Contents

CHAPTER VII

Study of Fifth U. S. Army Hospital Battle Casualty Deaths¹

Howard E. Snyder, M.D., and James W. Culbertson, M.D.

From 1 January 1944 until the surrender of the German armies in Italy on 2 May 1945 (the period covered in this study), 91,631 American soldiers serving in the Fifth U.S. Army were killed or wounded in action (table 120). Of this total, 16,648 (18.2 percent) died on the battlefield or before reaching a medical installation; 11,959 (13 percent) were treated and returned to duty from the division area (fig. 258). Of the remaining 63,024 (68.8 percent) who were admitted to Fifth U.S. Army hospitals (fig. 259), only 1,631 (1.8 percent) died after their admission. Records of 1,411 (86.47 percent) of these hospital battle casualty deaths were available for this study. In addition, the records of 39 casualties who were DOA (dead on arrival) at a hospital were utilized in many sections of this report. Gross post mortem findings formed a part of 733 of these records (table 121). Microscopic autopsy reports were received on 349. Most of the clinical records were fairly complete,

TABLE 120.-Distribution of 91,631 Fifth U.S. Army casualties in Italy, from 1 January 1944 to 2 May 1945, by category

¹The original three-volume report on which this chapter is based was submitted as a comprehensive survey and partial analysis of available information on 1,450 fatally wounded American soldiers. There has been a partial attempt to consolidate and interpret some of the findings, but there are still many lessons which may be drawn from this study.
Brig. Gen. (later Maj. Gen.) Joseph I. Martin, Surgeon, Fifth U.S. Army, at the time the study was started, encouraged and helped make possible the report. Col. Charles O. Bruce, MC, the Fifth U.S. Army surgeon during the latter months of the study, furnished needed advice. Maj. Richard A. Morrissey, SnC, statistician in the Fifth U.S. Army surgeon's office was a source of great encouragement.
To the cited personnel, as well as to the many individuals who have not been mentioned, we express sincere appreciation for their unselfish contributions.-H.E.S. and J.W.C.

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FIGURE 258.-Building occupied by field hospital platoon and four surgical teams, Porretta, Italy.

but, in some, much desirable information was missing. However, most of the autopsies were performed by the operating surgeons already engaged in the arduous surgical tasks associated with an offensive, and the records are a tribute to the scientific zeal of the surgeons working in the Fifth U.S. Army hospitals.

TABLE 121.-Postmortem studies available and total hospital battle casualty deaths studied,during survey period, 1 January 1944-2 May 1945

¹Includes records of 39 casualties who were DOA at a hospital.

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FIGURE 259.-95th Evacuation Hospital, Monghidoro, Italy.

It may be assumed that the 1,411 hospital battle casualty deaths studied are truly representative of the total of 1,631 who (according to MTOUSA MD Form 86f) died in Fifth U.S. Army hospitals. Beginning with 1 January 1944, General Martin requested submission of a complete record on all battle casualties dying in Fifth U.S. Army hospitals. From 1 January 1944 to 2 May 1945, the Adjutant General's "Wound Classification Report" submitted by the hospitals listed 58,677 battle casualty admissions and 1,562 battle casualty deaths in hospitals. These figures are lower than those reported on the MTOUSA MD Form 86f. From the latter, the figure for battle casualty hospital admissions is 63,024 and for battle casualty hospital deaths, 1,631. These larger figures have been used in setting 86.5 percent as the portion studied of all the hospital battle casualty deaths and have been correspondingly reduced when calculating percentage mortalities. In calculating percentages of total battle casualties or of battle casualty hospital admissions, by period, correction has been made for the percentage of cases studied during each period (table 122).

The Adjutant General's figures and the MTOUSA MD Form 86f include the injured in action as well as the WIA and the KIA casualties. Of the deaths studied, only a few who had crush injuries might be regarded as injured rather than as wounded in action. All of the casualties (20) due to crush injuries resulted from falling stones or bricks set in motion by the explosion of

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TABLE 122.-Correction of total battle casualty admission figures to agree with proportion of total deaths analyzed, by survey period, 1 January 1944-2 May 1945

¹Data obtained from MTOUSA MD Form 86f.
²Excludes records of 39 casualties who were DOA at a hospital.

an enemy shell, and most of these casualties had wounds in addition to the crush injury. It may be said, then, that the deaths studied represent a considerably larger percentage of WIA casualties who died than is indicated by the percentage of 86.5 percent which is based upon the total (1,631) of wounded and injured in action who died in Fifth U.S. Army hospitals during the period studied. The breakdown of injured in action and wounded in action is not available either for hospital battle casualty admissions or for the total resulting from the sum of the Adjutant General's figures on wounded in action plus killed in action.

