STUDY OF FIFTH ARMY HOSPITAL BRITTLE CASUALTY DEATHS A PRELIMINARY REP CRT IN THREE VOLUMES f'**" SNYDER and GUI BERTS OJ VOLUME THREE STUDY OF FIFTH ARMY HOSPITAL BATTLE CASUALTY DEATHS An Analysis of Case Reports from Field and Evacuation Hospitals on 1450 Fatally Wounded .American Soldiers A PRELIMINARY REPORT IN THREE VOLUMES by HOWARD Eo SNYDER, COLONEL, MO, ,4US Surgical Consuitonir Fifth Aimy. and JAMES W, CULBERTSON, CAPTAIN, MC, AUS Surgical Service, 8th Evacuation Hospital Gardone Riviera* Italy 1945- VOLUTE THREE SECTION TV SPECIAL STUDIES ON INTRA-ABDOl ■ INAL ROUNDS PRELIMINARY REMARKS In *108 cases, or 28.1$ of the IU50 deaths studied, the principal wound was intra-abdominal. Adding the 212 cases having thorace-abdominal wounds and the 59 cases having combined intra- abdominal and intrathcracic wounds, we find that 679, or *+6.8$ of the deaths had a wound of the a.bdomen. The latter two groups are not included in the study in this section. The group of *4-08 cases in which the principal wound was intra-abdominal have been studied as a group in the proceeding sections of this report. In this section, the cases are considered in further detail. Shock was the immediate cause of death in *+3.6$ of those U08 deaths in which the principal wound was intra-abdominal. This group of shock deaths in abdominal wounds (lJ8 causes) is considered separately in Part 1 of this section. It is found that 30*9$ died before surgery as compared to 7$ in the remaining cases. (See Part 2). Contamination from a hollow viscus was a factor in 65$ of those dying from shock, which is less than the incidence of 7*+$ in the rest of the group. Hemoperitoneum or continuing hemorrhage was noted in 6*+$ of the shock group and in 70$ of the remainder. There was very little difference in the incidence of peritonitis in the two groups, the figure approximating 21$. Likewise there was little difference in the incidence of associated wounds in the two groups. 319 Records of plasma and blood administered are a little difficult of interpretation. It will be noted on tables recording these data that there is no record of blood transfusion in a surpris- ingly large percentage of cases, It is probable that some re- ceived blood and no record was made, but also probable that in the majority, no blood was administered. The averages given are based only on those cases in which blood was given and a record made of its administration. Comparing the averages and the num- ber receiving blood in the group dying in shock with the whole group of cases, it is found that a larger percentage of cases re- ceived a larger average amount of blood in the shock group than in the group as a whole. Inasmuch as this series involves only deaths, and there are no figures at hand for the cases with intra- abdominal wounds who lived, comparisons cannot be made with a group of cases in which therapy was adequate. It is the opinion of the writers that blord administration in this group of cases who died was inadequate in amount. The percentage of bullet wounds in the shock deaths in the intra-abdominal group is 21 cJo% as compared with 25-3$ in the entire intra-abdominal group, while in the whole series (IU50) it is only 19. 855. Table CCXLVII, page 350» deals with miscellaneous conditions occurring in this group of cases with intra-abdominal wounds who 320 died of shock. Myocardial decompensation was evident in only two cases, and in these excessive administration of plasma and "blood was thought responsible. Pulmonary edema was noted in 13 cases in the group. As this is of unusual occurrence in un- complicated shock, search was made for factors to pulmonary edema. Table CCXLYIII on page 351 records plasma ther- apy and blood transfusion therapy on these 13 cases. It will be noted that all received plasma and blood before surgery. The averages were little different from the averages for those re- ceiving plasma and blood in the rest of the group in which, how- ever, a substantial number received none. It is difficult to draw any conclusions regarding the role plasma and blood played in the appearance of pulmonary edema in this group. Thoracic trauma, blast trauma, and pneumonia probably contributed to the incidence of "pulmonary edema". Study of blood pressure records (see page 328) reveals that I? of 55 recorded admission blood pressures were zero. The low- est pressure recorded was zero in of the JO cases. The aver- age duration of surgery in this shock group approached two and one-half hours. All of the cases coming to surgery received ether anesthesia. Pentothal was used once and nitrous oxide Uo times for induction. Part 2 of this section deals with those cases in which the principal wound was intra-abdominal, but the immediate cause of 321 death was not shock. It should he noted that there was no evi- dence of shock in only 6 of these cases. The remainder had evi- dence of shock at some time during the course of their hospital stay. (The terminal fall in hlood pressure occurring in every case immediately before death was not regarded as evidence of shock). Analysis of shock as a contributory or associated condition is included in the study of this group of cases. Both Parts 1 and 2 may be compared with Part 3 in which only cases with peritonitis and those suspected of having peritonitis were subjected to analysis. 322 SECTION IV Part 1 Those Cases in Phich the Principal Pound Pas Intra-abdominal .and the Immediate Cause of Death Pas Shock (178 Cases). TABLE CCXXIII PRINCIPAL WOUND INTRA-ABDOMHAL IMMEDIATE GAUGE OF DEATH SHOCK (1?8 CASES) DATA RELATIVE TO HOSPIT.X ADMISSION, ANESTHESIA, AND SURGEFY Dead on arrival 6 Dying on admission 11 Died before anesthesia (excludes above two groups) 35 Died during anesthetic condition 3 Died during primary surgery 16 Died subsequent to primary surgery 10? TOTLL 178 324 TABLE CraIV PRIHCIP.X LCU1JL INTRA-ABDOIXHAL IMEDIATE CAUSE OF DEATH SHOCK Ci.USi.TIVE AGENT Bullet, unclassified 23 Bullet, rifle 2 Bullet, machine gun 6 High Explosive, unclassified 17 High Explosive, shell 116 High explosive, mine 3 High explosive, booby trap 0 High explosive, bomb 8 High explosive, blast 0 Ho record 3 TYPE OF FOUND Penetrating 127-* Perforating 53 325 TABLE CCXXV PRINCIPAL V/OUKD IKTRWJBDOI INAL IMMEDIATE CAUSE OF DEATH SHOCK (1?8 CASES) ETIOLOGY OF SHOCK Trauma and hemorrhage 57 Trauma and hemorrhage plus contamination or sepsis 114 Trauma and hemorrhage plus cardiorespiratory embarrassment 3 Trauma and hemorrhage plus contamination or sepsis plus cardiorespiratory embarrassment 2 Type or etiology undetermined 2 TOTAL 1?8 326 TABLE CCXXVI PRINCIPAL T7CUKD INTFA-ABDONINAL IFISDIATE CAUSE OF DEATH SHOCK (1?8 CASES) C UNTiJ'v'UlvL'JT I ON OR SEPSIS A FACTOR* ll6 Cases Peritonitis, severe 20 Peritonitis, mild or moderate 17 Peritonitis, suspected 6 primary abdominal hemorrhage 89** Recurrent or delayed abdominal hemorrhage 5 Hemorrhage, profuse in hospital 12 CONT AMIMATION OR SEPSIS WOT L FACTOR 62 Cases Peritonitis, severe 0 Peritonitis, mild or moderate 1 Peritonitis, suspected 0 Primary abdominal hemorrhage 25** Recurrent or delayed abdominal hemorrhage 4 Hemorrhage, profuse in hospital 6 * Contamination from hollow viscus. ** Includes those cases in which note was made of homoperitoneunn or of active intra-abdominal bleeding* 327 table GC'Dn/ii PRINCIPiX worn© IRTRL-LBDOIX1UX lOISDIiXE CAUSE OF DEPTH SHOCK (1?8 CiXES) SYSTOLIC BLOOD PRESSURE OH ADMISSION TO HOSPITiJL 0 17 Cases 2-38 1 CO 1 0 -=t 5 60 - 68 5 -0 0 1 -~o 00 5 80 - 88 9 90 - 98 6 100 - 118 5 120 - I38 2 li|0 - 138 1 No record 122 TOTiJL 178 Cases LOWEST RECORDED SYSTOLIC BLOOD PRESSURE (EXCLUDES TERMINAL) 0 34 Cases 2 - ■ 38 2 40 00 » 8 6o - 78 13 80 - 88 10 90 - 98 3 100 or more but pulse rapid & weak 2 No record 104 328 TABLE ccxrmi PRINCIP.X V CURD IHTFX-XBDOJXKiX CXUSE OF DEATH SHOCK (1?8 CASES) INCIDENCE OF ASSOCIATED FOUNDS* Intra-cranial, known 1 Case Intra-cranial, suspected 5 Scalp 4 Maxillofacial, bone & soft tissue 3 Maxillofacial, soft tissue only 8 % Cervical, general 3 Intraspinal 13 Chest wall 1? Pulmonary blast injury 1 Intrathoracic, suspected 7 Upper extremity, bone & soft tissue 9 Upper extremity, soft tissue only 37 Upper extremity, traumatic amputation 1 Lover extremity, bone & soft tissue Lover extremity, soft tissue only 68 Lover extremity, traumatic amputation 3 TOTAL 193 Oases* No associated wounds 60 Oaves * Multiple associated wounds present in many instances 329 TABLE COTIX PRINCIPAL T OUND INTRA-ABD0MII1AL IIETEDIATE CAUSE OD DEATH SHOCK ANESTHETIC AGENTS USED 111 CASES DYING DUPING ANESTHESIA, SURGERY, AND AFTER SURGERY (126 GIBUS) Me record 36 Cases Ether, closed system 47 Ether, Flagg method l Ether, open drop 2 Ether, unclassified 36 • TOTLL 126 Coses Following agents v.ere used in cinbination nith ether or for induction: Ilitrous oxide 4° Coses Pcntothal sodium 1 Endotracheal anesthesia 47 330 TABLF CCXXX PRINCIPAL WOUND INTRA-ABDOI'.IINAL IMMEDIATE CAUSE OF DEATH SHOCK OPERATING TINE, CASES DYING DUR-ING CB AFTER SURGERY FIELD HOSPITAL CASES (77) EVACUATION HOSPITAL CASES (46) 0-3° Minutes 2 cases 0-3~ Minutes 1 case 30 - 60 Minutes 3 30 - 60 Minutes 0 60 - 90 IJinutes 3 60 - 90 Minutes 1 90 - 120 Minutes 2 90 - 120 Minutes 2 120 - 150 Minutes 5 120 - 130 Minutes 1 130 - 180 Minutes 4 130 - ISO Minutes 4 180 - 210 Minutes 3 180 - 210 Minutes 3 210 ~ 240 Minutes 3 210 - 240 Minutes 1 240 - 2?0 Minutes 1 Not stated 33 2?0 - 300 Minutes 1 Hot stated 30 Average - 142 Minutes Average - 146 Minutes 331 TABLE CCXTXI PRINCIPAL WOUND INTRA-ABDOMINiX BIIEDIATS CAUSE OF DEATH SHOCK (178 CASES) UNITS TINS i* TKSRaFY (250cc) iJ3,iINISTERED PRIOR TO NDIIISSIOK 1 Unit 19 Cases 2 Units kb 3 Units 17 Ij. Units 18 5 Units 13 6 Units ,10 7 Units 4 8 Units 1 9 Units 1 10 Units i Total receiving plasma 13° None or no record 48 Total I?8 Oases Those receiving plasma prior to admission Average amount administered 3.18 Units 332 REI.iAPJvS The preceding table has presented data on the amount of plasma administered prior to admission. It represents the replacement therapy carried out in battalion aid stations, collecting stations, and clearing stations, hhile it is believed that only the minimum amount of plasma necessary to insure transportability of the patient should bo given, just That that amount is in each case has to be determined by the in- dividual medical officer in charge. That his judgment has been excel- lent in nearly every case, is a statement to which medical officers in Amy hospitals will attest. Te have not as yet prepared figures on the average amounts admin- istered during different periods. However, Lt Col Eugene Sullivan has figures showing an increase in the amount administered in the latter months of the campaign based on battle casualty admissions. The tables on plasma and blood which follow are based on amounts administered in hospitals. 