse peritonitis resulting from leakage from two perforations in the jejunum which had been missed at the time of operations was discovered. In addition, penetrating wounds of the left and right thigh and the right knee were present.


409

Case 84.-A soldier of the 129th Infantry, while standing outside his foxhole, was struck by a fragment of a 4.2-inch U.S. mortar shell. The shell fell short and burst on the ground at a 3-yard distance. He was wounded on 27 March 1944. One fragment struck the right hip and coursed retroperitoneally. On 31 March 1944, an ileostomy was performed because of abdominal distention. The patient died on 1 April 1944. Death was attributed to paralytic ileus and unexplained uremia.

The major wound had its entrance (10 x 5 cm.) at the level of the right iliac crest. The fragment producing this wound fractured the ilium and fifth lumbar vertebra, severed the cauda equina, entered the right retroperitoneal space, and shattered the lower pole of the right kidney. A metal fragment was recovered in this area. An ileostomy had been performed through a right paramedian incision. The peritoneal cavity contained a small amount of free serous fluid. All coils of intestine were markedly distended. A large hematoma was present in the right kidney area. A penetrating wound of the right shoulder and a perforating wound through the soft tissues of the right arm were observed.

Case 85.-A soldier of the 25th Infantry, while on patrol, was carrying a grenade in his right hand, when it exploded. He was wounded at 1700 hours on 9 April. Laparotomy was performed at the 31st Portable Surgical Hospital at which time several loops of intestine were resected. On the following day, the patient was transferred to the 21st Evacuation Hospital and died at 2355 hours on 11 April 1944.

Examination revealed five penetrating wounds of the anterior left side of the abdomen, varying from 1.8 to 5 cm. in diameter. The peritoneal cavity contained a moderate amount of sanguinopurulent fluid. End-to-end anastomosis of the upper jejunum and left splenic flexure of the colon had been performed. Early gangrenous changes were noted in the descending colon. Small, multiple lacerations of the spleen, pancreas, and left kidney were present. One grenade fragment was recovered from the splenic fossa, another from the lumen of the transverse colon. Present also was a penetrating wound of the right hand with fracture of the fourth metacarpal and fourth proximal phalanges.

Case 86.-A soldier of the 145th Infantry, while lying in an open foxhole, was struck by a fragment of a 500-pound U.S. aerial bomb, which exploded in a tree 5 yards above. The bomb was dropped accidentally by a U.S. plane leaving on a bombing mission on 19 March 1944. The wound was debrided at the portable hospital shortly thereafter. The soldier was transferred to the evacuation hospital on the following day and died at 0830 hours on 23 March 1944. Death was attributed to peritonitis.

Examination revealed a large penetrating wound (21.4 x 15 x 7.5 cm.) over the crest and wing of the right ilium. This wound was grossly infected. The lamina and spinal process of the fifth lumbar vertebra were destroyed. The retroperitoneal space was filled with purulent exudate. Diffuse fibrinopurulent peritonitis had resulted from direct extension of infection from the wound. A small perforating wound of the right shoulder was clean and granulating.

Case 87.-A Fijian soldier, while on patrol, was struck in the left side of the groin by a .25 caliber Japanese bullet fired from a distance of 25 yards. Though aid reached him immediately, he died in several minutes at 1515 hours on 29 March 1944.

Examination revealed a penetrating wound of the left side of the groin. The wound of entrance (3.1 cm. in diameter) was located 1 cm. below the middle third of the left inguinal ligament. The femoral artery and vein were severed. The markedly deformed rifle bullet was imbedded in the pubis.

Case 88.-A soldier of the 25th Infantry left his foxhole at night to void. On returning, he was mistaken for the enemy and in the resulting confusion was stabbed to death by fellow soldiers. He died within an hour of hemorrhage, on 17 April 1944.

Examination revealed 10 stab wounds in the upper and lower extremities. The right femoral artery was severed in its upper third, and the left radial artery was divided. No other important structures were injured.

Case 89.-A Japanese soldier was brought by American soldiers to the aid post and treated for shock. Despite treatment, he died in several hours.


410

Examination revealed a perforating bullet wound of the right thigh. The entrance wound (2.5 cm. in diameter) was found on the lateral surface and the exit wound (2.5 cm. in diameter) on the medial aspect. The right femur was shattered in its middle third. Present also was a perforating bullet wound of the abdominal wall in the right lumbar region with wounds of entrance and exit both 2.5 cm. in diameter. This bullet did not enter the peritoneal cavity.

Case 90.-The body of an unknown Japanese soldier was partially decomposed when received for examination. It appeared that the soldier had been wounded by bullets. Death was attributed to shock associated with a severe fracture of the left femur.

Examination revealed a perforating wound of the lower third of the left thigh. The wound of entrance (0.5 cm. in diameter) was medial, and the extensive wound of exit (16.6 x 13.9 cm.) was located on the lateral aspect of the thigh. The lower third of the femur had been shattered, but the great vessels were intact. Present also was a perforating wound of the right buttock.

Case 91.-A soldier of the 132d Infantry, while on patrol lying in an open foxhole, was wounded by the direct burst of a Japanese mortar shell. His right foot was blown away (fig. 215). He was taken to the command post and remained there over night. On the following day, he bled to death while being carried to the rear on a litter. This was a preventable death. The aidman, when questioned, stated that he did not apply a tourniquet before beginning the litter carry because the stump was not bleeding at that time. The soldier was wounded at 1800 hours on 4 April 1944 and died at 1300 hours on 5 April.

Case 92.-A soldier of the 182d Infantry, while on guard beyond the perimeter, tripped the wire to a U.S. boobytrap (grenade). He heard a noise and hit the dirt but was struck on the left buttock by a fragment from a distance of 3 yards. He was wounded in the morning of 29 March 1944. At the clearing station, the wound was debrided and another incision made to remove the fragment. This incision was sutured. Sulfanilamide powder was insufflated into the entrance wound, and it was left open. The patient died at 1100 hours on 4 April 1944 of the gas gangrene which was diagnosed on the same day.

Figure 215.-Traumatic amputation stump.


