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Examination of 1,000 American Casualties Killed in Italy
William W. Tribby, M.D.1
PURPOSE OF STUDY
The purpose of this study was to provide accurate source material on the distribution of wounds in the bodies of American soldiers killed in action. The project was conceived and initiated by Brig. Gen. (later Maj. Gen.) Joseph I. Martin, Surgeon, Fifth U.S. Army, who requested that it be done by personnel of the 2d Medical Laboratory. Fieldwork, restricted to the bodies of those who died before reaching field or evacuation hospitals, was begun on 29 April 1944 at the U.S. Military Cemetery, Carano, Italy, under the supervision of Col. Kenneth F. Ernest, MC, then commanding officer of the 2d Medical Laboratory. It was completed on 6 November 1944 at the U.S. Military Cemetery, Monte Beni, Italy, with the very helpful advice and direction of Lt. Col. (later Col.) Harold E. Shuey, MC, who became commanding officer of the laboratory in July 1944. Results of the study were presented in a six-volume report,2 for which General Martin prepared the following foreword:
It is quite apparent to anyone who has seen the human wastage in war that provisions for the best possible protection of the soldier from enemy fire on the battlefield have not been achieved, nor has the problem received the study it deserves. If the Medical Department is to carry out its mission fully, we should do our part in furthering improvement in this field. This study was conceived in that light and as a necessary step in the process of final solution of the problem.
The extent of the effort required to complete this study should be apparent on the face of the data presented. It is only when it is known that this work was done as an additional
On several occasions it seemed that lack of time, obstinate weather of all kinds, the need for secrecy, the difficulty of working under battlefield conditions and the constantly changing military situation would contrive to halt this work. The reader is asked to consider these factors before becoming too critical. The completion of this unique project in its present form is a tribute to the indomitable desire for scientific investigation and [to the] * * * adherence to a high standard of scientific endeavor.
During the organization of the survey, it appeared that a study of this scope and character had not been done previously in the U.S. Army. Other casualty surveys were in progress (pp. 237-280 and pp. 281-436), but the details of the surveys were not available nor were either of them confined solely to the study of the killed in action. In the Bulletin of the U.S. Army Medical Department, No. 74, March 1944, a footnote to an article entitled "Need for Data on the Distribution of Missile Wounds" states: "The only data available in the Office of the Surgeon General are those from 1,175 Union soldiers who were killed in action during the Civil War. This footnote refers to the following statement:
The records in this office [Surgeon General of the U.S. Army] show the seat of injury in only one thousand one hundred and seventy-three cases of soldiers killed on the battlefield. Of these, four hundred and eighty-seven (487) were of the head and neck, six hundred and three (603) of the trunk, thirty (30) of the upper extremities, and fifty-three (53) of the lower extremities.3
It is evident that a thorough study of these cases was not made.
It was believed that the contemplated survey would partially satisfy the need for data on the distribution of missile wounds. More specifically, it was hoped that the material would be useful in helping to devise one or more forms of body armor which could be used in some of the varying conditions encountered in battle. The data should also be useful to ballisticians although much of the material required by this group was unobtainable, as explained later.
METHODS OF STUDY
It was decided that this work should be done in the U.S. military cemeteries because it is here that bodies become available in groups large enough to make possible the study of a thousand cases within a reasonable period of time. Information regarding the circumstances attending death could not be augmented by working farther forward. Furthermore, the removal of clothing from bodies cannot be permitted before they have been searched for identification tags and personal effects by personnel of the Graves Registration Service in preparation for burial. This latter function was performed in the ceme-
teries. The data for this study, therefore, were collected in the U.S. military cemeteries at Carano, Follonica, Castelfiorentino, and Monte Beni, Italy. The periods of time and numbers of cases studied in each location are shown in table 111.
Quartermaster Graves Registration Service
The methods employed by the Quartermaster Graves Registration Service for collection and delivery of bodies to the cemeteries are related to certain aspects of this study, and they merit brief description. The division quartermaster is responsible for evacuation of bodies to the Graves Registration Service. He, or his appointed representative, may act as the divisional graves registration officer. Each regiment has a graves registration officer who organizes collecting teams. These teams are composed of enlisted men who collect the dead and write the EMT'S (emergency medical tags). One platoon of a graves registration company is capable of operating a cemetery provided the number of burials is not too great. In Italy, it was usually possible for the 47th Quartermaster Graves Registration Company to have one of its platoons operate four collecting points so spread out behind the front as to cooperate with the divisional collecting teams. It was intended that regimental collecting teams would evacuate their dead to Graves Registration Service collecting points whence they were evacuated to the cemetery. This plan was not always followed because at times the regimental collection point was closer to the cemetery than it was to a Graves Registration Service collecting point. In static situations, the divisional collecting and evacuation system usually functioned without delay in cooperation with the Graves Registration Service. Most bodies were recovered promptly. However, when the army was advancing rapidly and actions occurred in widespread areas, it was more difficult to find bodies, and frequently they did not reach the cemetery for many days after death. When the divisional collecting system was forced to leave bodies behind, the task of finding and collecting them fell to the Graves Registration Service.