333 TABLE CCXXXII PRINCIPAL WOUND INTRA-ABDOMINAL II.MSDIATS GAUSS OF SHOCK (1?8 CASES) PLASMA THERAPY UNITS (250 cc) ADMINISTERED AFTER ADIvESCIOH BUT BEFORE SURGERY 1 Unit 14 Cases 2 Units 24 3 Units 16 4 Units 12 5 Units 2 6 Units 3 7 Units 1 8 Units 2 9 Units 1 10 Units 2 Total receiving plasma 77 Cases None ' or no record 95 Dead ' on arrival 6 TOTAL 178 Cases Those receiving Plasma after admass ion, but before Surgery; Average amount administered 3.16 Units 334- TABLE CCXTXIII ERINCX PAL WOUND INTRA-ABDOMINAL IIII.3DIi4.TS CAUSE OE DEATH SHOOK (1?8 CASES) ELASJA THERAPY UNITS (230 cc) ADMINISTERED DURING 3JRGERY 1 Unit 3 Cases 2 Units 10 3 Units 4 4 Units 3 5 Units 1 8 Units 2 Total receiving plasma 23 Cases None or no record 100 Died before Surgery 55 TOTAL 178 Cases Those receiving plasma during surgery: Average amount administered 2.95 Units 335 TABLE CCXTXIV PRINCIPAL WOUND INTIU-idBDOMINkL Ik mDIiiT‘3 CiiUSkj OP DEkTH iSHOCn (iy8 Ci*i3E3) ELAaiA ther;jy UNITS (250 cc) .UFTSH SURGERY* 1 Unit 4 Cases 2 Units 7 3 Units 2 4 Units 3 Total receiving plasma 16 Cases Hone or no record 91 Died before or during surgery 71 TOTAL 178 Cases Those receiving plasma after surgery* Average amount adminstered 2.25 Units only plasma administered for resuscitation. Does not include plasma ordered daily for those with abdominal wounds during the post-operative period. 336 TABLE CCmv PRINCIPAL WOUND INTRA-ABDOMINAL IMMEDIATE CAUSE OF DEATH SHOCK (1?8 CASES) BLOOD TRANSFUSION THERAPY UNITS ADMINISTERED BEFORE SURGERY 1 Unit 25 Cases 2 Units 30 Cases 3 Units 19 Cases 4 Units 23 Cases 3 Units 2 Cases 6 Units 7 Cases 7 Units 1 Case 8 Units 2 Cases 10 Units 8 Cases Total receiving blood before surgery 112 Case s None or no record 60 Cases Dead on arrival 6 Cases 178 Cases Those receiving blood before surgery. Average Amount Administered 3.O3 Units 337 TABLE CCXXXVI PRINCIPAL WOUND INTRA-ABDOMINAL IMMEDIATE CAUSE OF DEATH SHOCK (1?8 CASES) BLOOD TRANSFUSION THERAPY UNITS AHilNISTERED DURING SURGERY 1 Unit 6 Cases 2 Units 17 Cases 3 Units 17 Cases 4 Units 9 Cases 5 Units 2 Cases 7 Units 1 Case 8 Units 1 Case 9 Units 1 Case 10 Units 1 Case Total receiving blood during surgery 55 Cases None or no record 68 Cases Died before surgery SS Cases TOTAL 178 Cases Those receiving blood during surgery: Average Amount Administered 3.19 Units 338 TABLE CCXXXVII PRINCIPAL WOUND INTRA-ABDOMINAL MEDIATE CAUSE OF DEATH - SHOCK (1?8 CASES) BLOOD TRANSFUSION THERAPY UNITS ADMINISTERED AFTER SURGERY 1 Unit 10 Cases 2 Units 7 Cases 3 Units 2 Cases 4-Unitsj 2 Cases 5 Units 2 Cases 6 Units 1 Case FiUnits 1 Case 9 Units * 1 Case 10 Units 1 Case Total receiving blood after surgery 2? Cases None or no record 80 Cases Died before or during surgery ZL Cases TOTAL 178 Cases Those receiving blood after surgery: Average amount administered 3.07 Units 339 TABLE CCXXXVIII PRINCIPAL WOUND INTRA-ABDOMINAL IMMEDIATE CAUSE OF DEATH SHOCK TIME LAGS - WOUNDING TO DEATH 6 Cases Dead on Arrival No record U Gases U hours 1 Case 5 hours 1 Case 11 Cases Dying on Admission (Lived less than 1 hour) No record 2 Cases 1 hour 3 Cases 2 hours 1 Case 3 hours 2 Cases 5 hours 2 Gases 6 hours 1 Case Total: 11 Gases 340 TABLE CCXXXIX PRINCIPAL WOUND INTRA-ABDOMINAL IMMEDIATE CAUSE OF DEATH SHOCK CASES LIVING AT LEAST ONE HOUR AFTER /ADMISSION BUT DYING BEFORE ANESTHESIA (35) TIME LAGS - WOUNDING TO DEATH No record 11 Gases 5 hours 3 Cases 6 hours 2 Cases 7 hours 1 Case 9 hours 2 Cases 10 hours 1 Caso 11 hours 2 Oases 13 hours 1 Case 14 hours 1 Case 16 hours 3 Cases 18 hours 3 Cases 27 hours 1 Case 28 hours 1 Case 31 hours 1 Case 4.0 hours 1 Case 4-7 hours 1 Case Total: 35 Gases Average time wounding to death 16 hours 341 TABLE CCXL PRINCIPAL WOUND INTRA-ABDOMINAL MEDIATE CAUSE OF DEATH SHOCK TIMS LAGS - GASES DYING DURING ANESTHETIC INDUCTION(3 CASES) WOUNDING TO DEATH 10 hours 1 Case 20 hours 1 Case 4-9 hours 1 Case ADMISSION TO ANESTHESI. No record 1 Case 4- hours 1 Case 7 hours 1 Case 342 TABLE GCXLI PRINCIPAL T70UND INTRA-ABDOMINAL If MEDIATE CAUSE OF DEATH SHOCK THIS LAGS - GASES DYING DURING PRIfERY SURGERY (16) FIELD HOSPITAL CASES (ll) AXMISSIOIT TO SURGERY EVACUATION HOSPITAL CASES (5) ADMISSION TO SURGERY No record 2 Cases A hours 1 Case 1 hour 1 Case 6 hours 1 Case 3 hours 3 Cases 7 hours 1 Case A hours 2 Cases B hours 1 Case 5 hours 1 Case 22 hours 1 Case 6 hours 1 Case 19 hours 1 Case 3 A3 REMARKS Attention is called to the snail number of cases (l6) ulth intra- abdominal mounds dying of shock during primary surgery, (Only four others died from some cause other than shock during surgery). This loir incidence prevailed in spite of the general adoption of a policy to give battle casualties not responding to replacement therapy the benefit of emergency surgery. Table III, page 10, in Section I shorns that in all hospital battle casualty admissions the percentage dying during surgery decreased throughout the four periods covered by this report• 3hh TABLE CCXLII PRINCIPAL WOUND INTRA-ABDOMINAL MEDIATE CAUSE OF DEATH SHOCK TIME LAGS - GASES DYING DURING PRIMARY SURGERY (l6) No record BOUNDING TO DEATH 1 Case 5 hours 1 Case 7 hours 2 Cases 9 hours 2 Gas 0 s 11 hours 1 Case 13 hours 2 Cases 20 hours 1 Case 24- hours 1 Case 20 hours 1 Case 35 hours 1 Case 4-3 hours 1 Case 4-6 hours 1 Case 56 hours 1 Case Average Total: 16 Cases 21.7 or 21 hrs. 4-4- min. 345 TABLE CCXLm PRINCIPAL HOUND IHTEA-ABDOMINAL IIFKDIATE CUJJSE OF DEATH SHOCK TIME LAGS - CASES DYING AFTER PRIMARY SURGERY FIELD HOSPITAL CASES (66) EVACUATION HOSPITAL CASES (41) WOUNDING TO ADMISSION WOUNDING TO ADMISSION No record 11 Cases No record 11 Cases 1 hour 2 Gases 1 hour 3 Cases 2 hours '■ 2 Gases 2 hours 4 Gases 3 hours 5 Cases 3 hours 1 Case 4 hours 9 Cases 4 hours 5 Gases 5 hours 7 Cases 5 hours 1 Case 6 hours 4 Gases 6 hours 1 Case 7 hours 4 Cases 7 hours 2 Cases 8 hours 2 Cases 8 hours 4 Gases 9 hours 6 Gases i 9 hours 2 Cases 11 hours 2 Gases 11 hours 1 Case 12 hours 2 Cases 12 hours 1 Case L4 hours 1 Case 14 hours 1 Case 15 hours 2 Cases v 16 hours 1 Case 21 hours 1 Case 17 hours 1 Case 22 hours 3 Cases 31 hours 1 Case 34 hours 2 Cases 3B hours 1 Case 17 hours 1 Case Average - 9 hours Average - B hours 16 minutes 34.6 TABLE CCZLIV PRINCIPAL WOUND INTRA-ABDOMINAL IMMEDIATE CAUSE OF DEATH SHOCK TIME LAGS - Ci'AES DYING AFTER PRIMARY SURGERY FIELD HOSPITAL CASES (66) ADMISSION TO SURGERY EVACUATION HOSPITAL CASES (41) ADMISSION TO SURGERY No record 16 Gases No record 12 Cases 1 hour 3 Cases 1 hour 1 Case 2 hours 5 Cases 2 hours 3 Cases 3 hours 11 Gases 3 hours 2 Cases 4 hours 3 Cases 4. hours 6 Gases 5 hours 3 Cases 5 hours 4 Cases 6 hours 5 Cases 6 hours 4 Cases 7 hours 4- Cases 7 hours 1 Case 8 hours 7 Cases 8 hours 3 Cases 10 hours 5 Cases 10 hours 1 Case 11 hours 2 Cases 13''hours 2 Cases 12 hours 1 Case 15 hours 1 Case 13 hours 1 Case 25 hours 1 Case orago - 5 hours 4-1 minutes Average 6 hours 29 minutes 347 TABLE CCXLV PRINCIPAL ROUND INTRArA3D OMIUAL IMMEDIATE CAUSE OF DEATH SHOCK TIME LAGS - GASES DYING AFTER PRIMARY SURGERY FIELD HOSPITAL CLSES <66) SURGERY TO DEX.TH Ho record 13 Gases 18 hours 3 Gases 2 hours 3 Cases 19 hours 3 Gases 3 hours 4- Gases 22 hours 1 Case 4- hours 1 Case 24- hours 1 Case 5 hours 2 Cases 27 hours 2 Cases 6 hours 1 Gas o 28 hours 2 Cases 7 hours 1 Case 30 hours 3 Cases 8 hours 2 Gases 36 hours 1 Case 9 hours 2 Cases 37 hours 1 Case 11 hours 2 Gases 4-0 hours 1 Case 12 hours 4- Cases 4.6 hours 1 Case 13 hours 4- Cases 51 hours 2 Cases 14- hours 3 Gas cs 60 hours 1 Case 3.6 hours 1 Case Everare - 18 hours 348 TABLE CCXLVI PRINCIPAL ROUND INTRA-ABDOMINAL IMMEDIATE CAUSE OF DEATH SHOCK TIKE LAGS - GASES DYING AFTER PRIMARY SURGERY EVACUATION SURGERY TO HOSPITAL DEATH: CijSES (41) No record 11 Cases 1A hours A Cases 2 hours 1 Case 15 hours 1 Case 3 hours A Cases 17 hours 1 Case A hours 2 Cases 19 hours 1 Case 5 hours 1 Case 26 hours 1 Case 7 hours 2 Gases 28 hours 1 Case 8 hours A Gases 29 hours 1 Case 9 hours # 2 Cases A5 hours 1 Case 10 hours 1 Case A93 hours 1 Case* 13 hours 1 Case Average - 28 hours 12 hours - without last case vDied in shock from recurrent hemorrhage. % 9 TABLE CCXLVII PRINCIPAL ROUND INTRA-ABDOMINAL I MED I ATE CAUSE 0? DEATH SHOCK (178 CASES) MISCELLANEOUS DATA Nyocardial do compcns ation, evident 2 Ify’ocardial decompensation, suspected u Pulmonary edema, severe 1 Pulmonary edema, slight or moderate 12 Trachc o-bronchial obstruetion, aspirated vomitus 0 Tracheo-bronchial obstruction, blood and mucus 3 Trachc o-bronchial obs truetion, suspected 1 Thoracic trauma (chest nail) IB Pigment ITephropathy, evident 1 Pigment Nephropathy, suspected 5 Renal trauma, evident 24 350 TABLE CCXLVIII PRINCIPAL ROUND INTRA-ABDOMINAL II.1I-.1EDIATE CAUSE OF DEATH SHOCK PULMONARY EDEMA SEVERE - 1 CASE PULMONARY EDEIIA SLIGHT OR MODERATE - 12 CiEES plash; theraphy in those 13 cases teeth PULMONARY EDEMA 13 Cases Received Plasma before Admission* AVERAGE 2.3 Units 10 Cases Received Plasma after Admission before Surgery 3.2 Units 2 Gases Received Plasma during Surgery 1 Case 2 Units 1 Case 8 Units 0 Gases Received Plasma after Surgery None BLCOD TRANS FUSION THERAPY IN THOSE 13 CASES uITH PULMONARY EDEMA 13 Gases Received Blood Before Surgery** AVERAGE 3.08 Units $ Cases Received Blood During Surgery 2.8 Units 5 Cases Received Blood After Surgery 6 Units *1 Unit of Plasma equal to 250 cc **1 Unit of Blood cc mal to 500 cc 351 TABLE CCXLIX PRINCIPAL WOUND INTRA-ABDOMINAL MEDIATE CAUSE OR DEATH SHOCK PULMONARY EDEMA SEVERE - 1 CASE PULMONARY EDEI.fi SLIGHT OR MODERATE - 12 CASES MISCELLANEOUS DATA Thoracic trauma presort in 1 ease with slight or moderate pulmonary edema. Thoracic trauma not present in the 1 ease with severe pulmonary edema. Blast trauma suspected in 1 case with severe pulmonary edema and in 3 eases that had slight or moderate pulmonary edema. Myocardial decompensation was suspected in the one ease with severe pulmonary edema, and in sire eases with slight or moderate pulmonary edema. Myocardial decompensation was evident in one ease with slight or moderate pulmonary edema. Mild or moderate pneumonia mas present in two of the eases with slight or moderate pulmonary edema. 