Part II
ABDOMINAL INJURIES AND THE INITIAL SURGERYOF ABDOMINAL WOUNDS
W. Philip Giddings, M. D., Editor
CHAPTER IV
Derivation of Data, Source Material, andMethods of Analysis
W. Philip Giddings, M. D.
The data presented in the following pages, which concern onlyforward surgery of abdominal injuries, are derived from the report to TheSurgeon General, United States Army, dated 27 August 1945, which describes theactivities of the 2d Auxiliary Surgical Group in the Mediterranean (NorthAfrican) Theater of Operations and in the European Theater of Operations duringWorld War II.1 Innumerous instances, these data are characterized by the omissions anddiscrepancies inevitably associated with the collection of medical data undercombat conditions. It is therefore important that the manner in which they werecollected and compiled should be clearly understood.
THE 2D AUXILIARY SURGICAL GROUP
The 2d Auxiliary Surgical Group functioned under Table ofOrganization 8-571, which authorized 121 medical officers, 11 dental officers,70 members of the Army Nurse Corps, and 176 enlisted men. The enlisted men were,for the most part, surgical technicians who had been graduated from trainingschools operated by the Army Medical Department. The personnel of the group wasbroken down into surgical teams, 28 of which were assigned to general surgeryand the remainder to the various surgical specialties. As a rule, each teamconsisted of 6 members; namely, a surgeon, an assistant surgeon, an anesthetist,an operating-room nurse, and 2 enlisted technicians.
Except for a small permanent headquarters, the groupmaintained no formal installation of its own. Instead, the surgical teamsfunctioned on detached service with various other organizations. After theSicilian campaign, in 1943, the 2d was the onlyauxiliary surgical group assigned in the North African Theater of Operations.During 1944 and 1945, its surgical teams were employed by the Theater ChiefSurgeon chiefly to furnish surgical care in field hospitals and to augment thestaffs of evacuation hospitals as special needs arose. Individualteams were sometimes attached to British mobile casualty clearing stations,installations which in setup and function resembled United States Army fieldhospitals.
Teams from the 2d Auxiliary Surgical Group also participatedin all major amphibious operations of the Mediterranean campaigns, including theinitial landings at Anzio-Nettuno and in southern France. On these missions,they
1 Forward Surgery of the Severely Wounded. A History of the 2d Auxiliary Surgical Group, 1942-45, vols. I and II.
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functioned with field and evacuation hospitals, division clearing companies,and, during early phases of the operations, with special troops (Rangers). InAugust 1944, about half of the personnel of the group was attached to theSeventh United States Army for the invasion of southern France. These teamsremained with the Seventh Army until the end of the war, passing with it acrossFrance and Germany and into Austria. On this mission, they were divorced fromthe remainder of the group for almost a year.
Most of the work reported in the following chapters was done in the platoonsof the field hospitals customarily situated in close proximity to divisionclearing stations during periods of combat. These hospitals, which were small,mobile surgical units, were placed well forward, and their staffs were augmentedwith competent surgical teams on detached service from the auxiliary surgicalgroup. Nontransportable casualties, after being selected by triage in the nearbyclearing stations, were sent directly to these hospitals for resuscitation andurgent surgery. All patients with abdominal injuries were classified as nontransportable.
Some installation such as the field hospital was essential for the prompttreatment of abdominal wounds. It was also essential for psychologic andhumanitarian reasons. The morale of combat troops was strikingly improved by theknowledge that if they were wounded, all facilities for their care were ready athand and that, as far as possible, their priority for treatment would beproportionate to the severity of their injuries. The morale-raising effect ofthis knowledge was repeatedly commented upon both by combat officers and byenlisted men, even those who had not become casualties.
Field hospital platoons, because of their geographic position within thedivision area, were often uncomfortably close to legitimate military targets.They almost always worked forward of Allied heavy artillery and always workedwithin range of enemy artillery. At the Anzio beachhead, they were many timessubject to shellfire and to aerial-bombing attacks. Frequent changes of locationwere necessary for tactical reasons, and, on occasion, undesirably earlyevacuation of patients was necessary to protect them from enemy action. Thesefacts go far to explain deficiencies and discrepancies in the data to bepresented.
SOURCE MATERIAL
The source material of this report is 3,154 patients with abdominal injuriestreated by the surgeons of the 2d Auxiliary Surgical Group in forward surgicalinstallations during 1944 and until the conclusion of the fighting in Italy andelsewhere on the European Continent in May 1945.2This material does not include (1) casualties operated on by surgeons ontemporary duty with the group nor (2) 371 casualties with abdominal injuriestreated in 1943, during the Tunisian and Sicilian campaigns and during the first4 months of the fighting
2Unless specifically noted to the contrary, the terms "patient," "casualty," "case," "wound," and "injury" refer to single cases or patients. Multiple injuries were numerous in this series of cases, but the analysis is always made on the basis of single cases or patients unless otherwise specified.
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in Italy. These cases are the subject of previous reports3and are mentioned in these chapters only occasionally, for comparative purposes.