Bodies were examined as received in the cemeteries, without selection but with the requirement that they be in a condition fit for examination; that is,
not so decomposed nor so heavily infested with fly larvae as to make the location or extent of the wounds uncertain. In practice, the bodies were stripped of all clothing after having first been searched by graves registration personnel. The wounds were then described and recorded promptly so as not to delay interment. Every wound was probed and its extent determined as exactly as possible from external examination.
All data were recorded on mimeographed sheets on one side of which were outline forms of front and rear views of the body with three views of the head. Rough sketches of the wounds were made (fig. 229). On the reverse of the sheet was entered identifying information to include, when available, name, rank, Army serial number, organization, army branch of service, type of missile, type of action, position at time of injury, treatment, and description of wound and wound track. This information is essentially the same as that suggested
in the article in the March 1944 Medical Department bulletin. The worksheets were saved as a permanent record.
Certain difficulties were encountered in attempting to obtain the items of information just cited. All of these items, except descriptions of wounds and names and serial numbers, had to be obtained from EMT's or from Graves Registration forms. Names and serial numbers were usually copied from identification tags. When the latter were missing, other means of identification were sought, such as AGO cards, letters, and membership cards. Ranks, organizations, and serial numbers could not always be recorded at the time when the bodies were examined. After 1,000 cases had finally been studied, it was found that information on approximately one-third was incomplete. The missing data were obtained from the office of the Fifth U.S. Army Graves Registration Officer and the Adjutant General Casualty Section.
Efforts to ascertain and tabulate the missiles in this series met with almost insurmountable difficulties. A man killed in battle will be seen to fall only by his comrades who cannot know with certainty what type of missile caused a man's death. They may know that a man was hit by machinegun or rifle fire or that he encountered a mine, but they cannot state with accuracy the caliber of a high explosive shell which has been fired at them. In any event, even if accurate information regarding missiles is known to a man's comrades, it does not often find its way to the EMT's which are filled in by company aidmen or other medical personnel who arrive on the scene after the action has occurred. Those who actually see the death occur are seldom present when the body is tagged. Ballistic data on EMT's cannot therefore be depended upon since it is not known which ones are accurate. The best method of obtaining accurate information of this type is to perform an autopsy to locate and identify missiles4 (fig. 230) and to determine the extent of tissue damage. Early in this study, it became evident that the performance of an autopsy in every case was impracticable because of the time required for such a procedure. The first body autopsied in this project was thoroughly dissected in search of the missile. After a period of 3 hours, the missile had still not been found, and the search for it was abandoned. Even when fragments of metals are found, their small size usually precludes determination of their origin. Frequently, missiles were discovered near the surface of the body, in wounds, or in the clothing adjacent to wounds. The size and shape of all such pieces of metal were incorporated in
FIGURE 230.-High explosive steel fragments (primary missiles). All of these fragments were retained in and removed from the fatal wounds of infantrymen killed in action with the Fifth U.S. Army in Italy. The fragments range from 1 to 120 grams in weight.
the descriptions of each case. The data concerning missiles were copied from the EMT's with the important exception that the term "high explosive" did not occur on the tags. Under this heading were placed all casualties who obviously died as the result of having been hit by high explosive missiles but whose EMT's did not indicate a missile. Also included in this category were all cases for which there was definite evidence that the missile was erroneously stated on the EMT but which were manifestly hit by high explosive missiles. It was believed that the data as finally recorded on the case report were in general accurate with regard to gross categories of causative agents.
In warm weather, the condition of most of the bodies received in the cemeteries was so unsatisfactory that even external examinations were not done. During the months of August and September, the work was discontinued because too few bodies in fresh condition were received at the cemeteries to make an effort worth while. For this reason, the proportion between the number of cases included in this series and the number of interments varied considerably from one cemetery to another. For example, the sample of battle deaths included in this study was larger at Castelfiorentino in October than it was at Follonica in July.
The 1,000 casualties of the survey though not representative of casualties from all types of action during different seasons were not significantly different from those observed in areas other than where the survey was conducted. There was also no apparent difference in the types of cases received when the front was static as compared with those received during an offensive.
The exact type of action in which these battle casualties occurred could not be determined at the cemeteries. The available information consisted of the location where bodies were recovered, which was indicated on a majority of the emergency medical tags. The usual statement consisted of "Vic [victim] of," followed by the name of the nearest landmark or inhabited locality, often misspelled. Coordinates were usually not given. To obtain accurate type-of-action data, it would be necessary to study the history of each organization.
The position of the body at the time of injury could not be determined because it was impossible to make contact with anyone able to give this information.
