Book Review

The Textbook of Penetrating Trauma

N Engl J Med 1996; 335:1246-1247October 17, 1996

Article

The Textbook of Penetrating Trauma
Edited by Rao R. Ivatury and C. Gene Cayten. 1157 pp., illustrated. Baltimore, Williams & Wilkins, 1996. $179. ISBN: 0-683-04338-2

This may be the largest textbook published in the United States on a subdivision of surgery. It weighs 10 lb (4.5 kg). The enthusiasm of the editors is commendable, as is their attempt to cover practically every aspect of penetrating trauma and to follow almost every chapter with a commentary by another authority. There are 88 chapters, 149 contributors, and 89 commentators.

A more accurate title would be Penetrating Trauma in the United States, because although the format suggests a textbook, the contents are less concise than those of the usual textbook and much of the information refers exclusively to the United States. References to 20th-century trauma statistics or management in other countries are minimal. The broad range of topics covered makes the book a more useful reference than its title would suggest. For instance, chapter 7, “Penetrating the Mind: Television as a Cause of Violence,” by Centerwall, is unexpected and very well written. The book also includes information on blunt trauma. In some instances this inclusion causes confusion, such as in the discussions of military antishock trousers (pneumatic antishock garments).

Parts I through IV, “Evolution of Trauma Care,” “Epidemiology, Economics, Prevention,” “Injury Severity,” and “Initial Assessment and Resuscitation,” are applicable to all injuries, as is chapter 29, “Computed Tomography and Magnetic Resonance Imaging,” in part VI. The subsequent chapters concerning specific parts of the body would be more clinically useful if grouped anatomically rather than under the headings “Secondary Assessment,” “Ancillary Studies,” and “Organ System Injuries.” Most of the chapters already include these subdivisions.

Part II includes two chapters on the epidemiology of penetrating trauma. Chapter 3, by Fingerhut, concerns urban mortality, and chapter 4, by Gerberich et al., describes rural trauma. These contain useful statistics, such as (in Mercy's commentary on chapter 3) “the presence of a gun in a household was found to increase the risk of suicide almost fivefold and the risk of homicide almost threefold.”

Because some of the subjects have controversial aspects, it is commendable that commentaries follow almost every chapter. Unfortunately, all of the various opinions on a specific subject may not be included in the same chapter, which is awkward for textbook or quick reference use. For instance, varying opinions on use of pneumatic antishock garments are in three different chapters.

The editors have served more as collectors than as editors, permitting the authors and commentators to include in each chapter the material they consider important, even though information on the same subject is included in other chapters, where it may be contradictory, irrelevant, or even erroneous. For instance, despite the presence of a chapter on ballistics, the chapter on the epidemiology of rural penetrating trauma includes a discussion of ballistics that is not listed in the index. It erroneously states that “it makes no difference whether the energy is generated from a moving bullet, machinery, or some other object. If the same rate and amount of energy is concentrated at the same angle of impact on the same area of a given human body, the resulting damage will be the same.” There is no mention of other factors that may influence the amount of damage caused by a penetrating object, such as shape, deformation, fragmentation, and tumbling. A more accurate assessment of wounding effects is in chapter 59, “Extremities: Skeleton.” This chapter has a section entitled “Urban versus Rural.” This subject is also included in the chapter “Alternative Approaches to Resuscitation,” but neither is listed in the index under either “Urban” or “Rural.”

In the ballistics chapter, no mention is made of the strong pulsation of the temporary cavitation that follows the passage of a high-velocity bullet, especially in a perforating injury. The alternating positive and negative pressures not only contribute to injury remote from the wound tract but also can enable external material near the exit site to permeate the entire wound tract. This has been documented by high-speed photography and is probably the chief cause of contamination.

In chapter 27, “Extremities,” Phillips states that the U.S. Army “echelons of care” may cause a casualty to be transported through a series of facilities in the management of his or her wounds. The U.S. Army medical planning includes provisions for these levels of care, but does not mandate their use. In the Vietnam conflict, groups of casualties were transported by helicopter directly to the facility providing the level of care required by the most seriously injured.

In chapter 62, “Extremities: Soft Tissue,” the authors state, “it is not the velocity, but the kinetic energy achieved by the wounding missile that determines the extent of destruction.” It is not the kinetic energy achieved by the wounding missile that determines the extent of destruction, but the kinetic energy lost into the tissue, as well as other factors, such as the characteristics of the tissue and the projectile.

After reading this entire book, including some of the suggested readings, students may be able to decide how to care for a specific patient and may derive suggestions for further research. Considerable time will be required to find and evaluate all the scattered information on some of the subjects, but it is a useful resource.

Janice A. Mendelson, M.D.
3803 Barrington, #1D, San Antonio, TX 78217