All 3,154 abdominal injuries were the result of the violence of warfare,3,052 being caused by combat missiles. Approximately 90 percent of thecasualties sustained their injuries in actual combat. Wounded civilians,soldiers of other Allied armies, and prisoners of war made up about 15 percentof the series.
The series includes, in addition to injuries of intraperitioneal organs andof extraperitoneal abdominal viscera, 839 thoracoabdominal wounds, 26 injuriesof intraperitoneal viscera in which the abdominal wall was not penetrated (pp.329, 331), and 333 injuries in which exploration of the peritoneal cavityrevealed no intraperitoneal injury (p. 95).
METHODS OF ANALYSIS
This analysis was planned late in 1943, and the compilationof data was begun 1 January 1944. Mimeographed forms (fig. 14), prepared withspecial attention to brevity and completeness and entirely separate fromstandard army forms (field medical record), were supplied to the varioussurgical teams, with instructions to keep a separate clinical record for eachpatient treated. The accumulated completed case histories were sent periodicallyto the 2d Auxiliary Surgical Group Headquarters, where they were indexed andfiled.
Compilation of data for the final report was begun inDecember 1944, but for obvious reasons not a great deal could be done untilafter the German surrender, in May of the following year. Intensive work wasstarted in June 1945, when most of the teams were recalled from the field, theteams detached to the Seventh United States Army returned, and the entire groupwas reunited at Riva, Italy. For the next few months, all personnel who could bespared from other duties cooperated in the preparation of the report to TheSurgeon General,4 of which the section onabdominal injuries represents about a third. The entire report required thereview of, and tabulation of data from, approximately 22,000 case histories.
The various sections of the report were prepared byindividual medical officers, who worked under the direction of an editorialboard composed of six officers. Nurses and enlisted personnel assisted inclerical capacities, and the final report prepared overseas represented thecombined efforts of at least 200 persons. The last work on it was done duringthe period of redeployment, when clerks and typists, as well as medicalpersonnel, were constantly being transferred out of the unit. Upon thetermination of the operational activities of the 2d Auxiliary Surgical Group inthe summer of 1945, a small number of officers and enlisted men, who hadformally expressed the desire to remain in Riva until the report was finished,completed the work in August 1945.
3Report on the Surgery of Abdominal Wounds (unpublished data), submitted to the commanding officer, 2d Auxiliary Surgical Group, 14 April 1944.
4See footnote 1, p. 81.
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In its present form, the material on abdominal injuries represents a completerevision made in the United States. The original worksheets were reviewed, allthe data were subjected to recount and careful review, and revised data werethus secured for a number of sections, including those on timelag and themultiplicity factor. The entire manuscript was then rewritten, many sections
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several times, to incorporate these revisions and to give theauthors the opportunity to introduce whatever second thoughts had occurred tothem in a more normal environment than that in which the original manuscriptswere prepared.
LIMITATIONS OF THE ANALYSIS
The source material used in this report was naturally affected in respect toboth completeness and accuracy by certain uncontrollable military circumstances.In an occasional case, the special record form had not been filled out and hadto be discarded. Some records were lost or destroyed, as the result of enemyaction or for other reasons. Information secured from the patient himself, oreven from his emergency medical tag, was sometimes open to question. There wasoften doubt as to the precise hour of wounding; whether the sulfonamide pills inthe medical kit had been taken as soon as the wound was sustained, if at all;how much morphine had been given, and when it was given; and how much plasma hadbeen given prior to the patient's admission to the field hospital. These andother details were sometimes recorded incompletely on the battlefield and intransit, or, occasionally, were not recorded at all, and the patients themselvescould recall them only hazily. In the field hospitals, forced evacuation ofcasualties and the frequent shifting of surgical teams militated against themaintenance of complete case histories. Finally, during times of stress, whenthe load of casualties was heavy and continuous, recorded data had to be limitedto little more than brief statements concerning the nature of the wounds and thesurgical procedures.
Most patients with abdominal wounds stayed in forwardhospitals only briefly. Although the range of forward hospitalization perpatient in days was from 1 to 30, theusual period of hospitalization was from 8to 14 days. This fact, combined with the unavoidabledeficiencies of records kept under field conditions, explains the statisticalinadequacy of the section on postoperative complications (p. 203). Progress notes were, understandably,often sacrificed tothe press of other duties or to the imperative need of overworked surgeons forsome rest.
One point which should be emphasized at this time and which will be discussedagain later (p. 94) isthat the 756 deathsknown to have occurred in these 3,154 abdominal injuries are only the fatalities recorded in theforward hospitals in which the initial surgery in these cases was performed. Theother (presumed) fatalities were lost to the records for a variety of reasons. Somepatients were evacuated as a consequence of enemy action. When, for example, afield hospital was shelled out of action on the Anzio beachhead, some patientswho had only recently been operated on were moved to other hospitals, and, inspite of efforts to trace them, their ultimate fate was not discovered. Some ofthem very probably died. In other instances, the followup records were
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incomplete, usually because the surgical teams were moved and the patientswere left in other hands early in their postoperative course. Some of thesepatients unquestionably died. Finally, what happened to most of the patientsafter they left the field hospitals in which they were operated on also is notknown by the writers of this report, though there is no doubt that the greatmajority of all fatalities from abdominal wounds occurred in these forwardhospitals.