411

Post mortem examination revealed necrosis and infection of the wound and blood stream infection due to Clostridium welchii.

Case 93.-A soldier of the 129th Infantry, while lying prone in the open firing at the enemy, was struck by fragments from a Japanese mortar shell which burst on the ground nearby. He was wounded on 15 March 1944. On the following day, a guillotine amputation was performed through the lower third of the right thigh because of impairment of blood supply. A shattered fourth left toe was removed, and small wounds of the right buttock, lumbar region, right shoulder, and arm were debrided. He was evacuated on 19 March to a station hospital. He developed anuria on 23 March and died at 0845 on 25 March 1944. Death was attributed to uremia and cardiorespiratory failure. The uremia was thought to have been associated with "crush syndrome nephrosis."

At post mortem examination, the various wounds were healing and uninfected.

Case 94.-A soldier of the 148th Infantry, while running along a jungle trail, was struck by fragments of a "short" U.S. 81 mm. mortar shell which exploded between his legs. He was wounded at 0945 on 1 April 1944. At a portable surgical hospital, disarticulation of the left hip was done for an incomplete high traumatic amputation of the left thigh. Whole blood (2,000 cc.) was administered before and during the operation. The patient died of shock 6 hours later.

Examination revealed traumatic amputation of the right leg in the upper one-third, surgical disarticulation of the left hip, and mutilation of the right hand with multiple fractures (fig. 216).

Case 95.-A Japanese soldier was wounded in action on an unknown date. He sustained multiple penetrating wounds of the right lower extremity and a superficial wound of the scalp from fragments of a U.S. landmine. He was treated at the 21st Evacuation Hospital, developed gas gangrene of the right leg, and died at 1530 hours on 12 March 1944.

FIGURE 216.-Multiple mutilating wounds and traumatic amputations.


412

FIGURE 217.-A. Multiple wounds produced by U.S. landmine. B. Recovered fragments of U.S. landmine.

Examination revealed the characteristic odor and edematous discoloration of gas infection. The right tibia and fibula were fractured in the middle third. The largest of the penetrating wounds measured 2.5 centimeters.

Case 96.-A Japanese soldier was wounded in action on 24 March and died at 2000 hours on 28 March 1944. Death was caused by gas gangrene of the left thigh.

Examination revealed a large wound (17 x 16.2 cm.) involving the medial surface of the thigh. The wound apparently had been caused by an HE shell fragment. The femoral vessels were intact but thrombosed. The femur was intact. The wound exhibited characteristic features of gas bacillus infection.

Case 97.-A soldier of the 129th Infantry, while walking beyond the perimeter hunting for souvenirs, stepped on a U.S. landmine and was killed instantly on 30 March 1944.

Examination revealed multiple wounds of the head, chest, and abdomen (fig. 217). One missile destroyed the antral, orbital, and frontal areas of the skull. Only remnants of brain tissue remained. Another fragment entering the right side of the thorax had resulted in perforation of the right ventricle and almost total destruction of the right lung. Two fragments were recovered (fig. 217B), one from the pericardial sac and the other from the pleural cavity. A fragment penetrating the abdominal cavity had completely severed the right lobe of the liver.

Case 98.-This soldier was one of four men assigned to a pillbox. Thinking they were being surrounded by Japanese, the soldiers became alarmed and left the box and separated to seek other cover. Three of the men took cover in another foxhole. After a time, the


413

FIGURE 218.-Small mortar shell fragment recovered from brain.

fourth man came to join them. He was met with rifle fire and hand grenades from his apprehensive companions as he walked down the trench to enter the hold. He was killed instantly at 2130 hours on 20 April 1944.

Examination revealed seven wounds of the chest, scalp, back, and lower extremities. These wounds were all produced by grenade fragments; no bullet wounds were found. Instantaneous death resulted from the thoracic injury. One fragment traversed the left supraclavicular fossa and the posterior first right intercostal space. The entrance wound was 2.5 cm. in diameter. This missile fractured the first rib, lacerated the upper lobe of the left lung, and, in crossing the midline, fractured the bodies of the fourth, fifth, sixth, and seventh dorsal vertebras. Massive hemothorax was found. Bilateral fractures of the tibia and fibula and fracture of the left femur were present.

Case 99.-A soldier of the 131st Engineer Combat Battalion left his foxhole to rescue a friend who had been wounded. While running, he was struck by fragments of a Japanese 90 mm. mortar shell which burst on the ground 2 yards away. He died in the hospital several hours later at 0830 hours on 24 March 1944.

Examination revealed penetrating wounds of the left parietal and right kidney regions. The wound of entrance (1.5 cm. in diameter) in the left parietal region was filled with brain tissue. Stellate fracture lines coursed the cranial vault. The parietal lobe was lacerated, and intracranial hemorrhage was marked. A small fragment of metal was removed from the brain tissue (fig. 218). Another fragment pierced the 12th rib right to enter the abdominal cavity, fragmented the right kidney, and lacerated the right lobe of the liver. Massive hemoperitoneum was present.

Case 100.-A Fijian commando, while on patrol, stepped on a U.S. landmine. He was killed instantly at 1300 hours on 26 March 1944.

Examination revealed seven wounds (fig. 219A). A fragment entering the head produced an entrance wound (1.2 cm. in diameter) through the right frontotemporal region. In its course, this fragment fractured the maxilla, zygoma, the frontal and temporal bones, and destroyed the right frontal lobe of the brain. A penetrating wound (2 cm. in diameter) of the abdomen was located 6 cm. above the umbilicus. The fragment producing this wound severed or perforated the pylorus, duodenum, jejunum, and mesentery of the small bowel and was found lodged in the soft tissue at the aortic bifurcation. The peritoneal cavity was filled with blood. Another missile which produced a penetrating wound (2.2 cm. in diameter) in the left pectoral region severed the brachial plexus. This fragment was found in the subcutaneous tissue over the sixth rib in the posterior axillary line. In addition, 2 penetrating wounds of the chest wall, 1 of the abdominal wall, and 1 of the left thigh were discovered. Figure 219B shows the metal fragments recovered from the chest wall and peritoneal cavity.