As it was impossible to obtain the services of a photographer for an extended period of time, a camera was borrowed from the Army Pictorial Service. Photographs of 82 representative cases were made by the author and processed by the Army Pictorial Service (fig. 231). The photographs were made under an agreement with the Fifth U.S. Army Graves Registration Officer that no names would be associated with them.
At the beginning of the description of each case in the complete report is a statement which classifies the wounds as single or multiple and lists the various parts of the body which are involved. Tables 112, 113, 114, 115, and 116 are presentations of these data in tabular form. Each wound is mentioned separately in most of the cases except in instances where multiple wounds were present. In the latter cases, each wound is not described separately.
FIGURE 231.-Typical photograph of a casualty (Case No. 635) with multiple fatal and nonfatal wounds due to high explosive shell fragments. There are many penetrating wounds in the posterior surface of the torso and left arm varying from a few millimeters to 11 x 12 centimeters. This largest wound is a penetrating laceration in the left buttock and sacral area.
A compilation of the cases, arranged according to parts of the body which were affected and according to probable missiles, is presented in table 112. Emphasis must be placed upon the word "probable" when reference is made to missiles. It must not be forgotten that the placing of the majority of the cases in any particular group, with respect to missiles, is based upon the appearance of wounds and EMT data rather than upon actual finding of missiles. The columns labeled "Upper half of the body" and "Lower half of the body" list the cases which had wounds confined to the areas above and below the diaphragm, respectively, but with more than one region involved. The column labeled "Upper and lower halves of the body" lists the cases in which the wounds were distributed above and below the diaphragm. It will be seen that some of the cases in these three columns have single wounds. This means that from external examination it was determined that more than one region was affected. For example, a single wound in the chest, with intestine herniated through it, is of the thoracoabdominal type, and the case belongs in the group of cases with wounds both above and below the diaphragm. Undoubtedly, many of the cases with wounds which were too small to be probed would have been
found to have parts affected other than those listed had it been possible to perform autopsies in all such instances. The data, however, were uniformly recorded from the standpoint of external examination.
1Does not include 4 casualties cremated in a tank
and 13 casualties due to blast injury. See text, p. 446.
Some difficulty was encountered in attempting to classify wounds located in marginal areas; for instance, deciding whether axillary wounds should be listed as upper extremity wounds or as chest wounds. Axillary and shoulder girdle wounds were classified as chest wounds except in cases where they extended into or were distal to the head of the humerus. The same criteria were applied to wounds in the inguinal and buttock areas where they were classified as pelvic unless they extended into or were distal to the head of the femur. The terms "back" and "lumbar area" were not included in the classifications. Wounds located in the back above the level of the first lumbar vertebra were listed as "chest." Similarly, posterior wounds in the lumbar region above the iliac crests were classified as abdominal.
Four cases5 were classified as cremation in a tank, and thirteen cases were designated as blast injury. (These 17 cases are not included in table 112.) The latter cases were those with nonpenetrating wounds with blast injury the probable cause of death. Autopsies were performed upon four of these bodies and diffuse pulmonary hemorrhage was found in all four cases and pulmonary edema in three of them. Microscopic tissue studies were done in only one of the cases, the others having been decomposed to such an extent that tissues were not saved for this purpose. All cases in this group, except one, showed the presence of blood either in the nose or mouth or in body places. This finding, in the absence of penetrating wounds, was presumed to indicate pulmonary hemorrhage probably due to blast. Several other cases, without penetrating wounds sufficient to explain death, may have died of blast injury.
Even though the actual missiles were not recovered, the general breakdown of the causative agents was comparable to that determined in other ground force casualty surveys where witnesses were interrogated and autopsies were performed. Small arms accounted for 107 (10.9 percent) of the 983 missile-wounded casualties. Fragment-producing weapons were tentatively identified in the remaining 876 (89.1 percent) of these casualties. Shell fragments were identified with certainty in 382 (38.9 percent) of the casualties. However, the noncommittal term "high explosive" was used for 471 (47.9 percent) of the cases, and it was presumed that most of the missiles were derived from mortar and artillery shells. Hand grenades were positively identified in 3 (0.1 percent) of the casualties, landmines in 19 (1.9 percent), and aerial bombs in 1 (0.1 percent). If the exact identification of the missiles could have been made, the proportion of hand grenade and landmine casualties might have increased.
From the group of cases with wounds involving the upper half of the body, the lower half of the body, and the combined upper and lower halves of the body, data were compiled on regional incidence (number of times an anatomic region was involved). These data are presented in tables 113, 114, and 115. Table 116 is a compilation of all the data on actual distribution of wounds in the whole series and also lists the regional frequency of the probable lethal wounds. The thorax was most frequently involved, followed, in order, by the head, the upper and lower extremities, and the abdomen.