352 SECTION IV Part 2 Those Cases in "Nich the Principal ' /bund rras Intra-abdominal and the Immediate Cause of Death Tras Not Shock- (230 Cases) TABLE CCL PRINCIPAL WOUND INTRA-ABDOMINAL PlfflSDIATS GAT1SE OF DEATH - NOT SHOCK (230 GASES) DATA RELATIVE TO HOSPITAL ADMISSION ANESTHESIA AND SHRGIRY Dead on arrival 0 Dying on admission 1 Died "before anesthesia (Excluding above t* 70 groups) 10 Died during anesthetic induction 5 Died during primary surgery 4- Died subsequent to primary surgery 210 Totali 230 354 TABLE CCLI PRINCIPAL HOUND INTRA-ABDOMINAL IMMEDIATE CATJSE OF DEATH - NOT SHOCK (230 CASES) INCIDENCE OF SHOCK AS A CONTRIBUTORS OR AS OGIATED CONDITION Shock - Corrected by therapy 121 Cases Shock - Suspected, not proven 16 Gases Shock present - Successful correction doubtful 66 Cases Shock - Hncorrected 21 Cases No evidence of shock 6 Cases Total ; 230 Cases 355 TABLE CCLII PRINCIPAL NOT® INTRA-ABDOMINAL IT ESDIATS GRASS OF DEATH - NOT SHOCK (230 GASES) FARTHER ANALYSIS OF SHOCK AS A CONTRIBTJTORY OR ASSOCIATED CONDITION (224 CASES) Corrected by Therapy Chock Suspected not Proven Successful Hncorrected Correction Doubtful Total BIOLOGY ? Trauma & Hemorrhage 27 12 13 5 57 Trauma *£ hemor- rhage plus con- tamination or sepsis 91 K 51 15 161 Trauma & hemorrhage plus cardiorespira- tory embarrassment 2 0 0 0 2 Trauma & hemorrhage plus contamination or sepsis plus card- iore3plratpry em- barrassment • 1 0 / 2 1 k rnOTAL 121 16 66 21 22L 356 TABLE CCLIII PRINCIPAL T:rONND INTRA-ABDOMINAL GATlSE 0? DEATH-MOT SHOCK Bir SHOCK A G°|NTRIBT1T0RY OR ASSOCIATED CONDITION (224. GASES) M FINDINGS Hemorrhage, profuse in hospital 11 Gases Hemor rhage, pr iraary 156 Gases Hemorrhage, recurrent or delayed 10 Cases Peritoneal contamination from hollow viseus 165 Gases Peritonitis, severe 17 Cases Peritonitis, mild or moderate 31 Cases Peritonitis, suspected 4.0 Gases 357 TABLE CCLIV PRINCIPAL ’TmiD INTRA-A3”)0T IINAL PfSIDlATE CAUSE OE DEATH - "TOT SHOCK, BUT SUOTv A CONTRIBUTOR? E ACTOR (?2/+ CASES) mm. , 0 He SYBTOLIC BLOOD PHS3BTm ON ADMISSION 13 2 - 3B 0 4.0 - 5B 8 60 - 6B 4. 70 - 7B 3 BO - 88 5 90 - 98 5 100 ~ 118 13 120 - 138 13 U0 - 158 0 No record Total 160 224. L0-703T RECORDED (KXGLTU SYSTOLIC BLOOD PRESS TEE 3S3 TERMINAL) Tim. K 0 24. 2 - 30 • 1 4.0 - 58 11 60 - 7S 8 00 - 88 8 90 - 90 11 100 or a o CD but pulse rapid 7c vieak 6 No record 155 Total 224. 358 TABLE CCLV PRINCIPAL WOUND INTRA-ABDOMINAL IMMEDIATE CHASE OP DEATH - NOT SHOCK (230 GASES) INCIDENCE OF ASSOCIATED WOUNDS Intracranial, known 1 Case Intracranial, suspected 1 Case Scalp 3 Cases Maxillofacial, bone & soft tissue 1 Case Eye or orbit 2 Gases Maxillofacial & soft tissue only 7 Gases Neck, general 6 Cases Intras pina1, unclassfi ed 13 Cases Chest wall only 22 Cases Pulmonary blast 4. Gases Intrathoracic, suspected 10 Gases Thoraco-abdominal 1 Case Upper extremity, soft tissue only 2S Cases Upper extremity, traumatic amputation 1 Case Lower extremity, soft tissue only 72 Gases Lower extremity, bone and soft tissue 4,6 Cases Lower extremity, traumatic amputation 2 Gases No associated wounds 70. Gases 359 TABLE CCLVT PRINCIPAL WCPJND IMTI5DIAmE GTE.SE 07 ANESTHETIC AGENTS T1SED ANESTHESIA, SURGERY, INTRA-ABNOMINAL DEATH - NOT SHOCK IN CASES DYING DURING AND AFTER SURGERY No record 60 Ether, closed system 72 Ether, Flagg method 1 Ether, open drop 19 Ether, unclassified 71 * Nitrous oxide 56 *?entothal sodium 7 *Ethyl chloride 1 Endotracheal anesthesia 65 Two Anesthesia Deaths• One had endotracheal nitrous 0“ido? ether, oxygen One had ether (Unclassified) ■*These agents nearly always used for induction. Exact number not available in this table. 360 TABLE CCLVII PRINCIPAL WIND INTRA-ABDOMINAL IMMEDIATE CAUSE OF DEATH - NOT SHOCK (230 GASES) TIME LAGS - WOUNDING ADMISSION FIELD HOSPITAL (125 CASES) No record 38 cases 0 hours 1 caso 1 hour 2 casos 2 hours 8 casos 3 hours 14* cases 4 hours 9 cases 5 hours 4. cases 6 hours 7 cases 7 hours 9 cases 8 hours 3 cases 9 hours 4 cases 10 hours 4 cases 11 hours 4 cases 12 hours 2 cases 13 hours 3 cases 14. hours 4 casos 15 hours 2 cases 16 hours 1 caso 17 hours 2 cases 18 hours 1 case 19 hours 1 case 33 hours A 1 case 4,6 hours 1 case Total: 125 cases Average 7 hrs. 49 min. 361 TAELS CGLVIII PRINCIPAL WOUND IKTRA,-ABDOMINAL IMMEDIATE GATIS3 OF DEATH, NOT SHOCK (230 CASUS) TI'E LAGS - WOTJMDING TO ADMISSION TO KVAG HOSPTIAL (105 GASES) No record 30 Cases 1 hour 5 cases 2 hours 3 cases 4. hours 10 cases 5 hours 5 cases 6 hours B cases 7 hours 10 cases B hours 3 cases 9 hours B cases 10 hours 4. cases 11 hours 1 case 12 hours 2 cases 13 hours 2 cases 16 hours 1 case IB hours 1 case 19 hours 1 case 23 hours 1 case 24- hours 1 case 25 hours 1 case 29 hours 2 cases Total: 105 cases Average: 7.3 hours 362 TABLE GCL1X PRINCIPAL WONND IP'TMEDIATE GAT1SE OF TIME LAGS - ADMISSION rnO INTRA*-ABDOMINAL DEATH - NOT SHOCK (230 CASES) STTR0ERZ - FIELD HOSPITAL (125 CASTS) No record 42 cases 0 hours 1 case 1 hours 11 cases 2 hours 12 cases 3 hours 15 cases 4 hours 14 cases 5 hours & cases 6 hours 5 cases 7 hours 6 cases S hours 5 cases 9 hours 1 case 11 hours 1 case 12 hours 1 case 13 hours 2 cases 44 hours 1 case . i Total: 125 cases Average 4 hrs. 42 min. 363 TABLE CGLX PRINCIPAL WOUND INTRA-ABDOMINAL IMMEDIATE GANSU OF DEATH - NOT SHOCK (230 CASES) TIME LAGS - ADMISSION TO SURGERY EVACUATION HOSPITAL (105 CASES) No roo ord 34, casos ! 1 hour 4 oases 2 hours 9 casos 3 hours 11 cases 4. hours 6 cases 5 hours 6 cases 6 hours 10 cases 7 hours 4 cases 8 hours 5 cases 9 hours 2 oases 3.0 hours 4 cases 11 hours 3 cases 13 hours 1 case U hours 1 case 15 hours 1 case 17 hours 3 \ casos 19 hours 1 case Total: 105 cases Moan 3 hours Average 6 hrs* 31 min* 364 TABLE COLXI PRINCIPAL , HOUND INTRA-ABDOMINAL IMMED3 ;ate ca USE OF DEATH, NOT SHOCK TB/ □ LAGS - SURGERY TO DEAmH - FIELD HOSPITAL CASES No rocord 39 cases 96 hours 1 case 1 hour 1 case 97 hours 1 case 3 hours 1 case 101 hours 1 cas e 8 hours 1 caso 103 hours 1 case 9 hours 1 case 112 hours 1 caso 11 hours 1 caso 117 hours 1 case 12 hours 1 case 119 hours 2 cases 14 hours 1 case 125 hours 1 caso 26 hours 1 case 126 hours 2 casos 29 hours 2 casos 131 hours 1 caso 33 hours 2 cases 132 hours 1 case 35 hours 1 caso 133 hours 1 caso 40 hours 1 case 134 hours 1 caso 42 hours 1 case 136 hours 1 caso 43 hours 1 caso 148 hours 1 case 45 hours 1 caso 154 hours 1 caso 47 hours 1 caso 159 hours 1 caso 49 hours 2 casos 163 hours 1 case 50 hours 1 case 164 hours 1 case 53 hours 1 caso 169 hours 1 caso 59 hours 1 caso 173 hours 1 caso 60 hours 1 caso 183 hours 1 case 65 hours 1 caso 192 hours 1 caso 66 hours 2 casos 200 hours 1 caso 67 hours 2 casos 203 hours 1 caso 73 hours 1 caso 213 hours 1 case 75 hoi us 1 case 221 hours 1 caso 76 hours 1 case 228 hours 1 caso 78 hours 1 case ' 231 hours 1 caso 79 hours 1 caso 235 hours 1 caso 81 hours 1 caso 238 hours 1 caso 83 hours 1 caso 25 7 hours 1 caso 84 hours 2 casos 266 hours 1 case 85 hours 1 caso 295 hours 1 caso 86 hours 3 cases 315 hours 1 caso 87 hours 2 casos 427 hours 1 caso 91 hours 1 case 527 hours 1 caso 92 hours 1 caso Avoragos 1X5 hours 16 minutes 365 TAHLS CCLXII PRINCIPAL FOUND INTRA-. ABDO’CCNAL BTCDIAT ’E G;A1SE OF DEATH, NOT SHOCK LAOS - SHRGERT TO DEATH - STAC HOSP OASES No rocord 34. cases 101 hours 1 case 1 hour 1 caso 105 hours 1 caso 3 hours 1 case 106 hours 1 cas 0 4 hours 1 caso 110 hours 1 caso 5 hours 1 case 112 hours 1 caso 7 hours 1 caso 115 hours 1 caso B hours 2 cases 124 hours 1 caso 9 hours 1 caso 135 hours 1 caso 11 hours 2 casos 136 hours 1 case 14. hours 2 casos 145 hours 1 caso 15 hours 1 caso 150 hours 1 caso 17 hours 1 case 163 hours 1 case IB hours 2 casos 166 hours 2 casos 27 hours 1 caso 167 hours 1 caso 33 hours 1 caso 1B6 hours 1 caso 4.6 hours 2 casos 193 hours 1 caso 4-7 hours 1 caso X98 hours 1 caso 4.B hours 2 cases 20B hours 1 caso 4.9 hours 1 caso 224 hours 1 caso 5B hours 1 caso 23B hours 1 caso 59 hours 1 caso 242 hours 1 case 60 hours 1 caso 247 hours 1 case 64. hours 1 caso 251 hours 1 case 66 hours 1 caso 25B hours 1 caso 69 hours 1 caso 269 hours 1 caso 71 hours 1 caso 275 hours 1 case 72 hours 1 caso 2B1 hours 1 caso 75 hours 1 cases 295 hours 1 case 76 hours 2 cases 351 hours 1 caso BO hours 1 caso 401 hours 1 cas e 91 hours 1 caso 417 hours 1 case 100 hours 1 caso 524 hours 1 case Average: 120f 53” 366 SECTION IV Part 3 Those Cases in Tihich the Principal TTound Vlas Intra-abdominal and Peritonitis las Evident or Suspected To Be Present REMARKS The oases considered in the tables which follow are all taken from the group in which the principal wound was intra~ abdominal* (It was believed that a better picture of intra-» abdominal wounds might be obtained if they were not complicated by factors originating from concomitant wounds cf the chest and diaphragm*) Those with peritonitis and suspected peritonitis are examined in three groups* The first group is composed of those in which peritonitis was the immediate cause of death. In the second group peritonitis was evident, but not the immediate cause of death* This included the cases listed under contributory or associated conditions as "peritonitis, severe" and "peritonitis* mild or moderate." The third group is made up of those cases in which peritonitis was suspected but the evidence was not suf- ficient to confirm its presence. 