414

FIGURE 219.-A. Wounds of head and chest produced by U.S. landmine. B. Recovered fragments from chest wall and peritoneal cavity.

Case 101.-A soldier of the 164th Infantry, while crouching and advancing on patrol, was struck by several .25 caliber Japanese bullets fired by a sniper from a distance of 50 to 75 yards. The soldier was killed instantly at 1620 hours on 29 March 1944.

Examination revealed six perforating wounds. The thorax was perforated by a bullet entering posteriorly. The entrance wound (1.5 cm. in diameter) was found in the left third intercostal space at the costovertebral junction and the exit wound (6.2 cm.) over the right deltoid prominence. In its course, this missile fractured the third rib, perforated the upper lobes of the left and right lungs, and fractured the right clavicle and scapula. Massive bilateral hemothorax resulted.

The entrance wound (2.5 cm. in diameter) in the abdominal wall was situated in the left lower quadrant and the exit wound (5 cm. in diameter) on the right side of the scrotum (fig. 220). The missile producing these wounds lacerated the sigmoid colon, fractured the symphysis pubis, and avulsed the right testicle. The left femur was fractured in its lower third by a bullet which produced an oblique perforating wound. This bullet traversed the thigh from the lateral aspect of the upper third to the medial aspect of the lower third. In addition, perforating wounds of the left buttock, left shoulder, and left ear were present.

Case 102.-A U.S. soldier, while in front of the perimeter cutting down trees to improve line of fire, stepped on a U.S. landmine and was killed instantly at 1015 hours on 1 April 1944.

Examination revealed 18 widely distributed wounds. The head wound was obviously responsible for immediate death. The fragment which produced the extensive head wound (10 x 5 cm.) destroyed the right orbit and right frontal bone and avulsed both frontal lobes and part of the right parietal lobe of the brain. In addition, there were numerous penetrating and perforating wounds of the upper and lower extremities and abdominal and chest walls. The following compound fractures were found: Right tibia, left tibia and fibula, right femur, right ulna, and mandible.

Figure 221 shows the recovered landmine fragments.


415

FIGURE 220.-Perforating wound of abdomen, with catheter in place.

Case 103.-A soldier of the 140th Field Artillery Battalion, while walking through thick jungle on patrol, was shot by .25 caliber Japanese bullets fired from a distance of 10 yards. He was wounded at 1600 hours on 14 March 1944 and reached the hospital 1 hour later. The wounds sustained necessitated multiple operations. The severed left axillary vein was ligated and the wound left open. Exploratory cystotomy revealed no perforation of the urinary bladder making suprapubic drainage unnecessary. Compound comminuted fractures of the right femur and ilium were accompanied by extensive wounds of soft tissue about the right hip joint and buttocks. These wounds were debrided. The patient died at 1450 hours on 16 March 1944. His death was attributed to gas gangrene and peritonitis.

Examination revealed a foul, edematous, discolored crepitant wound of the right hip. A sinus track containing a serosanginous exudate led to the fractured head and neck of the femur. The edema and discoloration extended above to the wound into the right buttock. An operative incision was present in the low midline. The terminal ilium was gangrenous as a result of an unexplained thrombosis of the mesenteric vessels. Gangrene of the ilium accounted for the presence of a diffuse seropurulent peritonitis.

Case 104.-A soldier of the 132d Infantry stepped on a mine while on an authorized mission in front of the perimeter arming U.S. landmines at 0830 hours on 27 March 1944. He was taken immediately to the clearing station. There his numerous wounds, including the wound of a traumatic amputation of the left foot, were debrided. He died of shock at 1445 hours on 27 March 1944.

Examination revealed 13 wounds. The four wounds of the left lower extremity were the wound of an amputation stump in the lower third of the leg, a linear wound (12.5 x 6.2 cm.) over the knee accompanying a compound comminuted fracture of the patella, an irregular wound 10 cm. in length on the medial aspect of the knee, and a superficial wound on the medial surface of the thigh. Three wounds of the right leg were seen: A gutter wound 7.5 cm. long on the dorsum of the foot, a small penetrating wound of the ankle accompanying a fracture of the internal malleolus, and a superficial wound of the calf. A large wound


416

FIGURE 221.-Recovered fragments of U.S. landmine.

(12.5 x 7.5 cm.) of the right buttock was associated with a compound fracture of the sacrum. Present also was a compound comminuted fracture of the right ulna. In addition, wounds of the back (2), right forearm (2), and left buttock (1) were found.

CIRCUMSTANCES AND PROTECTIVE MEASURES

A study of the circumstances under which wounds occur may yield information regarding the effectiveness of weapons under battle conditions, the results of training, and the need for protective measures. Wounds occur under a variety of conditions which make classification difficult. However, an attempt was made to determine the position and occupation of the soldier when wounded, the type of cover, and the distance from the shellburst or weapon. This information was obtained from the wounded man or from his comrades or from both. The circumstances under which the soldier was wounded usually could be obtained in considerable detail. However, the caliber and exact type of weapon frequently could not be identified other than as belonging to the general classification of weapons, such as rifle, machinegun, and mortar.

Influence of Position and Cover on Number of Casualties

When the subject of "cover" is viewed broadly, casualties fall naturally into three general groups depending upon the relative degree of protection available at the time of wounding. In the first group are placed those who had the best protection, usually a well-constructed pillbox covered by fairly heavy logs. In the second group are those who had no overhead cover but were protected on all sides by well dug-in holes or trenches. The third group comprised those with the least protection and was subdivided into those who had no protection whatsoever and those who had partial protection. A soldier in a shallow foxhole or behind a tree or log would be considered one with partial protection. There were 81 casualties produced by miscellaneous weapons; however, their positions at the time of wounding were not considered significant.


417

These 81 casualties are excluded from the present discussion but will be discussed later in this chapter. In 150 instances, the position was not stated, therefore data regarding "protection and position" were available in 1,557 cases and are summarized in table 100.