1Includes 4 cases cremated in a tank not included in table 112.
With a view to determining the approximate total number of wounds and their regional distribution, the author's original case reports were reexamined.6 The total number of cases (983, table 112) remained the same, but a slight change was made in the distribution of the single and multiple regional involvements (missile wounds), as follows:
No change in classification was made for the 4 cases cremated in a tank and the 13 casualties which were due to blast injury, and they were not included in any of the tabulations.
In the original tabulation, a number of cases with perforating wounds had a missile track involving several body regions and were classified as multiple-region-type cases. It was decided that these should be considered as a single-region involvement of the entrance site regardless of the location of the exit wound. The demarcation of the anatomic regions was also based upon slightly different criteria7 and accounts for some of the changes in the regional frequency of wounds (table 117, compare with table 116). The buttocks, though considered as a portion of the lower extremity, were listed separately because of interest in this region in the development of lower torso body armor. Table 118 lists the regional distribution of the estimated 7,006 wounds in the 983 casualties. Of the total wounds, 55.4 percent (more than a half) occurred in the extremities and 25.7 percent were located in the thorax. Approximately 6,130 (87.5 percent) were penetrating8 type of wounds and 876 (12.5 percent) were perforating9 type of wounds. The wound incidence per casualty was approximately 7.1 percent, and this is very similar to that found in the study of KIA in the Korean War.
1Includes 4 casualties cremated in a tank and not included in
1Indicates frequency of anatomic regional incidence of wounds per casualty but not total number of wounds.
Rank and Type of Duty
The rank and type of duty of the 1,000 killed in action examined are listed in the following tabulations:
Emergency Medical Tag
Of the EMT's attached to the bodies examined, 119 gave indication that the casualties had been seen alive after having been hit. Data collected partly by examination of the bodies and partly from EMT's showed that 109 of the cases had received the following types of treatment:
For the remaining 10 cases listed as "WIA" on Graves Registration Burial Forms (GRS No. 1), no treatment was noted.
At the time this study was being done, diagnoses from the EMT's were not copied on the worksheets. The diagnoses on the tags were not changed or influenced by this study except in six cases which were autopsied. It became evident as the study progressed that diagnoses on EMT's were often erroneous. Since EMT's were frequently the only source of information on battlefield deaths available to the Medical Department, an effort was made to determine the accuracy of the diagnoses contained thereon. The EMT diagnosis was obtained for each case in this study from the Graves Registration Burial Form No. 1. A comparison of the diagnoses is presented in table 119. It is seen, for example, that 15.3 percent of the EMT's for these 1,000 cases had erroneous diagnoses for wounds of the head and 13.9 percent were in error for wounds of the neck. For the abdomen and pelvis, the errors were 20.2 percent and 16.3 percent, respectively. This deficiency was only partially the fault of those who wrote the EMT's for battlefield deaths. Accurate diagnoses are not to be expected unless the body is stripped of all clothing and examined by a medical officer.10
1Figures in column 1 minus figures in column 2 plus figures in column 3.
Indication for Body Armor
The following 198 cases with severe multiple mutilating wounds (figs. 232 and 233) are grouped according to the regions affected:
FIGURE 232.-Traumatic (partial) decapitation due to high explosive shell. Vault of skull laid open and brain completely eviscerated. Severe fragmentation of the bones of the vault and of bones of base of skull on left side.
FIGURE 233.-Extensive multiple and mutilating wounds of all regions of the body due to high explosive shell. A. Front of body. B. Back of body. C. Multiple wounds of lower extremities. There is almost complete dismemberment of the upper half of the body from the iliac crests upward. The head is missing. The chest and abdomen are completely mutilated and laid open from a posterior direction. Both arms are attached to the remainder of the body by segments of skin. Numerous lacerated penetrating wounds are found in both legs.
These 198 cases plus 4 which were cremated represent 20 percent of the total number examined which could not have been saved from death by any type of body armor.
In many cases with multiple wounds, it is difficult to determine which wound is the immediate cause of death. Undoubtedly, some of the traumatic amputations of extremities would not have resulted in death had they been the only wounds. Wounds of the head were considered as more likely to have been fatal than wounds of other regions. Of 432 head wounds, only 31 were either nonpenetrating or not serious enough to have been fatal. Although no study has been made to determine the percentage of head wounds involving the areas not protected by the helmet, the impression was obtained that a helmet could be designed to cover more of the head and neck and reduce the number of serious wounds of these regions. Other sites which would be difficult to protect by armor are the attachments of the extremities to the trunk, of which no studies were made in this report. About 20 percent of the cases could not have been protected by any type of body armor. Possibly some type of body armor could be designed to protect vital areas most often involved, such as the head and trunk. The data in the original report are source materials which can be studied further in an attempt to clarify this problem.