368 TAHLE CCLXIII DATA RFXATTVE TO UOSPITAL ADfCBSIO? AUESTHE3IA AND SITPQTP.7 Tr TTS3E CASED IF *T*TTCF THE PRIl-TCTFAI- WTO WAS I:TTR.S-AFDOHPrAL AND PERITONITIS "'AS BVJDE'TT OP. SUSPECTED TO IRESE’T (17-< CASES) F eritonitis F er itonit:* s Immed a ate C ontr ibutorv Cause of Death to Death Feritonit ■Suspected Died bef ore ane stbe s ia 0 2 0 Died during anesthetic induction 0 2 0 Died during primary surgery 0 3 0 Died after primary surgery 46 76 46 TOTAL 46 83 46 369 TABLE CGLXIY OPERATING THE FOR FRPuiRY SURGERY IN THOSE CASES IN T:HICH THE PRINCIPAL HOUND NAS INTRA-ABDOMINAL AND PERITONITIS WAS EVIDENT OR SUSPECTED TO BE PRESENT (175 CASES) Ieritonitis Immed iate Cause of Death Peritonitis Contributory to Death peritonitis Suspected Less than 30 minutes 0 2 0 30 to 60 minutes 0 1 0 60 to 90 minutes 1 0 1 90 to 120 nrnutes 1 3 1 190 to 150 minutes 0 5 3 150 to 180 minutes 3 4 0 180 to 210 minutes 4 6 0 210 to 24.0 minutes 2 1 0 240 to 300 minutes 1 1 0 300 to 36O minutes 0 1 0 Not stated 34 59 41 TOTAL'CASES 46 83 46 Average time in minutes; ISC 154 117 370 TABLE CGLXY DATA RELATIVE TO FRUIOY SURGERR O' TR05E CASES T:r TRICE THE IRXTCTPAL TOU'TD I*TPRA-ABDO!OTAI- / MD FH IT OTITIS WJ ETTTDEATT OR SUSPECTED TO BE TRESES (175 CASES) Peritonitis Immediate Cause of Death Peritonitis Contributory to Death Peritonitis •Suspected Lap ar ot omy perf or me d 45 eo 44 Debridement, abdominal wall wound only 0 2 1 Debridement other wounds, with primary operation associated 41 44- 26 Debr id ement other w ound s, deliberately omitted 1 4 1 Debridement other wounds, done partially 1 8 0 Debridement other wounds, statement regarding no 3 25 18 371 TAELS C CLXVI SECONDARE OITRATTQ-TS a.'T) 0'OrO'v’VT TEERAir T" TT'n3~' CASES J ™VIGT" TT0?. FRT'TCXT AX' 7*0UM) Tfl3 TErRA~ABDOT7TTTAT. A7D FERJTO-TTTS "AS BRIDE A’ OR RESPECTED TO BO PROSE ■'IT (173 C ASES) I eritonitis Immediate Cause of Death Ieritonitis Contributory peritonitis Suspected •Secondary Operations Amputation 1 0 0 Debridement 1 1 2 Laparotomy 2 3 0 Opening of colostomy 0 0 1 ■Secondarv closure 1 1 i 3tostomy 0 1 0 Oxymen Therapy Before operation 1 6 1 During operation 19 31 10 After operation 7 23 c ■'Jo record 22 AO 2C 372 TABLE CGLXVII DATA O'T CHEMOTHERAPY IN THOSE CASES IY rTTRA-APDOMI'IAL AST) PERITONITIS IAS (175 CASES) -jT-TTQT-T 'juts' TRT’rC’ OR SUSPECTED TO IP AT • WtJOTD BO- 3 PJOAE 'iT Peritonitis Immedlate Cause of De - th Peritonitis Contributor;- I sriton*”ti;? 3n 7 scted Chemotherapy (Excludes local at first dressing) Suitonamid alone 13 34- 14, Fenic i 11 in alone 9 e 3 Sulfonamid & penicillin 17 23 H :'io record 7 UJ 1—1 10 TOTAL 46 B3 46 373 TABLE CGLXVIII ADMISSIO ■ BLOOD FRESSURE I’ TTJ CASES "rA3 TRTRA-ABDOMITT£L AUD PERITONITIS RA.S ID! (175 CASES) ttm rpictt tee : T OR SUSI E Cl FRISCH AT T'T0UFD V~D TO BE PRESET F eri toniti g Immediate Gauge of De :th Fsri.ton.it is Contributory peritonitis Suspected Sy in stolic BF mni. Fg. Zero 1 10 0 2 - J>t 0 0 0 40 - 5B 1 3 3 60 - 6B 1 1 0 70 * 78 1 1 1 i o VJ 88 3 4 0 90 - 98 0 5 1 100 - 118 2 4 2 120 - 138 5 3 3 14.0 - 158 0 1 0 io record 32 55 36 37^ TABLE CCLXIX SHOCK DAT/: 0” THOSE CASES IT' WHICH THE ABDOTII T/.L ;:D HER ITCH JT IS HAS EVTDE’N1 OR SIT PRINCIPAL WOUND WAS I TRA- SPECTT) TO EE BREST "T (175 CASES) Peritonitis Immediate Cause of Death p er itonitis F er51 onitis Contributorv Suspacted Lowest Systolic BE in nm. Kg* Zero Shock Present 3 16 1 2 - 38 " «> 0 2 0 AO - 58 " " 2 22 5 60 - 78 " »» 2 A 1 80 - 88 »» " 2 5 1 90 - 98 " » 3 A 2 100 or more but pulse rapid and weak 3 1 2 Presence of shock stated (no other data) 8 23 11 Shock suspected but record inadequate 3 3 A Treatment suggests shock (no other data) 18 26 19 No evidence of shock 2 1 0 TOTAL A6 87 A6 375 TABLE CCLXX DAT * O'T tlRTNAET EXCRETI0T J T TF0S’T CASES I" WUTCU TFE FRI EDIT AT WOUEO EA3 rETRA-ARDOAIUAL AUD TERTTOUITTS 'VS EVIDE.UT OR SUSPECTED TO BE IF HESS'VT (:175 GASES) Feri.ton5.t5 .3 peritonitis peritonitis Immediate Contr .1 but or; Snaps cted Cause of Death Adequate output 5 3 1 Apparently sdeouate but record incomplete 2 1 1 Anur 5 a 0 e o Oliquria recorded 2 13 3 Oliguria suspected 3. 5 2 Ureu5 a suspected 2 9 2 Uremia 0 9 0 Record inadequate 36 56 39 376 TABLE CCLXXI NUMBER CP AUTOPSIES IN THOSE CASES IN TNTRA-ADD 0? TPTAL AMD IER IT OMIT IS MAS MIDI. (175 CASES) EH IGF TFE PRINCIPAL WOTRD MAS T OR SUSPECTED TO BE PRESENT P eriton.it 5.3 Immediate Cause of Death peritonitis Contributory P er it on? .tig Suspected Gross autopsy done no microscopic 22 4.1 7 Gross autopsy done microscopic reported 13 29 0 Total autopsies 35 70 7 No autopsy 11 17 39 377 TABLE CCLXXII THE MEDIATE CAUSE OF DEATH IN THOSE CASES IN WICH THE PRINCIPAL WOUND WAS INTRA-ABDOMINAL AND PERITONITIS WAS EVIDENT OR SUSPECTED TO BE PRESENT (175 CASTS) Petitonitis Immediate Cause of Death Peritonitis Contributory Peritonitis Suspected IMMEDIATE CAUSE OF DEATH; Peritonitis 4.6 0 0 Shock 0 39 6 Pigment’nephropathy 0 12 0 Ineumonia 0 Q y 2 Fat embolism (pulmonary) 0 3 0 Thrombotic embolism (pulmonary)0 2 0 Cellulitis, abdominal 0 1 1 Clostridial myositis, trunk 0 1 0 Clostridial myositis, extremityO 1 1 Intestinal obstruction 0 1 0 Sepsis, abdominal, unclassified© 1 0 Tracheobronchial obstruction, aspirated vomitus 0 1 0 Transfusion reaction 0 0 1 Undetermined, abdominal 0 2 0 Undetermined, unclassified 0 14 35 TOTAL 46 87 46 373 TABLE CCLXXIII ETIOLOGY OF SHOCK AS A CONTRIBUTORY OH ASSOCIATED CONDITION IN THOSE CASES IN WHICH THE PRINCIPAL WOUND WAS INTR/L, ABDOMINAL & PERITONITIS WAS EVIDENT OR SUSPECTED TO HE PRESENT Peritonitis Immediate Cause of Death Peritonitis Contributory Perit onitis Suspected ETIOLOGY OR TYPE OE SHOCK: Oardio-respiratory embarrassment plus trauma & hemorrhage 1 0 / 1 Cardio-respiratory embarrassment plus trauma & hemorrhage plus contamination or sepsis 0 1 0 Contamination or seosis ulus trauma & hemorrhage k2 hi 35 Trauma & hemorrhage 1 6 1+ 379 TABLE CGLXXIV DATA ON SHOCK IN ITS INCIDENCE AS A CONTRIBUTORY OH ASSOCIATED CONDITION IN THOSE OASES IN WHICH THE PRINCIPAL WOUND WAS INTRA-ABDOMINAL & PERITONITIS WAS EVIDENT OR $BPBCTED TO HE PRESENT Peritoniti s Immedi at e Cause of Death Peritonitis Contributory Peritonitis Suspected Shock present, corrected by therapy 29 31 IS Shock present, successful correction doubtful 12 13 IS Shock present, uncorrected 1 k 2 Shock suspected, not proved 2 0 2 No evidence of shock 2 1 0 3S0 TAHLS CGLXXY INTRACRANIAL, MAYILLOFACTAL, CERVICAL, I'ttr «VERTEBRAL AMD extremity contributory or associated conditions occmiNG IN THOSE C..SES IN TA] ICH THE PRINCIPAL rOUx© NAS INTRA- ABDOMIMAL A'JD PERITONITIS WAS EVIDENT OR SUSPECTED TO BE PRESENT Peritonitis Immediate Cause of Death Peritonitis Contributory Peritonitis Suspected CONTRIBUTORY OR ASSOCIATED CONDITIONS; Intracranial "blast trauma suspected 0 1 0 Enc ephalo raalaci a 0 1 0 Intracranial hemorrhage (or hematoma) preouerative 0 1 0 Cerebral ischemia 0 0 1 Intracranial trauma, evident 1 1 0 Maxillofacial trauma 1 2 3 Cervical hemorrhage 0 1 0 Cervical trauma 1 2 i Suinal hemorrhage 1 1 0 Transection of cord, complete 0 1 0 Transection of cord, partial 0 1 0 Spinal trauma 1 7 3 Frostbite or immersion syndrome 0 l 0 Extremity hemorrhage 1 k 2 Extremity sepsis 5 3 1 Extremity trauma, unclassified 26 52 20 381 TABLE C CLXXVI THORACIC CONTRIBUTORY OH ASSOCIATED CONDITIONS OCCURRING IN THOSE CASES IN WHICH THE PRINCIPAL WOUND WAS INTRA-ABDOMINAL AND PERITONITIS WAS EVIDENT OR SUSPECTED TO BE PRESENT (i) Peritonitis Immediate Cause of Death Peritonitis Contributory Peritonitis Susuected CONTRIBUTORY OR ASSOCIATED CONDITIONS; Atelectasis, severe 1 1 0 Atelectasis, slight or moderate 6 11 i Thoracic blast trauma, evident 1 1 0 Thoracic blast trauma, suspected 2 k 2 Dilatation of heart, marked 1 3 1 Dilatation of heart, slight or moderate 3 0 Empyema, mild or moderate l i 0 Empyema, suspected 2 0 0 Hemopneumothorax, evident 1 0 0 Hemopneumothorax, suspected 0 0 1 Hemothorax without pneumothorax 1 1 0 Hydro thorax, severe 1 0 1 Hydrothorax, slight or moderate 5 15 0 Intrauulmonary hemorrhage, mild or moderate 3 5 0 Intrauulmonary hemorrhage, severe 0 2 0 Intrauulmonary hemorrhage, susuected i 0 0 Lung abscess i 0 0 Mediastinal emuhyseraa i 0 0 3S2 Continued on next page TABLE CCLXXVI ContTd THORACIC CONTRIBUTORY OR ASSOCIATED CONDITIONS OCCURRING IN THOSE CASES IN WHICH THE PRINCIPAL WOUND WAS INTRA-ABDOMINAL AND PERITONITIS WAS EVIDENT OR SUSPECTED TO BE PRESENT (2) Peritonitis Immediate Cause of Death Peritonitis Contributory Peritonitis Suspected CONTRIBUTORY OH ASSOCIATED CONDITIONS s Mediastinal hemorrhage 0 1 0 Myocardial decompensation, evident 7 S k Myocardial decompensation, susp ect ed 7 16 k Pneumonia, mild or moderate 11 ll 0 Pneumonia, s evere 2 5 0 Pneumonia, suspected 1 0 h Pneumonitis 2 0 0 Pneumothorax without hemothorax 0 0 1 Pulmonary edema, severe 10 l6 6 Pulmonary edema, slight or moderate 7 12 i Purulent "bronchitis 3 2 i Tracheobronchial obstruction, aspirated vomitus l 0 0 Tracheobronchial obstruction, blood & mucus 3 1 0 Tracheobronchial obstruction, suspected 0 0 1 Thoracic trauma, unclassified 2 11 3 383 TABLE CCLXXVII ABDOMINAL CONTRIBUTORY OH ASSOCIATED CONDITIONS OCCURRING IN THOSE CASES IN WHICH THE PRINCIPAL WOUND WAS INTRA-ABDOMINAL AND PERITONITIS WAS EVIDENT OR SUSPECTED TO BE PRESENT (i) Peritonitis Immediate Cause of Death Peritonitis Contributory Peritonitis Susuected CONTRIBUTORY OH ASSOCIATED CONDITIONS: AMo mi nop el vie trauma, unclassified 0 6 6 Abscess, extraperl toneal 2 6 0 Abscess, intruder!toneal 3 2 0 Adrenal hemorrhage 0 2 0 Adynamic ileus, mild or moderate k 6 1 Adynamic ileus, severe 7 U 5 Abdominal blast trauma, evident 0 3 i Abdominal blast trauma, suspected 2 0 0 Cellulitis etc, mural & extra- peritoneal 1 k 0 Contamination from hollow viscus UU 82 hi Evisceration, postoperative 0 2 0 Evisceration, preoperative 7 7 8 Evisceration, preoperative & postoperative i 0 1 Gangrene of bowel, advanced 3 2 0 Gangrene of bowel, early 1 2 0 Gastric dilatation 3 3 0 Abdominal hemorrhage, primary 31 6o 35 Continued on next page 384 TABLE CCLXXVII Cont*d ABDOMINAL CONTRIBUTORY OH ASSOCIATED CONDITIONS OCCURRING- IN THOSE CASES IN WHICH THE PRINCIPAL WOUND WAS INTRA-ABDOMINAL AND PERITONITIS WAS EVIDENT OR SUSPECTED TO BE PRESENT (2) Peri ton!tls Immediate Cause of Death Peritonitis Contributory Peritonitis Suspected CONTRIBUTORY OR ASSOCIATED CONDITIONS? Abdominal hemorrhage, recurrent or delayed 0 6 1 Hepatic degeneration, toxic 8 7 2 Hepatitis, epidemic, evident 0 1 0 Hepatitis, epidemic, suspected 1 1 0 Hepatitis, seotic, secondary to trauma, evident 3 2 0 septic, secondary to trauma, suspected 0 3 2 Intestinal obstruction (mechanical) mild or moderate 1 1 0 Intestinal obstruction (mechanical) suspected 0 0 2 Leaking suture line k 0 0 Nephropathy, evident,unclassified 1 g 0 NeT)hro-nathy5 suspected 6 6 7 Nephropathy, toxic, degenerative 7 3 i Operative wound infection 6 2 i Other abdominal condition 1 2 i Pancreatic hemorrhage 0 1 0 Continued on next page 385 TABLE CGLXXVII Oont’d ABDOMINAL CONTRIBUTORY OR ASSOCIATED CONDITIONS OCCURRING- IN THOSE CASES IN WHICH THE PRINCIPAL WOUND WAS INTRA-ABDOMINAL AND PERITONITIS WAS EVIDENT OR SUSPECTED TO EE PRESENT (3) Peritonitis Immediate Cause of Death Peritonitis Contributory Peritonitis Suspected CONTRIBUTORY OH ASSOCIATED CONDITIONS; Pancreatic trauma 2 5 1 Peritonitis, mild or moderate 0 50 0 Peritonitis, severe 0 37 0 Peritonitis, suspected 0 0 h6 He nal s ep s i s (par enchymal) 2 0 0 Henal trauma, evident U 13 6 Splenic degeneration, toxic 3 3 0 Splenomegaly k 3 0 Unrepaired wound of hollow viscus 5 7 0 Ureter traumatized or tied, evident 