The 39 records of battle casualties DOA at a hospital comprise all the records submitted on this class of deaths. Statistics are not available to determine their percentage of the entire group of DOA's. Most of them were unquestionably patients who, when seen by the last medical officer, were expected to reach the hospital alive. The DOA group has been included in the tables on wound classification and causes of death and, in many instances, has been singled out for individual study as compared to the group of casualties who died shortly after admission, before anesthesia, during anesthetic induction, during primary surgery, and after primary surgery. The cases have not been included in tables dealing with hospital battle casualty deaths or in any of the percentage tables based on hospital battle casualty admissions or the total of wounded in action plus killed in action.

The information recorded in the tables of this report was first recorded in code form so that it might be transferred to machine records cards. Study of the cases and the primary recording of these data consumed the entire time of Capt. (later Maj.) James W. Culbertson, MC, (fig. 260), for a period of a little

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FIGURE 260.-Capt. James W. Culbertson, MC, (right) obtaining information from hospital personnel concerning battle casualties.

over 3 months. Col. Howard E. Snyder, MC, (fig. 261) then studied each case and checked the recorded data.² Each item was carefully weighed, matters calling for opinion were discussed, and all questionable data were recorded as questionable. The completed machine records cards were checked by hand for accuracy. Colonel Snyder and Captain Culbertson, with their clerical assistants, did all machine counting and recording of data. Many checks were made on the validity of the machine tabulations. It is considered that the margin of error in this method was no greater than, if as great as, the personal error in manual counting.

REGION, TYPE, AND DISTRIBUTION OF WOUNDS

Table 123 lists the general breakdown of the 1,450 casualties as related to hospital admission, anesthesia, and surgery. With experience and improvement in the preparation of battle casualties for surgery, the number of those dying before anesthesia decreased throughout the period covered in the report. When one compares the distribution of hospital deaths during the various time

²More data were accumulated than are presented in this chapter. In the original report, figures on timelags are available in all cases in which the information was in the record. Studies on all cases with nephropathies, fat embolisms, shock, thoracoabdominal wounds have been made. These studies are comparable in scope to that study on cases with intra-abdominal wounds which is presented in this report. It is hoped that the statistical information in the complete preliminary report will be of value to those studying and writing upon war surgery.-H. E. S. and J. W. C.

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FIGURE 261.-Col. Howard E. Snyder, MC, Surgical Consultant, Fifth U.S. Army, at the time the original report was compiled.

periods to the total hospital battle casualty admissions (table 124), there is a consistent reduction in the percentage of those dying before, during, and after anesthesia. Casualties at the Anzio beachhead were included in the first two periods of the survey (January-March 1944; April-July 1944) and unquestionably increased the percentage of those dying before anesthesia and the total hospital battle casualty mortality in the first two periods. The reduction in the latter mortality figure from 3.9 percent in the first period to 2.0 percent in the last is dependent on more than the Anzio casualties. The reduction in the percentage of those dying before anesthesia is in part due to the general adoption of improved methods of resuscitation and to a more available supply of blood. A hospital battle casualty mortality rate is influenced not only by the hospital's proximity to the battlefront but also by the quality of care administered the wounded who reach it alive.

Morrissey has called attention to the direct relationship of the percentage mortality of battle casualties admitted to hospitals, the percentage mortality of battle casualties admitted to hospitals and dying before anesthesia, and the percentage hospital battle casualty deaths comprised of the total who die of wounds (includes KIA) (table 125). He has shown that the latter percentage varies widely. At Anzio, 16 percent of all battle casualty deaths occurred in hos-

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TABLE 123.-Distribution of 1,450 deaths>¹ as related to hospital admission, anesthesia, and surgery, during survey period, 1 January 1944-2 May 1945

¹Excludes 39 DOA casualties.  Their distribution was as follows: For the January-March 1944 period, 7; for April-July 1944, 16; for August-December 1944, 16; for August-December 1944, 9; and for January-May 1945, 7.
²Lived less than an hour.
³Excludes those dying on admission.

