CHAPTER V
Distribution of Injuries and OtherStatistical Data
Luther H. Wolff,M. D., Samuel B. Childs, M. D., and W. PhilipGiddings, M. D.
DISTRIBUTION OF INJURIES
The statistical material used in this study is heavilyweighted by a preponderance of first-priority casualties. About 90 percent ofthe 3,154 casualties were operated on in field hospital platoons (table 5), andmost of the remainder (7.4 percent) were operated on in evacuation hospitals.The case fatality rate for each type of installation clearly reflects theseverity of the injuries treated in it.
TABLE 5.-Distribution of injuries anddeaths in 3,154 abdominal injuries, by hospital installation
Type of installation | Number of cases | Percent of total | Deaths | Case fatality rate |
Field hospital | 2,851 | 90.4 | 693 | 24.3 |
Evacuation hospital | 232 | 7.4 | 35 | 15.1 |
Casualty clearing station (British) | 58 | 1.8 | 26 | 44.8 |
Clearing station | 10 | .3 | 1 | 10.0 |
Not stated | 3 | .1 | 1 | 33.3 |
| 3,154 | 100.0 | 756 | 24.0 |
As might be expected, the actual numbers of abdominal woundsobserved in the various campaigns varied directly with the fury of the fighting,each offensive and each lull being mirrored in the number of casualties treated(fig. 15). The exact relationship of abdominal to other injuries is not known,but it is reasonable to assume that the curve for them closely paralleled thecurve for all casualties.
Since the infantry, as always, bore the brunt of thefighting, it naturally received the majority of injuries, 69.6percent (fig. 16). Whenonly American troops are considered, this proportion rises to 82 percent.
Involvement of viscera-Almost three-quarters of theseinjuries involved only abdominal viscera (table 6). The remaining 839wounds were thoracoabdominal.
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TABLE 6.-Regional distribution of wounds and deaths in 3,154abdominal injuries
Type of wound | Year | Cases | Deaths | Case fatality rate |
Abdominal | 1944 | 1,744 | 406 | 23.3 |
Thoracoabdominal | 1944 | 639 | 180 | 28.2 |
Abdominal | 1945 | 571 | 130 | 22.8 |
Thoracoabdominal | 1945 | 200 | 40 | 20.0 |
Total abdominal wounds | 1944-45 | 2,315 | 536 | 23.2 |
Total thoracoabdominal wounds | 1944-45 | 839 | 220 | 26.2 |
| --- | 3,154 | 756 | 24.0 |
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Analysis of these 3,154 abdominal injuries from the standpoint of theparticular viscera involved (tables 7 and 8) suggests that the frequency ofwounding of an abdominal organ was almost directly proportional to its size. Thefrequency of univisceral wounds of any given organ was apparently proportionalto the extent of its area of contact with the abdominal wall. In other words, inmodern warfare the frequency of wounding of any given abdominal organ seemsdirectly proportional to the space which it occupies. The soundness of thisconclusion is evident from a consideration of the agents of wounding in thisseries (p. 97). About 70 percent of the wounds were produced by fragmentationmissiles. The remaining injuries, while they were caused by bullets, werechiefly produced by roughly aimed automatic weapons. A sniper's bullet, nomatter how accurate the sighting might be, was not fired with selectiveintention toward any single abdominal organ. The fact that patients with certaintypes of injuries were not seen alive is the explanation of variations from therule that the frequency of wounding of any given abdominal organ was directlyproportional to the space which it occupies. A striking example
TABLE 7.-Distribution of univisceraland multivisceral wounds in 3,154 abdominal injuries 1
Organ injured | Univisceral | Multivisceral | Total | |||
Number | Each organ | Number | Each organ | Number2 | All patients | |
|
|
|
| Percent |
| Percent |
Stomach | 42 | 10.1 | 374 | 89.9 | 416 | 13.19 |
Duodenum | 2 | 1.7 | 116 | 98.3 | 118 | 3.74 |
Jejuno-ileum | 353 | 30.2 | 815 | 69.8 | 1,168 | 37.03 |
Colon only | 251 | 23.6 | 816 | 76.4 | 1,067 | 33.83 |
Rectum only | 64 | 55.2 | 52 | 44.8 | 116 | 3.68 |
Colon and rectum | 13 | 33.4 | 26 | 66.6 | 39 | 1.24 |
Liver3 | 339 | 40.9 | 490 | 59.1 | 829 | 26.28 |
Gallbladder and bile ducts | 0 | 0 | 53 | 100.0 | 53 | 1.68 |
Pancreas | 1 | 1.6 | 61 | 98.4 | 62 | 1.97 |
Spleen | 100 | 29.3 | 241 | 70.7 | 341 | 10.81 |
Kidney | 56 | 13.1 | 371 | 86.9 | 427 | 13.54 |
Ureter | 1 | 3.7 | 26 | 96.3 | 27 | .86 |
Urinary bladder | 21 | 13.5 | 134 | 86.5 | 155 | 4.91 |
Great vessels | 8 | 10.7 | 67 | 89.3 | 75 | 2.38 |
1The term "univisceral"refers to an abdominal wound in which a single viscus has been injured. Itcarries no implication concerning the number of injuries any single organ hassustained. The term "multivisceral" refers to a wound in which morethan 1 viscus has been injured, again without any implications concerning thenumber of injuries each single organ has sustained.