In addition to the errors and discrepancies inherent in the collection ofmedical data under combat conditions, one other possible source of statisticalerror must be mentioned, namely, the intrinsic human error which invariably andinevitably enters when a large number of different persons interpret the samedata. This error was enhanced by the fact that because of the specialcircumstances in which this report was compiled, a consistent editorial policycould not be developed in advance of the analysis of the data. The policy, infact, evolved with the project. Since all questions which might involveconflicts of views between individual authors could not be foreseen, dataderived by different authors from the same source material were not alwayspresented in the same manner. There was, for instance, no predetermined policyabout whether or not to classify nonperforating trauma to the walls of hollowviscera under visceral injuries. Some authors therefore included it in theseinjuries, while others excluded it. In the section on injuries to the jejuno-ileum,this type of injury is included as a visceral wound. In the chapter on wounds ofthe colon, it is not thus included. In certain other chapters, it is not alwaysclear which of these policies has been followed. Again, the authors of thesection on wounds of the colon, when they encountered the case history of asingle perforation of the colon and a severe contusion of the ileum, listed thecase as an instance of a univisceral wound of the colon. The authors of thesection on wounds of the jejuno-ileum classified the same case as amultivisceral wound of the ileum complicated by a wound of the colon (p. 241).Variations in critical standards thus led to certain numerical discrepancieswhich could not be reconciled after the original work had been completed and thegroup had separated.
The statistical material in this report cannot now be supplemented oraltered, and such errors as it contains must stand. Nevertheless, when thereport was completed, it was the unanimous opinion of the surgeons of the 2dAuxiliary Surgical Group that the presentation was substantially correct. Forone thing, the series is of such magnitude that, in the main, positive andnegative errors probably have canceled each other out. For another, theconclusions to which the data point represent the consensus of the surgeons ofthe group, partly as determined by informal polls and partly as derived from theuniformity of practice reflected in the case records. Finally, there was generalagreement that the trends reflected by the statistical data are entirelyconsistent with wartime clinical experiences.
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THE CONCEPT OF ABDOMINAL SURGERY IN WORLD WAR II
The concept of management of abdominal wounds underwent aradical reversal in the years before World War II.5 Between the BoerWar (the South African War of 1899-1902) and the outbreak of World War I in1914, the policy was one of strict nonintervention. The wisdomof this policy began to be questioned by many surgeons as World War Iprogressed, and by the end of hostilities there was rather general agreementthat most abdominal injuries should be treated surgically, though lack oforganization had prevented as wide an implementation of this principle as wasdesired. During the Spanish Civil War (1936-39), when competent surgeons were available and facilities andorganization were adequate, prompt intervention was the rule,6and the number ofcases in which the wounds were regarded as too severe to permit surgery wererelatively few.
The fundamental objective in the management of abdominalinjuries in World War II was as prompt surgical intervention as possible in allcasualties to whom the mere act of operation would not be fatal. Surgery wasalmost never withheld on the grounds of the severity of the wounds; the precisefigures are not available, but it is certain that considerably less than 1percent of the casualties with abdominal injuries who came under the care ofsurgeons of the 2d Auxiliary Surgical Group were regarded as too severelywounded to withstand operation. No matter what the man's condition might be whenhe was first seen, vigorous resuscitative measures were at once instituted, inthe expectation that surgery would be done. A small proportion of thesecasualties failed to respond and died during the attempt at resuscitation, butthey were the exceptions. In all other cases, the goal of giving every man withan abdominal wound the benefit of surgery could be met.
DEFINITION OF TERMS
In the past, the terms "uncomplicated" and"complicated" have frequently given rise to misunderstanding andconfusion when they were applied to wounds. In this analysis, they have beenreplaced by the terms "univisceral" and "multivisceral,"which are used in the following special senses:
1. The term "univisceral" refers to an abdominal wound in which asingle viscus has been injured. It carries no implications concerning the numberof injuries any single organ has sustained. Simultaneous perforations of thececum and sigmoid colon, for instance, are classified as a univisceral wound ofthe colon.
2. The term "multivisceral" refers to a wound in which more thanone viscus has been injured, again without any implications concerning thenumber
5Bailey,Hamilton: Surgery of Modern Warfare. Baltimore: the Williams and Wilkins Co.,1944, vol. II, pp. 867-869.
6Jolly, Douglas W.: FieldSurgery in Total War. New York: Paul B. Hoeber, Inc., 1941, p. 166.
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of injuries each single organ has sustained. Coincidental injury to the colonand the ileum, for instance, is regarded as a multivisceral wound of either thecolon or the ileum.
3. The term "associated wound" refers to a wound of a part of thebody other than the abdomen.