TABLE 124.- Percent of 1,411 hospital deaths studied to total battle casualty hospital admissions (53,904), during survey period, 1 January 1944-2 May 1945

¹Excludes 39 DOA casualties.
²Corrected to allow for percentage of deaths not studied during each period. (See table 122.)
³From table 123, includes those dying on admission.
⁴From table 123.

pitals (hospital mortality, 5.7 percent). In May 1944, 4.21 percent of all battle casualty deaths occurred in hospitals (hospital mortality, 1.7 percent). In June 1944, 15 percent of all battle casualty deaths were in hospitals (hospital mortality, 2.8 percent). In October 1944, 7.65 percent of all battle casualty deaths were in hospitals (hospital mortality, 2.1 percent). When evacuation of the wounded to the forward hospital (fig. 262) is easily accomplished,

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FIGURE 262.-Location of field hospital platoon used as a forward surgical unit before the breakthrough into the Po Valley.

the hospital mortality rises. Thus, hospital mortality tends to vary inversely with the percentage who are killed in action or who die of wounds before reaching a hospital. However, as is shown in table 125, there has been a steady, gradual decrease in the percentage which deaths occurring during and after surgery comprise of total battle casualty deaths. Table 124 shows a slight increase throughout the four periods in the percentage which deaths during surgery comprise of the deaths studied but a decrease in the percentage these deaths comprise of battle casualties admitted to hospitals.

The simple classification of cases by region of principal wound in table 126 is presented for comparison with similar tables on hospital battle casualty admissions and deaths which were available for all of the Tunisian, Sicilian, and Italian campaigns.

Table 127 lists battle casualty hospital deaths according to principal wound groups. It was found that in only 33.3 percent of the casualties studied were the wounds limited to one of the wound groups listed in this table, and 66.7 percent of the casualties had wounds involving multiple regions of the body. Many of the 33.3 percent had multiple wounds, but these wounds were limited to only one of the anatomic regions.³

³(1) A more detailed breakdown of the cases listed in table 127 is presented in tables 1 and 2, appendix D (p. 807). Table 1 presents the distribution of associated wounds as related to the region of the principal wound; table 2 presents the regional distribution of principal and associated wounds with the number of cases exhibiting each. (2) A further-clarification of the three wound classes in table 127, involving intrathoracic, thoracoabdominal, and combined intraabdominal and intrathoracic wounds, is presented in appendix E (p. 811).

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TABLE 125.-Demonstration of effect of increased efficiency of evacuation from forward areas on hospital mortality (an increase) and the remaining favorable trend after exclusion of those cases¹ dying before anesthesia

¹A variable quantity influenced by conditions affecting efficiency of evacuation to hospitals as well as by professional care before and after admission.
²Does not include those few deaths which occurred in base hospitals.
Source: History of Fifth Army Medical Service, 1945. [Official record.]

TABLE 126.- Distribution of battle casualty hospital deaths (1,450 cases), by region of principal wound

Table 127 may be compared with the distribution of wounds among all battle casualties admitted to Fifth U.S. Army hospitals during the period of 1 August 1944 to 2 May 1945 (table 128). Intra-abdominal wounds comprise only 2.84 percent of battle casualties admitted to a hospital but 20 percent of them died and these comprise 28.1 percent of all hospital battle casualty deaths.

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TABLE 127.- Distribution of battle casualty hospital deaths (1,450 cases), by principal wound

¹A more detailed classification is listed in appendix D, p. 807.
²A more detailed classification is listed in appendix E, p. 811.
³Includes 43 traumatic amputations.
⁴Includes 17 traumatic amputations.
⁵Includes 2 traumatic amputations.

TABLE 128.-Distribution of 20,747 American battle casualties admitted to Fifth U.S. Army hospitals, 1 August 1944-2 May 1945, by principal wound group

NOTE.-0.0 indicates a rate of more than zero but less than 0.05, and 0.00 a rate of more than zero but less than 0.005.