TABLE 100.-Distribution of 1,557 casualties by causative agent and by position and protection

Position and protection

Causative agent

Total casualties

Rifle

Machinegun

Grenade

Mortar

Artillery

Number

Percent

Standing:

No cover

184

57

49

189

88

567

36.4

Partial cover

4

1

1

5

2

13

.8

Total

188

58

50

194

90

580

37.2

Sitting:

No cover

92

25

39

114

15

285

18.3

Partial cover

10

0

1

15

2

28

1.8

Total

102

25

40

129

17

313

20.1

Prone:

No cover

72

30

62

122

26

312

20.0

Partial cover

13

3

5

12

2

35

2.3

Total

85

33

67

134

28

347

22.3

Pillbox

11

6

33

64

26

140

9.0

Trench hole

29

12

19

91

26

177

11.4

Total

40

18

52

155

52

317

20.4

Grand total

415

134

209

612

187

1,557

100.0


Those who were erect, standing, walking, or running were included under the classification "Standing." Those who had considerably less body area exposed, whether they were sitting or crouching or kneeling, were placed in the group designated "Sitting." The term "prone" does not require explanation. Among the 1,557 cases, the weapons were distributed as follows: Mortar, 39.3 percent; rifle, 26.6 percent; grenade, 13.4 percent; artillery, 12.0 percent; and machinegun, 8.7 percent.

It is obvious that the body surface exposed depends upon the position of the soldier when wounded and should bear some correlation with the number of hits. It is important to know whether the number of hits depends solely upon the body surface exposed or whether it is greater for aimed weapons. Data relating to this problem were obtained by examining the least protected


418

group (standing, sitting, and prone) which constituted 1,240 (79.9 percent) of the total 1,557 casualties.

By reference to table 101, it is apparent that there are approximately twice as many casualties among the standing as there are among either the sitting or the prone. Furthermore, the number of casualties is approximately equally divided between the two latter groups. When the factor of partial cover is excluded by omitting the small number (76 casualties) who had slight protection, the relative proportion of casualties in the three subdivisions remains unchanged (table 102). This is what might be expected were all missiles unaimed and traveling at random. In this event, the number of wounds received would be in approximate proportion to the projected body area exposed. On the basis of the foregoing finding, it appears that, in this particular jungle campaign, the number of casualties depended upon random unaimed hits which were roughly in proportion to the body area exposed (table 70).

In the total group (1,557), 317 or 20.1 percent (table 100) were wounded in well-covered pillboxes or well dug in but uncovered holes or trenches. These

TABLE 101.-Distribution of 1,240 casualties, by aimed and random fire and by position (with and without cover)

Position

Aimed fire1

Random fire2

Casualties

Number

Percent

Number

Percent

Number

Percent

Standing

246

50.1

334

44.6

580

46.8

Sitting

127

25.9

186

24.8

313

25.2

Prone

118

24.0

229

30.6

347

28.0

Total

491

100.0

749

100.0

1,240

100.0


1Rifle and machinegun.
2Mortar, artillery, and grenade

TABLE 102.-Distribution of 1,164 casualties, by aimed and random fire and by position (no cover)

Position

Aimed fire1

Random fire2

Casualties

Number

Percent

Number

Percent

Number

Percent

Standing

241

52.4

326

46.3

567

48.7

Sitting

117

25.4

168

23.9

285

24.5

Prone

102

22.2

210

29.8

312

26.8

Total

460

100.0

704

100.0

1,164

100.0


1Rifle and machinegun.
2Mortar, artillery, and grenade


419

casualties were nearly equally divided between the pillbox (44.8 percent) and the open trench (55.2 percent). In this relatively well protected group, 259 (81.7 percent) were wounded by random fire and 58 (18.3 percent) were wounded by aimed fire. Among the casualties produced by aimed weapons, 70.7 percent were in the open trench but only 29.3 percent in the pillbox. Casualties from random fire were approximately equally distributed between the pillbox (48.1 percent) and the open trench (51.9 percent). One may, therefore, conclude that the covered pillbox offers relatively greater protection against aimed weapons.

Type of Action

Among the total casualties, there were 1,620 cases in which information was available concerning the type of action in which the men were involved. The number wounded on patrol or in defensive and offensive action is shown in table 103.

Range of Small Arms or Distance From Burst

The approximate range was known in 339 casualties resulting from rifle fire and in 121 casualties resulting from machinegun fire. In table 104, this group is tabulated in percentages according to range and disposition of casualties. The higher lethal effect of bullets at close range should be noted. At longer range (over 75 yards), it would appear that the casualties received either minor or nonvital wounds since none received wounds of sufficient severity to cause evacuation to the United States. The distance from the weapon or shellburst was estimated in most instances and is, therefore, open to considerable error. It is likely that the actual distance from a shellburst was greater than the estimated distance. In future studies, suitable samples might be used to check on this error. Furthermore, indoctrination of troops, before combat, regarding the importance of such data might lead to more accurate observation.

Approximate distances from shellbursts (including knee mortars) were known in 623 casualties produced by mortar shell fragments (including knee mortars) and in 176 caused by artillery shell fragments. The percentage distribution of these casualties according to the disposition of the patient is shown in table 105. In the jungle, the effect of a shellburst should be more limited than in open terrain. Approximately 60 percent of the casualties were under 10 yards from the burst.

Similar results are tabulated for the grenade in table 106. It is rather surprising to find that the effectiveness of the Japanese hand grenade extends beyond 5 yards, as evidenced by the fact that 25.1 percent were wounded at this distance. However, it is possible that some of these casualties were produced by U.S. grenades.


420

TABLE 103.-Distribution of 1,620 casualties, by aimed and random fire of causative agent and by type of action

Type of action

Aimed fire

Total casualties (aimed fire)

Random fire

Total casualties (random fire)

Total casualties (combined fire)

Rifle

Machine-
gun

Number

Percent

Mortar

Artillery

Grenade

Number

Percent

Number

Percent

Number

Number

Number

Number

Number

Patrol

105

34

139

24.6

35

29

25

89

8.4

228

14.1

(61.0)

(39.0)

Defensive

253

78

331

58.7

588

136

152

876

83.0

1,207

74.5

(27.4)

(72.6)

Offensive

58

36

94

16.7

50

3

38

91

8.6

185

11.4

(50.8)

(49.2)

Total

416

148

564

100.0

673

168

215

1,056

100.0

1,620

100.0

(34.8)

(65.2)


NOTE.-Figures in parentheses express percent aimed and random fire of total of combined fire. A higher percentage were wounded on both patrol and offensive action by aimed fire. On defensive action, the majority were wounded by random fire.