The case reports which are included in this section were selected from the original report as illustrative of the types of wounds inflicted on the various anatomic regions of the casualties studied in this survey. In all instances, the case numbers assigned in the original report have been used.
Case No. 633.-Pfc., 168th Infantry, 14 Oct. 1944; missile: high explosive; single wound in the head (fig. 234). There was a through-and-through wound in the head with the wound of entrance, 2 x 4 cm., in the left cheek area and the wound of exit, 3.5 x 5 cm., in the right temporal and zygomatic area, passing through the external ear. The right temporal bone and bones of the face were severely crushed.
Case No. 641.-Pvt., 338th Infantry, 15 Oct. 1944; missile: shell fragments; multiple wounds in the head (fig. 235); treatment: plasma, 2 units local sulfonamide and dressing. Three deep lacerations were present in the right posterior half of the head. The right temporal bone was penetrated immediately behind the external ear in an area which measures 3 cm. in diameter.
Case No. 501.-Pfc., 362d Infantry, 7 Oct. 1944; missile: shell fragment; single wound in the neck (fig. 236). A large mutilating wound was present in the left anterior and lateral sides of the neck. There was exposure and fragmentation of several cervical vertebras.
Case No. 970.-Pfc., 362d Infantry, 5 Nov. 1944; missile: shell fragment; single wound in the neck (fig. 237). A wound, 1.3 x 2.5 cm., penetrated the anterior side of the neck immediately to the right of the midline and immediately inferior to the larynx. The trachea was perforated and the body of the C7 vertebra was crushed. The wound bled profusely.
Case No. 760.-Pvt., 338th Infantry, 19 Oct. 1944; missile: high explosive; single wound track in the chest (fig. 238). This through-and-through wound had its entrance, 1 x 2.5 cm., in the posterior left side of the chest at the level of the T5 vertebra, 10 cm. from the midline. The wound of exit, 4 x 6 cm., was located in the anterior left side of the chest at the level of the second and third ribs. There was a large opening into the thoracic cavity through the second, third, and fourth ribs.
Case No. 824.-Pfc., 936th Field Artillery, 27 Oct. 1944; missile: shell fragments; multiple wounds in the chest (fig. 239). There was a through-and-through wound in the chest with the entrance, 2 x 2.5 cm., in the left anterior axillary line. The wound track traversed the thoracic cavity in a slightly posterior and medial direction through compound comminuted fractures in the fourth and fifth ribs. The wound of exit, 3.5 x 4 cm., was located in the anterior lateral right side of the chest, where it passed through a compound comminuted fracture in the fifth rib. A superficial through-and-through lacerated wound was present in the posterior left side of the chest in the midscapular area. Another laceration was found near the medial angle of the right scapula.
Case No. 908.-Sgt., 755th Tank Battalion, 1 Nov. 1944; missile: high explosive; single wound track in the chest (fig. 240). This through-and-through wound in the chest had its entrance, 2 x 2.5 cm., through the body of the left pectoralis muscle group, near the axilla. The track proceeded downward and posteriorly through the fractured third rib. The wound of exit, 2.5 cm. in diameter, was found in the posterior side of the chest, immediately to the left of the midline at the level of the T4 vertebra. The wound opened into the spinal canal through the T4 and T5 vertebras and extended to the left of the spinal column into the thorax. The left fourth rib was fractured transversely at the site of exit..
Case No. 986.-Pvt., 363d Infantry, 5 Nov. 1944; missile: high explosive; single wound in the abdomen (fig. 241); treatment: local sulfonamide and dressings. A penetrating wound, 6.5 cm. in diameter, was located in the midline of the abdomen in the epigastrium. There was evisceration of numerous loops of small intestine through the wound.
Case No. 644.-Pfc., 338th Infantry, 14 Oct. 1944; missile: high explosive; multiple wounds in both lower extremities (fig. 242). There was traumatic amputation of both legs immediately distal to the knee joints. Lacerations extended into the distal medial third of the left thigh.
Case No. 759.-Cpl., 337th Infantry, 19 Oct. 1944; missile: high explosive; multiple wounds in both lower extremities (fig. 243). Numerous penetrating wounds were found in the left leg between the knee and the ankle. They varied in diameter from 1 cm. to 2.5 cm. There was traumatic amputation of the right leg through the middle third. The distal portion was attached by muscle and was completely mutilated. Two lacerated penetrating wounds were present in the lateral and anterior sides of the right knee. There was a compound comminuted fracture in the right patella. A laceration, 3 x 5 cm., was located in the anterior side of the right knee and leg. Maggots, visible in figure 243, were contaminants from another body.
Case No. 966.-Pfc., 339th Infantry, 4 Nov. 1944, missile: high explosive; multiple wounds in both lower extremities (fig. 244); treatment: local sulfonamide and dressings. There was traumatic amputation of the left leg through the proximal third of the tibia and fibula, with lacerations extending into and above the knee joint for a distance of 10 cm. There was essential traumatic amputation of the right foot through the ankle joint with severe mutilation of the entire foot; lacerations extended 12 cm. above the distal end of the tibia and fibula. Two intercommunicating lacerations in the right medial thigh were 6 cm. apart; the lower opening measured 1.5 x 2.5 cm. and the upper opening, 4 x 5 cm. A superficial laceration, 3.5 cm. in diameter, was found in the anterior proximal aspect of
the right thigh. There was a comminuted fracture in the middle third of the right femur, with a penetrating wound over the fractured area in the middle of the thigh, anteriorly. A laceration, 2 x 4 cm., in the medial side of the right leg exposed the periosteum of the tibia.
Case No. 80.-T5g., 338th Infantry, 15 May 1944; missile: shell fragments; multiple wounds in the head, neck, chest, and both upper extremities (fig. 245). A penetrating wound, 1 x 2 cm., was present in the vertex of the skull in the midline; the point of exit, 4 cm. in diameter, was located in the right parietal region; there was avulsion of brain tissue and extensive lacerations of the scalp. A through-and-through wound was noted in the right side of the neck: The point of entry, to right of the larynx anteriorly, was 1 cm. in diameter; the point of exit, 4 cm. in diameter, was at the anterior border of the trapezius muscle; two other small penetrating wounds were seen in the right side of the neck posteriorly. A penetrating wound, 3.5 cm. in diameter, was found in the left shoulder over the upper portion of the scapula; there were many other small penetrating wounds of both shoulders, posteriorly, and of the right arm and shoulder, anteriorly. A penetrating wound was present in the base of the left thumb. There was traumatic amputation of the right hand immediately distal to the wrist joint.
Case No. 631.-Pvt., 133d Infantry, 14 Oct. 1944; missile: high explosive; multiple wounds (two) in the chest and left upper extremity (fig. 246). There was traumatic amputation of the left arm through the proximal end of the humerus. The joint cavity was not involved. The arm remained attached by a small segment of skin. The wound extended into the left upper anterior side of the chest where the skin and muscles were extensively mutilated. A laceration, 4 x 6 cm., was located in the left lateral aspect of the thorax.
Case No. 678.-T. Sgt., 361st Infantry, 15 Oct. 1944; missile: shell fragments; multiple wounds in the head, neck, chest, and both upper extremities (fig. 247). Many penetrating wounds were found in the face, anterior neck, chest, left arm and shoulder. They varied in diameter from a few millimeters to 1.5 centimeters. The largest wound entered the chest anteriorly, at the level of the sixth intercostal space 6 cm. from the midline through
compound comminuted fractures of the second and third ribs. Another penetrating wound in the right anterior side of the chest at the level of the fourth intercostal space adjacent to the sternum extended downward into the thoracic cavity. Three penetrating wounds in the posterior left side of the chest measured 1 cm. in diameter, 3 x 5 cm. and 1 x .3 cm. A laceration, 2 x 5 cm., was present in the top of the right shoulder. The track passed through comminuted fractures of the proximal end of the humerus and lateral angle of the scapula.
Case No. 907.-T. Sgt., 755th Tank Battalion, 31 Oct. 1944; missile: high explosive; multiple wounds in the head, chest, and right upper extremity (fig. 248). There was a through-and-through wound in the vault of the skull with the entrance, 2 x 3 cm., in the left posterior parietal area and the wound of exit, 5 cm. in diameter, in the right posterior parietal area near the midline. The frontal, both parietal, and occipital bones were fragmented and the brain was partially eviscerated. A through-and-through wound in the lower jaw had its entrance, 1 x 2 cm., in the left cheek anterior to the angle of the mandible and its wound of exit, 1.5 x 4.5 cm., in the right side immediately anterior to the angle of the mandible. The entire mandible was fragmented. A laceration, 3.5 x 7 cm., was present in the anterior left side of the chest, with an irregular steel fragment, 2.3 x 1.2 x 0.6 cm., embedded in one end of it. Another laceration, 2 x 5 cm., was found in the right anterior side of the chest at the same level. A lacerated wound, 8 x 11 cm., was seen in the middle of the right arm, anteriorly. A penetrating wound, 3 x 5.5 cm., located proximal to the right wrist in the ventral surface, exposed a compound comminuted fracture in the distal end of the ulna.
Case No. 254.-Pvt., 437th Antiaircraft Artillery (Air Warning) Battalion, 4 July 1944; missile: landmine; multiple wounds in the head, chest, abdomen, right upper extremity, and both lower extremities (fig. 249). Many large severe penetrating wounds were found in the ventral surface of the body. There was complete mutilation of the head with total loss of the brain. A large opening in the left side of the chest revealed multiple fractures of the ribs. A large penetrating wound in the right upper quadrant of the abdomen had intestine eviscerated through it. The right arm was mutilated. Numerous small and large penetrating wounds were present in both thighs and legs and there was a compound comminuted fracture of the left femur in the distal third.