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The intra-abdominal, intrathoracic, thoracoabdominal, combined intra-abdominal and intrathoracic, and intracranial wounds comprise only 11.09 percent of hospital battle casualty admissions, and yet they account for 76.8 percent of all hospital battle casualty deaths. Table 129 relates the 1,411 hospital battle casualty deaths to the total hospital battle casualty admissions during the survey period.

TABLE 129.-Hospital battle casualty deaths listed as to principal wound with percentage of hospital battle casualty admissions

¹Does not include 39 DOA casualties.
²Figure of total 63,024 admissions corrected to allow for 13.5 percent of hospital battle casualty deaths not studied.

The type of causative agent as related to the principal wound is listed in table 130. Small arms accounted for approximately 15.11 percent of the hospital deaths while high explosive shell fragments (exclusive of mine, boobytrap, and bomb) were identified in 59.38 percent of the cases.

Table 131 correlates the principal wound with the time of death and the hospital admission, anesthesia, and surgery.

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TABLE 130.-Distribution of 1,450 casualties, by causative agent as related to principal wound

¹Cases of blast, crush, and mutilating injury could not be classified in this manner, and number is less than total of 1,450.

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TABLE 131.-Distribution of 1,450 battle casualty deaths as related to hospital admission, anesthesia, and surgery, by principal wound

¹Lived less than 1 hour.
²Excludes the DOA cases and those casualties who lived less than 1 hour.

CAUSES OF DEATH

General Observations

Certain problems were encountered in the classification and arrangement of this material. The Adjutant General of the Fifth U.S. Army and The Adjutant General of the U.S. Army report battle casualty deaths as "killed in action" or "died of wounds" (the latter includes those dying of injuries incurred in action). Hospitals report deaths according to a classification of principal wounds. Generally speaking, all battle casualties who die are said to die of wounds or injuries incurred in action. All of the cases reported in this study may be said to have died either of wounds or of injuries incurred in action against the enemy. Table 132 classifies the cases as to region of primary trauma leading to death. This classification is comparable to those just mentioned. For the purposes of this study, however, such classifications have been deemed inadequate.

A battle casualty who suffers a laceration of the popliteal artery may or may not lose sufficient blood to lead to severe shock, and death. If he does, the primary cause of death according to conventional reports is a wound of

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TABLE 132.- Distribution of battle casualty hospital deaths (1,450 cases) during survey period, 1 January 1944-2 May 1945, by region of primary trauma leading to death

¹Generalized conditions involving more than one region.

the posterior aspect of the knee, with laceration of the popliteal artery. For the purposes of this report, the important desideratum in such a case is that the immediate or precipitating cause of death is shock (peripheral vascular failure).

While fully aware of the controversial nature of the subject, the decision was made to include the uncorrected state of shock as an immediate or precipitating cause of death, along with other more specific, standard diagnoses. It may be contended, of course, that such patients actually die of their wounds and the severity of the trauma attending them and that the shock which is present is a syndrome reflecting a profound pathologic alteration of normal hemodynamics and is not an acceptable diagnosis. However, in this study, as just stated, each case has been classified as to primary trauma leading to death (the conventional primary or basic diagnosis), and the liberty of employing the concept of the state of shock as a "diagnosis" for the immediate or precipitating cause of death (the conventional secondary diagnosis) allows for a more complete classification of the causes of death for comparison and study. This sets in relief that important group of cases which succumbed from the gravity of their wounds in a state of uncontrolled shock. It seems that this group of cases is worthy of the special attention afforded by such a classification.

Shock was selected as the immediate cause of death in 523 cases in this series. A special study was made on this group and is presented on page 511. The criteria used in naming shock as an immediate cause of death are discussed there and are apparent in the information tabulated.

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"Neural trauma and/or intracranial hemorrhage or clot" was listed as the immediate cause of death in 212 cases and is second on the list of the immediate causes of death, as is shown in tables 133 and 134 and in the tabulation which is to follow. The relative importance as a lethal factor of the brain damage produced by the missile and the damage produced by an expanding intracranial hematoma was often difficult to determine. It seemed unwise, considering the available information and the qualifications necessary for evaluation, to attempt to separate these cases into two groups. It may be mentioned here that only 15 cases in whom the principal wound was intracranial were listed as dying of shock, while 210 were listed as dying of neural trauma or clot. (All 235 cases in these two categories were listed also under the heading "Primary trauma leading to death, intracranial.") Nephropathies were third on the list, and their incidence was relatively constant except during the first 3 months of the period covered by this report. The low incidence at that time may be attributed to failure of recognition and is therefore apparent rather than real.