2The figuresin this column considerably exceed the total number of cases because inmultivisceral wounds the same patient appears in more than one category. For thesame reason, the percentage distribution of wounds in the various visceraexceeds 100 percent.
3Calculationsfor injuries of the liver are made throughout part II of this volume on a totalof 3,066 abdominal injuries, instead of on 3,154, the base figure for all othercalculations. When the 88 histories which represent the difference between thetwo totals became available, the medical officers who had done the work onwounds of the liver had already been transferred from the command, and it wasthought wiser not to change their tabulations.
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of such a variation is the comparative incidence of wounds ofthe vena cava and of the abdominal aorta (pp. 318, 322). Thirty-three of theformer were observed, but none of the latter, presumably because wounds of theabdominal aorta were almost immediately fatal.
When the distribution of abdominal visceral injuries in thisseries is compared with the distribution in other reported series (table 8), twoimportant differences are at once apparent:
1. In general, the frequency of wounding of all organs was higher in thisseries than in most other series.
2. The rate of univisceral to multivisceral wounds wasstrikingly reversed in comparison with earlier experiences. The assumption seemswarranted that in this series a much higher proportion of severely wounded men(that is, men with multiple visceral wounds) reached forward hospitals, and wereoperated on, than was the case in other reported series. No other explanationseems reasonable for the overall increase in frequency of wounding of allorgans, or, more particularly, for the marked change in themultivisceral-univisceral ratio. The higher incidence of involvement of thevarious viscera in this series also makes it reasonable to assume that while thefigures probably are still too low, they more closely approximate the truefrequency of wounding of each organ than do those previously reported.
That so many more of the seriously wounded casualties were seen at forwardhospitals in World War II than in previous wars is difficult to explain, excepton the basis of the efficient performance of medical echelons working forward ofthese hospitals and responsible for the evacuation of the wounded from thefrontlines.1
CASE FATALITY RATES
In 1944, surgeons of the 2d Auxiliary Surgical Group treated 2,383 abdominalinjuries in forward hospitals supporting the Fifth and Seventh United StatesArmies, with 586 recorded deaths (24.6 percent). In 1945, they treated 771similar injuries, with 170 recorded deaths, 22.0 percent. The case fatality ratefor the whole series of 3,154 injuries was thus 24.0 percent (table 6).
Twothings must be emphasized in this connection:
1. These 756 deaths, as already pointed out, include onlythose known to have occurred in the forward hospitals in which initial surgerywas performed. The postoperative stay in these hospitals seldom exceeded 14 daysand was frequently briefer. Additional deaths undoubtedly occurred ininstallations farther to the rear, though since no followup of the patients waspossible, the exact number is not known. Informal inquiries indicated thatfatalities in these hospitals did not exceed 1 percent.
1NOTE.-Col. (later Maj. Gen.) Joseph I. Martin, MC, surgeon,Fifth U. S. Army, for many years had taught the principles of medical evacuationin forward areas of combat at the Medical Field Service School, CarlisleBarracks, Pa. During combat in Italy, where many of these casualties occurred,he not only placed hospitals as far forward as tactically feasible but alsodemanded and obtained early and efficient medical evacuation under mostdifficult combat conditions.-J. B. C., Jr.
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2. It is highly probable thatmore than 756 deathsoccurred in forward installations. The records of 256 patientscontained no note at all concerning their postoperative progress, and in 81 other cases progress notes ceasedafter the third postoperative day. These data were lacking chiefly because offorced movement of surgical teams or early evacuation of patients underdifficult tactical circumstances. In the completely recorded cases, the casefatality rate after the third day was 4.6 percent.If it is assumed that the rates in the 337 incompletelyrecorded cases just mentioned were the same as in the completely reported cases,there would have been 65 additionaldeaths. The total number of fatalities would thus be raised to 821 and the gross case fatality rateto 26.0 percent.
The case fatality rates require explanation from still another standpoint.Included in the series are 333 cases, 10.6 percentof the total, in which no visceral injury was found. In 41 of these cases, the indicationfor exploration was penetration of the peritoneal cavity by the missile. In theother 292 cases,the indication was suspected penetration of the cavity. In 59 of these explorations, aretroperitoneal hematoma was found. In the remaining cases, the exploration wasentirely negative.
There were 24 deaths, 7.2 percent,in these 333 negativeexplorations, 2 ofthem in the category of penetration of the peritoneal cavity without visceralinjury. These deaths were, for the most part, the result of associated wounds(p. 117). Whenthe 333 casesin which there was no visceral injury are deducted from the total number ofcases, there remain 2,821 cases, 732 ofwhich (25.9 percent)were fatal.
In assessing the relative distribution and lethality ofwounds of solid and hollow viscera, the analysis, for obvious reasons, must belimited to univisceral injuries. In 496 univisceralinjuries of solid viscera, there were 55 deaths(11.1 percent). In 734 similarinjuries of hollow viscera, there were 128 deaths (17.4 percent),the case fatality rate thus being 56.7 percenthigher than for injuries of solid viscera.