2 5 0 Ureter traumatized or tied, susuected 0 1 1 Urinary tract sepsis 2 5 0 Undetermined, contamination &/or hemorrhage, susuected 0 0 1 386 TABLE CCLXXVIII CLOSTRIDIAL MYOSITIS AS A CONTRIBUTORY OR ASSOCIATED CONDITION OCCURRING IN THOSE CASES IN WHICH THE PRINCIPAL WOUND WAS INTRA-ABDOMINAL AND PERITONITIS WAS EVIDENT OR SUSPECTED TO BE PRESENT Peritonitis Immediate Cause of Death Peritonitis Contributory Peritonitis Suspected CONTRIBUTORY OR ASSOCIATED CONDITION: Clostridial myositis of ex- tremity 9 evident 0 2 0 Clostridial myositis of ex- tremity, susnected k 0 1 Clostridial cerehritis or myositis of head, neck or trunk, evident 1 0 0 Clostridial cerehritis or myositis of head, neck or trunk, suspected 1 2 0 387 TABLE C CLXXIX EMBOLISM, INFARCTION, THROMBOSIS, AS CONTRIBUTORY OR ASSOCIATED CONDITIONS OCCURRING- IN THOSE CASES IN WHICH THE PRINCIPAL WOUND WAS INTRA-ABDOMINAL AND PERITONITIS WAS EVIDENT OR SUSPECTED TO BE PRESENT Peritoni tis Immediate Cause of -Death Peritoni tis Contributory Peritonitis Suspected CONTRIBUTORY OR ASSOCIATED CONDITION; Embolism, fat, evident 1 2 0 Embolism, fat, suspected 1 1 k Embolism, pulmonary, thrombotic, suspected 0 1 2 Embolism, brain, thrombotic, sust) ec ted 0 0 1 Embolism, pulmonary, thrombotic & infarction 1 0 0 Infarction, liver alone 1 0 0 Infarction, lung alone 0 1 0 Infarction, lung & liver, throne bosis, extremity, vein 1 0 0 Infarction, lung, thrombosis, mesentery 1 0 0 Thrombosis, kidney, evident 0 1 0 Anemia, refractory or severe 0 1 0 388 TABLE CCLXXX MISCELLANEOUS BATA IN THOSE CASES IN WHICH THE PRINCIPAL WOUND WAS INTR A-A 3B0MINAL AND PERITONITIS WAS EVIDENT OR SUSPECTED TO 33 PRESENT Peri tonitis Immediate Cause of Death Peritonitis Contributory Peritonitis Suspected Jaundice 3 k 1 Malnutrition, severe l 0 0 Shock death susuected 0 1 7 Transfusion reaction, severe 0 1 i Blast death, suspected 0 0 i 389 TABLE CGLXXXI TIME LAGS WOUNDING TO FIELD HOSPITAL IN THOSE CASES IN WHICH THE PRINCIPAL WOUND WAS INTRA-ABDOMINAL AND PERITONITIS WAS THE IMMEDIATE CAUSE OF DEATH. 24 CASES Hours ?tounding to Field Hospital No. of Gas os 1 1 2 1 3 3 4. 3 6 1 7 3 8 1 9 1 11 1 12 1 13 2 U 1 16 1 46 1 No record 4 AVERAGE: 7.6 390 TABLE CCLXXXII TIRE LAGS WOUNDING TO EVA.G • HOSPITAL IN THOSE CASES IN WHICH THE PRINCIPAL WOUND WAS INTRA-ABDOMINAL AND PERITONITIS THE IMMEDIATE CAUSE OF DEATH. 21 GASES Hours ’'founding to Bvac. Hospital No, of Cases 1 1 2 1 4 2 6 3 7 3 8 1 9 1 10 1 11 1 12 1 13 1 18 1 23 1 50 1 No record 2 AVERAGE: 8,2 391 TABLE CCLTOCIII TIME LAGS ADMISSION TO SHRGERY IN FIELD HOSPITAL IVT THOSE GASES IN WHIGH THE PRINCIPAL WOTTND WAS INTRA-ABDOMINAL & PERITONITIS THE MEDIATE CAUSE OP DEATH Hours Admission to Surgery No, of Gas os 1 2 2 2 3 3 4. 1 5 3 6 1 8 1 13 1 4*4 1 No record 9 AVERAGE; 5c7 392 TABLE CCLXXXIV TIME LAGS ADMISSION TO STTRGE.RY IN EMAC • HOSPITAL I T those gases IN WHICH THS PRINCIPAL WOUND WAS INTRA- ABDOMI * TAL & PERITONITIS THE IMMEDIATE GATBE OF DEATH Hours Admission to Surgery No, of •Cases I 1 2 4 3 5 5 2 7 2 B 2 9 1 14 1 No record k 393 TABLE CCLXXXV ' ’TIME LAGS STTRGERY TO DEATH IN FIELD & MG, .HOSPITALS IN mOSE CASES IN WHICH THE PRINCIPAL WOHND WAS INTRA-ABDOMIFAL & PERITONITIS WAS THE MEDIATE CA'TSE OF DEATH 4.6 GASES Hours Surgery to Death No. of Cases f Hours of r Surgery t to Death No, of Gases 8 1 t » 3.48 f 1 11 1 • 150 t 1 17 1 f 166 i 1 33 1 r 208 T 1 4.0 1 * 231 i 1 4 6 1 » 238 t 1 47 1 T 242 i 1 49 2 T 252 t 1 50 1 1 257 i 1 58 1 * 295 t 1 60 1 > 298 t 1 66 1 T 351 i 1 73 1 1 417 T 1 103 1 ’ 527 f 1 115 1 f No record f 12 126 1 t I 133 ]. t t 135 1 t 136 1 ’ AVERAGE: ! 149.5 394 TOTAL CCLXXXVI TIME LAGS WOTTNDING TO FIELD HOSPITAL IN THOSE GASES IN PHI OH THE PRIMGIPAL WOUND WAS INTRA- ABDOMINAL AND PERITONITIS WAS GONTHIBTJTORy BT1T NOT THE MEDIATE CAT1SE OF DEATH, 53 GASES Hours Wounding to F* H. No, of Gas os ' Hours f Wounding 1 to P. H. t No. of Cases 0 . 1 t 16 1 2 3 r i 17 2 3 7 t 19 1 4. 1 t » 20 1 5 3 ! i 21 1 6 2 T t 22 2 7 2 t t 24. 1 8 2 » t 36 1 9 4. t i 39 1 10 1 ! f No record 10 11 2 t ? 12 1 i i U 1 t 15 2 T AVERAGE: t 10,8 395 TABLE CCLXXXVII TIME LAGS WOUNDING TO HOSPITAL IN THOSE CASES IN WHICH mHE PRINCIPAL WOUND W.'S INTRA-ABDOMINAL AND PERITONITIS WAS CONTHIBTWOHy RUT NOT THE IMMEDIATE C'WSE OF DEATH 34 CASES Hours No, of Wounding Gas os to Evag• . 1 1 3 2 4 4 t 5 3 6 2 7 5 8 2 9 3 10 1 16 1 17 1 24 1 25 1 29 2 38 1 No record 4 AVERAGE: 10 396 TABLE CCLXXXVIII Til LAGS ADMISSION TO SWOT IN FIELD HOSPITAL IN THOSE GASES IN WHICH THE PRINCIPAL WOUND WAS INTRA-ABDOMINAL AND PERITONITIS WAS CONTRIBTITORy BHT NOT THE IW MEDIATE CATTSE OF DEATH Hours Adm. to Surgery No, of Gases 1 3 2 5 3 5 4 11 5 2 6 4 7 4. 8 3 10 2 11 1 No record 13 AVERAGE: 4.7 397 TABLE CCXXXIX TP® LAGS ADMISSION TO SURGERY- IN WAV HOSPITAL IN THOSE GASES IN WHICH THE PRINCIPAL WOUND WAS INTRA- ABDOMINAL AMD PERITONITIS WAS CONTRIBUTORY BUT NOT THE PP'fEDIArT1E CAttse OF DEARTH Hours Adm to Surgery No. of cases 1 1 2 3 3 2 4- 4- 5 2 6 3 8 2 10 4. 11 1 15 2 25 1 No record 9 AVERAGE: 7.1 398 TABLE CCXC TIME LAGS, SURGERY TO DEATH IE FIELD & EVAC HOSPITALS IN THOSE OASES IE WHICH THE PRIECIPAL WOUED WAS IETIUL, ABDOMINAL & PERITONITIS WAS CONTRIBUTORY BUT EOT THE IMMEDIATE CAUSE OF DEATH (1) Hours Surgery te Death Ho, of Cases 0 1 1 2 2 3 3 3 4 1 5 1 s 3 9 3 10 1 13 3 ih 2 15 2 17 1 is 2 19 1 26 1 27 2 35 1 36 1 ks 1 399 Continued on next uage TABLE CCXC Cont’d. TIME LAGS, SURGERY TO DEATH IN FIELD & EVAG HOSPITALS THOSE CASES IN WHICH THE PRINCIPAL WOUND WAS INTRA- ABDOMINAL & PERITONITIS WAS CONTRIBUTORY BUT NOT THE IMMEDIATE CAUSE OF DEATH (2) Hour a Surgery to Death Do. of Cases Uq 1 59 2 6o 2 66 1 67 1 75 2 76 1 78 1 79 1 80 1 83 1 8U 1 86 1 91 1 92 1 100 1 110 1 12U 1 132 1 1U5 1 Continued on next uage 400 TABLE CCXC Cont’d. TIME LAGS, SURGERY TO DEATH IN FIELD & EVaC HOSPITALS IN THOSE CASES IN WHICH THE PRINCIPAL WOUND WAS INTRJU ABDOMINAL & PERITONITIS WAS CONTRIBUTORY BUT NOT THE IMMEDIATE CAUSE OF DEATH (3) Hours Surgery to Death No. of Cases 166 1 193 1 203 1 213 1 221 1 258 1 295 1 315 1 U93 1 32k 1 401 SECTION V SPECIAL STUDIES Oil ALL THE CASES (£23) IN "WHICH THE LE'EDIATE CAUSE OF DEATH ' 'AS SHOCK PRELIMINARY REMARKS Reasons for recording shock as an immediate cause of death- in this study have been mentioned on pages SI end S2 in Section III. The cases which have been listed under this heading have been those in which there was good evidence of peripheral cir- culatory failure initiated by the initial trauma and hemorrhage, and perpetuated by trauma and hemorrhage with or without the added shock-producing factors of cardiorespiratory embarrassment, peri- toneal contamination from a wound of a hollow viscus, or early sepsis, or any combination of these factors. Tables on the "Eti- ology of Shock" show the evidence of these vp-rious factors. No effort was made to separate the factors of trauma and hemorrhage, as both occur in varying degrees and proportions in every battle casualty. In 13 casesfrecurrent or delayed abdominal hemorrhage was a factor. The tables which follow relate to the 323 cases in the series of IU50 deaths in which shock was listed as the immediate cause of death. Uo3 TA3LB CCXCI LOCATION OE PRINCIPAL WOUND IN ALL THOSE CASES IN WHICH THE IMMEDIATE CAUSE OE DEATH WAS SHOCK LOCATION OP PRINCIPAL WOUND CASES Intra-abdominal 17S Thoraco-abdominal 118 Intrathoracic 70 Unclassified* multiple Lower extremity, bone & soft tissue hi Combined intra— abdominal & intrathoracic 25 Intracranial 15 Cervical 11 Lower extremity, soft tissue 9 Intravertebral 1+ Uoper extremity, bone & soft tissue 3 Upper extremity, soft tissue 2 ofacial 1 Abdominal wall 0 TOTAL CASES 523 404 TABLE CCXCII DATA RELATIVE TO HOSPITAL ADMISSION ANESTHESIA, AND SURG-EHY IN AIL THOSE CASES IN WHICH THE IMMEDIATE CAUSE OE DEATH WAS SHOCK ♦I Dead on Arrival 25 *11 Dying on Admission 55 *111 Died before Anesthesia (Excludes I & II) 135 *IV Died during Anesthetic Induction 6 *Y Died during Primary Surgery Us ♦VI Died Subsequent to Primary Surgery TOTAL CASES 523 sf« These Homan numerals will be used in subsequent tables in this section as symbols to represent respective groups of cases with which they are identified in this table. the 405 TAHLE CCXCIII ETIOLOGY OF SHOCK IN ALL THOSE CASES IN WHICH SHOCK WAS THE IMMEDIATE CAUSE OF DEATH I II III IV V VI TOTAL ETIOLOGY OF SHOOS j Trauma & hemorrhage 15 35 71 0 10 53 ISk Contamination or sepsis plus trauma & hemorrhage • 1 2 10 3 11 93 120 Cardiorespiratory embarrassment plus trauma & hemorrhage plus con- tamination or sepsis 1 1 10 0 12 'ks 72 Cardiorespiratory embarrassment plus trauma & hemorrhage S 17 3 15 6o iky TOTAL CASES 25 55 135 6 ks 25U 523 406 TABLE GGXCIV ADMISSION BLOOD PRESSURE IN THOSE CASES IN MICH THE IMMEDIATE CAUSE OF DEATH WAS SHOCK Arterial Tension in mm* Hg II III TV V VI Total cases Zero 10 23 1 2 18 54 2 to 38 0 0 1 0 2 3 40 to 58 0 9 0 1 8 18 60 to 68 1 5 0 1 9 16 70 to 78 0 3 1 2 8 34 80 to 88 2 4 0 1 17 24 90 to 98 0 6 0 2 9 17 100 to 118 0 0 0 6 13 19 120 to 138 0 1 \ 0 2 6 9 140 to 158 0 1 0 0 2 3 No record 42 83 3 31 162 321 407 TABLE CCXCV LOWEST RECOBLED BLOOD PRESSURE* ALL OTHER EVIDENCE IN THOSE CASES IN WHICH THE IMMEDIATE CAUSE OE DEATH WAS SHOCK Arterial Tension in mm, Hg II in IV V f VI Total Cases Zero, shock nresent 10 26 1 7 91 2 to 33, shock present 0 0 1 1 2 4 IfO to 53, diock present 0 10 0 2 16 28 60 to 73, shock present 1 9 1 3 28 k2 80 to 88, shock present 2 7 0 2 IS 29 90 to 93, shock present 0 3 0 2 8 13 100 or more hut pulse rapid & weak:, (no comment on shock in record) 0 0 0 1 3 If Presence of shock recorded IS 52 2 15 77 16U Shock suspected hy inference 9 7 0 2 k 22 Treatment suggests shock 15 21 1 13 51 101 *Excluding the gradual terminal decline immediately preceding death u 4ca TABLE CCXCVI PLASMA THERAPY BEFORE ADMISSION IN THOSE CASES IN WHICH SHOCK WAS THE IMMEDIATE CAUSE OF DEATH Ho, of Units* 0 1 2 3 k 5 6 7 8 9 10 11 or more Total Cases Dead on arrival Ik 3 k 1 2 0 1 0 0 0 0 0 25 Dying on admission^ 7 8 k 5 1 2 3 1 1 0 0 55 Dying before anes- thesia 50 12 2k 20 9 8 k 3 If 1 0 0 155 Dying during anes- thetic induction 2 0 0 2 1 1 0 0 0 0 0 0 6 Dying during prim- ary surgery 13 6 15 6 U 2 1 1 0 0 0 0 k% Dying after surg- ery 66 ko 60 30 25 13 11 3 2 2 1 1 25U TOTAL CAS5Bi6g 68 111 63 k6 25 19 10 7 U 1 1 523 * (l Units 25000) 409 TABLE CCXCVII PLASMA. THERAPY AFTER ADMISSION, BEFORE SURGERY IN THOSE CASES IN WHICH SHOCK WAS THE IMMEDIATE CAUSE OF DEATH Ha of Units* 0 1 2 3 U 5 