CHAPTER X
Traumatic Evisceration (312 Casualties)
Samuel B. Childs, M. D.
In the 3,154 instances of abdominal injury observed by the 2dAuxiliary Surgical Group during 1944 and 1945, there were 312 traumaticeviscerations (table 19), 126 of which (40.4 percent) were fatal. Evisceration,for the purposes of this discussion, is defined as the protrusion of anabdominal viscus outside of the peritoneal cavity through a missile track whichhas interrupted the continuity of all layers of the abdominal wall.
Organs injured | Cases |
| Deaths | Case fatality rate |
|
|
|
|
|
Omentum only | 86 | 27.57 | 32 | 37.2 |
Stomach | 9 | 2.88 | 3 | 33.3 |
Stomach, small bowel, and colon | 5 | 1.60 | 2 | 40.0 |
Stomach and colon | 2 | .64 | 2 | 100.0 |
Stomach and spleen | 1 | .32 | 0 | 0 |
Small bowel | 123 | 39.43 | 43 | 34.9 |
Small bowel and colon | 24 | 7.69 | 14 | 58.3 |
Small bowel and liver | 1 | .32 | 0 | 0 |
Colon | 38 | 12.19 | 21 | 55.3 |
Colon and liver | 3 | .96 | 3 | 100.0 |
Colon and spleen | 1 | .32 | 0 | 0 |
Liver | 7 | 2.24 | 3 | 42.8 |
Spleen | 3 | .96 | 0 | 0 |
Not recorded | 9 | 2.88 | 3 | 33.3 |
| 312 | 100.00 | 126 | 40.4 |
In this series, the frequency of evisceration of a particularorgan apparently varied in relation to (1) its own mobility and volume and (2)the site and size of the missile track. The omentum alone, the small bowelalone, the colon alone, and the small bowel and colon in combination wereinvolved in 86.9 percent of the total number of eviscerations. In 5 injuries (4involving the small bowel and 1 the small bowel and colon), the protrudingabdominal viscus had not been injured. The organ extruded was not recorded in 9cases.
Exclusive of 25 cases in which the site of extrusion was not recorded and of86 in which only the omentum was involved, the evisceration occurred in theupper abdomen 75 times, in the lower abdomen 68 times, in the left flank 28times, the right flank 13 times, the left chest 10 times, the right chest 3times, the right side of the back twice, and the left sacral region and the leftbuttock
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in 1 case each. If the wound of entry in perforating wounds was sufficientlylarge, evisceration sometimes occurred through it. More often it occurredthrough the wound of exit. Sometimes a wide-open track was found between thewounds of entry and exit.
The wounding agent, which was recorded in 299 cases, was ashell fragment in 171 cases, a small-arms bullet in 97, and a mortar, bomb,grenade, or mine fragment in the remaining 31 cases.
CASE FATALITY RATE IN RELATION TO SHOCK AND PERITONITIS
In 86 cases, 32 of which (37.2 percent) were fatal, only theomentum protruded from the abdomen. The 24 deaths which occurred in this groupby the end of the second postoperative day were all attributed to shock. Twodeaths in this group (6.3 percent of the total number) which occurred on theninth postoperative day were attributed to peritonitis; perforations of thestomach and the colon were also present in both. Four patients in this groupdied of other causes, and in two instances (also 6.3 percent of the totalnumber) the cause of death was not recorded. The proportion of the 32 deathsattributed to peritonitis (6.3 percent), corrected for the 2 no-record cases to6.7 percent, did not exceed the case fatality rate for peritonitis (12.3percent) in the whole group of 3,154 cases (p. 208). The data suggest thatevisceration of the omentum alone introduced no additional factor ofcontamination and was significant only in relation to the severity of theabdominal wound.
In the 226 cases in which an abdominal organ other than theomentum was extruded, there were 94 deaths (41.6 percent). All but 2 of the 61deaths which occurred by the end of the second postoperative day were caused byshock (table 20). The 10 deaths caused by peritonitis accounted for 10.6 percentof the 94 fatalities, corrected for no-record cases to 11.6 percent. This rateapproximated the case fatality rate for peritonitis (12.3 percent) in the wholegroup of 3,154 cases.
The single fatality in the 5 cases in which there was noinjury to the extruded viscus (in all instances intestine) occurred on thefourth postoperative day and was caused by a massive pulmonary embolism. Whetherevisceration occurred in this group of casualties at the time of wounding orsubsequently was not known. It seems significant, however, that, whatever theduration might be, none of these 5 patients exhibited signs of clinical shockeither when they arrived at the field hospital or during their laterpostoperative course.