Case No. 655.-Pfc., 19th Engineer Battalion, 15 Oct. 1944; missile: shell fragments; multiple wounds in the chest, abdomen, left upper and both lower extremities (fig. 250 A and B). A penetrating wound, 1 cm. in diameter, was present in the anterior right side of the chest at the level of the second rib. Three other penetrating wounds were found in the anterior aspect of the chest, each 5 mm. in diameter. A laceration, 10 x 13 cm., was located in the lateral left side of the chest without penetration of the thorax. A penetrating wound, 2 x 3 cm., entered the abdominal cavity in the mid epigastrium. A mutilating wound, 10 x 20 cm., in the left ventral arm revealed a compound comminuted fracture through the middle third of the humerus. A through-and-through wound in the left proximal forearm had a ventral opening, 5 x 8 cm., and a dorsal opening, 6 x 12 cm. There was laceration of the muscles and a compound comminuted fracture of the radius in the track.
Three other penetrating wounds in the left arm and forearm varied from 5 mm. to 5 cm. in diameter. A penetrating laceration, 20 x 30 cm., was located in the left anterior and medial thigh; a comminuted fracture of the femur was visible in this wound. Mutilating penetrating wounds were present in both knees, with compound comminuted fractures of the tibia, fibula, patella, and femur in the left leg and compound comminuted fractures of the same bones, except the patella, in the right leg.
Case No. 663.-Pfc., 351st Infantry, 15 Oct. 1944; missile: shell fragments; multiple wounds in the neck and chest (fig. 251) and left lower extremity. A mutilating wound,
11 x 21 cm., was present in the superior anterior side of the chest and the lower portion of the neck. There were compound comminuted fractures of both clavicles and of the first and second ribs on both sides in the wound. The right lung was visible through the opening. A superficial through-and-through wound in the left anterior distal thigh had a lateral opening, 1.5 x 2 cm., and a medial opening, 1.7 x 2 cm.
Case No. 731.-2d Lt., 755th Tank Battalion, 18 Oct. 1944; missile: high explosive; multiple wounds in the head, neck, chest, and both upper and left lower extremities (fig. 252 A and B). A penetrating wound, 1.5 cm. in diameter, entered the skull in the midline through the coronal suture. There was slight evisceration of the brain through this opening. A lacerated penetrating wound, 2.5 x 7 cm., in the left cheek involved the lower and upper lips. Compound comminuted fractures of the mandible and maxilla were visible in this wound. A penetrating wound, 1.5 x 2 cm., entered the right cheek inferior to the zygomatic arch. A penetrating wound, 1 cm. in diameter, entered the base of the right side of the neck. A mutilating wound, 9 x 11 cm., was found in the posterior side of the right shoulder; there were fractures in the head of the humerus, the scapula, clavicle and first four ribs, and an opening into the thoracic cavity. A mutilating wound, 11 x 23 cm., in the anterior left side of the chest extended from the second intercostal space to the lateral left thoracic margin, accompanied with fractures of the fourth, fifth, and sixth costal cartilages and exposure of the pericardium but no penetration of the pericardial sac. A superficial laceration, 3 x 6 cm., was located in the left antecubital space. A lacerated wound in the left thumb and left fourth and fifth digits exposed compound comminuted fractures in the metacarpals and the first and second phalanges of the fourth and fifth digits. A deep laceration, 17 x 35 cm., in the left posterior and medial thigh extended from the popliteal space to the crease of the buttock. The left femur was not fractured. A penetrating wound, 1.5 cm. in diameter, entered the left anterior superior thigh. Four penetrating wounds were present in the left anterior leg and thigh. They varied from 1 cm. to 1.5 cm. in diameter.
Case No. 780.-Pfc., 760th Tank Battalion, 20 Oct. 1944; missile: shell fragments; multiple wounds in the head, neck, chest, abdomen, right upper extremity (fig. 253), and both lower extremities. A lacerated penetrating wound, 3 x 10 cm., in the face involved the right cheek, upper and lower lips, and part of the chin. It opened into the right maxillary sinus and passed through the right lower jaw. The right ear was lacerated adjacent to a penetrating wound, 2 x 3 cm., in the right mastoid process. The track extended downward and medially behind the sternomastoid muscle. A wound, 1 cm. in diameter, penetrated the neck above the middle third of the right clavicle. The track passed downward and medially and entered the thorax above the first rib. A wound, 4 cm. in diameter, entered the thoracic cavity in the anterior right side of the chest at the level of the first and second ribs, through compound comminuted fracture in the second and third ribs. The track penetrated in a downward medial direction. Six wounds in all four quadrants of the abdomen varied from 1 x 2 cm. to 2.5 x 3.5 cm. None of these wounds entered the abdominal cavity. A mutilating laceration in the right lateral distal forearm was located adjacent to the wrist. A compound comminuted fracture in the distal end of the radius was seen in this wound. A wound, 2 cm. in diameter, penetrated the left anterior superior thigh. An irregular steel fragment, 2 x .8 cm., was embedded in this wound. A laceration, 3 x 5 cm., was present in the medial side and dorsum of the right foot. Compound comminuted fractures were visible in the first and second matatarsal bones.