6 7 s 9 10 11 or more Total Cases Dead on arrival 2U 0 0 l 0 0 0 0 0 0 0 0 25 Dying on admission Ul s 5 l 0 0 0 0 0 0 0 0 55 Dying before anes- thesia 2U 22 15 10 5 7 2 2 1 2 2 135 Dying daring anes- thetic induction 1 0 3 0 2 0 0 0 0 0 0 0 6 Dying daring pri- mary surgery 32 2 5 3 0 3 0 1 1 0 1 0 Us Dying after sur- gery lUo 19 39 22 17 5 5 2 1 1 0 3 25U TOTAL CASES 281 53 ?U U2 29 13 12 5 1+ 2 3 5 523 * (l Unit: 250cc) 4io TABLE CCXCYIII PLASM THERAPY DURING SURGERY IE THOSE CASES IN WHICH SHOCK WAS THE IMMEDIATE CAUSE OE DEATH No. of Units* 0 1 2 3 h 5 6 7 s 9 10 11 or more To tal Cases Dying during anes- thetic induction 6 0 0 0 0 0 0 0 0 0 0 0 6 i>ying during pri- mary surgery 1 3 1 0 0 0 0 0 0 0 0 If8 Dying after sur- gery 210 6 20 If 6 3 2 0 3 0 0 0 25U TOTAL CASES 259 7 2h 5 6 3 2 0 3 0 0 0 308 * (l Unit! 25Ccc) TABLE CCXCIX PLASMA THERAPY AETER SURGERY IN THOSE CASES IN WHICH SHOCK WAS THE IMMEDIATE CAUSE OE DEATH Ho. of Units* 0 1 2 3 k 5 6 7 8 9 10 11 or more Total Cases Dying after surgery 210 12 18 5 k 0 2 2 1 0 0 0 25^ * (l Unit: 250cc) 411 tahle ccc BLOOD THERAPY 3BP0EE SURGERY IN THOSE CASES IE WHICH SHOCK mS THE IMMEDIATE CAUSE OP DEATH Ho., of Units*0 1 2 3 k 5 6 7 8 9 10 11 or more Total Cases %ing on admission 9 3 0 0 0 0 0 0 0 0 0 55 laying before anes- thesia 31 36 22 19 13 k 5 0 k 0 1 0 135 Dying daring anes- thetic induction Dying during pri- 0 0 2 1 2 0 1 0 0 c 0 0 6 mary surgery ik 7 9 6 8 0 2 0 0 2 0 0 U8 Dying after sur- gery 87 hi 31 26 9 6 5 1 1 k 0 25^ TOTAL GASES * (l Unit: 500cc) 175 S3 79 57 13 Ik 5 5 3 5 0 U98 412 TABLE GCCI BLOOD THERAPY DURING SURGERY IN THOSE CASES IN WHICH SHOCK WAS THE IMMEDIATE CAUSE OP DEATH No, of Units* 0 1 2 3 U 5 6 7 8 9 10 11 or more Total Cases Dying during pri- mary surgery 27 5 7 2 1 0 2 2 1 0 1 0 U8 %ing after sur- gery lUl 19 Ul 28 13 7 3 0 1 i 0 0 25U TOTAL CA3DS 168 2U Us 3C lU 7 5 2 2 i 1 0 302 * (l Unit: 500 cc) TABLE CCGII BLOOD THERAPY APTEH SURGERY IN THOSE CASES IN WHICH SHOCK ms THE IMMEDIATE CAUSE OP DEATH No, of Units* 012 3 k 5 6 7 8 9 10 11 or Total more Cases Dying after surgerylSl 29 22 6 5 5 1 1 1 2 0 1 * (l Unit: 5CCcc) 413 TABLE CGCXII PRIMARY OPERATIONS PERFORMED ON THOSE CASES IN WHICH THE MEDIATE CAUSE OF DEATH WAS SHOCK . v j V VI Total cases Abdominal stab without laparotomy 1 6 7 Amputation 2 17 19 Craniotomy 1 A 5 Debridement only 5 36 <41 Laminectomy 1 3 A Laparotomy 5 168 173 Other operation 1 3 A Thor ac olap arot omy 3 7 10 Thoracotomy U 50 6A 414 TABLE CCCIV DEBRIDEMENT ASSOCIATED WITH PRIMARY OPERATION IN THOSE CASES IN WHICH THE IMMEDIATE CAUSE OF DEATH WAS SHOCK V VI Total cases All wounds 10 123 133 Omitted deliberately 8 9 17 No statement regarding U 6 M SI Partial 8 22 30 . TO UAL CASES 218 261 415 TABLE CCCV SUBSIDIARY OPERATION AT TIME OF PRIMARY IN THOSE CASES IN WHICH THE IMMEDIATE CAUSE OF DEATH WAS SHOCK V VI Total cases Bronchoscopy 1 1C 11 Cast or plaster splint 0 32 32 Enucleation 0 1 1 Intercostal nerve block 0 4 4 Ligation of artery 1 18 19 Maxillofacial repair 0 4 U Other operation 0 20 20 Tracheotomy 0 2 2 416 TAHLS CCCVI OPERATING TIME IN THOSE CASES IN MICH THE MEDIATE CAUSE OF DEATH WAS SHOCK V VI Total cases Less than 30 minutes 3 0 3 30 to 59 minutes ♦ 4- 0 4- 60 to g9 minutes 7 7 14- 90 to 119 minutes 5 8 13 120 to minutes 7 13 20 150 to 179 minutes 4- 11 15 180 to 209 minutes 2 9 11 210 to 239 minutes 1 5 6 • 24-0 to 299 minutes 0 3 3 300 to 36O minutes 0 5 5 No record 15 . 193 20 & TOTAL OASSS ks 28U 302 417 TAHLE CCGVII SECONDARY (LATER) OPERATION IN THOSE CASES IN WHICH THE MEDIATE CAUSE OF DEATH WAS SHOCK V VI Total cases Amputation 0 -L 1 Cast or plaster splint 0 1 1 Craniotomy 0 2 2 Debridement 0 3 3 Died during secondary surgery 0 3 3 Drainage tube to pleural sac inserted 0 1 1 Secondary closure 0 1 1 Third or more operations 0 1 1 Cystostoray 0 1 1 Other operation 0 2 2 418 TABLE CCCVIII ANESTHESIA FOR PRIMARY SURGERY IN THOSE GASES IN WHICH THE IMMEDIATE CAUSE OF DEATH WAS SHOCK IV V VI Total cases Ether, closed system 3 26 86 115 Ether, Flagg method 0 0 2 2 Ether, open drop 0 0 10 10 Ether, unclassified 2 11 81 94 Endotracheal 1 27 89 117 Gas (nitrous oxide) , 3 21 77 101 Local 0 0 4 4 No record, or none 1 11 70 82 TABLE CGCIX ANESTHESIA FOR SECONDARY SURGERY IN THOSE CASES IN WHICH THE IMMEDIATE CAUSE OF DEATH WAS SHOCK IV V VI Total cases Ether, unclassified 0 0 1 1 Endotracheal 0 0 1 1 No record, or none 0 0 7 7 Pentothal 0 0 1 1 419 TABLE CCCX OXYGEN THERAPY IN THOSE CASES IN THIGH THE IMMEDIATE CAUSE OF DEATH WAS SHOCK I II III TV V VI Total cases After operation 0 1 0 0 0 4-2 43 Before operation 0 9 28 2 6 24. 69 During operation 0 0 1 1 29 98 129 No record 0 4-5 106 3 19 127 300 TABLE CCCXI URINARY EXCRETION AND UREMIA IN THOSE CASES IN MICH THE IMMEDIATE CAUSE OF DEATH WAS SHOCK I II III IV V VI Total cases Adequate output 0 0 0 0 0 1 1 Apparently adequate, but record incomplete 0 0 1 0 0 4 5 Anuria 0 0 0 0 0 2 2 Oliguria recorded 0 0 0 0 0 9 9 Oliguria suspected 0 0 0 0 0 3 3 Record inadequate 25 55 134- 6 ab 235 503 Uremia suspected 0 0 0 0 0 1 1 k20 TABLE COCXII CHEMOTHERAPY IN THOSE CASES IN WHICH THE IMMEDIATE CAUSE OF DEATH WAS SHOCK I II III TV V VI Tot ad- cases No record 24 53 107 4 25 106 319 No soda reported 1 2 13 1 12 111 140 Penicillin 0 0 16 1 14 76 107 Soda given 0 0 1 0 0 6 7 Sulfonamide 1 2 13 1 12 115 uu TABLE OGCXIII AUTOPSY PERFORMED IN THOSE CASES IN WHICH THE BRED I ATE CAUSE OF DEATH WAS SHOCK I IT III TV V VI Total cases No autopsy 13 39 B9 1 19 133 294- Partial gross done, no sections 0 0 1 1 0 2 4 Partial gross done, sections reported 0 0 0 0 0 1 1 Gross done, no sections 3 13 26 3 16 80 14-1 Gross done, sections not reported 2 0 2 1 2 9 16 Gross done, sections reported 7 3 17 0 11 29 67 TOTAL CASES 25 55 135 6 US 25^ 523 421 TABLE CCCZIV MISCELLANEOUS OBSERVATIONS IN THOSE CASES IN WHICH THE MEDIATE CAUSE OF DEATH WAS SHOCK II III IT V VI Total cases Burns present 2 3 0 0 A 9 Coma on admission B 20 0 1 7 36 Cyanosis, marked 0 2 0 3 A 9 Dying on admission 55 0 0 0 0 55 Exposure, severe, before admission 0 0 0 0 2 2 Hemorrhage, profuse, in hospital 0 1 0 9 19 29 Bailor noted A 2 0 1 2 9 Peritoneal closure impossible 0 0 0 0 A A Sweating noted 1 2 0 0 2 5 Tourniquet used before admission 6 10 0 1 12 29 Two or more of these present 18 6 0 1 7 32 422 TABLE CC&XV INTRACRANIAL CONTRIBUTORY OR ASSOCIATED CONDITIONS IN THOSE CASES IN WHICH THE MEDIATE CAUSE OF DEATH WAS SHOCK I II III r/ V VI TOTAL CASES Blast trauma, evident 0 0 0 0 0 1 1 Blast trauma, suspected 0 0 5 0 1 3 9 Encephalomalacia 0 0 2 0 1 0 3 Hem orrhage (or hematoma), prooperative 0 0 4 0 2 4 10 Hemorrhage (or hematoma), operative or postoperative 0 0 0 0 1 4. 5 Ischemia 0 0 2 0 0 4 6 Intracranial trauma, unclassified, evi dent Intracranial trauma, unclassified, 1 5 0 0 2 4 21 suspected 0 1 5 0 1 2 9 423 TABLE CCCXVI MAXILLOFACIAL CONTRIBUTOR? OR ASSOCIATED CONDITIONS IN THOSE CASES IN WHICH THE PflEDIATE CANS"’ OF DEATH WAS SHOCK I II III IV V VI TOTAL CASES Respiratory obstruction due to edema or hematoma 0 0 0 0 0 1 1 Respiratory obstruction due to plugging of airway 0 0 0 0 0 1 1 Sepsis 0 0 1 0 0 1 2 Maxi11ofac ial trauma 3 9 16 0 2 19 49 TABLE CCCXVII CERVICAL GONTRIRTfTOR? OR ASSOCIATED CONDITIONS IN THOSE CASES IN WHICH THE IMMEDIATE CAUSE OF DEATH WAS SHOCK I II III IV V VI TOTAL Cervical hemorrhage 0 1 4- 0 2 4. CASSS 11 Laceration, fatal, carotid or subclavian artery 0 0 2 0 1 l 4- Laceration, fatal, jugular or subclavian vein 0 1 2 0 1 2 6 Respiratory obstruction due to edema or hematoma 0 0 0 0 0 1 1 Cervical trauma 0 2 10 0 1 13 26 424 TABLE CCCXVIII SPINAL CONTRIBUTORY OR ASSOCIATED CONDITIONS IN THOSE CASES IN WHICH THE IMMEDIATE CAHSE OF DEATH WAS SHOCK I II III IV V VI TOTAL CAS3S Hematomyelia 0 0 1 0 1 i 3 Spinal hemorrhage 1 0 0 1 0 i 3 Transection of cord, complete 0 0 2 1 3 5 11 Transection of cord, partial 0 1 1 0 0 1 3 Spinal trauma 0 1 7 2 4. 23 37 TABLE CCCXIX EXTREMITY CONTRIBUTORY OR ASSOCIATED CONDITIONS IN THOSE CASES IN WHICH THE IMMEDIATE CAUSE OF DEATH WAS SHOCK I II III IV V VI TOTAL CASES Frostbite or immersion syndrome 0 0 0 0 0 1 1 Extremity hemorrhage 3 18 25 0 5 28 79 Sepsis 0 0 2 0 0 6 8 Extremity trauma, unclassified u 23 66 0 25 136 264 425 TABLE CCCXX THORACIC CONTRIBUTORY OR ASSOCIATED CONDITIONS IN THOSE CASES IN WHICH THE IMMEDIATE CAUSE OF DEATH WAS SHOCK (1) I II III IV V VI TOTAL Atelectasis, severe 1 0 1 1 2 5 CASES 10 Atelectasis, slight or moderate 0 0 3 0 1 10 14 Blast trauma, evident 1 2 5 0 2 12 22 Blast trauma, suspected 2 1 7 0 2 13 25 Bronchial fistula, evident 0 0 2 0 2 2 6 Bronchial fistula, suspected 0 1 0 0 0 1 2 Cardiac trauma, evident 2 2 4 1 2 9 20 Cardiac trauma, suspected 0 1 3 0 3 6 13 Continuing intrapleural hemorrhage 0 0 1 1 0 4 6 Crushing trauma, evident 0 0 1 0 0 1 2 Dilatation of heart, marked 0 0 1 0 1 2 4 Dilatation of heart, slight or moderate 0 0 1 0 2 4 7 Empyema, mild or moderate 0 0 0 0 0 2 2 Empyema, severe 0 0 0 0 1 0 1 External hemorrhage from chest wall 0 0 1 0 0 0 1 Hemopneumothorax, evident 4 u 38 1 25 93 175 Hemopneumothorax, suspected 2 6 20 0 2 5 35 Continued next page 426 TA3LS CCCXX Cont*d THORACIC CONTRIBUTORY OR ASSOCIATED CONDITIONS IN THOSE CASES IN WHICH THE IMMEDIATE CAUSE OF DEATH WAS SHOCK (2) I II III TV V VI TOTAL Hemothorax without pneumothorax 4 1 8 1 1 10 CASES 25 Hydrothorax, severe 0 0 0 0 0 1 ,1 Hydrothorax, slight or moderate 0 0 3 0 0 7 10 Intrapulmonary hemorrhage, mild or moderate 3 4 14 1 8 31 61 Intrapulmonary hemorrhage, severe 3 3 5 0 3 12 26 Intrapulmonary hemorrhage, suspected 1 2 3 0 4 9 19 Mediastinal emphysema 1 1 2 0 . 