421

TABLE 104.-Distribution of 460 casualties produced by small arms weapons, by range of fire and disposition

[Values expressed as percentages according to type of weapons]

Weapon and range (yards) of fire

Dead

Living wounded

Total average

Returned to duty

Evacuated to United States

Rifle:

0 to 25

54.7

17.9

37.7

33.9

25 to 50

27.3

8.3

19.4

16.8

50 to 75 

8.6

37.2

42.9

29.5

Over 75

9.4

36.6

.0

19.8

Total

100.0

100.0

100.0

100.0

Machinegun:

0 to 25

40.3

3.2

28.6

28.1

25 to 50

45.1

6.5

35.7

33.1

50 to 75

6.5

51.6

35.7

24.8

Over 75

8.1

38.7

.0

14.0

Total

100.0

100.0

100.0

100.0


TABLE 105.-Distribution of 799 casualties produced by shell fragments, by distance from point of burst and disposition

[Values expressed as percentages according to type of shell fragments]

Shell fragment and distance (yards) from point of burst

Dead

Living wounded

Total average

Returned to duty

Evacuated to United States

Mortar:

0 to 10

79.4

64.5

66.6

66.7

10 to 20 

8.2

19.1

22.0

18.3

20 to 50

11.0

12.1

7.6

11.2

Over 50

1.4

4.3

3.8

3.8

Total

100.0

100.0

100.0

100.0

Artillery:

0 to 10

86.0

50.5

53.8

59.6

10 to 20

9.3

21.5

19.2

18.2

20 to 50

4.7

15.9

16.6

12.9

Over 50

.0

12.1

15.4

9.7

Total

100.0

100.0

100.0

100.0


422

TABLE 106.-Distribution of casualties wounded by hand grenade fragments, by distance from point of burst

[Values expressed as percentages according to weapon]

Distance from point of burst

Dead

Living wounded

Total average

Returned to duty

Evacuated to United States

Yards:

0 to 3

100.0

67.3

56.7

67.6

3 to 5

.0

6.4

13.6

7.3

Over 5

.0

26.3

29.7

25.1

Total

100.0

100.0

100.0

100.0


Time Phase

In table 107, casualties are separated according to the period of time in which they occurred. The first phase extends to the beginning of the Battle of the Perimeter, 15 February to 7 March; the second phase covers the intensive period of perimeter activity of 8 March to 28 March; and the last phase, the subsequent relatively inactive period of 29 March to 21 April 1944. Eighty percent of the casualties occurred during the Battle of the Perimeter.

Miscellaneous Weapons and Circumstances

A total of 81 casualties (4.5 percent of 1,788) resulted from the following miscellaneous weapons: Landmine (excluding grenade boobytraps), 34; aerial bomb, 15; .45 caliber pistol, 14; powder explosions and flares, 6; bangalore torpedoes, 9; bazooka, 2; and bayonet, 1. Enumeration of the very varied circumstances surrounding the wounding of these patients serves no purpose since no general conclusion can be derived.

In jungle warfare, a fair number of casualties result from the overhead explosion of mortar or artillery shells, or aerial bombs overhead, as a result of detonation on impact with a tree or its branches. Such explosions are designated "tree bursts" as distinguished from "ground bursts." In 900 instances, there were 93 (11.5 percent) tree bursts. Mortar shells constituted 58.1 percent of all tree bursts; artillery shells, 34.4 percent; and aerial bombs, 7.5 percent. Ground bursts were divided as follows: Mortar shells, 79.1 percent; artillery shells, 20.0 percent; and aerial bombs, 0.9 percent.


423

TABLE 107.-Distribution of 1,707 casualties, by aimed and random fire of causative agent, during survey period (15 Feb.-21 Apr. 1944)

Period

Aimed fire

Total casualties

Random fire

Total casualties

Total casualties (combined fire)

Rifle

Machine-
gun

Number

Percent

Mortar

Artillery

Grenade

Number

Percent

Number

Percent

1944

First phase (15 Feb.-7 Mar.)

35

7

42

7.0

39

35

11

85

7.7

127

7.4

Second phase (8 Mar.-28 Mar.)

308

111

419

70.2

622

140

184

946

85.2

1,365

80.0

Third phase (29 Mar.-21 Apr.)

102

34

136

22.8

32

18

29

79

7.1

215

12.6

Total

445

152

597

100.0

693

193

224

1,110

100.0

1,707

100.0

(35.0)

(65.0)


NOTE.-Figures in parentheses represent percentages of aimed and random fire of total combined fire.


424

Protective Measures and Recommendations

Pillboxes.-Opinion has been expressed that the large size of the firing slit resulted in casualties which might have been avoided by a smaller opening. In some instances, nearby tree snipers were able to direct fire through the firing slit. Because of this fact, it has been suggested that an eave overhanging the firing slit might be a useful additional means of protection. The findings of the survey team indicate that gunfire directed through the slit is of little importance. Wounding through the firing slit did occur in 104 (6.7 percent) instances in 1,557 casualties. However, in this group, the aimed weapons (rifle and machinegun) were responsible for only 9 (8.6 percent) of those so wounded. In view of this small number, the advisability of the overhanging eave is doubtful. However, a considerable number of casualties (95) were caused by shell fragments passing through the firing slit. This would indicate the need for keeping the size of the firing slit as small as is consistent with observation and maneuverability of weapons within the pillbox (fig. 222).

Protection against the hand grenade was afforded by the use of wire (chicken) net (fig. 223) at night to cover peepslit openings and was favorably recommended. Some type of rubber net might serve to "bounce off" the unexpected grenade even better than the wire net. The earth should be sloped from the slit opening so that grenades will roll away.