CASE FATALITY RATE IN RELATION TO MULTIPLICITY FACTOR ANDTIMELAG
An analysis of the 298 cases in which sufficient data were available for thispurpose (1) indicated that the multiplicity factor played the same significantrole in the case fatality rate for traumatic eviscerations as for other groupsof injuries (table 21), and (2) further supported the concept that this
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TABLE 20.-Primary cause of death and timeof death in 94 traumatic eviscerations1
Cause | Deaths |
|
| |||||||||
2d | 3d | 4th | 5th | 6th | 7th | 8th | 9th | After |
| |||
|
| Percent |
|
|
|
|
|
|
|
|
|
|
Shock | 59 | 62.8 | 59 | --- | --- | --- | --- | --- | --- | --- | --- | --- |
Peritonitis | 10 | 10.6 | --- | 2 | --- | 1 | 1 | 1 | 2 | 1 | 2 | --- |
Anuria | 5 | 5.3 | --- | --- | 3 | 1 | --- | --- | 1 | --- | --- | --- |
Pulmonary embolism | 4 | 4.2 | --- | --- | 1 | 1 | 1 | --- | 1 | --- | --- | --- |
Pneumonitis | 3 | 4.2 | --- | 1 | --- | 2 | --- | --- | --- | --- | --- | --- |
Empyema | 1 | 4.2 | --- | 1 | --- | 2 | --- | 1 | --- | --- | --- | --- |
Thrombosis, inferior mesenteric vein | 1 | 1.1 | 1 | --- | --- | --- | --- | --- | --- | --- | --- | --- |
Brain injury | 1 | 1.1 | 1 | --- | --- | --- | --- | --- | --- | --- | --- | --- |
Intestinal obstruction | 1 | 1.1 | --- | --- | --- | --- | 1 | --- | --- | --- | --- | --- |
Jaundice, edema | 1 | 1.1 | --- | --- | --- | --- | --- | --- | 1 | --- | --- | --- |
Not recorded | 8 | 8.5 | --- | 2 | 1 | 2 | --- | --- | --- | --- | 2 | 1 |
| 94 | 100.0 | 61 | 5 | 5 | 7 | 3 | 2 | 5 | 1 | 4 | 1 |
1The 32 fatal cases in which only the omentum wasextruded are excluded from this table.
factor is a satisfactory index of the severity of battle-incurred abdominalinjuries.
The influence of the timelag is by no means as clear cut as is the influenceof the multiplicity factor (table 22). Variations in the case fatality ratesuggest that other factors played a part. Two are immediately apparent:
1. A large proportion of severely wounded men seen after a short timelag hadwounds whose lethality was not altered by surgery.
2. Men who were more lightly wounded (relatively orabsolutely) died after a longer timelag and in smaller numbers. Probably not allof the casualties with traumatic eviscerations would have died within a 10-dayperiod if they had not been operated on, and certainly surgery could not alterthe essentially lethal nature of the wounds sustained by many of the severelyinjured casualties.
Organs injured | Without evisceration |
| ||||
Cases | Deaths | Case fatality rate |
| Deaths | Case fatality rate | |
None | 287 | 21 | 7.3 | 5 | 1 | 20.0 |
One | 1,253 | 177 | 14.1 | 95 | 24 | 25.2 |
Two | 913 | 247 | 27.1 | 101 | 38 | 37.7 |
Three | 279 | 119 | 42.7 | 71 | 43 | 60.5 |
Four | 81 | 48 | 59.3 | 15 | 11 | 73.3 |
Five | 16 | 16 | 100.0 | 7 | 5 | 71.4 |
Six | 2 | 2 | 100.0 | 4 | 4 | 100.0 |
| 2,831 | 630 | 22.3 | 298 | 126 | 42.3 |
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TABLE 22.-Influenceof timelag on case fatality rates in 203 traumatic eviscerations
| Cases | Deaths | Case fatality rate |
0 to 6 hours | 77 | 29 | 37.7 |
6 to 12 hours | 94 | 42 | 44.7 |
12 to 18 hours | 16 | 5 | 31.3 |
18 to 24 hours | 6 | 2 | 33.3 |
Over 24 hours | 10 | 4 | 40.0 |
| 203 | 82 | 40.4 |
In 41 of the 123 instances in which evisceration of the smallbowel occurred, only the bowel was extruded, and there were no complicatingmultivisceral injuries. The bowel itself was injured in all 41 cases, but theabsence of the compounding effect of injuries to other structures makes itpossible to consider in this group the effects of evisceration per se on thecase fatality rate for abdominal injury.
There were 8 deaths, 19.5 percent, among these 41 patients.Four died within the first two postoperative days, in shock, with peritonealcontamination by small-bowel contents perhaps playing some part in the fatality.Two died of peritonitis, on the 8th and 22d days, respectively, after operation.Another died of pneumonia on the 5th day, and the remaining patient died on thesame day, of an unstated cause. The timelag in all of these cases was short, theaverage being 52/3 hours, which shows that itwas not necessary to keep the patients in the shock ward for a long time beforeoperation. It also implies priority of evacuation and surgery. In spite of thesefavorable factors, the case fatality rate in these 41 cases (19.5 percent) washigher than the rate of 13.1 percent for the 314 univisceral injuries of thesmall bowel in which evisceration did not occur.
This discrepancy suggests that traumatic evisceration is, in itself, aserious type of injury. This is well demonstrated by comparison of the casefatality rates in casualties who did and who did not sustain it. In the firstfive multiplicity categories (0 to 4 organs wounded), the average increase inrates from category to category when evisceration had occurred was approximately13 percent (table 21). The trend was reversed when five organs were injured, butthe figures are not large enough to be of statistical significance. Apparentlyevisceration affected the prognosis adversely to approximately the same degreeas did the involvement of each additional organ in the multiplicity factor scale(table 21).
The occurrence of traumatic evisceration was also, ingeneral, an indication of the severity of the wound. It was observed in only 1.7percent of patients having no visceral injury but in 4 out of 6 with 6 visceradamaged (table 21).