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TABLE 133.-Distribution of 1,450 battle casualty deaths¹ during survey period, 1 January 1944-2 May 1945, by cause of death

¹See tabulation on text page 487 for the total list of the immediate causes of death in the 1,450 cases.

In the first survey period, clostridial myositis was the third leading cause of death, the 35 cases comprising 6.5 percent of all deaths, and 0.28 percent of hospital battle casualty admissions. In the last period, it fell to the bottom of the list, with only one death attributed to it, comprising 0.6 percent of the deaths studied, and only 0.01 percent of all battle casualties admitted to hospitals. The educational program concerning clostridial myositis and the study of the problem conducted by Maj. Floyd H. Jergesen, MC, and Lt. Col. F. A. Simeone, MC, coupled with the more complete surgery on all wounds, the more liberal use of blood, and the advent of the extensive use of penicillin were important factors in effecting this striking reduction in mortality and the corresponding reduction in the incidence.

Peritonitis tended to show a slight increase in its percentage of the total battle casualty admissions and a more pronounced increase in its percentage of the deaths studied. There are two factors which may have contributed. First is the reduction in mortality from shock, clostridial myositis, extremity wounds,

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TABLE 134.-Distribution of 1,450 battle casualty deaths, showing percent of the total battle casualty admissions (53,904)¹ during survey period, 1 January 1944-2 May 1945, by cause of death

¹Corrected to allow for the percentage of hospital battle casualty deaths not studied in each period.

and unclassified wounds in the course of the 17 months covered by the study. This has led to a relative increase in peritonitis deaths, deaths from intracranial wounds, and other wounds or complications, the incidence of which was more or less inevitable. The second factor is the increase in the percentage of autopsies performed which probably accounts for the apparent but slight increase in the number of peritonitis deaths as compared to hospital battle casualty admissions.

The only striking variation in mortality from pneumonia is in the April-July 1944 period, in which pneumonia deaths comprised only 1.2 percent of the deaths studied as compared to the average of 3.4 percent for all four periods. It is the only one of the four periods which did not include winter months.

Tables 135, 136, and 137 compare the region of principal wound, the immediate cause of death, and the region of primary trauma. Attention is directed to the incidence of fat embolism. This diagnosis was not recorded except when microscopic reports indicated large amounts of fat in the pulmonary sections and the record indicated a clinical behavior justifying the diagnosis. It may be noted (table 148) that the diagnosis of fat embolism was evident in 22 additional cases in which it was listed as a contributory condition rather than as the immediate cause of death.

Thrombotic embolism and tracheobronchial obstruction from aspirated vomitus, blood, or mucus appear quite prominently in the leading causes of death. Their relative incidence showed a definite increase and the actual incidence perhaps a slight increase in spite of recognition of their importance and the inauguration of prophylactic measures early in the campaign.

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TABLE 135.-Comparison of principal wound with region of immediate cause of death (1,450 cases)

¹Multiple wounds.
²Cause of death undetermined.
³More than one region involved by cause of death, excluding shock.

TABLE 136.- Region of immediate cause of death as related to region of principal wound (1,450 cases)

¹Involving more than one region, a miscellaneous group, excluding shock.

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TABLE 137.- Region of primary trauma leading to death, by period

¹Record inadequate in description of wounds.

Tables 138 through 149 deal with the total reported incidence of immediate and contributing causes of death. In this report, they are the best source of information regarding the incidence of any one condition. All the figures in the column under "Immediate cause of death" represent evident or confirmed incidence. The figures in the middle column represent both evident and suspected evidence, but in every instance they are separated and properly identified by the index column. The same applies to the total figures in the last column.

TABLE 138.- Total reported incidence of shock in 1,450 battle casualty deaths

¹Probably somewhat lower than the actual incidence.

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The figures are believed to be lower than the actual incidence inasmuch as they represent only the reported incidence, and inasmuch as the records at times are not complete. The incidence figures on shock are perhaps nearer the actual than most of the other figures, because many indications of the presence of shock may be found in the record when it is present.