The construction of pillboxes might be improved by the use of heavier (12 inch) logs. Hardwood is recommended if obtainable as termites destroy

FIGURE 222.-Well-constructed pillbox showing size of firing slit.


425

FIGURE 223.-Wire netting covering firing slits. This netting was used successfully to "bounce off" enemy grenades.

soft timber quickly. Some concrete could be used to advantage. Since the location of the pillbox is usually known to the enemy, camouflage should be sacrificed for sturdy construction. The earth floor in a square log pillbox should not be excavated out to the edges of the logs. On the contrary, a stronger pillbox results if the central excavation is made circular in shape, thus leaving more earth in the corners.

Combat training.-The majority of the experienced combat personnel expressed the opinion that the Japanese soldier made better use of cover than did Allied troops and were better trained at "digging in" quickly. They utilized all natural cover (fig. 224). They crawled close to the ground, and their foxholes were small, efficient, and well suited to the purpose intended. On the contrary, Allied troops were frequently careless in exposing themselves unnecessarily (fig. 225) and ofttimes were content with foxholes which were entirely too shallow (fig. 226). Many wounds were received because soldiers crawled with buttocks elevated, making a large silhouette. In training and staging areas, more time devoted to digging in would serve not only to stress the importance of adequate cover but would also develop the necessary muscle.

When under fire, the importance of dispersion (figs. 227 and 228) should be emphasized. For example, in one instance, 13 men preparing to enter a truck were killed or wounded by a single shell. Neglect of this principle by enemy troops resulted in 600 enemy killed by Allied artillery fire in one area.


426

FIGURE 224.-Natural jungle growth which provided excellent camouflage.

Medical suggestions.-Aidmen should receive more preliminary training in vena puncture. Lack of familiarity and practice in this technique frequently delayed the administration of plasma. Since patients cannot be evacuated at night from frontline positions, every soldier should know the principles of first aid. Under combat conditions similar to those at Bougainville, it is felt that the oral administration of sulfanilamide medication should be discontinued in the field unless on patrol far from medical installations. It was often difficult to know later in the hospital whether a man had received this medication and, if so, in what amounts. It was estimated that less than 10 percent took the drug by mouth after having been wounded. This uncertainty as to dose frequently delayed adequate sulfonamide therapy. Finally, the practice of sending aidmen forward to remove the dead under fire is very demoralizing and should be condemned.

Body armor.-The subject of protection would not be complete without some expression of opinion regarding the advisability of body armor. Many line officers believe that under certain tactical situations the judicious employment of some type of body armor would be definitely advantageous. Its routine use is not recommended. The objections most frequently raised are that the infantry foot soldier is already burdened with a maximum amount of weight, that any further equipment would be cumbersome and would interfere with fighting efficiency, and, finally, that too much protection induces an "oyster complex." These objections could be overcome if the use of armor were restricted to a special circumstance. When the tactical situation demanded body armor, it could be transported to that point, issued, and later


427

FIGURE 225.-"Necessary" and "unnecessary" exposure. A. Necessary exposure of head and upper extremities. B. Necessary and unnecessary exposure in a position on Hill 700.


428

FIGURE 226.-"Little" and "moderate" protection. A. Machinegun emplacement with little protection. B. Shallow 81 mm. mortar emplacement with moderate protection.


429

FIGURE 227.-Unnecessary exposure and concentration of men.

FIGURE 228.-Infantry advancing behind tanks. Many casualties occurred when the Japanese withheld fire until the tanks had passed.


430

collected when the objective had been attained. In the type of combat at Bougainville, the soldier did not carry a full pack, and for brief intervals all unessential equipment could have been discarded in favor of armor.

SUMMARY

The primary purpose of this report was to evaluate the relative effectiveness of the different weapons as casualty-producing agents. In order to achieve this aim, it was necessary to determine and to correlate the varied circumstances surrounding wound production in each individual case. It was essential to know what weapon caused the wound, the anatomic region wounded, the range and distance from the burst, the available protection, the degree of disability, the treatment and disposition of the patient, and all details relating to death. This report comprises a study of all battle casualties (living and dead) occurring in the U.S. Army ground forces on Bougainville Island from 15 February to 21 April 1944.

The Bougainville campaign possessed certain features which are not ordinarily found in jungle warfare. A beachhead was made in virgin jungle for the purpose of establishing airfields. Not until 4 months later did the enemy engage in the major large scale attack referred to as the "Battle of the Perimeter." During this interval, the perimeter was extended and strongly fortified, and an excellent system of roads was constructed within the defended area. When the enemy attack came, the Allied force was superior both in numbers and in equipment. They had gained control of the air and in addition had the advantage of overwhelming artillery superiority. Ample vehicular transportation and smooth all-weather roads facilitated supply and evacuation. Medical installations had been completed which were easily accessible and adequate to meet all exigencies. Consequently, a high standard of medical care was maintained. The Japanese on the contrary were handicapped by the necessity of taking offensive action against a well-established perimeter defended by a greater number of better equipped troops. Furthermore, their supply problem was very difficult. They were compelled to transport supplies chiefly by pack through dense jungle and over narrow, rugged mountain trails. However, with the exception of artillery weapons and shells, the enemy by dogged effort was able to keep adequate supply of arms and ammunition.

The U.S. forces at Bougainville sustained 2,335 casualties from 15 February to 21 April 1944. Of these, 16.9 percent died; 69.5 percent were returned to duty; and 13.6 percent were evacuated to the United States. In the total group, there were 547 who were so lightly wounded that they were returned directly to duty from the battalion aid stations or collecting stations. Since the effect of weapons on this group was minimal and since these soldiers were not actually lost to combat, they were excluded from the remainder of the study. Therefore, all subsequent percentage figures were based on


431

1,788 battle casualties who were admitted to hospitals or were killed in action. Using the 1,788 casualties as a basis, it was found that approximately 1 battle death (KIA and DOW) occurred among every 4.5 casualties, making a mortality of 22.1 percent. The living wounded numbered 1,393; of these, 77.2 percent were returned to duty and 22.8 percent were evacuated to the United States.