2 0 6 Mediastinal hemorrhage 2 1 3 0 1 8 15 hfyocardial decompensation, evident 2 0 3 0 2 10 17 Myocardial decompensation, suspected 3 1 11 1 5 24 45 Other thoracic condition 0 0 1 0 1 2 4 Pneumonia, mild or moderate 0 0 4 0 1 7 I 12 Pneumonia, severe 0 0 1 0 0 0 1 Pneumonitis 0 0 0 0 0 0 1 Pneumothorax without hemothorax 0 0 0 0 1 1 2 Pulmonary edema, severe 0 2 9 1 1 12 25 Pulmonary edema, slight or moderate 3 1 10 0 3 16 33 Continued next page 427 TABLE CCCXX Cont!d THORACIC CONTRIBUTORY OR ASSOCIATED CONDITIONS IN THOSE CASES IN FTICH THE IMMEDIATE CAUSE OF DEATH WAS SHOCK (3) I II III TV V VI Tom Purulent bronchitis 0 0 1 0 0 0 CASES 1 Subpleural emphysema 0 0 2 0 0 0 2 Tension pneumothorax, evident 0 0 4 0 2 2 8 Tension pneumothorax, suspected 0 1 0 0 0 2 3 Tracheobronchial obstruction, aspirated vomitus 0 0 0 1 0 1 2 Tracheobronchial obstruction, blood & mucus 4 1 7 0 2 17 31 Tracheobronchial obstruction, suspected 0 1 3 0 0 4 8 Thoracic trauma, unclassified 5 3 27 0 6 24- 65 Combined intrathoracic & intra-abdominal trauma 0 0 1 0 0 0 1 Pleural contamination from abdomen, evident 0 0 0 0 3 10 13 Thoraco-abdominal trauma 0 0 1 1 0 2 4- Unrepaired wound of diaphragm 0 0 0 0 2 12 14- 428 TABLE CCCXXI ABDOMINAL CONTRIBUTORY OR ASSOCIATED CONDITIONS IN THOSE CASES IN WHICH THE IMMEDIATE CAUSE OF DEATH WAS SHOCK (1) T II III IV V VI TOTAL Abdominopelvic trauma, unclassified 7 5 a 0 0 13 CASES 66 Abscess, extra-peritoneal 0 0 0 0 0 2 2 Adrenal hemorrhage 0 0 1 0 0 6 7 Adrenal trauma 0 0 1 0 2 3 6 Adynamic ileus, mild or moderate 0 0 1 0 1 6 B Adynamic ileus, severe 0 0 1 0 1 4 6 Adynamic ileus, suspected 0 0 1 0 0 0 1 Blast tr auma, ev id ent 0 1 6 1 3 3 U Blast trauma, suspected 1 0 2 0 1 3 7 Cellulitis etc mural & * s extrap er it one al 0 0 1 0 1 4 6 Contamination from hollow viscus 3 3 20 3 27 155 211 Crushing trauma, evident 0 0 1 0 0 0 1 Evisceration, preoperative 3 3 B 1 5 21 41 Gangrene of bowel, advanced 0 0 0 0 0 3 3 Gangrene of bowel, early 0 0 1 0 1 7 9 Gastric dilatation 0 0 5 0 2 7 14 Abdominal hemorrhage, primary 6 5 2 B 5 33 160 237 Abdominal hemorrhage, recurrent or delayed 0 0 0 0 0 13 13 Continued next page 4^9 TAHLE CCCXXI Cont!d ABDOMINAL CONTRIBUTORY OR ASSOCIATED CONDITIONS IN THOSE CASES IN WICK THE IMMEDIATE CAUSE OF DEATH WAS SHOCK (2) I II III IV V VI TOTAL Hepatic degeneration, toxic 0 0 4 0 4 6 CASES 14 hepatitis, epidemic, evident 0 0 0 0 0 2 2 Hepatitis, septic, secondary to trauma,evident 0 0 0 0 3 3 6 Hepatitis, septic, secondary to trauma, suspected 1 0 0 0 0 3 4 Inflammation of G-I tract 0 0 0 0 1 1 2 Intestinal obstruction (mechanical) mild or moderate 0 0 0 0 1 2 3 Nephropathy, evident, unclassified 0 0 0 0 0 5 5 Nephropathy, suspected 0 0 1 0 0 12 13 Nephropathy, toxic, degenerative 0 0 0 0 0 4 4 Other abdominal condition 0 0 0 0 1 4 5 Pancreatic hemorrhage 0 0 0 0 0 2 2 Pancreatic trauma 0 1 0 0 1 9 11 Peritonitis, mild or moderate 0 0 2 1 3 36 42 Peritonitis, severe 0 0 1 1 4 20 26 Peritonitis, suspected 1 0 0 0 0 7 8 Renal trauma, evident 5 1 6 1 12 43 68 Renal trauma, suspected 0 0 0 0 0 2 2 Splenic degeneration, toxic 0 0 0 0 0 3 3 Continued next page 43C TABLE CCCXXI Cont*d ABDOMINAL CONTRIBUTORY OR ASSOCIATED CONDITIONS IN THOSE CASES IN WHICH THE IMMEDIATE CAUSE OE DEATH WAS SHOCK (3) I II in IV V VI TOTAL CASES Splenomegaly 0 0 i 0 0 2 3 Unrepaired wound of hollow viscus 0 0 0 0 3 11 lU Ureter traumatized or tied, evident 0 0 1 0 0 2 3 Urinary tract sepsis 1 0 0 0 0 3 h Undetermined: contamination &/or hemorrhage susnected 7 16 37 0 0 3 63 TABLE CCXXII MISCELLANEOUS CONTRIBUTORY OH ASSOCIATED CONDITIONS IN THOSE CASES IN WHICH THE IMMEDIATE CAUSE OP DEATH WAS SHOCK I II III IV V VI TOTAL OASES Anesthetic agent susuected 0 0 0 0 0 3 3 Jaundi ce 0 0 0 0 0 1 l Clostridial myositis of ex- tr emi ty, evi dent 0 0 1 0 0 0 1 Clostridial myositis of ex- tremity, suspected 0 0 0 0 0 3 3 Clostridial cerehritis or myositis of head, neck, or trunk, evident 0 0 0 0 1 0 1 & TABLE CCGXXIII EMBOLISM, INFARCTION & THROMBOSIS CONTRIBUTORY OR ASSOCIATED CONDITIONS IN THOSE CASES IN WHICH THE IMMEDIATE CAUSE OF DEATH WAS SHOCK I II III IV V VI TOTAL Air embolism, evident 2 0 0 0 0 0 CASES 2 Air embolism, suspected 2 0 0 0 1 2 5 Fat embolism, evident 0 1 3 0 0 1 5 Fat embolism, suspected 0 0 3 0 0 4 7 Thrombotic embolism, pulmonary, evident 0 0 0 0 0 1 1 Infarction alone, adrenal 0 0 0 0 0 1 1 Infarction alone, liver 0 0 0 0 0 1 1 Infarction alone, lung 0 0 0 0 0 1 1 Thrombosis, alone, brain, evident 0 0 1 0 0 0 1 Thrombosis, alone, extremity artery, evident 0 0 0 0 1 0 1 Thrombosis, alone, liver, evident 0 0 0 0 1 0 1 Thrombosis, alone, mesentery, evident 0 0 0 0 1 2 3 Thrombosis, alone, kidney, evident 0 0 0 0 0 1 1 Thrombosis, alone, other site 0 0 0 0 0 2 2 Thrombosis alone, mesentery, suspected 0 0 0 0 0 1 1 432 TABLE CCCXXIV TIMS LAGS IN THOSE CASES IN WHICH THE IMMEDIATE CAUSE OE DEATH WAS SHOCK TIMS LAGS - WOUNDING TO DEATH 25 Cases Dead on Arrival CASES lh record 17 1 hour 2 3 hours 1 h hours 2 $ hours 2 12 hours 1 Total: 25T Cases 55 Cases Joying on Admission (Lived less than 1 hour) No record 20 1 hour 7 2 hours 5 3 hours 5 k hours 8 5 hours 5 6 hours I 7 hours 2 8 hours 1 11 hours Total• JL 55 Cases h33 TABLE CCCXZV TIME LAGS - CASES LIVING AT LEAST ONE HOUR AFTER ADMISSION BUT DYING BEFORE ANESTHESIA IN IE IGH THE IMviEDIATE CAUSE OF DEATH WAS STOCK TIME LEGS - WOUNDING TO FIELD HOSPITAL ISio record GiOrSill/O ll 1 hour 5 2 hours 5 3 hours 2 4 hours 6 5 hours 2 7 hours 2 8 hours 1 10 hours 1 14 hours 1 Total: 36 Cases U3U TABIE CCCXXVI TIME LAGS - CASES LIVING AT HAST ONE HOUR AFTER ADMISSION BUT DYING BEFORE ANESTHESL. IN W ICH THE MEDIATE CAUSE OF DEATH WAS SHOCK TIME LAGS - FOUNDING TO HOSPITAL GASES No record 35 * 1 hour 7 2 hours 9 3 hours 6 4 hours ■ 9 5 hours 6 6 hours 3 7 hours 2 8 hours 2 10 hours 3 12 hours 3 13 hours 2 15 hours 3 17 hours l 26 hours 2 32 hours Total: 1 94 435 TABLE CCCXXVII TIME LAGS - CASES LIVING AT LEAST ONE HOUH AFTER ADMISSION BUT DYING BEFORE ANESTHESIA IN WHICH SHOCK WAS THE IMMEDIATE GAUSE OF DEaTH TIME LAGS ~ WOUHDIHG TO DEATH FIELD HOSPITAL CASES CASES Ho record 11 2 hours 1 3 hours 1 U hours 1 5 hours 3 6 hours 3 7 hours 2 8 hours k 9 hours 3 10 hours 2 11 hours 1 12 hours 1 lU hours 1 16 hours 1 18 hours JL. To tal5 36 Cases U36 TABLE CCCXXVIII TUT. LAGS - CASES LIVING AT LEAST 011E HOUR AFTER ADMISSION BUT DEBT G BEFORE ANESTHESIA IN NEIGH SHOCK mS THE BBEDIATE CAUSE OF DEATH TB'E LAGS - I FOUNDING TO DEATH EVACUATION' HOSPITAL CASES No record CASES 27 18 hours CASES 3 2 hours 3 ‘ 19' hours 2 3 hours 2 21 hours 3 k hours 5 2k hours 1 5 hours h hours 1 6 hours 2 2o hours 1 7 hours 5 27 hours 1 8 hours 2 28 hours 2 9 hours 3 30 hours 2 10 hours 2 31 hours 2 11 hours 2 32 hours 1 12 hours 2 36 hours 1 13 hours 5 [j.0 hours 1 Ik hours 2 k3 hours 1 16 hours 3 If.7 hours JL 17 hours 2 Total: 9k Cases h37 TABLE CGGXOT TIME LAGS - GASES DWlNG DOBING ANESTHETIC INDUCTION IN WEIGH IMMEDIATE GATSE OF nSATH WAS SHOOK WOtTNDITt TO FIELD HOSPITAL WOHNDING TO HOSPITAL 4. hours 1 Case 15 hours 1 Case 20 hours 1 Case 5 hours 1 Case 16 hours 1 Case 2 hours 1 Case FIELD HOSPITAL? ADMISSION STJRGSHZ ETA STATION HOSPITAL; ADMISSION TO SURGED 7 hours 1 Cease 7 hours 1 Case 4- hours 1 Case No record 2 Gases No record 1 Case % FIELD HOSPITAL? WOTJNDING TO DEATH HOSPITAL; WOHNDING TO DEATH 11 hours 1 Case 10 hours 1 Case 20 hours 1 Case 22 hours 1 Case 4.9 hours 1 Case 25 hours 1 Case 438 TABLE CCGXXX TIMS LAGS « OASSS DYING DURING PRIMARY SURGERY IN WHICH THE IMMEDIATE] CAUSE OF DEATH WAS SHOCK FIELD HOSPITAL OASES (28) WOUNDING- TO ADMISSION CASES EVACUATION HOSPITAL CASES (19) OT3»a9BO TO ADMISSION CASES No record 3 No record 2 1 hour 3 1 hour 2 2 hours 2 2 hours 1 3 hours 2 3 hours 1 U hours 3 k hours 2 5 hours k 5 hours 1 6 hours 2 7 hours 2 7 hours 1 5 hours 3 9 hours 2 10 hours 1 10 hours 1 11 hours 1 17 hours 1 kl hours 1 2k hours 1 k8 hours 1 36 hours 1 87 hours JL. 30 hours k2 hours 1 JL. Total 28 Total 19 439 TABLE GCCXXXI TIME LAGS - CASES DYING CUBING PRIMARY SURGERY IN WHICH THE IMMEDIATE CAUSE OE DEATH WAS SHOCK FIELD HOSPITAL CASES EVACUATION HOSPITAL CASHS ADMISSION TO SURGERY CASES ADMISSION TO SURGERY CASES No record 8 No record 2 1 hour 2 2 hours 1 2 hours 3 hours 3 3 hours 3 5 hours 2 U hours 3 6 hours 1 5 hours 2 7 hours 1 6 hours 1 8 hours 1 11 hours 3 9 hours 1 Ik hours 1 11 hours 1 15 hours 1 12 hours 2 19 hours Total: 1 28 lU hours l6 hours 22 hours Total: 2 1 _1 19 440 TABLE GGCXTHI TIME LAGS - CASES DYING DURING PRIMARY SURGERY IN WHICH TEE IMMEDIATE CAUSE OE DEATH WAS SHOCK FIELD HOSPITAL CASES EVACUATION HOSPITAL GASES WOUNDING TO DEATH CASES WOUNDING TO DEATH CASES No record 3 No record 3 3 hours 1 7 hours 2 5 hours 2 9 hours 1 7 hours 1 10 hours 1 8 hours 1 lU hours 1 9 hours 1 17 hours 1 10 hours 3 19 hours 3 11 hours 2 20 hours 1 12 hours 1 21 hours 1 13 hours 3 23 hours 1 IS hours 1 35 hours 1 19 hours 1 53 hours 1 20 hours / 2 56 hours 1 2k hours 25 hours U3 hours U6 hours 51 hours Total: 1 2 1 1 1 28 1C5 hours Total: 1 19 441 TABLE GCOXXmi TIME LAGS - CASES DYING AFTER PRIMARY SURGERY IN WHICH THE IMMEDIATE CAUSE OP DEATH WAS SHOCK FIELD HOSPITAL CASHS WOUNDING TO ADMISSION EVACUATION HOSPITAL" CASES WOUNDING TO ADMISSION •i CASES CASES No record 30 No record 27 1 hour k 1 hour 6 2 hours 5 2 hours 8 3 hours 10 3 hours 5 1+ hours Ik k hours 15 5 hours 13 3 hours 9 6 hours 5 6 hours 10 7 hours 12 7 hours 5 g hours 9 g hours S 9 hours g 9 hours 5 11 hours 3 10 hours 2 12 hours 5 11 hours k 13 hours 1 12 hours 3 lU hours # 1 13 hours 1 15 hours 3 lU hours 2 17 hours 1 15 hours 1 21 hours l l6 hours 3 22 hours 3 17 hours 1 hours 2 29 hours 1 37 hours To tal: 1 131 31 hours 1 3g hours 1 U9 hours TOTAL: 119 442 TABLE CCCXmV TIME LAGS ~ CASES DYING AFTER PRIMARY SURGERY IN WHICH THE IMMEDIATE CAUSE OF DEATH WAS SHOCK FIELD HOSPITAL CASES EVACUATION HOSPITAL oa&es ADMISSION TO SURGERY ADMISSION TO SURGES! OASES CASES No record 36 No record 32 1 hour 1 hour 2 2 hours 12 2 hours 5 # 3 hours 16 3 hours 9 h hours 8 U hours 13 5 hours 7 5 hours 11 6 hours 17 6 hours 9 7 hours 6 7 hours 5 8 hours 11 g hours 6 10 hours 7 9 hours 3 11 hours 2 10 hours 7 12 hours 2 11 hours 3 13 hours 1 13 hours k ll+ hours 1 hours 2 15 hours JL 15 hours 3 To tal: 131 17 hours 1 2U hours 1 25 hours 1 29 hours 1 30 hours 1 To tal • H9 443 TABLE GGGXXW TIMS LAGS ~ CASES DYING ASTER PRIMARY SURGERY IN WHICH THE IMMEDIATE CAUSE CS DEATH WAS SHOCK FIELD HOSPITAL GASES, SUHGEPY TO DEATH CASES CASES No record 26 20 hours 1 1 hour k 21 hours 1 2 hours 6 22 hours 3 3 hours 5 2U hours 2 H hours 3 25 hour s 1 5 hours H 27 hours 2 28 hours 3 6 hours 3 29 hours 1 7 hours 3 30 hours 3 8 hours 5 33 hours 1 9 hours 3 35 hours 1 10 hours 3 36 hours 1 11 hours H 37 hours 2 12 hours 5 Ho hours 1 13 hours H H-2 hours 1 iH hours h H6 hours 1 15 hours 6 H-7 hours 1 l6 hours 1 51 hours 2 17 hours 1 53 hours 1 18 hours 5 6n hours 1 19 hours 5 72 hours 1 Total: 131 4-4-4- TABUS GOrCWI TIME LAGS ~ CASES DYING AETER PRIMARY SURGERY IN WHICH THE IMMEDIATE CAUSE OE DEATH WAS SHOCK EVACUATION HOSPITAL GASES;SURGERY TO DEATH No record CASES 2° l6 hours CASES 2 1 hour u 17 hours 1 2 hours 5 18 hours 1 3 hours 7 1° hours 1 •U hours 5 2T hours 3 3 hours 5 21 hours 2 6 hours 3 26 hours 3 7 hours 3 28 hours 5 8 hours 7 2° hours 2 9 hours 5 31 hours 1 10 hours 1 38 hours 1 11 hours 2 U5 hours 2 12 hours 3 51 hours 1 13 hours 2 52 