Case No. 831.-Pfc., 401st Antiaircraft Artillery, 27 Oct. 1944; missile: shell fragments; multiple wounds in the head, chest, pelvis, both upper and both lower extremities, and genitalia (fig. 254). There was a through-and-through wound in the head. The probable wound of entrance was an opening, 1.3 x 2.5 cm., in the left temple and the point of exit, a wound inside the mouth which perforated the left maxilla. The left superior canine tooth, both premolars, and the first molar were avulsed. A penetrating wound, 2.5 x 3.5 cm., entered the posterior left side of the chest through a compound comminuted fracture in the 11th rib. The left leg was amputated through the pelvis, the perineum, genitalia, and medial side of the right thigh as far down as the knee. The bones of the left side of the pelvis were severely crushed and displaced. The right femur was also fragmented in its lower third. Three penetrating wounds entered the lateral proximal side of the left arm. They measured from 1 x 1.5 cm. to 2.5 cm. There was a comminuted fracture in the middle third of the humerus. Three lacerated open wounds were present in the left mid forearm revealing compound comminuted fractures in both bones. The left hand and wrist was severely mutilated. Several small wounds entered the right wrist. Numerous penetrating lacerations were found in both buttocks.
Case No. 882.-Sgt., 351st Infantry, 30 Oct. 1944; missile: shell fragments; multiple wounds (fig. 255) in the head, neck, chest, abdomen, pelvis, and both upper and both lower extremities. A superficial laceration, 1 x 5 cm., was present in the right side of the forehead. A wound, 3 x 3 cm., entered the anterior side of the neck in the midline, severing the trachea inferior to the larynx. A through-and-through wound in the abdomen had the wound of entrance, 6 x 12 cm., located in the left posterior flank and the wound of exit, 20 x 20 cm., in the left upper quadrant. There was partial evisceration of the intestine through the larger wound, which extended superficially into the left lower thorax. Other penetrating wounds were located in the left superior axillary margin, anterior left shoulder, left inguinal area, left anterior forearm adjacent to the elbow, where all three bones of the arm were comminuted in the wound, right antecubital space, where a compound comminuted fracture was visible in the distal end of the humerus, right anterior superior thigh, left anterior mid thigh and both anterior mid-legs, with compound comminuted fractures in both bones of both legs. The distal end of the left femur was also comminuted.
Case No. 904.-S. Sgt., 361st Infantry, 31 Oct. 1944; missile: high explosives; multiple wounds (two) in the neck (fig. 256) and left lower extremity. There was a through-and-through wound in the neck with the wound of entrance, 3 x 4 cm., in the left anterior side, where it passed through the body of the sternomastoid muscle. The wound of exit, 3 x 6.5 cm., was found in the midline posteriorly at the base of the skull. Fractures, at the site of exit, extended into the spinal canal through the third and fourth cervical vertebras. A lacerated wound, 1 x 1.5 cm., in the medial side of the left knee had an irregular steel fragment, 2 x 1.6 x .5 cm., embedded in it.
Case No. 929.-T5g., 532d Antiaircraft Artillery (Air Warning) Battalion, 3 Nov. 1944; missile: shell fragments; multiple wounds (fig. 257) in the head, neck, chest, abdomen, pelvis, and both upper and lower extremities. There were many lacerated penetrating wounds present on the anterior surface of the body, including both arms and both thighs, the chest, abdomen, face, and neck; the wounds varied in size up to 4 x 6 cm., which was the measurement of a wound located in the anterior superior margin of the left axilla. There was an avulsive wound in the right lower quadrant of the abdomen which extended from a point midway between the symphysis pubis and the thoracic margin into the right anterior mid thigh. Numerous loops of small intestine were eviscerated through the upper extremity of the wound. There was a compound comminuted fracture in the proximal third of the shaft of the right femur. The pelvis was not definitely fractured. The right leg was amputated through the middle third. The distal portion was attached by strips of skin. There was essential traumatic amputation of the left leg through the knee joint. The distal end of the femur was shattered; the severely mutilated distal portion of the leg was attached by a segment of skin; lacerations extended into the medial mid thigh. A lacerated wound, 6 x 10 cm., was present in the dorsum of the left wrist, with mutilation of the third, fourth, and fifth digits of the left hand and fragmentation on the proximal phalanges of all three digits. Compound comminuted fractures were found in both bones of the left forearm in their distal thirds.