The majority of casualties (78.8 percent) occurred during the Battle of the Perimeter, a period arbitrarily defined as extending from 8 to 28 March 1944. Most of these casualties occurred within U.S. lines. Because of the fortuitous circumstances of hospital accessibility, these wounded obtained adequate medical care, usually within 1 hour and in most instances in much less time. Patrol activity was chiefly responsible for the small number of casualties which occurred before and after this battle. These casualties constituted the major problem in the evacuation of the wounded. During the Battle of the Perimeter, the American loss was 210 killed in action as contrasted to 8,527 Japanese dead, a ratio of 1 : 24.6.

Anatomic distribution of wounds.-A striking contrast is observed in the percentage distribution (regional frequency) of wounds in the dead, in the living, and in both groups combined, when classified according to the anatomic region involved (table 108).

Wound distribution.-It was found that the distribution of wounds was dependent largely upon exposure to the random missile and not upon directed fire. This was demonstrated clearly by comparing the actual with the expected number of hits in each anatomic region. This was done by superimposing the percentage of hits over the percentage mean of the projected body area. In this way, the directed fire (rifle) was compared to the undirected fire (mortar) and to the total hits by all weapons. A close correlation exists between the expected number of hits and the mean projected body area except in the case of a single region, the head. In the head, the number of hits exceeded the expectancy by more than 100 percent. This would indicate that in combat

TABLE 108.-Percentage distribution (regional frequency) of wounds in 1,788 casualties (395 dead, 1,393 living wounded), by anatomic location and order of frequency

Order of frequency

Total casualties

Dead

Living wounded

Anatomic location

Regional frequency

Anatomic location

Regional frequency

Anatomic location

Regional frequency

1

Lower extremity

22.7

Head

36.5

Lower extremity

28.2

2

Head

21.5

Multiple

25.6

Upper extremity

22.9

3

Multiple

18.6

Thorax

22.0

Head

17.2

4

Upper extremity

17.9

Abdomen

12.1

Multiple

16.6

5

Thorax

12.9

Lower extremity

3.5

Thorax

10.3

6

Abdomen

6.4

Upper extremity

.3

Abdomen

4.8


432

exposure of the head exceeds that of any other anatomic region. However, the fact that percentage of rifle hits exceeded the percentage of unaimed mortar hits by a perceptible margin would tend to indicate that the factor of marksmanship does account for a moderate number of head wounds.

Effectiveness of weapons.-In table 109, the number of battle casualties produced by the different weapons is shown in relation to the relative lethal effect of each weapon. A clear distinction exists. The total number of casualties produced by a given weapon reflects not only the extent of its use by the enemy but also the effectiveness of that weapon when employed under the particular circumstances of that battle. On the other hand, the relative lethal effect of a weapon is defined as the percentage killed by all hits and is a measure of the effectiveness of that weapon under all conditions (providing facilities for medical care are comparable and constant). For example, though the mortar produced more casualties in the Bougainville campaign, the machinegun had the highest lethal effect.

TABLE 109.-Percent distribution of 1,788 casualties (395 dead, 1,393 living wounded) by relative effectiveness of weapons1

Weapon frequency

Percent of total

Weapon effectiveness

Relative lethal effect (percent)

Mortar

38.8

Machinegun

57.6

Rifle

24.9

Rifle

32.1

Grenade

12.5

Artillery

22.7

Artillery

10.9

Mortar

11.8

Machinegun

8.4

Grenade

6.2


1Mines and miscellaneous weapons are excluded (4.5 percent of total casualties).

A true measure of the effectiveness of a weapon cannot be obtained by a consideration of the total number of casualties and the relative lethal effect alone. A third factor must be considered; namely, the severity of the wound in the living. An estimate of the severity of the wound may be obtained by classifying the living casualties according to the ultimate disposition of the patient, whether he was returned to duty from the first or second echelon or evacuated to the United States. A still more important criterion of the effectiveness of a weapon from the standpoint of winning a battle is the ability of the wounded soldier to continue combat. This was determined by classifying the wounded according to arbitrary criteria based on whether the soldier could have continued combat for a few hours if his life were at stake (table 110). When measured by both of these standards, the relative effectiveness of the different weapons was found to be of the same order as follows: (1) machinegun, (2) rifle, (3) artillery, (4) mortar, (5) grenade.

Sufficient ballistics data were not available in this theater to determine the average velocity of shell fragments producing casualties. The exact size


433

of the shell causing these casualties was also unknown. Furthermore, there were insufficient clinical data to determine the size and mass of the fragments causing casualties. However, if one assumes that the average velocity of bullets is greater than that of shell fragments at the point of impact, these findings suggest that the effectiveness of a weapon is a function of the velocity of the missile.

TABLE 110.-Percent distribution of casualties lost to battle and combat, by distribution and effectiveness of causative agent1

[Values expressed as percentages according to type of weapon and effectiveness of weapon to total casualties]

Order of frequency

Lost to battle2

Lost to combat2

Weapon

Percent

Weapon

Percent

Distribution by weapon:

1

Mortar

35.7

Rifle

37.7

2

Rifle

32.3

Mortar

27.6

3

Machinegun

12.5

Machinegun

18.4

4

Artillery

10.6

Artillery

9.5

5

Grenade

8.9

Grenade

6.8

Effectiveness of weapon:

1

Machinegun

85.4

Machinegun

75.5

2

Rifle

74.8

Rifle

52.4

3

Artillery

56.7

Artillery

30.4

4

Mortar

53.1

Mortar

24.5

5

Grenade

40.6

Grenade

18.8


1Mines and miscellaneous weapons are excluded.
2Includes the dead and those casualties evacuated to the rear echelon or to the United States.
3Includes the dead or those casualties unable to continue to fight "if life were at stake."

Comparison of Japanese and U.S. Weapons.-A comparison of the effects of Japanese and U.S. weapons20showed a lower lethal effect for both the enemy artillery and the grenade. The fact that U.S. artillery was predominantly heavier than that of the Japanese may explain its greater relative effectiveness. The low lethal effect of the enemy grenade appeared to be characteristic of that weapon.

