Foreword
This volume on general surgery is set apart from other volumes of the historyof the Medical Department of the United States Army in World War II by a numberof special considerations.
This is a story not only of surgery performed in forward Army medical units,but of extremely urgent surgery; all abdominal injuries constituted emergencies,and all casualties with abdominal injuries were nontransportable. This volume isalso the record of the performance of an auxiliary surgical group, and as suchis typical of the outstanding work done in all theaters of operations by themedical officers assigned to similar units, as well as by medical officersorganically assigned to frontline hospitals in which surgical teams fromauxiliary surgical groups were employed.
The 3,154 abdominal injuries upon which this story is chiefly based were allthe result of the violence of war, and all but about a hundred were combatincurred. This is perhaps not the largest series of combat injuries of theabdomen ever to be recorded, but it is undoubtedly the largest series to beanalyzed in such detail. This series, furthermore, has the great advantage,which most recorded series do not possess, that the analysis of cases wasplanned in advance. There are some statistical inadequacies, it is true. Theywere inevitable in the circumstances in which the data were collected. Theseinadequacies, however, in no way alter the clinical conclusions which werearrived at by the experienced surgeons who made the analysis and which,incidentally, were merely the confirmation of the clinical impressions which hadalready become evident. The data were analyzed overseas, immediately after theywere collected. They were reanalyzed later, in the more normal environment ofthe United States, when more sober second thoughts were possible. The analysisis entirely objective. Errors of technique and mistakes of judgment are relatedas frankly as are surgical triumphs.
At the beginning of World War I, the policy of management of combat-incurredabdominal injuries was one of so-called surgical abstention. As the warprogressed, the undesirability of such a policy became more and more evident,and surgical intervention began to be practiced, but for a variety of reasons,including lack of organization, operation was still not the general rule whenthe war ended. In World War II, as the result of both the previous militaryexperience and the intervening civilian experience, the official policy was tooperate, as promptly as possible, on all casualties with abdominal injuries inwhom the mere act of operation would not be fatal. Only a small number ofpatients (considerably less than 1 percent) fell into this category.
The policyof prompt surgical intervention in abdominal injuries was made practical andpossible because of another concept that was new in World War II, the practiceof preoperative resuscitation, which is also described in this volume. Many ofthe fatalities in World War I occurred because the patients
were never in condition to be operated on. In World War II, asmall number died while resuscitation was being attempted, but at least theattempt had been made to bring them to a status in which surgery could betolerated. The liberal use of whole blood was the central feature ofresuscitation, but, as Doctor Beecher points out in his account of the program,every detail was important, from the placing of blankets underneath the patient,as well as over him, to the deliberate care with which his position was changedon the operating table. The program of resuscitation, combined with competentanesthesia, permitted surgery of great magnitude on patients whose initialcondition was such that in an earlier day they could only have been left to die.
Three extremely important departures from previous medicomilitary practicesrequire specific mention. The first is the management of wounds of the rectumand large bowel by colostomy, with or without exteriorization of the damagedsegment. Although colostomy had been an established procedure in civiliansurgical practice before World War I, it was used only in desperate cases inthat war and was never routine, even when surgical intervention in abdominalinjuries had become fairly general. United States Army medical officers usedcolostomy in the fighting in North Africa in 1942 and 1943 without knowledge ofthe previous British experience with it. The results were so good that its usebecame official Medical Department policy in October 1943. The performance ofcolostomy saved thousands of lives immediately after wounding, and theexcellence of the final results is described in the last chapter of this volume,which deals with the repair of colostomy in Zone of Interior hospitals.
Wounds of the liver were never treated surgically in World War I, even afterthe policy of surgical intervention for abdominal injuries had been introduced.Their management in World War II represents a process of evolution, since themilitary surgeons who encountered them had no decisive principles to guide themother than the general policy that surgical intervention in abdominal injuriesis in the best interests of all patients who survive to reach forward hospitals.Drainage of Morison's pouch, which eventually became established practice,resulted in a considerable salvage of life, as well as in a considerablereduction in both primary and postoperative complications in injuries of theliver.
The transdiaphragmatic approach to thoracoabdominal wounds, of which therewere 839 in this series, represents a new practice in military surgery. Thecardiorespiratory risks associated with this technique were reduced to a minimumby the ready availability of competent anesthetists and suitable anestheticequipment. The ease of intimate surgical exploration of the left upper quadrant,in properly selected cases, by way of this incision is evident in the goodresults achieved in injuries of the spleen, in which, in contrast to World War Ipractice, splenectomy was the accepted method of management in World War II.
The 333 negative explorations in this series are, in some respects, the mostimportant group of all. One of the outstanding observations in this analysis
was that in not a single instance did a missile pass harmlessly across thegeneral peritoneal cavity in a major diameter. The prompt exploration of everycase in which there was any suspicion of penetration of the peritoneal cavitywas therefore standard practice and was entirely justified, in view of theminimal mortality associated with exploration and the risks involved innonsurgical management of penetrating abdominal wounds. These 333 negativeexplorations may, in a sense, be described as unnecessary emergencies, but theywell illustrate the surgical philosophy which directed the management ofabdominal injuries in World War II.
I should be derelict if I brought this foreword to a close without specificrecognition of the technical competence, sound professional judgment, andsurgical courage of the members of the 2d Auxiliary Surgical Group who handledthese cases, and without paying tribute also to the indispensable assistancethey, like all other military surgeons, received from the anesthetists and theresuscitation teams whose part in the management of abdominal injuries isdescribed in this volume.
S. B. HAYS,
Major General,
The Surgeon General.