hours 1 lU hours 6 60 hours 1 13 hours 3 92 hours 1 ' i+93 hours 1* * Died in To tal: 119 shock from recurrent or delayed intreu-abdominal hemorrhage 445 TABLE CGCXXXrai TIMS LAG-3 ~ CASES DYIEG AFTEH PRIMARY SUHGEHY IE WHICH THE IMMEDIATE CAUSE OF DEATH WAS SHOCK No record FIELD HOSPITAL CASES CASES, WOUNDING TO DEATH CASES i 21 33 hours 3 if hairs 1 3U hours 1 7 hours 1 36 hours 1 9 hours 1 37 hours if 1C hours 2 38 hours 2 11 hcurs 1 39 hours 2 12 hours 2 ifO hours 1 13 hours 3 ifl hours 2 lif hcurs 2 if2 hours 1 15 hours 6 if3 hoars 1 l6 hours 3 ifif hours 1 17 hours 3 if5 hours 2 19 hours 3 if6 hours 1 20 hours 3 if7 hours 3 21 hours 3 50 hours 1 22 hours 3 53 hours 1 23 hours k 57 hoars 1 2 if hours if 58 hours 1 29 hours 60 hoars 2 26 hours 1 6l hours 2 27 hcurs 6 6if hours 1 28 hours 2 68 hours 1 29 hours if 70 hours 1 30 hours 3 91 hoars 1 31 hoars 32 hours if U Total; 131 44-6 TABLE GGGXXXVTII TIMS LAGS - CASES LYING ASTER PRIMARY SURGERY IN WHICH THE BMELIATS CAUSE OE DEATH WAS SHOCK No record EVACUATION HOSPITAL CASES, CASES 22 WOUNDING TO DEATH 3U hours CASES k 7 hours 1 35 hours 2 9 hours 2 36 hours 3 1C hours 2 37 hours 2 11 hours 1 38 hours 2 12 hours 1 39 hours 1 13 hours 5 Uo hours k 19- hours 2 9-3 hours 1 15 hours 2 9-A hours 2 l6 hours 2 9-9 hours 1 17 hours 6 50 hours 1 18 hours 1 51 hours 1 19 hours 3 52 hours 1 20 hours U 65 hours 1 21 hours 8 72 hours 1 22 hours 3 76 hours 1 23 hours 3 82 hours 1 29- hours 3 89 hours 1 25 hours k 97 hours 1 26 hours 1 10U hours * 1 27 hours 3 512 hours * 1 28 hours 2 Total: 119 29 hours 2 31 hours 1 32 hours 1 33 hours 1 *Had recurrent or delayed intrar-abdominal hemorrhage. SECTION VI APPENDICES APPENDIX A DISTRIBUTION OF 3TH ARMY HOSPITAL KETTLE CASUALTY DEATHS* NOT STUDIED IN THIS REPORT JAN F1AR 1944 APR JUL 1944 AUG DEC 1944 JAN MAY 1945 TOTAL loth Hold Hospital 2 9 X** X 11 11th " « 1 0 X X 1 32nd " » X X 25 18 43 33rd " « 4 11 0 0 15 Total Field Hospitals 7 20 25 18 70 8th Evacuation Hospital 0 0 0 0 0 11th " « 1 3 X X 4 15th " « 2 2 4 13 21 16th " « 2 2 3 0 7 36th " •' 0 0 0 0 0 36th " " •14 13 21 0 48 93rd « " 0 0 X X 0 94th " " 4 2 4 0 10 170th " " X X 0 0 0 l?lst " « X X X 1 1 Total 23 22 32 14 91 Total Field and Svac Hosp 30 42 57 32 161*** *1 January 1944 to 2 May 1945 ** X indicates-not functioning as a forvrard surgical hospital for Fifth Army, There are 59 additional cases not studied in this report if the MTOUSA MD Form 86f figure of 1631 hospital battle casualty deaths is used. 449 APPENDIX B CORRECTION OF TOTAL BATTLE CASUALTY ADMISSION FIGURES FOR EACH PERIOD TO AGREE WITH PROPORTION OF TOTAL DEATHS THAT' WERE ANALYZED FOR THIS' REPORT* Jan- Mar 19AA Apr- Jul 19AA Aug- Dec 19 AA Jan- May 19A5 Deaths reported 570 542 332 187 De aths s tudled (minus dead on arrival)- 522 A66 275 IAS Percent of total deaths studied 91.6? 86.0? 83.0? 79.2? Correction factor 8.4? 1A.0# 17.0# 20,8$ B. G. adraiss ions, uncorrected 1A, 4-9$ 23,111 16,221 9,19 A B. C. admissions, corrected 13,282 19,876 13,A6A 7,282 * See Table HI; Page 90: Casualty Deaths, Showing Admissions by Periods, The Leading Causes of tho Percentage of the Death in 1A50 Battle Total Battle Casualty 450 PRINCIPAL WOUND GROUP* TOT.IL cases I Abd AOS II Cran 297 III ThAbd 212 IV Thor 13S V LEB 11A VI UnMW 11A VII CoA&T 59 VIII LE,S IX Spin 27 X Cerv 25 . XI UE,B 10 XII MaxF 8 XIII UE,S A . XIV AbdW 3 T0TAI ■ U5.0 NO. OF CASES WITH ASSOCIATED WOUNDS; 1. HEAD Eye or orbit 0 22 0 0 0 3 0 0 0 . 0 0 0 0 0 25 Intracranial, known 2 0 6 2 0 39 7 1 2 1 0 0 0 0 60 Intracranial, suspected 6 0 2 6 3 10 2 0 0 0 1 A 1 0 35 Scalp only 7 0 2 5 5 1 3 2 0 1 -L 0 1 0 0 27 2. FACE AND JAWS Bone and soft tissue A 35 3 5 1 13 1 0 1 2 0 0 0 0 65 Eye or orbit 2 11 2 A 3 12 5 0 0 0 1 5 0 0 A5 Soft tissue only 15 25 3 1A 10 27 9 3 1 U 2 0 1 0 11A 3. NECK General (excluding spinal) 9 17 12 1A A 23 0 1 21 0 0 3 0 0 10A With carotid artery involved 0 0 0 1 0 1 0 0 0 0 0 0 0 0 2 With larynx or trachea involved 0 2 1 0 0 2 2 0 1 l 0 0 0 0 9 A. SPINAL CORD OR INTRAVERTEBRAL NERVES 26 2 19 22 0 10 5 1 0 0 0 0 0 0 85 5. CHEST Chest wall only A1 11 0 0 8 15 1 1 A 1 1 1 1 1 86 Combined intra-abdominal and intrathoracic 0 2 0 0 1 A 0 0 0 I 0 0 0 0 8 Intrathoracle, known 6 2A 1A 0 2 32 1 0 7 8 0 0 0 0 9A Thoraco-abdominal *See Table V, page 12, 1 1 0 1 0 2 0 0 0 0 Continued 0 next 0 page. 0 0 5 DISTRIBUTION OF ASSOCIATED WOUNDS RELATED TO REGION OF THE PRINCIPAL WOUND (l) APPENDIX C 451 principal found group I Abd II Gran III Tli Abd IV Thor V LEB VI UnMV VII GoA&T VIII LE.S , IX Spin X Cerv XI M. XII XIII MaxF UE.S XIV AbdV TOTAL CASES PITH AS OCIATED POUNDS: 6. ABDOMEN Abdominal wall only Combined intra-abdominal Sc in 0 11 0 8 ’15 19 0 6 1 0 3 0 1 0 64 trathoracle 0 1 0 0 1 0 0 0 0 0 0 0 0 0 2 Intra-abdominal, known 0 r' 5 0 1 2 12 C 0 0 0 0 0 0 0 20 Intra-abdominal, suspected 0 0 0 4 2 22 0 0 0 0 0 1 1 0 30 Thoraco-abdominal 0 0 0 0 0 2 0 0 0 0 0 0 0 0 2 7. UPPER EXTREMITY Soft tissue only 63 52 29 28 17 32 14 6 6 4- 0 3 0 2 256 Soft tissue & artery 2 1 1 1 0 0 0 0 0 0 0 0 0 0 5 S.T. & artery & bone 3 1 0 1 0 2 4- 0 0 0 0 0 0 0 11 S.T, & artery & bone Sc nerve 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 S.T, & artery Sc nerve 0 1 1 0 0 0 0 0 0 0 0 0 0 0 2 S.T, & bone 34 2/, 31 33 18 27 11 3 4. 4 0 0 0 0 189 S.T. Sc bone & nerve 1 1 1 1 2 1 1 0 0 0 0 0 0 0 8 S.T, & nerve 1 0 1 1 0 0 0 0 0 0 0 0 0 0 3 Traumatic amputation 0 1 2 0 2 10 1 1 0 0 0 0 0 0 17 8. LONER EXTREMITY Soft tissue only 135 37 43 26 0 39 25 0 3 3 2 1 1 1 316 S.T, & artery 6 1 0 0 1 3 1 0 0 0 0 0 0 0 12 S.T, Sc artery & bone 2 2 3 3 0 3 0 0 0 0 0 0 0 0 13 S.T, Sc artery & bone & nerve 0 0 0 0 0 1 1 0 0 0 0 0 0 0 2 S.T, & artery ond nerve 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 S.T. & bone 55 21 13 11 1 28 9 3 0 0 3 0 1 0 145 S.T, Si bone Sc nerve 3 0 0 0 2 1 0 0 0 0 0 0 0 0 6 S.T, Sc nerve 2 0 0 0 0 2 0 1 0 0 0 0 0 0 5 Traumatic amputation 5 1 1 0 2 10 2 1 0 0 0 0 0 Continued next page. 0 22 DISTRIBUTION OF ASSOCIATED FOUNDS RELATED TO REGION OF THE PRINCIPAL WOUND (2) APPENDIX C Cont’d. 452 PRINCIPAL ROUND GROUP I Abel II Gran III ThAbd IV Thor V LE3 ' VI UnHW VII CoA&T VIII IX Spin X Cerv XI UE.B XII MaxF XJLll TTr*' Q XIV Abd'7 TOTAL GX3E3 HITS ASSOCIATED ;OUITDS 2 9. ARTERIES INJURED (Excluding Traumatic ) Axillary 1 0 0 1 c 0 0 0 0 0 0 1 1 0 A Brachial a 3 2 1 0 1 2 0 0 0 0 0 0 0 13 fb moral 7 1 0 1 6 A 0 9 0 0 0 0 0 0 28 Intra-abdominal 26 1 A 0 0 1 0 0 0 0 0 0 0 0 32 Intracranial* 0 28 0 0 0 2 0 0 0 0 0 0 0 0 30 Intr a th or ac io 0 0 1 7 0 1 0 0 0 0 0 0 0 0 9 Multiple 1 2 1 0 1 0 0 0 0 0 0 0 0 0 5 Others 0 0 0 0 0 0 0 1 0 3 0 0 0 0 A Popliteal 0 0 0 1 0 $ 2 0 0 0 0 0 0 0 8 Radial or ulnar 0 0 0 ' 0 0 1 2 0 0 0 1 0 0 0 A Subclavian 0 0 0 0 0 0 0 0 0 3 0 0 0 0 3 Tibial or peroneal 1 1 2 2 rv 0 1 2 3 0 0 0 0 0 0 20 .0. NERVES INJURED (Excluding Traumatic Amputations) Brachial plexus 0 c 0 2 0 1 0 0 2 3 0 0 0 0 8 Pbmoral 0 0 0 0 0 0 0 2 0 0 0 0 0 0 2 Median “! X 0 1 0 1 0 0 0 0 1 0 0 0 0 A Multiple 0 0 0 0 2 1 1 0 0 2 0 0 0 0 6 Other nerve / 1 0 0 0 0 1 0 0 0 2 0 0 0 0 A Other plexus 1 0 1 0 0 0 0 0 0 C 0 0 0 0 2 Peroneal 0 0 0 0 1 0 1 0 0 0 0 0 0 0 2 Radial 2 1 0 0 0 0 2 0 0 1 1 0 0 0 7 Sciatic 6 0 0 0 1 1 2 0 0 0 0 0 0 0 10 Tibial 0 0 1 0 2 1 1 1 0 0 0 0 0 0 6 Ulnar 0 1 1 1 3 1 0 0 0 0 1 0 0 0 8 Unclassified 0 0 0 0 0 0 0 0 0 0- 0 0 1 0 1 D IS TR IB UT 01 Oil OF .ASSOCIATED WOUNDS RELATED TO REGION OF THE PRINCIPAL. WOUND (3) APPENDIX C Cont’d. *Artery or venous sinus, /Extracranial or extraspinal. 4-53 APPENDIX D FURTHER CLASSIFICATION OF CASES WITH PRINCIPAL WOUNDS OF CHEST TO SHOW HEMITHORAX INVOLVED AND RELATTVE IMPORTANCE OF ABDOMINAL AND THORACIC COMPONENTS WHEN BOTH ARE PRESENT (BASED ON SEVERITY OF INTERNAL INJURY AND SURGICAL APPROACH) Abdomen l -p m CD P O Total 1. Combined intra-abdominal & intrathoracic, bilateral 10 6 16 2. Combined intra-abdominal & intrathoracic, left 15 4 1.9 3. Combined intra-abdominal & intrathoracic. right 16 8 24 4. TOTAL 41 18 59 5. Intrathoracic, bilateral 26 6. Intrathoracic, left 43 7. IntrathOracle, right 65 8. Intrathoracic, unclassified 4 9. TOTAL 138 138 10. Thoraco-abdominal, bilateral 3 4 7 11. Thoraco-abdominal, left 41 67 108 12. Thora.co-abdom5.nal, right 45 50 95 13. Thoraco-abdominal, unclassified 2 0 2 14. TOTAL 91 121 212 GRAND TOTAL 409 454 APPENDIX S DISTRIBUTION AMONG- PIPTH ARMY PIELD AND EVACUATION HOSPITALS OP THE BATTLE CASUALTY PATALITIES STUDIED (l) 10 th 11th 15 th 32nd 33rd 8th 11th 15th Field Field Field Fi eld Field Svac Svac Svac PRINCIPAL V/0U1TD; Intracranial k k 2 2 13 51 10 27 Intravertebral 0 0 0 0 2 u 2 3 Maxillofacial 0 0 0 0 0 1 0 3 Cervical 1 3 0 1 1+ 2 1 3 Intrathoracic 1 11 1 6 35 13 3 Ik Tho rac o—abdo mi nal 5 32 1 16 59 9 7 18 Combined intra-abdominal 2 12 0 5 10 6 1 2 & intrathoracic Intra—abdominal 12 Us 1 3S H5 22 15 27 Abdominal wall only 0 0 0 0 1 0 0 1 Upper ext. soft tissue 0 0 0 0 1 0 0 1 only Upper ext. bone & 0 0 0 0 2 0 0 1 soft tissue Lower ext, soft tissue 0 3 0 0 2 k 2 1 only Lower ext, bone & soft 1 ii 0 2 18 13 5 .16 ti ssue Unclassified multiple 0 3 0 3 11 9 9 14 Total: 26 128 5 73 273 13U 55 131 Continued on next page 455 APPENDIX a Cont fd DISTRIBUTION AMONG- FIFTH ARMY FIELD AND EVACUATION HOSPITALS op the 1U50 battle casualty natalities studied (2) l6th 38th 56th 93rd 9Uth 95th 170th 171st Svac Svac Svac Svac Svac Svac Svac Svac PRINCIPAL WOUNDs Intracranial 31 23 3S IT Us 19 8 u Intravertebral 2 U 1 k 2 0 1 2 Maxillofacial 0 0 0 0 1 1 2 0 Cervical 1 6 2 0 1 0 0 0 Intrathoracic 5 10 15 9 11 0 k 0 Thoraco-abdominal 7 20 13 1 lU 9 U 1 Combined intra-abdominal 3 5 2 U u 1 2 0 & intrathoracic Intra-abdominal 10 15 C\J 23 27 lU 7 1 Abdominal wall only 0 0 1 0 0 0 0 0 Upper ext, soft tissue 0 0 1 0 1 0 0 0 only Upper ext, bone & 0 1 3 1 1 1 0 0 soft tissue Lower ext. soft tissue 3 k U 1 k 3 0 0 only Lower ext, bone & soft h 8 12 ll 11 1 1 0 tissue Unclassified multiple k 11 19 10 19 8 2 0 i Total • 70 107 139 81 1U0 U9 31 8 456 APPENDIX F POST MOHTEM STUDIES BY PERIODS JA&-MAS 19^ APR—JUL 191+1+ AUGv-DEC 191+1+ JAM-MAT 19U9 Total Number of deaths studied 529 1+82 28l+ 155 11+50 Number with gross autopsy reuorts 171 25U 180 128 733 Percentage in which gross autopsy is reported 32.3$ 52.7$ 63.1*^ 82.6$ 50.6^ Number in which microscopic sections are reported 37 119 99 9^ 31*9 Percentage of deaths studied in vhich microscopic sections are reported 7$ Zh.li 3>+.9$ 60.6 $ 2U$ Percentage cf gross autopsies in vhich microscopic sections are reported 21.6$ 1*6.9 $ 555S lb M 1*7.6$5 457