Circumstances.-On the basis of the study of a large group (79.9 percent) who had relatively little or no protection when wounded, it was found that the number of casualties depended upon random unaimed hits which were distributed roughly in proportion to the body area exposed. The remaining casualties which occurred under the circumstance of relatively good protection were equally distributed between the pillbox and the uncovered foxhole or trench. Aimed fire was responsible for 70.7 percent of the casualties in the uncovered trench or foxhole and for only 29.3 percent in the pillbox. On

20A comparison of weapons was possible in only a relatively small number of instances, since records were available for only 219 casualties produced by U.S. weapons.


434

patrol and offensive action, the majority were wounded by the aimed fire, whereas, on defensive action, the reverse obtained. Eighty percent of the casualties in this study occurred during the Battle of the Perimeter.

A number of casualties resulted from careless exposure, failure to dig in, and failure to take advantage of natural cover. A large number of casualties (219) resulted from U.S. weapons. These findings indicate the need for even greater emphasis on the importance of cover. The training program should also stress the avoidable circumstances under which troops are killed or wounded by careless behavior.

Medical treatment.-Exceedingly advantageous circumstances surrounded the treatment of the wounded at Bougainville. In the treatment of 2,015 casualties, the low mortality of 3.7 percent was obtained. Experience in this campaign indicates a need for portable blood banks. Shock and hemorrhage were well treated by the liberal use of plasma. Whole blood transfusions were used more extensively than in any previous campaign in the South Pacific. Nevertheless, a wider utilization of blood transfusions would have been beneficial, because of the large blood volume replacement needed. Fractures were well treated by plaster immobilization. There were no deaths due to compound fractures of the extremities. First aid treatment was excellent and in only two instances did a death occur which might have been attributed to an aidman's error of judgment. Inadvisable evacuation of patients before recovering from shock possibly contributed to a fatal outcome in a few instances.

Post mortem examinations.-Hemorrhage was the most common cause of death in 104 autopsies. Frequently, 4 or more liters of blood were found in the pleural or peritonal cavities. Extensive brain damage ranked second in producing death. Accurate determination of the causative missile by the appearance of the wound was not possible in either the dead or the living. There was no constant relationship between the size of the wound of entrance and exit and the underlying structural damage. Temporary cavity effect of high-velocity missiles was frequently noted in the more solid organs as well as in the lung and brain.

CONCLUSIONS

The ultimate aim in the study of wound ballistics is to provide data which will permit the production of weapons which will produce more casualties among the enemy. These data may enable an army to devise more efficient weapons, develop better protective measures, and will eventually reflect in improving the care of the wounded.

Data Required

Field studies should yield information which permits the proper evaluation of weapons as casualty-producing agents. The effectiveness of a weapon may


435

be measured by the number of casualties it produces and by the severity of the wound. Wound severity in turn must be gaged not by local appearance but by the ultimate disposition or length of disability of the patient. The following factors, therefore, must be considered:

Weapons.-Type and proportion of weapons employed, the range or distance from the shellburst, and the mass or velocity of the missile should be determined.

Local circumstances.-The number and character of casualties reflect battle condition; hence, local conditions must be ascertained. It is desirable to know the position and occupation of the soldier when wounded, the available cover, terrain, and the tactical situation.

Medical care.-A detailed study of the patient's medical record is essential and should include a description of the wound, with the exact location of the point of entry, evaluation of the treatment, and post mortem findings in case of death. The degree of disability measured in time lost from combat must be ascertained and evaluated, together with the mortality rates for each weapon.

Methods and Results

Data in this chapter were obtained by personal interview and by questionnaire. Because the wounded man frequently knew less about the circumstances of wounding than his uninjured companion, witnesses were interviewed at the front as soon as possible after the action. Hospital staff officers were not trained in the study of wound ballistics, and when casualties were heavy they were fully occupied with the care of the wounded. For this reason, it was found desirable to have an officer of the ballistics team assemble clinical data at the various hospitals. Since the action was confined to a small geographic area and transportation facilities were excellent, the collection of essential information was relatively easy. Under these rather ideal circumstances, the report falls short of attaining the full advantage of the opportunity presented for the study of wound ballistics. Its merit, if such there be, lies in the fact that it presents data on all who were killed and wounded in one battle.

Lessons Learned

The personal interview is preferable to the questionnaire. The questionnaire may be utilized as an adjunct, if its use is supervised by a ballistics investigator and its accuracy repeatedly checked.

There is need for the definition and standardization of terms used in the study of wound ballistics. To obtain comparable reports, it is necessary to adhere to some uniform plan of collecting and recording data.

The number of the wound ballistics team personnel was inadequate. For a comparable volume of work, the number should be doubled.


436

A wound ballistics team21 should be assigned to the combat unit a month before D-day. This will allow for indoctrination of medical officers, aidmen, and troops. In this interval, experienced team members can furnish valuable instruction by outlining the avoidable circumstances under which troops are killed or wounded.

Surgeons in hospitals along the line of evacuation should be instructed regarding the clinical data desired. They should understand the general objectives of the study in order to enable them subsequently to furnish the desired information.

The study of wound ballistics in the field requires special training and aptitude. It necessitates an attention to detail which an overloaded hospital staff does not have the time to devote during battle. Information collected in the routine manner without the aid of trained investigators lacks uniformity and accuracy. In order to collect adequate and accurate data, it is essential that a full-time wound ballistics team be assigned for that purpose.

21This could be identified as a battle casualty survey unit since it would be concerned with the identification of the types of battle casualties, the anatomic distribution of wounds, the causative agents, and the eventual disposition of the wounded. In addition, the ancillary factors contributing to the number of casualties should be investigated; for example, combat experience, type of action, and terrain. The survey team would also be in an advantageous position to collect information pertaining to other forms of trauma associated with modern day warfare. These could include vehicular accidents, bunker cave-ins, and airplane crashes. A casualty survey team should be an integral portion of the combat unit during peacetime maneuvers as well as in wartime. It is only in this way that a complete understanding of the purpose and scope of such a team could be adequately realized by the participating services. This unit should also investigate all accidents involving U.S. weapons during training procedures.-J. C. B.

RETURN TO TABLE OF CONTENTS