TABLE 139.- Total reported incidence of intracranial conditions in 1,450 battle casualty deaths

¹Probably somewhat lower than the actual incidence.
²As distinguished from blast trauma.

TABLE 140.- Total reported incidence of shock in 1,450 battle casualty deaths

¹Probably somewhat lower than actual incidence.
²In an additional 128 cases, shock was suspected as being a contributory cause of death.

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TABLE 141.-Total reported incidence of maxillofacial conditions in 1,450 battle casualty deaths

¹Probably somewhat lower than the actual incidence.

TABLE 142.- Total reported incidence of cervical conditions in 1,450 battle casualty deaths

¹Probably somewhat lower than the actual incidence.
²Immediate cause of death, listed as shock.

TABLE 143.-Total reported incidence of intravertebral conditions in 1,450 battle casualty deaths

¹Probably somewhat lower than the actual incidence.
²Includes cases from those in whom the immediate cause of death was intravertebral trauma.

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TABLE 144.- Total reported incidence of extremity conditions in 1,450 battle casualty deaths

¹Probably somewhat lower than the actual incidence.
²Also included in clostridial infections (table 147).

TABLE 145.- Total reported incidence of thoracic conditions in 1,450 battle casualty deaths

¹Probably somewhat lower than the actual incidence.
²Also included with coronary occlusions and raises the total conditions to 160 rather than the 158 as listed in table 136.
³Also included with embolism, thrombosis, and infarction (table 148).
⁴Does not include the three cases of coronary occlusion.

TABLE 146.-Total reported incidence of abdominal conditions in 1,450 battle casualty deaths

¹Probably somewhat lower than the actual incidence.
²Also reported with clostridial myositis (table 147).
³Recorded only for patients who had intraperitoneal surgery.

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TABLE 147.-Total reported incidence of clostridial myositis or cerebritis in 1,450 battle casualty deaths

¹Probably somewhat lower than the actual incidence.

TABLE 148.-Total reported incidence of embolism, infarction, and thrombosis in 1,450 battle casualty deaths

¹Probably somewhat lower than the actual incidence.

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TABLE 149.-Total reported incidence of miscellaneous conditions in 1,450 battle casualty deaths

¹Probably somewhat lower than the actual incidence.

Detailed Observations⁴

In this section, the cases in each of the principal wound groups are considered separately, and in each of the subdivisions a tabulation lists the immediate cause of death for the cases in that particular group.

1. The immediate cause of death in the 297 cases in which the principal wound was intracranial is as follows:

⁴Additional detailed information on surgery, anesthesia, replacement therapy, chemotherapy, oxygen therapy, and other miscellaneous data are presented in appendix F, p. 813.

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2. The immediate cause of death in the 27 cases in which the principal wound was intravertebral is as follows:

3. The immediate cause of death in the eight cases in which the principal wound was maxillofacial is as follows:

4. The immediate cause of death in the 25 cases in which the principal wound was cervical is as follows:

¹Includes 5 cases of cardiorespiratory embarrassment plus trauma and hemorrhage and 6 cases of trauma and hemorrhage.

5. The immediate cause of death in the 138 cases in which the principal wound was intrathoracic is as follows:

¹Includes 66 cases of cardiorespiratory embarrassment plus trauma and hemorrhage, 2 cases of contamination or sepsis plus trauma and hemorrhage, and 2 cases of trauma and hemorrhage.

6. The immediate cause of death in the 212 cases in which the principal wound was thoracoabdominal is as follows:

501

7. The immediate cause of death in the 59 cases in which the principal wound was combined intra-abdominal and intrathoracic is as follows:

8.  The immediate cause of death in the 408 cases in which the principal wound was intra-abdominal is as follows:

502

9. The immediate cause of death in the three cases in which the principal wound was of the abdominal wall is as follows:

10. The immediate cause of death in the four cases in which the principal wound was upper extremity, soft tissue only, is as follows:

11. The immediate cause of death in the 10 cases in which the principal wound was upper extremity, bone and soft tissue, is as follows:

12. The immediate cause of death in the 31 cases in which the principal wound was lower extremity, soft tissue only, is as follows:

13. The immediate cause of death in the 114 cases in which the principal wound was unclassified multiple is as follows: